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SMILE DESIGN, ESTHETIC MATERIALS, BONDING
UPDATE
GEORGIA DENTAL COLLEGE
All-Ceramic Crowns, Veneers & Bonding Update
Techniques and principles reviewed in this all-dayprogram 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
I
ESTHETIC DESIGN
Upper Lip Line
Lower Lip Line
Treatment Plan from Incisal Edge Up
ESTHETIC PRIORITIES ESTHETIC CHECKLIST
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1. PROPER LENGTH
2. INCISAL PROFILE
3. SMILE LINE DESIGN
4. TOOTH PROPORTIONS
Kinetics of Anterior Tooth DisplayVig , Brundo 1978
Dynamics of the Maxillary IncisorDickens , Sarver, Proffit 2002
I. Pleasing Display
1. Male Pt. 0.5 - 2 mm.
2. Female Cons. 2.0 - 3 mm.
3. Female Spark. 3.5 - 4.5 mm.
Treatment PlanFrom Incisal Edge UP
Central LengthShort Face: 10.0 mm.Medium Face: 10.5 mmLong Face: 11.0 mm & up
WAX-UP at KNOWN LENGTH
Diag. Cast 1 Diag. Cast 2 II. Incisal Profile
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TEAM FOUNDATION
VERIFY INCISAL LENGTH & PROFILE
CONVEX
FLAT
CONCAVE
TOO CONVEX
Amy & AramIII. SET SMILE LINE
CONVEX
FLAT
CONCAVE
RECORD LOWER LIP SHAPE !
CANINES & BICUSPIDS DESIGN
Dr B. Kadashta & Mr V. Tran
Eliminate Lateral Working Interference
1. Shorten Cusp Tip
2. Steepen Canine Guidance
3. Group Function
4. Move Cusp Tip Laterally
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MOVE BUCCAL CUSPS LABIALLY = LESS INTERFERENCES LESS INTERFERENCES, MORE LENGTH,UPRIGHT BICUSPIDS = LESS WEAR
IV. SET PROPORTIONS
10 mm. L
7.5-8.0 mm
11 mm. L
8.5-9.0 mm
Rule: When Set Proportions
Optimize Canine Guidance Patient’s Expectations – Reduce Gummy Smile & Porcelain Veneers
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Priorities
• CEJ Location Veneer Extent.
• Gal Margin – Bone Crest Gingivectomy > 3 mm.
• Root Length Bone Resection.
1. WHERE IS THE CEJ ?
Priorities
• CEJ Location
• Gal Margin – Bone Crest
• Root Length
3 mm RULE
GINGIVECTOMY : ONLY if > 3 mm. Preop.
LOW PREP VENEERS
Intrusion vs. Crown Lengthening
1. CEJ Location 2. Root Length 3. Type of Restoration
EX3CEJ Level = Maximum Veneer Extent
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8 and 9 : 8.5 mm.7 and 10 : 6.5 mm.6 and 11 : 7.5 mm. *
S. Chu2007
54 patients16-72 years
Relative Width Mesial of CaninesCompensates
Dr M. Tadros & Mr. S. Im
GINGIVAL ALTERATIONS ALTER ABUTMENT CONTOURS
1.5 mm.
M. Redmagni et alSoft Tissue Stability with ImmediateImplants and Concave AbutmentsEuropean J. Esthet Dent 2009: 4 - 4
H. Su et alConsiderations of Implant Abutment and
Crown Contour: Critical & Subcritical ContoursInt J. Perio Restorative Dent 2010: 30 - 335
I. SET INCISAL LENGTH
II. SET INCISAL PROFILE
I. SET INCISAL LENGTH
II. SET INCISAL PROFILE
RULE: MAXILARY INCISORS CONTROLMANDIBULAR INCISORS POSITION
Interdisciplinary Treatment
Axial Inclination
Rule: Maxillary Incisors Set-up Dictate Mandibular Incisors Plan
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Implant Restorations Goals
1. Proper Sagittal Inclination
22. Incisal Porcelain Thickness
3. Moderate Anterior Guidance
INCISAL EDGESUPPORT
INCISAL EDGESUPPORT PASSIVE FIT !Dr M. Tadros & Mr A. Torosian
If Cut-Back Must Support All Incisal Edges
All Zirconia & Emax Cases
Dr. A. Orta & Mr. A. Torosian
0
40
80
120
160
200
Zirconia Enamel Nano comp.
polished
Ghanta H, Ozer F, Yi Y, Irmak O, DiRienzoJ, Blatz MB.Effect of wear on bacterial adherence to material surfaces.
