Lab Tribune Middle East & Africa No. 6, 2021
Full-arch rehabilitation with lithium disilicate secondary crowns luted on the primary framework
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DTMEA_No.5. Vol.11_LT.indd
NL
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PR
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AL
DE
PUBLISHED IN DUBAI
www.dental-tribune.me
November-December 2021 | No. 6, Vol. 11
Full-arch rehabilitation with lithium
disilicate secondary crowns luted on the
primary framework
By Joaquín García Arranz (Quini),
Ramón Asensio Acevedo and Oscar
Jimenez Rodriguez, Spain
Dealing with implant restoration is
challenging, and this process would
be impossible if we did not communicate freely between the clinic and
laboratory.
At the start, we don’t know what type
of framework design we will have to
make, nor what the pink and white
proportions will be.
The starting point is that we work as
a team, maintaining constant communication through emerging technologies in photography or digital
smile design.
In a treatment protocol for complete edentulism with digital design
information, we transfer the ratios
of white and pink aesthetics to the
scanner, turning it into an analogue
test for a first analysis inside the
mouth via CAM.
When we know how far we need to
go with the case, we select the type
of material that will result in the best
outcome, mixing materials with different techniques throughout its development.
The patient’s needs are always taken
into account when searching for
greater durability of our prostheses
over time.
A patient with deprecated crown
and bridgework attended the clinic
because several abutment teeth had
failed. Due to the Class III occlusal
pattern and the small number of
remaining teeth with a good, longterm prognosis, we decided to go for
an implant-supported restoration in
the maxilla and a combined toothimplant restoration in the mandible.
Today, these technologies are a basic tool for treatment approach and
development. We combined Digital
Smile Design (DSD) and the patient’s
photographs and we entered them
into the GC Aadva Lab Scan’s Exocad
software. We merged the patient’s
facial contours with the Anteriores
Templates Contour Library provided
by Jan Hajtó. (Fig. 1) Once the teeth
matching the facial features were
selected, we started to adjust the
tooth shapes, keeping a close eye on
length-to-width ratio, midline and
labial and pupillary plane. When
the white aesthetics were finished,
we designed the pink aesthetics together with the implants; taking the
anatomical design and the cleansable basal area into account (Fig. 2). After the aesthetic design, we sent this
digital information to the CAM software to create a mock-up structure
in PMMA. This can be done by either
milling or printing (Fig. 3).
To check the precision, we systematically link our aesthetic mock-up
to the implants: we do this by screwing three implant interfaces to the
Figs. 1a
Fig. 2: Digital design of the gingiva.
Figs. 1b
Figs. 1a & b: Digital mock-up.
implants with the correct occlusion,
providing a tripod of accuracy.
With a constant, good communication between dentist and laboratory,
we did several aesthetic tests, working to a high degree of accuracy. In
this phase we need to work precisely
and consistently before we can continue with the treatment. All necessary changes were made to clear any
Fig. 3: Mock-up in PMMA with pink and white aesthetics.
doubts until we achieved the desired
integration of the mock-up into the
patients mouth and face (Fig. 4).
During the treatment protocol for
edentulous patients, we take the time
to evaluate the aesthetic mock-up
verify what the best obtainable result
would be and which material would
be ideal for the final restoration: a
conventional PFM restoration or a
Fig. 4a
Fig. 5a
Fig. 5b
Fig. 4b
Fig. 5c
Fig. 5d
Figs. 4a–b: Evaluating the integration of the mock-up in the patients
mouth.
Figs. 5a–d: Choice of different definitive materials.
white material, such as zirconia, combined with metal interfaces (Fig. 5).
For this type of design, there are
many elements we have to take into
account: the length from the implant to the incisal edge, implant-restoration ratio, widths of the design,
occlusion, etcetera.
ÿPage B2
[2] =>
DTMEA_No.5. Vol.11_LT.indd
B2
LAB TRIBUNE
Dental Tribune Middle East & Africa Edition | 6/2021
◊Page B1
Fig. 6a
Fig. 6b
Fig. 7
Figs. 6a, b & 7: Single crown design on different framework materials for easy repair.
Fig. 8: Scanning the aesthetic mock-up.
Fig. 9: Framework design in GC’s Exocad software.
Fig. 10: PFM framework: pink aesthetics with GC Initial MC.
Fig. 11: Single crown frameworks ready to be pressed.
Fig. 12a: Initial LiSi Press ingot.
Fig. 12b: Secondary frameworks pressed in GC Initial LiSi Press.
Fig. 13: Light dynamics of natural teeth in direct and indirect light.
Fig. 14: Light dynamics of natural teeth in fluorescent light.
Fig. 16: Etching and pretreatment of the ceramic surfaces.
Fig. 15: Layering with Initial LiSi.
Fig. 17: Cementation using G-CEM Veneer A2.
Fig. 18: Perfect integration of the pink and white parts after mechanical
polishing.
ÿPage B3
[3] =>
DTMEA_No.5. Vol.11_LT.indd
B3
LAB TRIBUNE
Dental Tribune Middle East & Africa Edition | 6/2021
◊Page B2
Fig. 19: Finished restoration.
Fig. 20: Intraoral view after treatment.
We take great care ensuring every
patient has a prosthesis customised to their needs. The restoration
should be durable and, in case of an
accident, easy to repair. Therefore,
in some metal-ceramic as well as in
zirconia restorations, we make single
crown designs on a primary framework (Figs. 6 & 7). This enables us to
repair or replace a broken element.
In this case, where we had sufficient
length, a change from a Class III to
Class I occlusion with a considerable
adaptation in the vestibular direction and long tooth structures in
proportion to the gingiva, we opted
for a PFM framework. We scanned
the aesthetic mock-up with the GC
Aadva Lab Scan and determined
implant positions with its dedicated
Scan Flags (Fig. 8).
Thanks to the tilt and swivel unit,
90-degree angulation and dual camera system, we were able to scan the
basal side of the mock-up. With the
exocad software we could make a
quick design of the restoration with
a proportioned reduction (Fig. 9).
Once the frame structure was designed, the .stl file was sent to the
milling unit to mill the metal framework. Although our protocol was carried out with rigid splinting of the
impression copings, we still tested
the framework’s passive fit , both on
the model and in the mouth.
For layering, we have two different
techniques , both with their advantages and disadvantages:
• Pink layering technique with white
aesthetic cut back technique.
• Pink layering technique with white
aesthetic full contour painting protocol. (as is also shown in the ‘Alternative method’ part)
Fig. 21: Frontal view after treatment.
Initial LiSi Press MT was used for the
secondary crown frameworks. The
cut-back technique was used in the
anterior area and full contour frameworks were used in the posterior area.
For this technique, we use duplicated
secondary crowns in milled PMMA
or wax to fit the emergence profile
correctly while layering the pink aesthetics with GC Initial MC.
using the polychromatic layering
technique using Initial LiSi veneering ceramics. This ceramic is exactly
cross-matched to the lithium disilicate framework and ensures a perfect fusion (Fig. 15). Once the macro
and microtexture surface have been
finished, we mechanically polish
it for a perfect integration with the
pink aesthetics.
After layering the pink aesthetics,
we applied a very fine layer of highly
chromatic ceramic (GC Initial MC)
onto the die’s surface (Fig. 10). Once
fired, this gives us the big advantage
of being able to create a chemical
bond between this feldspar-based
ceramic and the future lithium
disilicate secondary single crowns
(Initial LiSi Press) that can now still
be re-adjusted before pressing them
(Fig. 11).
Cementation and bonding
protocol
We use this technique mostly for
anterior restorations, leaving the lingual side monolithic with the correct
occlusion and without any protrusive risk of chipping the ceramic. GC
Initial LiSi Press looks very much like
natural teeth, enabling an excellent
integration (Fig. 12 a & b).
The best way to understand how the
light dynamics of a material works
is to conduct different tests with a
natural tooth and play around. Not
only in direct light but also in indirect light (Fig. 13) and even in black
light or fluorescent light (Fig. 14). By
matching these optical properties
we can achieve good aesthetic results. GC Initial LiSi Press is available
in degrees of translucency, from the
most opaque to the most translucent (MO, LT, MT and HT).
The bonding protocol to cement
the LiSi Press restorations onto the
surface of the ceramic covered dies
starts by applying a hydrofluoric
acid etch for 20 seconds on both ceramic surfaces. After rinsing and
drying, Ceramic Primer II or G-Multi
PRIMER is applied (Fig. 16).
Shade A2 of G-CEM Veneer was selected, verified with G-CEM Try-in
Paste to check the shade and used to
cement the restorations (Fig. 17).
The cement was tack-cured for 1 to
3 seconds to remove excess material
and then completely light-cured for
30 seconds. After completion (Figs.
18 & 19), the restoration was finished
and polished.
The finished restoration, placed in
the mouth (Figs. 20 & 21) showed
good integration. The correct implant seating was verified with CT
scan (Fig. 22). The basal adaptation
was perfect to enable optimal cleaning of the mucosa. Occlusal fit was
checked with active posterior cusps,
and canine and protrusive guidance.
Fig. 22: Radiograph after treatment.
2. “Implant Aesthetics” Luc & Patrick
Rutten. teamwork media GmbH 2001
3. “Evolution” Contemporary Protocols for Anterior Single-Tooth Implants. Iñaki Gamborena & Markus B.
Blatz. Quintessence Publishing Co Inc
2015
4. “Anteriores Natural & Beautiful
Teeth”. Jan Hajtó. teamwork media
GmbH 2006
5. “Crown – Bridge & Implants” The
Art of Harmony. Luc & Patrick Rutten.
teamwork media GmbH 2006
6. “Desafiando la Naturaleza”. Paulo
Kano. Quintenssence Editorial Itda.
2012
7. “Motivation”. Claude Sieber. VITA
Zahnfabrik
8. “Past Future” Envision 77 Heart
Beats. Naoki Hayashi. Ishiyaku Publishers, Inc. 2011
9. “Analysis” The New way in dental communication. Gérald Ubassy.
teamwork media Srl. 2003
10. “Sombras, un mundo de color “.
Agust Bruguera. Puesta al día en Publicaciones SL. 2002
11. “Prótese Fixa”Protocolo cerámico.
Pablio Caetano. Colecao Apdesp Br.
Volume II Napoleao Editora 2015
private labour since 1991. Director of
the Dental Training Center in Madrid by
Quini. Founding partner of the Fresdental
Mechanization Center. Professor of the
Master´s degree in implants at U.E.M University. Professor of the Master’s degree in
prosthesis for dental technitian at Vericat
training center. GC Iberica opinion leader.
Speaker of numerous courses in national
and international conferences. Author
of different articles published in national
magazines. Author of the book “Experience Group”
Ramón Asensio Acevedo
DDS, Universidad Alfonso X el Sabio,
Madrid, Spain. Master in Esthetic and
Restorative Dentistry, Universidad Internacional de Cataluña, Barcelona, Spain.
Master in Interdisciplinary Esthetic Rehabilitation, Universidad Internacional de
Cataluña, Barcelona, Spain. Assistant Professor in Aesthetic Dentistry, Endodontics
and Restorative Dentistry Department,
Universidad Internacional de Cataluña,
Barcelona, Spain. Private practice Madrid,
Barcelona and Toledo Spain.
About the authors
The anterior area is the most aesthetic demanding area and was veneered
1. “Restauraciones de porcelana adherida en los dientes anteriores”. Método
Biomimético. Pascal Magne. Editorial
Quintenssence SL. Barcelona 2004
Joaquín García Arranz (Quini)
Founder of the dental laboratory Ortodentis, which has been developing its
Oscar Jimenez Rodriguez
Dental technician specialized In dental
prosthesis. Speaker of numerous courses
of National Scope, at the Murcia Prosthetic School, Dental Miv Facilities and Inside
GC Iberica with GC Initial ceramics.
Fig. A: Micro and micro surface texture
engineering.
Fig. B: Application of the Initial Spectrum
Stains.
Fig. C: Fitting the LiSi Press restoration
onto the zirconia framework.
Fig. D: Highly fluid LiSi ceramic is applied
onto the zirconia framework.
References
Alternative method
In this case, zirconia was used for the
primary framework. Before sintering, the dies were infiltrated with colouring liquids and fluorescent effect.
The secondary, full anatomical
crowns are adjusted to the zirconia
framework. After pressing in LiSi
Press MT, the surface structure (macro and microtexture) is engineered
(Fig. A).
Here, the aesthetic details were
painted on the full contour zirconia
restorations, using the GC Initial
Spectrum Stains and fixated in the
ceramic furnace. A great advantage
of this approach is the ability to continue firing until the desired colour
is achieved (Fig. B).
Once the desired colour is achieved,
the surface is mechanically polished.
The inside of the LiSi Press crowns
and the zirconium die surfaces are
gently sandblasted with aluminium
oxide. We pay close attention to the
correct fit between the LiSi Press
Fig. E: Multi chromatic layering of gingival structures.
Fig. F: Polished gingiva and teeth, view from two different angles.
restorations and the zirconia framework (Fig. C).
conducted. Once both structures are
fired together, we layer the pink aesthetics with Initial Zr-FS. Multi chromatic layering during different firing
cycles is performed to reach the desired goal and have a perfect gingival
adaptation (Fig E).
The most delicate step in this technique is where we place highly fluid
Initial LiSi ceramic on the dies’ surface, manoeuvre the crowns into
their right position and take the marginal fit and occlusion into consideration (Fig. D).
A special firing for overall fusion of
the secondary LiSi Press crowns and
the primary zirconia framework is
The mucogingival surface is finished
and mechanically polished together
with the crowns (Fig. F), resulting in a
nice integration.
[4] =>
DTMEA_No.5. Vol.11_LT.indd
Removes Doubt
Osseo 100 measure implant stability and osseointegration
to enhance decisions about when to load the implant.
Especially important when using protocols with shorter
treatment time and treating higher risk patients.
Manage
higher
risk patients
Reduce
treatment
time
One stage,
immediate loading,
early loading.
Compromised bone,
smokers, bruxism,
diabetes, cancer,
osteoporosis, grafts,
membranes etc.
3-step procedure
1.
2.
Osseointegration Monitoring Device
www.nsk-inc.com
3.
)
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