MARGINAL ACCURACY OF LUMINEERS VERSUS

TRADITIONAL laminate VENEERS

Thesis Submitted to the

Faculty of Oral and Dental Medicine,
Cairo University

In Partial Fulfillment of the Requirement

for the Master Degree in Fixed Prosthodontics

By
Meral Salah Saleh Nadra
B.D.S
Ain Shams University
2008

Fixed Prosthodontic Department

Faculty of Oral and Dental Medicine
Cairo University
2012
 Supervisors

DR. Hesham katamish

Professor of fixed prosthodontics
Dean faculty of oral and dental medicine
Cairo university

DR. Mona Attia El Agroudi

Assistant professor fixed prosthodontics
Facuty of oral and dental medicine
Cairo University
 Contents
Contents Page No.

 Introduction 1

 Review of literature 3

 Aim of the study 29

 Materials and Methods 30

 Results 73

 Discussion 92

 Summary and Conclusion 104

 Recommendations 107

 References 108

 Arabic summary ‫أ‬

 List of tables
Table no. Title Page no.
1 The ceramic material used in the study 30

2 Composition of ceramic materials used in the study 31

3 Samples grouping 38
Manufacturer’s firing data of the ceramic materials used in
4 56
the study

Horizontal marginal gap results (Mean±SD) for all groups

5 before/after cementation as function of measurement site 74
{measured in µm microns}

Comparison of horizontal marginal gap results between

6 75
Low fusing porcelain and CERINATE porcelain

Comparison of horizontal marginal gap results between

7 76
prepared and non-prepared groups” in µm”

Comparison of horizontal marginal gap results between

8 77
measurement sites (in µm)

Comparison between horizontal marginal gap results

9 78
before vs. after cementation (measured in µm)

