Libro Estetica

THE AMeRICaN JOURNAL OF
DENTISTRY
VOL UME
N UMB E R 2 0 1 1
FA L L
The AMeRICaN JouRNal of EsthetIC DeNtIstRy
VoluMe 1 Number 1
Fall 2011(184)
The American Journal of
DENTISTRY
Volume 1 Number 1 Fall 2011
ISSN 2162-2833 (print) ISSN 2162-2841 (online)
Editorial: Welcome aboard! Minimally Invasive Restorative Treatment of Hypoplastic Enamel in Anterior Teeth
Richard J. Simonsen
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Jussara Karina Bernardon Renata Gondo Luiz Narciso Baratieri
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The Gray Zone Around Dental Implants: Keys to Esthetic Success
Iaki Gamborena Markus B. Blatz
48
Determining the Influence of Flowable Composite Resin Application on Cuspal Deflection Using a Computerized Modification of the Strain Gauge Method All-Ceramic Crowns and Extended Veneers in Anterior Dentition: A Case Report with Critical Discussion
Hamdi H. Hamama Nadia M. Zaghloul Ossama B. Abouelatta Abeer E. El-Embaby
60
Jnio S. Almeida e Silva Juliana Nunes Rolla Daniel Edelhoff lito Araujo Luiz Narciso Baratieri
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Guidelines for Authors Mandatory Submission Form
Readers are invited to submit personal photographs for consideration for use in the journal. The number of photos may vary in each issue, but we hope the images will provide an interesting break between the outstanding papers within. This is an opportunity for you, the reader, to share with your colleagues some of the images you are proud of, that may otherwise never see the light of day. For this inaugural issue, we present images from Antelope Canyon, a slot canyon in northern Arizona, photographed by Richard J. Simonsen (http://www.richardsimonsen.com). At certain times of the year and day, the sun may shine through from the slot above that communicates to the surface. Such canyons can be dangerous, as they fill with rainwater quickly in the event of a thunderstorm upstream, sometimes trapping those who choose to ignore natures warnings. It is the effect of the running water over millions of years that makes the unique patterns on the walls of the soft sandstone rock walls.
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DENTISTRY
ISSN 2162-2833 (print) ISSN 2162-2841 (online)
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EDITOR-IN-CHIeF Richard J. Simonsen, DDS, MS

Professor, Faculty of Dentistry Health Sciences Center Kuwait University PO Box 24923, Safat 13110, Kuwait richardjsimonsen@gmail.com
William G. Hartman
Editorial, Advertising, and Subscriptions Quintessence Publishing Co, Inc 4350 Chandler Drive, Hanover Park, IL 60133 Tel: (630) 736-3600. Fax: (630) 736-3633 Toll-free (US/Canada): (800) 621-0387 E-mail:service@quintbook.com Introductory subscription rate (Vols 1 and 2, six issues; includes online version): Regular rate for North America is $248; $430 institutional. International rate (outside North America) is $278 regular; $460 institutional. International subscribers add $30 to international rate for air mail. Special student rate is $150 ($180 international); verification of student status required on submission of subscription order. AJED is published quarterly by Quintessence Publishing Co, Inc. Postmaster: Send address changes to Quintessence Publishing Co, Inc, 4350 Chandler Drive, Hanover Park, IL 60133, USA. Copyright 2011 by Quintessence Publishing Co, Inc. All rights reserved. Printed in Germany. No part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information and retrieval system, without permission in writing from the publisher. The publisher and editors assume no responsibility for unsolicited manuscripts. The views expressed herein are those of the individual authors and are not necessarily those of the publisher. Information included herein is not professional advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures, or practices. To the extent permissible under applicable laws, the publisher disclaims responsibility for any injury and/or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from the use or operation of any ideas, instructions, procedures, products, or methods contained in the material herein. Permission to photocopy items solely for internal or personal use, and for the internal and personal use of specific clients, is granted by Quintessence Publishing Co, Inc, for libraries and other users registered with the Copyright Clearance Center (CCC) Transaction Reporting Service, provided that the base fee of $5 per article plus $.10 per page is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923 (www. copyright.com). Identify this publication by including the fee code: 2162-2833/11 $5 + $.10. Advertising Policy: All advertising appearing in AJED must be approved by the editorial staff. The publication of an advertisement is not to be construed as an endorsement or approval by the journal or its publisher of the quantity or value of the advertised products or services or of any of the representations or claims made by the advertisers. Printed in USA.
EDITORIAL BOARD
Joel H. Berg, DDS, MS Markus B. Blatz, DMD, PhD Jeff Brucia, DDS John R. Calamia, DMD Alexander Carroll, DDS, MBA David Chambers, EdM, MBA, PhD Gordon J. Christensen, DDS, MSD, PhD Theodore P. Croll, DDS Alessandro Devigus, Dr Med Dent Sillas Duarte Jr, DDS, MS, PhD Newton Fahl Jr, DDS, MS Jack L. Ferracane, PhD Ronald E. Goldstein, DDS Laura C. Kottemann, DMD Gerard Kugel, DMD, MS, PhD Tyler Lasseigne, DDS Pascal Magne, Dr Med Dent, PhD Tidu Mankoo, BDS Assad F. Mora, DDS, MSD Marc L. Nevins, DMD, MMSc Vijay Parashar, DDS, MS Andr V. Ritter, DDS, MS Richard D. Roblee, DDS, MS David D. Rolf II, DMD, MS Leo E. Rouse, DDS Frank Spear, DDS, MSD Douglas A. Terry, DDS Gwenlynn Werner, DMD David Winkler, DDS
EDITORIAL
Welcome aboard!
journals and books in dentistry. This is the first issue of The American Journal of Esthetic Dentistry, a journal dedicated to promoting the highest clinical standards of esthetic dentistry based on an evidence base and on a minimally invasive approach. We wish to share with our readers the research advances and clinical accomplishments of the profession over the past several decades. With our outstanding editorial board and many others who will aid in the review of papers and ideas for the journal, we pledge to provide you with the highest standard of peer-reviewed information in the form of papers submitted by you, the reader, and fellow dedicated members of our profession. The theme of esthetic dentistry is a broad one. One could argue that almost all phases of clinical dentistry involve directly or indirectlyesthetics, and we will publish papers in most areas of clinical interest to the general dentist, who is faced with the enormous task of keeping up with new developments in all fields of the profession. You can expect many papers of the quality you see here in this issue from around the globe, and also you can expect exciting new developments in terms of being able to review your journal and read the papers online with your iPad or similar instrument in months to come. Future editorials will discuss themes and trends in our profession that I hope will be of interest to a wide group of Richard J. Simonsen, DDS, MS Editor-in-Chief readers. I may take a certain position on an issue in order to stimulate conversation and responses such that a broad perspective of opinions can be aired. It will be my job as your editor to try to stimulate such debates and commentary, such as, for example, around the current overtreatment problems in the cosmetic dentistry arena. I also welcome guest editorials from those of you who may wish to tackle a particular subject of interest to the profession. An active and robust Letters to the Editor section is on my list of goals for development as time goes on. I hope that you will feel free to communicate with me on any ideas or constructive criticism you may have. Please enjoy the first issue of The American Journal of Esthetic Dentistry !
am very pleased to welcome you to a new addition to Quintessence Publishing Companys stable of fine
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VOLUME 1 NUMBER 1 FALL 2011
DENTISTRY
GUIDELINES FOR AUTHORS
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Original articles are considered for publication on the condition that they have not been published or submitted for publication elsewhere. The publisher reserves the right to edit all manuscripts to fit the space available and to ensure conciseness, clarity, and stylistic consistency. ARTICLE ACCEPTaNCE Article acceptance is pending receipt of images judged to be of sufficient quality for publication (see the guidelines below). Once a manuscript is accepted, authors should submit high-quality nondigital images or high-resolution digital image files (on disk) to: Managing Editor American Journal of Esthetic Dentistry Quintessence Publishing Co, Inc 4350 Chandler Drive Hanover Park, IL 60133 The disk/package should be labeled with the first authors name, shortened article title, and code number assigned upon acceptance. Nondigital Image Format. When submitting nondigital images please consider the following points: Clinical photographs/radiographs. 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Minimally Invasive Restorative Treatment of Hypoplastic Enamel in Anterior Teeth

Jussara Karina Bernardon, DDS, MS, PhD
Clinical Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Florianpolis, SC, Brazil.
Renata Gondo, DDS, MS, PhD

Clinical Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Florianpolis, SC, Brazil.
Luiz Narciso Baratieri, DDS, MS, PhD

Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Florianpolis, SC, Brazil.
Hypoplastic enamel can compromise the smile by altering the morphology and natural translucency of the teeth. To avoid performing iatrogenic procedures, etiologic knowledge of the enamel deficiency is essential to indicate the most appropriate treatment approach. In the case of white stains involving the enamel and dentin, a notable treatment option is a direct restoration with composite resin, which has excellent optical properties to reproduce the natural tooth structure and appropriate mechanical properties to ensure treatment longevity. In this article, a clinical case of a patient who reported dissatisfaction with her smile esthetics, prompted by the presence of hypoplastic enamel staining at the central and lateral incisors, is presented. Treatment consisted of composite resin restorations with the natural stratification technique. The final esthetic result proved the possibility of obtaining natural-looking restorations, while ensuring the esthetic and functional satisfaction of both the patient and clinician. (Am J Esthet Dent 2011;1:1024.)
Correspondence to: Dr Jussara Bernardon

