Minimally Invasive FullMouth Rehabilitation Adapting Digital Dentistry QUINTESSENCE OF DENTAL TECHNOLOGY 2018

www.pdflobby.com Editorial MACHINE LEARNING: Artificial Intelligence for Diagnosis and Treatment Planning One of the most complex tasks of any esthetic oral rehabilitation is the development of a treatment plan Assembling all the data gathered from multiple sources—such as medical and dental history, patient’s chief complaint, radiographs, cone beam computed tomography (CBCT), casts, bite registrations, occlusal analysis, tooth shade analysis, just to name a few—and then interpreting the data, coming to a conclusion, and fabricating visually acceptable prototypes (virtual or not) for communication with the patient and restorative team is not a easy task Although it is clear that the advances in digital technology in recent years have made a highly positive impact, information remains fragmented The restorative team still needs to collect different pieces of information using digital and nondigital formats and combine them using different digital platforms or analog methods to prepare an appropriate treatment plan Not to mention that there are so many variables involved in an oral rehabilitation that the process of establishing a final treatment plan itself is very stressful and intricate Minimal errors in data gathering can lead to unpredictable outcomes, and the lack of predictability is one of the most challenging fears in dentistry We urgently need digital tools that allow us to record, in an all-in-one single platform, patient data dynamically (lips at rest, teeth display during smile and exaggerated smile, occlusal excursions and movements), statically (intraoral scan, extraoral scan, digital dental shade analysis, and CBCT), and historically (medical and dental history) While many systems provide the opportunity to design smiles, plan restorations, determine implant placement, or evaluate underlying structures, most of the systems available still lack full integration Furthermore, many digital platforms remain based in traditional dentistry, where teeth still need to cut in order for the software algorithms to design and propose an acceptable restoration Ideally we need fully digital data sequencing, where all digitally recorded data would allow complete analysis and study of occlusion (including vertical dimension of occlusion), dental esthetics, tooth position, enamel and dentin thickness, edentulous space, root canal therapy, and gingival esthetics to create the ultimate virtual patient With the assistance of this technology, the human brain would then design a successful treatment plan with a minimally invasive approach in mind and monitor its outcome over time in the same digital platform As the machine stores more information, better decisions could be drawn This technology is already available in other fields In medicine, for instance, a surge of interest in machine learning has resulted in an array of successful data-driven applications, ranging from medical image processing and diagnosis of specific diseases, to the broader tasks of decision support and outcome prediction Through an artificial neural network—which resembles a biologic brain in the sense that it learns by responding to the environment and stores the acquired knowledge for future decisions—digital technology could help to predict the success of a given treatment or suggest its limitations Dentistry could truly benefit from artificial intelligence and artificial neural networks, or at minimum all-in-one digital platforms offered at a reasonable cost Digital workflow is clearly the theme of this year’s Quintessence of Dental Technology, with its collection of essays and cases demonstrating a combination of human ingenuity, artistry, and technology to promote better and high-quality dentistry I welcome you to take the time to explore the possibilities shown in this book, to be curious, and to crave for knowledge with the excitement of all new possibilities Sillas Duarte, Jr, DDS, MS, PhD sillas.duarte@usc.edu © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Copyright of Quintessence of Dental Technology (QDT) is the property of Quintessence Publishing Company Inc and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use www.pdflobby.com © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Minimally Invasive Full-Mouth Rehabilitation Adapting Digital Dentistry Masayuki Okawa, DDS1 Shigeo Kataoka, CDT2 Takahiro Aoki, CDT2 Koichi Yamamoto, DDS3 Private Practice, Daikanyama Address Dental Clinic, Tokyo, Japan Osaka Ceramic Training Center, Osaka, Japan Private Practice, Yamamoto Dental Clinic, Osaka, Japan Correspondence to: Dr Masayuki Okawa, Daikanyama Address Dental Clinic, 17-1-301 Daikanyama-cho, Shibuya-ku, Tokyo 150-0034, Japan Email: info@daikanyama-dental.com QDT 2018 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com