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Case Reports in Dentistry

Volume 2017, Article ID 3801419, 6 pages
https://doi.org/10.1155/2017/3801419

Case Report
A Step-by-Step Conservative Approach for CAD-CAM
Laminate Veneers

Gerardo Durán Ojeda,1 Ismael Henríquez Gutiérrez,1 Álvaro Guzmán Marusic,1

Abelardo Báez Rosales,2 and José Pablo Tisi Lanchares1
1
Health Sciences Faculty, Universidad Arturo Prat, Iquique, Chile
2
Restorative Dentistry Department, Andrés Bello University, Viña del Mar, Chile

Correspondence should be addressed to Gerardo Durán Ojeda; [email protected]

Received 13 March 2017; Accepted 2 July 2017; Published 13 August 2017

Academic Editor: Mariano A. Polack

Copyright © 2017 Gerardo Durán Ojeda et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

The use of CAD/CAM technology has allowed the fabrication of ceramic restorations efficiently and with predictable results.
Lithium disilicate is a type of glass ceramic material that can be used for the elaboration of laminate veneers, being monolithic
restorations which require characterization through a covering ceramic in order to achieve acceptable esthetic results. The next
case report shows a predictable clinical protocol for the rehabilitation of the anterior teeth through the preparation of CAD/CAM
veneers (e.max CAD, Ivoclar Vivadent, Liechtenstein) which have been characterized by a nanofluorapatite ceramic (e.max Ceram,
Ivoclar Vivadent, Liechtenstein) through the layering technique.

1. Introduction final translucency of the restoration. Finally, the quantity of

crystals and the flexural strength increases to 70% in volume
Glass ceramic materials have been widely used to restore and to 360–400 Mpa, respectively [3, 8].
enamel loss due to its mechanical and optical properties [1, 2]. At this point, the final restoration may not have the ideal
This restorative material, used for the indirect method, can tooth optical properties. In this case, there are three methods
be processed by traditional laboratory procedures, which is a for the characterization of the incisal third: (a) cut-back
highly sensitive technique or CAD/CAM technology [3, 4]. technique; (b) staining technique; and (c) layering technique.
The use of CAD/CAM nowadays is a useful tool that The present case report shows a step-by-step procedure
allows digital impression taking, digital design as part of of CAD/CAM lithium disilicate veneers characterized with a
the treatment planning, and the elaboration of monolithic final layering technique with nanofluorapatite ceramic.
restorations for ceramic materials, used most recently in the
field of ceramic veneers [5–7]. 2. Case Report
For the elaboration of ceramic laminate veneers, lithium
disilicate is a ceramic reinforced material which can be 2.1. Case Presentation. A 27-year-old female patient pre-
processed by CAD/CAM systems or through the press sented to the private practice of one of the authors with a main
technique. In case of CAD/CAM, this material is presented complain of dental erosion and attrition and size disharmony
as blocks of lithium metasilicate in a precrystallized state of the maxillary anterior dentition (Figure 1).
which contains cores of lithium metasilicate and disilicate,
reducing its flexural strength to 130 ± 30 Mpa. This allows 2.2. Treatment Planning. After a thorough clinical exami-
the milling process, in which the shape of the restoration is nation, a digital smile design was performed to decide the
obtained. Then, the ceramic is recrystallized at 850∘ C for 20 correct anterior tooth proportions (Figure 2) which includes
to 25 minutes. During this procedure, the lithium metasilicate tooth 14 to tooth 24. This design was transferred to a diag-
dissolves and the lithium disilicate crystalizes, obtaining the nostic wax-up in which the enamel loss could be appreciated
2 Case Reports in Dentistry

Figure 1: Intraoral image, showing disharmony in position and size, Figure 5: Mock-up with bisacrylic resin (Luxatemp Star A1, DMG).
dental attrition, and erosion. Notice the shape, which is the same as the DSD planning.

Figure 2: Digital smile design (DSD). Planning of the anterior teeth Figure 6: Orientation grooves for the vestibular reduction.
proportions for the wax-up.

Figure 7: Vestibular reduction until the painted grooves are

Figure 3: Wax-up, identical in form from the DSD.
removed; this ensures a controlled reduction for the ceramic space.

