cosmetic dentistry international No. 1, 2014

cosmetic dentistry international No. 1, 2014

Cover / Editorial / Content / Interdisciplinary approach in aesthetic dentistry / Projecting a new smile from a facial photograph: A new way to plan multidisciplinarydental treatments / Non-invasive reconstruction with ceramic veneers— Art or compromise? / Ceramics overview: Classification by microstructure and processing methods / “The trend towards the medium-price range has accelerated” / Maximal aesthetics in the periodontally compromised anterior maxilla / Planmeca makes CAD/CAM easier than ever / IMAGINA Dental: Digital dentistry experts meet in Monaco / “Clinician education is critical to success” / Meetings / Submission guidelines / Imprint

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CDE0114_01_Title 11.06.14 13:59 Seite 1

issn 2193-1429

Vol. 8 • Issue 1/2014

cosmetic
dentistry
_ beauty & science

1

2014

| CE article
Interdisciplinary approach
in aesthetic dentistry

| case report
Non-invasive reconstruction
with ceramic veneers—Art or compromise?

| review
Ceramics overview:
Classification by microstructure
and processing methods

[2] => Standard_300dpi

DTI_Mediamix2014_A3_NEU_Layout 1 22.01.14 10:19 Seite 1

Dental Tribune International
The World’s Largest News and
Educational Network in Dentistry
www.dental-tribune.com

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CDE0114_03_Editorial 11.06.14 14:00 Seite 1

editorial _ cosmetic dentistry

I

Dear Reader,
_Welcome to this year’s first edition of cosmetic dentistry!
In general dental practice, simple to moderate restorative cases dominate the total
workload in the practice and the financial gain ratio is comparatively high in simple cases
compared with full mouth rehabilitation or other complex treatment. However, it is interesting
to note that our young dentists in dental practice are focusing on complex case management
and not giving due priority to Class V restorations, inlays, onlays, mild anterior crowding,
maintaining optimal oral hygiene, enhancing tooth colour, etc. Globally, the focus is on
implant and full mouth restorations, which requires in-depth clinical knowledge and skills in
simple case management first. Personally, I always advise my trainees to develop hand skills
in direct composite resin restorations, as a good dentist must have artistic hands. Once we
understand the minute details (texture, colour, anatomy and effects) of natural teeth using
direct restorations, it is easy to obtain quality work from the laboratory and achieve high
clinical results. In order to treat complex cases, such as cosmetic full mouth rehabilitation,
temporomandibular joint dysfunction (TMD) and sleep medicine, one must complete the
required continuing education and learn clinical skills at quality training centres.

Dr Sushil Koirala
Editor-in-Chief

During 2013, my team was busy establishing a “regional training centre” for minimally
invasive cosmetic dentistry (MiCD) and teeth, muscle, joint and airway (TMJA) harmony
dentistry. Cosmetic dentistry, occlusion, TMD and dental sleep medicine are the areas on
which the team is focusing. MiCD and TMJA harmony dentistry are becoming quite popular
because of their do no harm approach to clinical practice and simplicity in training approach
that focuses on skill acquisition.
We have established training centres at Thammasat University in Thailand, the International
Center of Dental Excellence in India and the Bangladesh Institute of Advanced Dentistry,
and more are coming in Asia.
Our first regional five-day skill training programme is being organised in Thailand on TMJA
harmony dentistry and more than 70 senior clinicians from the Philippines, India, Indonesia,
Vietnam, Cambodia, Nepal, Thailand, Canada and the US will be participating.
As a practising clinician and presenter of various international training programmes,
I feel that every good clinician should participate in a clinical teaching programme, if possible,
because this will help clinicians to remain updated and promote personal happiness by
sharing their knowledge and skills for better patient care around the world.
We present various clinical articles in this issue and hope you will enjoy reading them.
Yours faithfully,

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

cosmetic
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_ 2014

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CDE0114_04_Content 11.06.14 14:00 Seite 1

I content _ cosmetic dentistry

page 06

page 12

I editorial

I technique

03

38

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

Interdisciplinary approach in aesthetic dentistry
| Dr Sebastian Ercus

I industry news
42

I special
12

Projecting a new smile from a facial photograph:
A new way to plan multidisciplinarydental treatments

I meetings

| Drs Marco Del Corso & Alain Méthot

44

IMAGINA Dental: Digital dentistry experts
meet in Monaco

46

“Clinician education is critical to success”
| An interview with AO Annual Meeting chairman
Dr Lyndon Cooper

Non-invasive reconstruction with ceramic veneers—
Art or compromise?
| Dr Magdalena Jaszczak-Małkowska & Robert Michalik

I review
26

Planmeca makes CAD/CAM easier than ever
| Planmeca

I case report
18

Maximal aesthetics in the periodontally
compromised anterior maxilla
| Drs Nikolaos Papagiannoulis, Eduard Sandberg
& Marius Steigmann

I CE article
06

48

International Events

I about the publisher

Ceramics overview: Classification by
microstructure and processing methods
| Profs. Edward A. McLaren & Russell Giordano

49
50

| submission guidelines
| imprint
issn 2193-1429

_ beauty & science

1

2014

“The trend towards the medium-price range
has accelerated”

| ce article
Interdisciplinary approach
in aesthetic dentistry

| case report
Non-invasive reconstruction
with ceramic veneers—Art or compromise?

| review

| An interview with Straumann executive board member Frank
Hemm about the company’s recent investment in MegaGen

page 26

04 I cosmetic
dentistry

Vol. 8 • Issue 1/2014

cosmetic
dentistry

I feature
36

page 18

1_ 2014

Ceramics overview:
Classification by microstructure
and processing methods

Cover image courtesy of Subbotina Anna

page 38

page 46

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Tel: +1 424 744 0608 / email: c.ferret@tribunecme.com / www.TribuneCME.com

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CDE0114_06-10_Ercus 11.06.14 14:02 Seite 1

I CE article _ interdisciplinary approach

Interdisciplinary approach
in aesthetic dentistry
Author_ Dr Sebastian Ercus, Belgium

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 1_The level of the maxillary central
incisors in the relaxed position
(2–4 mm in women and 1–2 mm in men).
Fig. 2_A maximum of 2 mm
from the incisal edge to the lower lip
during smiling, example 1.
Fig. 3_A maximum of 2 mm
from the incisal edge to the lower lip
during smiling, example 2.
Fig. 4_The middle third of the
maxillary central incisor should be
perpendicular to the occlusal plane.
Fig. 5_Evaluating width
to length ratios.

_ce credit cosmetic
dentistry
This article qualifies for
continuing education (CE) credit.
To take the CE quiz, log on
to www.dtstudyclub.com.
Click on “C.E. ARTICLES”
and search for this article.
If you have not registered
on the site, you will be asked
to do so before taking the quiz.

06 I cosmetic
dentistry

1_ 2014

_Introduction
In today’s dentistry, for rendering the best
comprehensive dental services to our aesthetically
driven patients, the paradigm has shifted to an
interdisciplinary team of specialists that work together steered by a clinical co-ordinator. This person
should be either a multi-competence general dentist or a specialist with additional training outside
his or her specialty area. This gives him or her the
ability to bring the surgical, orthodontic, restorative
and technical teams together as a whole, following
treatment sequences customised especially for the
patients’ best interests and expectations.
The challenge is making the correct diagnosis
and selecting the appropriate treatment regimen.
In order to achieve that, the clinician has to follow
certain guidelines and understand the relations
between teeth and the adjacent structures. Establishing the correct position of the incisal edge of
a maxillary central incisor in relation to the lower
lip, the correct ratios between the tooth’s width
and length, and the level of gingival margin when
smiling are very powerful diagnostic tools.
In order to aid memory, one may remember it as
the 42.2 rule:

(a) a maximum of 4 mm of maxillary central incisor
display when the lips are at rest (a minimum of
2 mm; Fig. 1);
(b) a maximum of 2 mm of gingival display during
smiling;
(c) a maximum of 2 mm from the incisal edge of the
maxillary central incisor to the lower lip during
smiling (Figs. 2 & 3); and
(d) the middle third of the maxillary central incisor
should be perpendicular to the occlusal plane
and the incisal edge should touch the plane
(± 0.5 mm; Fig. 4).
The correct ratio between the width and length
of a maxillary central incisor is 78 to 80 per cent.
With the incisal edge position already determined,
we can identify the position of the gingival margin
(Figs. 5 & 6).
Gingival margin positioning should be in accordance with the understanding of six conditions
present in the oral cavity with different aetiologies
and treatment regimens:
1. Altered passive eruption when the gingival margin does not recede to a level near the cementoenamel junction (CEJ) during tooth eruption.
Diagnostically, the gingival margin is located

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CE article _ interdisciplinary approach

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

incisal to the CEJ. Treatment options depend on
the amount of attached gingiva and the position
of the bone relative to the CEJ (as a general rule,
the biologic width should be a minimum of
2 mm):
(a) gingivectomy;
(b) osseous resection (ostectomy) with or without
flap surgery (without a flap, it is difficult to
control the osseous contour driven by the new
gingival margin);
(c) apically repositioned flap.

4. Delayed eruption followed by early loss of primary
maxillary incisors, delayed eruption of maxillary
permanent incisors or overeruption of mandibular
incisors. Diagnostic features are short maxillary incisors, over-erupted mandibular incisors or a Class
III maxillomandibular relation. Bearing the 42.2 rule
in mind, treatment should follow incisal reduction
done selectively with crown lengthening only or
crown lengthening combined with orthodontic
intrusion of mandibular incisors and possible
minimally invasive restoration of maxillary teeth.

2. Altered active eruption when the osseous crest
does not resorb to a level 2 mm apical to the CEJ.
The gingival margin is still located incisal to the
CEJ. This is treated with periodontal surgery with
osseous resection.

5. Vertical maxillary excess described as a hyperplastic growth of the maxillary skeletal base
where teeth are positioned farther from the
skeletal base, an increased facial lower third
and excessive gingival display, which is classified
according to three categories:

3. Compensatory eruption when the tooth surface is lost, with the reduction in facial height or
vertical dimension of occlusion unaffected (short
tooth syndrome). Treatment is either restorative
or, in the case of hypermobility of the lip, combined with a coronally positioned mucosal flap.

(a) Category 1: 2–4 mm of gingival display, treated with
only orthodontic intrusion, orthodontics and periodontics, or periodontics with restorative therapy;
(b) Category 2: 4–8 mm of gingival display, treated
with periodontics and restorative or orthognathic surgery (Le Fort type I); and

Fig. 13

Fig. 6_Altered passive eruption.
The enamel could be exposed by
a gingivectomy in one appointment.
Fig. 7_Lower third smile showing
altered passive eruption.
Fig. 8_Delayed eruption.
Fig. 9_A hypermobile lip and a slight
vertical maxillary excess.
Fig. 10_Lower third full smile design.
Fig. 11_Relaxed position (/m/ sound – ahhh).
Fig. 12_Superimposed photographs
10 & 11. The red arrow indicates
the distance from the incisal edge to
the upper lip in the relaxed position.
The yellow arrow indicates the height
of the upper lip in the relaxed position
(~ 21 mm). The white arrow indicates
mobility of the upper lip from
the relaxed to smile position.
Fig. 13_Initial lower third when smiling.
Fig. 14_Findings in order of importance
after establishing the incisal edge
position on the full smile photograph.
Fig. 15_The wax-up duplicated
in a stone model.

Fig. 15

Fig. 14

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I CE article _ interdisciplinary approach

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Fig. 20

Fig. 21

Fig. 22

Fig. 23

Fig. 24

Fig. 16_The new design proposal in wax.
Fig. 17_Very good communication
with the dental laboratory.
Fig. 18_The crown-lengthening
surgical guide.
Figs. 19–24_Crown lengthening
with osseous contouring.
(Surgery performed by
Dr Muriel Krischek, Belgium.)

Figs. 25–27_The bis-acrylic
prototype.

Fig. 25

(c ) Category 3: more than 8 mm of gingival display,
treated with orthognathic surgery with or without periodontal and restorative treatment.

Picture 10: Full smile—length of the central exposed
6. Hypermobile upper lip—the average mobility of the – measure digitally in pixels distance from incisal
upper lip is from 6 to 8 mm from the rest position. edge to the lower margin of the upper lip in full
More than 8 mm represents hypermobility. Con - smile.
sidering that the average distance from the lower
margin of the upper lip and the base of the nose (sub- Picture 11: Lips at rest – 2 mm central incisor reveal
nasion) is 21 mm, one could take two superimposed + 21 mm distance lower lip to base of the nose.
photographs with the patient at rest and the patient Incisal edge to base of the nose 23 mm (incisal edge
smiling fully to calculate the lip mobility very easily at the correct position).
using the 42.2 rule. Generally normal tooth length is
present and dental labial aesthetics is good to ideal. x = distance from the incisal edge to the lower
The treatment regimen could entail a coronally po- margin of the upper lip in full smile
sitioned mucosal flap, crown lengthening with osseous resection or a combination of both (Figs. 8 & 9) y = the amount of central incisor exposed at rest

Fig. 26

08 I cosmetic
dentistry

1_ 2014

Example: Photographs captured at the same magnification opened in Adobe Photoshop:

Fig. 27

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CE article _ interdisciplinary approach

Fig. 28

Fig. 30

Fig. 29

Since the aetiology is generally multifactorial,
by combining all the clinical data gathered during
the initial examination, including facial, periodontal, orthodontic, endodontic and restorative data,
as well as radiographs and diagnostic photographs,
the clinician has the ability to compose a very detailed and comprehensive treatment plan especially
for a patient with high aesthetic demands.
Following the digitally designed smile concept,
balancing the relations between the teeth and adjacent structures will help the clinical co-ordinator
and the specialty team propose treatment planning
to the patient. Presenting the plan in Keynote (Apple)
or Microsoft PowerPoint is a very powerful communication tool in obtaining treatment acceptance.

_Case presentation
A 32-year-old female patient came to the dental
office with her chief complaints being short teeth,
an uncomfortable bite, too much gingiva showing
when smiling, brown-coloured areas of her teeth
and insufficient contact points. The patient was in

Fig. 32

Fig. 31

Fig. 33

23 mm = 1,725 px; x = 900 px; mobility = x – y; = [(23
× 900) / 1,725] – 2 mm; = 12 mm – 2 mm; = 10 mm
(Figs. 10–12)

good general health with a good periodontal status
and probing depths of 2 to 3 mm. The aetiology of
the excessive gingival display was multifactorial,
a combination of delayed eruption, altered passive
eruption and hypermobility of the upper lip. From
an evaluation of the teeth, both clinically and from
the diagnostic photographs, we made the findings
given in Table 1 in order of importance (Figs. 13 & 14).
We placed incisal edge position first in order of importance because, in the majority of cases, without
proper placement whatever follows could result in
a tooth that tries to mimic nature but is not properly
exposed in a full smile.

Incisal edge position
Form
Value
Surface texture
Translucency
Chroma
Hue
Gummy smile evaluation
Teeth ratios
Contact points
Occlusal interferences

Fig. 34

Fig. 28_Controlled tooth reduction.
Fig. 29_Tooth preparation.
Fig. 30_Porcelain restorations
on alveolar models.
Fig. 31_The try-in paste
and organiser.
Fig. 32_Cementation.
Fig. 33_Situation before.
Fig. 34_Situation after.
(Ceramics performed by
Edwing Chung, Canada.)
Table 1_Findings.

