cosmetic dentistry international

Cover / Editorial / Content / Welcome letter / Immediate dentures: Are you missing out? / Ceramic restorations— What is the key to success? / Management of full mouth prosthodontic rehabilitation using high-strength CAD/CAM zirconium-oxide crowns / Anatomic stratification technique for lifelike anterior composites / Smile Design Wheel™: Apractical approach to smile design / Aesthetics and the brain / Ceramic instead of composite / Temporaries: Perfect provisional restorations / Customised abutments for long-term aesthetics— software tools to meet clinical and laboratory requirements / Ivoclar: Progress knows no clinical limitations / Enjoy your trip and indulge in the journey! / Events / Submissions / Imprint

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CDE0309_01_Titel

14.08.2009

15:38 Uhr

Seite 1

issn 1616-7390

Vol. 3 • Issue 3/2009

cosmetic
dentistry
_ beauty & science

3

2009

_case study
Management of full mouth
prosthodontic rehabilitation

_feature
Aesthetics and the brain

_industry report
Temporaries: Perfect provisional restorations

[2] => CDE0309_01_Titel

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[3] => CDE0309_01_Titel

CDE0309_03_Editorial

14.08.2009

15:44 Uhr

Seite 1

editorial _ cosmetic dentistry

Dear Reader,
_Since the beginning of the year cosmetic dentistry has shown a strong presence
at various international seminars, conferences, trade shows, and scientific meetings. The
amount of positive feedback we have received thus far has encouraged us immensely and
given more responsibility to our team in aiming to meet the expectations of our professional
colleagues around the world. With the electronic edition of cosmetic dentistry now available at www.dental-tribune.com, our readers across the globe now have 24/7 access to
information on the latest developments in the field.

Dr Sushil Koirala
Editor-in-Chief

It is encouraging to note that various aesthetic events are now hosted in Asia. Additionally, general dental associations are demonstrating increasing eagerness to invite speakers
on aesthetic topics to their scientific meetings. As the demand for aesthetic procedures
amongst our patients increases, so too does the demand for quality aesthetic dentistry lectures, training and accreditation programmes. Unfortunately, many Asian countries are still
lagging behind owing to the lack of such activities at a national level. Because of financial
and time constraints, participation in international aesthetic dentistry activities is not viable
for many of our Asian colleagues. I suggest that a possible solution to this for our Asian dental professional associations, societies, academies and various educational centres is to
utilise the advanced information technology available in the knowledge and skills dissemination process.
It is my pleasure to announce here that the South Asian Academy of Aesthetic Dentistry
will launch its online aesthetic dentistry accreditation (fellowship) programme at
www.dentistrysouthasia.com on November 2009. We believe that this effort is a milestone
in the development of voluntary professional accreditation systems in South Asia. In addition, the Asia Pacific Dental Federation is planning to launch a two-year fellowship programme in aesthetic dentistry. The concept paper and syllabus for this programme were
presented at the ICCDE board meeting during APDC Hong Kong 2009.
As always, I hope you will enjoy this new edition of cosmetic dentistry, in which we present a combination of clinical cases, expert opinion pieces and product information. I look
forward to receiving your valuable feedback. Please feel welcome to share your clinical expertise and experiences with us.

Sincerely,

Dr Sushil Koirala
Editor-in-Chief
President Vedic Institute of Smile Aesthetics (VISA)
Kathmandu, Nepal

cosmetic
dentistry 3
I 03
_ 2009

[4] => CDE0309_01_Titel

CDE0309_04_Content

14.08.2009

15:45 Uhr

Seite 1

I content _ cosmetic dentistry

page 16

I editorial
03

page 20

32

page 32

Ceramic instead of composite
_ Manfred Kern

Dear Reader
_ Dr Sushil Koirala, Editor-in-Chief

06

Welcome to our international colleagues

I industry report
34

_ Dr Suhit R. Adhikari

Temporaries: Perfect provisional restorations
_ Dr Hans Sellmann

I case study
08

38

Immediate dentures: Are you missing out?
_ Dr Craig Callen

12

_ Hans Geiselhöringer & Dr Stefan Holst

Ceramic restorations—What is the key to success?
_ Robert Michalik

16

I industry news

Management of full mouth prosthodontic
rehabilitation using high-strength CAD/CAM
zirconium-oxide crowns
_ Dr Ansgar C. Cheng et al.

42

Enjoy your trip and indulge in the journey!
_ Annemarie Fischer

Anatomic stratification technique
for lifelike anterior composites
_ Dr Ratnadeep Patil & Dr Kavita Mahesh

I meetings
48

I special
24

Ivoclar: Progress knows no clinical limitations

I lifestyle
44

I clinical technique
20

Customised abutments for long-term
aesthetics—software tools to meet clinical and
laboratory requirements

Smile Design Wheel™: A practical approach
to smile design
_ Dr Sushil Koirala

Cosmetic events

I about the publisher
49
50

_submissions
_ imprint

I feature
30

Aesthetics and the brain
_ Dr David L. Hoexter

page 34

04 I cosmetic
dentistry

3_ 2009

page 38

page 44

[5] => CDE0309_01_Titel

Anschnitt DIN A4

04.08.2009

9:18 Uhr

Seite 1

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[6] => CDE0309_01_Titel

CDE0309_06-07_Adhikari

14.08.2009

15:48 Uhr

I editorial _ welcome letter

06 I cosmetic
dentistry

3_ 2009

Seite 1

[7] => CDE0309_01_Titel

CDE0309_06-07_Adhikari

14.08.2009

15:48 Uhr

Seite 2

editorial _ welcome letter

Welcome to our
international colleagues
_The South Asian Academy of Aesthetic Dentistry (SAAAD) was founded in 2005
as the first web-based, regional professional academy in South Asia. The academy is
dedicated to advancing the art and science of aesthetic dentistry and to promoting high
standards of ethical conduct and responsible patient care, by institutionalising a standard continuing professional development programme through the provision of relevant accreditation (fellowship) processes. In order to fulfil its mission, the academy conducts regional aesthetics meetings and skills-oriented aesthetic training programmes
and aims to organise its biennial scientific conference on a rotation basis amongst its
member countries.

Dr Suhit R. Adhikari

It is my pleasure to announce here that Nepal, the home country of the SAAAD initiator, is hosting the first SAAAD biennial scientific conference from 28 to 29
November 2009. The conference theme is Minimally Invasive Cosmetic Dentistry:
A Holistic Approach. The conference is organised in collaboration with the Asian Academy of Aesthetic Dentistry, the Nepalese Academy of Cosmetic and Aesthetic Dentistry
(NACAD), the Sri Lankan Academy of Aesthetic and Cosmetic Dentistry, the Bangladesh
Academy of Aesthetic Dentistry and the Esthetic Academy of Bangalore, India.
It will be the first meeting of its kind in South Asia, with many renowned regional and
international aesthetic dentists meeting in one place to share their knowledge and skills
in order to promote the art and science of aesthetic dentistry. We believe that the conference theme demonstrates our interest in quality, health and ethical issues of aesthetic
dentistry in Asia. We look forward to bringing positive changes though our mutual collaboration.
On behalf of the organising committee and the host country, I would like to cordially
invite you all to participate in the forthcoming SAAAD conference in Kathmandu to foster great relationships as professionals and friends and to enjoy the hospitality, natural
beauty and cultural richness of Nepal. To sign up for the SAAAD Nepal conference, please
visit www.saaad.org. I hope to see you in Kathmandu!

Namaste,

Dr Suhit R. Adhikari
SAAAD 2009 Conference Organizing Chairman
SAAAD Secretary General
NACAD President

cosmetic
dentistry 3
I 07
_ 2009

[8] => CDE0309_01_Titel

CDE0309_08-10_Callen

14.08.2009

15:49 Uhr

Seite 1

I case study _ immediate dentures

Immediate
dentures: Are you
missing out?
Author_ Dr Craig Callen, USA

Fig. 1_After, full face.

_All of the courses advertised today tout
the productivity of porcelain facings, orthodontics, automated root canal and implants. While
any of these treatments can be rewarding and
profitable, the often-overlooked area of treatment that is highly rewarding and profitable
is that of removable prosthetics. Yes, I said it,
dentures! Many of us became burnt out on
making dentures in dental school and never
recovered, but times have changed. Not only is
there a huge untapped market for highquality dentures as the population ages,
but it can also be one of the most rewarding and profi-table procedures
you provide for your patients per hour.
In addition, with the materials available to you today, this can be a relatively
easy treatment. A lot of what we know
about cosmetic dentistry came from
prosthodontics. Full denture treatment
used to be the ultimate in cosmetic dentistry before periodontal care changed
the way dentists practice.
Prosthodontists were really the first
dentists to study things such as facial
proportions as related to tooth size and
shape.

Fig. 1

08 I cosmetic
dentistry

3_ 2009

_How to get denture patients
Our office offers a Free Aesthetic Denture
Consult. This allows patients to meet us and see
what we can do for them in a non-threatening
environment. If a patient calls in requesting fees,
they are offered the option of the free consult.
The patient is scheduled for a 10-minute time
block with a doctor in the consultation room. He
or she fills out a short form that pertains strictly
to dentures. Then the patient is given a printout
that describes his or her denture options and
procedures. We also show the patient pictures of
our cases and how natural they look.
We just had two large discount denture centres move into our area (and they tend to be more
bait-and-switch than discount centres). We not
only had to compete, but also differentiate our
office by showing that we provide high quality,
aesthetic dentures, not cheap ones.
Most of our dentures are set with Dentsply’s
Portrait IPN denture teeth, which look amazingly natural. We run a small advertisement
in the local paper promoting aesthetically
pleasing dentures. In addition, we belong to
www.denturewearers.com, which is a great
online informational site for denture patients

[9] => CDE0309_01_Titel

CDE0309_08-10_Callen

14.08.2009

15:49 Uhr

Seite 2

case study _ immediate dentures

Fig. 2

Fig. 3

Fig. 4

and will help drive them toward your own Web
site and office looking for solutions (Fig. 2).

_Technique appointment No. 1
Randy is a typical patient who came in for a
free consultation for immediate maxillary and
mandibular dentures. He had been told a long
time ago that he had severe periodontal
disease and that his teeth could not be saved.
A busy contractor, he put off treatment for years.
We were able to appoint him for a complete
examination and X-ray films, which verified his
story.
Financial arrangements were made and we
set-up an appointment for impressions, shade
and bite (Fig. 3). At the next appointment, we
took about an hour to get nice impressions with
the Accudent dual alginate system with stock
trays.
If Randy had been edentulous, we would
have used Accudent’s anatomically corrected
denture trays. This utilises a light and heavy

body alginate mixed in an alginator. The light
body sets slower and is applied in a large syringe.
Because Randy still had teeth to establish vertical and tooth position, we then took a bite
with Discus Dental’s Vanilla Mousse, but you
can, of course, use your material of choice. If
there are many missing teeth, you may also use
Discus Dental’s Impression Putty for a bite .

Fig. 2_A screen shot of
www.denturewearers.com.
Fig. 3_Accudent immediate denture
impression.
Fig. 4_Before, close-up.

The shade was chosen using the Dentsply
Portrait Shade Guide. As most people want to
bleach their teeth, we see more and more patients choosing lighter coloured teeth. We take
several clinical and portrait photos for our
records and the lab’s use in setting the case.
If the patient wants to change his or her smile,
we use The Smile Style Guide, written by Dr Lorin
Berland and Dr David L. Taub to pick a new smile
(www.Digident.com; +1 800 741 7966). It is a
great tool that contains a multitude of different
smiles progressing from square, pointed, round
and flat as well as various length combinations
that we include with detailed notes for the lab
about exactly what we and the patient want.

cosmetic
dentistry 3
I 09
_ 2009

[10] => CDE0309_01_Titel

CDE0309_08-10_Callen

14.08.2009

15:49 Uhr

Seite 3

I case study _ immediate dentures

Fig. 5
Fig. 5_After, close-up.

_Technique appointment No. 2
Because Randy did not need to have posterior
teeth removed and prolonged healing time, we
progressed right to a wax try-in appointment in
two weeks. I do a split set-up to verify the bite
and show the patient the set-up. Randy, and his
wife, approved the set-up and the aesthetics and
we scheduled the surgical appointment in another two weeks. The case is then sent to the lab
for proper festooning and life-like base material
processing.

