Clinical Approach To Anterior Adhesive Restoration

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Clinical approach to anterior adhesive restorations using resin composite

veneers
Article in European journal of esthetic dentistry : official journal of the European Academy of Esthetic Dentistry, The · February 2007
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Francesco Mangani Antonio Cerutti

University of Rome Tor Vergata Università degli Studi di Brescia
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CLINICAL APPLICATION pyrig
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Clinical Approach ss e n c e
fo r
to Anterior Adhesive Restorations

Using Resin Composite Veneers
F. Mangani, [Au: Please provide first names and academic degrees for all authors.]
Associate Professor and Head, Department of Esthetic Dentistry
School of Dentistry, University of Rome Tor Vergata, Italy
A. Cerrutti,
Associate Professor and Head, Department of Restorative Dentistry
School of Dentistry, University of Brescia, Italy.
A. Putignano,
Professor and Head, Department of Restorative Dentistry
School of Dentistry, University of Ancona, Italy
R. Bollero,
Lecturer, Department of Esthetic Dentistry
School of Dentistry, University of Rome Tor Vergata, Italy
L. Madini,
Clinic Tutor and Lecturer, Department of Restorative Dentistry
School of Dentistry, University of Brescia, Italy
figure has too small resolution - please provide 300 dpi

and a width of 16 cm
Correspondence to: Dr A. Cerutti

Department of Restorative Dentistry, School of Dentistry, University of Brescia, P.le Spedali Civili 1, 25123 Brescia, Italy;
fax: 39 038177879; e-mail: cerant@tin.it.
28
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 2 • NUMBER 2 • SUMMER 2007
MANGANI ET o ALpyrig
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Abstract ss e n c e fo r
Scientific progress in adhesive dentistry neers depends mainly on the tooth prepa-
has led to more conservative techniques, ration, which should be confined to enam-
both direct and indirect, to solve esthetic el, involve proximal contact areas, maintain
problems in anterior teeth. This article will the cervical enamel margin, and incorpo-
discuss only indirect techniques, which are rate the incisal edge to increase veneer re-
clearly superior in complex cases in which sistance and enable correct placement. Al-
it will be difficult to recreate harmonious though no clinical follow-up similar to that
tooth shape and color. After reviewing the of ceramic materials is available, the latest-
literature and highlighting the properties of generation resin composites offer interest-
this technique, the indications and benefits ing features. They can withstand mechani-
compared to the direct technique will be cal stress, have excellent esthetic
assessed. This is followed by a step-by- properties, and, most importantly, can be
step description of operative procedures, repaired intraorally without impairing their
from treatment planning to relining and physicochemical and mechanical proper-
polishing of the cemented adhesive ties.
restoration. The long-term success of ve- (Eur J Esthet Dent 2007;2:xxx–xxx.)

29
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In the past few years, patient requests for sessed. This is followed by a step-by-step
ss e n c e
fo r
esthetic treatment of anterior teeth have in- description of operative procedures, from
creased. In these cases, clinicians often treatment planning to relining and polish-
prefer the use of complete crowns to re- ing of the cemented adhesive restoration.
store esthetics.1 Finally, two clinical cases are presented to
Remarkable progress in adhesion re- illustrate the concepts discussed.
search has led to the introduction of more
reliable adhesive systems and highly filled
hybrid resin composites with microparti- History
cles, which offer better chemicophysical
properties and adequate mechanical prop- The use of ceramic veneers is not a recent
2
erties. development; in fact, in 1938 Pincus6 de-
Today, this evolution is clinically repre- scribed a technique used during Holly-
sented by the choice of direct and indirect wood filmmaking. A common adhesive for
techniques. Direct techniques are one-ses- total prostheses was used to retain veneers
sion procedures performed chairside by to the tooth surface. The introduction of ad-
directly applying resin composite to the hesive systems and their continuous im-
dental surface. They are used for simple provement has significantly helped the
restorations using an anatomic layering evolution and increasing clinical success
procedure, which aids the clinician in cor- of these techniques.
rectly defining the color and shape of the The materials of choice for veneers are
tooth, using the residual dental structure as porcelain and resin composite. Baked
reference.3 dental ceramics are made up of two com-
Indirect techniques demand at least two ponents: a glass matrix and crystalline in-
sessions and the collaboration of a dental clusions.7,8 In particular, those used in
technician,4 who will manufacture a veneer restorative dentistry are reinforced hetero-
to be luted to the prepared dental surface. geneous porcelains that contain a greater
Indirect techniques are preferred in more percentage of crystalline phase than
complex cases, in which restoring harmo- porcelain fused to metal.9
nious tooth shape and color is highly de- Ceramic has always been the material
pendent on variables such as the clini- of choice for indirect anterior restorations
cian’s skill and the technique and material because of its effectiveness in reproducing
used. Further, it should be considered the structure and translucency of the natu-
whether the patient will be more or less ral tooth. Long-term follow-up evaluations
compliant about a prolonged session.5 of ceramic veneers show excellent bio-
In this article, only indirect techniques compatibility and very good chemical sta-
are discussed, and the most commonly bility.10,11
used materials will be considered: dental The use of resin composite to build an-
porcelain and the more recent resin com- terior indirect restorations is more recent;
posites. After reviewing the literature and only in the last few years has research
highlighting the properties of each tech- identified materials that offer good polisha-
nique, the indications and benefits com- bility, hardness, and wear resistance.12,13
pared to the direct technique will be as- Such materials belong to a class of highly
30
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filled microparticle hybrid composites and ■ Metal-ceramic crown repair ss e n c e
fo r
are made up of glass filler (70% to 85% in ■ Discoloration caused by
weight) and particles varying from 0.04 to pulpal necrosis or inadequate
3 μm in size. root canal therapy
In the authors’ opinion, however, this final

