cosmetic dentistry international

Cover / Editorial / Content / Cosmetic periodontal surgery: Pre-prosthetic soft-tissue ridge augmentation (Part I) / Complete maxillary implant prosthodontic rehabilitation utilising a CAD/CAM fixed prosthesis / Aesthetic functional veneers in patients with habitual dysfunctions? / A new approach for patient acceptance and appreciation / Maintenance of periodontally compromised teeth with direct splinting—current materials and options / Minimally invasive cosmetic dentistry―Concept and treatment protocol / CAD/CAM expands the scope of restorative dentistry / Safety and reliability with CAD/CAM technology / Smile upgrade—Highly aesthetic composite restorations in the anterior region / Events / Submissions / Imprint

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CDE0409_01_Titel

23.11.2009

11:41 Uhr

Seite 1

issn 1616-7390

Vol. 3 • Issue 4/2009

cosmetic
dentistry
_ beauty & science

4

2009

| case study
Cosmetic periodontal surgery

| digital dentistry
Safety and reliability with
CAD/CAM technology

| special
MICD—Concept and treatment protocol

[2] => untitled

29.9.2009

7:21 Uhr

Seite 1

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[3] => untitled

CDE0409_03_Editorial

13.11.2009

10:50 Uhr

Seite 1

editorial _ cosmetic dentistry

Dear Reader,
_The end of 2009 is already drawing near, which is an opportune time to look back
and evaluate what we have achieved as dental professionals: What accomplishments
and changes have we been able to make thus far? How are we doing overall and what can
we improve in the coming year?

Dr So-Ran Kwon
Co-Editor-in-Chief

A survey conducted by the American Academy of Cosmetic Dentistry (AACD) revealed
that cosmetic-related income climbed to an average of US$495,000 per practice in 2007,
representing a 15 per cent increase over the previous year.
In August, the American Academy of Esthetic Dentistry hosted the International
Federation of Esthetic Dentistry Las Vegas meeting with the theme Passion, Esthetics
and New Technology: The Future of Dentistry. Leading lecturers from all over the world
con-tributed to an exchange of invaluable information. The meeting confirmed that the
future of dentistry is geared towards aesthetic dentistry with an emphasis on evidencebased dentistry. Cosmetic dentistry is a field of recognisable growth globally and this trend
is likely to continue.
I was invited to present at the annual scientific meeting of the AACD in Hawaii and received
much positive feedback on cosmetic dentistry. It is thus with great excitement and
pleasure that I introduce this year’s final edition. With the above-mentioned developments
in mind, we bring you the latest on the most significant international developments and
experiences. I am confident that this edition of cosmetic dentistry will satisfy your current
needs by providing you with guidelines, instructions and visions for your future cosmetic
dentistry procedures.
Please feel free to contact us with your valuable feedback, questions, concerns or
suggestions.
Sincerely yours,

Dr So-Ran Kwon
Co-Editor-in-Chief
President of the Korean Bleaching Society
Seoul, Korea

cosmetic
dentistry 4
I 03
_ 2009

[4] => untitled

CDE0409_04_Content

16.11.2009

12:06 Uhr

Seite 1

I content _ cosmetic dentistry

page 10

page 14

I editorial

I special

03

28

Dear Reader
| Dr So-Ran Kwon, Co-Editor-in-Chief

page 18

Minimally invasive cosmetic dentistry—
Concept and treatment protocol
| Dr Sushil Koirala

I case study
06

Cosmetic periodontal surgery:
Pre-prosthetic soft-tissue ridge augmentation (Part I)

I digital dentistry
34

| Dr David L. Hoexter

10

CAD/CAM expands the scope of restorative dentistry
| Manfred Kern

Complete maxillary implant prosthodontic
rehabilitation utilising a CAD/CAM fixed prosthesis

40

Safety and reliability with CAD/CAM technology
| Hans Geiselhöringer & Dr Stefan Holst

| Dr Neo Tee-Khin et al.

14

Aesthetic functional veneers in patients
with habitual dysfunctions?
| Prof Martin Jörgens

I industry report
44

Smile upgrade—Highly aesthetic composite
restorations in the anterior region
| Dr Ronald D. Jackson

I clinical technique
18

A new approach for patient acceptance
and appreciation
| Dr Lorin Berland & Dr Sarah Kong

22

Maintenance of periodontally compromised
teeth with direct splinting—
current materials and options
| Dr Ajay Kakar

I meetings
48

Cosmetic events

I about the publisher
49
50

| submissions
| imprint
Cover image courtesy of cardiae and Perov Stanislav.

page 28

04 I cosmetic
dentistry

4_ 2009

page 34

page 40

[5] => untitled

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[6] => untitled

CDE0409_06-09_Hoexter

13.11.2009

11:21 Uhr

Seite 1

I case study _ periodontal surgery

Cosmetic periodontal
surgery: Pre-prosthetic
soft-tissue ridge
augmentation (Part I)
Author_ Dr David L. Hoexter, USA

Fig. 1

Fig. 2

Fig. 1_Initial labial view of maxillary
#9 edentulous area with a flipper.
Fig. 2_Labial view of maxillary
#9 edentulous area.

06 I cosmetic
dentistry

4_ 2009

_Dentists understand that patients demand
outstanding aesthetic, as well as physiological, results in all phases of dentistry today. This places an
onus on dentists, who must therefore be able to apply the latest technologies and techniques to achieve
each patient’s unique aesthetic desires successfully.
A successful aesthetic outcome requires knowing
how to create the right illusion, which is subjective
for each individual. Yet, it can be measured in
objective and subjective standards. How then can
practitioners evaluate and achieve these goals?

Similarly, exposed gold crowns, gingival margins,
exposed gingival porcelain jackets or laminate margins will draw negative attention. Also, crowns
placed sub-gingivally in an inflamed area are likely
to lead to recession and an irregular gingival pattern,
resulting in dissatisfied patients.
After healthy periodontia has been achieved,
colour, hue, shape, form, symmetrical appearance
and individual choice must then be discussed. At
this point, the challenge of aesthetic dentistry is
at its zenith.

To begin, there are certain basic and objective
characteristics of a healthy periodontia that must
first be observed, respected and maintained.
A healthy periodontia is essential for achieving and
maintaining restorative aesthetics.

Part I of this series discusses the role of pre-prosthetic, cosmetic periodontal surgery to achieve and
maintain a healthy periodontia and to aesthetically
improve shape, colour, form and appearance.

A reddish, inflamed periodontia immediately
attracts negative attention to the area. In contrast,
a healthy zone of pink attached gingiva acts as a subtle background, providing dentists with significantly
more restorative options for teeth.

Clinicians should strive to achieve the appearance of a healthy symmetrical flow. For example,
patients will not be satisfied with an oversized pontic placed in a large irregular edentulous area with
a fixed bridge for long. It is unaesthetic and retains

[7] => untitled

CDE0409_06-09_Hoexter

13.11.2009

11:21 Uhr

Seite 2

case study _ periodontal surgery

food and plaque, which will lead to inflammation
and periodontal disease. Often, a phonetic problem
will also result. These patients will be thwarted in and
frustrated by their hygiene efforts, and dissatisfied
with the illusion of health and aesthetics that they
sought to achieve. Therefore, the relationship of
a pontic and the abutment teeth to the gingival
must be observed critically before the prostheses are
fabricated.

Fig. 3

Fig. 4

Fig. 5

Fig. 6

depressed edentulous ridges between abutments.
The opportunity to build out and create a symmetrically harmonious bridge that blends in with the
abutment’s periodontia is currently available.
The following illustrates an example of treatment
of one such case, resulting in a harmonious and
aesthetically pleasing appearance.

Fig. 3_Lateral view showing labial
concavity depression.
Fig. 4_Occlusal incisal edge view
showing concave labial ridge.
Fig. 5_Occlusal view of flap outline.
Fig. 6_Reflected muco-gingival flap
exposing osseous labial defect.

_Case 1
By correcting the edentulous area aesthetically
and physiologically with cosmetic periodontal surgery, a restorative dentist is able to fabricate a correctly shaped prosthesis that enhances aesthetics
and function.
It is important to make an assessment prior to
fabricating the prostheses. In the past, large pontics
were made to fill voids created by irregularly shaped,

A 25-year-old woman presented to the office
very interested in achieving ideal aesthetics with
a non-removable appliance. For years, she had been
wearing a flipper removable replacement for her
maxillary left central incisor (Fig. 1), which was traumatically lost in an accident when she was 15 years
old (Fig. 2). Following the accident, it was suggested
by her restorative dentist (because of her young age)

Fig. 7_Gingival connective tissue
graft placed in correct position.
Fig. 8_The gingival graft is sutured
to the flap, while the flap is
repositioned and sutured for stability.

Fig. 7

Fig. 8

cosmetic
dentistry 4
I 07
_ 2009

[8] => untitled

CDE0409_06-09_Hoexter

13.11.2009

11:21 Uhr

Seite 3

I case study _ periodontal surgery

Fig. 9a

Fig. 9b
Fig. 9a_Initial lateral view
of depressed area.
Fig. 9b_Healed ridge
augmentation, lateral view.

that she avoid a permanent splint and wait for the
pulps of the adjacent teeth to mature. Years later,
she was referred to me for pre-prosthetic cosmetic
surgery that would allow for a non-removable, aesthetically pleasing and physiologically maintainable
appliance.
Without the surgery, the permanent replacement
would have been a large bulky pontic or physiologically sized pontic, which would have retained food
and plaque because of a void between the gingival
space of the pontic and the crest of the edentulous
ridge. This void would then have created a dark and
unaesthetic contrast. If the pontic had been smaller,
there would have been a space between the pontic
and the edentulous ridge in which food and plaque
would also be retained.

Fig. 10_Buccal view of a posterior
maxillary area with an extreme
depression defect.
Fig. 11_Occlusal view of the same
posterior defect without
provisional prosthesis.
Fig. 12_Anterior-buccal view
of same defect.
Fig. 13_Tissue ridge augmentation
completed in posterior with new
provisional; note the physiological
and aesthetic enhancement.

08 I cosmetic
dentistry

4_ 2009

If a removable appliance had been fabricated, the
practitioner might have achieved an acrylic colour
that somewhat resembled the pinkish gingival area,
but it would have been discernible. If a clasp partial
was used for the removable prostheses, the clasp
would have been unsightly. An attachment-type
partial would require crowns to be prepared on the
remaining abutments, and the contrast of the replacement tooth would have been detected next to
the adjacent abutments. Either partial would have
been an obvious replacement that contrasted with
the adjacent teeth.
After consultation, it was determined that by
using a combination of periodontal surgery techniques, the shape, height and form of the ridge
could be corrected, enabling the restorative dentist

Fig. 10

Fig. 11

Fig. 12

Fig. 13

[9] => untitled

CDE0409_06-09_Hoexter

13.11.2009

11:21 Uhr

Seite 4

case study _ periodontal surgery

to place a physiological crown. The edentulous
ridge had a labial depression and an incisal edge
that appeared concave (Figs. 3 & 4). The tissue had
to be built up incisally and labially, and a harmonious
flow of pink attached gingivally had to be maintained.
Following a thorough evaluation, an autogenous
connective tissue graft was placed sub-epithelially
in one surgical procedure to achieve a symmetrical
look. After anesthetising the patient, the flap outline
and its reflection towards the labial were completed
(Figs. 5 & 6). The connective tissue donor site could
have been selected from various areas. In this particular case, the tuberosity area was used. The donor
tissue was de-epithelialised, and the deformed
edentulous area was sculpted to the desired shape.
The original flap outline was designed to prevent recession on the adjacent teeth and provide a covering
for the graft in order to avoid a keloid on the crest.
During healing, a keloid would have been a different
colour, which would have detracted from the goal of
harmonious colour integration. The flap outline was
then extended palatally to include more attached
gingival, which avoided a keloid and retained the
graft. Once the autogenous free connective tissue
graft was in the desired location, the flap was
repositioned and sutured for stability (Figs. 7 & 8).
In this case, the patient had worn a flipper for
years to replace a missing tooth. Following surgery,
I reduced the existing flipper to allow space for the
graft to heal.
After an uneventful post-operative period, the
patient healed and continued with good oral hygiene. The referring dentist had a choice of several
restorative techniques. In this case, a fixed splint was
fabricated with an acceptable pontic (Figs. 9a & b).

Fig. 14

that had been in the patient’s oral cavity for 20 years.
This shows the longevity, as well as the aesthetic
enhancement of the technique and its ability to
enhance the prosthesis. The finished prosthesis,
which is easily maintained by the patient, shows
that the unaesthetic, unphysiological defects were
successfully corrected (Figs. 13 & 14).

_Summary
In these presentations, depressed concave
ridges—one example in the anterior and the other
in the posterior—were corrected using soft-tissue
grafts. The results eliminated unaesthetic, dark, depressed food-gathering areas. This technique provides a pre-prosthetic treatment, thus avoiding
large pontics, which as illustrated make the area difficult to keep plaque free or cosmetically pleasing.
The restorative dentist will then have a positive
background to create the aesthetic and physiologic
prosthesis.

In a one-stage procedure, we avoided creating
a dark area of labial depression and/or an irregular,
concave gingival crestal margin. A lengthy, unsightly
pontic was replaced by a physiological, cosmetically
acceptable, natural-looking pontic, and the patient
was delighted.

