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6 Dental Tribune Middle East & Africa Edition | September-October 2014mcme Bleach Cases From dead white to natural bright By Aiham Farah, Syria S ubstituting the white opaque dentin ceramic ma- terial with a high brightness transparent effect is the secret of manipulating the 4 bleach shades (BL4, BL3, BL2, BL1), and the key factor to make them close to the natural-looking shades in our (A-D) shade guide. (Fig 1) • The visual perception in which Opal Effect ceramic material ap- pears to be radiating or reflect- ing light is called luminancity, and luminance is the intensity of light that generates what we see in dental ceramic as natural white. Why natural? Because it simulates the optical properties of the natural enamel of healthy tooth. Our following case is a very good example of producing attractive natural-looking bleach shade. Case Presentation A 45-year-old female presented to the clinic with an esthetic request, she desires a smile change. Apparently she was seeking a new look on multi- ple cosmetic aspects, and she chooses to start at the dental studio. The dentist interviewed her and found out what category she is seeking (esthetic), and what was hermajorcomplain.Hereported the followings; Major complain was a non-vital appearance of the current old restorations be- sides discoloration, which drew a pale smile on her face, and an inflammatory appearance of the surrounding gingiva. (Fig 2, Fig 3) The patient was examined in- traorally, and her dental history was recorded. The radiographic exam of the upper incisors re- vealed a good endodontic situ- ation. Preliminary impressions were also taken to produce a study model. The dental lab technician presented to the clinic to evaluate the old veneers condition, and grasp the pa- tient’s needs and discus her ex- pectations from the whole treat- ment. Complete photos protocol was taken to the teeth, lips and face, those photos were crucial during the lab working steps. Treatment plan The treatment plan included the following measurements; Removing the old veneers, re- prepping the incisors and the 4 upper premolars according to the general principles of all- ceramic veneers preparation, 0,6mm chamfer was created equigingivally and a 0.9mm buc- cle reduction was necessary to allow the veneers to mask from one hand and give the desired color from the other hand, final impression of the maxillary arch was made using addition silicon Virtual (IvoclarVivadent). Dental Laboratory procedure The failure According to the patient’s de- sire of having bleach veneers, the brightest color of IPS e.max press ingot suitable for veneers fabrication (Low Translucency, LT BL1) is used, followed by delicate cut back and layering Transpa-Incisal powders from IPS e.max Ceram. On the day of the try- in, patient showed up to the clinic, she was excited to see the new smile. When she looked at the mirror she felt the change. (Fig 5) All the measurements of esthetic smile, from teeth arrangement to lips dynamic appeared perfect on her face. The dental team members had different point of view on the shade after tak- ing few minutes to absorb the tried-in set. They all agreed that something still missing for the case to be esthetically pleasing, as if all the light rays coming from inside the veneers faded down after being placed on the prepped teeth (dentist stated in privacy). Soon we realized that the discoloration of the prepped dentin continued on darken- ing during the 10 days lab work process. So at the day of the try- in, it was ND4, noting that the one reported in the beginning was ND2. (Fig 4) It seems that those veneers lost luminos- ity after placing them on the prepped teeth, what indicated a bad influence on the final color. Nothing can be done at this mo- ment to get those veneers back to life. A decision to repeat the case was simply taken, with no hesitation, photos of the tried-in mCME articles in Dental Tribune have been approved by: HAAD as having educational content for 2 CME Credit Hours DHA awarded this program for 2 CPD Credit Points Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. CAPP designates this activity for 2 CE credits. set with the bleach shade guide held into position were impor- tant to be reviewed to find out what to do and what to avoid in the new veneer set. (Fig 6) A black and white photo was im- portant to define the matching level of brightness, and what bleach shade we reached. (Fig 7) Ingot selection judgment The Success Priority number one was mask- > Page 7 Fig 1. Bleach shade guide, (Ivo- clarvivadent A-D shade guide) Fig 2. The pre-operative situation Fig3.Thepre-opsituationreflecting the non-vital appearance of the old veneers and the surrounding gingiva Fig 4. The degree of discoloration of the prepped dentin according to the ND shade guide Fig 5. The patient checking her smile with the first set of veneers Fig 6. The non-vital appearance of the first set of veneers centrals on the day of Try-in Fig 7. The low value of the first set of veneers compared to the bleach shade guide in a B&W photo Fig 8a, 8b. Masking test of the MO0 ingot shells Fig 9. The texturized veneers on the control (non- segmented) model Fig 10. A comparison between the LT BL1 veneer and the MO0 veneer ing the discoloration and then; increasing the luminosity, though we choose the opacity ingot (Medium Opacity) MO0, to be pressed on a thickness of 0.5 mm, and before we pro- ceed I had to double check the masking capability, so I drew two marks on the stone (red- blue) and check if they are vis- ible through the MO0 shells (Fig 8a, 8b) then layered with dentin and incisal material and char- acterize with variety of brighter impulse colors from IPS e.max Ceram powders. Texturized Fig 9, glazed, then the final outcome shin was balanced by further manual polishing. A comparison with the failed previous set; in order to make sure that I succeeded boosting the luminosity level was impor- tant after transferring the dentin background of the natural prep from the patient mouth to my bench through the IPS Natural die material ND4. (Fig 10) Cementation Veneers were finally cemented with Bleach XL (only Base) Variolink-II resin cement (from Ivoclarvivadent), After they have been tried-in and all seating and