Lab Tribune Middle East & Africa No. 2, 2018
A case study using Dentsply Sirona’s Celtra® Press System / Achieving more with less - Wafer-thin and brilliantly shaded: lab fabricated non-prep veneers for correcting misaligned teeth
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DTMEA_No.2. Vol.8_LT.indd
Published in Dubai
March-April 2018 | No. 2, Vol. 8
www.dental-tribune.me
A case study using Dentsply
Sirona’s Celtra® Press System
SUBSCRIBE NOW
Aesthetic rehabilitation of the anterior mandible after tooth loss due to periodontal disease
4
By Dentsply Sirona
Tooth loss in the anterior mandibular
region can be a challenging situation
for dentists and dental technicians
tasked to provide an aesthetically
pleasing prosthetic rehabilitation.
For reasons of stability, a solid, torsion-resistant framework is a must in
these cases. Metal frameworks have
the drawback that thinner ceramic
veneer layers may yield aesthetically
less satisfactory results. Monolithic
zirconia frameworks usually do not
meet the aesthetic requirements of
the dentist and patient in these situations. However, care must be taken
to ensure sufficient strength even for
delicate bridges to achieve satisfactory long-term results.
The case described here was treated
with the new Celtra® Press pressable ceramic system. This outstanding system combines high strength
with brilliant aesthetics and is ideally
suited for demanding cases such as
this one.
Case report
The patient first presented in December 2015 with no systemic conditions, except that the patient was allergic to penicillin. A few years earlier
she had been diagnosed with periodontitis, in the course of which tooth
#24 had become mobile and had
had to be extracted. Prosthetic rehabilitation was performed at another
dentist with an adhesive bridge from
tooth #23 to tooth #25. This bridge
had loosened several times and had
to be re-bonded at regular intervals.
There was a ceramic implant at site
#12, and all four quadrants included
posterior teeth with ceramic inlays
or partial crowns as well as composite fillings. Horizontal bone loss due
to persistent chronic periodontal
disease in the posterior region was
evident radiographically.
The patient requested an aesthetic,
durable and stable restoration for
teeth #23 to #25 and rejected an
implant-supported crown at site
#24. Having presented several alternative types of bridge restorations,
the patient and dentist opted for a
bridge made of a highly translucent
all-ceramic material. As this case re-
www.me.dental-tribune.com/e-paper/
Vol. 8 • Issue 4/2017
issn 1616-7390
CAD/CAM
international magazine of
digital dentistry
2017
quired both excellent aesthetics and
high strength, we decided to use the
Celtra® Press high-strength ceramic
system.
interview
“Dentistry has finally arrived in the digital age”
The shade of the teeth was taken and
the teeth were prepared under infiltration anesthesia, followed by taking an impression and by recording
the habitual occlusion. The prepared
teeth received a temporary acrylic
resin restoration (Figs. 1 to 4).
In the dental laboratory, a saw-cut
model was created and the preparation margins defined cleanly and
precisely with the aid of a microscope (Fig. 5). The casts were scanned
and the data imported into the CAD
software. Thanks to the highly pre-
case report
Screw-retained implant-supported restoration
in the edentulous maxilla
cone beam supplement
Dynamic navigation for reliable
and predictable flapless implant placement
cise definition of the preparation
margins, the software recognised
them with 100% accuracy and integrated the data within fractions of
a second (Figs. 6 and 7). The models
were placed in the virtual articulator
ÿPage B2
Fig. 1: Clinical baseline situation and shade selection.
Fig. 2: Preparation of the abutment teeth.
Fig. 3: Precision impressions.
Fig. 4: Provisionalization.
Fig. 5: Model dies with accurate representations of
the preparation margins.
Fig. 6: Representation of the dies in the CAD software.
Fig. 7: Detail of the preparation margin.
Fig. 8: The models in the virtual articulator.
Fig. 9: Bridge design using the CAD software.
Fig. 10: Reduction of the vestibular surfaces for the
cut-back method.
Fig. 11: Finishing the contours.
