This document describes a case report of upgrading porcelain veneer restorations for a patient after 7 years. The initial veneers had discolored over time. The dentist used a laser to remove the existing veneers without removing additional tooth structure. New high value porcelain veneers were fabricated and cemented to achieve the patient's desired brighter smile. Photographs document the process from the initial veneer placement to the upgraded veneers 7 years later.

1. A full face view
of the completed
aesthetic upgrade.

2. www.oralhealthjournal.com April 2011 oralhealth 41
e s t h e t i c s
Upgrading Porcelain
Veneer Restorations:
A Case Report
Robert A. Lowe, DDS
Introduction
Placement of indirect labial ve-
neers (porcelain or composite) con-
tinues to be an excellent option to
correct many esthetic complaints
that our patients may have with
their smiles. Some of the more
common indications for their clin-
ical use include:
1) Minor corrections of anterior
tooth morphology and emer-
gence angles to fill in spaces in
the gingival embrasure areas
when these spaces are an es-
thetic concern for the patient.
2) Minor corrections in tooth po-
sition (rotation, labio-lingual
arch position, and crowding)
if orthodontics is either not in-
dicated or accepted as a treat-
ment option by the patient.
3) Diastema closures and correc-
tions of anterior tooth propor-
tion (golden proportion).
4) Establishment of anterior guid-
ance and canine disclusion in
patients where preparation for
full coverage restorations would
necessitate unnecessary removal
of healthy tooth structure.
5) Improving tooth color for a
patient where tooth whitening
was not a treatment option or
did not yield a satisfactory re-
sult for the patient.
Tooth Preparation
The amount of tooth reduction re-
quired depends on the specific clin-
ical situation. In general, .5mm to
.7mm of tooth reduction is needed.
In some cases, where “nature”
has done the tooth preparation
or natural tooth contours are less
prominent, “no prep” options are
also possible. If changes in tooth
position are required, some ar-
eas of the tooth may be prepared
more, others less. It is recom-
mended to first contour the teeth
to ideal position using a cylindri-
cal diamond, then use depth cut-
ters to remove a uniform amount
of tooth structure to compensate
for the thickness of the resto-
ration. If in extreme situations,
the dental pulp is encroached
upon, root canal therapy is recom-
mended rather than overcontour-
ing the restoration. In cases where
a low value (dark) preoperative
tooth color is to be changed to a
high value (light) color, more tooth
structure may need to be removed
(1.0mm - 1.5mm) to create enough
space for opacious dentin or opa-
quers to block out the darkness.
For some patients, preoperative
tooth whitening may be indicated
to increase the value of the un-
derlying tooth structure allow-
ing for less tooth structure to be
removed during the preparation
process. Gingival margins should
be placed at the gingival crest
or slightly above. The interproxi-
mal margins should be carried
into the lingual portion of the
contact area. If diastemata are
present, the interproximal mar-
gin of the preparation should be
carried lingually to the linguo-
proximal line angle. Also, when
closing spaces, it is important to
prepare the gingival margins far
enough into the proximal areas
so that the restoration margins
are not visible from a 3
⁄4 or oblique

3. 42 oralhealth April 2011 www.oralhealthjournal.com
e s t h e t i c s
of light bodied material when
seating the tray and a less than
desirable end result ensues from
an incomplete seating of the tray.
The difference here is the amount
of light bodied material that is
used. It is very important to inject
only a small amount of light bod-
ied material around the periphery
of the tooth indentations in the
heavy bodied material. The heavy
bodied material will then force
the light bodied material into
the intracrevicular space around
the teeth. The smaller amount of
light bodied material allows the
operator to more accurately seat
the impression and gain sufficient
“retraction” to force the light bod-
ied material into the crevice.
Provisionalization
A fast and simple technique to
fabricate provisional veneers uti-
lizes a preoperative wax up as a
template. Create a plastic pro-
visional stent of the corrected
view (when the patient turns their
head to the side). After the prepa-
rations are finished, it is recom-
mended to use a fine cylinder
finishing diamond to make the
preparations as smooth as pos-
sible. Aluminum oxide strips can
be used interproximally to smooth
and polish interproximal surfaces
without compromising the proxi-
mal contact.
Impressions
Since the gingival margin of most
veneers will be slightly above
the gingival crest, a very thin re-
traction cord, such as a 00 or 000,
can be placed in the sulcus and
left in place during the impres-
sion process. If a particular case
requires subgingival margins, a
#1 retraction cord is placed over
the 00 or 000. When taking the
impression, pull the #1 cord and
leave the 00 or 000 in place. This
“double cord” technique will pro-
duce flawless intracrevicular im-
pressions time after time.
There is also a technique that
can be used that will allow for
an “anesthesia free” and “retrac-
tion cord free” procedure. First, a
stock tray is selected to fit the pa-
tient’s maxillary arch form. Next,
a heavy bodied tray material is
injected into the tray and placed
in the patient’s mouth. This will
convert the “stock tray” to a “cus-
tom tray” filled with set heavy
bodied impression material. The
next step will be to wash with a
light bodied material...but a very
important technique difference
from a traditional “putty-wash”
technique is used. When most cli-
nicians perform a wash of a heavy
bodied impression, the papillae
between the tooth indentations
are removed and the space is
completely filled with light bod-
ied wash material and reseated
in the patient’s mouth. It is very
hard to displace the large amount
Figure 2—A full smile preoperative view.
Figure 4—A view of the maxillary and
mandibular minimal veneer prepara-
tions. Note the value (brightness or
darkness) of the prepared teeth. When
fabricating porcelain veneers, the ce-
ramist will lay down a thin opacious
layer based on the “preparation shade”
(stump shade), to block out the overall
influence of that shade on the final vis-
ible shade of the restoration.
Figure 3—A retracted full arch preop-
erative view.
Figure 5—The completed first set of max-
illary and mandibular porcelain veneer
restorations after delivery.
Figure 1—A preoperative full-face view
of Michele prior to placement of her
original set of porcelain veneers in
2002.

