Clinical Approach to Fulﬁll Esthetic Requirements: The Challenge of Nature’s Beauty
QDT 2020 211
A bonded hybrid abutment was chosen in this case as well. A semi-custom titanium base is effective in cases of long clinical
crowns. The lengthy axial surface increases the bonding surface, which has a direct impact on the strength of the superstructure.
Dentist: Dr Hiroyuki Takino
This patient had periodontal disease along with occlusal trauma and agreed to implant treatment. Comprehensive orthodon-
tic treatment was carried out to establish a favorable functional condition after extraction and ridge preservation.
SURGICAL APPROACH FOR ESTHETIC RESTORATIONS
This patient was concerned with the unesthetic
appearance of an existing porcelain-fused-to-metal
crown. It was determined that the discolored tooth
root affected the appearance through the thin-
biotype tissue. A connective tissue graft was carried
out for stability of the prosthesis and to mask the
root color. The IPS e.max Press crown was then
completed with a layering technique after soft
tissue management by the provisional restoration.
Dentist: Dr Kotaro Nakata (Nakata Dental Clinic)
Connective Tissue Graft
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Clinical Approach to Fulﬁll Esthetic Requirements: The Challenge of Nature’s BeautyQDT 2020 211CASE 3A bonded hybrid abutment was chosen in this case as well. A semi-custom titanium base is effective in cases of long clinical crowns. The lengthy axial surface increases the bonding surface, which has a direct impact on the strength of the superstructure.Dentist: Dr Hiroyuki TakinoThis patient had periodontal disease along with occlusal trauma and agreed to implant treatment. Comprehensive orthodon-tic treatment was carried out to establish a favorable functional condition after extraction and ridge preservation. TSUZUKIQDT 2020212SURGICAL APPROACH FOR ESTHETIC RESTORATIONSCASE 4This patient was concerned with the unesthetic appearance of an existing porcelain-fused-to-metal crown. It was determined that the discolored tooth root affected the appearance through the thin- biotype tissue. A connective tissue graft was carried out for stability of the prosthesis and to mask the root color. The IPS e.max Press crown was then completed with a layering technique after soft tissue management by the provisional restoration.Dentist: Dr Kotaro Nakata (Nakata Dental Clinic)Connective Tissue Graft Clinical Approach to Fulﬁll Esthetic Requirements: The Challenge of Nature’s BeautyQDT 2020 213CASE 5IPS e.max CrownsHarmony with Soft Tissue TSUZUKIQDT 2020214The patient in Case 5 is a woman in her 70s. She presented for a second opinion concerning the prosthesis placed a few months earlier. Color mismatch of the crowns and disharmony of the gingival level were especially noted. A continuous gingival framework was designed for the four incisors, and a root coverage procedure was carried out for the left canine. The gingival shape was completed by subgingival contour of the provisional restoration, which was designed according to the diagnostic wax-up. Favorable harmony between the crowns and gingiva is evident after temporary cementation. This biologic harmony is established by superior t, supra/subgingival shape, and biocompatibility of the ceramics.Dentist: Dr Hiroyuki Takino/Dr Yusuke Yamaguchi (Yamaguchi Dental Care)This article was originally published in Japanese in Jpn QDT 2018;43(5):1–8. NEW IN ESTHETICSA direct-indirect restoration is one in which the composite resin is sculpted directly on the tooth structure without previous adhesive preparation, light activated, removed from the tooth, heat tempered, nished and polished extraorally, and nally adhered indirectly in the mouth in a single appoint-ment. The resulting restoration exhibits improved mechanical properties, excellent esthetics, and unrivaled marginal adaptation and polishing. Furthermore, the direct-indirect technique has a wide range of applications, including prepless contact lenses and veneers, veneers with preparation (discolored teeth), fragments, diastema closure, and noncarious cervical lesions, among others. Written by world-renowned masters in their eld, this book systematically covers these many applications and provides step-by-step protocols with speci c layering strategies for each. Fifteen detailed case studies are included to showcase the technique.296 pp; 1077 illus; ©2020; ISBN 978-0-86715-959-2 (B9592); Available March 2020CALL: (800) 621-0387 (toll free within US & Canada) • (630) 736-3600 (elsewhere) 12/19FAX: (630) 736-3633 EMAIL: [email protected] WEB: www.quintpub.comQUINTESSENCE PUBLISHING CO INC, 411 N Raddant Rd, Batavia, IL 60510Newton Fahl, Jr and André V. RitterContentsThe Direct-Indirect Concept • Composite Resins and Layering Strategies • Prepless Contact Lenses and Veneers • Veneers with Preparation: Discolored Teeth • Indirect Restorations Fabricated on Flexible Silicone Models • Direct-Indirect Class V Inlays QDT 2020216Esthetics with Micro Restorations Esthetics with Micro RestorationsIt is a fact that software and machines make our labo-ratory processes faster and easier. Nevertheless, the human mind, with its inﬁnite expertise, is still necessary to perform individual restorations with their differing es-thetic requirements. Restoring a single tooth or a fragment of a tooth does not require a great deal of creativity, since either the contralateral tooth (in the case of a single crown) or the remaining tooth (in the case of a fragment) will be the principal reference. However, reproducing any shape and color by porcelain layering requires the ceramist to master