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 Editorial

Setting
the Benchmark

A
comprehensive approach to problem solving in esthetic dentistry involves representation of
several disciplines to redefine complications outside normal boundaries and reach solutions
based on a new understanding of complex situations. The coming together of diverse minds
representing varied backgrounds can inspire new benchmarks for esthetic dental treatment. However,
such an approach can be costly and difficult for obvious reasons. Practitioners today are therefore
encouraged to expand their vision by learning more about disciplines outside their field of practice.
Professionals highly focused on one field remain necessary, but those who have a comprehensive vision
and who seek collaboration and continuous knowledge are most likely to succeed.
Understanding limitations—those of the materials and techniques we seek to employ and of
the particular situation at hand, and considering our own limitations as well—is more vital than knowing
the success rate of a given treatment approach or plan. In modern dentistry, failures are potentially
catastrophic, and their repair is stressful, costly, and painful for the patient as well as the technician and
dentist. When the limiting factors are carefully analyzed, failures can be anticipated and prevented,
thus being a dynamic opportunity to expand the frontiers and strategies for esthetic dental treatment
planning. Although this learning exercise requires commitment, hard work, and perseverance, it leads
us to develop a different mindset, fostering an enhanced inner resilience that nurtures success.
For 35 years, Quintessence of Dental Technology has been a unique source of inspiration,
with articles presenting a benchmark for what is the epitome of esthetic dental rehabilitation. In this
commemorative issue, all articles were carefully selected to salute the reader with the finest examples
of novel approaches for treatment planning and for mastering the influence of color, light dynamics
of esthetic materials, communication, photography, materials science, dental composition, perio-
prosthetic connection, tooth preservation, and requirements for advanced esthetic treatment. Please
join me in relishing the inspiration generated by this delightful collection of artwork.

Sillas Duarte, Jr, DDS, MS, PhD

Editor-in-Chief
sillas.duarte@usc.edu

2 QDT 2012

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002_EDITORIAL.indd 2 3/20/12 10:37 AM
 2012

EDITOR-IN-CHIEF Editorial: 2
Sillas Duarte Jr, DDS, MS, PhD Setting the Benchmark
Associate Professor and Chair Sillas Duarte, Jr, DDS, MS, PhD
Division of Restorative Sciences
Ostrow School of Dentistry
University of Southern California
Los Angeles, California
Esthetic Rehabilitation of Compromised Anterior Teeth: 7
Prosthetic Treatment of an Orthodontic Case
ASSOCIATE EDITOR Leonardo Bacherini, DMD/Myra Brennan, DMD
Jin-Ho Phark, DDS, Dr Med Dent
Division of Restorative Sciences
Ostrow School of Dentistry Ultimate Ceramic Veneers: 29
University of Southern California A Laboratory-Guided Ultraconservative Preparation Concept for
Los Angeles, California Maximum Enamel Preservation
EDITORIAL REVIEW BOARD Oswaldo Scopin de Andrade, DDS, MS, PhD/José Carlos Romanini, CDT/
Pinhas Adar, CDT, MDT Ronaldo Hirata, DDS, MS, PhD
Atlanta, Georgia
Naoki Aiba, CDT
Monterey, California BIOMATERIALS UPDATE 44
Amir Avishai, PhD A Comprehensive Guide for Post and Core Restorations
Cleveland, Ohio Jin-Ho Phark, DDS, Dr Med Dent/Neimar Sartori, DDS, MS, PhD/
Markus B. Blatz, DMD, PhD Luana Oliveira, DDS, MS, PhD/Sillas Duarte, Jr, DDS, MS, PhD
Philadelphia, Pennsylvania
Gerard J. Chiche, DDS
Augusta, Georgia
Minimally Invasive Treatment of Initial Dental Erosion Using 65
Shiro Kamachi, DMD
Pressed Lithium Disilicate Glass-Ceramic Restorations: A Case Report
Boston, Massachusetts
Francesca Vailati, MD, DMD, MSc/August Bruguera, MDT/
Edward A. McLaren, DDS
Urs Christoph Belser, DMD, Prof Dr Med Dent
Los Angeles, California
Servando Ramos, DDS
US Army
Avishai Sadan, DMD Value, Hue, and Chroma: 79
Los Angeles, California Control of Value for Accurate Color Reproduction
Thomas J. Salinas, DDS Tomoyuki Hashinaka, RDT
Rochester, Minnesota
Neimar Sartori, DDS, MS, PhD
Florianopolis, Brazil An Alternative Treatment for an Ankylosed Central Incisor: 91
Oswaldo Scopin de Andrade, DDS, The Perio-Prosthetic Connection
MS, PhD
São Paulo, Brazil Eric Van Dooren, DDS/Murilo Calgaro, CDT/Gustavo Giordani, DDS/
Victor Clavijo, DDS, MS, PhD
Tomizaku Tada, CDT
Pasadena, California
Fabiana Varjão, DDS, MS, PhD
Los Angeles, California Digital Smile Design: 103
Aki Yoshida, CDT A Tool for Treatment Planning and Communication in Esthetic Dentistry
Weston, Massachusetts Christian Coachman, DDS, CDT/Marcelo Calamita, DDS, MS, PhD

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004–005_TOC.indd 4 3/20/12 10:38 AM
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 Volume 35

STATE OF THE ART 112 PUBLISHER

Achieving Excellence in Smile Rehabilitation Using H.W. Haase
Ultraconservative Esthetic Treatment: A Multidisciplinary Vision EXECUTIVE VICE-PRESIDENT
Victor Grover Rene Clavijo, DDS, MS, PhD/Paulo Fernando Mesquita de Carvalho, William G. Hartman
DDS, MS/Robert Carvalho da Silva, DDS, MS, PhD/Julio Cesar Joly, DDS, MS, PhD/
Luis Alves Ferreira, CDT/Victor Humberto Orbegoso Flores, DDS, MS, PhD
JOURNAL DIRECTOR
Lori A. Bateman

PRODUCTION EDITOR
Reproduction of Natural Vivid Appearance in Porcelain Restorations 131 Patrick Penney
Part 2: The Essence of the Internal Staining Technique
Naoto Yuasa, RDT ADVERTISING/EDITORIAL/
SUBSCRIPTION OFFICE
Quintessence Publishing Co, Inc
4350 Chandler Drive
Fluorescence: Clinical Evaluation of New Composite Resins 145 Hanover Park, Illinois 60133
Fernando Rey Duro, DDS, MS/Joana Souza Andrade, DDS, MS/ Phone: (630) 736-3600
Sillas Duarte, Jr, DDS, MS, PhD Toll-free: (800) 621-0387
Fax: (630) 736-3633
E-mail: service@quintbook.com
Website: http://www.quintpub.com
Smile Reconstruction: Esthetic and Functional Rehabilitation of a Patient 157 QDT is published once a year by
with Dentinogenesis Imperfecta Using Lithium Disilicate Glass-Ceramic Quintessence Publishing Co, Inc,
4350 Chandler Drive, Hanover Park,
Oliver Brix, MDT/Daniel Edelhoff, CDT, Dr Med Dent, PhD Illinois, 60133. Price per copy: $118.

MANUSCRIPT SUBMISSION
Micro and Macro Dental Esthetics: The Key to Smile Individualization 173 QDT publishes original articles covering
Ivan Contreras Molina, DDS, MS/Cláudia Ângela Maziero Volpato, DDS, MS, PhD/ dental laboratory techniques and meth-
ods. For submission information, contact
Luiz Narciso Baratieri, DDS, MS, PhD Lori Bateman (lbateman@quintbook.com).
Copyright © 2012 by Quintessence Pub-
lishing Co, Inc. All rights reserved. No part
Visagism: The Art of Dental Composition 187 of this publication may be reproduced or
transmitted in any form or by any means,
Braulio Paolucci, DDS/Marcelo Calamita, DDS, MS, PhD/ electronic or mechanical, including pho-
tocopying, recording, or any information
Christian Coachman, DDS, CDT/Galip Gürel, DDS, MS/ and retrieval system, without permission in
Adriano Shayder, CDT/Philip Hallawell writing from the publisher. The publisher
assumes no responsibility for unsolicited
manuscripts. All opinions are those of the
authors. Reprints of articles published in
Porcelain Buildup Inspired by Nature 201 QDT can be obtained from the authors.

Domenico Cascione, CDT, BS/Tzur Gabi, DMD/Jack Goldberg, DDS/ Permission to photocopy items solely for
internal or personal use and for the internal
Alireza Moshaverinia, DDS, MS, PhD/Mamaly Reshad, BDS, DDS, MSc or personal use of specific clients is granted
by Quintessence Publishing Co, Inc, for
libraries and other users registered with the
Copyright Clearance Center (CCC) Transac-
Customized Treatment for Esthetic Success: A Case Report 209 tion Reporting Service, provided that the
base fee of $5 per article plus $.10 per page
Stefano Inglese, CDT is paid directly to the CCC, 222 Rosewood
Drive, Danvers, MA 01923 (www.copyright.
com). Identify this publication by including
with your payment the fee code:
Chipping Occurrence in Zirconia-Based Prostheses 225 0-86715-375-0/12 $5 + $.10.
Francis Cunha Lima, DDS/Luiz Narciso Baratieri, DDS, MS, PhD/ Printed in China
Renan Belli, DDS, MS, PhD ISSN 0896-6532 / ISBN 978-0-86715-562-4

Cover photograph by Dudu Medeiros

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004–005_TOC.indd 5 3/20/12 10:38 AM
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 here are several treatment options to improve Utilizing a checklist, as described by Fradeani, will en­

T function and esthetics for patients with patho­

logic migration and incisal abrasion of the an­
terior teeth. These patients may often require a mul­
sure the comprehensive collection of data from the
face, teeth, and tissues to create the blueprint for suc­
cessful esthetic, functional, and biological integration
tidisciplinary treatment approach with orthognathic of the restorations.3
'
surgery, orthodontics, and/or complex restorative den­ A pleasing and attractive smile and face are influ­
tistry in order to reestablish occlusion and to create enced by the skeletal anatomy of the jaws, the occlu­
pleasing facial and dental esthetics. When prosthetic sal relationship of the teeth, and the facial soft tissue
treatment is needed, it is essential that the functional profile of the lips and chin.4 The relative position of
and esthetic goals of therapy be established through the mandible to the maxilla or of the chin to the tip
a comprehensive systematic analysis and previsualiza­ of the nose determines the nature of a person's facial
tion of the restorations using a diagnostic wax set-up.1 profile. The fullness and mobility of the upper and low­
The systematic diagnostically driven approach er lips determines the extent to which teeth are seen
should include the evaluation of facial and dental es­ during a smile and at rest position. Both facial profile
thetics, occlusal function, remaining tooth structure, and lip form can be altered by surgical movements of
and biological status of the pulp and periodontium.2 the jaw, by orthodontic movements of the teeth, or by
plastic surgery augmentation of the facial soft tissues.5
However, only restorative dental treatment can alter
morphology of the teeth and simultaneously enhance

1 Private Practice, Sieci-Pontassieve-Firenze, Italy.

the facial profile and lip form to create a pleasing and

2Private Practice Limited to Prosthodontics, Hingham, Massachu­ harmonious smile.

setts, USA. Electing a suitable treatment modality to achieve
an esthetic goal must be done in accordance with the
Correspondence to: Dr Leonardo Bacherini, Studio Odontoiatrico,
P.zza Aldo Moro, 7, Sieci-Pontassieve (FI), 50065 Italy.
patient's subjective interpretation of facial and dental
Email: leonardo@dentsign.it; www.dentsign.it esthetics and the understanding of the risks/benefits of

https://t.me/dental_books_lib ODT2012 -
 BACHERINI/BRENNAN ,

treatment. This article presents the prosthetic rehabilita­ divide the face in thirds and are superimposed to as­
tion of a patient with pathologic migration and incisal sess proportion of the face from the forehead to chin
abrasion of the anterior teeth, in which a comprehen­ and the dental esthetic occlusal plane. Dental esthet­
sive systematic analysis of the face and teeth, and their ics is most significantly influenced by the lower third of
respective soft tissues, is used to identify the most suit­ the face, and its normal, convex, or concave appear­
able treatment approach from the many treatment alter­ ance is assessed from the lateral view.9 The decision
natives for malpositioned and unesthetic anterior teeth. to alter these relationships and modality of treatment
should ultimately be guided by the patient's percep­
tion of and desire for facial balance and esthetics.10

FACIAL ANALYSIS:
Jaw Relationship, Tooth Position,
DENTAL ANALYSIS:
Facial Soft Tissue Contours
Tooth Morphology and Gingival Soft
Cephalometric and photographic analysis of the skel­
Tissue Contours
etal anatomy, dental relationships, and facial soft tis­
sue profile are used by oral and plastic surgeons as Facial profile and lip form are also affected by the
well as orthodontists to guide treatment that will alter dimension, proportions, and teeth display. An attrac­
_
the soft tissue contours of the face before the clinical tive smile typically has components of youthfulness,
procedures to move the jaw and teeth three-dimen­ which include a pleasing maxillary incisor length,
sionally are determined.6-8 The vertical relationships of maxillary central incisor dominance, moderate con­
the face as viewed from the frontal and sagittal planes vex smile line, progression of incisal embrasures, and
are measured from specific anatomical landmarks and high brightness.11 The smile is dynamic and should be
compared to ranges of normal. Meaningful esthetic observed during relaxed conversation, laughter, and
parameters on a cephalometric tracing relative to fa­ other facial expressions to reveal what is displayed in­
cial profile and lip form or support and ranges of nor­ traorally when the upper and lower lips are apart. By
mal for females are as follows: closely listening to both the verbal and nonverbal cues
during the initial interview, the dentist can assess the
• Skeletal classification = Class I patient's personality, facial expressions, and smile.12
• Lip protrusion = 3 .5 mm upper I 2.2 mm lower Most noticeable in a smile is the display of the maxil­
• Nasolabial line angle = 110 to 120 degrees lary central incisors. The location of the maxillary central
• lnterlabial gap = 0 to 3 mm incisor incisal edges is a critical aspect to be evaluated
• Maxillary incisor exposure = 3 to 5 mm in a functional and dental esthetic rehabilitation.13 Two
• Overjet/Overbite = 2 to 3 mm methods can be used to evaluate and modify the verti­
cal position of the incisal edges of the central incisors:
Interpretation and treatment according to these num­
bers should take into account the variations between 1. Record the incisal display against the resting upper
ethnic groups.4 lip. The range of display can be from 1 to 4.5 mm
Facial features and expressions characterize a par­ depending on the sex, age, and patient's esthetic
ticular style of an individual and also strongly influence desire.
the perception of their personality by others. When 2. Examine the lip during the "E" sound from the lat­
analyzing the face on a photograph, vertical reference eral view. The length of the maxillary central incisors
lines connecting points located at the glabella, tip of is acceptable when the teeth occupy 50% to 80% of
nose, and chin are superimposed on the face to assess the space between the upper and lower lips.
the coincidence of the facial and dental midlines as
well as right and left facial symmetry. Horizontal refer­ To evaluate and modify the horizontal position of inci­
ence lines at the hairline, eyebrows, ala, and tip of chin sal edges:

- ODT2012 https://t.me/dental_books_lib
 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

Figs 1 a to 1 c Initial presentation of the patient,

who is uncomfortable with the appearance of
her smile.

1. Record the relation' of the incisal edge to the lower oral mock-up with restorative materials, such as com­
lip during the "F" and "V" sounds. posite resin.1
2. Record the angle between the incisal third of the
maxillary central incisor and the maxillary posterior
occlusal plane.14
CASE PRESENTATION:
Tooth morphology, dimension, and proportion are
Systematic Analysis
also modified by gingival soft tissue contours, specifi­
cally the scalloped form and outline of the free gingi­
Step 1: Patient Interview (Fig 1)
val margin (FGM) and the interdental papilla form rela­
tive to the contact point. For example, a flat FGM and The patient, a 50-year-old woman, was unhappy with
short papilla can make a tooth appear more square, her smile and lip posture because of her flared and
or recession of the FGM can make a tooth appear lon­ unesthetic maxillary anterior teeth. She stated she
ger. The outline form and mobility of the lips provide had a history of advanced periodontitis that had been
the framework within which alterations to tooth length treated and stabilized with periodontal therapy, ex­
and convexity of arch form can be made to achieve a traction of posterior teeth and replacement with den­
pleasing and attractive smile.15 tal implants, and endodontic therapy on the anterior
Previsualization of any dental shape and form al­ teeth with direct composite restorations. She was in
terations should be done with a diagnostic wax-up on excellent general health and positively motivated to
study casts, which can then also be used for an intra- improve her smile.

https://t.me/dental_books_lib QOT 2012 1J1

 BACHERINI/BRENNAN

Figs 2a to 2e Esthetic evaluation of facial sym­

metry and proportions using the vertical and
horizontal reference lines in the frontal and lat­
eral views. The patient has good facial symmetry
and acceptable side profile revealing a skeletal
Class II jaw relationship with normal lip support
and nasolabial angle.

Step 2: Esthetic Analysis (Figs 2 to 13)

Face Smile
She presented with symmetry, balanced facial propor­ The dynamic evaluation of her smile reveals a medium,
tions, and parallel facial interpupillary and dental occlu­ convex smile line with lip incompetence due to the
sal esthetic planes (Figs 2a and 2b). In the lateral facial apparent improper facial angulation of the maxillary
view, all the parameters (eg, e-line, nasolabial angle, anterior teeth (Figs 4a to 4e). The buccal corridor is
and profile) are within the normal range considering sex esthetically pleasing; the occlusal plane is coincident
and race (Figs 2c to 2e). Though she has good upper lip with commissural line; and the philtrum of the upper
support, the incisal edges of the maxillary anterior teeth lip is coincident with the dental midline.
extend beyond the wet/dry border· of the lower lip.

- ODT2012 https://t.me/dental_books_lib
 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

Figs 3a and 3b Excessive vertical overbite and overjet of

the maxillary central incisors.

Figs 4a to 4e Photographic progression of the smile is use­

ful for completing the dentolabial analysis.

https://t.me/dental_books_lib QDT2012 -
 BACHERINI/BRENNAN

Figs Sa to Sc Lateral view of varying

lip postures, revealing lip incompe­
tence and overcontoured incisal edge
position with preexisting composite
restorations.

Figs 6a and 6b Three-quarter lateral

view reveals poorly positioned inci­
sal edges of the central incisors with
respect to the lower lip.

Fig 7 Complete intraoral frontal view of the mouth.

Fig 8 Intraoral measurement of 10 mm overjet using a periodontal probe and presence of cervical abrasion/abfraction of
the anterior teeth.

Incisal Edge Position individual anterior teeth. However, the length of the
The vertical position of the incisal edges appears be­ central incisor can provide a starting point to recreate
yond the normal range and can be reduced (Fig Sc). proportional tooth dimensions. The length is 12 mm
During "F" and " V " pronunciation, the incisal edges and can potentially be reduced.
of this patient extend horizontally beyond the wet/dry
line of the lower lip, and the angle with the occlusal Gingival T issue Contours
plane is acute (Fig Sb). She has thick, scalloped gingival tissue with an accept­
able scalloped FGM form that blends harmoniously
Tooth Dimensions with the FGM outline of the existing posterior restora­
She has existing incisal wear and interdental compos­ tions.
ite bonding, which disguise the true dimensions of the

- QDT2012 https://t.me/dental_books_lib
 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an O rthodontic Case

Fig 9 Occlusal view of interdental

composite bonding and spacing be­
tween the anterior teeth.

Fig 1 0 Although the patient's previ­

ous periodontal disease has resulted
in the loss of periodontal attachment,
the remaining outline form of the free
gingival margins and the present level
of interdental tissue is good for creat­
ing pleasing restorations.

Fig 11 Initial radiograph revealing pre­

existing endodontically treated anterior
teeth with periodontal bone loss and
posterior implant restorations.

Fig 12 Mandibular anterior incisors

occluding with the palate, not the max­
illary anterior incisors.

Step 3: Radiographic Findings Step 4: Periodontal Evaluation

Panoramic She was previously treated for chronic periodontal dis­

• Maxillary posterior implant restorations; maxillary ease; she has good oral hygiene, and probing depths
anterior endodontically treated teeth with 20% to are presently within normal range.
30% alveolar bone loss

Cephalometric Step 5: Functional Analysis

• Skeletal classification = Class II
• Lip protrusion = 6.3 mm upper I 3.37 lower The mandibular incisors occlude on the palate as a
• Nasolabial line angle = 112 degrees result of the retrusive mandible and labially migrated
• lnterlabial gap = 1.8 mm maxillary anterior teeth. Therefore, she lacks anterior
• Maxillary incisor exposure = 3 mm guidance.
• Overjet = 10 mm There is no history of temporomandibular joint
• Overbite = 4 mm noise or pain. Mandibular range of motion is within
normal limits. She has no muscle symptoms and no
parafunctional habits.

https://t.me/dental_books_lib QOT2012 -
 BACHERINI/BRENNAN

Figs 13a to
13e Close-up
view of stone casts
revealing the details
of altered gingival
contours, tooth
positions, and tooth
morphology resulting
from the periodontal
bone loss and splint
therapy.

Step 6: Diagnosis and Etiology The etiology of the malposed, worn anterior teeth
with loss of periodontal support was the prior loss of
The patient was diagnosed with the following: posterior teeth and the bacterial plaque that was pres­
ent before periodontal therapy and replacement of
• Secondary occlusal trauma the posterior teeth with dental implants.
• Class II skeletal and dental malocclusion
• Lack of anterior guidance
Excessive overbite and overjet
•
Step 7: Treatment Goals
• Supraeruption, flaring, and spacing of maxillary an­
terior teeth The treatment goals were:
• Abraded and worn incisal edges
• Gingival recession of the maxillary anterior teeth • Reduce overjet and overbite
with cervical abrasion/abfraction • Establish anterior guidance
• Periodontal alveolar bone loss, but stable periodon­ • Restore worn tooth structure and improve the mor­
tal support of maxillary anterior teeth phology of the maxillary anterior teeth
• Endodontically treated maxillary teeth • Align the maxillary anterior teeth
• Maxillary implant-supported posterior restorations • Create a pleasing and attractive smile

- QDT2012 https://t.me/dental_books_lib
 Esthetic Rehabilitation of Com promised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

�
Figs 14a to 14c Wax-up of the anterior teeth following all the principles of deal dental composition.

Fig 15 New measurem e,nt of the overbite after the complete wax-up.

Fig 16 Superimposition of the photos before and after the wax-up to show the difference in the amount of overbite.

Step 8: Diagnostic Wax-up (Figs 14 to 16) Step 9: Clinical Treatment Options

In this case, good anterior dental composition was pos­ To treat the skeletal and dental malocclusion, orthog­
sible because the apicocoronal position of the gingival nathic surgery to advance the mandible and ortho­
line and the final vertical incisal edge position allowed dontics to retract the maxillary anterior teeth, while
for a pleasing central incisor length. Moreover, reduc­ maintaining the acceptable gingival scalloping out­
ing the overjet also reduced the horizontal distance on line form, were considered. However, treatment with
an anterior curve from the distal of the canines. T his orthodontics could potentially reduce the upper lip
allowed for a good proportion of the individual width support; moreover, neither orthognathic surgery nor
of each tooth to the length and also good tooth-tooth orthodontics would improve the morphology of the
proportions (Figs 14a to 14c). So, by simply chang­ maxillary anterior teeth. Another possibility was to
ing the emergence profile of the palatal aspect of the treat the dental malocclusion with prosthetic restora­
teeth and the inclination of the crowns in the diagnos­ tions. Because an acceptable esthetic and functional
tic wax-up, it was possible to reduce the overbite and result could be achieved in the diagnostic wax-up and
overjet, as well as create anterior guidance (Figs 15 after discussing the risks and benefits of all treatment
and 16). possibilities, the patient decided to restore her smile
with ceramic crowns.

https://t.me/dental_books_lib ------- ----

QOT2012 -
 BACHERINI/BRENNAN

Figs 17a to 17d Initial tooth preparation

performed with the silicone index to cre­
ate the ideal volume for the final restora­
tion. Every tooth preparation was verified
with the silicone index also from the lateral
perspective.

Fig 18 Initial preparation was perfomed using a retraction cord to place the margin of the preparation in the sulcus. By do­
ing so, it is possible to change the emergence profile of the crown to close the interdental space.

Fig 19 Gingival soft tissue response after 1 week of provisionalization. Parameters for ideal gingival and dental composition
are met, and tissues and teeth appear balanced and proportional.

Step 10: Provisionalization (Figs 17 to 32) 17d). To close the interdental space, modify the emer­
gence profile of the provisional, and condition the form
The MIT technique was used to provisionalize the six of the marginal tissue, a retraction cord was used to re­
maxillary anterior teeth.17 A preliminary preparation of tract the free gingival margin and reposition the finish
teeth is performed utilizing a silicone index as a guide line of the preparation into the sulcus. The shell of the
to control the reduction of tooth structure and obtain provisional was relined, the occlusion was adjusted to
adequate space for the final restoration (Figs 17a to achieve anterior contact and posterior disclusion, and

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 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

Figs 20a and 20b Right lateral view before and after provisionalization/ revealing improvement in gingival form resulting
from the alterations of tooth morphology in the provisional restorations.

Fi gs 21 a and 21 b Left lateral view before and after provisionalization/ revealing the change of central incisor inclination
with the provisional crown restoration.

Fig 22 Lateral view of the lip at the rest.

Fig 23 Frontal view of the smile with the provis'ional restorations.

then the provisional was cemented with non-eugenol impression double-mixing impression technique with
zinc oxide cement (Freegenol, GC Dental, Tokyo, Ja­ a polyether material (lmpregum Penta Duo Soft, 3M
pan). After 1 month, the patient's speech, appearance, ESPE, Seefeld, Germany). Jaw relation records were
and function were reevaluated and acceptable to the taken with an intraoral facebow and a Lucia jig, and
patient. T he final impression was then taken using the the casts of the provisional restorations were cross­
double-cord technique (Uitrapack, Ultradent, South mounted with the master cast of the tooth prepara­
Jordan, Utah, USA), a light-activated custom tray (Pala­ tions.
tray LC, Heraeus Kulzer, Hanau, Germany)/ and single-

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 BACHERINI/BRENNAN

Fig 24 Overjet reduction of 5 mm was possible with the new provisional crown inclination.

Fig 25 New position of the upper lip and length of the central incisors with the provisional restorations during the "E"
sound.

Figs 26a and 26b New position of the incisal edges with the provisional restorations during the "F" sound.

Fig 27 Comparison with the initial study cast and the cast of the provisional restoration reveals the improvement in coronal
inclination and alteration of palatal form of the central incisor to achieve occlusal contact between the maxillary and man­
dibular incisors.

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 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

Fig 28 MIP coincident with CR on the casts of the

mounted provisional restorations.

Fig 29 Intraoral view of occlusal markings demon­

strate anterior guidance and canine disclusion with
the provisional restorations.

Figs 30a to 30c Frontal view of posterior disclusion

during protrusive, left lateral, and right lateral jaw
movements.

Fig 31 After final tooth preparation and reline of

the provisional, it is critical to measure the thick­
ness of surfaces of the provisional to verify the
amount of tooth reduction needed for the chosen
ceramic restoration.

Fig 32 Final preparation of the abutment teeth

with the enhanced interdental tissue contour and
formation of papilla.

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 BACHERINI/BRENNAN

Fig 33 The silicone index is utilized by the laboratory

technician to reproduce the morphology of provisional res­
torations and verify the shape of the ceramic restorations.
By doing so,' the functional and esthetic features previously
tested intraorally during the provisional phase can be de­
veloped properly in the laboratory.

Figs 34a and 34b The provisional restorations define

the esthetic and functional features of the teeth, but the
ceramist uses his artistic sensibility to provide pleasing and
natural esthetics through control of shape, shade, texture,
perspective, and translucency.

Fig 35a and 35b Lateral views of the restorations with

pleasing coronal inclination of the central incisors.

Fig 36 All-ceramic restoration made of lithium disilicate

(e-max) before the cementation phase.

Step 11: Laboratory Procedure (Figs 33 to 36) ing the esthetic and functional characteristics tested in
the provisional restoration. After the complete replica
The master casts were cross-mounted on the articulator of the provisional was fabricated with wax, the techni­
with the replica models of the provisional restoration. cian performed the closure and added marginal injec­
The silicone matrices were made from the cast of the tion channels to process the lithium disilicate (e.max,
provisional restorations to copy the tooth arrangement lvoclar Vivadent, Schaan, Liechtenstein) with the lost
and morphology. The technician used these as guide wax technique. This material was fired using a special
to create the definitive prosthesis, thereby reproduc- oven at a temperature of 920°C.

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 Esthetic Rehabilitation of Compromised Anterior Teeth: P rosthetic Treatment of an Orthodontic Case

Figs 37a to 37c Clinical presentation of the gingival

tissues and abutments at the day of cementation.
The preparation design of the abutment and the
emergence profile of the provisional restorations
enable creation of pleasing interdental papilla and
gingival form.

Fig 38 Occlusal view of the tooth preparations

before cementation.

Fig 39 Cl(nical protocol to prepare the abutment for

adhesive cementation.

Step 12: Delivery (Figs 37 to 60) The cementation of these restorations followed a
very precise protocol. Retraction cords were placed
At the try-in appointment, the restorations were evalu­ in the sulcus of every abutment to minimize the hu­
ated for marginal integrity of the proximal contacts, midity from the crevicular fluid and to act as a barrier
esthetic outcome, shade matching, contour, and oc­ for the penetration of the resin cement to the base
clusal relationships. After minimal occlusal adjustment of the sulcus. The restorations were etched with hy­
to optimize the contact in CR position and achieve the drofluoric acid 4.5% (lvoclar Vivadent) for 20 seconds,
proper disclusion of the posterior teeth during the ex­ treated with neutralization powder (lvoclar Vivadent)
cursive movements, the ceramic restorations were sent to neutralize the hydrofluoric acid, and put in an ul­
back to the laboratory for final polishing and glazing. trasonic bath with distilled water for 3 minutes. After

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Fig 40 Clinical protocol to prepare the intaglio surface of the ceramic according to the manufacturer/s instructions.

Fig 41 Cementation procedure with the three-step adhesive bonding technique. The two central incisors were cemented
simultaneously and then'the two canines were cemented. It was performed in this order to facilitate adjustments of the
interdental contact area.

Fig 42 After cementation of the central incisors and canines / the contact points of the two lateral incisors were adjusted
and then cemented.

thorough air drying/ the intaglio surface was silanized light-polymerized composite resin cement (Variolink II,
(Monobond-S/ lvoclar Vivadent) and dried for 60 sec­ lvoclar Vivadent) was selected to lute the restorations.
onds. Tooth preparations were cleaned with pumice The excess cement was removed from the buccal and
and polishing silicone burs (Opti. clean/ Kerr Haw�, lingual surfaces with a dental explorer, dental floss,
Boggio/ Switzerland)/ etched for 30 seconds on enam­ a double-edge blade (surgical scalpel blade no. 12,
el and 10 seconds on dentin with 37.5% phosphoric Swann-Marton, Sheffield, England) and a carver (VD8
acid (Ultra-Etch; Ultradent, Salt Lake City, Utah, USAL carver, Deppeler SA, Rolle, Switzerland).
rinsed and carefully dried, leaving the dentin moist. After cementation, final radiographs were taken of
The fitting surfaces, restorations, and teeth were coat­ the restorations and the patient returned for a reevalu­
ed with adhesive (Optibond, Kerr Hawe) and, due to ation after 1 week.
the reduced thickness of the ceramic restorationi a

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 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

Fig 43 Clinical presentation of the maxillary anterior teeth

before restorative dental treatment.

Fig 44 One week after cementation: The appearance of

the soft tissue is still not ideal.

Fig 45 One month after cementation: The biologic inte­

-gration of the crown is completed.

Fig 46 The ideal dental composition with the ceramic

crowns.

Fig 47 Right lateral view 1 week after cementation.

Fig 48 Right lateral view 1 month after cementation.

Fig 49 Left lateral view 1 week after cementation.

Fig 51 Occlusal view of ceramic restorations. Note the
Fig 50 Left lateral view 1 month after cementation. change in the arch length as compared with Fig 9.

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 BACHERINI/BRENNAN

Figs 52a and 52b Lateral views of the smile. Note the change in the dentolabial relationship as compared with Figs 6a and
6b.

