Novel Porcelain Laminate Preparation

Approach Driven by a Diagnostic Mock-up

PASCAL M A G N E , P H D , DR MED D E N T '
URS C . BELSER, D R M E D DENT'

ABSTRACT
One critical step in the porcelain laminate technique is the achievement of sufficient ceramic
thickness. At least two different strategies for tooth preparation can be found in the literature:
(1)earlier simplified techniques included the use of depth cutters guided by the existing tooth
surface-however, that approach did not take into consideration alterations of the tooth owing
to aging, wear, or loss of enamel and thus led to greater risks for dentin exposures; (2)more
recent and sophisticated methods have integrated an additive diagnostic procedure (ie, wax-up
or mock-up) to compensate for tooth aging or severe existing loss of tooth substance. This
approach allows for more enamel preservation and, as a consequence, more predictable bond-
ing, biomechanics, and esthetics. The present article illustrates in detail the latest development
in tooth preparation for porcelain laminates. This technique combines the time efficiency of
earliest methods with the rationale and diagnostic foundations of the more recent techniques.
CLINICAL SIGNIFICANCE
Using this new laminate porcelain preparation approach, clinicians should be able to produce
not only more accurate preparations, but also higher-quality tooth preparations in a time-
efficient fashion.
(JEsthet Restor Dent 16:7-18,2004)

T he primary preparation design

for porcelain veneers, also
called bonded laminates or bonded
luting composites subject the
tooth-restoration interface to sub-
stantial stresses. BPRs must be dif-
and mechanical parameters of the
tooth preparation, however, are
of only secondary importance.
porcelain restorations (BPRs), ferentiated from traditional This allows for maximal preser-
should simultaneously allow an cemented crown coverage, espe- vation of remaining sound miner-
ideal marginal adaptation of the cially with regard to retention and alized tissue during the tooth
final restoration and reflect an resistance form. A minimum preparation procedure and, con-
optimal adaptation of the hard amount of preparation geometry sequently, a conservative approach
tissue morpho1ogy.l Unlike tradi- is required to facilitate insertion (ie, approximately one-quarter
tional cementation, the adhesive and positioning of the ceramic the amount of tooth reduction of
properties and physicochemical restoration during the final bond- conventional complete-coverage
characteristics of the resin-based ing procedure. The geometric crowns; Figure 1).2

'Associate professor, Chair of Esthetic Dentistry, School of Dentistry, University of Southern California,
Los Angeles
fprofessorand chairman, Department o f Prosthodontics, School of Dental Medicine, University o f Geneva,
Geneva, Switzerland

V O L U M E 1 6 , NUMBER 1 , 2004 7
 NOVEL PORCELAIN LAMINATE PREPARATION APPROACH DRIVEN B Y A DIAGNOSTIC MOCK-UP

Figure 1 . Completed tooth preparations and final porcelain

laminates. A, Facial view with deflection cords just prior to
final impressions. B, Incisal view with silicone index showing
u n i f m facial clearance for porcelain. C, Final view a*
placement of s i x laminate veneers.

One essential goal-the long-term Different tooth preparation tech- Preparation Driven by Existing
preservation of the tooth-restoration niques for BPRs have been described Tooth Surface
complex-requires the achievement in the literature and are discussed in In techniques driven by the existing
of a sufficientceramic thickness to this re~iew.'*~3+19 Using the respec- tooth surface, the ultimate goal is to
provide the restoration with some tive advantages of existing methods, remove a uniform layer of the tooth
intrinsic mechanical resistance. The a recent novel tooth preparation smae.4s9-14J8J9 This can
recommended thicknesses are technique is illustrated, detailed in a achieved by freehand preparation
approximately< 0.3 to 0.5 mm in the clinical case, that results in a more using traditional diamond burs
cervical area, 0.7m m in the middle conservative and more timeefficient (round ended and shghtly tapered)
and incisal thirds, and a minimum preparation procedure. and silicone guides of the existing
of 1.5 mm for incisal tooth: The same objective can be
These values are compatible with T O O T H - P R E P A R A T I O N STRATEGIES attained by using depth cutters
average measurements of enamel Tooth-preparation techniques (eg, burs with calibrated diamond
thickness.* Accurate achievement of can be divided in two groups rings), which is a more accurate and
such dimensions constitutes the most according to their underlying prin- time-efficient strategy. Unlike the
difficult aspect of tissue reduction ciples (Figures 2 and 3): those dri- second method described below, in
because these ultimate thicknesses ven by the existing tooth surface, this approach reduced diagnostic
are intimately related to the final vol- and those driven by the final vol- steps and limited communication
ume and shape of the restoration.' ume of the preparation. with the dental laboratory technician

