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Laminates & Veneers

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Laminates & Veneers Treatment

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Laminates & Veneers

  1. 1. Laminate Veneers Guided By:- Dr. Dilip Dhamankar (Prof. & HOD) Dr. Ravi Kumar C.M. (Prof.) Dr. Meenaksi (Prof.) Dr. DRV Kumar (Reader) Dr. Arun Gupta (Reader) Dr. Manish Chadha (Senior Lect.) Dr. Devendra Singh (Senior Lect.) Dr. Mayank Lau(Senior Lect.) Dr. Soham Prajapati 2nd Year PG, Dept. of Prosthodontics & Maxillofacial Prosthetics Including Oral Implantology 19-1-14 & 20-1-14 1/148
  2. 2. Contents • Introduction • Definitions • History • Indications • Contraindications • Shade Selection Laminate Veneers 2/148
  3. 3. Contents • Tooth Preparation – Principles of tooth preparation – Rationale – Types of preparation – Armamentarium – Procedure • Provisional Restoration – Direct method – Indirect Method Laminate Veneers 3/148
  4. 4. • Laboratory Procedures • Cementation • Maintenance • Failures • Advantages & Disadvantages • Recent advances • Conclusion • References Contents Laminate Veneers 4/148
  5. 5. Introduction • The public is bombarded by media extolling the virtues of “The Perfect Smile”. • The dental profession is faced with specific esthetic demands and a rapid evolution of new but unproven techniques. • Although the direct bonding of porcelain veneers is relatively new, reports of success warrant its inclusion as a restorative treatment. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 5/148
  6. 6. Introduction • Laminate Veneers have evolved over the last several decades to become one of aesthetic dentistry’s most popular restoration. • The laminate veneer is a conservative alternative to full coverage for improving the appearance of an anterior tooth. Laminate Veneers V Rangarajan, Textbook Of Prosthodontics, pg 705-719 (2013 Edition) 6/148
  7. 7. Introduction • A survey in 1986 stated that 50 percent of U.S dentists provide indirect veneers and 41 percent of this group offer porcelain Veneers. Laminate Veneers Dental Products : Report: Trends in Dentistry, December, 1986 7/148
  8. 8. Definitions • Veneer:- – A thin sheet of material usually used as a finish. • GPT, 8th Edition. – A veneer is a layer of tooth colored material that is applied to a tooth to restore localized or generalized defects and intrinsic discolorations. • Sturdevant – A protective or ornamental facing. OR. A superficial or attractive display in Multiple Layers, frequently termed a Laminate Veneer. • Rosensteil Laminate Veneers 8/148
  9. 9. Definitions • Laminate veneer restorations : A conservative esthetic restoration of anterior teeth to mask discoloration, restore malformed teeth, close diastemas & correct minor tooth alignment. • Mosby’s dental dictionary Laminate Veneers 9/148
  10. 10. Definitions • Porcelain Laminate veneer: A thin bonded ceramic restoration that restores the facial surface and part of the proximal surfaces of teeth requiring aesthetic restoration. -GPT. Laminate Veneers 10/148
  11. 11. History Laminate Veneers We Read/Listen History, so we don’t repeat History. 11/148
  12. 12. History • With the advent of photography and motion pictures, a very accurate and lifelike facsimile of an individual could be reproduced. Any disfiguring mark was also reproduced with discomforting accuracy. Unlike paintings, in which artist could touch up the offending areas, FILMS ARE CRUELLY TRUTHFUL. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 12/148
  13. 13. History • In many still photographs of the 19th century, the grain of the film covers facial bleminishes to an extent, but significantly very few of the subjects were smiling. The dental blemishes are thus covered with the lips. • It is probably not an accident that many of the forbears seems so serious and strict; in many instances they were just hiding unsightly teeth. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 13/148
  14. 14. History • With the earliest motion pictures were produced, the films were so jumpy it was impossible to see the fine facial features, and close up sequences were rare. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 14/148
  15. 15. History • In the late 1920s, the talkies arrived. Combined with improved filming and projecting techniques, which made minor details more visible, Hollywood's film makers experienced a dental dilemma. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 15/148
  16. 16. History • Thus it became necessary for movie stars to have glamorous smiles. The audience expected nothing less than perfection from their heros and heroines, and the teeth were part of that package. Needles to say, not all of those who were or wanted to be, stars had perfect dentition. Thus Necessity led to Invention. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 16/148
  17. 17. History • Dr. Charles Pincus was a Beverly Hills Practioner, and a part of his patient’s load came from the movie industry. • Among these were makeup personnel from various studios. When they bought their star’s problems to Pincus, he became experimenting with certain techniques to improve their appearance. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244
  18. 18. History • Only consideration he had was esthetics and should not alter speech. No comfort was taken into consideration. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 18/148