_Technique appointment No. 3
Fourteen periodontally involved teeth were
removed with local anaesthetic and nitrous oxide and the dentures seated. I relined them with
a temporary soft liner to aid in the fit (Fig. 5). We
use a cartridge-based system, such as VOCO’s
UFI Gel SC. When Randy and his wife saw his new
smile, they both cried (in a good way) (Fig. 1). She
immediately scheduled herself for an appointment for dentures too. In six months we will provide relines.

_Technique appointment No. 4
Randy was back the next day with minimal
concerns. I will generally see the patient on the
first adjustment, and then delegate the simple
adjustments to my well-trained, experienced
staff.
My total chair time with the free consultation,
examination, impressions, try-in, extractions
and seating and the first healing check was
about 2.5 hours. My per hour production was
higher than what I make on a typical crown and
bridge case, and I provided a life-changing treat-

10 I cosmetic
dentistry

3_ 2009

ment for a patient who was a dental cripple. If
the patient has trouble wearing dentures, we can
proceed to implants to help in retention. One of
the keys to providing quality denture care for
your patients is to find a laboratory that also is
interested in quality. You will pay top dollar, but
it will be well worth it.
If you are not providing denture treatment in
your practice and you have holes in your schedule, you should think again about this under
served area of cosmetic dentistry. As baby
boomers age and lose teeth, there will be a real
need for quality denture care._

_author info

cosmetic
dentistry

Dr Craig C. Callen
is a full time practicing
dentist in the small city of
Mansfield, Ohio, USA, in
the centre of the rust belt.
He graduated from Case
Western Reserve School of
Dentistry at the age of 23.
Callen has written three
books for dentists: The Cutting Edge I, II, and III. He is the associate editor for
The Profitable Dentist Newsletter and has written
numerous articles for national dental publications.
Callen is a member of the ADA,AGD and the AACD.
He has lectured internationally on clinical and management topics in dentistry. His latest seminar is
titled, The Million Dollar Blue Collar Dental Practice.
Callen and his wife, Dee, have five children.They
live on a farm where they raise horses, alpacas and
llamas. In his spare time, he likes to spend time boating and travelling.You can reach Dr Callen via
E-mail at craigcallendds@gmail.com.

[11] => CDE0309_01_Titel

3384E_210x297 V09

28.11.2008

8:26 Uhr

Seite 1

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[12] => CDE0309_01_Titel

CDE0309_12-15_Michalik

14.08.2009

15:50 Uhr

Seite 1

I case study _ ceramic restorations

Ceramic restorations—
What is the key
to success?
Author_ Robert Michalik, Poland

Fig .1_Ceramic crowns made
on a metal substructure (CrCo).
Figs. 2–4_Crowns made on
a zirconium dioxide substructure.
Figs. 5–7_Ceramic crowns
made on a substructure using
the press technique.

Fig. 1

_The issue I would like to address in this article
is one well known to many of the readers. However, occasionally it can be beneficial for us to consolidate and evaluate our knowledge. Therefore,
I would like to set out my own experiences acquired
over many years of work as a dental technician.
I hope that the majority of readers will share my

Fig. 2

opinion that in order to guarantee a successful
ceramic restoration it is important to choose the
right material and construction and to ensure that
it is properly made. Prosthetic work carried out in
this way ensures an aesthetically pleasing appearance, perfect marginal seal and durability for the
entire restoration. Naturally, it cannot be expected
that crowns set on a non-precious metal will look
beautiful and provide a natural distribution of light,
for example.
Technicians will always face a dilemma when it
comes to choosing the right coping, and only a skilful consideration of all the arguments for and
against any specific solution will guarantee a successful outcome. My observations primarily concern
the materials and technologies that I have most
frequently used to make ceramic crowns.
The firing method used for a ceramic mainly depends on the material of the coping. In turn, the aesthetic quality of the prosthetic restoration (transparency, opalescence, fluorescence) is mostly influenced by the type of coping used.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

12 I cosmetic
dentistry

3_ 2009

Fig. 7

[13] => CDE0309_01_Titel

CDE0309_12-15_Michalik

14.08.2009

15:50 Uhr

Seite 2

case study _ ceramic restorations

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

Fig. 13

Fig. 14

Fig. 15

Fig. 16

Fig. 17

Ceramic prosthetic crowns differ both in the technology used to construct them and in the materials
from which the restoration is prepared. Porcelain can
be fired on:

_Porcelain fired directly on refractory die

_ alloys: precious metals (alloys with high gold content—above 75%, medium—50–70 %, low—up to
50 %) and non-precious metals (chrome, cobalt);
_ galvanic structures;
_ transparent zirconium dioxide ZrO2 (nanoceramic—
size of grain below 30 µm, purity of material
99.9999 %, and opaque zircon—grain value above
30 µm);
_ aluminium trioxide Al2O3;
_ press porcelain; and
_ feldspathic porcelain.
I will briefly outline the pros and cons of the
crowns we use most frequently in our office.

Advantages
_ natural distribution of light in finished restoration
_ optimal cohesion of material
_ excellent aesthetic effect when making individual
crowns for anterior non-discoloured abutment teeth
or veneers and inlay/onlay restorations
_ physiological wear with the antagonist
_ chameleon effect
Drawbacks
_ a difficult restoration technology, as no adjustments
can be made once the refractory material is removed
_ not possible to control and monitor individual stages
of the work
_ limited application for making individual anterior
crowns to be placed on non-discoloured abutments
or for inlay/onlay restorations

cosmetic
dentistry 3
I 13
_ 2009

[14] => CDE0309_01_Titel

CDE0309_12-15_Michalik

14.08.2009

15:51 Uhr

Seite 3

I case study _ ceramic restorations

Fig. 18

Fig. 19

Fig. 20

Fig. 21

_ preparation is possible only with a simple, relatively
even shoulder around the entire circumference

_Porcelain fired on zirconium dioxide ZrO2
Advantages
_ reproducibility and accuracy of restoration (only in
CAD/CAM system)
_ good light dispersion
_ covers dark abutments and metal posts and cores
(opaque zircon)
_ a wide range of applications (crowns, bridges, bars
and implant abutments, telescope crowns, ledges)
_ possibility of preparation with limited shoulder and
chamfer/bevel
_ individual stages of the work can be monitored,
even in the patient’s mouth
_ construction retains shape when ceramic is fired
Drawbacks
_ construction has limited elasticity
_ micro chipping on active surface
_ construction cannot be repaired
_ liners must be used

_Porcelain fired on metal
Advantages
_ chemical bonding of construction with porcelain
_ construction can be repaired
_ high elasticity
_ a wide range of applications (bridges, crowns,

14 I cosmetic
dentistry

3_ 2009

telescope prosthetics, posts and cores, bars and
implant abutments)
_ individual stages of the work can be monitored,
even in the patient’s mouth
_ oligodynamic effects (in the case of gold)
Drawbacks
_ no transparency in substructure
_ oxidation necessary
_ risk of margin deformation when firing ceramic
_ external factors may influence construction (temperature, proportion, refractory material)
I will present several cases in which various kinds
of substructures were used to achieve the most natural appearance possible.

_Case I (Figs. 8–17)
A 28-year-old patient presented with pronounced
discoloration of the teeth, which was a result of medication from the tetracycline group taken during her
childhood (Fig. 8). There was also significant damage
to the enamel of the patient’s teeth. The uneven cervical line had damaged the aesthetic appearance of
her dentition. The patient wished to change both the
shape and appearance of her teeth.
The first task was to ensure a proper cervical line
and achieve an effect of longer teeth without changing the occlusal line. Owing to the skilful work of the
dentist and the ideal construction of the temporary
crowns made by the technician, it was possible to

[15] => CDE0309_01_Titel

CDE0309_12-15_Michalik

14.08.2009

15:51 Uhr

Seite 4

case study _ ceramic restorations

Fig. 22

achieve excellent results in the red aesthetic zone.
Figures 16 and 17 show that the gingiva formed in
accordance with our expectations.
As I mentioned earlier, in order to guarantee
success, it is important to choose the right technology for crown fabrication. In this case, I considered
two possibilities for making the restorations: either
on a coping using press technology or fired directly on
the refractory material. I was faced with such a
dilemma because I was unsure whether the crowns
made using feldspathic porcelain would cover the
dark abutments of the patient’s teeth. After the
preparation, however, it turned out that the stumps of
the teeth were not as drastically discoloured as the
colour prior to the preparation had indicated.
The effect of the reconstruction is left to the appraisal of the readers. The use of a metal coping and
even a zircon solution would not have achieved the
desired aesthetic result.

_Case II (Figs. 18–21)
A 26-year-old patient presented with a discoloured tooth 11 (Fig. 18). Previously, the operations
performed by the dentist on the patient had involved
making composite veneers, which had changed
colour over time.

Fig. 23

angle it would be impossible to notice any features
distinguishing it from a natural tooth. Hence, I decided to make a crown based on a zirconium dioxide
substructure.

_Case III (Figs. 22–23)
A patient visited our surgery for a typical dental
check-up. After a preliminary examination, caries was
found to be present in several teeth, including the patient’s two lower premolar teeth (secondary caries
reaching the pulp chamber). Unfortunately, in cleaning the zone affected with caries the dentist had to
devitalise the tooth and perform endodontic treatment. On completion of the treatment, the remaining
dental tissue was found not suitable for partial
restoration. Hence, the dentist decided to make ceramic crowns and place them on stumps strengthened beforehand with gold alloy posts and cores. The
stumps prepared in this way were subjected to analysis that showed that the optimal solution in this case
would be porcelain crowns made on a zirconium dioxide substructure. This would ensure an aesthetically
pleasing appearance and durability. Such characteristics could not be achieved with crowns made using
the press method or fired on a refractory material or
a metal coping. Only using zirconium dioxide as a substructure guaranteed the intended effect, which is
left to the readers to judge.

The first stage of the work involved changing the
fillings in teeth 21 and 22, then making the preparation and taking the impression. In this case, I considered three variants for the substructure: made using
the press method, a zirconium dioxide coping or a
galvanic structure. The patient wanted a natural
restoration identical to the one on tooth 21.

In conclusion, I would like to thank the dentists
who helped me prepare the work presented here. I
would also like thank Robocam for providing the zirconium dioxide._

The press method would have been too risky, as the
stump of the tooth was severely discoloured. I was
concerned that the dark colour would show through
the cemented crown. A crown inserted on a galvanic
gold coping, in spite of its warm tone and its ability to
cover the dark abutments, would not have dispersed
light in such a way that when looked at from any

Robert Michalik
INTER-DENT Laboratory
Ul. Pustuleczki 23,Warsaw
Poland
Tel.: +48 22 651 5645
E-mail: info@inter-dent.pl

_contact

cosmetic
dentistry

cosmetic
dentistry 3
I 15
_ 2009

[16] => CDE0309_01_Titel

CDE0309_16-19_Cheng

14.08.2009

15:52 Uhr

Seite 1

I case study _ prosthodontic rehabilitation

Management of full mouth
prosthodontic rehabilitation
using high-strength CAD/CAM
zirconium-oxide crowns
Authors_ Dr Ansgar C. Cheng, Dr Helena Lee, Dr Neo Tee-Khin & Ben Lim, Singapore

Fig. 1

Fig. 2

Fig. 3

Fig. 1_Pre-treatment frontal view
showing attrition, erosion,
discolouration and compromised
aesthetics.
Fig. 2_Pre-treatment maxillary
occlusal view showing general loss
of enamel on the occlusal surfaces.
Fig. 3_Pre-treatment mandibular
occlusal view revealing loss of
occlusal tooth structure and
differential erosion loss of dentine.

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_Introduction
_Prudent clinical judgement and careful consideration of the risks and benefits of various treatment
options are essential for the treatment planning and
long-term success of prosthodontic treatment.1
It has been established that loss of the vertical
dimension of occlusion (VDO) may pose significant
clinical difficulties in prosthodontic treatment.2,3 Yet,
the re-establishment and maintenance of a new VDO
is seldom taught in undergraduate dental curricula.

VDO is defined as the vertical measurement of
the face between two selected points superior and
inferior to the oral cavity when the occluding
members are in contact.4 Various methods have
been proposed for the assessment and re-establishment of the VDO.3 The difference between the
vertical measurement of physiological rest position, which should have a higher value than the
VDO, and the VDO is referred to as the interocclusal rest space,4 which is essential for normal
patient function.