Indications item should actually be considered a con-
traindication, since the result is often affect-
Thanks to improved oral hygiene habits ed by dischromic relapses of the treated
and the greater reliability of recent esthetic tooth, which may have a negative effect on
materials, the indications for anterior indi- esthetics over time.
rect adhesive restorations have enlarged to
cover most patients.4 However, many au-
thors argue that adhesive restorations Choice of technique
should not be used in patients with para-
and material
functions. Magne et al14 reported that the
success rate of ceramic veneers is reduced The advantages offered by indirect tech-
to 60% in patients with bruxism. Further, niques compared to direct techniques are
they showed a decreased wear resistance as follows16:
in resin composite restorations and a high
incidence of fractures in ceramic restora- ■ Superior esthetic result
15
tions for these patients. Universally, the fol- ■ Adequate abrasion resistance
lowing clinical situations are considered in- ■ Biocompatibility with soft tissues
dications for anterior indirect restorations: ■ Dimensional and chromatic stability
over time
■ Enamel hypoplasia, waves, stains, ■ Strong bond between the two adhesive
grooves, etc interfaces (luting agent/etched enamel
■ Enamel abrasions and luting agent/etched porcelain or
■ Congenital imperfect amelogenesis postpolymerized resin composite)
caused by hormones or tetracyclines
■ Chromatic or distrophic alterations Obviously, these advantages are a result of
caused by fluorosis both the intrinsic properties of the materi-
■ Numerous esthetically unsatisfactory al (ceramics) and the superior quality ob-
superficial restorations tained with extraoral work (resin compos-
■ Coronal fractures located primarily ites). The disadvantages compared to
on the palatal side direct techniques are now being reconsid-
■ Retention of deciduous teeth ered, as resin composites can actually
with a reabsorbed root give excellent results in anterior indirect
■ Lateral incisor agenesia, when the restorations when used as an alternative to
canine has transposed to that position porcelain.
■ Volume anomalies (microdens) Several useful parameters for selecting
■ Diastemas the material to be used will now be pre-
■ Alignment defects sented.
31
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Position of the margins and t e s
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Wear resistance ■
se nc e
fo r
preparation shape
It has been shown that filler hardness and ■ Type of ceramic
dimension influence resin composite wear
when opposed by a natural tooth. The filler Resin composites are more elastic and
hardness should be equal or lower than less affected by microfractures; thus, their
that of hydroxiapatite.17 use is particularly recommended in pa-
It has also been demonstrated that when tients with parafunctions.
resin composites are subject to a final cur-
ing phase by means of both light and heat
inside a special oven, they show a remark- Laboratory procedures and cost
able increase in mechanical properties
(wear resistance, microhardness, etc) and Resin composite veneers require easier
physical properties (solubility, thermal ex- laboratory procedures than ceramic ve-
pansion coefficient, elasticity module, brit- neers, even though veneers built with the
tleness) compared to resin composites refractory cast technique take less time
cured with light alone.18–22 Further, microin- than those fabricated with other methods.
filtration, as measured with dye penetration, Generally, indirect restorations require a
decreases dramatically.22 greater amount of time and result in more
These procedures may affect resin com- technical difficulties, which explains the
posite brightness, so the postpolymeriza- higher overall cost of ceramic restora-
tion temperature should be controlled. In tions.26,27
23
1991, Rueggeberg et al suggested that a
final cycle at 100°C for 5 minutes is appro-
priate. Although ceramics show greater Repair potential
wear resistance than resin composites,
they also cause greater wear on the enam- If necessary as a result of secondary caries,
el of the antagonist teeth. margin subsiding, or other complications,28
resin composite veneers are easily re-
pairable intraorally. Marginal inaccuracies
Elasticity module and brittleness during luting can be corrected by curing a
small amount of material in place; howev-
According to many clinicians, fractures are er, this procedure may jeopardize the per-
more likely in adhesive restorations made formance of the definitive restoration.29
with ceramic than with resin composite, The intraoral repair of ceramic veneers
because ceramics are stiffer and transmit is also possible, and the clinical success
higher functional stresses to the adhesive depends on many factors. The type of ce-
24,25
interface. ramic used affects the choice of adhesive
To reduce this risk, the following param- material and clinical repair procedure.
eters that should be considered: Glass-based ceramics can be etched with
hydrofluoric acid for 2 minutes, followed
■ Relationship between resin composite by application of silane and bonding
cement and porcelain thickness resin.30,31
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Another method for bonding resin to Treatment planning e ss e n c e fo r
porcelain is the CoJet System (3M ESPE),
which uses silica acid–modified aluminum
Diagnostic waxup
oxide particles to sandblast the surface to
and color registration
be bonded. The sand bonds tribochemi-
cally (ie, creates a chemical bond using The esthetic result of an anterior restoration
mechanical energy) to the substrate. The depends on the shape and color, which are
surface should then be silanized and the key parameters of dental esthetics.3,5,39
bonding resin should be applied. The Co- For this purpose, diagnostic waxups
Jet system can be applied to aluminum ox- should be used to evaluate the shape of
ide ceramics and zirconium oxide ceram- the final restoration. Prior to tooth prepara-
30,32,33
ics. tion, the clinician will plan the final shape of
It can be difficult to select the proper pro- the veneer, type of preparation, and posi-
cedure for a long-lasting repair and optimal tion of the finishing margins. Using a color
esthetic result when resin composites are scale and a 5,000-K lighting system—which
used to seal and repair ceramic veneers, should eliminate every source of reflected
especially for small or medium defects. light and make it easier to discern the var-
Large defects or fractures at the incisal ious shades of gray—it will be possible to
margin of ceramic veneers can be re- detect all five dimensions of tooth color. As
paired, when possible, by adhesively luting reported by Vanini et al,3,39 the traditional
a lab-made partial veneer to the fractured way to detect tooth color (hue, chrome, val-
34
veneer. ue) can be redefined to include five param-
eters: basic chromaticity, value, intensives,
opalescents, and characterizations.
Polishability
Surface finishing and final polishing are Tooth preparation

