Upload
vodat
View
213
Download
0
Embed Size (px)
Citation preview
Carlos E. Pena, DDS
Graduate Student, Department of Operative Dentistry, Guarulhos University,
R Dr Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil
Ronaldo G. Viotti, DDS
Graduate Student, Department of Operative Dentistry, Guarulhos University,
R. Dr. Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil
Walter R. Dias, DDS, MS
Research Dentist, Dentsply Caulk, 38 W Clarke Ave, Milford, DE, 19963, USA
Edward Santucci, DDS, MS
Director of Clinical Research, Dentsply Caulk, 38 W Clarke Ave,
Milford, DE, 19963, USA
Jose A. Rodrigues, DDS, MS, PhD
Assistant Professor, Department of Operative Dentistry, Guarulhos University,
R. Dr. Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil
Andre F. Reis, DDS, MS, PhD
Assistant Professor, Department of Operative Dentistry, Guarulhos University,
R. Dr. Nilo Peçanha 81, Guarulhos, SP, 07011-040, Brazil
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
2
Esthetic rehabilitation of anterior
conoid teeth: comprehensive
approach for improved and
predictable results
Correspondence to: Dr. Andre F Reis
Department of Operative Dentistry, Guarulhos University, Rua Dr. Nilo Peçanha 81, Predio U, 6o. Andar,
Guarulhos, SP, Brazil, 07011-040, Phone: +55 11 6464-1769 Fax: +55 11 6464-1758, e-mail: [email protected]
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
PENA ET AL.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
3
composite resin used for the esthetic reha-
bilitation of a patient presenting conoid lat-
eral incisors, and an unsatisfactory class IV
restoration in the left central incisor are
presented. An accurate diagnostic and in-
terdisciplinary approach is necessary for
obtaining improved, conservative and pre-
dictable esthetic results in esthetically
compromised areas, such as the anterior
maxillary dentition.
(Eur J Esthet Dent 2009;4:XXX–XXX.)
Abstract
The esthetic success of a dental treatment
depends on the correct diagnosis, treat-
ment plan and clinical and laboratory pro-
cedures. This clinical report describes a
diagnostically based protocol for conser-
vative preparations on anterior teeth for ad-
hesively retained composite and porcelain
restorations. The diagnostic additive wax-
up, periodontal esthetic crown-lengthen-
ing, direct acrylic mock-up, conservative
preparations for ceramic laminate veneers,
luting procedures, direct restorations with
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
4
Introduction
The increasing demands of patients and
clinicians regarding esthetic restorations,
together with the improvements in adhe-
sive materials, composite resins and den-
tal porcelains have brought the possibility
of conservative long-lasting esthetic treat-
ments.1
Due to their lifelike appearance,
porcelain laminate veneers are often se-
lected for the esthetic restoration of the an-
terior dentition. The use of laminate ve-
neers and composite resins has matured
to a predictable treatment method in terms
of longevity, periodontal status and patient
satisfaction.2,3
Porcelain laminate veneers and com-
posite restorations offer a predictable op-
tion for creating a successful restorative
treatment that also preserves maximum
tooth structure.3-5
For conservative veneer
preparations, two essential tools are re-
quired during diagnostic steps and tooth
preparation procedures: the additive diag-
nostic waxup and the acrylic mock-up.6
When there is no need for color masking,
a minimal reduction of tooth structure al-
lows the translucency of the veneer to ren-
der a natural appearance. Furthermore, an
ultraconservative preparation preserves
the available enamel for bonding, thus in-
creasing the prognosis for long-term bond-
ing success.7
Factors contributing to the composition
of a pleasant smile, such as amount of gin-
gival display, gingival architecture, clinical
crown dimensions and tooth position play
an important role in the esthetic value of a
cosmetic restoration.8,9
In such cases, an in-
terdisciplinary approach is necessary to
evaluate, diagnose, and resolve esthetic
problems using a combination of ortho-
dontic, periodontal and prosthodontic treat-
Figs 1 and 2 Preoperative views of patient’s face
and smile.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
PENA ET AL.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
5
ments. The aim of this clinical report is to
describe a diagnostically based protocol
for conservative anterior teeth preparations
for adhesively retained composite and
porcelain restorations. In addition, this pro-
tocol is associated with an esthetic gingival
plastic surgery for maximal esthetic effect.