Armaro Antnio Viera 2489, apto 403, Itacorubi, Florianpolis, Santa Catarina, Brazil. Fax: 55 048 38799226. Email: jussara_bernardon@yahoo.com.br
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THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Fig 1 Proximal view of the anterior teeth. Note the change in color and presence of white spots.
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everal factors may compro mise the esthetics of the including hypoplastic
to the natural shine and translucency of enamel. This opacity prevents light transmission in the specific region of the lesion, providing a distinct difference between it and the surrounding enamel. Several types of treatments may be recommended according to severity, and the least invasive technique should always take precedence. Therefore, the etiologic diagnosis is of paramount importance and aims to prevent unnecessary treatment of the hypoplastic teeth. For mild (smooth, light) and superficial lesions, tooth bleaching can be performed, with or without abrasion of the enamel. This is a minimally invasive technique and is limited to the enamel of the affected area.6 In the case of moderate or severe stains with dentin involvement, the preferred treatment is a direct or indirect restorative procedure. With the ongoing development of composite resins, which present a wide range of available colors and excellent mechanical properties, it has been possible to perform more esthetic, predictable, and conservative restorations.7 The use of composite resin has the advantage of minimal reduction of the tooth structure and the completion of the procedure in a single appointment.8
smile,
enamel, which may affect the morphology, texture, and color of the tooth surface, the result of an incomplete or defective formation of the enamel organic matrix. The intensity and duration of stimulation on ameloblasts reflect the extent and location of enamel defects.1 Lesions may be triggered by hereditary or environmental factors. With hereditary factors, generally only the enamel of primary and permanent teeth is affected.2 Hypoplastic enamel resulting from environmental factors, however, can be caused by a variety of influences, including nutritional deficiencies, rashes (eg, measles, ver), chickenpox, syphilis, scarlet fehypocalcemia,
systemic disorders, ingestion of chemicals (eg, fluoride), trauma, infections of the primary dentition, or by idiopathic causes.2,3 Environmental factors usually affect only one arch and can alter both the enamel and Therefore, depending dentin.4 on the
etiology, stains resulting from hypoplastic enamel may have systemic features, affecting a group of teeth, or be localized, with asymmetric distribution and isolated to specific teeth.5 These spots compromise smile esthetics because they have an opaque, rough, and irregular appearance, compared
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Fig 2 Initial appearance of the patient. At conversation distance, the spots, while clearly visible, can be left untreated if they do not bother the patient. However, in this case, the patient was concerned about the appearance of her teeth.
Clinical case
The chief complaint of the patient was esthetic dissatisfaction from discoloration of the teeth and the presence of white spots on the incisors (Figs 1 and 2). After taking the case history with a clinical examination, it was determined that the teeth were naturally dark and that the white spots were hypoplastic
enamel areas at the incisal and middle thirds of the maxillary and mandibular incisors, without functional involvement (Figs 3 and 4). The patient underwent radiographic examination, and no periodontal or periapical changes were evident. The affected teeth yielded a positive response to the vitality test. An additional recommended baseline examination is transillumination,
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Fig 3 Preoperative labial view demonstrating yellow coloration of the teeth and the presence of white spots at the incisal and middle thirds of the maxillary central incisors and incisal third of the left lateral incisor.
Fig 4 Occlusal view of the maxillary incisors. Note the change in morphology and surface texture.
which involves the use of a transilluminator positioned along the palatal surface of the tooth being assessed (Figs 5a to 5c). This technique allows analysis of the transmission of light through the hypoplastic defects, identification of the thickness of the affected areas, and verification of the degree of compromised enamel (and dentin, if affected). Thus, transillumination is effective in de-
termining the treatment approach: the less the light propagation through the affected areas, the greater the depth of the stain. If the dentin is involved, the most common treatment approach is a direct restoration with composite resin and limited preparation of the compromised surface. Initially, because of tooth discoloration, the patient was asked to perform
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Figs 5a to 5c Using a transilluminator placed on the palatal surface of the involved incisors, it was possible to visualize the stain depth and relate this to the depth of the hypocalcified area.
Fig 6 Frontal view after home bleaching with 10% carbamide peroxide gel for 4 weeks (2 hours/ day). Note that the stains remained visible, confirming the need for restorative intervention.
a supervised home whitening or bleaching regimen with 10% carbamide peroxide gel for 4 weeks (2 hours/day) (Fig 6). Home bleaching is a relatively simple, obtained conservative, in a short and time effective period.11 treatment,9,10 with satisfactory results Bleaching, associated with restorative treatment, is a common approach that aims to establish a more homogenous
condition in terms of saturation and brightness of the teeth to be restored.12 The restoration was performed 14 days after completion of the bleaching process to ensure that the adhesive procedure and color selection were carried out properly.13 A microhybrid composite resin system (Opallis, FGM) with the appropriate mechanical properties to ensure
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Fig 7 (left)Choice of color using the color scale positioned on the facial surface of the affected tooth. The enamel and dentin colors were selected separately. Fig 8 (right)By placing the dentin shade guide against the enamel shade guide, the final shade can be visualized.
strength and maintenance of polishing and surface brightness and sufficient optical properties to mimic the features found in natural teeth was selected for the restorative procedure.14 A resin system with both enamel and dentin shades is recommended because the natural tooth overlaps these structures in different thicknesses, which creates the polychromatic effect seen on natural teeth.15 The selected system presented several hues and saturations for enamel and dentin beyond the transparent resins, which reproduce different degrees of translucency, opalescence, and fluorescence. When selecting the color for the restoration, the teeth should be clean and moist so that the natural translucency is preserved.15 Color scales are essential, and it is of paramount importance that they be of the same manufacturer as the resin system selected to avoid potential discrepancies between the
chemistry of the different brands available. This is because the enamel and dentin shade guides vary in saturation and translucency depending on the system used. The color scale should be positioned as closely as possible to the tooth. The color selection for dentin should be performed at the cervical third of the affected tooth, where the dentin is thicker and more saturated, and enamel color selection should occur at the middle third. The system used had separate scales for enamel and dentin, which is an advantage because it allowed for an individual evaluation of the structures. In addition, each tab had a different thickness, and it was possible to predict the shade of the final restoration by altering the thickness of the tab selected (Fig 7). By placing the enamel shade tab on top of the dentin shade tab, it was possible to predict how the resins would interact in the future restoration (Fig 8). The operative
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Fig 9 After rubber dam was used to isolate the affected teeth, the white spot was removed using diamond burs.
Fig 10 Occlusal view of the preparation. Note the remaining white spot that could compromise the restorative outcome if not removed.
Fig 11 After preparation, the white spot was still evident, which called for its removal with a diamond bur of smaller diameter.
Fig 12 Final aspect of the hydrated cavity preparation, which was restricted to removal of the white spot.
Fig 13 Etching of the hard tissue with 37% orthophosphoric acid (15 seconds for dentin, 30 seconds for enamel).
Fig 14 Application of the adhesive system according to the manufacturers instructions.
field was isolated to ensure a clean and suitable environment for the bonding procedures. The cavity preparation should be restricted to removing the hypoplastic enamel using diamond points compatible to the size of the lesion under constant irrigation to avoid heating of the structure (Fig 9). The entire depth of the hypoplastic enamel should be removed. Otherwise, the resulting difference in opacity between natural and affected tooth structure can negatively affect the outcome of the restoration (Figs 10 and 11).
There is no need to bevel the cavosuperficial angle, preserving as much healthy tooth structure as possible (Fig 12). The absence of preparations ensures a reversible treatment without compromising esthetics or the adhesive bond. After the preparation was complete, conditioning was performed with 37% orthophosphoric acid for 15 seconds on the dentin and 30 seconds on enamel (Fig 13), followed by application of the adhesive system, according to the manufacturers instructions (Fig 14).
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Fig 15 Composite resin was placed in the preparation to reproduce the dentin layer.
Fig 16 Mamelons must be defined when applying the composite resin.
Fig 17 Frontal aspect after placing the second dentin resin layer for bleached teeth. Note the design of the mamelons.
The restorative procedure was performed using the stratification technique, based on the techniques of building ceramics. This new trend is also referred to as the anatomical technique.16,17 In this technique, layers of selected materials are used to reproduce the enamel and dentin structures while also respecting their thickness and anatomical contour. The artificial dentin reconstruction was performed using the dentin resin DA1 (Opallis). This resin was applied covering the deepest portion of the cavity to sculpt the shape of the mamelons (Figs 15 and 16). Dentin mamelons can have various shapes and determine the translucent halo characteristics of the tooth (Fig 17). Each layer was photopolymerized for 40 seconds. To complete the artificial dentin, a resin for bleached teeth was applied at the tip of the mamelons (D-Bleach, Opallis). In a natural tooth, dentin presents as an intense and very reflective opaque white color on the tip of the mamelons. However, when light penetrates the dentin through the enamel, it results in
an orange appearance. This is the counter-opalescence feature of dentin. To reproduce this effect, an opalescent and highly translucent resin (T-Blue, Opallis) was placed on the tips of the mamelons and between the dentin and incisal edge of the tooth (Fig 18). Then, artificial enamel was reconstructed using a single enamel resin layer (E-Bleach) (Fig 19). In the stratification technique, it is important to consider that the artificial enamel thickness should correspond to one third of that of natural enamel18 to avoid value reduction of the restoration. This means that a thicker layer of artificial enamel results in a gray and more monochromatic restoration.14 This is because the refractory index of the natural tooth structure is different from that of the composite resin.14 The enamel surface was finalized at this time, avoiding use of diamond points (Fig 20). The same procedures were performed for the maxillary right central (Figs 21 to 24) and left lateral incisors (Figs 25 to 28). After complete polymerization and at a later session,
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Fig 18 A highly translucent resin was placed on the opalescent areas of the incisal third region of the tooth.
Fig 19 Positioning of the final enamel composite resin layer. Care was taken to cover all preparation margins.
Fig 20 Proximal view of the vertical development and lobes shaped in the definitive restoration.
Fig 21 Removal of the white spots on the right central incisor with a diamond bur.
Fig 22 After hydration, the preparation was completed with removal of the white spot.
Fig 23 Incremental technique for resin application: DA1, D-bleach H, T-Blue, and Bleach (Opallis).
Fig 24 Final aspect of the restoration of the maxillary right central incisor. Fig 27 (left)Mamelon design using dentin resin (DA1 and DBleach, Opallis). Fig 28 (right)Final aspect of restoration. Note the contrast between the restoration and the natural tooth, which is dehydrated as a result of absolute isolation.
Fig 25 Removal of the hypoplastic enamel on the left lateral incisor.
Fig 26 Final aspect of the hydrated cavity preparation, which was restricted to removing only the hypoplastic white spot.
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Fig 29 A surface enhancer was used to identify the different reflection areas of the teeth.
Fig 30 Vertical development and the edges were completed with an oval format extra-fine diamond bur.
Fig 31 Note the similarity in morphology between the central incisors after texturing.
Fig 32 The restoration was polished to make the surface bright and smooth.
the surface of the restoration was textured, and finishing and polishing were completed (Figs 29 to 32). Surface texturing is indispensable in ensuring a natural-looking restoration because
an irregular surface provides light dispersion. Lobules and development grooves (vertical texture), horizontal grooves, and perikymata should be reproduced using extra-fine diamond
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Figs 33a to 33c A transilluminator was again used to visualize the similarity in light transmission between tooth and restoration (compare to Figs 5a to 5c).
Fig 34 Final aspect of restorations, frontal view. Fig 35 (right)Final aspect of restorations, palatal view.
burs. Finishing was completed using flexible disks and rubber tips. Polishing with felt disks and polishing pastes ensures surface brightness and decreases plaque retention. The final
result showed that composite resin provides a suitable material to produce esthetic effects similar to that of the natural tooth structure (Figs 33 to 39).
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Figs 36 to 38 Final smile after bleaching and restorative treatment. Note the correct merging of the dental substrate with the composite resin and reproduction of the optical aspects in the incisal third region.
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Fig 39 The patient was satisfied with the end result. Note the naturalness and harmony of the smile with the facial esthetics.
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Conclusions and guidelines for practitioners

In cases of hypoplastic enamel, a correct diagnosis is indispensable for an appropriate treatment prognosis. In lesions with dentin involvement, direct composite resin restorations promote satisfactory results with conservation of a healthy dental structure, excellent mechanical
properties, and reproduction of the natural tooth color and characteristics.19 Proper color selection is not enough; satisfactory resin system selection and proper realization of the stratification technique must also be accomplished. Following this protocol is critical to the quality of treatment received.
This article is based on a chapter in the book Clinical Vision: Cases and Solutions by Dr Baratieri and was originally written in Portuguese.
References
1. Elcock C, Smith RN, Simpson J, Abdellatif A, Bckman B, Brook AH. Comparison of methods for measurement of hypoplastic lesions. Eur J Oral Sci 2006;114(suppl 1): 365369. 2. Clarkson J. Review of terminology, classifications, and indices of developmental defects of enamel. Adv Dent Res 1989;3:104109. 3. Ribas AO, Czlusniak GD. Anomalias do esmalte dental: Etiologia, diagnostico e tratamento. Biol Health Sci 2004;10:2326. 4. Bendo CB, Scarpelli AC, Novaes JB Jr, Valle MPP, Paiva SM, Pordeus IA. Enamel hypoplasia in permanent incisors: A six-month follow-up. RGO 2007;55:107112. 5. Sensi lG, Marson FC, Strassle H, Duarte SJ. Recuperao Cosmtica de Deformidades Dentais. Pro-odont Esttica, ed 2. Porto Alegre: Artmed, 2008: 156178. 6. Croll TP . Enamel Microabrasion. Chicago: Quintessence, 1991. 7. Simonsen RJ. Developmental defect restorations. In: Simonsen RJ. Clinical Applications of the Acid Etch Technique. Chicago: Quintessence, 1978:6370. 8. Machado FC, Ribeiro RA. Defeito de esmalte e crie dentria em crianas prematuras e/ou de baixo peso ao nascimento. Pesq Bras Odontoped Clin Integr 2004; 4:243247. 9. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 1989;20: 173176. 10. Leonard RH Jr, Bentley C, Eagle JC, Garland GE, Knight MC, Phillips C. Nightguard vital bleaching: A long-term study on efficacy, shade retention, side effects and patients perceptions. J Esthet Restor Dent 2001;13:357369. 11. Joiner A. The bleaching of teeth: A review of the literature. J Dent 2006;34:412419. 12. Hirata R. Tips: Dicas em Odontologia Esttica. So Paulo: Artes Mdicas, 2011:576. 13. McGuckin RS, Thurmond BA, Osovitz S. Enamel shear bond strengths after vital bleaching. Am J Dent 1992;5:216222 14. Baratieri LN, Belli R. Resinas compositas. In: Baratieri LN. Clinical SolutionsFundamentals and Techniques. Florianpolis: Editora Ponto, 2008:131142. 15. Baratieri LN, Belli R. Colo: Fundamentos bsicos. In: Baratieri LN. Clinical SolutionsFundamentals and Techniques. Florianpolis: Editora Ponto, 2008:2155. 16. Ardu S, Krejci I. Biomimetic direct composite stratification technique for the restoration of anterior teeth. Quintessence Int 2006;37:167174 [erratum 2006;37:408]. 17. Vanini L. Light and color in anterior composite restorations. Pract Periodontics Aesthet Dent 1996;8:673682. 18. Vanini L, Mangani F, Klimovskaia O. Colour in dentistry. In: Vanini L, Mangani F, Klimovskaia O. Conservative Restoration for Anterior Teeth. Viterbo, Italy: ACME, 2005:97200. 19. Bernardon JK, Gondo R. Restorative treatment of hypoplastic stains in anterior teeth. In: Baratieri LN. Clinical Vision: Cases and Solutions. Florianpolis: Editora Ponto, 2010:62101.
24
The Gray Zone Around Dental Implants: Keys to Esthetic Success

Iaki Gamborena, DMD, MSD, FID
Private Practice, San Sebastian, Spain; Clinical Assistant Professor, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.
Markus B. Blatz, DMD, PhD

Professor and Chairman, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.
Correspondence to: Dr Iaki Gamborena

