Ceramic Veneers - Cementation Guide

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Ceramic veneers manual

Smile Esthetics The esthetics are a subjective judgment about the perception of what is beautiful and sublime (Mills et al., 2012). Despite the subjectivity of this concept, the fashion industry together with the media and the contemporary community set up demanding beauty standards for the face and body.

These standards are rather difficult to reach and overestimate the people’s phenotype (Mills et al. 2012). In dentistry, the esthetic concepts idealize a smile with aligned and white teeth, free of wear and signs of earlier trauma. Structural abnormalities, changes in color, shape, and alignment of anterior teeth are also considered unacceptable in esthetic smiles (Mills et al. 2012, Smith et al. 2014).

Any of these undesirable characteristics imbalances the smile harmony and affects the occlusal function, phonetics as well as the psychosocial patients’ well being (Goldstein et al. 1994, Klages et al. 2004, Korkut et al. 2013). In face of that, the restoration of the facio-dental esthetics is within the most required procedures in the current restorative dentistry (Mills et al. 2012, Korkut et al. 2013).

There are many rehabilitation protocols for restoration of the smile esthetics: some are more invasive while others are very conservative (Soares et al. 2012, Soares et al. 2014). The cause of the esthetic imbalance influences the choice of the restorative protocol and material (Soares et al. 2012, Soares et al. 2014). Teeth that do not respond well to bleaching protocols, presenting morphological alterations such

as conoid teeth or microdontia, diastema, or those that require the increase in the incisal length are the best indications for conventional or minimally invasive veneers (Magne & Belser, 2002).

These anatomical variations are very common but their prevalence may vary according to age and population. The prevalence of diastema in adolescents is reported to range from 15.4 to 27% (Utomi et al. 2011, Kaur et al. 2013). Conoid teeth are present in 28.9% of the population (Costa et al. 2012), while microdontia affects a minor percentage of 1% (Patil et al. 2013).

All these alterations require the reestablishment of the proportion between teeth and the balance between the hard (teeth) and soft (gingiva) tissues to reach a natural and pleasant smile (Moslowitz & Nayyar, 1995). The mesio-to-distal width of the anterior teeth varies and this plays an important role on the smile harmony. The proportion that is aesthetically favorable and beauty is the gradual reduction of the mesio-distal width from the central incisor to the canine, also known as golden proportion (Levin, 1978).

The rehabilitation planning should produce the desired esthetic standard, which is usually dictated by the modern society. Besides that, this rehabilitation should maintain the patients’ individual characteristics such as their originality, authenticity and individuality (Paolucci, 2011).

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Minimally invasive

dentistry The improvement of the restorative materials in the last decades, mainly the adhesive systems, have changed protocols used for retention in dentistry. Macro-retentions, with excessive wear of the dental structure, are no longer required, allowing minimally invasive preparations (Soares et al. 2014).

Since 1980, the development of minimally invasive dentistry has become available with records of success. However, it was only recently that this procedure became widely accepted and popular as it provide clinicians the opportunity to improve the smile beauty without the need of excessive wear (Goldstein et al. 1994, Radz 2011, Korkut et al. 2013).

The main foundation of minimally invasive procedures is the bonding to the dental substrates (Giray et al. 2014). The indirect restorative procedure is highly specific since it depends on the complex step of bonding the restorative material to the dental substrate by adhesion procedures.

When preparing the dental substrate to receive conventional or minimally invasive veneers, extra care should be taken since an excessive preparation tapering can lead to lack of retention (Higashi et al. 2006).

Therefore, during rehabilitation with ceramic veneers, clinicians should respect and believe in the adhesive protocol, following all the steps strictly (Higashi et al. 2006, Soares et al. 2012, Soares et al. 2014).

One contributing factor for the retention of veneers in minimally invasive protocols is that the preparation is restricted to the enamel substrate (Soares et al. 2014). Besides being conservative, the bond strength of a

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conventional adhesive to enamel is higher than to dentin (Cardoso et al. 2011; Ozer & Blatz, 2013). To aid in the amount of wear of the dental preparation, the reverse planning is of paramount importance (Coachman et al. 2012, Soares et al. 2014).

For the implementation of the rehabilitation plan, clinicians should take photographs from the patient and measure the dimensions of the teeth to obtain a virtual file for digital planning. This will guide the preparation of the wax-up model and the next restorative test, widely known as mock-up (Coachman et al. 2012, Smith et al. 2014). The reverse planning will help clinicians with the esthetic diagnosis, the communication with the dental technician, the critical analysis of the pre- and post-treatment results and the relationship between the dentist and patient. Altogether, this will increase the patients’ motivation and confidence with the clinical staff and treatment plan. Additionally, it works as an excellent marketing tool (Coachman et al. 2012, Smith et al. 2014).

For a successful esthetic treatment, the professional must understand the main concern reported by the patients. This should be clear since the first clinical appointment (Paolucci 2011, Coachman et al. 2012, Smith et al. 2014). Thus, besides the knowledge of the materials, the importance of defining the patient’s personality and their level of expectation and demand on the final result is essential, so that a proper planning can be set up based on the patients’ characteristics (Andrade & Romani 2004, Fradeani 2006, Paolucci 2011).

Options

of restorative

materials

The constant search for dental harmony and standards set up by the contemporary society along with the increased level of patient’s expectations and demands stimulate the development of new dental materials and techniques to improve the cosmetic outcome of the restorative procedure (Goldstein 1969, Paolucci 2011, Coachman et al 2012, Soares et al. 2014).

For diastema closure, there are some available techniques such as the orthodontic treatment, direct composite restorations and indirect ceramic restorations. These protocols can be planned individually or together (Blatz et al. 1999, Soares et al. 2012, Soares et al. 2014).

Direct composite restorations have several advantages, such as preservation of dental tissues, low cost, treatment reversibility, simple technique and reparability (Heymann & Hershey 1985). Despite the great progress in its composition over the past 60 years, which resulted in improved mechanical and optical properties (Ferracane 2011), these materials have a high failure rate when used in large cavities (Tuncer et al. 2013), and require frequent maintenance when compared to the ceramic laminates.

As dental materials developed, ceramics became an excellent choice for indirect rehabilitation. This class of material is especially important for veneers, which have proved to be a successful protocol to restore the dental function and esthetics (Raigrodski & Walter 2008, Soares et al. 2012, Signore et al. 2013, Soares et al. 2014). Ceramic veneers have several advantages. They bring together some of the main qualities of composite resins (which is adhesion to the dental substrates) along with others, such as color stability, high strength and durability, excellent surface smoothness, abrasion resistance and low biofilm accumulation.

Additionally, the coefficient of thermal expansion, stiffness and optical properties of ceramics are similar to the dental enamel (Higashi et al. 2006, Giray & Blatz 2013). These features associated with the employment of a careful technique allow minimal removal of dental tissues, maintenance of dental vitality and esthetic harmony, and result in a restorative treatment with very low failure rates, which ranges from 0 to 5% in 1 to 5 years (Peumans et al. 2000).

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Dental

ceramics

Conventional dental ceramics consist mainly of glasses with favorable physical qualities.

They usually have a higher amount of feldspar compared to the other elements (Kina 2005, Smith et al. 2005, Kelly & Benetti 2011). Ceramics are classified according to their composition into those with high glass content (feldspathic, leucite-based and lithium disilicate-based ceramics) and those with low glass content (alumina and zirconia) (Kina 2005, Smith et al. 2005, Kelly & Benetti 2011).

The dental ceramics that mimic better the optical properties of the enamel and dentin

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contain predominantly amorphous glass phases (Kina 2005, Kelly & Benetti, 2011). These ceramics contain atoms grouped in a threedimensional network that does not follow a standard or regular structure (Benetti & Kelly 2011). These ceramics are mainly derived from a group of minerals called feldspar and silica (Benetti & Kelly 2011). Ceramics with a high content of glasses are classified as feldspathic.

For this reason, they provide a singular and excellent esthetic; however they are more brittle than other types of ceramics (Kina 2005, Smith et al. 2005, Benetti & Kelly 2011).

Table 1 – Classification of dental ceramics according to their main chemical composition.

+ ESTHETICS

- ESTHETICS

- STRENGTH

+ STRENGTH

FELDSPHATIC

LEUCITE

LITHIUM DISILICATE

ZIRCONIA/ALUMINA

Veneering material;

INDICATIONS

Veneering material;

Veneering material;

Pure Veneers;

Pure Veneers;

Inlays, onlays and overlays

Inlays, onlays and single; Crowns

Pure veneer; Inlays, onlays and single crowns;

Coping;

Single crowns;

Implant-supported prosthesis.

