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QUALITY CONTROL
in
ESTHETIC DENTISTRY
Gerard Chiche L.L.C.
SMILE BUILDER
1. PROPER LENGTH
2. DOMINANT CENTRALS
3. CONVEX SMILE LINE
4. INCISAL EMBRASURES
5. HIGH BRIGHTNESS
WHAT ARE THE STEPS?
1. Road map 2. Parameters 3. Confidence Builder
SEVEN OBJECTIVES
DISCLOSURE Dept. Grants & Funding, Honorarium 3M-ESPE, Vident, Brasseler USA Nobelbiocare, 3I, Zimmer
No Direct, indirect income or royalty from products discussed except Paid Consultant NORITAKE co. Teaching Faculty & Former Consultant
PANKEY INSTITUTE
Techniques and principles reviewed in this all-day program are derived from my
personal teaching and clinic experience.
They do not constitute a guarantee for success , the attendees should form their
own opinion.
Gerard Chiche L.L.C.
DISCLAIMER
IINCISAL PLANE
Incisal Plane . Convex
. Flat
. Concave
. Too Convex
Preview Length Adjustment
SMILE LINE 1. Record Shape
2. Record Lower Lip
Pitch of the upper anterior teeth should mirror the pitch of the lower anterior teeth
Edge to Edge
PRECAUTIONS WITH SMILE LINE
1. Harmonize Anterior Guidance 2. Harmonize Pitches and Bevels 3. Smooth Crossover
IIINCISAL PROFILE
PLAN
1. Incisal Length 2. Gingival Level
3. Implant Level
1. Harmony with Lower Lip + 2. Perpendicular Relation
+3. Final Restoration
INCISAL PROFILE
IIIINCISAL LENGTH
Pleasing Display 3.5 - 4.5 mm.
Pleasing Length 10 - 11 mm.
INCISAL LENGTH
1. Measure Display 2. Measure Length3. Test Drive New Envelope 4. Do not Steepen Guidance
when Increase Length without testing
IVTOOTH
PROPORTION
Short-Fat Proportion
Never Engineer
Narrow-Long Proportion
PLAN
1. Preview 2. Check against Face
3. Involve Lat. & Can.
Mesial Additions
Fat Central Incisor
Distal Reductions
Proportion
Display Length
RULE
1. Priority = Centrals
RULE Create Reference Points
1. Display
2. Length : At least 10 mm.
3. Width: At least 7.5 mm.
4. Midline : Must be Vertical
5. Lateral Incisor: 2mm. rule
6. Canine: 1mm. rule
10 mm. L
7.5-8.0 mm
11 mm. L
8.5-9.0 mm
Central Incisors
At Least
7.5 mm Width
VTOOTH to TOOTH
PROPORTION
TOOTH-TO-TOOTH PROGRESSION
Main Test ?
DELICATELateral Incisor
PROPORTION CONTROL Precautions
1. Implants
2. Short Papillae
3. Canine Substitution
4. Orthodontic Planning
LATERAL INCISOR IMPLANT
Deficient Papillae
=
Use Special Effects
SPECIAL EFFECTS
1. Decrease Reflection
2. Increase Deflection
3. Round Flatten
Lateral Incisor Design
1. Does not Compete for Attention
2. Deficient Papilla = Special Effects 3. Canines in Lateral Position =
Keep Centrals dominant 4. Lat. I. = CI-2mm., Can. = CI-1mm.
5. 70% Ratio for Normal Size Teeth
54 patients (36 F) (18 M) 16-72 yearsAverage width 8 and 9 : 8.5 mm.
7 and 10: 6.5 mm. 6 and 11: 7.5 mm.
