Clinical

Predictable and precise tooth

preparation techniques for porcelain
laminate veneers in complex cases
Galip Gürel1

Porcelain laminate veneers (PLVs) are one of the most (Belser UC, Magne P, Magne M, 1997). The best situation
conservative and aesthetic techniques that can be applied in which to place veneers is when the teeth are perfectly
when restoring the mouth for improved aesthetics. The aligned on the dental arch and the facial structures of the
longevity of the veneers is good and they are durable, teeth are not worn, which happens with age.
especially if the right indications are in place and the
correct techniques are applied (Horn HR, 1983). Standard preparation technique
The fundamental concept in any restorative case is to An amount of tooth structure, equivalent to the thickness
keep it simple and to concentrate on just one objective – of the veneer that will be placed on the tooth, should be
conservation of the sound tooth structure. removed. Since the shape, volume or contours of the
Where the dentine-enamel junctions (DEJ) meet is tooth will not be changed, standard tooth preparation
very important in terms of the structural strength of the techniques can be used (Figures 1a, 1b and 1c) (Strub JR,
tooth: a complex fusion occurs at the DEJ that can be Türp JC, 1999). When the exact depth needed for the
regarded as a fibre-reinforced bond (Lin CP, Douglas porcelain build-up is removed, finishing the restoration
WH, Erlandsen SL, 1993). should not pose any problems (Figures 2a, 2b and 2c).
If preparation is limited to the enamel, there would be The procedure should begin with the use of a depth
insufficient flexibility in the teeth (Magne P, Douglas WH, cutter (Garber DA, Goldstein RE, Feinman RA, 1988;
1999). If the preparation line passes through the DEJ Nixon RL, 1990; Garber DA, 1993), which indicates the
margin and enters into dentine, while it won’t create a exact depth that is to be prepared and which depends
major problem, a number of difficulties may occur if one on the material selection or the colour of the tooth to be
ends up finishing the preparation on large amounts of restored (Figures 3a and 3b). Once this is established, the
dentine. This will not only create complex bonding issues surface of the tooth should be painted a different colour,
on dentine but will also free the ‘flexing’ factor on the after which a round-ended fissure bur is used to finalise
tooth structure (Noack MJ, Roulet J-F, 1987; Van the facial reduction. The important factor here is that the
Meerbeek B et al, 1996; Van Meerbeek B et al, 1998). bur is used at three different angles in order to conform
When the tooth starts flexing, a new phenomenon to the facial convexity of the tooth structure. It is only in
occurs. Firstly, a tooth that has been aggressively prepared this way that the dentist can achieve consistent thickness
has a tendency to bend and the intention is to bond a of the porcelain material, i.e. the porcelain build-up.
veneer – a porcelain material – that is very rigid on top of Once this reduction has been performed, the
that. Adhesive luting resin will be used in between those preparation is finished at the gingival margin and then
two structures, which will try to absorb all the stresses. If extended towards the papilla to finish the interproximal
the tooth is subject to different occlusal forces and elbow preparation. This is important, especially when
continues to flex, the luting resin at the margin will slowly dealing with discolouration. If the depth is not prepared
start to peel off, and the clinician is likely to be faced with correctly, the connection between the dark-coloured
micro-leakage or de-lamination. tooth and the light-coloured porcelain will be visible
To minimise these effects and problems, precision and care when seen from an angle, which is clearly not
must be taken with case selection and tooth preparation aesthetically pleasing.
To set up for this dogleg preparation, the bur is held at
1
Private Practice, Istanbul, Turkey an angle of almost 60º towards the palate. Once the exact

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 Clinical

1a 1b 1c

2a 2b

3a 3b 2c

4a 4b 5

Figure 1a: Teeth exhibiting large composite fillings. Figure 1b: Teeth are bleached. Note the colour difference between the bleached parts of the
incisors and the existing composite fillings. Figure 1c: Note the existing large composites and cavity on the palatal side. Figures 2a and 2b:
Finished and bonded veneers with facial and lingual view after two years. Figure 2c: Full smile and facial integration. Figure 3a: The retraction
cord is placed in the sulcus to prevent soft tissue damage during tooth preparation and for better margin displacement during impression taking.
First the depth cutters are used for exacting the depth of the preparation. Figure 3b: Standard tooth preparation. Figure 4a: The last reduction
is from the incisal edges. The necessary depth is created with a fissure bur of choice by creating some ditches and then these are connected to
each other to create a butt joint. Figure 4b: To finish the preparation the existing composites are removed and the margins are rounded. Figure
5: Previously built shell provisionals are tried in the mouth, then filled with composite and temporarily bonded onto the prepared teeth.

