Conservative dentistry and Endodontics

1. CERAMIC VENEERS
ABIJITH R S
1 ST YEAR PG
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2. CONTENTS
• Introduction
• History
• Advantages
• Disadvantages
• Indications
• Contraindications
• Shade selection
• veneer preparation
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• Mandibular veneers: special considerations
• Impressions
• Temporaries
• Laboratory Procedures
• Try‐in
• Final insertion
• Post‐treatment care and instructions
• Failures of laminate veneers
• Repair
• Lumineers
• Conclusion
• Reference

3. INTRODUCTION
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• Esthetics is the science of either mimicking or harmonizing a restorative treatment
with nature, but it should not be restricted to restore shape and function of the teeth;
accordingly, it should act on the capacity of reestablishing a new smile adapting to
the patient‟slife style, job, social position as well as highlighting the esthetical
features.
• In the aesthetic dentistry, the porcelain veneers present the first class clinical
conservative modalities

4. • 1930s, California dentist Charles Pincus
• 1970s, Faunce one‐piece acrylic resin prefabricated veneer as an
improved alternative to direct composite resinbonding
• 1975 , Rochette, acid etching porcelain and bonding to a tooth with an
acid etch technique
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5. ADVANTAGES
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• Natural and stable color
• Highly acceptable tensile bond strength
• Inherent porcelain strength that permits reshaping teeth.
• Extremely good biocompatibility with gingival tissues
• Long lasting
• Exceptional resistance to wear and abrasion.
Fradeani M, Redemagni M, Corrado M. Porcelain laminate veneers: 6‐ to 12‐year clinical evaluation‐‐a retrospective
study. Int J Periodont Restor Dent 2005; Fradeani M, Redemagni M, Corrado M.Porcelain laminate veneers: 6‐ to
12‐year clinical evaluation‐‐a retrospective study. Int J Periodont Restor Dent 2005;

6. • Resistance to stain
• Much less absorption of fluids than any other veneering
materials.
• Surface luster retention.
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7. DISADVANTAGES
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• Difficult to repair
• The color cannot be easily modified once bonded in position
• Irreversibility of preparation versus little or no preparation for
direct composite resin bonding.
• Level of difficulty of fabrication and placement, time involved,
and expense

8. • Technical difficulties in avoiding overcontours and obtaining
closely fitted porcelain/enamel margins. The margins can be
especially brittle and difficult to finish.
• Susceptibility to pitting by certain topical fluoride treatments
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9. INDICATION
Type I: moderate tooth discolorations/color corrections:
• Tetracycline
• Fluorides
• Amelogenesis imperfecta
Type II: anatomical malformations/corrections of position:
• Type IIa Conoid teeth
• Type IIb Diastemata
• Type IIc Incisal edge lengthening
Type III: extensive damage/changes in form:
• Type IIIa Extensive coronal fractures
• Type IIIb Congenital and acquired malformations
9
Belser UC, Magne P,Magne M. Ceramic laminate veneers:continuous
5/17/20e2v0olution of indications. J Esthet Dent1997

10. CONTRAINDICATIONS
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• Bruxism or parafunctional habits such as pencil chewing or ice crushing
• In sufficient enamel
• Certain types of occlusion may have problems. These include Class III and
end‐to‐end bites
• Extreme bleaching‐resistant discolorations, such as deep tetracycline or amalgam
staining, or discolored devitalized roots and coronal tooth structure, are very difficult
to cover with porcelain ceramic restorations.

11. SHADE SELECTION
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• Teeth have not been dried out for any period of time
• It should be done inside the operatory using color‐corrected light, outside in
daylight, and inside using incandescent light
• A good external device to be able to see all three light values is the Rite‐Lite 2
shade‐matching light (AdDent).
• Finally, reconsider the shade after the enamel has been prepared.

12. • Degree of discolouration
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• Take photos with the shade guides on the same plane as the teeth to be restored

13. CURRENT MATERIALS FOR VENEER
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• Two types of materials are indicated for their translucency and
potential to be used in small thickness
sintered feldspathic porcelain and pressable ceramic,
• which can also be used milled using a computer-aided
manufacturing technique

14. FELDSPATHIC VENEERS
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• Feldspathic veneers are created by layering glass-based (silicon
dioxide) powder and liquid materials.
• Primarily composed of silicon oxide (60%–64%) and aluminum
oxide (20%–23%), and are typically modified in different ways
to create glass that can then be used in dental restorations
• Fluorapatite crystals