OKAWA ET AL T he minimally invasive intervention concept has become a standard prosthodontic treatment—a shift from the old standard concept of “retention and resistance.” The goal of prosthodontic treatment should be biomimetics and bioemulation, which lead to the minimally invasive concept by incorporating the current evolution of adhesive dentistry with further understanding of the biomechanics of tooth structure.1 Since Magne and Belser introduced various anterior bonded porcelain restoration cases in 2002,2 many clinicians, including the author, have been publishing welldocumented successful results for anterior teeth.3,4 Magne et al5,6 and Dietschi and Argente7 later published direct and indirect adhesive restorative techniques with the minimally invasive concept for posterior teeth Since then, Duarte et al,8 Fradeani et al,9 Vailati et al,10 Okawa,11 and other clinicians have published minimally invasive full-mouth rehabilitation cases.12 New clinical workflows and materials for minimally invasive restorations also continue to be introduced Moreover, the author has presented clinically successful minimally invasive restorations fabricated using a microscope to avoid technical errors.13 Since the introduction of digital dentistry—the recent paradigm shift in dentistry—it is important to understand its application in the minimally invasive restoration workflow.14 In this article, several important aspects of executing minimally invasive restorations are discussed through the presentation of full-mouth minimally invasive restorations for a case of severely acid-worn dentition CLINICAL GOAL OF INDIRECT MINIMALLY INVASIVE TREATMENT As previously noted, the author has been having excellent case outcomes and prognoses by working under the microscope In the patient shown in Figs to 6, the fractured anterior teeth were treated under the microscope with bonded porcelain restorations Marginal integrity was stable, with no sign of marginal porcelain chipping or discoloration years posttreatment The author did not have much exposure to digital dentistry at the time of treating this patient However, with micro dentistry (treatment under the microscope), high accuracy can be obtained and prosthetic errors avoided, with QDT 2018 no compromise on the standard of treatment For digital dentistry, this philosophical concept should be the same: not allowing any compromise on treatment quality The treatment approach for maintaining a high-quality outcome by efficiently combining prosthetic traditional workflow and digital workflow is presented in this article Clinical Questions/Concerns Regarding Minimally Invasive Full-Mouth Rehabilitation Recently, cases of minimally invasive or noninvasive fullmouth rehabilitations of severely worn dentition (due to chemical erosion, occlusal abrasion,15 enamel dysplasia, etc) have been presented widely Is tooth reduction necessary for those cases?16 If necessary, how much reduction is needed for different types of cases? What type of finish line is appropriate? Polymer versus all-ceramics: What is required to obtain accuracy of fit of restorations using a digital workflow? What kind of material choice is appropriate for milling the restoration? Should material choice be different depending on the location of the restoration, ie, anterior or posterior? The provisional stage is extremely important for fullmouth rehabilitation cases in order to evaluate function and esthetics Since adhesive restoration preparation does not require retention and resistance form, how can we choose the provisional restoration material? How we cement the provisional restoration? What kind of temporary cement can be used? RESTORATIVE TREATMENT FOR SEVERELY WORN DENTITION Severely worn dentition can be caused by acid erosion, parafunctional habits such as bruxism, malocclusion, or a combination of these Severely worn dentition can cause esthetic, functional, and biologic issues, and this can lead to complete bite collapse Restorative treatment is important to prevent further deterioration.17 Adhesive restoration to preserve the remaining tooth structure should be the treatment of choice in such cases.18 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Minimally Invasive Full-Mouth Rehabilitation Adapting Digital Dentistry Fig Preoperative photograph of patient with four fractured maxillary anterior teeth Fig Teeth preparation Fig After completion of restorative treatment under microscope Fig Three-year postoperative radiographs There is no detectable gap between the teeth and restoration margins even though radiopaque resin cement was used 5a 5b Figs 5a and 5b Nine-year postoperative photographs There is no discoloration on the anterior restoration supragingival margins Fig Magnification of supragingival margin under the microscope No significant clinical negative changes can be observed years