56 INSIDE DENTISTRY | October 2010 | insidedentistry.

net
S
ince their develop-
ment in the 1980s,
porcelain veneers
have undergone a
major metamorpho-
sis.
1
From minimally
prepared teeth utiliz-
ing feldspathic porcelain (0.3-mm to
0.5-mm preparation) to pressed ceram-
ics (0.7 mm or more preparation) such
as the IPS Empress

system (Ivoclar
Vivadent, www.ivoclarvivadent.us), to
the minimal- and no-preparation ve-
neers of today, ceramics have evolved
to meet the needs of practitioners and
patients alike.
With the introduction of products
made from lithium disilicate, such as
IPS e.max

(Ivoclar Vivadent), todays

no-preparation veneers are highly es-
thetic and extremely strong. A exural
strength of 400 MPa also allows the
practitioner to make them very thin.
2

IPS e.max restorations give dentists
the ability to provide excellent esthet-
ics and functionality, with minimal
preparation and/or damage to the
surrounding soft tissue and dentition.
2
The preparation for these products
is minimal compared to conventional
full crowns, which significantly de-
creases the risk of pulpal damage.
2

Also, there are less periodontal issues
because the margins of the veneers are
thin and usually end at or just above
the free gingival margin.
2
In proce-
dures that involve porcelain veneers,
the preparation should be kept in the
enamel whenever possible.
3
As the
linguals of the anterior teeth are usu-
ally left intact, the occlusion and ante-
rior guidance can also be more easily
maintained.
3
The nal esthetic result,
however, depends on the practitioners
communication with the laboratory
technician and the laboratory techni-
cians artistic ability.
3
Case Study
A 22-year-old man presented with the
chief complaint of shifting dentition
and spatial issues between his front
teeth (Figure 1 and Figure 2). These
issues developed upon completion of
orthodontic treatment 5 years earlier,
and he did not like the large diastema
between his central incisors.
A comprehensive oral evaluation was
completed, which included a temporo-
mandibular joint disorder (TMJ) ex-
amination and a periodontal evaluation,
including panoramic and full-mouth
radiographs. A series of photographs,
a bite registration, and impressions for
study casts also were taken. His TMJ
presented as asymptomatic, but there
was evidence of parafunction. His lip-
at-rest photograph also revealed that
he did not display enough of his cen-
tral incisors for someone his age. The
patients maxillary anterior teeth ap-
peared esthetically displeasing due to
a reverse smile line that resulted from
the unusually short central incisors.
The patients anterior teeth also di-
verged in different directions. Ideally,
the axial alignment of his front teeth
should have had a mesial inclination
toward the midline, beginning from
the central incisors and extending to
the canines.
4

