Lithium Disilicate Veneers Case Report with No Tooth Preparation

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Lithium Disilicate Veneers: A case report
with no teeth preparation
Dario Adolfi DDS, CDT * Oswaldo Scopin de Andrade DDS, MS, PhD**

18 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011


concept of biomimetic in dentistry implies that any
material utilized for a restoration brings not only the
esthetic and function but also act as it was the tooth;
restoration and tooth become one structure.
For better clinical results the laminate veneer is done
with a ceramic that can be altered by etching the intaglio
surface with hydrofluoric acid 2. Among the materials
available, glass ceramic made on the refractory
die-technique is the most documented because of its
esthetics, biocompatibility, shape and shade stability3.
Even though being a safe and documented procedure, that
permits the technician to obtain veneers as thin as
0.2 mm, many clinicians face difficulties during try-in and
bonding procedures.
This limitation has reduced the utilization of refractory
die-technique in the last two decades. As an option for
this technique leucite pressed ceramic has become popular
among clinicians and ceramists. The advantages of the
leucite pressed ceramic include: less sensitive laboratory
procedures and safer bonding because of better physical
properties. In this manner the technique was easier for the
laboratory and less risky for the clinician4.
However, the first pressed system launched for it
required more space to build a restoration and it was not
life-like when compared with the traditional refractory
die-technique. Even though laminate veneers have started
to be used more and more with pressed ceramic with high
level of acceptance by patients and dentists.
After the rise of the pressed ceramic on the market,
some cases that did not need a preparation to be done
were prepared to obtain clearance for the material that
need around 0.8 mm, to be pressed and then stained.
Nowadays the concept of enamel maintenance and
minimal preparation design restoration bring again the
concept of laminate veneers with minimal or even
without any tooth preparation.
Introduction The development and improvement of lithium
disilicate pressed ceramic has brought the concept back to
The utilization of laminate veneer in anterior dentition is less preparation for laminate veneers5.
the most documented approach in literature for procedures This ceramic permits the technician to build a pressed
such as extensive smile changing. Among the advantages restoration and carefully reduced using rubber wheels and
of this restorative strategy is the possibility of achieving a diamond bur with copious irrigation to less than 0.2 mm,
perfect harmony between soft and hard dental tissue. This with proper resistance to be tried and bonded with much
harmony is possible thanks to the physical properties of less risk when comparing with the traditional porcelain
the ceramic, which remains stable for a long term. made with the refractory die-technique.
However, to obtain a perfect balance besides soft tissue
health and function the clinical success is dependent of a Case Report
major factor: the bonding procedures.
In order to achieve an interaction between dental hard The case described in this article shows an esthetic smile
tissue and ceramic, what is called “bonding”, the structures changing in a young man because of anatomic
must be able to be altered to receive a material that bring irregularities on enamel surface in both arches. After all
together the surfaces creating a perfect interface. The the options have been explained and discussed such as
adhesiveness of the restorative material to be bonded to direct composite resin restorations he chose an esthetic
tooth structure creates a term named biomimetic1. The rehabilitation of the ten maxillary teeth: four incisors,

Spectrum dialogue – Vol. 10 No. 9 – November/December 2011 19


Fig. 1 Fig. 2 Fig. 3

Figs. 1-3: Portrait from the initial situation.

canines and two bicuspid on each side, with lithium • Addictive Wax-up
disilicate pressed ceramic restorations. A gengivoplasty
was performed on the premolars to establish a new line for For every esthetic dental planning a wax-up is indispensable,
gingival tissue and improve the esthetic deficiency in the and for cases where a minimal preparation is planned, the
buccal corridor region. procedure must be done with the additive technique. The
The only requirement asked by the patient was to make wax addition for planning must take in consideration the first
the restoration with no preparation or any enamel analysis of the case, that bring together the teeth
reduction. characteristics, the patient’s smile, the age of the patient, the
opposite arch, the gingival architecture, beyond the
• Diagnostic Approch perception of the patient’s personality8.
In this technique the ceramist adds wax onto the
The initial clinical evaluation includes critical and careful preliminary model based on anatomical parameters of natural
analysis of the occlusal scheme, periodontal examination teeth respecting function and occlusion. In this step, the
followed by a face photography protocol. The canines are technician restores the anterior dentition recovering a
very important in this role, developed with appropriate mimetic appearance but already thinking in how is going to
morphology maintaining adequate functional height, be the final ceramic restoration9. In a case where there will
quantity and quality of disocclusion6. be no temporaries involved the final treatment planning
must be approved by the patient.
• Flapless Esthetic Crown Lengthening The final planned case built in the preliminary model in wax
was transferred to the mouth for clinical evaluation in terms
Specifically for this case, to achieve a better esthetic result of shape, size and length. After the patient approval, all
with a more harmonious gingival contour of the information was collected by the mock-up using digital
premolars, a flapless surgical crown lengthening was photography and alginate impression, to obtain a simulation
planned and executed to develop a new gingival line. The cast. After all the information was collected, the mock-up
final length of the teeth involved were determined based was removed from the mouth and the teeth were pumiced for
on sulcus probing with the patient under anesthesia, to impression procedures.
reach the bone crest, but always avoiding extensive Only some specific sharp angles were removed with a
radicular dentin exposure7. rubber wheel in order to improve the passive fit avoiding any
kind of interference during the cementation procedures.



