LabTalkChris.pdf

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56 INSIDE DENTISTRY |October 2010 |insidedentistry.net

Since their develop-

ment in the 1980s,

porcelain veneers

have undergone a

major metamorpho-

sis.1From minimally

prepared teeth utiliz-

ing feldspathic porcelain (0.3-mm to

0.5-mm preparation) to pressed ceram-

ics (0.7 mm or more preparation) such

as the IPS Empresssystem (Ivoclar

Vivadent, www.ivoclarvivadent.us), to

the minimal- and no-preparation ve-

neers of today, ceramics have evolved

to meet the needs of practitioners and

patients alike.

With t he introduction of productsmade from lithium disilicate, such as

IPS e.max(Ivoclar Vivadent), today s

no-preparation veneers are highly es-

thetic and extremely strong. A flexural

strength of 400 MPa also allows the

practitioner to make them very thin.2

IPS e.max restorations give dentists

the ability to provide excellent esthet-

ics and functionality, with minimal

preparation and/or damage to the

surrounding soft tissue and dentition.2

The preparation for these products

is minimal compared to conventional

full crowns, which significantly de-

creases the risk of pulpal damage.2

Also, there are less periodo ntal issues

because the margins of the veneers are

thin and usually end at or just above

the free gingival margin.2 In proce-

dures that involve porcelain veneers,

the preparation should be kept in the

enamel whenever possible.3 As the

linguals of the anterior teeth are usu-

ally left intact, the occlusion and ante-

rior guidance can also be more easily

maintained.3

The final esthetic result,however, depends on the practitioners

communication with the laboratory

technician and the laboratory techni-

cians artistic ability.3

Case StudyA 22-year-old man presented with the

chief complaint of shifting dentition

and spatial issues between his front

teeth (Figure 1 and Figure 2). These

issues developed upon completion of

orthodontic treatment 5 years earlier,

and he did not like the large diastema

between his central incisors.

A comprehensive oral evaluation was

completed, which included a temporo-

mandibular joint disorder (TMJ) ex-

amination and a periodontal evaluation,

including panoramic and full-mouthradiographs. A series of photographs,

a bite registration, and impressions for

study casts also were taken. H

presented as asymptomatic, buwas evidence of parafunction.

at-rest photograph also reveal

he did not display enough of

tral incisors for someone his a

patients maxillary anterior te

peared esthetically displeasing

a reverse smile line that resulte

the unusually short central inc

The patients anterior teeth

verged in differ ent directio ns.

the axial alignment of his f ron

should have had a mesial incl

toward the midline, beginnin

the central incisors and exten

the canines.4

Different options were dis

such as orthodontics, direct b

and porcelain veneers. The

previously had orthodontics

not want to have that treatmen

Direct bonding was also a p

ity, but it would be difficult an

consuming to correct the pr

Porcelain veneers were part of h

ment plan for teeth Nos. 6 thro

Laboratory ProcedureInitially, the study casts, bite r

tion, and photographs were sen

dental laboratory for evaluatio

duction guide was also made to the teeth for movement into a

vorable alignment. Prior to com

Using MinimallyInvasive Veneers to Close

Anterior DiastemasNew ceramic materials facilitate a more conservative approach that can produce stronger,

highly esthetic restorations with minimal trauma to patients teeth.

ByBrian Dennis, DDS | Bradley L. Jones, FAACD

PRETREATMENT AND WAX-UP (1.)Preoperative portrait of the patienface and smile. (2.)Preoperative close-up of the patients smile. (3.)Thdiagnostic wax-up was completed. (4.)The preparation procedure for

veneers consisted of making 0.5-mm depth cuts into the provisionals.Close-up of the patients smile with the provisionals in place.

FIG. 2

FIG. 4

FIG. 3

FIG. 5

FIG. 1

BRADLEY L. JONES,

FAACD

Private Practice

Boise, Idaho

BRIAN DENNIS, DDS

Private Practice

Albuquerque, New Mexico

PRACTICE BUILDING | ROUNDTABLE | RESEARCH & APPLICATIONS LAB TALK

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of a diagnostic full-contour wax-up,

the teeth on the cast were reduced to

contour (Figure 3). A study cast, with

mock preparations for the veneers, was

also fabricated and used as a guide forthe reduction of teeth Nos. 6 through 11.

