INTRODUCTION

A person's inner self is reflected in their smile. The elegance of a person's

character is crowned by a radiant smile that harmonises with the lips, face and teeth. (1)
A smile is one of the best ways to express friendliness, agreement and gratitude. By
enhancing first impressions in interpersonal relationships, an attractive or appealing
smile clearly improves an individual's acceptance in our culture. A crooked smile may
be considered a physical disability. (2)
The terms "aesthetics" and "cosmetic" are both
derived from the Greek words "aesthesia," which means "sensation or sensibility" and
"kosmos," which means "adornment." Dental aesthetics was defined by Pilkington in
1936 as "the science of copying or harmonising our work with that of nature in order
to make our art inconspicuous."(3)

Teeth in the cosmetic zone have a big impact on how a person's smile looks.
Any deficiency in these teeth, whether in colour, shape or orientation can detract from
the smile's overall appearance. (4)The well-being of a patient is enhanced by a lovely
smile and harmonious facial aesthetics. The end outcome of a cosmetic procedure
should be as close to the patient's wishes as possible, thereby enhancing the patient's
facial aesthetics and smile.(5)

Restorative cosmetic dentistry should be done with the utmost caution. (6) For a
long time, full crowns were used to cover discoloured, defective, or deformed anterior
teeth. This procedure, however, results in substantial tooth structure loss.(7)

Laminate veneer is a treatment for a discoloured front tooth for aesthetics and
structural purposes..(6)

Modern advances in dental materials offer practitioners a variety of ways to

make veneers that look more natural and pleasant for aesthetic restorations.
Perfection in anterior restorations promotes the dental professional's abilities.
(9)

Patients can easily assess the dentist's ability to develop teeth that have a normal
geometric shape and colour that match the neighbouring teeth in order to obtain
pleasing cosmetic outcomes.(10)As we enter a new era of laminate veneers, this library
dissertation enlightens and emphasises on veneer materials, methods, techniques, and
recent advances.

1
INDICATION

As a result of advancements in technique and materials, the indications for

Laminate veneers (LV) have gradually changed. (50,3)

 Changes in tooth morphology –

 Mild to moderate diastemas

 Elis class IV Fracture–

 Enamel alterations

 Alterations in tooth color

 Repair of crown or bridge fractures

 Teeth with intrinsic / extrinsic discoloration

 Mal-aligned teeth which can be corrected by invasive method

 Multiple carious lesions and decalcifications.

 Attrition / abrasion / erosion.

 Trauma / fracture of multiple anterior teeth.

 Aging - For discoloured teeth or attrited teeth due to aging, improvement can
be done by bleaching or bleaching with subsequent veneering.

 Attrition and abrasion: If enough enamel remains and the desired length
increase is not too great, porcelain veneers can be cemented to the remaining
tooth structure to modify form, colour, or function.

 Agenesis of lateral incisor.

 Smile design

2
 CONTRAINDICATIONS

 Teeth having less enamel.

 Deciduous teeth.

 Severe attrition, as a result of para-functional habits.

 Severe periodontal involvement with severe crowding.

 Poor oral hygiene.

 Inability to etch the enamel in excessively fluoridated teeth.

 Patients with high caries rate

 Severe deep bite. (3)

DIAGNOSIS AND TREATMENT PLANNING

It is more important to spending time in the diagnosis and planning phase

helps to improve treatment predictability and execution efficacy.(52)

During the clinical examination, the facial aspects, the smile harmony, the
gingival contour, and the dental characteristics were evaluated.(52)

EXTRA ORAL EXAMINATION:

It is important to assess

 Shape of the face,

 Skin color,

 Symmetry,

 Maxillary and mandibular lip lines.

Patients with a narrow face may desire veneers with long and narrow teeth to
emphasize the facial shape or round and short teeth to soften the narrowness of the
face. Veneers appear brighter and high in value – dark skin and appear yellow and
low in value as the skin tone becomes lighter. (3}

3
INTRAORAL EXAMINATION

It is important to assess the shape, form, color of the teeth and the orientation
of the maxillary incisal edge in respect to the lower lip, the amount of gingival display
when smiling and speaking, and the overall quality of the smile should all be noted by
the dentist. When smiling, the smile line should align with or follow the curve of the
lower lip in an ideal teeth arrangement. The smile zone is the area of the mouth where
the teeth and tissues (inferior border of upper lip, superior border of lower lip) are
visible when smiling. Smile zones can be classified into the following types namely -
straight, curved, ellipse, bow, rectangular and inverted. This is helpful is assessment
of the smile.(3)

