It is common to see patients who tell us: “Doctor, when I smile I have a tooth that is out of place. It is a dark spot: we only see that, I dare not smile anymore! “. They tell us about a tooth in the incisor-canine sector in a palatal or lingual position, this break in the alignment generates an unsightly gray area in the smile that tends to increase with the loss of occlusal stability. The tooth, which is more difficult from brushing and therefore poorly cleaned, it is also prone to plaque retention.What solution can we offer our patients?A dental veneer?
Orthodontics, dental veneers
If the tooth is healthy and intact, the solution of choice is orthodontics to restore the position on the dental arch and occlusal stability.
” To achieve the esthetic goals of tooth position and angulation, many patients with esthetic problems require orthodontic treatment. (Riedel 1950; Peck and Peck 1970). But the limitations associated with this technique put off some of our adult patients.
A tooth that is discolored or whose physical integrity is altered (enamel fracture, caries, etc..) will eventually require cosmetic restoration.
Advantages and disadvantages…
Respect for the integrity of the dental organ.
Without treatment of dyschromias or anatomical defects.
” For malformed, poorly positioned or slightly damaged teeth, directly and indirectly bonded dental materials can restore esthetics and create a pleasing smile with minimal invasion and limited sacrifice of natural tooth structure. (Bayne et al. 2019).
Quick treatment (1 or 2 appointments depending on the technique).
Associated treatment of dyschromias and anatomical defects.
It requires touching the integrity of the dental tissue (enamel).
For equipped consultations, CAD/CAM (computer-aided design and manufacturing) allows you to prepare, design and place the prosthetic element in the same session. Recent studies attest to a good success rate for this technique (87.5% up to 27 years (Otto 2017), 93.5% after 10 years (Beier et al. 2012).
Saving time for the patient (only 1 trip).
Prevents the installation and removal of a temporary.
It requires a good mastery of the technique for a satisfactory aesthetic result.
Clinical case – dental veneer
Sabra, 30 years old, is presented with 31 in lingual position. The patient tells us that the position of her tooth is changing and she is becoming more linguistically literate (Fig. 1, 2). She offered, as a first intention, a treatment with alignment channels to reposition the incisor (31) in the arch. Our patient refuses, given the limitations and duration of the orthodontic treatment, but she asks us for another therapeutic alternative.
Fig.1, 2: Tooth 31 with lingual tip.
Dental veneer made in the office by CAD/CAM
1 – Preparation
a preparation at least of the receiving dental organ preserves the tissues and the vitality of the tooth. Preserving the enamel is essential to ensure an effective bond. Less is more. The minimum thickness of the ceramic veneer (Vita Mk2) is 0.3 mm + the bonding (NX3) 0.1 mm. Occlusal coverage 0.5 mm. The tooth in the lingual position is only buccal “frosty”. A positioning groove is created around the junctional edge of the future veneer with a diamond bur calibrated to 0.1mm (Fig. 3). The occlusal edge is reduced by 0.5 mm.
2 – Optical impression taking
In practice, we are equipped with the “Trios 3shape intraoral scanner” camera (Fig. 4 to 8).
Fig.4: Optical impression taking.
Fig.5 to 8: Optical impression (3Shape). Fig.5: Antagonist.
Fig.6: Mandibular arch.
Fig. 7, 8: Occlusion.
3 – Modeling
The digital impression is saved as an STL file and imported into our modeling software “Inlab” (Sirona) (Fig. 9 to 14).
Fig.9: Inlab software home page.
Fig.10: 3Shape and Inlab software superimposed.
Fig.11 to 14: Design of the veneer in the “Inlab” software.
4 – Machining
The virtual model is machined with the Inlab Cam software (Fig. 15) that controls our MCXL Premium milling machine (Sirona) (Fig. 17).
Fig.16: Vita MKII pedestal in feldspathic ceramic.
Fig.17: Inlab Premium milling machine.
Fig.18: Ceramic dental veneer after machining.
Fig.19: Testing the “raw” facet in the mouth.
5 – Testing the “raw” face that comes out of the milling machine
6 – Staining and ceramic firing
The raw veneer is placed on a firing support. After having covered the vestibular surface with a glaze (Vita Akzent plus) compatible with the feldspathic ceramic used, different stains allow characterizing the facet to integrate it as well as possible within the arch of our patient (Fig.20). .
Fig.20: Facette and our makeup palette.
The ceramic oven (Vita Atmomat) is programmed to reach a firing temperature of 940° for 1 minute 30, which allows the makeup to be fixed without altering the properties of our veneer (Fig.21).
Fig.21: Vita Atmomat oven.
7 – Bonding
We have been using NX3 (Kerr) adhesive resin for many years. L’intrados The veneer is treated with hydrofluoric acid “Ultradent Porcelain Etch” at 9%, rinsed and dried before applying a drop of silane. The bonding surface of the natural tooth is disinfected with chlorhexidine prior to treatment with a major and an “Optibond” adhesive. NX3 Facet Bonding Resin is light-curing. A first flash is applied with a polymerization lamp for 3 seconds, which allows easy removal of excess glue, then 40 seconds with 2 x 1200 W lamps (Fig. 22 to 26).
Fig.23: Elimination of excess with dental floss.
Fig. 24, 25, 26: Adhered sheet metal.
If orthodontic treatment is still the preferred solution to correct a malposition, performing a ceramic veneer in a single session (lasting approximately 1 hour) can restore the harmony of our patients’ smiles in a lasting way. The placement of this veneer restores the contact points with the adjacent teeth, ensuring occlusal stability. No restriction will be necessary.
Dr Cyrille FONTENEAU
Private practice in Paris
CAD/CAM fixed prosthetic restorative aesthetic dentistry
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Otto T. Long-term clinical results of up to 27 years of Cerec 1 CAD/CAM inlays and onlays in the office. Int J Calculate bulge. 2017.
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