Comparison of horizontal marginal gap results between

10 79
groups before cementation (in µm)
Comparison of horizontal marginal gap results between
11 80
groups after cementation (in µm)
 List of figures
Figure no. Title Page no.
1 LUMINEERS placement system kit by CERINATE 32
2 light body lumineers impression material 32
3 Etch ‘N’ Seal 33
4 Tenure A and Tenure B adhesive 33
5 Tenure S 34
6 CERINATE prime and conditioner 34
7 Ultra-bond plus resin cement ”A1” 35
8 Parallelometer 36
9 the tooth in the set epoxy resin block 37
10 three-wheel depth cutter stone 39
11 tapered stone with round end 40
12 Window preparation design for laminate veneers. 41
13 prepared tooth after finishing and roundation of all sharp angles 42
14 prepared tooth after finishing and roundation of all sharp angles 43
15 Precision measuring, electronic digital caliper, china checking the
43
thickness of the finish line after preparation of group1 and 2
16 closer view at the digital caliper tip measuring the finish line
44
thickness after preparation
17 Figure (17), (18), (19): fast set polyvinylsiloxane impression
18 material had been placed in the tray and around the finish line to 45
19 avoid any air bubble inclusions
20 impression before pouring 46
21 die after setting of the dental stone 46
22 wax pattern construction 47
23 spruing 48
Figure no. Title Page no.
24 two sprued wax patterns oriented onto the ring base 49
25 wax patterns inside the silicone ring 49
26 the IPS silicone ring used for investing 50
27 burnout heating furnace 51
28 The EP 600 Pressing Furnace 53
29 the investement ring placed at the centre of EP 600 press furnace 54
30 the investment ring left to cool on the IPS Empress cooling rack 54
31 the investment ring separated at the predetermined mark using a
55
separating disc
32 polishing jet 55
33 Etchant for the Ips Empress Esthetic 57
34 application of the etchant to the Empress veneers 57
35 application of porcelain conditioner 58
36 application of CERINATE prime 58
37 Etching of the enamel surface 59
38 application of tenure A&B to the prepared surfaces 59
39 applying tenure s to the prepared surface 60
40 showing sample in place under the predetermined load of the
62
cementing device
41 application of the resin cement 63
42 Figure (42,43): removal of the excess cement with a brush dipped
64
43 in tenure S.
44 showing Sapphire-Plus light curing unit 65
45 LUMINEERS® Finishing Kit (No. 033897100) 66
46 Showing Bur G cleaning any leftover resin cement 67
47 showing Bur C smoothing out any porcelain ledges 67
48 showing the mosquito diamond bur F refining the interproximal
68
margins
49 showing bur D for final polishong of the LUMINEERS 69
Figure no. Title Page no.
50 showing the polishing cup and paste for polishing 69
51 showing the SEM and accompanying analysis screens 70
52 Screens attached to the “SEM” showing the teeth blocks inside
71
the SEM chamber.
53 Showing teeth blocks fitted on the special mounting device 72
54 Histogram of horizontal marginal gap mean values for all groups
74
before/after cementation as function of measurement site
55 Histogram comparing horizontal marginal gap mean values
75
between Low fusing porcelain and CERINATE porcelain
56 Histogram comparing horizontal marginal gap mean values
76
between prepared and non-prepared groups
57 Histogram comparing horizontal marginal gap mean values
77
between measurement sites
58 Histogram comparing horizontal marginal gap mean values
78
before vs. after cementation
59 Histogram comparing horizontal marginal gap mean values
79
between groups before cementation
60 Histogram comparing horizontal marginal gap mean values
80
between groups after cementation
61 Scanning electron micrograph (x80) showing a gap width at the
cervical margin that is tapering at the sides with maximum width 81
more or less at the mid-cervical margin but it’s not very wide.
62 Scanning electron micrograph (x250) showing comparatively
very narrow gap proximally; noticing that there are unfilled parts
82
along the interface may be due to the very narrow gaps making it
harder for the try-in paste to fill it.
63 Scanning electron micrograph (x250) showing proximal gap
width readings that are emphasizing the previous micrograph 82
readings of the opposite side.
Figure no. Title Page no.
64 Scanning electron micrograph (x80) showing the cervical margin 83
with a homogenous gap width along the cervical margin.
65 Scanning electron micrograph (x250) showing a narrower gap 83
width proximally than in the cervical margin reaching half or less
the gap width readings than the cervical margin, noticing that in
some parts the try-in paste along the interface is not completely
filling the interface leaving unfilled spaces at the interface.
66 Scanning electron micrograph (x250) showing scanning electron 84
micrograph showing a narrower gap width proximally than in the
cervical margin relatively same readings as the other proximal
side.
67 Scanning electron micrograph (x80) showing a very wide, 84
homogenous gap tapering at the sides with the maximum width of
the gap at the middle cervical margin.
68 Scanning electron micrograph (x250) showing a very wide gap 85
noticing an irregular interface between the try-in paste and the
ceramic veneer margin; leaving some unfilled parts at the
interface due to dragging out of the try-in paste during removal of
the excess.
69 Scanning electron micrograph (x250) showing a very wide gap 85
noticing the interface at this side between the try-in paste and the
ceramic veneer margin was more or less smooth. Consistent
readings with no significant variation in the gap width between
the two proximal sides; noticing small gaps at the interface
between the ceramic veneer and the try-in paste due to dragging
out of the material.
70 Scanning electron micrograph (x80) showing relatively narrow 86
gap width tapering at the sides with the maximum width at the
mid-cervical region. with little insignificant unfilled grooving
along the interface.
Figure no. Title Page no.
71 Scanning electron micrograph (x250) showing narrow gap width 86
that is totally filled with no grooves along the interface.
72 Scanning electron micrograph (x250) showing narrow gap width with 87
no significant difference between both sides. The readings are relatively
having the same gap width as the other proximal surface of the tooth
”Figure (73)” indicating the homogeneity of the pressure the ceramic
veneer was subjected to during cementation.
73 Scanning electron micrograph (x80) showing narrow 87
homogenous gap width
74 Scanning electron micrograph (x250) showing completely filled 88
interface with some disturbance in the cement layer resulting
from the finishing procedures.
75 Scanning electron micrograph (x250) showing homogenous 88
relatively narrow gap width along the interface.
76 Scanning electron micrograph (x80) showing relatively narrow gap 89
width that is more or less homogenous.
77 Scanning electron micrograph (x250) showing irregular interface gap 89
widths, noticing that the ceramic veneer is not well adapted on the tooth
surface leaving furrows along the whole interface.
78 Scanning electron micrograph (x250) showing irregular interface 90
gap widths along the proximal margin as the previous
micrograph; noticing there is no significant difference in the
readings along the interface on the two sides. In addition to the
presence of the furrows along the interface indicating no good
adaptation between the ceramic veneer and the tooth structure
79 Scanning electron micrograph (x250) showing homogenous gap width 90
but with bulging excess cement at some parts indicating that some parts
have been abraded along the interface.
80 Scanning electron micrograph (x250) showing a more or less 91
homogenous gap width with readings relatively similar to the other side
indicating the equal pressure during cementation.
 List of Diagram
Diagram Page No.

