In the last decades the development of the porcelain materials, the reliable bonding strength to enamel and dentin, and the bonding of resin cement to the porcelain through the silane, Porcelain laminates become trusted type of treatment in the daily practice. It is an aesthetic treatment that concerns mainly the labial face of the anterior teeth, its thickness is about 0.3 mm in the cervical area to 0.4 -7 at the incisal third, in certain cases it can be done without any prep or just little touch of the enamel (lumineer), but in most prep is indicated to improve the adaptation in the cervical area also to remove the aprismatic enamel layer which which has low bonding strength with the resin cement, however prep should be in the enamel limits, 3 different type of prep are practiced, however, they are the same on the labial surface but the but the difference concerns the incisal edge. In this lecture, indications and contraindications are exposed. All the materials in use and their indications as well as the clinical procedures are detailed.

1. PORCELAIN LAMINATES.
By Dr. Bahjat Abu Hamdan
Consultant prosthodontist
DDS CES DSO
Damascus U. Paris Us.

2. Introduction.
 A nice smile, that reflects self confidence and
self esteem, is an important part of the face
beauty.
 The beauty of the teeth, that show when
laughing, through their
 - shape.
 - color.
 - Position and alignment.
is an essential part of the smile.

3. Introduction.
 Alteration of these elements, separately or
together, can be done by;
 Bleaching.
 Orthodontic treatment.
 Fillings.
 Crowning.
 Porcelain facings ( veneers ).
 Porcelain veneers, to certain limits, can alter the
color, the shape, and the position of the anterior
teeth by a minimal amount of tooth preparation
in the enamel limits ( 0.3-0.7mm).

4. Introduction.
 The following points;
 Esthetic and mechanical qualities and biocompatibility of the
porcelain.
 Saving of tooth tissues.
 Durability and reliability.
 improved quality and strength of bonding.
( the needed force to remove a PV is 63 MPa ).
Make the veneers a recommended treatment for the dentist and a
requested treatment for many patients.
Actually they are considered the first alternative to improve the
esthetic of the anterior teeth and by consequent the related
quality of life.

5. Introduction.
 Porcelain laminate veneers were introduced into
dentistry as Hollywood veneers by Pincus (1930).
 Buonocoreintroduced the concept of acid-
etching enamel as a means of mechanical
retention that composite resin restoratives had
retentiveness.
 Simonsen and Calamiadiscovered composite
resin’s ability to bond to porcelain if the ceramic
was treated with hydrofluoric acid. In 1983.

6. Both of them are smiling.

7. Porcelain laminate veneers were
introduced by Pincus (1930)

8. Celebrities before and after

9. Indications.
 1. Stained or darkened teeth.
 2.Tooth hypocalcification.
 3. multiple diastemas.
 4. Peg lateral.
 5. Chipped teeth.
 6. Lingual positioned teeth.
 7. Malposed teeth not requiring orthodontic.

10. Stained teeth.

11. Hypocalcification.

12. Multiple diastema.

13. Peg lateral.

14. Chipped teeth.

15. Lingual positioned teeth.

16. Discrepancy of teeth.

17. Contraindication..
 1. Available enamel; at least the periphery of
the laminate veneer should be surrounded by
enamel, lack of enamel support indicates
crowning of the concerned tooth.
 2. Ability to etch enamel; the bonding of
laminates is a micro-mechanical process of
etching. Deciduous and highly fluoridated
teeth may not etch effectively.

18. Contraindication..
 3. Oral habits; bruxism and nails and foreign
object bite. Porcelain withstands compressive
force than shearing stress.
 4. Patients with high caries index.
 5. compromised periodontal health.
 6.Endodontically treated teeth; a full crown
would hold the integrity of the non vital teeth
than a veneer.
 Teeth with gum recession.

19. Contraindications…
 7.Tooth with extensive restorations and small
triangular teeth.
 8. Unstable occlusion; pronounced overbite,
edge to edge occlusion, pronounced over jet,
severely crowded teeth and cases which have
to undergo another type of treatment ( endo,
resto, perio, and orthodontic).
 9. reduced inter occlusal distance and deep
overlap (higher tensile and shear stress).

