DENTAL TECHNIQUE

A technique to facilitate ceramic veneer cementation

Ra’fat I. Farah, BDS, MSc,a Abdullah Fahad Aldhafeeri, BDS,b and Rakan Saud Alogailic

Proper cementation is critical ABSTRACT

to the success and longevity of
This report describes a technique to facilitate ceramic veneer cementation. By stabilizing a ceramic
ceramic veneers. These resto- veneer in its fully seated position with miniature wooden spring clips before resin polymerization,
rations rely on resin cement excess luting resin cement can be removed from ceramic veneer margins without the risk of veneer
bonding not only for retention dislodgement or fracture. (J Prosthet Dent 2017;-:---)
but also for strength.1 Unfor-
tunately, adhesive resin luting cement, which lacks the ceramic veneer. It also enables the dentist to verify
simplicity of traditional cements, is a challenging material complete seating of the veneers before resin polymeri-
for ceramic veneer cementation and involves multiple zation by stabilizing them in their fully seated position
technique-sensitive steps. These cements become very
2
with mini, wooden spring clips.
hard after polymerization,3,4 making removal of excess
cement difficult without the use of rotary instruments TECHNIQUE
and serrated interproximal saws, which, in turn, may
damage the glazed surface of a seated veneer, adjacent 1. After the clinical evaluation, rinse the water-
periodontal tissue, and/or sound tooth structure. More- soluble evaluation paste thoroughly. Clean the
over, heavy instrumentation may also initiate bleeding or veneers and dry them by using oil-free air. Etch the
seepage from soft tissue, which may complicate subse- fitting surface of the lithium disilicate ceramic ve-
quent veneer cementation. However, removing excess neers with 9.6% hydrofluoric acid (Porcelain Etch
cement before light polymerization is complicated by the Gel Kit; Pulpdent Corp) for 20 seconds. Rinse and
sticky and runny nature of unpolymerized resin and the dry the veneers and apply silane coupling agent
risk of dislodgement or fracture of unstable, thin, and (Monobond-S; Ivoclar Vivadent AG) to the etched
fragile ceramic veneers. surface by using a microbrush. Allow the material
The inadequate removal of excess luting resin from to react for 60 seconds and then disperse it by
margins and interproximal areas will lead to biological using a strong stream of air.
and esthetic complications and will affect the patient’s 2. Isolate the teeth with a lip and cheek retractor
ability to maintain oral hygiene. Furthermore, any excess (OptiView; Kerr Corp), thoroughly clean the pre-
cement or polymerized bonding agent on the adjacent pared tooth surface with pumice slurry in a pro-
preparations, or interproximally, will lead to incomplete phylaxis cup, rinse thoroughly, and dry. Separate
seating of subsequent veneers and complicate the the adjacent unprepared teeth with polytetra-
cementation step itself.5 fluoroethylene (Teflon) tape to protect them from
This technique facilitates the removal of soft and gel- inadvertent etching. Etch the enamel surface with
like (tack polymerized) excess cement from all margins, 37% phosphoric acid (Scotchbond universal
especially in inaccessible interproximal areas, without the etchant; 3M ESPE) for 20 seconds, rinse the surface
risk of cracks, displacement, or detachment of the thoroughly for 10 seconds, and dry. According to

a
Assistant Professor, Department of Prosthodontics, College of Dentistry, Qassim University, Kingdom of Saudi Arabia, Qassim, Saudi Arabia.
b
Intern, College of Dentistry, Qassim University, Kingdom of Saudi Arabia, Qassim, Saudi Arabia.
c
Predoctoral student, College of Dentistry, Qassim University, Kingdom of Saudi Arabia, Qassim, Saudi Arabia.