8 J O U R N A L OF E S T H E T I C A N D R E S T O R A T I V E D E N T I S T R Y
 MACNE AND BELSER

diagnostic approach and require a

high level of communication with
the dental laboratory technician. In
these cases the BPR aims to restore
the original (not the existing) vol-
ume of the tooth, especially in the
presence of thin initial enamel.
Such cases typically involve
patients with altered existing tooth
shape (ie, indicated for BPR types
I1 and 111, according to Magne
and Belser) .195915-17

Figure 2. Two tooth preparation strategies illustrated in hori-

zontally sectioned incisors. Left, Use of the existing tooth sur-
face as a guide; in the case of thin enamel, such an approach A diagnostic wax-up that represents
results in significant dentin exposures. Right, Use of the final the original volume of the tooth
additive volume of restoration as a guide; thin existing enamel should be used as a reference for
can be preserved with this technique.
tooth reduction. This basic principle
saves a significant amount of sound
(ceramist)are required because the ing (ie, indicated for BPRs type I, hard tissue, not just enamel but also
intrinsic principle is the reproduction according to Magne and Belser).' the critical dentin-enamel junction.
of the initial situation (in terms of The simplest and most important
form and function). However, when Preparation Driven by tool for enamel reduction in this
the initial enamel is already thin, Final Volume of Restoration technique is represented by a well-
reduction based on the existing More recent tooth preparation pro- adapted horizontally sectioned sili-
tooth surface can lead to significant cedures for BPRs include a specific cone index from an additive wax-up.
dentin exposures (see Figure 2),8J4
which can be regarded as a possible
cause of long-term failures of BPRs
when not handled appropriately.20J1

This approach can be recom-

mended only after a careful pre-
operative evaluation of the case,
confirming the integrity of the
original enamel thickness and
knowledge that the final goal of the
restoration will be limited to the
reproduction of the existing tooth
volume, shape, and function. Such
cases are rare and typically involve Figure 3. Various tooth-preparation methods: (1) guided by a silicone
index of the existing tooth, (2) guided by depth cutters (diamond burs),
patients with intact discolored teeth (3)guided b y a silicone index of an additive wax-up, (4)guided by- a
that are not responding to bleach- moik-up (obtained from additive wax-up) and depih &t&s.

V O L U M E 1 6 , N U M B E R 1, 2 0 0 4 9
 N O V E L PORCELAIN LAMINATE P R E P A R A T I O N APPROACH D R I V E N B Y A DIAGNOSTIC MOCK-UP

