Relato de caso sem preparo - dissilicato de lítio.pdf

18 Spectrum dialogue Vol. 10 No. 9 November/December 2011

Lithium Disilicate Veneers: A case reportwith no teeth preparation Dario Adolfi DDS, CDT * Oswaldo Scopin de Andrade DDS, MS, PhD**

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Spectrum dialogue Vol. 10 No. 9 November/December 2011 19

Introduction

The utilization of laminate veneer in anterior dentition isthe most documented approach in literature for proceduressuch as extensive smile changing. Among the advantagesof this restorative strategy is the possibility of achieving aperfect harmony between soft and hard dental tissue. Thisharmony is possible thanks to the physical properties ofthe ceramic, which remains stable for a long term.However, to obtain a perfect balance besides soft tissuehealth and function the clinical success is dependent of amajor factor: the bonding procedures.

In order to achieve an interaction between dental hardtissue and ceramic, what is called bonding, the structuresmust be able to be altered to receive a material that bringtogether the surfaces creating a perfect interface. Theadhesiveness of the restorative material to be bonded totooth structure creates a term named biomimetic1. The

concept of biomimetic in dentistry implies that anymaterial utilized for a restoration brings not only theesthetic and function but also act as it was the tooth;restoration and tooth become one structure.

For better clinical results the laminate veneer is donewith a ceramic that can be altered by etching the intagliosurface with hydrofluoric acid2. Among the materialsavailable, glass ceramic made on the refractory die-technique is the most documented because of itsesthetics, biocompatibility, shape and shade stability3.Even though being a safe and documented procedure, thatpermits the technician to obtain veneers as thin as 0.2 mm, many clinicians face difficulties during try-in andbonding procedures.

This limitation has reduced the utilization of refractory die-technique in the last two decades. As an option forthis technique leucite pressed ceramic has become popularamong clinicians and ceramists. The advantages of theleucite pressed ceramic include: less sensitive laboratoryprocedures and safer bonding because of better physicalproperties. In this manner the technique was easier for thelaboratory and less risky for the clinician4.

However, the first pressed system launched for itrequired more space to build a restoration and it was notlife-like when compared with the traditional refractorydie-technique. Even though laminate veneers have startedto be used more and more with pressed ceramic with highlevel of acceptance by patients and dentists.

After the rise of the pressed ceramic on the market,some cases that did not need a preparation to be donewere prepared to obtain clearance for the material thatneed around 0.8 mm, to be pressed and then stained.

Nowadays the concept of enamel maintenance andminimal preparation design restoration bring again theconcept of laminate veneers with minimal or evenwithout any tooth preparation.

The development and improvement of lithium disilicate pressed ceramic has brought the concept back toless preparation for laminate veneers5.

This ceramic permits the technician to build a pressedrestoration and carefully reduced using rubber wheels anddiamond bur with copious irrigation to less than 0.2 mm,with proper resistance to be tried and bonded with muchless risk when comparing with the traditional porcelainmade with the refractory die-technique.

Case Report

The case described in this article shows an esthetic smilechanging in a young man because of anatomicirregularities on enamel surface in both arches. After allthe options have been explained and discussed such asdirect composite resin restorations he chose an estheticrehabilitation of the ten maxillary teeth: four incisors,



Figs. 1-3: Portrait from the initial situation.

Fig. 1 Fig. 2 Fig. 3

canines and two bicuspid on each side, with lithium disilicate pressed ceramic restorations. A gengivoplastywas performed on the premolars to establish a new line forgingival tissue and improve the esthetic deficiency in thebuccal corridor region.

The only requirement asked by the patient was to makethe restoration with no preparation or any enamelreduction.

Diagnostic Approch

The initial clinical evaluation includes critical and carefulanalysis of the occlusal scheme, periodontal examinationfollowed by a face photography protocol. The canines arevery important in this role, developed with appropriatemorphology maintaining adequate functional height,quantity and quality of disocclusion6.

Flapless Esthetic Crown Lengthening

Specifically for this case, to achieve a better esthetic resultwith a more harmonious gingival contour of the premolars, a flapless surgical crown lengthening wasplanned and executed to develop a new gingival line. Thefinal length of the teeth involved were determined basedon sulcus probing with the patient under anesthesia, toreach the bone crest, but always avoiding extensiveradicular dentin exposure7.

Addictive Wax-up

For every esthetic dental planning a wax-up is indispensable,and for cases where a minimal preparation is planned, theprocedure must be done with the additive technique. Thewax addition for planning must take in consideration the firstanalysis of the case, that bring together the teethcharacteristics, the patients smile, the age of the patient, theopposite arch, the gingival architecture, beyond theperception of the patients personality8.

