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Sem8smiledesign 170319130512
Sem8smiledesign 170319130512
Introduction
Definitions and classification
Esthetic diagnosis and treatment planning
Esthetic sequencing
Perceptual aspects – the art of illusion
Process of smile design and analysis
Esthetic contouring
Esthetics with composites
Esthetics with ceramics
Conclusion
INTRODUCTION:
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Scottish physiologist Charles bell (1774-1842) was quoted as remarking that the
thought is to the word that the feeling is to the facial expression.
The focus of dentistry in the present times is not only the prevention and
treatment of diseases but on meeting the demands for better esthetics.
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DEFINITIONS:
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Dental Esthetics
Cosmetic dentistry
is application of the principles of esthetics and certain illusionary
principles, performed to signify or enhance beauty of an individual to suit the
role he has to play in his day-to-day life or otherwise.
Smile designing
Is a process whereby the complete oral hard and soft tissues are studied
and evaluated and certain changes are brought about which will have a positive
influence on the overall esthetics of the face. These changes are governed by the
principles of esthetic dentistry
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CLASSIFICATION OF SMILE:(Solomon)
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papilla smile
Gingival smile
Mucosa smile
Straight smile
Convex smile
Concave smile
ESTHETIC DIAGNOSIS & TREATMENT PLANNING:
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1. Patient history :-
Information should cover aspects of -medical history- allergic, systematic
disorders , pervious surgeries e.t.c
Dental history- past dental experiences , apprehensions, expectations
e.t.c
Personal and social history
2. Clinical examination :-
TMJ :-
Palpated and auscultated for clicking
Crepitus
Hypermobility
Deviation
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OCCLUSION RELATIONSHIPS:-
Occlusal pattern
Type
Contacts
PERIODONTAL ATTCHMENT:-
Plaque
Calculus
Gingival inflammation
Amount of attached gingiva
Recession
Hyperplasia of gingiva
TEETH:-
Caries
Existing restoration
Discoloration
Wear facets
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TOTAL SMILE ANALYSIS:
Total smile analysis is a cumulative interference analysis, drawn by
interpreting and integrating various analysis like a visual, space profile
and computer analysis after performing the preliminary analysis.
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SPACE ANALYSIS:
help to gauge the amount of space available during the treatment planning
stage(measure the widths of all teeth and to compare it with the space present
in the arch).
Disproportionate space may be due to discrepancies in jaw and tooth size,
malformed teeth, missing teeth, malaligned teeth, etc
Corrections of labiolingual inclinations and rotations of teeth by restorative
procedures will result in a change in the width space ratio due to the change of
angulation involved.
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PROFILE ANALYSIS:-
straight orthognathic – normal profile.
Any deviation from this should be recorded and considered in treatment
planning.
Examination of the profile could be in the antero-posterior plane or in the
vertical plane.
COMPUTER ANALYSIS:-
Radiographic and photographic assessments can be used. Computer aided
technology has broadened the utility of radiographs and photographs in the
dental field.
They give enlarged images of the photographic and radiographic outputs on the
screen without the involvement of any hard copies of photographs or
radiographs with multiple magnifications & at various angles.
Esthetic enhancement with a change of arrangement , form , shape or color can
be demonstrated quickly.
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COMPONENTS OF AN
ESTHETIC SMILE
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During a relaxed 'ideal smile', the upper lip exposes the cervical aspects of the
maxillary anterior teeth.
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• Treatment modalities depend on the type of pathosis,
• hyperplastic gingivae gingivectomy or crown lengthening
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Vital Elements of Smile Design- Dental Components
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Axial inclinations
Interdental contact
Embrasures
SPA
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A slanted mid line, or a dental
mid line that is placed obliquely
in relation to the facial mid line,
will always distort the
symmetry, even placed in
exactly the correct position.
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INCIAL LENGTHS( EDGE POSITION) :
IMPORTANT PARAMETERS
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Degree of tooth display
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• In teeth with both angles fractured, this can serve as a guide in deciding
placement of incisal edge.
‘S’ or ‘Z’ sounds determine the vertical dimension of speech. Its pronunciation
makes the maxillary and the mandibular anterior teeth come in near contact
and determine the anterior speaking space.
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TOOTH DIMENSIONS
CENTRAL DOMINANCE dictates that the centrals must be the dominant teeth
in the arch and they must display pleasing proportions.
The shape and appearance of the centrals influences the placement of laterals
and canines.
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GUIDELINES FOR CORRECT PROPORTIONS…
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M PROPORTION (methot)
It has been applied to a lot of ancient Greek and Egyptian architecture and
may be expressed as the ratio 1.618:1.