IADR 2015 Abstract 2150.
Me
an
ba
cte
ria
co
un
t
Bacteria countbefore and afterdual axis wear with220,000 cycles at 49 N
S. gordonii on polished surface
S. gordonii on worn surface
Enamel highest bacteria count to both surfacesZirconia lowest bacteria count
B A C T E R I A LA D H E S I O N
Need Polished Subgingival Zirconia
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V. PERFECT vs NATURAL
1. POINTED CANINES
2. ASYMMETRIC LATERALS
3. INCISAL EMBRASURES
4. COLOR GRADIENTS
PERFECT vs PERSONALIZED
• 1 Emax (No Discoloration)
• 2 Lower Incisors
• 3 Thin Teeth, Large pulps
• 1 Zirconia (Layered)
• 2 Emax Discoloration ++
• 3 PFM
Glass Ceramics• 1 Best Translucency
• 2 Reduced Facial Thickness
• 3 Convenient & Versatile
• 4 Combines with Veneers
• 5 Plan Masking Strategy
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Crowns
Onlays
VeneersDr S. Dang & Mr A. Torosian
26.8
33.6
SB Univer UnetchedSB Univer etched
Single Bond Plus
Significance difference in enamel shear bond strength (p.<05) with SB Universal
SB Universal NO ETCH SB Universal WITH ETCH
SINGLE BOND PLUS WITH ETCH
Courtesy Dr. John Burgess
SELECTIVE ETCH
1. Diastema2. Proximal Composites3. Space Management4. Rotated Teeth / Crowding5. Black Hole / Short Papilla
4. Anterior ¾Veneer
BEST Veneer Prep if Black Holes and SHORT Papillae
Anterior ¾Veneer
5. Labial Extension Onlay
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Labial Extension Onlay
NO ENAMEL PERIPHERY = NO ONLAY
Lower 1st MolarMost Severe
Soda-Swishing
Cupping/Cratering
Smooth Lingual Wearof Upper Anterior
Regurgitation
Abrahamsen TC, Inside Dent 2011;10:38-50
Erosion
Even Posterior WearUpper & lower
Fruit-Mulling
Cupping/Cratering
Chewable Vit. CAsthma Spray
Chlorine
Less Frequent
Safety of Increasing Vertical Dimension of Occlusion: a Systematic ReviewJ. Abduo. Quintessence Int 2012
• Magnitude Maximum 5.0 mm. Meas. Anteriorly. Gough, Dahl, Ormanier.
• Patient Adapts Resolution 1-2 weeks (2 days - 3 mo.) Carllson, Rivera, Abekura, Tryde
• EMG Activity Back to pre-treatment levels 2 -3 mo. Carllson, Dahl, Gough, Manns.
• Relapse Unknown, Relatively Stable. Gough, Dahl, Ormanier.
EMAX REQUIRED OCCLUSAL THICKNESS1.5 mm. Minimum Adequate if Luted (RMGI)
M. Kern et al. JADA 2012 143; 3: 234
Fracture Strength of All-Ceramic Restorations after Fatigue LoadingB. Baladhandayutham, P. Beck, M. Litaker, D. Cakir, J. Burgess.
AADR 2012 Abstract # 24
REQUIRED OCCLUSAL THICKNESS
1465
2025
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Dr S. Aimplee & Mr A. Torosian
EMAX REQUIRED OCCLUSAL THICKNESS1.0 mm. Sufficient if Adhesively Bonded
(Ivoclar – Vivadent 2016) “One Wing”
AlvaroEsthetic Fellow
Cantilever Connector SizeLiSiO2 H. 4.0mm X 2.0 mm Tsitru 2012
LiSiO2 H. 3.6 mm X 2.8 mm Sun 2013
Emax Connector Size
4 X 3 = 12 mm² Total Size Kern 2012
Dr S. Dang & Mr S. Im
Glass Ceramics
• 2 Reduced Facial Thickness
• 3 Moderate Discolorations
• 4 Bonded Crowns, Veneers, Onlays(Occasional FPD’s)
• 1 Best Translucency
Glass Ceramics
• 2 Reduced Facial Thickness
• 3 Moderate Discolorations
• 4 Bonded Crowns, Veneers, Onlays(Occasional FPD’s)
• 1 Best Translucency
Maximum Translucency
BONDED1. CROWNS2. VENEERS3. ONLAYS(Occasional FPD)
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MicrostructureLi2Si2O5
• The microstructure of the pressable lithiumdisilicate material consists of approximately70% needle-like lithium disilicate crystalsembedded in a glassy matrix. These crystalsmeasure approximately 3 to 6 µm in length.