Prosthodontists, periodontists, orthodontists, and dental technicians must

coordinate and address the various treatment phases to get the desired clinical
outcome.(53)Any esthetic restoration requires an evaluation using a diagnostic guide.(54)

The treatment plan included impressions, diagnostic casts, and diagnostic

wax-ups. In difficult clinical cases, patients were provided with pretreatment
simulations. Diagnostic waxings help the dentist, the patient, and the lab technician
communicate more effectively. Prior to treatment, all patients received oral hygiene
prophylaxis and instructions.(55)

New Innovative diagnostic tools are available today that expedite the process
and aid in communication. Internet and video conferencing reach across distances,
while intraoral cameras and transmission of photographs offer information readily
available for viewing, which also saves time while clarifying and illustrating the
patient's condition. Although it does not replace actual communication with the
patient, these diagnostic tools serve as an adjunct to the traditional restorative process.
In order to get an accurate image of the anticipated final restoration, a composite
mock-up should be prepared. The closer the shades, resins and thicknesses are to the
expected final restoration, the better the patient's perception of the final outcome will
be.(56)

4
 SHADE SELECTION

Color has the ability to communicate with people from all walks of life. Color
perception requires an understanding of the colour language. It is frequently
discussed, but frequently misrepresented. It is essential to learn science and art of
colour, to overcome the problems related to shade selection in aesthetic dentistry.(1)

Shade selection for direct and indirect restorations has been a challenge for the
cosmetic dentist.(57) Shade guidelines are matching tools that most dental practitioners
use to identify and communicate color and shade information.

The ideal color match to the adjacent tooth is mandatory not only at the time
of insertion of the restoration but also over a long period of time . Tooth shade
(58)

matching is mostly a trial and error method influenced by clinician proficiency, visual
fatigue, and surrounding light source. Accurate color reproduction with a restorative
material is challenging. Furthermore, patient expectations for the outcomes of the
restorative treatment are often high.

COMPONENTS OF COLOUR;

According to Munsell’s Color Theory, color is usually described in terms of

 Hue,

 Chroma and

 Value.

HUE: signifies the dominant color in the shade that yields the perceived color.
It is signified by A, B, C and D on a Vita Classic Shade Guide.

CHROMA: on the other hand, is the intensity of the dominant wavelength or

the hue. It is represented by numbers on the Vita Classic Shade Guide in such a way
that increase in number represents the increase in chroma. (1)

VALUE (Brightness)is the amount of light that is returned from an object.

Munsell described the value in a white to gray scale that is High value objects have
lower amount of gray and low value objects have high amount of gray. Value of the
crown can be increased by either Reducing the Chroma or increasing the reflectivity

5
of the surface of the crown. If a dye is continuously poured in a glass of water. The
chroma i.e. the depth of the dye will increase with time but the value or the brightness
of the glass will reduce with time. Hence, Value is indirectly proportional to chroma.
(1)

METHODS OF SHADE SELECTION:

1.CONVENTIONAL

2.INSTRUMENTAL

CONVENTIONAL, VISUAL TECHNIQUE USING SHADE TABS:

The visual technique is subjective and is influenced by variables such as the

observer's colour perception, lighting circumstances, translucency, and the material's
optical characteristics. Visual colour matching using industry-fabricated shade
guidelines is the gold standard because the human eye can distinguish extremely
slight colour changes between two objects when compared side by side.

Manual Shade Guides are further divided into

 Hue-Based Shade Guides

 Value-Based Shade Guides

Majority of the commercially available shade guides are Hue-Based and not
Value-Based.

Detecting the Value of any object is the function of the Rod Cells of the
Retina, whereas the Cone Cells are sensitive to color. It is a known fact that Retina
has 120 million Rod Cells compared to 6-7 millions Cone Cells. Hence, human eye is
more sensitive to Value compared to Chroma. Thus, a good value match is much
more important than a perfect hue match. The most widely accepted and used Shade
Guide worldwide is VITA CLASSICAL SHADE GUIDE. It was introduced in 1927
by Vita Zahnfabrik in Sad Sackingen, Germany. It is a Hue-Based Shade Guide that
covers 6% of range of tooth color between it’s 16 shade tabs.(1)

6
The four hues are

 Reddish Brown (A),

 Reddish Yellow (B),

 Grey (C) and

 Reddish Grey (D).

Each of the tabs do not posses any specific value and can be arrange from
Lightest to Darkest. Other Hue-Based Shade Guides are Chromascop Shade Guide
(IvoclarVivadent) and Trubyte Bioform Color Ordered Shade Guide (Dentsply
Trubyte).