There must be constant communication between
the periodontist, restorative dentist and patient.
Detailed techniques must be combined with artistic
ideas and tempered with patience._

_Case 2

_about the author

The second case demonstrates the use of the
same technique in the posterior segment of a
patient’s maxilla. An extreme buccal-incisal defect
(Figs. 10 & 11) where an extraction was done is shown
in a maxillary posterior area (Fig. 12). The soft-tissue
ridge augmentation technique was used. A temporary provisional bridge shows the restored ridge
enhancing the cleanliness and cosmetic appearance.
The final prosthesis displays a prosthetic appliance

Fig. 14_With final
prosthesis in place.

cosmetic
dentistry

Dr David L.Hoexter is director of the International Academy for
Dental Facial Esthetics,an organisation 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 drdavidlh@aol.com.

cosmetic
dentistry 4
I 09
_ 2009

[10] => untitled

CDE0409_10-12_TeeKhin

13.11.2009

10:57 Uhr

Seite 1

I case study _ prosthodontic rehabilitation

Complete maxillary
implant prosthodontic
rehabilitation utilising
a CAD/CAM fixed prosthesis
Authors_ Dr Neo Tee-Khin, Dr Ansgar C. Cheng, Dr Helena Lee & Ben Lim, Singapore
_Endosseous implant treatment has been widely
reported as a highly predictable treatment modality with a low percentage of clinical complications.
Prudent clinical judgement and careful consideration
of the risks and benefits of various treatment options
are essential for the treatment planning and longterm success of prosthodontic treatment.1

Fig. 1_Pre-treatment intra-oral
frontal view: A large space was
noted between the intaglio surface
of the prosthesis and the maxillary
tissue, and there was significant
tissue resorption on the labial surface
of the implant over the maxillary
right canine area. The patient
was asymptomatic.
Fig. 2_Full thickness flap revealed
the advanced bone loss on
the labial surface of the implant.
In spite of the tissue damage,
this implant was clinically firm.

Fig. 1

Traditional implant prostheses are commonly
fabricated using acrylic resin teeth supported by
a metal framework. Significant space is designed at
the tissue surface of the prosthesis to enhance oral
hygiene maintenance. However, application of this
prosthetic design in the maxillary arch is occasionally
aesthetically inadequate and speech may be compromised.

dentistry

4_ 2009

Porcelain-fused-to-metal restorations are commonly used in the posterior teeth because of their
well-documented long-term clinical track record.6–13
CAD/CAM ceramic-based materials are prescribed
nowadays, owing to their demonstrated promising
physical properties14,15 and clinical longevity.16
This article describes the clinical application of
high-strength zirconium oxide restorations in the
prosthodontic management of an edentulous maxilla
with a failing implant prosthesis.

_Clinical report
Conventional porcelain-fused-to-metal-restorations require the placement of labial restoration
margins below the free gingival margin in order to
mask the hue and value transition between the subgingival implant sub-structures and the supra-gingival crown restorations. From a periodontal point of
view, sub-gingival placement of restoration margins

Fig. 2

10 I cosmetic

is related to adverse periodontal tissue response.2–5
As a result, restoration margins are best placed coronally from the free gingival margin.4,5

A 62-year-old female with an implant-supported
maxillary prosthesis was evaluated at the Specialist
Dental Group in Singapore. She presented clinically
with a maxillary fixed complete denture supported
by six endosseous implants (NobelReplace, Tapered
Groovy, Nobel Biocare). The prosthesis had acrylic

[11] => untitled

CDE0409_10-12_TeeKhin

13.11.2009

10:58 Uhr

Seite 2

case study _ prosthodontic rehabilitation

Fig. 3

resin teeth supported by a gold alloy metal framework. The implant at the patient’s maxillary right canine area was exposed. No symptoms were reported
by the patient (Fig. 1).
An occlusal examination revealed a stable maximal inter-cuspation position with insignificant
centric relation to maximal inter-cuspation slide at
the teeth level. A canine-guided occlusal scheme
was noted. No para-functional habits were reported.
Sub-optimal maxillary lip support was noted.
A significant amount of dead space was identified
between the intaglio surface of the prosthesis and
the maxillary soft tissue.
Upon removal of the maxillary prosthesis, all
the maxillary implants were found to be osseointegrated. The patient desired to correct the failing
implant, restore lip support, masticatory function
and facial aesthetics.
The overall treatment plan included removal of the
implant at the maxillary right canine area, replacement of a new implant at the maxillary right canine
region and fabrication of a full-arch, zirconium oxidebased ceramic restoration in the maxilla.

Under local anaesthesia, the implant at the maxillary right canine area was removed surgically (Fig. 2)
and a new 13 mm-long regular platform implant
was placed (NobelReplace, Tapered Groovy). The new
implant was submerged and primary wound closure
achieved. Her existing prosthesis was re-inserted
during the healing period to serve as a provisional
prosthesis. Once osseo-integration was achieved
a few months later, the new implant was exposed
and the maxilla was ready for prosthodontic rehabilitation after a few weeks of soft-tissue healing.
Six implant-level impression copings (NobelReplace) were placed onto the maxillary implants.
High-viscosity, vinyl polysiloxane material (Aquasil
Ultra Heavy, DENTSPLY DeTrey) was carefully injected
around all the impression copings. A stock tray loaded
with putty material (Aquasil Putty, DENTSPLY DeTrey)
was seated over the entire maxillary arch to make
the definitive impression. A jaw-relation record at the
treatment vertical dimension was made with a vinyl
polysiloxane material (Regisil PB, DENTSPLY DeTrey).
The maxillary and mandibular definitive casts were
mounted arbitrarily in the centre of a semi-adjustable
articulator (Hanau Wide-vue, Teledyne Waterpik) using
average settings.17,18 The custom zirconium oxide

Fig. 4

Fig. 3_Maxillary prosthesis after
the application of tooth-coloured
porcelain: Excessive crown length
was noted at this stage.
Fig. 4_Completed maxillary
prosthesis with gingival-coloured
porcelain applied to provide
adequate lip support: Excessive
crown height was reduced.

Fig. 5_Anterior view showing
the CAD/CAM-fabricated
full-ceramic implant abutments
at the approximated vertical
dimension of occlusion.
Fig. 6_Occlusal view of
the maxillary arch before insertion
of the maxillary prosthesis:
Favourable anterior-posterior spread
allowed the replacement of posterior
teeth with distal cantilevering.

Fig. 5

Fig. 6

cosmetic
dentistry 4
I 11
_ 2009

[12] => untitled

CDE0409_10-12_TeeKhin

13.11.2009

10:58 Uhr

Seite 3

I case study _ prosthodontic rehabilitation
management of implant failure is also a clinical
reality. In this clinical report, the failure of one implant
at a crucial location indicated the need for re-fabrication of the whole implant prosthesis.
As the patient desired a high level of aesthetics,
full-ceramic restorations were selected. By prescribing
tooth-coloured ceramic abutments and full-ceramic
restorations, prosthesis margins were made at the
gingival level and gingival retraction procedures were
eliminated during impression and prosthesis insertion.

Fig. 7
Fig. 7_Completed maxillary
implant-supported prosthesis;
note the placement of the
supra-gingival margins.

abutments with gold-alloy fitting surface (Procera,
Nobel Biocare) were CAD/CAM fabricated according
to the prosthesis design.
The development of the planned definitive maxillary restoration was carried out using a CAD/CAM
process. The maxillary definitive cast with the custom
full-ceramic abutments (Fig. 3) were scanned (Zeno
Scan, Wieland Dental+Technik), and the prosthesis
framework was designed using a software program
(D700, 3Shape). The framework was milled in zirconium-base material (Zeno Zr Bridge, Wieland Dental+Technik) with a milling machine (Zeno 4030 M1,
Wieland Dental+Technik). The prosthesis framework
was sintered according to the manufacturer’s recommendations. Subsequently, overlaying low-fusing,
tooth-coloured porcelain material (IPS e.max, Ivoclar
Vivadent) was manually applied onto the exterior
to create proper anatomic form (Fig. 4). Low-fusing,
gingival-coloured porcelain material (IPS e.max) was
applied to create proper lip support (Fig. 5).
During the delivery clinical session, the old prosthesis was removed and the new custom abutments
were torqued to 32 Ncm (Fig. 5). The new prosthesis
was tried-in to verify colour, occlusion, lip support,
teeth form, and comfort. Upon confirmation of the
patient’s acceptance, the implant abutments were
sealed in gutta-percha (Fig. 6) and the prosthesis was
cemented in resin-modified glass-ionomer luting
agent (RelyX Unicem, ESPE).
The patient was evaluated two weeks post-operatively. Anterior guided occlusal schemes were verified
intra-orally before and after prosthesis cementation
(Fig. 7). The patient reported no discomfort and she
had been functioning well with the new restorations.
No abnormal clinical signs were noted.

_Discussion
Osseo-integration is a well-documented and predictable clinical treatment option. On the other hand,

12 I cosmetic
dentistry

4_ 2009

Full-arch prosthodontic rehabilitation using fixed
prostheses usually requires longer-term provisional
restoration in order to facilitate a predictable treatment
outcome. In this patient, the existing maxillary prosthesis served as a long-term provisional restoration for
verifying her adaptability and multiple professional
clinical adjustments of provisional restorations was
not required. This treatment sequence increased the
margin of safety in the execution of the definitive fullceramic restoration. Intra-oral verification of the new
treatment occlusal scheme and detailed in situ clinical
adjustment of the restorations on the day of prostheses insertion still formed the essential foundation for
proper treatment execution. In any major prosthodontic treatment, the patient should be informed of
the potential financial and time implications should
the need for re-fabrication of the restorations arise.

_Conclusion
The functional management of an edentulous
maxilla using a full-ceramic implant-supported maxillary prosthesis has been reported. New CAD/CAMbased restorative materials were used in treating this
case. The use of high-strength full-ceramic restorations enhances overall aesthetic predictability and
long-term functional outcome._
Editorial note: A complete list of references is available
from the publisher.

_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

[13] => untitled

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[14] => untitled

CDE0409_14-17_Joergens

23.11.2009

11:08 Uhr

Seite 1

I case study _ veneers

Aesthetic functional
veneers in patients with
habitual dysfunctions?
Author_ Prof Martin Jörgens, Germany
_Presently, numerous options for nonpreparation veneers are available on the market.
These have been proven to be effective and
serve as an excellent marketing tool in the dental practice specialising in aesthetics. However,
these types of veneers are not applicable for
patients with individual colour or shape requests
or those suffering from a habitual dysfunction.
For such patients, a standardised veneer preparation is generally excluded.
Figs. 1–3_Initial situation with
pronounced habitual dysfunction.

Fig. 1

Fig. 2

In such cases, an extensive functional analysis is indispensable for the preparation of the
veneers in order to facilitate harmonious occlusion and, most importantly, to enable smooth
articulation. The aim of each veneer case should
always be to achieve health, aesthetics and
longevity of the veneers while minimising the
risk of fractures.
Accurate clinical examination and documentation of the basic functional parameters is essential in order to identify where overloading
exists or where it can occur. State-of-the-art
diagnostic instruments, like CADIAX and Freecorder, provide comprehensive functional analysis and are extremely helpful. The articulator
is programmed according to the patient’s articulation and allows the dental technician to
reproduce functional occlusion surfaces corresponding to the natural dentition. Functional
disorders resulting from imbalanced prosthetic
treatment and dysfunction can be avoided.
Smooth articulation should also be achieved in
the molar region where old fillings, inlays/onlays
or crowns may result in malocclusion and cause
para-function. If necessary, retained wisdom teeth
should be removed and orthodontic pre-therapies
used to correct existing malfunctions. In addition,
pre-prosthetic orthodontics may result in minor
material removal in a planned preparation.

_Case study

Fig. 3

14 I cosmetic
dentistry

4_ 2009

The following case study demonstrates the
interaction between aesthetics and function in
the preparation of veneers in a patient with
severely advanced habitual dysfunction. The patient also had severely damaged upper anterior
teeth due to extreme latero-trusion habits.

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Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

The case was documented according to the
European Society for Cosmetic Dentistry (ESCD)
guidelines as a requirement for obtaining certification as a specialist in Cosmetic Dentistry
ESCD (these guidelines are available from the
author upon request). An integral part of documentation is the use of identical camera settings
for all photographs that have to be taken before
and after any reconstruction.
In addition to the correction of the damage,
the following were especially important to the
patient: longevity of the reconstruction, ability
to select shape and colour of the veneers, use
of all-ceramics, minimally invasive preparation,
and harmonious aesthetics. Furthermore, the
patient desired a purely cosmetic optimisation
of the lower central incisors with slight contouring and, if needed, BRITESMILE bleaching after
the application of the upper veneers.
First, an aesthetic functional wax-up of the
six upper teeth was created in order to facilitate
optimal communication between patient, dentist and dental technician throughout each
stage of the veneer preparation. The patient’s
history revealed that four premolars had been
extracted in his youth, followed by orthodontic
therapy. Over the years, all teeth had been
treated conservatively and the wisdom teeth
were well adjusted. All upper and lower premolars and molars had been treated with allceramic zirconia crowns. The patient did not
desire a complete makeover with overbite reduction. Therefore, we focused on the design
of perfect and fracture-free veneers for the
mandibular central incisors. Thus, all interfering
factors had to be minimised.

The aesthetic contouring of the lower central
incisors naturally leads to a harmonious overall
appearance. In addition, one of the main causes
of veneer fracturing can be eliminated: patients
with extreme mandibular mobility are able to
shift into extreme areas of protrusion and latero-trusion, often going much beyond the cutting edge of the maxilla. However, fracturing and
failure of a veneer are not merely caused by forward movement. Problems often occur during
the backwards movement of the mandible when
the teeth slide back into retrusion and become
stuck and, owing to the extreme forces, a veneer
fracture can result. These extreme retrusions
can be imitated in the articulator only if the
technician registers a bite situation of this position. If the technician only considers standard
mandible movements, he will not be able to
reach the extreme areas of the existing habitual
dysfunction.

Fig. 4_Preparation without
gingival correction.
Fig. 5_Crown elongation.
Fig. 6_Preparation.
Fig. 7_Final preparation.
Fig. 8_Sulcus demonstration
with diode laser.
Fig. 9_Functional temporaries
according to wax-up.

