Invasive lumineer prosthodontic correction of malaligned teeth

Case Report Invasive lumineer prosthodontic correction of malaligned teeth Hem Chand 1, Sivanagini Yalavarthi 2, Ashish R. Jain 2 * ABSTRACT Laminate veneers are one of the most conservative techniques when compared to all other kinds of prosthodontic restorations. Making veneers with porcelain supplement will minimize the amount of tooth reduction and bacterial accumulation, also improve esthetics, and allow to provide life-like tooth structure in the name of shade and shape of the tooth. Till now, various designs were been explained by various authors, majorly concentrating on maximum tooth preservation and minimal intervention techniques. Here, in this article, we aimed at presenting two cases in which lumineers were been chosen as the treatment option considering the age of the patient, esthetic requirements, and time consumed for the treatment. Two different clinical conditions are presented here to illustrate the esthetic outcome of lumineers with minimal intervention. KEY WORDS: Lumineers, Minimal intervention, Porcelain crowns INTRODUCTION The patients knowledge about cosmetic dental procedures has changed dramatically in the past 10 years. In prior times, it would be pressed to find a patient who could tell you what a veneer was. Today, patients are calling and asking for them by name: Lumineers, [1] Da Vinci veneers, [2] durathin, [3] emprethin, and empress veneers. Along with patients knowledge, their esthetic demands have increased as well. As dentists, we have found ourselves in a situation where patients are requesting not to have their teeth drilled, while expecting the end result of a cutback and layered ceramic that typically requires removal of tooth structure. In the past, there have been very few options for dentists to provide ultra-thin minimal and nopreparation veneers. Powder and liquid or stacked veneers [4] have been one of the original ultra-thin restorations available. Their advantages have been the ability to modify opacities within the same restoration, ability to add internal coloring, [5] and layering and Access this article online Website: jprsolutions.info ISSN: 0975-7619 working with an artistic ceramist to fabricate them. Disadvantages have been marginal integrity, wear compatibility, strength, and difficulty. Lumineers have had the market cornered in branding over the past few years, and dentists have felt this is their only option to satisfy their parents desire for minimally invasive dentistry. [6] The advantages of lumineers are name recognition and manufacturers marketing. The disadvantages in the past have been lack of doctor-ceramist interaction, no choice in ceramist, and lack of vitality. With less than optimal results, dentists and ceramists alike have pushed to provide materials that will satisfy the patients minimally invasive demands while providing the results dentists strive to achieve. [7] Cerinate lumineers that are considered one of the best following the no-preparation technique introduces an alternative to traditional veneers that can be easily marketed and implemented to a versatile age group. [8] The advantages of this system are that the lumineers can be made as thin as a contact lens and may be placed over existing teeth without having to remove healthy tooth structure. In cases, where tooth reduction is necessary, it can be kept conservative. [9] These properties attract many seniors who may be concerned about complications with their medications 1 Department of Prosthodontics, Siddhartha Institute of Dental Science, Chinoutpalli, Gannavaram Mandal, Andhra Pradesh, India, 2 Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha University, Poonamallee High Road, Chennai 600 077, Tamil Nadu, India. Phone: +91-9884233423. E-mail: dr.ashishjain_r@yahoo.com Received on: 19-07-2018; Revised on: 20-08-2018; Accepted on: 25-09-2018 3391