postoperatively CASE PRESENTATION Chief Complaints The patient, a 21-year-old fashion model, was concerned with the esthetics of her thin and short central incisors She also complained of sensitivity in the anterior teeth and muscle pain caused by her clenching habit A later interview revealed that she had an eating disorder (bulimia) The patient wanted treatment to improve the anterior esthetics and posterior occlusion as well as eliminate teeth sensitivity QDT 2018 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com OKAWA ET AL 7b 7a Figs 7a to 7c Clinical evaluation of facial esthetics and face-to-tooth relationships The incisal edge position of the maxillary anterior teeth is shorter than the lower lip smile line, and the mandibular anterior teeth are slightly extruded Those are the major esthetic issues 7c Initial Clinical Work-up Analysis of facial features and lip and teeth relationship The incisal edge position was concave and did not match the smile line The mandibular anterior teeth were slightly extruded (Figs 7a to 7c) Intraoral photograph analysis Figures 8a to 8c show the anterior teeth in occlusion, anterior rest position, and anterior protrusive movement There was no significant concern in terms of the maxillary cervical gingival levels, but the occlusal plane was canted to the right The midline of the maxillary central incisors matched the facial midline The midline of the mandibular central incisors was shifted to the right; therefore, the left canine relationship was Class III The path of teeth guidance can be analyzed by examining the anterior teeth working contacts and wear pattern This case was diagnosed as pathway to end-toend wear Spear noted that overjet should be deeper and overbite shallower for cases such as this, with teeth contacts in functional movement until the end of the mandibular envelope movement.19 The four maxillary incisors appeared very thin (Figs 9a and 9b) All six maxillary anterior teeth showed incisal chip- 10 QDT 2018 ping and significant wear, so those teeth appeared to be very short There was no decay or restorations on these teeth The occlusal view (Fig 9b) shows the typical acid enamel erosion pattern and shiny worn-down occlusal surfaces.17 This wear pattern confirmed that acid erosion caused the dentin exposure, and the mandibular anterior labial incline and bruxism caused additional wear of the maxillary anterior teeth Study model analysis The acid erosion and occlusal wear of the palatal surfaces of the maxillary anterior teeth could be seen on the initial study models (Figs 10a to 10d) Hard tissue defects caused by the acid erosion and occlusal wear were more prominent on the anterior teeth than the posterior teeth The maxillary left first molar seemed to have been lost much earlier and left unrestored The second and third molars were tilted mesially and closed the space of the first molar The maxillary molars showed significant wear on the functional cusps, and the mandibular molars showed occlusal concavities, corresponding with the patient’s complaint of right molar clenching There also was pain on palpation of the posterior belly of the digastric muscle This implies that the right condyle could locate on the more posterior position © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Minimally Invasive Full-Mouth Rehabilitation Adapting Digital Dentistry 8c 8b 8a 9a 9b 10a 10b 10c 10d Figs 8a to 8c Initial preoperative photographs Figs 9a and 9b Initial preoperative facial and occlusal views of the maxillary anterior teeth Figs 10a to 10d Evaluation of initial preoperative study casts (a) Maxillary anterior teeth, palatal view; (b) maxillary teeth, entire occlusal view; (c) maxillary right first and second molars, occlusal view; (d) mandibular right first and second molars, occlusal view QDT 2018 11 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com OKAWA ET AL 11 12 Fig 11 Preoperative full-mouth radiographs Fig 12 Anatomy of thick enamel structure of anterior tooth’s lingual and interproximal areas It is important to preserve those structures for tooth flexure control Radiographic analysis All teeth were vital (Fig 11) Dental decay was found on the interproximal surfaces of the mandibular right first and second molars There were no periodontal concerns The maxillary left second molar was mesially tilted Restorative Treatment Objectives and Treatment Planning An organized and sequenced treatment plan was established along with eliminating the risk factors of the acid erosion.17 The treatment plan objectives for patients with acid erosion should be to recover proper anatomical features; reestablish proper occlusion and function; improve esthetics, such as the smile line; and eliminate teeth sensitivity.11 This particular patient had more significant anterior 12 QDT 2018 teeth wear compared to posterior wear Since the anterior teeth were already