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FALL 2012
The
Esthetic Issue OralHLab Fall12.indd 1
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editorial INTO THE FUTURE: TOGETHER So here it is. It has arrived. The very first edition of Oral Health Labs. It is with great pleasure and excitement that as the Editor, I welcome you to this inaugural edition, which showcases the aesthetics and clinical relevance of dental technology. I welcome readers with a desire to showcase their documented experiences in dentistry to contact me at trevor@dentalstudios.ca, so that they may share those experiences with the entire readership, in order that others may learn and better realize their potential. Oral Health Labs will be published bi-annually in 2013. It will accompany Oral Health, both in April (the “Aesthetic” issue) and August (the “Implantology” issue). As a dental laboratory technologist with a long family dental history, I am honored to represent my profession and to help foster and pursue an ever-important synergy of communication and understanding within the clinical and technical specialties of dentistry. The world of dental technology has evolved significantly since the first publication of Oral Health and continues to do so at an ever-increasing rate. We are all witnesses to the past. Our past has given us knowledge and experience; through education, families, friendships and career interactions. The future, well that is a different matter. Speculations of new technologies, their applications and their associated career opportunities abound, with both positive and negative opinions surfacing. Staying connected and current with relevant education and trends will, I feel, assist technicians as we venture into the future, together. The importance of dental technology education with the appropriate communication skills, lends itself to the ever- growing public awareness of restorative techniques and procedures; and to the very public visualization of achievable results. It is so commonplace amongst the media, the fashion and advertising industries that patients are being constantly educated in advancements in dental standards. Given their increased awareness, it is only appropriate that they demand an ever- increasing standard of dental care. Dental technicians of today work with a multitude of techniques and materials. Traditional lost wax techniques for precious metals, various alloys and ceramics still exist, alongside computer-generated procedures for milling, printing and fabricating both models and restorations. There are a plethora of materials available from which to select. The individual characterization of these restorations with aesthetic materials of many types and applications, are also many and varied. These techniques and materials used by technicians go into the fabrication of the restorations that compose the dental health and the smiles that we see today. Given the Canadian and international relevance of Oral Health as an educational journal and the scope of its readership, I hope to showcase within Oral Health Labs, articles of significance, that are both educational and relevant to all practitioners within dentistry, as we move forward together into an even closer synergy of relationships for better dental health. Please enjoy the first edition of Oral Health Labs, which includes an international group of extremely talented and respected professionals; it is my pleasure to showcase their work to you.
Editor
Trevor Laingchild’s sense of adventure has taken him on an international road in his profession. After formal Dental Education in London, England, he managed a Dental Laboratory in Germany and served as Chief Dental Technician for an American Hospital in Saudi
Trevor Laingchild, RDT, AAACD
Arabia. Further experiences included, expanding his technical horizons whilst working in Norway, Scandinavia. He currently owns and operates dentalstudios in Burlington and in Yorkville, Toronto. Trevor is an Accredited member and an Examiner within the American
Academy of Cosmetic Dentistry, in addition is a Certified LVI Master Aesthetic Technician. Trevor is very active lecturing and teaching whilst conducting numerous hands on courses in all aspects of restorative aesthetics, of which, he has had numerous articles published. FALL/WINTER
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contents
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Replacing worn restorations using a Pressed and Layered Lithium Disilicate material On the cover
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Denistry by Dr. William E. Turner Laboratory: Trevor Laingchild
cover story
Photography by Alan Dickson,
A Case Study in Contemporary Esthetic Dental Care
Thunder Bay, ON
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Advanced Aesthestics
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Replacing
worn restorations P
by Rafael Santrich, CDT
using a Pressed and Layered
L thium Disilicate material
atients presenting with chipped restorations, excessive wear, and fractures often seek correction for a more esthetically pleasing smile. More often than not, patients are educated consumers desiring minimally invasive treatments reflective of the best in smile design. These restorative goals are possible with material and technological advancements. In order to achieve success, comprehensive treatment planning, multidisciplinary
Rafael Santrich, CDT, Specializing in all fixed restorations and custom cosmetics, Rafael Santrich is a native of Cali, Colombia, who currently operates a private dental laboratory in Aventura, Florida. A graduate of the Press Technology Certification Programs for IPS e.max and IPS Empress at the Las Vegas Institute (LVI), along with the No-
bel Rondo program by Nobel Biocare, Rafael Santrich has also become an expert in CAD/CAM Scanners, including the Procera Piccolo and Procera Forte by Nobel Biocare, as well as the Cerec inLab and milling unit by Sirona. He also has completed courses on Nobel Guide, a technique to design surgical guides for implants, and digi-
tal photography courses taught by Dr. Ed McLaren and Dr. Claude Sieber. His cases and techniques have been featured in a variety of publications. He is a key opinion leader for GC America, a trainer for Nobel Biocare, and a member of the American College of Prosthodontics and the International Association of Dental Research. FALL/WINTER
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approach, and provisional restorations are incorporated into restorative procedures. Because patients are able to test-drive their restorations, clinicians and technicians gain
Figures 1-3 Preoperative views of the patient presenting with worn anterior restorations, and teeth nos. 7 and 10 lacking vertical dimension.