Case report
A 22-year-old female patient was initially
seen at the Graduate Operative Dentistry
clinic of the Guarulhos University School of
Dentistry with the chief complaint of ‘poor
dental esthetics’ especially due to conoid
lateral incisors. Relevant dental history in-
cluded previous orthodontic treatment. Be-
sides presenting with conoid lateral inci-
sors, the gingival contour of both teeth was
approximately 3 mm coronal to the zeniths
of the canines and central incisors. Thus,
before embarking upon the prosthetic
treatment, the ideal harmony in this specif-
ic region should be restored.9Her left cen-
tral incisor presented an unsatisfactory
Class IV composite restoration, whereas
the right central incisor, although unre-
stored, presented an inverted incisal edge.
The right canine showed white spots, and
the left canine presented a small but discol-
ored composite restoration on the buccal
surface.
After the patient had expressed her
treatment expectations, clinical and radi-
ographic examinations were performed. In
addition, photographs (Figs 1 to 5) and
stone casts were obtained to complete the
initial documentation. Based on the exam-
inations and diagnostic tools, the existing
problems and major elements of the treat-
ment were explained to the patient. The se-
quence of treatment planning consisted of
Figs 3 to 5 Preliminary intra-oral view of maxillary
anterior teeth. The patient presented lateral conoids, un-
satisfactory composite restorations and the central in-
cisors showed inverted incisal edges.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
6
tissue was removed from the lateral inci-
sors and right canine.
After healing of the gingival tissue, casts
of the teeth with the new gingival contour
were performed. One set of casts were
used for fabricating a soft tray for the night-
guard vital bleaching technique with 10%
carbamide peroxide, and the other set of
casts were sent, together with the initial
photographs to the laboratory technician
who produced the diagnostic waxup (Figs
12 and 13), with which a silicon index (Fig
14) was used to fabricate a mock-up di-
rectly in the patient’s mouth. This was done
using an auto-mix self-cured methacrylate
resin (Integrity) (Fig 15). Before applying
the resin for the mock-up, the teeth were
isolated with petroleum jelly. The excess
resin was trimmed with a no. 12 surgical
plastic periodontal surgery to optimize the
gingival contour, bleaching with the night-
guard vital bleaching technique, diagnos-
tic waxup, acrylic mock-up, laminate ve-
neers for the lateral incisors and composite
restorations for the central incisors and ca-
nines. The list of materials and manufactur-
ers’ is presented in Table 1.
Figures 6 to 11 demonstrate the se-
quence of the esthetic crown lengthening
procedure. According to probing depth
(Figs 6 and 7) the gingival margin covered
approximately 4 mm of the crown of the lat-
eral incisors, thus no osseous tissue re-
moval was necessary to establish a pleas-
ant gingival contour and rearrange zenith
positions. The heights of the lateral incisors
are generally 1 mm shorter at the gingival
margin than are the central incisors.10,11
Soft
Table 1
Product Procedure Manufacturer
#12 surgical blade Gingivectomy BD Bard-Parker, Franklin Lakes, NJ USA
10% carbamide peroxide Bleaching FGM, Joinvile, SC, Brazil
High Viscosity C-Silicone, Zetaplus Silicon index Zhermack, Badia Polesine, RO, Italy
Self-cure methacrylate resin, Mock-up and Dentsply Caulk, Milford, DE, USA
Integrity provisionals
Diamond burs Preparation KG Sorensen, São Paulo, SP, Brazil
Ultrapak deflection cord Gingival deflection Ultradent Products Inc., South Jordan, UT, USA
Aquasil Ultra Heavy and XLV (Digit) Impression Dentsply Caulk, Milford, DE, USA
Calibra Resin Cement Luting Dentsply Caulk, Milford, DE, USA
IPS Empress Esthetic, Laminate venners Ivoclar-vivadent, Schaan, Liechtenstein
leucite glass ceramic
XP Bond, two-step etch&rinse adhesive Bonding Dentsply Caulk, Milford, DE, USA
Teflon tape Isolating Tigre S.A., Joinville, SC, Brazil
SmartLite IQ2 LED curing unit Light curing Dentsply Caulk, Milford, DE, USA
Esthet-X Micro Matrix Restorative Restorations Dentsply Caulk, Milford, DE, USA
Enhance/Pogo Finishing and Dentsply Caulk, Milford, DE, USA
polishing
Astropol rubber polisher polishing Ivoclar-Vivadent, Schaan, Liechtenstein
Enamelize diamond paste polishing Cosmedent, Chicago, IL, USA
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
PENA ET AL.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
7
Figs 6 to 11 Sequence of the esthetic crown lengthening procedure.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
8
blade (Fig 16) and the final luster was ob-
tained with a light-cured resin material
(Lasting Touch, Dentsply Caulk). Minor de-
fects and irregularities of neighboring
teeth were also revealed by the mock-up.
