With the dental materials available today, there are a variety of ways to treat the cases that present themselves in our daily practices. It is a real triumph when cases such as bruxism, tetracycline staining, and fluorosis can be treated using established clinical principles and minimally invasive veneers. When confronted with such diverse cases, we have been led to believe that they require diverse treatments, often involving the heavy reduction of enamel and dentin. These beliefs have been fueled by past inherent weaknesses in indirect restorative materials and poor bond strengths.
In all of the cases described in this article, a minimally invasive veneer technique with pressed ceramic restorations was used. These restorations can be made as thin as a contact lens, and therefore do not require removal of sensitive tooth structure.1-5 The restorative material used in the cases presented was Cerinate Lumineer veneers (Den-Mat), a system that has been studied for more than 20 years6-8 and can be fabricated to very high-strength tolerances.9
The following 3 cases will demonstrate the use of Cerinate Lumineers in the restoration of 3 diverse clinical situations: bruxism, tetracycline staining, and fluorosis.
CASE 1: BRUXISM AND LINGUAL EROSION
There have been many reports in the literature regarding the restoration of occlusion damaged by bruxism in combination with erosion.10-13 The long-term success of these cases depends wholly on regaining proper occlusal function in the restorations.14-16 In an article by Ibsen and Yu, cuspid-guided occlusion was established using bonded Cerinate porcelain.17
In this case, the patient was a dentist who had hesitated to treat his severely worn anterior dentition (Figure 1). He waited for a treatment that would restore his dentition while preserving his tooth structure. When he heard that Cerinate Lumineers could restore his worn dentition and offer him the bonus of a simple, pain-free alternative, he decided to opt for this restorative material.
 |
 |
| Figure 1. The patient, a dentist, had hesitated to treat his severely worn anterior dentition. | Figure 2. It was determined that the patient suffered from damage to his anterior incisal enamel only. |
Following a complete examination with appropriate diagnostic records, it was determined that the patient suffered from damage that was limited to his anterior incisal enamel (Figure 2). This was due to a history of simultaneously swishing cola beverages and grinding his incisal edges, which he did as a youth. The vertical dimension of occlusion was preserved, and it was decided that the teeth would be restored from maxillary second premolar to second premolar followed by the fabri-cation of an occlusal hard/soft nightguard. The objective was to use Cerinate Lumineers as the restoration of choice in correcting an occlusion damaged by bruxism, while maintaining a maximum amount of tooth structure.
 |
| Figure 3. Modification was performed on the rough incisal enamel edges only. |
Following modification of the rough incisal enamel edges only (Figure 3), a final impression was made using a 2-stage polyvinyl siloxane impression material system (First Impression, Den-Mat). With this minimally invasive technique there was no need for fabrication of provisional restorations, nor was local anesthesia required.
Following seating of the patient, the pre-etched shade B1 Lumineers (Cerinate Smile Design Studio) were treated with a porcelain activator (Porcelain Conditioner, Den-Mat) for 30 seconds, rinsed, and dried well. This was followed by the application of a silanating agent (Cerinate Prime, Den-Mat) for 30 seconds, which was then blown thin with air. The Lumineers were then placed into the case box in their proper slots and set aside.
Prior to veneer try-in, the teeth were cleaned, dried, and etched with a desensitizing phosphoric acid-etching gel (Etch N’ Seal, Den-Mat) for 20 seconds, then rinsed and dried. Equal amounts of Tenure A and B (Den-Mat), a primer, were mixed together; 5 coats were applied to each tooth, and the tooth surfaces were gently dried. When adequately applied, the surfaces of the teeth should appear glossy.
 |
| Figure 4. A comparison demonstrating the Lumineers on the right teeth show an increase of 2 mm in incisal length. |
Ultra-Bond Plus Try-In Paste (Den-Mat) was syringed into the Lumineers and then tried on the teeth to verify the fit and evaluate the aesthetics (Figure 4). Following the gentle insertion of the Lumineers, a brush was used to clean the excess Try-In Paste. The patient was then allowed to examine and evaluate his new smile, as was the doctor. If the shade is not what you or the patient wants, remove the Try-In Paste from the Lumineers and tooth surface with a clean, dry brush, reapply a new shade of Try-In Paste, and check the shade again.
