pISSN, eISSN 0125-5614 Case Report M Dent J 2019; 39 (2) : 53-63 Esthetic treatment of anterior spacings in a patient with localized microdontia using no-prep veneers combined with periodontal surgery: A clinical report Pajaree Limothai, Chalermpol Leevailoj Esthetic Restorative and Implant Dentistry, Faculty of Dentistry, Chulalongkorn University
Objectives: This case report describes the treatment of a patient with maxillary anterior spacings, resulting from microdontia, using a multidisciplinary approach to improve her esthetic appearance. Materials and Methods: A 23-year-old Thai female patient had multiple spaces between her maxillary anterior teeth with a high smile line and an unsymmetrical gingival level. The Recurring Esthetic Dental (RED) proportion was used to determine the widths of maxillary teeth and Bolton’s analysis was used to confirm the RED results, after that a diagnostic wax-up model was fabricated. Esthetic crown lengthening was performed from the right maxillary canine to the left maxillary canine to reduce excess gingival exposure and increase the length of the teeth according to the proportion acquired from the calculation. After complete gingival healing, no-prep ceramic veneers were placed on the maxillary anterior teeth using the IPS Empress® Esthetic ceramic system. Results: The no-prep veneers preserved all tooth structures and gave a satisfactory esthetic result. The patient was satisfied with the outcome. The final restorations closed the spaces with the natural appearance the patient desired. The function and occlusion of the restorations were good. The veneers and the periodontal tissues were in good condition at the 1-year recall. Conclusion: The multidisciplinary approach and no-prep ceramic veneers used in this case restored the maxillary anterior spacing and provided an excellent esthetic outcome. However, successful treatment in the anterior esthetic zone requires a thorough diagnosis and meticulous step-by-step treatment planning. Keywords: ceramic veneer, maxillary anterior spacing, microdontia, no-prep veneer How to cite: Limothai P, Leevailoj C. Esthetic treatment of anterior spacings in a patient with localized microdontia using no-prep veneers combined with periodontal surgery: a clinical report. M Dent J 2019; 39: 52-63.
Introduction clinical outcome, both dental practitioners and laboratory technicians must carefully consider the available treatment options that provide long-term People have become increasingly concerned success and outstanding esthetic results. [1] about esthetics. Therefore, a perfect smile can give Anterior teeth spacing is a type of malocclusion patients more confidence and feel comfortable in whose effect is mostly esthetic. Microdontia is a social situations. Esthetic dental treatment plays condition in which the teeth are smaller than average an important role in improving a personal appearance due to the underdeveloped permanent teeth and through a great smile that also has good clinical typically creates gaps in the dental arch. Abnormal function. Thus, esthetic dental treatment is a tooth morphology, including tooth shape and combination of art and science. To obtain the desired size, result from genetics, specific syndromes,
Correspondence author: Pajaree Limothai Esthetic Restorative and Implant Dentistry, Faculty of Dentistry, Chulalongkorn University 34 Henri-Dunant Road, Patumwan, Bangkok, 10330, Thailand Tel: 02-218-8664 Fax: 02-218-8664 Mobile: 083-429-9917 E-mail: [email protected] Received : 5 April 2019 Accepted : 5 June 2019 Pajaree Limothai, et al environmental factors, trauma, medication use, In 1955, acid etching of the enamel surface and radiation patients receive while their teeth was introduced by Buonocore. [16] Subsequently, are developing. [2-4] Previous studies found Bowen developed the first bonding system. that 5.7–7.98% of females were affected by [17, 18] Due to improvements in ceramic materials microdontia and hypodontia, which was higher and bonding procedures, patients can now than that of males (3.1–5.8%) [5-8] receive bonded restorations that do not require Selecting the appropriate treatment preparing sound tooth structure. This allows modalities for anterior teeth spacing caused dentists to fabricate ceramic restorations that by microdontia requires the expertise of the are very thin (0.3 mm thick). [19-21] Thus, no-prep dentists and a multidisciplinary approach. veneers can be either partial or complete facial Orthodontic treatment alone cannot completely coverage veneers. close these spaces while maintaining the correct This clinical case report describes the occlusion and a satisfactory esthetic result. sequence of conservative treatment procedures According to Fekonja et al., 37.9% of subjects performed on a female patient at