Resurecccion m de Azkue, 6 20018 San Sebastian, Spain. Email: gambmila@telefonica.net
26
Single-implant restorations in the anterior maxilla have become a routine treatment option. While customized tooth-colored prosthetic components show greatly improved clinical outcomes, esthetic success relies not only on the restorative result, but also on the condition of the soft tissues. A common esthetic shortcoming is the grayish appearance of the peri-implant soft tissues, which are difficult to manipulate around dental implants. The parameters and clinical guidelines that should be used to influence esthetic success and avoid the gray zone around implant restorations can be categorized into five key factors: (1) optimal threedimensional implant placement for functional and esthetic long-term implant success; (2) maximized soft tissue thickness to conceal the implant-restorative interface; (3) proper abutment selection to improve biocompatibility, tissue stability, color, translucency, and fluorescence; (4) careful crown restoration to imitate the natural teeth; and (5) awareness of the lip line, which may greatly influence the final outcome. Mimicking the inherent optical properties, especially fluorescence, of natural teeth with implant components and crown materials is fundamental for ideal restorative and soft tissue esthetics. (Am J Esthet Dent 2011;1:2646.)
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he esthetic success of a dental restoration is judged by its inte-
and restorative esthetic success with maxillary anterior implant-supported restorations presents a great challenge for the entire dental team and depends on a variety of parameters.1014 The parameters and clinical guidelines that should be used to influence esthetic success and avoid the gray zone around implant restorations can be categorized into five key factors: (1) optimal three-dimensional (3D) implant placement for functional and esthetic long-term implant success; (2) maximized soft tissue thickness to conceal the implant-prosthetic component interface; (3) proper abutment selection to improve biocompatibility, tissue stability, and color to provide a perfect blend with surrounding tissues and teeth; (4) careful crown restoration to imitate the natural teeth; and (5) awareness of the lip line, which may greatly influence the final outcome.
gration with the surrounding dentition in respect to position, angulation, dimensions, proportions, shape, surface morphology, and shade.13 Other cru-
cial esthetic parameters that are often overlooked include the morphology, texture, and ultimately the color of the surrounding gingiva.3,4 The soft tissue is the natural frame of the teeth and any dental restoration and is, therefore, a fundamental parameter for esthetic success.1,3,5 This aspect is often neglected because successful soft tissue outcomesincluding handling, manipulation, and healingare very demanding, time intensive, and unpredictable.5 Magne et al6 described a prevalence of grayish soft tissue discolorations around tooth-supported full-coverage porcelain-fused-to-metal and even allceramic restorations. Interestingly, other perioral facial parameters such as position of the upper lip and height of the smile line79 also seem to influence the degree of gingiva discoloration. The authors note that this problem is particularly evident in the presence of the upper lip, which can generate an umbrella effect characterized by gray marginal gingivae and dark interdental papillae.6 This umbrella effect is magnified with dental implant restorations in the anterior maxilla because the supporting hard and soft tissues are often compromised even before restorative treatment and are influenced by the color and design of the implant, its prosthetic components, and the definitive restoration.1017 Therefore, ideal periodontal
3D implant placement
The fundamental factor for long-term functional and esthetic success as well as soft tissue color and stability is optimal 3D implant placement.18 A simple but essential guideline is to position the implant as close as possible to where the natural tooth was or ideally would be.10 If a line is drawn at the center of the implant along its long axis and extending through the tooth restoration, it should run through the center of the incisal edge of the prospective tooth (Fig 1). The greater the 3D mismatch between the crown and implant body, the poorer and less stable the final
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Fig 1 (right)Maxillary anterior implants should be positioned and angulated so that a virtual line through the center of the implant along its long axis would run through the center of the incisal edge of the prospective crown.
outcome will be. The incisal edge is also the target for the angulation of the implant. An implant that is angulated too far to the buccal aspect will result in greater tissue recession under functional load. Conversely, a palatally placed implant leads to a more extreme emergence profile, resulting in increased bone resorption and thinning of the tissues. Both situations will lead to an intensified grayish appearance of the soft tissues at the gingival margin. The third dimension is determined by the depth of the implant in respect to the marginal bone and soft tissue. An implant placed at the proper depth allows for the development of an ideal emergence profile and a soft tissue collar void of a gray zone. It is impossible to create a proper emergence profile when the implant is placed too shallow, while an implant placed too deep is difficult to manage clinically and increases the possibility of peri-implant infection, inflammation, and bone loss. A surgical guide fabricated from the diagnostic wax-up/setup is an indispensible tool to ensure proper 3D implant placement. The anticipated incisal edge position of the final tooth restoration determines the position, angulation, and depth of the implant in all three dimensions, which directly influence the position, height, and thickness of the surrounding hard and soft tissues.10,12 Even in cases where ideal implant placement was achieved, the esthetic outcome may become compromised over time due to resorption of the marginal bone and soft tissues.5,19
Soft tissue thicKness
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Case 1
Figs 2a and 2b A modified metal abutment was used after immediate implant placement at the maxillary right central incisor site without bone or soft tissue augmentation.
Fig 3 Postoperative situation showing the implant-supported crown.
Fig 4 (above left)Follow-up view after several years reveals a grayish appearance of the soft tissues. Fig 5 (above right)Follow-up view after 11 years showing soft tissue discoloration due to the metal abutment. Fig 6 (left)Periapical radiograph after 11 years reveals loss of buccal bone.
Case 1 (Figs 2 to 6) illustrates a situation where a single implant was placed immediately after extraction of the maxillary right central incisor without any hard or soft tissue augmentation. A modified metal abutment was fabricated, and the definitive restoration was
inserted (Figs 2 and 3). A follow-up photograph taken several years postoperatively reveals a grayish appearance of the soft tissue surrounding the implant restoration (Fig 4). This discoloration becomes increasingly evident 11 years after completion as a result of
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the resorption of the buccal bone and surrounding soft tissues, revealing the unfavorable gray color of the metal implant abutment (Figs 5 and 6). To avoid this result, it is advisable to maximize tissue thickness in every case and for both delayed and immediate implant placement.1922 In fact, the mucosal characteristics of the periimplant tissues necessitate connective tissue grafting for long-term esthetic success.21 With clear surgical objectives, a modern approach should always include the most conservative procedure that satisfies the esthetic and functional requirements. For example, if a bone graft is unnecessary, stage-one surgery should always be performed with a minimal flap incision, such as a split-thickness flap or even no flap, to avoid unnecessary exposure of the underlying bone. Several authors have indicated that flapless surgical implant placement using computerassisted surgical guides minimizes bone resorption, preserves soft tissue architecture, and improves the healing process.23 While some of these results still need to be verified in long-term clinical trials, the positive effects of flapless implant placement on patient comfort due to the minimally invasive nature of the procedure are clearly evident.23 The key components of this surgical process are maintenance of the interproximal bone, minimal bone exposure only on the implant site, precise coronal graft suturing central to the implant axis, and tension-free flap closure and adaptation. The design of the healing abutment, which can be placed during or after
connective tissue grafting, is another critical issue. Connective tissue grafts (CTGs) are placed around implants to enhance gingival margin stability and create a more fibrous and less mobile tissue complex.1922 In dentistry today, the clinicians search for soft tissue abundance in the early stages of implant treatment means creating a large amount of soft tissue during or soon after implant placement and manipulating these tissues during the prosthetic phase. This is a shift from traditional approaches in which multiple subsequent soft tissue grafts are performed until the desired thickness was achieved. Multiple surgical interventions, however, are less predictable because the scarring and compromised blood supply make every subsequent grafting attempt more challenging. For ideal prosthetic soft tissue manipulation, the healing abutment should be significantly narrower than the tooth to be replaced. At first, the tissue will not have the same scalloped architecture as found around natural teeth. However, when the provisional restoration is placed, its subgingival contour and shape will determine the position and scallop of the soft tissue margin.10,13 It also seems advantageous to connect the definitive abutment as early as possible and not to remove it after that time. Thicker peri-implant soft tissue masks the implant-abutment-restoration interface and provides a better color match between the soft tissues around the implant and those around the neighboring teeth.1517 Some basic guidelines for tissue thickness and abutment selection are as follows:
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Case 2
Fig 7 Thin peri-implant soft tissue of only 1 mm was evident on the buccal aspect.
Fig 8 A custom-colored zirconia abutment (Procera, Nobel Biocare) was fabricated to optimize the esthetic outcome.
Fig 9 Colored zirconia abutment and alumina crown (Procera Crown Alumina, Nobel Biocare).
Fig 10 Intraoral occlusal view showing the soft tissue support.
Fig 11 Postoperative buccal view. The tooth-colored abutment and all-ceramic crown blend favorably with the adjacent teeth and surrounding soft tissue despite the compromised soft tissue thickness.
Fig 13 (left)Occlusal view of the definitive implant-supported restoration.
Fig 12 Postoperative peri apical radiograph.
A soft tissue thickness greater than 3 mm allows for the use of titanium or zirconia abutments without negative esthetic implications. A thin soft tissue of less than 2 to 3 mm requires either a CTG or zirconia abutment. A dentin-colored abutment is always preferred. In Case 2 (Figs 7 to 13), a colored instead of a white zirconia abutment was placed due to the presence of less than 1 mm of labial soft tissue. This approach,
along with the adequate soft tissue support and contour, provided a satisfying outcome.
Abutment selection
In an evaluation of the soft tissue around single-tooth implant crowns, Frhauser et al24 showed that the color of the periimplant soft tissue matched that of the reference tooth in no more than onethird of cases. Another study found that all-ceramic implant abutment and crown
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Case 3
Fig 15 Preoperative intraoral situation.
Fig 16 Lateral tomogram showing the extent of the ridge defect.
Fig 14 Preoperative periapical radiograph of the missing maxillary left central incisor.
Fig 17 Intraoral view of the edentulous ridge topography.
Fig 18 Virtual implant placement for guided surgery.
materials provide a better soft tissue color match with neighboring teeth than do conventional metal-alloy components.16 Zirconia has been shown to be the preferred implant abutment material due to its high strength13,25,26 and excellent biocompatibility.2729 The shortcomings of zirconia include its higher cost and unfavorable optical properties in regard to color and fluorescence.30 Case 3 (Figs 14 to 55) includes all previously described factors and treatment parameters. The missing maxillary left central incisor was replaced with a
dental implant (Figs 14 to 18). Ideal 3D implant placement was planned on the computer and transferred via guided surgery. During stage-one surgery, the implant (3.5 13 mm, NobelActive, Nobel Biocare) was inserted, and a CTG harvested from the maxillary tuberosity was placed to increase tissue thickness (Figs 19 to 23). Figure 24 shows the augmented edentulous ridge 6 months postoperatively. Next, a zirconia abutment was connected to the implant, and a provisional restoration was fabricated, relined in the oral
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Case 3 Continued
Fig 19 Implant placement (3.5 13 mm, NobelActive, Nobel Biocare).
Fig 20 A subepithelial CTG was harvested from the maxillary tuberosity to augment the deficient ridge.
Fig 21 After placement of the CTG, the flaps were adapted without tension and sutured with thin suture material to limit trauma.
Fig 22 Labial view of the adapted flap after suturing.
Fig 23 Intraoral situation 1 week postoperatively.
Fig 24 Postoperative situation after 6 months reveals improved ridge morphology.
cavity, and cemented (Figs 25 to 29). The different lighting conditions (natural and ultraviolet [UV] light) shown in
Figs 30 to 33 reveal the optical shortcomings of these materials, especially the lack of natural fluorescence. Figure
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Case 3 Continued
Fig 25 Definitive zirconia abutment and provisional restoration. Fig 26 (right)Insertion of the colored zirconia abutment.
Fig 27 (above left)Try-in of the provisional crown. Fig 28 (above right)Precision of fit was verified extraorally. Fig 29 (right)Periapical radiograph used to verify fit.
34 shows the detailed optical characteristics of natural enamel and dentin under different light sources. Fluorescence is a crucial property for natural esthetics.3032 Colorants and fluorescent modifiers that can be
applied to zirconia abutments even after milling and finishing have recently been developed.30 The abutment or framework is dipped into a fluorescent coloring liquid before sintering to infiltrate the zirconia (Colour Liquid
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Case 3 Continued
Fig 30 Optical properties of the provisional crown under natural light.
Fig 31 Optical properties of the provisional crown under UV light. Note the lack of fluorescence.
Fig 32 Optical properties of the zirconia abutment under natural light.
Fig 33 Optical properties of the zirconia abutment under UV light reveals a lack of fluorescence. Fig 34 Color characteristics of natural enamel and dentin: (a) The three basic color zones; (b) areas of brightness/value; (c) enamel characteristics under a polarizing filter; (d) color characteristics of dentin; (e) degrees of dentin fluorescence under UV light.
Fluoreszenz, Zirkonzahn). The abutment is blow dried after the dipping process to remove the excess and then placed under a drying lamp to prevent damage to the heating elements of the sinter furnace.
In addition to the regular zirconia, a more translucent zirconia (Prettau Zirconia Translucent, Zirkonzahn)
along with 16 coloring liquids (Zirkonzahn) are available. Figures 35 to 37 illustrate the infiltration process and its
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Case 3 Continued Fig 35 Three different abutments were fabricated with conventional zirconia, a more translucent zirconia (Prettau Zirconia Translucent), and fluorescent colorants (Colour Liquid Fluoreszenz): colored translucent zirconia with fluorescence (transl + fluoresc) and without fluorescence (translucent), and conventional zirconia with fluorescence (Zr + fluoresc). Natural light reveals the chroma characteristics.
Fig 36 Fabrication of a fluorescent abutment: (a) Provisional composite abutment; (b) duplicated zirconia abutment before the sinter process; (c) dipping of the zirconia abutment into fluorescent colorants before sintering; (d) definitive abutment after sintering.
Fig 37 The three different abutments under UV light. Conventional colored zirconia and fluorescing liquid (Zr + fluoresc) reveal the most favorable effect.
effect on the optical appearance under different light sources. Three different abutments were fabricated: translucent zirconia with and without fluorescence and conventional zirconia with fluorescence. Figures 38 to 40 show the pa-
tients favorable soft tissue thickness and the clinical try-in of the three different abutments under regular and UV light. Interestingly, the translucent abutment provided the best match in natural light but the worst under UV light.
