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CONTENTS
INTRODUCTION
PRINCIPLES AND FUNDAMENTALS OF ESTHETICS
FACTORS OF ESTEHTIC DENTOFACIAL COMPOSITION
AND THEIR CLINICAL SIGNIFICANCE
ESTHETIC DIAGNOSIS AND TREATMENT PLANNING
ESTHETIC TREATMENT MODALITIES
o ESTHETICS WITH BLEACHING
o ESTHETICS WITH COMPOSITE
o ESTHETICS WITH CERAMIC
o ESTHETICS WITH PERIODONTICS
o ESTHETICS WITH ORTHODONTICS
o ESTHETICS WITH IMPLANT
CONCLUSION
BIBLIORAPHY
INTRODUCTION
Beauty is in the eye of beholder
Beauty in itself is a combination of reality and personal perception.
Beauty can be interpreted differently by different people. For many centuries
poetry and literature, both alike, have sung the praise of beauty.
Through the ages different cultures and races have had their own
concept of beauty, smile played a major role in it. For e.g. Japanese custom of
decorative tooth staining called Ohaguro is a 4000 year old custom that is
described as a purely cosmetic treatment, the procedure had its own set of
implements, kept as a cosmetic kit.
Although times have changed, human nature has not. Just as our
predecessors sought solution to their esthetic problems so do we.
Mouth is the one of the focal points of the face, so smile plays a major
role in how we perceive ourselves, as well as the impression we make on
people around us. Smile is the most beautiful of all the expressions. Pleasing
appearances often means the difference between success and failure in both our
personal and professional life.
Dr. Charles Pincus developed the concept of dental esthetic, in 1930s
while creating a perfect smile for Hollywood film actors.
Some decades ago, esthetics was considered at best, a fortuitous by
product of dental procedure. In the years that have ensued, esthetics have taken
its rightful place along with functionality as a bonafide objective of dental
treatment. The revolution that has transpired, complementing theory with
technology and advanced methodology.
Todays era of cosmetic and esthetic dentistry has placed emphasis on a
confident and captivating smile. A well designed smile is a product of
PRINCIPLES OF COLOR
Hue
The name of the colour is derived from hue. The visible spectrum, ranging
from 380nm to 750nm, produces a stimulus that evokes a response known as
hue. In Munsell , s words , It is that quality by which we distinguish one color
family from another .
Generally the rare six families ; violet ,blue,green,yellow,orange and red .
changes the hue of the seconday hue produced . Primary and secondary hues
can be organized on the color wheel with secondary hues positioned between
primary hues ..
3) Complementary hues
Color directly opposite to each other on the color wheel are termed
complementary hues . A peculiarity of this system is that a primary hue is
always opposite a secondary hue and vice versa . When a primary hue is mixed
with a complementary secondary hue , the effect is to cancel out both colors
and produce gray . This is the most important relationship in dental color
manipulation
Complementary hues also exhibit the useful phenomenon of intensification .
when complementary hues are placed next to one another , they intensify one
other and appear to have higher chroma .
Chorma
Chorama is the saturation or intensity of the hue ; therefore it can only be
present with hue
distinguish a strong color from a weak one .For eg to increase the chroma of
the porcelain restoration more of that hue is added . Chroma is the quality of
hue that is most amenable to decrease by bleaching . In general , the chroma of
teeth increases with age .
Value
Value is the relative lightness or darkness of a color . A light tooth has a high
value ;a dark tooth has a low value .It is not the quantity of the color rather than
quality of brightness . Value is the only dimension of color that can exit by
itself .
Properties of color
1) Opacity
2) Translucency
1) Opacity
When light strikes a surface , it is either totally reflected ,totally absorbed, or
combination of both . Opaque objects reflects all or most of the light that is
incident on them.
An opaque material does not permit any light to pass through . It reflects all
the light that is shined on it , For eg ; In porcelain fused to metal restoration
must have a opaque porcelain applied to the metal substructure to prevent the
color of metal from appearing through the translucent body and incisal
porcelains.
2) Translucency
When part of the light incident on an object is transmitted , while the rest is
scattered , the property of the object is known as translucency. Translucent
materials allow some light to pass through them . Only some of the light is
absorbed . Translucency , in effect is the three dimensional spatial relationship
or representation of value . There might be inter-tooth as wellas intra tooth
differences in the translucency . Translucency provides realism to an artificial
restoration.
Metamerism
It is a phenomenon that can cause two color sample to appear as the same hue
under one light source , but as un matched hues under a different light source .
For eg : A shade guide tooth matches the natural tooth under incandescent
light but not under fluorescent light . this can be attributed to the difference in
radiant energy of two different wavelengths of light .
The stimulus varies according to the difference in the radiant energy leading to
a perception of a different color . The standardization of lighting condition
during shade matching diminishes the effect of metamerism .
Fluorescence
The emission of light by an object at a different wavelength from that of
incident light is called fluorescence . The emission stops immediately on
removal of incident light. Teeth fluorescence with a stimulus in the range of
340nm to 410 nm .This spectrum is in blue range . thus , according to the
principles additive color , the emitted blue light acts with yellowness of tooth to
produce a whiter tooth . Fluorescin pigments incorporated in the ceramic
restoration by the ceramist and in composite restoration by the manufacture
may thus be advantageously used in altering the perception of the final result
Gloss
Gloss is an optical property associated with a smooth surface that produces
lustrous surface appearance and thus reduces the effect of color difference It
also lightens the color appearance and is associated with a smooth surface
which can be created on a restoration by finishing and polishing procedures
that increases the brilliance of the final result
COLOR CHARACTERISTICS OF TEETH
In a newly erupted tooth , the superficial layers of enamel are most
opaque . They appear as though they have white frost .This superficial
frosted enamel may have a higher organic component is less mineralized
and as more empty space between the enamel crystals all of which
causes increased opacity
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The thickness of dentin, the size of the pulp chamber, and the vitality of
the pulp tissue are different stages of tooth development. Teenagers
generally have a larger pulp chamber that add red. With secondary
dentin formation, the pulp chamber decreases in size and the teeth
becomes less red with age.
Older dentin or sclerotic dentin is darker (higher chroma, lower value)
and it has more green and blue. Young dentin is more red-yellow. (CIE
Lab color spaces a* and b* go negative with age). There is a positive
linear correlation between age and chroma of the roots. Through the
dentin undergoes a color shift from red yellow towards yellow, the
overall color of older teeth is redder than in youth because there is less
bright enamel covering the red dentin due to wear.
Different teeth in the arch can belong to different hue families. a * (red to
green gradient) is highest (most red) in canines, then centrals, then
laterals. b* (yellow to blue gradient) is highest (most yellow) in canines,
then laterals. then centrals.
Value is mainly determined by qualities of the enamel layer in the form
of reflectivity and opacity. As the superficial layers of the enamel
surface are worn, the translucency goes up and the dentin becomes more
visible and dentinal chroma begins to influence value more.
To raise the value in a restoration that needs to be highly
translucent( translucency normally drops value), the brightness needs to
be built into the dentin instead of the enamel.
Value is typically lowest at the cervical, then at the incisal, and highest
in the middle third of the tooth 39. Value increases going medially from
maxillary canines to centrals
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The mammelons and interproximal contact areas usually show the most
translucence.
The cervical hue is always redder than the middle or incisal.
Translucency is greatest in laterals therefore; opalescence (primarily in
translucent enamel) is most evident in the laterals.
Cuspids show very little translucency.
Remember that the upper cuspids are often one to two full shades darker
in chroma than the maxillary incisors and will sometimes give a better
clue to the average hue family.
The hue and chroma of natural teeth are not constant. If a laboratory
uses the same porcelain for all the teeth in an arch, it will make the
mouth look flat. A natural 3-dimensionality can be developed with
chroma gradients getting darker from the centrals on back.
SHADE SELECTION
Shade selection is a complex procedure due to the variations and differences in
the optical properties of the new generation of cosmetic restorative materials. It
can be well accomplished by understanding the fundamentals of color and
adopting a proper methodology of matching shades. The effective
communication with the laboratory and precise fabrication and meticulous
finishing of the restoration will affect the color of the final restoration.
Shade guides
One can avail of subjective or objective method of shade selection.
1) Conventional shade tabs (Subjective)
2) Advanced computer imaging analysis (Objective).
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illusions and aging leading to great variability in shade selection. Hence, a need
for objective standards became evident.
Digital shade analysis eliminates the subjectivity of color analysis and provides
exact information for laboratory fabrication of the prosthesis. The influence is
more objective can be repeatedly verified, is not influenced by external factors
like surrounding environment and involves less chair-side time. The reading
can be translated to materials that can reproduce those characteristics in the
fabricated restorations The other features that complicate color matching like
translucency, surface gloss, fluorescence, inhomogeneous tooth structure are
also incorporated in the readings. A few models are available in the market, but
are very expensive.
Shofu shademaster ex chromameter is a spectrophotometry based shade
determination device that employs point source references of information. The
drawaback is that the information remains subjective in nature.
Another system, Cortex machine-shade scan system, analyses tooth images and
objectively relates their characteristics based on color and translucency. Cross
checking with a database of known shade guides as well as additional scanning
of new shade guides is also possible. But this system does not provide an exact
method for laboratory fabrication.
Thus, in spite of certain drawbacks, technology based shade guide systems hold
a promising future in helping to mimic nature to the fullest.
The greatest art is . To Disguise the Art
Guidelines for Shade Taking:
Make the shade selection at the beginning of the procedure as well as
over different appointments (diagnosis, prophylaxis etc) and cross check
these observations.
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View the patients at eye-level. The operator should stand between the
light source and the patient.
In a contrasting environment, colors look more intense and brighter.
Hence it is wise to ask the patients to remove artificial lip color. The
patients drape and assistants clothing may also influence color
matching.
Place the tabs as close as possible to the area that is being checked.
Moisten the tab and eliminate the worst match.
Evaluate the value (upper to lower). Value is the most important factor
in shade matching. If the value blends, small variation in hue and
chroma will not be noticeable. The value is to be matched with eyes
half-closed.
After value, mark the translucency.
Match the chroma (more or less saturated) and finally, hue is that order.
To avoid hue sensitivity, rapid observation is made for 5 seconds (not
more than 20 seconds). Look away, ideally stare at a blue surface, which
will readapt the vision to the orange-yellow portion of the spectrum.
Staring at a tooth for 5 seconds causes yellow adaptation and blue
sensitivity. Stare at a blue card to become blue adaptive and yellow
sensitive.
Match prior to tooth preparation, since preparation dehydrates and
changes color due to the debris of preparation. Ensure that the teeth are
cleaned and unstained by rubber cup prophylaxis.
Never select shades after prolonged and fatiguing operative surgery. The
best time for shade selection is when the dentist is fresh.
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When in doubt about two tabs, hold them side by side on the tooth to be
matched and compare to get the finest match.
Match the tab with the opposing tooth also.
Metamerism complicates color matching, as the tabs look different
under different light sources. The best approach is to use three light
sources: cool white fluorescent light, incandescent operatory lamp and
day light if possible.
When in doubt, always select higher value and lower chroma, since it is
easy to lower value and increase chroma.
Shade tabs of different batches dont always match, hence it is wise to
send the actual selected shade tab to the technician.
Make a decision regarding relative translucency, area of hypocalcification, increased saturation, crack lines surface texture and other
characterization. Make a drawing of the facial surface and record all
patient information graphically.
If possible, take photographs with shade tabs in place.
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Cultural biases
Cultural biases are naturally occurring environmental observations about the
world around. We perceive that darker, heavily worn, highly stained, longer
teeth belong to an older person because we know that teeth naturally darken,
wear, and stain in grooves and along the cervical area with age, and that they
lengthen because of gingival recession. We perceive rounded, smooth-flowing
forms are feminine, whereas harsher, more angular forms are masculine.
Masculine and Feminine:
Culturally defined masculine qualities may enhance the appearance of a
women. However, usually these masculine nuances look best on a woman with
stereotypically feminine features. Square, angular anterior teeth, therefore, may
be desirable for a more feminine woman, but on other women this tooth
shape may not be as flattering. In Western culture, contrast evokes a certain
allure. With no contrast, the allure is gone.
The golden proportion:
Has been recognized in the beginning of the history.
It was given by Pacioli.
The proportion is 1.0 to 1.618.
The relationship links geometry to mathematics, hence it is called as
Sacred geometry, magic numbers, Golden cut.
The golden preparation is not only symlolizes beauty and comfort at a
perimeter level but it is also the key to much of normal morphology.
In case of the teeth, the lower central incisor may be used as a starting
reference. Interestingly the upper central incisor has a golden, phior 1.618
proportion to the lower incisor, and total width of both lower centrals are
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1) Principle of illumination
The law of the face
The law of the face is the most important single concept in shaping dental
restorations. Understanding this concept and its interplay with the concept of
light and dark enables the esthetic dentist to shape all esthetic restorations
correctly.
The face of a tooth is area on the facial surface of anterior and posterior teeth
that is bounded by the transitional line angles as viewed from the facial
(buccal) aspect. The transitional line angles mark the transition from the facial
surface to the mesial, cervical, distal, and incisal surfaces. The tooth surface
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slopes lingually toward the mesial and distal approximating surfaces and
toward the cervical root surface from these line angles. Often no transitional
line angle appears on the incisal portion of the facial surface; in this case the
face is bounded by the incisal edge or the occlusal trip. Shadows created as
light strikes the labial surface of the tooth begin at the transitional line angles.
These shadows delineate the boundaries of the face.
The apparent face of a tooth is the portion that is visible to the viewer from any
single view. The perimeter of the apparent face is dictated by the position of
the viewer relative to the tooth. For example, from the front view the entire
incisor faces are visible, but usually only the mesial half of the faces of the
maxillary canines are visible from this angle.
The law of the face states that in order to make dissimilar teeth appear similar,
the one should make the apparent faces equal. Creating equal apparent faces in
two dissimilar adjacent teeth produces dissimilar areas outside the transitional
line angles (i.e., outside the faces). These dissimilarities are esthetically
acceptable because they are essentially invisible; the similar faces of the teeth
catch the light and appear to protrude, whereas the dissimilar areas are in
shadow and appear to recede.
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Principle of line:
Horizontal lines in the form of cervical staining, texturing, white hypoplastic
lines, or long, straight incisal edges create the illusion of width. Widening the
face also produces an illusion of width.
Vertical lines in the form of accentuated developmental grooves, hypoplastic
lines, and vertical texturing accentuate height. Incisal edges of anterior teeth
carved to slope cervically toward the distal area with larger incisal embrasures
and narrower (mesiodistally) incisal edges create an illusion of increased
height. Narrowing the face also creates this illusion. These same concepts
apply for clothing and makeup. Individuals wearing clothing with vertical lines
appear thinner. Conversely, horizontal stripes accentuate width. To lengthen
and slim the nose with cosmetics, a light highlighter is applied in a vertical
line down the center bridge of the nose. Then a darker contour shade of
makeup is applied on each side of the nose to make that area recede.
Age:
Older teeth:
1. They are smoother.
2. They are darker
3. They have a higher saturation
4. They are shorter incisally
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Gender:
Lombardi described a theory of anterior esthetics in which he proposed that the
age, gender, and personality of a person was reflected in the shape and form of
the teeth. Factually, the concept of sexual dimorphism is difficult to prove or
disprove. This concept should be considered in the light of cultural bias.
Feminine: Feminine teeth are more rounded, both on the incisal edges and at
the transitional line angles. The incisal embrasures therefore are more
pronounced. The incisal edges are more translucent and white hypoplastic
striations may be used to give the illusion of delicacy. The translucency on the
incisal edges appears as a gray line in the incisal one-eighth of the facial
surface paralleling the incisal edge with a white hypoplastic rim on the edge.
Masculine: Masculine teeth are more angular and rugged. In older men chroma
is greater and body color often extends to the incisal edges. The incisal
embrasures are more squared and not a pronounced. Characterization is often
stronger, incorporating darker craze lines.
Cultural and artistic biases are central to understanding dental esthetics. They
must be thoroughly understood so that the dentist can use these biases
artistically to create illusions to satisfy the esthetic demands of the patient.
Only then can the technically proficient dentist rise to the level of an artist,
providing a higher level of care.
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a) Horizontal reference:
The horizontal perspective of the face is provided by the interpupillary line,
the ophriac and the commissural line.
The inter-pupillary line helps to evaluate the orientation of the incisal plane,
the gingival margins and the maxilla. An imaginary horizontal line through
the incisal plane and the gingival margins should be visibly parallel to the
inter-pupillary line. This helps to diagnose any asymmetry in the tooth
position or gingival location. When an imaginary line is drawn across the
gingival margins, it may not be parallel to the inter-pupillary line indicating
a certain degree of canting of the maxilla. Certain amount of canting of
maxilla is considered but severe canting may require an inter-disciplinary
approach involving surgical repositioning of the maxilla.
b) Vertical references:
The facial midline serves to evaluate the location and axis of the dental
midline and the medio-lateral discrepancies in tooth position.
The inter-pupillary line and the facial midline emphasize the T effect in a
pleasing face. The dental midline, if perpendicular to the inter-pupillary line
and coinciding with the bridge of the nose and the philtrum, produces an
attractive orientation of the smile. Ideally the dental midline should
coincide with the facial midline. The dental midline of the upper arch and
the lower arch may not coincide. Sometimes a perfectly centred midline
creates an artificial appearance while a slightly oblique dental midline
appears natural.