When do we Cement?1. Retentive Preparation2. Sufficient Occlusal Thickness3. Porcelain is Strong Enough
When do we Bond?1. Lack of Retention - Resistance2. Thin Occlusal – Lingual Area3. Need to increase Strength
BURGESS
Full Strength (3Y-TZP)
Dr. S. Arias & Mr. A. Torosian
CEMENTED1. SINGLE UNITS2. FPDs3. SCREW-RETAINED
ZenoStar MO Zirconia
MAXIMUM BITE FORCE
• 500 N
• 700 N
• 1000 N
Monolithic Zirconia Crowns
Thickness Fracture StrengthThickness Fracture Strength
0.8 mm. J Lee 2007 (N/A)
1.0 mm. G Jang 2011 (3216 N)
1.0 mm. S Jang 2013 (1780 N)
1.0 mm. C Johanson 2013 (2795 N)
1.0 mm. S Ting 2014 (2429 N)
Thickness for Safety 1.0 mm. and aboveTooth Reduction 1.0 to 1.5 mm.
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When do we Cement?1. Retentive Preparation2. Sufficient Occlusal Thickness3. Porcelain is Strong Enough
When do we Bond?1. Lack of Retention - Resistance2. Thin Occlusal – Lingual Area3. Need to increase Strength
Monolithic Zirconia High-Strength Minimum Thickness
Margin of Safety: 0.8 mm. Acceptable, 1.0 mm. Ideal
a
Courtesy Dr. J. Burgess
Monolithic Zirconia High-Strength Minimum Thickness
Margin of Safety: 0.8 mm. Acceptable, 1.0 mm. Ideal
Courtesy Dr. J. Burgess
Consecutive Case Series of Monolithic &Minimally Veneered Zirconia
Restorations on Teeth & ImplantsUp to 68 Months.M. Moskovich 2015
Long-Term Retrospective Dental Laboratory Survey of Zirconia-Based CrownsIADR 2010 Abstract # 148370, 2011Raigrodski A., Dogan S., Englund G.
Performance of Zirconia Based Crowns and FPDs in Prosthodontic PracticeIADR 2010 Abstract # 40705, 2010
Nathanson, Chu, Yamamoto, Stappert,C.
Clinical Comparison of Zirconia, Metal, Alumina Fixed-Prosthesis FrameworksVeneered with Layered or Pressed Ceramics: A Three-Year Report
J. Am. Dent. Assoc. 2010;141;1317-1329R. P. Christensen, B. J. Ploeger
Clinical survival of posterior zirconia crowns in private practiceIADR 2010 Abstract# 134121
Blatz M, et al
Recommended Body Firing Temperature
Cerabien CZR 930 – 940 Deg. CVita VM9 910Wieland Zirox 900 – 930
“…CZR Press veneer ceramic for zirconia was theexception with a performance comparable with
that of veneer ceramics for metals…”Courtesy Dr. J. Burgess
Gloss of Polished Zirconia
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Best diamondcutting
measured
Komet ZR 6881
Courtesy Dr. J. Burgess
Particle Size
Fonseca, R.G., Abi-Rached, F.O., Reis, J.M.S.N., Rambaldi, E., and Bldissaram P. (2013). Effect of particle size on the flexural strength and phase transformationof an airborne-particle abraded yittria-stabilized tetragonal zirconia polycrystal ceramic. Journal of Prosthetic Dentistry, 110, 510-514.
Song, J.Y., Park, S.W., Lee, K., Yun, K.D., Lim, H.P., (2013). Fracture Strengthand microstructure of Y-TZP zirconia after different surface treatments.
Journal of Prosthetic Dentistry ; 110: 274-280.
Full-Strength Zirconiafor
All Fixed Partial Dentures
Katana HTML / CZR
Dr. M. Silva & Mr. S. Im
9.0 mm² Post. FPD 1 Pontic7.0 mm² Ant. FPD 1 Pontic
12.5 mm² Post. FPD 2 Pontics
6.0 mm² Ant. Cantilever
Tsitru, 2012, Kern 2012, Sun 2013
Zirconia Connector Size
Raigrodski, 2006, Larrson 2007, Studardt 2007, Zasse 2012,
Edentulous Maxilla - Fixed Restorative Options
1. Fixed Hybrid: Economical, Practical, Versatile.
2. Full Zirconia: Additional Strength for Bruxer.
More Esthetic.
