Veneers E-Book

Maciej Zarow

• Herausgeber: Quintessence Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 412

Veröffentlichungsjahr: 2023

Beschreibung

Veneers is not a book to impress, but a book to teach, wherein the author's deep knowledge of the foundations of dentistry is revealed. The need to carry out adequate diagnoses that consider functional aspects fundamental to achieving success in this compromised type of treatment is emphasized. The book answers a number of questions: Is veneering a challenge? What do you need to have a predictable key to success in your workshop? And – What did I have to learn and remember well, after an era of uncertainty, trials, and material choices, to treat this therapy as an ordinary but demanding clinical procedure? Through detailed clinical cases, this book shows when veneers are indicated, when to avoid them, what risks lie in wait, how to prepare the teeth, what type of materials to use, and how to proceed with cementation. It also shows where this type of treatment is going in the future, with the incorporation of the digital workflow. This book is a must for clinicians dedicated to esthetic restorative dentistry.

Leseprobe

VENEERS

FANTASY RISK SUCCESS

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Copyright ©2023

Quintessenz Verlags-GmbH

All rights reserved. Reprinting and reproduction in any form of all

or part of the book without the written consent of the publisher is prohibited.

Editor: Iwona Koziel, Anya Hastwell

Design: Janina Knap

Design, typesetting and layout: Janina Knap, Małgorzata Trębicka, Sabine Theuring

Drawings: Julia Gebel

Translation: Natalia Jakubowicz, Anthony Casey

ISBN 978-1-78698-116-5

“A goal without a plan is just ... a wish”

Antoine de Saint-Exupéry

I DEDICATE THIS BOOK TO PROFESSOR ZBIGNIEW JAŃCZUK, OUR TIRELESS MENTOR

ABOUT THE AUTHORS

Maciej ŻAROW

Professional profile

He received his dental degree from the Faculty of Dentistry at Semmelweis University, Budapest (Hungary). Upon his graduation, Maciej pursued a Doctor of Medical Sciences title, obtained after Pass with Honors for his dissertation defense on composite inlays-onlays in the restoration of endodontically treated teeth. Maciej has been a long-time researcher and lecturer, working with dental students at the Department of Propedeutics of Conservative Dentistry of CMUJ, Krakow. During his International Association of Dental Research scholarship, he conducted research work on adhesive bridges (FDPs) as well as the restoration of endodontically treated teeth at the universities of Leeds and Manchester. He has been a visiting professor at the University of Chieti (Italy), and visiting lecturer the UIC University (Barcelona). In 2021 he became a mentor at the prestigious Kois Center in Seattle. In 1999 Maciej established his private practice “Dentist” in Krakow and maintains it with his energetic attitude and everlasting passion.

Clinical practice

Maciej is an experienced clinician working with an extensive spectrum of practical approaches to dental treatment. He is keen on promoting and implementing new restorative techniques in his everyday practice. He furthermore favors initiating modern interdisciplinary procedures that harmonize esthetics with function and minimize interference with the natural mechanisms of functioning of the whole stomatognathic system. Maciej successfully carries out this philosophy in his private dental practice “Dentist” in Krakow, as well as in his Postgraduate Courses Center.

Professional activity

Maciej takes pride in being Editor-in-Chief of the Quintessence for Dentists journal. His book, EndoProsthodontics: A Guide for Clinical Practice, has achieved success and is now published in English, Chinese, Croatian, French, and Russian. He has authored more than 80 scientific papers in both national and international journals. Maciej is also an active member in the Italian restorative dentistry research group “Style Italiano,” as well as the Polish Academy of Esthetic Dentistry. In 2019 he became a certified member of European Society of Cosmetic Dentistry.

Walter DEVOTO

Professional profile

A graduate with honors from the Faculty of Dentistry and Prosthodontics at the University of Genoa (Italy), Walter’s postgraduate studies are in the field of dental prosthetics. Initiator and participant of university research programs. University lecturer at medical schools in Madrid and Siena.

Clinical practice

Runs private practices specializing in esthetic dentistry and dental surgery in Sestri Levante and Portofino (Italy). He cooperates clinically with prestigious centers of esthetic dentistry around the world. Visiting professor at the Universitè de la Méditerranée in Marseille (France).

Professional activity

Member of the European Academy of Esthetic Dentistry – a founding member of its counterpart in Italy. Founder of the Style Italiano research group. An innovator of instrument technology and methods in the field of esthetics with composite material. Renowned lecturer at national and international congresses, author and co-author of books, including Le Guide Estetique, Odontoiatria Restaurativa, Traumatologia Oral, and Layers.

Margarida HENRIQUE

Professional profile

A dentist by choice and a graduate of the Medical University of Porto (Portugal), a few years later becoming a Master of Implantology at the University of Seville (Spain). There, she completed postgraduate studies in the field of esthetic dentistry.

Clinical practice

Runs a private dental clinic specializing in surgical and prosthetic treatment. She improves her knowledge and gains new experiences as a participant of renowned courses and congresses in prestigious dental training centers. She has unique knowledge in the field of tooth morphology, so necessary to optimize the esthetics and function.

Professional activity

Since 2019, she has actively participated in the activities of the Style Italiano group.

Louis HARDAN

Professional profile

A graduate of the Saint Joseph University of Beirut-Lebanon. Full Professor, DDS, CES, DEA, Ph.D. – and former head of the restorative and esthetic department and director of the Master’s program. He graduated in dentistry in 1989 and was awarded his Ph.D. in oral biology and dental materials in 2009.

Clinical practice

Owns a private practice in his hometown Byblos (Lebanon), dealing with esthetic dentistry. Inventor of Mobile Dental Photography systems for anterior and posterior documentation and optimizing dentist’s communication with the dental laboratory.

Professional activity

Member of the Lebanese Dental Society – former general secretary of this organization. Scientific Director and Honorary Member of Style Italiano. Renowned congress lecturer, author of numerous publications in international specialist journals and author of the book: Protocols for Mobile Dental Photography with Auxiliary Lighting (Quintessence Publishing, 2020).

