Written by Joel Benk, DDS Friday, 30 April 2004 19:00
Advances in dental technology and cosmetic dentistry have helped solve the problems of patients, the dentist, and office staff. Todays baby boomer generation is demanding more and more cosmetic procedures in order to look and feel younger. This group is willing to spend the money and look for the dental office able to deliver them that "winning porcelain smile" as quickly and efficiently as possible. These "time-impaired" consumers are eager for treatment once they realize that their dentists can deliver aesthetic, long-lasting restorations and a beautiful smile in both the posterior and anterior regions of the mouth.
Cosmetically aware patients seek out the high-tech dentist. Todays state-of-the-art dental practice may contain such items as digital x-rays, electric handpieces, and intraoral and extraoral photography. The dentist fitting this profile will have a clean, modern office and make every effort to distinguish the practice accordingly to help attract this type of patient. The staff works together to develop the kind of relationships that help get patients through the hurdles sometimes encountered while working toward the cosmetically restored smile.
With proper case selection and training, unpredictable aesthetic outcomes have become few and far between, thanks to the explosion of advanced technology in todays dentistry. Nothing is more frustrating for both the doctor and patient than an aesthetic restoration that falls short of expectations. And the demand for cosmetic dentistry is at an all-time high; bleaching, veneers, implants, laser gum surgery, bone grafting, all-ceramic restorations, and invisible braces have all become the standard in dental practices rather than the exception.
Television shows such as "Extreme Makeover" have become a catalyst, driving patients into the dental office seeking a new, cosmetically pleasing smile makeover. One of the greatest challenges facing todays dentist is keeping up to date on technology and trends in the industry. Those who are able to possess an edge that will allow them to take a leadership position in todays dental marketplace will actively be evaluating new technologies and incorporating those that benefit the patient, dentist, and practice.
Fortunately, manufacturers strive to develop user-friendly products with reduced learning curves. Once mastered, new technology and systems can be a very welcome tool for the cosmetic dentist. Additionally, master clinicians continue to raise the bar by developing predictable techniques that routinely produce life-changing aesthetic results for both patient and dentist alike.
The following case report provides an example of meeting an aesthetic need by utilizing new technologies.
Figure 1. Preoperative (worn flat maxillary and mandibular anterior dentition).
A 27-year-old patient presented with the chief complaint that her front teeth were too flat. She also felt that her laterals were too short and wanted to have something done to improve her smile (Figure 1).
Utilizing a Canon G3 camera with a diffuser macro lens, extraoral photographs were taken of her smile, including both maxillary and mandibular teeth. Restorative options were discussed with the patient to determine her preferences and goals for treatment. The patient was shown the CAESY video on the goal of cosmetic dentistry and was provided the options available to improve her smile. Due to a limited budget, the patient opted to lengthen her maxillary laterals and aesthetically contour the maxillary centrals, cuspids, and 6 mandibular anterior teeth.
|Figure 2. CEREC 3D acquisition unit.||Figure 3. Composite mock-up of tooth No. 7.|
After placing CEREC 3D (Sirona Dental Systems) posterior restorations, the patient asked if the veneers could be completed in one visit (Figure 2). The Easyshade digital shade guide (Vident) was utilized to determine that a TriLuxe block (Vident) would be an optimal aesthetic match. Both laterals were mocked up with composite (Figure 3), generating additional porcelain thickness so that the milled restoration could be contoured along with the remaining teeth to achieve the smile result the patient envisioned.