Patient-oriented articulation adjustments
Reference® SL
SKN

3 MM

5 MM

10 MM

TKN

3 MM

5 MM

10 MM

R INSERT

BLUE

R INSERT

WHITE

R ANGLE

L INSERT

BLACK

BLUE

L INSERT

WHITE

L ANGLE

SEQUENTIAL

PROTRUSIVE

LATERAL RIGHT

LATERAL LEFT

INSERT

ORANGE

STANDARD DISTANCE 200 MM, CALCULATED AT 110 MM
CADIAX® COMPACT 2.46 COPYRIGHT© 1999–2005 GAMMA GMBH. KLOSTERNEUBURG, AUSTRIA, HTTP://WWW.GAMMADENTAL.COM
LICENCE: 1736DCCPS

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Fig. 10

Fig. 11

Fig. 12

Fig. 10_Veneers on the model.
Fig. 11_Bleaching.
Figs. 12 & 13a–d_New harmonised
incisal guidance.

In such patients, the aim of the contouring
should be the removal of all uneven surfaces that
could cause dysfunction of mandible protrusions and retrusions. This must be done prior to
the initial veneer preparation. All possible movements of the mandible in the palatal surfaces
of the maxilla and beyond the incisal edge have
to be marked accurately.

Owing to the clear overbite of 3 mm, the
first step was to shorten the maxillary teeth sufficiently. This creates significantly less static
leverage forces in the veneer, which is thus subsequently shorter, than in veneers with normal
or greater length. Thus, even in habitual dysfunctions, a better force distribution can result
within the veneer.

Figs. 14_Post-op situation
from multiple angles.

Patients with extreme overbite and crowded
anterior teeth are especially exposed to veneer

In order to achieve an optimal aesthetic result, crown elongation was performed during

fractures. In such cases, orthodontic pre-treatment is often essential but refused by many
patients. Should this be the case, all edges must
be smoothened and rounded so that the veneers created subsequently have a chance of
survival.

preparation using ELEXXION’s diode laser system. On the one hand, length disparities between
the individual teeth can be balanced and on the
other hand, a general lengthening of the clinical
crowns of all the anterior teeth can be achieved
to create a harmonious smile. These measures
can always be carried out safely when a sufficient amount of attached gingival exists and
an excision with subsequent relocation of the
preparation edge does not lead to insufficient
biological width.

Fig. 14

Thorough functional analysis and subsequent documentation were performed. The waxup demonstrated that for the removal of the old
vestibular composite reconstructions and for
optimal veneer construction, this case required
preparation in order to achieve an aesthetic
result. The main concern in this case was to
identify which basic static design possibilities
were achievable.

16 I cosmetic
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4_ 2009

In this case, a prominent mesio-proximal defect of the cervical aspect of tooth 11 led to a significant length disharmony of tooth 21. The teeth
appeared to be of the same length after laser cor-

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case study _ veneers

rection and were prepared accurately. For indexing, the preparation margin was exposed through
minimal invasion using with the diode laser.
While preparing the temporaries, it has to
be ensured that they support the healing of the
gingiva after the excisions through optimal,
anatomic convexity. The new outer contours created in the wax-up need to be considered and
with the silicon key they may serve as model of
the new contour and thickness of the temporaries. With this procedure, excellent healing
results can be achieved that create optimal conditions for cementing. Photographs taken from
all angles facilitate comparison with the initial
situation and significantly aid the technician in
creating the veneers. The more extensive and
precise the photographs, the more accurately
and beautifully the veneers can be prepared.
At this point, which technical parameters can
be of use in patients with habitual dysfunctions?

Fig. 13a

Fig. 13b

Fig. 13c

Fig. 13d

Ao+Pressbody was applied followed by multiple
layers of Authentic. After the form of the veneers
had been modelled, they were pressed and coated.
The perfect result was achieved after four firings.
The durability of the veneers is a significant
advantage of this multiple-layering technique.
We were able to fulfil our patient’s aesthetic
and functional desires from try-in. The patient
was highly enthusiastic and immediately approved of his improved smile. He was given
a night guard to prevent possible problems due
to bruxism. In our opinion, a night guard should
always be used after the completion of reconstructions in habitual dysfunction cases, in order
to protect the veneers.

_Conclusion

For one, the above-mentioned static design
data of the veneer length play a significant role.
Protrusion and latero-trusion forces can easily
be compensated when the sagittal incisor guiding angle is levelled. Optimal function surfaces
can be created through fine adjustments. Thus,
the result of the treatment is not only a careful
alteration of the overbite–overjet relation, but
also a fine adjustment of the pathological anterior and lateral guidance.
Furthermore, the selection and quality of the
veneer ceramic plays a significant role. Ceramics
that are more elastic and abrasion resistant
should be preferred. In the present case, our team
decided to use the following combination: initially

Direct comparison of the preoperative and
post-operative situations demonstrates the
new, stress-free situation in the upper anterior
teeth, which is the aim in patients with habitual dysfunction. Accurate planning and careful
consideration of the veneer type—prepared or
non-prepared—is highly recommended._

_contact

cosmetic
dentistry

Prof Martin Jörgens
DentalSpecialists
Kaiserswerther Markt 25
40489 Düsseldorf-Kaiserswerth, Germany
www.dentalspecialists.de
ZTM Olaf van Iperen
Siebengebirgsblick 12
53343 Bonn-Wachtberg, Germany
www.vaniperen.de

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I clinical technique _ smile design

A new approach
for patient acceptance
and appreciation
Authors_ Dr Lorin Berland & Dr Sarah Kong, USA
the severe tetracycline staining, she felt her teeth were
worn from years of grinding. Moreover, she had old
resin bonding on her lower front teeth that was not only
discoloured, but also mismatched from years of patching and re-patching each time something broke off.
After performing a thorough examination (paying
particular attention to the areas noted above) and
cleaning, we recommended she try deep bleaching.
After evaluating the results of the whitening, we recommended a minimum of four minimal preparation
Microveneers for her lower front teeth and her upper
seven teeth, and a zirconium porcelain crown for tooth
#5, in order to achieve the smile she desired.

Fig. 1_Pre-op full face.

Fig. 2_Smile Style Guide.
Fig. 3_P-3, pointed canines with
square centrals and round laterals.
Fig. 4_Length code L-2, laterals
slightly shorter than centrals
and cuspids.

Fig. 2

Fig. 1

_This 61-year-old executive has lived with the
effects of tetracycline-stained teeth since she was
a little girl (Fig. 1). All her life she wanted to have a great
smile, but she never knew what her dental options
were. The general dentist she had seen for many years
told her there was nothing he could do to help her,
so he referred her to our office.
When the patient came for her first visit, she wished
to address a number of dental concerns. In addition to

Fig. 3

18 I cosmetic
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4_ 2009

Because her maxillary six anteriors had worn, flat
incisal edges, it was essential that we understood what
the patient desired in terms of shape and length. We
examined the Smile Style Guide (www.digident.com)
to select a smile design (Fig. 2). With the patient’s input, we determined that P3—pointed canines with
square centrals and round laterals—would be the best
for her (Fig. 3). The length combination she liked the
most was L-2—laterals slightly shorter than the centrals and canines (Fig. 4). We submitted her preoperative photo to SmilePix for a cosmetic image (Fig. 5) and
concluded with PVS impressions (Splash, Discus Dental) and a bite registration (Vanilla Bite, Discus Dental).

Fig. 4

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clinical technique _ smile design

Fig. 5_Cosmetic image.
Fig. 6_Diagnostic wax-up
and putty matrices.

Fig. 5

Fig. 6

At her second consultation appointment, we confirmed the smile design and length combination she
had previously selected by showing her a diagnostic
wax-up of her upper and lower teeth (Fig. 6). Matrices were fabricated from the wax-ups before this
appointment and used to make an upper and lower
Slip-On Smile right on the patient’s teeth. We
loaded the matrices with an A-1 bis-acryl temporary
material (examples are Temphase, Kerr; Integrity,
DENTSPLY Caulk; and PERFECtemp II, Discus Dental)—
and seated them in the mouth. After the material was
set, the matrix was removed; remaining on her teeth
was a new smile.

Once the preparations were finished and refined,
it was time to provisionalise the teeth. While an
assistant loaded a tray with alginate, hydrocolloid
(Dux Dental) was expressed over the prepared teeth
for an impression. Then the alginate-filled tray was
seated in the mouth, directly onto the hydrocolloid.
After a minute and a half, the impression was removed
with a snap and handed off to an assistant to pour.
In the laboratory, the impression was disinfected and
dried. Next, Mach-2 PVS (Parkell) was dispensed into
the impression to pour up the model on a vibrator.
A fast-setting bite registration material (SuperDent,
Darby Dental) was then placed directly onto the
Mach-2 for a model base.

We took a series of photographs with the Slip-On
Smile in place and the patient was ecstatic. She was
able to see and feel what her teeth would look like before committing to any dental work (Fig. 7). The patient
was truly amazed by this and wanted to wear the smile
home to show her husband.
Though the patient had loved the selected smile
design and cosmetic image, she was not convinced
about pursuing this treatment. This demonstrates that
the Slip-On Smile is an important part of treatment
presentation. She accepted the treatment as soon as
she could experience her new smile first hand. We began her treatment with a combination of in-office and
at-home whitening. The incisals of the canines and
bicuspids showed acceptable results. We used this as
a base shade, planning to make the lower veneers
even lighter towards the front and the upper veneers
slightly lighter than the lowers. As planned, teeth #6 to
12 were prepared for Microveneers in order to preserve
as much natural, healthy tooth structure as possible.
Tooth #5 had an existing crown that the patient
wished to replace to match tooth #12; thus, the tooth
was prepared for a zirconium crown at the same time.
Digital photographs of the preparation shades were
taken for our ceramic artist (Fig. 8).

In less than two minutes, an accurate, instant
silicone model was ready on which to fabricate
a provisional—all of which was completed outside
the patient’s mouth by an assistant. Using the matrices made from the diagnostic wax-up and approved
by the patient in her Slip-On Smile, the provisionals
were fabricated.
Fig. 7_Slip-On Smile full face.

Fig. 7

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I clinical technique _ smile design
Fig. 8_Upper preparations
and preparation shade.
Figs. 9a–10c_Upper and lower
indirect provisionals on instant
silicone models.

Fig. 8

Fig. 9a

Fig. 9b

Fig. 10a

Fig. 10b

Fig. 10c

First, the instant silicone model was lubricated
with a water-based lubricant (such as KY Jelly). Next,
the putty matrix was filled with bis-acryl and then
placed onto the silicone model. After a minute and
a half, the provisional was set up and ready to be
trimmed. Because this method of temporisation involves a quick way to make a model of the prepared
teeth, the provisional can be trimmed and polished
in the laboratory. Finishing provisionals in this manner
is much more accurate, as well as kinder to and easier
for the patient, and particularly the gingival and the
prepared and impressed teeth (Figs. 9a–10c).

There were no surprises, as she had chosen the smile
design she liked best before any work had even begun.

In order to prepare the gingiva for the final impressions, Expasyl (Kerr) was placed around the gum line.
Final impressions with a PVS material (examples are
Take 1 Advanced, Kerr; and Virtual, Ivoclar Vivadent)
were then taken in custom trays. A slow-setting
material was used to record her bite registration
(SuperDent). In order to cement the provisionals, the
same bis-acryl was placed in the temporaries and
seated in the mouth. The excess was removed with
a microbrush before the material set. The patient loved
the way her provisionals looked and fitted (Fig. 11).

20 I cosmetic
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4_ 2009

When she returned for the final porcelain restorations, the patient was concerned that they might not
look as good as her provisionals. Because the minimal
preparation was all in enamel, we could try the restorations with no anaesthetic and no discomfort. This
is important to allow the patient to gain a true feel of
the teeth, especially when length is being increased.
We assured her that we would try-in the restorations
and gain her approval before seating them permanently. Thus, we invited her entire family to the seating
appointment in order to offer their opinions. As is
often the case, it was especially important to please
one family member in particular, and for this case it
was her daughter.
For the try-in, we used different shade combinations of try-in pastes in order to determine what
looked the most natural. I call this the mix-to-match
method. This method is especially important for extensive cases with multiple types of restorations and
porcelains. In this case, feldspathic porcelain was

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clinical technique _ smile design

Fig. 11_Provisionals full face.
Fig. 12_Post-op full face.

Fig. 11

Fig. 12

used to fabricate the veneers, while the crown was
made with a zirconium core.

means. And for this patient, this meant a beautiful new
smile with minimal tooth reduction to achieve the most
natural aesthetics. Each step of this process gained more
of the patient’s acceptance of the proposed treatment,
which determined her appreciation of the results._

When it comes to mixing cements, we generally
like to use the lightest shade for centrals and warmer
shades as we go distally. This mix-to-match method
helps to achieve a natural-looking smile. We ultimately
decided, with the patient’s input, to use a dual-cure
resin cement (examples are Maxcem, Kerr; Multilink,
Ivoclar Vivadent; and PermaCem Automix Dual,
Foremost) for the zirconium crown on tooth #5;
Cosmedent Ludicrous for #8, 9, 24 and 25; Bright for
#6, 7, 10, 11 and 12; and Yellow-Red Universal for #23
and 26. A fresh bottle of bonding agent (examples are
Optibond Solo Plus, Kerr; Excite, Ivoclar Vivadent; and
Adper Single Bond Plus, 3M ESPE) was selected. Using
a fresh bottle ensured that the bond would be at its
strongest. The teeth were cured from all angles with
the FLASHlite Magna (Discus Dental). Because it is
a LED, there is little danger of overheating the teeth.
Once the restorations were seated, the patient was
ecstatic with the results. She simply could not believe
how natural her teeth looked. They were even better
in shape and shade than she had anticipated (Fig. 12).
The once tetracycline-stained smile was the only smile
she had ever known. Now, for the first time in her life,
she could look in the mirror and smile with confidence
knowing she has a beautiful, natural smile.
In this case, a cosmetic image was helpful in showing the patient a 2-D photo of how her smile would look.
Yet, it was not until she saw her personalised smile design in real life with the Slip-On Smile that she could really feel what her new smile would truly be like. She was
pleased with every step of her smile transformation,
with her provisionals and ultimately with the results.
Although the mix-to-match method is an extra step
that requires more chair time, the results justify the

_about the authors

cosmetic
dentistry

Dr Lorin Berland,an
accredited Fellow of the AACD,
is one of the most sought-after
speakers and published
authors on cosmetic dentistry
in America.He has featured in
national and regional magazines and major dental journals,
and recently on NBC News,
Fox News,and ABC’s 20/20.For more information on
The Lorin Library Smile Style Guide,the 8-AGD credit DVD,
www.denturewearers.com,and The One Appointment
Inlay/Onlay Kit and complimentary 8-AGD credit CD/ROM,
call +1 214 999 0110 or visit www.dallasdentalspa.com.
Dr Sarah Kong graduated
from Baylor College of
Dentistry where she served
as a professor in restorative
dentistry.She focuses on
preventive and restorative
dentistry,transitionals,
anaesthesia,and periodontal
care.Dr Kong has worked with
a master ceramist in one of the world’s finest dental
laboratories.She is an active member of numerous
professional organisations,which include The American
Dental Association,The Academy of General Dentistry,
The American Academy of Cosmetic Dentistry,The Texas
Dental Association,and The Dallas County Dental Society.

cosmetic
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Seite 1

I clinical technique _ direct splinting

Maintenance of periodontally
compromised teeth
with direct splinting—
current materials and options
Author_ Dr Ajay Kakar, India
Fig. 1_A common periodontal
situation with mobile anterior
maxillary teeth causing discomfort.
Fig. 2_Grooves prepared on the buccal
surface of the incisors at the incisal
third to enable placement of the fibre.
Fig. 3_The fibre in place and
polymerised after being coated
with flowable composite.
Fig. 4_The completed splint with
direct bonding composite build-up to
achieve a pleasing aesthetic result.
Fig. 5_A case of migration
of the central incisors.
Fig. 6_A splint done followed by
recontouring of the tooth and direct
bonding composite build-ups.