Fig 53 Inclination of teeth before treatment with the acute angle between the incisal third of the maxillary central incisor
and the maxillary posterior occlusal plane.

Fig 54 New inclination of the anterior teeth with the right angle between the incisal third of the maxillary central incisor and
the maxillary posterior occlusal plane.

Figs 55a and 55b Intraoral lateral views of the restorations.

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 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

Figs 56a to 56e Progression of the smile. Note the

changes as compared with Figs 4a to 4e.

Fig 57 Periapical radiographs of the final crown restora­

tions. Note that the emergence profile of the crowns closed
the interdental space.

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Fig 58 Occlusal markings during functional jaw movements with the new restora­
tions.

Figs 59a to 59c Esthetic and functional integration of the prosthetic rehabilitation.

Fig 60 Final profile. Note the maintenance of the correct nasolabial angle and the
good support of the upper lip.

Fig 61 Final appearance of the patient with her new smile.

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 Esthetic Rehabilitation of Compromised Anterior Teeth: Prosthetic Treatment of an Orthodontic Case

DISCUSSION of fullness to the lips, and the facial prominence of the

smile, which was not desired by the patient.
Orthognathic surgery and orthodontic treatment was A diagnostic wax-up was done on the study casts
discussed with the patient_ to advance the mandible to evaluate if treatment could be performed with only
and improve the faci�l and occlusal relationships. The restorative dentistry to accomplish both the functional
resulting changes in facial soft tissue would be a reduc­ and esthetic goals of treatment. The position of the
tion of overall facial convexity. She was satisfied with gingival margins as a result of the periodontal alveolar
her facial side profile and only dissatisfied with the ap­ bone loss was fortuitous. It was possible to create ver­
pearance of her maxillary anterior teeth. Preprosthetic tical tooth lengths as measured from the gingival mar­
orthodontic treatment was then considered to align gins to the incisal edges that were esthetic and propor­
the maxillary anterior teeth prior to placing ceramic tional to one another. The arch length and arch form as
restorations and to articulate them with the mandibular a result of the flaring of the teeth also made it possible
incisors. After analyzing the cephalometric tracing and to create horizonta I tooth widths that were propor­
discussing the desired dentofacial esthetic goals of the tional to the lengths and to one another. With respect
patient, it was suggested that closing the interdental to tooth structure removal, devitalization of the pulps
spaces by retraction/intrusion of the incisors would flat­ was not a concern because of preexisting endodontic
ten the maxillary anterior arch form/profile and also re­ therapy. This allowed for sufficient tooth preparation
duce the upper lip support (eg, nasolabial line angle). to reduce the overjet and overbite. Moreover, the axial
Closure of the interdental spaces would also reduce inclination was acceptable, such that adequate tooth
the arch length in the anterior segment, which would structure could be maintained and articulation with
decrease the width of each tooth/restoration, making the mandibular anterior teeth achieved with anterior
the anterior teeth appear narrower. The overall facial guidance and posterior disclusion . The overall esthetic
esthetic impact of orthodontics could therefore reduce result with respect to the smile and tooth proportions
the dimensions of the anterior teeth, the appearance was harmonious without orthodontic treatment.

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CONCLUSIONS REFERENCES
1. Kokich V, Spear F. Guidelines for managing the orthodontic­
The esthetic rehabilitation of a patient with both a
restorative patient. Semin Orthod 1997;3:3-20.
skeletal and dental malocclusion is complex. There
2. Kois JC. In: Cohen M (ed). Interdisciplinary Treatment Planning:
are a variety of treatment modalities to accomplish the Principles, Design, Implementation. Quintessence, 2008:193.

desired esthetic and functional goals of therapy. For 3. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol
1: Esthetic Analysis: A Systematic Approach to Prosthetic Treat­
this patient, key biological factors allowed a natural
ment. Chicago: Quintessence, 2004:323-333.
esthetic outcome without orthodontics: the initial clini­ 4. McCollum AGH, Evans WG. Facial soft tissue: The alpha and

cal presentation of an adequate tooth-to-tooth gingi­ omega of treatment planning in orthognathic surgery. Semin
Orthod 2009;15:196-216.
val margin height relationship, adequate interdental
5. Arnett GW, Jelic JS, Kim J, Cummings GR, Worley CM Jr, Chung
spacing to create pleasing tooth width-to-height pro­ B, Bergman R. Soft tissue cephalometric analysis: Diagnosis and
portions, and sufficient interdental gingiva to form in­ treatment planning of facial deformity. Am J Orthod Dentofacial
Orthop 1999;116:239-253.
terproximal papilla and to close gingival embrasures
6. Henderson D. T he assessment and management of bony de­
with ceramic restorations. The development of the formities of the middle and lower face. Br J Plast Surg 1974;
diagnostic wax-up was the critical step in this system­ 27:287-296.

7. Hohl TH, Wolford LM, Epker BN, Fonseca FJ. Craniofacial os­
atic analysis that revealed the potential for ceramic
teotomies: A photocephalometric technique for the prediction
crowns to functionally and esthetically rehabilitate her and evaluation of tissue changes. Angle Orthod 1978;48:114-
dentition and smile. Electing restorative dentistry as 125.

8. Kinnebrew MC, Hoffman R, Carlton DM. Projecting the soft tis­

the treatment modality to achieve the desired esthetic
sue outcome of surgical and orthodontic manipulation of the
goal was done in accordance with the patient's subjec­ maxillofacial skeleton. Am J Orthod 1983;84:508-519.
tive interpretation of facial and dental esthetics and 9. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol
1: Esthetic Analysis: A Systematic Approach to Prosthetic Treat­
the understanding of the risks/benefits of all treatment
ment. Chicago: Quintessence, 2004:36-51.
modalities.
10. Broder HL, Phillips C, Kaminetzky S. Issues in decision making:
Should I have orthognathic surgery? Semin Orthod 2000;6:249-
258.

11. Chiche GJ. In: Cohen M (ed). Interdisciplinary Treatment Plan­

ning: Principles, Design, Implementation. Chicago: Quintes­

ACKNOWLEDGMENTS sence, 2008:7-8.

12. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol

We would like to acknowleage and thank Dr Massimo Lupoli (Flor­ 1: Esthetic Analysis: A Systematic Approach to Prosthetic Treat­

ence, Italy) for the orthodontic evaluation and Guilherme Cabral ment. Chicago: Quintessence, 2004:21-29.
(Campinas, Sao Paulo, Brazil) for fabricating the ceramic restora­ 13. Dawson PE. Functional Occlusion: From T MJ to Smile Design.
tions. St Louis: Mosby Elsevier, 2007:164.
14. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol
1: Esthetic Analysis: A Systematic Approach to Prosthetic Treat­
ment. Chicago: Quintessence, 2004:118-125.
15. Magne P, Belser U. Bonded Porcelain Restorations in the Ante­
rior Dentition: A Biomimetic Approach. Chicago: Quintessence,
2002:58-66.

16. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol

1: Esthetic Analysis: A Systematic Approach to Prosthetic Treat­
ment. Chicago: Quintessence, 2004:104-115.
17. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol
2: Prosthetic Treatment: A Systematic Approach to Esthetic,
Biologic, and Functional Integration. Chicago: Quintessence,
2008:154-159.

https://t.me/dental_books_lib
 he use of ceramic laminate veneers is a well­ tures by providing a smooth interface between the

T documented, effective, and predictable treat­

ment option.1•2 This predictability results from
the physical properti es of the ceramic, which remain
restoratior,1 and enamel.
Among the materials available for laminate veneers,
glass-ceramic made using the refractory die technique
stable in terms of color and shape as long as proper is the most documented.3 Nevertheless, many clini­
treatment planning is carried out. Further, ceramic cians and dental technicians encounter difficulties
demonstrates low plaque adherence, thus permitting with this technique, partly because powder-and-liquid
soft tissue stability. Harmony among the soft tissues, glass-ceramic has a very low fracture resistance prior
esthetics, and function depends of the bonding ability to bonding.
of the material. Altering the intaglio surface of ceramic From a laboratory perspective, the refractory die
using hydrofluoric acid associated with a silane cou­ technique is time consuming, and the ceramic build­
pling agent enables better bonding to dental struc- up used to control all phases of treatment must be fab­
ricated without incorporating air bubbles, which can
influence the final physical and optical properties of
the restoration. From a clinical perspective, the try-in
1Director, Advanced Program in Implant and Esthetic Dentistry, procedures and lack of stability before bonding make
Senac University, Sao Paulo, Brazil.
the technique difficult to execute in some cases, such
2Dental Technician and Ceramist, Romanini Dental Laboratory,
Londrina, Parana, Brazil.
as those with minimal or no tooth preparation.
3Director, Advanced Program in Restorative Dentistry, Latin Ameri­ An experienced ceramist can produce laminate ve­
can Institute of Dental Research and Education, Curitiba, Brazil. neers as thin as 0.2 mm, resulting in a very conserva­
tive treatment.4 However, a restoration of this thick­
Correspondence to: Dr Oswaldo Scopin de Andrade,
Rua Barao de Piracicamirim 889, Apt 61, Piracicaba, Sao Paulo,
ness is difficult to fabricate and to handle, which makes
·

Brazil 13416-005. Email: osda@terra.com.br the procedure expensive and therefore unavailable to

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 SCOPIN DE ANDRADE ET Al
- �--- --
many patients. This limitation has been reduced in overlays, and laminate, occlusal, and full veneers. The
the last two decades following the dev�lopment of adhesive characteristics were maintained in the new
pressed ceramic in the early 1990s.5 The addition of version. The intaglio surface can be etched by hydro­
leucite to the composition of ceramic enabled press­ fluoric acid for 20 seconds, and the use of a silane cou­
ing of the material, such as through the lost wax tech­ pling agent increases the bond between the ceramic
nique, which represented a landmark development structure and resin cement.14
for ceramic restorations. The advantages of pressed Laboratory results show that this material can be
ceramic include less technique-sensitive laboratory used for minimally invasive restorations, and current
procedures and easier clinical handling due to its en­ clinical data demonstrate high survival rates for par­
hanced physical properties. tial restorations as well as for complete crowns and
Unfortunately, the first generation of this type of fixed partial dentures.15 Laminate veneers represent
ceramic required more space to build the restoration a particularly effective use of this material.16 The rise
compared with the refractory die technique, making it of minimally invasive dentistry and biologically driven
impossible to fabricate restorations with a conservative preparations that aim to conserve sound tooth struc­
preparation in most cases. Additionally, the esthetic ture caused the dental field to rethink the application
characteristics of pressed ceramic were less life-like of veneers and return to the primary concepts of mini­
than those of glass-ceramic. Despite these limitations, mally invasive restorationsY,18 Currently, the develop­
veneers and crowns fabricated with pressed ceramic ment of LDGC and the concept of ultraconservative
have been widely used and reported.2'6 veneers enable clinicians and ceramists to apply these
Following the success of the pressed technique, techniques to a large number of patients.
a new class of glass-ceramic was developed based This article presents the ultimate ceramic veneer
on lithium disilicate crystals. Lithium disilicate glass­ (UCV), an innovative technique for ultraconservative
ceramic (LDGC) has a wide range of applications for veneer treatment. Tooth preparation for a UCV is lab­
esthetic indirect restorations. Formerly developed as oratory-guided and fabricated after final impression
Empress 2 (lvoclar Vivadent, Schaan, Liechtenstein), taking, which means that, if necessary, the ceramist
this heat-pressed ceramic was indicated for crowns trims the cast only where there is no space for the ce­
and short-span fixed partial dentures up to the second ramic mat�rial. Utilizing customized laboratory-made
premolar_? For the latter indication, the manufacturer preparation guides, the clinician may reduce a specific
recommended a strict protocol to achieve sufficient tooth area, but only if necessary. The UCV technique is
resistance to the occlusal forces. For anterior and pos­ a highly conservative approach to bonded ceramic ve­
terior restorations, high survival rates were observed in neers in which all preparations are kept in enamel, thus
short-, mid-, and long-term clinical studies,8-10 confirm­ ensuring preservation of the tissues, which is essential
ing the results obtained in laboratory tests.11 for bonding stability and for successful long-term clini­
The use of LDGC for single-unit restorations was cal results.
restricted to crowns and posterior partial restorations
due to the opacity of the core material. This opacity
limited the esthetic results in cases with conservative
preparations or restorations with reduced thickness. To
CASE REPORT
solve this limitation, an advanced version of LDGC (IPS
e.max Press, lvoclar Vivadent) with improved physical The primary complaint of the young female patient was
properties and translucency was developed.12 the "anatomy of her smile," which showed misalign­
Compared to the original system, the flexural ment and irregularities at the incisal edge (Figs 1 to 3).
strength of the material jumped from 350 to 440 MPa. All treatment options were discussed with the patient,
Thanks to its increased mechanical properties and bet­ eg, direct composite resin restorations. Ultimately, the
ter shade control, the pressable LDGC can now be patient and clinician chose an esthetic rehabilitation of
used beyond its original indications using a monolithic the six maxillary anterior teeth with ceramic laminate
technique.13 The range of indications for this mate­ veneers.
rial now include applications such as inlays, onlays,

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 Ultimate Ceramic Veneers: A Laboratory- Guided U ltraconservative Preparation Concept

Figs 1 a to 1 c Preoperative smile

views showing irregularities at the
incisal edge and misalignment from
canine to canine.

Figs 2a to 2c Preoperative intraoral

views.

Figs 3a and 3b Lateral views show­

ing the lack of symmetry on both
sides, resulting in an unesthetic
smile.

Diagnostic Approach nine guidance is important not only as an esthetic pa­

rameter, but also to help maintain adequate functional
and Treatment Planning
height and the quantity and quality of disocclusion.
The initial clinical procedure included careful analysis This role is crucial to preserve the long-term quality of
of the occlusion, periodontal examination, and facial any restorative treatment in anterior dentition. Facial
and intraoral photography. A preliminary impression photography helps the ceramist attain the correct mid­
was taken with an accurate material that can be poured facial line, detect any inclination of the smile line, and
more than once with the same precision. The authors establish harmony between the soft tissues and smile
prefer to work with vinyl polysiloxane (VPS) even for line. A facebow record was taken and transferred to a
initial impressions used for treatment planning. The semi-adjustable articulator.
patient had intact canine and anterior guidance. Ca-

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Figs 4a to 4c Initial additive wax-u p

for the mock-up procedure.

Figs Sa and Sb Mock-up made with

bis-acrylic resin loaded into a vinyl
polysiloxane template.

Figs 6a to 6c Patient's smile with the

mock-up in place.

Additive Preliminary Wax-up Mock-up

For cases in which a minimal preparation is planned, the The waxed-up preliminary cast was transferred to the
wax-up procedure must be conducted with an additive mouth for clinical evaluation in terms of shape, size,
technique (Fig 4). The information collected through and length. The mock-up acts as a blueprint for the
the photography protocol and semi-adjustable artic­ final restoration. A bis-acrylic resin (Protemp 4, 3M
ulator enabled the development of all characteristics ESPE, St Paul, Minnesota, USA) was used. The material
required for a �uccessful smile during the additive wax­ was loaded into a silicone guide made on the wax-up
up, based on an esthetic checklist.19 (Fig 5) and positioned in the patient's mouth (Fig 6).
The ceramist added wax to the preliminary cast Any alterations desired by the patient or deemed nec­
based on the anatomical parameters of natural teeth essary by the clinician must be analyzed. This step is
and respecting the function and occlusion. In this step, important in any treatment involving laminate veneers
the technician should recover the desired smile and because it will help the ceramist finalize the smile de­
establish adequate occlusal function. sign. After patient approval, all information was col­
Another important issue in cases with no or minimal lected from the mock-up using digital photography
preparation is the lack of a provisional stage. There­ and an alginate impression to obtain a cast. The mock­
fore, the patient must approve the final esthetic design up was then removed from the mouth, and the teeth
in the mock-up session. were cleaned and pumiced for impression procedures.

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 Ultimate Ceramic Veneers: A Laboratory-Guided Ultraconservative Preparation Concept

Figs 7a to 7e Retraction cord in

place for the final impressions.

Figs Sa to Be Silicone guide in

position on the final casts, showing
the clearance available for the final
restoration.

Impression Procedures If this occurs, the interproximal spaces must be filled

with composite resin (Opal Dam, Ultradent).
A VPS one-step, double-mix impression technique
was used to produce an appropriate reproduction of
the teeth and surrounding tissues. Two impressions of
Laboratory Procedures
each arch were taken to ensure proper control. Thin
retraction cord (Uitrapack no. 00, Ultradent, Salt Lake All information obtained from the mock-up, including a
City, UT, USA) was placed in the sulcus for better vi­ ne w set of photographs and alginate impressions, was
sualization of the cervical region. In this case, there sent to the laboratory. Two casts were poured from the
was no intrasulcular margin even though the cord was same mold. The molds were poured and remounted
placed to deflect the gingival tissue (Fig 7). This pro­ on the articulator. One was kept intact and the other
cedure helps to establish the limits of the restoration was sectioned. Based on the wax-up and the cast ob­
in the final cast. In some cases, the interproximal areas tained by the mock-up, the ceramist determined the
of the mold may tear during removal from the mouth. space available for the veneers (Fig 8).

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 SCOPIN DE ANDRADE ET Al

Figs 9a to 9c Final master cast be­

fore preparation to produce the final
restorations.

Figs 1 Oa to 1 Oc Sectioned cast

preserving the area reflected by the
retraction cord.

Figs 11a to 11c The limits of the

gingival margins were marked with
red pencil.

Figs 12a and 12b The cast and dies after the stone margin was trimmed.
Note that the red line marks the limit of the restoration and helps maintain the
veneer at the level of the gingival margin.

An important step in this technique is the stone cast val margin of each individual die (Fig 1 0). A line was
preparation of the sectioned mold. The retraction cord drawn with red pencil at the level of the gingival mar­
used for the final impression permits better visualiza­ gin (Fig 11 ) . As the retraction cord reflected these ar­
tion of the intrasulcular area (Fig 9). An initial trimming eas, the red line marked the finishing line of the future
procedure was carried out 1 mm below the girigi- restoration. Next, each die was trimmed (Fig 12).

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 Ultimate Ceramic Veneers: A Laboratory-Guided Ultraconservative Preparation Concept

Figs 13a to 13e UCV prepara-

tion guide for the left central and
lateral incisors. Tooth preparations
were performed through the guide
window only where insufficient space
was available for the veneers.

Figs 14a and 14b Red marks on

the solid master cast showing the
prepared areas.

For this treatment modality/ the path of insertion USA). The guide was fabricated in the specific area
of the future restoration must be evaluated. The UCV that required reduction. The reduction was carried out
is based on the concept that tooth reduction should through the window of the guide (Fig 13). After proper
be performed only when there is insufficient clear­ reduction/ the preparation guide was removed/ and
ance for the restoration. As planned/ the laboratory the clearance was checked using the previously made
would guide any reduction necessary. Only areas that silicone guide obtained from the wax-up. If more room
showed no path of insertion or insufficient space for was necessary/ the guide was repositioned on the cast
the ceramic would be altered on the cast. After deter­ and more stone was removed. The same UCV prepara­
mining those areas/ if any/ the technician must create a tion guide used in the cast would be used for intraoral
preparation guide to use in the patienfs mouth. Thus/ tooth reduction. In this case/ only the facial aspect of
before preparation of the cast/ the ceramist for this the left central and lateral incisors required reduction
case created the UCV preparation guide with acrylic (Fig 14).
resin (GC Pattern Resin/ GC America/ Alsip/ Illinois/

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 SCOPIN DE ANDRADE ET AL

15a 15b

15c 15d

Figs 15a and 15b Master cast with the final wax-up.

Figs 15c and 15d Wax sprues in position for the investing procedure.

The wax-up of the final restoration was fabricated obtained in the wax-up. Final anatomy and morphol-
on the modified master cast (Fig 15). Six laminate ve- ogy were also determined at this time (Fig 16a).
neers were injected with a high-translucency LDGC With the final morphology defined, stains were ap-
ingot (IPS e.max Press, Ivoclar Vivadent). A careful di- plied to achieve life-like characteristics. For example,
vesting process was carried out in two steps: rough blue stain was used for the incisal edge and interprox-
divesting with polishing beads at a pressure of 4 bar imal areas, while white stain was used for the mam-
(60 psi) and fine divesting with the same material at 2 melons. The veneers were then baked. Glass powder
bar (30 psi). Sprues were cut off using a diamond disk. was used to protect the stained surface, and superfi-
Any morphologic corrections and marginal adaptation cial gloss was applied using a rubber wheel and pum-
were performed, and the veneers were adjusted on the ice powder. The thin veneers were checked again in
solid master cast. Marginal adaptation was checked on the master cast and delivered to the clinician (Figs
the sectioned cast. 16b to 16f).
The restorations were stabilized for occlusal adjust-
ments, and confirmation of the anterior guidance was

36 QDT 2012

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 Ultimate Ceramic Veneers: A Laboratory-Guided Ultraconservative Preparation Concept

Fig 16a Laminate veneers adapted to the master cast

before staining and glazing.

Figs 16b to 16d Final restorations on the solid master

cast after polishing.

Figs 16e and 16f The final veneers were kept very thin.

16a

16b

16c 16d

16e 16f

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 SCOPIN DE ANDRADE ET Al
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Fig 17a Solid master cast with the stone reduction of the left central and lateral incisors.

Figs 17b and 17c Sectioned master cast with the UCV preparation guide in position.

Figs 18a to 18c UCV preparation guide in position before enamel reduction.

Fig 18d Diamond bur used for the preparation through the guide window (previously trimmed in the laboratory).

Tooth Preparation tapered diamond bur (Fig 18d) was used to reduce the
labial crests of both teeth as in the laboratory phase.
The laboratory sent the following materials to the clini­ Finishing procedures were carried out with finishing
cian: the solid prepared cast, sectioned prepared cast, disks (Soflex, 3M ESPE) only at the areas prepared with
UCV preparation guide (Fig 17), and final restorations. the diamond burs. As for any procedure involving lam­
The preparation guide was positioned in the mouth inate veneers, the marginal adaptation, interproximal
for tooth reduction. It is extremely important to stabi­ contact, anatomical characteristics, and shade were
lize the guide for preparation (Figs 18a to 18c). A thin then examined.

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 Ultimate Ceramic Veneers: A Laboratory-Guided Ultraconservative Preparation Concept

Figs 19a to 19c Glycerin-based try-in paste used to evaluate t�e fit and shade of the resin cement.

Try-in and Bonding sonically for 5 minutes to remove any residual material.
The surface was air dried, and a silane coupling agent
Since no provisional restoration was used, the soft tis­ was applied for 2 minutes. Evaporation of the solvent
sue remained stable and healthy. For this reason, it was was completed with a constant blow of air. The inta­
not necessary to apply any special hemostatic control glio surface was coated with a hydrophobic bonding
protocols for try-in and bonding. agent (Heliobond, lvoclar Vivadent) and thinned by a
Correct selection of the resin cement plays an im­ gentle blow of air. The adhesive was left uncured, and
portant role in the final result when using laminate ve­ the previously selected resin cement (Variolink Veneer
neers. Try-in paste (Variolink Veneer Try-in Paste, Iva­ +2, High Value, lvoclar Vivadent) was injected carefully
dar Vivadent) was used to determine the appropriate into the veneer. The veneer was protected with a plas­
shade. Once the restorations were in place and filled tic cover to avoid premature adhesive polymerization.
with the try-in paste, the clinician and patient checked The enamel was pumiced, followed by air abra­
the final result (Fig 19). sion with aluminum oxide particles at 40 psi (PrepStart
The LDGC restorations were prepared for bond­ H20, Danville, San Ramon, California, USA). The sur­
ing. Initially, the intaglio surfaces of the veneers were face of each tooth was etched with 37% phosphoric
etched with 9% hydrofluoric acid for 20 seconds. After acid (Uitraetch, Ultradent) for 60 seconds, washed, and
washing to remove the acid, the UCVs were placed in dried. The same adhesive used for the intaglio surface
a glass container with distilled water and cleaned ultra- of the ceramic was applied (Heliobond) and also left

https://t.me/dental_books_lib QDT2012 •
 uncured. For laminate veneers, light-cured resin ce­ directions. A glycerin-based jelly (Liquid Strip, lvoclar
ment (Variolink Veneer, lvoclar Vivadent) is indicated Vivadent) was applied to block the air. Each surface
for better color stability. was light cured once more for 20 seconds. A new and
Next, each restoration was positioned on the spe­ sharp scalpel was used to remove excess adhesive and
cific tooth. Excess resin cement was removed, and a resin cement. For interproximal areas, finishing proce­
light source was used for curing for 40 seconds in four dures were performed with abrasive composite resin

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- QDT2011
strips (Epitex, GC America). To prevent scratching of justments were made with a diamond polishing sys­
the ceramic surface, the use of diamond strips should tem designed specifically for ceramic (Optrafine, lvo­
be avoided and the procedure must be carried out clar Vivadent). All interproximal spaces were flossed to
with caution. remove any excess material. Figure 20 shows the final
For better control of the bonding sequence, the result after 4 months.
veneers were cemented one at a time. Occlusal ad-

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 SCOPIN DE ANDRADE ET Al
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CONCLUSIONS 6. Fradeani M, Redemagni M. An 11-year clinical evaluation of

leucite-reinforced glass-ceramic crowns: A retrospective study.
Quintessence lnt 2002;33:503-510.
The clinical success of laminate veneers depends on 7. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic materials and
careful treatment planning. Among the factors respon­ systems with clinical recommendations: A systematic review. J
Prosthet Dent 2007;98:389-404.
sible for success, enamel preservation is the most im­
8. Toksavul S, Toman M. A short-term clinical evaluation of IPS Em­
portant. When teeth are prepared for ceramic veneers press 2 crowns. lnt J Prosthodont 2007;20:168-172.
without proper planning, overpreparation often leads 9. Valenti M, Valenti A. Retrospective survival analysis of 261 lithi­
um disilicate crowns in a private general practice. Quintessence
to dentin exposure, thus reducing long-term clinical
lnt 2009;40:573-579.
success. However, when the case is carefully planned
10. Guess PC, Strub JR, Steinhart N, Wolkewitz M, Stappert CF.
and the tooth preparation is guided by the laboratory All-ceramic partial coverage restorations-Midterm results of
a 5-year prospective clinical splitmouth study. J Dent 2009;37:
technician, maximum hard tissue preservation can be
627-637.
ensured. The UCV technique proposed in this article
11. Silva NR, T hompson VP, Valverde GB, et a!. Comparative reli­
can be used to minimize tooth preparation and maxi­ ability analyses of zirconium oxide and lithium disilicate restora­
tions in vitro and in vivo. J Am Dent Assoc 2011;142(suppl 2):
mize enamel preservation. In addition, etchable LDGC
4S-9S.
associated with this technique facilitates superior han­
12. Culp L, Maclaren EA. Lithium disilicate: T he restorative material
dling and bonding procedures. The UCV makes it pos­ of multiple options. Compend Cantin Educ Dent 201 0;31:716-
720, 722, 724-725.
sible to provide highly esthetic restorations with mini­
13. Giordano R, Maclaren EA. Ceramic overview: Classification
mal tooth preparation to a large number of patients.
by microstructure and processing methods. Compend Cantin
Educ Dent 2010;31 :682-684.
14. Spohr AM, Sobrinho LC, Consani S, Sinhoreti MA, Knowles JC.
Influence of surface conditions and silane agent on the bond of
resin to IPS Empress 2 ceramic. lnt J Prosthodont 2003;16:277-

REFERENCES 282.
15. Guess PC, Schultheis S, Bonfante EA, Coelho PG, Ferencz JL,
1. Dumfahrt H, Schaffer H. Porcelain laminate veneers. A retro­ Silva NR. All-ceramic: Laboratory and clinical performance.
spective evaluation after 1 to 10 years of service: Part 11-Ciini­ Dent Clin North Am 2011;55:333-352.
cal Results. lnt J Prosthodont 2000;13:9-18. 16. Scapin de Andrade 0, Borges G, Stefani A, Fujiy F, Battistella
2. Fradeani M, Redemagni M, Corrado M. Porcelain laminate ve­ P. A step-by-step ultraconservative esthetic rehabilitation us­
neers: 6- to 12-year clinical evaluation-A retrospective study. ing lithium disilicate ceramic. Quintessence Dent Techno!
lnt J Periodontics Restorative Dent 2005;25:9-17. 2010;33:'114-131.

3. Layton D, Walton T. An.up to 16-year prospective study of 304 17. Gurel G. T he Science and Art of Porcelain Laminate Veneers.
porcelain veneers. lnt J Prosthodont 2007;20:389-396. Chicago: Quintessence, 2003.

4. Kina S, Brugera A. Invisible: Esthetic Ceramic Restorations. Bra­ 18. Magne P, Magne M, Magne I. Porcelain jacket crowns: Back to
zil: Arte Medicas, 2009. the future through bonding. Quintessence Dent Techno! 201 0;
33:89-96.
5. Dong JK, Luthy H, Wohlwend A, Scharer P. Heat-pressed ceram­
ics: Technology and strength. lnt J Prosthodont 1992;5:9-16. 19. Adolfi D. Functional, esthetic, and morphologic adjustment
procedures for anterior teeth. Quintessence Dent Technol 2009;
32:153-168.

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 M1 -Carbon fiber

M2- Glass fiber

M3 -Zirconia

M4- Stainless steel

MS -Titanium

M6 -Cast metal

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PHARK ET AL

Physical Properties of Dental Tissues Compared to

Endodontic Post Materials

Thermal expansion Ultimate tensile

Elastic modulus coefficient strength
(GPa) (X10-6/oC) (MPa)

Enamel -80 -17 -10

Dentin -14 -11 -44-105

Fiber post 45-220 5.4-7.2 760-1020

Titanium -110 8.6-11.9 550-930

Zirconia 300 10.3 -25-40

Stainless steel 200 9.9-17.3 860

Gold -100 14.4 221-759

Adhesively luted FRC posts have demonstrated sat­ vitro study simulating bone loss around teeth restored
isfactory long-term survival rates.33 The long-term suc­ with posts showed that those without bone loss had
cess of these restorations has been attributed mainly to the highest load capability, whereas bone loss of 25%
the biomimetic behavior of FRC posts. Table 1 shows and 50% height markedly decreased load capability.39
the physical properties of different post materials. The Thus, alveolar bone loss increases the risk for root
stiffness of the post and core induces stresses during fracture.38
loading, increasing the risk of tooth fracture or cata­ The dec
, ision to restore periodontally compromised
strophic failure of the restorative sy stem.34•35 Prefabri­ endodontically treated teeth with posts or by surgical
'
cated FRC posts can reduce the risk of root fracture, crown lengthening should be made carefully. Crown
and failures are often clinically repairable.35-37 lengthening surgery may result in inadequate crown­
to-root ratio, compromised esthetics, possible loss.
of the interdental papilla, potential compromise of
support for the adjacent teeth, and reduced load ca­
Remaining Alveolar Bone
pability. When crown lengthening is not desirable or
The status of periodontal support of endodontically possible, orthodontic forced eruption may solve some
treated teeth is one of the most important consider­ of the aforementioned risks but not all of them. The
ations for indication of posts and cores. Periodontal crown-to-root ratio may still be compromised, and
failure of endodontically treated teeth is the sec­ orthodontic intervention adds significant time and ad­
ond most frequent type of dental failure (32%) after ditional cost to the restorative procedure, making it
crown fracture (60%).13 Clinical studies have shown unfeasible in many cases.15
an increased risk of fracture of endodontically treated
teeth with reduced bone support restored with end­
odontic posts compared to that of vital teeth with a
Post Length
comparable bone condition.14 Finite element analysis
(FEA) studies have suggested that mechanical stress Retention increases with the length of the posts, ir­
increases as bone support is reduced.38 At the lowest respective of what material the post is fabricated
level of bone height, root stresses were 4 to 10 times (fiber, titanium, or cast).40-42 Frictional retention is
greater than in teeth with normal bone height. An in directly proportional to the contact area: the larger

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 A Comprehensive Guide for Post and Core Restorations

Fig 4a Periapical radiograph showing excessive gap be­ Fig 4b Periapical radiograph showing remaining gutta­
tween the tip of the post and the remaining gutta-percha. percha in the prepared post space, which might impair
proper bonding of the FRC post (red arrow), and deviation
of the canal post space due to the original canal direc­
tion and incorrect pilot bur angulation and size (note the
reduced root dentin thickness-white arrow).

the contact surfaces, the better the retention. This The amount of remaining root canal filling material
fact. explains the results found in macro pull- or push­ is fundamental, since the apex is an area of greater an­
out tests, in which the complete post was pulled or atomical complexity, with many lateral and accessory
pushed out. canals_47A8 Endodontically restored teeth that have at
Another aspect influenced by the length of posts least 5 mm gutta-percha left in the apex region show
is fracture resistance. However, data regarding this low numbers of apical periodontitis.49 Yet, gaps be­
topic is not conclusive. Studies showed that in stain­ tween roo,t canal filling and the apical tip of the post
less steel posts,43 cast posts and cores,36 and fiber must be avoided because of possible periapical pa­
posts,43A4 post length did not influence the biome­ thosis (Figs 4a and 4b). The success rate of endodontic
chanical performance of the restored teeth. A recent treatment is significantly affected by the gap between
in vitro study showed that endodontically treated the post and remaining root canal filling.49
teeth restored with short fiber posts survived fatigue
loading as well as long fiber posts.45 Short posts may
lead to more favorable failures than long posts, thus al­
Post Space and Cement Thickness
lowing re-intervention and preservation of the tooth.45
Higher fracture resistance for short posts may also be When placing posts in accordance with standard clini­
explained by the less invasive buildup approach than cal protocols, pilot drills are used to create a form­
that required for long posts. congruent root canal up to the apical third of the root
However, it was reported that 1 0-mm-long posts to ensure primary post fit and retention (Fig 5). This
increased fracture resistance compared to 6-mm-long "form-congruence" aims to create maximal adaptation
posts.36 In another in vitro study evaluating even short­ of the post to the surrounding root canal walls with a
er posts after cy clic fatiguing in a chewing simulator, thin and even post-root cement interface.50 A better
6-mm-long posts performed significantly better than adaptation and fit of the FRC post to the root canal fa­
3-mm-long posts.46 Post length should be evaluated cilitates stress distribution along the canal wall during
carefully, taking into consideration the amount of bone clinical function.51 The retention of prefabricated posts
support around the root, remaining root dentin thick­ cemented with non-adhesive techniques is inversely
ness, stress concentration, and the type of restorative proportional to the disparity between the diameter of
treatment indicated. the post and that of the canal.50,52,53

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Fig 5 Form-congruence of post and dentin. C, cement; R, root; FP, fiber post.