 Diagram (1): diagram showing the window

42
design of laminate veneers

 Diagram (2): a diagram showing the cementing

62
device components
 Review of literature

Review of literature

The demand for tooth-colored restorations has grown

(1)
considerably during the last decade . This overwhelming trend
has been both a bane and a boon to the dental profession. As the
world nowadays strives towards perfection and excellence,
Esthetics and beauty have also gained importance and
professionalism in dentistry (2).

Cosmetic dentistry nowadays have become a necessity for

everyone in the dental profession; noticing that Changing trends,
concepts and treatments for dental disease have made it
necessary to diversify dental services.(2)

Recent modifications and advances in the techniques of

bonding porcelain to enamel created the possibility of the porcelain
veneers to become an alternative to the use of full crowns in
treatment of many clinical situations such as diastemas, worn
dentition, chipped teeth, malaligned and excessively discolored
teeth. Veneers were considered to be a more conservative
approach because its preparation was thought to involve less tooth
reduction than full crown preparations. Although this is technically
true it was actually found that the traditional porcelain veneer
preparation procedures needs aggressive tooth reduction similar to
the three-quarter crown preparations (3).

This conventional approach requires local anesthesia,

considerable treatment time and temporaries are needed to be
fabricated in most cases, so after all it was concluded that the
traditional porcelain veneer preparation were still aggressive. This

3
 Review of literature

urged dental companies to find a less aggressive approaches that

copes more with the” minimally invasive dentistry “. (3)

This led finally to a truly conservative approach in the world

of porcelain laminate veneers referred to as the “ no-prep
technique”, this technique is characterized by minor adjustments of
enamel in selected locations or in many cases no preparation of
teeth at all preserving the natural tooth structure. (3)

The no prep technique was made possible by advances

in custom-designed bonding systems and in porcelain materials
which are of high strength allowing it to be fabricated
into exceptionally thin veneers in the range of 0.3-0.5mm.
knowing that this thickness range there is no need to cut down bulk
of tooth structure to accommodate the thickness of the porcelain
veneers. (3)

CERINATE LUMINEERS that are considered one of the best

following the no prep technique introduces an alternative to
traditional veneers that can be easily marketed and implemented to
a versatile age group. The advantages of this system are that the
LUMINEERS can be made as thin as a contact lens and may be
placed over existing teeth without having to remove healthy tooth
structure. In cases where tooth reduction is necessary, it can be
kept conservative. These properties attract many seniors who may
be concerned about complications with their medications to local
anesthetic or about general health during a routine dental
procedure. (4)

4
 Review of literature

Introduction of laminates as an effective esthetic alternative

has overtaken all the conventional options and specially its
conservative approach in its preparation will always make a
sensible dentist to think before going on to any alternative esthetic
procedure.(2)

History of laminate veneers :

“Charles Pincus” a California dentist in 1938 first invented

teeth ceramic veneers that were thin-facings of air-fired porcelain
attached to sound teeth with adhesive denture powder to mask the
unesthetic teeth of actors and actresses but it was debonding
shortly after placement as denture adhesives bonded it. (5)

(6)
Later In 1982 Simonsen and Calamia had modified the
technique as they discovered that porcelain can be etched using
hydrofluoric acid and bond strengths could be achieved between
composite resins and porcelain that were predicted to be able to
hold porcelain veneers on to the surface of a tooth permanently
(7)
and that was confirmed by Calamia in an article describing a
technique for fabrication, and placement of Etched Bonded
Porcelain Veneers using a refractory model technique In 1983,
(8)
whereas Horn described a platinum foil technique for veneer
fabrication.

Kihn and Barnes,1998 evaluated the clinical longevity of

a brand of porcelain veneers and its accompanying cementation
system in a study using fifty-nine porcelain veneers that were
pepared and placed in 12 patients by one practitioner and
was evaluated using modified ryge criteria at baseline and 12
months. They found that Over the past 20 years veneers were

5
 Review of literature

constructed using various techniques and materials such as direct

composite resin, preformed acrylic laminates and laboratory
fabricated acrylic resins, microfill composite resins, porcelains and
glass ceramic veneers. (9)

Preformed acrylic laminates and composite veneers were

(9)
found to discolor and develop surface stains overtime .
Composite resin veneers undergo surface abrasion and softening
caused by solvents present in some mouth rinses, toothpastes and
alcoholic beverages. (10,11,12)

