QDT 2015

Editorial
Success,
Survival, or
Failure Rates:
Why They Do
Matter
I
ndependent scientific
investigations are,
unquestionably, one of
the most important sources
for understanding the
behavior of biomaterials or
techniques in our field. A
modest web-based search
reveals tens of thousands of
articles focusing on different
aspects of dental biomaterials
published in peer-reviewed
journals. However, when the
search is narrowed to clinical
trials, the amount of available
literature drops significantly,
to thousands of articles, and
once success rate or survival
rate is included in the search,
the information drops to only
a few hundred peer-reviewed
articles. The difficulty of
conducting an independent
clinical investigation is
titanic: developing a
hypothesis; performing in
vitro laboratory tests prior to
the in vivo testing; obtaining
and evaluating these results;
assessing which laboratorial
aspects (or techniques) could
be clinically translated and
truly important to be
investigated; designing a
research protocol that
accurately leads to coherent
results; preparing, submitting,
and obtaining approval of an
independent review board
(IRB, also known as an
independent ethics
committee); being awarded
financial support; and finding
a group of individuals who
agree to volunteer for the
investigation. These are only
the initial stages of the
process required to perform a
clinical trial.
Finally, when all of the
above is accomplished, the
actual testing can begin. But
first, an investigator or group
of investigators (researchers,
clinicians, professionals,
residents, and/or students)
will undergo a calibration
series to prevent one of the
most undesirable problems in
research: bias. Bias may
occur unintentionally during
trial planning,
implementation, and/or data
analysis. Rigorous criteria for
case selection are essential to
avoid confounding results.
Only cases that perfectly
satisfy the criteria can be
used. During the
surgical/restorative
procedures, personal
preferences and situations
beyond the control of the
investigators may arise that
can jeopardize the final
outcome of the investigation.
Performance bias may
obscure efforts to establish a
cause-effect relationship
between procedures and
outcomes. Thus, in addition
to undergoing calibration,
investigators must remain
impartial and dispassionate to
achieve reliable results in
clinical trials.
All the excitement of
clinical investigations is
realized only at the end, when
after many months or years of
work—and frustration—the
results come to fruition.
Inevitably, success, survival,
and failure rates become the
focus of many clinical
investigations. Needless to
say, failure rate is easy to
define, whereas success and
survival can be more
complicated. Success may be
validated by the absence of
any biologic, technical, and
esthetic complications, but
identical parameters can be
used for survival rate with
some variation. Therefore, an
unemotional, impersonal, and
meticulously well-defined
range for success is the most
appropriate form of
evaluation of a given work.
Clinical variables (such as
technique, area to be restored,
type of restoration,
complexity of occlusion,
periodontal health, and
patient demographic,
socioeconomic, and
behavioral variables) as well
as operator skill and
knowledge no doubt play
important roles in success,
survival, and failure rates.
Nonetheless, candid and
unbiased retrospective
analyses of treatments
rendered are sine qua non for
our own understanding of our
limitations and successes.
This year, I invite you to
celebrate our successes and
the clinical investigations and
retrospective analyses that
have led to them. In the
articles presented herein,
discover how concepts
explained in previous editions
of Quintessence of Dental
Technology are used with a
different approach to
elucidate and restore complex
clinical cases. A special series
of articles on treatment of the
worn dentition plus gingival
framework are worth your
time and consideration; they
will continue in future
editions of QDT. Join me in
exploring how CAD/CAM
technologies, allied with
human creativity, can reach
impressive levels of natural
beauty, or how
ultraconservative esthetic
surgical methods can grant
highly predictable results.
And the many exquisite
techniques presented for
delivering lifelike restorations
—all are successes to be
appreciated.
Sillas Duarte, Jr, DDS, MS,

PhD
Editor-in-Chief
[email protected]
QDT 2015
Volume 38
QUINTESSENCE OF
DENTAL TECHNOLOGY
EDITOR-IN-CHIEF
Sillas Duarte, Jr, DDS, MS,
PhD
Associate Professor and Chair
Division of Restorative Sciences
Ostrow School of Dentistry
University of Southern California
Los Angeles, California
ASSOCIATE EDITORS
Jin-Ho Phark, DDS, Dr Med
Dent
University of Southern
California
Neimar Sartori, DDS, MS,
PhD
California
QDT 2014 SECTION

CHAIRS
Gerard J. Chiche, DDS
Augusta, Georgia
Oswaldo Scopin de Andrade,
DDS, MS, PhD
São Paulo, Brazil
EDITORIAL REVIEW
BOARD
Pinhas Adar, CDT, MDT
Atlanta, Georgia
Naoki Aiba, CDT
Monterey, California
Amir Avishai, PhD
Cleveland, Ohio
Markus B. Blatz, DMD, PhD
Philadelphia, Pennsylvania
Ana Carolina Botta, DDS,
MS, PhD
Stony Brook, New York
Shiro Kamachi, DMD
Boston, Massachusetts
Avishai Sadan, DMD
Thomas J. Salinas, DDS
Rochester, Minnesota
Eric Van Dooren, DDS
Antwerp, Belgium
Fabiana Varjão, DDS, MS,
PhD
Luana C. Wright, DDS, MS,
PhD
Fort Lauderdale, Florida
Aki Yoshida, CDT
Weston, Massachusetts
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MANUSCRIPT
SUBMISSION
QDT publishes original articles
covering dental laboratory
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Copyright © 2015 by Quintessence
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ISSN 1060-1341 / ISBN 978-0-
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eISBN 978-0-86715-698-0
Cover photo by Naoki Hayashi
Table of Contents
Editorial:
Success, Survival, or
Failure Rates: Why They
Do Matter
Sillas Duarte, Jr, DDS, MS, PhD
Taking Control Over

Challenging Esthetic Cases
Using the Power Trio: 7
Pink Ceramics, Implants,
and Veneers
Victor Clavijo, DDS, MS,
PhD/Leonardo Bocabella,
CDT/Paulo Fernando Mesquita de
Carvalho, DDS, MS
Minimally Invasive
Prosthetic Procedures
(MIPP): Classification and
Clinical Cases
Leonardo Bacherini, DDS/Mauro
Fradeani, MD, DDS
BIOMATERIALS
UPDATE
CAD/CAM High-Strength
Glass-Ceramics
Neimar Sartori, DDS, MS,
PhD/Gilberto Tostado, DDS/ Jin-
Ho Phark, DMD, Dr Med
Dent/Kazunari Takanashi, RDT/
Richard Lin, DDS/Sillas Duarte,
Jr, DDS, MS, PhD
Adhesive Oral
Rehabilitation of a
Tetracycline-Stained
Dentition with Minimally
Invasive Indirect
Restorations
Oswaldo Scopin de Andrade, DDS,
MS, PhD/Messias Rodrigues,
DDS, MS/Ronaldo Hirata, DDS,
MS, PhD/Luiz Alves Ferreira,
CDT
Flapless Esthetic Gingival

Remodeling: The Ultimate
Approach for Crown
Lengthening
Ivan Contreras Molina, DDS, MSc,
PhD/Gildardo Contreras Molina,
DDS/Isis Carvalho Encarnação,
DDS, MSc, PhD/Cristiano Soares,
CDT/ Luiz Narciso Baratieri, DDS,
MSc, PhD
STATE OF THE ART

Mastering Esthetic and
Functional Rehabilitation of
the Severely Worn
Dentition
Sergio R. Arias, DDS, MS/Aram
Torosian, MDC, CDT/Somkiat
Aimplee, DDS, MS/Jimmy
Londono, DDS/Gerard Chiche,
DDS
Biologic Esthetics by
Gingival Framework
Design: Part 1. Factors for
Achieving Biologic and
Esthetic Harmony
Yuji Tsuzuki, RDT
Maintaining the Esthetics of

Anterior Teeth with a
Flapless Single-Tooth
Immediate Implant
Placement
Cristiano Soares, CDT/Luciana
Mara Soares, DDS/Guilherme
Ferreira Duarte, DDS/ Neimar
Sartori, DDS, MS, PhD
CAD/CAM: A Whole New

World of Precision and
Excellence
Paulo Kano, DDS, MDT/Luiz
Narciso Baratieri, DDS, MS,
PhD/Fabio Andretti, DDS, MS,
PhD/Priscila Saito, DDS/Emerson
Lacerda, MDT/Sillas Duarte, Jr,
DDS, MS, PhD
MASTERPIECE
A Challenge to Natural
Teeth
Naoki Hayashi, RDT
Biologic Esthetics by
Gingival Framework
Design: Part 2. Gingival
Esthetics Evaluation
Criteria
Yuji Tsuzuki, RDT
Esthetic Rehabilitation of
the Patient with
Tetracycline Discoloration
and Diastema
Gadzhy Dazhaev, DMD/Thomas
Sing, MDT
STATE OF THE ART:

CAD/CAM Technology for
Complete Denture
Fabrication
Tae H. Kim, DDS/Sillas Duarte, Jr,
DDS, MS, PhD
The Reservoir Technique

Hilal Kuday, CDT/Michel Magne,
MDT
Mental, Visual, and Manual

Training: The MVM
Concept
Ivan Contreras Molina, DDS, MSc,
PhD/Panaghiotis Bazos,
DDS/Pascal Magne, DMD, MSc,
PhD
Automated Production of
Multilayer Anterior
Restorations with Digitally
Produced Dentin Cores
Josef Schweiger, CDT/Daniel
Edelhoff, CDT, Dr Med Dent,
PhD/Michael Stimmelmayr, Dr
Med Dent/Jan-Frederik Güth, Dr
Med Dent/Florian Beuer, DDS, Dr
Med Dent, PhD
QDT 2015 is dedicated to Per-
Ingvar Brånemark in celebration
of his life.
Taking Control
Over
Challenging
Esthetic Cases
Using the
Power Trio:
Pink Ceramics,
Implants, and
Veneers
Victor Clavijo, DDS,

MS, PhD1
Leonardo Bocabella,
CDT2
Paulo Fernando
Mesquita de Carvalho,
DDS, MS3
ith the popularization of

dental implants for single to
complex restorations, the
importance of
W treatment planning
has
emphasized.
professionals who perform
been
If
implant surgery neglect the

necessary backwards
planning, especially in terms
of three-dimensional
positioning, they are fostering
future problems. The
problems most frequently
encountered with
malpositioned implants are
gingival recession, loss of the
interdental papilla, grayish
discoloration at the gingival
margin, and complex
prosthesis fabrication.1,2
When patients present with
malpositioned implants,
dentists and dental
technicians need to find
solutions for improving their
biologic, mechanical, and
esthetic conditions. This
article describes a technique
that combines gingival and
dental restorations on
malpositioned implants with
minimally invasive
restorations on the adjacent
contralateral teeth.
CASE REPORT
A 42-year-old man presented
with a chief complaint of
unsatisfactory smile esthetics.
Intraoral examination
revealed the presence of
dental disharmony,
malpositioned implants (at
the maxillary left central and
lateral incisor sites), gingival
recession, papilla loss, and
dental and gingival
discrepancy compared to the
contralateral situation (Fig 1).
To perform an effective
evaluation of the implants,
the cemented restorations
were removed. Upon so
doing, two metal abutments
were found with the
vestibular head of the screw
emerging. This confirmed the
poor position of the implants,
and immediately afterward,
the abutments were removed
to verify the intrasulcular
depth of the implants as well
as the periodontal condition.
Radiography and tomography
were also performed to better
evaluate the patient’s
condition.
Fig 1a Pretreatment intraoral

situation.
Fig 1b Metal abutment and screw
poorly positioned.
Fig 1c Gingival discrepancy and
poor anatomical tooth shape.
Treatment Plan
After the diagnosis was made,
and taking into account that
the patient did not wish to
have the implants removed,
the following treatment plan
and clinical sequence were
suggested (Fig 2):
Fig 2 Treatment plan (Digital

Smile Design, C. Coachman and
M. Voigt).
1. Transfer of implants to a
new provisional implant
prosthesis, with a pontic
on the maxillary left
lateral implant and a
screw-retained crown on
the left central implant to
create a concave profile
(subcontour).
2. After 3 months, flapless
crown length to be
increased on the
contralateral teeth (right
central and lateral
incisors) and a
connective tissue graft
performed at the position
of the implants to
improve the gingival
volume in this area, so
avoiding over-contour of
the prosthetic gingival
restorations.
3. Minimally invasive
preparation for veneers
on the right central and
lateral, and transfer to a
dentogingival prosthesis
of the left central and
lateral incisors on the
central incisor implant.
4. Bonded porcelain veneers
and delivery of the
dentogingival prosthesis.
Clinical Phases
Phase I: Provisional
Implants
First the transfer of the
central incisor implant was
performed by using a transfer
coping (Fig 3), and then a
splinted provisional of the left
central and lateral incisors
was fabricated in polyvinyl
siloxane (Virtual, Ivoclar
Vivadent) and screwed in
(Fig 4a). Also, in an attempt
to make the gingival tissue
migrate incisally, a more
concave intrasulcular profile
was included.3 Finally, the
left lateral incisor implant
was buried to improve the
interproximal appearance of
the left central and lateral
incisor restorations.
Figs 3a and 3b Transfer coping for
poorly positioned implant.
Fig 4a Provisional placement with

lateral incisor implant buried.
Phase II: Reshaping

Gingival Contours,
Tooth Preparation, and
Impression
Three months after the
provisional placement
(considering the
aforementioned
modifications), the patient
presented a small incisal
“migration” of the gingival
tissue. Thus, flapless4 crown
lengthening was performed
on the right central and lateral
incisors. A connective tissue
graft (palate donor site) was
used to increase the volume
in the gingival area of the
implants, which would reduce
the prosthesis contour and
facilitate its hygiene.
Two months after these
procedures were performed, a
significant improvement was
observed in the anterior
gingival discrepancy (Fig 4b);
however, the papilla loss in
the implant area remained,
which modified the tooth
form in this area. In order to
adjust and improve the shape
of the anterior segment, the
right central and lateral
incisors were minimally
invasively prepared for
veneer placement (Fig 5a),
thus correcting the incisal
contours and returning the
labial anatomy that had been
lost over the years. A mock-
up was designed, following
the technique described by
Magne and Belser5 and
Gürel,6 preserving all
remaining enamel. Then a
new impression of the
preparation and the implant
transfer was performed in
order to fabricate the final
ceramic restorations (Fig 5b).
The prepared teeth as well as
the gingival tissues were
photographed to ensure
accurate shade selection and
harmony with the adjacent
hard and soft tissues.
Fig 4b Remarkable esthetic

improvement after healing of the
crown, adaptation of the
provisional, and gingival grafting.
Fig 5a Minimally invasive

preparation of the right central and
lateral incisors and gingival
conditioning at the site of the left
central and lateral.
Fig 5b Transfer coping.
Laboratory Phases
In the laboratory, the dental
technician faced the multiple
challenges of gingival
discrepancy, poor implant
positioning, and difference
between the implant and
prepared tooth substrates. To
solve these issues, the work
was divided into several
laboratory phases.
Phase I: Fabricating
the Infrastructure
This first phase consisted of
finding a solution for the
implant restoration. In terms
of the poor implant position,
one might consider cementing
the final restoration.
However, cementation of
prostheses on malpositioned
implants may not guarantee
long-term success. Thus, a
customized screw-retained
implant restoration was
advocated, since it has many
clinical advantages as far as
long-term maintenance. For
that, a customized abutment
was created to correct the
positioning for the implant
restoration. A UCLA
abutment was used in
association with a
prefabricated extension
device for lingual access
(micro-UCLA, SignoVinces).
After casting, two screw
points, a main thread
following the long axis of the
implant and a secondary
palatal thread for correct
positioning of the final
restoration, were determined
(Figs 6a and 6b). Next, the
dentogingival framework was
fabricated (Figs 6c to 6e).
Fig 6a Metal abutment with main

and secondary palatal screw access
holes.
Fig 6b Metal framework on the

abutment after casting.
Figs 6c to 6e Metal framework and
abutment.
Phase II: Matching the

Substrates
After completion of the metal
framework, application of
ceramic was initiated. It was
decided to create a balance in
the gingival area—which was
incorrect in the previous
dentogingival prosthesis—
thus creating a suitable
architecture to construct the
ideal tooth anatomy.
To ensure better esthetic
integration among the implant
restorations and ceramic
veneers, the left central and
lateral incisor teeth were
customized on the
dentogingival prosthesis to
provide similar characteristics
to the right central and lateral
incisors. Thus, artificial
ceramic veneer preparations
were fabricated in the
dentogingival prosthesis
following a similar veneer
preparation design and
abutment shade of the natural
contralateral teeth. The
fabrication of customized
artificial ceramic veneer
preparations into a prosthesis
decreases the necessary
number of bake corrections,
thus avoiding modifications
in optical and mechanical
properties of the final
prosthesis. In addition, the
opportunity to fabricate all
porcelain veneers at the same
time improves the
predictability of color and
shape. However, an
additional step is added to the
restorative phase: bonding the
porcelain veneers to the
dentogingival prosthesis. One
may consider the adhesive
interface between ceramics a
concern; however, bonding
ceramic to ceramic is more
predictable than bonding to
dental structure and, should
any adjustments be necessary
in the future, repairs can be
easily performed.
By using digital
photographs with color
scales, it was possible to
reproduce the details of tooth
substrate shape and color, as
well as the gingival area, to
match the remaining teeth
(Fig 7), thereby facilitating
the manufacture of ultra-thin
restorations without concern
for the differences in tooth
substrate (Fig 8). Also, an
intraoral proof was used to
check adaptation and the
correct implant placement,
and new photographs were
taken to verify color and
shape of the created
substrates.
Figs 7a to 7c Dentogingival
prosthesis after ceramic
application.
Figs 8a to 8c Die cast reproducing
the color and shape of dental
substrates.
Phase III: Duplicating

the Infrastructure
A wax-up of the ceramic
structure was fabricated,
removing retentions and
creating dies. This
duplication was made with
polyvinyl siloxane (same
used in refractory die
duplication), and a replica
was made in plaster,
obtaining a working die cast
for waxing the veneers (Fig
9).
Fig 9a Wax application for
reproducing the ceramic structure.
Fig 9b Die cast.
Fig 9c Die cast of the four teeth.
Note the shape similarity of the
dies, which will facilitate a more
uniform and predictable ceramic
application.
Phase IV: Manufacture

of Ceramic Veneer
Restorations
Lithium disilicate–based
ceramic veneers were chosen
instead of feldspathic veneers
to avoid a new impression as
well as to allow try-in after
the bisque bake phase plus
possible corrections that
could present a problem for
feldspathic veneers.
The LT A1 (IPS e.max
Press, Ivoclar Vivadent) ingot
was selected. It would
provide the acceptable final
color and translucency for the
restorations (Fig 10).
Opalescent enamel effect was
then applied. After try-in to
check the final color and
shape, the final glazing and
texturing were performed
(Fig 11). The restorations
were tried-in again (Figs 12
and 13), and cementation for
implant placement was
performed in the same
laboratory.
Figs 10a to 10c Translucent, thin

veneers placed. Remaining teeth
matching.
Fig 11 Brightness definition areas.

Fig 12a Abutment placement.
Figs 12b and 12c Dentogingival

ceramic structure insertion.
Figs 13a and 13b Final try-in for

shape and color assessment.
Phase V: Final
Delivery
The artificial ceramic teeth on
the dentogingival prosthesis
were etched with 10%
hydrofluoric acid for 90
seconds (Fig 14a), followed
by rinsing and drying. To
remove glass particle debris,
35% phosphoric acid was
applied (Fig 14b), followed
by rinsing and drying. Silane
was subsequently applied for
60 seconds (Fig 14c) and air
dried, after which a thin layer
of adhesive was placed, air-
thinned, and left uncured.
Ceramic veneer restorations
in lithium disilicate were
treated similarly as described
above with the exception that
the lithium disilicate glass-
ceramic was etched for 20
seconds. The veneers were
bonded to the dentogingival
prosthesis and light
polymerized for 60 seconds
on each restoration. Polishing
was performed using silicone
carbide points (Exa-Cerapol,
Edenta AG Dental Produkte).
Fig 14a Hydrofluoric acid

application.
Fig 14b Phosphoric acid
application for residual removal.
Fig 14c Silane application for 60
seconds.
The implant abutment

was retained by 35 N torque
at the main abutment
followed by sealing with
Teflon tape. Next the
dentogingival prosthesis was
placed and the secondary
palatal access hole was screw
retained at 10 N.
The porcelain veneers
were then carefully bonded
(Variolink Veneer, Ivoclar
Vivadent) to the right central
and lateral incisors (Figs 15a
to 15c). Retraction cords were
removed by using a clinical
probe, and the excess resin
cement was removed with a
scalpel (Fig 15d). After the
veneers were bonded to the
natural teeth, the
dentogingival prosthesis was
removed and interproximal
space verified for any debris
before the final placement of
the implant restoration.
Occlusal adjustments were
made, and maintenance
appointments were scheduled
(Figs 16 and 17).
Fig 15a Phosphoric acid
application for 30 seconds.
Fig 15b After air jets were used for
drying, enamel preparation was
completed.
Fig 15c Thin adhesive layer
application.
Fig 15d Excess resin cement
removed with a scalpel.
Figs 16a and 16b Final aspect
after cementing.
Fig 17 Two-year follow-up.
CONCLUSIONS
The procedures described in
this article represent a
plausible solution for
malpositioned implants that
can provide patients with
satisfactory esthetic, biologic,
and functional outcomes with
favorable predictability. The
dental technician must have
the training to be able to
observe and report possible
eventual side effects of such
complex restorations.
REFERENCES
1. Henry PJ, Laney WR, Jemt T,
et al. Osseointegrated implants
for single-tooth replacement:
A prospective 5-year
multicenter study. Int J Oral
Maxillofac Implants
1996;11:450–455.
2. Dominguez E, Vazquez M,
González-Martín O, Alandez
J. Mucogingival therapy to
treat implant fenestration in
the esthetic zone: A case
report after 2 year follow up.
Int J Esthet Dent 2014;9:40–
53.
3. Su H, Gonzalez-Martin O,
Weisgold A, Lee E.
Considerations of implant
abutment and crown contour:
Critical contour and
subcritical contour. Int J
Periodontics Restorative Dent
2010;30: 335–343.
4. Joly JC, Mesquita CPF,
Carvalho SR. Flapless
aesthetic crown lengthening:
A new therapeutic approach.
Rev Mex Periodontol
2011;2(3):103–108.
5. Magne P, Belser UC. Novel
porcelain laminate preparation
approach driven by a
diagnostic mock-up. J Esthet
Restorative Dent 2004;16:7–
16.
6. Gürel G. Predictable, precise,
and repeatable tooth
preparation for porcelain
laminate veneers. Pract Proced
Aesthet Dent 2003;15:17–24.
____________________________
1 Professor, Advanced Program in
Implantology and Restorative
Dentistry, ImplantePerio
Institute, São Paulo, Brazil.
2 Dental Technician, Campinas,
Brazil.
3 Director, Advanced Program in
Implantology and Restorative
Dentistry, ImplantePerio
Institute, São Paulo, Brazil.
Correspondence to: Dr Victor
Clavijo, Rua Cerqueira Cesar,
1078 Indaiatuba, São Paulo,
Brazil 13330-005.
Email:
[email protected]
Minimally
Invasive
Prosthetic
Procedures
(MIPP):
Classification
and Clinical
Cases
Leonardo Bacherini,
DDS1
Mauro Fradeani, MD,
DDS2
T
he treatment of
patients with a worn
dentition has become
more and more common
nowadays due to an increase
of this type of pathology,
which also affects the
younger population.1 For this
reason, the clinician must
adopt a precautionary and
conservative treatment
approach to preserve as much
tooth structure as possible
while also reestablishing the
proper relationship between
function, esthetics, and
longevity of the restorations.
An understanding of
different types of wear, well
described in the literature by
several authors, is very
important for the clinician,
because the longevity of the
restorations will be greatly
influenced by the type of
wear.2 Most authors now
agree on the multifactorial
nature of dental wear.3 Often
different types of wear are
present in a patient with a
worn dentition, and diagnosis
can be challenging for the
clinician who must formulate
a proper treatment plan.4
Among different types of
wear, attrition is the most
important, because it
increases the risk of failure of
restorations due to abnormal
occlusal loads they will be
subjected to. Thus, when
treating patients suffering
from wear by attrition, the
clinician should consider the
possibility of eliminating or
reducing occlusion as a
causative factor.
It is still not yet clear
whether occlusion plays a
role in the onset and
persistence of the
parafunction that causes
wear. However, the clinician
must not ignore which
functional parameters to
evaluate, so to eventually
correct them in order to solve
the problem of wear by
attrition.5 A more
comprehensive approach to
treatment should comply with
two of the cornerstones of
modern dentistry: minimally
invasive treatment and the
combination of function and
esthetics.6
The purpose of a
comprehensive treatment plan
should be not only to restore
the initial volume that was
lost as a result of wear but
also to determine whether the
stomatognathic system is in a
state of equilibrium, knowing
that any possible alteration
could damage one of its
components, such as the
temporomandibular joint
(TMJ), muscles, or teeth.5
Most of the time, TMJ
disorders, occlusal instability,
and tooth wear are due to
abnormal muscle activity.
Sometimes, however, in
the absence of parafunction,
an inadequate dental occlusal
relationship can cause
excessive wear, especially in
the anterior teeth.5,7 For
example, a restricted
envelope of function often
leads to localized wear only
on the anterior teeth, resulting
in a loss of anterior guidance,
which is a factor considered
to be very important for
maintaining equilibrium in
the stomatognathic system.
The loss of anterior
guidance will determine both
working and balancing
contacts in the posterior area
during excursive movements.
Balancing contacts are
considered responsible for
abnormal muscle activity.8
Whenever evaluating a
patient with a worn dentition
limited to the anterior, both
esthetic and functional
parameters should be
considered during the
treatment plan formulation.
The main goal is the
achievement of the correct
relationship between the
maxillary and mandibular
anterior teeth during function
so to minimize the possible
tooth wear over time. The
ratio between overbite and
overjet that determines the
anterior guidance can be used
as a predictor of attrition-type
tooth wear of the maxillary
and mandibular incisors.9
The reestablishment of
the equilibrium of the
stomatognathic system is the
key to slowing the rate of
wear by attrition and to
subsequently increasing the
longevity of the restoration.
To accomplish this,
functional parameters must be
evaluated, managed, and
corrected. The centric relation
(CR), the vertical dimension
of occlusion (VDO), and the
anterior teeth are to be
considered as the most
important factors. The proper
management of these three
parameters will allow the
clinician not only to restore
esthetics and function, but
also to respect the modern
concepts of minimal
invasiveness while achieving
maximum longevity of the
final restoration.10
FUNCTIONAL
PARAMETERS
Centric Relation
CR is the position usually
used in more extensive
prosthetic cases. When a
limited number of
restorations are required and
no specific occlusal scheme
has to be followed, a
confirmatory approach can be
adopted. In that case,
maximal intercuspation (MI),
or acquired occlusion, must
be used.
Centric relation is
considered the most
physiological position for
articulation and musculature,
as well as the most stable
position from an orthopedic
standpoint.5 It is the only one
considered repeatable during
occlusal recording
techniques, such as the
bilateral manipulation, Lucia
jig, leaf gauge, and anterior
deprogrammer techniques.11
It is advisable to put the
mandible in CR
(reorganization approach) in
the following situations:
• Prosthetic rehabilitation of
one or both arches
• Rehabilitation two or more
quadrants
• Rehabilitation of the
anterior area where dental
attrition is evident
In the presence of dental

attrition, the clinician can
often identify a forward slide
of the mandible from CR
position to MI position. In
this case it is mandatory to
follow the reorganization
approach so to guide the
mandible in CR, thus
sometimes resulting in the
creation of a space between
the maxillary and mandibular
anterior teeth. In these cases,
the lack of anterior guidance
will be compensated by the
design of the restoration,
which from the buccal side
will be extended to the palatal
surface (full veneers). This
new crown design does not
require any tooth preparation
on the palatal side, and at the
same time it allows the
creation of contact with the
mandibular incisors. In this
full-veneer restoration design,
the complete maintenance of
the enamel on all tooth
surfaces allows very
predictable bonding and
consequently ensures an
exceptional resistance to
fracture.12
Vertical Dimension of
Occlusion
If the prosthetic rehabilitation
involves at least one complete
arch, the possibility of
increasing the distance
between the two arches
should be carefully
considered to minimize the
invasiveness of the prosthetic
procedure. When new space
is created between the two
arches, the need for tooth
structure removal will be
tremendously reduced.6
Whenever indicated,
permanent increase of the
VDO up to 5 mm represents a
safe and predictable
procedure without
detrimental consequences.
The associated signs and
symptoms that sometimes can
occur are self-limiting, with a
tendency to resolve within 2
weeks.13 Therefore, even
when there has been no loss
of VDO, the strategy of
increasing the distance
between the two arches has to
be evaluated in order to
minimize or even eliminate
the need to remove dental
tissue in a traditional way.
Tooth preparation can be
minimized, especially on the
anterior teeth, where a
remarkable space between the
two arches can be achieved.
Although many clinicians,
not sufficiently trained,
persist in thinking that in
these extensive rehabilitation
cases it is sufficient to use the
acquired position (MI), it
must be emphasized, as
widely suggested by many
experts in the field, that
increasing the VDO
necessarily involves
positioning the mandible in
CR (reorganization
approach).14–16 This is
especially true considering
that once the dentist starts to
grind the teeth of an entire
arch, the MI position (which
is a dental-related position)
will be automatically lost.17
Reduced Ceramic
Thickness
Another important
consideration of the
minimally invasive prosthetic
procedure (MIPP)6 is the
possibility of reducing the
thickness of the ceramic
material. When supported by
enamel, minimally invasive
lithium disilicate occlusal
restorations have a high load-
bearing capacity with a very
high resistance to fracture.18
Adhesive bonding of the
restorations, mainly in
enamel and fabricated with an
etchable ceramic material, is
likely the key element for the
success of the restoration.
MIPP
CLASSIFICATIONS
Confirmatory
Approach—Maximal
Intercuspation
• MIPP 0: Additional
restorations (anterior,
posterior) with no
preparation, mainly on
enamel
• MIPP 1: Partial
restorations (anterior
veneers, posterior
restorations) with minimal
tooth preparation, mainly
on enamel
Reorganization
Approach—Centric
Relation and Modified
Vertical Dimension
• MIPP 2A: Partial
restorations (veneers,
posterior restorations) with
minimal tooth preparation,
mainly on enamel in CR
• MIPP 2B: Full-coverage
veneers (patient with open
bite in CR) with minimal
tooth preparation, mainly
on enamel
• MIPP 3A: One arch in CR
with VDO alteration and
tooth structure
preservation, mainly on
enamel
• MIPP 3B: Two arches in
CR with VDO alteration
and tooth structure
preservation, mainly on
enamel
The following two
clinical cases demonstrate the
advantages of the approach
described above.
CASE 1
MIPP 2B
A 30-year-old woman
presented to the second
author’s clinic expressing
esthetic concerns about her
teeth based on the shortening
of her anterior teeth over time
(Fig 1). Her request was to
restore the appearance of her
smile so as to find a new
harmony with her face;
however, she did not want to
be submitted to any invasive
treatment.
Fig 1 Initial presentation of the
patient, who was
uncomfortable with the
appearance of her smile.
This case shows that an

esthetic issue may also
include different functional
aspects to be evaluated and
corrected.
Esthetic analysis: Main issues
• Lack of proper tooth

exposure at rest (Fig 2)
• Flattened incisal edges
• Reduced length of the
maxillary incisors (Fig 3)
Fig 2 No display of teeth in the

resting position.
Fig 3 Frontal view of the
maxillary anterior teeth
affected by dental attrition.
Functional analysis: Main

issues
• Attrition of the anterior

teeth
• Reduced overjet and
minimal overbite (Fig 4a)
• Lack of anterior guidance
(Fig 4b)
• Posterior interferences
during excursive
movements
• Discrepancy between CR
and MI
Figs 4a and 4b Static and
dynamic evaluation of the
occlusion. Note the lack of
anterior guidance due to wear
of the anterior teeth.
Step 1
• Compilation of the esthetic
checklist.19 The purpose is
to analyze the esthetic and
functional needs of the
patient to highlight the
most important parameters
to be altered, so as to
obtain a complete
integration of the
restoration.
• Functional evaluation. The
aim is to reestablish an
ideal incisal length and to
recreate an adequate ratio
between overbite and
overjet with an appropriate
anterior guidance.
Step 2
• Alginate impressions of
both arches, facebow
record, and CR occlusal
registration were taken to
mount the study casts in a
semiadjustable articulator.
The purpose was to
previsualize the amount of
tooth structure to be
removed to place the
mandible in CR through a
selective grinding
procedure.
• A simulated selective
grinding on the stone casts
was performed. The
proposed clinical
procedure was considered
noninvasive. Therefore,
together with the patient, it
was decided to follow the
same procedure in the
mouth.
Step 3
• Selective grinding
procedure in the patient’s
mouth. An open space was
formed on the anterior area
of the mouth after the
completion of the
procedure, with the
mandible in CR position
(Fig 5).
Fig 5 After selective grinding

to position the mandible in CR,
an open bite remained between
the maxillary and mandibular
anterior teeth.
Step 4
• New alginate impressions
and a new facebow
registration were taken.
The laboratory chart20 was
transmitted to the dental
technician for fabrication
of the wax-up.
Step 5
• A diagnostic wax-up of the
anterior maxillary and
mandibular teeth was
completed, and a silicone
index was fabricated. An
intraoral mock-up of the
proposed anterior
restorations was made
with a transparent matrix
and flowable composite
resin (Fig 6), and
modifications were made
to improve the esthetics of
the teeth.
Fig 6 Direct mock-up

performed with a transparent
matrix and flowable composite
resin.
• An impression of the
mock-up was taken to
guide the technician in
fabricating the definitive
restorations.
Step 6
• Tooth preparation, final
impressions, and
provisional restorations. A
calibrated tooth
preparation was performed
through the composite
resin mock-up (Figs 7 and
8). Because of the planned
volume increase in the
labial and incisal areas
(Fig 9), a sufficient
amount of space was
gained for the restorative
material. On the palatal
tooth surfaces, because of
the amount of space
gained by placing the
mandible in CR, no
grinding procedure was
necessary to create full-
coverage restorations (full
veneers). With this
minimally invasive
technique, the surfaces of
the final preparations were
completely covered by
enamel, except for a small
portion of dentin already
present in the incisal area
due to the original wear.
To obtain a better
integration with the
surrounding tissue, a very
light chamfer was chosen
for the finish line
configuration (Fig 10).
• A final impression was
taken with polyvinyl
siloxane material using a
one-step double-mix
technique. The shell of the
provisional restorations
was fabricated at the new
VDO with the modified
indirect technique
(MIT),20 then relined and
cemented temporarily with
dual-curing resin-based
cement (Telio CS Link,
Ivoclar Vivadent).
Fig 7 The mock-up represents
the preview of the final volume
of the restorations. Tooth
preparation was performed
through the mock-up to
precisely calibrate the tooth
reduction.
Fig 8 After removing the

mock-up, it is possible to
notice that the calibrated
reduction performed to create
enough space for the
restorative material is only
slightly visible on the teeth.
Fig 9 A silicone index made
from the wax-up was used to
check the amount of space
available for the full-veneer
restorations.
Figs 10a and 10b Definitive

tooth preparations of the four
maxillary anterior teeth. Note
the amount of enamel still
present on the entire surface.
Dentin was present only on the
incisal margins due to tooth
wear. The palatal surface
remained completely
untouched.
Step 7
• Try-in and cementation.
Four maxillary bilayered
lithium disilicate full
veneers were fabricated in
the laboratory with a
reduced thickness (0.2 to
0.8 mm) (Fig 11).
• Cementation followed a
precise protocol.
Retraction cords were
placed in the sulcus of
every prepared tooth to
minimize the humidity
from the crevicular fluid
and to act as a barrier for
the penetration of the resin
cement to the base of the
sulcus. In addition, rubber
dam was used to isolate
the anterior area from
saliva and humidity. The
inner surfaces of the
restorations were etched
with 4.5% hydrofluoric
acid (Ivoclar Vivadent) for
20 seconds, thoroughly
rinsed with water, and
placed in an ultrasonic
bath with distilled water
for 3 minutes. After
thorough air drying, the
intaglio surface was
silanized (Monobond-S,
Ivoclar Vivadent) and
dried for 60 seconds.
• Tooth preparations were
cleaned with pumice and
rubber burs (Opticlean,
Kerr), etched for 30
seconds on enamel and 15
seconds on dentin with
37.5% phosphoric acid
(Ultra-Etch, Ultradent
Products), rinsed, and
dried (Fig 12). Both fitting
surfaces, restorations and
teeth, were coated with the
adhesive system
(OptiBond FL, Kerr), and
because of the reduced
thickness of the ceramic
restorations, a light-curing
composite resin cement
(Variolink Veneer, Ivoclar
Vivadent) was selected to
lute the restorations.
Figs 11a and 11b Full veneers
ready for cementation.
Figs 12a and 12b After the

