A Conservative and Painless Approach to Anterior and Posterior Aesthetic Restorative Dentistry

A substantial number of people want a beautiful smile. Approximately 50% of the population is unhappy about the smile they have. In recent years the media has portrayed aesthetic dentistry as invasive, time-consuming, painful, and expensive. The people who want to enhance and change their smiles are most often hesitant to seek a dental consultation because of the fear that they will encounter these same obstacles. Patient treatment, especially in aesthetic dentistry, requires an individual approach based upon the periodontal and restorative needs of each case, and the patient's desires.
In recent years, evidence for the longevity of conservative aesthetic restorative techniques (that require minimal tooth reshaping and in some cases no preparation at all) with adhesive procedures to enamel has been demonstrated.1-4 Porcelain that has a physical property matched to tooth structure5 and improved composite resins6,7 allow the clinician to offer conservative, tooth-saving procedures with a high expectation of long-term success. With the development of these improved dental materials, dentists can now offer procedures that are relatively quick, painless, and long-lasting.

CASE REPORT

Figure 1. Preoperative unaesthetic appearance of porcelain-metal crown, shade of teeth, and spacing.

Figure 2. Postoperative smile after LUMINEERS were placed.

A middle-aged, dental-phobic patient presented himself for consultation to address several dental concerns (Figure 1), which we were able to address with great success (Figure 2).

(1) Tooth No. 8 had a porcelain-metal crown that was mismatched in shade and had an exposed metal gingival collar. The margins were closed and intact with no evidence of caries.

(2) Diastemas were present between teeth Nos. 7 and 8, and also Nos. 8 and 9.

(3) The patient desired a lighter color for his teeth, and when presented with choices of shade using a Vita shade guide, he chose shade A-1.

(4) In the posterior region (but still in the aesthetic zone) the patient had a missing tooth No. 13 that he wanted replaced.

As part of any consultation, examination of soft tissue and all hard tissues as well as a periodontal and occlusal evaluation was completed. With the data collected, the patient was presented with several treatment plans.  Acceptance and success of the aesthetic result are increased when a patient is made an integral part of the decision-making process. Therefore, treatment plans in the aesthetic zone included the patient as part of a co-diagnosis and included a clear understanding of the patientÌs aesthetic needs and desires, and the limitations of dental treatment.
A conventional treatment plan involved removing the unaesthetic porcelain-metal crown on No. 8 and preparing teeth Nos. 4 to 11 for porcelain veneers. Depending on the treatment, tooth No. 12 could be included as a porcelain veneer if treatment to replace tooth No. 13 was to be a 2-stage implant. The alternative choice presented was the replacement of No. 13 with a conventional porcelain-metal fixed partial denture using teeth Nos. 12 and 14 as abutments.  
This highly dental-phobic patient explained that even stepping into a dental office had been a victory. When presented with treatment options that included multiple dental visits, administration of local anesthetic, and (in the case of an implant) a surgical procedure, he was very hesitant. With further questioning, the patient stated that what had motivated him to see the dentist was an article about noninvasive aesthetic dentistry he had read in a magazine. Based on this article, the patient asked questions concerning the possibility of getting a smile "makeover" without local anesthesia and with little if any "tooth drilling." After reviewing the patient's oral conditions and aesthetic concerns, a more conservative treatment plan was developed. A treatment plan was created, motivated by the patient's request, that required no use of local anesthetic and maintained tooth enamel with minimal or no tooth reshaping for restoration. The following treatment options were presented:

(1) Tooth No. 8 with the aesthetically unsatisfactory crown but acceptable margins  would be prepared and receive a contact lens-thin por-celain veneer (LUMINEERS [Cerinate Smile Design Studios]) placed over it using a predictable crown and bridge repair technique.8

(2) Teeth Nos. 4 to 7 and Nos. 9 to 11 would also receive LUMINEERS, which are contact lens-thin and fabricated with a high-strength Cerinate Porcelain (Den-Mat), so that no painful removal of tooth structure would be necessary. For this patient, enamel would be the bonding substrate to the tooth. By leaving the enamel, and with minimal use of a handpiece for tooth preparation, there is no need for local anesthesia. For this case, many of the teeth needed no preparation at all. It should be noted that with no-prep veneers cases, an incisal wrap is recommended because it enables a positive seating for the veneer. With prep cases, the laminate will have a positive seat within the facial surface of the tooth at the chamfer finish line. The incisal wrap can be removed during the finishing stage if crown lengthening is not desired.