If the ratio is applied to the smile made up of the central, lateral incisor and
the mesial half of the canine, it shows that the central incisor is 62% wider
than the lateral incisor which in turn is 62% wider than the visible portion
of the canine which is the mesial half, when viewed from the front.
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RECURRING ESTHETIC DENTAL PROPORTION (ward)
• The successive width proportions when viewed from the facial aspect should
remain constant as we move posteriorly from midline.
• This offers greater flexibility to match the tooth proportions to the facial
dimensions.
• M PROPORTION
• CHU’S ESTHETIC GAUGE Computer software
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INDIVIDUAL TOOTH DIMENSIONS…
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Note :-
MAXILLARY BICUSPIDS-
Important role in arch design
Fill the buccal corridor
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BUCCAL CORRIDOR
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In an esthetic smile there is what has been termed negative space, which is a
small space between the maxillary posterior teeth and the inside of the cheek.
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Interdental contact areas & points
the '5 mm rule', states that when the distance from the contact point to the
interproximal osseous crest is 5 mm or less, there is complete fill of the gingival
embrasures with an interdental papilla.
For every 1 mm above 5 mm, the chance of complete fill is progressively reduced
by 50%.
Black triangle
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Interdental contact area can be moved apically to close the
gap
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GINGIVAL ZENITH OR HEIGHT OF CONTOUR:
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INCISAL EMBRASURES
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The lips frame the teeth and gingiva. The gingiva frames the teeth. The ratio of
tooth structure to the amount of gingival and labial tissue should be
harmonized to prevent an over-dominance of any one element.
Gingival Line :
GAL- gingival aesthetic line – the ideal gingival line from the cuspid to the
central incisors intersects the dental midline at an angle >45° but <90°.
The key esthetic issue is that the gingival line for the anterior teeth should be
relatively horizontal to the horizon and relatively symmetric on both sides of
the midline.
In an esthetic smile, the volume of the gingiva from the apical aspect of the free
gingival margin to the tip of the papilla is about 40% to 50% of the length of
the maxillary anterior tooth and fully fills the gingival embrasure.
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Image demonstrating the measurements
of the ideal gingival scallop, with the
percentages showing the papilla length relative
to tooth length.
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Periodontal biotype and bioform
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The thin periodontal biotypes are friable, escalating the risk of recession
following crown preparation and periodontal or implant surgery.
This is particularly significant for full coverage crowns for the following
reasons.
1. Mock up - with soft tooth colored wax or composite resin- Direct composite
resin placement along with the use of intraoral markers ( provide a visual three
dimensional means for the patient to see the final result prior to committing to
treatment). The functional movements in the mouth can also be checked at this
time to determine any occlusal obstruction or difficulties.
2. Diagnostic wax-up or study casts- This wax up can be evaluated by the
patient directly on the diagnostic casts of the articulator and also intraorally with
the use of acrylic overlays and acetate matrices.
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COLOR:
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ability to stimulate the cells in the retina which is interpreted by the brain,
discerning the sense of colour.
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CHROMA - in Munsell’s words, “it is the
quality by which we distinguish a strong
color over weak ones”. Human teeth fall into
the yellow to yellow red area of the Munsell
color order system. Pale colours have a low
chroma whereas intense colors have high
chroma.
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Principles of Shade Selection
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Vita Classic
Vitapan 3D –Master
2. Chroma Selection
3. Value Selection
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Hue selection has been made (B)
Chroma is selected from gradations within the B tabs
B1, B2, B3, B4
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OPACITY & TRANSLUCENCY:
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Opaque objects reflect all or most of the light that is incident on them
whereas transparent objects transmit all of the light that is incident on
them.
Translucency, in effect is the three dimensional facial relationship or
representation of value.
Highly translucent teeth tend to be lower in value, since they allow light to be
transmitted through the teeth, while opaque teeth have higher values.
To mimic natural teeth the effective use of restorative materials should largely
depend upon mimicking the translucent or opaque effect.
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METAMERISM:
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The change in color perception of two objects under different light sources is
called metamerism.
This can be attributed to the difference in the radiant energy of two different
wavelengths of light. The standardization of lighting condition during shade
matching diminishes the effect of metamerism.
FLUORESCENCE
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GLOSS-
Gloss is an optical property associated with a smooth surface that produces
lustrous surface appearance and reduces the effect of color differences.
PERCEPTUAL ASPECTS - THE ART OF
ILLUSION
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• The most important of these is the perception that light approaches and dark
recedes. This is termed as “principle of illumination”.
Horizontal lines make the objects appear wider and vertical lines make the object
appear longer. This is termed as the principle of line.
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Narrowing illusion
Widening illusion
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Lengthening illusion
Shortening illusion
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LAW OF TOOTH FACE:
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The face of a tooth is that area on the facial form on both anterior and
posterior teeth, that is bound by the transitional line angles as viewed
from the facial i.e.., labial or buccal aspect.