Fig. 12: Cut-back and layering technique using
Cercon® base wax.
Fig. 13: Only a single sprue needs to be attached to
the bridges.
Fig. 14: Detail of the sprue.
Fig. 15: Investing with Celtra® Press Investment.
Fig. 16: Placing the muffle in the pressing furnace.
Fig. 17: Divesting.
Fig. 18: After divesting, no reaction layer is present on
the objects.
Fig. 19: Framework after sandblasting: no reaction
layer and crisply defined structures.
Fig. 20: Excellent initial fit, no finishing needed.
[2] =>
DTMEA_No.2. Vol.8_LT.indd
B2
lab tribune
Dental Tribune Middle East & Africa Edition | 2/2018
◊Page B1
Fig. 21: The bridge on the master cast.
Fig. 22: Opalescence of the Celtra® Press matrix.
Fig. 23: First dentin firing.
Fig. 24: The object on the zirconia firing trays.
Fig. 25: Veneering after the first dentin firing.
Fig. 26: Completing the anatomical shape for the second dentin firing.
Fig. 27: After the second firing, in transmitted light:
Excellent light dynamics.
Fig. 28: Close-ups of the bridge from the vestibular
aspect.
to examine their relationship with
the TMJ, and a bridge was designed
on-screen with due regard to articulation and occlusal relationships,
something that presented a special
challenge due to the end-to-end occlusion (Figs. 8 and 9). Finally, the
bridge framework was reduced by
0.5mm in preparation for the cutback and layering technique, and the
contours were finished (Figs. 10 and
11).
The framework was milled completely in Cercon® base wax for the
cut-back and layering technique (Fig.
12). In the present case, we produced
two bridge frameworks to test the
simple sprueing technique that uses
only a single sprue for the pressing
procedure (Figs. 13 and 14). Celtra®
Press Investment, specially developed for this new pressable-ceramic
system, is characterised by very low
viscosity, making it easy to pour into
the investment ring and assuring a
precise flow around the fine details
of the object (Fig. 15). After setting,
a 6g Celtra® Press pellet was placed
on the muffle, which was then in-
troduced into the pressing
furnace.
Divesting after pressing
proved to be very easy
and was achieved simply
by removing excess investment compound and
sandblasting. One of the
main advantages of Cel-
Fig. 29: Completed bridge with antagonists.
tra® Press and Celtra® Press Investment is that virtually no reaction
layer is present on the object after
sandblasting, completely eliminating the acid-etching step with hydrofluoric acid (Figs. 17 and 18). After
sandblasting, the framework exhibited a perfect surface without any reaction layer; all details of the objects
had been reproduced meticulously
(Fig. 19). No finishing was required
beyond cutting off the sprue.
www.celtra-dentsplysirona.com
The initial fit of the framework was
excellent (Figs. 20 and 21). The outstanding aesthetic properties manifested themselves when transmitting light through the Celtra® matrix
on the cast (Fig. 22). The framework
was veneered with dentins and
enamels in two firing cycles (Figs. 23
to 27). Both the fit of the bridge and
its aesthetic appearance were as impressive on the master cast as they
appeared intraorally during the tryin (Figs. 28 to 30). Both the patient
and attending dentist were amazed
at the result.
Summary
The case presented here describes
the rehabilitation of an aesthetically
compromised mandibular anterior
tooth that had been lost to periodontal disease, with a delicate bridge
design. This had become necessary
because the patient had rejected implantological treatment followed by
a single-crown restoration.
CEREC® CAD/CAM Solutions
Designed to simply work better together
The inherent challenge in the situation was to create a restoration of
excellent aesthetic quality while at
the same time ensuring sufficient
strength to guarantee a stable result
for many years. This balancing act
was successfully achieved with the
new pressable-ceramic system Celtra® Press, because this zirconia-reinforced lithium silicate offers exceptional material properties not found
in conventional lithium disilicates.
Celtra® Duo (ZLS) blocks, Prime&Bond universal™ Adhesive, and Calibra® Ceram Cement
were designed to enhance and strengthen the individual benefits each of them
provides, resulting in an easy-to-use system that streamlines the restoration process.
Celtra Duo (ZLS) blocks
• Restoration longevity of Celtra Duo (ZLS) is ensured when used with
Prime&Bond universal Adhesive and Calibra Ceram Cement
• Firing is optional: choose either fire and seat or polish and seat
Prime&Bond universal Adhesive
• No need to use a self cure activator when used with Calibra Ceram Cement
• Low film thickness to allow passive seating of the crown
This new material with its clear translucence combines superior aesthetics with a strength that nevertheless
exceeds 500 MPa — a value that no
other lithium silicate can top. The
result of the treatment was thrilling
for the dentist and the patient alike.
Calibra Ceram Cement
• One-step curing when used with Prime&Bond universal Adhesive
• 10-second tack cure window and 45-second gel phase ensures an easy, no-stress cleanup
For more information on how the
Celtra® Press System can benefit
your lab, please contact your local
Dentsply Sirona representative.
358 CAD CAM Flyer V1.indd 1
04/05/2017 11:40
[3] =>
DTMEA_No.2. Vol.8_LT.indd
Dental Tribune Middle East & Africa Edition | 2/2018
B3
lab tribune
Achieving more with less
Wafer-thin and brilliantly shaded: lab fabricated non-prep veneers for correcting misaligned teeth
Fig. 1: Incisal view of the preoperative situation
Fig. 2: Mock-up in wax placed on the model
By Carola Wohlgenannt, MDT, Austria
Lab-fabricated non-prep veneers
made it possible to sidestep orthodontic treatment in the clinical case
presented in this report. Despite
the limited space available, brilliant
shade dynamics were achieved with
the help of specially shaded Enamel
and Effect materials (IPS e.max Ceram Selection).
“Less is more”. However, using less
is often difficult. In view of the high
demand for minimally invasive restorations, dental technicians are presented with new challenges in many
cases. The extent of the preparation
is often reduced to minimize the invasiveness of the treatment, leaving
only limited space for the fabrication of an esthetically pleasing, functional restoration. Such situations
necessitate adequate ceramic materials and experience to reproduce
the subtle interplay of shades seen
in natural teeth. While previously
various ceramic powders had to be
combined with each other to create
the required mixture, this procedure
has now been simplified with the introduction of new ceramic materials.
IPS e.max® Ceram Selection are specially shaded Enamel and Effect materials with brilliant shades and natural-looking light-optical properties.
The range comprises twelve shades
that are divided into three groups.
The six Special Enamel shades are
designed to produce lively translucent effects in the enamel area. The
three Light Reflector Effect materials
have light-reflecting capabilities and
are suitable for areas where a high
brightness value is desired.
The three Light Absorber materials
with light-absorbing properties are
used to increase the in-depth effect.
With this variation in materials, imitating natural teeth with individual
characteristics is much easier than
before. The range of possibilities
is particularly convenient in cases
where space is limited, such as in
very thin restorations (e.g. veneers).
Clinical case
The approximately 40-year-old
patient wanted the position of her
teeth corrected (Fig. 1). She consulted her dentist with regard to this
problem. She rejected orthodontic
treatment because of the expected
costs, the long treatment time and
the limitations during therapy. An
orthodontist had recommended the
extraction of a tooth in the lower jaw
to compensate for the crowdedness
and to provide the basis for orthodontic treatment. All of this was out
of question for the patient. She also
emphasized that no tooth structure
should be removed for the esthetic
correction.
Fig. 3: Selecting the basic tooth shade
(Dragon Shade, Drachenberg & Bellmann)
Fig. 4 & 5: Selecting the IPS e.max Ceram Selection materials using shade tabs. On the right: shade tab with the
intensive enamel shade “quartz”; on the left: shade tab with the light intensive Effect material “cream”
Fig. 6: Master model with dies made of investment material
Fig. 7: Investment material dies are being soaked with
water
Fig. 8: Building up the veneer for tooth 11 using IPS e.max Ceram Selection materials
Fig. 9: Incisal view of the completed veneers on the model
Treatment plan and mock-up
The possibilities of an esthetic improvement in the upper jaw were
discussed together. In particular,
teeth 11 and 13 were responsible for
the unevenness in the dental arch.