Range for central incisors: 7.1 – 9.62 (8) and 7.32 – 10.06 (9)
Range and Mean Distribution Frequency of Individual Tooth Width of the Maxillary
Anterior Dentition S. J. Chu
Pract Proced Aesthet Dent 2007; 19 (4)
VIGINGIVAL PLANE
SYMMETRY
1. Level against Face 2. Set Pleasing Ref. Level 3. Set Pleasing Ref. Line
VIIDESIRED FULLNESS
FULLNESS
1. Show on screen first
2. Mandibule Angle
3. Provide Canine Disclusion
4. Allow Cusps Escape
WHAT ARE THE STEPS ? 1. Record Shape
2. Phonetics, Occlusal Plane 3. Measure Display, Length 4. Record Proportion, Width 5. Delicate Lateral Incisor 6. Symmetry, Progr., Lip
7. Patient’s Desires, Cost
GINGIVAL PLANE
Follows
UPPER LIP LINE
Break Time
ALL-CERAMIC CROWNS
REALITY RATINGS 2009
1. IPS Empress Ivoclar
1. Lava 3M Espe
2. Cerabien Noritake
3. HeraCeram Heraeus
4. EX-3 Noritake
5. IPS D.Sign Ivoclar
5. Omega 900 Vident
5. Duceragold Dentsply
6. VM7 / VM9 Vident
6. Creation Jensen
6. Finesse Dentsply
I WHAT SYSTEM
?
ALL CERAMICS
TWO FAMILIES
=
TWO LOGICS
ALL CERAMICS
FAMILY
A
ALUMINA
FAMILY
A
“…The alumina particles did not show any surface alteration by the etchants...” Della Bona A. & Anusavice K. 2002
ZIRCONIA
.Degussa Allceram Ceram S
.Noritake Cerabien CZR, CZR Press
.Jensen Creation AV Lava Ceram
.Vident Alpha, VM7 VM9
.Nobelbiocare Rondo Rondo Zirconia
.Ivoclar EMax
ALL CERAMICS
FAMILY
B
Etchable Crowns
Empress Esthetics Emax Lith. Disil.
Authentic CZR Press
Duceram LFC Finesse
ProCad Mark II
Examples
II WHAT CEMENT
?
REALITY RATINGS RESIN GLASS IONOMERS LUTING
1 . FUJI PLUS
1 . FUJICEM AUTOMIX
2 . RELY X LUTING PLUS
3. RELY X LUTING
4. FUJICEM
5. KETAC-CEM
2009
Shear Bond Strength of Self-Adhesive Resin Cements: A comparative Study
R. Aljouni et al, 2006 (Abstract 329)
9 MPA
FUJICEM MAXCEM NEXUS 2 UNICEM
6 MPA
Shear Bond Strength to LAVA
WHY Adhesive Cementation ?Suggested Reasons include
1. Increase Retention
2. Increase Strength
3. Decrease Microleakage
4. Best for Thin Cores
The Effect of Preparation Height and Luting Agent on the Resistance Form of Cemented Cast Crowns under Load Fatigue.
E.W. Lepng et al. J. Prosthet Dent 102: 155 , 2009
Mean Cycles to Failure Prep. Height Zinc Phosh. Panavia F
2 mm. 9,238 187,347 3 mm. 120,895 215,998
4 mm. 200,375 250,0005 mm. 250,000 250,000
Blatz, Oppes, Sadan, Chiche. Quint Int. 2008
SBl. (10 sec.)
11.58 Mpa (4.13)
Rocatec soft+Silan
15.76 Mpa (4.10)
SBl +CPA / CSE
16.58 Mpa (3.17)
M.B. Blatz 2003
LAVA Zirconia (6 months testing)
REALITY RATING / DUAL CURE1 . INSURE / INSURE LITE
2 . NX3
2. VARIOLINK II
3. VITIQUE
4. LUTE-IT!
5. CALIBRA
2009
1 . RELYX UNICEM
1 . EMBRACE WETBOND
1. G-CEM
2. SMARTCEM 2
2, BISCEM
3. MAXCEM ELITE
1 . PANAVIA F 2.0
2 . MULTILINK AUTOMIX
3. CLEARFIL ESTH. CEM.
4. BISTITE II DC
1 . RELY X ARC
2 . DUO-LINK
3. CEMENT-IT!
“Ceramic material and bond quality significantly influence the load bearing capacity of leucite and
Lithia-disilicate ceramic restorations… This clearly demonstrates the importance of the
relationship between the adhesive process and the overall strength of the restoration”.
Influence of Bond Quality on Failure Load of Leucite- and Lithia disilicate-based
CeramicsN. L. Clelland et al.
J. Prosthet Dent. 2007; 97:18
No etch, no silane Unicem 9.6 +-1.9Multilink 6.2 +-1.2Panavia F 7.4 +-1.9
Doubles If etch and silane Unicem 18.8 +- 3.5Multilink 17.4 +-3.0Panavia F 15.7 +-3.8
Influence of ceramic surface conditioning and resin cements on microtensile bond Strength to
a glass ceramic. J. Pisani-Proenca et al.
