Sd v10 n9-lithium disilicate veneers-dr.adolfi


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Sd v10 n9-lithium disilicate veneers-dr.adolfi

  1. 1. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:17 PM Page 18 Lithium Disilicate Veneers: A case report with no teeth preparation Dario Adolfi DDS, CDT * Oswaldo Scopin de Andrade DDS, MS, PhD** 18 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  2. 2. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:17 PM Page 19 concept of biomimetic in dentistry implies that any material utilized for a restoration brings not only the esthetic and function but also act as it was the tooth; restoration and tooth become one structure. For better clinical results the laminate veneer is done with a ceramic that can be altered by etching the intaglio surface with hydrofluoric acid 2. Among the materials available, glass ceramic made on the refractory die-technique is the most documented because of its esthetics, biocompatibility, shape and shade stability3. Even though being a safe and documented procedure, that permits the technician to obtain veneers as thin as 0.2 mm, many clinicians face difficulties during try-in and bonding procedures. This limitation has reduced the utilization of refractory die-technique in the last two decades. As an option for this technique leucite pressed ceramic has become popular among clinicians and ceramists. The advantages of the leucite pressed ceramic include: less sensitive laboratory procedures and safer bonding because of better physical properties. In this manner the technique was easier for the laboratory and less risky for the clinician4. However, the first pressed system launched for it required more space to build a restoration and it was not life-like when compared with the traditional refractory die-technique. Even though laminate veneers have started to be used more and more with pressed ceramic with high level of acceptance by patients and dentists. After the rise of the pressed ceramic on the market, some cases that did not need a preparation to be done were prepared to obtain clearance for the material that need around 0.8 mm, to be pressed and then stained. Nowadays the concept of enamel maintenance and minimal preparation design restoration bring again the concept of laminate veneers with minimal or even without any tooth preparation. Introduction The development and improvement of lithium disilicate pressed ceramic has brought the concept back to The utilization of laminate veneer in anterior dentition is less preparation for laminate veneers5. the most documented approach in literature for procedures This ceramic permits the technician to build a pressed such as extensive smile changing. Among the advantages restoration and carefully reduced using rubber wheels and of this restorative strategy is the possibility of achieving a diamond bur with copious irrigation to less than 0.2 mm, perfect harmony between soft and hard dental tissue. This with proper resistance to be tried and bonded with much harmony is possible thanks to the physical properties of less risk when comparing with the traditional porcelain the ceramic, which remains stable for a long term. made with the refractory die-technique. However, to obtain a perfect balance besides soft tissue health and function the clinical success is dependent of a Case Report major factor: the bonding procedures. In order to achieve an interaction between dental hard The case described in this article shows an esthetic smile tissue and ceramic, what is called “bonding”, the structures changing in a young man because of anatomic must be able to be altered to receive a material that bring irregularities on enamel surface in both arches. After all together the surfaces creating a perfect interface. The the options have been explained and discussed such as adhesiveness of the restorative material to be bonded to direct composite resin restorations he chose an esthetic tooth structure creates a term named biomimetic1. The rehabilitation of the ten maxillary teeth: four incisors, Spectrum dialogue – Vol. 10 No. 9 – November/December 2011 19
  3. 3. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:18 PM Page 20 Fig. 1 Fig. 2 Fig. 3 Figs. 1-3: Portrait from the initial situation. canines and two bicuspid on each side, with lithium • Addictive Wax-up disilicate pressed ceramic restorations. A gengivoplasty was performed on the premolars to establish a new line for For every esthetic dental planning a wax-up is indispensable, gingival tissue and improve the esthetic deficiency in the and for cases where a minimal preparation is planned, the buccal corridor region. procedure must be done with the additive technique. The The only requirement asked by the patient was to make wax addition for planning must take in consideration the first the restoration with no preparation or any enamel analysis of the case, that bring together the teeth reduction. characteristics, the patient’s smile, the age of the patient, the opposite arch, the gingival architecture, beyond the • Diagnostic Approch perception of the patient’s personality8. In this technique the ceramist adds wax onto the The initial clinical evaluation includes critical and careful preliminary model based on anatomical parameters of natural analysis of the occlusal scheme, periodontal examination teeth respecting function and occlusion. In this step, the followed by a face photography protocol. The canines are technician restores the anterior dentition recovering a very important in this role, developed with appropriate mimetic appearance but already thinking in how is going to morphology maintaining adequate functional height, be the final ceramic restoration9. In a case where there will quantity and quality of disocclusion6. be no temporaries involved the final treatment planning must be approved by the patient. • Flapless Esthetic Crown Lengthening The final planned case built in the preliminary model in wax was transferred to the mouth for clinical evaluation in terms Specifically for this case, to achieve a better esthetic result of shape, size and length. After the patient approval, all with a more harmonious gingival contour of the information was collected by the mock-up using digital premolars, a flapless surgical crown lengthening was photography and alginate impression, to obtain a simulation planned and executed to develop a new gingival line. The cast. After all the information was collected, the mock-up final length of the teeth involved were determined based was removed from the mouth and the teeth were pumiced for on sulcus probing with the patient under anesthesia, to impression procedures. reach the bone crest, but always avoiding extensive Only some specific sharp angles were removed with a radicular dentin exposure7. rubber wheel in order to improve the passive fit avoiding any kind of interference during the cementation procedures. 20 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  4. 4. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:28 PM Page 21
  5. 5. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:29 PM Page 22 Fig. 4 Fig. 5 Fig. 6 Fig. 7 Figs. 4, 5, 6, 7: Using the lip retractor initial pictures show the patient compliances, which are enamel defects all over the surfaces of the anterior maxillary incisors. In the lateral view (right and left), is clear the space between teeth (diastemas). Furthermore, it can be seen a discrete gingival excess of tissue in the premolars areas. Fig. 8 Fig. 9 Fig. 10 22 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  6. 6. SD-V10N6 CMYK_Layout 1 11-06-15 9:24 AM Page 13
  7. 7. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:35 PM Page 24 Figs. 11, 12, 13, 14: A mock-up procedure with a bis-acryl resin works as a guide for the clinician and technician, besides acting as a simulation of the final result. It was also possible to analyze the necessity of Fig. 11 extending the treatment up to the premolars to improve the alignment of the buccal corridor. Fig. 12 Fig. 13 Fig. 14 24 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  8. 8. – the freedom of unlimited possibilities Patient-specific CAD/CAM abutments for all major implant systems Available for all major implant systems and in a full range of In addition, Atlantis™ patient-specific CAD/CAM abutments materials, Atlantis™ patient-specific abutments are uniquely are comprised of a unique combination of four key features, designed based on the final tooth shape. Through the use of known as the Atlantis BioDesign Matrix™, that work together 3D scanned imaging and proprietary Atlantis VAD™ (Virtual to support soft tissue management for ideal functional and Abutment Design) software, Atlantis helps eliminate the esthetic results. need for laboratory investment in materials, hardware and software, and time spent on waxing and milling as required with other CAD/CAM systems. Atlantis BioDesign Matrix™ Atlantis VAD™ — designed from the final tooth shape and the individual patient anatomy Natural Shape™ — shape and emergence profile based on individual patient anatomy Soft-tissue Adapt™ — optimal support for soft tissue 79482-US-1106 © 2011 Astra Tech sculpturing and adaptation to the finished crown Custom Connect™ — strong and stable fit – customized connection for all major implant systems 800-531-3481. www.astratechdental.comSpectrum NOV-DEC_Astra Tech.indd 1 10/7/2011 4:47:13 PM
  9. 9. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:37 PM Page 26 Fig. 15 Fig. 16 Fig. 17 Fig. 18 Fig. 19 Figs. 15, 16, 17: A flapless gingivectomy was done with sharp instruments to reshape the level of the tissue determining by the mock up. The procedures were done on teeth # 3, 4, 5, 12 and 13. Figs. 18, 19, 20: Three weeks after the surgery. The new gingival line respects the contour of the anterior teeth line. Fig. 20 26 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  10. 10. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:39 PM Page 27 Pressure thermoforming appliance DRUFOMAT® SCAN PRESSURE MACHINE fabrication Expand your services. Increase profitability. Save time. Find out what Pressure fabrication and the the Drufomat® Scan can do for your lab. We have everything you need to get started. Proven quality Essix® Plastics,expert tools and training. Hockey Tooth Loss Bleaching Bruxism Orthodontic Retention Overbite TMJ Orthodontic Relapse To schedule a free consultation, contact 1.800.263.1437 or email us at