Clinical PreparationPreoperative shades were taken using a

VITA shade guide (Vident, www.vident.

com), followed by digital photographs to

communicate the correct shading to the

laboratory. The patient was then anes-

thetized using lidocaine with epineph-

rine 1:100,000. The reduction guide was

placed over the teeth and the facial sur-

faces of the central incisors. The cusp tip

areas of the canines were then contoured

using a high-speed NSK electric hand-

piece and a KS1 diamond bur (Brasseler

USA, www.brasselerusa.com).

The putty matrix was then placed in

the mouth to ensure a proper fit. It was

filled with a bis-acryl resin (TurboTemp,

Danville Materials, www.danvillemate-

rials.com) and placed over the anterior

teeth, then removed. Upon discussion

with the patient, he was satisfied with

the appearance of the mock-up. Using

the mock-up as a guide, the teeth were

prepared for the porcelain veneers.

First, the incisal edges were reduced

with a depth cut of 1.5 mm using the

KS1 bur and connection of the depth

cuts to produce a uniform incisal edge.

Next, using an 834-016 bur (BrasselerUSA) as a guide, depth cuts of 0.5 mm

were made across the facial surfaces

(Figure 4). The initial depth cuts were

then connected using a KS1 bur to cre-

ate a uniform facial surface without

sharp internal angles. The interproxi-

mal margins were extended lingually

with a KS0 bur (Brasseler USA).

The margins for the veneers were car-

ried to the free gingival margins with the

KS1 diamond bur, using a Zykra retrac-

tor, to protect the gingival area from

being abraded. The margins were then

finished with a 661-420 white stone

(Brasseler USA). A 0053 brown rubber

point (Brasseler USA) was used on the

highest speed setting to leave a smooth

finish on the enamel surfaces.

Stumpf shades of the prepared teeth

were taken with the VITA shade guide

and photographed. An initial polyvinyl

impression (Aquasil, DENTSPLY Caulk,

www.caulk.com) was taken and poured

in stone (Denstone, Heraeus, www.her-

aeus-dental-us.com) to fabricate the pro-

visional restorations. A final impression

LABORATORY FABRICATION (6.)

Wax was injected through theputty matrix onto the master dies.(7.)IPS e.max, Impulse Value 1,

was then pressed to a thickness of0.5 mm. (8.)View of the markings

made on the restorations to showthe specific depths and tapers tobe cut into the restorations. (9.)

Utilizing a center diamond disc, anundercut was made to guarantee ahalo at the end of the process.

LAYERING EFFECTS (10.)Deepmesio-incisal and disto-incisal troughswere cut to create a natural low-val-

ue effect. (11.) High- and low-value

internal stain effects were added to therestorations to create an esthetically

pleasing result. Gray stain was alsoadded to the mesio-incisal and disto-incisal troughs for even more esthetic

value. (12.)IPS e.max Light MM powderwas then used, with a single segmentof Salmon MM in the middle lobe,

to make up the internal mamelons.White dentin powder was then feath-ered over the ends of the mamelons

and into the middle cervical. (13.) Tofinish the internal powder effects,Light MM was added to the incisal

edge to finalize the halo effect.

FINAL LAYERING AND FIRING(14.) View of the fired internaleffects prior to the enameling

process. (15.)Segmental enamel

layering was accomplished witha low-value opal and a high-value

tagged blue enamel powder. (16.)

Image of the segmental enamelafter the firing process. (17.)Afte

using a medium diamond disc tosmooth the surface, the line anglwere created and the heights of

the contour were established. Thdeflected and reflected zones alswere incorporated at this time.

FIG. 8 FIG. 12 FIG. 16




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58 INSIDE DENTISTRY |October 2010 |insidedentistry.net

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was then made of the maxillary arch using

the PVS materials.

