Partial Ceramic Veneer Technique for Challenging Esthetic Frontal Restorative Procedures

Round 1

Reviewer 1 Report

Dear authors,

the article entitled "Partial ceramic veneer technique for challenging esthetic frontal restorative procedures." describes the use of ceramic veneers to manage a darkened tooth after trauma.

Unfortunately the reviewer does not think this article should be published. The case is a classical bleaching case.

The authors support the decision to make a veneer because the bleaching treatment could have a relapse.

The relapse, the color change will be possible also on the prepared tooth and several literature is available confirming that color change is detectable through a veneer.  The selected ingot is a bleach ingot (high value) but is a HT (High Trasnlucency) one.  This material will most likely show (neutral cement shade) any color change beneath the veneer.

Furthermore the reader should be advised to opt for more conservative treatments (bleaching) in office or at home before more invasive treatmenrs

Author Response

Dear authors,

the article entitled "Partial ceramic veneer technique for challenging esthetic frontal restorative procedures." describes the use of ceramic veneers to manage a darkened tooth after trauma. Unfortunately the reviewer does not think this article should be published. The case is a classical bleaching case. The authors support the decision to make a veneer because the bleaching treatment could have a relapse. The relapse, the color change will be possible also on the prepared tooth and several literature is available confirming that color change is detectable through a veneer. The selected ingot is a bleach ingot (high value) but is a HT (High Trasnlucency) one. This material will most likely show (neutral cement shade) any color change beneath the veneer. Furthermore the reader should be advised to opt for more conservative treatments (bleaching) in office or at home before more invasive treatmenrs

 

Dear reviewer, thank you for your time and efforts to revise our manuscript. We appreciate your comments.

We totally agree with the reviewer's comment and this specific detail is reported in this manuscript (page 3 – lines: 83-86 – highlighted now for reviewer appreciation). As the reviewer pointed out correctly, the patient primarily tried to correct your demand by bleaching treatment two times previous to the intervention shown in this manuscript. With unsuccessful results and unsatisfactory esthetic reported by the patient, we decided to propose the treatment reported here with the agreement of the patient. This treatment was not our first option as very well-reported in this manuscript. Furthermore, we discussed in the discussion section about the unstable prognosis of results using bleaching treatments (as reported in this case – two unsuccessful bleaching interventions). Therefore, these facts contributed to an agreement between professional and patient to choose this treatment.

Additionally, we embraced the last suggestion of this reviewer and we added to the discussion section the advice of opting for more conservative treatments before any invasive treatments. 

Reviewer 2 Report

The authors processed the topic satisfactorily. The choice of topic is excellent as there is a growing need for aesthetic intervention these days. If this cannot be solved by internal or external bleaching, indirect Veneer or Crown is recommended.

Professionally, it is positive to see that two types of ceramic materials were used and that the patient was followed for 30 months.

What was DSD protocol exactly? What guidline is in this published form? If not, it is recommended to detail it.

After gingiva plastic, wasn't there recurrent during your healing period? The gums didn't grow back into its original position?

I would like to ask for the replacement of the pictures of Figure 6 as they are of poor quality. It is recommended to document similar cases and write Original Article.

 

Author Response

The authors processed the topic satisfactorily. The choice of topic is excellent as there is a growing need for aesthetic intervention these days. If this cannot be solved by internal or external bleaching, indirect Veneer or Crown is recommended.

Professionally, it is positive to see that two types of ceramic materials were used and that the patient was followed for 30 months. What was DSD protocol exactly? What guidline is in this published form? If not, it is recommended to detail it. After gingiva plastic, wasn't there recurrent during your healing period? The gums didn't grow back into its original position? I would like to ask for the replacement of the pictures of Figure 6 as they are of poor quality. It is recommended to document similar cases and write Original Article.

 

Dear reviewer, thank you for your time and efforts to revise our manuscript. We appreciate your comments and they really improved our manuscript.

