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MIPP: Key elements Case presentation matrix was fabricated and the fi-
nal composite resin mock-up was
The minimally invasive prosthetic A 38-year-old woman presented performed prior to the initial tooth
procedure (MIPP) is a compre- to the first author’s clinic stating preparation to evaluate function
hensive treatment modality rec- that she was unhappy with the ap- and esthetics (Fig 3). Subsequent-
ommended especially in cases of pearance of her teeth and she ex- ly, an impression of the two arches
severely worn dentition involving perienced difficulty in chewing and with the composite resin mock-up
the following procedures: sensitivity to cold. She was diag- was taken using irreversible hydro-
nosed with Sjögren syndrome and colloid (Jeltrate, Dentsply/Caulk)
• Increase of the VDO. In exten- was being treated with cortisone to fabricate the provisional acrylic
sive rehabilitations, alteration and azathioprine. In the clinical in- resin restoration. Tooth preparation
of the VDO is possible if the terview regarding her expectations was performed with the appropriate
restorative treatment plan in- to improve her smile, she empha- burs to achieve overall reductions
volves at least one arch. The sized her desire to have highly es- of 0.8 mm occlusally and 0.4 to
interocclusal space gained en- thetic restorations without the use 0.6 mm axially (Fig 4). Tooth struc-
ables the clinician to reduce of metal. A thorough clinical oral ex- ture removal on the occlusal sur-
the occlusal tooth preparation amination and radiographic evalua- face was limited to only 0.3 mm in
depth and to maintain tooth tion were performed. There were no the posterior teeth because 0.5 mm
structure and vitality. adverse findings during the muscu- of space was gained in both arches
• Minimally invasive tooth prepa- loskeletal examination. Significant by increasing the VDO by 1 mm
ration. The goal is to reduce intraoral findings included gener- posteriorly. Therefore, 0.8 mm of
tooth structure removal, espe- alized moderate-severe erosion of occlusal clearance was achieved
cially in the occlusal area, to cre- the cervical, midfacial, anterior inci- for the use of the monolithic mate-
ate a restoration with a thickness sal, and posterior occlusal surfaces; rial. As a result, it was also possible
not exceeding 0.8 to 1.0 mm caries lesions; minimal plaque ac- to maintain most of the remaining
and to preserve more enamel cumulation; and low salivary flow enamel on the abutment previously
surfaces along the axial walls and (Fig 1). It was proposed to increase built with the composite resin re-
the light chamfer finish line for a the incisal length of the maxillary construction (Fig 5). The finish line
superior bond over dentin.21 anterior incisors, together with al- on the cervical area was positioned
• Monolithic lithium disilicate pos- teration of the VDO 3 mm anteriorly. in the sulcus (intracrevicular prepa-
terior restorations. It is hypoth- These modifications were evaluated ration) to optimize the esthetic re-
esized that a monolithic lithium with a direct mock-up in the anterior sult and to include any possible
disilicate material with a re- segment using a flowable composite existing tooth structure deficiency
duced thickness (0.8 to 1.0 mm) resin material (Systemp Flow, Ivoclar in the restoration design. The shell
can be used with a full-contour Vivadent) (Fig 2). The initial study of the provisional restorations was
design for partial- and full- casts were mounted at the new fabricated at the new VDO with the
coverage restorations without VDO on a semiadjustable articulator modified indirect technique, then
adding veneering porcelain. (Denar Mark II, Denar) using an ar- relined and cemented temporarily
• Bonding the restorations. Ad- bitrary facebow transfer and poste- with zinc oxide noneugenol cement
hesively bonding the restora- rior wax (Beauty Pink, Moyco Union (Freegenol, GC Dental). The pa-
tions, mainly in enamel with an Broach), and the diagnostic wax-up tient’s comfort, speech, and appear-
etchable ceramic material, is was completed in accordance with ance were reassessed after 1 month,
likely the key element for the the clinical findings. After duplicat- and the final impression was fabri-
success of this restoration. ing the wax-up, the transparent cated. After placement of double
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Figs 2a and 2b Anterior direct mock-up allowed the clinician to evaluate the amount of increase in VDO that would have to be performed
to fulfill the esthetic and functional needs of the patient.
cord in the sulcus (Ultrapack, Ultra- nique (Fig 6). Then, an intraoral
dent), the final impression was taken facebow and centric relation records
with a polyether material (Impregum were taken at the new VDO such
Penta Duo Soft, 3M ESPE) using a that the stone cast replicas of the
light-activated custom tray (Palatray provisional restoration were able to
LC, Haraeus Kulzer) and the single- be cross-mounted with the master
impression double-mixing tech- cast of the tooth preparation.
