Reflect 3-11 English Asia

REFLECTREFLECTREFLECTd e n t a l p e o p l e f o r d e n t a l p e o p l e 0 3 / 1 1

Direct reconstruction

Not your regular patient case

Shining results

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Editorial

Dear Reader

The present issue of ourinternational customermagazine Reflect onceagain bears testimonyto the innovative powerof Ivoclar Vivadent AG.Even in economically dif-ficult times, innovativeproduct systems andtechniques are indispens -able for dental practicesand laboratories strivingto deliver quality dentalcare. In this issue of

Reflect, you will find specialized articles written by dental profes-sionals for dental professionals. At Ivoclar Vivadent, we are proudto provide our customers with a continuous supply of outstand -ing products for high-quality, esthetic dental restorations thatbenefit the patient.

Ensuring that customers receive the goods they order at theright time and in the right quality is part of my task as the per-son in charge of production and logistics. To this end we haveagain made substantial investments in the field of productionthis year. Innovation also plays a decisive role in this respect. Allour strategically important production plants are designed andbuilt by an internal team of engineers on the basis of state-of-the-art technology – just one of several aspects that help ensure

the high quality of our products. The technological know-howacquired is an important prerequisite in the creation of newmanufacturing processes, and as such plays an important partin the development of new products. It is the innovative spiritof the people working at Ivoclar Vivadent that has allowed thecompany to achieve and maintain its current position at theforefront of the marketplace.

As you can see, we are committed to driving innovation in allareas. As a result customers can fully depend on our productsand systems solutions in terms of reliability, cost-effectivenessand high esthetics, now and in the future.

I hope you will enjoy reading Reflect and that the articles contained in this issue will offer useful hints and tips for yourdaily work.

Best wishes

Wolfgang VogrinChief Production OfficerIvoclar Vivadent AG

The cover picture shows an artistic representation of upper anterior teeth restored with IPS e.max® materials (photo: Szabolcs Hant, MDT).

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Contents

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Editorial Creating important preconditions . . . . . . . . . . . . . . . . . . . . . . . 02

Wolfgang Vogrin (FL)

Dental medicine Direct reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 04

Juan Manuel Liñares Sixto, DDS, MD, PhD (E)

The strengths of composite resin . . . . . . . . . . . . . . . . . . . . . . . . 07

Dr Ali H Ozoglu (TR)

TeamworkThe truth is three-dimensional . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Dr Nihan Özlem Kuday and Hilal Kuday, CDT (TR)

Challenging, but far from impossible . . . . . . . . . . . . . . . . . . . 13

Dr Jean M Meyer and Gilles Philip, DT (F)

Not your regular patient case . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Prof Dr Daniel Edelhoff, Björn Maier, MDT, and

Dr Hela Ihloff (D)

Dental technologyShining results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Monica Basile, DDS, and Michele Temperani, CDT (I)

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PUBLISHER’S CORNERPublisher Ivoclar Vivadent AG

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Production teamwork media GmbH, Fuchstal/Germany

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Fig 1 Initial situation: severe attrition of upper anterior teethcaused by bruxism.

Composites were first used as restorative materialsin the 1960s. In the meantime, the field of appli-cation has been significantly expanded to includeindications in both the anterior and posteriorregion. Today’s materials allow the fabrication ofhighly esthetic restorations with minimal loss oftooth structure. This presents a clear advantage,because it has become an overriding objective formany dentists to keep the biological cost of restora-tions as minimal as possible.

Composite materials are successfully used for ante-rior restorations to reconstruct lost tooth structurecaused by carious lesions, fractures or wear processes.Composites are also suited for complex rehabilitationswhich have to meet exacting esthetic requirements,such as the closure of diastemas or the realignment ofteeth. Dental professionals can choose from a wealthof composite material systems offered by various man-ufacturers. Ideally, the physico-chemical properties ofthe material should ensure easy handling and provideoptical characteristics that allow the healthy naturalteeth to be accurately mimicked. Detailed knowledgeof the material properties and strict adherence to theinstructions for use and the adhesive protocol areessential to achieve predictable and durable results thatsatisfy both the patient and the dentist. Tooth wear – ie the progressive loss of tooth structure –is a frequently occurring problem among today’s popu-lation. The reasons for tooth wear vary; it is difficultto determine how widespread bruxism is. Increasingly,dental professionals are faced with the challenge tofind a minimally invasive treatment option for patientswho suffer from this condition.

Clinical case – initial situation A 27-year-old female patient came to our practice withher upper anterior teeth showing signs of severe attri-tion (Fig 1). She told us that her central incisors had

been getting smaller over the past two years and theirshape had been changing. Teeth grinding during sleepwas responsible for the attrition. The patient wantedthe progressive tooth wear to be stopped and the orig-inal shape of her teeth restored. At the beginning of the treatment, a clinical and a radio -logical examination were carried out and the initial sit-uation was documented with photographs. Subsequently,study models were fabricated and mounted on a semi-adjustable articulator. As the canine guidance and lat-eral movements of the teeth were found to work per-fectly and the patient was of a relatively young age, weopted for a minimally invasive treatment option. Onlythe incisal third of the upper anterior teeth should berestored with composite. The function and anatomy of the teeth were evaluatedusing a diagnostic wax-up (Fig 2). The envisaged resultwas simulated in the oral cavity with a silicone key. Thisallowed the patient to critique the esthetic and func-tional characteristics before the beginning of the restora-tive treatment. Silicone keys are generally useful as areference to reproduce the shape of the tooth as deter-mined at the beginning of the treatment. After thepatient had been appropriately informed of the treat-ment, the restorative procedure was commenced.

Direct reconstructionMinimally invasive restoration of worn teethJuan Manuel Lin͂ares Sixto, DDS, MD, PhD, La Coruna͂/Spain

Dental medicine

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A1 Dentin were selected to simulate the mamelons.Some of the material extended into the bevelled enam-el edges to mask the transition between the tooth andrestoration. The deepenings between the mamelonswere filled with Trans Opal. Finally, the restoration wascovered with a thin coating of Trans 30. This layer alsoextended into the bevelling (Fig 5). Each individualcomposite layer was polymerized with a bluephase®

curing light for ten seconds using the High Power pro-gram. Upon completion of the layering procedure, therestoration was finished using multi-blade burs andaluminium oxide discs.Finally, the restoration was carefully polished using thethree-step Astropol® polishing system, felt discs andaluminium paste until the desired high-gloss surfacewas attained (Fig 6).