These transitional line angles mark the transition from the facial surface
to the mesial, distal, cervical and incisal surfaces.
The tooth surface slopes lingually in the mesial and distal region while it
slopes cervically from the line angles towards the root surface.
The apparent face should be manipulated, not the actual face. This is
more importantly in the canine and the posterior as the “apparent face”.
The transitional line angles are relocated so that the apparent face looks
equal.
Similar faces produced attract light and appear highlighted while the
dissimilar areas that are in a shadow appear to recede.
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ESTHETIC CONTOURING
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INDICATIONS CONTRAINDICATIONS
Alteration of tooth structure Hypersensitivity of teeth.
Correction of developmental
anomalies Large pulp canals
Minor orthodontic problems Thin enamel
Removal of stains & discolorations Deeply pigmented stains
Periodontal problems – trauma
from occlusion Occlusal interferences
Bruxism Susceptibility to caries
Reshaping & rounding of the Extensive anterior crowding &
corners of CI & LI to give more
youthful look. occlusal disharmony
TECHNIQUES OF ESTHETIC RECONTOURING:
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Achievement of illusions
If the grooves are placed more apart illusion of more wide teeth can be
created & vice versa.
If there is dark pigmentation in the periphery and light in central portion
of the facial aspect of tooth an illusion of narrow teeth can be created.
Angle of correction
A lower incisor that actually or apparently, extends above the lower incisal plane is quite
noticeable.
The angle of view is important specially in shaping lower teeth. Because of the angle of
view, an anterior teeth which is in linguoversion appears to be much more prominent
than the one in labioversion.
To contour the tooth in linguoversion, its incisal edge should be beveled lingually.
Reduction
reshaping of the natural dentition must always be in relationship to the lip position in
both speaking and smiling.
In rare cases it may be necessary to desensitize the tooth - sodium fluoride or a dentin
sealer.
with the use of water, it is often possible to see a slight color shift before the enamel is
completely penetrated. The last few layers of enamel are more translucent so that the
yellow dentin becomes more visible. Enamel removal should be stopped as soon as color
shift is observed and hopefully before
Anterior teeth in the lower arch should be shortened only to the level where they still
occlude in protrusive movements.
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Reduction is accomplished by carefully shaping
the marked areas with the bulk reduction
diamonds except for the lower anterior teeth.
Bulk reduction in these teeth should be done
with fine finishing diamonds at high speed.
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ALTERATION OF TOOTH FORM:
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A canine that has drifted or been repositioned into the space of an extracted or a
congenitally missing lateral incisors can sometimes congenitally be reshaped to resemble
the missing tooth.
Another example is to remove the part of the lingual cusp and reshaping of the labial
surface of a first bicuspid so that it resembles a cuspid.
PEG SHAPED LATERALS: Treatment
options
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ESTHETICS WITH COMPOSITES
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This has opened many avenues for the use of these materials for esthetic
benefits in cases that probably could not be treated effectively or at all in their
absence.
The results with these materials are quick, esthetic, economical, repairs
are easy and the material does not require unnecessary tooth reduction for
their placement.
In most instances the final results are all in the control of the dentist without
the involvement of laboratory technicians thus providing the dentist an
opportunity to exhibit his skills.
BENEFITS OF DIRECT COMPOSITES:
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1. elimination of decay,
2. function and longevity and
3. esthetic predictability.
The facial form of all anterior teeth can be divided into various facial planes,
which converge or diverge from each other.
These planes reflect or refract light and give a texture to the facial surface.
The areas between any two planes are relatively prominent and hence
extensions of the margins of the preparation should be kept away from those
prominent areas.
When the caries involves the labial surface of the EFE, follow the general
guidelines explained earlier, following the facial planes.
In such cases the labial unsupported enamel is reduced and the composite
is extended on the facial surface.
If the carious lesion is large , then a full facial veneer preparation may be
the best option for optimal esthetic results.
During the placement of composite in the proximal areas, a mylar/metal strip
is placed between the preparation and adjacent tooth while acid etching and
bonding.
A small amount of flowable composite is placed along the wall and cured.
A layer of an opaque hybrid composite is placed more on the palatal half of the
restoration and also in conditions where palatal wall is absent.
This blocks the path of light passing through and through giving a grey
translucency to the restoration
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CLASS III RESTORATION
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Shade selection for the class III composite can be both time consuming and
frustrating.
The major problem is choosing the shade that will actually match after you
have inserted and finished the restoration.
Typically, the first thing you do is place a sample of intended material on the
tooth to be restored.
Those, including chipped or fractured teeth, are one of the top reasons for using
composite resins.