More Color Stable.
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PROVIDE OCCLUSAL GUARD !
Drs J. Kim, J. Londono, C. Susin & Mr A. Torosian
PROVIDE OCCLUSAL GUARD
OPPOSING EDENTULOUS MANDIBLE = METAL-ACRYLIC HYBRIDDr A. Blasi & Mr A. Torosian
INCISAL EDGE DESIGN
Dr A. Blasi & Mr A. Torosian
88
zirconia
copy-mill
All Incisal Edges in Zirconia At Least 2 mm. ZirconiaAround Screw Channel
PROTECTION DESIGN
1. Zirconia Functional Areas & Inc. Edges.
2. Occlusal Guard Mandatory.
3. Mandibular Opposing Hybrid.
4. Min. 2 mm. around Screw Channels.
5. Maximize Incisal Edge Thickness.
6. Provide Shallow Anterior Guidance.
7. Maximum Cantilever Length 7-9 mm.
DJ. Londono & Mr A. Torosian
• 1. Esthetics with More Strength i.e. Bruxer.
• 2. Cement versus Bonding for Simplicity, Esp. if gingivitis or deep margins.
• 3. Monolithic and milling reduce Cost.
The Journal of Cosmetic Dentistry April 2016
Translucent Zirconia(Maximize Thickness, Case selection)
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Translucent Zirconia Brands Vary in StrengthCourtesy Drs. N. Lawson & J. Burgess
1. Type of Zirconia - Not High Strength
2. No Passive Fit - No Verification Jig
3. Working Contacts - Group Function
FRACTURE CAUSES
4. Zirconia Thickness around Screw Channel
Alumina Yttrium to stabilize cubic phase
Cubic phase Content does not TransformTetragonal ZrO2 Resists Crack Propagation
Tetragonal ZrO2
1170°C-2370°C
Cubic ZrO2Above 2370°C
From : Zirconia as a ceramic biomaterial C. Piconi, G. Maccauro Translucent Zirconia
Zirconia classified - 3, 4, 5 mole% yttria continuum (Courtesy Dr. J. Burgess)
Opaque-3%-1000-1400 Mpa Less opaque- 4% Translucent - 5%
Lava Frame (3M) Lava Plus Lava Esthetic
Katana HT ML(Kuraray) Katana STML Katana UTML
Bruxir (Guidewell) Bruxir Anterior
ZirCAD LT & MO (Ivoclar) ZirCad MT Multi & MT
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•
Kwon, D N. Lawson, E. McLaren, A. Nejat J.O. Burgess 0.8mm thickness,
1194
737 688460
Katana HT Katana ST Katana UTML e.max0
200
400
600
800
1000
1200
1400
Flexural Strength
Flexural Strength
TRANSLUCENT ZIRCONIA = ESTHETICS WITH MORE STRENGTH
Hybrid Workflow for Monolithic Zirconia
1 2 3
4Overview of Steps: No Pressing, No Layering
Katana STML MonolithicDr. J. Londono & Mr. S. Im
TRANSLUCENT ZIRCONIA: ESTHETICS WITH MORE STRENGTH & MONOLITHIC (Better Lab. Cost)
MARGINAL GINGIVITISDEEP MARGINS
=MORE CONVENTIONAL
CEMENTATION
IF WANT TO CEMENTMEASURE THICKNESS
FIRST
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1. Minimum Wax Up on Occlusal SurfacesUncovered Areas =Vertical Stops 2. Etch Every Other Tooth H3PO4 – HF on Porcelain (W. Hall)
3. Bond and Load Clear Matrix with High-Filler Load Flowable Composite 4. Small Vent Holes Over Lingual Cusps Minimize Excess on Adjacent Teeth
5. Split Clear Silicone Matrix at Mandible to Facilitate Isolation New VDO After Occlusal Refining – Ready for Quadrant Work
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1. Prepare Anterior Teeth 2. Complete & Bond Anterior Crowns 3. Prep. & Complete Posteriors
Composite Buildups Hold VDO Ceramic Crowns Hold VDO
Margin Line Offset - set to .20
Komet94009
NoritakeSD-61
e.max
4-YTZP Translucent Zirconia
Marko Tadros DMD - USA
• Ceramics SelectionTranslucent Zirconia.
• Crown DeliveryCemented 6-11.
• AdvantagesBlock Discolorations.