(3) To replace tooth No. 13, a Hugger Bridge was planned using TrueVitality (Den-Mat), an adhesive, all-composite resin fabricated fixed-partial denture. Hugger Bridges are fabricated with or without fiber reinforcement depending on the needs of the case, with both facial and lingual wings. In planning the Hugger Bridge, the tooth contours must be taken into account to create a path of insertion. Since the restoration will be bonded to enamel, the tooth modifications are only those required to eliminate undercuts in the facial, lingual, and proximal surfaces that would interfere with insertion and bonding of the completed fixed-partial denture. In most cases, the amount of enamel that is removed is minimal when compared to a conventional fixed-partial denture that re-quires the complete removal of all enamel on the abutment teeth. Hugger Bridges are fabricated at the Cerinate Smile Design Stu-dios using tri-cured, self-cured, light-cured, or heat-cured TrueVitality microhybrid resin. TrueVitality composite resin allows the Hugger Bridge to be fabricated with an optimal physical property composite resin that demonstrates flexure compatible with the natural movement of teeth within the PDL. Also, this microhybrid composite resin is less brittle than porcelain in normal occlusal function. In contrast, all-ceramic bridges have a history of fracture due to their high flexural modulus and brittle nature.

TREATMENT

Most of the patientÌs teeth did not require any tooth preparation because LUMINEERS is thin and durable. Since there is no definite finish line, the laboratory uses the free margin of the gingiva as the reference for placement of the cervical margin of the porcelain veneers. The final impression was taken using LUMINEERS Impressions (Den-Mat), a polyvinyl siloxane impression material. An impression of the opposing arch was made with alginate. To ensure that the laboratory would fabricate the restorations without any occlusal interferences, a centric bite registration was taken as well. A laboratory authorization was completed describing the purpose for the LUMINEERS: the shade desired, the length and surface texture for the facial surface of the veneers, the spaces to be closed, the creation of facial alignment with all teeth, and fabrication of the restorations in shade A-1. The impression was sent to the Cerinate Smile Design Studios for fabrication of the restorations. Because the teeth were minimally reshaped, there was no need for provisional restorations be-tween visits.
The poor shade match of the porcelain-metal crown on No. 8 and the exposed unaesthetic gingival metal collar was also noted. Diastemas were present in the anterior region, and the Cerinate Smile Design Studios were  directed to close these spaces as well as create a good facial alignment using the LUMINEERS.
Since color change was not a major problem, the LUMINEERS were fabricated with fired and stacked Cerinate Porcelain. This is a high-strength porcelain with physical properties matched to tooth structure as well as bonding composite resin ce-ment for bonding to the porcelain. Fabrication of a Hugger Bridge was requested for the replacement of missing tooth No. 13.
The LUMINEERS and Hugger Bridge were received from the Cerinate Smile Design Studios. As part of the verification process, the restorations were tried on the model. The shade was checked to the shade guide. The internal surfaces of the LUMINEERS were verified as being etched.
On the day of insertion, the internal surfaces of the veneers were treated for bonding. The teeth and surfaces to be bonded were cleaned with a porcelain polishing paste using a disposable prophylaxis angle. Since for this case one of the LUMINEERS would be bonded to an existing porcelain-metal restoration, it was decided to use Den-Mat's Revitalize, a comprehensive crown and bridge repair kit. This kit contains all materials needed to accomplish the following:

  • etch the intraoral porcelain;
  • silanate the etched porcelain;
  • lute the porcelain veneer to the intraoral porcelain;
  • mask metal collars;
  • and, color modify the veneers.

 

The veneers were seated with Ultra-Bond Plus Try-In Paste (Den-Mat) to verify fit, aesthetic shape, and color. The patient was shown the veneers and approved their aesthetic appearance. The Hugger Bridge was also tried in. The interproximal surfaces were then finished using a safe-side-handled diamond blade (CeriSander  [Den-Mat]). Occlusal adjustment of the Hugger Bridge is done after the restoration is bonded to place.
The internal surfaces of the LUMINEERS were pretreated as follows:

(1) Porcelain Condition-er (Den-Mat) is applied and left in place for 30 seconds. The surfaces are thoroughly rinsed with water and dried.