  19. 19. History • In 1930’s Dr. Charles Pincus first used thin resin facings. • Then he baked a thin layer of porcelain onto the platinum foil and designed the appliance so it would not interfere with oral functions. • Thus, created the ‘Hollywood Smile’ for American Actors. • He used denture adhesive to hold the veneer in place. • The stars could not eat and wore then for performing only. Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 19/148
  20. 20. History • The development of acid-etch technique 30 years ago introduced an aspect of molecular dentistry known as ‘Bonding’. • Phosphoric acid applied to tooth enamel created a surface of microscopic interstices for mechanical bonding unfilled resin. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 20/148
  21. 21. History • The prototype system using silica resins was clinically deficient and was replaced with unfilled methylmethacrylates that were less toxic, easily polished, and improved esthetically. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 21/148
  22. 22. History • In 1970’s preformed plastic laminates were bonded to the teeth using composite resin. • However, due to polymerization shrinkage and a coefficient of thermal expansion that is higher than that of teeth, the marginal adaptation was compromised. • The soft methacrylate surfaces were also subjected to wear and discoloration. Laminate Veneers V Rangarajan, Textbook Of Prosthodontics, pg 715-719 Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 22/148
  23. 23. History • The evolution of the modern ceramic laminate was assisted by the following discoveries: – Etching of enamel by Buonocore (1955) – Bowen’s BISGMA resins (1960s) – Ceramic Etching and bonding by Rochette (1973) – Bonding porcelain to etched surfaces (1980s) – Calamia et al - Application of silane coupling agent (1984) Improved bond strength – Hsu et al - Mechanical retention increased by etch. Shear bond strength of etched 4 > Unetched (1985) Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 23/148
  24. 24. Comparison Of Veneer System • Three Veneer Systems are present – Direct Resin – Indirect Resin System – Porcelain Indirect System Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 24/148
  25. 25. Comparison Of Veneer System • Advantages of Direct Composite System – Only One Appointment is required – The dentist directly controls form and colour. – Cost of the patient is reduced – Composite Veneers are repairable. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 25/148
  26. 26. Comparison Of Veneer System • The indirect porcelain technique, which involves laboratory fabrication of the veneers, compensate for the short comings of the direct composite resin technique: – The dentist may use the time saving and artistic skills of a ceramist. – Multiple units can be placed with less chair time. – Porcelain is the optimum material for colour stability, esthetics, wear resistance and tissue compatibility. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 26/148
  27. 27. Comparison Of Veneer System • Processed materials other than porcelain have been suggested for the indirect technique: – Resin and composite processed at elevated pressures and/or temperatures (Dentacolor, Isosit and Visio-Gem) – Castable hydroxyapatite – Injectable ceramics (Dicor, Cerestore). Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 27/148
  28. 28. Considerations Direct Resin Indirect Resin Porcelain Strength Moderate Moderate High Esthetics Good Excellent Good Excellent Excellent Coverage of dark color Excellent (w/opaque) Good Good Longetivity Potential Fair-Good Fair-Good Good Repair Expectation Low-Modearte Low-Moderate Low Repair Difficulty Easy Easy Difficult Cost to Patient 1/3 Crown cost 1/3 -2/3 Crown cost 2/3-1X Crown Laboratory cost 0 Up to 65$ +/- 65 $ Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002) 28/148
  29. 29. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002) Resin (Direct) Resin (Indirect) Porcelain (Indirect) Indications 1. Need to cover multiple color stains of dark striations. 2. Bruxer, Clencher, abusive occlusal habits. 3. Pt. with financial difficulty. 4. Single teeth 1. Typical, routine veneering for patients without deeply stained or striated teeth. 2. Dentist does not like to develop tooth anatomy. 3. Bruxer, clencher, abusive occlusal habits 4. Multiple preps 1. Typical, routine veneering for patients without deeply stained or striated teeth. 2. Dentist does not like to develop tooth anatomy. 3. Multiple preps Contraindicati ons 1. Dentist does not like to develop tooth anatomy 2. Does not have ability with colour 1. Difficult to cover dark stains and striations without placement of underlying opaquers before impression for veneers. 1. Bruxer, clencher, abusive occlusal habits. 2. Difficult to cover dark stains and striations without placement of underlying opaquers before impression for veneers. 29/148
  30. 30. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002) Resin (Direct) Resin (Indirect) Porcelain (Indirect) Esthetic Potential Good excellent if dentist has ability with colour blending. Artistc dentist can produce excellent result. Good-excellent with high level laboratory support and correct patient selection 1. Excellent with high level laboratory support and correct patient selection. Expected Longevity 1. Some brands in current generation of resin now observed 7-8 years of success 2. Should last at least 5-10 years with aesthetic acceptability if placed correctly 1.Observed for about 5 years. 2. Should last at least 5-10 years with aesthetic acceptability if laboratory constructs correctly and placed correctly. 1. Observed for only 2 years. Should last +/- 10 years with esthetic acceptability if laboratory constructs correctly and placed correctly. 30/148
