Porcelain veneers/ orthodontic continuing education

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  • Before: Secere tetracysline stain with small multiple diastemas
    After: MAXILLARY – TILL FIRST molars Mandibular –till first premolars
    With P opacity in the laminate themselves.
  • Before: streaked discoloration of enamel.
    After :
  • Before : Class iv fracture of left CI.
    After : Two Labial Veneers
  • After : Along with slight shortening of the CI
  • Pumice should not contain flouride or oils
  • Passing it over the incisal edge may wipe the internal aspect of the veneers clean of composite resin leaving a void.
  • Passing it over the incisal edge may wipe the internal aspect of the veneers clean of composite resin leaving a void.
  • Passing it over the incisal edge may wipe the internal aspect of the veneers clean of composite resin leaving a void.
  • Passing it over the incisal edge may wipe the internal aspect of the veneers clean of composite resin leaving a void.
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  • Porcelain veneers/ orthodontic continuing education

    1. 1. PORCELAIN VENEERS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    2. 2. Key Terms • Veneer : A thin sheet of material usually used as a finish A protective or ornamental facing A superficial or attractive display in multiple layers, frequently termed a laminate veneer www.indiandentalacademy.com
    3. 3. Key Terms • Esthetic : Pertaining to the study of beauty and the sense of beautiful. Descriptive of a specific creation that results from such study; objectifies beauty and attractiveness, and elicits pleasure. www.indiandentalacademy.com
    4. 4. www.indiandentalacademy.com
    5. 5. THE PIONEERS • Dr. Charles Pincus (1930) : Developed thin facings of air fired porcelain, which were temporarily held in place with adhesive denture powder. “Hollywood Smile” www.indiandentalacademy.com
    6. 6. THE PIONEERS • Buonocore (1955) : Acid etch technique Bowen (1958) : Development of filled resins. Enabled mechanical bonding between etched tooth and filled resins. www.indiandentalacademy.com
    7. 7. THE PIONEERS • Rochette (1975): – Described the innovative restoration of a fractured incisor with an “etched silanted porcelain block”. – Introducing the concept of acid etching porcelain. www.indiandentalacademy.com
    8. 8. THE PIONEERS • In the early 1980’s American laminate developments – • McLaughlin G. • F.R. Faunce • D.R. Myers • J.R. Calamia • H.R. Horn • R.E. Goldstein www.indiandentalacademy.com
    9. 9. TYPES OF VENEERS • Directly fabricated veneers – Composite Veneers Indirectly fabricated veneers Preformed laminates Laboratory fabricated veneers Acrylic resin veneers Microfill resin veneers Porcelain veneers www.indiandentalacademy.com
    10. 10. ADVANTAGES • COLOR – Better inherent color control – Natural look – Color stability www.indiandentalacademy.com
    11. 11. ADVANTAGES • Bond strength – Better bond strength to the enamel surface than any of the other veneering systems. www.indiandentalacademy.com
    12. 12. ADVANTAGES • Periodontal Health – Highly glazed porcelain – Less depository area for plaque accumulations – Some authors say that they actually deter plaque accumulation www.indiandentalacademy.com
    13. 13. ADVANTAGES • Resistant to Abrasion – Wear and abrasion resistant exceptionally high as compared to composite resin. www.indiandentalacademy.com
    14. 14. ADVANTAGES • Inherent porcelain strength – Veneer itself is rather fragile, but once it is luted to enamel develops both high tensile and shear strengths. – Clinically evident by the fact that veneers cannot be “popped” off teeth but actually have to be ground away using rotary diamonds through to the original tooth surface. www.indiandentalacademy.com
    15. 15. ADVANTAGES • Inherent porcelain strength – Cohesive strength of porcelain is considerably greater than the bond between the resin and filler particles in a composite resin – Thus can be used to increase the length of tooth by extending it over the incisal edge • High bond strength to enamel. • High adhesive and cohesive strengths. www.indiandentalacademy.com
    16. 16. ADVANTAGES • Resistance to fluid absorption Absorbs less fluid than any other veneering material. www.indiandentalacademy.com
    17. 17. ADVANTAGES • Esthetics – Considerably better – Stained both internally and superficially – Natural Fluorescence lending certain vitality. – Surface texture can be readily developed to simulate that of adjacent tooth. www.indiandentalacademy.com
    18. 18. DISADVANTAGES • Time – Very technique sensitive and therefore time consuming. www.indiandentalacademy.com
    19. 19. DISADVANTAGES • Repair – Cannot be easily repaired once luted to the enamel www.indiandentalacademy.com
    20. 20. DISADVANTAGES • Cumber some – Indirect one – Two patient appointments – Impression making – Laboratory fees www.indiandentalacademy.com
    21. 21. DISADVANTAGES • Color modification – Difficult to modify color once luted in position on the enamel surface. www.indiandentalacademy.com
    22. 22. DISADVANTAGES • Tooth preparation – Requires some tooth preparation to prevent potential problems associated with over contouring. www.indiandentalacademy.com
    23. 23. DISADVANTAGES • Fragility – Extremely fragile and difficult to manipulate. www.indiandentalacademy.com
    24. 24. DISADVANTAGES • Cost – More expensive than other veneering systems. www.indiandentalacademy.com
