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  1. 1. issn 1616-7390 Vol. 3 • Issue 2/2009cosmeticdentistry _ beauty & science2 2009_specialOrthodontic surgery and aesthetics_industry reportSimplified digital impression-taking_meetingsIDS review
  2. 2. BEAUTY – COMPOSE IT!Highly aesthetic restorative Two simple steps Layers like in nature Brilliant results Now available in Gingiva shades Please visit us atVOCO GmbH · P.O. Box 767 · 27457 Cuxhaven · Germany · Tel. +49 (4721) 719-0 · Fax +49 (4721) 719-140 ·
  3. 3. editorial _ cosmetic dentistry IDear Reader, _I sincerely appreciate the enthusiastic support of our authors for the secondedition of cosmetic dentistry . Since we began, we have striven to fulfil the needs ofour valued readers, by providing innovative and informative articles on clinical tech- Dr So-Ran Kwonniques and new dental technologies. So far, we have received very positive and Co-Editor-in-Chiefencouraging feedback from many supporters. We are certainly grateful to have estab-lished a well-suited and efficient team in such a short time. Cosmetic and implant dentistry have without a doubt become of central interest,attracting the interest of many dentists worldwide. At many important academicseminars or conventions, the main theme is directly or indirectly related to these twospecialities. This trend is expected to be even more pronounced in the future. Dentaleducation, from undergraduate programmes to graduate programmes and continuingeducation courses, exhibits a continual shift towards cosmetic and implant dentistry. The number of patients in need of cosmetic and implant procedures is steadilyincreasing. I have personally witnessed this boom in Europe, Asia and the US during myinternational lectures and have been informed of it through regular feedback fromdentists and dental hygienists. If we are to satisfy our patients’ needs, additional skillsand knowledge are essential. In this edition, you will find solutions for quality and cosmetic restorations on nat-ural teeth and implants. Our industry reports introduce innovative materials anddevices that will make your clinical work not only more precise, but also much easier.I am confident that the more knowledge we have on cosmetic dentistry, the greater oursuccess in our dental practices will be. I hope you will enjoy this edition of cosmetic dentistry, and look forward to receiv-ing your valuable feedback!Sincerely yours,Dr So-Ran KwonCo-Editor-in-ChiefPresident Korean Bleaching SocietySeoul, Korea cosmetic dentistry 2 _ 2009 I 03
  4. 4. I content _ cosmetic dentistry page 06 page 12 page 22I editorial 32 Aesthetics with all-ceramics and tooth whitening03 Dear Reader _ Marcus Striegel _ So-Ran Kwon, Co-Editor-in-Chief 36 Learning and applying the Natural Layering Concept _ Didier DietschiI special06 Orthodontic surgery and aesthetics _ Nezar Watted et al. I industry news 44 Amaris Gingiva—I case study A beautiful smile, naturally12 Fixed prosthodontic management of a mutilated dentition: A team approach _ Helena Lee & Ansgar Cheng I meetings 46 IDS flourishes despite economic trouble _ Daniel ZimmermannI clinical technique 48 Cosmetic events18 Replacement of a faulty posterior restoration _ Sushil Koirala I about the publisherI industry report 49 _submissions 50 _ imprint22 Simplified digital impression-taking _ Helmut Götte26 The new NobelProcera system for clinical success: The next level of CAD/CAM dentistry _ Hans Geiselhöringer & Stefan Holst Cover image courtesy of coltène whaledent. page 26 page 32 page 4604 I cosmetic dentistry 2_ 2009
  5. 5. I special _ orthodonticsOrthodontic surgeryand aestheticsAuthor_ Prof Nezar Watted, Prof Josip Bill, Dr Ori Blanc & Dr Benjamin Schlomi, Germany & Israel _Orthodontic treatment generally follows aes- thetic, functional, and prophylactic objectives, where individual aspects of isolated cases are accorded vary- ing importance as they arise. Increasing aesthetic expectations and awareness of modern dental treat- ment options disseminated by the media have resulted in increased interest and greater willingness of adults to Fig. 1_Diagrammatic representation consider orthodontic treatment. Aesthetic orthodon- Fig. 1 of the osterotomy lines on the tics is thus primarily adult orthodontics. outer (continuous line) and the inner As a rule, aesthetically oriented adult orthodontics compacta (dashed line) of the A peculiarity of orthodontic treatment in adults therefore has an interdisciplinary inclination. Occlusion, mandible; 4 = inner saw cut above compared with paediatric or adolescent orthodontics is function and aesthetics are considered to be equivalent the N. mandibularis. the age-associated involution of the connective tissues parameters in modern orthodontics and particularly Figs. 2a & b_Lateral view of the that leads to a reduction in cell density, thickening of the here in combined orthodontic-maxillofacial surgical 25-year-old male patient, showing fibre bundles, delayed fibroblast proliferation, and treatment.32,33 This was achieved through optimisation lower facial retrusion diagonally reduced vascularisation. These are the causes of slower of diagnostic tools and further development and in- forward. The frontal view shows the dental movement and delayed tissue and bone reac- creasing experience in orthopaedic surgery.4right-sided deviation due to the laterog- tions. Absent sutural growth, the age of the periodon- nathia. The upper-lip vermillion is tium, specific periodontal diagnoses, and tissue atrophy Nowadays, treatment of adult patients with dental relatively weakly developed (b). also make treatment in adults particularly challenging. malposition and mastication impairment is one of the standard tasks of the orthodontist. If the discrepancies in spatial allocations of the upper and lower dentition are particularly pronounced and where the cause is primarily skeletal and not only dentoalveolar, conven- tional orthodontic therapy is limited and combined orthodontic-surgical therapy is indicated for remodel- ling of the jaw bases. Treatment for a skeletal dysgnathia (Class III) using combined orthodontic-maxillofacial surgical correc- tion is discussed in this article. _Chronological development of maxillofacial surgery of the mandible The first orthodontic-maxillofacial surgical proce- dure on the mandible described in the literature was that of the American surgeon Hullihen in 1848.13 This Fig. 2a Fig. 2b procedure was a segmental osteotomy of the anterior06 I cosmetic dentistry 2_ 2009
  6. 6. special _ orthodontics Imandible (a posterior shift [retrusion] of a protruding referred to the then most renowned orthodontistmandibular alveolar process, following a burn injury). Dr Edward Hartley Angle2, who ultimately recom-Towards the end of the 19th century, the method mended the surgical procedure mentioned above.of orthodontic-maxillofacial surgical correction ofdysgnathias by surgical retrusion or protrusion of the Six years later, the procedure in this osteotomy Figs. 3a–e_Clinical situation before themandible was revisited. Jaboulay14 described resection on the Corpus mandibulae was also published by the start of treatment.of the Processus condylaris and Blair4, osteotomy on Hamburg surgeon Floris.11 Parallel with this develop- Fig. 4_The cephalometric X-ray showsthe Corpus mandibulae. The continuity resection in ment in the US, Von Auffenberg3 in Europe conceived the disharmonious arrangement in thethe horizontal branch by Blair was the first surgical a step-by-step osteotomy for correcting a mandibular vertical axis. The lower face shows anprognathism procedure. The patient first visited the retrusion, which was performed by Von Eiselberg approx. 60 per cent enlargement indentist Whipple in St. Louis in 1891 and was then in 1901. relation to the upper face. Fig. 3a Fig. 3d Fig. 3b Fig. 3c Fig. 3e Fig. 4 Fig. 5 cosmetic dentistry 2 _ 2009 I 07
