44 INSIDE DENTAL TECHNOLOGY February 2011 dentalaegis.

com
P
atients today demand
youthful, attractive smiles.
Dental professionals ap-
proaching esthetic restor-
ative cases must take into
account the entire esthetic zone, not
just a single tooth.
1,2
Undertaking cases
of functionally compromised dentition
requires comprehensive and multidis-
ciplinary treatment plans that utilize
all members of the dental team.
1,2
To
achieve consistent predictability and
the best results, open communication
between the dentist, technician, and pa-
tient, as well as proper technique and
material selections, are a must to meet
the demands of patients undergoing
restorative dental work.
1-3
MATERIAL CHOICE
When choosing a restorative material,
dentists and technicians must con-
sider all factors, including the esthetic
desires of the patient, the functional
requirements of the case, tooth color,
core or abutment use, condition of
the tooth, where the tooth sits in the
mouth (anterior or posterior region),
and whether the restoration will be
cemented or bonded.
4
With a variety
of materials available on the market
today, dentists have the unique ability
to choose a product that ofers them the
best in functionality and esthetics while
providing the greatest amount of char-
acterization and placement options.
4
The following case demonstrates
how a lithium-disilicate glass-ceramic
material was used to restore the den-
tition of a young female patient who
presented with excessive wear and pre-
vious dental work. Through the use of
the pressable technique and a team ap-
proach, the patients desire for a more
esthetic smile was achieved, while func-
tion and strength were restored to the
oral cavity.
Lithium-disilicate ceramic mate-
rial contains approximately 70% by
volume needle-like crystals in a glassy
matrix. The matrix controls the size,
shape, and density of the crystals, giving
lithium-disilicate glass-ceramic greater
strength and durability.
5,6
Because the
material displays a relatively low re-
fractive index, optical qualities such
as translucency allow for optimal
esthetics.
5-7

Currently available for two diferent
processing techniques, lithium-disili-
cate ceramic material gives dentists and
technicians the opportunity to provide
highly functional and esthetic restora-
tions in a variety of indications.
6,8
In
the pressable form (IPS e.max

Press,
Ivoclar Vivadent, www.ivoclarvivadent.
com), restorations are fabricated with
a wax hot-press technique and dem-
onstrate a exural strength of 400
MPa.
6,8
Using CAD/CAM technology,
milled lithium-disilicate (IPS e.max

CAD, Ivoclar Vivadent) restorations
can be created in either the laboratory
or chairside in the dental ofce.
6,8
Due
to the diference in crystal size from
the lithium-disilicate press, exural
strength of the mill material is slightly
lower at 360 MPa.
6-9
Available in a variety of translucen-
cies, the esthetic nature of lithium-dis-
ilicate restorations can be further char-
acterized and enhanced using either a
cutback-and-layer or stain-and-glaze
technique.
5,10
In cases requiring the
restoration of worn dentition and re-
moval of previous restorative work and
materials, the use of lithium disilicate
is benecial because it demonstrates
high strength, esthetic qualities, ease
of fabrication, versatility, and predict-
able results.
6
CASE PRESENTATION
A 25-year-old woman presented with
signicant wear and an old composite
build-up on teeth Nos. 8 and 9 to close
a diastema (Figure 1 through Figure 4).
The patient wanted a glamorous smile,
therefore it was decided that the treat-
ment plan would include restoration
of teeth Nos. 6 through 11. A diagnostic
wax-up was completed to demonstrate
the nal results of the case to the pa-
tient and to ensure that the restorations
would meet the patients goals (Figure
5).
11,12
Once the patient accepted the
treatment plan, a preparation appoint-
ment was made.
BRAD JONES, FAACD
Owner
Professional Dental Arts
Boise, Idaho
MasterClass
Workshop
/
Hands On
/
Gallery
Repairing Worn
Dentition
Using the press technique, six anterior crowns restored the
patients beautiful smile.
By Brad Jones, FAACD
dentalaegis.com February 2011 INSIDE DENTAL TECHNOLOGY 45
Fig 1. A preoperative portrait
of the patient.
Fig 2. A preoperative view of
the patients smile.
Fig 3. A preoperative retracted
view of the patients dentition.
Fig 4. A preoperative close-up
retracted view of the patients
dentition, teeth Nos. 6 through 11.
Fig 5. The diagnostic wax-up
was completed.
Fig 1.
Fig 2.
Fig 3.
Fig 4.
Fig 1.
Fig 3.
Fig 4. Fig 5.
Fig 2.
46 INSIDE DENTAL TECHNOLOGY February 2011 dentalaegis.com
Hands On
CLINICAL APPOINTMENT
Using a matrix made from the diag-
nostic wax-up, a mock-up was formed
intraorally using a temporary material.
A 0.7-mm depth-cutting bur was then
used to cut into the mock-up. To ensure
conservative preparation and preserva-
tion of sound tooth structure, consider-
ation was made to avoid removing tooth
structure when cutting into the plastic.
A conservative approach was taken to
avoid over-preparing the teeth.
After the initial preparation was
done, 12 preoperative photographs
were taken of the patient before the
diagnostic wax-up was complete. After
the preparation and margins were -
nalized, a photograph of the prepara-
tion color was taken to communicate
the shade of the preparations to the
laboratory. Final impressions and a
bite registration were then completed.
To form the provisional restorations,
the same matrix from the diagnostic
wax-up was used. Photographs and
impressions of the provisionals were
taken one week after the preparation
appointment, including an eyebrow-
to-chin photograph of the patient smil-
ing, the most important of all clinical
images.
13
LABORATORY PROTOCOL
To meet the requirements of the cli-
nician and patient, laboratory techni-
cians must have all necessary diagnos-
tic tools and information available to
them prior to building the restorations.
These items include preoperative pho-
tographs, provisional photographs and
impressions, master impressions, bite
registrations, and a horizontal plane
reference (stick bite).
13
It is of the ut-
most importance to have an eyebrow-
to-chin photograph of the patient, with
the stick bite in place on the lower in-
cisors, to communicate the needs of
the case.
13
Proper model work forms
the foundation of the nal restorative
outcome.
In the laboratory, a matrix was ini-
tially formed over the cast of the pro-
visionals. The matrix was used as a
mold during wax injection onto the
treated master dies. Through the lost-
wax process, the nal restorations were
produced using lithium-disilicate glass-
ceramic (IPS e.max

