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2 INSIDE DENTISTRY—APRIL 2009 “The ideal material for inserting porcelain laminate inside EsTHetics veneers would be a composite resin material with a high filler concentration...” Porcelain Laminate Veneer Insertion Using a Heated Composite Technique Gregg A. Helvey, DDS Porcelain laminate veneers are placement, and the materials to be used rounded by a resin matrix and contain a POLYMERIZATION BEHAVIOR used routinely in cosmetic dentistry. The for bonding.7-13 photoinitiator; the basic difference is that OF COMPOSITE RESINS public usually refers to this mode of treat- Initially, porcelain laminate veneers they vary in the amount and configuration Composite resins shrink when polymer- ment simply as “veneers.” Their popu- were placed with restorative composite of the filler particles (volume percentage). ized and the amount of shrinkage is pro- larity has increased because of television resin. The same material used for anteri- The difference in filler amounts accounts portional to the filler type, shape, and makeover programs, commercials, and or restorations was used to insert veneers for varying rates of flow or viscosity. For volume of that material. 17-20 Shrink- magazine advertisements. Porcelain lam- because it was the only material availa- example, the low viscosity of a flowable age, in the form of bulk reduction, oc- inate veneers have so increased in their ble. A significant number of restorations composite is achieved by decreasing the curs during the polymerization process attractiveness that the general public is would fracture at the time of placement filler concentration, which in turn, in- as a result of the monomer molecules demanding this type of instant make- because the composite was thick and had creases the amount of resin and polymer- packing closer together, forming a poly- over. Further, dental laboratories are com- little flow. In pressing the veneer into ization shrinkage.15 On the other hand, mer network.20-23 In short, the higher peting in marketing their abilities as to place, clinicians sometimes used exces- increasing the percentage of filler particles the filler content of a composite resin, how thin they can make their porcelain sive force, resulting in cracks or complete increases the viscosity, thereby decreasing the less shrinkage occurs.24 Mechanical laminate veneers. Plus, certain manufac- fractures. Manufacturers recognized these the flow and polymerization shrinkage. properties and the wear resistance of a turers and laboratories advocate prepless problems and developed entire lines of The ideal material for inserting porce- composite resin are predisposed by the laminate veneer techniques. composite resin luting materials solely lain laminate veneers would be a com- filler content.25,26 The filler volume of Porcelain laminate veneers were first for the placement of porcelain laminate posite resin material with a high filler a composite resin has an effect on the introduced by Charles Pincus1 in the 1930s veneers and posterior porcelain restora- concentration for strength, low polymer- elastic modulus and volumetric shrink- and used to change the appearance of tions. The various luting materials differ ization shrinkage, high modulus of elas- age and is a key component in the devel- movie actors’ teeth. Unfortunately, denture in color, flowability, film thickness, and ticity, and a high flowability that allows opment of polymerization contraction adhesive was the only means of attaching volume percentage of filler material. To the ceramic restoration to be easily placed. stress.27 According to Hooke’s Law (vol- the veneers to the teeth, and they came keep the viscosity at a lower level, both This ideal luting material would have to umetric shrinkage x elastic modulus = off in a short period of time. It was not the size and amount of the filler particles allow the full seating of the restoration, stress), the greater the polymerization until after Buonocore2,3 introduced the are smaller than in restorative composite without the excessive pressure that can shrinkage and the higher the elastic mod- concept of acid-etching enamel as a means resins. The physical properties of these result in a fracture to the restoration. The ulus of a composite resin, the larger the of mechanical retention that composite materials can lead to post-insertion sit- material would have low solubility, as well contraction stress. resin restoratives had retentiveness. By uations, such as solubility, color change, as high compressive and tensile strengths. Another factor is the degree of con- 1982, Simonsen and Calamia 4 discov- and flexural strength.14 The proportional limit would be high version or the amount of free radical ered composite resin’s ability to bond to This article discusses a method and the and have excellent adhesion to porcelain monomers in the resin matrix that bond porcelain if the ceramic was treated with advantages of thermal conditioning a re- as well as