1. art and entertainment
2. visual art and design
3. restoration

QUALITY
CONTROL
in
ESTHETIC
DENTISTRY
Gerard Chiche L.L.C.
1.
PROPER LENGTH
2.
3.
4.
5.
DOMINANT CENTRALS
CONVEX SMILE LINE
INCISAL EMBRASURES
HIGH BRIGHTNESS
SMILE BUILDER
WHAT ARE THE STEPS?
1.
Road map
2. Parameters
3. Confidence Builder
SEVEN OBJECTIVES
DISCLOSURE
Dept. Grants & Funding, Honorarium
3M-ESPE, Vident, Brasseler USA
Nobelbiocare, 3I, Zimmer
No Direct, indirect income or royalty
from products discussed except
Paid Consultant NORITAKE co.
Teaching Faculty & Former Consultant
PANKEY INSTITUTE
DISCLAIMER
Techniques and principles reviewed in this
all-day program are derived from my
personal teaching and clinic experience.
They do not constitute a guarantee for
success , the attendees should form their
own opinion.
Gerard Chiche L.L.C.
I
INCISAL PLANE
Incisal Plane
.
.
.
.
Convex
Flat
Concave
Too Convex
Preview Length Adjustment
SMILE LINE
1.
Record Shape
2.
Record Lower Lip
Edge to Edge
Pitch of the upper anterior teeth should
mirror the pitch of the lower anterior teeth
PRECAUTIONS WITH SMILE LINE
1. Harmonize Anterior Guidance
2. Harmonize Pitches and Bevels
3. Smooth
Crossover
II
INCISAL PROFILE
PLAN
1.
Incisal Length
2. Gingival Level
3.
Implant Level
INCISAL PROFILE
1. Harmony with Lower Lip
+
2. Perpendicular Relation
+
3.
Final Restoration
III
INCISAL LENGTH
Pleasing Display
3.5 - 4.5 mm.
Pleasing Length
10 - 11 mm.
INCISAL LENGTH
1. Measure Display
2. Measure Length
3. Test Drive New Envelope
4. Do not Steepen Guidance
when Increase Length
without testing
IV
TOOTH
PROPORTION
Short-Fat Proportion
Never Engineer
Narrow-Long Proportion
PLAN
1.
Preview
2. Check against Face
3. Involve Lat. & Can.
Mesial Additions
Fat Central Incisor
Distal Reductions
RULE
1.
Priority = Centrals
Proportion
Display
Length
RULE
Create Reference Points
1.
Display
2.
Length : At least 10 mm.
3.
Width: At least 7.5 mm.
4.
Midline : Must be Vertical
5.
Lateral Incisor: 2mm. rule
6.
Canine: 1mm. rule
10 mm. L
7.5-8.0 mm
11 mm. L
8.5-9.0 mm
Central Incisors
At Least
7.5 mm Width
V
TOOTH to TOOTH
PROPORTION
TOOTH-TO-TOOTH
PROGRESSION
Main Test
?
DELICATE
Lateral Incisor
PROPORTION CONTROL
Precautions
1.
2.
Implants
Short Papillae
3.
Canine Substitution
4.
Orthodontic Planning
LATERAL INCISOR IMPLANT
Deficient Papillae
=
Use Special Effects
SPECIAL EFFECTS
1. Decrease Reflection
2. Increase Deflection
3.
Round Flatten
Lateral Incisor Design
1. Does not Compete for Attention
2. Deficient Papilla = Special Effects
3. Canines in Lateral Position =
Keep Centrals dominant
4. Lat. I. = CI-2mm., Can. = CI-1mm.
5. 70% Ratio for Normal Size Teeth
54 patients (36 F) (18 M) 16-72 years
Average width 8 and 9 : 8.5 mm.
7 and 10: 6.5 mm.
6 and 11: 7.5 mm.
Range for central incisors:
7.1 – 9.62 (8) and 7.32 – 10.06 (9)
Range and Mean Distribution Frequency of
Individual Tooth Width of the Maxillary
Anterior Dentition
S. J. Chu
Pract Proced Aesthet Dent 2007; 19 (4)
VI
GINGIVAL PLANE
SYMMETRY
1. Level against Face
2. Set Pleasing Ref. Level
3. Set Pleasing Ref. Line
VII
DESIRED FULLNESS
FULLNESS
1.
Show on screen first
2.
Mandibule Angle
3. Provide Canine Disclusion
4.