Fixed prosthesis with up to five elements;

Restoration cores;

Implanted-supported prosthesis

Minimum thickness

2.0 mm

1.5 mm

1.0 mm

0.3 mm

Acid etching time

120 – 150 s

60 s

20 s

Sandblasting

Due to the low strength of the feldsphatic ceramics and the need of fabricating pure ceramic crowns, manufacturers have developed new materials over the years by increasing the crystalline phase and reducing the amorphous glass phase (Kina 2005, Kelly & Benetti 2011). One of the options to increase the strength of the ceramics was through the addition of leucite to the feldsphatic ceramics (SiO2-Al2O3-K2O), which prevents the propagation of internal ceramic flaws. Although a significant increase in strength was observed, leucite-reinforced materials still present favorable translucency and optical properties, which is yet inferior to non-reinforced ceramics (Kina 2005, Soares et al. 2005, Kelly & Benetti 2011).

Leucite-reinforced materials do not have enough strength for use in large dental prosthesis (Kina 2005, Smith et al. 2005, Benetti & Kelly 2011). In face of that, lithium disilicate (SiO2-LiO2) was incorporated to feldspathic ceramics to strengthen even more these materials. These crystals infiltrate within the glassy matrix, preventing crack propagation within the material (Kina 2005; Smith et al. 2005, Benetti & Kelly 2011). In addition to improved mechanical strength as compared with the other glass ceramics, lithium disilicate ceramics still

have high esthetic standards keeping the ceramic translucency, due to the similar light refractive index of the glass matrix and lithium disilicate crystals. Besides that, lithium disilicate ceramics have a good bonding with resin after acid etching and silanization (Kina 2005, Smith et al 2005, Kelly & Benetti 2011).

Alumina and zirconia are the other types of ceramics, which have an even greater strength (Kelly & Benetti 2011). However, these ceramics are very opaque and they are mainly used as restorative copings that need to be covered by a glass ceramic to reach acceptable esthetics. Besides that, this type of ceramic has low bond strength with resin luting cements (Kina 2005, Soares et al. 2005, Kelly & Benetti 2011). These factors contra-indicate the use of alumina and zirconia in procedures that require minimal dental preparation (conventional and minimally invasive veneers) whose retention is solely based on the bonding to the dental surfaces (Soares et al. 2005, Kelly & Benetti 2011). Therefore, it is recommended glass ceramics for veneers, especially lithium disilicate-reinforced, due to its good optical, mechanical and bonding properties (Kina 2005, Smith et al. 2005, Kelly & Benetti 2011).

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Adhesive

interface

Dentin substrate

Resin luting cement

Adhesive system

Glass ceramic

Silane

Schematic illustration of the five materials the clinicians should care about to create an effective adhesive interface.

The process of bonding the material to the recently prepared dental substrate should be rigorously performed (Cardoso et al. 2011, Ozer & Blatz 2013). For a correct protocol, clinicians should know the substrate to which the bonding will be performed (enamel or dentin), the classification of the resin luting cement and the material used to prepare the indirect restoration (Soares et al. 2005).

The bond between the dental structure and the ceramic requires three intermediate materials (adhesive system, resin luting cement and silane) (Soares et al. 2005).

To reach adequate esthetics and strong bonding, clinicians should perform a deep treatment planning with careful analysis of the following five steps: Dental substrate for

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bonding (enamel or dentin); Adhesive system (classification and indications); Resin luting cements (classification and indications); Silane application, and Internal treatment of the ceramic (Coachman et al. 2012, Soares et al. 2014).

In order to reduce mistakes and contamination, rubber dam isolation is mandatory for indirect and/or direct restorative procedures. However, the cervical edge of veneers is usually in the gingival sulcus, which prevents clinicians from using rubber dam isolation. Therefore, the use of lip retractors, gauzes on the tongue dorsum, cotton rolls and retraction cords are highly recommended for luting procedures (Soares et al. 2012, Soares et al. 2014).

Dental substrate for bonding: Although enamel and dentin are both mineralized tissues, they differ greatly in their composition and morphology. The enamel is composed of 95% of inorganic components (hydroxyapatite; fluorapatite and carbonapatatie), 4% of agar and 1% of organic matrix. On the other hand, dentin presents 50 to 70% of inorganic components (hydroxyapatite), 18 to 30% of an organic matrix (mainly collagen) and 12 to 20% of water (Fehrenbach & Math-Balohg 2008).

Due to these differences between the dental substrates, clinicians should identify the main substrate of the dental preparation (Soares et al. 2012, Soares et al 2014).

Minimally invasive preparations are usually in enamel, while conventional veneers preparations extend to dentin, which has a bonding protocol different from that of enamel (Soares et al. 2012).

Additionally, it is essential to know the indications of conventional and minimally invasive veneers. The former is indicated to correct minor imperfections such as discrete misalignments, changes in color, shape and tooth length, in highly demanding patients in terms of esthetics (Shetty et al. 2011 apud Lima P, 2013). Javaheri et al. 2007 apud Lima (2013) pointed out that small teeth, especially those that are positioned slightly lingually, are ideal for contact lens without any tooth wear. Kacker et al. (2001) apud Lima (2013) reported that failures in the diagnosis and treatment planning can lead to undesirable outcomes such as excessively protrusion of the teeth, overcontour, and teeth with monochrome and artificial appearance. Only in very specific cases, veneers can be bonded to dental surfaces without any preparation. In most of the clinical situations, a superficial dental preparation is required to allow fabrication of an esthetically acceptable veneer with adequate mechanical properties.

Adhesive systems Several adhesive systems are available in the market. They can be classified according to the bonding strategy into etch-and-rinse and selfetch systems. Additionally, adhesive systems are also classified into the number of steps required for bonding into one, two or three steps (Cardoso et al. 2011, Ozer & Blatz, 2013). The etch-andrinse adhesives require a preliminary acid etching with 32 to 37% phosphoric acid for smear layer removal and demineralization of the most superficial dental surface (Cardoso et al. 2011, Ozer & Blatz, 2013). This step is followed by the application of the primer and/or adhesive. On the other hand, self-etch adhesives do not require the etching and rinsing steps. They contain acid monomers that can demineralize and infiltrate simultaneously the dental substrates (Cardoso et al. 2011, Ozer & Blatz 2013).

Regardless of the bonding strategy, simplified adhesive systems (2-step etch-and-rinse and 1-step self-etch) contain a higher amount of acid monomers, solvents and water that may jeopardize the bonding with resin luting cements (Cardoso et al. 2011, Ozer & Blatz 2013). Although self-etch adhesives are more contemporary, they still present low bonding effectiveness to the dental structure, mainly to enamel, when compared with etch-and-rinse adhesives (Cardoso et al. 2011, Ozer & Blatz 2013). For this reason, it is recommended the use of etch-andrinse adhesives on dental substrates, mainly for

cementation of minimally invasive veneers since enamel is the main bonding substrate (Cardoso et al. 2011, Ozer & Blatz 2013, Soares et al. 2014).

As previously reported, the enamel is the main substrate for minimally invasive preparations.

In this case, we do not expect the formation of a hybrid layer, but the penetration of the resin monomers into the enamel porosities produced by acid etching. Therefore, the primer step is not required; the acid should be rinsed off, the enamel surfaces dried and one coat of adhesive applied. This is then followed by light activation for 20 s (Cardoso et al. 2011, Ozer & Blatz 2013, Soares et al. 2014).

For conventional veneers, the preparation of the bonding substrate should follow the indications for enamel and dentin. Thus, when bonding to dentin, the acid etching time should be lower (15 s) than that needed for enamel. The substrate cannot be extensively dried - only the excess water should be removed with cotton paper.

The maintenance of a moist demineralized dentin avoids the collapse of the collagen fibrils.

Collagen collapse reduces the permeability of the demineralized dentin to the adhesive monomers and jeopardizes the formation of an adequate hybrid layer (Cardoso et al. 2011, Ozer & Blatz 2013).

Ambar Ambar (FGM) is a two-step etch-and-rinse adhesive from the fifth generation. It is a bonding agent for enamel and dentin.

The main advantage of this material is the incorporation of the functional MDP monomer, which can bond chemically with the calcium from the dental structure. MDP incorporation increases the bonding effectiveness of the material and provides bonded interfaces with a higher longevity. Besides the high immediate and long-term bonding performance, this material has a high degree of conversion, reduced nanoleakage, water sorption and solubility. Altogether these features make this material an excellent choice for highquality adhesive procedures.

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Resin luting cement: As well as the correct shade matching, the choice of the suitable resin luting cement is fundamental to produce a restoration with chromatic harmony. For this purpose, clinicians should understand the composition and the setting mechanism of the available luting cements. The current resin cements can be classified according to their bonding strategy to dental structure and setting reaction (Blatz et al. 2003, Ferracane et al.

2011).

Resin cements may be classified according to their polymerization mechanisms into light-cured, chemical-cured, and dual-cured (Blatz et al. 2003, Ferracane et al. 2011).

The chemical-cured resin cements have a reduced working time and they are mainly indicated for cementation of alumina and zirconia copings as light cannot pass through them (Blatz et al. 2003, Belli et al. 2009, Ferracane et al. 2011). Light-cured cements usually contain camphorquinone as initiator, and the polymerization is exclusively activated by light. As these materials only cure after light-activation, they have an excellent working time (Blatz et al. 2003, Belli et al. 2009).

The dual-cure resin cements have chemical activation but they can also be light-cured (Blatz et al. 2003, Ferracane et al. 2011).