_Periodontal disease is initiated in the main
as gingivitis, which in a smaller subset of individuals progresses to the more advanced form
referred to as periodontitis. Gingivitis is restricted to the marginal gingival area and does
not lead to destruction of osseous tissue. Gingivitis is the progression to periodontitis, which
encompasses extensive loss of bone surrounding
the tooth. Modern-day therapy can generally
ensure the arrest of the progression of periodontal destruction and, in favourable situations,
even the regeneration of all the components
of the periodontal apparatus, albeit to a much
lesser extent than the original. Of the periodontal structures, the loss of soft tissue makes the
process of complete regeneration much more
difficult.

In such circumstances, wherein the inflammation and infection has been controlled and the
disease activity has been curbed, it becomes imperative that the dentition, which is definitely
compromised owing to the pre-existing damage,
be supported and additional aids provided to create the optimum function, coupled with aesthetics. One of the key issues in such dentitions is
the mobility of the teeth. Such mobility may be
localised to certain teeth and in a specific path of
motion or may be much more generalised and
afflict many teeth. In either case, the benefits of
immobilisation are multiple. The comfort level of
the patient is sufficient reason to use this treatment option for mobile teeth. Additionally, this
also leads to tremendous patient motivation and
compliance in maintaining oral hygiene, which

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

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clinical technique _ direct splinting

directly translates into better periodontal health.
Furthermore, an immobile tooth will heal much
faster and better than a mobile one. Any regenerative therapy carried out around afflicted mobile
teeth will have better results than would have been
the case had the teeth been immobilised (Figs. 1–4).
Another critical manifestation of periodontal
disease, when coupled with imbalanced occlusal
loads, is the sequel of migration that results from
such a clinical situation. Migration, an extremely
slowly developing phenomenon, leads to drastic
consequences that can usually be optimally corrected only by using orthodontic appliances. But
even this correction requires a permanent splinting procedure to ensure that the concerned teeth
remain in place and do not migrate away once
again. This same technique can be used routinely
by orthodontists to place permanent non-invasive quartz splints. Another possible use of quartz
glass fibre splints is in cases of alveolar fractures.
The advent of bonding dentistry and the easyto-use quartz splint fibre make it a very strong
contender for the stabilisation and immobilisation of anterior alveolar fractures.
A key factor towards achieving the end point of
a good and long-lasting splint is the base material
used in conjunction with the composite restorative material for building and applying the splint.
It is very important that the splint functions like a
monobloc and bonds optimally to the enamel and
dentine. In order to provide this monobloc effect,
the substructure has to chemically bond and be in
unison with composite restorative material. In order to provide near-optimum bonding, the substructure and the entire monobloc, which has to
be built-up, have to be very closely adapted to the
teeth around all the curves, right into the interproximal spaces. This means that the fibre material should have physical properties that allow
curving and very easy manipulation into any
shape (Figs. 5 & 6).
The required materials for achieving a high
quality functional and aesthetic splint are:
_a pre-impregnated glass fibre-based splinting
material;
_a restorative micro/nano-filled composite material;
_a flowable composite material; and
_a bonding agent.
The above only highlights the materials required and does not list the armamentarium,
which would consist of a number of special hand
instruments to achieve a high quality result and

Fig. 7

Fig. 8

Fig. 9

Fig. 10

finish. Amongst the materials, the bonding agent
and the composite restorative material are dependent on the clinician’s preference. The microor nano-filled range of products from any of the
industry leaders in restorative materials are most
appropriate. A good flowable material is also
required to create a close fit of the splint material
to the tooth surface, while a sixth or seventh
generation bonding agent would be able to
achieve the desired bond strength.

Figs. 7–10_The clinical zero memory
effect of the woven quartz splint
demonstrated by adaptation around
the entire curvature of the crown
of an extracted molar. The material
is not polymerised but stays
in the newly adapted position.

The most critical aspect in achieving the ideal
splint outcome is the selection of the fibre used as
the substructure. There are a number of options
available on the market. I have tested different
splinting fibres throughout my career and quite
a number of them has given very good results and
lasted for years. Available materials have some
favourable properties at the cost of some other
undesirable elements and at times the clinician
has to choose between sacrificing several of
the desired elements in order to gain the others.
The ideal substructure fibre material has the
following properties:
_high strength subsequent to polymerisation;
_chemically bondable with composite resin material;
_available in a pre-impregnated state;
_no thicker than 0.2 mm;
_available in varying widths;
_easy to trim and cut; and
_no memory as regards its form.

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I clinical technique _ direct splinting
Figs. 11–14_The near zero memory
property of the rope quartz splint
demonstrated by distortion into
various shapes; the material
maintains its distorted position
without any polymerisation.

Fig. 11

Fig. 12

Fig. 13

Fig. 14

Of the above, the last property is a critical one.
Because of the difficult handling properties of
the fibre splint, splinting has been a very technique-sensitive procedure thus far. Unless the
clinician was extremely conversant with all the
requisite steps and also extremely skilful and
dexterous in the handling of the fibre and composite, the likelihood of a long-term success
would be reduced.

makes adapting and placing the splint in the oral
cavity a far simpler and more accurate task.

Many splint materials have a tendency to a
memory, that is the property of returning to original shape if deformed under load. This memory of
a material makes it resistant to being shaped
around curves, especially curves that doubleback, for example the interproximal areas around
the linguals of lower anterior teeth or around the
curvature of a maxillary premolar. If the material
can be fabricated in such a way that it bends and
adapts around curves without bouncing back, it

Glass-based fibres have an inherent tendency
to maintain their longitudinal direction. This can
easily be observed in any unidirectional fibre splint
material. The only way to negate this property of
the fibre is to interweave the fibres in a cross-stitch
pattern. This creates a kind of mesh framework,
thereby making the material almost free of memory.
The term zero memory can then be applied to such
a material, which will only minimally maintain any
form to which it is subjected (Figs. 7–10). Although
the material does possess a certain amount of memory, it becomes practically insignificant as regards
clinical application. For all practical purposes, the
material would then have zero memory.
My best experience thus far has been with a very
new entry in the splinting fibre market: Quartz

Fig. 15_Buccal view of a patient with
mobile lower central incisors.
Fig. 16_Lingual view of the same
patient with mobile lower
central incisors.

Fig. 15

24 I cosmetic
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Fig. 16

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clinical technique _ direct splinting

Fig. 17_A tin foil template
used to measure the size
of the required splint.
Fig. 18_Buccal view of the splint
done with the woven quartz splint.

Fig. 17

Fig. 18

Splint (Recherches Techniques Dentaires). The basic raw material used in this product is quartz glass,
unlike regular glass fibre. This is the same quartz
used to develop endodontic posts, which demonstrate cyclic fatigue resistance values that are
much higher than desired in the oral cavity. Quartz
glass is also homogenous with the Bis-GMA range
of unfilled resin, which makes it ideal for use with
restorative composite material, allowing it to become a monobloc with the composite. The quartz
splint is developed as a woven fibre using extremely thin strands of glass fibres.

has been achieved, it can be polymerised in that
position and then layered with micro/nano composite to complete the splint (Figs. 11–14).

The weave pattern imbibes certain physical attributes to the material. It allows force distribution in such a manner that it create the previously
mentioned clinical zero memory effect and not
resist and inhibit crack propagation. All of the
above-mentioned effects are achieved without
any compromise to the strength of the material. In fact, the quartz fibre will enhance and
strengthen the monobloc that is created with the
amalgamation of the unfilled resin, quartz fibre,
flowable composite, and micro-/nano-filled
composite material. Since the material is available
pre-impregnated and is soaked in unfilled resin, it
becomes all the more easier to use the splint right
out of the box. The zero memory allows it to be
adapted extremely easily around a curved arch
without polymerisation. Once ideal adaptation

Another critical factor in the variety of situations for which a splint is indicated is the width and
thickness of the material. Too thick a material can
be an encumbrance for placement and final positioning. An ideal thickness is between 0.1 and
0.25 mm. The thinner the material becomes, the
lower its ability to reinforce and strengthen will be.
The quartz splint is in the 0.2 mm thickness range,
making it useful in almost all clinical situations.
The quartz splint is available in a variety of
patterns and widths. The recommended pattern for
intra-oral splinting is the woven pattern. This is
available in widths of 1.5 mm, 2.5 mm and 4 mm. Of
these three, the 1 mm design is most suited for use
as a retention splint in post-orthodontic cases in
which the teeth are neither extremely mobile nor do
they exhibit gingival recession and loss of the supporting structures. The 2 mm fibres are most ideally
suited for teeth afflicted with previous periodontal
disease. When the teeth are large in size and exhibit
clinical crowns larger than the anatomical crowns,
the 3 mm fibre may be used in lieu of the 2 mm fibre.
The quartz splint has a unique design—much
like a braided rope—giving it extremely high flexFig. 19_Lingual view of the splint
done with the woven quartz splint.
Fig. 20_A case requiring
post-orthodontic retention
of the upper incisors; the splint is
to be placed on the palatal surface
of the maxillary anteriors.

Fig. 19

Fig. 20

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I clinical technique _ direct splinting
Fig. 21_Preparations done
on the palatal surface;
the area where the splint is to
be placed has been grooved.
Fig. 22_A tin foil template placed
on the grooved area to measure
the size of the required splint.
Fig. 23_The woven quartz splint
placed in the prepared area
on the palatal surface
of the maxillary anteriors.
Fig. 24_The completed splint.

Fig. 21

Fig. 22

Fig. 23

Fig. 24

ural strength values after complete polymerisation. The design of the material requires it to be
between 1 and 2 mm in diameter. A deep groove
has to be cut into the teeth where the splint is being placed to enable it to be adapted optimally.
This design can be utilised when in cases in which
an occlusal splint design is used to stabilise maxillary or mandibular premolars. Other than the
woven and rope patterns, the quartz splint is
available as a unidirectional fibre. This is not to be
applied in clinical situations, but rather as a laboratory reinforcement material used to develop
poly-ceramic prostheses. The quartz splint also
has a 4 cm x 4 cm mesh that can be applied in
denture repairs, for example.

ment of bonding dentistry technology. Shade
matching, polishability, enhanced bond strength
and much longer-lasting composites have all
contributed to a much greater usage of direct
bonding procedures in everyday dentistry. The
emphasis this has given to aesthetic procedures has been tremendous. Similarly, the quartz
fibre-based composite splint in a dentition with
pre-existing periodontal damage can be enhanced to achieve a much better aesthetic result
(Figs. 15–19).

With material benefits aiding and improving
the functional aspect of splints, there has been
a newer approach possible owing to the enhance-

_about the author

cosmetic
dentistry

Dr Ajay Kakar is in private practice specialising in
periodontics and implantology in Mumbai in India.
He is the secretary of both the International Academy
of Periodontology and the Indian Academy of Aesthetic
& Cosmetic Dentistry. He lectures extensively in India
and abroad and runs a web portal for Indian dentistry
at www.bitein.com. Dr Kakar can be contacted at
ajay@bitein.com or at +91 98210 15579.