  7. 7. I special _ orthodontics Fig. 5_Orthopantomographic image before the start of orthodontic treat- ment. An apical lucency at tooth 31. Pronounced maxillary-antrum expan- sion between teeth 25 and 27. Ortho- dontic closure of the gap is difficult.Figs. 6a–c_Situation after orthodonticpreparation for the surgical procedure. Figs. 7a–e_Occlusion at the end of treatment; there is a neutral stable occlusion with physiological anterior Fig. 6a Fig. 6b bite in the sagittal and vertical axesand a correct midline (a–c). Monitoring images of the upper and lower jaws. A ceramic bridge was made in the lower jaw (d & e). Fig. 6c Fig. 7a Fig. 7b Fig. 7c_contact cosmetic dentistry Fig. 7d Fig. 7e The era of orthodontic surgery in Europe began only In 1935, Wassmund, who saw its drawbacks in a pos- after World War I. The experience gained there led to a sible dislocation of the proximal segment by the mus- substantial extension of the indications for orthodon- cles inserted there, described a modification of the tic-maxillofacial surgical procedures, as well as to the Bruhn–Lindemann surgical technique.26 In the early transferral of this surgical technique to the area of elec- 1950s, a new era in orthodontic surgery of the mandibleProf Nezar Watted tive procedures.5,6,16–18,24 In the early 1920s, Bruhn and was begun with Kazanjian’s resumption12,15,23 of theWolfgangstraße 12 Lindemann set transversal osteotomy of the Ramus technique of transverse, oblique severing of the as-97980 Bad Mergentheim mandibulae as the standard method at the time for the cending ramus, first performed by Perthes in 1922.22Germany surgical correction of mandibular prognathism. This Shuchard modified this method in 1954 by enlargingE-mail: method, which continued to have many adherents well the bony insertion surface, and in 1955 into the 1960s, is today known as the Bruhn–Lindemann introduced sagittal splitting at the horizontal ramus of procedure.1,6,25,45 the mandible. He shifted the buccal osteotomy line08 I cosmetic dentistry 2_ 2009
  8. 8. special _ orthodontics Iobliquely from the last molar to the posterior margin ofthe jaw angle.19–21 In 1959, Dal Pont moved this buccalosteotomy line from the last molar to the inferior mar-gin of the mandible.8,9 Since then, this method of sagit-tal split at the mandible has been called sagittal splitaccording to Obwegeser–Dal Pont (Fig. 1). Epker10 devel-oped the incomplete sagittal splitinto a routine method._Clinical case presentation History and diagnosis A 25-year-old patient presented on his own initia-tive. He complained of functional (impairment of mas-tication and jaw joint pain) and aesthetic impairment(sunken face with facial asymmetry). He had undergoneorthodontic treatment between the ages of 8 and 15and reported pain in the area of the anterior mandible. The lateral image showed a retrusive lower face Fig. 8a Fig. 8binclined forward with mid-facial hypoplasia—regioinfraorbitale—a flat upper lip and an elongated lowerface compared with the mid-face—47%:53% insteadof 50%:50%29 (Table I; Fig. 2a). Owing to the negativesagittal overjet, there was a positive lower lip step. Thefrontal image shows mandibular deviation (laterog-nathia) to the right, which can be traced to growthasymmetry in the jaw (Fig. 2b). In addition, there was aClass III dysgnathia angle with conspicuous mandibu-lar midline deviation to the right, frontal and right lat-eral crossbite, anterior mandibular labial tilt, and a steepanterior mandible. Tooth 26 had been missing for sometime (Figs. 3a–e). FRS analysis (Table I & II) clearly showsthe strongly sagittal and relatively weak vertical dysg-nathia both in the soft-tissue profile and in the skeletalregion. The parameters indicated a mesiobasal jaw rela-tionship and a growth pattern with an anterior course:the vertical grouping of the soft-tissue profile showed a Fig. 8c Fig. 8ddisharmony between the mid-face and the lower face(G’-Sn:Sn-Me’; 47%:53%). This was relatively weakly 2. the optimisation of the facial aesthetics; Figs. 8a–d_The extra-oral treatmentexpressed in the bony structures (N-Sna:Sna-Me; 3. the optimisation of the dental aesthetics, considering results. The sagittal, vertical and trans-44%:56%). In the region of the lower face there was also the periodontal situation; verse were corrected (a & b). Change inmild disharmony (Sn-Stm:Stm-Me’; 31%:69%). Com- 4. the assurance of the stability of the results achieved; the oral profile: left pre-op, right post-opplementary assessment of the mandible showed that the 5. meeting the patient’s expectations. (c & d).area from the subnasal-labral inferius to the soft-tissuechin (Li-Me’), which should have been 1:0.9, was shifted The improvement of the facial aesthetics not only inin favour of the Li-Me’ part (0.9:1; Fig. 4).The panoramic the sagittal axis in the region of the lower face (theimage showed a lucency of teeth 31 and 41. A root canal mandibular region), but also in the region of the mid-faceprocedure followed by root apex resection was thus (hypoplasia) and in the transverse axis should be noted asperformed (Fig. 5). specific treatment objectives. The change in the region of the mid-face was intended to affect the upper lip and the_Therapeutic objectives and treatment upper-lip vermillion. These treatment objectives wereplanning achieved by two procedures: The objectives of this combined orthodontic- 1. a dorsal extension of the mandible with lateral sweepmaxillofacial surgical treatment were: to the left for correction of the sagittal and transverse defects, as well as occlusion and the soft-tissue profile;1. the establishment of neutral, stable, and functional 2. bone augmentation in the mid-face for harmonisation occlusion with physiological condylar positioning; of the face. It would not have been possible to achieve cosmetic dentistry 2 _ 2009 I 09
  9. 9. I special _ orthodontics Fig. 9 Fig. 10 Fig. 9_The cephalometric image after the desired treatment objectives with respect to func- 3. Splint therapy for determining the condylar position. conclusion of treatment shows a tion and aesthetics using orthodontic procedures This was performed in the 4 to 6 weeks prior to the harmonious ratio between the skeletal alone.27 surgical procedure. The objective was registration of structures, as well in the sagittal axis the jaw joint in a physiological position (centrics).and the vertical axis, and harmonisation Therapeutic procedure 4. Oral surgery for correction of the skeletal dysgnathia: in the soft-tissue profile between the Correction of the pronounced dysgnathia was done after model operation, determination of the transpo- upper and lower face. in six phases:28,30–33 sition path and production of the splint in the target Fig. 10_Orthopantomogram after con- occlusion, the surgical mandibular translocationclusion of the orthodontic treatment and 1. Splint therapy: a flat bite guard splint was installed for using sagittal split according to Obwegeser–Dal Pont before the prosthetic care. six weeks in order to determine the physiological was done. Augmentation in the mid-facial region was condylar position or centrics before the final treat- done using autologous bone. ment planning. By doing this, the forced bite could be 5. Orthodontics for fine adjustment of occlusion. Table 1_Proportions of soft-tissue demonstrated to its full extent. 6. Retention: 3-3 retainers were cemented in the structures before and after treatment. 