Axial inclination:
Is the direction of the anterior teeth in relation to the central midline and
becomes progressively more pronounced from the central incisor to the
canine. There is a definite mesial inclination to all the anterior teeth related
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to the midline. The axes of the premolars and the first molar on either side
also show mesial inclination in relation to the midline.
The perception of tooth inclination can be viewed from the frontal aspect
around the central vertical midline, which acts like a fulcrum around which
axial inclination of teeth on either side exhibit a phenomenon of balance of
lines. Natural smiles show a deviation from these standard axial
inclinations. Deviations in axial inclination cause a visual tension when
beyond the point of equilibrium.
c) Sagittal reference:
Soft tissue analysis at a standardized position helps in studying the profile
of an individual. The contours of the upper and lower lips and the lip
supports is determined by the position of the anterior teeth and can be used
as a guide for the placement of teeth when planning restorations. The lip
protrusion, the amount of prominence of chin, recession or prominence of
the nose and its degree, all help in profile analysis for diagnosis and
treatment planning.
The E-line or esthetic line is an imaginary line connecting the tip of the
nose to the most prominent portion of the chin on the profile. Ideally the
upper lip is 1-2mm behind and the lower lip 2-3mm behind the E-line. Any
change in the position of the E-line indicates the abnormality in the upper or
lower lip position.
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The main support of the upper lip is contributed by the gingival two thirds
of the maxillary central incisors rather than the incisal one third.
The relationship of the maxillary incisal edges to the lower lip is a guide for
the placement of the incial edge position and length. The pronunciation of
the F and V consonants helps determine the position of the incisal edges.
On pronouncing F and V the incisal edges should make a definite
contact at the inner vermillion border of the lower lip. Thus the position of
the incisal third of the maxillary central incisor can be determined. The
failure to contour the incisal third is a common mistake seen in anterior
restorations.
d) Phonetic references:
Certain sounds are made by touching the lips or the tongue against
maxillary teeth. Phonetics play a part in determining maxillary central
incisor design and position.
F and V sounds are used to determine the tilt of the incisal third of the
maxillary central incisors and their length. The M sound is used to achieve
a relaxed rest position and if repeated at slow intervals can help evaluate the
incisal display at rest position. S or Z sound determine the vertical
dimension of speech. Its pronunciation makes the maxillary and the
mandibular anterior teeth come in near contact and determine the anterior
speaking space. The amount of posterior speaking space varies with the
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and lower teeth concurrently. The key characteristic of this smile is the
strong muscular pull and retraction of the lower lip downward and back.
In this smile pattern both maxillary and mandibular incisal planes are
generally flat and parallel. Some celebrated personalities with complex
smiles include Julia Roberts, Marilyn Monroe, Will Smith and Oprah
Winfrey.
Stages of a Smile:
There are four stages in a smile cycle:
Stage I lips closed.
Stage II resting display.
Stage III natural smile (three-quarters).
Stage IV expanded smile (full).
Types of Smiles:
There are five variations in which dental and / or periodontal tissues are
displayed in the smile zones:
Type 1 maxillary only.
Type 2 maxillary and over 3 mm gingiva.
Type 3 mandibular only.
Type 4 maxillary and mandibular.
Type 5 neither maxillary nor mandibular.
In the vast majority of cases, people will be categorized under a single type,
although it is possible to combine types, if necessary. For instance, a patient
may have a complex smile prominently showing maxillary and mandibular
teeth and have a maxillary gummy smile displaying more than 3 mm of
gingiva. This odd smile pattern would be a type 2, 4.
The characteristics which can be used as a guidline for creating a pleasant
smile are:
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The maxillary lateral incisors and the canines complement the central
incisor in terms of proper shape and form.
The exhibit dominance of central incisors the
subsequent
elements
should
be
strong
and
complementary.
Similar recurring ratios are observed in the teeth from the central
incisor to the premolar.
The importance of order in the composition is crucial
for visual equilibrium.
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The complexion and texture on the face contrast with the lip color,
gingiva nd the teeth leading to a distinct demarcation between the
oral and the facial frame.
A strong centralized element creates unity and results
in an immediate, harmonious composition.
Lip and Lip Lines:
The length, the curvature and the shape of the lips significantly influence the
amount of tooth exposure during rest and in function. While smiling, the upper
lip curvature is generally expected to run upward from a center portion to the
corner of the mouth during normal muscle function.
Any muscular atrophy, degeneration, hypertrophy or neuromuscular disorders
can lead to asymmetrical and strained movements. The ideal location of the
upper lip height relative to the central incisor is at its gingival margin or 1mm
above it displaying the inter-dental papilla between the two central incisors
during moderate smile.
The average maxillary incisor display with the lips at rest is 1.91mm in men
and 3.40mm in women.
Upper lip line helps to evaluate the length of the maxillary incisor exposed at
rest and during smile and the vertical position of the gingival margins during
smile.
The upper lip line can be classified as low, medium or high depending upon the
amount of tooth or gingival display that is available at rest or during a moderate
smile. The gingival margins may be displayed in high lip line cases. The most
apical position of the gingiva over the facial aspect of the maxillary central
incisor and canine is slightly distal to the long axis of the tooth while in the
maxillary lateral incisor it is at the long axis of the tooth. This is called the
gingival zenith.
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A smile can be termed toothy if more than 6mm of incisal display is seen at
rest position or gummy if more than 3mm of gingival tissues are displayed in
moderate smile.
Lower lip line helps to evaluate the buccolingual position of the incisal edge of
the maxillary incisors and the curvature of the incisal plane.
Smile line: It is an imaginary line passing through the incisal edges of the upper
anterior teeth. The smile line usually coincides or runs parallel to the inner
vermillion border of the lower lip. In a youthful smile the incisal edges of the
central incisors and canines are aligned on a convexity and are longer than the
lateral incisors, incisal embrasures gradually deepen from central incisor to the
canine, giving the appearance of the wings of a gull. Thus the incisal plane is
said to have a gull-wing appearance. When the incisal edges of the central
incisors and canines are aligned on a convexity the incisal plane is convex.
Reduced incisal embrasures and leveling of the gull-wing effect as in a straight
smile line is associated with aging.
Negative space:
Negative space is a dark space appearing between the jaws and the mouth
opening either at the corner of the mouth or around the buccal aspect of the
posterior teeth during active smile and laugh.
It is an important factor which brings about a harmonious cohesion between the
various elements of the smile. The lateral negative space exists between the
labial surface of maxillary teeth and the corner of the mouth while the buccal
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negative spaces appear in the buccal vestibule on either side of the buccal
aspect of posterior teeth. Obliteration of these essential spaces by dental
elements like bulky canines, wide arches or over-contoured restorations can
lead to an unattractive smile. Excessive negative spaces seen in cases of
missing premolars or palatally placed posterior and a constricted arch also
appear unesthetic.
PROPORTION:
The position of the tooth in the arch, the relationship between the width, the
length and the face of the tooth can also be numerically established in relation
with certain anatomic landmarks.
The central incisors are predominant as they reflect the patients personality,
lateral incisors provide the charm and canines the strength. The shape of the
central incisor, whether square, ovoid or triangular, is often related to that of
the face seen upside down. The measurements will be in accordance with the
width of the face, width of the dental arch, inter-pupillary distance and volume
of the lips.
A central incisor is considered perfectly proportionate when the maximum
width is approximately 75% of the maximum length (of the clinical crown).
This is the ideal width to length ratio).
Golden Proportion is expressed in numerical form and applied by classical
mathematicians such as Euclid and Pythagoras in pursuit of universal divine
harmony and balance. It has been applied to a lot of ancient Greek and
Egyptian architecture and may be expressed as the ratio 1.618:1.
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If this ratio is applied to the smile made up of the central, lateral incisor and the
mesial half of the canine, it shows that the central incisor is 62% wider than the
lateral incisor which in turn is 62% wider than the visible portion of the canine
which is the mesial half, when viewed from the front.
SYMMETRY:
The composition has symmetry when identical recurring ratios with reference
to size, shape and position exist on either side of a dividing line or around a
center. Dental symmetry relates to right and left sides of the midline.
For harmony, certain symmetries are essential while certain asymmetries are
acceptable. Harmonious facial features should be more symmetrical close to
the facial midline and can be more asymmetrical away from the facial midline.
The goal is to strike a pleasing balance between idealism and deviation because
naturally esthetic dentitions do have subtle asymmetries. Maxillary central
incisors must be kept within reasonable symmetrical limits; the deviation of
the dental reconstruction should be accommodated by the asymmetry of the
lateral incisors.
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Ideal Situation
Straight
Acceptable deviation
Slightly oblique
facial midline
Teeth inclination in relation
Straight or slightly
Mesial inclinations
to midline
mesial
inclinations
Aligned in at least two
planes
planes.
Symmetrical
of central incisors.
Incisal plane
Either convex or
asymmetrical.
May be slightly less convex
Incisal embrasure
sinuous
Should gradually
incisor to canine
Should be bilaterally
Could be slightly
symmetrical
asymmetrical in shape,
Lateral incisors
Labiolingual
rotations.
Labio-lingual inclination
asymmetrical
plan should address the treatment periods, expenses, treatment sequencing and
all aspects related to the function and maintenance of the anticipated result.
Most esthetically motivated patients are eager to begin corrective treatment.
Nevertheless, their enthusiasm and, at times, self-diagnosis should not
influence the dentist's esthetic diagnosis. It is essential that the patient make an
informed decision, after receiving a thorough explanation of his/her condition
and the ramifications of treatment, including the advantages and disadvantages
of each treatment alternative.
1. PATIENT HISTORY
Information should cover aspects of:
2. CLINICAL EXAMINATION
A clinical examination involves a thorough evaluation of facial and
temporomandibular components and assessment of occlusal relationship,
periodontal attachment, teeth and intra-oral soft tissues.
Facial components
relationships of various parts of the face, position of lips and chin from
frontal as well as lateral aspect, relationship of horizontal and vertical
references of face with respect to teeth and gums.
37
3. ESTHETIC EVALUATION
The following analysis chart covers the facial, dentofacial, dental and
functional analysis. In case any abnormalities found in the soft tissues, hard
tissues, TMJ and occlusal pattern, a thorough evaluation is recommended
before esthetic treatment planning.
Visual Analysis Chart
Facial
Face forms
Frontal perspective
Nasio-Iabial groove
Exaggerated
Mento-labial groove
Normal
Adequate
Vertical height
More
Less
Competent
Lips
Incompetent
Full
38
Dento-facial
Inter-pupillary line
Incisal plane
Parallel/not parallel
Gingival margins
Parallel/not parallel
Maxilla
Length of maxillary
incisors visible at rest
<1mm
1 - 4mm
>4mm
Vertical position of
Low
gingival margins during Average
smiling
High
Lower lip line
Bucco-lingual position
Touching
of maxillary incisors
Not touching
Slightly covered
Curvature of incisal
plane
Convex
Straight
Concave/reverse
Facial midline
Dental midline
Center
Right of center
Left of center
Straight
Oblique
Moderate smile
Gingival display
<3mm
>3mm
Gingival patterns
Esthetic
Unesthetic
Vestibular space
Horizontal tooth
display
6/8/10/12 teeth
39
Dental
Teeth
Gingiva
Inflammation
Recession, black triangles
Hyperplasia
Altered gingival display
Pigmentation
Frenal attachment
40
Functional
Temperomandibular
Joint
clicking,
crepitus,
hyper-mobility,
joint
dislocation
Mandibular
movements
movements
Occlusion
Open bite
Deep bite
Edge to edge
Transverse plane
Rotation
Cross-bite
Phonetics
'S' sound
Adequate / deficient
Adequate / deficient
< 1mm
1-4mm
>4mm
41
SPACE ANALYSIS
Space analysis helps the dentist to gauge the amount of space available during
the treatment planning stage. The concept is to measure the widths of all the
teeth and compare it with the space present in the arch. The normal length to
width ratios of teeth should be borne in mind and the law of golden proportions
should be closely followed to prevent violation of natural proportions. Thus,
space maintenance for restorations in terms of illusions, rotations, overlaps etc.
can be carried out as planned.
PROFILE ANALYSIS
Patients with impaired dentofacial esthetics resulting from underlying skeletal
problems can be identified wit the use of profile analysis.
The patients profile can be:
Straiqht / Orthoqnathic
Convex / Retroqnathic :
Due to: - prognathic maxilla - normal mandible
- Normal maxilla - retrognathic mandible
Prognathic maxilla - retrognathic mandible
Features: - normal/increased / decreased lower facial height
- Lower lip trap, depending on the position of lower anteriors
Deep mentolabial groove
Concave / Prognathic:
Due to : retrognathic maxilla - normal mandible
- Normal maxilla - prognathic mandible
Retrognathic maxilla - prognathic mandible
42
DIAGNOSTIC AIDS
Study casts
Accurate study casts help give necessary inputs regarding intra-arch
relationships like arch-length versus tooth size discrepancies; alignments;
angulations and inter-arch relationships like Angle's classification, overbite,
overjet, plane of occlusion etc. They also reveal functional relationships
involving centric and protrusive interferences, working sidebalancing side
interferences, wear facets etc.
Radiographs
IOPA and bitewing radiographs are used to detect interproximal caries, bone
levels and quality, periapical pathologies etc. Panoramic radiographs help to
analyze
pathologic
lesions,
impacted
teeth,
teeth
angulations
etc.
laboratory
communication,
patient
management,
marketing,
43
Magnification loupes
Help in accurate, detailed observation of tooth characteristics. Magnifying
lenses of 2.5 diopter or greater are extremely valuable diagnostic tools.
T-scan occlusal analysis
Is a computerized system that uses sensor technology to identify the location,
timing and relative force of occlusal contacts.
Periodontal charting
No part of the esthetic examination is more important than ascertaining the
condition of the patient's supporting bone structure. The periodontal ligament
of each tooth is thoroughly probed in six locations and charted. This can be
done with either a traditional periodontal probe or an electronic device where
the data is recorded electronically using a voiceactivated system.
Computer imaging
Offers an unparalled method of visualizing your intended esthetic correction
and the effect it can have on the face. It helps patients to make suggestions and
is a brilliant motivational tool.
INITIAL THERAPY
Initial therapy is required before esthetic treatment planning to arrest active
pathoses, bring adequate health to the dentition or give the patient relief from
pain.
Periodontal therapy:control of all periodontal inflammation through
scaling and root planning replacement of overhanging restorations and
crowns with improper margins and contact areas extraction of
periodontally hopeless and non-strategic teeth relief from "trauma from
occlusion" by conservative selective grinding and use of occlusal splints.
Pulpal
therapy:
endodontic
procedures
for
asymptomatic
and
44
17.
18.
19.
20.
21.
22.
Treatment sequencing is an integral part of treatment planning. It is a phasewise distribution of treatment procedures, which will be programmed or
charted
considering
periods
of
healing,
patient
convenience
and
46
47
48
Neutral Zone
The direction and dissipation of load makes a difference in the forces exerted
on the anchored root and the surrounding bone. The process of directing
occlusal forces through the long axis of the tooth is called "Axial loading".
Vertical load causes less stress compared to lateral load. A thorough
examination reveals that canines are best suited to accept horizontal forces
during eccentric movements as they have the best crown-root ratio and dense
compact bone around the roots.
The maximum biting force is in the range of 30-50 psi for the incisors, 47-100
psi for the canines and 127-250 psi for the molars.
Mandibular movements:
The mandibular movements are influenced by the anatomy of the mandibular
fossae and the condylar head, shape of the articular eminences, musculature as
49
Types of articulation
Balanced occlusion: this occlusion has all teeth contacting in all
excursions. It is primary a denture occlusion. Naturally occurring
examples are cases of advanced attrition.
Mutually protected/canine-guided occlusion: when the mandible is
moved in a right or left laterotrusive excursion, only the maxillary and
mandibular canines contact and efficiently dissipate the horizontal
forces while disoccluding the posterior teeth. Canines are best suited for
this as they have large roots, dense surrounding bone and trigger fewer
50
Centric relation
Is defined as the completely retruded position of the mandible with the
condyles in their most superior anterior position at any vertical rotational
position of the mandible.
CR has been found clinically to be the best location for maximum
intercuspation of teeth. In good occlusion, all teeth in the mouth (anteriors and
posteriors) make simultaneous contacts. Anterior teeth should never contact
harder than the posteriors or fremitus may be produced with possible
endodontic and periodontal trauma and/or interproximal separation of teeth.
Normally, occlusal contacts on the anterior teeth in CR are not broad, but rather
two or three spots per tooth on the incisors and one on each canine. The total
contact area has been estimated to be about 4mm for the entire mouth,
including all of the anterior and the posterior teeth.
Stabilization of the craniomandibular relation in CR is important to the
comfort, function and longevity of dental restorations. .
51
52
the incisal edges of the maxillary anterior teeth (molar class III
relationship). This termed in edge-to-edge relationship.
Another anterior tooth relationship is one that actually has a negative
vertical overlap. In other words, with the posterior teeth in maximum
intercuspation the opposing anterior teeth do not overlap or even contact
each other. This anterior relationship is termed an anterior open-bite. In
a person with an anterior open-bite there may be no anterior tooth
contacts during mandibular movement (Fig.5, 6, 7)
Anterior guidance
Is the dynamic relationship of the lower anterior teeth against the upper anterior
teeth through all ranges of function. It literally sets the limits of movement of
the front end of the mandible.