26 I cosmetic
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Although function has been the paramount and
most critical issue when placing a periodontal
splint, aesthetics now also play an important role.
The patient and the clinician may not be completely
satisfied with function. It is quite easy to apply
standard bonding principles of a diastema closure
to ensure that the basic substructure is appropriately located and thereby enable an excellent
aesthetic outcome with longevity. This modification of a functional splint to an aesthetic splint
can be easily applied for anterior teeth exhibiting
extensive mobility or migration. Several of these
cases can be seen in the following figures, in which
the maxillary anterior teeth presented with diastemas and proclinations coupled with mobility.
The results have been very satisfactory.
This article has only touched on the fundamental concepts of splints and the new improvisations
available in terms of material technology._

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I special _ smile design

Minimally invasive cosmetic
dentistry—Concept and
treatment protocol
Author_ Dr Sushil Koirala, Nepal

_Introduction

Fig. 1

_Increased media coverage and the availability of free web-based
information has lead
to heightened public awareness and
thus to a dramatic
increase in patients’ aesthetic
expectations, desires and demands.
Today, a glowing,
healthy and vibrant
smile is no longer the
exclusive domain of the
rich and famous and most
general practitioners are
forced to incorporate various aesthetic treatment modalities in their daily
practices to meet this growing demand.
The treatment modalities of any health-care
service are aimed at the establishment of health
and the conservation of the human body with its
natural function and aesthetics. The concept of
minimally invasive (MI) treatment was initially
introduced in the medical field and was adapted
in dentistry in the early 1970s with the application of diamine silver fluoride.1 This was followed by the development of preventive resin
restorations (PRR)2 in the 1980s and the atraumatic restorative treatment (ART) approach3
and Carisolv4 in the 1990s. The major components of MI dentistry are the risk assessment
of the disease with a focus on early detection
and prevention; external and internal re-mineralisation; use of a range of restorations, biocompatible dental materials and equipment;
and surgical intervention only when required
and only after any existing disease has been
controlled.5–11

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Current basic treatment protocols (TPs) and
approaches in MI dentistry are the use of air
abrasion, laser treatment or sono abrasion to
gain cavity access and excavate infected carious
tooth tissue through selective caries removal or
laser treatment;12,13 cavity restoration by applying ART, PRR, or sandwich restoration; and the
use of computer controlled local anaesthesia
delivery systems14 with emphasis on the repair of
a failed restoration rather than its replacement.15 Thus far, the focus of MI dentistry has
been on caries-related topics16 and has not been
comprehensively adopted in other fields of dentistry. Dr Miles Markley, one of the great leaders
of preventive dentistry, advocated that the loss
of even a part of a human tooth should be considered a serious injury and that dentistry’s goal
should be to preserve healthy and natural tooth
structure. His words are much more relevant in
today’s cosmetic dental practice, in which the
demand for cosmetic procedures is rapidly increasing. With the treatment approach trend towards the more invasive protocols, millions of
healthy teeth are aggressively prepared each
year in the name of smile makeovers and instant
orthodontics, neglecting the long-term health,
function and aesthetics of the oral tissues.

_The need for a new concept
Contemporary aesthetic dentistry demands
well-considered concepts and TPs that provide a
simple, comprehensive, patient-friendly and
MI approach with an emphasis on psychology,
health, function and aesthetics (PHFA; Fig. 1).
The need for a holistic concept and basic treatment guidelines was expressed by concerned
practitioners, aesthetic dentistry associations
and academics around the world for the following basic reasons:
_Owing to an increased aesthetic demand,
aesthetic dentistry is becoming an integral part

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of general dentistry. The aesthetic outcome of
any dental treatment plays a vital role in the
patient’s treatment satisfaction criteria.
_MI dentistry currently focuses on prevention, remineralisation and minimal dental intervention
in the management of dental carious lesions.
It has failed to give the necessary attention to the
problems that negatively affect smile aesthetics,
for example non-carious dental lesions, or developmental defects and malocclusion.
_The treatment modalities of contemporary
cosmetic dentistry are trending towards more
invasive procedures with an over-utilisation of
crowns, bridges, thick full veneers, and invasive
periodontal aesthetic surgeries, while neglecting long-term oral health, actual aesthetic
needs and the characteristics of the patient.
_Social trust in dentistry is degrading, owing to
the trend of fulfilling the cosmetic demands
of patients without ethical consideration and
sufficient scientific background (the more you
replace, the more you earn; more is more
mentality).
In this article, I introduce a concept and TP for
minimally invasive cosmetic dentistry (MICD),
in order to address these facts properly and integrate the evidence-based MI philosophy and
its application into aesthetic dentistry.

3. adoption of the do-no-harm strategy in the
selection of treatment procedures and the
maximum possible preservation of healthy
oral tissues;
4. selection of dental materials and equipment
that support MI treatment options in an evidence-based approach;
5. encouragement of the keep-in-touch relationship with the patient to facilitate regular
maintenance, timely repair and strict evaluation of the aesthetic work performed.
The main MICD benefits include:
1. promotion of health, function and aesthetics
of the oral tissues and positive impact on the
quality of life of the patient;
2. preservation of sound tooth structures (banking the tooth structure), while achieving the
desired aesthetic result;
3. reduction of treatment fear and increased
patient confidence;
4. promotion of trust and enhancement of professional image.

_The MICD treatment protocol
In my experience, the TPs that are currently
in use in aesthetic dentistry are mostly based
on more invasive techniques and procedures.

_Defining MICD
As the perception of aesthetics and beauty is
extremely subjective and largely influenced by
personal beliefs, trends, fashion, and input from
the media, a universally applicable definition is
not available. Hence, smile aesthetics is a multifactorial issue that needs to be adequately
addressed during aesthetic treatment.17 MICD
deals both with subjective and objective issues.
Therefore, in this article I define MICD as “a holistic approach that explores the smile defects
and aesthetic desires of a patient at an early
stage and treats them using the least intervention options in diagnosis and treatment
technology by considering the psychology, health,
function and aesthetics of the patient.”18
The core MICD principles are:
1. application of the-sooner-the-better approach
and exploration of the patient’s smile defects
and aesthetics desires at an early stage in
order to minimise invasive treatments in the
future;
2. smile design in consideration of the psychology, health, function and aesthetics (Smile
Design Wheel18) of the patient;

MICD treatment options
NI TREATMENT OPTIONS

MI TREATMENT OPTIONS

SMILE TRAINING

MICRO- AND MACRO-ABRASION

TOOTH WHITENING

SELECTIVE CONTOURING (GUMS/TEETH)

RE-MINERALISATION OF WHITE SPOTS

DIRECT RESTORATIONS
WITH MINIMAL TOOTH PREPARATION

SHORT ORTHODONTICS (SECTIONAL)

MINIMAL PREPARATION
ADHESIVE BRIGDES

NON-PREPARATION VENEERS

VENEERS, INLAYS AND ONLAYS

ENAMEL AUGMENTATION

MI IMPLANTS

ADHESIVE PONTIC (LONG-TERM TEMPORARY RESTORATION)
ORAL APPLIANCE

With the use of such protocols, cosmetic dentists
are knowingly, or unknowingly, heading towards
the over-utilisation of invasive technologies in
their practices, which is becoming a professional
and ethical concern. The basic aim of the MICD
TP is to guide practitioners in achieving optimum
results with as little intervention as possible.
The intervention level of the treatment in MICD
depends on the type of smile defects and the
aesthetic needs (objective measurement and
subjective perception) of the patient.

Table 1

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Fig. 2

The basic framework and pathway of the
MICD TP are illustrated in Figures 2 and 3. It is
to be noted that the TP in medical and dental
sciences must be dynamic in nature and should
be flexible to incorporate evidence-based facts.
I have therefore outlined the MICD core principles that are required to achieve the optimum result in terms of health, function and aesthetics
with minimum intervention and optimal patient satisfaction. However, it is the practitioner’s
duty to incorporate all the necessary guidelines,
protocols and regulations of the authority
concerned (state or affiliated professional organisations) into the MICD TP.

medical and dental history, general health and
specific health (oral-facial) of the patient is
collected and complete dental and periodontal
charting is performed. In order to understand
the force elements, the existing occlusion, comfort, muscular activity, speech and phonetics are
thoroughly examined with the evaluation of
para-functional and other oral habits, comfort
during mastication and deglutition, and temporo-mandibular joints (TMJ) movements. The
necessary diagnostic tests, photographic documentation and the diagnostic study models are
prepared during this step for the further exploration of existing diseases, force elements and
aesthetic defects.

Phase I: Understand
In the first step of Phase I, the perception, lifestyle, personality, and desires of the patient are
explored. The primary goal of this first step is a
better patient–dentist understanding. As the aesthetic perceptions of the dentist and the patient
may differ, it is imperative to understand the subjective aesthetic perception of the patient. Various
types of questions, personal interviews and visual
aids can be used as supporting tools. In this step,
the practitioner should ask the patient to complete the MICD self smile-evaluation form. The
information obtained will help estimate the perceived smile aesthetic score (a-score) and will be
used as the base-line data in the evaluation step.
Next, diseases, force elements and aesthetic
defects of smile are explored. Information on the

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In the following step, the data collected
is analysed in relation to the accepted normal
values of a patient’s sex, race and age (SRA)
factors. The aesthetic components of the smile
are analysed in detail grouped into macro(facial and dental midline relation, facial profile, symmetry of the facial thirds and hemifaces), mini- (visibility of upper anterior teeth,
smile arc, smile symmetry, buccal corridor,
display zone, smile index and lip line) and microaesthetics (dental: central dominance, teeth
proportion, axial inclination, incisal embrasure,
contact-point progression, shade progression, surface texture; gingival: shape, contour,
embrasure and zenith height). The practitioner can now grade the smile in terms of
the patient’s health, function and aesthetics as
follows:

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_Grade A: The established parameters of oral
health, function and aesthetics are within
normal limits and aesthetic enhancement is
required only to fulfil the patient’s cosmetic
desires.
_Grade B: The established parameters of oral
health and function are within normal limits;
however, the aesthetic parameters are below the accepted level. Aesthetic enhancement can further improve the aesthetic parameters.
_Grade C: The established parameters of oral
health or function or both are below the normal
limits. An establishment treatment is mandatory prior to aesthetic enhancement.
From the above, the practitioner will obtain
a smile aesthetic grading in terms of the patient’s health, function and aesthetics, as well as
a complete overview over the smile aesthetic
problems and the macro-, mini- and micro-smile
defects.
The patient’s PHFA factors are the four fundamental components of aesthetic dentistry18
and must be respected to achieve healthy,
harmonious and beautiful smiles. The design
step depends on the information obtained from
exploration and analysis. The information on
psychology is subjective in nature; however,
health, function and aesthetic analysis provides
the objective information that will guide the
design with the various established and basic
principles of smile aesthetics and also the feasible and practical extent of the aesthetic desires
of the patient. The aesthetic mock-up, manual
tracing, digital makeover and smile catalogues
are some of the popular tools used in this step.
A new smile, alternative designs, types of treatments involved, complexity, possible risk factors
and complications, treatment limitation, and
tentative costs should be established during this
step.
For easy application, the aesthetic treatments
in MICD are categorised as follows:

I

_Grade I: Treatment that may require consultation with a specialist (preventive, simple oral
surgery/endodontics/periodontics/implants,
short orthodontics);
_Grade II: Treatment that requires the procedural involvement of other dental specialists
(complex endodontics/periodontics/orthodontics) but not oral and maxillofacial surgery or
plastic surgery; and
_Grade III: Treatment that requires the procedural involvement of oral and maxillofacial
surgery or plastic surgery.
With the aid of this simple grading system,
any practitioner can determine the complexity
of the treatment involved for the accomplishment of a new smile design for an individual
patient and can plan for the necessary multidisciplinary support.
The last step of this phase is the most important in MICD TP because in this step the patient
is presented with an image of his or her future
smile. Visual aids, such as a smile catalogue,
aesthetic mock-ups, manual sketches, modified
digital pictures, computer-designed makeovers
or animations can be used as presentation tools.
The results of the design step are systematically
presented to the patient with professional honesty and ethics. All pertinent queries of the patient related to the proposed smile need to be
addressed during presentation. The treatment
complexity, its limitations, the risks involved,
possible complications, treatment cost estimation and maintenance responsibility must properly be explained to the patient. The patient is
thus involved in finalising the treatment plan
and will sign the written informed consent form
before proceeding to Phase II.
Phase II: Achieve
As per the TP, which is finalised during the
presentation step, all necessary preventive interceptive and restorative (curative) dental

Fig. 3

_Type I: Micro-aesthetic components;
_Type II: Mini-aesthetic components; and
_Type III: Macro-aesthetic components: facial
and dental midline relation, facial profile, symmetry of facial thirds and hemi-faces.
As the treatment modality depends on the
professional capability and experience of the
practitioner, simple and practical methods are
used to categorise the MICD treatment complexity:

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Fig. 4a

Fig. 4b

Fig. 4a_Gummy smile with lack
of upper central dominance.
Fig. 4b_Harmonised smile with
proper central dominance.
Treated with MI approach.

treatments are conducted
in order to establish the
proper health and function
of the oral tissues. Owing to
the complexity of the treatment, a multidisciplinary
approach may be necessary
for a good result. Once the
case is stable in terms of
health (controlled disease)
and function (balanced
force elements) with good
oral habits, the patient is requested to re-evaluate his
or her smile in terms of aesthetics with the help of the
MICD self smile re-evaluation form. This is important,
because in some cases the
patient is fully satisfied
with the results of the establishment step alone and
may modify his or her idea
of further aesthetic enhancement. In MICD TP it
is considered unethical should the practitioner
not collect self smile re-evaluation information
from the patient.
The enhancement step of MICD is focused on
the fulfilment of the patient’s aesthetic desires,
which can be grouped into two categories based
on the patient’s needs and wants. Even though it
is sometimes difficult to draw a clear line between the two and their related treatment, in
MICD they are categorised as follows:
_needs: objective restorative needs of the patient in harmony with the SRA factors and due
emphasis on health and function of oral tissues
(naturo-mimetic smile enhancement)
_wants: subjective desires of the patient, which
may not be in harmony with the SRA factors
(cosmetic smile enhancement)
During any want-based aesthetic treatment,
where healthy oral tissue is treated with no direct
benefit to health or function, the treatment modalities should be within the scope of non-invasive
(NI) or MI procedures.19 The patient’s desires alone
should not be the rational for the treatment.20
Do no harm! should always be the credo pertinent
to all dental treatment procedures.
Phase III: Keep in touch
Regular maintenance, compliance and timely
repair play a crucial role in the long-term success
of aesthetic enhancement procedures. Hence,

32 I cosmetic
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MICD emphasises the keep-in-touch concept
and encourages patients to go for regular follow-up visits. Responsibility for maintenance is
grouped into two categories:
_Self-care: Patients are advised to continue
their normal oral hygiene procedures. If necessary, special care and precautionary methods
are given, as well as protective devices. Selfcare should focus on regular tooth brushing,
flossing, the use of prescribed protective devices and other pertinent professional advice
for maintaining general health.
_Professional care: The oral habits, health of the
oral tissues, and the functional and aesthetic
status of the work preformed are well documented during each follow-up visit, and necessary maintenance repair jobs are carried out.
Evaluation is the final step of MICD TP. Any
‘completed’ treatment without a proper evaluation
is considered incomplete in MICD protocol. The
following components need to be evaluated:
_Global patient satisfaction: After receiving
aesthetic dental treatment, the patient is requested to complete the MICD exit form, in
which the patient evaluates his or her new
smile, gives a second perceived smile aesthetic
score (b-score), and indicates his or her global
satisfaction score. The b-score is compared
with the previous a-score. This process helps
determine the patient’s actual satisfaction
status. In MICD, this is the main parameter for
evaluating a patient’s aesthetic satisfaction.
_Clinical success: Clinical success is a multifactorial issue. Selection of proper cases (the patient), restorative materials, TPs and their correct and skilful application are the key factors
for clinical success. Therefore, MICD TP suggests self-evaluation of the following four factors (4Ps) using the MICD clinical evaluation
form:
_Patient factors: regular maintenance status,
compliance issues and attitude of the patient
towards aesthetic treatment;
_Product factors: bio-compatibility, mechanical
and aesthetic quality of the products used for
the treatment;
_Protocol factors: TP used in terms of its simplicity, predictability and its evidence-based
nature;
_Professional factors: existing knowledge and
skills, and attitude towards developing these.
Detailed clinical documentation of the case
during maintenance and evaluation can provide

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various cues to the practitioner in the evaluation
of his or her clinical success in terms of case
planning, material and protocol selection, as
well as his or her existing restorative skills.
I believe that a thorough evaluation can support any practitioner in initiating practicebased research and keeping up-to-date with
the recent trend of evidence-based dentistry
(Figs. 4a–5b).

