Gerard Ku!l DMD, MS, PhD

Do’s & Don’ts of Porcelain Veneers Disclosure! Funded Research

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RecolorRepositionRecontourReshape: Occlusal EquilibrationRestore

Philosophy of Esthetic Dentistry

Referred for veneers

After Bleaching, Microabrasion, Class IV #10,Veneer #8

Veneer Referral?

Microabrasion Immediate Post-op

PREMA Micrabrasion and Zoom

“F” & “S” sounds & Incisal Edge position

Esthetic Evaluation in Wax

3D Printed Esthetic Evaluation in Wax or

Resin

Retaining or re-establishing Anterior Tooth Position is the most important factor in Esthetics and Speech

Vertical dimension

Anterior guidance

“S-F” sounds

Tooth shape

Esthetic and FunctionVirtual Articulation

Virtual Articulation is turned on or off during the setup phase. If turned on it will take the in to consideration the jaw movements of the patient to render a better initial proposal.

The articulator is an averaged based adjustable articulator, ranges may be changed if you have know values for the patient. Proper setting of the initial model axis is critical.

3D Printing

1986

2017

1928 Porcelain “Hollywood Bridge”, Dr. Charles Pincus

1937 Acrylic Veneers, Dr. Charles Pincus

1958 Development of Composite Resins, Dr. R. Bowen

1959 Acid Etch of Enamel, Dr. M. Buoncore

1976 Acrylic Veneers luted on Etched Enamel

1983 Etched Custom Porcelain Veneers Luted to Etched Enamel Surfaces, Dr. Harold Horn

HistoryofVeneers

Indications

HypoplasiaAmelogenesisImperfectaMalforma7ons(pegs)IntrinsicStaining

Contraindications

InsufficientEnamelLargeRestora7onsOcclusalInterferences

EdgetoEdgeCrossBite

Contraindications

DarkStainsBruxismPeriodontallyinvolved

Full Coverage?

Check Contraindications Mounted Study Models Posterior Occlusion Protrusive Interferences Lateral Interferences Centric Anterior Lingual Contacts

Treatment Planning Occlusion the patient makes when they fit their teeth together

in maximum intercuspation.

Intercuspation Position (ICP), Bite of Convenience or Habitual Bite.

Occlusion that the patient nearly always makes when asked to close their teeth together, it is the 'bite' that is most easily recorded.

Centric Occlusion (CO)

Veneers?

Premature contact in CR

If a patient has an ideal occlusion, centric occlusion (CO) is in centric relation (CR) with anterior guidance free from posterior

interferences. This is unusual!

The coincidence of Centric Occlusion in Centric Relation (CO = CR), when there

is freedom for the mandible to move slightly forwards from that occlusion in the same sagittal and horizontal plane

(Freedom in Centric Occlusion)

No matter how far back these teeth are they are anterior to the temporomandibular joints and so a patient with a severe anterior

open bite would still always have anterior guidance of their mandible, it could, for instance be on the second molars.

If, as this is happening, a posterior maxillary and mandibular tooth hit against each other and because these two posterior teeth are close to

the joint, then there is potential for the contact between these two teeth to influence or 'interfere' with the movement of the condyle within that

joint

The Lucia Jig helps obtain centric relation by de-programming muscles and allowing the condyles to seat in the most superior position. “It

separates the posterior teeth, and by separating the posterior teeth it allows the lateral pterygoid to release, and when the lateral pterygoid

releases, the condyle seats...it’s that simple,” Dr. F Spear

Standard Class II

Lucia Jig To Aid in CR Determination

Using red articulating paper, confirm that the lower centrals are contacting the jig evenly. Place the red

articulating paper between the jig and the lower centrals. Ask the patient to slide the lower incisors forward and

back several times marking the jig.

To determine the patient’s most retruded position ask the patient to bite down, slide forward, back, and squeeze. Repeat

and hold. Ask the patient to open slightly, place black articulating paper between the jig and the lower centrals and ask the

patient to tap three times. The most retruded point of contact of the lower incisors has now been marked in black on the jig.

Anterior Deprogrammers (Lucia jig, Leaf gauge)

Self-guided

Central Bearing Devices (Intra/Extra-oral devices), i.e., Coble tracer

Chin point/One-handed techniques

Bilateral Manipulation (Dawson Technique)

Myomonitor

Techniques for Recording Centric Relation

0.1mm thick polyester material Numbered 1-55 Polyester material is flexible Can be sterilized

Text

Leaf Gauge Record

Continue adding leaves until no posterior tooth contact is felt

remove leaves one at a time to determine the first contact

Record the number of leaves when the patient feels tooth contact.

Record the location of the initial tooth contact and location on the teeth.