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140
1.5–2.0 mm
0.8–1.0 mm
1.5–2.0 mm
Figs 4a to 4c Once the volume of the final restoration was defined by the complete mock-up, the preparation of teeth for the definitive
crown could be performed with calibrated burs to achieve an occlusal reduction of (a and b) 1.5 to 2.0 mm in the incisal aspect of the
anterior teeth and (c) 0.8 to 1.0 mm in the occlusal aspect of the posterior teeth.
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141
Figs 5a and 5b A very light chamfer preparation was performed, slightly deepening the margin in the intrasulcular position. Note the
minimum preparation thickness and remarkable maintenance of enamel.
Figs 6a and 6b Occlusal view of the final preparation. Note the minimum amount of tooth reduction performed.
Adhesive cementation vicular fluid and to act as a barrier onds, thoroughly rinsed with water,
for the penetration of the resin ce- and put in an ultrasonic bath with
Cementation followed a precise pro- ment to the base of the sulcus. The distilled water for 3 minutes. After
tocol. Retraction cords were placed inner surfaces of the restorations thorough air drying, the intaglio
in the sulcus of every abutment to were etched with hydrofluoric acid surface was silanized (Monobond-
minimize the humidity from the cre- 4.5% (Ivoclar Vivadent) for 20 sec- S, Ivoclar Vivadent) and dried for
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142
60 seconds (Fig 7). Tooth prepara- tions, and teeth were coated with
tions were cleaned with pumice and the adhesive system (Syntac, Ivo-
rubber burs (Opticlean, KerrHawe), clar Vivadent), and because of the
etched for 30 seconds on enamel reduced thickness of the ceramic
and 10 seconds on dentin with restoration, a light-polymerized
37.5% phosphoric acid (Ultra-Etch, composite resin cement (Variolink
Ultradent Products), rinsed, and II, Ivoclar Vivadent) was selected to
dried. Both fitting surfaces, restora- lute the restorations (Figs 8 and 9).
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143
b
Figs 9a and 9b (a) Initial and (b) final full-mouth radiographs. The ultraconservative MIPP approach
guaranteed the maintenance of vitality of all the teeth.
Discussion calcium phosphate ions; less sa- is a complex and challenging condi-
liva predisposes patients to car- tion for the dentist to diagnose and
Sjögren syndrome has been proven ies, especially on smooth surfaces manage.22 There is no evidence in
to be a progressive disease, since that are usually well protected. Sa- the literature that suggests pros-
patients have shown deteriorat- liva contains antimicrobial proteins thetic treatment for this type of
ing lacrimal and salivary secretion and immunoglobulins that help to patient and no indication whether
over time. Saliva is protective of limit the adherence and growth of a complete-coverage restoration
enamel by its supersaturation with plaque bacteria. Sjögren syndrome design can reduce the incidence
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144
Figs 10a and 10b The final result shows a satisfactory biologic, functional, and esthetic integration of the full-mouth rehabilitation.
Figs 11a and 11b Anterior guidance shows a correct disclusion of posterior teeth.
of caries in long-term follow-up. case.23 It is sensible and beneficial with a reduced thickness (0.8 mm)
Since patients with this condition to maintain pulpal vitality and pre- was used for the posterior teeth.
are at a higher risk for caries, they vent endodontic treatment and the Monolithic glass-ceramic struc-
need to be seen more regularly need for a post-and-core restora- tures offer some distinct ad-
for examinations, given preventive tion because these more invasive vantages in that they provide
treatment such as home fluoride approaches violate the biome- exceptional esthetics without re-
regimens to follow, and maintain chanical balance and compro- quiring a veneering ceramic (Figs
excellent oral hygiene that should mise the performance of restored 10 to 12). Therefore, by eliminating
be regularly reinforced by the teeth over time.24 An all-ceramic the veneered ceramic and using
dental practitioner. layered material over a lithium di- only a 0.8-mm-thick core mate-
Maintenance of tooth struc- silicate coping (e.max Press) was rial with 360 to 400 MPa of flexural
ture is the approach that guides chosen to achieve high esthetics in strength, greater structural integrity
the dentist during treatment, es- the anterior teeth, and the mono- can be achieved with minimal re-
pecially in this particular clinical lithic form of this ceramic material moval of tooth structure.
