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Dental Tribune Middle East & Africa Edition | 6/2016 LAB TRIBUNE B2 ◊PageB1 Fig.6 to8:Photoseriesfor theestheticanalysis Fig.11:Theimpressionwithvisibleprepa- rationmarginsanalysis Fig. 24: View of the palatal build-up, which contributes to the illusion of depth and essentially to an overall life-like ap- pearance Figs17 to19:Thefiredresults Fig.13:Secondopaquefiring Fig. 26: Final layering effects. The wide varietyofIPSStyleImpulseandEffect ma- terials allow ceramists to fully indulge in theirpassion Fig.12:Washfiringaftertheverythinfirst application Fig. 25: Steps towards creating mamel- ons: The stability of IPS Style materials during application and the edge stability areparticularlyapparent here Fig.14:Quickandeasy:Applicationofthe IPSStyleCeramIntensivePowderOpaquer tocompletelycover theframework. Fig. 27: Eagerly awaited:The results after thefirst dentinbakefiring.Theshapeand shade are already impressive.We are par- ticularlypleasedabout thelowshrinkage, whichwillsaveus time Fig. 28: The occlusal view shows clearly that the built-up shape was maintained during firing. Here are the fired results after the application of IPS Style Ceram IncisalI3on theocclusalsurfaces Fig. 20: The dentin build-up begins with a generous application of IPS Style Ceram DeepDentinup to themiddle third Figs 15 to 16: The second opaque layer is dusted with dry IPS Style Ceram Deep DentinandMarginpowdermaterials. Figs 21 to 23: Continuing the build-up with IPS Style Ceram Dentin to achieve the ana- tomicalshape,followedby thecut-back toallowspacefor thepatient individualdesign Figs 9 to 10: Measurements according to the Digital Smile Design concept by Dr Chris- tianCoachman terial can be selected. This saves any further shade corrections later on. In this patient case we used IPS Style Ceram Intensive Powder Opaquer white, which enhances the natural light transmission from the depths of the tooth. After mixing with the IPS Powder Opaquer Liquid, it was applied in a very thin, non-covering layer. The recommended tempera- ture for the wash firing (1st opaque firing) according to the manufac- turer’s Instructions for Use is 870°C. In the past, we have had good results at 900°C, so in this case we fired at a higher temperature than recom- mended by the manufacturer (Fig. 12). After a second application we carried out the covering firing (2nd opaque firing), this time at the usual temperature of 870°C. A complete and very good coverage of the pow- der opaquer is easily achieved using either a brush or other instrument (Fig. 14). We never use the opaque residues of the wash firing for the covering opaque layer, even though the manufacturer states that the driedresiduescanbemixedwithliq- uid to the required consistency. The results have always proved us right. This time was no exception; the sur- face was very homogenous with no microporosities(Fig.13). In order to optimize the bond of the opaque surface with the subsequent ceramic material and fully enhance the light-optical properties of the IPS Style ceramic, we dusted a small amount of IPS Style Ceram Deep Dentin and Margin material onto thesecondopaquelayer.Todoso,we dipped a large dry brush into the jar of ceramic powder and then dusted this onto the yet unfired second opaque layer (Figs 15 and 16). Any surplus was tapped off within the approx. two minutes opaque drying process, and then the next firing was carriedout(Figs17to19). Building-uptheanatomical shape Using a brush, we built up the body of the tooth with a generous ap- plication of Style Ceram Deep Den- tin. Instead of the usual method of only building up to the incisal edge of the framework, we applied the material to cover the complete up- per and middle third of the tooth (Fig. 20): We used it as a first layer of body material to create the ideal anatomicalshape.Thisextendeduse was possible due to the light flow- ing characteristics of the IPS Style materials (light transmission): The outline of the metal framework was well covered. For this reason, it was notnecessarytoadditionallyconceal these areas. The mamelons and fis- sures were already incorporated in thisstep. Asthesecondbodymaterialweused IPS Style Ceram Dentin in the usual manner to build-up the ideal tooth shape. The extremely finely grained IPS Style Ceram Dentin materials are very easy to apply and highly homogenous. Small amounts of IPS Style Ceram Cervical Transpa (or- ange-pink and yellow) create an ap- pearanceofvitalityinthecervicalre- gion. Using these four materials, the complete anatomical tooth shape wasbuiltupthencheckedforsize. Information: Tip: By creating a silicone matrix of a wax-up produced in the early stages, time can be saved during the ce- ramic build-up - in our experience 40-45%. However, this does not re- place the actual layering technique by hand. The IPS Style Ceram layer- ing materials are stable, efficient and easy to use, including the cut-back procedure(Figs21to23). Individualpatient design In order to achieve a vibrant, true-to- nature,patient-orientedappearance, we used IPS Style Ceram Mamelon yellow-orange in the palatal region and IPS Style Ceram Occlusal Den- tin orange in the incisal and lateral regions. The latter is coloured green so that it is easier to recognize (Fig. 24). In our opinion, intense colour- coding of the different ceramic ma- terials helps us to create our artistic design. When fired, the pigments burn-out completely without resi- due and a natural shade appearance isrevealed. IPS Style Ceram Mamelon yellow-or- ange and IPS Style Ceram Mamelon light were mixed together to a ratio of1:1(Fig.25)andappliedasultrathin accents to the vestibular mamelon structure. Information: Tip: It is advisable to use IPS Style Ceram Mamelon materials cautiously and economically as they are extremely opaque and highly fluorescent. A very nice result is achieved if you give them a vertically curved shape. Thehighdegreeofmaterialcohesion and edge stability of the material al- low very detailed and sharp struc- turestobeeasilycreated. Further effects were applied to the incisors and canines, as follows (Fig. 26):Inthemesialareasweintegrated IPS Style Ceram Incisal I2, IPS Style Ceram Opal Effect OE1 and OE5 as well as IPS Style Ceram Transpa blue and in the distal areas we added IPS Style Ceram Transpa blue. We also included IPS Style Ceram Opal Effect violet and IPS Style Ceram Incisal I3. We applied IPS Style Ceram Opal Ef- fect OE4 in a “U shape” starting from the centre of the tooth continuing up towards the approximal-incisal areas. To finalize the design we imitated the so-called “halo effect”, whichinthisparticularcasewasreal- ized with IPS Style Ceram Dentin A1. Unlike the mamelons - these effects were created with smoother transi- tions. The occlusal surface was designed age-appropriately with a pro- nounced formation. The patient had a cross-bite in the molar region so the lingual surface was made wider than usual, in particular in the sec- ond quadrant. This was done by incorporating the cusp of Carabelli (Tuberculum Carabelli) so that the cusps and fissures of the upper and lower teeth were completely aligned and an even distribution of pressure couldbeachieved. Dentinfiringsand assessment oftheresults The ceramic surface was compacted withadrybrushandthenfiredwitha first dentin firing (790°C). The shade and shape results are always eagerly awaited - in our patient case, the re- sultswerespectacular(Fig.27).Know- ing our past experience with previ- ously successful applications, these weretheresultswehadexpected.We must emphasize first and foremost: The IPS Style Ceram ceramic shrinks only minimally. Based on our expe- rience this material has the lowest shrinkage of all ceramics we have used before. We needed to add only a small amount to complete the ves- tibular surface (in this case with IPS Style Ceram Dentin A3). The second dentin firing (780°C) showed next to no shrinkage. Only small corrections were required with IPS Style Ceram IncisalI3.Thelayeredbuild-upmain- tained its shape and the youthfully designedocclusalprofiledidnotlose any of its steep cusps (Fig. 28). The light transmission from the depths of the tooth was as we had hoped, as was the shade graduation (Fig. 29). If corrections are necessary and there- fore further ceramic firing, rest as- sured, the shape and colour will not change. Finishingthesurface andshadecharacterization The next step was to work on the fa- cial surfaces of the teeth 11 to 15 and 21 to 25, to create an age-appropriate form: Diamond burs were used in particulartorecreatetheperikymata and longitudinal grooves (interseg- mental and margino-segmental ridges). The application of gold paint allowed the careful examination of the surface texture and all surface structures, including in the poste- rior region (Figs 44 to 52). Important: After use, it is extremely important to clean thoroughly with a steam cleaner to prevent discolouration whenfiring. The surfaces were individually char- acterized using the universal stain and glaze range IPS Ivocolor, which canbeusedforalllayering,pressand CAD ceramics from Ivoclar Vivadent and also zirconium oxide from Wie- land Dental. This enhanced the res- toration’s macro and micro texture andcreatedmoreexpression.Webe- gan with the base shade A2. Through individualization using the IPS Ivo- color stains, we were able to produce a shade A3 tooth with a cervical area in A3.5 (Figs 30 to 37). The character- ized surface had an outstandingly natural looking appearance. This is due to the fact that no opaque ce- ramic materials were used, but in- stead stains, which allowed the light to flow into the depths. Even the posteriorteethhadaveryvibrantde- sign with the mesio-palatal Carabelli cusp and with the stained fissure de- tails (Figs 38 to 41). We carried out a glazefiringbakeintheusualmethod (750°C). The ideal texture can be de- termined by the amount of glaze material applied: The thicker the application, the glossier the result. After the glaze firing and manual polishing of some areas, the results were impressive, literally “from all sides”(Figs42and43).Shapeandtex- ture were realized exactly as we had planned. Patient rehabilitated, dentist satisfied In the final session, the veneered restorations were first inserted and checked, (Fig. 53) and then conven- tionally cemented. Both dentist and patient were so delighted with the results that a whole series of photo- graphs were taken from all angles and under different lighting (Figs 54 to 71). The patient felt confident again to give a wide open mouthed ÿPageB3