QUINTESSENCE OF DENTAL TECHNOLOGY QDT 2016

2016 QDT QUINTESSENCE OF DENTAL TECHNOLOGY Sillas Duarte, DDS, MS, PhD for Personal Use Only Library of School of Dentistry,Tums Editor-in-Chief ©Naoki Aiba Photography for Personal Use Only Library of School of Dentistry,Tums OsseoSpeed™ Profile EV —A unique implant specifically designed for sloped ridges OsseoSpeed Profile EV is specially shaped for efficient use of existing bone in sloped ridge situations • Provides 360 degrees of bone preservation, maintaining soft tissue esthetics • Can help to reduce the need for bone augmentation • One-position-only components for accurate identification of the implant position throughout the treatment process OsseoSpeed Profile EV is an integral part of the new ASTRA TECH Implant System EV and is supported by the unique ASTRA TECH Implant System BioManagement Complex For more information visit www.jointheev.com Follow DENTSPLY Implants www.dentsplyimplants.com DENTSPLY Implants does not waive any right to its trademarks by not using the symbols đ or 32670837-USX-1511 â 2015 DENTSPLY Implants All rights reserved Follow nature‘s contour Editorial The Digital Disruption in Dentistry for Personal Use Only Library of School of Dentistry,Tums A recent study by Accenture and Oxford Economics projected a US $1.4 trillion growth in the world economy over the next years spurred by digital technology In dentistry, the interest in digital technology has increased exponentially in the last few years The heavy marketing of and interest and investment in novel digital scanners, sensors, treatment-planning software, and, of course, CAD/CAM technologies, created a digital disruption in dentistry “Going digital” became synonymous with growth and prosperity But if digital dental technology is considered as just another IT instrument, the outcome could be disastrous and the longevity of any program jeopardized in a short period of time Organizations (schools, clinics, corporations, private practices, and laboratories) must be ready to embrace this technology, thus fully accepting the digital disruption and transforming operations to soundly compete in a digital dental world Needless to say, any new technology comes with a price tag In dentistry this price tag can become very steep Investments in hiring of personnel (dentists, faculty, dental technicians, and/or staff) as well as their training, coaching, and development are essential And after all that, a program for career development must be pondered to ensure retention of highly committed and talented individuals Of course, technology is perishable; it can become obsolete in a short period of time (Ask yourself how many times you have changed your smartphone in the last few years and have looked forward to the introduction of the next new model.) Thus, a strategy for budget allocation must be clearly established for investment, maintenance, upgrades, and improvements—all of which are highly important and necessary even before adopting digital technology Our experience with digital disruption has revealed it to be exceedingly positive and exciting, since when carefully planned and executed, digital technology can produce meaningful rewards in all aforementioned aspects In this issue of Quintessence of Dental Technology, join me in discovering how digital disruption, when combined with art and science, can improve predictability, increase opportunities, and expand the breadth of esthetic oral rehabilitation to heights never before imagined Sillas Duarte, Jr, DDS, MS, PhD Editor-in-Chief sillas.duarte@usc.edu Yasser Magrami QDT 2016 for Personal Use Only Library of School of Dentistry,Tums How many new shades would it take to change your game? Anterior Crown Inlay/Onlay Anterior Veneer Posterior Crown 16 NEW KATANA UTML Standard Shades! Ultra Translucent Multi-Layered / 550 MPa Flexural Strength A1 A2 A3 A3.5 A4 B1 B2 C1 C2 C3 C4 D2 D3 D4 B3 B4 Kuraray America, Inc 1.800.496.9500 www.zahndental.com Exclusive distributor of Kuraray Noritake Products www.kuraraydental.com / www.kuraraynoritake.com QDT 2016 Volume 39 QUINTESSENCE OF DENTAL TECHNOLOGY EDITOR-IN-CHIEF Sillas Duarte, Jr, DDS, MS, PhD Associate Professor and Chair Division of Restorative Sciences Herman Ostrow School of Dentistry University of Southern California Los Angeles, California ASSOCIATE EDITORS for Personal Use Only Library of School of Dentistry,Tums Jin-Ho Phark, DDS, Dr Med Dent University of Southern California Los Angeles, California Neimar Sartori, DDS, MS, PhD University of Southern California Los Angeles, California QDT 