Centric occlusal interferences (occlusal prematurity)

StablePosteriorOcclusion

Protrusion

Template forCrown Lengthening

3 weeks post

3 weeks post op

Initial

Maxilla- 6 months

Mandible- 3 months

Final wax-up after surgery Printed Surgical Guide

UnaestheticGingivalMargins

Delivery

1 Month

Reduction Guide Made From Diagnostic Wax-up

1st Cut for Incisal 1/3 2nd Cut for Mid and Cervical Third Reduction

Under reduced based on Wax-up

SiliconeShell

Suckdown

Temporization

Shell to be Used on Preped Teeth Using Bis-acrylic

No PrepFacial PrepFacial Incisal OverlapFacial Incisal Butt Joint

Preparation Guidelines

Defined Chamfer LineProximal Chamfer ½ Way Through Contact0.5-1.0 mm Facial Reduction

Preparation Guidelines

1.0-1.5 mm Incisal ReductionAll Incisal Angles roundedNo UndercutsLingual Chamfer line must be either above or below the Centric Lingual Contact Line

Preparation Guidelines

1988-2012

Refined PrepsTry-in

Etch (with Hydrofluoric Acid) Prime (silanate)

Ceramic Etching Gel (5% HF or 9%) IPS Empress® (60 sec or 30 sec)

IPS e.max® (20 sec or 10 sec)

Silane All restorative Materials (60 second

application)

Over etched – frosted finish

Properly etched

Variolink Esthetic LC System Kit •3 syringes Variolink Esthetic LC, 2 g (light, neutral, warm)

•3 syringes Variolink Esthetic Try-In Paste, 1.7 g (light, neutral, warm)

•1 syringe Total Etch, 2 g •1 Adhese Universal, 2 ml or 5 g •1 bottle Monobond Plus, 5 g •1 syringe Liquid Strip, 2.5 g •Various accessories ®666433WW with Adhese Universal VivaPen, 2 ml ®666065WW with Adhese Universal bottle, 5 g

108

109

Linear Measurement

AxisandGingivallevel Golden Proportion

Alignment Guideline

115 116

117 118

120

Lithium Disilicate

LowerAnteriorPrepDesign

Shell to be Used on Preped Teeth Using Bis-acrylic

Temporization

Thin Area on Temp, Indicates more Reduction Needed

CementationIn general, dentists will select a total etch adhesive when bonding more to ENAMEL.

Better etch pattern on enamel(due to separate phosphoric acid etching)

Total EtchIn general, dentists will select a self etch adhesive when bonding to more DENTIN.

Less likely to have post op sensitivity (not removing smear layer with separate etching step)

Etch pattern is sufficient when bonding to “softer” dentin material

Self Etch

Try-in veneer with water or Translucent shade (water-soluble ) to verify fit and esthetics.

If color adjustment is needed, select appropriate shade.

If esthetics and fit are acceptable, remove veneer, rinse, dry and proceed with bonding procedure. May clean with etch.

Cementation Technique Shade Confirmation

Try-in

Restoration: Etch surface

IPS Empress- 60 seconds IPS e.max- 20 seconds Rinse and dry

Prime surface with Ceramic Primer and allow it react for 60 seconds. Thoroughly air dry

Variolink II Basic Steps

Etch (with Hydrofluoric Acid) Prime (silanate)

Ceramic Etching Gel (5% HF or 9%) IPS Empress® (60 sec or 30 sec)

IPS e.max® (20 sec or 10 sec)

Silane All restorative Materials (60 second

application)

Effect of Etching on Shear Bond Strength

0

10

20

30

40

Empress emax CAD emax Press

Under etched Recommended Etch Over Etched

Prep: Etch with phosphoric acid (Enamel 30 seconds/ dentin 15

seconds). Rinse and air dry leaving preparation moist. Apply Adhesive for 10 seconds. Thin with air for 2-3

seconds. Light cure Dispense cement into restoration and seat on prep Clean up excess cement Floss interproximally Final light cure- 20 seconds on each side

Basic Steps

Adhesive

Apply 2 consecutive coats of Dental Adhesive to enamel and dentin

Dry gently for 2-5 seconds. Light-cure?

Apply1coatofadhesivetothesilanetreatedbondingsurfaceoftheveneer(notrecommendedwithVariolink).

Drygentlyfor2-5seconds.DoNotLight-cure!

ApplyselectedshadeofVeneercementtotheveneer.

Treatment of veneers

Seat the veneer with gentle pressure.

Clean excess with brush wet with adhesive or tack cure & clean.

Tack cure the veneer on the facial/cervicle surface for 2-3 secs

Cementation Technique Seating

A thin layer of petroleum jelly on the paper enhances the contact points as they are transferred to the appliance.

Place approximately 1 mm of leaves on the patient’s centrals & ask them to bite down holding the Leaf Gauge, slide

forward, back, and squeeze. Ask the patient if he or she feels any contact.

Full Contact Splint with Anterior Guidance

Full Contact Splint with Anterior Guidance

Flat Plane Splint

Avoid doing only 6 teethCheck occlusion carefully before you drill!!Deliver 8 & 9 first then work backAvoid self etching BA Stay in enamel (if possible)Temps are your “test drive”Use light cured cementsLight cure the bonding agent on the tooth first?When in doubt do a crown

Don’t be afraid to talk to your lab tech

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