VITA classical A1-D4 (VC, VITA Zahnfabrik, Bad Säckingen, Germany)(Fig

4.e) is the most frequently used shade guide system in dental clinics and labs across
the world.

The VC shade tabs are organised empirically, but the VITA-3D Master is evidence-
based. Toothguide (3D) and Linearguide (VITA, which has the same tabs) cover the
colour spectrum of human teeth better, improving the chances of a successful shade
match.

BENEFITS OF CONVENTIONAL METHOD:

 Efficiently compares tooth colour with a standardised reference shade guide,

 Cost-effective,
 Easily accessible. (10)

The currently available tooth shade tabs are

 IPS e. max shade determination (Ivoclarvivadent),

 Vita classical-three-dimensional (3D) master (Vita),

 Portrait IPN shade guide (Dentsply),

 Vintage shade guide (Shofu), and

 Vita Lumina.

7
 The shade tab technique totally relies on human eye observation for choosing
a tooth colour. Under standard conditions, the human eye senses the colour difference
intraorally. The visual shade guide relies on two  variables. They are

 Subjective variable and

 Physical variable.

THE SUBJECTIVE VARIABLES ARE:

 Clinician Experience Variability

 Age
 Eye Fatigue
 Judgment Mood
 Emotional Shifts
 Illusions
 Color blindness

THE PHYSICAL VARIABLES INCLUDE:

 Extreme lighting conditions,

 Type and Intensity of light source,

 Angle of incidence,

 Tooth texture (contour),

 Wall colour, and the patient's and staff's clothing.

Among the commercially available shade tabs, the Vita 3D master shade
guide  is the most common. It provides a superb and consistent colour difference. In
the hands of young dentists, it dramatically increases the reproducibility of the shade-
matching process. The main difference between the Vita classic and the Vita 3D
master is that the Vita classic is based on the color's hue, whereas the Vita 3D master
is based on the color's value. In terms of gender differences, ladies performed much
better than males when it came to colour matching.(59)

8
THE INSTRUMENTAL TECHNIQUE WHICH EMPLOYS COLOUR
MEASURING TOOLS:

Advances in colour measurement systems may reduce subjectivity and

improve the consistency of shade matching and communication.

VITA Easyshade (VITA) is an intraoral contact-type spectrophotometer (Fig. 4.f.)

with integrated, uniform lighting that is unaffected by ambient light conditions.
Across the visible spectrum, it quantifies the quantity of light energy reflected from an
object at 25-nm intervals and sends the data to the International Commission on
Illumination's colour notation system, which can define all visible hues.(59)

In shade evaluation, the Vita Easy Shade (VES) spectrophotometer is more

accurate, dependable, and repeatable than other devices and visual systems.

Device that are used to determine tooth color are

 Spectroshade (spectrophotometer, MHT Optic Research AG, Niederhasli,

Switzerland),

 ShadeVision (digital camera with colorimeter, X-Rite America, Inc., Grand

Rapids, Michigan, USA),

 Vita easyshade (spectrophotometer, Vident, Brea, CA, USA), and

 ShadeScan (digital camera with colorimeter, Cynovad, Montreal, Canada). Fig

4.g.

INTRAORAL DIGITAL SCANNERS:

The incorporation of intraoral scanners (IOS) provides a new digital tool to

assess tooth color. Intraoral digital scanners (TRIOS 3; 3Shape, CEREC AC
OmniCam; Dentsply Sirona, CS 3500; Carestream Dental, and others) have been
increasingly used to make digital scans of dental arches. TRIOS 3 is an intraoral
digital scanner with a shade-taking function( Fig4.h.). There is no standard scanning
method for color detection with a digital scanner. During scanning in clinical practice,
it may be hard to control variables such as scan angle, scan distance, light source,
shadow of surrounding tissue, operator’s experience, and data overwrite due to
redundant scanning.(60)

9
DETERMINING FACTORS FOR SHADE OF RESTORATIONS INCLUDE:

 Restorative material,

 Underlying dental structure, and

 Shade and composition of the resin based luting agent

Light-correcting devices are available to minimize lighting interference and to

allow neutral clarity to assist the visual method of shade matching.

An example is a handheld lamp with light-emitting diode based technology

with a color temperature of 5500K. The device has a light source similar to that of the
internal light source of the most commonly used dental spectrophotometer.

