Q U I N T E S S E N C E I N T E R N AT I O N A L
ESTHETIC DENTISTRY
Marina Studart Alencar
Reestablishment of esthetics with minimum thickness veneers: A one-year follow-up case report Marina Studart Alencar, DDS, MSc1/Diana Ferreira Gadelha de Araújo, DDS, MSc 1/Rafael Massunari Maenosono, DDS, MSc 1/Bella Luna Colombini Ishikiriama, DDS, PhD2/Carlos Eduardo Francischone, DDS, MSc, PhD 3/Sérgio Kiyoshi Ishikiriama, DDS, MSc, PhD4 The evolution of adhesive procedures and ceramic systems has allowed for the placement of minimum thickness laminate veneers on unprepared teeth. A 20-year-old post-orthodontics male patient with multiple diastemas required restorative procedures. A multidisciplinary approach was performed, involving gingivectomy, in-office bleaching, and application of
minimum thickness veneers. The immediate and 1-year followup results exceeded expectations; however, long-term clinical trials are necessary to evaluate the performance of this new type of indirect restoration. (Quintessence Int 2014;45:593–597; doi: 10.3290/j.qi.a31804)
Key words: bleaching, diastema, esthetics, gingivectomy, lithium disilicate, porcelain veneer
Currently, patients are seeking esthetic treatments to achieve a more pleasant appearance, and the use of increasingly less-invasive techniques has become commonplace in dental practice.1 In this context, a new concept has emerged: indirect porcelain veneers with minimum thickness, also known as “contact lens” veneers.2,3 This technique consists of ceramic veneers adhered to the tooth structure with minimal or no preparation, providing highly satisfactory esthetic 1
PhD Student, Department of Restorative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
2
Assistant Professor, Department of Periodontology, University of Sacred Heart, Bauru, SP, Brazil.
3
Full Professor, Department of Restorative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
4
Assistant Professor, Department of Restorative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
Correspondence: Dr Sérgio Kiyoshi Ishikiriama, c/o Dr Octávio Pinheiro Brisolla, 9-75, PO Box 73, Bauru SP 17012-901, Brazil. Email: serginho@ usp.br
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
results.4 However, even associating the predictable success of adhesive bonding to enamel5,6 with the excellent mechanical properties of current ceramic systems,7,8 the longevity of minimum thickness veneers remains unknown. In addition to the development of new restorative techniques, it is sometimes not possible to establish an esthetic smile only through restorations. The correct distribution of the teeth and maintenance of the widthto-height ratio are essential factors in esthetic treatment; thus, a multidisciplinary approach is often critical to achieve excellent results.9 The long-term performance of this new technique has been studied; however, few case reports with a long duration of evaluation have been published. In this context, this paper reports a clinical case with 1 year of follow-up of diastema closure in a young patient through multidisciplinary treatment involving
593
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
Fig 1
Initial aspects of a patient with multiple diastemas.
periodontal surgery and restorative procedures with minimum thickness ceramic veneers.
CASE REPORT A 20-year-old male patient who had undergone past orthodontic treatment presented with well-distributed multiple diastemas, requiring restorative procedures. After the clinical and intraoral radiographic exams, multiple diastemas were observed in the anterior maxillary region, with a good distribution of the interdental spaces. Neither caries nor bone/root resorption were detected (Fig 1). The treatment plan for diastema closure was designed to restore form, function, and esthetics. The first step was the critical analysis of the diagnostic template and the evaluation of esthetic problems involving the height-width ratio of the anterior teeth, which were addressed with periodontal surgery. In-office bleaching was performed in sequence, and then indirect restorations with minimum thickness veneers were fabricated.
Periodontal surgery Periodontal surgery was performed to promote a previous increase in the height of the clinical crowns, allowing a subsequent enlargement of width and providing diastema closure with an esthetic height-width ratio for the teeth (Fig 2). In this clinical case, the presence of deeper gingival sulci indicated the need for a gingivectomy procedure to reestablish shallow sulci and to enlarge the crown height. Another benefit of periodon-
594
Fig 2
Gingival contouring was improved with gingivectomy.
tal plastic surgery is that the position of the gingival margin can also improve esthetic harmony in patients with a “gummy” smile.
