dentistry journal
Case Report
Partial Ceramic Veneer Technique for Challenging Esthetic
Frontal Restorative Procedures
Gustavo Marotto Caetano 1 , Cilea Slomp 1 , Jonas Pereira Andrade 1 , Ana Maria Spohr 1
and Marcel Ferreira Kunrath 1,2, *
Citation: Caetano, G.M.; Slomp, C.;
Andrade, J.P.; Spohr, A.M.; Kunrath,
M.F. Partial Ceramic Veneer
Technique for Challenging Esthetic
Frontal Restorative Procedures. Dent.
J. 2023, 11, 101. https://doi.org/
10.3390/dj11040101
Academic Editors: Akira Aoki and
Jorge Nuno do Martins
Received: 28 February 2023
Revised: 16 March 2023
Accepted: 6 April 2023
Published: 11 April 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Dent. J. 2023, 11, 101. https://doi.org/10.3390/dj11040101
1 Postgraduate Program in Dentistry, School of Health and Life Sciences, Pontifical Catholic University of Rio
Grande do Sul (PUCRS), Porto Alegre 90619-900, Brazil
2 Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg,
40530 Gothenburg, Sweden
* Correspondence: marcel.kunrath@edu.pucrs.br
Abstract: Frontal darkened teeth have shown to be one of the most challenging treatments for esthetic
dentistry in recent years. This case report, along with a 30-month follow-up, describes the application
of a partial ceramic veneer, restricted to the mid-cervical third region, made in the upper left central
incisor darkened by trauma. The procedure consisted of maintenance of the entire incisal face, as
well as esthetic and morphological rehabilitation of the smile line with veneers and ultra-thin partial
ceramic veneers. The planning process was thoroughly elaborated by photographs, study models, a
virtual smile designed, diagnostic waxing, and reproduction in the patient’s mouth through mock-
up. Following, dental home bleaching, esthetic gingival contouring, and minimally invasive tooth
preparation were performed. Two types of glass ceramics (lithium disilicate and feldspathic) were
used in different regions due to the peculiar characteristics of resistance, finishing, and polishing.
According to the present case report, preparing a cervical partial ceramic veneer is an innovative,
viable, and safe approach to maintaining the incisal portion of the tooth preserved and setting a
detailed tooth morphology/color. The application of partial ceramic veneer provides incisal edge
preservation and simplifies the reproduction of the adjacent tooth characteristics, avoiding multiple
esthetic appointments.
Keywords: cervical veneer; partial veneer; esthetic rehabilitation; conservative ceramic; minimally
invasive rehabilitation
1. Introduction
Dental trauma normally affects children and adolescents, with a prevalence of 4%
to 33% of the world population [1,2]. The most common problems are pulp, periodontal,
and esthetic complications [3,4], and the greatest occurrence is in the anterior teeth [5,6].
An esthetic intervention is considered necessary when there is a color change in the tooth,
especially when there is pulpal sclerosis due to dental trauma [7].
External bleaching is one intervention technique that can be performed [8,9]. However,
due to the unpredictability of this technique in determining the final color to be obtained
and its recurrence over the years [10,11] and unsatisfactory outcomes reported by picky
patients, other rehabilitation modalities have been proposed. Among them, ceramic crowns,
which require preparation of the whole coronary portion and the consequent wear of the
sound dental remnant, are traditionally used [12,13]. Nonetheless, the evolution of adhesive
techniques and materials allowing greater tooth preservation through the preparation of
ceramic veneers is being used [14–16]. As they allow only the buccal face of the affected
tooth to be covered, they provide a favorable cosmetic recovery with highly proven clinical
