Clinical Research

Minimally invasive vertical preparation

design for ceramic veneers
Mario Imburgia, DDS
Active member of the Italian Academy of Prosthetic Dentistry (AIOP)

Angelo Canale, CDT

Davide Cortellini, DDS, DMD

University of Bern, Switzerland
Active member of the Italian Academy of Prosthetic Dentistry (AIOP)

Marco Maneschi, MD
Specialist in Odontostomatology
Active member of the Italian Academy of Prosthetic Dentistry (AIOP)

Claudio Martucci, CDT

Active member of the Italian Academy of Prosthetic Dentistry (AIOP)

Marco Valenti, DDS

Active member of the Italian Academy of Prosthetic Dentistry (AIOP)

Correspondence to: Mario Imburgia, DDS

Passaggio dei Poeti, 11 – Palermo, Italy; Tel.: office +39 091 625 3662, mobile +39 392 507 9362; Email: [email protected]

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Abstract able dental ceramics, clinicians and

technicians have materials and proced-
The esthetic treatment of anterior teeth ures at their disposal that allow them to
has always presented a challenge in restore esthetics and function through
clinical practice. With the improvement a minimally invasive approach. New-
of dental materials, many restorative generation all-ceramic restorations and
options such as composite resins, all- adhesive systems allow a greater pres-
ceramic crowns, and ceramic veneers ervation of residual hard tooth struc-
have become available. The current tures, especially with regard to single
challenge in reconstructive dentistry is elements. This article describes a ver-
to obtain excellent esthetic results while tical preparation technique for ceramic
preserving the biological structures in- veneers.
volved as much as possible. Thanks to
the introduction of high-strength etch- (Int J Esthet Dent 2016;11:XXX–XXX)

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Introduction latest-generation dual-curing composite

resin cements.
Porcelain laminate veneers (PLVs) are
a minimally invasive esthetic restorative
option with a good long-term success The preparation dilemma
rate. This treatment option has been
used due to its color stability, biocom- Tooth preparations for fixed prosthetic
patibility, mechanical properties, and fa- restorations can be performed in differ-
vorable esthetic outcome1 (Figs 1 to 3). ent ways. There are basically two kinds
The idea of minimally invasive dental of preparation: 1) preparation with a de-
restorations is essential for successful fined margin, and 2) the so-called verti-
restorations.2-4 Thus, minimum-thick- cal (or feather-edge) preparation.
ness full-ceramic restorations have been Preparation with a defined margin is
increasingly indicated.5-13 Lithium disili- traditionally performed for full-ceramic
cate ceramic, used in its monolithic form restorations. This type of preparation
and individualized with a staining tech- was originally used for prosthetics on
nique, is a material particularly suited to teeth that had been treated with resec-
situations of erosion or abrasion where it tive surgery for periodontal disease. Al-
is necessary to replace or restore dam- though vertical preparation is commonly
aged enamel through a re-enameling indicated where periodontally involved
process,14-16 or for prosthetic correc- teeth are being used as abutments for
tion of malpositioned or diastematic fixed prostheses,17-20 this approach
teeth, as well as for restorations of teeth may represent a less-invasive alterna-
incongruous in shape or color due to ex- tive to a horizontal margin in various
tended, poor-quality composite restor- clinical conditions. The vertical prep-
ations (Figs 4 to 7). This material can be aration technique, when compared to
bonded to residual enamel and dentin other preparation techniques (chamfer,
after etching the ceramic with hydro- shoulder, etc), is simpler and faster in
fluoric acid (HF) and silanization, using terms of clinical steps.

Fig 1    Rehabilitation of the anterior zone through implants and lithium disilicate veneers on teeth 1.3 and 2.3.
Fig 2   The veneers on the cast, aimed at harmonizing the morphology and improving function.
Fig 3    Follow-up after 8 years of clinical service (veneers on vertical preparation are highlighted by red
arrows).

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Figs 4 and 5    The veneers can be used to modify the morphology of the anterior teeth.

Figs 6 and 7   The veneers can be used to correct diastematic, worn, and stained teeth.

The main advantages of vertical prep- „„Possibility of positioning the final fin-
aration are: ish line at different levels, either more
„„Minimally invasive in the cervical area. coronally or more apically within the
„„Saves dental structure and allows gingival sulcus, without affecting the
enamel preservation in the cervi- quality of the restoration’s marginal
cal area. In fact, this approach may adaptation.
contribute to limiting pulpal irritation „„Possibility of modulating the emer-
in vital teeth as a consequence of gence profile.
a well-preserved pulp-preparation „„Easy and fast to execute.
distance in the cervical area, which „„Ease of impression taking.
represents the most sensitive zone „„Ease of provisional manufacturing
for the pulp.21 and finishing.