2. Orthodontics for forming and adjusting the dental mandible. Table 2_Proportions of skeletal struc- arches relative to each other and decompensation of tures before and after treatment. the skeletal dysgnathia (Figs. 6a–c). Mandibular and maxillary plates were used as the retention appliance. Prosthetic care was provided after Parameter Mean Before treatment After treatment six months. G’-Sn/G’-Me’ 50 % 47 % 50 % _Results Sn-Me’/G’-Me’ 50 % 53 % 50 % Sn-Stm/Stm-Me’ 33 % : 67 % 31 % : 69 % 33 % : 67 % Figures 7a–e show the situation after the conclusion of treatment and after extraction of tooth 31 and subse- Sn-Li/Li-Me’ 1 : 0.9 0.9 : 1 1:1 quent prosthetic treatment, neutral occlusion, andTable 1 correct midline with physiological sagittal and vertical bite. The extra-oral images show a harmonious profile in Parameter Mean Before treatment After treatment the vertical as well as in the sagittal axis (Figs. 8a & b). The SNA 82° 90° 90° oral profile is harmonious. The upper-lip vermillion is distinctly visible in comparison to the original situation SNB 80° 93° 90° (Figs. 8c & d). ANB 2° - 3° ( indl. 4,5°) 0° ( indl. 4,5°) WITS-Wert ± 1 mm - 8 mm - 3 mm The FRS shows the changes in the parameters that arose as the result of the displacement of the mandible. ML-SNL 32° 20° 20° There is harmonisation in the vertical arrangement NL-SNL 9° 4° 4° of the bony and soft-tissue profile. The disharmony in the lower third of the face has been corrected (Fig. 9; ML-NL 23° 16° 16° Tables 1 & 2). Gonion-< 130° 120° 120° The OPG shows the positioning screws in both jaw SN-Pg 81° 93° 90.5° angles and the fixation screws of the augmented bone in PFH/AFH 63 % 74 % 76 % the mid-face (Fig. 10)._ N-Sna /N-Me 45 % 44 % 44 % Editorial note: A complete list of references is avail- Sna-Me/N-Me 55 % 56 % 56 % able from the publisher.Table 210 I cosmetic dentistry 2_ 2009
  10. 10. 2009 Greater New York Dental Meeting 85th The Annual Session Largest Dental Convention/ Exhibition/Congress in the United States NO Pre-Registration Fee! MEETING DATES:NOVEMBER 27th - DECEMBER 2nd EXHIBIT DATES: NOVEMBER 29th - DECEMBER 2nd For More Information: Please send me more information about...Greater New York Dental Meeting™ Attending the Greater New York Dental Meeting 570 Seventh Avenue - Suite 800 Participating as a guest host and receiving free CE New York, NY 10018 USA I speak _____________and am willing to assist international guests Tel: +1 (212) 398-6922 enter language Name Fax: +1 (212) 398-6934 E-mail: Address Website: City, State, Zip/Country Code Telephone E-mail Fax or mail this to: Greater New York Dental Meeting or visit our website: for more information.
  11. 11. I case study _ prosthodontic managementFixed prosthodonticmanagement of a mutilateddentition: A team approachAuthors_Dr Helena Lee & Dr Ansgar Cheng, Singapore Fig. 1_Pre-treatment intra-oralfrontal view, presenting with attrition, loss of posterior support, reduced VDO and compromised aesthetics. Fig. 1 _Abstract ment options are essential for a predictable long- term treatment outcome for prosthodontic treat- _Successful full mouth fixed rehabilitation ment.1 It is known that loss of the vertical dimen- of a mutilated dentition is always a prosthodon- sion of occlusion (VDO) may pose significant tic and surgical challenge. Accurate diagnosis, clinical difficulties in prosthodontic treatment.2 proper treatment planning, prudent choice of The clinical procedures for the re-establishment of prosthodontic materials and meticulous treat- a new therapeutic vertical dimension of occlusion ment execution are essential for a successful is seldom taught in undergraduate dental curric- treatment outcome over a long period. The treat- ula. VDO is defined as the superior–inferior meas- ment of a partially edentulous oral cavity using a urement between two points when the occluding combination of immediate-loading and delayed- elements are in contact.3 Various methods have loading implant-supported porcelain-fused-to- been proposed for the clinical assessment of the metal and full-ceramic restorations is presented VDO.4 Loss of the tooth structure does not neces- in this report. sarily equate to loss of the VDO,5 as the VDO may be maintained as a result of compensatory dental _Introduction eruption.6 When the clinical loss of the VDO is small, accurate diagnosis can be difficult.7 In this Prudent clinical judgement and careful bal- case study, the management objective was to ancing of the risks and benefits of various treat- determine whether there was any need for the re-12 I cosmetic dentistry 2_ 2009
  12. 12. case study _ prosthodontic management I Fig. 2 Fig. 3 Fig. 4 Fig. 5establishment of the VDO in the case of small loss matisation of the maxillary sinus occurs after Fig. 2_Pre-treatment intra-oraland whether the proposed change in the VDO was extraction of molars. In addition, the posterior occlusal view of the maxilla, showingclinically acceptable. When the loss of the VDO is maxilla has poorer bone quality, mainly Type IV dental attrition and inadequatelysmall, any change in the VDO should be based on bone.28 restored molars. The orthodonticthe amount of interocclusal space required to arch wire was broken.restore the dentition to proper form and function. Placement of implants in grafted bone sites Fig. 3_Pre-treatment intra-oralA significant alteration of the VDO should be has a high success rate of osseointegation.29–32 occlusal view of the mandible, show-approached with care, and unnecessary, excessive Several authors have reported an approximate ing dental attrition and inadequatelychanges of the VDO should be avoided. In general, 92 per cent success rate of implants after sinus restored teeth. A few of the ortho-a significant change of the VDO should be moni- augmentation.33 However, immediate implant dontic brackets were de-bondedtored over an extended period.8 loading under such conditions is generally from the mandibular incisors. avoided. The low failure rate may be attributed to Fig. 4_Pre-treatment orthopanto- Improvements in macroscopic implant mor- the placement of implants of greater lengths in mogram X-ray, showing adequatephology and surface treatments have led to the grafted bone sites.29, 30, 34 endodontic fillings, over-eruption ofreduction of healing time and the concept of im- maxillary molars, inadequatemediate loading of implants.9–18 Early implant This case study describes the team approach occlusal support and inadequatelyloading is a successful protocol in selected management of a mutilated dentition, using restored teeth. Posterior mandiblecases.19–24 Providing that sufficient bone volume different types of conventional and implant- bone bed was diagnosed as Type available, flapless surgical implant placement is supported fixed restorations with immediate- Fig. 5_Completed tooth preparationspredictable25, 26 and patients experience minimal loading and delayed-loading protocol. for full coverage restorations at thepost-surgical discomfort.27 approximated treatment VDO. Note _Clinical report the equi-gingival preparation The posterior maxilla presents a unique chal- margins. Implants were placedlenge to implant placement when minimal bone A 38-year-old patient presented with multiple immediately upon completion ofheight remains inferior to the sinus floor. Pneu- missing teeth. The patient desired the restoration crown preparations. cosmetic dentistry 2 _ 2009 I 13