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As teeth are worn down, the alveolar bone may
undergo an adaptive process that may compensate
for the loss of tooth structure.5 The VDO should be
carefully assessed before the initiation of restorative procedures.
Traditional porcelain-fused-to-metal anterior
crown restorations require the placement of labial
crown margins below the free gingival margin, in
order to mask the hue and value transition between
the root surface and porcelain-fused-to-metal
restoration. However, intra-crevicular placement
of crown margins is technique-sensitive and related
to adverse periodontal tissue response.6–9 From a
periodontal point of view, preparation margins are
best kept away from the free gingival margin.8,9
The dentition, masticatory muscles and temporomandibular joints form a Class 3 lever system.

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

In such a lever system, functional load is inversely
proportional to the length of the lever arm. Anterior
teeth are under a reduced functional load in comparison with posterior teeth. Porcelain-fusedto-metal restorations are commonly used in the
posterior teeth because of their well-documented
long-term clinical track record in anterior and
posterior teeth.10–17 Newer zirconium-oxide-based
materials are usually prescribed in the anterior
region owing to their demonstrated promising
physical properties18,19 and reasonable clinical
longevity.20 In vitro studies also show that the wear
of metal occlusal surfaces against porcelain
occlusal material is acceptable when there are no
bruxing activities.21
This article describes the prosthodontic management of a mutilated dentition using high-strength
zirconium-oxide crowns.

Fig. 4_Panoramic radiograph
showing adequate alveolar support.
Fig. 5_Anterior view of the full
maxillary and mandibular diagnostic
wax-up.
Fig. 6_Completed maxillary anterior
teeth preparations for full coverage
restorations. Note the equi-gingival
preparation margins.
Fig. 7_Completed mandibular
anterior teeth preparations for full
coverage restorations. Less than
1.5mm of tooth structure was
removed at the cervical third, owing
to smaller tooth size.
Fig. 8_Definitive maxillary cast.
No die-spacer was required in the
CAD/CAM manufacturing process.

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I case study _ prosthodontic rehabilitation
DENTSPLY DeTrey) was carefully injected onto all
tooth preparations, ensuring that all teeth surfaces
including the margins were recorded. A stock tray
loaded with putty material (Aquasil Putty, DENTSPLY
DeTrey) was seated over the entire dental arch to make
the definitive impression. A jaw relation record was
made with a vinyl polysiloxane material (Regisil PB,
DENTSPLY DeTrey). The maxillary and mandibular
definitive casts were mounted in the centre of the
articulator using standard settings.26,27 Provisional
crown restorations (Luxatemp Automix, Zenith/DMG)
were placed on the prepared teeth at the established VDO.

Fig. 10
Fig. 9_Definitive mandibular cast
Tooth reduction was generally more
conservative when compared with
conventional porcelain-fusedto-metal restorations.
Fig. 10_Coping milling machine
Zeno 4030 M1 (Wieland).

_contact cosmetic
dentistry
Dr Ansgar C. Cheng
Specialist Dental Group™
3 Mount Elizabeth #08-10
Singapore 228510
Republic of Singapore
E-mail:
drcheng@specialistdentalgroup.com

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_Clinical report
A 63-year-old fully dentate male patient presented with discoloured teeth and multiple areas of
loss of tooth structure. The patient desired the
restoration of function and aesthetics. He presented
clinically with defective restorations, insignificant
loss of VDO and compromised aesthetics (Figs. 1–3).
There were signs of loss of enamel at the occlusal and
labial surfaces of most of the teeth. The pre-treatment radiograph was within normal limits (Fig. 4).
In spite of the overall condition, the natural teeth
were free of active dental caries and oral hygiene was
good. An occlusal examination revealed a stable
maximal inter-cuspation position with insignificant
centric relation to maximal inter-cuspation slide
at the teeth level. No para-functional habit was
reported.
A diagnostic dental wax-up on mounted maxillary
and mandibular casts in a semi-adjustable articulator was performed (Hanau Wide-vue, Teledyne
Waterpik; Fig. 5). The proportions of the anterior
teeth were corrected to the estimated 0.618 widthto-height ratio of central incisors using the golden
proportion22–25 as a guideline. The results indicated
that no increase of VDO was needed at the incisal pin
level in order to restore proper incisal anatomy and
anterior guidance. The overall treatment plan included placement of fixed, high-strength zirconiumoxide base restorations in the maxilla and mandible.
The maxillary and mandibular teeth were prepared
in the usual manner for complete coverage crown
restorations (Figs. 6 & 7). The margins of the tooth
preparations were prepared at the gingival level
under magnification, and no gingival displacement
procedures on the prepared teeth were necessary
prior to definitive impression making. High-viscosity
vinyl polysiloxane material (Aquasil Ultra Heavy,

The development of the planned definitive crown
restorations was carried out using CAD/CAM. The
maxillary and mandibular definitive casts (Figs. 8 & 9)
were scanned (Zeno Scan, Wieland) and the crown
copings were designed using a software programme
(3Shape D700). The copings were milled in zirconium
base material (ZENO ZrBridge, Wieland) with a milling
machine (ZENO 4030 M1, Wieland; Fig. 10). The
copings were sintered according to the manufacturer’s recommendations. Subsequently, overlaying
low-fusing porcelain material (IPS e.max, Ivoclar
Vivadent) was manually applied onto the exterior to
create proper anatomic form. All maxillary and
mandibular anterior teeth were fabricated using the
same process. The completed restorations were
cemented in resin-modified glass-ionomer luting
agent (RelyX Unicem, ESPE; Figs. 11–12 & 15).
The patient was evaluated post-operatively. Anterior guided occlusal schemes were verified intraorally before and after prosthesis cementation (Figs.
13 & 14). The patient reported no discomfort and
adapted well to the new restorations. No abnormal
clinical signs were noted.

_Discussion
The maintenance and re-establishment of the VDO
is a crucial element in full mouth fixed prosthodontic
rehabilitation. It was necessary to make impressions
that registered all teeth preparations at once.
As the patient desired a high level of aesthetics, full
ceramic restorations were chosen for all restorations.
The minimum core thickness for this full ceramic
system is 0.4mm, this enabled conservation of tooth
structure and achievement of reasonable aesthetics
simultaneously.
By prescribing full ceramic restorations, intrasulcular placement of crown margins on the labial
surfaces become less important from an aesthetic
point of view. In this report, the teeth were essentially
caries free, teeth preparation margins were made at

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Fig. 11

Fig. 12

Fig. 13

Fig. 14

Fig. 15

gingival level and gingival retraction procedures were
eliminated. As gingival retraction cord placement was
not required, there was less physical trauma to the
gingival tissues and less clinical time was needed. This
is particularly beneficial for thin gingival biotypes.
Full mouth rehabilitation using fixed prostheses
usually requires longer-term provisional restoration
in order to facilitate a predictable treatment outcome.
In this patient, owing to his busy travel schedule, longterm provisional restoration for verifying his adaptability and multiple professional clinical adjustments
of provisional restorations were not feasible. The
anterior teeth were restored based on the diagnostic
wax-up without long-term provisional restoration
before definitive cementation of the definitive crown
restorations. This treatment sequence left almost no
room for clinical errors in the execution of the planned
treatment.

Intra-oral verification of the new occlusal scheme
and detailed in situ clinical adjustment of the restorations on the day of prostheses insertion are essential for
proper treatment execution. In this unique treatment
approach, the patient should be informed of the potential financial and time implications should any need for
re-fabrication of the definitive restorations arise.

_Conclusion
The functional management of complex prosthodontic rehabilitation is a clinical challenge. A relatively new restorative material was used in this case.
The use of high-strength full ceramic restorations enhances the overall aesthetic outcome and functional
predictability over the long-term._
Editorial note: A complete list of references is
available from the publisher.

Fig. 11_Occlusal view of completed
definitive maxillary full ceramic
crown restorations.
Fig. 12_Occlusal view of completed
definitive mandibular full ceramic
crown restorations.
Fig. 13_Side view at right
latero-trusion, canine-guided
occlusion.
Fig. 14_Side view at left
latero-trusion, posterior teeth were
out of occlusion during eccentric
movement.
Fig. 15_Anterior view of the
completed maxillary and mandibular
crown restorations. The crown
margins were placed at the gingival
margin with no sub-gingival
extension.

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I clinical technique _ anatomic stratification technique

Anatomic stratification
technique for lifelike
anterior composites
Authors_Dr Ratnadeep Patil & Dr Kavita Mahesh, India

Fig. 1

Fig. 2

Fig. 3

Fig. 4

_Introduction
_Direct composite resin restoration is a viable
treatment option for an aesthetic restoration with
minimal tooth reduction, especially in the case of
uncomplicated tooth fractures.1,2 Such fractures are
quite common amongst children and teenagers and
may cause aesthetic and psychosocial problems.3
In the past, the outcome of direct resin restorations was compromised as they reproduced the
optical properties of natural teeth poorly. Recent
advances in adhesive technology and material
properties, as well as improved understanding of the
optical properties of the natural tooth, have helped

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achieve improved vitality and depth of a restoration.
The direct resin build-up of a Class IV restoration
based on a contemporary layering technique allows
clinicians to provide conservative treatment and a
virtually imperceptible blend with adjacent tooth
structures.4

_Case report
A 19-year-old male patient presented with a fractured upper-left central incisor and a chipped upperright central incisor from a sports injury (Fig. 1).
Radiographic examination and the cold test did
not reveal any pulpal damage. After discussing various treatment options with the patient, conserva-

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tive restoration using direct composite resin was
selected.
Shade selection
The tooth shade was analysed before tooth preparation and thereafter evaluated for each layer of composite. Shade selection involves the dentist visually comparing the natural teeth shade to standard dental shade
guides.8 Such selection does not ensure that the sameshade composite will yield the desired outcome, as the

I

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

inherent opacity and layer thickness will determine
shade outcome. Shade matching, on the contrary, is a
highly technical process, but also with an unpredictable
outcome because it depends on individual skill and
knowledge.8 Shade matching has to be an integral part
of the layering technique.
Using the Tetric N-Ceram shade guide system
(Ivoclar Vivadent), the shade was determined to be A3,
with a high incisal edge translucency and an orange-red

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Fig. 13

Fig. 14

Fig. 15

Fig. 16

Fig. 17

for 30 seconds, followed by air drying, taking care not to
dry the tooth surface excessively (Fig. 6). A fifth-generation nano-optimised adhesive (Tetric N-Bond, Ivoclar
Vivadent) was placed in the preparation and agitated for
10 seconds, then gently air-thinned (Figs. 7 & 8) and
polymerised for 20 seconds (Fig. 9).

Fig. 18

Fig. 19

final effect. Occlusal view of the fractured teeth reveals
the difference in opacity and translucency of dentine
and enamel in tooth 21 (Fig. 2). Dentine is an opaque and
fluorescent tissue that determines the tooth’s hue and
chroma by reflecting light through the enamel. Enamel
is a translucent and opalescent tissue that determines
the tooth’s value.3,6 As the patient is young, the incisal
mamelons were intact (Fig. 1).
Preparation design
A 1mm bevel was placed along the margin of the
chipped enamel surface of tooth 11 (Fig. 3). An envelope
preparation design extending 2 mm with a 1 mm bevel
was prepared on the buccal surface of tooth 21 (Figs. 3
& 4). On the palatal surface of tooth 21, a rounded butt
margin was prepared (Fig. 4).
The cavity preparation was disinfected using a 2 %
chlorhexidine antibacterial solution. Etching was done
for 15 seconds using 37 % phosphoric acid (Fig. 5).
Thereafter, the etchant (Total Etch, Ivoclar Vivadent) was
removed and the tooth surface rinsed with water spray

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Composite layering
Composite layering was accomplished using the
anatomic stratification technique, which aids the natural appearance of restorations. Each layer has different
shades and opacities when stratified, giving a polychromatic effect with a more realistic depth of colour by
creating an illusion of the way light is reflected,
refracted, transmitted and absorbed, to simulate that of
dentine and enamel. This is crucial to overcome the
disadvantage of ‘shine through’ (silhouette of the fractured area is highlighted by the darkness of the oral
cavity) of traditional single- or two-layer techniques.6
Current composite resin systems use dentine materials that reproduce the fluorescence of natural dentine
and enamel materials that mimic the opalescence and
translucence of natural enamel.4
Although there is no exact formula for stratification
with such results, as shade layering varies from case to
case, the general rules are:
1. Replace palatal/lingual wall with an opaque composite. As they have higher colour saturation, when light
strikes the optically dense layer more light is reflected
back to the eyes, which contributes to the hue and
chroma by optically replacing dentine.6,7

