Indexación: Scopus.Dental erosion is a high prevalence condition characterized by the loss of dental substance due to chemical agents. It can also be associated with �physical wear, affecting function and aesthetics. Ceramic veneers can provide effective solutions to patients affected by erosive disorders, by means of an indirect approach and minimal intervention. Recent advances in cementation techniques and ceramic materials have allowed their use in reduced thicknesses, known as "dental contact lenses" or "ultra-thin veneers". They contribute significantly to the preservation of the dental structures, having excellent models or mock ups in order to preview the final outcome. Case: The aim of this report is to communicate the use of this technique for the treatment and successful 12-months follow-up of a patient affected by dental erosion of the maxillary central incisors. Special interest was placed on direct mock-up, which is a simple technique not requiring laboratory steps. Luting of the lithium disilicate veneers was carried out with a light-curing resin cement and try-in pastes, yielding a very satisfactory result. Conclusion: Diagnosis and early treatment of this disorder allows the application of conservative techniques, such as ultra-thin veneers, which are seen as a promising alternative treatment to full coverage restorations and traditional ceramic veneers. © 2018, Universidad de Concepcion. All rights reserved.http://joralres.com/index.php/JOR/article/view/481/45

Grandon, F.

Marcus, N.

Muster, M.

Journal Of Oral Research

English

Repositorio Institucional Académico (RIA) de la Universidad Andrés Bello

CaseISSN Online 0719-2479 - www.joralres.com © 2018254[Epub ahead of print]Fernando Grandon,1,2 Natalia Marcus1 & Maria Muster.3Affiliations: 1Departamento de Odontología Restauradora. Facultad de Odontología; Uni-versidad de Concepción, Chile. 2Programa Odontología Estética Adhesiva. Universidad  de Concepción, Chile. 3Facultad de Odontología, Universidad Andrés Bello, Concepción, Chile.Corresponding author: Fernando Grandon. Roosevelt 1550, Concepción, Chile. Phone: (56- 41) 2204481. E-mail: fgrandonv@gmail.com; fgrandon@udec.clAbstract: Dental erosion is a high prevalence condition characterized by the loss of dental substance due to chemical agents. It can also be associated with physical wear, affecting function and aesthetics. Ceramic veneers can provide effective solutions to patients affected by erosive disorders, by means of an indirect approach and minimal intervention. Recent advances in cementation techniques and ceramic materials have allowed their use in reduced thicknesses, known as "dental contact lenses" or "ultra-thin veneers". They contribute significantly to the preservation of the dental structures, having excellent mechanical properties and providing satisfactory aesthetic solutions. Their manufacture requires rigorous planning and the use of three-dimensional models or mock ups in order to preview the final outcome. Case: The aim of this report is to communicate the use of this technique for the treatment and successful 12-months follow-up of a patient affected by dental erosion of the maxillary central incisors. Special interest was placed on direct mock-up, which is a simple technique not requiring laboratory steps. Luting of the lithium disilicate veneers was carried out with a light-curing resin cement and try-in pastes, yielding a very satisfactory result. Conclusion: Diagnosis and early treatment of this disorder allows the application of conservative techniques, such as ultra-thin veneers, which are seen as a promising alternative treatment to full coverage restorations and traditional ceramic veneers. Keywords: Ceramic veneers; dental erosion; mock-up; lithium disilicate.INTRODUCTION.Adhesive dentistry has supported conservative therapies in the treatment of patients affected by various kinds of dental wear. Dental erosion is one of the common causes of wear, especially in young patients, being often dismissed by clinicians, which makes intervention in early stages difficult.1,2 It is defined as the loss of dental substance due to a chemical process and is caused mainly by the consumption of fruit juice, carbonated and isotonic drinks or by digestive disorders. Many patients have a combined etiology of erosion and attrition, resulting in a relatively rapid impact on tooth structure.3 In advanced stages, in addition to its negative aesthetic impact, it can seriously affect function.4  An early intervention prevents tooth loss and allows the use of additive procedures, in many cases not even requiring tooth substance removal. These direct or indirect adhesive techniques replace the missing structure and protect the patient from further damage.2 Ceramic veneers can help in the treatment of patients affected by Conflict of interests:  The authors report no conflicts of interest.Funding: None.Authors’ contributions: All authors contributed to the execution of the study. Acknowledgements: None.Cite as:  Grandon F, Marcus N & Muster M. Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report. J Oral Res 2018; 7(6):254-259.doi:10.17126/joralres.2018.053Receipt: 05/07/2018 Revised: 05/23/2018Acceptance:  07/04/2018 Online: 07/26/2018Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.255ISSN Online 0719-2479 - www.joralres.com © 2018[Epub ahead of print]erosive disorders, using an indirect approach with minimal intervention. Their use, long been considered just a aesthetic treatment, has recently expanded, mainly due to the superior mechanical properties of new glass-ceramics and to the improvement of the cementation strategies. The significant improvement in the fracture strength of glass-ceramic veneers has enabled their use in very reduced thickness.5 These features, in addition to a continuous demand for more aesthetic solutions, have strongly contributed to the increasing popularity of minimally invasive ceramic veneers (also known as dental contact lenses) among clinicians. Edelhoff et al., point out5 that their use enables restorative procedures even avoiding the need of a previous tooth preparation. Lithium disilicate based ceramics are preferred as they combine aesthetics and high strength. Alencar et al.,6 described ceramic veneers as thin as 0.6 millimeters, whereas Savi et al.,7 and Clavijo et al.,8 reported even lower thicknesses (down to 0.2 millimeters) by using refractory and pressing techniques. Specialized laboratory, a skillful clinician, and meticulous planning are essential to achieve successful results. Design and manufacture of such thin structures requires an appropriate determination of their morphology and size by the clinician, long before the laboratory stage. The use of prototypes or mock-ups, which rely on a previous diagnostic wax-up and are transferred by different techniques to the patient,9,10 offer an excellent alternative to preview the expected outcome. A variation of this technique is the direct mock-up, where a temporary restoration of the lost volume is directly applied to the tooth using polymeric materials and avoiding in this way the need of a laboratory wax-up.The aim of this report is to present the clinical case of a 31-year-old patient affected by dental erosion, treated using ultra-thin ceramic veneers in association with a direct mock-up technique. Immediate results and the 12-month recall were thoroughly documented.CASE REPORT.General profile of the patientA 31 year-old female patient, who reported dissatisfaction with her smile, with no relevant systemic medical history, was treated in the Adhesive and Aesthetic Dentistry Advanced Training Program at the University of Concepción, Chile.Clinical findingsExtra-oral examination of the patient revealed a symmetrical commissural plane and smile alterations (Figure 1A). The intraoral examination showed stable Grandon F, Marcus N & Muster M. Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053Figure 1. Initial clinic presentation.1A. Extra-oral evaluation of altered smile line. 1B. Intraoral view during occlusion. 1C. Close-up of upper central incisors. 1D. Palatal view of maxillary central incisors with wear compatible with erosion and attrition.ACBDISSN Online 0719-2479 - www.joralres.com © 2018256[Epub ahead of print]Figure 3. Clinical procedure.Figure 2. Direct mock-up.3A. Silicone index test prior to tooth preparation. 3B. Conservative tooth preparations. 3C. Ultra-thin ceramic veneers 3D. Conditioning of ceramic laminates with 10% hydrofluoric acid.2A. Application of composite resin for Direct mock-up. 2B. Finished direct mock-up in maxillary central incisors. 2C. Extra-oral view of direct mock-up, showing a recovered smile line. 2D. Disassembly of the mock-up from mouth.Grandon F, Marcus N & Muster M. Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053ACBDACBDocclusion, slight anterior-lower crowding and wear of the edges of the maxillary central incisors, compatible with dental erosion. During anamnesis, the patient reported the habit of chewing lemons, a behavior that she had already abandoned. In addition, resin restorations and mild attrition were observed in the lateral incisors (Figures 1B, C and D).Diagnostic evaluationAfter clinical examination, photographs, radiographs and stone dental models, it was concluded that the 257ISSN Online 0719-2479 - www.joralres.com © 2018[Epub ahead of print]Figure 4. Cementation of ceramic laminates.4A. Polymerization of photoactivatable resin cement with high power lamp. 4B. Cemented ceramic laminates that correct function and aesthetics. 4C. Right frontolateral view-12 months follow-up.  4D. Left frontolateral view -12 months follow-up.Grandon F, Marcus N & Muster M. Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053ACBDpatient had dental erosion at the initial stage, with an reverse smile line, as a result of this condition.Therapeutic interventionThe rehabilitation treatment consisted of the appli-cation of ultra-thin ceramic veneers in teeth 1.1 and 2.1, after direct mock-up with resin composite, given the moderate loss of dental structure. The lithium disilicate glass-ceramic IPS e.max® Press (Ivoclar Vivadent) was selected due to its widely documented clinical performance11,12 and a minimally invasive approach was followed.13 The teeth were prepared only after the volume to be replaced was determined. Here, the use of the direct mock-up technique resulted fundamental, allowing clinical projection of the results and avoiding an unnecessary tooth reduction. Resin composite TPH3 (Dentsply Sirona), shade A2, was used for this purpose. The mock-up was prepared by freehand modeling using a dental composite modeling instrument (Figure 2A), after previous application of the XP Bond adhesive system (Dentsply Sirona) to selectively etched enamel at the center of each tooth. Despite its temporary function, the prototype received a neat finishing. This was achieved by fine polishing with rotating elements and by subsequent application of a sealing agent (PermaSeal, Ultradent Products, Inc.) (Figure 2B).After approval by the patient (Figure 2C), the mock-up was maintained in the mouth for a week, in order to favor a progressive adaptation of phonetic functions and to observe its impact on the patient s´ social environment. After this period, silicone indexes, tooth preparation and functional impressions were obtained during a second clinical session. The prototypes were removed from each tooth with a sharp instrument (Figure 2D) and the extension of tooth preparations was estimated using a putty silicone index (Precise, Dentsply Sirona), previously obtained from the mock-up. It was thus observed that the tooth preparation would be restricted to some areas (Figure 3A). The preparations for the ultra-thin veneers were made with fine and ultrafine diamond burs and abrasive discs. The brittle incisal enamel was removed and a barely noticeable proximal and cervical termination lines were defined. Given the excellent translucency of this ceramic system, a supragingival cervical margin could be prepared (13) (Figure 3B). Temporary restorations were fabricated using a bis-acrylic based resin (Protemp 4, 3M ESPE). Complementary to the silicon impressions (Panasil Putty and Initial Contact Light, Kettenbach GmbH & Co. ISSN Online 0719-2479 - www.joralres.com © 2018258[Epub ahead of print]KG) and color selection, photographic sequences were taken. This allowed the dental technician to observe details and individual optical characteristics.Taking into account the high aesthetic relevance of the treatment for the patient and the proposed approach, the laboratory manufactured very thin ceramic veneers (0.3 millimeters), whose high light transmission favored mimicking of the restoration with the underlying substrate (Figure 3C). This high translucency required special considerations during the cementation phase of the restorations.14-16After final clinical adjustment and color check, comparing the outcomes of the veneers with the mock up photographs, the final color was simulated with Variolink Veneer Try-In pastes (Ivoclar Vivadent), shade +1. The veneers were then conditioned with 10% hydrof luoric acid (Figure 3D) for 20 seconds (Porcelain Conditioner, Dentsply Sirona). Following post-etching cleaning, the veneers were silanized with a silane coupling agent (Ultradent Products Inc.). The photopolymerizable resin cement Variolink Veneer (Ivoclar Vivadent), specially designed for this purpose, was applied to the intaglio surface of the veneers, which were then positioned in the mouth. The cement was polymerized with a high power lamp, and all excess was removed (Figure 4A). After occlusal adjustment, manual polishing was carried out to recover the brightness at the margin areas using the Optrafine® system (Ivoclar Vivadent) according to the manufacturer s´ instructions. An adequate aesthetic outcome was obtained and the patient reported to be very satisfied with her appearance (Figure 4B, C and D). DISCUSSION.The number of patients affected by dental wear has significantly increased in the last two decades, inducing dental health providers to reconsider their treatment protocols and to point towards early diagnosis and intervention.4 At present, adhesive procedures are the treatment of choice for this type of patients due to the important advances in the available restorative materials and in the adhesion techniques. Although several authors, such as Negrao et al.,18 point out that direct restoration techniques are feasible and low cost, strong clinical evidence support the safety and longevity of adhesively cemented ceramics, with survival rates up to 95% after 10 years and around 80% after 20 years.5,12,19 The advent of new technologies in the manufacturing and cementation of ceramic restorations has allowed continuous improvement of their aesthetics and natural appearance, expanding their indications towards implant and restorative dentistry.20 However, the use of ultra-thin veneers is a relatively recent technique, still requiring long-term clinical evaluation.6 Their application must be carefully planned and for this, the mock-up stage is essential. Just as architects and