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prosthodontic PERSPECTIVE

Ceramic restorations:
Bonded porcelain veneers - Part 1
By David M Roessler, BDS, MDSc, FRACDS, FADI, FPFA, FICD, MRACDS (Pros)

appy New Year! I hope you've


had a good break and recharged
the batteries for the year ahead.
Whether your last year was good, bad
or indifferent, I hope this one is better.
Today, we're going to talk bonded porcelain veneers or, if you prefer, bonded
ceramic facings. Strap yourself in because
this is going to take more than one article!
Now, I'm happy to admit that bonded
porcelain veneers are my favourite of all
indirect restorations. They're potentially
the most aesthetic, conservative and longlasting. Don't believe me? Check these
studies out;
Approximately 63% to 72% of the coronal tooth structure was removed when
teeth were prepared for all-ceramic
and metal-ceramic crowns. Ceramic
veneers required 3% to 30% tooth
removal. Edelhoff & Sorensen J Prosthet Dent 2002; 87; 503-9.
The estimated survival rate was 94.4%
after 5 years; 93.5% at 10 years; and
82.93% at 20 years. Significantly
increased failure rates were associated
with bruxism and non-vital teeth and
marginal discolouration was worse in
patients who smoked. Beier et al. Int J
Prosthodont 2012; 25:79-85.
Bonded ceramic restorations represent
a reliable, effective procedure to restore
extensive coronal volume and length in
the anterior dentition. 1.5 to 5.5mm incisai
edge increase, 4.5 years. Magne et al. Int
J Pedo & Rest Dent 2000; 20: 440-57.
All that seems great, but you will only
be able to achieve similar results if you
observe some guidelines.

7 2 Australasian Dental Practice

So what's possible?
Some of the biggest problems I see with
veneers occur when they are attempted
in inappropdate situations. Veneers are
totally dependent on bonding, and preferably, bonding to enamel, for their
strength. My rule here is that you want
a minimum of two thirds of the margin
bonded to enamel. Less that that and you
should start to think a crown might be
more appropriate.
An increased risk offailure is present
only when veneers are partially bonded
to dentin. The estimated survival probability over a period of 10 years is 91 %.
Dumfahrt & Schffer
Int J Prosthodont 2000; 13:9-18
Veneers can make only mild changes
to tooth colour. One of the things that
make veneers look so good is their lack
of an opaque layer giving them beautiful,
natural translucency. The fiipside of this
is that if the tooth underneath is too dark,
either it will show through, or you will
need an opaque layer which will make
the veneer look like white paint instead
of tooth structure. Again, if you're aiming
for a big shade change, think either whitening plus veneer or crown. And if the
tooth is very dark, you're probably better
off with porcelain/metal than an allceramic crown.
If the ceramic thickness is iess
than 1.0mm... colour matching of the
abutment is required.
Vichi et al.
J Prosthet Dent 2000; 83: 412-7

Can veneers make crowded teeth


look straight? Up to a point, the answer
is yes. You can certainly make a tooth
more prominent with a veneer (with the
bonus that much less prep is required).
You can also use a veneer to derotate a
rotated tooth (some of the tooth requires
less prep). But remember when you make
teeth more prominent, they get thicker
- not usually a big deal in uppers but a
problem for lowers because that thick
incisai edge is what we see.
In addition, when you "straighten"
teeth that were overlapping, they get
narrower so they might lose their proportions. Finally, if you bring them all
forward to avoid them becoming narrower, you might end up with someone
who is "all teeth". Alternatively, your
patient might come back saying that they
keep catching their lip on their new teeth
or, even worse, they keep getting lipstick
on their teeth.
What you pretty much can't do with
a veneer is move a tooth palatally. The
amount of tooth reduction required to
make a veneer that's is noticeably less
labial than the original tooth position is, in
my opinion, simply excessive. Remember
you and the patient have a choice. You
can always opt for orthodontic tooth
movement. I am a great fan of conventional adult orthodontics and I am also
an Invisalign practitioner. Whether you
are planning crown and bridgework or
veneers, moving teeth can sometimes
reduce the need for restorative work, or
make the work simpler and will often get
you the best result.

January/February 2013

prosthodontic PERSPECTIVE

Figure la. Cross section


through upper central incisor,

Figure lb. Prep when not


changing incisai length.

Figure 2a. Teeth with extensive composite resins.

Figure Ic. Prep when


changing incisai length.

Figure Id. Weakest prep avoid if possible!

Figure 2b. Veneer preps e.xtended past composite resin margins.