2016 SECTION CHAIRS Gerard J Chiche, DDS Augusta, Georgia Oswaldo Scopin de Andrade, DDS, MS, PhD São Paulo, Brazil EDITORIAL REVIEW BOARD Editorial: The Digital Disruption in Dentistry Sillas Duarte, Jr, DDS, MS, PhD Novel Guidelines for Bonded Ceramic Veneers: Part Is Tooth Preparation Truly Necessary? Victor Clavijo, DDS, MS, PhD/Neimar Sartori, DDS, MS, PhD/ Jin-Ho Phark, DMD, Dr Med Dent/Sillas Duarte, Jr, DDS, MS, PhD4 BIOMATERIALS UPDATE Bonding to Silica-Based Glass-Ceramics: A Review of Current Techniques and Novel Self-Etching Ceramic Primers 26 Jin-Ho Phark, DMD, Dr Med Dent/Neimar Sartori, DDS, MS, PhD/ Sillas Duarte, Jr, DDS, MS, PhD Analog Protocol for Obtaining the Ideal Soft Tissue Support and Contour in Anterior Implant Restorations 37 Eric Van Dooren, DDS/Cristiano Soares, CDT/Leonardo Bocabella, CDT/ Willy Clavijo, CDT/Victor Clavijo, DDS, MS, PhD Pinhas Adar, CDT, MDT Atlanta, Georgia Naoki Aiba, CDT Monterey, California SKYN Concept: A Digital Workflow for Full-Mouth Rehabilitation 47 Florin Cofar, DDS/Cyril Gaillard, DDS/Ioana Popp, CDT/Christophe Hue, CDT Amir Avishai, PhD Cleveland, Ohio Markus B Blatz, DMD, PhD Philadelphia, Pennsylvania Minimally Invasive Full-Mouth Rehabilitation for Dental Erosion 57 Masayuki Okawa, DDS Ana Carolina Botta, DDS, MS, PhD Stony Brook, New York Shiro Kamachi, DMD Boston, Massachusetts Avishai Sadan, DMD Los Angeles, California Thomas J Salinas, DDS Rochester, Minnesota Eric Van Dooren, DDS Antwerp, Belgium Fabiana Varjão, DDS, MS, PhD Los Angeles, California Luana C Wright, DDS, MS, PhD STATE OF THE ART Esthetic Rehabilitation of a Patient with Severely Worn and Compromised Dentition Somkiat Aimplee, DDS, MSc, FACP/Aram Torosian, MDC, CDT/ Sergio R Arias, DDS, MS/Alvaro Blasi, DDS, CDT/Sung Bin Im, MDC, CDT, BS/ Gerard Chiche, DDS Tooth Preparation and Ceramic Layering Guidelines for Bonded Porcelain Restorations in Different Challenging Situations Jon Gurrea, DDS/August Bruguera, MDT Fort Lauderdale, Florida Aki Yoshida, CDT Weston, Massachusetts QDT 2016 78 Cover photo by Naoki Aiba 95 The Anatomical Shell Technique: An Approach to Improve the Esthetic Predictability of CAD/CAM Restorations The Challenging Anterior Transition Zone: Details for Creating an Esthetic Result 111 Victor Clavijo, DDS, MS, PhD/Paulo Fernando Mesquita de Carvalho, DDS, MS/ Leonardo Bocabella, CDT Biologic Esthetics by Gingival Framework Design: Part Gingival Framework Design Procedures for Personal Use Only Library of School of Dentistry,Tums Tae Hyung Kim, DDS/Fabiana Varjão, DDS, MS, PhD MASTERPIECE The Challenge of a Natural-Appearing Fixed/Removable Implant-Supported Dental Prosthesis William G Hartman 129 Naoki Aiba, CDT, Oral Design Implant-Supported Full-Arch Zirconia Fixed Dental Prostheses for the Rehabilitation of a Patient with a Failing Dentition 141 150 162 170 179 197 Ivan Contreras Molina, DDS, MSc, PhD/Gildardo Contreras Molina, DDS/ Claudia Angela Maziero Volpato, DDS, MS, PhD/Sascha A Jovanovic, DDS, MS/ Kyle Stanley, DDS A Minimally Invasive Restorative Approach for Treatment of Gingival Impingement Nikolaos Perakis, DDS/Giuseppe Mignani/Francesca Zicari, DDS, MS, PhD ADVERTISING/EDITORIAL/ SUBSCRIPTION OFFICE Quintessence Publishing Co, Inc 4350 Chandler Drive Hanover Park, Illinois 60133 Phone: (630) 736-3600 Toll-free: (800) 621-0387 Fax: (630) 736-3633 E-mail: service@quintbook.com Website: http://www.quintpub.com QDT is published once a year by Quintessence Publishing Co, Inc, 4350 Chandler Drive, Hanover Park, Illinois, 60133 Price per copy: $132 MANUSCRIPT SUBMISSION Jack Goldberg, DDS, MS/Arman Torbati, DDS, FACP/Alexandre Amir Aalam, DDS/ Winston Chee, DDS, FACP Ultrasonic Devices for Minimally Invasive Periodontal Surgery and Restorative Dentistry Lori A Bateman Sue Robinson Nathaniel Lawson, DMD, PhD/John O Burgess, DDS DENTSCAPETM: Tri-Axis Portrait Posing JOURNAL DIRECTOR PRODUCTION Michael Bergler, MDT/Stephen J Chu, DMD, MSD, CDT BIOMATERIALS UPDATE Wear of CAD/CAM Materials H.W Haase EXECUTIVE VICE-PRESIDENT Yuji Tsuzuki, RDT 3D Printed Complete Dentures PUBLISHER 209 QDT publishes original articles covering dental laboratory techniques and methods For submission information, contact Lori Bateman (lbateman@quintbook.com) Copyright © 2016 by Quintessence Publishing Co, Inc All rights reserved No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information and retrieval system, without permission in writing from the publisher The publisher assumes no responsibility for unsolicited manuscripts All opinions are those of the authors Reprints of articles