Figure 4
Close-up preoperative view.
a better understanding of their desires while simultaneously ensuring accuracy and predictability of the final outcomes.1 Restorative cases are often dependent upon material selection, and even with an oversaturation of different materials on the market, not every material is appropriate for every case. Consequently, restorative materials must be carefully examined and considered in order to provide predictable long-term results that meet patient demands. Ceramists and dentists must select a material that withstands masticatory forces placed upon it and is appropriate for use in the specific region of the oral cavity being restored.2 Lithium disilicate (IPS e.max Press, Ivoclar Vivadent, Amherst, NY) demonstrates a flexural strength of 400 MPa, superior wear characteristics, and life-like esthetics, making it an ideal choice for restorative procedures. Demonstrating a low refractive index, excellent dimensional stability3 and optimized optical properties including natural translucency, lithiumdisilicate can be used for even the most challenging esthetic cases and can be adhesively bonded or conventionally cemented.4,5 Additionally, by using IPS e.max Press, clinicians can exercise minimal preparation techniques while enabling ceramists to cut back, layer, and thin down the material when needed.6 Ceramists are challenged by many caveats when fabricating predictable, reliable, and long-lasting restorations. In the instance of a full-mouth reconstruction, forces that result in wear (e.g., breakage, joint dysfunction, or malocclusion) should be addressed in the early stages of treatment planning before any procedural work begins. Occlusal instability has the potential to break down restorative dentistry, resulting in the need for re-cementation of crowns, re-bonding of veneers, and the repair of fillings and broken restorations.7 By working in collaboration with the clinician, stable and balanced occlusion can be achieved, as well as the restorations’ esthetic and functional success.8
Case Presentation Figure 5-6
Preparations were performed.
A full diagnostic wax-up was created.
Figure 7
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A 35-year-old woman presented with worn anterior restorations on teeth nos. 7 through 10. Previously teeth nos. 7 and 10 were broken and, although restored, lacked vertical dimension and were esthetically displeasing (Figures 1 through 4). A variety of alternative treatment plans were discussed with the patient. The first included restoring the anterior segment of teeth nos. 6 through 11 with monolithic crowns fabricated with a lithium disilicate material (IPS e.max) to maintain strength. The second alternative, as part of a combination case, would include performing a full maxillary reconstruction, placing posterior monolithic crowns enhanced with
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Figures 8-9 Full-contour posterior IPS e. max pressed crowns were seated onto the iTero Model to test fit.
Figure 13 After the cut-back technique was performed, the crowns were ready to be glazed in the laboratory with Essence stains (e.g., crème, copper, ocean, profundo, and shade 1) at special program 810c.
Figure 10 Full-contour anterior IPS e.max pressed crowns were seated onto the model to test fit.
Figure 11 The anterior crowns were cut-back. Figures 14 -17 The posterior crowns were also stained and glazed with Essence stains at 810c.
Figure 12 Incisal view of the anterior crown showing the contours from the distal to mesial areas.
staining and glazing, restorations in the anterior, and conducting incisal modification. The patient choose the second alternative, which entailed restoring seven posterior teeth with fullcontour monolithic crowns that would be stained and glazed, one onlay, and six pressed anterior crowns that would be fabricated using the cut-back and layer technique. The patient’s teeth were prepared (Figures 5 and 6). After approving the full diagnostic wax-up created to demonstrate the anticipated final results, a duplicate was made for use in fabricating provisional restorations (Figure 7). In this particular case, the traditional impression technique was not used. Instead, for the purpose of fitting properties, an ITero Model was utilized. First, the full-contour posterior IPS e.max Press lithium disilicate crowns were seated into the Itero Model for a test fit (Figures 8 and 9), the same was repeated with the full-con-
Several IPS e.max Ceram powders (OE1, OE4, Clear, OE5, TI1, TI2, Intercisal White, Blue Incisal Edge) were layered on the anterior crowns, then baked at 750c.
Figures 18-20
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tour anterior e.max crowns (Figure 10). Then digital impressions were taken of both sets of restorations.
Technique After obtaining all essential information from the dentist, the case was ready to be pressed from lithium disilicate glass-ceramic (IPS. emax Press). To begin fabrication, the ideal wax-up was produced, and a matrix was formed using the wax-up model. The wax was sprued, invested, burned-out, and pressed using a low translucency shade of lithium disilicate (IPS e.max LT). Then, the anterior crowns were cut-back (Figures 11-12), and the completed lithium disilicate anterior crowns examined against the model. Once deemed satisfactory, the restorations were ready for staining. The anterior crowns were glazed with careful consideration taken to mimic the patient’s natural internal tooth effects. Crème, copper, ocean, profundo, and shade 1 (Figure 13) were used. IPS e.max Ceram Glaze Paste (Fluo) was applied to impart fluorescence to the restorations. Once completed, the crowns were fired at 810c. Glazing facilitated bonding between the lithium disilicate material and the IPS e.max Ceram fluorapatite veneering ceramic. The stain, characterization, and glaze firing were repeated again with the posterior crowns, although some of the Essence Stains differed. Shade 1 and 2, copper, crème, white, and mahogany were used (Figures 14 through 17). Several layers of IPS e.max Ceram were layered to build up the anterior restorations’ incisal edges. In particular, shades OE1, OE4, Clear, OE5, TI1, TI2, Interincisal White, and Blue were applied (Figures 18 through 20). The build ups were baked at 750c. The same pattern was repeated for the posterior crowns. The restorations were sent back to the dental office for a try-in (Figures 21 and 22). The restorations underwent a thorough examination regarding position, contours, occlusion, color, value, and texture. Once the patient and dentist approved the restorations, they were returned to the laboratory for completion. By hand, and using a diamond paste and pumice, the ceramist polished the anterior crowns. This created the desired surface texture. Once completed, the crowns were fired at 770c (Figures 23 and 24). Then the posterior crowns were stained, glazed and fired. The purpose of using stain and glaze in the posterior is to take advantage of the strength (400 MPA) for more durable restorations (Figures 25 and 26).