Tooth preparation
I'm going to focus on upper anteriors initially and we'll discuss lower anteriors
a bit further on. There are three possible
situations here:
I.The tooth is intact and you are not
changing its length (Figure lb);
2. The tooth is intact and you are intending
to make it longer incisally (Figure lc); or
3. The tooth has a fractured incisai comer
and/or Class III or Class IV composite
resin(s).
Before knowing what to do, we need to
know what we're aiming at. As much as
possible, we want to stay in enamel. As a
mle of thumb, 0.5mm thickness of porcelain bonded to enamel is about as strong as
1mm thickness bonded to dentine. So we're
going to try to keep our preps conservative.
Second, it's important to maintain a
horizontal labial or, at worst, labioincisal
path of insertion. Why? When there is a
labial path of insertion, neither the mesiodistal taper of the tooth from incisai to
gingival nor the labial convexity in the
gingival third is of any concem. However, as the path of insertion becomes

January/February 2013

more incisai, these areas become potential undercuts requiring much more tooth
structure removal.
So, in point I (Figure lb), we should
be aiming for a veneer that has a fairly
even thickness covering all of the visible
parts of the tooth. Stop at the incisai edge
- there's no need to go over it. The one
exception here is an edge-to-edge occlusion - we don't ever want the opposing
incisai edge to be in contact with one of
our margins in centric occlusion.
Exactly how much tooth reduction you
require will depend on a few factors. If you're
maintaining the same tooth position and
making a fairly minor colour change, then
1 would suggest you need a 0.5mm reduction in the incisai two-thirds and a 0.3mm
reduction in the gingival third. Yes, this
will mean that the veneer is a bit over-contoured (not overhanging!) in the gingival
third but that over-contour doesn't affect
gingival health and it's really not visible.
In the more common point 2 (Figure
lc), veneers are used to lengthen teeth or
restore lost length. So we have a couple

of extra considerations here. First, the


ceramic incisai edge you're about to
create will almost certainly be loaded in
function, so you don't want the ceramic to
be too thin here. I prefer the ceramic to be
at least 1mm incisogingivally. Allowing
for cement thickness, this means that
you should aim for the incisai edge of
your prep to be about 1.2mm shorter than
the finished restoration i.e. if you are
increasing length by less than 1mm, you
need to do some incisai reduction.
Now that you're adding on to the incisai,
you've got a few more things to consider:
a. When you reduce the incisai edge, you
want it to be either horizontal or tilted
slightly so the palatal margin is slightly
more incisai than the labial margin. In
that way, you can maintain a horizontal
labial path of insertion. The palatal
margin here will need to be a butt
margin. If you chamfer or bevel it, you
will destroy the path of insertion. Also,
check centric occlusion and make sure
the palatal margin doesn't coincide with
the incisai edge of the lower incisor;

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prosthodontic PERSPECTIVE

Figure 3. Prep viewed from incisai edge when closing diastema between two upper central incisors.

Figure 4a. Veneer with "wings".

Figure 4b. Veneer prep with "wings".

Figure 4c. Veneer after bonding.

b. Ceramic does not like going from


thick to thin suddenly so don't simply
do your normal veneer prep and then
lop a bit off the incisai edge. If you do
that, your veneer will be quite weak. In
addition, your technician has an almost
impossible aesthetic challenge - relatively thin porcelain with cement and
tooth providing the background suddenly becoming thicker porcelain with
nothing behind it. The sudden change
in opacity almost always leaves a line.
The solution is to remove a bit more
tooth structure in the incisai third. So
gradually increase the reduction from
0.5mm to 0.7mm so that the porcelain
also becomes thicker gradually; and
c. When you've done the first two steps,
you will probably find that you have
quite a sharp line angle between the
labial and incisai reductions. Make
sure you round this off to prevent a
stress concentration area and a potential
visual problem.
Well, we're ready for the last scenario,
point 3. If you have mesial and/or distal
Class III composite resins, first decide
whether they occupy more than a third of
the final total margin length. If so, start
thinking about a crown. If they don't, do
they need replacement? If they're intact and
not discoloured, I think you can leave them.
However, if you intend replacing them
because they're discoloured or recurrent,
my preference is to leave them while you

