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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
Direct resin composite veneer technique
```  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
Longevity of direct resin composite veneer
Functional survival rate 100% | Overall survival rate of 84.6% after 5 years
27
Indirect composite veneer technique
``` 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
Questions for dentist to decide
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
Advantages of indirect over direct composite veneers
 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
Porcelain laminate veneers consists of 4 components
 A porcelain veneer  An acid-etched enamel surface  A silane coupling agent  A resin cement
31
Advantages of porcelain laminate veneers
```  Superior aesthetics  Excellent long term durability  Strength  Marginal integrity  Soft tissue compatibility  Minimal tooth reduction ```
32
Disadvantages of porcelain laminate veneers
 Time consuming – multiple appointments required  Fragility  Repairability difficult  Colour matching can be a challenge  Irreversibility  Inability to trial cement the restoration
33
Porcelain technology
 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
Veneer prep - to prep or not to prep
 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
Tooth preparation
```  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
Preparation types
 Window preparation  Long bevel  Complete veneer coverage
37
Different preparation designs
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
Evidence for veneer designs
 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
Temporisation
``` Aesthetics Reduce sensitivity Diagnostic  Contour  Shape  Length ```
40
Types of temporaries
 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
Cementation
 Veneer becomes an integral part of the tooth structure  Share part of applied loading stresses during masticatory cycle  Light cured composite luting agent
42
Try in stage
``` 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
Preparing veneer for cement
 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
Silane coupling agent
```  Apply to internal etched surface  Chemically bonds to ceramic  Makes ceramic surface hydrophobic ```
45
Cementation | -material
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
Cementation | -procedure
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
After cementation
Check occlusion | Finish with polishing strips
48
Failure
``` Fracture – especially with:  Unfavorable occlusion  Parafunction  Bonding to existing restorations Microleakage/marginal staining Debonding ```
49
3 types of veneer fracture
Static Cohesive Adhesive
50
Static fracture
Segment of veneer fractures but remains of tooth | Due to excessive loading or polymerisation shrinkage
51
Cohesive fracture
Within body of porcelain due to tensile loads from excessive functional or parafunctional loading Results in loss of fragment
52
Adhesive fracture
Failure of bonding interface | Due to weak bond or severe occlusal loading
53
Debonded veneer
 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
Occlusion before veneers
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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