performance, according to several studies [17–19].
To maximize dental preservation with an esthetic and functional purpose, ultra-thin
ceramic veneers ranging from 0.3 to 0.5 mm have recently been proposed [20–22]. Applying
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To maximize dental preservation with an esthetic and functional purpose, ultra-thin 2 of 10
ceramic veneers ranging from 0.3 to 0.5 mm have recently been proposed [20–22].
Applying these veneers on whole dental faces has evolved to the production of partial
ceramic veneers [23]. This modality requires greater precision and technical criteria,
these veneers on whole dental faces has evolved to the production of partial ceramic
especially in relation to the final stages of finishing and polishing, to mask the interface
veneers [23]. This modality requires greater precision and technical criteria, especially in
between the
relation to theceramic and the
final stages of enamel
finishing[24,25]. Hence, ato
and polishing, zero-degree angularbetween
mask the interface terminationthe is
desirable [26], differentiating the use of the partial over the total veneers.
ceramic and the enamel [24,25]. Hence, a zero-degree angular termination is desirable [26], However, these
techniques lack the
differentiating scientific studies
use of the and
partial case
over thefollow-ups in the
total veneers. literature.
However, these techniques lack
Therestudies
scientific is a greatandrestorative challenge
case follow-ups in theinliterature.
cases of single anterior teeth with darkening
on theThere
cervical face only,
is a great whichchallenge
restorative present in anatomical and anterior
cases of single optical teeth
integrity
withof the incisal
darkening
border.
on the Ceramic
cervical facestratification
only, which attempting to reproduce
present anatomical andthe sameintegrity
optical face of the homologous
of the incisal
border.
tooth Ceramic
precisely stratification
often produces attempting to reproduce
unsatisfactory the same
esthetic results face of
[27,28]. It the homologous
is also desirable to
toothintact
keep precisely often produces
the dental structureunsatisfactory
present in the esthetic
incisalresults
region[27,28]. It is also
to preserve its desirable
richness of
to keep intact
details [29]. the dental structure present in the incisal region to preserve its richness of
details [29].
Beyond the difficulty of mimicking the incisal region with ceramics and aiming for a
Beyond
minimally the difficulty
invasive approach,of mimicking the incisal
a restorative solutionregion with ceramics
for substrates and aiming
partially darkenedfor a by
minimally invasive approach, a restorative solution for substrates partially darkened by
trauma can be the manufacture of partial ceramic veneers covering the affected zone.
trauma can be the manufacture of partial ceramic veneers covering the affected zone.
2.2.Case
CasePresentation
Presentation
AA31-year-old
31-year-old female
female patient attended aa private
patient attended privateclinic
clinicwith
withananesthetic
esthetic complaint
complaint
regarding
regardingthethedarkening
darkening of
of the upper
upper left
leftcentral
centralincisor
incisortooth
tooth(Figure
(Figure 1a,b).
1a,b). This
This case
case
report
reportwaswasevaluated
evaluated and
and approved
approved by by the
the ethics
ethicscommittee
committeeofofthethePontifical
Pontifical Catholic
Catholic
University
UniversityofofRioRioGrande
GrandedodoSul
Sul(PUCRS)
(PUCRS)(protocol
(protocolnumber:
number:2.865.995).
2.865.995).Additionally,
Additionally,the
the patient
patient signedsigned an informed
an informed consent
consent agreeingwith
agreeing withthe
the report
report and
andexposition
expositionof ofyour
your
clinicalcase.
clinical case.

