Topics

Introduction, History, Indications, Contraindications, Advantages, Disadvantages Clinical: Case selection, Treatment planning, Tooth preparation Impression, Die preparation, Provisional/ temporary restorations Lab procedure Cementation/ adjustmentsmaterial aspect
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Clinical: Case selection, Treatment planning, Tooth preparation

Brijesh Maskey,1st year,P.G resident, Department of Prosthodontics and Maxillofacial Prosthetics,PDCH

Contents
Case selection Treatment planning Preparation/non preparation Tooth preparation-basic considerations, principles, step by step preparations,Preparation types Special clinical presentations
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Case selection
Color defects or abnormalities Abnormalities of shape Abnormal structure or texture Malpositioning

 Individual cases:
Diastemata Missing lateral with canines in lateral position Lingual laminate veneer Ceramic laminate veneer over ceramic crown Lengthening
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Treatment planning
Patients confidence

Procedures: Assess coronal/periodontal condition

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 Examine occlusion: ensure restorations free of occlusal stress Single tooth: consider- shape, position, available enamel and occlusion Gingival tissue: poor dental hygiene, gingival inflammation, gingival recession sitestreat before applying laminates
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 Appraising the smile: clinically examine not only the teeth to be restored but also consider face shape, lip size, lip to tooth relationship during various movements

 Diagnostic wax-ups
3D prediction of anticipated outcome Quick, inexpensive

 Computer imaging analysis 2D prediction Color and characterization changesmore life like prognostication

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 Patient education
1. Photographs-full face and profile: albums-before and after 2. Cast models: fabricated sample veneers;effective demonstration

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Preparation/non-preparation
The decision of whether or not to prepare a tooth prior to the fabrication of a porcelain veneer is dependent on three factors:
1. Tooth condition 2. Reason for seeking laminates 3. Predisposition of the dentist
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 Enhance the patient's appearance as much as possible, while keeping tooth modification 1. Minimal 2. Essentially reversible

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 Preparation:
1. Achieve long-term success 2. Maximize esthetics 3. Improve fracture resistance 4. Maintain soft tissue health

Non-preparation:
1. Patients desire can be subsequently understood and treatment modified accordingly 2. No anesthesia required

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 Enamel reduction: improves the bond strength of the resin composite to the tooth surface Unprepared tooth: aprismatic top surface, offering only a minor retentive capacity

M. Peumans, B. Van Meerbeek, P. Lambrechts, G. Vanherle. Porcelain veneers: a review of the literature. Journal of Dentistry: 28 (2000) 163177

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Tooth preparation
Minimal tooth preparation is required Ideal preparation-limited to the enamel but still sufficient enamel thickness must be removed-provide adequate space for a correctly contoured restoration
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 Basic consideration
1. Conservative as possible 2. Allow covering of approximately 0.5mm of porcelain without giving the tooth an overlay thick appearance 3. Limit/not penetrate into dentin if possible 4. Allow for a cleansable gingival margin
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5. Should not include any sharp internal angles esp. at the incisal edgegreatest stresses 6. Allow path if insertion of the veneer, free from undercuts 7. Interproximal clearance: enough for a mylar strip to be placed between adjacent teeth during fusing 8. Visually accessible area of the toothcovered by porcelain

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 Principles of preparation(perfect, functional, biological and esthetic)

Stabilization

Reinforce ment

Adhesion

Retention

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 Armamentarium:
1. Three wheel diamond depth cutter(0.3mm) 2. Three wheel diamond depth cutter(0.5mm) 3. Round end tapered diamond

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 Steps in tooth preparation

1. 2. 3. 4. 5. 6. Facial reduction Proximal reduction Sulcular extension and Marginal placement Incisal reduction Lingual reduction Finishing the preparation
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 Facial reduction
Reduction should be completely in enamel Amount of enamel: incisal half > gingival half Depth orientation grooves(instrument is merely stroked across the labial enamel surface from the mesial to the distal)
Gingival half: 0.3 mm-three wheel depth cutting diamond bur with three 1.6 mm diameter wheels mounted on a 1.0 mm diameter non-cutting shaft Incisal half: 0.5 mm-three wheel depth cutting diamond bur with three 2.0 mm diameter wheels mounted on 1.0 mm diameter noncutting shaft

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 Remove the tooth structure remaining between the depth orientation groove-round end tapered diamond

