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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
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
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.
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.
2.
3.
4.
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.
2.
3.
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.
2.
3.
4.
5.
Incisal Reduction
There are two techniques for placement of incisal finish line.
1. No
incisal
reduction
or
preparation
of
lingual
surface,
the
places
the
veneer
in
compression
during function.
Incisal
margins
in
cases
when
the
finish
line
is
placed
0.5mm
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.
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.
procedures
are
accomplished
under
x2
or
x4
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.