1- DSD question: Digital Smile Design by Christian Coachman protocol. Extra and intra-oral photos of the patient were performed and transferred to software (PowerPoint) for image manipulation, adding lines, drawings, shapes, and measurements to verify dental and smile harmony and symmetry. The objectives are for the patient to visualize the project of the future smile and to pass on precise information to the prosthetic laboratory in the manufacture of ceramics.

Additionally, a reference was added to the text and reference list in order to cite the protocol applied.

2- Gingiva plastic: Gingival plastic surgery aimed to remove only an excess of around 1mm of gingival tissue, without bone removal, in order to harmonize the gingival line of all teeth. There was no recurrence of the gingival tissue.

3- Figure 6 was changed to one with better quality.

4- We agree with the reviewer about the necessity of adding similar cases to an Original research and this sentence is described in our conclusion section.

Reviewer 3 Report

The manuscript entitled as “Partial ceramic veneer technique for challenging esthetic frontal restorative procedures.” Is a case report about ceramic veneers over darkened substrate. The novelty relies on the partial aspect of the ceramic piece. It is the first time that I have seen this technique and displaying it as a case report is useful and enriching. However, in the reviewer’s opinion, some critical information/images are lacking. Below, the authors can find some suggestions and concerns.

Abstract:

Good, has all relevant information.

Introduction:

Explains the rationale of a partial dental veneer, avoiding the enamel loss from the incisal part.

I have never seen this technique. It can be very useful, since prevents further enamel’s wear. Since Emax widespread usage, feel innovations have appeared in this area. However, some concerns can be raised, as the interface between the tooth and the ceramic fragment will be in the middle of the vestibular face. Pigmentation can occur in this interface, tampering the long-term esthetic result.

The authors used aesthetic and esthetic terms, mixing English from UK and US, respectively. Choose one to standardize the entire manuscript.

Case report:

First pictures are adequate, as well as the periapical radiography. I suggest adding the information of the vitality test in the figure’s 2 caption as well.

Was the gingivoplasty flapless? Despite the focus on the dental veneer itself, I suggest adding this information, since the post-operative and the time for recovery are significantly different between surgical techniques.

Being a case report, it would be useful a summarized description of the bursts used, as well as rotation, polish and so on.

To be consistent, add the brand of the used addition-reaction silicone elastomer.

Line 144: “Contact lens-thin ceramic veneers” term seems unusual.

Figure 5-b, legend/caption: The authors should primarily describe the veneer of the 21, since it is the focus of the case report. Therefore, add specific information about this veneer. Honestly, the characteristics of the other veneers are secondary in this case.

Main concerns: No pictures immediately after the luting nor the transformation were added. Being a case report about esthetic procedures that is set on intraoral pictures, this absence is unacceptable.

149: The veneer covered the entire vestibular face of the 21 and then, the incisal part of the veneer was worn off. I highly suggest the addition of a detailed description of the veneer transformation, since it is the main element of the report. A scheme of the transformation would be illustrative and useful. Moreover, pictures of the veneer alone, prior luting, would be enlightening. Add the initial thickness of the veneer prior transformation.

Figure 6 and follow-up. The resolution of the pictures is significantly lower than the other ones, in this version of the manuscript. Describe what is a, b, c and d. As a reviewer and reader, I cannot evaluate the esthetic result of the FU, due to the resolution. Moreover, being the interface between teeth and fragment in the middle of the vestibular face, it is critical to know if, how frequent and the technique of the proposed periodic polishing (line 172).  

Discussion:

Authors discussed the endodontic status of the element 21, choice of the material, thickness, past partial veneers for class V lesions. Tackles the problems of classic dental veneers preparation. It is adequate.

References:

Only one reference is from 2022. Most references are prior 2016. The authors should update them.

