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The tooth structure preservation is the best way to postpone more invasive therapies. Especially in young patients more conservative techniques should be applied. Bonded porcelain veneers and even more the direct composite restorations, are the two therapeutic procedures that require the fewer sacrifice of dental tissue, finalized to the optimal recovery of aesthetic and functional outcome. Although the two techniques require different methods and materials, is possible to achieve a correct integration of both the methods by some technical and procedural measures. In the presented case is planned a rehabilitation of the four upper incisors by ceramic veneers and direct composite restorations. Care is taken for the surface treatment of ceramic restorations, with the objective of achieving integration, not only between natural teeth and restorations, but also between the different materials in use. The purpose of this article is to show how a proper design of the treatment plan leads to obtain predictable results with both direct and indirect techniques.
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Annali di stomatologia
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Esthetic integration between ceramic veneers and composite restorations: a case report
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Esthetic integration between ceramic veneers and composite restorations: a case report
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                                                                                                                 Case report


Esthetic integration between ceramic veneers
and composite restorations: a case report




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                                                                                              na
Davide Farronato, DDS, PhD1                                    Introduction
Francesco Mangano, DDS2




                                                                                           io
Stefano Pieroni, MD1                                           Ceramics and composites present different superficial
Giuseppe Lo Giudice, MD4                                       nano-texturing and this leads in a different light reflection
Roberto Briguglio, MD3                                         at the surface. In the esthetic zone this difference could
Francesco Briguglio, DDS, PhD1                                 represent a limit to the choice of the restoring material be-




                                                                                        az
                                                               cause the two substances differently interact with the
                                                               light incidence. If little amount of saliva wets the surfaces
1
    Department of Prosthodontic and Implantology,              this difference can be noticed as shiny and well defined
    Fondazione IRCCS Ca’ Granda, University                    glassy reflections on the ceramics against matte and




                                                                        n
    of Milan, Italy                                            blurred reflections on the composites.
2
    Department of Biomaterials Science, Università             There are techniques that allow to manually polish the ce-




                                                                     er
    dell’Insubria, Varese, Italy                               ramic surface in order to maintain a certain grade of nano
3
    Department of Periodontology University                    roughness at the surface, such to obtain a composite like
    of Messina, Italy                                          reflection of the light.
4


    of Messina, Italy
                                           nt
    Department of Restorative Dentistry, University            In the presented case is described a solution to obtain fine
                                                               integration between the two materials. The technician
                                                               was requested to manual polish the ceramic surfaces in
                                                               order to achieve the same light reflections characteristic
                                         iI
Corresponding author:                                          of composites, by keeping a lightly augmented roughness.
Francesco Briguglio, DDS, PhD
Department of Prosthodontic and Implantology,
                                       on

Fondazione IRCCS Ca’ Granda, University of Milan, Italy        Case presentation
Via Commenda, 10
20100 Milano, Italy                                            The patient at the end of orthodontic treatment presents
Phone: +39 3392034125                                          aesthetic problems in the upper frontal area. In particular,
                               i


E-mail: fra.briguglio@alice.it                                 clinical examination detects inadequate composite
                            iz


                                                               restorations at 1.1, 1.2 e 2.1; tooth 2.2 is conoid and pres-
                                                               ents inter-proximal diastema.
Summary                                                        2.1 presents root canal filling, while the other tooth of the
               Ed




The tooth structure preservation is the best way to post-      sextant presents vital with optimal periodontal tissues.
pone more invasive therapies. Especially in young pa-          Light discolorations affect 1.2 and 2.1 (Fig. 1).
tients more conservative techniques should be applied.         Direct multilayered composite restorations upon 1.1, 1.2
Bonded porcelain veneers and even more the direct              e 2.3 and bonded feldspathic porcelain veneers at 2.1 and
composite restorations, are the two therapeutic proce-         2.2 are programmed to finalize the case (3-5).
dures that require the fewer sacrifice of dental tissue, fi-
 IC




nalized to the optimal recovery of aesthetic and func-
tional outcome.
Although the two techniques require different methods
and materials, is possible to achieve a correct integration
C




of both the methods by some technical and procedural
measures. In the presented case is planned a rehabilita-
tion of the four upper incisors by ceramic veneers and di-
rect composite restorations.
©