labially inclined, the ideal treatment choice preferably included either orthodontic intrusion or crown lengthening to create space for the future restorations rather than opening the vertical dimension of occlusion (VDO), in order not to create too much postoperative anterior teeth display Orthodontic treatment,20 including uprighting the maxillary left second molar, was discussed with the patient However, due to her occupational commitment, she could not undertake the suggested orthodontic treatment Therefore, full-mouth rehabilitation with opening of the VDO became the final treatment plan A predictable treatment outcome with opening of the VDO has been shown by Abduo.21 Spear stated that the ideal VDO21,22 does not exist; VDO can change and adapt to the patient’s condition, so an appropriate VDO for each individual patient needs to be determined.20 The restor- © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Esthetic Restoration with Ceramic Veneers in a Case of Altered Passive Eruption: The Appropriate Choice of Materials Is Key Davide Bertazzo Dental Technician Via Eccettuato 7/A, 15033 Casale Monferrato, Italy Email: info@bertazzolab.it, www.bertazzolab.it QDT 2018 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER 243 www.pdflobby.com BERTAZZO C eramic veneers adhesively cemented and limited to the enamel represent today’s treatment of choice for minimal correction of the shape and color of teeth They are a conservative solution for preserving tooth structure and have shown a high percentage of success over time, ranging from 93% to 96% at 15 years1 and 10 years,2 respectively The purpose of this article is to underline the importance of the characteristics of the materials to be used in the reconstruction, which should be chosen appropriately and not casually, thus making the materials compatible to the treatment plan Particular attention should also be paid to the planning phases and the interaction between the team members Through proper protocols, such phases will contribute to guarantee the success of the restoration, not only from an esthetic point of view but also for its duration over time ALTERED PASSIVE ERUPTION Altered passive eruption (APE) is a clinical situation in which patients present excessive gingival display Frequently, as in the case illustrated in this article, APE is associated with the presence of short and unesthetic crowns To recreate the right balance for the reconstruction, a surgical procedure must first be performed to reestablish the proper biologic width and then to correct the shape of the natural teeth hidden by the excess soft tissue In the case described herein, the teeth will have to be lengthened both apically and coronally By reestablishing harmony in shape and proportions, the final result will strike the right balance between biology and esthetics.3,4 Clinical studies and literature determine the success or failure of a technique and guide us toward correct application methodology Our task is to observe and study the teeth from their depths, examine their relationship with other structures, and study how they interact with restorative materials—not only during function or parafunction, but also, for instance, after traumatic events5 or abrasion processes (Fig 1) One of the most important treatment phases is the careful analysis of the primary stone cast—better if supplied with the mounting and setting of the articulator with the centric relation line of waxes and the dynamic facebow—to assess in perfect synergy the wear and tear of the veneers, precontacts, interferences, abrasion areas, as well 244 QDT 2018 as the Angle Class, overbite, overjet, general symmetry of the two arches, and inclination of the axis of every tooth Abrasion, mainly owing to mechanical procedures6 and erosion due to chemical processes, is difficult to evaluate and assess directly in the oral cavity As is well known, the involuntary grinding of teeth7 is a fundamental risk factor in abrasion of the tooth enamel8 as well as materials used in restorations.9 Bruxist patients, developing uncontrolled forces up to 10 times greater than normal mastication forces,10 cause restorations to break with high frequency The appropriate choice of restoration materials in these patients, as in every case, is required RESTORATIVE MATERIALS The state-of-the-art microhybrid composites, with their esthetic and mechanical qualities—improved considerably thanks to filler technologies11—represent an excellent alternative to dental ceramic for both anterior and posterior restorations.12,13 However, their limitations lie in their lower resistance to wear and tear under extreme or stressful conditions.14,15 Clinical studies have demonstrated that over time, composite veneers can display changes or modifications of their surface quality with a frequency six times higher than ceramic veneers.16,17 Another