Missing
Missing
Missing
Missing
Missing
Missing
Present
Missing
Missing
Missing
Present

Table I

cosmetic
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I CE article _ interdisciplinary approach

Fig. 35

Fig. 36

Fig. 35_Initial situation.
Fig. 36_Situation
five months post-op.
Fig. 37_Final result.

Based on the data gathered, the treatment plan
was then presented to the patient in 3-D on models
mounted in the articulator and in 2-D with a
Keynote presentation, allowing her to understand
the present situation, treatment proposed and
simulated final outcome.
Following the treatment proposal and acceptance, the case was sent to the dental laboratory,
where the dental ceramist fabricated a wax-up
and a stone model based on the clinician’s diagnostic findings (Figs. 15–17). A crown-lengthening
surgical guide (a vacuum-formed Essix appliance)
was manufactured on a duplicate model of the
wax-up for ideal osseous contouring during the
surgical procedure (Fig. 18). The gingivectomy was
performed following exactly the gingival margin
of the wax-up and then used for guiding the
osseous contouring, through which a biologic
width of a minimum of 2 mm was maintained
(Figs. 19–24).
The mock-up should be placed before the surgical appointment for an initial evaluation and then
ideally six to eight weeks post-crown lengthening.
If done earlier, a very well-adapted indirect acrylic
prototype would be advised or the utmost care in
adaptation of the bis-acrylic resin (Figs. 25–27).
For the ultimate control and when time management in a private office is not an issue, the osseous
contouring is performed and the flap is closed,
followed by guided gingivectomy and mock-up
placement at the next appointment in two to
three months’ time. With this approach, the risk of
recession or invasion of biologic width is reduced
to the minimum.
Controlled tooth preparation was performed
through the mock-up using 0.6 mm depth-gauge
burs (Figs. 28 & 29). In designing restorations, the
diagnosis of the initial situation and underlying
tooth structure, the new design proposal and the
patient’s expectations play a very important role.
The material of choice in this case was feldspathic
porcelain (VITA Zahnfabrik) on a refractory die in

10 I cosmetic
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Fig. 37

the anterior zone combined with pressed lithium
disilicate (IPS e.max, Ivoclar Vivadent) in the posterior zone (Figs. 30–33). As a rule of thumb, when
a material like feldspathic porcelain is used, which
filters the light through to the underlying structure,
a space of 0.2–0.3 mm is needed per shade change.
The restorations were adhesively cemented using
a total-etch technique and initially tried in with
a translucent try-in paste (CHOICE 2, BISCO, Inc.).
The occlusion was checked after cementation and
a processed acrylic night guard was delivered two
weeks post-operatively. The final result is shown in
Figures 34, 36 & 37)._

_about the author

cosmetic
dentistry

Dr Sebastian Ercus
graduated from the dental
faculty at Ovidius University
in Constanţa in Romania.
He subsequently obtained
a Master of Science degree
in Public Oral Health in 2005
from the same institution.
He completed one year of implant dentistry proficiency
training at Carol Davila University of Medicine
and Pharmacy in Bucharest in Romania in 2006.
He completed the one-year Master Clinician
Program in Implant Dentistry at the Global Institute
for Dental Education in Los Angeles in the US in
2008 and the two-year full-time Advanced Esthetic
and Restorative Dentistry Advanced Clinical Training
Program at the UCLA School of Dentistry in
Los Angeles in 2011. Dr Ercus is a sustaining member
of the American Academy of Cosmetic Dentistry.
He is in private practice in Brussels.
Dental Specialty Center
Av. Franklin Roosevelt 82 bte 1
Ixelles
1050 Brussells, Belgium
smile@sebastianercus.com
www.sebastianercus.com

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www.DTStudyClub.com

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CDE0114_12-16_DelCorso 11.06.14 14:03 Seite 1

I special _ digital smile design

Projecting a new smile
from a facial photograph:
A new way to plan
multidisciplinarydental treatments
Authors_ Dr Marco Del Corso, Italy, & Dr Alain Méthot, Canada
without any significant advances in technique or
case presentation.
Many options are now available to predesign
the most appropriate smile for the patient, such as
computer imaging, diagnostic wax-ups on models
or simply drawing on a patient photograph.4 For
decades, dentists have been using various forms
of software to preview, predict, and plan aesthetic
procedures. Many of these programs lapsed into
obsolescence because it took too long to develop
proper diagnostic marketing or clinical guides.

Fig. 1

Fig. 1_An example of a smile design
simulated in a few minutes
and shown to the patient using
Dental GPS software.

_Introduction
Aesthetic dentistry relies on professional trust,
traditional wax-ups and artistic modifications of
provisional restorations in the mouth to achieve the
desired final result. Many of the published articles
in aesthetic dentistry discuss the same principles in
smile design: Golden Proportion, gingival architecture, emergence profile, and shape related to facial
anatomy.1–3 These principles have been followed

In this article, we demonstrate the use of Dental
GPS software, developed and proven over the last
five years.5 The system uses the parameters captured
by one digital preoperative full-face photograph to
help clinicians with aesthetic diagnosis and automatically generates the best smile virtual wax-ups
in only minutes. The smile prescription is then sent
to the laboratory for technicians to create or transform a new aesthetic smile with precision (Fig. 1).

_From diagnosis to the smile project

Fig. 2a_Clinical case: A young
female patient previously suffering
from gastric reflux came to the clinic
with enamel erosion, gingival
recession and aesthetic demands.
Figs. 2b–d_The restoration of both
maxillary and mandibular arches
aimed at preserving tissue and
improving the aesthetic outcome.

12 I cosmetic
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The system generates the virtual wax-up and
laboratory prescription within minutes with the
digital facebow, which captures the exact position
of the dental and facial midline with the occlusal
plane to prevent canting and shifting of patient
cases. The diagnosis and treatment planning system
also uses the M Ruler, an algorithm that analyses
the best position of all maxillary teeth on a digital
image to design the smile.5 Compared with the
Golden Proportion, which offers only one ratio,
1: 618, the M Ruler determines the patient’s own
unique ratio for smile design.
Fig. 2a

The program is used for diagnosing, planning
and executing changes in the position, shape, di-

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special _ digital smile design

Fig. 2b

mension, and proportion of the teeth. The first advantage of this tool is the rapidity in sharing the
aesthetic proposal with the patient, making him
or her an active participant in the treatment plan.
The precision in transferring all the co-ordinates of
the computer-simulated 2-D proposal into a 3-D
wax-up allows the lead dentist, all associated specialists and the laboratory technician to access and
share information regarding the treatment plan,
ongoing procedural status, and the final results of
the case. Should any midstream correction be necessary, it is relatively simple to inform and receive
consent from all involved.

_Diagnosis
Diagnosis is simply achieved by importing a
facial photograph into the GPS software and the
program then establishes the best smile parameters
for the patient.

Fig. 2d

Fig. 2c

A full-face photograph of the patient is taken
directly from the front by placing the lens in line
with the patient’s nose (Fig. 2a). The facial photograph is taken with the patient’s Frankfurt horizontal plane parallel to the floor. The inter-pupillary line
is not important in this process because often one
eye is lower than the other. The long axis of the face
and the upper lip line are the reference planes for
diagnosis and treatment planning.
The digital facebow provided by the software is
adjusted by the operator to fit along the incisal
edges and the dental midline of the patient. Then,
the digital facebow is rotated to fit the long axis
of the face on the vertical axis and the upper lip on
the horizontal aspect (Fig. 3).
The photograph is automatically zoomed out to
place the M Ruler over the face. This helps the clinician to diagnose facial or maxillary asymmetries,

Fig. 3

Fig. 5

Fig. 3_The digital facebow of the
program is adjusted to fit along the
incisal edges and the dental midline
of the patient.
Fig. 4_When the digital facebow has
been set, the system automatically
zooms in on the mouth with the
M Ruler over the patient’s teeth.
Fig. 5_The M Ruler helps to diagnose
facial and dental asymmetries
to provide the most aesthetic tooth
position, shape, and smile design
for the patient’s facial frame.
Fig. 6_The M Ruler guides the
clinician in creating a virtual wax-up
for the best smile design using
specific libraries. The result
is precise because the image
is calibrated to maxillary
incisors dimensions.

Fig. 4

Fig. 6

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I special _ digital smile design
These vertical lines guide professionals in determining the best position of the maxillary arch and teeth
in relation to the patient’s face and in relation to the
patient’s lips and gingiva for smile design.

Fig. 7_The M Ruler.

Fig. 7

malpositioned teeth, gingival architecture discrepancies, improper axial inclination, dental midline
deviation, or indications for maxillofacial surgery
and/or orthodontic treatment (Fig. 4).
Without the patient’s facial data, it is impossible
to evaluate the smile and its harmony within the
patient’s face properly. As part of the diagnosis, it
is necessary to evaluate facial and dental asymmetries. As practitioners, we need to keep global
aesthetics in mind by using a full facial view in the
laboratory (Fig. 5). Close-up photographs of the
patient’s smile aid smile design, but the complete
facial photograph is required to evaluate the smile
on the patient’s face.6

_Simulation

Fig. 8_The before and after
simulation usually shown
to the patient at the end
of the first consultation.
Figs. 9a & b_The prescription
resulting from the software
(a) gives the laboratory the
co-ordinates necessary to mount
the model on to the articulator
and to wax up the final work.
Specific guidelines help the
technician to create a very precise
wax-up of the future smile (b).

Fig. 8

Computer software creates a simulation as a
virtual wax-up. The practitioner uses the virtual
wax-up in the diagnostic process to determine the
treatment options appropriate for the patient, such
as orthodontics, crowns, implants, bridges, or full or
partial dentures. This process aids the practitioner
in presenting and discussing different options with
the patient during a consultation (Fig. 6).
The diagnosis and treatment planning use the
M Ruler. This diagnostic tool for smile design uses
an algorithm based on maxillary central incisors
width and the width of the patient’s maxillary
arch to display an ideal arrangement of all the
teeth shown in the smile (Fig. 7). Each patient has
a unique maxillary arch width and upper central
width. Maxillary teeth best position should be disposed between those lines in respect of the width of
the upper arch and the width of the central incisors.

The computer software simulation or virtual
wax-up can be generated within minutes, and helps
(or guides) the clinician in determining treatment
options, which can be discussed with the patient
during the same consultation.
In this particular clinical case, the simulation
suggested longer central incisors to create a smile
line that would follow the lower lip and lend a more
pleasing proportion to the smile. Tooth whitening
was also indicated (Fig. 8).

_Communicating with the laboratory
After the virtual diagnostic wax-up, the patient
was informed of the treatment options, including
no treatment at all, and the risks, benefits, and costs
of treatment. Informed consent was obtained for
the treatment, which entailed placing ten veneers
from the second premolar to the opposite second
premolar on the maxillary arch and ten veneers on
the mandibular arch.
Once the simulation (Fig. 8) had been accepted
by the patient, alginate impressions of the maxillary
and mandibular arches were poured with white
stone and sent to the laboratory with a bite registration6, 7 taken using LuxaBite (DMG America).
The aesthetic prescription was sent to a certified
dental laboratory, which mounted the 3-D model on
to an articulator in accordance with the GPS smile
prescription and waxed up the final work following the future smile line (Figs. 9a & b). Because of
the image’s calibration, the wax-up coordinates are
very precise (Fig. 10).
Laboratory communication is a critical factor in
the development of a diagnostic wax-up. In order
to reproduce the simulation (virtual wax-up), the
laboratory technician requires the position of soft

Fig. 9a

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special _ digital smile design

Fig. 9b

Fig. 11a

tissue on the articulator. After simulating the final
outcome with respect to the rest of the face, the
GPS digital facebow will position the maxillary cast
on the articulator with the exact pitch, yaw and row
of the photograph to reproduce the virtual wax-up
on provisional and final restorations. The M ruler
guides the wax-up of the future smile. This process
is actually the easiest way to transmit the entire
aesthetic data concerning the facial soft tissue to
the laboratory.

_Project realisation
The model’s wax-up was used to fabricate a
preparation guide8 to perform minimally invasive
preparation, controlling ceramic thickness and
maintaining the structural integrity of the tooth.8, 9
A silicone impression of the wax-up was taken with
Sil-Tech Putty (Ivoclar Vivadent) and the impression
was filled with Luxatemp provisional material in
shade A2 (Luxatemp, DMG, USA) and then relined to
the prepared teeth in order to create a mock-up.
Once the wax-up had been used to create a
precise mock-up, the mock-up was scanned and
constituted the ghost guide for the CEREC system
(Sirona) to project (Figs. 11a–c) and produce chairside ten maxillary and mandibular veneers using IPS
Empress CAD blocks (Ivoclar Vivadent). The final
restorations were successively stained, glazed and
cemented with shade A3 Variolink (Ivoclar Vivadent;
Figs. 12a & b).
At the end of treatment, the smile line had been
corrected to follow the lower lip line contour, and
the final smile results were in harmony with the
patient’s face. Both maxillary central incisors were
dominant and had been designed to the specific
width and length by the GPS program to suit the

Fig. 10

Fig. 11c

Fig. 11b

patient’s face. The final aesthetic outcome fulfilled
the patient’s expectations, and an improved smile
and facial appearance were achieved (Figs. 13a & b).

_Discussion
By using a simple preoperative facial photograph of the patient, the dental practitioner can
diagnose, create a treatment plan, and produce
with precision a virtual wax-up and laboratory
prescription in less than 10 minutes. The software
in this case uses the M Ruler to determine the
best smile for the patient.
The Golden Proportion Rule, or Divine Rule, represents a ratio of 1:1.618. This ratio has been used in
a multitude of applications for many years, and is
well known in the arts and architecture, dating back
many centuries. Over the course of time, this Golden
Proportion Rule has been applied to facial aesthetics and dentistry to provide mathematical guidelines for the creation of pleasing and aesthetic
smiles by the determination of the appropriate
proportions of the central and lateral incisors, and
the canines in the smile. However, many authors
have observed that natural teeth do not follow the
Golden Proportion Rule for the display of teeth8, 10, 11
and this rule cannot be universally applied to all
patients. In order to achieve a good aesthetic result,
the ratio of the Golden Proportion Rule must be
changed or adapted for each patient.

Fig. 10_Once the wax-up has been
calibrated to the 2-D virtual
simulation, the realisation of the
project is very easy and will respect
the preprogrammed aesthetics.
Individualization of the final
ceramics is possible.
Figs. 11a–c_Prepared teeth and
project (a) are scanned using the
chairside CEREC Software 4.2.
The wax-up (b) is scanned and used in
“ghost” modality to guide the creation
of the definitive restorations (c).
These are milled with the
CEREC MC XL milling unit.

