LIMINATES

LAMINATES

INTRODUCTION

Esthetics in our culture has become a matter of necessary concern to the dentist.
Changing trends and treatments for dental disease have made it necessary to diversify dental
services. It is predicted that the demand for esthetic dental services will continue to grow,
prompted by an increasing population of consumers more knowledgeable in esthetic dental care
options. Laminate veneer restorations have a unique position in today's dental practice. These
are conservative restorations, a factor which is especially important for young permanent
dentitions. One indication for their use is restoration of discolored anterior teeth caused by
tetracycline staining and fluorosis.

The art of veneering teeth has progressed over 30 years to the current generation of
concepts and materials, which can be divided into two categories: (1) directly fabricated
composite resin laminates (i.e. free hand placed), and (2) indirectly fabricated laminates, such as
preformed laminates or laboratory fabricated acrylic resin, microfilled resin, or porcelain
laminates.

INDIRECT COMPOSITE RESIN LAMINATES

The fabrication of indirect resin laminates requires less effort in achieving the final contours of
the restoration. The chair side time is comparatively much less. They are capable of achieving
chemical bond to the composite resin-bonding medium with no pretreatment of the laminate
required. They have superior shading qualities and control of labial contours. As they are
fabricated with microfill resins, they can be polished to a lustrous finish. However, limited bond
strength restricts their use to cases not involving heavy functional contacts.

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Clinical Technique

Indirect composite resin laminates require two patient appointments. Shade selection is carried
out prior lo isolation of the teeth in order to eliminate shading variations that can occur because
of drying and dehydration of teeth. Both body and incisal shades of composite resin are available
and also the characterizing resins for optional esthetic modifications. Teeth are isolated using
absorbent cotton rolls and gingival retraction cord. All existing defective class III restorations or
small carious lesions should be replaced or restored prior to initiating the laminate preparations.
The selected tooth is prepared with a round or bevel-ended diamond stone to a depth
approximately three-fourth of enamel thickness. The depth of reduction usually ranges from 0.5-
0.6 mm mid-labially to0.2-0.3 mm along the gingival aspect. Greater reduction may be needed if
intrinsic stains are present. However, the entire preparation should be restricted to enamel to
allow acid etching for micro-mechanical retention. A no.1/4 round bur (0.4 mm in diameter)is
suited for gauging the depth cuts. This allows inspection of remaining unprepared tooth structure
in cross-section following preparation of only one half of the labial surface. A moderate chamfer
should be created along the margins of the preparation. The interproximal margins should be
extended beyond the interproximal line angles of the tooth yet to be positioned labial to contact
areas. The gingival margin is prepared at the level equal to that of the free gingival crest.

Subgingival extension of the prepared margins should be avoided. Incisally, preparation should
be restricted to labial aspect of the incisal edge and should never be terminated in an area
subjected to occlusal function. An elastomeric impression of the prepared teeth is made
following removal of the gingival retraction cord. A working cast within dividually removable
dies of the prepared teeth is fabricated. Removable dies are recommended. Prepared teeth are
thoroughly cleaned with pumice or an oil and fluoride-free cleansing agent. Teeth are once again
isolated with cottonrolls. Gingival retraction cord is placed in labial gingival sulcus. A try-in of
laminate is a must to evaluate the fit. Minor adjustments can be done with suitable composite
resin finishing bur to enhance adaptation.[61]

If the inner aspect of laminate is totally smooth, a coarse diamond stone should be used lo
roughen the underside of laminate, thus improving the potential for additional micro-mechanical
bonding. Care must be taken not co contaminate the underside of laminate prior to bonding.

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A thin film of unfilled resin bonding agent is placed on the etched enamel but not yet cured. The
laminate is then loaded with a homogenous layer of Visio-Fil/Visio-Bondblend, approximately
0.5mm thick and is seated on tooth. Laminate should be positioned first at gingival margin,
allowing excess cement to extrude incisally as the laminate is fully seated. Care should be taken
not to entrap air between tooth and laminate. However, prior lo polymerization, laminate should
be held firmly in place while an explorer is used for marginal adaptation.The underlying bonding
medium is polymerized for 40 seconds from both labial and lingual directions. If a layer of
opaque resin is added into the resin laminate then curing time should be doubled. Excess bonding
material is removed using a combination of 12 and 30 fluted flame-shaped composite resin
finishing burs. Gingival retraction cord should be removed to facilitate access and visibility.
After bonding occlusion must be evaluated to ensure that nonfunctional interferences have been
introduced. Protrusive and lateral functional contacts should be restricted to enamel if at all
possible.The preparations usually involve removal of considerable amount of sound tooth
substance, which might affect the pulp. Also the inherent nature of composite resins exhibiting
polymerization shrinkage, dimensional changes, staining and poor wear resistance will lead to
poor prognosis.

