Diagnostic and Technical Approach to Esthetic Rehabilitations

Diagnostic and Technical Approach to Esthetic Rehabilitations

GIUSEPPE ROMEO, C D T “ MARIO BRESCIANO, DDS, CDTt

ABSTRACT The success of an esthetic rehabilitation depends on the understanding of the patient’s needs and on effective communication among the entire dental team. The involvement of the dental technician since the beginning of the treatment plan is one of the keys for success. This article describes a systematic approach to oral rehabilitations involving esthetic areas. Technical suggestions for the construction of the diagnostic wax-up, the provisional, and the final ceramic restorations are illustrated in a logical sequence.

CLINICAL SIGNIFICANCE Esthetic areas challenge the restorative dental team’s abilities to mimic nature. Patient involvement, teamwork, and systematic technical and clinical steps are the keys to success in restorative rehabilitation.

(J Esthet Restor Dent 15:204-216, 2003)

he functional and esthetic suc- T cess of an oral rehabilitation depends on the understanding of the patient’s and on effective communication among the entire dental team.49

The active involvment of the patient in the decision-making process of the treatment plan is of paramount importance, especially when esthetics is concerned.1°-16 The entire treating team should understand completely the patient’s requirements and expectations. At the same time, the patient should be made aware of the limitations of the restorative therapy.

Good cooperation is guaranteed if the dental technician is involved from the beginning of the treatment plan, having direct contact with the patient. This increases the chances of a correct and straightforward fabrication of the prosthesis and avoids some of the miscom- munication problems that often arise during complex prosthetic treatments.

This article describes the technical steps required to achieve an optimal esthetic result that meets a patient’s espectations. The logically sequenced procedures are the diag-

nostic waxing up, the fabrication of stratified resin restorations, and the final fabrication of the ceramic restorations.

PRELIMINARY PROCEDURES

The laboratory receives the preliminary alginate impressions from the dental office, together with a com- plete set of slides, occlusal records, and proper prescriptions. The initial study models (Fujirock G.C. Europe, Leuven, Belgium) are then fabricated and mounted on a semiadjustable articulator. A second set of casts, which will be used for the diagnostic waxing up, is also fabricated.

‘Private dental laboratory, Torino, Italy TClinical instructor, Department of Prosthodontics, University of Torino, Torino, Italy; private practice, Torino, Italy

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R O M E O A N D R R K S C I A U O

At this point, the patient is exam- ined by the dental technician. This meeting is essential for creating an environment of confidence. The patient is able to understand the complexity of the prosthetic recostruction, and the technician gathers firsthand information of the patient’s needs and expectations. The smile and the shade and surface texture characteristics of the teeth are analyzed and recorded.

With all this information, the technician is able to work on a first hypothesis of the esthetic solution. This “technical treatment plan” is defined through the diagnostic waxing up, a wax simulation of the final result.

DIAGNOSTIC WAXING UP

The diagnostic waxing up of an esthetic rehabilitation is a demanding task. It should be kept in mind that the more effort that is placed in planning the therapy, the easier the execution of the final prosthesis will be. l7l1*

Well-established artistic guidelines can be followed to define the best suitable shape and arrangements of the teeth.19-24 Some of the patient’s old photographs and gypsum casts with intact teeth can be used as models to customize the smile of the patient.

Two waxing options can be used: additive waxing,25 best suited for

laminate veneers, and, for full-coverage crowns, veneered wax-up,26 made with preformed vestibular wax veneers (Form-up, Girrbach, Germany).

In additive waxing, the first step is to define the basic new volumes of the restorations by applying the vertical proximal crests, which determine the transitional line angles between the facial and proximal surfaces (Figures 1 and 2A and B). The second step is to define the surface topography by applying the superficial vertical lobes and the horizontal developmental lines (Figures 3-5).

When the wax-up is completed, a silicon matrix, to be used by the dentist as a reference for intraoral tooth reduction, is fabricated (Figure 6 ) .

P R O V I S I O N A L R E S T O R A T I O N S

Once the final result is planned with the diagnostic wax-up, it should

be verified intraorally to obtain the patient’s acceptance. For this purpose, provisional restorations are made from the diagnostic wax-up.

In case of laminate veneers, before tooth preparation an acrylic resin overlay, also called a mock-up, can be placed intraorally over the exist- ing teeth.25.27-31 This removable acrylic template can be made directly in the patient’s mouth or indirectly onto a study cast by means of a silicon matrix obtained from the wax-up (Figures 7 and 8). The use of a mock-up helps to ensure the success of the provisional and final restorations (Fig- ures 9 and 10).

In the case of full-coverage crowns, provisional restorations are made with a technique called sandwich stratification,26 thanks to which in- depth characteristics can be repro- duced. A silicon matrix of the wax-up is fabricated. In order to have precise details, it is allowed to

Figure 1 . Preoperative case of additive wax-up. The black lines show where the tooth lost its characteristics.