simpler for resin composite restorations
than ceramic restorations.26 It has been The guidelines regarding tooth prepara-
suggested that an aggressive finishing of tion for a veneer have changed drastically
ceramic veneers may remove the surface in the last few years. Initially, no preparation
glaze, thus increasing plaque retention and was recommended.40–42 As a result, there
35
gingival inflammation. Other authors as- was a remarkable increase in tooth thick-
sert that in these cases an accurate intrao- ness and, consequently, proximal and gin-
ral polishing (specific rubber cups, dia- gival overcontour. Shani et al43 reported a
mond paste, etc) can restore the surface to 90% failure rate for restorations of unpre-
its initial condition.36–38 pared teeth.
Today, most authors16,40,44–47 agree on the
importance of a conservative tooth prepa-
ration, which offers the following advan-
tages:
33
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■ More effective adhesive bond ■ Mild preparation for dischromic ss e n c e
fo r
between tooth surface and ■ Overpreparation for morphologic
resin composite cement modifications: conoids, diastemas
■ More stable veneer fitting due with black triangles (accentuate
to precise reference marks proximal and mild buccal preparation),
■ Reduced possibility of proximal or and changes to incisor length or
horizontal overcontouring prominence (up to 2 mm can be
(with consequent emergence profile added without inducing stresses)
alteration) ■ More extensive preparation for
■ Preserved marginal tissue health fractured elements or teeth with
acquired morphologic modifications
Enamel reduction Concerning resin composite veneers,