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clinical technique _ anatomic stratification technique

Fig. 20

2. Use thin increments and observe shade after curing
each layer, so that the shade of the next layer can be
planned. An advantage of this technique is that it
minimises the negative effects of shrinkage by creating small incremental shrinkage.5
3. Use translucent composites to encapsulate the dentine core. This alters the quantity and quality of the
light reflected and thus determines the value of the
restoration by optically replacing enamel in the
restoration.6,7
4. Finish and polish to replicate natural tooth textures.
In this case, a nano-composite resin (Tetric N-Ceram)
was selected as the material of choice for restoring
these teeth. Stratification was initiated with a thin
layer of flowable resin (Tetric N-Flow, Ivoclar Vivadent;
Fig. 10) and thereafter 1 mm of Bleach light shade
(Tetric N-Ceram) was placed and cured to replicate the
opaque dentine layer (Fig. 11). A metal matrix strip was
placed interdentally and a triangular, mesio-incisal
layer of the A2 and A3 dentine shades (Tetric N-Ceram)
was placed and sculpted to reconstruct the proximal
surface (Figs. 12 & 13).
Next, increments of A3 enamel shade (Tetric
N-Ceram) were layered (Figs. 14–16) with a long-bladed
instrument and texture lines created with a sable brush
before curing (Fig. 17). The mamelon effect was completed using the highly translucent Incisal shade (Tetric
N-Ceram) at the inciso-lingual matrix, and two notches
were placed to duplicate the external contours of the
mamelons. The last increment was done using a thin
layer of Translucent Opal Shade (Empress Direct Composite, Ivoclar Vivadent).
Finishing and polishing
Finishing focuses on contouring, adjusting, shaping,
texturing and smoothing the restoration (Fig. 18), while
polishing concentrates on producing a surface lustre
(Fig. 19) and highly reflective surface.6 For creating texture in finishing, various areas on the buccal surface of
the tooth were highly polished to give a lifelike effect to
the restoration.1,2 Eminence of the proximal convexity,
the horizontal and vertical ridges, the lobe effect and
facial flattening were effectively projected. The black

Fig. 21

and white image of the finished restoration shows that
the value of the tooth and restoration is similar (Figs. 20
& 21).

_Conclusion
The success of the anatomic stratification technique
lies largely in the fact that it draws inspiration from the
natural layering of dentine and enamel. Continuous
technological advances have provided us with materials that can successfully replicate tooth characteristics
and retain the characteristics built into them through
layering them on tooth surfaces. With this technique,
it is possible for clinicians to provide more conservative,
yet functional and aesthetic, treatment to their
patients._
Editorial note: A complete list of references is
available from the publisher.

cosmetic
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_author info

Dr Ratnadeep Patil has maintained a successful private practice
specialising in aesthetic and implant dentistry in Mumbai since
1988.He is a diplomate of the International College of Oral Implantologists and an active member of the International Association for
Dental Research.He has authored a clinical textbook on aesthetic
dentistry (Esthetic Dentistry:An Artist’s Science) and been actively
involved in conducting continuing dental education programmes.

Dr Kavita Mahesh has been in clinical practice since she graduated from the Government Dental College and Hospital in Mumbai in
2002.Since 2003,she has been a member of the team at Smile
Care in clinics and been involved in continuing dental education programmes and clinical research.She completed her Post-Graduate
Certificate in Implant Dentistry at New York University in 2005.

Smile Care
13,Geetanjali,234,S.V.Road
Bandra (West),Mumbai – 400 050
India

Tel.:+91 22 2643 1670/71
E-mail:smilecarepublication@gmail.com
www.smilecareindia.com

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I special _ smile design

Smile Design Wheel™:
A practical approach to
smile design
Author_ Dr Sushil Koirala, Nepal

_Modern trends in cosmetic dentistry and
media coverage of smile makeovers have increased public awareness of dental aesthetics.
People now know that smile aesthetics plays a key role in their sense
of well-being, social acceptance, success at work and
in relationships, and
self-confidence. The
aesthetic
expectations and demands of
dental patients have
increased substantially. Now, a glowing, healthy and vibrant smile is no
longer available only
to millionaires and
movie stars. Therefore,
many dentists are incorporating various smile design
protocols in their daily practices
to meet the increasing aesthetic demands of their patients.

Fig. 1

_Smile aesthetics
A smile is a facial expression that is closely related to the emotions and psychological state of
a person. A smile is exhibited when a person expresses happiness, pleasure or amusement.1 It is
the most important of facial expressions and is
essential in expressing friendliness, agreement
and appreciation.2 A smile requires the coordination of facial, gingival and dental components
that are stimulated voluntarily or involuntarily by
various emotions. It is evident that each smile is

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different and particular to each individual.3 An
impaired smile on the other hand, has been associated with higher incidences of depression.4
Aesthetics deals with objective and subjective
beauty.5 Objective beauty is based on the appreciable properties possessed by the object itself.
However, subjective beauty is relative to the perception and emotion of the observing person.
Perception, however, in smile aesthetics is based
on personal beliefs, cultural influences, aesthetic
trends and fashion, and input from the media.
Hence, smile aesthetics is a multifactorial issue,
which needs to be adequately addressed for any
aesthetic treatment. The objective beauty of a
smile can be established with the application of
various principles of smile design, and the creation of subjective beauty may enhance cosmetic
value.5,6

_Smile design
Smile design has been defined in various ways
in the literature; I would like to summarise it as
follows: “Smile design is a systematic process
governed by the psychology, health, function and
rules of natural aesthetics to bring about some
changes in soft- and hard-oral tissue within
anatomical, physiological and psychological limitations, thereby creating a positive influence on
the overall aesthetics of a person’s face and personality as a whole”.7
We all appreciate a beautiful smile when we
see it, but it is difficult to explain exactly what
makes a smile beautiful. It is evident that a pleasing smile depends on the following features: the

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quality of the dental and gingival components,
their conformity to the rules of structural beauty,
the relationship between teeth and lips, and their
harmonious integration with the facial components.8 Overall facial beauty and smile aesthetics
are normally judged by psychological aspects—
perception, personality, desire—the state of health,
the mathematical ratio of the facial, dento-facial
and dento-gingival components. The psychological aspects are highly subjective and fluctuate
constantly because of identity, peer and media
pressure. Hence, the only objective method of aesthetic analysis is mathematical.
Indeed, mathematics has been considered the
only frame of reference for comprehending nature.8 Therefore, the cosmetic dentist needs to be
familiar with various mathematical and geometric concepts for achieving smile aesthetics and
their clinical protocols.

_The Smile Design Wheel
For any smile design procedure, the clinician
needs to consider the elements of the smile design pyramids—psychology, health, function and
aesthetics (PHFA), listed here according to order
of importance.7 It is necessary to determine the
patient’s psychological status, establish a healthy
oral environment, restore function and then give
attention to enhancing the aesthetic aspect. All
four pyramids should be accorded equal importance to achieve a desirable clinical result.

aspect of our mental life: our thoughts, memories,
mental images, reasoning, decision-making, and
so on, in short, with all aspects of the human mind.
In smile design, we normally try to understand
the second part of psychology, i.e. the human mind
or rather the minds of our patients. There are three
fundamental zones we consider in detail for the
psychological pyramid assessment: perception,
personality and desire.
Perception
Perception is the process through which a person can select, organise and interpret input from
their sensory receptors. A person cannot imagine
beauty and aesthetics without some input in advance. The media is the most common source of
information at present regarding beauty and aesthetics. A patient usually conceives his or her own
perception of smile aesthetics based on his or her
own personal beliefs, cultural influences, aesthetic trends within society and information from
the media.
Dentists need to communicate with their patients to determine such information during the
initial consultation, which helps in understanding
the patient’s perception of the treatment result.
The use of questionnaires, visual aids, such as previous clinical cases or smiles of various celebrities,
can aid immensely in this process.
Personality

By integrating these PHFA pyramids, I developed the Smile Design Wheel (Fig. 1), in which
each pyramid is subdivided into three related
zones. The Smile Design Wheel was devised as a
simple guide to the most important components
of smile design, their clinical significance and sequence to be maintained during the smile design
procedure. I believe that the Smile Design
Wheel will help clinicians to easily comprehend the ‘complex’ smile design procedures
of aesthetic dentistry. In the next section,
I briefly explain the Smile Design Wheel
protocols with PHFH pyramids assessment and their basic objectives.

According to the human psychology, personality is an individual’s unique and relatively stable pattern of behaviour, thoughts and
emotions. It is to be noted that each patient’s
problem or concern should be comprehensively evaluated with respect to his or her
personality type. According to Roger P.
Levin,9 there are four personality
types:

_ Driven: This type of person
focuses on results, makes
decisions quickly and dislikes small talk. They
_Step I: Understand—
are highly organised,
The pyramid of psychology
like details in condensed form,
According to Prof. Robert A.
are businesslike
Baron, psychology is best defined
and assertive.
as the science of behaviour and cognitive
_ Expressive: This type of person
processes. Behaviour deals with any action or Fig. 2
wants to feel good, is highly emotional,
reaction of a living organism that can be observed makes decisions quickly, dislikes details or paor measured. Cognitive processes deal with every perwork, and likes to have a good time.

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_ Amiable: People with this personality type are
attracted by people with similar interests, fear
consequences, are slow in decision-making, react poorly to pressure, are emotional and slow
to change.
_ Analytical: This type of person requires endless
details and information, has an inquiring mind,
is highly exacting and emotional. This type is the
most difficult to convince and takes the longest
to reach a decision.
Desire
Desire is a subjective component. Increased
public awareness of smile aesthetics through the
media has lead to a rapid increase in patients’ desires and levels of expectation. Patients are now
willing to pay for the enhancement of their smile
aesthetics. Therefore, the ethical responsibilities
of cosmetic dentists in identifying the need- or
want-based desires of patients have also increased. The desires and levels of expectation in
many patients are higher than what is clinically
achievable, and it is the clinician’s duty to explain
and guide patients towards a realistic aesthetic
goal.
The psychological assessment of any person is
very subjective; however, aspects like perception,
personality, expectation or desire are important
for the smile design procedure. Patient satisfaction is closely related to these aspects. Hence,
understanding the pyramid of psychology is an
integral aspect in smile design.

_Step II: Establish—
The pyramid of health
The pyramid of health is divided into
three zones: general health, specific
health and dento-gingival health.
The health pyramid assessment
and its management play a vital role in most cases, as patients may have certain
limitations owing to their
health, like uncontrolled diabetes, soft-tissue pathology, poor bone
structure, poor oral hygiene, tooth decay, periodontal disease etc., which should be addressed
prior to functional and aesthetic treatment.

Fig. 3

The health pyramid assessment process includes patient history (medical, dental, nutritional), examinations (extra-oral, intra-oral) and
investigations (radiographs, pulp vitality test,
study models analysis). Various types of questionnaires and clinical examination and investi-

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gation protocols can be used to obtain the necessary information relating to the patient’s health.
The clinician can use this information to prepare
a personalised treatment protocol. All three components of the pyramid of health should be established within normal limits before starting any
aesthetic restorative procedure on a patient.

_Step III: Restore—
The pyramid of function
Function is related to force
and movement. Hence, for
the pyramid of function assessment, the existing occlusion, comfort and
phonetics are properly
examined with the
evaluation of parafunctional habits,
level of comfort
during chewing
and deglutition, and temporomandibuFig. 4
lar joint movement.
The clarity of normal speech
and pronunciation are also examined. The occlusion, comfort and phonetics components of the
functional pyramid should be restored and maintained at an acceptable level before starting the
treatment of any aesthetic component.

_Step IV: Enhance—
The pyramid of aesthetics
The pyramid of aesthetics is the last but most
sensitive pyramid of the
Smile Design Wheel, as
aesthetics has both
subjective and objective aspects. The
assessment of
the subjective
aspects—perception, personality, desire—is carried out durFig. 5
ing the pyramid of
psychology assessment.
It is to be noted that the assessment of the objective aspects depends on the distance (focal
length) used to visualise the aesthetic component. Hence, the aesthetics pyramid can broadly
be divided into three major zones: macro, mini
and micro.