published in QDT can be obtained from the authors Permission to photocopy items solely for internal or personal use and for the internal 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) provided the appropriate fee is paid directly to CCC (www.copyright.com) Printed in China ISSN 1060-1341  /  ISBN 978-0-86715-723-9 ERRATA The tooth displayed on the cover of QDT 2014, fabricated by Masaaki Honda (spelled incorrectly in the issue) et al, was made in acrylic, not ceramic as stated QDT 2016 presents The 25th International Symposium on Ceramics The New Frontiers of Esthetic Excellence: Successfully Integrating the Best of Traditional and Digital Dentistry for Personal Use Only Library of School of Dentistry,Tums JUNE 2–4, 2017 | SAN DIEGO, CA SHERATON SAN DIEGO HOTEL & MARINA Program Chair: Avishai Sadan For more information, go to www.quintpub.com/isc CALL: (800) 621-0387 (toll free within US & Canada) • (630) 736-3600 (elsewhere) 1/16 FAX: (630) 736-3633 EMAIL: service@quintbook.com WEB: www.quintpub.com QUINTESSENCE PUBLISHING CO INC, 4350 Chandler Drive, Hanover Park, IL 60133 for Personal Use Only Library of School of Dentistry,Tums Novel Guidelines for Bonded Ceramic Veneers: Part Is Tooth Preparation Truly Necessary? Professor, Advanced Program in Implantology and Restorative Dentistry, ImplantePerio Institute, São Paulo, Brazil; Visiting Scholar, Advanced Program in Operative and Adhesive Dentistry, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA 2 Assistant Professor, Division of Restorative Sciences, Herman Ostrow School of Dentistry, Assistant Director, Advanced Program in Operative and Adhesive Dentistry, University of Southern California, Los Angeles, California, USA 3 Assistant Professor, Division of Restorative Sciences, Herman Ostrow School of Dentistry, Director of Biomaterials Laboratory, Advanced Program in Operative and Adhesive Dentistry, University of Southern California, Los Angeles, California, USA 4 Associate Professor and Chair, Division of Restorative Sciences, Director, Advanced Program in Operative and Adhesive Dentistry, Herman Ostrow School of Dentistry, University of Southern California, Los Angeles, California, USA 1 Correspondence to: Dr Victor Clavijo, Rua Cerqueira Cesar, 1078 Indaiatuba, São Paulo, Brazil 13330-005 Email: clavijovictor@yahoo.com.br Victor Clavijo, DDS, MS, PhD1 Neimar Sartori, DDS, MS, PhD2 Jin-Ho Phark, DMD, Dr Med Dent3 Sillas Duarte, Jr, DDS, MS, PhD4 CLAVIJO ET AL for Personal Use Only Library of School of Dentistry,Tums D entists and dental laboratory technicians must have both technical and scientific knowledge to deliver high-quality, ultrathin bonded ceramic restorations.1,2 All esthetic treatments must be properly indicated to provide long-lasting restorations that not just create a beautiful smile, but also restore and maintain the oral health and function over time It is universally accepted that ceramic veneers bonded to intraenamel tooth preparations have higher survival rates.3 The mean thickness of enamel at the gingival third is 410 μm (0.410 mm) on the maxillary central incisor and 367 μm (0.367 mm) on the maxillary lateral incisor (Fig 1).4 Since traditional veneers have a chamfer gingival finish line with 0.5 mm of depth,5 dentin is exposed during the tooth preparation In other words, the enamel thickness at the gingival third does not permit a chamfer preparation of 0.5 mm depth.4 The long-term success and durability of ultrathin bonded ceramic restorations have been achieved due to the improvement of both ceramics and bonding systems.6 Nowadays, ultrathin bonded ceramic restorations, with 100 µm (0.1 mm) to 300 µm (0.3 mm) of thickness, can be fabricated to partially involve one or more tooth sur­ faces (ultrathin partial veneer) (Fig 2)7–9 or completely cover Fig 1  Maxillary central incisors showing less than 400 µm (0.4 mm) enamel thickness at the gingival third QDT 2016 the tooth facial surface (ultrathin veneer) (Fig 3).1,2,10,11 The main advantage of ultrathin ceramic restorations is tooth preservation, since minimal or no preparation is necessary Subgingival tooth preparation may cause gingival inflammation over time due to injuries from the operative procedures, presence of restorative materials, marginal gaps, overhangs, and roughness of the luting agents (Fig 4).12 However, if the veneer preparation is equigingival, the natural apical migration of gingiva may expose the adhesive luting interface and dark tooth substrates over time (Fig 5) In a 12-year longitudinal study evaluating the gingival recession on subjects with