grooves (868B.314.018, Komet) for the vestibular reduction

(Figure 6) through the bisacrylic material. Every groove was
marked with a graphite pencil. Then, a tapered shape bur was
used to complete vestibular reduction (6850.314.016, Komet)
until every marked groove was removed (Figure 7). 1,5 mm
grooves for the incisal reduction were done, followed by the
proximal preparation, which was made with an 8850.315.016
Figure 4: 3D resin model obtained from the wax-up scanning. tapered diamond bur, and finally, a diamond disc (952.180
+ 310.204, Komet) was necessary for the elimination of the
contact point between 11 and 21 tooth due to a misalignment
by the amount of wax over the cast model (Figure 3). Once problem. An image for the all tooth preparations after
the wax-up was done, it was digitalized with a model scanner polishing can be shown in Figure 8.
(dental wings 3 series) and printed into a 3D resin model
(PASTCure Model 310) (Figure 4), in which a silicone matrix 2.4. Impression Procedure and Fabrication of Laminate
was fabricated for the mock-up technique. The mock-up was Veneers. A retraction cord was placed into every sulcus of the
done with bisacrylic material (Luxatemp Star A1, DMG) and prepared tooth (000, Ultrapak, Ultradent Products Inc.). 3D
is shown in Figure 5. digital impression was performed using an optical intraoral
scanner (MHT IntraOralScanner, MHT Optic Research,
2.3. Tooth Preparations. Once the mock-up was approved by Zurich, Switzerland) and then digitalized (Figures 9 and 10).
the patient, the preparations were performed. This was made The software used for the restorations design process was
using the mock-up as a guide for a controlled preparation [9]. ExoCad DentalCAD (White Peaks Dental Systems GmbH &
A diamond bur kit for laminate veneers was used (Ceramic Co. KG), which created eight veneer restorations from tooth
Laminate Veneers Kit. Ref. 9933K3 000, LOT. 797593, 14 to tooth 24. The milling unit used in this case was Roland
Komet). The first step includes the creation of orientation DWX-4W (DWX-4W, Roland Easy Shape Dental Solutions,
Case Reports in Dentistry 3

Figure 8: Finished tooth preparations. Figure 10: Digital model with the finished preparations for the
ceramic digital design.

Figure 9: Intraoral scanning. Figure 11: Milled e.max CAD blocks.

light (Vivapad, Ivoclar Vivadent, Liechtenstein, Germany)

Australia), which milled eight IPS e.max CAD HT-A1 blocks (Figure 15).
(Ivoclar Vivadent, Liechtenstein, Germany). The immediate
result of the milling process is shown in Figure 11. Then, every
milled block was layered with a nanofluorapatite ceramic 2.6.2. Treatment Surface of the Prepared Tooth. All surfaces of
for the final incisal edge optics (IPS e.max Ceram, Ivoclar prepared tooth were in enamel. A phosphoric acid etching gel
Vivadent, Liechtenstein, Germany) (Figure 12). The final at 37% was applied in all the prepared surfaces for 30 seconds
result of the sintering and glaze procedure is shown in (Ultraetch, Ultradent Products, Inc.), and the acid was rinsed
Figure 13. off with water for 30 seconds. A thin layer of adhesive was
applied in the tooth surface (Bottle 2, Adhesive, OptiBond
FL, Kerr) (Figure 16), gently air-dried, and light-cured for 20
2.5. Try-In Procedure. Each restoration was tested into their seconds.
corresponding preparation for fitting. Try-in pastes were used The resin cement of choice in this case is a light curing
to select the color of the resin cement, always in consideration agent, which has no amines. This allows the final color of
with the patient needs and expectations. In this case, value +2 the cemented restorations to be stable in time. The veneers
of Variolink Veneer resin cement system was used (Try-In +2, were taken out from the pad and charged with resin cement
Variolink Veneer, Ivoclar Vivadent, Liechtenstein, Germany) in the intaglio surface (Value +2, Variolink Veneer, Ivoclar
(Figure 14). Vivadent, Liechtenstein, Germany) and then positioned with
continuous digital pressure into their correspondent tooth.
2.6. Cementation Procedure. The treatment surfaces can be The excess of cement was removed with a brush (Figure 17)
divided into two: (a) the treatment surface of the laminate and light-cured for 10 seconds (Bluephase, Ivoclar Vivadent,
veneers and (b) the treatment surface of the tooth prepara- Liechtenstein, Germany), and this ensures the positioning
tions. This procedure was done under rubber dam isolation, and fitting of the restoration. Finally, a thin layer of glycerin
which ensures the quality of bonding and allows clean and was putted into the interphase and then light-cured again
visible surfaces for cementation. for 60 seconds in every side of the tooth to ensure the
elimination of the oxygen inhibition layer (Figure 18). The
2.6.1. Treatment Surface of the Laminate Veneers. The treat- final excesses were removed using a scalpel blade number
ment of the intaglio surface of the lithium disilicate veneers 11 (Figure 19) and then the surface was polished. The
starts with the partial dissolution of the ceramic glass content immediate result of this clinical case after the cementation is
with 5% hydrofluoric acid for 20 seconds (Power C Etching shown in Figure 20. 11-month control pictures are shown in
5%, BM4, Florianópolis, Brazil), then the acid was rinsed Figure 21.
off with an air water spray for 30 seconds [10], and silane
coupling agent was applied in a thin layer (Monobond Plus, 3. Discussion
Ivoclar Vivadent, Liechtenstein, Germany) and heated at
100∘ C for 1 minute. A final thin layer of bis-GMA bonding The present article shows a conservative approach for the
agent was applied (Heliobond, Ivoclar Vivadent, Liechten- management of enamel loss in a predictable and conservative
stein, Germany) without light curing and protected from the way.
4 Case Reports in Dentistry