Care is taken for the surface treatment of ceramic
restorations, with the objective of achieving integration,
not only between natural teeth and restorations, but also
between the different materials in use.
The purpose of this article is to show how a proper de-
sign of the treatment plan leads to obtain predictable re-
sults with both direct and indirect techniques.                Figure 1. Frontal view at baseline: the patient presents ameloge-
                                                               netic defects at 1.2, old and inadequate composite restorations
Key words: ceramic veneers, composite resin, esthetic          at 1.1. The tooth 2.1 is devitalized, discolored and widely restored
rehabilitation, mimetic restoration.                           by composite, 2.2 is conoid and presents inter-proximal diastema.


132                                                                              Annali di Stomatologia 2012; III (3/4): 132-137
Esthetic integration between ceramic veneers and composite restorations: a case report


Materials and Methods

The early stages of the project include the creation of a
diagnostic wax-up based on aesthetic directions. A trans-
parent silicone index (Regofix, Dreve Dentamid GmbH,




                                                                                                        li
Germany), built from the additive wax-up, is made to
simulate the final outcome in patient’s mouth through a di-




                                                                                                     na
rect mock-up6 through a self curing resin (Fig. 2).




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                                                                                n              az
                                                                             er
    Figure 2. The transparent silicone index (Regofix, Dreve Den-
    tamid GmbH, Germany) is the impression of the wax-up and is



                                                  nt
    used to obtain the direct mock-up. Acetate matrixes are embed-
    ded in cuts made in the interproximal areas. These divisions help
    finishing the mock-up into the interproximal areas.
                                                iI
The mock up is helpful to establish phonetic, functional
and aesthetic limits (Fig. 3) and at an extra-oral view,                Figure 4. Extra oral view of the mock-up: patient’s face and
asymmetry is shown related to the face and the smile-line,
                                              on

                                                                        smile-line is asymmetric and gummy-smile is present.
which is angled to the left. It is also shown a high smile-
line with wide exposure of keratinized gingiva. The devel-
opment of the lower lip follows the front incisal edge with             Adhesion interfaces are prepared (Clearfil Se-Bond, Ku-
an asymmetric posture (Fig. 4).                                         raray Medical Inc., Japan) (Fig. 5).
                                     i


                                                                        The transparent silicone index is used as template for the
                                  iz


                                                                        palatal and interproximal composite layers. Acetate ma-
                                                                        trixes are embedded in cuts made in the interproximal ar-
                                                                        eas. Buccal surface of the silicone is cut approximately
                  Ed




                                                                        0,3 mm apical to the incisal edge, thus providing informa-
                                                                        tion about the thickness of the incisal portion of the
                                                                        restoration.
                                                                        On the silicone index, extraorally, are located resin com-
                                                                        posite masses avoiding light-curing: a thin layer of enamel
                                                                        is painted into the matrix and incisal halo is drawed by the
 IC




                                                                        use of staining resins.


Figure 3. Mock-up in position: phonetic and aesthetic consider-
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ations can be done and any mock-up modification has to be reg-
istered by a new impression. The silicon was rebased with a self-
curing resin composite without preparing for adhesion.
©




Adaptation of the modified mock-up are registered
through an impression to be sent to the technician. New
templates with the morpho-functional update are required
for the following sessions. The technician also provides
temporary resin veneers for 2.1 and 2.2.
Previous restoration are removed and sections of the
new template are used as a reference.
Operating field’s isolation is obtained by rubber dam sta-              Figure 5. The old composite and the enamel defect are removed,
bilized by knotting Gore wire (Glide, Crest, Toronto).                  surfaces are smoothed and prepared for adhesion.


Annali di Stomatologia 2012; III (3/4): 132-137                                                                                  133
D. Farronato et al.