etching procedure, it is possible
to better appreciate the amount
of enamel present.
Step 8
• Fine-tuning of the occlusal
adjustment and final
polishing were completed.
Posttreatment photographs
were taken immediately
(Figs 13 to 19) and after 6
years (Figs 20 and 21).
Fig 13 Definitive maxillary
anterior restorations after
cementation.
Figs 14a to 14c Static and
dynamic final evaluation of the
treatment. Note the new
anterior guidance (b and c).
Fig 15 Occlusal view of the
full veneers, where it is
possible to appreciate the
occlusal contacts obtained with
full veneers.
Fig 16 Lateral view of the
rehabilitation.
Fig 17 Lateral view of the

change in the dentolabial
relationship: (left) before and
(right) after.
Fig 18 The new smile of the

patient.
Fig 19 Final appearance of the
patient with her new smile in
harmony with the face.
restorations after 6 years in
service. No signs of wear
present.
Fig 21 Frontal view after 6

years.
CASE 2
MIPP 3B
A 38-year-old woman
presented to the first author’s
clinic, stating that she was
unhappy with the appearance
of her teeth (Fig 22). She
requested a prosthetic
treatment to improve her
smile, and she emphasized
her desire to have highly
esthetic restorations without
any invasive treatment.
Particularly, she was
complaining about the
diastemata between her
maxillary anterior teeth, and
she had noticed a progressive
wear of some of the incisors
over time.
Fig 22 Initial presentation:
Patient is uncomfortable with
the appearance of her teeth.
Esthetic analysis: Main issues
• Presence of diastemata
between some maxillary
anterior teeth
• Imperfect dental
arrangement with rotation
of some teeth
• Unsatisfactory tooth shape
in the maxillary anterior
area Functional analysis:
Main issues
Functional analysis: Main
issues
• Attrition of the anterior

teeth
• Nonphysiologic wear for
the patient’s young age
• Reduced overjet and
minimal overbite
(restricted envelope of
function)
• Lack of anterior guidance
• Posterior interferences
during excursive
movements
• Discrepancy between CR
and MI
• Muscle tenderness
Step 1
• Compilation of the esthetic
checklist.19 The purpose is
to analyze the esthetic and
functional parameters of
the patient to highlight the
most important ones to be
altered, so as to obtain a
complete integration of the
restoration (Figs 23 to 28).
• Functional evaluation. The
aim is to reestablish an
ideal incisal length and to
recreate an adequate ratio
between overbite and
overjet with an appropriate
anterior guidance (Figs 29
to 32).
Fig 23 Photographic
progression of the smile for the
facial analysis.
Fig 24 Photographic
progression of the smile is
useful for completing the
dentolabial analysis.
Figs 25a and 25b Details of

the dentolabial analysis.
Figs 26a to 26c View of the
maxillary anterior teeth, where
it is possible to appreciate an
unpleasant tooth arrangement
with some diastemata and
wear.
Figs 27a and 27b Lateral

views of the occlusion.
Figs 28a to 28c Occlusal view
of maxillary and mandibular
arches. Note the wear of the
incisal margin considered
nonphysiologic for the age of
the patient.
Fig 29 Complete dental

analysis with the proposed new
ideal dental composition.
Fig 30 Analysis of wear facets

was important to analyze the
type of wear and to formulate a
proper treatment plan. Note the
large amount of working and
balancing contacts.
Figs 31a and 31b Functional
analysis demonstrates the
absence of canine guidance
with many posterior contacts
during excursive movement.
Fig 32 Relationship between

anterior teeth. Note the reduced
amount of overbite and overjet.
Step 2
• Alginate impression,
facebow record, and CR
record (Fig 33). The aim
of this step, as in Case 1,
was to evaluate if, with a
selective grinding
procedure, it would be
possible to reestablish a
new anterior relationship
and consequently to
perform a restorative
treatment that respected
the esthetic and functional
parameters.
• The specific aim was to
achieve an adequate
anterior dental
composition, an ideal
overbite-overjet
relationship, and a
shallower anterior
guidance.
Fig 33 Initial facebow and CR
registration were taken to make
the wax-up of the maxillary
anterior teeth. After a complete
analysis, all data were sent to
the lab to fabricate the
diagnostic wax-up.
Step 3
• Selective grinding on the
stone casts. As this
procedure was considered
very invasive and not
useful in reestablishing a
proper anterior
relationship, it was
decided, in accordance
with the patient, not to
replicate it in the mouth.
Step 4
• Formulation of an
Primero artículo
en Roy después
alternative treatment plan.
en el articulador
ncrementó la dvo
Orthodontic treatment was
lo hizo mock up y
ese en boca
proposed but not accepted
ajustó la Oclusion
manteniendo la d
by the patient.
o incrementada y
luego reto,o el
• After placing the stone
registro en r.
casts in the articulator, it

was decided to increase
the VDO in CR position in
order to reestablish more
adequate functional and
esthetic parameters with a
minimally invasive
procedure (Figs 34 and
35).
Fig 34 A new relationship is

created between the anterior
teeth after increasing the VDO
in CR.
Fig 35 The space between the

two arches available for the
restorative material is shown.
The new relationship between
the anterior teeth will allow the
development of a new anterior
guidance.
• The diagnostic wax-up

clearly confirmed the
possibility of recreating a
new anterior relationship
with an ideal overbite-
overjet ratio, a pleasant
dental composition, and a
shallow anterior guidance
(Fig 36).
Fig 36 Wax-up of the
maxillary anterior teeth to
optimize both esthetic and
functional parameters.
Step 5
• Mock-up of the anterior
teeth (Figs 37 and 38). The
aim of this step was to
determine—and to adjust
directly in the patient’s
mouth—the anterior
component of the
occlusion (anterior
guidance). Moreover, an
esthetic evaluation of the
new anterior dental
composition was done,
checking the relationship
between anterior teeth,
face, and lips (Fig 39).
With the mock-up in situ
to serve as a jig, a new
facebow record and CR
registration were taken,
thus maintaining the
proposed VDO.
Figs 37a and 37b Indirect

mock-up fabricated with a
transparent matrix and
flowable composite resin.
Figs 38a and 38b The mock-

up is adjusted in the patient’s
mouth to allow the clinician to
precisely define the new VDO
and the new relationship
between the two arches.
Figs 39a to 39c A new
dentolabial relationship with
the mock-up on the maxillary
anterior teeth was tested.
Step 6
• With the anterior mock-up
in situ, a minimal
preparation of the
posterior mandibular teeth
was performed (Fig 40).
As the VDO increase
provided 0.5 mm of
additional space at the
level of the second molar,
tooth preparation on the
mandibular posterior teeth
was performed just to
round some line angles
and to facilitate the
esthetic integration of the
definitive restorations. A
very light chamfer finish
line was chosen for the
buccal areas for esthetic
optimization. The
interdental contact points
were maintained, as the
interdental area of every
tooth was found to be free
of caries.
Figs 40a and 40b Preparation

design in the occlusal surfaces
of the mandibular posterior
teeth was performed, avoiding
interproximal area involvement
with the aim of maintaining as
much enamel as possible.
Step 7
• A final impression of the
mandibular arch with
polyvinyl siloxane
material was taken with
the one-step double-mix
technique.
Step 8
• Posterior provisional
restorations were not
necessary. As the VDO
increase provided
sufficient space for the
restorative material, the
centric cusps of the
prepared teeth in the
mandibular posterior areas
were not reduced.
• After removing the mock-
up on the anterior area, the
mandible went back to its
original position thanks to
the maintenance of the
untouched cusps. As a
result of this procedure, it
was not necessary to
fabricate and position a
provisional restoration in
the posterior area.
Step 9
• Definitive posterior
restorations (Fig 41) and
maxillary anterior
provisionals. The
mandibular posterior
monolithic partial-
coverage ceramic
restorations were
fabricated together with a
shell for the provisional
restorations for the
maxillary anterior teeth.
Figs 41a to 41c Definitive
mandibular posterior
restorations fabricated using
monolithic lithium disilicate.
Note the minimal thickness of
the partial-coverage
restorations, which were luted
with a three-step adhesive
bonding protocol.
Step 10
• Bonding of the mandibular
posterior partial-coverage
restorations followed a
precise protocol (Fig 42).
The inner surfaces of the
restorations were etched
with 4.5% hydrofluoric
acid for 20 seconds,
thoroughly rinsed with
water, and placed in an
ultrasonic bath with
distilled water for 3
minutes. After thorough
air drying, the intaglio
surfaces were silanized
with Monobond-S and
dried for 60 seconds.
Tooth preparations were
cleaned with pumice and
rubber burs (Opticlean),
etched for 30 seconds on
enamel and 15 seconds on
dentin with 37.5%
phosphoric acid (Ultra-
Etch), rinsed, and dried.
Both fitting surfaces,
restorations and teeth,
were coated with the
adhesive system
(OptiBond FL); because of
the reduced thickness of
the ceramic restorations, a
light-curing composite
resin cement (Variolink
Veneer) was selected to
lute the restorations.
mandibular arch with partial-
coverage restorations in place.
Step 11
• Tooth preparation of the
(Figs 43 and 44). Once the
posterior mandibular
partial restorations were
cemented, a new mock-up
of the maxillary anterior
teeth was made with the
aim of guiding the
preparations using a
minimally invasive
procedure.
• Moreover, because of the
space gained in the palatal
area by the increase of the
VDO (already achieved
after having positioned the
eight posterior
restorations), a full-veneer
design was chosen for the
final preparations. The
prepared teeth were
covered completely by
enamel, even though a
delicate chamfer finish
line configuration was
performed on the margins
to obtain a better esthetic
integration of the
restoration (Figs 45 and
46).
Figs 43a to 43c Definitive

preparation of the anterior teeth
using a minimally invasive
procedure. Note that a very
light tooth preparation was
completed on the enamel.
Figs 44a to 44c On the stone

casts, it is possible to see the
design of the preparations, with
a delicate chamfer finish line
that extends to the palatal area
to better define the limit of the
preparation and to obtain a
more natural integration of the
restoration with the
surrounding tissue.
Figs 45a and 45b After the

VDO increase and
establishment of the CR
position, a large amount of
space was present between the
anterior teeth. The full-veneer
design of the restorations
allowed recreation of contact
with the mandibular teeth and a
new and more physiologic
function.
Figs 46a and 46b Using the

modified indirect technique
(MIT20) and a very minimal
tooth preparation, it is possible
to reline and refine the shell of
the provisional restoration.
Step 12
• Bilayered lithium disilicate
maxillary anterior
restorations were
fabricated. The final
impression of the anterior
tooth preparations was
taken with the definitive
posterior partial
restorations in situ.
Maxillary bilayered full
veneers were fabricated
and cemented following a
three-step adhesive
bonding protocol (Figs 47
and 48).
Figs 47a to 47c Maxillary

bilayered full veneers
fabricated with lithium
disilicate. Note the thickness of
the restoration and the new
relationship between maxillary
and mandibular teeth.
Fig 48 Maxillary central

incisors ready for the bonding
procedure after etching with
phosphoric acid. Note the
amount of enamel remaining
on the palatal surfaces because
of the space gained by
increasing the VDO.
Step 13
• Occlusal adjustment and
final polishing. By guiding
the mandible in CR with
the bimanual manipulation
(Dawson maneuver), a
precise final occlusal
adjustment was performed.
The goal was to obtain
well-distributed and
synchronized posterior
contacts, delicate contacts
on the anterior teeth, and
no posterior contacts
during excursive
movements (Figs 49 to
56).
definitive maxillary anterior
full veneers after cementation.
Fig 50 New occlusion of the
patient with well-distributed
and synchronized posterior
contacts, delicate contacts on
the anterior teeth, and no
posterior contacts during
excursive movements.
Figs 51a to 51d Final dynamic
evaluation of the new
occlusion. Note the
disocclusion of posterior teeth
during excursive movements.
Figs 52a to 52c Diagram of the
evolution of the treatment from
the initial presentation to the
definitive restorations. Note the
new overjet and overbite and
the new anterior guidance with
a flatter angle. Reducing the
angle of guidance may reduce
the muscle activity. An initial
restricted envelope of function
was reduced with the
treatment.
Fig 53 Final radiographs of the

maxillary anterior teeth show
the minimal invasiveness of the
treatment.
Fig 54 New anterior dental
composition.
Figs 55a and 55b Final

integration of the treatment
with the lips of the patient.
Fig 56 Satisfactory integration
of the rehabilitation in relation
to the lips and the face of the
patient.
CONCLUSIONS
Because of the proper
management of CR, with or
without a VDO increase, a
new relationship between the
two arches was obtained, and
all the functional and esthetic
parameters were optimized.
When facing these types
of clinical cases, the
prosthodontist needs to
consider that by limiting his
or her intervention to a
cosmetic treatment, there may
be a risk of failure of the
restorations due to an
improper relationship
between the maxillary and
mandibular anterior teeth
during function.
From an esthetic point of
view, a good integration of
the restoration with the face,
the lips, and the surrounding
tissue was obtained, and the
patients were truly happy
with their new smiles. From a
functional point of view, a
new relationship between the
anterior teeth was obtained
with an improved overbite-
overjet relationship and a new
flatter anterior guidance, thus
improving the envelope of
function. This ensures a better
distribution of load and a
more physiologic occlusion.
Once again, the goal of the
prosthetic treatment in these
patients is to reestablish a
new equilibrium in the
stomatognathic system and to
guarantee the longevity of the
restorations.
ACKNOWLEDGMENT
The authors would like to
thank Mr Giancarlo Barducci,
CDT, for his precious work in
fabricating all the restorations
in this article.
REFERENCES
1. Bardsley PF. The evolution of
tooth wear indices. Clin Oral
Investig 2008;12(suppl
1):S15–S19.
2. Paesani DA (ed). Bruxism:
Theory and Practice. Chicago:
Quintessence, 2010.
3. Grippo JO, Simring M,
Schreinder S. Attrition,
abrasion, corrosion and
abfraction revisited: A new
perspective on tooth surface
lesions. J Am Dent Assoc
2004;135:1109–1118.
4. Lee A, He LH, Lyons K,
Swain MV. Tooth wear and
wear investigations in
dentistry. J Oral Rehabil
2012;39:217–225.
5. Dawson PE. Functional
Occlusion: From TMJ to
Smile Design. St Louis:
Mosby Elsevier, 2006.
6. Fradeani M, Barducci G,
Bacherini L, Brennan M.
Esthetic rehabilitation of a
severely worn dentition with
procedures (MIPP). Int J
2012;32:135–147.
7. Silness J, Johnannessen G,
Røynstrand T. Longitudinal
relationship between incisal
occlusion and incisal tooth
wear. Acta Odontol Scand
1993;51:15–21.
8. Spear F. Fundamental
occlusal therapy
considerations. In: Mc-Neill C
(ed). Science and Practice of
Occlusion. Chicago:
Quintessence, 1997:421–436.
9. Yaffe A, Hochman N, Ehrlich
J. A functional aspect of
anterior attrition or flaring and
mode of treatment. Int J
Prosthodont 1992;5:284–289.
10. Bacherini L, Brennan M,
Bocabella L, Vigiani P.
severely discolored dentition
with a minimally invasive
prosthetic procedure (MIPP).
Quintessence Dent Technol
2013;36:59–76.
11. McKee JR. Comparing
condylar position repeatability
for standardized versus
nonstandardized methods of
achieving centric relation. J
Prosthet Dent 1997;77:280–
284.
12. Silva NR, Bonfante EA,
Martins LM, et al. Reliability
of reduced-thickness and
thinly veneered lithium
disilicate crowns. J Dent Res
2012;91:305–310.
13. Abduo J. Safety of increasing
vertical dimension of
occlusion: A systematic
review. Quintessence Int
2012;43:369–380.
14. Spear F, Kinzer F.
Approaches to vertical
dimension. In: Cohen M (ed).
Interdisciplinary Treatment
Planning: Principles, Design,
Implementation. Chicago:
Quintessence, 2008:249–281.
15. Becker CM, Kaiser DA.
Evolution of occlusion and
occlusal instruments. J
16. Keshvad A, Winstanley RB.
An appraisal of the literature
on centric relation. Part III. J
Oral Rehabil 2001;28:55–63.
17. Okeson JP. Management of
Temporomandibular Disorders
and Occlusion. St Louis:
Mosby Elsevier, 2012.
18. Ma L, Guess PC, Zhang Y.
Load-bearing properties of
minimal-invasive monolithic
lithium disilicate and zirconia
occlusal onlays: Finite
element and theoretical
analyses. Dent Mater
2013;29:742–751.
19. Fradeani M. Esthetic
Rehabilitation in Fixed
Prosthodontics, Vol Esthetic
Analysis: A Systematic
Approach to Prosthetic
Treatment. Chicago:
Quintessence, 2004.
20. Fradeani M, Barducci G (eds).
Esthetic Rehabilitation in
Fixed Prosthodontics. Vol 2:
Prosthetic Treatment: A
Systematic Approach to
Esthetic, Biologic, and
Functional Integration.
Chicago: Quintessence, 2004.
_________________________
1 Private Practice, Sieci-
Pontassieve-Firenze, Italy.
2 Private Practice, Pesaro, Italy.
Correspondence to: Dr
Leonardo Bacherini, Studio
Odontoiatrico, Piazza Aldo
Moro, 7, Sieci-Pontassieve (FI),
50065, Italy.
Email: [email protected]
BIOMATERIA
UPDATE
CAD/CAM
High-Strength
Glass-Ceramics
Neimar Sartori, DDS,
MS, PhD1
Gilberto Tostado,
DDS2
Jin-Ho Phark, DMD,
Dr Med Dent3
Kazunari Takanashi,
RDT4
Richard Lin, DDS5
Sillas Duarte, Jr, DDS,
MS, PhD6
T
he increased demand
for high-quality,
natural-looking
restorations fabricated in a
single appointment has fueled
the development of newer
restorative materials and
technologies.1 Highly esthetic
ceramic restorations can be
fabricated in less than an hour
using computer-aided
design/computer-assisted
manufacture (CAD/CAM)
technology.2,3
The main disadvantage of
esthetic all-ceramic
restorations made of
feldspathic porcelain or
leucite-reinforced glass-
ceramic has been related to
their relatively low flexural
strength (130 to 160 MPa).
However, the development of
high-strength glass-ceramic
with higher flexural strength
(210 to 540 MPa) offers an
alternative to conventional
feldspathic or leucite-
reinforced ceramics.4 Lithium
disilicate and zirconia-
reinforced lithium silicate
high-strength glass-ceramics
provide an adequately
esthetic appearance without
requiring the addition of
veneering ceramic, resulting
in superior structural
integrity.5 Furthermore, high-
strength glass-ceramics can
be used to fabricate ultrathin
restorations (less than 0.5 mm
thickness) with adequate
optical and mechanical
properties, as well as
improved marginal integrity.
In 1998, lithium disilicate
glass-ceramic (IPS Empress
II, Ivoclar Vivadent) using
the lost-wax press technique
was introduced. Lithium
disilicate glass-ceramic was
designed for single-tooth and
anterior three-unit fixed
partial denture (FPD)
restorations.6,7 The survival
rate of a lithium disilicate all-
ceramic system (IPS Empress
II) has been shown to be
within acceptable limits for
anterior (97.5%) and
posterior (98%) full-coverage
crowns after 10 years.8
However, the survival rates
reported for FPD restorations
made of the same material
ranged from 50% after 2
years9 to 70% after 5 years.10
A second generation of
lithium disilicate glass-
ceramic (IPS e.max Press,
Ivoclar Vivadent) was
released to the market in
2001.7 This newer
formulation includes a
microstructure with a higher
amount of smaller lithium
disilicate crystals
(approximately 70%). By
increasing the percentage of
lithium disilicate crystals on
the glass-ceramic material,
the optical and mechanical
properties are improved.11 A
long-term prospective study
of monolithic posterior three-
unit FPD restorations
fabricated of IPS e.max Press
revealed a survival rate of
87.9 % after 10 years.12
With the popularization of
CAD/CAM technologies,
ceramic (IPS e.max CAD,
Ivoclar Vivadent) for
CAD/CAM milling was
introduced in 2005.13
Recently, two zirconia-
glass-ceramics for fabrication
of monolithic restorations
using CAD/CAM technology
also became available
(Suprinity, VITA; Celtra
Duo, Dentsply).3 Due to
strength and versatility,
CAD/CAM lithium disilicate
and zirconia-reinforced
lithium silicate glass-ceramic
blocks can be used for
fabrication of numerous types
of restorations (partial-
coverage and full-coverage
crowns, implant abutments,
and three-unit FPDs). The
aim of this article is to review
the biomaterial properties of
CAD/CAM high-strength
glass-ceramics.
HIGH-STRENGTH
GLASS-CERAMICS
Glass-ceramics are
polycrystalline materials
produced through controlled
crystallization of base glass.
The process of controlled
crystallization of glasses is
essential to produce a ceramic
with acceptable optical and
mechanical properties.14
Controlled nucleation and
crystallization of glasses can
be obtained by employing
catalysts or nucleation
agents.15 The crystallization
process occurs in two
different stages: (1)
nucleation (formation of the
crystals) followed by (2)
crystal growth.
Controlling nucleation is
of paramount importance to
produce a suitable glass-
ceramic material. Nucleation
is the beginning of chemical
or physical transformation in
glass composition (phase
separation), in which a small
number of ions become
arranged in a pattern
characteristic of a solid
crystal.16 The addition of
nucleating agents, ie,
phosphorus pentoxide (P2O5),
to lithium disilicate
compounds provides
controlled nucleation and
crystal growth.14,17–19 The
microstructure of a given
glass-ceramic material can be
adjusted depending on the
type and amount of
nucleation agent incorporated
into the compound.
In addition to the
nucleation agents, raw
powders should be
incorporated into a binary
quartz and lithium dioxide
(Li2O–SiO2) system
composition to enhance the
chemical durability20 and
mechanical properties of
glass-ceramics.3,11,21,22
Examples of raw powders are
aluminum oxide (Al2O3),
potassium oxide (K2O),
aluminum metaphosphate
(Al[PO3]3), zirconium oxide
(ZrO2), zinc oxide (ZnO), and
calcium oxide (CaO). These
raw powders are mixed and
heated to form a new glass.23
After cooling down, this new
glass is then thermically
treated to allow the
crystallization of the glass-
ceramic components.11
The process of
crystallization of a lithium
disilicate glass-ceramic,
nucleation, and crystal
growth is complex,
intriguing, and temperature
dependent.14 The rise of the
temperature between 500°C
and 560°C forms nanophases
of lithium phosphate
(Li3PO4) and nucleation of
lithium metasilicate
(Li2SiO3) and lithium
disilicate (Li2Si2O5).14 From
560°C to 750°C, growth of
lithium metasilicate crystals
and agglomeration of lithium
disilicate nanophases (crystal
size smaller than 100 nm)
occur.24 When the
temperature reaches 820°C,
lithium metasilicate is
completely decomposed and
lithium disilicate crystals
grow quickly, reaching
maximum growth rate at a
temperature of 850°C.14,17,24
As a result of this
crystallization process,
lithium disilicate represents
the main crystal phase
(approximately 70%) of the
glass-ceramic microstructure
(Fig 1).6 The needlelike
lithium disilicate crystals (3
to 6 µm in length)11 are
embedded in a glassy matrix
of lithium orthophosphate
(Li3PO4).6 The surface on the
presents multiple holes (0.1 to
0.3 µm in length), indicating
the location of the previous
crystal precipitation (small
holes on the surface of the
crystals; see Fig 1).6
Fig 1 Microstructure of pressed

lithium disilicate glass-ceramic
(IPS e.max Press) after
crystallization followed by etching
with 5% hydrofluoric acid for 20
seconds (magnification × 10,000).
CLASSIFICATION
OF CAD/CAM
HIGH-STRENGTH
GLASS-CERAMICS
glass-ceramics can be
classified as lithium
disilicate–reinforced or
zirconia-reinforced lithium
silicate glass-ceramics.
CAD/CAM Lithium
Disilicate–Reinforced
Glass-Ceramic
IPS e.max CAD is an
example of a CAD/CAM
lithium disilicate–reinforced
glass-ceramic. Because
crystallized lithium disilicate
CAD blocks would be
difficult to mill using
chairside milling units, an
intermediate product, lithium
metasilicate glass-ceramic,
was developed using the two-
stage crystallization
process.25,26 In the first stage
of crystallization, lithium
metasilicate is precipitated by
controlled double nucleation
and then pressure-casted in
the block shape. These
partially crystallized IPS
e.max CAD blocks have a
blish appearance with
approximately 40% by
volume of lithium
metasilicate platelet-shaped
crystals embedded in a glassy
phase, with crystal size
ranging from 0.2 to 1.0 µm
and a nanocrystalline
disilicate matrix11 (Fig 2).
This partially crystallized
CAD/CAM block exhibits a
flexural strength of 130 to
150 MPa, which can
withstand the stresses during
the milling process without
chipping of margins while
allowing intraoral occlusal
adjustment.11,26
Fig 2 Microstructure of
CAD/CAM lithium disilicate–
reinforced glass-ceramic (IPS
e.max CAD) before crystallization
(blue stage), showing the glassy
matrix impregnated with
metasilicate crystals (magnification
× 10,000).
After milling and try-in of

the restoration in its blue
stage, it is then heat treated at
850°C.13 During this process,
lithium metasilicate glass-
ceramic is transformed into
ceramic. After crystallization,
the restoration presents a
toothlike color, with excellent
chemical durability of less
than 100 µg/ cm2, strength of
360 ± 60 MPa, and toughness
of 2 MPa·m1/2.25
The chemical
composition of crystalized
IPS e.max CAD is identical
to that of IPS e.max Press.
However, due to the
difference in size of the
lithium disilicate crystals, the
microstructure of IPS e.max
CAD is slightly different.
CAD/CAM lithium disilicate
glass-ceramic consists of 70%
by volume fine-grain
needlelike lithium disilicate
crystals with length of
approximately 1.5 μm
embedded into a glassy
matrix (Fig 3), whereas for
the pressed version (IPS
e.max Press) the lithium
disilicate crystals can grow
up to 7 μm.25 CAD/CAM
ceramic appears to have a
more homogenous
microstructure, in which the
lithium disilicate crystals are
more densely adhered to the
glass-ceramic matrix (Fig 4).
e.max CAD) after crystallization
followed by etching with 5%
hydrofluoric acid for 20 seconds
(magnification × 10,000).
Fig 4 Higher magnification of
e.max CAD) after crystallization
followed by etching with 5%
Because of its favorable

translucency and shade
assortment, CAD/CAM
ceramic can be used as
monolithic restorations or as
a core material for subsequent
layering with veneering
ceramics. Clinical results
revealed a 97% survival rate
after 7 years for partial-
coverage restorations
fabricated using CAD/CAM
technology.5
CAD/CAM Zirconia-
Reinforced Lithium
Silicate Glass-Ceramic
Two zirconia-reinforced
lithium silicate ceramics are
available for CAD/CAM
restorations: VITA Suprinity
(VITA Zahnfabrik) and
Celtra Duo (Dentsply). Both
materials rely on the addition
of 10% by weight zirconium
oxide to lithium silicate glass
compositions to improve their
mechanical and optical
properties. Zirconia-
glass-ceramics have
mechanical properties
comparable with those of
ceramics.27 After
crystallization, a dual
microstructure is obtained of
lithium metasilicate and
embedded in glassy matrix
containing zirconium oxide.28
VITA Suprinity
VITA Suprinity CAD/CAM
blocks are composed of
silicon dioxide (SiO2),
lithium oxide (Li2O),
potassium oxide (K2O),
phosphorus pentoxide (P2O5),
aluminium oxide (Al2O3),
zirconium dioxide (ZnO2),
cerium (IV) oxide (CeO2),
and pigments. These
CAD/CAM blocks are
produced in three distinct
stages.29,30 Initially,
zirconium dioxide, silicon
dioxide, lithium oxide, and
other ceramic components are
heated at a temperature of
1,500°C to melt all
components. After creating a
ho-mogenous solution, the
melted glass is poured into
molds to form blocks.30 The
resulting glass block is brittle
and not suited for the
CAD/CAM milling process;
thus, a second heating
treatment is necessary. In the
second heating stage (from
500°C to 600°C), the crystals
within the glass matrix form
lithium metasilicate30 and the
glass block achieves adequate
mechanical properties to
withstand the stresses of the
milling process. The resulting
translucent glass-ceramic
block is then made
commercially available (Fig
5).
CAD/CAM zirconia-reinforced
(VITA Suprinity) before
crystallization (magnification ×
10,000).
After milling, the

translucent glass-ceramic
restoration must be
recrystallized at a temperature
of 840°C for 8 minutes. The
crystallization forms a
homogeneous structure of
lithium disilicate with a
subsidiary crystal phase
containing zirconium oxide30
(Fig 6).
(VITA Suprinity) after
crystallization followed by etching
with 5% hydrofluoric acid for 20
seconds (magnification × 10,000).
Celtra Duo
Celtra Duo can be classified
as zirconia-reinforced lithium
silicate CAD/CAM blocks
containing 10% zirconia.31
The microstructure consists
of a large amount of ultrafine
lithium silicate crystals with
an approximate size of 0.5 to
0.7 μm embedded in the glass
matrix31 (Fig 7). According
to the manufacturer, zirconia
is completely dissolved into
the glass matrix.
(Celtra Duo) after etching with 5%
Celtra Duo blocks as

supplied are already sintered,
and, theoretically, no
additional sintering steps are
needed. However, if
additional heat treatment is
performed (ie, for external
staining and glazing), the
flexural strength is increased
by 76%.31
MATERIAL
PROPERTIES
Mechanical Properties
Although most clinical
situations involve complex
three-dimensional loading,
three of the most important
mechanical properties of a
material are modulus of
elasticity, fracture toughness,
and flexural strength. The
basic mechanical properties
for the high-strength glass-
ceramics are displayed in
Table 1.
Table 1 Mechanical
Properties of
CAD/CAM Glass-
Ceramics
Elastic Fracture
Material modulus toughness
(GPa) (MPa√m)
87–
Enamel 0.6–1.533
10032
Dentin 17–4035 2.336
IPS e.max
Press (Ivoclar 9526 2.7526
Vivadent)
IPS e.max 9526 2.2526
CAD (Ivoclar
Vivadent)
VITA
Suprinity
(VITA 7029 2.029
Zahnfabrik)
Celtra Duo
(Dentsply) 7031 2.031
after milling
Celtra Duo
(Dentsply)
— —
after
crystallization
The interlocking
arrangement of the lithium
disilicate crystal
microstructure increases the
flexural strength and
toughness of the glass-
ceramic, reducing crack
propagation within the glass
matrix.13 The improved
homogeneity of CAD/CAM
high-strength glass-ceramics
allows fabrication of ultrathin
monolithic restorations.5
Optical Properties
High-strength glass-ceramics
are available in different
shades and translucencies.
The shade of high-strength
glass-ceramics is controlled
by pigments (usually metal
oxides) dissolved into the
glass matrix.
IPS e.max CAD blocks
are available in 16 different
Vita shades and 4 bleach
(BL) shades. Different
translucencies, such as low
translucency (LT), high
translucency (HT), and
medium opacity (MO), are
available for different types
of processing techniques.
VITA Suprinity blocks are
available in 8 different Vita
shades (0M1, A1, A2, A3,
A3.5, B2, C2, and D2) and 2
different translucencies
(translucent: T, and high
translucent: HT). Celtra Duo
blocks are available in low
translucency (LT) and high
translucency (HT). LT blocks
are available in 5 shades (A1,
A2, A3, A3.5, and B2), while
HT blocks are limited to 3
shades (A1, A2, A3).
There is a significant
change in the translucency
and opacity of milled
CAD/CAM glass-ceramic
restorations after the
crystallization process (Fig
8). None of the tested highly
translucent CAD/CAM glass-
ceramics exhibited
opalescence when used with
the thickness recommended
by the manufacturer (after
crystallization) (Fig 9). When
highly translucent
CAD/CAM glass-ceramics
were compared, zirconia-
glass-ceramics presented as
more opaque than lithium
disilicate–reinforced glass-
ceramics.
Figs 8a and 8b Milled CAD/CAM

restorations (a) before and (b) after
crystallization: (left to right)
natural tooth, IPS e.max CAD,
VITA Suprinity, and Celtra Duo.
Fig 9 Translucency of different

CAD/CAM high-strength glass-
ceramics compared to natural
tooth: (left to right) natural tooth,
IPS e.max CAD, VITA Suprinity,
and Celtra Duo.
The fluorescence of
CAD/CAM reinforced glass-
ceramics was also evaluated
in our laboratories (Fig 10).
All of the tested restorative
ceramics displayed
significantly lower
fluorescence than that of the
natural tooth. Lithium
disilicate glass-ceramic (IPS
e.max CAD) exhibited low
fluorescence, within the
bluish wavelength range.
Zirconia-reinforced lithium
silicate glass-ceramics
emitted low and incorrect
fluorescence, with a greenish
fluorescent hue discrepant
from that of the natural
tooth.38
Fig 10 Fluorescence of different
CAD/CAM high-strength glass-
ceramics compared to natural
tooth: (left to right) natural tooth,
IPS e.max CAD, VITA Suprinity,
and Celtra Duo.
ADHESIVE
LUTING
An important advantage of
glass-ceramics is their ability
to be adhesively luted. Acidic
treatment of the restoration
modifies the surface by
creating microporosites that
allow micromechanical
interlocking of resin cements
to the restorative material.
Adhesive luting is
fundamental for minimally
invasive and conservative
restorations.
To develop a
microretentive surface, the
intaglio surface must be
etched using 5% hydrofluoric
acid for different times for
different materials according
to manufacturers’
recommendations (20
seconds for e.max CAD and
e.max Press, 20 seconds for
Suprinity, and 30 seconds for
Celtra Duo).11,29,31 The
hydrofluoric acid must be
rinsed off with forceful water
spray. The surface must then
be cleaned from crystalline
precipitates that accumulate
within the microporosities
after etching39 (Fig 11).
Crystalline precipitates may
compete with the adhesive
cement, decreasing the bond
strength. Thus, after etching,
the intaglio surface must be
cleaned with 35% phosphoric
acid under scrubbing motion
for 60 seconds or by
immersion in an ultrasonic
bath for 1 to 3 minutes in
98% alcohol (Fig 12). The
intaglio surface must be dried
and silane coupling agent
applied. The silane should be
allowed to react for 1 minute.
The silanol group will bond
to the glass network while the
organofunctional group will
copolymerize with the
methacrylate of the resin
cement. Recent data from our
laboratories suggested that
methacry-loyloxydecyl
dihydrogen phosphate
(MDP)-containing silane
yielded higher bond strengths
to zirconia-reinforced lithium
silicate glass-ceramics than
that of conventional silanes.
Fig 11 Microstructure of IPS
e.max CAD etched with
hydrofluoric acid showing
crystalline precipitates
Fig 12 Microstructure of IPS
e.max CAD after etching with
hydrofluoric acid followed by
cleaning with 35% phosphoric acid
(magnification × 20,000). Note that
the crystalline precipitates were
completely removed.
CONCLUSIONS
glass-ceramics present
adequate optical and
mechanical properties.
Monolithic CAD/CAM
lithium disilicate–reinforced
glass-ceramic has shown
adequate clinical longevity,
whereas CAD/ CAM
zirconia-reinforced lithium
silicate glass-ceramic needs
further independent clinical
investigation. Monolithic
restorations fabricated using
CAD/CAM technology are
reliable restorative options for
dental rehabilitation. Figures
13 to 27 demonstrate their use
in the restoration of a patient
with amelogenesis
imperfecta.
Fig 13 Preoperative view of a
patient with amelogenesis
imperfecta removing her dentures.
Figs 14a and 14b The patient wore

maxillary and mandibular complete
dentures for over 10 years.
Fig 15 Preoperative intraoral view

with the complete dentures.
Fig 16 Preoperative computed
tomography scan revealed that the
patient had had orthognathic
surgery to correct a skeletal Class
III malocclusion. At that time the
complete dentures were used as
reference to establish the position
of her maxilla. Presence of
impacted teeth can also be seen.
Fig 17 Preoperative view of the
patient’s smile without the
complete dentures.
Figs 18a to 18c Preoperative

intraoral views of the patient
displaying amelogenesis
imperfecta, prognathism, and
negative overjet (malocclusion
Class III according to Angle’s
classification).
Figs 19a and 19b Preoperative

view of maxillary and mandibular
arches. After careful analysis of the
treatment plan options, it was
determined that a nonpreparation
full-mouth adhesive rehabilitation
would the ideal treatment option.
Figs 20a and 20b Maxillary and

mandibular polymethyl
methacrylate (PMMA) provisional
restorations at the correct vertical
dimension of occlusion (VDO)
were fabricated based on the wax-
up. No tooth preparation was
performed.
Figs 21a and 21b CAD/CAM
monolithic restorations in the blue
stage. CAD/CAM monolithic
restorations (up to 0.3-mm
thickness) were milled with lithium
disilicate–reinforced glass-ceramic
(IPS e.max CAD) based the wax-
up (CAD/CAM biocopy).
Figs 22a and 22b CAD/CAM
lithium disilicate–reinforced glass-
ceramic monolithic restorations
after external characterization,
glazing, and crystallization.
Preoperative intraoral views show
prognathism and negative overjet,
and postoperative views show
positive overjet and overbite after
correction of VDO.
Right, frontal, and left views of the
amelogenesis imperfecta teeth
restored using nonpreparation
monolithic CAD/CAM
restorations.
Postoperative view of maxillary
and mandibular arches after
adhesively luting the CAD/CAM
restorations.
Final smile of the patient.
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_________________________
1 Assistant Professor, Division of
Restorative Sciences; Assistant

Director, Advanced Program in
Operative Dentistry, Ostrow
School of Dentistry, University
of Southern California, Los
Angeles, California, USA.
2 Resident, Advanced Program in
Prosthodontics, Division of
Restorative Sciences, Ostrow
Restorative Sciences; Director of
Biomaterials Laboratory, Ostrow
4 Director, Oral Design Center of
Los Angeles, Los Angeles,
California, USA.
5 Assistant Professor, Director,
CAD/CAM Technologies,
Division of Restorative Sciences,
Ostrow School of Dentistry,
California, Los Angeles,
California, USA.
6 Associate Professor and Chair,
Division of Restorative Sciences;
Director, Advanced Program in
Operative Dentistry, Ostrow
Correspondence to: Dr Neimar
Sartori, Division of Restorative
Sciences, Ostrow School of
Dentistry, University of
Southern California, 925 W 34th
Street, DEN 4365, Los Angeles,
CA 90089-0641.
Adhesive Oral
Rehabilitation
of a
Tetracycline-
Stained
Dentition with
Minimally
Invasive
Indirect
Restorations
Oswaldo Scopin de
Andrade, DDS, MS,
PhD1
Messias Rodrigues,
DDS, MS2
Ronaldo Hirata, DDS,
MS, PhD3
Luiz Alves Ferreira,
CDT4
T
he evolution of
materials science has
allowed the use of
adhesive procedures even in
patients requiring complex
oral rehabilitation.1–5
Currently, invasive tooth
preparations that remove
excessive enamel and
dentinal structure are being
gradually replaced by
adhesive dentistry concepts,
even in fixed
prosthodontics.5,6 However,
in patients exhibiting a
severely discolored dentition,
clinicians and technicians
face problems in applying
these concepts, established
and documented in the
scientific literature, because
most of those conservative
techniques are designed for
teeth with minor color
alterations.
For the severely
discolored dentition,
traditional restorative
dentistry has had limitations
—such as those seen in
earlier concepts of ceramic
build-up in which many
layers of material were
necessary to mask the
discoloration, requiring the
removal of more tooth
structure. This invasive
preparation may expose more
dentin, increasing the chance
of postoperative sensitivity
and jeopardizing clinical
longevity. Moreover,
depending on the approach
and ceramic selection, the
esthetic result sometimes may
not satisfy the patient or
dentist. With the evolution of
ceramic materials, it is now
possible to fabricate thin
restorations that mask tooth
discoloration and have
bonded characteristics.7,8
Lithium disilicate glass
ceramic (LDGC) can be used
in monolithic form, or it can
be reduced followed by a
veneering build-up with a
fluorapatite-based
ceramic.9,10 This type of
ceramic can be etched and
silanized for bonding to tooth
structure.11 The use of a
ceramic with adhesive
characteristics and a range of
options for fabricating the
restoration allows the dentist
and ceramist to preserve
sound tooth structure.12
The purpose of this article
is to present a clinical case
highlighting specific topics in
applying the adhesive oral
rehabilitation (AOR) concept
in a severely discolored
dentition.
CASE REPORT
A 46-year-old female patient
presented to a private office
with a complaint about
esthetic aspects of her smile.
The patient stated that she
had been trying to solve her
problem for years. She was
aware that the color change of
her teeth was caused by
excessive intake of
tetracycline during childhood.
Another issue pointed out by
the patient was that she never
pursued any restorative
treatment for fear that the
excessive enamel preparation
required for a ceramic
material could reduce the
lifespan of her natural
dentition. So, for years she
had been trying every type of
bleaching technique available
to improve her esthetics. At
the time of her initial
consultation, she realized that
bleaching was no longer an
option and she requested a
prosthetic treatment,
emphasizing that the damage
to her natural dentition should
be minimal.
Diagnostic and Initial
Approach
The initial clinical
examination included
intraoral analysis of
occlusion, periodontal health,
and preexisting restorations,
plus digital radiography and
photography. Clinical
examination showed that the
patient had a gummy smile;
however, the patient’s major
concern was only the color of
her teeth. She reported
previous orthodontic
treatment to improve tooth
alignment. The photographs
showed important details
necessary to select the best
treatment option for the
patient. Several initial
photographs were taken to
analyze various aspects of the
dentition:
• Lips in resting position—
the anterior tooth display
(Fig 1a)
• Discrete smile—initial
tooth display (Fig 1b)
• Frontal forced smile—total
tooth display in frontal
view (Fig 1c)
• Lateral forced smile—total
tooth display in both
lateral views (Figs 1d and
1e)
• Photographs with lip
retractor—details about
periodontal architecture
and general anatomy
• Facial photograph—teeth
in relation to face
Figs 1a to 1e Initial
photography sequence for
treatment planning, showing
adequate tooth display at
resting position and the
anatomy of the patient’s smile.
A polyvinyl siloxane
(PVS) impression material
was selected to produce the
initial study cast. This
material was selected because
it is a very precise material
that allows the technician to
obtain more than one cast
from the same impression.
The dental technician
performed an initial additive
wax-up7,121 with no
preparation of the teeth (Fig
2). By building an
overcontoured anatomy, it
was easy to analyze the initial
requirements for the case;
also, it allowed the clinician,
ceramist, and patient to
understand if, in this specific
case, a conservative approach
could be performed.
Figs 2a to 2e Additive wax-up

for the mock-up of the
proposed treatment and
evaluation of clinical and
laboratory options.
Figs 2f and 2g Close-up views

of the maxillary left canine: (f)
after additive wax-up and (g)
intact.
Because the patient had a

high lip line and a gummy
smile, no incisal lengthening
or changing of the vertical
dimension of occlusion
(VDO) was planned. In
planning an AOR, the
ceramist should be made
aware of such details by the
clinician before the wax-up
procedure. Because most of
the initial planning is
performed by additive
procedures only, and no stone
was prepared on the cast, no
facebow record was taken or
used in any phase of this case.
The casts were mounted in a
semiadjustable articulator
based on initial patient
photography. In cases of full-
mouth rehabilitation, it is
advisable to split the
rehabilitation into steps,
preserving references that
facilitate recording the
occlusion and mounting the
articulator. For patients with
no planned changes in VDO,
the following clinical
sequence is preferred:
1. Maxillary restorations,
second premolar to
second premolar
2. Mandibular restorations,
second premolar to
second premolar
3. First molar restorations,
right side
4. First molar restorations,
left side
Each area selected to be
restored is completed before
starting the contralateral side
to allow total control and
maintenance of the original
VDO and occlusal pattern of
the patient.
Bis-acrylic Resin
Direct Maxillary
Mock-up
The initial wax-up was
completed only for the
maxillary arch, to analyze if it
would be possible to perform
a minimally invasive
adhesive oral rehabilitation,
as requested by the patient. A
silicone index was fabricated
on a duplicated cast of the
wax-up. The reason was to
preserve the initial wax-up.
An intraoral mock-up of the
iniially proposed treatment
was made with a bis-acrylic
resin (Systemp II C&B,
Ivoclar Vivadent). New
photographs were taken, and
the simulation was analyzed
by the patient and clinician
(Fig 3). In this initial phase of
the treatment, it was
important to discuss all
possibilities and their clinical
sequencing with the patient.
Figs 3a and 3b Frontal views
of the patient’s smile before
and after the mock-up.
Figs 3c and 3d Lateral views

of the smile with the mock-up
in position.
Fig 3e Resting position with
the mock-up in place.
Figs 3f to 3i Intraoral views of
the mock-up.
The patient approved the

smile anatomy. Next, the bis-
acrylic resin shells were
carefully removed from the
patient’s mouth, trying to
preserve each shell that
simulated the wax-up. An
important set of photographs
for explaining the treatment
to the patient is the “half
mock-up,” in which the
simulation is removed from
one hemiarch so that the
patient can easily see the
difference (Fig 4). Each resin
shell was measured in three
different areas: cervical,
middle, and close to the
incisal edge. This information
was used to analyze and
predict the ceramic thickness
required to block the
discolored dentition (Fig 5).
In this patient there was
adequate space for ceramic
material to make laminate
veneers; however, as this was
a case with severe
discoloration, additional
analysis had to be carried out
before tooth preparation.
Figs 4a to 4f Photographs
showing the dentition with and
without the bis-acrylic resin
used to simulate the final
anatomy of the smile.
Figs 5a to 5d Measurement of
the resin shell with a caliper.
This information is utilized to
predict the final thickness of
the laminate veneer.
Prepreparation
Ceramic Test
When space is available for
the ceramic material, prior to
tooth preparation a
prepreparation evaluative test
can be done. This test helps
the ceramist to determine
which ingot of LDGC should
be pressed and also orients
the clinician to which areas
may require tooth
preparation.
The laboratory sent to the
clinician, in this case, two
laminate veneers made in
lithium disilicate (IPS e.max
Press, Ivoclar Vivadent) in
two different shades (Fig 6).
For the maxillary right central
incisor, a low-translucency
bleach (LT B1) ingot was
used, and for the left central
incisor, a high-translucency
bleach (HT BL3) ingot was
used. This “ceramic mock-
up” is an important tool for
conservative tooth
preparation. The role of this
test was to allow the clinician
to analyze prior to
preparation the potential of
the material to block the dark
shade of the tooth substrate.
The communication between
clinician and ceramist is
extremely important;
therefore, before tooth
preparation, the ceramist
performed a digital
photography analysis and
suggested that interproximal
preparation would be
necessary for a better esthetic
result and more natural
optical characteristics.
Fig 6 Two laminate veneers
made prior to tooth preparation
for the prepreparation ceramic
test.
Maxillary Tooth
Preparations
Even in a severely discolored
dentition, a conservative
approach is indicated to
preserve enamel as much as
possible. Three important
factors should be analyzed
prior to tooth reduction to
determine the need for and
amount of reduction.13
1. Space and thickness of the

final restoration. This
was confirmed during the
mock-up session by
measuring the thickness
of the bis-acrylic resin
shell of each tooth.
LDGC was the material
selected for this patient
because it allows the
fabrication of pressed
laminate veneers with
thicknesses between 0.3
and 0.5 mm, providing
durability and lifelike
esthetics.
2. Shade and color
modification. This was
inspected and evaluated
during the prepreparation
ceramic test. The ceramic
mock-ups were made
from two different
ceramic ingots.
3. Path of insertion. This is
determined so that tooth
reduction will be limited
to that which permits the
insertion of the
restoration onto the tooth
preparation.
During the mock-up

session it was possible to
analyze and check the
thickness of the final
anatomy. Note that there was
no need to prepare the teeth
on the basis of the first factor.
For the second factor, it was
confirmed that, for better
esthetics, interproximal
preparation would be
recommended. Thus, the final
and third step was to define
and determine the path of
insertion. In this patient, tooth
preparation was restricted to
controlled enamel removal of
identifiable areas with ridges
and surface irregularities that
would restrict the insertion of
the final restoration, because
the first two factors were
previously checked and
analyzed before tooth
reduction. If these three
factors are carefully
evaluated, a conservative
preparation can be performed
even in cases of severe shade
modification. Another
important issue is that there
was no need to place the
preparation inside the
gingival sulcus; in healthy
periodontal tissue it is always
preferable to preserve the
original and natural gingival
architecture.
The final tooth
preparations from canine to
canine are shown in Fig 7.
The maxillary right second
premolar had a previously
placed porcelain-fused-to-
metal crown that was
removed; a zirconia-based
crown was planned because
of the presence of a metal
post and core that could not
be removed. Following tooth
preparation, impression
procedures were carried out
with a PVS material (Virtual,
Ivoclar Vivadent).
Figs 7a to 7c Final
preparations for ceramic
laminate veneers, canine to
canine.
Final Shade Selection

for the Maxillary Teeth
Even when the prepreparation
ceramic test has been
performed, it is important to
reposition the selected
ceramic mock-up, which is a
try-in restoration, onto the
prepared tooth and to retake
digital photographs (Fig 8a).
For this patient, the ceramist
recommended taking
photographs of the tooth
substrate shade (Fig 8b) and
the final desired shade (Fig
8c).
Fig 8a Selected IPS e.max
Press ingot (LT B1) in position
after tooth preparation.
Figs 8b and 8c Photographs
with the Vita Shade guide of
the tooth substrate and the
desired shade.
Provisional
Restorations
For cases involving laminate
veneers, delivery of an
adequate provisional
restoration is always a
challenge.9 In a discolored
dentition, highly esthetic
provisional restorations
become a more difficult task.
When adequate space is
present, the authors prefer to
utilize conventional acrylic
resin provisionals made at the
laboratory. The restorations
were made as sets of two
splinted provisionals: first
and second premolar, canine
and lateral incisor, and two
central incisors. After being
relined, finished, and
polished, the provisionals
were luted with light-curing
resin cement (Variolink
Veneer, Ivoclar Vivadent)
(Fig 9). Tooth preparations
were restricted to enamel,
and, to facilitate removal of
the provisional, no etching or
adhesive was applied to the
teeth. Retention was achieved
by mechanical retention of
the relined acrylic resin and
the resin cement.
Figs 9a and 9b Intraoral view

of the acrylic resin provisionals
after being luted and polished.
Laboratory
Procedures
The impressions were sent to
the ceramist. At the
laboratory, two casts were
made to develop the
definitive restorations. IPS
e.max Press LT B1 ingots had
been selected previously
during the planning phase.
The ingots were pressed to
produce the cores (Fig 10a),
which were reduced and
layered with a fluorapatite-
based ceramic (Figs 10b and
10c) that is compatible with
LDGC. The current trend is
to work only with monolithic
LDGC, which is then stained.
However, the fluorescence of
this material in the monolithic
approach is only obtained
with a special glaze (FLUO
Glaze Paste, Ivoclar
Vivadent), which may be
removed during intraoral
polishing, changing its optical
and esthetic characteristics.
Therefore, if there is space
available, as detected in the
planning phase, the authors
always prefer to layer the
lithium disilicate core with a
compatible ceramic (IPS
e.max Ceram, Ivoclar
Vivadent), which improves
esthetics and optical long-
term results. The definitive
ceramic laminate veneers
were checked on both casts
for gingival contour, marginal
adaptation, and interproximal
contacts (Fig 11).
Fig 10a IPS e.max Press core
made in shade LT B1 ready to
be veneered.
Figs 10b and 10c Initial
ceramic stratification with IPS
e.max Ceram.
Figs 11a and 11b Definitive

restorations fitted and adjusted
on both casts.
Try-in and Bonding
Procedures for
Definitive Maxillary
Restorations
The soft tissue was healthy
enough after 2 weeks for
definitive bonding. The well-
adapted provisionals were
easy to clean as a result of the
careful and precise tooth
preparation, which preserved
enamel and positioned the
finish lines at the level of the
gingival crevice (Fig 12).
After removal of the
provisional restorations, the
tooth surfaces were cleaned
with pumice and water (Fig
13). Next, each individual
laminate veneer was checked
for marginal adaptation and
inter-proximal contacts (Fig
14). A try-in paste was used
to select the best shade of
resin cement. A high-value
light-curing resin cement
shade (Variolink Veneer +1,
Ivoclar Vivadent) was
selected for final bonding.
After esthetic approval by the
patient, the laminate veneers
were prepared for bonding.
The intaglio surface was
etched with 9% hydrofluoric
acid for 20 seconds. The
etched surfaces were rinsed
and cleaned with 35%
phosphoric acid for 10
seconds. The veneers were
once more rinsed and air
dried. A silane coupling agent
was applied for 2 minutes and
dried. The intaglio surfaces
were coated with a
hydrophilic adhesive resin
(Excite F, Ivoclar Vivadent),
air thinned for evaporation of
the solvent, and left uncured.
Figs 12a and 12b Maxillary
right central and lateral incisors
immediately after provisional
removal.
Figs 13a to 13c Frontal and

close-up views after
provisional removal. Note the
quality and health of the
gingival tissue.
Figs 14a to 14c Close-up

views of the insertion of the
laminate veneer on the left
lateral incisor.
The tooth preparations
were etched with 35%
phosphoric acid for 30 to 60
seconds, washed, and air
dried. The same adhesive that
was used for the veneers was
applied to the tooth structure
in the same manner. The
ceramic restorations were
loaded with the selected light-
curing resin cement and
positioned on the teeth. All
excess resin cement was
carefully removed before
light curing. An LED light-
curing unit (Bluephase,
Ivoclar Vivadent) in low-
power mode was used to cure
each surface for 40 seconds.
A water-soluble glycerin gel
was used to air block, and the
margin of the restoration was
polymerized again for 40
seconds per surface. The
excess resin cement was
removed with a scalpel and
composite resin strips. Only
one laminate veneer was
bonded at a time for better
control of the bonding and
cleaning process. The last two
veneers to be bonded were
the central incisors (Fig 15).
The zirconia crown on the
maxillary right second
premolar was the only
exception and was luted with
a resin cement with monomer
acid (Panavia F 2.0, Kuraray).
The final maxillary
restorations are shown in Fig
16.
Figs 15a and 15b Frontal view

immediately before the
bonding process of the
maxillary central incisors.
Figs 16a to 16c Final result of
the ceramic laminate veneer
restorations from the right first
premolar to the left second
premolar. The right second
premolar was restored with a
zirconia-based crown.
Mandibular Tooth
Preparations
After final bonding,
polishing, and finishing
procedures for the maxillary
teeth from premolar to
premolar, the next step was to
rehabilitate the mandibular
arch. The initial situation
prior to preparing the
mandibular arch is shown in
Fig 17. As previously noted,
for better occlusal records
and mounting on the
articulator, one arch was
prepared and finished at a
time. A new PVS impression
was taken of the maxillary
restored arch to articulate
with the wax-up of the
anterior mandibular teeth (Fig
18a). For this area, a 0.5-mm
incisal reduction was done
before the wax-up of the final
anatomy. This was necessary
because changing the VDO
was not indicated in this
patient. Silicone indices were
made to control tooth
reduction (Fig 18b).
Figs 17a to 17d Anterior

mandibular dentition before
tooth preparation. The patient
at this time wore a bonded
lingual orthodontic retainer
from canine to canine.
Fig 18a Close-up view of the

wax-up of the mandibular
anterior dentition.
Fig 18b Silicone indices made

to guide the tooth preparations
for the laminate ceramic
veneers.
The patient wore an
orthodontic retainer from
mandibular canine to canine
that was removed prior to
tooth preparation. For the
mandibular arch, the same
conservative approach was
used. In this way, an accurate
and precise tooth preparation
concept had to be applied
because the amount of
enamel was limited. In Fig
19, a prepared tooth can be
compared with an intact one.
Definitive preparations are
shown in Fig 20. In the
premolar area, special
attention had to be given to
avoid excessive removal of
tooth structure at the cervical
margin. The impression was
taken and sent to the
laboratory for fabrication of
the ceramic veneers from
second premolar to second
premolar. It is important to
emphasize that the path of
insertion of a laminate veneer
in this specific case is from
buccal to lingual at the
premolar area, so it was not
necessary to remove a large
amount of sound tooth
structure at the gingival
margin. Figure 21a shows the
conservative preparations on
the right canine and
premolars. The definitive
laminate ceramic veneers on
those teeth are shown in Figs
21b and 21c. Regarding the
path of insertion of those
elements, the sequence for
bonding was determined on
the cast; in this case, the
canine and second premolar
veneers were bonded before
the veneer on the first
premolar. If a different
sequence had been selected, it
is likely that an insertion
problem would have resulted
in excessive adjustments,
compromising the final result
and marginal adaptation.
Figs 19a and 19b Comparison

of the prepared teeth at the left
side of patient’s mouth with the
intact teeth at the right side.
Note that the removal of the
orthodontic retainer opened
small diastemata between the
incisors.
Figs 20a and 20b Final tooth

preparations for the mandibular
anterior and premolar teeth.
Fig 21a Occlusal view of the
final preparations for ceramic
laminate veneers on the right
canine and premolars.
Figs 21b and 21c Occlusal
view of the veneers on the
master cast. The path-of-
insertion test before bonding
showed that the restoration of
the first premolar should be
done after the canine and
second premolar.
Figure 22a shows the

tooth preparations on the left
canine and premolars; an
important highlight of this
photograph is that the left
lateral incisor had yet to be
prepared. As mentioned
before, the molars were the
last to be prepared. Note that
in this area it was not
necessary to prepare the
interproximal surfaces
between the first and second
premolars. Definitive
restorations of this area are
shown in Figs 22b and 22c.
Fig 22a Intraoral view of the

ceramic laminate veneer
preparations of the left canine
and premolars.
Fig 22b Occlusal view of the

veneers for the left canine and
premolars positioned on the
cast.
Fig 22c Close-up lateral view
of veneer for the left second
premolar.
All the steps until the

final bonding were carried
out exactly as for the maxilla.
As the provisionals were well
adapted, the gingival tissue
was stable and healthy for
final bonding. Figure 23
shows the situation
immediately after
cementation of the veneers on
the right side of the mandible.
Figs 23a and 23b Immediately
after the bonding procedure on
the left second premolar to left
central incisor. Observe the
immediate result of the
adhesive cementation on the
gingival tissue when properly
executed.
Restoration of the
Molar Teeth
With the approach of
restoring first the maxillary
anterior dentition and
premolars followed by the
same regions in mandibular
arch, it was possible to have
better occlusal control of the
case. When there is no need
to change the VDO, it is
always important to maintain
a reference to record and
articulate the original
occlusion so that the VDO
will be maintained. In this
case, the molars, which were
the final teeth to be restored,
helped in this important role.
Overlays and onlays were
fabricated for the maxillary
and mandibular molars. The
final result can be seen in Fig
24. At the end of the
treatment, the patient was
provided with an occlusal
nightguard.
Figs 24a to 24o Final result 5
months after the adhesive oral
rehabilitation customized for
the patient’s discolored
dentition.
CONCLUSIONS
The adhesive oral
rehabilitation concept implies
the use of minimally invasive
procedures even in cases of
severely discolored dentitions
with tetracycline staining.
Utilizing controlled
diagnostic procedures, it is
possible to predict the final
anatomy of the oral
rehabilitation to provide the
patient esthetic and functional
conservative restorations.
Combining ceramic materials
with adhesive characteristics,
it is possible to fabricate
conservative laminate veneers
that preserve dental hard
tissue while achieving long-
term results.
REFERENCES
1. Vailati F, Belser UC. Full-
mouth adhesive rehabilitation
of a severely eroded dentition:
The three-step technique. Part
1. Eur J Esthet Dent
2008;3:30–44.
2008;3:128–146.
2008;3:236–257.
4. Vailati F, Bruguera A, Belser
UC. Minimallly invasive
treatment of initial dental
erosion using pressed lithium
disilicate glass-ceramic
restorations: A case report.
2012;35:65–78.
5. Scopin de Andrade O,
Rodrigues M, Hirata R,
Ferreira LA. Adhesive oral
rehabilitation: Maximizing
treatment options with
minimally invasive indirect
restorations. Quintessence
Dent Technol 2014;37:71–93.
6. Fradeani M, Barducci G,
Bacherini L, Brennan M.
severely worn dentition with
procedures (MIPP). Int J
2012;32:135–147.
7. Gurel G. The Science and Art
of Porcelain Laminate
Veneers. Berlin: Quintessence,
2003.
8. Bacherini L, Brennan M,
Bocabella L, Vigiani P.
severely discolored dentition
with minimally invasive
prosthetic procedures (MIPP).
2013;36:59–76.
9. Scopin de Andrade O, Borges
G, Stefani A, Fujiy F,
Battistella P. A step-by-step
ultraconservative esthetic
rehabilitation using lithium
disilicate ceramic.
2010;33:114–131.
Romanini JC, Hirata R.
Ultimate ceramic veneers: A
laboratory-guided
ultraconservative preparation
concept for maximum enamel
preservation. Quintessence
Dental Technol 2012;34:29–
43.
11. Duarte S Jr, Phark JH, Blatz
M, Sadan A. Ceramic
systems: An ultrastructural
study. Quintessence Dent
Technol 2010;33:42–60.
12. Magne P, Belser U. Bonded
Porcelain Restorations in the
Anterior Dentition: A
Biomimetic Approach.
13. Scopin de Andrade O, Kina S,
Hirata R. Concepts for an
ultra-conservative approach to
indirect anterior restorations.
2011;34:103–119.
_________________________
1 Director, Advanced Program in
Implant and Esthetic Dentistry,
Senac University, São Paulo,
Brazil.
2 Assistant Professor,
Orthodontics, School of
Dentistry, UNITAU, Taubaté,
São Paulo, Brazil.
3 Assistant Professor,
Biomaterials and Biomimetics,
New York University College of
Dentistry, New York, New York,
USA.
4 Dental Technician and Ceramist,
Specialized Dental Laboratory,
São Paulo, Brazil.
Correspondence to:
Dr.Oswaldo Scopin de Andrade,
Rua Barão de Piracicamirim 889
#61, Piracicaba-SP-Brazil, CEP
13.416-005.
Flapless
Esthetic
Gingival
Remodeling:
The Ultimate
Approach for
Crown
Lengthening
Ivan Contreras Molina,

DDS, MSc, PhD1
Gildardo Contreras
Molina, DDS2
Isis Carvalho
Encarnação, DDS,
MSc, PhD1
Cristiano Soares,
CDT3
Luiz Narciso Baratieri,
DDS, MSc, PhD4
T
he integration of
knowledge from
various specialties of
dentistry has become
essential for comprehensive
diagnosis, planning, and
imple mentation of simple
restorative treatments to
extensive rehabilitations. The
evolution and scientific
development of the materials
available as well as the
improvement of surgical
techniques have contributed
to the achievement of
dramatic results in the dental
practice.
This case report
demonstrates the relationship
between periodontics and
restorative dentistry,
ultimately aimed at obtaining
a harmonious, balanced
smile. Without such
multidisciplinary interaction,
a minimally invasive
approach would not be
possible for both surgical and
restorative procedures.1
The case involves one of
the most widely used
minimally invasive
procedures for correcting
excessive gingival exposure
while smiling: periodontal
plastic surgery without flaps,
also known as “the flapless
procedure.”2–4 This technique
requires osteotomy, when
indicated, via the gingival
sulcus through the use of
microchisels. This article
proposes a new approach to
correct excessive gingival
exposure, one of the problems
that most negatively affects
the smile, with reduced
surgical time, without sutures,
and with minimal surgical
trauma, ultimately leading to
an excellent postoperative
phase.
CASE REPORT
A 23-year-old male patient
came to the Dental Clinic at
Federal University of Santa
Catarina, Florianópolis,
Brazil, requesting a solution
to improve his smile,
specifically the color and
shape of his teeth (Fig 1).
Figs 1a to 1e Preoperative
situation showing esthetic
deficiencies due to diastemas
and the location of the incisal
edges. Note the discrepancy of
the position of the gingival
margin.
Phase 1: Treatment
Planning and Surgical
Phases (Figs 2 to 4)
The first aim was to precisely
obtain the dimensions of the
biologic width for each of the
teeth involved in order to
determine whether osteotomy
would be required. The
periodontal probe is gently
positioned into the gingival
sulcus with light pressure to
determine the probing depth;
some pressure is then applied
on the probe until it is
inserted to the bone crest
(bone probing depth). The
biologic width of the given
tooth is determined by the
subtraction of the values of its
bone probing depth and the
gingival probing depth. A 15-
mm periodontal probe is used
to obtain the measurements to
the nearest 0.5 mm (Fig 2).
The incision is positioned on
the CEJ level when sound
teeth are treated, or along the
desired position of the future
gingival margin when
restorative procedures are
indicated as in this case (Fig
3a). The tissue collar band is
then removed using
periodontal curettes (Fig 3b).
Fig 2a Intraoral view of the

maxillary anterior teeth.
Fig 2b Probing to determine
the sulcus depth,
cementoenamel junction, and
bone crest.
Figs 2c and 2d Use of an air
jet inside the sulcus, showing a
visual reference of the
cementoenamel junction.
Fig 3a Gingival recontouring
with an internal bevel surgical
technique.
Fig 3b Sharp curette is used to

remove excess tissue.
The next step is to

determine whether bone
contouring is required. Once
again, bone probing depth is
determined (Fig 3c), and if
the obtained value is less than
the individual tooth’s biologic
width, osteotomy is
performed (Fig 3d). The
osteotomy, when indicated, is
performed through the
gingival sulcus using the
appropriate delicate
microchisels with small
movements (Figs 3e and 3f).
After the osteotomy, probing
is performed once again to
check the newly established
biologic space (Figs 3g and
3h).5,6 Because of the thin to
moderate tissue biotype
observed in this case,
osteoplasty or reduction of
bone thickness was not
performed. Figures 4a and 4b
shows the result obtained
after 8 days and 90 days,
respectively.
Fig 3c Bone probing, defining

the need to perform osteotomy.
Figs 3d to 3f Osteotomy
without flap elevation using a
micro-chisel.
Fig 3g After osteotomy, a

second probing is carried out to
check the new biologic space.
Fig 3h Immediate
postoperative view.
Fig 4a Clinical appearance 8

days after surgery.
Fig 4b Clinical appearance 90
days after surgery.
Phase 2: Mock-up and

Preparation (Figs 5 to
8)
A conservative approach
requires accurate tooth
preparation to restore the
original volume. A few basic
principles can be followed to
save a significant amount of
sound tooth tissue. The mock-
up (Telio, Ivoclar Vivadent)
shown in Fig 5 was used on
the teeth as a guide during the
preparation step.7 In this case,
the distal areas showed the
greatest retention (Fig 6a).
The retentive areas were
marked in the incisal region
with a pencil (Figs 6b to 6d).
An EVA handpiece and
diamond disks (Sof-Lex, 3M
ESPE) were used to smooth
the angles.
Fig 5a Initial additive wax-up
for the mock-up procedure.
Fig 5b Mock-up fabricated
with bis-acrylic resin loaded
into a vinyl polysiloxane
template.
Fig 5c Anticipated view of the
final restorations with the
mock-up.
Fig 5d Patient’s smile with
mock-up in place. The patient
and the clinician are able to
check the esthetic potential of
the restorations.
Fig 6a Mock-up in place to

view the space for the
restorations.
Figs 6b to 6d The retentive
areas of the teeth were marked
with pencil and carefully
corrected to facilitate insertion
of the future restorations.
The final
ultraconservative preparations
are shown in Fig 7. A single
retraction cord was used for
gingival displacement for the
double-mix single impression
technique with polyvinyl
siloxane (Fig 8).8
Figs 7a to 7c Close-up views

of the ultraconservative veneer
preparations.
Figs 8a and 8b Final
impression using polyvinyl
siloxane and a single-cord
technique.
Phase 3: Restorative
Phase (Figs 9 to 14)
Four feldspathic ceramic
veneers (IPS d.Sign, Ivoclar
Vivadent) were fabricated
using the refractory die
technique for closing the
diastema between the
maxillary central and lateral
incisors (Fig 9). All
restorations were checked for
marginal fit and proximal
contacts.9 The final shade
was evaluated using a
glycerin-based try-in paste
(Variolink Try-in, Ivoclar
Vivadent), resulting in the
selection of a clear
translucent resin cement (Fig
10).
Fig 9a Alveolar dies.

Fig 9b Alveolar cast.
Figs 9c and 9d Alveolar cast

with the correct emergence
profile and dies in position.
Fig 9e Wash and biscuit firings

with opalescent E1,
fluorapatite-rich, leucite-
reinforced glass ceramics (IPS
d.Sign, Ivoclar Vivadent).
Fig 9f Note the smoothness of
the ceramic after the first
firing. In this step, a
temperature 60ºC above normal
was used.
Fig 9g Opaque dentin (DDA1
+ 20% Bleach 2) and mamelon
masses (MM Salmon) were
used.
Fig 9h Final firing of the core
completed.
Figs 9i and 9j View of the

application of the proximal
(DA1 + 20% Bleach 2), enamel
(E1 + E2 1:1, in the incisal
angles) and the incisal edge
(E1 + 10% Tblue) masses.
Fig 9k Demarcation of the

labial surfaces and angles of
transition.
Fig 9l Smoothing of the angles

of transition to establish a
correct width-to-shape ratio.
Fig 9m Adjustment of the
tooth length and incisal edge.
Fig 9n Adjustment of the
incisal embrasures.
Fig 9o After glazing, the
veneers are removed from the
refractory and adjusted in the
cast.
Fig 10a (left) Etching with
hydrofluoric acid for 20
seconds (Porcelanite, 3M
ESPE). (center) Application of
phosphoric acid for 30 seconds
to remove the debris after
ceramic etching (Power
Etching, BM4). (right) Rinsing
of the ceramic etched surfaces
for 60 seconds.
Fig 10b (left) Application of

silane (Monobond, Ivoclar
Vivadent) and hot air drying
for 60 seconds. (center)
Application of the bonding
agent (Excite, Ivoclar
Vivadent). (right) Application
of the luting agent (Variolink
II, Ivoclar Vivadent).
The cementation
technique plays a crucial role
in the survival rate of ceramic
restorations. Following are
the steps used for surface
treatment and bonding:
1. Etching with hydrofluoric

acid (Porcelain Etch, 3M
ESPE) for 20 seconds
followed by copious
rinsing with tap water.
2. Additional etching with
35% phosphoric acid
(BM4) for 30 seconds for
the removal of debris.
3. Rinsing of the etched
ceramic restorations in an
ultrasonic bath using
90% alcohol for 5
minutes.
4. Silane application for 60
seconds (Monobond,
Ivoclar Vivadent),
followed by hot
air/drying for 20 seconds.
5. Adhesive application
(Excite, Ivoclar
Vivadent).
6. Luting using resin cement
(Variolink II, Ivoclar
Vivadent) (Fig 11).10
Fig 11a Prophylaxis of enamel
surfaces before bonding with
pumice slurry and sandblasting
with Rocatec (3M ESPE).
Fig 11b Enamel etching for 15
seconds (Power Etching,
BM4).
Fig 11c Application of a two-
step etch-and-rinse adhesive
(Excite, Ivoclar Vivadent).
Fig 11d Removal of excess
resin cement with a special
artist brush.
The teeth were then

isolated and cleaned with a
sandblasting device,
subsequently etched with
37% phosphoric acid (BM4)
for 15 seconds, followed by a
30-second rinsing, application
of a two-step etch-and-rinse
adhesive (Excite, Ivoclar
Vivadent), and cementation
(Fig 12).
Figs 12a to 12c Intraoral view
after cementation. The shade,
contour, form, and occlusion
were restored.
The occlusion was

checked, and the patient was
dismissed. The final result
and clinical follow-up after
24 months are shown in Figs
13 and 14.
Figs 13a to 13d Clinical

follow-up after 24 months.
Figs 14a to 14d Final result.
DISCUSSION
The treatment planning for
esthetic crown lengthening
should take into account the
necessity for the associated
prosthetic rehabilitation. In
clinical situations where
veneers or crowns are
required, the future prosthetic
margins should match the
contours of the gingival
margin, which will eventually
provide the needed
orientation for the extent of
the osteotomy. In such cases,
root exposure is not of
concern, since restorations
will cover these areas. There
should be sufficient time for
healing of the soft tissues
before the definitive tooth
preparation and impression.
The gingival sulcus will
appear to be completely
stabilized after 3 months,
although complete healing of
the tissues can take up to a
year, dependent on the
characteristics of the initial
surgery11 and the amount of
osteotomy and osteoplasty.
When a restoration is not
anticipated, the reference for
an eventual osteotomy is the
cemento-enamel junction.
Treatment planning is the
key for treatment success.12
Using a combination of two
different treatments, ie,
flapless surgery and nonprep
veneers, the tooth structures
can be preserved, especially
considering the noninvasive
procedures and latest
advances in adhesive
techniques, guaranteeing the
clinical success of this type of
restoration.13
CONCLUSIONS
The flapless approach is a
safe, easy, and predictable
procedure with considerable
clinical advantages. When the
proper indications for this
procedure are respected, it
can achieve stable and
esthetic outcomes. A
multidisciplinary approach
provides patients with high-
quality noninvasive
treatment, resulting in
superior esthetics.
REFERENCES
1. Garber DA, Salama MA. The
aesthetic smile: Diagnosis and
treatment. Periodontol 2000
1996;11:18–28.
2. Campelo LD, Camara JR.
Flapless implant surgery: A
10-year clinical retrospective
analysis. Int J Oral Maxillofac
Implants 2002; 17:271–276.
3. Harrel SK, Rees TD.
Granulation tissue removal in
routine and minimally
invasive procedures. Compend
Contin Educ Dent
1995;16:960–964.
4. Becker W, Goldstein M,
Becker BE, Sennerby L, Kois
D, Hujoel P. Minimally
invasive flapless placement:
Follow-up results from a
multicenter study. J
Periodontol 2009:80:346–352.
5. Carvalho PFM, da Silva RC,
Joly JC. Aumento de coroa
clinica estético sem retalho:
Uma nova alternative
terapéutica. Rev Assoc Paul
Cir Dent 2010;ed esp 1:26–33.
6. Joly JC, Carvalho PFM, Silva
RC, Flapless esthetic crown
lengthening: A new
therapeutic approach. Rev
Mex Periodontologia
2011;2:103–108.
7. Gurel G. The Science and Art
of Porcelain Laminate
Veneers. Chicago:
Quintessence, 2003.
Romanini J, Hirata R.
Ultimate ceramic veneers: A
laboratory-guided
ultraconservative preparation
concept for maximum enamel
preservation. Quintessence
Dent Technol 2012;34:103–
119.
9. Adolfi D. Functional, esthetic,
and morphologic adjustment
procedures for anterior teeth.
2009; 32:153–168.
10. Magne P, Magne M, Magne I.
Porcelain jacket crowns. Back
to the future through bonding.
2010; 33:89–96.
11. Müller HP, Könönen E.
Variance components of
gingival thickness. J
Periodontal Res 2005;40:239–
244.
12. Malik K, Tabiat-Pour S. The
use of diagnostic wax set-up
in aesthetic cases involving
crown lengthening—A case
report. Dent Update
2010;37:303–304,306–307.
13. Gresnigt M, Ozcan M, Kalk
W. Esthetic rehabilitation of
worn anterior teeth with thin
porcelain laminate veneers.
Eur J Esthet Dent 2011;6:298–
313.
_________________________
1 Graduate, PhD in Dentistry,
Federal University of Santa

Catarina, Florianópolis, Brazil.
2 Professor, Department of
Surgery, University Michoacana
de San Nicolas de Hidalgo,
Morelia, Mexico.
Brazil.
4 Professor, Department of
Dentistry, Federal University of
Santa Catarina, Florianópolis,
Brazil.
Correspondence to: Dr Ivan
Contreras Molina, Privada Plan
de Ayutla #39, Col. Chapultepec
sur, Morelia, Mexico.
Email:
[email protected]
State of the
Art
Mastering
Esthetic and
Functional
Rehabilitation
of the Severely
Worn Dentition
Sergio R. Arias, DDS,
MS1
Aram Torosian, MDC,
CDT2
Somkiat Aimplee,
DDS, MS1
Jimmy Londono,
DDS3
Gerard Chiche, DDS4
W
ith advances in all-
ceramic systems,
adhesive resin
cements, implant dentistry,
and computer-aided
technology, numerous
treatment options are
available for the fixed
prosthetic rehabilitation.
These alternatives increase
the quality and predictability
of dental treatment. A
systematic and organized
approach is essential in order
to evaluate, diagnose, and
resolve esthetic and
functional problems
predictably in a complex
restorative case.1
The following case is
presented to illustrate the use
of these treatment options in
the management of a patient
with a severely worn
dentition.
CASE
PRESENTATION
A 70-year-old male
patient presented for
treatment at the Ronald
Goldstein Center for Esthetic
and Implant Dentistry at
Georgia Regents University,
College of Dental Medicine.
The patient was in good
general health, and his
medical history was
noncontributory. His main
concern was “My front teeth
are getting thin and keep
chipping. They don’t look
natural.” The clinical
extraoral evaluation revealed
a deviated facial midline, a
slanted incisal plane, and a
retrusive maxillary incisal
profile (Fig 1).
Figs 1a to 1c Preoperative
extraoral views.
Intraoral evaluation
revealed significant
generalized incisal wear
caused by parafunction and
erosion, with loss of posterior
support and excessive
anterior vertical overlap.2 In
addition, the patient had
multiple failing restorations
with poor marginal
adaptation, and there was an
occlusal plane discrepancy
caused by supraeruption of
maxillary first and second
molars into the mandibular
edentulous sites. Finally, the
central incisors had a narrow
tapered appearance and
inadequate proportions due to
gingival recession and their
irregular gingival outlines
(Fig 2).
Figs 2a to 2c Preoperative intraoral
views.
The patient traveled

approximately 4½ hours for
appointments; therefore, he
preferred a treatment plan that
would require a minimal
number of visits. For this
reason, the patient declined
orthodontic treatment and
requested to have as few
surgical procedures as
possible.
Based on the
compromised esthetic and
functional situation of the
case, full-mouth rehabilitation
was pre-scribed to (1) correct
the occlusal plane
discrepancy, (2) decrease the
vertical overlap after
achieving proper tooth length,
(3) correct the incisal edge
position, (4) harmonize the
anterior guidance, and (4)
improve the esthetic
appearance. A diagnostic
occlusal splint was fabricated
to enable muscular relaxation
and to allow the condyles to
seat in centric relation (CR),
to protect the teeth from
further wear, and to evaluate
the patient’s tolerance of an
increase in vertical dimension
of occlusion (VDO).3
Esthetic Analysis
The treatment planning
started with the esthetic
evaluation and proceeded
with function, structure, and
biology.4 A seven-step
esthetic analysis was
performed as described by
Chiche and Pinault, which
allows for an early detection
of “esthetic red flags.”5 The
first four steps of the analysis
relate to the evaluation of the
incisal edge position of the
maxillary central incisors;
their correct position is the
foundation from which the
smile is built. When the
incisal edge position is set
correctly, it serves to
determine proper tooth
proportion and gingival
levels.1
Determination of
Incisal Edge Position
To improve the incisal
display at rest and the
irregular incisal edges (see
Figs 3a and 3b), a direct
composite mock-up was
made on the central incisors
at the pre-determined planned
position (Fig 3c). This was
done directly facing the
patient to reestablish
parallelism between the
occlusal plane and the
interpupillary line and to
reestablish verticality of the
dental midline (Fig 3d). The
composite mock-up was
preserved and transferred to
the diagnostic stone cast (Fig
3e). The mock-up resembled
an inverted “T” effect that
followed the interpupillary
line perpendicular to the
facial midline; it also served
as the reference for the
diagnostic wax-up (Fig 3f).
A polyvinyl siloxane
(PVS) matrix was made of
the mock-up seated on the
stone cast to record the new
incisal edge position (Fig 3g).
The matrix was marked and
trimmed to outline the incisal
edges (Figs 3h and 3i). The
matrix was reseated on the
cast without the composite
resin mock-up, and the space
was filled with wax to
reproduce the incisal edge
position and midline (Figs 3j
and 3k). The flash wax excess
was removed with a wax-
carving instrument (Fig 3l).
The esthetic smile design was
planned using the new incisal
edge position, creating proper
tooth proportions, tooth-to-
tooth proportions, and
gingival outlines, and
fulfilled with the esthetic
wax-up5 (Figs 3m and 3n).
Fig 3a Extraoral frontal view of

facial lower third at rest.
Fig 3b Moderate smile showing
abrasion phenomena on incisal
edges of maxillary anterior teeth.
Fig 3c Direct mock-up was
performed with composite resin.
Fig 3d New incisal edge position
demarcated by reference line.
Fig 3e Composite mock-up
transferred to diagnostic stone cast.
Fig 3f Vertical and horizontal
reference lines established with the
composite mock-up on the cast.
Fig 3g A silicone material is used
to record the new incisal edge
position.
Fig 3h Silicone matrix is marked
for trimming.
Fig 3i Silicone matrix is trimmed
at marked level to create space for
wax.
Fig 3j Silicone matrix is filled with
wax to transfer the new incisal
edge position.
Fig 3k Silicone matrix is removed.
Fig 3l Wax excess is removed.
Fig 3m New incisal edge position
in wax.
Fig 3n Diagnostic wax-up of
maxillary six anterior teeth,
completed at the new incisal edge
position.
The new esthetic smile

design was transferred to the
mouth with an indirect mock-
up so that it could be
reviewed with the patient, and
the patient and clinician could
get a preview of the new
smile (Fig 4). Following the
patient’s approval, a full-
mouth diagnostic wax-up was
made that incorporated the
following: an increase in
VDO to reduce vertical
overlap, anterior
disocclusion, and a leveled
plane of occlusion (Fig 5).
Figs 4a to 4c Intraoral and

extraoral views of the esthetic
indirect mock-up.
Figs 5a to 5c Full-mouth esthetic

wax-up.
Surgical Guide
Fabrication and
Implant Placement
The correct three-dimensional
(3D) implant placement into
an adequately prepared site is
imperative to achieve an
optimal esthetic and
functional implant
restoration. There are three
recommended 3D parameters:
(1) apicocoronal: the implant
position should be 2 to 4 mm
apical to the expected
gingival margin position; (2)
faciolingual: 2 mm of facial
bone is recommended to
prevent the loss of facial
tissue; and (3) mesiodistal:
there should be 2 mm
between an implant and
adjacent teeth and 3 mm
between implants.6–8
Following these
recommendations a
diagnostic wax-up was made
for planning future implant
placement in the positions of
the mandibular right and left
first molars (Fig 6a). The
diagnostic cast with wax-up
was mounted in a surveyor
for planning implant
angulations and positions
(Figs 6b to 6d). A surgical
guide was generated from the
wax-up utilizing a vacuum-
formed thermoplastic
template and orthodontic
acrylic resin (Fig 6e). The
surgical guide was seated
during osseous preparation,
and two 5 × 11-mm implants
were placed in the first molar
sites (Nobel Replace Tapered,
Nobel Biocare) (Figs 6f and
6g).
Fig 6a Stone cast with wax-up at
future implant sites, mandibular
right and left first molars.
Fig 6b Surveyor is aligned with
axis of adjacent teeth.
Fig 6c Planned mesiodistal
position for right first molar
implant.
Fig 6d Wax prototype for surgical
guide.
Fig 6e Surgical guide generated
from the wax-up utilizing a
vacuum-formed thermoplastic
template and orthodontic acrylic
resin.
Fig 6f Osteotomy preparation
using the surgical guide.
Fig 6g Implant placement.
Tooth Preparation
Sequence
The mock-up was made again
and used as a reduction guide
for tooth preservation, a
technique that has been
described for laminate
porcelain veneer preparation
by Gürel9 (Fig 7a). Calibrated
vertical and incisal depth cuts
were made and connected by
preparing half of the tooth on
adjacent teeth; this helped to
maintain the correct axis and
orientation between
preparations (Figs 7b and 7c).
Final anterior and full-mouth
preparations were completed
(Figs 7d and 7e).
Fig 7a Indirect mock-up used as a

tooth-reduction guide.
Fig 7b Calibrated depth cuts.
Fig 7c Adjacent teeth used as
preparation references.
Fig 7d Maxillary anterior
preparations completed.
Fig 7e Full-mouth preparations
completed.
CAD/CAM Provisional
Restorations
The interim restoration plays
an essential role in the
process of full-mouth
rehabilitations. It is
considered the blueprint for
fabrication of the definitive
restoration and should be
identical in all respects except
for the materials from which
it is fabricated.10,11 For this
patient, a CAD/CAM
provisional was fabricated
using the shell technique.
There are several advantages
of this treatment modality: (1)
high strength due to less
porosity, (2) the material is
long lasting, and (3) chairside
time is devoted to relining,
reducing, and polishing the
cervical areas with minimal
occlusal adjustment.12
The full-mouth wax-up
was scanned for fabrication
of CAD/CAM shells (Figs 8a
to 8c). Note the accuracy of
the maxillary shell in
occlusion against the
mandibular shell (Fig 8d).
Provisional restorations were
relined, finished, polished,
and delivered (Figs 8e and
8f).
Figs 8a to 8c CAD/CAM
provisional shell designs.
Fig 8d Maxillary and mandibular
CAD/CAM shells.
Fig 8e Provisionals after relining
and polishing.
Fig 8f Smile view with
provisionals.
Evaluation of
Provisionals
The patient tolerated the
provisional restorations well
over a period of
approximately 8 weeks.
During this time the
occlusion was checked and
adjusted to match the planned
occlusal scheme of the
diagnostic waxing. Prior to
final impressions, the
provisionals were measured
at the occlusal, incisal, and
middle thirds with the
temporary cement still in
place. This allowed the
clinician to determine if the
teeth had been sufficiently
reduced during preparation
(Figs 9a to 9c).
Fig 9a Provisionals with retained

temporary cement.
Fig 9b Measuring occlusal

thickness.
Fig 9c Measuring facial thickness.
Final Impressions
Preparations were cleaned
and pumiced, retraction cord
was placed, and final
impressions were made with
a PVS material (Fig 10).
Fig 10a Preparations are cleaned

with pumice.
Fig 10b Retraction cord is packed.
Fig 10c PVS impression is made.
Wax-up and
Processing of Pressed
Ceramics
Figure 11a shows the wax
design of the definitive
restorations on the master
cast. Wax separator was
applied, the margins were
sealed with inlay/onlay wax
(Schuler-Dental), and the
Ivan Ronald Huanca waxing
tool was used to finish the
margins and to create a
pleasing and natural
emergence profile (Figs 11b
to 11d). Surface texture,
irregularities, and unique
characteristics were verified
to mimic natural morphology
(Figs 11e and 11f). The 3-mm
wax sprues were attached in
the direction of the ceramic
flow at the thickest part of the
wax-up to allow the smooth
flow of the viscous ceramic
during pressing (Fig 11g).
The anterior segment was
pressed utilizing a lithium
disilicate glass ceramic ingot
in Value 3 (IPS e.max Press,
Ivoclar Vivadent). A delicate
divesting process was carried
out using fine glass beads
(Renfert).
Fig 11a Final wax-up of anterior
teeth.
Fig 11b Application of separator.
Fig 11c Sealing the margin.
Fig 11d Finishing the wax margin
and completing the emergence
profile.
Figs 11e and 11f Texture
verification.
Fig 11g Maxillary and mandibular
wax-ups with sprues.
Ceramic Layering
Procedures
The crowns were seated on
the master solid cast. The
crowns were airborne-particle
abraded in the laboratory with
glass beads to improve the
bond between the pressed and
the veneering ceramics. An
initial wash firing using a
combination of Essence stains
and opalescent and mamelon
powders was used to enhance
the bond between the lithium
disilicate and veneering
ceramic (IPS e.max Ceram,
Ivoclar Vivadent) (Figs 12a
to 12c). In the second bake, a
combination of Opal Effect 1,
Opal Effect 2, Opal Effect 3,
BL4 dentin, B1 dentin, and
mamelon powders were used
segmentally to create subtle
contrasts, translucency, and
mamelon effects mimicking a
natural tooth. The entire
build-up was covered with a
thin layer of Opal Effect
1/Bleach Incisal to filter the
internal stucture while
maintaining opalescence
(Figs 12d to 12f).
Fig 12a Pressed IPS e.max
restorations on cast, minimally cut
back at facial third.
Fig 12b First bake: Application of
the stain and powder for a bonding
layer as well as some internal
mamelon-structure effects.
Fig 12c Assessment of wash bake
for color and effects.
Fig 12d Second bake: Opal Effect
(OE) 1 Ceram material in the
interproximal areas.
Fig 12e Segmental ceramic

stratification of opalescent and
enamel powders, OE 1 on corners,
OE 2, OE 3, Bleach incisal, BL4
dentin, and mamelon powders to
create contrasts and high- and low-
value areas.
Fig 12f Initial ceramic

stratification covered by a thin
layer of mixed OE 1 and T1.
Morphologic
Contouring
Procedures
After fitting the crowns to the
master dies, the contacts must
be verified and perfected on
the solid cast in a systematic
manner starting from the
mesial of the central incisors
and moving to the distal of
the canines. Articulating
paper was used to disclose
interproximal contact
interferences for each and
every tooth. Larger
interference marks were
adjusted first (Fig 13). The
morphology of each tooth
was outlined in the facial,
cervical, and interproximal
areas. This provides an
overall preview of the final
proportions and form of the
teeth. It is during this stage
that fine adjustments were
made to visualize the changes
while using the marked
outlines as guides to make the
necessary morphologic
modifications (Fig 14a).
Fig 13a Solid cast.

Fig 13b Start with central incisors
when adjusting interproximal
contacts.
Fig 13c Identify the interproximal
contact interference with
articulating paper between the two
central incisors.
Fig 13d Tight contact between

proximal surfaces.
Figs 13e to 13j Steps in adjustment
of the interproximal contacts.
Fig 13k Proper interproximal

contacts.
Fig 13l It is important to adjust

interferences that cause larger
marks.
Fig 14a Outline of morphology
and surface characteristics to
replicate natural teeth.
Staining and Finishing

To achieve a lifelike
characteristic with the
ceramic, subtle external stain
was used on the surface prior
to glazing. A simple staining
approach was utilized to
achieve this look: blue stain
in the incisal area, white stain
mixed with a cervical shade
for the mamelons, and
cervical color for the basic
hue of the target shade. Pure
white should be applied in the
incisal area but in specific
spots using different
intensities. After staining the
effects, a fixation firing is
carried out to freeze all the
stains in place, followed by
glaze paste application and
hand polishing with silicone
wheels and fine pumice.
Morphology and surface
characteristics are shown in
Figs 14b to 14d, and
definitive anterior
restorations on the solid cast
in Fig 14e.
Figs 14b to 14d Morphology and

surface characteristics.
Fig 14e Completed all-ceramic
restorations on solid casts.
Posterior Segment
Finishing Procedures
Figure 15 shows the wax
designs of the restorations in
the posterior segments.
Completed lithium disilicate
and monolithic screw-
retained zirconia crowns were
placed on the solid casts (Fig
16). The milled monolithic
zirconia implant crown was
cemented to the NT Trading
Titanium Base (Custom
Automated Prosthetics) using
a dual-curing resin cement
(Panavia SA, Kuraray). The
titanium base was airborne-
particle abraded with
aluminum oxide to prepare
the surface and to enhance the
bond to the zirconia. The
screw channel was blocked
with wax to prevent residual
cement from blocking the
screw head. The crown was
airborne- particle abraded
with aluminum oxide, coated
with ceramic primer, and
loaded with the resin cement.
Fig 15a Maxillary wax-up.

Fig 15b Mandibular wax-up.
Figs 16a to 16c Completed all-

ceramic and screw-retained crowns
on solid casts.
The crown was seated on the

titanium base, and excess
cement was removed with a
microbrush prior to light
curing (Fig 17).
Fig 17a NT Trading Titanium
Base and screw for the screw-
retained monolithic crown.
Fig 17b Titanium base on implant

analog.
Fig 17c Airborne-particle abrasion
at 2 bar pressure with aluminum
oxide.
Fig 17d Wax added to the access
hole to protect the screw.
Fig 17e Airborne-particle abrasion
of inside the zirconia crown at 2
bar pressure to prepare the surface.
Fig 17f Application of Clearfil

ceramic primer (Kuraray).
Fig 17g Application of Panavia SA
resin cement (Kuraray).
Fig 17h Removing excess cement.
Try-In and Bonding of

All-Ceramic Definitive
Restorations
The all-ceramic materials
selected for the case were
monolithic zirconia crowns,
stained and glazed, for the
maxillary first molars;
monolithic zirconia screw-
retained implant crowns,
stained and glazed, for the
mandibular first molars; and
pressed monolithic lithium
disilicate crowns, stained and
glazed, for the anterior teeth
and premolars. The
completed restorations were
examined for accuracy of
contacts, fit, contour, and
esthetics. Anterior
restorations were seated and
compared to adjacent
provisional restorations to
evaluate length and anterior
guidance. Adjustments were
made as necessary (Fig 18).
Fig 18 Try-in of definitive
restorations against provisionals:
adjusting the length of definitive
restoration.
The crowns were

prepared for bonding,
prepared teeth were cleaned,
retraction cord was placed
(Ultradent), and adhesive was
applied (Scotch Bond
Universal, 3M ESPE). The
crowns were loaded with
dual-curing resin cement and
seated (RelyX Ultimate, 3M
ESPE), and excess cement
was removed with a brush
and floss. After light curing
for 40 seconds per surface, a
no. 12 scalpel blade was used
to remove excess cement, and
the retraction cords were
removed (Fig 19).
Fig 19a Retraction cord is placed

to control cement flow.
Fig 19b Adhesive is applied to the
prepared tooth.
Figs 19c to 19e Excess cement

cleaned and retraction cords
removed.
CONCLUSIONS
The procedure described in
this article is a full-mouth
rehabilitation completed with
all-ceramic systems, which
restored the patient to an
excellent esthetic outcome as
well as a stable and functional
occlusion (Fig 20). Close-up
views of the smile and
portrait views of the final
restorations are shown in Fig
21. The initial and final
panoramic radiographs
showed a stable bone
condition (Fig 22).
Figs 20a to 20i Postdelivery
intraoral views of definitive
restorations.
Figs 21a to 21c Extraoral lower-

third views.
Fig 21d Portrait frontal view.
Figs 22a and 22b Initial and
posttreatment panoramic
radiographs.
ACKNOWLEDGMENT
The authors thank Nobel
Biocare and The Georgia
Regents University Center for
Excellence for their support
in this case. Dr Jae Seon Kim
is also thanked for his
assistance in sharing his
unique expertise with the
treatment of the patient.
REFERENCES
1. Chiche G, Pinault A. Esthetics
of Anterior Fixed
Prosthodontics. Chicago:
Quintessence, 1993:202.
2. Carlsson GE, Egermark I,
Magnusson T. Predictors of
bruxism, other oral
parafunctions, and tooth wear
over a 20-year follow-up
period. J Orofac Pain
2003;17:50–57.
3. Dylina TJ. A common-sense
approach to splint therapy. J
545.
4. Spear FM, Kokich VG. A
multidisciplinary approach to
esthetic dentistry. Dent Clin
North Am 2007;51:487–
505,X–XI.
5. Chiche G. Proportion, display,
and length for successful
esthetic planning. In: Cohen
M (ed). Interdisciplinary
Treatment Planning:
Principles, Design,
Implementation. Chicago:
Quintessence, 2008.
6. Tarnow DP, Cho SC, Wallace
SS. The effect of inter-implant
distance on the height of inter-
implant bone crest. J
Periodontol 2000;71:546–549.
7. Salama H, Salama MA,
Garber D, Adar P. The
interproximal height of bone:
A guidepost to predictable
aesthetic strategies and soft
tissue contours in anterior
tooth replacement. Pract
Periodontics Aesthet Dent
1998;10:1131–1141.
8. Davarpanah M, Martinez H,
Tecucianu JF. Apical-coronal
implant position: Recent
surgical proposals. Technical
note. Int J Oral Maxillofac
Implants 2000;15:865–872.
9. Gürel G. Predictable, precise,
and repeatable tooth
preparation for porcelain
laminate veneers. Pract Proced
Aesthet Dent 2003;15:17–24.
10. Torosian A, Arias S.
Provisionalization of dental
implants in the esthetic zone:
A Blueprint for Success.
Labline 2013;3(1):116– 123.
11. Higginbottom FL. Quality
provisional restorations: A
must for successful restorative
dentistry. Compend Contin
Educ Dent 1995;16:442, 444–
447.
12. Chiche G. Improving
marginal adaptation of
provisional restorations.
Quintessence Int
1990;21:325–329.
_________________________
1 Esthetic and Implant Fellow,
Ronald Goldstein Center for

Esthetic and Implant Dentistry,
Georgia Regents University,
College of Dental Medicine,
Augusta, Georgia, USA.
2 Master Dental Ceramist, Ronald

and Implant Dentistry, Georgia
Regents University, College of
Dental Medicine, Augusta,
Georgia, USA.
3 Assistant Professor, Ronald
and Implant Dentistry, Georgia
Regents University, College of
Dental Medicine, Augusta,
Georgia, USA.
4 Director, Ronald Goldstein
Center for Esthetic and Implant
Dentistry, Georgia Regents
University, College of Dental
Medicine, Augusta, Georgia,
USA.
Correspondence to: Dr Sergio
R. Arias, College of Dental
Medicine, Georgia Regents
University Augusta, 1430 John
Wesley Gilbert Dr, Augusta, GA
30912.
Biologic
Esthetics by
Gingival
Framework
Design:
Part 1. Factors
for Achieving
Biologic and
Esthetic
Harmony
Yuji Tsuzuki, RDT1
B
iologic esthetics
means genuine oral
esthetics, which is the
result of the biologic
harmony of the prosthesis.
The cervical design of the
prosthesis is as important as
the coronal design in
achieving the most favorable
esthetic result. All factors—
esthetics, biology, function,
and structure—need to be
satisfied to lead to successful
prosthetic treatment. Each
clinical and laboratory step
should be performed well to
achieve the treatment goal
(Fig 1).
Fig 1 When the “prosthetic triangle

concept” is applied, the prosthesis
should first be designed to
eliminate biologic risk and create a
biologically stable environment.
Second, the prosthesis should be
structurally sound for long-term
stability. Third, function is
guaranteed on a solid structure.
Even though esthetics and function
are considered two sides of the
same coin, esthetics still should be
considered after creating a sound
foundation. All factors are equally
important, and requirements have
to be fulfilled to achieve a
harmonious prosthesis.
Factors for achieving

biologic and esthetic harmony
are presented in this article.
The potential and the
limitations of prosthetic
treatment are presented and
discussed through clinical
cases.
KNOWLEDGE OF
SURROUNDING
PERIODONTAL
TISSUES
Clear Understanding
of Healthy Periodontal
Tissue
If the prostheses are to obtain
biologic harmony with
periodontal tissues, control of
inflammation is an important
factor (Fig 2). Prosthetic
considerations for controlling
gingival inflammation
include (1) marginal fit, (2)
morphologic control
(subgingival morphology),
and (3) surface texture (Figs 3
to 5). Subgingival prosthetic
morphology is designed
according to the periodontal
environment, which is quite
different in the natural
dentition from that which
surrounds an implant. The
prosthetic treatment result
will be affected by the
periodontal condition,
including hard and soft tissue.
Greater care must be paid as
the prosthesis is extended
more subgingivally. It is
critical to have a thorough
knowledge of healthy
periodontal tissue and to be
able to recognize how it
differs around a natural tooth
and an implant (Fig 6).
Consideration given to
periodontal tissues in
different prosthetic
environments is presented in
Figs 7 to 10.
Fig 2 Prosthesis with proper

subgingival contour on the left
central incisor reflects biologic
harmony.
Fig 3 Importance of subgingival
contour, or the harmonization of
the prosthesis with periodontal
tissue, is illustrated by this
implant-supported fixed dental
prosthesis.
Fig 4 Smooth surface texture of the
enamel of a natural tooth.
Fig 5 Sectional view of IPS e.max
CAD lithium disilicate glass-
ceramic material and IPS e.max
Ceram Glaze Paste (Ivoclar
Vivadent) as seen under an
electron microscope. Note the fine,
smooth surface of the Glaze Paste.
The area of a crown that contacts
the gingiva is not finished with a
self-glaze, but instead with Glaze
Paste to improve gingival tissue
response.
Fig 6 Concept of biologic width

(Tsuchiya, 2010). (Illustration
from Yamazaki, 2004. Reprinted
with permission.)
Fig 7a Porcelain laminate veneer
restorations on the maxillary
central incisors. Particular
consideration for periodontal
tissues is not necessary when the
margin is placed supragingivally.
Fig 7b Veneers after insertion.
Gingival tissue health around the
restorations as well as around
adjacent natural teeth is
maintained. (Courtesy of Dr
Takashi Ueno, Ito Dental Clinic,
Japan.)
Fig 8a Fractured maxillary left
central incisor due to trauma
prepared for an all-ceramic
restoration. The preparation was
minimally invasive with margins
placed at the gingival level.
Fig 8b Greater attention can be
paid to esthetic elements such as
color and surface texture during
crown fabrication when minimal
consideration to gingival tissues is
necessary. (Courtesy of Dr
Tsutomu Kubota, Kubota Dental
Clinic, Japan.)
Figs 9a and 9b Combination of
prostheses on natural teeth and on
an implant. The subgingival
prosthetic morphology differs
along with differing prosthetic
conditions. With advanced surgical
techniques and materials, a highly
esthetic result including gingival
margin areas can be obtained.
Fig 10 Illustration of degree of
difficulty according to the
prosthetic condition. The difficulty
in achieving biologic harmony
increases as treatment involves a
more subgingival area.
Gingival Framework
and Incisal
Framework as
Evaluation Criteria
Recovery and maintenance of
healthy gingival tissue is the
major premise for esthetic
restorative treatment. A
comprehensive approach
including surgical and
orthodontic treatment in
addition to the prosthetic
treatment is indicated to
improve the prosthetic
condition and to achieve a
highly esthetic result.
Proper tooth alignment is
an absolute requirement when
composing an esthetic and
functional dentition.
Continuity and symmetry of
the gingival line (the gingival
framework [Tsuchiya, 2010])
are as important as continuity
and symmetry of the incisal
line (the incisal framework
[Tsuchiya, 2010]) in
producing esthetics that
achieve harmony with the
lips. In esthetic restorations,
the gingival/incisal
framework (defined as the
esthetic framework in this
article) is an important
evaluation criterion in the
design of a prosthesis with a
harmonized esthetic result
(Fig 11).
Fig 11 Gingival framework (dotted

line) and incisal framework (solid
line) of the dentition. Symmetry
and harmonized continuity are
factors for an esthetic result.
An example of managing
the gingival framework using
a prosthetic approach is
shown in Case 1 (Fig 12).
The chief complaint of this
patient, a female in her 40s,
was the color of the crown on
the maxillary right central
incisor, which did not match
the contralateral tooth.
CASE 1
Managemen
of the
Gingival
Margin
with a
Provisional
Restoration
Fig 12a The patient presented
with a gingival discrepancy and
undesirable color and shape of
the crown on the maxillary
right central incisor. The
gingival discrepancy was
corrected by subgingival
contouring of the prosthesis
without a surgical procedure.
Fig 12b Provisional

restoration. Several
adjustments were performed,
bringing the finish line
subgingivally to modify the
gingival architecture to the
ideal condition. Once a
harmonized gingival
framework was established by
the provisional restoration, the
final prosthesis was fabricated.
Fig 12c Definitive prosthesis

(IPS e.max Press, Ivoclar
Vivadent). The gingival line
was corrected by duplicating
the gingival contour of the
provisional restoration. A
thorough examination and
diagnosis are mandatory to
determine if surgical
intervention is indicated.
Fig 12d Two weeks after
insertion. The harmonized
gingival adaptation can be
appreciated because of proper
prosthetic contouring and
biocompatibility of the
ceramics. (Courtesy of Dr
Hiroyuki Takino, Takino
Dental Clinic, Japan.)
Case 2 describes the half-

pontic technique, another
method of using a prosthetic
approach to manage the
gingival framework (Fig 13).
The patient, a female in her
40s, was dissatisfied with the
esthetics of her anterior
crown. Her chief complaint
was resolved with treatment
of the maxillary right and left
central incisors and left lateral
incisor.
CASE 2
Improvemen
of the
Gingival
Framework
Using a
Half-
Pontic
Technique
Fig 13a Preoperative
photograph. The interproximal
space between the maxillary
left central and lateral incisors
is restored with a crown on the
central incisor and a distal
pontic. There is a size
discrepancy with the
contralateral teeth.
Fig 13b Dentition after

removal of the existing
restoration.
Fig 13c Direct composite resin
was added to the right central
and left lateral incisors as a
diagnostic step to balance the
width of the anterior teeth. It is
performed within the normal
limit of natural teeth with the
patient’s consent.
Fig 13d Porcelain partial
laminate veneer restorations for
the right central and left lateral
incisors.
Fig 13e Postoperative view of
the porcelain partial laminate
veneers and an all-ceramic
crown on the left central
incisor (IPS e.max Press). The
veneers were fabricated using
the staining method and the all-
ceramic crown using the cut-
back method.
Fig 13f The gingival

framework was harmonized
with the rest of the dentition
using a half-pontic technique,
and balanced width of the
dentition was also restored.
(Courtesy of Yamaba Dental
Clinic, Japan.)
POTENTIAL AND
LIMITATIONS OF
PROSTHODONTIC
TREATMENT
In prosthodontic
treatment, the dental
technician should be
involved at the
treatment-planning
stage so that
constructive
suggestions can be
made to organize an
effective and well-
thought-out treatment
plan and goal. It is also
important to recognize
limitations of
prosthodontic
materials and
techniques. There are
treat ment obstacles
that a prosthodontic
approach cannot over-
come. An
interdisciplinary
approach is important
to set a reasonable
treatment goal and to
construct the treatment
plan. The prosthetic
approach to improving
the prosthetic
condition is described
in Table 1.
Table 1 Prosthetic
Approaches to
Treatment with
Limitations and
Risks
Cases 3 and 4 show how
the limitations of
prosthodontic treatment
affected the patients’ therapy.
The patient in Case 3 did not
accept the proposed
orthodontic treatment for her
malaligned maxillary right
central incisor. The chief
complaint of the patient, a
female in her 40s, was “I am
not happy with the color of
my front crown” (Fig 14).
Case 4 presents the treatment
of a male patient in his 50s
with the chief complaint of
being unhappy with the
esthetics of his anterior fixed
dental prosthesis. Fabrication
of a new fixed dental
prosthesis from the maxillary
left central incisor to the left
canine was accompanied by
reshaping of the right central
incisor (Fig 15).
CASE 3 Refusal of
Orthodontic
Treatment
Figs 14a to 14d Even though

orthodontic treatment was
indicated and recommended to
treat the malaligned maxillary
and mandibular dentition, the
patient refused it. The case was
managed only by prosthetic
treatment. Root canal therapy
and a crown (IPS e.max Press)
on the maxillary right central
incisor and enameloplasty of
the maxillary left central
incisor were indicated as a
consequence.
CASE 4 Esthetic
Rehabilitati
with
Remaining
Functional
Risk
Fig 15a Orthodontic treatment
was indicated to improve
function and esthetics.
However, the patient refused
the recommended treatment
because of time restrictions.
The case was managed only by
prosthodontic treatment.
Figs 15b and 15c Lack of
prosthetic space was identified
as being due to the mesial tilt
of the maxillary right central
incisor. It was adjusted by (1)
reshaping its mesial aspect
(enameloplasty at the incisal
edge area and additive
composite resin at the cervical
area) and (2) placing a partial
laminate veneer restoration on
the distal aspect. The size and
long axis of the tooth were
corrected at the clinical crown
level.
Figs 15d and 15e The

available prosthetic space and
shape of the fixed partial
denture from the left central
incisor to the left canine were
improved by reshaping the
right central incisor. As a
result, the esthetics of the
maxillary anterior area was
dramatically improved.
However, the fundamental
functional problem was not
resolved.
Case 5 illustrates the

potential of prosthodontic
treatment to improve gingival
levels by controlling
subgingival contour. The
patient, a male in his 20s,
complained of dissatisfaction
with the color of the two
crowns on his maxillary
central incisors (Fig 16).
CASE 5
Improvemen
of
Gingival
Levels by
Controlling
Subgingival
Contour
Figs 16a to 16d The patient

presented with two short
clinical crowns and an
unbalanced gingival
framework. The gingival level
was corrected by controlling
the subgingival contour of the
prostheses without surgical
treatment. When the
subgingival area is involved,
priority is given to biologic
compatibility of the prosthesis
and periodontal tissue.
Prosthetic treatment is still
effectively utilized after proper
diagnosis and treatment
procedure (IPS e.max Press).
(a) Pretreatment; (b) abutment
preparation; (c) provisional
restoration; (d) definitive
restoration. (Courtesy of Dr
Tsutomu Kubota, Kubota
IMPORTANCE OF A
TEAM APPROACH
As mentioned before,
prosthetic treatment has its
limitations and it is
impossible to manage all
cases by a prosthetic
approach alone. The
technician should have
enough understanding and
knowledge of other treatment
options to be able to offer
appropriate suggestions that
can contribute to the
development of the treatment
goal and plan accordingly.
The importance of a
comprehensive team
approach is illustrated in Figs
17 to 20. Two examples of
the use of diagnostic tools
combined with surgical or
orthodontic treatment are
shown in Figs 17 and 18.
Other treatment options can
be combined with surgical
and orthodontic treatment in
improving the gingival
framework. The results of a
treatment plan combining
orthodontics and
prosthodontics are shown in
Fig 19. Periodontal plastic
surgery and prosthodontics
are also often integrated with
excellent results (Fig 20).
Diagnostic Tools +
Orthodontic/Implant
Treatment
Figs 17a to 17c Orthodontic and

implant combined case. Diagnostic
tooth alignment and wax-up on the
articulator simulates the final
occlusion, implant position, and
prosthesis.
Diagnostic Tools + Surgical

Treatment
Figs 18a and 18b Study cast with

simulation of gingival graft.
Gingival graft model is fabricated
of self-curing resin to make it
retrievable. The dentist can easily
estimate the size of the graft with
the removable tissue model.
Orthodontics +
Prosthodontics
Figs 19a and 19b The purpose of

orthodontic treatment is to improve
function and esthetics by
realigning teeth into their proper
positions. The condition of the
periodontal tissue (both hard and
soft tissues) may improve along
with orthodontic tooth movement.
As a result, the prosthodontic
condition improves as well. In this
case, proper prosthetic space and
gingival framework were achieved
by orthodontic expansion of the
dentition (crowns, IPS e.max
Press). (Courtesy of Dr Hiroyuki
Takino, Takino Dental Clinic,
Japan.)
Periodontal Plastic Surgery +

Prosthodontics
Figs 20a and 20b A crown-

lengthening procedure was
combined with prosthodontic
treatment in this patient who
presented with persistent
inflammation and violation of
biologic width. A surgical
approach was indicated.
Periodontal surgery was performed
prior to prosthodontic treatment to
obtain predictable biologic
compatibility. Proper contour and
prosthetic materials play important
roles in maintaining the health of
the periodontal tissue (crowns, IPS
e.max Press). (Courtesy of Dr
Kotaro Nakata, Nakata Dental
Clinic, Japan.)
CONCLUSIONS
This article has discussed and
illustrated the importance of
periodontal tissue
consideration and gingival
design for successful
prosthetic treatment. There
are close correlations between
esthetics and biology. The
combination of proper
preprosthetic and prosthetic
treatment plays an important
role in obtaining esthetic and
predictable results. It is not
possible to achieve these
goals with a prosthetic
approach alone.
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_________________________
1 Dental Technician, Kyoto,
Japan.
Correspondence to: Yuji
Tsuzuki, Ray Dental Labor, Elitz
Yamashina Building 3F, 18-8
Takehanatakenokaidocho
Yamashinaku, Kyoto City,
Kyoto, Japan.
Email:
[email protected]
Maintaining the
Esthetics of
Anterior Teeth
with a Flapless
Single-Tooth
Immediate
Implant
Placement
Cristiano Soares,
CDT1
Luciana Mara Soares,
DDS2
Guilherme Ferreira
Duarte, DDS2
Neimar Sartori, DDS,
MS, PhD3
he majority of patients today

are looking for esthetic dental
treatments. One of the biggest
esthetic challenges is
T the restoration of a
single anterior tooth
with an implant-
supported prosthesis. In this
treatment it is important to
mimic all lost structures—
such as bone level, soft tissue,
and clinical crown—as
closely as possible to those of
the contralateral tooth.1 The
final results are influenced by
the shape and position of the
implant, soft tissue
management during the
surgery, design of the
provisional restoration, type
of abutment, and
characteristics of the
definitive restoration.
Predictable esthetic
results can be achieved when
the oral situation is correctly
diagnosed, followed by the
execution of an adequate
treatment plan. Therefore,
some details must be assessed
before implant placement,
such as integrity of the bony
walls, quantity of apical bone,
gingival recession,
periodontal biotype, and
absence of acute infection.
The skills of the clinician and
technician are also important
in achieving predictable
results.
A crucial factor for the
esthetic outcome of the
definitive restoration is the
emergence profile, which
must be defined initially by
Moreover, the materials and
techniques selected for both
the abutment and restoration
influence the final result. In
some cases, a customized
abutment must be fabricated
to guarantee an esthetically
adequate definitive
restoration.
The improvement of
implant techniques associated
with modern restorative
materials has allowed the
development of other options
to create customized implant-
supported crowns. Therefore,
the aim of this article is to
describe, through a clinical
case report, how to
esthetically customize a
prefabricated zirconia
abutment with an adequate
emergence profile.
CASE REPORT
Diagnosis and
Treatment Planning
A 34-year-old female patient,
healthy and a nonsmoker,
came to the authors’ clinic
complaining of mobility and
extrusion of the maxillary left
central incisor (Fig 1).
Clinical examination
indicated that the mobility
was due to a subgingival
horizontal fracture of the root.
Radiographic evaluation (Fig
2) showed a satisfactory
endodontic treatment,
absence of intraradicular
retainers, and an increase in
the periodontal ligament
space without a radiolucent
lesion in the periapical area.
Fig 1 Initial intraoral view of
the maxillary anterior teeth.
Fig 2 Periapical radiograph of
the maxillary central incisor.
Clinical examination with

a periodontal probe (15 UNC
Color-Coded Probe, Hu-
Friedy) revealed that the
probing depth did not exceed
3 mm in any of the examined
areas (Fig 3). The subgingival
root fracture, approximately 4
mm from the gingival margin,
was confirmed during the
periodontal examination.
However, no fracture of the
buccal plate of bone was
detected. Neither acute
infectious process nor
gingival recession was
observed during the clinical
examination. The oral
hygiene of the patient was
satisfactory, with only minor
accumulation of plaque and
supragingival calculus.
Fig 3 Periodontal examination
indicated that there was no
fracture of the bone around the
fractured tooth.
It was also observed that

the patient had a flat and
thick periodontal biotype,
with an excellent profile of
gingival tissue and
preservation of the proximal
alveolar crests. A cone beam
computed tomography
(CBCT) scan confirmed that
the buccal bone plate was
preserved and revealed an
adequate amount of apical
bone available for the implant
placement.
Based on clinical,
radiographic, and CBCT scan
examinations, the best
treatment option for this
patient was extraction of the
tooth followed by immediate
implant placement and
provisionalization using the
patient’s own natural crown.
Immediate Implant
Surgery
To maintain the integrity of
bone and gingival tissue
around the maxillary left
central incisor, the crown was
removed using a forceps for
primary teeth without
touching the gingiva (Fig 4).
The remaining tooth root was
then prepared for the use of a
device for mechanical vertical
atraumatic root extraction
(Benex-Control Professional
Root Extraction System,
Meisinger) (Fig 5). The main
goal of using this device is to
decrease the forces on the
socket walls, providing a
conservative and minimally
traumatic extraction.
Fig 4 Tooth crown extraction
using a forceps for primary
teeth.
Figs 5a and 5b Atraumatic
root extraction.
The extraction socket was

carefully curetted to confirm
the integrity of the bony
walls. An implant (4.1 × 10-
mm Bone Level RC-SLA,
Straumann) was placed in its
ideal three-dimensional
position (Fig 6). The platform
of the implant was placed 4
mm below the future gingival
margin of the prosthetic
crown, which would permit
the creation of an ideal
emergence profile for the
future abutment2 (Fig 7).
Good primary stability
(approximately 25 Ncm) of
the implant was achieved but
was not adequate for
immediate provisionalization.
A 0.5-mm closure screw
(Straumann) was then placed.
Fig 6 Flapless implant

placement.
Fig 7 Implant placed at 4 mm
below the gingival margin and
confirmed using a periodontal
probe.
The gap between the

implant and facial socket
bony wall (Fig 8) was filled
with an anorganic bovine
bone matrix (Bio-OSS,
Geistlich) (Fig 9) to
compensate for the natural
reduction of the socket that
occurs after tooth
extraction.3–5 Because the
patient had a thick tissue
biotype, it was unnecessary to
place a connective tissue
graft.6 A gingival graft with a
similar shape as the socket
and with approximately 2 mm
of thickness was placed and
stabilized by four interrupted
sutures7 (Fig 10). This suture
technique aims to seal and
protect the bone graft and
implant and prevents the
collapse of the gingival
margins and papillae that
occur after extraction.
Fig 8 Best position for the
implant.
Fig 9 The gap was filled with
anorganic bovine bone matrix.
Fig 10 Free gingival graft

placed and stabilized with four
interrupted sutures.
Provisionalization
with Patient’s Natural
Crown
The patient’s extracted crown
was first stored in saline
solution and, after the implant
placement, used to fabricate
The pulpal chamber of the
patient’s crown was cleaned
using a coarse diamond. The
pulpal chamber was then
etched with 35% phosphoric
acid for 15 seconds. It was
rinsed and dried, and an
adhesive system was applied,
which was light cured for 20
seconds. The chamber was
filled with a flowable
composite (Sinfony, 3M
ESPE) to build the correct
shape of the cervical area (Fig
11). The contours of the
provisional restoration were
finished and polished using
flexible aluminum oxide
abrasive disks (Sof-Lex
Finishing and Polishing
System, 3M ESPE) to create
an adequate restoration
emergence profile (Fig 12).
The proximal surfaces of both
the provisional restoration
and adjacent teeth were
etched, rinsed, and coated
with primer and bonding
agent. The provisional
restoration was placed in an
adequate position, bonded to
the adjacent teeth using
composite resin (Filtek
Supreme Ultra, 3M ESPE),
and light cured for 40 seconds
(Fig 13). The occlusion of the
patient was checked, leaving
the prosthesis free of contacts
with the opposing teeth.
Fig 11 The pulpal chamber of
the extracted crown was filled
with a flowable composite
resin.
Fig 12 Provisional restoration
finished and polished with an
adequate emergence profile.
Fig 13 Provisional restoration
bonded to the adjacent teeth
using composite resin.
The patient was instructed

to suspend dental brushing in
that region and to rinse her
mouth with 15 mL of 0.12%
chlorhexidine solution for 1
minute every 12 hours for 14
days. The sutures were
removed 15 days after
surgery. Thirty days after
implant placement, a
favorable esthetic outcome,
contours, and symmetry of
the gingival tissue were
observed (Fig 14).
Fig 14 Clinical appearance 30
days after implant placement.
Screw-Retained
Provisionalization
Four months after the implant
placement, bone levels and
gingival contours were in an
adequate position. Because a
sufficient amount of soft
tissue was available, an
incision slightly shifted
toward the lingual was
performed to expose the
cover screw (Fig 15). The
cover screw was removed, a
prefabricated titanium
abutment (Straumann) was
screwed into position, and the
implant shoulder was
prepared prior to provisional
repositioning and adjustment.
Fig 15 Exposure of the cover
screw.
The internal portion of the

patient’s natural crown was
prepared to fabricate a screw-
retained provisional
restoration. The internal
portion of the crown was
cleaned and etched followed
by rinsing, drying, and
adhesive system application.
The prepared crown was
repositioned and connected to
the prefabricated titanium
abutment in the mouth using
a flowable composite resin
(Sinfony) (Fig 16). The voids
were filled using the same
composite resin, and proper
contouring and polishing
were carried out in the
laboratory (Fig 17). After the
final adjustments, the
provisional restoration was
screwed into position to
support the soft tissue,
creating a gingival emergence
profile and contour similar to
the contralateral maxillary
central incisor.
Fig 16 The patient’s own
crown was adapted to a
prefabricated titanium
abutment with flowable
composite resin.
Fig 17 View of the screwed-
retained provisional restoration
after filling voids with
composite resin, finishing, and
polishing.
At the 30-day follow-up

examination, adequate
contour and position of the
gingiva, guided by the correct
shape of the subgingival
portion of the provisional
restoration, were noted (Figs
18 and 19). The emergence
profile of the provisional
restoration should contain
two specific areas: one is
concave, about 1 mm
subgingival and continuing
for 360 degrees around all
margins of the provisional
restoration, to provide a
nonsurgical increase in tissue
thickness and long-term
stability; the interproximal
subgingival area of the
provisional restoration should
be convex to support the
papillae. Furthermore,
excellent finishing and
polishing of the emergence
profile of the provisional
restoration is indispensable
for precise soft tissue
management.8,9
Fig 18 Clinical appearance 30

days after placement of the
screw-retained provisional
restoration.
Fig 19 Periapical radiograph of

the maxillary central incisors.
Shade Selection
The use of digital
photographs for shade
selection is essential for
correct visual communication
with the dental technician.
This protocol for shade
selection with digital
photographs is quite simple
and effective; however, some
factors should be respected.
To correctly select the hue,
chroma, and value, a
photograph should be taken
with four shade guides (Vita
Classical Lumin Vacuum
shade guide, VITA) similar to
the tooth shade and
positioned at the same level
as the teeth (Fig 20).
Fig 20 Shade selection using
digital photography of the
anterior maxillary teeth.
A close-up photograph
with a black background
should be taken to evaluate
details such as mamelons,
translucence, opalescence,
incisal halo, regions with
higher and lower value, and
presence of staining. The
photograph can be
manipulated using photo-
editing software to increase
its contrast and sharpness and
to decrease the brightness to
highlight these
characteristics6 (Fig 21).
Fig 21 Close-up photograph of

the maxillary central incisors
with increased contrast and
reduced brightness for better
visualization of the tooth
details.
Final Impression
Using a Customized
Impression Post
After obtaining an adequate
emergence profile, it is
important to customize the
impression post to transfer
the provisional subgingival
contours along with the
implant position. The most
common method of
transferring the provisional
contours and preventing
gingival tissue collapse is to
use putty and acrylic resin.
The provisional
restoration was removed and
connected to a laboratory
analog, and an impression of
the subgingival contours of
the provisional restoration
was taken using condensation
silicone laboratory putty
(Zetalabor, Zhermack). The
provisional was removed
from the laboratory analog,
and the impression post (RC
Impression Post, Straumann)
was connected to the
laboratory analog. The space
between the impression post
and the putty was then filled
with a self-curing acrylic
resin (Pattern Resin LS, GC
America).
After acrylic resin
polymerization, the
customized impression post
was connected to the implant.
A previously fabricated
custom-made impression tray
was placed in position and
perforated to allow the
impression post to stick out,
which is necessary for the
opentray impression
technique (Fig 22). A single-
step impression was taken
using a vinyl polysiloxane
(VPS) impression material
(Virtual XD, Ivoclar
Vivadent). After VPS
polymerization, the screw
was uncovered and loosened
before removal of the
impression from the patient’s
mouth (Fig 23).
Fig 22 Customized impression
post connected to the implant
to transfer the provisional
subgingival contours.
Fig 23 Impression with the
customized impression post in
position.
Laboratory Phase
Master Cast
Fabrication
The implant laboratory
analog was placed and
attached to the impression
post to accurately replicate
the implant orientation and
position on the master cast.
The soft tissue surrounding
the implant was duplicated
using a resilient addition
silicone developed for
gingival reproduction on
models (Gingifast Rigid,
Zhermack). The excess soft
tissue was trimmed, and the
master cast was poured with
stone (Noritake Super Rock
EX, Kuraray) (Fig 24). The
removable soft tissue ensures
that the emergence profile of
the abutment and crown has
an optimal contour (Figs 25
and 26).
Fig 24 Fabrication of the
emergence of the abutment and
crown with a removable soft
tissue analog.
Fig 25 Facial view of the
master cast with the removable
soft tissue.
Fig 26 Incisal view of the
master cast with the removable
soft tissue.
Wax-up and
Laboratory Correction
of the Gingival
Asymmetry
The wax-up of the definitive
restoration must replicate the
height, volume, and contours
of the contralateral maxillary
right central incisor (Figs 27
and 28). After finishing the
wax-up of the definitive
restoration on the master cast,
two silicone indices, one from
the labial and another from
the palatal surface, were
made with condensation
silicone laboratory putty
(Zetalabor). The waxed
crown was then removed
from the master cast to
expose the soft tissue analog.
A line marking the ideal
transition position between
the crown (based on the
definitive wax-up) and the
soft tissue was drawn on the
indices using a blue pencil.10
The indices were pressed
against the master cast to
indicate the correct gingival
margin position of the
maxillary left central incisor11
(Fig 29). The gingival margin
was then reshaped using a
round diamond-coated bur
(Fig 30).
Fig 27 Facial view of the

master cast with the definitive
wax-up.
Figs 28a and 28b Left and

right profile views of the
definitive wax-up.
Figs 29a and 29b Silicone
indices pressed against the
master cast after removing the
waxed crown.
Fig 30 Gingival reshaping with

a round diamond-coated bur to
create an adequate emergence
profile for the definitive
restoration.
Customization of the
Implant Abutment
A prefabricated anatomically
shaped zirconium oxide
abutment (Straumann
Anatomic/IPS e.max
Abutment, Straumann) was
selected and connected with
the laboratory analog (Fig
31). The abutment was
customized using abrasive
instruments under light
grinding pressure (Fig 32).
The emergence profile and
the final shape of the
abutment were modified with
acrylic resin (Pattern Resin
LS) to meet the requirements
of the material for
cementation of the definitive
restoration (Fig 33). The
customized abutment was
invested with phosphate-
bonded investment material
(IPS PressVEST Speed,
Ivoclar Vivadent), and
subsequently a fluorapatite
glass-ceramic ingot (IPS
e.max ZirPress, Ivoclar
Vivadent) was pressed onto
the zirconium oxide
following the manufacturer’s
instructions (Fig 34).
Fig 31 Prefabricated
anatomically shaped zirconium
oxide abutment in position.
Fig 32 Abutment reshaped to
create adequate space to
accommodate the veneering
ceramic.
Fig 33 Abutment
customization with acrylic
resin.
Figs 34a and 34b Customized
abutment before and after
pressing a fluorapatite glass-
ceramic ingot onto the
prefabricated zirconium oxide
abutment.
The main goal of using a

customized abutment is to
properly restore both the
shape and the optical
properties, such as color,
translucency, opacity, and
fluorescence, of the lost tooth
structure12 (Figs 35 and 36).
The abutment design should
provide excellent adaptation
as well as biologic stability of
peri-implant soft tissues. It
was possible to create an
abutment emergence profile
with gentle curves with the
margin located 1 mm
subgingival because the
implant was placed 4 mm
from the buccal gingival
margin (Fig 37).
Fig 35 Sequence of abutment

customization based on the
natural central incisor root
morphology.
Fig 36 Image of the

customized abutment
superimposed on a natural
central incisor tooth.
Fig 37 Customized abutment
final shape.
Ceramic Application
A lithium disilicate coping
(IPS e.max Press, Ivoclar
Vivadent) was fabricated
using the press technique to
support the layering ceramic.
The coping was sand-blasted
with type 100 Al2O3 at 1 bar
(15 psi) pressure and then
cleaned with a steam jet to
remove any dirt and grease.
The definitive restoration was
then fabricated using a
nanofluorapatite layering
ceramic (IPS e.max Ceram,
Ivoclar Vivadent).
A thin layer of IPS e.max
Ceram Build-up Liquid was
first applied in the coping for
the wash firing. A layer of
DD A1 was applied on the
cervical area to reproduce the
deep dentin, followed by a
layer of D A1 + 20% D BL2
on the middle third to restore
the superficial dentin (Fig
38). After the dentin
stratification, the positions of
the mamelons were defined to
create a restoration with a
natural incisal third (Fig 39).
Vertical layers of ceramic D
A1 + 20% D BL2, extending
from the labial to the lingual
surface, were applied to give
a natural appearance to the
crown (Fig 40). The space
among the mamelons and the
incisor proximal contours
were filled with E1 + 10% T
blue, and a layer of MM
salmon was applied over the
mamelons to adequately
replicate the incisal third.
Finally, two horizontal bands
of ceramic E 03 were applied
to the cervical and middle
third, as well as stripes of
White Stain to the incisal
third (Fig 41). The restoration
was then fired according to
the firing parameters to
stabilize the ceramic layers in
the correct position (Fig 42).
Fig 38 Lithium disilicate
coping after the wash firing
and application of the deep and
superficial dentin.
Fig 39 Application of the
ceramic using the stratification
technique.
Fig 40 Ceramic cutback to
define the mamelon positions.
Fig 41 Creating the incisal
optical properties.
Fig 42 Appearance of the
restoration after the second
firing.
After firing, a second

layer of ceramic was
reapplied to compensate for
the shrinkage, complete the
missing areas, and enhance
the natural appearance of the
definitive restoration. A layer
of ceramic CT Orange was
applied on the cervical, and E
01 + E 02 mixed 1:1 and TS2
on the middle third. The
application of ceramic on the
mamelons and incisal third
was repeated as
aforementioned (Fig 43). The
restoration was submitted to a
third firing cycle (Fig 44).
Fig 43 Application of the

ceramic to create the correct
contour of the restoration.
Fig 44 Appearance of the
restoration after the third firing.
Creation of Adequate
Surface Texture
After finishing the firing
cycle, the first step to
replicate the morphology of
the contralateral tooth is to
roughen the entire crown with
a fine-grained diamond bur.
Next, the position of the
mesial and distal line angles
were marked with purple, and
the ideal position of the line
angles, based on the adjacent
central incisor, were marked
with a green pencil (Fig 45a).
The ideal position of the line
angles, shape, and superficial
texture were then created
using the patient’s maxillary
right central incisor as
reference (Figs 45b and 46).
Figs 45a and 45b Defining and

correcting the position of the
mesial and distal line angles.
Fig 46 Facial surface texture of

the restoration.
The crown was placed in

position without any glaze
(Figs 47 and 48). The shape
of the restoration, superficial
texture, position of the
contact points, and gingival
zenith were checked and
adjusted during the try-in of
the restoration. Any needed
shade corrections can be done
with external characterization
before glazing. After glazing,
the luster of the restoration
was adjusted using polishing
abrasive rubber points (Exa
Cerapol, Edenta).
Fig 47 Placing the abutment in

position.
Fig 48 Trying in the restoration
with-out glaze for final
adjustment of the gingival
zenith, as well as shape and
color corrections.
Restoration
Cementation
After confirming the adequate
position of the restoration,
both abutment and restoration
were cleaned with the steam
jet. The abutment (external
surface) and the crown
(intaglio surface) were etched
with 5% hydrofluoric acid
(IPS Ceramic Etching Gel,
Ivoclar Vivadent) for 20
seconds.13 The etching agent
was rinsed off under running
water for 60 seconds and then
placed in an ultrasonic bath
for 5 minutes to remove any
residual etching agent. The
restoration and abutment
were dried with a stream of
air, a universal primer for
conditioning glass ceramic
restoration (Monobond Plus,
Ivoclar Vivadent) was applied
for 60 seconds, and any
remaining excess primer was
dispersed with a strong
stream of air.13
Because of the stability of
the soft tissue, the abutment
was tightened with a final
torque of 35 N. The screw
access hole of the abutment
was sealed with
polytetrafluoroethylene tape
and composite resin. A
retraction cord (Ultrapack,
Ultradent) was inserted
subgingivally around the
torqued abutment to inhibit
any contamination by
gingival fluid and to prevent
penetration of composite
resin cement between the
abutment and gingiva.
The restoration was then
cemented with dual-curing
resin cement (Variolink 2,
Ivoclar Vivadent). After the
crown was seated in position,
the excess cement was
removed with artistic brushes;
after 1 minute, the cord was
removed. All margins were
checked, and any remaining
cement was removed before
the final polymerization of
each surface for 60 seconds
(Fig 49).
Fig 49 Light curing the dual-
curing resin cement.
At the 11-month
follow-up examination,
the restoration had a
natural appearance, with
excellent biologic, optical,
and esthetic integration.
Moreover, the gingival
position was adequate in
level and shape, without
any black triangles (Figs
50 to 53).
Fig 50 Intraoral view of the
maxillary anterior teeth with
the definitive restoration at 11-
month follow-up.
Fig 51 Optical properties of the

ceramic restoration are similar
to those of the natural tooth.
Fig 52 Superficial texture of
the restoration and tissue
volume can be observed.
Fig 53 Incisal third of the
restoration is similar to that of
the natural tooth.
CONCLUSIONS
The excellent outcome is
directly associated with the
correct tissue management
during the surgery,
anatomical screw-retained
provisional restoration, and
customization of the
abutment for the definitive
restoration. The correct
choice of biocompatible
materials allows the
fabrication of crowns with
adequate dental esthetics and
a natural appearance.
REFERENCES
1. Marinello CP, Meyenberg
KH, Zitzmann N, Luthy H,
Soom U, Imoberdorf M.
Single-tooth replacement:
Some clinical aspects. J Esthet
Dent 1997;9:169–178.
2. Saadoun AP, LeGall M,
Touati B. Selection and ideal
1072.
3. Araujo MG, Lindhe J.
Dimensional ridge alterations
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experimental study in the dog.
J Clin Periodontol
2005;32:212–218.
4. Araujo MG, Sukekava F,
Wennstrom JL, Lindhe J.
Ridge alterations following
implant placement in fresh
extraction sockets: An
experimental study in the dog.
J Clin Periodontol
2005;32:645– 652.
5. Araujo MG, Linder E, Lindhe
J. Bio-Oss collagen in the
buccal gap at immediate
implants: A 6-month study in
the dog. Clin Oral Implants
Res 2011;22:1–8.
6. Clavijo VGR, Carvalho PFM,
Calgaro M, Silva RC, Joly JC.
Integrated esthetic
rehabilitation with multiple
adjacent implants, periodontal
reconstruction, and ceramic
restorations. Quintessence
7. Landsberg CJ, Bichacho N. A
modified surgical/prosthetic
approach for optimal single
implant supported crown. Part
I—The socket seal surgery.
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provisional restoration for an
immediately-placed implant.
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9. Su H, Gonzalez-Martin O,
Weisgold A, Lee E.
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subcritical contour. Int J
2010;30:335–343.
10. Dooren EV, Soares C,
Bichacho N, Giordani G,
Clavijo V, Boca-bella L.
Model-guided soft tissue
augmentation. Quintessence
11. Bichacho N, Landsberg CJ.
Single implant restorations:
Prosthetically induced soft
tissue topography. Pract
Periodontics Aesthet Dent
1997;9:745–752.
12. Glauser R, Sailer I,
Wohlwend A, Studer S,
Schibli M, Scharer P.
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abutments for implant-
supported single-tooth
restorations in esthetically
demanding regions: 4-year
results of a prospective
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Prosthodont 2004;17:285–
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_________________________
São Paulo, Brazil.

2 Private Practice, Campinas, São
Paulo, Brazil.

Correspondence to: Cristiano
Soares, Street Germano
Casellatto 60, Campinas, São
Paulo, Brazil, CEP: 13084-776.
Email:
[email protected]
CAD/CAM: A
Whole New
World of
Precision and
Excellence
Paulo Kano, DDS,
MDT1
Luiz Narciso Baratieri,
DDS, MS, PhD2
Fabio Andretti, DDS,
MS, PhD3
Priscila Saito, DDS4
Emerson Lacerda,
MDT5
MS, PhD6
C
urrently, there are two
concurrent and
seemingly divergent
routes of approaching and
practicing dentistry: the
conventional clinical
laboratory and a second
practice model that is based
on the production of
restorations by automated
means.
With the modernization of
manufacturing, processes that
once demanded large
amounts of time began to be
developed in a standardized
manner serially. The
CAD/CAM systems
originated due to this need.
Because conventional
dentistry is a manual practice
that requires expertise, the
skill and esthetic sense
required by the professional
using these systems is greater.
Conceptually, CAD
stands for computer-aided
design, or the process by
which a computer is
responsible for planning,
designing, and modeling of
digital images obtained by
scanning or acquired in a
database.1 The mathematical
models designed by CAD
systems are interpreted by
computational elements.
CAM (computer-assisted
manufacturing) systems
receive the object data
digitally acquired and make it
tangible through prototyping.
The CAD/CAM
technology is not new; it has
been used in several fields for
decades. Far afield from
dentistry, the first system was
developed in 1950 by the
defense arm of the United
States Air Force Semi-
Automatic Ground
Environment (SAGE). In
1957, Patrick J. Hanratty
developed a system that
would become the base code
for what we know as
CAD/CAM.2 A few years
later, thanks to the spread and
standardization of numerical
codes, the system could be
implemented in various
industries, facilitating the
production of raw materials.
In 1977, Young and
Altschuler proposed the use
of optical instrumentation to
develop a system of surface
mapping for an intraoral
grid.3 A short time later, in
1979, Mormann and
Brandestini developed a
system called CEREC,
acronym for ceramic
reconstruction, which was the
first dental CAD/CAM
system. It was initially
marketed by Siemens and
later by Sirona.4 In 1984,
Francois Duret developed the
Duret System, which was
marketed as the Sopha
BioConcept system in 1992.5
The large-scale use of
CAD/CAM techniques in the
dental environment, however,
was not widespread, and it
remained very limited for two
main reasons: the high cost
and the difficulty of copying
structures with complex
geometry with the highest
fidelity.6
The scanning mechanism
consists of modeling surfaces
by creating a geometric
model, which may in turn be
stored and later used. In
addition to generating three-
dimensional models from
two-dimensional drawings,
the file created enables
communication with other,
different formats of software.
The program also calculates
the thickness of the produced
parts and assemblies, which is
important, for example, for
predicting the required
strength at each region of a
prosthetic element.
A major advantage of
using CAD/CAM systems is
that they allow the production
of single-unit restorations
(inlays, onlays, crowns,
laminate veneers), single-and
multiple-unit infrastructures,
implant-supported
infrastructures, models, and
surgical stents without
requiring significant
prosthetic skills on the part of
the operator. The systems can
also be classified according to
the workplace, as clinical
(chairside) or laboratory
systems.
The CAD/CAM
technology can be used
jointly with conventional
techniques. Thus, one can
enjoy the “best of both
worlds” by combining the
accuracy and speed of digital
systems with the excellence,
beauty, and art of
conventional dentistry.
However, knowing only the
hardware and software
without mastering specific
concepts of dentistry can
result in suboptimization of
the process. In other words,
CAD/CAM systems do not
replace the clinical steps but
make them more dynamic,
predictable, and effective.
For orthodontics,
conventional orthodontic
treatment has usually
involved setup, manual
preparation of working
models, insertion of
appliances, and application of
forces based on a treatment
plan obtained from
cephalometric calculations,
with the expectation that the
torque and the magnitude of
these forces would produce a
desired effect. Currently,
scanned virtual models and
radiographic images may be
over-lapped by a CAD/CAM
system, and the areas,
distances, and angles
calculated, allowing a
simulation of the result of the
movements even before
inserting the appliance.
For orthognathic and
implant dentistry surgeries, a
trend is the use of CAD/CAM
systems that enable planning
and preoperative simulation
of procedures by prototyping,
with the possibility of
integration of image
acquisition and milling
systems.
In the case of direct and
indirect restorations, the
digital age does not replace
planning, proper case
selection, the correct
indication of the material, nor
the preparation, gingival
retraction, and the
establishment of appropriate
conditions from the
periodontal and occlusal
points of view. Furthermore,
it does not ensure a successful
treatment on its own if the
steps of cementation,
finishing, polishing, and
maintenance are neglected.
Indeed, digital manufacturing
provides precision and time
savings in essential laboratory
steps that are invisible to the
patient, such as fabricating
the die, waxing, inclusion,
injection, divesting, etc.
When the goal is
recreating nature, numerous
variables enter the equation.
In dentistry, the correct
reproduction of shape,
texture, translucency, and
color are essential to mimic a
natural tooth element. The
CAD/CAM systems, at this
stage, uniquely allow the
reproduction of shape and
texture of the surfaces to be
restored. The aspects relating
to the color and translucency
vary according to the selected
and indicated material.
DEVELOPMENT
This article explains
specifically the dental
chairside CEREC (Sirona)
CAD/CAM system, which
has four operation modes or
workflows. These can be
described as follows:
database, mirroring copy,
customized digital
impression, and three-
dimensional application of
the adjacent morphology
(CEREC Biogeneric patented
technology, developed by
Sirona).
The simplest way to
acquire the images is through
a database formed by
standard pictures provided by
the manufacturer or a
software engineer. These
shapes may be purely digital,
ie, embedded in the CAD
system, or obtained by
scanning from any physical
model. In this type of work,
the dentist should simply scan
intraorally the tooth
preparation and the antagonist
teeth. The images are
acquired, the virtual model is
created by the system, and the
operator selects the most
appropriate tooth shape from
the database. The occlusion
with the antagonist teeth is
simultaneously checked by
the system, the proposed
restoration is generated, and
the material can be milled.
However, this database has a
limited amount of shapes.
The manufacturer in this case
typically provides four basic
morphologies (young, adult,
elderly, or Asian; these
shapes have been developed
by Sirona). This often may
not be enough to achieve
anatomy similar to the
adjacent teeth. This first
workflow differs from others
by the convenience of using
previously stored digital
images and the degree of
standardization.
The second approach is
the method of mirroring. The
dental arches are scanned in
the same manner as in the
previous workflow; however,
this scan is performed to
capture the image of an
element homologous to the
missing tooth, which in turn
can be mirrored to the absent
tooth. When using CEREC,
this workflow was originally
known as Bioreference.
Currently, it is called
Biogeneric Reference, with
the insertion of the
Biogeneric function with
which the restoration
proposal may also be
generated from a contralateral
or antagonist tooth. However,
this tooth should still belong
to the same class as the
missing tooth.
The workflow for the
customized digital impression
is called Biocopy (or
Correlation Mode, in version
3.8 of the software) and
offers the following
acquisition options: (1) from
a wax-up, (2) from a
provisional restoration, (3)
from a trial restoration, or (4)
from the morphology of the
patient’s own teeth (for teeth
requiring only color or
alignment changes), copied
before the preparation of the
teeth. Then, a second
scanning of the prepared teeth
is obtained. Therefore, this
technique is known as the
double-scanning technique.
The images are digitally
superimposed, the restoration
proposal is created, and the
material is milled. Currently,
in the CEREC system this
mode is called Biogeneric
Copy, and its main function is
the preservation of the
proposed morphology,
obtained from references
provided at the first scanning.
However, in the latest
versions of the software, the
Biogeneric technology has
been linked to the Biocopy
mode, and in some situations
it can merge parts of existing
surfaces and adjacent
anatomical landmarks to the
prepared tooth.
The fourth method is the
three-dimensional application
of the adjacent morphology,
called Biogeneric, which is
available only in the CEREC
system. This is a method that
analyzes and uses the
anatomy of the adjacent teeth
to compose a restoration. In
this workflow, the software
uses the anatomical
landmarks of the patient’s
other teeth, such as cusps,
inclines, slopes, and free
surfaces, to calculate the
missing part of the element to
be restored. Thus, for
example, when all molars are
absent, it is possible to
rebuild them using
information from the
premolars, considering the
occlusion and the functional
movements.
WORKFLOW
The following demonstrates
the potential of a CAD/ CAM
system to reproduce nature in
detail.
Fabrication and
Preparation of the
Cast
First, an impression of the
natural dentition of a
previously selected patient
was made with a high-/low-
viscosity polyvinyl siloxane
impression material (Virtual,
Ivoclar Vivadent). The
impression was poured with a
special stone material
(Fujirock EP, GC), which
was kept intact. After pouring
of the stone material, the
technicians waited at least 2
hours before removal of the
cast. Next, this cast was
replicated twice with high-
quality industrial silicone
(Poli 400 Polisil, Poli Resinas
Indústria Comércio Resinas).
In the first duplicated silicone
cast, the areas of the main
sulci with restorations were
corrected or emphasized.
In the second duplicated
silicone cast, all teeth were
individualized, and dies were
fabricated according to the
Geller technique. These dies
were isolated with petroleum
jelly and repositioned in the
impression. The spatulated
stone material was poured to
obtain the cast base. The dies
were removed from this cast
after 2 hours, and the dies and
the base (without dies) were
duplicated with industrial
silicone.
The impression of the
dies was poured again with
special stone. Medium-
hardness organic wax was
poured inside the impression
of the cast base, which was
fabricated with industrial
silicone (red Inowax,
Formaden). This wax was
poured into the mold in its
liquid state after being heated
over a flame until its melting
point (74°C). After pouring,
the assembly was kept in an
oven for temperature
homogenization of the wax
while still in a fluid state (at
74ºC). The wax impression
was placed in a muffle (at 4
bar pressure) for progressive
cooling to room temperature
to avoid bubble formation.
After this step, the wax cast
was carefully removed from
the silicone, resulting in a
gingival mask. The wax cast
obtained was finalized with
manual sculpture to define
the anatomy of the palatal
area and the marginal and
inserted gingiva with
differently colored waxes.
The duplicated stone dies
were prepared for all- ceramic
crowns with chamfer
margins. After the
preparation, the dies were
replicated with industrial
silicone, and the obtained
impression was poured twice:
first with stone and a second
time with acrylic resin
(Ivocron, dentin body and
incisal, Ivoclar Vivadent).
The prepared dies were
then repositioned in the base
of the cast and from this, the
scanning process (CAD) was
initiated for the fabrication of
the ceramic crowns by the
CEREC system (Cerec AC,
Sirona).
Image Acquisition
Double-Scanning
Technique using
Biocopy
For the Biocopy technique,
images of the stone cast with
emphasized sulci were
initially acquired with a
benchtop scanner (inEos
Blue, model D3446, Sirona).
This requires a contrast spray
to be applied prior to
scanning (CEREC OptiSpray,
Sirona). Next, image
acquisition of the cast with
prepared teeth was performed
— hence, the name “double-
scanning technique,” because
it seeks to correlate the
information of the initial
tooth morphology to that of
the tooth preparations. Only
through this technique is it
possible to obtain detailed
and accurate information of
the morphology found in the
cast with emphasized sulci
and to transfer this
information perfectly to the
digitally produced ceramic
restorations.
Double-Scanning
Technique Using
Biogeneric Copy
Importantly, the software
version (4.2) used in the
present example has a
working mode that combines
the Biogeneric and Biocopy
modes, which were distinct
modes in previous versions of
the software. The Biogeneric
Copy mode sometimes
produces defects in regions
that are not included in the
Copy Line step. To avoid this
shortcoming, the outlines,
embrasures, and emergence
profile of the restoration
should be thoroughly
determined during the
sculpture to avoid lack of
continuity of the preparation.
Therefore, every effort should
be made to preserve the
information gathered in the
previous step in order to
avoid adjustments and
modifications of the
calculated restorations.
Digital Design
First, the type of the
restoration (individual), the
design mode (Biogeneric
Copy), and the teeth
(maxillary third molar to third
molar) were determined in
the Administration tab of the
software, along with the
material to be used (IPS
Empress CAD Multi, Ivoclar
Vivadent; shade: A2; size:
C14). Next, under the
Acquisition tab, images were
acquired of both casts (the
nonprepared cast, with
emphasized sulci, and the
prepared cast) using a
benchtop scanner (inEos
Blue, model D3446).
After the image
acquisition, the software
generated the virtual models;
in this example, these were a
maxillary model and the
maxillary Biogeneric Copy
model, which were digitally
correlated. Using this
workflow, the final
restoration will represent the
external morphologic features
of the natural tooth (obtained
from the cast with
emphasized sulci) correlated
to the information obtained
from the prepared cast.
It is important to
emphasize that the scanning
of the opposing arch was not
mandatory in the Biogeneric
Copy mode, because all the
information required was
obtained from the initial cast
with emphasized sulci. The
virtual models were
subsequently positioned and
aligned in the arch, the areas
were trimmed, the
preparation margins were
virtually drawn, the
preparation axis was defined,
and the areas to be selected
for the correlation were
determined (see Fig 9). At
this point, the following
parameters were set in μm:
spacer; occlusal milling
offset; proximal, occlusal,
and dynamic contact
strengths; minimal occlusal
and radial thicknesses; and
margin thickness. Parameters
were also set for resources
such as instrument geometry
and removal of retentive
areas, which were both
disabled. Next, the
restorations were calculated.
Note that the calculated
restorations should be
preserved as much as
possible. Any adjustments
that may be necessary later
should be limited to the
proximal contacts, correction
of excessively thin areas, and
smoothing of cervical
regions, without retouching
the anatomy and the
morphology of the
restorations.
Milling
The milling unit, milling
speed (set to Normal), and the
block size (C14) were chosen
in this step. The restorations
were positioned within the
ceramic block in the software
screen according to the level
of saturation required for
each tooth, because the
chosen blocks were
polychromatic or multishade.
Nevertheless, the milling
time for each block depends
upon the type of material, the
volume, the complexity and
size of the restorations, and
the burs to be used. In this
case, where a CEREC milling
unit was used, the milling
time ranged between 8 and 15
minutes because the unit
operates with a pair of motors
(one motor uses a cylinder
bur positioned to mill the
external areas of the
restoration and to relieve or
compensate external areas,
and the other uses a step bur
that mills the intaglio
surfaces). This arrangement
speeds up the process to
approximately half the time
of other milling systems
using only one motor with
one bur.
Adjustments,
Finishing, and
Polishing
The sole adjustment required
was the removal of sprues
with stones, diamond points,
and diamond rubber wheels.
The asmilled ceramic
restorations showed excellent
fit on the preparations.
However, although the
restorations look matte,
lifeless, shallow, lacking
texture, and with undefined
occlusal morphology, a
simple yet careful polishing
technique using a diamond
paste (Universal Diamond
Gloss 2, 3 µm, KG Sorensen)
and goat-hair brushes (SUN)
revealed the richness of
texture and morphology that
was faithfully and accurately
reproduced by the CEREC
system.
Indeed, after milling, the
one single maneuver
required, in addition to the
elimination of sprues, was
manually highlighting the
main sulci and characterizing
them with tints (Universal
Stains, IPS Empress, Ivoclar
Vivadent). Finally, the pieces
were glazed (Universal Glaze
Paste, IPS Empress, Ivoclar
Vivadent) and again polished
manually with goat-hair
brushes in a handpiece and
diamond polishing paste
(Universal Diamond Gloss 2,
3 µm).
These steps, illustrated in
Figs 1 to 33, accurately
reproduced the texture and
the anatomical details exactly
as in the natural elements.
Figs 1a to 1c Occlusal and right
and left lateral views of maxillary
intact dentition to be used as
biocopy.
Fig 2 Note the detailed dental
morphology to be used as a guide
for the definitive replicas.
Fig 3a Occlusal view of maxillary
arch crown preparations.
Fig 3b Frontal view of maxillary
anterior crown preparations.
Fig 4a Occlusal view of the cast of
the maxillary arch crown
preparations.
Fig 4b Frontal view of the cast of
the maxillary anterior crown
preparations.
Fig 5 In the CEREC software,
under the Administration tab, the
tooth to be restored was chosen.
Under Design Mode, Biogeneric
Copy was selected; the Restoration
Type was “crown.”
Fig 6a Acquisition (scanning) of

the cast of the unprepared teeth for
biocopy.
Fig 6b Acquisition (scanning) of
the prepared teeth.
Fig 7a On the Model tab, the
model axis was set.
Fig 7b Under the Model tab, the
margins of the posterior prepared
teeth were drawn.
Fig 7c Under the Model tab, the
margins of the anterior prepared
teeth were drawn.
Fig 8a Defining the insertion axis
for posterior teeth.
Fig 8b Defining the insertion axis
for anterior teeth.
Fig 9 Delimitation of the biocopy

line of the maxillary teeth.
Fig 10 Design parameters for the
restorations.
Fig 11 Design based on the
biocopy.
Fig 12a Biocopy line.

Fig 12b Biocopy model.
Fig 13a Digital model of the
prepared teeth.
Fig 13b Biocopy model

superimposed over the digital
model of the prepared teeth
(occlusal view).
Fig 14a Biocopy model
model of the prepared teeth (lateral
view).
Fig 14b Biocopy model
model of the prepared teeth (lateral
view with transparency).
Fig 15a Final design based on the
biocopy.
Fig 15b Occlusal view of the final
design based on the biocopy.
Fig 15c Digital restorations ready
for milling.
Fig 16 Material selection step.

Fig 17a Digital positioning of an
anterior restoration within a
multishade block.
Fig 17b Digital positioning of a
posterior restoration within a
multishade block.
Fig 18a Milled lithium disilicate
restorations generated using
biocopy.
Fig 18b Occlusal view of the

milled restorations using biocopy.
Fig 18c Lateral view of the milled

restorations using biocopy prior to
finishing.
Fig 19a Milled restorations just
after initial polishing.
Figs 19b and 19c Lateral occlusal

views of the milled restorations
after initial polishing.
Fig 19d Occlusal view of the
milled restorations. Occlusal
developmental grooves and
fissures were carefully redefined
using a low-speed bur.
Fig 20 Facial and buccal
developmental grooves were
carefully highlighted.
Fig 21 Palatal/occlusal view of the
milled restorations.
Fig 22a Close-up view of posterior
teeth. Note that only the central
grooves were slightly redefined.
Fig 22b Palatal view of maxillary
anterior teeth. Only the marginal
ridges were slightly redefined.
Figs 23a to 23c Mild-intensity
characterization was applied onto
the buccal gingival third to impart
a more natural aspect to the
restorations followed by glazing
and manual polishing.
Figs 24a to 24c Lateral and close-
up views after mild-intensity
characterization was used.
Fig 25a Maxillary right posterior
teeth after mild-intensity
characterization.
Fig 25b Occlusal view of posterior

characterization.
Fig 25c Maxillary left posterior
characterization. A mixture of
ochre and orange was placed
internally to increase chroma
around the central grooves. Central
grooves were carefully stained
using the same mixture.
Fig 26 Incisal translucency and

halo were added to the maxillary
anterior teeth as a mild
characterization.
Fig 27 Lateral left side maxillary

view of CAD/CAM restorations
after intense characterization was
used.
Fig 28 Occlusal and palatal view
of the of CAD/CAM restorations
after intense characterization.
Fig 29a Maxillary right posterior
teeth after high-intensity
characterization.
Fig 29b Occlusal view of posterior
characterization.
Fig 29c Maxillary left posterior
characterization. A mixture of
ochre and orange was placed
internally to increase chroma
around the central grooves. Central
grooves were carefully stained
using brown stains.
Figs 30a to 30c Palatal, buccal,
and lingual views of CAD/CAM
restorations after high-intensity
characterization.
Figs 31a and 31b Maxillary

anterior CAD/CAM restorations
displaying intense characterization.
Figs 32a and 32b Palatal views of
CAD/CAM restorations displaying
intense characterization.
Figs 33a and 33b Characterized
CAD/CAM restorations using
biocopy.
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Noort R. Evaluation of the
marginal fit of three margin
designs of resin composite
crowns using CAD/ CAM. J
Dent 2007;35:68–73.
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image measurements of teeth
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_________________________
1 Visiting Professor, Federal
University of Santa Catarina,

Florianópolis, Brazil; Private
Practice, São Paulo, Brazil.
2 Professor and Chair, Department
of Dentistry, Federal University
of Santa Catarina, Florianópolis,
Brazil.
3 Visiting Professor, Federal
University of Santa Catarina;
Private Practice, Florianópolis,
Brazil.
4 Private Practice, São Paulo,
Brazil.
5 Dental Technician, São Paulo,
Brazil.
6 Associate Professor and Chair,
California, USA.
Correspondence to: Dr Paulo
Kano, Rua das Pitombeiras 126,
São Paulo, SP, 04321-160
Brazil.
MASTERPIEC
A Challenge to
Natural Teeth
Naoki Hayashi, RDT
Ultimate Styles Dental
Laboratory
23 Mauchly, Suite 111
Irvine, CA 92618, USA
Esthetic prosthetic treatment

is comprehensive treatment
that considers, through
examination and diagnosis,
many elements that are
required for long-term
success. The patient’s
expectations, facial outline,
position of the eyes, and
shape and movement of the
lips are some of the factors
that determine the incisal
position, length, and width of
restorations. The angle and
position of each tooth are also
determined with
consideration of these factors.
The author focuses
particularly on lip movement
(“lip dynamics”), whereby
the restoration is fabricated
over various examinations
and trials so that it looks
natural and well-balanced
with the shape and in all
movements of the lips.
Esthetic prosthetic dental
treatment involves restoration
of the anterior to premolar
teeth, those visible in daily
life, to improve esthetics and
function healthfully and
beautifully. Not as many
design elements or creativity
is required to restore a single
anterior tooth, since the
adjacent teeth will be the
primary guides. However,
elements of esthetics and
harmony with the dentition
have to be considered when
two central incisors are
restored.
A natural-looking
restoration, one that imitates
the natural tooth, is
considered the ideal by many
dental technicians. However,
a patient’s subjective view of
esthetics and the operator’s
objective view do not always
coincide. Today, the esthetic
restoration needs to be
balanced between the white
teeth often desired by the
patient and the natural-
looking teeth preferred by the
dental technician.
The author has
established a classification of
restorative treatment into five
types based on difficulty. A
patient’s desires/expectations
can be organized using this
classification to plan the
treatment. Four of the five
different types of cases
outlined below are presented
in this article (Type 1 to Type
4). Each case has a particular
treatment goal (pure
anatomical reproduction to
fulfillment of the patient’s
desires/expectations). Each
restoration has personality to
harmonize with the patient’s
dentition and face as total
esthetics.
Classification of
Restorative Treatment
Type 0: Basic restorative
treatment. Treatment is
limited to vital problems (ie,
pain, dislodged or damaged
previous restoration).
Type 1: Natural restorative
treatment. Treatment is
limited to a tooth with caries
or discoloration. The main
treatment goal is to
harmonize the color, shape,
and function of the treated
tooth with that of the adjacent
dentition.
Type 2: Enhanced natural
restorative treatment.
Multiple teeth are involved in
the treatment to arrange the
entire dentition to look and
function naturally.
Type 3: Esthetic treatment.
Prosthetic treatment is carried
out to improve esthetics of
mainly the anterior teeth to
harmonize with the face and
lip dynamics. Treatment is
indicated for purposes of
esthetics, not for a functional
problem.
Type 4: Esthetic treatment +
Total oral rehabilitation.
Comprehensive treatment
includes orthodontic and
surgical treatment in addition
to prosthetic treatment. The
dentition, including tooth
shape and color, are idealized
according to the patient’s
desires/expectations. The
facial appearance, lip
dynamics, and dentition need
to be harmonized for esthetics
and function.
Type 1: Natural
restorative treatment
In this typical crown
restoration of both maxillary
lateral incisors, many
elements for esthetic
prosthetic treatment already
existed. Attention was paid to
imitate the color, shape,
surface texture, and gloss of
the adjacent teeth to produce
a natural-looking dentition.
Esthetics was dictated by the
character of the patient’s
natural teeth.
Katana zirconia crowns (Kuraray
Noritake Dental). Collaboration
with Dr Gianmarco O’Brien.
Type 2: Enhanced
natural restorative
treatment
This case involved prosthetic

treatment of the maxillary
central incisors, one with a
porcelain laminate veneer and
the other a zirconia crown.
The main purpose was to
make these restorations
harmonize with the adjacent
dentition. However, it was
important to design the shape,
length, and width of the
restorations to harmonize
with the patient’s facial
appearance, entire dentition,
and lips as well. The minor
rotation of both lateral
incisors and the unbalanced
incisal and cervical lines were
visually managed by making
the shapes of the two
restorations slightly different.
The definitive restorations
work to improve the balance
of the anterior dentition.
Katana zirconia crown and CZR

laminate veneer (Kuraray Noritake
Dental). Collaboration with Dr
Kurt Schneider.
Type 2: Enhanced
natural restorative
treatment
This patient had multiple

facial caries lesions and
defective composite resin
restorations on the anterior
teeth. Noncarious areas were
included in the restorative
treatment to balance the
anterior dentition. The
canines were not involved.
Crown shape, position, color,
and internal characterization
were emphasized in the
treatment of this patient.
EX-3 laminate veneer (Kuraray
with Dr Shunya Sasaki.
Type 3: Esthetic
treatment
EX-3 laminate veneers (Kuraray

with Dr Ed McLaren.
Restorative treatment of four
anterior teeth to improve the
long axes, inclination, crown
shape, and interproximal
space was performed without
orthodontic treatment.
Minimum gingivectomy was
required to reduce the
patient’s gummy smile. The
teeth were healthy and so
needed only minimal
preparation. Because the
patient requested that both
lateral incisors be brought 1
mm facially, almost no
preparation was necessary on
these teeth. Harmony of the
six anterior teeth and proper
balance with the facial
appearance and lip dynamics
were achieved.
Type 4: Esthetic
treatment + Total oral
rehabilitation
Comprehensive treatment
was performed to fulfill the
patient’s request for
functional esthetic
rehabilitation. After multiple
periodontal plastic surgical
procedures, esthetic
prostheses that were well
balanced with the patient’s
facial appearance and lip
dynamics were fabricated.
Color control was difficult in
this case because of the
mixed dentition that included
a zirconia crown, an implant-
supported zirconia crown to
restore the right central
incisor, and porcelain
laminate veneers. The
multiple laminate veneer
preparations were created
first by applying porcelain on
zirconia copings. They were
tried in the patient’s mouth to
check the color. A unified
color of the zirconia copings
and abutments for the
laminate veneers was possible
by this process. Eventually,
color coordination of the
different materials was
achieved by simply applying
the same porcelain on color-
adjusted zirconia copings and
laminate veneer abutments.
Nobel Active RP (Nobel Biocare);
Katana zirconia crown and CZR
laminate veneers (Kuraray
with Dr Akitoshi Sato.
Biologic
Esthetics by
Gingival
Framework
Design:
Part 2. Gingival
Esthetics
Evaluation
Criteria
Yuji Tsuzuki, RDT1

T
here are three
fundamental
components to
presenting a beautiful and
healthy dentition. The first is
tooth morphology, the second
is gingival architecture, and
the third is the relationship of
the lip to all other
components. All of these
components will create a
positive or negative
impression depending on
color, morphology, and tooth
alignment.
Acquiring and
maintaining gingival health
and oral esthetics is the goal
when planning definitive
restorations. There are several
factors to consider when
evaluating gingival health,
such as the marginal
periodontal condition and
tooth alignment. In part 1 of
this article, the importance of
paying attention to the
periodontal condition and
constructing a healthy
gingival architecture during
prosthesis fabrication was
discussed in a general
manner. In this article,
specific techniques to achieve
this goal are presented.
GINGIVAL
ESTHETICS
EVALUATION
CRITERIA
It is necessary to pay
attention to the gingival
framework1 and to
understand the balance
between the coronal structure
and gingiva (Fig 1).
Generally, healthy gingiva
has its own features, which
vary according to the tooth
shape (square, triangle, or
ovoid). Moreover, the
horizontal alignment of the
cementoenamel junction
(CEJ), cervical bone crest,
and free gingival margin
usually appear to be similar to
the overlying gingiva2 (Fig
2). Left-right symmetry is one
of the most important factors
for a beautiful smile line. To
acquire this symmetry, there
should be ideal occlusion and
the teeth should be in an ideal
three-dimensional position.
When patients display this
ideal oral environment, it is
unlikely that they will need
major prosthetic work unless
they experience an accident
or trauma. Usually patients
who require major prosthetic
treatment have a preexisting
intraoral condition such as
tooth malalignment.
Therefore, it is very important
to evaluate the esthetics of the
gingiva at the treatment-
planning stage. Otherwise,
the treatment options will be
limited to prosthetics.
Fig 1 Gingival framework and

incisal framework formed by the
dentition. Right-left symmetry and
continuity toward the posterior
teeth determine the esthetic factor
of the dentition.
Fig 2 Vertical anatomical index of

the anterior teeth, gingiva, and
alveolar bone. Generally, a healthy
periodontium has its own features
that vary according to the tooth
shape (square, triangle, ovoid) and
that are usually similar to the
underlying horizontal alignment of
CEJ, cervical bone crest, and free
gingival margin. The gingival
framework is maintained by the
vertical relationship among CEJ,
cervical bone crest, and free
gingival margin.3 (Modified from
Obama4 with permission.)
Two-Dimensional
Considerations
Evaluation items of gingival
health and esthetics have
been enumerated by
Fürhauser et al in the concept
he named the “pink esthetic
score”5 (Fig 3). It is vital to
have interdental papillae as a
landmark for indication of a
healthy periodontal condition.
Adequate composition of the
dentogingival complex7
(tooth, gingiva, and alveolar
bone) (Fig 4) is required for
the interdental papilla to fill
the interproximal space below
the contact point. Two-
dimensional (mesiodistal,
horizontal, vertical)
consideration of the esthetic
area is performed based on
five evaluation criteria (Fig
5). It is generally considered
that a dentition with
triangular-shaped teeth
creates a more pleasing
impression than one with
square-shaped teeth in terms
of the balance of esthetics of
the mouth.
Fig 3 For calculation of the pink

esthetic score, there are five
esthetic evaluation items for a
single implant-supported
restoration replacing one missing
anterior tooth5: (1) mesial and
distal interdental papillae, (2) soft
tissue level and contour, (3)
alveolar process, (4) gingival
texture, and (5) gingival color. A
solely prosthetic approach is
limited for the fulfillment of all
esthetic requirements. Surgical
management of hard and soft tissue
is required. (Reprinted from Honda
et al6 [modified from Fürhauser et
al5] with permission.)
Fig 4 Anatomical composition of
the tooth/gingiva/alveolar bone
dentogingival complex advocated
by Kois.7 In general, the distance
from the highest to the lowest point
of the gingival margin is 5.5 mm;
for alveolar bone, 3.5 mm. Hence,
the distance from alveolar bone
crest to gingival margin is 3.0 mm
at midfacial and 4.5 to 5.0 mm at
the interdental papilla. (Reprinted
from Obama4 [modified from Elian
et al8] with permission.)
Fig 5 Esthetic evaluation criteria at

the dentition level including
coronal structures and gingiva.
Right-left symmetry and regularity
is evaluated two-dimensionally. As
long as healthy periodontium and
proper tooth positions are
maintained, the level of the
interdental papillae and proximal
contact areas are parallel. The
shape of the gingival zenith point
and triangle zone changes
dramatically according to the shape
of the tooth and interdental
distance.9 The existing condition of
the interdental papillae is
determined by these factors.
Three-Dimensional
Considerations
The volume of the alveolar
ridge is composed of hard
tissue (alveolar bone),
including teeth, and soft
tissue (gingiva). There is
much individual variation.
Three-dimensional (vertical
and horizontal) consideration
of the alveolar ridge is
required in fixed or implant
prosthetic cases. The
prosthetic result may often be
compromised without
surgical reconstruction of
hard and soft tissues in
patients with a defective
alveolar ridge. Moreover,
prosthetic treatment is often
compromised and limited
without orthodontic and
surgical treatment to improve
three-dimensional esthetics.
Seibert and Cohen10
classified alveolar ridge
defects (Fig 6), and soft tissue
or hard tissue grafting is
sometimes suggested by the
technician according to this
classification and diagnosis.
Fig 6 Classification of defect
patterns of the alveolar ridge by
Seibert and Cohen.10 Soft tissue or
hard tissue grafting is sometimes
suggested by the technician at the
diagnosis and treatment-planning
stage in the presence of such
defects. The prosthetic approach
may differ according to the
condition of the alveolar ridge. It is
important to evaluate the condition
thoroughly. (Reprinted from
Obama4
Cases 1 and 2 illustrate

the use of surgical
intervention to improve the
prosthetic outcome. In Case 1
(Fig 7), treatment of the
patient’s maxillary right
anterior dentition included
ridge augmentation with a
connective tissue graft. In
Case 2 (Fig 8), horizontal and
vertical ridge augmentation
improved the treatment
outcome of the patient, who
presented with a root fracture
of the maxillary left central
incisor.
CASE 1
Improvemen
of the
Prosthetic
Condition
by
Surgical
Treatment
Figs 7a to 7h The patient, a
female in her 20s, complained
of dissatisfaction with the
esthetics of her fixed partial
denture. Ridge augmentation
was performed in the defective
edentulous area of the
maxillary right lateral incisor
using a connective tissue graft
from the palate. The presence
of a defect at the pontic site in
fixed prosthetic treatment
affects not only the alignment
but also the shape of the whole
prosthesis. Surgical
intervention dramatically
improved the prosthetic
condition and the treatment
result. (Courtesy of Dr
Hiroyuki Takino, Takino
CASE 2
Improvemen
of the
Prosthetic
Condition
by
Surgical
Treatment
Figs 8a to 8h The patient, a
male in his 20s, presented with
a root fracture of the maxillary
left central incisor. A surgical
approach to improve soft and
hard tissue defects is inevitable
in fixed implant
prosthodontics. It improves the
treatment result dramatically.
The prosthetic condition of this
patient was improved by
horizontal and vertical ridge
augmentation to restore the
alveolar ridge defect. (Courtesy
of Dr Kotaro Nakata, Nakata
CLASSIFICATION
OF PROSTHETIC
CONDITION
For prosthodontic treatment
in esthetic areas, it is
necessary to clearly identify
the prosthetic condition
before setting the appropriate
treatment goal by first
considering the periodontal
health as well as
reconstruction of teeth. The
author’s classification of the
prosthetic condition
according to the gingival
framework is shown inTable
1.
Classification of Various
Prosthetic
Table Conditions
1 Considering the
Gingival Framework
Three of these
classifications are illustrated
with clinical cases. Case 3
(Fig 9) is a type 2 alternative
case. The patient’s gingival
level was improved by
prosthetic treatment. Case 4
(Fig 10) is an example of a
type 3 compromised case. In
Case 5 (Fig 11), a type 4
creative case, the gingival
contours are the result of an
implant-supported fixed
prosthesis.
CASE 3 Type 2
(Alternative
—
Improvemen
of the
Gingival
Level by
Prosthetic
Treatment
Figs 9a and 9b The patient
wanted to improve the esthetics
of her anterior teeth.
indicated but was not accepted
by the patient. Both central
incisors are discolored due to
previously placed restorations.
The maxillary lateral incisors
are peg-shaped. The long axes
of these teeth are not in
harmony. In particular, the
gingival level of the right
lateral incisor created
disharmony of the gingival
framework. Provisional
restorations were fabricated
from the diagnostic wax-up to
rearrange the balance of the
dentition (technique previously
described by Sulikowski and
Yoshida11).
Figs 9c and 9d Final
restorations on and off of the
master cast (IPS e.max Press,
Ivoclar Vivadent). The tooth
long axes were balanced, and
the gingival framework was
controlled by the subgingival
contours of the restoration.
Fig 9e The gingival levels were
altered by the provisional
restorations.
Fig 9f Long axes, size, and
proportion of teeth are
improved and harmonized.
Acceptable esthetics was
achieved by prosthetic
treatment alone in this patient.
(Courtesy of Kubota Dental
Clinic, Japan.)
CASE 4 Type 3
(Compromi
—
Prosthetic
Result
Not
Optimal
Without
Orthodontic
Figs 10a and 10b The patient

wanted to improve the esthetics
of the anterior teeth because of
their malalignment.
indicated and recommended,
but the patient refused it. The
patient was treated using a
prosthetic approach alone. As a
result, the maxillary right
central incisor underwent root
canal therapy, and adjacent
teeth were reshaped.
Figs 10c and 10d

Posttreatment photographs.
The marginal gingiva is
harmonized. Although the
patient is satisfied with the
result, this is not an optimal
solution to the chief complaint
because the tooth positions
were not changed (all-ceramic
crown, IPS e.max Press).
CASE 5 Type 4
(Creative)
—
Gingival
Design
by
Implant-
Supported
Prosthesis
Figs 11a and 11b Implant

treatment was indicated for this
patient who had fractured
anterior teeth. After extraction
and socket preservation, the
pontic area was designed and
contoured by the provisional
restoration in consideration of
the balance of the gingival
framework of the six anterior
teeth.
Figs 11c and 11d A custom

impression coping was
fabricated to transfer the
information of reshaped
gingiva in the pontic area.
Guided surgery was used to
place two implants while
maintaining parallelism.
Figs 11e and 11f Custom

impression coping. The tissue
surface of the implant and
pontic area was reproduced
with acrylic resin. A plastic bar
was used between the two
implants to maintain strength.
Figs 11g and 11h The cast was

sculpted into the contours of
the definitive tissue surface of
the restoration by grinding.
Zirconium abutments were
chosen.
Figs 11i to 11m Completed
supra-structure of the implant
prosthesis. The gingival
framework of the six anterior
restorations is well balanced
(IPS e.max Zirpress, Ivoclar
Vivadent).
Fig 11n Final prosthesis in

place.
A favorable gingival
framework has been
established after
well-planned
surgical and
prosthetic treatment
including implant
positioning.
SOLUTIONS FOR
OTHER CASES
Some cases do not fit easily
into the classifications
described in Table 1.
Creativity as well as some
compromise considering
tooth positions is required to
harmonize the total esthetics,
as in Case 6 (Fig 12).
CASE 6 Prosthetic
Treatment
with
Asymmetric
Tooth
Positions
Fig 12a The maxillary left
central incisor crown of the
patient, a male in his 50s, is
esthetically deficient and has a
defective marginal fit.
Fig 12b Posttreatment
photograph of the all-ceramic
crown (IPS e.max Press). Color
is reproduced well.
Figs 12c and 12d
Consideration was given to the
shape and tooth alignment to
harmonize with rest of the
dentition under the limited
prosthetic condition caused by
asymmetric tooth positioning
and gingival levels. (Courtesy
of Takino Dental Clinic,
Japan.)
Natural Beauty from
Asymmetry
Perfect right-left symmetry
does not exist in nature, nor
does it exist in the mouth.
This subtle asymmetry
produces natural beauty.
Perfect symmetry is
“imaginary beauty,” which is
created by human desire.
Reasonable symmetry
produces a more natural,
dynamic look (eg, Case 6)
than perfect, artificial
symmetry. Delicate
consideration of the dentition,
including the periodontium,
leads to the production of a
natural-looking prosthesis
that will be in harmony with
its surrounding environment
(Fig 13).
Fig 13 Some balance must be
created and maintained in the
dentition even when perfect
symmetry is not required. Factors
that influence the esthetic result of
the restored dentition are
enumerated and explained.
Central incisor is the
starting point of the
dentition. Alignment
condition is
determined by the
size of teeth and
alveolar ridge. Shape
1: Tooth and alignment of the
alignment central incisor
influences the
impression of the
mouth, which
represents the
personality.
Acceptable
symmetry of the two
central incisors is
inevitable.
Mesial line angle

produces regularity
of the dentition,
which continues
2: Mesial line toward posterior
angle teeth. Some
irregularity is
allowed according to
the existing dentition
and the prosthetic
condition.
Distal outline
produces the contour
of the dentition.
3: Distal
Harmonized outline
outline
of each tooth
produces regularity
of the dentition.
Gingival level
affects length of the
clinical crown.
Symmetry and
continuity is
required. In this
case, gingival level
4: Gingival was controlled by
level subgingival
contouring
considering the
symmetry and
continuity toward
the canine area
(high-low-high
gingival level
relationship).
Incisal edge level

affects length of the
clinical crown as
well as the gingival
5: Incisal edge level. In this case, it
level was designed
slightly longer to
compensate for the
incline of the facial
cusp line.
CORONAL-
GINGIVAL
BALANCE
Symmetry and balance of the
crown and gingiva can be
evaluated simply by
connecting the interdental
papillae and gingival zenith
points. This relationship can
be classified into three types:
regular, irregular, and flat. In
dentitions with irregular or
flat types, prosthetic
treatment may require a
special arrangement (such as
half pontics or long proximal
contacts to close the
interproximal space;
consideration of the axial
surface including subgingival
contour) in addition to
restoring the natural
anatomical shape (Table 2).
Evaluation of Coronal-
Gingival Balance Before
and After Treatment Based
Table 2 on the Relationship
Between Interdental
Papillae and Gingival
Zenith Points
CONCLUSIONS
Thorough examination and
diagnosis of the prosthodontic
condition is vital to set the
ideal treatment goals for the
prosthesis and gingival
health. This article has
presented gingival esthetics
evaluation criteria, with
clinical cases showing
components of the gingival
framework in esthetic areas
as well as prosthetic
considerations for gingival
designs.
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_________________________
1 Dental Technician, Kyoto, Japan.
Correspondence to: Yuji
Tsuzuki, Ray Dental Labor, Elitz
Yamashina Building 3F, 18-8
Takehanatakenokaidocho
Yamashinaku, Kyoto City,
Kyoto, Japan. Email:
[email protected]
Esthetic
Rehabilitation
of the Patient
with
Tetracycline
Discoloration
and Diastema
Gadzhy Dazhaev,
DMD1
Thomas Sing, MDT2
P
roviding dental
rehabilitation for
patients with
tetracycline-discolored teeth
sets a number of tasks before
the clinician, including
treatment planning and design
and degree of tooth
preparation. In addition, there
may be a conflict between the
desire to conduct minimally
invasive dental treatment and
the need to achieve the
desired esthetic result.
The following case report
describes the treatment of a
patient with the combined
esthetic problems of
discolored teeth and presence
of significant diastemas
between the teeth.
CASE REPORT
A 30-year-old woman came
to the dental clinic with a
chief complaint of
dissatisfaction with the
appearance of her teeth and,
in particular, their color and
shape and the presence of
spaces between the teeth. In
addition, the patient stated
that she did not want
orthodontic treatment (Fig 1).
Figs 1a to 1d Initial
presentation of a patient with
tetracycline-discolored teeth
separated by significant
diastemas.
Examination
The examination covered
three areas, periodontal,
functional, and esthetic, with
the use of a risk assessment
system in each:
Periodontium
The patient presented with a
healthy periodontal condition.
Function
The following functional
issues were identified:
• A shift from centric

relation (CR) position to
maximum intercuspation
(MIP) position of ≤ 0.5
mm
• Deep vertical overlap
• Presence of vertical wear
facets on the facial
surfaces of the mandibular
incisors and the palatal
surfaces of the maxillary
incisors
• Vertical pattern of
movement of the mandible
• No problems with
masticatory muscles or the
temporomandibular joint
(TMJ)
Esthetics
The esthetic examination
identified several problems:
• Tetracycline discoloration
of teeth
• Large diastemas between
the maxillary central
incisors and between the
lateral incisors, canines,
and premolars
• Palatal inclination of teeth
During the history-taking

and examination of the
patient, the sequence of the
three areas listed above does
not matter; however, when
drawing up the treatment
plan, the esthetic aspect is
crucial.
Treatment Planning
Esthetics
During facial analysis, the
midline, commissural, and
interpupillary lines were
evaluated.
Digital modeling of the
teeth helps to analyze the
smile and to perform
dentoalveolar analysis. In
order to measure the desired
dimensional changes of the
teeth, a digital ruler
calibration was performed.
The distance between the
distal surfaces of the
maxillary central incisors was
17 mm (Fig 2). Using this
measurement, the digital ruler
was calibrated, and a digital
mock-up was performed
using Keynote software
(Apple).
Fig 2 Distance between the

distal surfaces of the maxillary
central incisors was measured
with the use of a caliper.
Closure of gaps between
teeth inevitably leads to an
increase in the width of the
teeth and so, to retain their
proportions, their length must
also be increased. The use of
a calibrated ruler allows one
to measure the prospective
extension of the central
incisors, and digital modeling
helps to assess whether the
proposed changes are
esthetically acceptable (Fig
3).
Fig 3 Digital mock-up of the

proposed treatment was
performed.
An occlusal photograph
of the maxillary dentition
helps in planning changes to
the facial volume of the
maxillary teeth.
To improve the esthetic
concerns of the patient, the
following was recommended:
1. Teeth whitening
2. Fabrication of 10 bonded
porcelain veneers on the
maxillary teeth
Function
The proposed treatment also
addressed functional
concerns:
1. An equilibration of teeth
in CR
2. No creation of a
constricted envelope of
function when modeling
the restorations of the
3. Fabrication of a
nightguard at the
conclusion of treatment
Digital Simulation and

Fabrication of
Diagnostic Guides
Digital simulation of the teeth
facilitates communication
with the ceramist. A
presentation of this clinical
case was uploaded to a file-
hosting service into a folder
shared with the ceramist.
Photographs and videos of
the patient were shared.
Video documentation allowed
the ceramist to evaluate the
dynamics of the smile and
face, mobility of the lips,
facial expressions, and
phonetics. Both the dentist
and the dental technician can
insert comments directly onto
the slides of the presentation,
which facilitates
communication and exchange
of information.
The technician crafted the
diagnostic wax-up of the
teeth and forwarded it to the
clinician (Fig 4). A polyvinyl
siloxane index was created,
and the wax model was
transferred to the patient’s
teeth using self-curing
composite resin (Luxatemp,
DMG) (Fig 5). Phonetic tests
were conducted, and the
patient’s appearance and
smile were evaluated (Fig 6).
Fig 4a Analysis of the casts of

initial presentation.
Figs 4b and 4c Casts
duplicated from the diagnostic
wax-ups.
Figs 5a to 5d Contours of the

wax model were transferred to
the patient’s teeth with the use
of a silicone index and self-
curing composite resin.
Fig 6 Appearance and smile of
patient were evaluated.
The design and degree of

the tooth reduction was
thoroughly discussed with the
technician beforehand. The
volume of the preparation
was determined by the
following factors: (1) the
degree of change in tooth
color desired, (2) the degree
of change in the size and
position of the teeth, (3) the
closing of gaps between teeth,
and (4) the nature of the
occlusal relationship with the
opposing dentition.
Restorative Phase
Treatment of this patient was
complicated by two factors:
the production of veneers on
the mandibular teeth was not
planned, and the tetracycline-
stained teeth were difficult to
whiten. The patient could not
fully whiten her teeth because
she experienced intense
sensitivity during bleaching.
Moreover, a significant
change in maxillary tooth
color by the application of
veneers would lead to an
unnatural contrast with the
mandibular teeth. Thus, it
was decided to brighten the
maxillary teeth using bonded
porcelain veneers so that a
subtle difference would
remain between the maxillary
and mandibular teeth that
would be visually
imperceptible and
simultaneously improve the
patient’s smile.
This decision was
reflected in the degree to
which the teeth were
prepared. The cervical area
was not affected (Fig 7).
Nonpreparation veneers were
also considered for
preservation of tooth
structure; however, an
attempt to make
nonpreparation veneers in this
case would have resulted in
the impingement of the
overhanging ceramic
restoration edges on the
gingiva and an unnatural
appearance (Figs 8a to 8c).
The need to close the gaps
between the teeth led to the
preparation of interproximal
surfaces; otherwise, undercuts
would prevent the creation of
an accurate marginal fit. The
midline papilla was the only
area where it was necessary
to place the preparation
margin below the gingival
margin to form a chamfer of
0.1 to 0.2 mm (Figs 8d to 8f;
Fig 9). Only in this way was
it possible to close such a
large diastema between the
central incisors and to
provide the ceramist the
opportunity to create a natural
profile of the teeth while at
the same time maintaining a
healthy condition for the
midline papilla. All
preparations were performed
with the use of a surgical
microscope (Carl Zeiss).
Facial and palatal silicone
keys taken from the wax-up
provided an opportunity to
assess the degree of tooth
reduction (Fig 10).
Figs 7a to 7f Preparation of the

teeth through the diagnostic
mock-up.
Figs 8a to 8c Nonpreparation
veneers would have led to the
impingement of the
overhanging ceramic
restoration edges on the
gingiva and an unnatural
appearance.
Figs 8d to 8f The midline

papilla was the only area where
it was necessary to place the
preparation margin below the
gingival margin.
Fig 9 Small chamfers of 0.1 to
0.2 mm were created below the
gingival margin on the mesial
surfaces of the central incisors.
Figs 10a and 10b Silicone

keys taken from the wax-up
helped to assess the degree of
tooth reduction.
Gingival retraction was

only required in the area of
the midline papilla prior to
taking impressions (Fig 11).
Impressions were taken with
the polyvinyl siloxane
impression material (Express,
3M ESPE) (Fig 12).
Provisional veneers were
fabricated of composite resin
using a spot-etching
technique (Fig 13).
Figs 11a and 11b Gingival
retraction cords were required
only in the midline papilla area
prior to taking impressions.
Fig 12 Impressions were taken

with polyvinyl siloxane
impression material.
Figs 13a to 13f Fabrication of

provisional veneers.
In order for the technician

to have enough information
about the color of the teeth,
the maxillary teeth were
photographed with shade
guide samples before and
after the tooth preparation.
After receiving the
impressions from the dentist,
the technician created three
separate casts. The first pour
was cut, prepared, and
duplicated to make the
alveolar cast. After
duplication, the first pour was
stored and not touched again.
The second pour was used for
the fabrication of the veneers,
and the third pour was needed
for final fit tests.
After the technician made
the alveolar cast, he poured
the same duplication form
with refractory die material.
One must be aware that the
first pour cannot usually be
used for the veneer technique
because of the presence of
impurities. The silicone mold
is cleared of the fine layers of
residual contaminants by
pouring the impression the
first time. In addition, one can
also check the consistency of
the refractory die material. If
the first pour looks porous,
the refractory die material
used might be old and need to
be thrown away and a new
batch ordered. The technician
will use the second pour for
layering of the porcelain.
The dies were then
soaked in distilled water.
After at least two connection
firings, which close the still
minimally porous surface of
the refractory die and prevent
the ceramic margins from
lifting off the die during the
firing cycles, the ceramist
started the stratification of the
feldspathic porcelain (Willi
Geller Creation, Klema).
Mamelons, opalescence,
fluorescence, a balance of
opacity and translucency,
reverse opalescence, and the
use of polychrome grey are
needed to create a lifelike
natural appearance of the
ceramic work (Fig 14).
Fig 14 Porcelain layering.

After the veneers
proceeded through the
different ceramic firings,
surface texture treatment, and
glaze firing, as well as high-
gloss polishing of the margins
and pumice polishing of the
labial aspects, they were
divested from the refractory
die material by using glass
beads at the maximum
pressure of 1.5 bar. The
technician used the two
models or die sets he had left
to confirm the perfect fit of
the hair-thin ceramic shells.
After the fit of the veneers
was tested, they were cleaned
by immersion in a glass bottle
filled with 95% ethanol for 10
minutes. The veneers were
not etched before sending
them to the dentist (Fig 15).
Figs 15a to 15e Laboratory
steps of veneer fabrication.
Once the finalized

veneers were received from
the lab, they were tried in the
patient’s mouth with the try-
in paste to verify the marginal
fit and the overall esthetic
composition, and the dentist
had the patient evaluated and
provided feedback as to the
esthetic outcome achieved.
Once approved, the
veneers were etched for 90
seconds with 9.5%
hydrofluoric acid, rinsed, and
cleaned in ethanol in an
ultrasonic bath for about 10
minutes. The etched surface
was then cleaned manually
with a small-tipped
instrument.
The teeth were isolated
with the help of rubber dam
and Teflon tape (Fig 16a).
Before the adhesive
application, the tooth surface
was air abraded intraorally
with 27-μm aluminum oxide
(Rondoflex, KaVo Dental).
The veneers were seated, and
large amounts of excess
cement (Variolink Veneer,
Ivoclar Vivadent) were
removed with a dry brush and
an explorer. After most of the
excess cement was removed,
the veneers were tack cured
for 2 to 3 seconds, the rest of
the excess cement was
removed, and then the cement
was completely polymerized.
Glycerin gel was applied, and
the cement margins were
postcured through the
glycerin gel to avoid contact
with atmospheric oxygen to
eliminate the air-inhibited
layer (Fig 16b). The margins
were checked and cleaned
with a no. 12 scalpel blade
and periodontal microscaler.
Fig 16a Isolation of the teeth
with rubber dam and Teflon
tape.
Fig 16b Bonding of the
veneers.
The final result

completely satisfied the
patient (Figs 17 to 19). A
systematic approach to
history taking, examination,
and treatment planning
allowed the dentist to avoid
functional and esthetic
problems during
implementation.
Figs 17a and 17b Intraoral
photographs of the final
outcome.
Figs 18a to 18c Extraoral
photographs of the smile and
teeth.
Figs 19a and 19b Patient after

completion of treatment.
CONCLUSIONS
With the help of modern
means of communication—
using the Internet, working
with photographic and video
documentation, and using
presentation software— one
can create the correct
exchange of information
between the clinic and the
laboratory, even if they are
based on different continents.
Veneers are a very
satisfying option for both the
patient and the dentist as well
as the technician because the
transition from “before” to
“after” is enormous. With
minimal tooth preparation,
the patient can be given a big
change of smile, appearance,
and self-confidence. It
requires a great amount of
time, knowledge, and skill for
the dentist and technician to
create very thin porcelain
veneers that not only mimic
natural enamel but also mask
defects and alter the shade
and shape of the teeth.
BIBLIOGRAPHY
Coachman C, Calamita MA.
Digital smile design: A tool
for treatment planning and
communication in esthetic
dentistry. Quintessence Dent
Technol 2012;35:103–111.
Dawson PE. A classification
system for occlusions that
relate maximal intercuspation
to the position and condition
of the temporo-mandibular
joints. J Prosthet Dent
1996;75:60–66.
Dawson PE. Functional Occlusion:
From TMJ to Smile Design. St
Louis: Mosby, 2007.
Dawson PE. Optimum TMJ
condyle position in clinical
practice. Int J Periodontics
Restorative Dent 1985;3:11–
31.
Edelhoff D, Sorensen JA. Tooth
structure removal associated
with various preparation
designs for anterior teeth. J
509.
Fradeani M. Esthetic
Rehabilitation in Fixed
Prosthodontics. Vol 1:
Esthetic Analysis: A
Systematic Approach to
Prosthetic Treatment.
Fradeani M. Evaluation of
dentolabial parameters as part
of a comprehensive esthetic
analysis. Eur J Esthet Dent
2006;1:62–69.
Goldstein MB. No-prep/minimal-
prep: The perils of
oversimplification. Dent
Today 2007;26:10.
Gürel G. Predictable, precise, and
repeatable tooth preparation
for porcelain laminate veneers.
Pract Proced Aesthet Dent
2003;15: 17–24.
Gürel G, Morimoto S, Calamita
MA, Coachman C, Sesma N.
Clinical performance of
porcelain laminate veneers:
Outcomes of the aesthetic pre-
evaluative temporary (APT)
technique. Int J Periodontics
Restorative Dent
2012;32:625–635.
Hasanreisoglu U, Berksun S, Aras
K, Arslan I. An analysis of
maxillary anterior teeth: Facial
and dental proportions. J
538.
Kois JC. Diagnostically driven
interdisciplinary treatment
planning. Seattle Study Club J
2002;6(4):28–34.
Kois JC. “The gingiva is red
around my crowns”—A
differential diagnosis. Dent
Econ 1993;4:101–105.
Kois JC, McGowan S.
Diagnostically generated
anterior tooth preparation for
adhesively retained porcelain
restorations: Rationale and
technique. J Calif Dent Assoc
2004;32:161–166.
Kokich VO Jr, Kiyak HA, Shapiro
PA. Comparing the perception
of dentists and lay people to
altered dental esthetics. J
Esthet Dent 1999;11:311–324.
Magne P, Belser UC. Novel
porcelain laminate preparation
approach driven by a
diagnostic mock-up. J Esthet
Restor Dent 2004;16: 7–16.
Magne P, Gallucci GO, Belser UC.
Anatomic crown width/length
ratios of unworn and worn
maxillary teeth in white
subjects. J Prosthet Dent
2003;89:453–461.
Magne P, Hanna J, Magne M. The
case for moderate “guided
prep” indirect porcelain
veneers in the anterior
dentition. The pendulum of
porcelain veneer preparations:
From almost no-prep to over-
prep to no-prep. Eur J Esthet
Dent 2013;8:376–388.
McLaren EA, Garber DA, Figueira
J. The Photoshop Smile
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Digital dental photography.
Compend Contin Educ Dent
2013;34:772, 774, 776.
Page R, Martin J, Loeb C. Use of
risk assessment in attaining
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Compendium Contin Educ
Dent 2004; 25:657–669.
Schmidt KK, Chiayabutr Y,
Phillips KM, Kois JC.
Influence of preparation
design and existing condition
of tooth structure on load to
failure of ceramic laminate
veneers. J Prosthet Dent
2011;105:374– 382.
Spear FM. The maxillary central
incisor edge: A key to esthetic
and functional treatment
planning. Compend Contin
Educ Dent 1999; 20:512–516.
Wilkins RG. Using a system of
diagnosis and treatment
planning to reduce stress.
Compend Contin Educ Dent
2000;21:485–492.
_________________________
1 Private Practice, Moscow,
Russia.
2 Master Dental Technician, Oral
Design New England, Boston,

Massachusetts, USA.
Correspondence to: Dr Gadzhy
Dazhaev, 2 Novy Pereulok 3-5
17, 107140, Moscow, Russia.
State of the
Art
CAD/CAM
Technology for
Complete
Denture
Fabrication
Tae H. Kim, DDS1
MS, PhD2
F
or decades, the
fabrication of complete
dentures has involved
tedious and time-consuming
processes. They include
taking the preliminary
impressions with stock
impression trays, creating a
study cast upon which custom
trays will be fabricated,
taking definitive impressions
using the customized trays,
constructing occlusal rims
with wax, and recording
maxillomandibular jaw
relations. After these
preliminary steps, artificial
teeth setup takes place,
followed by try-in to ensure
proper jaw and occlusal
relationships as well as
patient comfort and
satisfaction.
Undoubtedly, the entire
complete denture fabrication
process involves a number of
visits by the patient,
additional time consumed by
the dentist, a significant
amount of manual labor by
the dental technicians, and the
possibility of human error
and dimensional instability of
the dentures. Much effort has
been directed toward
reducing these processes.1–4
In recent years, the use of
computer-aided design/
computer-assisted
technology (Dentca) has
allowed the fabrication of
digitally fabricated complete
dentures.5 Dentures created
via CAD/CAM software are
highly accurate, since there is
no manual teeth setup.6 No
plaster model, physical
mounting, or wax-up is
required.7 In addition, CAD/
CAM dentures are
convenient, as only two visits
are required. Furthermore,
intervention by dental
technicians and the
subsequent chances for
human error are greatly
reduced. CAD/CAM dentures
remain permanently on
record, allowing the digital
data to be reused to fabricate
duplicate dentures without the
need for an additional visit.
Lastly, digitally fabricated
dentures could make a
standardized and controlled
study easier to develop and
validate scientific data related
to removable prostheses.8
The following case
demonstrates the use of CAD/
CAM technology to fabricate
a natural-looking complete
denture.
PROCEDURES
Maxillary and
Mandibular
Impressions
The two-piece impression
trays provided with the
Dentca system are used to
take maxillary and
mandibular impressions. Each
tray has its own separate
anterior and posterior
components, which can be
detached and are provided
with a center pin and plate
used for jaw relation records.
The trays come in various
sizes—small, medium, large,
and extra large—to best fit
the patient’s arch (Fig 1).
Fig 1 Medium-size Dentca
impression tray.
To record the maxillary

impression, fast-setting
heavy-body polyvinyl
siloxane (PVS) impression
material is first loaded onto
the tray for the initial
customization. The tray is
placed in the patient’s mouth,
seated over the arch, and firm
finger pressure is applied on
designated finger spots
located on the bottom of the
tray for 5 seconds, followed
by border molding
movements. Once the heavy-
body PVS is set, any exposed
areas of the tray are adjusted
with a bur. The tray is then
covered with light-body PVS
in order to perform the final
impression procedure.
The mandibular
impression is recorded in
exactly the same fashion,
with mandibular border
molding movements. As
before, exposed areas are
trimmed and then covered
with light-body PVS, and the
final impression is taken.
Vertical Dimension
and Centric Relation
Recording
The posterior segments of
both trays are separated along
the separation line using a
blade (Fig 2). The center pin
is attached to the mandibular
tray (Fig 3).
Fig 2 Final impression is separated
with the use of a blade for CR
record.
Fig 3 Intraoral tracing pin is
attached to the mandibular
impression.
Gothic arch tracing is

used to record the centric
relation (CR) of the jaws,
whereby the mandibular
stylus draws lines on the
maxillary plate to form the
shape of an arrow. This
requires use of a denture
tracing pad (EZ-Tracer,
Dentca) on the cameo surface
of the maxillary tray (Fig 4).
It is inserted with the
maxillary tray into the
patient’s mouth, and the
center pin is adjusted
clockwise with the fingers or
a tweezer until the desired
vertical height is reached (Fig
5). If the trays are in contact
with each other at any point,
those areas can be trimmed
with a bur.
Fig 4 Denture tracing pad is
attached on the tray for Gothic arch
tracing.
Fig 5 Center pin is adjusted for
proper vertical dimension.
The trays are replaced in

the patient’s mouth with the
center pin attached to the
mandibular tray. The
patient’s mandible is guided
from the anterior-most to the
posterior-most position. The
mandible is then moved
laterally on each side from its
most posterior position and
then brought back into its
posterior position (Fig 6). The
arrow thus formed is the
Gothic arch tracing, where
the apex of the arrow on the
maxillary tray represents CR
(Fig 7). A small hole or
depression is drilled into the
apex to allow the center pin
to fit into it during bite
registration.
Fig 6 Lower tracing pin marks on

the denture tracing pad.
Fig 7 Gothic arch tracing on the

denture tracing pad.
Bite Registration
The trays are seated back in
the patient’s mouth, and the
center pin snaps into the CR
hole. Bite registration
material is then injected
between the trays. When the
material sets, the trays are
removed and evaluated for
accurate positioning of the
center pin within the CR hole
or recess.
A ruler is used to measure
the distance between the
incisive papilla and the upper
lip border. Once complet ed,
the trays are disinfected and
mailed to the Dentca
manufacturer along with a
printed denture order.
CAD/CAM Process
The maxillary and
mandibular impressions are
scanned to create virtual
images of the edentulous
arches using the specialized
Dentca CAD software (Figs 8
and 9). Once the CAD
process is complete, the
virtual images of the dentures
are transferred to a 3D printer
to create try-in dentures. At
this time, two different sets of
try-in dentures are generated
for the patient’s evaluation.
The first setup has bold
maxillary lateral incisors with
minor crowding of the
mandibular incisors (Figs 10
to 14). The second setup has
soft maxillary lateral incisors
with moderate crowding of
the mandibular incisors (Fig
15 to 19). After try-in of both
sets, the patient decides on
the second setup for her final
denture (Figs 20 to 23). Now
that the decision is made, a
converting process is
followed to fabricate the
definitive complete denture,
including internal staining
(Fig 24) to create a natural
appearance (Figs 25 to 27).
Fig 8 Digital image of the

edentulous maxilla and mandible.
Fig 9 Digital image of the patient’s
condition.
Fig 10 Digital image of first teeth

setup: bold maxillary lateral
incisors and minor mandibular
incisor crowding.
Fig 11 Digital image of completed
denture after festooning (first
setup).
Fig 12 Try-in denture (first setup).

Fig 13 Teeth alignment (first
setup). 3D printed dentures ready
for try-in.
Fig 14 Teeth alignment in denture
(first setup).
Fig 15 Digital image of second

teeth setup: soft maxillary lateral
incisors and moderate mandibular
incisor crowding.
Fig 16 Digital image of completed

denture after festooning (second
setup).
Fig 17 Try-in denture (second
setup).
Fig 18 Teeth alignment (second

setup). 3D printed dentures ready
for try-in.
Fig 19 Teeth alignment in denture
(second setup).
Fig 20 Patient’s evaluation of first
try-in denture in mouth.
Fig 21 Patient’s evaluation of
second try-in denture in mouth.
Fig 22 Patient’s smile with second
try-in denture.
Fig 23 Patient with chosen try-in
denture (second setup) in mouth.
Fig 24a Cutback for internal
staining and enamel layer.
Fig 24b After application of
internal stain.
Figs 25a to 25c Completed

CAD/CAM denture.
Fig 26 Patient’s smile with

definitive CAD/ CAM complete
denture.
Fig 27 Patient’s natural-looking
appearance with the CAD/CAM
denture.
CONCLUSIONS
CAD/CAM technology for
fabrication of complete
dentures represents a new
benchmark for the clinician’s
armamentarium. CAD/CAM
dentures provide reliable and
predictable oral rehabilitation
of edentulous patients with
superior performance when
compared to traditional
methods of denture
fabrication.
REFERENCES
1. Maeda Y, Minoura M,
Tsutsumi S, Okada M, Nokubi
T. A CAD/ CAM system for
removable denture. Part I:
Fabrication of complete
dentures. Int J Prosthodont
1994;7:17–21.
2. Kawahata N, Ono H, Nishi Y,
Hamano T, Nagaoka E. Trial
of duplication procedure for
complete dentures by
CAD/CAM. J Oral Rehabil
1997;24:540–548.
3. Busch M, Kordass B. Concept
and development of a
computerized positioning of
prosthetic teeth for complete
dentures. Int J Comput Dent
2006;9:113–120.
4. Zhang YD, Jiang JG, Liang T,
Hu WP. Kinematics modeling
and experimentation of the
multi-manipulator tooth-
arrangement robot for full
denture manufacturing. J Med
Syst 2011;35:1421– 1429.
5. Goodacre CJ, Garbacea A,
Naylor WP, Daher T,
Marchack CB, Lowry J.
CAD/CAM fabricated
complete dentures: Concepts
and clinical methods of
obtaining required
morphological data. J Prosthet
Dent 2012;107:34–46.
6. Sun Y, Lü P, Wang Y. Study
on CAD&RP for removable
complete denture. Comput
Methods Programs Biomed
20009;93:266– 272.
7. Kanazawa M, Inokoshi M,
Minakuchi S, Ohbayashi N.
Trial of a CAD/CAM system
for fabricating complete
dentures. Dent Mater J
2011;30:93–96.
8. Inokoshi M, Kanazawa M,
Minakuchi S. Evaluation of a
complete denture trial method
applying rapid prototyping.
Dent Mater J 2012;31:40–46.
_________________________
1 Section Chair, Removable
Prosthodontics, Division of
2 Chair, Division of Restorative
Sciences, Ostrow School of

Dentistry, Director, Advanced
Program in Operative Dentistry,
California, USA.
Correspondence to: Dr Tae Kim,
California, DEN 4377, 925
W34th Street, Los Angeles, CA,
90089-0641.
The Reservoir
Technique
Hilal Kuday, CDT1
Michel Magne, MDT2
T
o obtain maximum
esthetics with
conservative treatment,
it is important to select the
proper restorative technique.
In the anterior region,
composite resin and ceramic
materials are the alternatives
for providing an esthetic
solution, both offering their
own unique qualities. The
physical properties of
composite resins are much
like those of dentin.
Ceramics, which have
physical properties akin to
enamel, allow us to create
very thin partial veneers.
This article describes the
reservoir technique,1 which
uses these two materials in
concert to take best advantage
of their respective physical
properties to mimic nature in
restoring teeth. The case of a
young boy is presented to
illustrate the technique.
CASE
PRESENTATION
A 14-year-old boy, who had
broken the incisal edges of
the maxillary central incisors
and right lateral incisor a few
years earlier, presented for
treatment. The teeth were
tested and confirmed to be
vital (Fig 1). Since the patient
was still growing, full-
coverage ceramic crowns
were not considered a
restorative option. Using the
reservoir technique, the lost
enamel on the incisal edges
was reproduced by a ceramic
shell and the lost dentin with
composite resin.
Wax-up
A wax-up was made to
analyze the target form. Of
course, form needs to be in
harmony with occlusion,
emergence profile, phonetics,
and esthetics (Figs 2a and
2b). The second wax model
was designed according to the
silicone index. The die space
area was limited to 0.5 mm
from the marginal borders,
which were marked carefully
before the second model was
made (Fig 2c). Zhermack
silicone was used for die
duplication and silicone
matrices (Figs 2d and 2e) that
were made from the wax-up.
In this stage, the incisal
effects for the appearance of
the final image must be
considered (Fig 2f).
The positive incisal
characterization must be
imagined but the spaces
waxed as negatives of incisal
appearance (Figs 3a and 3b).
Effect Design
When shaping effects, the
chosen ingot’s optical
behavior must be considered.
Each ingot has different
effects that are possible based
on its thickness. Simply
playing with thickness allows
us to create internal and
external optical effects.
Highly detailed
microstructural effects can be
created in a basic simple
manner with grinding tools
on the surface of the internal
wax structure (see Fig 2e)
that would not be possible to
create with a brush.
Refractory Cast
The refractory cast2 is needed
because of the naturally
angulated structure of the
tooth. The wax model must
be cut carefully near the
margin; standard press
procedures can then be
followed (Figs 4a and 4b). It
must be remembered that the
liquid ratio of the mixture
may be changed due to
absorption while the
refractory cast is closed for
investment. Alcohol can be
used to control absorption so
that the concentration at the
flask closing procedure is
balanced. PressVest speed
investment material (Ivoclar
Vivadent) was used as
closing flask as well as a
refractory die material.
The wax model from the
silicone index was
transformed to a refractory
cast. This protects anatomical
curvatures of the tooth from
breakage when working,
since the wax can be less than
0.1 mm thick in some areas.
The refractory cast guarantees
the marginal fit and controls
distortion of the wax form
(Fig 4c).
If desired, incredible
microstructural effects can be
created using basic
manipulations under a
microscope even on the
refractory cast. This can
enhance the detail of the
optical reflection in the final
ceramic.
The wax modeling on the
refractory cast will be the
ceramic shell and it will act as
enamel. If the ingot choice is
opalescent, eg, e.max Opal 1
or Opal 2, the intensive blue
reflection and the halo effect
on the incisal border must be
controlled (Fig 4d).
Pressed Monolithic
Ceramics
The highly developed
textures of the internal and
external surfaces of the
ceramic (e.max Opal 1,
Ivoclar Vivadent) increase the
optical quality and afford
complex details that cannot
be produced with a brush.
The internal surface of the
ceramic shell can be stained
with composite-based effect
materials before the
composite filling procedure.
The effects can be
highlighted or can be filtered
in the desired areas. In this
case, internal stains were not
used. The effects shown in
Figs 5a to 5c were created by
internal micro-surface
structure.
One must not forget that
the effect of the chosen ingot
on the final appearance is also
related to the thickness.
Uncontrolled thickness can
cause unwanted grayish color
or nonhomogeneous opacity.
We can easily decide the

value and the color of the
effects on the ceramic shell,
either at the lab or at the
clinic. For single crowns or
anterior restorations, this
procedure provides a great
advantage in controlling the
value before cementation. In
this case, SR Nexco light-
curing composite (Ivoclar
Vivadent) was used at the lab
to fill in shells and then cured
in a Lumamat 100 light
furnace (Ivoclar Vivadent).
ACKNOWLEDGMENT
Special thanks to Dr Nihan
Özlem Kuday and Dr Ceren
Kücük for their wonderful
efforts from Dent-boutique
Clinic in Istanbul.
REFERENCES
1. Magne M, Magne I, Gandolfi
Paranhos MP. Bilayer effect
with press ceramics—The
Reservoir Technique.
Spectrum 23/2/2011.
2. Vailati F, Bruguera A, Belser
UC. Minimally invasive
treatment of initial dental
erosion using pressed lithium
disilicate glass-ceramic
restorations: A case report.
2012;35:65–78.
_________________________
1 Dental Technician, Istanbul,
Turkey.
2 Master Dental Technician, Los
Correspondence to: Hilal Kuday,
Mimarsinan cad. mimarsinan,
ap. No 12/2, 34843
Maltepe/Istanbul, Turkey.
Mental, Visual,
and Manual
Training: The
MVM Concept
Ivan Contreras Molina,
DDS, MSc, PhD1
Panaghiotis Bazos,
DDS2
Pascal Magne, DMD,
MSc, PhD3
chieving mastery in high-

fidelity dental reproduction is
based on the perpetual study
A of natural teeth by
ways of anatomical
reproduction via two-
dimensional (drawing) and
three-dimensional (waxing)
training.
Those who endeavor to
train further to enhance their
education, vocation, and
skills need to show
considerable individual
initiative, discipline, and
perseverance. This is
particularly true in the
evolving disciplines of
dentistry, and especially in
the areas that require
optimized esthetic
integration. During the
undergraduate training
curriculum and in the course
of the daily routine in the
laboratory, clinicians and
technicians have little chance
of obtaining improved
clinical or technical outcomes
due to the lack of time
available for continuous
training.
The current generation of
dental practitioners seek to
gain insight and acumen in
reproducing the “natural
morphology” with greater
detail; hence dedication and
diligent training of the visual
and perceptual abilities must
ensue, ultimately forming a
harmonious workflow with
superior end results. When
developing the critical ability
of spatial perception with
regard to the cognitive
process of understanding the
static dental morphology, it is
necessary to achieve levels of
self-paced training to
generate the necessary
motivation to create
autonomy in each of the
restorative processes.
This article describes a
visceral way to train our brain
(mental awareness), eyes
(visual perception), and hands
(manual dexterity) to achieve
higher dental esthetic
discernment.
STAGE 1
Observe the natural
teeth—study the
macro/micro
characteristics in
terms of shapes,
textures, and line
angles
There is a principal anatomy
among the anterior teeth. This
anatomy gradually changes
from the central incisor to the
canine. Understanding these
subtle changes at specific
points contributes to the
cognition and comprehension
of the dental morphology,
which will successfully lead
to superior esthetic and
functional integration.
Labial surface
The labial surface is
composed of three primary
planes: incisal, middle, and
cervical. The middle plane is
relatively large and straight,
accounting for half of the
labial surface. The incisal and
cervical planes are
accordingly inclined palatally
and cervically, and they
occupy the greater part of the
labial surface (Fig 1).1
Figs 1a to 1c The model optically

highlights the delicate features of
the surface structures, enabling
improved visualization in order to
observe the individualization of the
teeth and revealing the facial and
palatal morphology (lobes,
marginal ridges, concave lines, V
shapes) in detail.
The surface from the

facial marginal ridge to the
extension of the interproximal
contact is termed the
proximal transitional surface.
The area between the mesial
and distal marginal ridges is
termed the flat area or visual
area. In the flat area there are
two V-shaped groove
positions on the labial surface
of the tooth, and on the
proximal transitional surface
there are two points
corresponding to the mesial
and distal concave lines (Fig
1).2
On the central incisor,
characteristics are located on
virtually the same level, while
on the lateral incisor and
canine, they have different
heights and are located in a
lower position than on the
central incisor. These points
are carved deeper and spread
out more mesially on the
lateral incisor in the distal
interproximal area and are
carved primarily on the
proximal transitional mesial
surfaces. The distal area is
located more cervically on
the proximal transitional
distal surfaces and it must be
carved more aggressively
farther from the midline (Fig
2).3,4
Figs 2a and 2b Observation of the

three-dimensional planes (incisal,
medium, and cervical) of the
anterior teeth by high-lighting the
facial transitional topography: the
proximal transitional surfaces and
the central visually dominant area.
Palatal surface
On the palatal surfaces of the
teeth there are two V-shaped
grooves. On the central
incisor, the two V shapes are
located on virtually the same
level, while on the lateral
incisor and canine, they have
different heights and are
located in a lower position
than on the central incisor. It
is important to know these
areas when developing the
morphology of the lingual
surface. Observation of the
palatal surface further shows
that the central incisor has
well-developed marginal
ridges and less-developed
central and secondary ridges.
The central and secondary
ridges become gradually
more developed and clearly
visible at the canine and
lateral incisor (Fig 3).
Figs 3a and 3b The palatal surface

shows the differential development
of the marginal ridges,
complementary to the morphology
of the facial surface with variation
of heights.
Texture
Irregularities of natural teeth
will create unique
characteristics on tooth
surfaces. These irregularities
result from age, tooth
position, and enamel
hardness. The maturation
stage and relative wear are
important aspects in the
reproduction of teeth. The
two types of textures that
predominate are horizontal
and vertical over the labial
tooth surface (Fig 4). The
horizontal component is a
direct result of the lines of
retzius (growth lines), leaving
fine parallel stripes on the
enamel surface, also called
perikymata. The vertical
component is defined by the
superficial segmentation of
the tooth in expressing
developmental lobe
coalescence.
Figs 4a and 4b Horizontal
(perikymata and lines of Retzius)
and vertical (lobular elevations)
components are subtle, with
wavelike irregular ridges that
surround the tooth
circumferentially, being more
evident in young teeth and
gradually disappearing as the teeth
undergo perpetual attrition.
STAGE 2
Observe natural teeth
in situ— in the mouth
The morphology and surface
characteristics of natural teeth
must be used as a basis for
restorations. It is imperative
that dental students,
clinicians, and technicians
practice contour techniques
based on natural teeth.
Natural teeth must be directly
observed; therefore, master
casts of natural dentitions are
more effective during training
than using freestanding
natural teeth themselves as
the model. Successful contour
essentially involves training
the eye to appreciate natural
teeth and training the hands to
express what the eyes
observe. It is important to
highlight that the visual
characteristics of the teeth
change drastically depending
on the angle of observation.
A selection of casts of
maxillary and mandibular
natural teeth with different
characteristics and
morphology is extremely
useful. There are three basic
tooth shapes: square,
triangular, and oval.5 The
observation of these basic
shapes in the mouth from
different angles is useful for
understanding the
morphology and individual
characteristics of each tooth
(Fig 5). During the design
stage, all tooth forms must be
evaluated from an incisal,
cervical, and frontal view
with a right-lateral and left-
lateral projection. This
evaluation will provide an
overall sense of the tooth
organization as well as the
anatomical parts.
Figs 5a to 5e Analyis of the visual
characteristics of natural teeth in
the mouth under different angles of
observation.
STAGE 3
Observe a picture and
draw it
A conceptual part of training
is learning how to draw in 3D
using an approach inspired by
Betty Edwards6 and the five
perceptual skills of drawing.
Those five skills (edges,
spaces, relationship, light and
shadows, gestalt) were
adapted to the situation of a
tooth drawing:
1. Frame and dimensions