This type of cement takes the advantage of a higher working time than chemical-cured cements and the curing in areas where light does not reach (Blatz et al. 2003, Ferracane et al. 2011). On the other hand, resin cement

with chemical cure does not have as good color stability as that of light-cured cements.

This reduced color stability is attributed to the oxidation of tertiary amines, an essential component for chemical cure (Belli et al.

2009).

According to the bonding strategy, resin luting cements can be classified into conventional and self-adhesive systems (Behr et al. 2003, Ferracane et al. 2011).

Conventional resin luting cements do not bond to the dental substrates without the previous application of an adhesive system.

These resin cements can be activated by the three different polymerization mechanisms reported earlier (Behr et al. 2003, Ferracane et al. 2011). On the other hand, self-adhesive cements have a simpler technique as they can bond to the dental substrates without the need of acid etching and application of primer/adhesive (Behr et al. 2003, Ferracane et al. 2011). However these cements are only available in the dual-cure mode and they are contra-indicated for cementation of veneers due to their low color stability (Blatz et al.

2003, Ferracane et al. 2011).

In summary, the cementation of veneers (especially minimally invasive ones) should be done with conventional, light-cured resin cements, since they are very thin and highly translucent (Blatz et al. 2003, Soares et al. 2014). For the light curing procedure, a LED light curing unit with a minimum light intensity of 1,000 mW/cm² is needed.

Color proof with Try-in paste.

Allcem Veneer Allcem Veneer is mono-component and light-cured resin cement indicated for the cementation of prosthetic restorations that allow passage of light, such as “contact lens” or indirect veneers up to 1.5 mm thick. Allcem Veneer is radiopaque, has adequate rheological properties (thixotropic material) and a high content of inorganic filler (63 wt%), offering excellent mechanical properties.

As the “contact lens” and indirect veneers are generally quite translucent, the final color of the restoration is influenced by a greater or lesser degree by the final color of the resin cement and the thickness of the veneer. To maximize color matching, Allcem Veneer Try-in was designed to guide the dentist in the selection of the shade required for the definitive cementation with Allcem Veneer.

Removing the excesso of cement of the piece.

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Silano Silane is a bifunctional molecure, R’ – Si(OR)3, that works as coupling agent between the inorganic matrix of the restorative material with the organic matrix of the adhesive system and luting cement by means of covalent bonds (Soares et al. 2005, Brum et al. 2011).

After etching the internal ceramic surface with hydrofluoric acid for the recommended time, the application of silane increases considerably the bond strength of adhesive systems with feldsphatic, leucite- and lithium dissilate-reinforced ceramics (Soares et al.

2005, Brum et al. 2011, Soares et al. 2014).

On the other hand, silane is not effective when applied on alumina and zirconia. The bonding of silane to alumina is low and instable. Additionally, the amount of silica on these ceramics is very low (Soares et al. 2005, Brum et al. 2011).

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Prosil Prosil is a coupling agent indicated for bonding reinforcement. This product is indicated for application on bonding surfaces of ceramics with high silica content. In order words silane should be applied in ceramics that can be roughened by acid conditioning.

Silane is applied after pre-treatment of the bonding surface of the ceramic, which aims to create microporosities for better anchorage and retention.

Preliminary treatment of the internal ceramic surfaces: The application of silane in a glass ceramic without previous conditioning with hydrofluoric acid produces a weak adhesive interface (Soares et al. 2005). For this reason, the chemical conditioning of the internal surfaces of glass ceramics with 8 to 10% hydrofluoric acid are recommended.

This acid removes selectively the glassy matrix and produces honeycomb-like porosities, which are considered ideal for micromechanical retention (Peumans et al.

2000, Soares et al. 2005).

This conditioning is the result of the chemical reaction between the hydrofluoric acid and the silica presented in the glass ceramics, resulting in the formation of a salt known as hexafluorsilicate (Peumans et al. 2000).

The treatment protocol of the internal ceramic surface is mainly influenced by the ceramic composition. This has a clear clinical implication: the acid etching time depends on the amount of silica content present in the ceramic composition. This confirms that the knowledge of the type of ceramic composition and the correct treatment protocol are necessary for successful rehabilitation (Soares et al. 2005). Due to the high amount of vitreous phase, feldspathic ceramics should be conditioned for 120 to 150 s (Peumans et al. 2000). Leucitereinforced ceramics should be conditioned for 60 s, due to their reduced amount of

silica compared with feldspathic ceramics (Holand et al. 2000, Borges et al. 2003).

Following the gradual decrease in the proportion of amorphous glass phase, lithium disilicate-reinforced ceramics require conditioning for only 20 s. This is sufficient to remove the second crystalline phase and the glass matrix and create micro-retentions and an acceptable bonding standard (Ayad et al. 1996, Borges et al. 2003). 2014). As the reaction of the hydrofluoric acid with silica results in the formation of hexafluorsilicate, the surface should be cleaned by scrubbing 37% phosphoric acid with a microbrush for 60 s, or by immersing the ceramic veneer in an ultrasound bath for 3 min (Peumans et al.

2000, Soares et al. 2014).

Alumina and zirconia ceramics have optical properties that differ notably from enamel, since they are highly opaque. Additionally, they do not benefit from additional bonding provided by silane application. Chemical conditioning with hydrofluoric acid only produces very superficial changes on the ceramic, which are not enough to yield a good mechanical retention (Soares et al.

2005). These factors contra-indicate the use of these materials for anterior rehabilitations with veneers (Kina 2005, Soares et al. 2005, Kelly & Benetti 2011).

Condac Porcelana Condac Porcelain is a gel composed of 10% hydrofluoric acid that does not flow away from the applied surface. This characteristic of the product allows safe application only in the intended internal area of interest. The conditioning time varies according to the type of ceramic employed for fabrication of the veneer (see Table 1 for details). This procedure alters the superficial morphology of the internal surface of the prosthetic ceramic restoration, which can be noticeable by naked eye as an increase in the surface opacity.

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For didactic reasons, the authors selected different clinical cases that emphasize the esthetic transformation of smiles with conventional and minimally invasive ceramic veneers (popularly known as “contact lens�). The success of the this type of treatment requires careful attention for the following concepts and principles:

1. Treatment planning (digital planning, wax-up and mock-up); 2. Minimally invasive preparations; 3. Bonding to the dental substrate; whenever possible in enamel; 4. Correct treatment of the internal surfaces of the ceramics; 5. Proper selection of the bonding materials (adhesive systems and resin luting cements)

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CASE01 Female patient, 22 years old.

OBJECTIVES OF THE CLINICAL CASE To highlight the main steps for the rehabilitation of a smile with minimally invasive ceramic veneers, also known as “contact lens”, through reverse planning, minimally invasive dentistry concepts and adhesion to enamel.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration (x) Presence of diastema ( ) Misalignment of the teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change (x) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues (x) Need for gingival recontouring Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens”]. Teeth #: 12, 11, 21, 22 Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: 12, 11, 21, 22 (x) Increase of the mesio-distal width. Teeth #: 12, 11, 21, 22 ( ) Increase of the thickness of the buccal surface. Teeth #:

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Final

AUTHORS Paulo Vinícius Soares Igor Oliveiros Cardoso Guilherme Faria Moura Alexandre Coelho Machado Analice Giovani Pereira Luis Henrique Araújo Raposo

Initial

1

CASE REPORT The rehabilitation in this type of clinical case can be performed with direct composite resins. However, we opted for ceramic veneers due to their high strength, longterm stability of the surface texture and excellent light reflection and translucency, which mimics better the dental structure than any other material.

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3

4

5

1. Initial aspect of the patient’s smile. The patient reported dissatisfaction with the diastema and the discrepancy between the shape of the teeth in relation to the face format.

2. Facial view of the initial patient’s smile.

3. The patient presented favorable intermaxilliary relationship and interocclusal distance for rehabilitation with ceramic veneers. Note the need for periodontal surgery (gingival recontouring) 4. Initial aspect of the maxillary arch. The dental diastema and rounded teeth were responsible for the patient’s dissatisfaction.

5. Digital planning on the software Keynote. We used anatomical measures, which were planned according to the patient’s profile, face shape and aspect ratio. These procedures were done to improve the communication with the periodontist and laboratory technicians. This is the first step of the reverse planning.

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7

8

9 6 and 7. The periodontal surgery was performed to lengthen teeth in the cervical-incisal dimension. This moneuver favors the gain in thickeness due to diastema closure, corroborating to ideal proportions. Bone remodeling was performed with a long-neck spherical diamond bur (KG Sorensen).

8. Aspect of the maxillary arch 45 days after periodontal surgery and 15 days after at-home bleaching with 16% carbamide peroxide (Whiteness Perfect, FGM).

9. Diagnostic wax-up for planning the increments in the buccal, proximal and incisal areas of the teeth. This is the second step of the reverse planning for ceramic veneers. The diagnostic wax-up was prepared based on the measures defined in the digital planning.

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10. Silicone guide fabricated with addition silicone. This will guide the minimally invasive preparations (Fig. 16).