  13. 13. I case study _ prosthodontic management of function and aesthetics. He was undergoing side; and simultaneous bilateral placement orthodontic treatment. He presented clinically of implants in the maxillary posterior area, with moderate dental attrition, defective using the conventional two-stage protocol. This restorations, loss of posterior support, discolou- was followed by the placement of implant- ration, mild loss of the VDO and compromised supported prostheses in the maxilla after a healing aesthetics (Figs. 1–3). The pre-treatment radi- period of six months. ograph showed adequate endodontic obtura- tion, missing mandibular posterior teeth, over- Maxillary and mandibular diagnostic casts Fig. 6_Completed anterior full- eruption of maxillary posterior teeth and attri- were made of Type IV dental stone (Silky-Rock,ceramic crown restorations. Occlusal tion of the incisors. The dentition was free from Whip Mix). The casts were mounted on a semi- support was gained by definitive active dental caries and periodontal probing was adjustable articulator (Hanau, Wide-vue, Tele- restorations on all the natural teeth within normal limits. The maxillary left molar dyne Waterpik). Diagnostic wax-up was carried and mandibular implant-supported region bone bed was determined to be inadequate out to restore the anterior teeth to proper form. prostheses to maintain the newly for the placement of dental implants. The The resulting diagnostic wax-up indicated that established VDO. mandibular posterior bone bed was diagnosed as an increase of 1.0 mm in vertical dimension at Fig. 7_Panoramic radiograph after Type 2B with sufficient bone density for early the incisal pin level was required to restore the insertion of the crowns. Additional implant-loading prosthodontic treatment (Fig. 4). patient’s anterior teeth to proper form. Suchimplants were placed in the maxillary level of change of the VDO had no practical need posterior areas. The overall fixed prosthodontic treatment for prolonged provisionalisation before defini- Fig. 8_Occlusal view of completed plan included placement of endosseous im- tive prosthodontic treatment. The patient’s max- definitive maxillary restorations with plants in the mandibular posterior area for illary right second and third molars required a porcelain occlusal surfaces. prosthodontic rehabilitation, using the early im- reduction of 2.5 mm gingivo-incisal height, in Fig. 9_Occlusal view of completed plant-loading protocol; placement of fixed order to re-establish a proper occlusal plane. All definitive mandibular restorations restorations in the maxilla and mandible; sinus the natural teeth in the maxillary and mandibu- with porcelain occlusal surfaces. lift with bone augmentation on the patient’s left lar arches required full coverage restorations. Fig. 6 Fig. 7 Fig. 8 Fig. 914 I cosmetic dentistry 2_ 2009
  14. 14. case study _ prosthodontic management I Fig. 10_Post-treatment intra-oral frontal view. Fig. 10The maxillary right second molar was restored tray loaded with putty material (Aquasil Putty,with an amalgam post-and-core foundation DENTSPLY DeTrey) was seated over the entireprior to full coverage restoration preparation. An dental arch to make the definitive mandibularadequate pre-existing composite resin core re- impression. The maxillary definitive impressiontained by a prefabricated post with sufficient was made in the usual manner. A centric relationferrule was noted in the mandibular left second record was made with a vinyl polysiloxane mate-premolar. rial (Regisil PB, DENTSPLY DeTrey). On the day of teeth preparation, all teeth were The development of the definitive crownprepared to receive full crown restorations. In restorations was carried out as usual on theorder to establish anterior guidance,35 the treat- definitive casts. Except for the maxillary rightment indicated that the restoration of the ante- molars, all maxillary and mandibular crownsrior teeth should be completed before or at the supported by natural teeth were restored withsame time as the implant-supported restora- Cercon (DeguDent) full-ceramic crowns. Prefabri-tions. The anterior teeth were prepared in the cated abutments (NobelReplace, Nobel Biocare)usual manner for complete coverage crown were custom milled with a six-degree taper inrestorations. Margins of the tooth preparations the dental laboratory to facilitate the develop-were kept supra-gingival, and no gingival dis- ment of the restorations. Splinted, cement-placement procedures on the prepared teeth retained, implant-supported mandibular resto-were necessary. rations with porcelain occlusal surfaces were made of porcelain fused to metal material. Upon completion of the crown preparations,six endosseous implants (NobelReplace, Nobel On the day of restoration delivery, theBiocare) were placed by the periodontist in the mandibular implant abutments were torquedposterior mandible using a flapless surgical down to 32 Ncm. The abutment screw holesprotocol. All implants were placed with 45 Ncm were sealed with gutta-percha (Mynol, Blockinsertion torque (Fig. 5). No surgical template Drug Company). All the definitive crowns werewas used during the surgical phase; the prostho- cemented in resin-modified glass-ionomerdontist was present during the implant surgery luting agent (RelyX Unicem, ESPE). The insertionto ensure implant placement was prosthodonti- of crowns was followed by implant placement incally acceptable. the maxillary arch. Pick-up type implant impression copings In the presence of the prosthodontist, three(NobelReplace, Nobel Biocare) were attached to endosseous implants (NobelReplace, Nobelthe newly placed mandibular implants. High- Biocare) were placed by the periodontist in theviscosity vinyl polysiloxane material (Aquasil right maxilla, using a flapless surgical protocol.Ultra Heavy, DENTSPLY DeTrey) was carefully The implants were inserted with 45 Ncm inser-injected onto all tooth preparations and the tion torque. The implants were placed in the leftimplant impression copings. A stock polystyrene maxilla with a simultaneous sinus lift (Figs. 6 & 7). cosmetic dentistry 2 _ 2009 I 15
  15. 15. I case study _ prosthodontic management The sinus space was augmented with a xenograft beneficial for individuals with thin gingival material (Bioss, Geistlich Pharma). biotypes. After a six-month healing period, the left max- Porcelain-fused-to-metal restorations were illary implants were exposed. A definitive maxil- used in the posterior teeth because of the well- lary impression was made as usual. The fabrica- documented long-term clinical track record of tion of the definitive porcelain-fused-to-metal this restoration. In order to maximise the aes- implant-supported restorations was carried out thetic outcome, porcelain occlusal surfaces were in the usual manner on the definitive casts. prescribed. Splinted, cement-retained, porcelain-fused-to- metal restorations with porcelain occlusal surfaces _Conclusion were prescribed for the implant-supported maxillary posterior crowns. The maxillary implant- The clinical management of an aesthetically supported restorations were inserted in the same demanding, complex functional prosthodontic manner described earlier using resin-modified rehabilitation is a clinical challenge. Various glass-ionomer luting agent (RelyX Unicem, ESPE; restorative materials were used for this treat- Figs. 8 & 9). ment. A combination of full-ceramic restorations and porcelain-fused-to-metal restorations with _Discussion porcelain occlusal surfaces enhances the overall aesthetic outcome, as well as functional pre- Various newer implant clinical protocols and dictability. Various surgical and implant-loading conventional two-stage delayed-loading implant protocols were used, to ensure optimal results._ protocols have a high level of clinical predictabil- ity. In this report, a flapless implant procedure, Editorial note: A complete list of references is single-stage implant placement, sinus lift augmen- available from the publisher. tation, and early implant-loading and delayed implant-loading techniques were applied. _author info cosmetic dentistry The treatment