Fig.1
Frontal pre-op view

Fig.2
Right pre-op view

Fig.3
Left pre-op view

Fig.4
The smile of the patient

Fig.5
A silicone key is made to transfer the wax-up into the mouth

Fig.6
Teeth are easily isolated with teflon tape in order to have a quick excess removal

Fig.7
A self-curing composite (DMG Luxatemp Star) is really useful to easily transfer the mock-up into the mouth

Fig.8
After insertion of the silicone key, excess material is quickly removed with a micro brush

Fig.9
Thanks to the mock-up, the patient can understand our project and have an instant preview of the final result. It’s also very helpful for the clinician to make an evaluation of the wax-up, both from an aesthetic and functional point of view.

Fig.10
The smile line with the mock-up.
The patient can also be sent home with the mock-up in, and ask for a comment from relatives and friends.

Fig.11
During the next appointment a new mock-up is placed, and depth cuts are made with a diamond bur to guide the preparation.

Fig.12
With a pencil we can underline the depth cuts, in order to have a better control of the preparation. Making the initial preparation through the mock-up is a great help to be as  conservative as we can.

Fig.13
We can see that in some areas we still have the mock-up resin.

Fig.14
Where the mock-up resin is still in place, no the restoration will be performed at all.

Fig.15
It’s always important to check the thickness of the preparation with some silicone indexes.
With this one, we can control the middle third of the buccal surface from an incisal point of view.

Fig.16
With this one we can check the preparation of the incisal edge, understanding that we need to correct something.

Fig.17
The view from the right.

Fig.18
After some corrections we can check again with the same index.

Fig.19
Now it’s time to bring the cervical margins right where we want them to be, with the help of a retraction cord.
In this case we have no color problems, so we can keep the margins out of the gingival sulcus.
It’s much easier to prepare extra-gingival margins, to take a good impression, to isolate during cementation, to clean cement excess, to control as time passes and – last but not least – it’s easier for the patient to properly brush.

Fig.20
Cervical margins are placed near the gum, but definitely in an extra-gingival position.

Fig.21
View from the right.

Fig.22
View from the left.

Fig.23
A new retraction cord is placed in order to take the impression

Fig.24
After the impression, face bow registration is made.

Fig.25
Shade guide samples are used to take color picture for the lab.

Fig.26
Now it’s time to build up the temporary restoration. Teflon tape is placed to easily remove the excess of the material.

Fig.27
The patient had some problems in finding time for the cementation appointment, so we needed to wait more than 3 weeks.
This is quite a long time for such a thin and extended temporary restoration, so we decided to use a strong material (DMG LuxaCrown), in order to minimize the risk of fracture.

Fig.28
The material is really aesthetic, the surface luster is high and easy to obtain. This is the smile line with the temporary restoration.

Fig.29
Impressions, registrations, face bow, pictures and a couple of small videos are sent to the dental technician, Pasquale Casaburo.

Fig.30
Pasquale Casaburo starts layering the ceramics.

Fig.31
He’s adding several different ceramics to give a natural effect, with a lot of characterizations.

Fig.32
Veneers finally arrive from the lab.
VeneerMe is a smart tool to handle, move, treat, wash and clean veneers and all other kind of indirect restorations.

Fig.33
Temporary restorations are removed and ceramic veneers are tried with some try-in paste (DMG Vitique) to imitate the influence of the cement.

Fig.34
Complete isolation of the operative field is easily obtained thanks to the rubber dam, and essential instrument during adhesive procedures. Extra-gingival margins are isolated very quickly with additional clamps.

Fig.35
Now it’s time to try the veneers again, just to be sure that rubber dam is not preventing proper sitting of the work.

Fig.36
Teflon tape is applied on neighboring teeth to prevent contamination, and a dental adhesive is applied to the preparation.

Fig.37
The inner surface of the veneer is etched with hydrofluoric acid for 60 seconds.

Fig.38
Thanks to VeneerMe it’s really easy and safe rinsing with water, with no risk of the veneer falling down.

Fig.39
After completely drying the surface, a 2 component silane (DMG Vitique Silane) is applied for 60 seconds and gently dried with warm air blowing.

Fig.40
Then, a layer of bonding resin is applied both on the veneer and on the preparation without curing, followed by a drop of resin cement (DMG Vitique). After an easy excess removal, everything is light cured for 1 minute.

Fig.41
The whole procedure is repeated step by step, tooth by tooth. As we proceed, the more we have to carefully try the correct sitting of the veneer: the risk of a small excess of adhesive or cement interfering is pretty high.

Fig.42
Once every veneer has been luted, a layer of glycerine gel is applied over the teeth to completely light cure without oxygen.

Fig.43
Finishing and polishing procedures are made very carefully, starting with a sharp instrument (Eccesso from Styleitaliano LM Arte kit), continuing with low grit diamond burs, silicone tips, polishing stripes and diamond pastes. Occlusion is checked as well.

Fig.44
After 2 weeks gums are healthier, the chromatic integration is good, and the patient is very enthusiastic about the result!

Fig.45
The final smile of the patient.

Fig.46
Pictures made with a smartphone (MDP by prof. Louis Hardan).

Conclusions

We can really enjoy clinical cases like this one, if we follow protocols and team-work with a good dental technician. Everything starts with a good documentation, impressions, pictures, videos and a thorough chat with the patient, to understand what he’s expecting from us. A correct wax-up and the following make-up are crucial to communicate to the patient, and to understand if our project is fine. In veneer cases the temporary restoration is often tricky, because of the poor retention and the low thickness of the material. When we have time troubles we need for sure to pay attention to choosing the right material and technique. During cementation is always important to take your time and carefully take care of every step, tooth by tooth.

A big thank you to Pasquale Casaburo is mandatory, he’s a very talented dental technician and his help and support are always crucial.

Bibliography

1. Manauta J, Salat A. Layers: an atlas of composite resin stratification. Quintessence 2012.2. Magne P, Magne M. Use of additive waxup and direct intraoral mock-up for enamel preservation with porcelain laminate veneers. Eur J Esthet Dent. 2006 Apr;1(1):10-9.3. Galip G. The science and art of Porcelain Laminate Veneers , London, Quintessence, 20034. Gürel G. Porcelain laminate veneers: minimal tooth preparation by design. Dent Clin North Am. 2007 Apr;51(2):419-31, ix.