5
Vanini et al emphasized this material’s
Ideally, the preparation should be confined ability to limit the entity of reduction due to
to enamel,1,16,48 though Pippin et al1 con- the low elasticity module and resulting high
firmed the need to remove the aprismatic capacity to absorb functional stresses. In
enamel isles located mainly in cervical ar- fact, it is not mandatory to have a minimum
eas. These zones should be analogous to thickness of 0.5 mm for resin composite;
49
those identified by Gasperic in third mo- Perdigao and Lopes56 suggested a 0.2- to
lars at a distance between 103 to 756 μm 0.4-mm reduction at the cervical third, a
from the cementoenamel junction, and by 0.3- to 0.6-mm reduction at the middle
other authors in anterior teeth at a distance third, and a 1.5-mm reduction at the incisal
of 0.4 mm from the cementoenamel junc- third.
tion. This is the same area where many cli- Regarding interproximal surfaces, these
nicians commonly position the finishing same authors argue that the preparation
line, which is why it is often difficult to ob- must extend to the contact area without in-
50–52
tain a solid bond in this area. volving it; conversely, Christensen57 and
16
According to Caleffi and Berardi, Caleffi and Berardi16 suggest including half
enamel removal should not exceed 0.3 to the contact area in the preparation.
0.6 mm, depending on tooth dimension, A study by Magne and Douglas,58 in
shape, and pathosis. According to Ferrari agreement with Douglas,59 reported that in-
53
et al, the enamel thickness and exten- terproximal enamel reduction does not de-
sion in the cervical area of anterior teeth crease tooth resistance, while buccal re-
do not allow a 0.5-mm reduction without duction does. The buccal surface of the
54
dentin exposure. Chalifoux et al showed tooth-veneer complex seems to be more
that enamel removal should not be less subject to compressive stresses, even
than 0.5 mm or greater than 2 mm to though the use of porcelain instead of
avoid decreasing the resistance of ceram- enamel seems to recover the mechanical
ic veneers. properties of the restoration.
Magne et al55 listed the types of prepa- It is generally agreed that the position of
ration based on the various indications: the cervical margin is a key factor in soft tis-
sue reaction. Pippin et al1 underlined that
34
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the presence of a cervical enamel edge, low correct insertion. It should be ss e n c e
fo r
polishing of restoration margins, and good that most studies aiming to determine
oral hygiene are key factors to guarantee which preparation affords good resistance
the periodontal health of restored teeth. to ceramic fracture analyze samples using
loading systems that are directed from the
incisal margin and parallel to the long ax-
Preparation type is of the tooth; however, functional and
parafunctional loads (the latter having 6
Identifying which type of tooth preparation times the intensity)68 acting on the palatal
is least likely to lead to veneer fracture is surface of maxillary anterior teeth are di-
still controversial.60 This is especially true rected horizontally.69
for ceramic veneers, which theoretically Porcelain is exposed to fracture when
should be exposed to minimal occlusal subjected to tensile forces. The maxillary
load.41 Toh et al61 suggested that ceramic central incisors are mostly affected by this
veneers should be used only to solve es- kind of stress, because the compressive
thetic (and not functional) problems, while forces applied on maxillary incisal mar-
Friedman62 reported that ceramic veneers gins by mandibular teeth are less than in
can restore the anterior guide if there is an other teeth.63 According to the manufactur-
appropriate incisal length. In a 15-year fol- er, the maximum tensile resistance of
low-up study, fracture, detachment, and feldspar ceramic is 25 MPa [Au: which
microleakage were the most common manufacturer/product?].69
causes for ceramic veneer failure.63 Frac- Some authors64,70 report that a frame
ture alone represented 67% of the failures. preparation (ie, with no incisal reduction)
According to this study, the fractures were seems to be one of the most resistant.
primarily cohesive and located at the in- Greater fracture values were found in oth-
cisal margin, where stresses are higher. er types of preparation, especially when a
Several types of preparation have been palatal chamfer was present. Additionally,
64
described in the literature. Hui et al and no significant differences were observed
later Clyde and Gilmour65 described three when increasing the height of ceramics
different designs: (1) a “window” or “frame” unsustained by dental tissues from 1 to
preparation, where a 1-mm incisal margin 4 mm [Au: in which study?]. Therefore, the
is preserved; (2) a preparation with a 0.5- amount of unsustained ceramic is not a
to 1-mm incisal bevel; and (3) and a critical factor for fractures. Conversely, the
preparation with lingual extension. palatal chamfer, which is common to both
To increase veneer translucency, Wein- preparation types, appears to be the true
66
berg suggested a 1-mm incisal reduction weak point. Fractures at the chamfer level
with rounded angles and edges, while extending to the buccal side of the veneer
67
Sheet and Taniguchi described a prepa- were observed. Thus, it may be preferable
ration with a pronounced palatal chamfer to eliminate the palatal chamfer and re-
and rounded margin for adequate ceram- duce at least 2 mm at the incisal level,
ic thickness. Castelnuovo et al60 advised a while leaving a butt-joint palatal margin.
preparation incorporating the incisal mar- An experimental study by Magne et al,14
gin to increase veneer resistance and al- carried out by thermocycling the restora-
35
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Regarding the configurationt eof
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tion, reported that by increasing the porce- the cer-
ss e n c e
fo r
lain/resin composite cement ratio it is pos- vical third of the preparation, a recent study
sible to prevent porcelain fractures. These by Troedson and Derand48 examined the
authors further suggested that the ceram- stress distribution in ceramic veneers
ic thickness should be at least 3 times that made with three different cervical designs:
71
of the cement. Another study demon- (1) a “feather-edge” configuration (modi-
strated the need for a good ceramic thick- fied razor-edge configuration), (2) chamfer
ness and minimum resin composite thick- configuration, and (3) shoulder configura-
ness to reduce thermal contraction and tion. The results showed that in the pres-
polymerization stresses. Thus, preparation ence of moderate stress, the cervical mar-
becomes a critical factor in long-term ve- gin design does not influence veneer
neer predictability. The same study success. Further, when occlusal loads
showed that by providing an adequate have various directions reflecting the
resin composite/ceramic ratio, only a butt- forces applied on the tooth during masti-
joint configuration reduced the risk of ce- cation, a shoulder configuration is prefer-
ramic fracture after veneer insertion, as able. This study also demonstrated that ve-
caused by resin composite contraction neer adhesion is the most important factor
and thermal changes in the oral cavity. to reduce compression and traction forces.
Further, the butt-joint configuration with no The importance of pre-restoration
palatal extension allows enamel preserva- (buildup) in cases where the tooth is very
tion at the restoration margin, which is es- compromised must be discussed. Magne
sential to obtain an effective bond be- and Douglas58 evaluated the stress distri-
tween the veneer and dental surface. The bution in teeth with coronal fractures.
authors concluded that frame prepara- These teeth were divided into two groups:
tions with a butt-joint margin and a 2-mm (1) teeth restored with ceramic veneers af-
incisal reduction are the most reliable be- ter a resin composite buildup, and (2) teeth
cause they guarantee adequate mechan- restored with ceramic veneers only. The re-
ical resistance to the restoration and allow sults showed that pre-restoring compro-
better characterization of the incisal third. mised teeth is a valuable method for guar-
Moreover, compared to the palatal cham- anteeing better flexibility. A separate study72
fer configuration, the butt-joint with no showed that fracture resistance of porce-
palatal extension is simpler for the clini- lain is influenced by the elasticity module
cian, has a better definition when repro- of the material used for the pre-restoration.
duced with a cast, and is more easily read Such procedures also provide an ade-
by the dental technician. quate geometry to the preparation and
Further, a flat surface allows better ve- guarantee the restoration material will have
neer support and, as opposed to the constant thickness in every portion, which
palatal chamfer and extension configura- is an essential requirement for obtaining a
tion, has only one insertion axis. This con- thin layer of resin composite cement and
siderably reduces the risk of fracture in the greater control of material contraction.73
unsustained ceramic portion.60
36
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Operative phases Incisal reduction and butt-joint
ss e n c e
fo r
with no palatal extension
The operative phases and preparation
