Indirect Porcelain Veneer Technique for Restoring Intrinsically Stained Teeth Steven T. Cutbirth, D.D.S."

Indirect porcelain veneers are often the ideal restoration for intrinsically stained teeth. This articledetails a step-by-stepprocedure for estheticallyrestoring discolored teeth. Porcelain laminate veneers are often indicated when teeth bleaching or direct composite bonding procedures cannot provide the desired esthetic result. Veneers are more appealing to many patients than full coverage crowns because of the more conservative tooth preparation required. If technique details are followed meticulously and cases are appropriately selected, porcelain veneers are not only durable but also promote marvelous gingival health and may be the most esthetic anterior dental restoration.

Indirect Porcelain Veneers: Examination and Analysis

teeth/lip/smile relationship. Photographs are important for studying the teeth that are seen when the patient smiles, laughs, and talks. The number of teeth that should be laminated to produce the most pleasing esthetic result may then be determined. High quality photographs are also invaluable for analyzing the position of the incisal edges of the natural anterior teeth in relation to the upper and lower lips to determine whether or not that incisal edge position should be modified with the laminates. Impressions are taken for study models to be mounted in centric relation on a semiadjustable articulator. The patient's occlusion is analyzed both in the mouth and on the articulator. If an imbalance exists and/or the patient exhibits symptoms of temporomandibularjoint disorder, t h i s problem should be dealt with prior to restorative dentistry.

Preclinical Interview Interview the patient in a nonthreatening setting prior to performing any other phase of the examination or treatment. Determine the following: 1. How they perceive their dental problem: 2. Why they have come to see you: 3. Their understanding &nd appreciation of dentistry: 4. Any obstacles to ideal treatment (finances, time, distance, etc.): 5. Any other dental or medical problems; 6. Your initial impression of the patient's temperament: and 7. Whether you feel you can work with this patient and can satisfy their expectations.

Consultation

Show the patient high quality photographs of cases similartotheirs that you have completed. Be certainthat they understand the restorative process and the probable result prior to developing a specific treatment plan or having a formal postexamination treatment plan consultation.

Review with the patient their photographs and mounted models, describing treatment options. Also use books,journals, or other sources to make certain the patient has a clear understanding of the procedures you are suggesting. Agree on appropriate treatment. Present the patient with a typed letter covering the following:

Clinical Examination Appropriate radiographs should be taken. Perform thorough periodontal, caries, occlusal. temporomandibularjoint, and smileanalyses. Excellent photographs or slides should be taken of the anterior teeth and the

1. The patient's chief complaint and expectations: 2. The general discussion that took place during your preclinical interview, including before and after photographs viewed and procedures discussed; 3. Treatment options; 4. Cost/hancial arrangements: 5. Anticipated result and future of the restorations, including variables and the patient's and dentist's responsibilities for preserving the restorations.

*private Practice. Waco. Texas Address reprint requests to Steven Cutbirth. D.D.S., 16 13 Lake Success, Waco, TX 76710 0 1992 Decker Periodicals Inc.

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6. The dentist and patient should sign the consultation letter. The patient receives the original letter and the dentist retains the copy. This letter is not a contract. It merely helps prevent misunderstandings between the patient and dentist.

place indirect porcelain veneers on her upper 10 anterior teeth (Fig. 2). Procedures in sequence were performed according to the technique outlined below.

indirect Porcelain Veneer Tooth Preparation

TECHNIQUE

A middle-aged woman desired correction of discolored central incisor and, additionally, cosmetic improvement of the appearance of her smile. We decided to

A Brasseler 6856-018 or 016 round-ended coarse diamond was used to contour the labial and incisal aspects ofthe teeth to be laminated to the predetermined ideal dimension. This step is not tooth preparation, but tooth reshaping, based on preclinical analysis of study models mounted on a semiadjustable articulator in centric relation and excellent photographs or slides of the anterior teeth. The objective is to achieve the best possible arch form and incisal edge positions prior to laminate veneer tooth preparation. The same round-ended diamond was now used for preparation of the teeth for indirect porcelain laminates. The facial surfaces and the incisal edges of the upper anterior centrals, laterals, cuspids, and bicuspids were

A.