In-office bleaching Sixty days after periodontal surgery, in-office bleaching was performed (Fig 3) in order to achieve better esthetic results because the thickness of “contact lens” veneers is not capable of covering or masking unsatisfactory tooth color. Initially, prophylaxis was performed with pumice to remove any bacterial biofilm from the surface of the teeth. Using the Vita Classic scale, it was verified that the initial tooth color was A2. In-office bleaching was performed using hydrogen peroxide (25% Lase Peroxide Sensy II, DMC Equipment) and activated using an LED/laser hybrid light (Whitening Lase II, DMC Equipment). The bleaching gel was manipulated according to the manufacturer’s instructions and applied to the surface of the teeth for 1 minute. The gel was then activated by the hybrid light three times for 2 minutes each time, with a 1-minute interval between each light activation. Immediately, the bleaching gel was removed, and this procedure was performed four times in the same session, totaling 36 minutes of application. After the bleaching procedure, the teeth were polished with a felt disc impregnated with abrasives (Lase Peroxide, DMC Equipment), followed by the application of desensitizing gel (Lase Peroxide, DMC Equipment) composed of 2% sodium fluoride and 5% potassium nitrate for 4 minutes. After two in-office bleaching sessions, the teeth measured at B1 on the Vita scale.
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
Fig 3 In-office bleaching performed with 25% hydrogen peroxide gel.
Fig 4
Diagnostic wax-up template.
Fig 5 Preoperative mock-up performed with temporary acrylic resin restorations.
Fig 6
Contact lens veneer with 0.6 mm thickness.
Minimum thickness ceramic veneers
were sent back to the laboratory to receive the final glaze. In order to choose the ideal color of the luting agent, a try-in gel (Variolink Veneer, Ivoclar Vivadent) was applied in the inner portion of the veneers.11,12 In sequence, prophylaxis with extra-fine pumice was performed, the tooth enamel was etched for 30 seconds with 37% phosphoric acid (Condicionador Dental Gel, Dentsply) and then rinsed for 30 seconds. After vigorous drying, all-in-one adhesive (Variolink Veneer) was applied and light cured (Radi Cal, SDI; 1000 mW/cm2) for 20 seconds. The inner portion of the “contact lens” veneers was etched for 20 seconds with 10% hydrofluoric acid (Condicionador de Porcelanas, Dentsply), rinsed, and dried. A silane agent (Silano, Dentsply) was applied for 20 seconds, followed by light curing of the all-in-one adhesive (Variolink Veneer) in the veneer. Finally, the inner portion was filled with the luting agent (Variolink Veneer), and the veneers were placed properly on the surface of the teeth. After 5 seconds of
An alginate impression was taken to obtain a study template, and a diagnostic wax-up was created to assess shape and contour (Fig 4). Moreover, a preoperative mock-up based on the wax-up was made to simulate the final esthetic result and for the patient’s approval (Fig 5).10 In a subsequent visit, a second impression using a 3-0 retraction cord (Ultrapack, Ultradent) was taken with polyvinyl siloxane (Express XT, 3M ESPE), and the cast was sent to the laboratory with all specifications for manufacturing the veneers with lithium disilicate-reinforced glass ceramic (IPS e-max, Ivoclar Vivadent) (Fig 6). After 1 week, the patient returned for testing and adjustment of the manufactured “contact lens” veneers. Marginal adaptation, anatomical shape and contour, color, and esthetic harmony with the patient’s smile were evaluated. Considering the friability of the material before luting, necessary adjustments were carefully made with diamond burs, and the veneers
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
595
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
Fig 7
Satisfactory palatal adaptation of veneers.
Fig 8
Fig 9
Patient’s final smile after 1 week.
