Choosing the right material for anterior restorations. Dentistry continues to roll through an “esthetic revolution,” with more restorative choices than ever to take better care of your patients. This multitude of information provides you with a tremendous opportunity to provide optimum care from an esthetic, functional and disease prevention standpoint. However, it can also lead to confusion when deciding which option is best for your patients. (Continued inside) Anterior Restoration Selection Guide 1.800.227.4142 Dental Arts Laboratories, Inc. 241 NE Perry Avenue, Peoria, IL 61603-3625 www.dentalartslab.com Helping You Restore Beautiful Smiles. ™ • Indications • Prep Guidelines • Material Selection Criteria • Clinical Before/After Photographs •
Transcript
Choosing the right material for anterior restorations.
Dentistry continues to roll through an “esthetic revolution,” with more restorativechoices than ever to take better care of your patients. This multitude ofinformation provides you with a tremendous opportunity to provide optimumcare from an esthetic, functional and disease prevention standpoint. However, itcan also lead to confusion when deciding which option is best for your patients.
(Continued inside)
Anterior Restoration Selection Guide
1.800.227.4142
Dental Arts Laboratories, Inc.241 NE Perry Avenue, Peoria, IL 61603-3625w w w .d e n t al ar t s l ab . c o m
Choose the material that’s right for your patient.Perhaps nothing is more confusing thansifting through the myriad of estheticmaterials to choose the right product forany given situation. As practitioners, wehave a tendency to get comfortable withone or two materials, and then make ourpatients fit the material. But that is notthe best way to practice dentistry.
Know your options.A much wiser method is to spend timestudying the advantages of as manymaterials as possible so you canconsistently choose the right material tomeet the demands of each individualpatient. The purpose of this selectionguide is to provide you with pertinentinformation necessary to assist you whenconsidering the optimum treatment planfor your patients.
Material Selection CriteriaThere are at least six factors to consider when
choosing a restorative material. Let’s take a
look at each factor briefly.
1. Esthetic RiskTypically 1.0-3.0 mm of maxillary incisal tooth
structure shows at rest in a youthful smile.
From this position, if the patient has a high
esthetic demand and shows a great deal of
tooth structure (more than 7 mm of lip
hypermobility when smiling), choose a material
that is as cosmetic as possible.1 If the patient is
not as driven by esthetics and the teeth are not
too visible, it is more sensible to choose a more
durable material - even though there may be a
slight esthetic compromise.
Another consideration is whether the underlying
color of the anterior teeth needs to be blocked
or if the color is to be visible through the
restoration. A material should be used with
enough translucency to allow the natural color
to shine through or enough opacity to block out
unesthetic underlying chroma.
2. Occlusal RiskWhen working up the patient’s case, make sure
to note any evidence of intra-articulator TMJ
signs or symptoms, occlusal-muscle disorders,
masticatory muscle soreness or fatigue (tension
headaches), tooth wear, tooth mobility without
periodontal breakdown, or tooth migration.
These issues should be considered indicative of
a high occlusal risk patient.2 Esthetic
restorations may still be an option, but extra
attention to detail is essential to develop an
occlusal scheme that ensures a harmonious
stomatognathic system - minimizing stress on
the restoration.
3. Quantity of Remaining EnamelOne of the best reasons to preserve tooth
structure during an adhesive procedure is to
conserve a maximal amount of remaining
enamel, since the crystalline structure of enamel
is far less variable than dentin. Recent reviews
of porcelain veneers during the past ten years
suggest that, of the restorations that failed (4%),
six of seven were only partially bonded to
dentin.3 While the success rate shows the
wonderful results of porcelain veneers, it also
indicates a need to preserve as much enamel
as possible.