    25. 25. INDICATIONS • Discolorations – Tetracycline staining – Devitalization – Fluorosis www.indiandentalacademy.com
    26. 26. INDICATIONS Discolorations www.indiandentalacademy.com
    27. 27. INDICATIONS • Enamel defects – Hypoplasia – Malformation www.indiandentalacademy.com
    28. 28. INDICATIONS Enamel Defects www.indiandentalacademy.com
    29. 29. INDICATIONS Diastemata Single Multiple www.indiandentalacademy.com
    30. 30. INDICATIONS Single Midline Diastema www.indiandentalacademy.com
    31. 31. INDICATIONS Multiple Spaces www.indiandentalacademy.com
    32. 32. INDICATIONS • Malpositioned teeth – Developing the esthetic illusion of straight teeth where the teeth are actually rotated or malpositioned can be accomplished in people who have relatively sound teeth and do not wish to undergo orthodontic treatment. www.indiandentalacademy.com
    33. 33. Indications BEFORE AFTER www.indiandentalacademy.com
    34. 34. Indications BEFORE AFTER www.indiandentalacademy.com
    35. 35. Indications BEFORE AFTER www.indiandentalacademy.com
    36. 36. INDICATIONS • Malocclusion – The configuration of the lingual surface of the incisors can be changed to develop increased guidance or centric holding areas in malocclusions or peridontally compromised teeth www.indiandentalacademy.com
    37. 37. INDICATIONS • Poor restorations – Teeth with numerous small, unesthetic restorations on the labial surface can be dramatically restored. www.indiandentalacademy.com
    38. 38. INDICATIONS • Aging – The ongoing process of aging can result in color changes and wear in teeth. Can be improve by bleaching alone or sometimes bleaching with subsequent veneering. www.indiandentalacademy.com
    39. 39. Indications BEFORE AFTER www.indiandentalacademy.com
    40. 40. INDICATIONS • Wear patterns – Also useful in cases that exhibits slow progressive wear patterns. – If sufficient enamel remains and the desired increase in length is not excessive, porcelain veneers can be bonded to the remaining tooth structure to change shape, color or function. www.indiandentalacademy.com
    41. 41. Indications BEFORE AFTER www.indiandentalacademy.com
    42. 42. INDICATIONS • Agenesis of lateral incisor – In the problem of canine erupting adjacent to the lateral incisor, the veneer can be used to develop better coronal form in the canine thus simulating a lateral incisor. – This may have to be combined with veneers on central also, to develop a more ideal ratio in the relative proportion of teeth. www.indiandentalacademy.com
    43. 43. Indications BEFORE AFTER www.indiandentalacademy.com
    44. 44. CONTRAINDICATIONS • No specific contraindications • But some considerations to be taken into account: – Available Enamel – Ability to etch Enamel – Oral Habits www.indiandentalacademy.com
    45. 45. Available enamel  Should be enamel around the periphery of laminate Adhesion To seal the veneer to tooth surface  Should be sufficient enamel for bonding Bonding to dentin is relatively less retentive Better to go for crowns www.indiandentalacademy.com
    46. 46. Ability to etch enamel • Deciduous teeth and teeth that have been excessively fluoridated may not etch effectively. www.indiandentalacademy.com
    47. 47. ORAL HABITS • Patients with certain habits such as – Tooth to tooth habits : bruxism – Tooth to foreign objects habits • Not ideal candidates for veneers as the shearing stresses may be too great for porcelain to withstand. www.indiandentalacademy.com
    48. 48. ENAMEL REDUCTION Different opinions. Little or no reduction A full deep chamfer preparation on the labial aspect of the teeth and most or all the way through the interproximal areas. Best is to decide how to approach the preparation on an individual basis. www.indiandentalacademy.com
    49. 49. ENAMEL REDUCTION – To provide for an adequate dimensions of available space for the porcelain material. – To remove convexities and provide for a path of insertion in those situations where either the incisal or interproximal areas are to be included in the veneer; the best path of insertion is that which will require the least amount of enamel reduction. RATIONALE FOR ENAMEL REDUCTION www.indiandentalacademy.com
    50. 50. ENAMEL REDUCTION – To provide space for adequate opaquing where necessary and for the composite resin luting agent. – To provide a definite seat to help position the laminate during placement. – To provide a receptive enamel surface for etching and bonding the laminate. – To facilitate sulcular margin placemen in severely discolored teeth. RATIONALE FOR ENAMEL REDUCTION www.indiandentalacademy.com
    51. 51. ENAMEL REDUCTION – Esthetics : In lingually inclined teeth advantageous not to reduce or reduce less. – Relative tooth position: If one or more teeth are out of line with respect to others, this will influence the degree of preparation necessary. – Masking of tetracycline stain – Margin placement Decision of whether to reduce enamel depend on the following biological or technical factors: www.indiandentalacademy.com
    52. 52. ENAMEL REDUCTION • Age of the patient • Psyche : The attitudes of the patient to reduction should be determined prior to proceeding. • Plaque: the patient should be evaluated for the ability to remove plaque at a porcelain/tooth interface. www.indiandentalacademy.com