The device corrects for varying light conditions such as the time of day,
season of the year, and type of light sources in the dental office. Such devices reduce
reflected light to allow for a more accurate assessment of dental translucency and
therefore provide more reliable visual shade-matching results.Recently, mobile
application was evaluated for color matching, however the accuracy was inferior to
that of Vita classical shade tab.(59)

VISUAL SHADE SELECTION GUIDELINES RECOMMENDATION:(59)

Position of Clinician:

 The patient should be sitting in an upright position at the clinician's elbow

level.
 Patient-clinician distance of 25-35 cm (arm length) is recommended to reduce
subjective eye fatigue errors.
 The shade should be chosen soon (5-7 s)
 Increase the value of the shade by squint test (partially closing the eye).
Background and lighting conditions:
 Use 18 percent grey card (Kulzer's tiny intraoral grey cardboards, Pensler
shields screen) to diminish background light.
 Dark-colored lipstick should be removed before selecting a shade.
 If the patient is wearing a bright-colored fabric, cover them with a grey drape.
 Choose your shade between 10 a.m. and 2 p.m. in the afternoon.

10
  Use light that has been color-corrected. (Fig 4i.)
 Avoid bright color at the working area.
Comparison of shades

 Clean the selected tooth using prohy paste.

 Shade should be selected before tooth preparation as dehydration reduces the

translucency of the tooth.

 The selected shade tab should be viewed from above or below the tooth to
match and not adjacent to the selected tooth (binocular effect).

 The shade tab should be hold at the incisal edge of the tooth to be matched to
minimize the reflection of the adjacent tooth.

 The selected shade tab should be viewed from different angles (vectoring).

TOOTH PREPARATION

The preparation of the teeth greatly influences the durability and color of the
ceramic restoration, since the tooth preparation will determine the inner superficial
contour and the thickness of the ceramic material. This stage is determined by the
evaluation of the condition of the teeth, the indications of the clinical situation, and
the material chosen (feldspathic or glass ceramic). The desire for more durable
aesthetic outcomes did not confine to improve the material type only; new preparation
designs were introduced to the field of dental veneers.(4)

CLASSIFICATION BASED ON PREPARATION DESIGN AND MATERIAL

TYPE:

According To Preparation Design and Material Type- 4 types of

preparation(61)

1) Window preparation: in which the incisal edge of the tooth is

preserved.Fig.5a.

2. Feather preparation: in which the incisal edge of the tooth is prepared

Bucco-palatable, but the incisal length is not reduced.Fig.5b.

11
 3. Bevel preparation: in which the incisal edge of the tooth is prepared
Buccopalatable, and the length of the incisal edge is reduced slightly (0.5-
1 mm). Fig.5c.

4. Incisal overlap preparation: in which the incisal edge of the tooth is

prepared Bucco-palatable, and the length is reduced (about 2 mm), so the
veneer is extended to the palatal aspect of the tooth. Fig.5d

PRINCIPLES OF TOOTH PREPARATION:

Two major principles governs tooth preparation sounds

• Preparation must be conservative and

• Retention is solely by adhesion rather than tooth preparation.(62)

Armamentarium:

1. Diamond depth cutter with a wheel

2. Round bur,

3. Round end tapering bur,

4. Finishing diamond burs, and

5. Airotorhandpiece(62)

Procedure:

Facial reduction: Since the amount of enamel decreases at the

cementoenamel junction, some teeth permit less reduction at the gingival finish line to
a standard of 0.3 mm and the reduction at the incisal half and incisal edge to a
standard of 0.5 mm. Depth orientation grooves made with diamond depth cutter
(Fig.6a.) and the remaining tooth structure is removed with round end tapered
diamond(Fig.6.b &Fig.6.c). The tip of the diamond establishes a slight chamfer finish
line at the gingiva.(62,1)

Proximal reduction: Proximal extension is just a continuation of facial

reduction with the round end tapered diamond(Fig.6d.). Adequate reduction is
recommended at the line angle and uneven finish line is avoided by keeping the bur
parallel with the long axis of the teeth.(62,1)

12
 Incisal reduction: There are two techniques for the placement of incisal finish
line. The one in which we are terminating our preparation at the incisal edge and the
second technique in which the incisal edges slightly reduced and the porcelain
overlaps the incisal edges. As the porcelain is stronger in compression than in tension,
the wrap around preparation will place the veneers in compression and will provide
better results. The multiwheel diamond burs are used to create 0.5-mm deep
orientation grooves in the incisal edge and the remaining tooth structure is removed
by round end tapered diamond.(62) (Fig.6e.)

Lingual reduction.

