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November-December 2016 | No. 6, Vol. 6 PUBLISHED IN DUBAI www.dental-tribune.me IPS e.max® PRESS MULTI THE WORLD’S FIRST POLYCHROMATIC PRESS INGOT • Monolithic LS2 restorations showing a lifelike shade progression • Exceptional combination of strength, esthetics and efficiency • For crowns, veneers and hybrid abutment crowns • Coordinated with high-precision Programat press furnaces • Maximum cost effectiveness in the press technique • • • all ceramic all you need www.ivoclarvivadent.com Ivoclar Vivadent AG Bendererstrasse 2 | 9494 Schaan | Liechtenstein Tel.: +423 235 35 35 | Fax: +423 235 33 60 LIFELIKE ESTHETICS – EFFICIENTLY PRESSED Metal-Ceramic esthetics without boundaries Search: Where is the framework? ByDr.AdrianBacila&Florin Stoboran,Romania We have known for some years now that abrasion, erosion and other de- fects caused by stress and diet, are issues which are becoming increas- ingly common. Now we see that this type of problem is occurring more andmorefrequentlyamongstunder 30-year-olds who consume modern acidic drinks. An extreme example with a dreadful initial situation is presented here. The most suitable, patient-friendly and well proven method still used a lot today is the metal-ceramicrestoration. There are special requirements to be considered when creating a life- like rehabilitation of teeth in young adults:notjustintermsofthevestib- ular tooth surfaces, incisal edges and the occlusal surfaces, but also the type of veneering material used for the restoration with regard to tooth shade, translucency and light trans- mission. The correct choice from the start makes the dental technical workquickerandeasier.Tomakeour work with metal easier and in order to achieve convincing light optical results,wechosethenewceramicIPS Style Ceram from Ivoclar Vivadent (Schaan/Liechtenstein). The follow- ing article describes our production methods step by step, from the di- agnosticassessmentandplanningto thefinalinsertionoftherestoration. Diagnostic assessment and patient consultation A 27-year-old came to our den- tist’s practice, Dr. Adrian Bacila in Timişoara (Temeschburg), Banat/ Romania. He complained of gen- eralized, already chronic hyper- sensitivity and poor esthetics. He had long postponed his visit to the dentist and had neglected his teeth; he was now determined to have his dental defects corrected (Fig. 1 to 3). The following was recorded as pros- thetically relevant in the clinical as- sessment: multiple carious lesions, which required treatment and were responsible for the tooth sensitivity; 13 - tooth crown completely broken, 14, 15, 23-25, 33, 34, 37, 43-45, 47 - frac- tures and breakages with partially exposed pulp; 36 and 46 - missing. The sensitivity test and Spectra examination suggested extensive endodontic treatment, which was verified by an X-ray. It was possible to avoid extractions. Gingival reces- sion due to periodontitis was identi- fied in both the upper and the lower jaw. The papillae had fully receded, in particular the central papilla 11-21, exposing black triangles. The patient had a neutral bite (Angle Class I), however an increase in the vertical dimension was necessary (sunken biteinthemolarregion). Based on the results of the diagnosis, the dental team drafted a restora- tive plan. The dentist presented this to the patient including other pos- sible alternatives. A metal-ceramic bondedsolutionwasdecided-which included single crowns and small bridgesinthelowerjaw. Metal-ceramic bonded restorations are well proven solutions with a history of very long clinical success; this is supported by in-vivo studies. In comparison to zirconium oxide, metal frameworks have the advan- tage of higher elasticity and lower hardness,whichinthispatient’scase should restore the natural mastica- toryfeelingagain. As the patient had previously post- poned a visit to the dentist, the emphasis now had to be placed on rehabilitation with good long-term perspectives. This way it would be possible to minimize the amount of procedures required and therefore calmhisfears. The first steps in the practice andthelaboratory Almost all teeth required root canal treatment (Fig. 4). This was carried out under the operating microscope and completed with root post and subsequent crown restoration. This was also possible in tooth 13. The preparation was carried out accord- ing to the Dr. Domenico Massironi technique. The final impression was taken with the impression material ImpregumTM from 3M ESPE using the double cord retraction method. In addition, the patient underwent periodontitis treatment once and was thoroughly instructed in oral hygiene. These treatment methods prepared the patient’s teeth and gin- giva for the temporary restoration. A three month regeneration period followed. The temporary restoration, fabri- cated in the laboratory for this heal- ing phase, was necessary for verify- ing the endodontic situation and in particular to allow the gingiva time to recover (Fig. 5). This served as a vertical dimension therapy with a so-called functional and esthetical “testdrive”. The vertical dimension was not changed.Itwasvalidatedbythetem- porary restorations for 3 months. The temporary restorations were produced in a centric relationship. Functional diagnostic procedures, a sophisticated treatment plan and an extensive esthetic analysis of a photo status were required to pro- duce the temporary restoration - measures that formed the basis for the patient’s individual dental reha- bilitation (Figs 6 to 8). For the esthi- cal analysis (Figs 9 and 10), we used theprogramandprocedureprotocol from Digital Smile Design (DSD) ac- cording to Dr. Christian Coachman, São Paulo/Brazil. It includes tools and gauges for a wide range of virtu- al measurements and uses the infor- mation from patient’s portraits with avarietyoffacialsmileexpressions. This extensive input showed that the anterior length of the existing crowns in the upper jaw could be maintained. However, the tooth an- gles needed to be changed and the bucco-lingual position of the incisal edges had to be moved in order to accommodatethelowerincisorsand the lower lip. Function and esthet- ics played an important role in the design. The three-month therapeutic trial run showed that further measures to eliminate the black triangles, re- sulting from the degeneration of the papillae, had to be taken. The dentist then prepared the teeth for the fi- nal restoration according to metal- ceramic requirements, and gave our laboratory the impression (Fig. 11) to castthemastermodel. Preparing and covering the framework The following information is based mainly on the dental technically interesting upper jaw. We wanted Figs1 to3:Clinicalstartingsituation Fig.4:X-rayresultsof thestarting situation Fig. 5: The temporary restoration. For three months it was tested on function andestheticsandcontinuallyadjusted to use the new mixed-glass ceram- ics IPS Style Ceram, so the metal we chose for the crown frameworks was the non-precious metal alloy 4all from Ivoclar Vivadent. This was cast in the conventional method, and included holding pins to protect the framework during the follow- ing procedures. The metal copings were carefully finished. An oxide firing was carried out in preparation for the ceramic layer. Time and care invested in this phase prevents bub- blesintheceramiclater. It is effective to use a modern shade selectionmethodfromtheverystart, so that the best suitable opaque ma- ÿPageB2 Tel.: +4232353535 | Fax: +4232353360