    53. 53. If restorations are to be esthetic and biologically compatible, they will often necessitate adjustments to the tooth surface. This reduction in enamel can then be replaced with a similar thickness of porcelain, thereby making the end result the same size or, at worst, only nominally larger than original. ENAMEL REDUCTION www.indiandentalacademy.com
    54. 54. • Usually the enamel reduction necessary, will be in the realm of 0.3 to 0.6 mm or about half the thickness of the available enamel. ENAMEL REDUCTION www.indiandentalacademy.com
    55. 55. Five distinct aspects • Labial Reduction • Interproximal extension • Sulcular extension • Incisal or occlusal modification • Lingual reduction ENAMEL REDUCTION www.indiandentalacademy.com
    56. 56. LABIAL REDUCTION • Ideally, one would like to replace the same amount of enamel that is removed by the preparation. • Certain situations – Rotated teeth – Teeth in labial version ENAMEL REDUCTION www.indiandentalacademy.com
    57. 57. • The preparation should remain within the enamel wherever possible and most certainly at all the preparation margins. • Some cosmetic situations, dentin may have to be exposed. – Fraction of bond strength – Less effective seal – Pulpal hyperemia ENAMEL REDUCTION www.indiandentalacademy.com
    58. 58. AS A GENERAL RULE, OVER 50% OF THE PREPARATION SHOULD BE IN ENAMEL. ENAMEL REDUCTION www.indiandentalacademy.com
    59. 59. DEPTH GUIDE • LVS depth cutter diamond burs( Brasseler, Savannah, Ga.) ENAMEL REDUCTION www.indiandentalacademy.com
    60. 60. DEPTH GUIDE LVS no. 1 – 0.5 mm reduction LVS no. 2 – 0.3 mm reduction ENAMEL REDUCTION www.indiandentalacademy.com
    61. 61. DEPTH GUIDE Gently draw the diamond across the labial surface of the tooth from mesial to distal side. ENAMEL REDUCTION www.indiandentalacademy.com
    62. 62. DEPTH GUIDE ENAMEL REDUCTION www.indiandentalacademy.com
    63. 63. Alternative Method • Use a no. 1 diamond bur • Depth from the peripheral aspect of the bur to the shank is 0.4 mm • Hold the bur at a slight angle so that indentations can be made into the enamel to the depth limited by the base of the shank. www.indiandentalacademy.com
    64. 64. Alternative Method • Create these indentations randomly across the surface of the enamel • Problem with this type – Depth cuts can vary depending upon the angle the bur is held – More time consuming www.indiandentalacademy.com
    65. 65. Reduction of remaining enamel • The bulk of the reduction should be done with a coarse diamond in order to facilitate added retention and better refraction of the light being transmitted back out through the laminate. • At the marginal area, desirable to use a fine-grit diamond to develop a definitive, smooth finish line to enhance the peripheral seal. www.indiandentalacademy.com
    66. 66. Two grit LVS diamond burs LVS No. 3 LVS No. 4www.indiandentalacademy.com
    67. 67. Interproximal extension • Margin should be hidden within the embrasure area. • Extend about half way into the interproximal area. • Ensures a wrap around with etched resin bonds at right angles to the labial surface for increased bond strength. www.indiandentalacademy.com
    68. 68. Interproximal extension • Move the margin just lingual the buccal surface of the interproximal papillae so that it will not be visible from lateral oblique view or directly from the front. www.indiandentalacademy.com
    69. 69. Treatment of contact areas • Modify the contacts by passing a very fine, one sided diamond abrasive strip through the adjacent teeth. • Use it in ‘S’ configuration so that the abrasive side will reshape the contact areas rather than separate them. • Thus, a thinner contact is maintained as measured in the buccolingual direction. www.indiandentalacademy.com
    70. 70. Treatment of contact areas • The contact area is then clearly demarcated on the model, and easy, clean snapping apart of this model into dies is facilitated • Dental floss passed through these contact areas should still just catch, so arch integrity and stability are not disturbed. www.indiandentalacademy.com
    71. 71. Dentin exposure • If surrounded by enamel, it can be managed by dentin bonding agent. • May be a conventional dentin bonding agent, a phosphorus ester of the BIS-GMA molecule, or one of the newer systems such as aluminum oxalates or glutaraldehydes. www.indiandentalacademy.com
    72. 72. Dentin exposure • If dentin exposure occurs at the periphery, such as the cervical region, it is advisable to prepare a little deeper into this area. • Use a layer of GIC can be used as a base. • The GIC will bond to dentin, and seal it as opposed to a dentin bonding agent, which may only adhere but not seal effectively. www.indiandentalacademy.com
    73. 73. Dentin exposure • The GIC can subsequently be etched concomitantly with the enamel when placing the veneer, and the composite resin luting agent will then bond to it. www.indiandentalacademy.com
    74. 74. Sulcular extension & Marginal Placement • Desirable to place it just within the sulcus. • 0.5 to 1 mm into the sulcus or even to remain supra-gingival if a dramatic color change is not a high priority. • Place a narrow gingival displacement cord in the sulcus for about eight to ten minutes. www.indiandentalacademy.com
    75. 75. Sulcular extension & Marginal Placement • Advantages: Access for the diamond bur Less gingival trauma Direct vision of margin placement during all procedures. www.indiandentalacademy.com