The teeth were inclined from the
axis towards the palatal. The idea was
to use two ceramic non-prep veneers
to correct the misalignment and
achieve harmony in the dental arch.
With the help of a study model, the
ideal tooth position was established
in wax (Fig. 2) and then converted
into “fast and easy” resin veneers
(mock-up). The first impression after
the placement of the mock-up was
positive. There was a strong aha! effect. The patient agreed to the treatment. The existing chalky spot on
tooth 21 was masked with composite
in the dental practice.
Challenge: reproducing the
shade of the natural tooth
The shape and morphology of the
veneers were defined by the mockup.
Fig. 10a: Veneer 11 features an insertion
handle at the incisal edge to be removed
by grinding once the restoration is seated
Now a matching tooth shade for the
ceramic materials had to be determined. The challenges were posed
by the dynamic interplay of shades,
the “beautiful” translucency of the
natural anterior teeth and the limited space available. How can the lightoptical properties be reproduced as
perfectly as possible in only a wafer-
ÿPage B4
Fig. 10b: Despite their thin layer thickness, the veneers exhibit natural light-optical properties.
[4] =>
DTMEA_No.2. Vol.8_LT.indd
B4
lab tribune
Dental Tribune Middle East & Africa Edition | 2/2018
◊Page B3
Fig. 11: Conditioning of tooth 11 for the adhesive cementation procedure
Fig. 12: Situation after seating the veneers on teeth 11 and 13
Fig. 13: Final check of the functional aspects. The veneers blend in with the dental arch naturally and “invisibly”
ginal ridges (Fig. 5). The enamel shade “apricot” should
lend warmth to the incisal, enhance the translucency and
heighten the chroma. In addition, the slightly greyish but
still warm enamel shade “quartz” was chosen.
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thin layer of ceramic material? The
Enamel and Effect material concept
of IPS e.max Ceram Selection provided the solution to this conundrum.
First, the basic tooth shade was
determined, for which shade samples mounted on a gingiva shield
(Dragon Shade, Drachenberg & Bellmann, Germany) were used (Fig. 3).
Conventional shade tabs - without
gingival section – may impair the result. Already during the selection of
the basic tooth shade, it became evident that standard dentin materials
would not be sufficiently intensive
to reproduce the natural tooth shade
due to the thin layer thickness with
which the veneer had to be created.
It was therefore decided to use the
Enamel and Effect materials of the
IPS e.max Ceram Selection range.
Self-made shade samples were used
as reference for the targeted selection of the materials. Among others,
the Light Reflector Effect material
in shade cream should lead to the
desired result (Fig. 4). In addition,
three enamel shades were chosen.
The intensive enamel shade “aqua”
was selected to emphasize the bluish translucent areas along the mar-
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09:00 - 10:00
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Aiham Farrah, CDT, Syria
The Knows and How’s of Flawless
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Eric Berger, France
Aesthetic Realization with VITA:
Cut Back on VITA Block
10:00 - 11:00
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Innovative Method in Guided Surgery to
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Improving patient care through modern
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Digital Dentures – Complete story
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3D Printing on the Edge of Conversion
Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP does not approve or
endorse individual courses or instructors, nor does it imply acceptance of credit hours by
boards of dentistry.
