Lt Col Vikas Dhir. / IJRID Volume 5 Issue 4 Jul.-Aug INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY

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1 Available online at ISSN X Case report INTERNATIONAL JOURNAL OF RESEARCH IN DENTISTRY PORCELAIN LAMINATE VENEERS FOR A CONSERVATIVE AESTHETIC ENHANCEMENT OF SMILE Lt Col Vikas Dhir * *MDC BEG, East Kirkee, Pune Received: 21 June. 2015; Revised: 25 Jul. 2015; Accepted: 29 Aug. 2015; Available online: 5 Sep ABSTRACT Aesthetics is an inseparable part of today s dental treatment and has influenced the malady of dental diseases. Porcelain laminate veneers have been used for numerous decades for enhancing the aesthetics. Minimally invasive preparation designs and modern ceramic materials make this treatment option increasingly conservative to the natural tooth structures, while providing both predictable and long-lasting aesthetics. Key Words: anterior, minimally invasive, porcelain, porcelain laminate veneers (PLVs) INTRODUCTION In the present era of Aesthetic dentistry, patient s expectations and demand for dental esthetic treatment has increased and achieving ithas become a reality especially with the advent and popularity of Porcelain Laminate Veneers (PLV).Porcelain veneers are thin bonded ceramic restoration that restore the facial surface and part of proximal surfaces of the teeth requiring esthetic restoration. It is used to recreate the natural look of teeth, enhancing the smile and aesthetics while also providing strength and resilience comparable to natural tooth enamel. It is often the material of choice for those looking to make slight position alterations, or to change tooth shape, size, and/or color. A case series of Aesthetic and smile enhancement by conservative Porcelain Laminate veneers has been discussed. CASE REPORT- Case 1. A 35 years old patient came to Dept with desire of improving the aesthetics of upper front teeth and enhancing smile. He was born and brought up in Haryana (high fluoride belt). He noticed his discolouration of teeth since childhood. Parents and other siblings also had multiple discoloured teeth. On extra-oral examination, he was systemically healthy. Intra-oral examination revealed he had generalized brownish and patchy white spots and discolouration of teeth. Mild physiological pigmentation of gingiva. Generalized spacing of maxillary anterior teeth. No signs of periodontal disease or trauma from occlusion. He had relatively healthy 96 Lt Col Vikas Dhir / IJRID Volume 5 Issue 4 Jul.-Aug. 2015

2 dentition with adequate oral hygiene. While there was minimal occlusal wear on the posterior teeth, slight wear of anterior teeth was evident. No joint or muscle tenderness was noted. Routine blood and urine investigation were within normal limits. IOPA radiographs and OPG did not reveal any gross abnormality or pathology of jaws and teeth. Diagnosis Generalized mild Fluorosis of teeth and generalized spacing in maxillary anterior region. Treatment plan- Oral prophylaxis including polishing. Upon consultation with the patient, it was decided to take a minimally invasive approach to smile design using Porcelain /ceramic laminates veneers for maxillary anterior teeth. Detailed Procedure The armamentarium for the procedure was laid out. Gingival zenith was noticed. Length and width of each anterior maxillary teeth were recorded. Spacing was measured. Silicon impression putty guide was made for evaluation and guidance. Reduction commenced with the establishment of arch form; 0.5-mm depth cuts were subsequently made on all of the teeth. The teeth were prepared as minimally as possible utilizing a diamond bur for gross reduction and a round-ended bur for cervical margins and placement of interproximal elbow and incisal lingual wrap preparation was done. Significant enamel was conserved by minimally reduction of mm on labial aspect. Silicon reduction guide was used to evaluate amount of reductions in incisal, middle and cervical region. Impressions were made with silicon putty impression material. Casts were poured and articulated. Bite was recorded to prevent canting of incisal edges. Shade of teeth were selected and communicated to ceramist/laboratory technician. Wax up was done and try-in was done. After approval from patient, these were sent to lab with instructions in length and width of wax try in. No provisionalization was done. Pressed ceramics (IPS e-max, Ivoclar Vivadent) were used in lab for preparation of veneers. After preparation of veneers, patient try-in were done in unglazed state but wetted in water in next appointment. After checking shade, aesthetics, function and phonetics, veneers were sent back to lab for glazing. When returned from the laboratory, the restorations were evaluated for marginal integrity on the trimmed working die and solid models. The restorations were removed and etched with 4% Hydrofluoric acid for 120 seconds each, rinsed thoroughly with running water, dried and silanated with Porcelain primer (Bisco, USA). The recipient teeth were polished with pumice slurry. The preparations were etched with 32% phosphoric acid for 10 to 15 seconds before being thoroughly rinsed and excess water was removed. A fifth generation bonding agent (Prime & Bond NT, Dentsply) was 97 Lt Col Vikas Dhir / IJRID Volume 5 Issue 4 Jul.-Aug. 2015