Figure 1. (a) Facial preoperative view of the smile. (b) Intraoral view revealing the darkening of the
Figure 1. (a) Facial preoperative view of the smile. (b) Intraoral view revealing the darkening of
upper left central incisor tooth. The incisal aspect of the upper left central incisor is intact, with optic
the upper left central incisor tooth. The incisal aspect of the upper left central incisor is intact, with
and morphological properties homologous to the upper right central incisor. (c) Lateral view
optic and
showing morphological
composite resin properties
restorationhomologous to the upper
to close a diastema right central
between incisor.
the upper (c)canine
right Lateraland
viewfirst
showing
upper rightcomposite
premolar.resin
(d) restoration to showing
Lateral view close a diastema
diastemabetween thethe
between upper right
upper canine
left and
canine andfirstfirst
upperleft
upper right premolar. (d) Lateral view showing diastema between the upper left canine and first
premolar.
upper left premolar.
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In
Inthe
theanamnesis,
anamnesis,a previous incident
a previous of dental
incident traumatrauma
of dental in her adolescence was reported.
in her adolescence was
The patient also reported having previously undergone, with a specialist,
reported. The patient also reported having previously undergone, with a specialist, unsuccessful
attempts (two)attempts
unsuccessful at bleaching
(two)and endodontics
at bleaching andbecause of obliteration
endodontics because of
of the pulp chamber
obliteration of the
and root canal (Figure 2).
pulp chamber and root canal (Figure 2).