Final Seating After receiving the IPS e.max Press crowns from the laboratory, the dentist prepared the dentition and restorations for final cementation. The temporaries were removed and the preparations cleaned. A mixture of Multilink Self-etching
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The patient received the restorations for a try-in conducted in the dental office. A thorough check for position and occlusion was performed.
Figures 21-22
Figures 23-24 The anterior crowns were already glazed at 770c. The ceramist placed the polish by hand.
Primer was applied to the patient’s teeth. The anterior preparations were scrubbed for 15 seconds and air dried. Multilink Automix Cement was loaded into the restorations and then seated into place (Figures 27 and 28). The excess cement was partially cured using an LED Bluephase Style Curing Light (Ivoclar Vivadent). All excess cement was removed with a scaler from the proximal and gingival margins and a final cure was conducted for 20 seconds from all sides of the restoration. This process was repeated for the posterior crowns. The patient was checked again for articulation and occlusion. The completed restorations displayed exceptional fit, function, and esthetics. The patient was pleased with the final results (Figures 29 through 32) of her new smile.
Conclusion The dentist and ceramist satisfied the patient’s expectations and the esthetic goals of this case by using a lithium disilicate material (IPS e.max). Minimally invasive and adaptable to all varieties of restorations, lithium disilicate remains an idyllic choice for full-contour restorations. Despite advancements in restorative dentistry, cases may still present challenges. However, by implementing a multidisciplinary approach and careful treatment planning, success is achievable, resulting in functional and esthetically pleasing restorations. L
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Figure 29 Front view of completed anterior crowns.
The posterior crowns were stained and glazed in place, then cemented with Multilink Automix Cement.
Figures 25-26
Figure 30 Postoperative view of the restorations in centric relation displaying excellent esthetics.
Figure 31 Postoperative view of the patient’s new smile displaying the lithium disilicate crown and filter.
Lateral view of the anterior crowns cemented with MultiLink Automix Cement.
Figures 27-28
The patient returned a few months later for a follow-up and was still pleased with the final results. Figure 32
References 1. Jones B. Slovan J. Repairing severely worn dentition. Inside Dentistry. 2011; 2(6):34-42. 2. Spear FM. Treatment planning materials, tooth reduction, and margin placement for anterior indirect esthetic restorations. Advanced Esthetics and Interdisciplinary Dentistry. 2008;4(1) 3. Michel A, Lewis H. Repairing worn dentition with lithium-disilicate glass-ceramic. Inside Dentistry. 2011; 7(3):32-36. 4. McLaren EA, Phong TC. Ceramics in dentistry-part I: classes of materials. Inside Dentistry. 2009;5(9):94-103.
5. Tysowsky GW. The science behind lithium disilicate: a metal-free alternative. Dent Today. 2009;28(3):112-13. 6. Javajeri D. Considerations for planning esthetic treatment with veneers involving no or minimal preparation. J Am Dent Assoc. 2007;138(3):331-337. 7. Hess, LA. The relevance of occlusion in the golden age of esthetics. Inside Dentistry. 2008;4(2):36-44. 8. Jones, B. Engelberg B. Achieving an Esthetic, Additive Full-Mouth Reconstruction. Inside Dental Technology. 2012;3(7). FALL/WINTER
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cover story
A CASE STUDY IN
Contemporary Esthetic Dental Care by William E. Turner, DMD Cert. Esth. FAGD FADI FADFE
rom time to time the practice of esthetic dentistry is criticized for being frivolous, or lacking in the professional standards of more traditional disciplines within dentistry.1 While such criticism is not always without merit, esthetic dentistry as a field within dentistry is in its infancy. It will take time for the profession to find its way. The Royal College of Dental Surgeons of Ontario has recently come out with educational standards for dentists who wish to place and restore implants, in recognition of the fact that developed. With that in mind, the following case is presented the body of knowledge within the field has as an example of an esthetic case that was completed to conreached the point that a new graduate cannot temporary professional standards of esthetic dental care.
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reasonably be expected to be fully competent without advanced training. The same is certainly true of esthetic dentistry, and it is reasonable to expect that in time, similar standards may be Dr. Bill Turner is a 1981 graduate of the University of Manitoba, and maintains a full-time general and esthetic dental practice in Thunder Bay, Ontario, Canada. He holds a certificate of Proficiency in Esthetic Dentistry from SUNY at Buffalo. The subject of his post graduate
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K.C was an esthetic dentist’s dream: a pretty girl with unattractive teeth, and no complications to treatment. She first presented with a chief complaint that she didn’t like
thesis was Direct Fiber-Reinforced Composite Bridges, and he has lectured and published a number of articles on this and other techniques, and most recently authored the chapter on direct fiber reinforced bridges in Freedman’s textbook “Contemporary Esthetic Den-
tistry”. Dr. Turner holds Fellowships in the Academy of General Dentistry, the Academy of Dentistry International, and the International Academy of Dental-Facial Esthetics. He is married and has two children who keep him occupied with sports and outdoor activities.