Treatment procedureAs the first step, the incisal edge was given a slightbevel. Care was taken to remove as little tooth struc-ture as possible and yet to achieve optimum retentionand ensure an accurate fit of the restoration. Next, theenamel areas were etched with phosphoric acid andExciTE® F adhesive was applied (Fig 3). In the present case we decided to utilize the IPSEmpress Direct® composite system. The materials wereapplied in layers using the silicone key fabricatedbeforehand. The silicone key enabled us to reproducethe anatomical characteristics of the tooth as true tonature as possible (Fig 4). To build up the tooth shade,we decided to use A1 Enamel to achieve an increaseddegree of brightness and halo effect in the incisal thirdand create intensely translucent areas. Shades A2 and

Fig 5 The surface is provided with appropriate characteristicsbefore the composite is polymerized.

Fig 6 The high-gloss restorations on teeth 21 and 11 are virtuallyindistinguishable from the natural tooth structure.

Fig 4 Composite material is applied in layers using the siliconekey as a reference.

Fig 2 Diagnostic wax-up Fig 3 Adhesive is applied to the slightly bevelled enamel edges.

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case (Figs 9 and 10). The continuing development ofappropriate technologies and improved understandingof adhesive cementation, layering, polymerization andpolishing enable dental professionals to use compositesin a more targeted fashion and predict the results morereliably. q

Contact details:

Juan Manuel Liñares Sixto, DDS, MD, PhDSan Andrés, 78, 1º, Dcha15003 La Coruñ[email protected]

Figs 7 and 8 The lateral incisors are restored using the same procedure.

The incisal third of the upper lateral incisors was built upusing the same procedure to achieve the appropriateanatomical and functional characteristics (Figs 7 and 8).

AftercareAlthough the anterior guidance had been re-estab-lished, parafunctional activity may still occur. Therefore,the patient received a night guard. Bruxism may com-promise the outcome and durability of any restoration,no matter how well designed.

ConclusionIncreasingly, composites are used for standard rehabili-tations of the anterior region. Detailed knowledge ofthe material in use, the tooth anatomy, shade designand occlusion were, among other things, instrumentalin achieving the optically pleasing result in the present

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10Figs 9 and 10 A night guard enhances the durabilityand long-term prognosis of the opticallypleasing result.

to a bicycle accident which had occurred three yearspreviously. As the parents of the patient refused tohave the tooth invasively restored with a crown, welooked for a viable alternative. We suggested a com-posite resin restoration – a minimally invasive proce-dure that was instantly accepted by the patient and herparents. An esthetically oriented restorative approachwas chosen, which involved the imitation of the nat-ural tooth layers using different shades of composite(dentin, enamel, translucent shades etc).

In the case presented, we used the nano-hybrid com-posite Tetric® N-Ceram. The following shades wereselected: Tetric N-Ceram A2, B2 Dentin as well as atranslucent shade. Several different regions wereused as a reference in the selection of the shades.The dentin shade was selected based on the cervicalportion of the canine, while the undamaged adjacenttooth 11 served to determine the enamel shade. Theonly invasive measure consisted in placing an undulat-ed bevel on the fractured edges of tooth 21. This wasdone to improve adhesion and attain a more estheticresult (Fig 2). In order to achieve reliable adhesion inthe enamel portion, the total-etch technique was used.For this purpose, 37% phosphoric acid was applied to

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For many patients, unsightly anterior teeth pres-ent a major problem. Straightforward, minimallyinvasive restorative procedures may be an appro-priate treatment option in such cases because ofthe advantages they offer.

When patients present with fractured teeth, dentistsusually suggest restoring them with ceramic crowns orveneers. Very frequently, however, patients are deterredby the considerable time, cost and loss of healthy toothstructure involved and ask for a minimally invasive alter-native to solve their esthetic problem. In general, patientsare not aware of the possibilities offered by compos-ite resin in these cases. Nano-hybrid composites havegained in popularity among experts lately – a fact thatshould be more thoroughly communicated to patientsand made allowance for by using them more frequent-ly in daily practice. When used in conjunction with asuitable layering technique, state-of-the-art compositesallow optimum restorative results to be achieved andthus represent a convincing option to patients.

Case presentationA 14-year-old girl with a fractured left central incisorwas referred to our clinic (Fig 1). The fracture was due

The strengths of composite resin

Fig 1 A 14-year-old patient presented with a fractured leftcentral incisor.

Fig 2 In order to achieve optimum adhesion, an undulatedbevel was placed along the fractured edge.

Esthetics, strength and minimal invasivenessDr Ali H Ozoglu, Adana/Turkey

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the dentin and enamel surfaces beyond the beveledareas. A plastic matrix was placed between the lateraland central incisor to prevent the adjacent tooth frombeing etched (Fig 3). The etching gel was left to react30 seconds on the enamel and 10 seconds on thedentin. Subsequently, the tooth was rinsed with waterspray for 30 seconds and dried with an air gun. Carewas taken not to overdry the etched surfaces. Then abonding agent (Tetric® N-Bond) was applied to the

etched surfaces, slightly dispersed with air and curedwith the bluephase® curing light for 10 seconds usingthe Low Power mode.

To create the palatal wall, Tetric N-Ceram A2 compos-ite was applied and cured for 15 seconds with the blue-phase light using the Soft Start mode (Fig 4). This cur-ing mode was also used for the intermediate curing ofall the other composite layers applied. The translucent

Fig 3 A plastic matrix was placed between the lateral and central incisor and 37% phosphoric acid gel was applied.

Fig 4 Tetric N-Ceram A2 was applied to a plastic strip whichwas then used to create the first portion of the palatal wall.

Fig 5 Tetric N-Ceram T was used for the translucent incisal portion of the palatal wall.

Fig 6 Contouring of the palatal wall …

Fig 7 … and creation of the mamelons using an opaque dentinmaterial

Fig 8 In order to achieve the required translucency in the incisalarea, Tetric N-Ceram T was placed between the mamelons.

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Tetric N-Ceram T shade proved to be ideal for thereproduction of the translucent incisal portion of thepalatal wall (Fig 5). To facilitate the build-up of theproximal wall, Tetric N-Ceram A2 was applied to a plas-tic strip (Fig 6), while the mamelons were created withTetric N-Ceram B2 Dentin. The opaque dentin materialprevented the darkness of the oral cavity from shiningthrough the restoration (Fig 7). The right central incisorserved as a reference in the creation of the mamelonsand helped ensure a lifelike appearance. To achieve therequired translucency in the incisal portion, the translu-cent material (Tetric N-Ceram T) used earlier on wasplaced between the mamelons (Fig 8). Subsequently,the dentin build-up was coated with a layer of enamelmaterial (Tetric N-Ceram A2). This was followed by theapplication of a thin layer of Tetric N-Ceram T (Fig 9).