Figure2.2.Periapical
Figure Periapical radiography
radiography showing
showing obliteration
obliteration of
of the
the pulp
pulp chamber
chamber and
and root
rootcanal
canalof
ofthe
the
upper left central incisor. Pulp sensitivity test showed positive reaction.
upper left central incisor. Pulp sensitivity test showed positive reaction.

Duringclinical
During clinicalexamination,
examination,ititwas wasobserved
observedthat thatthe
theupper
upperleft leftcentral
centralincisor
incisortooth
tooth
had been restored with a composite resin on the lingual side, showing
had been restored with a composite resin on the lingual side, showing a darkening of the a darkening of the
mid-cervical face.
mid-cervical face. Its
Its incisal
incisal aspect
aspect was
wasintact,
intact,withwithoptic
opticand
andmorphological
morphologicalproperties
properties
homologous to the upper right central incisor, in which the incisal
homologous to the upper right central incisor, in which the incisal border was within the border was within the
ideal esthetic parameters (Figure 1b). A pulp sensitivity test was carried
ideal esthetic parameters (Figure 1b). A pulp sensitivity test was carried out on the affected out on the affected
tooth, which
tooth, which responded
respondedpositively.
positively. Radiographic
Radiographic examination
examination revealedrevealed no no periapical
periapical
alteration(Figure
alteration (Figure2).2).
Theother
The otherteeth
teethwerewerehealthy,
healthy,with
withsomesomehavinghavingrestorations
restorationsmade madeof ofaacomposite
composite
resinto
resin toclose
closeaadiastema
diastemabetween
betweenthe theupper
upperright rightcanine
canineandandfirst
firstupper
upperright
rightpremolar
premolar
(Figure1c)
(Figure 1c)and
andaadiastema
diastemabetweenbetweenthe theupper
upperleft leftcanine
canineand andfirst
firstupper
upperleftleftpremolar
premolar
(Figure 1d). Clinically, gingival esthetics was also compromised,
(Figure 1d). Clinically, gingival esthetics was also compromised, causing disharmony in causing disharmony in
relationto
relation tothe
theupper
upperlip. lip. The
The functional
functional anterior
anterior and andlateral
lateraldislocation
dislocation guides
guides were
werein in
agreement,with
agreement, withaamutual
mutualbalanced
balancedocclusion.
occlusion.
Theesthetic
The estheticplanning
planningbegan beganbyby taking
taking photographs
photographs of of
thethe
faceface
andand intraoral
intraoral (Figure
(Figure 3),
followed by aby
3), followed virtual analysis
a virtual usingusing
analysis DSD DSD(Digital SmileSmile
(Digital Design) [30]. An
Design) impression
[30]. with
An impression
awith
vinylapolyxiloxane (Virtual, (Virtual,
vinyl polyxiloxane Ivoclar Vivadent, Schaan, Liechtenstein)
Ivoclar Vivadent, was performed
Schaan, Liechtenstein) was
to obtain gypsum models. Subsequently, assembly of the models
performed to obtain gypsum models. Subsequently, assembly of the models was carried was carried out in a
semi-adjustable articulator (Bio-Art, São Paulo, Brazil). Dental
out in a semi-adjustable articulator (Bio-Art, São Paulo, Brazil). Dental and gingival and gingival diagnoses
were performed
diagnoses on the models
were performed according
on the modelsto the previous
according to theplanning
previousperformed. Based on
planning performed.
aBased
guideon made of vinyl
a guide madepolyxiloxane, diagnostic
of vinyl polyxiloxane, waxing was
diagnostic waxingreproduced directlydirectly
was reproduced in the
patient’s mouth. mouth.
in the patient’s Esthetic Esthetic
and functional evaluation
and functional was obtained
evaluation at the endatbythe
was obtained mock-up
end by
with bisacrylic
mock-up withresin (Protemp,
bisacrylic resin3M Espe, St. 3M
(Protemp, Paul, MN,St.
Espe, USA).
Paul, TheMN, patient
USA).approved this
The patient
evaluation prior to the execution of the other rehabilitation procedures.
approved this evaluation prior to the execution of the other rehabilitation procedures.
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Figure 3. (a)Esthetic
Figure Esthetic planning by
by a virtual analysis using DSD (Digital Smile Design). (b) Esthetic
Figure3.3.(a)
(a) Esthetic planning
planning by aa virtual
virtualanalysis
analysisusing
usingDSDDSD(Digital
(Digital Smile
Smile Design).
Design). (b)(b) Esthetic
Esthetic
andfunctional
and functionalevaluation
evaluation by
by mock-up
mock-up withwith bisacrylic
bisacrylic resin.
resin.
and functional evaluation by mock-up with bisacrylic resin.