Factors affecting restoration selectionBy Dr. John C. Cranham
You Can Choose DAL Restorations with Confidence.Dozens of materials may be utilized for anterior restorations. This publication highlights several products that demonstratecommon patient situations. These materials were chosen because they allow the most conservative preparation (maximumtooth conservation), provide maximum esthetics, and withstand the functional demands of most patients. In addition, thematerials in this selection guide are products that, in our opinion, provide exceptional esthetics and predictable performance.These choices are based on our knowledge of the industry, more than 76 years of experience, recommendations from ouraccounts and our understanding of the practitioner/patient relationship.
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4. Quantity and Quality of Remaining DentinRecent studies also look at how bonding to
sclerotic and carious dentin can affect bond
strength.4,5 While predictable bonding success
is hard enough to obtain inside the mouth, it
seems that bond strengths may also vary
depending on the kind of dentin that exists. A
good rule of thumb is to consider a traditional
cemented restoration if areas of discolored
dentin are present that lack sensitivity to cold
water, air blast or to preparation without
anesthesia. This evidence may indicate that the
wet collagen network within the dentin has
been significantly altered, affecting the necessary
optimum bond strengths.
5. Ability to Maintain 100% IsolationIf 100% isolation cannot be obtained during an
adhesive procedure, failure is imminent.6 Deep
subgingival restorations, patients with limited
openings (TMJ), or any area that is impossible to
isolate are pure examples of clinical situations
where traditionally cemented restorations may
be indicated.
6. Desire for Maximum Tooth ConservationGenerally, it is recommended to only remove
the amount of tooth structure necessary to
maximize esthetics, obtain the necessary
retention and resistance form, and preserve
remaining tooth structure.
References
1. Spear F: The maxillary central incisor edge: a key to esthetic and functional treatment planning. Compend Cont Educ Dent 20 (6): 512-516, 1999.9. Garber DA: Porcelain laminate veneers: ten years later. Part I: Tooth preparation. J Esthet Dent 5(2):56-59, 1993.
2. Dawson P: Evaluation, Diagnosis, and Treatment of Occlusal Problems. C.V. Mosby, 1989.
3. Dumfahrt H, Schaffer H: Porcelain laminate veneers,a retrospective evaluation after 1 to 10 years of service: Part II--Clinical results. Int J Prothodont 13(1):9-18, 2000.
4. Youshiyama M, Urayama A, Kimoch T, et al: Comparison of conventional vs self-etching adhesive bonds to caries-affected dentin. Oper Dent 25 (3):163-169, 2000.
5. Nakajima M, Ogata M, Okuda M, et al: Bonding to caries-affected dentin using self-etching primers. Am J Dent 12(6):309-314, 1999.
6. Nakabayashi N, Pashley D: Hybridization of Dental Hard Tissues. Quintessence Publishing Co., 1998.
Our panel of esthetic restoration experts
Dr. Leonard HessMonroe, NC
Dr. John CranhamC hesapeake,VA
Dr. Robert LoweC harlotte, NC
• Received his Doctor of DentalSurgery degree fromNorthwestern Dental School in Chicago
• Member of the ADA, the AACD,the North Carolina DentalSociety and the CharlotteDental Society
• Member of the Venus SmileProgram
• National lecturer• Published author
• Director of Education at the Dawson Center for Advanced Dental Education
• Associate Clinical Professor for the Medical College of Virginia
• Founder of Cranham Dental Seminars
• Co-chair of the CE Advisory Boardfor Advanstar (publisher of Dental Products Report)
• International lecturer• Published author
• Co-founder and lecturer for the Charlotte Center for Cosmetic Dentistry
• Clinical evaluator of products and materials for several major dental product manufacturers
• Received the 2004 Gordon Christensen Outstanding Lecturers Award
• International lecturer• Published author
AfterBefore
The custom fabricated stackable porcelain veneer isthe material of choice when a case is to be done tocorrect discolored or misaligned teeth, to lengthenteeth, to create space closures or to simply improvea smile cosmetically. Porcelain veneers can befabricated using a traditional pressed glass material,like IPS Empress, that requires at least.7-.8 mm reduction or by using a customfabrication technique referred to asstacked porcelain veneers. This veneertechnique uses a traditional feldspathicporcelain that is stacked and fired in layersto form a custom veneer. It requires theleast amount of tooth reduction and can beas thin as .3 mm (contact lens veneer) or up to.5 mm (traditional stacked veneer), allowing the dentistto stay in enamel over 95% of the tooth. The DALceramist has the flexibility to either let the underlyingtooth structure shine through by fabricating with onlyopal incisal porcelains creating the contact lenseffect, or to fabricate traditional stacked veneers byadding opacious dentins and body porcelains whichblock out undesirable underlying colors.