Anterior relationships must be determined with extreme preciseness because
along with the discomfort and look of artificiality, improperly restored anterior
teeth may contribute to the destruction of the entire dentition. When their
position allows it, anteriors should be made to form a very stable stop for the
front of the mandible, thereby limiting its closing motion.
Anterior guidance is of two types:
Incisal guidance (in protrusive-retrusive movements) : its primary
importance is for proper incising as well as rest positions and speaking
functions.
Canine guidance (in mediotrusive lateral movements) : the primary
importance of the canine guidance is to help prevent lateral eccentric
posterior tooth interferences and allow the condyles to move
uninhibitedly along their border pathways in the fossae as well as to
guide jaw closures more vertically to load the posterior teeth in their
long axis.
PERIODONTAL CONSIDERATIONS
53
Biologic width
The importance of not violating this physiologic dimension was suggested by
Ochsenbein and Ross and stressed by other authors. When margin placement
impinges on the biologic width, gingival recession or pocket formation and
periodontal disease may ensue, depending on the thickness of the keratinized
gingiva and the underlying bone. Invasion of the biologic with may result in
apical migration of the dentogingival unit with gingival recession and may be
self-limiting. With relatively thicker bone, it may result in apical migration of
the epithelial attachment and pocket formation.
54
55
Intrinsic
Tetracycline stains
Cigarettes
Fluorosis
Diet
Trauma to tooth
Tobacco
Systemic conditions
Jaundice
Amelogenesis imperfecta
Erythroblatosis foetalis
Enamel hypoplasia
Iatrogenic
56
Aging
Calcific metamorphosis
Loss of vitality
Tetracydine ingestion
Amoxicillin syrup
Stannous fluoride
Imipenem for cystic fibrosis
Amelogenesis imperfecta
Opaque
Fluorosis
Sickle cell anemia
Osteogenesis imperfecta
White
Fluorosis
Chronic kidney failure
Hypomineralization
Brown
Fluorosis
Smoking
Coffee
Soy sauce
Cola
Tea
Calcific metamorphosis
Loss of vitality
Chlorhexidine ingestion
Iron
Tetracydine ingestion
Antitartar toothpaste
Osteogenesis imperfecta
Chlorhexidine glucamate (Hibitane)
disinfectant
Tannic acid
57
Ochronosis
Dental materials
Black
Blue
Tetracvcline ingestion
Osteogenesis imperfecta
Green
Hyperbilirubinemia
Congenital biliary atresia
Occupational: brass factory
Marijuana smoking
Nasmyth's membrane
Orange
Red
Internal resorption
Congenital erythropoietic porphyria
Periapical granuioma in lepromatous
leprosy
Death
Gray
58
Chemistry
The bleaching process is based on an oxidation-reduction reaction. Hydrogen
peroxide undergoes reduction and oxidizes the stained tooth structure to change
its appearance. Oxidation is the chemical process by which organic materials
are converted into carbon dioxide and water.
Bleaching slowly transforms the organic substance in the stained tooth into
chemical intermediates that are lighter in color than the original tooth shade. In
a redox reaction the peroxide (oxidizing agent) has free radicals with unpaired
electrons, which it gives up, becoming reduced. The stained tooth structure
accepts these electrons and becomes oxidized thereby reducing the organic
colorants: The free radicals produced by the peroxides, are perhydroxyl and
nascent oxygen. Of these, the perhydroxyl is a more potent free radical which
is responsible for a better bleaching action.
In order to promote the formation of perhydroxyl radicals, the peroxide is buffered to a pH range of 9.5 to 10.8. The buffering provides a greater amount of
perhydroxyl free radicals, which results in a better bleaching effect.
The most common bleaching materials used are hydrogen and carbamide
peroxide. Carbamide peroxide first breaks down into hydrogen peroxide which
then further liberates the above mentioned free radicals. Un like the hydrogen
peroxide, the carbamide peroxide bleaching agent must remain in contact with
the teeth for a longer period of time to obtain complete efficiency of the
reaction. Carbamide peroxide is less irritatiog to the gingival tissues thus better
tolerated by the patients when used as a home bleaching agent.
Mechanism of bleaching
The hydrogen peroxide diffuses through the material into the tooth enamel. The
free radicals produced have unpaired electrons, they are unstable and hence
will attack most other organic molecules to achieve stability.
59
60
61
Case Selection
As a rule of the thumb, extrinsic stains are better managed by bleaching as
compared to the intrinsic stains. A large part of the success of bleaching lies in
judicious diagnosis and case selection. Not all cases of discolored teeth are
ideal candidates for dental bleaching. Management of dental decay, enamel loss
and periodontal pathosis is a prerequisite to bleaching. Cases showing severe
enamel loss, fluorosis leading to mottling of enamel and developmental defects
in enamel formation are contraindicated for bleaching.
Non-vital teeth that have discoloured as a result of trauma can be successfully
bleached, but those with other intrinsic stains such as amalgam or remineralised
lesions will be more resistant to colour change. Teeth with minor restorations
on the buccal surface or, ideally, those with only an access cavity are the most
successfully bleached. Teeth with extensive restorations are usually more
effectively crowned.
Preparation for bleaching
1) Record keeping and photographs Record keeping should begin at the
treatment planning stage. Records should document decision for treatment
and alternative. It is absolutely essential to take adequate photographs of a
patients preoperative condition. No amount of description can exactly
depict, how the patient looked before treatment. In addition, photographs
are more reliable than memory in documenting the progress of treatment.
2) Careful diagnosis, using radiographs and transilluminating techniques : In
this, the possibilities of any periapical abnormalities can be ruled out.
Caries and decalcified or hypocalcified areas will be disclosed. The size and
vitality of the pulp can be determined and the opacity, depth and layers of
62
Application of Orabase/Vaseline
63
64
a)
Thermocatalytic method
- Light
- Heat
b)
McInnes solution
- Old
- New
2)
3)
Teeth are covered with gauze saturated with 35% H2O2. (Fig. 1)
Bleaching light positioned 13 inches from the teeth with the light
shining directly on them. A rheostat setting of 5 usually used. (Fig. 2)
65
Excess solution rinsed off with copious amounts of warm water. Brush
and then polish.
At one time, it was considered to etch the teeth with phosphoric acid
before bleaching, supposedly to enhance the effect. However, etching is
not actually necessary.
66
On lingual surface
Protection lenses for the pt
Keep the light about 30 cms (13 inches) from the teeth and direct the beam to the
surface to be bleached temperature ranges from 115-140F. (Fig. 2)
(Acidic medium)
Old McInnes
Ratio
Bleaching
enamel
Etches
enamel
Removes
surface
debris
a) 30% H2O2
5 parts
b) 36% HCl
5 parts
0.2% ether
1 part
Alkaline medium)
New McInnes
Ratio
30% H2O2
1 part
20% NaOH
1 part
Application was repeated till the desired bleaching effect was observed.
With Old McInnes solution the solution was neutralized with baking
soda.
Disadvantages:
1)
2)
3)
68
4)
5)
Custom fitted prosthesis filled with 10% carbamide peroxide is worn for
few hours each day for a few weeks.
69
Shortly after the dentist home systems were introduced, several systems
were sold directly to the consumers.
70
71
human teeth results in a enamel loss of less than 200m. In 1989 Kendell
reported that 5 second application of HCl acid pumice mixture removes 46m
of enamel which should be considerably tolerated.
An important concern about the safety of the hydrochloric acid pumice
abrasion procedure is the low viscosity and high concentration of 18% HCl. To
eliminate this problem and ensure safety of this technique, the viscosity of the
acidic solution is increased by mixing 18% HCl acid with quartz particles so
that the solution takes on a water soluble gel like form. This came to be known
as the modified 18% HCl acid quartz-pumice abrasion technique.
The procedure is as follows:
1.
2.
3.
After the teeth were dried with air, the paste which
consisted of 18% HCl acid quartz-pumice particles, was applied with
a cotton tip applicator to the stained areas of enamel.
4.
5.
6.
7.
72
In this procedure, the quartz particles convert the acid into a gel form
and functions as an additional abrasive agent. Six months following this
treatment on several patients showed that the objectives of the treatment was
achieved.
The advantage of this technique is that it is relatively economical,
involving no laboratory costs, making this technique readily acceptable to
children.
73
In office bleaching.
2)
3)
complete seal in the root canal. The agent could escape through a porous root
canal filling and cause the patient extreme discomfort as well as probably loss
of tooth.
-
Surface stains visible on the inside of the preparation are removed, the
entire preparation is swabbed with chloroform or acetone to dissolve any
fatty material and facilitate the purification of the bleaching agent into
the tubules.
74
The pulp chamber is filled loosely with cotton fibres and the labial
surface is covered with a few strands of cotton fibre to form a matrix for
retaining the bleaching solution.
This is saturated with 35% H2O2 using a glass syringe fitted with a
stainless steel needle. The solution should be discharged slowly to
saturate the cotton inside the pulp chamber and on the labial surface
excess should be wiped immediately.
75
An alternative to activate the H2O2 is the use of light and heat from a
heat and light bleaching powerful light. The tooth is subjected to 6, 5
minute exposures and one replenishes the bleaching agent at frequent
intervals.
The heating instrument and cotton can then be removed. Repeat the
above process 4-6 times or for 20-30 minutes each time placing new
cotton fibres.
76
When sealed into the pulp chamber, it oxidizes and discoloures the
stain slowly, continuing its activity over a longer period.
77
A small pledget of cotton wool is placed on the paste and the cavity
is sealed with polycarboxylate cement kept under pressure till the
cement sets.
The GP is the root canal is sealed off from the pulp chamber with GIC
or resin modified GIC.
Patient is taught how to inject 10% carbamide peroxide into the canal
orifice and into the mouthguard with a syringe.
The patient may either sleep with the gel or remove the mouthguard
after 1 or 2 hours. If the patient prefers the latter, it will take a few days
longer.
At the end of the daily treatment, patient rinses his or her mouth and
then places a cotton pellet to prevent food from getting into the opening.
The total treatment proceeds and rapidly concludes with the results in as
few as 3 or 4 days.
80
These teeth may not have enough enamel to respond properly to bleaching.
Complications:
1.
Cervical resorption
81
Possible mechanism is that H2O2 percolates from the access cavity to the
root surface through the acid treated patent dentinal tubules.
Alternative theory bacteria that have leaked into the pulp chamber
from the gingival crevice via the dentinal tubules or directly from the
access cavity may cause resorption.
2.
3.
Failure to bleach
4.
Over bleaching
5.
82
83
84
Elimination of decay
The cavity design is mainly governed by the extent of the decay. The gross
caries is removed using a round bur and any residual soft caries excavated
thoroughly to leave behind a hard tooth structure. The caries indicator helps the
dentist to identify areas of active caries. Anti-microbial agents used separately
or along with the etchants help to eliminate bacterial contamination remnant at
the base of the cavity.
85
Esthetic Predictability
After elimination of the decay and determining the extent of preparation
required, for function and longevity, the preparations are evaluated and if
required redefined. The preparation design is extended to allow a smooth
transition of shade from the composite restoration to the rest of the tooth. This
enables the restorations to achieve esthetic excellence.
To create proper tooth form, shape, shade and texture, and to optimize function,
all cavity preparation designs should have extension for function and esthetics
(EFE). The facial form of all anterior teeth can be divided into various facial
planes, which converge or diverge from each other. These planes reflect or
refract light and give a texture to the facial surface. The areas between any two
planes are relatively prominent and hence extension of the margins of the
preparation should be kept away from these prominent areas. Extension for
functional esthetics (EFE) is achieved using a long bevel extending a few mm.
from the cavity margin arid ending on a relatively flat area on one of the
planes.
The EFE ensures that the margin of the restoration overlays the defects. The
esthetic advantages are:
The EFE is usually prepared using a long tapered fissure bur on the labial
aspect to make a bevel and a chamfer bur on the lingual and proximal aspects
to make a chamfer. The preparation designs will differ in various clinical
situations like carious lesions fractured teeth, malposed teeth, discolored teeth,
and closing spaces and in areas of abrasion or abfraction etc. depending upon
86
87
88
89
Before
After composite
the dentist will have difficulty to maintain the tooth form, tooth proportions, as
well as allow good gingival contours for favorable gingival response. Sometimes
an excessive frenal tissue makes it difficult for the dentist to restore this area and a
frenectomy may be advised in some cases.
When a diastema is small up to 2mm, no tooth preparation is required. The
minimal thickness of composite can be adequately shaped especially at the
cervical region to allow good maintenance. However, in cases of a moderate
diastema between 24mm the EFE should be given on the proximal curvature of the
labial surface of the tooth. The extension preparation is close to the gingival
margin and follows the contour of the interdental papilla to end on the palatoproximal line angle. The preparation is in the form of a depression, which provides
a definite stop and is done with a chamfer bur. The preparation design ensures
adaptation of sufficient bulk of the composite at the gingival margin creating
contours favorable for gingival health. The labial extension allows smooth
blending at the composite-tooth interface while the palatal extension provides
stability and retention. The composite can then be easily contoured from the
prepared area to the incisal edge. In cases with diastemata larger than 4mm a
similar preparation coupled with recontouring of the other proximal surface of the
tooth to maintain tooth proportions and form may be required.
Diastemata are filled in one tooth at a time. A celluloid matrix is effectively used
to get the desired contour. In the diastema, opaque composites are used to build up
a palatal wall followed by placement of hybrid composites of the desired shade on
the palatal and cervical aspect of the cavity. Microhybrid or microfilled
composites are then used as the final layer
92
Midline Diastema
After composite
93
toration following various planes. The restoration gets its final luster from the
polishing paste.
Before
After composite
94
COMPOSITE BONDING
Bonding, which offers a quick and easy way to mask many stains and
discolorations, is often an excellent treatment alternative for patients who are not
good candidates for bleaching.
Advantages:
1.
Painless.
2.
3.
4.
5.
Disadvantages:
1.
2.
3.
4.
5.
6.
95
7.
8.
96
Procedure:
Before isolation of the field, a tapering bullet-nosed diamond instrument is used to
rough out labial chamfer-shoulder preparations. The chamfer preparation should
extend gingivally to just level with the crest of the gingival tissue, proximally to
just labial to the mesial and distal contact areas, and incisally to the crest of the
incisal ridge.
97
98
Acid etching. Many light-cured composite materials come with gel-type etchants.
An etching gel is painted over the enamel surface area and left in place for a
minimum of 15 to 20 seconds; continuous stroking motion is not used. After 12 to
15 seconds of thorough water lavage, the labial enamel is thoroughly air dried.
The composite material may be placed over the bond resin surface before lightcuring or preferably after the bond resin has been cured by means of a 20-second
99
exposure to visible light. The latter procedure is recommended since the composite
material is much easier to control when placed on a prepolymerized surface. After
the 20-second period of light cure, the air-inhibited layer is clearly evident.
Insertion. A polyethylene strip is placed between the proximal chamfer margins
and the adjacent teeth to control the placement of the composite material. By
means of a flat-bladed anodized aluminum-coated instrument, the composite paste
is then applied and contoured over the labial surface. Wetting the side of the
instrument with a little bond resin before contouring facilitates the procedure and
allows for proper shaping and forming of the composite material without "pull
back". The prefitted crown form matrix is filled with additional composite material
and subsequently placed in proper alignment over the labial surface. Ideally, the
composite material should be highly viscous, readily moldable, and free of
"slumping" or uncontrolled flow. The flat-bladed composite instrument wetted
with a slight amount of bond resin may be used to shape and form the marginal
areas before curing, in which case it is unnecessary to remove gross excess during
finishing or the excess composite may be allowed to squeeze between the matrix
and the chamfer margins.
100
101
Finish. In finishing, most of the smooth matrix-cured labial surface should be left
intact if possible. Marginal finishing should be done by means of a tapering,
multifluted finishing bur, and final finishing is carried out with aluminum oxide
discs. The use of 3/8-inch aluminum oxide discs on a small-headed snap-on
mandrel facilitates the finishing procedure in the gingival region. Careful
adjustment of the occlusion in centric, protrusive, and protrusive lateral positions
should follow. Group function is mandatory.
102
Although direct labial veneer composite restorations are mainly indicated for
white spots, severe fluorosis, and severe hypoplastic discoloration, it should be
remembered that indirect porcelain veneers may also be utilized.
fabricated either in the office or in the dental laboratory. They can be light cured
or processed. They can be made of micro-filled, small particle, or hybrid
composite resin. The glass in the small particle or hybrid composite resin can be
etched with hydrofluoric acid, which provides micromechanical retention rivaling
that of etched porcelain.
Chairside repairs. These restorations can be repaired at the chairside with lightcured composite resins. The technique described below is for a light-cured
hybrid composite resin that is heat tempered, etched with 10% hydrofluoric acid
gel, and treated with silane. The silane chemically bonds to the remaining glass
103
particles and then to the luting composite resin, which is used to attach the veneer
to the etched enamel surface of the tooth.
Procedure
1. Clean the tooth and the neighboring teeth with pumice.
2. Select the desired shades of composite resin while the teeth are wet with saliva.
3. Determine the desired alignment of the teeth.
4.
enamel with a medium grit flame or chamfer diamond bur. If only minimum
preparation is necessary to improve alignment and increase facial contour, remove
only 0.25 to 0.50 mm of enamel from the facial area and none from the incisal
area. If incisal reduction is necessary, remove 1 to 1.5 mm.