3 applied copiously to the preparations and allowed to penetrate the dentin for 20 seconds. The preparations were then lightly air-dried before being cured with a halogen LED light for 30 seconds. The restorations were internally coated with the bonding agent but were not cured. A dual cure self adhesive resin luting cement (3M,ESPE, RelyX U-200, UAE) was used to bond the veneers into place. The restorations were then seated together cured for 2 sec each. Excess cement was removed and again light cured for 60 sec in each surface. Then restorations were finished and polished, and occlusion was adjusted for centric contacts and anterior guidance. He was satisfied with the aesthetic enhancement achieved through this predictable restorative conservative approach. Instructions and care and follow up- Patient was instructed to perform brushing and flossing regularly, Use non-abrasive fluoridated toothpaste. Avoid the excessive stresses: don t bite your fingernails, chew ice, or open beer bottles with front veneered teeth. Review regularly after one week, one month and every six months for gingival health and margins of veneers. The patient returned to the clinic after 1 week later to permit a final examination of aesthetics, phonetics, and occlusion. Patient came for follow-up after 1 month and 3 months. Case 2. A 21 years old patient came to Dept with desire of improving the unaesthetic appearance of front teeth and enhancing smile. After thorough examination she was diagnosed as a case generalized mild Fluorosis with hypoplasia of enamel. She was taken up for with In-Office Bleaching using Pola-Office Bleach using H 2 O 2 and Power bleach LED System in initial stage. As result was not very encouraging, Porcelain Laminate Veneers in region were done for the patient to enhance her smile and aesthetics. Similar protocol was followed and instructions were given. Patient has been followed up after 1, 3 months. Discussions- Porcelain veneers are an important part of aesthetic dentistry s armamentarium. Porcelain/Ceramic Laminate Veneers can be used in all aesthetic situations including diastema closure, peg laterals, revitalizing PFMs, correcting severely prominent teeth, lightening discoloured or dark teeth, and correcting poor arch contour, misaligned and rotated teeth, as well as other indications especially for enhancing smile in anterior region. Veneers were invented by California dentist Charles Pincus in 1928 to be used for a film shoot for temporarily changing the appearance of actors' teeth [1] by Simonsen and Calamia revealed that porcelain could be etched with hydrofluoric acid and bond strengths could be achieved between composite resins and porcelain that were predicted to be able to hold porcelain veneers on to the surface of a tooth permanently [2]. 98 Lt Col Vikas Dhir / IJRID Volume 5 Issue 4 Jul.-Aug. 2015