) HTBL1 ingots
pressed at a temperature of 917C.
After pressing, the facialincisal edge
was marked with a red pencil, followed
by marking with a 0.3-mm lead pencil
(Figure 6). The pencil marks were
used to accurately indicate a line 0.5
mm lingually for facial reduction. This
reduction was completed using a K6974
220 centered diamond disc (KOMET
USA, www.kometusa.com). A red pen-
cil was again used to mark the incisal
interproximal area to be troughed out
with the K6974 220 centered diamond
disc (Figure 7). The trough was created
to carry the gray-blue stain, which im-
parted an incisal efect similar to that of
the patients natural dentition.
Universal stains were then applied
to emulate the high and low value de-
tails found in the internal structures
of the patients natural teeth (Figure
8). After building the center lobe with
Fig 6. A 0.5-mm facial reduc-
tion was accomplished using
a KOMET K6974 220 centered
diamond disc to bevel down
approximately one-half of the
restoration.
Fig 7. A red pencil was used to
mark the incisal interproximal
area to be troughed out using
the KOMET K6974 220 centered
diamond disc.
Fig 8. Using universal stains,
both high and low value details
that are typically found inter-
nally in a natural tooth were
emulated.
Fig 5.
Fig 7.
Fig 6.
Fig 8.
Fig 6.
Fig 7. Fig 8.
dentalaegis.com February 2011 INSIDE DENTAL TECHNOLOGY 47
light and salmon mamelon powders
(Ivoclar Vivadent), OE4 white dentin
powder (Ivoclar Vivadent) was applied
to create the mesial and distal internal
lobes (Figure 9). To nalize the inter-
nal efects, light mamelon material
was placed on the incisal edge using a
fanned build-up brush in order to cre-
ate a natural halo efect (Figure 10).
Once this process was complete, the
internal efects were red (Figure 11).
Opal clear (OE1) and high-val-
ue enamel (TI1) powders (Ivoclar
Vivadent) were then segmented care-
fully to maintain OE1 on the outermost
incisal, mesial, and distal edges (Figure
12 and Figure 13). The contoured enam-
els were carefully placed on the restora-
tions, which were then red at the high
temperature of 750C. After ring, the
facial lobes and surface texture were
created using an 842r diamond bur
(KOMET USA). The surfaces of the
restorations were then glazed, polished,
and ready for delivery.
FINAL CEMENTATION
After the completed restorations
were received from the laboratory,
the patient returned to the ofce for
the cementation appointment. Once
the provisionals were removed and
the teeth prepared for cementation,
the patient was administered 15 mg
of propantheline bromide 30 minutes
prior to treatment. Propantheline was
used because of its ability to stop most
salivary ow for several hours, mak-
ing isolation and cementation easier
to achieve. However, care should be
taken when using propantheline with
patients who wear contact lenses.
These patients should remove them
prior to taking the medication since it
will cause excessive drying of the eyes.
The patient was rst tted with a
lip and cheek retractor (OptraGate