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her teeth. In talking to her it was immediately obvious that she was extremely self-conscious about her smile, covering her mouth with her hand every time she smiled. At her first appointment a full examination was performed. Her teeth had few restorations, which were in generally good condition. She had occlusal caries on tooth #48. Otherwise the teeth were in excellent condition. The periodontal health was excellent. The arches were well related in class I occlusion. Occlusal interferences were noted in protrusive and right working excursions. Fremitus was present on tooth #14 along with a non-carious cervical lesion. The natural teeth were quite yellow, approaching A3 in colour. A course of home bleaching prior to treatment was discussed, and it was explained to her that the colour of the veneers could not be substantially changed after treatment, and that if she wished to have whiter teeth, now would be the time. Also at the first appointment a cosmetic preview was performed in composite. Alginate was used to make an impression of the mock up, and photographs were taken. Tooth #48 was restored in composite and models were made of her teeth. These models were mounted in centric relation to a Denar Combi semi-adjustable articulator for analysis. Based on the analysis of her occlusion, it was determined that some occlusal equilibration would be required prior to treatment with veneers. A modest occlusal equilibration was performed and a course of home bleaching was started. K.C. had substantial difficulties with sensitivity during bleaching, in spite of treatment with a variety of desensitizing solutions, but she insisted on persevering, a testament to her dedication to treatment. The patient continued with her whitening treatment for close to three weeks of night time wear followed by another three weeks to allow the colour to stabilize. In the meantime, her mounted models were sent to the lab along with the model of her cosmetic preview, for a diagnostic waxup. The waxup was duplicated, and a mould was made from 3 mm. mouthguard material for fabrication of provisionals. Teeth # 12, 11, 21, and 22 were prepared for ceramic veneers. The lab was provided with approximately 0.8 mm. of space for ceramic on the labial surface and 1.2 mm. on the incisal. This required approximately 0.5 mm of labial reduction and 0.8 mm of incisal reduction. Two polyvinyl impressions were made (Extrude, Kerr Corporation, Orange CA) in pressure moulded custom impression trays. Provisional restorations were fabricated (Instatemp, Sterngold Dental, Attleboro, MA), the teeth spot etched for two seconds with 35% phosphoric acid (Ultra-etch, Ultradent, South Jordan UT), and the provisionals cemented with luting resin in shade A1 (Variolink, Ivoclar Vivadent, Amherst NY).
K.C. had substantial difficulties with sensitivity during bleaching, in spite of treatment with a variety of desensitizing solutions, but she insisted on persevering, a testament to her dedication to treatment.
The patient was seen for a post op check 48 hours after the preparation appointment. At this time she was very pleased with the result, and no alterations were made to the provisionals. Alginate impressions were made of the provisional veneers and photographs were taken to guide the technician. Veneers were fabricated from pressable ceramic (e.max, Ivoclar Vivadent, Amherst NY) using a cut-back technique. The veneers were tried in twice over the next month, with minor alterations to form and colour made each time. Once both the patient and the operator were satisfied with the result, the patient was booked for the bonding procedure. The veneers were bonded individually using a Belvedere Matrix technique 2,3,4 for isolation (Contour Strips, Ivoclar Vivadent, Amherst NY). The veneers had been etched at the laboratory and were only cleaned using 35% phosphoric acid (Ultra-etch, Ultradent, South Jordan UT). They were then silanated (Monobond Plus, Ivoclar Vivadent, Amherst NY) and allowed to air dry. The teeth were etched with 35% phosphoric acid ( Ultra-etch, Ultradent, South Jordan UT) for 17 seconds, rinsed thoroughly, and bonded with two layers of acetone-based bonding agent (Uno, Pulpdent Corporation, Watertown MA). Luting resin (Variolink Bleach XL, Ivoclar Vivadent, Amherst NY) was applied to the inner aspect of the veneer, the veneer applied to the tooth, and the resin light cured. No chemical accelerators were used in the bonding process. Once the bonding FALL/WINTER
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resin was fully cured, the matrix was removed, and any excess bonding resin removed with a #12 scalpel blade. Occlusion was adjusted,, and any adjusted ceramic polished smooth with rubber points. (Optra Fine, Ivoclar Vivadent, Amherst NY ). The patient was again seen six days post-insertion for verification of the occlusion, and final post-op photographs. Treatment was conservative and life-changing for this patient. Given the predictability of modern ceramic materials and current bonding procedures, it is reasonable to expect many years of service from her restorations. Esthetic dentistry is here to stay. L
References 1. Mulcahy D F. Cosmetic dentistry: Is it really health care? JCDA 2000;66:86-87. 2. Belvedere P C. Direct composite restorations, the solution for our aging society. Oral Health. Apr 2011 101(4):93-106. 3. Turner W E. The concealed margin restoration: Anterior margin placement for optimum esthetics. Oral Health Apr 2003 93(4):77-86. 4. Belvedere P C, Lambert D L. Advancing your direct composites through the use of a specialized matrix. Oral Health Apr 2002; 92(4):75-83.
Laboratory Comments by Trevor Laingchild RDT, AAACD
Dr. Turner, in preparation for the diagnostic wax-up component of treatment had completed an occlusal equilibration and assessed the functional aesthetics with an intra-oral mock-up. These are important diagnostic evaluations that when carried out, ensure an elevated accuracy of occlusion and function that assist the technician with refined instructions, in order to communicate the present and possible re-positioning of the following: Incisal Edge Position Facial Inclination Lingual Contours Functional Parameters Cuspid Functions Protrusive Functions Tissue Support Gingival Symmetry Whenever the maxillary incisors are restored, leaving the cuspids unrestored, care must be taken to safeguard the viability and longevity of the restorations. Replacing worn edges and/ or the re-positioning of the incisal edges, may result in longer incisors, leave the restorations vulnerable to damage when in function. This is due to the possible inability of the cuspids to maintain disclusion of the maxillary and mandibular incisors during function. An intra-oral mock-up will demonstrate to the clinician any proposed changes required in preparation of the diagnostic wax-up. In addition to the above, speech patterns, gingival spacing, negative spacing, facial contours, reflective and deflective surfaces can be evaluated. To be given a clinical in-depth review and information on the proposed restorations provides increased accuracy in preparation for the diagnostic wax-up and subsequent temporization.
