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10 Dental Tribune Middle East & Africa Edition | February 2015AESTHETICS By Aiham Farah, Syria B eing able to Choose the same material for fabricat- ing every single restora- tion in one case (whether they were bridges, full crowns or ve- neers) is always a big advantage, it serves in achieving the accu- rate matching and harmony among all the restorations in the following dimensions: (Value, Hue, Chroma, translucency, depth.. etc). The challenge for the dental manufactures have been always strength and es- thetic level of the dental restora- tive material, finally we started testing new generations that combine both, but the question is still: Did we esthetically get to the level of the glass-based ma- terial such as (Lithuim Di-Sili- cate), the answer might be no, but perhaps we are close with the TFZ (Translucent Full-Con- tour Zirconia) for the long span bridges in the posterior region. The pre-operative situation 38 years old lady, presented to her consultation appointment at the dental studio asking to change her smile. Her main concern was the ex- tensive yellowish-brownish dis- coloration in her front teeth, es- pecially the upper ones. Besides the miss arranged teeth set up that reflected older age effect on her face (according to her). She was a senior manager in one of the beauty & skin care compa- nies in Dubai, and her overall look was important to her. (Fig. 1b, 2, 3) Data collection and analyses We evaluated the patient pre- operatively, went through her dental history, took many pho- tos from different angles, and discussed her expectations and goals. Intra-Oral Diagnoses After the dentist diagnosed the case he reported the following; Sever tetracycline discoloration, lack of vitality, poor appearance, besides disproportional dimen- sions of the teeth proportions, and conflicting smile line with the curvature of the lower lip line. (Fig. 4) Radiographic exam revealed a need for endodontic treatment for some of the posterior teeth. Preliminary impressions were taken to have a study model for us to be our physical refer- ence where we can draw our lines, straighten long axes, ad- just length and do the cosmetic countering, etc.. The need for DSP (Digital Smile Philosophy) in this case Lips dynamic Enrolling the photos we took on our PC screen and digitally redesign the teeth arrangement according to the lips movements and curvature in the means of (Digital Smile Philosophy), was necessary since our patient ‘s main complaint was the smile. (Fig. 1a) There for, as a dental team, we should think further than esthet- ically reshaping each individual tooth. We should think more of relation between each tooth to the neighboring tooth next to it, from one hand, and to the har- mony between the entire teeth arrangement and the lips move- ments, on the other hand. (Fig. 1b) The Philosophy of redesigning the smile digitally Through a simple software (power point Or Keynote), we can edit our photos based on our knowledge in the dento-facial esthetic and harmony. To have more sufficient ways of commu- nicating between the clinic and its laboratory on one end, and for our patient to visualize our final outcome whether its meet- ing his/her expectation of the whole treatment or not. So the dentist will not go over- invasive in his/her preparation of the patient teeth anymore, neither the dental technician will have to guess in creating the shape and measurements of his/her final restorations. But they both will follow a interdis- ciplinary plan where results are controlled and expected accord- ing to a preapproved-by-patient mock up test. The trick is that we need to make our measure- ments on our PC screen match the real measurements on our patient teeth and their replica of a cast stone model, therefor we develop a digital roller, which measures distances on the PC. This will be our communicating tool between the digital world and the real world. Then we calibrate our pho- tos according to it (shrink & stretch), for any editing done on the photos from lengthening to shortening etc, will be able to be measured using our digital roll- er and these measurements can be used by the dental technician to fabricate his esthetic diagnos- tic wax-up. (Fig. 4, 5, 6, 7) Choosing the tooth contour for our ceramic. No link has been proven 100 percent, between the face and tooth contour, and no certain rule has been followed to sim- plify the mission of choosing the fabricated restoration couture. However, some theories have been put into good use, most of them rely on the physical facial analysis from all over contour and rounding. The rest rely on the morpho-psychology and emotional features of the pa- tient. The question still is whether the original tooth shape, that our pa- tient was born with, is what we need to go back to when we de- sign our restorations, OR a NEW tooth shape is what we need to improvise, that might add up on the patient character. (Fig. 8, 9) Preliminary treatment and preparation 6 upper anteriors were prepared according to the general princi- ples of preparing all-ceramic Ve- neers, 0.9 mm buccal reduction was given, taking the degree of stump discoloration and final shade approached into consid- eration. 1 mm bevel preparation was prepared at the incisal edge, and 0.6mm rounded shoulder (almost 1-1.5 mm subgingival- ly). 8 lower anterior and one addi- tional left premolar were pre- pared according to the general principles of preparing porce- lain laminate veneer, 0.5 mm buccal reduction was given with a 0.4 chamfer (equigingivally). 2 bridges were prepared in the posterior region, one on the up- per jaw, one in the lower jaw. (Fig. 10) Final impression was made us- ing additional silicone (Virtual, Ivoclar Vivadent). Shade of the prepped teeth was also taken using the natural die material shade guide (from Ivo- clar Vivadent) and reported as ND6, which needed a special cautioninchoosingtheingotlev- el of (Translucency – Opacity), in order to mask this discoloration and reach the bleach BL4 shade (according to the patient need). (Fig. 11; shows the bleach shade guide, in color comparison with the ND situation). Direct temporary restorations were made with the aid of an index. No signs or symptoms of discomfort were observed or reported over two weeks. The periodontal situation was kept under surveillance, and the healing process of the gin- gival tissue was clear, in means of color and positioning. At the same time, those restorations were our patient’s future look. So adjustments in shape at this stage can still be conducted in- traorally by carving or adding Translucent Full-contour Zirconia... Innovation in the dental industry Fig. 1a Fig. 4 Fig. 5 Fig. 6 Fig. 7 Fig. 8 Fig. 1b Fig. 2 Fig. 3 > Page 11 The challenge of combining Zirconia to e.max in the same case. > Explained in details in Lab Tribune page 1C Lab Tribune on to reach adequate harmony among lips, smile and face char- acter. Working technique Restric- tion Our lab working techniques for characterizing a pressed set of veneers are either staining technique, cut back technique, or layering technique. But in combination cases where we