The microfill composite resins can achieve satisfactory appearance and shine. However,
microfill composites wear at twice the rate of conventional composites as a result of tooth
brushing. To overcome this problem it is suggested that conventional or hybrid composite
should be used to form the bulk of the laminate and a thin layer or microfill composite be placed
on the surface or appearance and surface shine. This superficial layer would have to be replaced
at intervals .(Fig. 1 a,b).The acrylic laminate could overcome some of these problems, but the
long term results were clinically unacceptable. The restored teeth were bulky and the weak
chemical bond between cement and laminate was the common site of failure. Both composite
and acrylic laminates have a dull, monochromatic appearance. Lowabrasion resistance leading to
loss of contour and staining, and loss of surface luster, biological incompatibility with gingival
tissue, limited bond between laminates and composite, were the major drawback of these resin
laminates.

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Fig.No. 1 (a) Preoperative Fig. No. 1 (b) Postoperative

Bond Strength

Two bonding interfaces are involved (i) the inner surface of the processed composite resin
laminate and lii) the acid-etched enamel. Tensile strength ranges from 2000-2750 psi. Etched
porcelain laminates treated with a silane coupling agent appear to provide greater retentive
strength to etched enamel than is attainable with indirect composite resin laminates.

Because of processing procedures involved in fabricating an indirect resin laminate, degree of

polymerization is significantly greater than that achieved by chair side conventional
polymerization techniques. Therefore the potential for establishing strong chemical bonds
between the processed laminate and resin-bonding medium is significantly diminished.

The surface glaze of unfilled resin polymerized on the labial surface of the laminate wears away
within first year. A highly lustrous surface, however, can reestablish through conventional chair
side finishing and polishing techniques. A more permanent and durable surface luster is attained
if operator simply finishes and polishes the laminate immediately after bonding. Also the
indirectly fabricated resin laminatesare prone to chipping and fracture when exposed to excessive
functional forces.[62]

PORCELAIN LAMINATES

Earlier, thin facings of air-fired porcelain were temporarily held on to tooth with adhesive
powder. These facings presented a viable option to full crowns for actors needing temporary

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change in their looks. Porcelain as a material for laminating was first built up inlayers on a
platinum foil mains adapted to a model of the prepared tooth. Etched silanated porcelain block
has been used to restore fractured incisors. The development of porcelain laminates and the
associated technique for their fabrication and placement were developed in early 80’s. At
present, a number of systems have been employed viz.castable, pressable and glass infiltrated
ceramics. [63]

A cross section of the laminate systemreveals the following components:

a. Etched porcelain

The first component of the system is the etched porcelain. Earlier the unglazed porcelain was
etched and tried in class IV cavities. It is established that abrasive treatment of porcelain at its
fractured surface permitted repair with composite resin. Etching the porcelain with 5 to 7%
hydrofluoric acid for varying lengths of time increases the bond strength. The bond strength
increases from 88p.s.i. (6.0 Mpa) for no etch to 110 p.s.i. (7.5Mpa) for a 20 second etch. In the
un-etched specimens, bond failure occurred at the resin/porcelain junction. In all the etched
specimens, fracture occurred in the body of the porcelain.

b. Coupling agent

Coupling agent is defined as ‘an agent, which acts by adsorbing on to and altering the surface of
a solid, to facilitate either a chemical or physical process’. The commonly used coupling agents
are-amino-propyltriethoxy-silane, methacryloxy-propryltrimethoxy-silane and 10-amino-propyl-
vinylsilane. The mode of action of silane coupling agents is by chemically bonding to both the
silica in the porcelain and the matrix of the composite/acrylic resin.The chemical bonding of
porcelain teeth to acrylic denture bases by means of coupling agents has been tried. Since the
coefficient of thermal expansion varies, the bond gets deteriorated on bench cooling in case of
heat-cured acrylic. The silane-coupling agents are being used as an integral part of the porcelain
laminate system. The bond formed between composite and porcelain is resistant to thermal

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cycling, owing to similar coefficients of thermal expansion of both porcelain and composite
resins. No bond was formed between glazed porcelain and silane/composite resin.

c. Luting cements

The laminates require luting cements of low viscosity and small particle size for good adaptation.
The limited working time of the self-curing cements caused some seating problems with the
earlier laminates. A longer working time became available when light-cured cements with
similar physical properties were introduced. The recently introduced dual-cure cements ensure
maximum polymerization of the resin while retaining the option of an extended working time.