• RequirementsAdequate Thickness.
Dr. M. Tadros & Mr. A. Torosian
ESTHETICS WITH 1. MORE STRENGTH 2. MONOLITHIC 3. MORE CEMENTATION
Relationship between bond-strength tests and clinical outcomesB. Van Meerbeek et alDental Materials 2010
Ca-10-MDP salt
WEBBED PROPHY CUP SMALL PARTICLE ABRASION
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MDP BONDS TO CA & PROVIDES STABLE BOND20 Seconds MILD DENTIN DEMINERALIZATION
“ Ca-10-MDP salt is one of the most hydrolyticallystable salts” (Perdigao 2013)
Emax Bonding
BOND TWO CROWNSAT A TIME
Lithium Disilicate Crowns
FLOSS INTERPROXIMAL FIRSTLIGHT-CURE 1-2 SECOND / Tooth
PEEL OFF & FLOSSLIGHT-CURE 1-2* SECOND
Light Cure 1-2 Sec.
Clean Excess
Floss Interprox.
ASAP
Apply Heavy GlycerineIf Bleeding Finish Flossing
Remove Cord
Verify No Cement Light-Cure
20 sec. +
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SIMPLICITY
ZIRCONIA1. Resin Ionomer2. Resin Cement if Need
More Retention
Courtesy Dr. John Burgess Crown RetentionNewtons
493
431385
411
346
SELF-ADHESIVE RESIN CEMENTS
1. RELYX UNICEM 2
2. PANAVIA SA CEMENT *
2. ABSOLUTE
3. BISFIX SE
3. BREEZE
REALITY RATINGS* November 2013
0.00
5.00
10.00
15.00
20.00
Max Unic Unic Ap BC Pan SA
In vitro comparative bond strength of contemporary self-adhesive resincements to zirconium oxide ceramics with and without air-particle
abrasion.
Clinical Oral Invest 2010;14:187-92.Blatz et al.1. SANDBLAST
Efficacy of silane after thermal-fatigue on bond-strengths degradation to zirconiaJ. Phark et al. Abstract 640, AADR 2012
2. PRIMER
Zirconia S-C-P
Saliva IVOCLEAN MDPSaliva AL-OX MDP
2. ZIRCONIARMGI LUTING Preferred !
zirconia
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6
Abutment Connection 2 weeks 4 weeks 6 weeks
Increase Cervical Profile
Bonding Zirconia = S-C-P
Saliva IVOCLEAN MDPSaliva AL-OX MDP
BONDING ZIRCONIA zirconia
Bonding Zirconia = S-C-P Bonding e.max = HF-P
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PREPARATION SYSTEM
828 - 026 LVS 3 – LVS 4 8392 - 016
I
Classic Preparation
Main AdvantageIntra-enamel Most of Times
0.3 mm.
0.5 mm.0.6 mm.
R. Winter 2011 NO DISCOLORATION
0.5 mm.
0.7 mm.0.8 mm.
MODERATE DISCOLORATION
I
Classic Preparation
Potential to Expose DentinWhen Thin Enamel
Or if Need Deeper Prep
Incisor Compliance Following Operative ProceduresRapid 3-D Finite Element Analysis - Micro-CT Data
P. Magne & D. Tan J. Adhesive Dent. 2008
50 N Load50 N Load
100% Removal Facial Enamel = 91% Flexure Increase
Natural Tooth Veneer Preparation
“Low-Prep” Veneers = Undersized + Retrusive Incisors
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Dr A. Camba, E. Bailey & Mr S. Im
Lower Lip Tolerates Additive Treatment
Additive & Low Veneer Preps Advantages.Provides Maximum Enamel!.Increases Veneer Strength.
Precautions.Need Additive Wax-up..Needs Precise Technique..Needs Esthetic Try-in
SILICONE INDEX
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BUR 8392 – 0.16
1
2
3
4V
“Low- Prep” Veneer
Advantages. Minimum / No Enamel Reduction!
Precautions.Need Room for Line Angles.
.Need Room for Labial Embrasures.Needs Esthetic Try-in
Additive Mock-upAdditiveWax-up
Harmony with Lower Lip
Incisor Compliance Following Operative Procedures Rapid 3-D Finite Element Analysis with Micro-CT DataP. Magne & D. Tan J. Adhesive Dent. 2008
100% Removal Facial Enamel = 91% Flexure Increase
50 N LoadLOW Flexure Case
Low Flexure Case
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REALITY RATINGLIGHT/ DUAL CURE
1 . INSURE / INSURE LITE
2 . NX3
2. VARIOLINK II
3. VITIQUE
4. LUTE-IT!
5. CALIBRA
LIGHT CURE ONLY1 . RELY X VENEER CEM.
