philosophy of esthetic dentistry
TRANSCRIPT
Gerard Ku!l DMD, MS, PhD
Do’s & Don’ts of Porcelain Veneers Disclosure! Funded Research
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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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