Fig 10
light curing, the excess was removed with a spatula and dental floss. A final light cure was performed for 60 seconds on the buccal and lingual surfaces. The excess luting agent was removed and occlusal adjustment was performed immediately to eliminate the most severe interference in order to reduce the tension in the cementing line freshly obtained (Figs 7 and 8). At the 1-week follow-up visit, after the luting agent had achieved its complete curing, a refined occlusal adjustment was performed. At this time, no gingival inflammation was detected in the gingival margins (Fig 9). After 1 year, a new evaluation was performed. The clinical examination demonstrated no marginal failures and color stability. Gaps, infiltrations, or gingival inflammation were not found. Moreover, even with the minimum thickness of the veneers, no fracture was detected on the indirect restorations (Fig 10).
596
Satisfactory buccal adaptation of veneers.
Patient’s final smile after 1 year.
DISCUSSION Diastema closure is a clinical procedure that aims for the esthetic reestablishment of the smile. There are many techniques available to perform this treatment, with the most recent being the use of minimum thickness ceramic restorations. This technique does not require preparation of the teeth. However, for a better result, a multidisciplinary treatment is necessary, providing the correct tooth proportions in addition to the closure of the spaces between the teeth. In this context, periodontal surgery is a part of the treatment. For a good long-term prognosis of the periodontal surgery, the surgical procedure should be well selected based on clinical parameters. Periodontal probing and a radiographic exam can determine the necessity for osseous resection to support tooth crown height enlargement. When a shallow probing depth is associated, osseous resection is necessary to avoid recurrence caused by gingival sulcus healing above the marginal bone. In this case, the osseous resection was
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
not necessary, and a gingivectomy procedure was performed. The results can be optimized with bleaching. Office bleaching of vital teeth is a well-accepted and safe procedure for the treatment of intrinsic and extrinsic pigmentation. Bleaching is usually performed with an agent containing carbamide peroxide or hydrogen peroxide at various concentrations, which can be used with a light source to accelerate the bleaching reaction.13,14 In this case, 25% hydrogen peroxide was used to obtain good results with significant color change. The preservation of enamel is related to higher survival rates of porcelain laminate veneers,15 but the use of minimum thickness ceramic veneers is a recent technique and does not yet have an established clinical protocol. Thus, professionals refer to the technical aspects of conventional indirect veneers.16 The main difference between these two techniques is related to the tooth structure preparation because “contact lens” veneers do not require drilling. The evolution of ceramic systems, especially considering the increased fracture resistance over the years, has allowed changes in concepts related to the preparation of the tooth structure. Thus, minimally invasive or no preparation is possible because the ceramic laminate, with a thickness of up to 0.5 mm, may have its fracture resistance increased after effective adhesive cementation. The choice of a safe treatment with these veneers requires a diagnostic wax-up template that allows one to determine whether a ceramic laminate can perfectly adapt to the proximal face of the unprepared teeth,17 in addition to evaluating the insertion plan through the buccal face and esthetic pre-results. The follow-up to this type of treatment is essential to determine its longevity. After 1 year, the restorations maintained satisfactory performance and did not yield any failures, which demonstrates that the multidisciplinary approach was the best choice and that the minimum thickness ceramic veneers can be safely used when indicated. The final esthetic results exceeded the expectations of the patient.
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
CONCLUSION Minimum thickness laminate veneers seem to be a valid alternative treatment for diastema closure. The treatment’s success depends on the correct diagnosis based on the wax-up template, and in many cases, a multidisciplinary approach is necessary to improve the final esthetic results. The longevity of laminate veneers placed on unprepared teeth is still unclear, and longterm clinical trials are necessary; however, satisfactory results were noted after a 1-year follow-up in this case report.