2 . VARIOLINK VENEER
3. DA VINCI
4. ACCOLADE PV
5. CHOICE 2
Clear
White
Clear
White
(Thin Veneers)
THIN VENEERS
(B 0.5 or TR)
THIN VENEERS
(B 0.5 or TR)
VENEER CEMENT SELECTION
2. Tissue Health
Sticky Viscous Cement Da Vinci
Low Viscosity Cement Rely Veneer
1. Thin vs. Thick Veneer
3. Number of Veneers
BONDING PRECAUTIONS
1. Microblast or roughen Dentin
2. Retraction String
3. Cure 5th Gen. Adhesive separately
Cure First Cure First
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BONDING VENEERS
1. Etch 2. Adhesiveon Dentin
LIGHT-CURE 3. Adhesiveon whole prep
SEAT VENEERLIGHT-CURE
THIN ADDITIVE LAYER RECHECK LOWER LIP !
RECHECK HARMONY with LOWER LIP !
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D. Layton2012
G. Gurel2013
S. Rinke2012
A. Walls1995
D. Layton2013
M. Friedman1998
M. Fradeani1998
• Intra-enamel prep. > 80%
• Exposed Dentin Prep. > 50%
Feldspathic 96% 10 yrs93% 15 yrs91% 20 yrs
Pressed 98% 5-12yrs
Feldspathic 86% 5 yrs
Pressed 93% 3 yrs
Flexural Strength
0,0
20,0
40,0
60,0
80,0
100,0
120,0
140,0
Stru
ctur
Premium
Experim
entalProtemp
Acrytem
p
Kan
itemp
Roy
al
Integrity
Fluores
cenc
e
Luxatemp
[MPa]
Relative Fracture Toughness of Bis-Acryl Interim Resin MaterialsKnobloch et al , J. Prosthet Dent 2011; 106: 118
Marko Tadros, DMDJimmy Londono, DDS
A. DIRECT TECHNIQUE – SHRINK WRAP
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Additive Veneer Preparation
Dr M. Tadros & Mr A. Torosian
Limited Treatment – Level I
• Veneer Ceramics Lithium Disilicate
• Bonding Substrate Maintain Enamel
• Available Thickness Augment Labial Volume
• Required Compliance Occlusal Guard
• Difficult Cases Test Drive w. Composites
CONTROL of ONE-ARCH
1. Adjust VDO
2. Gain Space
3. Increase Length
4. Improve Overbite
5. Reduce Anterior Force
Limited Treatment – Level II
For every 100 change in the angle of disclusion, thereis a 35% change in force applied.
L. WeinbergInt. J. Prosthodont. 1998; 11: 55
15 Deg.=
50%
Somkiat & Bin
Emax
Comprehensive Treatment – Level III
• Restorative SpaceMore room – Less Prep
• Reduce Vertical OverlapGenerate Overjet
• Level Occlusal PlaneLess Interferences
• Esthetic ContinuityFront-to-back
po
sto
p
VDO Decision – 4 Questions
Dr. S. Aimplee & Mr. S. Im
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© Bite FX1. Shallow Guidance 2.Adjust Chewing pathway Until Patient Comfortable
Final Guidance Comfortable & Less Steep than Planned …Or
3. Group Function
Drs A. Camba, J. Kim & Mr A. Torosian
Group Function Indications
1. Weak or Mobile Canine
2. Canine Implant
3. Patient Does not tolerate
Canine Guidance
Canines Rule
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DESIGN CANINES UPRIGHT and LESS CONVERGENT
Dr. S. Arias & Mr. A. Torosian
RESTORE CANINE GUIDANCE
with Canines Upright & less Convergent
Parallel to Cheek Planes
Botulinum Toxin Injections Effect on Bruxism
Dr. M. Stevens
• Tinastepe N. Cranio (14) 2014• Long H. Int Dent J (62) 2012• Lee SJ. Am J Phys Med Re (89) 2010• Hoque A. NY State Dent J. (75) 2009• Monroy PG. Spec Care Dentist (26) 2006• Tan EK. J Am Dent Assoc. (131) 2000
Reconstruction Checklist
1. EstheticsOptimize Maxillary Esthetics.Optimize Gingival Levels.
2. FunctionProvide Restorative Space.
Set VDO.