Especially in teeth with oval or irregularly shaped commodate the larger post diameters. However, for
canals, preparation of a round and form-congruent FRC posts, no influence of the post diameter in bio­
post space can lead to excessive removal of the inner mechanical performance43 or bond strength tests58 has
dentin, resulting in weakening and reduced fracture been observed.
resistance of the tooth.54 In irregularly shaped canals
(no form-congruence)46 the use of oval posts and prep­
aration tips55·56 is necessary to avoid excessive tooth
Flared Root Canals
reduction. A post must always be selected with the
aim to preserve the inner dentin structure; therefore, Despite data indicating that cement space does not
to correspond best to the natural root-canal diameter affect bond strength in ideally shaped canals, bond­
with no or minimal preparation of the root canal. ing to wide and flared root canals is still a concern.
The high configuration cavity factor (C-factor) within
the canal may lead to gap formation because of po­
lymerization shrinkage of the thicker cement either
Post Diameter
along the cement-dentin interface or the cement-post
For metal posts, the diameter seems to have a signifi­ interface.59·60 Additionally, thicker cement layers might
cant impact on fracture resistance. Increasing the diam­ present voids or air bubbles, which are frequently in­
eter has been shown to lower fracture resistance,43·57 troduced during application of the cement into the
evidently by the additional removal of dentin to ac- canal.61-6s

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 A Comprehensive Guide for Post and Core Restorations

Figs 6a and 6b Tooth showing weakened root due to wide and flared canal. (a) Lingual view. (b) Incisal view. (c) FRC post.
(d) Customization of FRC post after reline with composite.

To overcome the aforementioned issues, relining rum (iron). In technical terms it is an encircling band
fiber posts with resins, fibers, or additional auxiliary or clamp, mostly made of metal for fastening, joining,
posts is an attempt to minimize the cement gap and or reinforcement of fibers, wires, or posts. In dentist­
customize the post to the shape of the root canal. Re­ ry the ferrule or ferrule effect is defined as a "360-
lining a post increases its retention and the fracture degree metal collar of the crown surrounding the
strength of the teeth.37•66 In addition, relining is also parallel walls of the dentin extending coronal to the
beneficial to reduce the stress transfer to the cervical shoulder of the preparation. The result is an increase
root surface (Figs 6a to 6d)_67 Auxiliary fiber posts also in resistance form of the crown from the extension of
increase fracture strength, but they do not necessarily dentinal tooth structure."69 Providing resistance to
increase post retention.68 dislodgment, it also prevents fracture. Often the term
ferrule is misinterpreted; it is used synonymously as an
expression of the amount of remaining sound dentin
Influence of Ferrule on Fracture above the finish line. In fact, it is not the remaining
tooth structure but rather the actual bracing of the
Resistance
complete crown over the tooth structure in the gingi­
The origin of the term ferrule is thought to come val aspect above the preparation margin that consti­
from the Latin terms viriola (small bracelet) and fer- tutes the ferrule effect.15

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PHARK ET Al

The ferrule is considered crucial to stabilize end­ mally invasive as possible. Maximum preservation of
odontically treated restored teeth and for their prog­ dentin walls is the aim to obtain adequate ferrule.
nosis.16·23·24 However, in severely compromised teeth,
ferrule should not be provided at the expense of coro­
nal or root structure.15·17 It is important to bear in mind
Number of Walls and Ferrule Location
that a ferrule effect is just one piece of a complex sys­
tem that ensures correct restoration of an endodon­ Various studies have demonstrated superior perfor­
tically treated tooth. The clinical performance of the mance of a homogeneous and circumferentially even
entire restorative complex is also affected by several ferrule over a ferrule that varies in different parts of the
other factors, including the post and core material, tooth.83-86 However, it is not always clinically possible
luting agent, overlying crown, and functional occlusal to prepare a circumferential ferrule of uniform height.
loads.70 A ferrule of non-uniform height, ranging between
0.5 mm proximal and 2.0 mm buccal and lingual, or
a 2.0-mm ferrule present just on the palatal or buc­

Ferrule Height cal aspect, or even a ferrule interrupted by biproximal

cavitation, is less effective in preventing failure than a
Having sufficient dentin height is fundamental for uniform circumferential 2.0-mm ferrule.84·85 Conversely,
a stable restorative system. The ferrule height sig­ the presence of only a buccal or palatal wall improves
nificantly increases the fracture resistance71 and the the performance of a tooth that has no ferrule at all.87·88
number of loading cycles before failureJ2.73 While A tooth with a non-uniform ferrule length is still more
1.0 mm of vertical height appears to be a minimum fracture resistant then a tooth without ferrule.83·85
compared to teeth without a ferrule,69,73 other studies Some strategies like crown lengthening or orthodontic
reported that 1.5 to 2.0 mm or even more remain­ forced tooth eruption might be necessary to provide
ing vertical tooth structure provided superior long­ an adequate ferrule.15 Therefore, it is suggested that
term performanceJ-2.74-78 Even though some studies a 2.0-mm ferrule should be provided at least on the
reported no benefit of the ferrule in comparison to buccal and lingual walls.
teeth with no ferrule/9·80 fracture patterns were more
favorable when a fer_rule was present. Furthermore,
the majority of fractures in teeth without a ferrule are Biomechanical Considerations of
nonrestorable.79
Core Buildups

The core material has a significant influence on the

Ferrule Width success of an endodontically treated tooth. Compos­

ite resin bonded to dentin can strengthen the tooth
It is the thickness of the coronal extension above the and reinforce cusps,89 in addition to increasing t�e
crown margin that is thought to be significant in the load capacity of endodontically treated teeth.90 When
fracture resistance of crowned teeth.15 The thickness adequate ferrule is present, the placement of a post
of the buccal wall can be severely compromised by ag­ does not significantly improve fracture resistance com­
gressive preparation to suit esthetic demands or previ­ pared to teeth restored only with composite cores and
ously existing large caries lesions or existing crowns. no posts.91·92 The survival rate for crowns with under­
Clinically, dentin walls less than 1.0 mm in width might lying composite buildups with and without posts and
be considered too thin.15 Even so, minimal thickness cast posts and cores is not different, only the remain­
of 1.0 mm for the remaining dentin walls is frequently ing height of dentin after preparation is of influence.93
accepted/3·81 but such thin walls tend to fracture more Also, Jung et al reported no differences in survival and
often than 2.0- or 3.0-mm-thick walls.82 Therefore, the complication rate for cast post-and-core buildups and
preparation for post and core buildup must be as mini- direct composite post buildups.94 Thus, the amount of

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 A Comprehensive Guide for Post and Core Restorations

remaining tooth structure is what dictates the place­

BONDING CONSIDERATIONS OF FRC
ment of a post.
TO ROO T CANAL
The association of composite core buildup and fiber­
reinforced posts leads to less catastrophic failure com­
pared to that of titanium posts.90 An in vivo 5-year and Effect of Chemicallrrigants on Bond
a 1 0-year study showed that composite buildups with
Strengths of FRC Posts
prefabricated posts performed clinically similar to cast
posts and cores.93·94 Hand and rotary instrumentation techniques used in
The procedures for post cementation and core endodontic treatment produce an irregular, granular,
buildup usually involve two steps, where the post is and amorphous layer that covers the dentin root ca­
cemented first followed by the buildup usually with a nal.98 Chemical irrigant solutions are used to clean the
composite-based material. Some resin cements, how­ root canal and remove the smear layer created during
ever, can be used as buildup material as well in a one­ root canal instrumentation. Chemical irrigants alter the
step procedure (eg, Paracore, Coltene Whaledent, dentin surface significantly and thus affect bonding to
Altstatten, Switzerland) because of their low viscosity. the root canal.99-101 Nonetheless, the use of chemical
Recently the performance of a self-adhesive cement irrigants during endodontic treatment is essential to
used simultaneously for cementation of the post and remove pulp remnants and residual bacteria from the
as buildup material was investigated.95·96 However, the intricate root canal systems.102,1o3
mechanical properties of self-adhesive cements need Ethylenediaminetetraacetic acid (EDTA) is common­
to be enhanced to validate this technique clinically. ly used as a pre-final irrigating agent. EDTA demineral­
Composite-based materials for core buildup still izes dentin and cleans root canal walls, improving the
need to be applied in incr�ments to reduce polymer­ contact between the obturation material and dentin
ization shrinkage. Polymerization shrinkage can lead walls.104 Sodium hypochlorite (NaOCI) also promotes
to undesired microleakage at the gingival margins.18 debridement, lubrication, disinfection, tissue dissolu­
Recently developed low-shrinkage and bulk-fill com­ tion, collagen layer removal, and dentin dehydration.103
posites may be an acceptable alternative to compos­ Long-term exposure of dentin to a high-concentration
ite core buildup. In addition, composites offer the sodium hypochlorite has a detrimental effect on den­
opportunity rebuild the abutment esthetically, pro­ tin elasticity and flexural strength.105·106 Microscopi­
viding not only ade q uate tooth color but also fluo­ cally, NaOCI causes permanent erosion of intertubular
rescence. These optical properties are fundamental and peritubular root canal dentin.107·108 Sodium hypo­
for anterior reconstruction when using thin veneers c�lorite reduces the bond strength between the root
or glass-based ceramics. During composite place­ canal dentin and adhesive resin cements,109 and its use
ment, exposed fiber posts must be covered with the as final irrigation should be avoided.107
buildup material. Chlorhexidine digluconate (CHX) has been increas­
The provisional material used for temporary resto­ ingly employed as a potential chemical irrigant due to
ration may negatively affect the integrity of composite its antimicrobial properties and low-grade toxicity.109·110
core buildups. Composites are affected by moist heat CHX can be used for final irrigation, at the end of the
stress,97 thus, when making acrylic resin provisionals endodontic treatment, as a substitute for the NaOCI
on composite core buildups, the methacrylate exo­ to promote additional disinfection without having any
thermic reaction must be relieved by continuous wa­ adverse effect on bond strength.111-113
ter cooling. Conversely, bis-acryl provisional materials
can adhere to composite core buildups if the oxygen
inhibition layer is not completely removed after final Post Space Preparation, Smear Layer
polymerization and before fabrication of the provi­ Remova-l, and Disinfection
sional restoration.
Post space preparation of endodontically treated teeth
is needed to shape the root lumen according to prefab-

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PHARK ET AL

Figs 7a and 7b The presence of residual gutta-percha leads to gap at the adhesive interface between the cement and den­
tin. (a) Elliptical root canal showing remaining gutta-percha. (b) Higher magnification showing gap at the adhesive interface.
D, dentin; FP, fiber post; GP, gutta-percha; C, cement.

Fig 8 Root dentin etched with 35% phosphoric acid for 15 seconds.

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 A Comprehensive Guide for Post and Core Restorations

ricated posts. Mechanical preparation of the root canal collagen.119 Nonetheless, long-term clinical studies are
improves the fit of prefabricated FRC posts to the root still needed to validate the efficacy of EDTA as a clean­
canal walls. Although post space preparation removes ing solution before bonding fiber posts.
sound tooth structure, the superficial root canal dentin Disinfection of the root canal is imperative before
altered by canal irrigants or medicaments, or filled with any bonding procedures. For this purpose, CHX can be
canal sealers, is also removed.114 The presence of re­ used as an effective disinfecting solution. The final irri­
sidual gutta-percha in the canal prevents the adhesion gation with CHX promotes additional disinfection and
between cement and dentin, leading to debonding stops the chelating effect without any adverse effect
at the adhesive interface or leakage (Figs 7a and 7b). on bond strengths.111-113 CHX is a strong MMP inhibi­
However, rotary instruments are commonly employed tor, improving long-term bonding to decalcified den­
without ideal irrigation, producing a thick smear layer tin.129 Disinfecting procedures after root space prepa­
with remnants of plasticized gutta-percha and sealer.25 ration are essential to increase and sustain adequate
Attaining clean dentin surfaces after mechanical bond strength of fiber posts to the root canal.111-113
post space preparation is an essential step for opti­
mal post retention and bonding.115 Acidic monomers
presented in self-etching dentin adhesives or the self­
Pretreatment of FRC Posts
etching resin cements are less predictable to modify
the thick smear layer and to· form the hybrid layer Bonding effectiveness in the root canal is decisive
along the walls of the post space-.116 Moreover, the top for the fiber post retention.130 Special attention must
of the hybrid layer produced by self-etch agents con­ be paid to the bonding interface of the composite
tains disorganized collagen fibrils that degrade over cements and fiber posts.116·130-132 The absence of a
time, reducing post retention.117 Acid etching of root chemical union between methacrylate-based resin
dentin with phosphoric acid followed by copious water composites and the resin matrix of fiber posts-which
rinsing with an endodontic needle is helpful to remove are often made of epoxy resin-makes the procedure
the smear layer created after post space preparation even more difficult.131
(Fig 8).118 However, the effectiveness of acid etching In an attempt to improve the resin bonding to fiber
is questionable at the apical level, because intricate posts, numerous surface treatments have been pro­
narrow and deep canals cannot be completely cleaned posed.116 These approaches can be divided into three
and free from the smear layer.25·119-121 categories: (1) increase of the surface roughness, (2)
Chemical irrigation with ultrasonic agitation was chemical bonding, or (3) combined micromechanical
shown to be helpful for removal of the thick smear and chemical treatment.116·133
layer before the bonding procedures.119·122·123 How­ To increase the surface roughness of fiber posts,
ever, chemical solutions-often used during endodon­ etching with strong acid, air abrasion with aluminum
tic procedures (EDTA and/or NaOCI)-Iead to severe oxide, and tribomechanical coating have been indi­
erosion on the root canal dentin surface.123·124 Specifi­ cated.134-136 Because the silica and quartz present in
cally, NaOCI adversely effects the bond strength of the fiber-reinforced posts are comparable in chemi­
self-etching adhesive systems111 due to the oxidation cal structure to ceramic materials, hydrofluoric acid
of some dentin matrix component,125 forming pro­ was recently proposed for etching post surfaces.134
tein-derived radicals126 that would compete with the Although hydrofluoric acid may enhance the post­
spreading of vinyl free-radicals, resulting in premature resin cement bond strength, it can produce substantial
·
chain termination and incomplete polymerization of damage to the glass fibers, ranging from microcracks
the adhesive resin.127 Recently, it was found that 17% to longitudinal fractures of the fiber layer, affecting the
EDTA significantly inhibits endogenous dentin matrix integrity of the post.134·137 Thus, the use of a strong acid
metalloproteinase (MMP) activity, minimizing hybrid for etching_ fiber posts is not advisable.116 Air abrasion
layer degradation after bonding.128 EDTA is a mild with alumina particles results in an increased surface
chelating agent that removes the hydroxyapatite and roughness and surface area, allowing mechanical in­
noncollagenous protein, selectively facilitating the terlocking with the resin cement135 and, consequently,
mechanical interlocking of resin cement to interfibrillar a significant increase in surface retention.136 In tribo-

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PHARK ET AL

chemical coating, a silicate layer is welded onto the

post surface, allowing penetration of the particles of
about 15 microns.137 Tribochemical coating must be as­
sociated with silanization in order to improve the bond
strength between fiber post and resin cement, thus
combining micromechanical and chemical retention.116
Since surface pretreatment of posts might improve
the adhesion to resin cement, different solutions have
been tested in an attempt to dissolve or alter the epoxy
matrix of the post without damage to the fibers.138,139
Acetone, chloroform, potassium permanganate, hy­
drogen peroxide, and sodium ethoxide have been em­
ployed to,dissolve the epoxy resin of the post surface
and expose glass fibers of the post.132,134,139-142 Pretreat­
ment of the post surface with hydrogen peroxide was
suggested as an easy and clinically feasible method
for enhancing interfacial bond strengths between fi­
ber posts and resin cements.132,134,141 However, a recent
study showed that hydrogen peroxide had no influence
on bond strength values.143
After post try-in, debris and smear layer of the post
space preparation penetrates into the microspaces
between the fibers and the epoxy matrix, jeopardizing
the bond at that interface. Careful air abrasion135 fol­
lowed by cleaning with ethanol143 appears to be an ac­
ceptable approach for better bonding between resin
cement and the post. By removing the surface layer of
epoxy resin matrix, a larger surface area of glass fibers
Fig 9 Fiber crack due to air abrasion (F, fiber; R, resin; C is exposed. The spaces between these exposed fibers
cement).
provide a�ditional sites for micromechanical retention
Figs 1 Oa to 1 Oc FRC post. (a) External surface of a FRC of the resin composites.116 However, even gentle air
post; note the surface irregularity. (b) Higher magnification
abrasion can create cracks in the fibers of FRC posts
showing the fibers and resin of a FRC post. (c) Cross-section
view of a FRC post. F, fibers; R, resin. (Fig 9). Therefore, since most of the post exhibits ad­
equate surface roughness, only cleaning is indicated
(Figs 1 Oa to 1 Ob).

QDT 2012 ·
https://t.me/dental_books_lib
 A Comprehensive Guide for Post and Core Restorations

Selection and Polymerization Mode of setting process, which is followed by a long gradual
rise in pH after 24 to 48 hours post-cure until it be­
Resin Cements
comes neutral.159,160 Dual-cure resin cements are not
Light-cured resin cements have better handling prop­ fully set just after cementation, even if light-polym­
erties, but light transmission through the post space erization is used. Therefore, after the post is bonded
inside the root is extremely limited.144 Conversely, to the root canal, a waiting period of 24 to 48 hours
controlled placement of the post within the canal us­ before final tooth preparation must be respected to
ing self-cured resin cements can be difficult because ensure maximum polymerization and post retention.
of limited working time.144 Thus, dual-cured resin ce­
ments are the cement of choice for posts to the root
canal.145 Dual-cured resin cements offer longer work­
ing time and, by inclusion of chemical initiators, the
CONCLUSIONS
ability to polymerize in the absence of light.146,147
Dual-cured resins cements provide rapid polymer­ Preservation of coronal and radicular tooth structure
ization in areas where the curing light penetrates ef­ is essential for long-term success of FRC posts adhe­
fectively and a slower chemical polymerization in areas sively bonded to teeth. For maximum preservation of
far from the reach of the curing light.145 The self- and the dentin walls, the aim is to provide a 2.0-mm cir­
light-activation modes in dual-cure resin cements are cumferential ferrule. Post length should be evaluated
independent. However, when dual-cured resin ce­ carefully, taking into consideration the amount of bone
ments are not exposed to the curing light (or light is support around the root, remaining root dentin thick­
attenuated), a decrease in the degree of conversion is ness, stress concentration, and the type of restorative
found.148,149 Poorly polymerized resin cement results in treatment indicated. At least 5.0 mm of gutta-percha
compromised mechanical properties and deleterious must be left at the apical third of the root periapical
effects on periodontal tissue, such as inflammatory re­ pathosis. FRC posts can be customized according to
actions, cytotoxicity, mutagenesis, and apoptosis.150-152 the root canal to reduce the cement thickness and
Glass fiber posts with higher potential for light improve fracture resistance and stress distribution. A
transmission can be used to improve the polymeriza­ composit� core buildup must be incrementally made
tion ·degree of dual-cured resin cements within the to reduce polymerization shrinkage and microleakage.
root canal.149 Yet, glass fiber posts showed a decrease Chlorhexidine is indicated for final irrigation (at the end
in the amount of light transmitted as the depth in­ of endodontic treatment) and after post space prepa­
creased.153 To improve the degree of conversion of ration. Cleaning of the post with ethanol is indicated
dual-cure resin cements, photoirradiation time of after post manipulation to ensure adequate bonding
resin cements through fiber posts must be increased to the resin cement. Dual-cured resin cements/adhe­
to achieve an adequate polymerization degree at sives and self-adhesive resin cements are recommend­
the cervical and middle thirds of the post space.154,155 ed for post adhesive cementation. However, a waiting
Nonetheless, at the apical third the amount of light period of 24 to 48 hours before final tooth preparation
that reaches the resin cement is not effective for set­ must be respected to ensure maximum polymerization
ting off a light-induced polymerization, thus relying and post retention.
only on the self-curing mode.156
Post retention rises significantly from 15 minutes
to 24 hours after cementation.157 Dual-cure polymer­
ization (light-induced and. chemical polymerization)
APPENDIX
takes longer to achieve an adequate degree of con­
version, and this fact can explain the increased post Findings of clinical studies on nonmetallic posts and
retention over time. Moreover, some authors have also of studies comparing fiber with metal posts are pre­
reported a significant increase in post retention after sented in Tables 2 and 3, respectively. Table 4 shows
artificial aging.158 For RelyX Unicem (3M ESPE)-a self­ the chemical composition and shape of selected fiber­
adhesive dual-cure resin cement-there is a rapid reinforced posts.
initial rise in pH (from 2 to 4) over the first hour of the

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 .,.,...
PHARK ET Al

Clinical Studies of Nonmetallic Posts

Mean No. of Amount of Post brand

observation teeth residual coronal name and Type of Type of Tooth Failure
Study period (mo) included structure manufacturer post restoration type rate
Fredriksson et al161 32 236 NS Composipost (RTD) Carbon All-ceramic I metal- All teeth 2%
(Retrospective) ceramic full crown

Ferrari et al162 31 1304 NS Composipost vs Carbon All-ceramic I metal- All teeth 3.2%
(Retrospective) Aestheti-Post vs Quartz ceramic full crown
Aestheti-Pius (RTD)

Ferrari et al163 90 985 NS Composipost vs Carbon All-ceramic I metal- All teeth 8%

(Retrospective) Aestheti-Post vs Quartz ceramic full crown
Aestheti-Pius (RTD)

Hedlund et al164 26 65 NS Composipost vs Carbon All-ceramic I metal- All teeth 3%

(Retrospective) Endopost (RTD) ceramic full crown I
veneers

Glazer 2000 165 28 59 NA Composipost (RTD) Carbon All-ceramic /metal- All teeth 7.7%
(Prospective) ceramic full crown

Mannocci et aF 36 114 Class II premolars Composipost (RTD) Carbon Direct composite I Premolars 6%
(Prospective) metal-ceramic
crown

Malferrari et al166 30 180 NS Aestheti-Pius (RTD) Quartz All-ceramic I metal- Premolars 6.2%
(Prospective) ceramic full crown

Monticelli et al167 24 225 NS Aestheti-Pius (RTD) Quartz All-ceramic crown Premolars 6.2%
(Prospective) vs DT (RTD) vs Glass
RFC Postec (lvoclar)

Naumann et al168 24 105 1-5 walls remaining Luscent Anchor Glass All-ceramic I metal- All teeth 12.8%
(Prospective) (Dentatus) vs ceramic
FibreKor (J Pentron)

Naumann et al169 39 149 NS Luscent Anchor Glass All-ceramic I metal- All teeth 19.7%
(Prospective) (Dentatus) vs ceramic
FibreKor (J Pentrori)

Grandini et al170 30 100 Anterior: 50% DT (RTD) Quartz Direct composite All teeth 0%
(Prospective) residual tooth
structure;
Posterior: 2-3 walls

Cagidiaco et al171 24 162 NS Composipost (RTD) Carbon All-ceramic I metal- All teeth 7.3%
(Prospective) ceramic full crown

Ferrari et al163 24 120 1-4 walls, ferrule, DT (RTD) vs no post Quartz All-ceramic I metal- Premolars 7.5%
(Prospective) no ferrule ceramic full crown

Cagidiaco et al172 36 120 1-4 walls, ferrule, DT (RTD) vs no post Quartz All-ceramic I metal- Premolars 9.1%
(Prospective) no ferrule vs Ever Stick ceramic full crown
(Stick Tech)

Bitter et al173 32 120 2:2 walls, 1 wall, DT Light (VDW) VS Quartz Direct composite I All teeth Post: 7%
(Prospective) no wall, but ferrule no post full crown No post:
10%

Paul et al174 51 145 NS Experimental Zirconia Composite core I Incisors, Composite:

(Retrospective) zirconia post vs glass-ceramic core I canines, 0%
Cosmopost all-ceramic crown premolars Ceramic:
(RTD) 5%

Nothdurft et al175 29 30 NS Cerapost (Brasseler) Zirconia Glass-ceramic All teeth 0%

(Retrospective) �s Cosmopost core I all-ceramic I
(lvoclar) full crown

NS, not specified.

mJ QOT 2012 https://t.me/dental_books_lib

........;.
......·�
.
�l• lli
Clinical Studies Comparing Fiber with Metal Posts
]
Mean No. of Amount of Post brand
observation teeth residual coronal name and Type of Type of Tooth Failure
Study period (mo) included structure manufacturer post restoration type rate

Schmitter et al176 14 50 VS 50 NS Glass-fiber posts Glass vs Full crown All teeth Glass fiber:
(Prospective) (ER, Brasseler) vs metal 6.5%
metal screw posts Metal screw:
(BKS, Brasseler) 24.6%

Schmitter et al177 61 50 vs 50 NS Glass-fiber posts Glass vs Full crown All teeth Glass fiber:
(Prospective) (ER, Brasseler) vs metal 28.2%
metal screw posts Metal screw:
(BKS, Brasseler) 50%

Ferrari et al162 48 100 vs 100 NS Composipost Carbon All-ceramic I All teeth Composipost:
(Prospective) (RTD) vs cast post vs metal metal-ceramic 2%
and core full crown Cast: 9%

King et al178 87 10 fiber vs NS Carbon posts vs Carbon Full crown Maxillary Carbon: 40%
(Retrospective) 16 metallic cast metallic vs metal anterior Cast: 4%
posts posts teeth

Mannocci et al89 60 110 vs 109 Class II Carbon posts vs Carbon vs Direct Premolars Carbon: 3.8%
(Prospective) premolars amalgam amalgam composite Amalgam: 2%

NS, not specified.

Chemical Composition and Shape of Selected Fiber-Reinforced Posts

Post Manufacturer Fibers Resin matrix Shape

RelyX Fiber Post 3M ESPE, St Paul, USA Glass Resin Double-tapered

ParaPost Taper Lux Coltene Whaledent, Alt- Glass Resin Serrated, double-tapered,
statten, Switzerland three-sphere head
'

ParaPost Fiber Lux Coltene Whaledent, Alt- Glass Resin Serrated, two-sphere
statten, Switzerland head

LuxaPost DMG, Hamburg, Glass Resin Tapered, circumferential

Germany head grooves

FRC Postec Plus lvoclar Vivadent, Schaan, Glass UDMA, TEGDMA, Tapered
Liechtenstein Ytterbiu-m, trifluoride,
silicon dioxide

GC Fiber Post GC, Tokyo, Japan Glass Methacrylate Double-tapered

DT Light Post lllusion/DT ROT, Grenoble, France Quartz Epoxy Double-tapered

Light Post

Macrolock Illusion Post ROT, Grenoble, France Quartz Epoxy Double-tapered

Radix Fiber Post Dentsply Maillefer, Zirconium Epoxy Double-tapered

Ballaigues, Switzerland enriched glass

DT Light Safety Lock VOW, Munich, Preconditioned Epoxy Double-tapered

Germany quartz

Dentin Post X Komet, Lemgo, Germany Glass Epoxy Tapered with a retentive head

Snowpost Abrasive Technology, Zirconia-rich Epoxy Cylindrical with long

Lewis Center, Ohio, USA glass apical cone

Reforpost Angelus, Londrina, Brazil Glass Bis-GMA Serrated

FibreKieer Serrated Post J Pentron, Wallingford, Glass Bis-GMA, UDMA, Serrated

Connecticut, USA HDDMA

Composipost
https://t.me/dental_books_lib
RTD, Grenoble, France Carbon Epoxy Two-stage parallel
 PHARK ET Al

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76. Pereira JR, de Ornelas F, Conti PC, do Valle AL. Effect of a crown 92. Massa F, Dias C, Bios CE. Resistance to fracture of mandibu­
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posts. Dent Mater 2007;23:138-144.
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fiber post on fracture resistance of endodontically treated teeth.
idine digluconate and chlorhexidine digluconate gel. lnt En­
J Appl Oral Sci 2010;18:360-363.
dod J 2004;37:38-41.

QOT 2012 https://t.me/dental_books_lib

 A Comprehensive Guide for Post and Core Restorations

111. Santos JN, Carrilho MR, De Goes MF, Zaia AA, Gomes BP, 129. Kim J, Uchiyama T, Carrilho M, Agee KA, Mazzoni A, Breschi L,
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122. Crumpton BJ, Goodell GG, McClanahan SB. Effects on smear 140. Monticelli F, Osorio R, Toledano M, Goracci C, Tay FR, Ferrari
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147. Braga RR, Cesar PF, Gonzaga CC. Mechanical properties of 164. Hedlund SO, Johansson NG, Sjogren G. A retrospective study
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 Minimally Invasive Treatment of Initial
Dental Erosion Using Pressed Lithium
Disilicate Glass-Ceramic Restorations:
A Case Report

Francesca Vailati, MD, DMD, MSc1

August Bruguera, MDT2
Urs Christoph Belser, DMD, Prof Dr Med Dent3

ental erosion is spreading rapidly among ment. In fact, only additive adhesive procedures were

D younger generations of patients. Clinicians of­

ten underestimate the extent of this disease
and postpone its treatment due to a lack of aware­
implemented to replace the missing tooth structure and
protect the remaining dentition from further damage.

ness or to uncertainty regarding the proper course

of action. The discussion of when and how to treat
young individuals affe-cted by dental erosion has split
CASE REPORT
the dental community into t'{'v'o groups: clinicians who
treat eroded teeth excessively and clinicians who do A 25-year-old male Caucasian patient presented to the
not treat eroded teeth at all. School of Dental Medicine at the University of Gene­
In this case report, a young adult patient affected by va, Geneva, Switzerland. His chief complaint was the
generalized dental erosion was treated even though weakening and fracturing of his maxillary incisal edg­
his tooth degradation was only at an initial stage. The es. During a previous dental consultation, a parafunc­
rationale behind this early intervention was that no or tional habit (bruxism) was suggested as the main cause
minimal tooth preparation would be required for treat- of lost tooth structure; however, no occlusal guard had
been prescribed. Clinical examination revealed that
the patient also showed generalized initial dental ero­
1Private Practice, Geneva, Switzerland; Senior Lecturer, Department
sion (Figs 1 to 6).
of Fixed Prosthodontics and Occlusion, School of Dental
Medicine, University of Geneva, Geneva, Switzerland. The patient presented accelerated loss of enamel,
2Director, Disseny Dental Laboratory and Dental Formation Center, . especially on the palatal aspect of the maxillary ante­
Barcelona, Spain.
rior teeth and occlusal surfaces of the premolars. In
3Chairman, Department of Fixed Prosthodontics and Occlusion,
School of Dental Medicine, University of Geneva, Geneva, addition, the mandibular first molars presented con­
Switzerland. cave occlusal surfaces with reduced areas of contact
with the antagonistic teeth. Wear facets at the canines
Correspondence to: Dr Francesca Vailati, School of Dental
were also present, indicating moderate parafunctional
Medicine, rue Barthelemy-Menn 19, University of Geneva,
1205 Geneva, Switzerland. Email: Francesca.vailati@unige.ch habits. The remaining dentition was intact.

https://t.me/dental_books_lib ODT2012 -
VAILATI ET Al

Fig 1 Initial situation. Note the very conservative smile, showing the patient's
insecurity regarding the eroded teeth. Also note the darker yellowish color of
the maxillary central incisors.

