A clinical case by our Community member Dr. Kareem Nagi
This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.
Laminate veneers are today a common restorative procedure thanks to their highly aesthetic outcome and longterm predictability. A good understanding of the indications and choosing this type of restorations as a treatment option require specific guidelines such as: good teeth alignment, enough enamel thickness, healthy occlusion, normal occlusal relationship, and good oral hygiene. Throughout this article I’m going to focus on minimal preparation veneers restored with monolithic with incisal cutback.
This 33-year-old male patient was suffering form yellow, spaced teeth which have been making him unhappy with his smile for a long time. He adopted a shy and irregular mouth frame since he felt his mouth caught his friends’ eyes, every time he smiled. Such a psychological trauma is described by Duchenne as a “Miserable smile” in which a grin-and-bear-it is expressed. A slight, asymmetric smile with an expression of deep sadness.
The first treatment option proposed was non-invasive: orthodontic alignment followed by teeth bleaching. However, he refused to have a long treatment option, asking for a final, long-lasting, and quick solution.
So a veneer makeover was suggested as a quicker, yet minimally invasive form of treatment. Sophisticated and precise minimally prepared veneers require a good Dental Technician (DT), along with thorough planning. To restore minimal preparations without over contouring, communication with the DT must be very accurate communication, otherwise, the result will be unpredictable and unsatisfactory for both, even before considering the patient’s opinion. For the DT to restore such type of preps, three techniques are adopted according to the amount of tooth preparation: (1) Direct Layering on refractory dies (whatever the amount that’s prepared). (2) Monolithic ceramics +/- 3D staining (at least 0.3mm buccal reduction and
0.5mm incisal). (3) Monolithic ceramics with incisal cutback (0.5mm facial and 1.00mm incisal). In this case, based on the case study, a monolithic approach was chosen, along with incisal cutback.
A pre-operative photo was taken at rest, to see the amount of centrals and laterals displayed.
A close view of the anterior region. Note that there is an upper arch minor spacing, and minor misalignment that can be easily corrected.
Close view to the centrals. Note the abrasion and notches of the incisal edge that denote a hidden bad habit. History was taken. Instructions after final veneers delivery are essential for the long term survival.
For the preparation rounded cylindrical burs were used. Green, red and yellow (left to right) grit were used in sequence to prepare a smooth, definite surface.
Since the upper arch was well aligned, a diamond 0.5 mm depth cutter bur was used buccally and incisally to get an even enamel reduction, thereby limiting the preparation into enamel only, without dentin exposure.
The picture shows the three preparation planes from the side view. A correct buccal prep should follow these planes to respect the tooth contour. That’s why it’s critical to start with the depth cutter as a guide for the three planes preparation.
This picture shows a wrong preparation. The one plane facial preparation.
Final tooth preparation. Note that finish line was placed juxta-gingivally.
Butt-margin incisal edge configuration inclined buccally (on the left) allows a lower stress concentration at the facio-incisal angle, and the palatal enamel provides a skirt for the veneer thereby blending the veneer with the tooth structure. A butt-margin inclined palatally (on the right) provides better mechanical resistance to palatal forces, while creating critical line of demarcation which may be seen if the veneer is too thin.
Note that the proximal margins of the preparation should be keptt at or behind the papilla, otherwise sound tooth structure will be visible after veneer placement.
A diagram showing the proximal preparation and margin configuration.
Inadequate preparation of proximal transitional line angle will result in bad aesthetics. A sound tooth structure well seen after veneer placement.
0.3 mm supra-gingival smooth definite margins are key for the long term survival.
An immediate post-operative photo of the upper arch. Note the visibility of part of the tooth structure cervical to the finish line; as a result of gingival retraction and excess cement removal.
An immediate post-operative photo of the lower arch. Note the visibility of part of the tooth structure cervical to the finish line; as a result of gingival retraction and excess cement removal.
A lateral preoperative photo. Note mouth frame and the restriction in muscles.
A week later after delivery, beside giving the patient a nicely looked tooth alignment and shade, note the enhancement of his smile and the release of muscle tension and restriction.
Side view of the full arch veneers in occlusion after one week of delivery. Note the ideal maxillo-mandibular relationship regarding the over-jet and over-bite.
A week later after delivery, note the enhancement of tooth shapes, proportions and alignment. Healthiness of the surrounding periodotium.
Laminate veneers are just one of the options for smile makeover. Among the advantages of this technique over other conservative non-invasive procedures we can mention there is color improvement and stability.
Choosing such type of treatment requires an accurate diagnosis and analysis of occlusion and overall facial and dental structures. Good communication with a good technician is essential to provide an aesthetic result. Remember the ultimate goal is to always provide a healthy oral environment for the patients and enhancing their aesthetics and self-confidence.
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