Frequently bonding is the ideal solution, providing both an immediate answer to
an esthetic emergency and a long term, low cost restoration.
CLASS V RESTORATIONS
The quickest and the most economic method of obtaining an esthetic tooth
transformation is through the direct resin labial veneer.
The best candidate for the direct resin veneer is the monochromatic shaded
tooth, since multicolored restorations are much more easily constructed in the
laboratory.
Minor malalignment can be corrected with minimal reduction of tooth
structure by changing the tooth form in the preparation design to allow the
composite restoration to recreate the desired form.
In some of the cases, the preparation design resembles the one made to treat
the minor fractures.
The most difficult tooth to be treated is marked and may be the ultimate guide
on which the corrective treatment may be used, as it gives an idea of the
limitations within which the dentist has to give an esthetic final result.
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PLACEMENT OF COMPOSITE FOR DISCOLOURED
TEETH
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The dentist has to consider the masking of the dentin surface not only at the
facial surface but at the cervical margins and incisal edges.
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PLACEMENT OF COMPOSITE FOR
CLOSING SPACES
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cases where the size of teeth is normal and a diastema still exists, restorative
creations using principles of illusion is recommended.
Boundaries of these space are assessed apico-coronally and mesio-distally as
they will differ with the location of the interdental papilla and the proximal
contours of the teeth.
These closing spaces in such cases may pose a challenge as the dentist may
have difficulty to maintain the tooth form, tooth preparations as well as allow
good gingival contours for favorable gingival response.
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When diastema is small (2mm) – no tooth
preparation required.
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Diastema are filled in one teeth at a time. Acelluloid matrix is effectively used
to get the desired contour.
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Overlapping/ mal-aligned central
incisors:
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This straightens the portion that overlaps the adjacent tooth and makes the long
axis of teeth more parallel to each other.
The incisal embrasure between the teeth is reopened to at least 0.25 to 0.50mm
length.
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ESTHETICS WITH CERAMICS
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In many dental practices, the ceramic crowns and bridges are one of the most
widely used fixed restorations.
Metal ceramic and all ceramic restorations have excellent esthetic potential.
All ceramic restorations are characterized by a dentin like core which makes it
possible to mimic the translucency of natural teeth.
They are biocompatible with the gingival tissue and exhibit excellent marginal
fit due to newer thermoplastic processing while some exhibit wear resistance
similar to enamel.
PRE-OPERATIVE ANALYSIS
The position of the cingulum and occlusion will help to determine the extent
of preparation. X-rays help in determining the pulpal morphology and
crown-root ratio.
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INDICATIONS OF METAL CERAMIC CROWNS
Tooth requiring full coverage with high demand for esthetics.
Retainer for fixed partial denture.
Extensively destroyed teeth as a result of caries, trauma, or existing
previous restorations with a need for superior retention and strength.
Need to re-contour axial surface or correct minor malocclusions.
CONTRAINDICATIONS
Patients with active caries or untreated periodontal disease.
Young patients with large pulp chambers.
When an intact buccal wall is present.
When the use of more conservative retainer is possible.
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ADVANTAGES
Combines the strength of all metal crown with the esthetics of an all
ceramic crown.
Excellent retentive qualities as axial wall is included.
Easy correction of axial forms.
DISADVANTAGES
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ALL CERAMIC RESTORATIONS:
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Indications
Contraindications
Disadvantages
Reduced strength compared to metal ceramic crowns.
Proper preparation extremely critical
Least conservative preparation.
Brittle nature of material.
Can be used as single restoration only
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Goals for achieving maximum esthetics…
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INDICATIONS:
Discolorations
Enamel defects
Diastema
Malpositioned teeth
Faulty / poor restorations
Aging
Wear patterns
Malformed lateral incisors
CONTRAINDICATIONS:
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TYPES …
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1. Directly fabricated veneers- These are composite resin materials applied to the
tooth surface free hand by clinician.
Full veneers- Indicated for the restoration of the generalized defect or area of
intrinsic staining involving the majority of the facial surface of the tooth.
PORCELAIN LAMINATE VENEERS:
103
ADVANTAGES: DISADVANTAGES:
Color Time
Bond strength Repair is difficult once luted
Periodontal health to enamel
Resistance to abrasion Technique sensitive
Inherent porcelain strength Difficulty in color
modification
Resistance to fluid absorption
Tooth preparation
esthetics
Fragility of porcelain
Cost is high
104
The crafting of an ideal smile requires analyses and evaluations of the face, lips,
gingival tissues, and teeth and an appreciation of how they appear collectively .
Such an ideal smile depends on the symmetry and balance of facial and dental
features. The color, shape, and position of the teeth are all part of the equation.
Recognizing that form allows function and that the anterior teeth serve a vital
role in the overall health and well being of the patient is paramount.