4. 44 oralhealth April 2011 www.oralhealthjournal.com
e s t h e t i c s
tooth positions using a vacuum
former and .040 plastic mate-
rials. After tooth preparation
and final impressions, fill the
stent with a bisacrylic provi-
sional material and place over
the teeth for two minutes. The
patient can close in centric oc-
clusion over the stent material
during this time. After initial
setting of the bisacrylic mate-
rial, it can be removed from the
stent and contoured with abra-
sive discs and fine laboratory
acrylic carbide burs. Any repair
or addition to the provisional
restoration is accomplished us-
ing flowable composite material
and light curing, either at the
lab bench, or intraorally while
the provisional restoration is
in place on the preparations. It
is not necessary to use bonding
agents prior to the addition of
the flowable resin if the sur-
face is first roughened to cre-
ate micromechanical retention.
Also, the secret to successful
addition of flowable resin to
bisacrylic provisional restora-
tions is to create a long bevel
on the bisacrylic material, add
the flowable resin to the repair
area and continue to “feather”
the flowable composite over the
beveled surface of the bisacrylic
3 to 4 mm beyond the repair
area. Finally, finish with abra-
sive discs to original tooth con-
tour and a seamless repair is
created
Cementation
Placement of porcelain veneers
can be accomplished using dual
cured or light cured resin ce-
ments. The veneers are first
tried on individually to check
margins, then collectively to
evaluate contact and esthetics.
A drop of water on the inside
of the veneers can help to hold
them in place for evaluation
by the doctor and the patient.
For most cases, transparent
or clear resin cement will be
Figure 6—A full smile view of the com-
pleted initial aesthetic makeover.
Figure 9—A retracted full arch seven-
year postoperative view of the initial aes-
thetic reconstruction. When compared
with Figure 5, a definite change in tooth
color of the restorations is apparent.
Figure 7—A full face view of the com-
pleted initial aesthetic makeover.
Figure 10—A full smile seven-year post-
operative view.
Figure 8—A full face view of the initial
aesthetic makeover seven years after
placement. Compare this to Figure 7. It
is difficult at normal speaking distance
to perceive a change in the color of the
restored teeth.
Figure 11—The shade based on the
Vita Lumin Shade Guide of the existing
restorations is B1. The original restora-
tion shade was “Hollywood White”,
or bleached shade (B0). The patient’s
desire is to have an upgrade to Bleach1
(BL1), which is the highest value of re-
storative material available.