,
Ivoclar Vivadent). The teeth were then
etched with a 37% phosphoric acid
system (Total Etch, Ivoclar Vivadent)
for 10 to 20 seconds. To prevent post-
operative sensitivity, a dentin surface
conditioner (Systemp.

Desensitizer,
Ivoclar Vivadent) was placed and air-
dried. A single component bonding
agent (Optibond

Solo Plus, Kerr

Corporation, www.kerrdental.com)
was placed in the veneers, which had
been prepared using a standard etching
technique consisting of 5% hydrochlo-
ric acid and a silane agent. The bonding
agent was then applied to the prepara-
tions, air-dried, and light-cured.
Resin cement (Calibra

, DENTSPLY
International, www.dentsply.com) in
a translucent base shade was then
used to ensure proper midline sym-
metry of the restorations for the cen-
tral incisors, which were seated and
bonded. These were tacked with a
2-second cure directly on the facial
using a 4-mm turbo tip. The resto-
rations for the lateral incisors were
then seated, followed by the canines,
each with a 2-second turbo tack cure.
Because all six restorations were to
be seated in 2 minutes, efficiency and
speed were required. After seating,
an 11-mm curved curing tip was used
for approximately 10 seconds to wave
over the buccal and lingual aspects of
all restorations.
Excess cement was then removed
with a sickle scaler and oss. Glycerin
gel was placed on all margins and a -
nal cure was completed with an 11-mm
tip for 20 seconds on both the buccal
and lingual aspects. It was ideal to use
two curing lights at the same time, one
on the lingual of the tooth and one on
the buccal, to ensure even curing and
to prevent any shrinking of the cement
toward or away from the light. Upon
completion of the procedure, a beautiful
Fig 9. After the center lobe
was built in using light and
salmon mamelon powders, OE4
(white dentin) powder was used
to create the mesial and distal
internal lobes.
Fig 10. To nalize the internal
powder efects, light mamelon
material was placed on the inci-
sal edge with a fanned build-up
brush, creating a natural halo
efect.
Fig 11 A view of the internal
efects after ring.
Fig 12. An incisal view of
internal efects before powder
enamel placement. Notice the
interproximal troughs were
ready for low value, highly opal
(OE1) powder.
Fig 13. An image of the enam-
el powder placement diagram.
It was ideal to use two curing lights at the same time, one on
the lingual of the tooth and one on the buccal, to ensure even
curing and to prevent any shrinking of the cement toward or
away from the light.
Fig 9.
Fig 10.
Fig 12. Fig 13.
Fig 11.
48 INSIDE DENTAL TECHNOLOGY February 2011 dentalaegis.com
Hands On
Fig 14. A nal postoperative
portrait view of the patient and
her new smile.
Fig 15. A nal postoperative
view of the patients lips in
repose.
Fig 16. A view of the patients
postoperative smile.
Fig 17. A retracted postopera-
tive view of the patients smile
makeover.
Fig 18. A postoperative
close-up retracted view of the
patients new restorations, teeth
Nos. 6 through 11.
esthetic outcome was achieved through
the use of predictable methods and ma-
terials (Figure 14 through Figure 18).
CONCLUSION
When undertaking cosmetic restor-
ative treatments, it is important to
consider all modalities of treatment
and available materials. With this case,
sustained and proper communication
between the dentist and technician, as
well as with the patient, allowed opti-
mal results to be achieved.
11,12
Exceptional outcomes are accom-
plished not only through experience,
but also by the ability of the dentist and
technician to closely predict the results
of each and every case. By considering
case selection, method of treatment,
and material, and by visualizing the
anticipated restorations, dentists and
laboratory ceramists can succeed in de-
livering optimal esthetics and fullling
patient desires.
13
The author would like to thank Tim Huf,
DDS, for his excellence in dentistry.
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Fig 14.
Fig 15.
Fig 17.
Fig 18.
Fig 16.