engineers use plans for the design of their projects, the clinician must use three-dimensional guides, not only to preview the final result of the treatment, but also to favor dental structure preservation.10 The reported direct mock-up technique seems to be an interesting treatment alternative for aesthetic rehabilitation of single teeth. Its rapid application, low cost and a very positive impact on the patient contrast with the traditional indirect mock-up technique,11 which involves longer and more expensive laboratory steps.CONCLUSION.The use of ultra-thin ceramic veneers in association with direct mock-up seems to be a promising alternative for the treatment of dental erosion, compared to traditional veneers and full coverage restorations. The direct mock-up technique allows a rapid preview of the final outcome, contributing to the predictability of this minimally invasive treatment. REFERENCES.1.  Fradeani M, Barducci G, Bacherini L. Esthetic rehabilitation of a worn dentition with a minimally invasive prosthetic procedure (MIPP). Int J Esthet Dent. 2016;11(1):16–35. 2.  Vailati F, Bruguera A, Belser U. Minimally Invasive Treatment of Initial Dental Erosion Using. 65. Pressed Lithium Disilicate Glass-Ceramic Restorations: A Case Report. Quintessence Dental Tech. 2012;35:65–78.3.  Bahillo J, Jané L, Bortolotto T, Krejci I, Roig M. Full-mouth composite rehabilitation of a mixed erosion and attrition patient: a case report with v-shaped veneers and ultra-thin CAD/CAM composite overlays. Quintessence Int. 2014;45(9):749–56. 4.  Gaillard C, Cofar F, Popp I, Bellamy J, Hue C. Repairing dental erosion with mini-mal-preparation dentistry. Validation of biological and functional esthetics in a full-mouth rehabilitation. Grandon F, Marcus N & Muster M. Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053259ISSN Online 0719-2479 - www.joralres.com © 2018[Epub ahead of print]Grandon F, Marcus N & Muster M. Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053J of Cosmetic Dent. 2016;32(3):96–109.5.  Edelhoff D, Prandtner O, Saeidi Pour R, Liebermann A, Stimmelmayr M, Güth JF. Anterior restorations: The performance of ceramic veneers. Quintessence Int. 2018;49(2):89–101.6.  Alencar MS, Araújo DF, Maenosono RM, Ishikiriama BL, Francischone CE, Ishikiriama SK. Reestablishment of esthetics with minimum thickness veneers: a one-year follow-up case report. Quintessence Int. 2014;45(7):593–7.  7.  Savi A, Crescini A, Tinti C, Manfredi M. Ultra-Thin Veneers Without Tooth Preparation in Extensive Oligodontia. Int J Periodontics Restorative Dent. 2015;35(6):e97–e103. 8.  Clavijo V, Sartori N, Phark JH, Duarte S. Novel Guidelines for bonded ceramic veneers: part 1. Is tooth preparation truly necessary? 1st Ed. Hanover Park, IL: Quintessence of Dental Technology; 2016.9.  Magne P, Magne M. Use of additive waxup and direct intraoral mock-up for enamel preservation with porcelain laminate veneers. Eur J Esthet Dent. 2006;1(1):10–9. 10.  Gurrea J, Bruguera A. Wax-up and mock-up. A guide for anterior periodontal and restorative treatments. Int J Esthet Dent. 2014;9(2):146–62.  11.  Teichmann M, Göckler F, Weber V, Yildirim M, Wolfart S, Edelhoff D. Ten-year survival and complication rates of lithium-disilicate (Empress 2) tooth-supported crowns, implant-supported crowns, and fixed dental prostheses. J Dent. 2017;56:65–77. 12.  Beier US, Dumfahrt H. Longevity of silicate ceramic restorations. Quintessence Int. 2014;45(8):637–44. 13.  Soares PV, Spini PH, Carvalho VF, Souza PG, Gonzaga RC, Tolentino AB, Machado AC. Esthetic rehabilitation with laminated ceramic veneers reinforced by lithium disilicate. Quintessence Int. 2014;45(2):129–33. 14.  Azer SS, Rosenstiel SF, Seghi RR, Johnston WM. Effect of substrate shades on the color of ceramic laminate veneers. J Prosthet Dent. 2011;106(3):179–83.  15.  Chen XD, Hong G, Xing WZ, Wang YN. The influence of resin cements on the final color of ceramic veneers. J Prosthodont Res. 2015;59(3):172–7.  16.  Igiel C, Weyhrauch M, Mayer B, Scheller H, Lehmann KM. Effects of ceramic layer thickness, cement color, and abutment tooth color on color reproduction of feldspathic veneers. Int J Esthet Dent. 2018;13(1):110–9. 17.  Koubi S, Gurel G, Margossian P, Massihi R, Tassery H. A Simplified Approach for Restoration of Worn Dentition Using the Full Mock-up Concept: Clinical Case Reports. Int J Periodontics Restorative Dent. 2018;38(2):189–97.  18.  Negrão R, Cardoso JA, de Oliveira NB, Almeida PJ, Taveira T, Blashkiv O. Conservative restoration of the worn dentition - the anatomically driven direct approach (ADA). Int J Esthet Dent. 2018;13(1):16–48. 19.  Morimoto S, Albanesi RB, Sesma N, Agra CM, Braga MM. Main Clinical Outcomes of Feldspathic Porcelain and Glass-Ceramic Laminate Veneers: A Systematic Review and Meta-Analysis of Survival and Complication Rates. Int J Prosthodont. 2016;29(1):38–49.  20.  Grandon F, Galdames B, Marcus N, Muster M. Cerámica libre de metal terminada y caracterizada por pulido manual. Rev Clin Periodoncia Implantol Rehabil Oral. 2018;11(1):39–42.

Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – Case report

Dental erosion is a high prevalence condition characterized by the loss of dental substance due to chemical agents. It can also be associated with physical wear, affecting function and aesthetics. Ceramic veneers can provide effective solutions to patients affected by erosive disorders, by means of an indirect approach and minimal intervention. Recent advances in cementation techniques and ceramic materials have allowed their use in reduced thicknesses, known as "dental contact lenses" or "ultra-thin veneers". They contribute significantly to the preservation of the dental structures, having excellent mechanical properties and providing satisfactory aesthetic solutions. Their manufacture requires rigorous planning and the use of three-dimensional models or mock ups in order to preview the final outcome. Case: The aim of this report is to communicate the use of this technique for the treatment and successful 12-months follow-up of a patient affected by dental erosion of the maxillary central incisors. Special interest was placed on direct mock-up, which is a simple technique not requiring laboratory steps. Luting of the lithium disilicate veneers was carried out with a light-curing resin cement and try-in pastes, yielding a very satisfactory result. Conclusion: Diagnosis and early treatment of this disorder allows the application of conservative techniques, such as ultra-thin veneers, which are seen as a promising alternative treatment to full coverage restorations and traditional ceramic veneers

Grandon, Fernando

Marcus, Natalia

Muster, Maria

Journal of Oral Research (J Oral Res - Facultad de Odontología de la Universidad de Concepción)