Figures 17 to 19 shows the acrylic
mock-up, which was approved by the pa-
tient. The patient subsequently used this
mock-up for several days to evaluate if the
planned restorative procedures were com-
patible with her personality, face, smile, oral
functions and subjective expectations.6,10
For preparation of the lateral incisors, a sim-
Fig 14 Silicon index.
Fig 16 The excess resin was trimmed with a no. 12
blade.
Fig 15 The silicon index was used to fabricate a
mock-up using a self-cured methacrylate resin
Figs 12 and 13 Initial stone casts and diagnostic wax-up.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
PENA ET AL.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
9
Figs 17 to 19 The clinical situation of the mock-up
and its effect on the patient’s smile and face is shown
on Figs 17 to 19.
plified technique for porcelain laminates
driven by the diagnostic mock-up de-
scribed by Magne & Belser was used.12
The
advantages of this technique compared to
tooth-preparation techniques based on the
existing tooth surface are: time efficiency,
enamel preservation, subsequent improve-
ment of adhesion and mechanics, and re-
spect of the pulp. The recommended thick-
nesses for porcelain veneers are less than
0.5 mm in the cervical area, 0.7 mm in the
middle and incisal thirds, and greater than
1.5 mm incisal coverage.6,10,12
To accurately
achieve these dimensions, the tooth provi-
sionally restored by the acrylic mock-up
was prepared using round calibration dia-
mond burs guided by the template itself
(Fig 20). Two round diamond burs were
used in this step: no. 1014 (Ø 1.4mm) and
no. 1016 (Ø 1.8 mm), (KG Sorensen) to act
as differential depth cutters. The larger bur
is used between the middle and incisal
thirds to produce a groove of approximate-
ly 0.7 mm, and the small round bur is used
to create a groove of 0.5 mm between the
cervical and middle thirds. This technique is
very conservative and most of the enamel
should be preserved. The grooves were
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
10
Fig 21 The grooves were then marked with a pencil.
Figs 23 and 24 Tapered round-ended diamond burs were used for removal of excess tooth structure.
Fig 22 The remnants of the mock-up were removed
with a scaler
Figs 20 to 26 For preparation of the lateral incisors,
a simplified technique for porcelain laminates driven by
the diagnostic mock-up was used. Two round diamond
burs were used in this step to act as differential depth
cutters.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
PENA ET AL.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
11
then marked with a pencil (Fig 21) and the
remnants of the mock-up were removed
with a scaler (Fig 22). Tapered round-ended
diamond burs were used for removal of ex-
cess tooth structure. Sufficient tooth reduc-
tion is obtained when the pencil marks dis-
appear (Figs 23 and 24). The need for
incisal reduction can be accurately checked
with the silicon palatal index (Fig 25). The fi-
nal tooth preparation can be observed in
Figure 26. The impression was made using
a polyvinyl siloxane material (Aquasil Ultra
Heavy and XLV Digit, Dentsply Caulk, Mil-
ford, DE, USA). The one-step/double-mix
impression in conjunction with a double
cord gingival displacement technique was
used (Fig 27).13,14
The impression was sent to
the lab technician together with the photo-
graphs obtained from the mock-up. Provi-
sional restorations were prepared using the
same silicon index that was used for fabri-
cating the mock-up.
Fig 25 The need for incisal reduction was checked
with the silicon palatal index.
Fig 27 The impression was made using a polyvinyl
siloxane material. The one-step/double-mix impression
in conjunction with a double cord gingival displace-
ment technique was used.
Fig 28 Intra-oral view of preparation of the lateral in-
cisors prior to luting procedures.