Marco NICASTRO

Professional profile

A graduate of the Faculty of Dentistry and Prosthodontics at the University of La Sapienza in Rome (Italy). He also completed studies in the field of prosthetics. He gained new experience in prosthetic procedures at Oral Design Center Roma, and in the field of new directions of esthetic dentistry by participating in courses conducted at the University of Geneva (Switzerland).

Clinical practice

His practice “Studio Dr. Nicastro” in Rome uses modern therapeutic methods. Minimally invasive procedures, shaping optimal occlusive conditions, integrating esthetics and functions, and finally, the methodology of digital dentistry set the tone for everyday practice in this therapeutic center. This renowned center is dominated by two specialties: esthetic dentistry and implantology, with a wide range of accompanying prosthetic procedures.

Professional activity

Member of the Italian Dental Society and the Italian Academy of Dental Prosthetics, and one of the founders of the Interdisciplinary CAD/CAM Study. Author of many international publications, lecturer at national and international congresses in the field of esthetic restorative dentistry.

Daniele RONDONI

Professional profile

Master of Dental Technology. A graduate of the renowned P. Caslini Dental School in Genoa (Italy). Lecturer and co-founder of Dental Technician School in Savona (Italy). He gained professional experience in leading centers for dental technicians in Switzerland, Germany, and Japan. Visiting professor at the University of Chieti-Pescara.

Clinical practice

Since 1982, he has been running his own dental laboratory. By devoting himself to an in-depth analysis of dental morphology and creating optimal esthetics in restorative dentistry, he has gained a reputation as a respected authority in the world of modern dentistry. He is the creator of original protocols of performing indirect composite techniques on metal structures and restorations on implants, known as the Inverted Hardness Layering System.

Professional activity

Member of the European and Italian Academy of Esthetic Dentistry. Persistently participates in the activities of Style Italiano. Author of the book Ceramic Multilayering Technique and co-author of the book Conservative Restoration of Anterior Teeth. He lectures on numerous educational projects and as a key lecturer at international congresses.

FOREWORD

I have known Dr. Maciej Żarow as a consummate student, gifted practitioner, and provocative thinker. He also is an excellent writer who answers complex clinical questions with clarity and simplicity.

I am honored to recommend his newest book, Veneers. Dr. Żarow’s combined teaching, research, and clinical expertise are evident in the book’s content. As you read, you will be exposed to new ways of thinking about veneers. The book begins with consideration of the “why” of veneer placement. Then, he carefully describes in detail the systems and proven methodologies that will allow the reader to achieve predictable, excellent outcomes. His treatment planning process includes a functional risk assessment to better ensure the long-term survival of the veneers. He also provides in-depth selection criteria for porcelain vs composite material choices. Other chapters include dental morphology, photographic communication, tooth preparation, provisional fabrication, and cementation.

I am certain this book will help any dentist fabricate and deliver veneers with predictable outstanding outcomes using a practical workflow that can be incorporated into any dental practice.

John C. Kois DMD MSD

The Kois Center, Founder and Director University of Washington School of Dentistry, Affiliate Professor, Graduate Restorative Program

The Compendium of Continuing Education in Dentistry, Co-Editor-in-Chief

PREFACE

It is a great honor to introduce a book for my good friend Maciej Żarow. Maciej is passionate about life, a passion manifested in everything he does: in personal relationships, in travel, in fun, in treating patients, in teaching … Over the years, he has been able to forge bonds of friendship all over the world, and from humility, study, and work, he has developed a deep and solid knowledge of broad aspects of dentistry, which has made him a referent in conservative and esthetic dentistry worldwide.

In this book, he has managed to bring together a team of excellent dentists and technicians, as well as great friends, to show us a new vision of ceramic veneers, a classic treatment of renewed validity. It is not a book to impress, but a book to teach, where his deep knowledge of the foundations of dentistry is revealed. The need to carry out adequate diagnoses that consider functional aspects fundamental to achieving success in this compromised type of treatment is emphasized. Through detailed clinical cases, it shows us when they are indicated, when we have to avoid them, what risks lie in wait for us, how we have to prepare the teeth, what type of materials to use, how to proceed with cementation, and also shows us where the future of this type of treatment is going, with the incorporation of digital workflow.

This is an excellent book by an exceptional person, which should be a must for clinicians dedicated to esthetic restorative dentistry.

Miguel Roig Cayón President

Spanish Society of Prosthodontics and Esthetic Dentistry Professor and Head

Department of Restorative Dentistry Universitat Internacional de Catalunya Barcelona, Spain

INTRODUCTION

Is veneering a challenge? What do you need to have a predictable key to success in your workshop? What did I have to learn and remember well, after an era of uncertainty, trials, and material choices to treat this therapy as an ordinary but demanding clinical procedure?

For 20 years, I have been offering my patients porcelain and composite veneers, and – more precisely – comprehensive esthetic treatment, in which the beauty and harmony of the anterior teeth put life in first place. I have come across dozens of cases of varying degrees of difficulty. Do I know enough about this micropart of modern dentistry today to authoritatively face every challenge that nature can give us? Probably not – although already in the hundreds of clinical situations that I have encountered over many years of practice, I find an extensive set of experiences, regularities, and rules that allow me to search for effective treatment procedures. And that is what I wanted to share in the pages of this book.

To make the book even more comprehensive and valuable, I invited my dear friends and eminent dentists to contribute. They are: Dr. Marco Nicastro, Dr. Walter Devoto, Prof. Louis Hardan, Dr. Margarida Henrique, and dental technician Daniele Rondoni. The first has been my mentor of esthetic dentistry for 20 years; the second is a long-standing motivator in the constant search for newer and simpler treatment methods; and the third is an innovator in dental photography. Margarida, on the other hand, is an absolute “freak” when it comes to her passion for her field – which made me consider that her extraordinary knowledge about the details of teeth would be a great enrichment of the knowledge contained in this book. The artist of the sketches is Dr. Julia Gebel, whom I would like to thank for her commitment and the countless number of drawings made. I must thank Dr. John Kois from Seattle – my teacher and mentor – who had put together my knowledge about functional risk assessment in esthetic cases.