This method, however, can be time- tooth volume (eg, correction of 4 atm of pressure during setting. In
consuming, inspiring researchers to tooth position), the new simplified this way, the silicone matrix presents
develop an improved technique. approach requires preliminary an increased stiffness and facilitates
corrections of the crown shape to handling and repositioning.
New Simplified Technique allow the complete seating of the
As is the case for all types of prepa- silicone index and subsequent real- For optimal stability the silicone
rations based on the final volume ization of the mock-up. Only after must overlap two teeth on each side
of the restoration, the diagnostic the patient’s approval or objectively of the modified segment. Palatal sur-
approach is part of the newest sim- justified modification of the mock- faces must remain accessible to
plified technique, which is a modifi- up configuration can the tooth allow the early elimination of palatal
cation of the original technique preparations be achieved. excess resin (see Figure 4C). For the
and is published by Giirel.” This same reason, the facial aspect of the
new technique avoids the short- Detailed Procedures. The first matrix is then sectioned and ground
comings of existing methods, simul- stage of the diagnostic approach to follow the contour of the scal-
taneously combining their related consists of defining a preliminary loped gingival sulcus (see Figure 4D
advantages (see Figure 3 , technique restorative goal, which is mostly to G). Palatal tooth surfaces and
4): time efficiency, enamel preserva- obtained by the addition of wax facial gingiva are then appropriately
tion, subsequent improvement of onto the preliminary model (see isolated with petrolatum.
adhesion and mechanics, and Figure 4A and B). This procedure
utmost respect of the pulp. There requires a precise knowledge of the Existing enamel is etched partially
are practically no disadvantages elements of tooth anatomy but also for 5 to 10 seconds (see Figure 5A
associated with this new technique. needs intuition, sensitivity, and a and B), rinsed, and dried to secure
It is based on the intraoral fabrica- good perception of the patient’s retention for the acrylic resin. The
tion and bonding of an acrylic tem- individual personality. This often silicone matrix is then filled par-
plate reproducing the diagnostic calls for a direct relationship tially with a dentin-type liquid
wax-up. The remodeled tooth seg- between the patient and the dental acrylic resin (eg, New Outline@,
ment is then prepared using round laboratory technician.22 Anaxdent, Stuttgart, Germany).
calibration diamonds guided by the One must wait until the resin sur-
acrylic template itself (described The second phase consists of fabri- face becomes dull in appearance
below; Figures 4 to 7). cating the corresponding acrylic (see Figure 5C). The index is then
template directly in the patient’s applied to the teeth and maintained
Before proceeding with the tooth mouth using self-curing resin molded in position while all accessible areas
preparation sequence, the bonded on the existing tooth surfaces with are cleared of excess resin (see Fig-
acrylic mock-up is used by the a silicone matrix of the wax-up (see ure SD). Pressure to the silicone
patient for several days or weeks Figures 4 and 5 ) . The patient can must be applied occlusally at the
to ensure that the objective repre- easily appreciate this removable level of unrestored teeth (in this
sented by the wax-up is compatible “mask.” It is highly recommended case, premolars). Abundant rinsing
with the individual’s personality, that the most accurate silicone is recommended to cool the opera-
face, smile, oral functions, and sub- index be fabricated preoperatively tory field while the resin sets.
jective expectations. Under some by firmly applying the material onto
specific circumstances aimed at the model and then immediately The acrylic mask is uniform in
retracting or displacing the original subjecting it to approximately color but provides good insight to

10 J O U R N A L OF ESTHETIC AND RESTORATIVE D E N T I S T R Y

 MACNE AND BELSER

Figure 4. A, Prelimitmy cast of upper anterior teeth showing

severe erosiolls (BPR indiaation type ZZIB), enamel w w , and
breaching. El, Wm-up obtained by a slight addition of wax to
restomotiginalvolrrmcs of enamel on teeth no. 6 to 11. This
eonfigwa&m must be assessed intraoralEy before tooth prepa-
rations are madc. C, Silicone index /%oma wax-up to be used
fbr frrbtication of a tpock-up; the silicone must extend onto
teeth no. 4and5and 12 and 13 formtprovcdkrtraotrJstabil-
ity Pahtal ckurrwrca fm*litatespremature remwal of excess
rwin. D,The f& aspect of the silicone index is fhst sectioned
horkontuUyat 1 mm of thegkrgivalsnltw. E, A d p e l is used
to remove silicone material / b n interdental papilkae between
teeth no. 6 to 11. F,A large diamond bur is used at a low speed
for fine removal of the silicone covering the gitagiua G, The
completed silicone index follows the fdgingiual umtw
without exposing the teeth; this fm'litatespremature renuwal
of excess resin.