Lingual finish line is created by round end tapered diamond by holding the bur
parallel to the lingual surface and forming a slight chamfer of 0.2-mm deep (Fig.6f.).
Moreover, the lingual finish line depends on the thickness of the teeth and the
patient’s occlusion. Finishing is done further.(4)

CLASSIFICATION BASED ON PREPARATION TECHNIQUE BY

COACHMAN(62)

Coachman et al proposed a three-generation classification to describe veneer

preparation techniques.

I. Preparations guided by calibrated burs to standardize facial and incisal edge

reduction.

ADVANTAGE:

 Reduce the tooth structure in a uniform way.

DISADVANTAGE:

 Result in aggressive preparations as the technique does not take into account,
among other things, the position and anatomy of the final restoration or wear
and loss of existing enamel. Consequently, there is high risk of dentin
exposure.

THE SECOND GENERATION:

II. Refers to Magne's use of a diagnostic waxup as a blueprint (Fig.7b)

13
 In this technique, silicone indices are made over the wax-up to guide incisal
and facial reduction. This approach aims to create the necessary space by taking into
account the proposed restorative material and the future anatomy of the restoration.

Fig.7b.

ADVANTAGE:

 It allows for more conservative as well as individualized preparation since

customization is not determined or guided by the existing tooth surface.

 The clinician can assess the position of future restorations.

DISADVANTAGE:

 Limited precision

 Technique-sensitive since silicone is a flexible material.

 Limited visibility through the silicone indices, which prohibits the clinician
from observing the entire preparation surface.

THE THIRD GENERATION:

III. Refers to Gürel'saesthetic pre-evaluative temporary (APT) technique (Fig.7c.)

This preparation technique involves placing a temporary mock-up fabricated

via a diagnostic wax-up over the teeth. The clinician can use the mock-up to
determine whether more material should be added, which allows a faster and more
conservative preparation as the technique is guided by the position and anatomy of the
final restoration.

Fig.7c.

ADVANTAGE:

Allow the clinician to assess esthetics, function, and phonetics before final
veneer application.

DISADVANTAGE:

14
 Subtractive cases require prereduction before the mock-up can occur. Further,
it is not unusual that before the facial preparation is completed, part of the APT may
dislodge.

CLASSIFICATION BASED ON VOLUME OF ENAMEL REMAINING AND

DENTIN EXPOSED BY LESAGE(63)

LeSage in 2013 classified veneer preparation according to volume of enamel

remaining

ENAMEL
REDUCTION FACIAL
REMAINING
Class-I No-Prep or Detectable with magnification, 0* with or 95% to 100%
Practically Prep-less without gingival finish line

Class-II Modified up to 0.5 mm 80% to 95%

Prep-less or
Minimally Invasive

Class-III 0.5 mm to 1 mm 50% to 80%

Conservative Design

Class-IV 1+ mm <50%
Conventional All-
Ceramic Design

LeSage in 2013 classified veneer preparation according to percentage of dentin

exposed.

REDUCTION FACIAL DENTIN

EXPOSED

Class-I No-Prep or Practically Prep- Detectable with 0

less magnification, 0* with or
without gingival finish line

Class-II Modified Prep-less or up to 0.5 mm 10% to

Minimally Invasive 20%

Class-III Conservative Design 0.5 mm to 1 mm 20% to

15
 50%

Class-IV Conventional All-Ceramic 1+ mm 50%

Design
PROVISIONAL RESTORATION

Provisionalization of veneer preparations can be difficult, as veneers have a

different preparation design when compared to full coverage crowns and rely on
bonding to the tooth structure. A provisional restoration should help maintain healthy
tissues, which establishes the environment for correct esthetic and physiological
contours of the dentogingival complex.(64)

An imp ortant consideration in provisional restorations is the control of

biofilm. If this is not achieved, gingival inflammation can occur.(64)

Functions of provisional restorations include:

1. Serving as a prototype for the final restorations.

2. Serving as an aid to evaluating esthetics and phonetics.

3. Serving as a guide for soft tissue healing around preparations.(65)

Many concerns arise during the provisional restoration stage;

 Occlusion,

 Inflamed tissues,

 Predisposition to secondary caries,

 Sensitivity, or dentin exposure can all alter the final result.

