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7Dental Tribune Middle East & Africa Edition | July - August 2014 mcme 6. The room light conditions should have a temperature of 5500-6500° K. (when pictures are taken, these parameters are no longer relevant, because the light of the flash will prevail). 7. Obtain value levels by squint- ing. 8. Women are far less likely to be color blind than men, so it is a good idea to have your as- sistant assist in shade taking decisions (assuming that the assistant is a woman and not color blind) In Part 1 of this article, the necessary equipment and ac- cessories for adequate intraoral pictures was discussed. Please refer to it for the necessary in- formation if you are planning to purchase adequate equipment. Figures 13 and 14: Colored and black and white picture. Figure 15: Unhappy patient with unsatisfactory crowns. Figure 18: Discolored stump. Figure 20: IPS e.max CAD crowns after milling with the MC XL (Sirona) unit. The copings need to be crystalized in order to get the final shade. Figure 23: Proximal contact and integration control in the model. Figure 26: Bonding with Excite DSC. Figures 27 and 28: Mixing and application of Variolink N (Ivoclar Vivadent). Figure 29: Final result after 2 weeks. Figure 30: The value of the restorations match the one from the natural teeth. Figure 31: Natural integrated crowns. Figure 21: Layering steps. The shade is compared with the natural die material stumps. Figure 24: A retraction cord was placed prior etching. Figure 22: Final appearance of the crowns placed on top of the natural die material stumps, which has the same shade than the dentin-composite stumps in the patient´s mouth. Figure 25: Etching with hosphoric acid. Figures 17a-17d: The stump shade is shown compared with a shade tab. Ideally the natural die material shade guide should be used. As an example A2 looks similar to ND2. Figure 16: The smile is high, situation that makes the metal marginofthePFMcrownobvious. Figure 19: Situation after internal bleaching and composite build up. < Page 6 mCME SELF INSTRUCTION PROGRAM CAPP together with Dental Tribune provides the opportunity with its mCME- Self Instruction Program a quick and simple way to meet your continuing education needs. mCME offers you the flexibility to work at your own pace through the material from any location at any time. The content is international, drawn from the upper echelon of dental medicine, but also presents a regional outlook in terms of perspective and subject matter. Membership: Yearly membership subscription for mCME: 600 AED One Time article newspaper subscription: 200 AED per issue. After the payment, you will receive your membership number and Allowing you to start the program. Completion of mCME • mCME participants are required to read the continuing medical education (CME) articles published in each issue. • Each article offers 2 CME Credit and are followed by a quiz Questionnaire online, which is available on http://www. cappmea.com/mCME/questionnaires.html. • Each quiz has to be returned to events@cappmea.com or faxed to: +97143686883 in three months from the publication date. • A minimum passing score of 80% must be achieved in order to claim credit. • No more than two answered questions can be submitted at the same time • Validity of the article – 3 months • Validity of the subscription – 1 year • Collection of Credit hours: You will receive the summary report with Certificate, maximum one month after the expiry date of your membership. For single subscription certificates and summary reports will be sent one month after the publication of the article. The answers and critiques published herein have been checked carefully and represent authoritative opinions about the questions concerned. Articles are available on www.cappmea.com after the publication. For more information please contact events@cappmea.com or +971 4 3616174 FOR INTERACTION WITH THE WRITERS FIND THE CONTACT DETAILS AT THE END OF EACH ARTICLE. Once the patient is ready, place the shade tabs in front of the anterior teeth, before starting the treatment itself. The same applies for pictures with lips. It is important to repeat the same protocol intraorally, as well as extraorally, because of the large influence of the reds in shade taking. (Figures 7-8) In addition to the points presented before, the following should be considered initially when pho- tographs are taken: (Figures 9 - 13) 1. Avoid the large reflection areas of the metal parts of the shade guide as they reduce the detail of the pictures 2. Take pictures using two dif- ferent shade tabs 3. The surface of the shade tab must be at exactly the same lev- el of the buccal surface of the teeth, as even minor discrep- ancies can make a tooth look darker or brighter due to the power of the flash) 4. The incisal edge of the tabs should be at roughly 1mm dis- tance from the natural teeth, or as close as possible, without touching each other. 5. Take pictures with and with- out contrasters. This is espe- cially relevant in young teeth with opalescent areas and clear halo effects. 6. In cases where an all-ce- ramic restoration is planned, the shade of the stump should also be given to the lab, using a special shade guide, such as the natural die material shade guide of the IPS e.max system (Ivoclar Vivadent, Liechten- stein). 7. Consider taking some pic- tures in black and white. A black and white photograph will help show the value of the shade tab in relation to the pa- tient’s tooth. (Figure 14) Clinical case A 27-year-old female patient came to our office unsatisfied with the appearance of her 2 anterior pfm crowns (Figure 15). The value of both crowns clearly did not match the other teeth and her smile line unfor- tunately also showed the dis- colored cervical part of tooth 11 (Figure 16). An overview picture of the stump shade was taken with a reference (Figure 17a). This reference should ideally be the natural die material A - D shade guide (Figure 17d). Both shade guides, the natural die mate- rial guide and the A-D shade guide have some similarities, for example, as a rule of thumb an ND2 looks quite similar to an A2 (Figure 17b). Obviously, the natural die material shade guide has shades that are dark, since its purpose is to correlate to artificially discolored stumps and not to recreate natural shades as the A-D shade guide (Figures 17c and 17d). Internal bleaching of the stump was then performed with 35% hy- drogen peroxide (Figure 18) in 2 sessions of 20 minutes each. Figure 19 shows the final result after the composite build-up with Excite DSC and Multicore flow (Ivoclar Vivadent, Liech- tenstein). An impression was taken and sent to the lab. The cast was scanned and an IPS e.max Cad LT block was milled (Figure 20). The appearance of the crowns is always checked with the natural die material stumps in order to get the cor- rect value and chroma (Figures 21 and 22). Finally, contacts and final integration of the crowns were checked in the solid cast (Figure 23, labora- tory work done by CDT Volker Brosch, Germany). A retraction cord was placed prior to bond- ing the crowns (Figure 24). The stumps are etched with phosphoric acid (Figure 25) and Excite DSC was applied (Figure 26). Variolink N (base and catalyst, translucent shade) were mixed and applied to the crowns (Figure 27 and 28). After 4 weeks a natural inte- gration of the crowns with the right hue, value, chroma and effects can be seen in Figure 29. Acknowledgements The author would like to thank CDT Juergen Seger and Volker Brosch for their valuable tech- nical work presented in this article. Editorial note: References are available from the author. Contact Publisher for author’s information if needed. Contact Information