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To arbitrarily complete a diagnostic wax-up without refined instructions will often lead to inappropriate provisionals and the possibility of miscommunication, leading to unsatisfactory aesthetic and functional results. The diagnostic wax-up was completed using Dr. Turner`s instructions and a relined silicon matrix fabricated for the intraoral placement of the provisional. At every stage of the treatment, high quality digital photographs were taken for documentation and communication purposes. After clinical preparations and temporization of the maxillary incisors, the model of the provisionals was cross-mounted to the mandibular model as to accurately reproduce the form and function of the established provisionals. The maxillary incisors were fabricated with IPS E-max using LT B1 ingots and using the manufacturer’s established protocols for the pressing technique. With careful evaluation of the photographic and instructional shade analysis, incisal reductions were made to the pressed restorations and various additions of translucent enamels were added. The use of e-mailed photography was absolutely paramount in the communication process, as the patient could not visit the laboratory. On final polishing and confirmation of fit and contour, the restorations were delivered to Dr. Turner`s office for try in. Photographs of the try in were e-mailed to my office and it was decided that a slight addition of chroma at the cervical and a soft white calcification to the enamel should be added. This was undertaken and the restorations returned. The restorations at the next clinical appointment were fitted with both Dr. Turner’s and the patient`s approval. Subsequent post-operative photographs give evidence to the importance of both the clinical and technical communication, for a successful aesthetic and functional outcome.
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ADVANCED
Aesthetics
Understanding Materials and Protocols by Steve Hoofard, CDT, AAACD Dentistry by Dr. Ed Lowe Bsc, DMD, AAACD
ith the evolution of restorative materials and a shift from traditional metalceramic restorations to metal free or all-ceramic, understanding the elements and required information needed in the restorative process has become paramount in achieving predictable results. Our choices within the metal-free/all-ceramic category include composites, both direct and indirect, zirconium oxide, and a variety of pressable ceramics (which also have milled variants). Composites may not provide has emerged as the material of choice for many clinicians us with a durable and long-term solution. Zir- because of a variety of favorable attributes such as strength conium oxide, while very strong (800-1200 (400Mpa in pressed form), range of opacity to translucency Mpa) has aesthetic limitations as a mono- (56 ingots/blocks), method of use (monolithic or veneered),
W
lithic material. Very nice results can be achieved by utilizing zirconium as a framework and applying veneering ceramic over it. Unfortunately the 100Mpa veneering material has proven to be very susceptible to failure if not supported properly. Out of the pressable/milled group lithium disilicate
Steve Hoofard, CDT, AAACD, founded and manages Aesthetic Designs Laboratory in Hermiston, Oregon, specializing in implants, aesthetic and complex reconstructions. He is a second-generation technician and his 34-year career in dental technology includes membership and affiliation with the Ameri-
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wear is very similar to natural dentition, and it can be bonded or conventionally cemented. In this article I would like to focus on how to achieve predictable results utilizing lithium disilicate (eMax, Ivoclar) and what information and communication is required from the
can Academy of Cosmetic Dentistry, The National Association of Dental Laboratories, the Oregon Association of Dental Laboratories, and the Great Blue Heron Study Group. He has authored a number of technical articles and participated in numerous aesthetic and live-patient courses presented
by leading clinicians and ceramists from around the world, and has studied occlusion and function with such experts as Drs. Frank Spear, Peter Dawson, and John Kois. He is one of only 30 technicians worldwide to be accredited with the American Academy of Cosmetic Dentistry.
FALL/WINTER
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restoring dentist. Also it is important to understand the limitations of the material so we will cover the contra-indications. The restorative protocols for this material include treatment planning, prep design, records, and shade communication. Of these, shade communication is the most challenging and important in achieving beautiful and natural results. With all-ceramics, the challenge is anticipating the proper combination of the elements that influence the outcome – stump color, thickness of the restoration, and the needed opacity/translucent level of the material.
Treatment Planning 3
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It is always helpful to acquire pre-op models, radiographs, and photos to aid in the treatment planning discussions with your laboratory, which will narrow your material selection options. I recommend that you implement a routine practice of shooting the 12 AACD pre-op views (figures1-12) , which include: • Full face, chin to forehead • 1:2 smile views, front and lateral • 1:2 retracted views, front and lateral • 1:1 retracted views with black background, front and lateral • occlusal mirror shots, Maxillary and Mandibular A bonus of this practice is that you will build a historical library that can be tapped when you are compiling a presentation, writing an article, or working towards your accreditation (be sure to shoot in RAW). Contra-indications of this material include: • Posterior bridges reaching into the molar region • 4 or more units in a bridge • Inlay retained bridges • Very deep sub-gingival preparations • Bruxism • Cantilever bridges • Maryland bridges
Prep Design With all-ceramic materials, prep design plays a huge role in the predictability and aesthetic outcome of the case. For example, when evaluating a multi-unit anterior case for the possibility of veneers, consider existing symmetry and alignment. If the goal is to do a ”no prep” approach, then for the most part, it must be an additive situation. This would include increasing incisal length, augmenting buccal contours, and changing shades. It is very difficult, if not impossible, to shift contact points (for balanced ratios) and have space for layering without reduction. Also, for the ceramist, it is difficult to fabricate multiFALL/WINTER
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unit veneers on preps that don’t break the proximal contacts. Margins and contacts in the same place can often result in unfavorable aesthetics. Breaking or slicing contacts allows the ceramist to develop symmetry within the arch and create ideal and broad contacts. To avoid or overcome “black triangles” proximal sub-gingival preparations are necessary. This allows the ceramist to develop emergence profiles that can mold papilla and fill spaces. Prep guidelines to follow: • No angles or sharp edges • Shoulder preps if possible with rounded inner edges • Minimal occlusal reduction on molar restorations is 1.5mm • Minimum veneer thickness is 0.3mm
Records
oralhealthLABS •
back behind the ears) (Figure 14). • Shade information including stump or core shade Digital impression acquisition is now a mainstay in the everyday restorative process. Intra oral scanners such as the iTero (Align Technologies) provide geometry data in the form of STL files that are sent to the laboratory. We can then design the restorations utilizing our 3Shape software and send the completed design off to the appropriate milling center for fabrication. Advantages of digital impressions include the ability of the clinician to immediately analyze the completeness of the acquisition and re-scan portions if needed. Also, any under-prepped areas will be identified so the clinician can make additional reductions where indicated.
