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Porcelain Veneer Procedure

This is a two appointment procedure which requires some minor irreversible tooth preparation. It does however produce the strongest, most trouble-free, most esthetic and long-lasting conservative restoration. These procedures are not recommended if the patient does not wish to have the teeth minimally prepared or wants immediate results. There is usually a two week period between the preparation phase and the cementation appointment.. First Appointment (VENEER PREPARATION PROCEDURE) Shade Selection- Clean teeth with pumice and water to remove any extrinsic stains which exist. Select a tentative shade with your patient participating. Most patients want there teeth to be light. Many veneers are made with B1 porcelain since it is easier to darken the veneers when bonding than it is to lighten them. The B1 porcelains have the most scattering and can block out the darkest stains. It is much easier to establish the final shade in the porcelain rather than trying to modify the shade with the cement. Tooth preparation- For normally aligned teeth that require only moderate color changes, a uniform 0.5 mm intraenamel reduction is sufficient. The preparation is performed with a medium grit, round-end tapered diamond. Depth cuts can be made prior to the preparation procedure to aid in uniform reduction. Depth limiting burs or #2 round (1/2 depth) can be used to establish 0.5 mm depth. If there are misaligned teeth they can be recontoured and brought into better alignment through the preparation. Preparing into dentin is not a real problem to bonding. There are some considerations with respect to sensitivity before veneers are seated. A composite temporary may be required. Sometimes all the misalignment cannot be prepared out without encroaching on the pulp. Some misalignment can be corrected in the veneer buildup. Generally the preparations are extended to the gingival crest and into the interproximals without breaking contact. Is useful to lightly strip the interproximals with a diamond strip to facilitate removable die fabrication for some laboratory techniques. Sometimes the proximals can be carried through the interproximals to cover proximal composites. This will make the prepared teeth look obviously different when the patient smiles. Be prepared to have to make temporaries if this type of preparation is used. If the existing proximal composites are small it is easier to replace them and treat like tooth structure than to cover with ceramic. On proximal surfaces of veneers next to crowns, when closing diastemas, or for veneer bridge abutments, the finish lines should extend to the linguoproximal line angle of the tooth. This will allow for a transition from veneer to tooth.

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The placement of the incisal finish line is controversial. If the teeth are not worn and the length does not need to be altered it is easiest to end the margin at the facio-incisal line angles. Some lab studies have

2 shown that this is an area of less stress and may have less of a tendency to fracture. However clinically, veneers rarely fracture regardless of where the margin is placed. For teeth that require lengthening, the incisal edge is merely smoothed of any rough areas and sharp angles. No extensions onto the lingual are required. 0.5 mm of edge coverage is minimal and no more than 1.5 mm is max. There are three ways to manage incisal edge coverage. no incisal edge coverage- easiest to manage, requires provisionalization less because there is less dramatic change in appearance. cover incisal edge less stress on internal aspect of veneer if rounded, less chance of die abrasion, I use on centrals and laterals most for unworn teeth wrap around incisal edge- this technique used more when significant wear already exists and B-L width is thick. Also provides some mechanical retention for longer extensions (>1.5mm) The gingival margin is placed initially at the free gingival margin. Once the preparation is complete, unmedicated retraction cord is placed in the sulcus. Even the unmedicated cord usually causes the tissues to recede slightly. Once the cord is placed the margins are refined apically to just above the level of the cord. This will assure that the final margin is at or slightly below the free gingival margin. Often hemostatic agents are not required with these procedures. If it is required, it is best placed after all the cords are in place so that all the tissues experience the agent for the same period of time. Impression- The retraction cord should be left in place if possible during the impression. Usually the cord is apical to the gingival margins and leaving it in place guarantees hemostasis and allows for another impression to be taken immediately if the first fails. It is best to use a polysiloxane or polyether material for the impression since multiple pours are often needed for the laboratory procedures. Placing soft wax or putty in the lingual embrasures prior to taking the impression will minimize tearing of the impression in these areas. Shade selection- The shade of the teeth after preparation should be evaluated and recorded. Confirm that the shade you and the patient desire is as was selected initially. Photographs of the teeth with the shade tabs held up to them will aid the technician in determining the type and shade of porcelain required to achieve the desired shade. Temporary Veneers- A great majority of patients do not require that temporaries be placed. If they are necessary or desired, they are hand sculptured using composite, kept supragingival, out of heavy occlusion, and attached by spot etching the enamel in the center of the tooth away from any margins. Other methods can be used which include acrylic type indirect methods. whichever method is used, it is a time consuming procedure which needs to be considered when deciding on a fee. Between appointments

