ceramic | TECHNIQUES

Fusion of modern and ancient: Feldspathic/refractory veneers using zirconia porcelain

By Yugo Hatai

T
Traditionally, PFM porcelain has been used for the fabrication of refractory veneers, however, have you thought about using zirconia porcelains instead?

he Feldspathic/Refractory veneer is one of the oldest techniques practised in dental technology and is still widely used in todays increasingly metal-free world. The advancement of CAD/CAM technology and the development of new materials has enabled a consistent, predictable aesthetically pleasing result. Having said that, this old veneering technique could also consistently deliver aesthetically pleasing results, due to its translucency and the control of the colour of the porcelain itself. Traditionally, PFM porcelain has been used for the fabrication of the restorations, however, have you thought about using zirconia porcelains instead? In general, modern zirconia porcelain delivers a denser, stronger result without shrinkage cracks and it is easier to achieve better aesthetics. This is due to the variety of ready-made porcelains available in newer zirconia porcelain kits compared to traditional PFM porcelains that require mixing many different colours to achieve a decent result. It also opens up more opportunities for material choice. For example, when we work on a combination case - veneers with zirconia crowns - if we are able to use the same zirconia porcelain for the feldspathic/refractory veneers, then we can use the same porcelain throughout the restorations which would provide a more consistent, accurate result in the colour matching and material wear that affects the longevity of the restorations.

In this article, Id like to present an example of a feldspathic/refractory veneer technique using a zirconia porcelain - Lava Ceram (3M ESPE).

Case planning
Figure 1 and 2 shows the pre-op condition of a male patient in his late 20s. The main issue is the microdont on the laterals as well as a reasonably high smile line. The treatment plan is for crown lengthening on the four anterior teeth to reduce the gummy smile appearance, bleaching to increase the brightness overall and a composite build-up on the incisal third of the canines to increase the length incisally. Figure 3 and 4 shows the result of crown lengthening and bleaching. There is a big improvement already! For the laterals, our goal is to build them out by increasing the length and width to keep them in proportion. Only minimal preparation is required so as to preserve the existing enamel as much as possible. The existing colour is close to the desired final result, hence we should consider incorporating the stump shade colour (i.e. the natural colour from beneath) into the final restorations. Anterior guidance will be maintained with existing dentition palatally, so the strength of the material is not a major concern in this case, hence why the feldspathic/refractory veneer is chosen over a pressable technique.

32 eLABORATE

March/April 2010

Figure 1. Pre-op Smile.

Figure 2. Pre-op Retracted View.

Figure 3. Smile after bleaching and crown lengthening.

Figure 4. Retracted View after bleaching and crown lengthening.

Figure 5. Working Model.

Figure 6. Sectioned Dies of the prep. this article). Adding a relocation groove is necessary (Figure 8) to place the die accurately back onto the model later on. The original dies should be kept separate after the initial duplication and should be used to check the fit once the veneers are completed. The trimmed stone dies have to be duplicated with a high quality silicon material (Figure 9). Deguform (DeguDent, Dentsply Australia) is recommended for a consistent, precise and accurate result. We will now refer to this duplication mould being the Master Duplication, as this will be used again later in this article. Debubbliser is sprayed (Figure 10) and then stone dies poured (Figure 11). Once set, two coats of spacer is painted (0.5 1mm away from the margin) (Figure 12) prior to the second duplication of the dies (Figure 13). Now here is the million dollar question: why is it that we dont use zirconia porcelain for feldspathic/refractory veneers? It is because unless you use a special refractory die material, you simply cannot get a consistent result. A lot of sweat and tears has been put into testing and researching and finally, here is a solution and such a simple one too!