the Esthetic who were affected by dental anomalies require Restorative and Implant Dentistry clinic at the treatment by dental specialists, including restorative Faculty of Dentistry, Chulalongkorn University. dentists, periodontists, prosthodontists, oral and The patient was chosen because of her dental maxillofacial surgeon. They also found that 92.4% anomalies; microdontia that caused multiple of the patients were satisfied with the treatment spaces in the anterior maxillary region, and an outcome. [9] Treatment options for microdont teeth excessive gingival display. Her treatment included are based on the patient’s complaints and expectations esthetic crown lengthening and no-prep veneers and range from orthodontic treatment, restorative that comprised a combination of partial and treatment, extraction followed by tooth replacement, ultrathin ceramic veneers. or no treatment. [10] To close the spaces, direct composite restorations are the most conservative Clinical report approach because this method can be performed A 23-year-old Thai female presented at the without removing tooth structure. [11] Another Esthetic Restorative and Implant Dentistry Clinic, minimally invasive option is traditional porcelain Faculty of Dentistry, Chulalongkorn University, laminate veneers (PLVs). This is an indirect restorative Bangkok, Thailand with a chief complaint of technique that requires minimal enamel reduction multiple spaces between her upper anterior teeth and gives a superior esthetic appearance, higher which caused by microdontia (Figure 1). Her major abrasive resistance, and good color stability. concern was an unesthetic appearance and she However, the mean enamel thickness at the cervical desired to close these gaps in a manner that area of the central and lateral incisors are 345µm resulted in a natural look. The patient had never and 235µm respectively. Thus, a 0.5 mm chamfer undergone orthodontic treatment and was satisfied preparation creates a dentin exposure at the with her tooth color. A brief evaluation of her porcelain veneer margins. [12] Long-term studies medical history indicated no immediate concerns. reported that the survival rate of porcelain veneers The treatment began with a clinical was 97.5%. [13, 14] In addition, veneers with their examination, and a series of pre-operative intra- preparation margin in enamel are more likely to and extra-oral photographs were taken. These have a long-term success compared with those photographs were used to determine the facial bonded to dentin. [15] profile, smile line, gingiva zeniths, occlusal planes, tooth color, and shape. A preliminary impression
54 M Dent J 2019 August; 39 (2): 53-64 Esthetic Treatment of Anterior Spacings in a Patient with Localized Microdontia using No-prep Veneers combined with Periodontal Surgery: A clinical report was taken with alginate to fabricate diagnostic casts, followed by a facebow transfer and bite registration. Her intra-oral examination revealed generalized spacing and abnormal tooth shape and size of the upper anterior teeth from the right maxillary canine to the left maxillary canine (Figure 2), and mild gingival inflammation due to dental plaque-induced gingivitis. A thick gingival biotype Figure 3 Periapical radiographs of the anterior dentition demonstrated sound maxillary teeth and and high frenum attachment were observed. normal pulp and periapical tissue. Radiographic evaluation revealed a healthy periodontium and a normal pulp and periapical The overjet and overbite were 2 mm. The condition. (Figure 3). The occlusal relationship dental midline was deviated 1 mm to the right classification was class I molar and class I canine. compared with the facial midline. The facial analysis revealed that her interpupillary line and commissural line were parallel to a horizontal line. The patient had a normal profile (skeletal class I). The smile analysis indicated that the patient had a high lip line with excessive gingival exposure and an asymmetrical gingival level between the left and right sides of the upper dental arch at full smile. The curvatures of the upper anterior teeth and the lower lip line were harmonious (Figure4). The evaluation of the inclination and arrangement of the patient’s maxillary anterior teeth revealed that the maxillary lateral incisors had a slight distal flare. Figure 1 A 23-year-old Thai female patient presented with a chief complaint of her anterior teeth The examination of the tooth color and characteristics spacings. Patient’s full-face photographs: (A) found that the maxillary central and lateral incisors Rest position and (B) Full smile. had a light yellowish color, pronounced macro- and micro- texture on the tooth surfaces, and a halo effect at the incisal edges. In contrast, the canines had a darker shade.
