prefabricated composite resin veneers a clinical review · prefabricated composite resinveneers –...

Prefabricated Composite Resin Veneers – AClinical ReviewGEORGE GOMES, DMD,*,† JORGE PERDIGÃO, DMD, MS, PhD‡

ABSTRACT

Objective: This clinical technique article is focused on the use of prefabricated veneers to enhance the estheticappearance of the anterior dentition in patients who needed an alternative esthetic solution more affordable thantraditional porcelain veneers.Clinical considerations: Because prefabricated composite veneer systems have been recently introduced, they are notwidely used.The Componeer system (Coltene, Altstätten, Switzerland) contains thin pre-polymerized hybrid compositeshells, several shades of a direct hybrid composite resin, an etch-and-rinse adhesive system, and restorative accessoriesincluding finishing points and disks.The prefabricated restorations can be customized in the mouth for color and shape.The technique described in this article can be used to restore function and esthetics in one office visit.Conclusions: The prefabricated composite veneer technique has some of the advantages of direct compositerestorations, as only one session is required without the need to take impressions to send to the dental laboratory.This new treatment option may open new opportunities for dental professionals and their patients. However, it isparamount to carry out controlled clinical studies with this restorative technique prior to recommending it withoutrestrictions in general practice.

CLINICAL SIGNIFICANCE

The clinical technique described in this paper has the potential for being used routinely to lengthen anterior teeth, tocorrect malpositioned teeth, to mask discolorations, and to close diastemas.The technique can also be used to restoreextensive caries lesions and tooth fractures, and to refurbish large old anterior restorations, especially when othertreatment options are out of reach for the patient for financial reasons.

(J Esthet Restor Dent ••:••–••, 2014)

INTRODUCTION

The increasing demand for esthetic restorativetreatments and recent advances in adhesive dentistryhave led to the development of materials andtechniques aimed at restoring the natural toothappearance, especially in the anterior segment.

Ceramic crowns have been considered a predictableand durable treatment option for anterior teeth.

However, crowns require an aggressive toothpreparation that may cause adverse effects to the pulpand periodontal tissues.1 Dental ceramic materials havedemonstrated excellent properties, such asbiocompatibility, esthetics, and chemical and wearresistance.2 Nevertheless, their mechanical limitationssuch as brittleness, low fracture toughness, low tensileand flexural strengths, and the wear inflicted to theopposing dentition have been described as potentialshortcomings.3

*Private Practice, CCDO, Oeiras, Portugal†Clinical Professor, Post-Graduate Program in Esthetic Dentistry, University Rey Juan Carlos, Madrid, Spain‡Professor, Department of Restorative Sciences, Division of Operative Dentistry, University of Minnesota, Minneapolis, MN, USA

CLINICAL ARTICLE

© 2014 Wiley Periodicals, Inc. DOI 10.1111/jerd.12114 Journal of Esthetic and Restorative Dentistry Vol •• • No •• • ••–•• • 2014 1

After the pioneer work of Dr. Pincus in 19384 toenhance movie stars’ smiles, the turning point inporcelain veneer technique optimization started withthe work by Rochette5 and, thereafter, improved bySimonsen and Calamia.6 The introduction of ceramicetching and adhesive cementation became a standardprocedure for porcelain veneers. This treatmentmodality gained widespread popularity because of itsesthetic outcome, as well as durability, biocompatibility,and minimal tooth preparation.7 Bonded porcelainrestorations mimic the biomechanical properties andstructural integrity of the original tooth8 resulting ingood clinical performance.1

Some of the mechanical properties of indirectcomposite resin veneers versus ceramic veneers are thelower elastic modulus and higher capacity to absorbfunctional stresses of composite restorations.9 Indirectcomposite veneers may allow better absorption of thepolymerization stresses generated by the cement duringcementation procedures.10 In spite of being consideredless esthetic than ceramic veneers, indirect compositeveneers are easy to finish and polish, can be modifiedbefore luting without compromising either theiradhesive potential or their mechanical properties.Additionally, the corresponding laboratory proceduresare easier, thus lowering the manufacturing cost.11 Newlaboratory-made composite restorations with improvedwear resistance have widened the indications ofcomposite resins to extensive restorations.11–13

Prefabricated composite resin veneers have beenrecently introduced. Componeer (Coltene, Altstätten,Switzerland) prefabricated veneers are thin compositeresin shells (0.3 mm cervically and 0.6–1.0 mm to theincisal edge). These prefabricated veneers are made of apre-polymerized hybrid composite resin, Synergy D6(Coltene). The veneers are cemented with the samehybrid composite resin that they are made from, whichhas the potential of making the complete restoration asa monoblock unit. These veneers can be trimmed andbonded to the tooth structure using direct hybridcomposite resin. One Coat Bond (Coltene) is the dentinadhesive included in the system, which is used to bondthe prefabricated composite shells to the toothstructure using an etch-and-rinse bonding strategy.