depth has been achieved, the bur should be held in an What if the teeth are not aligned properly?
upright position to finish the interproximal preparation One of the major indications for using PLV is space
(Morley J, 1999). The butt joint preparation of the incisal management. It becomes more of a challenge if the teeth
edge should be omitted to give the laboratory technician are spaced or not properly aligned on the dental arch - for
enough room to build up the artistic, translucent, example, in the case of crowding. The dentist is afced with
opalescence effects, incisal silhouette, etc (Figures 4a and two problems when the teeth are not aligned properly on
4b). As in every PLV case, the direct or prefabricated the dental arch:
provisionals are placed after the impression has been 1. Visualising the aesthetic outcome
taken (Figure 5). 2. Tooth preparation.

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Figure 6: The unaesthetic appearance of the Figure 7: Analysing the smile at an angle Figure 8: From this view the AOP can easily
smile, which is relatively dark in colour, has shows the crowding of the centrals. be evaluated. The deciduous canines display
short crowns, uneven gingival levels, a distinct concavity.
crowded incisors, an uneven incisal
silhouette and a deciduous canine on the
second quadrant.

Aesthetic communication appearance. The patient may wish to reinstate a look that
Creating natural-looking smiles has been established over a long period of time or may
When considering the approach for smile design, the request an alteration that is totally unrealistic for their
dentist undertakes to create a new, but natural aesthetic face. Perhaps one of the most difficult tasks is selecting
effect. With each restoration the patient must be the right treatment in order to achieve successful
considered as a whole, rather than focusing merely on one aesthetic dentistry. It should be noted that one setback
or two teeth. Each tooth exists as part of the mouth and can easily erase many brilliant and successful procedures.
face, contributing to the formation of a smile that reflects The ability to say ‘no’ will prevent problems. If the
the patient’s personality. When creating a restoration, aesthetic dentist and patient find it difficult to agree on
harmony in the size, shape and arrangement of the teeth is the propsed objectives, it is in the best interests of both
required to enhance each individual patient’s facial features. parties not to begin the treatment.
Once the teeth, the surrounding soft tissue and the patient’s
facial characteristics are taken into consideration, a three- Analysing the smile
dimensional overview is needed. The dentist must be aware In order to have a clear visual idea of the final outcome, the
of the ratio between the anterior teeth and the surrounding existing smile should be analysed three-dimensionally.
tissue, and to analyse them to achieve the desired result.
An aesthetic case may vary from the simple aesthetic The facial view
contouring of a corner of a single tooth to the complete When the smile is analysed from a full-face perspective, only
recreation of a new smile involving the entire dentition. The mesio-distal or vertical problems can be dealt with.
mouth and its physiological make-up for each individual In the second illustrated case it is evident that the centrals
patient must be studied carefully by the aesthetic dentist, overlap, causing a vertical canting of the mid-line that is
who should analyse and anticipate any problems that may visible even to people with no dental knowledge.
arise during the treatment. Proportionally speaking, the existing teeth are short for the
The first hurdle involves managing the patient’s face and the gingival levels are uneven (Figure 6).
expectations. What the patient wants and what the
clinician can achieve needs to be successfully 45º angle view (checking buccal-lingual
communicated. This communication and co-operation dimension)
between the patient and the dentist will determine the This angle allows the dentist to check the crowding in

mesial incisal tip of 1L is more buccally placed relative to

success or failure of the treatment. The aesthetic a more reliable manner. In this case it is evident that the

tooth L1 (Figure 7). However, at this very early stage it

dentist needs to be completely attuned to the patient,
interpreting both verbal requests and the less obvious
non-verbal cues. may not be possible to decide which incisal edge

dimension. Should tooth L1 be built up buccally or

The dentist who is able to generate a confident, position to use as a reference point in a buccal-lingual

should tooth 1L be brought lingually?

competent and observant manner will inspire confidence
in the proposed treatment and help the patient to feel
relaxed. The dentist’s perception of a desirable smile and
the type of design should be discussed with the patient Aesthetic occlusal plane (AOP)
and be considered with their personal thoughts on their The third dimension to be checked in the aesthetic

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9 10 11

Figure 9: The incisal edges are aligned with a composite mock-up and the incisal edge position is defined. Then a reverse mock-up is applied
over the soft tissues in order to determine where the soft tissues should be after the perio operation. Meanwhile the length to width ratio
of the teeth are carefully worked out. Figure 10: After perio surgery, a new mock-up is produced in order to gauge the new proportions and
relations among the teeth more successfully. Figure 11: Teeth are bleached after crown lengthening. Note the altered gingival margins.

