Esthetic rehabilitation of a complex clinical case
- highly esthetic,
- works reliably and
- will be long-lasting.
Dr Mirela Feraru
Prof. Dr Nitzan Bichacho
Dr Galit Talmor
Dr Mirela Feraru
Prof. Dr Nitzan Bichacho
Dr Galit Talmor
Direct or indirect? The agony of choice
- direct composite restorations
- indirect composite restorations
- layered veneers
- all-ceramic restorations made of lithium disilicate
- preserving the vitality of the teeth
- amount of healthy tooth structure available
- functional aspects
- personal preferences
- esthetic expectations
- financial means
Direct restorative therapy: maximum conservation of tooth structure
Indirect restorations: highly esthetic results
- teeth that do not respond to whitening procedures
- substantial morphological alterations
- extensive restorative work in adult patients
Planning the treatment steps
- Esthetic analysis based on the clinical assessment and static photographic documentation of the preoperative situation and on dynamic video documentation
- Replacement of the defective composite fillings in the posterior region
- Refurbishment of the buccal corridor in the premolar region with glass-ceramic restorations (right and left)
- Replacement of the defective composite fillings in the anterior region and evaluation of the remaining tooth structure
- Guided ¾ veneer and crown preparation with the aim of improving the proportions and shapes of the teeth in the esthetic zone
- Adhesive cementation
Now see how the treatment team implemented these six steps in detail.
First step: Esthetic analysis
- 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
- The upper right 1 served as reference for the length and shape of the anterior teeth. All incisal proportions should be adjusted accordingly.
- Reshaping of the upper right 3 – shortening the incisal edge
- Refurbishment of the premolar buccal corridor on both sides with the help of ceramic restorations (additive method)
- Replacement of all defective composite fillings
The diagnostic wax-up was created by the dental technician in line with the preoperative esthetic analysis.
Second step: Replacement of the defective composite fillings in the posterior region
Third step: Refurbishment of the buccal corridor
Fourth step: Replacement of the defective composite fillings in the anterior region
Already at this point, a clear improvement of the patient’s smile could be observed.
Fifth step: Guided ¾ veneer and crown preparation
Subsequently, the preparation was checked with the help of the silicone key.
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).
The temporary composite restorations were fabricated directly at chairside with the help of the transparent silicone key produced from the diagnostic wax-up.
Sixth step: Adhesive cementation
After the treatment field had been isolated with a rubber dam and B4 dam clamps (Brinker), the veneers were seated using an adhesive method.
A glimpse behind the scenes in the dental lab
Basic conditions: a shared philosophy and a common goal
- 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 steps in the dental laboratory
First step: Checking the impression
- 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.
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.
Second step: Reproducing the gingival tissues
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.
Third step: Fabricating the framework
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.
- 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).
- 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.
- 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.
- 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)
Fourth step: Finishing the framework
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.
Fifth step: Final checking with silicone keys
Copings fitted onto the solid model and verification of the space available for the layering ceramic (IPS e.max Ceram) with a silicone key
Sixth step: Firing the framework
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.
Seventh step: Finishing
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.
Eighth step: Final checking
- occlusal contacts
- functional guidance of the palatal surfaces
- functional guidance of the incisal edges and
- proximal contact surfaces
The emergence profiles affect the biological integration and therefore the appearance of the gingival tissues, enhancing the overall esthetic appearance.
Result: Joy all round
The vitality of all teeth could be preserved. The patient is absolutely delighted with the result.