In this technique the ceramist adds wax onto thepreliminary model based on anatomical parameters of naturalteeth respecting function and occlusion. In this step, thetechnician restores the anterior dentition recovering amimetic appearance but already thinking in how is going tobe the final ceramic restoration9. In a case where there willbe no temporaries involved the final treatment planningmust be approved by the patient.The final planned case built in the preliminary model in waxwas transferred to the mouth for clinical evaluation in termsof shape, size and length. After the patient approval, allinformation was collected by the mock-up using digitalphotography and alginate impression, to obtain a simulationcast. After all the information was collected, the mock-upwas removed from the mouth and the teeth were pumiced forimpression procedures.

Only some specific sharp angles were removed with arubber wheel in order to improve the passive fit avoiding anykind of interference during the cementation procedures.



Figs. 4, 5, 6, 7: Using the lip retractor initial pictures show the patient compliances, which are enamel defects all over the surfaces of the anteriormaxillary incisors. In the lateral view (right and left), is clear the space between teeth (diastemas). Furthermore, it can be seen a discrete gingivalexcess of tissue in the premolars areas.

Fig. 8

Fig. 4 Fig. 5

Fig. 6 Fig. 7

Fig. 10Fig. 9


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Figs. 11, 12, 13, 14:A mock-upprocedure with abis-acryl resin worksas a guide for theclinician andtechnician, besidesacting as asimulation of thefinal result. It wasalso possible toanalyze thenecessity ofextending thetreatment up to thepremolars toimprove thealignment of thebuccal corridor.

Fig. 11

Fig. 12

Fig. 13

Fig. 14


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Figs. 15, 16, 17: A flapless gingivectomy was done with sharp instrumentsto reshape the level of the tissue determining by the mock up. Theprocedures were done on teeth # 3, 4, 5, 12 and 13.

Figs. 18, 19, 20: Three weeks after the surgery. The new gingival linerespects the contour of the anterior teeth line.

Fig. 15 Fig. 16

Fig. 17

Fig. 19

Fig. 20

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Fig. 21: Picture shows the area before the impression procedures; theplacement of the retractor cord is necessary to the lab to develop themost appropriate emergence profile and ceramic finish line. Theonly preparation done was a small opening between the centralincisors for better passive fit during the cementation procedures.

Fig. 22: The impression was done with a PVS based material(Flexitime-Heraus Kulzer). Fig. 22

Fig. 23 Fig. 24

Fig. 25

Figs. 23, 24, 25: A pressed lithium disilicate ceramic laminates (EmaxPress-Ivoclar Vivadent) for teeth 4 and 14.

Fig.26: The ten veneers placed on sequence and with the special illumination it is possible to observe how thin therestorations are .

Fig. 21



Figs. 27, 28, 29: Restorations in place with a try-in paste to select the shade of the resincement (Variolink Venner-Ivoclar Vivadent), and for patient approval.

Fig. 27 Fig. 28

Fig. 29



Fig. 30 Fig. 31

Fig. 32

Fig. 33 Fig. 34

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Fig. 37 Fig. 38

Fig. 39

Figs. 30 to 39: Close-up view of the bonding procedure on tooth #11 with the resin cement. It can beseen that the tooth was pumice before bonding. Another important procedure is to realize one bondingeach time, always protecting the neighboring teeth.



Fig. 40

Fig. 41

Figs. 40 to 46: Final resultafter cementation; itspossible to see theintegration of the tissue aswell as the importance ofcanine guidance tomaintain the occlusalstabilization.

Fig. 42 Fig. 43

Fig. 44



Fig. 45

Fig. 46

Impression of the Teeth

A VPS one-step, double mix impression technique,brought forth appropriate reproduction of the teeth andsurrounding tissues. Two impressions of each arch weretaken to ensure proper control during laboratory build-upof the veneers.

A retraction cord was utilized for better visualization ofthe cervical region to control the finish line and thicknessof the ceramic material during the laboratory procedures.

Laboratory Procedures

Based on all the information obtained from the mock-up,wax-up to the final shape of the final restorations andthen the 10 laminates veneers were injected with theceramic ingot HT. Carefully divesting using 50malumina sands at a pressure of 58-87 psi( 0.4 MPa-0.6MPa). Once the pressed veneers are exposed, lower thesandblasting pressure to less than 29Psi (0.2MPa) andcontinue alumina sandblasting carefully. The sprues are

cut off using a diamond disc, morphological correctionsare performed placing the laminates on the model and thefit is checked at the margin under magnification. After thecontours have been finalized, clean the restorations for 5minutes in an acetone solution using ultrasonic cleaner .

Apply the stain glaze over the surface and body stain Ais first applied in the cervical region. For incisal edge,apply blue stain in the approximal area and white stain forthe mamelons. Then, bake in temperature of 770 degreesCelsius to fix these characterizations. If necessary thisprocess should be repeated until the final result isachieved. After the fixation, two layers of glaze powder isapplied to protect the characterization and the superficialgloss is performed with rubber wheel and pumice powder.

