Porcelain Veneers: Providing Beautiful Aesthetics

Introduction
Because of their beauty and strength, today’s porcelains offer unparalleled options for different cosmetic and restorative challenges. Researchers and manufacturers have been very effective in developing and providing modern materials that yield excellent bond strengths to tooth structure. In fact, we are doing things with restorations today that we would have only dreamt about just 2 decades ago. Because of our success with bonding techniques, we have the ability to cosmetically enhance smiles using either direct/indirect composite resins or porcelain veneers.


The aim of this article is to highlight a conservative porcelain veneer case that demonstrates a technologically difficult blending of porcelain to artistically highlight the natural beauty of the existing teeth and the smile. Most would agree that this is a very difficult task to accomplish for the dentist and his/her dental laboratory team.

 

PREOPERATIVE CONSIDERATIONS: MATERIAL SELECTION
Prior to case preparation, it is important to plot the smile design of the case so one can achieve a predictable and long-lasting result. It’s also equally important to think about the type of porcelain that you will use in order to achieve the optimal aesthetics desired.

Before Image. Preoperative portrait view.

After Image. Facial view of postoperative smile.

For this patient, we wanted to use high quality porcelain that would exhibit optimal aesthetic characteristics. Any porcelain to be considered for use in a highly aesthetic situation must possess certain characteristics: a chameleon aesthetic effect when placed into the mouth, and the ability to exhibit adequate luminescence and fluorescence causing the porcelain to react to light the same way a natural tooth does, thereby creating a harmonious blending of natural to veneered teeth.


Once the specific porcelain material is chosen, the dental laboratory team needs to be selected. The dental technicians/ceramists must have the proven ability to work with the material of choice (Venus Porcelain [Heraeus Kulzer] was the ceramic system used in this case). They must possess the knowledge and experience to execute the smile design effectively, thus predictably translating your instructions into beautiful restorations. 

 

CASE REPORT
Diagnosis and Treatment Plan

Allison, a 32-year-old female, presented with a history of existing restorations on her maxillary lateral and central incisors (Before Image and Figures 1 and 2). They were placed when she was a teenager due to the presence of “peg” laterals and a slight diastema that had existed between her central incisors. Allison disliked the way her restorations had discolored over the years and thought that her front teeth were disproportionately short. This made her self-conscious about smiling. She wanted a long-lasting solution that would address her “fang-like” canines, disproportionate teeth, and “dingy” appearing smile.

Figure 1. Preoperative closeup.

Figure 2. Preoperative maxillary arch.

According to Allison, “It is time to start feeling good about my smile again!”


Other than the previously placed anterior restorations, Allison had very little old dentistry in her mouth and she demonstrated an unremarkable health history. Given her age and health history, the goals were simple: conservative preparations, a functional bite, and a “killer,” natural-looking smile.

 

Treatment Planning: Smile Design
When preparing the smile design, consideration must be given to the desires of the patient. However, a high degree of scrutiny needs to be placed on bite functionality as well. Allison presented with an atraumatic Class II Div II occlusal relationship and an overall healthy oral environment.

Figure 3. Retracted view, teeth apart used to evaluate proportions.

Figure 4. Preoperative central length.

Figure 5. Preoperative central width.

Further evaluation of her smile design (Figures 3 to 5), using the SMILES acronym developed at LVI (Las Vegas Institute for Advanced Dental Studies, Las Vegas, Nev), is as follows:


Size and Golden Proportion: Because we were considering only 4 teeth in this smile transformation, it is important to evaluate the proportionality of the teeth to be restored. They must look like they proportionally blend into the limited space with which we have to work. Considering size and proportion at this stage also helps develop an insight into the preparation design which will be utilized in the next step. In addition, it helps in our communication with the dental technician team regarding the diagnostic wax-up. 

The central incisors were 8.3 mm wide and 9.5 mm long. Her current height/width proportion represented a 94% ratio. An acceptable height to width ratio is 75% to 80%. This means the current proportion of her front teeth appeared too wide and too short.

Because of the existing restorations on the anterior incisors, it was impossible to tell the size of the original teeth. Therefore, we had to consider the amount of space that was available to work with from the mesial of the left canine to the mesial of the right canine. The Golden Proportion of the central incisors could then be determined. The proportion of teeth Nos. 8 and 9 is 0.618 times the width of teeth Nos. 7 to 10. The width of teeth Nos. 7 to 10, in this case, was 31.0 mm. We multiplied 31.0 mm by 0.618 and then divided the result by 2. This approximated the width of teeth Nos. 8 and 9. In this case, the approximate width of Nos. 8 and 9 would be 9.5 mm. The length, therefore, was proportionally determined to be between 75% to 80% of the width; so a starting point for the length of the centrals would be 10.5 mm. 

Midline and Canting: The midline and canting were within normal limits for this case.

Axial Inclination: Teeth Nos. 7 to 10 would be improved if they were axially inclined toward the mesial. Some axial inclination correction could also be accomplished by correcting the zenith of the soft tissue of these teeth. In addition, some inclination could be corrected by the dental technician. (This was communicated to the laboratory team in the instructions for the wax-up.) 