  31. 31. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002) Resin (Direct) Resin (Indirect) Porcelain (Indirect) Ease of placement Preparation easy. Placement moderately difficult because dentist must to have esthetic sense for color and contour. Preparation easy. Placement not difficult because veneer material is same as cementing medium and new polish can be placed on veneer if surface disturbed. Preparation easy. Placement difficulties are: 1. Veneer is fragile and can break. 2. Selection of cement colour 3. Loss of glaze through finishing. Time required for 6 veneers after experience Prep and place 1 ½ - 3 hours. Prep ½-1 hour. Seat 1-2 hours Prep ½-1 hour. Seat 1-2 hours 31/148
  32. 32. Resin (Direct) Resin (Indirect) Porcelain (Indirect) Frequency & location of clinical problems 1. Incisal Edge fracture +/- 10% cases +/- 3 years of service. 2. Discolouration of gingival and proximal Margins at +/- 3 years if not placed correctly. 3. Can cause gingival irritation 1. Infrequent incisal edge fracture +/- 3 years into service. 2. Discolouration of gingival and proximal Margins at +/- 3 years if not placed correctly. 3. Can cause gingival irritation 1.Very little repair needed in 2 years of observation. 2. Discolouration of gingival and proximal Margins at +/- 3 years if not placed correctly. 3. Can cause gingival irritation Time required for 6 veneers after experience Prep and place 1 ½ - 3 hours. Prep ½-1 hour. Seat 1-2 hours Prep ½-1 hour. Seat 1-2 hours Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002) 32/148
  33. 33. Resin (Direct) Resin (Indirect) Porcelain (Indirect) Repair Difficluty Simple. Remove defective portion down to enamel surface, etch, bond and repair with resin. Simple. Remove defective portion down to enamel surface, etch, bond and repair with resin. Difficult. Must replace veneer or patch with resin with esthetic difference between resin and porcelain. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002) 33/148
  34. 34. Comparison Of Veneer System • The indirect resins have better physical properties than light cure composites, but reduced bond strength. • The cast ceramics have the advantage of waxup stage, excellent translucency, and reduced plaque adherence. But technique sensitive. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 34/148
  35. 35. Comparison Of Veneer System • Thus the choice of veneer material and techniques depends on – Physical properties of the material. – Enamel discolorations. – Experience of the dentist – Number of unit treated. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 35/148
  36. 36. Indication Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 36/148
  37. 37. Indications Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 37/148
  38. 38. Indications • Extreme Discolorations: Such as tetracycline staining, fluorosis, devitalized teeth and teeth darkened by age which are not conductive for bleaching. • Enamel Defects:- Small cracks in the enamel due to aging, trauma or hypoplasia. Laminate Veneers 38/148
  39. 39. Indications • Diastema: Single or multiple spaces between the teeth. • Attritions and root exposure: Can be used to restore localized attrition and root sensitivity due to cemental exposure. • Malpositioned teeth and abnormalities of shape: Peg laterals and rotated teeth. Laminate Veneers 39/148
  40. 40. Indications • Repair of functionally sound metal ceramic or all ceramic restoration with unsatisfactory colour: The labial surface of old porcelain restoration is prepared and a ceramic laminate is bonded correcting the anomaly. • Tooth Fracture: Restricted to incisal third • Restoring anterior guidance in worn mandibular incisors. Laminate Veneers 40/148
  41. 41. Contraindications • Insufficient coronal tooth structure: Fractured teeth with more than 1/3rd loss of tooth structure, grossly carious or extensively restored teeth. Full coverage restorations are preferred. • Actively erupting teeth • Parafunctional Habits like bruxism Laminate Veneers 41/148
  42. 42. Contraindications • Severe Periodontal involvement and Crowding. • Endodontically treated teeth: Present a poor receptive surface for bonding and full coverage restorations are indicated. Laminate Veneers 42/148
  43. 43. Veneer indications 1. Restorations 2. Diastema 3. Fracture 4. Attrition 5. Large pulps 6. Discoloration 7. Malformation 8. Root exposure 9. Erosion/abrasion Veneer Contraindications 1. Poor enamel quality 2. Insufficient sound enamel 3. Severely Rotated or overlapped teeth.If indication present NO 1. Fixed / Removable Prosthetics. 2. Orthodontics 3. Orthognathic Surgery YES Absolute Contraindications present? 1. <50% enamel for bond 2. Weak coronal tooth structure 3. Severe malposition YES NO 43
  44. 44. Comparison Of Veneer System • Albers indicated that a tooth to be bonded should have at least 50 percent of its surface composed of etchable enamel. • Preferably, the peripheral margins are of enamel conform to the “one millimeter circumferential principle” for long term marginal integrity of the enamel resin bond. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition)
  45. 45. Does the patient have these conditions 1. Bruxism / Clenching Habit? 2. Severe discoloration? 3. Single unit? 4. Limited finances Color / Contour Abnormality Slight? • Bleaching • Cosmetic contouring • Esthetic fillings Is Results OK? YES NO NO YES TREATMENT SUCCSESFUL YES TREAT WITH DIRECT COMPOSITE VENEER TREAT WITH PORCELAIN VENEER Select Porcelain shade slightly lighter than desired shade 45
