CASE REPORT

Optimal Tooth Reduction for Veneer Restorations:

A Case Report
Carlos A Jurado

A b s t r ac t​
Bonding to enamel has been shown to provide reliable results, and thus conservative tooth reduction is key to the success of the ceramic
bonded veneers. The diagnostic wax is the first available to evaluate disparities between current and ideal tooth measurements. The mock-up
provides the patient with a physical perception of the size and shape of the proposed veneers. The use of reduction guides assists the clinician
in evaluating the specific amount of tooth structured to be removed during the preparation. This article demonstrates a conservative approach
to tooth preparation combining different tooth reduction guides. Long-term success of the restoration requires following well-defined protocols
for restorative material selection, conservative tooth preparation, and bonding ceramic protocols.
Keywords: Dental prostheses, Esthetic dentistry, fixed prosthodontics, Prosthodontic management.
International Journal of Prosthodontics and Restorative Dentistry (2019): 10.5005/jp-journals-10019-1244

B ac kg r o u n d​ Clinica Digital Dentistry, AT Still University, Arizona School of Dentistry

Optimal tooth reduction is a fundamental requirement for function, and Oral Health, Mesa, Arizona, USA
esthetics, and longevity in restorative dentistry, especially for Corresponding Author: Carlos A Jurado, Clinica Digital Dentistry, AT
all ceramic restorations.1 Satisfactory tooth preparation can Still University, Arizona School of Dentistry and Oral Health, Mesa,
provide uniform reduction and acceptable clearance to allow the Arizona, USA, Phone: +1 (480) 248 8152, e-mail: [email protected]
necessary thickness of the final restoration without disrupting How to cite this article: Jurado CA. Optimal Tooth Reduction for
the periodontal health and esthetics. It is highly suggested that Veneer Restorations: A Case Report. Int J Prosthodont Restor Dent
a conservative approach be used on any occasion possible as an 2019;9(3):99–103.
alternative treatment. The ability to retreat the restored tooth needs Source of support: Nil
to be considered by the clinician when choosing a conservative Conflict of interest: None
or aggressive restorative treatment, especially for young adult
patients. 2 Veneers are the most conservative fixed restoration
because they require to only remove 25–50% of the tooth structure
in comparison to full coverage crowns. 3 Furthermore, conservative
C a s e ​ D e s c r i p t i o n​
tooth reduction are mandatory to create ideal adhesion, because A female patient aged 25 years presented to the dental clinic with
excessive buccal reduction can lead to compromised bond strength the chief complaint “I do not like my smile because my teeth are
due to penetration of the dentin.4 It has been demonstrated that small and I have spaces” (Figs 1 and 2). The patient stated that
conservative restorative techniques relies on bonding and adhesive she just finished the orthodontic treatment and she was referred
luting, because intact enamel provides the most reliable substrate to close the spaces with restorations. After detailed evaluation,
for etched ceramic laminate veneers.5
Currently, it is possible to fabricate ultrathin ceramic veneers
with a thickness of 0.1–0.5 mm, which need to be bonded with
minimal or no tooth preparation in order to improve the tooth
position, color, and shape.6 Several ceramic options are available
for the clinician such as lithium disilicate, feldspathic porcelain,
feldspathic reinforced with leucite, and lithium disilicate reinforced
with zirconia. These types of ceramic materials have high proportion
of glassy matrix that produces highly esthetic results and excellent
adhesion with resin cement when treated with hydrofluoric acid
followed by silane application.7 High survival rates with low failure
numbers have been found for ceramic veneers bonded to enamel.8
Tooth reduction guides are recommended to make uniform
space for the restoration in order to avoid undesirable situations.
For fixed dental prostheses, ideal contours are established with the
diagnostic wax-up, including any modification in vertical dimension
and orientation in the plane of occlusion. Typical reduction guides
are fabricated with polyvinyl siloxane (PVS) putty impression
material or thermoplastic sheet. Fig. 1: Pre-operative photograph

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 Optimal Tooth Reduction for Veneer Restorations: A Case Report

the diagnosis was excessive space between teeth #6 to 7 and #10

to 11 (Figs 3 to 5). Patient was informed of the need to perform a
diagnostic wax-up (GEO Classic Renfert) followed by diagnostic
mock-up with self-cured temporary composite material (Protemp
Plus, 3M Espe) in order to evaluate the tentative future dimension of
the restorations (Figs 6 and 7). The diagnostic mock-up was placed
intraorally, and patient was pleased with the results and asked to
move forward. The final treatment plan included lithium disilicate
ceramic veneers on teeth #6, 7, 10, and 11. Patient was explained
that minimal tooth preparations will be performed in order to have

Fig. 2: Initial smile (upper dental)

