Christopher Ramsey, DMD

	Taking a comprehensive approach to diagnosing esthetic cases proves an invaluable first step in comprehensively treatment planning even the most seemingly straight forward of cosmetic cases.

	Then, applying the necessary skills to evaluate the biological, structural, functional and esthetic factors that influence the smile and the oral health that supports and maintains it becomes equally important to ensure long-term predictability.

Most significant, however, is coordinating communication among all members of the interdisciplinary team-including the laboratory ceramist-to coordinate treatment and ensure the selection and use of the most appropriate materials and restorative designs.

	The female patient, in her mid-30s, was retreated comprehensively after enduring poorly planned and executed cosmetic dentistry. The combination of dentist/patient communication, comprehensive evaluation and planning and detailed multidisciplinary team coordination allowed her to confidently proceed with a cosmetic treatment.

	The patient showing her smile before the results of the case.

	When the patient ultimately decided to pursue “true” comprehensive cosmetic treatment (

), she had already been prepared and provisionalized (

) for a treatment from a different dentist. That treatment involved crowns and a conventional porcelain-fused-to-metal (PFM) bridge in which all teeth would be splinted on tooth Nos. 9 through 14. When she went for try-in and delivery of her final restoration, she was distraught by the sight of the unpleasant cosmetic result and immediately sought alternative treatment.

Related how-to: How collaboration between the dentist and lab can pay big dividends

	During the initial visit and subsequent comprehensive examination, the patient explained and demonstrated that her chief complaints were her under-proportioned and small teeth and misalignment (

). She wanted a larger, broader and more dominantly white smile. By evaluating her pre-operative photographs, radiographs and examination findings, the proposed and agreed-upon treatment plan would involve a multi-disciplinary approach that coordinated orthodontic, implant and restorative care. A laboratory-fabricated diagnostic wax-up was a common communication denominator during this collaborative planning process.

 It was agreed that treatment would be phased to focus primarily on the maxillary arch but establishing a functionally stable mandibular foundation for future treatment. Because tooth Nos. 6 and 11 were primary teeth in soft tissue only, as confirmed via radiographs, they were extracted. Tooth Nos. 9 through 14 were individually provisionalized. The patient was then immediately placed in orthodontic brackets, with bracketed denture teeth at tooth Nos. 6 and 11.

Step-by-step: Creating fluorescence through shade matching

 Following 16 months of orthodontic treatment (

), the laboratory fabricated a surgical stent based on the diagnostic wax-up and required incisal edge position for use in guided implant placement (

). The periodontist then placed two 4.1 mm x 11 mm implants at Nos. 6 and 11. Minor crown lengthening was also performed on tooth Nos. 7 through 10. The patient wore an Essix retainer (

) during the six-month healing period to fill and shape the pontic areas (

 After six months, impressions were taken and sent to the laboratory for creating a new diagnostic wax-up. This was transferred to the mouth via bis-acryl provisional restorations. To achieve functional esthetics and compensate for the under-proportioned tooth size, the right side was prepared for full-coverage restorations, similar to the previously prepared left side.

 Temporary cylinders helped to create screw-retained temporaries on Nos. 6 and 11 to begin correctly shaping tissue contours (

), and screw-retained provisionals were attached to the integrated implants (

). The patient wore the temporaries for an approximate eight-week test drive to evaluate esthetics and function, as well as enable proper tissue healing around the screw-retained implant provisionals.

 After eight weeks, the provisionals were removed, and a master impression was taken to enable the laboratory to design and fabricate the definitive crown and screw-retained implant supported restorations. At the laboratory, a scanner (

) was used to create a digital, full-contour wax-up of the provisionals (

). After creating the digital wax-up and preparation model, the technician split the digital file to allow the software to differentiate between the coping design and the fit of the wax-up units over them. 

 Several factors contributed to material selection in this case, including the patient’s under-proportioned teeth and the need to combine full-coverage crowns with screw-retained implant restorations. Therefore, functional and strength considerations dictated material selection as much as esthetics. Fortunately, zirconia demonstrates the strength, esthetics and crack inhibition properties demanded for this case.

 The selected zirconia system (Zenostar, Ivoclar Vivadent) is also biocompatible, durable and cost-effective.

Lee Culp explains why he loves Zenostar

 The selected zirconia material was designed into copings and restorations using CAD/CAM software, milled, sintered and then pressed over using a lithium disilicate-compatible fluorapatite glass-ceramic (

, Ivoclar Vivadent). This allowed the ceramist to perform an esthetic cutback and layering technique by applying assorted ceramics to achieve the appropriate contour, shade and esthetics.

