Esthetic rehabilitation of a complex clinical case

A case report by Dr Mirela Feraru, Stefano Inglese, Dr Galit Talmor and Prof. Dr Nitzan Bichacho
A 55-year-old female would like her smile to look more beautiful. The solution: esthetic veneers in the entire maxillary area. Experience the rehabilitation of this complex case and immerse yourself in the clinical and technical workflows from start to finish.
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The patient

Name: Valerie
Age: 55 years
Country: Israel
 
Valerie is a 55-year old woman from Israel. She has been unhappy about her smile for as long as she can remember and this is why she would like it to be improved.
Valerie has already undergone several treatments. The last treatment was abandoned prematurely to avoid the devitalization of her teeth and the associated need for root canal treatment and even further reaching therapies.
Valerie is frustrated. All she wants is a solution that will work for her. In other words, a solution that is
  1. highly esthetic,
  2. works reliably and
  3. will be long-lasting.
A demanding and thrilling task for the treatment team!
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The operators

Dr Mirela Feraru

Dr Mirela Feraru

Mirela Feraru, DMD, graduated in 2005 from the Dental Faculty of the Timisoara University in Romania. In 2009, she joined the Bichacho Clinic in Tel Aviv. For the last eight years, she has gained in-depth knowledge and experience in the fields of perio-prosthetics and esthetic dentistry, focusing on restorative and perioplastic surgical treatments. She continues expanding her knowledge and participating in advanced programs and courses in various fields of modern perio-prosthetics. In addition, Dr Feraru is an expert in high quality dental photographic documentation and shares her photographic skills with colleagues in articles, lectures and workshops across the globe.
Dr Feraru has published international articles on adhesive restorations, interdisciplinary state-of-the-art concepts in perio-prosthetics and high-end treatment-dedicated dental visualization. On the latter topic, she has authored a book, published by Quintessence Publishing.
Prof. Dr Nitzan Bichacho

Prof. Dr Nitzan Bichacho

Nitzan Bichacho, DMD, holds the post of expert in prosthodontics at the rank of Professor, at the Faculty of Dental Medicine of the Hebrew University and Hadassah, Jerusalem, Israel.
He is a Faculty Member of the Departments of Oral Rehabilitation of both dental facilities at the Hebrew University in Jerusalem and at Tel Aviv University in Tel Aviv, Israel.
In addition, he is Past President and a Life Member of the European Academy of Esthetic Dentistry (EAED).
He serves on the editorial boards of leading dental journals. Prof. Bichacho is co-inventor of the Nobel Active System (Nobel Biocare) and the V3 Implant System (MIS/Dentsply) and other techniques and systems that have come to be widely used around the world. Prof. Bichacho is a popular international speaker in the fields of dental implant therapy, fixed prosthodontics and innovative treatment modalities in esthetic dentistry. His private practice in Tel Aviv focuses on interdisciplinary treatments, where he and his team collaborate with world-renowned dental technicians.
Dr Galit Talmor

Dr Galit Talmor

Galit Talmor, DMD, MSc, graduated from the Dental Faculty of the Hebrew University in Jerusalem, Israel, in 2003. She is a Faculty Member of the Department of Oral Rehabilitation of both dental facilities at the Hebrew University in Jerusalem and at Tel Aviv University in Tel Aviv, Israel.
Dr Talmor joined the Bichacho Clinic in Tel Aviv in 2005, and her focus is on prosthetic treatments with esthetic orientation, mainly adhesive restorative treatments with special emphasis on direct complex restorations.
Dr Talmor lectures locally and internationally, sharing her wide experience and knowledge.
She lectures and holds practical workshops in the field of prosthetic and restorative dentistry, focusing on direct and indirect composite restorations.
Stefano Inglese