In addition, I must acknowledge two outstanding Polish professors. The first is Prof. Stanisław Suliborski, whose lecture in 1995 and passion for veneers inspired me to become involved in this field, and the second is Prof. Jerzy Krupiński, my great teacher and friend. He had endless patience in teaching me how to logically put my thoughts on paper.

I hope that all the students, novice dentists, and experienced practitioners who read this book will find many useful tips for their practice.

Maciej ŻarowCracow, Poland 2021

Ceramic tiles “azulejos”! I have always been fascinated by the facades of Andalusian and Portuguese cities. The experts in their fabrication and “gluing” did it well enough that they could survive for hundreds of years. They have been my inspiration when planning porcelain veneers...

CONTENTS

CHAPTER 1WHY VENEERS?

Questions the patient may ask

CHAPTER 2PORCELAIN VENEERS – YES or NO?

Porcelain veneers – why yes?

Advantages of veneers from a clinical perspective

Porcelain veneers – why no?

Absolute contraindications

Relative contraindications

CHAPTER 3PLANNING VENEERS

Medical history

Clinical examination

Structural risk factors

Functional risk factors

Photographic documentation

Creating a diagnostic wax-up

Dental office – dental laboratory communication card

Mock-up or test drive veneers

CHAPTER 4DENTAL MORPHOLOGY

Tooth structure

Dental morphology

The function of incisors and canines

Primary anatomy

Secondary anatomy

Tertiary anatomy

Teeth position and gingival architecture – esthetic considerations

CHAPTER 5PHOTOGRAPHY COMMUNICATION

Photography: diagnostic and training importance

Photography: dentist’s communication with the dental technician

Photography: communication with the patient

CHAPTER 6PREPARATION – IMPRESSION – PROVISIONAL VENEERS

Starting the preparation

The veneers drive-test (mock-up) before preparation

Ten steps for successful preparation

Final impression

Provisional veneers

Preparation dilemmas

CHAPTER 7VENEERS CEMENTATION

Checklist

The most important stages of color verification

Veneer esthetic evaluation before cementation

Adhesive preparation of the veneers

Adhesive preparation of the tooth surface

Porcelain veneers cementation procedures

Procedures after veneers cementation

CHAPTER 8ATLAS OF CLINICAL PROCEDURES

Veneers and teeth with multiple direct restorations

Veneers and discolored teeth after root canal treatment

Veneers and occlusal problems

Constricted chewing pattern

Occlusal dysfunction

Esthetics and function: A, B, C, D of restorative strategy

Veneers: changing the tooth shape

Veneers: diastema closure

No-prep veneers; partial veneers

Veneers: creating symmetry with the prosthetic crown

Veneers: creating symmetry with the implant-supported crown

Veneer replacement

CHAPTER 9MINIMALLY INVASIVE VENEERS OR NO-PREP VENEERS?

Preparation techniques

Choice of the ceramic material

No-prep veneers

CHAPTER 10COMPOSITE VENEERS

Tooth discoloration after root canal treatment and composite veneers

Simplified composite veneers performed with the Style Italiano technique

Indirect composite veneers

Other solutions for esthetic problems

CHAPTER 10+DIGITAL VENEERS

Porcelain veneers: a digital platform

Procedure protocol

SUMMARY  

Advantages of direct composite veneers

Advantages of indirect porcelain veneers

Parameters for selecting veneers

Video list

CHAPTER 1

WHY VENEERS?

MACIEJ ŻAROW

Patients are interested in veneers because they consider them an excellent way to change their smile. Veneers have, after all, glamorized many famous people, including actors, politicians, and other celebrities. Patients believe that the world of veneers will open the door to a fuller and better life …

Why veneers?

Veneers start a risky game. They can improve the patient’s well-being and comfort, increase their chance of professional success and social standing. On the other hand, they can also – even irreversibly – change everyday life for the worse. Do we know the answers to all the questions that a patient might ask?

THE PATIENT’S POINT OF VIEW

Patients are interested in veneers because they are an attractive treatment; they improve their smile and well-being relatively quickly. They know that veneers have glamorized many famous people, such as actors, entrepreneurs, politicians, and celebrities. They hope that entering the world of veneers will change their daily life, give them social confidence, increase their chances of professional success, and raise their social position. Therefore, it is safe to say that veneers or esthetic treatment can sometimes work in the same way as good psychological therapy.

More than once, I have hosted in the dental clinic modest and almost non-smiling patients who, after veneer treatment, have completely changed their lifestyle; they smile widely, are more talkative, change their hairstyle to a new, more sophisticated cut, and alter their wardrobe for a more fashionable one often intended for young and confident people.

CLINICAL POINT OF VIEW

I write on purpose about veneer treatment, not about cosmetic change. After all, this type of therapy is, in most cases, a dental treatment. Despite all the aspects of our changing reality, the role of social media into our clinics, and the generational change in the business approach to running dental practices, we must not forget that we are dentists, and our primary goal is to treat. Veneers do not only change the shape and the color of the teeth, but they also have a therapeutic effect, which goes beyond the improvement of esthetics and the patient’s comfort. Their therapeutic meaning can be outlined in ten aspects1–10:

They improve the function of anterior guidance and lateral guidance,protecting molars and premolars from tooth wear

They improve the function of eating

They can have a positive effect on phonetics

With gentle preparation, they often strengthen tooth stiffness, which is compromised due to root canal treatment and structural loss

They are nearly non-invasive for the periodontium (with supra- or juxtagingival preparation and with an appropriate emergence profile)

They are less invasive than prosthetic crowns, where the preparation means a significant structural loss

They improve health conditions for the gingival papilla by creating carefully planned and stable contact points

They reduce plaque accumulation by covering the composite fillings

They protect thin and chipped incisal edges, thanks to their appropriate material strength

QUESTIONS THE PATIENT MAY ASK:

Do veneers require significant tooth damage?