[27] => CDE0309_01_Titel

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special _ smile design

Fig. 6

Macro-aesthetics
Macro-aesthetics deals with the overall structure of the face and its relation to the smile
(Fig. 6). To appreciate the macro-aesthetic components of any smile, the visual macro-aesthetics
distance should be more than 5 feet. However, in
clinical practice the assessment of the macroaesthetic components is done using various facial
photographs with geometric and mathematical
appraisals, using reference points and their interrelation. Various facial reference points and
guidelines are used for aesthetic assessment
for orthognathic and facial cosmetic surgery;
however, in smile design the following macroaesthetic guidelines are considered fundamental:

Fig. 7

acteristics of the smile. Clinical photographs are
the basic tools for mini-aesthetic analysis. The
smile can be analysed at rest (M-position) or smile
(E-position).
In the M-position, the following references are
measured and analysed:
_ commissure height;
_ philtrum height; and
_ visibility of the maxillary incisors.
In E-position the following references should
be analysed:

_ facial midline;
_ facial thirds;
_ interpupillary line;
_ naso-labial angle; and
_ Rickett’s E-plane.

_ smile arc (line);
_ dental midline;
_ smile symmetry;
_ buccal corridor;
_ display zone and teeth visibility;
_ smile index; and
_ lip line.

Mini-aesthetics

Micro-aesthetics

Mini-aesthetics deals with the aesthetic correlation of the lips, teeth and gums at rest and in
smile position (Fig. 7). The aesthetic correlation
can be appreciated properly when viewed at a
closer distance than the visual macro-aesthetics
distance.

Micro-aesthetics deals with the fine structure
of dental and gingival aesthetics (Fig. 8). Miniaesthetics can be appreciated at a visual microaesthetic distance of less than 2 feet or within
normal make-up distance. For the clinical assessment of micro-aesthetic components of the teeth
and gingival tissue, appropriate illumination and
magnification tools are required for intra-oral
examination. Necessary clinical intra-oral photographs should be taken for documentation and
future reference.

The visual mini-aesthetics distance is similar
to the across-the-table distance, which is normally within 2 to 5 feet. There are various guidelines in aesthetics based on the relationship and
ratio between lips, teeth and gingival tissue. These
can be analysed during mini-aesthetic assessment using frontal, vertical and transverse char-

For micro-aesthetics, the detail of the individual tooth structure and its relation to the sur-

cosmetic
dentistry 3
I 27
_ 2009

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I special _ smile design

Fig. 8

rounding gingiva and the adjacent teeth should
be analysed. The following are the major points
to be considered:
_ upper centrals (tooth size ratio);
_ principle of golden ratio;
_ axial inclination;
_ incisal embrasures;
_ contact point progression;
_ connector progression;
_ shade progression; and
_ surface micro-texture.
In smile design, the aesthetic conditions related to gingival health and appearance are an
essential component. The gingival shape, position, embrasure, and contour in relation to the
teeth are interdependent. The following are major aspects that should be addressed during
smile design to achieve gingival or pink aesthetics:
_ gingival shape;
_ gingival contour;
_ gingival embrasure;
_ gingival zenith; and
_ gingival height (position or level).
To achieve higher patient satisfaction and
long-lasting treatment results, the following
should be the sequence in any smile design procedure: proper comprehension of psychological
aspects, the establishment of health and the
restoration of function within its normal limit,
and the subsequent enhancement of aesthetic
components.

28 I cosmetic
dentistry

3_ 2009

_Conclusion
Today, various protocols of smile design are
available in cosmetic dentistry. However, most clinicians wish to use the simplest protocol with the
most predictable results. It is to be noted that
smile design should always be a multifactorial
decision-making process that allows the clinician
to treat patients with an individualised and interdisciplinary approach.
The Smile Design Wheel presented in this article
clearly indicates the most important components
(PHFA pyramids) of smile design, their clinical significance and sequence to be maintained during
the smile design procedure. I believe that the
Smile Design Wheel is a simple and practical protocol in smile design that can help the clinician to
easily comprehend the ‘complex’ smile design
procedures of aesthetic dentistry._
Editorial note: A complete list of references is
available from the publisher.

_contact

cosmetic
dentistry

Dr Sushil Koirala, VISA president, can be reached
at skoirala@wlink.com.np.

[29] => CDE0309_01_Titel

22.7.2009

13:21 Uhr

Seite 1

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[30] => CDE0309_01_Titel

CDE0309_30-31_Hoexter

14.08.2009

15:55 Uhr

Seite 1

I feature _ opinion

Aesthetics and
the brain
Author_ Dr David L. Hoexter, USA

_The age-old question as to
what constitutes beauty has been
subjected to yet another wrinkle. Research has been presented showing
that left-sided brain people perceive
beauty differently than right-sided ones.
Beauty is and has been perceived through
the ages through individual eyes. Perhaps
different cultures encourage different
zones of desire and contentment; also, people of different ages may have different views.
Whatever the cause or conditioning, our visions encourage that beautiful zone. Is it due
to our youth’s environment, perhaps where our
mother’s left side of the brain influenced our concepts early, relating to beauty?
When I was presenting cosmetic periodontal techniques in Sicily, Italy, at a congress dedicated to aesthetics in dentistry, Dr DeLucca, an exquisite prosthodontist
with exceptional aesthetic prosthetic results, brought
up factors and questions regarding the effects of aesthetics from the right and left sides of the brain as well
as the male/female dominance in their respective
spheres.
The brain has been relegated to different functions
on its left and right side in several factors. The right side
is said to be more analytical, more detailed, as well as
more scientific, mathematical, computeristic, logical
and analytical. In general, the right side is usually related
to males. The left side of the brain is, in general, attributed to the female gender. Its characteristics are said to
be non-verbal, intentional, emotional, excellence in
spacial relationships, and good colour perception.
In the past 20 plus years of dentistry, aesthetics has
changed the face of the profession. This is not meant to
be a pun but an actual fact. The desire by patients to electively choose to have dentistry is a huge leap from its image of yesteryear. Not relying on motivation from pain
or trauma, patients are eagerly trying to improve their

30 I cosmetic
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feature _ opinion

appearance orally. A wonderful bright smile can
light up the face and the public is now aware of
this fact. At about the same time that cosmetic
improvement was encouraged by our profession, the profile of the dental school population started to change. The number of female
dental students became more predominant
than ever before in the United States. Was
this the left side of the brain making its
mark?
The initiating pioneers in the dental aesthetic field, Drs Irwin Smigel and Ron Goldstein, forged awareness to the public as
well as dentists, and encouraged the patient to request looking better orally. In
turn, they encouraged the dentist to provide the services that stimulated dental
companies to research and provide better
aesthetically appearing, yet formidable,
restorative materials. Did it take these pioneers the use of the right side of their brain
to forge this field of aesthetics?
In other countries throughout the world,
the number of female dental school graduates
has been higher than males for years. In addition, 85 per cent is the common percentage of female dentists practicing in many such countries. In the
US, that number hovers at about 50 per cent.
Does the right side of the brain dominate our field
with the necessary precision that is demanded? Have
the materials in dentistry today improved so much that
there is compensation in techniques to allow the left
side of the brain’s activity to transcend and emit an aesthetic sensitivity for the patient’s appearance? Can the
individual dentist utilise the left and right side of his or
her brain as noted in today’s terminology by the expression ‘crossover’?
Will the economic turmoil of today affect the demand
by patients for cosmetic dentistry beyond the necessary
health requirements? I know that for me to find the
answer regarding the male/female, left and right brain
relationships, I should smilingly have to ask my wife._

_author info

cosmetic
dentistry
Dr David L. Hoexter is director of the International Academy for
Dental Facial Esthetics, an organization that combines physicians
and dentists with other related fields in research and relates its finding to clinical practice. He lectures throughout the world and has
published internationally. He has been awarded 11 fellowships including FACD,FICD and Pierre Fauchard.He maintains a practice in
New York City, limited to periodontics, implantology and aesthetic
surgery.He can be reached at dr-davidlh@aol.com.

cosmetic
I 31
dentistry 3
_ 2009

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CDE0309_32-33_Kern

14.08.2009

15:57 Uhr

Seite 1

I feature _ practical experience

Ceramic instead of
composite
Author_ Manfred Kern, Germany

Fig. 1_Dr Otto and his team have
worked with CEREC for 18 years.
(Photo: Manfred Kern)

_Dr Tobias Otto, a dentist in private practice in
Aarau in Switzerland, witnessed the ‘death’ of
amalgam as a student at the University of Zurich.
The University was reacting in response to the
prohibition of amalgam in Sweden. Composites
and the adhesive technique were the new hopefuls

for treatment with fillings. The tooth-coloured
restorations met the patients’ aesthetic desires.
Dr Otto learned how to perform this timeconsuming procedure, which includes rubber dam,
dentine adhesives, the composite layering technique and light polymerisation. He also saw how
two- to four-surface composite restorations soon
fractured under masticatory loading due to insufficient contact points and porosities, became
discoloured and abraded after longer service, or
needed replacement because of recurrent caries.
Inspired by natural aesthetics, patients no
longer found cast gold fillings attractive. The new
alternative, such as laboratory-manufactured
ceramic inlays, taught Dr Otto that this restoration
technique too failed to provide the hoped-for,
long-term survival quality and was too expensive.
He found that the fracture resistance of the
delicate edges of pressed silicate ceramic inlays left
much to be desired, as did the colour stability of
the surfaces. Dr Otto dreamt of an industrially
sintered, dense, stable ceramic. But how could this
be milled?
While he studied hard for his licensing exams,
the first CEREC machine, which could mill an inlay
from an industrially produced ceramic blank, was
being developed in the clinic one floor above his
office. The protagonists of this method were confronted by many sceptics who denied the new
system their support because of the adhesive joint
between ceramic and enamel. However, Dr Otto
recognised that here was a highly resilient silicate
ceramic, whose flexural strength surpassed that of
both composites and laboratory-layered sintered
ceramics.

Fig. 1

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feature _ practical experience

Fig. 2

He began working with CEREC 1 in 1989 in a
partner practice in Zurich. He wished not only to
provide his patients with aesthetic and longlasting restorations, but also to prove to the hesitant university and the professional community
that this method, together with adhesive bonding,
was capable of providing the basis for highly
resilient ceramic restorations. With typical Swiss
thoroughness, he documented all of the CEREC
treatments he performed and recorded all findings
from recall appointments. “I was convinced that in
the long run, ceramic would be more durable and
economical than composite,” remembers Dr Otto.
“For three and more surfaces, composite is, in my
opinion, a poor compromise and, if recurrent caries
develops or the filling has to be replaced a short
time later, the patients will consider me a bad
dentist. In terms of long-lasting dental aesthetics,
we Swiss are very particular; we don’t accept compromises.”
Time would prove him right. After ten years,
data from his practice demonstrated a survival rate
of 90.4% for CEREC inlays and onlays. Thus, these
results corresponded to those of the gold standard,
that is, cast gold fillings.1 The study was published
internationally and the media acknowledged the
findings for ceramic restorations in private practice. Meanwhile, Dr Otto has been working with

a CEREC 3 unit, and the study is now in its 18th year.
The consistently applied multistep adhesive technique has proven to be sufficient, even with an
adhesive joint of 150 µm. With a survival rate of
88.7 per cent after 17 years, Dr Otto has set the new
gold standard with his restorations.2

Fig. 2_Patients appreciate that the
complete treatment requires just one
sitting. (Photo: Dr Otto)

He satisfies his patients’ dental and aesthetic
desires using CEREC thanks to the material, which
combines excellent aesthetics with stability, and
to the longevity, which makes the restoration
economical. “What my patients appreciate about
CEREC is that their tooth-coloured ceramic
restoration is manufactured and inserted in one
sitting, and for an average yearly cost of 47 Swiss
Francs—based on the minimum expected service
life—they really get tailor-made aesthetics.”_
Editorial note: A complete list of references is
available from the publisher.

_contact

cosmetic
dentistry

Manfred Kern, Wiesbaden, Germany
German Society of Computerized Dentistry –
International Society of Computerized Dentistry
secretariat@dgcz.org
www.dgcz.org

cosmetic
dentistry 3
I 33
_ 2009

[34] => CDE0309_01_Titel

CDE0309_34-36_Sellmann

14.08.2009

15:58 Uhr

Seite 1

I industry report _ provisionals

Temporaries: Perfect
provisional restorations
Author_ Dr Hans Sellmann, Germany

Fig. 1_The initial situation: teeth 11,
21 and 22 cannot be preserved.
Fig. 2_Plaster model for making
a formed component for the longterm temporary.
Fig. 3_The post-extraction alveoli
after removing teeth 11, 21 and 22.
Fig. 4_Processing the miniplast tray.
Fig. 5a_Filling the shaped piece with
a highly aesthetic provisional
crown-and-bridge material
(Structur Premium).
Fig. 5b_Structur Premium: complete
set with dispenser (application gun)
for fabricating perfect temporary
restorations.

