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ABSTRACT The evolution of porcelain veneers started by Pincus, who attached thin labial porcelain veneers temporarily with denture adhesive powders to enhance the appearance of Hollywood stars close-up photographs has now became one among the most recommended treatment for a dentist and a requested treatment by many of the patients. They are considered as the first alternative to improve the esthetics of the anterior teeth and by consequent-related quality of life. Successful results of porcelain veneers depend on the clinical and laboratory steps involved, along with the understanding of the scientific background of procedure. Therefore, porcelain veneers have to be reviewed and discussed in detail. The purpose of this article is to review literature and present important parameters such as case selection, shade selection, tooth preparation, provisionalization, cementation, and patient maintenance for long-term success of porcelain veneers. Key words: Esthetics, bonding, laminate veneers, provisionalization How to cite this article: Hari M, Poovani S. Porcelain laminate veneers: A review. J Adv Clin Res Insights 2017; 4:187-190. Received: 01 September 2017; Accepted: 01 December 2017
Journal of Advanced Clinical & Research Insights (2017), 4, 187–190
Journal of Advanced Clinical & Research Insights Vol. 4:6 Nov-Dec 2017 187
REVIEW ARTICLE
Porcelain laminate veneers: Areview
Meenakshy Hari, Shwetha Poovani
Department of Prosthodontics, Rajarajeswari Dental College and Hospital, Bengaluru, Karnataka, India
Abstract
The evolution of porcelain veneers started by Pincus, who attached thin labial porcelain
veneers temporarily with denture adhesive powders to enhance the appearance
of Hollywood stars close-up photographs has now became one among the most
recommended treatment for a dentist and a requested treatment by many of the patients.
They are considered as the rst alternative to improve the esthetics of the anterior
teeth and by consequent-related quality of life. Successful results of porcelain veneers
depend on the clinical and laboratory steps involved, along with the understanding
of the scientic background of procedure. Therefore, porcelain veneers have to be
reviewed and discussed in detail. The purpose of this article is to review literature and
present important parameters such as case selection, shade selection, tooth preparation,
provisionalization, cementation, and patient maintenance for long-term success of
porcelain veneers.
Key words:
Esthetics, bonding, laminate veneers,
provisionalization
Correspondence:
Meenakshy Hari, Department of
Prosthodontics, Rajarajeswari Dental College
and Hospital, Bengaluru, Karnataka, India.
E-mail: rmeenakshyhari22@gmail.com
Received: 01 September 2017;
Accepted: 01 December 2017
doi: 10.15713/ins.jcri.190
Introduction
The prettiest thing anyone can wear is a perfect smile. The
restoration of unesthetic anterior teeth has always been a
problem, involving large amounts of sound teeth structure,
with adverse eects on the pulp and gingiva. Laminate veneers
are a conservative alternative to full coverage restorations for
improving the appearance of anterior teeth and have evolved
over the last several decades to become esthetic dentistry’s most
popular restoration. The esthetic and mechanical qualities and
biocompatibility of the porcelain, preservation of the tooth
structure, durability and reliability of the treatment and improved
strength of bonding made veneers a recommended treatment for
the dentist, and a requested treatment for many patients.[1]
The purpose of this article is to review literature and presents
important parameters such as case selection, shade selection,
tooth preparation, provisionalization, cementation, and patient
maintenance for long-term success of porcelain veneers.
Method of Data Collection
An electronic search of publications was made using electronic
databases, Medline, and PubMed. The language of choice was
English in this review and the keywords used include laminate
veneers, ceramic veneers, porcelain veneers, and dental ceramics.
All articles from both electronic databases were collected and
duplicates were deleted.
Literature sources also include textbook references.
In general, the selected articles met the following inclusion
criteria: Clinical trials, case reports, review or systematic reviews,
and prospective studies, all written in English.
Indications
Porcelain laminate restorations are recommended in case of:
Extreme discolorations in the anterior teeth, which include
tetracycline staining, uorosis, devitalized teeth, and teeth
darkened by age, which are not conductive of bleaching.
Small enamel defects say cracks can be masked by veneers.
Diastemas and multiple spacing between the teeth are better
treated by laminate veneers.
Laminates can be further used to restore localized attrition
and root sensitivity due to cemental exposure.
A functionally sound metal ceramic or all ceramic restoration
with unsatisfactory color can be repaired by veneers.
Malpositioned teeth and abnormalities of shape: Peg laterals and
rotated teeth can be esthetically restored by porcelain veneers.[2]
Contraindications
Full coverage restorations are preferred over veneers in case
of insucient coronal tooth structure. A fractured teeth, with
more than one-third of loss of tooth structure, are a poor case
for veneers.[1]
Hari and Poovani Veneers
188 Journal of Advanced Clinical & Research Insights Vol. 4:6 Nov-Dec 2017
Actively erupting teeth should not be subjected for veneering.