We can plan and minimize the range of the tooth preparation. Using appropriate methods, it is possible to perform veneers with a preparation depth of 0.2–0.4 mm or less into the hard tissues (Fig 1-1). What is important is that we try to prepare the tooth so as not to remove the entire thickness of the enamel or expose the dentin (exposing the dentin may reduce the durability of the veneers).1,11–12

Fig 1-1It is possible to perform veneers with reduced tooth preparation using appropriate methods. (The photograph shows tooth 22 before veneer cementation.)

How long do veneers last?

Under optimal conditions (a significant amount of enamel ensures good adhesion of the veneer to the tooth), we can expect durability up to 15 years and more (Fig 1-2).13–15 However, with age, physiological atrophy of the gums may progress and, after many years, the veneer–tooth transition can be visible. That is why professional oral hygiene and plaque control are important, contributing to slowing down the periodontal aging process.

Fig 1-2Under optimal conditions, we can expect the durability of these restorations to be up to 15 years or even more. These veneers have been successfully functioning in the mouth for over 12 years.

Can veneers be placed over teeth with composite restorations?

Of course, veneers are recommended wherever it would be too difficult to perform direct composite restorations, especially in the case of multiple restorations. In such complex situations, it is much easier to improve the smile with the indirect veneers (Fig 1-3).16

Fig 1-3aA patient presented to the dental office to improve the smile esthetics in the maxillary anterior sextant. The patient was unsatisfied with unesthetic tooth reconstructions.

Fig 1-3bSix feldspathic porcelain veneers were performed.

Figs 1-3c to 1-3ePatient’s smile in different shots after veneers cementation.

Fig 1-3fThe initial situation, before veneer treatment.

Fig 1-3gClinical situation after veneers cementation.

Is it true that veneers often fall off or break?

Veneers fall off due to incorrect indications (occlusal overload or structural compromise) or an error during the cementation procedure. If the teeth are overloaded, the risk of failure increases significantly. Sometimes, additional procedures should be performed in advance. Such procedures can include the functional risk assessment, removal of the premature occlusal contacts, and in certain cases, increasing the vertical dimension of occlusion (Fig 1-4).17,18 There are also clinical cases where the tooth may not have enough of its own healthy structures, and veneer adhesion to the tooth will not be predictable.3

Fig 1-4(a) The anterior teeth of this patient might appear ideal for veneers. However, after a thorough overview of the medical history and physical examination, it was found that the patient actively wears her teeth (b to d). After deprogramming, it was found that the cause of the tooth wear can be the avoidance pattern of premature contacts. (e) These premature contacts are visible after deprogramming and obtaining the central relation (CR). Only appropriate preparation of the occlusal conditions will reduce the functional risk of the veneers.

What does it mean: altering the vertical dimension?

Altering the vertical dimension means increasing the clinical height of the posterior restorations that will provide the front teeth with more necessary space for chewing, swallowing, breathing, and talking. The principle is as follows: reconstruction of the teeth in the mandibular arch, in the maxillary arch, or reconstruction in both, which will relieve the front teeth (Fig 1-5).17,18

Fig 1-5aThe female patient shown in Fig 1-4 was qualified for altering the vertical dimension – initial situation.

Fig 1-5bTooth preparation for indirect restorations in the fourth quadrant.

Fig 1-5cIndirect restorations after cementation in the fourth quadrant.

Fig 1-5dTooth preparation for indirect restorations in the third quadrant.

Fig 1-5eIndirect restorations after cementation in the third quadrant.

Fig 1-5fAnterior teeth isolated with a rubber dam, ready for direct composite restorations.

Fig 1-5g“Palatal frames” of composite restorations were made with silicone index obtained for the diagnostic wax-up.

Fig 1-5hMamelons were created with the dentin composite resin layer.

Fig 1-5iSituation after restoration with final enamel composite and initial characterization.

Fig 1-5jAltering the vertical dimension of the occlusion provided appropriate space for the porcelain veneers.

Figs 1-5k and 1-5lPatient’s smile from (k) the right and (l) the left semi-profile after veneers cementation.

Can a veneer be performed on one discolored tooth in the anterior region?

Making a single veneer is risky. If we want to achieve a predictable, satisfactory appearance of the front teeth, it is better to perform the veneers in pairs – symmetrically, so they will look natural (Fig 1-6).19

Figs 1-6a and 1-6b(a) A 37-year-old female patient presented to the dental clinic seeking a better esthetic outcome for tooth 21. (b) Discoloration of the tooth was related to root canal treatment performed in childhood.

Fig 1-6cThe decision was taken to perform two feldspathic porcelain veneers on teeth 11 and 21, which will not only increase the predictability of color matching but also improve the symmetry and the incisal line of the central incisors.

Fig 1-6dTeeth 11 and 21 were prepared for veneers.

Fig 1-6eClinical situation 3 months after cementing veneers on teeth 11 and 21.

Figs 1-6f and 1-6gPatient’s smile with (f) the right and (g) the left semi-profiles after treatment is completed.

Can an old crown be replaced and a veneer performed on an adjacent tooth?

Yes. Using the same porcelain, it is possible to make an all-ceramic crown with a veneer on an adjacent tooth. Such a procedure with the central incisors will allow the same symmetrical restorations in terms of shape, color, and characterization (Fig 1-7).

Fig 1-7aA 52-year-old patient presented to the clinic to replace the old ceramic crown on tooth 11. It was recommended to perform a porcelain veneer on tooth 21 at the same time to achieve symmetry between the maxillary central incisors.

Fig 1-7bClinical situation after removing the old crown 11.

Fig 1-7cPreparation depth grooves obtained from mock-up position on tooth 21.

Fig 1-7dSituation after the final preparation for the crown 11 and porcelain veneer 21.

Fig 1-7eProsthetic crown and veneer made of lithium disilicate – ready for cementation.