2. Outline—negative spaces
3. Elements—internal
morphology and shadows
4. Shading and highlights—
cross-hatching/smudging/
eraser
5. Gestalt (“whole”)
6. Details (Figs 6 to 8)
Figs 6 to 8 Skills (edges, spaces,
relationships, light and shadows,
gestalt) and final result. Drawings
by author Pascal Magne.
STAGE 4
Make an impression of
teeth and analyze the
morphology in 3D
The physical form of a tooth
is determined by its outline,
comprising the incisal border,
proximal ridges, and cervical
line. These lines dictate the
path of the ridges and the
shape of the lobes. Thus, the
outline of the tooth should be
evaluated before analyzing
the tooth three-dimensionally
(Fig 9).
Fig 9 Impression-making for
model analysis.
Surface torsion is another
important factor in the design
of an artificial tooth. From an
incisal view, distal protrusion
becomes evident at the level
of the cervix. Failure to
consider this surface torsion
may result in artificial
incisors that appear flat or
distally protruded. The line of
rotation starts from the facial
aspect and continues
lingually. It is essential to
know about the interplay of
light and shade to understand
form (Figs 10 and 11).
Figs 10 and 11 Observing the

model from different angles
provides us with valuable
functional and esthetic
information. It is essential for
comprehending the interplay of
light, generating high-lights and
low-lights, which is necessary for a
deep understanding of form.
Torsion is common to all

teeth, although to varying
degrees of intensity. Surface
torsion is gentler in the
incisors and more pronounced
in the canines; however, the
dentist may define the extent
of torsion based on the
desired tooth form. In more
facially positioned teeth,
surface torsion becomes more
evident (Fig 12).7
Fig 12 Lateral view of a central
incisor makes it possible to
observe the effect of morphologic
torsion with the flexion expressed
distally.
It is important to highlight
that the visual characteristics
of the teeth change drastically
depending on the angle of
observation. In this regard,
analysis of a selection of casts
of maxillary and mandibular
natural teeth with different
characteristics and
morphology is extremely
useful.8 If they are painted
with all the features already
learned by our brain, their
comprehension will be much
easier; the use of lines and
marks gives us a different
perspective of the tooth
shape.
Maxillary Central
Incisors
Incisors are characterized as
follows: The medial outline
of the crown can be straight
or slightly convex for
maxillary incisors, with a
more rounded mesioincisal
angle for the lateral incisors.
The distal of the crown is
more convex compared to the
mesial outline. Its curvature
and inclination can vary
significantly according to the
typical form of the tooth, and
the distal angle is rounded.
The incisal outline of the
crown can be irregular or
rounded but usually becomes
flat due to functional wear.
The incisor shape is also
related to the anatomy of the
interproximal ridges, or
transition line angles, which
represent strategic light-
reflecting areas. These
vertical and oblique crests do
not influence the crown
outline; however, the
apparent tooth length and
width can be easily modified
by the length, position, and
direction of the transition line
angles.
Maxillary Lateral
Incisors
As previously mentioned, the
lateral incisors closely
resemble the central incisors
in their basic outline and
transition line angles, which
they supplement in function.
They differ mainly in terms
of their reduced size and
more rounded mesioincisal
angle.
Maxillary Canines
The maxillary canines are
considered to be the
reinforced “cornerstones”
within the anterior dentition,
characterized by a series of
transitional curves and arcs,
being thicker labiolingually
due to the increased
development of the cingulum
compared to that of incisors.
A distinction is marked by the
cusp tip, which is in line with
the center of the root.
The mesial outline of the
crown of the canine can be
slightly convex and resembles
that of the lateral incisor, the
mesial transition line angle
being well developed in the
form of a small medial lobe.
The distal outline of the
crown is flat or concave and
resembles that of the
premolar (Figs 13 and 14).9
Figs 13 and 14 Scribing is essential
for the rumination of morphology,
as these lines and marks on the
model serve as topographic
references for
morphodifferentiation between the
maxillary central incisors, lateral
incisors, and canines.
The characteristics of
tooth form are not separate
entities; rather, they combine
to create a single feature. In
other words, a tooth’s
topography is characterized
by grooves that determine the
three-dimensional anatomical
areas. A frontal view alone
does not provide enough
information to reproduce the
area around a transition line.
Thus, the operator should
begin working on each
transitional line starting from
the lingual surface. In all
natural teeth, the ridges and
grooves begin at the lingual
surface and then connect to
the proximal and facial
surfaces (Fig 15).9
Fig 15 Incisal and palatal views
showing the continuum of the
proximal and facial morphology.
STAGE 5
Wax up the same
anatomical fidelity
within a model
This procedure requires
precise knowledge of the
strategic elements of tooth
anatomy, which can be
learned through systematic
observation of natural teeth.
This stage is defined by
intuition, attention to detail,
and good visual perception.
Rigorous training should
allow the dentist to define and
attain the end goal of tooth
reproduction (Fig 16).
Fig 16 Model training involves
sequential placement of wax (drop
by drop) via the “dip and draw”
technique.
Fig 16a Initial situation.
Figs 16b and 16c Starting at the

incisal edge (lobe creation is
fingertip assisted), one may
establish continuity between the
vertical lobes and horizontal
sectors for each tooth in the three
main planes. One must also keep in
mind that the labial curves of the
lobes collectively slope toward the
distogingival margin (sagittal
plane), creating coronal torsion and
in the process a convex smile line.
Figs 16d and 16e Incisal and

cervical sectors are defined (dip
and draw technique), linking the
lobes initially with the horizontal
incisal sectors and subsequently
with cervical sectors.
Fig 16f “Windows” of space

between vertical lobes and
horizontal sectors are filled in,
starting at the incisal edge (use
fingertip for incisal part),
establishing continuity between the
vertical and horizontal topography
for each tooth. Thickening of the
incisal edge at the lingual aspect,
before and after incisal edge
thickening and continuity with
lingual surfaces. (One’s knowledge
of natural tooth anatomy is used
here, as well as direct comparison
with models of natural dentitions.)
Figs 16g and 16h View of
windows filled.
Fig 16i To establish continuity

with the interdental surfaces, labial
interdental surfaces are filled in
with hot wax.
The basic tooth shapes are

defined by the vertical
proximal crests, representing
the transition line angles
between the facial and
proximal surfaces. The next
step of the wax-up procedure
is to recreate the superficial
development lobes and
horizontal components of
surface topography resulting
from the growth lines (Fig
16).10 Because of their
prominence, these ridges are
the first to wear off and
therefore should be the first
elements to be restored by the
additive wax-up technique.
The position and arrangement
of the lobes will influence the
tooth form; the differential
placement and contouring of
the transition line angles can
easily generate the illusion of
a shorter or wider tooth.10
The final form and surface
texture, vertical labial lobes
and V shapes between lobes,
horizontal texture within the
incisal V shapes, and the
horizontal texture across the
labial surface (Fig 17) all
define the visual replication
of natural anatomically
formed teeth (Figs 18 to 20).
Figs 17a and 17b Final form and
surface texture: defining the
vertical labial lobes and V shapes
between lobes, horizontal texture
within the incisal V shapes,
horizontal and vertical texture
across the labial and palatal
surfaces.
Figs 18 to 20 The final wax-up
must be carefully evaluated from
all dimensional aspects. Every
detail, no matter how miniscule it
may be, is considered essential for
an exact reproduction of the
morphology of the original natural
dental archetype, that of the intact
tooth.
CONCLUSIONS
The creative moments
between our hands, our eyes,
and our brain always must be
marked by the fluidity of a
single motion. MVM training
provides the ultimate path in
continuous education and
personal training, ensuring
gratifying results by the
perpetual achievement of
higher-fidelity dental
reproduction. Study nature
and she will reveal her
secrets.
ACKNOWLEDGMENT
The authors would like to
express gratitude and
appreciation to Bianca Bianco
for being the model in this
article.
REFERENCES
1. Krishnan IS, Kheur MG.
Esthetic considerations for the
interdental papilla:
Eliminating black triangles
around restorations: A
literature review. J Indian
Prosthodont Soc 2006;6:164–
169.
2. Nishimura Y. Reconstruction
of coronal anatomy in ceramic
restorations of the anterior
teeth. Quintessence Dent
Technol 1994;17:67–94.
3. Andrews LF. The six keys to
normal occlusion. Am J
Orthod 1972;62:296–309.
4. Andrews LF. Straight-Wire:
The Concept and Appliance.
San Diego: LA Wells, 1989.
5. Kataoka S, Yoshimi N.
Nature’s Morphology—An
Atlas of Tooth Shape and
Form. Chicago: Quintessence,
2002.
6. Edwards B. Aprender a
Dibujar, Un Metodo
Garantizado. Madrid:
Hermann Blume, 1997.
7. Adolfi D. Natural Esthetics.
8. Adolfi D. Functional, esthetic,
and morphologic adjustment
procedures for anterior teeth.
2009;32: 153–168.
9. Chiche GJ, Pinault A.
Esthetics of Anterior Fixed
Prosthodontics. Chicago:
Quintessence, 1994.
10. Magne P, Belser U. Bonded
_________________________
1 Visiting Scholar of Esthetic
Dentistry, Division of
2 Private Practice, Athens, Greece.
3 The Don and Sybil Harrington
Professor of Esthetic Dentistry,
California, USA.
Correspondence to: Dr Ivan
Contreras Molina, Privada Plan
de Ayutla #39, Col. Chapultepec
sur, Morelia-Mexico.
Email:
[email protected]
Automated
Production of
Multilayer
Anterior
Restorations
with Digitally
Produced
Dentin Cores
Josef Schweiger,
CDT1
Daniel Edelhoff, CDT,
Dr Med Dent, PhD2
Michael Stimmelmayr,
Dr Med Dent3
Jan-Frederik Güth, Dr
Med Dent3
Florian Beuer, DDS,
Dr Med Dent, PhD3
W
hen producing
digital dental
restorations, it is
now possible to mirror the
geometry of teeth, to output
the result as a data record,
and to mill the resulting shape
monolithically from a tooth-
colored blank. The result is
acceptable when restoring an
entire anterior maxilla or
mandible, although the
esthetic results achieved with
layered tooth build-ups will
generally be more natural
looking. The identical
replication of adjacent teeth
creates the illusion of
“natural-identical”
restorations.
Single maxillary anterior
teeth, especially the central
incisor, cannot be
successfully realized as
monolithic crowns, as these
cannot adequately mimic the
individually layered structure
of anterior teeth. Here the
craftsmanship of an
experienced dental technician
will continue to be required.
But even the most skillful
expert will have to redo
maxillary anterior crowns at
times, as the desired esthetic
result does not always
materialize on the first try.
In addition to the correct
shape and surface, the shade
also plays a significant role.
In particular, the correct
individual layering—or, in
other words, the correct three-
dimensional structure—of the
crown is crucial for a perfect
reproduction of a natural
tooth.
The internal structure of
the crown—especially the
dentin—will determine the
esthetics of an anterior
restoration to a considerable
extent. Experienced dental
technicians are able to mimic
the dentin in its three-
dimensional manifestation
but will generally not be able
to provide any precise spatial
definitions. The design of the
dentin core is therefore based
mainly on the training and the
experience of the dental
technician and often follows a
“traditional” approach. Thus,
almost all dental technicians
leave a clearly discernible
“signature” as they prepare
their restorations, a
restorative artefact that does
not, strictly speaking, have
any connection with the case
at hand.
STATE OF THE ART

Ingots with Plane-
Parallel Layers
Various approaches have
been used to imitate the
layered structure of natural
teeth using digital methods.
For example, various
manufacturers offer ingots for
computer-aided
processing that consist of
several plane-parallel layers,
with the individual layers
having different shades.
Examples include the
Vitablocs TriLuxe forte ingot
(Vita Zahnfabrik), the
CEREC Bloc C PC (Sirona),
and the Noritake Katana
Zirconia ML disc (Kuraray
Noritake). These ingots
attempt to mimic the shade
gradient of the natural tooth,
from cementum and dentin to
enamel, by presenting
differently colored layers
within the material. The
software can modify the
vertical alignment of the
restoration within the ingot,
allowing the chroma of the
restoration to be modified.
The esthetic results of
restorations from these
polychromatic blocks are
certainly better than the
esthetics of restorations made
from monochromatic blanks.
Nevertheless, they cannot be
used to create customized,
patient-specific layers.
Three-Dimensional
Ingot Structure with
Dentin Core and
Enamel Coating
A second approach to
imitating the layered structure
of natural teeth is a millable
ingot that has a three-
dimensional block structure
with dentin core and enamel
coating and an arched
gradient between the dentin
and incisal (VITA RealLife
Block, Sirona CEREC Blocs
C In). The software can
relocate the virtual design
within the ingot such that the
proportion of dentin and
enamel is modified. This is
supposed to give users the
opportunity to imitate the
appearance of natural teeth as
closely as possible. But even
these ingots cannot be used to
produce customized, patient-
specific layers.
Semi-finished Crowns
A third approach is that of the
so-called semi-finished
crowns, such as the priti
crown (pritidenta), which
already features the
anatomical outer geometry of
the clinical crown and a
standardized layered structure
of the dentin and incisal
areas. The only thing left to
do is use the CAD/CAM
system to remove a volume
corresponding to the prepared
tooth in shape and form of the
basal aspect of the crown.
The disadvantage is that only
subtractive processing is
possible, so that slightly
larger blanks are generally
used that are reduced by
milling to match the CAD
design. Milling can never add
material!
Tooth Databases
Systems for computer-aided
manufacturing of dental
restorations include tooth
databases based on data from
scanned natural teeth,
scanned prefabricated teeth,
or scanned manually waxed-
up tooth shapes. However,
these databases invariably
refer only to the external
tooth geometry.
Biogeneric Occlusal
Surfaces
Sirona’s CEREC system uses
so-called “biogenic occlusal
surfaces” (developed by
Professor Dr Albert Mehl of
the University of Zürich,
Switzerland), which operates
on the basis of several
thousand scanned natural
teeth. The system determines
the closest match in the tooth
database to the remaining
tooth structure, “adds” the
missing portions, and thereby
obtains a very natural partial-
crown (or inlay, or onlay)
geometry. But even the
“biogeneric tooth model” is
confined exclusively to the
external tooth geometry.1 In
the biogeneric tooth model,
missing parts of the external
tooth surface are added in by
adapting a generic record of
the desired tooth to the
residual tooth structures
and/or antagonists and/or
adjacent teeth situation and/or
bite registration. Furthermore,
Sirona provides a database
for the CEREC system in
which the user is presented
with a static mamelon
structure, generated according
to geometric design
guidelines, which is then
customized by CAD and
produced by CAM in the
milling unit.
In his doctoral thesis,
Probst2 described the
morphology of maxillary
anterior teeth and the
determination of similarity
metrics of identical anterior
tooth types in the left and
right maxilla. However, he
did not address the layered
internal three-dimensional
structure of anterior teeth.
Looking at the current
state of the art as just
presented, it can be
summarized that no database
is currently available for the
layered internal three-
dimensional tooth structures
in the anterior and posterior
regions. The term “tooth-
structure database” as used
below denotes a
database/library that includes
internal three-dimensional
tooth structures and the
corresponding surfaces of the
respective specific teeth in
digital and/or physical form.
Neither has a method been
described for the automated
generation of the layered
internal tooth structure,
especially the dentin.
DEJ AND OES

By far the largest part of the
human tooth consists of
dentin, which forms the inner
“protective coating” for the
pulp cavity in its center. The
pulp consists mainly of
loosely packed connective
tissue with numerous cells,
intercellular basic substance,
reticular and collagen fibers,
and—not least—nerves and
blood vessels.3 The dentin in
turn is covered by enamel in
the clinical crown area and by
cementum in the root area.
Together, enamel, dentin, and
cementum represent the hard
tissue of the human tooth.
The enamel is the hardest
substance in the human body,
with a Vickers hardness of
250 to 550 and a compressive
strength of 300 to 450 MPa.
Its modulus of elasticity is
50,000 to 85,000 MPa.4 The
dentin, by contrast, is much
more elastic (Young’s
modulus of 15,000 to 20,000
MPa), because it contains a
significantly higher
percentage of organic matter.
The Vickers hardness of the
dentin is 60 to 70, and its
compressive strength is 200
to 350 MPa.4 The cementum
is similar to human bone in
both structure and hardness
but differs from bone in that
it is not vascularized. The
cementum is already
considered part of the
attachment apparatus, or
periodontium. This is where
the periodontal fibers are
attached that keep the teeth in
their bony sockets, or
alveoli.3
The dentinoenamel
junction (DEJ) and the outer
enamel surface (OES) (Fig 1)
are essential features of the
three-dimensional structure of
the tooth and significantly
affect its visual appearance.
Some study results indicate
that the DEJ provides
considerable information
about the OES.5–25 It is
known that the shape of the
DEJ closely resembles the
shape that the OES
reflects6,7,26 and that, unlike
the OES, the DEJ is
preserved intact in abraded
teeth.
Fig 1 Sagittal sections of anterior
crowns. The dentinoenamel
junction (DEJ) and the outer
enamel surface (OES) are clearly
discernible.
There are different ways

to represent the DEJ in three
dimensions, as described as
follows.
Chemical Removal of
the Enamel Layer
Chemical removal of the
enamel layer is a destructive
method for preparing the
DEJ. The entire enamel layer
can be removed with 37%
phosphoric acid.5,15–18 Since
the enamel layer is destroyed
in the process, it is necessary
to preserve the OES. This can
be done in an analog manner,
by taking an impression of
the tooth crown and
subsequent pouring of a cast,
or digitally, by scanning the
tooth crown. The scan
operation can be performed
mechanically (eg, Procera
Forte, Nobel Biocare) or by
means of an optical scanner
(eg, BEGO 3Shape D 700,
Bego Medical).
Computed
Tomography
The three-dimensional
geometry of the OES and
DEJ can be acquired by
standard computed
tomography (CT) or cone
beam computed tomography
(CBCT). The resolution and
accuracy of the data vary
greatly depending on the
manufacturer. Therefore, it is
often difficult to obtain 3D
data sufficiently accurate for
further processing from CT or
CBCT data. The InVesalius
software (CTI Renato Archer)
can convert two- dimensional
data from CT scans to three-
dimensional DICOM (Digital
Imaging and
Communications in
Medicine) data. These
DICOM data are then
converted to STL (Standard
Tessellation Language)
data.27–29
Microcomputed
Tomography
The best way to acquire
three-dimensional OES and
DEJ data is by
microcomputed tomography
(microCT). In the study
presented here, the extracted
teeth were scanned with the
exaCT S S60 HRE desktop
CT unit (Wenzel
Volumetrik). The voxel size
was 45 µm. The exaCT
Analysis software (Wenzel)
was used for data acquisition
and output. The data for the
enamel (with the OES on the
outside and the DEJ on the
inside) and the root with
dentin core (DEJ) and pulp
chamber were converted to
the STL format and output.
PRINCIPLE OF THE
DENTIN-CORE
CROWN
As early as 1945,
Weidenreich had noted that
the surface relief of the dentin
(the DEJ) could not be a
purely accidental feature
without any morphologic
importance.19,30 The basic
principle of the digital dentin-
core crown/digital dentin-
core bridge according to
Schweiger31 is as follows:
“There is a clear correlation
between the three-
dimensional tooth surface
(OES) and the layered
internal structure of a tooth
(the dentin core and DEJ)”
(Fig 2). As used here, the
term “correlation” signifies
the association of a record
describing the structure of the
internal layer (ie, the DEJ)
with a record defining the
external geometry of the
tooth (ie, the OES).
Fig 2 Principle of the digital
dentin-core crown according to
Schweiger (“inward biogenerics”).
OES = outer enamel surface. DEJ
= dentinoenamel junction.
Based on this axiom,32 a

tooth-structure database can
be compiled that allows, for
the first time, crown or bridge
restorations to be produced
accurately and with an
esthetic appearance that
replicates the natural model
(Fig 2).
Tooth-Structure
Database
The idea on which the
invention is based calls for
acquiring not only the outer
structures of the tooth but
also the layered internal tooth
geometry and to use it in
conjunction with the external
geometry, for example by
storing them in a database
(Figs 3 to 9).31,33,34 If the
external and layered internal
tooth structures can be
connected with each other
dynamically, this is a
particular advantage, as a
virtual modification of the
external geometry of the
tooth can then be reflected by
corresponding changes in the
internal structure. Another
advantage is that the digital
acquisition of a large number
of three-dimensional external
and internal tooth geometries
allows the establishment of a
well-defined relationship
between the layered structure
of the inner tooth and its
outer shape. Furthermore,
once a suitable external
geometry has been selected,
the database can propose an
internal tooth geometry that,
with great probability, will
correspond to the internal
geometry of the natural tooth.
Fig 3 Natural tooth, metal-ceramic
crown, and dentin-core crown
(longitudinal sections).
Fig 4 Natural tooth with
corresponding dentin core.
Figs 5a and 5b STL records from

a tooth structure database of the
outer enamel surface and the
dentinoenamel junction.
Fig 6 CAD/CAM dentin cores,

manufactured based on STL data
of the dentinoenamel junction.
Fig 7 Virtual rendering of the outer
enamel surface and the CAD/CAM
dentin cores.
Correlations between the

external and internal tooth
geometries are recognized,
for instance when certain
types of tooth shapes (eg,
oval, square, triangular) are
associated with characteristic
internal tooth structures (eg,
pronounced mamelons in the
case of projecting triangular
teeth). Tooth types can be
further subdivided into
different shape groups by
looking at tooth-specific
surface and shape
characteristics, including:
• Mesiodistal curvature
• Incisocervical curvature
• Rounding of the distal
incisal edge
• Rounding of the mesial
incisal edge
• Angle characteristics
• Incisal edge contours
• Surface-structure
components such as
longitudinal grooves or
elevations
Data records of scans can be
assigned to shape groups
either by visual inspection or
digitally using the best-fit
alignment method. Either
way, the result will be a
database of teeth that
subdivides the different tooth
types into multiple shape
groups.
Similarly, it is possible to
assign the acquired internal
tooth structures (especially
the dentin cores) of the
various tooth types (central
incisors, lateral incisors,
canines, first and second
premolars, first to third
molars) to different shape
groups by using the same
method. Here, again, the
assignment can be made by
visual inspection or using the
best-fit alignment method.
The result is a database of
internal tooth structures,
again subdivided into
multiple shape groups. In
addition, it is possible to
establish a correlation
between the internal and
external tooth geometries.
Using the database data, an
internal tooth geometry is
proposed for a given external
tooth shape. It is highly
probable that this proposal
corresponds to the “real”
internal tooth geometry (Figs
8 and 9)—the more so, the
more records are included in
the tooth database. BEGO
Medical already realized this
in its Dentaldesigner software
from 3Shape. This software
stored, for the first time, tooth
geometries that are created on
the basis of the real tooth.
Fig 8 Palatal view of tooth
structure data of maxillary anterior
teeth, showing the dental pulp, the
dentinoenamel junction, and the
outer enamel surface.
Figs 9a to 9c STL records of
dentin cores and enamel coatings
of maxillary anterior teeth.
A novel application—the
biogeneric tooth model— is
also supported. This model
calculates, based on the vast
number of different tooth
records in the database, an
internal tooth geometry (eg, a
dentin core) that has all the
features characteristic of the
respective tooth type. This is
not achieved by merely
averaging or superimposing
the individual data points (xn,
yn, zn) that describe the
internal tooth geometry, as
this would result in noisy,
unstructured data that do not
correspond in any way to the
typical geometry. Rather, the
dentin core is segmented into
individual building blocks
(mamelons, incisal grooves,
incisal contours of the dentin,
etc) to uncover
correspondences and to
compare like with like. This
prevents essential structures
of the dentin core from being
averaged out in calculating
the geometry, as happens, for
example, with mamelons
during conventional
alignment calculations, for
example with regard to
mamelons. This method
produces an average internal
tooth geometry with averaged
values for the characteristic
building blocks, such as
mamelons, incisal grooves,
incisal edges, etc.
In the next step, the
deviation of the individual
internal geometries from the
respective average geometry
is calculated by a principal-
axis transformation. If the
goal is to reconstruct a
layered internal tooth
structure, the biogeneric tooth
model must be correlated
with the external tooth
geometry. Here, the layered
internal tooth structure—
especially the dentin core—
corresponds to the missing
hard tissue of the tooth
substance in a biogeneric
inlay reconstruction. A
certain spatial distribution of
a few design points on the
external tooth surface
requires a certain morphology
of the dentin core. The
combination of an average
dentin core with the
biogeneric model of the
external tooth geometry
makes it possible to assign
the most probable dentin core
to a given external tooth
geometry. The morphologic
external tooth geometry and
the layered internal tooth
structure is essentially based
on a genetic blueprint. The
probability is high that a
specific external tooth
geometry can be correlated
with a specific layered
internal tooth structure,
especially with regard to the
dentin core, and vice versa. It
should be pointed out in this
context that one of the lead
structures during
odontogenesis is the
preformative membrane,
which eventually forms the
DEJ.
This membrane is an
anatomical structure that
forms during tooth
development. As a basement
membrane, it constitutes the
interface between the
mesenchymal connective
tissue (the mesodermal
papilla) and the ectodermal
enamel organ. Shortly before
the dentin begins to form, this
basement membrane thickens
and henceforth separates the
dentin from the enamel. Here,
odontoblasts and ameloblasts
are initially located back-to-
back as the pre-dentin/pre-
enamel is converted,
gradually moving away from
each other while the hard
tissues of the tooth they have
formed are left behind.
Once the external tooth
geometry has been digitally
linked to the internal tooth
geometry, a correlation is
formed between the two
records, a correlation that can
be either dynamic or static. In
a static correlation, the
internal geometry is not
changed by a modification of
the outer geometry, which
among other things implies
that the dentin core always
retains its shape. In a
dynamic correlation,
however, the internal tooth
structure is modified in
response to any modifications
of the external tooth surface.
On modifying the external
tooth geometry, all X/Y/Z
values of the internal tooth
geometry change
proportionately to the X/Y/Z
values of the external tooth
geometry (scaling). Rotations
will be performed with the
same angle, and translations
with the same X/Y/Z values
will be performed by adding
the translation values.
This database with
correlations between the
internal and external tooth
geometries (correlations
database) can be used in
different ways in the
production of dental
restorations. Using computer-
assisted output devices
(computer numerical control
[CNC]; rapid prototyping
[RP]), restorations can be
produced that mimic the
layered internal structure of a
natural tooth. The internal
structure of the restoration is
produced based on a record
from the database, where the
external surface corresponds
exactly to the internal tooth
structure of a record selected
from the database. Suitable
materials for creating the
internal core include
materials with a toothlike
esthetic appearance in terms
of shade and translucency,
especially resin, glass
ceramics, feldspar ceramics,
lithium disilicate ceramics,
and oxidic high-performance
ceramics such as zirconia and
alumina. Once this computer-
generated internal aspect of
the restoration has been
produced, the incisal aspects
can be added. This can be
performed manually using a
ceramic layering technique or
a wax-up technique with
subsequent overpressing.
Alternatively, this incisal area
can be designed by
subtracting the internal tooth
structure from the external
tooth surface, creating a
differential record that can be
transformed into a real-world
object using a CAM
procedure. In a subsequent
additive step, this incisal area
is then connected to the
dentin core by sintering
(using a ceramic connector
mass), by a polymerization
process, or adhesively.
In the context of the
method described here, there
are several ways to design
and manufacture dental
restorations digitally (Fig 10),
as shown below.
Fig 10 Schematic representation of
the fabrication of dental
restorations with the aid of a tooth-
structure database.
Best-fit alignment
The arch situation comprising
the teeth to be replaced as
well as the adjacent teeth is
acquired by three-
dimensional scanning
(intraoral or extraoral). If a
“mirror tooth” is present, its
three-dimensional structure is
mirrored. A study2 has shown
that mirror-image
replacements of anterior teeth
are satisfactory with respect
to interproximal, occlusal,
and esthetic aspects. Using an
iterative procedure, the
external structure of the
mirror-image tooth is
compared to and correlated
with the natural or manually
designed teeth in the
correlations database until the
most appropriate record is
found. To determine the
appropriate record by way of
an iterative procedure, it is
possible to devise a similarity
metric based on the standard
deviation of the smallest
distances of points on the
surface of the mirrored tooth
from the respective closest
points of each tooth record in
the database. (SD = standard
deviation over the shortest
distance = similarity metric)
This method is also called
“best-fit alignment.” To
achieve a best-fit alignment,
the tooth is mirrored and then
superimposed on a reference
tooth from the database in the
optimal position by rotation,
translation, and possibly also
scaling. Image analysis
software (eg, Geomagic
Qualify, Geomagic GmbH)
can be used for this. As a
layered internal tooth
structure exists for the best-
fitting record, this structure
can be used for designing the
restoration, and specifically
its dentin core, using
computer-assisted methods.
Once the dentin core has been
created, the incisal aspect can
be built up manually;
alternatively, a CAM-created
incisal segment can be
connected to the dentin core
by sintering or adhesively.
Customizing the data
according to user
preferences
acquired by three-
(intraoral or extraoral). If no
mirror-image tooth is present,
a record presumed to be
appropriate is selected from
the database and can be three-
dimensionally adapted to the
actual situation by rotation,
translation, and scaling. Due
to the dynamic correlation of
the record of the three-
dimensional external tooth
geometry with the record of
the three-dimensional layered
internal tooth structure, a
design for a layered core, eg,
a dentin core, will be
suggested. The suggested
dentin core can then be
customized as required. The
three-dimensional record is
implemented physically on a
computer-assisted output
device such as a CNC or RP
unit.
Best-fit alignment
after customizing the
data according to user
preferences
acquired by three-
(intraoral or extraoral). If no
mirror-image tooth is present,
the software compares the
residual dentition with the
records from the database of
arch segments, and the record
presumed to be the most
appropriate is selected using
the best-fit alignment method.
Since this record is assigned
to exactly one record of the
missing tooth, it can serve as
a basis for the tooth to be
replaced. Due to the dynamic
correlation of the three-
dimensional external tooth
geometry with the three-
dimensional layered internal
tooth structure, a design for a
layered core, eg, a dentin
core, will be suggested. The
suggested dentin core can
then be customized as
required. The three-
dimensional record is
implemented physically on a
computer-assisted output
device such as a CNC or RP
unit (eg, Bego Medical).
Automated
Manufacturing
Process for Individual
Anterior Crowns
Using tooth-structure
databases it is possible to
produce—using a partially or
fully automated process—
highly esthetic restorations,
especially for the anterior
region.
Let us assume a single
anterior crown is to be
provided for the maxillary
left central incisor using a
digital process, where the
natural right central incisor is
used as a template. Producing
a single crown for a maxillary
central incisor is considered
one of the most difficult
challenges in prosthodontics.
The procedure consists of the
following steps:
1. Acquiring the external

tooth surface
2. Identifying the matching
dentin core
3. Mirroring the external
tooth surface and dentin
core data
4. Digital manufacturing of
the dentin core
5. Adding the incisal region
6. Digital finishing of the
tooth surface
7. Finalizing the crown
(glaze firing, polishing,
etc)
Acquiring the external
tooth surface
The external surface of the
natural right central incisor
can be acquired by three-
dimensional digital scanning
(Fig 11) with a mechanical or
optical scanner or using a
sonographic or radiologic
procedure such as CT, CBCT,
or micro-CT.
Fig 11 Maxillary right central
incisor and the corresponding die
of the left central to be restored.
Identifying the
matching dentin core
The dentin core matching the
external surface of the tooth
dentin can be determined
based on the tooth structure
database. The acquired
surface data are compared
with the records of tooth
surfaces in the tooth-structure
database, and the record that
is in closest agreement with
the newly acquired data is
selected. In the tooth-
structure database, each
external tooth surface is
associated with a unique
dentin core. Consequently, it
is possible, on the basis of the
acquired data, to identify the
matching dentin core.
Mirroring the external

tooth surface and
dentin core data
Next, the two records are
mirrored (Fig 12) to produce
the crown based on the
mirrored external tooth
surface and dentin core data.
Figs 12a and 12b STL data of the

mirrored dentinoenamel junction
of the maxillary right central.
Digital manufacturing
of the dentin core
Using dental CAD software,
the record of the digital
dentin core can be placed on
the prepared tooth. The three-
dimensional orientation of the
dentin core data set is
determined by the external
tooth surface data. Next, the
CAM software calculates the
milling paths and
corresponding NC file based
on the CAD record of the
dentin core. In the example
shown, the dentin core was
produced using the Everest
unit (KaVo) and was
prepared using the “counter-
bed” procedure. In this
procedure, once the cavity
side has been milled, the
cavity is filled with
polyurethane resin. Once the
resin has hardened, the
surface of the dentin core (the
DEJ) is milled. The material
used was lithium disilicate
(IPS e.max CAD LT, Ivoclar
Vivadent). A side benefit of
the counter-bed procedure is
that it produces a copy of the
die in polyurethane that is
precisely positioned within
the CNC unit in relation to
the machine zero and
workpiece zero points,
facilitating precise
repositioning of the crown
within the CNC unit. The
CAM process uses diamond
grinding points. The IPS
e.max CAD material is
present in the metasilicate
phase because it is easier to
mill in this phase. After
milling, the dentin core is
crystallized at 840°C; then
the lithium metasilicate is
converted into lithium
disilicate, attaining the target
tooth shade and the final
strength of 360 MPa (Figs 13
and 14).
Figs 13a and 13b CNC-milled
dentin core made of lithium
metasilicate to restore the
maxillary left central.
Fig 14 Dentin core from lithium
disilicate after crystallization at
840°C.
Adding the incisal

region
The ceramic veneer was made
of IPS e.max Ceram (Ivoclar
Vivadent). Before the actual
application of the ceramic in
the incisal area, a wash firing
was performed at 760°C.
Experience has shown that a
mixture of Transpa Incisal
and Opal Effect 1 at a ratio of
1:1 achieves a good result
when using the incisal single-
layer technique. Material is
applied generously to the
incisal area to provide enough
bulk for the subsequent
subtractive process. Once
applied, the ceramic material
is fired at 750°C (Figs 15 and
16).
Fig 15 Application of incisal
veneering material (IPS e.max
Ceram, 50% Transpa Incisal 2,
50% Opal Effect 1).
Figs 16a and 16b The ceramic

material is fired at 750°C.
Digital finishing of the

tooth surface
After ceramic firing, the
entire crown is repositioned
on the polyurethane die that
was produced by the counter-
bed process. Next, the tooth
surface is machined based on
the three-dimensional record
of the outer enamel surface
(Fig 17). The result is a two-
layer restoration in which
both the inner dentin core and
the outer enamel surface were
obtained in a digital
procedure.
Figs 17a to 17d The tooth surface

is machined based on the three-
dimensional record of the outer
enamel surface. Repositioning is
done with the aid of the
polyurethane “copy.”
Finalizing the crown

(glaze firing,
polishing, etc)
The manufacturing process is
finalized with a stain-and-
glaze firing and final
polishing of the restoration
(Fig 18).
Fig 18 The restoration is
completed with a stain and glaze
firing.
CONCLUSIONS
The process described in this
article allows, for the first
time, fabrication of highly
esthetic anterior restorations
based on tooth structure
records in a digital, and
therefore reproducible,
procedure. The result is
predictable, and good
outcomes can be achieved
even by users who are
experienced in these technical
matters. The digital dentin
core is the key to digital
anterior esthetics. It is
important to create tooth
structure databases that
contain data both for the
external geometry of the teeth
and the corresponding dentin
cores. The data for natural
teeth especially will open up
an entire new dimension of
natural anterior esthetics.
Production options include
both subtractive and additive
manufacturing processes (Fig
19).
Fig 19 (Left to right) Natural tooth,

CAD/CAM-fabricated anterior
crown on tooth, 3D-printed (RP)
tooth.
Users have the ability to
access a wide variety of tooth
shapes and their structural
designs to achieve
reproducible results.
Ultimately, it should be
possible to use the digitally
acquired external geometry of
a tooth to identify the
corresponding dentin core
from a database in a highly
predictable manner. Future
research projects will have to
demonstrate the statistical
external tooth shapes and
dentin cores.
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_________________________
1 Dental Technician, Department
of Prosthodontics, Dental
School, Ludwig-Maxmilians
University, Munich, Germany.
2 Director and Chair, Department
3 Assistant Professor, Department
Correspondence to: Josef
Schweiger, Department of
Prosth-odontics, Ludwig-
Maxmilians University,
Goethestrasse 70, 80336
Munich, Germany.
Email:
[email protected]
muenchen.de
Learn more about
Quintessence Publishing
Co., Inc
www.quintpub.com

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Editorial

Sillas Duarte, Jr, DDS, MS,

QDT 2014 SECTION

QDT is published once a year by

Taking Control Over

Flapless Esthetic Gingival

STATE OF THE ART

Maintaining the Esthetics of

CAD/CAM: A Whole New

STATE OF THE ART:

The Reservoir Technique

Mental, Visual, and Manual

Victor Clavijo, DDS,

ith the popularization of

implant surgery neglect the

Fig 1a Pretreatment intraoral

Fig 2 Treatment plan (Digital

Fig 4a Provisional placement with

Phase II: Reshaping

Fig 4b Remarkable esthetic

Fig 5a Minimally invasive

Fig 6a Metal abutment with main

Fig 6b Metal framework on the

Phase II: Matching the

Phase III: Duplicating

Phase IV: Manufacture

Figs 10a to 10c Translucent, thin

Fig 11 Brightness definition areas.

Figs 12b and 12c Dentogingival

Figs 13a and 13b Final try-in for

Fig 14a Hydrofluoric acid

The implant abutment

Fig 17 Two-year follow-up.

In the presence of dental

This case shows that an

• Lack of proper tooth

Fig 2 No display of teeth in the

Functional analysis: Main

• Attrition of the anterior

Fig 5 After selective grinding

Fig 6 Direct mock-up

Fig 8 After removing the

Figs 10a and 10b Definitive

Figs 12a and 12b After the

Fig 17 Lateral view of the

Fig 18 The new smile of the

Fig 21 Frontal view after 6

• Attrition of the anterior

Figs 25a and 25b Details of

Figs 27a and 27b Lateral

Fig 29 Complete dental

Fig 30 Analysis of wear facets

Fig 32 Relationship between

casts in the articulator, it

Fig 34 A new relationship is

Fig 35 The space between the

• The diagnostic wax-up

Figs 37a and 37b Indirect

Figs 38a and 38b The mock-

Figs 40a and 40b Preparation