This modified Golden Proportion Rule is achieved
by application of a mathematical formula relating
to the inter-molar distance of each patient, representing the width of the arch and the width of the
central incisors to determine the correct balance
for the teeth displayed within that arch to create
a pleasing smile.5

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I special _ digital smile design

Fig. 12a

Fig. 12b

Fig. 13a

Fig. 13b

Figs. 12a & b_The final restorations
were realised with a CAD/CAM
technique using IPS Empress
CAD blocks milled with
the CEREC system.
Figs. 13a & b_The final smile
and facial improvement.
The smile design contributes
to the changed facial appearance.

The virtual wax-up generated by the computer
generates an electronic prescription that can be
sent to the laboratory to create an accurate wax-up
of the proposed smile. Once the position of the maxillary cast correlates to the smile prescription and
the articulator, it is possible to fabricate provisional
and final restorations that match the virtual wax-up
with the software. This guides the laboratory technician in arranging each final restoration according
to length, width and position to establish the new
smile line, occlusal plane, and vertical dimension of
occlusion (Figs. 13a & b). The ceramist simply follows
the GPS digital prescription to create the final
restorations.
This new concept allows practitioners to increase their cosmetic workflow in their practice. The
visual simulation allows the patient to understand
the treatment plan from the preoperative image
through to the final cementation of the restorations. Several aesthetic projects can be simulated
and discussed with the patient in the first consultation, whereas traditional laboratory wax-up allows
the patient to visualise only one smile design possibility, often with no idea of the final aesthetic result
with respect to the rest of the face. Traditional
mock-ups also help practitioners and patients to
evaluate the smile design; however, in many cases

16 I cosmetic
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with diastemas or malpositioned teeth, the mockup itself—derived from
the traditional wax-up—
still gives only one alternative and cannot simulate the final result accurately without reducing
teeth. In addition, it entails a great deal of work
to take an impression,
create a wax-up and try
the mock-up in the patient’s mouth for an evaluation. Even if a diagnostic wax-up is made by
the dental laboratory and
shown to the patient, or if
a provisional is made from
the wax-up and tried as
a mock-up in the patient’s
mouth, this single proposed wax-up may not
be the optimal aesthetic
solution for that partic ular patient.12

_Conclusion
This article demonstrates the accuracy of imaging using the digital
facebow, a 3-D cast positioning system that requires a single facial photograph of your patient,
and the M Ruler, a diagnostic device for smile design.
Practitioners are able to fit the best possible smiles
in minutes to the patient’s face by trying different
simulated smiles using morphing technology to
create predictable and pleasing smiles for their
patients. This simple protocol saves significant
time and chairside adjustments. Moreover, patients
receive better cosmetic dental treatment by seeing
their best custom smiles, and can actively participate in the smile design process._
Editorial note: A complete list of references is available
from the publisher.

_about the authors

cosmetic
dentistry

Dr Marco Del Corso (DDS, DIU) is in private
practice in Turin in Italy. He can be contacted at
marco.delcorso@fastwebnet.it.
Dr Alain Méthot (DDS, MSc) is in private practice
in Laval in Canada. He can be contacted
at alain@drmethot.com.

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P R O F E S S I O N A L

M E D I C A L

C O U T U R E

EXPERIENCE OUR ENTIRE COLLECTION ONLINE
WWW.CROIXTURE.COM

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I case report _ ceramic veneers

Non-invasive reconstruction
with ceramic veneers—
Art or compromise?
Authors_ Dr Magdalena Jaszczak-Małkowska & Robert Michalik, Poland

Case 1:
Figs. 1a & b_Exposure of teeth
during smiling and a close-up
of the stumps before preparation.
Visible enamel discolouration
caused by fluorosis.
Figs. 2a & b_A mock-up of the
planned restoration made in the
patient’s mouth based on a wax-up.
Control of smile and occlusion.

Fig. 1a

Fig. 1b

Fig. 2a

Fig. 2b

_My professional evolution proceeded in
parallel with the change of the concept of
“aesthetics” and the accompanying technological
revolutions. By nature, humans are open to
novelties, regardless of the correctness of their
application. Over time, my professional experience has confirmed the principle that the key
to success is thorough planning of each case,
detailed diagnostics before commencing work,
and the resulting proper selection of materials
and procedures. Success is created by efficient
communication between the patient, the dentist
and the dental technician. Nowadays, patients
can use all kinds of media (mostly online) to learn
about dental problems they have. In many cases,
patient education helps to establish expectations
regarding a prosthetic solution. However, we
should not forget that we should always realistically assess our reconstructive capabilities in a
given case. My experience has taught me that one
should not submit to the patient’s desires if this
interferes with a treatment plan or our feelings.
The challenge for the whole team is to achieve

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a compromise between aesthetics, functionality
and the technological possibilities. Achieving
a common vision for the restoration ensures
ultimate success and satisfaction.
From the beginning of my professional career,
I have sought to find a happy medium between
my expectations, those of the patient and medical
indications, to achieve full health and harmony
of the smile. Contrary to appearances, it is an
extremely difficult task, and the higher the sense of
aesthetics the dentist possesses, the more difficult
the task. Patients often come to me with a request
to improve their smile and create beautiful teeth.
As I have already mentioned, media and often
dentists themselves have accustomed patients to
the idea that beauty is defined by the whiteness
of one’s teeth. As a result, the patient does not
receive beautiful, natural and functional dentition,
but a set of white dentures, often made in a way
that does not allow him or her to function efficiently and perform basic hygiene. Frequently,
in order to achieve such an effect, tooth tissue

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case report _ ceramic veneers

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 4a

Fig. 4b

Fig. 4c

is permanently lost, which, as we know, can lead
to many, even long-term, complications. We are
primarily doctors and, in achieving patient satisfaction, we must not forget the overarching objective, which is treatment, and this must be achieved
by avoiding any harm to our patients. Of course,
“aesthetics” is a relative notion, but it is we who,
from the perspective of our profession and experience, should shape the aesthetic desires of our
patients and present the best solutions to them.
Our activity in this respect is an art and it should
be treated as such.
In order to attain success in treatment, we
have at our disposal an increasing choice of
modern equipment, technologies and materials.
Each technology requires human input. Contact
with a person of similar sensibility and sense
of aesthetics is essential; with a person who is
able to understand and meet the often-high
demands of the patient and the dentist. This
person is the dental technician, who contributes
equally to our success, the achievement of

which is not possible without complete understanding. His or her work should also be considered an art.
In the cases presented, the primary objective
was to achieve the maximum aesthetic effect with
minimally invasive treatment, especially because
the cases concerned young patients. We wanted
our work to be a harmonious and functional addition to the patient’s smile, adapted to the individual case and not a replica of a standard matrix.
In order to choose a method of treatment to
achieve this goal, we considered each case according to the following:
(a) case description;
(b) analysis of the white and red aesthetics
(analysis of the planned restoration aesthetics
in the context of facial features, lip shape, smile
lines and characteristics of the patient’s own
teeth);
(c) analysis of occlusion and articulation;
(d) treatment plan and choice of material.

Figs. 3a–c_Prepared stumps from
teeth 12 to 22. Visible minimally
invasive preparation of the enamel
and no chamfer preparation
of the gingival area.
Figs. 4a–c_Fitting of the finished
veneers showing visible ceramic
shading around the gingival zone
to about 0.1–0.2 mm.

Figs. 5a–f_Comparison
of the veneers before and after
cementation. No visible
veneer–stump junction after
placement. The colour is the result
of the colours of the veneers,
cement and stumps.

Fig. 5a

Fig. 5b

Fig. 5c

Fig. 5d

Fig. 5e

Fig. 5f

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I case report _ ceramic veneers

Fig. 6a

Fig. 6b

Fig. 6c

Fig. 7a

Fig. 7b

Fig. 7c

Figs. 6a–c_Comparison of the
teeth before and after treatment.
The black and white photograph
shows the texture
of the veneer surfaces.
Figs. 7a–c_Aesthetics before
and after treatment. Perfect
adaptation of the colour, shape
and texture of the veneers compared
with the patient’s natural teeth.

Case 2:
Figs. 8a & b_Exposure of the
maxillary incisors during smiling
and close-up of the stumps
before treatment.
Figs. 9a & b_The mock-up
in the patient’s mouth.
Exposure control of the teeth during
smiling and in occlusion.
Figs. 10a & b_Correction
of the gingival margin.

_Case 1
Case description
A 24-year-old male patient came to the practice
for improvement of the aesthetics of his anterior
teeth. During the anamnesis, he reported dissatisfaction with the discolouration and shape of his
maxillary incisors, but was satisfied with the colour of the rest of his teeth. The patient confirmed
endogenous application of fluoride during childhood, which may have been the aetiology of the
existing discolouration. The patient’s priority was
the least invasive prosthetic treatment with a
natural and aesthetic restoration.
Analysis of white and red aesthetics
Smile and intra-oral images (Figs. 1a & b) were
taken, and diagnostic models were prepared. With
the lips in rest position, 2–3 mm of the maxillary
incisors was visible. The full length of the maxillary incisors and the anterior gingival margin

were visible in a smile. The contour of the maxillary incisors appeared excessively rounded in
relation to the patient’s masculine facial features.
Analysis of occlusion
Diagnostic models were mounted in an articulator after facebow registration and centric
relation (CR) registration (Dawson’s technique).
In CR, the first contacts occurred on the palatal
cusps of the premolars on the right side. Preliminary equilibration on the models was performed.
The correction concerned the premolar palatal
cusps (medial slopes) on the right side and then
in the same way on the left side, and the buccal
cusps of the premolars on both sides (medial
slopes) with lateral movements. Equilibration was
performed until CR was in accordance with the
maximum intercuspal position (CR = MIP) with
preserved occlusion and until canine guidance
on both sides during lateral movements was
obtained. Then intra-oral equilibration was performed similar to the models. The equilibration

Fig. 8a

Fig. 8b

Fig. 9a

Fig. 9b

Fig. 10a

Fig. 10b

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case report _ ceramic veneers

Fig. 12

Fig. 11

was performed using 14 µm-thick articulating
paper with a fine, pear-shaped drill bit (redcoated) mounted on a 1: 5 increasing handpiece
on a micromotor.
Subsequent to completion of equilibration, the
corrected surfaces were polished. Again, diagnostic models were created for the wax-up, and
for planning the final scope and type of restoration. On the basis of the wax-up, a mock-up was
made in the patient’s mouth to check the function
and acceptance of the shape of the restoration
(Figs. 2a & b).
Treatment plan
The preparation of feldspathic ceramic veneers
on the maxillary incisors (teeth 12, 11, 21 and 22)
was planned in order to alter the shape of the
incisors, while maintaining the original length
and colour of the teeth. Preserving the natural
colour of the teeth allowed for application of
a more transparent and thus more aesthetically
favourable ceramic, since fluoride discolouration
is present only within the superficial layer of
enamel, which can be removed during preparation. After another clinical analysis, based on
the diagnostic mock-up and consultation with
the patient and dental technician, it was decided
to perform power whitening of the maxillary
canines (teeth 13 and 23) in order to make the
existing discolouration on the labial surfaces the
same colour as the rest of the teeth. This was made
possible by predetermining the aetiology of the
discolouration to be dental fluorosis. Discoloura-

tion caused by demineralisation of enamel would
have become even more visible after the whitening treatment.

Fig. 11_Prepared stumps from teeth
13 to 23. Stump preparation was
limited to smoothing the surface
of the enamel and the removal
of existing composite restorations.
Fig. 12_The finished veneers after
being released from the refractory mass.

Maxillary canine whitening was performed
selectively using a 16 % BriteSmile preparation
(Philips Oral Healthcare) activated by a dedicated
light (two sessions of 20 minutes each). The key
issue for the mechanics and durability of ceramic veneers is not to cross the amelodentinal
junction. Preparation of the stumps was limited
to alignment and rounding of the incisal edges
and to elimination of the most visible discolou ration (Figs. 3a–c). The gingival area was not
subjected to chamfer preparation owing to the
possibility of shading the feldspathic veneers
even up to 0.1 mm. The preparation was performed using a red-coated tip on a 1:5 increasing
handpiece on a micromotor with water-cooling.
After preparation, the enamel surface was
polished with Sof-Lex discs (3M ESPE). Then
a double-layer one-step impression was taken
with polyvinyl siloxane material (BISCO, Inc.).
Because the enamel surface preparation was
performed supragingivally, no retraction cord Figs. 13a–c_Comparation of the
was placed before taking the impression.
teeth before and after treatment.

Fig. 13a

Fig. 13c

Fig. 13b

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I case report _ ceramic veneers

Fig. 14

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Laboratory procedure:
Fig. 14_A model prepared
for duplication.
Fig. 15_Positioning of the stumps
in the polymerisation vessel.
Fig. 16_The stumps coated
with silicone.
Fig. 17_The finished stumps
on the working model.
Fig. 18_The finished model
in an articulator.
Fig. 19_The stumps baked
in a furnace.

Laboratory procedure
After receiving the restorations from the laboratory, their tightness and adherence to the stumps
were checked (Figs. 4a–c). In the case of veneers,
it is not possible to check the contact surface and
articulation before cementation. Therefore, the
cementing of each veneer should be carried out
separately, while checking the passivity of fit of
the adjacent veneer.
It should also be remembered that the final
colour of restoration is the combination of the
colour of the veneer and of the underlying stump
(Figs. 5a–f). Its initial assessment is possible
with Variolink Try-in Paste (Ivoclar Vivadent), but
the final selection of the colour of the adhesive
material depends on the dentist’s experience.
Under rubber dam isolation, the stump surfaces were cleaned with pumice paste, rinsed
thoroughly with water and etched with 37 %
orthophosphoric acid for 45 seconds. Then they
were rinsed with a water spray for the same
period. After that, the Variolink Veneer lightcuring luting composite system was applied. Each
time, the contact surfaces of the adjacent teeth
were isolated using Teflon insulation tape. In the
meantime, the inner surface of the veneers was
etched with 7 % hydrofluoric acid for one minute,
the etching agent was pre-rinsed with a water
spray and the veneers were placed in an ultrasonic
cleaner for two minutes. The etched surface of the
veneers was covered with silane (Monobond Plus,
Ivoclar Vivadent), dried and covered with a bonding agent (Heliobond, Ivoclar Vivadent). Variolink
Veneer in shade High Value +1 was applied to the

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etched surface of the veneers, which were placed
on the stumps. After excess material had been
removed, the veneers were cured for about
ten seconds. The restoration edges were smeared
with glycerine gel to prevent the formation of
an oxygen inhibition layer in the composite.
Each surface was irradiated with a curing light at
800 mW/cm2 for 60 seconds. Excess composite
was removed with a #12 scalpel blade, and
polished with strips and bands for polishing
composites. Finally, the veneers were checked
for occlusion and articulation with 14 µm-thick
articulating paper. Corrections were made with
a 45 µm smooth diamond-coated tip on a 1: 5 increasing handpiece on a micromotor. If any adjustments to the intra-oral ceramics are necessary, it is important to avoid the use of a turbine
owing to its very fast speed and the ability to
cause chipping or microcracks in the porcelain
structure. Finally, the stump–veneer interface
was polished with rubber bands and strips for
polishing composites (Figs. 6a–c). The outcome
of prosthetic treatment was satisfactory to both
the dentist and the patient, both immediately and
in the long term (Figs. 7a–c).