11. An addition silicone guide was used for preparation of the mock-up; third step of the reverse planning. An impression of the diagnostic wax-up model was done using the addition silicone. The mold was then filled with bis-acryl resin and placed onto the patient’s teeth to replicate the re-anatomization performed in the diagnostic wax-up model. Note the significant cuts in the embrasure areas and the cervical contouring to allow better flow and adaptation of the bys-acryl material.

12. Facial aspect of the patient’s simile after mock-up with bysacryl resin, shade A2 (Structur 2, Voco).

13. Close view of the diagnostic mock-up. This is a very important step of the reverse planning since it increases the patient’s confidence on the clinicians and includes the patient significantly on the planning process. Similarly, it also provides an opportunity for the operator to verify the contours of the planned restorations and make any necessary adjustments (wear or additions) if necessary. This step is also fundamental for communication with the laboratory technician.

14. The minimally invasive preparation was made on the buccal surface of the teeth with a diamond bur 2135F (KG Sorensen) mounted on high-speed hand-piece coupled with a LED light (Cobra LED UV, Gnatus). The dental preparation was very superficial with removal of the excess enamel that would interfere on the cementation of the ceramic veneer. For conoid teeth, for instance, there may be no need to make dental preparations due to the natural slope of the teeth surface that facilitates the creation of an insertion axis.

15. A proximal chamfer was prepared on the proximal surfaces to facilitate the ceramic veneer fitting and cementation.

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16. The silicon guide indicates areas that require wear and the ones to remain intact (fig. 10). This identifies a minimally invasive tooth preparation.

17. Preparation of tooth 21 was concluded.

Compare the wear made on tooth 21 with the dental structure of tooth 11, which was not prepared yet. There is no dentin exposure, which favors the longevity of the adhesive interface.

Note the minimum incisal reduction helping the characterization and the strength of the minimally invasive ceramic veneer.

18. Preparations were concluded and the retraction cord #000 (Pro Retract, FGM) was placed in the gingival sulcus.

19. Addition silicone mold (President, Coltene) obtained on a single-step impression technique.

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20 21

20. Stone model. We emphasize the importance of the laboratory technician on fitting the ceramic on the cervical area since the tooth preparation does not present a conventional shoulder or chamfer margin.

21. Ceramic veneers are supported on the incisal edge without any coverage of the lingual surface. Average veneer thickness = 0.4 mm.

22

23

22. The veneers were tested with the try-in paste shade A2 (Allcem Veneer Try-In, FGM). This phase is the try-in step or simulation phase, a fundamental step to evaluate the influence of the resin cement shade on the final color of the indirect restorations. There is a wide range of colors and effect resins for characterization and reproduction of translucency or opacity of the restorations. After selection of the try-in paste, clinicians should cement the ceramic veneer with the respective resin cement shade.

23. Allcem Veneer Try-In paste (FGM) used in this clinical case.

24

27

25

28

26

29

30

24. Dental preparation. Conditioning the enamel surface with 37% phosphoric acid (Condac 37, FGM) for 30 s.

25. 37% phosphoric acid (Condac 37, FGM) used in this clinical case.

26. After water rinsing for 30 s with water spray, the dental preparation was dried and the etch-and-rinse adhesive (Ambar, FGM) was applied with a thin microbrush (Cavibrush, FGM). Careful attention should be given for removal of the adhesive excess. The adhesive should not be light-cured after application to avoid misfit during cementation of the ceramic veneers.

27. Adhesive system applied (Ambar, FGM) in this case.

28. Treatment of the bonding surfaces of the lithium disilicate veneers (e-Max, Ivoclar). Conditioning with 10% hydrofluoridric acid (Condac Porcelana, FGM) for 20 s. Each type of ceramic should be conditioned by different periods, which depends on the amount of amorphous glass phase of each ceramic.

29. 10% hydrofluoridric acid employed (Condac Porcelana, FGM).

30. After water rinsing for 60 s and air-drying, the bonding surfaces of the ceramic veneers should be cleaned with 37% phosphoric acid (Condac 37, FGM) for 60 s.

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21

31A

31B

31C

31. A) The silane coupling agent (Prosil, FGM) was applied. Silane is an organic bi-functional molecule that allows chemical bonding between the ceramic and the resin luting cement. B) This agent has a high wettability on etched ceramic surfaces. C) After Silane application on the bonding surfaces of the ceramic, the material should be left undisturbed for at least 60 s.

32

33

34

32. Placement of the light-cured resin luting cement (Allcem Veneer, FGM). We selected the shade A2 during the try-in phase. The internal surfaces of the ceramic veneers were then filled with the resin cement shade A2. The cure of the resin cement will depend on the quality of the light emmited by the light curing unit.

33. Resin luting cement Allcem Veneer (FGM) employed in this clinical case.
 34. Each restoration margin was light cured for 40 s after removal of resin excess. The minimal light intensity of a LED device required for cementation of indirect ceramic veneers is 1,000 mW/cm².

35. Immediate final aspect of the maxillary arch after cementation of the minimally invasive ceramic veneers.

22

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35

37

36A

36B

36C

Final

36. A) Close facial view of the patient’s smile. B) Patient’s smile in low magnification C) Close lateral view.

37. Final facial view of the patient’s smile, showing the patient’s satisfaction.

Initial

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CASE02 Female patient, 42 years old.

OBJECTIVES OF THE CLINICAL CASE To show the importance of the try-in paste for selection of the adequate shade of the resin luting cement, for confirmation of the esthetic result and the prediction of possible adjustments on the shade of the ceramic veneer that may be required.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration ( ) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth ( ) Sound (x) Partial loss of the dental structure ( ) Need for intra-radicular retention (x) Significant color change ( ) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues ( ) Need for gingival recontouring

Final

Type of ceramic veneer (x) Conventional veneers. Teeth #: 12, 11, 21, 22

AUTHORS

( ) Minimally invasive veneers [“contact lens”]. Teeth #: 12, 11, 21, 22

Paulo Vinícius Soares

Characteristics of the dental preparation for ceramic veneer

Paola Gomes Sousa

(x) Increase of the cervico-incisal length. Teeth #: 12, 11, 21, 22

Lívia Fávaro Zeola

( ) Increase of the mesio-distal width. Teeth #: 12, 11, 21, 22

Pedro Henrique Spini

( ) Increase of the thickness of the buccal surface. Teeth #: Initial

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Ceramic veneers manual

1

CASE REPORT In this clinical case, a patient with inadequate restorations due to premature debonding and dentin exposure sought for dental treatment. The use of bleaching gels directly on dentin is not indicated; so this is a major limitation for preparation of minimally invasive veneers, as the color of the underlying dentin cannot be masked. Therefore, we opted for preparation of conventional veneers due to their bigger thickness. An important step for such clinical condition is the correct selection of the resin cement as it opacifies the darkened preparation.

2

3

4

1. Initial aspect of the patient’s smile. The patient was dissatisfied with the old restorations that debonded prematurely. 
2. After re-preparation of the remaining dental structures, the presence of dentin with variable shades was observed. In this clinical case, we opted for the preparation of conventional ceramic veneers.

3. Characteristic of the conventional veneer preparation: high preparation depth, wide exposure of dentin and preparation of a cervical shoulder for the ceramic.

5

4. Trying the ceramic veneer on tooth #21 with the try-in paste shade Trans (Allcem Veneer Try-In, FGM).

The use of a translucent paste allows evaluation of the individual effect of the ceramic veneer on the final color of the restorative treatment.

5. As one can observe, the resin cement cannot be translucent, as the darkened color of the underlying preparation will be visible because of the translucency of the veneer. Opaque or shaded resin cements should be selected after testing other try-in pastes of the Allcem Veneer Try-In.

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25

6

7A

7B

6. Facial view of the veneer seated on tooth 11 with the Allcem Veneer Try-in shade A3. On tooth 21, the veneer was seated with the try-in paste opaque white.

7A. After removal of the paste excess, one can observe different results mainly in the cervical third where the translucency of the veneer is higher due to the lower thickness (0.3 mm) than the average veneer thickness (0.5 mm).

7B. This translucency is the result of the high amount of amorphous glass phase and the reduced thickness of the ceramic veneer. For didactic reasons, the authors positioned 3 veneers with three different fluid impression materials in this image. This allowed us to demonstrate the effect of the translucency on the final color change produced by the “cement line�. Therefore, clinicians should be very careful in the selection of the adequate resin luting cement.