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Figs 8, 9, and 10    Preoperative views of the clinical case. The patient complained of numerous dis-
colored teeth and changes in form and color, as well as the visibility of previous restorations that were stable.

Figs 11 and 12    The clinical examination and the cast analysis help the clinician to evaluate the emer-
gence profile of the existing dentition. The lateral view of the central incisor allows the clinician to assess
whether it is appropriate to increase the emergence profile.

Moreover, the introduction of high- ing vertical preparation for lithium disili-
strength ceramics has allowed the clin- cate ceramic veneers.
ician to use this margin preparation also
in full-ceramic restorations. The verti-
cal finish line has already been tested Technique description
in vitro22,23 and in vivo24,25 with zirconia
crowns. Furthermore, in vitro26 and clin- Before starting the procedure, a care-
ical27,28 observations reported results ful esthetic and functional evaluation of
with high success rates with lithium disili- the patient must be made. In this case,
cate full crowns on vertical preparations. a carefully defined treatment plan and
No publications to date have examined good communication between the clin-
the use of vertical margins with lithium ician and the technician helped to maxi-
disilicate ceramic veneers. This article mize the efficiency of the treatment and
presents a step-by-step prosthetic tech- the predictability of the esthetic out-
nique for periodontally healthy teeth us- come29 (Figs 8 to 10).

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The clinical approach to preparation

is founded on the selective reduction of
tooth substance guided by a mock-up
that mimics the golden reference: the
wax-up itself. Regarding of thickness
control, the preparations were performed
according to the aesthetic pre-evalua-
tive temporary (APT)30-32 protocol. With
this technique, after a three-dimensional
(3D) smile design analysis, the clinician
gives all the information and clinical re-
cords to the technician to execute the Fig 13   The wax-up is only additive, with care be-
ing taken to develop the contour of the gingival third
diagnostic wax-up. A digital analysis of
so that it is as similar as possible in shape and vol-
the clinical picture is performed to evalu- ume to the gingival margin.
ate the esthetic changes. Preoperative
impressions are taken, and a wax-up is
performed.
One of the key points in developing
a proper wax-up is the evaluation of the
emergence profile. The use of this tech-
nique is particularly indicated in cases of
a semi-additive approach in the gingival
third. The clinical evaluation and the cast
analysis could give the proper informa-
tion about the possible modification of
the emergence profile (Figs 11 and 12).
The gingival third was modified to ob-
tain a contour that could mimic the mor-
phology of the gingival tissues33 (Fig 13)
and the natural light over the contoured
crown of the natural tooth (Fig 14).
This approach has several advan-
tages:
„„Improves the emergence profile of the
restoration, allowing a more natural
appearance.
„„Saves tooth structure, especially
enamel in the cervical third.
„„Reduces patient discomfort (if the
final volume of the restoration al-
lows a semi-additive approach, local
Fig 14   The crown of an intact tooth shows a slight
anesthesia is unnecessary in most overcontouring at the cementoenamel junction. (Im-
cases). age courtesy of Dr. Jordi Manauta.)

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to prepare the tooth structure, based

on the planned final tooth contours. The
tooth structure will undergo only the
most necessary and minimal prepar-
ation, or even no preparation in certain
areas, using depth cutter burs through
the APT restoration, according to the
pre-established final contour.
In the present case, starting with
round burs, the teeth were prepared to
generate 0.3  mm (gingival third), 0.5  mm
Fig 15   Through a silicone index and bisacrylic (middle third), and 0.8 mm (incisal third)
resin, morphological changes can be transferred
calibration grooves (Figs 16 to 24). The
over the existing dentition.
mock-up was removed from the teeth,
and diamond burs were used for ver-
tical preparation to remove the tooth
substance between the depth cuts. The
The wax-up is then transferred to the preparation was performed by using
mouth using a silicone index (Fig 15), a 0.12-mm diamond bur for a feather-
which is tested esthetically and func- edge margin. A retraction cord (000)
tionally. This wax-up represents the en- was placed into the gingival sulcus to
hanced natural dentition, is the corner- displace the gingival margin, and the
stone of the entire approach, and will margin was finished with a 30-µm dia-
provide critical guidelines such as the mond bur and silicone points. The final
position and length of the maxillary inci- impression was taken with a polyether
sors. In most cases, the additive wax-up material, and the provisional restoration
allows for the maintenance of the prep- (in this case, necessary) was performed
aration entirely, or at least in the major- using a scalloped silicone index and
ity of cases within enamel,34 limiting the bisacrylic composite resin.
need for immediate dentin sealing (IDS).
Moreover, besides restoring esthetics,
the restorative treatment improves the Laboratory procedure
function of the anterior guidance, which
is tried immediately after the application The definitive cast was molded and the
of the mock-up. definitive wax-up performed following
The mock-up should be tested for 1 the initial project and the clinician’s indi-
to 2 weeks to ascertain the length and cations. The key point in the laboratory
shape of the future restoration and en- procedure is starting the wax-up of the
sure that there are no interferences with gingival third before ditching the cast, so
function, phonetics, and overall patient as to have the gingival tissues as point
comfort. Once approved by the restora- of reference.
tive team and the patient, the APT res- The difference between horizontal
toration is used as a precise guideline and vertical preparations is that in the