Patients with parafunctional habits like bruxism should
hardly receive veneers.[1]
Endodontically treated teeth are again not recommended for
veneers as they present a poor receptive surface for bonding
and full coverage restorations are indicated.
Case selection for Porcelain Laminate Veneers
A static and dynamic occlusal relationship is of prime concern
in the patients receiving veneers. Since the usual mode
of failure is the fracture at the incisal edges, the incisal tips
should be placed in such a manner that they do not contact
the opposing dentition at rest position.
As any other restoration, a healthy periodontium forms a
sound foundation on which the restoration rests. Mouth
breathers are considered as poor candidates for veneers.
Degree of discoloration of teeth along with the extent of
preexisting caries lesion and the restorations, if any, should be
examined before the treatment. Absence of enamel or a large
restoration that denies to give a proper surface for bonding
makes the teeth again a poor candidate to receive veneers.
Patient’s attitude and motivation to maintenance makes the
treatment more successful.
Oral habits say nail biting should be corrected before
initiation of the treatment to avoid the shear stress on the
ceramics after the cementation of veneers.
All Ceramic Systems used for Porcelain Laminate Veneers
Conventional ceramics.
Castable ceramics.
Machinable ceramics.
Pressable ceramics.
Inltrated ceramics.
Shade Selection
Tooth color has an intimate relation with the color of eyes,
skin, and hair as all of these elements have the same embryonic
origin and is considered in shade selection. Instead of precisely
matching the shade, a shade of lower chroma and higher value
can be selected. This provides the dentist latitude and allows
for slight darkening attributable to increase translucency with
polymerization of the composite luting cement.[2] Increased
thickness of the porcelain makes the conventional shade guides
such as vita porcelain shade guide non-ideal for veneers.
Tooth Preparation
Two major principles governs tooth preparation sounds
Preparation must be conservative and
Retention is solely by adhesion rather than tooth preparation.
Types of preparation
Three dierent types of preparation include:
Type 1: Contact lens preparation in which the preparation
does not cover the incisal edges.
Type 2: Classic or conventional preparation, which is
commonly used by the practitioners. Here, the preparation
covers the incisal edge and terminates lingually.
Type 3: Wrap around preparation, which is almost similar
to that of full coverage preparations, which is indicated for
extensive color and contour.[3]
Armamentarium
A diamond depth cutter with a wheel diameter of 1 mm, another
depth cutter with a wheel diameter of 1.6 mm, a round bur, a
round end tapering bur, nishing diamond burs, and Airotor
handpiece contributes to the armamentarium.
Procedure
Facial reduction: Since the amount of enamel decreases at the
cementoenamel junction, some teeth permit less reduction
at the gingival nish 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. The two diamond cutting burs of diameters 1.6 mm
and 1.0 mm will create the exact depth orientation grooves
and the remaining tooth structure is removed with round end
tapered diamond. The tip of the diamond establishes a slight
chamfer nish line at the gingiva.[3,4]
Proximal reduction: Proximal extension is just a continuation
of facial reduction with the round end tapered diamond.
Adequate reduction is recommended at the line angle and
uneven nish line is avoided by keeping the bur parallel with
the long axis of the teeth.
Incisal reduction: There are two techniques for the placement
of incisal nish 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.[4]
Lingual reduction: Lingual nish line is created by round
end tapered diamond by holding the bur parallel to the
lingual surface and forming a slight chamfer of 0.5-mm deep.
Moreover, the lingual nish line depends on the thickness
of the teeth and the patient’s occlusion. Finishing is done
further.
Provisional Restoration
Provisional restorations for laminates may not be essential as
there is no exposure to the dentin and the proximal contacts are
Veneers Hari and Poovani
Journal of Advanced Clinical & Research Insights Vol. 4:6 Nov-Dec 2017 189
maintained. However, most often it may be necessary for the
patient to maintain their social engagements and if the proximal
contacts are broken. The two methods of provisionalization
include direct method using composite resin with central spot
itching and autopolymerizing acrylic resin and indirect method
after the cast fabrication.[5]
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:[6]
Platinum foil technique
Refractory die technique and
Computer-aided design-computer-aided manufacturing milling.
Hydrouoric acid is applied to the tting surface after
fabrication, which provides bonding strength by partly dissolving
the glassy matrix of the porcelain. Foggy appearance is noted for
the proper itching and the etched veneers are not placed back on
the master cast to avoid contamination and not to compromise
with the bonding strength.[6]
Veneer Try-in
Major three steps in try-in procedure include:
Dry try-in for marginal t, where a retraction cord is placed to
prevent the sulcular moisture or bleeding and each veneer is
tried on the dry tooth surface for the marginal accuracy.