    76. 76. Sulcular extension & Marginal Placement • This region of the sulcus has the least potential for inducing gingival reaction because the sulcular supporting enamel has not been tampered with and the subgingival coronal contour remains the same. www.indiandentalacademy.com
    77. 77. Finish line configuration • Somewhat controversial • Feather edge to a rounded shoulder. • Requires a cervical reduction of minimum 0.25 mm www.indiandentalacademy.com
    78. 78. Benefits of modified chamfer finish line • Increased bulk of porcelain at margin and hence increased strength contour without overcontour. • Correct enamel preparation exposing correctly aligned enamel rods for increased bond strength at cervical margin. • A well defined finish line for the laboratory. www.indiandentalacademy.com
    79. 79. Benefits of modified chamfer finish line • A definitive stop to aid in seating the laminate in the correct position. • A sound marginal seal www.indiandentalacademy.com
    80. 80. Incisal reduction • Indicated if length has to be increased. • Definitive flattening of the incisal edge to create increased enamel width and potential bonding surface for laminate. • Never end the incisal edge where excursive movements of the mandible will cause shearing stresses at the junction of porcelain laminate and tooth. www.indiandentalacademy.com
    81. 81. www.indiandentalacademy.com
    82. 82. www.indiandentalacademy.com
    83. 83. www.indiandentalacademy.com
    84. 84. www.indiandentalacademy.com
    85. 85. www.indiandentalacademy.com
    86. 86. www.indiandentalacademy.com
    87. 87. www.indiandentalacademy.com
    88. 88. IMPRESSION MAKING www.indiandentalacademy.com
    89. 89. DIRECT COMPOSITE RESIN TEMPORARIZATION www.indiandentalacademy.com
    90. 90. DIRECT COMPOSITE RESIN VENEER UTILISING VACUFORM MATRIX www.indiandentalacademy.com
    91. 91. www.indiandentalacademy.com
    92. 92. www.indiandentalacademy.com
    93. 93. INDIRECT COMPOSITE RESIN/ACRYLIC RESIN VENEER www.indiandentalacademy.com
    94. 94. www.indiandentalacademy.com
    95. 95. Shade selection • Advisable to select a shade that is slightly lighter than desired by the patient. • Subtle shade modification possible with composite resin systems • Easier to darken any given shade. • In general, select a shade that is higher in value and lower in chroma. www.indiandentalacademy.com
    96. 96. Shade selection • Final shade depends upon – Porcelain shade selected – The original tooth color – Amount of opacifier added – Color and opacity of composite resin luting agent – Use of resin shade modifiers and characterizers www.indiandentalacademy.com
    97. 97. Laboratory procedures • The refractory investment technique • The platinum foil technique • The IPS Empress system. www.indiandentalacademy.com
    98. 98. Processing principle – easy and efficient An anatomical wax-up of the restoration is fabricated, sprued, and invested. After preheating the investment ring, the ceramic material is pressed into the investment ring. After divesting the pressed objects, complete the restorations according to the esthetic requirements using the IPS Empress staining technique and the IPS Empress Esthetic Veneer materials. www.indiandentalacademy.com
    99. 99. Material Leucite-reinforced glass-ceramic The IPS Empress glass-ceramic material is made of a glass phase and a leucite crystal phase. The growth of the leucite crystals starts at the grain boundaries of the glass frit. The leucite crystals are grown in a multi-step fabrication process up to a size of few microns. The semi-finished product in powder form is then pressed to ingots and fired. www.indiandentalacademy.com
    100. 100. www.indiandentalacademy.com
    101. 101. The new, phosphate bonded IPS Empress Esthetic Speed Investment is used . The system consists of a powder and a liquid www.indiandentalacademy.com
    102. 102. Sprueing the wax pattern • Depending on the size of the waxed-up pattern, directly attach a wax sprue (diameter 2.5–3 mm / 8 gauge) to the object. • The length of the sprues depends on the size of the objects. • The sprues should measure 3 mm to max 8 mm in length. • large (long) wax pattern = shorter sprue • small (short) wax pattern = longer sprue www.indiandentalacademy.com
    103. 103. www.indiandentalacademy.com
    104. 104. www.indiandentalacademy.com
    105. 105. The sprue and wax pattern should not be longer than 15–16 mm. Observe a 45-60° angle. www.indiandentalacademy.com
    106. 106. Provide sprues in the direction of flow of the ceramic material. www.indiandentalacademy.com
    107. 107. Always attach the sprue to the thickest part of the wax pattern. The internal surface of the wax pattern points outwards. www.indiandentalacademy.com
    108. 108. The attachment points of the sprues must be rounded. Observe a 45–60° angle. www.indiandentalacademy.com
    109. 109. Observe a distance of at least 3 mm between the individual wax pattern. Observe a distance of at least 10 mm between the paper ring/ring gauge and the wax patterns to be pressed. Consider the direction of flow of the ceramic material when positioning the sprues. www.indiandentalacademy.com
    110. 110. Investing • Investment is carried out with the IPS Empress Esthetic Speed. • Determine the accurate wax weight: – Weigh the ring base (seal the opening of the ring base with wax). – Position the wax patterns to be pressed on the ring base and attach them with wax. Weigh again. – The difference between the two values is the weight of the wax used. www.indiandentalacademy.com
