Published online: 2021-10-01

THIEME
Case Report 1

Esthetic Rehabilitation of Anterior Dentition with

Different Types of Ceramic Restorations: Two Case
Reports
Michal Krump1  Zelmira Krumpova1

1 Department of Esthetic Dentistry, Private Dental Practice, Puchov, Address for correspondence Michal Krump, PhD, Private Dental
Slovak Republic Practice, Nabrezie slobody 527, 020 01 Puchov, Slovak Republic
(e-mail: [email protected]).

 Eur J Dent

Abstract All-ceramic systems represent an excellent restorative alternative for fixed dental
prostheses, single crowns, and veneers in the anterior dentition. With respect
to improved mechanical properties, lithium disilicate ceramic material provide a
broad range of indications, and extended veneers can serve as an alternative to full
Keywords crowns. Although ceramic veneers represent a more conservative approach com-
► esthetic rehabilitation pared to crowns, the correct indication is essential to achieving the ideal outcome.
► ceramic veneers The following case reports describe two types of fixed restorations of the anterior
► all-ceramic full crowns dentition: extended lithium disilicate ceramic veneers and lithium disilicate full crowns.
► lithium disilicate Factors influencing treatment selection for each type of restorations are presented.

Introduction The group of ceramic materials that contains a glass

matrix with varying amounts of crystalline mineral including
All-ceramic systems represent an excellent restorative alter-
leucite, lithium disilicate, or fluoroapatite.
native for fixed dental prostheses, single crowns, and veneers
These filler particles grow inside the glass matrix during
in the anterior dentition.1,2
the crystallization process to improve mechanical proper-
Full-coverage crowns offer predictable treatment options,
ties and to control optical effects such as color, opalescence,
but a certain amount of tooth material must be removed
translucency, and opacity.9-11
to allow space for the required thickness of the restorative
Fluoroapatite-based ceramic materials consist of fluoro-
material. Progress in adhesive technologies and in ceramic
apatite crystals in an aluminosilicate glass matrix are used to
materials strength has made possible a more conservative
restoration techniques, such as thin ceramic veneers.3-5 veneer porcelain substrates for developing the final morphol-
Silica-based all-ceramics have been proven effective in ogy and shade of the restoration.12,13
numerous long-term clinical studies as an appropriate mate- The leucite glass-ceramic material consists of a glass
rial for esthetic restorations.6-8 matrix surrounding leucite crystals. In concentrations of 35%
Feldspathic ceramics provide the best representa- to 55%, the leucite is used as a reinforcing material. Leucite
tion of the optical properties of the natural tooth. Because possesses an index of refraction similar to that of feldspathic
their mechanical properties are low (flexural strength glasses, which allows the translucency to be maintained.9,11.
of 60–70 MPa), these materials are generally used for veneer- Lithium disilicate ceramic material consists of a glass
ing to metal or ceramic substructures or for veneer fabrica- matrix highly filled with lithium silicate, with micron-size
tion by using the platinum foil or refractory die technique.9 lithium disilicate crystals in between.10,14

DOI https://doi.org/ © 2021. European Journal of Dentistry.

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2 Esthetic Rehabilitation with Different Types of Ceramic Restorations  Krump, Krumpova.

These incorporated crystals significantly increase the

materials strength (400 MPa), and despite a high crystalline
content, the low refractive index of the lithium disilicate crys-
tals allows the material to maintain a high translucency.9,15,16
With respect to this, lithium disilicate ceramic material
allow the production of thin ceramic veneers with minimum
reduction of dental tissues.4,5
In the cases of extended defect-oriented preparation
designs, lithium disilicate ceramics veneers offer an alterna-
tive to full crowns in the anterior dentition.17,18
Although ceramic veneers represent a more conservative
approach compared to crowns, the correct indication is essen-
tial to achieving the ideal outcome in terms of longevity.19,20
The following case reports describe the esthetic rehabil- Fig. 1  Preoperative labial view. Disharmony between the upper inci-
sors with insufficient length of the central incisors results in inverted
itation of anterior dentition involving both type of resto-
incisal edge configuration.
rations. The lithium disilicate ceramic material was used in
both cases because of its mechanical properties, high esthet-
ics, and abrasion compatibility with the opposing natural
dentition.21