Case
ISSN Online 0719-2479 - www.joralres.com © 2018254
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Fernando Grandon,1,2 Natalia Marcus1 & Maria Muster.3
Affiliations: 1Departamento de Odontología 
Restauradora. Facultad de Odontología; Uni-
versidad de Concepción, Chile. 2Programa 
Odontología Estética Adhesiva. Universidad  de 
Concepción, Chile. 3Facultad de Odontología, 
Universidad Andrés Bello, Concepción, Chile.
Corresponding author: Fernando Grandon. 
Roosevelt 1550, Concepción, Chile. Phone: 
(56- 41) 2204481. E-mail: fgrandonv@gmail.
com; fgrandon@udec.cl
Abstract: Dental erosion is a high prevalence condition characterized by the 
loss of dental substance due to chemical agents. It can also be associated with 
physical wear, affecting function and aesthetics. Ceramic veneers can provide 
effective solutions to patients affected by erosive disorders, by means of an 
indirect approach and minimal intervention. Recent advances in cementation 
techniques and ceramic materials have allowed their use in reduced thicknesses, 
known as "dental contact lenses" or "ultra-thin veneers". They contribute 
significantly to the preservation of the dental structures, having excellent 
mechanical properties and providing satisfactory aesthetic solutions. Their 
manufacture requires rigorous planning and the use of three-dimensional 
models or mock ups in order to preview the final outcome. Case: The aim of 
this report is to communicate the use of this technique for the treatment and 
successful 12-months follow-up of a patient affected by dental erosion of the 
maxillary central incisors. Special interest was placed on direct mock-up, which 
is a simple technique not requiring laboratory steps. Luting of the lithium 
disilicate veneers was carried out with a light-curing resin cement and try-
in pastes, yielding a very satisfactory result. Conclusion: Diagnosis and early 
treatment of this disorder allows the application of conservative techniques, 
such as ultra-thin veneers, which are seen as a promising alternative treatment 
to full coverage restorations and traditional ceramic veneers. 
Keywords: Ceramic veneers; dental erosion; mock-up; lithium disilicate.
INTRODUCTION.
Adhesive dentistry has supported conservative therapies in the 
treatment of patients affected by various kinds of dental wear. Dental 
erosion is one of the common causes of wear, especially in young 
patients, being often dismissed by clinicians, which makes intervention 
in early stages difficult.1,2 It is defined as the loss of dental substance 
due to a chemical process and is caused mainly by the consumption of 
fruit juice, carbonated and isotonic drinks or by digestive disorders. 
Many patients have a combined etiology of erosion and attrition, 
resulting in a relatively rapid impact on tooth structure.3 In advanced 
stages, in addition to its negative aesthetic impact, it can seriously 
affect function.4  
An early intervention prevents tooth loss and allows the use of 
additive procedures, in many cases not even requiring tooth substance 
removal. These direct or indirect adhesive techniques replace the 
missing structure and protect the patient from further damage.2 
Ceramic veneers can help in the treatment of patients affected by 
Conflict of interests:  The authors report no 
conflicts of interest.
Funding: None.
Authors’ contributions: All authors contributed to 
the execution of the study. 
Acknowledgements: None.
Cite as:  Grandon F, Marcus N & Muster M. 
Esthetic rehabilitation with ultra-thin ceramic 
veneers and direct mock-up in the treatment of 
dental erosion – case report. J Oral Res 2018; 
7(6):254-259.
doi:10.17126/joralres.2018.053
Receipt: 05/07/2018 Revised: 05/23/2018
Acceptance:  07/04/2018 Online: 07/26/2018
Esthetic rehabilitation with ultra-thin ceramic 
veneers and direct mock-up in the treatment of 
dental erosion – case report.
255ISSN Online 0719-2479 - www.joralres.com © 2018
[Ep
ub
 ah
ead
 of
 pr
int
]
erosive disorders, using an indirect approach with 
minimal intervention. Their use, long been considered 
just a aesthetic treatment, has recently expanded, mainly 
due to the superior mechanical properties of new glass-
ceramics and to the improvement of the cementation 
strategies. The significant improvement in the fracture 
strength of glass-ceramic veneers has enabled their use 
in very reduced thickness.5 These features, in addition 
to a continuous demand for more aesthetic solutions, 
have strongly contributed to the increasing popularity 
of minimally invasive ceramic veneers (also known as 
dental contact lenses) among clinicians. Edelhoff et al., 
point out5 that their use enables restorative procedures 
even avoiding the need of a previous tooth preparation. 
Lithium disilicate based ceramics are preferred as they 
combine aesthetics and high strength. Alencar et al.,6 
described ceramic veneers as thin as 0.6 millimeters, 
whereas Savi et al.,7 and Clavijo et al.,8 reported 
even lower thicknesses (down to 0.2 millimeters) by 
using refractory and pressing techniques. Specialized 
laboratory, a skillful clinician, and meticulous planning 
are essential to achieve successful results. Design 
and manufacture of such thin structures requires an 