Fig 1-7fClinical situation after cementation of all-ceramic crown 11 and veneer 21.

Fig 1-7gPatient’s smile after treatment is completed.

Can veneers be bleached?

Unfortunately, no. Therefore, it is strongly recommended to whiten the teeth before starting the treatment. For esthetic reasons, it is easier and better to match the veneer color to bleached teeth.20 Moreover, the patient’s appetite usually grows with what it is fed, and after cementing the veneers (if whitening has not been performed), the patient will say: “Doctor, the veneers are nice, but now I would like to whiten them, one or two tones.” Remember, whitening veneers will never be possible. However, it will be possible to refresh the whitening of adjacent teeth, which can become slightly discolored over time due to the dye absorption (Fig 1-8).

Fig 1-8When planning porcelain veneers, teeth whitening should always be considered. After completing orthodontic therapy, the female patient presented to the dental office seeking esthetic treatment. With the help of veneers in the maxillary arch, it was planned to lighten the color of the teeth and lengthen the maxillary incisors to improve the smile line. Thanks to the whitening, the dental technician had an easier task to match the veneer color to the brighter teeth, which harmonized them with the adjacent teeth: (a) clinical situation before whitening; (b) clinical situation after whitening; (c, d) clinical situation after porcelain veneers cementation.

How should one deal with a gingival recession, making the tooth-veneer transitions or cervical tooth discoloration visible?

With proper prophylaxis (regular visits to a dental hygienist, bilaterally balanced occlusion, relaxation mouthguard, and appropriate tooth-brushing), the patient should not be exposed to rapid gingival recession (Fig 1-9). If such a situation occurs many years later, the veneers can always be redone.21

Fig 1-9aA 40-year-old female patient presented to the dental office wishing to replace the old veneers done several years ago. She complained that the junction between the tooth and the veneer has become particularly visible over the years.

Fig 1-9bPreparation was obtained based on existing veneers, which were used as a mock-up (preparation through mock-up), and photographs were taken during the procedure.

Fig 1-9cFeldspathic porcelain veneers performed in the laboratory – ready for cementation.

Fig 1-9dRubber dam isolation ensures predictable adhesive cementation.

Fig 1-9eClinical situation after performing the veneers.

Fig 1-9fThe patient’s smile after treatment.

Which porcelain should be chosen for veneers?

Currently, two main types of ceramic materials are used: feldspathic porcelain and lithium disilicate porcelain (pressed or milled). A dentist should choose based on clinical indication and cooperation with an experienced dental technician (Fig 1-10).22

Fig 1-10Example of a feldspathic porcelain veneer set (13 to 23) ready for cementation. The patient cannot distinguish what material the veneer is made of. The indication depends on the individual clinical situation and the experience of the dental technician with a given ceramic material.

Can veneers replace orthodontic treatment?

In some limited clinical cases, it is possible; for example, in case of slight rotation of the teeth or in case of retrusion of the maxillary incisors and the retroposition (here, the position of the teeth allows for esthetic tooth additive reconstruction). However, in the case of protrusion, when maxillary incisors extend beyond the normal contour of the dental arch, their correction with veneers requires extensive tooth preparation (Fig 1-11).23

Fig 1-11aThis female patient presented with an esthetic problem of rotated central incisors.

Fig 1-11bThe patient was performing on stage, and she was concerned by a shadow appearing on her teeth in some camera shots and pictures.

Fig 1-11cStudy cast with visible rotation of the central incisors.

Fig 1-11dDiagnostic wax-up shows rotated teeth correction possibility with minimally invasive porcelain veneers.

Fig 1-11eClinical situation after cementing porcelain veneers.

Will veneers fail on the canines?

The canines indeed fulfill a special functional aim by performing canine guidance, which creates disclusion of the posterior teeth in the lateral movement of the mandible and protects the teeth from excessive abrasion/wear.

On the other hand, the convex shape of the canine on the palatal side (more convex than the maxillary incisors) makes the stress distribution on the porcelain veneers more favorable.24,25 So, do not be afraid to make veneers on the maxillary canines if you wisely plan them. Look at the extreme case where a veneer was made after unsuccessful orthodontic treatment (ankylosis of the maxillary canine) (Fig 1-12). However, special attention should be paid not to overdo the inclination of the canine guidance (steep guidance may result in overloading and breaking the veneers).

Fig 1-12aA patient was referred to improve esthetics after unsuccessful orthodontic treatment, which involved extrusion of the retained canine 23.

Fig 1-12bDue to ankylosis of tooth 23, orthodontic treatment was completed at this stage.

Fig 1-12cVeneer preparation was done only in the enamel. Adhesive steps of the tooth structure were obtained in rubber dam isolation …

Fig 1-12d... and the porcelain veneer was cemented.

Fig 1-12eClinical situation after veneer cementation on the tooth 23.

Fig 1-12fA satisfied patient’s smile after improving the esthetics of tooth 23 (it should be mentioned that the veneer has been functioning successfully for more than 14 years now).

REFERENCES

1. Burke FJ. Survival rates for porcelain laminate veneers with special reference to the effect of preparation in dentin: a literature review. J Esthet Restor Dent 2012;24:257–265.

2. Radz GM. Minimum thickness anterior porcelain restorations. Dent Clin North Am 2011;55:353–370.

3. Gürel G, Sesma N, Calamita MA, Coachman C, Morimoto S. Influence of enamel preservation on failure rates of porcelain laminate veneers. Int J Periodontics Restorative Dent 2013;33:31–39.

4. Gürel G, Morimoto S, Calamita MA, Coachman C, Sesma N. Clinical performance of porcelain laminate veneers: outcomes of the aesthetic pre-evaluative temporary (APT) technique. Int J Periodontics Restorative Dent 2012;32:625–635.

5. Gürel G, Bichacho N. Permanent diagnostic provisional restorations for predictable results when redesigning the smile. Pract Proced Aesthet Dent 2006;18:281–286; quiz 288, 316–317.