  11. 11. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:40 PM Page 28 Fig. 21 Fig. 21: Picture shows the area before the impression procedures; the placement of the retractor cord is necessary to the lab to develop the most appropriate emergence profile and ceramic finish line. The only preparation done was a small opening between the central incisors for better passive fit during the cementation procedures. Fig. 22: The impression was done with a PVS based material (Flexitime-Heraus Kulzer). Fig. 22 Fig. 23 Fig. 24 Figs. 23, 24, 25: A pressed lithium disilicate ceramic laminates (Emax Press-Ivoclar Vivadent) for teeth 4 and 14. Fig. 25 Fig.26: The ten veneers placed on sequence and with the special illumination it is possible to observe how thin the restorations are . 28 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  12. 12. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:41 PM Page 29 Fig. 27 Fig. 28 Fig. 29 Figs. 27, 28, 29: Restorations in place with a try-in paste to select the shade of the resin cement (Variolink Venner-Ivoclar Vivadent), and for patient approval. Spectrum dialogue – Vol. 10 No. 9 – November/December 2011 29
  13. 13. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:42 PM Page 30 Fig. 30 Fig. 31 Fig. 32 Fig. 33 Fig. 34 Fig. 35 Fig. 36 30 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  14. 14. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:43 PM Page 31 Fig. 37 Fig. 38 Fig. 39 Figs. 30 to 39: Close-up view of the bonding procedure on tooth #11 with the resin cement. It can be seen that the tooth was pumice before bonding. Another important procedure is to realize one bonding each time, always protecting the neighboring teeth. The Right Material for STRONGER DENTURES FiBER FORCE® is a sys- tem of pre-impregnated light-curable meshes, braids and UD fibers. • Fast, easy and Call SYNCA today or visit our website inexpensive • Bonds to acrylic and adds no weight 1-888-582-8115 • Esthetically pleasing in Canada: 1-800-667-9622 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011 31
  15. 15. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:44 PM Page 32 Fig. 40 Fig. 41 Fig. 42 Fig. 43 Figs. 40 to 46: Final result after cementation; it’s possible to see the integration of the tissue as well as the importance of canine guidance to maintain the occlusal stabilization. Fig. 44 32 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  16. 16. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:45 PM Page 33 Fig. 45 Fig. 46 • Impression of the Teeth cut off using a diamond disc, morphological corrections are performed placing the laminates on the model and the A VPS one-step, double mix impression technique, fit is checked at the margin under magnification. After the brought forth appropriate reproduction of the teeth and contours have been finalized, clean the restorations for 5 surrounding tissues. Two impressions of each arch were minutes in an acetone solution using ultrasonic cleaner . taken to ensure proper control during laboratory build-up Apply the stain glaze over the surface and body stain A of the veneers. is first applied in the cervical region. For incisal edge, A retraction cord was utilized for better visualization of apply blue stain in the approximal area and white stain for the cervical region to control the finish line and thickness the mamelons. Then, bake in temperature of 770 degrees of the ceramic material during the laboratory procedures. Celsius to fix these characterizations. If necessary this process should be repeated until the final result is Laboratory Procedures achieved. After the fixation, two layers of glaze powder is applied to protect the characterization and the superficial Based on all the information obtained from the mock-up, gloss is performed with rubber wheel and pumice powder. wax-up to the final shape of the final restorations and then the 10 laminates veneers were injected with the Try-in and bonding procedures ceramic ingot HT. Carefully divesting using 50µm alumina sands at a pressure of 58-87 psi( 0.4 MPa- As mentioned, no provisional crowns were used, and for 0.6MPa). Once the pressed veneers are exposed, lower the this reason the periodontal tissue was stable and any sandblasting pressure to less than 29Psi (0.2MPa) and hemostatic control protocol was not necessary. No cords continue alumina sandblasting carefully. The sprues are were used for the bonding procedures. For the veneers a Spectrum dialogue – Vol. 10 No. 9 – November/December 2011 33