Advantages

Porcelain is the preferred choice as laminate because of the following advantages: i. Colour:
Since the porcelains are available in different colours, they can be used in variable degrees of
discolouration and offer better colour control and stability. ii. Bond strength: The bond of etched
porcelain laminate and enamel is considerably stronger than any other laminating system.iii.
Periodontal health: The highly glazed porcelain surface resists deposition of plaque thus
maintaining periodontal health. iv. Resistance to abrasion; The wear and abrasion resistance of
porcelain is exceptionally good .v. Inherent porcelain strength: These materials have good
compressive strength but poor flexural strength. These strengths however increase considerably
alter the restoration is bonded to the tooth.vi. Resistance To fluid absorption: Porcelain absorbs
less fluid as compared to any other laminating material.vii. Esthetics: The esthetics is
considerably better than any other laminating material because ceramics have the ability to
control colour and texture. [64]

Disadvantages

The following are the disadvantages of porcelain: i. Technique sensitive: The placement of
porcelain laminates is technique sensitive. Utmost precision is required.ii. Repair: The repair of
laminates is difficult once they are luted to the enamel.iii. Time: The process of making

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laminates require patient’s two visits i.e. preparation and impression making and luting. iv.
Colour: It is difficult to modify the colour once the laminates are luted in position on the enamel
surface.v. Tooth preparation: Tooth preparation is always required to prevent potential problems
associated with over contouring.vi. Fragility: The laminates are extremely fragile and difficult to
manipulate, especially when pre bond adjustment is required. [64]

Indications

It is mandatory that an adequate area of enamel should be available for etching and also the
patient maintains high standards of oral hygiene for ceramic laminates. These are indicated in
following circumstances:

i. Tooth discolouration resistant to vital bleaching procedures, such as fluorosis, endodontically

treated teeth, tetracycline staining etc. ii. Tooth discolouration brought about by the process of
aging. iii. Anterior teeth requiring major morphologic modifications:

a. Conical teeth (peg laterals)

b. Closure of diastemas

c. Elongation of incisal edges

d. Various types of enamel hypoplasias

iv. Rehabilitations of compromised anterior teeth.

a. Extended coronal fractures

b. Congenital and acquired malformations

c. Malpositioned teeth: Developing the esthetic illusion of straight teeth where

orthodontists have limitations due to prolonged treatment time.

d. Malocclusion: The configuration of lingual surfaces of anterior teeth can be changed to

develop incisal guidance or centric holding contacts in malocclusions, especially in
periodontally compromised teeth.

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e. Poor restorations: Teeth with numerous, shallow, unesthetic restorations on labial

surfaces.

f. Wear patterns: Porcelain Laminates are indicated in cases that exhibit slowly progressive
wear patterns.

Contraindications

i. The teeth with poor quality enamel or insufficient sound enamel. There should be enamel
around the whole periphery of the laminates for good bonding. The sufficient enamel should be
available for bonding, because bonding to dentin provides much less retention than to enamel. If
the tooth lacks enamel and is composed predominantly of dentin, then ceramic crowns will be
the treatment of choice. ii. Rotated or overlapped teeth present problems in the placement of the
laminates. iii. Broken down teeth also offer limited support for laminates. iv. Patients having oral
habits as bruxism or rubbing foreign objects to teeth may not be ideal candidates for laminates.
The shearing stress in such habits may be too great for the porcelain to withstand. [63]

Pre-restorative evaluation

The colour transparencies provide a useful reference for characterization in the laboratory and
for future reference. The shade should be thoroughly discussed with the patient before finalizing.
The shade of the existing teeth and the proposed shade should be decided and recorded.

The patient’s static and dynamic occlusal relationships should also be assessed. The contact
relationships between the incisors and canines, both in centric occlusion and during excursive
movements will be the determining factors for deciding the positions of finish line at the incisal
level.

Presence of incisal facets may lead to unsupported porcelain on incisal edges, especially on
canines. Loss of posterior support along with mandible in edge-to-edge or Class III incisor
relations also influences the treatment modality.

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TOOTH PREPARATION

The type of restoration proposed determines the extent of tooth preparation. There is no single
and ideal way to prepare teeth for porcelain laminates. The decision of whether to reduce the
enamel or not, and if to reduce, then to what extent, should depend on the following biological
and technical factors. i. Esthetics ii. Relative position of the tooth in the arch.iii. Masking of
stains, whether intrinsic or other defects. iv. Placement of margins. v. Age and psychology of the
patient. vi. The potential for periodontal changes. vii. Maintaining the restoration and oral
hygiene etc.