good oral hygiene, the recession increased from 44% to 88% in the group of 18- to 29-year-olds, mainly at incisors and canines.13 Moreover, wear of the adhesive luting interface of traditional veneers over time also raises both esthetic and biologic concerns (Fig 6).14 These depressions on the interface act as a niche for plaque,15 which could expedite the development of secondary caries as well as gingival inflammation by retaining periodontal pathogens.16 The aim of part of this article is to give the clinician step-by-step guidelines for properly selecting, planning, executing, and delivering ultrathin bonded ceramic restorations Novel Guidelines for Bonded Ceramic Veneers: Part Is Tooth Preparation Truly Necessary? 2a 2b for Personal Use Only Library of School of Dentistry,Tums Figs 2a to 2c  Ultrathin bonded partial ceramic veneer restorations with areas of less than 100 µm (0.1 mm) of thickness 2c 3a Figs 3a and 3b  Ultrathin bonded ceramic veneers with less than 300 µm (0.3 mm) of thickness are the ultimate goal for enamel preservation 3b QDT 2016 PERAKIS ET AL 4a 4b 4c 4d for Personal Use Only Library of School of Dentistry,Tums Fig 4  (a) The maxillary and mandibular casts are mounted after facebow registration in centric relation position Note the gingival impingement in the maximal intercuspation position (b to d) The technician was asked to open the VDO and wax the mandibular molars and premolars without modifying contacts during eccentric movements, in particular between the maxillary first premolar and mandibular canine on the left side and between the maxillary and mandibular canines on the right 5a 5b 6a 5c 6b Figs 5a to 5c  Diagnostic wax-up Figs 6a and 6b  The silicone index has to be cut in two halves at the dental equator, or at the supposed finishing line of the mock-up The lower (apical) index provides dental or mixed dentogingival support and makes excess material removal much easier when pressing the mock-up The upper (coronal) index holds all the functional aspects of the wax-up 212 QDT 2016 for Personal Use Only Library of School of Dentistry,Tums A Minimally Invasive Restorative Approach for Treatment of Gingival Impingement 7a 7b 7c 7d 7e 7f Clinical procedures for the occlusal-functional mock-up Fig 7a  Once the apical part of the index is stabilized in the mouth and the contact with natural teeth verified, etching and bonding procedures can be performed Figs 7b to 7d  Only the coronal part of the teeth (where the mock-up will be bonded) is involved The coronal part of the index should be inserted slowly in order to allow the excess resin to flow away Fig 7e  The MSI has to be kept in place until the resin is completely hardened Fig 7f  Occlusal-functional mock-up after finishing procedures Occlusal-Functional Mock-up The mock-up was pressed and adhesively bonded on the mandible by using the MSI, after having cleaned the tooth surface with a slurry of pumice After checking stability and fit of both apical and coronal parts of the MSI, the coronal part was filled with diacrylic resin (Protemp 4, 3M) All adhesive procedures are shown in Fig After removing the MSI, the excess resin was easily removed using a knife, and surfaces were finished and polished by using a dedicated handpiece and tips (Contra-angle with Intra EVA head, Kavo) Static occlusion, dynamics, and phonetics were immediately checked, and eventually fine adjustments were done Prophylactic instructions were delivered to the patient, who was asked to brush her teeth normally and use interproximal soft-silicone brushes and a fluoride solution for rinsing.25 The patient was also asked not to change her usual chewing habits in order to test the masticatory effectiveness of the mock-up and the comfort of the new occlusal design After placing the mock-up, the interarch relationship, smile line, relationship between the maxillary incisors and lower lip, and the profile of the patient looked more natural and harmonious (Figs and 9) At this step, the new VDO was clinically registered (Fig 10) QDT 2016 213 PERAKIS ET AL Fig 8a  Intraoral view after placement of the mock-up Fig 8b  The smile line and the relationship between the maxillary incisors and lower lip look more natural and harmonious 8a 8b for Personal Use Only Library of School of Dentistry,Tums Figs 9a and 9b  Extraoral images Note the improvement of the lower lip position and posture after placement of the mock-up 9a 9b Fig 10  Clinical registration of the augmented VDO immediately after placement of the mock-up Fig 11  Occlusal scheme tested by the patient: Occlusal-functional