Clinicians staying abreast of dental literature have been bombarded with countless articles reporting that today’s patients are becoming increasingly savvy about aesthetic treatment options. As more information is available to patients, this consumer group is also likely to become more demanding and discriminating regarding the results that are achieved through dental treatment. Therefore, if these patients are not fully satisfied with the treatment products placed in their mouths and the subsequent aesthetic outcomes, then they may request, if not demand, that they be corrected until they are completely satisfied.
While the literature and education programs are replete with articles and seminars identifying those factors that contribute to patient satisfaction, including personalized service, comfortable waiting rooms, painless dentistry, etc, predicting exactly how to achieve the otherwise elusive “patient satisfaction” is a collective effort encompassing visual acuity, specific diagnostic and clinical protocol,1 and precise technical skill in the laboratory. It also involves managing patient expectations, which can often exceed reality, because most people do not understand the complex clinical, technical, and mechanical aspects of aesthetic restorative dentistry.2
It will no longer be enough for us (collectively, clinicians and their laboratory technicians) to get “close” to the aesthetic and functional goal we and the patient wish to achieve. We must achieve those goals. This article describes a case in a which a patient presented requesting a complete redo of veneer restorations, which had been placed and already remade once since the original seating appointment 6 months earlier, in order to correct discrepancies with form, fit, function, and aesthetics. According to one source, veneer restorations are remade more frequently than other types of all-ceramic restorations (ie, inlays/on-lays, crowns).3
A 35-year-old male patient presented with a chief complaint regarding the aesthetics, fit, and feel of the 8 maxillary anterior veneer restorations that had been placed and redone in the previous 6 months (Figure 1). He wanted the veneers replaced with more aesthetic, correctly fitting restorations, and he also requested restoration of his anterior mandibular dentition (Figure 2). Specifically, he felt that the current veneers were too opaque and lifeless with no incisal translucency.
|Figure 1. Preoperative view of the patient, presenting with 8 maxillary anterior veneer restorations that had been placed and redone within the previous 6 months.||Figure 2. Preoperative view of the patient’s mandibular anterior dentition, which had been bleached previously, but which he felt would not reach his desired shade without restorative work.|
His past dental history involved orthodontics in his late teens, but he also had severe tetracycline staining. Previously, the patient had undergone vital tooth bleaching. However, he felt that he could not achieve the shade he wanted for his lower teeth through bleaching alone, nor did the shade match his maxillary dentition.
A thorough examination was performed that included radiographs, study models, intraoral photographs, and an evaluation of the patient’s occlusal condition.4 In particular, the patient’s centric relation was checked and found to coincide with his maximum intercuspation. Evaluating this condition prior to initiating restorative work was significant to achieving long-term successful clinical outcomes. If his centric relation had not been checked, upon placement of his restorations there could have been interferences that might have changed his occlusal relationship, precipitated parafunction, and led to a detrimental effect on the proposed restorations.4
Treatment Planning and Materials
Proposed treatment was to place veneer restorations on 10 maxillary teeth and 10 mandibular teeth, from second bicuspid to second bicuspid in each arch. The material selected for this case was a leucite-reinforced glass ceramic (IPS Empress Esthetic, Ivoclar Vivadent) from a shade 02 ingot that would mask the deep tetracycline stain (Figure 3) while still maintaining a vital appearance. Additionally, the morphology and placement of the restorations were planned in such a way as to ensure complete and proper cuspid rise, anterior guidance, and occlusal function.4 In particular, a balanced protrusive movement would be achieved.
IPS Empress Esthetic is a pressed ceramic that demonstrates enhanced optical properties and improved physical characteristics, including a 16% increase in flexural strength for greater clinical longevity compared to IPS Empress. Specifically, new production methods have enhanced the ingots by improving their quality and color clarity and increasing the leucite crystal distribution, and hence, their density. Ingot colors are also now standardized for greater aesthetics.
