Laminated Veneers with Stratified Feldspathic Ceramics
Patient R.C., 52-year-old male subject, sought dental treatment demonstrating dissatisfaction with the upper anterior teeth aesthetics, which had extensive composite resin restorations, pigmentation, spots, and infiltration. After the anamnesis, as well as the X-rays, photographs and upper and lower arches’ evaluation, the case was prepared and an aesthetic rehabilitation treatment was proposed, consisting of a ceramic crown, with zirconia infrastructure in element 15 and laminated veneers, with feldspathic ceramics in elements 11, 12, 13, 14, 21, 22, 23, 24, and 25.
Following the references from the digital smile design, which is performed using pictures of the face and smile of the patient and a computer program, PowerPoint (Microsoft) or Keynote (Mac), it is possible to correct positioning and minor glitches using smile lines and median with teeth proportionality; a diagnostic wax-up of the upper model was produced, and based on it, silicon guides were made to create the mock-up, guide the enamel/dentin preparation, and subsequently assist in the preparation of a temporary crown with bis-acryl resin. Considering tooth 15, a metal-free preparation was made to cover the full crown with zirconia infrastructure; elements 14, 24, and 25 were chosen for inverted-type 4/5 preparations, and for the anterior teeth, tooth preparation for laminated veneers with incisal wear and no overlap was considered for the treatment . When the tooth preparation was finalized, gingival separation was done by applying the double-wire technique. For this, wires no. 000 and no. 00 (Ultrapak, Ultradent), embedded in hemostatic solution (Hemostop, Dentsply), were used. Considering the molding process, at the time of the light A-silicone insertion, the second wire (no. 00) was removed and the material flowed into the gingival sulcus, copying the terminus region. Soon after, the tray with the putty A-silicone was positioned (Flexitime, Heareus Kulzer). After analyzing the mold quality, the temporary crowns were prepared with A3-colored bis-acryl resin (Structur, Voco), using the silicone guide built on the model with diagnostic wax-up .
The working model was obtained using stone rock type IV (Elite Rock, Zhermack) and then punched through the Accutrac system (Coltene/Whaledent), in laboratory, for later duplication and confection of the veneers in feldspathic ceramics (IPS Empress II, Ivoclar Vivadent). Once tested, adjusted, and approved, the cement agent color was chosen. In order to do so, temporaries were removed and the cement was tested using the try-in system (Variolink II, Ivoclar Vivadent), which are glycerin-based compounds that simulate the cement final color. Thus, based on this choice, the cement was finally selected. Once the cement color (color A3) was chosen, pieces were taken for cementation. Firstly, the try-in was removed, washing it under running water, and, subsequently, 10% hydrofluoric acid was applied (Ceramic Etching Gel, Ivoclar) for 60 seconds. The samples were then washed thoroughly in running water, and after a two-hour drying process, two different layers of silane (Monobond-Ivoclar) were applied for 60 seconds. After the piece preparation, isolation and gingival separation were done, using retractor wire # 000 (Ultrapak, Ultradent), embedded in hemostatic solution (aluminum chloride, Dentsply). The process was then accomplished on the buccal face of the teeth that would receive the veneer. The dental substrate was degreased, with detergent solution (Tergensol, Inodon), conditioned with 37% phosphoric acid (Condac, FGM) for 15 seconds, and then washed for 45 seconds for subsequent drying, leaving the substrate slightly moist. The adhesive system (Gluma, Heraeus Kulzer) was applied for 30 seconds, waiting for the adhesive to penetrate in the conditioned dentin tubules. A light air jet was applied, and then, each tooth was light cured for 30 seconds.
The light-cured resin cement (Variolink II, Ivoclar Vivadent) was activated and placed inside the pieces that were placed into position and light cured again for additional two seconds. The excess cement was removed, using a scalpel blade, and the curing cycle was terminated (40 seconds on each side). Finally, a glycerin layer (Liquid Strip, Ivoclair Vivadent) was applied, on the cervical region, between the union piece and tooth, and resin cement was light cured for another 20 seconds, aiming at blocking the oxygen entrance. The excess cement was removed with the aid of scalpel blade number 15c (Solidor) and polished with silicone cups and felt disks.
After completing the case, the patient evaluated the final result of the installed work, comparing the before and after the installation of the ceramic veneers, and he was very satisfied with the result.
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