Stefano Inglese

After completing his degree in Dental Technology, Stefano Inglese, MDT, pursued his strong interest in high-accuracy esthetic and functional production of dental restorations, concentrating on dental ceramics. Stefano Inglese has perfected his technique and precision in esthetics, function and biological integration due to this passion for the artistic and scientific aspects of his profession and the participation in numerous courses and work experiences with renowned master technicians and clinicians abroad.
He is the owner of a dental laboratory in Pescina, Italy.
In 2003, he won the second prize in the “Occlusal Compass” international competition for dental technicians and the first prize for the best scientific and photographic documentation. He is a member of Oral Design and is an active member of IAED (Italian Academy of Esthetic Dentistry).
Stefano Inglese writes for national and international dental publications, such as QTD (Quintessence of Dental Technology) 2012, 2014 and 2018 as well as for Quintessenz Zahntechnik. He and Dr Anthony Sclar contributed to the book “Interdisciplinary Treatment Planning II”, edited by M. Cohen. He lectures at international conferences and collaborates with internationally renowned clinicians in Italy and abroad. Stefano Inglese is the author of the book “Aesthetic Dental Strategies”, published by Quintessence Publishers in 2013 and currently available in Italian, English and Chinese with a Russian version coming soon.
Dr Mirela Feraru
Prof. Dr Nitzan Bichacho
Dr Galit Talmor
Stefano Inglese
Dr Mirela Feraru

Dr Mirela Feraru

See complete profile
Mirela Feraru, DMD, graduated in 2005 from the Dental Faculty of the Timisoara University in Romania. In 2009, she joined the Bichacho Clinic in Tel Aviv. For the last eight years, she has gained in-depth knowledge and experience in the fields of perio-prosthetics and esthetic dentistry, focusing on restorative and perioplastic surgical treatments. She continues expanding her knowledge and participating in advanced programs and courses in various fields of modern perio-prosthetics. In addition, Dr Feraru is an expert in high quality dental photographic documentation and shares her photographic skills with colleagues in articles, lectures and workshops across the globe.
Dr Feraru has published international articles on adhesive restorations, interdisciplinary state-of-the-art concepts in perio-prosthetics and high-end treatment-dedicated dental visualization. On the latter topic, she has authored a book, published by Quintessence Publishing.
Prof. Dr Nitzan Bichacho

Prof. Dr Nitzan Bichacho

See complete profile
Nitzan Bichacho, DMD, holds the post of expert in prosthodontics at the rank of Professor, at the Faculty of Dental Medicine of the Hebrew University and Hadassah, Jerusalem, Israel.
He is a Faculty Member of the Departments of Oral Rehabilitation of both dental facilities at the Hebrew University in Jerusalem and at Tel Aviv University in Tel Aviv, Israel.
In addition, he is Past President and a Life Member of the European Academy of Esthetic Dentistry (EAED).
He serves on the editorial boards of leading dental journals. Prof. Bichacho is co-inventor of the Nobel Active System (Nobel Biocare) and the V3 Implant System (MIS/Dentsply) and other techniques and systems that have come to be widely used around the world. Prof. Bichacho is a popular international speaker in the fields of dental implant therapy, fixed prosthodontics and innovative treatment modalities in esthetic dentistry. His private practice in Tel Aviv focuses on interdisciplinary treatments, where he and his team collaborate with world-renowned dental technicians.
Dr Galit Talmor

Dr Galit Talmor

See complete profile
Galit Talmor, DMD, MSc, graduated from the Dental Faculty of the Hebrew University in Jerusalem, Israel, in 2003. She is a Faculty Member of the Department of Oral Rehabilitation of both dental facilities at the Hebrew University in Jerusalem and at Tel Aviv University in Tel Aviv, Israel.
Dr Talmor joined the Bichacho Clinic in Tel Aviv in 2005, and her focus is on prosthetic treatments with esthetic orientation, mainly adhesive restorative treatments with special emphasis on direct complex restorations.
Dr Talmor lectures locally and internationally, sharing her wide experience and knowledge.
She lectures and holds practical workshops in the field of prosthetic and restorative dentistry, focusing on direct and indirect composite restorations.
Stefano Inglese