_Case 2
Case description
A 30-year-old female patient came for treatment because of the progressive wear of the masticatory surfaces of the teeth in both the maxillae
and mandible. The patient complained about a
stressful lifestyle and perceptible excessive masseter muscle strain, even after waking up. She also
reported habitual nail biting in stressful situations.

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case report _ ceramic veneers

Fig. 20

Fig. 21

Fig. 22

Fig. 23

Fig. 24

Fig. 25

Analysis of white and red aesthetics
The incisal edges of the maxillary incisors were
not visible with the lips in rest position. There was
a reverse smile line. The gingival margin of the
maxillary incisors and canines was unbalanced
(Figs. 8a & b).
Analysis of occlusion and articulation
A slight tenderness of the masseter muscles
and medial pterygoid muscles was observed.
There were no audible symptoms during abduction and adduction, or during lateral movements.
Mandibular movements were within the normal
range. During load testing of the mandible
according to Dawson’s technique, no pain was
observed. There was generalised abrasion of
the teeth in both the maxillae and the mandible.
No evident points of first contact in CR were
present. There were enamel defects on the vestibular surfaces of the maxillary incisors. Initially,
bruxism was diagnosed without lesions in the
temporomandibular joint.
Treatment plan
An increase in the height of occlusion in CR,
a correction of the gingival margin in the anterior zone, and feldspathic ceramic veneers for
the maxillary canines and incisors were planned.
CR registration was performed with Dawson’s
technique using a wax plate (Bite Registration Wax
wafer, DeLar) after 15-minute deprogramming by
means of a deprogrammer (Lucia Jig) with a flat
surface on the incisors and no contact between

the lateral teeth. Facial arch registration was performed and the models were placed in a partially
adjustable Artex articulator. A diagnostic wax-up
was made, partly reconstructing the worn tissue
of the lateral teeth. Incisal and canine guidance
was obtained in the anterior section. On the basis
of the wax-up, a mock-up was made in the patient’s mouth to obtain acceptance of the shape
and length of the incisors and canines, and to check
the function (Figs. 9a & b).

Fig. 20_Drawing of preparation lines.
Fig. 21_Coating with a ceramic.
Fig. 22_Baking of the ceramic layers.
Fig. 23_Subsequent ceramic layers.
Fig. 24_Finished crowns,
veneer side view.
Fig. 25_Finished crowns,
palate side view.
(Ceramics performed
by Dorota Michalik.)

Occlusal conditions planned on models were
reconstructed in the patient’s mouth with temporary restorations retained for a period of
four weeks, and adjustments to occlusion and
lateral movements at weekly intervals. After the
adaptation period, the temporary restorations
were replaced with final ones. Pressed ceramic
onlays, crowns with a zirconium dioxide core
and direct composite restorations were fabricated for the posterior section. Adjustments to
the gingival margin of the maxillary incisors
and canines were done with a #15 scalpel blade
(Figs. 10a & b) and the effect was maintained
by appropriate shaping of the temporary re storations.
Two weeks after correction of the gingival margin, the final preparation for feldspathic ceramic
veneers on the maxillary incisors and canines was
performed. The preparation was carried out with
a red-coated drill in the shape of a rounded cylinder, followed by smoothing with fine Sof-Lex discs
(Fig. 11). The preparation was limited to the removal of old composite restorations of Black’s
Class V, and to smoothing the facial surface and
the incisal edges.

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I case report _ ceramic veneers
Figs. 26a–d_The aesthetics
of the smile after completion
of the work. The black
and white photographs show
the texture of the veneer
surfaces (case 2).

Fig. 26a

Fig. 26b

Fig. 26c

Fig. 26d

The impressions were taken according to a
double-layer one-step method with polyvinyl
siloxane material of two different resiliences
(BISCO, Inc.). Gingival retraction was performed
using Ultrapak #0 retraction cord (Ultradent).

is based on a homogenous structure of fused
ceramics. There is no intermediate foundation
between the patient’s tooth stump and the veneer ceramics as is the case with crowns fused
to zirconium dioxide or metal. This means that
there are no intermediate steps of control in the
patient’s mouth. The feldspathic veneer or crown
is removed from the refractory mass after sintering. If the diagnosis was not correct and the
patient is not satisfied with the work, there is no
opportunity for any correction. Therefore, as we
have mentioned, this technique, which mimics
the beauty of nature, will yield satisfying results
if the initial analysis and preparation are accurately performed before the fabrication of the
veneers.

Laboratory procedure
The modern concept of “aesthetics” constitutes
a significant challenge in the work of both the
dentist and the dental technician. Society’s desire
to be trendy means not only being associated with
fashionable brands, but also emanating a healthy
lifestyle. We want our design to attract the attention of others; we want others to perceive the
beauty in us. The concept of “beauty” is difficult
to define. But it is certain that beauty results from
the harmony of shape and colour.
The progressive development of technology in
dentistry and dental techniques aids the ongoing
elimination of errors and increase in predictability
in every area of dentistry. However, many treatments still depend on the artistic work of the
dentist and the dental technician.
One area of work in which the technology
has remained unchanged for many years is the
feldspathic technique of the direct application of
ceramics to a refractory mass followed by fusion.
This technique offers the best cosmetic results.
If we combine it with an artistic shape, we can
achieve the full harmony of beauty.
This technique requires above all a perfect initial diagnosis. Why? The feldspathic technology

24 I cosmetic
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1_ 2014

Although the physical parameters of the
material are unfavourable, restorations made
from it—after correct adhesive application—
are the least defective type of ceramic restoration.
Of course, their application requires the fulfilment of many conditions, in the absence of which
the work would fail. Feldspathic restoration
can be performed only on incisors with straight
chamfer preparation around the perimeter of the
tooth. It is important that the patient demonstrate correct incisal and canine guidance, as well
as lateral support.
This type of restoration allows a dramatic
reduction in the amount of preparation of the
patient’s tooth. Therefore, we can use it to restore
lost tissue and change colour, as well as to successfully correct diastemas and rotate teeth.
The obtained values of veneer wall and crown

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case report _ ceramic veneers

thickness range from 0.2 to 1 mm. Different wall
thicknesses on the same veneer are not recommended with the foundation ceramic veneer
technique.
The fabrication process begins with impression taking of the tooth stumps (Fig. 14) in silicone
and obtaining duplicates of these stumps in
plaster in a refractory mass (Figs. 15 & 16). It is
important that the position of the plaster stumps
in the model coincide perfectly with the position
of the stumps in the refractory mass (Figs. 17 &
18). In order to achieve this, one should use an appropriate polymerisation vessel and removable
pins (Fig. 18). Stumps produced in the refractory
mass should be baked in a furnace according to
the manufacturer’s instructions (Fig. 19). The next
step is drawing preparation lines with a pencil
designed for withstanding high temperatures
(Fig. 20). Then the technician applies glaze to
the stumps, creating a glossy surface owing to
the ceramic microfilm, to protect them from
possible damage. The prepared stumps are then
ready for coating with an appropriate ceramic
in layers, forming the desired veneer shape
(Figs. 21–23).
The most complicated tasks are removing the
refractory mass from the thin layer of ceramic and
checking the marginal fit on the working model
(Figs. 24 & 25). The process requires skill and
attention from the dental technician. Structures
of 0.2 mm in thickness are very brittle and even
the slightest bending can break the veneer. The
mass is removed by sandblasting at 0.1 MPa with
50 µm sand. The prepared veneers are then ready
to be placed in the patient’s mouth. Careful work
will be confirmed by marginal fit and colour
compatibility.
After receiving the restorations from the laboratory, checking of the passivity of fit of the
veneers on the stumps was performed. Cementation, adjustment and final polishing were
carried out in the same way as in the first case.
After cementation, the restorations were perfectly integrated with the gingival zone, and
mimicked the characteristics and structure of the
patient’s natural teeth. The outcome of prosthetic
treatment was satisfactory to both the dentist
and the patient, both immediately and in the long
term (Figs. 26a–d).

Owing to proper assessment of the conditions
and to the selection of suitable material, the
objective could be achieved for both patients.
The patients received restorations perfectly harmonised with their own teeth and facial features.
In addition, the application of the proper criteria
for assessment of the cases and for indications for
rehabilitation with feldspathic ceramic veneers
ensured the functionality and durability of the
restorations, which have been confirmed by
several years of observation._

_about the authors

cosmetic
dentistry

Dr Magdalena
Jaszczak-Małkowska,
DMD, graduated from the
Medical University of Warsaw
in 1996. Until 1998, she was
a collaborator with the Institute
of Genetics and Animal
Breeding of the Polish
Academy of Sciences. In 2008, she obtained
a certificate in Prosthodontics. She has worked
in a private practice specialising in aesthetic
and prosthodontic dentistry since 2000. She may
be contacted at m.jaszczak@estedentica.pl.
ESTEDENTICA
ul. Dobra 27/A
00-344 Warszawa, Poland
Robert Michalik graduated
from the Faculty for Dental
Technicians in Warsaw Medical
School in Poland in 1987.
After two years of work in the
university’s dental laboratory,
he opened his own dental
laboratory, Inter-Dent, which
he is still running. In 2003, he was the first in
Poland to start working with dental CAD/CAM
systems. In 2007, he began development of the
first Polish CAD/CAM system in collaboration with
Delcam and 3Shape. Also in 2007, he submitted
an application to patent a method of creating
telescopic crowns with intermediate crowns.
He is the author of several articles for the trade
press and may be contacted at info@inter-dent.pl.

_Conclusion

Laboratorium Inter-Dent
ul. Pustułeczki 23
02-811 Warszawa, Poland

In both of the cases presented, the patients
came to the dental clinic to improve the aesthetics
of their smiles with minimally invasive treatment.

www.inter-dent.pl

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I review _ ceramics

Ceramics overview:
Classification by microstructure
and processing methods
Authors_ Profs. Edward A. McLaren & Russell Giordano, USA

Fig. 1

Fig. 2a

Fig. 1_A scanning electron
micrograph of the microstructure
of a glass veneer porcelain.
Figs. 2a & b_An anterior porcelain
veneer restoration.

Fig. 3_A scanning electron
micrograph of the microstructure
of a feldspathic veneer porcelain.
Acid etching removes the glass
and reveals the leucite glass.
Fig. 4_A metal–ceramic restoration.
(Ceramics performed
by Yi-Wing Chang.)
Fig. 5_A scanning electron
micrograph of the microstructure
of a pressable ceramic.
Leucite crystals reinforce the glass.

Fig. 3

_Abstract
The plethora of ceramic systems available today
for all types of indirect restorations can be confusing and overwhelming for the clinician. Having
a better understanding of them is important. In this
article, the authors use classification systems based
on microstructural components of ceramics and the
processing techniques to help illustrate the various
properties.

_Introduction
Many different types of ceramic systems have
been introduced in recent years for all types of
indirect restorations, from very conservative nonpreparation veneers, to multi-unit posterior fixed
partial dentures and everything in between. Understanding all the different nuances of materials and
material processing systems is overwhelming and

Fig. 4

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Fig. 2b

can be confusing. This article will cover what types
of ceramics are available based on a classification
of the microstructural components of the ceramic.
A second, simpler classification system based on
how the ceramics are processed will give the main
guidelines for their use.
The term “ceramic” derives from the Greek
“keramos”, which means “a potter or a pottery”.
This word is related to a Sanskrit term meaning
“burned earth”, since the basic components were
clays from the earth heated to form pottery. Ceramics are non-metallic, inorganic materials. Ceramics
refer to numerous materials, including metal oxides,
borides, carbides, nitrides and complex mixtures
of these materials.1 The structure of these materials
is crystalline, displaying a regular periodic arrangement of the component atoms, and may exhibit
ionic or covalent bonding. Although ceramics can
be very strong, they are also extremely brittle and

Fig. 5

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Fig. 6a

Fig. 6b

will catastrophically fail after minor flexure. Thus,
these materials are strong in compression but weak
in tension.
Contrast that with metals: metals are non-brittle (display elastic behaviour) and ductile (display
plastic behaviour). This is because of the nature of
the interatomic bonding, which is called metallic
bonds; a cloud of shared electrons that can easily
move when energy is applied defines these bonds.
This is what makes most metals excellent conductors.

Fig. 7

can be very confusing. Ceramics can be classified
by their microstructure, (i.e. amount and type
of crystalline phase and glass composition). They
can also be classified by processing technique
(powder/liquid, pressed or machined) and by their
clinical application. We will give a classification
based on the microstructure of ceramics, with
the inclusion of how the ceramics are processed
and the effect of this on durability, to help the
reader better understand the ceramics available
in dentistry.

Figs. 6a & b_A pressed
ceramic restoration.
Fig. 7_A scanning electron
micrograph of the microstructure
of a lithium disilicate glass-ceramic.
Acid etching reveals the fine
crystal structure.

_Microstructural
classification
Ceramics can be very translucent to very opaque.
In general, the more glassy the microstructure
(i.e. non-crystalline), the more translucent; and the
more crystalline, the more opaque. Many other
factors contribute to translucency, for example,
particle size, particle density, refractive index and
porosity to name a few.

_Different types of ceramics
used in dentistry
The term “ceramic” technically refers to a
crystalline material. Porcelain is a mixture of
glass and crystal components. A non-crystallinecontaining material is simply a glass. However,
dentistry typically refers to all three basic materials as dental ceramics. How ceramics are classified

Material

Inlays, onlays, veneers

At a microstructural level, we can define ceramics by the nature of their composition of glass–
crystalline ratio. There can be infinite variability in
the microstructures of materials but they can be
broken down into four basic compositional categories with a few subgroups:
_Category 1: glass-based systems (mainly silica);
_Category 2: glass-based systems (mainly silica)
with fillers, usually crystalline (typically leucite or
a different high-fusing glass);
_Category 3: crystalline-based systems with glass
fillers (mainly alumina); and
_Category 4: polycrystalline solids (alumina and
zirconia).

Table 1_A clinical use
selection guide.

Anterior crowns Posterior crowns Anterior bridges Posterior bridges Translucency

Leucite/feldsparbased pressable

YES

Lithium disilicate

YES

Alumina

YES

VITA In-Ceram ALUMINA

YES

VITA In-Ceram SPINELL

YES

VITA In-Ceram ZIRCONIA

YES

Pure zirconia

YES

VITABLOCS Mark II

YES

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Fig. 8a

Fig. 8b

Figs. 8a & b_IPS e.max restorations
replacing existing amalgam.
Fig. 9_A scanning electron
micrograph of the microstructure
of VITA In-Ceram ALUMINA.