Fabrication of refractory dies

Upon receipt of the impression, the technician who completes the model work (Figure 5) usually does not know if the case is to be processed with refractory veneers or the pressable technique (as most likely the material is chosen after the model work is done), so the first pour might be processed as a pin/section model. That, however, will not in any way negatively affect the result as the stone die has to be sectioned anyway, either with or without pins (Figure 6). The model is then trimmed with a tapered bur (Figure 7) to a root shape, so that the die can come on and off (as will be shown later in

March/April 2010

eLABORATE

33

Figure 7. Shaping the dies with a tapered bur.

Figure 8. Completed trimmed dies with relocation groove.

Figure 9. Initial Duplication of the dies.

Figure 10. Applying debubbliser to avoid potential bubbles.

Figure 11. Pouring Stone into the Master Duplication.

Figure 12. Applying Spacer onto the duplicated dies.

Figure 13. 2nd Duplication using the dies with spacer.

Figure 14. Nori-Vest Zirconia Refractory Die Material.

Figure 15. Applying debubbliser on the 2nd duplicated silicon mould.

Figure 16. Pouring the refractory material .

Figure 17. Marking the margin with refractory pen.

Figure 18. Creating a bur hole for stabilisation of the dies on firing tray.

Figure 19. Degassing of the refractory dies. Figure 14 shows the answer. Its a refractory material especially made for zirconia porcelain called Nori-Vest Zirconia from Noritake (Alphabond Australia), and it works very well

Figure 20. Completed Refractory Dies. with a zirconia porcelain like Lava Ceram. Debubbliser is sprayed (Figure 15) and the refractory material is poured (Figure 16). Once set, the margin is marked with a refractory pen so the marking doesnt burn off (Figure 17) and a hole needs to be drilled on the bottom of the dies (Figure 18) so it can be stabilized on a firing tray. Finally, degassing takes place (Figure 19) and the refractory dies are complete (Figure 20).

34 eLABORATE

March/April 2010

Figure 21. 2nd set of stone dies to be poured using Master Duplication.

Figure 22. Applying denture wax on the stone dies as a separator.

Figure 23. Securing the dies in the impression using sticky wax and wire.

Figure 24. Pouring 1st layer of stone.

Figure 25. Showing the uncovered die heads.

Figure 26. Applying denture wax after removal of sticky wax and wire.

Figure 27. Pouring 2nd layer of stone.

Figure 28. Completed Master Model showing exposed denture wax.

Figure 29. Completed Master Model with the original stone dies.

Figure 30. Completed Master Model with the refractory dies.

Fabrication of master model

The master model for build up is next created by pouring another stone die from the Master Duplication (Figure 21). Once set, a thin layer of wax is applied to all areas (Figure 22) apart from the area that goes back into the impression (everything above the margin except the contact points). It is important to ensure that the layer of wax is thin enough around the relocation grooves so that it will not be too

loose when we place the refractory dies on the completed model later on. The wax coated dies are placed back on the impression and secured with wires and sticky wax (Figure 23) so that it will not move during vibration when the stone is poured (Figure 24). Ensure the bottom of the stone dies are exposed (Figure 25), as the pour has to be done in two steps for an accurate result. Once the stone is set and the pins and

sticky wax removed, denture wax is placed (about 3-5mm in height) onto the exposed bottom of the stone dies (Figure 26) so we are able to locate their position easily (Figure 28) after the second pour (Figure 27). The denture wax is then steam cleaned and with some soft tapping through the exposed hole, the dies should be easily separated from the master model. The refractory dies can then be inserted onto the model (Figure 30) instead of stone dies (Figure 29).

March/April 2010

eLABORATE

35

ceramic | TECHNIQUES

Figure 31. Shade photos with B1 and B2 Vita Classical Shade Guide.

Figure 32. Shade photos with B1 and B2 Vita Classical Shade Guide.

Figure 33. Ducera Lay Saturation Fluid (DeguDent GmbH). A little trick for better visualization of the final shape is that part of the wax up can be done on the stone dies, then a key is taken as a reference, then the dies are switched back onto the refractory dies and the same key is used during the build up as a guide. As you may know, anything we can use to achieve a better result always helps.