J. Prosthet Dent. 2006; 96:412
Auto Pol. Light Pol. Rely ARC 96.1 (14.3) 131.2 (21.7) Unicem Translucent 75.6 (114) 130.6 (19.6) Unicem A3 70.2 (5.9) 99.4 (18.2) Maxcem Clear 104.0 (9.5) 156.2 (10.8) Maxcem Yellow 76.3 (8.3) 139.1 (17.7)
E. Saskalauskaite et al Flexural Strength, Elastic Modulus and pH profile
of Self-etch Resin Luting Cements. J. Prosthodontics 2008: 262
“…All dual-cured cements both self-etch and conventional showed highly superior properties when photopolymerized … One self-etch cement revealed a unique rapid rise to neutrality in both dual-cure and self-cure mode…”
Bond Strength to Enamel (Unetched) Rely Unicem Aplicap 6.2 (2.0) Rely Unicem Clicker 5.7 (2.8) Maxcem 4.0 (3.3)
A. Piwowarczyk et al Bond Strength, f Self-adhesive Cementing agents
to dentin and enamel IADR Abstract 2007 #1540
1. Etch 2. Silane
3. Light-Cure
Glass Ceramics
Dual-Cure Cements
4. Neutral Shade
Marginal Enamel Etch in selective situations
(Varies with Cement – Check with manufacturer first)
III WHAT PRECAUTIONS
?
. 169 Procera Crowns – 26 Mo.
. Failures : 1 Decay, 6 veneer fractures.
Survival of Procera AllCeram Ceramic Crowns in Students Clinics.
J. Hochstedler et al. 2004
. Survival of Procera AllCeram Ceramic Crowns in Students Clinics
J. Hochstedler & A. Sadan 2004
1. Core Integrity
2. Short Preparations
3. Marginal Ridge Support
4. Anatomical Cores
Adequate Support May Increase Restoration Strength by 30%
Fischer et al. JIADR 2006, Abstract 546
“…Copings for crowns must be designed to minimize tensile loading of
veneering porcelain…”
Marschak et al. J Prosthet Dent 2008
99: 169
Raigrodski AJ, Chiche GJ, Potiket N, Mohamed SE,
Hochstedler JL, Mercante DE, Billiot S.
The efficacy of posterior three-unit zirconia-based bridgesA prospective pilot clinical study
J Prosthet Dent 2006;96:237-44
ZIRCONIA FPD
1. Patient Selection
2. Insure Thick Connectors
3. Facial Shoulder
4. No Lateral Interferences
5. Fine Diamonds – Reglaze
6. Slow Cooling Cycle
7. Zirconia – Veneer Interface
Marginal Fit of Zirconia Crown Copings on chamfer and Shoulder preparations
IADR 2007, # 0885 J Dent. Research Vol 86, Special Issue A
D. Augusti, G. Augusti
Chamfer Preparation 21 mic. (6 mic.) Shoulder Preparation 11 mic. (6 mic.) Difference was significant.
Shear Bond Strength of Veneering Ceramics to Zirconia J Dent Res 2006;85:Abstr 0888
Blatz MB, Chapman L, et al
Effect of veneering Techniques on Damage and Reliability of Y-TZP Trilayers
European J Esthet Dent 2009;4-3P. Guess
Zirconia Posterior Fixed Partial Dentures Prospective Clinical 3-Year Follow-up
Int J Prosthodont 2009;22:597 Schmitt J, et al
NO NEW CHIP SINCE FIRST YEAR
Int. J Prosthodont; 2009; 22: 553 Sailer I. et al
ZIRCONIA CERAMICS FPD’S SIMILAR 3-YR SURVIVAL RATE TO METAL CERAMIC FPD’S
J Prosthet Dent 2006;96:237-44Raigrodski AJ, et al
100% RETENTION AT THREE YEARS PRECAUTIONS WITH SECOND MOLARS
Int. J Prosthodont; 2009; 22: 597 Wichan & Holst
Main Precautions
1. Patient Selection
2. Insure Thick Connectors
3. Facial Shoulder
4. No Lateral Interferences
5. Fine Diamonds – Reglaze
6. Slow Cooling Cycle
7. Zirconia – Veneer Interface
IV CERAMIC SELECTION
CRITERIA
Alumina / Zirconia . 1 Discolored Teeth
. 2 No Bonding Requirement
. 3 Need Adequate Thickness
. 4 Thinner Cores on Facial
CRITERIA
Etchable Crowns • 1 Best Translucency• 2 Reduced Facial Thickness• 3 May be Equigingival• 4 Plan Masking Strategy
DISCOLORATIONS&
SYSTEM SELECTION
1. CREATE BONUS SPACE
2. MATCHED PAIRS
3. INGOT SELECTION
4. AVOID EXCESSIVE TRANSLUCENCY
M. Roberts 2007
“The Common Denominator must NOT be the most discolored
tooth”