|Figure 4. Powdered composite mock-up ready for an optical preoperative impression.||Figure 5. Composite mock-up optical impression taken using the CEREC 3D camera and displayed in the Image Catalogue.|
|Figure 6. CEREC veneer prep tooth No. 7.||Figure 7. Incisal view of CEREC veneer prep showing the lingual margin extension.|
|Figure 8. Facial view of CEREC veneer prep powdered and ready for its optical impression.||Figure 9. Optical impression of the CEREC veneer prep as seen in the Image Catalogue.|
The CEREC 3D Correlation program was used since it allows the dentist to make an exact copy of the tooth (in this case, the composite mock-ups). A thin coat of titanium dioxide powder (Figure 4) was placed on the mocked-up laterals and a preoperative optical impression was taken of teeth Nos. 10 and 7 (Figure 5). The optical impressions were stored in the Image Catalogue under the CEREC 3D Occlusion icon. Both teeth were then prepped for veneers, reducing the incisal 2 mm with a butt joint on the palatal margin (Figure 6). A No. 7 retraction cord was then placed in the facial sulcus. The mesial and distal proximal margins were extended lingually, and the contact was opened (Figure 7), allowing the margins to be easily coated with powder (Figure 8) and virtually trimmed using the CEREC 3D software trimming tool. This type of margin also makes it easier to seat the veneer and polish the lingual margin after seating. A sloping shoulder facial margin was placed, with a crisp, clean, and easily defined cavosurface margin. The sloping shoulder allows the porcelain to disappear into the tooth, creating the ultimate chameleon effect. An optical impression was made of the powdered preparation (Figure 9) and placed into the Image Catalogue using the Acquire Preparation icon.
|Figure 10. The virtual model showing the green copy line. Everything inside of that line is copied.||Figure 11. CEREC veneer presented on the virtual model.|
When using the CEREC 3D Correlation Program, the occlusal view is generated, and an outline of the facial, lingual, mesial, and distal heights of contour is traced to obtain the mocked-up veneers mesial/distal dimension and the facial/lingual heights of contour. The next step is to copy as much of the mocked-up preoperative tooth as possible by using the Copy Line function (Figure 10). This function allows the copying of anything inside the generated line; in this case, the incisal edge and mesial, distal, facial, and lingual surfaces. The veneer was then proposed on the virtual model (Figure 11). The final edits to the restoration were then accomplished, paying close attention to the interproximal to ensure that enough porcelain would be milled to fill the facial embrasures.
|Figure 12. CEREC veneer previewed with the sprue on the mesial.||Figure 13. CEREC veneer try-in viewed from the lingual.|
The veneer was then previewed (Figure 12) before milling to ensure that the sprue was located on the mesial of the TriLuxe block so the 3 layers of porcelain (facial, body, and cervical) would be milled out in the correct position. With milling completed, the sprue was cut off using a diamond wheel mounted on a straight handpiece, and the veneer was tried in (Figure 13). Contact pressure was carefully adjusted to preserve interproximal porcelain from the facial so that the facial embrasure remained closed. Once try-in was completed, the veneer was polished and the surface to be bonded was micro-etched with a Danville Micro Etcher. This sandblasting process functions both to remove the oily residue left from milling and to produce a better surface for bonding. The porcelain surface was then etched with 5% hydrofluoric acid for 60 seconds and thoroughly rinsed and dried. Monobond S (Ivoclar Vivadent) silanation agent was painted on, then completely dried after 60 seconds using a dry air syringe. Excite (Ivoclar Vivadent) was placed on the porcelain surface, and the veneer was then placed under a dark lid, ready for bonding. The preparation was cleaned with a peroxide scrub in an effort to remove all of the powder coating, then etched with 36% phosphoric acid for 15 seconds. Multiple applications of Gluma (Heraeus Kulzer) were applied to the rinsed-off wet dentin. After the first coat, it was blown dry, and an additional 2 or 3 coats were applied and dried so that the dentin appeared shiny. It was then light-cured for 20 seconds. Prime & Bond NT (DENTSPLY Caulk) was then placed, air-thinned, and light-cured. Variolink II base clear (Ivoclar Vivadent) was loaded into the veneer and light-cured for 60 seconds. The excess cement was then removed and the veneer was polished.
|Figure 14. Post-op showing both CEREC veneers Nos. 7 and 10 bonded and polished and the remaining maxillary and mandibular teeth aesthetically contoured.|
Aesthetic contouring of the incisal embrasures was completed, creating a rounded embrasure and a much softer smile line, which was the patient's aesthetic goal from the outset of the procedure (Figure14).
By utilizing the latest advances in technology, we are able to quickly and accurately respond to the patients demand for a highly aesthetic smile.
Disclosure: Dr. Benk is on the faculty of the CEREC Success Center of the Southeast, where he provides training to both dentists and their staffs on CEREC 3D basic, intermediate, and advanced courses. He is a certified Patterson Basic Trainer for CEREC 3D and lectures on practice integration of CEREC 3D and the advantages of machinable ceramics.
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