REFERENCES 1. Tyas MJ, Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry: a review. FDI Commission Project 1–97. Int Dent J 2000;50:1–12. 2. Materdomini D, Friedman MJ. The contact lens effect: enhancing porcelain veneer esthetics. J Esthet Dent 1995;7:99–103. 3. Okida RC, Filho AJ, Barao VA, Dos Santos DM, Goiato MC. The use of fragments of thin veneers as a restorative therapy for anterior teeth disharmony: a case report with 3 years of follow-up. J Contemp Dent Pract 2012;13:416–420. 4. Signore A, Kaitsas V, Tonoli A, Angiero F, Silvestrini-Biavati A, Benedicenti S. Sectional porcelain veneers for a maxillary midline diastema closure: a case report. Quintessence Int 2013;44:201–206. 5. Loguercio AD, Moura SK, Pellizzaro A, et al. Durability of enamel bonding using two-step self-etch systems on ground and unground enamel. Oper Dent 2008;33:79–88. 6. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc 1998;129:55–66. 7. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. J Prosthet Dent 2003;89:268–274. 8. Ozcan M, Vallittu PK. Effect of surface conditioning methods on the bond strength of luting cement to ceramics. Dent Mater 2003;19:725–731. 9. Furuse AY, Franco EJ, Mondelli J. Esthetic and functional restoration for an anterior open occlusal relationship with multiple diastemata: a multidisciplinary approach. J Prosthet Dent 2008;99:91–94. 10. Reshad M, Cascione D, Magne P. Diagnostic mock-ups as an objective tool for predictable outcomes with porcelain veneers in esthetically demanding patients: a clinical report. J Prosthet Dent 2008;99:333–339. 11. Christensen GJ. Facing the challenges of ceramic veneers. J Am Dent Assoc 2006;136:661–664. 12. AL Ghazali N, Laukner J, Burnside G, Smith PW, Preston AJ. An investigation into effect of try-in pastes, uncured and cured resin cements on the overall color of ceramic veneer restorations: an in vitro study. J Dent 2010;38(Suppl 2):e78–e86. 13. Mondelli RFL, Azevedo JFDG, Francisconi AC, Almeida CM, Ishikiriama SK. Comparative clinical study of the effectiveness of different dental bleaching methods: two year follow-up. J Appl Oral Sci 2012;20:435–443. 14. Li Y. Safety controversies in tooth bleaching. Den Clin N Am 2011;55:255–263. 15. Gurel 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. 16. Roberts M, Shull GF Jr. Treating a young adult with bonded porcelain veneers. J Am Dent Assoc 2011;142(Suppl 2):10S–13S. 17. Christensen GJ. Thick or thin veneers? J Am Dent Assoc 2008;139:1541–1543.
597
ESTHETIC DENTISTRY
Marina Studart Alencar
Reestablishment of esthetics with minimum thickness veneers: A one-year follow-up case report Marina Studart Alencar, DDS, MSc1/Diana Ferreira Gadelha de Araújo, DDS, MSc 1/Rafael Massunari Maenosono, DDS, MSc 1/Bella Luna Colombini Ishikiriama, DDS, PhD2/Carlos Eduardo Francischone, DDS, MSc, PhD 3/Sérgio Kiyoshi Ishikiriama, DDS, MSc, PhD4 The evolution of adhesive procedures and ceramic systems has allowed for the placement of minimum thickness laminate veneers on unprepared teeth. A 20-year-old post-orthodontics male patient with multiple diastemas required restorative procedures. A multidisciplinary approach was performed, involving gingivectomy, in-office bleaching, and application of
minimum thickness veneers. The immediate and 1-year followup results exceeded expectations; however, long-term clinical trials are necessary to evaluate the performance of this new type of indirect restoration. (Quintessence Int 2014;45:593–597; doi: 10.3290/j.qi.a31804)
Key words: bleaching, diastema, esthetics, gingivectomy, lithium disilicate, porcelain veneer
Currently, patients are seeking esthetic treatments to achieve a more pleasant appearance, and the use of increasingly less-invasive techniques has become commonplace in dental practice.1 In this context, a new concept has emerged: indirect porcelain veneers with minimum thickness, also known as “contact lens” veneers.2,3 This technique consists of ceramic veneers adhered to the tooth structure with minimal or no preparation, providing highly satisfactory esthetic 1
PhD Student, Department of Restorative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
2
Assistant Professor, Department of Periodontology, University of Sacred Heart, Bauru, SP, Brazil.
3
Full Professor, Department of Restorative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
4
Assistant Professor, Department of Restorative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, Bauru, SP, Brazil.
