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Indirect Veneer Techniques

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Many dentists find that the preparation, placement, and finishing of several direct

veneers at one time is too difficult, fatiguing,

and time-consuming.

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Some patients become uncomfortable and

restless during long appointments.

In addition, veneer shades and contours can

be better controlled when made outside ofthe mouth on a cast.

 

For these reasons,

indirect veneer techniques are usually preferable.

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Indirect veneers include those made

of:

(1) processed composite,

(2) feldspathic porcelain, 

and

(3) cast or pressed ceramic.

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Processed Composite Veneers

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Composite veneers can be processed in

a laboratory to achieve superior

 properties.

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After shade selection, the teeth areisolated with bilaterally placed

cotton rolls and gingival retractioncord.

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All existing defective Class III

restorations or small carious lesions

should be restored before preparation.

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Multiple large existing restorationscompromise the potential to bond

the veneer to the tooth and mayrepresent a contraindication. 

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Usually no anesthetic is required forintraenamel tooth preparations for

veneers.

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In fact, the patient's response isimportant in judging preparation depth,

especially in the gingival third of thetooth.

 

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If possible, the preparations should

be restricted entirely to enamel. 

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The window preparation is made with a

tapered, rounded end diamond instrumentto a depth of approximately 0.5 to 0.75 mm

midfacially, diminishing to a depth of 0.3to 0.5 mm along the gingival margin, 

depending on enamel thickness.

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The gingival margin should be positioned

 just at or slightly above the level of the

gingival crest unless defects, caries, or dark

discoloration warrant subgingivalextension.

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Also, the interproximal margins shouldextend into the facial and gingival

embrasures, without engaging an undercut,

yet should be located just facial to the

 proximal contacts.

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Generally no temporary restorations

are placed because the preparations are

restricted to enamel.

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An elastomeric impression is made

of the preparations.

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At the second appointment the teeth tobe veneered are cleaned with a pumice

slurry, the shade confirmed, and theoperating site isolated.

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The fit of each veneer is evaluated on

the individual tooth and adjusted ifnecessary.

All of the veneers should fit closely to

the tooth at the gingival area.

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The veneers should be tried in place

(both individually and collectively) to

ensure the fit of adjacent seated veneers.

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Veneers should be tried in place only on

clean, dry teeth to eliminate any potential

for contamination.

If accidental contamination occurs, theveneer should be thoroughly cleaned with

alcohol or acid etchant, rinsed, and dried

before bonding.

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On removal, each veneer is placed tooth

side up (i.e., concave side facing upward)

on an adhesive pad or palette.

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Some processed composites requirethat a priming agent be applied to the

tooth side of the veneer according tothe manufacturer's instructions.

 

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A light-cured, resin cement is recommended

for bonding the veneer to the tooth.

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Shade selection of the bonding medium is determined when the fit of the

individual veneers has been evaluatedand confirmed. 

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Shade selection is made by first placing auniform layer of a selected shade of resin

cement, approximately 0.5 mm in thickness,on the tooth side of a single veneer.

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The veneer is seated on a clean, dry, unetchedtooth, the excess resin cement is removed

with a brush, and the overall shade of theveneer evaluated.

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After try-in, the veneer is removedquickly and placed in a container

to prevent curing of the cement. 

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If the shade of the cement is determined to

be appropriate, more of the same shade is

added to the veneer just before bonding.

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If a different shade is deemed necessary,the existing shade is wiped from the inner

aspect of the veneer with a disposable

microbrush and a new shade of resincement is placed in the veneer. 

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The veneer loaded with the new shadeof cement is reseated and evaluated as

 previously described.

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After the try-in process, a light-curedresin cement of the same shade is used

for final cementation.

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Polyester strips are placed in the proximal

areas of the first tooth to be restored.

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Wooden wedges can be used to secure the position of the strips, but care must be

taken not to irritate the gingival papilla forrisk of inducing hemorrhage.

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The acid etchant is artfully appliedwith a small microbrush, sponge, or

syringe etchant applicator . 

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The prepared tooth is ready for veneer

bonding after acid-etching, rinsing, and

drying.

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A thin layer of adhesive is applied to the

etched enamel, lightly blown with air, butnot cured until placement of the veneer.

Premature curing of the bonding agent may

 preclude full seating of the veneer. 