Shade Communication
Required records can vary depending on the complexity of the case. Typical multi-unit treatment plans would include: • Pre-op impression • Prep impression • Face bow (Figure 13) • CR bite • Stick bite (include a chin to forehead photo of the stick bite in position. Make sure patient is not wearing glasses or earrings and hair is pulled
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As mentioned earlier, with all-ceramics the trick is anticipating the proper combination of the elements that influence the outcome. Here are the elements of the formula: • Stump shade or implant abutment • Thickness of the restoration (prep design) • Opacity of the ingot or block • Amount of cut back (veneering material) • Type of cementation
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Shade simulation with Variolink II Try-In The Variolink II Try-In pastes feature the same optical properties as the subsequently used luting composite Variolink II. 17
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All too often we receive all-ceramic cases in the laboratory without stump shade information. Depending on the ultimate thickness of the restoration an unfavorable stump color can have a dramatic affect on its appearance when seated. On multiple unit cases there can be varying colors between preps and color gradation on individual preps (Figure 15). A picture truly is worth a thousand words. In the laboratory, high-resolution images can be viewed on large monitors to be analyzed. For these images to be useful, specific information must be included and proper exposure achieved. Multiple shade tabs must be included in the images and, most importantly, the tabs reference on the handle must be visible. Make sure the tabs are on the same plane as the patient’s teeth for correct focus and exposure. To avoid flash “burn” shoot your images at a low or high angle, not straight on. Also, different angles can reveal subtle effects present in the dentition that you are trying to match (Figures 16-19). The real challenge for the ceramist is selecting the proper ingot or block. When Empress Esthetic (Ivoclar) was our “go to” material for all-ceramic cases, we had just 12 ingots to choose from. Currently with eMax we have a selection of 56 ingots. • 5 – HO (high opacity) (Figure 20) • 4 – MO (medium opacity)
Thus, the aesthetic effect of the luting composite on the restoration can be checked prior to adhesive cementation.
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• 21 – LT (low translucency) • 21 – HT (high opacity) • 3 – Value • 2 – Impulse (Figure 21) When the definitive restorations arrive back at the dental office, resist doing a “fly by” to check the shade before temps are removed. Because the restorations were fabricated with the stump shade as part of the over all formula, an accurate evaluation cannot be performed unless they are actually tried in. During the try-in you must use a wetting agent to bring through the stump color into the restorations. Try-in pastes, propylene glycol, or just water can be used (Figures 22 - 23). If, when the restorations are tried in, changes or modifications are required, make sure images are taken with the restorations in place and reference tabs (with tab identification viable) are included. Select tabs that depict the closest match for the changes required. Because the restorations are in place with a wetting agent, the true impact or influence of the stump color can be observed by the ceramist in these images. Adjustments can now be accurately completed. The try-in pastes that were used, or combinations of, should be recorded and replicated when the restorations are returned for cementation. FALL/WINTER
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Contact:
Variolink II Veneer Value shade concept
The High Value shades enable a gradual brightening. The highly translucent shade Medium Value 0 (MV 0) only minimally influences the restoration due to its neutral effect. The Low Value shades provide a gradual “warming” effect to the final restoration. 24
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Results When the clinician and ceramist develop and utilize communication protocols, outcomes on restorative cases become very predictable (Figures 24-25). Also, an understanding of the many possible combinations of elements by the dentist will help the ceramist’s proficiency. L References 1. Blitz N, Steel C, Willhite C. Diagnosis and Treatment Evaluation in Cosmetic Dentistry: A Guide to Accreditation Criteria. Madison, WI: American Academy of Cosmetic Dentistry; 2004. 2. Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach. Chicago, IL: Quintessence Pub. Co.; 2002. 3. Chu SJ, Devigus A, Mieleszko AJ. Fundamentals of Color: Shade Matching and Communication in Esthetic Dentistry. Chicago, IL: Quintessence Pub. Co.; 2004.
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4. Adolfi D. Natural Esthetics. Chicago, IL: Quintessence Editora; 2002. 5. Steel C. Photographic Documentation and Evaluation in Cosmetic Dentistry: A Guide to Accreditation Photography. Madison, WI: American Academy of Cosmetic Dentistry; 2004. 6. Sidney K, August B. Invisible – Esthetic Ceramic Restorations. Artes Medicas, Ltda. 7. I.P.S. eMax Wear Compatibility. J.ESQUIVEL-UPSHAW1, W. ROSE2, E.R. OLIVEIRA, DDS2, and K.J. ANUSAVICE1, 1University of Florida, Gainesville, FL, 2Univ. of TX, HSC at San Antonio, San Antonio, TX, IADR 2009 General Session, Miami, Florida Abstract #1009 8. Petra C Guess 1, Ricardo Zavanelli 2, Nelson Silva and Van P Thompson, NYU – Mouth Motion Fatigue and Durability Study; June 20, 2009 Acknowledgements The author would like to thank Dr. Ed Lowe BSc, DMD, AAACD, Vancouver Centre for Cosmetic and Implant Dentistry, for his clinical expertise in the fabrication of these restorations.
