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Operative Dentistry, 2017, 42-5, E139-E147

Using CAD/CAM–Modified
Correlation Mode to Produce
Laminate Veneers: A Six-Month
Case Report
FSF de Siqueira ! AFM Cardenas ! YL Gruber ! C Kose
YM Pupo ! GM Gomes ! OMM Gomes ! JC Gomes

Clinical Relevance
This six-month clinical report demonstrates the use of a new self-etching glass ceramic
primer with the CAD/CAM–modified correlation and biogeneric modes in the fabrication of
porcelain laminate veneers to achieve esthetic clinical outcomes.

SUMMARY common requires an impression of the pre-

The expectation of an esthetically harmonious pared tooth, an impression antagonist, fabri-
smile increases the level of difficulty when cation models, and extensive laboratory time.
The computer-aided design/computer-aided
treating patients. Laminate veneers stand out
manufacturing (CAD/CAM) system optimizes
as a treatment option for cosmetic rehabilita-
the fabrication of prosthetic structures, reduc-
tion in clinical practice, as they are a more
ing chairside time and promoting good esthet-
conservative procedure and mimic dental ic results. Thus, the purpose of this case report
structures. These laminate veneers are gener- is to present the esthetic result of multiple
ally made with different techniques; the most CAD/CAM manufactured laminate veneers us-
Fabiana Suelen Figuerêdo de Siqueira, DDS, MS, PhD ing a new self-etching glass ceramic primer
student, State University of Ponta Grossa, Department of
Giovana Mongruel Gomes, DDS, MS, PhD, professor, State
Restorative Dentistry, Ponta Grossa, Paraná, Brazil
University of Ponta Grossa, Department of Restorative
*Andres Felipe Millan Cardenas, DDS, MS, PhD, professor, Dentistry, Ponta Grossa, Paraná, Brazil
CEUMA University, Department of Restorative Dentistry,
Osnara Maria Mongruel Gomes, DDS, MS, PhD, professor,
São Luiz, Maranhão, Brazil
State University of Ponta Grossa, Department of Restorative
Yançanã Luizy Gruber, DDS, MS, PhD student, State Dentistry, Ponta Grossa, Paraná, Brazil
University of Ponta Grossa, Department of Restorative
João Carlos Gomes, DDS, MS, PhD, professor, State Univer-
Dentistry, Ponta Grossa, Paraná, Brazil
sity of Ponta Grossa, Department of Restorative Dentistry,
Carlos Kose, DDS, MS, PhD, State University of Ponta Ponta Grossa, Paraná, Brazil
Grossa, Department of Restorative Dentistry, Ponta Grossa,
*Corresponding author: Rua Josué Montello, 1 - Renascença
Paraná, Brazil
II, São Luiz, Maranhão 65075-120, Brazil; e-mail:
Yasmine Mendes Pupo, DDS, MS, PhD, professor, Federal andresfelipemillancardenas@[Link]
University of Paraná, Department of Restorative Dentistry,
DOI: 10.2341/15-300-t
Curitiba, Paraná, Brazil
E140 Operative Dentistry

with a lithium disilicate ceramic, using the

modified correlation and biogeneric modes.