Lip Line & Incisal Edge of Teeth: The lip line was found to follow the incisal edge of the teeth and did not need to be corrected.

Extra Hard Tissue Guidelines: 

Contact Point—Contact points start from the mesial contact of the central incisors and gingivally migrate posteriorly; this requires improvement in the final restoration. 

Gradation of Teeth Proper—This was to be addressed in the dental laboratory and would be dictated by the function on the teeth.

Arch Form Proper—The arch form in this case was within normal limits.

Soft Tissue Conditions:

Gingival Symmetry—The gingival symmetry in this case needed improvement in the lateral areas and the left central incisor.

Height and Contour—The height of the lateral gingivae needed to be addressed. (This would be accomplished using a diode laser at the time of preparation.)

 

TREATMENT SEQUENCE
Pretreatment Protocol

Prior to initiation of this case, a standard protocol of information was gathered. This included a photo release and informed consent. These were reviewed with, and signed by, the patient. Pretreatment photographs were taken. Tooth shape and shade were discussed with her. High quality pretreatment vinyl polysiloxane (VPS) impressions (Flextime [Heraeus Kulzer]) and bite registration were taken. A symmetry bite [CLINICIAN’S CHOICE]) was also taken in order to evaluate the case and to construct a lab-fabricated pretreatment wax-up, temporary stent, and reduction guide that followed the smile design that we had selected.

Figure 6. Preoperative wax-up width.

One of Allison’s goals in pursuing her smile rehabilitation was to have whiter teeth. Since we were veneering only the maxillary central and lateral incisors, whitening prior to initiation of veneering needed to be considered. Customized take-home whitening trays were fabricated and a 16% take-home carbamide peroxide gel (Venus White [Heraeus Kulzer]) was used to obtain the final desired shade. It took approximately 3 weeks to reach the whiter shade that Allison loved. Allison was instructed to discontinue whitening 2 weeks prior to the preparation appointment in order to account for any rebound that often occurs after the whitening process is completed. During the last whitening check, we showed the lab-fabricated diagnostic wax-up to Allison (Figure 6). She approved of the design and was excited to go to the next stage of preparation.

Preparation, Impressions, and Temporization
Prior to initiation, topical gel (FTP Gel [Flourish Pharmacy]) was placed on the buccal tissue to optimize comfort when administering the local anesthetic. Injection of 2 carpules of lidocaine (1:100,000 epinephrine) was given using an anesthetic delivery system (The Wand [Milestone Scientific]). A final shade was then taken of the still hydrated teeth and recorded prior to initiation of the preparation (Figure 7).

Figure 7. Preprep shade match.

Figure 8. Preprep laser initiation.

Figure 9. Preprepped sculpted gums.

Figure 10. Removal of restorations.

Figure 11. Finalizing the preparations.

Figure 12. Presymmetry bite.

Figure 13. Enamel and dentin shade with stumpf shade.

Figure 14. Isolated dentin shade.

Figure 15. Provisional restorations.

Next, gingival recontouring was performed with the diode laser (BIOLASE) prior to removing the existing restorations (Figures 8 and 9) and following the guidelines set in the smile design (SMILES). By conservatively recontouring the gingivae, the gingival zeniths of all of the incisors were corrected. Also, Allison’s concern about her “gummy” appearing smile was addressed by conservatively reshaping both lateral incisor areas, giving a more elongated appearance of the lateral incisors and a more pleasing overall look.


In preparing teeth that have already been restored, care must be given in removing the existing restorations, so as to conserve tooth structure and to maintain the proper preparation design (Figure 10). After the existing restorations were removed, it was necessary to prepare a 360º preparation around the 2 laterals. Both centrals were prepared both mesially and distally with interproximal slice preps so the laboratory technicians could proportionalize the restorations to the space available (Figure 11). The lingual portion of the natural tooth of the central incisors was left unaltered. 

After final review of the preparations, a symmetry bite (Figure 12), a VPS check bite, and VPS full-arch maxillary final impression were taken, making sure to capture both hamular notch areas. For the maxillary impression, a Sure-Lock Full Arch Tray (Pearson Dental Supply) was used. A mandibular impression was not taken because no alteration took place in the lower arch. A lower VPS impression (Flextime [Heraeus Kulzer]) was taken only as part of the pretreatment protocol.

Photos of the prepared teeth were taken with the stumpf shade guide and desired final shade (Figures 13 and 14). A photo disc was created and sent into the dental laboratory with the prescription for review. 

Prior to temporization, the teeth were cleaned (Consepsis [Ultradent Products]), and Gluma (Heraeus Kulzer) desensitizer was applied. Immediately after this, the temporary stent (Sil-Tech [Ivoclar Vivadent]) was loaded with a bleach white temporary bis-acrylic material (Temp C&B [Heraeus Kulzer]) and placed in the mouth for 2 minutes. Then, the silicone stent was taken out and the temporary restorations remained on the prepared teeth. Flash was removed and the material was custom stained and glazed at the chair (Figure 15). Finally, the bite was checked/slightly adjusted, and the patient was given instructions for care and released.

