PAULO MONTEIRO

INDIRECT ANTERIORS - LABORATORY - CASES SUGGESTIONS - TIPS AND TRICKS

THE FIVE SENSES OF ADHESIVE

REHABILITATION - PART II

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Increasingly in dentistry it is necessary to use various specialties to try to get the best final aesthetic and
functional result.
Moreover the adhesive materials and techniques presently allow us to preserve much tooth structure.
A young patient came to our office after finishing an orthodontic treatment to improve the dental
aesthetics in anterior teeth.
In the intra-oral examination we observed some interproximal spaces to close, a severe change in the
shape and color of existing teeth and the presence of deciduous teeth. The existence of a primary tooth in
place in the canine, took us to the placement of an implant.
One might we follow different treatment plans: ceramic restorations or composite resin restorations.
However, the treatment planning would always be the same.
Compared to a composite resin, the ceramic has the advantage of being biocompatible and stable in
surface gloss and color.
In this case, because of the high aesthetic demand the patient has chosen to make ceramic veneers.
We want to share the importance of good planning between the various dental specialties and try to
preserve the dental tissues, hoping to get a proper and natural aesthetic and functional result.

Img. 1 - Extra-oral clinical situation: the patient came asking for aesthetic rehabilitation in the anterior area
after having undergone orthodontic treatment.

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Img. 2 - Intra-oral clinical situation.

Img. 3 - Detail of the tooth structure in the anterior area. We can observe modification in shape and and
color.

Img. 4 - After having taken an impression, and having done a smile analysis, a wax-up was made by the
dental technician.

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Img. 5 - A silicone index was made onto the wax-up in order to produce a mock-up. The mockup is the best
way to communicate our aesthetic treatment plan to the patient, who can visualize an close idea of the
final result. For the mock-up, in this case we used a bis-acryl resin (Protemp 4, 3M).
Also, the mock-up is the way to predict the space needed for the restorative material during preparation.

Img. 6 - In the cases in which space is available to add restorative material onto untouched enamel we
should use a hard grain disc (Sof-Lex red disc or black disc) to remove the aprysmatic surface enamel and
round the sharp angles.

Img. 7 - Before the impressions and with the tooth hydrated, we should select the shade we want to our
final ceramic restorations. This shade selection should be made with the same shade guide used by the
dental ceramist.
Using a proper photographic protocol helps in the communication with the laboratory.
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Img. 8 - We place the retraction cord #000 and #00 (Ultrapack, Ultradent) and take the final impression
to send to the Lab.
In this case we have also an impression of an implant to take, so we proceed with all the tooth impression
at same time.

Img. 9 - Zirconia abutment try-in. With a acetate pen we draw a line surrounding the gingival margin for
the dental technician to know where the actual cervical margin is, and also the excess of zirconia to
remove in the incisal area.
After that, a feldspathic glass ceramic layer was applied to cover the Zirconia abutment. This procedure
will allow us to bond the ceramic veneers to this structure.

Img. 10 - After we send the impressions to the Lab, the dental technician starts layering the glass ceramic
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veneers with some different opacities (dentin, enamel, effects). The glass ceramic used was Criation.

Img. 11 - Glass ceramic veneers finished.

Img. 12 - Glass ceramic veneers in the stone model.

Img. 13 - Details of texture of the glass ceramic veneers.

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Img. 14 - Glass ceramic veneer ready to bond in the feldspathic / zirconia abutment.

Img. 15 - Try in of the glass ceramic veneers. During this step we can check the shade of the resin cement,
the fit and the contacts.

Img. 16 - After having placed the implant abutment the adhesive surface preparation was made (9%
hydrofluoric acid per 90 seconds, wash, 37% phosphoric acid per 60 seconds, wash, dry, silane application,
bonding resin agent application).
We use the ScotchBond Multi Propose adhesive.
The main purpose of using a glass ceramic veneer on a glass ceramic abutment is to have a better control
of the final shade of the resin cement, compared with the other ceramic veneers.

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Img. 17 - Application of the silane in the abutment.

Img. 18 - In this clinical procedure we follow the technique of Pascal Magne, published in 2008.

Img. 19 - The same preparation was made on the inner surface of the glass ceramic veneer (9%
hydrofluoric acid per 90 seconds, wash, 37% phosphoric acid per 60 seconds, wash, dry, silane application,
bonding resin agent application).
We use the Variolink Veneer resin cement as a luting agent.

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Img. 20 - After bonding, application of glycerin gel on the restorative margins and light-cure for 20
seconds.

Img. 21 - Before we remove the rubber dam the excess near the margins should be removed, and the
ceramic margins polished.

Img. 22 - Intra-oral aspect immediately after removal of the rubber dam.

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Img. 23 - Intra-oral aspect five days after the ceramic veneers adhesion.

Img. 24 - Intra-oral aspect two months after the ceramic veneers adhesion.

Img. 25 - Intra-oral aspect of the natural opalescence ceramic outcome.

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Img. 26 - Intra-oral aspect three years after the ceramic veneers adhesion.

Img. 27 - Four years follow-up after the ceramic veneers adhesion.

Img. 28 - Four years follow-up after the ceramic veneers adhesion.

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Img. 29 - Detail of the natural integration between the glass ceramic veneers and the adjacent tissues:
gingiva and lips.

Img. 30 - Integration of the new smile in the face of the patient after four years.

Img. 31 - Natural integration of the glass ceramic veneers with the face of the patient after four years.

Conclusions
Performing a proper functional and aesthetic planning, using effective communication between the dentist,
the ceramist and the patient, increases the chances of the restorative success and longevity.
I want to thank the whole team who worked with me on this case at the Instituto Superior de Cincias da
Sade Egas Moniz: Joo Rua, Ctia Moreno, Helder Costa and Pedro Brito.
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References
Devoto W. Direct and indirect restorations in the anterior area: a comparison between the procedures.
QDT Yearbook 2003;26:127-138.
Belser UC, Magne P, Magne M, Ceramic laminate veneers: Continuous evolution of indications. J Esthet Dent
1997; 9: 197-207.
Calamia JR, Calamia CS, Porcelain laminate veneers: Reasons for 25 Years of success. Dent Clin N Am
2007:51: 399-417.
Magne P, Magne M, Jovanovic SA, An esthetic solution for single implant restorations - type III porcelain
veneer bonded to a screw-retained custom abutment: A clinical Report. J. Prosthet Dent 2008;99:2-7.
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