20. Contraindication..

21. The current used materials.
 Based on the lab procedures used to fabricate
these laminate veneers;
 1. Sintered feldspathic porcelain. Using
platinum foil.
 2. Pressable ceramic by injection (feldespath
+ leucite).
 3. CAD/ CAM technique (feldspath reinforced
with leucite or lithium block) .

22. The current used materials.
 Based on translucency and opacity ;
 1.The amorphous glassy microstructure (non
crystalline) appears translucent (SiO2, quartz
with small amount of alumina, feldspath).This
type has low flexural strength.
 2.The crystalline microstructure appears opaque
(ZrO2, Al2O3).This type has high flexural
srength.
 The used porcelain for facing is feldspathic and
glass infiltrated (ceramic), both of them have
long term survival rate 96-98% for 5 years.

23. The current materials
 In general feldspathic, glassy and translucent
highly imitate the enamel, bonding to
enamel increase its strength, most of the
cases can be treated by glassy porcelain.
 Feldspath + leucite or lithium can be pressed
or milled. It has high translucency and high
flexural strength (cerinate).
 Incase of deep stain, a sintered zirconia
milled using CAD/CAM of 0.2mm then a
felspatic veneer is baked over it of 0.4mm.

24. Which material to choose?
 (a)Type I patients: facets are out of
functional stresses and are just esthetic, and
are referred to as simple esthetic facets; use
feldspathic ceramics.
 (b)Type II patients: in these cases the facets
are exposed to functional loading, and are
referred to as functional esthetic facets, this
cases needs high flexural strength; use
feldspath reinforced with leucite or lithium.

25. Available materials used
under different brands.

26. Materials and manufacturers.

27. Shade selection.
 Tooth color has intimate relation with the
color of the eyes, skin, and hair. All of these
elements have the same embryonic origin.
 Shade selection has three element; Hue
(color), chroma (saturation of color) and value
(lightness and darkness).

28. Shade selection.
 How to match a shade;
 1. Pt. should have neutral color clothes and
remove the lip stick.
 2. Clean the teeth, and have Pts mouth at the
dentist’s eye level.
 3. Use the canine as a reference for shade
because of the highest chroma of the
dominant hue of the teeth."

29. Color elements.

30. Shade selection.
 4. If unable to precisely match the shade,
select a shade of lower chroma and higher
value.
 5. Obtain value levels by squinting.
 6. Shade comparisons should be performed
at five-second intervals.

31. Shade selection.
 The final shade of the veneers depends on;
 .The color,( hue, chroma, and value.)
 . Opacity and thickness of the porcelain.
 . Underlying tooth shade.
 . Color and thickness of the luting composite.
 It is impossible to mask a strong discoloration by
a thin layer of porcelain (0.3–0.7 mm) without
making the restoration opaque and lifeless.

32. Good shade selection.

33. Poor shade selection.
Opaque and lifless.

34. Prepare or not to prepare.
 The porcelain facets, laminates, or facings
include the lumineers and the veneers.
 Lumineers are as thin as contact lens and
bond to the teeth with very little if any prep.
 They are made of cerinate porcelain
(feldspath leucite reinforced).They are strong
(F. strength 216 Mpa).
 Its thickness as thin as 0.2 to 0.3 mm.
 They are designed using CAD CAM or
pressable ceramic.

35. A lumineer is compared to
contact lens.

36. Prepare or not to ..
 The advantages of lumineers are; no need for
injection, no prep or little, its placed completely
on the enamel so no sensitivity at all and it can
be removed without damage to tooth tissues.
 But, due to no prep a small bulk and larger teeth
are likely to develop, also, due to its thickness, it
can not cover all the indications of the facets.
 They are considered as ideal for minor cosmetic
adjustment.