required a small increase in the VDO. It was therefore necessary to make impres- Dr Helena Lee sions that registered all tooth preparations simul- obtained her dental training taneously. at the National University of Singapore and her The patient desired a high level of aesthetics; periodontics specialty full-ceramic restorations were chosen for the training from the University anterior teeth. As the minimum core thickness for of London-Eastman Dental this full-ceramic system is 0.4 mm, this enabled Institute, UK. She is conservation of tooth structure while achieving a consultant periodontist excellent aesthetics. with Specialist Dental Group™ in Singapore. Traditional porcelain-fused-to-metal anterior Dr Lee can be reached at crown restorations require the placement of labial crown margins within the gingival sulcus, in order to mask the transition between the root surface Dr Ansgar Cheng and the porcelain-fused-to-metal restoration. obtained his dental training By prescribing full-ceramic restorations, intra- from the University of Hong sulcular placement of crown margins on the labial Kong, his prosthodontics surface becomes less important from an aesthetic specialty training from standpoint. Northwestern University, USA, and his Certificate In this report, the cervical tooth structure of in Maxillofacial Prostho- the anterior teeth was free of caries, teeth pre- dontics from UCLA, USA. paration margins were made at the gingival He is a Consultant Prosthodontist with Specialist level and gingival retraction procedures were Dental Group™ in Singapore. eliminated. As gingival retraction cord packing was not required, mechanical trauma to the Specialist Dental Group™ gingival tissues was reduced and significantly less clinical time was required. This is particularly16 I cosmetic dentistry 2_ 2009
  16. 16. The event of the year inPeriodontology and Implant Dentistry Partners
  17. 17. I clinical technique _ restoration replacementReplacement of afaulty posteriorrestorationAuthor_ Dr Sushil Koirala, Nepal _A 21-year-old male patient presented com- with Beautifil Flow as a base and Beautifil fluoride- plaining of sensitivity and mild pain when chewing releasing materials (all SHOFU). Effect colours were on tooth #36. During examination, an under filled used on the occlusal surface to mimic the adjacent tooth with poor marginal seal and marginal discol- tooth. oration was visible. The peri-apical radiograph indi- cated secondary caries. The main challenges in this case were the removal of the faulty composite restoration with minimal in- After careful removal of the faulty composite tervention of the healthy tooth structure and the restoration, the cavity was treated with the fluoride- mimicking of the occlusal anatomy and proper releasing bonding system Fl-Bond II and restored shade._ Fig. 1_Poorly restored composite restoration on tooth 36. Fig. 2_Cavity after careful removal of faulty restoration with diamond point #340s. _contact cosmetic dentistry Dr Sushil Koirala, VISA president, can be reached at Fig. 1 Fig. 218 I cosmetic dentistry 2_ 2009
  18. 18. clinical technique _ restoration replacement I Fig. 3_Isolation of tooth 36 with rubber dam. Fig. 4_Application of self-etchingFig. 3 Fig. 4 primer on the entire cavity. Fig. 5_Uniform application of bonding agent and subsequent light-curing. Fig. 6_Application of a thin layer ofFig. 5 Fig. 6 flowable resin on the cavity floor. Fig. 7_Application of flowable opaque (#UO) to mask the discolouration. Fig. 8_Build-up of the dentin layer,Fig. 7 Fig. 8 obtaining occlusal anatomy. cosmetic dentistry 2 _ 2009 I 19
  19. 19. I clinical technique _ restoration replacement Fig. 9_Build-up of the enamel layer and carving of the pits and fissures to achieve natural anatomy. Fig. 10_Application of dark brown stain on the pits and fissures to match adjacent tooth 7, and light-curing. Fig. 9 Fig. 10 Fig. 11_Checking the occlusal contact with articulating paper. Fig. 12_Reduction of the high points with Dura White Stone #FL2. Fig. 11 Fig. 12 Fig. 13_Note the restored anatomycomparable to natural adjacent tooth. Fig. 14_Restoration after finishing and polishing. Fig. 13 Fig. 1420 I cosmetic dentistry 2_ 2009
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  23. 23. I industry report _ digital impression-takingSimplified digitalimpression-takingAuthor_ Dr Helmut Götte, Germany _As the only system in the world that uses the The advantages of an improved intra-oral principle of triangulation for intra-oral measure- image-capturing system do not stop at producing ments, the CEREC system is setting higher stan- larger restorations chairside. The simplified inclu- dards in CAD/DAM technology with CEREC AC and sion of the adjacent teeth and the opposing jaw the CEREC Bluecam camera. Never before have makes it possible to improve the occlusal and func- intra-oral scans been made as fast, sharp, or accu- tional design, and the more exact measurement of rately in 3-D. Whole-jaw images broaden the indi- the preparation enables an increase in the infor- cation spectrum and, with virtual models, allow mation content of the image. Furthermore, intra- the dental office and the dental laboratory to work orally recorded 3-D data sets of gnathic situations together impression-free. offer new diagnostic possibilities. Fig. 1_CEREC Bluecam Intra-oral The acquisition unit of the CEREC 3D system— The heart of CEREC AC is the Bluecam camera. Scanner. called CEREC AC (acquisition center)—has been Instead of infrared light, Bluecam emits short- (Image: Götte) equipped with a new camera (Bluecam). CEREC AC wave blue light produced by diodes. In addition,Fig. 2_Quadrant scan with prepara- replaces the previous CEREC 3 acquisition unit; the lens configuration is new: aspherical lenses tions, created from automatically however, the new software still supports the bundle the light beam and orient it parallel to the joined individual images to CEREC 3 camera. CEREC AC is compatible with both image sensor (CCD). The light sensitivity has been yield a 3-D preview. milling units—CEREC 3 milling unit and CEREC MC increased, the image capture time shortened by 50 (Image: Götte) XL (extra large). per cent, and the image sequence accelerated. The Fig. 1 Fig. 222 I cosmetic dentistry 2_ 2009
  24. 24. industry report _ digital impression-taking Iprojection matrix still employs the tried-and- Because of the image depth and focus depth, ittested light-stripe grid. is not necessary to keep an exactly determined distance from the preparation; the camera’s prism_Faster, sharper, blur-free window can be placed directly on the tooth, which makes image acquisition easier, particularly in the As a result, the new Bluecam offers higher im- distal region. The Autocapture function, responsi-age accuracy in the clinical situation: the meas- ble for actually taking the image, engages auto-urement depth has been increased by 20 per cent matically upon ensuring that the image is in focus.and the focus depth deepened to 14 mm. The Hence, there is no need to operate a footswitch,sharpness of individual images has been height- which requires eye–foot coordination. This meansened, and marginal blurring eliminated. Blur con- that an entire quadrant can be scanned in 30 sec-trol (automatic capture), the sensitivity of which onds. The blur control makes the image sequencecan be pre-selected, checks the intended image, and menu operation accurate and simple; thus,and the camera automatically takes the image only this phase can be delegated to the dental assistant.when it is certain there is no blurring. In quadrants If the acquisition unit has a wireless or WLAN con-and across the dental arch, any number of pictures nection to the milling unit, the