tooth structure. together, forming a polymer network. hydrofluoric acid. In 1983, using a refrac- storative composite resin or commercial The question is: Which available ma- The greater the number of monomer- tory model technique, Calamia5 described luting cement that can be used for place- terial is the closest to ideal? There are many to-polymer formations that occur, the a technique for fabrication and placement ment of porcelain laminate veneers. commercial luting cements for porcelain higher the degree of conversion a com- of porcelain laminate veneers. Around laminate veneers. Manufacturers provide posite is said to have. There is a correla- the same time, Horn6 described a tech- LUTING CEMENTS ample advertising of their commercial pro- tion between the degree of conversion and nique of porcelain laminate veneer fab- AND COMPOSITE ducts. For unsuspecting clinicians, these shrinkage.23,28 Shrinkage manifests as rication using platinum foil. Since that RESIN RESTORATIVES advertisements can sway their choices in stress.20 This stress can have adverse ef- time there have been numerous articles Composite resin restoratives and luting selecting products. For the more discrim- fects on the composite resin material describing tooth preparation protocols, cements share the same component parts. inate clinician, the literature is filled with (internal crack formation), 29 the sur- techniques for fabrication, methods for Each is made up of filler particles sur- countless studies on different luting ce- rounding tooth structure (flexure or de- ments. But a relatively small number of formation),30-32 and/or failure of the properly conducted clinical trials have adhesive layer interface between the tooth been reported, so clinicians must formu- and the composite material (gap forma- Gregg A. Helvey, DDS late their decisions from various sources.16 tion).33 Factors that effect these mani- Adjunct Associate Professor There are numerous laboratory studies festations include: the flexibility of the Virginia Commonwealth University School of Dentistry available that show the differences of luting surrounding tooth structure, the bond Richmond, Virginia cements in regard to compressive strengths, strength of the adhesive interface layer, diametral tensile strength, tooth structure and the temperature of the composite Private Practice adhesion, film thickness, flowability, trans- resin during the polymerization stage. Middleburg, Virginia lucency, and other physical factors of these Interestingly, the temperature of the materials. Does the improvement of these composite resin at the point of insertion physical factors proportionally improve has been the subject of discussion in the the clinical success of the material? literature.34-37 As previously mentioned, EsTHetics INSIDE DENTISTRY—APRIL 2009 3 Figure 1 Each composite resin was placed between two glass slabs at room temperature. Figure 2 The glass slabs were placed in an oven Figure 3 Tetric EvoCeram A-2 exhibited a flow Figure 4 Prodigy B-1 exhibited a flow rate per- Figure 5 Venus B-1 exhibited a flow rate per- at 150.3°F for 4 minutes. rate percentage increase of 108%, calculated by centage increase of 85%; 14 mm diameter after 4 centage increase of 76%; 17 mm diameter after 4 measuring the diameter of the sample after 4 min- minutes at room temperature (top) and 26 mm minutes at room temperature (top) and 30 mm utes at room temperature (12 mm, top) and again diameter after 4 minutes at 150.3°F (bottom). diameter after 4 minutes at 150.3°F (bottom). after 4 minutes at 150.3°F (25 mm, bottom). Figure 6 Point 4 T-2 exhibited a flow rate per- Figure 7 Gradia A-2 exhibited a flow rate per- Figure 8 8 Filtek Supreme A-1 exhibited a flow Figure 9 Clearfil Majesty Flow exhibited an centage increase of 74%; 15 mm diameter after 4 centage increase of 41%; 17 mm diameter after 4 rate percentage increase of 40%; 15 mm diameter increased flow of 5 mm after 4 minutes at minutes at room temperature (top) and 26 mm minutes at room temperature (top) and 24 mm after 4 minutes at room temperature (top) and 21 150.3°F. diameter after 4 minutes at 150.3°F (bottom). diameter after 4 minutes at 150.3°F (bottom). mm diameter after 4 minutes at 150.3°F (bottom). the amount of monomer conversion to elevation in temperature increases mon- increase in conversion rates was also a polymer network of a composite resin omer mobility, which results in addition- found in the study by Prasanna et al.45 when photoactivated is less than 100%. al polymerization and lessened composite Using the manufacturer’s required amount In fact, it can vary from 50% to 75%.38 viscosity.34,35,41,42 Trujillo et al43 found of light exposure to the composite resin, The problem with incomplete polymer- that an increase in the temperature of they not only found an increase in the ization is the effect of unreacted mon- composite resin could significantly in- conversion rates, but also an increase in omer on the physical and mechanical fluence resin polymerization. These