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Ceramic veneers manual

8A

8B

8A and 8B - Aspect of the veneers cemented with Allcem Veneer Opaque White (FGM), showing successful esthetic and functional modifications on anterior teeth.

initial

Final

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CASE03 Female patient, 20 years old

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration ( ) Presence of diastema ( ) Misalignment of the teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change (x) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues (x) Need for gingival recontouring Type of ceramic veneer

Final

( ) Conventional veneers. Teeth #:

AUTHOR

(x) Minimally invasive veneers [“contact lens�]. Teeth #: 15 to 25

Fabio Sene

Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: 15 to 25 (x) Increase of the mesio-distal width. Teeth #: 15 to 25 (x) Increase of the thickness of the buccal surface. Teeth #: 15 to 25 Initial

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Ceramic veneers manual

CASE REPORT

1

The patient sought for dental assistance after orthodontic treatment with the aim to improve her smile esthetics. During anamnesis and clinical examination, we diagnosed the presence of gingival hyperplasia. We suggested a periodontal surgery to re-anatomize the gingival tissue. Four months later, a treatment planning for preparation of minimally invasive veneers on teeth 15 to 25 was done. For this purpose, a diagnostic wax-up was prepared and only the superficial enamel removed due to the presence of amelogenesis imperfecta. After preparation, the impression mold was sent to the laboratory technician for fabrication of the ceramic veneers. The veneers were tried in to check the marginal fit on the dental preparation.

Before definitive cementation, the shade of the resin cement was selected using try-in pastes (Allcem Veneer Try-in). The bonding surfaces of the ceramic veneers were conditioned with hydrofluoridric acid, followed by application of silane and adhesive. Then, the ceramic veneers were cemented with Allcem Veneer shade Trans (translucent).

2A

2B

2C

1. Initial patient’s smile.
 2. A) Intra-oral view of the patient’s mouth showing the gingival hyperplasia, gingivitis and irregular texture of the dental enamel; B) surgery planning for the gingivoplasty and C) post-operative view 4 months after the surgery showing a healthy gingival tissue.

3

4

3. Diagnostic wax-up.

4. Mock-up;

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5A

5B

5C

6A

6B

7A

7B

7C

5. A to C. Dental preparations for indirect veneers.

6. A and B. Retraction cord in position into the gingival sulcus and impression taken with a putty and light-body addition silicone.

7. A to C. Ceramic veneers fabricated for this clinical case.

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8A

8B

8C

8. A to C. Aiming to check the fitting of the prosthetic pieces on the teeth, the veneers were placed in position firstly without the try-in paste.

9A

9B

9C

10B

10A

10C

9. A) Veneers seated on teeth 11, 12 and 13 with the try-in paste shade A1 (Allcem Veneer Try-in, FGM); B) veneers seated on teeth 21, 22 and 23 with the try-in paste Trans and C) veneers seated into position with different try-in pastes for color matching. We selected the shade Trans.

10. A to C. Preparation of the bonding surface of the veneer. Acid etching (Condac Porcelain, FGM) for 20s, application of silane (Prosil, FGM) and the etch-andrinse, MDP-containing Ambar (FGM) adhesive.

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11A

11B

11D

11C

11. A to D. Placement of the resin cement on the bonding surface of the veneer; veneer seated on the dental preparations; excess removed and the material light-cured.

12A

12B

12C

12. A to C. Cementation of the veneers.

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13A

13B

13D

13C

13E

13F

13. A to F. After cementation of the veneers, photographs of the patient’s smile were taken to highlight the correct interaction between lips and teeth.

Final

Initial

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CASE04 Female patient, 23 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration (x) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need of intra-radicular retention ( ) Extensive color change ( ) Need of previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues (x) Need for gingival recontouring Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens”]. Teeth #: 12 (x) Partial coverage of the buccal surface [“ceramic fragment”].

Teeth #: 13 (mesial surface) Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: 12 (x) Increase of the mesio-distal width. Teeth #: 12 and 13 ( ) Increase of the thickness of the buccal surface. Teeth #:

Final

AUTHORS Adriano Sapata Cláudio Sato

Initial

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Ceramic veneers manual

CASE REPORT This clinical case reports the removal of a defective composite resin restoration with a multi-fluted bur for preservation of the dental structure.

Note the presence of diastema in the mesial and distal surfaces of tooth 12. However, the diastema on the distal surface is wider. The best clinical alternative to distribute homogeneously the layers of ceramic veneers and reach an ideal veneer thickness is making a partial coverage of tooth 13 at its mesial surface. In this protocol, the buccal surface of tooth 13 will not be totally covered by the veneer. This partial indirect restoration is known as “ceramic fragment”.

1

2

3

1. Initial view showing the presence of diastema in teeth 12 and 13 and the presence of a defective restoration in the distal surface of tooth 12.

2. Multi-fluted bur used for removal of the composite resin restoration in tooth 12.

3. Aspect of the tooth after removal of the restoration.

4

6

5

7

8

4. Placement of the retraction cord # 000 (Pro Retract, FGM) for impression.

5. Selection of the shade of the indirect restoration.

6. Ceramic veneers seated on the stone model. A minimally invasive ceramic veneer was created for tooth 12 (contact lens) and a ceramic fragment was created for tooth 13.

7. The prosthetic pieces were placed in position to check margins fitting and proximal contacts.

8. The shade of the resin cement was tested using the try-in paste A1 (Allcem Veneer Try-in, FGM).

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9

10

13

11

12

14

15

9. Aspect of the minimally invasive veneer before conditioning.

10. Aspect of the ceramic fragment before conditioning.

11. Conditioning of the conventional feldsphatic ceramic with hydrofluoridric acid (Condac Porcelana FGM) for 2 min.

12. Silanization (Prosil, FGM).

13. Phosphoric acid etching (Condac 37, FGM) of the enamel surface of tooth 12 for 30 s.

14. Application of the etch-and-rinse adhesive Ambar (FGM).

15. Cementation of the indirect restorations with the light-cured resin luting cement Allcem Veneer (FGM), shade A1.

16

16. Light-curing step after cleanup.

17. Phosphoric acid etching (Condac 37, FGM) of the enamel surface of tooth 13 for 30 s.

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17

18

19

21

20

18. Application of the etch-and-rinse adhesive Ambar (FGM).
 19. Aspect of tooth 13 with the ceramic fragment in position, before removal of resin cement excess.

20. Restoration view after light-curing.

21. View of the patient’s smile.

Final

Initial

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CASE05 Female patient, 35 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration (x) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change ( ) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits ( ) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues ( ) Need for gingival recontouring Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens”]. Teeth #: 13 to 23 Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: 13 to 23 (x) Increase of the mesio-distal width. Teeth #: 13 to 23

Final

AUTHOR Fabio Sene

( ) Increase of the thickness of the buccal surface. Teeth #:

Initial

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Ceramic veneers manual

1

2A

1. Initial patient’s smile.

2. A to C. Intra-oral photographs showing discrepancies in the morphology of the teeth.

CASE REPORT

2B

The patient sought for dental care with the aim to have her anterior diastema closed and re-anatomize the smile. During anamnesis and clinical examination, we observed the morphology and anatomy of teeth 13 to 23 and informed the patient that we could perform minimally invasive veneers to improve her smile. We also explained that a conservative preparation would be required, with minimal wear to remove retentive areas of the patients’ teeth.

We initially performed the treatment planning and diagnostic wax-up. The reanatomization performed on the stone model was transferred to the patients’ mouth with bys-acryl resin.

2C

After viewing the result, the patient accepted the proposed protocol immediately. Based on the study model, minimal wear at some sites of the teeth were done to remove slopes and retentive areas.

An impression of the preparations was performed.

The laboratory fabricated the veneers, which were tested for correct fitness. The definitive shade of the resin cement was selected using the try-in pastes of Allcem Veneer. The bonding surfaces of the ceramic veneers were etched with hydrofluoridric acid; then, a silane and an adhesive were applied. The veneers were cemented with a light curing resin cement shade A2.

3A

3B

3C

3D

3. A to D. Diagnostic wax-up model. An impression of the stone model was done with putty-body silicone. This silicone mold was tested in a stone model that was not waxed. This procedure allows visualization of the areas where minimal wear of the teeth will be required.

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4A

4B

4C

6

5

4. A to C. To allow visualization of the final result on the patient’s mouth, a mock-up was done.

5. After patient’s approval, the dental preparations were performed.

6. Impression of the dental preparations was performed with putty and light-body addition silicone.

7A 7B

7. A and B. Minimally invasive ceramics created for this clinical case.

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Ceramic veneers manual

8A

8B

8D

8C

8. A) Application of the try-in paste Allcem, shade A2 onto the internal surface of the ceramic veneers. B) ceramic veneers from teeth 11, 12 and 13 were seated into position with the try-in paste A2. Note that the veneers from teeth 21, 22 and 23 did not receive the try-in paste and they are extremely translucent. C) Seating the ceramic veneers on teeth 21, 22 and 23 with Allcem Try-in shade Trans (Translucent); D) Try in was performed with two different shades to highlight the differences on the final shade outcome: right side - shade A2; left side: shade Trans.

9A

10A

9B

10B

10C

9. A and B. Treatment of the internal surfaces of the ceramic veneers: acid etching with 10% hydrofluoridric acid (Condac Porcelana, FGM) for 20 s. After water rinsing and drying, the silane (Prosil, FGM) was applied.

10. A to C. Acid etching (Condac 37, FGM), application of the adhesive (Ambar, FGM) followed by light-curing for 20 s.

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41

11A

11C

11B

11D

12

11. A to D. Application of Allcem Veneer shade A2, which was selected using the try-in pastes. The ceramic veneers were seated onto the teeth; excess of resin cement were removed followed by the light-curing step.