INTRODUCTION
Techniques and materials for indirect dental resto-
rations have evolved quickly. Laminate ceramic
veneers are becoming a more popular conservative
treatment to achieve esthetic demands.1 Restorative
treatment using porcelain laminate veneers is done
with different techniques, all of which typically
require an impression of the prepared teeth, impres-
sion of the opposing arch, preparation of casts, and
extensive laboratory time.2-4
Recently, manufacturing materials, techniques,
and office time have been simplified by digital
dentistry and the introduction of stronger glass-
infiltrated ceramics. With the introduction of these
ceramics, especially pressed lithium disilicate (LD),
laminate veneers can be made using either the
conventional lost-wax technique or by designing a
prosthetic structure on a computer, followed by its
manufacture in a milling machine. This technique is
referred to as computer-aided design/computer-
aided manufacturing (CAD/CAM).5,6
The use of LD in a pressed technique and its
applications in the dental clinic were introduced by
Brodkin and others in 1998.7 The material is
composed of 65% LD in the form of crystalline
structures,8 resulting in a relatively strong ceramic.9
The LD ceramic has a flexural strength of about 400
MPa, a fracture toughness of 3.3 MPa, and good Figure 1. Baseline aspect of smile.
translucency. In addition to all these, the LD glass
portion can be etched using a 5% to 10% hydrofluoric
acid (HF) solution and can be bonded to enamel and
manufacturers have released more versatile self-
dentin. The HF etching makes a microporous
etching glass-ceramic primers to shorten the pre-
surface, which increases the bond strength.10 Differ-
treatment of dental restorations, which includes
ent clinical applications are suggested for LD,
providing the etching and silanization steps in only
including veneers, anterior and posterior single
crowns, and anterior or posterior fixed prostheses one bottle.
of up to three elements.11 There is not enough information in the literature
The LD glass ceramic (IPS [Link] CAD, Ivoclar- regarding the performance of this new class of
Vivadent, Barueri, SP, Brazil) was designed for the universal primers and the development of a high
CAD/CAM processing technology. In the presintered reactivity between the glass ceramic and the primer.
state, the CAD/CAM block exhibits a flexural Digital technology is rapidly emerging and has
strength of 130-150 MPa, allowing for small intra- introduced many new possibilities in dental prac-
oral adjustments. After sintering at 8508C, LD has a tice because of the different advantages that the
flexural strength of 360 MPa.12 Because of the system offers. Therefore, the aim of this case report
translucency and variety of colors, LD can be used is to present the esthetic results of multiple LD
for full anatomical restorations (monolithic) with ceramic veneers manufactured with CAD/CAM
subsequent surface color characterization.12 using the correlation mode associated with the
Because of differences in professional judgment biogeneric mode and a new self-etching glass
regarding the number of steps for cementation, ceramic primer.
de Siqueira & Others: CAD/CAM-Correlation Mode and Porcelain Veneers E141

Figure 2. Immediate result of gingi-

vectomy.
Figure 3. Preparations made follow-
ing the wear tab for guidance.
Figure 4. Aspect before polishing
and finishing preparations.

TECHNIQUE DESCRIPTION and radiographic examinations and obtaining initial

A 36-year-old female patient presented to the School of impressions, it was determined that the patient had
Dentistry at the State University of Ponta Grossa for a low caries risk and did not have active caries
esthetic treatment. Her main complaint was the lesions or signs of periodontal disease.
presence of clinical diastemas between her maxillary The esthetic treatment plan alternatives were
anterior teeth after orthodontic treatment. These discussed with the patient, including dental bleach-
anterior maxillary teeth were restored using composite ing and gingivectomy, followed by direct composite
resin five years previously, presenting several frac- resin or ceramic veneers. After careful evaluation of
tures and staining of the resin composite (Figure 1). the patient’s expectations regarding her smile, a
In addition, the patient was not satisfied with the dental bleaching, gingivectomy, and ceramic veneers
color and shape of her natural teeth. After clinical option was selected. Dental bleaching provides the
E142 Operative Dentistry