system can operatecan be taken as an overlapping sequence. without power with no data loss for up to six min- utes, thanks to its own optional, uninterrupted The 3-D image catalogue manages the individ- power supply—ideal for changing location duringual images on the screen. The software assesses the milling/grinding phase.their usefulness, marks and rejects useless scans,and joins the images to form a complete row of _Up to four-unit bridges chairsideteeth (matching) and a virtual cast modelled on thenatural example. Images acquired at the beginning Bluecam takes about 30 seconds to scan a com-of the sequence, the quality of which may have plete quadrant and is suitable for scanning stonebeen lessened owing to the presence of rubber dam casts. In addition, bite records with static and dy-or cotton rolls, are automatically exchanged for a namic occlusion are digitised and prepared forsuitable image pair as soon as this is found. In this functional articulation of the restoration. After se-way, inadequate images are quickly replaced. In lecting bridge tooth databank, the preparation forvitro studies in the laboratory at the University of a four-unit bridge can be scanned with Bluecam.Zurich in Switzerland have shown that the image This enables the construction and chairside man-accuracy deviates from the reference measure- ufacture of long-term, provisional composite-ment of a master laboratory scanner by only resin restorations employing the CEREC milling19 µm—this is equivalent to one-third of the diam- unit, which broadens CEREC’s indication spectrum Fig. 3_Crown restoration: adjustingeter of a human hair. This means Bluecam’s accu- considerably. the counterbite for occlusal surfaceracy is similar to that of stationary laser scanners. design, region 24.Such precision increases the marginal fitting As when constructing crowns with CEREC 3D, (Image: Götte)accuracy of the restoration; thus, less excess fissure axes and cusps of the adjacent teeth are Fig. 4_Completing the crown’soccurs during adhesive luting, which in turn takes analysed—if desired, the antagonists’ morphology occlusal surface.less time to remove. is also analysed—and incorporated into the (Image: Götte) Fig. 3 Fig. 4 cosmetic dentistry 2 _ 2009 I 23
  25. 25. I industry report _ digital impression-takingFig. 5 Fig. 6 Fig. 5_Crown 24 after adhesive occlusal surface calculation. The software adjusts smallest possible initiation into the CEREC system, insertion. the occlusal contact points and sliding planes of which can be expanded upon to any extent desired. (Image: Götte) the crown construction to the occlusal surface of Every inLab laboratory can make use of this optionFig. 6_CEREC AC showing Bluecam the antagonist. The wall thickness of the projected to accept work from impression-free practices and and Quadrant Scan. ceramic framework is checked beforehand, as are manufacture all-ceramic crowns and bridges (Image: Sirona) the insertion paths of the abutment crowns. After using CAD/CAM technology. designing the restoration, the data set can be transmitted to the milling unit or the practice’s With the milling unit CEREC MC XL, the new laboratory, or sent via LAN or wireless LAN to the CEREC 3D software and CEREC Connect, CEREC AC dental laboratory. In the rapid milling mode of the sets a new standard in restorative dental treat- CEREC MC XL milling unit, a four-unit bridge can ment. The system’s ease of operation allows a con- be produced in about 20 minutes. Composite resin stant and time-saving workflow in the dental blocks by VITA (CAD-Temp) and Merz (artBloc Temp) office. The progressive technology also offers new can be used to fabricate the provisional restora- opportunities for highly efficient cooperation with tion. The milling preview shows the size of the block the dental laboratory. In addition, the modular required and the positioning of the restoration in nature of the CEREC system, its consistent devel- the material—ideal when using ceramic blocks opment, and its total compatibility with all system with integrated, density-determined enamel/ components, including the labside system inLab, dentine colour progression (VITA TriLuxe, Ivoclar ensure complete treatment flexibility and sustain- Multishade). able investment security._ _The virtual cast, online _author info cosmetic dentistry Using the CEREC Connect system, the digital data of the optical impression, even of the whole Dr Helmut Götte jaw, can be sent from CEREC AC to the dental lab- studied dentistry at the oratory. This enables the cast-free manufacture of University of Munich were the restoration. In the future, it will be possible to he graduated in 1993. manufacture a physical cast using these data from Today, Dr Götte runs a a portal, for dental laboratory use. In this manner, fully digitalised, paper- all single-tooth restorations could be manufac- less dental office in tured, such as inlays, onlays, partial crowns, ve- Bickenbach, Germany. neers, crowns and temporaries. For crown-and- He has been using CEREC bridge frameworks of up to four units, any dental since 1996 and is a laboratory lacking a CEREC milling unit will in member of German Society of Computerized the future be able to access the Internet portal Dentistry. infiniDent to have a cast manufactured, which will serve as the starting point from which the labora- Dr Götte can be reached at tory itself can manufacture the framework. Thus, CEREC AC and CEREC Connect together offer the24 I cosmeticdentistry 2_ 2009
  26. 26. I industry report _ CAD/CAMThe new NobelProcerasystem for clinical success:The next level ofCAD/CAM dentistryAuthors_ Hans Geiselhöringer Dr Stefan Holst, Germany Fig. 1 Fig. 1_Modern materials combined _Introduction methods, excellent precision of fit, and outstand- with CAD/CAM technology present ing biocompatibility, combined with adequate solutions for all clinical indications. _While implant dentistry has broadened the mechanical strength and provisions for aesthetic range of treatment options available for patients, design. While there are many CAD/CAM systems CAD/CAM technology is changing the restorative on the market, only very few actually provide a quality and concepts of the future. Advantages re- broad range of products for different indications. lated to material and manufacturing will promote The NobelProcera system advances digital den- the continued preference of CAD/CAM systems to tistry to the next level in that it provides the abil- conventional casting techniques. The advantages ity to manufacture high-quality conventional new technologies offer include standardised restorations and implant-retained restorations quality guaranteed by industrial fabrication from various materials.26 I cosmetic dentistry 2_ 2009