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Figs 16, 17, and 18   The calibration grooves are made horizontally by ball diamond burs of various
thicknesses through the mock-up. Once they are made, it is useful to highlight them with a pencil.

Figs 19, 20, and 21   The residues of the mock-up are removed and the tooth substance between the
calibration grooves is removed, using a drill for a vertical preparation and taking care to change its inclina-
tion in the three thirds of the buccal surface.

Figs 22, 23, and 24    The preparations are finished and polished. After the impression taking, a direct
temporary restoration is made using the same silicone index.

former, the margin is positioned by the was performed by the technician, tak-
clinician and leaves a well-defined line ing as point of reference the cervical
on the tooth, which is then replicated in margin detected by the impression. The
the impression and the working model. emergence profile was developed fol-
In vertical preparations, the margin is lowing the profile of the gingival tissue.
positioned by the technician, based on The final wax-up was pressed and sin-
the gingival tissue information. In this tered (Figs 25 and 26), and finishing and
case, the position of the finishing line mechanical polishing were performed,

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Figs 25 and 26   The final wax-up before and after the pressing procedure.

0.3 mm

0.5 mm

1 mm

Initial Wax-up Mock-up Depth cuts

Depth cuts (after Preparation Finishing Final wax-up

mock-up removal)

Fig 27    Summary of the three main steps. Fig 28    The control of the thickness of the ceramic
veneers shows how the volume of the final restor-
ation was the same as the planned restoration.

always considering the maintenance of paid to the cervical appearance and

the planned emergence profile (Fig 27). shade transition. The thickness of the
The finished veneers were tried on the veneers, once verified by an Iwanson
tooth preparation, and the translucency gauge, was equal to the volume of the
was checked through the try-in paste of planned prosthetic restoration (Fig 28).
the luting agent. Careful attention was The emergence profile of the veneers

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Figs 29 and 30    The integration of the restoration profile must be verified on all restorations before start-
ing with the conditioning of the inner surface of the veneers and their cementation.

Figs 31, 32, and 33    The emerging profile copies and adapts to the morphology of the gingival tissues.

Figs 34, 35, and 36    The change of the emergence profile: preoperative vision after preparation and
cementation of the final restorations.

must be checked carefully before start- ed. The finishing of the margin was per-
ing with the luting procedure (Figs 29 to formed using a cutting blade, scalers,
33). and a diamond rubber point specifically
Following an adhesive protocol and for intraoral adjustment of high-strength
the conditioning of the intaglio surfaces ceramics. The same adjustment was
of the veneers, the restorations were lut- carried out for the occlusal surface. The

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Conclusion
Rehabilitation through porcelain veneers
allows for the restoration of anterior teeth
in a predictable manner. Moreover, it
provides a good esthetic outcome and
mechanical strength in the long term.
However, the finishing of the horizontal
margins of the preparations often re-
Fig 37    Postoperative view: 1-year follow-up. quires more invasive clinical steps that
are difficult to manage. The use of ce-
ramics with high resistance, the pressing
techniques, and a design of the cervical
third that mimics the morphology of the
clinical control of the emergence profile gingival tissues allow for the use of ver-
in different steps is the key point of this tical preparations for ceramic veneers.
technique. The ideal situation is a semi- Such an approach considerably sim-
additive scenario in which the controlled plifies the procedures for preparing ve-
preparation and the vertical finishing line neers, as it minimizes tooth preparation.
allow for the preservation of the enamel Although the clinical response to this
in the cervical third, as well as an im- prosthetic procedure seems to be ex-
provement of the relationship between tremely favorable, further scientific in-
the emergence profile and surrounding vestigations are needed to adequately
tissues (Figs 34 to 37), avoiding bulky confirm the long-term predictability of
veneer restorations. the proposed method.

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