Aesthetic Treatment With a Pressed Ceramic Veneer Material: Case Reports

Why is a smile important? The power of a smile promotes confidence and self-esteem, enhances professional and business life, and improves one’s social life. Your smile states who you are. Regarding the value of a smile, “It happens in a flash and the memory of it sometimes lasts forever” (–Anonymous). In addition, 50% of the United States adult population is not satisfied with its smile, and 9 out of 10 people think a smile is an important asset1 (Figure 1).
  

Figure 1. Fifty percent of US adults want a more attractive smile but are afraid to go because of pain.


Porcelain veneers are an important part of aesthetic dentistry’s armamentarium. Several excellent porcelain/ceramic veneering materials and systems are currently available in dentistry.
This article will present 3 case reports demonstrating the use of a new pressed ceramic veneer material to achieve the desired aesthetic results.

MATERIAL SELECTION

Figure 2. Traditional veneers require tooth reduction to accommodate required material thickness. Cerinate Lumineers can be fabricated as thin as 0.2 mm, requiring little to no tooth reduction. Figure 3. Left Image: Traditional preparations requiring a minimum of 0.8 to 2 mm removal of tooth structure. Right Image: Little to no reduction in tooth structure is required since the Cerinate porcelain is strong enough to be fabricated as thin as 0.2 mm.

Cerinate Lumineers (Den-Mat) are a new development in pressed ceramic restorations. (Note: Cerinate veneer porcelain has been in clinical use and studied for many years.2) Because of its microcrystalline structure—even and uniform distribution of ceramic crystals with reinforcing irregular leucite crystals—this porcelain can be fabricated to a tolerance as thin as 0.2 mm (approximately the thickness of a contact lens) without the need for the removal of sensitive tooth structure3 (Figures 2 and 3). When little or no tooth preparation is required, there is no need for local anesthesia and obviously no pain or tooth sensitivity. In addition, provisionals are no longer required. Cerinate Lumineers can be used in all aesthetic situations including diastema closure, peg laterals, revitalizing PFMs, correcting severely prominent teeth, lightening discolored or dark teeth, and correcting poor arch contour, misaligned and rotated teeth, as well as other indications.4

CASE REPORTS

Case 1

 
Figure 4. This patient presented with the desire to have her teeth cosmetically corrected.


The patient presented with the desire to have her teeth cosmetically corrected. As a popular hair designer, she was in close and constant contact with the public and felt that a beautiful smile would enhance her abilities in her work environment. Following a complete examination, including radiographs, study models, and intraoral and extraoral exams, it was noted that due to the patient’s tongue thrust habit, the maxillary anterior teeth were never in occlusal function and therefore never worn (Figure 4). This left them with sharp incisal edges and supereruption of the maxillary canines.

 

Figure 5. The sharp incisal edges and minor bulk in the facial enamel of the maxillary teeth from canine to canine were modified without the need for local anesthesia.

At a following appointment, the sharp incisal edges and minor bulk in the facial enamel of the maxillary teeth from canine to canine were modified using a combination of fine finishing diamonds (ET Diamond Combo Kit, Brasseler USA) and abrasive-coated vinyl discs (EP Polishing System, Brasseler USA, Figure 5). This gave the upper arch an immediate aesthetic improvement. A final impression was made using a 2-step polyvinyl impression technique (1st Impression, Den-Mat). It should be noted that during this entire procedure, local anesthesia was not needed, sensitive tooth structure was not removed, and provisional restorations were not required, saving the patient from pain and additional time spent in the chair.

Upon the return visit, the definitive Cerinate Lumineer stacked ceramic restorations were received from the Den-Mat Cerinate Studio in shade B1. Since the Cerinate Lumineers were pre-etched by the Cerinate Design Studio, they were simply treated with Porcelain Conditioner (Den-Mat), which was applied to the intaglio surfaces of the veneers for 30 seconds, rinsed, and dried. This increases the surface tension of the surface porcelain and activates the Cerinate Prime (Den-Mat), a silane-coupling agent that is immediately applied to these surfaces for 30 seconds and gently air dried. The Lumineers were tried in using Ultra-Bond Try In Paste Clear Shade (Den-Mat), a noncure try-in resin. Excess paste was removed, the margins were examined, and the overall aesthetic scheme was evaluated. The patient was then given a mirror in order to evaluate her new smile. Once it was agreed that the smile was beautiful, the Lumineers were removed and the try-in paste was removed with a resin-saturated applicator (Dabeze, Den-Mat). Because Ultra-Bond Try In Paste has all of the chemical components of a bonding cement minus the photo or chemical bond initiators, the remaining thin layer is incorporated into the final, dual-cure composite cement and therefore need not be entirely removed. The Lumineers were set aside and the teeth prepared for cementation.