Because of the conservative nature of this preparation,stackable porcelain veneers are the ideal restoration forthe patient who requires a cosmetic change. Stackedporcelain, however, needs to be supported by eithertooth structure or a high strength core material. Ideally
the porcelain should not have greater than 2.0-3.0 mmof unsupported porcelain. If more than 2.0 mm ofunsupported porcelain will exist in the final product, apressed ceramic material is indicated (IPS Empress).Violating this rule will increase the probability offailure due to occlusal stress.
Indications and Material Benefits• The material of choice for correction of
discolored or misaligned teeth, to close spaces or lengthen teeth and for purely cosmetic reasons
• The most conservative preparation(.3-.5 mm of reduction)
• Bonding to 90-95% enamel
• Allows for underlying color of tooth to shine through (the contact lens effect)
• Underlying dark colors can be blocked out with opacious dentins and body porcelains (traditional stacked veneer) when necessary
Contraindications• Not to be used when greater than 2.0 mm of
unsupported porcelain is required. This will increase the chance of fracture
• Not to be used in situations when maximum strength is required
Bonding/CementationStacked porcelain veneers must be bonded witha light cure resin cement (NX3 from Kerr,Variolink Veneer or Variolink II from IvoclarVivadent or RelyX Veneer Cement System from 3M ESPE).
Occasionally an all-ceramic restoration that isstronger than stacked porcelain is needed to achievethe ideal esthetic goals. Pressed ceramic restorationsare ideal in these situations. They can be used forveneers, full crowns and inlays/onlays.
Pressed ceramics do well in situations when greaterthan 2.0 mm of unsupported ceramics exist. It isalso possible to place veneers next to crowns of thesame material and achieve a beautiful esthetic result.It is important to note that when planning an estheticrehabilitation, it is never a good idea to place differingporcelains next to one another since the opticalproperties of the ceramic materials differ. When anall-ceramic crown is placed next to a veneer, pressedceramic materials work extremely well.
IPS Empress Esthetic: For years we haveprovided our customers with the many benefits andesthetic advantages of IPS Empress pressed glass.Now, dramatic esthetic results are even furtherimproved with the addition of IPS Empress Estheticto the IPS Empress family. IPS Empress Estheticoffers a leucite reinforced glass ceramic with abroader ingot shade range and enhanced ingotdensity for improved flexural strength. Whencoupled with the line of IPS Empress EstheticLayering Porcelains, IPS Empress Esthetic offers theultimate benchmark for highly esthetic, pressedporcelain veneers and anterior single toothreplacement (bicuspid forward).
Indications and Material Benefits• All-ceramic option when greater strength
is required• Can be used when greater than 2.0 mm of
unsupported porcelain exists• Use for all-ceramic veneer with .6-.8 mm
of facial reduction• Use for all-ceramic crown with 1.5-2.0 mm
of reduction• Use for indirect inlays/onlays• Use to mix and match ceramic veneers with
all-ceramic crown/bridge
Contraindications• Not to be used when a more conservative
option is possible• Not to be used when underlying color is
to shine through (cannot achieve contact lens affect)
Bonding/CementationIPS Empress Esthetic crowns should be bondedwith an enamel-dentin adhesive bonding system– a dual cure resin cement (NX3 from Kerr,RelyX Unicem Self-Adhesive Universal ResinCement System from 3M ESPE or Variolink IIfrom Ivoclar Vivadent). Veneers should bebonded using a light cure resin cement (RelyXVeneer Cement System from 3M ESPE orVariolink Veneer from Ivoclar Vivadent).