 To fabricate the restorations, a Translucent Pure shade of zirconia copings (

, Wieland Dental) and the modeling wax units (

, Wieland Dental) were designed and milled (

). To maximize efficiency, the zirconia copings were sintered while the wax was milling, after which the copings were fit to the working model. The ceramist applied a zirconia liner (

) to provide the white zirconia oxide frameworks with shaded character and enhanced bond.

 The wax was seated over the zirconia copings, marginated and pressed with a high translucency lithium disilicate-compatible fluorapatite glass-ceramic in shade BL4 (IPS e.max Zirpress, Ivoclar Vivadent). After pressing, the restorations were divested, the sprues cut off and the contacts adjusted.

Free e-book: How to improve your bottom line with e.max

 The ceramist cut back the restorations to allow 1 mm of subtle diffused layering. Multiple layers of a highly esthetic lithium disilicate layering ceramic (

). To evaluate the contours on a level color/shade gradient, the ceramist used silver colorant, since differentiating contours on white ceramics can be difficult. After contouring and evaluation, the restorations were glazed once, then hand polished with polishing paste (

). The restorations were then sent to the restorative dentist for evaluation (

	The interdisciplinary nature of this case was predicated on a comprehensive evaluation, coordinated treatment planning and collaborative communication among all team members, including the ceramist. With laboratory-fabricated diagnostic wax-ups as a foundation for planning and establishing long-term functional stability, the digitally designed and fabricated restorations achieved the patient’s esthetic objectives (

. Factors to consider when treatment planning for patients seeking comprehensive aesthetic dental treatment. 

. Smile design and treatment planning with the help of a comprehensive esthetic evaluation form. 

	3.     Tortopidis D, Hatzikyriakos A, Lokoti M, Menees G, Tsiggos N. Evaluation of the relationship between subjects’ perception and professional assessment of esthetic treatment needs. 

. The assessment of dentofacial esthetics in restorative dentistry: a review of the literature. 

. Seven-year prospective clinical study on zirconia-based single crowns and fixed dental prostheses. 

	6.     Schmitt J, Wichmann M, Holst S, et al. Restoring severely compromised anterior teeth with zirconia crowns and feather-edged margin preparations: a 3-year follow-up of a prospective clinical trial. 

. Effect of veneering techniques on color and translucency of Y-TZP. 

This article originally appeared in the January 2015 issue of 

. For more great articles like this every month, 

Articles

A dentist and a lab technician show how to work together to repair a previously failed case.

Technique: How to cooperatively fix a failed cosmetic case

In today’s dental market, there’s a choice of many different composites. Some composites are universal, some indicated for anterior restorations, and others are made strictly for direct posterior restorations.1

Each composite category demonstrates advantages and disadvantages, and they often vary in terms of physical properties such as wear characteristics and compressive strength.

Traditionally, direct composite restorations have required the use of a layering technique to minimize the negative effects associated with polymerization shrinkage. This layering technique is intricate, time consuming and sometimes time sensitive, depending on the amount of working time provided by the material.

To address the layering requirements of posterior restorations, several manufacturers have developed new bulk fill materials (i.e. 

, Kerr Corp.) to eliminate the disadvantages associated with conventional composites. The goal of these new bulk fill composites is to eliminate or minimize the layering requirements, enabling clinicians to fill a cavity preparation in a single increment up to 4 mm.

Conventional direct posterior composites have required placing and curing incremental layers of 2 mm or less.2,3

 also are helping to reduce shrinkage stress and ensure a complete depth of cure without the need for a final “capping” layer. Recent composite research and development has addressed such issues as polymerization shrinkage and shrinkage stress.1

Polymerization shrinkage and shrinkage stress can result in negative consequences for the tooth/composite interface and, subsequently, affect the longevity of the posterior restoration.1 Polymerization shrinkage is considered the primary negative characteristic of composites.3 It can contribute to marginal leakage and, ultimately, post-operative sensitivity and secondary caries.2

Tetric EvoCeram® Bulk Fill, a nanohybrid composite from Ivoclar Vivadent.

This bulk fill composite contains a new patented photo initiator. The initiator, Ivocerin, a dibenzoyl geranium derivative, facilitates the application and curing of posterior restorations in larger increments without compromising the composite’s optical properties.

In addition, Ivocerin acts as a polymerization booster permitting the material to polymerize more rapidly, allowing the material to cure in a 4 mm increment in just 10 seconds (power intensity of the curing light is >1,000mW/cm2).

This bulk fill composite also features a shrinkage stress reliever, which is an additional filler technology (e.g. pre-polymer) that is flexible and relieves shrinkage stress during polymerization.

