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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 3  |  Page : 142-146

Lithium disilicate ceramic veneers for esthetic restoration of anterior teeth: Two case reports


Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Secunderabad, Telangana, India

Date of Submission30-Apr-2020
Date of Decision11-May-2020
Date of Acceptance27-May-2020
Date of Web Publication08-Oct-2020

Correspondence Address:
Pratyasha Kaushik
Department of Conservative Dentistry and Endodontics, Army College of Dental Sciences, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_33_20

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  Abstract 


In recent years, laminate veneer restorations have been used in dentistry as a more conservative and esthetic treatment option. Lithium disilicate ceramic material yields most thin veneers and has better properties compared to other materials. These two case reports aim to describe the complete clinical procedure, from treatment planning to lithium disilicate ceramic veneer cementation. Patients were informed about the treatment plan. Tooth preparation was done using porcelain veneer preparation burs (Pivo, Korea) and was limited to enamel in both the cases. Veneers were etched with 9.5% hydrofluoric acid, followed by the application of a silane coupling agent. Teeth were etched using 37% phosphoric acid, and then bonding agent was applied. Dual-cure resin cement was used for cementation of veneer to the tooth structure. A layer of oxygen barrier was also applied just before light curing the resin cement. Lithium disilicate ceramic veneers are minimally invasive as these require very less tooth reduction. These veneers have esthetically promising results due to their properties similar to that of enamel.

Keywords: Esthetic, lithium disilicate, veneers


How to cite this article:
Kaushik P, Singh R, Soujanya E, Prasad LK. Lithium disilicate ceramic veneers for esthetic restoration of anterior teeth: Two case reports. J Dent Res Rev 2020;7:142-6

How to cite this URL:
Kaushik P, Singh R, Soujanya E, Prasad LK. Lithium disilicate ceramic veneers for esthetic restoration of anterior teeth: Two case reports. J Dent Res Rev [serial online] 2020 [cited 2020 Oct 23];7:142-6. Available from: https://www.jdrr.org/text.asp?2020/7/3/142/297522




  Introduction Top


One of the greatest challenges of esthetic dentistry is the restoration of the anterior teeth. It is among the most important topics in dentistry, in addition to function and phonation. In order to solve esthetic problems such as color, structural abnormalities, and abnormalities in the position of anterior teeth, the most frequently preferred technique is to cover the teeth with partial or full-coverage crowns. The major disadvantages of full-coverage crowns include the excessive removal of healthy tooth structure and damage to the adjacent soft tissues. The objective of every product or procedure used in dentistry is to impart successful dental treatment with conservative approach and good esthetics. Therefore, the use of laminate veneers has escalated in recent years owing to better esthetics and minimal invasiveness.[1]

Sintered feldspathic porcelain or hot-pressed glass ceramics are the commonly indicated porcelain materials for use as veneers. This is because these materials can be used in small thickness and have good translucency. These materials can be formed in varied tones, thus allowing good shade matching to mimic natural tooth color. The durability and longevity of ceramic restorations is superior to direct composite veneers provided the case selection, and clinical procedure is correctly performed.[2] The mechanical and optical properties of enamel and silicate ceramic materials are similar. Therefore, this material is preferred for the replacement of lost enamel.[3] Lithium disilicate ceramic material yields thin veneers owing to the greater fracture toughness and biaxial strength, compared to other materials.[4],[5]

In this case report, a detailed series of clinical steps, from treatment planning to cementation of lithium disilicate ceramic veneers, used for two patients with problems related to fractured teeth, sensitivity, discoloration, and malalignment of teeth has been described. An informed consent was obtained in both the cases.


  Case Reports Top


Case 1

A 28-year-old female presented with yellowish discoloration in her maxillary anterior teeth and proclined maxillary left central incisor [Figure 1]. A thorough case history of the patient was taken with proper clinical and radiographic evaluations. The presence of generalized fluorosis and labial proclination of the maxillary left central incisor was diagnosed.
Figure 1: Preoperative frontal view (a) and occlusal view (b)

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Vital bleaching of the anterior teeth was performed using 35% hydrogen peroxide (Pola Office, SDI Limited). This procedure improved the color, but the outcome was unsatisfactory [Figure 2].
Figure 2: Vital bleaching using pola office. (a) Rubber dam and gingival barrier application, (b) application of the bleaching agent, (c) frontal view after bleaching procedure

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Alternative treatment modalities that were discussed with the patient included:

  1. Vital bleaching
  2. Microabrasion
  3. Direct composite veneers
  4. Indirect veneers.


Following the patient's consent, the treatment plan was finalized, which included placement of ceramic veneers on maxillary anterior teeth.