After finishing and polishing, the restoration showed anatural appearance and was symmetric with respect totooth 11 (Fig 10). The restoration was imparted withthe desired high lustre by using OptraPol® NG polish-ers and Astrobrush®. Finally, all the restoration surfaceswere light-cured again with the bluephase curing lightusing the High Power mode.

ConclusionHigh-quality composite resins, when used in conjunc-tion with an appropriate placement technique, allowsuccessful tooth restorations to be achieved whichrepresent a conservative alternative to ceramic crownsor veneers (Figs 11 and 12). q

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Contact details:

Dr Ali H OzogluAtaturk Cad Ogrtm Sit Cigdem Apt K:1Seyhan, [email protected]

Fig 9 To mimic the enamel layer, a coat of Tetric N-Ceram A2 wasapplied to the dentin build-up. Finally, the entire restorationwas coated with a thin layer of Tetric N-Ceram T.

Fig 10 After finishing and polishing, the restoration had a nat-ural-looking appearance. High-gloss polishing was performedwith OptraPol NG and Astrobrush.

Figs 11 and 12 The patient’s smile – before and after the treatment

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Fig 1 By means of the digital mock-up we were able to visualizethe anticipated result.

A high degree of imagination is required by anydentist who strives to provide patients withbespoke restorative solutions. Before the treat-ment can begin, all relevant data have to be gath-ered, as this gives the operator an idea of thefinal result that can be achieved. Thus an imagi-nary goal is set, based on which the treatmentprocedure can be determined and the appropriatematerials selected. This article provides a detaileddescription of a complex case which involved therestoration of the entire upper arch with all-ceramiccrowns. It covers everything from the fabrication ofthe virtual prototypes to their conversion into thereal restorations using an efficient procedure.

Evaluating the patient’s expectations is an essential stepbefore starting the treatment. Face-to-face conversa-tions and photographic images provide a host of detailswhich we can combine to form a picture of the finalrestoration in our mind’s eye. In order to share this imag-inary restoration goal with the patient and to assist him/her in the decision process, our treatment strategy usu-ally involves the design of a digital prototype. We havefound this to be a key element in the creation of out-standing, bespoke anterior restorations and crucial for asuccessful outcome.

Starting situationA 38-year-old female patient presented to our prac-tice with heavily worn dentition. She suffered from theesthetic and functional problems caused by this condi-

tion. After a thorough diagnosis and an evaluation ofpossible treatment options, we decided to restore theentire upper arch with all-ceramic crowns. We opted fora non-invasive treatment approach, ie no tooth prepa-ration was performed. Temporary restorations made ofhigh-quality resin material would be worn by the patientas a transitional solution during the treatment phase.

Two-dimensional, digital mock-upAs this type of treatment is very comprehensive, time-consuming and difficult for patients to understand, aconsiderable amount of time was reserved for the con-sultation appointment. Photos of the initial situation,which were taken according to an established proce-dure in our practice, served as the basis for the discus-sion with the patient. The digital technology availabletoday enables different construction options to be dis-played and compared on the computer screen. Based onthe imaginary goal we set ourselves, several differentmock-ups were digitally designed using a special photoediting tool (Fig 1). This allowed us to visualize the antic-ipated result for the patient. We also used this oppor-tunity to answer her questions and eliminate any doubtspreoperatively. By choosing such a procedure, patientsare involved in the planning process at an early stage,which is crucial for a positive outcome. Apart from itspsychologically valuable effect, this early involvementgives patients an opportunity to express their desires andexpectations so that these can be included in the digitaldesign. However, the problem with digital mock-ups isthat they are easily “overdone” and may be difficult toconvert into a real restoration later on. Even though thelimitations posed by essential biological principles andthe properties inherent in the material can be ignoredduring the design phase, they definitively need to betaken into account when the actual restoration is fabri-cated. Promising the patient too much at this stagemay result in a high level of patient dissatisfaction oncethe restoration is in place. After a few small adjustments,the digitally designed mock-up was approved by all the

The truth is three-dimensionalFrom the creation of the virtual mock-up to the final restorationDr Nihan Özlem Kuday and Hilal Kuday, CDT, both Istanbul/Turkey

Teamwork

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mixture was used to create the crown body. Subsequently,the restoration was cut back. Effect materials were appliedand the enamel portion was rebuilt with Enamel mate-rial. For the purpose of achieving a lifelike transition, thebasic mixture was diluted slightly and placed betweenthe mamelons. To enhance this effect, an Effect material(Telio Stains orange) was applied to the respective surfaceareas. Low-value areas were also created with a suitableEffect material (Telio Stains white) (Fig 3). During the layer-ing process, it is advantageous to light-cure the build-upin stages. This helps to stabilize the ceramic layers oncethey are placed and avoids running or bleeding. By pol-ishing the restorations mechanically they obtained theirfinal surface lustre (Fig 4). The moment when the restorations were incorporated wasa very exciting one for us all. Had we been successful inconverting our virtual goal, the digitally designed restora-tion (2-D), into a three-dimensional temporary? Yes, wehad. Figures 5 and 6 clearly show that we were on theright track to achieving the goal we had set ourselves. Inpreparation for the definitive restoration, a silicone matrixhad to be fabricated based on the provisional restoration.Before that, however, occlusion, phonetics and esthetics wereverified and adjusted where necessary. The silicone matrixserved as the basis for the fabrication of the copings (Fig 7).

The final restorationAt this stage, the major part of the work had alreadybeen accomplished. The patient had worn the provision-al restorations for a prolonged period of time and neithercomplained about functional nor phonetic problems,which confirmed that the preparatory work had beensuccessful. This only left us with the task of reproducingthe temporary restorations in ceramic. Since our objec-tive was to create highly esthetic restorations, we choseto use pressed-ceramic copings in combination with aceramic layering technique (IPS e.max).The copings were modelled in wax and pressed using IPSe.max® Press Opal 1 ingots (Fig 8). In order to achieve an

persons involved in the case presented. It was used as areference during the working steps that followed.