A.

B.

B.

Figure 1. Cwe 1: Tetracycline-stained teeth.

Figure 2. Case 2: Discolored central incisor and need for cosmetic improvement of patient's smile.

Case 1 A 30-year-old woman desired esthetic correction of her tetracycline-stained teeth (Figs. 1A and B). We determined that her esthetic objectives could be met by placing indirect porcelain veneers on her upper 10 anterior teeth (see Fig. 1).

Case 2

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Figure 3A. Case 1: Teeth prepared for porcelain veneers.

Figure 4. Case 2:Etching with 10%phosphoric acid.

Figure 3B. Case 1: Porcelain veneer tooth preparations.

Figure 6. Case 2:Etched, rinsed, and dried prepared teeth.

Figure 3C. Case 1: Teeth prepared for porcelain veneers.

Figure 6. Silane porcelain primer applied to etched surface.

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A. B. Figure 7. A and B, Three to five coats of dentin/enamel primer were applied to moist, prepared surface of the teeth. The tooth surface should appear glossy.

reduced approximately 0.5 mm. The incisal finish line should be located on the lingual surface so that the laminate covers the entire incisal edge. The incisal preparation should taper gingivally from the lingual to the facial surface. The interproximal margins should be locatedjust labiallyto the proximal contact areas, taking care to extend the proximal preparations lingually in the gingival third of the teeth so that margins are not evident facially. A deep chamfer margin is placed gingivally and interproximally. The preparation is completed using a Brasseler 8878-016 or 014 fine chamfer diamond to finish all margins. Seldom is retraction cord necessary. Extend the tip of the 8878 chamfer diamond approximately 0.05 mm into the gingival crevice and remove any “lipped” enamel that may have been left after preparation with the 6856 round-ended diamond. Do not create a knifeedge margin. The margin should be a deep chamfer. Gently polish the remaining margins of the preps with the 8878 chamfer diamond to smooth any rough edges (Figs. 3A, B, and C).

Provisional veneers are seldom placed, so every effort should be made to seat the laminates as soon as possible. Apply three to five coats of dentin/enamel primer (Primer A & B, not unfilled bonding resin) to the moist, prepared surfaces of the teeth. Do not light cure. This will reduce tooth sensitivity while the patient is waiting for the laminates to be fabricated. Advise the patient that they may experience some sensitivity until the final restorations are placed. Have the patient wipe the teeth twice a day with a cotton ball soaked in hydrogen peroxide mixed with lukewarm water. Flossing should also be part of the daily regimen. It is essential that the gingival tissue is healthy and does not bleed or “weep” when the porcelain veneers are seated. This allows an environment for ideal bonding.

Indirect Porcelain Laminate Veneer Insertion 1. After administeringlocal anesthesia, gently floss the

2.

3.

4.

5. 6. 7. Figure 8. A thin matrix strip is placed interproximally between d teeth to be laminated.

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teeth with unwaxed dental floss dipped in hydrogen peroxide. Clean the prepared teeth with cotton balls soaked in hydrogen peroxide. Rinse thoroughly. The lingual surface of the porcelain veneers is etched with hydrofluoric acid by the laboratory technician prior to delivery to the dentist. Place a 2 x 2 inch cotton gauze square behind the patient‘s teeth as a safety net. Dip the porcelain veneers in water and try them on the teeth. The water allows the veneers to stick to the teeth. The margins of the laminates should fit the prepared teeth precisely. Remove the laminates, rinse with distilled water, and dry. Etch enamel/dentin surface with 1OYo phosphoric acid for 15 seconds. Rinse and dry (Figs. 4 and 5). Apply silane porcelain primer to etched surface of veneers (Fig. 6). The Bisco Choice Porcelain Veneer System was used to bond the indirect porcelain veneers. Apply three to five coats of dentin/enamel primer to the dry, prepared surface of the teeth. Allow 10to 15 seconds between coats. The tooth surface should appear

JOURNAL OF ESTHETIC DENTISTRY VOLUME 4, NUMBER 6 Novemher/Decemher

1992

9. Coat the silane-primed lingual surfaces of porcelain veneers with three to five coats of dentin/enamel primer (Primer A & B) (Fig. 9). Do not light cure.

