Ceramic Veneers: Steps to Simplify Delivery

You're listening to the Phil Klein Dental Podcast. Many of us rely on ceramic materials to do our indirect restorations. And with today's choices, we need to be aware of how we handle these materials before we cement them in. We also need to understand the differences between ceramic and zirconia and how to prepare the material itself prior to placing it over the tooth. To tell us all about it and share some invaluable clinical tips is our guest, Dr. Todd Snyder. Dr. Snyder is a popular speaker on VivaLearning.com, a cosmetic dentist, international author, lecturer, and consultant to dental companies. He hosts a weekly podcast, Delusional, Winning the Weekly War of Dentistry. You can reach Dr. Snyder at legion.dentist. Dr. Snyder, it's a pleasure to have you back on the show. Thanks. Always great being here. So typically when we talk about veneers, we're thinking of ceramic, but there are other options. Before we get into the details of ceramic veneers, talk to us about the other options that are out there, including additive techniques by using composite resin directly on top of the tooth. There's zirconia, which we've talked about in other podcasts and so forth. You know, I think it's great to have numerous different modalities of care for your patient based on what they need. And I think each person should have a good understanding of these different steps, whether it be direct resin veneers or being different types of ceramic veneers or even modern zirconia can make phenomenal veneers. I think that getting training and knowledge in all of these that you can become very versed at them and can offer them to your patients becomes beneficial. At the same time, it seems like we're having a full circle resurgence of direct resin veneers. As amazing as resins are nowadays with translucency and colors and whatnot, strength, polishability, we still know that resins have some color shift over time. What I see is, okay, we're using resin to be conservative. It's like, well, if you can add that much resin onto a tooth that's, you know, half a millimeter, millimeter thick, then you can do a no prep veneer unless you can't wrap it around a corner. So in that sense, I see that a no prep, whether it be resin, ceramic or zirconia, I think are all coming into their own right now, which is great to see being conservative. So getting back to the subject of this podcast, which is the delivery of ceramic veneers. What are some of the pitfalls or what are some of the dangers that dentists run into when placing a ceramic veneer that would cause a failure? I think there's a few things. I think it starts with preparation design. You know, if you're someone who does extensive reduction to tooth structure and you're in the dentin, you have a lot more risk of sensitivity and debonding over time. We know that MMP activity happening inside the tooth will break down the resin hybrid zone in as little as 6 to 12 months. And so I think doing extensive tooth reduction creates more problems in the long run for something debonding and coming off, but also having less tooth structure, as you mentioned earlier, being minimally invasive, having less tooth structure for the next best thing 10 years down the road. So we know that the most durable, long-lasting bond is to enamel. So hence, minimally invasive staying on the enamel becomes what I would see the better technique for longevity. But it's more challenging to take just a small amount away and make it still look amazing. Because if you don't have a skilled technician that can fabricate something that's very thin, well, then you end up with something that may look a little bulbous or peculiar compared to the natural emergence profile and shape of the tooth structure. Do you typically utilize whitening techniques in order to allow for possibly a thinner veneer, which obviously goes along with more minimally invasive dentistry? You know, every case is different. We always talk about where we're ending. So we start with the end in mind, like what color are we going for? And then based on the color we're trying to achieve, is that even something we can have in life? Or is that something unrealistic that we have to create through the gift of ceramics? And so in that sense, you go, okay, well, If we're only doing a certain number of teeth, then we definitely need to whiten the teeth around it so that it doesn't have a very peculiar change in color from the ceramic to the natural tooth. Or in the case of some of them where we would call them like ice chips, where they're literally just paper thin, milky translucent, that when you lay it on the tooth, that underlying tooth color comes right through it. In those cases, you definitely want to whiten. So it kind of depends on how much you're covering with the ceramics. how translucent the material is and what the final shade determination is. So a lot of communication before you get started with a case. So there are certainly instances where dentists are using both ceramic and zirconia, depending on the clinical application. We're talking about the same patient and even delivering it at the same