 

In the reviewer’s opinion, presenting a case of a partial veneer as a conservative approach, aiming less enamel wearing significantly contrasts with the election of performing five additional dental veneers around the element, in a fairly esthetic initial smile. “Saving” a single incisal region while preparing other health tooth using a normal veneer technique, underwhelms the “conservative accent” of the case report altogether. Nevertheless, is a different technique and should be discussed and displayed in case reports like this. 

Author Response

The manuscript entitled as “Partial ceramic veneer technique for challenging esthetic frontal restorative procedures.” Is a case report about ceramic veneers over darkened substrate. The novelty relies on the partial aspect of the ceramic piece. It is the first time that I have seen this technique and displaying it as a case report is useful and enriching. However, in the reviewer’s opinion, some critical information/images are lacking. Below, the authors can find some suggestions and concerns.

Abstract:

Good, has all relevant information.

Introduction:

Explains the rationale of a partial dental veneer, avoiding the enamel loss from the incisal part.

I have never seen this technique. It can be very useful, since prevents further enamel’s wear. Since Emax widespread usage, feel innovations have appeared in this area. However, some concerns can be raised, as the interface between the tooth and the ceramic fragment will be in the middle of the vestibular face. Pigmentation can occur in this interface, tampering the long-term esthetic result.

The authors used aesthetic and esthetic terms, mixing English from UK and US, respectively. Choose one to standardize the entire manuscript.

Case report:

First pictures are adequate, as well as the periapical radiography. I suggest adding the information of the vitality test in the figure’s 2 caption as well.

Was the gingivoplasty flapless? Despite the focus on the dental veneer itself, I suggest adding this information, since the post-operative and the time for recovery are significantly different between surgical techniques.

Being a case report, it would be useful a summarized description of the bursts used, as well as rotation, polish and so on.

To be consistent, add the brand of the used addition-reaction silicone elastomer.

Line 144: “Contact lens-thin ceramic veneers” term seems unusual.

Figure 5-b, legend/caption: The authors should primarily describe the veneer of the 21, since it is the focus of the case report. Therefore, add specific information about this veneer. Honestly, the characteristics of the other veneers are secondary in this case.

Main concerns: No pictures immediately after the luting nor the transformation were added. Being a case report about esthetic procedures that is set on intraoral pictures, this absence is unacceptable.

149: The veneer covered the entire vestibular face of the 21 and then, the incisal part of the veneer was worn off. I highly suggest the addition of a detailed description of the veneer transformation, since it is the main element of the report. A scheme of the transformation would be illustrative and useful. Moreover, pictures of the veneer alone, prior luting, would be enlightening. Add the initial thickness of the veneer prior transformation.

Figure 6 and follow-up. The resolution of the pictures is significantly lower than the other ones, in this version of the manuscript. Describe what is a, b, c and d. As a reviewer and reader, I cannot evaluate the esthetic result of the FU, due to the resolution. Moreover, being the interface between teeth and fragment in the middle of the vestibular face, it is critical to know if, how frequent and the technique of the proposed periodic polishing (line 172).

Discussion:

Authors discussed the endodontic status of the element 21, choice of the material, thickness, past partial veneers for class V lesions. Tackles the problems of classic dental veneers preparation. It is adequate.

References:

Only one reference is from 2022. Most references are prior 2016. The authors should update them.

In the reviewer’s opinion, presenting a case of a partial veneer as a conservative approach, aiming less enamel wearing significantly contrasts with the election of performing five additional dental veneers around the element, in a fairly esthetic initial smile. “Saving” a single incisal region while preparing other health tooth using a normal veneer technique, underwhelms the “conservative accent” of the case report altogether. Nevertheless, is a different technique and should be discussed and displayed in case reports like this.

 

Dear reviewer, thank you for your time and efforts to revise our manuscript. We really appreciate your comments and they improved our manuscript.

1- Introduction: The term “esthetic” was standardized.

2- Case report: Information about periapical radiography, gingivoplasty, bursts, brands, and figure 5 caption were corrected as suggested by the reviewer. (highlighted in the text)

3- Main concerns: We agree with this reviewer about the lack of one picture after luting. The photo was added (figure 6 now). The initial thickness of the ceramic was also added to the text (line 150).