12. Ceramic veneers after cementation and before removal of the resin excess on the canines.

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13D

13A

13B

13C

13. A to D. Intra-oral and social photographs showing the conclusion of the clinical treatment.

Initial

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Final

CASE06 Female patient, 21 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration (x) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change ( ) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues ( ) Need for gingival recontouring Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens�]. Teeth #: 12 and 22 Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: 12 and 22 (x) Increase of the mesio-distal width. Teeth #: 12 and 22 ( ) Increase of the thickness of the buccal surface. Teeth #:

Final

AUTHORS Claudio Sato Adriano Sapata David Morita da Silva

initial

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Ceramic veneers manual

CASE REPORT The ultra-thin ceramic veneers, also known as “dental contact lens”, have been widely explored by clinicians for esthetic improvement and harmonization of patients’ smile. However, treatment should indicated after strict observation of factors. For some clinical instance, the belief that there is no need to perform dental preparation for minimally invasive veneers is usually a misconception. In the great majority of the cases, a minimal wear of enamel is required to produce an insertion axis for cementation. Another misconception is that minimally invasive veneers are indicated for situations that require modification of the shade of the dental structure. As these veneers are very thin, they cannot mask the underlying color of the dental substrate.

In the present clinical case, ultra-thin veneers were indicated to improve the shape of the conoid lateral incisors; the reason of the patient’s dissatisfaction with her smile.

1A

1B

1C

2A

2B

2C

1. A to C. Initial patient’s smile. One can observe the conoid morphology of the lateral incisors.

2. A to C. Checking the lateral and protrusion movements of the jaw to diagnose if there was available space for fabrication of the restorations in the lateral incisors.

4A 3

4B

3. We took photographs of the patient’s face and smile for digital planning and diagnostic wax-up.

4. A and B. An impression of the wax-up model was done to aid in the fabrication of the mock-up with bys-acryl resin. Note that the areas of the cervical embrasures were cut to allow material flow. The removal of the excess should be conducted with a scalpel blade or multi-fluted drills. Brightness can be achieved with felt discs and diamond paste (Diamond Flex and Diamond Excel, FGM).

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5 4C

6A

6B

4. C. Teeth with the mock-up. 
 5. After patient’s approval, we recommended the in-office bleaching with Whiteness HP Blue 35%, which was applied in 3 sessions of 40 min each.

6. A to B. Through an impression of the diagnostic wax-up model, we prepared a silicone guide to aid the dental preparations of the teeth 12 and 22.

From the incisal view, one can observe that the mold touches the areas where wear (approximately 0.3 to 0.5 mm thick) will be required. In figure A) the silicone guide was positioned in the medium third and we could visualize the need for buccal wear of tooth 12. In figure B) the guide was positioned in the cervical third, highlighting the need of dental wear in teeth 12 and 22.

7A

7B

7. A to D. The dental wear can be performed with the fine-grit diamond burs F or FF or multi-fluted burs. The finishing of the dental preparations can be performed with fine-grit felt disks (Diamond Pro, FGM).

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Ceramic veneers manual

7C

7D

8

10A

9

10B

10C

8. Selection of the shade for the ceramic veneers. An impression was performed after placement of the retraction cords. The laboratory technician fabricated the ceramic veneers.

9. The veneer was seated to examine the marginal fit and proximal contact points – this step is known as “dry try-in step�.

10. A to C. After checking the adequate fit, we can perform the try-in step. The veneers were positioned on the enamel surfaces with the try-in paste, which consists of a glycerin gel that mimics the shade of the resin cement that will be used for definitive cementation. In this case, we selected shade A1.

11

12

13

11. Before definitive cementation, clinicians should know which type of ceramic material was employed for the fabrication of the contact lens. This influences significantly the etching time with hydrofluoridric acid (Condac Porcelana, FGM). In this clinical case, a feldsphatic ceramic was employed and therefore, their bonding surfaces were conditioned for 2 min before water rinsing.

12. Due to the formation of hexafluoride salts onto the ceramic surface etched with hydrofluoridric acid, an additional cleaning should be performed. It is recommended the immersion of these veneers in an ultrasound bath for 5 min or the additional conditioning with 37% phosphoric acid (Condac 37, FGM) for 1 min under active application.

13. After rinsing and drying, the bonding surfaces of the ceramic veneers should be silanized (Prosil, FGM). The silane should be left undisturbed for 1 min on the surface.

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14A

14B

15B 15A

14. A and B. A retraction cord (Pro Retract # 000, FGM) was placed in the gingival sulcus to avoid contamination with the crevicular fluid. 
 15. A and B. The enamel surfaces were etched with phosphoric acid (Condac 37, FGM) for 30 s, followed by the application of the adhesive (Ambar, FGM) on teeth 12 and 22. The adhesive was applied on the dental preparations for 20 s with a sonic device, followed by light curing for 40 s.

16A

16B

16C

16D

16E

16F

16. A and F. The selected shade of the resin cement was A1 (Allcem Veneer). The veneers were filled with the selected shade of the resin luting cement and seated manually on the dental preparations with rubber brushes. The resin excess was initially removed with a microbrush. At the proximal areas the cement excess was removed with dental floss and teflon tape. After light curing and before removal of the retraction cord, a scalpel blade was used for removal of the resin cement excess at the restoration margins.

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17A

Final

initial

17B 17C

17D

17E

17 A and E. Pictures of cemented pieces and patient’s smile.

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49

CASE07 Female patient, 21 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration ( ) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth ( ) Sound (x) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change ( ) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues ( ) Need for gingival recontouring Type of ceramic veneer (x) Conventional veneers. Teeth #: ( ) Minimally invasive veneers [“contact lens”]. Teeth #: 12 Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: 12 ( ) Increase of the mesio-distal width. Teeth #: ( ) Increase of the thickness of the buccal surface. Teeth #:

Final

AUTHORS Paulo Vinícius Soares Camila Carvalho Almança Lopes Fabrícia Araújo Pereira Lívia Fávaro Zeola Veridiana Rezende Novais Initial

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Ceramic veneers manual

CASE REPORT The rehabilitation of this clinical case could have been perfomed with direct composite resin. However, the patient reported that due to the failure of four direct restorative procedures, which had been previously done, she would prefer rehabilitation with ceramics. A minimally invasive veneer was not indicated in this clinical case due to the depth of the dental preparation performed earlier for the direct veneer. Therefore the old preparation was reanatomized to receive conventional ceramic veneers.

1A

1B

2

3B

1C

3A

3C

1. A and C. Initial aspect of the patient’s smile. Lateral view showing the defective composite resin restoration.
 2. The old restoration was removed with a diamond bur 2135F (KG Sorensen), and the dental preparation was redefined avoiding the wear of the remaining dental structure. Note that in this type of conventional preparation, the bonding is usually performed on dentin. To improve the stability of the restoration we included the incisal edge onto the dental preparation. 
 3. A to C. Final aspect of the restorative procedure after light-curing.

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51

CASE08 Male patient, 31 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration (x) Presence of diastema ( ) Misaligment of teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change (x) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues (x) Need for gingival recontouring Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens”]. Teeth #: 13, 12, 11, 21, 22 and 23 Characteristics of the dental preparation for ceramic veneer

AUTHORS

(x) Increase of the cervico-incisal length. Teeth #: 12, 11,

Alexandre Coelho Machado

21, 22

Andrea Barros Tolentino

(x) Increase of the mesio-distal width. Teeth #: 12, 11,

Ramon Gonzaga Lopes

21, 22

Michelle Pereira Costa Mundim

(x) Increase of the thickness of the buccal surface. Teeth #: 13 and 23

52

Final

Ceramic veneers manual

João Vitor Soares Paulo Vinícius Soares

Initial

CASE REPORT In this clinical case, the preliminary dental bleaching facilitates the right choice of the ceramic hue, chroma and translucency as well as the type of resin cement (opaque, translucent or with defined chroma). Dental bleaching promotes homogenization of the natural polychromatic aspect of the anterior teeth, making the color selection easier for the operator. The use of the try-in pastes before definitive cementation is a fundamental step to reach clinical success.

1A

1B

2A

3A

1C

2B

3B

1. A and C. Initial aspect of the patient who was dissatisfied with the appearance of his smile because of the short teeth and presence of diastema. After removal of the orthodontic brackets one should evaluate some important features of the teeth such as dental morphology (homologous teeth should be compared one another and with esthetic proportions), characteristics of the periodontal contouring (note that teeth 11, 12 and 13 are shorter due to the gingival contour and the volume occupied by the papilla) and finally one should evaluate the teeth color to determine whether or not dental bleaching will be required.

2. A and B. The minimally invasive preparations were initialized with the diamond bur 2135F. One should take advantage of the diastema to establish the inciso-cervical insertion axis. The incisal edges should be rounded to avoid stress concentration that may weaken the restoration. The dental preparations should be measured with a compass and digital caliper to check if they are in accordance with the digital planning and diagnostic wax-up.