Fig 26 The final tooth preparation is shown.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
area, they were protected with a teflon
tape. The adhesive system was applied
(Fig 31) and a gentle air stream was used
to evaporate the solvent and air thin the
adhesive. A coat of adhesive resin was al-
so applied to the veneers. It was air thinned
but not light cured, in order to avoid prob-
lems with marginal fit. The resin cement
was dispensed directly onto the veneer
and the restoration was seated slowly. Ex-
cess was removed with a microbrush pri-
or to light curing for 60 seconds with an
LED (SmartLite IQ2, Dentsply) from the
buccal surface, followed by another 60
seconds from the palatal surface. Polymer-
ized excess resin cement was removed
with a No.12 surgical blade (Fig 32). Final
polishing of the margins was performed
with silicon dioxide rubber polishers (As-
tropol, Ivoclar-Vivadent).
In the following session, the central inci-
sors were restored with a microhybrid
resin composite (Esthet-X, Dentsply). A sil-
icon index was obtained from the working
model after the central incisors were
waxed-up and with the ceramic veneers in
place (a procedure that was performed
prior to the final cementation of the ve-
neers). This palatal index guided the
palatal and incisal shape of the restoration
(Fig 33). After etching enamel for 15 sec-
onds, the single bottle XP Bond adhesive
system was applied and light cured for 10
seconds. The first composite resin incre-
ment (shade Y-E) was inserted with the aid
of the silicon index and light cured for 20
seconds (Fig 34). The second composite
increment was formed using an opaque
resin (shade W-O) in an attempt to mask
the dark background and simulate dentin
mamelons (Fig 35). The incisal edge was
formed using shade W-E (Fig 36) and the
final increment to simulate enamel was
Figure 28 shows the preparation of the lat-
eral incisors prior to luting procedures. The
porcelain laminate veneers were made of
a leucite-reinforced ceramic (IPS Empress
Esthetic, Ivoclar-vivadent, Schaan, Liech-
tenstein) (Fig 29). Veneers were first
checked for seating and marginal fit on
their original stone die and then on the
tooth preparations. Laminate veneers were
luted with a light-cured resin cement sys-
tem (Calibra, Dentsply) in order to bond
the ceramic restoration to the tooth struc-
ture. The adequate shade for the resin ce-
ment was confirmed by using the try-in
paste and the light shade was selected. Af-
ter try-in procedures, the internal surfaces
of the veneer were thoroughly rinsed with
a water spray and air-dried. In order to ob-
tain an effective bonding to the leucite-
based ceramic a combination of microme-
chanical interlocking produced by etching
with 10% hydrofluoric acid for 60 seconds
and chemical coupling with a silane (Cali-
bra Silane Coupling Agent) was used.15 Af-
ter rinsing the etchant, and prior to applying
the silane, the veneers were placed in a
95% alcohol ultrasonic bath for 4 minutes.
After the internal surfaces of the ceram-
ic veneers were prepared, the teeth were
bonded for receiving the ceramic restora-
tions. Deflection chords (Ultrapak #000)
were used to isolate the preparations. A
two-step etch-and-rinse adhesive system
was used (XP Bond, Dentsply). The prepa-
ration was etched with 34% phosphoric
acid for 15 seconds (Fig 30), thoroughly
rinsed with water for 15 seconds and air-
dried. The dry bonding technique was
used because the conservative prepara-
tion was limited to enamel. In order to pro-
tect the adjacent teeth from being unnec-
essarily etched and prevent accumulation
of excess resin cement in the interproximal
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
12
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
PENA ET AL.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
13
Fig 31 The adhesive system was applied and a gen-
tle air stream was used to evaporate the solvent and air
thin the adhesive.
Fig 33 A silicon index guided the palatal and incisal
shape of the restoration.
Fig 34 The first composite resin increment was in-
serted with the aid of the silicon index and light cured
for 20 seconds.
Fig 32 Polymerized excess resin cement was re-
moved with a No.12 surgical blade.
Fig 29 Porcelain laminate veneers were made of a
leucite reinforced ceramic.
Fig 30 The preparation was etched with 34% phos-
phoric acid for 15 seconds thoroughly rinsed with wa-
ter for 15 seconds and air-dried.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
14
Fig 37 The final increment to simulate enamel was
placed using shade A1 resin composite.
Fig 39 Finishing was performed with extra fine dia-
mond burs. Initial polishing was accomplished with
rubber cups, and the final luster was obtained with a di-
amond polishing paste.
Fig 40 The final composite restorations, together with
the ceramic laminate veneers can be observed.
Fig 38 The restoration prior to polishing is shown.