types are identical for ceramic or resin The first phases are identical to the frame
composite veneers. The preparation pro- preparation. A 2-mm incisal reduction
cedures and necessary tools that, accord- should follow, providing clean incisal and
ing to evidence-based literature, are able to palatal margins.
guarantee a long-term success will now be
briefly examined. The use of a silicone tem-
plate based on a diagnostic waxup is ad- Preparation
vised during preparation to control tooth
with palatal extension
reduction. The preparation procedures will
now be summarized. After carrying out the first two phases of the
frame preparation and performing the in-
cisal reduction, two interproximal (mesial
Frame preparation and distal) steps should be taken, which
should join at the palatal side. The palatal
For the cervical third preparation, a guide- margin, as explained later, may be located
groove is executed along all cervical con- at the incisal third (chamfer) or inside the
tours by means of a round bur. It is very im- palatal cavity (shoulder), depending on the
portant to preserve a sufficient enamel rim veneer extension. The chosen palatal fin-
above the cementoenamel junction. ishing line configuration should be a con-
For the mesial, distal, and incisal prepa- sequence of the bur design itself and be
rations, the contact points should not be clearly visible in cross-sectional images.
entirely involved, in order to avoid creating
undercuts that will prevent proper veneer
insertion. A sufficient enamel rim should be Provisional restoration
preserved at the incisal level.
For the buccal preparation, a longitudi- Since most of the preparation is contained
nal guide-groove is executed to gain bet- to enamel, patients seldom complain about
ter control over reduction depth. These intolerable postpreparation sensitivity. Most
grooves should be connected by means of authors prefer to avoid the application of
a chamfer bur, respecting the different re- provisional restorations for several reasons.
duction angles of the whole buccal side. First, any provisional restoration represents
For preparation finishing at cervical and a chemicophysical-irritating factor that may
buccal level, fine-grit burs (red and yellow cause tissue inflammation.27 Furthermore,
rings) or medium-abrasive rubber burs provisional restorations are unstable and
should be used. unesthetic. In addition, according to se-
veral authors,16,74–77 the use of temporary
cements or adhesive resins would com-
promise the effectiveness of adhesive pro-
37
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smallt e
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cedures; however, Tjan and Nementz78 ar- ing resin, and adding a amount
ss e n c e
fo r of
gued that the total etch technique can re- material.87 To restore the mechanical prop-
move any residue left on the tooth surface. erties of the restoration, further postpoly-
With no provisional restorations, oral hy- merization is necessary.
giene procedures will be easier for the pa-
tient, thus guaranteeing ideal health of the
periodontal tissues with a remarkable im- Luting procedures
provement of the tooth-periodontium com-
plex once the restoration is luted. In this Luting procedures are a crucial step in the
case, it is extremely important that the overall treatment. Indirect adhesive restora-
restoration be completed within a maxi- tions are retained by means of microme-
mum time frame of 3 to 5 days. chanical adhesion between the resin com-
If significant tooth sensitivity develops, posite cement and both the tooth surface
the application of fluoride-based gels us- and restorative material. Marginal quality
ing an individual tray can be used. Paul and precision of luted restorations is strict-
79
and Sharer demonstrated that applying a ly dependant on the following factors.
bonding resin after cavity preparation
(dual bonding technique) reduces postop-
erative sensitivity, which is generally con- Adhesive potential of substrate
sidered a symptom of bacterial contami-
nation and hydrodynamic phenomena.80,81 As mentioned previously, the best internal
If necessary, such as with very large adaptation and marginal seal are obtained
preparations and/or after patient request, it when the preparation is entirely surround-
is possible to execute chairside direct pro- ed by enamel.4 It has been demonstrated
visional self-curing acrylic resin veneers, that exceedingly aggressive etching, ex-
using a silicone template based on an es- cessive dryness of the etched surface, or
thetic diagnostic waxup. These provisional high compression of the collagen fiber net-
veneers should be temporarily fixed by po- work during impression taking or luting
sitioning a small amount of resin compos- procedures23,80 may cause denaturation
ite without any adhesive procedures.82–85 and/or collapse of the collagen fibers. A
hybrid layer only partially impregnated with
resin would allow enzyme and ion infiltra-
Veneer clinical check tion. This phenomenon, called nanoleak-
age, can cause adhesive bond failure and
A veneer is tried on to evaluate the margin- restoration detachment.
al adaptation, stability, shape, and color. No The dual bonding technique (ie, the ap-
corrections by adding material can be per- plication of a bonding resin at the end of
formed on porcelain veneers, and all oc- the preparation) can stabilize adhesion be-
clusal checks should be performed after cause it does not allow contamination
86
luting to avoid accidental fracture. caused by impression materials and tem-
If resin composite veneers are used, it is porary cement, but still preserves the ad-
possible to modify them before luting by hesive interface from the above-men-
roughening their surface, applying bond- tioned procedures.77
38
MANGANI ET o AL
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89,90
Adhesive potential of ceramic ss e n c e
fo r
and ceramic type, influence morphology
Adhesion between resin composite and and thus the retentive capacity of etched
porcelain is based on a combination of mi- ceramics.96,99 It has been reported that in-
cromechanical and physical bonds, which creased etching time increases the initial
has been shown in vitro to be more effec- microfractures of ceramic surfaces, thus
tive than either type of bond by itself.74,88,89 reducing the flexural resistance of the ve-
By etching the veneer surface with hydro- neer.43,100 To obtain a significant increase in
fluoric acid and then applying silane, the surface energy, etching with 7.5% to 10%
bond between resin composite cement hydrofluoric acid for 2 to 10 minutes is
and porcelain is stronger than that be- necessary.48
tween cement and etched enamel.47,89–91 Ultrasonic devices are useful to remove
Scanning electronic microscope (SEM) acid residues on ceramic surfaces.101 An
imaging of etched ceramics has shown a SEM analysis of treated feldspar ceramics
structure filled with micropores,47,89,92 which surfaces showed more retentive surface in
would increase the available surface for terms of penetrability.94,102
adhesion and allow the micromechanical
bond of resin composites.
Many authors report that the adhesive Adhesive potential
bond between the cement and treated sur-
of resin composite
face depends on the type of silane
39,93–95
used. Treating the silanized surface For inlays, roughening the internal surface
with heat (about 100°C) has been proven of resin composite veneers is effective to
to create an adhesive bond that is twice as create microretentions and obtain a bond
strong.96 Pretreated ceramic bonds are between the resin layered on the restora-
negatively influenced by external factors tion and the free radicals. This should
such as water absorption, changes in tem- preferably be performed via sandblasting
perature, and contamination by latex or a coarse-grit diamond bur.103–105 Once
97
gloves, saliva, and the fit checker. In these the veneer has been roughened, it should
cases, retreating the contaminated surface be cleaned with alcohol and silanized with
with 37% phosphoric acid followed by thermal treatment.
silanization may restore the original adhe-
sive potential. However, Sheth et al97 ar-
gued that the original bond strength can- Resin composite cement
not be restored after contamination.
Stacey47 observed that 43% of ceramic
Cement type
veneer adhesive failures were found at the
enamel-cement-composite interface. Par- The use of light-curing cement is preferred
ticularly, the micromechanical bond was to a dual-curing cement101 because it allows
lower at the cervical level. Arakawa et al98 a longer working time for luting procedures.
confirmed this result by observing minimal It also makes it easier to remove any ex-
size interdigitations in this area. Many fac- cess before light activation. Finally, the
tors, such as etching time, etching agent chemical stability of light-curing cements
39
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helps maintain esthetics over time. It should low correct veneer placement andss e n c e
fo r
be noted, however, that ceramic absorbs al precision; also, a thin cement layer will
40% to 50% of the light emitted; therefore, have a minimal contraction73 and leave a
its thickness will be the main factor influenc- smaller gap between the tooth and
ing the amount of light absorbed.92,106 Color restoration.111
and opacity, on the other hand, have only Die spacer application provides a layer
a minimal influence.92,107,108 of about 25 μm or more depending on the