significant difference that affects the final result is attributable to the stratification techniques used for restorations made with composite and ceramic materials The fact that the ceramic mass can be worked when wet allows penetration for obtaining subtle and delicate effects The stratification technique of composite, by its very nature and because of its plasticity, is completely different The shades and effects that can be produced are proportional to the dexterity of the professional layering and mixing the different strata of the material to be polymerized This should be done without losing control of the shape or creating unesthetic gaps between the various strata Correlating qualities such as flexural resistance and elastic modulus (Young’s modulus), we are able to calculate the fragility of a material Unlike metal restorations, dental ceramics are subject to breakage when they reach their elastic limit, even with an allowance for elastic deformation This characteristic classifies ceramic as a fragile material compared to metals, which are plastically deformable.18 Glass-ceramics stratified and sintered on refractory dies or with the platinum sheet technique, whether or not © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Esthetic Restoration with Ceramic Veneers in a Case of Altered Passive Eruption Fig Our role is to study and copy nature (Courtesy of Alessandro Conti, DDS.) their vitreous phase had been strengthened by leucitebased crystals, feldspar, or fluorapatite, have achieved satisfying results with an excellent chromatic stability, thanks to very thin layers By directing the light on the underlying tissues and the gingiva, the unesthetic “umbrella” effect described by Pascal Magne can be avoided, taking advantage of the characteristic translucence of the material at its best.1,19 The weak point of glass-ceramics is their substantial fragility during try-in and the traction tension to which they are subjected following contraction of the volume during the hardening process with the composite cement This vulnerability is represented by the flexural resistance of glass-ceramics, which ranges between 70 and 120 MPa The correct color of the cement material also is an important consideration, for if underestimated it can lead to failure by lowering of the quality of the final restoration as light filters through the translucent material With the evolution of Empress to IPS e.max Press (Ivoclar Vivadent), it is possible to utilize a glass-ceramic whose glassy matrix is filled by around 70% lithium disilicate crystals,20 thereby obtaining a material with flexural resistance values ranging from 350 to 400 MPa.21 The re- sults in terms of precision are adequate using either the press technique or CAD/CAM.22 CASE PRESENTATION A 24-year-old patient came to the office for consultation on improving the esthetics of her smile (Fig 2) She did not like the shape of her teeth, finding them too short and lacking in proportion (Fig 3a) Full-mouth radiographs confirmed the diagnosis of APE Type subtype B, indicating that surgery would be the first step of treatment to achieve new tooth proportions (Fig 3b).23 The analysis of the primary stone casts showed a degree of abrasion with protrusive canine guidance paths involving the incisal edge of the teeth in need of restoration This led the team to choose a veneering material with a high flexural strength and with mechanical characteristics sufficient to guarantee longevity of the functional guidance restoration (Fig 4) QDT 2018 245 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com BERTAZZO 3a 3b Fig Baseline lateral views for evaluation of abrasion and demonstrating proportion of lips and teeth Fig 3a Baseline extraoral photos for correlation of the patient’s face, age, and personality Fig 3b Baseline radiographs Fig Stone cast for evaluation of abrasion and for restoration of functional guides in wax 246 QDT 2018 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Esthetic Restoration with Ceramic Veneers in a Case of Altered Passive Eruption 5a 5b Fig 5a New esthetic guide lines Fig 5b New tooth shapes determined using the Digital Smile Design (DSD) Evaluation for First Wax-up and Mock-up The new plan was designed (by Dr Alessandro Conti) based on an analysis of the shapes, the new guide lines, and the positions of the teeth using the Digital Smile Design (DSD, Christian Coachman), as well as taking into account other esthetic parameters (Fig 5) Lips, for instance, play a fundamental role in their support function and the spatial projection of the teeth themselves (Fig 6) The smile line differs between masculine and feminine anatomy, with the latter more curved in the inferior lip, and higher and more parallel to the incisal superior line compared to the mascu- line one, which is nearly always shorter and straighter In this case an effort had to be