1. Category 1: Glass-based systems
Glass-based systems are made from materials
that contain mainly silicon dioxide (also known as
silica or quartz) and various amounts of alumina (or
aluminium oxide, chemical formula Al2O3). Aluminosilicates found in nature that contain various
amounts of potassium and sodium are known as
feldspars. Feldspars are modified in various ways to
create the glasses used in dentistry. Synthetic forms
of aluminosilicate glasses are also manufactured
for dental ceramics. We could not find any doc umented references that demonstrated that nat urally occurring aluminosilicate glasses perform
better or worse than synthetic glasses, even though
there have been claims to the contrary. These materials were first used in dentistry to make porcelain
denture teeth.
The mechanical properties are low flexural
strength, usually in the 60–70 MPa range. Thus, they
tend to be used as veneer materials for metal or
ceramic substructures, as well as for veneers using
either a refractory die technique or a platinum foil.
The microstructure of a glass is shown in Figure 1.
This is an electron micrograph of an acid-etched
glass surface. The holes indicate a second glass,
which was removed by the acid. The veneer restoration uses a glassy porcelain (Figs. 2a & b).
2. Category 2: Glass-based systems
with crystalline second phase, porcelain
This category of materials has a very large
range of glass–crystalline ratios and crystal types.
So much so that we can subdivide this category
into three groups. The glass composition is similar
to the pure glass of category 1. The difference is
that varying amounts of different types of crystals
have been either added or grown in the glass
matrix. The primary crystal types today are leucite,
lithium disilicate and fluorapatite. Leucite is created in dental porcelain by increasing the potassium oxide (chemical formula K2O) content of the
aluminosilicate glass. Lithium disilicate crystals
are created by adding lithium oxide (chemical formula Li2O) to the aluminosilicate glass. It also acts

28 I cosmetic
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Fig. 9

a flux, lowering the melting temperature of the
material.
These materials have also been developed into
very fine-grained machinable blocks, VITABLOCS
Mark II (VITA Zahnfabrik), for use with the CEREC
CAD/CAM system (Sirona Dental Systems). This material is the most clinically successful documented
machinable glass for the fabrication of inlays and
onlays, with all studies showing a less than 1 % per
year failure rate, which compares favourably with
metal–ceramic survival data.2–7 The benefit of a premanufactured block is that there is no residual
porosity in the finished core that could act as a weak
point, which could lead to catastrophic failure.
2.1 Subcategory 2.1: Low to moderate
leucite-containing feldspathic glass
Even though other categories have a feld spathic-like glass, these materials have come to be
called “feldspathic porcelains” by default. Leucite
may alter the coefficient of thermal expansion (CTE)
of the material, as well as inhibit crack propagation,
which improves the strength of the material. The
amount of leucite may be adjusted in the glass,
based on the type of core and the required CTE.
These materials are the typical powder/liquid materials that are used to veneer core systems and are
the ideal materials for porcelain veneers.
The original materials had a fairly random size
and distribut leucite crystals, with the average particle size being around several hundred microns.
This random distribution and large particle size contributed to the materials’ low fracture resistance
and abrasive properties relative to enamel.8 Newer
generations of materials (e.g. VITA VM 13, VITA
Zahnfabrik) have been developed with much finer
leucite crystals (10–20 µm) and very even particle
distribution throughout the glass. These materials
are less abrasive and have much higher flexural
strengths.9 An electron micrograph of a typical
feldspathic porcelain reveals a glass matrix surrounding leucite crystals (Fig. 3). The most common
use of these materials is as veneer porcelains for
metal–ceramic restorations (Fig. 4).

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Fig. 10a

2.2 Subcategory 2.2: High leucite-containing
(approximately 50 %) glass, glass-ceramics
The microstructure of these materials consists
of a glass matrix surrounding a second phase of
individual crystals. The material starts out as a
homogeneous glass. A secondary heat treatment
nucleates and grows crystals that give this class of
materials improved mechanical and physical properties owing to the physical presence of the crystals
and generation of compressive stress around the
crystals. Glass-ceramic materials may be ideally
suited for use as dental restorative materials. Glassceramics generally have improved mechanical and
physical properties, such as increased fracture resistance, improved thermal shock resistance, and
resistance to erosion. Improvements in properties
are dependent upon the interaction of the crystals
and glass matrix, as well as on the crystal size and
amount. Finer crystals generally produce stronger
materials. Glass-ceramics are in widespread use for
cookware, missile nose cones, and even heat shields
on space vehicles. They may be opaque or translucent, depending upon the chemical composition
and percentage of crystallinity. A fundamental
method of improving strength and fracture resistance is to add a second phase to a glass material,
causing dispersion strengthening. The crystals may
act as roadblocks to crack propagation. A crack
spreading from a defect must go through or around
the crystal, which takes some energy away from the
propagating crack and may stop its progress. Thus,
the restoration may continue to function instead of
being cracked in half. In addition to the roadblock
effect, compressive stresses around the growing
crystals may help pin cracks and further enhance
fracture resistance.
The most widely used version is the original
pressable ceramic, IPS Empress (Ivoclar Vivadent),
but there are several other products in this category (Figs. 5, 6a & b). A number of pressable materials with properties and microstructures similar
to IPS Empress are available. This include Finesse
(DENTSPLY), Authentic (Jensen), PM9 (VITA) and
OPC (Pentron). A machinable version, IPS Empress
CAD (Ivoclar Vivadent), designed for both the

Fig. 10b

CEREC (Sirona) and E4D Technologies (Planmeca)
CAD/CAM systems for high-leucite ceramics, has
performed well clinically when used for posterior
inlays and onlays, as well as anterior veneer and
crown restorations.9–14 Machinable and pressable
systems have much higher fracture resistance
than powder/liquid systems, and have shown
excellent clinical results for posterior inlay and
onlay applications, and anterior veneer and crown
restorations.2–7, 10–14

Fig. 10c

Figs. 10a–c_A VITA In-Ceram
SPINELL crown.

2.3 Subcategory 2.3:
Lithium disilicate glass-ceramic
This is a type of dental glass-ceramic originally
introduced by Ivoclar Vivadent as IPS Empress II
(and later in the form of IPS e.max pressable and
machinable ceramics). Increasing the crystal content to about 70 % and refining the crystal size
achieved improvements in flexural strength. The
glass matrix consists of a lithium silicate with micron-size lithium disilicate crystals in between
submicronlithium orthophosphate crystals (Figs. 7,
8a & b). This creates a highly filled glass matrix.
A veneer porcelain consisting of fluorapatite
crystals in an aluminosilicate glass may be layered
on to the core to create the final morphology
and shade of the restoration. The shape and the
volume of crystals increase the flexural strength
to about 360 MPa, or about three times that of
IPS Empress.15–19 This material can be very translucent even with the high crystalline content. This
is due to the relatively low refractive index of the
lithium disilicate crystals. This material is translucent enough that it can be used for full contour
restorations or for the highest aesthetics and can
be veneered with special porcelain. Veneer porcelain consisting of fluorapatite crystals in an aluminosilicate glass may be layered on the core to
create the final morphology and shade of the
restoration. Fluorapatite is a fluoride containing
calcium phosphate (chemical formula Ca5(PO4)3F).
The fluorapatite crystals contribute to the veneering porcelain’s optical properties and CTE so that
it matches the lithium disilicate pressable or
machinable material. Both the veneering material
and the lithium disilicate material are etchable

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Fig. 11

Fig. 12a

Fig. 11_A scanning electron
micrograph of the microstructure
of an alumina ceramic.
Figs. 12a & b_Alumina
anterior crowns.

owing to the glassy phase. Initial clinical data for
single restorations with this material is excellent,
especially if it is bonded.20
3. Category 3: Interpenetrating phase ceramic
VITA In-Ceram (VITA Zahnfabrik) consists of a
family of all-ceramic restorative materials based
on the same principle introduced in 1988. The
family includes a range of strengths, translucencies
and fabrication methodologies designed to cover
the wide scope of all-ceramic restorations, including veneers, inlays, onlays, anterior and posterior
crowns, and bridges. VITA In-Ceram SPINELL (alumina and magnesia matrix) is the most translucent,
of a moderately high strength and used for anterior
crowns. VITA In-Ceram ALUMINA (alumina matrix)
is of high strength and moderate translucency,
and is used for anterior and posterior crowns. VITA
In-Ceram ZIRCONIA (alumina and zirconia matrix)
has a very high strength and lower translucency, and
is used primarily for three-unit posterior bridges.
Additionally, these materials are supplied in a block
form for producing milled restorations using a
variety of machining systems.
VITA In-Ceram belongs to a class of materials
known as interpenetrating phase composites.21
They consist of at least two phases that are intertwined and extend continuously from the internal
to the external surface (Fig. 9). These materials possess improved mechanical and physical properties
relative to the individual components owing to
the geometrical and physical constraints that are
placed on the path that a crack must follow to cause
a fracture. A tortuous route through alternating
layers of both components is required to break
these materials.
Interpenetrating phase materials are generally
fabricated by first creating a porous matrix, in
the case of VITA In-Ceram a ceramic sponge. The
pores are then filled by a second-phase material,
a lanthanum aluminosilicate glass, using capillary
action to draw a liquid or molten glass into all
the pores to produce the dense interpenetrating
material.

30 I cosmetic
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Fig. 12b

The system was developed as an alternative to
conventional metal–ceramic restorations and has
met with great clinical success.22, 23 The system
utilises a sintered crystalline matrix of a highmodulus material (85 % of the volume), in which
there is a junction of the particles in the crystalline
phase. This is very different from glasses or glassceramic materials, in that these ceramics consist of
a glass matrix with or without a crystalline filler in
which there is no junction of particles (crystals).
Slip casting24 may be used to fabricate the ceramic
matrix or it can be milled from a pre-sintered
block.25 Flexural strength ranges from 350 MPa for
VITA In-Ceram SPINELL, 450 MPa for VITA In-Ceram
ALUMINA and up to 650 MPa for VITA In-Ceram
ZIRCONIA. Several clinical studies support the
use VITA In-Ceram ALUMINA for single units
anywhere in the mouth. In those studies, VITA
In-Ceram ALUMINA had the same survival rate
as porcelain fused to metal up to the first molar,
with a slightly higher failure rate for the second
molar.26–28 VITA In-Ceram ZIRCONIA should only
be used on molars owing to its very high opacity,
which is not ideal for anterior aesthetics. For anterior teeth, VITA In-Ceram SPINELL is ideal, owing
to its higher translucency (Figs. 10 a–c).
4. Category 4: Polycrystalline solids
Solid sintered monophase ceramics are materials formed by directly sintering crystals together
without any intervening matrix to form a dense,
air-free, glass-free polycrystalline structure. There
are several different processing techniques that
allow the fabrication of solid sintered alumina or
zirconia frameworks. The first fully dense polycrystalline material for dental applications was Procera
AllCeram alumina (Nobel Biocare) with a strength
of about 600 MPa.29 The alumina powder is pressed
and milled on a die, and sintered at about 1,600 °C,
leading to a dense coping but with about 20 %
shrinkage (Figs. 11, 12a & b).
The use of what is commonly referred to as
zirconia in dentistry has increased rapidly over
the past few years. This is not pure zirconia; it
is partially stabilised by the addition of small

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Fig. 13

amounts of other metal oxides. Partially stabilised
zirconia is one of the materials that allow production of reliable multi-unit all-ceramic restorations
for high-stress areas, such as the posterior region of the mouth. Zirconia (or zirconium dioxide,
chemical formula ZrO2) may exist in several crystal
types (phases), depending upon the addition of minor components, such as calcia (or calcium oxide,
chemical formula CaO), magnesia (or magnesium
oxide, chemical formula MgO), yttria (or yttrium
oxide, chemical formula Y2O3), and ceria (or
cerium(iv) oxide, chemical formula CeO2). Specific
phases are said be stabilised at room temperature
by the minor components. Typically for dental
applications, about 3 wt% of yttria is added to the
pure zirconia (Figs. 13, 14a & b).
Zirconia has unique physical characteristics that
make it twice as strong and tough as alumina-based
ceramics. Values for flexural strength for this material range from about 900 to 1,100 MPa.30, 31 It is
important to note that there is no direct correlation
between flexural strength (modulus of rupture) and
clinical performance. Another important physical
property is fracture toughness, which has been
reported to lie between 8 and 10 MPa m1/2 for zirconia.30 This is significantly higher than any previous
dental ceramic. Fracture toughness is a measure
of a material’s ability to resist crack propagation.
Zirconia has the apparent physical properties to
be used for multi-unit anterior and posterior fixed
partial dentures. Clinical reports on zirconia have
not demonstrated problems with zirconia frameworks.32–34 The problems have been associated with
chipping and cracking of porcelain. Using a slowcooling protocol at the glaze bake to equalise the
heat dissipation from the zirconia and porcelain
increased the fracture resistance of the porcelain
by 20 %.
Zirconia may be in the form of porous or dense
blocks that are then milled to form the frameworks, or recently full contour single-unit restorations. Most are fabricated from a porous block,
milled oversize by about 25 % and sintered to full
density in about a 4–6 hour cycle. An alternate
approach involves milling a fully dense block.

Fig. 14a

However, owing to the nature of zirconia, this
approach requires about 2 hours of milling time
per unit, whereas milling of the porous block requires only about 30–45 minutes for a three-unit
bridge.

Fig. 14b

Fig. 13_A scanning electron
micrograph of the microstructure
of a zirconia ceramic.
Figs. 14a & b_A zirconia crown.

Within categories 2 and 3, there can be great
variation of composition and there are several
commercial materials in these groups. Glass-based
systems (categories 1 and 2) are etchable and thus
easily bondable. Crystalline-based systems (categories 3 and 4) are not etchable and thus much more
difficult to bond. Categories 1–3 can exist in a powdered form that is then fabricated using a wet brush
technique, or they can be preprocessed into a block
form that can be pressed or machined. As a rule,
powder/liquid systems have much lower strength
than pre-manufactured blocks do owing to a much
larger amount of bubbles and flaws in the finished
restoration.

_Classification based
on processing technique
A more user-friendly and simplistic way to
classify the ceramics used in dentistry is by how
they are processed. It is important to note that
all materials can be processed by various techniques but in general for dentistry they can be
classified as:
_powder/liquid glass-based systems;
_machinable or pressable blocks of glass-based
systems; and
_CAD/CAM or slurry, die-processed, mostly crystalline (alumina or zirconia) systems.
It is an important classification method, as there
appears to be a greater correlation with clinical
success (and thus failure) due to processing
technique. Even though a material may have the
same chemistry and microstructure, the processing
methodology used to produce a restoration may improve or decrease the final properties and clinical
success. Specifically, machined blocks of materials
have performed better than powder/liquid versions
of the same material.

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Fig. 15

Fig. 16

Fig. 15_Slip casting a
VITA In-Ceram framework.
Fig. 16_An electron micrograph
of the microstructure of a
hand-layered porcelain, a pressed
crown, and a VITABLOCS Mark II
CAD/CAM block.