tissue because the cementoenamel junction was

more than 2 mm below the free gingival margin.
An external bevel incision was performed for teeth 7,
8, 9, and 10, and a collar of marginal gingiva was
removed to expose more of the crown of the tooth.
After waiting for a healing period of 21 days, an
initial impression was made using addition silicone
(Virtual, Ivoclar-Vivadent) to prepare stone models
and a diagnostic wax-up. A mock-up was also
prepared to make the procedure more predictable.
The maxillary anterior teeth were prepared fol-
lowing the silicone preparation guides made from
the diagnostic wax-up model (Figure 3). The prepa-
ration started with a butt-joint diamond bur No.
1013 (KG Sorensen, Cotia, SP, Brazil). Guides from
0.5 to 0.7 mm in depth were prepared following the
slope of the buccal surface of the tooth with a
rounded-tip, diamond bur No. 2135. Reductions of
1.5 to 2.0 mm were also performed at the incisal
surface. The dental preparation was refined using a
No. 2135 FF diamond bur (KG Sorensen). After that,
the preparations were finished and polished using
Sof-lex discs (3M ESPE, Sumaré, SP, Brazil; Figure
4).
An impression of the prepared teeth was carried
out using a double-cord technique with addition
silicone (Virtual, Ivoclar-Vivadent), where the first
single-cord Ultrapack No. 000 (Ultradent Products
Inc., Indaiatuba, SP, Brazil) was inserted into the
Figure 5. (A): Digitally planning the correlation mode through the gingival sulcus and the second single-cord Ultrapack
digitalization wax-up model. (B): Scanning model with the prepared No. 0 (Ultradent Products Inc.) was positioned to
teeth. (C): Supplement to the biogeneric order to improve and adapt
shape and contour. enlarge the gingival sulcus. At the time of impress-
ing, the second single cord was removed and the first
dentist the opportunity to use a more translucent single cord remained within the gingival sulcus.
glass ceramic, preventing opaque teeth and ensuring To make the provisional veneers, A1 color Ceremill
greater translucency, better esthetics, and a more TEMP resin multilayer blocks (AmannGirrbach,
natural look. Minor soft-tissue crown lengthening Curitiba, PR, Brazil) were used with transitioning
was recommended to the patient before veneer from the dentin to the incisal areas. The provisional
preparations to correct soft-tissue asymmetry. Ce- veneers were designed using Ceramill Mind CAD
ramic laminate veneers are considered a conserva- software (AmannGirrbach) and milled under water
tive treatment with excellent results. cooling using the Ceramill Motion 2 system (Amann-
In-office dental bleaching was performed using Girrbach). Excellent provisionals were made at the
35% hydrogen peroxide (35% Whiteness HP Maxx, initial session to provide for adequate oral hygiene
FGM, Joinville, SC, Brazil) for 40 minutes at two and to approximate the final restoration design,
sessions separated by a one-week interval (White- where the patient had the option to experience the
ness HP Blue, FGM). The initial shade of the esthetic result and determine possible changes to the
patient’s teeth was A2 (Vita-Zahnfabrik, Spitalgasse, final restorations.
BS, Germany); after bleaching, the shade was A1. This case was planned using the correlation
One week after dental bleaching, the patient mode,13 but as the patient did not have an ideal
underwent an esthetic periodontal surgery. (Figure shape of the contours of natural teeth to be intra-
2). Soft-tissue recontouring (gingivectomy) was indi- orally scanned, the wax-up model was used for this
cated in this case to remove the excess gingival purpose. A spray contrast was applied to the waxed
de Siqueira & Others: CAD/CAM-Correlation Mode and Porcelain Veneers E143

Figure 6. Ceramill Mind computer-

aided design software overlays digital
information obtained from the upper
and bottom model, scanning to form a
record of the virtual bite of joint.
Figure 7. Provisional veneers made
in Ceramill TEMP resin.
Figure 8. Cemented provisional ve-
neers.

model (Vita Cerec powder; Vita-Zahnfabrik, Spital- Provisional veneers were tried in for marginal
gasse, BS, Germany) to obtain the digital informa- integrity, functionality, occlusion, esthetics, and
tion. When necessary to aid and improve the patient satisfaction. The provisionals were tempo-
contours, this procedure was complemented using rarily cemented (Figure 8) using an acid-etched
the biogeneric mode to improve and adapt shape and point technique (midfacial) and bonded using the
contour (Figures 5A-C). flowable composite resin, Filtek Z350 (3M ESPE) in
The CAD/CAM-software, Ceramill Mind (Amann- the A2 color. Excess composite was removed, and the
Girrbach), superimposed the digital information restorations were light cured with a LED device
obtained from scanning the maxillary and mandib- (Radii Plus, SDI, Bayswater, VIC, Australia) for 40
ular models to form a record of the virtual occlusal seconds. The occlusion was checked and adjusted.
bite (Figure 6). Ceramill Map400 (AmannGirrbach) The provisional veneers were reevaluated after one
was used to manufacture provisional veneers using week following the patient’s evaluation of form,
the digital information of the patient wax-up and the function, and esthetics. The patient was allowed to
biogeneric model (Figure 7). request modifications, which were performed, and
E144 Operative Dentistry