made to achieve a restoration with a high-low-high trend in the anterior teeth.24 After the evaluation, the dental technician developed the clinical plan with a first wax-up for initial esthetic analysis but especially to establish the gingival levels during the surgical resetting phase The wax-up was prepared with the addition of esthetic wax on a white extra-hard stone cast (Fujirock EP, GC Europe) including a gingival portion that would simulate the apical lengthening of the crowns Less attention was paid to the details of the new shapes in this wax-up phase, placing more importance on the surgical phase (Fig 7) QDT 2018 247 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com BERTAZZO Fig New proportion of lips and teeth (compare to baseline in Fig 2) 6a 6b Fig First and second wax-ups (Top) Final wax-up is more accurate and precise (Bottom) First stone cast and first wax-up for surgical procedures Fig Surgical procedure phases (Courtesy of Roberto Rossi, DDS, MScD) Through a transparent silicone mask, the mock-up with the dual composite (Protemp, 3M Espe) was printed on the 248 QDT 2018 patient, followed by the resective surgical procedures (performed by Dr Roberto Rossi) shown in Fig © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Esthetic Restoration with Ceramic Veneers in a Case of Altered Passive Eruption 9a 9b Figs 9a and 9b Second mock-up with final tooth shapes obtained through the second wax-up for evaluation Second Mock-up One year later, when the tissues had reached maturation, a new series of stone casts were made, again in white extrahard stone (Fujirock EP) This was followed by a new, more precise esthetic wax-up, taking into account the shapes and the correlation between the face, age, and personality of the patient Particular attention was directed to the po- sitioning of the apex of the distal third of the maxillary central incisors in order to give a symmetrical design to the gingival edge with a pleasing esthetic result (Fig 9a) The second mock-up was designed (by Dr Conti) once again through a silicone mask and a dual composite, completing it all with a series of intra- and extraoral photographs and video for a dynamic evaluation of the new plan with the patient (Fig 9b) QDT 2018 249 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com BERTAZZO Fig 10 The microscope is necessary for the clinical and laboratory phases (Right, from top) Baseline, month postsurgery, and after minimally invasive preparation After the patient accepted the mock-up and agreed to the plan, the team went on to the next phase of preparation, once again with the aid of a microscope (Zeiss OPMI Pico) Use of the microscope by the dental technician is necessary to guarantee success using a minimally invasive approach with a defect-oriented preparation,25 together with quality adhesion through a correct cementation protocol and perfect isolation of the operative field,26,27 as well as precision in the construction of the indirect restorations (Fig 10) Veneer Fabrication For the construction of the veneers, two different master stone casts were made The first was made using the Zeiser technique (Zeiser Sockelplatten, Zeiser Dentalgeräte GmbH), sectioned with removable dies The second was made in polyurethane resin, nonsectioned (ExactoForm, Bredent) The wax-up for the construction of the veneer cores was carried out on the sectioned master cast with execution and control of the preparation finishing lines as well as the successive adaptation under the microscope (Zeiss Stemi 1000) The anatomy of the shapes in the ceramic phase was performed on the nonsectioned master cast, creating each veneer individually and compar- 250 QDT 2018 ing each with the original wax-up of the mock-up approved of by the patient, reprinted on the stone cast specifically for the ceramic phase (Fig 11) All this was done to better concentrate attention on the detail and particulars and above all to try to replicate with greater ease the shapes of the second wax-up/mock-up, which had been obtained with great effort, taking care not to change the personality of the teeth to be reproduced The choice of the core material is of fundamental importance for the final result and luminosity The stratification technique must resemble nature itself as much as possible and, in so doing, try to imitate dental structures in relation to the age of the tooth to be replicated The six veneers were fitted with the press technique by the viscous sliding of the material, using a core LT (Ivoclar Vivadent) LT is a pure dentin core with a good fluorescence that requires the cutback technique (Figs 12 and 13) To ensure appropriate luminosity to the final restorations and to avoid a possible decrease in value during multiple firing cycles, A1 shade was used to yield 70% of the core volume and 30% of the ceramic stratification sintered (over the core itself) This