in- residual stress in the bulk of the materi- properties of the composite resin. Un- creased conversion rates could lead to al.45 This increase in residual stress can reacted monomers act as plasticizers, improved properties of composite restor- lead to reduced resistance to wear, result- reducing the mechanical strength and ative materials.43 Daronch et al44 found ing in surface cracks. increasing swelling of the composite res- similar results in their study, which show- On the other hand, Daronch et al37 Figure 10 The restorations are etched with a in.39,40 Monomer conversion is effected ed an increase in conversion rates that found the duration of light exposure 10% hydrofluoric acid for the appropriate condi- by the temperature, which in turn affects were attributed to pre-warming com- could be reduced by 50% to 75% with tioning time. the composite resin properties.34-36 An posites before photopolymerization. An preheated composite, which yielded the EsTHetics 4 INSIDE DENTISTRY—APRIL 2009 same or significantly higher conversion tested and found to have an increased flow ceramic surface. Water, alcohol, acetone, Bond® FL, Kerr Corp). The elevated (P = .001) than with a control (22°C, of 5 mm after heating (Figure 9). acetic acid, and other by-products, if not temperature of the ceramic surface will 20 sec). They concluded that preheat- completely removed by air-drying, may increase the flow of the adhesive resin ing a composite before photoactivation RAISING THE remain hydrogen-bonded to the hydrox- into microporosities and any surface flaws provided greater conversion, requiring TEMPERATURE OF SILANE yl-rich silica fillers of the composite sub- present. The surface flaws on a ceramic reduced light exposure than with room- The literature cites several studies on the strate and decrease the number of bond surface may increase the potential of crack temperature composite. They also found effectiveness of the use of silane appli- sites available for reacting with silane, propagation.65 Unseen microscopic flaws that the reduced light exposure of heat- cation to ceramic surfaces creating high- thus compromising the final degree of can develop at the laboratory, during the ed composite lowered the contraction er bond strengths of composite resins to siloxane bond formation.55-58,63 There- try-in phase, or during conditioning steps. stress more than the control. ceramic surfaces.49-52 Silane improves fore, the heat treatment of silane accom- Magne has presented a case scenario where the wettability and adds to the covalent plishes several things: It drives the silane/ prebonding cracks existed in a porcelain INCREASING THE bond formation between ceramic and res- silica surface condensation reaction toward veneer and remained invisible after 5 FLOW RATE WITH in composite.51 It provides a bi-functional completion; it promotes silane/silica for- years.62 He attributed the phenomenon TEMPERATURE ELEVATION attachment to both the resin and the ce- mation; and it advances the evaporation to the efficient sealing of the flaw by the In their study, Blalock et al46 found that ramic.52 The adhesive bond of composite of water and solvents.58 adhesive resin. Only the heated ceramic preheating composite resin did yield high- resin to enamel is purely mechanical and condition could have increased the flow- er flow rates for some composite resins. is solely dependent on the quality of the Technique Sequence ability of the adhesive resin and aided in They also found that there was no corre- etch pattern created by phosphoric acid. After the provisional restorations are re- the ceramic flaw repair. lation between the composite resin clas- However, the adhesive bond of compos- moved, clean the prepared teeth careful- After the adhesive resin application sification, filler content or shape, and ite resin to a ceramic surface is not only ly, using 50-µm aluminum oxide with (Figure 14), apply a composite resin to the film thickness. generated through mechanical means (hy- light pressure. Wet the veneers with wa- bonding surface of the porcelain veneers To simplify the effect of increasing the drofluoric acid conditioning53,54), but ter and try them in for verification of fit (Figure 15). Then, arrange the “loaded” flow of the composite, the authors placed also by chemical means through the use and patient approval. After the try-in, veneers in the wells in the order of place- several commercially available compos- of the silane coupling agent.55 clean the bonding surfaces of the res- ment, cover them, and allow them to reach ite resins between two glass slabs at room Several studies have shown that warm- torations with phosphoric acid for 5 sec- the desired insertion temperature.37 temperature (Figure 1). The weight of air drying of the silane improves the ad- onds to remove salivary proteins that can the top glass slab was a constant pressure hesive–ceramic bond.51,56,57 After the interfere with the ceramic etching with CONDITIONING THE applied to each sample. After 