3. A and B. Facial view immediately after cementation of the veneers with the resin luting cement Allcem Veneer (FGM). The treatment of the internal surfaces of the ceramic veneers was similar to that described in the clinical case 01. The average veneer thickness was 0.3 mm.

Note the final aspect of the patient’s smile and diastema closure after cementation of minimally invasive ceramic veneers.

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CASE09 Male patient, 35 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration (x) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change ( ) Need for previous dental bleaching Occlusal pattern ( ) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues (x) Need for gingival recontouring Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens”]. Teeth #: 13, 12, 11, 21, 22 and 23 Characteristics of the dental preparation for the ceramic veneer (x) Increase of the cervico-incisal length. Dental elements: 13, 12, 11, 21, 22, 23 (x) Increase of the mesio-distal width. Teeth #: 12, 11, 21, 22 ( ) Increase of the thickness of the buccal surface. Teeth #:

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Final

AUTHORS Paulo Vinícius Soares Ana Cristina Peres Magalhães Alexia da Mata Galvão Tatiana Carvalho Montes Marina Ferreira de Lima Naves Pedro Henrique Spini

Initial

CASE REPORT The presence of incisal tooth wear is a sign of active parafunctional habit. In such case, it is fundamental to diagnose the cause. For some cases, we indicate the use of mouth-guards to protect the restorations. In this particular case, the parafunctional patient’s habit was no longer active and therefore a protective mouth-guard was not required.

1A

1B

1C

2A

3A

2B

3B

3C

1. A and C. Initial patient’s aspect after removal of the orthodontic devices. The patient was dissatisfied with the appearance of his smile due to the presence of diastema and short teeth.

2. A and B. Mock-up with bis-acryl resin. In this moment, the aspects of the face, smile, dental alignments, phonetic and other individual characteristics of the patient should be evaluated. This is one of the purposes of the mock-up. The second purpose of the mock-up is as important as the first. In this stage, we should evaluate the contact points, the adjustments required in maximum intercuspidation, anterior guide, canine guide and phonetics. To the author’s opinion, the evaluation and adjustments in this stage is the most important step of the protocol to provide minimally invasive veneers with high strength. To allow a better communication with the laboratory technician, it is suggested the replication of the mock-up by making an impression with addition silicone.

3. A to C. Minimally invasive veneers (“contact lens”), which are in average 0.4 mm thick, after cementation with Allcem Veneer A1 (FGM). As the veneers are very thin, the presence of active parafunctional habits requires the indication of an acrylic mouth-guard that should be worn at night to protect the restorative treatment. Note the final aspect of the patient’s smile after diastema closure and reanatomization of the teeth.

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CASE10 Female patient, 29 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration ( ) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth ( ) Sound (x) Partial loss of the dental structure (x) Need for intra-radicular retention ( ) Significant color change ( ) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues ( ) Need for gingival recontouring Type of ceramic veneer (x) Conventional veneers. Teeth #: 12 (x) Minimally invasive veneers [“contact lens”]. Teeth #: 11 and 21 (x) Single crown. Teeth #: 22 Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: 12 and 22 ( ) Increase of the mesio-distal width. Teeth #: (x) Increase of the thickness of the buccal surface. Teeth #: 11 and 21

Final

AUTHORS Paulo Vinícius Soares Ana Cristina Peres Magalhães Alexia da Mata Galvão Tatiana Carvalho Montes Marina Ferreira de Lima Naves Pedro Henrique Spini

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Initial

CASE REPORT The tooth 22 received a glass fiber post and the tooth was prepared to receive a single crown due to the high fragility of the remaining dental structure. The tooth 12 was prepared to receive a conventional veneer, while teeth 11 and 21 were treated with minimally invasive veneers. Previous dental bleaching was not performed due to the favorable thickness of the ceramic restorations, which would be sufficient to prevent the color of the underlying dental structure from altering the final esthetic result.

1B

1A

2A

2B

3

4B 4A

1. A and B. Initial aspect of the patient’s view showing morphological alteration at the cervical area of tooth 11. The minimally invasive preparation should compensate for this alteration.

2. A and B. Dental aspect after minimally invasive preparations. A silicone guide that was prepared after impression of the diagnostic wax-up model was compared with the dental preparations.

3. Color selection using the try-in paste Allcem Try-in. For tooth 11, shade OW (opaque white) was selected, while for tooth 21, shade A3 was chosen. This simulation clearly demonstrates the effect of the resin luting color on the final esthetic result after cementation of the veneer.

Although the dental preparations were minimally invasive, with similar depth, and the veneers were fabricated with the same type of ceramic, the effect of the reduced veneer thickness and its high translucency yielded different results in the two teeth. This clinical step highlights the importance of the try-in pastes in the selection of the correct color of the resin cement. In this clinical case, we employed the OW shade after approval of patient and the professional’s team.

4. A and B. Patient’s smile after concluding the restorative procedure – all ceramic veneers were cemented with Allcem Veneer (FGM).

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CASE11 Female patient, 19 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration (x) Presence of diastema (x) Misalignment of teeth in the arch Characteristics of the teeth (x) Sound ( ) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change (x) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues (x) Need of gingival re-contour Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens”]. Teeth #: 12, 11, 21 and 22 Characteristics of the dental preparation for ceramic veneer

AUTHORS

(x) Increase of the cervico-incisal length. Teeth #: 12, 11,

Paulo Vinícius Soares

21 and 22

Ana Cristina Peres Magalhães

(x) Increase of the mesio-distal width. Teeth #: 12, 11,

Alexia da Mata Galvão

21 and 22

Tatiana Carvalho Montes

( ) Increase of the thickness of the buccal surface. Teeth #:

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Marina Ferreira de Lima Naves Pedro Henrique Spini

Initial Inicial

CASE REPORT The patient sought for dental care after orthodontic treatment. We could observe the slight buccal positioning of tooth 21, which was easily corrected after enameloplasty during minimally invasive preparation. In a more severe situation, alignment with orthodontic devices would be required.

1A

1B

2

4A

1C

3

4B

4C

1. A to C. Lateral view of the patient’s smile. The rehabilitation of this clinical case was performed with minimally invasive veneers with the aim to conclude the orthodontic treatment. The patient was dissatisfied with the dental diastema and the different dimensions of the anterior teeth. We planned the reanatomization of the anterior teeth and diastema closure. However, a gingivoplasty was recommended to aid the re-establishment of the correct dental morphology.

2. In this clinical photograph, one can observe the post-operative result 45 days after the gingivoplasty, 15 days after at-home bleaching with 16% carbamide peroxide (Whiteness Perfect, FGM) and after minimally invasive preparations. Note the minimum taper for insertion and accommodation of the “contact lens”. Rounded corners are important to strengthen the restoration.

3. Lingual view of the ceramic veneers showing conservative preparation and the support for the ceramic on the incisal edge.

4. A to C. Patient’s smile after cementation of the veneers with Allcem Veneer shade A1.

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CASE12 Female patient, 51 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration ( ) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth ( ) Sound (x) Partial loss of the dental structure ( ) Need for intra-radicular retention (x) Significant color change ( ) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation ( ) Occlusal stability ( ) Absence of significant wear facets Periodontal tissues ( ) Need for gingival recontouring Type of ceramic veneer (x) Conventional veneers. Teeth #: 14, 13, 12, 11, 21, 22, 23 and 24 ( ) Minimally invasive veneers [“contact lens”]. Teeth #: Characteristics of the dental preparation for ceramic veneer (x) Increase of the cervico-incisal length. Teeth #: ( ) Increase of the mesio-distal width. Teeth #: (x) IIncrease of the thickness of the buccal surface. Teeth #: 14, 13, 23 and 24.

Final

AUTHORS Paulo Vinícius Soares Fernanda Rodrigues Guedes Analice Giovani Pereira Luis Henrique Araújo Raposo

Initial

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CASE REPORT The re-establishment of the occlusal stability with posterior restorations is fundamental for the success of restorations placed on the anterior teeth. In this clinical case, the functional and esthetic rehabilitation was perfomed with conventional veneers due to the discoloration of the remaining dental structure. Because of exposed dentin on the cervical area as well as several unsatisfying composite resin restorations that covered the buccal surface of the teeth, dental bleaching was not recommended.

1A

1B

1C

2

3A

3B

3C

1 A to C. Initial aspect of the patient’s smile. The patient was not satisfied with the composite resin restorations and the shade of her teeth. The defective restorations stand out in a facial view. We did not recommend a gingival recontouring due to the limitations imposed by the biological distances and teeth profile. The presence of dentin exposure at the cervical area contraindicated the bleaching protocol. On the other hand, this does prevented dental re-anatomization and modification of the teeth shade. In this clinical case we used a lithium disilicate-reinforced ceramic due to its low translucence.

2. Facial view of the dental surfaces after minimally invasive preparations. Note the intermaxillary space. There is sufficient space for material addition, with the aim to strengthen the restored teeth.
 3. A to C. Buccal view of the ceramic veneers cemented with Allcem Veneer A1 (FGM).

