laminates
- 1. Presented By: Dr Shria Dhaon
- 2. CONTENTS Definitions Introduction History Porcelain Laminate Veneers Direct Composite Resin Veneers Indirect Composite Resin Veneers Conclusion References
- 3. DEFINITIONS Laminate : A superficial or attractive display in multiple layers Veneers : A thin sheet of material usually used as a finish protective facing (GPT-8)
- 4. INTRODUCTION The laminate veneer is a conservative alternative to full coverage for improving the appearance of an anterior tooth. A porcelain laminate veneer is an extremely thin shell of porcelain applied directly to tooth structure. Tooth preparation is minimal, remaining within enamel.
- 5. HISTORY In the 1930s and 1940s, Dr Charles Pincus , used thin porcelain veneers to improve the esthetics. He used denture adhesive to hold the veneer in places. In the mid-1970s and early 1980s, the composite resin laminate veneer evolved. The second evolution of veneers involved the development of preformed veneers that were joined to the etched tooth structure. The popularity of porcelain laminate skyrocketed in 1980's partly because of its conservative nature and the dental researches in the acid etched technique and new bonding methods.
- 8. ADVANTAGES OF PORCELAIN LAMINATE VENEERS Color Bond Strength Periodontal Health Resistance to abrasion Inherent Porcelain Strength Resistance to fluid absorption Esthetics
- 9. DISADVANTAGES OF PORCELAIN LAMINATES Repair Technique Sensitive Fragility Cost
- 10. INDICATIONS Stained or darkened teeth Hypocalcification
- 17. Poor oral hygiene Mouthbreathing Clenching or bruxing Extreme midline deviation
- 18. TOOTH PREPARATION FOR PORCELAIN LAMINATE VENEERS Sequence of tooth preparation Labial reduction Interproximal extension Sulcular extension Incisal modification Lingual reduction
- 19. Armamentarium A diamond depth cutter with three, 1.6mm diameter wheels mounted on a 1.0mm diameter non-cutting shaft. The radius of wheel from the non-cutting shaft is 0.3mm. three wheeled diamond depth The wheels extend from the non-cutting shaft to a diameter of 2.0mm with a 0.5mm radius from the shaft to the perimeters of the wheels.
- 20. Round end tapered diamond. Two grit tapering diamond. Finishing strips (Diamond strips) Gingival retraction cord Local anesthetic
- 21. LABIAL REDUCTION The preparation should remain within the enamel . Depth cutter diamond is used to create horizontal striations or depth-cut grooves on the labial aspect of the tooth. The round end tapered diamond is used to remove the remaining enamel to the depth of the original grooves.
- 22. INTERPROXIMAL EXTENSION It is an extension of facial reduction using round end tapered diamond, where the reduction is continued into the proximal areas. Depth can often be as great as 0.81mm, since the enamel layer is thick towards proximal surface The proximal reduction should stop just short of breaking the contact. When multiple adjacent teeth are prepared for veneers, the contacts should be opened to facilitate
- 23. SULCULAR EXTENSION AND MARGINAL PLACEMENT The teeth are prepared on labial aspect so that the finish line is exactly at the gingival margin. Place a thin gingival retraction cord lightly into the sulcus.
- 24. The tissue will be displaced apically, exposing the preparation line, which used to be right at the gingival margin. Use the tip of the round end tapered diamond to refine this finish line without moving it apically. Ensure that it is a smooth harmonious finish line.
- 25. INCISAL REDUCTION Window- preparation is taken close but not up to the incisal edge. Feather-in which the veneer is taken upto height of the incisal edge but edge is not reduced.
- 26. Bevel- a bucco-palatal bevel is prepared across the full width of the preparation. Some reduction of incisal length. Incisal overlap- or wrap incisal edge is reduced and then the veneer preparation extended onto the palatal aspect of the preparation. Reduction at least 1mm.
- 27. LINGUAL REDUCTION Create lingual finish line with the round end tapered diamond. Hold the instrument parallel to the lingual surface, with its end forming a slight chamfer 0.5mm deep. The finish line should be 1.0mm from centric contacts and connecting the two proximal finish lines.
- 28. IMPRESSION TAKING The impression material used should be of two viscosities: light and heavy body.
- 29. Tray material should be of the heavy type. Inject the tip-mixed light body directly onto the teeth, along the cervical margin and interproximally.
- 30. The putty filled tray is then compressed over the arch. Once the impressions and occlusal records have been taken, the shade is established.
- 31. CLINICAL TECHNIQUE FOR SHADE MATCHING Since the light source is one of the major potential problems, the dentist should try to take shades in a room free from wall coverings and decorations highly saturated with color. If the patient is wearing bright colors, they should be offset by using a relatively neutral colored apron like pale blue apron, since this color is most restful to the operator's cones. The patient's lipstick should be removed.
- 32. Dentists should remove all tinted glasses before matching colors.
- 33. Temporarization Two methods of fabricating are Direct method Indirect method
- 34. 1. Direct method a. Composite resin is applied with a spatula after tooth is prepared with a separating media, the resin is contoured and then removed from the tooth. It is trimmed, polished and temporarily cemented, “Spot welding” technique by etching a small spot of facial enamel for added retention. Microfilled resin is placed, finished and polished.
- 35. b. Direct composite resin using vacuform matrix: A complete upper and lower impression is made before preparing teeth, a template is fabricated using a thermoplastic material once the preparation is over the separating media is applied on the prepared teeth and the template filled with composite resin is placed and cured, then it is trimmed, polished and cemented.
- 36. 2. Indirect method Requires a lab support immediately after the tooth is prepared the impression is made and poured with quick setting plaster and it is fabricated in the lab with acrylic shells or polycarbonate crowns.
- 37. LABORATORY PROCEDURE FOR PORCELAIN LAMINATE VENEERS Two basic approaches to the laboratory fabrication of porcelain laminate veneers. Refractory investment model technique Platinum Foil Technique
- 38. REFRACTORY INVESTMENT MODEL TECHNIQUE First proposed by McLaughlin Fabricate the die-stone master cast.
- 39. Application of Die Spacer Master cast with die spacer. Block-out wax is placed to fill undercuts.
- 40. Fabrication of Refractory Model: Select a preformed plastic disposable tray to fit over the master cast to include the area being veneered and the teeth adjacent to it.
- 41. Block the undercut ares. Make an impression of the master cast using an elastomeric impression material. The impression must accurately reproduce the labialincisal areas to be veneered.
- 42. A second refractory model may be poured, following the same procedure used with the first refractory model. The porcelain veneers may be built on either a solid refractory model or on individual refractory dies taken from two refractory models.
- 43. De-Gassing the Refractory Investment: To avoid contamination of the ceramic, ammoniated gasses inherent in the refractory material must be removed. The basic procedure is as follows : Introduce the refractory model to the pre-heated furnace at low temperatures ranging from 540°C to 650°C and heat-soak it for 15 to 30 minutes. Place the model under vacuum and set the temperature between 1,040°C to 1,066°C with a heat rate increase of 25°C per minute.
- 44. Hold the temperature at 1,040°C to 1,066°C for two to six minutes. Release the vacuum with a slow decline in temperature to approximately 540°C. Remove the refractory model (or dies) from the furnace and bench cool them.
- 45. SEALANT APPLICATION A specific refractory sealant may be placed over all porcelain bearing surfaces and marginal areas. Then fire the painted refractory model according to the firing cycle of the porcelain being used. When the refractory model is removed from the furnace it should have a sheen to the surface. If not, repeat the procedure of sealing.
- 46. The porcelain is build up to full contour and the veneers are finished and contoured
- 47. Removal of Veneers from Refractory Material Trim the refractory investment material with ultrathin diamond disk until only a minimal amount of refractory material remains around the veneers.
- 48. Carefully remove and clear 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. Return the veneers to the master cast for final adjustment.
- 49. PLATINUM FOIL TECHNIQUE This method was first developed by Greggs Platinum foil commonly used for veneering is 0.001 to 0.00085 inch in thickness, and is usually sold in widths of 11/6 to 13/8 inch. The platinum foil acts as a surface substrate for veneer buildup.
- 50. Model and Die Preparation : Starting with a good quality elastomeric impression, use a dental die stone to pour a working model. Pin all teeth to be veneered, including the adjacent teeth. Pour the base.
- 51. Section and cut individual dies from the master cast. This is done by sectioning the cast from the base toward the incisal edge but stopping short of the contact points.
- 52. Once the contact area is reached, snap apart the cast. Remove excess stone from the base of the dies to create a smooth, rounded shape, providing easy access to the working surface of the die. Cover all undercuts with the block-out-wax to facilitate easy removal of the foil.
- 53. Foil Matrix With a triangular template specifically designed for veneering, cut the foil into the designated shape. Place it over the labial surface of the die with the apex pointing downward, thus forming a tab portion which extends below the gingival margin.
- 54. Wrap the foil over the incisal edge and into the undercuts of the gingival/proximal margins.
- 55. Using an orange wood stick, adapt and burnish the foil into a intimately fitting form. The excess foil on the proximal surface beyond the margins must be trimmed away using a scalpel.
- 56. To remove the foil matrix from the die, elevate the platinum foil off the underlying die by moving it from the cervical aspect and rotating it around the incisal edge. Hold this foil matrix over a Bunsen burner flame until it glows bright orange to decontaminate it.
- 57. The decontaminated foil is then readapted to the die and secured with several peripherally placed drops of sticky wax. Mix and apply the preselected porcelain shade to the platinum foil
- 58. The two foils and first application of porcelain are ready to be fired. After the first firing, the laminate is built up to full contour.
- 59. Lift the foil and the completed porcelain off the underlying die. The two laminate buildups are ready to be placed into the furnace.
- 60. Buccal and lingual view of the completed laminates showing the ongoing maintenance of the platinum foil form. Remove the platinum foil by teasing it away from the porcelain using finepointed tweezers. This may be facilitated by doing it under water. Trim and refine the laminate margins.
- 61. Porcelain veneers should be finished with a high speed (approximately 150,000 rpm) handpiece and microfine (15 to 45 grit size) friction-grip diamonds. Contour facial areas using a flame-shaped diamond. Marginal areas of the veneer are lightly contoured with (carborundum) sandpaper disks. A thin layer of porcelain-fusing glaze is painted on the porcelain surface to seal any microporosities and achieve a more natural luster.
- 62. Try-in Try-in is a three stage procedure The intimate adaptation of each individual porcelain laminate to the proposed tooth surface. The collective fit and relationship of one laminate to another and the contact points. Color needs to be assessed.
- 63. ETCHING Place the labial surface of the veneer on a clay strip, allowing the concave inner aspect of the veneer to act as a receptacle. Then fill the interface of the veneer with the etching gel (e.g. 7.5% hydrofluoric acid) and allow it to stand for seven to ten minutes.
- 64. Lift the entire clay strip by both edges and completely submerge the veneers in a 10% solution of baking soda and water until the acid is neutralized. The gel will bubble and rise to the surface of the solution. Remove the veneer from the solution and dry. Clean the veneers in a detergent solution in an ultrasonic bath for three minutes each and dry it. The complete veneers are now ready for bonding.
- 65. VENEER PLACEMENT PROCEDURE Retraction cord should be placed in the gingival sulcus. No modification for shape is done until the final seating and curing are completed.
- 66. SILANATION First treat the etched surface of the veneers with the silance coupling agent to enhance the adhesive properties of the resin. A silane is painted onto the etched porcelain surface and allowed to dry for about one minute.
- 67. ENAMEL ETCHING The cleaned tooth is isolated. The tooth is etched with a 30% to 37% phosphoric acid solution for 15 to 20 seconds. The etching material is washed from the enamel surfaces with copious amounts of water for 30 seconds. Do not let the patient rinse or in any way contaminate this etched enamel surface with saliva. If this occurs the surface must be re-etched for ten seconds, washed, and dried again to redevelop a reactive enamel surface.
- 68. APPLICATION OF DENTAL BONDING AGENT Again isolate the underlying etched tooth surface and coat it with a combined enamel-dental bonding agent of the light-activated type. Coat the internal aspect of the veneer (which has been silanated) with an unfilled resin bonding liquid; blow it into a thin layer but do not light cure it.
- 69. 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.
- 70. SEATING SEQUENCE It is best to seat one laminate at a time. In multi-unit cases, start with the distal most tooth on each side of the arch and work mesially to the canine. Next seat the two central incisors simultaneously to ensure that they match. The two lateral incisors are then seated, one at a time, to accommodate any discrepancies in overall fit.
- 71. PLACEMENT Rotate the veneer onto the buccal surface of the tooth and then gently manipulate it until contact is made in the region of the gingival finish line. The motion must be a gently rocking or "pulsing" motion that slowly allows the excess material to escape from all sides of the veneer. The gross excess may be removed with a firm, pointed paintbrush or a curette.
- 72. Once the veneer is in place and seated, check the intimacy of fit between the margin and the preparation line with an explorer. Begin the polymerization process with the light. Cure for just 20 seconds from the lingual aspect and a further 20 seconds from the labial aspect in the incisal half of the tooth.
- 73. During this curing process, it is essential to maintain complete stability of the relationship between the veneer and the underlying tooth. The polymerization process is completed by curing the various areas of the veneer for at least two minutes each. This extra time is important due to the fact that the light has to travel through the porcelain to reach the underlying composite resin.