CAPP designates this activity for 14 CE Credits
Round Table Trainings
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Aiham Farah, CDT
Syria
Eric Berger, MDP
France
Philippe De Moyer
Belgium
Elie Elkhoueiry
Lebanon
Rik Jacobs
The Netherlands
Chritopher Adamus
Denmark
The White & Pink
Esthetic in Ivoclar
Porcelain System
Aesthetic Realization
with VITA: Cut Back
on VITA Block
The Real on “X"
Innovative Technicians Practical Guide hybrid technic known
on How to Make
as REAX
Immediate Loading
on Dental Implant
3D Printing on the
Edge of Conversion
CAD Design
Session A: 10:30 - 12:00
Session B: 12:00 - 13:30
Session C: 14:15 - 15:45
Session D: 15:45 - 17:15
Session A: 10:30 - 12:00
Session B: 12:00 - 13:30
Session C: 14:15 - 15:45
Session D: 15:45 - 17:15
Session A: No Session
Session B: 12:00 - 13:30
Session C: 14:15 - 15:45
Session D: 15:45 - 17:15
Session A: 10:30 - 12:00
Session B: 12:00 - 13:30
Session C: 14:15 - 15:45
Session D: 15:45 - 17:15
Session A: 10:30 - 12:00
Session B: 12:00 - 13:30
Session C: 14:15 - 15:45
Session D: 15:45 - 17:15
Session A: 10:30 - 12:00
Session B: 12:00 - 13:30
Session C: 14:15 - 15:45
Session D: 15:45 - 17:15
Tel: +971 4 347 6747 | Mob: +971 50 2793711 | E: events@cappmea.com
www.cappmea.com/dtim
Creating the veneers
Refractory dies for teeth 13 and 11 were created with the
help of the master model (Fig. 6). The dies were then soaked
in water to prevent them from drawing moisture from
the ceramic materials during the layering procedure (Fig.
7). The veneers were built up in layers in accordance with
the shape defined by the mock-up (Fig. 8). No dentin material was used. The colour-intensive Effect shade “cream”
was used for the dentin core replacement. The other Effect
shades selected served to bring out the warm-translucent
interplay of shades. It did not take long to build up the
veneers in ceramic. However, the esthetic appearance of
a restoration is not determined by the shade effect alone.
Subtle, barely noticeable surface structures can underline
the natural appearance of a restoration. Adequate time
and attention was therefore dedicated to designing the
surface morphology of the veneers. At the final firing, the
ceramic surfaces were slightly smoothed and, once fired,
refined by mechanical polishing. Polishing was carried out
carefully by hand. Figure 9 shows that the teeth were successfully brought into alignment with the adjacent teeth
to create a harmonious appearance. An initial evaluation
in the dental lab showed that the veneers demonstrated
a natural interplay of shades in spite of the thin material
thickness (Fig. 10). However, the effect in the mouth will
ultimately decide the success of the restoration.
Seating the restoration and final result
An essential aspect for the success of veneers is the cementation procedure. No matter how brilliant the ceramic materials are and how skilful the work of the dental technician
is, if the shade of the adhesive cementation material is not
chosen correctly, the joy of the “new smile” will be short
lived. Variolink® II luting composite in shade neutral was
used for incorporating the veneers. Prior to placing the veneers, they were tried in with try-in paste to confirm that
the treatment goal had been achieved. Once the ceramic
veneers and tooth surfaces were conditioned (Fig. 11), the
veneers were bonded to the teeth. The result was impressive. Teeth 13 and 11 now blended in harmoniously with the
rest of the dental arch (Fig. 2). The tooth shape was aligned
with the shape of the adjacent teeth, while slightly asymmetrical contours supported the natural appearance of
the restorations. The light-optical properties of the veneers
left nothing to desire. The intrinsic interplay of shades and
variations of translucency seen in the adjacent teeth were
faithfully reproduced. After the functional criteria had
been checked, the patient was discharged from the practice
(Figs 13 and 14).
Conclusion
In principle, such challenges can only be met if the dental
technician understands the light-optical properties of natural teeth and is able to use appropriate ceramic materials.
The procedure demonstrated in this report eliminated the
need for dental technicians to mix the individual materials
themselves. Suitable materials in the ideal shade could be
applied “directly from the tub”. In this way, the balancing
act between maximum esthetics and minimum invasiveness was successfully and reliably accomplished.
Carola Wohlgenannt, MDT
Wohlgenannt Zahntechnik OG
Kurze Gasse 2, 6850 Dornbirn, Austria
team@wohlgenannt-zt.com | www.wohlgenannt-zt.com
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