CLINICAL REPORT

Minimum intervention in restorative dentistry with

V-shaped facial and palatal ceramic veneers
Adilson Yoshio Furuse, DDS, MS, PhD,a Juliana Volpato Soares, DDS,b
Rafael Schlögel Cunali, DDS, MSc,c and Carla Castiglia Gonzaga, DDS, PhDd

Dental erosion can be defined ABSTRACT

as the progressive loss of dental
The esthetic and functional rehabilitation of worn anterior teeth should follow the principles of
tissue due to the chemical minimally invasive dentistry. When dental wear occurs at both the facial and palatal surfaces, the
dissolution by acids without sandwich approach of reconstructing eroded anterior teeth with palatal followed by facial veneers
bacterial involvement and is is a straightforward treatment that preserves sound dental structure. (J Prosthet Dent 2015;-:---)
considered a multifactorial dis-
ease. The substances involved in this process can come However, they can be conservatively treated with esthetic
from intrinsic and extrinsic acid. Intrinsic erosion is caused restorative procedures such as indirect composite resin
by gastric acids that come into contact with teeth during restorations or ceramic laminate veneer to achieve the
vomiting, mainly in individuals who suffer from gastro- most predictable esthetic and functional outcome.6,7
esophageal reflux disease or eating disorders. Exogenous Rehabilitation of extensive erosion, however, remains a
acids present in some foods and drinks, work environment, challenge because multiple teeth are often involved.5
medicine, and some drugs are the primary causes of The sandwich approach, developed by Vailati et al,5,8
1,2
extrinsic dental erosion. is a technique that consists of reconstruction of the
Studies have reported a wide range (from 4% to 82%) of lingual aspect of eroded anterior teeth with resin palatal
dental erosion in adults, and men are reported to be more veneers, followed by restoration of the facial aspect with
prone to erosive tooth wear than women.3 Moreover, data ceramic veneers. This technique is specifically designed
showed that erosive wear can be located on all tooth sur- for patients with a combination of buccal and lingual
faces but is most common on the occlusal and facial sur- erosion on anterior teeth. It requires minimal tooth
faces of all maxillary and mandibular teeth and on palatal preparation, following the principle of minimal inva-
surfaces of the maxillary anterior teeth.3 Tooth wear has a siveness and preserving the tooth structure in the center
multifactorial nature and is caused not only by erosion. between the facial and palatal veneers.5
Attrition, abrasion, and abfraction can also contribute to This article describes the use of adhesively bonded
the loss of teeth. Degradation of tooth surfaces can be due 1-piece V-shaped ceramic laminate veneers to rehabili-
to chemical and/or mechanical factors, and the damage of tate the facial and palatal surfaces of severely worn and
dental hard tissues significantly increases when acid- discolored anterior teeth.
etched surfaces are mechanically loaded.4
CLINICAL REPORT
Ideally, dental erosion lesions should be treated as soon
5
as possible after the identification of dentin exposure. In A 48-year-old man who was dissatisfied with the
some situations, the patient takes a long time to seek appearance of his smile due to deficiencies in both the
treatment and esthetics and function are compromised. form and color of his anterior teeth attended the Positivo

a
Professor, Department of Operative Dentistry, Endodontics and Dental Materials, Bauru School of Dentistry, University of São Paulo, São Paulo, Brazil.
b
Private practice, Paraná, Brazil.
c
Graduate student, Graduate Program in Dentistry, Positivo University, Paraná, Brazil.
d
Professor, Graduate Program in Dentistry, Positivo University, Paraná, Brazil.

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Figure 1. Intraoral facial view showing discoloration and wear of anterior
teeth.
Figure 3. Diagnostically waxed casts.
University dental clinic. The maxillary anterior teeth were
severely worn and discolored on both the facial and
palatal surfaces (Figs. 1, 2). The patient reported he had
been a smoker since the age of 25 and ingested various
amounts of distilled beverages and cola soft drinks daily.
He also reported that he had been diagnosed with dia-
betes mellitus type 1 16 years previously and had used
neutral protamine Hagedorn insulin. He also had sys-
temic hypertension diagnosed 4 years previously. Addi-
tionally, he had received a diagnosis of peripheral
neuropathy and was receiving hemodialysis 3 times a
week.
After teeth cleaning and oral hygiene instruction, ra-
diographs and diagnostic casts were obtained and waxed
to define shape and form (Fig. 3). Facial and palatal
ceramic veneers were the treatment option chosen for
the 6 maxillary anterior teeth. Because of financial issues,
the patient opted to have the mandibular teeth restored
with direct placement composite resin.
Initially, the shade was selected, and direct composite
resin trial restorations were placed for diagnosis and
treatment planning (Fig. 4). Preparations were kept to a
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Figure 2. Intraoral occlusal view showing wear at palatal surfaces.
Figure 4. Direct composite resin trial restorations on maxillary anterior
teeth.
minimum because of the severe wear of the teeth. When
needed, diamond rotary instruments were used to refine
the distal and incisal areas. The preparations were
finished with aluminum oxide disks (Sof-Lex; 3M ESPE),
and the contact areas were removed with a 6-mm
diamond-coated steel strip (Diamond Strip; TDV).
Displacement cords (Ultrapak Cord #000 and #0; Ultra-
dent Products Inc) were placed and an impression was
made with polyvinyl siloxane material (HydroXtreme;
Coltène/Whaledent) (Fig. 5).
Because of the discolored underlying dentin, facial
and palatal veneers were fabricated with a low-
translucency lithium disilicate reinforced glass ceramic
(IPS e.max; Ivoclar Vivadent AG) formed with the
heat-press technique. They were veneered with a layer-
ing ceramic (IPS e.max Ceram; Ivoclar Vivadent AG) to
improve the appearance of the incisal edge. In teeth with
tapered surfaces at both the palatal and facial areas, a
V-shaped design was used (Fig. 6). In this design, 1-piece
double-sided veneers were made to restore both the
facial and palatal surfaces without including the
Furuse et al
- 2015 3