12 13 14

Figure 12: The final wax-up. Figure 13: A silicone index (SI) according to this wax-up is built to be used during the preparation stage. This

L
SI is tried on the teeth. Note that SI can not be seated on the arch passively, due to the protruded position of the mesio-incisal corner of
tooth 1 . Figure 14: In such situations, APR (aesthetic pre-recontouring) is carried out. The protruding surfaces of teeth that are positioned

L
labially – relative to the final contours of the finished PLVs – are trimmed down until the silicone index can be passively seated on the dental
arch. Note the trimmed mesio-incisal edge of tooth 1 and how passively the index is seated on the arch after the APR. In order to test the
final outcome of the proposed smile design, the APTs (aesthetic pre-evaluative temporaries) have to be tested.

evaluation is the AOP, which can simply be done from visualise the final outcome of the veneers, and one can see
how the smile will look when these composites are
canine exists (tooth Lc ), which creates a problem
a saggital view. In this particular case, a deciduous
placed (Figure 9). This does not need to be as precise as
related to the AOP since it is too short (Figure 8). At this a wax-up but it will give the dentist an idea of how/where
point, it is preferable if the angulation of the centrals is the length of these teeth should be, where to place the
perpendicular to the AOP. facial bulkiness and its effect on the lip structure, on
phonetics and on occlusion (Peumans M et al 1998;
Functional evaluation Chiche GJ, Pinault A, 1994; Romano R, Bichacho N,
Since the final restorations must be long lasting, their Touati B, 2005). This mock-up will be a great tool or
foundation is of great importance. When the root of guide for the lab technician to build up his wax-up. At the
the deciduous tooth Lc was checked on the X-ray, it was end of the process, this information should be shared
obvious that it would not be able to withstand the with the patient to confirm the first step towards a
lateral forces, especially during occlusion. Nor would it functional and aesthetic outcome (Dawson PE, 1989).
survive if canine-guided occlusion is planned.
Second mock-up
Treatment planning However, in cases where the gingival levels need to be
At this stage, It is almost impossible to be sure of the final altered (which will change the length of the crown
outcome just by looking at this case intra or extra-orally. apically), it is always more reliable to make a second
With all these problems or imperfections in the mouth, mock-up. This will illustrate the new proportions and the
the aesthetic final outcome should initially be visualised smile design more successfully than a reverse mock-up.
and realised and this knowledge or information shared Six to eight weeks after the perio surgery is finished, a
with the patient. The first step towards achieving this is new mock-up is produced (Figure 10). This second mock-
the composite mock-up (Dietschi D, 1995; Vanini L, 1996; up following the perio surgery will help the dentist and
Baratieri LN et al, 1998). the ceramist design the teeth proportions in relation to
the position of the new gingival margins. The new
Mock-up impression based on this mock-up is then sent to the
A simple freehand carved composite can be used to ceramist for the wax-up. The new mock-up will provide

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15a 15b 16

Figures 15a and b: An impression taken of the wax-up is filled with a flowable composite (or any material of choice) and placed on the
unprepared teeth Figure 16: Completed smile design, before any tooth preparation is carried out (APT). This should now mimic the exact
final contours, texture and shape of the final PLVs.

the ceramist with more reliable information for the final this stage: one or few teeth may touch or push the
wax-up. silicone index bucally, indicating that these teeth are

prepare the deciduous canine Lc and tooth L4 for crowns

Another decision that can be made at this point is to either rotated or positioned more labially than the
expected final outcome. Those teeth must then be
and connect them to each other for better support. This trimmed down in order to place the silicone index
will result in a small group function (instead of canine passively on the dental arch in a process called APR
only) through the canine and first premolar, which will (aesthetic pre-recontouring) (Gurel G, 2003a) (Figure 14).
also affect the design of the final wax-up. If necessary,
the teeth can be bleached during this period (Figure 11). APT (aesthetic pre-evaluative temporaries)