appropriate determination of their morphology and size 
by the clinician, long before the laboratory stage. The 
use of prototypes or mock-ups, which rely on a previous 
diagnostic wax-up and are transferred by different 
techniques to the patient,9,10 offer an excellent alternative 
to preview the expected outcome. A variation of this 
technique is the direct mock-up, where a temporary 
restoration of the lost volume is directly applied to the 
tooth using polymeric materials and avoiding in this 
way the need of a laboratory wax-up.
The aim of this report is to present the clinical case of 
a 31-year-old patient affected by dental erosion, treated 
using ultra-thin ceramic veneers in association with a 
direct mock-up technique. Immediate results and the 
12-month recall were thoroughly documented.
CASE REPORT.
General profile of the patient
A 31 year-old female patient, who reported 
dissatisfaction with her smile, with no relevant systemic 
medical history, was treated in the Adhesive and 
Aesthetic Dentistry Advanced Training Program at the 
University of Concepción, Chile.
Clinical findings
Extra-oral examination of the patient revealed a 
symmetrical commissural plane and smile alterations 
(Figure 1A). The intraoral examination showed stable 
Grandon F, Marcus N & Muster M. 
Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.
J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053
Figure 1. Initial clinic presentation.
1A. Extra-oral evaluation of altered smile line. 1B. Intraoral view during occlusion. 1C. Close-up of upper central incisors. 
1D. Palatal view of maxillary central incisors with wear compatible with erosion and attrition.
A
C
B
D
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Figure 3. Clinical procedure.
Figure 2. Direct mock-up.
3A. Silicone index test prior to tooth preparation. 3B. Conservative tooth preparations. 3C. Ultra-thin ceramic veneers 3D. 
Conditioning of ceramic laminates with 10% hydrofluoric acid.
2A. Application of composite resin for Direct mock-up. 2B. Finished direct mock-up in maxillary central incisors. 2C. Extra-oral 
view of direct mock-up, showing a recovered smile line. 2D. Disassembly of the mock-up from mouth.
Grandon F, Marcus N & Muster M. 
Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.
J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053
A
C
B
D
A
C
B
D
occlusion, slight anterior-lower crowding and wear of the 
edges of the maxillary central incisors, compatible with 
dental erosion. During anamnesis, the patient reported 
the habit of chewing lemons, a behavior that she had 
already abandoned. In addition, resin restorations and 
mild attrition were observed in the lateral incisors 
(Figures 1B, C and D).
Diagnostic evaluation
After clinical examination, photographs, radiographs 
and stone dental models, it was concluded that the 
257ISSN Online 0719-2479 - www.joralres.com © 2018
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ub
 ah
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 of
 pr
int
]
Figure 4. Cementation of ceramic laminates.
4A. Polymerization of photoactivatable resin cement with high power lamp. 4B. Cemented ceramic laminates that correct function and 
aesthetics. 4C. Right frontolateral view-12 months follow-up.  4D. Left frontolateral view -12 months follow-up.
Grandon F, Marcus N & Muster M. 
Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.
J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053
A
C
B
D
patient had dental erosion at the initial stage, with an 
reverse smile line, as a result of this condition.
Therapeutic intervention
The rehabilitation treatment consisted of the appli-
cation of ultra-thin ceramic veneers in teeth 1.1 and 2.1, 
after direct mock-up with resin composite, given the 
moderate loss of dental structure. The lithium disilicate 
glass-ceramic IPS e.max® Press (Ivoclar Vivadent) 
was selected due to its widely documented clinical 
performance11,12 and a minimally invasive approach 
was followed.13 The teeth were prepared only after the 
volume to be replaced was determined. Here, the use 
of the direct mock-up technique resulted fundamental, 
allowing clinical projection of the results and avoiding 
an unnecessary tooth reduction. Resin composite TPH3 
(Dentsply Sirona), shade A2, was used for this purpose. 
The mock-up was prepared by freehand modeling using 
a dental composite modeling instrument (Figure 2A), 
after previous application of the XP Bond adhesive 
system (Dentsply Sirona) to selectively etched enamel at 
the center of each tooth. Despite its temporary function, 
the prototype received a neat finishing. This was 
achieved by fine polishing with rotating elements and 
by subsequent application of a sealing agent (PermaSeal, 
Ultradent Products, Inc.) (Figure 2B).
After approval by the patient (Figure 2C), the mock-
up was maintained in the mouth for a week, in order 
to favor a progressive adaptation of phonetic functions 
and to observe its impact on the patient s´ social 
environment. After this period, silicone indexes, tooth 
preparation and functional impressions were obtained 
during a second clinical session. The prototypes were 
removed from each tooth with a sharp instrument 
(Figure 2D) and the extension of tooth preparations was 