The internal areas of the laminate veneers were

conditioned using Monobond Etch & Prime (Ivoclar-
Vivadent Inc., Amherst, NY, USA) by scrubbing for
20 seconds and allowing the primer to react on the
surface for 40 seconds, according to the respective
manufacturers’ instructions. This single ceramic
primer allows for etching and silanization of the
glass ceramic surface. This combination is effective
and shortens the pretreatment for glass-ceramic
restorations as compared with the conventional
method, making the process easy and reducing the
risk of error. After conditioning, the surfaces were
washed with an air-water spray to remove the
Monobond Etch & Prime (Ivoclar-Vivadent Inc.)
and dried prior to the application of the Excite
adhesive system (Ivoclar-Vivadent; Figure 10A, B).
The adjacent teeth were protected using a Teflon
strip, and the prepared tooth surfaces were etched
with 37% Total Etch phosphoric acid (Ivoclar-
Figure 9. Try-in test to select the color of the resin cement.
Figure 10. (A): Individual laminate veneers etched for 40 seconds Vivadent) and rinsed after 15 seconds with an air-
with Monobond Etch & Primer. (B): Application of the Excite adhesive water spray. Excess water was removed by gently
system.
blowing air. An Excite light-cure adhesive system
(Ivoclar-Vivadent) was applied in two coats to the
the ceramic laminate veneers were made using LD prepared surfaces. Gently blown air was used for
IPS [Link] CAD HT–A1 (Ivoclar-Vivadent). solvent evaporation. The adhesive was not light
Prior to cementation, the marginal adaptation, cured. Then, the light-cured Variolink Veneer resin
interproximal contacts, and occlusion of the laminate cement (Ivoclar-Vivadent) was placed on the intaglio
veneers were checked and modified using a No. 2135 surface of the veneer and seated into position. The
FF diamond bur (KG Sorensen) and polished using excess resin cement was removed, and the veneers
the Dialite LD ceramic polishing kit (Brasseler were light cured for 40 seconds from each of the
Dental EUA, Savannah, GA, USA). The color dental surfaces (Figure 11A-D).
evaluation was tested with low-, medium-, and After cementation, the cervical edges of the
high-value try-in paste of the Variolink Veneer indirect restorations and the gingiva were checked,
cement (Ivoclar-Vivadent; Figure 9). and excess cement was removed using a No. 12

Figure 11. (A): Etching of the teeth

with phosphoric acid for 15 seconds.
(B): Rinsed with an air-water spray.
(C): Application of Excite adhesive
system. (D): Cementation of the lam-
inate veneers of teeth 11 and 21.
de Siqueira & Others: CAD/CAM-Correlation Mode and Porcelain Veneers E145

Figure 12. Appearance immediately

after cementation.
Figure 13. Outcome after six months.

scalpel blade for better hygiene and prevention of The first method for designing a restoration using
biofilm retention in the cervical region. CAD/CAM is the biogeneric mode, which uses a
database of hundreds of teeth that have been
The immediate outcome of the restorative proce-
imported as a ‘‘library of shapes and forms.’’ The
dure can be seen in Figure 12 and the controlled
shape and form are chosen by the dentist to best
outcome after six months in Figure 13. The patient
serve the patient’s case. The second method of
was instructed on proper oral hygiene, and the case
design is the correlation mode. This mode is
will be periodically evaluated at six-month intervals. recommended for duplicating a tooth in the pa-
tient’s mouth, to provide the ideal contours of the
DISCUSSION teeth to be scanned intraorally before preparation.
In 2005, an improved material consisting of press- In this case report, we opted for the correlation
able glass-ceramic LD, IPS [Link] Press, was mode with modification because it involved a wax-
introduced. The chemical basis of this material is up model, since the patient had no contour and
the same as IPS Empress 2 (Li2O-2SiO2) but with optimal shape in her natural teeth. When neces-
properties altered by using a different burning sary, the projection of the model was improved by
process.14 When compared with IPS Empress 2, analysis of the library teeth (biogeneric model).22,23
Although there are advantages of fabricating
IPS [Link] Press shows significant improvement in
porcelain veneers using CAD/CAM in the laborato-
physical properties and provides a high translucen-
ry, all the clinical procedures (ie, teeth preparation,
cy15; therefore, it was the material chosen for the
cementation) are similar to the conventional fabri-
present case report.
cation of porcelain veneers.
The use of CAD/CAM to design a dental restora- In this case report, multiceramic laminate veneers
tion is efficient and highly precise.16-19 Both the were fabricated using an all-digital workflow. This
fatigue and tensile strength of [Link] Press indicate technique provides the opportunity to produce
that it is an excellent material for use with CAD/ precise provisional restorations with an as-proposed
CAM.20,21 Furthermore, the use of these systems to contour for the final laminate veneers, which could
manufacture porcelain veneers allows the dentist to improve the esthetic results of the restorations to the
control the time as well as color, contour, and form. patient’s liking before cementation, allowing the
This treatment plan has the advantage of being patient to evaluate the provisional veneers critically
conservative while providing great optical and for a period of time, providing more security for the
esthetic results.22 patient and the final restoration.24 This method also
E146 Operative Dentistry