Figure 2 Pre-operative intraoral photographs: (A) Right, (B) Frontal view, (C) Left, (D) Occlusal view of the upper arch, and (E) Occlusal view of the Figure 4 The relationship between the maxillary incisors lower arch. and lower lip when smiling.
http://www.dt.mahidol.ac.th/division/th_Academic_Journal_Unit 55 Pajaree Limothai, et al
Treatment plan Treatment procedures The following treatment plan was accepted Direct Resin Composites by the patient: The defective restorations on molars were 1. Full mouth prophylaxis, scaling, and replaced using a resin composite. After local direct resin composite restorations on the posterior anesthesia and rubber dam application, the old teeth to correct old defective restorations. restorations in teeth 16, 17, 26, 27, 36, 46, and 47 2. Periodontal surgery; frenectomy, and teeth were removed. The tooth cavities were etched for 13 to 23 esthetic crown lengthening to increase the 15 sec with 37.5% phosphoric acid gel (Kerr Gel teeth length and provide the right proportion of the Etchant; Kerr, Orange, CA, USA), rinsed thoroughly, maxillary anterior teeth with a 3-month healing period. and air dried leaving moist dentin surfaces. Primer 3. Non-prep ceramic veneers; teeth 13 to and bonding agents (OptiBond FL; Kerr, Orange, 23 partial and ultrathin ceramic veneers to restore CA, USA) were applied following manufacturers’ the upper anterior tooth spacing. instructions and then light-cured for 20 sec. Before the execution of the treatment plan, A nanofilled resin composite material A3.5 shade the Recurring Esthetic Dental (RED) proportion [22] (Premise; Kerr, Orange, CA, USA) was placed in and Bolton’s analysis [23] were used to determine the tooth cavity using an incremental technique the correct dental proportions and create a diagnostic (2-mm thick layers) and light cured for 40 sec. wax-up. Ward described the RED proportion as The resin composite was then shaped, finished, the proportion of the successive width of the teeth and polished (Figure 6). remaining constant as viewed from the front when Periodontal Surgery progressing distally from the midline. [24] The 70% Esthetic crown lengthening RED proportion has been recommended for normal Prior to esthetic crown lengthening, a wax-up length teeth with a 78% width/height ratio of the model of the six anterior teeth was created to maxillary central incisors. [25, 26] After calculating determine the required gingival reduction on each the esthetic proportions of the upper anterior teeth, tooth. The information from the wax-up model was Bolton’s analysis needs to be done to confirm that transferred to the patient’s mouth using a silicone the restorative dentist can increase tooth width jig of the waxed diagnostic cast. The mock-up was without tooth size discrepancy. In 1958, Bolton made from a temporary material, A2 shade calculated that when the occlusion is perfect, (LuxaTemp®; DMG America, Englewood, NJ, USA) there is a constant proportion between the upper to evaluate the proper gingival level and allow the and lower dentition. Class I occlusion will be possible patient to approve the proposed treatment plan only when the mesio-distal dimension of the lower (Figure 5B). An impression of the mock-up was anterior teeth is 77.2% of the mesio-distal dimension taken. A clear acrylic periodontal stent was of the upper anterior teeth. [23] The results of the fabricated from the stone model of the final intraoral RED/Bolton’s analysis then need to be transferred correction cast. Esthetic crown lengthening was to a diagnostic wax-up. The diagnostic wax-up performed on teeth 13 to 23 under local anesthesia. should be performed using wax with a different An oral antibiotic (1,000 mg) was administrated 1 h color from the diagnostic cast, preferably without before surgery and antiseptic mouthwash 0.12% any dental reduction on the cast. The diagnostic chlorhexidine gluconate was used. The surgical wax-up allows visualizing the areas that will be stent was inserted and then the gingivectomy covered by the ceramic restorations and determining outline was marked. After removing the gingival the gingival margins. Using the wax-up allows the