Fig. 3: Initial intraoral view Fig. 4: Initial intraoral frontal view

Fig. 5: Initial intraoral lateral views

Fig. 6: Diagnostic wax-up

100 International Journal of Prosthodontics and Restorative Dentistry, Volume 9 Issue 3 (July–September 2019)
 Optimal Tooth Reduction for Veneer Restorations: A Case Report

Fig. 7: Diagnostic mock-up

Figs 8A to D: Different types of guides used: (A) Putty guide for mock-up and provisional restorations; (B) Clear matrix for tooth preparation
evaluation; (C) Incisal reduction putty guide; (D) Facial reduction putty guide

overall vision of the reduction, including areas not easily accessible,

such as interproximal sites. Moreover, a putty reduction guide matrix
(Hydrorise Putty, Zhermack SpA) was fabricated in order to evaluate
incisal and facial reduction, and a periodontal probe was used to
measure the reduction thickness. After minimal tooth reductions
were completed, teeth were polished and smoothed, and corners
were rounded using discs (Soft-Lex Discs, 3M ESPE), followed by
sandblasting of the teeth with water and 20-micron aluminum
oxide particles (AquaCare Aluminum Oxide Air Abrasion Powder,
Velopex) (Fig. 10). A double-cord impression technique was used,
first packing cord #00 and then #0 (Ultrapak, Ultradent Products
Inc.), and the final impression was made using light body and
heavy body consistency PVS (Virtual 380, Ivoclar Vivadent). Master
Fig. 9: Tooth reduction evaluation cast and alveolar dies were fabricated with type IV stone (Fujirock,
GC America Inc.). Ceramic veneers were fabricated out-of-lithium
the ideal space for the ceramic restorations. At the following clinical disilicate (IPS E.max Press LS2, Ivoclar Vivadent). The placement
appointment, the same previously approved mock-up of self-cured sequence of the ceramic restorations was first #6 and 7, and then #10
material was created and placed in the patient’s mouth and then and 11. The ceramic restorations received hydrofluoric acid surface
horizontal and vertical depth grooves were cut on the teeth with a treatment (IPS Ceramic Etching Gel, Ivoclar Vivadent) for 15 seconds,
round diamond bur (801 Spherical, JOTA AG). Many reduction guides, followed by rinsing and drying and then silane (Monobond-S, Ivoclar
based on the diagnostic wax-up, were fabricated; first the putty Vivadent) was applied for 60 seconds and then rinsed and dried.
guide for provisional restorations (Fig. 8A), a putty guide to evaluate The tooth surface was first treated with 32% phosphoric acid gel
incisal reduction (Fig. 8B), a clear matrix guide to evaluate the overall (Uni-Etch w/BAC, Bisco Dental) for 20 seconds and then rinsed and
preparations (Fig. 8C), and finally a putty guide to evaluate the facial gently dried. Then primer was applied (OptiBond FL, Kerr Dental),
reduction (Fig. 8D) (Figs 8 and 9). The clear matrix also allowed an with the excess being removed by air, followed by light curing (VALO
International Journal of Prosthodontics and Restorative Dentistry, Volume 9 Issue 3 (July–September 2019) 101
 Optimal Tooth Reduction for Veneer Restorations: A Case Report

Fig. 11: Final intraoral frontal view

Fig. 10: Final tooth preparations

Fig. 12: Final lateral views

Fig. 13: Final intraoral Fig. 14: Final smile (upper dental)

LED Curing Light, Ultradent Products Inc) for 20 seconds. The light
color cement (Variolink Esthetic LC, Ivoclar Vivadent) was applied
to the ceramic veneers, which were inserted onto the teeth, with
the excess cement being removed with a micro brush and floss
in the interproximal surfaces before light curing for 20 seconds
on the facial, 20 seconds on mesial, 20 seconds on distal, and 20
seconds on the incisal surface. Glycerin gel was then applied to
the ceramic surfaces in order to prevent an oxygen inhibition layer
(Liquid Strip, Ivoclar Vivadent), and the surfaces were again light
cured for 20 seconds each. Occlusion, excursive movements, and
protrusion were checked. The patient was pleased with the final
result (Figs 11 to 15). An occlusal device was provided to wear at
night in order to prevent any damage to the restorations.

D i s c u s s i o n​
This article describes how a properly planned diagnostic evaluation,
Fig. 15: Post-operative photograph thorough treatment planning, conservative tooth preparation, and

102 International Journal of Prosthodontics and Restorative Dentistry, Volume 9 Issue 3 (July–September 2019)
 Optimal Tooth Reduction for Veneer Restorations: A Case Report

ideal ceramic selection can fulfill a patient’s high expectations. and the fabrication of successful veneers. Conservative tooth
First, an additive diagnostic wax-up was made in order to perform preparation and appropriate adhesive systems should improve the
the diagnostic mock-up. The wax-up information is transferred to longevity of the restorations.
the mouth and provides the patient an opportunity to experience
a physical model of the proposed size, shade, and shade of the
final veneers.9 Upon the patient’s approval, several reduction
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