V O L U M E 1 6 , N U M B E R 1, 2004 11
 N O V E L P O R C E L A I N LAMINATE P R E P A R A T I O N APPROACH D R I V E N B Y A DIAGNOSTIC MOCK-UP

Figure 5. A, Preliminary intraoral view. B, Palatal tooth surfaces and facial gingiva have been isolated with petrolatum; the
facial enamel is spot etched with H#04 for a few seconds (then rinsed and dried) to secure the retention of the future mock-
up. C, Silicone index loaded with A1 dentin-like acrylic resin. D, Silicone index positioned intraorally with axial pressure at
the level of the premolars; because of the silicone shape, facial (and palatal) excess resin can be removed immediately. Silicone
is cooled with water and maintained until comp/ete curing of resin. E, Clinical appearance just after the removal o f the silicone
index. F, Brownish light-curing stains are mixed with glaze liquid and inserted with a scalpel at the level of cervical embrasures
for optical enhancement of the interdental contact. G, The mock-up is glazed with a very-low-viscosity light-curing liquid
(Skin Glaze). H, General view o f the mock-up after comp~ementarylight curing through glycerin jelly (air block). (The assess-
ment at 2 weeks reveals a harmony between the incisal edge positions and the lower lip.)

12 J O U R N A L OF E S T H E T I C A N D R E S T O R A T I V E D E N T I S T R Y
 MAGNE AND BELSER

the possible esthetic and functional patient from the previous situation. facial reduction is assisted by two
outcomes of the restoration (see Conformity with the lower lip con- round diamond burs (see Figure 6).
Figure SE). It is recommended to tour is of paramount importance in When used appropriately, round
increase the color saturation of the esthetic evaluation (see Figure burs can serve as extremely accu-
iqtc?.rlmtalspaces using brownish SH). Howeveq speech and occlusal rate depth cutters.18J9
light-curhg stains (see Figure 5F) comfort are also addressed during
to visually 'break" the bonded this test phase. A word of caution: In the fmt bur the difference between
connection between teeth. The final inaccurate repositioning of the sili- the diameter of the bur (dl) and the
luster can be obtained by glazing cone index while fabricating the diameter of the shaft (d2)is roughly
with a very-low-viscosity resin (eg, mock-up as well as over-glazing (or 1.4 mm, ultimately leading to
Skin Glaze@,Anaxdent; see Figure use of a viscous glaze liquid) can 0.7 mm of depth cut (DC)when the
SG),preliminary light curing (to fix result in a diagnostic q s k that is shaft is placed against the incisal
the glaze), and complementary cur- too thick. This directly and ne+ third of the facial surface (see
ing through a layer of glycerin jelly tively influences the subsequent Figure 7A and B). A single horizon-
(to avoid the inhibition layer). tooth preparation. tal groove is obtained and marked
with a pencil (see Figure 7C). In the
The mock-up should not be modi- Tooth preparation procedures can second bur the difference between
fied prior to completion of an be initiated upon agreement of the d l and d2 is roughly 1.0 mm, ulti-
assessment of 1to 2 weeks, which patient on the final objective, which mately leading to 0.5 mm of depth
is the usual elapsed time required can be easily assessed through the cut when the shaft is placed against
for "deprogramming" of the mock-up. The most critical step of the middle third of the facial surface

A B and single depth cutter and differential depth cutter

Figure 6. A, Simple round diamond burs represent ideal depth cutters. The depth of cut (DC) is easily calculated with formula
shown by measuring the diameter of the bur (dl)and the diameter of the shank (d2).A DC of 0.5 mm is recommended for
Cenrical preparations and 0.7 mm for the incisal two-thirds.ByPreparation of the tooth with thin initial enamel. Left, Omis-
sion of the additive diagnostic procedures and the use of a singk depth cutter can lead to total enamel loss (red dotted line).
Right, Use of differential depth cutters in combination with an additive mock-up (red additive line) should mamtam most of
the enamel (red dotted line).

V O L U M E 1 6 , N U M B E R 1, 2004 13
 NOVEL PORCELAIN LAMINATE PREPARATION APPROACH DRIVEN B Y A DIAGNOSTIC MOCK-UP

Figure 7. Step-by-step tooth preparations guided by a 2-week-

old mock-up. A, A depth cut of 0.7 mm is made with a bur to
create a horizontal groove at the junction between the middle
and kid thirds of facial+aces. B, The shank of the depth
cutter must always stay in contact with the mock-up. C,The
bottom of the depth groove is marked with pencil. D,A
depth cut of 0.5 mm is made with a bur to create a slightly
scalloped groove at the junction between the middle and cer-
vicalthirds of the f&l surfaus. I t is then marked with pen-
cil. E,Remnants of acrylic from the mock-up are eliminated
with a maler.