Stefano Inglese

See complete profile
After completing his degree in Dental Technology, Stefano Inglese, MDT, pursued his strong interest in high-accuracy esthetic and functional production of dental restorations, concentrating on dental ceramics. Stefano Inglese has perfected his technique and precision in esthetics, function and biological integration due to this passion for the artistic and scientific aspects of his profession and the participation in numerous courses and work experiences with renowned master technicians and clinicians abroad.
He is the owner of a dental laboratory in Pescina, Italy.
In 2003, he won the second prize in the “Occlusal Compass” international competition for dental technicians and the first prize for the best scientific and photographic documentation. He is a member of Oral Design and is an active member of IAED (Italian Academy of Esthetic Dentistry).
Stefano Inglese writes for national and international dental publications, such as QTD (Quintessence of Dental Technology) 2012, 2014 and 2018 as well as for Quintessenz Zahntechnik. He and Dr Anthony Sclar contributed to the book “Interdisciplinary Treatment Planning II”, edited by M. Cohen. He lectures at international conferences and collaborates with internationally renowned clinicians in Italy and abroad. Stefano Inglese is the author of the book “Aesthetic Dental Strategies”, published by Quintessence Publishers in 2013 and currently available in Italian, English and Chinese with a Russian version coming soon.

Direct or indirect? The agony of choice

A variety of treatment modalities are worth considering when creating adhesively bonded restorations in the esthetic zone:
  • direct composite restorations
  • indirect composite restorations
  • layered veneers
  • all-ceramic restorations made of lithium disilicate
The decision whether a direct or indirect modality should be used depends on a number of factors:
  • preserving the vitality of the teeth
  • amount of healthy tooth structure available
  • functional aspects
  • personal preferences
  • esthetic expectations
  • age
  • financial means
 

Direct restorative therapy: maximum conservation of tooth structure

Direct restorative therapies ensure maximum conservation of healthy tooth structure. This treatment modality is especially suitable for Class V, IV and III restorations and for elective minor shape and shade adjustments.

 

Indirect restorations: highly esthetic results

Indirect restorations provide highly esthetic final results due to the long-lasting optical characteristics and dimensional stability of the glass-ceramic materials used for these restorations. The final shape can be optimally controlled. This comes especially into play when large proportions of the teeth need replacing. Indirect procedures to provide patients with ceramic veneers are well documented and highly efficient. They enable predictable results. They can be considered the treatment of choice in cases where enough healthy tooth structure is available. Based on the classification by Magne and Belser, there are three main indications for ceramic veneers:
  • teeth that do not respond to whitening procedures
  • substantial morphological alterations
  • extensive restorative work in adult patients
Careful planning and accurate execution of each individual treatment step are essential to attain predictable high-quality results with veneers.

Planning the treatment steps

Detailed planning is key - especially in a complex patient case like the one presented here. A structured, well-thought-out approach is instrumental in obtaining the desired result, in which every part fits together perfectly.
For “Case Valerie”, the treatment team defined these six treatment steps:
  1. Esthetic analysis based on the clinical assessment and static photographic documentation of the preoperative situation and on dynamic video documentation
  2. Replacement of the defective composite fillings in the posterior region
  3. Refurbishment of the buccal corridor in the premolar region with glass-ceramic restorations (right and left)
  4. Replacement of the defective composite fillings in the anterior region and evaluation of the remaining tooth structure
  5. Guided ¾ veneer and crown preparation with the aim of improving the proportions and shapes of the teeth in the esthetic zone
  6. Adhesive cementation

Now see how the treatment team implemented these six steps in detail.

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First step: Esthetic analysis

As a first step, the clinicians carried out an esthetic analysis based on the clinical examination. During this process, they also captured static photographic documentation of the preoperative situation as well as dynamic video recordings.
 