_MICD treatment modalities
Various types of treatment modalities are
available in MICD. Their effective use depends on
the level of smile defects, type of smile design,
proposed treatment type and the treatment
complexity grade. There is only one principle in
selecting treatment modalities in MICD: always
select the least invasive procedure as the choice
of the treatment.
The two categories of MICD treatment are
NI and MI treatment (Table 1). However, conventional invasive treatment modalities may
also be required, depending on the complexity of
the case.

_Conclusion
MI dentistry was developed over a decade ago
by restorative experts and founded on sound
evidence-based principles.21–30 In dentistry, it
has focused mainly on prevention, re-mineralisation and minimal dental intervention in caries
management and not given sufficient attention
to other oral health problems. I believe that the
MI philosophy should be the mantra adopted
comprehensively in every field of the dentistry.

_about the author

For this reason, I have explained the MICD concept
and its TP, which integrates
the evidence-based MI
philosophy into aesthetic
dentistry, in the hope that
it will help practitioners
achieve optimum results in
terms of health, function
and aesthetics with minimum treatment intervention and optimum patient
satisfaction.

Fig. 5a

_Acknowledgements
In formulating the MICD
TP, I discussed the concept
with several national and
international colleagues in
order to ensure that it is
simple, practical and comprehensive. I would like to
extend my gratitude to Dr Akira Senda (Japan),
Dr Didier Dietschi (Switzerland), Dr Hisashi
Hisamitsu (Japan), Dr Oliver Hennedige (Singapore), Dr Dinos Kountouras (Greece), Dr Mabi
L. Singh (USA), Dr Ryuichi Kondo (Japan), Dr
So-Ran Kwon (Korea), Dr Prafulla Thumati (India),
Dr Vijayaratnam Vijayakumaran (Sri Lanka), as
well as Dr Suhit R. Adhikari, Dr Rabindra Man
Shrestha, Dr Binod Acharya and Dr Dinesh
Bhusal of Nepal, for their valuable comments,
advice and feedback._

Fig. 5b

Fig. 5a_Smile after establishment
treatment.
Fig. 5b_Smile aesthetic
enhancement with non-invasive
veneers treatment.

Editorial note: A complete list of references and the
MICD forms are available from the publisher.

cosmetic
dentistry

Dr Sushil Koirala is the founding president
of the Vedic Institute of Smile Aesthetics and
the chief instructor of Comprehensive Aesthetic
Dentistry, a two-year training programme based
upon Vedic philosophy of beauty and aesthetics. He maintains a private practice
focusing primarily on MI cosmetic dentistry (MICD). Based on more than 17 years of
clinical experience in aesthetic dentistry, Dr Koirala developed the Vedic Smile Concept,
the Smile Design Wheel, the MICD TP, and various clinical techniques for direct
aesthetic restorations. He is the founding president of the Nepalese Academy of
Cosmetic and Aesthetic Dentistry and South Asian Academy of Aesthetic Dentistry.
He has published numerous clinical articles in aesthetic dentistry and authored A clinical guide to Direct
Cosmetic Restorations with Giomer, published by Dental Tribune International GmbH. In addition, Dr Koirala
serves as Editor-in-Chief of cosmetic dentistry_beauty & science. He frequently conducts hands-on
programmes and delivers lectures globally on smile aesthetics. He can be contacted at skoirala@wlink.com.np.

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dentistry 4
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I digital dentistry _ CAD/CAM

CAD/CAM expands the
scope of restorative dentistry
Author_ Manfred Kern, Germany
Owing to the high degree of polymerisation shrinkage, these inlays required extensive machining, did not
fit exactly to the inner surfaces, and displayed large
tolerances at the margins. In addition, Prof Mörmann
wished to use ceramic on account of its similarity
to natural enamel and dentine. Only with the aid
of computer-controlled profile-grinding and milling
machines was it possible to mill silicate ceramics (and
later oxide ceramics) subtractively for highly aesthetic
restorations—restorations that displayed constant
and reproducible material characteristics, as well as
scope for cost optimisation. The broad acceptance of
dental CAD/CAM procedures is evident from the more
than 20 million all-ceramic restorations (chairside
plus labside) that have been produced worldwide.

_Adhesive bonding furthered the
development of CAD/CAM restorations

Fig. 1
Fig. 1_Prof Werner Mörmann and
Dr Marco Brandestini in 1985 with
the CEREC 1 prototype.
(Photo: Prof Werner Mörmann/
Quintessenz)

_Today, it is impossible to imagine dentistry
without digital technology and CAD/CAM procedures. Intra-oral and extra-oral measuring, the scanning of antagonists and bite registrations, 3-D design
on a computer, the availability of countless tooth
shapes in a dental database, the creation of anatomically shaped occlusal surfaces, functional articulation on a virtual model, the subtractive machining
of high-performance ceramics—all this would be
impossible without computers.
The groundwork for this quantum leap was laid in
Switzerland in 1985. For the first time ever, a 3-D optical impression of a prepared tooth was acquired using an intra-oral video camera (triangulation measuring technique) and then transferred to a computer.1
Using a computer, special imaging software and a
CNC milling unit, Prof Werner Mörmann and Dr Marco
Brandestini from Zurich University created the first
CAD/CAM inlay from a silicate ceramic material
(Fig. 1). This development was occasioned by Prof
Mörmann’s unpromising experiments with occlusionborne composite inlays as a substitute for amalgam.

34 I cosmetic
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4_ 2009

Two factors played a role here. The first factor was
the desire of proponents of computer-aided chairside
restorations to machine an industrially manufactured silicate ceramic with defined physical characteristics directly adjacent to the chair, and treat
the patient in a single visit, without the need for a
temporary. The second factor was the introduction of
adhesive bonding, which creates a force-locked link
between the ceramic restoration and the residual
tooth tissue, does not display a mechanical interface
and hence prevents crack-inducing tensile stresses.
Since the introduction of adhesive bonding, it has
been possible to apply defect-oriented and substance-conserving preparation techniques.
The combination of CAD/CAM ceramics and adhesive bonding facilitated the permanent stabilisation
of seriously weakened cusps (Fig. 2). It was possible
to dispense with mechanical retention in the cavity
geometry because adhesive bonding guarantees an
intimate link with the residual tooth. In many cases,
a partial ceramic crown eliminated the need for
a metal-based crown. This latter type of crown has
the disadvantage that it necessitates a circular preparation (and hence the loss of healthy tooth tissue)
in order to achieve the necessary retention. The mechanical strength of individually machined silicate
ceramics is transferred directly to the tooth tissue.

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digital dentistry _ CAD/CAM

This is particularly beneficial in the case of inlays,
onlays, partial crowns and seriously weakened cusps.
Prof Mörmann’s goal was to deploy CAD/CAM
technology to create immediate all-ceramic restorations chairside without the need for temporaries.
This goal derived from his experience that temporarily restored inlay cavities have a significantly negative
influence on the integrity of the enamel. In many
cases, the non-adhesively bonded temporary was
positioned like a wedge in the cavity and transmitted
the chewing forces to the weakened residual tooth.
The applied forces also deformed weakly protected
cusp walls. This resulted in cracks in the oral and
vestibular enamel surfaces.

The probability of survival was significantly higher
than that of layered laboratory-produced ceramic
inlays and was approximately equivalent to that of
alternative long-term restorations, such as cast-gold
inlays, which have a survival rate of 87 % after 20 years
and an annual failure rate of 0.7 %.3 Dr Otto established
that 166 of the CEREC inlays (of an original basis of
200 restorations in 1991) were clinically intact. This is
equivalent to a success rate of 83 % after an average
service time of 15 years. The survival rate was superior

A second goal was to make use of high-strength
oxide ceramics, such as aluminium oxide (Al2O3) and
zirconium oxide (ZrO2), and computer-controlled
milling machines in order to create crown-andbridge frameworks and hence pave the way for
metal-free prosthetic treatment.
Another recent development is the online transmission of intra-oral and extra-oral digital impressions and restoration design data to external dental
laboratories, which then perform the milling tasks. As
a result, the dental laboratories are now more closely
integrated into the work flow of dental practices.

_Clinically proven
All-ceramic chairside restorations number amongst
the most intensively researched dental treatment
procedures. Numerous studies confirm that the
clinical performance of inlays and onlays is at least
comparable with that of cast-gold restorations.
Durability is one of the most important evaluation criteria for ceramic materials. This underlines the importance of the study published in 2008 by Dr Tobias
Otto (Aarau, Switzerland) that presented long-term
clinical data going as far back as 17 years.2 Since 1989,
Dr Otto (one of the first CEREC users in Switzerland)
has monitored 200 inlays and onlays produced using
the CEREC 1 system and feldspar ceramic (VITA Mark I).
These restorations were placed in 108 patients in
his dental practice between period 1989 and 1991.
He evaluated his findings on the basis of the modified
USPHS criteria and summarised his clinical observations after 10 years and 17 years, respectively.
According to Dr Otto, 187 of the 200 restorations
were still in place after 17 years. This was a survival
rate of 88.7% after an average service time of 15 years
(Figs. 3–5). In other words, the annual failure rate was
0.75%. Failures with Charlie and Delta ratings (USPHS)
occurred between the 6th and 13th year. In most cases,
these failures were attributable to ceramic fractures.

Fig. 2

to that established by Smales4 for cast inlays after
15 years (loss rate: 1.5 %). It also compares favourably
with the 1.3 % annual failure rate established for allceramic, non-CAD/CAM ceramic inlays.5
A contributing factor is that chairside ceramic
inlays can be placed immediately in a single appointment, thus eliminating the need for temporaries.
In the case of conventional labside restorations, a
temporary is unavoidable. Prof Roland Frankenberger
established that under the influence of chewing
forces, the tooth is subjected to torsional stress due to
the low elastic modulus of the temporary composite
material. These forces can deform inadequately protected cusp walls, cause partial fractures and incipient enamel cracking, and weaken dentine adhesion.
By contrast, the immediate placement of the ceramic
inlay facilitates a contamination-free adhesive bond
with the hard tooth tissue and stabilises weakened
cusps. The stabilising effect on the residual tooth and
the existence of an adhesive bond obviously offset the
consequences of wider adhesive gaps, as evidenced
by long-term clinical findings.6

Fig. 2_Finite element measurement
with the exertion of chewing forces:
the ceramic inlay bears the chewing
load; the tooth substance remains
stress free (inlay is hidden).
(Illustration: Prof Albert Mehl)

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I digital dentistry _ CAD/CAM
composite are ignored), the Kaplan–Meier survival
rate was 89 % over the observation period. Dental
adhesives were not yet available at the beginning of
the study. If the patients are separated into two
groups (that is, patients treated with and without the
use of a dental adhesive), a significant difference is
revealed. Without dental adhesive, the survival rate
fell to approximately 80 % after 16 years; with dental adhesive, the survival rate was 90 %. The size of
the filling did not play a role. Premolars performed
better than molars. Vital teeth performed better
then non-vital teeth. During the observation period,
122 events occurred. In 86 % of the cases, this resulted in the loss of the restoration. Fractures (39 %)
were the most frequent reason for renewal.7

Fig. 3

Similar findings were reported by Prof Gerwin
Arnetzl. Between 1988 and 1990, Prof Arnetzl placed
358 two- and three-surface inlays made of Dicor,
Optec, Hi-Ceram, Duceram and CEREC 1 (Mark I) using the adhesive bonding technique. The control
group consisted of cemented gold inlays. After
15 years, CEREC and gold had a survival rate of 93 %.
This was significantly higher than the equivalent
figure for laboratory-produced sintered ceramic
inlays, which had a failure rate of 32 %.8
Dr Reinhard Hickel and Dr Jürgen Manhart reviewed the scientific literature over a period of
10 years and calculated the annual failure rates
of various materials used for Class I and II cavities.
They found that CEREC restorations displayed 25 %
fewer failures than cast-gold fillings.9

Fig. 4

Fig. 5

Fig. 3_Survival rate (according to
Kaplan–Meier) of CEREC inlays and
onlays: 88.7% after maximum of
17 years. (Source: Dr Tobias Otto)
Fig. 4_Survival rate of one- to foursurface restorations (no significant
difference) after maximum of
17 years. (Source: Dr Tobias Otto)
Fig. 5_Survival rates of restorations
on molars and premolars:
CEREC restorations on premolars
display a slightly higher success rate.
(Source: Dr Tobias Otto)

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_CAD/CAM ceramics conform
to the gold standard
A further long-term study of the durability of
CEREC restorations was published by Dr Bernd Reiss
in 2006. In a private dental practice, 1,010 CEREC
inlays and onlays were placed in 299 patients. After
15 to 18 years, 84.4 % of these restorations were
still clinically perfect (Figs. 6 & 7). Up to the end point
of the study (18.3 years), no further events were
observed. If the retention of the restoration is seen
as the sole criterion for evaluating survival (that is,
if therapeutic procedures such as trepanation and
subsequent margin corrections with the aid of

A particularly interesting investigation was
carried out by Dr Anja Posselt and Prof Thomas
Kerschbaum, who analysed the performance of
2,328 CEREC restorations placed in 794 patients in
a dental practice.10 The survival rate after 9 years was
95.5 %. The filling size, tooth vitality, the prior treatment of caries profunda, the type of tooth and the
location of the filling (separated according to upper
and lower jaw) did not have any influence. The most
common reasons for failure were tooth extractions
(22.9 %) and fractures (17.1 %).
Dr Andreas Bindl confirmed the suitability of
chairside fabrication methods for anatomically sized
CEREC crowns, milled and placed in a single visit.11
Various stumps were prepared for 208 feldspar
ceramic crowns. After 5 years, 97 % (premolar) and
94.6 % (molar) of the conventionally prepared
crowns (chamfer preparation) were still intact.
Clinically short crowns with a reduced stump
height achieved a survival rate of 92.9 % (premolar)
and 92.1 % (molar), respectively. The failure rate
for endo-crowns placed on premolars was significantly higher.