tooth 1L has to be positioned and restored lingually. The

It is now evident that the incisal-mesial corner of The wax-up can then be applied to the tooth structure
while the provisionals are being made. The technique
best choice of treatment would be to pull it back with used is to make a transparent silicone impression from
orthodontics first and then to continue with minimal the wax-up and in the mouth, fill it with the flowable
invasive techniques. However, time limitations for this composite, then place it on the unprepared teeth; light
specific case did not allow for such treatment planning. cure it and take the translucent impression material out
However, this situation should be communicated to the of the mouth (Figures 15a and b). This would not have
lab so that they know to trim that corner slightly been possible had the teeth been rotated or positioned
inwards during the wax-up. buccally, nor been recontoured with APR as the
At this stage, two impressions of the patient's dental transparent impression wouldn’t fit on those teeth.
arches must be taken: one of the original existing tooth The gingival margins are then trimmed slightly to create,
structure with all diastemas and misaligned teeth, and in plastic, the exact expected final outcome of the porcelain.
the second with the mock-up. Because the patient is not numbed, this is the best way to
The lab technician should relate these two using a assess the aesthetic outcome (Figure 16). The lip support of
silicone index and finalise his wax-up with all the these restorations and the aesthetic length can be evaluated
details, as though building up the porcelain easily, and should be approved by the patient. The
restorations. The technician is now free to reduce the functional movements of the patient must also be

1L ) and then finish the wax-up according to the

facial surface of the protruding teeth (in this case tooth evaluated to see whether an anterior constriction is present,
and if phonetics may be a problem in the future. Once this
guidelines of the mock-up (Figure 12). is approved by the patient, the dentist can move onto the
next stage.
APR (aesthetic pre-recontouring) The APT (aesthetic pre-evaluative temporaries) are no
At the next appointment when the patient comes for the different from a provisional on the tooth structure before
tooth preparation, the dentist should be provided with a the teeth have been touched (Gurel G, 2003a; Gurel G
silicone index (made from the wax-up model) that will 2003b; Gurel G, 2003c). These provisionals can then be
indicate the final contours of the teeth. The index is then double checked with silicone index to make sure that they
placed over the dental arch in order to visualise the are placed in the mouth correctly.
existing positions of those teeth on the dental arch,
relative to the final outcome of the wax-up and veneers Tooth preparation in complicated cases
(Figure 13). It may be possible to detect one problem at There is a second potential problem at this stage: what if

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17 18 19

Figure 17: Since the APT resembles the exact facial contours of the proposed smile design, now the tooth operation can be done through the

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APT. This will give the dentist and the ceramist the exact volume of reduction, hence being minimally invasive. Figure 18: Incisal reduction
finished through the APT. Figure 19: The final preparation. Note how the mesio-incisal corner of the tooth 1 had to be reduced more than
all the other teeth due to its protrusive. position. Hence all the other teeth are minimally prepped with almost all the enamel left intact on
their surfaces

20 21 22

L L
Figure 20: The deciduous canine c and the premolar 4 are prepped to receive crowns connected to each other in order to support the
functional loads, especially during the excursions. Note the 360° champher all around the gingival margin. Figure 21: The final check for
preparation depth of the veneers as well as the crowns with the SI. Figure 22: Provisional temporarily bonded in the mouth, replicating the
final result exactly.

the standard preparation technique cannot be used? When interproximal lines can then be finished.
the teeth are not aligned properly into the dental arch With rare cases such as this, if a substractive correction
(the teeth may have rotations or may be placed lingually was done on the wax-up stage, far more tooth structure

depth, and tooth 1L gets a substractive correction. The

or buccally), how can the final success of that case be would be removed than would for a standard preparation
assessed and the teeth prepared precisely and
predictably every time? mesial incisal corner is prepared aggressively in order to
align it properly, while the facial contours of the expected
Tooth preparation through APT dental arch are formed as planned after the veneers are
The beauty of these aesthetic provisional temporaries, finished. As mentioned previously, the best way of
besides the evaluation of aesthetic functions and handling such a case is to prealign the position of such
phonetic aspects, is that the dentists have a great tool at teeth orthodontically before beginning the preparations.
their disposal to prepare the teeth. They can simply use The same reduction will be carried out on the incisal
these APTs as a guideline for preparing tooth structure. edge and surprisingly, most of the time, it is unnecessary
APT resembles the exact contours of the final outcome. to prepare too much incisal healthy tooth structure
such as the incisal edge position and the facial volume (Castelnuovo J et al, 2000) (Figure 19).
(contours) of the teeth. Since everything is already set in In PLV preparation the dentists tend to finish the
advance, preparation of the teeth through the APT can gingival champher supragingivally unless they are dealing
begin as if though dealing with a simple case where the with a severe discolouration or with spaced dentition.

