QUALITY CONTROL

in

ESTHETIC DENTISTRY

Gerard Chiche L.L.C.

SMILE BUILDER

1. PROPER LENGTH

2. DOMINANT CENTRALS

3. CONVEX SMILE LINE

4. INCISAL EMBRASURES

5. HIGH BRIGHTNESS

WHAT ARE THE STEPS?

1. Road map 2. Parameters 3. Confidence Builder

SEVEN OBJECTIVES

DISCLOSURE Dept. Grants & Funding, Honorarium 3M-ESPE, Vident, Brasseler USA Nobelbiocare, 3I, Zimmer

No Direct, indirect income or royalty from products discussed except Paid Consultant NORITAKE co. Teaching Faculty & Former Consultant

PANKEY INSTITUTE

Techniques and principles reviewed in this all-day program are derived from my

personal teaching and clinic experience.

They do not constitute a guarantee for success , the attendees should form their

own opinion.

Gerard Chiche L.L.C.

DISCLAIMER

IINCISAL PLANE

Incisal Plane . Convex

. Flat

. Concave

. Too Convex

Preview Length Adjustment

SMILE LINE 1. Record Shape

2. Record Lower Lip

Pitch of the upper anterior teeth should mirror the pitch of the lower anterior teeth

Edge to Edge

PRECAUTIONS WITH SMILE LINE

1. Harmonize Anterior Guidance 2. Harmonize Pitches and Bevels 3. Smooth Crossover

IIINCISAL PROFILE

PLAN

1. Incisal Length 2. Gingival Level

3. Implant Level

1. Harmony with Lower Lip + 2. Perpendicular Relation

+3. Final Restoration

INCISAL PROFILE

IIIINCISAL LENGTH

Pleasing Display 3.5 - 4.5 mm.

Pleasing Length 10 - 11 mm.

INCISAL LENGTH

1. Measure Display 2. Measure Length3. Test Drive New Envelope 4. Do not Steepen Guidance

when Increase Length without testing

IVTOOTH

PROPORTION

Short-Fat Proportion

Never Engineer

Narrow-Long Proportion

PLAN

1. Preview 2. Check against Face

3. Involve Lat. & Can.

Mesial Additions

Fat Central Incisor

Distal Reductions

Proportion

Display Length

RULE

1. Priority = Centrals

RULE Create Reference Points

1. Display

2. Length : At least 10 mm.

3. Width: At least 7.5 mm.

4. Midline : Must be Vertical

5. Lateral Incisor: 2mm. rule

6. Canine: 1mm. rule

10 mm. L

7.5-8.0 mm

11 mm. L

8.5-9.0 mm

Central Incisors

At Least

7.5 mm Width

VTOOTH to TOOTH

PROPORTION

TOOTH-TO-TOOTH PROGRESSION

Main Test ?

DELICATELateral Incisor

PROPORTION CONTROL Precautions

1. Implants

2. Short Papillae

3. Canine Substitution

4. Orthodontic Planning

LATERAL INCISOR IMPLANT

Deficient Papillae

=

Use Special Effects

SPECIAL EFFECTS

1. Decrease Reflection

2. Increase Deflection

3. Round Flatten

Lateral Incisor Design

1. Does not Compete for Attention

2. Deficient Papilla = Special Effects 3. Canines in Lateral Position =

Keep Centrals dominant 4. Lat. I. = CI-2mm., Can. = CI-1mm.

5. 70% Ratio for Normal Size Teeth

54 patients (36 F) (18 M) 16-72 yearsAverage width 8 and 9 : 8.5 mm.

7 and 10: 6.5 mm. 6 and 11: 7.5 mm.

Range for central incisors: 7.1 – 9.62 (8) and 7.32 – 10.06 (9)

Range and Mean Distribution Frequency of Individual Tooth Width of the Maxillary

Anterior Dentition S. J. Chu

Pract Proced Aesthet Dent 2007; 19 (4)

VIGINGIVAL PLANE

SYMMETRY

1. Level against Face 2. Set Pleasing Ref. Level 3. Set Pleasing Ref. Line

VIIDESIRED FULLNESS

FULLNESS

1. Show on screen first

2. Mandibule Angle

3. Provide Canine Disclusion

4. Allow Cusps Escape

WHAT ARE THE STEPS ? 1. Record Shape

2. Phonetics, Occlusal Plane 3. Measure Display, Length 4. Record Proportion, Width 5. Delicate Lateral Incisor 6. Symmetry, Progr., Lip

7. Patient’s Desires, Cost

GINGIVAL PLANE

Follows

UPPER LIP LINE

Break Time

ALL-CERAMIC CROWNS

REALITY RATINGS 2009

1. IPS Empress Ivoclar

1. Lava 3M Espe

2. Cerabien Noritake

3. HeraCeram Heraeus

4. EX-3 Noritake

5. IPS D.Sign Ivoclar

5. Omega 900 Vident

5. Duceragold Dentsply

6. VM7 / VM9 Vident

6. Creation Jensen

6. Finesse Dentsply

I WHAT SYSTEM

?