Designed with simplicity and versatility in mind, IPS e.maxis the ultimate in metal-free esthetics and strength, offeringhigh-strength lithium disilicate materials for both the PRESSand the CAD/CAM technique. The nano-fluorapatitelayering ceramic, IPS e.max Ceram, completes the all-ceramic system. This material is used to layer or veneerboth the PRESS and CAD/CAM lithium disilicaterestorations, allowing for highly characterized and natural-looking restorations even with complex cases. This uniquematerial combination provides optimum esthetics yet hasthe strength to enable conventional or adhesivecementation.
IPS e.max Lithium Disilicate: One of the primarychallenges faced by today’s dental restorative team is theneed to deliver high-strength restorative options withoutcompromising the esthetic outcome fueled by ever-increasing patient demands. The monolithic glass structureof IPS e.max lithium disilicate offers distinct advantages. Byeliminating the traditional veneered ceramic layer and itsrequisite bond interface, greater structural integrity can beachieved which then eliminates potential chipping orfracturing of the veneering material during function.
IPS e.max PRESS Lithium Disilicate Glass-Ceramic Ingot: IPS e.max PRESS is a newbiocompatible lithium disilicate glass-ceramic ingot. Theseingots offer fit, form and function which are expected frompressed ceramics. In addition, they offer improved flexuralstrength (400 MPa’s). With optimized esthetic properties,creating all-ceramic restorations that offer true-to-natureresults has never been so easy.
IPS e.max CAD: IPS e.max CAD unites modernCAD/CAM processing technology with a high-performancematerial. The lithium disilicate glass-ceramic ismanufactured in an innovative technological process,processed for the laboratory in a crystalline intermediatephase. In this “soft” state, the material exhibits its unusual“bluish” color and a strength of approximately 160 MPa’s.
In this “blue” phase, the restorations can be manuallyadjusted or cut-back for layering. IPS e.max CAD acquiresits final strength of 360 MPa’s and the desired estheticcharacteristics (such as tooth color, translucency andbrightness) during a simple and quick crystallizationprocess in a porcelain oven at 850°C. IPS e.max CADblocks are available in three levels of opacity - mediumopacity (MO), low translucency (LT) and the new hightranslucency (HT) for inlays/onlays.
Indications
Veneers
Thin Minimal Prep Veneers (.3 mm)
Inlays/Onlays
Single Crowns
Bridges (anterior and premolar region)
Bonding/CementationBecause of its high flexural strength and itsmonolithic structure, IPS e.max PRESS or CAD canbe cemented with your choice of conventionalcements, resin-reinforced glass ionomer cements(RelyX Luting Plus Cement System from 3M ESPE)or resin-reinforced luting cements (Maxcem Elitefrom Kerr, RelyX Unicem Self-Adhesive UniversalResin Cement System from 3M ESPE, Variolink IIfrom Ivoclar Vivadent or Multilink Automix fromIvoclar Vivadent).
Inlay/OnlayD2610 Inlay - Porcelain/Ceramic – One SurfaceD2620 Inlay - Porcelain/Ceramic – Two SurfacesD2630 Inlay - Porcelain/Ceramic – Three or More SurfacesD2642 Onlay - Porcelain/Ceramic – Two SurfacesD2643 Onlay - Porcelain/Ceramic – Three SurfacesD2644 Onlay - Porcelain/Ceramic – Four or More Surfaces
Prep Design1.0 – 1.5 mm circumferential, moderate chamfer;1.5 – 2.0 mm incisal reduction
Before
IPS e.max®
High StrengthLithium Disilicate All-Ceramic Restorations
CAD/CAM SystemDAL mills IPS e.max CAD with the new Sirona inLab MC XL and enhanced CEREC 3D Softwareto deliver better, faster, easier crowns. DAL is a certified CEREC Connect Laboratory.