mock-up after months of clinical service 10 11 Figs 12a and 12b  Anterior jig Keeping the mock-up in situ, a small amount of resin is placed on the margin of the maxillary incisors and the CR position is recorded at the VDO that was tested over the previous months 12a 12b Clinical Evaluation The first recall was performed the next day The patient indicated that she had experienced no pain and no muscle tension with the mock-up in place She noted that the new occlusion felt better to her For this reason, future recalls were set to take place every weeks for the next months, which was the total time for this diagnostic step 214 QDT 2016 At the 2-month recall, the mock-up was still intact with no wear facets nor chippings (Fig 11) The occlusal contacts were still homogeneously distributed and did not show any variations In addition, the new VDO was maintained, thus proving that the new occlusal design was well accepted by the patient The definitive restorations could now be planned A Minimally Invasive Restorative Approach for Treatment of Gingival Impingement for Personal Use Only Library of School of Dentistry,Tums Figs 13a to 13d  Teeth preparation guided by the occlusal-functional mock-up The occlusal and buccal grooves allow a calibrated and precise reduction of the two surfaces Excess resin is removed using a scaler (M23, Deppeler) 13a 13b 13c 13d Figs 14a and 14b  The anterior jig is used to check the occlusal and buccal teeth reduction at the correct VDO 14a Registration of the Interarch Relationship The first, very important step was to register the position of the mandible (CR) at the evaluated VDO and transfer it to the articulator for mounting of the definitive casts The anterior jig technique was used, as it is accurate and not time-consuming (Fig 12) The jig was fabricated clinically in the mouth using autocuring acrylic resin (Pattern resin, GC) The jig allowed the dentist to: (1) check the thickness of final restorations at the new VDO during teeth preparation (by holding the jig in the right position); (2) make sure that the provisional restorations did not vary from the mock-up regarding VDO and occlusal contacts; and (3) proceed with the definitive cast mounting at the new VDO Teeth Preparation Lithium disilicate glass-ceramic (IPS e.max Press, Ivoclar Vivadent) occlusal veneers were fabricated to restore the 14b posterior teeth This material has an elastic modulus of 95 ± GPa and a flexural strength of 400 ± 40 MPa, which makes it ideal for fabricating partial restorations with a heat-press technique The ideal thickness of lithium disilicate restorations has been discussed in several studies.26–29 Thanks to the patient’s increased VDO and to the consequently augmented interocclusal space, as much tooth structure as possible could be preserved, thus yielding minimally invasive preparations A minimal thickness of 1.5 to mm was provided in order to benefit from the mechanical properties of the material itself The mock-up and the anterior jig were used to guide the preparations, using a similar technique as presented by Gurel for laminate veneers30 (Figs 13 and 14) Once the geometry of the cavity had been defined, dentin was sealed as recommended by Magne,31 who demonstrated that “immediate dentin sealing” may improve the long-term survival of ad- QDT 2016 215 PERAKIS ET AL 15a 15b 15c Figs 15a to 15c  (a, b) Old restorations have been removed where necessary and (c) composite build-ups reestablish optimal cavity geometry Fig 16a  Final tooth preparations for Personal Use Only Library of School of Dentistry,Tums Fig 16b  Final impression (Express putty/light-body regular set, 3M ESPE) 16a 16b Figs 17a and 17b  Registration of the interarch relationship is very straightforward in this case Using the anterior jig to maintain the correct interarch relationship (CR at the VDO tested), only two posterior jigs are used to stabilize the occlusion in the posterior region 17a 17b hesively bonded restorations by significantly increasing the bond strength between restorative material and tooth structure Furthermore, this approach has been observed to protect dentin from contamination during the provisional phase and to reduce postoperative sensitivity Old fillings were removed and, where necessary, a composite build-up was performed to reestablish an optimal cavity geometry in order to eliminate undercuts and guarantee a consistent thickness of the restorations, and allow good stability of the restorations during try-in and luting procedures (Fig 15) After checking the thickness by keeping the anterior jig