Improving Aesthetics With Porcelain Laminate Veneers

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					                                                                   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
                                                                 Veneer                                                Veneer
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.
          inate 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:
                                                      patient education.
    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
                                                                                      prophy visit.

    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
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                                                                                                   7. Nash LB. The role of the dental hygienist in caring
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  • Counsel patients regarding good                    with bruxism and a mouthguard for
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Practical Hygiene                                                      24                                                        May/June 1996

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