Indicated for full-coverage, partial, veneer, inlay, and onlay restorations, the new material is available in 11 shaded ingots (9 original and 2 bleached shades). To accommodate specific prescriptions and color maps, an assortment of powders, wash pastes, and other aesthetic veneer materials are also available. Because the material is based on a highly developed glass ceramic with clinically relevant physical properties, it is suitable for adhesively placed restorations.5,6
Mock-Ups and Impression-Taking
The existing restorations were modified using an intraoral mock-up technique to determine the appropriate length, width, and tooth morphology for the patient based on the basic aesthetic principles of Golden Proportion as well as to achieve the functional goals of creating cuspid rise, anterior guidance, and balanced protrusive movements. An impression was taken of this mock-up and used as a transfer for the creation of the provisional restorations.
Preparation Protocol and Provisionalization
Local anesthetic was administered, and the patient’s teeth were more aggressively prepared to allow for adequate thickness of the ceramic to mask the incredibly dark tetracycline stain.7 Lack of consideration for the amount of preparation necessary may have contributed to the opaque appearance of the original restorations with which the patient presented, since an extremely opaque ceramic—without any vitality—was necessary to mask the staining.
However, the strength of the restorations, as well as the anticipated porcelain buildup, was also considered during the preparation protocol. Differently from an “ideal” preparation guideline—where the facial reduction is 0.06 mm—this patient’s teeth were prepared on the facial aspect with 1 mm of reduction to allow for a solid millimeter of ceramic material. This would adequately block out the stained dentin and allow natural light transmission through the ceramic material.
Slice preparations were also performed on this patient’s dentition. The interproximal enamel was reduced to allow the laboratory technician to use an adequate thickness of the porcelain in these areas to produce a more natural appearance.
It is important to note that throughout the preparation protocol, the gingival tissue was treated atraumatically. During impression taking, no cord was placed because the preparation margins were just equi-gingival, or at most 0.25 mm subgingival. Atraumatic treatment of the gingival tissues contributed to accurate impressions.
Stumpf shades (Figure 3), face bow transfer, and stick bite registration were obtained. The latter records, in particular, were necessary to ensure that the morphological relationship between the centrals, laterals, and canines would be appropriate to the patient’s face. A final impression of the preparations was taken, and the previously obtained transfer impression was then used to fabricate the provisional restorations (shade B1, Luxatemp, Zenith, Figure 4).
|Figure 3. Stumpf shades were taken to help determine the appropriate ingot shade to mask the underlying tetracycline stain.||Figure 4. The patient was fitted with provisional restorations (Luxatemp) in shade B1.|
When the definitive restorations were returned from the laboratory, the provisional restorations were removed, and the preparations were cleansed thoroughly. The maxillary restorations were then tried in first using an opaque try-in cement on the right side (Variolink XL, Ivoclar Vivadent) and a transparent try-in paste on the left side (Variolink Transparent, Ivoclar Vivadent) for comparison (Figure 5).
|Figure 5. The maxillary restorations were tried in using Variolink XL try-in cement on the right side and a transparent try-in paste on the left side for comparison.|
The restorations were removed, and the maxillary preparations were etched for 15 seconds using 35% phosphoric acid gel, rinsed, and dried thoroughly. A desensitizing agent (Gluma Desensitizer, Heraeus Kulzer) was applied to the preparations for 15 seconds, after which a single component enamel/dentin bonding agent (Excite Advanced Adhesive, Ivoclar Vivadent) was applied for 15 seconds. Excess solvent was evaporated with a warm air-drier. The adhesive bonding agent was light-cured for 10 seconds per tooth. The preparations were then ready to receive the restorations (Figure 6).
|Figure 6. View of the maxillary preparations prior to placement of the definitive veneer restorations.||Figure 7. The restorations were spot tacked into place by curing each tooth for 5 seconds using a 2-mm light guide.|
The internal aspects of the maxillary veneer restorations were then cleaned using 35% phosphoric acid and silanated. The adhesive bonding agent was also placed into the restorations, lightly air-thinned, but not cured. The adhesive cement (Variolink Transparent) was placed in the restorations, and the restorations were seated into position and spot-tacked using a 2-mm light guide (Ivoclar Vivadent) for 5 seconds per tooth (Figure 7).