  46. 46. Is tooth Free of 1. Faulty Restorations 2. Abnormal /Unesthetics Contours 3. Caries • Cosmetic Coronoplasty • Recontour incisal edges • Restore/ replace defects with glass ionomer of suitable shade Prepare Tooth for Porcelain Veneer 46 NO YES 46/148
  47. 47. Comparison Of Veneer System • Veneer can be bonded to sound composite or glass-ionomer restorations. • Composite repair studies have revealed that a delayed resin-resin bond is formed, but with a reduced bond strength. • Glass-ionomer bases etched with phosphoric acid provides some micromechanical retention to composite and and promote fluoride release. Laminate Veneers Monterio et al, evaluation of materials and techniques for restoration of erosion areas, J Prosthet. Dent. 55:434,1986 47/148
  48. 48. Shade Selection • Before starting preparations, establish the desired shade. • It has to be done when the teeth have not been dried out for any period of time. • It is done under colour corrected light or outside in daylight. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) V Rangarajan, Textbook Of Prosthodontics, pg 705-719 (2013 Edition) 48/148
  49. 49. Shade Selection • A shade is selected from a porcelain system that is one half shade lighter than the desired shade. • This provides the dentist latitude and allows for a slight darkening attributable to increase translucency with polymerization of the composite luting cement. • The conventional shade guides such as vita porcelain shade guide, are not ideal for veneers because their porcelain thickness is high. Laminate Veneers V Rangarajan, Textbook Of Prosthodontics, pg 705-719 (2013 Edition) Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 49/148
  50. 50. Preliminary Tooth Modification • Contouring deficiencies greater than 1 mm resulting from caries , erosion, or attrition are restored with GIC of a suitable shade. • When Class III is present, remove sufficient filling just prior to bonding to expose the enamel margins that are then etched and sealed with bonding composites. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 50/148
  51. 51. Preliminary Tooth Modification • The tooth crown should have a uniform thickness of veneer and luting agent. • Unless incisal lengthening is desired, laminate incisal margins terminate at the facioincisal angles. • Preliminary cosmetic contouring defines the esthetic alignment and incisal profile. • Recontouring of rotated , tipped or malpositioned tooth surfaces projecting labially from a uniform facial plane ensures restoration of harmonious facial contour. Laminate Veneers Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition, 194 (2002 Edition) 51/148
  52. 52. Classification 1 Partial 2 Full 1 Prefabricated 2 Custom made 52/148
  53. 53. Tooth Preparation • Principles of tooth Preparation – Conservation of tooth structure: the preparation should be conservative which is the main principle governing the fabrication of the ceramic laminate. – Retention is solely by adhesion: Adhesive luting or bonding using resin cements is the main contributor to retention rather than tooth preparation. Laminate Veneers 53/148
  54. 54. Tooth Preparation • Rationale – Enamel preparation is done: • To provide adequate space for porcelain opaquing and composite resin luting materials. • To remove convexities in the surface and provide a definitive path for insertion. • To assist veneer seating during placement and bonding the laminate. • To facilitate margin placement • To provide adequate contour and colour without over contouring. Laminate Veneers 54/148
  55. 55. Types of Preparation • Type I – Contact Lens Type • Type II – Classic or Conventional Type • Type III – Wrap-around or ¾th type Laminate Veneers V Rangarajan, Textbook Of Prosthodontics, pg 715-719 55/148
  56. 56. Types of Preparation • Type I – Contact Lens Type: Does not cover the incisal edge. Laminate Veneers 56/148
  57. 57. Types of Preparation • Type II – Classic or Conventional Type: most commonly used. Covers the incisal edge and terminates lingually. Thickness of tooth, needed for increasing tooth length and occlusion determine whether type I or type II is used. Laminate Veneers 57/148
  58. 58. Types of Preparation • Type III – Wrap-around or ¾th type: almost similar to full coverage preparations. Indicated for extensive changes and colour and contour. Laminate Veneers 58/148
  59. 59. Armamentarium • A diamond depth cutter with three 2mm diamond wheels mounted on a 1.0 mm diameter non cutting shaft. The radius of wheels from the non-cutting shaft is 0.5. Produces a depth cut of 0.5 mm. Laminate Veneers 59/148
  60. 60. Armamentarium Laminate Veneers • A diamond depth cutter with a wheel diameter of 1.6mm, produces a depth cut of 0.3 mm. • Round Bur (No.1) (0.8 mm diameter)
  61. 61. Armamentarium • Round end tapering diamond (medium and fine grit) • Finishing diamond burs • Airotor Handpiece. Laminate Veneers 61/148
  62. 62. Procedure Laminate Veneers • It involves the following steps: – Labial Reduction – Proximal reduction – Sulcular Extension – Incisal Reduction – Lingual Reduction. 62/148
  63. 63. Labial Reduction • The thickness of the ceramic laminate should be 0.5 mm. • To achieve this, the labial preparation should achieve a uniform reduction of 0.3-0.5 mm, less gingivally and more incisally. • This involves:- – Depth Cuts – Reducting Remaining Enamel Laminate Veneers 63/148