Linden107 demonstrated that ceramic number of coats.112 Kramer et al113 reported
opacity becomes an important factor when that recent luting cements have excellent
ceramic thickness is greater than 0.7 mm. flow characteristics with mean film thick-
In these cases, O’Keefe et al92 suggested nesses ranging from 8 to 21 μm. The
doubling the veneer exposition time. Con- flowability of viscous luting composites or
versely, Linden et al107 argued that the only conventional restorative composites can
solution is to use dual-curing cement, be- be increased by using an ultrasonic tip
cause thick ceramic seems to prevent the and/or by preheating the resin composite
cement from reaching sufficient hardness. itself.
It is also better to use a highly filled resin A finite element model study by Magne
composite cement (at least 65% in volume) et al,71 which aimed to highlight the effects
with a medium-high viscosity, because of of thermal changes and resin composite
its low thermal expansion coefficient and cement shrinkage on microfracture forma-
lower polymerization shrinkage.44,78,109 This is tion in ceramic veneers, reported some in-
essential for ceramic veneer luting, be- teresting results. It was demonstrated that
cause it allows the creation of an elasticity the amount of stress generated by resin
module gradient through the dental sur- composite shrinkage on the surface and at
face, resin composite cement, and porce- the restoration interface is strictly due to the
110
lain surface. The viscosity of this kind of ratio of porcelain to cement thickness. As
cement is very high, so resin composite mentioned before, the ceramic thickness
preheating is required to decrease the vis- should be at least three times that of ce-
cosity when it is applied as a thin layer on ment; if this ratio decreases, a preparation
the veneer surface. Next, the veneer should configuration with an incisal reduction and
be positioned gently on the tooth prepara- palatal butt-joint is needed to reduce the
tion. palatal fracture risk caused by restoration
insertion or resin composite shrinkage and
thermal changes in the oral environment.
Cement thickness This problem is relevant mostly at the
restoration margins, where ceramic thick-
A meticulous application of the operative ness is remarkably reduced compared to
protocol requires a highly precise impres- that of resin composite cement.
sion of the preparation. Once the stone As has already been discussed, fracture
cast is made, die spacer should be applied risk is significantly less likely in resin com-
onto the cast to provide space for the lut- posite veneers. Resin composite is not as
ing agent. The resin composite cement fragile as ceramic, and may absorb func-
layer should be as thin as possible to al- tional stress through the adhesive interface
40
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to a greater extent.25 Thus, it is not impera- Finishing and polishing e ss e n c e fo r
tive to obtain a material thickness three
times greater than adhesive cement, as for A number of materials are now available
ceramic restorations. on the market. These procedures are per-
formed to correct any superficial defects,
smooth irregular surfaces, and obtain per-
Application and polymerization fect marginal continuity between the
4
restoration and tooth surface.
Once the provisional restoration has been It has been shown that polishing ce-
removed using hand instruments, and af- ramic veneers may remove the superficial
ter field isolation using rubber dam and glaze, which could be a cause of plaque
floss binding, the teeth should be cleaned retention and gingival irritation.120 Accord-
with pumice and ultrafine brushes. During ing to Magne et al,37 ceramic should be
this phase, some authors prefer the use of polished intraorally to avoid this problem
a bicarbonate spray to easily remove and obtain a surface with analogous prop-
74,76,77,79
residual pigmentation. The tooth sur- erties to one finished in the laboratory.
face and internal side of the restoration The best finishing of a ceramic veneer
surface should be treated to prepare them is that obtained on a laboratory bench;
for adhesion,2 and cement should then be therefore, if possible, the authors absolute-
applied onto both surfaces with a spatula ly advise not to touch ceramic veneers with
and dragged to the margins with a small abrasive tools during luting procedures.
114
brush. Since there may be a slight loss Regarding resin composite veneer finish-
in value after restoration luting, a white ing, the operative sequence comprises the
mass should be used during this phase. following: fine-grit diamond burs, silicone
For resin composite veneer luting, it is rec- points, brushes impregnated with dia-
ommended to use the same material from mond paste, and aluminum oxide. These
which the veneer itself is made. will guarantee a brilliant restoration.2,110
The veneer should be positioned and Sealing the restoration margin using a
any excess cement removed using brush- flowable resin composite is an effective
es, probes, and floss. The restoration way to fill eventual marginal microdefects.
should then be light cured (at least 1
minute per side) to guarantee an optimal
degree of conversion of the material.115–117 It Restoration maintenance
is well known that oxygen hinders com-
plete monomer conversion.118,119 so a glyc- As with esthetic inlays/onlays, a recall vis-
erine-based gel should be applied to the it should be performed every year to check
interface during final light curing to avoid the functional stability, closure margins,
the formation of an inhibited layer (air and health of the surrounding gingival tis-
block). sues, as well as to evaluate any esthetic
modifications required. After veneer sur-
face polishing with aluminum oxide, mar-
gin etching and sealing with flowable resin
composite should be performed.
41
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Evaluation parameters the gingival contour.129 All authors
ss e n c e
fo r
that in the presence of good oral hygiene,
margins that are precise, well-finished, and
Esthetic result
placed above the gingival level will guar-
Long-term studies of the esthetic behavior antee good periodontal health.35,65,129–132
of resin composite veneers are very prom- To demonstrate these concepts, two
ising, thanks to the excellent esthetic prop- clinical cases demonstrating the most
erties of recent materials. Several stud- prevalent indications for ceramic or resin
ies28,121,122 have confirmed the color stability composite veneers will now be presented.
of porcelain veneers over time.
Indirect resin composite restorations are
useful for masking severe discoloration or Clinical Case Reports
achieving a certain esthetic effect. Be-
cause the veneer should be luted with the
Case 1
same material used for its fabrication, the
clinician has a greater choice of color This case involved remaking incongruous
shades, making it easier to produce slight Class 4 restorations on the maxillary cen-
modifications of the esthetics. tral incisors, restoring shape/color defects
on the maxillary lateral incisors and ca-
nines using ceramic veneers, and correct-
Periodontal response ing enamel hypoplasia on the mandibular
incisors (Figs 1 and 2).
Only a few long-term studies confirming A clinical situation such as this is one of
the good integration of resin composite the clearest indications for esthetic veneer
veneers with the surrounding periodontal treatment, especially for patients who have
tissues have been published. Indirect tech- repeatedly sought a perfect esthetic inter-
niques allow a level of marginal precision vention and instead found their smile ruined
that is absolutely comparable to that of ce- by unsatisfactory restorations. Today, it is
ramics. In addition, the latest-generation possible to achieve excellence even with di-
resin composites show enhanced superfi- rect techniques; however, in the authors’
cial polishing and smoothness character- opinion, in cases like this it is simpler and
istics. Thus, it is possible to achieve prom- more predictable to use indirect techniques.
ising results in terms of periodontal Figures 3 and 4 show the preparations
integrity. of the maxillary and mandibular teeth. The
A number of long-term studies demon- veneers received from the dental techni-
strated the biocompatibility and low plaque cian are shown in Figs 5 and 6. After repli-
retention of ceramic.35,123–130 Peumans et al120 cating the cast, the ceramic (Avanté,
reported mild plaque presence at the mar- Jeneric Pentron) was layered and baked in
ginal level 5 years after luting as a result of the oven. The veneers were tried in, adhe-
glaze removal during finishing. sively luted (with the use of rubber dam),
Margin positioning plays a fundamental and polished. The cement used was Cali-
role in periodontal tissues response, which bra (Dentsply). The final result is shown in
suffers when the margin is placed far from Figs 7 to 9.
42
MANGANI ET o AL
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figure has too small resolutionte- ot n
n
please provide 300 dpi
ss
fo r
e n c e
figure has too small resolution - and a width of 8 cm
and a width of 8 cm
Figs 1 and 2 Initial situation.
figure has too small resolution - figure has too small resolution -
please provide 300 dpi please provide 300 dpi
and a width of 8 cm and a width of 8 cm
Figs 3 and 4 Preparations of the maxillary and mandibular teeth.
figure has too small resolution -