1. Powder/liquid
1.1 Conventional
These are typically veneer materials, which may
be all glass or a mixture of glass and crystal components. These include veneers for all-ceramic and
metal frameworks, and may also be used alone
as anterior veneer restorations. Typically, these
materials are mixed by hand with deionised water
or a special modelling liquid supplied by the manufacturer. They are built up by hand and vibrated
(condensed) to remove water and air. These are
fired in a vacuum to help remove remaining air and
improve the density and aesthetics of the veneer.
Since these restorations are made by hand, there
are often voids present in the fired material. This is
inherent to the process and may be worse or better
depending upon environmental conditions, the
skill of the technician, and the firing cycle. Often,
one sees bubbles remaining in the hand-layered
veneer material.
1.2 Slip casting
The original VITA In-Ceram and some partially
stabilised zirconia blocks are fabricated based on
slip casting of alumina or zirconia. The slip is a homogenous dispersion of ceramic powder in water.
The pH of the water is often adjusted to create
a charge on the ceramic particles and the ceramic
powder is coated with a polymer to cause the
particles to be evenly suspended in the water. In
the case of VITA In-Ceram, the slip is painted on a
gypsum die with a brush to form the underlying
core for the ceramic tooth. The water is removed
via capillary action of the porous gypsum, which
packs the particles into a rigid network (Fig. 15).
The alumina core is then slightly sintered (0.2 %
shrinkage) in a furnace to create an interconnected
porous network. The lanthanum glass powder is
placed on the core, and the glass becomes molten
and flows into the pores by capillary action to
produce the interpenetrating network. The last

32 I cosmetic
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1_ 2014

step in the fabrication of the restoration involves
application of aluminous porcelain to the core to
produce the final form of the restoration. Other
powder dispersions, such as those created with
zirconia, may be poured into a gypsum mould that
withdraws the water and leads to a homogeneous
block of zirconia being formed.
2. Pressable
Pressed ceramic restorations are fabricated
using a method similar to injection moulding.
Monochromatic porcelain or glass-ceramic ingots
are heated to allow the material to flow under pressure into a mould formed using a conventional
lost-wax technique. The restoration may be cast to
its final contours and subsequently stained and
glazed to provide an aesthetic match. Alternatively,
a coping may be moulded upon which porcelain is
added to achieve the final shape and shade of the
restoration. IPS Empress restorations and other
materials with a similar leucite/glass structure
are fabricated in this manner. The glass-ceramic
IPS e.max is also fabricated this way. Pressables
may be used for inlays, onlays, veneers and singleunit crowns.
3. CAD/CAM
3.1 Subtractive (removal of excess material to fabricate the restoration, milling)
3.1.1 Full contour
Full contour restorations, such as inlays, onlays,
crowns and veneers, may be fabricated from various
blocks of materials. In general, these blocks are
fabricated from starting powders that are mixed
with a binder and then pressed into a mould or extruded like a sausage into a block form. The binder
helps hold the powder together so that the shape is
maintained after pressing or extrusion. The blocks
are then transferred to a furnace to remove the
binder and sintered to full density. As mentioned

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review _ ceramics

Fig. 17a

previously, restorations milled from blocks tend to
have improved density and mechanical properties
compared with powder/liquid or pressed restorations owing to the standardised manufacturing
process (Fig. 16).35, 36
3.1.2 Glass/crystal
VITABLOCS Mark II are fabricated using finegrained powders, which produce a nearly pore-free
ceramic with fine crystals. This was the first material
specifically produced for the CEREC system and
has an excellent history of clinical success for inlays,
onlays, and anterior and posterior crowns.36 The
restoration may be characterised with external
stains or porcelain may be added to produce a layered effect (Figs. 17a & b). These blocks are available
as monochromatic, polychromatic with stacked
shades as in a layer cake, and more recently in a form
replicating the hand-fabricated crowns for which
an enamel porcelain is layered on dentine porcelain.
3.1.3 Glass/leucite
IPS Empress CAD is based on the pressable
IPS Empress and has the same microstructure,
a feldspathic glass with about 45 % leucite crystal.
These blocks also have a fine leucite crystal structure
(about 5–10 µ) and may be further characterised
using external stains or porcelain. IPS Empress CAD
is available in monochromatic and polychromatic
stacked shades. Its strength properties are similar
to that of VITABLOCS Mark II. Common to all of
these blocks is a microstructure with a fine particle
size that helps resist machining damage, improve
mechanical properties and decrease the polishing
time of the finished restoration.
3.1.4 Lithium disilicate
The IPS e.max block (lithium disilicate) is not
initially fully crystallised. This improves milling
time and decreases chipping from milling. The
milled restoration is then heat-treated for about

Fig. 17b

20–30 minutes to crystallise the glass, and produce
the final shade and mechanical properties of the
restoration. The crystallisation process changes
the restoration from a blue colour to a tooth shade.
The microstructure and chemical composition are
essentially the same as those of IPS e.max Press.
The IPS e.max block has several translucency levels,
the least translucent used primarily as a framework
material and the higher translucency blocks used
for full contour restorations.

Figs. 17a & b_A milled crown.

3.1.5 Framework
(a) Alumina: Interpenetrating phase
or glass-infused
VITA In-Ceram blocks are fabricated by pressing
the alumina-based powder into a block shape in
a manner similar to that of VITABLOCS Mark II. However, these blocks are only fired to about 75 % dense.
Porous blocks of VITA In-Ceram materials are milled
to produce a framework. The blocks are then infused
with a glass in different shades to produce a 100 %
dense material, which is then veneered with porcelain. Glass infusion only requires about 20 minutes
for a coping and 1.5 hours for a three-unit bridge.
The microstructure is the same as that of slip-cast
alumina. The blocks are available in all three types
of VITA In-Ceram.
(b) Alumina: Porous
Alumina frameworks may be fabricated from
porous blocks of material. Pressing the alumina
powder with a binder into moulds produces the
blocks. The blocks may be partially sintered to improve resistance to machining damage or used as
pressed in a fully green state (unfired, with binder).
The frameworks are milled from the blocks and
then sintered to full density at about 1,500 °C for
4–6 hours. The alumina has a fine particle size of
about 1 µ and a strength of about 600 MPa, and
is designed for anterior and posterior single units,
as well as anterior three-unit bridges.

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I review _ ceramics
versus the porous block method and may be preferred for large frameworks that span the arch.

Fig. 18_A diagram of hot
isostatic pressing.

3.2 Additive
3.2.1 Electrodeposition
VITA In-Ceram powder dispersions used in the
slip-casting technique have been applied to electrodeposition systems, which apply a current across
the dispersion and deposit the powder particles
automatically on the surface of a conductive die.
This approach is efficient for single units, but becomes cumbersome and potentially unreliable for
multi-unit frameworks.

_Discussion and summary
Fig. 18

(c) Partially stabilised zirconia: Porous
Zirconia frameworks milled from porous blocks
are fabricated in a similar fashion to those milled
from alumina blocks. There are a variety of methods to press the powder into a mould. Uniaxial
pressing involves pressing from one direction,
biaxial pressing involves pressing from two equal
and opposite directions, and isostatic pressing
involves uniform pressing in all directions. There
are advantages and disadvantages to all methods
but the desired result is the same: to produce a homogeneous block that shrinks uniformly. As is the
case with the alumina block, the milled zirconia
framework shrinks about 25 % after a 4–6 hour
cycle at around 1,300–1,500 °C. The particle size
is about 0.1–0.5 µ.
(d) Partially stabilised zirconia:
Hot isostatic pressing blocks
Fully dense zirconia is produced by a method
called hot isostatic pressing. The zirconia powder
may be pre-pressed into a block or the powder
itself may be packed into a flexible mould. Either
the block or mould is then vacuum sealed in an
airtight rubber or plastic bag and placed into
a fluid-filled chamber. Pressure is then applied to
the fluid and this pressure is transmitted evenly
all around the zirconia. Heat is applied to the
chamber, which sinters the zirconia to full density
(Fig. 18). Zirconia blocks produced in this manner
may achieve flexural strength values of about
1,200–1,400 MPa. However, it requires extended
milling to produce the framework and the higher
strength value does not generally justify the loss
in productivity. The accuracy may be improved

34 I cosmetic
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1_ 2014

Ceramics can be classified in many ways. Two
classification systems were given to aid the reader
in understanding the types of ceramics available
for dental use. The processing technique has a very
large impact on strength and thus clinical performance, and should be one of the primary considerations in choosing a material.
There are many clinical aspects that are important for success with all-ceramic materials that
are not as critical with metal-based restorations
that cannot be covered here (e.g. preparation design, management of stresses, and cementation
techniques). The reader is advised that significant
knowledge and training in these areas are requisite
for success with all-ceramic materials._

Editorial note: A complete list of references is available
from the publisher.

_about the authors

cosmetic
dentistry

Prof. Edward A. McLaren, DDS, MDC,
is the founder and director of UCLA postgraduate
aesthetic dentistry, and Director of the UCLA Center
for Esthetic Dentistry in Los Angeles in California
in the US.
Prof. Russell Giordano, DMD, CAGS, DMSc,
is an associate professor in Materials Science and
Engineering at the Boston University College
of Engineering in Massachusetts in the US.
He received his DMD from the Harvard School of Dental
Medicine in the US. Presently, he has several private
and federally funded projects. His major research
foci are ceramics and ceramic matrix composites.

[35] => Standard_300dpi

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[36] => Standard_300dpi

CDE0114_36-37_Hemm 11.06.14 14:08 Seite 1

I feature _ interview

“The trend towards
the medium-price range
has accelerated”
An interview with Straumann executive board member Frank Hemm
about the company’s recent investment in MegaGen
_Following previous investments in Brazil,
Germany and Spain, Straumann recently announced that it has bought convertible bonds
worth US$30 million from MegaGen, one of the
largest dental implant solution providers in South
Korea. At the recent World Symposium of the
International Team for Implantology in Geneva
in Switzerland, on behalf of cosmetic dentistry,
implants magazine Managing Editor Georg
Isbaner had the opportunity to talk with Frank
Hemm, a member of Straumann’s executive management board, about the investment and how
it will affect his company’s position in the Asia
Pacific region.
_cosmetic dentistry: According to analysts,
South Korean manufacturers are expected to dominate the market for dental implants in Asia in the
years to come. Is this projected development the
main reason for your investment in MegaGen?
Frank Hemm: South Korea is one of the largest
markets for implants in terms of volume. More
than two million implants are placed every year
and local manufacturers are looking to expand
into other Asian markets with high potential.
China is a good example, where the market is
still comparatively small but under-penetrated
and growing quickly.
In these markets, the premium implant segment, where Straumann has been and still is very
active, is growing less dynamically than the
medium- and low-price segments are. We see
the same trend in other markets, like Brazil,
where companies like Neodent sell higher volumes than premium providers do. Two years
ago, we had to ask ourselves whether we could

36 I cosmetic
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1_ 2014

address the non-premium segment with our
existing brand or whether we needed a second
brand. We decided on the latter and purchased
a 49 per cent stake in Neodent. As an established
brand in the region, MegaGen gives us a foothold
in the Asian “value” (medium-price) segment.
The convertible bond approach means that we
have the option to gain a majority stake in 2016
with a managed low risk.
Straumann has always provided premium
dental implants backed by solid scientific evidence and service excellence. These key differentiators make it necessary to use a separate brand
strategy to address customers who are willing
to accept lower standards and who want to pay
less for implants. The value segment is growing
exponentially and developing a new brand from
scratch would simply take too much time and too
many resources, which is the reason we chose to
invest in other established companies.
_Both companies have said that they will continue to operate separately. Still, do you expect
any synergies to arise from this partnership?
It is important to keep both businesses
completely separate to ensure that customers
do not think that Straumann is MegaGen and
vice versa. The only synergies we see are in
supporting the value brand companies to enter
selective markets, and in sharing back-office
functions, like infrastructure, information technology or accounting. Everything else is handled
by each company independently. Straumann
products are certainly produced in Straumann
facilities and this will continue to be the case
in the future.

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feature _ interview

_Is there the risk that you might be creating
more competition for yourself with this investment?
We would not have taken this step if the
market situation had not required it. The trend
towards products in the medium-price range has
accelerated and there is already strong competition, even without MegaGen. We are not adding
more competition; rather, we are competing
where we could not compete as Straumann.
_What position is your company generally
aiming for in the Asia Pacific region?
We aspire to market leadership in the region.
We are not there yet, partly because our Roxolid
implants with the SLActive surface are not yet
available in the larger markets. We recently received
approval for SLActive Tissue Level implants in
Japan and the sales figures demonstrate the extent
of the potential of our innovative technologies.
Achieving a leading position in Asia will certainly have a positive influence on our global
position.
_What requirements will have to be fulfilled
for you to exercise the option to convert and
acquire a majority stake in MegaGen in 2016?
We are keeping a close eye on the company’s
development. MegaGen is a relatively new enterprise. It is growing dynamically and has many
ambitions that still have to be realised. We also

want to see how the market develops and the
extent to which MegaGen can penetrate certain
areas. The company’s valuation is another item
on our radar. If our expectations are met, we can
convert the bonds into shares in 2016 or require
repayment with interest. That is the flexibility
that this option allows us.

Georg Isbaner (left) in talks
with Frank Hemm.
(DTI/Photo Henrik Schröder, Germany)

_Should you decide to convert the bonds into
stock, another large international implant conglomerate would be created. Is it only possible to
survive in the long run as a large market player?
The implant market is still very fragmented
and the market share of larger corporations is
actually declining. There are hundreds and hundreds of smaller providers, often founded by dental clinicians, that come and go because they do
not have the capability to expand internationally.
Few companies succeed in making this jump and
remaining in the market for a longer period.
Unlike in some industries, scale in the dental
implant industry does not have inherent returns.
What we are seeing is a consolidation in a larger
context, as many distributors have started to
include implants in their portfolios with the aim
of becoming one-stop shops. This development
needs careful scrutiny because implants involve
other factors that only we as specialists can
deliver.
_Thank you very much for the interview.

cosmetic
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CDE0114_38-41_Papagiannoulis 11.06.14 14:09 Seite 1

I technique _ periodontally compromised situation

Maximal aesthetics in the
periodontally compromised
anterior maxilla
Immediate implantation
Authors_Drs Nikolaos Papagiannoulis, Eduard Sandberg & Marius Steigmann, Germany

_Introduction
In addition to habits, systemic diseases and bruxism, periodontal diseases are challenging problems
in oral implantology. Here, surgeons have to deal
with tooth loss, prolonged epithelia, bone resorption and loss of periodontal ligament. In the following case, we could clearly see at the preclinical
analysis that major bone resorption had occurred
horizontally as well as vertically. The bony defects
referred to more than one wall, the bone resorption
around the root was like a crater, infiltrated with
soft tissue. Primary stability was difficult to achieve
for the implant.

Fig. 1_Initial clinical situation.
Fig. 2_Initial clinical situation,
coronally.
Fig. 3_Situation models for
provisional planning.

The periodontal treatment was the primary focus, accompanied by fillings and extraction therapy
to cure acute inflammations and achieve oral
health. Nevertheless, periodontal treatments result
in regular to functionally and aesthetically compromised situations and unsatisfied patients. Further,
periodontal treatment does not secure the adequate prosthetic treatment of the patient. Depend-

Fig. 2

Fig. 1

38 I cosmetic
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1_ 2014

ing on the art of the restoration, teeth often have
to be extracted, in spite of successful periodontal
treatment. So the question to be asked is whether
and when a periodontal treatment makes sense as
a definite treatment or if it should be a tool that
enhances later surgical and restorative procedures.

_Clinical and radiological findings
The clinical examination showed a severe periodontal defect, screening index of Grade IV, pockets
of up to 6 mm, tooth mobility grade II–III and
a bleeding index of 3–4. The functionality was very
limited and the aesthetic situation unsatisfactory.
The existing prosthetics on the central incisors were
too long to cover the recessions, resulting in further
attachment loss. The aesthetics also were compromised, following periodontal fibre loss and bone
support. Especially the lateral incisors suffered
severely from loss of interproximal bone, followed
by mesiorotations and ante-inclination (Figs. 1 & 2).
Radiological findings confirmed that all four upper
incisors needed to be extracted.