After the clinical examination, the intraoral area was photographed in detail to optimize the basis for communication and facilitate the esthetic analysis. In addition, video recordings were taken. Documentation of the preoperative clinical situation included:
  • portraits,
  • anterior images of the lips in a relaxed position,
  • anterior images of the lips during smiling,
  • lateral images of the smile,
  • basic intraoral images and
  • 12 - o’clock view from above
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The conclusions and decisions made on the basis of the esthetic analysis are listed below. They were communicated to the lab with the help of a diagnostic wax-up.
  1. The upper right 1 served as reference for the length and shape of the anterior teeth. All incisal proportions should be adjusted accordingly.
  2. Reshaping of the upper right 3 – shortening the incisal edge
  3. Refurbishment of the premolar buccal corridor on both sides with the help of ceramic restorations (additive method)
  4. Replacement of all defective composite fillings

The diagnostic wax-up was created by the dental technician in line with the preoperative esthetic analysis.

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Second step: Replacement of the defective composite fillings in the posterior region

The dental treatment was started by replacing the defective composite fillings in the posterior region (on the right) that exhibited leaking margins and secondary caries. The upper right 3, 4, 5 and 6 were affected. The direct restorative therapy with composite enabled maximum preservation of healthy tooth structure. The treatment field was isolated as prescribed. A total-etch bonding technique was employed. The composite was built up from the outside to the inside.
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Third step: Refurbishment of the buccal corridor

At the third step, the practitioners refurbished the inadequate buccal cusps in the premolar region on the left and right with ceramic restorations.
Following the esthetic analysis, the upper right 4 and 5 were prepared with a slight chamfer, using a minimally invasive method. Hardly any tooth structure was removed due to the additive nature of the restoration. On the left side, a crown preparation was performed on the upper left 4 and an inlay preparation on the upper left 5.
The material used for the planned partial and full-contour restorations was IPS e.max Press lithium disilicate. The restorations were fabricated by Yuli Kuperstein, MDT, in Rehovot, Israel.
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After the treatment field had been adequately isolated, the restorations were seated using an adhesive technique.
 
Ceramic conditioning was performed with IPS Ceramic Etching Gel according to the manufacturer’s instructions. Residual salt crystals were removed with 5% hydrofluoric acid. Then, the restorations were cleaned in an ultrasonic bath with alcohol for one minute. Subsequently, Monobond Plus was applied to initiate the silanating process.
 
Conditioning the prepared tooth structure – Total-etch technique in conjunction with Adhese Universal prior to cementation with Variolink Esthetic LC and DC.
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Fourth step: Replacement of the defective composite fillings in the anterior region

At the fourth step, the practitioners proceeded to replace the defective composite fillings in the anterior region. In addition, they evaluated the residual tooth structure with a view to deciding on the correct further restorative procedure.
 
To create a healthy, solid foundation for the future ceramic restorations, all defective composite fillings were replaced with new restorations prior to veneer preparation. A translucent palatal silicone key was created with the help of the diagnostic wax-up. The silicone key served as a tool for the correct morphological and functional design of the composite build-up. At this point, the remaining tooth structure was examined and it was decided to provide the upper right 1 and the upper left 1 and 2 with ¾ veneers and the upper right 2 with a full-contour restoration.
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Already at this point, a clear improvement of the patient’s smile could be observed.

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Fifth step: Guided ¾ veneer and crown preparation

This step was about achieving new proportions and contours in the esthetic anterior region. To do this, the practitioners performed a guided ¾ veneer and crown preparation with the help of the silicone key.
 
In cases like this, where the labial plane of the future restorations matches that of the existing dentition, the preparation can be done without a mock-up. The amount of tooth structure to be removed can be controlled by using appropriately sized drills (0.3 mm or 0.5 mm).
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Subsequently, the preparation was checked with the help of the silicone key.

