The Five Senses of Adhesive Rehabilitation

We have lately heard a lot about minimally invasive rehabilitation, and when it comes to anterior teeth we are sometimes advised to use ceramic veneers with a minimum thickness.
As in the past, what we should always be looking for is trying to preserve as much tooth structure as possible in any clinical procedure, aiming for balance between function and aesthetics, preserving the maximum amount of enamel.
Anterior adhesive rehabilitation is often a complementary procedure to a longer and differential treatment such as complex oral rehabilitation or orthodontics.
Being keen of sound tooth structure preservation and perfect balance between function and aesthetics is very important when planning a treatment. Such planning may be performed in a digital or conventional manner, but always with a focus on constructing a wax-up and then on transferring into the patient’s mouth with the mock-up.
This will allow proper communication between the clinician, the ceramist and the patient. It is important to always involve the patient in the planning process because it will dictate the fundamentals to make his/her desires and concept of aesthetics to come into reality.
It is crucial to use all of our senses to achieve the best possible outcome for the patient, always trying to replicate what nature has created, but always with good sense.
This article aims to highlight some of these clinical and laboratory steps, with some details that may be important for the final outcome of our clinical procedure.

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Fig.1
Initial situation. The patient was sent to us to make a aesthetic rehabilitation of the anterior teeth after orthodontic treatment.
It was planned make ceramic veneers on the lateral and central incisors to close the interproximal spaces and improve the aesthetics.

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Fig.2
Initial situation. Note the old composite resin restoration that needs to be replaced before the ceramic treatment.
The old composite resins was replaced by a new one, with G-aenial, GC).

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Fig.3
To increase predictability of the final aesthetic result, it is mandatory to include a wax-up into the planning.
This wax-up will allow us to make the mock-up, the dental preparations, the provisional restorations and mainly communicate with the patient.

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Fig.4
It is important that the wax-up is as accurate as possible in terms of shape and texture. This way, the patient will have a better perception of the final result.

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Fig.5
Because there is a slight disharmony within the gingival architecture (especially tooth 2.3), a surgical splint is made from the wax-up. This allows to perceive during surgery what was planned in the wax-up.

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Fig.6
Mock-up made from the diagnostic wax-up. Bis-acryl resin Protemp 4 A2 (3M ESPE) was used.

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Fig.7
Mock-up made from the diagnostic wax-up.

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Fig.8
Tooth preparations should be guided by mock-up. Only in this way we can control the preparations according to the desired final volume for the ceramic material.
Preparation of 2 mm at the incisal edge.

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Fig.9
Tooth preparation is finished. A very conservative preparation was carried out, because in this case we had the space required for the ceramic material.
Whenever possible our preparations should finish on enamel.

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Fig.10
Retraction cord placement before the elastomer impressions (Ultrapack, Ultradent).

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Fig.11
It is recommended to send to the ceramist photos with good quality of our patient´s situation. Especially photos with the shade guide and polarized photos (Smile Lite) help the ceramist to achieve a more natural optical result in dental ceramics.

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Fig.12
Tooth preparation impressions made with silicone (Imprint 4, 3M ESPE).

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Fig.13
Different steps of the application of dental ceramics, trying to reproduce the optical properties of dental tissues.

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Fig.14
Details of different optical ceramic outcome.

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Fig.15
Final ceramic veneers (GC Initial, GC).

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Fig.16
Some details of ceramic translucency of a lateral incisor veneer.

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Fig.17
Ceramic veneers on the stone model.
We can see the natural details of translucency of the incisal edge.

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Fig.18
Detail of the Geller alveolar model used.

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Fig.19
Geller alveolar model with the acrylic dies with the subtract shade.

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Fig.20
Making the acrylic resin dies of the same shade of the tooth preparation may be an advantage for the dental technician. Even though it constitutes a further step in the laboratory process, it provides a better control of the optical ceramic behavior, depending on the substrate.

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Fig.21
Geller dies: translucent acrylic resin, white die stone and acrylic resin with tooth shade substrate.

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Fig.22
Comparison of the optical behavior of the veneers with the white plaster die and with acrylic resin with tooth shade substrate.

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Fig.23
Comparison of the optical behavior of the veneers with the translucent acrylic resin die and with acrylic resin with tooth shade substrate.

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Fig.24
First try-in with glycerin.
After clinical observation, we and the patient together consider the width and proportion of the central incisors was excessive. We send the work back to the lab to be rectified.

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Fig.25
Second try-in with glycerin.
The patient is satisfied with the new shape and proportion of the central incisors.

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Fig.26
Comparison between the first and second try-in.
It has only changed the shape of the central incisors. We worked on the angle lines and incisal battlements, giving the illusion of a narrower and proportional tooth.

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Fig.27
After placing the rubber dam, the gum was gently retracted with a clamp (#212) in order to expose the preparation margin.

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Fig.28
After the rubber dam isolation the tooth are ready to start the bond procedures.

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Fig.29
Try-in of the ceramic veneers with the rubber dam and clamps in position.

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Fig.30
Tooth preparation sandblasting with Cojet system (3M ESPE).
The clean appearance of the tooth surface after sandblasting is observed.

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Fig.31
Application of phosphoric acid and adhesive system (Optibond FL, Kerr) in tooth preparation.

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Fig.32
For the cementation we use a highly filled flowable composite resin with (G-aenial Universal flow, GC).
Light-curing first from palatal side and then for the vestibular side.

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Fig.33
Ceramic veneers after the cementation procedure and after polishing the margins (with ceramic rubbers).

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Fig.34
Immediate result after cementation. Despite the use of rubber dam, note the favorable gum health.

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Fig.35
Immediately result after cementation.

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Fig.36
Polarized picture (Smile Lite) after the cementation of the ceramic veneers. Note the correct chromatic integration of the ceramic restorations with other dental structures.

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Fig.37
Natural integration of ceramic veneers.
The shape and texture reproduced allow a correct and natural integration of the restorations.

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Fig.38
Natural integration of ceramic veneers.

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Fig.39
Natural integration of ceramic veneers.
Details of macro and micro texture.

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Fig.40
Final outcome of the ceramic restorations.

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Fig.41
Final outcome of the ceramic restorations.

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Fig.42
Integration of ceramic restorations with the adjacent structures, teeth, gums and lips.

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Fig.43
Natural integration of the ceramic restorations with the adjacent structures.

Conclusions

Restorative treatments can provide, when properly planned, very natural aesthetic results. It is essential through each phase to achieve this result.
Communication between the different clinicians is also important to the final result, never forgetting to involve the patient in the communication process.
In conclusion, we can say that, for a proper adhesive rehabilitation, it is necessary to follow not only the clinical procedures, but also to use our five senses, to get a natural aesthetic rehabilitation.
I want to thank the whole team who worked on this case, the orthodontic team of the Instituto Superior de Ciências da Saúde Egas Moniz, Ricardo Alves, João Rua and to my friend and ceramist Pedro Brito.

Bibliography

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.

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