A Smile Makeover – Indirect Lithium Disilicate Veneers & Bleaching

Indirect ceramic veneers are a very well established way to achieve a smile makeover. The key to success with this kind of aesthetic rehabilitation, is to use a minimally invasive approach and carefully lay out your protocol. A 29 year old young female reported with some discoloured bonded restorations, diastemas and also the desire to have a wider and more harmonious smile.

smile aesthetic analysis

Fig.1
When the case was examined closely, it was observed that, apart from her complaints, there was a midline shift and also the smile line wasn’t harmonious. The centrals were not in balance with the form of the face and the personality of the patient.

laterak view of smile and canine diastema

Fig.2
The right lateral view shows the diastema in between 12 and 13, and a distal inclination of the canine.

lateral view of female smile

Fig.3
The left lateral view shows a diastema in between 12 and 24
The mesial line angle of the canine is very steep.

dark central incisor

Fig.4
Intra-oral frontal view also showing a disharmonious gingival architecture, along with the observations made earlier. It was also noted that the shade of the teeth was Vita A2 on some and A3 on others.

diastema between canine and lateral incisor

Fig.5
Retracted right view.

diastema between canine and lateral incisor

Fig.6
Retracted left view.

tipped and dark central incisor

Fig.7
A retracted frontal view of the upper arch only. A face bow was taken and impressions as well. It was sent to the laboratory for Wax Up. It was decided in this case not to do any gingival re-contouring as the lip line is rather low and the periodontium was rather healthy to begin with.

at home bleaching product and trays

Fig.8
A retracted frontal view of the upper arch only. A face bow was taken and impressions as well. It was sent to the laboratory for Wax Up. It was decided in this case not to do any gingival re-contouring as the lip line is rather low and the periodontium was rather healthy to begin with.

precision mock up with double impression paste

Fig.9
An impression of the waxed-up model was taken using putty and light bodied materials in a plastic tray. This allows compression of the material and thereby the most accurate mock-up. This, as also suggested by many authors, helps to save a lot of time, as with a soft putty and light body combination a lot of adjustment is needed on the mock-up. This is because the material flexes and with the inability to have uniform pressure with fingers usually results in an over-sized mock-up.

resin mock-up

Fig.10
The mock up was tested for esthetics, phonetics and function.

resin mock-up for smile make over

Fig.11
Right lateral view of the mock up. One is able to check the inicisal edge and lip relationship.

resin mock-up for smile makeover

Fig.12
Left lateral view of the mock up. One is able to check the inicisal edge and lip relationship.

comparison between mock-up and original smile

Fig.13
Frontal view of the mock up, one side only. It allows to visualize the volume that will be added on the tooth for the final restoration, and to minimize tooth reduction during preparation.

minimal invasive preparation for veneers

Fig.14
A 3 plane reduction through the mock-up protocol was followed and the preparations were kept in the enamel, minimizing tooth reduction. Where diastemas were to be closed, the proximal finish line was carried out as knife edge, all the way to the palatal side of the proximal wall. Where no diastemas were to be closed, the finish lines were carried 2/3rds into the inter proximal contact area. A proximal polishing diamond polishing strip is used to ensure 0.6 mm clearance between teeth to facilitate a good impression and a good fit of the restorations on the teeth once received from the laboratory.

smooth preparation for veneers

Fig.15
The prepared surface must be very smooth. Note that the cervical finish line in the areas where a large diastema was being closed, was located 1 mm inside the sulcus to improve the mimicry of the emergence of the ceramic restorations after luting.

retraction cord for precision impression

Fig.16
The right lateral view of the preparations showing a very smooth preparation and the finish lines.

retraction cord for precision impression

Fig.17
The left side view of the preparations showing a very smooth preparation and the finish lines.

double retraction cord for displacement of free gingiva

Fig.18
A close-up of the double retraction cord inserted for tissue management. Half of the second cord should be visible.

suculus after second cord removal

Fig.19
A close-up of the sulcus with the first retraction cord after removing the second cord. Note how nicely the free gingiva was displaced vertically and horizontally to protect the junctional epithelium.

precision silicone impression

Fig.20
A one-step, double paste silicone impression was taken using Imprint II (3M Espe). A closed metal tray allows good compression of the impression material and to record the finest details of the prepared teeth.

step by step conditioning of lithium disilicate with acid etching

Fig.21
The veneers were etched with HF 9% (Ultradent) for 20 seconds and then rinsed.
They were then etched with 37% Phosphoric Acid (3M Espe) for 20 seconds for residue removal. They were thoroughly rinsed after. A ceramic primer (RelyX Ceramic Primer, 3M Espe) was placed on the veneers for 3 minutes and dried with air aftewards. A bonding agent was then applied, thinned with air, and the veneers, ready for bonding, were protected form light. A very helpful device during these procedures is the VeneerMe (Smile Line powered by Style italiano).

ceramic veneers after luting

Fig.22
10 Emax Veneers, fabricated with a cut back technique, were cemented using a light-cured resin cement, RelyX Veneer Cement (3M Espe) after ensuring proper isolation.

lithium disilicate veneers after luting

Fig.23
Frontal retracted view of the cemented veneers. Note the excellent tissue integration of the veneers 10 days after they were bonded to the teeth.

smile after smile makeover

Fig.24
Right lateral view of the smile after the veneers were bonded to teeth and their relationship with the lower lip.

smile after makeover

Fig.25
Left lateral view of the smile after the veneers were bonded to teeth and their relationship with the lower lip.

beautiful smile after veneer makeover

Fig.26
The 12 o’clock view is a very important one to ensure the smile curve is even, though it’s sometimes ignored by clinicians. From this point of view one can see a very nice balance in the smile curve and the lip position.

style italiano styleitaliano dentistry

Fig.27
Checking for Esthetics and Phonetics in Dynamic Motion.

natural beautiful veneers

Fig.28
The natural new smile.

before and after smile makeover

Fig.29
Before and after.

before and after smile makeover

Fig.30
Before and after.

before and after smile makeover

Fig. 31
Before and after.

Conclusions

This article provides an insight of this 3 step protocol, including bleaching. A minimal invasive approach to preserve dental sound tissue, especially enamel which is key to optimal adhesion, should always include through-the-mock-up preparation and buccal thickness of the restorations. It is mandatory to keep in mind all the key components of smile design in treatment planning, and also to have invisible margins of the restorations, by positioning the finish lines appropriately. A well bonded restoration to enamel can last for decades and that should be the aim of clinicians trying to practice indirect bonded dentistry with lithium disilicate veneers.

Bibliography

1. Guess PC, Schultheis S, Bonfante EA, Coelho PG, Ferencz JL, Silva NR. All-ceramic systems: Laboratory and clinical performance. Dent Clin North Am. 2011;55:333–52.
2. Bloom DR, Padayachy JN. Aesthetic changes with four anterior units. Br Dent J. 2006;200:135–8.
3. Radz GM. Minimum thickness anterior porcelain restorations. Dent Clin North Am. 2011;55:353–70.
4. Schmidt KK, Chiayabutr Y, Phillips KM, Kois JC. Influence of preparation design and existing condition of tooth structure on load to failure of ceramic laminate veneers. J Prosthet Dent. 2011;105:374–82.
5. Vargas MA, Bergeron C, Diaz-Arnold A. Cementing all-ceramic restorations: Recommendations for success. J Am Dent Assoc. 2011;142(Suppl 2):20–4S.

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