If the restorations are to be esthetically and biologically compatible, they will often necessitate
adjustment of the tooth surface. The enamel is prepared for the following features:

 To provide an adequate space for the porcelain material.

 To remove convexities and provide a path of insertion, where either the incisal or the
interproximal extensions are to be included in the laminate. The best path of insertion is
that which will require the least amount of enamel reduction.
 To provide space for the opaquer and the luting agent.
 To provide a definite seat to help position the laminate during placement.
 To prepare a receptive enamel surface for etching and bonding the laminate.
 To facilitate sulcular margin placement in severely discoloured teeth.

It is not always essential that the tooth be reduced to receive a porcelain laminate. In the young
patient or where teeth are in linguoversion or retroclined or of abnormal shape like peg-shaped
laterals, reduction of enamel can usually be avoided. However, where there is need to mask the
discolouration or modify the contours, enamel reduction is mandatory.

Procedure

The first step in the reduction of the labial enamel is the establishment of a confluent finish line.
The ideal choice of finish line is chamfer or radial shoulder. Since the porcelain laminate is
bonded restorations, chamfer is preferred. A feather or knife-edge finish line is the most
conservative preparation, but it is difficult to accurately fabricate porcelain to the required degree
of thinness. The thin margin invariably produces poor marginal fit and potential laboratory

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problems in delineating the exact end of preparation finish line. The finish lines are extended
proximally and gingivally by means of a round-ended tapered diamond Point. Alternatively, a
round bur of 1.2 mm diameter can be used. When the round bur is held at 45 degree to the
surface of the tooth, it creates such a finish line.

The segment of the arc, which is towards the line of dermarcation between tooth and the
preparation, provides a positive chamfer of 135 degree for operator and technician to work on.
The proximal finish line is extended into the embrasures, but usually short of the contact point.
The contact is never broken and the finish line is usually extended half way into the contact area.
Sometimes the contact is broken to establish esthetic proximal translucency and is extended to
the proximolingual line angle. Cervically, the out-line follows the gingiva and is in level with the
contour of the free gingival margin. In the absence of any discolouration, the finish line may
even be left in a supra-gingival position; but where the tooth is discoloured, it is necessary to
extend the finish line subgingivally by 0.5-1.0 mm. Over-enthusiastic increase in depth of
subgingival preparations results in gingival inflammation and subsequent periodontal tissue loss.
It is extremely difficult for the technician to fabricate an accurately fitting laminate on a feather
edge finish line. Usually 0.5 to 0.6mm or approximately half the thickness of the available
enamel is reduced for laminates. [65]

Enamel reduction is carried out preferably in following sequence:

1. Labial reduction

2. Interproximal reduction/extension

3. Sulcular extension and margin placement

4. IncisaI or occlusal modification

5. Lingual reduction

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1. Labial Reduction

Local anesthesia is usually not required. The preservation of an intact enamel surface minimizing
reduction of enamel has distinct advantage, which virtually eliminates the need for temporary
cover. The labial preparation and the amount of reduction should be such as to facilitate the
placement of the laminate. The preparation should remain within the enamel and should include
all the peripheral margins to ensure an adequate seal to enamel. In certain cases, to facilitate
cosmetic alignment, some amount of dentin is to be exposed by the preparation of the tooth. This
may not be critical if it is limited to only small areas and the peripheral margins remain on
enamel.

Depth Guide

The depth cutting diamonds are available in two sizes, LVS No.1 (diameter 0.5 mm )andLVS
No.2 (diameter 1.3 mm).The selection of the cutting instruments depends upon the necessity of
enamel reduction. Usually LVS No.1 is used incisally and LVS No. 2 cervically. This type of
preparation provides enough surface for the dentin, enamel and translucent layer of porcelain.
The LVS is drawn gently across the labial surface of the tooth in a mesial to distal direction. This
will develop the depth cuts as horizontal grooves, leaving a raised chip of enamel in between
(Fig. 2). Then this remaining enamel is removed by using round-ended taper fissure diamonds to
the depth of the original grooves. This would reduce the tooth to the desired depth.

Alternatively a round bur No.1 (diameter 1.2 mm) can be used. The depth from the peripheral
aspect of the bur to the shank is about 0.4 mm. The bur should be held at a 45° angle so that
grooves can be made in the enamel to the depth limited by the base of the shank. The problem
with this type of approach is that these cuts can vary in depth depending on the angle at which
the bur was held. Secondly the process is also time consuming. The round bur can be used to
create a three-plane reduction as in a full veneer crown preparation by incorporating two
horizontal cuts and one vertical cut (Fig. 3).Another option is to create three cervical depth
orientation grooves; one across the surface of the enamel and two cervically using round-ended
tapered fissure burs.