deciduous canine Lc and first premolar tooth L4 can be

teeth are aligned properly. At this point, it is of no After finishing the tooth preparation for the veneers,
consequence how the teeth are aligned underneath
(Gurel G, 2003a) (Figures 17 and 18). In some situations, prepared for the all ceramic crowns. They will then be
the tooth surface may not be prepared if, for example, connected to each other for functional support and a
the tooth is too palately placed (i.e. more than 0.6 mm small group function for the lateral excursions (Figure 20).
away from the facial contours of the APT). Once the Once the preparation is finished, the same silicone index
major reduction with the depth cutters is made, followed is used once more to check and verify the correct
by the round ended fissure burs, the major facial volume preparation depths (Figure 21). The impression is made
reduction will be completed. The gingival margins and and the provisionals are fabricated. The provisionals

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23a 23b
Figures 23a and b: The smile from different angles.

should be exactly the same as the APT as this will be a veneer in place. Then switch the tip of the light source to a
second chance for the patient to assess the final outcome larger diameter such as 13mm and light cure the excess
during the fabrication (Figure 14). flesh around the gingiva for only one or two seconds. This
will not fully polymerise the luting resin but bring it to a jelly-
The lab procedures like consistency, which can be easily cleaned with an
The veneers can be fabricated with feldspathic porcelain explorer dipped into an adhesive liquid. The interproximal
on a refractory die, or on platinum foil. Alternatively, one contacts can then be cleansed using dental floss between
can use pressable ceramics with external staining or the veneers. Once everything is completed, the luting resin
layering techniques. can be fully polymerised.
In this case, the pressable porcelain will be used with In order to finalise the bonding procedure, a # 12 blade
the layering technique. Whichever technique is used, it is will help to clean the undetected remaining composite on
important that the ceramist uses the same silicone index the margins. If necessary, the margins can be polished with
that was used in the mouth, which fits perfectly on the a rubber cup. Using a diamond bur should be avoided as it
APT that was approved as the final outcome. The rest is would totally ruin the glaze and polish of the porcelain on
down to the ceramist’s knowledge, ability and talent for the margins.
integrating the colours, form, shape and texture. The PLVs’ final position, form, phonetics, lip support is
guaranteed as the same aesthetic, functional and
Try in phonetic results established during the APT and
When the veneers arrive from the lab, they should first be provisionalisation will be the same after the PLVs are
tried in the mouth. Preferably, the provisionals should be bonded (Figures 15a and 15b).
taken out and PLVs tried in without anaesthesia, making
it easier to check the lip support and the incisal edge Summary
position relative to the upper lip. The PLV is one of the most common aesthetic restorations.
The veneers should initially be tried one by one in order Even though it is one of the most conservative of treatment
to check the marginal fit accurately, and then together, to options, some rules have to be followed. Aesthetics is a very
see their overall integration with each other, with the lips objective subject and necessitates excellent communication
and finally, with the face. between the dentist, patient and ceramist. The case has to
be carefully selected and treatment planned. The use of the
Bonding mock-ups, followed by a wax-up, APT and silicone index
The author prefers a sectional rubber dam placed in the will not only allow the dentist to achieve the best aesthetic,
mouth. Once the teeth and the inside of the veneers are phonetic and functional outcome, but also to communicate
surface treated they can be bonded two by two. Preferably, this to the patient. More importantly, it results in minimum
the bonding should start with the centrals, proceeding with invasion of the recipient tooth.
the lateral, canine on one side and then the lateral, canine The use of PDP (permanent diagnostic provisionals) will
on the other side. The soft tissues should be handled very have a further impact on this solid communication. That
gently. The easiest way to do that is to place the veneer on way, the patient will have a chance to evaluate the
the tooth and once it is completely seated, spot tack it from aesthetics, function and phonetics themselves as well as
the middle third with a 2mm turbo tip; this will hold the within their immediate circles (Figures 24 and 25).

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24 25

Figures 24 and 25: Full face before and after.

Acknowledgements Lin CP, Douglas WH, Erlandsen SL (1993) Scanning

Special thanks to Ulrich Werder MDT for the first case and electron microscopy of type I collagen at the dentin-
Shigeo Kataoka RDT for the second case. enamel junction of human teeth. J Histochem Cytochem;
41: 381-388
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