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Case 3 Continued
Fig 38 (above left)Intraoral try-in of the three abutments under natural light. Fig 39 (above right)Ideal soft tissue thickness (> 3 mm). Fig 40 (left)Intraoral try-in of the three abutments under UV light.
The most favorable fluorescent effect was achieved with colored conventional zirconia and fluorescing liquid. In summary, the selection of zirconia implant abutments should be based on the following factors: 3D implant position: The screwaccess opening in the abutment should not compromise mechanical strength, and the circumferential thickness should be at least 0.8 mm. Soft tissue thickness: A minimum of 3 mm is ideal. Interocclusal space: Sufficient abutment height is required for ideal strength and resistance. Implant abutment color: The order of priority should be fluorescence/
value,
translucency,
and
shade
(chroma and hue). Color of the intended crown restoration (alumina versus zirconia). For optimal stability and fit of the coping, the preparation margin of the implant abutment is generally a circumferential chamfer or rounded shoulder. On the labial aspect, the margin is typically placed deeper than on the palatal aspect, but should not extend more than 1 mm subgingivally to avoid difficulties during cement removal. The abutment should support approximately 90% of the total surrounding soft tissue contour, with the crown supporting no more than 10%.30
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The provisional restoration generally remains in place for 4 to 6 weeks until the position of the tissue is stable. A final impression of the abutment should then be made to transfer this information to the laboratory for fabrication of the definitive restoration.
while enamel has low fluorescent properties.3032 Ceramic coping materials such as alumina37 and zirconia39 do not provide natural fluorescence and, therefore, are treated with fluorescent modifiers and/or veneered with fluorescent dentin stains, liners, and shoulder porcelains.30,37,39 As in natural teeth, the fluorescent effect is most prominent
Crown restoration
The definitive crown material is selected based on its core structure to enhance the optical characteristics of the intended restoration. The coping is chosen by its ability either to mask underlying structures or to complement the underlying abutment color. Zirconia is increasingly used as a coping material due to its versatility in respect to strength, thickness, color, and translucency, but especially due to its inherent brightness and options for fluorescence through infiltration.1317,30 It seems only logical that when a fluorescent abutment is used, the material selected for the definitive crown should also offer a certain degree of fluorescence to match the adjacent natural dentition.3032 It is important to evaluate the optical properties of the coping in relation to the remaining natural dentition under different light sources. UV light reveals the dramatic effects of fluorescence, which provides the vitality and brightness exhibited by natural teeth. Fluorescence is an inherent property of natural teeth31,32 but is rarely found in esthetic dental materials.3340 In natural teeth, the root and coronal dentin show the highest degree of fluorescence, especially in the gingival third,
in the gingival third of the restoration. Therefore, natural fluorescence does not only influence the optical effects of the restoration itself, but also greatly influences the color and appearance of the surrounding soft tissues.30 Figures 41 to 55 show the selection of the definitive coping material and the final outcome of Case 3. Figures 41 and 42 reveal the influence of fluorescent stains on the value and chroma of alumina and zirconia copings under natural and UV light. The impact of using a fluorescent (Fig 43) versus a nonfluorescent coping (Fig 44) is quite obvious on the stone cast (Figs 45 and 46) and even more so in the oral cavity (Figs 47 to 55). The definitive implant-supported crown shows optical and fluorescent properties that ideally match the existing natural dentition under various light sources.
Lip line
A high lip line or smile line that reveals all anterior teeth and large amounts of gingival tissue7,8 is a great challenge for the dental team since it is impossible to hide the implant-restorative interface. A high smile line may be due to vertical maxillary excess or a hypermobile lip.
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Case 3 Continued
Fig 41 The influence of fluorescent stains on the value and chroma of alumina and zirconia copings under natural light: (a and c) without fluorescence; (b and d) with fluorescence.
Fig 42 Fluorescent properties of alumina and zirconia copings under UV light: (a and c) without fluorescence; (b and d) with fluorescence.
Fig 43 Definitive fluorescent abutment on the stone cast demonstrating ideal fluorescence under UV light.
Fig 44 Nonfluorescent coping on the cast under UV light.
Fig 45 Fluorescent coping on the cast under UV light.
Fig 46 Definitive crown showing fluorescent properties under UV light.
It is a common rule that, besides being symmetric, the most cervical aspect of the gingival margins of the central incisors should be at the same level as the
canines, while the margins of the lateral incisors should be approximately 1 mm below an imaginary line drawn from the canine-centrals-canine.1 It seems
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Case 3 Continued
Fig 47 Intraoral try-in of definitive crown under natural light shows an excellent blend with the shade of the adjacent teeth.
Fig 48 Intraoral try-in under UV light demonstrates ideal blending of the fluorescent properties of the definitive crown with the adjacent teeth.
Fig 50 Postoperative occlusal view showing the soft tissue support and contour.
Fig 49 Definitive implant restoration. Fig 51 (right)The definitive abutment and restoration provide the same degree of fluorescence as a natural tooth.
advisable for central incisor implant restorations to initially place the gingival margin slightly more incisally. This slight overcompensation will prove
extremely helpful to counterbalance tissue recession typically seen over time. The CTG now becomes an essential aspect for functional and esthetic
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Case 3 Continued
Fig 52 Postoperative view under natural light showing the color match of the implant-supported crown with the natural dentition.
Fig 53 Postoperative view under UV light showing the ideal blend of fluorescent properties between the restoration and natural dentition.
Fig 54 Postoperative intraoral situation. No gray zone is evident.
Fig 55 One-year postoperative peri apical radiograph of the implant at the left central incisor site.
integration of the implant-supported restoration, especially in the presence of a high lip line. Occasionally, unfavorable changes of the gingival margin levels may occur at the teeth adjacent to the implant restoration. These are based on the distance between the free gingival margin and the supporting bone and may require more extensive tissue grafting to control gingival levels at both the
natural and implant-supported teeth. The added connective tissue causes the fibrotic mucosa around the implant to migrate more coronally. In rare cases, the additional soft tissue becomes so abundant that a gingivectomy followed by a fibrotomy becomes necessary to establish ideal crown lengths and gingival margin contours. The unfavorable umbrella effect is most prevalent in patients with a high
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Case 4
Fig 56 Intraoral view of the definitive zirconia abutment.
Fig 57 A CTG was placed earlier to ensure ideal soft tissue thickness.
Fig 58 Intraoral situation after 1 year reveals differences in peri-implant soft tissue color and morphology.
Fig 59 Preoperative view showing the patients high lip line.
Fig 60 Postoperative situation. An unfavorable gray zone is visible during an average smile.
Fig 61 A high smile reveals the gray zone through the umbrella effect.
smile line.6 The gray zone may become visible at the implant restoration site even when all of the key factors are implemented perfectly. Differences in soft tissue thickness and volume may cause these color dissimilarities, which are then amplified by the shear presence of
the upper lip, causing a shadow on the soft tissue and the light to be reflected and transferred in a different manner. Case 4 (Figs 56 to 61) demonstrates a situation in which the maxillary left central incisor was replaced with an implantsupported crown in a patient with a high
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Case 5
Fig 62 Intraoral view of the crown preparation of the right central incisor and the definitive colored zirconia implant abutment at the left central incisor.
Fig 63 UV light reveals the natural fluorescence of the modified zirconia implant abutment.
Fig 64 Preoperative intraoral view of the failing central incisor crowns.
Fig 65 Postoperative intraoral situation showing the color and soft tissue match.
Fig 66 Initial situation. Note the high lip line.
Fig 67 Successful implementation of the five key factors prevented the appearance of a gray zone despite the high smile line.
smile line. A CTG was placed to enhance the soft tissue contours. While all of the key aspects were implemented successfully, the slight differences in soft tissue volume created an unfavorable grayish effect (Figs 60 and 61).
In contrast to the previous case, Case 5 (Figs 62 to 67) exemplifies successful implementation of these key factors in a patient with a high lip line for long-term esthetic and functional success.
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Conclusions
Five key factors were identified to avoid the gray zone around maxillary anterior implant restorations: 3D implant placement, soft tissue thickness, abutment selection, crown restoration, and lip line. Mimicking the inherent optical properties, especially fluorescence, of natural teeth with ideal prosthetic implant components and crown materials is fundamental for ultimate restorative and soft tissue esthetics.
AcKnowledgments
The authors would like to thank Iigo Casares for the beautiful porcelain work featured in this article and Fernando Zozaya for the detailed fabrication on the zirconia abutments.
References
1. Chiche G, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Chicago: Quintessence, 1994. 2. Matthews TG. The anatomy of a smile. J Prosthet Dent 1978; 39:128134. 3. Fradeani M. Esthetic Analysis: A Systematic Approach to Prosthetic Treatment. Chicago: Quintessence, 2005. 4. Bitter RN. The periodontal factor in esthetic smile designAltering gingival display. Gen Dent 2007;55:616622. 5. Blatz MB, Hrzeler MB, Strub JR. Reconstruction of the lost interproximal papillaPresentation of some surgical and non-surgical procedures. Int J Periodontics Restorative Dent 1999;19:395406. 6. Magne P, Magne M, Belser U. The esthetic width in fixed prosthodontics. J Prosthodont 1999;8:106118. 7. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;39:502504. 8. Passia N, Blatz MB, Strub JR. Is the smile line a valid parameter for esthetic evaluation? A review of the literature. Eur J Esthet Dent (in press). 9. Fradeani M. Evaluation of dentolabial parameters as part of a comprehensive esthetic analysis. Eur J Esthet Dent 2006;1:6269. 10. Gamborena I, Blatz MB. Current clinical and technical protocols for single-tooth immediate implant procedures. Quintessence Dent Technol 2008;31:4960. 11. Holst S, Blatz MB, Hegenbarth E, Wichmann M, Eitner S. Prosthodontic considerations for predictable single-implant esthetics in the anterior maxilla. J Oral Maxillofac Surg 2005;63(suppl 2):8996. 12. Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: Surgical and prosthodontic rationales. Pract Proced Aesthet Dent 2001;13:691698. 13. Blatz MB, Bergler M, Holst S, Block M. Zirconia abutments for single-tooth implants Rationale and clinical guidelines. J Oral Maxillofac Surg 2009;67(suppl):7481. 14. Yildirim M, Edelhoff D, Hanish O, Spiekermann H. Ceramic abutmentsA new era in achieving optimal esthetics in implant dentistry. Int J Periodontics Restorative Dent 2000;20:8191. 15. Jung RE, Sailer I, Hmmerle CH, Attin T, Schmidlin P. In vitro color changes of soft tissues caused by restorative materials. Int J Periodontics Restorative Dent 2007;27:251257. 16. Jung RE, Holderegger C, Sailer I, Khraisat A, Suter A, Hmmerle CH. The effect of all-ceramic and porcelainfused-to-metal restorations on marginal peri-implant soft tissue color: A randomized controlled clinical trial. Int J Periodontics Restorative Dent 2008;28:357365. 17. van Brakel R, Noordmans HJ, Frenken J, de Roode R, de Wit GC, Cune MS. The effect of zirconia and titanium implant abutments on light reflection of the supporting soft tissues [epub ahead of print 20 Jan 2011]. Clin Oral Implants Res. 18. Garber DA. The esthetic dental implant: Letting restoration be the guide. J Am Dent Assoc 1995;126:319325. 19. Grunder U. Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after a healing period of 6 months: Report of 24 consecutive cases. Int J Periodontics Restorative Dent 2011;31:917.
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20. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: A 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants 2009;24:712719. 21. Speroni S, Cicciu M, Maridati P, Grossi GB, Maiorana C. Clinical investigation of mucosal thickness stability after soft tissue grafting around implants: A 3-year retrospective study. Indian J Dent Res 2010;21:474479. 22. Wiesner G, Esposito M, Worthington H, Schlee M. Connective tissue grafts for thickening peri-implant tissues at implant placement. Oneyear results from an explanatory split-mouth randomised controlled clinical trial. Eur J Oral Implantol 2010;3:2735. 23. Esposito M, Grusovin MG, Maghaireh H, Coulthard P, Worthington HV. Interventions for replacing missing teeth: Management of soft tissues for dental implants. Cochrane Database Syst Rev 2007;(3):CD006697. 24. Frhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single-tooth implant crowns: The pink esthetic score. Clin Oral Implants Res 2005;16:639644. 25. Att W, Kurun S, Gerds T, Strub JR. Fracture resistance of single-tooth implant-supported all-ceramic restorations after exposure to the artificial mouth. J Oral Rehabil 2006; 33:380386.
26. Nothdurft FP, Merker S, Pospiech PR. Fracture behaviour of implant-implantand implant-tooth-supported all-ceramic fixed dental prostheses utilising zirconium dioxide implant abutments. Clin Oral Investig 2011;15: 8997. 27. Scarano A, Piattelli M, Caputi S, Favero GA, Piattelli A. Bacterial adhesion on commercially pure titanium and zirconium oxide disks: An in vivo human study. J Periodontol 2004;75:292296. 28. Rimondini L, Cerroni L, Carrassi A, Torricelli P. Bacterial colonization of zirconia ceramic surfaces: An in vitro and in vivo study. Int J Oral Maxillofac Implants 2002;17: 793798. 29. Degidi M, Artese L, Scarano A, Perrotti V, Gehrke P, Piattelli A. Inflammatory infiltrate, microvessel density, nitric oxide synthase expression, vascular endothelial growth factor expression, and proliferative activity in periimplant soft tissues around titanium and zirconium oxide healing caps. J Periodontol 2006;77:7380. 30. Gamborena I, Blatz MB. FluoresenceMimicking nature for ultimate esthetics in implant dentistry. Quintessence Dent Technol 2011;34:723. 31. Benedict HC. A note on the fluorescence of teeth in ultra-violet rays. Science 1928;67:442. 32. Araki T, Miyazaki E, Kawata T, Miyata K. Measurements of fluorescence heterogeneity in human teeth using polarization microfluorometry. Appl Spectrosc 1990;44:627631.
33. Lee YK, Lu H, Powers JM. Fluorescence of layered resin composites. J Esthet Restor Dent 2005;17:93100. 34. Tani K, Watari F, Uo M, Morita M. Discrimination between composite resin and teeth using fluorescence properties. Dent Mater J 2003;22:569580. 35. SantAnna Aguiar Dos Reis R, Casemiro LA, Carlino GV, et al. Evaluation of fluorescence of dental composites using contrast ratios to adjacent tooth structure: A pilot study. J Esthet Restor Dent 2007;19:199206. 36. Monsngo G, Burdairon G, Clerjaud B. Fluorescence of dental porcelain. J Prosthet Dent 1993;69:106113. 37. Komine F, Blatz MB, Yamamoto S, Matsumura H. A modified layering technique to enhance fluorescence in glass-infiltrated aluminum oxide ceramic restorations: Case report. Quintessence Int 2008;39: 1116. 38. Marchack BW, Futatsuki Y, Marchack CB, White SN. Customization of milled zirconia copings for all-ceramic crowns: A clinical report. J Prosthet Dent 2008;99:169173. 39. Nik Mohd Polo Kinin NM, Wan Mohd Arif WI, Zainal Arifm A. Study on the effect of Y2O3 addition to the fluorescent property of dental porcelain. Med J Malaysia 2004;59 (suppl B):2324. 40. Ferreira Zandon AG, Kleinrichert T, Analoui M, Schemehorn BR, Eckert GJ, Stookey GK. Effect of two fluorescent dyes on color of restorative materials. Am J Dent 1997;10:203207.
46
Determining the Influence of Flowable Composite Resin Application on Cuspal Deflection Using a Computerized Modification of the Strain Gauge Method
Hamdi H. Hamama, BDS, MDS
Assistant Lecturer, Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
Nadia M. Zaghloul, BDS, MDS, PhD