(see Figure 7D).The resulting cervi- initial reduction grooves (see F w proximal separation (seeFigure 71;
cal groove is slightly d o p e d (see 7F). All other steps are traditional. Vision Flex@disk,B-1- !hail-
Figure 7D and E). nah, GA, USA)to enhance proximal
A horizontally sectioned silicone margin definition during the imp-
The remaining part of the mock-up index is recommended for double- sion and to facilitate the subsequent
can be removed (see Figure 7E). checking the available space (see fabrication of stone dies during lab-
This is followed by the use of tradi- Figure 7G), and a palatal index is oratory procedures. All transition
tional burs (see Figure 7F) until the used to assess the 1.5 mm incisal line angles are finally rounded with
pencil marks are completely clearance (seeFigure 7H).More flexible disks at.a low speed (see
removed. Control of initial tooth substance must be removed, as out- Figure 73).A last but essential pro-
reduction is improved because the k e d by pencil marks. Finishing cedure before making final impres-
bur stands at a right angle with the procedures first include a slight sions is the immediate sealing of the

14 J O U R N A L OF E S T H E T I C A N D R E S T O R A T I V E D E N T I S T R Y
 MAGNE AND BELSER

Figure 7 continued. F, Traditional burs (round ended, slightly

tapered) are used for the removal o f remaining tooth substance
between reduction grooves; sufficient space should be created
automatically when the pencil marks disappear. G, Horizon-
tally sectioned silicone index from the wax-up (with marked
occksal stops on premolars) is used to double-check for facial
clearance. H , Incisal edge preparation is controlled with the
palatal index. More reduction is required (pencil marks)
to reach the minimum 1.5 mm incisal clearance. I , Finishing
steps include a slight proximal separation with ultrathin
diamond disks (Vision Flex) to enhance margin definition.
J , Coarse flexible disks are used to remove all sharp transition
line angles. (Completed preparations are shown in Figure 1).

dentin, that is, the identification of cementation should be required The authors thank attendees of var-
possible dentin exposures and sub- because the friction fit (resin shrink- ious lectures and hands-on courses
sequent sealing of these areas with a age) and existing proximal undercuts who have shared their ideas and
dentin adhesive.23-26 (owingto gingival retraction) should inspired the content of this work.
ensure sufficient stability and locking We give special thanks to Antonello
Following final impressions, pre- of the provisional restoration. Pavone, Dr Med Dent (Rome) for
pared tooth surfaces are isolated his helpful clinical insights.
with petrolatum. The temporary DISCLOSURE A N D
ACKNOWLEDGMENTS REFERENCES
restoration is then immediately fabri-
The authors have no financial inter- 1. Magne P, Belser U. Bonded porcelain
cated intraorally with the same prin- restorations in the anterior dentition-a
ciples (the same silicone index) used est in the companies whose prod- biomimetic approach. Chicago: Quintes-
ucts are mentioned in this article. sence Publishing Co, 2002.
for the mock-up. No provisional

V O L U M E 1 6 , NUMBER 1 , 2 0 0 4 15
 NOVEL PORCELAIN LAMINATE PREPARATION APPROACH DRIVEN BY A DIAGNOSTIC MOCK-UP

2. Edelhoff D, Sorensen JA. Tooth structure 12. Sheets CG, Taniguchi T. Advantages and 21. Friedman MJ. A 15-year review of porce-
removal associated with various prepara- limitations in the use of porcelain veneer lain veneer failure-a clinician’s observa-
tion designs for anterior teeth. J Prosthet restorations. J Prosthet Dent 1990; tions. Compend Contin Educ Dent 1998;
Dent 2002: 87503-509. 64:406411. 19:625-628.