in place, a 45-degree bevel was prepared on the coronal third of the vestibular surface in order to get an ideal esthetic integration of the restorations 216 QDT 2016 A final polymerization under glycerin gel was carried out before taking impressions to eliminate the oxygeninhibition layer and prevent interaction with the impression material.32,33 The impression of the mandible was taken with a polyvinyl siloxane material (Fig 16) The impression of the maxilla was not taken at this stage, since the maxillary cast had already been mounted onto the articulator For this reason, any further registrations were not necessary Only two posterior jigs were used for support in the posterior regions, while the anterior jig maintained the correct interarch relationship (Fig 17) A Minimally Invasive Restorative Approach for Treatment of Gingival Impingement Fig 18a  Provisional restorations are fabricated using the same MSI used for the mock-up At this stage, interproximal spaces are closed by placing and curing a small amount of resin (Telio Universal, Ivoclar Vivadent), in order not to let the resin chosen for the provisional restorations (Protemp 4, 3M ESPE, A3 color) flow into those spaces, as well as food residuals, which could provoke gingival inflammation for Personal Use Only Library of School of Dentistry,Tums 18a 18b 18c Fig 18b  The spot-etch technique is used to guarantee retention of the provisionals A small amount of 37% phosphoric acid is applied in a selected point for 30 seconds After rinsing and drying, a small drop of bonding material (Optibond FL, Kerr) is applied with a brush and light-cured for 20 seconds The etching area has to be clearly visible, since bonding material has to be removed and the etched area perfectly cleaned before final cementation Fig 18c  Immediately afterward, provisionals are fabricated directly (Protemp 4, 3M ESPE, A3 color) Provisional Restorations Provisional restorations were fabricated using the same silicone index that was used to place the mock-up; this allowed duplication of the occlusal design that the patient had found to be comfortable Provisional restorations could be pressed and cemented simultaneously using the spotetch technique The procedures for provisional cementation are described in detail in Fig 18 (Fig 20) Completed wax-ups were then sprued and invested, followed by burnout and pressing, strictly following the manufacturer’s instructions (Fig 21) After pressing, the restorations were devested, sandblasted, and placed in a dissolving liquid to eliminate the surface reaction layer The lithium disilicate overlays were then cut from the sprues and checked for fit, marginal integrity, and accuracy on the working cast (Fig 22) Laboratory Procedures Bisque Bake Try-in After receiving all pertinent diagnostic and case information from the dentist, the laboratory technician could manufacture the definitive restorations (IPS e.max Press, MT Ingots, A3 shade) Two casts made of type IV gypsum were obtained: one working cast with segments and a solid cast, which remains intact, that was subsequently used to check the contact area during bisque try-in and after glazing A matrix was prepared from the diagnostic wax-up and an organic wax was injected for contouring (Fig 19) Afterward, the shape was refined and margins were sealed The restorations were sent to the dentist for the bisque bake try-in The provisionals and adhesive residuals were removed using a scaler (M23, Deppeler) and teeth were polished (Depurdent, Ogna) Fit and contact points were eval­ uated for each restoration individually before testing occlusion (Fig 23a) A thin layer of a temporary resin cement (Temp Bond Clear, Kerr) was applied on the restorations to keep the position stable during evaluation of static and dynamic occlusion (Fig 23b) QDT 2016 217 PERAKIS ET AL for Personal Use Only Library of School of Dentistry,Tums Figs 19a and 19b  Working cast: spacing and first waxing from a matrix Sealer is applied to harden the surface and protect the stone die A spacer is then applied in three layers of 10 µm each, up to a maximum of mm to the preparation margin Figs 20a and 20b  Completed wax-up and sealing of the margins Figs 21a and 21b  Spruing, investing, and burnout are carried out following the manufacturer’s instructions 218 Finishing and Polishing Final Seating A few ready-to-use stains were used to make the restorations appear more natural The IPS e.max Ceram shades and were used to characterize occlusal and vestibular surfaces, respectively, whereas the IPS e.max Ceram Essences White and Crème were