The try-in paste was removed from the tooth surfaces using a cotton pellet saturated in an alcohol-based mouthrinse. The surfaces were then rinsed and dried, and all enamel surfaces to be bonded were etched for 30 seconds with EtchN’Seal (Den-Mat), a 25% phosphoric acid gel containing oxalate crystals designed to prevent acid-etch-induced sensitivity. Tenure A and B (Den-Mat), a 2-bottle, chemical-curing, mul-tipurpose adhesive system, was applied in 5 coats to all surfaces. This was followed by the application of Tenure S (Den-Mat), a single-component, light-cured, hydro-philic agent that further enhances bonding. For the past 2 decades, the Tenure system has demonstrated a proven clinical record of high bond strengths, excellent retention, and significant re-duction of microleakage and postoperative sensitivity.5-7 These characteristics can be attributed to the formation of a hybrid zone8 that can eliminate root sensitivity instantly. The 2-step process of Tenure A, B, and S exhibits bond strengths of more than 20 MPa to dentin.

The veneers and crowns were then cemented to place by dispensing clear shade Ultra-Bond Plus (Den-Mat) from an automix, dual-barrel syringe. Ultra-Bond Plus is a multipurpose, dual-cure resin cement designed specifically for bonding porcelain restorations. A study reviewed an initial veneer placement of Cerinate Veneers with Ultra-Bond in 1985 and then evaluated the veneers after 17 years when they were replaced due to aesthetic wear.2 The 17-year-old case showed no evidence of microleakage, gingival recession, cracks, or fractures.

Ultra-Bond closely matches a tooth’s natural physical properties and Cerinate Lumineers’ physical properties.

The restorations were all seated to place, and excess cement was removed using an applicator brush saturated in an unfilled resin (Visar Seal, Den-Mat). Each resto-ration was then firmly seated by directing gentle pressure from the incisal and facial aspects simultaneously until a thin bead of resin cement was expressed from the marginal areas. The restorations were held in this fashion and individually light cured for 3 seconds at the mid-facial aspect with a 4-mm light tip using the Sapphire Curing Light (Den-Mat), a versatile PAC (plasma arc) light known for deep penetration.

This allowed the veneers to now become bonded to the teeth while allowing the additional uncured Ultra-Bond Plus resin cement to be removed from the margins. An 8-mm light tip was then used with the Sapphire Curing Light to complete the veneer cementation by fully curing each veneer for a full 5 seconds on the facial and lingual. In a study by Wa-tanabe,9 the bond strength achieved by plasma-arc curing was found to be relatively unaffected by the shade or opacity of porcelain. It was found that plasma-arc curing for 6 seconds was sufficient to obtain bond strengths similar to those of specimens polymerized with halogen light for 40 seconds.

 

Figure 6. The veneers following cementation.

Once cured, gross excess Ultra-Bond Plus resin ce-ment was first removed from the margins using carbide finishing burs (ET Carbide Combo Kit, Brasseler USA). This was followed by removal at the facial aspects using the Schure 349 (Den-Mat), a nonscratching, resin-remo-val hand instrument. The flake-like remaining translucent resin cement was re-moved from the facial surfaces using a ComposiPro silicone-carbide-impregnated brush (Brasseler USA). The interproximal contacts were then opened using the Ceri-saw, a manual interproximal separating instrument (Den-Mat). The Cerisaw, a stainless steel, 0.05-mm serrated blade, was placed at a 45º angle to the incisal plane of the interproximal junctions, and gently rocked in a see-saw fashion toward the gingival until the cement bond was separated. No occlusal adjustment was required due to the existing anterior open bite. The margins were given a final polish using the CeramiPro Universal Ceramic Polishers (Brasseler USA) followed by a final luster with a goat-hair brush in combination with Tru luster diamond polishing paste (Brasseler USA, Figure 6).

 

Figure 7. Left Image: Prior to treatment, the upper anterior teeth displayed a noticeable labial flair. Right Image: The teeth displayed a more normal appearance. Figure 8. Left Image: before; Right Image: after.

The teeth were then evaluated in profile, and it was noted that prior to treatment, the upper anterior teeth displayed a noticeable labial flair, whereas now they appeared to be more retrusive (Figure 7). This gave the patient a dramatic improvement to her smile and her overall self-esteem (Figure 8).

Case 2

Figure 9. Because of the presence of diastemas, missing maxillary lateral incisors, and disproportionately small maxillary central incisors, this case was deemed especially difficult. Figure 10. The teeth were modified without the need for local anesthesia, removing the sharp incisal edges and “debulking” the enamel where appropriate.

In this case, the patient desired to have a complete aesthetic makeover. Because of his diastemas, missing maxillary lateral incisors, and disproportionately small maxillary central incisors (Figure 9), this case was deemed especially difficult. Following a complete exam as in case No. 1, the teeth were modified without the need for local anesthesia, removing the sharp incisal edges and “debulking” the enamel where appropriate (Figure 10). The mandibular teeth were not modified. Impressions were made using 1st Impression PVS, and provisional restorations were not required.

 

Figure 11. The veneers following cementation. Figure 12. The patient requested his diastema opened, and fine adjustments in the artistry of the smile design and occlusion were made at this time.