The purpose of this case report paper is to describeclinical cases step-by step, in which the patients’ smileswere restored with prefabricated composite veneershells.

CASE PRESENTATIONS

Shade and Size Selection

The shade is selected with the use of the ComponeerSynergy D6 Shade Guide (Coltene). The color guidecomes with six dentin cores and two enamel shells(Figure 1). After teeth are cleaned, the enamel anddentin shades are evaluated separately. The enamelshell guide is superimposed over the dentin core todetermine the approximate final color. The size of thecomposite shell for a specific patient is selected withComponeer Contour Guides (Figure 2). A wider andlonger size is recommended rather than a short andnarrow shape, as the clinician will have the possibilityof trimming and customizing the prefabricated veneerwith an abrasive disk to match the shape of the naturaltooth as close as possible (Figure 3).

Tooth Preparation

The tooth preparation must be uniform and, wheneverpossible, restricted entirely to the enamel. A #2 roundbur is used to delimit the cervical margin (Figure 4).Subsequently, the buccal surface is prepared as forporcelain veneers using a tapered-cylinder, round-enddiamond bur. Metal abrasive strips may be used tocreate a separation between the teeth in the proximalarea to facilitate the definition of the proximal marginand the correct positioning of the composite shells. It isimportant to try the prefabricated composite shells onthe teeth a few times to guide the gradual toothreduction.

Abrasive aluminum oxide disks and an extrafine,tapered-cylinder, round-end diamond bur are used tosmoothen the preparation and round the angles(Figure 5). After making adjustments to theprefabricated composite veneer, the final try-in iscarried out. If it is deemed necessary to mock-up the

PREFABRICATED COMPOSITE RESIN VENEERS Gomes and Perdigão

DOI 10.1111/jerd.12114 © 2014 Wiley Periodicals, Inc.Vol •• • No •• • ••–•• • 2014 Journal of Esthetic and Restorative Dentistry2

final esthetic result, the composite shells can be filledwith Synergy D6 according to the dentin shadepreviously chosen, without light-curing.

Clinical Case 1

A 24-year-old female patient had major complaintsabout the appearance of her smile. This patientspecifically requested an improvement in theappearance of her discolored maxillary anterior teeth(Figure 6). After clinical examination and taking the

patients’ medical history, a radiographic assessment wasperformed. Teeth #7, 8, and 10 were root canal treated(Figure 7), with multiple composite restorations in needof replacement.

Patient’s oral hygiene and periodontal condition wereexcellent. The ideal treatment included fiber posts andcomposite build-ups, followed by all-porcelain crownsfor teeth #7, 8, and 10. However, due to financiallimitations, patient declined this treatment plan.Prefabricated composite veneers were then proposed as

FIGURE 1. Componeer SynergyD6 shade guide.

FIGURE 2. Componeer contourguides.



an alternative and the respective limitations wereexplained to the patient.

The dentin shade selected from the Synergy D6 colorguide was A1/B1, while the enamel shade was whiteopalescent (Figure 8). With the help of the contourguides, size “L” was selected (Figure 9). After localanesthesia and rubber dam application, teeth wereprepared (Figure 10). The prefabricated veneers werecustomized with abrasive discs (SwissFlex, Coltene) andtried-in. One Coat Bond was applied to the intaglio andleft undisturbed without light-curing (Figure 11). Afterthe preparations were etched with 35% phosphoric acidfor 15 seconds (Figure 12), the etchant was thoroughlyrinsed for 20 seconds. The bonding substrate was gently

air-dried followed by the active application of One CoatBond for 15 seconds (Figure 13). The adhesive was thengently air-dried from cervical to the incisal aspect andlight-cured for 20 seconds (Figure 14). An opaquer(Paint-on Color, Coltene) was applied to mask thetooth discolorations (Figures 15 and 16). The whiteopaque tint was mixed with the yellow tint in aproportion of 50/50 and applied with a sable brush overthe cured adhesive. The same mixture was applied tothe yellow-brown enamel spots of teeth #6 and 11(Figure 17). After the masking agent was light-cured for40 seconds, Synergy D6 dentin composite was appliedon to the tooth surface (Figure 18), while the enamelcomposite was applied on the intaglio surface of the

FIGURE 4. The cervical margin is delimited with a #2 roundbur.

FIGURE 5. An extra-fine diamond is used to finish thepreparations.

FIGURE 6. Clinical case 1—preoperative frontal view. Notethe discolorations and multiple old restorations. Both uppercanines have localized yellow-brown enamel stains.