allows for the opportunity to further customize the 2. Calamia JR (1983) Etched porcelain facial veneers: a new
final restorations based on feedback from the patient treatment modality based on scientific and clinical
evidence New York Journal of Dentistry 53(6) 255-259.
regarding his or her desires and expectations. The
only disadvantage associated with this technique is 3. Sorensen JA, Strutz JM, Avera SP, & Materdomini D
(1992) Marginal fidelity and microleakage of porcelain
the increased manufacturing costs of the provisional
veneers made by two techniques Journal of Prosthetic
veneers.4 Dentistry 67(1) 16-22.
Moreover, a system that allows for the simulta- 4. Zandinejad A, Lin WS, Atarodi M, Abdel-Azim T, Metz
neous conditioning and silanization of the ceramic MJ, & Morton D (2015) Digital workflow for virtually
was used in this case report. The Monobond Etch & designing and milling ceramic lithium disilicate veneers:
Primer contains trimethoxypropyl methacrylate a clinical report Operative Dentistry 40(3) 241-246.
(methacrylate silane) for silanization and 15%-25% 5. Lin WS, Harris BT, Ozdemir E ,& Morton D (2013)
ammonium polyfluoride for conditioning the surface. Maxillary rehabilitation with a CAD/CAM-fabricated,
long-term interim and anatomic contour definitive pros-
In addition, this primer contains 75%-85% alcohol
thesis with a digital workflow: a clinical report Journal of
and water by weight as solvents and less than 1% of Prosthetic Dentistry 110(1) 1-7.
colorant by weight. This material creates a rough-
6. Fritzsche G (2013) Cerec omnicam and the virtual
ness pattern that is less pronounced than HF but is articulator: a case report International Journal of
as efficient for bonding.25-28 The silanization reaction Computerized Dentistry 16(1) 59-67.
with this primer is similar to silanization with 7. Brodkin D, Panzera C, & Panzera P (2004) Lithium
Monobond S or Monobond Plus.29 disilicate glass-ceramics US Patent 20030073563.
CAD/CAM technology is emerging and there is a 8. Albakry M, Guazzato M, & Swain MV (2003) Biaxial
learning curve involving software, dentists, and flexural strength, elastic moduli, and x-ray diffraction
dental lab technicians. With more experience, this characterization of three pressable all-ceramic materials
Journal of Prosthetic Dentistry 89(4) 374-380.
innovative technology will yield further esthetic
improvements in dentistry, ensuring better patient 9. Holand W, Schweiger M, Frank M, & Rheinberger V
(2000) A comparison of the microstructure and properties
satisfaction.
of the IPS Empress 2 and the IPS Empress glass-ceramics
Journal of Biomedical Materials Research 53(4) 297-303.
CONCLUSION
10. Guarda GB, Correr AB, Goncalves LS, Costa AR, Borges
This article presented a technique for producing GA, Sinhoreti MA, & Correr-Sobrinho L (2013) Effects of
laminate veneers using CAD/CAM technology. surface treatments, thermocycling, and cyclic loading on
the bond strength of a resin cement bonded to a lithium
disilicate glass ceramic Operative Dentistry 38(2)
Acknowledgements 208-217.
The authors are very grateful to Nippon Lab for manufactur- 11. Giordano R, & McLaren EA (2010) Ceramics overview:
ing the indirect restoration. Thank you to Ivoclar-Vivadent for classification by microstructure and processing methods
the donation of materials. This study was supported by the Compendium of Continuing Education in Dentistry 31(9)
National Council for Scientific and Technological Develop- 682-684, 686, 688.
ment (CNPq).
12. Guess PC, Schultheis S, Bonfante EA, Coelho PG,
Regulatory Statement Ferencz JL, & Silva NR (2011) All-ceramic systems:
laboratory and clinical performance Dental Clinics of
This study was conducted in accordance with all the North America 55(2) 333-352, ix.
provisions of the local human subjects oversight committee
guidelines and policies of State University of Ponta Grossa, 13. Vafiadis D, & Goldstein G (2011) Single visit fabrication
Paraná, Brazil. of a porcelain laminate veneer with CAD/CAM technol-
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Conflicts of Interest 106(2) 71-73.

The authors declare that they have no conflicts of interest. 14. Jiang W, Bo H, Yongchun G, & LongXing N (2010) Stress
distribution in molars restored with inlays or onlays with
(Accepted 23 January 2016) or without endodontic treatment: a three-dimensional
finite element analysis Journal of Prosthetic Dentistry
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