ESTHETIC LAMINATES

The laminate veneer is a conservative

alternative to full coverage for improving the
appearance of an anterior tooth
Considered to be one of the most popular
restorations of esthetic dentistry
Laminates may be used to improve the color of
stained teeth, alter contours of misshapen
teeth, and close interproximal space
A dentist may use one veneer to restore a single tooth or
multiple to create multiple teeth to create a Hollywood
type of makeover.
Porcelain veneers were introduced Dr. Charles Pincus
for hollywood actor to be retained temporarily by
adhesive powder in 1930s
TYPES OF VENEERS
Directly fabricated veneers
Composite Veneers
Indirectly fabricated veneers
Preformed laminates
Laboratory fabricated veneers
Acrylic resin veneers
Microfill resin veneers
 Porcelain veneers
INDIRECT /PROCESSED COMPOSITE VENEERS
Two visits
1st visit-tooth preparation and impression making
2nd visit-placing the laminates
Advantages-
-can mask dark stains more esthetically than direct
bonding
-no anaesthesia is usually required
-can easily be repaired in the mouth if and when
staining or chipping occurs
-more conservative- less tooth reduction than
crowning
-usually less expensive than crowning
-color change possible
Disadvantages

- This is two appointment procedure.

- Under stress veneer may cleave away from

underlying resin cement.
- The lab fee must be added to patient cost.

- Unless care is exercised. Excess bulk is present in the

veneer.
For above reasons these are often recommended for
placement in children and adolescents as interim
restorations until teeth have fully erupted and achieved
their complete clinical crown length. At that time
usually at age 18 to 20 yrs, a more permanent
alternative such as porcelain or castable ceramic
veneer can be pursued.

PORCELAIN VENEERS
ADVANTAGES
Better inherent color control. Natural
Fluorescence lending certain vitality.
Better bond strength to the enamel surface than
any of the other veneering systems.
Better periodontal health as they deter plaque
accumulation
Wear and abrasion resistant exceptionally high
as compared to composite resin.
Inherent porcelain strength
 Veneer itself is rather fragile, but once it is luted
to enamel develops both high tensile and shear
strengths.
DISADVANTAGES
Very technique sensitive and therefore time
consuming. Cannot be easily repaired once luted
to the enamel
Requires some tooth preparation to prevent
potential problems associated with over
contouring.
More expensive
INDICATIONS
Enamel defects - Hypoplasia, Malformation
The ongoing process of aging can result in color
changes and wear in teeth. Can be improved by
bleaching alone or sometimes bleaching with
subsequent veneering.
Tetracycline stains
Fluorosis
Devitalized teeth

CONTRAINDICATIONS

Patients with certain habits such as

Tooth to tooth habits : bruxism
 Tooth to foreign objects habit
Are not ideal candidates for veneers as the shearing stresses
may be to great for porcelain to withstand

Deciduous teeth and teeth that have been excessively

fluoridated may not etch effectively.

Lower incisor teeth. These veneers are more complex to

place than the uppers and should only be attempted when
the alternatives are unacceptable. The occlusal forces are less
favourable than for upper incisors and the available bond area
considerably less.
Gross loss of labial enamel, for example acid induced
erosions.

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.
No preparation veneers are not reversible at all as they
cannot be removed with a handpiece without doing
damage to the teeth.
Best is to decide how to approach the preparation on an
individual basis.
RATIONALE FOR THE 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
To facilitate sulcular margin placemen in
severely discolored teeth.
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
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.
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.
AS A GENERAL RULE, OVER 50% OF THE PREPARATION
SHOULD BE IN ENAMEL.
ENAMEL REDUCTION
LVS(Laminate Veneer System) depth cutter diamond
burs( Brasseler, Savannah, Ga.)
 DEPTH GUIDE
LVS no. 1 0.5 mm reduction
LVS no. 2 0.3 mm reduction
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.
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.
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.
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 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.
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.
Finish line configuration
Somewhat controversial
Feather edge to a rounded shoulder.
Requires a cervical reduction of minimum 0.25 mm

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.

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.

Laboratory procedures
The refractory investment technique
The platinum foil technique
The IPS Empress system.
The platinum foil and refractory die techniques are common
choices because there is no need to purchase expensive laboratory
equipment, and both methods are simple and can produce
 reasonably well-fitting veneers. The refractory die technique is
becoming more popular, although it was found that vertical
marginal discrepancy for platinum foil veneers was significantly
less (187 microns) than that for veneers made with the refractory
die technique (242 microns),even though the platinum' foil
occupies about 25 microns
The authors suggested that divesting refractory die
material with aluminium oxide abrasive causes an
inadvertent abrasion of the delicate inner porcelain
surfaces to produce the increased discrepancy The
authors believed that the marginal fit of castable
ceramics was not reliable enough for veneer fabrication.

There are contrasting observations on the fitting of

CAD/CAM veneers. The authors suggest that, after some:
internal surface grinding, the CAD/CAM veneers were as
acceptable as those fabricated in the laboratory. A
problem with the computer system veneers is the need to
alter the colour of the originally monochromatic ceramic
blocks with shade modifiers placed under the veneers or
with surface stains fired over them.