(2) A silane ceramic primer, Cerinate Prime (Den-Mat), is then applied to the etched porcelain and left in place for at least 30 seconds, then blown thin with dry air.

(3) Tenure S adhesive resin (Den-Mat) is painted onto the etched porcelain surfaces but not light-cured at this time. The LUMINEERS are returned to their light-safe storage box.

TECHNIQUE FOR PLACEMENT

(1) To prepare the surface of porcelain-metal crown No. 8, the facial porcelain was deglazed using a mini intraoral sandblaster with a 50-µm aluminum oxide particle (Mini-etcher 2 [Den-Mat]). The exposed metal cervical collar was prepared and removed using a high-speed half-round medium-grit diamond. (Note: Wearing 4x magnification loupes allows the removal of the metal collar to be done with great precision. This magnification is strongly recommended for preparation and finishing marginal areas because it allows for conservative, precise results.)

(2) Revitalize Porcelain Etching Gel (Den-Mat), a blue-colored, intraoral use hydrofluoric acid, was applied for 4 minutes to the deglazed porcelain of the No. 8 crown. 

(3) After approximately 3.5 minutes, pink-colored phosphoric acid etchant (Etch "N"Seal [Den-Mat]) was ap-plied to the other teeth to be restored with LUMINEERS (Nos. 4 to 7 and Nos. 9 to 11) for 15 to 30 seconds (Figure 3). All etchants were rinsed with an air-water spray for 10 seconds, and the teeth to be restored were air-dried. Etch-ing of the enamel and porcelain is verified by their frosty appearance.

(4) Adhesive was applied to all natural teeth with 3 to 5 applications of Tenure A/B (Den-Mat) bonding a-gent, and the surfaces were air-dried. The teeth will have a glossy appearance. The wetting coat of Tenure S light-cured bond enhancer was applied to all the natural teeth. It was blown thin with dry air. Light-curing is not done until the LUMINEERS are placed.

Figure 3. Application of Etch ÎNÌ Seal etchant to enamel and PorceLock to the porcelain surface. Figure 4. Etched porcelain on the No. 8 porcelain-metal crown is treated with Porcelain Conditioner.

(5) The etched porcelain on the No. 8 porcelain-metal crown was treated with Porcelain Conditioner for 30 seconds. It was then rinsed and air-dried (Figure 4).

(6) The facial surface of the treated crown was then painted with Cerinate Prime for 30 seconds and air-dried.

(7) All LUMINEERS to be placed had Ultra-Bond Plus Shade A-1 (Den-Mat) luting composite placed on the internal surfaces.

Figure 5. LUMINEERS seated on No. 8 porcelain-metal crown.

Figure 6. During color matching, the prepared margin of the No. 8 crown is masked with the addition of TetraPaque dentin shade as the LUMINEERS is inserted.

(8) The first LUMINEERS was seated on the No. 8 porcelain-metal crown (Figure 5). To opaque the gingival margin area of the crown, TetraPaque dentin shade (Den-Mat) was placed at the prepared gingival margin for additional masking (Figure 6). The veneer for No. 9 was then placed to verify the color match. Note the excess luting composite extruding from the margins (Figure 7). The gross excess was removed with a Skubes (Den-Mat) wetted with Tenure S. In this case, no adjustment was necessary to match the shades of No. 8 (covering the porcelain-metal crown) and No. 9.