(a) (b) (c)

Figure 12: Ceramic layering technique. (a) The fitting of the veneers is being checked. (b) Power Dentin (IPS e.max Ceram) is being applied.
(c) A final layer application of Power Enamel (IPS e.max Ceram).

low translucency, and MO: medium opacity), colors (20

colors for HT and LT and 5 for MO) and two shapes of
blocks according to the manufacturer information allows an
extended clinical indication with several restorative possi-
bilities for the anterior region. The flexural strength of the
final laminate veneer restoration is approximately 360 MPa
[14], which is sufficient to cover the optical and functional
needs for this clinical case [15]. Other ceramic CAD-CAM
Figure 13: Finished ceramic veneers and vestibular and intaglio systems based on zirconia-reinforced lithium silicate have
surface view. been used for the elaboration of laminate veneers [6].
VITA Suprinity (VITA) and Celtra Duo (Dentsply) are
both two types of glass ceramic with improved mechanical
properties, which can also be considered to restore the
posterior teeth, but these new ceramics have only two types
of translucency (HT and T for VITA Suprinity; HT and
LT for Celtra Duo), with less number of colors and shapes
of the blocks, having less clinical potential in comparison
with the IPS e.max CAD system, even in those cases where
the dental substrate must be masked by a medium opacity
ceramic.
Figure 14: Try-In +2 value.
The selected technique for the veneers finalization cor-
responds to a layering technique, which allows obtaining a
tridimensional effect that simplifies the correction of texture
CAD/CAM technology has been a recently incorporated and shape. On the other hand, the staining technique is very
technology in dentistry, reducing the time of fabrication common and its real advantage for the characterization and
of ceramic restorations; this clinical advantage has allowed application of stains in the ceramic surface is the ease and
clinicians to make chairside restorations in a single session speed with which it can be realized; even so, it is a superficial
[11, 12]. In this case report, the restoration of the tooth initiates pigmentation, which can be removed if the shape or texture
from the digitalization of the wax-up. This information is must be corrected in some cases, constituting a great dis-
then tested through the mock-up phase until the final ceramic advantage. In the layering technique, as the characterization
restorations are fabricated, always keeping the identical is given by ceramic masses, the modification of the shape
shape from the deciding design in every step during the or texture of the restoration is not as critical as the staining
treatment. technique, being the technique of choice for the similarity of
Lithium disilicate ceramic veneers processed through natural teeth in this case [16, 17].
CAD/CAM systems are monolithic restorations [3, 13], which Adhesive resin materials, such as those used for cement-
means that the final shape of the restoration will be obtained ing laminate veneers, require a dry environment because
in a single ceramic material and which usually lacks the most saliva, blood, and gingival fluids can destabilize the adhesive
common effects of the incisal edge of the anterior dentition phase between resin-based materials and tooth structure,
such as opalescence, counter-opalescence, different kind of either enamel or dentin [18, 19]. In order to prevent this prob-
characterizations like white spots, and well-defined mamelon lem, the authors suggest performing rubber dam isolation
[1]. to avoid this contamination of the enamel bonding surface,
The advantages of the IPS e.max CAD system includes a allowing a clean restorative environment, with a correct
reduced number of clinical appointments, with these ceramic visualization of the gingival margin during the adjustment of
veneers being made in one single session (chairside). The the veneer restorations, and finally to facilitate the removal of
variety of translucency blocks (HT: high translucency, LT: excess cement as shown in Figure 19.
Case Reports in Dentistry 5

(a) (b) (c)

Figure 15: Ceramic treatment surface. (a) The conditioning of the veneer with 5% hydrofluoric acid for 20 seconds. (b) Silane application
(Monobond Plus, Ivoclar Vivadent, Liechtenstein, Germany). (c) Application of bonding agent (Heliobond, Ivoclar Vivadent, Liechtenstein,
Germany).

(a) (b) (c)

Figure 16: Treatment of the enamel surface for bonding. (a) Tooth 11 under rubber dam isolation. (b) 37% phosphoric acid etching. (c)
Bonding application.

Figure 18: Light curing of the ceramic in position.

Figure 17: Excess cement removal with a brush. The cement used
was value +2 from Variolink Veneer system (Ivoclar Vivadent,
Liechtenstein, Germany).

4. Conclusions
Within the limitation of this article, the authors recommend
the need to finish monolithic CAD/CAM restorations with
nanofluorapatite ceramics to ensure the final esthetic results
and the optimal reproduction of details of the characteristics Figure 19: Magnified image showing the elimination of excesses
of the incisal third in the anterior teeth. with a number 11 scalpel.
6 Case Reports in Dentistry

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