Upon return from the Cerinate Studio, the Lumineers were treated, tried in to verify fit and to meet the patient’s approval, and the teeth prepared for cementation of the restorations. Following cleanup of the Ultra-Bond Plus cement and occlusal adjustment (Figure 11), the patient was reappointed one week later. At the follow-up appointment, the patient requested his dia-stema opened, and fine ad-justments in the artistry of the smile design and occlusion were made at this time (Figure 12). Final polishing was accomplished using the Brasseler Dialite Intraoral Polishing Kit, followed by a goat-hair brush and Diamond Paste (Brasseler USA).

Case 3

Figure 13. In this case, the patient was previously evaluated for occlusal discrepancies and had been given treatment plans for combined orthognathic surgery and orthodontic care.

In this case, the patient was previously evaluated for oc-clusal discrepancies and had been given treatment plans for combined orthognathic surgery and orthodontic care (Figure 13). The patient did not desire this solution due to its length of time, the pain involved, the potential for permanent loss of feeling in the lower lip, chin, and tongue, as well as numerous other objections. After evaluating the case using the objective criteria in the examination used in case No. 1, it was decided that a compromise could be reached where the occlusion could be stabilized and even normalized and the aesthetics corrected simultaneously using Cerinate Lumineers.

Figure 14. The teeth were modified without the need for local anesthesia, removing the sharp incisal edges of the maxillary central incisors.
Figure 15. The veneers following cementation.
Figure 16. Prior to treatment, the upper anterior teeth displayed a noticeable lack of occlusal contact.
 
Figure 17. Following treatment with Cerinate Lumineers, the upper and lower arches functioned in harmonious occlusion.
Figure 18. Left Image: before; Right Image: after.


The teeth were modified without the need for local anesthesia, removing the sharp incisal edges of the maxillary central incisors (Figure 14). The mandibular teeth were not modified. Impressions were made using 1st Impression PVS, and provisional restorations were not required. Upon return from the Cerinate Studio, the Lumineers were treated, tried in to verify fit and to meet the patient’s approval, and the teeth prepared for cementation of the restorations. Following cleanup of the Ultra-Bond Plus cement and occlusal adjustment (Figure 15), the teeth were evaluated in profile. It was noted that prior to treatment, the upper anterior teeth displayed a noticeable lack of occlusal contact (Figure 16), whereas now they appeared to be in complete and harmonious occlusion (Figure 17). This gave the patient a dramatic improvement to his smile and his overall self-esteem (Figure 18).

CONCLUSION

Three cases were presented using a pressed ceramic veneer material to achieve the desired aesthetic results. The properties of the material allowed minimal tooth preparation with no need for local anesthesia and no provisionalization.


References

1. Hewitt G. Attractive smiles important to self-esteem and key to succeeding socially and at work. Available at: teeth-whitening-smiles.com/19683-smile.html. Accessed August 30, 2004.
2. Sapp Jr, Baxter, Sapp, HT Macon, The evolution of the esthetic veneer: a 20-year case study. Contemp Esthet Restorative Pract. 2002;6:44-53.
3. Ouellet D. Using Rembrandt veneers in my daily practice. DentalTown. May 2003.
4. Ibsen R. Conservative treatment provides outstanding long-term results. DentalTown. March 2003.
5. Barkmeier WW, Huang CT, Hammesfahr PD, et al. Bond strength, microleakage, and scanning electron microscopy examination of the Prisma Universal Bond 2 adhesive system. J Esthet Dent. 1990;2:134-139.
6. Tyas MJ. Three-year clinical evaluation of Tenure dentine bonding agent. Aust Dent J. 1994;39:188-189.
7. Godder B, Settembrini L, Zhukovsky L. Direct-shrinkage composite placement. Gen Dent. 1995;43:444-446.
8. Abel MG. Contemporary restoration of class II caries. Direct posterior composites. Dent Today. November 2002;21:94-97.
9. Watanabe K, Ohnishi E, Kaneshima T, et al. Porcelain veneer bonding to enamel with plasma-arc light resin curing. Dent Mater J. 2002;21:61-68.



Dr. Shuman maintains a full-time private practice outside Baltimore, Md, emphasizing reconstructive and aesthetic dentistry. He is a fellow in the Academy of General Dentistry, a fellow of the Pierre Fauchard Academy, and a member of the American Dental Association. Since 1989, Dr. Shuman has published more than 50 dental research and clinical articles that have appeared in numerous dental journals. He presents seminars and hands-on courses and has produced several educational videos including “The Joy of Clinical Dentistry” and “Do Your Dentures Suck?” as well the book Creating the Denture Practice of Your Dreams. These educational materials are CERP-approved for a minimum of 4 CE credits each. Dr. Shuman can be reached at (877) 4-SHUMAN or by visiting ianshuman.com.

Disclosure: Dr. Shuman has received research support from the Den-Mat Corporation in preparation for this article.

Banner