5. Make a full arch impression of the prepared teeth with a vinyl polysiloxane
impression material. No retraction cord is needed because the margins are placed
at the gingival crest.
6. Make a full arch irreversible hydrocolloid opposing impression.
7. Place a provisional restoration if needed
104
8. Pour stone models of both the prepared and the opposing arches. Veneers can
be fabricated on the stone model by using a separating medium or on a flexible
model as described below.
9. After the stone is fully set, soak the model of the prepared arch in water for 10
minutes and make an irreversible hydrocolloid impression of the model.
10. Inject a vinyl polysiloxane impression material (medium to heavy viscosity)
into the irreversible hydrocolloid impression and form a flexible model. This
technique was first developed by Dr. K. Michael Rhyne for use in indirect
composite resin inlay fabrication.
Vinyl polysiloxane is injected into an alginate impression of a stone model of prepared teeth.
11. On the flexible model, fabricate composite resin veneers using a technique
similar to that described for direct intraoral application.
105
13. Contour and polish the veneers using 12- and 30-fluted finishing carbide burs
in a high-speed hand-piece or porcelain contouring and polishing wheels on a
lathe.
14. Place the veneers on the original stone model to check the fit and margins;
adjust further if necessary.
15. Heat treat the veneers in boiling water or a heat device, such as the Coltene
unit, for 10 minutes to achieve the heat-curing benefits.
16. Acid etch the lingual side of the veneers with 10% hydrofluoric acid gel for
30 seconds or lightly sandblast with a microetcher or air abrasion unit and rinse
thoroughly.
17. Evaluate the internal surfaces of the veneers to ensure that an etched surface
has been achieved
106
18. Clean the teeth with No. 4 fine pumice in a prophylaxis cup, rinse, and dry
with water-free and oil-free air.
19. Use 37% phosphoric acid for 15 seconds to etch the enamel and remove the
smear layer from any exposed dentin surface of the first central incisor.
107
24. Paint a thin layer of bonding resin onto the internal surface of the veneers.
25. Apply a luting composite resin to the internal surface of one of the veneers.
Place the veneer on the prepared tooth and remove excess luting composite resin
with a brush dipped in bonding agent
.
Excess luting composite resin is removed with a brush dipped in bonding agent.
26. Light cure for 40 seconds on the facial and lingual surfaces of the tooth.
27. Remove excess cured luting composite resin with a #12 surgical blade or a
sealer.
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Finish the margins with 12- and 30-fluted carbide finishing burs, fine
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110
COMPOSITE INLAY
Posterior composite materials have been available to the dental profession for over
three decades.
Although posterior composite restorations have increased in popularity, direct
composite restorations are still considered to have a number of limitations.
1. Despite the incremental build up technique, polymerization shrinkage of
the resin during curing is still considered to be a problem which contributes
to marginal defects, cuspal distortion, crack formation, and propagation
within the tissues of the tooth and resultant postoperative sensitivity.
2. Lack of stability in anatomic form and susceptibility to damage in load
bearing situations.
3. Water sorption with resultant hydrolytic instability.
4. Technique sensitive and user demanding in terms of manipulation and
time.
Composite inlay is one candidate system which overcomes the above limitations.
Definition:
A composite inlay is a restoration which is cemented into a dental cavity as a
solid mass that has been fabricated from the composite resin with a form
established either by an indirect or a direct procedure.
Thus inlay fabrication techniques include direct, direct/indirect, and indirect
techniques.
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materials.
9. Ideally, where all the cavity margins are in enamel.
Contraindications:
1. Patients with poor oral hygiene/ inadequate motivation.
2. Teeth exhibiting gross wear.
3. Teeth with insufficient tooth substance for bonding.
4. Preparations with excessive undercuts.
5. Where adequate moisture control cannot be achieved.
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113
Method of curing:
Composite inlays may be supercured, secondary cured or merely cured by a
conventional VLC( visible light cure) unit at ambient temperatures.
1. Super cured:
This may be described as a one-stage cure at elevated temperature under pressure,
the composite employed being heat cured rather than light cured as used in the
secondary and conventional cured systems. Eg for it is the SR- Isosit system,
where the inlays are cured at 120C at 6 bar pressure under water.
2. Secondary cured:
After initial light curing at room or body temperature, additional curing is affected
by heat and light. Eg for this type of system are the Coltene Brilliant esthetic Line
system, in which the inlay is secondary cured in high intensity light at up to 120
0 for seven minutes, and the Kulzer inlay system, in which the inlay is secondary
cured in high intensity light in an enclosed light activating unit attachment with
internal mirrored surfaces( vide infra)
3. Conventional cure
One mode of curing only is employed in such systems. An example is the EOS
system, where the inlay is cured by light only, on a die. Conventional cured inlays
may be secondary cured.
III. Type of composite:
Composite inlays are generally made from the existing categories of dental
composite types, as classified according to the filler types, for example:
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115
Composition:
The system incorporates a fine particle size (0.5 micro meters) hybrid composite
containing 78.5% by mass glass filler and is available in four Vita shades and has
seven paint on colors.
The inlays are built up and light cured in increments on a laboratory fabricated die,
prior to further polymerization in the Coltene DI-500 light/heat curing oven for 7
minutes at a temperature rising to 120 0. This restorative system can be deployed
in both direct as well as indirect modes, as well as being used as a direct placement
restorative. Before cementation, the composite restoration is subjected to a
photothermic treatment (post curing process) in a special oven. This procedure
allows the optimal resin conversion rate to be reached in few minutes ensuring
dimensional stability. This effect is of paramount importance as photocured resins
are known to continue their polymerization spontaneously which subsequently
generate internal and marginal stresses.
Kulzer inlay:
Employed is the Estilux Posterior CVS composite, a glass ceramic filled material
containing 80% filler by mass and available in four shades, with a more heavily
filled (86% by mass) radioopaque base component.
Direct inlays are produced intra- orally and indirect inlays on a die by
conventional light curing prior to tempering for either 180 s in the Dentacolor XS
light unit, or 6 min in the light box, an accessory to the Translux EC intraoral light
unit.
Visio- Gem
Was introduced in 1983 as a material suitable for the construction of anterior
composite veneers, but its use was expanded in 1985 to include indirect inlays. In
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this system, the inlays are initially cured in the ESPE Visio Alfa light source,
followed by a fifteen min light cure under vacuum in Visio Beta unit
Clinical technique for adhesive inlays
Despite the differences in the physical properties of composite and ceramic
inlay materials, the suggested cavity preparation designs may be similar.
The concepts described above for adhesive preparations may be employed.
This type of restoration will normally be appropriate to larger rather than
smaller cavities, and will often be a replacement for a failed amalgam or
gold restoration. While cavity designs for direct placement posterior
composite restorations may involve only minimal preparation other than
that required for caries removal, preparation for inlays, of necessity
involves preparation of the cavity to create withdrawal form.
The aesthetic inlay cavity will therefore often have an approximal box and
occlusal key.
Dimensions of the preparation:
A typical inlay cavity in premolars may have an interproximal box width equal to
one half of the buccolingual width and an occlusal isthmus width of one third the
BLW.
For molars, the typical inlay cavity has a box width of 0.4 BLW , with an isthmus
width of 0.29 BLW.
Cavities should be at least 2 mm deep occlusally.
The taper for the preparation should be greater than that employed for gold
inlay preparations, i.e. at least 6, given that the inlays are weak before
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118
1.
2.
3.
Aim to restore the strength of the tooth. Clinical and laboratory technique
for aesthetic inlays are outlined in Table. Using these techniques, a
satisfactory aesthetic result is achieved.
Rationale
Request for etching of the fitting surface of ceramic
inlays with hydrofluoric acid to provide a
micromechanirally retentive fitting surface The fitting
surface of composite inlays are sandblasted as the
achievement of a micromechanically retentive fitting
surface
A silane bond enhancer should be applied to both
ceramic and composite inlays both in the laboratory and
also pnor to cementation
Temporary restoration
Handle inlay with care, try into Inlay is weak prior to cementation
cavity: do NOT check
occlusion
If satisfactory fit, clean inlay Fitting surface may have been contaminated with
fitting surface with phosphoric salivary pellicle
acid for 15 seconds
Apply silane bond enhancer to Silane will improve adhesion of resin to ceramic inlay by
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inlay fitting
Remove excess luting material Removal of excess luting material is much more difficult
from accessible surfaces with when it has been cured
sponge pellets OT equivalent,
and interproximal excess with
a probe or floss if a matrix has
not been placed
air-inhibition gel
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2.
3.
4.
Depending on the restorative material to be used, minimal thickness and width are
required for occlusal isthmus and cuspal coverages.
The semi direct intra oral technique (Indirect direct) requires more taper greater
than 15 deg to facilitate removal of the restoration from the cavity. The indirect
technique (semi direct extra oral) can tolerate small internal undercuts which can
be later compensated with a die spacer.
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123
2.
3.
4.
5.
6.
Expensive
125
Incisal Reduction
Proximal reduction
Lingual reduction
126
Clinical situation
127
need to bury the margin beneath the gingiva. The finish line is smoothed with hand
instruments , this will help in removing any lip of enamel that might extend occlusally
from the cavosurface angle.
Esthetic considerations for Metal Ceramic Restorations
The poor appearance of some metal ceramic restorations is often due to
insufficient porcelain thickness. On the other hand, adequate porcelain thickness is
sometimes obtained at the expense of proper axial contour (such overcontoured
restorations almost invariably lead to periodontal disease). In addition, the labial margin
of a metal ceramic crown is not always accurately placed. To correct all these
deficiencies, certain principles are recommended during tooth preparation and fabrication
of the metal ceramic prosthesis. Otherwise good appearance is only achieved at the
expense of the periodontium.
Subgingival margins may be indicated for esthetic reasons, particularly when the
patient has a high lip line and the use of a metal collar labial margin is contemplated.
However, if the root surface is not discolored, appearance can be restored with a
supragingival porcelain labial margin sometimes called a collarless design.
Metal collars when used may be hidden below the gingival crest, although they
may cause some discolouration if the gingiva is thin. Successful margin placement within
the gingival sulcus requires care to ensure that inflammation and /or recession, with
resulting metal exposure, are avoided or minimized.
The preparation sequence listed above must be followed and adequate amount of
preparation must be made to ensure optimal esthetics.
Proper framework design for metal ceramic prostheses (especially multiple unit
and long span fixed partial dentures) must be planned. The framework design controls the
morphology of the restorations and in turn promotes good health. Good physiology and
good esthetics promote health.
There are three areas of framework design that promote proper construction of
fixed prostheses and will ensure good oral health of the hard and soft tissues: marginal fit,
contour control, and lingual metal band design. These are the factors that determine
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structural integrity, esthetic appearance, and the physiologic response to the fixed partial
denture or individual crown.
Marginal fit
The accuracy of the marginal fit has a significant influence on maintaining the
health of the hard and soft tissues. There are three types of inaccuracies pertaining to
marginal fit: short margin, overexpansion, and underexpansion. A well-fitting crown
placed on an abutment protects the dentinal hard tissues by sealing the prepared tooth
from the bacterial environment of the oral cavity. The short margin, whether caused by a
discrepancy between the preparation and the impression or an error in the fabrication of
the restoration, is an open invitation to plaque attachment leading to inflammation.
Overexpansion
Overexpansion can cause the cast restoration to rock on the prepared tooth,
opening either the facial or lingual margin, but, even more detrimental, if seated, the
overexpanded restoration creates an overhang extending beyond the margin of the tooth.
The overhang creates an area for plaque collection. The shelf created by the
overexpansion of the casting prevents debris from being easily removed by the patient.
The persistence of this condition will lead to deterioration in the health of the surrounding
tissues.
Underexpansion
Underexpansion makes fitting of the cast restoration extremely difficult because
the internal dimension of the casting is smaller than the preparation. Machining the
internal surface of the casting, ie, making its internal dimension larger, may allow the
casting to seat fully on the prepared tooth, but it will not eliminate the physiologic
negative of a short margin. The marginal periphery of an underexpanded cast crown is
always smaller (less in circumference) than the marginal periphery of the prepared tooth.
Placing an underexpanded or overexpanded crown, which has been machined to
fit, will always leave an exposed surface around the periphery of the prepared tooth.
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wax sculpture to create a uniform space for the porcelain veneer. Alternatively, the
impression of the diagnostic wax sculpture can be used create a matrix for positioning
preformed wax patterns.
Interproximal connectors: Design for strength
Fixed partial dentures rarely fail because of fracture within a pontic or abutment.
The weak section is the connector area. Inadequate design of the connector can allow the
framework to flex. A flex distortion of the framework will result in either a fracture in the
porcelain or, in severe cases; the framework itself may fracture at the connector. The size
of a connector is determined by the stresses that will be placed upon it. The greater the
stress or the longer the unsupported span between the abutments, the greater the
requirement for adequate cross section of metal in the connector areas. In the vocabulary
of structural engineering, the law of beams states that the strength of beam (its ability to
support a load) is proportional to its cross-sectional area.
The cross-sectional area has two factors: height and width. The law of beams also
states that the height, in the direction opposing the force, is by far the more important of
the two factors. Relating to metal framework design, this law indicates that the strength
of a multiple-unit metal framework can be optimized by maximizing the height of the
interproximal connector. All the multiple-unit frameworks built in laboratories use the
law of beams and their strength is a function of their design rather than bulk. When we
translate the structural engineer's vocabulary into the dental laboratory technician's
vocabulary, the law of beams means that the occlusogingival connector cross-sectional
dimension is of greater importance in providing strength through support to the prosthesis
than the faciolingual dimension. This places severe demands on the design and position
of the interproximal connector, for it must strongly support the pontic while still allowing
adequate space for the overlying porcelain. The faciolingual placement of the connector
requires careful planning because the facial aspect of the connector area must allow
sufficient space for porcelain placement without sacrificing strength.
To meet the requirements of support and esthetics, the connector is developed in
the lingual zone. By placing the connector on the lingual, optimal thickness of porcelain
can be placed on the facial aspect in the interproximal. By placing the interproximal
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connector on the lingual surface, maximum strength can be achieved because the
connector remains in metal, taking advantage of the greatest occlusogingival connector
cross section allowable.
Interproximal design: Esthetics
How the interproximal connector is shaped, where it is placed, and how it blends
to the pontic body are critical in achieving the optimum esthetics of the restoration. This
is a three-dimensional consideration involving the facial form as well as the incisal and
gingival aspects. To allow adequate separation of the units without exposing metal, it is
essential to provide space for porcelain on both sides of the pontic body. Placing the
metal framework toward the lingual allows for the creation of an adequate facial
embrasure. Placing the connector toward the lingual will allow for a deep interproximal
embrasure creating separation of the units, which is important to the esthetic appearance.
Providing adequate space for porcelain in the interproximal zone will allow the correct
thickness of porcelain to be veneered over the framework, ensuring vitality and color the
restoration.
Pontic-tissue relationship
Porcelain is widely recognized as being compatible with the residual ridge tissues.
Enough space must be provided on the tissue side of the pontic to ensure that the surface
will not have concavities and that the porcelain that is in contact with the tissue can be
glazed or highly polished, leaving a smooth surface to contact the ridge. Sufficient
clearance for porcelain can result in opaque porcelain tissue contact. Opaque cannot be
finished to smooth surface by glazing or polishing and will leave rough surface that will
collect food and plaque, irritating and inflaming the tissue.
Designing the framework so that the junction of the metal and porcelain occurs on
the bottom of the pontic should also be avoided. It is virtually impossible to provide a
metal-porcelain junction that is as smooth and as resistant to plaque attachment as an allporcelain tissue contact. When the pontic tissue contact cannot be maintained by the
patient, inflammation will occur under the restoration. When constructing the framework
wax pattern, it is helpful to place a 1-mmthick wax spacer over the residual ridge area on
the working model over which the pontic can be positioned. The wax spacer will hold the
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wax pontic section in place while creating a uniform 1-mm space under the section. After
casting, all the pontics will be a uniform 1 mm from the surface of the tissue. Providing a
1-mm space will permit adequate porcelain thickness to ensure a smooth, properly
contoured, and highly glazed surface.
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135
Lingual preparation
Completed preparation
Clinical Situation
Completed crowns
136
Etching
Silane application
137
Preparation sequence
Complete
ceramic
crowns
should
have
relatively
even
thickness
138
Finishing : all axial walls should be smoothed accentuating the shoulder at the same
time. All sharp angles should be rounded. The shoulder is smoothed with a sharp
round angled chisel to remove any loose enamel rods at the cavosurafec angles.
All Ceramic Systems
Aluminous core porcelains: the high strength ceramic core was first introduced by
Mclean and Hughes in 1965. they advocated using aluminous porcelain , which is
composed of aluminium oxide (alumina) crystals dispersed in a glassy phase. The
technique devised by Mclean used an opaque inner core containing 50%by weight
alumina for high strength . this core was veneered by a combination of esthetic body
and enamel porcelains with 15 and 5% crystalline alumina respectively and matched
thermal expansion . The resulting restorations were approximately 40% stronger than
those using traditional feldspathic porcelain.