and a width of 8 cm
and a width of 8 cm
Figs 5 and 6 Veneers for the maxillary and mandibular teeth.

please provide 300 dpi and a width of 8 cm
and a width of 8 cm
Figs 7 and 8 Final result.
43
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figure has too small resolution - please provide
300 dpi
Fig 9 Final result.
Case 2
This case involved replacing two direct ite veneers are shown in Fig 12. The labo-
restorations on the maxillary right lateral in- ratory procedures for this material are
cisor and left central incisor, and correcting much simpler than for ceramic veneers; the
enamel anomalies on the right central inci- material is layered on the cast and each in-
sor and left lateral incisor (Fig 10). Resin crement is light cured. A final postpolymer-
composite veneers (Enamel Plus HFO, ization treatment inside a light-heat oven is
Micerium) were used, and luted with the necessary, but no baking is required. Use
same resin composite material. The dentin of rubber dam not only provides operating
bonding agent used was EnaBond (Miceri- field isolation, but also allows the clinician
um). to carry out each operative step with ab-
In this case, a conservative preparation solute calm and concentration (Fig 13). The
confined to the enamel layer was used final result is shown in Fig 14.
(Fig 11). The manufactured resin compos-
figure has too small resolution - figure has too small resolution -
Fig 10 Initial situation. Fig 11 A conservative preparation was carried out.
44
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Fig 12 Resin composite veneers. Fig 13 Rubber dam was used for field isolation.

