Clinical presentation and treatment background

The case presented in this article is unusual in that it arose unexpectedly, without typical pretreatment planning steps such as a diagnostic wax-up or mock-up. These were omitted because of time and budget constraints on the patient’s part—a reality to which many clinicians can relate. Financial considerations often limit acceptance of comprehensive treatment plans; therefore, phased planning and effective communication are essential in fostering patient trust and long-term commitment. The rationale for this approach in the present case will become clearer as the case unfolds.

The patient was a 70-year-old female retiree whom I had been treating for several years. Treatment up to that point had focused on stabilising and gradually improving her posterior restorations, and the longer-term aim was to address the anterior dentition to enhance both function and aesthetics. The patient presented for an emergency appointment with a fractured porcelain veneer on tooth #21 (Fig. 1). Owing to the existing phased approach to her care, it was possible to transition into aesthetic restoration with minimal resistance or hesitation by the patient.

Material selection and considerations for veneer cementation

Glass-ceramic veneers have traditionally been cemented using a wide range of resin cements. Recently, the use of flowable or preheated paste resin composite for cementation has gained attention.

Material overview: PANAVIA Veneer LC system

Based on the considerations for veneer cementation, PANAVIA Veneer LC was selected. This light-polymerising resin cement is indicated for ceramic and composite restorations of less than 2 mm in thickness. It is available in four shades—Clear, Universal (A2), White and Brown (A4; Fig. 8a)—and PANAVIA V5 try-in pastes are available in corresponding shades (Fig. 8b), enabling simulation of the final restoration appearance. The system consists of four components: a 35% phosphoric acid etching gel (K-ETCHANT Syringe, Kuraray Noritake Dental), a tooth primer (PANAVIA V5 Tooth Primer), a ceramic primer (CLEARFIL CERAMIC PRIMER PLUS, Kuraray Noritake Dental) and PANAVIA Veneer LC paste (Figs. 9a–d).

Adhesive cementation protocol

For adhesive cementation of the veneers, the teeth were isolated using a latex-free dental dam (Isodam HD, heavy gauge, Four D; Fig. 12). After placement of the dental dam, clamps were placed and the veneers tried in again to confirm fit (Figs. 13a & b).

Afterwards, tooth surface pretreatment began with the central incisors. Adjacent teeth were protected with a metal strip, and air abrasion with a 35 μm aluminium oxide powder was performed (Fig. 14a). After roughening of the surface (Fig. 14b), the phosphoric acid etching gel was applied and left for 15–30 seconds (Fig. 15), followed by thorough rinsing and drying. The lateral incisors were then isolated with PTFE tape to facilitate removal of excess cement (Fig. 16).

The actual cementation steps included priming of the tooth structure with PANAVIA V5 Tooth Primer (Fig. 17), left for 20 seconds and gently air-dried. The intaglio surfaces of the veneers were treated with hydrofluoric acid for 20 seconds and, after thorough rinsing, primed with CLEARFIL CERAMIC PRIMER PLUS (Fig. 18) and dried.

PANAVIA Veneer LC was then applied to the pretreated ceramic surfaces, and the veneers were seated carefully (Figs. 19a & b). Gentle, controlled pressure using a soft instrument ensured accurate seating. When light-polymerising resin cements are used, excess material can often be removed prior to polymerisation, thereby reducing excess and simplifying clean-up.

The resin cement provides a seamless marginal transition between tooth and restoration, enhancing both aesthetic and functional integration of the veneers. Glycerine gel was applied to the restoration margins before light polymerisation to prevent formation of an oxygen inhibition layer (Fig. 19c).

The lateral incisor veneers were cemented in the same manner; however, floss was used for gingival retraction instead of clamps (Figs. 20a & b). Sequencing the procedure by first cementing the central incisors and subsequently the lateral incisors is recommended. This protocol gives the practitioner full control over the positioning of the central incisor veneers, which is particularly important because their position has a considerable impact on the overall appearance of the smile. When the lateral incisor veneers are cemented first, the risk of positioning errors in the central incisor region and resulting aesthetic issues is increased. However, any error with the positioning of the central incisor veneers can also lead to problems such as the misfit of the lateral incisor veneers. Therefore, the whole procedure needs to be carried out with utmost care and precision.

A comprehensive polymerisation protocol, including palatal, incisal and facial light exposure, is necessary to ensure complete polymerisation. After placement of the veneers, excess cement was removed using ultra-high molecular weight polyethylene floss (Gorilla Floss, Erskine Products) to protect the margins (Figs. 21a–c). Final polishing of the ceramic–tooth interface was performed using polishing rubbers. The dental dam remained stable throughout the procedure.

The immediate outcome after cementation showed slightly erythematous and tender gingival tissue, reflecting a transient response to the adhesive procedure (Fig. 22). This represents a temporary tissue response and typically improves over the following days as healing progresses. With a consistent and appropriate oral hygiene routine, full recovery of the soft tissue can be expected. This should be clearly communicated to the patient after removal of the dental dam.

Clinical follow-up

At the follow-up appointment, soft-tissue healing and patient adaptation were assessed. The gingival tissue had fully recovered after three weeks (Fig. 23). This visit also provided an opportunity for final photographic documentation (Figs. 24a–d). At this appointment, careful evaluation of the interproximal areas is essential to detect any residual cement, which may result in chronic inflammation and compromise aesthetics. Inspection from the occlusal aspect helps ensure complete removal of excess material and supports long-term gingival health.