to local anesthetic or about general health during a routine dental procedure. This approach, frequently referred to as the nopreparation technique, [10] characterized by little or no preparation of the teeth. In many cases, there is literally no preparation of the teeth, and in some cases, there is minor adjustment of the enamel at selected locations. Either way, this approach to veneers is highly simplified and preserves natural tooth structure. [1] CASE REPORT Case 1 A 20-year-old female patient came to the department with the chief complaint of malaligned front teeth and unesthetic smile as the major concern [Figures 1.1 and 1.2]. After diagnosing the patient, all the treatment options were been explained to the patient in detail. As the patient needs the treatment as the earliest and also considering the severity of malocclusion, the innovative technique of lumineers was followed to correct the malalignment. Minimal preparation would have been demanded in this case minimizing the substantial reduction of sound tooth structure. A step-by-step procedure was followed to reach the needs of the patient. Initially, the impression was taken and the diagnostic mock-up was done. Keeping this as guide everything was planned. Diagnostic mock-up was done directly for the maxillary central incisors closing the spaces with composite [Figure 1.3]. This helps in clinical guidance and also to show the patient roughly the outcome of the treatment. Lumineers are been prepared and they have been prepared on the die-sectioned model [Figures 1.4-1.7]. Ceramics are treated with hydrofluoric acid at 9.7% for 90 s. Cleaned with phosphoric acid 37% for 2 min and then with an ultrasonic bath for 5 min in alcohol. After this, a silane agent is applied to the surface. This treatment perfectly cleans the etched ceramic surface and achieves a mean microtensile bond strength of 46.3 Mpa. Magne P, Cascione D, 2006. Patient s mouth has been prepared initially by cleaning the tooth surface [Figure 1.8] followed by application of rubber dam [Figure 1.9]. Then, the surface of tooth is acid etched [Figure 1.10] followed by the application of primer, adhesive, and bonding agents in a succeeding manner on the tooth surface [Figures 1.11-1.13]. The resin cement is mixed and applied on the lumineer surface to tack it in place using plasma arc curing tooth surface to polish the lumineer over the tooth [Figures 1.14-1.16]. The surface of the lumineer is polished by removing the excess material from the tooth using a probe and floss is used to cleanse the interproximal area [Figures 1.17-1.20]. The comparison of pre-operative and post-operative view will ultimately satisfy clinician as well as the patient [Figures 1.21-1.23]. Case 2 An 18-year-old female patient has come to the department with the chief complaint diastema in the maxillary anterior region [Figure 2.1]. The patient was with good gingival health, though the oral hygiene is not perfect. The patient was explained with all the available treatment options. Orthodontic treatment was refused by the patient considering its duration. Hence, the lumineer prosthetic treatment was chosen in this case to close diastema. In this case, direct mock-up with composite was done to check the esthetics, and then, it was proceeded further with minimal labial preparation and master impression [Figure 2.2]. A semi-direct mock-up has also been done in the laboratory and was checked in the patient s mouth for esthetics [Figure 2.3]. Once after achieving the satisfactory mock-up, the final impression was made in the patient s mouth by packing the cord in the patient s mouth [Figure 2.4]. Little incisal over contour is preferred to get a precise position for cementation [Figure 2.5]. Then, the tooth is checked for color, contour, and contacts [Figure 2.6]. Then, the inner surfaces of the veneers were prepared and cemented over the tooth surface [Figure 2.7a-d]. A complete pre-operative and post-operative picture can be observed in the pictures [Figure 2.8-2.10]. Cleaning of the ceramic is made with a phosphoric acid 37% brushed on the surface for 2 min, then the veneers are cleaned again in an ultrasonic bath with alcohol for 5 min. Now, the ceramic is ready for silanization and adhesion [Figure 2.7a-d]. Occlusion is checked and the incisal guidance is maintained. The first polishing is done, but it has been repeated after 1 week to have a shiny surface that will be more stable over the time. DISCUSSION A porcelain lumineer is a thin shell-like structure which is extremely thin and can be applied directly on the tooth structure. The indications for lumineers/ veneers vary vastly such as minimally malaligned teeth, diastema, fractured edges, defective restorations, root exposure, discolored tooth, crown lengthening, 3392

1.1 1.3 1.2 1.7 1.6 1.11 1.13 1.17 1.21 1.18 1.22 1.5 1.10 1.9 1.8 1.12 1.16 1.4 1.14 1.19 1.15 1.20 1.23 Figure 1.1: Case 1 - Labial pre-operative view, 1.2: Palatal pre-operative view, 1.3: Direct mock-up: Simply closing the spaces with composite, 1.4: Preparation of the inner surface of lumineers, 1.5: Die-sectioned model, 1.6: Preparation of lumineers, 1.7: Try-in of lumineers over the model, 1.8: Cleaning the surface, 1.9: Application of dental dam, 1.10: Acid etching, 1.11: Primer application, 1.12: Adhesive application, 1.13: Bonding agent application, 1.14: Apply resin cement to the lumineers, 1.15: Remove, 1.16: Tack lumineers in place using plasma arc curing light, 1.17: Check the interproximal areas with dental floss for smoothness, 1.18: Polish the lumineer, 1.19: Removal of excess material with the probe, 1.20: Application of liquid strip over the tooth surface, 1.21: Pre-operative, 1.22: Post-operative, 1.23: A full smile view of the completed lumineer congenitally malformed crowns, stained teeth, and adolescent teeth (teeth with large pulp).[11] In the past, almost all the cases were indicated for full crowns, but there are many advancements happening in restorative materials and adhesive dentistry which revolutionizes cosmetic dentistry as minimal invasive techniques.[12] Though this kind of preparation is minimally invasive, the preparation depends on the intensity of the malalignment of teeth.[13] The cases discussed in this paper show two different conditions and their unique way of restoring. It shows the unique way of preparing lumineers with maximum conservation of tooth structure and minimal intervention meeting the patient s esthetic requirements while maintaining periodontal and gingival health.[14] The material of choice was depended on its superiority over other materials; hereby, we have chosen feldspathic ceramics, alumina, and glass-infiltrated zirconia. In this case series, highly durable Emax has been selected which is lithium disilicate glass ceramic.[15] Penumas et al. in his review had stated that veneers had an excellent periodontal response, with long-term esthetic characteristics and high patient satisfaction. Dumfahrt and Schäffer in his 10-year retrospective study had stated that porcelain veneers were 99% acceptable and were 63% excellent marginal integrity. He also stated that there is 91% survival rate if they are provided with supragingival finish lines.[16] Fradeani et al. had stated that porcelain veneers showed a low clinical failure rate of approximately 5.6% after 12 years of survival.[17] Although there are many advantages with minimally invasive lumineer technique, teeth with defective tooth structure, 3393