 

Porcelain Veneers

Tom M. Limoli, Jr
A number of reimbursement challenges are presented within the confines of this article. Both the take-home whitening and gingival recontouring are integral subcomponents of the overall completed procedure. As such, they would be separately documented in the clinical record, coded, and billed. Reimbursement by the patient’s benefit plan for these subcomponents is another story.


The bleaching of vital teeth, in most cases, is considered cosmetic in nature. However, there are benefit plans in the marketplace that cover bleaching and/or bonding for other than purely cosmetic reasons. Reimbursable liabilities include severe tetracycline staining, severe fluorosis, hereditary opalescent dentin and amelogenesis imperfecta.

When the patient presents with these clinical conditions, the third-party payer will need radiographs, diagnostic photographs and a narrative report. Remember that some plans specifically exclude benefits for the correction of congenital conditions.

When bleaching is purely cosmetic in nature, the associated components of the procedure are not reimbursable benefits. To deceptively use code numbers for diagnostic casts, night guards, stents, or individually fabricated trays is a fraudulent and unprofessional attempt to secure money from the benefit plan that is simply not payable. Expect limited or no reimbursement from the third-party payer.

Gingivectomy is usually not reimbursable when it is performed for aesthetic rather than anatomical reasons. For example, it may be considered a cosmetic exclusion when the recontouring of the gingival line produces a more pleasingly complete clinical crown. In short, it is not a covered benefit if you are simply correcting a “gummy smile.” A crown with a 50/50 anatomical contour is not 60% long and 40% wide. Removal of a wedge of gingival tissue to achieve an anatomically aesthetic objective, in the absence of pathology, is considered a cosmetic exclusion.

 

Table. Porcelain Venneer Codes and Fees
Code Description Lower Low Medium High Higher Average RV
D4210 Gingivectomy or gingivoplasty-4 or more contiguous teeth or tooth bounded spaces per quadrant $340 $402 $527 $666 $841 $517.88 11.77
D4211 Gingivectomy or gingivoplasty-3 or more contiguous teeth or tooth bounded spaces per quadrant $125 $138 $188 $283 $350 $202.38 4.60
D9972 External bleaching-per arch $148 $200 $200 $255 $265 $208.63 4.74
D9973 External bleaching-per arch $20 $30 $36 $50 $88 $38.63 0.88

CDT-2009/2010. Copyright American Dental Association. All rights reserved. Fee Data. Copyright Limoli and Associates/Atlanta Dental Consultants. This data represents 100% of the 90th percentile. The relative value is based upon the national average and not the individual columns of broad-based data. The abbreviated code numbers and descriptors are not intended to be a comprehensive listing. Customized fee schedule analysis for your individual office is available for a charge from Limoli and Associates/Atlanta Dental Consultants at (800) 344-2633 or visit the Web site limoli.com.

DELIVERY APPOINTMENT
The patient returned to the office 2 weeks later for removal of the provisional restorations and for bonding of the porcelain veneers.

Figures 16 to 18. Preseat model check.

Figure 19. Closeup of postoperative smile.

The veneers were evaluated and measured on the model one week prior to patient arrival (Figures 16 to 18). The restorations were perfectly proportioned and stained as specified in the instructions given to the laboratory. The restorations were tried in the mouth for shade match, contact evaluation, proportionality, and overall look of the restorations blending into the natural dentition. The patient was given the opportunity to view the restorations prior to permanent placement, giving her final approval to her aesthetic presentation. The restorations were removed and cleaned with a 37% phosphoric acid gel (Ultra-Etch [Ultradent Products]). Then, they were rinsed, dried, and silanated for placement.


The patient loved the result and stated that she felt confident about her smile (Figure 19 and After Image).

 

CONCLUSION
There are many factors to consider when restoring an anterior cosmetic case. First, the smile design must be addressed in order to achieve long-lasting functional results. Second, when considering cosmetic results, one must consider the material of choice for the restorations. With so many material choices today, it is important to have an understanding of the porcelain system that you are using because this can have a profound effect on the outcome of your case. Choosing a quality porcelain system, using sound preparation, temporization, and bonding techniques, and choosing a quality-minded laboratory team will address the cosmetic challenges of any anterior case. In this way, you too can create a natural, long-lasting smile that your patients will feel confident in showing off for years to come.

Acknowledgement: The author would like to thank Hamid Babaeian, CDT, and team at Pacific Dental Laboratory, Thousand Oaks, Calif. They were chosen due to their extensive knowledge of, and experience with, the Venus porcelain system used to complete this case.


Dr. Simos received his Doctorate of Dental Surgery at Chicago’s Loyola University. Founder and president of Allstar Smiles and the Allstar Smiles Learning Center, he teaches post-graduate courses to practicing dentists on comprehensive and restorative dentistry in Bolingbrook, Ill, and throughout the country. He is one of 50 leading dentists nationwide who, as part of the Dental Team Concepts & Catapult coterie, promote awareness, communication, and education within the dental profession. He can be reached at (630) 378-9987 or sam@allstarsmiles.com

Disclosure: Dr. Simos reports no conflicts of interest.