Following try-in, the Lumineers were gently teased off the tooth surfaces using the Schure 349 instrument (Lumineers Finishing Kit) and/or cotton pliers. The Try-In Paste was removed from the Lumineers and tooth surfaces with a Tenure S Dab-Eze saturated Skube (Den-Mat), and the Tenure S was gently air-thinned. Note that there is no need to re-apply Porcelain Conditioner or Cerinate Prime when cementing directly after try-in.
The Ultra-Bond Plus cement was then injected into the Lumineers, the Lumineers were seated to place at the same time, and the gross excess was rapidly removed. Each of the Lumineers was spot-tacked for 1 second on the facial center of the tooth using the Sapphire PAC curing unit with a 2-mm Ceri-Taper Tacking Tip (Den-Mat). With the Lumineers safely tack-bonded to place and the cement around the margins in a gel-like state, the excess marginal cement was easily removed. The Lumineers were then fully cured for 5 seconds each on the facial and lingual using the Sapphire PAC curing unit with a 9-mm Ceri-Taper Curing Tip. Using the Schure 349 hand instrument, hardened cement remnants were safely removed.
 |
 |
| Figure 5. The case following placement of the Lumineers. | Figure 6. The patient before treatment. |
 |
 |
| Figure 7. The patient after restoration with Cerinate Lumineers. | Figure 8. This case demonstrates that Cerinate Lumineers can be used to correct a problem that would typically have been treated by reducing the majority if not all remaining enamel for partial-coverage or full-coverage restorations. |
A No. 8392016 Mosquito Finishing Diamond Bur (Lumineers Finishing Kit) was used to blend the Cerinate porcelain, Ultra-Bond Plus cement, and enamel into a single smooth marginal surface. The CeriSaw (Lumineers Finishing Kit) was used to open the interproximal contacts and re-move cured resin cement (Figure 5). Following this, the occlusion was evaluated and adjusted. This was especially important now that the patient was given new canine-guided occlusion and anterior guidance for protrusive disclusion.
This case demonstrates that Cerinate Lumineers can be used to correct a problem that would typically have been treated by reducing the majority if not all remaining enamel for partial-coverage or full-coverage restorations (Figures 6 to 8).
CASE 2: TETRACYCLINE-STAINED DENTITION
According to Bassett and Patrick18, tetracycline exposure in utero and in early childhood often results in intrinsic tooth staining that varies in severity based upon timing, duration, and form
of tetracycline administered. Traditionally, dental aesthetics compromised by tetracycline staining have been restored with modalities re-quiring aggressive tooth preparation. However, other clinical research has demonstrated that minimally invasive laminate veneers can accomplish this goal in a conservative manner.19 The purpose of this study was to evaluate the clinical result of 546 tetracycline-stained teeth re-stored with a porcelain laminate veneer system (Cerinate, Den-Mat) for aesthetic reasons.20 The research indicated that the porcelain veneer restoration system under investigation provided a reliable and highly satisfactory choice for the aesthetic restoration of tetracycline-stained teeth.
 |
| Figure 9. Due to tetracycline staining, this patient attempted whitening with mixed results. |
This patient fell into the category of 50% of the US population who want a more attractive smile but are afraid to go to the dentist because of pain. Due to tetracycline staining (Figure 9), she attempted whitening with mixed results. Lumineers offered her a pain-free alternative. The objective here was to demonstrate the use of Cerinate Lumineers as the restoration of choice in correcting a smile aesthetically compromised by tetracycline staining and rotated teeth, while maintaining a maximum amount of tooth structure.
 |
 |
| Figure 10. Minimal enamel modification was completed. | Figure 11. Cerinate Lumineers in shade B1 were tried-in, delivered, and cemented to the enamel tooth surfaces. |
 |
 |
| Figure 12. The patient’s smile before treatment. | Figure 13. The patient’s new smile, with Lumineers completely masking her severe tetracycline staining while correcting her rotated teeth. |
 |
 |
| Figure 14. The patient before treatment. | Figure 15. The patient was now able to smile confidently. |
As in the previous case, minimal enamel modification was completed (Figure 10), and a final impression was made. Upon return from the Cerinate Smile Design Studio, the Cerinate Lumineers in shade B1 were tried-in, delivered, and cemented to the enamel tooth surfaces as previously described (Figure 11). The patient was now able to smile confidently after minimally invasive treatment (Figures 12 to 15).