15. • Mechanical properties are low, with flexural strength usually from 60 to 70 MPa.
• Therefore, a good bond, in combination with a stiffer tooth substructure (enamel), is
essential to reinforce the restoration
• The ideal conditions for the bond between the veneer and the substrate are the
presence of a rate of 50% or more of the enamel remaining on the tooth; 50% or
more of the bonded substrate being enamel; and 70% or more of the margin being in
enamel
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16. Glass-based ceramics
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• Strength in glassy ceramics is achieved by adding appropriate fillers that
are uniformly dispersed throughout the glass, such a aluminum,
magnesium, zirconia, leucite, and lithiumdisilicate
• For aesthetic veneers, ceramics reinforced by leucite and lithium
disilicate are commonly indicated for their optical properties andbecause
they are acid-sensitive
• Thickness must be more than 0.8 mm margin of approximately 0.3 mm

17. • These materials are efficient for bonding in substrate, even if
less than 50% of the remaining enamel remains; however, at
the margin, at least 30% of the enamel must be present
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21. TOOTHPREPARATION
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Volumetric
reduction
Preparation
Geometry

22. VOLUMETRICREDUCTION
• Creating space for the restoration
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23. PREPARATIONGEOMETRY
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● Path of insertion & undercuts
● Margin location & design
● Rounding of internal line angle

24. Armamentarium
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• Three-tier extra-coarse diamond depth cutter (BrasselerUSA)
• (LVS-1) 0.5 mm
• (LVS-2) 0.3 mm
• (LVS‐3 or ‐4)
• The LVS-5 (Brasseler) is used to trim composite resin flashfollowing
polymerization
• The LVS-6 is used to contour or reshape asnecessary
• Gingival reduction shaping or contouring could also be easily managed
with the LVS-7 15 μm diamond

25. • The LVS-8 is helpful to establish appropriate occlusal anatomy and
shape lingual surfaces.
• Final porcelain finish should be done with the 30-bladedcarbide
(ETUF-OS1, Brasseler USA).
• Many clinicians prefer an 8 μm diamond (DET4UF) for final finishingof
gingival margins
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26. • EVE (Ceramic polishers)
• Oral retractor
• Depth Cutting (0.5 & 0.3mm)
• IPR strip/ needle bur
• Loupes
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28. • Finishing after Diamonds
• Glass over rough surface is not
a good idea
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29. 1. Flexing of tooth
2. Predictable bonding
3. Pulpal protection (long term prognosis)
4. Stronger tooth/restoration complex
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Goal is alwaysto maintain maximumenamel

30. Preparationdesign
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31. There is now a consensus on what should ideally
be a veneer preparation:
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32. 1. LABIALPREPARATION
• The preparation of the buccal plane of the incisors (which are
convex)needs to be addressed in multiple planes
• A careful labial reduction of tooth structures is carried out to provide a
minimum of 0.6mm.
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33. How many planes does a curved surface
have?
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36. 2.Incisal edgereduction
• 1 to 1.5mm incisal butt joint Most common
• Advantages:
1. Positive seating
2. Incisal translucency
3. Stronger
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37. 5/17/2020 37

38. LingualWrap
• When there is
inadequate enamel from
preditible bonding
• Quality and Quantity
•The ceramic wrap
prevents tooth flexion and
provides additional
bonding surface
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39. Potentialproblemswithlingualwrap
• Path of insertion. Wrapping createsa
more complex path ofinsertion.
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• Strength: Wrapping porcelain on the
lingual more susceptible to fractureas
thickness maybe limited, and its
functional area oftooth

40. Margindesign
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• Tooth preparation should follow the circumferential FGM, which
mimics the underlying alveolar bone architecture and hence
ensures biologic width integrity
Based on J. Kois and F.Spear there are tworules:
a.If probing depth is 1.5 mm or less, extend .5 to .7 mm below
tissue.
b.If the probing depth is greater than 1.5 mm, go half the depth
of the sulcus below tissue

41. 1. SUPRA
2. EQUI
3. SUB
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42. • This margin determination is
dictated primarily by the esthetic
goals.
• Ideally, subgingival margins
should be avoided unless
necessary because of the existing
tooth color that needs to be
blocked out and/or a dramatic
change in the higher value of the
porcelain shade requested
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Subgingival margins will
complicate:
1. Tooth preparation
2. Impression
3. Temporization
4. Isolation & bonding

43. • With the gingiva pushed
apically, it is very easy to
prepare now because
we have a much better
visibility.
To prevent damage to the gingiva, we
need some vertical retraction during
margin placement
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44. Proximalpreparation
• a) Wing/ proximal margin design
• b) Slice preparation
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45. SLICE PREPARATION
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46. 5/17/2020 46