Exposed dentin can alter the bonding capabilities of the restoration and
increase the possibility of sensitivity. Magne has described the use of the immediate
dentinal sealing (IDS) technique which allows the creation of a hybrid layer over
freshly cut dentin to enhance the bonding properties. Cases that have been treated
with IDS require special measures during the provisionalization process. The
chemical interaction between the highly reactive bonding layer and the interim
restorative material can cause a provisional restoration to become permanently
bonded. This problem could be solved by isolating with Vaseline or any other

16
separating agent (eg, Pro-V-Coat; Bisco Dental, Schaumburg, Illinois), or using a
different provisionalization approach that does not require cement.(64)

Material to consider for provisionalizing veneer restorations:

 Poly(methyl methacrylate) (PMMA).

 Light and chemical cured Composite and

 Bis-acryl interim restorations, (64)

FABRICATION OF PROVISIONAL VENEER RESTORATION:

Provisionals can be fabricated by

 Direct&

 Indirect

 CAD- CAM (64)

DIRECT METHOD:

The direct method involves the use of a matrix for fabrication in the patient's
mouth. The matrix can be made with putty, or any other type of polyvinyl siloxane
(PVS), elastomeric material, or with an Omni-vacuum form. Partial etching of a small
zone in the incisal one third of the prepared tooth surface or spot etching (Fig.8.) has
been the most popular method for provisional restoration.(64,1)

INDIRECT METHOD:

Indirect fabrication requires the use of a cast or a scan of the patient's mouth.
The provisional is made in the lab and is then delivered to the patient.

Direct fabrication of provisional veneer restorations can be completed faster

compared to indirect fabrication. The direct approach brings its own set of challenges
such as the refinement of the embrasures and margins once the provisional is bonded
to the patient's teeth. Indirect fabrication can be time-consuming in the laboratory but
if done correctly and ahead of time it can save chair time.(64)

(CAD-CAM):

17
 Computer-aided design and computer-aided manufacturing (CAD-
CAM)technology have significantly reduced the amount of time it takes to deliver
many restorations.(64)

LABORATORY PROCEDURES

Good communication with the laboratory with laboratory prescription, pre-

treatment models, photographs of the teeth, and accurate impressions should be done.

Laboratory fabrication techniques include:

• Pressed porcelain veneer

• Computer-aided design-computer-aided manufacturing milling.

• Platinum foil technique

• Refractory die technique and

The last two methods are not used these days because of their technique
sensitive procedures. Thus, these days veneers are either fabricated by pressed
technique or CAD/CAM technique.(66)

MECHANISM OF BONDING

The direct bonding of ceramics to natural teeth is inadequate for dental use
because ceramics do not have a natural affinity to teeth. Etching of tooth enamel with
30% to 40% phosphoric acid gel and the bonding surface of the ceramic is etched
with an 5% hydrofluoric acid etchant so that luting resin cement can penetrate into the
pores and the material necessarily silanized to ensure good bonding between the
ceramic veneer and luting resin cement.(70)

Etching the enamel:

Chemical retention is directly dependent upon the total surface area, the higher
the surface area, the greater the potential bond strength. Etching the enamel increases
the enamel surface area nearly a hundredfold'. Thus, etching before cementing can
greatly enhance the bond strength.

18
 Orthophosphoric 30% to 40% acid etchant etched for 60 seconds and the
etchant is rinsed off. Rinse the liquid for at least 20 seconds, and the gel for at least
one minute before proceeding.(71)

Acid Etching of porcelain in Bonding:

Acid etching is the most effective procedure in enhancing and retaining bond
integrity between feldspar-based ceramic restoration and resin composite cement
compared with sandblasting and grit-blasting the surface of ceramics.(70)

ADVANTAGES:

 A porous structure is created facilitating micromechanical retention between

resin composite and porcelain
 Cleansing the ceramic surface by removing debris and unwanted oxides and
 Enhancing wettability of the ceramic substrate.

Examples of acid etchants:

 Hydrofluoric acid -5%-9%,

 Acidulated phosphate fluoride23%, and

 Ammonium hydrogen difluoride 10 %.(72)

Hydrofluoric Acid Etching:

Hydrofluoric acid5%-9%, cre ates the porous structure on the ceramic surface
by reacting with the silica matrix of the ceramic to form volatile SiF4. Optimum
etching time to be 2 min using 5% hydrofluoric acid etching as evidenced by the
highest mean shear bond strength.