Slip Cast Ceramics: High Strenght core frameworks for all ceramic restorations can
be produced with a slip casting procedure such as the in ceram. Slip casting is a
traditional technique in the ceramic industry and is used to make sanitary ware. The
starting media in slip casting is the slip that is an aqueous suspension of fine alumina
particles in waterwith dispersing agents. The slip is applied onto a porous refractory
die , which absorbs water from the slip and leads to the condensation of the slip on the
die. The piece is then fired at a high temperature (1150 0C). The refractory die shrinks
more than the condensed slip, which allows easy separation after firing. The fired
porous core is later glass infiltrated, a unique process in which molten glass is drawn
into the pores by capillary action at high temperatures. Materials processed by slip
casting tend to exhibit lower porosity and producing fewer defects than traditionally
sintered ceramic materials. The strength of In Ceram is about three to four times
greater than earlier alumina core materials, a finding that has prompted its use in high
stress situations such as FPDs. Two modified porcelain compositions for the In
Ceram technique have been introduced: In- Ceram Spinell contains a magnesium
spinell (MgAl2O4) as the major crystalline phase, which improves the translucency of
the final restoration. In ceram Zirconia contains Zirconium oxide (ZrO2) and is said to
have the highest strength. Marginal fit of In- Ceram has been reported as very good.
Hot Pressed Ceramics: Leucite Based- hot Pressed ceramics are becoming
increasingly popular in dentistry. The restorations are waxed, invested and pressed in
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a manner similar to gold casting. Marginal adaptation seems to be better with hot
pressing than with the high strength alumina core materials. Most hot pressed
materials contain leucite as a major crystalline phase, dispersed in a glassy matrix.
The crystal size varies from 3-10 microns and the leucite content varies from about
35-50% by volume depending on the material. Leucite is used as a reinforcing phase
due to the tangential stress it creates within the porcelain. Ceramic ingots are pressed
at high temperatures from 900-11650C depending on the material into the refractory
mold made by the lsot wax technique. The ceramic ingots are available in different
shades. Two finish techniques can be used: a characterization technique (surface stain
only) and a layering technique, involving the application of a veneering porcelain.
The two techniques lead to comparable mean flexure strength value for the resulting
porcelain composite.the thermal expansion coefficient of the core material for the
veneering material is usually lower than that of the amterial for the staining technique
to be compatible with the thermal expansion coefficient of the veneering porcelain.
Among the currently available leucite- containing materials for hot pressed craemics
are IPS Empress, Optimal Pressable Ceramic and two lower fusing materials Finesse
and Cerpress.
Lithium Silicate Based: IPS Empress2 is a recently introduce hot pressed ceramic.
The major crystalline phase of the core material is a lithium disilicate. The material is
pressed at 9200C and layered with a glass containing some dispersed apatite crystals.
Machined Ceramics
The evolution of CAD/CAM systems for the production of machined inlays, onlays,
veneers and crowns led to the development of a new generation of ceramics that are
machinable.
Cerec System: has been marketed for several years with the improved cerec2 system
introduced in the mid 1990s. the equipment consists of a computer integrated imaging
and milling system , with restorations designed on the computer screen. At least three
materials can be used with this system: Vita Mark II, Dicor MGC, Procad. Vita mark
II contains sanidine(KALSi3O8) as a major crystalline phase within a glassy matrix.
Dicor MGC is a mica bsde machinable glass ceramic that contains 70 volume % of
crystalline phase. Procad is a leucite containing ceramic designed fro making
machined restorations .
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choice if the tooth exhibits discoloration that would not be well masked by a more
translucent material. Conversely, when concern exists about fracture, the higher
strength materials should normally be the first choice.
Abrasiveness: one concern of ceramic restorations is the potential of abrasion of
enamel, particularly in patients with parafunctional habits. Whenever possible, a low
abrasion material should be considered.
Tissue management
A healthy periodontium is a prerequisite for any gingival retraction procedure.
The gingival deflection that takes place should be reversible in nature and should
allow vertical and horizontal access to the impression material at the cervical margin.
The retraction should be sufficient to allow a certain bulk of the impression material
to avoid tearing or deformation while removing the tray.
The retraction cord is placed in a definite but gentle manner. The thickness of
the cord is often determined by the free gingival depth. The cord is placed with a cord
packer with continuous strokes in the same direction slowly moving the packer along
the margin.
A knitted or braided cord impregnated with an astringent like aluminum
chloride or ferrous sulphate is preferred for optimum displacement of gingival tissues.
A double cord technique is used in hemorrhagic cases when a 000 cord or a
thin black silk suture is used as the first cord. The second cord used is often a woven
or knitted one. After establishing sufficient displacement the second cord is removed.
The retraction cord with the chemical should not be kept for more than 10 min, to
prevent irreversible changes in the gingival tissues. Prolonged usage may lead to
sloughing of the tissues, inflammation followed by recession, leading to unesthetic
results. The impression is then made. The first cord controls-the bleeding allowing
clear path for the impression material.
Impression methods
Elastomeric impression materials have good accuracy. These materials are
technique sensitive and the dentist would take some time and experience to master the
technique. The deviation in accuracy varies according to the type and rigidity of the
tray, the delay in pouring the impression, the viscosity and the brand variations in
142
products etc.
The tray used can be a perforated metal tray or a custom-made tray. The
perforated metal tray is used when putty impression material is used. This is a time
saving procedure. Acrylic custom trays are used to make impression in medium and
low viscosity impression material. This allows for uniform thickness of 2mm of
impression material giving the most accurate impression. Tray adhesive is a must
since it prevents separation of the impression material from the tray.
Double mix technique is simple and fast and suitable for a single or few units
of crowns. The low viscosity material is injected all over the prepared tooth and the
tray loaded with the high viscosity silicone putty is placed over it.
The wash technique is usually used for multiple preparations. It is a double
impression technique where the putty impression is taken first. After curing and
rinsing of the impression, undercuts and interdental areas from the impressions are
trimmed. The shapes of the teeth are also eliminated allowing space for low viscosity
material. The second impression is now taken with the injectable silicone. These
impressions can be stored for several hours.
Provisionalization of crowns
The role of provisional restorations is three fold. It protects the preparation
and also helps to establish a corrective interface for the final restoration, both
biologically and esthetically. The long term gingival response can be envisaged with
provisional restorations and the satisfaction and comfort of the patient can also be
gauged. Hence the provisional restoration should mimic the final restoration in form,
shape and color.
Many techniques including the use of single preformed polycarbonate crown,
shell technique, block technique and heat cured acrylics are used to make provisional
restorations.
A polycarbonate crown is used over the prepared tooth. The polycarbonate
crown is adjusted for height and axial contours as far as possible. A thin mix of mouth
acrylic is placed in the crown which is seated over the lubricated preparation. The
excess is then trimmed, the margins are defined. A second relining might be needed to
get a superior marginal adaptation.
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In the shell technique which is probably the best and most effective technique,
a cast is obtained from the diagnostic wax-up. A polyvinyl template is made on the
cast and then the teeth on the cast are under-prepared. Tooth colored acrylic is poured
into the template which is placed over the lubricated cast. After curing, the shells are
trimmed and finished. The shells are relined in mouth after complete tooth
preparation.
Alternatively the provisionals can be made on casts obtained after tooth
preparation using the template. This technique provides provisionals with correct
contour, contacts, proper occlusion and finish, saving chairside time.
In block technique an acrylic block is molded on the preparation and a free
hand sculpting is done by the dentist. This is a time consuming technique hence is not
favorable.
The heat cured provisional restorations are long-lasting and serve as better
provisionals. They seal the cervical margins, extend till the areas in contact with the
periodontium and produce accurate occlusal contact along with good esthetics. A
duplicate working cast is obtained and the heat cured provisional is fabricated and
then carefully polished with cotton thread wheels, polishing pastes and cemented
using non-eugenol cement.
Some dentists make impressions with elastomeric material before tooth
preparation. After preparation, mouth acrylic of low viscosity is poured on the
impression where the tooth is prepared. The tray is placed in the mouth for a few
minutes. A replica of the preoperative tooth form is instantly ready which can be
adjusted, relined and finished as a provisional restoration. This technique can be used
only when the preoperative tooth form is intact and if esthetic correction in relation to
incisal length and incisal profile is not desired.
Try-in
All metal castings are evaluated for margin integrity, internal fit stability and
adequate space for ceramic material. Intra- occlusal relationship record is needed in
extensive rehabilitation cases. Bisque trial for ceramic restorations are assessed for
location, site and tightness of proximal contacts, marginal adaptation and favorable
centric and eccentric occlusal contact without interferences. Besides the shape,
contours and color; adequate surface characterization is checked and incorporated.
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The trial for all-ceramic restorations are assessed for a passive fit margins,
proximal contacts, stability, shade, form, characterization and occlusion.
Cementation
It is advisable to lute a restoration provisionally to assess the esthetics and
function in the mouth for a longer period of time. Noneugenol based cements are
preferred. For permanent cementation, sand blasting the inner surface of the metalceramic restoration and the use of a reliable cement with low film thickness is
advisable. The luting agent of choice for final cementation of metal ceramic
restorations is glass ionomer cement while adhesive resin cements are recommended
for all-ceramic crowns. Removal of excess from around the restoration and from the
interdental areas should be done with utmost care .
Recall
Periodic appraisal of oral hygiene regimen, function and comfort of the
restorations should be carried out for successful results. Planned corrective measures
have to be initiated at the right time for long service of the restorations.
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LAMINATING
Laminating, like bonding, consists of applying a thin veneer of preformed porcelain.
Advantages of Bonded Porcelain Restorations
The main advantages of bonded porcelain restorations are the following:
1.
Excellent esthetics. Porcelain offers unsurpassed esthetics and inherent color control. In addition, unlike direct laminate
veneers, the porcelain laminate veneers depend less on the esthetic skill
of the dentist.
2.
3.
4.
6.
Soft
tissue
compatibility.
Properly
polished
Minimal
tooth
reduction.
Anterior
porcelain
porcelain-fused-to-metal
and
all-porcelain
full
coverage
restorations.
146
The advantages of the refractory model include tighter contacts and the absence
of the gap created by the use of platinum foil. The disadvantages are less room
for coloring agents and more difficulty in adjusting proximal areas by the
technician.
Direct Castings. Cast ceramic restorations are fabricated using the "lost wax"
technique. This eliminates the need for multiple firings but requires extrinsic
staining for coloration.
CAD/CAM Machining. Ceramic restorations can be manufactured either in
the dental office or in the laboratory. A model or video image of the
preparation is required, and the restoration always requires modification of the
surface porcelain to obtain proper color esthetics.
Clinical Technique
1. Evaluate the high lip line.
2. Administer suitable anesthesia (if necessary).
3. Prepare three horizontal surface depth cuts in the labial surface with a
friction grip three-tiered LVS-1 or LVS-2 depth cutting diamond. Depth cuts
should be 0.5 to 0.7 mm deep for "ideal" teeth, and 0.3 mm deep for
mandibular incisors. Lingually positioned teeth and those with thin enamel
require less reduction.
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4. Prepare three incisal depth cuts with an LVS-3 or LVS-4 diamond bur. (The
incisal reduction should create a preparation that is 1 mm shorter than the
desired final restoration.)
5. Using the depth cut as a guide, prepare the incisolingual finishing line to a
modified butt joint with the diamond wheel bur. The labioincisolingual angle
should be approximately 75 degrees.
A butt incisal finishing line should slope approximately 75 degrees gingivally from the labial to
provide resistance to restoration displacement and to provide for adequate thickness of porcelain at
the margin to prevent restoration fracture.
6. Using the depth cuts as a guide, prepare the labial surface with an LVS-3 or
LVS-4 diamond bur.
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The labial surface is prepared using the horizontal depth cuts as a guide.
B.
151
If the final porcelain laminate veneer will be similar in color to that of the prepared tooth, the
proximal finishing line terminates 0.2mm labial to the contact area.
Proximal representation of porcelain laminate veneer preparation before reduction of the proximal
subcontact area. The proximal finishing line terminates 0.2mm labial to the contact area because
the final porcelain laminate veneer will be similar in color to that of the prepared tooth. The contact
area is indicated with diagonal lines
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If the final porcelain laminate veneer will significantly differ in color from that of the prepared
tooth, the proximal finishing line terminates within the interproximal contact area at a depth of one
half the labiolingual dimension of the contact area.
i.
Proximal representation of porcelain laminate veneer preparation before reduction of the proximal
subcontact area. The proximal finishing line terminates within the interproximal contact area at a
depth of one-half the labiolingual dimension of the contact area because the final porcelain
laminate veneer will be significantly different in color from that of the prepared tooth.
ii. Prepare the proximal subcontact area with an LVS-3 or LVS-4 diamond bur.
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B. For subgingival margins: Gently place gingival retraction cord . The cord
should extend into the sulcus of the interproximal papillae beyond the proximal
finishing line
9. Extend the gingival finishing line (for subgingival preparations only)
approximately 0.1 mm subgingivally with an LVS-3 or LVS-4 Diamond bur.
Use the pencil line as a guide. Severely discolored teeth may require a 1 -mm
subgingival extension of the finishing line.
10. Round the incisal line angles with an LVS-3 or LVS-4 diamond bur. The
thinner LVS-5 or LVS-6 diamond bur may be necessary to access line angles
that are close to adjacent teeth.
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Clinical Technique
1.
2.
LABORATORY COMMUNICATIONS
Natural versus Idealized Artificial Appearance
Natural teeth are polychromatic and characterized. Canines are usually slightly
lower in value or higher in chroma than incisors and premolars. These can be
disturbing insights for patients who often desire an idealized artificial
appearance (monochromatic, white "chiclets"). Both of these alternatives, and
the myriad options in between, should be discussed before a final shade
selection is made. It may be helpful to elicit the opinion of the patient's friend
or family member.
Shade
To achieve the desired shade change, the percentage of opaquing porcelain and
the amount of die spacer can be appropriately adjusted by the dental laboratory
technician. The specific ratios vary depending on the type and brand of
materials used. Close communication with the dental laboratory technician is
essential in this regard.
Shape
Indicate the desired shape and size of each individual porcelain laminate
veneer. As a general rule, feminine teeth are more rounded, less textured, and
smaller than masculine teeth; however, this is not always appropriate nor is it
always desired by the patient. Therefore specific characterizations should be
specified diagrammatically, or in writing, on the laboratory prescription.
Texture
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Try-in Considerations:
Clinical Technique
1. Inspect the porcelain laminate veneers for cracks and imperfections. Place
the veneers on the model and verify appropriate fit individually and collectively.
4.
Moisten the teeth and the internal surfaces of the porcelain laminate
veneers with water. Glycerin, a more viscous liquid, may be used if greater
retention of the porcelain laminate veneer is desired during this stage.
5.
Place the porcelain laminate veneers on the teeth and evaluate for proper
fit and color. Adjustments to the fit can be made with a fine diamond bur.
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The porcelain laminate veneers are placed on the prepared teeth and evaluated for proper fit and
appearance.
6. Verify shade.
A. If the shade is correct: Verify that untinted luting resin will be acceptable
by placing untinted water-soluble try-in paste or the actual resin lut-ing cement
into the internal surface of the porcelain laminate veneers and placing the
veneers on the teeth.
B. If the shade must be altered: Place the appropriate shade of water-soluble
try-in paste or the actual resin luting cement into the internal surface of the
porcelain laminate veneers and place the veneers on the teeth.
7. Clean the internal surfaces with a cotton-tipped applicator followed by a
water spray, and finally in an ultrasonic cleaner with acetone or alcohol. Apply
37% phosphoric acid for 15 seconds to remove any salivary contamination
from the etched surface.
8. Clean the teeth again with oil-free pumice ; wash and dry with oil-free air
9. Clean proximal surfaces with a finishing strip ; wash and dry thoroughly
with oil-free air.
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8. Try-in the porcelain laminate veneer. If the shade is still not acceptable,
repeat steps 1 through 7.
9. Verify with the porcelain manufacturer whether re-etching of the internal
aspect of the porcelain laminate veneer with hydrofluoric acid is necessary. Do
not allow the etchant to contact the external surfaces.
CEMENTATION
Clinical Technique
1. Apply silane coupling agent to the internal surface of all the porcelain
laminate veneers according to the manufacturer's instructions.
2. If the tooth surface has been contaminated, pumice the labial and lingual
tooth surfaces again.
3. Place matrix strips between the first teeth to be restored and the adjacent
teeth.
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Matrix strips are placed between the first teeth to be restored and the adjacent teeth.
5. Wash with water and or water/air spray for a minimum of 10 seconds for gel
or liquid etchants.
6. Air dry. Repeat the etching process and rewash the enamel if it is not
"frosty" white. Repeat if necessary.
7. Place new matrix strips between all interproximal areas.
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The restoration is carefully seated onto the prepared tooth and the incisal tip is cured from the
incisolabial direction for 10 seconds.
14. Remove excess luting cement with a sable brush moistened with bonding
agent.
15. Cure the remaining luting cement from the buccal, lingual, and incisal
directions according to the man-facturer's instructions.
16. Remove the matrix strips.
17. Remove excess flash with composite resin carving instruments.
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18. Repeat steps 2 to 17 for the remaining porcelain laminate veneers. Two
adjacent teeth can be placed simultaneously.
FINISHING AND POLISHING
Marginal discrepancies immediately after cementation of indirect restorations
are, to some degree, inevitable. Postcementation intraoral finishing of both
porcelain and resin at the tooth-restoration interface can be accomplished with
rotary instruments. Scanning electron microscope and spectrographic
reflectance analyses reveal that adjusted porcelain can attain a surface
smoothness that is superior to that of glazed porcelain if a specific protocol is
followed." This protocol is outlined below and involves the use of
progressively finer abrasives. Finishing and polishing instruments include
diamond burs, a 30-fluted carbide bur and a 2m to 5m particle size diamond
polishing paste on a webbed rubber prophylaxis cup.