37. Tooth prep for veneers.
 The ultimate key to long-term success with
etched porcelain veneers is to use an intra-
enamel preparation. Research shows that
bonds to enamel are far more predictable and
durable than those to dentin.
 Several methods to attain the required
preparation.
 1. Free hand.
 2. Use depth or cut grooves.

38. Tooth prep..
 3. Use of silicone putty index. It derived from
the wax-up model that allows a visualization
0f reduction required of the preplanned
veneers.
 Different types of preparation differ only at
the incisal region of the tooth.

41. Porcelain kit veneer.

42. Tooth prep Incisal edge ..
 a. No reduction of the incisal edge, this the
case where there no modification of tooth
length, also it is called window prep.
 B. 1.5-2 mm reduction of the incisal edge
 (Incisal butt).
 C. Incisal reduction that carried the incisal
edge from labial to palatal, which provide a
positive seating during cementation. Also
margin is not subjected to protruded forces
so stresses are reduced on the veneer.

43. Different type of incisal
prep.

45. Proximal contact..
 Do not break the proximal contact (prepare
2/3 of it).When the teeth are not spaced.
 In case of spaced teeth, include the proximal
by slice prep.

46. Proximal contact.

47. Cervical margin prep..
 It will be chamfer design with maximum
depth 0.3-0.4 mm, also it should be supra-
gingival or at the gum level (use the
retraction cord when taking the impression).
 This design allows the veneer to integrate in
the tooth anatomy without any discernible
demarcation.
 No dentin exposure which give less chance to
micro leakage.

52. Final impression.
 Before taking the final impression of the
prepared tooth, fabricate a preliminary
provisional restoration using a bis-acryl
provisional material.This will give the chance
to evaluate the thickness, the shade, and the
alignment which can be modified before the
final impression.
 This could be done by a silicone impression
of the waxed-up model, filled by acrylic and
inserted in the mouth till setting.

53. Final impression.
 Use metallic tray (rim lock) to avoid any
distortion or separation of the impression
material.
 Vinyl polysiloxane is the material of choice.
 You can use the wash technique or double
mix technique.
 In case where the dentin is exposed mainly in
the cervical, use the dentin adhesive before
the impression.

54. Cementation…
 1.Try in ..
 Remove provisionals, clean, isolate and dry.
 Moisten the veneers, place them on the
teeth, and check up the fit and the shade.
 Use try-in paste to adjust the shade (water
soluble).
 Use 37% Ph A for 30 sec to clean the veneers
if they are etched in the lab.
 Rinse and dry.

55. Cementation..
 2. cementation..
 Apply silane to the etched teeth for 60 sec and
air dry.
 The teeth are well cleaned, dried and isolated.
 Etch for 10 to 20 sec, rinse and dry.
 Apply enamel/dentin bonding and light cure the
adhesive, or do not cure up to the manufaturer
instruction prior to seat the veneer.
 Apply unfilled resin if indicated.
 Apply composite resin on the veneer and place it
in an inciso-gingival direction

56. Cementation..
 Hold the veneer and check its proper seating,
remove any additional excess using adhesive
coated brush.The adjacent teeth should be
isolated using celluloid strips, cure starting in
the gingival area for 10 sec, some request
curing in the center first then proceed
removing the excess. then continue around,
then the whole face for 60 sec.
 If all the anterior teeth are concerned,
cement 2 by 2 starting from the midline.

57. Cementation..
 High filled resin cement should be applied in the
cervical when the margins are in the dentin, this
cement has reducedTEC and reduced setting
shrinkage. So that reduced microleakage
consequently sensitivity, discoloration, and
recurrent caries.

58. Cementation..
 Tay et al. [109] advised to remove the excess
of non- polymerised composite cement with
a brush moistened with bonding resin.This
will reduce the dragging out tendency of the
resin out of the marginal gap and ensure a
smoother margin that is polishable.

59. Cementation.
 Light curing is preferred for porcelain veneers.
 It has the following advantages; in addition to its
color stability , it has long working time
compared to dual cure or chemical cure cements
which give enough time to finish.
 The porcelain veneer absorb between 40-50% of
the emitted light.Thickness and opacity
determine the light transmittance.
 Use dual cure when the thickness exceeds
0.7mm.