Fig. 4 Fig. 5

Fig. 6 Fig. 7

Figs. 4, 5, 6, 7: Using the lip retractor initial pictures show the patient compliances, which are enamel defects all over the surfaces of the anterior
maxillary incisors. In the lateral view (right and left), is clear the space between teeth (diastemas). Furthermore, it can be seen a discrete gingival
excess of tissue in the premolars areas.

Fig. 8

Fig. 9 Fig. 10


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Figs. 11, 12, 13, 14:
A mock-up
procedure with a
bis-acryl resin works
as a guide for the
clinician and
technician, besides
acting as a
simulation of the
final result. It was
also possible to
analyze the
necessity of
Fig. 11 extending the
treatment up to the
premolars to
improve the
alignment of the
buccal corridor.

Fig. 12

Fig. 13

Fig. 14


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Fig. 15 Fig. 16

Fig. 17

Fig. 18

Fig. 19

Figs. 15, 16, 17: A flapless gingivectomy was done with sharp instruments
to reshape the level of the tissue determining by the mock up. The
procedures were done on teeth # 3, 4, 5, 12 and 13.

Figs. 18, 19, 20: Three weeks after the surgery. The new gingival line
respects the contour of the anterior teeth line.

Fig. 20



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Fig. 21

Fig. 21: Picture shows the area before the impression procedures; the
placement of the retractor cord is necessary to the lab to develop the
most appropriate emergence profile and ceramic finish line. The
only preparation done was a small opening between the central
incisors for better passive fit during the cementation procedures.

Fig. 22: The impression was done with a PVS based material
(Flexitime-Heraus Kulzer). Fig. 22

Fig. 23 Fig. 24

Figs. 23, 24, 25: A pressed lithium
disilicate ceramic laminates (Emax
Press-Ivoclar Vivadent) for teeth 4
and 14.

Fig. 25

Fig.26: The ten veneers placed on sequence and with the special illumination it is possible to observe how thin the
restorations are .



Fig. 27 Fig. 28

Fig. 29

Figs. 27, 28, 29: Restorations in place with a try-in paste to select the shade of the resin
cement (Variolink Venner-Ivoclar Vivadent), and for patient approval.



Fig. 30 Fig. 31

Fig. 32

Fig. 33 Fig. 34

Fig. 35 Fig. 36



Fig. 37 Fig. 38

Fig. 39

Figs. 30 to 39: Close-up view of the bonding procedure on tooth #11 with the resin cement. It can be
seen that the tooth was pumice before bonding. Another important procedure is to realize one bonding
each time, always protecting the neighboring teeth.

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Fig. 40

Fig. 41

Fig. 42 Fig. 43

Figs. 40 to 46: Final result
after cementation; it’s
possible to see the
integration of the tissue as
well as the importance of
canine guidance to
maintain the occlusal
stabilization.

Fig. 44



Fig. 45

Fig. 46

• Impression of the Teeth cut off using a diamond disc, morphological corrections
are performed placing the laminates on the model and the
A VPS one-step, double mix impression technique, fit is checked at the margin under magnification. After the
brought forth appropriate reproduction of the teeth and contours have been finalized, clean the restorations for 5
surrounding tissues. Two impressions of each arch were minutes in an acetone solution using ultrasonic cleaner .
taken to ensure proper control during laboratory build-up Apply the stain glaze over the surface and body stain A
of the veneers. is first applied in the cervical region. For incisal edge,
A retraction cord was utilized for better visualization of apply blue stain in the approximal area and white stain for
the cervical region to control the finish line and thickness the mamelons. Then, bake in temperature of 770 degrees
of the ceramic material during the laboratory procedures. Celsius to fix these characterizations. If necessary this
process should be repeated until the final result is
Laboratory Procedures achieved. After the fixation, two layers of glaze powder is
applied to protect the characterization and the superficial
Based on all the information obtained from the mock-up, gloss is performed with rubber wheel and pumice powder.
wax-up to the final shape of the final restorations and
then the 10 laminates veneers were injected with the Try-in and bonding procedures
ceramic ingot HT. Carefully divesting using 50µm
alumina sands at a pressure of 58-87 psi( 0.4 MPa- As mentioned, no provisional crowns were used, and for
0.6MPa). Once the pressed veneers are exposed, lower the this reason the periodontal tissue was stable and any
sandblasting pressure to less than 29Psi (0.2MPa) and hemostatic control protocol was not necessary. No cords
continue alumina sandblasting carefully. The sprues are were used for the bonding procedures. For the veneers a