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Fig. No. 3 Three – plane reduction

Fig. No. 2 Horizontal and vertical
groove placement

Reduction of remaining enamel

The remaining enamel must be removed to the depth of these initial cuts. The labial reduction
should encompass two aspects. The bulk of the reduction should be carried out with a coarse
diamond. At the marginal area, it is desirable to use a fine grit diamond that will create a definite
smooth finish line enhance peripheral seal. The LVS 2 grit diamond is specifically designed to
prepare labial enamel and margins simultaneously with only one bur. The instrument has 1.3 mm
of fine grit diamond at the tip and a hybrid mixture of rapidly cutting diamond all around. Move
the diamond across the labial surface from a mesial direction, following the contour of the
gingiva from the top of the mesial interproximal aspect to the most apical extent of the free
gingival margin and back to the lip of the distal interproximal aspect. The Finish line should
preferably be at the gingival margin.

2. lnterproximal Reduction/extension

The margin of the porcelain laminates should generally be hidden within the embrasure area.
Depending on the individual form of the tooth, it is usually desirable to extend this margin about
half way into the interproximal contact area. Extension of the laminate beyond the proximal
contact to the proximolingual line angle ensures the wraparound effect (Fig. 4).

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Fig. No. 4 Inter-proximal extension

This is achieved with the same LVS 2 grit diamond, moving the margin into this embrasure area
and just lingual to the buccal surface of the interproximal papilla so that it will not be visible
from the lateral oblique view or directly from the front. For the technician, it is also useful to
have extra reduction in the embrasure area so as to facilitate the addition of porcelain bulk in
this region as it improves the strength of the laminate around the periphery and also to achieve a
good colour control for proximal translucencies.

3. Sulcular Extension & Margin Placement

At this stage the preparation has been extended at the gingival margin. In some cases the margin
is to be placed just within the sulcus. In routine, there is no need to hide the margin sub-
gingivally. The porcelain with the underlying composite resin will blend harmoniously with the
rest of the tooth without showing a cement line. In case extension is required there is no need to
extend more than 0.05 to 0.1 mm into the sulcus. Supragingival laminates are preferred if a
dramatic colour change is not required. The sulcular extension is preferably carried out by end-
cutting burs. Place a gingival displacement cord in the sulcus for about two to three minutes. The
system of first developing a preparation line confluent with the gingival margin and then placing
retraction cord prior to refining and extending it into the sulcus ensures:

 Access for the diamond

 Less gingival damage

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 Direct vision of the margin

This sulcular preparation does not disturb the biologic width area, so there is little potential of
subsequent gingival inflammation. The margin must remain at a point where it will be visible for
finishing of the porcelain laminate and will not lead to tissue displacement.

4. IncisaI or Occlusal Modification

The fabrication of a porcelain laminate overlapping the incisal edge makes placement of the
restoration easier because of having a definite stop during seating. This incisal overlap can be
fabricated purely as a positioning device and later can be removed once the laminate is bonded in
place. This latter type of incisal extension does not require crown type preparation .

The reduction should be at least 1.0 mm if it is desired to restore the original length. Simple
reshaping at the edge without vertical reduction, will surface the demarcation, if the teeth are to
be lengthened. If incisal edge is to be included, it is useful to increase the horizontal tooth
reduction at the periphery of the preparation (interproximal areas) and also the incisal edges.
This will give the technician extra space to stack porcelain and develop a thick periphery for
strength.

Depending on the incisal preparations, the laminate system can be of following three types:

. Window preparations

 Preparations without incisal lengthening

 Preparations with incisal lengthening

The preparation varies at the incisal end. The preferred method is to reduce the incisal edge by
applying a bevel at the expense of the labial surface of the incisal edge to a depth of 0.5-1.0 mm.
The feathered incisal edge leads to a weak and ragged finish. The window preparation however
is designed to protect the laminate. In circumstances where it is necessary to lengthen the tooth
or to protect part of the palatal surface, the overlapped incisaI edge preparation is useful. Such

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apreparation changes the line of insertion of the laminate from a labial to an incisal one. Take
care not to end the incisal edge where excursive movements of the mandible will cause shearing
stress across the junction of porcelain laminate and tooth. The type of restoration resulting in a
sort of reverse three-quarter crown is useful in the repair of larger crown fractures, This
potentiates the fracture of the porcelain, debonding and on going exposure of the composite resin
in this crucial area.