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The selected shade of light-cured resincement is added to the tooth side of the

veneer with enough material to cover the

entire treated surface.

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The veneer is carefully placed on the

appropriate tooth and lightly vibrated into

 position with a blunt instrument or light

finger pressure. 

A microbrush is used to remove excess

cement.

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With the veneer properly positioned and

excess cement removed, a visible lightcuring unit is used to polymerize the

material with a minimum exposure time of

40 to 60 seconds each from the facial and

lingual directions for a total exposure of 80

to 120 seconds.

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When the veneers are all bonded, only

a minor amount of finishing is required

at the marginal areas.

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Patients also should be cautioned to avoidbiting hard foods or objects to prevent

fracturing the incisal edge, especially if an

incisal-lapping design was used.

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Etched Porcelain Veneers

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The preferred type of indirect veneer isthe etched porcelain (i.e., feldspathic)

veneer .

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Porcelain veneers etched with hydrofluoricacid are capable of achieving high-bond

strengths to the etched enamel via a resin-

bonding mediums.

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The procedures for preparation, impression,try-in, and cementation are the same as for

indirect processed composite veneers, with

a few exceptions.

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The only difference in this procedure for

 porcelain veneers from the composite

veneers is the need to condition the internal

surface of each veneer with a silane primer just before applying

 

the resin-bonding

agent.

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The silane acts as a coupling agent, forming a

chemical bond between the porcelain and the

resin.

It also improves wettability of the porcelain.

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Pressed Ceramic Veneers

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Another esthetic alternative for veneeringteeth is the use of pressed ceramics, such

as IPS Empress.

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Excellent esthetics are possible using pressed ceramic materials for most cases

involving mild to moderate discoloration.

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Because of the more translucent natureof pressed ceramic veneers, however,

dark discolorations are best treated with

etched porcelain veneers.

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The clinical technique for placing pressedceramic veneers, such as those made by IPS

Empress, is not markedly different from thatfor feldspathic porcelain veneers.

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The procedures for tooth preparation, try-in,and bonding of pressed veneers are the same

as for etched porcelain veneers except that

the marginal fit is often superior.

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For that reason, little marginal finishing is

often necessary.

Only the excess bonding medium needs to beremoved.

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Repairs of Veneers

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Failures of esthetic veneers occur because of

breakage, discoloration, or wear.

Consideration should be given to conservative

repairs of veneers if examination reveals that

the remaining tooth and restoration are sound.

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It is not always necessary to remove all of the

old restoration.

The material most commonly used for makingrepairs is light-cured composite. 

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Veneers on Tooth Structure

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Small chipped areas on veneers can often be

corrected by recontouring and polishing.

When a sizable area is broken, it usually canbe repaired if the remaining portion is sound.

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For direct composite veneers, repairs ideallyshould be made with the same material that

was used originally.

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After cleaning the area and selecting the

shade, the operator should roughen thedamaged surface of the veneer or tooth or

both with a coarse, tapered, rounded end

diamond instrument to form a chamfered

cavosurface margin. 

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Roughening with microetching (i.e.,

sandblasting) is also effective.

For more positive retention, mechanical locks

may be placed in the remaining composite

material with a small, round bur.

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Acid etchant is applied to clean the prepared area and etch any exposed

enamel, which is then rinsed and dried.

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 Next, an adhesive is applied to the preparation

(i.e., existing composite and enamel) and polymerized.

Composite is added, cured, and finished in the

usual manner.

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Indirect processed composite veneers arerepaired in a similar manner.

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To repair porcelain veneers, a mildhydrofluoric acid preparation, suitable for

intraoral use, must be used to etch the fractured

 porcelain. 

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Hydrofluoric acid gels are available in

approximately 10% buffered

concentrations that are intended for

intraoral porcelain repairs.

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Isolation of the porcelain veneer to be repairedshould be accomplished with a rubber dam to

 protect the gingival tissues from the irritating

effects of the hydrofluoric acid.

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The manufacturer's instructions must befollowed regarding application time of the

hydrofluoric acid gel to ensure optimal

 porcelain etching.

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A lightly frosted appearance, similar to that

of etched enamel, should be seen if the

 porcelain has been properly etched.

A silane coupling agent may be applied tothe etched porcelain surface before the

adhesive is applied.

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Composite materials is added, cured, and

finished in the usual manner.

Large fractures are best treated by replacingthe entire porcelain veneer.