used to intensively stain the cusps Before delivering the restorations to the dentist for placement, they were glazed and polished The interproximal contact areas were checked on the solid cast (Figs 24 and 25) After removing the provisional restorations, teeth were cleaned (Depurdent, Ogna) and restorations were tried in and accurately checked before final seating All restorations were adhesively cemented using a three-step total-etch adhesive system (Optibond FL, Kerr) and a microhybrid composite (Empress Direct, Ivoclar Vivadent) For pretreatment of the restorations (Fig 26), the lithium disilicate was etched with 5% hydrofluoric acid for 20 seconds, after which restorations were rinsed and then QDT 2016 for Personal Use Only Library of School of Dentistry,Tums A Minimally Invasive Restorative Approach for Treatment of Gingival Impingement Fig 22  Final check on the working cast before bisque try-in Fig 23a  Bisque try-in Fig 23b  A thin layer of a temporary resin cement (Temp Bond Clear, Kerr) is applied on the restorations to keep the position stable during evaluation of static and dynamic occlusion Fig 24  Final check of the restorations on the working cast Further microdefects have to be detected at this point and eventually eliminated before sending the restoration to the dentist for cementation Figs 25a and 25b  Proximal adjustments are performed on the solid cast 26a 26b 26c 26d 26e 26f Figs 26a to 26f  Pretreatment of the restorations (a) Etching with 5% hydrofluoric acid for 20 seconds; (b) rinsing; (c) cleaning in ultrasonic bath for minutes; (d, e) applying a thin layer of a silane (Monobond Plus, Ivoclar Vivadent) and waiting for 60 seconds for evaporation; (f) drying QDT 2016 219 PERAKIS ET AL Step-by-step adhesive cementation for Personal Use Only Library of School of Dentistry,Tums Fig 27a  A rubber dam is placed Fig 27b  Sandblasting using the Cojet System (3M ESPE) Fig 27c  Etching with 37% phosphoric acid for 40 seconds Figs 27d and 27e  Rinsing for 20 seconds and drying Figs 27f and 27g  Primer is applied on the tooth with microbrushes Figs 27h and 27i  Bonding material is placed both on the restoration and tooth, without light curing the adhesive layer Fig 27j  Restoration is seated using a composite resin Fig 27l  Each surface is light cured for 90 seconds Figs 27n and 27o  Finishing and polishing with a thin scaler and diamond strips on the vestibular/lingual areas and on the interproximal areas, respectively Fig 27m  Airblock gel (Dentsply) is applied for a final polymeri­ zation step of 20 seconds Fig 27k  Removal of excess composite resin Fig 27p  Completed restoration of tooth 220 QDT 2016 A Minimally Invasive Restorative Approach for Treatment of Gingival Impingement for Personal Use Only Library of School of Dentistry,Tums Figs 28a and 28b  Following the same procedure, all restorations are placed one by one Fig 29  Occlusal view of the mandible immediately after final cementation Figs 30a to 30c  Occlusal control Figs 31a to 31c  Control of dynamics placed in an ultrasonic bath with alcohol for minutes to completely eliminate etching debris This procedure is suggested especially for feldspathic ceramic,34 but it can also be applied to heat-pressed and machined ceramics A thin layer of a silane (Monobond Plus, Ivoclar Vivadent) was then applied and left in place for 60 seconds Prior to adhesive cementation, the rubber dam was placed for isolation Since the dentin had been previously hybridized, treatment of the teeth could proceed as follows (Fig 27): sandblasting the composite build-up (Cojet System, 3M ESPE), etching with a 37% phosphoric acid for 40 seconds, rinsing for 20 seconds, and drying The primer was applied on the teeth, whereas the bonding material was placed both on the teeth and restorations without curing in order not to interfere with seating After removing excess composite resin, each surface was cured for 90 seconds.35 A final polymerization was carried out for 20 seconds on each surface under glycerin gel Finishing and polishing were performed very easily, with a thin scaler on the vestibular/lingual areas and diamond strips on the interproximal areas, respectively All the restorations were placed individually using the same procedures (Fig 28) The rubber dam was then removed and the occlusion eventually checked (Fig 29) At least one contact per tooth was obtained (Fig 30) Interferences during functional movements were avoided (Fig 31) QDT 2016 221 PERAKIS ET AL Figs 32a to 32c  For stabilization, an intracoronal splint is placed on the mandibular anterior teeth for