When selecting a method for the fabrication of porcelain

veneers, there is the need to consider whether the whole
process of construction is economical and simple. Among
the present available methods, the casting, pressing and
milling systems require special equipment, and it does
not seem that these methods of fabrication of porcelain
veneers can produce superior results to direct porcelain
application. The refractory die technique requires no
special equipment and is simple and economical to use.

The refractory investment technique

Fabricating the master cast A type -IV die stone is

used for pouring the impression, the impression surface
may be treated with a liquid to reduce the surface tension
for better flow and details. After using a die location
system, the master cast is sectioned and later used to
check the marginal fit of the individual veneers
after divesting,

Making the working cast- it is poured directly after the

master cast has been poured and the space maker
refractory material is applied to act as space for luting
cement, this spacer should be limited to the labial surface
and 2mm short of the preparation finishing lines.

Preparatory firing of the refractory cast-

degassing/hardening of the refractory cast is achieved at
a temperature according to the manufacturer's
instructions. This step allows the removal of gases from
heating of the refractory cast, thus, contamination of the
porcelain can be avoided during firing.

With the refractory cast, the technician is unable to

predict the final shade of the porcelain veneers before
divesting, because the veneers are thin and sufficiently
transparent for the colour of the underlying investment
material to affect the technicians visual perception
.Dentine like coloured investment such as 3M Refractory
Material for porcelain veneer fabrication are available, but
they still cannot give an accurate background colour. In
case of tetracycline stains veneers slightly thicker than
usual and more space provided beneath them for resin
opaquer cement. The porcelain veneers are built up and
contoured with reference to the diagnostic wax-up or
study model taken before tooth preparation, noting the
general appearance of the arch and the relationship of
the teeth with the opposing arch in order to achieve good
harmony.

Removal of porcelain veneers from refractory die

refractory investment material should be carefully
trimmed such that only a minimal amount of refractory
material remains around the veneers. Air abrade the
refractory cast with 20 to 50 m particles of aluminium
oxide at 60 psi to remove the refractory material from
the interface of the veneer.

Carefully remove and clean the veneers in an ultrasonic

detergent bath for three minutes. Use a rubber wheel to
lightly remove all porcelain flash and overextensions from
the edges before returning the veneers to the master cast
for adjustment.

Etching the fitting surface- hydrofluoric acid is

applied to the fitting side of the veneer to provide good
bonding strength by partial dissolution of glassy matrix.
The labial surface is protected by sticky wax and the acid
applied on the fitting surface with a plastic coated
tweezers. The acid is washed in copious amount of
running water, Hydrofluoric acid is available in varying
concentrations for porcelain veneer bonding and for
intraoral porcelain repair, and duration of application
varies considerably. Prolonged etching increases opacity,
this can be of an advantage in masking more Severe
discolorations.

Finishing and Contouring:

Porcelain veneers should be finished with a high

speed (approximately 150,000 rpm) handpiece and
microfine (15 to 45 grit size) friction-grip diamonds. Do
not use larger grit sizes as they tend to chip the fragile
porcelain laminate. Diamonds, when finishing with a low
speed (45,000 rpm) handpiece, do not built up the
surface heat that a metal bur or stones would create.
Contour facial areas using a flame shaped diamond.
Marginal areas of the veneer are lightly contoured with
(carborundum) sand paper disks. If separating
embrasures between veneers on a refractory model, use
an ultrathin diamond disk followed by a double-sided
cutting disk to carefully reduce the refractory material at
the gingival areas. Finish the incisal edges with a
sandpaper disk, and redefine facial anatomy with a fine
diamond contouring bur. Removal of as much refractory
material as possible is important to reduce the amount of
any residual ammoniated gasses during subsequent firing
and glazing.

Glazing:
 A thin layer of porcelain-fusing glaze (17000 F/927
C) is painted on the porcelain surface to seal any
microporosities and achieve a more natural luster. To add
chroma to the veneer, stains are applied usually to the
incisal or gingival third in areas requiring characteristic
color. Paint slurry mix of glaze over the labial surface,
apply stains, and allow them to dry, the veneer is then
fired to the desired surface glaze.

A medium fine grit diamond can be used to make any

adjustment to allow for intimate fit

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.

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.

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.

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.

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.

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.

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.

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.

Composite resin color check

The actual composite resin selected can be placed on

the veneer and seated on the tooth.

Excess resin is removed with an explorer and the Final color will
become evident
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
Better technology is to use specially formulated and colored keyed
try- in paste.
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.
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.
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.
ENAMEL ETCHING
Wash and air dry the teeth
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

APPLICATION OF DENTIN BONDING AGENTS

Coat the etched tooth surface with bonding agent of

the light activated type, which is gently air dispersed
into a thin, layer.

Gently blow aside all excess bonding agent

Light cure this evenly dispersed layer to seal the

tooth surface.

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.

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.

Distance: should never be more than 1 mm.

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

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.

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.

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.