How to Use Cerinate Porcelain for a Prep Case By: Robert Maher, DDS

Cerinate porcelain, a proprietary product of Den-Mat Corporation, is extremely strong and known for its use in non-prep cases because it can be fabricated to create ultra-thin veneers. The following case required some preparation, but not as much as required for other ceramics when significant reduction is necessary to accomplish esthetic goals. Because of the size of the diastemas, the strength of the Cerinate porcelain dictated its use rather than conventional feldspathic veneers.

The patient, a 22-year-old professional chef, works at a local upscale restaurant and is pursuing a career advancement, planning to attend the prestigious Culinary Institute of America in Hyde Park, New York. The “before” photo reveals multiple anterior diastemas, one between teeth 8 and 9, and two between the lateral and the cuspids (Figs. 1 and 2). Earlier bonding filled the central diastema, creating centrals that were too large. Bonding on the distals of the laterals had also chipped away.

Due to budgetary consideration, the treatment plan consisted of eight veneers rather than ten veneers. In order to create pleasingly proportioned centrals, it was necessary to reduce the distals of the centrals by approximately 1.5 millimeters, and place mesial subgingival margins to allow for a proper emergence profile at the midline. Reducing the mesial of teeth 7 and 10, and placing subgingival margins on the distal of the two laterals effectively distalized the laterals. The mesial margins of the cuspids were also placed subgingivally to allow the laboratory to create pleasing proportions and proper emergence profiles interproximally. The preparations were taken interproximally to the lingual of all eight teeth to allow the laboratory to adequately contour the interproximal spaces.

Prior to preparation of the teeth, an intraoral mockup was completed using flowable composite to approximate the look we were hoping to achieve (Fig. 3). All the teeth were slightly lengthened and the incisal edge contours the patient desired were created. It was the patient’s desire to have what is considered to be a very masculine look, with the incisal edges being quite straight and embrasure spaces minimal, along with rather square mesial and distal incisal corners. An impression of this was then made in a full-arch triple tray using Clear Bite Registration (Discus Dental) and a wash of 1st Impression-PVS (Den-Mat). The impression was set aside for the fabrication of the provisional veneers.

After completing the preparations (Fig. 4) with minor gingival contouring using a diode laser, prep shades were recorded and photographed to provide the laboratory with the proper shade of the underlying tooth structure (Fig. 5). A face bow record and a stick bite were made for confirmation of the mounting and photographed. Full-arch PVS impressions were made using 1st Impression-PVS. The opposing model was made using a medium-body material with a light-body wash while the anesthetic was taking effect. The tray was loaded with the medium-body material and set aside. The teeth were air dried and the light-body wash was placed on the occlusal surfaces using a small bore yellow tip, but without the very small curved tip used for preps. After allowing the tray to remain on the table for 10–15 minutes, it was then seated over the lower arch and the patient closed into it seating it fully. The impression was done in two stages because the tray material gains more body during the working time it takes for the assistant to place the light body material. When the tray material is seated, it displaces the light-body material more than it would otherwise; the results are consistently excellent impressions. A similar technique was used for the master impression. The operator loaded the tray with heavy-body material and set it aside while the assistant cleaned the teeth with Consepsis (Ultradent) and then coated them with Gluma (Heraeus Kulzer) and dried the teeth in preparation for the final impression. Light body, 1st Impression-PVS was then syringed around each preparation in a circular fashion, never removing the tip from the impression material. (This lessened the likelihood of voids or bubbles in the impression.) The tray was then seated by first placing it distally to the second molars, seating the wax palatal dam against the roof of the mouth. The tray was seated in an arcing, upward motion towards the anterior teeth, until it was fully seated. At this point, a bead of heavy body material was run from bicuspid to bicuspid above the rim of the stock tray. The impression was then border molded as you would a denture impression. This assured an intimate adaptation of the VPS material to all the critical areas. Photos of the preps were then taken.

The temporaries were fabricated using Luxatemp (DMG/Zenith) with a lock-on technique. They were then contoured and modified as necessary to achieve the final look and length. Care was taken to assure that the patient could use Super Floss (Oral-B) or floss threaders interproximally during the interim period while the restorations were being fabricated. The temporaries were then polished with composite polishers and coated with Palaseal (Heraeus Kulzer) for a glossy finish. The patient was satisfied with the length and contours of the provisionals. The restorations were then fabricated accordingly. An impression of the provisionals was made and forwarded to the laboratory.

Insertion of the Cerinate Porcelain Veneers was accomplished using our standard techniques of cleaning the preparations with a finishing bur and Consepsis. Then, the teeth were isolated. The Cerinate Veneers were bonded using Ultra-Bond Plus, Clear Shade (Den-Mat). Finishing was accomplished with multi-fluted finishing burs and polishing cups. Lastly, the margins were coated with an unfilled resin and cured a final time.

The “after” photos show that the desired goals were accomplished: better proportions, elimination of the diastemas, and proper emergence profiles (Figs. 6 and 7). This self-assured young man, who feels he now has even more self-confidence in the knowledge that his smile is an asset rather than a liability, met the case results with great satisfaction.

Dr. Robert Maher is a continuing education provider, who offers a unique one-on-one clinical mentoring program that brings hands-on, esthetic, live-patient treatment courses to your office, allowing you to treat your own patients in the comfort of your office. Dr. Maher also lectures and presents “hands-on” workshops for dental laboratories, dental offices, study clubs, and dental organizations about digital photography, PowerPoint, and adhesive dentistry. Dr. Maher was a founding faculty member of PAClive and has taught adhesive cosmetic dentistry at the nation’s two premier teaching programs since 1995. He practices esthetic dentistry in Palm Desert, California. Visit his website: www.drbobmaher.com for more information. He can be contacted at (760) 836-0700, or by e-mail at elpaseodoc@msn.com.