  27. 27. industry report _ CAD/CAM I Fig. 2_The working principle of a conoscopic laser scanner. The sig- nificant difference to conventionally used non-contact triangulation scanners is the co-linearity of the laser beam. Fig. 2 Fig. 3a_Schematic illustration of the Fig. 3a conoscopic holography (left) and tri- angulation working principle (right). The impact of advanced materials and manu-facturing techniques on dentistry is significant.Owing to their many advantages, CAD/CAM tech-nology and industrial fabrication of prostheticcomponents will replace several conventionallaboratory fabrication processes in the future. To-day, almost any clinical situation from conven-tional tooth-supported to implant-retainedsuperstructures can be manufactured. This broadversatility and a guarantee of the highest qualitymaterial and precision of fit ensure reliable andsafe solutions for any clinical indication irrespec-tive of the type of finishing (Fig. 1). Moreover,industrialised fabrication methods reduce cost-intensive manual labour and provide cost-effi-ciency in the dental laboratory and practice. Fig. 3b The CAD/CAM system is able to minimise Fig. 3b_General set-up of triangula- material incompatibilities, corrosive phenomena tion scanners prevents scanning of due to dissimilar metal alloys, interfaces between deep cavities due to shadowing effects cast and machined components, and inadequate (left). Co-linearity of the beam in precision of fit. conoscopic holography (right) allows for scanning of deep cavities This influences both the long-term success of a (e.g. impressions). restoration and the aesthetic outcome. How- Fig. 4_The new NobelProcera scan- ever, the predominant criteria for suc- ner (Nobel Biocare) based on cono- cess are adequate treatment planning scopic holography provides high and the precise transfer of the intra- accuracy for both impression-scan- Fig. 4 oral situation into a digital data set. ning and conventional cast-scanning. cosmetic dentistry 2 _ 2009 I 27
  28. 28. I industry report _ CAD/CAM Fig. 5a Fig. 5b Fig. 5c Fig. 5dFig. 5a_CAD/CAM technology allows _Conoscopic holography: The next level of applications. In conoscopic holography—virtual design of single- and multiple- in non-contact digitisation in dentistry unlike triangulation—the measurement is not unit frameworks (a NobelProcera based on the geometry of the sensor and the software, Nobel Biocare). Currently the majority of scanners utilised in system. Conoscopic holography creates a special Figs. 5b–d_Advanced software sys- dentistry apply the triangulation principle. The fringe pattern and signals proportional to the tems provide an additional margin of configuration consists of two sensors (one a dig- distance from the object, and obtains a large safety for the technician and the ital sensor and the other a camera or light-pro- amount of quality data reflected back from the patient, as cross-sectional views jector) observing the object. The triangulation surface, increasing measurement capability and allow for assessment of the correct sensor projects light onto the object, which is precision. The scanner can digitise any convex framework dimension. As the reflected back to a detector that is at an angle to (positive) or concave (negative) geometry that connector area is the most critical the emitted light. The position of the illuminated the laser beam is capable of ‘seeing’ with cover- aspect of long-term clinical success, pixel creates a triangle (light, object, detector) age of up to 240º (180º + 60º undercuts). This set- special software features (Nobel- that allows the calculation of the distance from up combined with the co-linearity also allows Procera software, Nobel Biocare) the sensor to the object. Owing to the working for the scanning of impressions, eliminating a help to design the connector principle, this technique is adequate for scan- potential step for inaccuracies, such as model appropriately. ning conventional dental casts predominantly. fabrication (Figs. 2–4). Although initial attempts to scan cavities were made, the general set-up has distinct limitations _Ease of use and additional safety (shadowing effect). A variation of triangulation features with improved design software is structured light (projected fringes) projected onto the object. A camera, offset slightly from In order to ensure efficient workflow, the the pattern projector, looks at the shape of the digitisation and manufacture of components light and uses a triangulation technique to is needed, as well as a user-friendly software calculate the distance of every point on the line. interface and intuitive handling. An innovative technology introduced with Current scientific findings and clinical expe- the new NobelProcera non-contact scanner is rience underscore the need for adequate mate- conoscopic holography. The most significant rial manufacture and framework design to difference to triangulation is the co-linearity of minimise clinical failures, such as the chipping of the laser beam: the light is emitted and reflected veneering ceramics or fracture of frameworks. in the same axis, allowing for a whole new range The most important request—especially when28 I cosmetic dentistry 2_ 2009
  29. 29. industry report _ CAD/CAM I Fig. 6working with zirconia substructures—is that the cavity, biocompatibility, and post-processing Fig. 6_In order to maximise aestheticframework is anatomically designed and no options (for example, the type of veneering ma- outcome, shaded zirconia abutmentsmanual post-processing adjustments are terial). (NobelProcera Abutment Shadedneeded. Previously, double-scans were per- zirconia, Nobel Biocare) can beformed to achieve this goal. However, with new Advancements in ceramic materials research combined with alumina or zirconiasoftware design tools, these time-consuming have led to the development of high-strength, copings.and cost-intensive steps are unnecessary, as non-silica-based ceramics that have beneficial‘anatomic tooth-libraries’ support the user in properties, including biocompatibility, aesthet-optimal restoration and framework design. Au- ics and long-term function. Aluminium oxidetomatic cutback functions increase the ease of (Al2O3) and zirconium oxide (ZrO2) ceramics areuse and provide an additional margin of safety the most common materials for copings, FPDby ensuring homogenous veneering material frameworks, and implant abutments. It is oftenthickness. wrongly assumed that CAD/CAM technology is only applicable to zirconium ceramics. Actually, An equally important aspect to consider is the CAD/CAM technology can be applied to a varietydesign and dimension of the connector cross- of materials. Aluminium oxide ceramics are thesection for fixed dental prostheses. Long-term material of choice in aesthetically demandingclinical success is ensured only if minimum con- areas, for example the anterior dentition, owingnector dimensions are respected. Newly devel- to their beneficial light optical properties.oped software tools support the user in virtualdesign of the frameworks and provide immedi- In addition, the clinical applicability of Al2O3ate feedback on cross-sectional area, connector in single-tooth and short-anterior FPD has beenheight and width, as well as coping thickness clinically proven, and Al2O3 surpasses zirconium(Figs. 5a–d). in terms of long-term clinical success and aes- thetic outcome. In contrast, for large-span and_Versatility for patients’ demands posterior restorations, yttria-stabilised zirco-and expectations: Material selection nium dioxide (Y-TZP) is the material of choice. The material fracture strength properties of A wide range of materials can be used in Y-TZP allow its application in any area of the oralCAD/CAM manufacturing. Important aspects to cavity where strength and stability are moreconsider include long-term stability in the oral important than aesthetics. Additionally, the cosmetic dentistry 2 _ 2009 I 29
  30. 30. I industry report _ CAD/CAM material properties of zirconium make it a reliable alternative to cast alloys for implant-retained superstructures, including implant abutments and multi-unit implant-retained bridge frame- works. The availability of shaded zirconia is yet another step towards extensive and highly aesthetic solutions for the patient (Fig. 6). Alternative materials are titanium and non- precious alloys, such as cobalt-chrome (CoCr). If centrally manufactured, these materials ensure excellent precision and long-term function in the oral cavity (Figs. 7a b). Additionally they may be applied whenever space requirements or expected biomechanical forces prohibit the use of ceramic materials or as long-term provisional restorations. With the new NobelProcera software, deciding on the appropriate material needs merely a click of a button. _Clinical versatility through solutions for natural teeth and implants A basic requirement of a modern CAD/CAM system is providing solutions for natural teeth and implants. In the future, implant-retained restorations for missing teeth will become the predominant form of restoration. The clinicalFig. 7aFig. 7b30 I cosmetic dentistry 2_ 2009