Temporization phase –Converting the 2-D digital mock-up into a 3-D wax-up The digital construction was measured. Based on thesemeasurements, a wax-up was fabricated on the model(Fig 2). This wax-up created the basis for the fabrication ofthe provisional restoration. We decided to use the sand-wich technique with Telio® Lab resin for this purpose. Thismaterial is designed to stay in the mouth for a prolongedperiod of time, which is an asset when complex restora-tions such as the one presented are undertaken. Moreover,temporary restorations fabricated with Telio Lab featurea homogeneous structure and are easy to polish. Due tothe excellent shade match of the materials involved, theshade guide prepared for the final all-ceramic restoration(IPS e.max®) can also be used for the temporary restora-tion. By using materials with different levels of translu-cency (similar to layering ceramics), Telio restorations areimparted with the desired translucency and customizedshading. Even though Telio materials and IPS e.maxceramics feature similar shade characteristics, the shadesaturation of a 0.4 mm thick resin build-up is differentfrom that of a 0.4 mm thick ceramic build-up. However,we should not forget that the provisional is only intendedto stay in the mouth for a limited period of time.Using one main shade in combination with an additionalincisal shade is usually sufficient to achieve an optimumresult when fabricating temporary restorations. However,in the case presented, it was essential to meet the highesthetic expectations of the patient already at the tempo-rization stage. This represented no problem – it just meantthat some extra effort had to be put into the fabrication ofthe temporary. A basic mixture of materials was requiredto build up the crowns. Our experience has shown that anatural shade effect in combination with the desired shadesaturation is best achieved with a mixture of one partDentin material and two parts Incisal 2 material. This basic

Fig 2 A wax-up was fabricated on the modelbased on the digital design.

Figs 3 and 4 The temporaries were fabricated with Telio Lab resin using the sandwichtechnique.

Fig 7 The silicone matrix served as a guidewhen the digital design was convertedinto the real restoration.

Figs 5 and 6 The temporary restorationsin situ

Fig 8 The pressed crown coping

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Fig 11 Preparations are made for the second firing cycle.

Fig 10 After the first firingFig 9 The crowns were layered with thehelp of the silicone matrix.

Fig 15 … that our efforts were crowned with success.

Fig 12 Surface texture was applied prior toglaze firing.

Fig 13 The crowns are ready for incorpo-ration.

Fig 14 The frontal view of the final resultproves …

optimum chameleon effect and a natural-looking result,the restorations were designed with highly translu-cent cervical areas. This was easy to accomplish withIPS e.max materials. However, if these materials are usedarbitrarly or incorrectly, they can absorb light, which mayresult in a greyish tinge. As the thickness of the pressedcopings was between 0.5 and 0.6 mm, they appearedvery fragile. Using the silicone matrix as a guide, IPSe.max® Ceram layering ceramic was applied to the cop-ings. For the first firing, a mixture of Dentin and DeepDentin materials was applied (Figs 9 and 10). Using asophisticated, well-practiced technique, internal charac-terizations were added using different Effect materials(Fig 11). Finally, the build-up was coated with a layer ofEnamel material. Prior to glaze firing, surface texturewas applied to the surface of the restoration. This work-ing step is crucial to attaining a lifelike appearance ofthe final result (Fig 12). After the glazing paste had beenapplied, glaze firing was conducted. Then the crownswere ready to be incorporated (Fig 13).This was another exciting moment. Had we succeededin reproducing the shape, function and phonetics of thetemporary restoration in the final ceramic restoration?Yes, we had. Figure 14 shows the crowns after finalincorporation. The end result proves that the treatmentcan be considered a complete success (Fig 15).

ConclusionIn the case presented, we succeeded in converting thevirtual goal we had set ourselves into a real restoration.Our treatment strategy involved the design of a digitalmock-up based on photographs of the preoperative sit-uation. Our patient was given a say in the treatment asshe was able to contribute her ideas when the restora-tion was digitally designed. We would like to emphasizeonce again that realistic digital mock-ups should be cre-ated. Limitations posed by nature or material sciencescan be ignored when digitally designing the restoration

on the computer screen; however, being “overenthusi-astic” at this stage can lead to problems during the real-ization phase. The digital mock-up was used as the basisfor creating a long-term provisional via the wax-up.All the desirable functional and phonetic characteristicswere already included in the provisional restorations. Asthe patient wore them for a fairly long period of time,they represented a reliable basis for the creation of thedefinitive all-ceramic restorations. q

Contact details:

Dr Nihan Özlem KudaySaray Mah Site Yolu CadNo:7 34768Ümraniye / IstanbulTurkey [email protected]

Hilal Kuday, CDTValikonagi cad Valikonagi plazaNo:179 B/4Tesvikiye / Istanbul [email protected]

(Fig 1). Furthermore, the teeth were severely stained.Another complicating factor was that tooth 13 was ina central position between teeth 14 and 11 (Fig 2). Asan extended treatment time was not an option for thepatient, a protracted orthodontic treatment was ruledout. Also if such an approach had been pursued, anesthetically satisfying outcome would have been verydifficult to achieve without modifying the other ante-rior teeth.

Planning the restorationThe planning phase is an important part of the restora-tive process, as it allows us to achieve the desiredesthetic outcome on the basis of a clear sequence ofworking steps. It also enables us to pursue an antici-pative approach in most cases, rather than having toreact to unexpected situations. Thanks to this targetedmethod, compromises in terms of the treatment out-come that could emerge during the restorative processare eliminated. In the case described here, the main problem wasthe lack of space in the first quadrant; tooth 13 waslocated in the position of tooth 12 (see Fig 2). After anextensive planning stage and discussions with thepatient and the dental technician, we chose to fabri-cate two bridges and one crown, made with the high-strength lithium disilicate (LS2) glass-ceramic materialIPS e.max® Press.We decided to place the distal portion of the cervicalpreparation margin of tooth 13 below the gingiva (Fig 3), in order to reduce the size of the tooth neckand therefore to make the gap appear larger. Themesial area of tooth 14 was rather large, which iswhy we were able to remove some of the enamel with-out being too invasive. With this preparation con-cept, enough room was created to accommodate therestoration in the first quadrant. As an alternative, theteeth could have been slightly repositioned towardsthe vestibular aspect. In the second quadrant, a reverse

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If lateral incisors are missing, the classic treatmentoption would involve two implants placed in theposition of the missing teeth. However, this is onlypossible if the clinical situation allows for such aprocedure. In this article, the authors describe atreatment concept which can be applied if the ini-tial situation is not optimal.

In this day and age, looking attractive is considered anindicator of social success. As a result, more and morepatients want a “perfect” smile and sparkling whiteteeth. The media play a major role in this, by placingthe images of beautiful people with flawless teeth andan air of success on the cover pages of large magazines.

Initial situationOur patient also came to the practice with the wish tohave a “perfect” smile. The clinical situation, however,was anything but perfect. The patient suffered fromhypodontia, ie the lateral incisors had failed to develop

Challenging, but farfrom impossible

Fig 1 Labial view of the initial situation

Fig 2 Occlusal view of the initial situation

Correcting a hypodontia of the maxillary lateral incisorsDr Jean M Meyer and Gilles Philip, DT, both Marseille/France

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Fig 8 Prior to seating the final restoration

Fig 4 The situation after tooth whitening

Fig 5 The silicone key

was also used to check the

preparations.

