Kois DS
Kois DS
Kois DS
2, 2001
Esthetic
Technique
An MWC Publication
ADVISORY BOARD
Dear Reader:
The preparation of anterior adhesive ceramic facial veneers or fullceramic veneers should not be a dogmatic procedure where all preparations are done exactly the same way. The translucency of this conservative category of restoration offers the advantage of assisting in the final
esthetic match by allowing natural tooth color to pass through. At times,
however, this translucency can also be problematic, especially when trying to cover discolored teeth, and must be compensated for. In addition,
variations in the functional demands of individual patients will require
modifying the preparation design. For optimal adhesion, it is always
desirable to keep the preparation in enamel, but sometimes this is not
possible because of many factors. Analysis of these factors and justification must be carefully considered before preparation. Finally, the restorative material should not require excessive tooth reduction just to satisfy
fabrication criteria.
Dr. Kois and Mr. McGowan have successfully researched the subject
and written an excellent article on it for this issue of Esthetic Technique.
They discuss how and why each zone of the tooth is prepared to meet the
biological requirements of the tooth. In addition, they show how function,
dentofacial parameters, and periodontal concerns will often require modifying the preparation criteria and design. Optimal results are achieved by
treating each patient individually and not dogmatically treating everyone
the same way. This article clearly describes and defines a philosophical
and technical approach that allows for the most esthetic and conservative
results when using adhesive ceramic restorations.
Dental Learning Systems would like to thank Brasseler USA for
sponsoring this clinical series.
Best regards,
Nasser Barghi,
DDS
Bruce Crispin,
DDS, MS
John Kois,
DMD, MSD
Edward A.
McLaren, DDS
Gerard Kugel,
DMD, MS
Larry Rosenthal,
DDS
Douglas A.
Terry, DDS
Howard
Strassler, DMD
Thomas F.
Trinkner, DDS
Publisher and President, Daniel W. Perkins; Vice President of Sales and Associate Publisher, Anthony Angelini; Senior Managing Editor, Allison W. Walker; Associate Editor,
Projects, Lisa M. Neuman; Projects Director, Eileen R. Henry-Lewis; Copy Editors, Barbara Marino and Susan Costello; Design Director, Jennifer Kmenta; Circulation Manager,
Jackie Hubler; Northeast Regional Sales Manager, Jeffery E. Gordon; West Coast Regional Sales Manager, Michael Gee; Executive and Advertising Offices, Dental Learning
Systems Co., Inc., 241 Forsgate Drive, Jamesburg, NJ 08831-1676, Phone (732) 656-1143, Fax (732) 656-1148.
Postmaster: Send address changes to Contemporary Esthetics and Restorative Practice, Attn: Data Control, One Broad Avenue, Fairview, NJ 07022-1570. Send correspondence regarding subscriptions or address changes to Data Control, One Broad Avenue, Fairview, NJ 07022-1570, or call (800) 603-3512. Periodicals postage paid at Monroe
Township, NJ 08831, and at additional mailing entries.
Contemporary Esthetics and Restorative Practice (ISSN 1523-2581, USPS 017-212) is published 12 times a year by Dental Learning Systems Co., Inc., 241 Forsgate Drive,
Jamesburg, NJ 08831-0505. Copyright 2001 by Dental Learning Systems Co., Inc./A division of Medical World Communications, Inc. Printed in the USA. All rights reserved.
No part of this issue may be reproduced in any form without written permission from the publisher.
Contemporary Esthetics and Restorative Practice is a trademark of Dental Learning Systems Co., Inc. Medical World Communications Corporate Officers: Chairman/CEO,
John J. Hennessy; President, Curtis Pickelle; Chief Financial Officer, Steven J. Resnick; Chief Operating Officer, Melissa J. Warner; Vice President of Manufacturing, Frank A. Lake
BPA International Membership Applied for October 1998.
The Esthetic Technique series is made possible through an educational grant from Brasseler USA,
Inc. To order additional copies call 800-926-7636, x180.
D450
Kenmore, Washington
Private Practice
in Fixed Prosthodontics
Tacoma, Washington
LEARNING OBJECTIVES
ABSTRACT
A diagnostically based protocol for anterior
tooth preparations for adhesively retained
porcelain restorations offers dentists and laboratory technicians new options to approaching
these restorations. Rather than designing a
preparation and restoration based more on the
needs of the products used than on the preservation of the remaining tooth structure, practitioners can enhance the predictability of these
restorations by concentrating simultaneously
on three distinct zones of the tooth (incisal,
middle, and cervical) and four diagnostic categories (periodontal, biomechanical, functional,
and dentofacial). The result of following the
technique presented in this article is achieving
an individualized design that offers a predictable option with minimal risks to the
remaining tooth structure.
ESTHETIC TECHNIQUE
Figure 2
Radiograph
of teeth Nos.
7 through
10 shows
large endodontic access opening and fill
in tooth No.
8, which is
a high biomechanical
risk.
orcelain laminate
veneers offer a
predictable option for
creating a successful
restorative treatment
that also preserves a
maximum amount of
tooth structure.
I NCISAL ZONE
Representing the initial starting
point, restoration of the incisal
zone is based primarily on the functional and esthetic requirements of
the individual patient. If the incisal
edge position is correct in the face
and in harmony with the smile, no
vertical tooth reduction is necessary. This, unfortunately, does not
provide the laboratory technician
any flexibility to modify shape,
position, or incisal translucency.
Vertical reduction is not desirable,
however, if the functional risk is
high. If functional risk is low, the
dentist has more flexibility to
develop incisal reduction based on
ESTHETIC TECHNIQUE
Reduction Considerations
Ideally, the vertical incisal
reduction is 2.0 mm from the
desired position, where it does not
create a biomechanical compromise to the remaining tooth structure. It also offers minimal functional risk to the porcelain extending beyond the incisal edge, and
gives the laboratory technician
esthetic options to alter tooth
form and build incisal effects in
the porcelain. In addition, strict
guidelines about not reducing the
incisal zone more than 2 mm vertically as discussed in previous articles are not supported by clinical
findings. Unsupported vertical
incisal porcelain even greater than
4 mm is predictable if the
he parameters of
anterior tooth
preparation are focused
on three distinct zones:
incisal, middle, and
cervical.
Margin Design
Most practitioners recommend
a lingual chamfer margin design,
which is acceptable, although it is
not ideal.6 It appears more prudent
to develop a butt margin design
incisally, with its lingual compoa
M IDDLE ZONE
The key concern for this zone
is performing minimal facial
reduction that retains tooth structure comparable to the retained
enamel to optimize the limitations
of composite technology. This will
provide a unique blend of stiffness
vs flexibility and preserve the biomechanical behavior of the original tooth.7-12 Unfortunately, this
must be balanced by the need to
create sufficient porcelain thick-
Margin Design:
Butt
Lingual finish line
in enamel
ESTHETIC TECHNIQUE
estoration of the
incisal zone is
based primarily on the
functional and esthetic
requirements of the
individual patient.
The mean facial enamel thickness in the middle zone is 0.8 mm to
0.9 mm.13 Therefore, while facial reduction less than this amount is
desirable, maintaining the thickness
of porcelain less than this amount
Reduction Requirements
To maintain enamel facially
and recreate the original biomechanical behavior of the tooth, a
0.5-mm to 0.7-mm reduction is
ideal. Interproximal finish lines
should be terminated in enamel to
minimize microleakage, and all
sharp corners should be eliminated
to minimize stress concentration in
the porcelain as well as seating
concerns for the restoration. Based
on functional relationships, as
much lingual enamel as possible
Maintain enamel
Minimal structural
compromise
Margin Design:
Option 1 Maintain contact point if no
proximal restorations
Option 2 Open contact point if previous caries restorations
or to change tooth form
Instrumentation:
KS 0 depth guide 1/2
Diameter 0.5 mm
KS 7gross reduction
KS 0complete remaining
preparation
ESTHETIC TECHNIQUE
Margin Design
The facial incisal aspect of the
preparation must be rounded and
beveled slightly to create an invisible transition of porcelain to the
incisal edge and to eliminate stress
concentration and seating concerns. All other aspects maintain a
butt type of finish line (Figures 10
and 14 through 17).
he key concern
for the middle zone
is performing minimal
facial reduction that
retains tooth structure
comparable to the
retained enamel.