6. Magne P, Magne M. Use of additive wax-up and direct intraoral mock-up for enamel preservation with porcelain laminate veneers. Eur J Esthet Dent 2006;1:10–19.

7. Kinderknecht KE, Kupp LI. Aesthetic solution for large maxillary anterior diastema and frenum attachment. Pract Periodontics Aesthet Dent 1996;8:95–102; quiz 104.

8. da Cunha LF, Gonzaga CC, Saab R, Mushashe AM, Correr GM. Rehabilitation of the dominance of maxillary central incisors with refractory porcelain veneers requiring minimal tooth preparation. Quintessence Int 2015;46:837–841.

9. da Cunha LF, Pedroche LO, Gonzaga CC, Furuse AY. Esthetic, occlusal, and periodontal rehabilitation of anterior teeth with minimum thickness porcelain laminate veneers. J Prosthet Dent 2014;112:1315–1318.

10. Dietschi D, Argente A. A comprehensive and conservative approach for the restoration of abrasion and erosion. Part II: clinical procedures and case report. Eur J Esthet Dent 2011;6:142–159.

11. Farias-Neto A, de Medeiros FCD, Vilanova L, Simonetti Chaves M, Freire Batista de Araújo JJ. Tooth preparation for ceramic veneers: when less is more. Int J Esthet Dent 2019;14:156–164.

12. Burke F, Lucarotti P. Ten-year outcome of porcelain laminate veneers placed within the general dental services in England and Wales. J Dent 2009;37:31–38.

13. Beier US, Kapferer I, Burtscher D, Dumfahrt H. Clinical performance of porcelain laminate veneers for up to 20 years. Int J Prosthodont 2011;25:79–85.

14. Layton DM, Walton TR. The up to 21-year clinical outcome and survival of feldspathic porcelain veneers: accounting for clustering. Int J Prosthodont 2012;25:604–612.

15. Dumfahrt H, Schäffer H. Porcelain laminate veneers. A retrospective evaluation after 1 to 10 years of service: part II – clinical results. Int J Prosthodont 2000;13:9.

16. Gresnigt MM, Kalk W, Özcan M. Clinical longevity of ceramic laminate veneers bonded to teeth with and without existing composite restorations up to 40 months. Clin Oral Investig 2013;17:823–832.

17. Kois JC, Phillips KM. Occlusal vertical dimension: alteration concerns. Compend Contin Educ Dent 1997;18:1169–1180.

18. Kois DE, Kois JC. Comprehensive risk-based diagnostically driven treatment planning: developing sequentially generated treatment. Dent Clin North Am 2015;59:593–608.

19. Zarow M. Contraindicated internal bleaching: what to do? Styleitaliano; 4/2017. Dostępne. Available at: www.styleitaliano.org/contraindicated-internal-bleaching-what-to-do/

20. Berland L. Bleaching and porcelain veneers: consider the combination. Dent Today 1994;13:78–81.

21. Calamia J, Calamia Ch. Porcelain laminate veneers: reasons for 25 years of success. Dent Clin N Am 2007;51:399–417.

22. Edelhoff D, Prandtner O, Saeidi Pour R, Liebermann A, Stimmelmayr M, Güth JF. Anterior restorations: the performance of ceramic veneers. Quintessence Int 2018;49:89–101.

23. Curry FT. Porcelain veneers: adjunct or alternative to orthodontic therapy. J Esthet Dent 1998;10:67–74.

24. Magne P, Douglas WH. Design optimization and evolution of bonded ceramics for the anterior dentition: a finite-element analysis. Quintessence Int 1999;30:661–672.

25. Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, van Meerbeek B. A prospective ten-year clinical trial of porcelain veneers. J Adhes Dent 2004;6:65–76.

CHAPTER 2

PORCELAIN VENEERS: YES OR NO?

MACIEJ ŻAROW

Like this shell, found on one of the islands of the Palawan archipelago (Philippines), the light penetrates through thin porcelain veneers to the inside of the tooth, resulting in a final color that is a combination of the tooth and the veneer …

Porcelain veneers – why yes?

Are porcelain veneers a good choice? The answer is yes because they have many advantages: they are highly esthetic and look like natural teeth, and they are thin enough to let the light penetrate inside the tooth, just like alabaster or shells. In addition, preparation time is minimized, and the enamel is maintained as much as possible.

ADVANTAGES OF VENEERS FROM A CLINICAL PERSPECTIVE

They are less invasive than prosthetic crowns1,2

There is no risk of losing pulp vitality when performing a slight preparation (enamel) (Fig 2-1)3

Fig 2-1Example of a standard preparation made under the control of a silicone index to minimize the enamel.

Assuming that we are preparing the tooth within the enamel, the risk of hypersensitivity is minimized (Fig 2-1)4

By definition, they do not interfere with periodontal tissues (juxtagingival preparation) (Fig 2-2)5

Fig 2-2aVeneer preparation on teeth 11 and 21 with respect for the gingival margin – the juxtagingival preparation did not violate the integrity of the soft tissues.

Fig 2-2bThe preparation margin becomes visible only after inserting the first and then the second retraction cord.

Fig 2-2cClinical situation after veneers cementation.

They are biocompatible and well tolerated by the gingiva, even when a minimal subgingival preparation is performed (subgingival preparation for veneers is generally not recommended. However, in some cases, it is required to cover intense discoloration or to close the black triangles in the interdental space – the veneer gently interferes with the subgingival area)5

They successfully improve function: symmetrical anterior guidance and lateral guidance (Fig 2-3)6

Fig 2-3aA 41-year-old female patient was offered four porcelain veneers in the maxillary arch, not only for esthetic reasons but also to improve anterior guidance – shown here is the clinical situation in anterior guidance before treatment.

Fig 2-3bFour porcelain veneers were obtained.

Fig 2-3cThe patient’s smile from the semi-profile after cementation of the veneers.

Fig 2-3dCemented veneers from the palatal view.

Fig 2-3eMarking the front guidance after tooth lengthening with the veneers.