Fig 6 The finished preparations prior to impression-taking

Fig 7 The direct temporary restoration

situation was found: The gap was too spacious in orderfor an esthetic reconstruction of tooth 22 to be inte-grated. The central incisors were somewhat more promi-nent and straight and had a beautiful shape. This wasa sound starting point for a beautiful, harmonious out-come. The wax-up was designed in accordance withthe planned reconstruction. Prior to preparation, theteeth were bleached (Fig 4).

Clinical procedureExcept for tooth 13, all teeth were vital. In order totransform this tooth into a lateral incisor, pulp extir-pation was performed. The root canal was filled witha glass fibre-reinforced post (FRC Postec® Plus) lutedwith Variolink® II composite material. After the applica-tion of a total-etch adhesive (ExciTE®), the core was builtup as required with composite material (MultiCore® Flowlight).The periodontal soft tissue was protected during thesubsequent preparation procedure by means of retrac-tion cords (No. 000). First, the tooth with a straighttooth axis was ground. This preparation then servedas a reference for the other teeth that were to be

ground. In order to ensure even preparation, the diag-nostic wax-up was used as a basis. Three silicone pat-terns were prepared from this wax-up: One was usedfor the fabrication of direct temporaries and the remain-ing two were cut open in a sagittal and vertical direc-tion in order to ensure that enough space was avail-able for the final restorations with an adequate thick-ness (Fig 5).The preparation margins were created close to the gin-gival margin. Tooth 13 was an exception, as the prepa-ration extended below the gingiva line. It was thanks tothis measure that the canine was converted into a lat-eral incisor and thus sufficient space for an adequatelysized bridge pontic was made available. Before animpression of the prepared teeth was taken (Fig 6), thedentin tubules were sealed with an adhesive (ExciTE)in order to avoid contamination of the dentin tissueand postoperative sensitivities.Conventional impressions were taken. In order to pro-vide the patient with a temporary restoration, we fab-ricated a provisional on the basis of the wax-up. TheTelio® CS material is a self-curing composite material inpaste form which can be used for the direct fabrication

Fig 3 A wax-up provides a good opportunity to explore thegiven situation on the model. In this case, the cervical areaof tooth 13 was critical.

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of temporary restorations. After removing the impres-sion, we applied a layer of adhesive to the tooth sub-stance and isolated it with glycerin gel before fabricat-ing the temporaries. Finally, the temporary restorationwas seated (Fig 7). If vital teeth are treated, it is advis-able to leave the temporary restoration in the patient’smouth for no longer than a month. Even if the fit of thetemporaries is excellent, contamination of the dentinmust be prevented. In case of decementation, the prepa-ration has to be cleaned again and another layer ofExciTE has to be applied.

Fabrication in the dental labThe treatment plan encompassed a bridge restorationfor the teeth 14 to 12 and one for teeth 21 to 23 anda single crown for tooth 11. The restorations werefabricated with IPS e.max Press lithium disilicate all-ceramic. As the frameworks that were fabricatedwere to be veneered in a subsequent step, we choseIPS e.max Press LT ingots (LT = Low Translucency) inthe shade A1. In order to achieve an esthetic outcomeand to create a lifelike vestibular transition, the con-nectors of the bridge pontics were positioned moretowards the lingual aspect. The importance of the con-nectors must not be underestimated, and the dura-bility of a restoration must not be compromised foresthetic reasons.

Seating the restorationAfter removing the temporary restoration, we condi-tioned the prepared teeth appropriately (Fig 8). Duringtry-in, the ceramic restorations were checked withregard to esthetics, phonetics and function.After the application of hydrofluoric acid to etch theinner aspect of the ceramic and the subsequentsilanization with Monobond Plus, the restorations wereready for adhesive cementation. For this procedure,we used the transparent version of the dual-curingVariolink II composite system. In this way, the shade ofthe preparations could be optimally utilized and lifelikeadaptation was achieved. Due to the translucency ofthe restorations and the cementation materials, thefinal outcome showed a vital appearance (Fig 9).Because we used IPS e.max Press material in the “LT”(Low Translucency) level and IPS e.max® Ceram mate-rial in the shade A1, the patient obtained brilliantwhite teeth as requested. It was possible to give thepatient his smile back after many years of having suf-fered because of the unattractive appearance of histeeth (Fig 10). The images of the seated restorationsshow their outstanding integration into the surround-ing tooth structure. Thanks to IPS e.max®, all teeth fea-ture an outstanding luminosity. This material showsexceptional biomimetic behaviour, which allows dentalprofessionals to create lifelike restorations (Fig 11). q

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Fig 9 The all-ceramic system we used (IPS e.max) offers excel-lent possibilities to achieve lifelike adaptation of ceramicrestorations.

Fig 11 Thanks to the IPS e.max ceramic system, we were able toachieve an esthetic outcome in spite of the challenging initialsituation.

Fig 10 The seated restorations made the patient smile.

Contact details:

Dr Jean M Meyer314 avenue du Prado13008 Marseille [email protected]

Gilles Philip, DT Laboratoire Philip 5 bd Onfroy13008 [email protected]

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Several therapeutic approaches are available tosolve cases of missing anterior teeth. The mostcommon of these approaches involves the place-ment of implants or the fabrication of Marylandbridges. However, tooth transplantation is alsoan option. In this article you will learn how theauthor team – using a rather unconventional con-cept – managed to provide a suitable restorativesolution for a young female patient who had lostan anterior tooth.