Figure 34. Lava Ceram - ICE 2 - Fluorescent Transparent - Opal.

Shade selection
Colour matching to the natural dentition is a challenge for any ceramist. Shade taking face to face with the patient has traditionally been the way we have ascertained the correct colour from which to build the restorations. However, these days the quality of digital cameras has become excellent and with careful interpretation based on experience, it is possible to match the colour from the digital images. This also provides more opportunities - a good quality digital camera is a great communication tool that allows information to be sent via email worldwide and within seconds and if the ceramist is able to match the colour without ever seeing the patient, it means the laboratory suddenly opens up to a much broader client base. In fact, this case was completed without ever seeing the patient and the colour matching

was achieved with only two photos (Figure 31 and Figure 32). For this case, the colour of dentin on the centrals is lighter than the B1 VITAPAN Classical shade guide and these are bleached teeth, so we should consider increasing both the value of dentin shade from B1 as well as the enamel. There is more of an A (reddish-orange) colour within instead of B (yellow), so A1 dentin mixed with some bleach coloured dentin (i.e. W3) would be suitable. For the enamel, natural coloured porcelain (Mother of Pearl colour - N1 and N3) with Enamel porcelain (E2) would be suitable to achieve a high value enamel with a high translucent appearance. For the cervical, simply CI2 would be suitable (Central - 1 - CI1, Lateral - 2 - CI2 and Canine - 3 - CI3) - this is a simple decision with readymade porcelain available from the kit! It is important to build up the case using your imagination prior to the actual build up so you know where you are heading. The colour has to be placed in the right position with precisely the right depth/layer to match the colour during the build up of the shape you are after. It is very important to set your goals first before you ever start building your porcelain.

Wash firing
The initial wash firing onto the refractory dies is such an important step for a smooth porcelain build up. By covering the surface with a thin layer of porcelain to start with, it will prevent the layered porcelain from drying out during the dentin and enamel build up. The refractory material absorbs a great amount of moisture which could cause some micro bubbling within the restoration, so it is essential to maintain the moisture during the build up. It is recommended to use Ducera Lay Saturation Fluid from DeguDent (Figure 33) to saturate the dies prior to the build up. Place the liquid into a small container, dip the dies, leave it for approximately 5 minutes and then youre ready to continue. It is important to do a wash firing beyond the margin (at least 1-2mm over) for a better fit. Some Fluorescent Transparent - Opal porcelain is useful for the wash firing (i.e. Lava Ceram ICE 2) (Figure 34). This provides you with the right amount of fluorescence in the right place and a warm reddish translucent effect from beneath, which helps towards achieving a natural looking result.

36 eLABORATE

March/April 2010

ceramic | TECHNIQUES

Figure 35. Post-op Smile.

Figure 36. Post-op retracted view.

Figure 37. Black and White image of Post-op retracted view.

Figure 38. An example of Natural Dentition.

Figure 39. Lateral view of Post-op - Right.

Figure 40. Lateral view of Post-op - Left.

Final restorations
Figure 35 and Figure 36 show the final result of the fabricated veneers. It is an aesthetically pleasing natural looking result. The restorations blend into the surrounding natural dentition, being undetectable. There are some check points to go through to achieve a natural looking result which I detail next. Figure 37 shows the black and white image. It defines the value far more easily than coloured photos can. As you can see, the centrals are higher in value compared to the rest of the arch and this is quite often the case in an all natural dentition. Figure 38 is an example of a natural dentition showing the dif-

ference in chroma of the centrals, laterals and canines. The chroma is different in those three teeth and quite often, you see additional reddish chroma in the laterals and yellowish chroma in canines, from the base shade in the arch. As a result, they appear lower in value compared to the centrals in general. Breaking up the chroma keeps your eyes from not focusing on one particular area or point and that makes the restorations undetectable (have a look at a nice photo of natural dentition. Your focus wont stay in one area it moves around. Do you notice that? Its because they are irregular and unbalanced, but perfectly in proportion in shape as well as with colour). Figure 39 and Figure 40 show the effect of the difference in