Using a duplicated model of the diag-

nostic wax-up, a provisional vacuum-

formed matrix was made (Copyplast,Scheu-Dental GmbH, www.scheu-dental

.com) using a positive-pressure thermal-

forming machine (Biostar/MiniSTAR,

Scheu-Dental GmbH). The matrix was

then filled with shade A1 TurboTemp

and placed over the preparations.

The provisional restorations were

removed from the cast in one piece and

then trimmed to fit the teeth. Once the

provisional was completed, it was tried

in to verify fit, esthetics, and phonetics.

Upon patient approval, the provisional

was taken back to the laboratory and

coated with Palalseal (Heraeus) to give

it the smooth appearance of the sur-

rounding dentition.

Teeth Nos. 6 through 11 were then

etched for 15 seconds with 37% phos-

phoric acid (Ultradent Products Inc,

www.ultradent.com), followed by rins-

ing. Gluma (Heraeus) was then applied

to all of the teeth to kill bacteria and de-

sensitize them. The provisionals were

then filled with a flowable composite

(Accolade, Danville Materials) in shade

A1 and seated on the teeth.The excess resin was removed with

a No. 3 synthetic brush (Cosmedent

Inc, www.cosmedent.com) and then

light-cured. Care was taken to remove

any residual composite, and then the

occlusion was checked with articulat-

ing paper (AccuFilm, Parkell Inc, www.

parkell.com). The provisionals were ad-

justed and polished. Photographs of the

provisionals and an alginate impression

were taken to communicate specifica-

tions to the laboratory (Figure 5).

Laboratory FabricationThe first step of the laboratory fabri-

cation process was to inject the matrix

from the approved provisional model

onto the prepared master dies (Figure

6). Once completed, a medium translu-

cency lithium disilicate ingot (IPS e.max

Impulse Value 1, Ivoclar Vivadent) was

pressed to a thickness of 0.5 mm (Figure

7). The restorations were marked for a

0.5-mm reduction on the facial (Figure

8). A 9001 contour stone (Komet USA,

www.kometusa.com) was utilized at alow setting to reduce 0.5 mm of the in-

cisal facial area and to taper the face of

the restorations. Next, a K6974 cintered

diamond disc (Komet USA) was used

to undercut the restorations (Figure 9).

It was also necessary at this time to cut

a deep mesio-incisal and disto-incisal

trough to create a natural low-value ef-

fect (Figure 10).

High and low internal staining ef-

fects were then utilized, with gray stain

added to the mesio-incisal and disto-in-

cisal troughs (Figure 11). After staining,

IPS e.max Light MM powder (Ivoclar

Vivadent) was used, with a single seg-

ment of Salmon MM in the middle lobe

to compensate for the internal mamel-

ons (Figure 12).

A white dentin powder (IPS e.max,

shade 0E3, Ivoclar Vidadent) was then

feathered over the mamelons and the

cervical middle. The internal powder

effects were finished with the addition

of IPS e.max Light MM to the incisal

edge (Figure 13). Once all internal ef-

fects were completed, they were fired in

preparation for the enameling process

(Figure 14).

A low-valu e o pal a nd a high-value

tagged blue enamel powder (IPS e.max

shades 0E1 and TI1, respectively) werelayered in segments until the restoration

appeared esthetically correct (Figure

15). Upon completion, the segmental

enamel was fired (Figure 16). A me-

dium diamond 842 disc (Komet USA)

was used to smooth the surface, create

line angles, and establish the heights of

the contour (Figure 17). The 842R disc

was then used to define the surface lobes

and morphology. Once the restorations

were glazed and polished, they were sent

to the practitioners office for final place-

ment (Figure 18 and Figure 19).

Clinical ProcedureUsing a medium-value try-in gel (Vario

link Veneer MVO, Ivoclar Vivadent), each

veneer was tried in to verify the fit and

path of insertion. Clinical photographs

were taken to check the appearance of the

veneers. The try-in paste was removed

from the veneers, and each veneer was

steam-cleaned to remove contaminants.

