How to achieve the final results your patients desire

November 18, 2015

Esthetic dentistry can transform people’s appearance and have a resounding impact on their lives by enhancing their smiles with completely natural-looking restorations.

Esthetic dentistry can transform people’s appearance and have a resounding impact on their lives by enhancing their smiles with completely natural-looking restorations.

Achieving esthetic and functional restorative treatments requires comprehensive evaluation, accurate diagnosis and thorough treatment planning for each individual’s case.1

In addition to selecting the most appropriate restorative option, clinicians must ensure the recognized components of a smile are evaluated and incorporated into treatment planning to create a harmonious foundation for esthetics. By examining the entire smile (i.e., hard and soft tissues, smile line, gingival contours, symmetry, etc.), clinicians can avoid post-treatment complications (i.e., chronic pain, gingival irritation, loss of alveolar bone, unequal gingival contours, etc.) and ensure that treatment produces more than just an attractive smile but one that is also healthy and functional.

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Additionally, today’s esthetic dentistry aims to achieve an enhanced appearance while simultaneously maintaining as much healthy tooth structure as possible. Fortunately, materials available today (e.g., lithium disilicate) are indicated for a variety of clinical situations while enabling a more conservative approach to treatment. One such material, IPS e.max Press (Ivoclar Vivadent, Amherst, N.Y.), helps to reduce the frustrations and challenges associated with conventional press materials and demonstrates improved durability and exceptional true-to-nature esthetics.2

This material enables the creation of expressive esthetics, independent of the tooth shade, with minimal preparation. The IPS e.max Press lithium disilicate material can be pressed as thin as 0.3 mm while still ensuring strength of 400 MPa.3 Additionally, the monolithic property of pressed lithium disilicate allows the material to maintain its physical and optical properties.4

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Case presentation

A 32-year-old female patient presented with the chief complaint of dissatisfaction with her smile. After a preliminary evaluation, the initial areas of concern included short clinical crowns, insufficient buccal corridors, asymmetric gingival architecture, unaesthetic tooth color, large and poorly contoured and discolored composite restorations (tooth Nos. 7 and 10) and a diastema between tooth Nos. 8 and 9. Additionally, a failing amalgam restoration was present on tooth No. 13.

Extensive pre-operative photography was taken, and diagnostic casts were created to ensure proper facebow articulation and bite registration. A full-mouth diagnostic wax-up was also made. Using this diagnostic wax-up, the patient’s condition was thoroughly evaluated with respect to formulating a treatment plan.

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To increase the overall esthetics of the patient’s smile, additional procedures beyond providing esthetic restorations would be required. Hard tissue crown lengthening surgery would be needed prior to restorative treatment to establish proper biologic width and enable ideal preparations for the restorations. Although veneers were preferred to conserve healthy tooth structure, tooth No. 13 would require a full-coverage crown due to the extensively failed amalgam restoration.

Therefore, the treatment plan included hard tissue crown lengthening with eight weeks of healing. The old amalgam restoration on No. 13 would be removed and tooth Nos. 4-13 conservatively prepared. The maxillary teeth would then be restored using lithium disilicate (IPS e.max Press) veneers (Nos. 4-12) and a lithium disilicate (IPS e.max Press) full-coverage crown on tooth No. 13.

Lithium disilicate was selected for this treatment because of its monolithic strength and high esthetics. It is also ideal for minimally invasive treatments and predictable for all types of restorations.

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Clinical protocol

After the patient accepted the treatment plan, the diagnostic wax-up was reviewed and a surgical stent, axial and incisal reduction guide and provisional matrix were created from the wax-up.

Hard tissue crown lengthening on tooth Nos. 4-13 was completed by a periodontist (Charles Goodman, DDS; Chicago, Ill.), and the patient was allowed to heal for eight weeks.

The amalgam restoration on tooth No. 13 was removed, and all teeth were prepared with minimal preparation design (e.g., 0.3 mm marginal reduction, 0.5 mm axial reduction, 1 mm incisal reduction). An equigingival light chamfer was created for the finishing line margin. The existing proximal contacts were not broken by the preparation or interproximal elbows. Areas without proximal contacts underwent a slice preparation to the lingual line angle. The incisal facial angles of the preparations were finished with a finishing diamond and red discs (Sof-Lex, 3M ESPE), and interproximal finishing was performed with finishing strips (Flex Wide Fine, Brasseler USA).