    111. 111. Investing • Large investment ring – Up to max. 1.4 g wax weight and two ingots • Small investment ring – Up to max. 0.6 g wax weight and one small ingot www.indiandentalacademy.com
    112. 112. Investing • Remove the protective tape from the paper ring. Form a cylinder exactly along the marked line. • Tightly press the two ends together along the entire line. • When working with ready-to-use paper rings, double-check the adhesive area for optimum adhesion. Form a ring exactly along the marked line. www.indiandentalacademy.com
    113. 113. Set the paper ring on the base of the investment ring and check for correct fit. Use the ring stabilizer to stabilize the paper ring. Mix IPS Empress Esthetic Speed Investment material under vacuum. Pour the investment material slowly. Avoid the formation of air bubbles.www.indiandentalacademy.com
    114. 114. Remove the stabilizing ring and slowly place the ring gauge on the investment ring with a hinged movement. Remove rough spots on the bottom surface of the investment cylinder with a plaster knife. The light material overlap created by the paper ring is also removed with a plaster knife until the line is no longer visible.www.indiandentalacademy.com
    115. 115. Preheating Always preheat IPS Empress Esthetic ingots Always place the investment rings in the rear part of the firing chamber. This allows homogeneous preheating. The investment rings must be placed in the hot preheating furnace as quickly as possible. Make sure that the furnace temperature does not drop significantly. Always place in the investment rings in the preheating furnace with the opening pointing downwards. The investment rings must not touch each other. This would negatively influence the heat absorption and stability.www.indiandentalacademy.com
    116. 116. Pressing • Placing the ingots • Remove the investment ring from the preheating furnace. • Place the corresponding preheated ingot that matches the desired tooth shade. Large investment ring – Max. 2 ingots per pressing cycle Small investment ring – Max. 1 ingot per pressing cycle www.indiandentalacademy.com
    117. 117. Remove the investment ring from the preheating furnace. Place the preheated IPS Empress Esthetic ingot in the investment ring. Place the rings in the preheating furnace as quickly as possible. Next, position the AlOx plunger. www.indiandentalacademy.com
    118. 118. Divesting After approx. 60 minutes After cooling, the investment ring may show cracks. These cracks develop (immediately around the AlOx plunger) during cooling as a result of the different CTEs of the various materials (AlOx plunger, investment material, and pressed materials). They do not compromise the result of the pressing cycle. www.indiandentalacademy.com
    119. 119. Mark the length of the AlOx plunger on the cooled investment ring. Separate the investment ring using a separating disk. This predetermined breaking point enables reliable separation of the AlOx plunger and the ceramic material. Break the investment ring at the predetermined breaking point using a plaster knife www.indiandentalacademy.com
    120. 120. Rough divestment is carried out with Polishing Jet Medium at 4 bar (60 psi) pressure. For fine divestment, only 2 bar (30 psi) pressure is applied. When divesting the object, blast from the direction indicated in the schematic at the top. www.indiandentalacademy.com
    121. 121. www.indiandentalacademy.com
    122. 122. www.indiandentalacademy.com
    123. 123. www.indiandentalacademy.com
    124. 124. www.indiandentalacademy.com
    125. 125. Placement of veneers • Three stage Try-in procedure – Check Intimate adaptation of each individual porcelain laminate to the prepared tooth surface. – Evaluate the collective fit and relationship of one laminate to another and the contact points. – Assess the color and if necessary, modify. www.indiandentalacademy.com
    126. 126. The preliminary procedure • Remove the temporaries, if any. • Expose the finish line if extended at or below the gingival margin with a thin retraction cord. www.indiandentalacademy.com
    127. 127. The preliminary procedure • Veneers returned from lab in a protective box in their etched state. • Very fragile and must be handled with utmost care. • Handle at their edges and at the unetched labial surface. www.indiandentalacademy.com
    128. 128. The preliminary procedure • Examining the veneers – Inspect inner aspect for even etching all the way to the marginal periphery. Drop of water on a correctly etched surface will spread and wet it evenly. – Check periphery to see that it is smooth – Check for crack lines and foreign body inclusions using the composite resin light as a transilluminator. www.indiandentalacademy.com
    129. 129. Stage I: Check for individual fit • Clean the teeth with a slurry of fine flour of pumice with a non webbed rubber cup. • Clean contact areas with a fine composite resin finishing strip • Patient in supine or horizontal position so that the labial surface to be veneered can be made horizontal or parallel to the floor, thus preventing it from sliding off. www.indiandentalacademy.com
    130. 130. Stage I: Check for individual fit • Select the most distal veneer and try it on the respective tooth. • If it does not fit in position, do not force it. • Check for any undercuts or contact point impingement and use a microfine (LVS no. 6) bur under magnification to adjust it until it seats easily. www.indiandentalacademy.com