_Temporaries are indeed only an interim solution.
They do, however, fulfil important functions until the
permanent restorative is available and thus have a lasting effect on the success of the treatment in restorative
dentistry.
The quality of the temporary restorations has great
importance with respect to their protective function
until the integration of the permanent restoration. Temporary crowns and bridges combined with luting cements protect the dentine and pulp from thermal,
chemical, mechanical and bacterial damage. Today,
modern temporary crown-and-bridge materials facilitate the fabrication of temporary restorations that meet
the highest medical standards of reliability and provide
incredible, natural aesthetics.

_The challenge of fabricating temporaries
The fabrication of temporary crowns and bridges
that provide an accurate fit is not easy. Much effort
goes into it, as building a perfectly integrated protection for the prepared abutment requires extreme precision. For the clinical success of a temporary, there are
several aspects of the fabrication to consider.
One such aspect is the quality of the marginal seal;
the temporary must sufficiently close the preparation
border so that the patient does not suffer from sensitivity. Additionally, care must be given to provide a
consistent occlusion and appropriate contact points
to the neighbouring teeth; ultimately, the teeth should
not wander until the definitive restoration is inserted.

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5a

Fig. 5b

34 I cosmetic
dentistry

3_ 2009

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industry report _ provisionals

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11a

The temporary should also be easy to polish and
exhibit good surface quality in the interdentium and
region of the crown boundary. The gingiva is already
irritated from the preparation and shaping and
should not become infected and retract because of a
temporary’s rough edge. Owing to these requirements, materials for the fabrication of temporaries
should not only permit safe and quick handling, but
also facilitate an optimal medical and aesthetic result.

_The clinical case
A female patient presented who had to have her
maxillary anterior teeth removed and a bridge had to
be prepared for her. The initial situation showed that
teeth 11, 21 and 22 could not be preserved (Fig. 1).
Normally, we would extract the teeth, insert a removable temporary (or an expensive one made by a
laboratory) and prepare accordingly, after the postextraction alveoli have healed. This procedure, however, is accompanied by the problem that the pontics
are always recognised as such, as there is no emergence profile or papilla formation typical of the natural tooth.
In contrast, a procedure is used in the following
case that permits the fabrication of a bridge with the
most naturally appearing bridge pontic area possible.
To begin with, a plaster model is fabricated for making a formed component for the long-term temporary (Fig. 2). After the preparation and extraction of
the teeth to be removed, we went with the fabrication of a long-term temporary with pontics for the
formation of the alveoli, for which we use the postextraction alveoli (Fig. 3). In this manner, the emer-

gence profile of the bridge pontics could be made so
that it appears that they are emerging from the gingiva and thus have the appearance of natural teeth
(keyword ‘red aesthetics’).
We used a deep-drawn miniplast splint made from
a soft foil for the impression and processed it with an
instrument especially for this purpose from the preparation kit (Komet; Fig. 4). The shaped piece offers the
advantage that it is not sensitive to external influences
(shrinkage etc.), can be stored longer and is more hygienic than a precast.
In the next work step, the mould was filled with a
highly aesthetic provisional crown-and-bridge material (Structur Premium, VOCO; Figs. 5a & b). The
quality of the margin was assessed after removing
the temporary bridge from the formed component
(Fig. 6). The temporary was subsequently finished
with tools from the preparation kit. First, a one-sided
sandpaper disc was used for rough finishing (Fig. 7),
followed by the smooth finishing of the edges with a
cross-cut carbide bur (Fig. 8). We segmented the pontics with the diamond disc from the finishing set
(Fig. 9) and used a rubber cup for the pre-polish on
the temporary (Fig. 10). Small irregularities or defects
(‘bubbles’) were corrected with Structur Premium
QM in incisal shade (Figs. 11a & b).

Fig. 6_Assessing the quality of the
edge before finishing.
Fig. 7_Rough finishing of the
temporary bridge with the one-sided
sandpaper disc.
Fig. 8_Smooth finishing of the edges
with the cross-cut carbide bur.
Fig. 9_Segmenting the pontics with
the diamond disc.
Fig. 10_Pre-polishing with
the rubber cup.
Fig. 11a_Correcting small irregularities and defects with a highly aesthetic provisional crown-and-bridge
material in incisal shade (Structur
Premium QM).

We carried out the subsequent high-gloss polish
with the equally fast and effective fibre-buffing disc
(Fig. 12). For a perfect finish, we applied a nano-filled
protective varnish to seal the surface (Easy Glaze,
VOCO; Figs. 13a & b), which we light-cured afterwards (Fig. 14). The protective varnish provides a

cosmetic
dentistry 3
I 35
_ 2009

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CDE0309_34-36_Sellmann

14.08.2009

15:59 Uhr

Seite 3

I industry report _ provisionals

Fig. 11b

Fig. 12

Fig. 13a

Fig. 13b

Fig. 14

Fig. 15

Fig. 16

Fig. 17

Fig. 11b_Structur Premium QM:
highly aesthetic provisional crownand-bridge material in incisal shade.
The QuickMix syringe permits perfect
handling and exact application.
Fig. 12_High-gloss polish with the
fibre-buffing disc.
Fig. 13a_A protective varnish (Easy
Glaze) is applied for the perfect finish.
Fig. 13b_Easy Glaze: nano-filled,
light-curing protective varnish
for surface sealing.
Fig. 14_Light-curing the
protective varnish.
Fig. 15_A smooth surface on the
pontics is especially important for
the alveoli because the temporary
will rest on them.
Fig. 16_The finished long-term
temporary.
Fig. 17_The integration of the temporary created an ideal initial
situation for an aesthetic emergence
profile for the future pontics.

36 I cosmetic
dentistry

3_ 2009

naturally shiny, smooth and aesthetic surface that
protects against more than just discolouration.
A smooth surface is especially important for the
pontics that rest on the alveoli, in order to prevent
plaque retention and the potential resulting inflammation (Fig. 15). The completed long-term temporary was
finally integrated (Fig. 16). It created an ideal initial situation for an aesthetic emergence profile for the future
pontics (Fig. 17).

_Billing for the long-term temporary
In contrast to a removable long-term temporary, a
fixed long-term temporary is not covered by insurance.
My patients gladly pay the difference, however, because
of the increase in comfort. This is especially the case
when I describe the positive aesthetic results to them.
Successful creation of durable long-term temporaries is ensured with the provisional crown-and-bridge
material I used here. Structur Premium is not just for
long-term temporaries, it is also my first choice for fabricating ordinary, routine temporaries._

_author info

cosmetic
dentistry

Dr Hans Sellmann studied
dentistry at Westfälische
Wilhelms-Universität in Münster,Germany,and has practised as a general dentist since
1976.He is the author of
books on dental entrepreneurship,managing problem
patients and microbiological
diagnostic methods,and of DVDs for continuing professional development in the fields of anaesthetic treatment,
cranio-mandibular dysfunction,halitosis,paedodontics
and risk diagnosis in the dental practice.He has developed several instruments for dentistry,is an expert lecturer in CPD courses and has published over 100 articles.
Dr Hans Sellmann
Langehegge 330
45770 Marl,Germany
E-mail:dr.hans.sellmann@t.online.de
www.zahnarzt-sellmann.de

[37] => CDE0309_01_Titel

_Advertorial

Structur Premium –
The ÀUVWFKRLFHIRUWHPSRUDULHV
Highly aesthetic provisional crown and bridge material from VOCO

_Durable and naturally aesthetic

Structur Premium – Prime advantages
for users and patients

Structur Premium is characterised by its ingenious
material composition. It has the proven material properties
of a nano-particle composite and provides the temporaries with excellent stability and a brilliant shine. Structur
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B1, B3 and BL). All shade versions exhibit natural ﬂuorescence and thus provides the temporaries with exceptional
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of the temporaries in the anterior area can be improved
even more with Structur Premium QM (QuickMix) in the
shade I (incisal).

s !ESTHETIC LIKE PORCELAIN

_Simple and economical application
_The expectations are increasing for highly aesthetic treatments. This equally applies to provisional crowns
and bridges, especially in the anterior region. Temporary
restorations must not only provide superior aesthetics, but
also durable protection for the prepared teeth until the
deﬁnitive restoration is inserted. Therefore, the mechanical
stability is especially an important quality feature for crown
and bridge materials. With Structur Premium, VOCO offers
a highly aesthetic provisional crown and bridge material
that equally fulﬁlls all of the different requirements and it
can also be used universally.

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P.O. Box 767
27457 CUXHAVEN
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By completing and submitting this coupon, I give VOCO GmbH permission to contact me using the information provided above. I understand that
no purchase is necessary to participate in this sweepstakes promotion and I do not have to submit to a sales presentation. Check here to opt out of
being contacted. Drawing held 30/09/2009. Void where prohibited. ©2009 VOCO GmbH – CDI0309StrPre

Cosmetic Dentistry_Advertorial_0709.indd 1

24.06.2009 13:49:50 Uhr

[38] => CDE0309_01_Titel

CDE0309_38-41_Geiselhöringer

14.08.2009

16:00 Uhr

Seite 1

I industry report _ abutments

Customised abutments
for long-term aesthetics—
software tools
to meet clinical and
laboratory requirements
Authors_ Hans Geiselhöringer & Dr Stefan Holst, Germany

Figs. 1a & b_Virtual design of an
implant abutment (NobelProcera system software, Nobel Biocare).
The display of the surrounding
anatomy provides detailed information on the ideal design and retentive
contour. The abutment height and
taper must be idealised to provide
functional stability. Suggested
contour by software (a) and
customised height (b).

Fig. 1a

_Replacing missing single teeth with dental
implants has become routine, yet restoring anterior teeth with implant-supported restorations is
a technique-sensitive task for which aesthetic
and functional success remains a challenge for
the surgical-restorative team.
Indispensable factors for success are the
amount of available alveolar bone, morphological
soft-tissue type, correct positioning of the implant in all three dimensions, and a successful
provisional phase. In addition to establishing an
adequate implant recipient site and a harmonious

Fig. 1b

38 I cosmetic
dentistry

3_ 2009

and natural blending of the restoration with the
surrounding tissues and dentition, the long-term
stability of the peri-implant tissue architecture is
a significant challenge. The selection of suitable
materials and an optimal design are paramount
for the success of the definitive restoration. This
is where the advantages of CAD/CAM technology
and all-ceramic materials become evident.
These technological advancements have had a
considerable impact in various areas of dentistry
and will continue to do so into the future. Advantages related to material and manufacturing

[39] => CDE0309_01_Titel

CDE0309_38-41_Geiselhöringer

14.08.2009

16:00 Uhr

Seite 2

industry report _ abutments

processes will promote the ongoing adoption of
CAD/CAM systems in preference to conventional
casting and manufacturing techniques. This is
because CAD/CAM technology offers numerous
benefits compared to conventional framework
fabrication, including reproducible precision,
material homogeneity, individual customised
design, and ease of fabrication. At the same time,
industrialised fabrication methods guarantee
standardised quality and reduce cost-intensive
manual labour. In addition, the availability of
homogeneous, bio-compatible materials will
minimise material incompatibilities and corrosive phenomena arising from dissimilar metal
alloys and interfaces between cast and machined
components.
Ongoing research in ceramic materials development has led to the use of high-strength, nonsilica-based ceramics in dentistry with beneficial
properties in terms of bio-compatibility, aesthetics and long-term clinical function that have been
investigated in numerous scientific investigations. Aluminium oxide (Al2O3) and zirconium
dioxide (ZrO2) ceramics are the most common
oxide ceramic materials used today. Owing to its
material properties and strength, ZrO2 is applied
whenever high loads are expected (e.g. posterior
fixed dental prosthesis frameworks, implant
abutments and multi-unit implant restorations).
In addition to its strength, the greatest advantage

Fig. 2a

Fig. 2b

Fig. 2c

Fig. 2d

of ZrO2 is its excellent tissue integration. Various
studies have demonstrated the successful application of zirconia abutments in terms of stability
of soft tissue and marginal bone. Results indicate
that the type of material used affects both the
amount and quality of the surrounding tissues
(when comparing zirconia to cast alloys). Also,
ceramic abutments minimise bacterial and plaque
adhesion and prevent soft-tissue inflammation.

Figs. 2a–d_The intuitive software
helps simplify the design process.
Occlusal and lateral view of the
margin radius that can be homogenously adapted at the click of a
button (a & b). Note the location of the
abutment-crown margin at the
cervical margin (c & d).

_Customised abutments: manufacturing
options
The clinician may choose between prefabricated or customised abutments for implantretained single or multi-unit restorations. The
primary objective must always be proper support
of the surrounding tissues, optimal morphology
to support the restoration without impairing hygiene maintenance, and anatomic design to allow
for proper support of the veneering ceramics in
case of screw-retained restorations. These goals
can easily be achieved if an abutment is custommade. Using prefabricated abutments, on the
contrary, has several disadvantages. Customising
is a time-consuming and highly unpredictable
process in the laboratory, requiring additional
finishing procedures in the dental office. Postsintering manipulation of oxide ceramic components significantly increases the risk of microcracks that could result in subsequent failure

cosmetic
dentistry 3
I 39
_ 2009

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CDE0309_38-41_Geiselhöringer

14.08.2009

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I industry report _ abutments

Fig. 3a

Fig. 3b

Figs. 3a & b_The anatomic tooth
library is an extremely useful tool that
eliminates the need for a wax-up and
ensures an homogenous veneering
porcelain thickness using an
automated reduction tool (see dark
green contour of the definitive
abutment and the transparent
morphology of the anticipated
final restoration).

under clinical function. Scientific investigations
have revealed that the reaction of cells towards
materials with a corrosive potential such as castalloy components or veneering porcelain is inferior to homogenous materials such as titanium
or zirconia.

_Fast and intuitive design of implant
abutments
Work processes to fabricate an individual abutment that in the past required significant amounts
of time can be realised within minutes today. The
newest generation of CAD software eliminates the
need for a wax-up to achieve the desired definitive
abutment shape. While an automated software

Table 1_
Biological advantages of customised
CAD/CAM abutments:
• formation of an intimate soft-tissue contact
• long-term clinical stability through
bio-compatible and homogenous materials
• eliminates the risk of corrosion in contact areas
of dissimilar metals and alloys
• maximises aesthetic results through
application of shaded Zirconia

Table 2_
Customised CAD/CAM abutments:
design advantages
• free-virtual design options
• screw- or cement-retained restorations
• optimal support of peri-implant soft tissue
through individual abutment profile
• round contours, no sharp edges
• ideal positioning of cement line

40 I cosmetic
dentistry

3_ 2009

function suggests a superstructure or abutment
following a model or impression scan, the dental
technician can easily adapt the contour and form
virtually to any desired shape (Figs. 1a & b). In
addition, one software programme offering an
intuitive software interface and the ability to restore using different implant systems is a very
interesting alternative to conventional fabrication, for which cast-on components have to be
ordered for the respective implant system and
then customised.

_Virtual design of transgingival
contour and positioning of the crownabutment margin
When designing an abutment, the following
two major criteria supporting long-term success
should be considered: the contour and shape of the
abutment in the sub-gingival area and the height,
angulation and taper to provide adequate retention for a cement-retained crown. There is no
scientific evidence that supports a more concave
or a convex peri-implant abutment contour.
Communication and close collaboration between
the dental technician and the dentist are needed,
taking the individual clinical situation into consideration. This includes the position of the implant
in relation to the definitive crown contour, the
thickness and biotype of the surrounding tissue,
and location within the arch.
It is generally agreed that the abutment-crown
margin should always be located at or slightly below the gingival crest in order to allow for complete
removal of cement (Figs. 2a–d). If remnants of the
cementation media remain, peri-implant inflammation and adverse tissue reactions are very likely.
Here another advantage emerges. While metal
abutments or porcelain-fused-to-metal crowns
had to be positioned deep underneath the gingival
margin in order to minimise the risk of discolouration, utilising oxide ceramic materials eliminates
this concern and improves the aesthetic outcome.

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CDE0309_38-41_Geiselhöringer

14.08.2009

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industry report _ abutments

_Mechanism of retention
A significant disadvantage of screw-retained
restorations in the past compared to cemented
restorations was the aesthetic closure of the
screw access channel. Using metal-based frameworks and composite resin for closure resulted in
impaired aesthetic outcomes on the occlusal
surface. Zirconium-dioxide-based frameworks
eliminate this disadvantage. If white or shaded
substructures are used, easy and fast closure of
the screw access channel can be achieved with
conventional composite resin materials. The
retrievability and the absence of cement between
the abutment and the crown are amongst the
greatest advantages compared to cemented
solutions or cast abutments.

Fig. 4

Fig. 5a

Fig. 5b

Fig. 5c

retained crown is cemented or the abutmentcrown complex is screw retained depends on
the dentist’s preference and the positioning of
the implant (Figs. 4 & 5a–c). A cement-retained
restoration on an individual ceramic abutment
allows for simple compensation of misaligned
implants and can be treated like a natural tooth.
The main disadvantage of cemented prostheses
is irretrievability._
The authors acknowledge Dr M. Thorwardt from
Friedrich Schiller University Jena for conducting
the implant surgery.
Editorial note: A complete list of references is
available from the authors.

_contact
Porcelain is fired directly onto the abutment
and the abutment-crown complex can be
screwed onto the implant. Here again CAD technology supports the dental technician in the
design of the final abutment shape. Numerous
publications emphasise the need for an homogenous veneering material thickness in order
to minimise the potential problem of chipping
(Figs. 3a & b). Utilising a software system that
makes use of an anatomic tooth library supports
the user in designing the later contour of the
final restoration (taking occlusal and functional
aspects into consideration). Whether an implant-

cosmetic
dentistry

Hans Geiselhöringer
Dental Technician
Dental X Hans Geiselhöringer GmbH & Co. KG
Lachnerstraße 2
80639 Munich, Germany

Fig. 4_The combination of the
strength of a zirconia abutment and
the aesthetic advantages of an
alumina crown (NobelProcera crown
alumina, Nobel Biocare) demonstrate
the advantages and versatility of the
NobelProcera system.
Fig. 5a–c_The clinical advantages of
custom-designed CAD/CAM
abutments are unrivalled. Homogenous and bio-compatible materials
allow for correction of implant
angulation and ensure long-term
clinical tissue stability (NobelProcera
zirconia abutment, Nobel Biocare; a)
Initial clinical situation with an
unacceptable provisional restoration
replacing the lateral incisor (b).
Definitive clinical outcome following
implant treatment (c).

Dr Stefan Holst
University Clinic Erlangen
Dental Clinic 2 – Department of Prosthodontics
Glückstraße 11
91054 Erlangen, Germany

cosmetic
dentistry 3
I 41
_ 2009

[42] => CDE0309_01_Titel

CDE0309_42_Ivoclar

14.08.2009

16:01 Uhr

Seite 1

I industry news _ Ivoclar Vivadent

Progress knows
no clinical limitations
Fig. 2

Fig. 1

Fig. 3
Fig. 5

Fig. 4

Fig. 6

_contact cosmetic
dentistry
Ivoclar Vivadent AG
Bendererstrasse 2
9494 Schaan
Liechtenstein
www.ivoclarvivadent.com.

42 I cosmetic
dentistry

3_ 2009

_Second generation LED lights are notorious for
offering a much narrower emission spectrum than the
gold standard halogen lights. For this reason, several
bleach shade composites, adhesives and protective
varnishes cannot be entirely cured owing to the
photoinitiator used. This is where bluephase and its
specifically developed poly-wave LED come into play.

power for polymerisation close to the pulp and soft start
for stress-reduced polymerisation, is relatively costeffective (Figs. 3 & 4). Owing to the 10 mm light probe,
which offers an enlarged treatment field, timeconsuming multiple polymerisations are a thing of the
past. In addition, proximal boxes can easily be cured
using this elegant light (Fig. 5).

_Simply clever: The new poly-wave LED

_Continuous cooling:
A must-have for LED lights

Reliable polymerisation of composites and luting
materials is a crucial step in the dental practice. This is
exactly where the new bluephase family—bluephase C8,
the classic bluephase and bluephase 20i—show their
strength. The specifically developed poly-wave LED
activates all photoinitiators. The four LEDs—three blue
ones (dominant wavelength: approximately 410nm)
and a violet one (dominant wavelength: approximately
470nm) that operate simultaneously—allow unlimited
use in the dental practice and are thus suitable for all
photoinitiators and materials (Figs. 1 & 2).

_Bluephase C8: On an economical mission
The mains-operated curing light bluephase C8,
featuring a light intensity of 800mW/cm2 and three
programmes—high power for fast polymerisation, low

Does this sound familiar? If a certain temperature is
exceeded, the LED light switches off in order to prevent
damage. The light is only operational again after several
minutes. The virtually noiseless, invisible fan of the
bluephase family allows continuous operation without clinical limitations, even when used for extensive
indirect restorations.

_Conclusion
The cordless bluephase has proven its value with
its functional properties and ergonomic concept
(Fig. 6). The more compact basic edition bluephase
C8 is a more economical option. Now the versatile
bluephase model featuring a poly-wave LED is available
for every practice._

[43] => CDE0309_01_Titel

Anschnitt DIN A4

12.06.2008

14:44 Uhr

Seite 1

It really would have been possible to meet each other much sooner, because in 1955 we were already the first
company worldwide to supply elastomeric, condensation-curing impression materials. And by now the news
has made the rounds internationally that our research department is responsible for ground-breaking developments
in the A-silicone sector. Thus, our partners in laboratories and dental practices are always a bit ahead of their
time. You don't know us yet? Then please invite us in and test the Kettenbach precision products.
www.Kettenbach.com
www.Kettenbach.com

020447_1208

Allow us to introduce ourselves:
Kettenbach. In Germany we are
world-famous.

[44] => CDE0309_01_Titel

CDE0309_44-47_Lifestyle

14.08.2009

16:04 Uhr

Seite 1

I lifestyle _ travel

Enjoy your trip and
indulge in the journey!
Author & Photographer_ Annemarie Fischer, Germany

“The Amer

ican Road T
rip isn’t just
a pastime; it
’s a
a necessity, birthright,
a rite of pas
sage,
it’s a way of
life.”
(Erin McH
ug
h, The Littl
e

_The road trip is a constant narrative in US-American pop culture and is
synonymous with escape, freedom, and independence from borders and boundaries. In the
land of the free and the home of the mobile, the
Asphalt Nation of America, as observed by Jane
Holtz Kay, is built around automobiles and cherishes the ideal of mobility. Some road—enthusiasts, referring to themselves as road trippers—
have developed the science
of a road trips, roadology,
that explores the effects of
roads on societies.
A true American road
trip starts at the first
crossroads, not knowing

44 I cosmetic
dentistry

3_ 2009

Road Trip H
andbook)

if you would like to go
straight, left or right,
and not planning
ahead too much. It
is about impromptu
‘moseying’ down the
road rather than following a strict schedule.
This road trip combines two routes, the
hiker-favourite Appalachian Trail, starting in Pennsylvania and
exploring Southern Atlanta, and the NYC–Miami
Atlantic Coast Route to Florida. The routes
explore the historical birthplace of the United
States in Philadelphia, the impressive nature
of the Shenandoah, Great Smoky Mountains
and Everglades National Parks, Ivy League
university campuses of Cornell, Princeton
and Pennsylvania University, the cradle of
the African-American civil rights movement
and global news in Atlanta, the spacy Kennedy
Space Center in Cape Canaveral, and the
colourful Miami.

[45] => CDE0309_01_Titel

CDE0309_44-47_Lifestyle

14.08.2009

16:04 Uhr

Seite 2

lifestyle _ travel

For outlanders, a well-kept rental car, sufficient insurance coverage, a working mobile
phone and a good map as well as credit cards and
some dollar bills to secure cash-flow are enough.
In local supermarkets, one can get a regular supply of water, fresh fruit and chopped veggies. In
some states, one might be lucky to find on-theroad selling stations of local produce. With most
rentals nowadays, you get access to hundreds of
digital radio stations that complete the road
track with the perfect sound track. Jamie Jenson,
author of Road Trip USA, offers a road trip blog
and podcast at www.roadtripusa.com.
Motels are available easily down the road;
with the Days Inn as well as Jamestown being on
the (more) pleasant side. However, their early
nutrition consists mostly of a crime called Con-

tinental Breakfast. The Waffle House, for example, offers a more decent way to start the day and
is open-all-night to savour fresh waffles with
maple syrup, eggs’n’bacon and grits in enormous
portion sizes. For a decent dinner, one should
always ask for the best local diner on the way, and
fast food branches offer a quick snack to go.