the artistic skills—through knowledge, experience, and continual practice—to conﬁdently achieve esthetically demanding results. Bonded porcelain restorations have been proven, in medium- to long-term evaluations, to provide excellent es-thetics, high patient satisfaction, and no adverse effects on the supporting tissues. They are also associated with max-imum enamel preservation due to their ability to be acid etched and bonded to the dental structure. Bonding proce-dures allow us to replace old preparation concepts, based on restoration retention by friction, with a much more con-servative approach, based on insertion pattern and posi-tional stability, maximizing the preservation of the remaining tooth structure.1This article describes the technical steps to develop minimally invasive ceramic fragments to restore the smile of a young girl. Anabell Bologna, DDS, CDT1Rafael Laplana, DDS11Private Practice, Caracas, Venezuela.Correspondence to: Dr Anabell Bologna, LaplanaBologna Estetica Dental Avanzada, Av. Venezuela, Policlínica Americana, 2ab, El Rosal, Caracas 1060, Venezuela. Email: [email protected] 2020 BOLOGNA/LAPLANAQDT 2020218CASE PRESENTATION The patient, a 14-year-old young girl who suffers from coughing syncope, presented with fractured incisal edges of the maxillary central incisors and right lateral incisor af-ter suffering a severe coughing episode that resulted in her fainting and falling down. The preoperative situation is shown in facial view (Fig 1), smile (Fig 2), and intraoral view with black contrast (Fig 3). When the patient visited the restorative team, tests were done to conﬁrm the vitality of the involved teeth. Teeth fragments were not recovered during the accident, so bonding those fragments to the remaining teeth2 was not an option. Taking into account the young age of the patient, full-coverage restorations were not considered. Due to the need to restore substantial coronal volume and length,3 the treatment plan was to develop three feldspath-ic ceramic fragments, following the refractory die tech-nique, and to bond them to the remaining teeth, restoring the missing dental tissue.Communication of Color and Photographic ProtocolEven with all the technological advances, the selection, communication, and reproduction of color can be challeng-ing in some cases and can result in an unpredictable out-come. Effective communication between the clinical team and the dental laboratory is mandatory to achieve a suc-cessful shade match, with photography being an excellent communication tool for this.4For reference photographs, it is important to note that those taken with a ring ﬂash are good for basic shade in-formation, as well as proportion and arrangement. Howev-er, they are not good for sharing information to reproduce 1 23Fig 1 Preoperative facial view.Fig 2 Preoperative smile view.Fig 3 Preoperative intraoral view. Esthetics with Micro Restorations QDT 2020219the color in a precise way. Lateral light photography is con-sidered a better option, since it allows us to see through the layers of the tooth. Nowadays, cross-polarized light photography is highly recommended, since it reduces the glare, allowing visualization of the gradation of the chroma, which enables an easier and more precise dentin shade selection and layering map.5 Comparative preoperative in-traoral images taken with lateral light (Twin Lite MT-24EX, Canon) and with cross-polarized light (polar_eyes, Emula-tion) are shown in Figs 4a and 4b.Shade SelectionWhen tooth selection is carried out in a conventional way, the knowledge and experience of each professional can make a difference. Conventional shade guides have limita-tions in communicating the color precisely, due to the sig-niﬁcant variability of the shades they represent. For more precise information, shade selection with color scales constructed from the pure materials—for example, deep dentin, mamelon, dentin, incisals, and opals—is highly rec-ommended.6Layering Map—Chromatic SampleDue to the amount of dentin structure lost vertically, while developing the layering map it was key to mix the Opaque Dentin with the Mamelon Light (the most reﬂective mate-rial of the system) to block the darkness of the oral cavity, thereby avoiding the risk of a low-value restoration (Figs 5a to 5c).In any type of single anterior restorations, a chromatic sample is made immediately after the color selection to avoid any doubt as to the correct selection of color and future layering. To make this chromatic sample, once the shade is decided upon, a schematic stratiﬁcation with the selected materials is made on a piece of tissue paper using the main colors and effects. Incisal is placed only in half of the layering to allow us to check, after the porcelain ﬁring, the veracity of the internal stratiﬁcation at the uncovered portion by the incisal layer and the correct enamel selec-tion and thickness in the other half.7 The ﬁring process is carried out at 50ºC above the regular ﬁring temperature of the porcelain in order to obtain a shiny sample (Fig 6). This process allows us to detect any corrections required dur-ing the layering of the fragments. 4aFigs 4a and 4b Preoperative intraoral images taken with lateral and polarized light.4b QDT 2020220BOLOGNA/LAPLANAFigs 5a and 5b Development of the layering map.Fig 5c Opaque Dentin is mixed with the most reﬂective material, Mamelon Light, to counter the darkness of the oral cavity and resulting low-value restoration.Fig 6 Shiny chromatic sample, achieved by ﬁring at 50˚C above the regular porcelain ﬁring temperature, to detect any corrections required during layering of the fragments.5a5b5c