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Rejuvenating a Smile with IPS e.max® Restorations
A comprehensive approach to function and esthetics
Restoring a smile and opening a bite require a systematic approach to diagnostics and treatment planning, as well as close communication between the dentist and laboratory. Functionality, esthetics, preparation, clinical considerations, and patient requirements determine material selection. When metal-free restorations are desirable, a glass-ceramic lithium disilicate material (IPS e.max®, Ivoclar Vivadent, www.ivoclarvivadent.com) demonstrates the low refractive index that produces unmatched optical properties, such as translucency, and a controlled size, shape, and density of crystalline structure for greater strength (ie, 400 MPa) and durability than most all-ceramic systems.
An internationally known dental practice management consultant decided to end a cycle of single-tooth dentistry that began in 2008. She had upper veneers placed approximately 16 years prior. Since then, the margins began staining due to normal wear and tear, she experienced natural gingival recession (Figure 1), and the right lateral veneer fractured horizontally.
These issues were discussed, as was opening her bite, because the incisal edges of her centrals closed to the gingival border of her lower anterior teeth. She wanted to replace the worn restorations, improve function, and brighten the color of her smile. She requested an esthetic material she had heard about at dental conferences that would provide brighter shades while achieving a more natural appearance.
Consultation and treatment planning incorporated an oral and esthetic examination; digital full-mouth x-ray; digital photographs; joint examination and manipulation into centric relation using a jig followed by a Futar® (Kettenbach LP, www.kettenbach.com) bite, face-bow, and stick bite; and impressions mounted on a Denar® Combi (Whip Mix, www.whipmix.com). Cotton rolls were placed between the posterior teeth to visualize the difference in facial structure that opening the bite would achieve (Figure 2). The case was mounted to determine the vertical dimension of occlusion (VDO) and sent to the laboratory (MACSTUDIO by Microdental Laboratories, www.microdental.com) for a wax-up with instructions for VDO and desired esthetic changes.
Preparation and Temporization
Intravenous sedation was administered and 28 teeth were prepared (ie, posterior for crowns, anterior for veneers with cutbacks for esthetic porcelain layering) by removing old crowns and checking for decay. A Sil-Tech® (Ivoclar Vivadent) jig was made at the predetermined VDO and used to capture left and right Futar bites. The anterior gingival heights were corrected with a laser.
A stump shade was taken and photographed, and a bite registration, impressions, and upper face-bow were taken. The Futar bites were placed in the right and left posterior, and an anterior stick bite was created simultaneously.
Temporaries were made using a bleach shade provisional material placed into a Sil-Tech impression of the wax-up. They were sectioned between the bicuspid and cuspid, then placed (posterior: TempBond®, Kerr Corporation, www.kerrdental.com; anteriors: flowable FL2 and B1, Kerr), bonded, and contoured.
The patient returned 48 hours later to verify the color, shape, function, and occlusion of the temporaries, and she was satisfied. Smile, retracted, and full-face photographs of the temporaries were taken. Stick bite and impressions were made to communicate esthetics to the laboratory, because the temporaries were prototypes for the definitive restorations.
The anterior color was created using a combination of 030 and 020, and 030 was used for the posterior. Photographs of the restorations were reviewed online by the dentist and ceramist before being sent to the laboratory to address any changes required before glazing and shipping (Figure 3).
The patient was anesthetized, upper and lower left and right posterior temporaries removed, and the restorations tried in. The teeth were cleaned and a desensitizer placed. A bonding agent (OptiBond® All-In-One Bond, Kerr) was placed and activated, and the restorations filled with cement (Maxcem Elite™, yellow, Kerr), placed on the teeth, and cured for 3 seconds on the buccal/lingual. Excess was removed interproximally with floss and a scaler, and a final 20-second cure was performed from the buccal, lingual, and occlusal aspects.
A rubber dam was placed to isolate the six anterior teeth. The temporaries were removed and the veneers tried in with water to check fit, then with try-in paste (+2 Variolink® Veneer, Ivoclar Vivadent) for shade. The veneers were removed, rinsed, and prepared for insertion. Bonding agent (OptiBond XTR, Kerr) and cement (+2 Variolink) were used for placement.
Brushes were used to remove excess luting material, and the veneers were tacked by curing for 5 seconds at the gingival margin (Figure 4). A Brasseler saw (www.brasselerusa.com) was placed interproximally to prevent the material from luting together, and each tooth was cured from the buccal and lingual for 20 seconds. A scaler and scalpel were used for final cleaning, and a final 20-second cure from the buccal/lingual was performed.
Floss was placed through each contact, and an extra-fine interproximal yellow abrasive strip (Brasseler USA) (Figure 5) was placed through each contact gingivally to smooth the margins. A final cleaning of the restorations was performed, and the occlusion adjusted in all excursive movements. Because all quadrants were numb, final adjustments would be made subsequently.
The patient returned for final photographs and occlusal adjustments (T-Scan®, Tekscan, www.tekscan.com), and was pleased with the esthetic results and occlusal scheme. The final results broadened her smile, creating a more youthful appearance and improved function (Figure 6).
The author would like to acknowledge Dr. John Dashty’s expertise with this case.
Kenneth Hamlett, DDS, FAACD, FAGD
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