  64. 64. Labial Reduction – Depth Cuts • These can be done using round bur only or a combination of round bur and the depth cutter. • Depth Cuts using only round Bur. Laminate Veneers 64/148
  65. 65. Labial Reduction • Depth Cuts using only round Bur. Laminate Veneers 65/148
  66. 66. Labial Reduction – Depth Cuts • Depth Cuts diamond depth cutter. Laminate Veneers 66/148
  67. 67. Labial Reduction – Reducing Remaining Enamel Laminate Veneers 67/148
  68. 68. Labial Reduction – Reducing Remaining Enamel Laminate Veneers 68/148
  69. 69. Proximal Reduction – Depth can often be as 0.8- 1 mm, since the enamel layer is thick towards proximal surface. – Done with round end tapered diamond is just continued into the proximal area. – It is ensured hat the diamond is parallel with the long axis of the tooth. – Proximal reduction should stop just short of breaking the contact. Laminate Veneers 69/148
  70. 70. Proximal Reduction Laminate Veneers 70/148
  71. 71. Proximal Reduction – Reasons to preserve contact area • It is an anatomical feature that is extremely difficult to reproduce. • It prevent displacement of the tooth between the preparation and placement appointment if no provisional restorations are planned. • Post insertion oral care is easier. • Simplifies try-in- no need to adjust the contact. • Simplifies the bonding and finishing. Laminate Veneers 71/148
  72. 72. Sulcular extension – Routinely the margins are placed supragingivally. – When discoloration is excessive, the margins are extended supragingivally. – A rounded 0.3mm chamfer serves as an ideal margin for ceramic laminate veneer. Laminate Veneers 72/148
  73. 73. Sulcular extension – Advantages of Supragingival Margin • Increased areas of enamel in the preparation • Simplifies moisture control • Visual confirmation of marginal fit • Margins are accessible for finishing and polishing • Access to margins for routine maintenance and dental hygiene procedure. Laminate Veneers 73/148
  74. 74. Sulcular extension – Advantages of Supragingival Margin Laminate Veneers 74/148
  75. 75. Sulcular extension – Advantages of Chamfer finish line • Conservative , Distinct. • Provides increased bulk of porcelain giving adequate strength, avoids over contouring. • Good marginal seal. • Accuracy of fit – veneers is easily inserted at try-in and final placement. Laminate Veneers 75/148
  76. 76. For type I, the tooth preparation ends here. For type II preparations incisal and lingual reductions are necessary. Laminate Veneers 76/148
  77. 77. Incisal Reduction – As porcelain is stronger in compression than in tension, wrapping the porcelain over the incisal edge and terminating it on the lingual surface places the veneer in compression during function. – It also provides a vertical stop that aids in proper seating of the veneer and improves translucency. – Reduction • 1 mm in thickness. Laminate Veneers 77/148
  78. 78. Incisal Reduction Laminate Veneers 78/148
  79. 79. Incisal Reduction Laminate Veneers 79/148
  80. 80. Incisal Reduction – Key Point :- • Never end incisal edge where excursive movements of the mandible will cause shearing stresses across the junction of porcelain laminates and tooth. Laminate Veneers 80/148
  81. 81. Incisal Reduction – Indications for incisal coverage • The incisal thickness is too thin to support the veneer. • A lengthening of the incisal edge 1.0-2.0 mm is desired. • Facioincisal margin is visible and unaesthetic. • Incisal enamel is structurally compromised. • The incisal edge is subjected to functional stress. Laminate Veneers 81/148
  82. 82. Incisal Reduction Laminate Veneers 82/148
  83. 83. Lingual Reduction – The round end tapered diamond is held parallel to the lingual surface with its end forming a slight chamfer 0.5 mm deep. – Besides placing the porcelain under compression lingual extension will also enhance the retention and increase the surface areas for bonding. Laminate Veneers 83/148
  84. 84. Lingual Reduction Laminate Veneers 84/148
  85. 85. Types of Preparation Laminate Veneers Ramya Raghu, Clinical Operative Dentistry Principles and Practice, 3rd edition, 404 Advantages Disadvantages Retain Natural enamel over incisal edge Incisal edge is weakened by the preparation. Esthetically not pleasing as the margin may be visible. Guidance on the natural tooth is maintained Veneer is fragile at the incisal edge and get dislodged during protrusive movements. More control over incisal esthetics. More extensive tooth reduction Provides a positive seat for luting the veneer More extensive tooth reduction 85/148
  86. 86. Prepare Tooth for Porcelain Veneer Determine depth of enamel reduction None – Minimum • Root Surface Minimum Requires  0.3 to 0.5 mm • Tooth Color • Linguoversion • Near CEJ • Mandibular incisor gingival half Required Heavy 0.5 to 0.7 mm • Tooth Color shade mismatch • Labioversion • Mandibular incisor gingival half Heavy 1.0 mm • Functional clearance 8686/148
  87. 87. Prepare Labial depth guide cuts for controlled reduction Place gingival chamfer margin Is there severe Discoloration? Place chamfer at free gingival margin Place chamfer of 0.5-1.0 mm below the gingival margin Continue Margin interproximally to below contact area Is existing M-D width suitable and proximal contacts present? Place chamfer lingual to contact area. Avoid undercut to facioincisal path of draw Place chamfer just labial to proximal contact NO NOYES YES Extend chamfer to incisal. Complete uniform gross facial enamel reduction to peripheral margins and depth guided 8787/148
