Improving Aesthetics With
Porcelain Laminate Veneers
Linda Burke Nash, CDA, RDH, BS
Today, many patients are making investments in their smiles
by means of aesthetic dental procedures. As a member of
the dental health team, the hygienist is in an excellent posi-
tion to guide patients regarding the many options available
he long-term use of porcelain in cosmetic dentistry, including bleaching, bonding, veneers,
laminate veneers has been successful; and crown restorations. The dental hygienist also can
porcelain laminate veneers have assumed extend the life of new aesthetic restorations through prop-
the position of the ultimate conservative er clinical techniques and can help patients understand the
restoration.2 Since the introduction of por- value of cosmetic dentistry. By using proper clinical care
celain veneers in the early 1980s, im- and educating patients about their dental care responsi-
provements in dental materials have
bilities at home, hygienists can have a significant, positive
impact on clinical success.1 This article describes a case
resulted in increased bond strength in treated with porcelain laminate veneers and outlines the
the porcelain and enamel interface.1, 3 role of the dental hygienist in aesthetic evaluation, patient
Acid etching of the enamel margins and education, and follow-up care.
the use of enamel/dentin bonding
agents and dual curing-luting composite CASE REPORT in good overall health. An oral examina-
help ensure a strong bond to tooth struc- A 30-year-old female patient whose tion revealed that the soft tissue was with-
ture, which also provides lamination of profession was public speaking was dis- in normal limits and the gingival tissue
the porcelain to the tooth. Lamination is satisfied with the appearance of her was firm and pink, with generalized 1 mm
partly responsible for the more-than- teeth, especially the dark color and to 2 mm sulcus depths and little or no
adequate strength of the porcelain, be- spaces (Figure 2). Her objective was to bleeding on probing. The radiographs
cause it promotes even support across achieve a more attractive smile and to exhibited excellent bone support and no
the surface of the tooth (Figure 1). Thus, feel more confident in public. periapical or osseous abnormalities.
focal points of stress that could result in Her medical history was noncon- The patient’s self-care, which was
fracture do not occur.1, 4 tributory. She was active, energetic, and excellent, included regular flossing and
Today, porcelain laminate veneers
not only bond to enamel with as much
strength as enamel bonds to dentin, but
also strengthen the tooth itself. With the
rapid advancement of ceramic technol-
ogy, porcelain has the ability to retain
its subtle surface anatomy over the life- alone bonded
span of the restoration.2 to tooth
Linda Burke Nash, CDA, RDH, BS,
President-Elect of the North
Carolina Dental Hygiene asso-
ciation, is an instructor in den-
tal hygiene and assisting, an
author, lecturer, clinical hygien-
ist, and President of Nash Con-
sulting Services. She is also a
hygiene consultant with McKenzie Figure1. Lamination (right) promotes even support across the surface of the tooth.
Management (800-288-1877). Veneer alone is fragile until bonded to tooth surface.
Practical Hygiene 21 May/June 1996
Figure 2. Preoperative view of patient requesting porcelain lam- Figure 3. Postoperative smile exhibiting porcelain veneers.
the use of a soft toothbrush. In the pos- tions. The patient realized that 10 maxil- two distinct, yet equally important,
terior area, defective amalgam restorations lary teeth required veneers to prevent aspects: to administer appropriate profes-
had been replaced with indirect compos- any discoloration from being visible. sional care, and to ensure proper patient
ite inlays and onlays. Anteriorly, she had Allowing the patient to participate in eval- self-care.1-3, 5, 6
no restorations, the maxillary right lateral uation in this manner helped achieve a Appropriate professional care includes
appeared peg-shaped, open spaces were more satisfactory result (Figure 3). The the following:
maxillary and mandibular teeth were spot-
present, and brown/gray discolorations • Use sharp curettes. Dull scalers ditch
etched (Figures 4 and 5) before placing
appeared throughout the dentition. The and/or scratch the surfaces of veneers.
patient had completed orthodontic treat-
ment in her early teens, but did not want • Avoiding using ultrasonic scalers.
The hygienist’s role in pro- They can damage the veneer surface,
any additional orthodontic treatment. She
longing the life of porcelain chip the margins, and disturb the ce-
exhibited class I occlusion with incisal laminate veneers involves ment bond. The gingival margin may
wear on the maxillary cuspids. administering appropriate be a weak link in the veneer because
Aesthetic Evaluation professional care and ensur- of the resin cement, so care must be
A video imaging consultation—per- ing proper patient self-care. taken when cleaning this area.
formed by the hygienist, with the dentist
providing the final recommendations— • Avoid the use of air polishers. Air
demonstrated the attractive appearance the provisional veneers (Figure 6), which abrasive systems can scratch and pit
of the patient’s teeth with spaces closed are optional, and then the porcelain laminate the surfaces of porcelain restora-
and teeth reshaped. Imaging also demon- veneers (Figure 7). tions. Because porcelain has a sur-
strated how tooth color can be lightened THE ROLE OF THE HYGIENIST face that is smooth and nonporous,
and the incisal edges can appear more The hygienist’s role in prolonging the life it does not accumulate stain as easily
translucent with white hypoplastic stria- of porcelain laminate veneers involves as enamel; therefore, air polishing is
Practical Hygiene 22 May/June 1996
Figure 4. Maxillary teeth spot-etched before the placement of Figure 5. Mandibular teeth spot-etched before the placement
the temporary veneers, which are optional. of the temporary veneers.