Clinical Technique
1. Carefully finish the facial margins with the Ml finishing diamond in a highspeed handpiece at low speed (regulated by applying appropriate pressure on
the rheostat) with water coolant.
2. Finish the lingual areas with a fine "football-shaped" diamond.
3. Dry the marginal areas to evaluate for smoothness and repeat steps 1 and 2 if
necessary.
4. Evaluate the occlusion with articulating paper in both centric occlusion and
in all eccentric excursions. Adjust porcelain, if necessary, with an extra-fine
"football-shaped" diamond bur.
5. Repeat steps 1 through 4, substituting first an M2 finishing diamond, then an
M3 finishing diamond, and lastly, a 30-fluted carbide bur.
6. Finish and polish the proximal areas with interproximal abrasive strips.
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7. Evaluate the interproximal contact areas with unwaxed dental floss and
repolish if necessary.
8.
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CERAMIC INLAYS
Indications for ceramic inlays:
1. Patients who maintain good oral hygiene.
2. Patients requesting for tooth colored restorations in posterior teeth.
3. In the cervical regions and proximal regions of anterior teeth where
esthetics is of prime concern.
4. Teeth in which strengthening of the remaining tooth structure is needed.
5. No evidence of excessive attrition in relation to the patient s age.
6. Cavity free from marked undercuts.
7. Ideally where all cavity margins are in enamel.
8. Sufficient tooth structure is available for bonding.
9. Lesions on the occlusal and proximal surfaces of posterior teeth.
Contraindications:
1. It is not a restoration of choice if an anterior tooth is grossly involved
either proximally or cervically. There must be adequate tooth structure
to support the restoration.
2. When access to the lesion is poor and overcutting of tooth structure
would be required Eg in rotated teeth. In such conditions other
restorations should be considered.
3. Patients with poor oral hygiene and inadequate motivation.
4. When short teeth preclude developing adequate resistance and retention
forms Eg: Heavily worn down teeth.
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Increased cost and time for fabrication when compared with a direct
restoration.
2.
3.
4.
5.
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6.
7.
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c) Dicor MGC.
The refractory die technique uses a direct build up of porcelain onto an
investment model whose coefficient of thermal expansion is similar to that of
ceramic material.
Atleast three firings are generally necessary to compensate for firing shrinkage
before a final glaze is applied.
This method eliminates the use of platinum foil, which in part causes
inaccuracy and deformation.
Procedure:
After the cavity has been prepared, an impression is taken and a master
working cast is poured in die stone or epoxy resin. Die pins aid in
forming a die.
The master cast is separated and trimmed. A die spacer is applied to the
cavity preparation usually on the pulpal and axial walls.
The prepared master model is then duplicated with a silicone impression
and poured in the refractory investment capable of withstanding
porcelain firing temperatures.
After hardening the cast is fired at 1000 deg C to eliminate
decomposition gas which may be generated during the first porcelain
firing.
It is then soaked in a conditioning solution until completely saturated.
This solution enables the porcelain contraction to be directed towards
the cavity itself.
Ceramic inlays produced on refractory die
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Disadvantages:
3. Technique sensitivity
4. Higher incidence of fracture compared to the other ceramic
systems.
5. Problems may be encountered in the fit and marginal integrity of
these restorations.
Preparation design:
1. Occlusal reduction, 2. Axial reduction, 3. Types of margins, 4. Internal form
and finish, 5. Treatment of dentin, 6. Taper and extension, and 7. Cuspal
preparation / reduction.
Occlusal reduction:
Approximately 1.5 mm to 2 mm of occlusal reduction is done for all ceramic
systems.
Axial reduction:
Cerapearl material needs 1.5 mm of reduction.
Cavity preparation for posterior ceramic restoration:
Color match with the tooth structure, which makes the interproximal extension
undetectable.
When entire cusps are fractured and require replacement, the facial or lingual
finish lines may be carried to within 0.5 mm of the gingival tissue to provide a
harmonious blend of tooth color.
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Excellent fit.
Excellent esthetics.
Disadvantages:
Potential to fracture in the posterior areas.
Need for special equipment( pressing oven and die materials.)
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The time taken to mill the restoration depends on the experience of the
operator, complexity of the restoration and sharpness of the cutting disks. The
average time for milling is 20 to 30 min.
Copy milling:
Disadvantage: One problem frequently encountered during the use of copy
milling technique is the difficulty in obtaining accurate proinlays.
Ultrasonic/ Sono erosion (DFE, Erosonic) used for grinding ceramic requires a
metal based negative form of the interior and exterior contours of the
restoration, which are produced by wax moulding and casting or by intensive
copper plating of the impression.
These are called Sonotrodes. Both sonotrodes fitting exactly together are
guided into a ceramic blank after connecting to an ultrasonic generator under
slight pressure.
The ceramic blank is surrounded by an abrasive suspension of hard particles
such as boron carbide, which on acceleration by ultrasonics erodes the
restoration of the ceramic block.
Mormann and Brandestini for the first time used a CAD-CAM device to
digitize and store cavity parameters, and a copy milling device to then shape
out a restoration out of the ceramic block. This method was commercially
available as an integrated CAD-CAM unit for dental use in 1988 by Siemens,
known as Cerec. The original system was known as Cerec I when in September
1994 an improved version Cerec II was introduced. The unit consists of
1.
2.
3.
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Cerec I cannot prepare the occlusal anatomy of the restoration whereas Cerec II
can. In addition to the grinding wheel, the Cerec II is also equipped with a
cylindrical diamond stone which is able to finish off undercuts at buccal
extensions, curved shoulders at
Erosion method:
CAD- CAM generated inlays:
Cuspal preparations and the proximal areas. Also Cerec II is a definite
improvement over the Cerec I comparing the camera and image processing
systems.
Briefly CAD- CAM system uses digital information about cavity preparation or
a pattern of the restoration to provide a computer aided design( CAD) on the
video monitor for inspection and modification. Once the three dimensional
image of the restoration is accepted, the computer translates the image into a
set of instructions to guide a milling tool (Computer Assisted Manufacturing
CAM) in cutting the restoration out of the ceramic block. In a way, the
computerized unit serves as an automated mini dental lab.
Cavity preparation for CAD-CAM inlays:
Tooth preparation for CAD-CAM inlay or an onlay requires
conventional cavity design with slight modifications:
No convexities should be present in the pulpal and gingival walls. They
may be flat or concave buccolingually.
The occlusal step should be prepared 1.5 to 2 mm in depth and any
isthmus or groove extension should atleast be 1.5 mm wide to decrease
the possibility of fracture of the restoration.
The buccal and lingual walls of the occlusal portion of the preparation
may converge towards the occlusal. This feature is unique to the Cerec
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system as it can automatically block out any undercuts during the optical
impression. A more conservative cavity preparation is therefore
permissible along the occlusal aspect, especially when replacing the old
amalgam restoration when undercuts were purposefully given in the
restoration for retention. The facial and lingual walls of the preparation
in the proximal box are prepared in the usual fashion with slight
divergence toward the occlusal. Convergence is not given here so as to
avoid excessively thick composite cement lines.
Axial walls should be straight and not follow the convex contour of the
proximal surface of the tooth.
No cavosurface or marginal bevels should be given.
Technique:
Five steps for fabrication of CAD- CAM fabricated inlays:
Computer surface digitization
Computer aided designing.
Computer aided manufacturing.
Computer aided esthetics.
Computer aided finishing.
The last two steps are very difficult and hence not a feature of the commercial
systems available.
Surface digitization:
Optical impression is used to collect the information in the shape of the
preparation using a Scanning device. The image is displayed on the monitor
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The cavity surface of inlays, onlays are milled to the dimensions of the scanned
image with diamond disks or other instruments that are electrically driven and
lubricated with water. The occlusal surface cannot be ground with Cerec I but
the occlusal surface can be ground with Cerec II. The occlusal anatomy when
using CEREC-1 is
Controlled cutting of the ceramic is done by: rotation of the block; horizontal
movement of the block into the wheel and vertical movement of the cutting
wheel. The fit of the restoration is confirmed in the patients mouth and any
necessary adjustments made. Proximal contours
provisionally adjusted.
At the cementation visit rubber dam is applied and the fit of the inlay is verified
on the tooth. Proximal adjustments are done with abrasive diamond disks that
run from coarse to fine. Proximal surfaces are adjusted at this stage itself, as
these would be difficult to be reached later.
The inlay is then prepared for bonding which includes preparation of both the
restoration and the tooth. Etching is done on the cavity surface of the inlay
either with a microetcher and/ or ammonium bifluoride or hydrofluoric acid.
After etching, a silane bonding enhancer is painted onto the surface
Surface of the preparation of the tooth follows the usual procedure. The cavity
surface is etched for 15- 30 sec with 30% phosphoric acid. Depending on the
bonding system used, the appropriate primer and the bonding agent are applied
to the tooth surface.
The cementation procedure and subsequent finishing and polishing are similar
to as in other ceramic inlays. Glazing may not be required in these restorations.
Disadvantages of the CAD-CAM system:
Initial high cost for the purchase of the ceramic unit.
Time and cost must be invested to master the technique.
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Contouring the occlusal surface may still have to be carried out by the
clinician.
Cerec III
This system simplifies and accelerates the fabrication of ceramic restorations
compared to the former systems. It accommodates advances in computer
technology thus allowing numerous simplifications and increased automation.
Cerec III software simplifies occlusal and functional registration. Proper
occlusion is established accurately and quickly, manual adjustment is reduced
to a minimum.
The separate branding device, which provides greater detail and is fitted with
two finger cutters is connected via radio control wave to control unit.
The grinding unit receives data from the control unit independent of its location
in the practice. The second restoration can be designed when the first is being
milled. The grinding unit is also equipped with a LASER scanner and can be
used for indirect applications through a personal computer. Since it is equipped
with an intraoral video camera or a digital radiography unit, it can also be used
for patient education and for user training.
Cicero system for fabrication of ceramic restorations (Cicero Dental Systems
B.V.( Hoorn, The Netherlands)
The Cicero (Computer integrated ceramic reconstruction) method for
producing ceramic restorations uses optical scanning, ceramic sintering and
computer assisted milling techniques to fabricate restorations with maximal
static and dynamic occlusal contact relations.
The technique consists of optimally digitizing the die, designing the crown
layer build up, and subsequent pressing , sintering and milling consecutive
layers of a shaded high strength alumina core material, a layer of dentin
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Modeling the future restoration with wax and preparing it for casting.
Specific procedures for Conventionally fired porcelain
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inadequate
crown
lengths,
hyper-pigmented
gingiva
and
open
interproximal spaces, which require correction. Recognition of these esthetic mucogingival problems and a treatment plan for their correction are the prerequisites for
esthetic success in restorative rehabilitation.
Therefore, a precise implementation of these procedures in this emerging field of
perio-esthetics mandates a complete understanding of all periodontal principles and its
applications to achieve a perfect esthetic therapeutic outcome.
Esthetic periodontal considerations
A healthy periodontal environment with sufficient tissue volume to fill in the
interproximal spaces is an essential element for ideal anterior esthetics. The gingival
tissues are visible during smile, laughter and even speech, as a result, any normality or
abnormality of the gingiva can be easily appreciated.
A healthy periodontium with an ideal gingival scallop and knife edge contour.
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ing harmony in the dental composition. However, in cases of recession or postperiodontal therapy the embrasures may open up revealing a black triangle.
The apical location of the interdental papilla creates a black triangle effect between the upper left
central and lateral incisors.
Biologic width: It has been demonstrated from autopsy recordings that the mean
sulcus depth is 0.69mm, mean length of the junctional epithelium is 0.97mm and connective attachment is 1.07mm; the combined width of the latter two is 2.04 mm and is
called the 'biologic width'. This biologic width is always present, therefore restorative
margins must maintain a distance from the alveolar crest that respects the biologic
width, otherwise gingival recession or pocket formation ensues.
Esthetic periodontal defects and its correction
Periodontal defects posing an esthetic problem can be addressed once the patient is
adequately motivated in periodontal health maintenance and demonstrates efficient
plaque control. These defects may include:
Violations of biologic width.
Gingival asymmetries.
Excessive gingival display.
Localized gingival recessions.
Abnormal frena.
Excessive gingival pigmentation.
Inadequate interproximal papilla.
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Severe recession in relation to the left central and lateral incisors due to the violation of biologic
width by the margins of the crowns.
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Interim restorations placed after periodontal correction. Note the reduction in the interproximal
space between the central and lateral incisors.
Violation of the biologic width in relation to the right central incisor. Note the severe circumferential redness with absence of recession.
Osseous reduction and suture placement to correct violation. Interim restoration placed in harmony with the gingival margin.
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Full ceramic crown placed as a final prosthesis. Note the restoration of the healthy gingival
margin.
In cases of restoring teeth with a healthy periodontium after the exact position of the
restoration margin is decided, the position of the gingival margin is surgically
established Surgical technique for establishing proper biologic width involves
recontouring the osseous crest so that a minimum of 3mm of the flap can be placed
coronal to the position of the recontoured osseous crest. This will take into
consideration the average biologic width of 2mm. Sometimes a loss of 0.25mm0.5mm of crestal bone can be anticipated due to surgical trauma. In cases of thick
gingiva with thicker bone the bone loss can be minimal however in cases of thinner
bone and thin gingiva as in the lower anterior region, greater bone loss can be
anticipated. A minimum of 6 weeks of healing is required before final restoration can
be placed.
In accidental tooth fractures or any other clinical situations where the restorative
margins may violate the biologic width, bone removal in the adjacent teeth might be
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then to maintain the biologic width, osseous reduction is carried out, wherein a labial
and palatal flap is raised and osseous reduction is done all over including the
interproximal region using low speed round carbide of known diameter with copious
irrigation and the flap is then sutured back.
The gingival tissue is excised using a B. P blade number 15 to correct the asymmetrical gingival
margins in relation to the left maxillary cuspid and bicuspids.
A full thickness flap is raised and osseous reduction is carried out using a low speed hand piece
and round carbide bur.
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In cases of a single tooth gingival asymmetry where crown lengthening with minimal
osseous reduction is indicated, a technique is described wherein after the
gingivectomy is carried out, two vertical incisions are made on the gingival margins
without involving the interdental papilla. After raising the flap the osseous reduction
is carried out. While contouring the bone, care should be taken to avoid any ledge
formation in the bone crest.
Crown lengthening can be done either for esthetic or functional purposes:
Esthetic crown lengthening: When a disparity in the clinical crown length exists between contralateral teeth resulting in a left / right side height discrepancy, esthetic
surgical correction can be provided to enhance the cosmetic result before restorative
measures.
In such cases 'esthetic crown lengthening' may be carried out by performing
gingivectomy and or osseous resection only on the facial aspect, for better esthetics.
Root exposure is often a common complication and intentional root canal or post
surgical treatment with veneers or crowns may be required
Functional crown lengthening: Whenever such a procedure is carried out in order to
gain crown length for restorative purposes it is called 'functional crown lengthening'.
The gingiva and bone follow a definite pattern interproximally, facially and palatally.
Whenever the functional requirement needs more than 2mm of bone resection on the
facial and palatal osseous crest a facial and palatal flap should be reflected and
osseous resection is done all over including the inter-proximal region. This maintains
the osseous contour around the tooth.
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a)
Gingival margins of the right central incisor is at a lower level than the left
central incisor.
b)
The dotted line indicates the oblique vertical incision without involving the
interdental papilla.
c)
A full thickness flap is raised to gain access for osseous reduction; the blue
dotted line indicates the amount of bone to be resected.
d)
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203
Note the straight smile line, improper progressive abating and lack of balance in the smile.
maxillaryarch.
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Rotational flaps: The lateral sliding pedicle flap is a predictable way of covering the
recession. The availability of sufficient donor tissue contiguous to the recipient site
limits the use of this technique. Color match is a major advantage of this technique.
Free gingival grafts: These are successfully used to cover recessions, especially when
the graft is thick. This thick graft should be placed on vigorously prepared root
surfaces with a retentive preparation on the recipient site with the use of mattress
sutures to hold the graft in place. The greatest disadvantage of a free gingival graft is
the shade difference, which is obvious. An alternative coronally repositioned flap with
the already placed gingival graft, as a method to promote root coverage has also been
described. This technique would need two separate surgical procedures but achieves
the desired esthetic result.
Autogenous connective grafts: The conventional free autogenous graft technique describes a procedure where in a sub-epithelial connective tissue graft is placed over the
root secondarily vascularized by the overlying split thickness flap. This technique not
only increases the predictability of the graft by improving the blood supply but also
provides a closer color match with the adjacent tissue. In addition the technique is
more comfortable to the patient post opera-tively and allows multiple areas of
recession to be covered by a single surgery.
Technique: At the donor site on the palatal mucosa, a flap is reflected to expose the
underlying connective tissue which is excised and the overlying flap is sutured back
in place. The recipient site is prepared to receive the graft. A partial thickness flap is
raised. The donor tissue should extend on the neighboring periosteum to help in
adequate circulation to donor tissue. The connective tissue graft is sutured to the
underlying connective tissue at the recipient site. The overlying recipient flap is then
sutured in place. A three month healing period is suggested to assess the healing
result.
When the patient presents with severe facial alveolar bone loss or localized alveolar
bone loss then the facial gingival tissues have to be restored through bone
regeneration techniques.