4 minutes, silane is applied to the ceramic surface, hydrofluoric acid (Figure 10). Rinse the TEETH AND INSERTING the amount of flow was noted by meas- heat treatment causes a condensing ef- restorations with water and dry them. THE RESTORATIONS uring the diameter of the sample. To- fect of the coupling silane molecules on Then, etch the internal surfaces with a Isolate the prepared teeth, etch them gether, the glass slabs were then placed the ceramic surface.58,59 The heat treat- 10% hydrofluoric acid for the appropri- with phosphoric acid, rinse them with into an oven at 150.3°F for 4 minutes ment can be accomplished through sev- ate conditioning time. Each type of por- water, and then suction them dry (no (Figure 2). Then, the flow rate or the eral methods. Magne described placing celain has a specific etching time, which air-water syringe used). Using a three- amount that the composite resin spread the silanated ceramic restoration in a dry should be recognized and followed by step bonding system (OptiBond FL), out was noted by measuring the diame- furnace at 100°C for 1 minute or using the clinician to prevent improper condi- apply the primer to the teeth and suction ter. A percentage increase was then cal- the warm air from a hair dryer for 2 mi- tioning. After the acid is rinsed off, place them dry. Then, apply the adhesive resin. culated for each sample. The elevation in nutes. 60 Improved microtensile bond the restorations into a distilled water ul- Thinning the resin with the air-water temperature did affect some composite strengths have been reported using a dry- trasonic bath for 4 minutes.62 This bath syringe is not necessary. resins more than others. The following ing temperature less than 100°C (212°F) will remove the ceramic residue of sodi- Starting with the central incisors, pick list shows the percentage increase for sev- but greater than room temperature.56,61 um, potassium, aluminum, and remin- up each veneer with a college pliers in- eral different composite resin products. High-temperature air-drying (50°C to eralized salts53,64 (Figure 11).Then, dry strument (Figure 16), placing each veneer 100°C) has been proven to increase ceram- the porcelain veneers, and apply two coats on the appropriate tooth. Because the • Tetric EvoCeram® A-2 (Ivoclar Vi- ic–composite bond strength in luting of silane to the bonding surface. Next, composite luting material is warm (in- vadent, Inc, Amherst, NY; Figure 3): ceramic restorations.62 Silane solutions place the veneers in the preheated (155°F) creasing both the conversion rate and 108% contain water and solvents that, when veneer warming tray (Figure 12 and Fig- flow of the resin66), light finger and thumb • Prodigy™ B-1 (Kerr Corp, Orange, CA; present, decrease the condensation poly- ure 13), then cover and warm for 2 minutes pressure is all that is necessary to place Figure 4): 85% merization reaction that chemically bonds (CalSet™ veneer warming tray, AdDent the restoration in the correct position. • Venus™ B-1 (Heraeus Kulzer, Inc, the silane to the ceramic. Evaporation of Inc, Danbury, CT). Even though there is a reduction in tem- Armonk, NY; Figure 5): 76% water and solvents contributes to the bond After the silane heat treatment is com- perature after restoration placement and • Point 4™ T-2 (Kerr Corp; Figure 6): strength of the composite resin to the pleted, apply a filled adhesive resin (Opti- before photoactivation, benefits still may 74% • Gradia® A-2 (GC America Inc, Alsip, IL; Figure 7): 41% • Filtek™ Supreme A-1 (3M ESPE, St. Paul, MN; Figure 8): 40% Preheating some composite resins that demonstrate a significant increase in flow rate should allow them to be used as luting agents. The choice of the type of luting agent and its filler loading becomes more important when the marginal gap distance between the restoration and the tooth structures increases.47 Torii et al48 found that cements with a higher filler content had an increased wear resistance and work- ed remarkably better in wider gaps. One flowable composite (Clearfil Maj- Figure 11 The bath will remove the ceramic Figure 12 The CalSet veneer warming tray is Figure 13 The porcelain veneers are placed in esty™ Flow, Kuraray America, Inc, New residue of sodium, potassium, aluminum, and rem- preheated to 155°F. the warming tray, covered, for 2 minutes. York, NY) that has an extremely high ineralized salts. filler content of 81% by weight was also EsTHetics INSIDE DENTISTRY—APRIL 2009 5 Figure 14 Adhesive resin is applied to the Figure 15 Composite resin is loaded into the Figure 16 Each veneer is picked up with a col- Figure 17 The index fingers are placed on the bonding surfaces of the porcelain veneers. porcelain veneers. lege pliers instrument. incisal edges while the thumbs are placed on the labial surfaces to fully seat the restorations. be seen in comparison with room-tem- Calif S Dent Assoc. 1938;14:125-129. 17. Filho HN, Nagem HD, Francisconi PAS, et 29. 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