  88. 88. 88 Gross Facial Reduction Complete Facial Free of localized spots of severe color/stain? Reduce Discolored enamel to accommodate thin, etch retained, shaded opaque. NO YES Is the existing Inciso gingival tooth length acceptable? NO Reduce length • Esthetics • Overbite • Thin incisal • Functional clearance Reduce incial 1 mm short of desired length. Place linguo incisal chamfer. Round Incisal angles. Add length • Esthetics • Overbite • Attrition • Fracture Veneer may add 2 mm length. Place lingual chamfer 1-2 mm from incisal edge. Round incisal angles. YES Is Facio Lngual dimension at incisal edge sufficient for veneer support? NO YES YES 88/148
  89. 89. 89 Refine Preparation with fine diamond or 12 Bladed carbide to extend margins, round angles, and remove striations and roughness. Polish Facial enamel to high gloss with super fine diamonds and finishing discs to provide a normal enamel surface needing to temporization Does the patient have problem or concern for • Exposed dentin • Sensitivity • Opened contacts • Abnormal Contours • Discoloured teeth • Place 2 layers of dentin enamel bonding agent. • Temporary composite or resin laminate spot etched to labial surface Make an impression of veneer preparation using addition silicone or polyether elastomers. Block out open gingival embrasures. Place retraction cord if required. YES NO Prepare Laboratory pescription for a shade slightly than desired. Specify color, character and contour modifications. Indicate whetever heavy, moderate, or slight or no opaque to mask partially discolored tooth. Color slides and study models may be helpful. 89/148
  90. 90. Provisional Restoration – Provisional restoration for laminates may not be essential as there is no exposure of dentine (no sensitivity) and the proximal contacts are maintained (no drifting of adjacent teeth). – But most often it may be necessary for a patient to maintain their social engagements and if proximal contact is broken (wrap-around technique). Laminate Veneers 90/148
  91. 91. Provisional Restoration – Two Methods:- • Direct Method • Indirect Method Laminate Veneers 91/148
  92. 92. Provisional Restoration • Direct Method – The provisional is fabricated intraorally. It can be done using:- » Composite Resin • A few spots on the prepared tooth or a central spot is etched (spot etching) with phosphoric acid and bonded. • Restorative composite is buit up on prepared tooth and light cured. • This acts as a provisional restoration as it can be easily removed prior to try in, as the entire surface was not etched. Laminate Veneers 92/148
  93. 93. Provisional Restoration • Direct Method – The provisional is fabricated intraorally. It can be done using:- » Composite Resin Laminate Veneers 93/148
  94. 94. Provisional Restoration • Direct Method – The provisional is fabricated intraorally. It can be done using:- » Autopolymerizing Acrylic Resin » Tooth coloured acrylics can also be used simiar to routine fixed prosthodontics. Laminate Veneers 94/148 94/148
  95. 95. Provisional Restoration • Direct Method – The provisional is fabricated intraorally. It can be done using:- » Autopolymerizing Acrylic Resin Laminate Veneers 95/148
  96. 96. Provisional Restoration • Indirect Method – A model fabricated following tooth prepartion will allow the acrylic provisional to be made indirectly on a cast. Laminate Veneers 96/148
  97. 97. Provisional Restoration • Indirect Method – A model fabricated following tooth prepartion will allow the acrylic provisional to be made indirectly on a cast. Laminate Veneers 97/148
  98. 98. Laboratory Procedures • Leucite and lithium-disilicate reinforced ceramics are preferred due to their excellent transulency and aesthetics. Laminate Veneers 98/148
  99. 99. Laboratory Procedures • Three methods 1. Investment Model Technique(McLaughlin) 2. Platinum foil technique (Greggs) 3. Milling systems : CAD/CAM Laminate Veneers George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition, 1-244 99/148
  100. 100. Investment Model Technique Laminate Veneers 100/148
  101. 101. Platinum foil technique (Greggs) Laminate Veneers 101/148
  102. 102. 102 Are processed Veneers free of cracks, excessive thickness, and marginal discrepancies? NO Color shade choice. Return for remake. YES Give LA to ensure patient comfort in placing retraction cord to expose gingival margins, to prevent etch contamination, ad to facilitate finishing procedures Clean preparation and interproximate with flour of pumice. Try in fit: Do veneers, trial seated with glycerin, fit preparations? Individually Collectively NONO MAKE NEW IMPReSSION Reduce excess proximal contact with fine diamond YES 102/148
  103. 103. 103 Try in color: Is Veneer, Trial seated with glycerin approximately the same shade as the tooth? NOYES Select a trial composite luting agent of neutral or universal shade Select a trial composite luting agent with some opaque added. Is the basic shade of the veneer trial seated with composite satisfactorily? NO Remove trial composite with alcohol. Repeat until shade acceptable. YES Is the selected basic shade accurate for the gingival and for the incisal areas of the tooth? NO Remove unsatisfactory trial composite with alcohol. Select alternate shade or add no more than 20% tint YES Shade and fit confirmed. Prepare tooth and veneer for bonding. YES YES 103/148
  104. 104. Cementation Laminate Veneers – Preparation of veneer • Following cleaning of the veneer with a solvent such as acetone, it is etched with 10-15% hydrofluoric acid for 30 seconds to 1 minute according to the manufacturer’s instructions and the ceramic used. • A silane coupling agent is now applied to the fitting surface of the veneer and is allowed to remain for one minute. • It is then air-dried. The silane creats a chemical bond between composite cement and ceramic. 104/148