Associate Professor, Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
Ossama B. Abouelatta, BEng, MSc Engg, PhD

Associate Professor, Production Engineering and Mechanical Design Department, Faculty of Engineering, Mansoura University, Mansoura, Egypt.
Abeer E. El-Embaby, BDS, MDS, PhD

Lecturer, Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
Correspondence to: Dr Hamdi H. Hamama

Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, PO Box 35516, Mansoura, Egypt. Email: hamdy@hku.hk
48
This study evaluated the influence of the application of flowable composite resin on cuspal deflection using a computerized modification of the strain gauge method. Forty sound extracted mandibular molars, which received a mesioocclusodistal slot preparation, were divided into two groups of 20 molars each based on the type of restorative materials used. Each group was further divided into two subgroups of 10 molars each relative to the application of flowable composite resin at cavity internal line angles. Cuspal deflection was measured using a new computerized modification of the strain gauge method. The mean cuspal deflection values (m/m) and standard deviations were calculated and subjected to normality and homogeneity of variances tests. If they passed the tests, they were subjected to parametric statistical analysis (independent sample t test). The results showed that groups containing flowable composite resin exhibited higher cuspal deflection values than groups without flowable composite resin. The application of flowable composite resin at the internal cavity line angles increased cuspal deflection, possibly due to the materials high volumetric shrinkage levels, which exerted more stress at the tooth-restoration interface. Further, the validity of the new computerized modification of the strain gauge method was proven by the agreement found between the output results and those of previous studies of cuspal deflection. (Am J Esthet Dent 2011;1:4859.)
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apid development of resin-based dental composites is one of the
line angles is one of the most controversial topics in dentistry. Some studies support its use due to its stretching capability (ie, its low Young modulus of elasticity), which provides sufficient elasticity to relieve polymerization contraction stresses.5,1014 In contrast, some studies suggest that the application of flowable composite resin increases contraction stresses due to the materials high resin content.1517 Cuspal deflection is a common biomechanical phenomenon observed in teeth restored with composite resin. It results from the interactions between the polymerization shrinkage stresses of the composite resin and the compliance of the cavity wall.18 There are many methods to measure cuspal deflection, including noncontact methods (photography,19 microscopy,20,21 laser scanning,22 contact able and three-dimensional and vari(strain and gauge,6,24 linear microcomputed tomography23)
main characteristics of modern esthetic dentistry. Resin-based composite is now widely used as an alternative to amalgam in stress-bearing areas.1 Consider-
ing the polymeric nature of composite resin, it has an inherited volumetric polymerization shrinkage property that leads to contraction stresses at the restoration-cavity interface.2 This poly merization shrinkage has been reported to be one of the factors directly responsible for marginal leakage at the composite restorationcavity wall interface.3 The interaction of the polymerization shrinkage stresses and the adhesive bond plays a large role in the long-term function of a composite resin restoration. At sites where these stresses are higher than the bond strength between the restoration and dental substrate, a microgap will form, increasing the probability of postoperative sensitivity and recurrent caries.4,5 On the other hand, if the bond strength is higher than the polymerization contraction stresses, the stresses will transfer to the cusps, resulting in cuspal resins, commonly deflection.2,68 called flowable A class of low-viscosity composite composite resins, has been commercially introduced for restorative dentistry. Flowability is regarded as a desirable handling property because it allows the material to be injected through smallgauge dispensers, thus simplifying the placement procedure and amplifying the range of applications suggested by the manufacturers.9,10 The effectiveness of flowable composite resin as an intermediate layer at the internal cavity
methods
interferometers,25 differential
transformers2629).
Because these methods depend primarily on measuring the difference between precuring and postcuring values, they have not provided detailed data regarding how cuspal deflection happens in relation to time. However, the present authors introduce a modification of the strain gauge method, which was developed in cooperation between the engineering and dental teams of this study. This study was designed to evaluate the effect of the application of flowable composite resin on cuspal deflection of mesio-occlusodistal (MOD) composite restorations. Cuspal deflection was
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Table 1 Composite resin systems used in this study

Material Scientific classification Trade name Batch no. Manufacturer
Composite resin Restoration Nanohybrid Tetric EvoCeram HB Grandio Tetric EvoFlow Grandio Flow Excite J25791 J25793 J25470 K20207 K15010 J13387 J14049 Ivoclar Vivadent VOCO Ivoclar Vivadent VOCO Ivoclar Vivadent
Restoration liner
Nanohybrid Filled, light-curing single component bonding agent for enamel and dentin in conjunction with the acid etch technique Etching gel containing 37% phosphoric acid
Bonding system
Total Etch
Ivoclar Vivadent
measured using the new modification of the strain gauge method. The null hypothesis was that application of flowable composite resin does not increase the cuspal deflection of MOD composite resin restorations.
distance. The collected molars were observed under magnification (10) in a binocular stereomicroscope (LOMO SF-100 Binocular Stereo Microscope, MBC-10). Teeth with preexisting cracks, caries, or attrition were discarded. The selected molars were carefully cleaned using an ultrasonic scaler (UDS-J
Materials and methods

The materials used in this study are listed in Table 1.
Ultrasonic Scaler, Ningbo Sunglow Imp & Exp) and then debrided with pumice (Americos Industries) using a rotary brush (Merssage Brush, Shofu). The molars were disinfected with 0.2% sodium azide solution for 48 hours.30 To prevent dehydration, they were stored in physiologic saline for a period of no more than 1 month at 37C until the time of the test. The molars were randomly divided into two groups (20 molars each) based on the restorative material used (Tetric EvoCeram or Grandio). Next, each group was randomly subdivided into two subgroups (n =10) relative to the application of flowable composite resin at the internal cavity line angles.
Tooth selection and preparation

A total of 40 sound extracted mandibular molars were collected from the Oral Surgery Department, Faculty of Dentistry, Mansoura University, Mansoura, Egypt. The patients were informed that the voluntarily donated extracted teeth would be used for research purposes. To be included in the study, the molars were required to have the following crown dimensions: 9-mm buccolingual distance and 10- to 11-mm mesiodistal
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Each specimen received a nonretentive MOD slot preparation with the following criteria: occlusogingival depth of 4 0.3 mm without an axial wall and a buccolingual diameter of 3 0.3 mm. The remaining buccal and lingual cavity walls were measured using an electronic digital caliper (MAX-CAL) after preparation for verification of the buccolingual diameter. The preparation was carried out using a no. 59 carbide bur (Komet Dental).
connected to the gauge so that the gauge constituted one-half of a Wheatstone bridge, with the other half internal to the strain gauge indicator. One layer of the Excite universal bonding system was applied and cured using a lightcuring unit (Bluephase C8, Ivoclar Vivadent) at 800 mW/cm2 for 20 seconds. The light intensity was checked by radiometer (Bluephase Meter, Ivoclar Vivadent) prior to performing the test to confirm that the light intensity was not less than 700 mW/cm2. The teeth were restored with resinbased composite materials in shade A2 according to the following groups: Group A: Flowable composite resin (Tetric EvoFlow) was applied at the internal cavity line angles with a small-gauge needle and cured for 20 seconds. Tetric EvoCeram was inserted horizontally in increments. Each increment was approximately 2-mm thick and cured for 60 seconds: 20 seconds from the occlusal aspect, 20 seconds from the mesial aspect, and 20 seconds from the distal aspect. Group B: This group was similar to group A, except it did not receive flowable composite resin prior to insertion of Tetric EvoCeram. Group C: Flowable composite resin (Grandio Flow) was applied at the internal cavity line angles with a small-gauge needle and cured for 20 seconds. Grandio was inserted horizontally in increments. Each increment was approximately 2-mm thick and cured for 60 seconds: 20 seconds from the occlusal aspect,
Cuspal deflection test

A 3-cm polyvinyl chloride tube was filled with acrylic resin (Rapid Repair, Dentsply) in the dough stage. The molars roots were positioned at the tube center and parallel to its long axis, leaving the crown and 2 mm of the root below the cementoenamel junction uncovered to accommodate the leads of the strain gauge. A dental surveyor was used to verify that the tooth was parallel to the tube. After setting of the acrylic resin, the parallelism of the cavity buccal and lingual walls was confirmed by the same surveyor. All prepared cavities were etched using Total Etch for 15 seconds according to the manufacturers instructions. Two precision strain gauges (KFG-2N120-C1-11L1M2R, Kyowa Electronic Instruments) were attached to the buccal and lingual surfaces of each unrestored specimen and bonded with epoxy adhesive resin (Strain Gauge Cement, Kyowa Electronic Instruments) to the middle third of the cavitys external buccal and lingual walls (Fig 1). The leads of the strain gauge indicator were
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Personal computer Strain indicator program AD card Tooth fixation 3-channel amplifier Curing unit
a Fig 1 (above)Buccal view of the strain gauges bonded to the middle third of the external cavity wall. Fig 2a to 2c (right)The strain measurement system.
20 seconds from the mesial aspect, and 20 seconds from the distal aspect. Group D: This group was similar to group C, except it did not receive flowable composite resin prior to insertion of Grandio. During polymerization, the strain
The present study is based on the data range, ie, the difference between the maximum and minimum strain values. However, the data curves will be analyzed in detail in future studies.
Strain measurement system

The strain measurement system consisted of a three-channel amplifier circuit (Metrology Lab, Faculty of Engineering, University of Mansoura), an AD card, and a personal computer with the Strain Indicator Program (SIProg), which was designed for this study by Dr Abouelatta (Fig 2). SIProg was fully written in house using Matlab packages. The main interface is shown in Fig 3. It consists of a title bar, menu bar, measuring information panel, processing panel, option panel, and display area. To calibrate
gauge recorded the changes in voltage signals, which were then amplified by the recording system. The amplified signals were transferred using an analog-todigital converter (AD) card to a specially designed computer program (SIProg) for analysis. The results appeared as a curve between the time (seconds) and strain values. These readings for the Wheatstone bridge are directly proportional to the internal cuspal deflection of the buccal and lingual cusps of tested specimens.31
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Title bar Menu bar Display area
Fig 3 Graphical user interface of the Strain Indicator Program (SIProg).
the strain measuring system, specific
microstrain () values were applied on a sample tooth. The strain measurements were recorded using P-3500 Strain Indicators and SB-10 Switch and Balance Units (Vishay Measurements Group). The same values were recorded by the system in millivolts. A graph representing the relation between the strain measurement and corresponding voltage was plotted using an Excel spreadsheet (Microsoft).
statistically significant when P < .05 with a confidence level of 95%.
Results and discussion