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Within the framework of a meta-analysis, the
clinical survival probability of high-quality conservative restoration types with the respective
production costs was investigated. Gold inlays
and CEREC inlays had the highest success rates.
The CEREC restorations perform better in terms
of cost effectiveness versus durability. The higher
production costs of cast-gold inlays are a disadvantage here.12

_Biogeneric occlusal surfaces
The design of functional occlusal surfaces poses
a challenge to rehabilitating the chewing function.
In this area, too, CEREC has exploited advances in
digital technology. IT provides valuable assistance
with recreating lost tooth tissue in such a way that
the restoration harmonises well with the existing
dentition in terms of its structural and functional
characteristics. With the aid of biogeneric modelling
software, Prof Albert Mehl et al. succeeded in automatically creating patient-specific occlusal surfaces
for inlays, onlays and partial crowns.13–15 In this case,
the residual occlusal tooth tissue was compared
with several thousand digital scans of natural occlusal surfaces contained in the CEREC tooth library
(Fig. 8). The software identifies matching morphological characteristics (fissures, cusps, marginal
ridges, gliding contact angle) and then inserts corresponding cusps, fossae, fissures and contact
surfaces into the virtual model of the restoration.
On the basis of the contact point distribution, the
cusp apexes and the proximal contacts, the software
is capable of creating a well-matched tooth and detecting possible collisions with the bite registration.
This biogeneric modelling process creates natural,
individual and functional occlusal surfaces.
The extension of the CEREC indications spectrum
to chairside crowns and multiple-unit labside
bridges (both temporary and permanent) has placed
increased demands on the intra-oral measuring
process. The recently introduced CEREC AC system
deploys a short-wavelength blue LED light source.
In combination with the built-in anti-shake system
this blue light source reduces the measurement
tolerance to 19 µm in comparison with a stationary
reference laser scanner.16 The preparation is optoelectronically scanned from various angles in
the patient’s mouth. The individual images are then
combined to create complete quadrants (Fig. 9).
Inadequate images are automatically detected. With
a scan of the antagonists, the digital impression of
the partial arch/quadrant is transmitted via a wireless link to the in-house dental laboratory. Alternatively, the data can be sent via the CEREC Connect
web portal to an external dental laboratory or to an
external milling centre equipped with a stationary

Fig. 6

Fig. 7

Fig. 8

CAD system. This is followed by the virtual design
of the restoration. If required, a 3-D working model
can be created using a special stereolithography
process (SLA). This model provides the basis for the
fine tuning of the CAD/CAM-milled crown or bridge
framework.
‘Impression-free’ dentistry offers numerous
advantages. The patient does not have to endure
the discomfort of a conventional impression (such
as gag reflex). In addition, dental laboratories can
reduce their production times and achieve significant productivity gains.

Fig. 6_Survival rate of CEREC inlays
and onlays: 84.4 % overall after
18 years. (Source: Dr Bernd Reiss)
Fig. 7_Survival rate: 90 % with
dental adhesive; 80 % without dental
adhesive. (Source: Dr Bernd Reiss)
Fig. 8_Examples of the tooth
surfaces contained in the library
(here: 6th molar of the upper jaw);
at present, approximately 400 tooth
surfaces are available for each
posterior tooth type.
(Illustration: Prof Albert Mehl)

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I digital dentistry _ CAD/CAM

Fig. 9

Fig. 10

Fig. 9_The individual images are
combined in an anatomically correct
way in order to create a virtual quadrant model. (Photo: Dr Andreas Bindl)
Fig. 10_CBVT image showing the
adjustment of the implant post;
the CEREC data record shows
the location and insertion axis
of the planned crown.
(Illustration: Dr Andreas Bindl/Sicat)

_Implant planning with the help
of imaging systems
The integration of the CEREC system and conebeam volumetric tomography (CBVT) enhances the
reliability of implant planning. The low-radiation
CBVT system generates a detailed 3-D image of the
bone structure. This ensures greater diagnostic accuracy, as well as the precise localisation of the
anatomical structures. CBVT thus provides the basis

reported that anatomically sized, adhesively bonded
implant molar crowns (VITA Mark II silicate ceramic)
with occlusal wall thicknesses of 1.5 mm have performed well in laboratory tests. This applies to crowns
placed on titanium abutments and crowns placed
on ZrO2 abutments.18

_Summary
CEREC has been transformed from a computerbased ‘inlay machine’ into a highly versatile system
for single-visit dentistry. In future, CEREC will coordinate various functions in dental practices and
laboratories. Numerous internationally recognised
studies have proved that chairside ceramic inlays
and onlays achieve clinical survival rates that are
comparable to those of cast-gold restorations.
With the introduction of optoelectronic impression-taking for entire quadrants, CEREC has opened
the door to impression-free dentistry and has integrated dental laboratories more closely into the work
flow of dental practices. CEREC technology has
demonstrated to dental professionals that CAD/CAM
processes and computer-aided treatment methods
will determine the future activities and actions of
dental practices and laboratories._

Fig. 11

Fig. 11_Prof Mehl, physicist and
biologist (left), has been collaborating
closely with Prof Mörmann in Zurich
in his role as visiting professor.
(Photo: DGCZ/Kern)

for the surgical planning of the implant.17 The CEREC
intra-oral camera is used to scan the implant site
and the adjacent teeth. Following this, the software
generates a virtual 3-D model, on the basis of which
the future implant crown is designed and prosthetic
planning conducted. The 3-D model with the implant
crown is then superimposed on the 3-D CBVT image.
This allows the clinician to position the implant with
reference to the planned prosthesis and the available
bone structure (Fig. 10).
CEREC is already deployed for the fabrication
of implant superstructures. Dr Daniel Wolf et al.

38 I cosmetic
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4_ 2009

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

[39] => untitled

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CDE0409_40-43_Geiselh

23.11.2009

11:11 Uhr

Seite 1

I digital dentistry _ NobelProcera

Safety and reliability with
CAD/CAM technology
Authors_ Hans Geiselhöringer & Dr Stefan Holst, Germany
clinical protocol. Simplicity for the dental technician primarily concerns the time required to design
and manufacture a restoration. However, in order
to ensure an efficient workflow, a user-friendly
software interface and intuitive handling are also
of utmost importance.

Fig. 1a

Fig. 1b

Figs. 1a & b_Application of zirconia
for long-span restorations requires
high manufacturing precision
and excellent material quality.
Only if colouring pigments are
equally distributed in the framework
will material properties be optimal.

_Today, dental technicians and general practitioners are challenged by an ever-increasing number
of CAD/CAM systems in the dental market. In order
to determine which system is best suited, various
aspects need to be considered. While CAD/CAM technology was initially associated with zirconia-based
restorations, advanced systems offer an extensive
range of materials and solutions for both natural
teeth and implants. The benefits are not limited to a
more cost-efficient fabrication of dental restorations
in the laboratory; practitioners and patients benefit
from the technological advancements equally. This
article discusses the various aspects that need to be
considered in the decision-making process.

_Simplicity in clinical and
laboratory routines
A key aspect of the successful application of
new technologies and clinical protocols is the time
required to adapt to and utilise a system in a daily
routine. This aspect is not only of relevance for the
dental laboratory in manufacturing a restoration,
but also to the practitioner considering changes in

40 I cosmetic
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Current scientific findings and clinical experience underscore the need for adequate material
manufacture and framework design to minimise
clinical failures, such as chipping of veneering ceramics or fracture of frameworks. The most important request, especially when working with zirconia
substructures, is that the framework be anatomically designed and require no manual post-processing adjustment. In the past, double scans were
performed in order to achieve this goal. New software design tools eliminate these time- and costintensive steps, as anatomic tooth-libraries support
the user in ideal coping and framework design.
Automatic cut-back functions increase ease of use
and provide an additional margin of safety by ensuring homogenous veneering material thickness.
An equally important aspect to consider is the design and dimension of the connector cross-section
for fixed dental prostheses. Only if minimum connector dimensions are respected will long-term
clinical success not be jeopardised. Newly developed
software tools support the user in the virtual design
of the frameworks and provide immediate feedback
on the cross-sectional area, connector height and
width, and coping thickness.
The most eminent facts for the practitioner are
that no major changes in clinical protocol are required when working with CAD/CAM technology
and industrially manufactured components. Only
when it comes to oxide ceramics are slight modifications of preparation design required for longterm success. These are limited to a slight chamfer
margin preparation, provision of an adequate occlusal space of 1.5 to 2 mm and rounded edges
(eliminating sharp transitions). The true benefit
when working with materials such as zirconia or
aluminium oxide is that conventional cementation
protocols can be applied. Adhesive luting—a require-

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digital dentistry _ NobelProcera

Fig. 2a

Fig. 2b

Fig. 2c

Fig. 3a

Fig. 3b

Fig. 3c

ment for all glass-based ceramics—is only applicable in clinical situations with reduced vertical crown
height or extensive preparation taper in which loosening of a restoration is likely (Figs. 1–5). Clinical
simplicity is relevant not only to restoring natural
teeth, but also to placing dental implants. It is important to realise that CAD/CAM-manufactured implant superstructures do not require any change in
clinical protocol when compared to conventional
cast restorations. Rather, the consistent fit of milled
components reduces the need for chairside adjustments significantly.

_Safety for the patient
Providing the patient with a reliable and longterm successful restoration is key in today’s highly
competitive dental market. Product and material
quality significantly influence the long-term clinical outcome. From a clinical perspective, important
aspects to consider include long-term stability in
the oral cavity, bio-compatibility, post-processing
options (for example, type of veneering material),
reasonably low costs and clinical versatility. While

the aesthetic potential was initially due to using
high-strength all-ceramic restorations, the true
benefit of Y-TZP/ZrO2 (yttria-stabilised polycrystalline tetragonal zirconia), for example, is its excellent bio-compatibility paired with flexural strength
values that allow for application in any area of the
oral cavity for both natural teeth and dental implants. When in close contact with the surrounding
tissues, the reduced plaque and bacterial accumulation, as well as the development of currently undefined pseudo-attachments leads to long-term tissue stability around these components (Figs. 6 & 7).
This fact makes zirconia products the primary choice
not only for non-compromised clinical situations,
but also for pre-existing periodontal conditions
whenever restorations, such as implant abutments,
are in close contact with surrounding tissues.
Despite these advantages, it is important to
understand and respect the material properties of
these materials. If inadequate space or extensive
leverage arms are unavoidable, alternative materials should be selected. Advanced systems such
as the NobelProcera system (Nobel Biocare) offer

Figs. 2 & 3_Efficient CAD/CAM
systems support the dental
technician (NobelProcera System
software, Nobel Biocare) by providing
automated tools for anatomic
framework design (Figs. 2a–c)
and in manufacturing the
ready-to-use components
to eliminate any alterations after
sintering (Figs. 3a–c).

Fig. 4_Shaded zirconia
(NobelProcera Bridge Shaded
Zirconia, Nobel Biocare) guarantees
maximum strength combined with
excellent aesthetic results and
application of any veneering material
within the CET range of zirconia.

Fig. 4a

Fig. 4b

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I digital dentistry _ NobelProcera

Fig. 5a

Fig. 5b

Fig. 5_Intra-oral lateral and occlusal
view of definitive solutions; the
clinical benefit of zirconia products
is the application of everyday clinical
protocols, including cementation
with conventional cements.

Figs. 6 a–d_Standard clinical
protocols apply when restoring
natural teeth or dental implants with
cement-retained crowns. For
long-term success, it is important to
position the abutment-crown margin
at the level of or slightly below the
gingival margin to ensure complete
removal of excessive cement.

a wide range of materials ranging from aluminium
and zirconia-based oxide ceramics, titanium, acrylics and non-precious alloys.
An indispensable factor for long-term clinical
success of implant-retained superstructures is the
precision of fit. Depending on the complexity of
a restoration, poor fit can have a significant impact
on function and stability in the oral environment.
In terms of reproducible precision, CAD/CAM technology clearly outperforms conventional framework-manufacturing techniques. New generation
software tools eliminate the need for time-consuming framework design on the master cast. Instead, the scan of the implant position can easily be
matched with the scan of a wax-up, followed by a
virtual framework design in the CAD tool. Adjusting

Fig. 6a

Fig. 6b

Fig. 6c

Fig. 6d

42 I cosmetic
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4_ 2009

the design and dimensions according to the anticipated final contour of the definitive restoration is
achieved in a few minutes instead of taking several
hours with conventional fabrication protocols.