  17. 17. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:46 PM Page 34 Fig. 47 Fig. 48 Fig. 49 Fig. 50 Figs. 47 to 50: Portrait from the final esthetic outcome. high translucency lithium disilicate etchable ceramic laboratory technician and the clinicians. The patient was (Emax Press, Ivoclar Vivadent) was selected. Final luting not anesthetized. of the ceramic restorations was preceded by a try-in The intaglio surface of the laminate veneers made with procedure, to select the best shade for the resin cement. Emax Press (Ivoclar Vivadent), a lithium disilicate based As a thin veneer the final result is also dependant of the ceramic was etched with a hydrofluoric acid (5 to 9%) for shade of the cement. The try-in was applied and checked 20 seconds. The intaglio surface was washed to remove the by the clinicians and patient. The approval of final acid and the veneer was placed in a glass recipient with esthetics by the patient was in agreement with the distilled water, and an ultrasonic cleaner was utilized for 34 Spectrum dialogue – Vol. 10 No. 9 – November/December 2011
  18. 18. SD-V10N9 CMYK-final_Layout 1 11-11-24 2:46 PM Page 35 five minutes to remove the residual material originated by Conclusions surface alteration10. The intaglio surface was dried and a silane coupling agent applied for two minutes, the The clinical success of a treatment planning execution evaporation of the solvent was completed with a constant made with laminate veneers is dependent of four majors blow of air. The restoration was coated with a factors: enamel preservation, bonding procedures and hydrophobic bonding agent (Heliobond, Ivoclar carefully occlusal adjustments. In additive cases such as Vivadent), followed by a gentle blow of air, and left the case described it is possible to do an ultra-conservative uncured at that time. A cover protected the ceramic procedure with all the benefits of the adhesive technology. veneer during etching dental procedures, to avoid The purpose of this article was to exemplify important adhesive polymerization. steps to obtain a reliable lithium disilicate esthetic As a non-preparations veneers the enamel was cleaned restoration, with no preparation. with a paste with pumice powder and water. Then the References surface of each tooth was etched with a 37% phosphoric acid (Ultraetch, Ultradent), for no more than 60 seconds, 1. Magne P, Douglas WH. Porcelain veneers: dentin bonding optimization and biomimetic recovery of the crown. Int J washed and dried. The adhesive (Excite, Ivoclar Prosthodont. 1999 Mar-Apr;12(2):111-21. Vivadent) was applied on the enamel surface, a gentle 2. Duarte S Jr, Phark JH, Blatz M, Sadan A. Ceramic Systems. An blow of air was applied to thin the adhesive film, and ultrastructural study; Quintessence Dental Technol 2010; 33; 42-60. 3. Calamia JR, Calamia CS. Porcelain laminate veneers: reasons for cured for 10 seconds. 25 years of success. Dent Clin North Am 2007 Apr; 51(2): 399- The previous select shade of the light cured resin 417. cement (Variolink Venner, Ivoclar Vivadent), was applied 4. Kina S, Brugera A Invisible: Esthetic Ceramic Restorations Arte onto the ceramic restoration and positioned to the tooth. Médicas, Brazil 2007. 5. Scopin de Andrade O, Borges G, Stefani A, Fujiy F, Battistella P. A After, resin cement was removed carefully and LED light step-by-step ultraconservative esthetic rehabilitation using lithium (Bluephase, Ivoclar Vivadent), in low power mode was disilicate ceramic. Quintessence Dental Technol 2010; 33: 114-131 utilized for 40 seconds on each surface. A glycerin-based 6. Groten M Complete esthetic and functional rehabilitation with adhesively luted all-ceramic restorations-case report over 4.5 years. jelly (Liquid Strip, Ivoclar Vivadent) was utilized to air Quintessence Int 2007Oct;38(9) 723-731. block and cured again for 20 seconds per surface. The 7. Joly JC, Carvalho PFM, da Silva RC, In: Reconstrução Tecidual excess of the resin cement was removed with a new and Estética, Artes Medicas, Brazil, 2010, p. 253-309. 8. Gurel G The Science and Art of Porcelain laminate Veneers sharp scalpel to avoid scratches on the ceramic facial Quintessence Pub 2003, Berlin, Germany. surface. Only one restoration was cemented each time, as 9. Magne P, Belser UC. Novel porcelain laminate preparation it is possible to see in the pictures. approach driven by a diagnostic mock-up. J Esthet Restor Dent. After all the veneers cemented finishing procedures 2004;16(1):7-16. 10. Magne P, Belser UC. Bonded Porcelain Restorations in Anterior were done with abrasive strips. Occlusal adjustments were Dentition: A Biomimetic Approach. Chicago: Quintessence 2002. made with a diamond polishing system for ceramic. It is possible to see the esthetic quality, healthy gingival tissue and the final smile as requested by the patient. INCISAL EDGE DENTAL LABORATORY Cosmetics Without Compromise Certified laboratory for CAPTEK, CRISTOBAL+, IPS EMPRESS, IPS E-MAX, PROCERA, INCISAL EDGE DENTAL ATTACHMENTS, IMPLANTS, CUSTOM IMPLANT ABUTMENTS & LASER WELDING. Looking after all of your Dental Laboratory needs. We pride ourselves on quality work, great service and exceptional value. Thomas Kitsos, RDT #92184 L ABOR T ORY A Spectrum dialogue – Vol. 10 No. 9 – November/December 2011 35