The independent sample t test showed a statistically significant difference (P < .001) between flowable and nonflowable groups in both the buccal and lingual cusps. This finding led to a rejection of the null hypothesis. Specimens with flowable composite resin had higher cuspal deflection values than specimens without flowable composite resin. The results of the statistical analyses are shown in Tables 2 and 3. Figure 4 shows an example of the output curves. The mean cuspal deflection values obtained from the buccal cusp for flowable composite resin groups were 41.91 m/m for Tetric EvoCeram and 44.59 m/m for Grandio. The mean cuspal deflection values of the nonflowable groups were 32.64 m/m and 39.40 m/m for Tetric EvoCeram and Grandio, respectively. This showed
Data analysis
Ten specimens were tested for each group. SAS version 6.12 for Windows (SAS Institute) was used for all statistical analyses. The mean cuspal deflection values (m/m) and standard deviations were calculated and subjected to normality and homogeneity of variance tests. If they passed the tests, they were subjected to parametric statistical analysis (independent sample t test). All tests were two-sided analyses, and differences were considered
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Table 2 Comparison (t test) of cuspal deflection in specimens with and without flowable composite resin (buccal cusp)
P SE SD Mean (m/m) N Flowable composite Composite system
< .001* < .001*
1.71 0.51 0.57 0.34
4.52 1.35 1.79 1.09
41.91 32.64 44.59 39.40
10 10 10 10
Yes No Yes No
Tetric EvoCeram Grandio
SE = standard error; SD = standard deviation. *Significantly different at P < .05.
Table 3 Comparison (t test) of cuspal deflection in specimens with and without flowable composite resin (lingual cusp)
P SE SD Mean (m/m) N Flowable composite Composite system
< .001* < .001*
0.55 1.18 0.41 0.36
1.46 3.12 1.29 1.13
22.24 16.02 21.73 16.51
10 10 10 10
Yes No Yes No
Tetric EvoCeram Grandio
SE = standard error; SD = standard deviation. *Significantly different at P < .05.
that groups without flowable composite resin exhibited less cuspal deflection than groups with flowable composite resin (Table 2). The mean cuspal deflection values obtained from the lingual cusp for flowable composite resin groups were 22.24 m/m for Tetric EvoCeram and 21.73 m/m for Grandio. The mean cuspal deflection values of the nonflowable groups were 16.02 m/m and 16.51 m/m for Tetric EvoCeram and Grandio, respectively. This showed that groups without flowable composite resin exhibited less cuspal deflection than groups with flowable composite resin (Table 3). This study used two commercial nanohybrid composite resin systems, each with its own flowable composite
resin. This was done to exclude the manufacturing factor and to avoid bias toward one brand. The width of the buccolingual cavity was slightly larger than that of an ideal clinical situation. This was selected to decrease the remaining buccal and lingual walls and increase the sensitivity of the strain gauge. The selection of a nanofilled universal twostep etch-and-rinse adhesive system was based on previous studies showing that this system is the gold standard for bonding with dentin. The advantage of the new computerized measuring system used in this study was that it provided accurate details about the process of deflection in a curve format consisting of peaks and valleys, which will be further explained in future studies. The
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Hamama et al
Fig 4 Sample of an output
3630
curve drawn using SIProg.
3620 Strain (m/m)
3610
3600
3590
10
20
30
40 Time (s)
50
60
accuracy of measurements even when based only on deflection range values (difference between the postcuring and precuring values) is more reliable than with conventional measuring systems because the data are automatically calculated by SIProg. This new measuring system also provides a large amount of data storage and easy recall. The results showed that the highest levels of strain were produced during exposure of the restoration to the light source for polymerization. The high stresses associated with the application of flowable composite resin may be explained by the materials low filler content and high resinous content, which increases the polymerization shrinkage.9,3235 The strain levels did not decrease during placement of the restoration, and any stress relaxation resulting from the flow of the material was not sufficient to overcome the poly merization shrinkage. The results support the findings of previous studies. One study suggested
that flowable composite resins shrink more than conventional composite resins, creating more stress on the bonding agent during curing and possibly allowing for premature deflection of the overlaying conventional composite resin. The authors attributed this to the difference in flexural modulus caused by the changes in filler content.33 Another study disagreed with the concept that shrinkage stress generated by a subsequent layer of higher modulus composite resin could be absorbed by an elastic intermediary layer.17 A review article on polymerization shrinkage noted that flowable composite resins produced stress levels similar to those of nonflowable materials.36 In addition, an in vitro study concluded that the use of flowable materials does not lead to marked stress reduction and increases the risk of debonding at the adhesive interface as a result of polymerization shrinkage.37 Oliveira et al38 strongly confirmed that using flowable composite resin as a liner or base
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material under a composite resin restoration increases polymerization shrinkage stresses at the adhesive interface, potentially leading to adhesive failure. Chuang et al39 concluded that the use of flowable composite resin lining may aggravate cusp flexure. On the other hand, some studies did not support the current results. One study showed that the use of composite resin liners with a low elastic modulus was a satisfactory technique for partial absorption of the stress generated by polymerization shrinkage; however, this study was performed using composite resin blocks, which were not inserted in prepared cavities.40 Another study supported the inverse relationship between filler percentage and shrinkage strain, which was explained by the corresponding decrease in the volume fraction of monomers present to undergo polymerization. The conclusion of this study should not be generalized, however, because it showed bias toward two types of flowable composite resins and ultimately stated that these types still suffered from polymerization shrinkage.41 Finally, a study introducing a new method of measuring cuspal deflection reported that polymerization shrinkage tended to decrease as filler content increased. This study used a noncontact cuspal deflection measuring method based on a laser displacement sensor; unfortunately, the validity of noncontact measurements is still under investigation.22 Based on the results of this study, the null hypothesis that application of flowable composite resin does not increase cuspal deflection of MOD com-
posite resin restorations was rejected. Further, the validity of the new computerized modification of the strain gauge method was proven by the agreement of the results with those of other cuspal deflection studies.
Conclusions
Under the conditions of this study, it was concluded that the application of flowable composite resin at the internal cavity line angles increased cuspal deflection, possibly due to the materials high volumetric shrinkage, which exerts more stress at the toothrestoration interface. The limitation of the new measuring system used was the need to obtain two symmetric buccal and lingual channels to be able to judge whether the deflection occurs simultaneously in both cusps or in one cusp more than the other. This limitation can now be addressed by the engineering team of this study. The use of flowable composite resin is not preferred in MOD cavities because it increases internal polymerization stress, which leads to greater cuspal deflection. Further investigation is needed to carefully study the SIProg output curves.
Acknowledgments
The authors express their deepest gratitude and appreciation to Dr Geoff Smith, Center for Applied English Studies, The University of Hong Kong, for his work in revising the articles language. They also thank VOCO for supplying the Grandio and Grandio Flow materials.
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References
1. Jokstad A, Mjr IA. Analyses of long-term clinical behavior of class-II amalgam restorations. Acta Odontol Scand 1991;49: 4763. 2. Marchesi G, Breschi L, Antoniolli F, Di Lenarda R, Ferracane J, Cadenaro M. Contraction stress of lowshrinkage composite materials assessed with different testing systems. Dent Mater 2010;26: 947953. 3. Ozgnaltay G, Grc J. Fracture resistance of class II packable composite restorations with and without flowable liners. J Oral Rehabil 2005;32: 111115. 4. Eick JD, Welch FH. Polymerization shrinkage of posterior composite resins and its possible influence on postoperative sensitivity. Quintessence Int 1986;17:103111. 5. Li QS, Jepsen S, Albers HK, Eberhard J. Flowable materials as an intermediate layer could improve the marginal and internal adaptation of composite restorations in Class-V-cavities. Dent Mater 2006;22:250257. 6 McCullock AJ, Smith BG. In vitro studies of cusp reinforcement with adhesive restorative material. Br Dent J 1986;161: 450452. 7. Suliman AH, Boyer DB, Lakes RS. Polymerization shrinkage of composite resins: Comparison with tooth deformation. J Prosthet Dent 1994;71:712. 8. Van Ende A, De Munck J, Mine A, Lambrechts P, Van Meerbeek B. Does a low-shrinking composite induce less stress at the adhesive interface? Dent Mater 2010;26:215222. 9. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymerization shrinkage and elasticity of flowable composites and filled adhesives. Dent Mater 1999;15:128137. 10. Lee IB, Min SH, Kim SY, Ferracane J. Slumping tendency and rheological properties of flowable composites. Dent Mater 2010;26:443448. 11. Beun S, Bailly C, Dabin A, Vreven J, Devaux J, Leloup G. Rheological properties of experimental Bis-GMA/ TEGDMA flowable resin composites with various macrofiller/microfiller ratio. Dent Mater 2009;25:198205. 12. Lindberg A, van Dijken JMV, Hrstedt P. In vivo interfacial adaptation of class II resin composite restorations with and without a flowable resin composite liner. Clin Oral Investig 2005;9:7783. 13. Roberson TM, Heymann H, Swift EJ, Sturdevant CM. Sturdevants Art and Science of Operative Dentistry, ed 5. St Louis: Elsevier Mosby, 2006. 14. Summitt JB. Fundamentals of Operative Dentistry: A Contemporary Approach, ed 3. Chicago: Quintessence, 2006. 15. Stefanski S, van Dijken JW. Clinical performance of a nanofilled resin composite with and without an intermediary layer of flowable composite: A 2-year evaluation [epub ahead of print 23 Nov 2010]. Clin Oral Investig. 16. Gallo JR, Burgess JO, Ripps AH, et al. Three-year clinical evaluation of two flowable composites. Quintessence Int 2010;41:497503. 17. Unterbrink GL, Liebenberg WH. Flowable resin composites as filled adhesives: Literature review and clinical recommendations. Quintessence Int 1999;30:249257. 18. Lee MR, Cho BH, Son HH, Um CM, Lee IB. Influence of cavity dimension and restoration methods on the cusp deflection of premolars in composite restoration. Dent Mater 2007; 23:288295. 19. Segura A, Donly KJ. In vitro posterior composite polymerization recovery following hygroscopic expansion. J Oral Rehabil 1993;20:495499. 20. Alomari QD, Reinhardt JW, Boyer DB. Effect of liners on cusp deflection and gap formation in composite restorations. Oper Dent 2001; 26:406411. 21. Suliman AA, Boyer DB, Lakes RS. Cusp movement in premolars resulting from composite polymerization shrinkage. Dent Mater 1993; 9:610. 22. Miyasaka T, Okamura H. Dimensional change measurements of conventional and flowable composite resins using a laser displacement sensor. Dent Mater J 2009; 28:544551. 23. Sun J, Lin-Gibson S. X-ray microcomputed tomography for measuring polymerization shrinkage of polymeric dental composites. Dent Mater 2008; 24:228234. 24. Meredith N, Setchell DJ. In vitro measurement of cuspal strain and displacement in composite restored teeth. J Dent 1997;25:331337. 25. Suliman AA, Boyer DB, Lakes RS. Interferometric measurements of cusp deformation of teeth restored with composites. J Dent Res 1993;72: 15321536. 26. Jantarat J, Panitvisai P, Palamara JE, Messer HH. Comparison of methods for measuring cuspal deformation in teeth. J Dent 2001;29:7582. 27. Li JY, Fok ASL, Satterthwaite J, Watts DC. Measurement of the full-field polymerization shrinkage and depth of cure of dental composites using digital image correlation. Dent Mater 2009;25:582588. 28. Pearson GJ, Hegarty SM. Cusp movement of molar teeth with composite filling materials in conventional and modified MOD cavities. Br Dent J 1989; 166:162165. 29. Pearson GJ, Hegarty SM. Cusp movement in molar teeth using dentine adhesives and composite filling materials. Biomaterials 1987;8:473476. 30. Dietschi D, Olsburgh S, Krejci I, Davidson C. In vitro evaluation of marginal and internal adaptation after occlusal stressing of indirect class II composite restorations with different resinous bases. Eur J Oral Sci 2003;111:7380.
58
Hamama ET AL
31. Donly KJ, Wild TW, Bowen RL, Jensen ME. An in vitro investigation of the effects of glass inserts on the effective composite resin polymerization shrinkage. J Dent Res 1989;68:12341237. 32. Alvarez-Gayosso C, BarcelSantana F, Guerrero-Ibarra J, Sez-Espnola G, CansecoMartnez MA. Calculation of contraction rates due to shrinkage in light-cured composites. Dent Mater 2004;20:228235. 33. Bayne SC, Thompson JY, Swift EJ Jr, Stamatiades P, Wilkerson M. A characterization of first-generation flowable composites. J Am Dent Assoc 1998;129:567577. 34. Kleverlaan CJ, Feilzer AJ. Polymerization shrinkage and contraction stress of dental resin composites. Dent Mater 2005;21:11501157.
35. Stansbury JW, Trujillo-Lemon M, Lu H, Ding X, Lin Y, Ge J. Conversion-dependent shrinkage stress and strain in dental resins and composites. Dent Mater 2005;21:5667. 36. Braga RR, Ferracane JL. Alternatives in polymerization contraction stress management. Crit Rev Oral Biol Med 2004;15:176184. 37. Cadenaro M, Marchesi G, Antoniolli F, Davidson C, Dorigo ED, Breschi L. Flowability of composites is no guarantee for contraction stress reduction. Dent Mater 2009;25:649654. 38. Oliveira LCA, Duarte S Jr, Araujo CA, Abraho A. Effect of low-elastic modulus liner and base as stress-absorbing layer in composite resin restorations. Dent Mater 2010;26: e159e169.
39. Chuang SF, Chang CH, Chen TY. Spatially resolved assessments of composite shrinkage in MOD restorations using a digital-image-correlation technique. Dent Mater 2011; 27:134143. 40. Cunha LG, Alonso RC, Sobrinho LC, Sinhoreti MA. Effect of resin liners and photoactivation methods on the shrinkage stress of a resin composite. J Esthet Restor Dent 2006;18:2936. 41. Baroudi K, Saleh AM, Silikas N, Watts DC. Shrinkage behaviour of flowable resin-composites related to conversion and filler-fraction. J Dent 2007;35: 651-655.
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All-Ceramic Crowns and Extended Veneers in Anterior Dentition: A Case Report with Critical Discussion
Jnio S. Almeida e Silva, DDS, MSc
PhD Student, Operative Dentistry Division, Federal University of Santa Catarina, Florianpolis, Brazil; Visiting Researcher, Department of Prosthodontics, Ludwig-Maximilians University, Munich, Germany.
Juliana Nunes Rolla, DDS, MSc, PhD

Professor, Department of Conservative Dentistry, Federal University of Rio Grande do Sol, Porto Alegre, Brazil.
Daniel Edelhoff, DDS, MSc, PhD

Associate Professor, Department of Prosthodontics, Ludwig-Maximilians University, Munich, Germany.
lito Araujo, DDS, MSc, PhD

Professor, Integrated Clinic, Federal University of Santa Catarina, Florianpolis, Brazil.
Luiz Narciso Baratieri, DDS, MSc, PhD

Professor and Chair, Operative Dentistry Division, Federal University of Santa Catarina, Florianpolis, Brazil.
Correspondence to: Dr Jnio S. Almeida e Silva

Goethestrasse 70 apt. 314, LMU Dental School, Munich, Germany 80336. Email: juniosantos1710@yahoo.com.br
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All-ceramic crowns and veneers have been used extensively in prosthodontics with proven clinical success. The development of new reinforced ceramics has led to a broader range of indications. Traditional veneer preparations are now often replaced with extended defect-oriented preparation designs, ie, extended veneers. However, although extended veneers can serve as an alternative to fullcrown preparations, they are not the best choice for all clinical situations. Choosing correctly between all-ceramic crowns and extended veneers when restoring the anterior dentition is crucial to achieving a conservative and long-lasting treatment. This article addresses key evidence-based considerations regarding the rehabilitation of the anterior dentition using all-ceramic crowns and veneers. Further, a case report involving both types of restorations is presented. (Am J Esthet Dent 2011;1:6081.)
placement for missing teeth and is available in a range of shades and translucencies.1,2 In the past, due to
eramic is known as the most natural-looking synthetic re-
its relatively low tensile strength and brittleness, ceramic was generally fused to a metal substrate to increase fracture resistance, and its indication was limited to full-coverage crowns for
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AlMeida E Silva et al
both anterior and posterior dentition.3 However, the metal base compromises esthetics by decreasing light transmission through the porcelain and by creating metal ion discolorations that can cause significant darkening of the surrounding gingiva. This is known as the umbrella effect.4 To overcome such problems, new ceramic systems and innovative restorative techniques that wed esthetics with function have been introduced, along with scientific evidence endorsing their clinical application. As a result, all-ceramic systems now represent an excellent restorative alternative for fixed dental prostheses, single crowns, and veneers in the anterior dentition.5,6 The successful clinical performance of all-ceramic crowns and veneers has been well established.612 However, the combination of media-driven treatment plans, rushed-to-the-market products, and dentists eager to satisfy their patients esthetic demands have formed a dangerous triad with little concern for the risk/benefit calculus of dental treatment.13 The resulting overuse of ceramic veneers is likely a result of these new reinforced ceramics, which have a broader range of indications and which have led to the replacement of traditional veneer preparations with extended defect-oriented preparation designs. These extended veneers offer an alternative to full crowns in the anterior dentition.10,1417 The remarkable clinical success of all-ceramic veneers and crowns notwithstanding,5,6 the restoration enters into a restorative cycle as soon as it is placed following tooth preparation.18,19
All-ceramic crowns have been used extensively in prosthodontics over the past few years because their clinical success has been similar to that of metal-ceramic crowns, with excellent survival rates of 98.9% in the anterior region after 11 years.5,6,13,20 The main causes of failure include catastrophic fracture, chipping of the veneer ceramic, and secondary caries.5 Although ceramic veneers are a minimally invasive approach compared to crowns, less tooth reduction does not always result in increased longevity. It has been shown that after 10 years of clinical service, reintervention without restoration replacement occurs in 36% of teeth restored with ceramic veneers, whereas 7% of teeth restored with ceramic veneers might receive a more invasive treatment approach.21,22 The main reported causes of ceramic veneer failure include fracture, microleak age, and debonding. That is to say, ceramic veneers are more susceptible to future interventions; therefore, it is crucial that the clinician be aware of the correct indications for ceramic veneers to provide the ideal result in terms of longevity.19 Nevertheless, neither all-ceramic crowns nor traditional ceramic veneers should always be the first choice in the anterior dentition because several factors must be taken into consideration before elaborating a treatment plan. This article addresses key evidencebased considerations regarding the rehabilitation of the anterior dentition using all-ceramic crowns and veneers. Further, a case report involving both types of restorations is presented.
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Almeida e Silva ET AL
Fig 1 Preoperative labial view. Note the unesthetic appearance of the anterior dentition.
Fig 2 Preoperative palatal view showing proximal excess of the former composite resin llings, especially on the mesial surface of the maxillary left central incisor.
Case report
The following case report describes the rehabilitation of the anterior dentition with all-ceramic crowns and extended veneers as well as two ceramic partialcoverage restorations on the maxillary left and right first premolars using leucite glass-ceramic (IPS Empress, Ivoclar Vivadent). The 29-year-old male patient presented for esthetic rehabilitation of
the anterior teeth. Clinical and radiographic examination revealed the presence of unsatisfactory Class III and IV composite resin fillings, some of which were associated with secondary caries, discolored teeth due to root canal treatment, and slight tooth misalignment with length discrepancies in the anterior dentition (Figs 1 and 2). Periodontal evaluation found no pathologic probing depths. Occlusal examination revealed
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normal Class 1 occlusion with functional canine and incisal guidance and the presence of a slight anterior overjet. No signs of parafunction were observed. Both lateral incisors and the left central incisor had been endodontically treated, and their clinical crowns were deeply compromised. For these nonvital teeth, fiber posts were cemented, the pulp chambers were restored, and the pre-existing Class III and IV composite resin fillings were replaced. The old composite resin fillings of the remaining vital teeth were replaced as well. Three all-ceramic crowns were planned to restore the nonvital teeth. Extended ceramic veneers were planned to restore the anterior vital teeth, and each premolar would receive a partial-coverage ceramic restoration. The decision to prepare the vital anterior teeth for extended veneers was based on the extension of the preexisting composite resin fillings, which further oriented the preparations palatally.10 Moreover, since these ceramic veneers would be placed adjacent to ceramic crowns, an extended preparation allowed the crowns and veneers to be made with the same ceramic. There is usually an interproximal cosmetic mismatch due to the differing thicknesses of the adjacent restorations, which can be corrected by the ceramist if extended veneer preparations are made.23 The maxillary premolars were included in the rehabilitation because both had unsatisfactory mesio-occlusodistal composite resin restorations, which were not only associated with secondary caries, but also showed enamel cracks at the mesial and facial surfaces.
Although some of the composite resin fillings were associated with secondary caries, the patient did not present high caries activity. Caries lesions were more likely to be developed due to proximal composite resin excess and poor bonding of the former restorations; therefore, removal of the pre-existing restorations eliminated the source of microleakage and secondary caries incidence. Leucite glass-ceramic was the material of choice because it allows for adhesive cementation. All vital teeth displayed plenty of enamel, and even the nonvital teeth had preparation margins completely bounded by enamel. Further, the longevity of this ceramic system for both crowns and extended veneers has been well established.5,6,10,20 Finally, this esthetic material was a feasible choice because the patient did not present any para functional habits.
Crown preparation
The first phase of the crown preparation involved the use of a spherical diamond bur, which was positioned 45 degrees perpendicular to the tooth long axis on the facial cervical area so that the reduction would end at half of the burs diameter (Fig 3). A cylindric, tapered, round-end diamond bur was used in the second phase to create three facial reduction grooves respecting the axial inclinations of the tooth. The grooves were subsequently evened (Figs 4 to 6). The depth of each reduction was constantly controlled using the silicone guide. The final crown preparations would be approximately 2.0 mm deep.
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Fig 3 (right)First phase of crown preparation of the maxillary left central incisor. The spherical diamond bur was positioned 45 degrees perpendicular to the tooth long axis. Figs 4 to 6 (below)Second phase of crown preparation. Facial reduction grooves were created respecting the tooth axial inclinations.
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Fig 7 Third phase of crown preparation. A 1.5-mm reduction was still necessary to achieve the desired 3 mm. Incisal reduction was performed using the same diamond bur used for the second phase.
The incisal reduction was carried out in the third phase of the preparation. Because the silicone guide registered a pre-existing incisal space of approximately 1.5 mm according to the waxup, an additional 1.5-mm reduction was performed with the cylindric, tapered, round-end diamond bur to achieve a 3-mm incisal reduction (Fig 7). The fourth phase consisted of the interproximal and palatal wraparound. A very thin and tapered diamond bur was used to create a slit from the facial to palatal surfaces (Figs 8 and 9). This maneuver created space for the
application of a larger bur for the wraparound (Figs 10 and 11). The palatal surface was then reduced with the aid of a spherical diamond bur positioned parallel to the tooth long axis to create a supragingival cervical groove (Fig 12). Next, a cylindric, tapered, round-end diamond bur and a rounded bur were applied parallel to the tooth long axis on the palatal surface and palatal concavity, respectively, to create functional room for the ceramic (Figs 13 and 14). Following these reductions, the gross preparation was completed.
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Figs 8 to 14 Fourth phase of crown preparation, which consisted of the interproximal and palatal wraparound.
Figs 15 and 16 Finishing was carried out using extra-ne diamond nishing burs with decreasing coarseness.
Special extra-fine finishing diamonds with decreasing coarseness were used along with rubber points to obtain a wellrefined preparation and working cast (Figs 15 and 16). Finishing is essential
to eliminate sharp angles and undercut and provide smooth contours.24 Wellfinished preparations reduce the risk of postbonding cracks and facilitate the technicians work.25,26
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Figs 17 to 19 Completed tooth preparations.
Extended veneer preparation