Personal Use Only Library of School of Dentistry,Tums Fig 33  Vacuum-formed retainer for stabilization of the maxillary arch 32a 32b 32c 33 Stabilization of Anterior Teeth Because of the augmented VDO, the mandibular anterior teeth were stabilized with an intracoronal splint and the maxillary arch with a vacuum-formed retainer (Figs 32 and 33) Control and Follow-up After week, the restorations appeared well integrated, and the patient was satisfied with the esthetics and function The relationship between the maxillary incisors and lips was significantly improved, and the mucosa on the retro­ incisal area appeared healthier (Fig 34) At the 1-year recall, the clinical situation appeared stable (Figs 35 and 36) The recessions on the palatal aspect of the maxillary incisors were drastically improved (Fig 37) CONCLUSIONS The treatment of gingival impingement due to the overeruption of mandibular incisors and canines in Class II/I adult patients is very challenging and must be carefully evaluated by the dental team A multidisciplinary approach involving orthodontics, orthognathic surgery, and restorative procedures guarantees the best and most stable clinical outcome Nevertheless, patients often refuse this complex option because of the cost and the time required 222 QDT 2016 for treatment, or due to fear of the surgical intervention In such cases, the minimally invasive restorative approach described in this article can be considered as an alternative to the “ideal” multidisciplinary treatment Raising the VDO in Class II/I patients has to be carefully evaluated, as the clockwise rotation of the mandible that can occur with this procedure may worsen the occlusal clinical situation and create functional problems For this reason, it is important that the clinician evaluate the new VDO and occlusal schemes during the diagnostic steps before starting the treatment The occlusal-functional mock-up, which is directly bonded to the teeth, allows the patient to test function, phonetics, and esthetics in a very early diagnostic phase The presented technique is simple, economical, and timesaving Furthermore, patients can experience the new situation without the burden of a removable occlusal splint After the prosthetic phase has been accomplished, the position of the anterior teeth must be stabilized; if missing good contact with the opposing arch, the mandibular incisors could re-erupt, leading to a relapse of the gingival impingement The retention device has to be carefully evaluated with the orthodontist before starting the prosthetic rehabilitation An adhesively bonded fiber-reinforced intracoronal splint is very effective to stabilize the position of mandibular anterior teeth, whereas a thin acrylic vacuumformed retainer can be used in the maxillary arch A Minimally Invasive Restorative Approach for Treatment of Gingival Impingement for Personal Use Only Library of School of Dentistry,Tums Figs 34a and 34b  One-year recall, extraoral images Fig 35  One-year recall, intraoral image of mandible Fig 36  The mandibular splint is still intact at 1-year recall Figs 37a and 37b  Palatal mucosa before treatment and at 1-year recall QDT 2016 223 PERAKIS ET AL for Personal Use Only Library of School of Dentistry,Tums REFERENCES 224 Muts EJ, van Pelt H, Edelhoff D, Krejci I, Cune M Tooth wear: A systematic review of treatment options J Prosthet Dent 2014;112:752– 759 Dietschi D, Spreafico R Evidence-based concepts and procedures for bonded inlays and onlays Part I Historical perspectives and clinical rationale for a biosubstitutive approach Int J Esthet Dent 2015;10:210–227 Edelhoff D, Beuer F, Schweiger J, Brix O, Stimmelmayr M, Guth JF CAD/CAM-generated high-density polymer restorations for the pretreatment of complex cases: A case report Quintessence Int 2012; 43:457–467 Weston JF Conservative full-mouth reconstruction of a worn dentition utilizing digital impression technology and modern ceramic materials Compend Contin Educ Dent 2011;32:44–51 Spreafico RC Composite resin rehabilitation of eroded dentition in a bulimic patient: A case report Eur J Esthet Dent 2010;5:28–48 Vailati F, Belser UC 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Exclusive distributor of Kuraray Noritake Products www.kuraraydental.com / www.kuraraynoritake.com QDT 2016 Volume 39 QUINTESSENCE OF DENTAL TECHNOLOGY EDITOR-IN-CHIEF Sillas Duarte, Jr, DDS, MS, PhD... California Neimar Sartori, DDS, MS, PhD University of Southern California Los Angeles, California QDT 2016 SECTION CHAIRS Gerard J Chiche, DDS Augusta, Georgia Oswaldo Scopin de Andrade, DDS, MS,