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Impressions were taken using polyvinyl siloxane and forwarded to the lab together with the clinical pictures.
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For better assessment of the brightness and chroma, additional images were taken with and without shade guide: in monochrome (black & white) and in standard colour (settings in the “image control” menu of the camera).

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The temporary composite restorations were fabricated directly at chairside with the help of the transparent silicone key produced from the diagnostic wax-up.

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Sixth step: Adhesive cementation

In the sixth and last step, the practitioners inserted the lab-fabricated restorations using an adhesive bonding technique.
The final ceramic restorations were fabricated by the dental technician, using IPS e.max Press LT ingots in the BL2 bleach shade in the press technique. The pressed restorations were then completed with IPS e.max Ceram in the layering technique. The individual steps done in the dental laboratory are explained in detail below.
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At the try-in, the accuracy of fit, shape and final brightness of the restorations were checked. Seating was accomplished with the light-curing Variolink Esthetic LC in shade Light+. The ceramic restorations were conditioned for adhesive placement according to the manufacturer’s instructions.
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After the treatment field had been isolated with a rubber dam and B4 dam clamps (Brinker), the veneers were seated using an adhesive method.

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A glimpse behind the scenes in the dental lab

Stefano Inglese covered the dental lab side in the anterior region for this case. Let us see what he has been up to.

Basic conditions: a shared philosophy and a common goal

Stefano Inglese considers the following points as essential to the esthetic, functional and biological success of dental restorations:
  • expertise
  • experience
  • proficiency in the use of the available technologies and materials
  • interaction and communication between the team members
  • shared work philosophy and a common goal
 
The technical and clinical stages are much easier to carry out if these requirements are met. Each clinical phase should simplify the laboratory phase, and vice versa.
“Dental technicians should be aware of the clinical concepts when carrying out their work,” Stefano Inglese points out. “This enables them to create dental restorations that respect and protect the biological structures.” From dentists, he expects: “Dentists should provide dental technicians with all the information they need to facilitate and expedite the steps in the lab and achieve more accurate results.”
 
Harmony and mutual respect are the key elements for this Italian Master Dental Technician to achieve optimum levels of collaboration for the benefit of the patients.

The steps in the dental laboratory

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First step: Checking the impression

As soon as the impression is received, it is checked under the microscope. This is the only way to see if an impression is accurate down to the smallest detail. Important:
  • The dental model - or the positive copy of the impression - should be an accurate reflection of the intraoral relations. For this reason, the technician should create the model with care to ensure that all details are reproduced accurately.
  • It is also important to minimize potential errors that may arise due to physical properties, such as expansion or shrinkage.
Any imperfections and inaccuracies occurring at this stage would decisively affect the accuracy of the final restoration.
 

Master model: The reduction and completion of the individual dies must be performed under the microscope (10- to 20-fold magnification) to make sure that none of the intricate structures become damaged or destroyed - especially not the margins.

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Second step: Reproducing the gingival tissues

A fundamental step was the subsequent reproduction of the soft tissues by means of a gingival mask, which would then serve as a reference for the cervical emergence profile of the dental restoration. In this way, the soft tissues will be adequately supported and protected and the gingiva will be prevented from undergoing an apicalization process.
 
Important: “Design, esthetics and appearance of gingival tissue strongly affect overall esthetics. Gingival and dental esthetics should be in perfect harmony, one supporting the other and together contribute significantly to the final appearance,” Stefano Inglese advises.


Soft tissues should be accurately reproduced by means of a gingival mask. This forms the basis for an accurate reproduction of the anatomically correct cervical contours and the emergence profiles of the restorations.

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“Every working step in the dental lab and every stage in the practice should be performed with a magnification system.
In my opinion, it is essential to use a microscope or loupes from preparation to impression taking, through to the laboratory phase and polishing up to the final try-in and seating phase in order to allow biological integration and pleasant esthetics of restorations.”
Stefano Inglese

Third step: Fabricating the framework

At this stage all the requisites and information required for fabricating the framework has been collected. This included a gingival mask and silicone key which were obtained by taking an impression of the temporaries in situ. These tools allow the monitoring of the emergence profiles and the clearances necessary for optimum support of the layering ceramic (IPS e.max Ceram) and help to forestall weak spots and possible chipping.