(9) The remaining LUMINEERS were bonded to place using a multiple placement, no-matrix technique that has been described by Putter and associates. This technique has greatly simplified the placement of porcelain veneers. In other techniques, veneers are bonded to place either 1 or 2 at a time. When this is done, the composite resin cement must be finished at the proximal margins before the seating of adjacent veneers. This can be problematic. In some cases, finishing the interproximal margins of porcelain veneers can cause gingival hemorrhage that can interfere with subsequent continued bonding of the adjacent veneers. In this case, the veneers were placed simultaneously on the teeth. As each veneer was placed, the back end of a brush handle was used to seat the veneers fully. Because of the viscosity of the resin cement, this seating of the veneers was repeated several times to be certain the veneers were not lifting up on the teeth. When it was verified that all the veneers were fully seated without any matrix strips, each veneer was tack-cured for 1 second using a Sapphire Plasma Arc curing light (Den-Mat) with a 2-mm tacking tip in the middle of the facial surface of each veneer (Figure 8). Using only 1 second of curing time allows for additional easy clean-up of excess resin ce-ment using a sponge wetted with the resin adhesive, Tenure S. This technique ensures that the resin cement will be at the margins of the veneers.

Figure 7. Color verification of No. 8 and No. 9 LUMINEERS.

Figure 8. The LUMINEERS were in place and tack-cured with a 2-mm tip for 1 second.

(10) Curing of the LUMINEERS was completed using the 9-mm curing tip on the Sapphire Curing Light. The curing time is 5 seconds each on the palatal and facial surfaces.

(11) Final marginal finishing and occlusal adjustments were made using high-speed finishing diamonds and carbide finishing burs and instruments that are in the LUMINEERS Finishing Kit (Figure 9).
The completed LUMINEERS case shows total aesthetic correction of the No. 8 crown as well as complete diastema closure and shade correction to Vita A-1 (Figures 2 and 10).

HUGGER BRIDGE

Figure 9. Final marginal finishing and occlusal adjustments.

Figure 10. Postoperative smile after LUMINEERS were placed.

Figure 11. Preoperative view of missing tooth No. 13.

Figure 12. The Hugger Bridge fabricated by the Cerinate Smile Design Studios (facial view).
Figure 13. The Hugger Bridge fabricated by the Cerinate Smile Design Studios (occlusal view).

To replace the missing No. 13 without discomfort or painful  removal of tooth structure, the fabrication and placement of a Hugger Bridge best suited this patientÌs needs (Figure 11).
The abutment Nos. 12 and 14 required only minimal tooth modification on the facial, lingual, and interproximal surfaces so that a path of insertion could be created for the final fixed partial denture. (In some cases, the patientÌs cast should be checked for undercuts using a surveyer, and overcontoured facial and lingual surfaces may need to be flattened slightly within the enamel.) As part of the original laboratory authorization, the Hug-ger Bridge was described as having facial and lingual wings extending onto the surfaces of teeth Nos. 12 and 14. The Hugger Bridge was fabricated using the same impression and models used for the LUMINEERS.
The Cerinate Smile De-sign Studios fabricated the bridge from TrueVitality tri-cure microhybrid composite resin. The abutment teeth were almost completely covered facially and lingually, but with no occlusal coverage (Figures 12 and 13). For this case, because of the lack of height of contour on the interproximal surfaces, there was no need for additional tooth modification.

TECHNIQUE FOR PLACEMENT

The internal surfaces of the bridge retainers were treated on the day of insertion with the following steps:

(1) Microetch the internal surfaces of the Hugger Bridge wings. Wash and dry.

(2) Apply an organic solvent such as Dry Bond (Den-Mat) and air-dry.

(3) Apply Cerinate Prime to the internal surfaces as a bond enhancer between the TrueVitality and Tenure S adhesive.

(4) Apply Tenure S to the internal surfaces of the bridge. After 30 seconds, air-thin but do not light-cure at this time. Place the Hugger Bridge in a light-safe box.

As previously described, the teeth and surfaces to be bonded were cleaned with a water-pumice paste using a disposable prophylaxis angle, and the Hugger Bridge was tried in. The surfaces of the abutment teeth were treated as follows:

(1) Etch for 15 to 30 seconds with a phosphoric acid etch, such as Etch "N" Seal (Den-Mat); rinse for 10 seconds with an air-water spray and dry. The teeth will have a frosty appearance.

(2) Apply 4 to 5 coats of Tenure A/B and air dry. The teeth will have a glossy appearance.

(3) Apply Tenure S bond enhancer and air-thin but do not light-cure at this time.

(4) Mix together equal amounts of the TrueVitality A and B cementation paste and apply to all internal surfaces of the Hugger Bridge and onto the surfaces of the teeth to create a sandwich effect so that porosities are not incorporated into the cement.