They can be redone in the future7

They restore the tooth stiffness due to the physical properties of porcelain, which is important for the functional aspects of the anterior teeth8,9

They can mask tooth discoloration, which is unpredictable and extremely difficult when working with composites (Fig 2-4)10–13

Fig 2-4aMany years ago, a female patient presented to the dental office requesting to cover her teeth with veneers because multiple attempts at teeth whitening had not brought any results. The cause of the discoloration was taking tetracycline in early childhood.

Fig 2-4bThe clinical situation in the maxillary and mandibular arches.

Fig 2-4cTen maxillary porcelain veneers were proposed as a treatment – the photograph shows minimal veneer preparation with preservation of enamel.

Fig 2-4dSituation after cementing porcelain veneers (feldspathic porcelain was used, now it would be possible to use “better masking” lithium disilicate porcelain).

Fig 2-4ePatient’s smile after cementing 10 veneers in the maxilla.

CONSIDER PLANNING PORCELAIN VENEERS WHEN:

1. Maxillary anterior teeth have extensive, highly visible composite restorations (Fig 2-5)

Fig 2-5The replacement of extensive restorations can cause many difficulties, such as correct color composite matching or durability problems. In such cases, veneers can be considered.

2. Esthetic composite restorations are difficult to perform due to the need to reconstruct many teeth (Fig 2-6)

Fig 2-6If the replacement of extensive restorations involves many teeth (for example, four or six), it is even more worth considering veneers.

Consider the advantages of porcelain veneers when you are planning esthetic treatment ... but do not forget about the functional risk !

3. When a significant change of the shape or lengthening is necessary (Fig 2-7)14–16

Fig 2-7aWhen maxillary central incisors are not visible in the “lips at rest” position, tooth extension should be considered for esthetic improvement. In such cases, porcelain veneers are among the treatment options.

Fig 2-7bWhen the maxillary central incisors have a similar length to the maxillary lateral incisors, consider changing the length or shape of the teeth to achieve dominance of the maxillary central incisors.

4. It is necessary to close the diastema (Fig 2-8)17,18

Fig 2-8Diastema is one of the indications for porcelain veneers. However, this therapeutic option should always be analyzed individually and be visualized by mock-up before starting the treatment.

5. Reducing/closing visible black triangles (Fig 2-9)5

Fig 2-9Closing black triangles is one of the indications for porcelain veneers. To achieve permanent black triangle closure, it should be done based on the knowledge of the alveolar bone position and the biological width.

6. Changing the long axis of the anterior teeth or the midline between the maxillary central incisors (Fig 2-10)5

Fig 2-10One of the indications for porcelain veneers is changing the line course between the maxillary central incisors so that it overlaps more with the facial midline and is perpendicular with the pupillary line.

REMEMBER

If you want to improve the midline course with veneers, you should plan the restoration appropriately and involve the proximal surfaces in the preparation. A photograph from the 12 o’clock position helps us understand the coincidence of a facial midline with a dental midline (see page 55, point 14).

7. Tooth is discolored and cannot be whitened or masked predictably with the composite material (Fig 2-11)19

Fig 2-11One of the indications for making two symmetrical porcelain veneers is a discolored tooth where for some reason, internal bleaching is contraindicated, so the color cannot be masked predictably with the composite.

8. We perform a single crown and want to balance the esthetics on the other side of the dental arch (Fig 2-12)20

Fig 2-12When replacing the crown on one of the maxillary central incisors, the ideal solution is to cover the symmetrically positioned incisor with a porcelain veneer made of the same porcelain as the crown.

9. When a single implant-supported crown is performed, and there is a need to balance the symmetry and to close a possible black triangle (Fig 2-13)21

Fig 2-13When performing the maxillary central incisor implant crown, the gingival margin can change its architecture from the baseline, requiring shape change on both teeth. For this purpose, it is often necessary to carry out a veneer on the adjacent tooth.

10. When the position of the rotated tooth needs to be corrected, and orthodontic treatment is not possible for some reason (Fig 2-14)22

Fig 2-14Orthodontic treatment remains the best solution for patients who require teeth aligned in the dental arch. However, it is possible to align the dental arch and improve the smile with porcelain veneers in some cases, especially when the teeth position enables us to minimize tooth preparation.

11. When complex occlusal rehabilitation is planned – as the last step of restoring the function and esthetics in the anterior segment (Fig 2-15)23

Fig 2-15In cases like this, porcelain veneers are indicated but usually only after reconstruction of the occlusion by creating appropriate space for restorative material in the anterior teeth.

Porcelain veneers – why no?

You cannot agree to even very convincing suggestions from patients who are absolutely sure that porcelain veneers are the only possible treatment. The clinical situation and indications should be realistically assessed. Sometimes, even the greatest efforts can lead to months of disputes and resentments.

DO NOT PLAN PORCELAIN VENEERS WHEN:

1. There is a small amount of tooth structure, and less than 50% of the tooth structure would adhere to the veneer after preparation (Fig 2-16)13

Fig 2-16Two different clinical situations. (a) There is enough tooth structure in teeth 11 and 21. (b) After veneer preparation in tooth 11, less than 50% of the hard tissues will be left, and in tooth 21, the quantity of hard tissues will be around 50%. Therefore, the replacement of fillings or ceramic crowns should be considered. It is possible to make porcelain veneers in this case, but the risk of failure in the future (for example, cracks) increases significantly when the veneer has a composite build-up on most of its preparation surface.

If more than 50% of the hard tissues remain after veneer preparation, we can expect proper adhesion and durability for such reconstruction. The more enamel, especially on the margins of the preparation, the better chance for a long-lasting marginal seal. The same is true for the ratio of tooth structure to composite surface within the preparation. Although similar to tooth tissues (especially to dentin), composite behaves slightly differently over the years. It shows a tendency to water sorption and volume change, which means that the veneer may “work” differently when it is bonded to the hard tissue surface and the composite surface.