Allow Cusps Escape
WHAT ARE THE STEPS ?
1.
Record Shape
2. Phonetics, Occlusal Plane
3. Measure Display, Length
4. Record Proportion, Width
5. Delicate Lateral Incisor
6. Symmetry, Progr., Lip
7. Patient’s Desires, Cost
GINGIVAL PLANE
Follows
UPPER LIP LINE
Break Time
ALL-CERAMIC CROWNS
REALITY RATINGS 2009
1. IPS Empress
Ivoclar
1. Lava
3M Espe
2. Cerabien
Noritake
3. HeraCeram
Heraeus
4. EX-3
Noritake
5. IPS D.Sign
Ivoclar
5. Omega 900
Vident
5. Duceragold
Dentsply
6. VM7 / VM9
Vident
6. Creation
Jensen
6. Finesse
Dentsply
I
WHAT SYSTEM
?
ALL CERAMICS
TWO FAMILIES
=
TWO LOGICS
ALL CERAMICS
FAMILY
A
FAMILY
A
ALUMINA
ZIRCONIA
“…The alumina particles did not show
any surface alteration by the etchants...”
Della Bona A. & Anusavice K. 2002
.Degussa
Allceram
.Noritake
Cerabien
.Jensen
Creation AV
.Vident
.Nobelbiocare
.Ivoclar
Alpha, VM7
Rondo
Ceram S
CZR, CZR Press
Lava Ceram
VM9
Rondo Zirconia
EMax
ALL CERAMICS
FAMILY
B
Etchable Crowns
Empress Esthetics Emax Lith. Disil.
Authentic
CZR Press
Duceram LFC
Finesse
ProCad
Mark II
Examples
II
WHAT CEMENT
?
REALITY RATINGS
RESIN GLASS IONOMERS LUTING
1.
FUJI PLUS
1 . FUJICEM AUTOMIX
2 . RELY X LUTING PLUS
3.
RELY X LUTING
4.
FUJICEM
5.
KETAC-CEM
2009
Shear Bond Strength to LAVA
9 MPA
6 MPA
FUJICEM MAXCEM NEXUS 2 UNICEM
Shear Bond Strength of Self-Adhesive Resin
Cements: A comparative Study
R. Aljouni et al, 2006 (Abstract 329)
WHY Adhesive Cementation
?
Suggested Reasons include
1.
2.
3.
4.
Increase Retention
Increase Strength
Decrease Microleakage
Best for Thin Cores
Mean Cycles to Failure
Prep. Height
2 mm.
3 mm.
4 mm.
5 mm.
Zinc Phosh.
9,238
120,895
200,375
250,000
Panavia F
187,347
215,998
250,000
250,000
The Effect of Preparation Height and Luting Agent
on the Resistance Form of Cemented Cast Crowns
under Load Fatigue.
E.W. Lepng et al.
J. Prosthet Dent 102: 155 , 2009
Blatz, Oppes, Sadan, Chiche. Quint Int. 2008
SBl.
(10
sec.)
LAVA Zirconia
11.58
Mpa
(4.13)
(6 months testing)
Rocatec soft+Silan
15.76 Mpa (4.10)
M.B. Blatz 2003
SBl +CPA / CSE
16.58 Mpa (3.17)
REALITY RATING / DUAL CURE
1.
2.
2.
3.
4.
5.
INSURE / INSURE LITE
NX3
VARIOLINK II
VITIQUE
LUTE-IT!
CALIBRA
1 . RELYX UNICEM
1 . EMBRACE WETBOND
1. G-CEM
2. SMARTCEM 2
2, BISCEM
3. MAXCEM ELITE
1 . PANAVIA F 2.0
2 . MULTILINK AUTOMIX
3. CLEARFIL ESTH. CEM.
4. BISTITE II DC
1 . RELY X ARC
2 . DUO-LINK
3. CEMENT-IT!
2009
“Ceramic material and bond quality significantly
influence the load bearing capacity of leucite and
Lithia-disilicate ceramic restorations… This
clearly demonstrates the importance of the
relationship between the adhesive process and the
overall strength of the restoration”.
Influence of Bond Quality on Failure Load
of Leucite- and Lithia disilicate-based
Ceramics
N. L. Clelland et al.
J. Prosthet Dent. 2007; 97:18
No etch, no silane
Unicem
9.6 +-1.9
Multilink 6.2 +-1.2
Panavia F 7.4 +-1.9
Doubles If etch and silane
Unicem
18.8 +- 3.5
Multilink 17.4 +-3.0
Panavia F 15.7 +-3.8
Influence of ceramic surface conditioning and
resin cements on microtensile bond Strength to
a glass ceramic.
J. Pisani-Proenca et al.
J. Prosthet Dent. 2006; 96:412
Rely ARC
Unicem Translucent
Unicem A3
Maxcem Clear
Maxcem Yellow
Auto Pol.
96.1 (14.3)
75.6 (114)
70.2 (5.9)
104.0 (9.5)
76.3 (8.3)
Light Pol.
131.2 (21.7)
130.6 (19.6)
99.4 (18.2)
156.2 (10.8)
139.1 (17.7)
“…All dual-cured cements both self-etch and
conventional showed highly superior properties
when photopolymerized …
One self-etch cement revealed a unique rapid
rise to neutrality in both dual-cure and self-cure
mode…”
E. Saskalauskaite et al
Flexural Strength, Elastic Modulus and pH profile
of Self-etch Resin Luting Cements.
J. Prosthodontics 2008: 262
Rely Unicem Aplicap
Rely Unicem Clicker
Maxcem
Bond Strength to Enamel
(Unetched)
6.2
(2.0)
5.7
(2.8)
4.0
(3.3)
A. Piwowarczyk et al
Bond Strength, f Self-adhesive Cementing agents
to dentin and enamel
IADR Abstract 2007 #1540
Glass Ceramics
1. Etch
2. Silane
Dual-Cure Cements
3. Light-Cure
4. Neutral Shade
Marginal Enamel
Etch in selective situations
(Varies with Cement – Check with manufacturer first)
III
WHAT PRECAUTIONS
?
169 Procera Crowns – 26 Mo.
. Failures : 1 Decay, 6 veneer fractures.
.
Survival of Procera AllCeram Ceramic
Crowns in Students Clinics.
J. Hochstedler et al. 2004
1.
Core Integrity
2.
Short Preparations
3. Marginal Ridge Support
4. Anatomical Cores
. Survival of Procera AllCeram Ceramic
Crowns in Students Clinics
J. Hochstedler & A. Sadan 2004
Adequate Support May Increase
Restoration Strength by 30%
Fischer et al. JIADR 2006, Abstract
546
“…Copings for crowns must be designed
to minimize tensile loading of
veneering porcelain…”
Marschak et al. J Prosthet Dent 2008
99: 169
Raigrodski AJ, Chiche GJ, Potiket N, Mohamed SE,
Hochstedler JL, Mercante DE, Billiot S.
The efficacy of posterior three-unit zirconia-based bridges
A prospective pilot clinical study
J Prosthet Dent 2006;96:237-44
ZIRCONIA FPD
1.
Patient Selection
2. Insure Thick Connectors
3.
Facial Shoulder
4. No Lateral Interferences
5. Fine Diamonds – Reglaze
6.
Slow Cooling Cycle
7. Zirconia – Veneer Interface
Chamfer Preparation
21 mic. (6 mic.)
Shoulder Preparation
11 mic. (6 mic.)
Difference was significant.
Marginal Fit of Zirconia Crown Copings on
chamfer and Shoulder preparations
IADR 2007, # 0885 J Dent. Research Vol 86,
Special Issue A
D. Augusti, G. Augusti
Shear Bond Strength of Veneering Ceramics to Zirconia
J Dent Res 2006;85:Abstr 0888
Blatz MB, Chapman L, et al
Effect of veneering Techniques on Damage and Reliability
of Y-TZP Trilayers
European J Esthet Dent 2009;4-3
P. Guess
Zirconia Posterior Fixed Partial Dentures
Prospective Clinical 3-Year Follow-up
Int J Prosthodont 2009;22:597
Schmitt J, et al
Int. J Prosthodont; 2009; 22: 553
Sailer I. et al
Int. J Prosthodont; 2009; 22: 597
Wichan & Holst
J Prosthet Dent 2006;96:237-44
Raigrodski AJ, et al
Main Precautions
1.
Patient Selection
2. Insure Thick Connectors
3.
Facial Shoulder
4. No Lateral Interferences
5. Fine Diamonds – Reglaze
6.
Slow Cooling Cycle
7. Zirconia – Veneer Interface
IV
CERAMIC SELECTION
Alumina / Zirconia
.
.
.
.
1
Discolored Teeth
2 No Bonding Requirement
3 Need Adequate Thickness
4 Thinner Cores on Facial
CRITERIA
Etchable Crowns
•1
Best Translucency
• 2 Reduced Facial Thickness
•3
May be Equigingival
• 4 Plan Masking Strategy
CRITERIA
DISCOLORATIONS
&
SYSTEM SELECTION
1. CREATE BONUS SPACE
2.
MATCHED PAIRS
3.
INGOT SELECTION
4. AVOID EXCESSIVE
TRANSLUCENCY
“The Common Denominator must
NOT be the most discolored tooth”
M. Roberts
2007
V
OCCLUSAL
PRECAUTIONS
DETERMINE ANTERIOR GUIDANCE
1. Test-Drive New Envelope.
2. Transfer Existing Guidance.
3. Custom Guide Table.
4. Half try-in when Feasible.
5. Passive Anteriors – No Fremitus
Static: 3 positions & Dynamic: Chew
6. Maintain Guidance if shorten.
Protection Strategy
1.
2.
3.
Assess Risk
Discover What they are
Likely to do with their Teeth
Do not Put Teeth in the Way
of Habitual Function and
Envelope of Parafunction
J. Fondriest & M. Fling
…:
Move Tooth to
Safe Position First
…:
Shallower
Cuspid Guidance
The flatter the angle of guidance, the lower the muscle
activity.
G. Williamson J. Prosthet Dent 1983
For every 100 change in the angle of disclusion, there
is a 35% change in force applied.
L. Weinberg
“…The resultant closure forces of the
mandible are upward and forward. This
produces a mesial force between the
interproximals resulting in anterior teeth
more vertical and a constricted
envelope…”
T. Tanaka 2008
VI
PORCELAINVENEERS
FRIEDMAN M.J.
A 15-Year Review of
Porcelain Veneer Failure
A Clinician’s Observations
COMPENDIUM. 19, 1998
FAILURES (7%)
1. FRACTURES
(67%)
2. MICROLEAKAGE
(22%)
3. DEBONDING
(11%)
LONG-TERM BONDING
Cervical Dentin + Heavy Occlusion
=
CONTROL FLEXURE
Canines Management
1.
2.
3.
Contact Intensity
Contact Location
Steepness of Guidance
VII
PREPARATION
SYSTEM
. LVS 4
. LVS 3
. 8392 016
. 828 026
FRACTURE STRENGTH
31.0 Kg. (10.38 s.d.)
27.4 Kg. ( 9.63 s.d.)
19.2 Kg. ( 6.18 s.d.)
Fracture Strength and Failure Mode for Different Ceramic
Veneer Designs.
Castelnuovo J. et al. J. Dent. Res. 77; Abstract 1373
“Maxillary restored with the 3 types
of IPS Empress 1 Veneers showed
fracture resistance similar to that of
unprepared incisors …”
Longevity and Failure Load of Ceramic Veneers
with Different Preparation Designs after
Exposure to Masticatory Stimulation
C. F. J. Stappert et al
J. Prosthet. Dent. 2005, 94, 132-139
VIII
VENEER SELECTION
Making a Six-Unit Smile Design “Disappear” in
the mouth
using feldspathic porcelain
B. Jones
Jrl. Cosmetic Dentistry 2007, 22 (4)
Conservative Aesthetic Enhancement of the
Maxillary Anterior Using Porcelain Laminate Veneers.
J.M. Lerner
Pract Proced Aesthet Dent 2006; 18 (6)
Permanent Diagnostic Provisional Restorations for
Predictable Results when Redesigning the Smile.
G. Gurel, N. Bichacho
Pract Proced Aesthet Dent 2006; 18 (5)
Pressed vs. Feldspathic
Veneers
1.
2.
3.
1.
2.
3.
P Combination with Crowns.
P Complex Occlusal Rehabs.
P Better Cost.
F Better Esthetic.
F More Conservative, No Prep.
F Contact Lens Effect, Varying Trsl
IX
SHADING SYSTEM
Efficacy of a computerized shade
selection system in matching anterior
metal-ceramic crowns. A double-blind
clinical pilot study.
A.J. Raigrodski & G.J. Chiche.
2004
Cervical Shade
Incisal Shade
Basic Shade
Mix Colors
Two Tabs
SHADING EFFECTS
CHECKLIST
HALO
TRANSPARENT
STREAKS
PROXIMAL CLEAR
Incorporate
for Natural - Driven
Incisal Effects
Soften or Eliminate
for Perfect - Driven
Bleached Shades
A1
B1
1M1
0M3 0M2
NW05 NW0
BL3 BL2
PW4 PW7
X
CLINICAL
VARIATIONS
.
.
.
Set Goals
Increase Brightness
Increase Length
Fuller Smile
INCREASE FULLNESS
1. Set Perpendicular Relation
+
2. Check Harmony with Lip
INCREASE LENGTH and FULLNESS
1.
Mock-up for Length
2. Wax-up for Fullness
3.
Instant Mock-up
4. Show First on Screen !
5. Preparation Guide
6.
Always Augment
7. Verify Gingival Levels
VENEER PROVISIONALS
1. Preop. Silicone Impression
2. Undercontour Cervical Wax
3. Duplicate Wax-up, Pour Model
4. Score Cervical with Cleoid
5. Spot Etch & Bond Preps
6. Fill Matrix with Bis-Acryl
7. Trim with ET3, ET4 & #12
Base of Proximal
Contact to Bone crest
Presence of
Interdental Papilla
5 mm
6 mm
7 mm
98%
56%
27%
The effect of the distance from the contact point to the
crest of bone on the presence or absence of the
interproximal dental papilla
D. Tarnow et al 1992
“… Results showed a mean
distance of 4.33 mm. between the
location of the gingival margin
post-treatment and the bone level
during surgery…”
Regeneration of the Interdental Soft Tissues
Following Denudation Procedures
U.Van Der Velden 1982
PAPILLA HEIGHT
Healthy Papilla = 5 mm.
Healing Papilla = 4 mm.
J. Kois
PAPILLA “COME BACK”
1.
Short Papilla < 4 mm
2. 4 mm Esthetically Acceptable
3. Healing from Trauma
3 QUESTIONS
1. Maximize Symmetry
2.
Special Effects
3. Unilateral Pair
D. Tarnow 2004
Unilateral Pair
1.
Select Cantilever
2.
Forced Eruption
3. Sequential Placement
Interimplant Papilla Preservation in the Esthetic Zone. Report
of six consecutive Cases
J. Kan, K. Rungcharassaeng
Internaltional J. Perio Restor Dent 2003; 23 (3)
Forced Eruption
“…0.5 mm to 1 mm. per month of eruption
and then maintain this position 1 month
for each millimeter of coronal
movement…”
Advanced Esthetics & Interdisciplinary Dentistry 2006; 2 (3)
XI
BONDING UPDATE
REALITY RATING
LIGHT CURE DUAL CURE
1.
2.
2.
3.
4.
5.
INSURE / INSURE LITE
NX3
VARIOLINK II
VITIQUE
LUTE-IT!
CALIBRA
LIGHT CURE ONLY
1.
2.
3.
4.
5.
2009
RELY X VENEER CEM.
VARIOLINK VENEER
DA VINCI
ACCOLADE PV
CHOICE 2
Clear
White
(Thin Veneers
8 Authentic Block pairs all air abraded
and etched with HF
“…Omission of the post-etching cleaning resulted
in more than 50% loss in bond strength
Influence of post-etching cleaning and connecting porcelain on the
microtensile bond strength of composite resin to feldspathic
porcelain.
P. Magne and D. Cascione
J. Prosthet Dent. 2006; 96:354
BONDING PRECAUTIONS
1.
Rubber Dam
2. Glistening Preparation
3.
Agitate Primers
4. Evaporate Solvent
J. Burgess 2005
XII
PROTECTION
STRATEGY
Functional Considerations
1.
2.
3.
4.
5.
6.
7.
MIP coincident with CR
Night-time Appliance
Envelope of Function
Custom Guide Table
Dentin Bond Technique
Porcelain Selection
Incisal Extension
Three-Dimensional Assessment of Dental Occlusion.
(Occlusal Fencing) A Clinical Technique.
N. Mehta, E. Abdallah et al , Advanced Esthetics &
Interdisciplinary Dentistry. 2006
Clinical Case Report. Anterior Wear: Orthodontic and
Restorative Management.
J. Kois, B. Filder. Compendium, 30; 7: 420 September
2009
Restricted Envelope
Deep Bite
Bulky Crowns
Over-retracted
Misalignment
Retrusion
S. Ratcliff
Optimize Anterior Guidance
1.
Constriction Involved ?
2. Crowns with Proper envelope
3. Reposition Teeth before Veneers
4.
5.
Restore or Increase VDO
Occlusal Guard
THANK YOU