(5) After the bridge is completely seated, remove excess cement using Tenure S either on a Skubes or using a disposable brush. TrueVital-ity low viscosity cement is a dual-cured cement. A snap-cure of the cement is accomplished with a 5-second exposure using the 9-mm Sapphire Light tip. In areas shadowed from the curing light, the dual-cured cement will set on its own in 5 to 6 minutes.

Figure 14. Bonded Hugger Bridge (occlusal view).

Figure 15. Postoperative view with Hugger Bridge in place.

(6) Once the cement is completely set, use finishing diamonds and fluted carbide burs to remove any excess cement and to make final occlusal adjustment. Note that the completed Hugger Bridge restored the missing No. 13 both anatomically and aesthetically (Figures 14 and 15).
The patientÌs preoperative smile demonstrated an unaesthetic crown and anterior spacing (Figure 1). The completed LUMINEERS case shows total aesthetic correction of the No. 8 crown as well as complete diastema closure and shade correction to a Vita shade A-1 (Figure 2). The patient was pleased with the result.

CONCLUSION

By revitalizing the unaesthetic porcelain-metal crown on tooth No. 8 and placing conservative LUMINEERS and a Hugger Bridge, the patient received the smile he always wanted. With no injections and very minimal tooth modification, this former dental-phobic patient was amazed at how pain-free and easy the entire procedure was. He said that his faith in the dental profession had been renewed. The final result was a pleased patient whose smile had been restored in a minimally invasive manner.


References

1. Nash WR. A 6-year follow-up on cerinate porcelain veneers. Compend Contin Educ Dent. 1998;19:664-669.

2. Strassler HE. Long term clinical evaluation of Cerinate porcelain veneers [abstract]. J Dent Res. 2005;84(spec issue A). Abstract 432.

3. Strassler HE. Clinical evaluation of single-visit anterior bonded fiber reinforced composite bridges. Presented at: Annual Meeting of the Academy of Operative Dentistry; February 23-25, 2005; Chicago, Ill.

4. Strassler HE, Serio CL. Single-visit natural tooth pontic fixed partial denture with fiber reinforcement ribbon. Compend Contin Educ Dent. 2004;25:224-230.

5. Chadwick TC, Ibsen RL. Properties of a new porcelain for veneers, inlays and crowns. J Dent Res. 1989;68(spec issue):956. Abstract 712.

6. Strassler HE. Product advances with direct placement composite resins: current state-of-the-art. Contemp Esthet Restor Pract. 2006;10(2):16-19.

7. Gedik R, Hurmuzlu F, Coskun A, et al. Surface roughness of new microhybrid resin-based composites. J Am Dent Assoc. 2005;136:1106-1112.

8. Strassler HE. Aging patients/aging restorations: predictable crown and fixed partial denture repair. Contemp Esthet Restor Pract. 2002;6(11):20-32.

9. Putter H, Ibsen RL. Simultaneous placement of multiple porcelain veneers. J Esthet Dent. 1990;2:67-69.

10. Strassler HE, Putter H, Serio CL. Managing the interproximal contact areas with safe, effective instruments. Contemp Esthet Restor Pract. 2004;8(8):58-60.


Dr. Ibsen is a graduate of the University of Southern California School of Dentistry. Co-author of the first textbook on adhesive restorative dentistry in 1974, Dr. Ibsen has led projects resulting in numerous US and international patents. He is a practicing dentist, is the inventor of LUMINEERS Porcelain Veneers by Cerinate, and is responsible for the development of the REMBRANDT Oral Care product line. He can be reached at (805) 922-8491, extension 2806, or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Disclosure: Dr. Ibsen is the founder and president of Den-Mat Corporation.

Dr. Weinberg is a clinical assistant professor in the Department of Restorative Dentistry at the Univer-sity of Pennsylvania School of Dental Medicine. He has been on the faculties of 4 other dental schools for their post-graduate aesthetic programs. Dr. Weinberg opened his private practice in New Jersey in 1978 with an emphasis on aesthetic and restorative dentistry. He has been lecturing nationally and internationally on aesthetic and restorative dentistry for more than 22 years. He can be reached at (856) 696-4618 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .