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Intermediate restorative skills (Den 305) > Laminate veneers > Flashcards

Laminate veneers Flashcards

1
Q

Beautiful smile often regarded as sign of

A

Good health
Youth
Good social status
Success

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2
Q

Not very attractive smile can in some cases affect one’s

A

Personality… and in effect

  • sociability
  • sociality
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3
Q

‘I don’t like the appearance of my teeth’ - ask

A 
What is it you don’t like?
How long have you had this problem?
Why has it occurred?
Has it improved or worsened?
How would you like your appearance altered?
Look and listen to pt
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4
Q

Look and listen to your pt

A

Assessment of the type of patient helps you to
understand how the appearance is affecting their life
e.g. self image, expectations
The cause of the problem may be preventable – thereby avoiding extensive treatment
Explanation of the cause leads to the reassurance of
pt and > confidence in dentist

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5
Q

Different perceptions - pt will see their teeth every morning in bathroom mirror

A

Different countries have different cultures
50yr old dentist could have different perception of good dental appearance to 25yr old dentist
Pt’s decision not that of dentist - dentist acts as guide only

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6
Q

What is a veneer?

A

A veneer is a layer of tooth-colored material that is applied to
a tooth to restore localized or generalized defects and
intrinsic discolorations.
Improve shape, colour, position
A thin facing fabricated either by ceramic or composite material
It is the most conservative and aesthetically pleasing
direct or indirect restoration

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7
Q

Indications for veneers

A

Colour defects or abnormalities
-i.e. amelogenesis imperfecta, medication, fluorosis, age, trauma, extrinsic staining with infiltration of tissues
Abnormalities of shape i.e. microdontia, atypical tooth shape, malformed incisor, retained deciduous teeth
Abnormal structure or texture i.e. dysplasia, erosion, attrition,
abrasion, coronal fracture
Malpositioning – rotated teeth, change of angulation
Diastema
Missing teeth i.e. lateral with canine in lateral position
Lingual laminate veneers; correct anterior guidance, create canine guidance, palatal erosion
Lengthening – proportions, volume of unsupported ceramic

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8
Q

Contraindications for veneers

A

 Insufficient surface enamel
 Pulpless teeth; fragile teeth, liable to change colour in time
 Unsuitable occlusion i.e. pronounced overbite
 Parafunction i.e. bruxism, nail biting
 Unsuitable anatomical morphology i.e. too small clinical
crown, outstandingly triangular teeth
 Single laminate veneers? Very difficult to match with
neighbouring teeth especially if very discoloured
 Heavily restored dentition; caries and fillings present
In relation with..
 Poor OH

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9
Q

Examination and assessment

A 
Problem?
Pt?
Oral health?
Teeth in question?
Quality and quantity of enamel?
Occlusion?
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10
Q

Treatment planning

A 
Listen to pt describing their aesthetic problem
Take a full history relating to problems
Determine causative factor(s)
-hereditary
-systemic
-traumatic
-parafunction
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11
Q

Tetracycline discolouration

A

Brown banding chronologically when teeth were developing

Need quite opaque veneers to cover

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12
Q

Solitary discolouration due to trauma

A

Could be pinkish

Need internal bleaching first

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13
Q

Abrasion or attrition

A

E.g. with rope, metal held between teeth, tooth surface loss

Composite or veneer?

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14
Q

Detailed clinical examination

A

OHI, caries, failed restorations
Periodontal status
Endodontic status
Smile analysis
Occlusal analysis - centric, protrusive, lateral
Must not coincide with veneer margins
Placement of margins on occlusal marks will cause resin to wear and unsupported ceramic to eventually fracture or chip

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15
Q

Assessment of face

A

Not just teeth!
Shape of face, lips, maxillary and mandibular lip lines
Skin colour e.g. sun tain
-skin will change colour in future
-veneers that look bright and high in value against tanned skin will look more yellow and lower in value as skin becomes lighter

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16
Q

Smile analysis

A 
View from front and sides
-shape of face
-size of lips
-visible coronal and gingival levels - at rest, talking, broad smile
Harmony and proportion
-of cervical line
-of line of incisal edges
-of lip line
Tooth colour
-hue
-value
-chroma
-translucency
-texture and luster
Tooth shape
-size of tooth (height : width)
-incisal edges
-contour
-assessing triangular tooth shape
Analysis of static and dynamic occlusion
-centric - ICP
-protrusive
-left and right excursions
Spatial arrangement of teeth
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17
Q

Treatment planning: demonstrate the proposed aesthetic changes before and after

A 
 Diagnostic wax up
 Direct placement of composite resin, NO etch or bond to
assess outcome
 Temporary composite resin restorations
 Diagnostic wax up + matrix + Protemp
 Resin composite shell or overlay on diagnostic cast – place
intraorally
 Computer imaging
 Demonstration models
 Photography
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18
Q

Treatment planning: evaluate and discuss all possible treatment options

A

 Advantages and disadvantages of each option
 Informed consent – post op sensitivity, marginal
discolouration, fracture, debonding
 Short and long term maintenance
 Financial implications
 Do not make a decision at the very first appointment

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19
Q

Veneer preparations are dependent on

A 
 Method of fabrication
 Occlusion
 Desired aesthetics
 Any parafunction
 Presence of enamel at all proposed margins
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20
Q

Veneer can be made of

A

Resin composite

Porcelain (ceramic)

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21
Q

Direct resin composite veneer indications

A

 Extensive damage to incisal or buccal surface
 Defective restoration
 Discoloration not amenable to bleaching
 Mal-aligned teeth - patient doesn’t want orthodontics
 Congenitally deformed teeth
 Patient does not have time or finances for indirect
porcelain veneer
 Where indirect porcelain veneer would require excessive
tooth structure removal

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22
Q

Direct resin composite veneer contraindications

A

 Inability to obtain correct shades to blend with
adjacent teeth
 Inability to obtain correct contours
 Inability to obtain correct surface characteristics
 Inability to obtain proper isolation
 Multiple teeth due to the extensive time and
difficulty in achieving consistent shade, contours & surface characteristics

23
Q

Advantages of direct resin composite veneer

A

 Very little or no tooth preparation required
 Many composite wear similarly to natural tooth
structure and do not cause iatrogenic wear of opposing
dentition
 Chairside repairs
 Can be made either at the chairside or in the dental lab

24
Q

Disadvantages of direct resin composite veneer

A

 Colour stability? Composite takes stain from
environment
 The result is not as long lasting as porcelain alternative
 Strength; not as strong as ceramic
 Wear; it wears more compared to ceramic

25
Q

Direct resin composite veneer technique

A 
 Veneers are made by dentist at the chairside
 One appointment only needed
 Minimal or no preparation required
Armamentarium
 Colour modifiers
 Resin composite; microfilled, hybrid
26
Q

Longevity of direct resin composite veneer

A

Functional survival rate 100%

Overall survival rate of 84.6% after 5 years

27
Q

Indirect composite veneer technique

A 
Minimal preparation
0.25 – 0.5 mm tooth reduction – case dependent
Resin cement for cementation
Bonding procedure similar to porcelain veneers
A variety of systems exist
 Artglass
 Belleglass
 Sculpture
 Targis
 Paradigm MZ100 (CAD/CAM)
28
Q

Questions for dentist to decide

A
  1. Alternative treatments?
    e.g. orthodontics, crowns,
    implants, surgery etc
  2. Pre-treatment?
    e.g. bleaching, crown
    lengthening, restoration
    replacement etc
  3. Which veneer preparation?
29
Q

Advantages of indirect over direct composite veneers

A

 Reduced polymerisation shrinkage
 As a result a smaller marginal gap created
 Reduced marginal leakage, sensitivity, recurrent
caries, staining
 Physical properties of composite have been found to
improve with additional curing
 Better control over interproximal contours and
contacts
 Less technique sensitive than direct one

30
Q

Porcelain laminate veneers consists of 4 components

A

 A porcelain veneer
 An acid-etched enamel surface
 A silane coupling agent
 A resin cement

31
Q

Advantages of porcelain laminate veneers

A 
 Superior aesthetics
 Excellent long term durability
 Strength
 Marginal integrity
 Soft tissue compatibility
 Minimal tooth reduction
32
Q

Disadvantages of porcelain laminate veneers

A

 Time consuming – multiple appointments required
 Fragility
 Repairability difficult
 Colour matching can be a challenge
 Irreversibility
 Inability to trial cement the restoration

33
Q

Porcelain technology

A

 Feldspathic e.g. Mirage II
 Leucite reinforced e.g. Empress I, Cerinate
 Lithium disilicate e.g. Empress II / Emax
 Glass infused e.g. InCeram
 Cast glass e.g. Dicor

34
Q

Veneer prep - to prep or not to prep

A

 Reversible
 Painless?
 Overcontoured?
 Margins?
 Hygiene?
 Gingival inflammation?
 High failure rates?
Stress concentration is less on veneers fitted to
prepared teeth
Preparation also removes aprismatic and
hypermineralised enamel layers which are more
resistant to acid etching
Should aim for preparation to be completely in enamel
to maximise resin bond strength and reduce tensile
stress in the porcelain

35
Q

Tooth preparation

A 
 Minimal preparation
 0.3 to 0.5 mini chamfer
 0.6 to 0.8 for incisal and
buccal reduction
 Facial reduction in 2
planes
 Special bur kits available
 Remember depth
grooves/pits
36
Q

Preparation types

A

 Window preparation
 Long bevel
 Complete veneer coverage

37
Q

Different preparation designs

A

Extension of preparation over incisal edge was proposed to > strength of veneer-tooth
Intra-labial or ‘window’ – useful in canine guidance,
Class II Div II and Class III incisor relationships
 Contained wholly within labial surface
 No temporary restoration necessary
 Minimal preparation

38
Q

Evidence for veneer designs

A

 Conflicting results exist in literature regarding
success of veneers with different prep designs
 Stappert et al. Longevity and failure load of ceramic
veneers with different prep designs after exposure to
masticatory simulation. 2005
 Assessed 3 different preps compared to unprepared tooth – no significant difference found

39
Q

Temporisation

A 
Aesthetics
Reduce sensitivity
Diagnostic
 Contour
 Shape
 Length
40
Q

Types of temporaries

A

 Direct composite build up with spot-etching of enamel
 Chairside – clear matrix made on diagnostic wax up,
then spot etch and Protemp/composite in matrix and placed over multiple preparations
 Indirectly made temps in lab
 Temporisation is not always necessary as reduction is
minimal
 When preps more aggressive and dentine is exposed is
mandatory
 They can also serve as provisionals

41
Q

Cementation

A

 Veneer becomes an integral part of the tooth structure
 Share part of applied loading stresses during
masticatory cycle
 Light cured composite luting agent

42
Q

Try in stage

A 
Resin luting agent
Veneers should be tried in
before cementation to assess fit
and aesthetics
Try in paste used for this stage
 Water soluble
 Matches cement
 Optical contact
Handle veneer with extra care
as very fragile
Use of veneer carrier
43
Q

Preparing veneer for cement

A

 Veneer surface treated with HF acid
 Clean the fitting surface of veneer with acetone to remove
try in paste
 Treating the surface with phosphoric acid has been found
to improve the bonding
 Rinse and dry
 Silane application and keep away from light

44
Q

Silane coupling agent

A 
 Apply to internal etched
surface
 Chemically bonds to
ceramic
 Makes ceramic surface
hydrophobic
45
Q

Cementation

-material

A

Variety of resin cements exist in the market
nowadays e.g. Variolink II, Calibra, Nexus
Standard material – translucent
Also more opaque available for discoloured/dark teeth

46
Q

Cementation

-procedure

A

The procedure includes:
 Etching of tooth surface
 Bonding agent
 Resin cement
Veneer carrier – avoids handling and avoids too much pressure during placement
Too much pressure during placement will cause the veneer to crack
Veneer must be held in 2 planes during initial palatal
polymerisation
If veneer not held firmly during initial polymerisation then suck back occurs causing gaps at margins
Resin spaces can be caused by insufficient luting resin and incorrect sequence of seating multiple veneers

47
Q

After cementation

A

Check occlusion

Finish with polishing strips

48
Q

Failure

A 
Fracture – especially with:
 Unfavorable occlusion
 Parafunction
 Bonding to existing restorations
Microleakage/marginal staining
Debonding
49
Q

3 types of veneer fracture

A

Static
Cohesive
Adhesive

50
Q

Static fracture

A

Segment of veneer fractures but remains of tooth

Due to excessive loading or polymerisation shrinkage

51
Q

Cohesive fracture

A

Within body of porcelain due to tensile loads from excessive functional or parafunctional loading
Results in loss of fragment

52
Q

Adhesive fracture

A

Failure of bonding interface

Due to weak bond or severe occlusal loading

53
Q

Debonded veneer

A

 Must determine which bonded interface has
failed
 If luting agent still on tooth – due to inadequate
etching of veneer or no silane coupling agent
 If luting agent still on veneer – problem with bonding
materials, placement technique or bonding substrate,
more likely when predominately to dentine

54
Q

Occlusion before veneers

A

Occlusal movements marked - must not coincide with veneer margins
Placement of margins on occlusal marks will cause resin to wear and unsupported ceramic to eventually chip and break

Intermediate restorative skills (Den 305) (16 decks)

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