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CERAMIC VENEER LAMINATES

Introduction
Ceramic laminate veneers have opened a new era in the field of
dentistry known as esthetic dentistry. Laminate veneers are a good
alternative to full crowns as they preserve the tooth structure.
History
It was first put forward by Dr. Charles.L. Pincus (1930). It was
used to temporarily change the smile of Hollywood actors and was called
Hollywood smile.
The procedure of veneering increased with the introduction of
effective adhesive cements and acid etching of porcelain that the clinical
step caught pace as an alternative to full crowns when possible.
Advantages
Less invasive requires minimal preparation.
Color and surface texture can be matched with natural teeth.
Good

biocompatibility

with

gingiva

at

the

margins

of

the

restoration.
Excellent durability as it has good bond strengths between
ceramic, composite and tooth.
Resistance to abrasion, wear and solvent attack.
Disadvantages

Uniform and minimal preparation required makes it difficult to


execute.
No alterations possible once the veneer is ready.
Bonding procedure is time consuming technique sensitive and
governs the success.
Due to their fragility may lead to fractures while trying-in or
cementation.
Proper selection of underlying cement is critical for effective final
result.
It is difficult to repair.

Indications
Extreme discolorations
Such as tetracycline staining, fluorosis, devitalized teeth and teeth
darkened by age which are not conducive for bleaching.
Surface defects
Small cracks in the enamel caused by aging trauma
Closing of diastemas
Single or multiple space between the teeth and
appearance of rotated or malpositioned teeth.
Short teeth
Can be lengthened for more esthetic, appropriate size.
Agenesis of lateral incisor

improving the

When the cuspid erupts adjacent to the central incisor in situations


in which there is a missing lateral incisor. Porcelain veneers can be
used to develop a coronal form of the cuspid, simulating a lateral
incisor.
Functionally-sound ceramometal or all ceramic crowns with
unsatisfactory color
The labial surface of old porcelain is prepared as for conventional
laminate and etched with buffered hydrofluoric acid and cemented.
Contra indications
Teeth having insufficient crown material:
If the teeth are composed of dentin and cementum crowning may
well be the preferable treatment.
Young permanent teeth
Parafuncitonal habits
Severe periodontal involvement and crowding.

Shade selection
This should be done before beginning treatment, during the
consultation or treatment planning appointment. It is done using a color
corrected light, outside in daylight and reconsider the shade after
preparation of enamel as the prepared teeth may have turned darker.

If some teeth are to be covered with veneers the porcelain veneers


should be placed first because of the difficulty in modifying the veneers
once they are bonded to place.

The available shade guides such as Vita porcelain shade guide, are
not ideal for veneers because they are toothick and composed of several
layers of opaquer. It is best for ceramist to make an individualized shade
guide.
Tooth preparation
Rationale for enamel preparation
Enamel preparation has to be done for the following reasons.
1.

To provide adequate space for porcelain opaquing and composite


resin luting materials.

2.

To remove convexities and provide a path for insertion. The best


path of insertion is that which will require the least amount of
enamel reduction.

3.

To provide a definite seat to help position the laminate during


placement.

4.

To prepare a receptive surface for etching and bonding the


laminate.

Enamel reduction should be considered from five different aspects:


1. Labial reduction

2. Interproximal reduction
3. Sulcular extension
4. Incisal or occlusal modification
5. Lingual reduction

Armamentarium
1. 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.
Second three wheeled diamond depth cutter produces the
correct reduction in the incisal half of the facial surface. 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.
2. Round end tapered diamond.
3. Two grit tapering diamond.
4. Finishing strips (Diamond strips)
5. Gingival retraction cord
6. Local anesthetic
Facial reduction
Depth orientation grooves
The 1.6mm diameter depth cutter is placed on the gingival half of
the tooth parallel to the gingival plane and depth orientation grooves are
prepared in depth. Diamond is to be moved from mesial to distal aspect.

The 2.0mm diameter depth cutter is placed on the incisal half of the
tooth, parallel to the incisal plane and depth orientation grooves are
prepared. This will create a dual convergence of the labial reduction to
preserve the anatomical form of the labial surface.
Tooth structure remaining between the depth orientation grooves is
then removed with a round end tapered diamond. This will create long
chamber margin or two-grit tapering diamond can be used as it provides a
rough enamel surface for retention and finer grit at the lower end will
create a definitive polished finish line to enhance the seal.
Inter proximal reduction
Depth can often be as great as 0.8-1mm, since the enamel layer is
thick towards proximal surface. The facial reduction using the round end
tapered diamond is continued into the proximal area being sure to
maintain adequate reduction. It is made sure that the diamond is parallel
with the long axis of the tooth. This will guarantee a parallel surfaces of
the tooth. 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 separation of the dies without
damaging the interproximal finish line.
Reasons to preserve contact area
1.

It is anatomical feature that is extremely difficult to reproduce.

2.

It prevents displacement of the tooth between the preparation and


placement sessions when no provisional restorations are used.

3.

It allows better access for home care techniques.

Sulcular extension
Under normal circumstances it is always advisable to extend the
margin supragingivally or 0.2mm into the sulcus, only under exceptional
cases in which discoloration is excessive, the margin is extended
subgingivally. A rounded 0.3mm chamber serves as an ideal margin
ceramic laminate veneer.
Advantages of supragingival margin
1.

Increased areas of enamel in the preparation.

2.

Simplified moisture control.

3.

Visual confirmation of marginal fit.

4.

Margins are accessible for finishing and polishing.

5.

Access to margins for routing maintenance and dental hygiene


procedure.

Incisal Reduction
There are two techniques for placement of incisal finish line.
1. No

incisal

reduction

or

preparation

of

lingual

surface,

restoration ends at the facio-incisal angle.


2. Incisal wrap: The laminate terminates on a lingual chamber.

the

As porcelain is stronger in compression than in tension, wrapping


the porcelain over the incisal edge and terminating it one the lingual
surface

places

the

veneer

in

compression

during function.

Incisal

reduction should provide a ceramic layer of at least 1mm in thickness, a


thicker layer of 1.5-2mm for canines.
Indications of incisal w rap
1. The incisal thickness is too thin to support the veneer.
2. A lengthening of the incisal edge 1.0 to 2mm is desired.
3. Facioincisal margin is visible and unaesthetic.
4. Incisal enamel is structurally compromised.
5. The incisal is subject to functional stress.
Lingual reduction
The instrument is held parallel to the lingual surface with its end
forming a slight chamber 0.5mm deep. The finish line should be
approximately t h the way down the lingual surface, preferably 1.0mm
from the centric contacts and connecting the two proximal finish lines.
Besides placing the porcelain under compression lingual extension
will also enhance the retention.
Tissue management
Gingival retraction can be done just prior to tooth preparation in the
cervical

margins

in

cases

when

the

finish

line

is

placed

0.5mm

subgingivally. Otherwise it is done during the impression mating try-in


stage and for the final positioning of the restoration. During cementation
placement of retraction cord prevented contamination of the cervical
margins with sulcular fluid and facilitated the finishing of the cervical
margin.
Impression procedure
An accurate impression is required for the fabrication of precise
restoration. The impression is normally made with a standard fixed
prosthodontic impression material such as polyvinyl siloxane as they have
excellent accuracy, remarkable mechanical properties and good stability.
The syringe material is placed on the prepared teeth and gently
spread so that the entire preparation is covered and no air bubbles exist.
After applying the syringe material a tray is filled with putty and is kept
in place.
Temporarization
Temporaries in case of laminates are unnecessary as there is no
exposure of dentine hence no sensitivity and the proximal contacts are
maintained hence no drifting of the adjacent teeth.
Two methods of fabricating are
1. Direct method
2. Indirect method

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.
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.
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.
Try-in
Try-in is a three stage procedure
1. The intimate adaptation of each individual porcelain laminate to the
proposed tooth surface.

2. The collective fit and relationship of one laminate to another and


the contact points.
3. Color needs to be assessed.
Stage I
Check for individual fit
The prepared tooth is cleaned with pumise and water using rubber
cups to remove all traces of salivary glycoproteins. Each veneer is trial
seated with a water, glycerin or try- in paste for assessment of color and
fit. Try-in paste is no available with most veneer bonding kits. However,
it is often found that the color of try-in paste does not exactly match that
of the bonding composite, especially after polymerization.
Stage II
Collective fit try-in
The inter proximal contacts must be confirmed by trying in all the
laminate together. Any contact too tight is adjusted using a diamond.
Stage III
Color check
The following factors have varying influences on the color
1. The tooth color
2. The color of the porcelain selected and the number of layers of
opacifiers used.
3. The color and opacity of composite resin luting agent.

The laminate is placed with a try-in paste that does not polymerize
or a small portion of luting composite on the veneer to reseat the veneer
on the prepared tooth to check the color.
Etching the laminate
The labial surface of the veneer is placed on a clay strip and 7.5%
hydrofluoric acid is filled on the inner aspect of the veneer and allowed to
stand for 7 to 10 minute then it is dipped in a 10% solution of baking soda
until the acid is neutralized. Then it is air abraded with 50gm oxide
particles at 20psi air pressure to remove the etched ceramic debris. Then it
is cleaned in detergent solution in a ultrasonic bath.
Enamel etching
The tooth is etched with a 30% - 37% phosphoric acid solution for
10-20 seconds. The tooth surface is checked for a dull, frosted white
appearance of properly etched enamel.
Silanization of laminate veneer
The etched surface of the veneer is treated with a silane-coupling
agent to enhance the adhesive properties of the resin.
Silane coupling agent vary considerably in regard to
1. Their chemical composition.
2. Degree of hydrolysis.
3. How they act during aging.

Some authors postulate a correlation between the degree of silane


hydrolysis and adhesion of the composite.
If the hydrolysis is more the efficiency of coupling agent is better.
Due to aging there is evaporation of the silane agent and failure of
bonding.
For the bonding of composite resin (organic substance) to a
porcelain surface (inorganic substrate) requires modification of porcelain
surface to enhance the compatibility of resin and achieve high bond
strength.
Bonding
The underlying etched tooth surface is coated with multiple
applications of a light-activated enamel-dentin bonding agent which is
gently air-dispersed into a thin layer and polymerized. The silanated
internal surface of veneer is also coated with the bonding agent.
Luting agent
Desirable features for luting materials
1. Thin film thickness, 10-20 micrometer.
2. High compressive strength.
3. High tensile strength.
4. Ability to tint, opaque and characterize.

5. Low polymerization shrinkage.


6. Color stability.
Several manufactures produce customized composites with flowable
viscosity and prepackaged shades with and without added opaque.
Polymerization
1. The greater the time the resin is exposed, the greater the percentage
of cure.
2. The light should contact the resin at right angles for maximum
effectiveness.
3. Darker shade resin and resins with increased opacifiers in them
need an increased amount of time for curing.
4. The distance of the light source to the surface of the resin should
never be more than 1mm.
Curing should be not more than 20 seconds for each surface.
Finishing
Finishing

procedures

are

accomplished

under

x2

or

x4

magnification. Any excess resin is chipped off. Then a microfine diamond


is run along the interface between the veneer and the underlying tooth
surface to remove all excess resin.

Finally a polishing diamond is used to refine the interface of the


tooth/resin/porcelain with help of polishing points.

Post-treatment care and instruments


Initial 72-96 hrs after insertion patient to avoid highly colored
foods, tea or coffee, hard food and extreme temperatures also should
be avoided.
Routine cleaning should be done at least every 4mth ultrasonic
scalers should be avoided.
Soft tooth brush and floss should be used.
Less abrasive tooth paste ad highly fluoridated 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.

Failures of laminate veneers


Classified
Mechanical
Biological
Esthetic

Mechanical failures
Chips
Cracks
Fractures during try-in
Debonding attributed error in bonding procedure.

Biological failures
Post operative sensitivity
Marginal micro-leakage

Esthetic failures
Shade selection is wrong
Visible margins in cases of discolored teeth increases some years
after the placement of veneers.
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.