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Hyper-pigmentation of gingiva.
thelial excision
Gingivo-abrasion technique: It is a very simple and effective technique. A medium
grit football shaped diamond bur is used at high speeds on the epithelium to denude it.
Care should be taken not to abrade the periosteum. The pressure used with the diamond should be minimal and copious irrigation is recommended. Hand instruments
with a circular cutting edge may also be used. A periodontal pack is then placed over
the denuded epithelium. Usually in a week a new epithelium is formed .
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A diagrammatic representation of a
circumferential incision involving the
pigmented area.
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The main objective of the depigmentation surgery is to remove the epithelium leaving
the connective tissue intact. The healing brings about a change in the color of the new
epithelial tissue. This tissue looks pink and brings about a significant difference in the
smile. However over a period of time pigments redeposit in the epithelium. It has
been observed that the deposition of the pigments is faster after the abrasion technique
as against the excision technique.
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213
It is therefore imperative to restore the size of the lateral incisors after the completion
of orthodontic treatment for good overall treatment result. During the finishing stage
of orthodontic treatment, if excessive space exists in the anterior segment, it should be
redistributed to restore the proper crown width. If insufficient space exists to restore
these teeth, an adequate space should be gained which will permit the restoration of
proper crown width. To determine the space required to restore the crown width,
during the treatment planning stage, construction of a diagnostic wax-up is an
important step to visualize the final result. After removal of the fixed orthodontic
appliances, restorative phase should be immediately started and provisional
restorations should be given be-forefinal restorations to avoid relapse.
During the finishing stage of orthodontic treatment sufficient space should be maintained to restore the normal width of peg-shaped lateral incisors. Maxillary pegshaped lateral incisors can be restored with ceramic veneers.
Proximal recontouring: Orthodontists often treat patients with larger anterior teeth.
When the widths of the anterior teeth do not follow the golden proportion, that is,
when there is a discrepancy in the widths of the central incisor and the lateral incisor
then the larger teeth should be recontoured to smaller size and the space thus created
is effectively utilized by the orthodontist to resolve the discrepancy. This procedure is
usually done before starting orthodontic treatment and care should be taken not to
alter the morphology of the teeth and the contact points.
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215
a)
b)
c)
d)
Space regaining
Adult orthodontic patients are more likely to have dentitions that have undergone
some degree of mutilation over a period of time, which may require some alterations
in treatment strategy. This is usually seen in patients with missing or premature loss
of teeth where adjacent and opposing teeth get drifted into the edentulous space
complicating already existing malocclusion. If this involves multiple teeth, it may
lead to collapse of dental arches and significant esthetic and periodontal implications.
Therefore, a decision must be made that results in optimal esthetics, function and
occlusion.
Space gaining for a single tooth restoration
Loss of a permanent tooth in the dental arch, if not restored immediately, leads to a
number of occlusal problems. Loss of a tooth in the posterior segment can lead to
tipping and drifting of adjacent teeth, poor inter-proximal contacts, poorgingival
contour, reduced inter-radicular bone, and supra-eruption of' unopposed teeth.
Segmental stainless steel wire with compressed Nitinol coil spring was placed between the first molar and the premolar. The maxillary first molar was moved distally
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creating sufficient space for the pontic. After provisional restorations the final
restorations were placed.
Loss of maxillary right second premolar which led to mesial tipping and mesio-palatal rotation of
first molar. Unesthetic bulky prothesis is seen in the anterior region.
Maxillary right first molar has been moved distally to create a space for the pontic.
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Dental agenesis occurs quite frequently, especially of the maxillary lateral incisors,
and it presents a true challenge for an esthetic solution. For a long time, many dentists
had suggested an alternative treatment approach by moving the entire lateral segment
mesially to place the cuspid in the lateral incisor position. However, this approach
ends up with compromised results that do not fulfil the esthetic requirements of good
orthodontic treatment, since the cuspid has a very different crown and root shape to
that of the lateral incisor, as well as a darker shade. When, missing lateral incisor
space is closed by moving the entire lateral segment mesially, lateral excursions are
made using bicuspids, which have shorter, thinner roots, thus, functional requirements
area also not fulfilled.
If fixed restoration is the treatment of choice, it requires reshaping neighboring teeth,
with consequent removal of varying amounts of enamel, and eventual risk of gingival
recession, caries etc.
The osseo-integrated implant is the most conservative and biological method, since
the missing tooth can be replaced without damaging the neighboring teeth.
Maxillary lateral incisors are missing and the adjacent teeth have drifted into the space.
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If the use of implants is the part of treatment plan for the missing lateral incisors, it is
necessary to decide the exact placement of implants, evaluate the smile line and
gingival contour. When the lateral incisors are missing, there is usually no adequate
space to restore them due to drifting of the adjacent teeth. In such cases, it is essential
to gain adequate space with orthodontics for the placement of implant and crown restoration for good esthetic result. The exact amount of space created should be according to the proposed size of lateral incisors, which should be proportionate to the width
of the central incisors. After opening up of sufficient space, acrylic teeth may be selected closer to the shade of the patient's teeth, bracketed and attached to the arch wire
for esthetic purposes. Before the orthodontic appliances are removed it is important to
evaluate radiographically the position of the roots of adjacent teeth. The roots of the
central incisors and canines on either side in case of bilaterally missing laterals should
be parallel to each other with adequate space between the roots for implant placement.
Before removal of orthodontic appliances, it is common to see adequate space for the
prosthesis and inadequate space between the roots of the adjacent teeth for an implant.
This usually occurs due to tipping movement of adjacent teeth, which requires proper
uprighting of the roots during the finishing stage of orthodontic treatment. The
minimum space of 6.5mm between adjacent roots is required to place a standard
implant of 3mm width.
Intra-oral periapical radiograph shows inadequate space between the roots of the adjacent teeth
for placing an implant.
219
Implant placed in the space created by orthodontic intervention between the central incisor and
the cuspid.
220
Therefore, it is not only important to get healthy favorably positioned impacted teeth
into occlusion but also to position them in such a way that they maintain the integrity
of occlusion, provide good function and optimal esthetics.
Bilaterally impacted canines exposed surgically, and orthodontic attachment bonded to the
crown.
Ligature wire passed through the attachment on the impacted canine and tied to the main arch
wire. The flap is then sutured back into its place.
After the forced eruption of bilateral impacted canines; they are positioned normally into the
arch.
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Discolored teeth
In case of discolored anterior teeth, due to intrinsic stains, teeth are first properly
aligned and positioned as per the treatment goals. However, during the finishing stage
of orthodontic treatment, discolored teeth should be palatally positioned with respect
to the adjacent teeth since it is difficult to mask these dark teeth in the final restoration
without additional labial preparation. Additional preparation would leave a thin tooth
structure creating a potential weak area at the neck of the tooth.
Ortho-perio-restorative perspective
The diversity of mutilated and periodontally compromised patients has made it
imperative for orthodontic therapy to be not only adjunctive, but also an integral part
of the comprehensive treatment plan. An integrated orthodontic, periodontal and
restorative treatment is useful in wide variety of patients for improved occlusal
relationships of teeth, propergingivalarchitectureand esthetic, biologically sound
restorations.
a, b) Labial and occlusal views of discolored central incisors and crowded anterior teeth, c)
Teeth are aligned with slight lingual positioning of central incisors. d) Esthetic restoration on
central incisors.
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Color, contour and the health of the gingival tissues provide the framework and backdrop for the esthetic smile. Even if the case is well finished with orthodontic
treatment, abnormality of the gingiva either in the form of loss of papilla,
asymmetrical pattern and excessive display leads to a poor result. It is therefore
essential to have proper gingival architecture and display to achieve a maximum
esthetic result. During the process of eruption the whole periodontal apparatus is
carried with the erupting tooth. When there is asymmetric eruption of the teeth it will
also result in discrepancies in heights of the underlying crestal bone. This, in turn,
results into asymmetries in gingival heights (gingival zenith) from one side of the arch
to the other. This type of a clinical situation can be managed orthodontically by
intrusion or extrusion of teeth.
Forced eruption
Forced eruption is one of the adjunctive orthodontic treatment procedures where controlled vertical extrusion of a tooth is carried out to improve the prognosis of other
treatment procedures. When performed, it allows the placement of crown margins on
sound tooth structure, improves gingival contour thereby producing better esthetics.
During the forced eruption, as the tooth moves occlusally, attached gingiva
(periodontal apparatus) follows the cemento-enamel junction. After the completion of
forced eruption, the tooth should be stabilized in its new position for a period of 3 to 6
weeks. This will allow proper reorganization of the periodontal fibers and remodeling
of the bone preventing relapse.
Gingival heights of the left central and lateral incisors were at a higher level than that
of right central and lateral incisors. Orthodontic brackets were bonded to the teeth for
supra-eruption of incisors (forced eruption) more so on the left central and lateral
incisors This was to move the finishing margins of the restorations incisally. More extrusive force on the left central and lateral incisors due to cervical positioning of
brackets on these teeth would move the gingival margins incisally.
After differential forced eruption of incisors, arch wire was changed and left passive
into the slots of the brackets. There was still slight discrepancy in the gingival heights
of left and right incisors. Therefore, the crown lengthening procedure was planned on
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the right central and lateral incisors to resolve the residual discrepancy. And the final
result was achieved.
When a tooth is badly decayed, to the extent that the whole crown is broken down and
only the root is remaining, the future line of treatment would depend upon whether
the root can be preserved or not. If the root length is sufficient enough to support the
prosthesis, it would be worth the effort to preserve the root. Preservation of the root
involves complete removal of decay and locating the margins of the final restoration
respecting the biologic width. Following treatment options can be considered.
Crown lengthening procedures
Orthodontic forced eruption
Corrective periodontal surgery
Supra-crestal fibrotomy
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Controlled extrusion of the fractured root carried out with bonded attachment in the root canal.
If the root length is not adequate to support the prosthesis, it can be extracted and
other treatment options such as implants or other prosthesis could be considered. In
case of adolescents where traumatic crown fractures are encountered, the roots may
have to be saved not only to give interim restorations but to preserve the bone and
allow root formation to facilitate the proper growth of the jaw before such time that a
final solution could besought.
To summarize this, forced eruption with crown extension procedure enables the
dentist to achieve symmetrical gingival heights, identical crown lengths, healthy gums
and great esthetics.
225
esthetics
226
The single tooth anterior implant situation is of great concern as the esthetic
requirements and expectations have to be properly balanced keeping in mind
anticipated post-surgical results. The dentist should analyze anterior single
tooth implant situation considering the adjacent teeth, contra-lateral tooth,
probable emergence profile and presence or absence of interdental papilla
whenever the active smile exposes enough of gingival tissues.
There are many limitations and contraindications specific to the maxillary
single tooth implant apart from the routine contraindications associated with
implant therapy. The common causes of a missing maxillary tooth is traumatic
loss, root fracture, agenesis and periodontal disease. All these leave some deficiency in the facial bone over the root of the missing tooth. Majority of the
cases of maxillary single tooth implant in patients with high upper lip line
require bone grafting for ideal esthetics while in some cases bone grafting
would be necessary to provide adequate healthy peri-implant soft tissue to
maintain optimal hygiene in the cervical region.
The congenitally missing tooth requires at least 6mm of bone between the roots
of adjacent teeth apart from sufficient labio-palatal thickness to accommodate
the implant dimension, proper soft tissue contour and interdental papilla. In
cases of periodontal disease the adjacent teeth should be stable to allow proper
dissipation of forces in all anterior teeth and the implant prosthesis as excessive
forces will have to be borne by the implant which could be detrimental to its
success. The inter-occlusal space should also be assessed carefully. In cases of
diminished vertical space implants may be best avoided unless other measures
to correct the occlusion are considered.
Apart from the inadvertent deficiencies in the facial bone associated with
various clinical situations, the soft tissue form also plays a major role in the
esthetic outcome of single tooth implants.
227
There are two basic human gingival types i.e. thick flat type and thin scalloped
type. Although minor variations are seen in some cases, most of the human
perio-types fall in the above mentioned categories.
Thick, Flat type
Tooth form is more bulbous or squarish and roots are broad and taper
gradually.
The contact areas begin more apically and are usually broad incisogingivally and facio-lingually.
228
Normal rise and fall in gingiva and bone with a disparity between direct
facial and interproximal gingiva.
Tooth form is usually more triangular and roots are more tapered.
inciso-gingivally
and
facio-lingually.
In all cases of inadequate tissue quantity, the disparity between the facial and
interproximal gingiva and a more triangular crown form pose difficulties for
optimum esthetic results. Masking interproximal spaces is thus more of a
problem in thin scalloped gingiva than the thick flat type.
229
Proceed
Caution
Alert
Esthetic demand
Reasonable
High
Unrealistic
Dental
Gingival
Gummy
Considerable
Significant
Gingival architecture
Thick fibrous
Thin fragile
Mucosal thickness
4.5 mm
3 mm
Vestibular concavity
Absent
Present
Exaggerated
Very large or
Mesiodistal dimension of Adequate to insert Larger than the
smaller than tooth to
the edentulous area
implant
tooth to be replaced
be replaced
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On an average the implant fixture head should be placed far enough apical to
the cemento-enamel junction of the adjacent natural teeth to allow sufficient
231
room for the crown to emerge from a round implant to a triangular emergence
profile.
The implant should be 3mm apical to the gingival margins of the adjacent
teeth. The cemento-enamel junction of the adjacent teeth can be taken as a
reference provided the cemento-enamel junction and the gingival margins
coincide. Sometimes certain procedures may be needed in the adjacent teeth to
give the desired result.
Labio-lingual orientation of the implants helps to achieve desired emergence
profile. Placing the implant slightly palatally helps the dentist to build up a
proper emergence profile to the crown.
Tooth extraction leads to loss of bone, both, in the apical and palatal direction.
A labial concavity is thus created. To avoid this labial concavity during surgery
the implants have
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However, in cases where the implant is placed too palatally, the crown would
have an unfavorable shape near the gingiva leading to persistent inflammation
of the gingiva and abnormal forces.
In cases of vertical resorption of bone the implant may have to be placed too
apically making the pontic too long compared to its contra-lateral tooth.
To obtain satisfactory peri-implant gingival morphology, tissue volume should
be 20-25% more than the estimated need to allow adaptation of gingiva to the
prosthetic reconstruction. It will help solve certain esthetic problems that
involve the emergence profile. Wider diameter implant will ease the transition
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of the implant head to the artificial crown as it emerges from its soft tissue
housing. The wider diameter implants will not be required to be placed far
apical to the cemento-enamel junction of the adjacent tooth. Immediate
implants help to preserve the hard and soft tissues, and maintain the emergence
profile as in natural teeth.
Abutment selection
In anterior situations, abutment selection will depend on factors like the
angulation of the implant, the quality and quantity of the soft tissue at the
prosthesis interface of the implant and whether a metal-free restoration is
planned on these implants. When the maxillary anterior implant is placed
labially then a cemented prosthesis may be mandatory. In palatally placed im-
234
The polished collar of the abutment can be trimmed to suit the gingival
Abutments of tooth colored materials are used to create ultimate esthetic prosthesis. These are especially important for cases of thin scalloped gingiva treated
with metal-free prosthetic restorations.
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Augmentation
One of the biggest challenges in a single tooth implant in the esthetic zone is
the creation of a harmonious gingival contour around the restoration. Soft or
hard tissue deficiencies of the edentulous space are the most
obstacles
in
common
When the alveolar ridge dimensions are not adequate (width less than 5mm and
height less than 10 mm) for the correct placement of the implant then
augmentation of the alveolar ridge is needed. Ridge augmentation techniques
may involve either osseous or soft tissue reconstruction or a combination of
both procedures. These methods have been adapted for use in the treatment of
patients with implants.
The onlay graft technique is effective for solving moderate to severe vertical
defects but often does not achieve a close color match of graft tissue to the
adjacent gingiva. A more popular soft tissue grafting technique uses
autogenous sub-epithelial connective tissue harvested from the palate or the
maxillary tuberosity. In the treatment of either horizontal or moderate vertical
defects the connective tissue is placed under a labially reflected split thickness
flap. In patients with only a horizontal defect, a sub-epithelial pouch can be
prepared at the site receiving the autogenous connective tissue graft. In certain
defects a second stage surgery is recommended to get the desired dimension of
the ridge.
Some soft tissue augmentation techniques offer the advantage of overcontouring of the defect. Recontouring during the prosthetic phase of treatment
to create gingival symmetry with the adjacent teeth can easily be accomplished.
The osseous augmentation procedures can be performed for pre-implant site
development and during implant placement. If primary stability or appropriate
positioning cannot be achieved, ridge augmentation is recommended before implantation.
236
237
Six months postoperative view showing healthy gingival tissue around the implant supported
restoration
The use of autogenous bone graft is preferred because of its good osteogenic
properties. Various extraoral donor sites have been used but the iliac crest is the
most common site to harvest large amounts of autogenous bone. Local bone
defects in the anterior maxilla usually need only a small graft for which donor
sites can be found within the oral cavity. Common intraoral donors sites
include the mandibular symphysis and the maxillary tuberosity. Intraorally
harvested grafts show better results than iliac crest and rib grafts. Resorption is
most pronounced after use of maxillary tuberosity grafts and negligible in case
of mandibular grafts.