    131. 131. Stage I: Check for individual fit • Check the margins for accuracy and intimacy of fit. A drop of glycerin placed on the etched surface can facilitate adhesion of veneer to tooth surface. • Try-in each laminate individually www.indiandentalacademy.com
    132. 132. Stage 2 : Collective fit try-in • Try all veneers together. • Verify interproximal contacts. • Adjust any contacts that are too tight with LVS no. 6 bur. • All veneers should passively fit in place. www.indiandentalacademy.com
    133. 133. Stage 3: Color check • Difficult to ascertain the actual color because there is a space between enamel surface and veneer itself. • This “air refraction” prevents underlying tooth surface from being transmitted to the surface of the veneer. • The porcelain tooth interface is filled with glycerin, which will then transmit some of the underlying color to the veneer. www.indiandentalacademy.com
    134. 134. Stage 3: Color check • Place one laminate in position with glycerin and compare with the shade tab selected. • If laminate appears darker than the shade tab selected, the a lighter colored composite resin should be selected and conversely. www.indiandentalacademy.com
    135. 135. Composite resin color check • The actual composite resin selected can be placed on the veneer next and veneer seated on the tooth. • Excess resin is removed with an explorer and the ‘Final’ color will become evident. www.indiandentalacademy.com
    136. 136. Points of caution • Avoid exposure to operatory light as it may initiate the curing process, especially with ‘dual’ cure type of composite resins. • Most composite resin change color on initial curing. • Most composite resin undergo a further shift in color over the next 72 hours in moist oral environment. www.indiandentalacademy.com
    137. 137. • Better technology is to use specially formulated and colored keyed try- in paste. www.indiandentalacademy.com
    138. 138. • The composite resin material used during the try in stage will generally need to be removed in its entirety by placing the veneer in a container of pure alcohol in an ultrasonic solution for 10 minutes. www.indiandentalacademy.com
    139. 139. Characterization & staining • Characterized on the internal surface by the use of composite resin color characterization kits. • Veneer is etched and silanated and color resin is painted onto this etched surface. • Veneers can then be tried and if found satisfactory the resin stain can be cured onto the veneer in very thin layer. www.indiandentalacademy.com
    140. 140. Characterization & staining • Characterized on the external surface by using a special laminate low-fusing stain system. www.indiandentalacademy.com
    141. 141. Opaquing • P.A. opacity system • Using a thicker layer of luting composite resin specially in localized areas • Laying down striae of opaque porcelain as a base and building over it. • Leads to some loss of vitality for the veneer. www.indiandentalacademy.com
    142. 142. Luting agents • Desirable features for luting agents – Thin film thickness: 10 to 20um. – High compressive strength – High tensile strength – Relative low viscosity – Ability to opaque, tint and characterize – Low polymerization shrinkage – Color stability. www.indiandentalacademy.com
    143. 143. Luting agents • Light cured composite resin system preferred. • In case of thick or very opaque veneers, dual cured system are preferred. • “Submicrofill Hybrid” type preferred www.indiandentalacademy.com
    144. 144. Veneer placement procedure 1. Tissue management Place patient in supine or recumbent position. Place retraction cord in gingival sulcus Decrease crevicular fluid Displace the tissue. www.indiandentalacademy.com
    145. 145. 2. Layout • Layout the cleaned, etched veneers in their respective tooth order, in easy reach. • Assemble the necessary instruments and materials in appropriate sequence. • Prevents any slowing down during the bonding procedure. www.indiandentalacademy.com
    146. 146. 3. Silanation • Treat the etched veneer with a silane coupling agent to enhance the adhesive properties of resin. • A pre-activated silane is painted onto the veneer surface and allowed to dry for one minute. • Then the excess alcohol vehicle is gently evaporated by passing a stream of air parallel to and approx. 6 in. above the surface of veneer. • This leaves a dry, silanated veneer. www.indiandentalacademy.com
    147. 147. Silanation • In the non-hydrolyzed from the surface of laminate must first be conditioned with an acid medium to hydrolyze and activate the subsequent layer of silane. www.indiandentalacademy.com
    148. 148. 4. Enamel Activation • Clean the teeth with a slurry of fine pumice and water using a rubber cup to remove all traces of salivary glycoproteins and previous composite resins from try-in. • Wash and air dry the teeth www.indiandentalacademy.com
    149. 149. 5. Isolation • Isolate with check retractors and cotton rolls. • Place a saliva ejector near the back of the throat and instruct the patient to breathe through the nose, further decreasing the moisture contamination that is caused by humid vapors. www.indiandentalacademy.com
    150. 150. 6. Enamel etching • Tooth is isolated on both sides by placing either mylar strips or soft metal matrix band mesially and distally. • Tooth is etched with 30 to 37 % phosphoric acid solution for 15 to 20 seconds. • The etching material is washed from the enamel surfaces with copious amount of water for full 30 seconds. www.indiandentalacademy.com