FIGURE 3. Trimming the prefabricated veneer with anabrasive disk.



veneers (Figure 19). Starting with teeth #8 and 9, theprefabricated veneers were gently placed (withoutexcessive pressure). The restorations were then alignedwith the midline and the incisal position wasdouble-checked for symmetry (Figure 20). If spaces arecreated between the composite shell and the toothstructure, they are filled with the same enamel hybridcomposite resin used to seat the prefabricatedcomposite shells.

While holding the veneers in position, the obviousexcess was removed and the composite smoothly

adapted to the Componeer with a sable brush. Theentire restorative complex was then light-cured fromthe lingual side for at least 40 seconds, and from thefacial side for 40 seconds cervically and 40 secondsincisally. For the finishing steps, the margins can beadjusted with Proxoshape oscillating diamond-coatedfiles (Intensiv SA, Montagnola, Switzerland) as shownin Figure 21. Finishing and polishing strips were usedfor the interproximal areas. Flexible aluminum oxidediscs are ideal to adjust the incisal angles. Siliconerubber polishers (prepolishers and polishers ortwo-stage polishers) were used for the polishing steps(Figure 22).

The other veneers were inserted in pairs as describedfor teeth #8 and 9 (Figures 23 and 24). Figure 25 showsthe patient’s smile 2 weeks after the restorativeprocedure.

In case any old restorations are removed first,the direct dentin-shaded composite resin isused to restore the corresponding preparationsas in a conventional direct composite restoration,prior to cementing the prefabricated veneer. The samedentin-shaded composite resin is then applied to thebuccal surface of the tooth and the prefabricated veneerloaded with the enamel composite and inserted asdescribed above. If needed, direct composite resin maybe applied to the interproximal areas that are notcovered with the prefabricated veneer, especially when

FIGURE 7. Radiographies of upper central and lateralincisors.

FIGURE 8. Shade selection with the enamel shade tabsuperimposed over the dentin shade tab.



FIGURE 9. Size selection using the contour guide. FIGURE 10. Preparation for the prefabricated compositeveneers.

FIGURE 11. Adhesive was applied to the intaglio and leftuncured.

FIGURE 12. Preparations were etched with 35% phosphoricacid for 15 seconds.

FIGURE 13. Application of the dentin adhesive to thepreparations.

FIGURE 14. Adhesive was light-cured for 20 seconds oneach surface.



closing a diastema. Sable brushes may be used tosmoothen the composite and adapt it to the margins.

Clinical Case 2

A 34-year-old male patient, extremely unhappy with hissmile, had a major concern with “the space between hisfront teeth.” A clinical examination revealed severaldiastemas, multiple carious lesions, discoloredrestorations, and a size and shape discrepancy(Figure 26). After the treatment options were discussedwith the patient, and taking into account the patient’sfinancial restrictions, the decision was made to restorethe six maxillary anterior teeth with prefabricated

composite veneers to reestablish the size andthe shape of the teeth and enhance the esthetics of hissmile.

The dentin shade selected was A2/B2 and the enamelshade white opalescent (Figure 27). As with clinical case1, size “L” was chosen with the help of contour guides(Figure 28). After local anesthesia and rubber damapplication, teeth were prepared. After etching, rinsing,and application of the adhesive (Figures 29 and 30), theadhesive was light-cured. Dentin-shaded compositeresin was free-handed and recontoured from the lingualaspect of the veneers to close the diastema, followed bylight-curing from the lingual for 40 seconds. All the

FIGURE 15. The masking agent was applied with a sablebrush to mask the discoloration of the upper right centralincisor.

FIGURE 16. The masking agent was light-cured for 40seconds.

FIGURE 17. The same masking agent was applied on thelocalized enamel discolorations of the upper canines.

FIGURE 18. Dentin-shaded composite was applied on to thetooth surface.



subsequent clinical steps were identical to those ofclinical case 1, except for the restorative steps to closethe midline diastema. Postoperative views are shown inFigures 31 and 32. Figure 33 shows a non-retracted view2 weeks after the bonding procedure.

DISCUSSION

Composite resins are available in different shades andopacities to match the optical characteristics of enameland dentin. Most current composite resins replicate theappearance of a natural tooth when used with thenatural layering technique.14,15 One of the advantages offree-handed direct composite veneers is the need of

fewer appointments compared withlaboratory-processed veneers, as no impression isrequired for direct composite veneers. Several clinicalreports have corroborated the success of compositeresins in direct veneers and large anteriorrestorations.16–18 However, direct composites have beenreported to suffer from surface and marginaldiscoloration, wear, and marginal chipping.16

The concept of one-visit prefabricated resin-basedveneers is not new. In the early 1980’s, prefabricatedacrylic veneers were introduced as Mastique LaminateVeneer System (Caulk, Milford, DE, USA). The intagliosurface of Mastique veneers was etched with polyacrylicacid and then adapted to acid-etched enamel using a

FIGURE 19. Enamel-shaded composite was applied on theintaglio surface of the prefabricated veneer.