Diferent options were discussed,
such as orthodontics, direct bonding,
and porcelain veneers. The patient
previously had orthodontics and did
not want to have that treatment again.
Direct bonding was also a possibil-
ity, but it would be difcult and time-
consuming to correct the problems.
Porcelain veneers were part of his treat-
ment plan for teeth Nos. 6 through 11.
Laboratory Procedure
Initially, the study casts, bite registra-
tion, and photographs were sent to the
dental laboratory for evaluation. A re-
duction guide was also made to prepare
the teeth for movement into a more fa-
vorable alignment. Prior to completion
Using Minimally
Invasive Veneers to Close
Anterior Diastemas
New ceramic materials facilitate a more conservative approach that can produce stronger,
highly esthetic restorations with minimal trauma to patients teeth.
By Brian Dennis, DDS | Bradley L. Jones, FAACD
PRETREATMENT AND WAX-UP (1.) Preoperative portrait of the patients
face and smile. (2.) Preoperative close-up of the patients smile. (3.) The
diagnostic wax-up was completed. (4.) The preparation procedure for the
veneers consisted of making 0.5-mm depth cuts into the provisionals. (5.)
Close-up of the patients smile with the provisionals in place.
FIG. 2
FIG. 4
FIG. 3
FIG. 5
FIG. 1
BRADLEY L. JONES,
FAACD
Private Practice
Boise, Idaho
BRIAN DENNIS, DDS
Private Practice
Albuquerque, New Mexico
PRACTICE BUILDING | ROUNDTABLE | RESEARCH & APPLICATIONS
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of a diagnostic full-contour wax-up,
the teeth on the cast were reduced to
contour (Figure 3). A study cast, with
mock preparations for the veneers, was
also fabricated and used as a guide for
the reduction of teeth Nos. 6 through 11.
Clinical Preparation
Preoperative shades were taken using a
VITA shade guide (Vident, www.vident.
com), followed by digital photographs to
communicate the correct shading to the
laboratory. The patient was then anes-
thetized using lidocaine with epineph-
rine 1:100,000. The reduction guide was
placed over the teeth and the facial sur-
faces of the central incisors. The cusp tip
areas of the canines were then contoured
using a high-speed NSK electric hand-
piece and a KS1 diamond bur (Brasseler
USA, www.brasselerusa.com).
The putty matrix was then placed in
the mouth to ensure a proper t. It was
lled with a bis-acryl resin (TurboTemp,
Danville Materials, www.danvillemate-
rials.com) and placed over the anterior
teeth, then removed. Upon discussion
with the patient, he was satised with
the appearance of the mock-up. Using
the mock-up as a guide, the teeth were
prepared for the porcelain veneers.
First, the incisal edges were reduced
with a depth cut of 1.5 mm using the
KS1 bur and connection of the depth
cuts to produce a uniform incisal edge.
Next, using an 834-016 bur (Brasseler
USA) as a guide, depth cuts of 0.5 mm
were made across the facial surfaces
(Figure 4). The initial depth cuts were
then connected using a KS1 bur to cre-
ate a uniform facial surface without
sharp internal angles. The interproxi-
mal margins were extended lingually
with a KS0 bur (Brasseler USA).
The margins for the veneers were car-
ried to the free gingival margins with the
KS1 diamond bur, using a Zykra retrac-
tor, to protect the gingival area from
being abraded. The margins were then
finished with a 661-420 white stone
(Brasseler USA). A 0053 brown rubber
point (Brasseler USA) was used on the
highest speed setting to leave a smooth
nish on the enamel surfaces.
Stumpf shades of the prepared teeth
were taken with the VITA shade guide
and photographed. An initial polyvinyl
impression (Aquasil, DENTSPLY Caulk,
www.caulk.com) was taken and poured
in stone (Denstone, Heraeus, www.her-
aeus-dental-us.com) to fabricate the pro-
visional restorations. A nal impression
LABORATORY FABRICATION (6.)
Wax was injected through the
putty matrix onto the master dies.
(7.) IPS e.max, Impulse Value 1,
was then pressed to a thickness of
0.5 mm. (8.) View of the markings
made on the restorations to show
the specic depths and tapers to
be cut into the restorations. (9.)
Utilizing a center diamond disc, an
undercut was made to guarantee a
halo at the end of the process.
LAYERING EFFECTS (10.) Deep
mesio-incisal and disto-incisal troughs
were cut to create a natural low-val-
ue efect. (11.) High- and low-value
internal stain efects were added to the
restorations to create an esthetically
pleasing result. Gray stain was also
added to the mesio-incisal and disto-
incisal troughs for even more esthetic
value. (12.) IPS e.max Light MM powder
was then used, with a single segment
of Salmon MM in the middle lobe,
to make up the internal mamelons.
White dentin powder was then feath-
ered over the ends of the mamelons
and into the middle cervical. (13.) To
nish the internal powder efects,
Light MM was added to the incisal
edge to nalize the halo efect.
FINAL LAYERING AND FIRING
(14.) View of the red internal
efects prior to the enameling
process. (15.) Segmental enamel
layering was accomplished with
a low-value opal and a high-value
tagged blue enamel powder. (16.)
Image of the segmental enamel
after the ring process. (17.) After
using a medium diamond disc to
smooth the surface, the line angles
were created and the heights of
the contour were established. The
deected and reected zones also
were incorporated at this time.
FIG. 8 FIG. 12 FIG. 16
FIG. 9 FIG. 13 FIG. 17
FIG. 6 FIG. 10 FIG. 14
FIG. 7 FIG. 11 FIG. 15
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58 INSIDE DENTISTRY | October 2010 | insidedentistry.net
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was then made of the maxillary arch using
the PVS materials.
Using a duplicated model of the diag-
nostic wax-up, a provisional vacuum-
formed matrix was made (Copyplast