    151. 151. Enamel etching • Do not let the patient rinse or in any way contaminate this etched surface with saliva. • If this occurs, the surface must be re- etched for 10 seconds, washed and dried again. • The enamel surface is ideally dried with a stream of warm air to ensure an uncontaminated, oil-free surface. www.indiandentalacademy.com
    152. 152. 7. Application of dentin bonding agent • Coat the etched tooth surface with bonding agent of the light activated type, which is gently air dispersed into a thin, even layer. • Gently blow aside all excess bonding agent • Light cure this evenly dispersed layer to seal the tooth surface. www.indiandentalacademy.com
    153. 153. • Next coat the internal aspect of veneer with an unfilled resin bonding liquid; blow it into a thin layer but do not light cure it. • Place the composite resin luting agent on the laminate, using some form of syringe and express the material into the center so that it spreads laterally, without trapping air bubbles. 7. Application of dentin bonding agent www.indiandentalacademy.com
    154. 154. 8. Seating Sequence • Best to seat one laminate at a time. • Move the light away from the operatory field • Some feel it is useful to sticky wax and attach some form of handle( such as a tooth pick) to the labial surface of veneer. www.indiandentalacademy.com
    155. 155. 9. Placement • Rotate the veneer onto the buccal surface of the tooth and ten gently manipulate it until contact is made in the region of the gingival finish line. • Motion must be gently rocking or “pulsing” motion that slowly allows the excess material to escape from all sides of the veneer. www.indiandentalacademy.com
    156. 156. 9. Placement • Gross excess is removed by a firm, pointed paint brush or curette. • Important not to slide veneer in place. • Hold the laminate firmly in place to prevent “ suck back” and begin the polymerization process with light. • Cure for just 20 sec from the lingual aspect and a further 20 sec from the labial aspect in the incisal half of the tooth. www.indiandentalacademy.com
    157. 157. 9. Placement • Remove the rest of the excess partially cured material-still holding the veneer firmly in place- from the gingival margin and interproximal area, using a sharp scaler and/or an explorer. • The two matrix strips are now pulled from the buccal aspect toward the lingual aspect to clear the interproximal area of excess material. www.indiandentalacademy.com
    158. 158. 9. Placement • The matrix strips must be reinserted between the teeth to prevent them from bonding to one another. • The light is then reapplied to the labial and lingual surfaces to complete the polymerization. • The polymerization process is completed by curing the various areas of the veneer for at least 2 minutes each. www.indiandentalacademy.com
    159. 159. 9. Placement • This extra time is important due to the fact that the light has to travel through the porcelain to reach the underlying composite resin. • The more excess resin is removed prior to the finishing process, the easier the final finishing will be. www.indiandentalacademy.com
    160. 160. 10. Curing • Time: the greater is the time resin is exposed, greater is the percentage of cure. • Angle of contact: Should contact resin at right angles for maximum effectiveness. • Shade of the resin: Darker shades of resins and increased opacities of resin need an increased amount of time for curing. www.indiandentalacademy.com
    161. 161. 10. Curing • Composite resin composition: Vary from resin to resin with a variation in degree of cure when exposed to the same light. • Distance: should never be more than 1 mm. www.indiandentalacademy.com
    162. 162. 11. Finishing • Best accomplished with some form of x2 or x4 magnification. • Following complete polymerization, chip off any excess composite resin with a carbide interproximal carver or gold foil knife. www.indiandentalacademy.com
    163. 163. 11. Finishing • LVS no. 5 bur ( carbide finishing bur with straight profile) : Remove any resin at the gingival margin. • LVS no. 7 bur ( microfine diamond point): Gently machine down any excess porcelain horizontal ledge beyond the preparation. And to get the emergence profile. www.indiandentalacademy.com
    164. 164. 11. Finishing • LVS no. 6 or 7 bur( polishing diamond): refine the tooth-resin-porcelain interface. • LVS no. 8 ( Football shaped diamond): For finishing the lingual veneer-enamel interface. www.indiandentalacademy.com
    165. 165. 11. Finishing • Final polishing: Ceramic polishing points followed by a diamond dust impregnated paste with a non webbed rubber cup. • Can take 5 min or more per tooth. • Interproximal areas polished with composite resin finishing strips. • Floss passes through smoothly and does not catch or tear. www.indiandentalacademy.com
    166. 166. 12. Occlusal assessment • Ensure no excessive contacts with opposing arch in any excursive movements. • More critical when incisor edge is lapped. www.indiandentalacademy.com
    167. 167. 13. Cosmetic contouring • After several days( to ensure complete polymerization of resin) the veneer can further be refined with fine diamonds for esthetic harmony. • The bonded veneer, at this stage, are extremely strong and readily amenable to cosmetic contouring. • Never contour unsupported porcelain veneers until bonding is complete. www.indiandentalacademy.com