47. PROXIMALPREPARATION
Tobreak or not to break?
Breaking the contact (“slice preparation”) may be necessary to clear the contact in certain
situations, such as changing the shape or position of teeth. This allows the ceramist
freedom to adjust the contours and position of the teeth.
1. Easy in Lab procedures (Die Fabrication)
2. In Case there is papillary defect below contact point.
3. Caries
4. Slice preparation for diastema closure

48. MANDIBULAR VENEERS: SPECIALCONSIDERATIONS
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• Provide an excellent result in most situations
• However its life expectancy can be drastically compromised unless the patient‟s
occlusion is favorable
• The usual problem with preparations for lower veneers is leaving enough tooth
structure remaining after the horizontal and vertical reduction.
• A potentially weak point is at the incisolabial junction, which must always be
sufficiently reduced and rounded to allow the veneer to be thick enough in that area
to have the strength to resist fracturing when placed under an occlusal load

49. • Sufficient incisal reduction is needed to ensure a normal incisal edge appearance for
that patient.
• One advantage of the mandibular veneer is that it is seldom necessary to go
subgingivally
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50. Impression Technique
• Tissue Management:
The tissue is displaced so that the final finish line can be seen
in the sulcus..
This procedure will displace tissue laterally and provide
access to the sulcus.
The cord needs to remain in place for some five minutes.
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51. IMPRESSION
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The impression material used should be of two
viscosities; light and heavy.
The light material should be be syringed into the sulcus

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53. Digital impression
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• Intraoral chair side scanners (e.g. CEREC‐Sirona Dental Systems, Lava
COS‐3 M Dental ESPE, iTero, TRIOS‐3Shape Dental) allow digital
impressions to be taken, yet still the basic principles and preparations of
conventional impressions must be followed
• Dry field and clear margin with sufficient soft tissue retraction are
critical
• CAD/CAM systems (such as NobelProcera, CEREC, Lava 3 M) utilize the
digital scanning data to fabricate the final restorations directly

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55. CEREC milling of the CEREC e.max CAD restoration inprocess.
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56. Temporization
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• Temporization for laminates
because, in most situations, only
is usually unnecessary
half of the enamel surface is
removed and the dentinal tubules are not exposed; therefore
there should be little or no sensitivity and only minimal
esthetic compromise.
• However, in certain situations, temporization may become
necessary

57. These are the basic techniques for developing
the temporary veneers.
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Direct composite resin veneer.
Direct Acrylic Veneers.
Indirect Composite Resin/ Acrylic ResinVeneer

58. Basic laboratorytechnique
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Platinum foil backing
Refractory models
Direct castings
CAD –CAM machining

59. Platinum foil backing :
•thin layer of platinum foil is placed on the die .The porcelain is
layered on the foil. Then the porcelain foil combination is
removed from the die and fired in an oven . Before try-in ,the foil
is removed and the porcelain is etched .
Refractory models :
•The restoration is fired directly on the refractory die. This
eliminates the platinum layer but makes repeated firings difficult
once the laminate veneer has been removed from the die.
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60. Direct castings :
•cast ceramic restorations are fabricated using the „lost wax‟
technique. This eliminates the need for multiple firings but
requires extrinsic staining for coloration.
CAD/CAM Machining :
• A model or video image of preparation is required. Restoration
always required modification of the surface porcelain to obtain
proper colour aesthetics
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61. Placement ofveneers
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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.

62. Porcelain conditioning
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Combination of micromechanical interlocking and chemical
coupling
Hydrofluoric acid etching
Silane coupling agent applied

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64. 5/17/2020 64

65. • Bifunctional coupling agent provides a chemical link between
the luting resin composite and porcelain
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• A silane group at one end chemically bonds to the hydrolyzed
silicon dioxide at the ceramic surface and a methacrylate group
at the other end copolymerizes with the adhesive resin

66. • Enamel etched with 37% phosphoric acid for 30 to 40 sec
• A light activated resin luting system which involves separate etching of enamel (and
dentine), followed by application of a bonding agent and cementation with resin is
preferred [example products: Ultra-Bond Plus (Den-Mat, Santa Maria, CA, USA),
Variolink II (Ivoclar Vivadent, Amherst, NY, USA), Calibra (Dentsply, York, PA,
USA)]
• Dual-cure resins should be used cautiously for luting veneers because they may
discolour with time due to their aromatic amine content.
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67. PLACEMENT ANDCURING
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placement gently rocking or pulsing motionDuring
is used.
Don’t slide the veneer into place.
Lingual aspect is cured first.
Polymerization process is completed by curing various
areas of veneer for at least 60 sec. each.