Wax pattern of the wax frameworks: The gingival masks and silicone keys, obtained from the diagnostic wax-up, are essential elements to achieve restorations with identical contours and volumes as the mock-up and the temporaries.

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If the press technique with lithium disilicate (IPS e.max Press) is used – as in the case described here – these points are essential:
  1. A deformation- and fracture-resistant wax pattern that reproduces the restoration down to the smallest detail is required. Here, a combination of soft and hard waxes is used. This gives stability and precision to the wax-up. The margins of the restorations are finished under the microscope (20- to 40-fold magnification).
  2. To be avoided: deformation of the wax pattern, in particular the thin marginal areas, when sprueing and relocating the wax pattern from the die to the investment ring and when pouring the investment material.
  3. Once the press procedure is complete, the restorations should be divested with care by blasting with glass beads (50 μm). First, use a pressure of 4 bar (58 psi) and then reduce it to a maximum of 2 bar (29 psi) near the thin margins. Protect delicate margins with your fingertip.
  4. Check and adapt the structures under the microscope at a 20- to 40-fold magnification. This is the result you need to obtain to achieve a restoration that can be called accurate and suitable for integrating into the biological environment.


The margins of the waxed restorations should be adapted under a microscope to be able to take into account every last detail. Important: When sprueing and investing the wax pattern, care should be taken not to destroy the details that have been created so minutely.

Marginal fit of the restoration margins after the press procedure and adaptation under the microscope (IPS e.max Press)

 

The high level of precision is to be maintained throughout all the steps in the lab. Sprueing, investing, pressing, divesting, layering, finishing and final polishing of restorations must be performed accurately and in line with the relevant work protocols.
 
Important: Marginal gaps that you can see with the naked eye or at a low magnification will lead to a considerable exposure of the luting material. This would not be ideal for the health of the gums – especially not with subgingival or proximal preparation margins, where the cement joint cannot be finished and polished as perfectly as in other areas.
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Fourth step: Finishing the framework

Lithium disilicate can be finished quickly and with little effort - as long as the wax-up of the framework has been prepared adequately. The material must not become overstressed or overheated to prevent microcracks from forming. Microcracks may grow bigger when the ceramic is fired in the lab or during chewing in situ later on in the oral cavity. In the worst case, they may lead to breakage and loss of the restoration. To make sure that this does not happen, grinding should be carried out at low speed (max. 10,000/min) whilst providing cooling with water to the area being ground.


Reducing and finishing the lithium disilicate copings: The inner surfaces have been coloured in pencil to show how thin the copings are (0.2 - 0.3 mm) and to keep the thickness under control during the grinding process.

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Fifth step: Final checking with silicone keys

After the frameworks were mounted on the master model and the solid model, one last check was carried out with the help of the silicone keys. Only then did the ceramic layering procedure begin.
Having been made from an IPS e.max Press LT ingot in shade BL2, the framework exhibited the high level of brightness and fluorescence required for this case.
 
 
Tip: At this point, apply a wash to the lithum disilicate framework, using either IPS e.max Ceram ceramic materials (Dentin, Power Dentin or Mamelon) or IPS Ivocolor stains, depending on the effect that you wish to achieve and on the clearance available for the layered ceramics. This way, you can control the chroma, brightness and fluorescence from inside. In addition, optimum bonding and light scattering properties can be achieved on the surface of the framework.
 
