Ceramic Veneers and Root Coverage

The ideal situation for a clinician to bond bonding ceramic veneers is to bond them all on enamel. This, however, is not always the case and one often comes across Class V lesions or dentinal areas that need to be covered or bonded onto. This could be necessary for reasons of aesthetics, function, preservation of the tooth or a combination of these.
3 cases are here presented to suggest different modalities that one can employ to facilitate such coverage.
The author would like to thank MDT Lamberto Villani for the ceramic work in these cases.

Fig.1

CASE 1
A 52 year old male came complaining of some old crowns on upper incisors and upper right second premolar and also wanted to enhance aesthetics. Diagnosis and treatment planning led to the choice of a multiple restorations protocol. Home bleaching for 2 weeks was given to the patient.

Fig.2

The old crowns were removed and a new composite core build up was done for 11. The rest of the teeth were minimally prepared. All Class V lesions were restored with flowable composite, Filtek Supreme, 3M ESPE.

Fig.3

The Class V restorations were treated as a part of the tooth while preparing the teeth.
TIP#1: once the Class V restorations are done the final curing cycle should be carried out with a water soluble oxygen blocking gel that eliminates the oxygen inhibition layer. This will otherwise interfere in the polymerization of the silicone impression material.
TIP#2: when temporary veneers are being cemented in such cases, usually using flowable composite, apply a thin layer of vaseline to these areas which have been restored to ensure that the composite layers do not bond to each other making it difficult to remove the temporary veneers on a later date.

Fig.4

Before.

Fig.5

After.

Fig.6

After, right view.

Fig.7

After, left view.

Fig.8

CASE 2
A 50 year female with a fair bit of recession and multiple class V lesions, all of which were not restored. The patient wanted to improve the health of her teeth and her smile.

Fig.9

Bilateral connective tissue grafts gave a much more favorable tissue contour to work with. There were still some recession areas that were not covered completely with tissue augmentation where the previously stated technique was repeated.

Fig.10

The teeth were prepared through a mock up. All class V lesions were restored with Flowable composite before the tooth preparation began.

Fig.11

An attempt was made to minimize tooth reduction and to preserve as much enamel as possible.
TIP#4: After placing the first thinner cord it is suggested not to prepare any more then the level of the gum tissue at this point even if the second cord suggests a further retraction.

Fig.12

Ten feldspathic veneers were cemented using the appropriate bonding protocol and using Rely X Veneer Cement (3M ESPE).

Fig.13

CASE 3
A 42 year old female had existing veneers but was unhappy about the esthetics. She had a history of periodontal surgery a few years before, after which a clinician placed veneers for her. The central incisors were over 14mm long and tooth number 23 even longer.

Fig.14

The old veneers were removed and the teeth were cleaned. The preparations were finalized and impression made.

Fig.15

Ceramic veneers were fabricated using feldspathic porcelain. The veneers were fabricated in a way that the white in the teeth were proportioned in a balance and the rest of the veneer was made with pink ceramic.

Fig.16

Upon doing a try in, it was realized that the pink looked rather obvious. It was not the exact same pink and also reflected too much light.
TIP#5: texture is the most important element that make the restoration blend in with its surroundings and make restorations look lifer like. It was thereby decided to change the reflective index of the pink in the veneers using ceramic polishing rubbers (Shofu Co.)

Fig.17

Try in shows too much gloss on the top surface of the pink in the veneers.

Fig.18

Much less reflection of light and thereby the veneers blend in better. They were then cemented.

Fig.19

Before.

Fig.20

After.

Fig.21

 

Smile close-up where one can appreciate better proportion of teeth and a more harmonious smile.

Conclusions

The aim in contemporary dentistry is to be able to enhance aesthetics, conserve tooth tissue and also to improve function but by minimally compromise on healthy tooth tissue.
In the earlier times it was considered that one do a full coverage restoration if there was a fair bit of dentine exposed in any part of the tooth.
Now with bonding protocols and the understanding of tooth bonding improving it can be confidently suggested to seal the dentine with composite when it is being prepared and later bond on to it using the protocols suggested.
The author would like to thanks that team at The Dental Studio and MDT Lamberto Villani for their contribution.

Bibliography

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