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Well kept teeth and an appealing smile come in first place in terms of attractiveness. Thanks to brand new technologies and high-tech materials the patient’s desire for beautiful teeth can easily be realized. In this particular case, a 52 year old female patient presented. After detailed examinations and analysis we decided that a complete restoration of the maxilla and mandible with bridges on implants was required. By using zirconium dioxide for the frameworks we could meet the patient’s wish for a fully biocompatible restoration.
Proper planning is essential with every piece of dental work, especially in regards to aesthetics. As a first step, we have to undertake an analysis of the actual dental status. Secondly, we have to think about the desirable result. The third step is to define the necessary procedures of treatment. In this connection we want to emphasize that the cooperation between the Dentist, Dental technician and the patient is absolutely necessary to achieve a positive result. Slogans like “Beautiful Teeth Within 2 Hours” lead patients to have misconceptions of what is meant by modern, patient-oriented, responsible dentistry.
Patient: Age 52, female. We think there is no further comment necessary on the aesthetic and functional aspects of this absolutely disastrous situation (Fig. 1 and 2). In the first treatment unit we removed the bridges, extracted teeth numbers 22, 23, 24 and 17 and started to augment the alveolas with Beta-TCP (Ostim) and supplied the patient with a temporary bridge (Fig. 3). In the second treatment unit we extracted teeth numbers 31, 32 36, 41, 42 and 48. Similar to the measurement in unit 1 we augmented the alveolas and supplied a temporary bridge for the patient. We extracted teeth numbers 11, 21 and 14 and implanted Wi.tal implants with immediate loading function. One week later we implanted in region 31 and 32 another 2 implants (Fig. 4)
To obtain a high quality dental prosthesis there is only one preference which is to be considered: The natural tooth. The analysis of this sample for the reconstruction of the crown is therefore essential. Fifteen years ago highly qualified dental technicians developed a simple, all around work philosophy to reconstruct crowns with an exact method.
Indications: combination technique, combination of Metal-Ceramic and Pressed ceramic, Staining techniques, Pressed Ceramic, Press-over (pressed to metal) and stratification (layering) technique.
In recent times CAD/CAM , technology has developed tremendously. We believe, that these systems offer very interesting technical and aesthetic possibilities. At this moment they meet obstacles like the incapability of routinely being able to reproduce with high precision. There are certain borders for aesthetics ( control of level of opacity). They are not as yet clinically sufficiently proven and there is the high cost factor of involvement which is not feasible for an average dental laboratory to undertake. Since it is foreseeable that there will be a lot of changes in this sector, we asked ourselves if it would be possible to use the already existing materials and equipment in our laboratory to produce simple and satisfying work. Our goal was to get innovative results without bringing on too much extra costs while at the same time achieving high results in aesthetic quality. We came to the conclusion that the press-over technique was the choice and cutting edge for us in these innovative ceramic systems. Here with our long term experience we are able to implicate and combine metal ceramic systems and the aesthetic quality of all ceramics in an optimal fashion. With every innovative technique, we consider that it is of great importance to orientate ourselves with the existing publications. In this way we were able to avoid mistakes (too large of a frame work, disproportional reconstructions, etc.).
Copy milling is an easy and economical method to produce zirconia frameworks for dental restorations. From the technician's point of view, this precise technique comprises well-known work processes, e.g. modellation and manual milling. Thus, only a short introduction period is required to learn how to produce highly accurate ceramic frameworks. All production steps are uncomplicated and easily understandable. Furthermore, the experience of the dental technician has a positive effect on the production process. The user of the copy milling technique also benefits from a similar flexibility than in the casting technique, e.g. expansion control as well as delicate framework design up to fully anatomical crowns. This report shows the complete production process from the model preparation to the finished porcelain-faced zirconia framework.
Key words: all-ceramic, zirconia, technique, copy milling, Ceramill Thanks to the advantages of an all-ceramic, metal-free and at the same time very sturdy dental restoration, the high-performance ceramic zirconia has quickly gained an excellent reputation in the dental field. The knowledge that almost any type of dental restoration can be realized with this material offering long durability and utmost fitting precision caused a run on this ceramic framework material and the according technology. Although many dental technicians have a great interest in using zirconia as material for their frameworks, they have hesitated so far to invest their money in the relatively expensive CAD/CAM production technology. Reasons, which so far scared off the prospectives from buying such a system, were a high financial risk as well as the necessity to learn the comprehensive use of the new software for framework design.
In this regard, the copy milling technique (e.g. Ceramill by Amann Girrbach GmbH - see fig.1) is a reasonable means to finally start with the production of the very popular zirconia frameworks.
This article by Dr. Jan Hajtò and Hubert Schenk, which is published parallel in the teamwork journal, is a description of a switch-over to a complete anterior restoration in the maxilla which is compromised by a parodontal situation. This descript case is based on an extensive pre-treatment.The insertion of laboratory fabricated provisionals, over a longer period of time has a therapeutic effect on the formation of the soft tissue and is the foundation of a «lege artis» restoration. For the definitive restoration Zircon oxide copings veneered with ceramic are used.
Especially where anterior teeth are considered patients have a big obstacle to overcome to decide for new restorations, even in isolated situations. The guilt lays with the missing trust to the dentist/technician team. This is based on bad experiences patients have had in the past.
In these cases, the possible solution is offered to the patient before fabrication of the final ceramic prosthesis to opt for laboratory produced temporaries and to find and test the new situation. This is a very good possibility to help the patient and to find confidence in the treatment. Prior condition is correct tissue management, a precision impression, the fabrication of the provisional and a bacterial free, long-term temporary cementation. These acrylic restorations should be considered proto-types instead of temporaries. Their time frame in the mouth could be easily more than one year, during that time the soft tissue can regenerate (fig 2). The gingival has to a certain degree a memory and therefore the possibility to regenerate under certain circumstances back into its original form.
The dental ceramics field has seen an unprecedented growth in the last decades. Starting with the advent of Porcelain-Fused-to-Metal restorations by Morris Weinstein (1962) followed by introduction of Porcelain Jacket Crowns by Sigmund Katz (1989) and vision of CAD/CAM by Francois Duret (1973-1983) new restorative materials and technologies are emerging with an ever increasing rate. This tremendous expansion of materials causes dental technicians some uncertainty in what materials to use.
Question of Choice
With all these new porcelain assortments on the market today, how is one to choose or know which to get into bed with?
There is no single answer or solution. It all depends on the situation, the type, size and space limitations. For single crown restorations simple pressable ceramics should suffice and in cases of limited room would be material of choice. This would result in the easiest method and achieve best color. This would include onlays, inlays, 1/2, 3/4 and full crowns as well as veneers. These types of restorations would be very difficult and even not feasible with zirconia and other materials which require that a core or understructure be fabricated to support layered ceramics to complete the structure. Once bonded these restorations will have sufficient strength and support to endure for a long time.
How do these new pressable ceramics compare to the “old” feldspathic layered onto refractory porcelains? My Dr’s keep insisting that I use feldspathic materials.
I get a lot of this also from some of my accounts. It is a question of education and not what someone heard in a lecture somewhere. The Pressable porcelains are feldspathic in composition the same as layered porcelains. The benefit of pressing is that the form can be easily achieved in wax (no worry or frustration about drying time or sintering shrinkage) invested and then through lost wax technique injected with feldspathic porcelain. The choice would then be yours as to cut back the surface and layer on or simply to refine surface and stain and glaze.
Working on refractory models (or even platinum foils) is a well known technique which has been around for 20-30 years. Evolution does take place and the new techniques and materials are excellent and easy to use. Even more significant than ease of use is the understanding that pressed ceramics are noticeably stronger. During the pressing procedures the grains are squashed forming flattened particles. This produces a compressed stratified construction which considerably enhances the strength.
Today’s restorative dentist has many materials and techniques from which to choose for conservative restorative care. An evidencebased approach is prudent for the astute clinician. Moreover, informed consent is essential for ethical practice and peace of mind, both for the clinician and the patient. This paper presents a case for consideration in which a patient requested to have four silver amalgam restorations replaced and after a thorough evidence-based discussion of materials and techniques the silver amalgam restorations were replaced with four different restorative techniques (pressed and layered porcelain inlay, cast gold inlay, direct composite, laboratory processed composite inlay). Using key words, selected references were obtained by Medline search (1990-present) and contemporary restorative textbooks.
Operator experience and bias tempered with patient values help facilitate treatment decision making. Integrating these two variables with the best evidence available will enhance and maximize positive oral health outcomes and patient satisfaction.
Electroforming has been used in dentistry for more than 30 years. This precise technique to fabricate pure gold frameworks is ideal for aesthetic metal-ceramic restorations. In some cases, all-ceramic prosthetics are not possible to fabricate if the tooth reduction is less than what is required. In these instances, electroforming is an important tool for a technician.
Today all-ceramic restorations seem to be the only biocompatible aesthetic solution. However, there are many parameters that must be attained. Tooth reduction must be at least 1.5mm with occlusal reduction being 1.5 to 2mm. Also, a significant margin preparation or chamfer preparation is requited. Finally, the preparation has to be very smooth, especially when CAD/CAM milling techniques are applied. Not very often is the ideal tooth preparation reality in the dental laboratory.