The introduction of the porcelain veneer brought about many

advantages and solutions not only for the dentists and dental
technicians but also for patients as well; because of its peculiar
properties as it’s strong, durable, esthetically pleasing maintaining
their color stability and do not harm the peridontium (9). Along with
the innovations in the types of porcelain used in fabrication of the
veneers; Bonding agents and adhesive systems are being
developed as well in order to reach the ultimate bond between the
tooth structure and porcelain leading to more durable restorations,
superior bond strength, marginal adaptability and therefore better
esthetics. (13)

The majority of teeth receiving porcelain laminate veneers

should have some enamel removal, usually about 0.5mm that
allows for the minimal thickness of porcelain(14). Christensen
1991(15) states that the optimal amount of enamel that should be
(16)
removed is 0.75mm however, according to patroni et al 1992
the extent and thickness of the enamel gingivally in anterior teeth

6
 Review of literature

doesn’t permit a reduction of 0.5mm without exposing dentine,

which may be a cause of postoperative sensitivity.

While Natress et al. 1995(17) in an in vitro study examining

the depth of preparation and the incidence of dentin exposure
resulting from a freehand technique to prepare maxillary central
incisors for porcelain veneers. It was found that in case of freehand
preparation the proximal and cervical enamel was reduced more
than 0.5mm and exposure of dentin was inevitable in majority
of cases.

Paul et al. 1997(18) proposed the application of the dentin-

bonding agent immediately after completion of tooth preparation;
as this technique may prevent bacterial leakage and dentin
sensitivity and was associated with improved bond strength in vitro.

Regarding the incisal preparation for porcelain veneer there

are three basic techniques used the window technique, the
(14,15)
overlapped incisal edge and the feathered incisal preparation
There was a debate on which type would result in less stresses
and occlusal load on the veneer but as a conclusion it was found
that if strength is the primary concern the most conservative
preparation design would be using the window design. (19)

(20)
Dhawan et al. 2003 conducted a study to assess to both
clinical and scanning electron microscopy of porcelain and ceromer
resin veneers,the study was proposed as ceromer resin was
expected to provide a cost effective modality alternative to
porcelain veneers . the study was done to evaluate the surface
finish and esthetic quality clinically and by scanning electron
microscope as well at 12 months period. Seventy-two veneers, 36

7
 Review of literature

porcelain and 36 ceromer resin veneers were placed in 12 patients

and were luted with opal luting composite and scotchbond multi
purpose system and the SEM assessment was made by
quantitative analysis of the marginal fit of the two veneering
materials.it was found that although ceromer exhibited a good
anatomiacal form during the study period there were changes in
color, surface appearance, marginal adaptation, increased
marginal discoloration, and tissue response. Inability to achieve a
good finish with high gloss was a major drawback of the ceromer.
Porcelain exhibited better esthetics, marginal adaptation, finish
qualities, and tissue response. The SEM showed good to excellent
marginal fit at baselinne in ceromer and porcelain veneers, but loss
of luting resin at the margins was evident in both the materials after
12 months, leading to visible gaps in a number of veneer
restorations. Ceromer veneers exhibited poor surface
characteristics in several restorations, which further degraded in
oral conditions over 12 months.

(21)
DiTolla 2005 carried out a study “Prep & No-prep
Comprehensive Porcelain Veneers Techniques” concluded that
Although material should not determine the amount of preparation
of tooth structure that will be removed, Traditional porcelain
veneers materials that have been used in the past 30 years needs
a specific amount of tooth preparation according to the type of
porcelain used to give the sufficient bulk to the porcelain to
maintain its strength. This brought about some drawbacks like
cutting through dentin causing postoperative sensitivity in most
cases.

8
 Review of literature

During the past 25 years, there has been an ongoing debate

regarding the preparation techniques used for porcelain veneers.
(7)
Calamia 1983 and other early pioneers looked at veneers as a
noninvasive, additive process and worked primarily with a no-
preparation concept but it didn’t meet the success because of the
type of porcelain used back then wasn’t strong enough.

As porcelain laminate veneers became one of the most

common if not the first choice when considering esthetic bonded
restorations because of its natural translucency and its ability to be
manipulated in laboratories creating a beautiful transition of colors
that mimics the polychromatic nature of natural tooth structure and
because of the fact that glazed porcelain was found to be the most
biocompatible dental material in the oral cavity; these made the
porcelain the best candidate for constructing a natural looking
durable, functioning and strong laminate veneers that last for long
years.(22)

Tooth preparation for porcelain veneers has undergone

a cyclical evolution. It began in the early 1980s with minimal or no
preparation, progressed to more aggressive tooth reduction in the
1990s, and today, has returned to very little, if any, tooth reduction
when possible. (23)

Ceramics overview:

In an article reviewed by Font et al. (24) about the choice of

ceramic for use in treatments with porcelain laminate veneers.
Ceramics can be classified according to their composition into two
main groups, silicate ceramics and oxide ceramics. Silicate
ceramics are further classified into feldspates and alumina

9
 Review of literature

porcelains. feldspates in which silica oxide is the predominant

component 46-66% versus 11-17% alumina are sub-classified into
conventional feldspate porcelain and the high resistance reinforced
feldspate porcelains.