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Final impressions were taken using light-body (Aquasil Ultra XLV, DENTSPLY Caulk) and heavy-body (Aquasil Ultra Heavy, DENTSPLY Caulk) impression materials. Preparation and bite stick photographs were captured, as well as bite registration. The preparation shades were determined (i.e., Nos. 4-6 at ND2, Nos. 7-10 at ND1, Nos. 11-13 at ND2).

Provisionals were created and placed using the “lock-on” technique and a two-component temporization material (Protemp Plus, 3M ESPE) in shade bleach. The preparations were spot etched for 12 seconds, rinsed and a light-curing bonding agent (Heliobond, Ivoclar Vivadent) applied on the surface and light cured. Using the putty matrix, the provisional material was seated with firm pressure. Once light cured, the provisionals were shaped, contoured, polished and glazed (LuxaGlaze, DMG America) and the occlusion verified.

After 48 hours, the patient returned and the smile was reviewed and evaluated. The patient and clinician were satisfied with the smile design and occlusion. Impressions and photographs were taken, and the shade of the final restorations determined (OM2). This information was sent to the laboratory for fabricating the final IPS e.max Press restorations.

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In the laboratory, the wax-up was reduced in the incisal and occlusal areas, invested and then pressed. The restorations were then completed with layering ceramic, staining and glazing. The final restorations were sent to the dental practice.

The patient returned for delivery of the final restorations two weeks after provisionalization. The provisionals were removed, and AICI gel was applied for maintaining hemostasis. The teeth were cleaned with a chlorhexidine gluconate rinse and then etched for 12 seconds. A desensitizer (GLUMA, Heraeus Kulzer) was placed, after which a total-etch adhesive (ExciTE F, Ivoclar Vivadent) applied. Although the laboratory had already etched the veneers, each veneer and the crown were scrubbed with a universal primer (Monobond Plus, Ivoclar Vivadent) for 60 seconds, which was then dispersed with a strong stream of air.

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The two primer liquids (Multilink Primer A and B, Ivoclar Vivadent) were mixed in a 1:1 ratio and applied onto the entire bonding surface using a microbrush, starting with the enamel surface, and scrubbed for 30 seconds. Excess was dispersed with blown air until the mobile liquid film was no longer visible.

The restorations were fully seated, and excess cement was removed using microbrushes. The restorations were tacked into place using a curing light (VALO, Ultradent Products, Inc.) for four seconds using the spot cure accessory. Using floss, the interproximal contacts were cleaned. All of the restorations were light cured, and the margins were finished using a yellow carbide finishing flame, a scaler and interproximal strips (Brasseler USA Dental, Savannah, Ga.).

In-office whitening was then performed on the mandibular arch.

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Conclusion

Today’s esthetic restorative dental treatment options enable clinicians to achieve dramatic yet natural-looking smile transformations that enhance a patient’s self-confidence and change their lives. However, thorough and comprehensive evaluation and diagnosis are necessary to ensure that treatment plans and the restorations delivered will produce functionally sound results. In this case, fully assessing the patient’s smile and its framework to determine what procedures and restorative materials were most appropriate (e.g., IPS e.max Press) allowed conservative preparation and placement of high strength and natural-looking restorations. As a restorative material, lithium disilicate (IPS e.max Press, Ivoclar Vivadent) provides long lasting, esthetically pleasing and durable treatments. In this case, the patient was pleased and satisfied with the final result and her beautiful new smile. After receiving her treatment, the patient said, “I can tell that I hold myself differently, smile differently and feel more confident in every way.”  

Special thanks to Peter Kouvaris, CDT, for his outstanding ceramic skills.

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References
1. Kristopher K. Aetiology of a diagnosis: the key to success in treatment planning. Int J Orthod Milwaukee. 2014;25(2):13-5.
2. Tysowsky GW. Monolithic lithium disilicate restorations are now everyday players. Inside Dentistry. 2013;9(1):38-40.
3. Sorensen JA, Cruz M, Mito WT, et al. A clinical investigation on three-unit partial dentures fabricated with a lithium disilicate glass-ceramic. Pract Periodontics Aesthet Dent. 1999;11(1):95-106; quiz 108.
4. Culp L, McLaren EA. Lithium disilicate: the restorative material of multiple options. Compend Contin Educ Dent. 2010;31(9):716-20, 722, 724-5.

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