5. Lingual Reduction

Any reduction of the incisal edge necessitates lingual enamel modification so that there is no butt
joint at the incisal-lingual junction but rather a rounded chamfer .This modification will help to
prevent the porcelain from shearing away from the incisal edge during function. It also ensures
increased thickness of porcelain in this critical lingual area that is being used for incising and
guidance. The bonding of enamel is at right angles to the porcelain on the incisal edges, thus
increasing the strength at the restoration. Excessive buccal convexity of a tooth may make it
difficult to overlap the incisal edge and still maintain incisal path of insertion. An excessive
amount of labial tooth structure may have to be removed to facilitate a path of insertion, thereby
resulting in large exposure of dentin. In these situations the laminate should be designed to rotate
about the rounded incisal preparation during seating. The final step in the preparation is the
production of a smooth enamel surface. The fine diamonds are used with a light sweeping
motion, followed by polishing with small diameter, waterproof, flexible discs. The discs are also
used to round off the sharp angles, if any. Any defect in the surface of the preparation may be
filled with composite or glass-ionomer cement as the situation warrants.

A clinical case showing stepwise preparation of laminates on canines is depicted in Fig. 5 a-l.

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Fig. No. 5(a)Preparing cervical margin Fig. No. 5(b) Prepared cervical margin

Fig. No. 5(c)Highlighting cervical margin Fig. No. 5(d)Proximal view

Fig. No. 5(e) Prepared tooth margin Fig. No. 5(f) Highlighting tooth margin

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Re-evaluation

The tooth preparation is reevaluated keeping in mind the following features before final
impression is made. [66]

 Even and adequate reduction

 Definite smooth finish line
 A single path of insertion
 Rounded line angles
 Modification of the contact areas

TEMPORIZATION

Temporization is not necessary, provided the preparation is maintained intra-enamel. Minor

undercuts or other irregular surface, if any, are filled with composite resin. The shade selection is
performed using both porcelain shade guide and composite resin shade guide. Patients seldom
experience sensitivity as a result of the preparation and are usually not unhappy about the
appearance. In case temporary cover is mandatory, it is virtually impossible to place temporary
cover of either acrylic or composite resin without some degree of chemical and physical irritation
of the gingiva. The temporary cover also leads to loss of esthetics of final restoration because of
chronic inflammation and migration of the gingival tissues. With no temporary cover, patients
usually do not feel difficulty in maintaining good oral hygiene. However, spot etching of the
prepared surfaces and luting with a resin without a bonding agent can fix the temporary
composite or acrylic laminates.

IMPRESSION MAKING

The elastomeric impression material is suitable for recording the preparations. The choice
depends on the operator’s preference and the working time required, which in turn is dependent
on the number of preparations being recorded. A special tray is optional, however, excellent
results may be obtained with a stock tray modifying the labial flange. The addition of acrylic

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stops in the tray help prevent penetration of the prepared incisal edges through the impression
material.

Retraction cord is used when the finishline has been carried subgingivally. Heavy or prolonged
retraction is damaging to the gingival tissues. If simple blowing with an air syringe reveals the
finish line, then low viscosity impression material can be carried into the sulcus without further
retraction.

LABORATORY TECHNIQUES

The impression may be poured in type IV dental stone, which provides accurate and durable
dies. Duplicate dies, if required, can be prepared with duplicating materials. The laminate can be
fabricated by two techniques.

a. Incremental technique with platinum foil matrix

b. Direct buildup art refractory dies

a. Incremental technique with platinum foil matrix

The platinum foil is adapted on the individual dies. The porcelain is built up incrementally on
closely adapted platinum matrices. The margins are trimmed to achieve a flush relationship with
finish lines. The thickness of the porcelain laminate varies from0.5 to 1.0 mm and hence it is the
combined effect of the composite resin and porcelain which confers the colour to the restoration.
It is vital that the chroma, hue and intensity of both resin and the porcelain should be closely
matched. Blank pieces of porcelain of similar thickness may be constructed for use in testing the
effect of different resin shades on the overall colour of the restoration at the try-in stage.[67] The
laminates are finished and glazed, and the platinum matrices are removed. The labial surfaces of
the laminates are then coated with clear varnish and sticky wax. The laminates are then placed in
a 10% solution of hydroflouric acid for 15 minutes with ultrasonic agitation. This regime may be
changed according to the manufacturers recommendations. On removal from the acid, the
laminates are thoroughly washed in water and soaked in a dilute bicarbonate solution to

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neutralize any residual acid. The laminates are kept an acetone bath for couple of hours to
remove the varnish and wax. The internal surface should now appear frosted.

b. Direct buildup on Refractory dies

Porcelain laminates made directly on a refractory dies are less likely to warp and distort during
the firing process, thus providing much better adaptation. The laminates by this method can be
fabricated with feldspathic, pressable and castable ceramics. Previously the refractory technique
was primarily restricted to slurry buildup of feldspathic porcelain. The present day laminates are
fabricated with pressable ceramic.