  31. 31. industry report _ CAD/CAM I Figs. 7a b_Industrial fabrication provides consistent product quality irrespective of material ordered, owing to material-specific milling and sintering strategies impossible in small units (Nobel Biocare production facility Tokyo, Japan). Fig. 8_Screenshot of the design tool for implant-retained frameworks (NobelProcera software, Nobel Biocare). Cost-efficient workflow and high precision make this approach a very promising one for the future. Fig. 8success rates, the high predictability and a re- tools eliminate the need for time-consumingduction of costs, as well as the implementation framework design on the master cast. Instead, aof implantology in dental school curricula will scan of the implant position can easily belead to more frequent and earlier implant place- matched to a scan of a wax-up, followed by ament when a tooth is deemed non-restorable. virtual framework design in the CAD tool. Ad- justing the design and dimensions according to The abutment design and material to restore the anticipated final contour of the definitiveimplant-retained single-tooth or implant- restoration is done in a few minutes instead ofretained FPD restorations must fulfil some basic several hours with conventional fabrication pro-requirements. Today, multiple abutment types tocols (Fig. 8).are available. Various studies have demon-strated the successful application of ceramic Eliminating time-consuming and cost-inten-and titanium abutments in terms of acceptable sive fabrication steps in the laboratory is notsoft-tissue and marginal bone stability. only beneficial for economic considerations, but also leads to an overall increase in precision and A study examining different abutment mate- component quality through industrial manufac-rials and their influence on soft-tissue barriers turing processes._surrounding dental implants found that the typeof material used affected both the height and the Editorial note: A complete list of references isquality of the tissue. Titanium and ceramic abut- available from the authors.ments permitted the formation of a mucosalattachment, while gold-alloy and metal-ceramic abutments led to soft-tissue recessionand crestal bone resorption. Similar findings _contact info cosmetic dentistrywere observed through in vitro studies that val-idated the finding of reduced plaque and bacte- Hans Geiselhöringerrial adhesion on titanium or zirconia abutments. Dental Technician Dental X Hans Geiselhöringer GmbH Co. KG An indispensable factor of the long-term Lachnerstraße 2clinical success of implant-retained superstruc- 80639 Munich, Germanytures is the precision of fit. Depending on thecomplexity of a restoration, poor fit can have a Dr Stefan Holstsignificant impact on function and stability in University Clinic Erlangenthe oral environment. When it comes to repro- Dental Clinic 2 – Department of Prosthodonticsducible precision, CAD/CAM technology clearly Glueckstraße 11outperforms conventional framework manufac- 91054 Erlangen, Germanyturing techniques. New generation software cosmetic dentistry 2 _ 2009 I 31
  32. 32. I industry report _ all-ceramics tooth whiteningAesthetics withall-ceramics andtooth whiteningAuthor_ Dr Marcus Striegel, Germany _Many dentists continue to have reservations dental practice—a treatment that is cost-effec- about bleaching and are hesitant to include tooth tive and will leave most patients completely whitening in the range of services they offer to satisfied. their patients. At the same time, increasing numbers of patients are more aware of their teeth Surveys have shown that over 90 per cent of and tooth colour. Many people feel upset about patients are highly satisfied with the results their teeth not meeting their expectations of an achieved by whitening discoloured or yellowish ideal aesthetic appearance. teeth with bleaching materials applied under the supervision of a dental professional. However, it A smile that is marred by a dark anterior tooth is essential to have a thorough understanding of can be restored to its natural beauty by means of the aetiology of the discolouration and to adhere a minimally invasive bleaching treatment in the strictly to the indication guidelines regarding Fig. 1a Fig. 1b32 I cosmeticdentistry 2_ 2009
  33. 33. industry report _ all-ceramics tooth whitening Ithe risks and limitations of bleaching, to ensure the market. Higher concentrations provide fasterthat the treatment provides safe and predictable results, but they involve the increased risk ofresults in practice. reversible side effects, such as a burning sensation of the gums and hypersensitivities. It is important_Case presentation to provide the patient with clear guidance on how to apply the whitening gel. A young female patient presented with a re-quest for a lighter tooth shade. Teeth 12, 11 and 21 According to the treatment plan, the upper jawhad previously been restored with ceramic was first bleached using VivaStyle gel (Ivoclarcrowns. In the course of the patient’s consulta- Vivadent) containing 16 % carbamide peroxide Figs. 1a b_Initial situation: toothtion, the need for replacing the existing crowns and a tray. The patient wore the tray for one hour shade of the existing restorationwas discussed. a day over a three-week period. In the course of (A3.5). the subsequent recall visit, she decided to extend Figs. 2a b_Tooth shade after the It is often advisable to commence the bleach- the treatment to the lower jaw. Figures 2a and b application of VivaStyle 16 % foring treatment in one jaw only, to demonstrate the show the teeth at the end of the bleaching treat- three weeks. The shade of the naturaloutcome of the whitening process to the patient ment. Compared with the shade of the crowns on teeth is clearly lighter than the shadeand align the treatment to the patient’s expecta- teeth 12, 11 and 21, the bleaching effect is clearly of the existing restorations.tions. This simple step soon raised the patient’s noticeable. Figs. 3a–c_Prepared teeth and oralenthusiasm for the treatment. situation after cementation. Normally, the degree of brightness achieved Fig. 4_Final situation._How can I access the ‘world of bleaching’? during the bleaching process will slightly de- crease upon completion of the treatment. It is Tooth whitening, using a deep-drawn tray and therefore necessary to wait at least two weeksappropriate gels in the practice or at home, is an before initiating any further treatments. In theestablished bleaching method, even if this option present case, the existing crowns were replacedis not quite as spectacular for the patient as two months after completion of the whiteningbleaching with laser or UV-light. Deep-drawn procedure.trays are produced in a relatively straightforwardprocedure using thermoformable material on a Figures 3a to c show the prepared teeth. Thestone model. It is worthwhile equipping the prac- original dentine shade contrasts with the shade oftice with a basic thermoforming unit, if you have the adjacent bleached teeth. In this case, we didnot already done so. Various concentrations of not have to forgo the aesthetic advantages ofcarbamide peroxide preparations are available on glass-ceramic materials, as special opaque ingots Fig. 2a Fig. 2b cosmetic dentistry 2 _ 2009 I 33