Case Reports
Ceramic Veneers
The 30-year-old female patient presented herself for esthetic
rehabilitation of the anterior teeth. The patient’s chief
complaint was unesthetic appearance of the upper denti-
tion. First, the extra-oral clinical examination was done.
Subsequently, the intra-oral examination revealed Angle
Class I occlusion right side and half Angle Class II maloc-
clusion left side, presence of unsatisfactory Class III and IV
composite resin fillings with no carious lesions (marginal dis- Fig. 2  Preoperative intraoral view. Note the apparent unesthetic
colorations probably caused by inadequate etching or bond- appearance of the anterior dentition with unsatisfactory composite
ing around the preparation margins as well as composite resin fillings.
overhangs caused by inadequate finishing and polishing) and
length disharmony between the central and lateral incisors.
Periodontal evaluation found no pathologic probing depths. were created by respecting the axial inclinations of the
Tooth number 13 was endodontically treated with minimal tooth and were subsequently evened by using the cylindric
discoloration at the cervical area. Radiographic examina- diamond bur with larger diameter (Edenta AG). The gin-
tion revealed extended composite restorations; no carious gival margin was placed at the level of the gingival crest.
lesions and endodontically treated tooth number 13 with no The minimum reductions in tooth structure during prepara-
findings of periapical pathology. The quality of endodontic tion were as follows: cervical reduction was 0.3 mm, facial
treatment was assessed with a favorable outcome. Evaluation reduction was 0.3 to 0.5 mm, and incisal reduction with butt
of the patient’s medical history was insignificant. Based on joint design was 1.0 mm. The veneer preparation and depth
examination (age, enamel thickness, no dentin exposure, of reduction was controlled by using the silicon index.
no attrition of the palatal surfaces, and possibility to place The next phase consisted of the interproximal preparation
the preparation margins on enamel) extended ceramic with extended defect-oriented preparation design. If resin
veneers were planned to restore the teeth number 13, 12, restorations were located at the preparation margins, the
11, 21, and 22. Because of possible value mismatch caused by preparation was extended deeper into the palatal surfaces
different ceramic thickness, the extended ceramic veneer was until the margins were on sound enamel. Extra-fine finish-
used also for the restoration of the endodontically treated ing diamonds were subsequently used to obtain smooth con-
tooth number 13. Digital photography was performed to pro- tours (Edenta AG). The next phase involved the impression
vide diagnostic information to the restorative team, such as at the same appointment, using addition silicone (Variotime,
visualization and quantification of a patient’s smile (►Fig. 1 Kulzer) and a double-cord technique for gingival deflection
and ►Fig. 2). The color shade was selected by using a IPS (7 Siltrax AS, Pascal and 1 Ultrapak, Ultradent). Provisional
e.max Shade Guide (Ivoclar Vivadent). restoration was created chairside with self-curing acrylic
The first phase of the veneer preparation involved the use resin-based provisional restoration material (Structure 2SC,
of round-end diamond bur with 1.0 mm diameter (Edenta Voco). In the laboratory, the lithium disilicate ceramic (IPS
AG) to create three facial reduction grooves. The grooves e.max Press A1 HT, Ivoclar Vivadent) was used for fabrication

European Journal of Dentistry  © 2021.

 Esthetic Rehabilitation with Different Types of Ceramic Restorations  Krump, Krumpova. 3

of the veneers (►Fig. 3 and 4). The ingot was hot pressed at
915°C to flow viscously into the dental mold made by the lost
wax technique to form the restorations and was held at this
temperature for 15 minutes. The fully contoured restorations
were further characterized with stains and glazed.
After 7 days (the time between the final impression and
cementation), the provisional restoration was removed and
luting procedures were initially performed by using a try-in
test paste to select the best shade option (Variolink Esthetic
Try-In-Paste, Ivoclar Vivadent). The interior surfaces of the
veneers were etched with 9% buffered hydrofluoric acid
(Porcelain Etch, Ultradent Products, Inc.) for 20 seconds to
create surface roughness, followed by rinsing and air-drying.22
A silane agent was then applied to the etched ceramic
Fig. 3  Labial view of lithium disilicate ceramic veneers.
surface of the veneers and air-dried (Monobond plus, Ivoclar
Vivadent). The gingival displacement was acquired by using a
retraction cord (7 Siltrax AS, Pascal). Subsequently, adequate
surface treatment for the dental tissues was done. The teeth
were cleaned by using fluoride-free cleaning paste (Proxyt,
fluoride-free prophy paste, Ivoclar Vivadent), rinsed, and
then air-dried. Subsequently, the teeth were etched with 35%
phosphoric acid for 15 seconds (UltraEtch, Ultradent), and
after rinsing and air drying, a light curing adhesive was
scrubbed into the preparation surface for 20 seconds
and then dispersed with compressed air until an immo-
bile film layer results (Adhese Universal VivaPen, Ivoclar
Vivadent). Polymerization was performed for 10 seconds
(1,400 mW/cm2). The light-cured composite cement in neu-
tral shade (Variolink Esthetic LC neutral, Ivoclar Vivadent)
was applied onto prepared internal surface of each ceramic
veneer that were gently seated with finger pressure. The Fig. 4  Palatal view of lithium disilicate ceramic veneers. Note the
excess cement was polymerized for 2 seconds and then preparation based on the extension of the pre-existing composite
resin fillings and preparation margins located exclusively in enamel.
removed with a scaler. Immediately after excess removal, the
restoration margins were covered with glycerine gel (Liquid
Strip, Ivoclar Vivadent) and polymerized from the facial, lin-
gual and incisal aspects for 10 seconds each (light intensity
of 1,400 mW/cm2, Valo Cordless, Ultradent). After polymer-
ization, the retraction cord and excess polymerized cement
was removed. Finally, the margins were finished with carbide
bur (Edenta AG) and polished with rubber points (Kenda)
(►Figs.  5, 6 and 7). The follow-up was performed 1 month
after cementation and then annually.

All-Ceramic Full Crowns

The 40-year-old female patient sought treatment com-
plaining about the esthetic of the maxillary anterior teeth
(►Fig.  8 and 9). The patient’s chief complaint was unat-
tractive smile. The extra-oral and intra-oral clinical exam- Fig. 5  Final result 1 month after cementation. Note the harmonious
association of incisal edges of upper anterior teeth with the lower lip
inations were performed and revealed half Angle Class III
during moderate smiling.
malocclusion right side and half Angle Class II malocclusion
left side, good oral hygiene, unsatisfactory composite resin
fillings (composite overhangs), discolored teeth due to root periapical pathology. The quality of endodontic treatments
canal treatment (12, 11, and 22), and teeth misalignments was assessed with a favorable outcome. Evaluation of the
with length disharmony between the central and lateral inci- patient’s medical history was insignificant. Based on exam-
sors. No periodontal problems or carious lesions were found. ination (teeth discolorations, endodontically treated teeth,
Radiographic examination revealed extended composite res- dentin exposures, teeth misalignments), the all-ceramic
torations of the upper incisors, endodontically treated teeth full crowns were planned to restore all maxillary incisors.
number 12, 11, and 22 with no findings of carious lesions or The diagnostic wax-up model was fabricated to provides a

European Journal of Dentistry  © 2021.

4 Esthetic Rehabilitation with Different Types of Ceramic Restorations  Krump, Krumpova.

three-dimensional view of the future restoration. Diagnostic

wax-up model improve communication between the restor-
ative team and the patient. The silicone index fabricated
according to diagnostic wax-up allows the clinician to control
the amount of tooth reduction during preparation.
The first phase involved the selection of the color
shade using a IPS e.max Shade Guide (Ivoclar Vivadent).
Subsequently, the digital photography was performed to pro-
vide diagnostic information to the restorative team.
The crown preparation involved the use of a round-end
diamond bur (Edenta AG) to create three facial reduction
grooves respecting the axial inclinations of the tooth. The bur
was positioned on the facial cervical area so that the reduc-
tion would end at half of the bur’s diameter. The grooves were
Fig. 7  Intraoral view of left side. 18-month follow up of the ceramic
subsequently evened by using the cylindric diamond bur veneers showing a favourable periodontal situation.
(Edenta AG). The gingival margin was prepared to 1.5 mm
chamfer and was positioned 0.5 mm subgingivally. The depth
of reduction was controlled by using the silicone index fab-
ricated according to a diagnostic wax-up. Subsequently, the
3-mm incisal reduction was carried out. The next phase con-
sisted of the interproximal and palatal wraparound. A thin
tapered diamond bur was used to create an interdental space
for the application of a larger diamond bur for the wrap-
around (Edenta AG). Subsequently, a round-end and ovoid
diamond burs were used for the palatal reduction (Edenta
AG). Extra-fine finishing diamonds were used to eliminate
sharp angles and obtain smooth contours (►Fig. 10).
The next phase involved the impression at the same
appointment, using addition silicone (Variotime, Kulzer) and
a double-cord technique for gingival deflection. Compression
cord with a small diameter was placed at the bottom of the
sulcus (7 Siltrax AS, Pascal). Next, a more superficial thicker Fig. 8 Intraoral frontal view of the anterior dentition. Note the
unsatisfactory composite resin fillings, dentin exposures on teeth 12
deflection cord was inserted in the entrance of the sulcus
and 22 and discolored teeth due to root canal treatment.
(1 Ultrapak, Ultradent). Gingival deflection was carried out
for 5 minutes to allow the deflection cord to expand by water
sorption. Before the impression was taken, the deflection cord
was removed to obtain deflected sulcus, which allows pene-
tration of the light-body impression material into the sulcus,
beyond the preparation margins. Provisional restoration was
created chairside with self-curing acrylic resin-based provi-
sional restoration material (Structure 2SC, Voco).

Fig. 9  Intraoral lateral view of the anterior dentition. Note the teeth
misalignments with length discrepancies.

In the laboratory, the lithium disilicate ceramic (IPS e.max

Press A1 LT, Ivoclar Vivadent) was used for the fabrication
of the frameworks, which were consequently veneered by
Fig. 6  Intraoral view of right side. 18-month follow up of the ceramic
using the layering technique (IPS e.max Ceram). The time
veneers showing a favourable periodontal situation. between the final impression and cementation was 10 days.

European Journal of Dentistry  © 2021.

 Esthetic Rehabilitation with Different Types of Ceramic Restorations  Krump, Krumpova. 5

Fig. 10  Prepared upper incisors. Fig. 13  Two-year follow up of ceramic crowns.

Discussion
Silica-based all-ceramics have been proven effective in
numerous clinical studies as an appropriate material for
esthetic single tooth restorations.17,23-25 Ceramic veneers are
considered advantageous for maintaining tooth vitality and
preserving hard tissues.26
Full crown preparations require removal of 63 to 72% of
tooth structure, while veneers require removal of only 3 to
30% of tooth structure.27
On the other hand, the patient-related factors as well as
amount and quality of remaining tooth tissue should be pre-
cisely evaluated when choosing between all-ceramic crowns
Fig. 11  Postoperative frontal view 1 month after definitive place- and extended veneers.19
ment of the crowns (IPS e.max Press, LT- framework, IPS e.max The veneer preparation should be confined primarily
Ceram-veneering ceramic). within the enamel or should display a substantial (50–70%)
enamel area, especially at the preparation margins.
Debonding of ceramic veneers has been reported when
dentin comprises 80% or more of the tooth substrate. In con-
trast, debonding is highly unlikely when the preparation
margins are placed in enamel.19,28,29
Therefore, the longevity of all-ceramic restorations can be
compromised in elderly patients because of enamel thick-
ness, which diminishes over time. Especially, cervical area of
the tooth may have little or no enamel. Moreover, there may
be an increased load due to the lack of posterior dentition
as well as risk of the microleakage incidence related to root
dentin exposure.19,28
Further, the condition of the tooth in terms of whether the
tooth is vital or endodontically treated should be taken into
consideration. Meijering et al demonstrated that veneers on
Fig. 12 Postoperative lateral view 1 month after definitive place-
ment of the crowns.
nonvital teeth show higher risk to fail than veneers placed
on vital teeth.30 Another long-term study by Beier et al also
demonstrated that veneers on nonvital teeth showed a sig-
Except for adhesive (Multilink Primer, Ivoclar Vivadent) nificantly higher failure risk.31 In contrast, von Stein-Lausnitz
and luting system (Multilink Automix transparent, Ivoclar et al indicated that in endodontically treated maxillary cen-
Vivadent) used for the cementation of the crowns, the next tral incisors with Class III defects, less invasive veneers appear
clinical steps (try-in, surface treatment, finishing and pol- to be more beneficial than ceramic crown restorations.32
ishing) were performed similarly as described in the previ- The presence of tooth discoloration is common for nonvital
ously presented case report. The follow-up was performed teeth. Due to the thinness, the masking ability of the ceramic
1 month after cementation and then annually ( Figs. 11, 12 veneers is limited.33 Therefore, more reduction of the hard
and 13). tissues may lead to better esthetic result of the full-crown