3 Lab Prescription- The lab prescription should be very specific concerning the type of veneer material, length of veneer, degree of opacity, shade, thickness etc. Photographs can be extremely helpful to the technician. It is important that you let the technician know how much of a color change you are trying to achieve either by shade or photograph with shade tabs visible. Etching and silanation can be done at the lab but must be specified. Veneer assessment on casts. Veneers are somewhat fragile, and should be handled carefully. Check accuracy of fit - the gingival margin is critical and must fit accurately. Gross adjustments for overcontours can be done prior to cementation but care must be taken. The fit of the veneers will vary from laboratory to laboratory depending on the quality and technique used to fabricate the veneers. The hot pressed technique and refractory die technique tend to fit better than the foil technique but this can vary. The fit of each veneer is evaluated individually. Check inside of veneer for uniformity of etch and contaminants. The etched surface should look frosty. The Empress material has a much less obvious etched surface than conventional porcelain. Check proximal contacts- The proximal contacts are checked with all veneers in place to make sure that complete seating occurs. The contacts can sometimes prevent complete seating and need to be adjusted. Check marginal contours- The contours are evaluated particularly at the gingival area to assure they are not overcontoured. This can be adjusted after cementation on veneer systems that are not surface color modified. Systems which use surface color modifications need to be adjusted in these areas prior to cementation and reglazed and stained. Second Appointment (VENEER CEMENTATION PROCEDURE) Remove temporary- The temporaries are removed if they had been previously placed. The most common method of temporization is with direct composite and these are spot etched on the mid facial. These temporaries sometimes need to be cut off and care must be taken not to damage margin areas of preparations. Making a groove in the center and prying the two segments apart usually works. Clinical try-in. Evaluate fit and esthetics.-All veneers should be placed without bonding medium on teeth to assess the fit. Contacts need to be carefully assessed to make sure one veneer does not prevent the seating of another. Contacts are carefully adjusted with a fine diamond and high speed or flexible diamond disks. Proximal contacts can be adjusted but occlusal adjustments are best done after final cementation. Try in with K-Y jelly or glycerin as the trial adhesive. This will simulate cementation with a clear bonding cement and optically connect the veneer to the tooth. Most of the time this is adequate for tryin particularly with multiple veneers. Single veneers sometimes require shade modification with tints and modifiers or shaded cements. If multiple restorations are being done, make sure all restorations are tried in to verify proximal contact relationships and insure full seating. Check marginal fit at this time. Fit checker can be used if restoration does not fully seat and contacts have been assessed. Mock-up with Try-in pastes. If the shade of cement is drastically different than the natural tooth structure or the porcelain, a cement line will be visible. Ceramic materials can be translucent and will

4 take on the color of the surrounding tooth structure or made to be opaque to block out underlying tooth structure. Trial color modification with tints and composite cements may be used in some cases but I like staining ceramic for major esthetic changes and then cement with translucent cement. With the Empress and other pressable systems surfaces stains can be removed during adjustment and finishing. Preparing the restoration for cementation. Clean the restorations with acetone or Cavilax if you have tried it in with resin based systems. If you have used only water soluble medium (glycerin, K-Y jelly, Try-in pastes) you need only to rinse. It is a good idea to clean with enamel etchant (35% phosphoric acid) to help clean any salivary contaminants that may have come in contact with the bonding surface. Etch. Most of the time the laboratory has etched the restoration. Visually reevaluate the quality of the etched surface (frosted look). If the restoration has not been etched, etch with porcelain etchant (porcelain conditioners- 10% HF acid). The time of etch depends on the ceramic materials used. (Porcelain > 3min Empress < 1 min.). Apply Porcelain Primer or Silane Coupling Agent. We use a prehydrolized silane which means you do not have to mix two components (usually contained in cementation kit (Nexus, Kerr) The porcelain primer is a silane coupling agent that is applied with a brush. The coupling agent acts to wet the surface of the porcelain. The silane coupling agent is allowed to set on the surface (usually for at least 60 sec but some are shorter periods). It can be dried with a gentle stream of air. Do Not Rinse. Set prepared veneer in a lightproof box until ready for cementation Prepare tooth for bonding. Isolation. Rubber damn isolation is usually not practical for multiple anterior cementation techniques. Cotton roll isolation and an assistant are usually sufficient for cementation. Clean all tooth surfaces with rubber prophy cup and pumice/water mixture or chlorohexidine soap/pumice mixture and rinse thoroughly. Place clear Mylar strip between involved adjacent teeth to minimize etching and placement of adhesive and cement on the adjacent unbonded teeth . This will also expedite removal of excess composite in the embrasures and leave a smooth finish in the interproximal area.. Do two veneers at a time. The sequence I usually use is: both centrals first, then lateral and cuspid on one side and finally the lateral and cuspid on the opposite side. Etch the preparation. The enamel is etched for 15-30 seconds with 35% phosphoric acid. Gel etches are easier to control. Rinse the tooth thoroughly to make sure no etchant remains and air dry with air syringe or high evacuation. NOTE: Most systems now use dentin/enamel bonding agents so bonding to areas of exposed dentin no longer require separate applications of primers.

5 Adhesive is applied to the surfaces of the preparation. In the Nexus system this layer is air thinned and cured prior to cementation. In other systems this layer may be left to cure during the cementation. Read Directions carefully! Final resin cementation. Apply the cement (Nexus, Kerr) to the preparation and the surface of the veneer with a brush or plastic instrument. Light cured materials are used for cementation since the veneers are extremely thin and transmit enough light. Some restorative composite materials can be used for cementation and are preferred by some clinicians since they make cleanup easier but they require significant amounts of pressure to completely seat. Most cementation kits now contain two viscosities of cement. I like to use a high viscosity for veneers. Seat the restoration with firm finger pressure and hold in place while the excess cement is removed with a sable brush. Light cure veneer from the facial surface for at least 60 seconds. You cannot overcure these restorations. Cure from lingual surface if the incisal edge is included in the restoration. Finishing and polishing procedures. Remove excess set bonding material with a #12 Bard-Parker blade and/or sharp carvers. These instruments will not damage ceramic surfaces and will minimize hard tissue damage. Keep instruments stable against restoration and tooth surface to minimize soft tissue damage. Recontouring and occlusal adjustments of the porcelain are done with a fine diamond and high speed using water coolant. Any surface which has been modified with a finishing diamond needs to be polished. If no marginal discrepancies were present between the tooth and ceramic, finishing can be initiated with finishing carbides, discs and rubber points. This will minimize any alterations to the ceramic surface and thus minimize finishing time Porcelain Finishing Sequence: 1. Extra fine diamonds 2. 30 fluted finishing burs 3. Shofu polishing points (no stripe[coarse], yellow stripe[med], white stripe[fine]) 4. Diamond polishing paste and prophy cup