,
Scheu-Dental GmbH, www.scheu-dental
.com) using a positive-pressure thermal-
forming machine (Biostar

/MiniSTAR

,
Scheu-Dental GmbH). The matrix was
then lled with shade A1 TurboTemp
and placed over the preparations.
The provisional restorations were
removed from the cast in one piece and
then trimmed to t the teeth. Once the
provisional was completed, it was tried
in to verify t, esthetics, and phonetics.
Upon patient approval, the provisional
was taken back to the laboratory and
coated with Palalseal (Heraeus) to give
it the smooth appearance of the sur-
rounding dentition.
Teeth Nos. 6 through 11 were then
etched for 15 seconds with 37% phos-
phoric acid (Ultradent Products Inc,
www.ultradent.com), followed by rins-
ing. Gluma (Heraeus) was then applied
to all of the teeth to kill bacteria and de-
sensitize them. The provisionals were
then lled with a owable composite
(Accolade, Danville Materials) in shade
A1 and seated on the teeth.
The excess resin was removed with
a No. 3 synthetic brush (Cosmedent
Inc, www.cosmedent.com) and then
light-cured. Care was taken to remove
any residual composite, and then the
occlusion was checked with articulat-
ing paper (AccuFilm, Parkell Inc, www.
parkell.com). The provisionals were ad-
justed and polished. Photographs of the
provisionals and an alginate impression
were taken to communicate specica-
tions to the laboratory (Figure 5).
Laboratory Fabrication
The first step of the laboratory fabri-
cation process was to inject the matrix
from the approved provisional model
onto the prepared master dies (Figure
6). Once completed, a medium translu-
cency lithium disilicate ingot (IPS e.max
Impulse Value 1, Ivoclar Vivadent) was
pressed to a thickness of 0.5 mm (Figure
7). The restorations were marked for a
0.5-mm reduction on the facial (Figure
8). A 9001 contour stone (Komet USA,
www.kometusa.com) was utilized at a
low setting to reduce 0.5 mm of the in-
cisal facial area and to taper the face of
the restorations. Next, a K6974 cintered
diamond disc (Komet USA) was used
to undercut the restorations (Figure 9).
It was also necessary at this time to cut
a deep mesio-incisal and disto-incisal
trough to create a natural low-value ef-
fect (Figure 10).
High and low internal staining ef-
fects were then utilized, with gray stain
added to the mesio-incisal and disto-in-
cisal troughs (Figure 11). After staining,
IPS e.max Light MM powder (Ivoclar
Vivadent) was used, with a single seg-
ment of Salmon MM in the middle lobe
to compensate for the internal mamel-
ons (Figure 12).
A white dentin powder (IPS e.max,
shade 0E3, Ivoclar Vidadent) was then
feathered over the mamelons and the
cervical middle. The internal powder
efects were nished with the addition
of IPS e.max Light MM to the incisal
edge (Figure 13). Once all internal ef-
fects were completed, they were red in
preparation for the enameling process
(Figure 14).
A low-value opal and a high-value
tagged blue enamel powder (IPS e.max
shades 0E1 and TI1, respectively) were
layered in segments until the restoration
appeared esthetically correct (Figure
15). Upon completion, the segmental
enamel was fired (Figure 16). A me-
dium diamond 842 disc (Komet USA)
was used to smooth the surface, create
line angles, and establish the heights of
the contour (Figure 17). The 842R disc
was then used to dene the surface lobes
and morphology. Once the restorations
were glazed and polished, they were sent
to the practitioners ofce for nal place-
ment (Figure 18 and Figure 19).
Clinical Procedure
Using a medium-value try-in gel (Vario
link Veneer MVO, Ivoclar Vivadent), each
veneer was tried in to verify the t and
path of insertion. Clinical photographs
were taken to check the appearance of the
veneers. The try-in paste was removed
from the veneers, and each veneer was
steam-cleaned to remove contaminants.
The veneers for the central incisors
were first treated with a conditioner
(Clearfil porcelain bond activator,
Kuraray Dental, www.kuraraydental.
com) for 20 seconds and lightly cleansed
with air. A bonding agent (Clearfil
Photobond, Kuraray Dental) was then
placed in the veneers and lightly air-
blown to remove the volatile monomers.
After Variolink Veneer was placed in the
veneers, they were set in a Resin Keeper
(Cosmedent).
The prepared teeth were isolated
with the cheek and lip retracted, us-
ing OptraDam (Ivoclar Vivadent) and
cotton rolls were placed in the buccal
vestibule. The veneers were cemented
in pairs, the central incisors, teeth Nos.
10 and 11 and teeth Nos. 6 and 7. The
central incisors were etched with 37%
phosphoric acid for 15 seconds and
rinsed. Gluma was then applied to
the central incisors. Photobond was
dispensed, mixed, and placed with a
micro-brush on teeth Nos. 8 and 9. The
teeth were then dried with an air dryer
(A-dec Inc, www.a-dec.com).
Next, the veneers on Nos. 8 and 9
were placed and seated in their nal
position. The gingival margins of the
veneers were then light-cured for 5 sec-
onds to tack them into place. Using a No.
6 sable brush (Cats Tongue, Princeton
Art and Brush Co, www.princetonart
andbrush.com), the excess resin was
removed facially, lingually, and inter-
proximally. The veneers were cured
for 20 seconds on the facial and lingual.
DeOx