tissue, a labial full-thickness mucoperiosteal flap restorative dentist to communicate with the dental was reflected, and osteotomies were performed technician and the patient (Figure 5A). to provide a 3 mm clearance between the final 56 M Dent J 2019 August; 39 (2): 53-64 Esthetic Treatment of Anterior Spacings in a Patient with Localized Microdontia using No-prep Veneers combined with Periodontal Surgery: A clinical report restoration margin and the alveolar crest to maintain Frenectomy the biologic width. [27] The flap was repositioned Due to the patient’s high labial frenum and sutured in place using interrupted sutures with attachment, a frenectomy was performed under 4-0 Vicryl (Ethicon/Johnson & Johnson, Somerville, local anesthesia. The frenum was held with a small NJ, USA). The sutures were removed 7 d after surgery, curved hemostat and the upper and lower aspect followed by a healing period of 3 months (Figure7). of the frenum was cut through with a 15c blade. Interrupted sutures using absorbable Vicryl 5-0 sutures (Ethicon/Johnson & Johnson, Somerville, NJ, USA) were placed along the lateral margins of the wound in a linear direction after the mucosa of the wound margins was undermined using scissors (Figure 7). Figure 5 (A) The use of a diagnostic wax setup Ceramic Veneers for the Anterior Maxillary Teeth determined the case requirements anad helped formulate the treatment plan. (B) The Based on the path of insertion of the no-prep correct tooth proportions were transferred to veneers, tooth preparation was not required on the patient’s mouth from the mock up. this patient. Teeth 11 and 21 were planned for partial veneers, and the rest of the upper six anterior teeth were assigned no-prep veneers. Before the final impression, the teeth were polished with pumice and shade selection was performed visually using a Vita 3D-Master Shade Guide (Vita Zahnfabric, Bad Säckingen, Germany). For the correct shade matching of value, chroma, and hue, dental Figure 6 The old defective restorations were replaced with direct resin composite restorations to photographs were taken with a shade tab similar create good posterior support. to the tooth shade. A close-up picture with a black background can also be taken to evaluate details such as mamelons, translucency, opalescence, incisal halo, and tooth surface characteristics. The gingival sulcus of the six anterior maxillary teeth was gently packed with retraction cord #000 (Ultrapak®, Ultradent Products Inc., Salt Lake City, UT, USA) to obtain adequate gingival displacement. A full-arch impression was taken with polyvinylsiloxane (Flexitime®, Heraeus Kulzer South Bend, IN, USA) using a double-mixed single-impression technique and submitted to the laboratory (Dental Art Lab, Bangkok, Thailand). A bite registration was performed using a fast-set silicone (Blu-Mousse®; Parkell Inc., Edgewood, NY, USA). The working model was used Figure 7 Periodontal surgery: (A) Periodontal stent try in, (B) Frenectomy and gingivectomy, (C) Full to prepare the wax-up of the final tooth shapes that periosteal flap reflection and bone reduction, were proportionally correct (Figure 8). The no-prep (D) Wound sutured, (E) Before operation, and ultrathin and partial veneers were fabricated from (F) at the 3-month follow-up. a low translucent heat-pressed ceramic ingot shade http://www.dt.mahidol.ac.th/division/th_Academic_Journal_Unit 57 Pajaree Limothai, et al
A1 (IPS e.max® Press, Ivoclar Vivadent, Schaan, Liechtenstein) with a layering technique to mimic natural tooth characteristics (Figure 9, 10). The fabricated veneers were inspected on the original stone dies for their seating, proximal contacts, Figure 11 The fabricated veneers were examined for marginal adaptation, and path of insertion (Figure 11). marginal adaptation on the working models. Clinically, the veneers were tried in until they were well-seated on each tooth and the color of the ceramic veneers were evaluated on the teeth using a water-soluble try-in gel (NX3 Try-In Gel; Kerr, USA) (Figure 12). Prior to cementation, the restorations and teeth were prepared for bonding according to the manufacturers’ instructions. The