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69. Post-treatment care and instructions
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• First and foremost, a night appliance should be constructed to
protect the veneers from the possible damage due to abnormal
chewing, grinding, or clenching during sleep

70. First 72 hours: Avoid any hard foods and maintain a relatively soft diet.Avoid
extremes in temparatureAlcohol and some medicated mouthwashes should
not be used during this period
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.
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71. Failures of laminateveneers
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MECHANICAL
 Chips
 Cracks
 Fractures during try in
 Debonding –attributed to error in bonding procedure.
BIOLOGICAL
 Postoperative sensitivity
 Marginal microleakage
ESTHETIC
 Shade selection inappropriate

72. Repair of veneers
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• Isolation is done with an oral retractor.
• Initial shade selection is done.
• A quick mock-up of the repair with the selected resin composite can verify the shade
selection.
• A 2mm wide bevel is placed on the porcelain surrounding the fracture.
• To protect the adjacent soft tissue and the restoration surface- EtchArrest – sodium
bicarbonate gel is applied.10% of hydrofluoric acid gel is applied for 1 min.
• To prevent the potentially harmful acid splatter and to neutralize the effect of HF acid

73. • Etch Arrest is again applied.Next the porcelain surface is rinsed and dried. The silane
primer is applied and allowed to dry for 60 sec.
• This silane treatment of the exposed silica surface results in the formation of siloxane
bond with the methacrylate groups of the composite.Bonding agent is applied and
cured.
• The resin composite is applied to the fractured site, cured, finished and polished.
• Large fractures are treated by replacing the entire porcelain veneer.
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74. Lumineers
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• Lumineers that are made from a special patented Cerinate
porcelain that is very strong but much thinner than traditional
laboratory fabricated veneers are currently in trend
• Lumineers are a reversible procedure and it hardly requires
removal of tooth structure. They will bond directly to the tooth
making the bond very strong and the longevity
• Ideal patients required

75. LINGUAL VENEERS
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76. Conclusion
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Perfect smile improves the self personality; social life and have psychological effect on
improving self image with enhanced self esteem of the patient. New emerging
concepts in esthetic dentistry with regards to materials, technology and public
awareness has made veneers on demand. The objective of cosmetic dentistry must be
to provide the maximum improvement in esthetic with minimum trauma to the
dentition. There are a number of procedures to achieve this and the most notable is
that of porcelain laminate veneers. But the process is highly technique sensitive and
must be performed with utmost care for optimum results.

77. REFERENCE
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• Ronald E. Goldstein’s esthetics in dentistry 3 rdedition
• Conservative esthetic solution with ceramic laminates: literature review, Gisely Naura etal
2013.RSBO
• Porcelain veneers – preparation design:Aretrospective review ,Kosovka Hem. ind. 68
(2) 179–192 (2014)
• Esthetics with Veneers:AReview S. Sowmya International Journal of Dental Health
Concerns (2015), 1, 1-5
• Incisal preparation design for ceramic veneersAcritical review Sy Yin Chai, JADA
2018:149(1):25-37

78. • Esthetic rehabilitation with laminated ceramicveneers reinforced by lithium disilicate
Paulo Vinícius Soares Quintessence Int 2014;45:129–133;
• Quintessence Int 2014;Quintessence Int 2014;45:129–133; doi: 10.3290/j.qi.a31009)
• Porcelain laminate veneers: A review Meenakshy Hari, Journal of
Advanced
Clinical & Research Insights (2017), 4, 187–190
• Peumans M, Van Meerbeek B, LambrechtsP,Vanherle G. Porcelainveneers: a review
of the literature. JDent2000;28:163–177
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79. • Magne P,Belser U. Bonded Porcelain Restorations in the Anterior Dentition:A
Biomimetic Approach. Chicago, IL: Quintessence Publishing; 2002:239-292.
• Christensen GJ. Ceramic veneers: state of the art, 1999. JADA. 1999;130(7):1121-
1123.
• Christensen GJ, Christensen RP. Clinical observations of porcelain veneers: a three-
year report. J Esthet Dent. 1991;3(5):174-179.
• Li Z, Yang Z, Zuo L, Meng Y.A three-dimensional finite element study on anterior
laminate veneers with different incisal preparations. J Prosthet Dent. 2014;112(2):
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