Hydrofluoric acid dissolves in the epithelial lining fluid to form a weak acid
and is toxic to the lungs and eyes. It is readily absorbed through the skin into the
blood and may cause tissue necrosis and degeneration of bones. HF may cause severe
burns on mucosa, eyes, and skin. The HF etching must take place in a dental lab and
never intraorally. It is suggested to use as low concentration as possible, to neutralize
hydrofluoric acid before disposing, and to keep hydrofluoric acid containers closed at
all times when not in use.(70)

19
Ultrasonic Cleaning :

After etching the surface is rinsed with copious amounts of water, a great
number of acid crystals still stay deposited on the etched surface that may affect the
bond strength. In order to eliminate this, the veneers should be placed into the
ultrasonic cleaner. All residual acid and dissolved debris can be removed from the
surface of etched porcelain with an ultrasonic cleaning in 95% alcohol for 4 minutes,
or acetone or distilled water. Remineralized salts seen as white residue or deposit
must not remain due to inadequate rinsing. The immersion of the etched porcelain in
an ultrasonic bath creates the best surface that allows penetrability. (72)

Silane Coupling Agents :

Silane coupling agents (silanes) are synthetic organic– inorganic hybrid

compounds with direct ≡C-Si≡ bonds. They are silicon esters that may contain
trialkoxysilane groups. They bond dissimilar materials together by forming a
branched 3D siloxane (-Si-O-Si-) film between two materials.

Silanes are used as surface primer agents for adhesion promotion, a process
called conditioning or priming. Conditioning can increase the critical surface energy
of a surface. A high critical surface energy on the substrate surface and low surface
tension of a liquid is desired because liquids will spread evenly onto the surface.

Low energy contaminants such as oil and grease inhibit wetting and prevent
adhesion. In order to achieve complete wetting, the adhesive must have low viscosity
and the surface tension must be lower than the critical surface tension of the substrate
surface.(70)

When the inside of the veneer is ready to receive the silane treatment to create
a chemical link between the bonding composite and the ceramic, a fine layer of a
silane coupling agent is painted over the internal surface after it comes out of the
ultrasonic cleaner.

The silane is allowed to remain in contact with the etched porcelain for one
minute. At the end of that time it is dried with an air syringe by blowing the air
parallel to and slightly above the veneer and thus allowing the solvent to evaporate
completely. At this stage, it has been reported that drying the inside of the veneer,

20
with "warm air" (possibly with asmall hair dryer) will enhance the effect of the silane.
When the silane-coated porcelain is heated to 100°C it results in bond strength double
that of the porcelain where no heat was used.(72)

CEMENTATION

Multiple factors affect the success of prosthodontic restorations with

preparation design, oral hygiene/microflora, mechanical forces and restorative
materials being some of them. However, the key to success is the choice of proper
luting cement and cementation procedure.

The word “LUTING” is derived from a Latin word lutum-which means mud.
Dental luting agents provide a link between the restoration and the prepared tooth,
bonding them together through some form of attachment, which may be mechanical,
micro-mechanical, chemical or combination. This is necessary to prevent
microleakage and pulpal irritation and mechanically lock the restoration in place to
prevent its dislodgment during mastication.(73)

Choice of resin cement is according to the shade of the veneers and

cementation is followed by proper retraction to avoid moisture control and
contamination. (74)

Resin cements are the adhesive of choice for veneers as they have a favourable
fracture load, good longevity and satisfactory clinical performance. The resin
composite cement acted to heal some of the surface imperfections thereby providing
enhanced strength by acting to heal key defects, namely large.(75)

The resin adhesive is used in a thin layer, as increased thickness may also
produce a lifeless aesthetic result.

RESIN CEMENTS

• Fujicem, GC America, IL

• Bistite II DC

• C&B Cement

• Cement-It Universal C&B

21
 • Duo-Link

• LinkMax

• RelyX ARC

• Resinomer

• Ultra-Bond Quik

A light-curing luting composite is preferred for cementation of porcelain

veneers. A longer working time compared with dual cure or chemically curing
materials is the major advantage of light curing.The veneers are carried with the
sticky pole for luting(Fig.11.b.)(1)

For full seating, incisally wrapped veneers require first facial and then
gingivally directed pressure.

Excess composite is carefully removed from the edges, and the entire laminate
is cured for 1.5–2 minutes, depending on thickness, colour, and opacity.

Any excess cement removed by using fine grit and final polishing is
accomplished by diamond polishing pastes. (1)

PATIENT EDUCATION AND THE MANAGEMENT OF

ESTHETIC DENTISTRY(76)

It's necessary to inform patients that veneers can chip; they're much like real
teeth in that they fracture and shatter. Although veneer failures are uncommon, they
do occur; yet, it should be mentioned that veneers are easily repaired or replaced.