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Dental Marketplace
Contact: Karen Shaw • tel: 416-510-6770 • fax: 416-510-5140 • e-mail: kshaw@oralhealthgroup.com Toll free: CDA 1-800-268-7742 ext 6770 • Toll free: USA 1-800-387-0273 ext. 6770
Professional Services CONSULT | DESIGN | BUILD | CABINETRY/MILLWORK
DENTAL MARKETPLACE HELP
M: (416) 871-0000 E: monty@terrakongroup.com W: terrakongroup.com
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Associateships ASSOCIATE POSITION KITCHENER-WATERLOO AREA
Practices & Offices EAST CENTRAL ALBERTA
Well-established practice, good revenue, 4 ops, 1300 sq feet, located in the Medical Center, oilfield thriving town. Contact Dr. Maria Tarcu at 780-753-6242 or 403-918-3334 after 9 pm or email: mctarcu@gmail.com
VANCOUVER PERIODONTAL PRACTICE FOR SALE
RICHMOND HILL, ON
1,331sq ft for rent in retail plaza anchored by Future Shop, NoFrills, 3 Major Banks, new tenant being added — Hakim Optical and Deserres. Space is adjacent to a Family Medical Practice on site for 10 yrs. approximately 3,000 patient per month foot traffic. Located at 16th Avenue and Yonge Street in Richmond Hill. Long terms lease structure. Please contact: Moe Jiwan, Uptown Health Management Inc. T: 416 709 8876 or e-mail: mjiwan@uptownhealthcentre.com
YOUR ADVISOR IS IN
Excellent staff trained in periodontal procedures. Beautiful office in great location. Price reduced to $199,000. Very profitable practice netting over $500,000 per year. Annual gross billing over $900,000 on 3.5 days per week. Extremely motivated Periodontist wishes to sell this lucrative practice in the next month. Excellent opportunity — this will sell very quickly. Contact Henry Doyle for more information: Phone 1-866-638-6194 Cell 604-724-1964
KAREN SHAW TEL: 416-510-6770 FAX: 416-510-5140 BRAMPTON, ON E-MAIL: kshaw@oralhealthgroup.com A new dental office for sale in Brampton, located in a busy plaza anchored by TOLL FREE CDN: 1-800-268-7742 ext 6770 grocery store, banks and medical office. TOLL FREE USA: 1-800-387-7742 ext 6770 Private sale. E-mail: gtadentalofficeforsale@gmail.com WEBSITE: www.oralhealthgroup.com Associateships
OSHAWA AREA
Part time associate required for a very successful, large group practice. E-mail: kathleen@healthcentredental.com or tel: 905-438-9977.
URGENTLY NEEDED: PEDODONTIST
ST. ALBERT, ALBERTA
City of Guelph, population 100,000 has only one Pedodontist and needs one more. 1700 sq. feet available in a facility with lots of parking zoned for Dental. Full General Anaesthesia available. Please call Dr. Cooperband (519)767-2886. NIAGARA REGION, ON
OTTAWA/SASKATOON/HALIFAX
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GREAT OPPORTUNITY! Ontario-Midland: Small town charm on Georgian Bay, ideal for outdoor enthusiasts. Currently seeking associate with the potential for future ownership. Practice all aspects of dentistry, including sedation and implantology in a well-established, modernly equipped office. Interested applicants please fax resumes to 705-527-7775 or email: allison@lifestylesmidland.com. GUELPH / MILTON, ON
P/T Associate needed to replace one leaving. New associate will be taking over an existing patient load. Please specify days available. E-mail resumes to guelphdentist@rogers.com for Guelph and miltondentist@rogers.com for Milton.
KINGSTON, ON
Leading Dental Group looking for an associate for an established family practice. Must have at least 5 years experience. Contact Trish: at trishc_9@hotmail.com
P/T 2 or 3 days per week or F/T Associate required immediately for modern, busy office in excellent demographic area. High new patient flow. New grads welcome. Call (780) 458-7040, fax (780) 458-6669 or e-mail resume to: drbeau@shaw.ca
Associate required for a busy family orientated, progressive practice in Thorold. All aspects of dentistry. Excellent opportunity to work with a great team in a wonderful atmosphere. Please email a resume to: thoroldassociate@gmail.com
Replacing Associate who billed $4050,000 per month. Income is 45% of collections. Schedule is 5 days per week with no weekends. We require experience and commitment. Email your resume to: kwdentalgroup@gmail.com
Associates wanted both full and part-time in established practices. Ottawa, Saskatoon, Halifax locations. Email: info@finetouchdental.com or phone Andy 888-526-3535.