Correspondence: Dr Sérgio Kiyoshi Ishikiriama, c/o Dr Octávio Pinheiro Brisolla, 9-75, PO Box 73, Bauru SP 17012-901, Brazil. Email: serginho@ usp.br
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
results.4 However, even associating the predictable success of adhesive bonding to enamel5,6 with the excellent mechanical properties of current ceramic systems,7,8 the longevity of minimum thickness veneers remains unknown. In addition to the development of new restorative techniques, it is sometimes not possible to establish an esthetic smile only through restorations. The correct distribution of the teeth and maintenance of the widthto-height ratio are essential factors in esthetic treatment; thus, a multidisciplinary approach is often critical to achieve excellent results.9 The long-term performance of this new technique has been studied; however, few case reports with a long duration of evaluation have been published. In this context, this paper reports a clinical case with 1 year of follow-up of diastema closure in a young patient through multidisciplinary treatment involving
593
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
Fig 1
Initial aspects of a patient with multiple diastemas.
periodontal surgery and restorative procedures with minimum thickness ceramic veneers.
CASE REPORT A 20-year-old male patient who had undergone past orthodontic treatment presented with well-distributed multiple diastemas, requiring restorative procedures. After the clinical and intraoral radiographic exams, multiple diastemas were observed in the anterior maxillary region, with a good distribution of the interdental spaces. Neither caries nor bone/root resorption were detected (Fig 1). The treatment plan for diastema closure was designed to restore form, function, and esthetics. The first step was the critical analysis of the diagnostic template and the evaluation of esthetic problems involving the height-width ratio of the anterior teeth, which were addressed with periodontal surgery. In-office bleaching was performed in sequence, and then indirect restorations with minimum thickness veneers were fabricated.
Periodontal surgery Periodontal surgery was performed to promote a previous increase in the height of the clinical crowns, allowing a subsequent enlargement of width and providing diastema closure with an esthetic height-width ratio for the teeth (Fig 2). In this clinical case, the presence of deeper gingival sulci indicated the need for a gingivectomy procedure to reestablish shallow sulci and to enlarge the crown height. Another benefit of periodon-
594
Fig 2
Gingival contouring was improved with gingivectomy.
tal plastic surgery is that the position of the gingival margin can also improve esthetic harmony in patients with a “gummy” smile.
In-office bleaching Sixty days after periodontal surgery, in-office bleaching was performed (Fig 3) in order to achieve better esthetic results because the thickness of “contact lens” veneers is not capable of covering or masking unsatisfactory tooth color. Initially, prophylaxis was performed with pumice to remove any bacterial biofilm from the surface of the teeth. Using the Vita Classic scale, it was verified that the initial tooth color was A2. In-office bleaching was performed using hydrogen peroxide (25% Lase Peroxide Sensy II, DMC Equipment) and activated using an LED/laser hybrid light (Whitening Lase II, DMC Equipment). The bleaching gel was manipulated according to the manufacturer’s instructions and applied to the surface of the teeth for 1 minute. The gel was then activated by the hybrid light three times for 2 minutes each time, with a 1-minute interval between each light activation. Immediately, the bleaching gel was removed, and this procedure was performed four times in the same session, totaling 36 minutes of application. After the bleaching procedure, the teeth were polished with a felt disc impregnated with abrasives (Lase Peroxide, DMC Equipment), followed by the application of desensitizing gel (Lase Peroxide, DMC Equipment) composed of 2% sodium fluoride and 5% potassium nitrate for 4 minutes. After two in-office bleaching sessions, the teeth measured at B1 on the Vita scale.
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
Fig 3 In-office bleaching performed with 25% hydrogen peroxide gel.
Fig 4
Diagnostic wax-up template.
Fig 5 Preoperative mock-up performed with temporary acrylic resin restorations.
Fig 6
Contact lens veneer with 0.6 mm thickness.