Full Coverage Crown
Posterior Crown
Anterior 3-Unit BridgePosterior Crown
1.5 - 2.0 mm incisal reduction • 1.0 - 1.5 mm lingual reduction1.0 - 1.5 mm lingual reduction • Round the internal line angles
Chamfered preparation1.0 mm circumferential chamfer applied at an
angle of 5° or larger (horizontal)
1.5 - 2.0 mm occlusal/incisal reduction • 1.0 - 2.0 mm axial reduction
Zirconia is a high-tech ceramic material that is characterized by its outstanding stability,biocompatibility, and strength levels that aresignificantly higher than other all-ceramic materials.In addition, zirconia restorations display excellentesthetics and precise fit characteristics through the use of precision CAD/CAM technology. Whenconventional cementation and maximum strength are vital factors in the selection of an all-ceramicmaterial, DAL highly recommends the application of one of our several zirconia materials.
Noritake Katana: Katana features a zirconiumsubstructure with noticeably higher translucency andnine colored core shades for even and stablecoloring. Noritake CZR layering or pressableporcelains provide a perfect balance of chroma andvalue that leads to stunningly lifelike restorations forboth anterior and posterior crown and bridgework upto 16 units.
DAL EZ Esthetic Zirconia: Translucent, shadedzirconia frameworks using CAD/CAM EstheticZirconia result in beautifully vital esthetics that exceedthose of PFM’s. The excellent marginal adaptation ofDAL EZ is equal to PFM’s. With Esthetic Zirconia,there is no metal to show through the ceramic and nounsightly black lines at the gingival. Your patientsreceive the esthetics they demand and you receivethe strength and affordability you desire. DAL EZ isindicated for anterior and posterior single unit crownsand 3-unit bridges.
Procera® Zirconia: Procera Zirconia offers you a proven all-ceramic restoration that combinesthe vital, translucent esthetics of an all-ceramic withthe strength and durability of a PFM. The newProcera Zirconia, made of yttria stabilized zirconiumoxide, provides almost twice the strength of theoriginal Procera Alumina and is indicated for anteriorand posterior single unit crowns and bridges up to 16 units.
Lava™: The Lava All-Ceramic System is aninnovative CAD/CAM technology for all-ceramiccrowns and bridges featuring layered porcelain build-ups on a zirconium oxide base. The estheticsand biocompatibility of Lava restorations represent the optimum in zirconia all-ceramic systems. Lava features a full range of eight shades ofcolorable copings and frameworks that are thin and translucent to ensure a natural and vital appearance.
Indications and Material Benefits• Single units and bridgework up to 16 units
for the anterior or posterior region• Zirconia Maryland Bridge type restorations,
zirconia inlay bridges and zirconia CAD/CAM stressbreaker keyway attachments
• The all-ceramic option when maximum strength is required
• An all-ceramic option where conventional cementation is required - can be conventionallycemented or bonded to tooth structure
Contraindications• We do not recommend a feather edge
preparation, as it does not provide adequate reduction for the porcelain build-up, or the trough or “gutter” shoulder because the outermost edge may not be detected when scanned
Bonding/CementationBecause of zirconia’s high flexural strength, allzirconia restorations can be cemented with yourchoice of conventional cements, resin-reinforcedglass ionomer cements (RelyX Luting Plus CementSystem from 3M ESPE) or resin-reinforced lutingcements (Maxcem Elite from Kerr, RelyX UnicemSelf-Adhesive Universal Resin Cement System from3M ESPE, Variolink II from Ivoclar Vivadent orMultilink Automix from Ivoclar Vivadent).
Prep DesignThe optimal preparation is a shoulder orchamfered preparation with a circumferentialstep or chamfer which must be applied at anangle of 5° or larger (horizontal). The angle ofthe preparation (vertical) should be 4° or larger.The inside angle of the shoulder preparationmust be given a rounded contour.