To reproduce the dynamic interplay of colour and light, alternate layers of ceramic materials (IPS e.max Ceram) were applied in different levels of translucency, fluorescence and opalescence. This way, the contrast between light and shadow and the brightness value can be controlled and the optical properties of the material can be emphasized.
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“It is important to bear in mind that natural tooth structure and dental ceramics are two different things,” Stefano Inglese explains. “It is almost impossible to come close to the natural tooth simply by applying a couple of ceramic layers or by painting some ceramic onto the surface. Dental technicians should keep that in mind. They should be aware of the limitations and possibilities that the individual techniques can offer them.”
By combining contrasts of brightness, opalescence, fluorescence and shade, dental technicians can deceive the human eye and let it perceive what in reality does not exist (illusionary perception).


Copings fitted onto the solid model and verification of the space available for the layering ceramic (IPS e.max Ceram) with a silicone key

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Sixth step: Firing the framework

Nearly optimal shapes and dimensions can be achieved at the first firing process if the contours defined by the silicone key are observed and allowance is made for the sinter shrinkage occurring during firing. This means that no significant adjustments are necessary.
Defining the proximal transition line is important to the optical shape and optical dimension of the tooth (illusionary perception) and to trick the human eye. Labial and cervical emergence profiles from the soft tissues are best designed on the unsegmented model.
 
Finally, surface texture characteristics are designed in detail to control the reflection and scattering of light. All these elements affect the way we perceive a restoration (illusionary perception).
Different tools can trick the human eye and change the visual perception, or rather, the final appearance of dental restorations. These must be individualized in relation to the somatic and emotional characteristics of each patient. The results should be individualized and unique for each patient and this is the goal to be achieved in terms of dental esthetics.
“It must be borne in mind that it is not possible to previsualize and reproduce natural harmony with all the individual characteristics of the patient via digital systems. This point needs to be clear,” says Stefano Inglese.
 

Layering the veneering ceramic: ceramic materials (IPS e.max Ceram) with different levels of translucency, fluorescence and opalescence are applied in an irregular pattern to enhance the optical effect of the materials and make them look more like natural teeth.
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Seventh step: Finishing

If required, slight corrections in shape with small amounts of powder ceramics can be done during the glaze prior to mechanical polishing. By polishing with rubber discs, pumice and diamond paste, we can individualize the light reflection in order to harmonize the restorations to the adjacent natural teeth. The convex and prominent tooth areas should look smoother than the concave areas. By creating reflection and deflection light effects, it is possible to enhance the three-dimensional appearance of the dental restorations.


Adaptation of the final restoration on the solid model. Opalescence, internal effects such as the mamelons in the dentin and the influence of the surface texture on the way light is reflected can all be observed. The three-dimensional proportions, tooth axes, inter-incisal area and morphological characterization of the incisal edge all contribute to the pleasing and natural esthetic appearance of the restorations.

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Eighth step: Final checking

At the final step, the restorations were checked, focusing on the following aspects:
  • occlusal contacts
  • functional guidance of the palatal surfaces
  • functional guidance of the incisal edges and
  • proximal contact surfaces
This was followed by checking and high-gloss polishing of the marginal areas and all subgingival proximal areas to ensure an optimum biological integration.


The emergence profiles affect the biological integration and therefore the appearance of the gingival tissues, enhancing the overall esthetic appearance.

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If treatment teams proceed as shown in this clinical case, then they meet all the requirements to deliver a successful piece of work, using less time, making fewer errors and causing less stress not only to the operators but mostly to the patients who deserve respect.
Stefano Inglese

The postoperative images show that the restorations blend in well with the patient’s existing dentition and facial features in terms of morphology, function and appearance. 
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The vitality of all teeth could be preserved. The patient is absolutely delighted with the result.

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Expert advice
 
An appropriate and efficient communication strategy within the treatment team and a sound treatment plan helped us achieve a harmonious result in spite of our minimally invasive approach.
Dr Mirela Feraru

4th International Expert Symposium

Did you know: Prof. Bichacho and Dr Feraru will give a presentation at the 4th International Expert Symposium in Rome/Italy on 16 June 2018. The topic of their presentation is:

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