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| Indirect Porcelain Veneers |
| By Mary Fran Rocca, DMD Napa, CA |
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Porcelain veneers give dentists and their patients an attractive, technically-satisfying method of changing shape and color of existing dentition. These restorations provide for long-term wear, stain resistance, and translucency that closely approximates that of natural tooth structure. Their gloss and texture are maintained indefinitely. With the introduction of newer fourth generation adhesive systems and luting agents, the bonding strength of porcelain to etched enamel and dentin surpasses that of composite bonded to enamel and dentin.
History
The patient is a 24 year-old female who is very attractive, but she has been self-conscious for years about her teeth. She complained of the size, shape and spaces between her teeth. She is the hostess at a world famous restaurant and has felt self-conscious about her smile when attending to the restaurant patrons. She is in excellent physical health, has had orthodontic treatment previously, and wears a retainer at night. The patient has a very highly developed fear of dentistry, and is very apprehensive about treatment.
Clinical Data
Our examination revealed a normal soft tissue environment with some gingivitis present. Oral hygiene was reviewed, and the patient was instructed to floss daily and increase the duration of brushing.
Her full mouth series of radiographs showed no signs of active decay, normal bone levels, and no periapical lesions. The teeth are all very stable.
There are spaces between her anterior teeth and the lateral incisors are small. The central incisors are slightly shorter than average.
Diagnosis
This patient presented with a need for cosmetic treatment to improve her smile. She has a very full smile and shows all her anterior teeth when smiling. Porcelain veneers for teeth #5 through #12 were recommended. IPS Empress veneers were chosen. This ceramic material utilizes a pressed ingot, producing a more fracture resistant material. Fracture propagation is minimized due to the controlled crystallization and leucite formation. The flexural strength of the material is higher than both conventional porcelain and Dicor.
Treatment Plan
Impressions for diagnostic casts were taken to evaluate teeth. A diagnostic wax-up was made, which would aid in both fabrication of the provisional restorations and in determining the form of the final restorations. The veneers will be fabricated to approximately .6 mm thickness to allow for Empress veneers to be pressed.
Armamentarium
1. Alginate (Jeltrate)
2. Flour pumice
3. Telescopic lenses 2.5x and 3.5x (designs for Visions)
4. Ivoclar shade guide
5. Yashica Dental Eye II Camera
6. Prepwash
7. Prepdisinfect
8. 6 x 6 rubber dam
9. 32% phosphoric acid etch gel
10. Microprime
11. All Bond 2 kit
12. Ultrapak cord #000 and #00 (Ultradent)
13. Ultradent Astringedent
14. Express STD putty
15. Kerr Extrude polyvinylsiloxane impression material
16. Almore wax bite registration tabs
17. Insure Lite clear cement (Cosmedent)
18. Silane Bond Enhance (Mirage)
19. Brasseler ET finishing carbide burs
20. Brasseler porcelain veneer diamond burs
21. Bard Parker #12 blade
22. Epitex finishing strips
23. Accufilm II articulating paper (Parkell)
24. Polishing kit (Cosmedent)
25. Luxatemp temporary material
26. Revolution flowable composite
27. DeOx oxygen barrier solution (Ultradent)
28. CU5 Polaroid camera
Preparation
At the first appointment, preoperative photos were taken. Shade selection was discussed with the patient who was happy with the existing shade of her teeth. Empress shade 120 was chosen as a base shade by the doctor, staff and patient.
At the next appointment, Express putty was mixed and placed in a stock tray, covered with plastic and placed into the patient’s maxillary arch for 30 seconds. The tray was then removed and set aside for the final impression. An opposing impression was taken and poured. This model was sent to the lab with the final impression. The patient was provided with virtual reality glasses and her choice of movies. The patient was then anesthetized and a rubber dam was placed to isolate the teeth. While wearing the telescopic lenses, the teeth were prepared starting with the maxillary central incisors. Preparation consisted of using the Brasseler porcelain veneer kit diamonds for depth cuts, followed by the KS2 for gross reduction. Approximately .6 mm of facial enamel was removed. A chamfer margin was placed on the facial. Because we were going to be closing several diastemas, the interproximal prep was extended straight through to the lingual to allow the lab to give a more natural emergence form.
Any slight hemorrhaging areas of tissue were then lavaged with Astringedent (Ultradent) for complete hemostasis. Ultrapak #000 cord was gently placed and final preparation touch ups were accomplished. The facial margin was placed just into the sulcus. The contacts between the cuspids and premolar teeth were maintained. Fine diamond polishing strips were used to slightly smooth and polish the interproximals in order to facilitate the fabrication of the veneer at the lab. The preparations were checked and all sharp edges rounded off in order not to create a stress area in the final porcelain restoration. After waiting ten minutes, the teeth were rinsed with water and air-dried. Kerr light body impression material was then flowed onto the teeth and also placed into the Express putty tray prepared earlier. The tray was seated and held in place by the doctor for five minutes. The impression was then removed, rinsed and examined with the telescopic lenses. The impression looked very accurate and was set aside for the lab after being sprayed with disinfectant and bagged. A bite relation was taken with Almore wax bite registration tabs. A horizontal plane bite record was also taken.