Once tacked into place, excess cement was removed from along the gingival margins and interproximally (Figures 8 and 9), and a glycerin agent (De-Ox, Ultradent) was placed to prevent the formation of the oxygen inhibiting layer (Figure 10). Subsequently, the restorations were each light-cured for 40 seconds per surface. To complete the restorations, the use of a proxy disc ensured flossable contacts (Figure 11), and polishing along the gingival margins (Figure 12) was performed. The mandibular restorations were tried in and seated in a similar manner.
|Figure 8. Excess cement is removed from along the gingival margins.||Figure 9. Prior to final curing, excess cement is removed interproximally.|
|Figure 10. De-Ox was placed to prevent the formation of the oxygen inhibiting layer.|
|Figure 11. The maxillary restorations were finished interproximally.||Figure 12. The maxillary restorations were polished along the gingival margins.|
Two weeks postoperatively, the patient returned for a full evaluation of the case (Figures 13 and 14). At that time, it was confirmed that proper occlusal function, anterior guidance, and cuspid rise were re-established and achieved (Figures 15 through 17). Overall, the patient was fully satisfied with the aesthetic and functional outcomes of this case (Figure 18).
|Figure 13. View of the maxillary restorations 2 weeks postoperatively.||Figure 14. View of the mandibular veneers 2 weeks postoperatively.|
|Figure 15. Retracted view of the patient’s restorations demonstrating that occlusal force is evenly distributed, and a balanced protrusive has been achieved.||Figure 16. View of the patient in right working movement.|
|Figure 17. View of the patient in left working movement.||Figure 18. View of the patient’s definitive restorations in natural smile.|
In some cases of severe tetracycline staining, clinicians may be faced with the need to place full-coverage crown restorations on the affected dentition in order to provide the optical properties interproximally that are required for a natural and lifelike appearance. Certainly in this case, the preparations were very dark. However, because the 02 shaded IPS Empress Esthetic ingot was selected, it was not necessary to wrap the restoration along the lingual. Rather, the clinician and technician were able to maintain the restorations as veneers, as opposed to full-coverage crowns, as a result of the material’s optical properties.
This case clearly demonstrates that when placing veneer restorations for a patient with severe tetracycline staining, it behooves the clinician to consider material benefits—including shade range, physical properties, and optical characteristics—when prescribing the selected restorations. When the appropriate material is identified, the definitively placed restorations can demonstrate very good aesthetics.
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2. Levin RP. Exceeding patient expectations. Compend Contin Educ Dent. 2003;24:492-494.
3. Hekland H, Riise T, Berg E. Remakes of Colorlogic and IPS Empress ceramic restorations in general practice. Int J Prosthodont. 2003;16:621-625.
4. Wynne WP. Considerations for establishing and maintaining proper occlusion in the aesthetic zone. Dent Today. April 2004;23:112-119.
5. Probster L, Geis-Gerstorfer J, Kirchner E, et al. In vitro evaluation of a glass-ceramic restorative material. J Oral Rehabil. 1997;24:636-645.
6. Fradeani M. Six-year follow-up with Empress veneers. Int J Periodontics Restorative Dent. 1998;18:216-225.
7. Cavanaugh RR, Croll TP. Bonded porcelain veneer masking of dark tetracycline dentinal stains. Pract Periodontics Aesthet Dent. 1994;6:71-79.
The author wishes to thank ceramists Juan and Nelson Rego, CDTs, from Smile Designs by Rego, Downey, Calif, for fabricating the definitive IPS Empress Esthetic veneer restorations seated in this case.
Disclosure: The author receives material support from Ivoclar Vivadent.