ASSOCIATE — EAST GTA East GTA practice seeking to compliment our team with a new Associate. Our facility is open 7 days a week providing dentistry to our regular patient base along with the emergency needs for some of the community dentists. e/o Saturday & e/o Sunday are our primary concern however we are able to compliment these two shifts with Wednesdays & Thursdays for a suitable candidate. This opportunity will appeal to an individual who can maintain a high level of professionalism & is interested in building a long term business relationship. We offer state of the art equipment and a team of professionals to work alongside. Please forward your resume to Oral Health Labs Box 10 e-mail: kshaw@oralhealthgroup.com
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Grundy Family Dental Care in Hanover and Lucknow Ontario We are looking for an Associate with strong clinical and interpersonal skills to assume an established associate position in our busy practice. We are a state of the art general dentistry practice known for exceeding patient expectations and providing a full range of dental services in office including sedation. New Associates immediately leverage our market presence, established patient pool, terrific facilities, professional systems and support teams to deliver excellent and comprehensive dental care. Our Associates earn above average compensation, and those wanting professional development opportunities have consistently increased their competence, scope and earnings within our established general dentistry, sedation and implant practice. Work full-time or part-time, in a rewarding professional environment, have a great quality of life in a lovely area of Ontario with very affordable housing and nature at your door. All with Toronto and Pearson Airport just 2 hours away. Check out our website at www.grundyfamilydentalcare.com Please send your resume via email to laurieg@grundyfamilydentalcare.com Or call us at 1-519-378-7425
NORTHERN BRITISH COLUMBIA
Full-time or part-time associate needed immediately for established, busy family practice in Burns Lake with high income potential. The clinic features high quality full time hygienists, dental assistants, Cerec and friendly, hard working staff. Contact Curtis: cklmanagement@gmail.com or 801-376-0976. CORNWALL AND OTTAWA WEST, ON Looking for full time associates for 2 busy locations. Minimum 1 year exp. required. Long term commitment required. To apply for this excellent opportunity please email: rsandhu@sandhudental.ca
ASSOCIATES FOR DOWNTOWN TORONTO
OTTAWA VALLEY, ON
DENTIST required for our well established practice in the beautiful Ottawa Valley. The area is paradise for boating, fishing, hunting, and the outdoor enthusiast. Self-motivated, caring individual with the highest quality of all aspects of family dentistry in mind. This is an excellent opportunity to work with a great team that thrives in providing exceptional and comprehensive patient care. This is an incredible opportunity for the right candidate. Enjoy a full schedule from day one. Please send resume to ottawavalleydental@gmail.com. WILLIAMS LAKE, BRITISH COLUMBIA DENTAL ASSOCIATE POSITION
Full Time Dental Associate needed for large multidisciplinary family dental practice. Whether you’re someone who’s just starting off in your dental career or a seasoned provider we would welcome you to join our team. We are a digital and paperless practice, newly renovated with the latest technology (including CBCT). Come and work in an office where you can experience a variety of dental cases, work with the latest technology and be supported by our highly trained and skilled team. We have a very successful clinic that is a great place to practice dentistry! This is an excellent environment to gain experience and earn a six figure income while enjoying a healthy lifestyle. Position Available July 2013. Call Perry @ 250-398-0532 Vitoratos@shaw.ca and visit us at www.cariboodentalclinic.com
ASSOCIATES FOR HAMILTON & WATERLOO, ON
Associates required, for TWO VERY busy and modern practices with VERY strong new patient flow. E-mail: associatedentist@ymail.com Fax CV: 888-880-4024
PICTON OR BRACEBRIDGE, ON
Full time associateship available immediately for a busy Dental office. Two locations, Picton or Bracebridge, ON. Guaranteed production, No late hours, No weekends. Please email resume to: connect_dental@yahoo.ca
PICKERING, ON
Associate position available immediately 3-4 days a week in a well established Family Practice with a busy patient load. Must be fluent in English with minimum 2 yrs experience. Email: brockington@polardental.com
ST. THOMAS, ON
Looking for an experienced associate for a very busy high end office. Good hours and relaxed environment. Commitment for 3-5 years required. E-mail: dentalpositions4u@gmail.com
Leading Dental Group looking for an associate for an established family practice. Must have at least 5 years experience. Contact Trish: at trishc_9@hotmail.com
CALGARY, AB
KITCHENER-WATERLOO AREA — IMMEDIATE POSITION.
Part-time associate position available in recently renovated, well-established, family practice. We have an experienced team and provide all aspects of dental care. Please email resume in confidence to dental_team@yahoo.ca.
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F/T associate needed leading to partnership. We are a busy, established group of practices with long standing staff, great hours and full schedule. Serious inquiries only should reply to: dentistsreply@yahoo.ca
ASSOCIATES EAST OF GTA Starting Part-Time leading to Full-Time. New Grads Welcome. Please contact Dr. Alex Rhee at 905-706-7665 or alexrheedds@gmail.com
ORILLIA, ON
Part time associate required 1-2 days per week for busy general family practice. Please forward resume to dental_2010@live.ca
FT/PT ASSOCIATES
FT/PT Associates required for very busy offices in Mississauga, Barrie and Scarborough. Please email: Dentaldreams@live.com. Please specify which location you are applying for.
Equipment Highspeed Handpiece Rebuilds Starting as low as $99.99. Call for details. All Makes and Models. 1-800-465-8442 Selmar Dental (Barrie) since 1984 Your Handpiece Specialists.
GO DIGITAL! Scanx with Pan system Pan Instrumentarium OP200 , 2006 model retails new $36000.00. Air Techniques Scanx ILE retails new $24000.00. To be sold together ONLY $20,000.00. E-mail: fletchersmeadows@gmail.com or tel: 905-846-7645.
12-10-25 12:02 PM
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The Mainstay™ Disposable Articulator System does not require model formers or a gypsum base, and adjusts to accommodate any occlusal relationship. Its base was designed without external walls or raised edges to prevent interference with the seating of dies and model segments. This unique feature also means that it can easily be used with gypsums of all expansion ratios. Choose between Pin Models in Full Arch, Anterior and Quadrant sizes. Pinless Model offered in a Quadrant size only. Stable Fit with Pin or Pinless System • Raised anti-rotational spine prevents movement of dies • Numbered bases for quick reference of die position • Excellent for scanning • Pinless design eliminates pinning, drilling and gluing • Combine Pin Quadrant for working model and Pinless Quadrant for opposing To receive a Free Sample Box of MainStay™ Disposable Articulators, call 800-626-5651 x1270 or visit whipmix.com Like us on Facebook!
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