_Cost-efficient solutions
for laboratory and patient
Another aspect of providing cost effectiveness
and safety is centralised manufacturing of products. Centralised milling evidently outperforms inhouse systems: the workflow is permanently monitored; industrialised fabrication guarantees consistent quality; materials can be ordered as needed
for any particular situation, eliminating the need
for stock components; and time-consuming and
expensive adjustments, updates, or repairs do not

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digital dentistry _ NobelProcera

accumulate. From a cost-saving perspective for
laboratories, the delivery of all metal frameworks of
the NobelProcera system highly polished and readyto-use adds to the true benefits of centralised manufacturing. The five-year warranty on all products
cannot be met by conventional fabrication techniques. The warranty ensures that if complications
occur during clinical function, a new product can
be ordered free of charge. Here, the uniqueness of
virtual planning comes into play again, as all data
is always available even after years and merely requires the click of a button to reorder.

_Benefits of a versatile CAD/CAM system
CAD/CAM technology has significantly revolutionised dental laboratory techniques and protocols. Advantages related to material and manufacturing processes will promote the continuous
adoption of CAD/CAM systems over conventional
casting techniques, as the technology offers several
benefits compared to conventional framework fabrication. This development provides true benefits for
the dental laboratory, the practitioner and, above all,
the patient. From a laboratory perspective, the benefits of the technology and the new NobelProcera
system are obvious. Cost-efficient and time-saving
workflow with only one CAD/CAM system in the
dental laboratory, high-quality products with unrivalled precision and free-virtual design options,
and centralised production.

Fig. 7a

Fig. 7b

Fig. 7c

Fig. 7d

The greatest advantage of the NobelProcera
system is its clinical versatility. Not only the clinical
situation, but also patients’ expectations and
means can be met. The base components such
as copings, frameworks and bars always guarantee maximum precision, material homogeneity and stability for all patients. This is true
whether a low-cost, non-precious alloy substructure is veneered with resin or ceramic material
or a high-end all-ceramic solution is requested,
whether a conventional denture set-up is retained
by an overdenture bar or an implant-retained
removable restoration is finished with custom allceramic teeth and individualised gingiva-coloured
composite._

_contact

Figs. 7a–d_Screw-retained restorations
on dental implants (Nobel Active Implant,
Nobel Biocare) simplify the clinical
protocol by eliminating the need
for correct alignment of multiple
single abutments, in the case of
a cement-retained bridge, allowing for
easy removal if required (NobelProcera
Implant Bridge Zirconia). The availability
of NobelProcera restoration for use with
numerous implant systems and
platforms increases the laboratory
and clinical efficiency of the system. The
application of zirconia frameworks allows
for easy closure of screw access channels
with conventional composite resin.

cosmetic
dentistry

Hans Geiselhöringer
Dental Technician
Dental X Hans Geiselhöringer GmbH & Co. KG
Lachnerstraße 2
80639 Munich, Germany
Dr Stefan Holst
University Clinic Erlangen
Dental Clinic 2 – Department of Prosthodontics
Glückstraße 11
91054 Erlangen, Germany

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CDE0409_44-46_Jackson

13.11.2009

11:26 Uhr

Seite 1

I industry report _ composite restorations

Smile upgrade—
Highly aesthetic
composite restorations
in the anterior region
Author_ Dr Ronald D. Jackson, USA
Figs. 1 & 2_Female patient with
a prominent white spot on the right
central incisor: The influence of
the white spot on full face
appearance is clearly visible.

Figs. 3 & 4_This ‘appearance lesion’
was treated with a conservative IPS
Empress Direct restoration, showing
that a small treatment can have
a significant effect on the overall
image. Note that the patient
underwent tooth bleaching prior to
the placement of the restoration.

Fig. 1

Fig. 2

_The emphasis on appearance is pervasive
in today’s media-driven culture. It is particularly
keen in adolescents as a result of constant exposure to images of beautiful young celebrities
(real or media-created) in magazines, television,

pop music and everywhere on the Web. Because
the smile is such a significant factor in facial
appearance, the impact of this culture shift on
dentistry has been enormous. In particular, young
teenagers are seeking out aesthetically oriented
dentists and requesting correction of mild to
moderate imperfections in teeth that previous
generations tolerated because dentistry lacked a
simple, predictable aesthetic solution (Figs. 1–4).

_History and diagnosis

Fig. 3

Fig. 4

44 I cosmetic
dentistry

4_ 2009

A sixteen-year-old female patient presented
with the chief complaint of being dissatisfied
with the previous dental treatment of her maxillary central incisors. Her dental history revealed
that she had large white spot lesions in the incisal
one third of each of these teeth, which she
said appeared following orthodontic treatment.
She had seen a dentist several months earlier,
who placed composite resin restorations in both
centrals, but she was dissatisfied with the result
(Fig. 5). The clinical examination showed these

[45] => untitled

CDE0409_44-46_Jackson

13.11.2009

11:26 Uhr

Seite 2

industry report _ composite restorations

Fig. 5_Clearly visible white spot
lesions.
Fig. 6_An oval diamond was used
to create a saucer-shaped
preparation of approximately
0.8 mm central depth.

Fig. 5

Fig. 6

quite visible restorations to be lacking in natural
appearance and to have marginal discolouration.
Although the shade was close to being correct,
the lack of a lifelike appearance was deemed to be
the result of using a single opacity of composite
resin. The discolouration was likely due to inadequate enamel adhesion at the margins.

(Fig. 6). No anaesthetic was used. The preparation using this diamond is saucer-shaped
with a centre depth of approximately 0.8 mm
and tapering to a shallow depth at the margins.
The preparation is feathered and scalloped
another 1.0 mm beyond the outline of the white
lesion (Fig. 7).

_Clinical technique

The preparation, including enamel beyond
the margins, was etched with 37 per cent phosphoric acid for 20 seconds, then washed and
dried. Since no dentine was exposed, Heliobond,
an enamel-bonding resin without hydrophilic
monomers or solvent, was placed and lightcured.

It is important to record the shade quickly
at the beginning of treatment to avoid the effects
of dehydration. Using the middle third of the
lateral incisors as a reference, the shade was
determined to be A1. Also observed were mild,
dispersed white areas scattered irregularly in all
the upper incisors.
The existing composite resin on the right central incisor was removed using an oval diamond

A new, naturally shaded composite resin
system (IPS Empress Direct) was selected because
of its accurate shades and consistent opacities.
As the combination of the dentine and enamel

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 7_The preparation was
feathered and scalloped an additional
1 to 1.5 mm beyond the white spot.
Fig. 8_Opaque Dentin shade A1
blocks the visibility of the white spot.
Fig. 9_A1 Enamel was extended
to just short of the prepared margin.
It occupied approximately two
thirds of the remaining depth
of the preparation.
Fig. 10_Tetric Color white was
placed with a brush.

cosmetic
dentistry 4
I 45
_ 2009

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CDE0409_44-46_Jackson

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I industry report _ composite restorations
Fig. 11_The restoration was
completed to slight over-contour
with a translucent composite
resin, Trans 30 (clear).
Fig. 12_Post-op view of the
minimally invasive, aesthetic
restorations fabricated with the
IPS Empress Direct composite
resin system.

Fig. 11

Fig. 12

of the tooth yielded a shade of A1, A1 Dentinand A1 Enamel-shade composite resins were used
to restore the cavity. No recipes or combinations
of a darker dentine and lighter enamel were
needed.

_Conclusion

The A1 Dentin was applied on the white spot
area only and occupied about one half the
depth of the preparation. Because of the opacity
of the dentine composite resin, the white spot
was no longer visible (Fig. 8). After curing,
the A1 Enamel was applied. This increment of
material occupied approximately two thirds of
the remaining depth of the preparation and was
extended to just short of the prepared margins.
Before light curing, multiple grooves and surface
irregularities were sculpted with a thin, bladed
instrument (Fig. 9). A small amount of Tetric Color
white was then placed with a brush and lightcured (Fig. 10).
Depth and natural-looking aesthetics were
achieved by the application of translucent
composite resin (Trans 30), which completes the
restoration to slight over-contour. This layer
extended beyond the prepared margins (Fig. 11).
Finishing and polishing were accomplished
using aluminium oxide discs and the Astropol
System. The patient was pleased with the result
(Fig. 12).

_about the author

Today’s patients want their dentistry to be
more aesthetic but less invasive. Directly placed
composite resin accomplishes both. Further, there
is no question that the emphasis on appearance
and, in particular, the smile, has raised the aesthetic standard in dentistry. Good enough is no
longer good enough. Manufacturers have met
this challenge by creating materials that better
mimic tooth structure. The challenge for dentists
is to learn the skills to use them in order to satisfy
the desires of today’s discerning patients.
Fortunately, this challenge is made much easier when using the naturally shaded composite
resin system IPS Empress Direct. The broad range
of shades (which are true to the shade guide), the
three opacities (Dentin, Enamel and Translucent),
each accurate in a narrow range, combined with
excellent handling and ease of polish significantly
shorten the learning curve. In addition, the new
opalescent shade allows an easier and more
accurate creation of the effect seen in bleached
teeth.
Finally, the joy of creation is enhanced further
for dentists when the results are evident to
patients. In addition to gratitude, patients express
admiration of clinicians’ artistic skills._

cosmetic
dentistry

Dr Ron Jackson has published many articles on aesthetic and adhesive
dentistry and has lectured extensively across the United States and
abroad. He has presented at all the major US scientific conferences.
Dr Jackson is a fellow in the American Academy of Cosmetic Dentistry,
a fellow in the Academy of General Dentistry and is director of the
Advanced Adhesive Aesthetic Dentistry and Anterior Direct Resin
programmes at the Las Vegas Institute for Advanced Dental Studies.
He maintains a private practice in Middleburg, VA, USA, emphasising
on comprehensive restorative and cosmetic dentistry.

46 I cosmetic
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Anschnitt DIN A4

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Seite 1

AACD
comes to

EUROPE
London, England

Surround yourself with progressive, world-class dental professionals, educators, and exhibiting partners at this ﬁrst-of-its-kind event.
Experience the camaraderie and values for which AACD is known. Gain conﬁdence in your clinical skills through hands-on workshops
and in-depth lectures. Strengthen your team dynamic while fostering your passion for cosmetic dentistry. Register with the AACD today!
This special event is brought to you by the AACD, the British Academy of Cosmetic Dentistry, the Dental University of Paris Study Group,
the European Society of Cosmetic Dentistry, the German Society of Cosmetic Dentistry, and the Swedish Academy of Cosmetic Dentistry.

WWWAACDCOM s INFO AACDCOM s

[48] => untitled

CDE0409_48_Eventlist

13.11.2009

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Seite 1

I meetings _ events

Cosmetic events
2010
ACE Conference
Where:
Tampa, FL, USA
Date:
19–20 March 2010
Tel.:
+1 800 701 6223
E-mail:
contact@ACEsthetics.com
Web site: www.acesthetics.com
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
FDI Annual World Dental Congress
Where:
Salvador da Bahia, Brazil
Date:
2–5 September 2010
Tel.:
+33 450 4050 50
E-mail:
congress@fdiworldental.org
Web site: www.fdiworldental.org
AACD & ESCD Joint Meeting
Where:
London, UK
Date:
23–25 September 2010
Tel.:
+1 608 222 8583
E-mail:
info@aacd.com
Web site: www.aacd.com
Greater New York Dental Meeting
Where:
New York, NY, USA
Date:
26 November–1 December 2010
Tel.:
+1 212 398 6922
Web site: www.gnydm.org

2011
34th International Dental Show
Where:
Cologne, Germany
Date:
22–26 March 2011
Tel.:
+49 221 8210
E-mail:
ids@koelnmesse.de
Web site: www.ids-cologne.de
7th IFED World Congress
Where:
Rio de Janeiro, Brazil
When:
21–24 September 2011
Tel.:
+44 207 6369933
Web site: www.ifed.org

48 I cosmetic
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CDE0409_49_Submission

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Seite 1

I about the publisher _ submissions I

submissions:
formatting requirements
_Please note that all the textual elements of
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The fact is that no matter how careful
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Questions?
Please contact us for our Author Kit, or if
you have other questions:
Managing Editor
Claudia Salwiczek
c.salwiczek@dental-tribune.com

cosmetic
dentistry 4
I 49
_ 2009

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CDE0409_50_Impressum

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Seite 1

I about the publisher _ imprint

cosmetic
dentistry
_ beauty & science

asia pacific edition

Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
Editor-in-Chief
Dr Sushil Koirala
skoirala@wlink.com.np
Co-Editor-in-Chief
Dr So-Ran Kwon
smileksr@hotmail.com
Managing Editor
Claudia Salwiczek
c.salwiczek@dental-tribune.com
Product Manager
Bernhard Moldenhauer
b.moldenhauer@dental-tribune.com
Executive Producer
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g.meyer@dental-tribune.com
Designer
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Copy Editors
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International Administration
President/CEO
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p.witteczek@dental-tribune.com
Executive Vice President
Finance
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d.wunderlich@dental-tribune.com

International Media Sales
Europe
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a.kahnt@dental-tribune.com

Advisory Board
Dr Michael Miller, USA
Dr Seok-Hoon Ko, Korea

Editorial Board
Asia Pacific
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p.witteczek@dental-tribune.com
North America
Humberto Estrada
h.estrada@dtamerica.com

International Offices
Europe
Dental Tribune International GmbH
Contact: Nadine Parczyk
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Tel.: +49 341 484 74 302
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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
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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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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

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Anschnitt DIN A4

12.11.2009

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Seite 1

[52] => untitled

PERFECT BLEACH –
NATURALLY WHITE

Perfect Bleach

The effective and gentle whitening gel for discoloured teeth
r Carbamide peroxide-based home whitening system
r Concentration available in 10 % and 17 %
r Gentle to the tooth substance
r Visible whitening after only a short time
r User-friendly, simple handling

VOCO GmbH · P.O. Box 767 · 27457 Cuxhaven · Germany · Tel. +49 (4721) 719-0 · Fax +49 (4721) 719-140 · www.voco.com

GB_CosmetDentInt_0409_PerfBleach_210x297.indd 1

03.11.2009 12:44:02 Uhr

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[cover] => cosmetic dentistry international

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