Index is placed in mouth with the composite still uncured.           Tooth number 2.3 is shaped with mesial and incisal incre-
A good control of ambient lighting is necessary in order to          ments with the aim of improving relations with the lip and
avoid unintended polymerization. Furthermore, it is rec-             harmony of the smile line without interefring with the ca-
ommended to use heated composite, in order to better                 nine guidance.
spread the masses in thin layers.                                    Tooth 2.1 and 2.2 are prepared using the template as a




                                                                                                     li
After curing the template is removed (the matrix can be              reference. A map of the discromies was drawn for the tec-
lived in the mouth) and the reconstructions of 1.1 and 1.2           nician using 3D Master as a reference and pictures were




                                                                                                  na
can begin (Fig. 6).                                                  captured and sent to the tecnician.
                                                                     Temporary veneers (Fig. 8) are rebased in mouth with
                                                                     flowable composite. Regofix index is used as a guide, so
                                                                     that the provisional restorations are placed in the right po-




                                                                                               io
                                                                     sition. Resin veneers are bonded according with spot
                                                                     etching technique (10) (Fig. 9).




                                                                             n              az
                                                                          er
Figure 6. A silicon index guided the palatal and incisal edges
shaping.



                                               nt
The masses of dentin are stratified with cromaticity desat-
urated from cervical to incisal and from palatal to buccal
                                             iI
(from A4 to A2).
                                                                     Figure 8. Temporary resin veneers on the model.
Among dentinal mamelons, the three-dimensional effects
and the translucence effects, are obtained by the applica-
                                           on

tion of characterizations like Opalescent Blue; a thin layer
of ocher is spread at the incisal third. A final layer of
enamel is spread to finalize the facial surface of the
restorations (Fig. 7), which is thoroughly cured under
                                 i


oxygen insulation (glycerol).
                              iz
              Ed
 IC




                                                                     Figure 9. Temporary veneers are cemented with the spot etching
                                                                     technique.


                                                                     Patient is discharged and followed weekly. A month later
C




                                                                     lip’s profile and smile line are positively evaluated.
Figure 7. The restoration are ultimated and are ready for the fin-   After removing the temporary restorations, preparations
ishing.                                                              are polished using sonic and ultrasonic instruments
                                                                     (Figs. 10, 11). The final impression is taken and the tech-
©




                                                                     nician can ultimate the ceramics. A Try-In simulation is
Masses of composite enamel should be thinner than the                tested to ceck the optimal shading of the discromies and
one of natural teeth, in order to avoid inconsistencies in           the bleaching of 2.1 was confirmed to be unnecessary.
value (7-9).                                                         The cementation of the two porcelain veneers (3M Re-
Interproximal and palatal portions are finished by the use           liX) is performed to complete the treatment (11) (Figs.
of burs and abrasive strips.                                         12, 13).
Surfaces’ polishing is performed with diamond teflon                 Essential shrewdness is to ask the technician to avoid mir-
brushes mounted on the handpiece and diamond pastes                  ror-glazing ceramics to simulate the composite gentile
applied with cotton pads at high-speed.                              opacity (12) (Fig. 14).

134                                                                                   Annali di Stomatologia 2012; III (3/4): 132-137
Esthetic integration between ceramic veneers and composite restorations: a case report




                                                                                                       li
                                                                                                    na
                                                                                                 io
Figure 10. Tooth preparation before the cementation of the ce-
ramic veneers: frontal view. 2.1 was quite damaged and a large
amount of dentine was exposed: it needed an extended prepa-




                                                                                              az
ration to the palatal side to gain enamel adhesion at the veneer     Figure 14. Two months follow-up: frontal view.
edges.

                                                                     At two years follow up the result is stable (Figs. 15, 16).




                                                                              n
                                                                     The new tooth profiles has allowed an improved lip sup-
                                                                     port and a propioceptive conditioning of the development




                                                                           er
                                                                     of the lower lip during the smile gesture. Dental relations
                                                                     seems harmonic and smile’s horizon has a good link with
                                                                     the lower lip line reducing the original sense of asymme-
                                                                     try (13) (Figs. 17, 18).