Figs 2a to 2c The patient was asked to show an exaggerated smile with an

open mouth, but the patient could not fully relax because he had learned to
smile while covering as much of the teeth as possible. No gingiva was visible
in the maxillary arch. Note the presence of a reverse smile due to the fractur­
ing of the incisal edges of the maxillary anterior teeth.

Fig 3 Intraoral view. At this early

stage of dental erosion, the teeth
had not supraerupted, thus simplify­
ing the restorative treatment plan.

Fig 4 The mandibular anterior teeth

were intact, as is often the case with
dental erosion.

Figs Sa and Sb Occlusal view and

contact points. Since the patient did
not have a deep bite (shallow verti­
cal overlap), the risk of incisal edge
fracture was high even at this early
stage.

Figs 6a and 6b The maxillary

premolars presented thinning of the
enamel and small areas of exposed
dentin. The mandibular first molars
also presented thinning of the oc­
clusal enamel and a concave occlusal
surface.

DDT 2012 https://t.me/dental_books_lib

 Minimally Invasive Treatment of Initial Dental Erosion

The patient was questioned regarding the possible evident. The percussion test was also negative. Af­
etiology of the dental erosion, and he denied any ter consultation with an endodontist, it was decided
excessive consumption of acidic beverages or food. to maintain the status quo without performing elec­
The clinician recommended further investigation of a tive endodontic therapy until signs or symptoms of
possible intrinsic origin of the acid (eg, gastric reflux) pulp necrosis arose. Consequently, two facial veneers
through a visit to a gastroenterologist. However, the were also planned to mask the discoloration.
patient did not comply with this suggestion, and the Delivering two veneers, one palatal and one fa­
etiology of the dental erosion remained unknown. cial, to restore a single tooth is called the "sandwich
Anterior erosive classification (ACE)1 was used to approach/' which has been proven to be the most
determine the extent of erosion. Following examina­ conservative treatment for ACE class IV to VI anterior
tion, the patient's erosion was classified as ACE class teeth. However, in this ACE class Ill patient, the sand­
Ill because the palatal dentin was exposed at the level wich approach was dictated more by the patient's es­
of the contact points with the antagonistic mandibular thetic demands than by loss of tooth structure.
teeth and the incisal edges were starting to fracture
(loss of less than 2.0 mm of the original tooth length).
Since reduced vertical overlap (overbite) was a risk fac­
Modified Three-Step Technique
tor for accelerated damage of the incisal edges and
the etiology of the problem was still unknown, the po­ Generally, patients at the University of Geneva affected
tential for a higher ACE classification was a concern by dental erosion are treated following the three-step
(see Fig 5). technique.2-4 Due to the early detection of the erosion,
The benefits of early intervention were discussed, this patient did not require full-mouth rehabilitation.
with special consideration paid to the young age of Thus, a modified three-step technique was used.
the patient. It was decided to restore the patient's af­ The typical first step (maxillary vestibular mock-up)
fected teeth with no or minimal tooth preparation fol­ was not necessary because the occlusal plane did not
lowing exclusively adhesive principles. require alteration and the shape of the maxillary anteri­
ACE class Ill maxillary anterior teeth may be re­ or teeth needed only minor modification (lengthening
stored using palatal veneers. To obtain the necessary of the inci$al edges). Instead, treatment began directly
interocclusal space to deliver the restorations without with the increase of the VDO and creation of anterior
-
tooth preparation, an increase of the vertical dimen­ open bite (step two). Due to the minimal increase of
sion of occlusion (VDO) may be considered as long as the VDO, no provisional restorations were necessary.
no orthodontic measures are implemented. Since the Consequently, instead of the posterior provisional
posterior teeth also showed signs of dental erosion, stage in the classic three-step technique, final restora­
it was decided to increase the VDO by restoring the tions for the posterior teeth were fabricated.
posterior teeth as well. During the first visit, two alginate impressions were
In addition to the loss of tooth structure related to taken, and casts were mounted on a semi-adjustable
dental erosion, the patient presented esthetic prob­ articulator using a facebow in maximum intercuspal
lems at the maxillary central incisors (see Figs 1 to 4). position. The VDO was arbitrarily increased to obtain
Even though the facial aspect of these teeth was in­ the space necessary to restore the occlusal surfaces of
tact (except for their incisal edges), their coloring was the posterior teeth and the palatal aspect of the maxil­
darker compared to the rest of the dentition. Several lary anterior teeth.
unsuccessful attempts at external bleaching had been The space gained in the posterior quadrants by
made in the past. The central incisors had changed the increased VDO was shared between the maxillary
color following prior trauma to the anterior teeth. At premolars and mandibular molars (Fig 7). Posterior
the radiographic examination, both pulp chambers support at the increased VDO was obtained only by
were obliterated, and the vitality test was negative. insertion of the eight ceramic onlays. The remaining
However, neither radiographic signs of periapical le­ posterior teeth were not involved in the restorative
sions nor symptoms related to a loss of vitality were treatment.

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Fig 7 As confirmed by the diagnostic wax-up, the interocclusal space obtained at

the posterior quadrants was shared between the mandibular molars and maxillary
premolars. Interdental spaces were kept free of wax during wax-up procedures.

Once this stage of treatment was finalized, the pa­ called Geller or alveolar casts are used as the working
tient was scheduled for another appointment. The fi­ casts, the teeth to be restored can be easily duplicated
nal impression of the maxillary and mandibular arches with the investment material (Fig 9).
was made using vinyl polysiloxane to fabricate the The wax-up of the occlusal onlays must be made di­
working casts. rectly on the investment replica following the morphol­
ogy obtained in the wax-up. Waxing directly to the in­
vestment is a far more delicate procedure than waxing

Posterior Ceramic On lays directly on the microstone. Since investment material

is less rig)d than stone, contact of the hot waxing in­
An additive diagnostic wax-up was used as the starting strument on the investment may damage its surface,
point for fabrication· of exceptionally thin and highly resulting in permanent distortion (Figs 10 and 11 ) .

conservative posterior lithium disilicate ceramic on­ Correct placement of the sprue is crucial during
lays. Developing thin occlusal ceramic onlays while the fabrication of thin occlusal ceramic onlays (Fig 12).
simultaneously providing adequate occlusal function An inadequate placement and amount of wax for the
is a complicated procedure. Conventional ceramic on­ sprue may result in loss of the ceramic onlay's periph­
lays require a minimum thickness of 1.5 to 2.0 mm, eral contour. A solution for this drawback is to wax the
whereas thin occlusal ceramic onlays have a maximum sprue directly over the investment. This procedure al­
thickness ranging from 0.5 to 0.6 mm. These highly lows better contour and marginal fit without removing
conservative restorations can be produced with mini­ the wax before investment into the cylinder. Once the
mal or no tooth reduction and are highly indicated to restorations are waxed with the correctly located sprue,
restore eroded posterior teeth. the investment material surrounding the restorations is
Thin occlusal ceramic on lays are very fragile and may carefully trimmed, leading to individual waxed invest­
fracture during waxing or fabrication procedures. The ment dies. Trimming the investment around the waxed
first step is to make the investment casts. The working tooth facilitates positioning into the investment ring.
casts must be duplicated in the investment (Fig 8). The However, before positioning the whole set into the in­
working casts are painted with die spacer (Color Spacer, vestment ring, the investment dies should be soaked
Yeti Dental, Engen, Germany) and then duplicated. us­ in alcohol to prevent them from absorbing moisture
ing vinyl polysiloxane (Zhermack Elite, Zhermack, Badia from the investment coating too quickly.
Polesine, Italy) and phosphate-bonded investment ma­ The thin occlusal onlays were made with a highly
terial (IPS Press Vest Speed, lvoclar Vivadent). Wheri so- opalescent shade ingot (Impulse 01, IPS e.max Press,

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 Minimally Invasive Treatment of Initial Dental E rosion

Fig 8 The preoperative casts were duplicated in investment material to facili­

tate waxing of the thin occlusal onlays.

Figs 9a and 9b With Geller or alveolar casts, only the teeth to be restored
can be duplicated in investment material.

Fig 10 To avoid permanent distor­

tion, the hot waxing instrument
must not touch the investment.

Fig 11 The study wax-up must be

replicated in the investment casts.

Figs 12a to 12c (a) Close-up view

of the waxed restoration; (b) the
investment surrounding the wax-up
was carefully trimmed; (c) correct
placement of the sprues for thin
occlusal onlays.

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VAILATI ET Al

Figs 13a and 13b (a) Thanks to this new

investment technique, thin occlusal onlays
can be pressed on top of retentive areas; (b)
pressed thin occlusal onlays.

Fig 14 Highly opalescent ingots.

Figs 15a and 15b (a) Occlusal view of the

thin occlusal veneers after adjustment to the
master cast; (b) 0.6-mm thin occlusal onlays.

15b

lvoclar Vivadent) to match the natural teeth (Figs 13 Orange, California, USA) was applied on the teeth and
and 14). According to the manufacturer, opal ingots left unpolymerized.
can be used as enamel replacements because of their The pressed lithium disilicate glass-ceramic onlays
optical properties and adequate strength. To provide were etched with hydrofluoric acid for 20 seconds and
suitable optical properties, the maximum thickness of cleaned in alcohol in an ultrasonic bath. Three coats of
the opalescent ingot must not exceed 0.5 to 0.6 mm silane were applied (Monobond Plus, lvoclar Vivadent)
(Fig 15). Thicker restorations often result in an undesir­ to the intaglio surfaces of the restorations, and a final
able increase in value. The final step is to glaze the layer of the adhesive resin was added without curing.
restorations as recommended by the manufacturer. A microhybrid composite resin (Enamel plus, Mic­
The patient was informed that the third appoint­ erium, Avegno, Italy) was heated and applied to the
ment would be a long one since the eight ceramic on­ restorations before they were placed on the teeth and
lays had to be inserted at the same visit. No anesthesia light polymerized. The challenge was to bond the ce­
was required, and the field was isolated with rubber ramic onlays while maintaining the original interproxi­
dam. Figures 16 to 23 demonstrate the placement pro­ mal contacts. The extremely thin onlays also required
cedures. Enamel was etched (37% phosphoric acid) for additional attention to avoid fracture during the bond­
30 seconds, and the adhesive resin (Optibond FL, Kerr, ing procedure.

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 M inimally Invasive Treatment of Initial Dental Erosion

Figs 16a and 16b Extremely thin

onlays were delivered to restore the
mandibular molars.

Figs 17a and 17b Irregular margins

were smoothed with a diamond bur.

Figs 18a and 18b Onlay try-in at the

maxillary premolars. The two onlays
were bonded at the same time. Metal
strips were used to keep the teeth
apart.

Fig 19 The exposed dentin was

roughened with a coarse diamond bur
to eliminate the most superficial layer.

Fig 20 Enamel was etched with

phosphoric acid for 30 seconds. Den­
tin was etched for 15 seconds.

Fig 21 An ethanol- and water-based three-step etch-and-rinse was used (Optibond FL). The bond was not cured. Im­
mediate dentin sealing was not carried out before the final impression due to the minimal dentin exposure and risk of
creating interference with the occlusion.

Figs 22a and 22b Some excess cement remained due to the closed interproximal contact and the presence of the
metal strips.

Fig 23 A scalpel was used to remove the excess composite resin.

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VAilATI ET Al

Figs 24a and 24b After delivery of

final posterior restorations, the patient
presented stable occlusion in the pos­
terior quadrants.

Fig 25 The increased VDO with the

contact points only on the posterior
teeth generated an anterior open bite.
This space was sufficient for the palatal
veneers.

Figs 26a and 26b Preparation for the

six palatal veneers. The unsupported
enamel prisms were smoothed at the
incisal edge, and the exposed dentin
was sealed before the final impression.

Anterior Veneers mediately sealed without anesthesia. The palatal

dentin was cleaned with nonfluoridated pumice, and
The patient's new occlusion was controlled after 1 the most superficial layer was removed with diamond
week to intercept occlusal interferences (Figs 24 and burs. The exposed sclerotic dentin was etched with
25). The patient was comfortable, and no signs of tem­ 37% phosphoric acid for 15 seconds and immediately
poromandibular joint disorders were detected. sealed with three-step etch-and-rinse ethanol- and wa­
In the following appointment, the palatal aspect ter-based adhesive (Optibond FL) and flowable com­
of the maxillary anterior teeth was prepared for the posite resin (Tetric Flow T, lvoclar Vivadent) just before
palatal veneers (Fig 26). All exposed dentin was im- the final impression was taken. 5-9

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 Minimally Invasive Treatment of Initial Dental Erosion

Figs 27a and 27b The final impres­

sion was taken with the interproximal
contacts closed. To facilitate trimming
of the dies, metallic matrix bands were
placed in between the teeth. Access
holes and the application of adhesive
were used to ensure that the strips
were removed with the tray during
impression taking.

Fig 28 Die spacer was applied to

the master cast before duplication.

Fig 29 In the investment cast, the

palatal veneers were waxed similarly
to the occlusal onlays.

Figs 30a to 30c Palatal view of the

finished veneers. The maxillary lateral
incisors and canines were made with
highly opalescent pressed ceramic 29
(Impulse 1, IPS e.max Press), whereas
the maxillary central incisors were
made with composite resin (Adora).

30b 30c

Finally, the irregular margins of the incisal edges maxillary central incisors. The presence of composite
were smoothed. No additional tooth preparation was resin on the palatal aspect would facilitate not only the
necessary. The interproximal contacts between the bonding procedure with the future ceramic facial ve­
maxillary anterior teeth were left closed, and the final neers (sandwich approach), but also the eventual cre­
impression was taken using metal strips in between ation of an access hole for future root canal treatment.
the teeth, as for the posterior teeth (Fig 27). No provi­ The same laboratory technique described for the
sional restorations were delivered. thin occlusal ceramic on lays was adopted for the pala­
It was decided to fabricate the palatal veneers in tal veneers, with the exception of those for the maxil­
pressed lithium disilicate glass-ceramic (IPS e.max lary central incisors (Figs 28 and 29). For the central
Press) for the maxillary lateral incisors and canines and incisors, a laboratory microfilled composite resin was
in composite resin (Adora, lvoclar Vivadent) for the used (Fig 30).

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 VAILATI ET AL

Fig 31 Each palatal veneer was indi­

vidually bonded using rubber dam.
Note the closed interproximal contacts.

Figs 3'2a and 32b (a) Before and (b)

after reestablishment of the anterior
contacts and guidance using palatal
veneers.

Fig 32c Occlusal view of the palatal

and occlusal veneers on the premolars.

Fig 33 Frontal view after completion of the modified three-step technique. The new edges of the
lateral incisors were well blended, whereas the central incisors showed a highly translucent band at
the interface with the palatal veneers. Due to the color discrepancy, it was proposed to remove the
length added by the composite resin restorations. However, the patient preferred to keep the teeth
longer until the facial veneer preparation.

After 2 weeks, the six palatal veneers were bonded, The intaglio surfaces of the two palatal composite
one at a time, under rubber dam without anesthesia resin veneers were also tribochemically coated. The
(Fig 31 ). A 3-hour appointment was necessary. The four pressed ceramic palatal veneers were instead
sealed palatal dentin was tribochemically coated (Co­ etched with hydrofluoric acid for 20 seconds.
jet, 3M ESPE, St Paul, Minnesota, USA), the surround­ All veneers were cleaned in alcohol and placed
ing enamel was etched with 37% phosphoric acid for in an ultrasonic bath, followed by the application of
30 seconds, and the adhesive (Optibond FL) was ap­ three coats of silane (Monobond Plus). A coat of the
plied to the enamel and dentin and left uncured. adhesive resin was placed and left unpolymerized.

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 Minimally Invasive Treatment of Initial Dental Erosion

Figs 34a and 34b Profile views (a)

before and (b) after restoration of the
incisal edges using palatal veneers.

Figs 35a to 35c Facial veneer prepara­

tion. The original teeth were very wide
mesiodistally. Minimal preparation was
necessary at this level. The original
tooth length was preserved.

Composite resin (Enamel plus) was heated and ap­ proach). Thanks to the preview provided by the mock­
plied to the restorations before they were placed on up on the central incisors, the patient agreed to the
the teeth and then light polymerized for 90 seconds slightly thicker teeth. The option to restore the facial
for each surface. Following the completion of the aspect of the lateral incisors was not considered due
modified three-step technique, the patient presented to the principle of minimal invasiveness. Unfortunately,
stable occlusion at an increased VDO (Figs 32 and 33). minimal tooth preparation of the central incisors was
T he incisal edges were also strengthened by the pres­ inevitable due to their dark yellowish color. Facial ve­
ence of the palatal veneers (Fig 34). neers with a thickness of 1.0 mm were necessary to
To complete the treatment, the next step was the mask the underlying color. Because the teeth did not
restoration of the facial aspect of the maxillary cen­ respond to the vitality test, no local anesthesia was
tral incisors. Unfortunately, the initial position of these necessary for the preparation (Fig 35).
teeth was very labial. To keep the tooth preparation After the final impression, provisional restorations
to a minimum, the prospect of a slightly bulkier facial were fabricated directly in the mouth using a provision­
surface was discussed with the patient (additive ap- al composite resin material (Telio, ! voclar Vivadent), and

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VAILATI ET Al

36a 36b

36c

Figs 36a to 36c (a) Feldspathic porcelain veneer

buildup; (band c) extremely thin and highly translucent
porcelain veneers.

Fig 37 Rubber dam isolation for veneer placement. A

clamp with a retraction cord was used to ensure expo­
sure of the gingival margins. The veneer preparation was
confined to enamel. Remaining composite resin is still
visible at the incisal surface. No dentin was exposed.

retention was achieved by the contraction of the prod­ patient was very satisfied with the overall treatment
uct and the presence of minimal interproximal excess. (Figs 38 to 40). In terms of biologic success, no tooth
The labial veneers were fabricated using the refrac­ preparation was performed for this almost full-mouth
tory die technique and feldspathic porcelain (Fig 36). rehabilitation except for the facial surfaces of the max­
Ceramic layering was performed to better match the illary central incisors.
color and optical details of the adjacent anterior teeth. The incisal edges of the maxillary anterior teeth
These highly translucent facial veneers blend easily were reinforced by the presence of the restorative
with the underlying preparation. materials, the exposed dentin was covered, and the
Bonding of the feldspathic ceramic veneers was thinner enamel was also reinforced. An occlusal guard
carried out after 2 weeks, following the protocol de­ was delivered to the patient to control his light para­
veloped by Magne et al (Fig 37).10-14 Final external functional habit, and a visit to a gastroenterologist was
bleaching provided a pleasing esthetic outcome. The again recommended.

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 Minimally Invasive Treatment of Initial Dental Erosion

Figs 38a and 38b The onlays

restored the convex profile of
the occlusal surfaces.

Figs 39 and 40 Final result.

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6. Paul SJ, Scharer P. The "Dual Bonding Technique"-A modified

CONCLUSION method to improve adhesive luting procedures. lnt J Periodon­
tics Restorative Dent 1997;17:537-545.
This article presented a case report of a patient affect­ 7. Magne P, So WS , Cascione D. Immediate dentin sealing sup­
ed by initial dental erosion. Early intervention was per­ ports delayed restoration placement. J Prosthet Dent 2007;98:
166-174.
formed due to the exposed dentin and risk of fracture
8. Magne P, Kim TH , Cascione D, Donovan TE. Immediate dentin
of the anterior teeth. Only time will tell if this type of sealing improves bond strength of indirect restorations. J Pros­
early and minimally invasive approach is the best solu­ thet Dent 2005;94:511-519.
9. Magne P. Immediate dentin sealing: A fundamental procedure
tion for patients affected by dental erosion.
for indirect bonded restorations. J Esthet Restor Dent 2005;17:
144-154.

10. Belser UC , Magne P, Magne M. Ceramic laminate veneers: Con­

tinuous evolution of indications. J Esthet Dent 1997;9:197-207.
11. Magne P, Belser UC. Novel porcelain laminate preparation ap­
REFERENCES proach driven by a diagnostic mock-up. J Esthet Restor Dent
2004;6:7-16.
1. Vailati F, Belser UC. Classification and treatment of the anterior 12. Magne P, Perroud R, Hodges JS , Belser UC. Clinical perfor­
maxillary dentition affected by dental erosion: The .ACE classifi­ mance of novel-design porcelain veneers for the recovery of
cation. lnt J Periodontics Restorative Dent 201 0; 30:559-571. coronal volume and length. lnt J Periodontics Restorative Dent
2. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a se­ 2000;20:440-457.
verely eroded dentition: The three-step technique. Part 3. Eur J 13. Magne P, Douglas WH. Porcelain veneers: Dentin bonding op­
Esthet Dent 2008;3:236-257. timization and biomimetic recovery of the crown. lnt J Prostho­
3. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a se­ dont 1999;12:111-121.
verely eroded dentition: The three-step technique. Part 2. Eur J 14. Magne P, Douglas WH. Additive contour of porcelain veneers:
Esthet Dent 2008;3:128-146. A key element in enamel preservation, adhesion , and esthetics
4. Vailati F, Belser UC. Full-mouth adhesive rehabilitation of a se­ for aging dentition. J Adhes Dent 1999;1:81-92.
verely eroded dentition: The three-step technique. Part 1. Eur J
Esthet Dent 2008;3:30-44.
5. Bertschinger C, Paul SJ, Luthy H , Scharer P. Dual application of
dentin bonding agents: Effect on bond strength. Am JDent 1996;
9:115-119.

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https://t.me/dental_books_lib
 estoring ankylosed teeth in the anterior region Extracting an ankylosed tooth for implant place­

R is a highly complex task that often involves in­

vasive surgical treatment. Although the literature
describes several options for the replacement of such
ment can cause severe bone destruction in addition
to the surgical difficulties related to this vertical ridge
defect.6-9 Although rare instances of spontaneous re­
teeth, most authors agree on the extremely challeng­ eruption of an ankylosed tooth have been reported,
ing nature of these cases.1-5 Decoronation, segmental severe vertical discrepancies and esthetic and func­
distraction osteogenesis, extraction, and vertical bone tional problems are the more likely outcome.1,10 Un­
and soft tissue augmentation are frequently reported fortunately, few treatment alternatives are available,
as treatment options; however, these approaches rare­ especially for younger patients with incomplete maxil­
ly result in satisfactory long-term esthetic outcomes. lary growth. This case report describes a conservative
approach for esthetic treatment of an ankylosed maxil­
lary central incisor in a young patient.

CASE REPORT
1 Private Practice Limited to Periodontics/ Fixed Prosthodontics/ and
Implants/ Antwerp/ Belgium; Visiting Professor/ University of Liege/
The 17 -year-old male patient presented with esthetic
Belgium/ and University of Marseille/ France.
2Dental Technician/ Campinas/ Brazil. concerns related to trauma-induced ankylosis of the
30ral and Maxillofacial Surgeon/ Sao Paulo/ Brazil. maxillary left central incisor (Fig 1 ). Although periapical
4Professor/ Advanced Program in lmplantology and Restorative radiographs showed severe root resorption, the tooth
Dentistry lmplante-Perio Institute/ Sao Paulo/ Brazil.
was stable and firmly anchored in the alveolar bone
(Fig 2). Despite that there were no visible signs of gin­
Correspo�dence to: Dr Eric Van Dooren/ Tavernierkaai 2/ 2000
·

Antwerp/ Belgium. Email: vandoorendent@skynet.be gival inflammation (Fig 3), the patient's oral hygiene

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VAN DOOREN ET Al

Figs 1 a and 1 b Patient presented

with trauma-induced ankylosis of the
maxillary left central incisor.

Fig 2 Periapical radiograph shows

severe root resorption.

Figs 3a to 3c Evaluation of amount/

height of keratinized tissue available
and probing of CEJ and bone level
for proper understanding of the sur­
gical possibilities and limitations.

Figs 4a and 4b Preoperative facial

photographs.

was less than optimal. The labioversion and partial Treatment Planning
egression of the mandibular incisors required orth­
odontic treatment to creat � space for optimal three­ Vinyl polysiloxane impressions were taken (Virtual, Iva­
dimensional positioning of a ceramic crown. dar Vivadent, Schaan, Liechtenstein), and two sets of
Facial photographs of the patient smiling revealed stone casts were fabricated. A full-contour wax-up (af­
the need for a comprehensive treatment plan (Fig 4). ter cutback of the stone cast) allowed for three-dimen­
The patient's age prevented extraction and bone and sional evaluation of the defect (Figs Sa to Si). Since
soft tissue regeneration b�cause final maxillary growth the tooth had been ankylosed for several years, labia­
had not been attained. Therefore, an alternative but version of the maxillary left central incisor was evident
comprehensive treatment plan was proposed to the (Fig Sa). Pink wax was added to the gingival portion of
patient. the ankylosed tooth to simulate the ideal coronal and
gingival shape and contour (Figs Sb to Si).11 The distal

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 An Alternative Treatment for an Ankylosed Central Incisor: The Perio - Prostheti c Connection

Figs Sa to Si Full-contour wax-up is fabricated

to evaluate the defect three-dimensionally. (a)
Labioversion of the maxillary left central incisor is
evident. (b to i) Pink wax is added to simulate the
ideal coronal and gingival shape and contour.

aspect and diameter of the left central incisor required rication of an ideal wax-up and thorough knowledge of
tooth reduction to create symmetry with the right cen­ proper gingival shapes and contours are key factors in
tral incisor in terms of form and gingival contour. Fab- planning complex cases.12•13

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VAN OOOREN ET AL

Fig 6 Silicone index is fabricated from the wax-up.

Figs 7a to 7c Try-in of the mock-up indicates the

need for distocoronal reshaping.

Fig 8 Computer software is used to simulate the new gingival contours.

A silicone index was fabricated (Matrix Form 60, treatment was necessary to resolve the vertical gingi­
Anaxdent, Stuttgart, Germany) from the wax-up, and val and tooth/form discrepancies; however, it would
a mock-up (Anaxflow, Anaxdent) was used to simulate be unrealistic to expect that any soft tissue grafting
the tooth form and length (Fig 6). Try-in of the mock­ procedure would provide complete defect coverage.
up revealed the need for distocoronal reshaping (Fig In the authors' treatment-planning protocol, it is
7). The more coronal the preparation, the larger the standard procedure to assess the need for modifica­
prosthetic diameter. It became evident that surgical tion of the gingival contour (ie, clinical crown length-

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 An Alternative Treatment for an An kylosed Central Incisor: The Perio-Prosthetic Connection

Figs 9a and 9b Deep chamfer crown preparation is made, followed by substantial

distal and buccal reduction to flatten the crown contour.

Fig 10 Electrosurgical crown lengthening is performed .

•

ening) of the adjacent teeth. In many cases, this simple Surgical and Restorative Treatment
procedure can reduce the ampunt of vertical augmen­
tation. The use of computer software (Keynote, iWork, The diagnostic procedures revealed the need to fab­
Apple, Cupertino, California, USA) to draw horizontal ricate and bond the final restoration on the ankylosed
reference lines and simulate future gingival contours tooth before initiating connective tissue grafting. A
can facilitate treatment planning (Fig 8) deep chamfer crown preparation was performed on
Combined resective (right central and lateral incisors) the left central incisor (Fig 9) to achieve symmetry with
and additive surgical procedures (connective tissue graft the soft tissue contour of the right central incisor after
on the left central incisor) were the only realistic and crown lengthening. To establish the final gingival con­
conseNative treatment options to restore balance, sym­ tour of the right central and lateral incisors, electro­
metry, and harmony of the maxillary anterior teeth.12•14•15 surgical clinical crown lengthening was performed (Fig
Clinical evaluation and probing indicated clinical crown 1 0). Maximum enamel exposure was obtained for both
lengthening on the right central and lateral incisors. teeth. Since probing revealed that the biologic space
A substantial amount of enamel was unexposed was still maintained (3.0 to 3.5 mm) after tissue resec­
(localized modified passive eruption). The cementa­ tion, no surgical flap procedure was required. It should
enamel junction and bone levels were determined by be noted, however, that this situation is uncommon. In
probing the sulcus. Next, the amount of possible gin­ most cases of clinical crown lengthening, bone resec­
gival resection was determined. tion is needed.

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Figs 11 and 12 The diameter is reduced on both

the buccal and distal aspects.

Fig 13 Vinyl polysiloxane impression is made.

Fig 14 Four shade tabs are used for the intraoral

shade-taking photograph.

Fig 15 Grayscale image is used to evaluate value.

Fig 16 Oversaturated image for better visualiza­

tion of tooth details.

At the same time, the portion of tooth enamel api­ 12). A vinyl polysiloxane impression was made, and
cal to the deep chamfer preparation was aggressively stone casts were fabricated (Fig 13).
flattened with a bur up to the most apical part of the To determine the exact shade of the tooth, four shade
sulcus to reduce the facial crown contour and the pres­ tabs (Classical VITA, VITA Zahnfabrik, Bad Sackingen,
sure on facial gingival tissues. On the distal aspect, the Germany) were used for an intraoral shade-taking pho­
diameter was also substantially reduced (Figs 11 and tograph (A1, A2, B1, B2) (Fig 14). This allowed the tech-

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 An Alternative Treatment for an Ankylosed Central Incisor: T he Perio-Prosthetic Connection

Fig 17 Precise wax-up is made.

Fig 18 Pink wax is added to show

missing soft tissue.

Figs 19a and 19b Lithium disilicate

coping.

Fig 20 Polishing wheel is used to

reduce the contour of the coping.

Figs 21 a and 21 b Reduction is

checked on the solid cast.

nician to better understand the basic shade to be used. symmetry with the right central incisor (Fig 17). The miss­
Next, the shade-taking photograph was copied three ing soft tissue was shaped in pink wax to evaluate the
times side-by-side into computer software (Keynote, Ap­ vertical component of the defect (Fig 18). At this stage,
ple). The first image was left intact (Fig 14). In the second it became clear that the distal aspect of the restoration
image, the saturation was lowered until a grayscale pho­ and the diameter of the future crown would not ideally
tograph was obtained (Fig 15). Grayscale images make match the diameter of the natural contralateral central
it easier to evaluate the value of the tooth. In the third incisor, despite the aggressive tooth preparation.
image, the brightness was lowered and the contrast was A lithium disilicate coping (IPS e.max Press, MO In­
increased, resulting in an oversaturated image (Fig 16) got, lvoclarVivadent) was fabricated (Fig 19). To achieve
that helped the technician visualize details such as mam­ optimal form and symmetry, it was decided to modify
melons, translucency, and the incisal opalescent layer, all the distal aspect of the crown and reduce the contour
of which are important for the ceramic buildup. of the coping on the die. A polishing wheel was used
A solid cast and die cast were fabricated, and a pre­ to reduce both the die and coping distally (Fig 20). The
cise wax-up was made to obtain optimal tooth form and reduction was then checked on the solid cast (Fig 21 ).