Tooth preparation

A1 shade was selected using the vita classic shade guide. Minimal tooth preparation was done using porcelain veneer preparation burs (Pivo, Korea) as shown in [Figure 3]. The preparation was confined to enamel with no dentin involvement. Labially, 1 mm of tooth preparation was done. Two plane facial reduction was done using a round end tapered diamond to maintain the natural contour of the tooth and to ensure uniform thickness of the veneer. Proximal reduction was kept just short of breaking the contact by an “elbow preparation” type of extension. Incisal reduction of 1 mm was done leaving a butt finish line configuration on the lingual surface to improve translucency and to provide positive seat for luting. Labially, the gingival margins of the tooth preparation were kept equigingival to achieve a definitive margin and to encourage correct positioning of the veneer while cementing. All the internal line angles were rounded to reduce the stresses in the margins of the veneers.
Figure 3: Tooth preparation for indirect veneers

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Recording an impression

Retraction cord (Medi-Pak 000 knitted nonimpregnated, Medicept dental, India) was placed in the facial gingival sulcus for 5 min after which it was removed. Full-arch impressions were made using polyvinyl siloxane (Aquasil soft putty/regular set, Dentsply, Germany) using putty reline technique. In the dental laboratory, the maxillary and mandibular impressions were poured, dies were formed, and veneers from lithium disilicate (IPS e. max CAD; Ivoclar Vivadent AG) were fabricated.

Try-in procedure

On receiving the veneers from the laboratory, try-in was done. The veneers were verified in terms of marginal adaptation, shade, contour, and alignment, and the results were completely satisfactory.

Veneer cementation

Veneer cementation was performed individually for each tooth, and the same sequence of steps was followed. Conditioning of veneers included application of 9.5% hydrofluoric acid (Porcelain Etch; Ultradent, South Jordan, Utah) on the internal surfaces for 1 min, followed by rinsing with running water and air-drying. Then, a silane coupling agent (Ultradent Products, South Jordan, UT, USA) was applied on the internal surfaces for 60 s and air-dried. The teeth and the adjacent tissues were isolated. Etching of prepared tooth was performed by the application of 37% phosphoric acid (Total Etch; Ivoclar Vivadent AG, Schaan, Liechtenstein) for 15 s, after which it was rinsed and dried. This was followed by the application of bonding agent (Tetric N-Bond, Ivoclar/Vivadent, Schaan, Liechtenstein), gentle air-drying, and polymerization for 40 s. Dual-cure resin cement (RelyX™ U200, 3M ESPE, St. Paul, MN, USA) was used for luting the porcelain veneers. All the gross excess was removed using an explorer, a layer of oxygen barrier was applied along the margins (Liquid Strip; Ivoclar), and the luting resin was polymerized using light-emitting diode (LUX V curing light, Guilin Woodpecker Medical Instruments Co. Ltd, China) for 40 s each. The cement margins were finished and polished using flexible aluminum oxide disks. [Figure 4] shows the postoperative views of the patient.
Figure 4: Postoperative frontal view (a) and occlusal view (b). Patients smile at the end of treatment (c)

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Case 2

A 38-year-old male reported with a chief complaint of broken teeth, discoloration, and sensitivity. A thorough case history of the patient was taken. Clinical and radiographic evaluation revealed attrition of the maxillary central and lateral incisors, interproximal spacing with respect to 11, 12, 13, 21, and 22, proximal caries involving distal aspect of 22, cervical caries with respect to 23, and post and core with respect to 24 [Figure 5]. Following alternative treatment modalities were discussed with the patient:
Figure 5: Preoperative frontal view (a), right buccal view (b), and left buccal view (c)

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  1. Direct composite veneers with respect to 11, 12, 13, 14, 21, 22, and 23 and full-coverage crown with respect to 24
  2. Indirect veneers with respect to 11, 12, 13, 14, 21, 22, and 23 and full-coverage crown with respect to 24.


An esthetic rehabilitation treatment plan was formulated, which included a full-coverage ceramic crown with respect to 24 and lithium disilicate veneers with respect to 11, 12, 13, 14, 21, 22, and 23.

Tooth preparation for veneers

Carious lesions involving 22 and 23 were excavated with a round bur. Labial preparation of 1 mm was done in two planes and was continued to the proximal surface using a round end tapered diamond. Minimal incisal reduction was done for incisors due to attrition, and for other teeth, 1 mm reduction was done leaving a butt finish line configuration on the lingual surface to improve translucency and to provide a positive seat for luting. Labially, the gingival margins of the veneer preparation were kept supragingival to achieve a definitive margin except for 23 on which equigingival margins were placed to include the cervical defect [Figure 6].
Figure 6: Tooth preparation for indirect veneers-frontal view (a), right buccal view (b), and left buccal view (c)

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Tooth preparation for all-ceramic (Emax) crown [Figure 6]

The 1.5 mm buccal and palatal preparation was done using flat end-tapered diamond, and supragingival shoulder margins were prepared both buccally and palatally. Occlusally, 1.5 mm reduction was done for buccal cusp and 2 mm reduction for palatal cusp.