CASE 3: FLUOROSIS AND CARIES
According to Akpata21, the prevalence of dental fluorosis is on the increase in different parts of the world, even in areas with fluoride-deficient public water supplies. This may be due to increased use of fluoride in preventive dentistry. In some countries, exposure to apparently low fluoride concentrations in drinking water has resulted in severe dental fluorosis in some children. This underscores the importance of taking into consideration all sources of fluoride intake in a community before prescribing fluoride supplements or recommending appropriate fluoride concentration for the public water supply. Preventive management of dental fluorosis includes de-fluoridation of drinking water in endemic areas, cautious use of fluoride supplements, and supervision of the use of fluoride toothpaste by children less than 5 years of age.
Akpata continues by saying that aesthetically objectionable discoloration of fluorosed teeth may be managed by bleaching, micro-abrasion, veneering, or crowning. This problem affects not only teeth, but skeletal tissue as well, and has become a worldwide problem.22-26 There has been little discussion in the literature regarding the treat-ment of the fluorosis-affected dentition specifically using minimally invasive techniques.27 However, it is perfectly logical to remove the minimal amount of carious and fluorosis-affected tooth structure while restoring it with a highly durable, longlasting, aesthetic restoration such as Cerinate Lumineers.
 |
| Figure 16. This case demonstrates a combination of fluorosis and caries. |
This patient finished orthodontic therapy and was dissatisfied with her appearance and her enamel health (Figure 16). Other dentists gave her treatment plans that recommended full-coverage restorations. She was seeking a more conservative option.
Following a complete examination, it was determined that this patient suffered from a combination of fluorosis damage with a history of poor home care during orthodontic treatment. The objective here was to demonstrate the use of Cerinate Lumineers as the restoration of choice in the correction of a fluorosis-destroyed dentition while maintaining a maximum amount of tooth structure.
 |
 |
| Figure 17. A minimally invasive enamel modification and caries removal was performed. | Figure 18. Cerinate Lumineers in shade B1 cemented to the enamel tooth surfaces, prior to cement removal. |
 |
 |
| Figure 19. The patient before treatment. | Figure 20. The patient was now able to smile confidently. |
In this particular case, due to the depth of decay, local anesthetic was used, followed by complete caries removal, a minimally invasive enamel modification (Figure 17), and a final impression. Upon return from the Cerinate Smile Design Studio, the Cerinate Lumineers in shade B1 were tried-in, delivered, and cemented to the enamel tooth surfaces as previously described (Figure 18). The patient was now able to smile confidently after minimally invasive treatment (Figures 19 and 20).
CONCLUSION
These cases demonstrate that Cerinate Lumineers can be used to correct even difficult problems. Minimal to no tooth preparation is required, and patient acceptance, revenue, and referrals increase. Provisionals are not usually required, and there is no anesthesia, no sensitivity, and no pain during or after the procedure. The procedure is reversible, and the technique is noninvasive to the tooth structure and periodontium. Other clinical indications for this material include diastema closure, peg laterals, and revitalizing PFM fixed units, among others.
References
1. Ouellet D. Using Rembrandt veneers in my daily practice. DentalTown. May 2003.
2. Malcmacher L. No-preparation porcelain veneers. Dent Today. Apr 2003;22:66-71.
3.Nash WR. A 6-year follow-up on cerinate porcelain veneers. Compend Contin Educ Dent. 1998;19:664-669.
4. Shuman IE. Aesthetic treatment with a pressed ceramic veneer material: case reports. Dent Today. Nov 2004;23:80-84.
5. Shuman IE. Aesthetic correction of a damaged occlusion using varied preparation designs and pressed ceramic restorations. Dent Today. Mar 2004;23:66-72.
6. Sapp B Jr, Sapp HTM. The evolution of the esthetic veneer: a 20-year case study. Contemp Esthet Restor Pract. 2002;6:44-53.
7. Strassler, HE and Weiner, S. Long term clinical evaluation of etched porcelain veneers. University of Maryland Dental School, presented at the American Society for Clinical Research Meeting, March 2004.