Fig. 47 Fig. 48

Fig. 49 Fig. 50

Figs. 47 to 50: Portrait from the final esthetic outcome.

high translucency lithium disilicate etchable ceramic laboratory technician and the clinicians. The patient was
(Emax Press, Ivoclar Vivadent) was selected. Final luting not anesthetized.
of the ceramic restorations was preceded by a try-in The intaglio surface of the laminate veneers made with
procedure, to select the best shade for the resin cement. Emax Press (Ivoclar Vivadent), a lithium disilicate based
As a thin veneer the final result is also dependant of the ceramic was etched with a hydrofluoric acid (5 to 9%) for
shade of the cement. The try-in was applied and checked 20 seconds. The intaglio surface was washed to remove the
by the clinicians and patient. The approval of final acid and the veneer was placed in a glass recipient with
esthetics by the patient was in agreement with the distilled water, and an ultrasonic cleaner was utilized for



five minutes to remove the residual material originated by Conclusions
surface alteration10. The intaglio surface was dried and a
silane coupling agent applied for two minutes, the The clinical success of a treatment planning execution
evaporation of the solvent was completed with a constant made with laminate veneers is dependent of four majors
blow of air. The restoration was coated with a factors: enamel preservation, bonding procedures and
hydrophobic bonding agent (Heliobond, Ivoclar carefully occlusal adjustments. In additive cases such as
Vivadent), followed by a gentle blow of air, and left the case described it is possible to do an ultra-conservative
uncured at that time. A cover protected the ceramic procedure with all the benefits of the adhesive technology.
veneer during etching dental procedures, to avoid The purpose of this article was to exemplify important
adhesive polymerization. steps to obtain a reliable lithium disilicate esthetic
As a non-preparations veneers the enamel was cleaned restoration, with no preparation.
with a paste with pumice powder and water. Then the References
surface of each tooth was etched with a 37% phosphoric
acid (Ultraetch, Ultradent), for no more than 60 seconds, 1. Magne P, Douglas WH. Porcelain veneers: dentin bonding
optimization and biomimetic recovery of the crown. Int J
washed and dried. The adhesive (Excite, Ivoclar Prosthodont. 1999 Mar-Apr;12(2):111-21.
Vivadent) was applied on the enamel surface, a gentle 2. Duarte S Jr, Phark JH, Blatz M, Sadan A. Ceramic Systems. An
blow of air was applied to thin the adhesive film, and ultrastructural study; Quintessence Dental Technol 2010; 33; 42-60.
3. Calamia JR, Calamia CS. Porcelain laminate veneers: reasons for
cured for 10 seconds. 25 years of success. Dent Clin North Am 2007 Apr; 51(2): 399-
The previous select shade of the light cured resin 417.
cement (Variolink Venner, Ivoclar Vivadent), was applied 4. Kina S, Brugera A Invisible: Esthetic Ceramic Restorations Arte
onto the ceramic restoration and positioned to the tooth. Médicas, Brazil 2007.
5. Scopin de Andrade O, Borges G, Stefani A, Fujiy F, Battistella P. A
After, resin cement was removed carefully and LED light step-by-step ultraconservative esthetic rehabilitation using lithium
(Bluephase, Ivoclar Vivadent), in low power mode was disilicate ceramic. Quintessence Dental Technol 2010; 33: 114-131
utilized for 40 seconds on each surface. A glycerin-based 6. Groten M Complete esthetic and functional rehabilitation with
adhesively luted all-ceramic restorations-case report over 4.5 years.
jelly (Liquid Strip, Ivoclar Vivadent) was utilized to air Quintessence Int 2007Oct;38(9) 723-731.
block and cured again for 20 seconds per surface. The 7. Joly JC, Carvalho PFM, da Silva RC, In: Reconstrução Tecidual
excess of the resin cement was removed with a new and Estética, Artes Medicas, Brazil, 2010, p. 253-309.
8. Gurel G The Science and Art of Porcelain laminate Veneers
sharp scalpel to avoid scratches on the ceramic facial Quintessence Pub 2003, Berlin, Germany.
surface. Only one restoration was cemented each time, as 9. Magne P, Belser UC. Novel porcelain laminate preparation
it is possible to see in the pictures. approach driven by a diagnostic mock-up. J Esthet Restor Dent.
After all the veneers cemented finishing procedures 2004;16(1):7-16.
10. Magne P, Belser UC. Bonded Porcelain Restorations in Anterior
were done with abrasive strips. Occlusal adjustments were Dentition: A Biomimetic Approach. Chicago: Quintessence 2002.
made with a diamond polishing system for ceramic. It is
possible to see the esthetic quality, healthy gingival tissue
and the final smile as requested by the patient.

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