The patient had lost tooth 11 due to an endodonticcomplication. When this tooth was extracted, tooth 15was transplanted into the space left by tooth 11 andthe gap was preserved by means of orthodontic mea -sures. As the healing process had been successful, wewere able to grind the premolar tooth to the requiredshape and prepare it for a crown. To improve the over-all esthetics, we decided to additionally place non-prep veneers on teeth 12, 21 and 22. Furthermore, thecanines were to be built up with composite materialto ensure proper function.Time and again, restoring upper anteriors proves tobe a challenging task to the dental team. Criteria suchas esthetics, function and strength have to be individ-ually assessed in each case. However, due to the devel-opments in the field of dental materials, today’s dentalteams have many all-ceramic restorative options at hand.From zirconium oxide-based framework materials topress ceramics and layer ceramics for individualized lay-ering on refractory dies, the range of materials for thefabrication of dental restorations is immense.The lithium disilicate (LS2)-based IPS e.max® Press ceram-ic is an ideal material for cases where single-toothrestorations with exacting esthetics are required. Withthis material, the wax model is precisely reproducedwith the ceramic material and the fully anatomicalrestoration is characterized with stains and then fired.A more exacting option would be to use the cut-back

technique, in which Impulse and Incisal materials (ofthe IPS e.max® Ceram range) are applied in the occlusaland incisal areas of the pressed framework. By applyingsmall amounts of layering material, highly estheticrestorations can be achieved in just a few steps.The same applies to the fabrication of ceramic veneers:On the basis of a wax model, partially or fully anatom-ical restorations are pressed with ceramic and subse-quently characterized by means of stains and layeringmaterials. The individual build-up of the veneers withlayering materials of the IPS e.max Ceram range onrefractory dies is a more time-consuming and demand-ing option. The outcome, however, makes the addi-tional effort worthwhile.

Patient caseThe 32-year-old female patient came to our clinic afterthe orthodontic treatment had been completed andthe transplanted premolar tooth had healed in place(tooth 15 was transplanted to the gap left by tooth 11)(Fig 1). She wished to have the transplanted tooth mod-ified to obtain an impeccable esthetic appearance.We relied on preoperative models to understand thecase and discussed the various options on the basis ofa wax-up. As shown in Figure 2, the transplanted pre-molar has a strong vestibular inclination as a result of

Not your regular patient caseEsthetic reconstruction of a transplanted premolar toothProf Dr Daniel Edelhoff, Björn Maier, MDT, and Dr Hela Ihloff, all Munich/Germany

Teamwork

Fig 1 Initial situation:transplantedpremolar inplace of tooth 11.

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arises as to how it should be fabricated. Whenever pos-sible, an adhesively cemented, conservative all-ceramicsolution should be chosen. Veneers made of layeringceramic, such as the nano-fluorapatite glass-ceramicIPS e.max Ceram, on refractory dies can be fabricatedwith very thin wall thicknesses and with pleasing opti-cal effects. If a non-invasive approach is pursued, thistype of restoration allows you to exploit its full poten-tial in terms of esthetics and function. In this case,tooth 11 was prepared according to morphologicalguidelines and conditioned for the placement of anall-ceramic crown, which was individually layered inthe incisal area.

The working modelAfter preparation and impression-taking, we fabricatedthe restorations on the model. As we needed refrac-tory dies to complete the individually layered veneers,we prepared a model with removable dies (Fig 6). As aresult, we were able to precisely reposition the doubleddies in the model of the initial situation when the mate-rials were fired. It is crucial, however, that the dies arefabricated with utmost precision. Undercuts had to beprevented at all cost. For an optimal fit of the dies onthe model, it is advisable to create parallel surfaceswhich do not allow for any torsion movement of thedies. A guidance groove is therefore not necessary(Fig 7). If the work is carried out precisely, the methoddescribed herein allows a high accuracy of fit to beachieved. After the glaze firing, the completed restora-tions showed an accurate fit also in the vertical dimen-sion almost at once.

its specific anatomy. This was a complicating factor inachieving a harmonious outcome. When we measuredthe preoperative model, we noted that the width ofthe orthodontically modified gap was somewhat toolarge in relation to the width of tooth 21. The immedi-ate solution we thought of was to build up the mesialaspect of tooth 12 with composite material to restorethe harmonious relationship between the central inci-sors. However, this would have caused the lateral inci-sors to be in disharmony. Another criterion was thelength/width ratio of the anterior teeth (odontomet-rics). In order to achieve a harmonious appearance thatmatched the age of the patient, the incisal areas ofthe anteriors would have had to be lengthened by 1 to 1.5 mm. These aspects were discussed with the patientand visualized with models and the wax-up. A goal wasdefined together with the patient, and we eventuallydecided that one crown (tooth 11) and three veneers(teeth 12, 22 and 21) were needed. The wax-up wasoptimized accordingly and an esthetically pleasing finalgoal was developed (Figs 3 and 4).To provide a better preview of the final outcome, thefinalized wax-up was transferred to a mock-up bymeans of a template. The patient was thus allowed togain a more detailed impression of the outcome thatwas planned before the treatment commenced (Fig 5).She agreed to have the final restorations fabricated onthe basis of this mock-up.

Prosthetic planningIf, as in the present case, a restoration has to be madein a largely healthy masticatory system, the question

Fig 2 Incisal view of the initial situation onthe stone model

Figs 3 and 4 Wax-up for the intraoral transfer to a mock-up

Fig 5 Mock-up in place in the patient’smouth

Fig 7 The refractory dies can be directlyrepositioned in the working model.

Fig 6 Fabrication of the working modelwith removable dies

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Fig 10 Mamelon structures were created.Fig 9 Firing of the ceramic materials on therefractory dies

Fig 8 The preparation margin was markedon the refractory dies.

Figs 11 to 13 Much attention was also paid to the creation of the surface texture.

Fabrication in the dental labThe information captured in the previously completedwax-up was transferred to the working model bymeans of a silicone template, which was additionallyfine-tuned to the situation. Then, another silicone tem-plate was prepared, which served as a reference for thesubsequent ceramic layering.Depending on the material used, the refractory dies areleft to dry for one day after fabrication without addition-al heat. If required, they may be degassed. It is importantthat the dies are immediately removed from the siliconematrix after the 45-minute setting time, as the die mate-rial may start to dissolve the silicone material after longercontact. Subsequently, the preparation margin of theveneers is marked on the dies with a refractory pencil andwash firing is conducted (Fig 8). A thin application ofmaterial ensures that the ceramic layer is even and homo-geneous, which is important for the fit of the veneers. It is advisable to use a clear, transparent material for washfiring, for instance IPS e.max® Ceram Transpa clear or IPS e.max® Ceram Add-On Incisal. In order to keep theshrinkage as low or as constant as possible during themain firing cycle, it is possible to create an “isthmus“ withceramic material. In this case, this structure was createdin the cervical area (Fig 9).Layers of an even thickness were then applied. Startingin the cervical area, Dentin materials were used first.The incisal portion was created in accordance with thepatient situation and supplemented with the suitableIncisal and Transpa materials (Fig 10). This procedurewas used to create individual characteristics (eg mame -lons, opalescent areas) against a translucent background.