Initially,the
Initially,
Initially, thetreatment
the treatment
treatment consisted
consisted of
of daily
of daily
consisted homehome
daily homebleaching
bleaching with 16%
bleaching with 16%
16%carbamide
carbamide
with peroxide
carbamide
peroxide (FGM,
(FGM, Joinville, Joinville, SC, Brazil) for three weeks. Flapless gingivoplasty was then
peroxide (FGM, SC, Brazil) SC,
Joinville, for three weeks.
Brazil) Flapless
for three gingivoplasty
weeks. Flaplesswas then performed
gingivoplasty wasfor
then
performed
the esthetic for the esthetic
correction of the correction
gingival of the gingival
contour of the contour
upper ofcentral
right the upper right
incisor and central
upper
performed for the esthetic correction of the gingival contour of the upper right central
incisor
left andincisor
central upper (Figure
left central
4a) incisor
without(Figure 4a) without bone removal.
bone removal.
incisor and upper left central incisor (Figure 4a) without bone removal.

Figure 4. (a) Gingivoplasty performed for esthetic correction of the gingival contour of the upper
right central incisor and upper left central incisor. (b) Preparation of the upper left central incisor.
Figure
Greater
Figure 4.4.wear
(a)
(a)Gingivoplasty
in the cervical performed
Gingivoplasty third
performed for esthetic
for esthetic
was performed, correction
being ofof
finished
correction at
thethe
zerogingival
degrees
gingival contour
in the of
contour of the
margins
the upper
and
upper
right central
towards the incisor
incisal and upper
third. left central incisor. (b) Preparation of the upper left central
right central incisor and upper left central incisor. (b) Preparation of the upper left central incisor. incisor.
Greater wear in the cervical third was performed, being finished at zero degrees in the margins and
Greater wear in the cervical third was performed, being finished at zero degrees in the margins and
towards the incisal
After third. of gingival healing, dental preparations for the ceramic veneers
three weeks
towards the incisal third.
were made in the anterior teeth of the maxilla and premolars, except for the upper right
After
central
After three
incisor
threeandweeks of
second
weeks gingival
upper left
of gingival healing,
premolar.
healing, dental preparations
Thepreparations
dental upper forfor
right centralthethe ceramic
incisor
ceramic veneers
remained
veneers
were made
intactmade
were in
and did the anterior
not anterior
in the teeth of
receive any treatment the maxilla
because
of the maxilla and
andit didpremolars,
not show
premolars, except for
an esthetic
except the upper
for thecompromise. right
upper right
central
central incisor
Preparation ofand
incisor and second
the upper upper
secondleft leftincisor
central
left premolar. Theupper
consisted
premolar. The upper right
of greater
right central
wear
central theincisor
in incisor
cervicalremained
third
remained
intact
usingand
intact anddid
burs not
notreceive
2135/2135F,
did 1.0any
receive mmtreatment
any on average,
treatment because
beingititfinished
because didnot
did notshow
atshow
zeroanan esthetic
degree
esthetic compromise.
incompromise.
the margins
Preparation
and towardsof
Preparation of
thethe
the upper
incisal
upper left central
third, aimingincisor
central consisted
preservation
incisor of the
consisted ofofhealthy
greater
greater wear
border
wear inwithout
thethe
in cervical
wearthird
due
cervical third
using burs
to its burs
using 2135/2135F,
similarity 1.0 mm
to the homologous
2135/2135F, on
1.0 mm on tooth average, being
(Figure
average, finished at zero degree in the
4b).finished at zero degree in the margins
being margins
andtowards
and towards theincisal
Afterward,
the incisal third, aiming
the impression
third, aimingwaspreservation
performed ofwith
preservation ofthe
thehealthy border
intra-sulcular
healthy border without
cords
without wear duedue
(Ultradent,
wear
to its
South similarity
Ultradent, to the
UT, homologous
USA), tooth
intra-sulcular
to its similarity to the homologous tooth (Figure 4b).(Figure
#000, 4b).
and overlaid #1 (Figure 5a), followed by a
vinyl polyxiloxane application (Virtual, Ivoclar Vivadent,
Afterward, the impression was performed with intra-sulcular cords (Ultradent, Schaan, Liechtenstein).
South Ultradent, UT, USA), intra-sulcular #000, and overlaid #1 (Figure 5a), followed by a
vinyl polyxiloxane application (Virtual, Ivoclar Vivadent, Schaan, Liechtenstein).
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Afterward, the impression was performed with intra-sulcular cords (Ultradent,
South Ultradent, UT, USA), intra-sulcular #000, and overlaid #1 (Figure 5a), followed
by a vinyl polyxiloxane application (Virtual, Ivoclar Vivadent, Schaan, Liechtenstein). Sub-
Subsequently,
sequently, thethe provisional
provisional restorations
restorations were were obtained
obtained using bisacrylic
using bisacrylic resin (Protemp
resin (Protemp A1,
A1,3M
3M ESPE,
ESPE, St. St. Paul,
Paul, MN,MN,
USA)USA) onprevious
on the the previous silicone
silicone guide. guide.