The low fracture resistance of the conventional feldspate

porcelains which reaches 56.5 Mpa urged the evolution of the
higher resistance reinforced feldspathic porcelain that lead to
diversification of the present dental porcelain materials used.either
the leucite reinforced feldspathic porcelain or the lithium di silicate
reinforced feldspathic.

Porcelain which reaches 300-450 mpa respectively are the

most widely used porcelain nowadays specially for porcelain
laminate veneers. As a result of the pressing process used to
manufacture the leucite reinforced feldspathic porcelain, the
porosity is reduced and adequate and reproducible fit precision is
achieved. The perfect distribution of the leucite crystals within the
glass matrix observable during the cooling phase and after
pressing, contributes to increase resistance without significantly
diminishing translucency.(24)

Glass ceramics consists of glass matrix phase and at least

one crystal phase that is produced by controlled crystallization of
glasss. It’s available in castable, machinable, pressable and
infiltrated forms which is used in all types of ceramic
restoration.(25,26)

The pressable glass ceramic is the type that involves

pressure moulding in the manufacture process. Heat pressed
ceramics were introduced in dentistry in the early 1990s; in which

10
 Review of literature

the restoration is waxed, invested and pressed in a manner

somewhat similar to that of gold casting. Ceramic ingots are
pressed at high temperature over a 45 min. period into a refractory
mold made by the lost-wax technique. Two finishing techniques
can be used; characterization technique and the layering technique
which lead to a translucent ceramic core with advantages of
moderately high flexural strength, excellent fit and esthetics. The
first generation of the heat-pressed ceramics was leucite-based
e.g. IPS EMPRESS 1 (SiO2-AL2O3-K2O), while later generations
involves the use of lithium disilicate e.g. IPS EMPRESS 2 (SiO2-
Li2O) (25,27).

IPS EMPRESS was released in the market in the early 1990s

this material was used to fabricate veneers, inlays, onlays and
crowns, the chemical composition was based on the SiO2-AL2O3-
K2O system and the microstructure consisted of homogenously
dispersed leucite crystals (KALSi2O6) embedded in a glassy
matrix(28)

IPS EMPRESS ESTHETIC was recently introduced after that

as an improved product that offers a more homogenous
microstructure where the leucite crystals are more evelnly
distributed with increased density and smaller grain size with
subsequently enhanced esthetics, it consists of highly esthetic
reinforced glass-ceramic with a chemical composition of more than
98% SiO2BaO,AL2O3,CAO,CeO2,Na2O,K2O,B2O3,less than 2% TiO2
and pigments;it has been clinically tried and tested for years being
characterized by excellent strength values and outstanding esthetic
appearance and thus it’s used in fabrication of all ceramic
restorations such as inays,veneers and crowns.(29)

11
 Review of literature

(30)
MCLAREN 2009 did a research reviewing different
classes of ceramic materials in which it was found that ceramics
and dental porcelain with its different classes in dentistry have
been invading the field of esthetic dentistry in the past 25 years
with an overwhelming modifications in the microstructural
components and processing techniques in order to enhance the
properties for the good of the patients.

It was concluded that Properties of ceramics may differ

greatly according to the microstructure of each type of porcelain, it
can be very translucent to very opaque affected by many factors
such as the ratio of the non-crystalline glassy microstructure to the
crystalline structure which if it’s high gives a more opaque type of
porcelain, additionally Porcelain particle size, particle density,
refractive index and porosity are also contributing factors in
different properties of different ceramic materials.

According to the Microstructural components of porcelain,

ceramics can be classified into four major categories, category
1,which is a glass based system containing mainly silicon dioxide
with various amounts of alumino-silicate glasses called “feldspars”,
category 2 which is the glass based systems with fillers that differ
according to the type of crystals that have been added or grown
within the glassy matrix, category 3 is the crystalline based
systems with glass fillers and the fourth category is the
polycrystalline solids.(30)

Pressable ceramics were manufactured to be extremely

dense and demonstrating much higher strength ratings such as
flexural strengths up to 180 MPa and due to this improved strength

12