38 eLABORATE

March/April 2010

ceramic | TECHNIQUES
References
1. Pascal Magne, Urs Belser - Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach - 2002 Quintessence. 2. Yugo Hatai - Reproducing Nature Part 1 - Understanding the shape, colour and composition of natural teeth - eLABORATE Nov/Dec 2005. 3. Yugo Hatai - Reproducing Nature Part 3 - Tooth replacement with root and colour matching using digital photo - eLABORATE Nov/Dec 2006. 4. Yugo Hatai - Reproducing Nature Part 4 - Smile Design - eLABORATE May/June 2007. 5. Yugo Hatai - Reproducing Nature: Smile Design LVI VISIONS Jan/Feb/Mar/Apr 2008. 6. Yugo Hatai - Reproducing Nature: Understanding the Composition of Natural Dentition - The European Journal of Esthetic Dentistry, Volume 3 Number 4 Winter 2008.

Figure 41. Cervical third Post-op. Figure 42. Body third Post-op. Figure 43. Incisal third Post-op.

Figure 44. Before.

Figure 45. After.

chroma. This is particularly important when you are working on a larger case to avoid creating a monochromatic uncharacterized restoration. These subtle differences are very effective in a positive way. Figure 41 shows the greatest difference in chroma with the teeth appearing healthy and natural despite the difference in chroma. The gingival level of the 22 is slightly higher than the ideal position hence some subtle root surface was created within the restoration to keep them in proportion. Figure 42 shows the mid third of the dentition. This is probably the most uncharacterized and uniform coloured area of the tooth itself. Keeping this area simple will provide a clean look yet natural appearance, so less is more! Figure 43 shows the incisal effect. Unless being specified, the irregular incisal edge of 11 is considered slightly too extreme, but it is a natural dentition with this case so some extra effect is added on the 12. Its right next to 11 so it is not that noticeable from the patients point of view, yet provides a natural effect.

22 has the opposite effect in shape, it is fairly nice and smooth, matching with 21 and 23. The shape of the laterals are quite irregular in natural dentition, so creating different shaped laterals can appear natural and helps breaks up the smile in a positive way. In this case, the area available on the laterals were different i.e. the space available for 12 was larger than 22, hence the distal of 22 was rotated protrusively to make them appear slightly wider, thus keeping them in proportion. In Figure 39 and Figure 40, the size of the laterals seem mostly the same, but in Figure 35 and Figure 36, the 22 appears slightly wider than the 12. Again, this will not be noticeable until someone points it out and again, it is a positive step towards a natural effect. Figure 44 and Figure 45 show the Before and After. What a difference!

and also for the contribution of the clinical photographs in this article. Id also like to thank my wonderful dedicated team at Smile by Yugo for their assistance.

About the author

Yugo Hatai is a master ceramist based in Sydney who has enjoyed numerous accolades from many leading clinicians for his attention to detail and ability to re-create a natural tooth. He was born in Japan in 1978 and completed the dental technicians course from Amagasaki Dental College and was then registered as a dental technician. He was later selected to further his studies at Osaka University of Dentistry Hospital. He migrated to Australia in 2000 and became a registered dental technician in NSW in 2001. Since then, he has attended many courses covering advanced dental studies. In 2008, Yugo established Smile by Yugo in Sydneys Darlinghurst to create a space to meet his vision, the fusion of Fashion and Art into dentistry. For info, see www.smilebyyugo.com.au.

Acknowledgements
Id like to thank Dr Tony Rotondo who is a Prosthodontist based in Brisbane, Australia for his outstanding skill and knowledge on both the clinical and technical perspectives

40 eLABORATE

March/April 2010