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145
Figs 12a to 12d Appropriate function helped maintain the integration achieved after 3 years of service.
There is a lack of data on the ence on the fatigue resistance of studies comparing different mate-
selection of the appropriate mate- such thin (0.8-mm thick), nonreten- rials suggest that lithium disilicate
rial, specifically regarding the influ- tive restorations. However, recent seems to be more effective when
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147
15. Stappert CF, Att W, Gerds T, Strub JR. 21. Sorensen JA, Munksgaard EC. Relative 27. Wolfart S, Eschbach S, Scherrer S, Kern
Fracture resistance of different partial- gap formation of resin-cemented ce- M. Clinical outcome of three-unit lithi-
coverage ceramic molar restorations: An ramic inlays and dentin bonding agents. um-disilicate glass-ceramic fixed dental
in vitro investigation. J Am Dent Assoc J Prosthet Dent 1996;76:374–378. prostheses: Up to 8 years results. Dent
2006;137:514–522. 22. Bayetto K, Logan RM. Sjögren’s syn- Mater 2009;25:e63–e71.
16. Bindl A, Lüthy H, Mörmann WH. Strength drome: A review of aetiology, pathogen- 28. Edelhoff D, Florian B, Florian W, Johnen
and fracture pattern of monolithic CAD/ esis, diagnosis and management. Aust C. HIP zirconia fixed partial dentures—
CAM-generated posterior crowns. Dent Dent J 2010;55(suppl 1):39–47. Clinical results after 3 years of clinical ser-
Mater 2006:22:29–36. 23. Edelhoff D, Sorensen JA. Tooth structure vice. Quintessence Int 2008;39:459–471.
17. Hill TJ, McCabe P, Tysowsky G. Bond- removal associated with various prepa- 29. Fasbinder DJ, Dennison JB, Heys D,
ing and thickness effect on fracture load ration designs for posterior teeth. Int J Neiva G. A clinical evaluation of chair-
of CAD/CAM crowns [abstract 2321]. Periodontics Restorative Dent 2002;22: side lithium disilicate CAD/CAM crowns:
J Dent Res 2008;87(Spec Iss B). 241–249. A two-year report. J Am Dent Assoc
18. Esquivel-Upshaw JF, Young H, Jones J, 24. Torbjörner A, Fransson B. Biomechanical 2010;141(suppl 2):10S–14S.
Yang M, Anusavice KJ. In vivo wear of aspects of prosthetic treatment of struc- 30. Clausen JO, Abou Tara M, Kern M. Dy-
enamel by a lithia disilicate-based core turally compromised teeth. Int J Prostho- namic fatigue and fracture resistance of
ceramic used for posterior fixed partial dont 2004;17:135–141. non-retentive all- ceramic full-coverage
dentures: First-year results. Int J Prostho- 25. Petra G. All-ceramic partial coverage res- molar restorations. Influence of ceramic
dont 2006;19:391–396. torations: Effect of minimal invasive prep- material and preparation design. Dent
19. Heintze SD, Cavalleri A, Zellweger G, aration on fracture resistance. Presented Mater 2010;26:533–538.
Büchler A, Zappini G. Fracture frequency at the 2010 SCAD meeting, Newport
of all-ceramic crowns during dynamic Beach, California, 24–25 Sept 2010
loading in a chewing simulator using dif- 26. Guess PC, Zavanelli RA, Silva NR, Bon-
ferent loading and luting protocols. Dent fante EA, Coelho PG, Thompson VP.
Mater 2008:24:1352–1361. Monolithic CAD/CAM lithium disilicate
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Anusavice KJ. In vivo analysis of enamel parison of failure modes and reliability
wear against ceramic materials. Pre- after fatigue. Int J Prosthodont 2010;23:
sented at the IADR/AADR/CADR 87th 434–442.
General Session and Exhibition, Miami,
Florida, 1–4 April 2009.
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