inner surfaces of the ceramic veneers were treated with 9% hydrofluoric acid (Porcelain Etch®, Ultradent Figure 8 The wax-up of the no-prep veneers on the Products Inc., South Jordan, UT, USA) for 20 sec, working model; the mesial and distal aspects washed thoroughly with air-water spray, and then of tooth #11 and #21 were partial veneers and tooth ® #13, #12, #22, and # 23 were ultrathin veneers. air-dried. A silane coupling agent (Monobond-S , Ivoclar Vivadent, Schaan, Liechtenstein) was applied to the internal ceramic surfaces and gently air-blown with hot air for 1 min. A coat of adhesive (Heliobond®, Ivoclar Vivadent, Schaan, Liechtenstein) was then applied to the inner surface of the restoration and left uncured. The enamel surfaces of the teeth were cleaned with pumice, washed with water, air-dried, and etched with 37.5% phosphoric acid (Kerr Gel Etchant, Kerr, Orange, CA, USA). An alcohol-based adhesive system ® Figure 9 The no-prep veneers were fabricated from (Optibond Solo Plus ; Kerr, Orange, CA, USA) heat-pressed ceramic ingots (IPS e.max® was thinly applied on the tooth surface, air dried, Press, Ivoclar Vivadent, Schaan, Liechtenstein) and light cured for 10 sec. A thin layer of light-cured and a halo effect was created with a nano- resin cement (NX3 Nexus, Kerr, Orange, CA, USA) fluoroapatite layering ceramic.
Figure 12 Clinically, the veneers were tried in until they Figure 10 The minimum thickness 0.3-0.5 mm that no- were well-seated on each tooth and the color prep veneers could be fabricated. of the ceramic veneers were evaluated. 58 M Dent J 2019 August; 39 (2): 53-64 Esthetic Treatment of Anterior Spacings in a Patient with Localized Microdontia using No-prep Veneers combined with Periodontal Surgery: A clinical report was loaded on the internal surface of the ceramic permanent teeth. [28, 29] Microdontia tends to be veneer. The restorations were slowly seated on hereditary and often causes multiple spaces in the teeth and the pressure was applied to allow the dental arch that result in an altered occlusal the luting cement to adapt to the tooth surface. pattern. [29, 30] A patient’s chief complaint is While holding the veneers in place, excess resin always esthetics when their teeth are smaller in cement was carefully removed using a sponge size or shape compared with the adjacent teeth, and a fine-tipped brush, and then light cured by or have gaps between the teeth. However, in this an LED light-curing tip (DEMI PLUS, Kerr, WI, USA) situation, orthodontic treatment cannot completely for 40 sec on both labial and palatal surfaces. close these spaces while maintaining the correct The sequence of cementation depended on the occlusion and good esthetic appearance. In the path of insertion. During cementation, it was difficult present case, a comprehensive treatment plan to position a small piece of the partial ceramic involving a multidisciplinary approach including veneers. Therefore, the full veneers on tooth 12 and operative, periodontics, restorative, and surgery 22 were cemented prior to the partial veneers on was required. The diagnostic wax-up was a tooth 11 and 21 to provide proximal contact for the significant tool, which can help to communicate partial veneers while cementation. with the patient and the dental technician. Before After cementation, an occlusal adjustment the final restorations, the RED proportion was was done and the remaining cement excess was calculated and transferred to a wax-up model to removed. The interface between the enamel surface provide the actual width and length of each tooth. and partial veneers was blended with resin composite (A1 shade, Premise; Kerr, Orange, CA, USA), finished, and polished. The patient was satisfied with the result (Figure 13). Radiographs were taken to ensure that there were no overhanging restorations (Figure 14). The patient was given instructions for proper home care and maintenance of the ceramic veneers. Figure 13 No-prep porcelain veneers after cementation The follow-up evaluations at 1 month, 6 months, and 1 year after cementation showed a pleasing result and the patient was very satisfied with her smile (Figure 15).