time. So they're putting in zirconia and ceramic at the same time. So it's really important, I think, to have really good protocol, good systems in place so that when you're dealing with a ceramic veneer, you treat it completely differently than you do the zirconia veneer or zirconia crown. So talk to us about managing both those materials and the techniques and how important that is. And of course, if you don't follow the protocol carefully and have your staff up to speed, you can run into some real problems. So the first thing I would consider is that with your ceramic, whether it be, you know, like a lithium disilicate, like an Emacs. or you know feldspathic you're doing traditional ceramics at that point so restoration comes from the lab already etched so you've got to use some type of silane and then you're typically going to use you know your favorite bonding agent and your light curable resin and so with your bonding agent and your light curable resin you can mix and match companies so whether you want to use visco and Kerr or 3M and GC, you can mix and match when it becomes a light curable based product typically. Now, where you're going to run into problems, if you're going to put a zirconia restoration at the same time, the zirconia needs a totally different primer and cleansing aspect, which we talked about in a prior podcast episode. And so to put some type of zirconia cleanser and zirconia primer on the zirconia material is totally different than your ceramic. But then you go, okay, well, if I've conditioned them differently because they're uniquely different, And I have different products for that purpose. The next thing becomes, okay, adhesion. Is adhesion using just a resin cement? Is any resin cement the same? It's like, no, here's what you got to think twice and be careful. When I said you could put something in with light cure resins, you could mix and match. The problem becomes with zirconia. If you're going to go to a dual cure based resin looting system, you're going to have to be very careful with the chemistry. You typically. Don't want to mix one manufacturer, let's say bonding agent with a different manufacturer's looting cement because the chemistries oftentimes will not work properly simply because of the acidity and or chemistry differences in the product. So that's where me personally to make life easy because I've got a case like that right now. It's a big zirconia bridge in the front with a bunch of Emax next to it in the back. And so to keep life simple, I use my Bisco All Bond Universal. which allows me to use it for both direct and indirect restorations. It allows me to use it for a total etch, a self etch or a selective etch. It allows me to use it for both a light curable resin from an indirect ceramics. It allows me to use that same exact bottle with no additional bottles or extra additives necessary for my dual cure resin system. So for like zirconia, the only thing I'm going to change is I'm going to use a dual barrel resin cement from Bisco. that matches my chemistry with my all bond universal. And then I might use my choice to light curable resin for my veneers, inlays and unlays. So I pretty much have the same system across everything other than I'm grabbing a dual barrel resin that has both light cure and self cure capabilities for the zirconia and a light cure product for my ceramics. Now you can't do that necessarily with most manufacturers. products. I will tell you, if you're using the Albon Universal from VSCO, that is one product they've tried with different dual-cure resins from different manufacturers. And you can, for their chemistry, use it with other companies' dual-cure resins. But that is not the norm. That is one of the only cases you can do it. So hence I mentioned. stay within one manufacturer's chemistry when it comes to dual cure products. That wasn't particularly easy to articulate, but I think you did a pretty good job. I did notice that you mentioned that you used zirconia anteriorly and towards the back you used Emacs. I assume that's for an anterior bridge? Anterior six unit zirconia bridge. And then I've got posterior veneers and veneer onlays that I didn't need the same strength because I have plenty of tooth structure there. I'm adhering the existing ceramic to the tooth. So in that case, why not just use zirconia for everything and simplify it to one material and then one delivery cementation technique? You totally could. Yeah, I would just say Emacs is easier to handle for the lab technician to get the colors right because the zirconia bridge is so big and they're going to be layering on it to make a thin piece of zirconia in the back. Just a little more challenging since you're typically machining it. Not that you can't layer at the back too, but you might have to take more two structure away to make it possible. And so in having a conversation before we start a lab case, I asked them, you know, what are we thinking here as far as materials? What can we get away with? What is the easiest for you in the lab when I finally get it there? And so it was like, yeah, we can do Emax in the back, keep it simple. And we'll do a nice strong