Figure 6 was changed for a high resolution (now figure 7). And, the time for re-polishing in re-appointments was included (line 184).

4- References: Several references were updated as highlighted. Some references are kept in order to have a balance between current studies and important older studies.

Round 2

Reviewer 1 Report

Dear authors,

I understand your point of view, nevertheless I continue thinking that the message of more invasive treatments shall be avoided. In this case the incisal portion of the tooth is amazing. Insisting with bleaching cervically could have probably solved the problem.

Author Response

Dear reviewer, thank you for your re-revision and comments.

As previously mentioned, we fully agree with the reviewer's position in terms of prioritizing non-invasive treatments before any other option, and this detail is well described in this manuscript. However, as very well described in this manuscript, the non-invasive bleaching treatment was tried twice without success, leaving the patient dissatisfied and seeking solutions after these attempts.

The reviewer cites the option of performing a third attempt at tooth bleaching, however, as very well described in this manuscript, the tooth in question had pulp chamber and root canal obliteration. Details that impair the success of tooth whitening in high percentages.

Additionally, the reviewer is suggesting a hypothetical third bleaching attempt (citing his opinion in the case as an external viewer). In the reality of the dental clinic, the patient would not like to perform and pay for procedures that would generate a possible third failure, vehemently requesting solutions. At this moment, the case described in this study was suggested, where the patient agreed and fully accepted the treatment proposal in agreement with the professionals.

Also, we agree with the reviewer's comments that the incisal tooth is perfect. And precisely for this reason, the innovative technique described in this study was proposed, seeking to preserve the incisal of this tooth without wear. In addition, the 30-month follow-up shows the successful result and the patient's happiness with the proposed treatment decision, not achieved by tooth bleaching. Again, the decision for a differentiated treatment was an option for the patient in agreement with professionals seeking solutions for the case. This case report is not encouraging invasive treatments at any time, on the contrary, it is showing a differentiated solution for repeated attempts at unsuccessful whitening treatments. Hence the proposal to write a case report, as it is a different condition and not a protocol applied daily in clinics.

Finally, we added a last sentence in the conclusions section further clarifying the importance of non-invasive treatments before any tooth wear.

 

Reviewer 3 Report

The authors addressed most of the concerns pointed out by the reviewer. However, some improvements can still be made. The authors can find it below.

Figure 5 and line 146-149. In the text, the chosen material for the veneer of 21 apparently is feldspathic ceramic. However, in the figure 5-b caption, the authors describe this veneer as Emax. Please, clarify.

 

Figure 6: 6-a is useful, showing the placed veneers immediately after the luting. It is evident that the incisal part of the tooth is still covered by the ceramic. In addition, it is possible to see the gingival part with mild inflammation due to the luting, which is perfectly normal. However, figure 6-b is described as “immediate after luting and polishing procedures”, which the reviewer think it is inaccurate. It is noticeable that the gum is completely healed in the figure 6-b (despite the black and white accent). In fact, figure 6-b looks very similar to the figure 7-d (a bit zoomed in, black and white). The authors should address this question, adding a more representative picture of the “immediate after luting and polishing procedures” or leaving only figure 6-a. 

Author Response

Dear reviewer, thank you for your time and efforts to revise our manuscript again.

1-    Thank you for the correction. The figure caption was described wrongly, the correct ceramic type is feldspathic ceramic as well observed by the reviewer. Now, corrected. 
2-    Thank you for your comments about the figures. We decided to follow your suggestions and remove figure 6b, keeping only figure 6a. 

Round 3

Reviewer 1 Report

Dear authors,

thanks for your email and comments. I confirm my opinion. I leave to the academic editor the decision whether to accept your paper or not.

Reviewer 3 Report

The reviewer congratulates the authors for the improvements performed.

No further questions.