The preparation sequence for the extended veneers was similar to that described for the crown reductions. However, veneer preparations are by nature less invasive and do not involve the entire palatal surface. The first phase consisted of the use of a spherical diamond bur with a 1-mm-diameter head. The diamond was positioned 45 degrees perpendicular to the tooth long axis on the facial cervical area so that the reduction would end at half of the burs diameter, thus generating an approximate 0.5-mm depth reduction. A cylindric, tapered, round-end diamond
bur was used in the second phase. Three facial reduction grooves were created respecting the axial inclinations of the tooth, and the grooves were subsequently evened. The interproximal finish lines were extended to the linguoproximal line angle. If pre-existing resin restorations are located at the preparation margins, the linguoproximal extension is extended deeper into the palatal surfaces until the margins are on sound enamel. The extended veneer preparations were then finished and polished similarly to as described for the crown preparations. The completed preparations are shown in Figs 17 to 19. The extended
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Fig 20 Acrylic resinbased provisional restorations.
veneer preparations were kept slightly supragingival because no discoloration was shown for the vital teeth, whereas the crown preparation margins were kept in the intrasulcular space for esthetic reasons.
the patient assessed the function and esthetics of the restorations. Following clinical evaluation of the function, phonetics, and esthetics, along with the patients feedback, it was decided that the definitive restorations should be at least 1 mm shorter in length. A transfer impression with the provisionals in place was made and sent to the laboratory along with instructions regarding the definitive restorations.
Provisionalization
Provisionalization was carried out with acrylic resinbased restorations, which were fabricated at the laboratory. The provisional restorations (Fig 20) were contoured so that a smooth emergence profile could be achieved. The patient was then able to floss under the connectors of the provisionals. After 1 week,
Impression taking
Appropriate reproduction of the preparations, adjacent teeth, and surrounding soft tissues is mandatory. To obtain
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high-quality
impression,
addition
light-body material to ensure penetration into the sulcus. A full-mouth metallic tray was loaded with the heavy-body impression material, inserted into the patients mouth for 5 minutes, and then removed.
silicone materials (polyvinyl siloxane) are recommended due to their elasticity and resistance to tearing. They also allow multiple pours, which is an essential requirement for fabrication of adequate master casts.27 A double-cord technique was used for gingival deflection. The cords were soaked in astringent solution (25% aluminum sulfate; Gel Cord, Pascal International). Compression cord with a small diameter (no. 00, Ultrapak, Ultradent) was placed at the bottom of the sulcus. Next, a more superficial and thicker deflection cord (no. 0, Ultrapak) was inserted in the entrance of the sulcus. Deflection of the gingival sulcus was carried out for 4 minutes while the deflection cord expanded due to water sorption. With this technique, the first compression cord must remain in place during impression taking to seal the sulcus and limit the flow of the crevicular fluid, whereas the deflection cord is removed after deflection. A one-step, double-mix impression technique was carried out. The deflection cord was removed, and the gingival sulcus remained deflected due to its viscoelastic behavior. It is important to emphasize that the deflection cord must be wet during removal so that it does not attach to the inner walls of the gingival sulcus and cause bleeding. After removal of the deflection cord, the gingival sulcus was air dried, and the light-body impression material was inserted throughout the gingival sulcus to penetrate into the sulcus and slightly beyond the preparation margins of each tooth. Gentle air was blown on the
Definitive restorations
After 2 weeks, the patient returned for placement of the definitive ceramic restorations (Figs 21 and 22). Try-in of the definitive restorations must be carried out before initiating the luting procedures. After removal of the provisional restorations, the preparations were cleaned with pumice and dried. The transparent try-in paste (Variolink II Try In, Ivoclar Vivadent) was placed, and any excess was removed with a spatula. The adaptation of the restorations was checked with a probe, and the patient assessed the esthetics of the final restorations with the aid of a mirror. Adequate surface treatment for both the hard tissues and ceramic is crucial to achieve successful bonding.5 The ceramic restorations were placed on the original stone die, and addition silicone was manipulated and placed over them. After setting, the addition silicone was removed with the restorations attached (Fig 23). This provided protection of the glazed external ceramic surfaces and facilitated the handling of the ceramic during surface treatment. A hydro fluoric acid was applied at the inner walls of the restorations for 60 seconds (Fig 24). After rinsing, the ceramic residues and remineralized salts were eliminated by applying phosphoric acid for 20 seconds, followed by rinsing and air
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Figs 21 and 22 Leucite glass-ceramic restorations.
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Fig 23 Removal of the addition silicone with the restorations attached for surface treatment.
Fig 24 Etching of the inner walls of the restorations with hydrouoric acid for 60 seconds.
Fig 25 Application of 35% phosphoric acid to the inner walls for 20 seconds.
Figs 26 (above) and 27 (top right)The phosphoric acid was rinsed off, and the restoration was air dried. Fig 28 (bottom right)Silanization.
drying (Figs 25 to 27). Silane, a chemical coupling agent, was applied with a microbrush to the inner surfaces of the restorations and left for 1 minute (Fig 28). No rubber dam was used for adhesive placement. Although total isolation could be achieved for some teeth, other abutments, especially those with crown preparations and subgingival margins, did not allow proper isolation. The
cementation sequence depends on the arrangement of proximal contact points, which can be better controlled when all teeth are isolated at the same time. A relative isolation with retraction cords is feasible and allows good isolation, especially for the maxillary anterior dentition. Thus, relative isolation was used. Compression cord was inserted at the bottom of each tooths gingival sulcus
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Figs 29 to 32 Insertion of compression cord and application of 35% phosphoric acid onto each abutment tooth. Note that the entire extended veneer preparation is located within the enamel shell.
(Fig 29), and surface conditioning of the preparations was carried out following the two-step etch-and-rinse strategy. First, 35% phosphoric acid was applied on the preparations and approximately 2 mm beyond the preparation margins for 30 seconds on enamel and 15 seconds on dentin, when such tissue was present (Figs 30 and 31). After rinsing and air drying (Fig 32), a dual-curing
adhesive (Excite DSC, Ivoclar Vivadent) was rubbed against the preparation surfaces and a little beyond the surrounding preparation margins, followed by gentle air thinning, and was left unpolymerized (Figs 33 and 34). A coat of the adhesive was applied to the inner walls of the restorations, which were then loaded using the transparent paste of the lightcuring resin cement system (Variolink II,
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Figs 33 and 34 Hybridization of the dental hard tissues and application of a dual-curing adhesive system onto the maxillary right central incisor.
Figs 35 and 36 Application of a coat of adhesive onto the previously silanized ceramic restoration and subsequent loading with the transparent paste of the light-curing resin cement.
Fig 37 (left)Placement of the restoration with gentle nger pressure.
Ivoclar Vivadent). Both restorations were slowly seated by gentle finger pressure along the insertion axis (Figs 35 to 37). Gross excess of the resin cement was eliminated with a spatula. The instrument was guided using a cutting motion
parallel to the margin to avoid extraction of resin cement from the marginal joint (Fig 38). Flossing should be avoided before light curing because it can dislocate or detach the ceramic from the teeth. Light curing was performed at the
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Figs 38 and 39 Removal of excess resin cement with a spatula, followed by light curing.
Figs 40 and 41 Removal of the compression cord and scraping of the polymerized resin cement with a surgical blade.
Figs 42 and 43 Placement sequence.
facial, incisal, and palatal surfaces for 90 seconds at each surface (Fig 39). Next, the gingival cord was removed using dental pincers, and excess resin cement was removed and chipped off with a no. 12 surgical blade (Figs 40
and 41). Refined finishing and polishing were performed at a subsequent session. The cementation sequence is shown in Figs 42 and 43. The final result is shown in Figs 44 to 50.
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Figs 44 to 50 Final result.
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Discussion
To optimize the longevity of all-ceramic crowns and veneers on anterior dentition, the clinician must have a thorough understanding of all patient-related factors, the quality of the remaining tooth tissue, and the proper ceramic system for the individual situation.5,16,17
factors, extra attention and strong monitoring must be conducted for elderly patients with all-ceramic restorations. Patient compliance with the clinicians recommendations is also particularly important in such cases.
Remaining tooth tissue

The amount and quality of remaining
Patient-related factors
Several patient-related factors can influence the survival of crowns and veneers. As with any restorative approach, patients with high caries activity do not respond well to treatment because of the high incidence of secondary caries, especially if the preparation margins are localized on dentin.28,29 For these patients, any attempt to restore the anterior dentition with all-ceramic crowns and veneers should only be made if preventive and monitoring measures have been carried out.30 Age matters. The longevity of allceramic restorations can be compromised in individuals over the age of 60.18 There may be an increased load due to the lack of posterior dentition, reduced salivary flow resulting from the use of medication, and periodontal problems that can weaken the stability of the tooth. Because enamel thickness diminishes over time, ceramic restorations in elderly patients also do not perform as well because the cervical area of the tooth may have little or no enamel.18,31 Root dentin exposure is common,32 and thus the preparation margins are usually localized on dentin, which is related to microleakage incidence.33 Due to these
tooth tissue is an essential factor when choosing between all-ceramic crowns and veneers in the anterior dentition. During elaboration of the treatment plan, the clinician must verify whether the tooth is endodontically treated or vital. If the tooth is nonvital, the need for placement of intraradicular posts must be evaluated, and the clinician should bear in mind that a minimum of 1 mm of sound dentin must be maintained circumferentially as ferrule design after post placement.34 The presence of darkened substrate is common for nonvital teeth, and an extra reduction of approximately 2 mm may be required to provide room for an esthetic restoration.35,36 All-ceramic crowns are superior to veneers for nonvital teeth because they provide increased strength, retention, esthetics, and longevity.3537 However, stability of the endodontically treated abutment tooth can be diminished by the large amount of tooth structure removed.5,6,37 Ceramic veneers should only be chosen when bonding is a completely feasible option, which means the more enamel the better. The tooth preparation should be confined primarily within the enamel shell or should display a substantial (50% to 70%) enamel
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area, especially at the preparation margins.33,38 Debonding of ceramic veneers has been reported to occur when dentin comprises 80% or more of the tooth substrate. In contrast, debonding is highly unlikely when a minimum of 0.5 mm of enamel remains peripherally.13,33,38 Therefore, to avoid microleakage and secondary caries, it is crucial that the preparation margins are bound by enamel and do not end in composite resin fillings.18,39 Moreover, partial adhesion to dentin or to extensive composite resin restorations and high load during static and/or dynamic occlusion increase susceptibility to ceramic fracture.18 If dentin is the main bondable substrate or if there are extensive Class III and IV composite resin restorations whose dimensions extend beyond the crown, all-ceramic crowns should be the first restorative choice.
with hydrofluoric acid followed by silanization prior to bonding to the tooth substrate.13,36 Further, since esthetics is of primary concern for the anterior dentition, an adequate ceramic system for veneers should have a relatively translucent core for the ceramist to build in color intrinsically. Leucite glass-ceramic and traditional feldspathic ceramic are the two systems that best meet such requirements.5,6,10,36 For all-ceramic crowns, a broader range of systems can be used. Leucite glass-ceramic and lithium-disilicate glass-ceramic (IPS e.max, Ivoclar Vivadent) are suitable for cases in which adhesive bonding is possible. Leucite glass-ceramics especially rely on the bond strength between tooth and ceramic and provide good esthetics with proven longevity.5,6,12,20 Ceramics that cannot be etched and bonded, such as alumina- and zirconia-based ceramics, are known as high-strength all-ceramic materials due to their improved physical properties. These are best used in patients with high functional or parafunctional loads. On the other hand, such ceramics present inferior esthetic features compared to glass-ceramics. Alumina and zirconia systems are recommended for cases in which adhesive cementation is not feasible.5,6 These systems, along with monolithic lithium-disilicate crowns for the posterior dentition, can be conventionally luted with glass-ionomer or zinc-phosphate cements, which are less technique-sensitive than adhesive cementation.32,40,41 Table 1 summarizes the advantages and disadvantages of all-ceramic crowns and extended veneers in the anterior dentition.
Ceramic system
In a recent review conducted by Della Bona and Kelly,6 it was concluded that for veneers and crowns for single-rooted anterior teeth, clinicians may choose from any of the all-ceramic systems available. However, the choice of ceramic system is highly dependent on the type of restoration (crown or veneer), type of cementation (adhesive or traditional), and esthetic and functional demands. Ceramic is particularly well suited for veneer restorations and should be primarily used with an additive approach to restore missing enamel. Therefore, it is paramount that the ceramic system allows for surface treatment by etching
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Table 1 Advantages and disadvantages of all-ceramic crowns and extended veneers in anterior dentition
All-ceramic crowns Extended veneers
Tooth structure removal Restoration stability Abutment stability Risk of discoloration due to abutment tooth
+ = recommended; = not recommended *If translucent glass-ceramic is employed.
+ +
+ + / +*
Critical discussion of case report