Before After
After
ZirconiaHigh StrengthAll-Ceramic Restorations
PosteriorCrown
1.5-2.0mm
1.5-2.0 mm
1.5-2.0mm
1.5-2.0 mm
1.0-1.5 mm1.0-1.5 mm
1.0 mm1.0 mm
FeatherEdge Undercut “Trough”
Shoulder 90º Shoulder
angle of ≥4º(vertical)
angle of ≥5º(horizontal)
1.0 mm 1.0 mm
Anterior Crown
After
It is important for every dentist to have the ability toprovide a restoration that is traditionally cementedwith the necessary strength to handle both single andmultiple unit bridgework cases. Historically, porcelainfused to metal ceramic restorations (PFM’s) havebeen the “workhorse” of fixed restorative dentistry.While providing a very strong restoration, traditionalPFM’s require a great deal of tooth preparation. Infact, standard facial reduction as great as 1.8 mm iscurrently being taught in many of the teachingcenters throughout the United States. While thisamount of reduction will certainly provide theceramist adequate room for metal, an opaque layer(to block out the gray metal) and layered bodyporcelains, it also has the potential to leave the teethin a weakened state. Contemporary metal ceramicsystems like the Captek System have the advantageof providing the additional strength required withoutthe gross reduction. Using Captek, facial reduction of1.0-1.2 mm is more than enough room to provide astrong, traditionally-cemented, esthetic restoration.
3 New and Improved VersionsThe re-engineered Captek Nano materials offerup to 33% more strength and three new oxide-free materials - perfectly engineered to maximizeesthetics and bacteria control while achieving thestrength requirements for any clinical situation.Based on each particular case, the experts at
DAL will choose one of the following Captekmaterials:Captek Nano Bridge and Implant™ isperfect for high strength and maximum toughness(i.e., bruxers, large molars, bridges and implantrestorations).Captek Nano Esthetic Zone™ is the thinnestcore material available at under 0.2 mm and isperfect for absolutely gorgeous upper and loweranterior restorations.Captek Nano Universal™, at only 0.235 mm,allows for maximum tooth conservation whilebalancing the strength and esthetic requirementsnecessary for premolars and small molars.
Indications and Material Benefits• Anterior and posterior single crowns, multiple
unit bridgework up to 5 units and implant retained single and multiple unit bridgework
• To be used when maximum strength is required• To be used when maximum esthetics are
needed, but a traditionally cemented restoration is most predictable. This could be due to the inability to isolate properly, or due to the presence of sclerotic dentin
• To be used for anterior bridgework when additional strength is required or multiple unitbridgework is necessary (up to 5 units)
• Does a great job of blocking out dark posts or dark tooth structure
• Can be used with or without a porcelain margin • Indicated for patients with perio concerns
Contraindications• Not to be used with bridgework greater than
5 units or in with bridgework requiring more than 2 pontics in a high stress area
Bonding/CementationCaptek can be conventionally cemented with your choice of cement.
Insurance CodesSingle Crown
D2750 Single Crown -porcelain fused to high noble metal
Bridgework D6750 Crown - porcelain fused to high noble metalD6240 Pontic - porcelain fused to high noble metal
Prep DesignAny margin design with .8-1.0 mm reduction; 1.5 mm occlusal reduction necessary; 1.5 mmincisal reduction, 1.0-1.5 mm axial wall reduction
Smooth and refine preparation with either the rounded endtapered chamfer med 8856 016 or the tapered chamfer 8878 K 016. Polishing preparations with Brasseler points
and cups to remove rough edges is recommended.
Captek Nano™
Contemporary Gold PFM Restorations
A Brasseler 169L should be taken through the contact area. The super coarse 5856 016 can be used to create depth cuts.Creating at least 1.25 mm reduction on the labial tapering to
.8-1.0 mm at the gingival margin is adequate for Captek.
Sinking the 5856 016 full depth will create good reduction on the labial, proximal and gingival lingual. Incisal reduction can be
accomplished with the 5856 (1.5-2.0 mm). The 5379 023 is ideally contoured for lingual reduction (1.2-1.5 mm).