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 Proximal reduction
Round end tapered diamond Extension of the facial reduction into the contact area just short of breaking the contact Placing margins beyond the visible area Ensure that the bur is parallel with the long axis of the tooth so as to avoid uneven finish line
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 Inter-proximal extension??
1. Improves adhesion of the laminate to underlying tissue 2. Hides the interface between the new veneer and the discolored tooth in a non-visible area

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 Preserving contact point:

1. Anatomical feature-extremely difficult to reproducesaves clinical adjustment of contact areas 2. Prevents tooth displacement between the preparation and placement sessions when no provisional restoration is provided 3. Simplifies try-in procedures/bonding and finishing procedures 4. Allows better access for home care techniques
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 Sulcular extension and Marginal placement

Most desired-within the confines of the gingival sulcus(visible for finishing of laminate and resin luting agent) Subgingival desire: extremely dark tetracycline stained teeth for veneers

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 Desired configuration of the finish line: modified chamfer Provides : 1. Adequate thickness of porcelain for strength without overcontouring 2. Enamel preparation exposing the enamel rods at the correct angle for increased bonding strength during the luting process 3. Definitive seat for positioning the laminate accurately on the tooth 4. An easily distinguishable finish line(impressions and during laminate fabrication) 5. A smooth, finished tooth surface and harmonious form for accurate adaptation of the porcelain to the preparation

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 Incisal reduction
Depth orientation groove- 0.5 mm three wheel depth cutting diamond bur Round end tapered to remove the remaining Atleast 1mm reduction;1.5-2mm in canines and lower incisors
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 Three techniques for placement of the incisal finish line: 1. Window/intra-enamel preparation 2. Overlapped incisal edge preparation 3. Feathered incisal edge preparation

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 Window preparation: most conservative and can withstand axial stress most favorably

Hui KKK, Williams B, Davis EH, et al. A comparative assessment on the strengths of porcelain veneers for incisor teeth dependent on their design characteristics. British Dental Journal 1991;171:515 Gilde H, Lenz P, Furst U. Untersuchungen zur belastbarkeit von Keramikfacetten. Deutsche 32 Zahnartzliche Zeitschrift 1989;44:86971

 Overlapped incisal edge technique:

1. Increase resistance to incisal fracture 2. Improves the translucency of the restoration 3. Provides a vertical stop(aids in the proper seating of the veneer) 4. Places the veneer in compression during function (porcelain: stronger in compression than in tension)
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5. Facilitates changes in tooth position 6. Enables occlusion adjustments 7. Facilitates handling and positioning of the laminate veneer at try-in and, in particular,during bonding 8. Enables the margin to be placed outside the area of occlusal impact
Bernand Touti,Paul Miara,Dan Nathanson. Esthetic Dentistry and Ceramic Restorations. United Kingdom: Martin Dunitz ltd; 1999

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 Feathered incisal edge preparation:

1980s: Preservation of sufficiently thick incisal edge(confined to upper anterior region) Higher rate of fractures

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 Lingual reduction
Round end tapered diamond 0.5 mm slight chamfer was prepared by holding the bur parallel to the lingual surface Finish line: approximately 1/4th the way down the lingual surface, preferably 1mm from the centric contacts, connecting the two proximal finish lines
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 Finishing Remove all sharp angles(focal point for stress concentration) particularly at the junction of incisal angle and lingual surface-round end tapered diamond
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 Reassure by examining thickness, occlusion, path of insertion, shape and position of margins before proceeding to make an impression

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Tooth preparation techniques for porcelain laminate veneers-comparison

Freehand labial reduction(typical of clinical practice)porcelain laminate veneers would tend to be under preparedover-contoured restored tooth
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 Teeth prepared with a silicone index or a depth gauge bur slightly over prepared increased amounts of dentine exposed

P. A. Brunton,A. Aminian,and N. H. F. Wilson.Tooth preparation techniques for porcelain laminate veneers: British Dental Journal, Volume 189, no. 5, September 9 2000

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 Preparation types:
Type I. Minimal Preparation Type II. Incisal Preparation Type III. Over the Incisal Edge Type IV. Over the Incisal Edge with a Lingual Ledge Type V. Maximal Preparation Type VI. Double Preparation
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George A Freedman, Gerald L.Mc Laughlin. Color atlas of porcelain laminate veneers: Ishiyaku Euro America Inc. Publishers: 1st edition; 1990

 Type I: Minimal Preparation

No tooth reduction is undertaken except for that necessary to provide a path of insertion that is free from undercuts knife edge on all its margins

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 Type II: Incisal Preparation

Cut into the incisal edge in such a way as to allow for an even thickness of porcelain as the incisal edge is approached Greater thickness of porcelain at the incisal edge than at the knife edged finish line provided by the Type I preparationshade control
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 Type III: Over the Incisal Edge

The porcelain extends beyond the incisal edge Slight reduction of the lingual aspect of the incisal edge to make room for the porcelain Gingival margin of the lingual porcelainthe laminate ends in a knife edge
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 Type IV: Over the Incisal Edge with a Lingual Ledge

Similar to the Type III preparation: 1. Both extend past the incisal edge of the tooth and wrap around to the lingual surface 2. From the facial aspect,the two preparation types are identical
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 Difference: Gingival porcelain on the lingual is a deep chamfer or even a shoulder

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 Type V: Maximal Preparation

consists of a general reduction of the entire labial surface of the tooth to be veneered Chamfer finish line at the gingival used whenever maximum bulk of porcelain is desired for masking out underlying discolorations, or whenever any increase in labial bulk must be minimized
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 Type VI: Double Preparation

Dentist desires maximum change between the natural color of the tooth and the final shade Preparation consists of two stages 1. First stage: type I preparationimpression 2. Second stage: veneers arrivetry intype V preparation (areas of the tooth requiring maximum change in color)
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Special clinical presentations

Severe discoloration(antibiotics intake, diseases such as fluorosis or dentinogenesis imperfecta)
Two modifications:
Location of the cervical margin: slightly subgingival(0.5mm) More extensive preparation: mask the discolored tooth(0.7-0.8mm incisaly and 0.4-0.5mm cervicaly) 54

 Diastemata
Proximal preparation: more comprehensive; ridges sloped off in a lingual direction Occasionally reduced to a simple slice
Prevents the proximal margins of the veneer from being visible from the front and side

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 Lingual laminate veneers

Lingual addition of artificial enamel configured in various shapes depending on their purpose Eg.canines: appropriate to re-establish disclusionsimple resurfacing
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 Atypical teeth
Pronounced microdontia (eg.lateral incisors):
Preparation limited in depth Encompass virtually the entire available surface Only type requiring fine, knife edge margins
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 Angle fractures
Permanent restorations Shade matching Variation of thicknessdifficult creating the same optical effect

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 Lower incisors
Occlusal reduction=1.5-2.0mm Ridge between the labial surface and the incisal edge-rounded off,check both static and dynamic occlusal relationship Lingual margin-extended to 1/3rd of the way down the lingual surface
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 Premolars
Labial cusp-reduced by at least 1mm(occlusal margin placed away from occlusal contact and grooves) Overlay extension: 3/4th of the labial cusp

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 Dentin zones and caries

Extension of preparation into dentin Not too deep-tubules sealed with new generation adhesives Deeper pitting-modified GIC prior to veneer preparation Caries(proximal/cervical) or old restorations: caries removed and restoration removed; filled with light cured resin modified GIC
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References
Bernand Touti,Paul Miara,Dan Nathanson. Esthetic Dentistry and Ceramic Restorations. United Kingdom: Martin Dunitz ltd; 1999

Herbert. T. Shillingburg,Sumiya Hobo, Lowell D. Whitsett, Richard Jacobi, Susan E.B rackett. Fundamentals of Fixed Prosthodontics.Quintessence book.India:3rd edition.1997
George A Freedman, Gerald L.Mc Laughlin. Color atlas of porcelain laminate veneers: Ishiyaku Euro America Inc. Publishers: 1st edition; 1990

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 Claude R.Rufenacht. Fundamentals of esthetics. Chicago. Quintessence publishers;1990

Barry G.Dale,Kenneth W.Aschheim.Esthetic dentistry-clinical approach to techniques and materials. Lea and Febiger,USA;1993 P. A. Brunton,A. Aminian,and N. H. F. Wilson.Tooth preparation techniques for porcelain laminate veneers: British Dental Journal, Volume 189, no. 5, September 9 2000 63

 Hui KKK, Williams B, Davis EH, et al. A comparative assessment on the strengths of porcelain veneers for incisor teeth dependent on their design characteristics. British Dental Journal 1991;171:515 Gilde H, Lenz P, Furst U. Untersuchungen zur belastbarkeit von Keramikfacetten. Deutsche Zahnartzliche Zeitschrift 1989;44:869 71 M. Peumans, B. Van Meerbeek, P. Lambrechts, G. Vanherle. Porcelain veneers: a review of the literature. Journal of Dentistry: 28 (2000) 163177

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Thank you..
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