60. Cementation..
 Finishing..
 Remove gross excess using sharp hand
instruments or fine and extra fine diamond
finishing burs.
 Finish the proximal using fine strips.
 Place the next two.
 Use porcelain finishing paste for polishing if
needed.
 Check up the occlusion.

62. Related facts.
 Enamel reduction is required to improve the
bonding strength. Doing so means removal of
the aprismatic enamel layer which offer less
retention.
 Reduction is in the limit of 0.3 to 0.7 mm. free
hand always remove more than 0.5.
 If dentin is exposed, use dentin bonding after
prep directly and provisional restoration is
important.
 96% of success rate refers with incisal coverage,
86% W/O incisal coverage.

63. Related facts.
 Clinical exam and diagnostic impose the amount
of prep as well as the type of restoration.
 To successfully bond veneers, 50% of the bonded
substrate must be enamel, 70% or more of the
peripheral must be in the enamel.
 higher failure rates in vivo when porcelain
veneers were partly bonded to underlying
composite restorations. It is advised to change
the old fillings to improve the retention.

64. Related facts
 Preparation depth in the range of 0.4 to 0.6
mm was largely seen to be intra enamel,
except in the cervical region. (cherokara et
al).
 Wax-up, followed by silicone index, is an
important step, in certain cases, to visualize
the predicted results.
 Transparent resin cement is suitable for 90%
of the cases.

65. Related facts.
 The mean vertical marginal discrepancy (for
all positions combined) for platinum foil
veneers (187 mic) was significantly less than
that for veneers made with the refractory die
technique (242 mic). ( another study 74 versus
132 mic),
 Light-cured and dual-cured luting
composites show a similar leakage pattern at
the luting composite/tooth inter- face
according to Zaimoglu et al.

66. Related facts.
 The strength of the combined
porcelain/luting composite/enamel bond (63
MPa), composite/etched enamel (31 MPa)
and luting composite/etched-and-silanized
porcelain (33 MPa) bond strengths.
 Poor adaptation means large gap, due to the
setting shrinkage (volumetric S. 2.6-5.7) will
create marginal opening and expose the
cement to wear.

67. Related facts.
 Ceramic composition and surface
treatment protocols
 Ceramic Conditioning Feldspathic 9.5%
hydrofluoric acid for 2 to 2.5 min; 1 min
washing; silane application. Leucite-
reinforced 9.5% hydrofluoric acid for 60 s; 1
min washing; silane application. Lithium
disilicate-reinforced 9.5% hydrofluoric acid
for 20 s; 1 min washing; silane application

68. Related factors.
 During cementation, due to setting shrinkage
and bonding retention certain veneers may
crack, leave but follow up.
 A ceramic and luting composite thickness
ratio above 3.This ratio also appears to have
a relevant influence on the stress distribution
in porcelain laminates.Too thin veneer ,
combined with poor internal fit , resulted in
higher stresses at both the surface and
interface of the restoration.

69. Related facts
 Micro leakage at the luting composite/porcelain
interface was negligible compared to the luting
composite/tooth interface.
 Setting shrinkage and difference of TEC between
the resin , tooth tissues and porcelain, will cause
stress at composite/ enamel, and composite/
porcelain.
 Due to the aprismatic enamel in the cervical leakage
is more pronounced.
 Stresses are more important than in a composite
filling (done by increment).

70. Relate facts.
 Vitro studies have demonstrated a
dissolution of the resin matrix of composite
resin in oral fluids, so that decreased filler in
the resin cement means higher dissolution
and more gaps.
 As a conclusion, microleakage can be
minimised by locating the preparation
margins of the veneer in enamel and by
selecting a highly filled luting composite.

71. Maintainance.
 1. Avoid colored beverage during initial 72-97
hours.
 2. Use soft brush with non abrasive tooth-
paste.
 3. Do not shear or bite hard objects.
 4. Avoid acidulated mouth rinses.

72. Thanks.