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VAN DOOREN ET Al

Figs 22a to 22c Coping is layered with porce­

lain.

Figs 23a to 23c Diamond bur is used to reduce

the distal asp ect of the left central incisor.

The coping was layered with porcelain (IPS e.max Vivadent). Next, a concavity was created apical to the
Ceram, lvoclar Vivadent) (Fig 22). At the second try-in, crown margin with a round high-speed diamond bur
the form, texture, color, and line angles were evaluated. (Fig 25). This provided space for the connective tissue
The distal aspect of the left central incisor was clinically graft while simultaneously eliminating enamel and ex­
reduced with a diamond bur (Fig 23) to obtain perfect posing dentin for better attachment of the graft to the
fit of the restoration on the prepared tooth (Fig 24). tooth surface (Fig 26). The exposed dentin was treated
After glazing and finishing, the crown was adhe­ with hypersaturated citric acid for 2 minutes, and a
sively cemented (Variolink Veneer Medium, lvodar connective tissue graft was harvested from the max-

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 An Alternative Treatment for an Ankylosed Central Incisor: T he Perio-Prosthetic Connection

Figs 24a to 24d Ceramic crown in place (a and b) before and

after bonding and distal enamelplasty reshaping. Close-up
(c and d) before and after bonding and reshaping.

Fig 25 Concavity is created apical to the crown margin.

Fig 26 Space is now adequate for a connective tissue graft.

Fig 27 Connective tissue graft in place.

illary tuberosity (Fig 27). To achieve optimal suturing was carried out beneath the papillae, extending be­
(Seralene 6/0, American Dental Systems, Vaterstetten, yond the mucogingival junction with periostal releas­
Germany) and healing, a split-thickness buccal pouch ing incisions while avoiding vertical incisions.

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VAN DOOREN ET AL

Microsurgical ophthalmologic tunneling blades were

CONCLUSION
used to ensure minimally invasive surgery (Fig 28). Two
composite resin anchorage points were used on the The replacement of ankylosed teeth is a clinical chal­
mesial and distal aspects of the restoration to allow for lenge that may result in poor long-term outcomes.
a coronally advanced flap and complete graft cover­ This article described an alternative approach to the
age (Fig 29). Healing was uneventful (Fig 30) and the restoration of an ankylosed maxillary central incisor in
final result was satisfactory. The marginal gingival level a young patient. A detailed and comprehensive treat­
remained stable over time (Fig 31). The thickness of ment plan allowed for a more stable and less invasive
the connective tissue graft and the slightly concave treatment. Satisfactory functional and esthetic results
root shape allowed for mechanical resistance and soft were achieved.
tissue stability (Fig 32)/ and the patienfs smile confirms
a successful outcome (Fig 33).

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 An Alternative Treatment for an Ankylosed Central Incisor: The Perio-Prosthetic Connection

Figs 28a and 28b Tunneling blades

ensure a minimally invasive surgery.

Fig 29a Interproximal phosphoric

acid etching.

Fig 29b Application of bonding

resin.

Fig 29c Anchorage with flowable

composite.

Fig 30a Immediately postoperative.

Fig 30b Healing after 10 days.

Figs 31 a and 31 b Preoperative and

final anterior views.

Figs 32a and 32b Close-up views.

Fig 33 Final smile.

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VAN DOOREN ET Al

REFERENCES 8. Nozawa T, Tsurumaki S, Yamaguchi S, Enomoto H, Ito K. T he

concept of the interdental gingival midpoint line in cervical line
management. Eur J Esthet Dent 2009;4:46-68.
1. Allen EP. Surgical crown lengthening for function and esthetics.
9. Grunder U. Crestal ridge width changes when placing implants
Dent Clin North Am 1993;37:163-179.
at the time of tooth extraction with and without soft tissue aug­
2. Deas DE, Moritz AJ, McDonnell HT, Powell CA, Mealey BL. Os­
mentation after a healing period of 6 months: Report of 24 con­
seous surgery for crown lengthening: A 6-month clinical study. J
secutive cases. lnt J Periodontics Restorative Dent 2011;31:9-
Periodontal 2004;75:1288-1294.
17.
3. Hempton TJ, Esrason F. Crown lengthening to facilitate restor­
10. Ward DH. Proportional smile design using the recurring esthetic
ative treatment in the presence of incomplete passive eruption.
dental (red) proportion. Dent Clin North Am 2001;45:143-154.
J Calif Dent Assoc 2000;28:290-298.
11. Malik K, Tabiat-Pour S. T he use of a diagnostic wax set-up in
4. Pontoriero R, Carnevale G. Surgical crown lengthening: A
aesthetic cases involving crown lengthening-A case report.
12-month clinical wound healing study. J Periodontal 2001;
Dent Update 2010;37:303-307.
72:841-848.
12. F radeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol
5. Zanatta FB, Giacomelli BR, Dotto PP, Fontanella VR, Rosing CK.
1: Esthetic analysis-A Systematic Approach to Prosthetic Treat­
Comparison of different methods involved in the planning of
ment. Chicago: Quintessence, 2004.
clinical crown lengthening surgery. Braz Oral Res 201 0;24:443-
13. Rufenacht CR. Fundamentals of Esthetics. Chicago: Quintes­
448.
sence, 1990.
6. Chu SJ. A biometric approach to predictable treatment of
14. De Waal H, Castellucci G. T he importance of restorative margin
clinical crown discrepancies. Pract Proced Aesthet Dent
placement to the biologic width and periodontal health. Part II.
2007;19:401-409.
7. �� u SJ, Tan JH, Stappert CF, Tarnow DP. Gingival zenith po­
lnt J Periodontics Restorative Dent 1994; 14:70-83.
15. Ingber JS, Rose LF, Coslet JG. T he "biologic width"-A con­
Sitions and levels of the maxillary anterior dentition. J Esthet
cept in periodontics and restorative dentistry. Alpha Omegan
Restor Dent 2009;21:113-120.
1977;70:62-65.

ODT 2012
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 o obtain consistent esthetic outcomes, the de­ overlooked during clinical, photographic, or diagnos­

T sign of dental restorations should be defined as

soon as possible. The importance of gathering
diagnostic data from questionnaires and checklists1-7
tic cast-based evaluation procedures. The drawing of
reference. lines and shapes over extra- and intraoral
digital photographs in a predetermined sequence
cannot be overlooked; however, much of this informa­ can widen diagnostic visualization and help the restor­
tion may be lost if it is not transferred adequately to the ative team evaluate the limitations and risk factors of a
design of the restorations. The diagnostic data must given case, including asymmetries, disharmonies, and
guide the subsequent treatment phases,8 integrating violations of esthetic principles.1 DSD sketches can be
all of the patient's needs, desires, and functional and performed in presentation software such as Keynote
biologic issues into an esthetic treatment design.9•10 (iWork, Apple, Cupertino, California, USA) or Microsoft
The Digital Smile Design (DSD) is a multi-use con­ PowerPoint (Microsoft Office, Microsoft, Redmond,
ceptual tool that can strengthen diagnostic vision, Washington, USA). This improved visualization makes
improve communication, and enhance predictabil­ it easier to select the ideal restorative technique.
ity throughout treatment. The DSD allows for careful The DSD protocol is characterized by effective com­
analysis of the patient's facial and dental characteris­ munication between the interdisciplinary dental team,
tics along with any critical factors that may have been including the dental technician. Team members can
identify and highlight discrepancies in soft or hard tis­
sue morphology and discuss the best available solu­
tions using the amplified images. Every team member

1Private Practice, Sao Paulo, Brazil. can add information directly on the slides in writing
or using voice-over, thus simplifying the process even
Correspondence to: Dr Christian Coachman, Oral Esthetic more. All team members can access this information
Rehabilitation, Well Clinic, Rua Bento de Andrade, 116, Sao Paulo,
whenever necessary to review, alter, or add elements
SP, Brazil, 04503-000. Email: ccoachman@hotmail.com;
www.wellclinic.com.br during the diagnostic and treatment phases.

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COACHMAN/CAlAMITA

The adoption of the DSD protocol can make di­ This individual has the ability to better communicate
agnosis more effective and treatment planning more the patient's personal preferences and/or morpho­
consistent. The efforts required to implement DSD are psy chologic features to the technician, elevating the
rewarded by more logical and straightforward treat­ excellence of the restoration from acceptable to ex­
ment sequencing, leading to savings in time, materi­ ceptional.7·8·11
als, and cost during treatment. Successful restorative treatment involves control­
ling the four dimensions of treatment: esthetics, func­
tion, structure, and biology. In relation to esthetics,
there are four main issues that must be controlled to

DIGITAL SMILE DESIGN improve predictability and meet patient expectations:

the horizontal reference plane, facial midline, smile
The DSD protocol offers advantages in the following design (tooth shape and arrangement), and color. The
areas: question is how to precisely transfer this information
from the face to the mouth, to the cast, and to the final
• Esthetic diagnosis restoration. The primary goal of the DSD protocol is to
• Communication facilitate this process.
• Feedback With this valuable information in hand, the dental
• Patient management technician can fabricate a three-dimensional wax-up
• Education more efficiently, focusing on developing anatomical
features within the parameters provided, including the
planes of reference, facial and dental midlines, rec­
ommended incisal edge position, lip dy namics, basic
Esthetic Diagnosis
tooth arrangement, and incisal plane.
When the dentist first evaluates a new patient with This information is transferred from the wax-up to
esthetic concerns, many critical factors may be over­ the try-in phase through a mock-up or provisional res­
looked. A digital photography and digital analysis toration.4·6·12 The design of the definitive esthetic res­
protocol enables the dentist to visualize and analyze torations spould be developed and tried-in as soon as
issues that he or she may not notice clinically. Drawing possible to guide the treatment sequence. Efficient
of reference lines and 'shapes over extra- and intraoral treatment planning helps the entire dental team iden­
digital photographs can easily be performed using tify any challenges and reduce total treatment time.8
presentation software.

Feedback
Communication
The DSD allows for precise evaluation of the results
Traditionally, smile design has been instituted by the obtained in every treatment phase. The sequence of
dental technician. The technician performs the restor­ treatment is organized on the slides with photographs,
ative wax-up, creates the tooth shapes and dental ar­ videos, notes, graphics, and drawings. At any time,
rangements, and follows the instructions and guide­ team members can access the slide presentation to
lines provided by the dentist in writing or by phone. In track and analyze the treatment provided. With the
many cases, however, insufficient information is given digital ruler, drawings, and reference lines, easy com­
to the dental technician to utilize his or her skills to parisons can be made between pre- and posttreat­
maximum potential. As a result, the final restoration is ment photographs. These comparisons help deter­
less likely to fully satisfy the patient's desires. mine whether the treatment has successfully followed
When the treatment coordinator or whichever mem­ the original plan or if other adjunctive procedures are
ber of the restorative team has developed a personal necessary to improve the final outcome. The dental
relationship with the patient takes responsibility for the technician also gains feedback related to tooth shape,
smile design, the results are likely to be far superior. arrangement, and color to facilitate any necessary re-

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 Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry

finements. This constant double-checking ensures the

excellence of the final result and provides a great learn­
ing tool for the entire interdisciplinary team. The DSD
tool also serves as a useful library of treatment pro­
cedures. Clinicians can revisit treatments performed
years ago and learn from past results.

Patient Management

The DSD can be used as a marketing tool to motivate

the patient, an educational tool to help explain issues
Fig 1 Slide presentation software (Keynote, iWork, Apple)
related to treatment, and an evaluative tool by com­ with crossing lines placed on the middle of the slide.
paring before and after photographs. Further, the li­
brary of slides from past treatments can be used 'to
demonstrate treatment possibilities during patient
consultation. The treatment planning presentation
will be much more effective because the DSD allows
patients to visualize the multiple factors responsible
for their orofacial issues. The problems presented in lines, shapes, and measurements over the clinical and
each case can be superimposed in list form directly laboratory images.
over the patient's own photographs. The clinician can Three basic photographic views are necessary: full
express the severity of the case, introduce treatment face with a wide smile and the teeth apart, full face at
strategies, discuss the prognosis, and make case man­ rest, and retracted view of the full maxillary arch with
agement recommendations. In addition, DSD aids in teeth apart. A short video is also recommended in
patient acceptance by helping them visualize and un­ which the patient is prompted by the clinician to ex­
derstand both past and future treatments. plain his qr her treatment concerns and expectations.
Simultaneously, the video should capture all possible
dental and smile positions, including 45-degree and
profile views. The photographs and videos are down­
Education
loaded and inserted into the slide presentation. The
This personal library of clinical cases can also be shared DSD workflow then proceeds as follows:
with patients and colleagues, and the most appropri­
ate cases can be transformed into a slideshow for den­ 1 . The cross: Two lines must be placed on the center
tal presentations and lectures. DSD can increase the of the slide, forming a cross (Fig 1 ). The facial pho­
visual impact of a lecture by incorporating the slides tograph with the teeth apart should be positioned
from clinical cases. The audience can better under­ behind these lines.
stand the concepts discussed, and the presenter can 2. Digital facebow: Relating the full-face smile image
minimize the use of a laser pointer. to the horizontal reference line is the most impor­
tant step in the smile design process. The inter­
pupillary line should be the first reference line to
establish the horizontal plane, but it should not be
DSD Workflow
the only one. The face as a whole must be analyzed
The authors carry out the DSD protocol using Key­ before determining the best horizontal reference to
note software (iWork); however, similar software such achieve harmony. After determining the horizontal
as Microsoft PowerPoint can be used with minor ad­ reference line, the facial midline is outlined accord­
justments to the technique. Keynote allows for simple ing to facial features such as the glabella, nose, and
manipulation of the digital images and the addition of chin (Fig 2).

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COACHMAN/CALAMITA

Fig 2 T he facial photograph with a wide smile and the Fig 3 Transferring the cross to the smile: grouping the
teeth apart is moved behind the cross to determine the lines with the facial photograph and zooming in to analyze
ideal horizontal plane and vertical midline (ie, the digital the relationship between the facial lines, lips, teeth, and
facebow). gingiva.

Fig 4 Basic dental simulation performed by cropping Fig 5 Drawing the three reference lines that will allow for
the images of the teeth qnd placing them over the smile transf�rring of the cross to the intraoral photograph.
photograph, correcting the gingival levels, length, and the
canting of the anterior teeth.

3. Smile analysis: Dragging the horizontal line over a) Line 1: from the tip of one canine to the tip of
the mouth will allow for initial evaluation of the rela­ the contralateral canine.
tionship of the facial lines with the smile. Grouping b) Line 2: from the middle of the incisal edge of
the lines and the facial photographs will allow the one central incisor to the middle of the incisal
clinician to zoom in on the image without losing the edge of the contralateral central incisor.
reference between the lines and photograph. Mid­ c) Line 3: over the dental midline, from the tip
line and occlusal plane shifting and canting can be of the midline interdental papillae to the incisal
easily detected (Fig 3). embrasure.
4. Smile simulation: Simulations can be performed to
fix the incisal edge position, canting, shifting, tooth It is necessary to calibrate four features on the
proportions, and soft tissue outline (Fig 4). photograph: size, canting, incisal edge position,
5. Transferring the cross to the intraoral images: To and midline position. Line 1 will guide the two first
analyze the intraoral photographs in accordance aspects (size and canting), line 2 will guide the inci­
with the facial references, the cross must be trans­ sal edge position, and line 3 will guide the midline
ferred to the retracted view using three transferring position (Fig 6).
lines drawn over the smile view as follows (Fig 5):

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 Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry

Fig 6 Intraoral photograph adjusted to the three reference Fig 7 Intraoral photograph with the cross used to measure
lines. the actual length/width proportion of the right central
incisor.

Fig 8 A rectangle with ideal length/width proportion (80%) Fig 9 Drawing the tooth outline, as guided by the cross
is placed over the central incisor to compare the actual and by the rectangle proportion.
pretreatment proportion with the ideal one.

6. Measuring tooth proportion: Measuring the width/

length proportion of the central incisors is the first
step toward understanding how to best redesign the
smile. A rectangle is then placed over the edges of
both central incisors (Fig 7). The proportions of the
patient's central incisors can be compared to the ide­
al proportions destribed in the literature (Fig 8). 2-8

7. Tooth outline: From this step on, all drawings may

be performed depending on what needs to be vi­
sualized or communicated for each specific case.
For example, tooth outlines can be drawn over
the photograph, or premade tooth outlines can be
Fig 10 Final teeth outline showing the relationship between
copied and pasted. The selection of tooth shape the preoperative situation and the ideal design.
will depend on factors such as the morphopsycho­
logic interview and the patient's desires, facial fea­
tures, and esthetic expectations (Figs 9 and 1 0).11•13

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Fig 11 Other drawings and lines can be added as needed Fig 12 Measuring the length of the left central incisor
to help visualize the esthetic issues and improve the ef­ (1 0.6mm) on the cast. This measurement will be transferred
ficiency of communication. to the computer for calibration of the digital ruler.

Fig 13 Calibrating the digital ruler on the slide by shrink­ Fig 14 Measurements can be taken of the difference be­
ing/stretching until it matches the measurement done on tween the preoperative location of the cervical areas of the
the cast. The digital ruler is a photograph of a ruler (JPEG canines compared to the ideal location. In this case, one
file) that is dragged on top of the slide and can be posi­ maxillary canine needed crown lengthening and the other
tioned as necessary. required root coverage.

8. White and pink esthetic evaluation: After all refer­ the cast (Fig 12) and transferring this measurement
ence lines and drawings have been provided, the to the computer (Fig 13). Once the digital ruler
clinician should have a clear understanding of the is calibrated, the clinician can make any measure­
esthetic issues involved in the patient's maxillary ments needed over the anterior area of the image
arch, including the tooth proportions, interdental (Fig 14).
relationship, relationship between the teeth and 10. Transferring the cross to the cast: First, the hori­
smile line, discrepancy between facial and dental zontal line over the intraoral photograph should
midlines, midline and occlusal plane canting, soft be moved above the gingival margin of the 'six
tissue disharmony, relationship between the soft anterior teeth. The distance between the horizon­
tissues and teeth, papillae heights, gingival margin tal line and the gingival margin of each tooth is
levels, incisal edge design, and tooth axis (Fig 11 ). measured using the digital ruler, and these mea­
9. Digital ruler calibration: The digital ruler can be surements are written down on the slide (Fig 15).
calibrated over the intraoral photograph by mea­ The measurements are then transferred to the cast
suring the length of one of the central incisors on with the aid of a caliper. Pencil marks are made on

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 Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentistry

Fig 15 The horizontal line is placed randomly above the Fig 16 Measuring the discrepancy between the facial mid­
gingival margin of the anterior teeth. This distance is then line and dental midline.
measured and transferred to the stone cast using the digital
ruler.

Fig 17 All the measurements are transferred to the cast, Fig 18 The diagnostic wax-up is fabricated using the cross
and the cross is drawn. and morphopsychologic design as guides. The new incisal
length is measured on the computer and transferred to the
wax-up with a caliper.

the cast at the same distances above the gingi­ to transfer any necessary information, such as gin­
val margins as shown on the digital images. Those gival margins, root coverage, crown lengthening,
dots are then connected, creating a horizontal line incisal edge reduction, and tooth width. At this
above the teeth. The next step is to transfer the stage, all information the technician will need to
vertical midline. Because the vertical line must develop a precise wax-up is available on both the
be perpendicular to the horizontal line, only one slides and cast (Fig 18).
point is necessary to determine its location. The
distance between the dental midline and the fa­ The guided diagnostic wax-up will be an important
cial midline at the incisal edge is measured on the reference for any surgical, orthodontic, and restorative
computer, and the distance is then transferred to procedures. Several guides can be produced over
the cast with the caliper (Fig 16). Subsequently, this wax-up to control the procedures, such as surgi­
the line can be drawn perpendicular to the hori­ cal stents, orthodontic guides, implant guides, crown
zontal line passing over this reference point. After lengthening guides, and tooth preparation guides.
drawing the cross on the cast (Fig 17), it is possible The next important step to evaluate the precision of

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 COACHMAN/CALAMITA

Fig 19 Try-in provisional made with bis-acrylic resin is Fig 20 Final minimally invasive tooth prep aration guided
obtained from a silicone index fabricated on top of the by the silicone indexes.
diagnostic wax-up.

Fig 21 Final ceramic veneers (IPS e.max, lvoclar Vivadent, Fig 22 Ceramic veneers after bonding.
Schaan, Liechtenstein) fabricated according to the silicone
indexes.

the DSD protocol and the wax-up is to perform a clini­

cal try-in (Fig 19). The clinical try-in can be carried out
using a direct mock-up or a provisional restoration de­
pending on the complexity of the case. After patient
approval, the restorative procedures can be adjusted
as necessary. Tooth preparation should be minimally
invasive, allowing just enough clearance to create
proper space for ceramic restorations (Fig 20). Fabri­
cation of the final restorations should be a controlled
process with minimal final adjustments (Fig 21). If all of
these steps are carried out properly and carefully, the
final result will likely exceed the patient's expectations
(Figs 22 and 23).

Fig 23 Final outcome after 6 months.

• QDT2012 https://t.me/dental_books_lib
 Digital Smile Design: A Tool for Treatment Planning and Communication in Esthetic Dentist ry

CONCLUS IONS R�FERENCES

1. Coachman C, Van Dooren E, Gurel G, Landsberg CJ, Calamita
The Digital Smile Design is a multi-use tool that can
MA, Bichacho N. Smile design: From digital treatment planning
assist the restorative team throughout treatment, im­ to clinical reality. In: Cohen M (ed). Interdisciplinary Treatment
proving the dental team's understanding of the es­ Planning. Vol 2: Comprehensive Case Studies. Chicago: Quin­
tessence, 2012:119-17 4.
thetic issues and increasing patient acceptance of
2. Goldstein RE. Esthetics in Dentistry. Vol1: Principles, Communi­
the final result. The placement of references lines and cation, Treatment Methods, ed 2. Ontario: BC Decker, 1998.
other shapes over extra- and intraoral digital photo­ 3. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodon­
tics. Chicago: Quintessence, 1996.
graphs widens the dental team's diagnostic vision and
4. Magne P, Belser U. Bonded Porcelain Restorations in the Ante­
helps to evaluate the limitations, risk factors, and es­
rior Dentition: A Biomimetic Approach. Chicago: Quintessence,
thetic principles of a given case. These critical data will 2002.

lead to improved results in all phases of treatment. 5. Fradeani M. Esthetic Rehabilitation in Fixed Prosthodontics. Vol
1: Esthetic Analysis: A Systematic Approach to Prosthetic Treat­
ment. Chicago: Quintessence, 2004.
6. Gurel G. T he Science and Art of Porcelain Laminate Veneers.
Chicago: Quintessence, 2003.
7. Rufenacht CR. Fundamentals of Esthetics. Chicago: Quintes­
ACKNOWLEDGMENT sence, 1990.
8. Dawson PE. Functional Occlusion: From TMJ to Smile Design.
The authors would like to thank Dr Marcos Pitta, Oral Surgeon; Dr
St Louis: Mosby, 2007.
Milton Missaka, Orthodontist, and Adriano Shayder, CDT, members
9. Spear FM. The maxillary central incisor edge: A key to esthetic
of the interdisciplinary team, for their remarkable contributions to
and functional treatment planning. Compend Cantin Educ Dent
the results obtained and for all dental laboratory support.
1999;20:512-516.

10. Kois JC. Diagnostically driven interdisciplinary treatment plan­

ning. Seattle Study Club J 2002;6:28-34.
11. Paolucci B. Visagismo e Odontologia. In: Hallawell P. Visagis­
mo lntegrado: ldentidade, Estilo, Beleza. Sao Paulo: Senac,
2009:243-250.

12. Gurel G, Bichacho N. Permanent diagnostic provisional resto­

rations for predictable results when redesigning smiles. Pract
Proced Aesthet Dent 2006;18:281-286.
13. Paolucci H. Visagismo: A Arte de Personalizar o Desenho do
Sorriso. Sao Paulo: VM Cultural, 2011.

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112–130_CLAVIJO.indd 112 3/20/12 12:56 PM
 Achieving Excellence in Smile Rehabilitation
Using Ultraconservative Esthetic Treatment:
A Multidisciplinary Vision

Victor Grover Rene Clavijo, DDS, MS, PhD1

Paulo Fernando Mesquita de Carvalho, DDS, MS2
Robert Carvalho da Silva, DDS, MS, PhD2
Julio Cesar Joly, DDS, MS, PhD2
Luis Alves Ferreira, CDT3
Victor Humberto Orbegoso Flores, DDS, MS, PhD4

T
oday, esthetic restorative dentistry can offer smile reha-
bilitations using a conservative approach with minimal re-
moval of sound dental structures. The aim of this article is
to demonstrate a multidisciplinary, ultraconservative method of
restoring the harmony of the smile.

CASE REPORT
The patient was extremely embarrassed of her smile, resulting in
shyness and minimal social interaction. The initial clinical exam
revealed diastema, congenitally missing maxillary lateral incisors
with the canines located in the lateral incisor positions, and the
primary maxillary canines still located in their original positions
(Fig 1). These aspects created not only esthetic deficiencies, but
also malocclusion.1 Therefore, a multidisciplinary treatment was
suggested to restore both esthetics and function.2

1
Professor, Advanced Program in Implantology and Restorative Dentistry,
ImplantePerio Institute, São Paulo, Brazil.
2
Director, Advanced Program in Implantology, ImplantePerio Institute,
São Paulo, Brazil.
3
Dental Technician, São Paulo, Brazil.
4
Associate Professor; Restorative Dentistry, Preventive, and Fixed
Prosthodontics; Federal University of Alfenas School of Dentistry, Alfenas,
Minas Gerais, Brazil.

Correspondence to: Dr Victor Clavijo, Rua Cerqueira Cesar, 1078 Indaiatuba,

São Paulo, Brazil 13330-005. Email: clavijovictor@yahoo.com.br;
www.implanteperio.com.br QDT 2012 113

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 Achieving Excellence in Smile Rehabilitation Using Ultraconservative Esthetic Treatment

Phase 1: Planning Phase 4: Restorative (Figs 8 to 36)

All dental professionals involved in the treatment (or­ After a period of healing and osseointegration, uncov­
thodontist, periodontist, master ceramist, and opera­ ering surgery was performed. The transfer copings were
tive dentist) evaluated the clinical case individually to then positioned, and a vinyl polysiloxane (VPS) impres­
decide which noninvasive procedures were indicated. sion was made to fabricate the working cast. Zirconia
Next, the four professionals discussed the prognosis abutments and provisional crowns were fabricated to
and limitations of the case. The master ceramist p�r­ shape the gingival margins to the desired contour.
formed a diagnostic wax-up to provide a model of the After the gingival tissues were remodeled and con­
multidisciplinary treatment. After patient approval, toured, acrylic resin impression copings (Duralay, Reli­
the conservative treatment was then split into three ance Dental, Worth, Illinois, USA) were fabricated for
restorative phases: orthodontic, surgical, and restor­ the implant abutments before the final pickup impres­
ative. sion was taken using VPS. Before the impression pro­
cedures, an interocclusal bite registration was taken
and the shade was selected.

Phase 2: Orthodontics (Figs 2 to 6) Two lithium disilicate all-ceramic crowns (IPS e.max
Ceram, lvoclar Vivadent, Schaan, Liechtenstein) were
The orthodontic phase began with the analysis of made for the implants, and two feldspathic ceramic
craniofacial growth, radiographs, and study casts. Pri­ fragments (IPS d.Sign, lvoclar Vivadent) were fabri­
mary maxillary canines were extracted, and a fixed cated using the refractory die technique to close the
orthodontic appliance was used to close the diastema diastema between the maxillary central incisors.
between the maxillary central incisors and redistribute All restorations were checked for fit, marginal adap­
the interdental spaces for esthetic rehabilitation. The tation, and interproximal contacts. The final shade was
orthodontic treatment used the following parameters evaluated using glycerin-based try-in paste (Variolink
for evaluation: sagittal relationship between the den­ Try-in, lvoclar VivadentL which resulted in the selection
tal arches; posterior occlusion; location, shape, and of clear translucent resin cement. All restorations were
size of the canines; amount of remaining interdental adhesivel¥ cemented. The fragments were etched with
space; and profile and facial skeletal pattern of the pa­ hydrofluoric acid for 90 seconds, rinsed, and dried.
tient.3 After orthodontic treatment was finalized, the To remove any ceramic debris, additional etching was
orthodontic brackets were removed and a removable carried out with 35% phosphoric acid for 30 seconds.
appliance was used to replace the missing maxillary All fragments were silanated (Monobond, lvoclar Viva­
lateral incisors. dent). The lithium disilicate crowns were also processed
as described above, except that the hydrofluoric acid
etching was performed for only 20 seconds.
The ceramic fragments were simultaneously bond­
Phase 3: Surgical (Fig 7)
ed to etched enamel using light-polymerized dental
The surgical phase was initiated with esthetic flap sur­ adhesive (Excite, lvoclar Vivadent) and a clear translu­
gery to reposition the zenith of the maxillary canines cent light-polymerized resin cement (Variolink II, Iva­
and central incisors. On the same day, open full-flap dar Vivadent). Facial and palatal ceramic overcontour­
envelope surgery allowed the placement of two im­ ing was removed with a high-speed fine diamond bur,
plants to replace the congenitally missing maxillary followed by polishing with intraoral ceramic finishing
lateral incisors (3.3 X 14 mm, Straumann Bone Level and polishing points. After cementation of the ceramic
Narrow CrossFit, Straumann, Basel, Switzerland). After fragments, the lithium disilicate ceramic crowns were
implant placement, conjunctive grafts were performed adhesively cemented to the zirconia implant abut­
to increase the gingival volume, and healing caps were ment. The zirconia abutments were silanated (Mono­
placed. These procedures were necessary to restore bond PlusL and dual-cured resin cement was used for
the harmony of the pink (gingival) and white (dental) bonding (Variolink II). Occlusion was checked, and the
architecture. patient was dismissed.