(Ultradent Products) was placed

around the margins of the veneers,
which were light-cured for 40 seconds,
facially and lingually. The DeOx was
rinsed-of, and residual cement was
removed from the distal.
The veneers for teeth Nos. 6 and 7
were tried on as a pair to ensure that
they would t. The veneers for teeth
Nos. 10 and 11 were tried on as well.
However, once the rst two veneers
were cemented, the lateral incisors and
canine did not t completely in place.
This was the case with tooth No. 7 as
well. Using a 952 Vision Flex diamond
disk (Brasseler USA), the distal of tooth
No. 8 was lightly bufed until the veneer
for tooth No. 7 seated completely.
The veneers were cleaned with the
steamer and treated with silane and
Photobond. The veneers were then
lled with Variolink Veneer and placed
in the Resin Keeper. Teeth Nos. 10 and
11 were etched with 37% phosphoric
acid, and the veneers were seated. This
procedure was repeated with teeth Nos.
6 and 7.
insidedentistry.net | October 2010 | INSIDE DENTISTRY 59
Very little resin needed to be cleaned
up, and residual cement was removed
with a No. 12 scalpel. Floss was used
to remove any cement left interproxi-
mally and to administer a nal check of
the contacts. Acculm was then used
to mark the occlusal contacts, and any
occlusal discrepancies were adjusted.
During a follow-up visit, periapical
radiographs were taken to check for
any cement that may have been un-
der the gingiva. Occlusion was then
marked and adjusted once again. An
upper alginate impression was taken
for use in fabricating a maxillary oc-
clusal appliance to help protect the
veneers and the rest of the teeth from
parafunction.
There were several areas where the
gingiva was still slightly inamed, and
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FINAL RESULTS (18.) A retracted postoperative view of the patients restorations. (19.) Postoperative portrait of the
patients face and new smile.
FIG. 19 FIG. 18
the contour of the gingiva around tooth
No. 8 did not match that of tooth No. 9.
Topical anesthetic was placed on the
gingival of tooth No. 8, and a single wire-
tipped electro-surgery unit (Parkell)
was used to sculpt the gingiva slightly
on the distal half.
Conclusion
Advances in new ceramic materials
such as IPS e.max lithium disilicate
allow clinicians and laboratory tech-
nicians to take a more conservative
approach when removing tooth struc-
ture to ensure that as little is removed
as possible. With new material inno-
vations, it is now possible to provide
highly esthetic restorations that are
stronger and procedures that are less
invasive, causing minimal trauma to
teeth.
References
1. Rufenacht CR. Fundamentals of Esthetics.
Hanover Park, Ill: Quintessence Publishing;
1990:329-332.
2. Terry DA. Leinfelder KF, Geller W. Aesthetic
& Restorative Dentistry: Material Selection &
Technique. Hanover Park, Ill: Quintessence
Publishing; 2009:152-153.
3. ChicheGJ, PinaultA. EstheticsofAnteriorFixed
Prosthodontics. Hanover Park, Ill: Quintessence
Publishing; 1994:42-48.
4. Rufenacht CR. Fundamentals of Esthetics.
Hanover Park, Ill: Quintessence Publishing;
1990:85-109.