Fig. 3

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technique _ periodontally compromised situation

Fig. 4_Wax-up of the
provisional bridge.
Fig. 5_Provisional bridgework
with pontics.
Fig. 6_Provisional
bridgework frontally.
Fig. 7_Extraction sockets.

Fig. 4

Fig. 5

Fig. 6

Fig. 7

_Treatment plan
Taking into consideration that the goal of surgical periodontal treatments is a screening index
of 2–3 mm and that they almost always result in
recessions, the outcome of these procedures is
aesthetically poor. Especially in highly scalloped
biotypes, patients are rarely satisfied. Longer prosthetics to cover the free root surface do not improve
this outcome. On the other hand, these procedures
are not always successful, resulting additionally in
thermal sensitivities and persisting tooth mobility.
Because of the high costs of surgical periodontology and the previous arguments, patients increasingly ask for alternative procedures. In the case discussed in this article, periodontal treatment would
further neither aesthetic nor functional improvement, but only maintain the teeth for some months
or years. The risk would be additional loss of bone
and soft tissue, compromising future plans and
prosthetic possibilities. The treatment plan for this
case included conservative periodontal treatment
and recall to treat inflammations, tooth extraction
and immediate implantation with guided bone and
tissue regeneration.

_Surgery
Before extracting the incisors, the crowns 13 and
23 were removed and the teeth were prepared to
receive temporary bridgework. With a wax-up on
the situation model and pontics, an optimal form
was created to support and manipulate soft tissue
during the healing phase. At the same time the

temporary bridge functions as wound coverage if
primary closure is not possible (Figs. 3–6).1-4
In the next step, the teeth 12 to 22 were extracted. The flap outline spared the middle papilla
and mesial ones on 12 and 22. Due to interproximal
bone defects, raising of the papilla in this region
would have led to severe recessions. The vertical
bone defects, especially between 11 and 12, were
obvious after raising a full-thickness flap. Releasing
incisions were placed distally at the canines and only
in the attached gingiva to prohibit scar formation
through vertical cuts in the mucosa. The low
vestibule made a split thickness or periosteal pocket
flap less logical. Mobilizing soft tissue from the
lips by other flap designs would provoke functional
limitations, suture tension and a secondary gum
plastic to reposition the coronal transpositioned
soft tissue. The wound margins were freshened to
remove prolonged epithelia and the bone defects
freed from soft tissue ingrowth (Figs. 7–10). The
horizontal bone loss was moderate. Implants were
placed slightly subcrestally. Although the gap between implants and the buccal plate was approximately 1–1.5 mm and the buccal plate thickness
1–1.5 mm due to the resorption, we decided for
3.8 mm implants, leaving a 1.5 mm gap to the
buccal plate.5-10
The interimplant space and the buccal plate were
augmented with a combination of allograft and
xenograft. Xenograft was also placed on the buccal
plate so as to manipulate buccal plate resorption. A
pericardium membrane was used as barrier (Fig. 11).

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I technique _ periodontally compromised situation

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

Fig. 13

Fig. 8_Flap raising and implantation.
Fig. 9_Implantation of four implants.
Fig. 10_Inserted implants, coronally.
Fig. 11_Radiological control
after surgery.
Fig. 12_Flap closure.
Fig. 13_Provisional bridge in situ.

The anatomy of the upper jaw and the low vestibule
did not allow primary closure. To protect the membrane from proteolytical resorption and the augment, we placed two layers of tissue fleece above
the membrane. Through the collagen fleece and
the protection of the provisional bridge, free granulation of the extraction socket cover was expected
after two weeks (Fig. 12).11,12
The patient received a weekly recall with prophylaxis and hygiene instructions. Three weeks postoperatively, sutures were removed. The clinical situation
showed no irritation and the wound healing and
closure ideal (Fig. 13).

_Re-entry and prosthetics
The re-entry was performed after three months
with minimally invasive crestal cuts. A papilloplastic
adjusted the wound margins between 11-12 and
21-22 (Fig. 14). After three additional weeks, impression was performed. The healed situation showed
optimal soft tissue quality and adequate attached
gingiva quantity. We measured 2–2.5 mm soft tissue
height above the implant necks, enough for the
necessary emergence profile. With the help of convex
or concave formed prosthetics, soft tissue can be
manipulated to the direction needed for esthetics
(Figs. 15 & 16).13-16
The final crowns show great results. The papillas
and pseudopapillas fill up the approximal space. The
approximal contact had to be longer and wider than
normally in order to compensate the former vertical
bone loss, especially in the region 11-12. Nevertheless,
there were no black triangles, the patient was satisfied

40 I cosmetic
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1_ 2014

and with the proper hygiene, the aesthetic outcome
will be optimized in the next months. Therefore, there
was no need to work with rose ceramics (Figs. 17–19).

_Discussion
In the periodontally compromised situation, it is
important to decide on whether a curative periodontal treatment offers satisfactory long term results.
As in this occasion, the extraction in a crucial moment
helps us preserve what we have, use it to the maximum
for the implant surgery and risk no further bone loss
or recessions. Any other procedure would have led
to a two-stages surgical approach and probably to
removable prosthetics. Very favourable was the thick
biotype of the patient, such as the low lip line. The soft
tissue quantity was evident. Tension on the flap closure was prohibited by the surgical protocol and the
free granulation of the wound. The bone quantity
insured a primary stable implant insertion. Immediate implantation provided stability for the augmentation and less material. The positioning of the
implant allowed us to create an optimal emergence
profile, making complicated soft tissue procedures
unnecessary.17-19
The clinical situation and the bony defects made
clear during surgery that we would have to make
an aesthetic compromise in region 11-12. The bony
support of the interproximal soft tissue is difficult
to regenerate and the pseudopapilla formation not
predictable. Immediate implantation in these regions
preserve hard and soft tissue. Through the positioning
of the implants and the free granulation of the extraction wound, we enhance the soft tissue, a major
advantage for the re-entry and prosthetics.20-22

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technique _ periodontally compromised situation

Fig. 14

Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

The implants placed feature micro grooves at the
implant neck in a height of 1 mm. This laser manufactured design imitates biology and promises an improved cell adhesion on this surface. These modern
designs, combined with the advantages of platform
switching, result in high tech products. Modern crestal bone maintenance functions because of the protection of the crestal bone. When implants are placed
subcrestally or crestally, a soft tissue ring builds on the
platform and protects the bone beneath. When implants are placed supracrestally, implant neck options
secure the crestal bone beneath, through soft tissue
fibre attachment of their necks.23, 24

internal stabilisation at the augmentation area.
Often is an external stabilization with pins or screws
unnecessary. The porosity of the particles is defined
through their biology. This is the reason why we prefer no alloplastic biomaterials and take advantage
of the pros of combined allografts and xenografts.
At the same time, these are the requirements of modern biomatierials, accompanied of course by inductivity and conductivity. 28-30 Periodontal diseases are
a regular limitation factor in oral implantology. Thus,
there are situations in which periodontal disease pose
no contraindication to implantology. Preconditions
for similar procedures are understanding and knowledge of biology, surgery and prosthetics. These procedures underlie no algorithms but proper diagnosis,
analysis and planning of every individual patient
and the choice of the appropriate implant system and
biomaterials. Modern implantology provides all tools
for successful implant treatment. Complications are,
however, severe and can hardly be solved without
compromises._

In cases in wich primary closure is not possible or
mobilization of neighbouring soft tissue through
other flap designs is not wanted, temporary prosthetics are essential. The soft tissue manipulation begins from the very first moment and decides about
the aesthetic outcome.25-27
The clinical situation after three weeks with healing abutments needed to be altered buccaly at 11
and 21 and manipulated 0.5 mm apically. This was
achieved via individualized abutments with convex
base and breadth of 1 mm. In contrast, the gingiva
margins at the lateral incisors needed to be corrected
coronally. Therefore, we used narrow abutments to
give soft tissue more space to head coronally.13-15
The combination of the biomaterials belongs to
our standard augmentation protocol and is well documented. The results of guided bone regeneration are
predictable and can be planned, even in major defects.
In addition to the combined biomaterials, their structure is very important. Rocky and edgy particles help

Fig. 14_Re-entry with healing
abutments.
Fig. 15_Three weeks after re-entry.
Fig. 16_Papilla morphology after
healing abutments.
Fig. 17_Definite abutments try-in.
Fig. 18_Final prosthetics.
Fig. 19_Pseudopapilla formation
after three months of loading.

Editorial note: A complete list of references is available
from the publisher.

_contact

cosmetic
dentistry

Dr Nikolaos Papagiannoulis
Steigmann Institute
Bahnhofstraße 64
69151 Neckargemünd, Germany
m.steigmann@t-online.de
www.implantologie-heidelberg.de

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I feature _ interview

Planmeca makes CAD/CAM
easier than ever
_Planmeca’s open-interface CAD/CAM solutions
introduce, above all, quality, cost efficiency and precision to the daily workflow at dental clinics or laboratories. Petri Kajander, product manager of Planmeca’s
CAD/CAM solutions, explains the revolutionary features of these new products in this article.

_State-of-the-art solutions for dentists:
Superfast Planmeca PlanScan
The new Planmeca PlanScan is a digital and powderfree intra-oral scanner that scans the patient’s dentition quickly and accurately. The scanner produces realtime digital impressions from one-tooth to full arch
scans. Thanks to the open STL data, the scanned files can
be sent to any dental laboratory for design work. This
is the world’s first dental unit-integrated intra-oral
scanner that can also be connected to a laptop.

Fig. 1
Fig. 1_Petri Kajander,
product manager of Planmeca’s
CAD/CAM solutions.

Fig. 2_Planmeca PlanScan.
Fig. 3_Planmeca PlanCAD Easy.

Fig. 2

“The scanner has only one cable, so it is extremely
easy to move from one place to another, for example
between different treatment rooms or clinics,” said
Kajander. “In addition, the scanner is delivered with
a laptop, so the device can be flexibly shared between
different users. In other words, Planmeca PlanScan
offers value for your investment: it is not a device for
just one dentist but can be used by the entire clinic.”
The scanner uses the blue-laser technique. It projects a pattern on the surface of the teeth and then
analyses it from different directions to calculate distances. In this way, the device is able to calculate a model
that is extremely accurate. “You can view the result as
a real-time video image. The video recording and the
dental surface identification algorithm make the device
extremely flexible to use. Thanks to these features, you
can pause the scanning at any time and continue later
on at any point from where data is already available.”

Fig. 3

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The scanner includes a range of exchangeable tips
in various sizes, the smallest of which facilitates access
to the posterior areas, particularly in small children
and trauma patients. The tips can be autoclaved for
efficient infection control. In addition, the scanner is
extremely durable, since it has no internal moving parts
other than a fan that removes warm air. “Thus, the
device stays calibrated and is not subject to mechanical wear,” explained Kajander.

_Planmeca PlanCAD Easy,
an efficient design tool for prostheses
Planmeca also offers dentists a new kind of open
software solution for 3-D design. Planmeca PlanCAD
Easy is seamlessly integrated into Planmeca Romexis
software, and it is a user-friendly design tool for the
design of inlays, onlays, veneers, crowns and bridges.
“The software runs on a floating licence basis. This
means that it is not tied to just one computer or workstation, but the work is saved on the Planmeca Romexis
server. In this way, the scanning station can be used
only for scanning, while another workstation is used
for the actual design work. This is a truly unique feature, which allows work to be continued straight away
on another computer, while the scanner is freed for
more productive operation,” said Kajander.
Every dentist who designs his or her own prostheses
will also face cases that require assistance from a dental
laboratory. For this reason, Planmeca’s system utilises
an open STL file format that allows the work to be sent
immediately to a partner via the Planmeca Romexis
Cloud service.
Since Planmeca PlanCAD Easy is integrated into
Planmeca Romexis software, soft-tissue scans can also
be conveniently paired with CBCT scans of the patient.
This combined data provides valuable information for
implant planning, for example, because it visualises
the soft tissue and the crown that is designed for the
occlusion. This facilitates the planning of the implant
screw’s location.
The Planmeca PlanCAD Easy workflow, from preparation to the finished result, includes just five easy
stages: work description, scanning, marking of the
margin line, automatic design, and sending the work

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feature _ interview

to the mill. “Once the work has been sent to the mill, it is
transferred there in its entirety and the mill’s computer
finishes the work. In this way, the software and scanner
are immediately freed for a new assignment.”
The software is very user-friendly. All design phases
are saved automatically and previous phases can be returned to flexibly if further impressions are needed. The
design software automatically takes into account the
cusps and marginal ridges of the adjacent teeth, in addition to the contact strengths defined by the user. This
creates a design that blends into its surroundings well.

Fig. 4

Fig. 5

_Planmeca PlanMill 40, a fast and
precise milling unit for dental clinics
Planmeca PlanMill 40 is an extremely precise fouraxis milling unit controlled by its own computer. The
device is suitable for all single-tooth indications, in
other words for the milling of crowns, inlays, onlays and
veneers. The mill can manage bridges of up to five units
in the posterior area and three units in the anterior area.

Fig. 6

Fig. 7

Since the mill handles the milled pieces completely
independently, as many as several dozen pieces can
be sent to the mill at a time. In addition, the device
determines which block size, colour and material should
be used, so any member of the staff can place the block
in the mill. “This saves everyone working time. The
dentist does not need to put the block in himself,” said
Kajander.

Design takes place in the open Planmeca PlanCAD
Premium laboratory software, which can be used for
the design of all prostheses, ranging from one-tooth
units to full arch structures. The software can also be
used to design for example individual abutments, night
and sports guards, different crown and bridge work
and implant bridges and bars for cement-retained and
screw-retained solutions.

Planmeca PlanMill 40 has a six-tool exchange mechanism, and it changes tools independently according to
different job requirements. In addition, the device mills
different materials according to their properties. For
example, it knows how to handle delicate ceramics gently in work phases that require precision. “If you force
the material, it may break prematurely. Even the smallest hairline crack in the material can lead to a cemented
piece breaking when pressure is applied to it.”

The software has an order manager page that lends
efficiency to the workflow by reporting each stage of
work. In this way, several work orders can be entered
into the software in one go. The last phase is always
saved in the memory so that work can be continued
freely at the most convenient time. In addition, precise
values can be set for each workpiece to allow for
cement space and the milling unit’s blade.

Also, the maintenance of the device is easy. The mill’s
computer calculates the service life of the tools, monitors wear and reports on these via the user interface.
It also calculates the time that milling will take and
lets the user know when the tools or water should be
replaced. “Similar to a car, a mill requires maintenance
at certain intervals and notifies the user of this.”

An open STL file is created from the design, and the
design can be manufactured with any milling unit that
supports the open file format, including Planmeca
PlanMill 50. This milling unit can mill any soft, wet
and dry materials and for example glass ceramics.
In addition, the file can be sent to a milling centre, such
as Planmeca’s own PlanEasyMill milling centre, for
manufacture._

_An ideal solution for laboratories too

_contact

For dental laboratories, Planmeca offers a comprehensive solution that utilises the open STL file format.
Planmeca PlanScan Lab is an accurate desktop scanner
that uses blue light for scanning gypsum models and
impressions. The device scans gypsum models quickly
and effortlessly with an accuracy of 15 µm.