Figure
Figure5.5.(a) Intra-sulcularcords
(a) Intra-sulcular cords positioned
positioned beforebefore impression
impression with
with vinyl vinyl polyxiloxane.
polyxiloxane. (b) Felds- (b)
Feldspathic ceramic veneer being positioned for luting procedure on the upper left incisor.
pathic ceramic veneer being positioned for luting procedure on the upper left incisor. Visible trans- Visible
transparency
parency on the incisal region can be noticed due to the methodology applied in this case promoting a case
on the incisal region can be noticed due to the methodology applied in this
promoting a ceramic
ceramic finishing linefinishing line at zero-degree.
at zero-degree.

TheTheceramic
ceramicrestorations
restorations werewere mademadeatata adental prosthesis
dental prosthesis laboratory and varied
laboratory and varied
according to the technique used. Ceramic veneers were made
according to the technique used. Ceramic veneers were made for the buccal surfaces for the buccal surfaces of of
the upper right canine, first and second upper right premolars,
the upper right canine, first and second upper right premolars, and upper left central and upper left central
incisor. Moreover, a partial ceramic veneer was obtained for the distal face of the upper left
incisor. Moreover, a partial ceramic veneer was obtained for the distal face of the upper
canine and the mesial face of the first upper left premolar. Feldspathic ceramic was chosen
left(Noritake
canine and the mesial face of the first upper left premolar. Feldspathic ceramic was
EX3, Suita, Osaka, Japan) for these teeth. A veneer covering the entire buccal face
chosen
was made(Noritake
for theEX3,upper Suita, Osaka,
left central Japan)
incisor, forathese
with greaterteeth. A veneer
thickness covering
(1.0 mm) the entire
in the most
buccal face was
chromatic area made for the upper
of the preparation, an left central incisor,
intermediate thicknesswith a greater
on the middlethickness
third (0.5 mm)(1.0 mm)
in and
the is
most chromatic
finished area ofatthe
in zero-degree thepreparation,
incisal border.an intermediate thickness on the middle
third (0.5Formm)the upper
and isleft and right
finished lateral incisors,
in zero-degree at lithium disilicate
the incisal border. ceramic veneers were
made in an HTBL3 color (e.Max Press, IvoclarVivadent, Schaan,
For the upper left and right lateral incisors, lithium disilicate ceramic Liechtenstein). Afterward,
veneers were
they received a thin layer of stratification on the buccal
made in an HTBL3 color (e.Max Press, IvoclarVivadent, Schaan, Liechtenstein). face with feldspathic ceramic
(Noritake EX3) (Figure 5b).
Afterward, they received a thin layer of stratification on the buccal face with feldspathic
The ceramic restorations were luted with Variolink Esthetic (IvoclarVivadent, Schaan,
ceramic (Noritake EX3) (Figure 5b).
Liechtenstein), neutral shade, following the adhesive luting protocol recommended by
The ceramic restorations
the manufacturer. were luted
The partial veneers withfinished
were then Variolink Esthetic directly
and polished (IvoclarVivadent,
in the
Schaan,
mouth usingLiechtenstein),
3118 FF, 3216 neutral
FF diamond shade,bursfollowing
(KG Sorensen, the Cotia,
adhesive luting
SP, Brazil) and Eveprotocol
recommended by the manufacturer.
silicon abrasives—disk format (Neureutstr, The partial
Keltern,veneers
Germany) were
in thethen finished
following andblue,
order: polished
directly
pink, andin the
graymouth
using ausing
rotation3118 FF,of3216
speed 1200FF
rpm; diamond
moreover, burs (2.5 × zoom,
(KG Sorensen,
a magnifier Cotia, SP,
ExamVision,
Brazil) and Eve Copenhagen, Denmark) was applied
silicon abrasives—disk formatfor(Neureutstr,
careful detailing. The ceramic
Keltern, Germany)veneerin the
of the upper
following left blue,
order: centralpink,
incisorandwasgray
transformed
using ainto a partial
rotation ceramic
speed veneer
of 1200 by intraoral
rpm; moreover, a
wear in the incisal third and partially in the middle third, finishing at zero degrees in the
magnifier (2.5 × zoom, ExamVision, Copenhagen, Denmark) was applied for careful
incisal direction (Figure 6). After this step, the transition between tooth and ceramic was
detailing. The ceramic veneer of the upper left central incisor was transformed into a
visually imperceptible.
partial ceramic veneer by intraoral wear in the incisal third and partially in the middle
third, finishing at zero degrees in the incisal direction (Figure 6). After this step, the
transition between tooth and ceramic was visually imperceptible.
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Figure 6. Immediate photo after luting and polishing procedures in frontal smile.
Figure6.6.Immediate
Figure Immediate photo
photo after
after luting
luting andand polishing
polishing procedures
procedures in frontal
in frontal smile.smile.
The protrusive and laterotrusive functional guides were preserved and adjusted,
resulting in TheaThe
mutually
protrusive
protrusive protected
and
and occlusionfunctional
laterotrusive
laterotrusive at the end
functional of the
guides were
guides treatment.
preserved
were After
preservedand and theadjusted,
adjusted,
treatment,resulting in a mutually protected occlusion at the end of the treatment.sixAfter the
the
resultingpatient
in a was instructed
mutually protectedregarding
occlusion oral
at hygiene
the end of and
the periodic
treatment. visits
After every
the treatment,
the
months, apartpatient
from
treatment, was instructed
periodic
the regarding
patientpolishing
was of oral
the hygiene
instructed partial
regarding andoral
veneerperiodic
when visits
hygiene every
considered
and sixnecessary
periodicmonths,
visitsapart
every six
from
(recommended periodic
months, annual polishing
apart visit
fromfor of the partial
ceramicpolishing
periodic veneer
polishing). when considered necessary (recommended
of the partial veneer when considered necessary
annual
Follow-up visit
wasfor
(recommended ceramic
annualpolishing).
performed 30 months
visit after polishing).
for ceramic the conclusion of the treatment, which
Follow-up
clinically demonstrated was performed
maintenance 30 months
of30the after the
ideal after conclusion
biological, of the treatment,
functional, which clin-
Follow-up was performed months the conclusion of and esthetic
the treatment, which
ically
conditions demonstrated
of the successful maintenance
rehabilitationof the ideal
treatment biological,
(Figure functional, and esthetic conditions
clinically demonstrated maintenance of the ideal7).biological, functional, and esthetic
of the successful rehabilitation treatment (Figure 7).
conditions of the successful rehabilitation treatment (Figure 7).