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Figure 1. Wooden spring clips placed on veneers and separate adjacent
teeth with ultrathin metal matrix band segments.
the manufacturer’s instructions, apply 2 coats of
bonding resin (Single Bond Universal Adhesive;
3M ESPE) to the entire prepared tooth surface by
using a microbrush. Then, lightly dry the bonding
resin with an air syringe to thin it out and evapo-
rate any solvent, leaving the bonding resin layers
unpolymerized.
3. Load the inside of the veneer with resin luting
cement (RelyX Veneer Cement; 3M ESPE). Seat
the veneer along the insertion axis from the incisal
corner and push apically and palatally with gentle
finger pressure until it is fully seated. Use a sharp
explorer to ensure the gingival margin is in place,
being careful not to twist the laminate and trap any
air bubble underneath. The excess luting resin
should be visible on all margins, confirming that
sufficient material has been used.5
4. Remove excess soft, unpolymerized luting com-
posite resin from only the incisal margin by using a
microbrush dipped in bonding agent. Use a motion
parallel to the margin to avoid pulling the material
away from the margins, which would result in a
marginal gap and microleakage and future discol-
oration, sensitivity, or caries.6
5. The remainder of the veneers can be seated in the
same manner before moving to the next step, or,
alternatively, the veneers can be cemented indi-
vidually or in pairs.
6. Place wooden spring clips (Stationery Clips & Pins;
Dalian Hongyue Stationery Co) on the veneers.
This will maintain complete stability of the rela-
tionship between the veneer and the underlying
tooth.
7. Test the clips’ stability and retention by lifting them
gently in an occlusal direction by using a fingertip
under the jaws of the clips and verify the marginal
integrity and stability of the veneers with a sharp
explorer. An improperly fitting clip or veneer can
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Figure 2. Gross marginal excess of unpolymerized luting resin removed
with microbrush in motion parallel to margin.
be rocked or easily dislodged. If the stability of the
clip or the underlying veneer is questionable or if
the veneer moves or tips during clip attachment,
recontour the jaws of the clip to achieve a better
adaptation between the clip and veneeretooth
surface(s) with a #15-scalpel blade or by grinding
with a mounted stone (Dura-Green Stone TC1-
CA 0089020; Shofu Dental Corp). Then, remove
the veneer, refill it with cement, reseat it, and
attach the spring clip.
8. Place ultrathin metal matrix band (Dead Soft Ma-
trix Strip, Fintrec; Pulpdent Corp) segments (0.025-
mm thick) in the interproximal areas between
adjacent teeth to ensure that the resin cement in
the interproximal areas does not lock in or bond
together or to the adjacent tooth after luting resin
polymerization (Fig. 1).
9. Remove the gross marginal excess of soft unpoly-
merized luting resin with a brush or rubber-tipped
instrument by using the same parallel-to-margin
motion (Fig. 2). Tack polymerize the cement on
the margins for 1 to 2 seconds by using a light-
emitting diode (LED) visible light-polymerizing
unit (SmartLite Max LED Curing Light; Dentsply
Sirona). The remnant excess cement with gel-like
consistency can be easily separated and removed
by using an explorer in a motion parallel to the
margin. Ensure that all excess cement is removed
at this stage, especially in the embrasures. The
explorer should be handled with care in order not
to induce bleeding from the soft tissues.
10. Confirm the marginal fit of all seated veneers by
using a sharp explorer. The resin luting agent is
completely polymerized by using an LED visible
light-polymerizing unit, starting from the lingual
surface first so that shrinkage will occur toward the
tooth and then the facial surface for at least 40
seconds for each area. The light should be applied
Farah et al
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Figure 3. Veneers immediately after removal of spring clips and matrices. A, Right lateral view. B, Left lateral view.
to different areas from different angles to avoid
overheating the tooth and thus postoperative
pulpal sensitivity.7
11. Remove the spring clips and matrices and inspect
the margin and interproximal area for excess
cement. As seen in Figure 3, the bulk of the mar-
ginal excess luting cement was removed with
minimal trauma to soft tissue. Any excess cement
can be removed by using a #12 scalpel blade or
sharp curette. Then, apply glycerin over the mar-
gins to prevent the formation of an oxygen-
inhibiting layer and repeat light polymerization.
12. Perform the final polishing and occlusal adjust-
ments by using finishing diamonds, a fluted car-
bide bur, abrasive disks, rubberized abrasives,
finishing strips, and diamond polishing paste to
achieve the definitive cemented ceramic veneers as
seen in Figure 4.
DISCUSSION
This report describes a technique for stabilizing ceramic
veneers by using miniature wooden clips before the
polymerization of luting resin cement. The method fa-
cilitates the removal of excess cement and verification of
veneer seating without the risk of veneer dislodgment.
These clips are made from wood that will not scratch the
veneer and are similar to the orangewood recommended
for use in seating ceramic restoration(s). The force exer-
ted by these clips is only 7.8 N when measured with a
digital force gauge, which is significantly less than the
average seating force exerted by a dentist (38 to 67 N).8,9
The pressure generated (approximately 0.46 MPa) is
significantly less than the flexural strength of most
commercially available ceramics used in veneer fabrica-
tion.10 Therefore, this minimal force is sufficient to retain
and stabilize veneers in their definitive seating position
without the risk of fracturing. Furthermore, the applica-
tion of sustained seating pressure during cement
Farah et al
3
Figure 4. Cemented ceramic veneers.
polymerization will improve the final bond strength of
the resin cement.11
Because of the shape and size of these clips, they
contact the veneers in the middle third, which clears the
margins for cleaning and verification of complete seating.
Moreover, they sustain intimate contact between the
fitting surface of the veneers and the tooth in an apical
and palatal direction. Full veneer seating can be verified
by visually assessing the margins and using an explorer.
If it is found margins are open or improperly seated or
have voids not filled with luting cement, they can be
detected before luting resin polymerization, increasing
the predictability of the cementation step.
To achieve complete seating of the veneer and sta-
bility of the veneer and the attached clip, they should be
in intimate contact between the jaws of the clip and
middle third of the seated veneer and lingual concavity
(lingual fossa) in the tooth, as seen in Figure 5. The jaws
of the clip must sometimes be recontoured to fit the
shape of the tooth. In some situations, the lingual
morphology is unfavorable (convex) or has a lingual ridge
(as in lower and upper canines), which can lead to slip-
page or instability of the clips. The stability of these clips
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Figure 5. Ideal contacts of mini-spring clip to stabilize maxillary central
incisor veneer seated on removable die.
can be improved by using a tiny piece of chewing gum
kneaded by wet-gloved fingers and fastened to the
lingual jaw of the clip before attachment.
SUMMARY
This straightforward technique involving wooden spring
clips makes the veneer cementation step more predict-
able and less cumbersome and time consuming and does
not require extra equipment. Moreover, these clips are
inexpensive, autoclavable, and small. With dimensions
that fit most teeth, they can be easily adjusted as
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necessary by using a scalpel blade or grinding with a
mounted stone.
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Corresponding author:
Dr Ra’fat I. Farah
College of Dentistry
Qassim University
Al-Mulaydah, Qassim, Ksa 51452
P.O. Box 6700
SAUDI ARABIA
Email: Dr.rafat.farah@qudent.org
Copyright © 2018 by the Editorial Council for The Journal of Prosthetic Dentistry.
Farah et al