A decision was made to place provisional restorations. The patient had originally presented with poor oral hygiene; therefore, provisional restorations were used to prevent sensitivity, which could have led to inadequate oral hygiene. Provisionalization also served a function in obtaining feedback from the patient, which would aid the dentist and lab technician in developing the smile design preferred by the patient.
The provisional restorations were fabricated directly using Luxatemp temporary material. The teeth were cleansed and treated with Prepwash and Prepdisinfect. An alginate impression taken of the diagnostic wax-up was then filled with Luxatemp and seated over the prepared teeth. After two minutes, the impression was removed with the provisional restorations remaining on the prepared teeth. After carefully peeling off excess material, any small voids were filled in with Revolution flowable composite and cured. Then the margins were carefully smoothed and polished. At this time, all diastemas were closed, and approximately 1 mm of incisal length was added to the central and lateral incisors. The patient was instructed on care while wearing provisional restorations and dismissed.
Laboratory Instructions
The laboratory technician was given a detailed lab prescription for pressed and cut-back Empress porcelain veneers. The patient had requested a soft, rounded design for her smile. A wax mock-up was sent to the lab along with slides and CU5 Polaroids to further aid in the fabrication of the veneers.
Finishing
Upon their return from the dental laboratory, the laminate veneers were seated on the master model. They were inspected for marginal fit and a frosty appearance. At the insertion appointment, the temporaries were removed and the teeth pumiced with a mixture of flour pumice and hydrogen peroxide. After rinsing the teeth well with water, the veneers were tried in with water to check the marginal fit, contacts, and overall appearance. Everything looked good, and the patient gave her approval.
The veneers were etched with 32% phosphoric acid for one minute, rinsed, air-dried, and Silane Bond Enhancer (Mirage) was applied. The teeth were then isolated with a rubber dam, cleansed with Prepwash and Prepdisinfect, and etched with 32% phosphoric acid for 15 seconds. After rinsing with water for 30 seconds and air-drying with water-free air, Microprime was applied to re-wet the teeth. The teeth were then primed with hydrophilic dentin primer (All Bond II), and Pre-Bond resin was placed on both the teeth and the restorations. Utilizing the "Rapid Cementation Technique" taught by Drs. Hornbrook and Dickerson, the veneers were then placed. Insure Lite clear cement (Cosmedent) was loaded into both #8 and #9 veneers and they were placed. A rubber tip was used to remove excess cement. Next #’s 7, 6, and 5 were placed. Then #’s 10, 11, and 12 were placed. Once all the veneers were in place and the excess cement removed with a rubber tip, a 2 mm light tip was used to tack all the veneers in place. Once all the veneers were tacked in place, floss was used interproximally to remove excess cement, applying pressure from the facial to the lingual. DeOx (Ultradent) was then placed around the margins to prevent the formation of an air-inhibited layer on the resin cement. The veneers were cured with a laser light for five seconds from the lingual, followed with ten seconds from the facial. Excess cement was removed from the margins with a #15 Bard Parker blade and a scaler. Polishing burs followed by cups and points (Cosmedent) were used to smooth and polish. Epitex strips were used to finish the interproximals.
Summary
Porcelain veneers are one of modern dentistry’s most exciting treatment options. They allow the dentist to change shape, shade, and surface characteristics of teeth to nearly perfectly replicate the beauty of natural teeth. When the strongest, most esthetic, and longest lasting cosmetic procedure is desired, porcelain veneers are clearly the cosmetic dentists’ first choice. To be able to give a patient the ability to smile confidently is one that gives the cosmetic dental team a sincere sense of accomplishment.
While perfection is always just out of our reach, excellence is not, and these restorations truly allow excellence to be achieved.
References
1. Miller M.B.; Reality; Volume 10; Houston, Texas; Reality Publishing Company; 1996; page 444
2. Barkmeier, W., D.D.S., M.S., Menis, D., Ph.D., Barnes, D., D.D.S., M.S., "Bond Strength of a Veneering Porcelain using Newer Generation Adhesive Systems". Practical Periodontics and Aesthetic Dentistry; August 1993; Volume 5; Number 6; pages 50-55
3. Clinical Research Associates; CRA Newsletter; August 1992; Volume 15; Issue 8; page 2
4. Miller M.B.; Reality; Volume 10; Houston, Texas; Reality Publishing Company; page 447
5. Freedman, G.A. and McLaughlin, G.L.; Color Atlas of Porcelain Laminate Veneers; First Edition; St. Louis, Missouri; Ishiyaku EuroAmerica, Inc; 1990; page 63
6. Nixon, R.L.; Provisionalization for Ceramic Laminate Veneer Restorations; A Clinical Update. Practical Periodontics and Aesthetic Dentistry; 1997; 9 (1): 17-27
7. Miller M.B.; Reality; Volume 10; Houston, Texas; Reality Publishing Company; page 437
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