CERVICAL ZONE
The key concerns in this zone
are similar to the middle zone
Preserve enamel
Esthetics requirements
Margin Design:
Option 1 Supragingival margin
location
Normal tooth color
Minimal change in tooth
form
Option 2 Intracrevicular location
Dark color
Change shape
Close gingival embrasures
Instrumentation:
KS 0
ESTHETIC TECHNIQUE
he individual
talents of the
laboratory technician
are far more important
than the specific brand
of porcelain used.
Reduction Requirements
To preserve enamel, ideal
reduction should be no more than
0.3 mm to 0.4 mm. This minimizes
microleakage resulting from more
predictable enamel bonding and
minimizes the biomechanical compromises to the remaining tooth
structure. This is especially critical
with endodontically treated teeth.
The larger the access opening and
the greater the removal of internal
tooth structure, the more critical the
concerns for cervical reduction.
This is especially a concern for a
high-risk functional patient where
tooth flexure is potentially greater.
Biomechanically and functionally, the minimal cervical reduction
Margin Design
From a periodontal perspective, supragingival margins are
ideal. Concepts of intracrevicular
tooth preparation have been previously discussed14,15 and are not any
different for these restorations.
From a biomechanical perspective,
the actual configuration of the finish line exhibits little influence on
stress variation in the porcelain.
The most significant factor in minimizing marginal failure is ultimate-
ased on functional
relationships,
as much lingual enamel
as possible should be
preserved to minimize
opposing wear.
SUMMARY
This article presented a diagnostically generated protocol for
anterior tooth preparation for
adhesively retained porcelain
restorations. This approach eliminates a standardized design based
solely on the requirements of
restorative materials. By shifting
the focus to three distinct zones of
the tooth and four diagnostic categories of periodontal, biomechanical, functional, and dentofacial
parameters, the clinician can create an individualized design.
Therefore, this design is determined
based on the need to minimize risk
in the highest risk categories. With
this approach, we can achieve the
best possible result with minimal
risks to the remaining tooth structure and the best chance for longevity (Figures 20 and 21).
REFERENCES
1.
ESTHETIC TECHNIQUE
9.
10.
11.
12.
13.
2.
3.
4.
5.
6.
7.
8.
14.
15.
16.
17.
WARNING: Reading an article in Esthetics Technique does not necessarily qualify you to integrate new techniques or procedures into your practice. Dental Learning Systems
expects its readers to rely on their judgment regarding their clinical expertise and recommends further education when necessary before trying to implement any new procedure.
The views and opinions expressed in the article appearing in this publication are those of the author(s) and do not necessarily reflect the views or opinions of the editors, the
editorial board, or the publisher. As a matter of policy, the editors, the editorial board, the publisher, and the university affiliate do not endorse any products, medical techniques, or diagnoses, and publication of any material in this journal should not be construed as such an endorsement.
ESTHETIC TECHNIQUE
CE QUIZ
Dental Learning Systems Co., Inc., provides 2 hours of Continuing Education credit for those who wish to
document their continuing education endeavors. Participants are urged to contact their state registry boards
for special CE requirements.
To receive credit, complete the enclosed answer form, include a check for $14, and mail both in the envelope provided.
10
ESTHETIC TECHNIQUE
PREP STEPS
Adjusting and Polishing of Porcelain and
Polymer Glass Restorations
crowns or veneers. This disc features an autosafe chucking center to stop rotation if the disc becomes engaged in
contacts.
Polishing ceramic and polymer glass restorations:
The following steps will return to porcelain the wet
look of the glazed porcelain before adjustment.
Polish porcelain with Brasseler USA Dialite polishers;
begin with the blue coarse wheel, points, or discs to smooth
scratches or further reduce the surface (Figures 4 and 5).
The pink or medium-grit Dialite further prepares the surface for final high shine. Speed range of 3,000 rpm to
7,000 rpm provides optimal polishing while maintaining
long instrument life.
The gray Dialite (wheel, point, or cup) high shines the
porcelain, returning the natural wet look (Figure 6).
Dialite diamond-impregnated polishers are autoclavable
and available in latch shank for intraoral use.
For final polishing of textured and/or faceted surfaces,
the Truluster Polishing Kit is recommended. The use
of diamond paste and brushes does not remove surface
texture.
For polishing polymer glass, which is less dense than
porcelain, the Ceroshine Kit provides a diamond paste with
a specific particle range suitable for polymer glass.
Included in the kit are scotch brite wheels, goat-hair brushes, a chamois wheel, and a cotton buff.
ESTHETIC TECHNIQUE
11