    168. 168. Atlas of laminate placement 1. Enamel Activation Preoperative view of an esthetically dark canine Porcelain laminate returned from the laboratory www.indiandentalacademy.com
    169. 169. Clean the canine with a slurry of pumice and water www.indiandentalacademy.com
    170. 170. Isolate the tooth with two soft matrix bands placed mesially and distally and etch enamel for 15 to 20 seconds. ENAMEL ETCHING www.indiandentalacademy.com
    171. 171. Wash the tooth with copious amount of water for 30 seconds Dry the teeth with an oil free syringe and /or utilize a jet of warm air www.indiandentalacademy.com
    172. 172. APPLICATION OF BONDING AGENT Isolate the tooth once again and coat the etched enamel surface with DBA and/or unfilled resin Disperse the bonding agent ito a fine thin layer using a stream of dry air and light cure and seal the surface of the tooth. www.indiandentalacademy.com
    173. 173. Clean the inner aspect of the veneer with orthophosphoric acid or citric acid. Wash and dry. Drying is further facilitated by coating with a drying agent. Then coat this surface with a layer of silane which is allowed to evaporate dry. Over the dry silane layer, place a layer of unfilled resin. Disperse into a fine layer with a stream of air. www.indiandentalacademy.com
    174. 174. Fill the laminate with the selected composite resin luting agent.. www.indiandentalacademy.com
    175. 175. VENEER PLACEMENT Hold the laminate firmly in place to prevent suck back an light cure for five seconds to tack the laminate in place. Place the laminate in position on the tooth rotating it about the incisal edge and toward the gingiva. Ensure that excess luting material extrudes from all peripheral aspects. www.indiandentalacademy.com
    176. 176. Cure the laminate for at least two minutes on each aspect of the buccal surface and similarly on the lingual surface. Two lights used simultaneously are preferred. Remove excess with a explorer or sharp scaler. www.indiandentalacademy.com
    177. 177. FINISHING Use the LVS no. 8 bur to remove composite resin along the incisal margin. Use carbide finishing bur to remove excess cement. www.indiandentalacademy.com
    178. 178. Clear the contacts with a extra fine metal strip to ensure they are free If there is excessive amount of porcelain beyond the enamel, refine this with a LVS no. 6 bur to develop emergence profile. www.indiandentalacademy.com
    179. 179. Polish the tooth/composite resin luting agent/porcelain interface with diamond polishing paste. Wash and dry. Polish contact area with composite resin finishing strip www.indiandentalacademy.com
    180. 180. Post operative view Check interproximal areas for clearance with dental floss www.indiandentalacademy.com
    181. 181. A cross sectional view of final laminate placedwww.indiandentalacademy.com
    182. 182. Patient Instruction sheet • First 72 hours: Avoid any hard foods and maintain a relatively soft diet. Avoid extremes in temperatures. Alcohol and some medicated mouthwashes should not be used during this period. www.indiandentalacademy.com
    183. 183. Patient Instruction sheet • Maintenance: Routine cleanings are must- at least every four months with a dentist. • Use a soft brush with rounded bristles, and floss, as you do with your natural teeth. • Use a less abrasive toothpaste and one that is not highly fluoridated. www.indiandentalacademy.com
    184. 184. Patient Instruction sheet • Maintenance: Avoid excessive biting forces and habit patterns: nail biting, pencil chewing etc. • Avoid biting on hard pieces of candy, chewing on ice etc. • Use a soft acrylic mouth guard when involved in any form of contact sports. www.indiandentalacademy.com
    185. 185. Patient Instruction sheet Mouth rinses: • Acidulated fluoridated mouth rinses can damage the surface finish of your laminates and should be avoided. • Cholorhexidine antiplaque mouth rinses can stain your laminates. www.indiandentalacademy.com
    186. 186. Conclusion • The final veneer provides the patient with the durability and beauty of porcelain, coupled with minimal tooth reduction and dentin exposure. • This also provides a good treatment option in certain situations when patient does not wish to undergo extensive orthodontic treatment. • But the process is highly technique sensitive and must be performed with utmost care for optimum results. www.indiandentalacademy.com
    187. 187. References • Alberts H.F. tooth colored restoratives. 7th ed Cotali,calif.: Alto books, 1985. • Garber, David A. Porcelaim laminate veneers. Quintessence publication co.1988. • Goldstein RE. Esthetics in dentistry. Vol. 1- principles, Communication and treatment methods. 2th ed. www.indiandentalacademy.com
    188. 188. References • Horn HR. Porcelain laminate veneers bonded to etched enamel. DCNA 27(4);1983:671-683. • Goldstein RE. Diagnostic dilemma: to bond, etch or crown? Int J perio Rest Dent 1987;5:9-27. • Clyde, Gilmore. Porcelain veneers: a preliminary review. Br Dent J 1988;184(9):9-14. www.indiandentalacademy.com
    189. 189. THANK YOU www.indiandentalacademy.com
    190. 190. Success is not final, failure is not fatal: it is the courage to continue that counts. www.indiandentalacademy.com
    191. 191. www.indiandentalacademy.com

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