Try-in and bonding procedures

As mentioned, no provisional crowns were used, and forthis reason the periodontal tissue was stable and anyhemostatic control protocol was not necessary. No cordswere used for the bonding procedures. For the veneers a



Figs. 47 to 50: Portrait from the final esthetic outcome.

Fig. 48

Fig. 49 Fig. 50

Fig. 47

high translucency lithium disilicate etchable ceramic(Emax Press, Ivoclar Vivadent) was selected. Final lutingof the ceramic restorations was preceded by a try-inprocedure, to select the best shade for the resin cement.As a thin veneer the final result is also dependant of theshade of the cement. The try-in was applied and checkedby the clinicians and patient. The approval of finalesthetics by the patient was in agreement with the

laboratory technician and the clinicians. The patient wasnot anesthetized.

The intaglio surface of the laminate veneers made withEmax Press (Ivoclar Vivadent), a lithium disilicate basedceramic was etched with a hydrofluoric acid (5 to 9%) for20 seconds. The intaglio surface was washed to remove theacid and the veneer was placed in a glass recipient withdistilled water, and an ultrasonic cleaner was utilized for



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five minutes to remove the residual material originated bysurface alteration10. The intaglio surface was dried and asilane coupling agent applied for two minutes, theevaporation of the solvent was completed with a constantblow of air. The restoration was coated with ahydrophobic bonding agent (Heliobond, IvoclarVivadent), followed by a gentle blow of air, and leftuncured at that time. A cover protected the ceramicveneer during etching dental procedures, to avoidadhesive polymerization.

As a non-preparations veneers the enamel was cleanedwith a paste with pumice powder and water. Then thesurface of each tooth was etched with a 37% phosphoricacid (Ultraetch, Ultradent), for no more than 60 seconds,washed and dried. The adhesive (Excite, IvoclarVivadent) was applied on the enamel surface, a gentleblow of air was applied to thin the adhesive film, andcured for 10 seconds.

The previous select shade of the light cured resincement (Variolink Venner, Ivoclar Vivadent), was appliedonto the ceramic restoration and positioned to the tooth.After, resin cement was removed carefully and LED light(Bluephase, Ivoclar Vivadent), in low power mode wasutilized for 40 seconds on each surface. A glycerin-basedjelly (Liquid Strip, Ivoclar Vivadent) was utilized to airblock and cured again for 20 seconds per surface. Theexcess of the resin cement was removed with a new andsharp scalpel to avoid scratches on the ceramic facialsurface. Only one restoration was cemented each time, asit is possible to see in the pictures.

After all the veneers cemented finishing procedureswere done with abrasive strips. Occlusal adjustments weremade with a diamond polishing system for ceramic. It ispossible to see the esthetic quality, healthy gingival tissueand the final smile as requested by the patient.

Conclusions

The clinical success of a treatment planning executionmade with laminate veneers is dependent of four majorsfactors: enamel preservation, bonding procedures andcarefully occlusal adjustments. In additive cases such asthe case described it is possible to do an ultra-conservativeprocedure with all the benefits of the adhesive technology.The purpose of this article was to exemplify importantsteps to obtain a reliable lithium disilicate estheticrestoration, with no preparation.References

1. Magne P, Douglas WH. Porcelain veneers: dentin bondingoptimization and biomimetic recovery of the crown. Int JProsthodont. 1999 Mar-Apr;12(2):111-21.

2. Duarte S Jr, Phark JH, Blatz M, Sadan A. Ceramic Systems. Anultrastructural study; Quintessence Dental Technol 2010; 33; 42-60.

3. Calamia JR, Calamia CS. Porcelain laminate veneers: reasons for25 years of success. Dent Clin North Am 2007 Apr; 51(2): 399-417.

4. Kina S, Brugera A Invisible: Esthetic Ceramic Restorations ArteMdicas, Brazil 2007.

5. Scopin de Andrade O, Borges G, Stefani A, Fujiy F, Battistella P. Astep-by-step ultraconservative esthetic rehabilitation using lithiumdisilicate ceramic. Quintessence Dental Technol 2010; 33: 114-131

6. Groten M Complete esthetic and functional rehabilitation withadhesively luted all-ceramic restorations-case report over 4.5 years.Quintessence Int 2007Oct;38(9) 723-731.

7. Joly JC, Carvalho PFM, da Silva RC, In: Reconstruo TecidualEsttica, Artes Medicas, Brazil, 2010, p. 253-309.

8. Gurel G The Science and Art of Porcelain laminate VeneersQuintessence Pub 2003, Berlin, Germany.

9. Magne P, Belser UC. Novel porcelain laminate preparationapproach driven by a diagnostic mock-up. J Esthet Restor Dent.2004;16(1):7-16.

10. Magne P, Belser UC. Bonded Porcelain Restorations in AnteriorDentition: A Biomimetic Approach. Chicago: Quintessence 2002.


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