Select the appropriate shade of porcelain adhesive paste and apply a thin layer to the lingual surface of the porcelain veneer to be seated first (Fig.10). 10. Seat the incisal portion of the veneer first, then apply gentle pressure on the laminate in a gingival/lingual direction until the laminate is completely seated. Seat the laminate initiallywith finger pressure, then hold in place with a cotton-tipped applicator. Excess composite should extrude from all margins. Do not remove excess composite until after final light curing or marginal voids may occur. Immediately cure each laminate for 20 seconds while applying pressure in a gingivolingual direction with a cottontipped applicator. This brief curing will lock the laminate in place until final curing once all laminates have been seated (Figs. 11A and B). 11. Repeat this process with all laminates. Once all laminates have been seated with porcelain adhesive paste, light cure for 60 seconds on the facial surface,

Figure 9. The silane-primed lingual surfaces of the porcelain veneersare coated with dentin enamel primer.

glossy following primer application (Figs. 7A and B). If the surface does not appear glossy after drying, apply three to five more coats of PrimerA & B. Do not light cure. When bonding indirect porcelainveneers to teeth, do not apply unflkd dentin/enarnel bonding resin (All-Bond) to the teeth or veneers. Several coats of Primer A and B are all that is required for ideal bonding. 8. A thin matrix strip (shim stock-O.0005 inch thick) is placed interproximally between all teeth to be laminated. Do not use a wedge (Fig. 8).

A.

B. Figure 11. A and B, The laminate is held in place with a cotton-tipped applicator. Each laminateis cured for 20 seconds while applying pressure with a cotton-tipped applicator.

Figure 10. A thinlayer of porcelain adhesive paste is applied to the lingual surface of the veneer to be seated fist.

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Figure 12. Laminates immediately after curing.

Figure 13. Excess marginal composite is removed.

A. Figure 14. A and B,Postoperative photographs of Case 2.

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A.

B.

Figure 15. A and B, Postoperative photographs of Case 1. 195

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C.

Figure 16. Two-year postoperative photograph of Case 1.

60 seconds on the lingual surface (through the tooth), and 30 seconds on the incisal surface of each tooth. This may be overcuring, but remember that the primary cause of bonding failure is undercuring. Overcuring is never a problem (Fig. 12). 12. Remove excess marginal composite with thin 12and 30-fluted carbide finishing burs (Fig. 13). 13. Polish the interproximal areas with finishing strips. Check the interproximal areas for overhangs with unwaxed dental floss. 14. Check centric occlusion and all excursive movements. 15. Polish the interproximal and incisal areas with porcelain paste applied with a rubber prophylaxis cup. Be very gentle when polishing the gingival margins as the diamond paste may be irritating to the gingival tissue. Figures 14A and B are postoperative photographs of Case 2. Figures 15A, B, C, D, and E are postoperative photographs of Case 1, and Figure 16 is a 2-year postoperative photograph of Case 1.

D.

REFERENCES 1. Cutbirth ST. Restoration of maxillary anterior teeth using porcelain jacket crowns and porcelain veneers. J Esthet Dent 1992; 41-5. 2. Jordan RE.Esthetic composite bonding. Toronto/Philadelphia: BC Decker, 1988.

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PyeUre 15. C, D,and E, Postoperative photographs of Case 1. 196

Indirect porcelain veneer technique for restoring intrinsically stained teeth.

Indirect porcelain veneers are often the ideal restoration for intrinsically stained teeth. This article details a step-by-step procedure for esthetic...
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