Discussion
The key to a successful treatment outcome Figure 14 Periapical radiographs were taken to ensure is a correct diagnosis and an appropriate treatment there were no overhanging restorations. plan. The etiology and contributing factors for maxillary anterior spacing such as genetics, caries, periodontal disease, tongue thrusting, and high frenum attachment should be carefully considered before determining the final restoration type. In the present case, the patient had microdontia, Figure 15 (A) Pretreatment photos and (B) Follow-up 1 year after which is a condition that results from underdeveloped treatment. http://www.dt.mahidol.ac.th/division/th_Academic_Journal_Unit 59 Pajaree Limothai, et al
An excessive gingival display can be caused discrepancies, the patient’s occlusion should be by maxillary overgrowth, short upper lip, or reduced examined and the tooth size discrepancy calculated eruption of the maxillary anterior teeth. Different using Bolton’s analysis to confirm the proposed treatments are required depending on the individual tooth proportion that was obtained from the RED diagnosis. In the present case, a gummy smile resulted proportion. [26] In the present case, the patient from limited passive eruption, which can be corrected had a class I canine and class I molar classification. by crown lengthening surgery, gingivectomy, or The width of each upper anterior tooth from the an apically positioned flap with or without osteotomy diagnostic wax-up was calculated and had the based on the distance between the alveolar bone correct dimension in accordance with the Anterior crest to the cementoenamel junction. [27] Bolton’s discrepancy analysis. [23] There is a wide range of treatments that can The contraindications for no-prep ceramic be used to restore anterior spacing. The most veneers are improper tooth alignment and masking drastic is a full contour-crown, which results in the darkened tooth structure. An incorrect tooth axis greatest loss of tooth structure. However, there are and angulation may lead to an overcontoured numerous more conservative treatment options restoration and injure the gingival tissue. No-prep available as direct and indirect restorations for veneers cannot mask discolored teeth due to the anterior teeth. Direct resin composite restoration is thinness of the restorations. However, the main a conservative approach and less expensive advantage of using veneers without preparation is compared with other indirect restorations. [31] the preservation of enamel. The enamel surface is However, its short-term color stability and its low suitable for bonding with resin due to its highly resistance to wear are disadvantages of this mineralized structure and low moisture content material. In contrast, porcelain veneers offer excellent compared with dentin. Ceramic veneers bonded longevity and appearance. Beier et al. found that to enamel demonstrated high survival rates, which porcelain laminate veneers offer a predictable and decreased when bonded to dentin. [36, 37] In a successful outcome with an estimated survival retrospective survey of up to 12 years, Gurel et al. rate of 93.5% over 10 years. [32] founded a survival rate of 99% for veneers with Currently, it is unacceptable to sacrifice preparations within enamel and 94% for veneers sound enamel to create a space for an artificial with enamel only at the margins. [15] restorative material. Bonding techniques combined To mimic the natural tooth color of the with novel laboratory techniques have markedly nonprepared teeth in the present case, IPS e.max improved to allow the maximum preservation of Press was chosen. In 2005, IPS e.max Press dental tissues. Previously, PLVs were first used in (Ivoclar Vivadent, Schaan, Liechtenstein) was a “no-prep” manner using feldspathic porcelain. [33] introduced as a new material to replace IPS As PLVs gradually evolved, minimally invasive Empress II. This material consists of lithium preparation resulted in increased esthetics by disilicate with a high crystalline content in a glass masking tooth discoloration and improved gingival matrix. The chemical basis of the material is the tissue responses. [34] Moreover, ceramic veneers same as the chemical basis of IPS Empress II, cemented on dental preparations restricted to however, its physical properties and translucency the enamel have a high survival rate. [35] Thus, are improved due to its different firing process. a no-prep ceramic veneer is indicated in situations [38] The IPS e.max materials are available in that allow a material to be added to the tooth structure, several degrees of translucency and have a high including an ideal occlusion and proper tooth position. flexural strength of up to 360–400 MPa. Thus, this To avoid overcontouring the restorations and tooth size material can give a smooth and harmonious color