Figure 7.Figure
Postoperative views views
7. Postoperative after 30
aftermonths, showing
30 months, showingmaintenance
maintenanceofofthe the ideal biological,
biological,func-
functional, and esthetic
tional,
Figure and conditions.
7. esthetic
Postoperative (a)
conditions. Extraoral
after frontal
(a) Extraoral
views smile.
30frontal (b,c)
smile.
months, Lateral
(b,c)
showing extraoral
Lateral extraoralviews.
maintenance views.(d)
of the(d)Intra-
Intra-oral
ideal biological,
oral frontal photo
frontal showing
photo
functional, and maintenance
showing maintenance
esthetic of esthetic
conditions. of(a) conditions
esthetic after
conditions
Extraoral frontal re-polishing.
after re-polishing.
smile. (b,c) Lateral extraoral views. (d) Intra-
3.oral frontal photo showing maintenance of esthetic conditions after re-polishing.
Discussion
3. Discussion
Masking the remaining darkened teeth is a hard task for the clinician and labora-
3. Discussion
Masking the remaining darkened teeth is a hard task for the clinician and laboratory
tory technician. The etiology of this darkening may help predict the degree of tissue
technician. The etiologythe
Masking of remaining
this darkening may help
darkened teethpredict thetask
is a hard degree of tissue
for the response
clinician and laboratory
to the proposed interventions,
technician. The etiologysuch
of as bleaching
this procedures
darkening may help[31,32].
predictHowever,
the degreethe of degree
tissue response
to the proposed interventions, such as bleaching procedures [31,32]. However, the degree
Dent. J. 2023, 11, 101 7 of 10

response to the proposed interventions, such as bleaching procedures [31,32]. However,

the degree to which this tooth will be exactly whitened at the end of the process cannot
be defined [33,34]. In addition, recurrence of the initial color may present over the years,
or even little prediction of the results [33], requiring frequent repairs required by picky
patients. This fact contributed to choosing a definitive basis treatment in the case proposed,
with the restoration in ceramic for masking the darkened substrate. However, non-invasive
treatments should be prioritized before any definitive treatment aiming integrity of teeth;
after unsuccessful outcomes, definitive treatments should be suggested with the patient’s
agreement.
Dental trauma is one of the main causes of dental darkening [35]. Along with that, the
presence of pulp vitality is more frequently found than necrosis [6,36]. In the present case,
an endodontic treatment was attempted because the dental pulp was undergoing a sclerosis
process. However, there was a painful sensation at the moment of the coronary opening,
and the root canal obliteration was verified. Because of this, the endodontic procedure
was not carried out, but only clinical and radiographic control at the end of the esthetic
rehabilitation. Following the precepts of conservative dentistry, the integrity of the root
canal after trauma was prioritized in agreement with the literature [6].
The new approach and evolution of adhesive dentistry and new dental preparation
philosophies for enamel have caused a growing demand for highly conservative esthetic
treatments, obtaining maximum structural preservation. Considering this, the thickness
of the ceramic veneers can be reduced from the one commonly reported in dental veneers
(1–1.5 mm) to 0.3 mm [37]. At the same time, the application of these veneers can be
limited only to the specific desirable tooth area by partially covering its structure, thereby
configuring the so-called partial veneer [26]. Although its most cited indication is for
morphological adaptations [38], such as the closure of diastemas described in the present
case, the use of partial veneers involving only the cervical face of teeth has also been
reported [37]. However, such a study refers to the purpose of covering non-carious lesions
rather than changing the final tooth color obtained in esthetic treatments, which was
proposed in this case.
The choice of the ceramic type should be made based on some criteria, among them
the mechanical and esthetic properties and the processing method [39]. One complexity
presented in the skills of the case proposed was making the veneers with two ceramic
systems, which were separately implied and executed in different techniques. The systems
were represented by the feldspathic ceramic, which was manually stratified, and the injected
lithium disilicate ceramic, later characterized with pigments in the refractory die.
The lithium disilicate ceramic veneer technique was chosen for the upper left and
right lateral incisors because of its higher intrinsic mechanical resistance [40]. It is desirable
because both teeth, in this case, received an increase in their incisal heights. In the case
of the darkened upper left central incisor, feldspathic ceramics were used due to the
possibility of stratification in increments with different opacities and color saturation in
successive layers, simulating enamel and dentin [41]. This provided a better reproduction
of the characteristics of the homologous tooth through the artistically developed sculpture.
Another purpose for this tooth was to allow adequate finishing and polishing at the ceramic–
resin cement–enamel interface, a fundamental requirement in this partial veneer. Because it
contains more glass and fewer crystals, feldspathic ceramic facilitates the finishing steps in
the mouth of the beveled end of the partial ceramic veneer [41,42].
When there is an esthetic impairment on a single central incisor tooth, the use of
ceramic restorations is normally indicated in both central incisors to obtain the best esthetic
result [43]. However, aiming at a minimally invasive ideology, in the case described, a single
restoration was performed on the upper left central incisor, maintaining the integrity of the
upper right central incisor, as it had rich esthetic details that deserved to be reproduced
in its darkened counterpart. The incisal border may be considered a prime region of a
tooth that has not received attrition over the years, and as such, dentists seek to maintain
it intact [29,43]. Studies recommend an incisal reduction of around 1.5 to 2 mm as a way
Dent. J. 2023, 11, 101 8 of 10