estimated using a putty silicone index (Precise, Dentsply 
Sirona), previously obtained from the mock-up. It was 
thus observed that the tooth preparation would be 
restricted to some areas (Figure 3A). The preparations 
for the ultra-thin veneers were made with fine and 
ultrafine diamond burs and abrasive discs. The brittle 
incisal enamel was removed and a barely noticeable 
proximal and cervical termination lines were defined. 
Given the excellent translucency of this ceramic system, 
a supragingival cervical margin could be prepared (13) 
(Figure 3B). Temporary restorations were fabricated 
using a bis-acrylic based resin (Protemp 4, 3M ESPE). 
Complementary to the silicon impressions (Panasil Putty 
and Initial Contact Light, Kettenbach GmbH & Co. 
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KG) and color selection, photographic sequences were 
taken. This allowed the dental technician to observe 
details and individual optical characteristics.
Taking into account the high aesthetic relevance of 
the treatment for the patient and the proposed approach, 
the laboratory manufactured very thin ceramic veneers 
(0.3 millimeters), whose high light transmission favored 
mimicking of the restoration with the underlying 
substrate (Figure 3C). This high translucency required 
special considerations during the cementation phase of 
the restorations.14-16
After final clinical adjustment and color check, 
comparing the outcomes of the veneers with the mock 
up photographs, the final color was simulated with 
Variolink Veneer Try-In pastes (Ivoclar Vivadent), 
shade +1. The veneers were then conditioned with 
10% hydrof luoric acid (Figure 3D) for 20 seconds 
(Porcelain Conditioner, Dentsply Sirona). Following 
post-etching cleaning, the veneers were silanized with 
a silane coupling agent (Ultradent Products Inc.). The 
photopolymerizable resin cement Variolink Veneer 
(Ivoclar Vivadent), specially designed for this purpose, 
was applied to the intaglio surface of the veneers, which 
were then positioned in the mouth. The cement was 
polymerized with a high power lamp, and all excess was 
removed (Figure 4A). After occlusal adjustment, manual 
polishing was carried out to recover the brightness at 
the margin areas using the Optrafine® system (Ivoclar 
Vivadent) according to the manufacturer s´ instructions. 
An adequate aesthetic outcome was obtained and the 
patient reported to be very satisfied with her appearance 
(Figure 4B, C and D). 
DISCUSSION.
The number of patients affected by dental wear has 
significantly increased in the last two decades, inducing 
dental health providers to reconsider their treatment 
protocols and to point towards early diagnosis and 
intervention.4 At present, adhesive procedures are the 
treatment of choice for this type of patients due to the 
important advances in the available restorative materials 
and in the adhesion techniques. Although several authors, 
such as Negrao et al.,18 point out that direct restoration 
techniques are feasible and low cost, strong clinical 
evidence support the safety and longevity of adhesively 
cemented ceramics, with survival rates up to 95% after 10 
years and around 80% after 20 years.5,12,19 The advent of 
new technologies in the manufacturing and cementation of 
ceramic restorations has allowed continuous improvement 
of their aesthetics and natural appearance, expanding their 
indications towards implant and restorative dentistry.20 
However, the use of ultra-thin veneers is a relatively recent 
technique, still requiring long-term clinical evaluation.6 
Their application must be carefully planned and for this, 
the mock-up stage is essential. Just as architects and 
engineers use plans for the design of their projects, the 
clinician must use three-dimensional guides, not only 
to preview the final result of the treatment, but also to 
favor dental structure preservation.10 The reported direct 
mock-up technique seems to be an interesting treatment 
alternative for aesthetic rehabilitation of single teeth. Its 
rapid application, low cost and a very positive impact on 
the patient contrast with the traditional indirect mock-
up technique,11 which involves longer and more expensive 
laboratory steps.
CONCLUSION.
The use of ultra-thin ceramic veneers in association 
with direct mock-up seems to be a promising alternative 
for the treatment of dental erosion, compared to 
traditional veneers and full coverage restorations. The 
direct mock-up technique allows a rapid preview of the 
final outcome, contributing to the predictability of this 
minimally invasive treatment. 
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Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.
J Oral Res 2018; 7(6):254-259. doi:10.17126/joralres.2018.053
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Grandon F, Marcus N & Muster M. 
Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.
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Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – case report.

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Esthetic rehabilitation with ultra-thin ceramic veneers and direct mock-up in the treatment of dental erosion – Case report

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