Some specific aspects of the illustrated case report should be discussed. Leucite glass-ceramic was the material of choice due to the possibility of adhesive cementation since all vital teeth displayed a sufficient amount of enamel. Even the preparation margins of the nonvital teeth were totally bounded by enamel. Finally, leucite glass-ceramic has proven long-term results for both crowns and extended veneers.5,6,10,20 Although the restorations can be considered esthetically successful overall, a subtle value mismatch is evident between the maxillary right lateral incisor and the remaining restorations. This value discrepancy was not noticed during try-in, most likely because the final chromatic result of the cured resin cement can be different from that achieved with the homologous glycerin-based try-in paste.42 The value mismatch
might have been caused by a lack of ceramic thickness due to insufficient facial reduction during preparation. Since extra reduction of endodontically treated teeth is not recommended,43 the use of a lithium-disilicate glassceramic system with adequate masking power (IPS e.max Press LT or MO) could be an alternative to overcome the insufficient masking ability of the leucite glass-ceramic. Lithium-disilicate glass-ceramic provides better strength and responds better chromatically to small thicknesses than does leucite glass-ceramic in cases with discolored abutment teeth.5,44,45 If lithiumdisilicate glass-ceramic is selected to mask the discolored abutment tooth, the authors recommend restoring all other teeth with the same system to achieve a harmonic esthetic outcome. Table 2 summarizes the indications for all-ceramic crowns and extended veneers in the anterior dentition.
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Table 2 Indications for all-ceramic crowns and extended veneers in anterior dentition
All-ceramic crowns Extended veneers
Preparation margin located exclusively in dentin Nonvital teeth Extensive composite resin fillings Large amount of enamel including preparation margins Discolored teeth
+ = recommended; = not recommended. *If opacious glass-ceramic with high masking ability is used.
+ + + +
+ / +*
Conclusions
Restoring the anterior dentition with ceramic is an excellent approach if the correct treatment plan is developed. Several patient-related and material factors can determine the success or failure of all-ceramic crowns and veneers. Neglecting even a single step of the restorative process can severely compromise the treatment outcome.
Acknowledgments
Special thanks to Wilmar Porfrio for manufacturing the ceramic restorations. The first author was supported by the Brazilian Federal Agency for Support and Evaluation of Graduate Education (CAPES) (grant no. BEX 2354101).
References
1. Filho AM, Vieira LCC, Baratieri LN, Lopes GC. Porcelain veneers as an alternative for the esthetic treatment of stained anterior teeth: Clinical report. Quintessence Int 2005;36: 191196. 2. Spear F, Holloway J. Which allceramic system is optimal for anterior esthetics? J Am Dent Assoc 2008;139(suppl): 19S24S. 3. Rosenblum MA, Schulman A. A review of all-ceramic restorations. J Am Dent Assoc 1997;128:297307. 4. Magne P , Magne M, Belser U. The esthetic width in fixed prosthodontics. J Prosthodont 1999;8:106118. 5. Conrad HJ, Seong WJ, Pesun IJ. Current ceramic materials and systems with clinical recommendations: A systematic review. J Prosthet Dent 2007; 98:389404. 6. Della Bona A, Kelly JR. The clinical success of all-ceramic restorations. J Am Dent Assoc 2008;139(suppl):8S13S. 7. Reich SM, Wichmann M, Rinne H, Shortall A. Clinical performance of large, all-ceramic CAD/CAM-generated restorations after three years: A pilot study. J Am Dent Assoc 2004;135:605612. 8. Raigrodski AJ. All-ceramic full-coverage restorations: Concepts and guidelines for material selection. Pract Proced Aesthet Dent 2005;17: 249256. 9. Toksavul S, Toman M. A shortterm clinical evaluation of IPS Empress 2 crowns. Int J Prosthodont 2007;20:168172. 10. Guess PC, Stappert CFJ. Midterm results of a 5-year prospective clinical investigation of extended ceramic veneers. Dent Mater 2008;24:804813. 11. Mansour, YF, Al-Omiri MK, Khader YS, Al-Wahadni A. Clinical performance of IPSEmpress 2 ceramic crowns inserted by general dental practitioners. J Contemp Dent Pract 2008;9:916. 12. Suputtamongkol K, Anusavice KJ, Suchatlampong C, Sithiamnuai P, Tulaporncha C. Clinical performance and wear characteristics of veneered lithia-disilicate-based ceramic crowns. Dent Mater 2008;24:667673.
80
13. Sadowsky SJ. An overview of treatment considerations for esthetic restorations: A review of the literature. J Prosthet Dent 2006;96:433442. 14. Christensen GJ. Facing the challenges of ceramic veneers. J Am Dent Assoc 2006;137:661664. 15. Christensen GJ. Veneer mania. J Am Dent Assoc 2006;137:11611163. 16. Christensen GJ. Are veneers conservative treatment? J Am Dent Assoc 2006;137: 17211723. 17. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137:160169. 18. Burke FJT, Lucarotti PSK. Ten-year outcome of porcelain laminate veneers placed within the general dental services in England and Wales. J Dent 2009;37:3138. 19. Elderton RJ. Clinical studies concerning re-restoration of teeth. Adv Dent Res 1990; 4:49. 20. Fradeani M, Redemagni M. An 11-year clinical evaluation of leucite-reinforced glassceramic crowns: A retrospective study. Quintessence Int 2002;33:503510. 21. Dumfahrt H, Schffer H. Porcelain laminate veneers. A restrospective evaluation after 1 to 10 years of service: Part IIClinical results. Int J Prosthodont 2000;13:918. 22. Fradeani M, Redemagni M, Corrado M. Porcelain laminate veneers: 6- to 12-year clinical evaluationA retrospective study. Int J Periodontics Restorative Dent 2005;25:917. 23. Rouse JS. Full veneer versus traditional veneer preparation: A discussion of interproximal extension. J Prosthet Dent 1997;78:545549. 24. Barghi N, Berry TG. Postbonding crack formation in porcelain veneers. J Esthet Dent 1997;9:5154. 25. Magne P, Versluis A, Douglas WH. Effect of luting composite shrinkage and thermal loads on the stress distribution in porcelain laminate veneers. J Prosthet Dent 1999;81: 335344.
26. Atsu SS, Aka PS, Kucukesmen HC, Kilicarsian MA, Atakan C. Age-related changes in tooth enamel as measured by electron microscopy: Implications for porcelain laminate veneers. J Prosthet Dent 2005;94: 336341. 27. Johnson GH, Craig RG. Accuracy of addition silicones as a function of technique. J Prosthet Dent 1986;55:197203. 28. Kidd EAM, Fejerskov O. What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cariogenic biofilms. J Dent Res 2004;83(special issue C): 3538. 29. Magne P, Kwon KR, Belser UC, Hodges JS, Douglas WH. Crack propensity or porcelain laminate veneers: A simulated operatory evaluation. J Prosthet Dent 1999;81:327334. 30. Yoshiyama M, Tay FR, Doi J, et al. Bonding of self-etch and total-etch adhesives to carious dentin. J Dent Res 2002;81: 556560. 31. Featherstone JD. The science and practice of caries prevention. J Am Dent Assoc 2000;131:887899. 32. Tay FR, Pashley DH. Resin bonding to cervical sclerotic dentin: A review. J Dent 2004; 32:173196. 33. De Munck J, Van Meerbeek B, Yoshida Y, et al. Four-year water degradation of total-etch adhesives bonded to dentin. J Dent Res 2003;82:136140. 34. Cheung W. A review of the management of endodontically treated teeth. Post, core and the final restoration. J Am Dent Assoc 2005;136:611619. 35. Meijering AC, Creugers NHJ, Roeters FJM, Mulder J. Survival of three types of veneer restorations in a clinical trial: A 2.5-year interim evaluation. J Dent 1998;26:563568. 36. Donovan TE. Factors essential for successful all-ceramic restorations. J Am Dent Assoc 2008;139(suppl):14S18S. 37. Christensen GJ. Are veneers conservative treatment? J Am Dent Assoc 2006;137: 17211723.
38. Friedman MJ. A 15-year review of porcelain veneer failure A clinicians observations. Compend Contin Educ Dent 1998;19:625630. 39. 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;6:6576. 40. Ozkurt Z, Kazazog lu E. Clinical success of zirconia in dental applications. J Prosthodont 2010;19:6468. 41. Etman MK, Woolford MJ. Three-year clinical evaluation of two ceramic crown systems: A preliminary study. J Prosthet Dent 2010;103:8090. 42. AlGhazali N, Laukner J, Burnside G, Jarad FD, Smith PW, Preston AJ. An investigation into the effect of try-in pastes, uncured and cured resin cements on the overall color of ceramic veneer restorations: An in vitro study. J Dent 2010; 38(suppl 2):e78e86. 43. Magne P, Douglas WH. Cumulative effects of successive restorative procedures on anterior crown flexure: Intact versus veneered incisors. Quintessence Int 2000;31:518. 44. Edelhoff D, Brix O. All-ceramic restorations in different indications: A case series. J Am Dent Assoc 2011;142(suppl 2): 14S19S. 45. Edelhoff D, Gth JF , Lungwirth F , et al. Light transmission through lithium-disilicate ceramics with different levels of translucency [abstract 3660]. J Dent Res 2010;special issue B:89.
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THE AMeRICaN JOURNAL OF

The AMeRICaN JouRNal of EsthetIC DeNtIstRy

The American Journal of

Volume 1 Number 1 Fall 2011

ISSN 2162-2833 (print) ISSN 2162-2841 (online)

Jussara Karina Bernardon Renata Gondo Luiz Narciso Baratieri

The Gray Zone Around Dental Implants: Keys to Esthetic Success

Iaki Gamborena Markus B. Blatz

Hamdi H. Hamama Nadia M. Zaghloul Ossama B. Abouelatta Abeer E. El-Embaby

Guidelines for Authors Mandatory Submission Form

The American Journal of

Director, Journal Publications

Director, Advertising Sales

EDITOR-IN-CHIeF Richard J. Simonsen, DDS, MS

The American Journal of

Mandatory Submission Form and Copyright Assignment Agreement

Minimally Invasive Restorative Treatment of Hypoplastic Enamel in Anterior Teeth

Renata Gondo, DDS, MS, PhD

Luiz Narciso Baratieri, DDS, MS, PhD

Correspondence to: Dr Jussara Bernardon

Fig 14 Application of the adhesive system according to the manufacturers instructions.

Fig 16 Mamelons must be defined when applying the composite resin.

Fig 25 Removal of the hypoplastic enamel on the left lateral incisor.

Conclusions and guidelines for practitioners

The Gray Zone Around Dental Implants: Keys to Esthetic Success

Markus B. Blatz, DMD, PhD

Correspondence to: Dr Iaki Gamborena

Gamborena and Blatz

he esthetic success of a dental restoration is judged by its inte-

Gamborena and Blatz

Soft tissue thicKness

Gamborena and Blatz

Fig 3 Postoperative situation showing the implant-supported crown.

Gamborena and Blatz

Gamborena and Blatz

Fig 10 Intraoral occlusal view showing the soft tissue support.

Fig 13 (left)Occlusal view of the definitive implant-supported restoration.

Fig 12 Postoperative peri apical radiograph.

Gamborena and Blatz

Fig 15 Preoperative intraoral situation.

Fig 16 Lateral tomogram showing the extent of the ridge defect.

Fig 17 Intraoral view of the edentulous ridge topography.

Fig 18 Virtual implant placement for guided surgery.

Gamborena and Blatz

Fig 19 Implant placement (3.5 13 mm, NobelActive, Nobel Biocare).

Fig 22 Labial view of the adapted flap after suturing.

Fig 23 Intraoral situation 1 week postoperatively.

Fig 24 Postoperative situation after 6 months reveals improved ridge morphology.

Gamborena and Blatz

Gamborena and Blatz

Fig 30 Optical properties of the provisional crown under natural light.

Fig 32 Optical properties of the zirconia abutment under natural light.

Gamborena and Blatz

Gamborena and Blatz

Gamborena and Blatz

Gamborena and Blatz

Fig 44 Nonfluorescent coping on the cast under UV light.

Fig 45 Fluorescent coping on the cast under UV light.

Fig 46 Definitive crown showing fluorescent properties under UV light.

Gamborena and Blatz

Gamborena and Blatz

Fig 54 Postoperative intraoral situation. No gray zone is evident.

Gamborena and Blatz