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Figure 2. A and B, The proximal lobes are waxed to defilze the lzew volume of the tooth.

Figure 3 . A and B, The second step is to define the surface topography. The black lines indicate where changes are necessary.

Figure 4. A and B, Completed wax-up of tooth 11.

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Figure 5. Completed wax-up of teeth 12 to 22.

polymerize at 3 to 4 atm. The acrylic resin dentin (New Outline, Anaxdent, Germany) is mixed, applied to the working cast using the silicon matrix, and allowed to cure under pressure (Figures 11-13). Burs are used to cut back the material to allow space for the enamel (Figure 14A and B). With another sectioned silicon matrix the spaces are checked; pigments are brushed

on and light cured (Creactive, Hereaus Kulzer, Wehrheim, Germany). The last layer of enamel is then applied and polymerized under pressure (Figure 15). The final result is an esthetic provisional restoration that can be finished and polished mechanically without los- ing its color characteristics. This is then checked, adapted, and placed in the mouth.

Provisional restorations are the in vivo conversion of the monochro- matic wax-up into polychromatic resin teeth. Therefore, they not only restore the missing portions of the prepared teeth, they are the final step of the diagnostic phase, serving as guide for the final restorations (Figures 16-1 8) .15p26 ,32-36

In complex esthetic rehabilitations, the integration of the provisional restorations should be evaluated after some time.25,37 Usually, in these cases the patient has lost the volume and the morphology of the teeth over years and may have some difficulties adapting to a new appearance. Changing the shape and the arrangement of the teeth has a big impact on the self-perception of the ~ a t i e n t . ~ y ~ * ~ ~ Knowing this, the dentist and the technician should transmit confidence and support

Figure 6. Silicon matrix obtained from the wax-up used to check the intraoral preparation.

Figure 7. Preoperative case of two central maxillary incisors requiring laminate veneers.

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Figure 8. Direct acrylic resin mock-up; the black lines indicate where changes are required.

Figure 9. Provisional restoration.

Figure 10. Final restoration after cementation.

Figure 12. Tooth preparations.

Figure 11. Preoperative case: teeth 12 and 11 to be restored with feldspathic laminate veneers, and teeth 21 and 22 to be restored with feldspathic all-ceramic crowns.

Figure 13. Fabrication of the stratified provisional restorations: the polymerized acrylic resin dentin on the working cast.


R O M E O AR’D B R E S C I A U O

Figure 14. A and B, The material is cut back and is checked with a silicon matrix.

Figure 15. Pigments are photopolymerized. Figure 16. Transitional lines are indicated to modify the surface morphology.

Figure 17. Finished provisional restoration on the cast. Figure 18. Provisional restoration in the mouth.

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D I A G N O S T I C A N D TECHNICAL, . A P P R O A C H T O E S T H E T I C REHABILIT .4TIONS

to the patient during the adapta- tion period.

At this point in the treatment, it is important for the technician to see the patient. The diagnostic effort created with the wax-up can be appreciated only when the provisional restorations are in place. Before proceeding with the fabrication of the final prosthesis, the new smile should be accepted by the patient in its length, shape, size, and basic color. If extensive corrections are needed, a second provisional must be fabricated. Smaller changes are corrected on the definitive prosthesis and evaluated during the check of the ceramic biscuit. Impres- sions and slides of the provisional resorations in situ are then taken.

C E R A M I C R E S T O R A T I O N S

The final step of an esthetic rehabilitation is the application of the ceramic. The principles that guide this step are the same for both

Figure 19. Master dies.

metal-ceramic and all-ceramic restorations.

The purpose of the ceramic stratification is to mimic the composite structure of natural teeth, with its effects of contrasts given by layers of different transparency, translucency, and opacity.4549 This can be obtained by achieving a proper relationship among the different layers of ceramic based on the spe- cific shape of the tooth.

Generally, from inside out, layers of maximum opacity are gradually followed by others with less opacity, until no opacity is present. In every tooth, however, there are some areas where a layer of high opacity is placed over a layer of low opacity or where a layer of high transparency is placed underneath a layer with low transparency. This arrangement creates contrasts and produces a dynamic final result that simulates the internal characteris-

tics of natural teeth and allows the perception of t r a n s p a r e n ~ y . ~ ~ - ~ ~ To enhance this color-contrast effect, it is important to differentiate the degree of the value by using transparent, translucent, and incisal ceramic masses of different shades.

From the final impression, several gypsum casts (Fujirock, G.C. Europe) are obtained? (1) the master dies to check the fit (Figure 19), (2) a nonsectioned cast without gingiva to check contact points and occlusion (Figure 20), and (3) a sectioned cast with removable dies and gingiva to use as a working cast (Figure 21). In all-ceramic restorations, ceramic cores are fabricated directly on the master dies. Veneers or feldspathic ceramic restorations are fabricated on refractory replicas of the master dies.