This prevents the material from pulling away from cavity walls resulting in improved elasticity and marginal integrity of the restoration.

Tetric EvoCeram Bulk Fill also contains a light sensitivity filter, which increases the composite’s immunity to ambient operatory lighting. As a result, clinicians are provided with ample working time to place the composite and sculpt the final anatomy of the restoration.4

Available in three shades (e.g., IVA for slightly reddish teeth; IVB for slightly yellowish teeth; and IVW for white or deciduous teeth), it allows clinicians to select the most esthetic alternative. IVW was chosen for this patient.

Using Tetric EvoCeram Bulk Fill composite to fill a posterior cavity eliminates the need for several composite increments, reduces the chance of shrinkage induced failure,5-7 and eliminates the need for a final layer. As a result, direct posterior composites can be placed with greater efficiency, resulting in a more predictable restoration.

See the Case Presentation on the next page ...

A 23-year-old female presented with caries on tooth No. 4 (

). After the initial examination and consultation, the patient agreed to have the cavity filled with direct composite. The clinician recommended this nanohybrid composite to streamline the restorative procedure and provide a predictable and esthetic result.7-11

After rubber dam was placed and the tooth prepared to isolate the gingival and interproximal areas from saliva or blood contamination (

), all caries were removed and the tooth prepared for a direct composite restoration.

). Fuji Lining LC glass ionomer was applied (

). Total Etch 37% phosphoric acid gel (Ivoclar Vivadent) was applied to the prepared dentin for 10-15 seconds and the prepared enamel for 15-30 seconds. The etchant was rinsed with a vigorous water spray for 5 seconds and then air dried (

Gluma desensitizer was applied as a re-wetting agent (

). ExciTE F adhesive bonding agent (Ivoclar Vivadent) was applied for 10 seconds onto the dentin and enamel (

) using an VivaPen applicator pen (Ivoclar Vivadent). The adhesive was then air dried to evaporate any remaining solvent. The adhesive was then light cured for 10 seconds.

A 4 mm increment of Tetric EvoCeram Bulk Fill composite was placed into the preparation (

Using an Optrasculpt composite placement instrument (Ivoclar Vivadent), the bulk fill composite was packed, contoured and sculpted to the preparation walls. The final anatomy was created (

). The restoration was cured to a complete depth of cure in 10 seconds.

Occlusion and articulation were verified using articulation paper (

Continue the Case Presentation on the next page ...

Final finishing and polishing were completed using appropriate finishers. A series of 

Astropol finishing and polishing points (Ivoclar Vivadent) were used to complete the restoration. Gray finishing points were used to smooth the surface (

Green polishing points were used to polish the surface (

). Pink polishing points were used to achieve a high gloss (

). Because the optical properties of this material are designed specifically to match the refractive index of the fillers and polymer matrix, the restoration appeared imperceptible from the surrounding tooth structure because of the enamel-like translucency of 15%.

Bulk fill composites allow clinicians to provide patients with fast and easy direct posterior restorations, without compromising marginal integrity, esthetics or long-term predictability. Additionally, the innovative light-intiator, Ivocerin of Tetric EvoCeram Bulk Fill composite allows clinicians to confidently place posterior restorations, without concern for time sensitivity, the need for intricate layering, or using time consuming techniques.


	1. Ferracane JL. Resin composite--state of the
	art. Dent Mater. 2011 Jan;27(1):29-38. Epub
	2010 Nov 18.
	2. Cheung GS. Reducing marginal leakage of
	posterior composite resin restorations: a review
	of clinical techniques. J Prosthet Dent. 1990
	Mar;63(3):286-8.
	3. Giachetti L, Scaminaci-Russo D, Bambi C,
	Grandini R. A review of polymerization shrinkage
	stress: current techniques for posterior
	direct resin restorations. J Contemp Dental
	Pract. 2006;7(4):79-88.
	4. Tetric EvoCeram Bulk Fill: The bulk composite
	without compromises. Scientific Documentation.
	Schaan, Liechtenstein: Ivoclar Vivadent;
	2011: 1-20.
	5. Roggendorf MJ, Krämer N, Appelt A, Naumann
	M, Frankenberger R. Marginal quality of
	flowable 4-mm base vs. conventionally layered
	resin composite. J Dent. 2011 Jul 27. [Epub
	ahead of print] .
	6. Kuijs RH, Fennis WM, Kreulen CM, Barink M,
	Verdonschot N. Does layering minimize shrinkage
	stresses in composite restorations? J Dent
	Res. 2003 Dec;82(12):967-71.
	7. Souza-Junior EJ, de Souza-Régis MR,
	Alonso RC, de Freitas AP, Sinhoreti MA, Cunha
	LG. Effect of the curing method and composite
	volume on marginal and internal adaptation of
	composite restoratives. Oper Dent. 2011 Mar-
	Apr;36(2):231-8. Epub 2011 Jun 24.
	8. Quellet D. Considerations and techniques for
	multiple bulk-fill direct posterior composites.
	Compend Contin Educ Dent. 1995;16(12):1212,
	1214-6, passim; quiz 1226.
	9. Utterodt A, Rist AC, Eck M, Schaub M.
	Polymerization shrinkage stress and flexural
	strength of nano-composites. 42nd annual
	meeting of IADR-Continental: 2007.
	10. Lowe RA. The search for a low-shrinkage
	direct composite. Oral Health Journal. March
	2010.
	11. Van Ende A, De Munck J, Mine A, Lambrechts
	P, Van Meerbeek B. Does a low shrinking
	composite induce less stress at the adhesive
	interface? Dent Mater. 2010;26(3):215-22.

