Lab Tribune Middle East & Africa No. 6, 2016
Metal-Ceramic esthetics without boundaries / CAD/CAM Final spurt 2016: Dentsply Sirona presents inLab CAD Software 16.0
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DTMEA_No.6. Vol.6_LT.indd
www.dental-tribune.me
PUBLISHED IN DUBAI
November-December 2016 | No. 6, Vol. 6
Metal-Ceramic esthetics without boundaries
Search: Where is the framework?
By Dr. Adrian Bacila & Florin
Stoboran, Romania
We have known for some years now
that abrasion, erosion and other defects caused by stress and diet, are
issues which are becoming increasingly common. Now we see that this
type of problem is occurring more
and more frequently amongst under
30-year-olds who consume modern
acidic drinks. An extreme example
with a dreadful initial situation is
presented here. The most suitable,
patient-friendly and well proven
method still used a lot today is the
metal-ceramic restoration.
There are special requirements to
be considered when creating a lifelike rehabilitation of teeth in young
adults: not just in terms of the vestibular tooth surfaces, incisal edges and
the occlusal surfaces, but also the
type of veneering material used for
the restoration with regard to tooth
shade, translucency and light transmission. The correct choice from
the start makes the dental technical
work quicker and easier. To make our
work with metal easier and in order
to achieve convincing light optical
results, we chose the new ceramic IPS
Style Ceram from Ivoclar Vivadent
(Schaan/Liechtenstein). The following article describes our production
methods step by step, from the diagnostic assessment and planning to
the final insertion of the restoration.
Diagnostic assessment and
patient consultation
A 27-year-old came to our dentist’s practice, Dr. Adrian Bacila in
Timişoara (Temeschburg), Banat/
Romania. He complained of generalized, already chronic hypersensitivity and poor esthetics. He
had long postponed his visit to the
dentist and had neglected his teeth;
he was now determined to have his
dental defects corrected (Fig. 1 to 3).
The following was recorded as prosthetically relevant in the clinical assessment: multiple carious lesions,
which required treatment and were
responsible for the tooth sensitivity;
13 - tooth crown completely broken,
14, 15, 23-25, 33, 34, 37, 43-45, 47 - fractures and breakages with partially
exposed pulp; 36 and 46 - missing.
The sensitivity test and Spectra
examination suggested extensive
endodontic treatment, which was
verified by an X-ray. It was possible
to avoid extractions. Gingival recession due to periodontitis was identified in both the upper and the lower
jaw. The papillae had fully receded,
in particular the central papilla 11-21,
exposing black triangles. The patient
had a neutral bite (Angle Class I),
however an increase in the vertical
dimension was necessary (sunken
bite in the molar region).
Based on the results of the diagnosis,
the dental team drafted a restorative plan. The dentist presented this
to the patient including other possible alternatives. A metal-ceramic
bonded solution was decided - which
included single crowns and small
bridges in the lower jaw.
Metal-ceramic bonded restorations
are well proven solutions with a
history of very long clinical success;
this is supported by in-vivo studies.
In comparison to zirconium oxide,
metal frameworks have the advantage of higher elasticity and lower
hardness, which in this patient’s case
should restore the natural masticatory feeling again.
As the patient had previously postponed a visit to the dentist, the
emphasis now had to be placed on
rehabilitation with good long-term
perspectives. This way it would be
possible to minimize the amount of
procedures required and therefore
calm his fears.
The first steps in the practice
and the laboratory
Almost all teeth required root canal
treatment (Fig. 4). This was carried
out under the operating microscope
and completed with root post and
subsequent crown restoration. This
was also possible in tooth 13. The
preparation was carried out according to the Dr. Domenico Massironi
technique. The final impression was
taken with the impression material
ImpregumTM from 3M ESPE using
the double cord retraction method.
In addition, the patient underwent
periodontitis treatment once and
was thoroughly instructed in oral
hygiene. These treatment methods
prepared the patient’s teeth and gingiva for the temporary restoration.
A three month regeneration period
followed.
The three-month therapeutic trial
run showed that further measures
to eliminate the black triangles, resulting from the degeneration of the
papillae, had to be taken. The dentist
then prepared the teeth for the final restoration according to metalceramic requirements, and gave our
laboratory the impression (Fig. 11) to
cast the master model.
to use the new mixed-glass ceramics IPS Style Ceram, so the metal we
chose for the crown frameworks
was the non-precious metal alloy
4all from Ivoclar Vivadent. This was
cast in the conventional method,
and included holding pins to protect
the framework during the following procedures. The metal copings
were carefully finished. An oxide
firing was carried out in preparation
for the ceramic layer. Time and care
invested in this phase prevents bubbles in the ceramic later.
Preparing and covering the
framework
It is effective to use a modern shade
selection method from the very start,
so that the best suitable opaque ma-
The following information is based
mainly on the dental technically
interesting upper jaw. We wanted
ÿPage B2
the lower lip. Function and esthetics played an important role in the
design.
The temporary restoration, fabricated in the laboratory for this healing phase, was necessary for verifying the endodontic situation and in
particular to allow the gingiva time
to recover (Fig. 5). This served as a
vertical dimension therapy with a
so-called functional and esthetical
“test drive”.
LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED
The vertical dimension was not
changed. It was validated by the temporary restorations for 3 months.
The temporary restorations were
produced in a centric relationship.
Functional diagnostic procedures,
a sophisticated treatment plan and
an extensive esthetic analysis of a
photo status were required to produce the temporary restoration measures that formed the basis for
the patient’s individual dental rehabilitation (Figs 6 to 8). For the esthical analysis (Figs 9 and 10), we used
the program and procedure protocol
from Digital Smile Design (DSD) according to Dr. Christian Coachman,
São Paulo/Brazil. It includes tools
and gauges for a wide range of virtu-
IPS e.max PRESS MULTI
®
THE WORLD’S FIRST POLYCHROMATIC PRESS INGOT
• Monolithic LS2 restorations showing a lifelike shade progression
Figs 1 to 3: Clinical starting situation
al measurements and uses the information from patient’s portraits with
a variety of facial smile expressions.
Fig. 4: X-ray results of the starting
situation
Fig. 5: The temporary restoration. For
three months it was tested on function
and esthetics and continually adjusted
This extensive input showed that
the anterior length of the existing
crowns in the upper jaw could be
maintained. However, the tooth angles needed to be changed and the
bucco-lingual position of the incisal
edges had to be moved in order to
accommodate the lower incisors and
amic
all cer need
u
all yo
• Exceptional combination of strength, esthetics and efficiency
• For crowns, veneers and hybrid abutment crowns
• Coordinated with high-precision Programat press furnaces
• Maximum cost effectiveness in the press technique
www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstrasse 2 | 9494 Schaan | Liechtenstein
Tel.: +423 235 35 35 | Fax: +423 235 33 60
[2] =>
DTMEA_No.6. Vol.6_LT.indd
B2
LAB TRIBUNE
Dental Tribune Middle East & Africa Edition | 6/2016
◊Page B1
terial can be selected. This saves any
further shade corrections later on.
In this patient case we used IPS Style
Ceram Intensive Powder Opaquer
white, which enhances the natural
light transmission from the depths
of the tooth. After mixing with the
IPS Powder Opaquer Liquid, it was
applied in a very thin, non-covering
layer. The recommended temperature for the wash firing (1st opaque
firing) according to the manufacturer’s Instructions for Use is 870°C.
In the past, we have had good results
at 900°C, so in this case we fired at
a higher temperature than recommended by the manufacturer (Fig.
12). After a second application we
carried out the covering firing (2nd
opaque firing), this time at the usual
temperature of 870°C. A complete
and very good coverage of the powder opaquer is easily achieved using
either a brush or other instrument
(Fig. 14). We never use the opaque
residues of the wash firing for the
covering opaque layer, even though
the manufacturer states that the
dried residues can be mixed with liquid to the required consistency. The
results have always proved us right.
This time was no exception; the surface was very homogenous with no
micro porosities (Fig. 13).
In order to optimize the bond of the
opaque surface with the subsequent
ceramic material and fully enhance
the light-optical properties of the
IPS Style ceramic, we dusted a small
amount of IPS Style Ceram Deep
Dentin and Margin material onto
the second opaque layer. To do so, we
dipped a large dry brush into the jar
of ceramic powder and then dusted
this onto the yet unfired second
opaque layer (Figs 15 and 16). Any
surplus was tapped off within the
approx. two minutes opaque drying
process, and then the next firing was
carried out (Figs 17 to 19).
Building-up the anatomical
shape
Using a brush, we built up the body
of the tooth with a generous ap-
plication of Style Ceram Deep Dentin. Instead of the usual method of
only building up to the incisal edge
of the framework, we applied the
material to cover the complete upper and middle third of the tooth
(Fig. 20): We used it as a first layer
of body material to create the ideal
anatomical shape. This extended use
was possible due to the light flowing characteristics of the IPS Style
materials (light transmission): The
outline of the metal framework was
well covered. For this reason, it was
not necessary to additionally conceal
these areas. The mamelons and fissures were already incorporated in
this step.
As the second body material we used
IPS Style Ceram Dentin in the usual
manner to build-up the ideal tooth
shape. The extremely finely grained
IPS Style Ceram Dentin materials
are very easy to apply and highly
homogenous. Small amounts of IPS
Style Ceram Cervical Transpa (orange-pink and yellow) create an appearance of vitality in the cervical region. Using these four materials, the
complete anatomical tooth shape
was built up then checked for size.
Information:
Tip:
By creating a silicone matrix of a
wax-up produced in the early stages,
time can be saved during the ceramic build-up - in our experience
40-45%. However, this does not replace the actual layering technique
by hand. The IPS Style Ceram layering materials are stable, efficient and
easy to use, including the cut-back
procedure (Figs 21 to 23).
Individual patient design
In order to achieve a vibrant, true-tonature, patient-oriented appearance,
we used IPS Style Ceram Mamelon
yellow-orange in the palatal region
and IPS Style Ceram Occlusal Dentin orange in the incisal and lateral
regions. The latter is coloured green
so that it is easier to recognize (Fig.
24). In our opinion, intense colour-
coding of the different ceramic materials helps us to create our artistic
design. When fired, the pigments
burn-out completely without residue and a natural shade appearance
is revealed.
incorporating the cusp of Carabelli
(Tuberculum Carabelli) so that the
cusps and fissures of the upper and
lower teeth were completely aligned
and an even distribution of pressure
could be achieved.
IPS Style Ceram Mamelon yellow-orange and IPS Style Ceram Mamelon
light were mixed together to a ratio
of 1:1 (Fig. 25) and applied as ultra thin
accents to the vestibular mamelon
structure.
Dentin firings and
assessment of the results
Information:
Tip:
It is advisable to use IPS Style Ceram
Mamelon materials cautiously and
economically as they are extremely
opaque and highly fluorescent. A
very nice result is achieved if you
give them a vertically curved shape.
The high degree of material cohesion
and edge stability of the material allow very detailed and sharp structures to be easily created.
Further effects were applied to the
incisors and canines, as follows (Fig.
26): In the mesial areas we integrated
IPS Style Ceram Incisal I2, IPS Style
Ceram Opal Effect OE1 and OE5 as
well as IPS Style Ceram Transpa blue
and in the distal areas we added IPS
Style Ceram Transpa blue. We also
included IPS Style Ceram Opal Effect
violet and IPS Style Ceram Incisal I3.
We applied IPS Style Ceram Opal Effect OE4 in a “U shape” starting from
the centre of the tooth continuing
up towards the approximal-incisal
areas. To finalize the design we
imitated the so-called “halo effect”,
which in this particular case was realized with IPS Style Ceram Dentin A1.
Unlike the mamelons - these effects
were created with smoother transitions.
The occlusal surface was designed
age-appropriately with a pronounced formation. The patient had
a cross-bite in the molar region so
the lingual surface was made wider
than usual, in particular in the second quadrant. This was done by
Fig. 12: Wash firing after the very thin first
application
Finishing the surface
and shade characterization
The next step was to work on the facial surfaces of the teeth 11 to 15 and
21 to 25, to create an age-appropriate
form: Diamond burs were used in
particular to recreate the perikymata
and longitudinal grooves (intersegmental and margino-segmental
ridges). The application of gold paint
allowed the careful examination of
the surface texture and all surface
structures, including in the posterior region (Figs 44 to 52). Important:
The surfaces were individually characterized using the universal stain
and glaze range IPS Ivocolor, which
can be used for all layering, press and
CAD ceramics from Ivoclar Vivadent
and also zirconium oxide from Wieland Dental. This enhanced the restoration’s macro and micro texture
and created more expression. We began with the base shade A2. Through
individualization using the IPS Ivocolor stains, we were able to produce
a shade A3 tooth with a cervical area
in A3.5 (Figs 30 to 37). The characterized surface had an outstandingly
natural looking appearance. This is
due to the fact that no opaque ceramic materials were used, but instead stains, which allowed the light
to flow into the depths. Even the
posterior teeth had a very vibrant design with the mesio-palatal Carabelli
cusp and with the stained fissure details (Figs 38 to 41). We carried out a
glaze firing bake in the usual method
(750°C). The ideal texture can be determined by the amount of glaze
material applied: The thicker the
application, the glossier the result.
After the glaze firing and manual
polishing of some areas, the results
were impressive, literally “from all
sides” (Figs 42 and 43). Shape and texture were realized exactly as we had
planned.
Patient rehabilitated,
dentist satisfied
In the final session, the veneered
restorations were first inserted and
checked, (Fig. 53) and then conventionally cemented. Both dentist and
patient were so delighted with the
results that a whole series of photographs were taken from all angles
and under different lighting (Figs
54 to 71). The patient felt confident
again to give a wide open mouthed
ÿPage B3
Figs 9 to 10: Measurements according to the Digital Smile Design concept by Dr Christian Coachman
Fig. 6 to 8: Photo series for the esthetic analysis
Fig. 11: The impression with visible preparation marginsanalysis
The ceramic surface was compacted
with a dry brush and then fired with a
first dentin firing (790°C). The shade
and shape results are always eagerly
awaited - in our patient case, the results were spectacular (Fig. 27). Knowing our past experience with previously successful applications, these
were the results we had expected. We
must emphasize first and foremost:
The IPS Style Ceram ceramic shrinks
only minimally. Based on our experience this material has the lowest
shrinkage of all ceramics we have
used before. We needed to add only
a small amount to complete the vestibular surface (in this case with IPS
Style Ceram Dentin A3). The second
dentin firing (780°C) showed next to
no shrinkage. Only small corrections
were required with IPS Style Ceram
Incisal I3. The layered build-up maintained its shape and the youthfully
designed occlusal profile did not lose
any of its steep cusps (Fig. 28). The
light transmission from the depths
of the tooth was as we had hoped, as
was the shade graduation (Fig. 29). If
corrections are necessary and therefore further ceramic firing, rest assured, the shape and colour will not
change.
After use, it is extremely important
to clean thoroughly with a steam
cleaner to prevent discolouration
when firing.
Fig. 13: Second opaque firing
Fig. 14: Quick and easy: Application of the
IPS Style Ceram Intensive Powder Opaquer
to completely cover the framework.
Figs 15 to 16: The second opaque layer
is dusted with dry IPS Style Ceram Deep
Dentin and Margin powder materials.
Figs 21 to 23: Continuing the build-up with IPS Style Ceram Dentin to achieve the anatomical shape, followed by the cut-back to allow space for the patient individual design
Fig. 20: The dentin build-up begins with
a generous application of IPS Style Ceram
Deep Dentin up to the middle third
Figs 17 to 19: The fired results
Fig. 24: View of the palatal build-up,
which contributes to the illusion of depth
and essentially to an overall life-like appearance
Fig. 25: Steps towards creating mamelons: The stability of IPS Style materials
during application and the edge stability
are particularly apparent here
Fig. 26: Final layering effects. The wide
variety of IPS Style Impulse and Effect materials allow ceramists to fully indulge in
their passion
Fig. 27: Eagerly awaited: The results after
the first dentin bake firing. The shape and
shade are already impressive. We are particularly pleased about the low shrinkage,
which will save us time
Fig. 28: The occlusal view shows clearly
that the built-up shape was maintained
during firing. Here are the fired results
after the application of IPS Style Ceram
Incisal I3 on the occlusal surfaces
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DTMEA_No.6. Vol.6_LT.indd
Dental Tribune Middle East & Africa Edition | 6/2016
B3
LAB TRIBUNE
◊Page B2
Fig. 29: A good result after the final dentin firing: oral view of the crowns, without individualizations
Figs 30 to 32: Checking the results after the application of stains and after the glaze firing. The translucency, the shade and light transmission are pleasing to the eye from all perspectives (angles)
Figs 33 to 37: Checking the results after the application of stains and after the glaze firing. The translucency, the shade and light transmission are pleasing to the eye from all perspectives (angles)
Figs 42 to 43: The finished upper crowns after having been polished, as given to the dentist.
Figs 38 to 41: A trick we used: The deliberate incorporation of Carabelli cusps to avoid
a cross-bite and to achieve an even distribution of masticatory forces. Even though this
shape is different from the patient’s original bite, it provides the patient with greater
comfort
Fig. 53: X-ray examination and checking the fit
Figs 44 to 52: Careful examination of the surface texture and tooth shape
Figs 54 to 71: The patient is confident and self-assured once again. Is this still the same
metal-ceramic as we know it?
smile. The chosen restoration gave
him his joy of life back. His confidence grew.
Conclusion
According to the manufacturer, all
colour components in the IPS Style
contain oxyapatite crystals in different quantities. For this reason, the
opaquer is also an essential part of
the colour concept of the restoration.
In the end result, the metal-ceramic
IPS Style Ceram impressed us in
particular through its natural translucency and the depth of light transmission. IPS Style helps the dental
technician to achieve highly esthetic
restorations efficiently with easy
material handling and a low level of
shrinkage during firing. There are no
particular specifications to observe
in terms of design on the metal. The
dental restoration is so vibrant and
life-like that no one would think it
had a metal substructure.
One specific advantage of the visual
properties of IPS Style is that the
outline of the framework is not seen
through the ceramic as sharp edges.
Due to the high degree of reflection
and wide range of light-scattering,
much less Deep Dentin material is
required for concealing in comparison to conventional metal-ceramic
materials. Less space is required for
the ceramic. Without the problem
“framework outline”, less experienced ceramic technicians are also
able to use the IPS Style Ceram layering ceramic.
the ceramist can let his artistic abilities and skills run free.
Dental technical assessment
of the new veneering ceramic
We would like to thank Dr. Adrian
Bacila for the good working cooperation.
How the IPS Style Ceram is for us
dental technicians: We are able to
fully concentrate on the layering
technique and build-up process. The
IPS Style materials are very easy to
work with: finely granulated and
homogenous, with a pleasant and
individually adjustable consistency.
They are stable. Sharp edges and
detailed structures can be easily created. The layers adhere well to one
another.
In addition, a very important point is
the working efficiency. The ceramic
has a low degree of shrinkage, only
slight over-contouring is required.
The built-up morphology design is
maintained. Our assessment, which
also applies to this patient case:
When using the IPS Style materials,
Dr. Adrian Bacila,
Romania
Florin Stoboran
graduated from the
Dental Technician
School in Oradea,
Romania, in 1994. He
continued his studies
in ceramics and
specialized in fixed prosthetics, esthetics
and implantology.
[4] =>
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Dental Tribune Middle East & Africa Edition | 6/2016
CAD/CAM Final spurt 2016: Dentsply Sirona
presents inLab CAD Software 16.0
By Dentsply Sirona
The inLab CAD SW 15.0 software has
been an indispensable part of the
digital workflow in dental labs for
over a year now. The extensive update inLab CAD SW 16.0 now offers
additional options. The wide range
of inLab applications has now been
extended even further with new indications, tools and functions as well
as the option for additional implant
systems and a completely optimized
workflow. For the first time, scan
data from inEos X5 for suprastructures can also be transmitted to Atlantis®. Dentsply Sirona continues to
enable access to individual implant
restorations for dental laboratories.
Following the successful market
launch of inLab Software 15.0 last
year, the first update is now available. The latest inLab CAD SW 16.0
offers new features across all CAD
modules. In the Removable dental
prosthesis module, dental splints
and individual impression trays can
be designed for the first time using
the new inLab Splint plugin.
The Implantology module has been
extended to include screw-retained
bridges and dental bars at implant
level, thus allowing the FLO-S Scanbodies from Atlantis® to be scanned
and identified with inEos X5 and
inLab SW 16.0. Starting next year,
the scan data can be transmitted to
Atlantis® for the design and production of suprastructures. Coinciding
with the introduction of this software, infiniDent, Dentsply Sirona’s
production center, is launching a
new production service for directly
screw-retained bridges that have
been independently designed by the
customer in inLab CAD SW 16.0. The
corresponding design dataset can
be exported directly from the inLab
software to infiniDent for subsequent production. The Atlantis® and
infiniDent services will be launched
as a beta phase for selected customers in November. After successful
completion, it will then be available for all inEos X5 users. For the
production of individual adhesive
abutments (TiBase), the following
implant systems are also supported
by inLab SW 16.0: Astra Tech Implant
System EV and Ankylos from Dentsply Sirona Implants as well as BioHorizons and Osstem TS.
For the production of restorations on
other milling machines, STL data export via the inLab software interface
module is required. In addition to
the actual STL dataset, the additional
*.sci file (Sirona case information)
is also created. This supplements
the STL data with additional information, such as implant positions,
preparation margins, information
on materials, etc.
As the only laboratory software on
the market with J.O.B.S. (Jaw Orientated Biogeneric Setting), inLab
supports rapid patient-specific positioning of teeth with minimal of
corrections, even for work over long
spans. The inLab CAD SW 16.0 is now
extending this convenience with a
new function: inLab Check. The new
plugin tests the designed restorations with an FEM analysis for critical, strain-sensitive areas and visualizes these areas. The tool offers inLab
users practical design support for
large, complex cases or where space
is constricted.
pendent tooth position in the design
of implant bridges.
The inLab CAD SW 16.0 now runs
under both the Windows 7 and
Windows 10 operating systems. Furthermore, it comes with numerous
optimizations in terms of processing power, tools and design options,
like screw channel design, additional
tooth shapes for the restoration design (for example a third premolar
in tight spaces) or the implant-inde-
In addition, the current inLab CAM
Software 16.0 update for the inLab
MC X5 and inLab MC XL production
units will be available free of charge
as an automatic update or internet
download in the next few days.
More information at: http://www.sirona.com/inlab
Screw-retained bridges and bars at implant level with the inLab CAD SW 16.0
Implantology module.
inLab MC X5:
DENTAL LAB
FREEDOM OF CHOICE.
Experience new freedom in your lab processes breaking the chains of
former dependencies with inLab and the new 5 axis milling and grinding
unit inLab MC X5. Open for all restoration data, combining the largest
material range and the possibility to machine both wet and dry disks
and blocks – for no limitations to your production. Enjoy every day.
With Sirona.
INLABMCX5.COM
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