and a width of 8 cm
Fig 14 Final result.
Conclusions
The success of anterior indirect restora- ■ Chairside finishing and polishing ma-
tions depends on proper treatment plan- neuvers are simpler and less likely to
ning and application of the operative pro- increase fracture risk, as in ceramic.
tocol. Medium- and long-term follow-up ■ Resin composite veneers can be
studies35,65,129–134 of ceramic veneers have modified before luting without compro-
shown satisfactory results regarding es- mising either their mechanical proper-
thetic result and periodontal response. Re- ties or adhesive potential.
specting every step of the treatment proto- ■ Cost is lower due to simpler laboratory
col will reduce the percentage of failure in procedures, and the range of applica-
cases with a high risk of veneer fracture. tion is wider than with ceramic.
Despite the small number of studies in the
literature, it should be underlined that resin With these considerations in mind, it is the
composite veneers have undeniable ad- authors’ opinion that in the near future the
vantages and may represent the future of use of ceramic in anterior indirect adhe-
this technique for the following reasons: sive restorations will decrease, while the
use of resin composite will increase.
■ Luting procedures are less complicat-
ed and risky thanks to the resin com-
posite’s greater ability to absorb the
polymerization stress of the adhesive
cement.
45
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Clinical approach to anterior adhesive restorations using resin composite

Francesco Mangani Antonio Cerutti

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Angelo Putignano Lorenzo Madini

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to Anterior Adhesive Restorations

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Correspondence to: Dr A. Cerutti

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In the authors’ opinion, however, this final

Surface finishing and final polishing are Tooth preparation

Enamel reduction Concerning resin composite veneers,

Figs 1 and 2 Initial situation.

Figs 3 and 4 Preparations of the maxillary and mandibular teeth.

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Figs 5 and 6 Veneers for the maxillary and mandibular teeth.

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Figs 7 and 8 Final result.

Fig 9 Final result.

Fig 10 Initial situation. Fig 11 A conservative preparation was carried out.

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Fig 14 Final result.

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