60 M Dent J 2019 August; 39 (2): 53-64 Esthetic Treatment of Anterior Spacings in a Patient with Localized Microdontia using No-prep Veneers combined with Periodontal Surgery: A clinical report with the existing shade of the abutment tooth. select the cases, plan, execute, and deliver the A retrospective study on the clinical outcomes restorations. A comprehensive treatment plan of IPS e. max Press restorations demonstrated involving a multidisciplinary approach was required. a 97.2% survival rate and 1.7% failure rate for The diagnostic wax-up is a significant tool for analyzing ceramic veneers after function for up to 5 years. the proposed treatment plan and communicating The failures mainly occurred in the first 3 months with the dental team and the patient. after cementation and the main reasons were Funding: None ceramic chipping and fracture. [39] However, the Competing interests: None major challenges of the present case were the Ethical approval: None (case report) ceramic-tooth transition zone and the handling technique of the partial coverage no-prep veneers. The partial veneer restorations had to be carefully Acknowledgements transferred from the master cast to the patient’s mouth in the correct position. The irregularities of A special thanks to Dr. Suphot Tamsailom at the restoration margins and direct resin composite the Department of Periodontology, Faculty of can be used to blend the color and smooth the Dentistry, Chulalongkorn University, for the frenectomy surface at the transition area. and esthetic crown lengthening surgery. A special Friedman reported that 93% of porcelain thanks to Dental Art Lab, Bangkok, Thailand for veneers are successful over a period of 15 years; their outstanding ceramic work. the 7% that failed resulted from fracture (67%), microleakage (22%), and de-bonding (11%) of the veneer. [40] Factors that affect the bond References strength of ceramic veneers are the adhesive technique and placement technique, including 1. Strassler HE. Minimally invasive porcelain veneers: etching the porcelain and enamel, silane coupler, indications for a conservative esthetic dentistry bonding resin, luting agent, and veneer fit. Fradeani treatment modality. Gen Dent 2007; 55: 686-94. 2. Shafer WG, Hine MK, Levy BM. A Textbook of Oral et al. suggested that porcelain laminate veneers Pathology. 1st ed. Philadephia: Saunders; 1958: 26. must be bonded using the correct adhesive technique 3. Neville BW, Allen CM, Damm DD, Chi AC. Oral and to reach a high survival rate. [41] Moreover, patient’s maxillofacial pathology. 4th ed. Missouri: Saunders; habits and compliance are also important factors 2015: 76. 4. Poulsen S, Koch G. Pediatric dentistry: a clinical that have to be considered to maintain the porcelain nd laminate veneer restorations in a good condition for approach. 2 ed. Chichester: Wiley-Blackwell; 2013. a long period of time. 5. Niswander JD, Sujaku C. Congenital Anomalies of Teeth in Japanese Children. Am J Phys Anthropol 1963; 21: 569-74. Conclusion 6. Egermark-Eriksson I, Lind V. Congenital numerical variation in the permanent dentition. D. Sex distribution of hypodontia and hyperodontia. Odontol Revy 1971; This clinical report presented the treatment 22: 309-15. of multiple spaces in the anterior maxillary region 7. Bergstrom K. An orthopantomographic study of in the patient with microdontia. No-prep ceramic hypodontia, supernumeraries and other anomalies in school children between the ages of 8-9 years. veneers are the primary choice for anterior esthetic An epidemiological study. Swed Dent J 1977; 1: 145-57. rehabilitation for a patient who has an ideal occlusion and proper tooth position. It is important to properly
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