5. 46 oralhealth April 2011 www.oralhealthjournal.com
e s t h e t i c s
the cement of choice. There are
some clinicians who report a
color change with time when us-
ing dual cure tinted cements. It
is the opinion of this author that
color change in older veneer cases
occurs because of color change in
the tooth, not in the 10-micron
layer of cement between the por-
celain and the tooth. The reason
dual cured cements are selected
by some clinicians is because of
the ease of the clean up process.
These types of cements will reach
a “gel phase” about two minutes
after mixing. At that time, the
operator can use an explorer or
fine curette to remove cement ex-
cess prior to light curing. Dental
floss can also be passed through
the interproximal areas to be
sure they are free of cement.
While performing the cement
clean up during the “gel phase”,
the dental assistant stabilizes
the restoration using finger pres-
sure. Once the excess resin ce-
ment is removed, the restorations
are light cured. Using this tech-
nique will minimize any rotary
finishing, and polishing should
also be kept to a minimum. Light
cured cements can be used suc-
cessfully if the operator has a
tacking tip on the curing light
and selectively “tacks” the center
of the restoration on the tooth
while leaving the cement at the
margins uncured. The marginal
excess is then removed with a
brush, floss is used to clear the
interproximal areas while stabi-
lizing the restoration, and finally
a total cure is done once the clean
up is complete.
As previously mentioned, some
clinicians and researchers be-
lieve that dual cure resin cements
change color over time and affect
the visual shade of the restora-
tion. This may be true in the lab,
but is this really happening clini-
cally? If one takes a clear shade
of resin cement, and an A3 shade,
places a drop of each on a glass
slide, then squeezes another slide
on top of the cements to simulate
a restorative interface and inter-
esting thing occurs. It is difficult,
if not impossible to distinguish
between the two colors because
the cement layer is so thin. How
much color can be squeezed into
a 10-micron layer of cement? How
does that “change” become vis-
ible behind an opacious layer of
dentin porcelain followed by body
Figure 13—The preparations after laser
veneer removal. Note the resin cement
is still present on the teeth.
Figure 12—The Waterlase MD (Biolase
Technologies) with a 600 micron tip is
used to atraumatically remove the exist-
ing veneer restorations.
Figure 14—The preparations after polish
with Enhance point (Dentsply Caulk)
and minor margin refinement.
Figure 16—Bleached shade provisional
restorations are shown that have been
placed after completion of the master
impression.
Figure 15—Retraction cord is placed
prior to making of the master impression.
Figure 17—A view of the newly fab-
ricated high value maxillary central
incisor porcelain restorations (Venus
Porcelain: Heraeus Kulzer).
PULL QUOTE

6. www.oralhealthjournal.com April 2011 oralhealth 47
e s t h e t i c s
porcelain? The “contact lens” ef-
fect does allow the color of the
tooth to affect the final shade of
a restoration if the ceramist does
not lay down an opacious material
first or if the restorative gap is too
large so that the cement layer is
too thick.1-5
Case Report: Upgrading
Porcelain Veneers
Placement of the Initial
Porcelain Veneer Restorations
In 2002, my wife Michele ex-
pressed a desire to have porcelain
veneers placed to enhance the
aesthetics of her smile. She pre-
sented (Figs. 1-3) with a Class
I occlusion and had very thin,
opalescent enamel that did not
respond well to tooth whiten-
ing. Her desire was to have a
“brighter, more youthful looking
smile”. Following the methodology
described above, the teeth were
prepared using a minimal prepa-
ration technique (Fig. 4), master
impressed, and then provisional-
ized using bisacrylic provisional
material. A bleached white color
of feldspathic porcelain was cho-
sen, the restorations were fabri-
cated, and finally cemented with
a clear, dual cured resin cement.
Figures 5-7 show Michele’s post-
operative full smile, retracted full
arch, and full face views respec-
tively. Michele was thrilled with
her new smile makeover!
Seven Years Later...
Michele had never specifically
commented that she noticed her
veneers were not as bright as they
were when placed because there
was such a gradual change over
time (Figs. 8-10). Compare the
post cementation photo, Figure
5 and the seven-year post op-
erative photo, Figure 9. A sig-
nificant color shift is very notice-
able when performing a direct
comparison of these photographs.
Being surrounded by the dental
field, Michele was also aware that
newer porcelains were being
developed that were brighter
in value than those that were
available when here initial aes-
thetic restorations were fabri-
cated. She therefore expressed
a desire to have her veneers
redone. Although a color change
had been observed (Fig. 11),
from a pure dental perspective,
the initial restorations were
still very serviceable, with no
signs of fracture, wear, or mar-
ginal breakdown. Knowing that
conventional removal of these ve-
neers with rotary instrumenta-
tion would result in removal of
more healthy tooth structure, the
dilemma is whether to intervene
and replace the veneers at this
time, or to wait until such a time
that the restorations breakdown
and require replacement. As with
most patients, Michele was not
concerned with the potential loss
of a tenth or two of a millimeter
of tooth structure....she wanted
brighter porcelain veneers!
So, it was decided to grant her
request and upgrade her aesthetic
restorations. During this period
of time, as an all tissue laser
user, it had been discovered that
the laser could be used to conser-
vatively remove porcelain veneer
restorations without further loss
of tooth structure. It is believed
that since the laser wavelength
of the Er, Cr, YSGG laser seeks
water, the resin cement is dena-
Figure 19—The upgraded high value
porcelain veneers cemented on the max-
illary arch. Note the difference in value
when compared to the mandibular res-
torations that have yet to be replaced.
Figure 22—A full smile view of the com-
pleted aesthetic upgrade.
Figure 18—Kleer Veneer light cured ve-
neer cement (Pulpdent Corporation) is
shown being placed into the porcelain
veneer restoration). Note the complete
lack of color in the cement.
Figure 21—A retracted full smile view
of the completed aesthetic porcelain
veneer upgrade.
Figure 20—This slide shows the removal
of the initial mandibular ceramic ve-
neers with the all tissue laser (Waterlase
MD: Biolase Technologies).

7. 50 oralhealth April 2011 www.oralhealthjournal.com
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tured and expands causing the
veneer to fracture and separate
from the tooth. The veneer can
then be easily removed using a
scaler (Figs. 12-13). Michele had
ten porcelain veneers on her max-
illary arch, all of which were
completely removed with the la-
ser in less than ten minutes! The
cement layer remains visible on
the preparation surface (Fig. 13).
Next, an Enhance point, a com-
posite polishing point (Dentsply
Caulk), is used to remove the ce-
ment from the preparation. Air
abrasion can be used for this as
well. After minor marginal ad-
justment of the preparations to
compensate of a small amount
of gingival recession on the mid-
facial of some of the preparations
(Fig. 14), retraction cord is placed
(Fig. 15), a new master impres-
sion is made, and bisacrylic pro-
visional restorations are placed
(Fig. 16). The ceramist will now
fabricate the newer, high value
porcelain veneers. Figure 17
shows the finished central incisor
restorations. A new light cured
cement (Kleer Veneer: Pulpdent
Corporation) is used to cement
the newly fabricated porcelain
veneer restorations (Fig. 18). Note
that this veneer cement is totally
transparent, unlike many other
“untinted” resin cements on the
market. It is the authors opinion
that this type of cement is par-
ticularly useful for very thin “no
prep” veneers when blocking out
tooth color is not required. At
a subsequent visit, the process
is completed on the mandibular
arch. Figure 20 shows the man-
dibular veneers being removed
with the Waterlase MD (Biolase
Technologies). The completed por-
celain veneer aesthetic upgrade
can be viewed in Figures 22-25.
Note that clear porcelain was
used at the gingival margins to
gradually blend the root color
at the restorative interface and
make the margin less apparent.
Conclusion
“Wants based” dentistry, espe-
cially that which is purely aes-
thetic in nature, is often on a
“different time table” than con-
ventional restorative or rehabili-
tative dentistry. Its “useful life”
is not determined necessarily by
marginal or occlusal breakdown,
but by what the patient sees in
the mirror. For some dentists, it
is hard philosophically to remove
and replace “serviceable” dental
restorations. However, in this day
of elective dentistry, we must re-
alize that replacement of existing
restorations can now be deter-
mined on aesthetics alone....and
this at any moment, is done at the
sole discretion of the “wearer”.
In the author’s case......”Happy
wife......Happy life!! OH
Robert A. Lowe, DDS, FAGD,
FICD, FADI, FACD, FIADFE,
Diplomate, American Board of
Aesthetic Dentistry.
Oral Health welcomes this orig-
inal article.
References
1. Strassler HE, Minimally Invasive Porcelain Veneers:
Indications for a Conservative Esthetic Dentistry
Treatment Modality, General Dentistry, November
2007 Special Edition, pp 686-694. Malcmacher L,
No-Preparation Porcelain Veneers - Back to the
Future, Dentistry Today Vol 24, No 3, March 2005.
pp 86,88, 90-91.
2. Etman MK, Woolford MJ, Three-Year Clinical
Evaluation Of Ceramic Crown Systems: A Pre­
liminary Study, Journal of Prosthetic Dentistry, Vol
103, No 2, Feb 2010, pp. 80-90.
3. Guess PC, Strub JR, Steinhart N, Wolkewicz
M, Christian FJS, All Ceramic Partial Coverage
Restorations- Midterm Results of a Five Year
Prospective Clinical Splitmouth Study, Journal of
Dentistry 37 (2009) pp. 627-637.
4. Lowe RA, Shade Instability: Examine a Root Cause
of Mismatched Ceramic Restorations, Dental
Products Report, September, 2008, pp. 116-122.
Figure 24—“Happy wife.....happy life!”