The cast is modified to exaggerate the finish lines and also to block out the undesirable
undercuts. This model is duplicated with silicones and the refractory material. Thin disks are
used under magnification to separate the refractory cast into individual dies. Margins are
trimmed and contoured to final form. In routine gray shade cast is produced. To produce a white
refractory cast, the temperature and time are modified during the pre-burnout phase for
degassing. A temperature of 1400 to 1450ºF for 30 minutes (or longer if the cast is extremely
large)is used to produce a white cast. The maximum length of time a cast should be degassed is
one hour. This will eliminate ammonia, which interferes with the build up procedures. Margins
are marked on the refractory cast with a refractory marking pencil. The margins must be
protected during this procedure. Because improper use can open the margins, stereoscope
magnification should be used when marking the refractory cast. The line is often so thin that it
can be seen only with magnification, especially after the porcelain is fired. The coefficient of
thermal expansion of the refractory and the porcelain should match. It is preferred to use the
refractory and porcelain of the same company. Porcelain is built up in layers on the individual
refractorydie and baked according to a precise firing programme. Body, incisal, and sometimes
translucent or effect porcelains may be added and fired to bring the laminates to full Contour. A
second layer of porcelain compensates for the shrinkage of the first firing and restores the
laminates to full contour. The contour and surface texture is created before the final glaze and the
contacts are evaluated for insufficiencies. The laminates are made as smooth as possible with
sandpaper disks and porcelain polishing wheels. The finishing helps to lower the final

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temperature required to achieve a smooth porcelain surface, which aids in eliminating micro-
fractures and rounding of sharp margins. Insufficient contacts are corrected and the laminates are
glazed. Shaping, staining trimming and glazing are completed on the refractory die and the
refractory is removed by air-abrasion. The dies are divested as much as possible by use of
carborundum points. Final divesting is accomplished with an air abrasive unit using glass beads
at approximately 20 pounds pressure.

After divesting, the fit and marginal integrity of the laminates arc verified on the epoxy cast.
Areas of excessive internal pressure are located with a coloured powder spray and are corrected.
After all laminates fit individually, they are rechecked collectively and the contacts are adjusted.
The surfaces are finished and polished again.

The laminates are prepared for etching by covering the labial surface with sticky wax. Etching is
accomplished with hydrofluoric acid for 30 seconds in an ultrasonic unit. The laminates are
washed and neutralized in baking soda solution and water for one minute. The sticky wax is
removed using fluoromethane spray. After etching, the laminate is thoroughly washed and dried
and a silane coupling solution is applied.

TRIAL AND CEMENTATION

The laminates are fragile and should be handled with care. A colour-contrasting surface such as a
dark paper napkin should always be used. Fit and contour are checked on the model. This does
not spoil the etched porcelain surface. Where several laminates are being fitted, all must be tried
on the model to ensure that there is no binding at the contact. If there are any overlaps, the same
should be adjusted to check the correct order of seating. Adjustments are made with fine
diamonds, always holding the laminate in the fingers. In spite of the fragility of the laminates,
accidental breakages are because of mishandling. The teeth are cleaned with pumice/water slurry
and isolated with cotton rolls. The laminates are tried wet; first individually to check the fit, then
together to confirm that there is no proximal binding. The general shape and contour are
assessed. Minor alterations of shape or length can be adjusted after cementation, since the
laminates are supported and less prone to accidental fracture. The laminates are removed, lightly
cleaned with a soft paint brush using isopropyl alcohol and dried.[68]

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One of the laminates is selected at random and luting cement of the appropriate shade is spread
evenly over the fitting surface. The laminate is positioned with the luting agent and the excess
cement is removed. The shade and appearance of the laminate is assessed. Different shades may
be tried until the desired effect is achieved. The trial luting agent is removed by peeling it out
with a nylon plastic instrument. The laminate is soaked in acetone for few seconds and washed.
Special effects such as crack lines, white hypoplastic patches and translucent incisal edges are
normally incorporated into the porcelain during build up in the laboratory, but slight staining
modifications may be made at the chair side with coloured composites. There are a number of
staining kits, mainly in the form of low viscosity resins, which include colouring agents. These
are supplied in either translucent or opaque forms, tints and opaquers. The colour match of both
porcelain and composite resin should be checked. The combined colour effect and masking can
be judged by using a blank piece of selected shade porcelain of similar thickness and uncured
selected resin shade. The final colour is also influenced by the colour of the tooth after
preparation .The technician should be informed about the colour accordingly.