Wet try-in for proximal t, where the itched surface with
water-soluble glycerin to minimize the vertical dislodgement
is tried with all the teeth together for the assessment of
proximal t.
Resin cement try-in done for color matching where if the
color is acceptable cementation goes smoothly. If the veneers
are lighter than that of intended shade, resin cement that is
darker or approximately same degree is recommended. If it
is darker than the intended shade, one part of light opaque
resin cement and 10 parts of light translucent resin cement
are recommended.
Cementation
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. Incisally wrapped veneers
require rst facial and then gingivally directed pressure for
complete seating. Excess composite at the margins is removed
carefully and the entire laminate is cured for 1.5–2 min,
depending on the thickness, color, and opacity of laminate. Fine
grit is used to remove any excess cement and nal polishing is
accomplished by diamond polishing pastes. Patient should be
advised to avoid highly colored foods, tea or coee, hard foods,
and extreme temperature for another 72–96 h.[7-9]
Maintenance
Success of any restoration depends on how the patient maintains
it. Maintenance on the other hand should be a combined eort
of dentist as well as the patient. Patient should be motivated:
To avoid ultrasonic scaling and to undergo routine hand
scaling.
Abrasives and highly uoridated toothpastes should be
avoided.
Excessive biting forces and nail biting and other habits should
be under control.
Soft acrylic mouth guards can be used during contact
sports.[10,11]
Recent Advances
Lumineers that are made from a special patented Cerinate
porcelain that is very strong but much thinner than traditional
laboratory fabricated veneers are currently in trend. The
thickness is comparable to contact lenses. Lumineers are
a reversible procedure and it hardly requires removal of
tooth structure. They will bond directly to the tooth making
the bond very strong and the longevity is more as up to
20 years.[12] However, after all the treatment is confined to
ideal patients.
Conclusion
Ceramic laminate veneers remain as prosthetic restorations that
best comply with the principles of present-day esthetic dentistry.
These are pleasing to the soft tissues and possess excellent
esthetic quality yet a conservative restoration can be called as
“bonded articial enamel.”
References
1. Highton R, Caputo AA, Mátyás J. A photoelastic study of
stresses on porcelain laminate preparations. J Prosthet Dent
1987;58:157-61.
2. Herbert victor E. Predictability of colour matching and the
possibilities for enhancement of ceramic laminate veneers.
JProsthetic Dent 1991;65:619-22.
3. Brunton PA, Aminian A, Wilson NH. Tooth preparation
techniques foe porcelain laminate veneers. Br Dent J
2000;189:260-2.
4. Cherukara GP, Davis GR, Seymour KG, Zou L,
SamarawickramaDY. Dentin exposure in tooth preparations for
porcelain veneers: Apilot study. JProsthet Dent 2005;94:414-20.
5. Rada RE, Jankowski BJ. Porcelain laminate veneer
Provisionalisation using visible light curing resin. Quintessence
Int 1991;22:291-3.
6. Cho SH, Chang WG, Lim BS, Lee YK. Eects of die spacer
thickness on shear bond strength of porcelain laminate veneers.
JProsthet Dent 2006;95:201-8.
7. Linden JJ, Swi EJ, Boyer DB, Davis BK. Photoactivation of resin
cements through porcelain veneers. JDent Res 1991;70:154-7.
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8. Hobo S. Porcelain laminate veneers with three-dimensional
shade reproduction. Int Dent J 1992;42:189-98.
9. Wall JG, Reisbick MH, Espeleta KG. Cement luting thickness
beneath porcelain veneers made on platinum foil. JProsthetic
Dent 1992;68:448-50.
10. Dunne SM, Millar BJ. A longitudinal study of the clinical
performance of porcelain veneers. Br Dent J 1993;175:317-21.
11. Peumans M, Van Meerbeek B, Lambrechts P,
Vuylsteke-Wauters M, Vanherle G. Five-year clinical
performance of porcelain veneers. Quintessence Int
1998;29:211-21.
12. Stappert CF, Ozden U, Gerds T, Sturb JR. Longevity and failure load
of ceramic veneers with dierent preparation designs aer exposure
of masticatory stimulation. JProsthet Dent 2005;94:132-9.
How to cite this article: Hari M, Poovani S. Porcelain laminate
veneers: A review. J Adv Clin Res Insights 2017; 4:187-190.