VOCCLUSAL
PRECAUTIONS
1. Test-Drive New Envelope.
2. Transfer Existing Guidance.
3. Custom Guide Table.
4. Half try-in when Feasible.
5. Passive Anteriors – No Fremitus
Static: 3 positions & Dynamic: Chew
6. Maintain Guidance if shorten.
DETERMINE ANTERIOR GUIDANCE
Protection Strategy
1. Assess Risk
2. Discover What they are Likely to do with their Teeth
3. Do not Put Teeth in the Way of Habitual Function and Envelope of Parafunction
J. Fondriest & M. Fling
… :
Move Tooth to
Safe Position First
…:
Shallower
Cuspid Guidance
For every 100 change in the angle of disclusion, there is a 35% change in force applied.
L. Weinberg
The flatter the angle of guidance, the lower the muscle activity.
G. Williamson J. Prosthet Dent 1983
T. Tanaka 2008
“…The resultant closure forces of the mandible are upward and forward. This produces a mesial force between the interproximals resulting in anterior
teeth more vertical and a constricted envelope…”
VIPORCELAINVENEERS
A 15-Year Review of Porcelain Veneer Failure A Clinician’s Observations
FRIEDMAN M.J.
COMPENDIUM. 19, 1998
FAILURES (7%)
1. FRACTURES
(67%)
2. MICROLEAKAGE
(22%)
3. DEBONDING
(11%)
Cervical Dentin + Heavy Occlusion
=
CONTROL FLEXURE
LONG-TERM BONDING
Canines Management
1. Contact Intensity 2. Contact Location
3. Steepness of Guidance
VIIPREPARATION
SYSTEM
. LVS 4 . LVS 3
. 8392 016
. 828 026
INCISAL REDUCTION
Unrestored Tooth
2 mm.
4 mm.
FRACTURE STRENGTH
31.0 Kg. (10.38 s.d.)
27.4 Kg. ( 9.63 s.d.)
19.2 Kg. ( 6.18 s.d.)
Fracture Strength and Failure Mode for Different Ceramic Veneer Designs.
Castelnuovo J. et al. J. Dent. Res. 77; Abstract 1373
Longevity and Failure Load of Ceramic Veneers with Different Preparation Designs after
Exposure to Masticatory Stimulation
C. F. J. Stappert et alJ. Prosthet. Dent. 2005, 94, 132-139
“Maxillary restored with the 3 types of IPS Empress 1 Veneers showed
fracture resistance similar to that of unprepared incisors …”
VIIIVENEER SELECTION
Permanent Diagnostic Provisional Restorations for Predictable Results when Redesigning the Smile.
G. Gurel, N. BichachoPract Proced Aesthet Dent 2006; 18 (5)
Conservative Aesthetic Enhancement of the Maxillary Anterior Using Porcelain Laminate Veneers.
J.M. Lerner Pract Proced Aesthet Dent 2006; 18 (6)
Making a Six-Unit Smile Design “Disappear” in the mouth
using feldspathic porcelain B. Jones
Jrl. Cosmetic Dentistry 2007, 22 (4)
Pressed vs. Feldspathic Veneers
1. P Combination with Crowns.
2. P Complex Occlusal Rehabs.
3. P Better Cost.
4. F Better Esthetic.
2. F More Conservative, No Prep.
3. F Contact Lens Effect, Varying Trsl
IXSHADING SYSTEM
Efficacy of a computerized shade selection system in matching anterior metal-ceramic crowns. A double-blind
clinical pilot study.
A.J. Raigrodski & G.J. Chiche.