Fig 35 The second composite increment was
formed using an opaque resin in an attempt to mask
the dark background and simulate dentin mamelons.
Fig 36 The incisal edge was formed.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
PENA ET AL.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
15
placed using shade A1 resin composite
(Fig 37). The restoration prior to polishing
is shown on Figure 38. Finishing was per-
formed with extra fine diamond burs. Initial
polishing was accomplished with rubber
cups (Enhance Pogo, Dentsply), and the fi-
nal luster was obtained with a diamond
polishing paste (Enamelize, Cosmedent,
Chicago, IL, USA) (Fig 39). The white spot
on the right canine was also restored and
the composite restoration that existed on
the buccal surface of the left canine was
replaced.
Fig 40 The final composite restorations, together with
the ceramic laminate veneers can be observed.
Figs 41 to 43 The integration of the esthetic restora-
tive treatment with the patient’s lips is shown.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 3 • AUTUMN 2009
16
References
1. Magne P, Magne M. Treatment of extended ante-
rior crown fractures using Type IIIA bonded
porcelain restorations. J Calif Dent Assoc
2005;33:387–396
2. Peumans M, De Munck J, Fieuws S, Lambrechts
P, Vanherle G, Van Meerbeek B. A prospective
ten-year clinical trial of porcelain veneers. J
Adhes Dent 2004;6:65–76
3. Magne P. Composite resins and bonded porce-
lain: the postamalgam era? J Calif Dent Assoc
2006;34:135–147.
4. Kois JC, McGowan S. Diagnostically generated
anterior tooth preparation for adhesively retained
porcelain restorations: rationale and technique. J
Calif Dent Assoc 2004;32:161–166.
5. Edelhoff D, Sorensen JA. Tooth structure removal
associated with various preparation designs for
posterior teeth. Int J Periodontics Restorative Dent
2002;22:241–249.
6. Magne P, Magne M. Use of additive waxup and
direct intraoral mock-up for enamel preservation
with porcelain laminate veneers. Eur J Esthet
Dent 2006;1:10–19.
7. Rouse J, McGowan S. Restoration of the anterior
maxilla with ultraconservative veneers: clinical
and laboratory considerations. Pract Periodontics
Aesthet Dent 1999;11:333–339.
8. Claman L, Alfaro MA, Mercado A. An interdiscipli-
nary approach for improved esthetic results in the
anterior maxilla. J Prosthet Dent 2003;89:1–5.
9. Fradeani M. Esthetic rehabilitation in fixed
prosthodontics. Volume 1: Esthetic analysis.
Chicago: Quintessence; 2004;352.
10. Magne P, Belser U. Bonded porcelain restorations
in the anterior dentition: a biomimetic approach.
Chicago: Quintessence; 2002.
11. Reddy MS. Achieving gingival esthetics. J Am
Dent Assoc 2003;134:295–304.
12. Magne P, Belser UC. Novel porcelain laminate
preparation approach driven by a diagnostic
mock-up. J Esthet Restor Dent 2004;16:7–16.
13. Perakis N, Belser UC, Magne P. Final impres-
sions: a review of material properties and
description of a current technique. Int J Periodon-
tics Restorative Dent 2004;24:109–117.
14. Cloyd S, Puri S. Using the double-cord packing
technique of tissue retraction for making crown
impressions. Dent Today 1999;18:54–59.
15. Soares CJ, Soares PV, Pereira JC, Fonseca RB.
Surface treatment protocols in the cementation
process of ceramic and laboratory-processed
composite restorations: a literature review. J
Esthet Restor Dent 2005;17:224–235.
The final composite restorations, together
with the ceramic laminate veneers can be
observed in Fig 40. The integration of the
esthetic restorative treatment with the pa-
tient’s lips is shown in Figures 41 to 43. The
pleasant smile, as seen in figure 44 shows
the success of this esthetic treatment.
Conclusion
The present report describes an interdisci-
plinary approach for obtaining an excellent
final esthetic and functional result. Predict-
ing the treatment outcome is essential
when planning a substantial esthetic reha-
bilitation. The diagnostic steps were ex-
tremely important tools for the ultraconser-
vative laminate preparations and for the
satisfaction of the patient.
Acknowledgements
The authors give special thanks to Mr. José Carlos Ro-
manini for the excellent work on the ceramic laminate
veneers.
Copyrig
ht
by
N
otfor
Qu
in
tessence
Not
forPublication