Recording an impression and temporization

Retraction cord (Medi-Pak 00 knitted nonimpregnated, Medicept Dental, India) was placed in the facial gingival sulcus for 5 min after which it was removed. Full-arch impressions were made using polyvinyl siloxane (Aquasil soft putty/regular set, Dentsply, Germany), using the putty reline technique. In the dental laboratory, the maxillary and mandibular impressions were poured, dies were formed, and veneers from lithium disilicate (IPS e. max CAD; Ivoclar Vivadent AG) were fabricated.

Temporary protective and functional prosthesis made of acrylic resin was placed over the prepared teeth for use until the fabrication of veneers and crown [Figure 7].
Figure 7: Temporization of prepared teeth

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Veneer and crown cementation

Following a satisfactory try-in, the crown and the veneers were prepared for cementation [Figure 8]. Veneer cementation was performed individually for each tooth, and the same sequence of steps was followed. Conditioning of veneers included application of 9.5% hydrofluoric acid (Porcelain Etch; Ultradent, South Jordan, Utah) on the internal surfaces for 1 min, followed by rinsing with running water and air-drying. Then, a silane coupling agent (Monobond N, Ivoclar Vivadent, Liechtenstein) was applied on the internal surfaces for 60 s and air-dried. The teeth and the adjacent tissues were isolated. Etching of prepared tooth was performed by the application of 37% phosphoric acid (Total Etch; Ivoclar Vivadent AG, Schaan, Liechtenstein) for 15 s, after which it was rinsed and dried. This was followed by the application of bonding agent (Tetric N-Bond, Ivoclar/Vivadent, Schaan, Liechtenstein), gentle air-drying, and polymerization for 40 s. Dual-cure resin cement (RelyX™ U200, 3M ESPE, St. Paul, MN, USA) was used for luting the porcelain crown and veneers. The crown and the veneers were seated while applying light figure pressure. All the gross excess was removed with an explorer, a layer of oxygen barrier was applied along the margins (Liquid Strip; Ivoclar), and the luting resin was polymerized using light-emitting diode (LUX V curing light, Guilin Woodpecker Medical Instruments Co. Ltd, China) for 40 s each.
Figure 8: Lithium disilicate veneers on the cast (a); Postoperative frontal view (b), right buccal view (c), and left buccal view (d)

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  Discussion Top


Earlier, full-coverage crowns were indicated for esthetic corrections. This procedure involves the reduction of large amount of healthy tooth structure. Tooth preparation for full-coverage ceramic or metal ceramic crown leads to removal of 63%–72% of coronal tooth structure and thus, is considered as an invasive procedure.[4] Due to the advances in esthetic dentistry and introduction of newer materials such as lithium disilicate ceramics, it is now possible to fabricate veneers with 0.1–0.7 mm thickness.[6] Therefore, the use of veneers is minimally invasive and may also allow placement without tooth preparation.[4]

Indications of porcelain veneers are modifications of the shape and size of the teeth, corrections of slightly malpositioned teeth, fractured anterior teeth, diastema closure, and correction or alteration of tooth shade resistant to bleaching.[2],[7] Contraindications include severe parafunctional activities such as bruxism, anterior deep bite without overjet, and reduced interocclusal distance.[2]

According to Meijering et al., the survival rate for porcelain veneers is 94%, whereas survival rates for indirect and direct composite veneers are 90% and 74%, respectively.[8] Various other studies have concluded that survival rate, over a clinical service of 10 years, for bonded porcelain laminate veneers is more than 90%.[9],[10],[11]

In the present case reports, lithium disilicate ceramic veneers were used for esthetic rehabilitation. Lithium disilicate ceramic veneers are the thinnest veneers. The fracture toughness and biaxial strength of this material is greater than other materials. It is either processed as pressed ceramic or as an easy-to-trim “blue” intermediate phase (lithium metasilicate).[4]

Various types and depths of preparations have been considered for porcelain veneers. Deeper preparations extending into dentin lead to the fabrication of thick ceramic veneers. On the contrary, if thick ceramic veneers are placed on minimally prepared teeth, it may cause periodontal problems and may lead to compromised esthetics due to overcontouring.[12]

Good survival rates have been demonstrated when ceramic veneers are bonded to sound enamel.[12] Hahn et al. found that the strength of bonded porcelain veneer (Empress), placed on 0.5 mm deep buccal preparations, was greater than intact unprepared teeth.[13] Therefore, minimal tooth preparation limited to enamel is advisable for adhesive bonding.[3],[12],[13] In the present cases, 1 mm labial reduction was done.