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... Contraindications [45] ▪ Insufficient coronal tooth structure ▪ Actively erupting teeth ▪ Patients with parafunctional habits like bruxism ▪ Endodontically treated teeth ▪ Reduced interocculsal distance ▪ Deep vertical overlap anteriorly All Ceramic Systems used for Porcelain Laminate Veneers [45] . Conventional ceramics, Castable ceramics, Machinable ceramics, Pressable ceramics and infiltrated ceramics. ...
... Contraindications [45] ▪ Insufficient coronal tooth structure ▪ Actively erupting teeth ▪ Patients with parafunctional habits like bruxism ▪ Endodontically treated teeth ▪ Reduced interocculsal distance ▪ Deep vertical overlap anteriorly All Ceramic Systems used for Porcelain Laminate Veneers [45] . Conventional ceramics, Castable ceramics, Machinable ceramics, Pressable ceramics and infiltrated ceramics. ...
... Two major principles governs tooth preparation sounds Preparation must be as conservative as possible and retention is solely by adhesion rather than tooth preparation [45] . ...
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A total of 315 porcelain labial veneers were fitted in 96 patients in two teaching hospitals, between July 1986 and October 1991, and were evaluated after a period of up to 63 months. During the evaluation period 53 (17%) restorations in 31 (32%) patients presented with a problem at review. Of these, 25 (8%) were of a minor nature and the veneer remained in use while 34 (11%) debonded or were removed. Increased problem and failure rates were associated with veneers placed on existing restorations, where tooth surface loss had occurred prior to treatment, and where inappropriate luting agents were employed. Age, gender, fabrication technique (platinum foil or refractory die), use of rubber dam and year of bonding were not significant factors.
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The overall clinical performance of porcelain veneers was evaluated at 5 years. Porcelain veneers were placed on 87 maxillary anterior teeth in 25 patients (19 to 69 years) by a single operator following a standardized clinical procedure. At the 5-year recall, esthetics, marginal performance, vitality, fracture rate, and patient satisfaction were recorded. At recall, 93% of the veneers were satisfactory without intervention. The remaining 7% presented clinically unacceptable problems such as recurrent caries, porcelain fracture, severe clinical microleakage, or pulpal reaction. The retention rate of the porcelain veneers was 100%, and the maintenance of esthetics was perfect. Only 14% of the veneers presented excellent marginal adaptation over the entire outline of the restoration; however, the impact of the slight marginal defects on the clinical performance was negligible. Labial porcelain veneers offer a reliable and effective procedure for the conservative treatment of discolored, malformed, and malaligned anterior teeth.
Article
Laminate veneers are widely used in the management of unesthetic anterior teeth. However, limited information is available regarding the influence of preparation design on longevity of ceramic veneers. This study evaluated the influence of preparation design on longevity and failure load of ceramic veneers bonded to human maxillary central incisors after cyclic loading and thermal cycling in a dual-axis masticatory simulator. Sixty-four caries-free maxillary central incisors were divided into 4 groups (n = 16). The control group remained unprepared (NP). For Group WP, a window preparation was made. Specimens in Group IOP were prepared with an incisal overlap of 2 mm without palatal chamfer. For Group CVP, specimens were prepared with a complete-veneer design of 3-mm incisal reduction and 2-mm palatal extension. Forty-eight IPS Empress 1 ceramic veneers were bonded adhesively with dual-polymerizing composite (Variolink II). All specimens were subjected to cyclic mechanical loading (1.2 million cycles, cycle frequency 1.3 Hz, invariable palatal load 49 N) and thermal cycling (5 degrees C-55 degrees C, dwell time 60 seconds, 5500 cycles) in a masticatory simulator. Failure was defined by bulk fracture of a specimen. Subcritical crack patterns were observed. Surviving specimens were loaded in a universal testing machine until fracture. The failure-load values (N) (1.5 mm/min crosshead speed) were automatically recorded by controlling software. Statistical analysis of data was performed by Kruskal-Wallis analysis of variance (alpha = .05) and pairwise Wilcoxon rank sum tests (alpha = .05). Three specimens from group NP, 1 specimen each from the WP and CVP groups, and 2 specimens from group IOP fractured during fatigue. After 1.2 million cycles, the highest crack rates were observed for complete veneers and originated in the palatal concavity extending to the facial surface. The median (interquartile range = x .25 - x .75 ) failure loads (N) were as follows: NP 713.3 (404.4-777.1), WP 549.5 (477.5-597.7), IOP 695.3 (400.0-804.6), and CVP 519.2 (406.1-732.9). No significant differences in longevity and failure load were demonstrated between natural teeth and teeth restored with ceramic veneers ( P = .555). Maxillary teeth restored with the 3 types of IPS Empress 1 veneers showed fracture resistance similar to that of unprepared incisors ( P = .555).