  105. 105. Cementation Laminate Veneers – Preparation of veneer 105/148
  106. 106. • Chemical coupling : Silanization o Silica content - chemical bond o -methacryloxypropyl trimethoxy silane o Inorganic substrates and organic polymer. o Improved wettability 106/148
  107. 107. • Apply Porcelain Primer or Silane Coupling Agent. • Use a prehydrolized silane which means you do not have to mix two components (usually contained in cementation kit (Nexus, Kerr). • It is applied with a brush. The coupling agent acts to wet the surface of the porcelain. The silane coupling agent is allowed to set on the surface (usually for at least 60 sec but some are shorter periods). • It can be dried with a gentle stream of air. Do Not Rinse. Set prepared veneer in a lightproof box until ready for cementation 107/148
  108. 108. 108/148
  109. 109. Cementation Laminate Veneers Preparation of Veneer Preparation of Tooth Clean Clean Etch Isolate Silane Etch Bond Bond 109/148
  110. 110. Cementation Laminate Veneers 110/148
  111. 111. Cementation Laminate Veneers – Luting • The choice of cement is resin cement. • Ideal requirements of the luting cement – Thin film thickness, 10-20 microns – High compressive and tensile srength – Ability to tint, opaque and characterize – Low viscosity – Low polymerization shrinkage – Good colour stability 111/148
  112. 112. Cementation Laminate Veneers –Uniformly load the veneers with composites and cover to protect them from light polymerization. –Low viscosity composites facilitate fast, low stress placement. –Incisally wrapped veneers require first facial, then gingivally directed pressure for complete seating. 112/148
  113. 113. – While maintaining a steady pressure on the veneer, slightly pull the interproximal matrix lingually to clear proximal margins of excess composite. – With the finger applying pressure and blocking light to the gingival half of the laminate, “tack”the veneer in place with a 20 second light exposure with a wide curing light tip. Cementation Laminate Veneers 113/148
  114. 114. Laminate Veneers –Repeat the removal of the composite excess at the margins and cure the entire laminate for a total of 1.5 to 2 minutes, depending on thickness, color, and opacity of laminate. Cementation 114/148
  115. 115. Cementation Laminate Veneers 115/148
  116. 116. Cementation Laminate Veneers – The excess material is removed with a probe and then light curing is continued for 45-60 seconds. 116/148
  117. 117. Cementation Laminate Veneers 117/148
  118. 118. Cementation Laminate Veneers 118/148
  119. 119. Finishing Laminate Veneers –Fine grit are used to remove any excess cement from the margins. –Final finishing is accomplished with discs and diamond polishing pastes. –Proximal areas are finished with finishing strips. 119/148
  120. 120. Maintenance Laminate Veneers –For 72-96 hours following insertion, patients should avoid highly coloured foods, tea or coffee, hard food and extreme temperatures. –Routine scaling should be done and ultrasonic scalers should be avoided. 120/148
  121. 121. Maintenance Laminate Veneers –Abrasive and highly fluoridated tooth pastes should be avoided. –Excessive biting forces and nail biting and pencil chewing habits should be avoided. –Soft acrylic mouth guard can be used during contact sports. 121/148
  122. 122. Failures Laminate Veneers 122/148 Biological • Three Types: – Mechanical – Biological – Aesthetic
  123. 123. Failures Laminate Veneers 123/148 • Mechanical – Fracture- poor positioning of incisal margin, less incisal thickness, margin too subgingival. – Debonding use of expired cement, faulty veneer/tooth preparation during luting
  124. 124. Failures Laminate Veneers 124/148 • Biological – Postoperative sensitivity – improper curing of cement, poor marginal adaptation. – Marginal Microleakage – poor fit and extension
  125. 125. Failures Laminate Veneers 125/148 • Aesthetic – Improper shade selection – Gingival recession – overcontour and improper subgingval placement
  126. 126. Advantages and Disadvantages Advantages Disadvantages 1 Minimally Invasive – Conservative Tooth preparation, however, minimal is required. 2 Excellent colour and light transmission – good aesthetics Cementation is time consuming and technique sensitive 3. Good Tissue response Difficult to repair Laminate Veneers 126/148
  127. 127. Advantages and Disadvantages Advantages Disadvantages 4 High Colour Stability Fragile – may fracture if improperly handled during try-in or cementation 5 Good Tissue response Difficult to repair Laminate Veneers 127/148
  128. 128. Advantages and Disadvantages Advantages Disadvantages 6 Excellent durability – good response, wear resistance and no fluid absorption. Proper selection of underlying cement is critical for success 7 Speed and Simplicity Cost 8 Does not compress interdental gingiva 9 Maintains natural contacts and incisal guidance Laminate Veneers 128/148
  129. 129. Recent Advances • Lumineers: Laminate Veneers 129/148
  130. 130. Recent Advances • Lumineers – What is the difference between Lumineers and standard porcelain veneers? • The main difference is that Lumineers are made from a special patented CERINATE porcelain that is very strong but much thinner than traditional laboratory-fabricated veneers. Their thickness is comparable to contact lenses. Laminate Veneers 130/148
  131. 131. Recent Advances Advantages • Lumineers can be placed on the teeth without removal of the tooth structure. • Lumineers are a reversible procedure • Patients can receive their veneers quickly, usually within two weeks from the date that the impressions are made. • Lumineers bond directly to the tooth, making the bond very strong. They are also very long-lasting- up to twenty years or longer. Laminate Veneers 131/148
  132. 132. Recent Advances Although Lumineers are the most advantageous option, there are certain limitations to be considered: • Lumineers can only be placed on teeth that are in good structural condition. The teeth must be free of decay. Any existing fillings must also be in good condition, along with the surrounding gum in the area where the Lumineers will be placed. Laminate Veneers 132/148
  133. 133. Recent Advances • The patient must have good oral hygiene, with no receding gums or signs of gum disease. Bleeding of the gums will interfere with the bonding process. • Because there is very little or no tooth preparation, a small bump is likely to develop between the veneers and the gum.. The bump may create an irritation to the gum, and may increase the chances for staining and tooth decay. Laminate Veneers 133/148
  134. 134. Recent Advances The LUMINEERS No-Prep Technique allows LUMINEERS to be placed over the existing teeth without the removal of any form of tooth structure. Therefore, anesthesia and temporaries are also not required. The LUMINEERS Minimal Contouring Technique requires slight modification of the enamel but never touches dentin during LUMINEERS placement. Only .3 mm-.5 mm enamel is removed, causing no sensitivity for the patient and therefore no need for any anesthesia. Laminate Veneers 134/148
  135. 135. Recent Advances PREPARATION OF LUMINEERS 1. Polishing Clean the teeth with Porcelain Laminate Polishing Paste and rinse. 2. Refresh the Enamel Perform minimal enamelplasty with a prep diamond bur, using light pressure. –Use the whole length of the bur, keeping contact with the teeth. Laminate Veneers 135/148
  136. 136. Recent Advances 1. Interdental Strips Isolate the teeth receiving LUMINEERS from the teeth not receiving LUMINEERS by applying Paint-On Dental Dam or placing metal interdental strips in order to prevent etchant from contacting adjacent teeth. 2. Etching 1. Etch the teeth with Etch ‘N’ Seal® for 20 seconds. 2. Rinse thoroughly with water, then dry. Laminate Veneers 136/148
  137. 137. Recent Advances Bonding Application 1. Add 5 coats of Tenure® A+B. 2. Add 1 coat of Tenure S to the teeth. Note: Tooth surfaces must be shiny. Laminate Veneers 137/148
  138. 138. Recent Advances Prime-Bonding on LUMINEE RS 1. Add 1 coat of Tenure A+B on the inner side of the LUMINEERS. 2. Add 1 coat of Tenure S on the inner side of the LUMINEERS. 3. Ultra-Bond® Plus on LUMINEE RS Add an even layer of Ultra-Bond® Plus resin cement to the inner side of the LUMINEERS. Work upwards from incisal edge of the LUMINEERS to gingival edge and keep light contact with the LUMINEERS Laminate Veneers 138/148
  139. 139. Recent Advances Insert the LUMITray 1. Remove the Paint-On Dental Dam or interdental strips. 2. Center the LUMITray (midline). 3. Insert the tray in one smooth movement. Apply light and continuous buccal pressure. Take your time for the placement. 4. Remove excess Ultra-Bond Plus resin cement from the gingiva with a microbrush. Laminate Veneers 139/148
  140. 140. Recent Advances Cure LUMINEE RS Through LUMITray 1. Tack-cure each tooth using a sweeping movement. Set Light for 3 seconds. 2. Remove more excess cement with a probe. 3. Light-cure each tooth for 3 seconds through the tray. Laminate Veneers 140/148
  141. 141. Recent Advances Light-Cure the LUMINEE RS Light-cure each LUMINEERS individually for a second time, on both the lingual and buccal sides, for 5 seconds with curing Light Laminate Veneers 141/148
  142. 142. Recent Advances • Lumineers – Lumineers vs veneers are thinner; roughly the thickness of a contact-lens. Laminate Veneers 142/148
  143. 143. Acid Etching Laminate Veneers 143/148
  144. 144. Acid Etching Laminate Veneers 144/148
  145. 145. Conclusion Laminate Veneers • Ceramic Laminate Veneers remain as prosthetic restorations that best comply with the principles of present day aesthetic dentistry. These are pleasing to the soft tissue and possess excellent aesthetic quality yet a conservative restoration can be called ‘bonded artificial enamel’. 145/148 Goldstein, Esthetics In Dentistry, Vol. 1, 2nd edition
  146. 146. References Laminate Veneers 1. Fundamentals of Fixed Prosthodontics Herbert T Shillingburg 3rd edition. 2. Tylman’s Theory & Practice of Fixed Prosthodontics 8th edition. 3. Contemporary Fixed Prosthodontics Stephen F Rosenstiel 3rd edition. 4. Sturdevant’s Art and Science of operative dentistry – Fifth edition. 5. Porcelain Laminate Veneers for Dentists & Technicians Roger J smales 146/148
  147. 147. References Laminate Veneers 6. Esthetic dentistry – second edition, Aschheim, Dale. 7. V Rangarajan, Textbook Of Prosthodontics, pg 707-719 8. George Freedman,Gerald McLaughlin, Colour Atlas of Porcelain Laminate Veneers,1st edition 9. Ramya Raghu, Clinical Operative Dentistry Principles and Practice, 3rd edition, 404 10. Monterio et al, evaluation of materials and techniques for restoration of erosion areas, J Prosthet. Dent. 55:434,1986 11. Goldstein, Esthetics In Dentistry, Vol. 1, 2nd edition 147/148
  148. 148. Thank You 148/148

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