4 This was confirmed by Calamia [3]. Horn describing a platinum foil technique for veneer fabrication [4]. Additional articles have proven the long-term reliability of this technique [5]. Various indications for Veneer placement include functional and cosmetic corrections of stained or darkened teeth, hypocalcification, multiple diastemas, peg laterals, chipped teeth, lingual positioned teeth, malposed teeth not requiring orthodontics. However, few contraindications for Veneer Placement also exist: insufficient tooth substrate (enamel for bonding), Labial version, excessive interdental spacing, poor oral hygiene or caries, parafunctional habits (clenching, bruxism), moderate to severe malposition or crowding [6]. Numerous advantages of veneers include: minimal tooth preparation required, porcelain veneers are stronger and more durable than composite veneers, alternative to full coverage restoration in case of incisal fractures or tooth discoloration and color stability. However, few disadvantages of veneers are potential for over-contouring, requires laboratory procedures, porcelain enamel margins may be thin and difficult to finish, brittle margins, pitting by acidulated fluoride treatment, cannot be repaired easily, color cannot be altered substantially after placement and placement is difficult and time-consuming [6,7]. Heat pressed ceramics were used in this case. These products are melted at high temperatures and pressed into a mold created using the lost-wax technique. Because of its microcrystalline structure even and uniform distribution of ceramic crystals with reinforcing irregular leucite crystals this porcelain can be fabricated to a tolerance as thin as 0.2 mm without the need for the removal of sensitive tooth structure. Porcelain veneers have greatest advantage that they are more durable and less likely to stain than veneers made of composite. If a porcelain veneer is bonded with a correct adhesive technique and optimal oral hygiene care is maintained, studies have shown that the long-term survival rate of veneers is very high [8,9]. A preparation model and guide are very helpful to the dental practitioner, as they allow him or her to visualize the amount of tooth reduction necessary to achieve the desired aesthetic result. The more conservative the tooth preparation, the greater the life expectancy of the veneer restorations [8]. Porcelain laminate veneers, by nature a conservative modality that provides excellent potential for aesthetic enhancement when their indications are respected, can be effective in this regard. Preservation of sound tooth structure must remain a goal throughout tooth preparation [8,9]. A careful, controlled conservative preparation of tooth is essential for success of PLV. For ultimate success, patients selected for PLV should have good oral hygiene, healthy gingival tissue and no occlusal disharmony [10,11]. 99 Lt Col Vikas Dhir / IJRID Volume 5 Issue 4 Jul.-Aug. 2015

5 Conclusion- A case series was presented using a pressed ceramic veneer material to achieve the desired aesthetic result. The conservative treatment with PLVs can lead to a successful outcome for both the clinician and the patient. This gave the patients a dramatic improvement to their smile and overall self-esteem. With the advent of newer porcelains and better bonding agents, they are considered to be strong and have great aesthetics and long term prognosis. References- 1. Pincus CL."Building mouth personality" A paper presented at: California State Dental Association;1937:San Jose, California. 2. Simonsen R.J. and Calamia John R. "Tensile Bond Strengths of Etched Porcelain", Journal of Dental Research, Vol. 62, March 1983, Abstract # Calamia JR. "Etched Porcelain Facial Veneers: A New Treatment Modality Based on Scientific and Clinical Evidence", New York Journal of Dentistry,1983; Vol. 53, (6), Sept./Oct., pp Horn HR. "A new lamination, porcelain bonded to enamel". NY St Dent J 1983;49(6): Nathanson D, Strassler HE. Clinical evaluation of etched porcelain veneers over a period of 18 to 42 months J Esthet Dent 1989:1(1): Belser UC, Magne P, Magne M. Ceramic laminate Veneers: continuous evaluation of indications. J Esthet Dent 1997;9: Cherliyn GS, Tadanori T. Advantages and limitations in the use of porcelain veneer restorations. J Prosthet Dent 1990; 64: Lerner JM. Conservative aesthetic enhancement of the maxillary anterior using porcelain laminate veneers. Pract Proced Aesthet Dent 2006;18(6): Ashfaq Yaqoob et al. Porcelain laminate veneer: a review. International Journal of Research in Dentistry 2014; 4 (3): 3 May.-June. 10. Ching Chiat Lim. Case selection for porcelain veneers. Quintessence Int 1995;26: John RC, Christine SC. Porcelain laminate veneers: Reasons for 25 years of success. Dent Clin N Am 2007; 51: Lt Col Vikas Dhir / IJRID Volume 5 Issue 4 Jul.-Aug. 2015

6 CASE- 1 CASE Lt Col Vikas Dhir / IJRID Volume 5 Issue 4 Jul.-Aug. 2015