The intensity of the materials that were used could beprecisely controlled and was not hampered by theopaque effect that is sometimes caused by an underly-ing layer of dentin material.The crown on tooth 11 was fabricated in the cut-backtechnique. The IPS e.max Press LS2 framework whichwas required for the crown was fabricated at the sametime as the veneers. Subsequently, the incisal third ofthe framework was individually layered with IPS e.maxCeram veneering materials. With this procedure, opti-mum integration of the restoration into the surround-ing tooth structure and a shade effect that was identi-cal to that of the veneers was achieved.After the Dentin firing process, in which the shade wasadjusted, the crown and the veneers were fitted on themodel, the proximal contacts were designed and theshape and surface structure of the restorations werecreated in accordance with the situation using silverpowder (Figs 11 to 13). With the final glaze firing, theceramic layering was completed. The investment mate-rial was removed using 50-µm glass polishing beadsand a pressure of 0.5 bar (7.25 psi) (Fig 14).

Seating the restorationA water-soluble gel which burns out without leavingresidue was used to secure the sandblasted restora-tions in place on the model. This allowed us to checkthe laterotrusive and protrusive movements and toadjust the restorations by means of rubber instrumentswhere necessary. Taking the functional aspects alreadyincorporated in the wax-up into account, we built upthe canines with composite material. A canine-based

dynamic occlusion that relieved the anterior restora-tions was thus ensured.Prior to being seated, the veneers were etched withhydrofluoric acid, which was carefully rinsed off after20 seconds. The restorations were then silanized andaccurately seated according to the established protocolfor adhesive cementation.At the recall appointment after seven days, the teethwere rehydrated and the soft tissue had recovered fromthe intervention (Figs 15 and 16).

ConclusionThe case described in this article shows how complextreatment concepts can be systematically implementedby the dental team on the basis of a detailed plan.Thanks to the intensive counselling of the patient andplanning of the treatment by means of the transfer ofthe mock-up to the patient’s mouth, a high-quality,esthetically satisfactory outcome was achieved. q

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Contact details:

Prof Dr Daniel EdelhoffTenured Associate Professor

Policlinic for Dental ProstheticsLudwig Maximilian University

Goethestr. 7080336 Munich

[email protected]

Björn Maier, MDTPoliclinic for Dental ProstheticsLudwig Maximilian UniversityGoethestr. 7080336 [email protected]

Dr Hela IhloffAcademic Director

Policlinic for OrthodonticsLudwig Maximilian University

Goethestr. 7080336 Munich

[email protected]

Fig 14 The completed restorations prior to seating

Figs 15 and 16 In place: The outcome was precisely in line with the treatment plan and made both the patient and the treatment teamhappy.

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Fig 1 The 30-year-old patientwas dissatisfied with theappearance of his smile.

With the availability of a wide range of innova-tive restorative materials, the esthetic demandsof patients can be met efficiently and effectivelyby the collaborative efforts of practiced dentalteams. As the technology behind these materialshas become increasingly sophisticated, clinical casesthat were considered to be challenging previouslycan now be treated without having to compro-mise on esthetics or remove healthy dental tissue.The authors describe their approach in cases suchas these in the following article.

Immaculate teeth are associated with good healthand vitality. A bright smile radiates self-confidenceand heightens a person’s attractiveness. State-of-the-art esthetic dentistry can achieve small wonders in thisrespect. The shape and colour of teeth as well as theirlength and position can be adjusted. Nevertheless, in allthese treatments, conservation of healthy tooth struc-ture is paramount. For this purpose, procedures have tobe planned in detail by the dental team consisting ofthe dentist and dental lab technician.

An uncommon preoperative situationThe 30-year-old patient was dissatisfied with theappearance of his smile and requested us to correc-tively adjust his front teeth (Fig 1). We visually identi-fied the problem at a speaking-distance to the patient.The overall appearance of the dentition was marredby gaps between the teeth (diastema) and the unusualshape of the upper lateral incisors (Fig 2). A panoramicscanning dental X-ray revealed the failed developmentof tooth 12 and 22 (Fig 3). As a result, the canines hadmoved into the position of the lateral incisors. In thepast, the appearance of both canines had been slightlyadjusted to that of the incisors. Moreover, it is impor-tant to note that the dental arch also featured twodeciduous canines.

What patients wantThe patient let us know exactly what he wanted anddid not want. Today’s patients are usually knowledge-able and well informed. They clearly express theirideas and demand tailor-made solutions. This particularpatient had been searching for a suitable and non-inva-sive treatment for quite a long time. Previous treatmentplans had incorporated the suggestion of removing thetwo deciduous teeth and replacing them with implants.However, the patient did not agree with this solution.He wanted to keep his natural teeth until they fell outof their own accord, even though the lifespan of theseteeth was limited. Until this time, however, the patientwanted to have a gap-free and even-looking anteriordentition, in other words, an attractive smile. We wereunable to predict the survival rate of the deciduousteeth on the basis of the X-rays. Nevertheless, a thor-ough examination showed that they were still secure-ly in place. Furthermore, there were no signs of peri-odontal disease. The patient was fully aware of thelimited lifespan of the deciduous teeth and asked fora “reversible” solution in order to prevent the existingtooth structure from being permanently damaged. He

Shining resultsMinimally invasive and esthetic restorative treatmentMonica Basile, DDS, and Michele Temperani, CDT, both Florence/Italy

Dental technology

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produced on the basis of the previously fabricated sili-cone matrix (Fig 5). Therefore, a composite resin wasapplied to tooth 14 and 24. The size of the two decid-uous teeth was increased and the appearance of theexisting canines was transformed with the compositeresin to look like lateral incisors (Fig 6). Even though theproportions of the central incisors were not yet in har-mony with the overall appearance, the patient wassatisfied with the esthetics of the try-in results of thisminimally invasive solution.

ImplementationThe final restorative procedure involved ten teeth. Withthe mock-up as a reference, the shape, size and min-imal thickness of the restorations was established.Measures were taken to ensure the predictability ofthe quality and the control of the technical and clinicalaspects of the procedure (Figs 7 and 8). On the basis ofthe wax-ups fabricated on the working models, six verythin veneers (facial) were planned for tooth 14, 24, 53,63, 11 and 21. The veneers were so thin that the teeth

wanted to make sure that further treatment in thefuture would be possible without having to make func-tional or esthetic compromises.

Planning the right wayAs usual, we documented the preoperative situationwith photographs. In addition, we determined the“where and how” of the restorative procedure on thebasis of working models. Our aim was to produce anesthetic appearance that would meet the requirementsof the patient. A diagnostic wax-up was produced anda silicone matrix was created in the dental lab, takinginto account the clinical requirements and the technicallimitations (Fig 4). In cases such as this one, the mate-rials that are selected for the treatment are an impor-tant component of the treatment plan. As a result, itmust be clear at the beginning of the clinical procedurewhat ideally should be done and what can be accom-plished from a practical point of view. In this case, thecorresponding information was transferred to the clin-ical situation by means of a direct mock-up, which was

Fig 2 The gaps in the front row of teethand the unusual shape of the upper lateral incisors bothered the patient.

