CASE REPORT

Esthetic Rehabilitation with Ceramic Veneers: A Case Report

Shailendra Gupta,1 Deepak Raisingani,2 Pradyumna Misra3
Because ceramic veneers are primarily indicated for the improvement of esthetic, the design of the smile should respect the symmetry and the harmonious arrangement of dento-facial elements4,5.The patient is often the final judge of restorations in esthetically driven treatment. If the clinician and patient do not have the same result in mind there is the possibility that the patient will not approve the definitive restorations. For these reasons it is important to accurately visualize the restorations before finalization6,7.

ABSTRACT
Veneers are the most frequently prescribed aesthetic restorations today. Ceramic veneers can be offered as the treatment option in a wide variety of different cases such as correcting tooth defects, abrasion, orthodontics, diastema, tooth discoloration, coronal fracture or to adjust occlusion. Before preparing the teeth a complete analysis should be carried out in order to optimize the result. In this way it can be ensured that the teeth being veneered will need only minimal preparation, or in some areas none at all.

Case Report
A 26 year old male patient presented for esthetic treatment of anterior teeth. He wanted a treatment that could enhance his smile. Complete history of the patient along with preoperative photograph was taken (fig 1.)

Keywords: smile, ceramics, enamel hypoplasia, fluorosis

Introduction
Since their introduction in the early 1980 ceramic veneers have gained wide acceptance as a primary mode of restoration in esthetic dentistry1. As patients esthetic expectations continue to increase, dental teams are challenged to identify a systematic approach for achieving natural oral and facial esthetics with ceramic veneers. Advances in ceramic materials and Veneering techniques allow practitioners to restore function and esthetics using conservative and biologically sound methods as well as promoting long term oral health2,3. Esthetics, treatment planning and clinical care should be considered in accordance with the interrelationship between the teeth, gingival tissues, lips and face. Considered as to how the facial and physiological parameters can influence a natural smile design must also be taken into account.
Fig 1. Preoperative intra oral photograph

Following a detailed clinical examination the objective parameters of the patients smile were carefully evaluated. Tooth no. 21 was diagnosed as suffering from enamel hypoplasia and rest of his anterior tooth Because Ceramic Veneers are primarily indicated for having chalky white stains were diagnosed as fluorosis IJCD JANUARY, 2011 2(1) 13 the improvement of esthetic, the design of 2011smile of Contemporary Dentistry was also found rotated mesially. the Int. Journal .His tooth 11 should respect the symmetry and the harmonious

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from enamel hypoplasia and rest of his anterior tooth having chalky white stains were diagnosed as fluorosis . His tooth no. 11 was also found rotated mesially. Noninvasive methods like bleaching considered due to the limitations. were not

Ceramic veneers were best suited for the condition. These veneers have the advantage of preserving most of the natural tooth structure while achieving all the cosmetic aids. It is important for the clinician crowns. Six anterior maxillary veneers were required while one was required for lower incisor. But keeping cost factor in mind, patient agreed for 2 maxillary anterior veneers and one mandibular veneer which was most visible. Prior to beginning preparation of the teeth, the colour of ceramic veneers was chosen and incisal guidance was checked. Tooth reduction began by using a 0.5mm depth cutting bur on the buccal wall, starting from the gingival level covering the incisal edge. The lingual margin was placed such that it was above the contact point. The reduction was done less on distal part of tooth 21 intentionally to give it a bulk and straighten the teeth with ceramic veneer. A long tapered chamfer ended diamond bur was used to reduce the buccal wall, creating definite gingival and interproximal finishing line angles. The chamfer was taken slightly into the interproximal areas to allow the veneers to cover all the visible aspects of the teeth. Full arch impressions were taken with a polyvinyl siloxane impression material and an occusal registration was made. Lab instructions included the underlying and final shades, the desired length, width and position of frontal teeth. At the dental laboratory, refractory stone models of the prepared teeth were made and 3 veneers from E-max porcelain were fabricated fig 2 and 3. The three veneers were inspected in the dental office prior to the appointment of the seating.

Fig 3. Lingual views of model after teeth were prepared for ceramic
restoration.

Fit, natural appearance, translucency and the absence of the black triangle in the gingival area were checked. The porcelain veneers were tried in using a try-in glycerin medium and the most convenient shade was selected, Rubber dam and retraction cord was placed to prevent gingival fluids from contaminating the teeth during the bonding process. The teeth were pumiced and rinsed. Multilink Primer A + B were mixed and applied on enamel / dentin using a brush and dried with an air syringe to remove the solvent carrier and residual water. (left to react for 20 s) The internal aspects of the veneers were rinsed with water and blow dried. Metal primer (Multilink , Ivoclar) for thirty seconds was applied between the ceramic and composite resin luting agent. Extrude Multilink cement and mix (20 s). It was placed inside the veneers and the veneers were placed on the prepared teeth. Excess luting composite was removed with a brush. After setting, floss was gently placed into the interproximal areas to remove uncured resin. This was followed by labial and lingual simultaneous light curing for 60 seconds. Carbide-finishing burs were used to remove excess cured composite resin at the margins and aluminium oxide polishing strips were used to smooth these areas. Slight occlusal adjustments were accomplished with carbide finishing burs. Polishing cups and points were used to bring all surfaces to a smooth finish. Figure 6 and 7 present the three ceramic veneers from the facial retracted view after cementation.