zirconia with a, you know, very translucent, newer system that matches the Emax very nicely. So when you have a case where you're delivering two different materials, in the case you just described, I assume your staff is well-trained and they're on top of things because obviously you don't want to make a mistake there. I would say almost a nice cheat sheet that's laminated that's sitting to the side where they know which materials to have out and ready for the delivery process. But also as we're going through delivery, they know on the checklist what's next is a nice thing to have chair site. So if you would, Dr. Snyder, review the steps that you employ when delivering a ceramic veneer in your practice. So when I go to try in the ceramic veneer, I've already cleaned the tooth and my veneer has already been pre-silinated. And so when I'm going into the mouth, that veneer having been pre-silinated helps protect it. And the silane chemistry has already adhered to that veneer. So that's when I take it out of the mouth after try in, it's contaminated, but it's easier for me to use a steam cleaner to clean the entire inside area that had been contaminated. You could also use an alcohol acetone water bath. I just like a steam cleaner personally. And then after that's been done, some people would say, well, do you have to go back and silenate it again? You don't have to. If you want to, you can. From there, I'm using a unfilled resin that I utilize as kind of a surfactant, you could say, a very thin layer of unfilled resin. The one that I use comes from Bisco and their Choice 2 system. And what it's basically doing is allowing the resin looting agent to lay down easily and adapt well to the ceramic veneer. And so as I'm using my Choice II resin looting cement, it slides more easily, it adapts better, so I'm having less bubbles, less problems potentially if not getting good adaptation. Now, once that resin looting cement is inside the veneer, I push it down in the tooth, I get all the excess coming off. It's at that point I either have a decision to tack cure it or to cure it to completion. Me personally, I'll wipe off, let's say 40%, 50% of the gross excess and I will cure it to completion. I'm not someone who tack cures and tries to wipe everything up because oftentimes you may wipe something out of a margin and create a defect or potentially cause bleeding and now you can't get the veneer off. So me personally, I cure it all at one sitting. What do you see as one of the major pitfalls that dentists face when dealing with ceramic veneers and ceramic restorations? Well, I'd say one of the things I find is that trying to work quickly or trying to make things easier oftentimes creates more problems. And so where I mentioned just a moment ago, if you try to tack cure something, it's not that it can't work. But again, you've got a thick resin looting material there that if you're wiping off all the gross excess, you're not going to see some tiny micron gap that just opened up until later when the patient comes back on recall and they have a brown line or something leaking. Pretty hard to fix that at that point. Now it's a redo. For the same token, if you try to clean everything off and you're flossing the contacts, and in flossing the contacts to make it easy, you hit the papilla and it starts to bleed. Now that blood goes underneath where you've already tack cured it, and that blood is going to become a brown stain, a mark under that veneer in the coming weeks as it oxidizes. And so you go, wow, trying to clean everything up to make life easy actually potentially could create a lot of problems going forward, as opposed to saying, well, if I... everything and potentially curing teeth together. And I got a bunch of excess on my margins. At least I know everything was sealed up. And when I'm cutting off the excess, I know there's nothing that has come out of my margins. And you go, wow, that's a lot of time and effort. What a difficult process. And I said, yeah, it is. But it's far better than having to redo a case for free months or a year down the road. So that's my philosophy on it. So doing a full cure outright sometimes will cause some cement to harden in approximately. What do you do to clear that? Yeah, well, I do minimal prep. So a lot of times I haven't broken the contact. So I'll literally get enamel to enamel adhesion as well as enamel to ceramic. And so going in there, I might use where I have access a 12 or 30 fluted carbide burr. And then to break that final little part, if you think of like Brassler or Axis or Ultradent, they'll have these little interproximal saws that you can go through carefully. you know, strip away resin, resin being softer than tooth or ceramic, the resin strips away. So it's very easy, but it is, you know, it takes a little pressure and time to get through them, but it's doable. Thank you, Dr. Snyder, for sharing with us that invaluable clinical tip. And thank you for the nice discussion today. We really enjoyed your input and we look forward to seeing you on future podcasts and webinars. Thank you so much. Thanks, Bill. 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