European Journal of Dentistry  © 2021.

6 Esthetic Rehabilitation with Different Types of Ceramic Restorations  Krump, Krumpova.

restorations. When the ceramic veneers and full-crowns 13 Gracis S, Thompson VP, Ferencz JL, Silva NR, Bonfante EA. A
are used simultaneously in rehabilitation of anterior teeth, new classification system for all-ceramic and ceramic-like
restorative materials. Int J Prosthodont 2015;28(3):227–235
the value mismatch could be evident because of different
14 Oh SC, Dong JK, Lüthy H, Schärer P. Strength and microstruc-
ceramic thickness. Therefore, if discolored abutment tooth is ture of IPS Empress 2 glass-ceramic after different treatments.
presented, all other teeth should be restored with the same Int J Prosthodont 2000;13(6):468–472
system to achieve a harmonic esthetic outcome.19 15 Zarone F, Ferrari M, Mangano FG, Leone R, Sorrentino R.
Digitally oriented materials: focus on lithium disilicate ceram-
ics. Int J Dent 2016;2016:9840594
Conclusion 16 Albakry M, Guazzato M, Swain MV. Biaxial flexural
strength, elastic moduli, and x-ray diffraction characteri-
These case reports demonstrated two types of fixed resto- zation of three pressable all-ceramic materials. J Prosthet
rations of the anterior dentition-extended ceramic veneers Dent 2003;89(4):374–380
and full-coverage crowns. 17 Guess PC, Stappert CFJ. Midterm results of a 5-year prospec-
When selecting an appropriate treatment, ceramic veneers tive clinical investigation of extended ceramic veneers. Dent
should only be chosen when bonding is a completely feasible Mater 2008;24(6):804–813
18 Christensen GJ. Facing the challenges of ceramic veneers. J Am
option. In the cases, when this attribute cannot be achieved
Dent Assoc 2006;137(5):661–664
(e.g., reduced enamel area-extensive composite restorations or 19 Silva JSA, Rolla JN, Edelhoff D, Araujo E, Baratieri LN.
dentin exposures, especially at the preparation margins; highly All-ceramic crowns and extended veneers in anterior den-
discolored teeth, when large amounts of enamel must be tition: a case report with critical discussion. The American
prepared to obtain the sufficient thickness and masking abil- Journal of Esthetic Dentistry 2011;6:60–70
20 Elderton RJ. Clinical studies concerning re-restoration of teeth.
ity of the ceramic material; significant teeth misalignments)
Adv Dent Res 1990;4:4–9
all-ceramic crowns seems to be the better treatment option. 21 Silva NR, Thompson VP, Valverde GB, et al. Comparative
reliability analyses of zirconium oxide and lithium dis-
Funding
ilicate restorations in vitro and in vivo. J Am Dent
None. Assoc 2011;142(Suppl 2) :4S–9S
22 Sudré JP, Salvio LA, Baroudi K, Sotto-Maior BS,
Conflict of Interest
Melo-Silva CL, Souza Picorelli Assis NM. Influence of sur-
None declared. face treatment of lithium disilicate on roughness and bond
strength. Int J Prosthodont 2020;33(2):212–216
23 Land MF, Hopp CD. Survival rates of all-ceramic systems dif-
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European Journal of Dentistry  © 2021.