Technique Step-by-Step: How to place monolithic composites

For many years, the IPS Empress all-ceramic brand was known for the highest level of esthetics when imitating the characteristics of natural teeth. Since it was introduced, more than 37 million indirect crown and veneer restorations fabricated from the

pressed ceramic material have been placed.

It’s not surprising, then, that dentists have sought to recreate the same esthetic qualities they’ve achieved with indirect porcelain with direct composite. Unfortunately, ensuring long-term functional and esthetic durability of direct composite restorations is challenging, even with enhancements to direct restorative materials.

To keep pace with the latest trends in cosmetic dentistry, which include the need for durable, esthetic and convenient materials for placing direct restorations, the IPS Empress system has advanced significantly. The newest addition to the IPS Empress System is IPS 

IPS Empress Direct is a light-curing, nano-hybrid composite that demonstrates excellent handling properties to achieve the consistent anterior and posterior esthetics of ceramic with the on-demand ease of composite. Additionally, IPS Empress Direct is based on the latest technology and features a variety of true-to-nature dentin and enamel shades, and different levels of translucencies and opacities to create limitless opportunities for realizing esthetic results for all indications.

allows dentists to mimic the optical effects of natural tooth structures in a way that is similar to ceramic, but with the direct simplicity of composite. The basis for consistent and quality shade selection when using the IPS Empress Direct composite is two high-quality ceramic shade guides.

To demonstrate the convenience of placing IPS Empress Direct composite, the creation of an anterior restoration is illustrated. This esthetically optimized nano-hybrid composite was selected for treating a 50-year-old male who presented with a failing composite restoration on tooth No. 11 

 Before removing the defective restoration and preparing the tooth, an accurate shade was taken 

. It was determined that IPS Empress Direct A2 Dentin and IPS Empress Direct A1 Enamel composities would be used.

. To ensure complete isolation, rubber dam (OptraDam) was placed.

. The defective restoration was removed from tooth No. 11 and the tooth prepared 

 An etchant gel (Total Etch) was applied to the tooth for 15 seconds, after which the preparation was rinsed and dried.

. A fifth-generation adhesive bonding agent (ExciTE) was applied to the preparation for 10 seconds using a convenient dispensing tool (ExciTE VivaPen)

. The bonding agent was air-thinned with high pressure and light cured for 10 seconds using an LED curing light (bluephase 20i).

. After light curing, the dentin replacement layer of IPS Empress Direct A2 Dentin was placed 

. This increment was sculpted into place using an artist’s brush 

 This composite layer was cured for 40 seconds.

. IPS Empress Direct A1 Enamel was placed 

. The mylar strip was used to help adapt the composite into the mesial and distal areas of the tooth 

 The rubber dam was removed, and the restoration was initially finished using Assorted ET Carbide (Brasseler) 

 The restoration was then polished using a series of integrated products, including the green OptraPol polisher 

To further enhance the restorative process, IPS Empress Direct exhibits high stability, shade fidelity and enhanced polishing properties 

. As a result, dentists can achieve the esthetics of ceramic with the chairside, direct placement convenience of a composite. Its physical properties are specifically designed for simplified application, while low sensitivity to light ensures ample, pressure-free working time for designing restorations. To meet the highest clinical demands, this nano-hybrid composite also demonstrates an optimum radiopacity.

 is accredited by the American Academy of Cosmetic Dentistry and lectures internationally on cosmetic dentistry. He also serves as a product consultant to dental product 

For many years, the IPS Empress all-ceramic brand was known for the highest level of esthetics when imitating the characteristics of natural teeth. Since it was introduced, more than 37 million indirect crown and veneer restorations fabricated from the IPS Empress pressed ceramic material have been placed.