FIGURE 20. Restorations were aligned with the midline andthe incisal position checked prior to light-curing.

FIGURE 21. Margins were adjusted with Proxoshapediamond files.

FIGURE 22. Finishing and polishing the restorations usingsilicone rubber points.



light-curing composite and an unfilled bonding resin.Mastique veneers had limited success because oftechnological limitations and poor surfacequalities.19,20

Clinical studies have confirmed good performance ofporcelain veneer restorations, with excellent esthetics,overall patient satisfaction, and no adverse effects onthe periodontal tissues.1 A recent study21 evaluated 318ceramic veneers in 84 patients over 10 years. Theestimated survival probability was 93.5% at 10 years.Whereas the main reason for failure was fracture of theceramic, increased failure rates were associated withbruxism and nonvital teeth.

FIGURE 23. Postoperative frontal view. FIGURE 24. Postoperative frontal view.

FIGURE 25. Non-retracted view 2 weeks after insertion. FIGURE 26. Clinical case 2—frontal preoperative viewshowing a moderate midline diastema between the uppercentral incisors, caries lesions, discolored restorations, anddiscrepancy in size and shape.

FIGURE 27. Frontal view with the selected color guides.



No significant differences in absolute failures werefound between indirect composite veneers and ceramicveneers at up to 36 months. Surface quality changeswere more frequently observed in the composite veneermaterial, which required more maintenance over time.22

The group of composite laminate veneers in this study22

had two cohesive fractures indicating that the adhesivestrength of the interface was greater than the cohesivestrength of the indirect composite material. An in vitrostudy23 had also described cohesive fractures as beingthe predominant failure mode for the same indirectresin composite tested in the clinical study.22

The clinical outcome of indirect veneers depends onthe strength of two interfaces—the tooth/resin cement

and the veneer/resin cement interfaces. A recent bondstrength study reported that Componeer prefabricatedveneers resulted in microshear bond strengthsstatistically similar to those of etched IPS e.max Press(Ivoclar Vivadent, Schaan, Liechtenstein)24 when therespective adhesive and luting composite were appliedto the intaglio surfaces.

The high bond strengths obtained between theComponeer intaglio surface and the respective hybridcomposite may be a result of two mechanisms:

1 – A strong adsorbed layer of polymer materialforms on the intaglio surface. This adsorption is aconsequence of an initial increase in the ionization

FIGURE 29. Preparations were etched with 35% phosphoricacid.

FIGURE 30. Application of the dentin adhesive One CoatBond.

FIGURE 31. Postoperative frontal view.

FIGURE 28. Componeer size selection.



rate of the carboxylic groups in One Coat Bondbecause of the production of acid via thephotoinitiator.24,25

2 – Residual reactive methacrylate functionalities onthe intaglio surface may form a network with thebonding agent after polymerization, which, alongwith the wetting characteristics of 2-hydroxyethylmethacrylate26,27 in One Coat Bond, may explain therelatively high bond strengths associated with theadhesive joint formed by the prefabricated veneer,the dentin adhesive, and the direct hybrid compositeresin.

The clinical technique described in this paper has thepotential for being used routinely to lengthen anteriorteeth, to correct malpositioned teeth, to maskdiscolorations, and to close diastemas. The techniquecan also be used to restore extensive caries lesions andtooth fractures, and to refurbish large old anteriorrestorations, especially when other treatment optionsare out of reach for the patient. Although thistechnique has shown promising results, controlledclinical studies are essential to validate the general useof this technique in clinical practice.

CONCLUSION

Prefabricated composite veneers have some of theadvantages of direct composite restorations, as only onesession is required without the need to make

impressions or laboratory work. Additionally, therestorations can be customized (color and shape) andare more affordable than other indirect restorations,resulting in a very esthetic outcome. It is crucial toassess the clinical behavior of this restorative techniqueprior to recommending it in general practice.

DISCLOSURE STATEMENT

Author Jorge Perdigāo has received two research grantsfrom Coltene.

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FIGURE 32. Postoperative frontal view. FIGURE 33. Non-retracted view 2 weeks postoperatively.



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Reprint rests: Jorge Perdigão, DMD, MS, PhD, Professor, University of

Minnesota, Department of Restorative Sciences, Division of Operative

Dentistry, 515 SE Delaware St, 8-450 Moos Tower, Minneapolis, MN

55455, USA.Tel.: 612-625-8486; Fax: 612-625-7440; Email:

[email protected].



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