VENEER CARE GUIDANCE:

Temporary changes in speech : This is typical and to be expected when the form
and size of the teeth have been altered. In the beginning, your speech may alter until
your tongue adjusts to the modifications. Your mouth is incredibly sensitive and will
exaggerate such emotions at first, even if the alterations are little (measured in mm).
The sensations usually fade after a few days, and your mouth returns to normal.

Daily hygiene:

22
 To extend the life of your veneer, brush twice a day with an ultra-soft
toothbrush and floss overnight. Tobacco, coffee, tea, red wine, colas, and other stains
may discolour the veneer, much like your real teeth.  Do not use baking soda or
toothpaste. Avoid regular rinsing with mouthwash containing alcohol. Alcohol softens
the bond and weakens the adhesion of porcelain. Choose a mouthwash that does not
contain alcohol or a solution of hydrogen peroxide and water.

Diet and habits:

Avoid eating hard things like hard sweets, nuts ,spare ribs ,hard bread and rolls
, raw carrots on your veneered teeth. Using your teeth to open packages, Cutting
thread, Nail biting ,Pipe smoking are all bad habits to avoid. This puts stress and
could result in a fracture of veneer. Do not bite extremely hard objects with one tooth.

Participating in sports activities:

Extreme force or trauma can break porcelain veneers, When participating in

sports or in other potentially stressful circumstances, take care. In these situations, we
recommend using a mouthguard.

Care after the initial treatment:

Visit clinician for examinations and continuing care at regular six-month

intervals. Problems with the veneers may often be detected early and readily rectified,
however waiting a longer period of time may necessitate re-doing the complete
restoration.

ADJUNCTIVE ORTHODONTICS, AS RELATED TO

PERIODONTICS AND AESTHETIC DENTISTRY

Laminate and veneers have become more popular as patients' interest in

aesthetics has recently grown. Because of the imbalance of tooth proportions, the
interdental space in the anterior tooth offers an orthodontic problem that was difficult
to rectify with typical full veneer crown treatment choices. In such cases, a
multidisciplinary approach involving orthodontics, periodontology, and
prosthodontics is required to assess, diagnose, and treat aesthetic issues.

23
Communication between disciplines is essential in generating enhanced aesthetic
outcomes in the anterior teeth when a complete approach is required. Uneven space
between anterior teeth can be treated orthodontically. After the teeth have been
rearranged, the anterior aesthetics can be restored using porcelain laminate veneers for
minimal teeth preparations, preserving sound tooth structure and preventing pulp
irritation.(77)

SPECIAL CONSIDERATION

Success of any restoration depends on how the patient maintains it.

Maintenance on the other hand should be a combined effort of dentist as well as the
patient.(78)

Patient should be motivated::

• To avoid coloured food, tea, or coffee during initial 72-96 hours

• To use a soft toothbrush with rounded bristles, and to floss daily.

• To avoid ultrasonic scaling and to undergo routine hand scaling. 78)

FAILURES

Failure of laminate veneers can be associated with

1. Case selection: This is the most important step affecting the success of the
restoration. Suitable indication must be present for successful veneer placement.

2. Tooth preparation: Preparation extending into dentin is less retentive as compared

to preparation limited to enamel.

3. Laboratory processes: Incorrect choice of ceramic material and improper

fabrication technique can lead to weaker restoration resulting in failure.

4. Try in and handling: As veneers are extremely fragile before cementation,

improper handling can result in breakage of veneer.

5. Choice of cement: Choice between light cured, dual cured and chemically cured
resin cement must be made depending on the case requirement. If the thickness is
more, dual cured cement must be preferred as light cure cement do not reach their
maximum hardness.

24
6. Bonding procedures: Failure to isolate and curing for insufficient time can lead to
weaker bond resulting in failure. (78)

PREVENTION OF FAILURE:

During veneer fabrication Proper case selection should be done.

To avoid inaccuracies proper steps of tooth preparation and impression making should
be followed.

For cementation of veneers, steps should be followed in terms of etching time and
isolation.(78)

RECENT ADVANCES IN MATERIAL ASPECT OF VENEERS

1. Stacked or feldspathic teeth veneers with reinforced leucite

2. Componeers

3. E – max veneers

4. Zirconia veneers

5. Lumineers

6. Da Vinci veneers

7. MAC veneer

8. Durathin

9. Vivaneers

10. Gingival veneer

CONCLUSION

A lovely smile is the equivalent of a green light at a crosswalk. The ultimate

purpose of veneers is to improve the appearance of a smile. Veneers are a valuable
addition to a dentist's toolkit for treating aesthetic issues in both young and older
patients.(3)

25