8. Ibsen R. Conservative treatment provides outstanding long-term results. DentalTown. March 2003.
9. Hahn P, Gustav M, Hellwig E. An in vitro assessment of the strength of porcelain veneers dependent on tooth preparation. J Oral Rehabil. 2000;27:1024-1029.
10. Bernardo JK, Maia EA, Cardoso AC, et al. Diagnosis and management of maxillary incisors affected by incisal wear: an interdisciplinary case report. J Esthet Restor Dent. 2002;14:331-339.
11. Murray MC, Brunton PA, Osborne-Smith K, et al. Canine risers: indications and techniques for their use. Eur J Prosthodont Restor Dent. 2001;9:137-140.
12. Darbar UR, Hemmings KW. Treatment of localized anterior toothwear with composite restorations at an increased occlusal vertical dimension [published correction appears in Dent Update. May 1997;24:157]. Dent Update. Mar 1997;24:72-75.
13. Briggs P, Bishop K. Fixed prostheses in the treatment of tooth wear. Eur J Prosthodont Restor Dent. 1997;5:175-180.
14. Hornbrook DS. Porcelain veneers: optimizing esthetics while reestablishing canine guidance. Compend Contin Educ Dent. 1995;16:1190-1194.
15. McIntyre F. Restoring esthetics and anterior guidance in worn anterior teeth. A conservative multidisciplinary approach. J Am Dent Assoc. 2000;131:1279-1283.
16. Ibsen RL, Yu XY. Establishing cuspid-guided occlusion with bonded porcelain. J Esthet Dent. 1989;1:80-85.
17. Bassett J, Patrick B. Restoring tetracycline-stained teeth with a conservative preparation for porcelain veneers: case presentation. Pract Proced Aesthet Dent. 2004;16:481-486.
18. Strassler HE. Esthetic restoration of discolored teeth using porcelain laminate veneers. Compend Contin Educ Dent. 1998;19:518-525.
19. Chen JH, Shi CX, Wang M, et al. Clinical evaluation of 546 tetracycline-stained teeth treated with porcelain laminate veneers. J Dent. 2005;33:3-8.
20. Akpata ES. Occurrence and management of dental fluorosis. Int Dent J. 2001;51:325-333.
21. Sanchez H, Parra JH, Cardona D. Dental fluorosis in primary school students of the department of Caldas, Colombia [in Spanish]. Biomedica. 2005;25:46-54.
22. Khandare AL, Harikumar R, Sivakumar B. Severe bone deformities in young children from vitamin D deficiency and fluorosis in Bihar-India. Calcif Tissue Int. 2005;76:412-418.
24. Assefa G, Shifera G, Melaku Z, et al. Clinical and radiological prevalence of skeletal fluorosis among retired employees of Wonji-Shoa sugar estate in Ethiopia. East Afr Med J. 2004;81:638-640.
25. Kumar JV, Swango PA. Fluoride exposure and dental fluorosis in Newburgh and Kingston, New York: policy implications. Community Dent Oral Epidemiol. 1999;27:171-180.
26. Evans RW. Changes in dental fluorosis following an adjustment to the fluoride concentration of Hong Kong’s water supplies. Adv Dent Res. 1989;3:154-160.
27. Marais JT, Herbst D. Treatment of severe fluorosis with the aid of modern techniques: a case report. J Dent Assoc S Afr. 1995;50:93-94.
Dr. Shuman maintains a full-time private practice outside Baltimore, Md, emphasizing reconstructive and aesthetic dentistry. He is a fellow in the Academy of General Dentistry, a fellow of the Pierre Fauchard Academy, and a member of the American Dental Association. Since 1989, Dr. Shuman has published more than 50 dental research and clinical articles that have appeared in numerous dental journals. He presents seminars and hands-on courses and has produced several educational videos, including “The Joy of Clinical Dentistry” and “Do Your Dentures Suck?” as well the book Creating the Denture Practice of Your Dreams, which includes an instructional CD-Rom. These educational materials are CERP-approved for a minimum of 4 CE credits each. Dr. Shuman can be reached at (877) 4-SHUMAN or by visiting ianshuman.com.