This will not matter for small composite restorations,13 but it is difficult to predict how the veneer will behave when the base surface is a large Class 4 restoration.

Suppose we add a lack of stable occlusion and bilateral support on the lateral teeth or constricted chewing pattern. In that case, the total of the unfavorable factors becomes even greater.

2. There are subgingival cavities or Class 5 restorations reaching the cementum (Fig 2-17)24

Fig 2-17When cavities reach the cementoenamel junction and interfere in the cementum zone, the risk of the veneer entering the cementum should be taken into account (faster aging of the adhesion and risk of stress accumulation).

When Class 5 composite restorations are placed subgingivally deep enough that placing a rubber dam to control the moisture and removing excess material during cementation is not possible, veneers are contraindicated. In addition, the cervical part of the veneer is a critical zone in terms of stress distribution. The cervical area of the tooth accumulates much stress: this is where the enamel reaches the cementum (cementoenamel junction, CEJ), and main types of non-carious cervical lesions are formed, ie, abfractions (due to occlusal overload).

If the margin of the preparation can be located in the enamel in this critical gingival zone, the durability of the veneer will increase. If a significant part of the preparation is located subgingivally in the cementum, the veneer’s adhesion to the tooth will decrease critically. In addition, it will not be possible to control moisture during cementation or to remove excess material.

For these reasons, the marginal seal of the veneer and periodontal health will be unpredictable. The location of the veneer margin on the composite in the gingival zone is contraindicated in the case of an existing Class 5 restoration. The veneer may cover the entire filling, but the gingival margin should not finish on the restoration but on the tooth structure.

REMEMBER

If the gingival margin of the veneer preparation is located deep subgingivally, the long-term marginal seal of the veneer and periodontal health will not be predictable. In such a clinical situation, think about alternative solutions such as direct or indirect composite restorations. In the event of chipping or other problems, they can be repaired!

3. Class 3 subgingival restorations when rubber dam isolation is not possible (Fig 2-18)

Fig 2-18With deep subgingival Class 3 cavities, a different type of treatment than porcelain veneers should be considered.

As with Class 5 cavities, deep subgingival Class 3 cavities are contraindicated for porcelain veneers.24 The veneer cannot have a margin placed juxtagingivally on the composite restoration.

4. The patient is an adolescent (Fig 2-19)25

Video: Alternative treatment of an adolescent https://books.dentist.com.pl/veneers/video/1

Fig 2-19A 15-year-old female patient presented to the dental office to obtain porcelain veneers to cover the enamel hypoplasia. The patient’s young age and the ongoing bone growth phase are contraindications for an indirect porcelain restoration.

As a rule, we do not make porcelain veneers for patients under the age of 21. It used to be considered that the patient’s occlusion was formed and stable by the age of 18–20; currently, it is assumed that this limit should be extended even to the age of 25. This is shown by studies related to implantation failure in patients in their early 20s. For young people, direct composite veneers will be a perfect solution.

5. Incorrect occlusal conditions were diagnosed26–28

Lack of a stable and balanced occlusion on both sides (no lateral support) (Fig 2-20)

Fig 2-20Missing teeth in the posterior segment of the dental arch is a contraindication for porcelain veneers. First, occlusion rehabilitation should be performed – only then can veneers be made according to previous planning (see Chapter 8).

A constricted envelope of function means that there is no space between the front teeth of the maxilla and mandible when performing basic functional activities, such as chewing, talking, breathing, or swallowing. Clinically, it is common to see shelves of wear as exposed dentin on the palatal surface – Dr. John Kois calls this a vertical wear pattern (Fig 2-21).

Fig 2-21A 22-year-old female patient was diagnosed with a constricted envelope of function, which led to a vertical wear pattern on the palatal surface of the anterior maxillary teeth.

The occurrence of premature contacts leads to bypassing with mandibular movements, which can often be destructive for the teeth by excessive abrasion. In this situation, we are usually dealing with a horizontal wear pattern (Fig 2-22).

Fig 2-22Premature contacts in the posterior segment of the dental arch were detected by a Kois Deprogrammer (KD) (horizontal wear pattern; occlusal dysfunction in Kois functional risk classification).

Video: Correction no-prep with the composite https://books.dentist.com.pl/veneers/video/2

6. The patient’s esthetic problems can be solved in a less invasive way than performing veneers29,30

Porcelain veneers, although they are minimally invasive, do in most cases require slight preparation, which can be avoided in many situations

Teeth can be whitened and fillings can be replaced with minimally invasive composite restorations (Fig 2-23)

Fig 2-23A female patient presented to the dental office seeking treatment with porcelain veneers: whitening and slight correction of the shape with composite was proposed.

White spots (hypomineralization) that can be eliminated or removed by resin infiltration (Icon) (Fig 2-24)

Fig 2-24A 19-year-old female patient presented to the dental office to improve the esthetics of anterior teeth due to enamel hypoplasia occurring as white/brown spots. The solution, in this case, can be bleaching and resin infiltration (see Chapter 10).

Video: Whitening and shape correction with the composite https://books.dentist.com.pl/veneers/video/3

Teeth with an unesthetic shape that can be corrected with rotary instruments (Fig 2-25)

Fig 2-25A female patient was unsatisfied with the length of the maxillary incisors, which were catching the lower lip. A minimally invasive shape correction was planned with the Sof-Lex disk (red) and the addition of composite resin, which allowed a significant improvement in the patient’s smile to be achieved.

RELATIVE CONTRAINDICATIONS FOR PORCELAIN VENEERS

1. Extreme discoloration of the tooth (Fig 2-26)31,32

Fig 2-26A patient presented to the dental office to improve the esthetics of the extremely discolored tooth 11. Due to the post and core, it would be too risky to perform internal bleaching. Such discoloration is not an absolute contraindication, but due to the difficulty of laboratory fabrication, it is a relative contraindication. It is easier for the dental laboratory to fabricate a ceramic crown than a thin porcelain veneer. If we can cooperate with an appropriate laboratory, an attempt should be made to perform a veneer.