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CLAVIJO ET Al

DISCUSSION CONCLUSION
Although alternative treatment options were available This article presented the successful multidisciplinary
for this clinical case, the chosen technique guaran­ treatment of a patient with severe esthetic and func­
teed the preservation of sound dentition. Orthodontic tional deficiencies. Multidisciplinary treatment plan­
mesialization of the teeth with intrusion and extrusion ning can provide patients with high-quality noninva­
could also have been performed; however, the final sive treatment that results in superior esthetics.
esthetic outcome would not be the most desirable.4
Conversely, a mesiodistal and facial-palatal alignment
of the maxillary canines is completely different from
that of the maxillary lateral incisors, which hinders smile
ACKNOWLEDGMENTS
esthetics and may contribute to bite overload during
T he authors thank Dudu Medeiros for the facial photography of the
chewing.3 Correct positioning of teeth and maxillary
patient.
bone allows for better lip support and smile esthet­
ics.2 The distalization of the maxillary canines ensured
restoration of anterior guidance and occlusal function
along with the esthetic rehabilitation.4•5
Treatment planning is the key to treatment success. REFERENCES
Using a combination of three different treatment phas­ 1. Kokich OV Jr. Congenitally missing teeth: Orthodontic manage­
es, no reduction or preparation was necessary, and the ment in the adolescent patient. Am J Orthod Dentofacial Or­
thop 2002;121:594-595.
dental structures remained inta.ct. The diastema was
2. Davis NC. Smile design. Dent Clin North Am 2007;51 :299-318.
closed using an additive approach via the adhesive ce­
3. Rosa M, Zachrisson BU. Integrating esthetic dentistry and space
mentation of ceramic fragments.6.7 Recent advances in closure in patients with missing maxillary lateral incisors. J Clin
Orthod 2001;34:221-233.
bonding techniques for both teeth and ceramic guar­
4. Oquendo A, Brea L, David S. Diastema: Correction of excessive
antee the clinical success of this type of restoration.
spaces in the esthetic zone. Dent Clin North Am 2011;55:265-
After adhesive cementation of the ceramic frag­ 281.

ments, minimal facial or palatal overcontouring was 5. Okeson JP. Management of Temporomandibular Disorders and
Occlusion, ed 5. St Louis: Mosby, 2003.
observed. This overcontouring must be removed by
6. Rads MG. Minimum thickness anterior porcelain restorations.
finishing and polishi�·g at the ceramic-enamel inter­ Dent Clin North Am 2011 ;55:353-370.
face. High-speed fine diamond burs under copious 7. de Andrade OS, Kina S, Hirata R. Concepts for an ultraconser­
vative approach to indirect anterior restorations. Quintessence
water-cooling can be used to adjust the ceramic inter­
Dent Techno! 2011;34:103-119.
face. Next, intraoral ceramic polishing rubber points
were used to minimize roughness and restore smooth­
ness until achieving a surface analogous to the glazed
ceramic.6 Ceramic fragments bonded to unprepared
enamel present very few disadvantages; nonetheless,
communication between the clinician and technician is
fundamental to obtain an acceptable result.6

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 Photography has become a vital tool in dentistry.
MATERIALS AND METHODS
The primary advantage of photography is that it can
be used to record teeth-lighting interactions .15 In the A volunteer patient was selected for the clinical evalu­
case of fluorescence, however, generating a standard­ ation . Inclusion criteria were as follows: all teeth per­
ized method of photographic evaluation is not easy. fectly aligned, nonsmoking, adequate oral hygiene,
The aim of this study was to analyze the fluorescence and no dental restorations present. Contrary to natural
of the natural tooth in vivo and to compare a variety of teeth, in which dentin is the main source of the fluo­
composite resins using a standardized photographic rescence, the enamel composite resin layer (the final
procedure. layer) is the main source of fluorescence in a dental

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restoration. It has been shown that including a thin California, USA). Fifty-two indirect composite resin ve­
nonfluorescent composite resin layer as the final lay­ neers with a uniform thickness of 0.5 mm were fabri­
er14 or applying a resin sealer with a width of approxi­ cated for the maxillary right central incisor (Table 1 ).
mately 70 IJm16 can completely block the fluorescence The casts were isolated with die separator, and the
of a restoration. Therefore, only enamel-shade com­ composite resin veneers were fabricated and light-po­
posite resins were used in the present study. lymerized for 90 seconds at an output of 800 mW/cm2
A vinyl polysiloxane impression of the patient's max­ under constant monitoring.
illary arch was made, and multiple casts were poured A darkroom was specially prepared for fluorescence
in type IV stone (Velmix Stone White, Kerr, Orange, photography. A lighting device consisting of two ultra-

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REVET Al

Composite Resins Tested

Composite Resin Shades Composition Manufacturer

Filtek Supreme Plus A2B,A2E Resin matrix: bis-GMA,bis-EMA(6), UDMA, 3M ESPE,St Paul,MN,
TEGDMA USA

Fillers: combination of non-agglomerated/non-

aggregated 20-nm nanosilica filler and loosely
bound agglomerated zirconia/silica nanocluster,
consisting of agglomerates of primary zirconia/
silica particles with 5- to 20-nm fillers

Filtek Supreme Ultra A1E,A2E, Resin matrix: bis-GMA, UDMA, TEGDMA, 3M ESPE
A2B,A2D, bis-EMA(6)
A3D,A4E,
Fillers: combination of non-agglomerated/non-
A4B,B1B,
aggregated 20-nm silica filler,non-agglomerated/
B1E,AT
non-aggregated 4- to 11-nm zirconia filler,and
aggregated zirconia/silica cluster filler

Empress Direct A1E,A2E, Resin matrix: dimethacrylates lvoclar Vivadent,Schaan,

A3E,A4E, Liechtenstein
Fillers: barium glass, Ba-AI-fluorosilicate glass,
B1 E, Opal,
ytterbium trifluoride, mixed oxide, silicon dioxide,
A2D
copolymer

Enamel Plus HFO GE2 Resin matrix: bis-GMA, UDMA,butandioldimeth- Micerium,Avegno, Italy
acrylate,pigments

Fillers: glass filler silanized,silicium oxide silanized

Enamel Plus HRi UE2 Resin matrix: diurethandimethacrylate, Micerium

Iso-propyliden-bis (2(3)-hyd roxy-3(2)-4(phenoxy)
propyl-bis(methacrylate) (Bis-GMA), 1,4- Butan-
dioldimethacrylate.

Fillers: silium bioxide

Miris 2 NR,WR, IR, Resin matrix: bis-GMA, TEGDMA, UDMA Coltene/Whaledent,

WR,NT Altstatten,Germany
Fillers: Barium glass, silanized amorphous silica

Rename! Microfill Incisal Light, Resin matrix: bis-GMA, UDMA,butanediol Cosmedent, Chicago, IL,
A2 dimethacrylate USA

Fillers: strontium aluminum boron silicate, silicon

dioxide

Herculite HRV Ultra A2E Resin matrix: bis-GMA,ethoxylated bisphenoi-A- Kerr, Orange, CA, USA
dimethacrylate, TEGDMA

Fillers: barium aluminoborosilicate glass with

fumed silica

Premise A2E Resin matrix: bis-GMA,ethoxylated bisphenoi-A- Kerr

dimethacrylate, TEGDMA

Fillers: barium aluminoborosilicate glass,silica

nanofiller,proprietary prepolymerized filler (blend
of low-shrinkage resin and barium glass)

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 Fluorescence: Clinical Evaluation of New Composite Resins

Composite Resin Shades Composition Manufacturer

Esthet-X HD A2 Resin matrix: bis-GMA-adduct/ ethoxylated Dentsply/ York/ PA/ USA

bisphenoi-A-dimethacrylate/ TEGDMA

Fillers: barium aluminofluoroborosilicate glass with

silicon dioxide particles

Gradia Direct A2 Resin matrix: UDMA/ dimethacrylate comonomers GC EUROPE/ Leuven/

Belgium
Fillers: silica and prepolymerized filler

Kalore A2 Resin matrix: UDMA/ DX-511 comonomers GC EUROPE

Fillers: Dimethacrylate/ fluoroaluminosilicate glass/

prepolymerized filler/ silicon dioxide

G-aenial Anterior JE Resin matrix: UDMA dimethacrylate comonomers G·c EUROPE

Fillers: prepolymerized fillers (16-17 1-1; silica/ strontium

and lanthanoid fluoride), silica/ and fumed silica

Estelite I Ouick A2E Resin matrix: bis-GMA/ TEGDMA Tokuyama/ Tokyo/

Japan
Fill�rs: silica-zirconia/ composite resin filler

Estelite Omega A1E, A2E/ Resin matrix: bis-GMA/ TEGDMA/ dibutyl hydroxy Tokuyama
B1E/ MW, toluene/ mequinol
Trans
Fillers: silica-zirconia

Durafill A2 Resin matrix: bis-GMA/ UDMA TEGDMA Heraeus Kulzer/ South

Bend/ IN/ USA
Fillers: prepolymerized particles/ disperse silicon
dioxide/ quartz/ amorphous fu�ed silica

Durafill VS A11 A2 / A4/ Resin matrix: bis-GMA/TEGDMA, UDMA Heraeus Kulzer

B1
Fillers: silicon dioxide/ prepolymerized filler

Venus Diamond A2 Resin matrix: bis-GMA/ TEGDMA Heraeus Kulzer

Fillers: barium aluminum boron fluoride silica glass

with silicon dioxide particles

Opallis A2E Resin matrix: bis-GMA bis-EMA TEGDMA/ UDMA FGM/ Joinville, Brazil

Fillers: barium aluminum boron fluoride silica glass

Amaris TN Resin matrix: bis-GMA/ UDMA/ TEGDMA VOCO/ Cuxhaven/

Germany
Filler: silica glass

Clearfil Majesty A2E Resin matrix: bis-GMA/ TEGDMA Kuraray/ Okayama/

Esthetic Japan
Filler: barium glass

Amelogen Plus EN Resin matrix: bis-GMA-adduct/ UDMA Ultradent/ South

Jordan/ UT/ USA
Fillers: strontium boroaluminasilicate glass silicon
dioxide particles

Tetric Evo-Ceram A2E Resin matrix: bis-GMA, UDMA/ ethoxylated bis-EMA lvoclar Vivadent

Fillers: filler ytterbium trifluoride/ barium glass fillers/

mixed oxides

bis-GMA = bisphenol glycidyl methacrylate; TEGDMA = triethyle ne glycol dimethacrylate; UDMA = urethane dimethacrylate; bis-EMA = bisphenol A polyethyl­
ene glycol diether dimethacrylate.

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 tripod (Manfrotto, Cassola, Italy), and the location and
Standardized Photographic Settings distance of the camera from the patient's mouth were
for Clinical Evaluation of Fluorescence
standardized. All photographs were taken wirelessly to
Magnification 1:2 avoid any vibration.
Bilateral cheek retractors were placed on the pa­
Speed· 1/4
tient, and each light source was positioned 20 em
Aperture 9 from the camera, the patient's teeth, and the other

ISO 400
light source. This distance was selected based on the
distance of a typical social conversation. After numer­
White balance 4,000 K
oUs attempts to accurately capture the patient's teeth,
Size Large the camera settings were calibrated according to the
(3,888 X 2,592 pixels) parameters shown in Table 2. Each composite resin
Image quality RAW veneer was placed over the right maxillary central inci­
sor using the patient's saliva as the connecting agent.
No dental adhesive was used to avoid optical interfer­
ence. The patient was instructed to occlude carefully,
and photographs were taken according to the stan­
dardized method described above. All photographs
violet (UV) lamps (Sylvania S18W/BLB, Danvers, Mas­ of the individual veneers were taken at intervals of 10
sachusetts, USA) was fabricated and positioned over minutes to avoid dehydration of the teeth and pos­
the patient. A digital single-lens reflex camera (Can­ sible changes in fluorescence. The images were evalu­
on EOS 4000 with a 1 OO-mmlf.28 USM macro lens, ated for composite resin veneer fluorescence accord­
Canon, Tokyo, Japan) was used for the photographic ing to composite resin type, shade, and translucency
evaluation. The equipment was attached to a sturdy in comparison to the natural dentition (Fig 3).

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 Fluorescence: Clinical Evaluation of New Composite Resins

• Classification of Composite Resin Fluorescence

Fluorescence

Composite resin Low Optimal Exaggerated Incorrect

Durafill X

Filtek Supreme Plus X

Empress Direct X

Enamel Plus H FO X

Renamel Microfill X

Esthet-X HD X

Estelite I Quick X

Durafill VS X

Opallis X

Amaris X

Clearfil Majestic X

Filtek Supreme Ultra X

Estelite Omega X

G-aenial anterior X

Tetric EvoCeram X

Kalore X

Venus X

Amelogen Plus X

Miris 2 X

Gradia X

Venus Diamond X

Enamel Plus HRi X

Herculite HRV Ultra X

Premise X

RESULTS fluorescence as follows: low, optimal, exaggerated,

and incorrect (Table 3). Low fluorescent composite
Significant differences were found in the clinical fluo­ resin displayed low value and a dark bluish aspect.
rescence of the tested composite resins compared to Low florescence was found only in older generations
natural teeth. T he results were classified in terms of of composite resins (Fig 4). Many composite resins ex-

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hibited fluorescence close to that of natural teeth (Figs optimal (Fig 5), optimal (Fig 6), and high-optimal (Fig
5 to 7). However, within the acceptable fluorescence, 7) depending on the composite resin's composition,
a range of hues and luminosities was observed. Thus, luminophore dyes, chroma, and translucency. Some
optimal fluorescence could be subcategorized as low- of the composite resins revealed exaggerated fluores-

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cence (Fig 8). Composite resins with exaggerated fluo­ rect fluorescence, meaning that the fluorescent hue
rescence exhibited higher fluorescence than natural was discrepant from the natural tooth (Fig 9). Herculite
teeth, with a white-bluish hue and significant increase XRV Ultra and Premise exhibited a strong whitish-blue
in value. Finally, a few composite resins showed incor- fluorescent hue, whereas Enamel Plus HRi (Micerum)

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exhibited a vivid azure bluish fluorescent hue, both of aggerated or even to incorrect. Current dentin-shade
which are unlike the fluorescent hue of natural teeth. composite resins were less fluorescent than enamel or
Fluorescence was highly de pendent on the comp o­ translucent shades. Chroma negatively affected the
sition and manufacturer of the composite resins tested fluorescence of comp osite resins; as chroma increased,
(Figs 4 to 9). Newer generations of composite resin the fluorescence decreased (Fig 11 ). For instance, an
-
exhibited substantial improvements in fluorescence A1 shade composite is more fluorescent than an A4
compared to older generations. Significant differences shade composite from the same manufacturer, irre­
in fluorescence were observed within the same manu­ spective of the composite's translucency. The fluores­
facturer and within the same brand (Fig 1 0). cence of achromatic enamel composites is dependent
The fluorescence of composite resins is also greatly of their composition, which can range from low o ptimal
influenced by translucency, chroma, and value. Trans­ (see Fig Se), to exaggerated (see Fig 8b), to incorrect
lucency played a major role in fluorescence (Fig 1 0). fluorescence (see Fig 9c). In addition, value affects the
Within the same composite resin sy stem, highly trans­ fluorescence of most tested comp osites. Our findings
lucent shades showed increased fluorescence, causing showed that the higher the value, the more fluorescent
changes in the fluorescence rating from optimal to ex- is the composite.

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----------·------------
DISCUSSION components, age, and biotype. These many factors
make fluorescence one of the most difficult optical
The ideal esthetic restorative material must have char­ properties to replicate artificially.
acteristics similar to the reflection and fluorescent The fluorescence found in composite resins is at­
light dispersion found in the natural tooth. This clinical tained by incorporation of fluorescent (luminophore)
evaluation showed a lack of standardization of fluores­ dyes.11•22 �owever, it is very difficult to correctly repro­
cence for different composite resins. Only a few com­ duce the luminescent spectrum of enamel and dentin
posite resins showed acceptable fluorescence. The re­ in terms of color and intensity. Rare elements are often
sults of this investigation allow for the classification of used as luminiferous, including terbium, cerium, ytter­
composite resins based on their fluorescence. bium, and europium; however, none of these can truly
All vital teeth show bluish-whitish fluorescenceY reproduce the blue-mauve fluorescence of natural
Fluorophores are responsible for the fluorescence in teeth. Thus, adjustment of the amount of fluorophores
natural teeth. The chemical nature of fluorophores var­ is necessary to achieve fluorescence similar to that of
ies widely in both organic and inorganic components.8 the natural dentin.23 Generally, when the saturation
Dentin fluorescence is three times more fluorescent and/or chromaticity of the color increase, the fluores­
than that of enamel.18 The higher organic content of cence decreases.24 Fluorescence is highly dependent
the dentin (especially the collagen fibers) is respon­ on the type of pigments and opacifying agents used to
sible for this optical phenomenon.19 mimic the optical characteristics of natural teeth.
Studying fluorescence is a complex task because Fluorescent UV tubes covered with special phos­
fluorescence is lost after extraction unless fixation phorus (Wood's coating) absorb the larger portion of
procedures are performed. Fixation of the collagen visible light and emit UV rays over a long distance.
proteins and their components is technique-sensitive These tubes are violet in color, and the light they pro­
but essential to study fluorescence.20·21 Moreover, duce is commonly known as "black light." Fluorescent
other dentinal components are responsible for dental UV tubes are a useful source of UV radiation for studies
fluorescence, including minerals, pyrimidine, trypto­ of fluorescence.25
phan,4·5 pyridinoline, and hydroxylapatite-pyridinoline A fluorescent composite resin will exhibit higher lu­
complex.8 Therefore, fluorescence is a multifactorial minosity than nonfluorescent or low-fluorescent com­
phenomenon based on multiple organic and inorganic posite resins of the same color.13 Lee26 showed that UV

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light emitted from a light source influences the color 7. Alfano RR, Lam W, Zarrabi HJ, et al. Human teeth with and with­
out caries studied by laser scattering, fluorescence, and absor­
not only of the composite resin, but also of the tooth.
tion spectroscopy. IEEE J Quantum Electr 1984;20;1512-1515.
When fluorescence is absent, the restoration will show 8. Fukushima Y, Araki T, Yamada MO. Topography of fluorescence
decreased luminosity.9 Therefore, it is desirable that and its possible composites in human teeth. Cel Mol Biol 1987;33:
725-736.
composite resins emulate the fluorescent behavior of
9. Lee YK, Lu H, Powers JM. Fluorescence of layered resin com­
the natural tooth and minimize metamerism.11,27 - posites. J Esthet Rest Dent 2005;17:93-100.
Matching the fluorescence of composite resins with 10. Panzeri H, Teixeira L, Minelli CJ. Spectral fluorescence of direct

that of natural teeth is complicated because each tooth anterior restorative materials. Aust Dent J 1977;22:458-461.
11. Miller MB. Composite resin fluorescence. J Esthet Restor Dent
has its own fluorescence and each restorative system has
2004;16:335.
a determined level of fluorescent pigments. Therefore, 12. Lee YK, Lu H, Powers JM. Changes in opalescence and fluores­
the clinician must have thorough knowledge of the fluo­ cence properties of resin composites after accelerated aging.
Dent Mater 2006;22:653-660.
rescent characteristics of the restorative system used.14
13. Lee YK, Lu H, Powers JM. Influence of fluorescent and opales­
Esthetic restorative materials should perfectly simu­ cent properties of resin composites on the masking effect. J
late the optical properties of the natural tooth. This Biomed Mater Res B Appl Biomater 2006;76:26-32.
14. Sensi LG, Marson FB, Hawerroth T, Baratieri LN, Monteiro S.
optical behavior is highly influenced by the inter­
Fluorescence of composite resins: Clinical considerations. Quin­
action of light with the dental components and soft tessence Dent Techno! 2006;29:43-53.
tissues.17•22•24•28 Fortunately, the importance of fluores­ 15. Magne P, SoWS. Optical integration ofincisoproximal restorations

cence in esthetic dental materials is becoming more using the natural layering concept. Quintessence lnt 2008;39:
633-643.
recognized, particularly because of its effect on the lu­
16. Lee YK, Lu H, Powers JM. Effect of surface sealant and stain­
minosity of a restoration. ing on the fluorescence of resin composites. J Prosthet Dent
2005;93:260-266.
17. Magne P, Holz J. Stratification of composite restorations: Sys­
tematic and durable replication of natural aesthetics. Pract Peri­
odontics Aesthet Dent 1996;8:61-68.
CONCLUSIONS 18. Monsenego G, Burdairon G, Clerjaud B. Fluorescence of dental
porcelains. J Prosthet Dent 1993;69:106-113.

Few of the available composite resins can perfectly 19. Perry A, Biel M. A comparative study of the native fluorescence
of human dentine and bovine skin collagen. Arch Oral Bioi
match the fluorescence of a natural tooth. Fluorescence
1969;14:1193-1211.
is significantly affected by composite type, shade, 20. Matsum�to H, Kitamura S, Araki T. Autofluorescence in human
translucency, chroma, and value. A standardized photo­ dentine in relation to age, tooth type and temperature mea­
sured by nanosecond time-resolved fluorescence microscopy.
graphic procedure is fundamental to study and critically
Arch Oral Biol 1999;44:309-318.
analyze the fluorescence of different restorative materi­ 21. Matsumoto H, Kitamura S, Araki T. Applications of fluorescence
als in vivo. Manufacturers of esthetic composite resins microscopy to studies of dental hard tissue. Front Med Bioi Eng
2001;10:269-284.
must find a way to better reproduce the fluorescence of
22. Vanini L. Light and color in anterior composite restorations.
natural teeth to facilitate their selection and use. Pract Periodontics Aesthet Dent 1996;8:673-682.
23. Magne P, Belser U. Natural oral esthetics. In: Bonded Porcelain
Restorations in the Anterior Dentition: A Biomimetic Approach.
Chicago: Quintessence, 2004:86-87.

24. Chu SJ, Ahmad I. Light dynamic properties of synthetic, low­

REFERENCES fusing, quartz glass-ceramic material. Pract Proced Aesthet
Dent 2003;15:49-56.
1. Benedict HC. Note on the fluorescence of teeth in ultra-violet
25. Langford M, Bilissi E. Special techniques. In: Langford M, Bilissi
rays. Science 1928;67:442.
E (eds). Langford's Advanced Photography, ed 7. Oxford: Focal
2. Hartles RL, Leaver AG. The fluorescence of teeth under ultravio­
Press, 2008:310-314.
let irradiation. Biochem J 1953;54:632-638.
26. Lee YK. Influence of the changes in the UV component of illumi­
3. Armstrong WG. Fluorescence characteristics of sound and cari­
nation on the color of composite resins. J Prosthet Dent 2007;
ous human dentin preparations. Archs Oral Bioi 1963;8:79-90.
97:375-380.
4. Hoerman KC, Mancewicz SA. Fluorometric demonstration of
27. Sant'Anna Aguiar Dos Reis R, Casemiro LA, Carlino GV. Evalua­
tryptophane in dentin and bone protein. J Dent Res 1964;43:
tion of fluorescence of dental composites using contrast ratios
276-280.
to adjacent tooth structure: A pilot study. J Esthet Restor Dent
5. Foreman PC. The excitation and emission spectra of fluorescent 2007;19:199-206.
components of human dentine. Archs Oral Biol 1980;25:641-647.
28. Dietschi D. Free-hand composite resin restorations: A key to
6. Ten Bosch JJ, Booij MA. Fluorescent compound in bovine den­ anterior aesthetics. Pract Periodontics Aesthet Dent 1995;7:15-
tal enamel'matrix compared with synthetic dityrosine. Arch Oral 25.
Bioi 1982;27:417-421.

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 odern dental technology and materials have
CASE REPORT
M promoted new treatment strategies, includ­
.
ing the use of an extended provisional phase
to better determine the functional and esthetic as­
A 16-year-old patient diagnosed with dentinogen­
esis imperfecta type II was seen at the Department of
pects of a specific case. This case report illustrates the Prosthodot;�tics, Ludwig-Maximilians-University, Munich,
complex rehabilitation of a generalized hard tissue de­ Germany (Figs 1 a to 1 f). Dentinogenesis imperfecta
fect of a young patient using lithium disilicate glass­ · is an autosomal dominant genetic trait that affects
ceramic. Computer-aided design/computer-assisted both primary and permanent teeth 1.2; it is character­
manufacture (CAD/CAM)-fabricated long-term provi­ ized by yellow-brown or bluish-gray hard tissue discol­
sional restorations made of high-performance polymer oration. The dentin malformation is caused by a defect
(Vita CAD-Temp, a high-molecular, cross-linked acrylic in the dentin sialophosphoprotein (DSPP) gene. DSPP
polymer containing 14 wt% microfillers, Vita Zahnfab­ is involved in the formation of noncollagen proteins
rik, Bad Sackingen, Germany) were used during the in dentin.3A Afflicted patients tend to have enamel
patienfs growth phase to allow for long-term verifica­ defects that lead to dentin exposure and accelerated
tion of the restorative plan. This strategy enhanced the attrition.5 Radiographs show bulbous crowns, short
predictability of the definitive lithium disilicate glass­ roots, and progressive obliteration of the root canal
ceramic restorations. system.3•6
This case presented a particular challenge because
of the young age of the patient, who had not finished
the growth stage. Therefore, the planned treatment
1Dental Technician, Innovative Dentaldesign Oliver Brix,
Wiesbaden, Germany.'
involved two phases. The first phase aimed to quickly
2Tenured Associate Professor, Department of Prosthodontics, improve esthetics, provide adequate functional mor­
Dental School, Ludwig-Maximilians-University, Munich, Germany. phology, adjust the vertical dimension of occlusion
(VDO), and obtain canine/anterior guidance. The sec­
Correspondence to: Oliver Brix, Innovative Dentaldesign Oliver
Brix, Dwight-D. Eisenhowerstrasse 9, 65197 Wiesbaden, Germany.
ond phase aimed to provide adhesively bonded de­
Email: Oliver-Brix@t-online.de finitive restorations for the compromised hard tissues.

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BRIX/EDELHOFF

Figs 1 a to 1f Initial presentation:

dentinogenesis imperfecta type II
with significant hard tissue damage
and an obvious need to restore the
vertical dimension of occlusion.

Treatment Planning Press copings (shade MO 0) veneered with IPS e.max

Ceram veneering porcelain.
The connection between enamel and dentin was com­ Detailed planning and execution are essential for
promised due to dentin malformation. Therefore, non­ complex restorations with significant modifications of
invasive bonded restorations were not feasible. The functional and esthetic conditions. The following clini­
IPS e.max system (lvoclar Vivadent, Schaan, Liechten­ cal sequence was planned:
stein) was selected because of its material toughness,
flexible luting possibilities, and esthetic potential. The • Photographic records and arbitrarily mounted casts
posterior teeth received full crowns using IPS e.max • Diagnostic wax-up/thermoformed template
Press LT, while the anterior teeth received IPS e.max • Mock-up using the thermoformed template

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 Esthetic and Functional Rehabilitation of a Patient with Dentinogenesis lmperfecta

Figs 2a to 2d Diagnostic wax-up to determine functional and esthetic parameters and establish canine­
guided occlusion at 47 degrees for clear disocclusion.

• Transfer of the wax-up with increased VDO to a Clinical and Laboratory Procedures
modified Michigan splint for 8-week functional eval­
uation The photographic records were sent to the dental tech­
• Tooth preparation guided by the diagnostic tem­ nician for analysis. The casts were arbitrarily mounted,
plate and the VDO was increased by 2.5 mm. The diagnostic
• Precision impression and ,alternating bite registra­ wax-up included all teeth to better clarify the esthetic
tion according to the separated Michigan splint requirements and possibilities. The desired dynamic
• Scanning of the wax-up and fabrication of identical occlusion with canine/anterior guidance was included
CAD/CAM long-term provisionals in the wax-up (Fig 2). This step is the cornerstone of
• Twelve-month clinical trial of the long-term provi­ such a treatment because only the wax-up can enable
sionals a preview of all parameters.
• Definitive maxillary restorations mounted against An impression of the wax-up was made, and casts
the mandibular provisionals of the arches were fabricated to duplicate the wax-up.
• Fabrication of definitive maxillary restorations Hard and highly translucent thermoplastic sheets (Du­
• Adhesive insertion of the definitive maxillary restora­ ran 0.5 mm, hard-transparent, Scheu-Dental, lserlohn,
tions Germany) were thermoformed on the duplicate casts.
• Similar procedure for mandibular restorations These patterns 'are ideal for a mock-up to ass.ess the
preparation and the fabrication of provisionals.

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BRIX/EDELHOFF

Figs 3a and 3b Reproduction of the wax-up us­

ing thermoplastic splints to visualize the desired
treatment.

Figs 4a to 4c CAD/CAM-produced long-term

provisiona Is.

Fig 5 Identical duplication of the wax-up into

the provisionals via scanning. (Dental technician:
Josef Schweiger, LMU, Munich, Germany.)

To visualize the wax-up, templates were filled with transferred, and the vertical relation was recorded us­
a bisphenol glycidyl methacrylate (bis-GMA)-based ing a segmented Michigan splint. The in-house dental
provisional restoration material and placed into posi­ laboratory fabricated CAD/CAM long-term provision­
tion in the mouth (Fig 3). This step helps to assess the als from high-performance polymer plastic (Figs 4 and
esthetic demands of all parties involved. 5). The provisionals were made identical to the wax-up
After preparation and soft tissue healing, impres­ via scanning procedures. The crowns of the long-term
sions were taken in both arches, facebow records were provisionals were splinted into segments of three to

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 Esthetic and Functional Rehabilitation of a Patient with Dentinogenesis lmperfecta

Fig 6 Atraumatic preparation of the heavily

discolored abutments.

Figs 7a and 7b Sequential bite registration

using a bis-GMA-based material.

Fig 7c Crown lengthening procedure with an

oscillating instrument to adjust the gingival
contour.

four units and luted with glass-ionomer cement to pre­ At the conclusion of the provisional phase, a new
vent loosening of the provisionals from the relatively set of study casts was made and mounted as a first
short abutment teeth. step toward definitive restoration. The maxillary pro­
The long-term provisionals allowed the patient to visionals were removed in segments. Figure 6 shows
evaluate the esthetics and function. The provisionals the prepared anterior teeth, the perfectly conditioned
were left in place for 1 year, during which time they gingiva, and the severely discolored abutment teeth.
were initially checked monthly and then in intervals Maxillomandibular registration records were fabricat­
of 3 months. Small corrections were performed as ed to determine the position of the prepared teeth
needed, eg, minimally invasive crown lengthening for against the mandibular provisionals (Fig 7).
the maxillary left central incisor using oscillating instru­ Master casts were mounted using a facebow (Figs 8
ments. and 9), and a so-called cross-mounting was performed:

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201-2
I
BRIX/EDElHOFF

Figs Sa to Be Mounted casts of the provisionals.

Figs 9a and 9b The occlusal surfaces do not show any abrasion marks/ which is a testament to the
precision and quality of the material used.

the master cast of the prepared maxillary teeth was and injected into the lubricated silicone registration.
mounted against a cast of the mandibular provision­ The hardened wax forms a perfect copy of the provi­
als/ followed by mounting of the maxillary provisionals sionals (Fig 13). The benefits of this method are a sig­
against the mandibular provisionals (Fig 1 0). nificant time savings and the exact conversion of the
The relationship of the mounted provisionals was already tried-in morphology and occlusion of the pro­
recorded with a silicone bite record. This record was visionals. Figure 14 shows the adjusted posterior teeth
used again to orient the maxillary master cast (Figs 11 and wax copings of the anterior teeth. Due to lack of
and 12). Molten casting wax was drawn into a syrin"ge retention/ the individual crowns were splinted in pairs

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 Esthetic and Functional Rehabilitation of a Patient with Dentinogenesis l mperfecta

Figs 1 Oa and 1 Ob Master casts mounted using

the cross-mounting approach.

Fig 11 Occlusal surface of the provisionals regis­

tered with a silicone key.

Figs 12a and 12b The maxillary master cast and

silicone key before application of liquid wax.

Figs 13a and 13b After removal of the silicone

key, the wax accurately reproduced the occlusal
morphology of the provisionals.

Figs 14a and 14b The previously tested mor­

phology was exactly duplicated.

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 BRIX/EDELHOFF

15 16

17a

17b

Fig 15 After placement of the copings on the master cast, only small details need to be corrected.

Fig 16 The posterior restorations were pressed with IPS e.max Press LT, and the anterior copings with IPS e.max Press
MO 0.

Figs 17a and 17b Homogenous and accurate results after pressing.

and in groups of three in the posterior and anterior the master cast (Fig 15), the material’s precise render-
regions, respectively. All wax copings were pressed ac- ing of esthetic details and homogeneity are evident.
cording to the manufacturer’s guidelines. Anterior cop- The anterior copings were shaped similarly to the
ings were pressed with IPS e.max Press MO 0, while provisionals by using a silicone key and individually
posterior teeth were pressed with IPS e.max Press LT layered IPS e.max Ceram (Fig 16). Figure 17 shows
A2. After pressing, divesting, and trial placement on the finished, as yet unpolished anterior crowns in an

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 Esthetic and Functional Rehabilitation of a Patient with Dentinogenesis Imperfecta

18 19

20

Fig 18 Predictable results for the anterior restorations

were facilitated by the silicone key.

Fig 19 The anterior crowns before final glaze firing.

Fig 20 A clear advantage of the IPS e.max system is the

potential for corrections of the pressed crowns by add-
ing incisal porcelain mass.

Fig 21 Double-stacked honeycomb sagger trays allow

for higher placement in the oven and thus better control
during firing.

Figs 22a and 22b The finished restorations on the cast

demonstrating perfect shade match. 21

22a 22b

unsectioned solid cast. Incisal mass was added to the ability to apply corrections to all components using
buccal surfaces of the premolars to create a smooth layering porcelain makes the IPS e.max system very
transition from canines to molars (Figs 18 to 21). The user friendly (Fig 22).

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 BRIX/EDElHOFF

Fig 23 Manual polishing.

Figs 24a to 24c Anatomically pressed posterior crowns

after glaze firing and polishing.

Fig 25 Maxillary restorations.

Figs 26a to 26c Maxillary restorations mounted in an ar­

ticulator against the long-term mandibular provisionals.
This concludes the first phase of the rehabilitation.

Final Restorations the mandibular provisionals. All restorations were ad­

hesively luted with Variolink II (lvoclar Vivadent) with­
While the anterior restorations were polished for a nat­ out further adjustments.
ural glaze (Fig 23), the posterior restorations were fired After several weeks, the restorations for the man­
for coloring and glazing (Figs 24 and 25). Figure 26 dibular teeth were fabricated in a similar fashion and
shows the finished maxillary restorations in relation to inserted (Figs 27 to 29). Figures 30 to 32 show the

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 Esthetic and Functional Rehabilitation of a Patient with Dentinogenesis l mperfecta

Fig 27 The second phase begins with the

sectional mandibular cast and additional cross­
mounting.

