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B2 ◊Page B1 LAB TRIBUNE Dental Tribune Middle East & Africa Edition | 3/2017 Fig. 7: Try-in of the mock-up and validation of the functional and esthetic parameters Fig. 8: Prepared teeth ready for the permanent restorations Fig. 9 Grinding in of functional abrasion facets on the veneers in the lower jaw Fig. 10 The finished all-ceramic restorations on the model of the lower jaw Fig. 11: Harmonious picture of the all-ceramic restoration in situ Fig. 12: Examination of the functional parameters Figs 14 and 15: The recall examinations of the ceramic restora- tions showed that the soft tissue in the cervical region of the up- per and lower teeth was strong and healthy. Fig. 16: Six months later. The patient is highly satisfied with the result. She can smile with confidence. tor. Furthermore, the new vertical di- mension was verified in the mouth and it was raised by about 1 mm compared with the original state. From wax-up to mock-up The models were articulated and then a diagnostic wax-up (Figs 3 to 5) was created. The teeth were built up according to the new vertical di- mension of occlusion. The anterior teeth were designed in such a way that their shape and length would suit the face of the patient. The es- thetic parameters, such as the smile line, mid-line and the buccal corri- dor, were given as much attention as the functional requirements of the occlusion. Since we wanted to check the planned tooth length and shape in the patient’s mouth, we fabricated an acrylic mock-up on the basis of the wax-up (Fig. 6). The try-in of the mock-up allowed the dental team to obtain indispensible insight into the esthetics and function of the resto- ration. It also provided the patient with a preview of the restoration and helped her to get used to her new ap- pearance. Actively involving patients in the planning process at this stage has a highly motivating effect and it positively influences the treatment result. During the try-in, the function of the restoration was tested in terms of the static and dynamic occlusion. Phonetic criteria were also checked in the process. Finally, some esthetic details were discussed (Fig. 7). The patient asked for light teeth and bold tooth shapes. Implant insertion and preparation The prosthetic restorations in the lower jaw were removed and im- plants were placed in the gaps left by tooth 46 and 36. The wounds took about three months to heal. Follow- ing the osseointegration of the im- plants and the conditioning of the soft tissue, the teeth were prepared for receiving the prosthetic restora- tions. The premolars and molars required only light preparation. The upper anterior teeth were prepared for 360° veneers and the lower ante- rior teeth for ultra-thin veneers (Fig. 8). We pursued a minimally invasive strategy, which was quite easy to implement due to the additive ap- proach of the treatment plan. An im- pression of the situation was taken. Based on the mock-up, long-term composite resin temporaries (Telio Lab, Ivoclar Vivadent) were fabri- cated. During the next three months, the patient was able to accustom her- self to the new conditions. She was given the possibility to test the new vertical dimension of occlusion and inform us about any esthetic and functional needs. Permanent prosthetic restorations The patient had no trouble adjust- ing to the new situation. She ea- gerly anticipated the placement of the permanent restorations. At this Fig. 13: Harmonious appearance. The tooth shape and shade perfectly match the face of the young woman. stage, she emphasized her require- ments again: beautiful and above all light teeth. We decided to create the veneers with the press technique us- ing a very light material (IPS e.max Press, HT BL 3). The copings for the crowns in the upper and lower jaw were fabricated with the press tech- nique (IPS e.max Press, LT BL 3) and they were individually veneered (IPS e.max Ceram). The long-term tem- poraries served as a template. The restorations were produced accord- ing to the established protocol. The requirements of both function and esthetics were fulfilled. As requested by the patient, the anterior teeth were given a bold shape. The surface of the ceramic was imparted with a distinctive micro and macro-texture, which produced a play of light simi- lar to that of natural teeth (Figs 9 and 10). Placement of the restorations In preparation for the adhesive ce- mentation of the restorations, the provisionals were removed and the teeth were cleaned. The anterior res- torations were checked in the mouth using a try-in paste and the esthetic results were subsequently assessed. The occlusion was checked in detail. Next, the ceramic restorations were etched with 5% hydrofluoric acid for 20 seconds. They were cleaned in an ultrasound bath and dried. Their contact surfaces were silanized (Monobond Plus). Thereafter, a bond- ing agent (Heliobond) was applied. The individual ceramic components were temporarily stored in a contain- er which protected them from light and contamination. Then the teeth were conditioned. A rubber dam was placed and the teeth were carefully air-abraded with aluminium oxide (0.50 microns). Subsequently, phos- phoric acid gel (37%) was applied and thoroughly rinsed off after a reaction time of 15 to 20 seconds. The prepa- rations were dried to the extent that a slightly moist shimmering dentin surface was visible. The ap- plication of the bonding agent (Syn- tac) followed. The restorations were placed with the light-curing luting composite Variolink Veneer (Ivoclar Vivadent). First, the veneers of the two central incisors were seated and their fit was checked. Then one resto- ration after the other was placed on both sides. Before the restorations were light cured for the last time, the margins were coated with glycerine gel to prevent the formation of an inhibition layer. We removed excess with fine diamonds and polishers and then we polished and smoothed the margins. After the final exami- nation, we checked the esthetic and functional parameters in particular (Figs 11 and 12). We provided the pa- tient with a protective bite guard and then released her from the practice. Result Esthetic results that work. The all- ceramic restorations look complete- ly natural in the patient’s face. Her facial expression has completely changed. The young woman appears relaxed and enjoying her new smile (Fig. 13). The first recall examination took place three days after the res- torations were placed. At that stage, the condition of the soft tissue was excellent. It had fully adapted to the ceramic surfaces (Figs 14 and 15). The success of the treatment was con- firmed after the six-month and the twelve-month recalls (Fig. 16). Conclusion Sound functional principles, excel- lent esthetic design skills and an out- standing materials system teamed up to fulfil the patient’s ardent wish for a smile makeover. The restora- tions have given her new zest for life and they have improved her health at the same time. Dr Anna Giorgadze 11141 Galats, Greece annaesthdent@yahoo.gr Ilias Psarris Ilias Psarris Dental Laboratory 16561 Athens, Greece info@psarris-ilias.gr