Figure 6. Provisional (temporary) veneers in place. Figure 7. Close-up postoperative view of porcelain laminate
not necessary. Similarly, the use of Research, Inc., New York, NY) has the hygienist should stress the impor-
abrasive (coarse or medium) polish- been specifically developed for tance of good plaque control in extend-
ing pastes is contraindicated. brightening cosmetic restorations ing the life of cosmetic materials.
and whitened teeth. Patient self-care tips include the
• For interproximal stain removal, use
a flexible, aluminum oxide polishing • Use only neutral sodium fluoride following:
strip (Figure 8). These strips clean treatments, when needed, for in- • Instruct patients in proper brushing
beneath the gingival margin without office application. Acidulated fluo- technique. “Scrubbing” near the gin-
damaging the tissue. A polishing
gival margin is not appropriate, be-
paste can also be carried on floss be-
cause veneer margins lie either at or
tween the teeth.
just below the gingival crest. The au-
The hygienist’s role is key
• Facial and lingual surfaces can be thor recommends the modified Bass
in ensuring the long life of
polished using a soft, flexible pro- technique using a soft toothbrush.
veneers through regular
phy cup or flexible felt disk with an Several powered plaque removal de-
professional care and
aluminum oxide paste (Figure 9). vices are convenient and effective:
For best results, dilute the paste with electric brushes (Braun Oral-B, ®
water as the polishing progresses. Oral-B Laboratories, Redwood City,
Other options are to utilize, with CA; Interplak, ® Bausch & Lomb,
careful instructions, a diamond pol- ride preparations will etch porcelain Tucker, GA; and RotaDent, ® Pro
ishing paste, if available; otherwise, surfaces.6, 7, 9-11 Dentec, Batesville, AR), sonic brushes
an over-the-counter toothpaste is At each recall appointment—sched- (SenSonic, ™ Teledyne Water Pik,
often available in sample size for uled in frequencies of 2 to 6 months, Fort Collins, CO; and Sonicare, ™
most offices. SuperSmile® (Robell depending on individual patient needs— Optiva Corp., Mercer Island, WA)
Practical Hygiene 23 May/June 1996
Figure 8. Interproximal polishing strips in use. Figure 9. Hygienist using a special polishing paste during the
and ultrasonic brushes (Ultra- alcoholic beverages and the use of Acknowledgments
Sonex,® Sonex International Corp., mouthwashes containing alcohol The author would like to acknowledge
Brewster, NY). Furthermore, these can cause marginal breakdown. Ross Nash, DDS, of Charlotte, NC, for pro-
devices may enhance patient com- Several alcohol-free mouthwashes viding the dentistry and photography.
pliance. (Rembrandt,® Denmat Corp., Santa Veneers were fabricated by the Americus
Maria, CA; and Oral-B ® Anticavity Dental Laboratory Group, New York, NY.
• Instruct patients in interproximal
Rinse, Oral-B Laboratories, Redwood
plaque removal. The use of newer, References
City, CA) are available over-the-
user-friendly flosses (Colgate ® 1. Nash LB. The hygienist’s role with porcelain veneers.
Precision, Colgate Palmolive Co., Journal of Practical Hygiene 1992;1(2):17-21.
Canton, MA; Glide, ™ W.L. Gore & • Recommend only neutral sodium flu- 2. Miller MB. Porcelain and Indirect Resin Veneer.
oride for home use. Acid-containing Houston: Reality Publ Co 1993:359-370; 1995:41-
Assoc., Flagstaff, AZ; and Easy 48, 345-350.
Slide,™ Johnson & Johnson Medical, fluorides can etch resin cement and
3. Miller LM. Maintaining Aesthetic Restorations.
Inc., Arlington, TX) facilitate plaque porcelain.1-3, 5, 7 Houston: Reality Publ Co 1989.
removal. Also, home irrigation using • Advise patients to avoid chewing 4. Nash RW. Subtle changes, brighter smiles with
porcelain veneers. Compend Contin Educ Dent
water and a low power setting may hard objects, such as ice and hard 1994;15(1):8-12.
offer additional benefits by helping candy. This is the most common 5. Nash LB. Special care requirements of cosmetic
to disrupt plaque bacteria near the cause of fractures and chipping.1-3, 5, 7 restorations. Dental Practice Success 1990;1(8):2-3.
veneer margins. Using a special mar- In addition, such habits as biting fin- 6. Nash LB. The hygienist’s role in aesthetic and cos-
ginal tip (Pik Pocket, ® Teledyne gernails, pencils, and paper clips metic restorations. Journal of Practical Hygiene
Water Pik, Fort Collins, CO) allows cause breakage.
7. Nash LB. The role of the dental hygienist in caring
patients to target the margin area. for cosmetic-aesthetic restorations. Dental Econ
• Prescribe a nightguard for patients
• Counsel patients regarding good with bruxism and a mouthguard for
nutritional habits. The intake of sugar those involved in contact sports. Bibliography
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• Remind patients that alcohol can ensuring the long life of veneers through
Nash RW. Correcting multiple esthetic problems: A
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Practical Hygiene 24 May/June 1996