LAMINATE PLACEMENT

The placement of laminate involves the following steps:

a. Preparation of laminate

The fitting surface of all the laminates is coated with silane coupling agent, which is allowed to
dry for one to two minutes. Excess, if any, is blown off and bonding agent is placed on the
silane-treated surfaces. One school of thought is not to apply bonding agent to the etched
porcelain surface. Excess bonding agent is also blown off. The silane coupling agent attaches
chemically, both to the etched porcelain and the resin matrix of the composite cement and
bonding agent. It the etched surface is contaminated, it should be re-soaked in acetone, cleaned
and the procedure of silane and bonding is repeated. When the fit is considered satisfactory, the

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laminates may be cemented individually. Cotton wool should not be used to wipe the surfaces
dry, because it may leave tags.

b. Preparation of the tooth

The prepared tooth is washed and polished. The teeth are isolated using rubber dam. The selected
tooth is separated from its neighbours with mylar strips, etched with ortho-phosphoric acid for 60
seconds, thoroughly washed and dried with an oil and water-free air supply .

The bonding agent is applied to the etched enamel and the excess is blown off. The remaining
thin film is then light cured. Thick films of bonding agent prevent proper seating of laminate. It
can also cause fracture arising from loss of congruity of the fitting surfaces. If any dentine is
exposed, a dentine adhesive maybe used.

The selected shade of cement is placed evenly on the porcelain to cover the whole fitting surface
without trapping air and the laminate seated in exactly the same way as for the try-in, starting
with the cervical end and using gentle and even pressure. Fresh matrix strips prevent excess
cement, blocking off the contact area and allow some shaping of the proximal surfaces. All
excess cement is removed. After the laminate has been properly positioned, a 10-second spot
cure of the cement is carried out before final polishing.

Porcelain versus Composite Laminates

Superior strength and retention can be achieved with etched porcelain laminates.Due to this
advantage, they are preferred in case, requiring lengthening of teeth or involving functional and
occlusal contacts.

Surface texture of glazed porcelain is superior to that of polished resin because of its durability
and high lustre. However, in areas where the laminate surface is disturbed by contouring and

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finishing, it is difficult to re-establish a highly polished surface to porcelain laminates, than to

resin.

Porcelain laminates are more durable than composite laminates.

The indirect composite laminates are easily matched, repaired and replaced. If the original
master cast is retained, a new composite laminate can easily be produced.

Replacement of porcelain laminates require, at least two appointments. However, need for repair
or replacement is less with porcelain laminates due to their superior bond strength and retention
to etched enamel.[69]

REPAIR OF LAMINATES

Failures of esthetic laminates occur because of breakage, discolouration or wear. The

conservative repair of laminates should be preferred if the remaining tooth and restoration are
sound. It is not always necessary to remove the old restoration. The light-cure composite is
commonly used to repair the laminates. Re-contouring and polishing can often correct small
chipped areas on the laminates.The direct composite laminates should be repaired with the same
material that was used originally. After cleaning the area and selecting the shade, the operator
should roughen the damaged surface of the laminate or tooth or both with a coarse, tapered,
round-ended diamond instrument to form a chamfered margin. Roughening with micro etching is
also effective. For more positive retention, mechanical locks may be placed in the remaining
composite material with a small round bur. Acid etchant is applied to clean the prepared areas
and etch any exposed enamel that is then rinsed and dried. Next, a resin-bonding agent is applied
to the existing composite and enamel and polymerized. Composite is then added, cured and
finished. Indirect composite laminates are repaired in a similar manner. To repair porcelain
laminates, a mild hydrofluoric acid must be used to etch the porcelain. Hydrofluoric acid gels are
available in approximately 10% buffered concentrations that are intended for intraoral porcelain
repairs. The lower acid Concentration allows for relatively safe intraoral use.Full-strength
hydrofluoric acid should never be used intraorallyfor etching porcelain. Isolation of the porcelain

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laminate to be repaired should be accomplished with a rubber dam to protect the gingival tissue,
from the irritating effects of hydrofluoric acid.

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