Figs 28a to 28e After impression-taking of the

maxilla, the cast reveals all relevant details and
provides a perfect foundation for the mandibu­
lar restorations.

Figs 29a to 29c The mounted casts.

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BRIX/EDElHOFF

Figs 30 and 31 Finished mandibular restorations. Note the dynamic optical effects.

Figs 32a to 32c Final check in the articulator.

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 Esthetic and Functional Rehabilitation of a Patient with Dentinogenesis lmperfecta

Figs 33a to 33d Close-up view of the functional concept, highlighting the collaboration between the
dentist and technician.

complete mandibular restorations. All crowns for for adjustment, and the patient was immediately
the mandible were fabricated in the same way as placed into a recall program. Figures 34 to 37 show the
described earlier to complete the case (Fig 33). The final result.
mandibular crowns were inserted without any need

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 BRIX/EDELHOFF

Fi gs 34a and 34b Finished and bonded maxillary and mandibular restorations.
F igs 35a to 35h Definitively luted restorations.

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 Esthetic and Functional Rehabilitation of a Patient with Dentinogenesis lmperfecta

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BRIX/EDELHOFF

Figs 36a to 36c Sequence of treat­

ment: (a) initial situation, (b) provi­
sional phase, (c) definitive restora­
tion.

Fig 37 Extraoral view with the lips

partly open showing the excellent
esthetic result.

CONCLUSION REFERENCES
1. Delgado AC, Ruiz M, Alarcun JA, Gonz<;lez E. Dentinogenesis
The successful result of this unusual clinical case is a
imperfecta: The importance of early treatment. Quintessence
testament to the collaboration and disciplined group lnt 2008;39:257-263.
effort of the dental team. Lithium disilicate glass­ 2. Shields ED, Bixler D, EI-Kafrawy AM. A proposed classification
for heritable human dentine defects with a description of a new
ceramic, which has a flexural strength of 400 MPa, pro­
entity. Arch Oral Bioi 1973;18:543-553.
vided the foundation for long-term success. Both the 3. Kim JW, Simmer JP. Hereditary dentin defects. J Dent Res 2007;
esthetics and function were successfully restored. 86:392-399.
4. MacDougall M. Refined mapping of the human dentin sialo­
phosphoprotein (DSPP) gene with the critical dentinogenesis
imperfecta type II and dentin dysplasia type II loci. Eur J Oral
Sci 1998;1 06:227-233.
5. Croll TP, Sasa IS. Carbamide peroxide bleaching of teeth with
ACKNOWLEDGMENT dentinogenesis imperfecta discoloration: Report of a case.
Quintessence lnt 1995;26:683-686.
The authors thank Josef Schweiger, CDT, Department of P rostho­
6. Cage JP, Symons AL, Romaniuk K, Deley TJ. Hereditary opal­
dontics, Ludwig-Maximilians-University, Munich, for the fabrication
escent dentine: Variation in expression. J Dent Child 1991;58:
of the CAD/CAM long-term provisionals.
134-139.

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 he smile is undoubtedly a great means of com­ The construction of a beautiful, natural smile de­

T munication. Its impact on an individual's appear­

ance is immeasurable; it can directly affect one's
social life and psychological well-being.1•2 Thro� gh
pends· on how the dental professional identifies the
esthetic problems and understands the patient's ex­
pectations. Accurately diagnosing these problems,
cosmetic dentistry we can help deliver a beautiful applying the principles of esthetics, and developing
smile by reproducing and integrating restorations so artistic sensibility are essential for clinical success.3 But
that our work becomes imperceptible. the greatest challenge is to meet all of these require­
ments with ease and functionality.
An esthetic resolution is accomplished only through
1Graduate Resident/ Master of Science in Dentistry/ Federal the use of effective parameters based on clinical ob­
University of Santa Catarina/ Florian6polis/ Brazil.
servations. The dental professional can minimize the
2Professor/ Department of Dentistry/ Federal University of Santa
subjectivity of esthetics by observing the shape, tex­
Catarina/ Florian6polis/ Brazil.
3Professor/ Department of Dentistry/ Federal University of Santa ture, and color of teeth in detail (microesthetics) and
Catarina/ Florian6polis/ Brazil. correlating these features to the whole in a broader
view (macroesthetics), which includes factors related
Correspondence to: Dr Ivan Contreras Molina/ Privada Plan de
to the harmony of the teeth as a whole, gingival archi­
ayutla #39/ Colonia Chapultepec sur/ CP 58260 Morelia/ Mexico.
Email: dr.ivancontreras@gmail.com tecture, and esthetics of the periodontium.4

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 The degree of roughness or smoothness of the Similar to shape, the appearance of texture is in­
tooth surface is determined by horizontal (perikymata) fluenced by light .behavior. Smooth surfaces reflect
and vertical elements (developmental lobes), as well little, making the teeth look darker. When areas are
as by defects or depressions. Young teeth have more textured, the light is reflected in various directions, re­
surface details, whereas adult teeth present smoother, sulting in optically clear surfaces. This strategy can be
flat facial surfaces due to physiological wear. When used to influence the overall appearance of a restora­
necessary, a�e-related features should be included in tion, yielding more natural-looking areas, with reflec­
restorations.9 tion and brightness effects.

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 c 0 0 r

Along with shape and texture/ color makes up the Shade selection of a natural tooth is a complex pro­
triad responsible for dental esthetics. Tooth polychro­ cess because it involves subjective factors that depend
matism is directly affected by the thickness and com­ directly on the observer/ light source/ and the object.
position of tissues. Dentin has a role in the reflection The surrounding tissues/ the time of observation and
/
of light/ being primarily responsible for the shade of weather conditions/ the observer s visual condition
natural teeth/ due to its high saturation and low trans- and experience/ as well as the shade guide used may

lucency. Since enamel is rich in minerals/ it behaves change the perceived color. For standardization/ shade
like a translucent object/ allowing light to pass through guides have been made following MunseWs11 color
it/ come back/ and re�ch dentin/ resulting in light scat­ parameters. In these shade guides/ the color name is
tering. Thus/ these two layers provide different optical known by hue (basic color)/ chroma (saturation)/ and
effects/ creating an esthetic result that is unique in the value (brightness).
human body.10

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 Despite the unique and fantastic features of the prehensively. In this analysis, several aspects must be
natural teeth, dentistry should not be limited to restor­ considered: alignment and proportion of dental incisal
ing form and function of teeth, but also to creating es­ curvature, dental midline, axi"al inclinations, buccal cor­
thetics through an expressive and pleasant smile that ridor, smile line, and interdental embrasures. A care­
is harmonious to the lifestyle, profession, and status ful analysis of these aspects will allow the esthetic and
of the patient. Therefore, after the individual dental harmonious dentofacial integration.
appraisal, it is imperative to analyze the teeth com-

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 Micro and Macro Dental Esthetics: The Key to Smile Individualization

The gingival concave arch, gingival zenith, and in­ has a high smile line. Healthy gingival tissue, with sym­
terdental papilla form the gingival architecture. In a metrical contour and height, is the ideal tissue frame
pleasant smile, a regular and continuous gingival con­ for the dental elements.4 If the frame is not appropri­
tour should exist. Changes in this relationship compro­ ate, the desired esthetic success of properly restored
mise the esthetic balance, especially when the patient teeth will not be achieved.

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 The Definitive Guides to
Tooth Mor holo��
Nature's Morphology: An Atlas of Tooth Shape
and Form
Shigeo Kataoka and Yoshimi Nishimura
To attain esthetic ceramic restorations, the dental technician must be able to
recreate tooth morphology in its variety and nuance. This beautifully illustrated
atlas focuses on mastery of anterior tooth morphology from the point of view of
the dental technician. Written by world-renowned ceramists, this book guides
technicians from a basic understanding of crown shapes to identification of the
Shig>o Kataoka 0 Yo.himi Nishimur.t
lobes that compose the tooth, the subtle transitions between lobes, and the keys
to surface texture. An essential book for every technician.

Contents
Fundamentals of Tooth Morphology • Characteristics of Tooth Morphology • The
1 00 pp; 336 illus (298 color);
Effect of Aging on Tooth Morphology • Contouring a Single Ceramic Restoration
ISBN 978-0-86715-411-5 (B411X); US $78 • Contouring a Multi-Unit Fixed Partial Denture

Challenging Nature
Paulo Kano
Fabrication of posteriqr prosthetic teeth is an art that requires techni­
cians to reproduce the minute details of occlusal form using difficult
methods of wax-up. This unique atlas will change the way that tech­
nicians wax up teeth. It guides readers, step-by-step, through the
author's revolutionary wax-up technique to re-create the complex
morphology of premolars and molars. The accompanying text pro­
vides straightforward explanations of all techniques. Lavishly illus­
trated throughout, each chapter builds technical knowledge with
chapters on nomenclature, morphology, wax handling and applica­
tion, functional wax-up sequences for maxillary and mandibular den­
tition, and adhesive cementation and culminates in a series of
impressive clinical cases. A must-have resource for any dental tech­
nician wanting to review occlusal form and improve the functional
morphology of posterior restorations.
630 pp (approx); 1,600 color illus (approx); ISBN 978-1-85097-203-7
Contents (B9062); us $280
Nomenclature • Morphologic Characteristics • Wax-Up Training
Exercises • Maxillary Teeth with Antagonists • Mandibular Teeth
with Antagonists • Clinical Cases • Cementation

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 he const9nt evolution of dental materials and however, truly successful results have been elusive. The

T techniques has made it possible to effectively

restore tooth form and function using a mini­
mally invasive approach. However, the final esthetic
aim of this article is to present a novel concept: Visa­
gism.5·6 The Visagism concept helps dental clinicians
provide re�torations that account not only for esthetics,
results may fail to meet the patient's expectations but also for the psychosocial features of the created im­
due to disharmony between the smile design and the age, which affect patients' emotions, sense of identity,
patient's personality. The patient may feel that the behavior, and self-esteem. These factors, in turn, affect
restored teeth do not really "belong" to him or her. how observers react to patients following treatment.
Without the proper knowledge, the origin of this dis­
harmony can be difficult to identify.
For decades, dental clinicians have sought to harmo­
nize the shapes of the teeth with the entire face based
THE CONCEPT OF VISAGISM
on parameters such as gender, personality, and age 1-4;
Derived from the French visage, meaning "face," the
concept of Visagism was never precisely defined un­
til it was expanded and developed by the artist Philip
Hallawell.5·6 Visagism involves the creation of a custom­
1Private Practice, Barbacena, Brazil.
ized personal image that expresses a person's sense
2Private Practice, Sao Paulo, Brazil.
of identity. The method used to apply this concept is
3Private Practice-Well Clinic, Sao Paulo, Brazil.

4Private Practice, Istanbul, Turkey. derived from the association of the principles of artis­
5Dental Technician, Well Lab, Sao Paulo, Brazil. tic visual language with disciplines such as psychology,
6Artist, Atelier Sao Paulo, Brazil. neurobiology, anthropology, and sociology. Visagism
makes it possible to determine which emotions and
Correspondence to: Dr Braulio Paolucci, Rua Rodrigues Alves, 53,
personality traits patients wish to express through their
Barbacena, MG, Brazil 36.200-000. Email: braulio@brauliopaolucci.
com.br appearance and, specific to dentistry, through their

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PAOlUCCI ET Al

Fig 1 Choleric/strong tem­ Fig 2 Sanguine/dynamic Fig 3 Melancholic/sensitive Fig 4 Phlegmatic/peaceful

perament: determined, ob­ temperament: extroverted, temperament: organized, temperament: diplomatic,
jective, explosive, intense, expansive, communicative, meticulous, perfectionist, pacifist, mystic, and spiritual,
and passionate. joyful, full of life, and enthu­ timid, reserved, and with but with a tendency to be
siastic . a great capacity to think apathetic and conformist.
abstractly.

smile. With the Visagism concept, clinicians can de­ brain recognizes an archetype, recent research has
sign a smile that blends the patient's physical appear­ explored how these symbols are processed mentally
ance, personality, and desires. One of most significant and how they affect the viewer.? The neuroscientist
challenges is to uncover these personality traits and Joseph LeDoux discovered that the limbic system is
desires in order to translate them into natural tooth not responsible for the creation of emotions, as was
shapes in psychodentofacial harmony. The achieve­ commonly assumed. Several autonomous systems are
ment of this goal is what we call beauty. associated with basic survival functions, indicating that
the visual ,thalamus is capable of recognizing arche­
types that trigger the systems that generate emotions. 8
Archetypical Symbols and the This would explain why an image always provokes an
immediate emotional reaction, as observed by many
Emotional Brain
researchers and artists. When an individual observes an
Carl Jung spent the final years of his life researching image, the emotional brain first perceives it as a com­
different cultures and civilizations. He discovered that bination of lines, shapes, and colors that have specific
certain symbols and images have been used in all cul­ meanings. Only afterward, once the visual cortex is
tures with the same meaning. Jung created the term stimulated, is the image observed as a whole concept.
archetypical symbols to define these images.? When the clinician provides personalized treatment
The simplest of these archetypes are geometrical using Visagism, an immediate emotional reaction by
shapes: the square, the triangle, the circle, the lem­ the patient is evident and can be accompanied by
niscate (figure-eight), and their variations. Primary changes in behavior, posture, and even phonetics.
and secondary colors are also archetypes. Hallawell
observed that every visual composition is structured
on one or a combination of these shapes and that
T he Temperaments
the lines that form them can also be considered ar­
chetypical. These visual elements-lines, shapes, and According to Hippocrates,9•10 an individual's personality
colors-establish a universal language, regardless of is formed by a unique combination of four types of tem­
an individual's culture, race, or education.5·6 perament choleric (Fig 1 ), sanguine (Fig 2), melanchol­
Jung theorized that this language was part of the ic (Fig 3), and phlegmatic (Fig 4). One or two of these
subconscious. Although it is not yet known how the types are generally dominant in relation to the others.

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 Visagism: The Art of Dental Composition
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Fig 5 Trapezoidal tooth shape. Fig 6 The smile and its configurative lines and
forms: incisal plane, tooth axis, gingival zeniths,
papillae, incisal embrasures, and tooth shapes
proportions.

Clinicians should note, however, that patients will likely • Melancholic/sensitive: This type of individual has
feel uncomfortable being classified as melancholic or close-set eyes and an oval face with features that are
choleric and may not understand terms such as san­ either rounded or formed by thin lines. The melan­
guine and phlegmatic. Therefore, the authors prefer to cholic/sensitive personality is characterized by gen­
substitute Hippocrates' original denominations with the tleness and a capacity for awareness and abstract
terms strong, dynamic, sensitive, and peaceful. thinking.
• Phlegmatic/peaceful: This type of individual is gen­
tle, disc�eet, and diplomatic; he or she has a round
or square face, protruding lower lips, and heavy eye­
Facial Analysis
lids.
By integrating the theory of archetypical symbols with
visual elements from the art world, Hallawell attribut­
ed meaning to the lines, angles, shapes, and colors
that compose objects. Now, all professionals who deal
VISAGISM IN DENTISTRY
with facial esthetics can apply theses elements to their
work. The shape of the face in relation to the four tem­ The shapes of the anterior teeth are defined by the
peraments can be described as follows: area that reflects light directly forward, ie, the area be­
tween the cusps of reflection of mesial, distal, cervical,
• Choleric/strong: This type of individual has a rect­ and incisal light, forming the so-called Pincus silhou­
angular face formed by well-defined angles, vertical ette (Fig 5).11-15
and horizontal lines around the forehead and mouth, When observing maxillary anterior teeth, a number
and deep-set eyes. Choleric/strong individuals have of reference lines should be considered, such as those
a personality characterized by strong leadership that unite the gingival zeniths, incisal embrasures, gin­
qualities, decisiveness, daring, and fearlessness. gival papillae, and incisal plane (Fig 6). These lines are
• Sanguine/dynamic: This type of individual has an archetypical symbols, which means specific variations
angular face formed by slanting lines around the in their composition will arouse different emotions in
eyes and forehead, a prominent nose, and a wide the observer. Clinicians must understand the emotion­
mouth. The sanguine/dynamic individual is very ac­ al message behind any smile design, and this aspect
tive, communicative, and extroverted. should be discussed with the patient before treatment.

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PAOLUCCI ET Al

Figs 7a to 7d Basic shapes of maxil­

lary central incisors: (a) rectangular, (b)
triangular, (c) oval, (d) and square.

Figs 8a to 8d Basic arch forms: (a)

rectangular, (b) triangular, (c) oval, and
(d) circular.

There are four basic tooth shapes: rectangular, tri­ librium, passivity, and tranquility. They can also rep­
angular, oval, and square (Fig 7), with some possible resent a barrier.
variations. Vertical, horizontal, inclined, straight, and • Inclined straight lines express dynamism, move­
curved lines interact in infinite way s to create the diver­ ment, and joy.
sity of natural tooth shapes. These lines contain their • Curved lines represent the gradual transition be­
own power of expression and emotional significance, tween two planes (vertical and horizontal) and ex­
which can be classified as follows: press gentleness, delicacy, femininity, and sensuality.

• Vertical straight lines represent strength, power, and The dental arches also follow these basic formats,
masculinity. though it is important to note that variations are fre­
• Horizontal straight lines represent the surface on quently encountered (Fig 8).
which we are born, live, and die and express equi-

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 Visagism: The Art of Dental Composition

Figs 9a to 9d Maxillary arches with

esthetic designs in relation to the four
temperaments: (a) strong, (b) dynamic,
(c) sensitive, and (d) peaceful.

c d

Figs 1 Oa to 1 Od Schematic drawing

of maxillary teeth with esthetic designs
in relation to the four temperaments:
(a) strong, (b) dynamic, (c) sensitive,
and (d) peaceful.

Nonverbal Communication illary lateral incisors are associated with intellectual and
emotional aspects of the personality, while the canines
The oral region dominates the lower third of the face express an individual's aggressiveness, ambition, and
and immediately attracts the human eye because it dynamism. The lips also express important information
contains both verbal and nonverbal communicative through their shape, size, thickness, and smile width.
functions. Nonverbal communication, which is the pri­
mary issue of study in Visagism, occurs in only a frac­
tion of a second. When the eye focuses on the mouth,
Intraoral Design
the archetypical symbols are instantly registered in the
brain and understood unconsciously and emotion­ The design of the maxillary anterior teeth, the char­
ally.s-8,16 acteristics of the lips, and the form of the dental arch
The maxillary central incisors are the most important compose a potent nonverbal message. The esthetic
dental elements in nonverbal communication because dental design in relation to the four temperaments can
of their prominent position in the mouth.7·8·16 The max- be categorized as follows (Figs 9 and 1 0):

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• Choleric/strong: This design is composed of the Based on this information, the clinician should ex­
maxillary anterior teeth positioned with their long plain to the patient which emotions and personality
axes perpendicular to the horizontal plane, visually traits are evoked by his or her appearance. The ob­
dominant rectangular central incisors, and vertical jective is to help patients reflect on what messages
canine position. The choleric/strong design shows they would like to express through their smile and
radial symmetry. The connection line of the embra­ which personality traits they wish to emphasize. The
sures is horizontal between the central and lateral whole process makes the patient a co-creator of the
incisors, while the connection line of the gingival work, which enhances satisfaction with the treatment
zeniths from canine to canine is horizontal with the provided.
lateral incisors below it. The maxillary arch is pre­ After consultation, the restorative team develops
dominantly rectangular. a treatment plan using the Visagism concept. The
• Sanguine/dynamic: This design is composed of the Visagism begins with one or more diagnostic digital
maxillary anterior teeth positioned with their long smile designs, wax-ups, and mock-ups of the maxil­
axes slightly inclined distally, with discreet radial lary anterior region, which are evaluated by the pa­
symmetry. The connection line of the zeniths is as­ tient and clinician with the aid of extra- and intraoral
cendant or in a zigzag pattern, and the connection photographs.
lines of the embrasures and the incisal plane are as­
cendant from the medial line. The central incisors
are usually triangular or trapezoidal, and the labial
aspect of the canines is straight and inclined pala­
CASE REPORT (FIGS 11 TO 31)
tally. The maxillary arch is predominantly triangular
or polygonal. The 34-year-old female patient came to the clinic with
• Melancholic/sensitive: This design is composed of complaints about the worn aspect of her teeth. The
the maxillary anterior teeth with rectilinear or distally anamnesis was conducted with a visagistic approach,
inclined long axes, with discreet radial symmetry. and all of the patient's complaints and expectations
The connection lines of the zeniths and embrasures were recorded in writing. During the first consulta­
descend from the medial line, creating an inverted tion, irrev�rsible hydrocolloid impressions of both
incisal plane. The shape of the central incisors is arches were made. Study casts were fabricated and
usually oval, while the labial aspect of the canines mounted on a semi-adjustable articulator. A com­
is curved and inclined medially. The maxillary arch is plete photographic protocol was followed, including
predominantly oval. photographs of the smile, face at rest, forced smile,
• Phlegmatic/peaceful: This design is composed of half-opened mouth, profile, dental arches in occlu­
the maxillary anterior teeth with long axes perpen­ sion, anterior maxillary arch without the mandibular
dicular to the horizontal plane, except for the canine, teeth, and maxillary and mandibular occlusal views.
which may be slightly rotated sideways. No group of Further, the patient interview was video recorded,
teeth is dominant. Horizontal symmetry is present, not only the to keep the conversation on file, but also
generally with diastemata in a wide arch. The con­ to capture the relationship of her teeth with the lips
nection line of the gingival zeniths is straight, as is and face during speaking and smiling. After this ses­
the connection line of the embrasures. The central sion, the interdisciplinary team defined which mor­
incisors tend to be square and small, while the labial phopsychologic facial and intraoral features required
aspect of the canines is curved and vertically posi­ treatment.
tioned. The maxillary arch is usually round. Next, a second consultation took place with the pa­
tient. The patient and clinician discussed how the vi­
sual elements of her teeth affected her image. The in­
formation gathered during this consultation was used
Consultation and Treatment Planning
to help the patient decide which characteristics of her
The consultation involves an analysis of the face to temperament she would like to emphasize in her smile
determine the patient's dominant temperament(s). and which she would like to soften.

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CASE REPORT

14

Fig 11 Photographic records according to the Digital Smile Design (DSD) protocol.

Fig 12 Intraoral preoperative view. Esthetic issues included the presence of old restorations, an inverted smile line,
mandibular extrusion, and incisal and labial abrasion.

Fig 13 Occlusal view showing severe palatal erosion.

Fig 14 Facial photograph following the DSD protocol. The facial midline and horizontal plane of reference are deter­
mined digitally.

Fig 15 Transferring the reference lines to the intraoral photograph. The tooth outline is placed according to the Visa­
gism interview with the patient.

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PAOLUCCI ET Al

Fig 16 Basic intraoral designs in relation to the four temperaments.

Fig 17 Guided diagnostic wax-up following the DSD protocol and the Visagism interview with the patient.

Fig 18 Mock-up done on top of the teeth with the silicone index fabricated over the wax-up cast.

Figs 19 and 20 Facial views with the mock-up in place.

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 Visagism: The Art of Dental Composition

Fig 21 Tooth analysis prior to preparation. (1) The dotted line shows the estimated shape of the central incisor before
abrasion and erosion; the full line shows the actual shape. (2) T he mandibular incisors extruded and moved buccally.
(3) The orange dotted line shows the mock-up and the amount of volume that was added buccally and incisally.
(4) The red line shows the amount of tooth preparation needed to restore the palatal aspect of the maxillary central
incisors; however, this would probably expose dentin. (5) To preserve the palatal structure of the maxillary incisors,
orthodontic movement of the mandibular incisors was planned (intrusion and lingual movement). (6) The red dotted
line shows the minimal reduction needed for a thin veneer; the yellow dotted line shows the reduction needed for a
full crown. (7) To avoid the crown preparations and preserve tooth structure, the restoration was divided in two, with a
direct composite resin on the palatal aspect and a thin veneer on the labial aspect.

Figs 22a to 22d (a) Preoperative occlusal relationship of the incisors, showing the insufficient
space for a restoration. (b) Orthodontic treatment, showing the clearance obtained for the
restorations. (c and d) Palatal wax-up used to guide the direct composite resin restoration.

The patient wished to express the strength and cent her sensitivity and femininity. The lateral incisors
sensitivity of her smile because she believed those were designed to be straight and slightly rounded
were her most striking features. Thus, the dental team (sensitivity and intensity), while the canines were giv­
developed a design with straight lines and rectangu­ en inclined labial surfaces (dynamism and perfection­
lar shapes (strength) that were slightly rounded to ac- ism) (see Fig 16).

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PAOLUCCI ET Al

Fig 23 Fabrication of the palatal direct composite resin restoration.

Figs 24a to 24d Tooth preparation sequence: (a) Replace the

bis-acrylic resin mock-up; (b) create grooves with depth-cutter burs
to guide the depth of the preparation; (c) remove the bis-acrylic
resin and analyze the amount of enamel reduction; (d) finalize the
preparation by smoothing the grooves, placing the finishing lines,
and rounding all edges.

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 Visagism: The Art of Dental Composition

Fi g 25 Final ceramic veneers (IPS e.max LT ingots with incisal layering using. IPS e.max
Ceram, lvoclar Vivadent).

Fig 26 Final try-in.

Fig 27 Bonding procedure.

The wax-up was produced according to the patient's before patient approval, and the ceramic veneers
desires and reproduced as a mock-up in bis-acrylic res­ were fabricated in lithium disilicate glass-ceramic (IPS
in for the try-in stage. Some adjustments were made e.max, lvoclar Vivadent, Schaan, Liechtenstein).

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 PAOLUCCI ET Al
··..
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Fig 28 Before-and-after facial views.

Fig 29 One year after bonding, good integration with the soft tissue is evident.

CONCLUSION
Visagism is a novel concept that applies the principles of visual art to the
composition of a customized smile. The aim is to create a smile design that
expresses the patient's personality and lifestyle, ensuring harmony between
the restorations and the patient's physical appearance/ values/ and attitudes.

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 Visagism: T he Art of Dental Composition

Figs 30 and 31 Final result.

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PAOLUCCI ET Al

REFERENCES 9. Rufenacht CR. Fundamentals of Esthetics. Chicago: Quintes­

sence, 1990.
10. Rufenacht CR. Principles of Esthetic Integration. Chicago: Quin­
1. Frush JP, Fisher RD. Introduction to dentogenic restorations. J
tessence, 2000.
Prosthet Dent 1955;5:586-595.
11. Pincus CL. Cosmetics-The psychologic fourth dimension in full
2. Frush JP, Fisher RD. How dentogenic restorations interpret the
mouth rehabilitation. Dent Clin North Am 1967;3:71-88.
sex factor. J Prosthet Dent 1956;6:160-172.
12. Hatj6 J. A Beleza Natural dos Dentes Anteriores. Sao Paulo:
3. Frush JP, Fisher RD. How dentogenics interprets the personality
Santos, 2008.
factor. J Prosthet Dent 1956;6:441-449.
13. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodon­
4. Frush JP, Fisher RD. The age factor in dentogenics. J Prosthet
tics. Chicago: Quintessence, 1996.
Dent 1957;7:5-13.
14. Fradeani M. Esthetic rehabilitation in fixed prosthodontics. In:
5. Hallawell P. Visagismo: Harmonia e Estetica. Sao Paulo: Senac,
Esthetic Analysis: A Systematic Approach to Prosthetic Treat­
2003.
ment. Chicago: Quintessence, 2004.
6. Paolucci B. Visagismo e odontologia. In: Hallawell P (ed). Visa­
15. Ahmad I. Geometric considerations in anterior dental esthet­
gismo lntegrado: ldentidade, Estilo, Beleza. Sao Paulo: Senac,
ics: Restorative principles. Pract Periodontics Aesthet Dent
2009:243-250.
1998;10:813-822.
7. Jung CG. Man and His Symbols. New York: Dell, 1968.
16. Paolucci B. Gurel G, Coachman C, Ricci A, Calamita C, Hallaway
8. LeDoux J. The Emotional Brain: The Mysterious Underpinnings
P, et al. Visagismo: A Arte de Personalizar o Desenho do Sor­
of Emotional Life. New York: Simon and Schuster, 1998.
riso. Sao Paulo: Vm Cultural, 2011.

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 RUTTEN/GAMBORENA/RUTTEN

9a

9b

Fig 7 Horizontal bands added to the porcelain buildup to mimic the natural tooth structure and surface texture.

Fig 8 Internal aspect of the porcelain buildup.

204 QDT 2011 Fig 9a and 9b Internal stain.

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201–207_CASCIONE.indd 204 3/16/12 9:16 AM
 Fluorescence: Clinical Evaluation of New Composite Resins

11

10a

12

10b

13

Figs 10a and 10b Transparent and translucent porcelain buildup. Final porcelain buildup and characterization are
Fig 11 Transparent and translucent powders.
carried out as mapped (Figs 10 to 12). Figure 13
shows the definitive restorations prior to delivery and
Fig 12 Surface texture added.
Fig 14 in smile view upon delivery—satisfactory in
Fig 13 Final restorations on the cast prior to delivery. terms of form, color, phonetics, and function.
QDT 2012 205

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https://t.me/dental_books_lib
https://t.me/dental_books_lib
 Pasquale Loiacono and Luca Pascoletti

Whether they are used for patient communication, consultation

with a laboratory or colleague, diagnosis, clinical or legal
records, or scientific presentation or publication, images are a
much more powerful means of communication in the field of
dentistry than the spoken or written word. However, dental pho­
tography is lacking set standards that would allow the continuity
and reproducibility essential to clinical and scientific documenta­
tion. To address this need, this book presents guidelines for
photographic documentation that will enable practitioners to
produce images that faithfully convey clinical data. Precise
instructions, including the positions of the patient, assistant, and
practitioner; camera settings and flash positions; aiming and
focal points; and the types and positions of required accessories
are detailed in text and images, and an example of the desired
final image is provided.

Contents
• General Principles of Photography
• The Optical System
• The Concept of Exposure
• Principles of Digital Photography
• The Role of Photography in Clinical Practice

336 pp; 847 color illus; • Camera Settings for Dentistry

ISBN 978-88-7492-169-0 (89516); US $160 • The Orthography of Images

• Flash Units
• Photographing Radiographs
• Equipment and Accessories
• Extraoral Series
• Intraoral Series
• Photographic Documentation

CALL: (800) 621-0387 (toll free within US & Canada) • (630) 736-3600 (elsewhere)
•
o3/12

TO ORDER FAX: (630) 736-3633 EMAIL: service@quintbook.com WEB: www.quintpub.com

qulntciiCftCC
bookl https://t.me/dental_books_lib
QUINTESSENCE PUBLISHING CO INC, 4350 Chandler Drive, Hanover Park, IL 60133
 sthetic dentistry involves the principles of natu­
CASE REPORT
E ral and artistic beauty. Clinicians should not ap­
proach esthetics solely from an objective point
of view based on rigid esthetic parameters; rather,
The patient presented to the clinic with a desire to im­
prove the esthetic appearance of her maxillary anterior
esthetics must also be considered in terms of the in­ teeth (Figs 1 to 4). She wanted to be able to smile free­
dividual patient's personality and character. Only in ly without embarrassment or insecurity. Her primary
this way will true harmony between the patient's face complaint was the appearance of her maxillary central
and the dental restorations be achieved. If treatment incisors, which were oddly shaped, crooked, and se­
is not customized and personalized for each patient, verely discolored . Both central incisors had been end­
clinicians risk producing restorations that are ideal in odontically treated years earlier. She wished to avoid
theory but too artificial in reality. orthodontic realignment, which would have eliminated
Modifying the morphology of only a few teeth in the crowding and simplified the prosthetic treatment.
the maxillary anterior segment can have a profound
effect on the overall esthetics not just of the mouth
and smile, but also of the patient's entire face. This ar­
Diagnostic Procedures
ticle presents a case report involving the restoration of
maxillary central and later incisors with severe esthetic Careful analysis of the lips revealed disharmony be­
deficiencies. tween the smile curve of the lower lip and the incisal
edge of the maxillary central incisors (Fig 5). It was nec­
essary to adjust the proportions and symmetry of the
central incisors by altering their relationship with each
other and with the lateral incisors.1'2 It was planned to
provide two crowns for the central incisors and two
1Pescina, L'Aquila, Italy. veneers for the lateral incisors. This would help to re­
store the proper relationships between the teeth/-4
Correspondence to: Stefano Inglese, Via Romola Tranquilli 15,
thus optimizing the overall esthetic appearance while
67057 Pescina, L'Aquila, Italy. Email: stefanoinglesedentalart@ .
yahoo. it preserving function and phonetics. Another important

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 INGLESE

CASE REPORT

Figs 1 to 3 Preoperative views.