of obtaining greater mechanical resistance and reproduction of the anatomical details in

teeth with veneers [29]. However, the upper left central incisor revealed an incisal edge
with desirable translucency, opalescence, anatomical texture, and color, and there was no
need for ceramic coating. Therefore, the preparation of the border was contraindicated.
Consequently, it was chosen the preservation of the tooth and the adaptation of a partial
veneer involving only its mid-cervical face instead of a total buccal coverage veneer.
As for the case, thin and ultra-thin veneers (0.3–0.7 mm) could not mask the color of
the darkened substrates [14,20,28,42]. Then, the dental preparation consisted of slightly
greater wear in the more saturated region in the cervical face of the tooth.
A veneer was initially made to acquire the final configuration of a single cervical
partial veneer covering the entire buccal surface. It was subsequently abraded, finished,
and polished in the incisal and middle thirds directly in the mouth after luting. Finally, it
was transformed into a partial veneer. The partial ceramic veneer consisted of a greater
thickness in the more chromatic area of the preparation and obtained a level termination in
the middle of the incisal third. The purpose of finishing and polishing with the intraoral
technique was to ensure a marginal termination at a zero-degree angle and promote the
absence of a visual luting line. This approach is efficient and innovative, but unfortunately,
there are no long-term studies up to now, and it is not a habitual clinical routine such as
procedures using composite resins, showing a limitation for this specific approach [44].
Currently, studies describe total darkened teeth treated with total veneer and not with
partial veneer, as in the present case report [45].
The success of the treatment conducted was possible due to adequate planning. Main-
tenance of the esthetic and functional requirements after 30 months and a longitudinal
follow-up of the present case proved successful. Additionally, the cooperation between pa-
tient and dentist maintaining annual appointments for re-polishing ceramics and marginal
termination is of paramount importance.

4. Conclusions
Despite the limitations of this single case report, it can be concluded that preparing a
cervical partial ceramic veneer is an innovative, viable, and safe approach after a short-term
follow-up.
Additionally, this technique demonstrated a minimally invasive approach to preserve
the incisal edge of the tooth, maintaining the natural characteristics and simplifying the
laboratory technician work, reducing the possible number of re-appointments in order
to achieve the correct tooth color and tooth morphology. However, minimally invasive
esthetic rehabilitation with conservative ceramic veneers requires adequate planning and
the appropriate skill for its success. Furthermore, long-term follow-ups and multiple cases
should be investigated in order to confirm the findings revealed in this report. Moreover,
non-invasive treatments such as bleaching protocols should be prioritized before any tooth
wear, evolving to prosthetic treatments after unsuccessful results if agreed with patients.

Author Contributions: Conceptualization, G.M.C., C.S. and J.P.A.; methodology, G.M.C., C.S. and
J.P.A.; validation, G.M.C., C.S., J.P.A., A.M.S. and M.F.K.; investigation, G.M.C., C.S. and J.P.A.;
writing—original draft preparation, C.S., J.P.A., A.M.S. and M.F.K.; writing—review and editing,
M.F.K.; supervision, A.M.S. and M.F.K.; funding acquisition, A.M.S. and M.F.K. All authors have read
and agreed to the published version of the manuscript.
Funding: This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de
Nível Superior—Brasil (CAPES)—Finance Code 001.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Committee of Pontifical Catholic University of Rio Grande do
Sul (protocol code 2.865.995/2018).
Informed Consent Statement: The patient signed an informed consent agreeing with the report and
exposition of your clinical case.
Dent. J. 2023, 11, 101 9 of 10

Data Availability Statement: All data created with this study is reported and shared in this article.
Acknowledgments: The author, M.F.K., thanks the Osteology Foundation (Switzerland) and the
Department of Biomaterials (Gothenburg, Sweden) for supporting his research.
Conflicts of Interest: The authors declare no conflict of interest.

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