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CASE13 Female patient, 25 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration ( ) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth ( ) Sound (x) Partial loss of the dental structure ( ) Need for intra-radicular retention ( ) Significant color change (x) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues (x) Need for gingival recontouring Type of ceramic veneer ( ) Conventional veneers. Teeth #: (x) Minimally invasive veneers [“contact lens”]. Teeth #: 13, 12, 11, 21, 22 and 23

Final

Characteristics of the dental preparation for ceramic veneer

AUTHORS

(x) Increase of the cervico-incisal length. Teeth #: 12, 11, 21 and 22

Paulo Vinícius Soares

( ) Increase of the mesio-distal width. Teeth #:

Fernanda Rodrigues Guedes

(x) Increase of the thickness of the buccal surface. Teeth #: 13 and 23

Analice Giovani Pereira Luis Henrique Araújo Raposo

Inicial

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CASE REPORT

1A

This is a very common clinical situation: replacement of old composite restorations and the desire of the patient for longer teeth. During examination, we concluded that the occlusal pattern of the patient was favorable and we also noted the need for gingival recontouring.

The gingivoplasty increases the cervico-incisal length of the teeth and reduces the need for ceramic addition in the incisal area of the teeth.

Therefore, the increase in the cervico-incisal dimension will not rely solely on ceramic addition at the incisal edge. This procedure can cause occlusal interferences and/or weaken the ceramic veneers. Dental bleaching was performed in the premolars and first molars to allow better color matching with the ceramic veneers.

1B

1C

2

3B

1D

3A

3C

3D

3E

1. A to D. Initial aspect of the patient’s smile. The patient was not satisfied with the color of her teeth and the presence of defective composite restorations. Note the need of gingivoplasty to aid dental reanatomization.
 2. Forty-five days after the periodontal surgery, we placed a retraction cord # 000 (Pro Retract, FGM) into the gingival sulcus and finished the dental preparations with coarse and medium-grit finishing disks (Diamond Pro, FGM).
 3. A to E. Minimally invasive veneers (average thickness of 0.3 mm) cemented with Allcem Veneer A1. Note the gain in the cervicoincisal length achieved by the gingivoplasty and the addition of ceramic on the incisal edge.

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CASE14 Female patient, 52 years old.

PLANNING Analysis of the main characteristics of the clinical case: Smile change (x) Morphological dental alteration ( ) Presence of diastema ( ) Misalignment of teeth in the arch Characteristics of the teeth ( ) Sound (x) Partial loss of the dental structure ( ) Need for intra-radicular retention (x) Significant color change ( ) Need for previous dental bleaching Occlusal pattern (x) Absence of parafunctional habits (x) Favorable intermaxillary relationship (x) Favorable occlusal space for rehabilitation (x) Occlusal stability (x) Absence of significant wear facets Periodontal tissues ( ) Need for gingival recontouring Type of ceramic veneer (x) Conventional veneers. Teeth #: 14 to 24 ( ) Minimally invasive veneers [“contact lens”]. Teeth #: Characteristics of the dental preparation for ceramic veneer

Final

AUTHORS

(x) Increase of the cervico-incisal length. Teeth #: 12, 11, 21 and 22

Paulo Vinícius Soares

( ) Increase of the mesio-distal width. Teeth #:

Bruno Rodrigues Reis

Andrea Barros Tolentino

(x) Increase of the thickness of the buccal surface. Teeth #: 14, 13, 23 and 24

Initial

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CASE REPORT The patient presented composite resin veneers in almost all anterior teeth; most of them were unsatisfying. After removal of the restorations and dentin exposure, dental bleaching was not recommended. The gingivoplasty was also not recommended as the patient had been submitted to periodontal surgeries in the last years. In this clinical case, the correct selection of the ceramic and the use of the try-in paste for selection of the resin cement shade are fundamental steps to manage the dental discoloration and improve the esthetics of the patient’s smile. A considerable rejuvenation was achieved with the final esthetic result.

1A

2

1B

3A

3C

3B

3D

1. A and B. Initial aspect of the patient’s smile. The patient was not satisfied with the color of her teeth and her composite resin veneers. Note that the defective composite resin restorations are clearly identified in a facial view. We did not recommend gingival recontouring due to the limitations imposed by the biological distances and emergence profiles. The relative proportion and length of the teeth were inadequate. The lateral incisors stand out for size.

2. All veneers were removed for dental preparations. Due to the depth of the earlier dental preparations, dentin exposure occurred in all teeth; the reason why we opted for conventional ceramic veneers with cervical edge and incisal coverage. The average veneer thickness was 0.6 mm.

3. A to D. Ceramic veneers cemented with the Allcem Veneer shade Opaque White. Note the patient rejuvenation with the esthetic result.

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COLABORATORS TEXT AND CLINICAL CASES: Paulo Vinícius Soares Professor from the Departments of Restorative Dentistry and Dental Materials - FO.UFU Coordinator of Research Group LCNC.FO.UFU Alexandre Coelho Machado Professor of Restorative Dentistry from the School of Dentistry - FAMA/GO Analice Giovani Pereira PhD in Dentistry clinics - FO.UFU Fabrícia Araújo Pereira Professor of the Department of Restorative Dentistry and Dental Materials - FO.UFU Guilherme Faria Moura MS in Dentistry clinics - FO.UFU Lívia Fávaro Zeola Professor at the Technical course in Oral Health ESTES/UFU Pedro Henrique Spini MS in Dentistry clinics - FO.UFU Department of Restorative Dentistry and Dental Materials – School of Dentistry from the Federal University of Uberlandia. Members of the Clinical and laboratory research group LCNC-FOUFU.

CLINICAL CASES Adriano Sapata Specialist and MS in Restorative Dentistry (UnG).

Professor of Restorative Dentistry at FUNDECTO-USP Alexia da Mata Galvão DDS in Dentistry - FO.UFU Ana Cristina Magalhães Professor of Dental Prosthesis and Implantology INPEO/MT

Anaíra R. G. Fonseca Costa DDS in Dentistry - FO.UFU Andrea Barros Tolentino DDS in Dentistry - FO.UFU Bruno Rodrigues Reis PhD in Dental Materials - FO.USP Camila Carvalho Almança Lopes MS in Dentistry clinics - FO.UFU Cláudio Sato Coordinator of the Discipline of Restorative Dentistry at FOUBC. Professor of the department of Restorative Dentistry – University Braz Cubas - SP David Morita Da Silva President of the 14th International Congress of Dental Prosthesis – APDESP Fábio Mesquita Laboratory technician Fabio Sene Professor of Dentistry Clinics at the School of Dentistry – UEL/PR. Fernanda Rodrigues Guedes DDS in Dentistry - FO.UFU Igor Oliveiros Cardoso DDS in Dentistry - FO.UFU João Vitor Soares Specialist in Orthodontics - Uberlandia Juliane Thaís M. de Arruda Esthetic course in Anterior teeth – UFU Luis Henrique Araújo Raposo Professor of the Department of Fixed Prosthodontics and Dental Occlusion - FO.UFU Marina Ferreira de Lima Navaes DDS in Dentistry - FO.UFU Michele Borges Silva

ACKNOWLEDGMENTS

DDS in Dentistry - FO.UFU Michelle Pereira Costa Mundim MS in Dentistry clinics - FO.UFU Murilo Sousa Menezes Professor of the Department of Restorative Dentistry and Dental Materials - FO.UFU Paola Gomes Sousa DDS in Dentistry - FO.UFU Paulo César Freitas Santos-Filho Professor of Restorative Dentistry and Dental Materials - FO.UFU Paulo Sérgio Quagliatto Professor of the Department of Restorative Dentistry and Dental Materials - FO.UFU Priscilla Fernanda Silva DDS in Dentistry - FO.UFU Rafaella Rodrigues Gomes DDS in Dentistry - FO.UFU Ramon Gonzaga Lopes DDS in Dentistry - FO.UFU Rodrigo Borges Fonseca Professor of the Department of Restorative Dentistry and Dental Materials - FO.UFU Sônia Cristina de Sousa DDS in Dentistry - FO.UFU Tatiana Carvalho Montes DDS in Dentistry - FO.UFU Thaís Mendonça Rosa Course in Esthetic in Anterior teeth - UFG Thiago Andriani Borges DDS in Dentistry - FO.UFU Tiago Augusto Quirino Barbosa DDS in Dentistry - FO.UFU Veridiana Rezende Novais Professor of Restorative Dentistry and Dental Materials - FO.UFU

The authors are grateful to the laboratory technician Marco Aurélio Dias Galbiati – Uberlândia/MG and the professors Jair Costa, João Lenza and Marcelo Witzel.

Manual of veneers and “Contact Lenses” is a publication of Dentscare Ltda., Av. Edgard Nelson Meister no 474, CEP 89219-501, Joinville-SC, Brazil. All rights reserved. No part of this publication may be reproduced without written permission. The technical information herein described is the responsibility of the respective authors. The articles does not reflect, necessarily, the manual opinion. The Dentscare Ltda recommends reading the “instructions manual” for correct instruction on how to use the products.

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