                                               nt
                                             iI
                                           on

Figure 11. Tooth preparation before the cementation of the ce-
ramic veneers: occlusal view. The conoid is slightly prepared such
to obtain a good ceramic support at the interproximal areas.
                                 i
                              iz
              Ed




                                                                     Figure 15. Two years follow-up: zoom of the veneers edges.
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Figure 12. Veneers before the cementation: frontal view.
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©




                                                                     Figure 16. Two years follow-up: the result is stable and the opac-
Figure 13. Veneers before the cementation: internal view.            ity of both ceramics and composites is still similar.


Annali di Stomatologia 2012; III (3/4): 132-137                                                                                   135
D. Farronato et al.


                                                                      tions associated to composite veneers at 2.1 and 2.2. The
                                                                      option was excluded, because at the time of the treatment
                                                                      the literature was not able to show evidence of pre-
                                                                      dictable results at long therms follow-up. Nowdays this
                                                                      treatment option could support interesting discussions.




                                                                                                         li
                                                                      The treatment option choosed with the patient was rep-
                                                                      resented by the optimal solution with a modication of the




                                                                                                      na
                                                                      ceramic surface: direct multilayered composite restora-
                                                                      tions on 1.1, 1.2 e 2.3 and bonded feldspathic porcelain
                                                                      veneers at 2.1 and 2.2. The technician was requested to
                                                                      manually polish the ceramic surface in order to maintain




                                                                                                   io
                                                                      a certain grade of nano roughness at the surface, such to
                                                                      obtain a composite like reflection of the light. The solution
                                                                      leads a good integration between composite and porce-
                                                                      lain restorations.




                                                                                                az
Figure 17. The new tooth profiles has allowed an improved lip         Some authors are convinced that a good polishing can
support and a propioceptive conditioning of the development of        substitute a heat glazing of ceramics, even if the clean-
the lower lip during the rest gesture.                                ing capabilities of the smear layer is lightly different (1,2).
                                                                      Considering the accessibility of the site this was not con-




                                                                               n
                                                                      sidered a consistent problem against the possibility to
                                                                      achieve a good integration between adjacent composite




                                                                            er
                                                                      and porcelain restorations.
                                                                      Furthermore the Try-in simulations revealed that bleach-
                                                                      ing of 2.1 was unnecessary to achieve the expected re-


                                               nt                     sult, because the composite chosen for the cementation
                                                                      of 2.1 was sufficient to mask the light discoloration.
                                             iI
                                                                      Conclusion

                                                                      For aesthetic restorations, both porcelain veneers and
                                           on

                                                                      composite restorations are predictable treatments (14-16).
                                                                      To achieve a good integration in the appearance and in
                                                                      the form, two points are essential: a close collaboration
Figure 18. Dental relations seems harmonic and smile’s horizon
                                                                      with technician allows a correct design of the case through
has a good link with the lower lip line reducing the original sense
                                  i


of asymmetry.
                                                                      the basic steps of diagnostic wax-up and direct mock-up.
                               iz


                                                                      Secondarily particular attention must be dedicated to the
                                                                      surface finishing of ceramic that has to mimic the slight
Discussion                                                            surface roughness typical of many composites subjected
               Ed




                                                                      to function’s wear and to abrasive toothpastes (12).
The treated patient showed a wide smile and elevated ex-
pectations in terms of aesthetic and conservativity. The
optimal treatment options between the frontal teeth were              References
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                                                                           ramics. Coll Antropol. 2010; 34:235-8.
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                                                                      2.   Aykent F, Yondem I, Ozyesil AG, Gunal SK, Avunduk MC,
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                                                                           Ozkan S. Effect of different finishing techniques for restora-
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                                                                           tive clinical investigation of extended ceramic veneers. Dent
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Annali di Stomatologia 2012; III (3/4): 132-137                                                                                      137