2004
Cervical Shade
Basic Shade
Incisal Shade
Mix ColorsTwo Tabs
SHADING EFFECTS CHECKLIST
HALO
TRANSPARENT
STREAKS
PROXIMAL CLEAR
Incorporate
for Natural - Driven
Soften or Eliminate
for Perfect - Driven
Incisal Effects
A1 B1 1M1 0M3 0M2
NW05 NW0
BL3 BL2
PW4 PW7
Bleached Shades
XCLINICAL
VARIATIONS
Set Goals
. Increase Brightness
. Increase Length
. Fuller Smile
INCREASE FULLNESS
1. Set Perpendicular Relation
+
2. Check Harmony with Lip
1. Mock-up for Length 2. Wax-up for Fullness 3. Instant Mock-up
4. Show First on Screen !
5. Preparation Guide
7. Verify Gingival Levels
INCREASE LENGTH and FULLNESS
6. Always Augment
1. Preop. Silicone Impression 2. Undercontour Cervical Wax 3. Duplicate Wax-up, Pour Model 4. Score Cervical with Cleoid
5. Spot Etch & Bond Preps
7. Trim with ET3, ET4 & #12
VENEER PROVISIONALS
6. Fill Matrix with Bis-Acryl
Base of Proximal Presence of
Contact to Bone crest Interdental Papilla
5 mm 98%
6 mm 56%
7 mm 27%
The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla
D. Tarnow et al 1992
“… Results showed a mean distance of 4.33 mm. between the
location of the gingival margin post-treatment and the bone level
during surgery…”
Regeneration of the Interdental Soft Tissues Following Denudation Procedures
U.Van Der Velden 1982
PAPILLA HEIGHT
Healthy Papilla = 5 mm.
Healing Papilla = 4 mm.
J. Kois
1. Short Papilla < 4 mm
2. 4 mm Esthetically Acceptable
3. Healing from Trauma
PAPILLA “COME BACK”
3 QUESTIONS
3. Unilateral Pair
D. Tarnow 2004
1. Maximize Symmetry
2. Special Effects
Unilateral Pair
1. Select Cantilever
2. Forced Eruption
3. Sequential Placement Interimplant Papilla Preservation in the Esthetic Zone. Report
of six consecutive Cases J. Kan, K. Rungcharassaeng
Internaltional J. Perio Restor Dent 2003; 23 (3)
Forced Eruption
“…0.5 mm to 1 mm. per month of eruption and then maintain this position 1 month
for each millimeter of coronal movement…”
Advanced Esthetics & Interdisciplinary Dentistry 2006; 2 (3)
XIBONDING UPDATE
REALITY RATING
LIGHT CURE DUAL CURE LIGHT CURE ONLY
1 . INSURE / INSURE LITE
2 . NX3
2. VARIOLINK II
3. VITIQUE
4. LUTE-IT!
5. CALIBRA
2009
1 . RELY X VENEER CEM.
2 . VARIOLINK VENEER
3. DA VINCI
4. ACCOLADE PV
5. CHOICE 2
Clear
White (Thin Veneers)
Influence of post-etching cleaning and connecting porcelain on the microtensile bond strength of composite resin to feldspathic
porcelain. P. Magne and D. Cascione
J. Prosthet Dent. 2006; 96:354
8 Authentic Block pairs all air abraded and etched with HF
“…Omission of the post-etching cleaning resulted in more than 50% loss in bond strength
BONDING PRECAUTIONS
1. Rubber Dam 2. Glistening Preparation 3. Agitate Primers 4. Evaporate Solvent
J. Burgess 2005
XIIPROTECTION
STRATEGY
1. MIP coincident with CR2. Night-time Appliance3. Envelope of Function4. Custom Guide Table5. Dentin Bond Technique6. Porcelain Selection7. Incisal Extension
Functional Considerations
Three-Dimensional Assessment of Dental Occlusion. (Occlusal Fencing) A Clinical Technique.
N. Mehta, E. Abdallah et al , Advanced Esthetics & Interdisciplinary Dentistry. 2006
Clinical Case Report. Anterior Wear: Orthodontic and Restorative Management.
J. Kois, B. Filder. Compendium, 30; 7: 420 September 2009
Deep Bite
Over-retracted
Bulky Crowns
Misalignment
Retrusion
Restricted Envelope
S. Ratcliff
2. Crowns with Proper envelope
3. Reposition Teeth before Veneers
4. Restore or Increase VDO
5. Occlusal Guard
Optimize Anterior Guidance
1. Constriction Involved ?
THANK YOU