In metal-ceramic restorations, the metal frameworks are fabricated on the working cast and their marginal fit checked on the master dies. The opaque ceramic layer is then brushed on and baked. Shoulder ceramic is applied on the cervical margin to allow for proper bright- ness of periodontal tissue^.^^-^^

The first step of the ceramic stratification is the application of opaque dentin (Creation, Jensen Industries, Inc, North Haven, CT, USA), which is followed by the application of regular dentinal masses to create


ROMEO A N D B R E S C I A N O

Figure 20. Nonsectioned cast without gingiva. Figure 21. Working cast with removable dies and soft tissues.

the basic dentinal shape. A wall of translucents and enamel (powders

Creation) is then applied on the incisal third (Figures 22-25). Over this, more opaque modifiers and pigments are infiltrated, and a vari- ety of ceramic masses, such as blue-transparent (TI1 ), transparent and enamel (S58+CLO), cervical translucents (HT52), and translucents with opalescent effect (SI2-TI2-SIl-S13-T14), are placed (Figure 26A and B). The palatal

S58-S58+CLO 1: 1-TI4-OT,

zone is completed with opaque dentin (OD32) and a modifier (MI63), dentin, enamel (S58), and translucents (SI3) (Figures 27-29). The proximal areas are covered with opaque dentin with higher chroma (AD2), dentin, and cervical-transparent (HT53+54+51). The ceramic is then placed in the oven for the first bake at 900°C, at a rate of 55"Clmin.

The restorations are mechanically refined and surface pigments are

brushed on and then blocked in the oven at 850"C, at 8O0C/min (Figure 30). Enamel and translucent ceramic are then applied to com- plete the shape, and the restoration is baked at the same temperature and rate of the first bake. This layer creates an "enamel skin" that pro- tects the characterizations previ- ously i n ~ e r t e d . ~ ~ J ~

Figure 22. Ceramic stratification: application of dentin. Figure 23. Incisal wall.

The restorations are then mechanically refined, polished, and checked on the nonsectioned cast and then

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Figure 24. Infiltration of modifiers.

Figure 26. A and B, Enamels and translucents.

Figure 27. Palatal surface with opaque dentin.

Figure 25. Application of ceramic with high value.

Figure 28. Palatal surface with dentin.


Figure 29. Palatal surface with enamel and translucents. Figure 30. Ceramic restoration aft.. the first bake.

in the mouth (Figure 31). Their color is verified by wetting the surface of the ceramic with a small amount of glazing liquid. Their occlusion, shape, and harmonic integration with the periodontal tissues are also checked. Once the final corrections are made and the restoration is checked again intraorally, if necessary, the finalization of the work can proceed. Slides of the situation can be taken to improve the final results.

The restorations are glazed in the oven at 895"C, at a rate of

130"C/min, and then polished mechanically (Figure 32). The final prosthesis is checked in the mouth one last time. After the patient's con- sent has been obtained, the prosthesis is finally luted (Figures 33-35).

CONCLUSIONS

The demanding task of rehabilitat- ing esthetic areas can be success- fully achieved with a twofold strat- egy: psychological and technical. The dental team and the patient should understand each other from the beginning of the treatment plan and fully cooperate during the

entire therapy. The dental technician should have direct contact with the patient all along, to fully gather the information necessary for an optimal construction of the prosthesis. The patient has to par- ticipate in the decisions and be made aware of the complexity and limitations of the treatment.

The technical execution of the restoration should follow a series of steps and checks logically sequenced. The diagnostic waxing up should receive adequate attention so that the following steps are a

Figure 31. The surface topography is modified following the indicated lines.

Figure 32. Final restoration after glazing.

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Figure 33. Final rehabilitation in the mouth. Figure 34. The emergence profile shows an excellent soft tissue integration of the restoration.

Figure 35. New aspect of the patient’s smile.

straightforward process. A stratified provisional restoration helps the patient and the dental team to visualize the final result and allows for easy modifications. The application of ceramic with properly sequenced layers of different translucency, value, and chroma can mimic the composite structure of the natural teeth by giving the perception of natural transparency.

DISCLOSURE A N D ACKNOWLEDGMENTS

The authors have no financial inter- est in any products or companies mentioned in this article.

The authors wish to thank Michel Magne, CDT (Montreux, Switzerland), for his invaluable and continous support; Pascal Magne, DMD (Geneva, Switzerland), for

his instructions and collaboration; and Domenico Massironi, MD, DDS (Melegnano, Italy), for his clinical execution of the illustrated cases.

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Reprint requests: Giuseppe Romeo, CDT, Piazza Peyron 15, Torino, Italy, 101 43; e-mail: [email protected] 02003 BC Decker Inc

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