case required reproduction of a young tooth that was slightly opaque but with in-depth luminosity, desaturating the dentin to make it progressively more translucent in the incisal third In this area the light absorption mass, or colored translucent mass, was ap- © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Esthetic Restoration with Ceramic Veneers in a Case of Altered Passive Eruption 11 13 12 14 Fig 11 Second master cast in polyurethane resin (From left) Minimally invasive preparation, comparison of wax-up and lithium disilicate core, and lithium disilicate cores (LT A1) adapted on model Fig 12 Stratification phase Fig 13 Wax ready to be pressed Fig 14 Ceramic phases (from left): dentin and dentin desaturation, opal effects, and absorption masses plied during the layering so that the light could penetrate the tooth more rapidly28 (Fig 14) After the first bake, the effects were heightened in a targeted manner by fixing the Essence colors and shades (Ivoclar Vivadent) in an oven at low temperature This was done because in a ceramic with a low point of fusion, the best result is obtained with a minimum number of firings near the final point of sintering (705°) To complete the process, the Enamel and Neutral (60% to 40%) filter was applied to condition the translucence level in the incisal area, completing the final anatomy of the veneers A small amount of dentin was inserted in the proximal areas with a mix of orange opaque dentin and translucent cervical (70%-20%-10%) to stop the light in this area (Fig 15) QDT 2018 251 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com BERTAZZO 15 16 Fig 15 Ceramic phases (from left): light absorption masses and Enamel filter Fig 16 Tools used in finishing and polishing phases The finishing phase was done with diamond burs cooled by water, starting with the macro surface weaving with a pronounced convexity and concavity to reproduce a young tooth, followed by micro surface weaving with Retzius lines and microgrooves to allow better light reflection The transition lines, in keeping with the parameters and the three Kuwata planes, achieved a three-dimensional effect.1,29 The final bake and glazing was obtained by very delicately applying a small quantity of glaze with a brush However, this was preceded by the mechanical polishing phase carried out with rubber cups, felt, and diamond paste (Figs 16 to 18) 252 QDT 2018 Cementation Adhesive cementation calls for a very strict protocol to be observed for isolation of the operating field and the adhesion procedures (Fig 19) A 4th-generation total-etch adhesive (OptiBond FL, Kerr) and a microhybrid composite as the cementing material were heated to 52˚C for the cementation Figure 20a to 20e show the intraoral results and Figs 21a and 21b the before-and-after extraoral evaluation © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Esthetic Restoration with Ceramic Veneers in a Case of Altered Passive Eruption 17 18 19 Fig 17 Final veneers Fig 18 Stratified lithium disilicate veneers adapted on uncut master cast Fig 19 Adhesion phases (from left): isolation, etching, rinsing, bonding, cementation QDT 2018 253 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com BERTAZZO 20a 20b 20c 20d Figs 20a to 20e Extraoral photographs and radiographs of definitive restorations Figs 21a and 21b Extraoral evaluation of final outcome (a) and preoperative view (b) 20e 21a 254 QDT 2018 21b © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Esthetic Restoration with Ceramic Veneers in a Case of Altered Passive Eruption Fig 22 Successful outcome; satisfied patient CONCLUSION Esthetic dentistry is well established today It aims to create dental restorations that are perceived by patients as esthetically pleasing Restorations with ceramic veneers represent one of the most demanding challenges but also one of the most satisfying in this respect The clinical result is influenced by several factors that must be taken into consideration while working as a team to guarantee the success of the end result Correct planning through specific protocols, preparing teeth with a minimally invasive approach, with an appropriate final cementation technique together with precision in the construction of the dental fittings and an impeccable choice of materials, are all necessary to guarantee a professional result as well as the health and satisfaction of every patient (Fig 22) QDT 2018 255 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com BERTAZZO ACKNOWLEDGMENTS My very special thanks to Dr Roberto Rossi and Dr Alessandro Conti for making me a part of this important project A thank you to all the professionals with whom I collaborate for their trust, an indispensable factor in our line of work And a special word of thanks to Quintessence for granting me this opportunity REFERENCES Friedman MJ A 15-year review of porcelain veneer failure—A