3. Highton R. Caputo AA, Matyas J. A 13. Garber DA. Porcelain laminate veneers: 22. Magne P, Magne M, Belser U. Natural
photoelastic study of stresses on porcelain ten years later. Part I: tooth preparation. and restorative oral esthetics. Part I: Ratio-
laminate preparations. J Prosthet Dent J Esthet Dent 1993; 557-61. nale and basic strategies for successful
1987; 58:157-161. esthetic rehabilitations. J Esthet Dent
14. Nattress BR, Youngson CC, Patterson CJ, 1993: 5:161-173.
4. Christensen GJ, Christensen RP. Clinical Martin DM, Ralph JP. An in vitro assess-
observations of porcelain veneers: a three- ment of tooth preparation for porcelain 23. Bertschinger C, Paul SJ, Luthy H, Scharer
year report. J Esthet Dent 1991; 3:174-179. veneer restorations. J Dent 1995; P. Dual application of dentin bonding
23:165-1 70. agents: its effect on the bond strength.
5. Lehner CR, Margolin MD, Scharer P. Am J Dent 1996; 9:115-119.
Crown and laminate preparations. Standard 15. Magne P, Douglas WH. Additive contour
preparations for esthetic ceramic crowns of porcelain veneers: a key-element in 24. Paul SJ, Scharer P. The dual bonding tech-
and ceramic veneers. Schweiz Monatsschr enamel preservation, adhesion and esthetics nique: a modified method to improve
Zahnmed 1995; 1051560-1575. for the aging dentition. J Adhes Dent adhesive luting procedures. Int J Periodon-
1999; 1:81-91. tics Restorative Dent 1997; 17536-545.
6. Magne P, Kwon KR, Belser U, Hodges JS,
Douglas WH. Crack propensity of porce- 16. Magne P, Perroud R, Hodges JS, Belser 25. Paul SJ. Effect of a dual application of
lain laminate veneers: a simulated opera- UC. Clinical performance of novel-design dentin-bonding agents on shear bond
tory evaluation. J Prosthet Dent 1999; porcelain veneers for the recovery of coro- strength of various adhesive luting systems
8 1:327-334. nal volume and length. Int J Periodontics on dentin. In: Paul SJ, ed. Adhesive luting
Restorative Dent 2000; 20441-457. procedures. Berlin: Quintessence,
7. Magne P, Versluis A, Douglas WH. Effect 1997:89-98.
of luting composite shrinkage and thermal 17. Gurel G. The science and art of porcelain
loads on the stress distribution in porce- laminate veneers. Chicago: Quintessence 26. Magne P, Douglas WH. Porcelain veneers:
lain laminate veneers. J Prosthet Dent Publishing Co, 2003. dentin bonding optimization and bio-
1999; 81:335-344. mimetic recovery of the crown. Int J
18. Cherukara GP,Seymour KG, Prosthodont 1999; 12:lll-121.
8. Ferrari M, Patroni S, Balleri P. Measure- Samarawickrama DY, Zou L. A study
ment of enamel thickness in relation to into the variations in the labial reduction
reduction for etched laminate veneers. Int of teeth prepared to receive porcelain Reprint requests: Pascal Magne, PhD,
J Periodontics Restorative Dent 1992; veneers-a comparison of three clinical Dr Med Dent, Chair o f Esthetic Dentistry,
12:407-413. techniques. Br Dent J 2002; 192:401-404. University of Southern California, School
of Dentistry, 925 West 34th Street,
9. Calamia JR. Etched porcelain veneers: the 19. Cherukara GP, Seymour KG, Zou L, Los Angeles, CA 90089-0641; e-mail:
current state of the art. Quintessence Int Samarawickrama DY. Geographic distrib- [email protected]
1985; 165-12. ution of porcelain veneer preparation 02004 BC Decker lnc
depth with various clinical techniques.
10. Garber DA, Goldstein RE, Feinman RA. J Prosthet Dent 2003; 89544-550.
Porcelain laminate veneers. Chicago:
Quintessence Publishing Co, 1988. 20. Dumfahrt H, Schaffer H. Porcelain lami-
nate veneers. A retrospective evaluation
11. Weinberg LA. Tooth preparation for after 1 to 10 years of service: part II-
porcelain laminates. N Y State Dent J clinical results. Int J Prosthodont 2000;
1989; 55:25-28. 13:9-18.