Fig 4 Ideal midline and esthetic plane.

Fig 5 Ideal smile curve.

task was to restore the vertical midline, which was es­ before the patient consented to the procedure follow­
tablished after careful analysis of the face.5 ing an esthetic mock-up.
After endodontic retreatment and internal tooth A preliminary analysis of the diagnostic casts (Figs
bleaching of the maxillary central incisors, fiberglass 8 and 9) helped to determine whether the morpho­
posts were cemented. The enamel surface was kept logic changes for each tooth required an additive,
intact to preserve the sound tooth structure and origi­ subtractive, or combined approach. Before any addi­
nal tooth shapes for the diagnostic wax-up (Figs 6 and tive procedures were carried out, the tooth areas to be
7). Thus, no reference points on the teeth were lost reduced were marked with red pencil on the cast to

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 Customized Treatment for Esthetic Success: A Case Report

Fi gs 6 and 7 Reconstruction of the central incisors with fiberglass posts and composite resin
using an adhesive technique.

Figs 8 and 9 Diagnostic casts.

Figs 10 and 11 Areas to be reduced were marked in red on the wax-up.

obtain an accurate mock-up (Figs 10 and 11 ) . The cast The treatment plan was to create more rounded
was checked using silicone guides obtained from the mesiodistal incisal angles for the lateral incisors/ which
final wax-up.6J would produce a more youthful appearance. This
The gingival contours were also marked for correc­ would also provide additional space for the central in­
tion. In these areas the preparation limits were extend­ cisors/ which needed to be made more dominant.
ed a bit subgingivally to permit buildup of the new On the right central incisor/ which exhibited pro­
cervical emergence of the restorations to support the nounced rotation/ a combined subtractive and addi­
marginal gingiva and move the gingival zenith distally tive wax-up was performed. An additive wax-up was
from the tooth axis/ optimizing the esthetic gingival performed for the left central incisor/ while a subtrac­
design. tive wax-up was carried out for the lateral incisors at

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INGLESE

Figs 12 to 15 Finished wax-up.

the mesial surface and incisal angles, optimizing the tion, accurate emergence profiles support the gingival
tooth shapes. Figures 12 and 13 show the finished marginal tissues, improving their appearance and bio­
wax-up, which can be duplicated to produce a single­ logic integration.8
color wax-up suitable for visualizing tooth shapes and
fabricating silicone guides without risking damage to
the wax-up.
Tooth Preparation
The labial profile plays an important role in esthet­
ics and function as well as in the biologic integration It is important to establish the co.rrect tooth shapes
of the restoration (Figs 14 and 15). The extent of labial for the restoration before carrying out any irreversible
convexity affects the optical dimensions of the tooth, steps, such as tooth preparation. The diagnostic wax­
while proper positioning of the incisal edge is crucial up and subsequent mock-up serve as a preview of the
for anterior guidance and phonetic function. In addi- final restoration. The use of silicone guides simplifies

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 Customized Treatment for Esthetic Success: A Case Report

Figs 16 to 18 Silicone guides were used to determine the amount of tooth preparation.

the clinician's work by ensuring preservation of the bio­ incisors were reduced more markedly at the mesial as­
logic structures. Silicone guides also reduce treatment pect to create space for the reshaped central incisors
time and thus make visits to the clinic less stressful for (Fig 18).
the patient. The goal should be rational tooth preparation that
Following these diagnostic measures, the neces­ preserves as much tooth substance as possible, espe­
sary space can be made for a restoration that is thick cially enamel, which is needed for adequate bonding.
enough to provide adequate strength and has suffi­ According to the dental literature, the longevity of
cient ceramic buildup to create the desired esthetic metal-free restorations depends less on the strength
effects. The silicone guides helped the clinician estab­ of the ceramic material and more on the quality of the
lish a definitive dental midline and reduce the number bond established between the material and the tooth
of teeth involved by limiting mesial preparation to the itself.9
left central incisor (Figs 16 and 17). Similarly, the lateral

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INGLESE

Fig 19 The impression must reproduce details without defects and distortion.

Figs 20 to 23 Master casts with the gingival tissues reproduced in silicone.

Fabrication of Crowns and Veneers The lost-wax technique for pressed ceramic was
used for fabrication (Figs 24 to 29). Sprues (3-mm
Careful impression and master cast procedures are an wide and 3- to 4-mm long) were attached to the wax
important way for the dental clinic and laboratory to crowns. The lithium disilicate ceramic was injected into
communicate. Missing or incorrect information, a lack the cavity of an investment ring preheated at 850°C for
of precision caused by a poorly produced cast, or even approximately 1 hour. Modern pressing furnaces have
tiny distortions or an "illegible" area of the impression, a series of predefined programs to accommodate the
especially at preparation margins, can adversely affect ·size of the investment ring and the type of material
the fit of the restorations (Figs 19 to 21 ). Equally im­ to be pressed. The ingots to be pressed should be
portant is the creation of artificial gingival tissues (Figs chosen based on the desired degree of luminosity and
22 and 23), which serve as the reference points for the the color of the tooth preparations; further, different
emergence profile and provide support for the natural materials offer varying degrees of fluorescence and
gingival tissues. opacity. The pressed lithium disilicate cores were fit­
A metal-free technique was used to fabricate the ted onto the master cast, and any rough spots were
veneers and crowns with lithium disilicate glass-ceram­ removed to achieve completely passive fit. The spatial
ic (IPS e.max press, lvoclar Vivadent, Schaan, Liechten­ relationships that guided the buildup were checked
stein) individually layered with IPS e.max Ceram (Iva­ using ·silicone guides.
dar Vivadent). The tooth shapes from the diagnostic The dentin ceramic should be trimmed lightly to
wax-ups were reproduced and then carefully cut back avoid microcracks in the substructure. Microcracks,
so that the ceramic buildup could be fabricated. which cannot be repaired, will inevitably open as a re-

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 Customized Treatment for Esthetic Success: A Case Report

Figs 24 to 29 Fabrication of the lithium disilicate glass-ceramic substructure.

suit of heat stress during ceramic firing or masticatory ceramic of varying degrees of translucency and fluo­
stress after cementation. This can ultimately lead to rescence during the buildup stage.
complete crown failure. Therefore, indiscriminate fin­ A wash firing (IPS e.max Ceram) was first carried out
ishing must be avoided. Instead, it is recommended to improve the dentin shape and to aid in the applica­
to refine the dentin structure with small amounts of tion of all internal effects in the appropriate locations,

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INGlESE

Figs 30 and 31 Wash firing for adhesion and to improve the morphology of the dentin.
Enamels and other internal effects are applied later during the body firing.

Figs 32 and 33 The middle third of the tooth received opaque enamel with a high degree of
diffusion (shades OE3 and OE4) to create a high-value zone. The incisal zone received trans­
lucent materials with different degrees of luminosity, applied alternately and irregularly (Ti, I,
EO, and CT enamels).

assisted by silicone guides (Figs 30 and 31 ). Fixation of If the ceramic buildup is performed correctly, mini­
the optical effects through wash firing ensures p redict­ mal retouching will be needed after firing. The labial
able esthetic results. In addition, this technique greatly profiles were defined and subdivided into three dis­
reduces sintering contraction of the enamels in the first tinct planes, and the mesiodistal transition lines were
body firing and avoids repeated heat cycles for correc­ established. The farther the line angles are located
tions that may compromise the optical p ro perties of from the dental axis, the broader and shorter the re­
the ceramic. Naturally, the app lication of enamel ce­ sulting teeth will be (Fig 34).
ramic should be clearly defined and performed care­ Particular attention must be p aid to the interproxi­
fully. Enamel with different optical pro perties should mal contacts, which should be checked on a solid cast.
be applied alternately and irregularly to enhance the The most apical portion of the contact areas should be
light dy namics inside the restorations (Figs 32 and 33). located approximately 5 mm from the tip of the crest

------- ·

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 Customized Treatment for Esthetic Success: A Case Report

Figs 34 Defining the contour and texture of the restorations,

responsible for optical tooth dimension.

Figs 35 to 37 After pre-polishing firing, additive corrections were

made as needed, and the thickness of the incisal third was checked.

of the intraradicular bone. During the biscuit bake try­ stage in which to make any additive corrections need­
in, the clinician should take all measurements required ed. To achieve natural translucency and an anatomical
and mark the correct levels on the proximal aspects of shape, the thickness of the incisal edge should not ex­
the crowns. This is the only way to ensure that every ceed approximately 3.0 to 3.5 mm at the incisal third
interdental space has been closed with properly sup­ (Figs 36 and 37).
ported gingival papillae.10 When seating the restorations on the master cast,
After establishing the proper tooth shapes and ap­ the emergence profiles can be assessed in relation
propriate macro- and microfinishing, the restorations to the gingival margins, bearing in mind any retrac­
received a pre-polishing firing (Fig 35). This is also the tion caused by the cord when lifting off the impression

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ODT 2012 fJII

INGlESE

Figs 38 to 41 Restorations seated on the' master cast.

(Figs 38 and 39). In this case, the cast showed small tri­ Cementation
angular interdental spaces, which were perfectly filled
by the papillae after the restorations were cemented Precise crown margins ensure a good seal and mini­
and the gingival tissues had matured. mize the thickness of the resin cement layer. At the
Achieving the correct surface texture and light dy­ crown cementation appointment, the gingival tis­
namics is crucial for a successful esthetic result, espe­ sues should have a satisfactory appearance (Figs 42
cially in cases where the restorations are adjacent to and 43). After carefully cleaning the preparations, the
natural teeth. Any variations in light reflection will be crowns were cemented (Fig 44). Gingival fluids were
immediately obvious even to an untrained eye.11-14 The isolated with retraction cord. Once any excess cement
labial aspect exhibits the mesiodistal transition lines was removed, the veneers were also cemented (Figs
marking the border between light reflection and light 45 to 48). Rubber dam was applied for all subsequent
deflection (Fig 40). This interplay of light and shade procedures to prevent contamination of the prepara­
creates dynamic three-dimensional effects. The total tion surfaces and ensure perfect adhesion.
reflection of light determines the halo effect. This total
reflection is a result of the typical angle of the incisal
plane to the labial surface (Fig 41 ).

ODT 2012 https://t.me/dental_books_lib

 Customized Treatment for Esthetic Success: A Case Report

Figs 42 and 43 Preparations ready for

crown cementation.

Figs 44 to 48 The crowns were cemented

first, followed by the veneers, using an ad­
hesive technique.

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INGLESE

Figs 49 to 51 A few weeks after crown cementation, the restorations are well integrated with the gingival tissues.

Final Result ration cannot compensate for defects in the gingival

tissues, just as perfect, healthy gingiva cannot distract
A few weeks after cementation, the excellent condi­ from unsightly restorations. Both dental and gingival
tion of the gingival tissues indicated successful bio­ esthetics must be in harmony.15
logic integration (Figs 49 to 51). Correct emergence Figures 52 and 53 show the final treatment result.
profiles and good support for the gingival margins en­ The dominance of the central incisors distracts the eye
sured rapid soft tissue healing and maturation, tested from any imperfections of the posterior teeth that were
by applying retraction cords and retraction clamps visible before treatment. The incisal edge was placed
(no. 212) to attach rubber dam during cementation of in perfect harmony with the curve of the smile. The pa­
the lithium disilicate crowns and veneers, respectively. tient's face has become more luminous, and the mouth
The pink esthetics plays an important role in the over­ has become more dominant, producing a rejuvenating
all esthetic appearance. Even a highly esthetic resto- effect.Y·16

ODT 2012
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 Customized Treatment for Esthetic Success: A Case Report

Figs 52 and 53 Final result. The incisal edge of the restorations is now in harmony with the smile.

An entity becomes an entity with individuality when it stands out because of its own proper characteristics.
Diversity is a precondition of individuality.

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INGLESE

CONCLUSION 4. Gillen RJ, Schwartz RS, Hilton TJ, Evans TB. An analysis of se­
lected normative tooth proportions. lnt J Prosthodont 1994;7:
410-417.
Correcting the shape of only the four maxillary inci­ 5. Johnston CD, Burden DJ, Stevenson MR. The influence of den­
sors completely changed the overall appearance of tal to facial midline discrepancies on dental attractiveness rat­
ings. Eur J Orthod 1999;21:517-522.
the patient's face. Esthetic success can be achieved by
6. Magne P, Belser U. Restauri Adesivi in Ceramica dei Denti Ante­
considering both objective and subjective perceptions riori. Milan: Quintessenza Edizioni, 2003:196-214.
of esthetics. Treatment should be customized to the 7. Magne P, Magne M, Belser U. The diagnostic template: Key
element of a comprehensive esthetic treatment concept. lnt J
individual patient's personality and desires to achieve
Periodontics Restorative Dentistry 1996;16:561-569.
the best restorative results.
8. Rufenacht CR. Principles of Esthetic Integration. Chicago: Quin­
tessence, 2000:63-168.
9. Magne P, Belser U. Restauri Adesivi in Ceramica dei Denti Ante­
riori. Milan: Quintessenza Edizioni, 2003:23-53.
10. Tarnow DP, Magner AW, Fletcher P. The effect of the distance

ACKNOWLEDGMENTS from the contact point to the crest of the bone on the presence or
absence of the interproximal dental papilla. J Periodontal 1992;
63:995-999.
The author thanks Dr Riccardo Becciani, Florence, Italy, for his excel­
11. Adolfi D. Estetica Natural. Sao Paulo: Livraria Santos, 2002:55-
lent clinical work, which is the result of his experience, professional­
72.
ism, and wisdom.
12. Ubassy G. Forme e Colori. Le Chiavi del Successo Nella Ce­
ramica Dentale. Berlin: Resch, 1994:197-210.
13. Ubassy G. Trues and Astuces. Vitoria-Gasteiz, Spain: Team Work
Media, 2008:190-215.
14. Suckert R. Estetica Funzionale Degli lncisivi. Brescia, Italy : Mea
REFERENCES Editrice, 1991.
15. Chiche G, Pinault A. Artistic and scientific principles applied to
1. Rufenacht CR. Fundamentals of Esthetics. Chicago: Quintes­
esthetic dentistry. In: Esthetics of Anterior Fixed Prosthodontics.
sence, 1990.
Chicago: Quintessence, 1994:13-32.
2. Preston JD. The golden proportion revisited. J Esthet Dent 1993;
16. Goldstein RE. Esthetics in Dentistry. Philadelphia: JB Lippincott,
5:247-251.
1976.
3. Lombardi RE. The principles of visual perception and their clini­
cal application to denture aesthetics. J Prosthet Dent 1973;29:
358-382.

QDT 2012 https://t.me/dental_books_lib

Introduction to Metal-Ceramic
Technology, Second Edition
W. Patrick Naylor

This completely revised and updated edition presents the theory and technical
procedures for physically constructing an esthetic metal-ceramic restoration using
contemporary dental porcelain systems. Readers are introduced to the complex
technical language of this technology as they are patiently guided through each step
of the process. New to this edition is an increased emphasis on evidence-based
documentation; information on biocompatibility, including indications of intra- and
extraoral allergic responses; explanations of the rationale for variations in substruc­
ture design; expanded dental materials content; updated dental porcelain and den­
tal alloy classifications; firing schedules for current products; selected annotated
bibliographies; and much more. Written specifically for dental technology students,
dental students, graduate students, and residents in advanced education programs
and advanced technical courses.

Contents
• History and Overview
• Chemistry of Dental Porcelain
• Casting Alloys for Bonding to Dental Porcelain
• Essentials of Metal-Ceramic Substructure Design
• Fundamentals of Spruing, Investing, and Casting
• How Does Dental Porcelain Bond to Metal?
• Preparation of the Metal Substructure for Porcelain
• Applying Porcelain to the Metal Substructure
• Adjusting and Finishing the Metal-Ceramic Restoration
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232 pp; 492 illus (mostly color);

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https://t.me/dental_books_lib
Tools for Treating
the Esthetic Zone
Fundamentals of Color: Shade Matching and
Communication in Esthetic Dentistry, Second Edition
Stephen J. Chu, Alessandro Devigus, Rade D. Paravina, and AdamS. Mieleszko

Fundamentals of When dental practitioners lack training in the art and science of color, the deficiency often becomes glaringly
evident in the quality of their restorative work. This book was written to simplify the study of color and help
dentists communicate shade easily and accurately. It begins by presenting the basics of color theory within
the context of esthetic dentistry and the factors that affect the transmission and perception of color. This is
followed by how-to chapters on conventional and technology-based shade matching, which highlight the
Shade Match•ng and Commumcation '" Esthetic Dentistry/ Second Edition advantages and drawbacks of each approach and provide step-by-step shade-matching methods and
protocols. This updated and expanded second edition also includes chapters on the use of digital photog­
raphy for shade verification and the influence of material selection on color matching. In the final two
chapters, the authors present their own recommended shade-matching protocol (which combines conven­
tional and computer-based techniques) and an expanded series of cases demonstrating its application in
various clinical scenarios. Highly recommended for students, general practitioners, and specialists.

Contents
Why Study Color • Color Theory • Elements Affecting Color • Conventional Shade Matching • Technology­
Based Shade Matching • Digital Photography • Material Selection • Recommended Shade-Matching
Protocol • Clinical Cases

168 pp; 366 illus (mostly color); ISBN 978-0-86715-497-9 (B4979); US $68

Cf/)0/</d
World of Anterior Ceramic Restorations 'tf'
Anterior C eramic
I
Restorations
Yeojoon Koh

This beautifully designed and visually stunning clinical atlas offers myriad clinical situa­
tions in which anterior ceramic restorations can be used to correct esthetic problems.
Each section presents one case that focuses on a distinct set of esthetic and dental
conditions that necessitate restoration, such as fracture, crowding, rotation, asymmetry,
discoloration, contour, caries, or implant considerations, among others. The case pre­
sentation begins by showing the definitive esthetic result alongside a succinct, multilin­ Y• ojooo Koh, DS, MS

gual (English, German, Japanese, and Korean) description of the initial conditions and
the procedure used. Then follow the clinical images illustrating the procedure, step-by­ Elil OoehanNarae
step. With its inviting presentation and its emphasized visual component, this book is
intended as a communication tool between the dentist, the ceramist, and the patient: It
functions as a guide to various approaches for the dentist, a tool for understanding tooth 216 pp; 614 color illus; ISBN 978-89-5741-207-7 (BC997);
shape and conditions for the ceramist, and a preview of the esthetic result for the US$120
patient. Because communication and cooperation between these three parties are
essential for a successful esthetic outcome, this book is an indispensable resource for
any esthetic dentist.

Contents
Light and Color/Form • Normally Aligned Tooth • Rotated or Malpositioned Tooth •

Discolored Tooth • Severely Destructed Tooth • Periodontally Compromised Tooth •

Porcelain Laminate Veneer • Bridge • Implant

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C
atastrophic fracture is the characteristic failure is evident in the small gain in strength observed for
mode for porcelain- and glass ceramic-based ln-Ceram Zirconia in comparison to ln-Ceram Alumina,
prostheses.1 In fact, high-strength core ceram­ even though the former comprises approximately 33%
ics that contain glass, such as lithium disilicate glass­ zirconia..
infiltrated alumina (ln-Ceram Alumina, VITA Zahnfab­ Glass-free ceramics for infrastructures such as
rik, Bad Sackingen, Germany) and glass-infiltrated densely sintered alumina (Procera, Nobel Biocare,
alumina/zirconia (ln-Ceram Zirconia, VITA Zahnfabrik), Goteborg, Sweden, or ln-Ceram AL, VITA Zahnfab­
also tend to fail by fracture. Although the high crys­ rik) and yttrium- or ceria-stabilized tetragonal zirconia
talline phase in high-strength ceramic acts via tough­ polycrystals, on the other hand, tend to deflect the
ening mechanisms that decrease crack energy and propagating crack, resulting in veneer crack alone.
increase durability, the glass phase surrounding crys­ This fracture mode resembles that of metal-ceramic
tals and grains is still the weak link through which the prostheses. Therefore, chipping occurrence in rein­
crack propagates.2 An example of this phenomenon forced ceramic prostheses should not be regarded as
an unexpected phenomenon. Nonetheless, the high
chipping incidence reported for zirconia-based pros­
theses has placed clinicians, technicians, and research­
1Private Practice, Goiania, Brazil.
ers on full alert. In a clinical trial of 33 three- to five­
2Professor, Department of Operative Dentistry, School of Dentistry,
Federal University of Santa Catarina, Florian6polis, Brazil. unit fixed partial dentures (FPDs), a 15% incidence of
3PhD Candidate, Department of Operative Dentistry, School of veneer fracture was reported after 5 years.3 Another
Dentistry, Federal University of Santa Catarina, Florian6polis,
study reported a chipping incidence of 25% for three­
Brazil.
unit FPDs after 2 to 5 years.4 In a study of 19 three-unit

Correspondence to: Dr Renan Belli, Universidade Federal de FPDs, 36% developed veneer fracture after 5 years.5
Santa Catarina, Campus Universitario, Centro de Ciencias da Vult Von Steyern et al evaluated the clinical perfor­
Saude, Departamento de Odontologia, Disciplina de Dentfstica,
Florian6polis, Santa Catarina, Brazil 88040-900.
mance of 23 three- to five-unit FPDs and found that
Email: renanbelli@yahoo.com.br 15% presented veneer chipping after only 2 years.6

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 liMA fT Al

For implant-supported prostheses, the lack of com­ ture down to T is not converted into stress. However,
g

pliance provided by the periodontal ligament during as the temperature further decreases, the veneer so-
occlusion seems to escalate stresses at the contact lidifies, and all contraction down to the ambient tem­
point and accelerate crack development in the veneer perature cannot be dissipated through viscous flow.
porcelain. In a clinical trial by Larsson et al, 54% of 13 This becomes a problem when there is a mismatch be­
two- to five-unit zirconia-veneered FPDs placed onto tween the CTEs of the infrastructure and the veneering
titanium implant abutments showed veneer fracture porcelain. If one of the components contracts more
after 1 year in service_? A direct comparison between during cooling than the other, stress is built up at the
three- to five-unit FPDs with either zirconia or metal­ interface and spontaneous cracking may occur.10 Mod­
alloy frameworks revealed that the incidence of minor erate mismatches usually do not result in immediate
chipping was equivalent for both materials, whereas veneer fracture but may generate stresses below the
chipping that required replacement of the prosthesis tensile strength of the porcelain. Under occlusal load­
occurred only for zirconia-based FPDs (8.4%) after 3 ing, tensile stresses locked in the interior of the porce­
years.8 After systematically evaluating clinical studies lain affect crack propagation resistance and decrease
that compared zirconia and metal as infrastructure ma­ the life span of the prosthesis. To prevent highly unsta­
terials for FPDs, Heintze and Rousson found chipping ble tensile stresses from developing within the veneer,
rates of 54% for the former and 34% for the latter after a positive mismatch (acore - aveneer +fla ppm/ °C) is
=

3 years.9 preferred over a negative mismatch.11 Since the CTE of

This article briefly discusses the thermodynamics of the infrastructure material does not vary greatly from
the sintering process and focuses on the factors that one manufacturer to another, the choice of veneer will
influence the chipping phenomenon in zirconia-based determine the thermal compatibility of the system.
prostheses. Additionally, the authors present a case re­ As opposed to in the core materials, CTE differences
port involving full-mouth prosthetic rehabilitation em­ between veneering porcelains may surpass 1 ppm/°C.
ploying the measures discussed to prevent premature Table 1 shows the CTEs for some commercially avail­
failure and increase clinical longevity. able veneering porcelains. Unfortunately, many tech­
nicians choose their working veneer porcelain based
only on per$onal preferences, handling, and esthetic
properties. To improve mechanical longevity, the CTE,

THE SINTERING PROCESS which can be found in the manufacturer's instructions,

should be given increased importance in the adopted
In any bilayer system (metal-ceramic or ceramic­ criteria for material selection.
ceramic), the mechanical properties (eg, elastic modu­ In an attempt to revert the stress state from tensile
lus) and thermal properties (eg, thermal conductivity, to compressive at the surface of the porcelain, many
heat capacity, thermal diffusivity, coefficient of thermal laboratories employ strengthening techniques used in
expansion [CTE]) of the components affect the stress the glass industry for tempering dental prostheses. Ba­
state of the other during cooling from the final sinter­ sically, instead of turning off the oven after glaze firing
ing temperature. At the heating stage, the veneering and leaving the working piece to cool down slowly,
porcelain powder covering the framework turns from technicians remove the prostheses immediately after
a solid state to a viscoelastic state at the glass tran­ firing to cool them benchside. Forced air stream has
sition temperature (T9) (around 550°C to 600°C for also been used to cool down the veneer after removal
most veneering porcelains). The temperature is further from the oven. This quickly cools downs the porcelain
increased so that the veneer particles fuse homoge­ surface, generating high compressive stresses on the
neously, but never to the melting point (after which the outer 1 5% of the veneer. The interior of the veneer lay­
material would become a liquid). Between T9 and the er, however, instantly develops tensile stresses due to
final sintering temperature, the veneer assumes a vis­ the increased density on the surface layer under com­
coelastic behavior, in which all deformation is relaxed pression.12 Clinically, surface wear and occlusal adjust­
through molecular rearrangement. Therefore, the con­ ments performed by the clinician remove the strength­
traction deformation from the final sintering tempera- ening compressive layer and expose the tensile zone

u-----
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----- --------- ------- -----------· --- --------------·---
 Chipping Occurrence in Zirconia-Based Prostheses

Coefficients of Thermal Expansion (CTEs)

of Commercially Available Veneering Porcelains
Brand Manufacturer

Noritake CZR Noritake (Aichi, Japan) 10.1

Lava Ceram 3M ESPE (St Paul, Minnesota, USA) 9.9

IPS E.max ZirPress lvoclar Vivadent (Schaan, Liechtenstein) 9.75

Nobel Rondo Nobel Biocare (Goteborg, Sweden) 9.7

IPS E.max Ceram lvoclar Vivadent 9.5

Wieland XRZ Wieland Dental+ Technik (Pforzheim, Germany) 9.3

Vita PM9 VITA Zahnfabrik (Bad Sackingen, Germany) 9.2

Vita VM9 VITA Zahnfabrik 9.1

*CTE of zirconia = 10.5 ppmfOC.

underneath. Contact-induced cracks initiate and prop­ gradient is created across the thickness of the veneer
agate much faster in a substrate under tension, greatly and tensile stresses develop close to the core. These
compromising the life span of the prostheses. stresses are proportional to the temperature difference
between surface and inner porcelain, which in turn is
somewhat proportional to the cooling rate.15 When us­
ing fast-cooling protocols, stresses add up for high­
Zirconia Sintering
mismatch zirconia-veneer systems,16 and the longevity
Zirconia is not necessarily a special case in terms of the of the prosthesis decreases substantially.17 For areas
factors that influence the chipping phenomenon. The with a high core-veneer thickness ratio, these effects
same primary factors responsible for residual stress escalate <;Jnd increase the residual stresses inside the
build-up within the veneer in other bilayer systems (ie, veneer porcelain. Interestingly, anatomically designed
thermal mismatch and cooling rate) also apply to the frameworks (with a thicker zirconia core at regions of
thermal behavior and mechanical response of zirconia­ unsupported porcelain) do not seem to ameliorate the
based prostheses. The reason for the higher chipping situation even though the thicker core stores heat for
incidence of zirconia-based prostheses is related to longer periods.14
the increased sensitivity of the zirconia bilayer to these Thus, by making adjustments in the fabrication pro­
factors. cess and controlling the factors discussed in this article
Because zirconia has a low thermal conductivity (ie, choosing a veneer with a CTE close to the zirconia's
(2 Wm-1K-1) compared to other infrastructure materi­ and employing a slow-cooling protocol at the last fir­
als (base metals and ln-Ceram Alumina, for example, ing), the technician can significantly enhance the dura­
have a thermal conductivity of 40 and 14 Wm-1K-1, re­ bility of zirconia-based prostheses. Waiting for nearly 1
spectively) and a high density (6.1 g cm-3L the quan­ hour for every glazed prosthesis to slowly cool inside
tity of heat that dissipates from the zirconia core into the oven may be too unproductive for the workflow of
the adjacent porcelain and out to the external envi­ some laboratories. The wait time for slow-cooling pro­
ronment per unit time is also reduced in comparison tocols can be reduced by opening the oven after the
to other materials.13 In other words, the zirconia core temperature has dropped below T9. However, since the
remains hot for a longer period of time,14 and thus the inner veneer remains in the viscoelastic state while the
adjacent porcelain cools down at a slower rate than surface veneer has already solidified, it is best to wait
it would if adjacent to more thermal conductive ma­ until the temperature drops approximately 1 oooc be­
terials. Therefore, upon cooling from the sintering low T (the manufacturer should provide the glass tran-
g

temperature down through T9 , a high temperature sition temperature in the product information sheet).

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liMA ET Al

CASE REPORT

Figs 1a to 1c Initial extraoral views.

Figs 2a to 2f Initial intraoral views.

Fig 3 The maxillary anterior teeth

showed the presence of multi ple
restorations with poor esthetics.

Fig 4 The mandibular anterior teeth

presented severe wear and non­
carious cervical lesions.

CASE REPORT cooling protocol after firing to minimize stress devel­

opment and reduce the potential for fracture. At the
Figures 1 to 21 present a case involving the full-mouth 2-year follow-up appointment after cementation, clini­
rehabilitation of a patient with existing unesthetic res­ cal inspection for chipping found no structural dam­
torations, severe wear, and noncarious cervical lesions. age to the veneer other than wear facets.
All-ceramic restorations were fabricated using a slow-

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 Chipping Occurrence in Zirconia-Based Prostheses

Figs Sa to Sc Preparations were made on the cast for the fabrication of provi­
sional restorations.

Fig 6 Extraoral view of the cemented provisional restorations. Note the

recovery of interocclusal space.

Figs 7a and 7b Preparations ready for impression procedures.

Fig 8 A double-cord technique was used for impression taking with a vinyl
polysiloxane material.

Figs 9a to 9c Full-mouth and partial impressions were taken for the fabrica­
tion of zirconia copings.

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liMA ET AL

Fig 10 Single zirconia copings with a thickness of

0.5 mm were fabricated.

Figs 11 a to 11 c Framework try-in.

Fig 12 lnterocclusal records for accurate transfer of the vertical dimension of

occlusion and cross-mounting of the casts.

Figs 13a to 13c Full-arch pickup impressions.

Figs 14a and 14b Zirconia frameworks on the master casts.

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 Chipping O cc u rrence in Zirconia-Based Prostheses

Figs 15a to 15f Definitive all-ceramic crowns. During

the final firing, the crowns were left inside the oven to
cool slowly to minimize stress development within the
veneer.

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liMA ET Al

Figs 16a to 16j Implant-supported zirconia crowns were separately cemented over a metal infrastructure.

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 Chipping Occurrence in Zirconia-Based Prostheses

Figs 17a to 17d Intraoral views of the final result.

Figs 18a to 18e Definitive maxillary anterior crowns.

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QOT2012 ml
liMA ET Al

Figs 19a to 19c Definitive man­

dibular anterior crowns.

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 Chipping Occurrence in Zirconia-Based Prostheses

Figs 20a to 20d Definitive posterior crowns.

Fig 21 Extraoral views of the final result.

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LIMA ET AL

9. Heintze SO, Rousson V. Survival of zirconia- and metal-support­

REFERENCES ed fixed dental prostheses: A systematic review. lnt J Prostho­
dont 2010;23:493-502.
1. Belli R, Guimaraes JC, Lohbauer U, Baratieri LN. On the brittle­
10. Dehoff PH, Barrett AA, Lee RB, Anusavice KJ. Thermal compat­
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