With a perfect preparation and no undercuts, either an all-ceramic or galvanoform restoration is an option (Fig.2). However, if there is no shoulder and/or with undercut , a galvanoformed coping is a better choice (Fig.3). If the shoulder preparation is too small, a galvanoformed coping will have more aesthetic advantages with clinical function.
In the previous article, we saw how to solve technically esthetic problems with zirconia, problems due to patients neglecting their oral health. There is nothing better than when the patient, the dentist, the specialist and the lab are on the same wavelength. The following cases show how important time, planning and provisional restoration are to manage the soft tissue.
They all are very crucial to a restoration’s success.
“TISSUE IS THE ISSUE” — CASE N°1
This case is similar to the one in my previous article, except that time and provisional restoration were not an issue. Plus, there was no negligence on the patient’s side.
Zirconia abutment made with a Procera CAD/CAM system (NOBEL BIOCARE) Fig1 , and porcelain layered on it with E.MAX (Ivoclar Vivadent ) Fig2, in Fig3, the tow veneers mad with Empress IPS Esthetic (ivoclar Vivadent) bonded on the zirconia abutment and natural tooth, three months after insertion.
The most important thing is to maintain the soft tissue and the papilla around the implant and the natural tooth; and in order to do that ,the flap in time of surgery And the provisional restoration before implant placement and after are essential.
For dental technicians, working precisely, esthetically, and predictably is becoming more important. In this article, Paolo Smaniotto and Dr. Flavio Tura present us with their own successful technique, here in the context of a fixed total prosthesis. Taking this as a sample case, they demonstrate their structured method, which they have been using for several years.
Key Words: correlator, Rossini method, total restoration with a fixed prosthesis, transfer technique
This 50-year old male patient needed fixed total restorations for both dental arches. An examination of the situation models and initial pictures indicated we had a very complex case in hand. The clinician, Dr. Flavio Tura, informed me that the patient was a heavy smoker and very deficient in oral hygiene (Figs. 1–4). He was also a freelance businessman and had to keep numerous appointments and therefore needed good-looking temporary dentures (Figs. 4–10). So it was a difficult case with few advantages to start from.
Patient is a 47 year old female was unhappy with her smile and self conscience of her appearance. She is missing teeth, which was impinging during mastication. The treatment plan included sealing and root planning, along with orthodontic therapy to manage the spaces and to align the teeth in proper centric relation (Fig 1).
The patient underwent comprehensive examination and evaluation. FMX, Models, face bow, centric relation bite, soft and hard tissue exam, TMJ exam, cancer screening, and periodontal analysis. After the orthodontic treatment was completed (Fig 2), a new set of study models were taken and a stick bite in centric relation were taken. The models were articulated and a LSK treatment plan wax up was completed by the dental laboratory. The wax up was used to provide anterior guidance and cuspid disclussion.The patient agreed to the treatment plan of full mouth reconstruction and was appointed to have her teeth prepared in one visit (Fig 3 & 4).
Using only one photograph, this article will demonstrate in three easy steps, how to determine the appropriate smile design parameters, for an accurate simulation of the patient’s future smile. With the “Guided Positioning System” the dentist, other practitioners, and your lab technician will be able to create a pleasing smile design for the patient utilizing the new Modified Golden Proportions.1
The modified Golden Proportion formula, which is only available in the dental GPS computer program, provides the Dentist with the ability to eliminate the previously necessary “Artistic Element”, in preference to a “Scientific” one, resulting in a more accurate approach to the creation of ideal proportions and smile design. This system provides the dental team with a tool to diagnose and treatment plan in a more advanced and comprehensive manner.
Only one photograph is required for the entire analysis. The 1:10 full facial view2 showing the patient’s face with a full natural smile is all that is required. Two optical principles are important to obtain an accurate picture.
The completion of the V. segment is done by producing the distal enamel crest with a transition to the secondary cone. It runs from the tip of the cone in a curve towards distal and transforms into the secondary cone and finishes into the disto- approximal marginal cone of the second segment. Between both segments is a fissure, which means that the first molar is open on the distal. (fig 351) A stop is produced on the distal enamel crest. This stop is no7 and marks complimentary on the mesial secondary cone of the fourth segment of tooth 37 (fig 342 to 346). The analysis of function with the occlusal compass shows the as a result the functional direction, which is of importance: the protrusion. Because of this, stop no 7 becomes a black exclamation mark.
At the end all functional directions are controlled with the articulator and have to function with out interruption.