When threads of a stable implant are exposed because of a small bone defect in
the area or some other reason, then a membrane may be used to act as an
occlusive barrier that impedes the entry of rapidly proliferating gingival
epithelial cells into the osseous defect, while osteo-competent cells, which
migrate at a slower rate, gradually fill the defect with bone. The membrane
may or may not be resorbable. The advantage of using a resorbable membrane
is the elimination of a subsequent surgery to remove it. The non-resorbable
membranes are used for bigger defects which need more time to heal. In
orderto put a membrane, a full thickness flap is raised and the membrane is
carefully placed so that it does not touch the adjacent teeth or the papilla but
extends 2-3mm overthe defect. The defect is filled with bone chips and is
condensed well so that no empty spaces are left under the membrane. The
membrane is then pressed over the bone and the flap is sutured in two layers.
238
239
When interdental anatomy is not adequate, incision is made on palatal aspect of the ridge. Flap is
raised and the healing cap inserted into implant body.
The cover screw of the implant is removed and replaced by a healing cap of
2mm height. Hydroxyapatite is densely packed around the healing cap and the
flap is sutured back allowing the palatal portion to heal by proliferation of soft
tissue. After 3-4 weeks gingivoplasty is performed to remove the healing screw
and a suitable abutment is placed. An interdental papilla may be reconstructed
in an edentulous region using this procedure.
240
When the distance between the crest of bone and the contact point is less or
equal to 5mm, then a papilla exists. This accommodates for the periodontal
infrastructure in this region. If we increase the distance more than 5mm no
papillae will be present. Papillae regeneration is related to the contact points of
adjacent teeth. So, if the implant crown does not have a good contact with the
adjacent teeth then the interdental papilla will be lost. The objective is to preserve or develop interproximal peaks of bone at stage 1 (implant placement) in
order to optimally support the papillae.
Prosthetic factors required for papilla growth can be explained as follows:
At second phase, the prosthetic restoration should exert lateral pressure on the
soft tissues in the interproximal zone as soon as possible. This gentle pressure
is the key to reformation of the gingival peaks. Proceeding with the impression
immediately after uncovering and temporizing as soon as possible during the
inflammatory period is advisable as the gingiva has the best dynamic potential
for guidance.
To create natural interdental papillae, an interim restoration is placed to exert lateral pressure
on the interproximal soft tissue
241
242
REVIEW OF LITERATURE
Simon J. (2004) Many dental patients are unhappy with their smile but believe a
beautiful smile is outside their budget. The first step is to listen to the patient in order
to understand what his or her primary concerns are. The second step is to examine
carefully and analyze the case to develop a treatment plan that will fulfill as much as
possible of the patient's desires within the context of his or her constraints (financial
or otherwise). Also, remember that dentistry doesn't end when the last veneer is
placed or the last bill is paid. The final step is to maintain a strong relationship with
your patients to ensure good oral hygiene and restorations that are as long-lasting as
they are beautiful.
Neves FD, Mendonca G, Fernandes Neto AJ. (2004) The lip line and lip support
influence esthetics and selection of implant-supported prosthetic designs for maxillary
edentulous patients. This article describes a procedure to analyze the influence of lip
line and lip support on the esthetics of an existing maxillary complete denture,
revealing potential limitations when planning a fixed implant-supported prosthesis.
Ibbetson R. (2004) Many dental practitioners do not use adhesive bridges because of
concerns over high failure rates. Techniques for these restorations should be based on
the fundamental principles of bridge design which require rigid, accurately fitting
frameworks and careful control of the occlusion. The abutments generally require
little if any tooth preparation. Greater security will result from more extensive
coverage of abutment teeth: the routine use of relative axial tooth movement is a
predictable method for creating the space that this approach requires.
Flores-Mir C, Silva E, Barriga MI, Lagravere MO. (2004) To compare the
aesthetic perception of different anterior visible occlusions in different facial and
dental views (frontal view, lower facial third view and dental view) by lay persons.
The different views were rated by 91 randomly selected adult lay persons. Visual
Analogue Scale (VAS) ratings of aesthetic perception of the views. Anterior visible
occlusion, photographed subject and view (p<0.001) had a significant effect on the
aesthetic ratings. Also gender (p=0.001) and the interaction between gender and level
of education (p=0.046) had a significant effect over the aesthetic rating. A lay panel
perceived that the aesthetic impact of the visible anterior occlusion was greater in a
243
dental view compared with a full facial view. The anterior visible occlusion,
photographed subject, view type are factors, which influence the aesthetic perception
of smiles. In addition, gender and level of education had an influence.
Olsson KG, Furst B, Andersson B, Carlsson GE. (2003) The purpose of this study
was to evaluate the long-term outcome of In-Ceram Alumina fixed partial dentures
(FPD) performed in a general dental practice from 1992 to 1996. The study was
conducted as a retrospective assessment of up to 9 years of patient records and a
clinical follow-up examination of patients treated with In-Ceram Alumina FPDs. In
37 patients, 42 FPDs had been inserted during the selected period. After randomized
selection, 16 patients with 18 FPDs were examined clinically. The most common
restorations comprised two and three units. Cantilever extensions were present on
64% of the FPDs. Sixty-two percent of the FPDs extended into the posterior region.
The mean time in function for the 42 FPDs was 76 months (range 2 to 110 months),
with 86% being followed for > 5 years. No adverse effects to either periodontal or
pulpal tissues were recorded. The technical quality was very good, and patient
satisfaction very high. Five FPDs fractured during the observation period, resulting in
a total failure rate of 12%. Two of these FPDs fractured as a consequence of external
trauma. Excluding these, the total survival rate during the observation period was
93%. Cumulative survival rate according to life table analysis was 93% after 5 years
and 83% after 10 years. The results suggest that the In-Ceram Alumina short-span
FPD is a viable prosthetic alternative.
Frindel F. (2003) The present study aims at establishing elements for diagnosis and
construction of a harmonious, balanced, desirable and durably young smile. Once the
importance of a harmonious smile in today's society has been studied, smile is
analyzed under two aspects. One considers it in its own unitary structure, the other in
its living immediate environment: the face. Sixteen key rules have been defined to
characterize and analyze it. Those various "keys of smile" will enable the practitioner
to construct it in positioning the maxillary teeth in a facial balance, thus meeting the
criteria of esthetics and appeal so much wanted by our patients. Taking into account
the criterion of general aging of the face, the smiles thus realized will remain young
for a longer period of time. Three principles of analysis have been used to achieve this
task: the observation in "dynamic" situation (as opposed to a "static" frozen study),
244
the reference to particular measurements for each case (as opposed to measurements
refering to statistics tables), and the evaluation of the interlabial space at rest of the
case considered. This leads to the definition of the measurement of the "golden
section dynamic smile" (G.S.D.S.) and a reminder of the measurement of "the
constant of ideal smile" (C.I.S.). Adorned with such smiles, our patients will benefit
from a real feeling of well-being which they will communicate to their circle of
friends and acquaintances for their greatest delight.
Naylor CK. (2002) It is sometimes difficult to identify esthetic problems let alone
pre-visualize an esthetic end-result. The Esthetic Grid Analysis is a system for
analyzing the basic problems that detract from the concept of an attractive smile. A
photograph is taken of the anterior teeth with the lips retracted. The upper and lower
frame of the photograph is aligned parallel with the interpupillary line, assuming that
the interpupillary line is parallel with the horizon. Where this is not the case, the
vertical margins of the photograph are aligned parallel with the facial midline.
Through orienting the photograph to the facial guidelines and incorporating the
idealized positions of the incisal plane, highest lipline, midline axis, and proportionate
contact areas, a grid is formed. The grid built from these components provides a
method of demonstrating deviations from an esthetic arrangement of anterior teeth.
Integrating facial guidelines with the dental composition using a grid highlights
deviations from the ideal. It thereby assists in the treatment planning process by
communicating esthetic problems to the patient, laboratory personnel, and other
specialists.
Gillet D, Miquel JL, Jeannel A. (2002) The aim of this study was to evaluate the
importance of the dental aesthetic for the patients, the dental surgeon and the dental
teachers by the study of the consultation reason, the complaints, the post-university
congress program, the practical program of the dental students and the programs of
the IADR congress. It appears that in odontology, patients ask strongly for aesthetic
care, in consultation and litigation. The content of congress and professional literature
shows that dental surgeons answer to that request. Only the practical teaching was a
bit less but it was recently modify. The research workers are also very interesting for
aesthetic care.
245
Rosenstiel SF, Ward DH, Rashid RG. (2000) This study aimed to determine
dentists' esthetic preferences of the maxillary anterior teeth as influenced by different
proportions. The goal was to link choices to demographic data as to the experience,
gender, and training of the dentist. Computer-manipulated images of the 6 maxillary
anterior teeth were generated from a single image and assigned to 5 tooth-height
groups (very short, short, normal height, tall, and very tall). For each group, 4 images
were generated by manipulating the relative proportion of the central incisors, lateral
incisors, and canines according to the proportions 62% (or "golden proportion"), 70%,
80%, and "normal" or not further altered. The images were randomly ordered on a
web page that contained a form asking for demographic data and fields asking for a
ranking of the images. Dentists were asked via e-mail to visit the web page and
complete the survey. The responses were tabulated and analyzed with repeated
measures logistic regression with the alpha at 0.05. A subset of North American
respondents was chosen for further analysis. A total of 549 valid responses were
received and analyzed from dentists in 38 countries. There were statistically
significant differences in all groups for the variables of proportion, group (tooth
height), and their interaction. The 80% proportion was judged best for the Very Short
and Short groups. Three of the choices were almost equally picked for the Normal
Height and Tall groups, and the golden proportion was judged best for the Very Tall
group. The variables of year of graduation, gender, professional activity, generalist or
specialist, or number of patients were not significantly correlated with the choices for
the North American respondents. Dentists preferred the 80 percent proportion when
viewing short or very short teeth and the golden proportion when viewing very tall
teeth. Golden proportion was worst for normal height or shorter teeth and the 80%
proportion for tall or very tall teeth. They picked no clear-cut best for normal height
or tall teeth, and their choices could not be predicted based on gender, specialist
training, experience, or patient load.
Snow SR. (1999) With increasing application of cosmetic dental treatment comes the
need for a greater understanding of esthetic principles. Scientific analysis of beautiful
smiles has revealed repeatable, objective principles that can be systematically applied
to evaluate and improve dental esthetics in predictable ways. Symmetry across the
midline, anterior or central dominance, and regressive proportion are three
composition elements required to create utility and esthetics in a smile. The Golden
246
Proportion has been suggested as one possible mathematic analysis tool for assessing
dominance and proportion in the frontal view of the arrangement of maxillary teeth. It
has proven to be controversial in developing esthetically beautiful smiles and
cumbersome for evaluating symmetry. This article considers a bilateral analysis of
apparent individual tooth width as a percentage of the total apparent width of the
anterior segment and proposes the concept of the Golden Percentage as a more useful
application in diagnosing and developing symmetry, dominance, and proportion for
esthetically pleasing smiles.
Magne P, Magne M, Belser U. (1999) With the evolution of adhesive dentistry and
the increasing use of porcelain veneers, single-unit crowns generally are restricted to
the replacement of pre-existing full-coverage crowns and the restoration of nonvital
and/or severely damaged teeth. Porcelain-fused-to-metal restorations are still widely
used to generate single-unit crowns and fixed partial dentures. Collarless metalceramic restorations represent the most successful evolution among efforts to meet
maximum esthetic requirements using porcelain-fused-to-metal restorations. Extended
metal frameworks and opaque aluminous ceramic cores are associated with
unpleasant optical effects in the soft tissues surrounding such restorations. 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. Based on the concept of the biologic width, a systematic approach is
proposed for the elaboration of an "esthetic width," including: 1) positioning of
preparation margins; 2) reduction of the metal framework; and (c) appropriate
marginal design of porcelain-fused-to-metal restorations. Strategic features of pontics
and a specific interdental design are suggested to compensate for deficient anatomical
features of the soft tissue and the edentulous ridge.
Smukler H, Chaibi M. (1997) When the clinical crowns of teeth are dimensionally
inadequate, esthetically and biologically acceptable restoration of these dental units is
difficult. Often an acceptable restoration cannot be accomplished without first
surgically increasing the length of the existing clinical crowns; therefore, successful
management requires an understanding of both the dental and periodontal parameters
of treatment. This report provides further insight into this interdependence by
examining the effects of tooth form on the periodontal morphology and surgical
247
248
mold, the desired canine-to-canine measurement produced by the ratio range of 1.3 to
1.38 reported in Parts I and II of this study should be maintained.
Matthews TG. (1978) The anatomy of smile is an integral part of dentistry. Its
understanding involves close scrutiny of all elements of the oral region. It is not
enough to establish the size of teeth based on the high and low lip lines, size of the
mouth, and a shade to blend with the age and complexion. To create a harmonious
smile the dentist must maintain or create the normal curvature of lips, proper exposure
of the red zone of the lips, an undistorted philtrum, and undisturbed naso labial
grooves. These entities, maintained in harmony with the exposed teeth, constitute the
anatomy of a smile.
Levin EI. (1978) A system of esthetic predictions is described that has been used
since antiquity. The naturalness of the system is emphasized by showing examples
from nature and how artists and designers use it. The application of this system to
dental esthetics is facilitated by the description and inclusion of a dental grid for the
anterior esthetic segment.
Lombardi RE. (1977) Factors mediating against excellence in dental esthetics have
been classified and enumerated in this article. A formula for producing unaesthetic
prostheses can be hypothesized as follows: Educational de-emphasis + Lack of
research + Technical orientation + Technical tradition + Delegation (abdication) +
Poor economics + Fatigue + Poor office design + Convention + Conditioning +
Schemata leads to POOR DENTAL ESTHETICS. It is postulated that a formula for
excellent dental esthetics can be produced by reversing these factors: Altered
schemata + Deconditioning + Altered convention + adequate office design +
Elimination of fatigue + Favorable economics + Personal participation + Research +
Educational emphasis leads to Esthetic Excellence.
Lombardi R. (1973) A real need for a very detailed, almost histologic approach to
dental esthetics exists. Indeed, the perspective principles may be regarded as the
cellular elements of which the tissue of denture esthetics is composed. As familarity
with the principles increases, so does proficiency in their application. With
experience, the basic shape and characteristics of the dental tooth arrangement can be
visualised even before a single tooth is placed in wax. All that remains is a detailed
249
examination at try-in to look for minor perspective conflicts, and this too becomes
less of a task with the training of the eye to really see.
Weinberg LA. (1960) This article emphasizes the dynamic relationship of the design
and construction of full coverage restorations with regard to esthetic appearance and
gingival health. Esthetic appearance with full coverage restorations is dependent on
anatomic form, the materials used, and the maintenance of gingival health.
250
CONCLUSION
The change in dentistry from need based dentistry to elective dentistry
has made a significant impact on the profession and the public perception of
dentists. It is estimated that up to one half of the dentistry accomplished at this
time is elective. Much of this treatment is what could be considered to be
esthetic dentistry including bleaching, bonding, veneers, tooth colored inlays
and onlays, non metallic crowns and fixed prosthesis, orthodontics and surgical
procedures, and many other procedures.
Dentists and their staff must be proactive in their patient educational
activities to stimulate patients to desire these elective procedures. If dentists ask
for patients to ask for the procedures, practice activity can be influenced
negatively.
This dissertation will assist interested persons in becoming updated in
the broad scope of esthetic dentistry. Self instruction is perhaps the best way to
cope with the expanding area of esthetic dentistry.
251
REFERENCES
Book References
1.
2.
3.
4.
5.
6.
7.
8.
Shillingburg
Fundamentals
of
fixed
prosthodontic. Quintessence.
9.
10.
Carranza
F.A.
Newman
M.G.
Clinical
252
12.
13.
14.
15.
16.
17.
18.
19.
253
Article References:
1. Burckett PJ, Christensen LC. Estimating age and sex by using color,
form and alignment of anterior teeth. J Prosthet Dent. 1988;59:175-9.
2. Christensen GJ. Ensuring retention for crowns and fixed prostheses. J
Am Dent Assoc. 2003 Jul;134(7):993-5.
3. Flores-Mir C, Silva E, Barriga MI, Lagravere MO, Major PW. Lay
person's perception of smile aesthetics in dental and facial views. J
Orthod. 2004 Sep;31(3):204-9; discussion 201.
4. Frindel F. Sixteen keys for building a youthful smile J Orthod . 2003
Mar;74(1):83-102.
5. Gillet D, Miquel JL, Jeannel A. Patients, practitioners, faculty and
dental esthetics: the same level of perception? Odontostomatol Trop.
2002 Jun;25(98):5-11.
6. Ibbetson R. Clinical considerations for adhesive bridgework. Dent
Update. 2004 Jun;31(5):254-6, 258, 260 passim.
7. Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent.
1978 Sep;40(3):244-52.
8. Lombardi R. Visual perception and dental esthetics. J Prosthet Dent
1973; 29:352-382.
9. Lombardi RE. Factors mediating against excellence in dental esthetics.
J Prosthet Dent. 1977 Sep;38(3):243-8.
10. Mac Arthur DR. Are anterior replacement teeth too small? J Prosthet
Dent 1987; 57:462-465.
11. Mack MR. Vertical dimension: a dynamic concept based on facial form
and oropharyngeal function. Prosthet Dent. 1991 Oct;66(4):478-85.
254
255
22. Weinberg LA. Esthetic and the gingiva in full coverage. J Prosthet Dent
1960;10:737-744.
256