Minimum thickness ceramic veneers
were sent back to the laboratory to receive the final glaze. In order to choose the ideal color of the luting agent, a try-in gel (Variolink Veneer, Ivoclar Vivadent) was applied in the inner portion of the veneers.11,12 In sequence, prophylaxis with extra-fine pumice was performed, the tooth enamel was etched for 30 seconds with 37% phosphoric acid (Condicionador Dental Gel, Dentsply) and then rinsed for 30 seconds. After vigorous drying, all-in-one adhesive (Variolink Veneer) was applied and light cured (Radi Cal, SDI; 1000 mW/cm2) for 20 seconds. The inner portion of the “contact lens” veneers was etched for 20 seconds with 10% hydrofluoric acid (Condicionador de Porcelanas, Dentsply), rinsed, and dried. A silane agent (Silano, Dentsply) was applied for 20 seconds, followed by light curing of the all-in-one adhesive (Variolink Veneer) in the veneer. Finally, the inner portion was filled with the luting agent (Variolink Veneer), and the veneers were placed properly on the surface of the teeth. After 5 seconds of
An alginate impression was taken to obtain a study template, and a diagnostic wax-up was created to assess shape and contour (Fig 4). Moreover, a preoperative mock-up based on the wax-up was made to simulate the final esthetic result and for the patient’s approval (Fig 5).10 In a subsequent visit, a second impression using a 3-0 retraction cord (Ultrapack, Ultradent) was taken with polyvinyl siloxane (Express XT, 3M ESPE), and the cast was sent to the laboratory with all specifications for manufacturing the veneers with lithium disilicate-reinforced glass ceramic (IPS e-max, Ivoclar Vivadent) (Fig 6). After 1 week, the patient returned for testing and adjustment of the manufactured “contact lens” veneers. Marginal adaptation, anatomical shape and contour, color, and esthetic harmony with the patient’s smile were evaluated. Considering the friability of the material before luting, necessary adjustments were carefully made with diamond burs, and the veneers
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
595
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
Fig 7
Satisfactory palatal adaptation of veneers.
Fig 8
Fig 9
Patient’s final smile after 1 week.
Fig 10
light curing, the excess was removed with a spatula and dental floss. A final light cure was performed for 60 seconds on the buccal and lingual surfaces. The excess luting agent was removed and occlusal adjustment was performed immediately to eliminate the most severe interference in order to reduce the tension in the cementing line freshly obtained (Figs 7 and 8). At the 1-week follow-up visit, after the luting agent had achieved its complete curing, a refined occlusal adjustment was performed. At this time, no gingival inflammation was detected in the gingival margins (Fig 9). After 1 year, a new evaluation was performed. The clinical examination demonstrated no marginal failures and color stability. Gaps, infiltrations, or gingival inflammation were not found. Moreover, even with the minimum thickness of the veneers, no fracture was detected on the indirect restorations (Fig 10).
596
Satisfactory buccal adaptation of veneers.
Patient’s final smile after 1 year.
DISCUSSION Diastema closure is a clinical procedure that aims for the esthetic reestablishment of the smile. There are many techniques available to perform this treatment, with the most recent being the use of minimum thickness ceramic restorations. This technique does not require preparation of the teeth. However, for a better result, a multidisciplinary treatment is necessary, providing the correct tooth proportions in addition to the closure of the spaces between the teeth. In this context, periodontal surgery is a part of the treatment. For a good long-term prognosis of the periodontal surgery, the surgical procedure should be well selected based on clinical parameters. Periodontal probing and a radiographic exam can determine the necessity for osseous resection to support tooth crown height enlargement. When a shallow probing depth is associated, osseous resection is necessary to avoid recurrence caused by gingival sulcus healing above the marginal bone. In this case, the osseous resection was
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L Alencar et al
not necessary, and a gingivectomy procedure was performed. The results can be optimized with bleaching. Office bleaching of vital teeth is a well-accepted and safe procedure for the treatment of intrinsic and extrinsic pigmentation. Bleaching is usually performed with an agent containing carbamide peroxide or hydrogen peroxide at various concentrations, which can be used with a light source to accelerate the bleaching reaction.13,14 In this case, 25% hydrogen peroxide was used to obtain good results with significant color change. The preservation of enamel is related to higher survival rates of porcelain laminate veneers,15 but the use of minimum thickness ceramic veneers is a recent technique and does not yet have an established clinical protocol. Thus, professionals refer to the technical aspects of conventional indirect veneers.16 The main difference between these two techniques is related to the tooth structure preparation because “contact lens” veneers do not require drilling. The evolution of ceramic systems, especially considering the increased fracture resistance over the years, has allowed changes in concepts related to the preparation of the tooth structure. Thus, minimally invasive or no preparation is possible because the ceramic laminate, with a thickness of up to 0.5 mm, may have its fracture resistance increased after effective adhesive cementation. The choice of a safe treatment with these veneers requires a diagnostic wax-up template that allows one to determine whether a ceramic laminate can perfectly adapt to the proximal face of the unprepared teeth,17 in addition to evaluating the insertion plan through the buccal face and esthetic pre-results. The follow-up to this type of treatment is essential to determine its longevity. After 1 year, the restorations maintained satisfactory performance and did not yield any failures, which demonstrates that the multidisciplinary approach was the best choice and that the minimum thickness ceramic veneers can be safely used when indicated. The final esthetic results exceeded the expectations of the patient.
