focus Edition 5 - May 2015
with Lino Adolf www.dental-education.co.uk // www.ivoclarvivadent.co.uk
Using digital technology to create an aesthetic smile Dental aesthetics often depends upon the creation of symmetry of the patient’s midline. This concept can be expanded further with the aesthetics of a smile which has a symmetry and harmony between horizontal and vertical planes. This is demonstrated in this article with a prosthetic alternative to repeat composite bonding for a patient who required an immediate change to their smile. The following case illustrates the importance of all these guidelines and how this can be achieved with minimal intervention using digital technology. In dentistry, optimum aesthetics often depends upon the clinician’s ability to create symmetry across the midline. Subtle changes in symmetry are permissible as one moves further laterally away from the centre-line. Attractiveness in a smile has historically been attributed to a general sense of parallelism which is the most harmonious relationship between two lines. The inter-pupillary line and the smile line of the incisal edges of the teeth create an overall sense of balance and horizontal perspective in an aesthetic face. The general direction of the incisal plane of the maxillary teeth must be parallel to the interpupillary line. This harmony must be further reinforced by the incisal plane which should follow the lower lip during the act of smiling.
Fig 1,2 & 3 Patients pre-op smile
Through a combination of correct tooth preparation techniques, guided soft tissue healing, establishment of correct contact areas and papillae form as illustrated in this case, anterior spacing or crowding can be effectively corrected by restorative dental treatment.
Patient Presentation A 35 year old female patient with excellent medical health requested help from my practice for an aesthetic smile enhancement. She expressed her desire to have straight, evencoloured, whiter, fuller teeth. She had undergone a series of orthodontic treatment to close diastemas and was frustrated with how her smile looked “incomplete”. She was really unhappy with the shape of the lateral incisors, especially with the deep embrasures on the left hand side.
Clinical examination revealed a healthy periodontium and soft tissue architecture that was symmetrical and well defined. Analysis of the temporomandibular joint demonstrated no tenderness to palpation and an acceptable curve of Spee with no loss of vertical dimension. The anterior teeth presented with good arch form however slightly collapsed buccal corridor on the right hand side. The upper left lateral incisor was peg like and rotated slightly mesiobuccally. The right lateral incisor was also peg like and had an uneven surface texture. The Upper central incisors were of good proportion but slightly retroclined. The maxillary posterior teeth were in good condition and unrestored. Slight Wear facets were noted on the upper and lower canines, however the patient was still canine guided. It was noted that the patient had thin biotype and a high smile line so emphasis on supra gingival preparation if any would be required. All the anterior teeth were tested for vitality and they
Fig 4
Fig 6 & 7
Fig 8
Digital Impression
Fig 5
were all vital. Periapical radiographs were taken of the anterior teeth which showed healthy teeth with complete periodontium, good bone levels and an intact lamina dura. After an evaluation of the patients smile and a discussion with the patient about her cosmetic goals, a treatment plan was presented.
Diagnosis The patient’s self confidence is being affected by the peg like upper incisors which is compromising the natural aesthetic smile. Given the patient’s career, it was decided that porcelain restorations in the form of IPS Empress® CAD would be the way forward. Using porcelain allows for the inclusion of the ceramist artist expertise. Also porcelain will have more vitality in the restorations which will be advantageous for her job which requires her to work under bright lights. Five maxillary veneers would be fabricated. These would be 14,13,12,22,23.
Impression Registration
Designing smile using inLab 4.2
2 Step mill - Milled with inLab MCXL
Fig 9
Some surface texture, micro layering on the incisal third and glazed
Given the patient’s youth, the overall good condition of her teeth and the acceptable occlusal and arch form alignment, it was decided to use a no prep technique. We decided to use a digital impression scanning technique using the Apollo Di. The Veneers were lab made using the MCXL milling units from IPS Empress® CAD Multi Blocks, with micro layering on the incisal third.
records, including pre-operative photographs, radiographs, periodontal, and occlusal temporomandibular exam were taken. We also took preoperative impressions & centric bite registration using Virtual® Putty and the Ivoclar Vivadent Centric Tray. To facilitate communication between the patient and ceramist, a pre-operative model was printed where a diagnostic wax up was done.