Figure 5. Prepared teeth with displacement cords. Figure 6. V-shaped, facial, and palatal laminate veneers before
cementation.

Figure 7. Facial view after cementation of ceramic veneers. Mandibular Figure 8. Occlusal view of maxillary anterior teeth restored with facial
teeth were restored with direct composite resin. and palatal ceramic laminate veneers.

Before light activation, gingival and proximal excesses

interproximal areas. The maxillary right central incisor
of cement were removed with an explorer and dental
was restored with 2 veneers. The veneers were placed on
floss. The light-activation was performed with a light-
the teeth to evaluate the adaptation and color.
emitting diode device (Radii-cal; SDI) for 40 seconds at
The veneers were bonded with a dual-polymerizing
the facial, mesial, distal, and palatal aspects of each tooth.
resin cement (RelyX ARC; 3M ESPE). The intaglios
After cementation, the veneer of the adjacent tooth was
were etched with 10% hydrofluoric acid (Porcelain
bonded in the same way. For the facial and palatal
Etchant; FGM Ind) for 20 seconds, washed, and dried.
veneers of the maxillary right central incisor, the facial
Silane was then applied (RelyX Ceramic Primer; 3M
veneer was cemented first followed by the palatal one
ESPE). One thin coat of resin (Adper ScotchBond
(Figs. 7, 8). The cementation line between these 2
Multi-Purpose; 3M ESPE) was applied and light activated
veneers can be seen in Figure 8. The restorations were
for 10 seconds. The tooth surfaces were prepared for
then evaluated for occlusal interferences. After 24 hours,
cementation, and the adjacent teeth were protected
subgingival excess was removed with a #12 surgical
with Mylar strips. Each tooth was adhesively treated, and
blade, and the marginal areas were polished with a sili-
the veneer was cemented. The tooth surface was treated
cone rubber polisher (Exa Cerapol; Edenta AG).
with a 3 step-adhesive system (etched with phosphoric
Completed restorations can be seen in Figures 7, 8.
acid gel, rinsed with water, excess water removed;
followed by the application of the primer, evaporation of
DISCUSSION
the solvent, application of light-polymerizing adhesive
resin, spread into a thin layer with gentle air, and This clinical report demonstrates an approach to
light activated) (Adper ScotchBond Multi-Purpose; 3M restoring severely worn maxillary anterior teeth with
ESPE). minimum dental preparation and adhesively bonded

Furuse et al THE JOURNAL OF PROSTHETIC DENTISTRY

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facial and palatal ceramic laminate veneers. Only a few
reports of esthetic palatal veneers have been pub-
lished,5,8-10 although this treatment option is much less
invasive than a complete crown. Additionally, the tooth
preparations, when needed, and impression making are
straightforward procedures. For this patient, tooth prep-
aration was minimal, and local anesthesia was not
needed.
A V-shaped veneer design for both facial and palatal
restoration was demonstrated, simulating a crown
without interproximal preparation. Composite resin
V-shaped veneers have been reported.11 The main
advantage of the V-shaped veneers is that they facilitate
a conservative approach since they require only marginal
preparation and, if necessary, a small correction in the
middle third of the anterior teeth to achieve an incisal
path of insertion. Additionally, the contact points were
not removed, allowing more tissue preservation.11
However, the insertion axis was carefully evaluated
during waxing for the heat-press technique. Because of
the lack of an insertion path, instead of using the
V-shaped design, the maxillary right central incisor was
restored with 1 veneer for the facial and 1 for the palatal
surface.
The conservative approach with an alternative design
of 1-piece double-sided adhesively bonded facial and
palatal ceramic laminate veneers for the rehabilitation of
severely worn and discolored anterior teeth presented
satisfactory esthetic and functional results.
SUMMARY
In the present clinical report, a patient with severely worn
and discolored maxillary anterior teeth was treated with
facial and palatal ceramic veneers requiring minimal
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tooth preparation. Tooth preparation was limited to
rounding angles at the proximal and incisal areas. This
conservative approach with facial and palatal ceramic
laminate veneers presented satisfactory esthetic and
functional results.
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Corresponding author:
Dr Carla Castiglia Gonzaga
Universidade Positivo
Rua Prof Pedro Viriato Parigot de Souza 5300
81280-330, Curitiba, PR
BRAZIL
Email: carlacgonzaga2@gmail.com
Copyright © 2015 by the Editorial Council for The Journal of Prosthetic Dentistry.
Furuse et al