- 74. FINISHING Finishing procedures are accomplished under 2x or 4x magnification. Use microfine finishing diamonds at slow speed with water spray to blend the margins. A polishing diamond is used to refine the tooth/resin/porcelain interface. Polishing of the laminate is done with ceramic polishing points with diamond dust impregnated paste. Check the interproximal contacts to see that floss passes through smoothly and does not catch or tear.
- 75. OCCLUSAL ASSESSMENT Verify occlusion and ensure that the veneers do not make excessive contact with the opposing arch in any excursive movements of the mandible. This is obviously more critical when the incisal edge is lapped due to a fracture or the desire to increase the length of the teeth.
- 76. DIRECT COMPOSITE RESIN VENEER Tooth preparation Acid etching the enamel Application of bonding agent to enamel Bonding agent polymerization(20 sec) Application of thin layer of opaquer and polymerized(20 sec) For severe to moderate color alteration, preparation usually will be deep
- 77. Resins inserted incrementally, starting by cervical or by incisal The first part of the first layer must be inserted at the cervical region polymerized through a 20 second exposure. The second part is extended from the cervical third to the proximities of the incisal edge and polymerized through a 20 second exposure. The third and last part is extended to cover the incisal edge with a specific resin for that region, being then polymerized(20 second exposure).
- 78. INDIRECT COMPOSITE RESIN VENEERS Two patient appointments : 1st : preparation of the teeth and the securing of an elastomeric impression 2nd : bonding and finishing the veneers. Shade selection is determined prior to isolation of the teeth.
- 79. The teeth are prepared with a round diamond stone to a depth approximately equivalent to half the enamel thickness. The depth of reduction - 0.5 to 0.6mm midfacially, to 0.2 to 0.3mm along the gingival aspect of the preparation. Greater reduction may be required if significant intrinsic staining exists, as in cases involving severe tetracyline staining. Ideally, however, the entire preparation should be restricted to enamel to allow acid-etching for micromechanical retention.
- 80. A moderate chamfer should be created along the margins of the preparation. The interproximal margins should be extended beyond the interproximal line angles of the tooth yet be positioned labial to the contact areas. The gingival margin is prepared at a level equal to that of the free gingival crest. Subgingival extension of the prepared margins should be avoided. Incisally, the preparation should be restricted to the facial aspect of the incisal edge and should never be terminated in an area subjected to occlusal function. In these situations, or if a tooth requires lengthening, indirect composites resin veneers are not recommended.
- 81. An elastomeric impression is made. A working cast with individually removable dies of the prepared teeth is fabricated. Removable dies are recommended to allow the technician complete access to interproximal areas. Once the completed composite resin veneers are returned, they should be inspected for fracture lines, chips, or other significant defects that would preclude successful placement.
- 82. At the second appointment, the basic placement process for composite resin veneers is similar to that described for porcelain veneers. To evaluate veneer fit, a try-in of each veneer is recommended. Minor adjustments to the veneer can still be made with suitable composite resin finishing burs or diamonds to enhance adaptation.
- 83. Care must also be taken not to in advertently contaminate the underside of the veneer prior to bonding. If the inner aspect of the veneer is touched, it should be cleaned with acetone or ethyl alcohol prior to bonding so as to remove any oils or surface contaminants.
- 84. A thin film of the unfilled resin bonding agent is placed on the etched enamel but not yet cured. The veneer should be positioned first at the gingival margin, allowing the excess cement to extrude incisally as the veneer is fully seated. Caution must be exercised not to entrap air between the tooth and veneer. An explorer is used to check for marginal adaptation.
- 85. The underlying bonding medium is polymerized for at least 40 seconds with a visible light curing unit from both facial and lingual directions. Following complete polymerization, excess bonding material is removed using conventional composite resin finishing burs and instruments. Removal of the gingival retraction cord at this time facilitates access and visibility for finishing procedures.
- 86. The incisal edges are maintained in enamel to protect the veneer from shearing forces experienced during protrusive excursions. Following bonding of all veneers, the occlusion must be evaluated to ensure that no functional interference have been introduced.
- 87. CONCLUSION Ceramic laminate veneers remains a prosthetic restoration that best complies with the principles of present day esthetic dentistry. It is the king of soft tissue and excellent esthetic quality yet a conservative restoration and can be called “bonded artificial enamel”.
- 88. REFERENCES William F.P. Malone, David L. Koth. Tylman’s Theory And Practice Of Fixed Prosthodontics. David A. Garber, Ronald E. Goldstein, Ronald A. Feinman. Porcelain Laminate Veneers Theodore M. Roberson, Harald O. Heymann, Edward J. Swift. Sturdevant’s Art & Science Of Operative Dentistry