Fig 2. Labial views of model after teeth were prepared for

ceramic restoration.

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Fig 4. Veneer after cementation from palatal aspect

in maxillary teeth

Fig 5: Veneer after cementation from lingual aspect in

mandibular teeth

Fig 6: Veneer after cementation from labial aspect in maxillary

teeth

Fig 7: Veneer after cementation from labial aspect in

mandibular teeth

Discussion
Bonded porcelain veneers have a number of significant advantages over metal-ceramic or all-ceramic crowns2,8. One of the most important advantages is that they are extremely conservative in terms of tooth structure. Conservation of tooth structure is a major factor in determining the long-term prognosis of any restorative procedure. Another remarkable advantage of porcelain veneers is their durability. As long as sufficient tooth structure remains to provide adequate support for the bonded porcelain the incidence of fracture is very low. This durability allows minimal reduction resulting in decreased potential pulpal involvement.

contemporary dentin bonding systems, margins can be successfully placed on the dentin/cementum when necessary10.

Like every procedure in dentistry, the success of porcelain veneers depend upon understanding the principles involved in their fabrication and application. The success of treatment with ceramic veneers can be assured if the dentist follows a defined protocol with each patient to ensure that all factors such as smile design, margin placement, material and shade selection are considered. Communication between patient, dentist and technician must be rigorously controlled7 as well. When utilizing anterior veneers the current evidence suggests that when all of these factors are thoroughly considered, dentists can achieve predictable results which are satisfactory to their patients 11. The The periodontal response is outstanding. The patient is often the final judge of restorations in restoration can blend imperceptibly with the cervical aesthetically driven treatment. If the clinician and tooth structure, allowing the cervical margins to be kept patient do not have the same results in mind, there is in a supragingival position9. These cervical margins the possibility that the patient will not approve of the should be placed in enamel; however, with definitive restorations. Thus it is critical to provide contemporary dentin bonding systems, margins can be IJCD when 15 sufficient successfully placed on the dentin/cementum JANUARY, 2011 2(1) visualization to the patient before 2011 Int. Journal of Contemporary Dentistry 6,12 finalization . necessary10.

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the definitive restorations. Thus it is critical to provide sufficient visualization to the patient before finalization6,12. This article describes the treatment of three anterior teeth with porcelain veneers. Excellent esthetics can be achieved with minimal reduction because of the cover ability of the porcelain used, and the scattering effect of the luting resin. 10. Cho GC, Donovan T, Chee WL. Clinical experiences with bonded porcelain laminate veneers.J Calif Dent Assoc, 1998; 26(2), 121-7 11. Peumans M, De Munck J, Fieuws S, Lambrecht P, Vanherle G, Van Meerbeek B. A prospective ten-year clinical trial of porcelain veneers. J Adhes Dent.2004 Spring; 6(1):65-76. 12. Almong D, Sanchez Marin C, Proskin HM. The effect of esthetic consultation methods on acceptance of diastema closure tratement plan: A pilot study. J Am Dent Assoc 2004;135(7):875-881

References:
1. Peumans M, Van Meerbeek SI, Lambrecht P, Vancherle G- Porcelain veneers : a review of the literature, J Dent, 2000 March;28(3); 163-77 2. Gurel G, ed. The science and art of porcelain laminate veneers. Carol Stream, IL: Quintessence Publishing Co.; 2003 3. Malmacher L. Back to the future with porcelain veneers. Dent Today. 2005 March; 24(3):88, 90-1. 4. Bichacho N. Porcelain laminates: integrated concepts in treating diverse aesthetic defects. Pract Periodontics Aesthet Dent. 1995 Apr;7(3):13-23 5. Magne P, Belser U. Bonded porcelain restorations in the anterior dentition: a biomimetic approach. Carol Stream, IL: Quintessence Publishing Co;2002. 6. Mizrahi Basil. Visualization before finalization: a predictable procedure for porcelain laminate veneers. PPAD, vol.17, No8, 2005 7. Derbabian K, Marzola R, Donovan TE. The science of communicating the art of esthetic dentistry. Part II: Diagnostic provisional restaorations. JEsthet Dent, 2000;12(5):238-247 8. Chalifoux PR, Darvish M. Porcelain veneers:concept, preparation, temporization, laboratory and placement. Pract Period. Aesthet Dent. 1993May; 5 (4):11 9. Magne P, Belser U. Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Estet Rest Dent 2004;16(1):7-18

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About the Authors:

1. Dr.Shailendra Gupta Professor & Head Department of Conservative Dentistry & Endodontics Mahatma Gandhi Dental college & Hospital Jaipur 2. Dr. Deepak Raisingani Associate Professor Department of Conservative Dentistry & Endodontics Mahatma Gandhi Dental college & Hospital Jaipur

3. Dr. Pradyumna Misra

Professor Dept. of Conservative Dentistry and Endodontics UP Dental College and Research Centre, Lucknow

Corresponding Author

Dr. Deepak Raisingani Department of Conservative Dentistry & Endodontics Mahatma Gandhi dental college & hospital RICCO institutional area Sitapura Jaipur-302022 Ph:0141/2770300/220 +919414221345 Fax:0141/2770326
Email:

draisingani@gmail.com

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