Fig.1
Initial problem, multiple unaesthetic restorations, misaligned teeth and mild darker and lighter discolorations.

Fig.2
The lateral view shows cervical defects on the lateral and disproportions all over the anterior teeth.

Fig.3
On the right side we find as well plenty of defects, as the opaque aspect of the 11, previously endodontically treated and restored with a fiber post, proximal stains and disproportions.

Fig.4
Occlusal view is one of the most important pieces of a correct analysis when planning veneers, this vision will indicate us how much material we can add or how much should we subtract. Working additively is of utmost importance and should be our goal as much as possible. We can appreciate here how much we can add material to both centrals and laterals, where the centrals will need a little preparation (especially in the incisal area), the laterals will not need any preparation.

Fig.5
Mock-up from the wax-up stamped in the mouth, the additive material shows us now a very accurate situation of what the project is going to look like at the end of the treatment. Usually, immediately after the project is satisfactory, we can prepare teeth over this material for minimal tissue loss. This wax-up is mandatory and it will help us in the following key stage
1- Case acceptance
2- Volumetric Guided Preparation (as mentioned above)
3- Provisionals
4- Final work assessment.

Fig.6
The silicone guide was placed. Here is the occlusal view of the teeth after being prepared over the mock-up resin. Note how little structure was removed. After this vestibular preparation, we can get rid of the mock-up and finish accordingly our proximal and cervical areas.

Fig.7
Veneers are cemented one by one under complete isolation. In this image, the detail of the isolation of tooth 11 with a 212 clamp and the other proximal areas accessible through the other holes, note how the enamel surface of tooth 12 is untouched while the centrals, as mentioned above, required adjustments at the incisal level. All proximal and cervical margins are located in enamel. Composite build-up is previously treated with 50 micron Aluminum Oxide particle sandblasting to guarantee maximum boding levels as well in the old composite.

Fig.8
We decided to follow a total etch technique. The tooth is etched for 30 seconds with 37% phosphoric acid.

Fig.9
In any etching technique, the complete elimination of the etching agent is of utmost importance, we recommend to wash generously for about 20 seconds in order to remove all the acid debris that could be left. Dry carefully when performing total etch as the collagen network can collapse if over drying. We can always choose the self-etching technique in case we need or want to dry thoroughly.

Fig.10
The aspect of the etched substrate. Preparation must look opaque and clean.

Fig.11
While preparing the intra-oral field, the feldspathic ceramic veneers are etched. If we etch with a 10% hydrofluoric acid we etch for 1.5 minutes, instead if we use 5% acid, the recommended time is about 3 minutes. Make sure that the internal surface of the veneers looks even and frosted, without the presence of debris, white spots or shiny areas. If that is the case, clean with phosphoric acid and etch again. If veneers do not remain clean we may consider air abrasion of the internal surface. (For Emax veneers we etch for 20 seconds)

Fig.12
Application of the bonding agent, in this case ScotchBond™ Universal 3M, which can act as a self-etching material or as a total etch. The bonding agent is rubbed for 20 seconds.

Fig.13
After rubbing movement the agent has to be thinned with air, ensuring that there will be no excess on the surface that can interfere with the passive sitting of the veneer.

Fig.14
Polymerization should be done properly. Manufacturers recommend generally 20-30 seconds. We suggest to over-polymerize, this will guarantee a strong hybrid layer even in areas where the light cannot arrive from the intimate contact of the lamp but slightly further.

Fig.15
The internal surface of the veneer should be treated with silane and then the bonding resin. In this case while using ScotchBond™ Universal 3M, which has in its composition phosphate monomers (MDP) and silane. This bonding agent has been reported to have similar bond strength values as for those silane+bonding separate systems, which is why the use of silane can be avoided in this case. Both asseverations about silane use or avoidance are backed with interesting scientific evidence. At this point we have to silanize the veneer before bonding, even if we could avoid this step because of the silane inside scotch bond universal. A lot of dentists still prefer to maintain the use of silane.

Fig.16
Bonding layer must be generously thinned with air in order to avoid a thick film that can interfere with the fitting of the veneer.

Fig.17
Polymerization strategy is exactly the same. An extended polymerization will help to increase the quality of the bonding layer. We recommend to light cure for one minute only if we have thinned the layer of bonding to the maximum.

Fig.18
The cement is applied in the internal surface of the veneer. We recommend using veneer dedicated cements, which are full light curing materials, which because of its consistency can be denominated as “heavy flowables” or “soft composites”. This kind of materials allow to the clinicians the following things.
1- Passive fitting of the veneer
2- When external light conditions are low, unlimited placement time
3- Good stability of the material and less risk of voids due to its consistency
4- Excellent structural and surface properties due to its high filler content.
5- Proper excess removal thanks to its density.

Fig.19
The excess of the cement coming out from the margins; initially the gross excess is taken out with a hand instrument.

Fig.20
After removing the big excess a brush is passed to smoothen the margins and finish removing the small excess. After we are sure all the margins are correctly filled and there is no excess cement, we can proceed to polymerization.

Fig.21
Light passes properly through the whole veneer, especially in the incisal area. The more intimate the contact of the lamp is with the veneer, the better conversion of the material. Extended polymerization is strongly suggested.

Fig.22
A sharp curette (Eccesso, LM Arte) is used to remove cement and bonding excess from the vestibular and proximal margins.

Fig.23
Fine abrasive strips are used to remove the excess and finish the margins.

Fig.24
Extra-fine abrasive strips are used to polish the proximal margins.

Fig.25
The final situation after one month. Look how the color is now even, proportions are better and the overall surface and texture are pleasing to both dentist and patient. A very small excess was taken out from the mesial of the tooth 22, where you can note the bleeding area. Further controls will be done afterwards.

Fig.26
Lateral view of the excess that was removed.

Fig.27
Lateral view of 11 and 12, look how the sound tissues have healed properly.

Fig.28
Detail of the two centrals.

Conclusions

Of course every single step of a veneer case is fundamental and important. Cementation stage is the culmination of all those efforts. In the dental world we have a very polarized set of opinions where many colleagues complain about how everything debonds and other colleagues which seem to do heroic bondings and have no problem. Our opinion is that the keyword is enamel, if we respect the sound tissues and bond to the best of the substrates, we will achieve high clinical success. Respecting and following thoroughly the cementation steps will grant us high clinical success.

Bibliography

1. Devoto W. Direct and indirect restorations in the anterior area: a comparison between the procedures. QDT Yearbook 2003;26:127-138.
2. Magne P. Composite resins and bonded porcelain: the postamalgam era? J Calif Dent Assoc 2006;34:135-147.
3. Paolone G., et al. Esthetic direct restorations in endodontically treated anterior teeth. Eur J Esthet Dent. 2013 Spring;8(1):44-67.