_Going green
Nature parks in the
States truly signify the
gorgeousness of this
country, and function
as an oasis from civilization—no gigantomanic malls and
no fast food restaurants
disturb the scenic nature. A small entrance fee is
valid for a couple days up to a week. Hotels or
camping facilities offer a place to stay for the
night.
Being thrown into nature, one is to respect
the speed limit in order not to hurt an animal.
A 35-mile-speed limit in Skyline Drive explores
Shenandoah National Park. Down the Appalachian
Trail, the fog-covered mountains name the Great
Smoky Mountains National Park and amaze visitors in the most popular
park in the United States.
Alligators, pythons, and
vultures come close in
the Florida Everglades
Park, and protection
from mosquitoes is
mandatory.

_Going Ivy
American elite Ivy League Universities—
Cornell, Pennsylvania University, and Princeton
—are always worth the trip, since their campuses blend in with the nature and offer an

The concept of Park and Ride is not compulsory in most cities. Most downtown areas are
quite car-friendly, with most sights offering free
parking or at rates for a couple of dollars per
hour. Park and Ride is only mandatory in city
molochs like New York.

impressive architecture. University bookstores are tea’n’coffee havens to indulge in the oeuvres of university lecturers,
for instance novelists Vladimir Nabokov in
Cornell, Philip Roth at PennU, and Jeffrey
Eugenides at Princeton.

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CDE0309_44-47_Lifestyle

14.08.2009

16:05 Uhr

Seite 3

I lifestyle _ travel
The campuses also own captivating museums: The University of
Pennsylvania, that claims to be
America’s First University, possesses in Museum of Archaeology
and Anthropology one of the
finest ethnology collections in
the world.

_Shopping in the USA
Since consumption of goods has
been elevated to a true art form in the
United States of America, a typical
road tripper goes shopping. In times of
crisis, outlet shopping centres
function as a holy grail for an almost guilt-free indulgence. It is
more fun to explore the lesscrowded centres in the South,
such as in nomen est omen
Commerce.

impressive art collections. Film legend
Rocky Balboa turned its stairs into an American
pop culture icon—to climb and conquer the
stairs and to cheer on top
has become a verb, “to do
the Rocky (Balboa)”. Cruising South Philly is even
more amazing–it unravels
graffiti buildings, outdoor
neighbourhoods and family businesses. Geno’s and
Pat’s just face each other
to win the culinary competition over the Best
Philly Cheese Steak, a
sandwich filled with steak
and cheese sauce.

_Rocking Philly
Philly forms the perfect symbiosis between
history and relaxation. The City of Brotherly Love
is the historical birthplace of the United States
and welcomes you with American historical sites
in the Independence National Historical Park,
home of the Liberty Bell, as well as the Betsy Ross
House, where historians still debate if the
first US-American
flag had been indeed
designed there. The
Philadelphia Museum of Art offers
one of the most

_Hotlanta
Temperatures and heartiness rise as one
reaches the capital of the Peach State Georgia,
Atlanta. Hotlanta is the home of Coca-Cola
and CNN, and of Martin Luther King Jr, who was
born and raised here. The King Center and
his birthplace blend in unpretentiously with
the neighbourhood. King’s powerful rhetoric
accompanies insightful information on his
life path that reflects the struggles of the civil
rights movement, and on current human rights
movements around the world in this living memorial.
When Hotlanta makes hungry, The
Varsity is considered as the best DriveIn hot dogs, greeting the customers
with the legendary “What’ll ya have?”.

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CDE0309_44-47_Lifestyle

14.08.2009

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Seite 4

lifestyle _ travel

The CNN Headquarters satisfies an appetite
for information, where the longest escalator of
the world guides one to the CNN studios, where
visitors can see directly into studio windows.
News is today a highly-complex and digitalised
production. CNN anchormen and -women work
directly from news bureaus, endowed with
highly-sensitive microphones that block surrounding noises, and are digitally beamed into
futuresque studio settings.
calypso sound. The Spanish churros pastry, along with hot chocolate, drench the
night.

_Going up
The Kennedy Space Center is financed
uniquely with entrance fees, and is the most gigantic PR measure to promote aerospace. The
spacy center is located in a gigantic

_Bienvenidos a Miami!
Miami truly cites its Miami Vice
pop culture reference, shimmering
in pleasant pastel colours, and
glowing as the vibrant and voluptuous as the eighties era. Pastelblue daytime skies change into
dramatic evening shades. The Art Déco district
can be explored with guided tours, and it is the
sight of a tragedy: Gianni Versace was murdered
at Ocean Drive 1116 in his Casa Casuarina.
The Magic City merges into a true melting
point and is the largest and most vibrant out-ofLatin America community, visible in Little Havana. Two-thirds of Miami people cite Spanish as
their mother tongue. Those Latin, Carribean,
Central and South American as well as European
influences melted into the unique New World, or
Nuevo Latino, cuisine. In the Las Vegas Restaurant, one can get a taste of the Cuban Fusion
cuisine. After sun-bathing at South Beach, synonymous to “showing what you’ve got”, most
restaurants turn into nightclubs. Coconut Grove
offers after-dinner cocktail in outside cafés and
bars, where one cannot only indulge in tastes,
but also sounds of Latin America and the Carribean. Cubans brought the conga and rumba
to Miami from their homelands, instantly popularising it into US-American culture. Dominicans carried bachata, and merengue into the
bars, while Caribbeans brought reggae, soca,

nature reserve and is
not only a high-tech playground,visitors can’
witness work in progress on the working facilities.
For outlanders, an All-American road trip
is the path to understand that theUnited States
of America is a gathering of civilizations and
cultures, flora and fauna, images and sounds,
flavours and aromas, styles, and feelings; and
“to get the feel of the road”, notes Erin McHugh
in The Little Road Trip Handbook, “remember
that it’sthe journey, not the destination.”_

cosmetic
dentistry 3
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_ 2009

[48] => CDE0309_01_Titel

CDE0309_48_Eventlist

14.08.2009

16:07 Uhr

Seite 1

I meetings _ events

Cosmetic events
2009
FDI Annual World Dental Congress
Where:
Singapore, Singapore
Date:
2–5 September 2009
Tel.:
+33 450 4050 50
E-mail:
congress@fdiworldental.org
Web site: www.fdiworldental.org

ACE 2009 Symposium on Esthetic Dentistry
Where:
Scottsdale, AZ, USA
Date:
11–14 November 2009
Tel.:
+1 800 701 6223
E-mail:
contact@ACEsthetics.com
Web site: www.acesthetics.com

ESCD 6th Annual Meeting
Where:
Paris, France
Date:
25–27 September 2009
Tel.:
+33 495 09 38 00
Web site: www.escdonline.eu

SAAAD Aesthetic Dental Conference
Where:
Kathmandu, Nepal
Date:
28–29 November 2009
Tel.:
+977 142 425 64
Email:
skoirala@wlink.com.np
Greater New York Dental Meeting
Where:
New York, NY, USA
Date:
27 November–2 December 2009
Tel.:
+1 212 398 6922
Web site: www.gnydm.org

2010
26th AACD Anniversary Scientific Session
Where:
Grapevine, TX, USA
Date:
27 April–1 May 2010
Tel.:
+1 800 543 9220
E-mail:
pr@aacd.com
Web site: www.aacd.com
EAED Spring Meeting
Where:
London, UK
Date:
27–29 May 2010
Tel.:
+39 02 295 236 27
E-mail:
info@eaed.org
Web site: www.eaed.org
IACA Annual Meeting
Where:
Boston, MA, USA
Date:
22–24 July 2010
Tel.:
+1 866 669 4222
E-mail:
info@theIACA.com
Web site: www.theiaca.com
AAED 35th Annual Meeting
Where:
Kapalua, HI, USA
Date:
3–6 August 2010
Tel.:
+1 312 981 6770
E-mail:
meetings@estheticacademy.org
Web site: www.estheticacademy.org

48 I cosmetic
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[49] => CDE0309_01_Titel

CDE0309_49_Submission

14.08.2009

16:07 Uhr

Seite 1

I about the publisher _ submissions I

submissions:
formatting requirements
_Please note that all the textual elements of
your submission:
_the complete article,
_all the figure captions,
_the complete literature list, and
_the contact info (bio, mailing address,
E-mail address, etc.)
must be combined into one Word document.
Please do not submit multiple files for each
of these items.
In addition, images (tables, charts, photographs, etc.) must not be embedded into the
Word document. All images must be submitted separately, and details about how to do
this appear below.

If you would like to emphasize certain
words within the text, please only use
italics (do not use underlining or a larger
font size). Boldface is reserved for article
headers.
Please do not ‘center’ text on the page,
add special tab stops, or use underling as
all of this must be removed before layout. If you require a special layout, please
let the word processing programme you
are using help you to do this formatting
rather than doing it by hand on your
own.
If you need to make a list, or add footnotes or endnotes, please let the Word
processing programme do it for you automatically. There are menus in every
programme that will help you to do this.
The fact is that no matter how careful
one might be, errors have a way of creeping in when you try to hand number
footnotes and literature lists.

Larger images are always better, and
something on the order of 1 MB is best.
Thus, if you have an image in a large size,
do not bother sizing it down to meet our
requirements but send us the largest file
sizes available. (The larger the starting
image is in terms of bytes, the more leeway the designer has in terms of resizing
the image to fill up more space should
there be room available).
Also, please remember that you should
not embed the images into the body of
the text document you submit. Images
must be submitted separately from the
textual submission.
You may submit images through a zipped
file via E-mail, unzipped individual files
via E-mail, or post a CD containing your
images directly to us (please contact us
for the mailing address as this will depend upon where in the world you will be
mailing them from).

Text length
Article lengths can vary greatly—from a mere
1,500 to 5,500 words—depending on the
subject matter. Our approach is that if you
need more or less words to do the topic justice then please make the article as long or
as short as necessary.
We can run an extra long article in multiple
parts, but this is usually discussing a subject
matter where each part can stand alone because it contains so much information. In addition, we do run multi-part series on various
topics.

Image requirements
Please number images consecutively
throughout the article by using a new
number for each image. If it is imperative
that certain images are grouped together, then use lowercase letters to designate the images in a group (ie, 2a, 2b,
2c).

In short, we do not want to limit you in terms
of article length, so please use the word
count above as a general guideline and if you
have specific questions, please do not hesitate to contact us.

Please put figure references in your article wherever they are appropriate,
whether that is in the middle or end of a
sentence. If you are not directly mentioning the figure in the body of your article, when it appears at the end of the
sentence the figure reference should be
enclosed within parenthesis and be inside the sentence, meaning before the
period.

Text formatting

In addition, please note:

Please use single spacing and un-indented
paragraphs for your text. Just place an extra
blank line between paragraphs.
We also ask that you forego any special formatting beyond the use of italics and boldface, and make sure that all text is left justified.

_We require images in TIF or JPEG format.
_These images must be no smaller than
6 x 6 cm in size at 300 DPI.
_Images cannot be any smaller than 80
KB in size (or they will print the size of a
postage stamp!).

Please do not forget to send us a head
shot photo of yourself that also fits the
parameters above so that it can be
printed along with your article.

Abstracts
An abstract of your article is not required.
However, if you choose to provide us with
one, we will print it in a separate box.

Contact info
At the end of every article is a Contact
Info box with contact information along
with a head shot of the author. Please
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cosmetic
dentistry 3
I 49
_ 2009

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I about the publisher _ imprint

cosmetic
dentistry
_ beauty & science

asia pacific edition

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cosmetic dentistry_Copyright Regulations
_cosmetic dentistry asia pacific edition is published by Dental Tribune Asia Pacific Ltd. and will appear in 2009 with one issue every quarter. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
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the opinion of the afore-mentioned, and do not have to comply with the views of Dental Tribune Asia Pacific Ltd. Responsibility for such articles shall be borne
by the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility
shall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply, legal venue is North Point, Hong Kong.

50 I cosmetic
dentistry

3_ 2009

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Dental Tribune International GmbH | Contact: Nadine Parczyk
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n.parczyk@dental-tribune.com | www.dental-tribune.com

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23.03.2009 15:53:50 Uhr

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