16 JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY

 MAGNE A N D BELSER

COMMENTARY
NOVEL P O R C E L A I N L A M I N A T E P R E P A R A T I O N A P P R O A C H D R I V E N BY A D I A G N O S T I C M O C K - U P
Mark J. Friedman, DDS*

Drs. Magne and Belser have written an exceptional article on a modified clinical approach to improving the predictabil-
ity and longevity of bonded porcelain veneer restorations. The patient in the clinical case example has substantial loss
of natural enamel, possibly from attrition and abrasion. The novel technique involves the fabrication of a provisional
acrylic mock-up of the final porcelain restorations prior to tooth preparation. Generated from a diagnostic wax-up, the
provisional is temporarily bonded in place and serves as a preview for the dentist, the dental technician, and the patient.
It also serves as a valuable reference during tooth preparation. Using diamonds of known dimension, the dentist can
prepare through the acrylic template to a prescribed depth, thereby reducing the risk of excessive axial reduction and
further loss of enamel substrate on which to bond. Without the mock-up, tooth preparation is likely to be performed in
reference to existing axial contours instead of the final restorative volume predicted by the wax-up.
Consistent with their attention to detail and precision, and with their clinical excellence, Magne and Belser present a
well-organized technique designed for “time efficiency, enamel preservation, subsequent improvement of adhesion and
mechanics, and utmost respect of the pulp.” Nonetheless, relative to the specific example discussed and illustrated,
there is an issue that bears further discussion.
Some authors have expressed concern that the bonded porcelain veneer restoration has been transformed from a highly
conservative operative procedure to a much more aggressive one.’I2 If preserving existing enamel is a worthy goal, then
orthodontic movement prior to tooth preparation should always be considered. I have found that even minor retraction
and rotation of anterior teeth can have a profound impact on enamel preservation (Figures 1-3). The left lateral incisor
in Figure 1A of Magne and Belser’s article demonstrates an uninterrupted enamel substrate owing to its lingual position
prior to tooth preparation. Could further enamel have been preserved if orthodontic retraction of the anterior teeth was
achieved? What if no tooth preparation is initiated other than a subtle peripheral finish line? That practice was com-
monplace when porcelain veneer restorations were first introduced over 20 years ago, and this author has observed
excellent longevity with the techniq~e.~Are bonded porcelain veneer restorations really doomed to failure if they do not
meet certain minimum requirements of uniform thickness?

Figure 1 . A 37-year-old male undergoes orthodontic Figure 2. The maxillary central incisors have been
treatment to retract the anterior teeth in preparation for retracted into a position to allow for minimal tooth prepa-
porcelain veneer restorations. ration, maximum enamel preservation, and proper
anatomic contours o f the final restorations.

V O L U M E 16, N U M B E R I , 2 0 0 4 17
 N O V E L PORCELAIN LAMINATE P R E P A R A T I O N APPROACH D R I V E N B Y A DIAGNOSTIC M O C K - U P

Figure 3. The final porcelain veneer restorations are

retained on an intact substrate of enamel and exhibit both
acceptable esthetics and proper axial contours.

With this article, Magne and Belser have added another excellen conservative restorative technique to the literature.
Hopefully, they will continue to help stem the increasing tide of practitioners who casually prepare teeth for traditional
crown restorations, and refer to them as “veneer restorations,” with no regard whatsoever for enamel preservation.
REFERENCES
1. Heymann H. Is tooth structure not sacred anymore? (Editorial)J Esthet Restor Dent 2001; 13:283.
2. Friedman MJ. Porcelain veneer restorations: a clinician’s opinion about a disturbing trend. J Esthet Restor Dent 2001; 13:318-327.
3. Friedman MJ. A 15-year review of porcelain veneer failure: a clinician’s observations. Compend Contin Educ Dent 1998; 19:625-628,
630,632.

*Private practice, Encino, CA; and professor, Clinical Dentistry, University of Southern California School of Dentistry, Los Angeles, CA, USA.

18 JOURNAL O F FSTHETIC AND RESTORATIVE DENTISTRY