2.1 2.2 2.3 2.4 2.5 2.6 2.7a 2.7b 2.7c 2.7d 2.8 2.9 2.10 Figure 2.1: Case 2 - Patient 18 year s old request: Close diastemas. Good gingival health, even if oral hygiene not perfect. The patient does not want orthodontic treatment, 2.2: Direct mock-up: Simply closing the spaces with composite, 2.3: Semidirect mock-up: This is the try-in of the wax-up made from the laboratory, 2.4: Final impression, 2.5: Veneers try-in - Little incisal over contour: This is made to have a precise position for the cementation, 2.6: Veneers try-in - Check for forms color and contacts, 2.7: (a-d) Veneers try-in - Preparation of veneers, 2.8: Full smile view - Pre-operative, 2.9: Full smile view - Postoperative, 2.10: Full smile view - Post-operative smile periodontal problems, parafunctional habits, and severe crowding are not ideal for this kind of treatment. [11,18] Clinical Significance Lumineers need no tooth structure removal, thus bonded directly on the tooth surface. Patients receive their final lumineers within three appointments; starting from the impression and consultation day. Lumineers bond directly to the surface tooth, making it a conservative cosmetic approach. They are very durable, 10 years or longer with good oral hygiene according to clinical studies. The lumineers are a minimally invasive technique making them placed over the existing teeth without the removal of any a tooth structure or minimal preparation; however, only very few people were considered as good candidates for lumineers. Lumineers are thin porcelain material, custom made for the patient, and applied with a permanent bonding agent to the tooth. The main difference between conventional dental veneers and lumineers is the very thin thickness of lumineers, like ultra-thin. Lumineers require slight modification of the enamel during placement (0.3 mm maximum is removed if needed). It just needs polishing the teeth with porcelain paste and rinse, then refreshing the enamel performing minimal enameloplasty. The difference between lumineers and conventional veneers is the dental material of construction which is called Cerinate porcelain which is very strong one and much thinner than the traditional veneers. Their thickness is comparable to contact lenses. Lumineers are the ideal choice when you want to make smile makeover or go for just minimal contouring and brighter shade with no or minimum preparation involved. If you have teeth that protrude, are recessed, overcrowded, or present excessive gaps or damage, then one can choose dental veneers or dental crowns to achieve the end result that is expected. CONCLUSION If you think you are too old for the braces, but not old enough for dentures, veneers may be the middle ground that you are looking for. Lumineers are thin tooth-like coverings that are placed over the surface of your stained, chipped, or crooked teeth. They are custom made in a shade that would best match your surrounding teeth. Both lumineers and veneers will best deal with patient s needs. However, in the battle of lumineers versus porcelain veneers, some key differences may encourage you one over the other. This article put forth the importance of minimal intervention and maximum tooth conservation to maintain patient s optimal esthetics. REFERENCES 1. Strassler HE. Minimally invasive porcelain veneers: Indications for a conservative esthetic dentistry treatment modality. Gen Dent 2007;55:686-94. 2. Materdomini D, Friedman MJ. The contact lens effect: Enhancing porcelain veneer esthetics. J Esthet Restor Dent 1995;7:99-103. 3. Radz GM. Porcelain laminate veneer therapy. Inside Dent 2010;6:52-8. 4. Radz GM. Minimum thickness anterior porcelain restorations. 3394

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