clinician’s observations Compend Contin Educ Dent 1998;19:625–628 Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van Meerbeek B A prospective ten-year clinical trial of porcelain veneers J Adhes Dent 2004;6:65–76 Gargiulo AW, Wentz FM, Orban B Dimensions and relations of the dentogingival junction in humans J Periodontol 1961;32:261–267 Rossi R, Benedetti R, Santos-Morales RI Treatment of altered passive eruption: Periodontal plastic surgery of the dentogingival junction Eur J Esthet Dent 2008;3:212–223 Magne P, Belser U Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach Chicago: Quintessence, 2002 Kunzelmann KH Wear Analysis and Quantification of Restorative Materials In Vivo and In Vitro [in German] Aachen: Shaker Verlag, 1998 Baba K, Clark GT, Watanabe T, Ohyama T Bruxism force detection by a piezoelectric film-based recording device in sleeping humans J Orofac Pain 2003;17:58–64 Bernhardt O, Gesch D, Splieth C, et al Risk factors for high occlusal wear scores in a population-based sample: Results of the Study of Health in Pomerania (SHIP) Int J Prosthodont 2004;17:333–339 Pallesen U, Qvist V Composite resin fillings and inlays An 11-year evaluation Clin Oral Investig 2003;7:71–79 10 Nishigawa K, Bando E, Nakano M Quantitative study of bite force during sleep associated bruxism J Oral Rehabil 2001;28:485–491 11 Dietschi D, Spreafico R Adhesive Metal-Free Restorations Chicago: Quintessence, 1997 12 Monaco C, Scotti R, Miceli P Die mit dem neuen, mikrogefüllten Komposit-Material SR Adoro verblendete Inlay-Brücke: Ein klinischer Fallbericht Quintessenz Zahntech 2003;29:292–305 13 Ferracane JL Resin Composite - State of the Art Dent Mater 2011; 27:29-38 256 QDT 2018 14 Tyas MJ Correlation between fracture properties and clinical performance of composite resins in Class IV cavities Aust Dent J 1990; 35:46–49 15 Schlichting LH, Stanley K, Magne M, Magne P The non-vital discolored central incisor dilemma Int J Esthet Dent 2015;10:548–562 16 Gresnigt MM, Kalk W, Ozcan M Randomized clinical trial of indirect resin composite and ceramic veneers: Up to year follow-up J Adhes Dent 2013;15:181–190 17 Moura FR, Romano AR, Lund RG, Piva E, Rodrigues Júnior SA, Demarco FF Three-year clinical performance of composite restorations placed by undergraduate dental students Braz Dent J 2011; 22:111–116 18 Kappert HF Dental materials: New ceramic systems Academy of Dental Materials Proceedings Transactions 1996;9:180–199 19 Fradeani M, Redemagni M, Corrado M Porcelain laminate veneers: 6- to-12-year clinical evaluation—A retrospective study Int J Periodontics Restorative Dent 2005;25:9–17 20 Edelhoff D, Spiekermann H, Rùbben A, Yildirim M Kronen- und Brückengerüste aus hochfester Presskeramik Quintessez 1999;50: 177–189 21 Pospiech P, Kistler ST, Frasch C, Rammelsberg P Clinical evaluation of posterior crowns and bridges of IPS Empress 2: Preliminary results after one year [abstract 1610] J Dent Res 1999;78(special issue):307 22 Rinke S, Behi F, Hüls A Fitting accuracy of all-ceramic posterior crowns produced with three different systems [abstract 997] J Dent Res 2001(special issue);80:651 23 Garber DA, Salama MA The aesthetic smile: Diagnosis and treatment Periodontol 2000 1996;11:18–28 24 Hidaka T Solutions for Dental Esthetics: The Natural Look Tokyo: Quintessence, 2008 25 Massironi D, Pascetta R, Romeo G Precision in Dental Esthetics: Clinical and Laboratory Procedures Milan: Quintessence, 2007 26 Brentel AS, Ozcan M, Valandro LF, Alarca LG, Amaral R, Bottino MA Microtensile bond strength of a resin cement to feldspathic ceramic after different etching and silanization regimens in dry and aged conditions Dent Mater 2007;23:1323–1331 27 Edelhoff D, Liebermann A, Beuer F, Stimmelmayr M, Güth JF Minimally invasive treatment options in fixed prosthodontics Quintessence Int 2016;47:207–216 28 Ubassy G Shape and Color: The Key to Successful Ceramic Restorations Chicago: Quintessence, 1993 29 Kataoka S, Nishimura Y Nature’s Morphology: An Atlas of Tooth Shape and Form Chicago: Quintessence, 2002 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER www.pdflobby.com Copyright of Quintessence of Dental Technology (QDT) is the property of Quintessence Publishing Company Inc and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission However, users may print, download, or email articles for individual use ... 17-1-301 Daikanyama-cho, Shibuya-ku, Tokyo 150-0034, Japan Email: info@daikanyama-dental.com QDT 2018 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL... improve the anterior esthetics and posterior occlusion as well as eliminate teeth sensitivity QDT 2018 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL... second molars, occlusal view; (d) mandibular right first and second molars, occlusal view QDT 2018 11 © 2018 BY QUINTESSENCE PUBLISHING CO, INC PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL