Laminate veneers ( under-graduate)

veneer is a thin covering that is bonded to the

front (visible) part of the tooth.

#ncisal vie(
TYPES O L!"#$!TE %E$EE&S'

1. 1. Direct Direct )ustom made laminates

Preformed stoc* laminates

Composite resin material

Composite resin material Ceramic (lumineers direct and indirect ) Acrylic ($OT +SE, an-more)

2. 2. Indirect Indirect )ustom made laminates

Composite resin material Ceramic

1. 1. Temporary Temporary
Composite resin material Acrylic

2. 2. Permanent Permanent
Composite resin material Ceramic

(inside (inside the the mouth) mouth)

Light-cured composite resin build up to onla- the entire visible etched enamel surface.
/) +se a labial cro(n form. 0) !dd ).&. free-hand.

Direct Direct

.hen adding )omposite resin for a direct veneer (e ma-'

/) +se a labial cro(n form.

Labial cro(n form tried on tooth

0) !dd ).&. free-hand.

!dvantages Of ,irect )omposite %eneers

Onl- one appointment is re1uired. The dentist directl- controls color and form. )ost is reduced. &epairable.

,isadvantages Of ,irect )omposite %eneers

Time consuming. &e1uires artistic s*ills. E2hibit poor color stabilit- and (ear resistance.

(outside (outside the the mouth) mouth)

Preformed stoc* laminates
Ceramic (lumineers)
.hat are Lumineers porcelain veneers3
Lumineers porcelain veneers are a read-made

2.Indirect 2.Indirect

veneers made out of the patented porcelain )erinate.

 )erinate is an e2ceptionall- strong t-pe of porcelain and this propert- allo(s Lumineers veneers to be fabricated e2tremel- thin. The thic*ness of Lumineers veneers can be as little as 4.0 to 4.5 mm (along the same lines as a contact lens). #n comparison traditional porcelain veneers t-picall- re1uire a minimal thic*ness of around 4.6 mm. The- cost from 7844.44 - 7//44.44 veneer. per Lumineers

!dvantages Of Lumineers
Onl- one appointment is re1uired. E2tremel- thin ( 4.0-4.5 mm)

"anufacturer claims9 no drilling no shot protocol.

,isadvantages Of Lumineers
Poor fit bet(een teeth and laminates. +nevenl- thic* cement la-er. Liabilit- of over-contouring and subse1uent gum disease and inflammation . Tooth deca-. E2pensive.

(outside (outside the the mouth) mouth)

)ustom made laminates
Ceramic

2.Indirect 2.Indirect

!ccording to a statistical stud- dra(n up b- :;rich +niversit-< the failure rate of ceramic laminate veneers is not more than 6= in 6 -ears< i.e. ver- similar to that of highl- popular metal-ceramics.

!dvantages

/.

"inimall-

invasive

treatment

method.

#t

utili>es

minimal tooth preparation mainl- confined (ithin enamel. ?eeping clear of the gingival margins. 0. Tissue response. "inor degree of tissue damage during preparation or ta*ing an impression (usuall- supragingival finish line). @la>ed porcelain is highl- biocompatible.

5. Shape< position and surface appearance can be modified. )hange canine into lateral incisor< adAust tooth length or transform surface te2ture permanentl- and elegantl- .

B. Effective color change. .hen bleaching techni1ues becomes ineffective< laminate veneers ma- be the treatment of choice. 6. Light transmission. #f the tooth is not stained the laminate veneer should transmit light progressivel- through its thic*ness < cement and tooth structure giving a natural appearance . C. ,urabilit-. )eramic laminate veneers sho( e2cellent biological< chemical and mechanical properties. 8. Speed and simplicit-. .hatever the number of laminates re1uired< the- can be prepared and luted over t(o sessions separated b- a fe( da-s. D. re1uentl- do not re1uire anaesthetic. The preparation is confined to enamel.

,isadvantages

/.Preparation. The sophisticated preparation re1uires a great s*ill to master the 4.5-4.6 mm preparation. 0. )ost. ,ue to the refined lab and dental (or* %eneers are e2pensive. 5. #rreversibilit-. +nli*e bleaching< tooth reduction is re1uired. B. Tempori>ation. ,ifficult to adAust the margins and the provisional cementation is complicated. 6. ,ifficult- in color matching. Precise matching of a desired shade can be difficult

C. Post-firing modifications. )eramics can not be re-fired once removed from its support (not applied to the #PS Empress). 8. #nabilit- to trial cement the restoration. #t can not be retained b- temporar- cement for evaluation. D. Liabilit- to fracture. Laminates are e2tremel- fragile during the tr- in and cementation phase. E. Fonding procedures. !t the bonding stage< the slightest error can mean failure< either immediatel- or later on. /4. Lac* of repairabilit-. The- are difficult < if not impossible to repair.

#ndications
Some authors suggested that at least 64= of prepared tooth surface be composed of etchable enamel. (@arber< /EE/) The peripheral margin of enamel should confirm to the GOne millimeter circumferential principleH etchable enamel <for long term marginal integrit-. On the other hand< the ongoing evolution to dentin adhesion< (hich is no( as reliable as adhesion to enamel and ma- go be-ond the classical limitations of bonding onto dentin surfaces. of

/. )olor defects or abnormalities' !melogenesis imperfecta. "edications (Tetrac-cline). ph-siological aging. Trauma.

"ild Tetrac-cline staining

0. Shape abnormalities' "icrodontia. !t-pical tooth shape (malformation).

"alformation
5. Structure or te2ture abnormalities' ,-splasia Erosion !ttrition !brasion )oronal fractures

!ttrition
B. Position abnormalities' )orrection of minor malposition' &otated teeth )hange of angulation.

"alpositioned Teeth
6. ,iastema.

C. Lingual laminate veneer. 8. Lengthening. D. Stained or (orn &estoration. E. &oot e2posure. /4. Ps-chological-perceived needs of the patient. !ll caries and old fillings should be restored using composite resin or glass ionomer. The final preparation of veneers should include and cover these restoration as possible.

)urrent )ontraindications
#t must be stressed that contraindications should not be too rigidl- set for a techni1ue no( still evolving. The incontrovertible rule prevailing over the last decade re1uired the positioning of the veneer margins in enamel< and ensuring that at least 64= of the prepared surface remained in enamel (@arber< /EE/< !lbers) ,entin adhesion is becoming as reliable as adhesion to enamel again. E2tensive loss of supporting enamel . This (ill re1uire that (e revie( our preparations and e2tend the terms of our indication

 +nsuitable

anatomic

presentation

Short

or

triangular teeth) Severe abrasion< erosion < attrition or abfraction ( loss of tooth surface caused by tensile and compressive forces during tooth function) E2tensive e2isting restoration or caries Parafunction (bru2ism) "oderate or severe malpositions Oral habits (nail biting< pencil biting) Pulpless teeth. Poor dental care and h-giene

Oral habits (nail biting< pencil biting)

Tooth Preparation or ceramic Laminate %eneers

/
!rmamentarium

! E

!<F<) ,epth cutter (heels ,. Tapered (ith round end E. Olive (!merican football) ,

T-pes of preparation

)ontact lens li*e preparation

Type I preparation

Preparation (ithout overlapping incisal edge

Type II preparation

Preparation (ith overla- incisal edge

I li*e preparation

Type III preparation

path of insertion is critical Preparation (ith overlapping incisal edge

Type ### preparation is preferred by many authors because: #t restricts angle fractures. .hen the free edge is not overlaid< the occlusal third of the laminates are verthis ( less than 4.5 mm) and liable to fracture. #t enhances esthetic properties of laminates.

Places the porcelain in compression rather than tension. %ertical stop. #ncrease area for bonding

Amount of tooth reduction

acial reduction @ingival third ' 4.5 J 4.6 mm "iddle K #ncisal ' 4.6 - 4.D mm

#ncisal reduction /J /.6 mm ( or t-pe ## K ### prep) Lingual reduction 4.6J 4.8 mm ( or t-pe ### prep) Fefore the preparation is begun< some putt- impression material is adapted to the facial K palatal surfaces of the teeth to be prepared. #t serves as a depth-reduction inde2.

Preparation Se1uence

Step / Facial Reduction

#nstrument used ' 0 ,epth cutter (heels follo(ed b&ound-end tapered diamond. To achieve' a) )learance of 4.5-4.6 mm gingival and 4.6 -4.D mm incisal.

b) #n lo(er incisors a cervical depth of 4.5 mm often e2pose patches of dentin.

er!ical mar"ins
! 4.5 mm chamfer or 4.6 mm in deep discoloration< placed Au2tagingival or ver- slight supra-gingival. The supra-gingival margins remain invisible because of their optical properties. #n cases of severe discoloration a 4.6 mm deep subgingival finish line is established.

Step 0 proximal Reduction

The preparation of pro2imal surfaces (ill have alread- been plotted during labial preparation and creation of gingival margins. The pro2imal reduction should e2tend into the contact area< but should stop Aust short of brea*ing the contact. T(o maAor principles should be follo(ed' Preserving the contact area. Placing margins beyond the visible area.

ontact area
.h- preserve the contact area3
#t is an anatomical feature that is e2tremel- difficult to reproduce. #t prevent displacement of the tooth bet(een preparation and placement sessions. #t saves clinical adAustment of contact area in fine ceramics. #t simplifies bonding and finishing procedures. #t simplifies tr- in procedure and prevent their fracture.

.hen not preserve the contact area3

/. #n cases (here pro2imal contact is lost "ultiple spacing. ,iastema. Pro2imal restorations. Fro*en angles. "alpositions. 0. #n cases of multiple laminates ( to facilitate separation of the dies (ithout damaging the interpro2imal finish line).

Step 5 Incisal Reduction

#n t-pe ## and ### preparations
! /-/.6 mm reduction for better strength and esthetics. /.6-0 mm used for canines and lo(er incisors. On mandibular incisors the incisal edge should be reduced #ncisal reduction should be uniform (hori>ontall-) for more uniform esthetics

Step B #in"ual Reduction

#n t-pe ### preparation
! 4.6 mm lingual chamfer finish line is created holding a round end tapered stone parallel to lingual surface. The lingual finish line should be appro2imatel- L the (a- do(n the lingual surface. #n e2tremel- thin teeth < lingual finish line placed on incisal edge.

 !ll sharp point and line angles should be rounded. +sing fine grit (-ello( coded) tapered diamond stone.

Step 6 Finishin" the preparation Impression

Laminates

are

most

commonl-

Au2ta-

or

even

supragingival and re1uire no gingival displacement. #t is onl- re1uired (hen the cervical margin is subgingival.

Pro!isional Restorations
,espite the minor degree of tissue reduction re1uired and the relativel- lo( incidence of postoperative sensitivit-< provisionals ma- be a must due to patientsM esthetic demands.

abrication of provisional veneers are most delicate stage. ,irect or indirect methods could be used.

1. 1. Direct Direct
)omposite resins are generall- used and are onlapplied to a single preparation at a time. The tooth has to be coated (ith a la-er of (atersoluble separator.

2. 2. Indirect Indirect
#t uses composites or chemicall- cured resins. #t is suitable (hen a group of several laminates are to be constructed. ! complete upper and lo(er impression is made before preparing the teeth. !n- corrections desired (lengthening or closing up diastema) using either light-cured resin or (a2 should be made. ! transparent plastic mold produced in a vacuum so as to give an e2act replica of the teeth to be treated. The plastic mold is loaded (ith resin and applied to the prepared teeth and light cured. The temporar- coverings is then trimmed and adAusted.

 The provisionals are then luted (ith a temporarcement not containing eugenol or >inc phosphate cement.

)eramic veneers abrication techni1ues

,irect build up of eldspathic porcelain (%"E) Platinum foil techni1ue &efractor- die techni1ue Pressed ceramics "achined ceramics /) ,irect build up of eldspathic porcelain (%"8) Platinum foil techni1ue &efractor- die techni1ue

!dvantages Of Platinum oil Techni1ue +se of standard stone for removable dies. Platinum foil can be easil- adapted.

 Eas-

to

measure

thic*ness

of

veneer

during

fabrication )an be tried on prepared teeth before gla>ing ,isadvantages Of Platinum oil Techni1ue Opening the contact is a must. oil distortion is possible.

)ost of foil ,ifficult to assess the actual color due to color of foil itself. The platinum foil techni1ue involves splitting he (or*ing model in order to obtain individual dies onto (hich the foil ma- be burnished. This (ould re1uire the contact areas to be openedNN33 !dvantages of &efractor- die techni1ue Overall accurac- and fit generall- better. Easier techni1ue for less e2perienced technician to master. ,isadvantages of &efractor- die techni1ue &e1uires duplication of stone dies or double pouring the impression. ,ivestment is re1uired. it must be verified on stone dies.

"ore difficult to control veneer thic*ness.

0) Pressed ceramics

!lumina plunger

)eramic blan* &ing Lost-(a2 techni1ue mold

5)

"achined ceramics

Try in of !eneers
The laminates should be tried (ith utmost care (ithout pressure to' "onitor the color. ,etermine the color of the composite cement. )hec* the fit of each laminate veneer.

Occlusion should be neither chec*ed nor adAusted before the laminates have been bonded.

The veneers are tried one at a time< ta*ing care to moisten them to produce adhesion b- surface tension< as (ith contact lenses. .ith a set of several laminate veneers< it is helpful to arrange them is strict order so as to avoid anchance of error. Tr- in begins (ith the most posterior teeth.

Fonding steps of the ceramic veneers

/. )leansing the teeth 0. )leansing the laminate veneer 5. Etching the laminate veneer

B. Silani>ation of the laminate veneer 6. Etching of tooth C. Primer on the tooth and the laminate veneer 8. )ementing D. &emoval of e2cess cement E. Light curing ( for light cured and dual cured cements) /4. 1. inishing leansin" the teeth The prepared teeth are first cleaned (ith a slurr- of fine pumice O (ater using a rubber cup. The teeth then rinsed to eliminate an- traces of pumice. $O brushes should be used as the- can trigger bleeding< (hich is detrimental to bonding. 2. leansin" the laminate !eneer / minute of ultrasonic treatment. Eradicates all contamination caused b- manipulation. $. %tchin" the laminate !eneer Each ceramic re1uires a different gel substance< for glass concentration and period of time for etching9 /4= ammonium difluoride ceramics. 0-/4= h-drofluoric acid gel for other ceramics. #n-)erams could not be etched. $eutrali>ing' 0 minutes in sodium bicarbonate gel. #ts role'

)reates micromechanical retention Eliminates superficial microcrac*s. Enhance (ettabilit-. )ompletes the cleaning process.

&. 'ilani(ation of the laminate !eneer ! fine la-er of silane coupling agent is painted over the internal surface of the veneer ' left for 0 minutes then dried. #t creates a chemical lin* bet(een the ceramic and bonding composite . The surface cleaning < etching and silani>ation can be completed in the laborator-. ). %tchin" of tooth 58= phosphoric acid' for enamel areas (54 seconds) and for dentin areas (/6 seconds) ollo(ed b- rinsing and dr-ing.

#t creates micromechanical retention. $e( generation dental adhesives adhere to the enamel and dentine simultaneousl-. !ll products should be applied to a slightl- moist surface. ,r-ing (ithout actuall- dr-ing out is re1uired. *. Primer on the tooth and the laminate !eneer Spread o B-6 la-ers< leave for 54 seconds and dr-. The primer promotes intimate bonding bet(een the tooth< composite and ceramic. +. ementin"

 The laminate veneer is eased into place accuratele2erting a stead- moderate pressure. #ts held in place b-9 ! special instrument ( !ccu-placer ) ! (a2 ball mounted on a plastic handle ! Flu-Tac* ball at the end of a large condenser. The strips pulled off in a lingual direction. ,. Remo!al of excess cement Frushes< scalpels ((ith straight blades)< dental floss and plastic strips. E2cess soft composite should be cleared a(a- before curing. -. #i"ht curin" . for li"ht cured and dual cured cements/ Laminates held in place b- (a2 or !ccu-placer or large condenser support< light curing . Light curing must ta*e place from angles to ensure complete cure. 10. Finishin" Strips< scalpel<< -ello(-banded diamond instruments or silicon polishers. .ait about /4 minutes before attempting ancleansing procedures.

ailure of laminate veneer

1. Fracture (The most common failure)

Causes: a) Inadequate porcelain thickness (insufficient reduction) b) Inadequate retention to the tooth c) Faulty case selection (e.g. parafunctional habits) !. Chipping

P P P

Fracture does not e"pose tooth structure.

#mooth$ then$ polishing

%ut$ &ith surface defect $.acid etch $. silane application and$..composite placement.

'. (oor esthetics Causes: a) Improper shade cement b) Improper shade selection c) Incomplete masking to the discolored tooth d) )*ercontouring (improper reduction)

+. ,ecreased marginal integrity and discoloration Causes: a) -se of luting cement .ith lo. .ear resistance b) Cracks and fractures /. Incomplete fit of the laminate Causes0 a) Improper impression b) -se of thick adhesi*e (consistency) making it difficult to seat the laminate properly.

c) (resence of contaminant on the fitting surface d) )*ere"tension of the gingi*al margins 1. ,ebonding Causes: a) Inability to pro*ide dry field during cementation b) (oor manipulation of the cement c) Inability to a*oid contamination of etched enamel (or laminate) d) -nsteady laminate during setting of the cement

2. Caries Causes: a) ,efecti*e margins b) 3icroleakage c) (oor oral hygiene d) 4emaining caries during preparation 5. 6ypersensiti*ity &ith e"posed dentin after preparation and not protected 7. (atient discomfort a) Improper contact (food impaction) b) (oor esthetics