Temporization following tooth preparation should be considered depending on the extent of preparation. In the present case reports, temporization was done in one case only. Temporaries can be avoided if the patient agrees to be without them. Temporaries should be provided when dentin exposure is present. This is done to prevent thermal and chemical injuries to the dental tissues, protect them against bacterial invasion, and to restore tooth form and function temporarily. Temporization can be achieved using light-curing composite or acrylic resin and silicon mock-ups.[7] Here, acrylic resin was used to fabricate temporary for the patient.

Success during cementation depends on tooth preparation, conditioning of ceramic veneer and tooth structure, and the agent used for cementing the veneer. Thirty-seven percent phosphoric acid is used for conditioning the tooth surface followed by thorough rinsing with water. Salivary contamination should be avoided to prevent reduction of surface energy of enamel.[7] Conditioning of the internal surface of ceramic veneer is done using hydrofluoric acid and silane. Depending on the composition of ceramic, the duration of application is varied.[7]


  Conclusion Top


Porcelain veneers are indicated in cases with discoloration and malformed or malposed teeth and teeth with extensive restorations. Lithium disilicate ceramic veneers are most thin and can be used without excessive tooth structure removal.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Korkut B, Yanıkoǧlu F, Günday M. Direct composite laminate veneers: Three case reports. J Dent Res Dent Clin Dent Prospects 2013;7:105-11.  Back to cited text no. 1
    
2.
Rotoli BT, Lima DA, Pini NP, Aguiar FH, Pereira GD, Paulillo LA. Porcelain veneers as an alternative for esthetic treatment: Clinical report. Oper Dent 2013;38:459-66.  Back to cited text no. 2
    
3.
Liebermann A, Erdelt K, Brix O, Edelhoff D. Clinical performance of anterior full veneer restorations made of lithium disilicate with a mean observation time of 8 years. Int J Prosthodont 2020;33:14-21.  Back to cited text no. 3
    
4.
Schmitter M, Seydler B B. Minimally invasive lithium disilicate ceramic veneers fabricated using chairside CAD/CAM: A clinical report. J Prosthet Dent 2012;107:71-4.  Back to cited text no. 4
    
5.
Malchiodi L, Zotti F, Moro T, De Santis D, Albanese M. Clinical and esthetical evaluation of 79 lithium disilicate multilayered anterior veneers with a medium follow-up of 3 years. Eur J Dent 2019;13:581-8.  Back to cited text no. 5
    
6.
Martins JD, Lima CM, Miranda JS, Leite FPP, Tanaka R, Miyashita E. Digital smile designing, pressing and stratifying ceramic lithium disilicateveneers to rehabilitate dental agenesis: a clinical report. RGO, Rev Gaúch Odontol 2019;67:e20190043.  Back to cited text no. 6
    
7.
Tuzzolo Neto H, do Nascimento WF, Erly L, Ribeiro RA, Barbosa JS, Zambrana JM, et al. Laminated veneers with stratified feldspathic ceramics. Case Rep Dent 2018;2018:5368939.  Back to cited text no. 7
    
8.
Meijering AC, Creugers NH, Mulder J, Roeters FJ. Treatment times for three different types of veneer restorations. J Dent 1995;23:21-6.  Back to cited text no. 8
    
9.
Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van Meerbeek B. A prospective ten-year clinical trial of porcelain veneers. J Adhes Dent 2004;6:65-76.  Back to cited text no. 9
    
10.
Friedman MJ. A 15-year review of porcelain veneer failure – A clinician's observations. Compend Contin Educ Dent 1998;19:625-8, 630.  Back to cited text no. 10
    
11.
Fradeani M, Redemagni M, Corrado M. Porcelain laminate veneers: 6- to 12-year clinical evaluation – A retrospective study. Int J Periodontics Restorative Dent 2005;25:9-17.  Back to cited text no. 11
    
12.
Gresnigt M, Ozcan M. Esthetic rehabilitation of anterior teeth with porcelain laminates and sectional veneers. J Can Dent Assoc 2011;77:b143.  Back to cited text no. 12
    
13.
Hahn P, Gustav M, Hellwig E. Anin vitro assessment of the strength of porcelain veneers dependent on tooth preparation. J Oral Rehabil 2000;27:1024-9.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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