Fig 3 A panoramic scanning dental X-rayrevealed that tooth 12 and 22 had failedto develop.

Fig 4 A diagnostic wax-up and a siliconematrix were fabricated.

Fig 8 ... and the necessary volume and the minimal thicknesswere established.

Fig 7 Reference patterns of the mock-up were fabricated forthe permanent restoration ...

Fig 5 The silicone matrix was used to produce a mock-up of therestoration.

Fig 6 The finished mock-up (composite resin). The patient wassatisfied with the prospective result.

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did not require preparation. Tooth 12 and 22 were pre-pared for two conventional veneers. They were theonly two teeth that required the removal of 0.6 mm ofthe dental enamel. Furthermore, mesial microprepara-tion of tooth 41 and 31 was planned with the aim ofaugmenting these teeth with the corresponding veneers.Despite the smallness of this corrective step, it served toclose what the patient considered to be an unattractivegap in the lower jaw (Fig 9).

Skill and precisionThis case required utmost skill and precision. Therestoration involved six very thin non-prep veneers (Fig 10). Moreover, two veneers had to be fabricat-ed for teeth with micropreparations (the deciduouscanines were only ground on the distal side to remove0.3 mm of dental enamel) as well as two veneers forteeth that had been reduced by 0.6 mm. We decidedto use IPS e.max® Press lithium disilicate glass-ceramic(LS2) to produce the ten restorations. This material isused to fabricate monolithic restorations, which arecharacterized by high strength (400 MPa) and excep-tional esthetics. We used the new IPS e.max Press Valueingots for the veneers on the central incisors and thetwo deciduous teeth. The brightness of restorationscan be carefully controlled with this material. As aresult, smooth integration into the existing dentition isensured (Fig 11). In the present case, the high translu-cency of this material enabled us to lengthen the edgesof the central incisors. Therefore, the proportions ofthe teeth were more balanced, which enhanced thepatient’s smile. Instead of a Value ingot, an IPS e.maxPress Opal ingot was used to construct the lower inci-sors. In contrast to the shades of the Value ingots,these blocks are opalescent and the level of this opti-cal property can be adjusted as necessary (Fig 12).

Furthermore, these materials are characterized by theirability to match the shade of the underlying toothstructure. As a result, certain physical properties, suchas brightness and opalescence, which are often diffi-cult to reproduce, can be faithfully imitated or evenenhanced.In order to improve the appearance of the canines andmake them look like lateral incisors, we also used thepress technique, but combined it with the cut-backtechnique. Due to the shallowness of the preparation,a very delicate framework was required. Therefore, wechose a highly translucent ingot (IPS e.max Press HT,shade BL3) for this purpose. The pressed substructurewas subsequently built up with IPS e.max® Ceram usingthe conventional layering method (Fig 13). If the rela-tionship between a monolithic restoration and the sup-porting dental tissue is incorrect in the anterior region,it may be difficult to adjust the shade satisfactorily. Inother words, if little natural tooth structure is availablefor the shade adjustment, the restoration may lack suf-ficient brightness and it may fail altogether. Therefore,the aim in the case described was to remove as littletooth structure as possible.

A steady handIt is thoroughly understandable that the dental practi-tioner was slightly apprehensive when she opened thepacket from the laboratory, as the delicate veneerswere much thinner than a fingernail (Figs 14 and 15).The subsequent challenge was to place these restora-tions precisely. The teeth, with the exception of the twopermanent canines and the minimally prepared decid-uous canines, had not been ground. As a result, noclear references were available for the placement ofthe veneers. Nevertheless, the OptraStick proved to bea useful placement tool. This disposable auxiliary aid

Fig 9 The prepared teeth Fig 10 The restorations were modelled inthe dental laboratory and ...

Fig 11 ... reproduced with pressed ceramics.

Figs 12 to 14 The material used for the film-thin veneers (IPS e.max Press) enabled utmost translucency to be achieved and the opacityto be adjusted according to the requirements.

allowed the individual restorations to be handled with-out the risk of dropping or breaking them. Anotherimportant aspect of the treatment was the fact thatthe dental technician was on hand to offer invaluableadvice on the positioning of the restorations he hadfabricated.In addition, the cementation material selected wasdecisive for the successful shade adaptation of therestoration. In accordance with the recommendationsfor cementing restorations that are thicker than 1.5 mm,a dual-cure adhesive luting composite (Variolink® II) wasused to place the faced crowns. First, a suitable cementshade was established with the help of the special try-inpastes. Next, the ceramic restorations were etched withhydrofluoric acid and the enamel areas were conven-tionally conditioned. Monobond Plus was used to con-dition the restorations, which were subsequently placedwith the adhesive luting composite. Furthermore, at thetry-in, the flowable composite Tetric EvoFlow® was cho-sen to cement the eight veneers. The flowability of theproduct was enhanced by warming it at 37 °C for twen-ty minutes before its application. Each individual veneerwas placed under the watchful eyes of the dental tech-nician and only polymerized once it was correctly inplace on the tooth.

ConclusionThe subsequent working steps were carried out withthe same care as cementation. Excess cement wasremoved completely and all the necessary checks, suchas the occlusion in lateral and vertical movements,were carried out. Despite the fact that esthetics played

an important part in the treatment plan, functionalaspects were not ignored in any way. Even though theceramics and cements used are by far stronger andmore adaptable to natural dentition than the materialsused in the past, their function has to be checked nev-ertheless to avoid any undesirable consequences.The effect of the restorations immediately followingcementation as well as at the one-week and one-month recall satisfied everyone involved. The materi-als we had selected allowed us to offer the patientminimally invasive treatment and highly esthetic results(Figs 16 and 17). q

A list of literature references is available from the editors on request.

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Contact details:

Monica Basile, DDSViale Morgagni Giovan Battista, 150134 [email protected]

Michele Temperani, CDTVia Livorno, 54/250142 [email protected]

Fig 15 Some of the veneers were much thinner than a fingernail.

Fig 16 View of the restorations one week after their placement Fig 17 Successful esthetic results were achieved with minimallyinvasive treatment.

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Healthy teeth produce a radiant smile. We strive to achieve this goal on a dailybasis. It inspires us to search for innovative, economic and esthetic solutions fordirect filling procedures and the fabrication of indirect, fixed or removablerestorations, so that you have quality products at your disposal to help peopleregain a beautiful smile.

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