VOLUME 45 • NUMBER 7 • JULY / AUGUST 2014
CONCLUSION Minimum thickness laminate veneers seem to be a valid alternative treatment for diastema closure. The treatment’s success depends on the correct diagnosis based on the wax-up template, and in many cases, a multidisciplinary approach is necessary to improve the final esthetic results. The longevity of laminate veneers placed on unprepared teeth is still unclear, and longterm clinical trials are necessary; however, satisfactory results were noted after a 1-year follow-up in this case report.
REFERENCES 1. Tyas MJ, Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry: a review. FDI Commission Project 1–97. Int Dent J 2000;50:1–12. 2. Materdomini D, Friedman MJ. The contact lens effect: enhancing porcelain veneer esthetics. J Esthet Dent 1995;7:99–103. 3. Okida RC, Filho AJ, Barao VA, Dos Santos DM, Goiato MC. The use of fragments of thin veneers as a restorative therapy for anterior teeth disharmony: a case report with 3 years of follow-up. J Contemp Dent Pract 2012;13:416–420. 4. Signore A, Kaitsas V, Tonoli A, Angiero F, Silvestrini-Biavati A, Benedicenti S. Sectional porcelain veneers for a maxillary midline diastema closure: a case report. Quintessence Int 2013;44:201–206. 5. Loguercio AD, Moura SK, Pellizzaro A, et al. Durability of enamel bonding using two-step self-etch systems on ground and unground enamel. Oper Dent 2008;33:79–88. 6. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc 1998;129:55–66. 7. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. J Prosthet Dent 2003;89:268–274. 8. Ozcan M, Vallittu PK. Effect of surface conditioning methods on the bond strength of luting cement to ceramics. Dent Mater 2003;19:725–731. 9. Furuse AY, Franco EJ, Mondelli J. Esthetic and functional restoration for an anterior open occlusal relationship with multiple diastemata: a multidisciplinary approach. J Prosthet Dent 2008;99:91–94. 10. Reshad M, Cascione D, Magne P. Diagnostic mock-ups as an objective tool for predictable outcomes with porcelain veneers in esthetically demanding patients: a clinical report. J Prosthet Dent 2008;99:333–339. 11. Christensen GJ. Facing the challenges of ceramic veneers. J Am Dent Assoc 2006;136:661–664. 12. AL Ghazali N, Laukner J, Burnside G, Smith PW, Preston AJ. An investigation into effect of try-in pastes, uncured and cured resin cements on the overall color of ceramic veneer restorations: an in vitro study. J Dent 2010;38(Suppl 2):e78–e86. 13. Mondelli RFL, Azevedo JFDG, Francisconi AC, Almeida CM, Ishikiriama SK. Comparative clinical study of the effectiveness of different dental bleaching methods: two year follow-up. J Appl Oral Sci 2012;20:435–443. 14. Li Y. Safety controversies in tooth bleaching. Den Clin N Am 2011;55:255–263. 15. Gurel 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. 16. Roberts M, Shull GF Jr. Treating a young adult with bonded porcelain veneers. J Am Dent Assoc 2011;142(Suppl 2):10S–13S. 17. Christensen GJ. Thick or thin veneers? J Am Dent Assoc 2008;139:1541–1543.
597