The veneers for the central incisors

were fi rst t reated with a co nditio ner

(Clearfil porcelain bond activator,

Kuraray Dental, www.kurara

com) for 20 seconds and lightly c

with air. A b onding agent (C

Photobond, Kuraray Dental) w

placed in the veneers and lighblown to remove the volatile mo

After Variolink Veneer was place

veneers, they were set in a Resin

(Cosmedent).

The prepared teeth were i

with the cheek and lip retrac

ing OptraDam (Ivoclar Vivade

cotton rolls were placed in the

vestibule. The veneers were ce

in pairs, the central incisors, te

10 and 11 and teeth Nos. 6 and

central incisors were etched w

phosphoric acid for 15 secon

rinsed. Gluma was then app

the central incisors. Photobo

dispensed, mixed, and placed

micro-brush on teeth Nos. 8 an

teeth were then dried with an a

(A-dec Inc, www.a-dec.com).

Next, the veneers on Nos. 8

were placed and seat ed in the

position. The gingival margin

veneers were then light-cured f

onds to tack them into place. Usi

6 sable brush (Cats Tongue, Pr

Art and Brush Co, www.princ

andbrush.com), the excess re

removed facially, lingually, an

proximally. The veneers wer

for 20 seconds on the facial and

DeOx(Ultradent Products) waaround the margins of the v

which were light-cured for 40

facially and lingually. The De

rinsed-off, and residual ceme

removed from the distal.

The veneers for teeth Nos.

were tried on as a pair to ensu

they would fit. The veneers fo

Nos. 10 and 11 were tried on

However, once the first two v

were cemented, the lateral incis

canine did not fit completely i

This was the case with tooth N

well. Using a 952 Vision Flex d

disk (Brasseler USA), the distal

No. 8 was lightly buffed until the

for tooth No. 7 seated complete

The veneers were cleaned w

steamer and treated with sila

Photobond. The veneers wer

filled with Variolink Veneer and

in the Resin Keeper. Teeth Nos

11 were etched with 37% phos

acid, and the veneers were seat

procedure was repeated with te

6 and 7.


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insidedentistry.net |October 2010 |INSIDE DENTIS

Very little resin needed to be cleaned

up, and residual cement was removed

with a No. 12 scalpel. Floss was used

to remove any cement left interproxi-

mally and to administer a final check ofthe contacts. Accufilm was then used

to mark the occlusal contacts, and any

occlusal discrepancies were adjusted.

During a follow-up visit, periapical

radiographs were taken to check for

any cement that may have been un-

der the gingiva. Occlusion was then

marked and adjusted once again. An

upper alginate impression was taken

for use in fabricating a maxillary oc-clusal appliance to help protect the

veneers and the rest of the teeth from

parafunction.

There were several areas where the

gingiva was still slightly inflamed, and

FINAL RESULTS (18.)A retracted postoperative view of the patients restorations. (19.)Postoperative portrait of the

patients face and new smile.

FIG. 19FIG. 18

the contour of the gingiva around tooth

No. 8 did not match that of tooth No. 9.

Topical anesthetic was placed on the

gingival of tooth No. 8, and a single wire-

tipped electro-surgery unit (Parkell)was used to sculpt the gingiva slightly

on the distal half.

ConclusionAdvanc es in new cerami c m ateri als

such as IPS e.max lithium di

allow clinicians and laborato

nicians to take a more conse

approach when removing toot

ture to ensure that as little is reas possible. With new materi

vations, it i s now possi ble to p

highly esthetic restorations t

stronger and procedures that

invasive, causing minimal tra

teeth.

Referenc es

1. Rufenacht CR. Fundamentals of E

Hanover Park, Ill: Quintessence Pu

1990:329-332.

2. Terry DA. Leinfelder KF, Geller W.

& Restorative Dentistry: Material Se

Technique. Hanover Park, Ill: Quin

Publishing; 2009:152-153.

3. Chiche GJ, Pinault A.Esthetics of Ante

Prosthodontics. Hanover Park, Ill: Qui

Publishing; 1994:42-48.

4. Rufenacht CR. Fundamentals of E

Hanover Park, Ill: Quintessence Pu

1990:85-109.

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