do your prep and then replace them after


you bond the veneer. Sometimes it's possible to take your prep through a bit further
and actually get past the composite resin
and on to the palatal enamel (Figure 2b).
If it's a Class IV composite resin or
fractured incisai edge, things are a bit different. Here, I would suggest you remove
all of the "Class IV" part of the restoration.
Then make sure that you have a horizontal
not diagonal finishing line. If there is any
intact incisai edge, you should reduce that
as well by about 1mm. You don't need to
reduce it all the way to the same level as
the Class IV, but where the Class IV meets
the prepared incisai edge, use a vertical not
diagonal finishing line. A vertical finish
line that happens to be visible under your
veneer because of the change in opacity or
porcelain thickness or cement, just look?
like one of the many normal vertical check
lines we all have on the labial surfaces but
if it's diagonal, it catches our eye because
it looks like a crack. Thus, this is the
reason for avoiding diagonal finish lines.
What should we do about contact points?
If a contact point already exists in the natural tooth structure, then I usually would
not remove it. I would end my veneer
preparation slightly labial to the contact.
The bigger issue is what to do when we
have a gap that we're trying to close. This
is where many dentists make the mistake
of not carrying the prep far enough palatally. If your prep stops midway between

the labial and palatal surfaces, the technician has no way to develop a smooth
anatomical transition from tooth to veneer.
What you end up with is a bulge of porcelain that forms a sideways overhang at the
margin. Generally, this area will also be
too translucent because of the lack of porcelain, so it will look dark. The solution
is to take the prep through to the palatal
third (Figure 3). Now, the technician can
develop adequate contour and opacity.
While we're talking about preparation, I
should mention lower anteriors. First, I'm
sure that we all agree that lower incisors in
particular are horrible little teeth and any
time you can avoid restoring them, do so!
If you are going to porcelain veneers, however, start by accepting that the veneers
are going to be over-contoured unless you
outrageously over-prepare them. You probably can't reduce the labial by more than
about 0.3mm without ending up in dentine,
and you really want to stay in enamel. So
check to see that you have occlusal room to
make over-contoured restorations.
The other modification is that you should
always cover the incisai edge when doing
lower veneers. First, because, if you don't,
you will have the incisai margin of your
veneer under heavy load in centric and in
function. Second, because the incisai edge
of a lower anterior is the most visible surface, so it won't look very good if there's an
interface there. So, you need to reduce the
incisai edge to make about 1.2mm space

7 4 Australasian Dental Practice

January/February 2013

prosthodontic PERSPECTIVE
between it and the upper so you have 1mm
of bonded porcelain there. By the way, if
the patient is having some form of orthodontics, you can deliberately make that
space between the uppers and lowers so
you don't need to reduce the teeth so much.

What about the margin?


You might have noticed that I've written
a lot about the prep but haven't mentioned
the gingival margin. It's common practice
for veneers to be given no definite margin
or some sort of knife-edge finish line. Of
course, when your technician sees this,
they take a deep breath and accept that life
wasn't meant to be easy. They don't know
exactly where they should finish the restoration and it's almost impossible to finish
porcelain to a knife-edge and it's going
to be weak. So you get something that's
grossly over-contoured and/or chipped (or
you chip it) and then when you try to bond it
into place, it has no definite position so it's
potluck whether you actuafly seated it correctly. So make a rounded chamfer margin
about 0.3mm deep and everything will be
easier - you'll get better bonding as well.

The next question is where you are


going to put this margin. I'll give you a
clue - I rarely need any form of retraction to take impressions for veneers. The
first thing I do is evaluate the patient's
smile. If they have a low smile line and
they are never going to show the margins anyway, I show them and, if they are
happy, I stay well away from the gingiva.
It makes everything easier and the last
1mm of enamel before the CEJ is aprismatic, so you get really poor bonding
there anyway.
If the margin will be visible, I usually
put it equigingival or even very slightly
supragingival. The only time I tend to go
subgingival at all is if I'm forced to by a
restoration in the tooth or If I'm going for
a significant colour change. Even then, I
avoid retraction cord and usually use one
of the retraction pastes.
I want to mention one last thing about
the extent of the preparation. Dentists
often prepare the tooth following the classical gingival curve and it means that at the
labioproximal near the gingiva, there is a
little bit of visible tooth structure which is

not covered by your veneer and ends up


looking dark. If you maintain a horizontal
path of insertion, you can extend you prep
in these areas so it ends up having wings
or ears (Figures 4a-c).
Now that we agree on what we're
aiming at, it's time to get practical so I can
help you achieve the result you, your technician and your patient all want.

About the author


Dr David Roessler is a Prosthodontist
in Sydney's CBD where he is Supervising Specialist Clinical Consultant of
The Dental Specialists, a multidisciplinary specialist centre. He has been a
Keynote Speaker at many international
conferences and has given more than 500
lectures and hands-on courses in almost
every facet of restorative, aesthetic and
implant dentistry in Australia, Asia and
the USA. As a prosthodontist, David has
the opportunity to see where it all goes
wrong in both the difficult and seemingly
easy situations. He treats patients with the
highest expectations and has learnt from
his own mistakes and those of others.

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