Indirect ceramic veneers: Predictable bonding protocols

Ceramic veneers represent a highly minimally invasive treatment option for restoring teeth, offering both aesthetic and functional benefits. When proper planning, precise tooth preparation, and meticulous bonding protocols are followed, ceramic veneers have been shown to deliver years of reliable and excellent clinical performance.

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Fig. 1 - Initial situation. Frontal view of a 34-year-old patient with existing 12-year-old veneers, a congenitally missing lateral incisor, and an extracted canine.

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Fig. 2 - Chief complaint. The patient reported excessive gingival display, an unaesthetic bridge on teeth 12 and 13, mild diastema, and gingival recession with visible root surfaces.

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Fig. 3 - Digital planning. Digital planning was performed to modify the shape, volume, and form of the teeth. The patient was also advised to undergo Botox treatment to reduce upper lip elevation and address the gummy smile—particularly in the region of tooth 13, where thin gingival tissue revealed a grayish discoloration from the underlying implant.

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Fig. 4 - Implant position. The implant was positioned close to the free gingival margin, significantly limiting both abutment design and soft tissue contouring options.

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Fig. 5 - Mock-up. A mock-up was created based on the digital design to confirm the volume, size, and position of the final prosthesis

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Fig. 6 - Veneer removal. The old veneers were carefully removed to preserve the tooth structure. A double cord technique with Kerr retraction cords (Kerr) was used for optimal gingival management.t.

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Fig. 7 - Retraction cord packing. PikPak (Pascal), a highly effective instrument for packing retraction cords, was used during this process.

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Fig. 8 - VPS impression and provisional restorations. A precise VPS impression was made using light body and putty impression materials (Kerr). Temporary veneers and a two-unit bridge were placed while the final restorations were being fabricated in the lab.
 

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Fig. 9 - Final prosthesis try-in. The final prostheses were tried in, and then treated using Veneer ME, a highly useful tool for step-by-step preparation of the veneersfor 20 seconds.

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Fig. 10 - Ceramic surface treatment. The ceramic type used for these veneers is feldspathic. Proper surface treatment is crucial; for feldspathic ceramics, etching is done with hydrofluoric acid for 90 seconds. The sequence of preparing the surface is outlined in the diagram below.

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Fig. 11 - Isolation and cementation. An open dam was applied for adequate isolation, and the cement used was NX3 (Kerr) light-curable clear shade cement, chosen for its excellent handling, shade stability, and long-term bond strength.

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Fig. 12 - Bonding process. A total-etch technique was employed after air abrasion of the tooth surface with 27-micron aluminum oxide. OptiBond Universal (Kerr) was used as the bonding agent of choice.

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Fig. 13 - Veneer bonding. The veneers were bonded starting with the two central incisors, followed by the remaining veneers.

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Fig. 14 - Cement excess cleanup. The excess cement cleanup after achieving the flash is performed in different steps: 1. Using a brush when the cement is in gel form and has not yet polymerized. Due to its viscous yet highly thixotropic nature, most excess cement can be easily removed at this stage.

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Fig. 15 - Cement excess cleanup (Step 2). 2. Use Eccesso (LM Dental) to remove any remaining excess after spot polymerization.

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Fig. 16 - Final polymerization. After the initial cleanup and cement setting, the restoration is covered with a liquid glycerine gel and polymerized for 30 seconds, starting from the palatal side and then the buccal side in three planes.

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Fig. 17 - Cement excess cleanup (Step 3). 3. A 15-number surgical blade is used to remove any remaining excess, ensuring no exposed resin is left behind.

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Fig. 18 - RInterproximal cement cleanup. A metal proximal strip is used to ensure no interproximal cement remains.

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Fig. 19 - Final restorations. The two-unit bridge was screw-retained. To enhance aesthetics, an illusion of a papilla was created between the pontic on tooth 12 and the retainer on tooth 13. The size, volume, and final form of the veneers were redefined. The final restorations resulted in a fuller and more pleasant smile.

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Fig. 20 - Final restorations. Final situation.
Conclusion
The use of appropriate protocols and materials ensures a treatment outcome that delivers exceptional aesthetics, with a well-integrated restoration that exhibits no postoperative sensitivity and long-term success.
Bibliography
1.    Ajay Juneja, https://www.styleitaliano.org/no-prep-and-minimal-prep-veneers/
2.    Gilbert Jorquera. https://www.styleitaliano.org/complete-digital-work-flow-for-laminate-veneers/
3.    Strasseler HE. Minimally invasive porcelain veneers: indications for a conservative esthetic dentistry treatment modality. Gen Dent. 2007:55(7):686-694.
4.    Javaheri D. Considerations for planning esthetic treatment with veneers involving no or minimal preparation. J Am Dent Assoc. 2007:138(3):331-337.
5.    Calamia JR. Etched porcelain facial veneers: a new treatment modality based on scientific and clinical evidence. N Y J Dent. 1983:53(6):255-259.
6.    Calamia JR, Calamia CS. Porcelain laminate veneers: Reasons for 25 Years of success. Dent Clin N Am 2007:51: 399-417.
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Disclosure: Dr. Ajay Juneja is a consultant for Kerr. The opinions and technique expressed in this article are based on the experience of Dr. Ajay Juneja. Kerr is a medical device manufacturer and does not dispense medical advice. Clinicians should use their own professional judgment in treating their patients. All trademarks and brand names are the property of their respective owners.