Pre-operative Work Up
Using a combination of before and after photography of completed in surgery cases, magazine pictures that the patient brought in and different Smile design books, we discussed the
Once the treatment plan was agreed and consent signed, clinical
shape/contour that the patient found appealing. It was decided to create the veneers with square round centrals and shorter round laterals. This information was communicated to the laboratory technician who waxed up the pre-operative models to create a preview of the final ceramic objective.
porcelain veneers to be fabricated on the upper right, premolar, canine and lateral incisors and the upper left lateral incisor and canine, as well as the material for the restorations
Preparation Appointment
The patient returned within 7 days for the delivery of the feldspathic veneers. They were assessed on the digital model and seemed the correct shade, correct shape and appeared harmonious. Each veneer was tried in using a wetting medium. The veneers were tried in individually and then together to evaluate the fit, colour and contour.
There was no preparation for these veneers. A thin retraction cord was used to retract the gingival slightly before the powdering and then the scanning from the Apollo DI. Using in surgery photography and a new extended IPS Empress® CAD shade guide, we discussed the patient’s desired final colour. Many patients today want a new smile that is lighter in colour and a higher value. The patient wanted her teeth to be whiter so using the shade tabs as a guide the patient requested the final shade that matched A1 shade tab guide. The equivalent IPS Empress® CAD Multi block was used. No temporaries were required.
Laboratory On the online order form sent to the laboratory, it was requested
Fig 10
Left side treatment
Delivery Appointment
The veneers were cemented sequentially using the new Variolink® Esthetic light curing cement as the veneers are thin enough to allow for the use of light cure only resin cements. All the veneers were initially tacked in place, then once cemented we fully light cured the teeth using a Bluephase® Style. Fine grit diamond finishing strips were used to carefully remove the interproximal excess cement. Once all the veneers were cemented in place the occlusion was evaluated and refined. Optrapol® fine polishers were used with water spray to create proper centric contacts and functional pathways.
Fig 11
Right side treatment
Conclusion The patient is very happy with her aesthetic result. She returns for regular hygiene and examination appointments and has had a successful, beautiful aesthetic result for nearly 1 year. It is the Dentist and the Technician as a team who have the responsibility to understand the smile design protocols and about the latest proven materials and techniques to provide the patients with the best cosmetic result in the most conservative manner. Fig 12
Finished smile after treatment
Lino Adolf was born and raised in South Africa. He studied at a university in Portugal, where he obtained in 1998 the Bachelor Degree in Dental Technology and later in 2002 the Degree in Dental Technology - fixed prosthodontics. He developed his technical education in fixed prosthodontics until today. Between 1998-2006 he was teaching at CESPU University, fixed prosthodontics and lab orthodontics. During that time he also worked as a Dental Technician doing crown & bridge and implant work at CDI and Dental Creations. In 2001 he became Victor Hugo do Carmo’s - Oral Design International (Switzerland) - Protégé. In 2006 is started working as Self-employed which changed to Majestic Smile Ltd in 2011. He has been working with CAD/CAM since 1998, initially with Nobel Biocare Procera and then Sirona inLab system. He became a Sirona Certified inLab Trainer in 2011, where he shares his knowledge to current and future users.
Lino Adolf, Majestic Smile, 16 Wilford Drive, Ely-Cambs, CB6 1TL E-mail: info@majesticsmile.co.uk
IPS e.max CAD Chairside Solutions with Lino Adolf
Confidence with Composites Applied Technology and Techniques
Objectives: with Chris McCo
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• Learn about the IPS e.max® During this course you will cover planning, shade selection & intra oral situations CAD material, indications are replicated with the IPS Natural Die material and are shown to demonstrate the As a structured programme, this course will provide comprehensive hands-on training, focusing onand howprocessing to achieve communication required for successful whereequipment. the underlying is not optimum results all-ceramics using highly efficient Guidingsituation you through the science behind Empress Direct, our ideal. • with Understand the different experienced tutors will provide you with knowledge you need to combine this innovative composite adhesives such as the easy to use single component ExciTE F. translucencies available, Provided with the IPS e.max® CAD overview, participants will be guided through and know their benefits and VENUE course aims torestorations provide participants withathe knowledge and understanding to ® CAD characterise their own IPSThis e.max using formula which can be limitations ICDE UK, confidently apply techniques conjunction with advanced materials to promote adapted to suit the aesthetics required for eachlearnt case.in This advanced material delivers Compass Building, aesthetics and function in clinical dentistry. • Learn higher strength and highly aesthetic results easily. Feldspar Close,effective Enderby, communication skills given a Leicester, LE19 4SD Objectives: non-ideal situation whether th Cementation with aesthetic adhesive systems, adhesive systems and self-adhesive/ DATE: 16 Jan 2015 • Clarify the factors that influence success and failure of the case is direct or an conventional cementation is explored given the clinicians’ choice based TIME: 9.30am - 5.00pm composite restorations indirect all-ceramic restorative on having to cement high/low strength all-ceramic, the latest bonding Y •
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