Planmeca Oy
Asentajankatu 6
00880 Helsinki, Finland

Fig. 4_Planmeca PlanMill 40.
Fig. 5_Planmeca PlanScan Lab.
Fig. 6_Planmeca PlanMill 50.
Fig. 7_Planmeca PlanCAD Premium.

CAD/CAM

www.planmeca.com

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I meetings _ IMAGINA Dental

IMAGINA Dental:
Digital dentistry experts
meet in Monaco
dentistry and organised by MONACO MEDIAX, one
of the world’s most highly regarded event organisers.
The rapid development of 3-D and CAD/CAM
technologies has necessitated essential changes for
all dental practices and laboratories. The challenge
is to keep up to date with this growing industry and
implement this digital workflow in dental practices.

Fig. 1_At the congress, Dr Scott Ganz
introduced cone beam,
international magazine
of cone beam dentistry.
(Photo courtesy of Dr Scott Ganz)

Fig. 2_Dr Scott Ganz during his
presentation at IMAGINA Dental 2014.
(Photo courtesy of MONACO MEDIAX)

_In the middle of February, over 500 dental
professionals from all over the world gathered
at the Grimaldi Forum in Monaco for the third
IMAGINA Dental congress. IMAGINA Dental is a
prestigious international dental meeting entirely
dedicated to 3-D and CAD/CAM technologies in

According to the organisers, the three-day
conference featured educational content on digital
dentistry relevant to every dental professional.
Internationally well-known speakers, experts and
trainers in the fields of implantology, CAD/CAM,
prosthetic dentistry and laser shared their knowledge and experience with passion and enthusiasm.
Participants learnt about the latest digital oral scanners, 3-D printers, 3-D diagnosis tools, treatment
planning, guided surgery and aesthetic restoration
in dentistry.
Parallel to the lectures, numerous workshops
were organised, which offered dentists answers to
many practical questions, clinical knowledge and
tips on the latest technologies in dentistry.
According to the organisers, IMAGINA Dental is
one of the few industry events to apply a policy
of fairness towards all brands and thus does not
favour one over another.
At the congress, Dental Tribune International
launched cone beam international magazine
of cone beam dentistry, a quarterly continuing
education publication devoted entirely to CBCT in
dentistry. Editor-in-Chief Dr Scott Ganz presented
the first issue of the high-gloss English-language
magazine.
The new magazine covers the most significant
developments in the field and is targeted at experts
who use CBCT, such as implantologists, orthodontists, prosthodontists and endodontists. It presents
the latest research and case studies in the field,

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meetings _ IMAGINA Dental

as well as pertinent industry news, trends in procedures and techniques, and the newest education
and events.

cone beam, which is the official publication
of the International Cone Beam Institute and several other education providers in the field, will be
distributed at all major international congresses,
exhibitions and many specialty-specific events.
“The evolution of CBCT, which started with the
introduction of 3-D imaging for dental applications
in the 1980s, continues within the pages of the
new cone beam international magazine. We will do
our best to provide our readers with useful information by presenting a variety of clinical applications
and state-of-the-art concepts that showcase CBCT
technology and related applications. It is time to
realise that there is a real danger when we are bound
by 2-D concepts, when clearly today we live in a
3-D world,” Ganz said.
The first issue is available for free download in
the e-paper archive of the Dental Tribune website
(www.dental-tribune.com).

Press releases and videos from IMAGINA Dental,
as well as interviews with the organisers, are already available online at www.youtube.com/user/
IMAGINADental and www.imaginadental.org._

Fig. 3_During the breaks participants
could see newest 3-D and CAD/CAM
technologies. (Photo courtesy of
MONACO MEDIAX)

save the date

Speakers
Dr. Ady Bayer
Dr. Mauro Bazzoli
Dr. Richard Bouchez
Dr. Gaetano Calesini
Roberto Canalis, CDT.
Prof. Bob Khanna
Leonardo Cavallo, CDT.
Dr. Andrea Chierico
Dr. Giovanni Manfrini
Alessandro Iorio, CDT.
Paolo Miceli, CDT.
Dr. Stephen Koubi
Dr. Francesco Mangani
Simone Maffei, CDT.
Dr. Silvia Masiero
Dr. Gianluca Paniz
Dr. Marco Rosa
Dr. Giorgio Tessore
Lamberto Villani, CDT.

Luca Lorenzo Dalloca
Attilio Muscio
Gregory Brambilla
Mauro Bazzoli
Guido Picciocchi
Luca Tacchini
Antonio Olivo

esthetics
Rome
9-11 october 2014

www.escdonline.eu

Organizing Secretariat
PLS Educational SPA
Via della Mattonaia 17 - 50121 Florence – Italy
Tel. +39 055 24621 - Fax. +39 055 2462270
barbara.giannelli@promoleader.com

Congress Venue
Auditorium Antonianum
Viale Manzoni, 1 – 00185 Roma

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CDE0114_46-47_AO 11.06.14 14:11 Seite 1

I meetings _ AO Annual Meeting

“Clinician education
is critical to success”
An interview with AO Annual Meeting chairman Dr Lyndon Cooper
Author_Sierra Rendon, DT America
_The Academy of Osseointegration is recognized as the premier association for professionals
interested in implant dentistry. It has always been
at the forefront of scientific advances in dental
implant and tissue replacement therapy. In an interview, Annual Meeting chairmen Lyndon Cooper,
DDS, PhD, and Donald Clem III, DDS, discuss this
year’s meeting, which was held recently, and plans
for the 2015 event.

Dr Lyndon Cooper

The 29th annual meeting of the
Academy of Osseointegration.

_Sierra Rendon: How many people attended
AO Annual Meeting 2014?
Dr Lyndon Cooper: More than 2,000 clinicians
joined us for the 29th annual meeting of the Academy of Osseointegration (6–8 March 2014, Seattle,
USA), which recorded the fourth largest attendance
in its history. We had 624 international attendees
representing 45 countries and more than 1,100 exhibitors who showcased products and services to
support implant dentistry.

_Why did AO choose the theme “Real Problems,
Real Solutions”?
We have seen that implants are widely applicable
and generally successful, and we recognize that
clinician education is critical to success among our
patients. This year, we sought to inform clinicians
that a segment of our population will experience
implant complications and failure, but emerging
strategies can help them recover success. We
encouraged the clinical team to examine implants
carefully, address issues promptly and recognize
when—and learn how to—intervene to preserve
dental implant and patient health.
_What were some highlights of the clinical
sessions?
Leading experts led the program with insights
on who experiences complications, why they occur
and what evidence says about how well we address
these complications. Consistent with the plan,
a broad range of data was presented. The early
focus on periimplantitis opened the minds of the
audience, while the closing futuristic presentations
certainly left everyone feeling inspired. Our clinical
presentations anchored the meeting by demonstrating what good science offers great clinicians
who adopt an evidence-based approach to caring
for people.
_Was research a big focus of the meeting?
Yes, presentations ranged from digital planning,
new aesthetic techniques and prevention strategies to molecular strategies and stem cell biology.
Abstract presentations explored original scientific
and clinical research, clinical innovations and case
presentations that could help shape the future of
implant dentistry. We had a record number of more
than 250 Scientific Posters as well.
_The new board of directors was also announced
in Seattle. How does the AO enjoy such a seamless
transition in leadership?

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meetings _ AO Annual Meeting

The 29th annual meeting of the
Academy of Osseointegration.

Approaching its 30th year, the AO is fortunate
to have organization leadership and leadership
development that are very carefully managed. We
are all very excited to announce that Dr. Joseph
Gian-Grasso, a periodontist from Philadelphia, was
elected to serve as the 2014–2015 president of AO.
He will follow in the footsteps of a very successful
president, Stephen Wheeler, DDS. Dr. Gian-Grasso
—along with the rest of us—ill remain committed
to establishing a nexus where specialists and generalists from around the world can come together
to learn and stay up-to-date on the rapidly advancing clinical research and innovations in the dental
implant and tissue engineering industries.
_Have you already started planning for AO 2015?
Yes, because it’s AO’s 30th anniversary, we’re all
very excited about it. Mark the calendar now to join
us in San Francisco from 12 to 14 March 2015, where
we plan to on the power of collaboration to advance
the art and science of dental implant therapy.
_Can you give us a few glimpses at what’s in
store for next year?
The opening symposium will feature teams of
doctors presenting on how they manage patients
together for optimal results. The keynote speaker
will be Dr Daniel Alam, who was a member of the
multi-disciplinary team of doctors and surgeons at
Cleveland Clinic who performed the first near-total
face transplant in the United States. He will speak to
the critical importance of different disciplines coming together to support a patient’s medical, surgical
and emotional needs to make them whole again.

AO also will take a look at what the academy
has learned throughout its 30-year history and
summarize current recommendations to address
the most challenging conditions in implant dentistry. AO has enlisted some of the foremost authorities in both surgical and restorative dentistry
to share their knowledge and views to support this
initiative.
Keeping with AO tradition, we also want to
ensure the closing symposium doesn’t disappoint.
It will be an interactive session where attendees can vote on keypads to give their opinion
on various treatment options for presented cases.
A panel of experts will also discuss and debate
the options.
_What are you most excited about for the
meeting?
At the annual meeting, we are excited to build
on AO’s past and chart the way for its future.
This will be done via top-notch surgical and
restorative tracks, as well as a “Morning with
the Masters,” for which AO has put together
an outstanding group of experts to a give attendees pearls that can be used in the office
on Monday morning. Ultimately, patient safety
and benefit must be based on sound evidence
—that’s what the academy is all about and our
annual meetings are as well. To learn more
about AO membership, please visit our website
(www.osseo.org/NEWmembership.html).
_Thank you very much for the interview._

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I meetings _ events

International Events
2014
APDC 36th Asia Pacific Dental Congress
17–19 June 2014
Dubai, UAE
www.apdentalcongress.org
18th World Congress on Dental Traumatology
19–21 June 2014
Istanbul, Turkey
www.iadt-dentaltrauma.org
AAED 39th Annual Meeting
5–8 August 2014
Santa Barbara, CA, USA
www.estheticacademy.org
ICOI Summer Implant Prosthetic Symposium
21–23 August 2014
Chicago, USA
www.icoichicago2014.org

FDI Annual World Dental Congress
11–14 September 2014
New Delhi, India
www.fdi2014.org.in
EAO 2014
25–27 September 2014
Rome, Italy
www.eao.org
EPA Annual Conference
25–27 September 2014
Istanbul, Turkey
www.epa2014.org
ICOI World Congress
3–5 October 2014
Tokyo, Japan
www.icoi.org
ESCD Annual Meeting
9–11 October 2014
Rome, Italy
www.escdonline.eu
155th ADA Annual Session
9–12 October 2014
San Antonio, USA
www.ada.org
Digital Dentistry Show
16–18 October 2014
At the International Expodental Milano, Italy
www.digitaldentistryshow.com
6th Dental Facial Cosmetic International Conference
14–15 November 2014
Dubai, UAE
www.cappmea.com/aesthetic2014
ADF Meeting
25–29 November 2014
Paris, France
www.adf.asso.fr
Great New York Dental Meeting
28 November–3 December 2014
New York, USA
www.gnydm.com

Athens. Photo: Anastasios71

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about the publisher _ submission guidelines

submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
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address, e-mail address, etc.).

I

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Please number images consecutively throughout the article
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In addition, please note:

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Please consider this when formatting your document.

Questions?
Magda Wojtkiewicz (Managing Editor)
m.wojtkiewicz@dental-tribune.com

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I about the publisher _ imprint

cosmetic
dentistry
_ beauty & science

asia pacific edition

Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com

International Media Sales
Matthias Diessner
m.diessner@dental-tribune.com

Editor-in-Chief
Dr Sushil Koirala
skoirala@vedicsmile.com

Europe
Melissa Brown
m.brown@dental-tribune.com

Co-Editor-in-Chief
Dr So Ran Kwon
soran-kwon@uiowa.edu
Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com
Executive Producer
Gernot Meyer
g.meyer@dental-tribune.com
Designer
Franziska Dachsel
f.dachsel@dental-tribune.com
Copy Editors
Sabrina Raaff
Hans Motschmann
International Administration
Marketing & Sales
Esther Wodarski
e.wodarski@dental-tribune.com
Executive Vice President
Finance
Dan Wunderlich
d.wunderlich@dental-tribune.com

Asia Pacific
Peter Witteczek
p.witteczek@dental-tribune.com
The Americas
Jan M. Agostaro
j.agostaro@dental-tribune.com
International Offices
Europe
Dental Tribune International GmbH
Contact: Esther Wodarski
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173

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

Editorial Board
Dr Anthony Au, Australia
Dr Bao Baicheng, China
Dr Helena Lee, Singapore
Dr Hisashi Hisamitsu, Japan
Dr Jiraporn Charudilaka, Thailand
Dr Mostaque H. Sattar, Bangladesh
Dr Ratnadeep Patil, India
Dr Suhit Raj Adhikari, Nepal
Dr Takashi Nakamura, Japan
Dr Vijayaratnam Vijayakumaran, Sri Lanka

cosmetic

dentistry _ beauty & science
is the official publication of:

Asia Pacific
Dental Tribune Asia Pacific Ltd.
Contact: Tony Lo
Room A, 26/F, 389 King’s Road
North Point, Hong Kong
Tel.: +852 3113 6177
Fax: +852 3113 6199
The Americas
Dental Tribune America, LLC
Contact: Anna Wlodarczyk
116 West 23rd Street, Suite 500
NY 10011, New York, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185

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www.dental-tribune.com

Copyright Regulations
_cosmeticdentistry_ beauty & science is published by Dental Tribune Asia Pacific Ltd. and will appear in 2014 with two issues. The magazine and all articles
and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to prosecution.
This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
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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.

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[cover] => cosmetic dentistry international No. 1, 2014

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => Interdisciplinary approach in aesthetic dentistry [page] => 06 ) [4] => Array ( [title] => Projecting a new smile from a facial photograph: A new way to plan multidisciplinarydental treatments [page] => 12 ) [5] => Array ( [title] => Non-invasive reconstruction with ceramic veneers— Art or compromise? [page] => 18 ) [6] => Array ( [title] => Ceramics overview: Classification by microstructure and processing methods [page] => 26 ) [7] => Array ( [title] => “The trend towards the medium-price range has accelerated” [page] => 36 ) [8] => Array ( [title] => Maximal aesthetics in the periodontally compromised anterior maxilla [page] => 38 ) [9] => Array ( [title] => Planmeca makes CAD/CAM easier than ever [page] => 42 ) [10] => Array ( [title] => IMAGINA Dental: Digital dentistry experts meet in Monaco [page] => 44 ) [11] => Array ( [title] => “Clinician education is critical to success” [page] => 46 ) [12] => Array ( [title] => Meetings [page] => 48 ) [13] => Array ( [title] => Submission guidelines [page] => 49 ) [14] => Array ( [title] => Imprint [page] => 50 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

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