ALL CERAMICS

TWO FAMILIES

=

TWO LOGICS

ALL CERAMICS

FAMILY

A

ALUMINA

FAMILY

A

“…The alumina particles did not show any surface alteration by the etchants...” Della Bona A. & Anusavice K. 2002

ZIRCONIA

.Degussa Allceram Ceram S

.Noritake Cerabien CZR, CZR Press

.Jensen Creation AV Lava Ceram

.Vident Alpha, VM7 VM9

.Nobelbiocare Rondo Rondo Zirconia

.Ivoclar EMax

ALL CERAMICS

FAMILY

B

Etchable Crowns

Empress Esthetics Emax Lith. Disil.

Authentic CZR Press

Duceram LFC Finesse

ProCad Mark II

Examples

II WHAT CEMENT

?

REALITY RATINGS RESIN GLASS IONOMERS LUTING

1 . FUJI PLUS

1 . FUJICEM AUTOMIX

2 . RELY X LUTING PLUS

3. RELY X LUTING

4. FUJICEM

5. KETAC-CEM

2009

Shear Bond Strength of Self-Adhesive Resin Cements: A comparative Study

R. Aljouni et al, 2006 (Abstract 329)

9 MPA

FUJICEM MAXCEM NEXUS 2 UNICEM

6 MPA

Shear Bond Strength to LAVA

WHY Adhesive Cementation ?Suggested Reasons include

1. Increase Retention

2. Increase Strength

3. Decrease Microleakage

4. Best for Thin Cores

The Effect of Preparation Height and Luting Agent on the Resistance Form of Cemented Cast Crowns under Load Fatigue.

E.W. Lepng et al. J. Prosthet Dent 102: 155 , 2009

Mean Cycles to Failure Prep. Height Zinc Phosh. Panavia F

2 mm. 9,238 187,347 3 mm. 120,895 215,998

4 mm. 200,375 250,0005 mm. 250,000 250,000

Blatz, Oppes, Sadan, Chiche. Quint Int. 2008

SBl. (10 sec.)

11.58 Mpa (4.13)

Rocatec soft+Silan

15.76 Mpa (4.10)

SBl +CPA / CSE

16.58 Mpa (3.17)

M.B. Blatz 2003

LAVA Zirconia (6 months testing)

REALITY RATING / DUAL CURE1 . INSURE / INSURE LITE

2 . NX3

2. VARIOLINK II

3. VITIQUE

4. LUTE-IT!

5. CALIBRA

2009

1 . RELYX UNICEM

1 . EMBRACE WETBOND

1. G-CEM

2. SMARTCEM 2

2, BISCEM

3. MAXCEM ELITE

1 . PANAVIA F 2.0

2 . MULTILINK AUTOMIX

3. CLEARFIL ESTH. CEM.

4. BISTITE II DC

1 . RELY X ARC

2 . DUO-LINK

3. CEMENT-IT!

“Ceramic material and bond quality significantly influence the load bearing capacity of leucite and

Lithia-disilicate ceramic restorations… This clearly demonstrates the importance of the

relationship between the adhesive process and the overall strength of the restoration”.

Influence of Bond Quality on Failure Load of Leucite- and Lithia disilicate-based

CeramicsN. L. Clelland et al.

J. Prosthet Dent. 2007; 97:18

No etch, no silane Unicem 9.6 +-1.9Multilink 6.2 +-1.2Panavia F 7.4 +-1.9

Doubles If etch and silane Unicem 18.8 +- 3.5Multilink 17.4 +-3.0Panavia F 15.7 +-3.8

Influence of ceramic surface conditioning and resin cements on microtensile bond Strength to

a glass ceramic. J. Pisani-Proenca et al.

J. Prosthet Dent. 2006; 96:412

Auto Pol. Light Pol. Rely ARC 96.1 (14.3) 131.2 (21.7) Unicem Translucent 75.6 (114) 130.6 (19.6) Unicem A3 70.2 (5.9) 99.4 (18.2) Maxcem Clear 104.0 (9.5) 156.2 (10.8) Maxcem Yellow 76.3 (8.3) 139.1 (17.7)

E. Saskalauskaite et al Flexural Strength, Elastic Modulus and pH profile

of Self-etch Resin Luting Cements. J. Prosthodontics 2008: 262

“…All dual-cured cements both self-etch and conventional showed highly superior properties when photopolymerized … One self-etch cement revealed a unique rapid rise to neutrality in both dual-cure and self-cure mode…”

Bond Strength to Enamel (Unetched) Rely Unicem Aplicap 6.2 (2.0) Rely Unicem Clicker 5.7 (2.8) Maxcem 4.0 (3.3)

A. Piwowarczyk et al Bond Strength, f Self-adhesive Cementing agents

to dentin and enamel IADR Abstract 2007 #1540

1. Etch 2. Silane

3. Light-Cure

Glass Ceramics

Dual-Cure Cements

4. Neutral Shade

Marginal Enamel Etch in selective situations

(Varies with Cement – Check with manufacturer first)

III WHAT PRECAUTIONS

?

. 169 Procera Crowns – 26 Mo.

. Failures : 1 Decay, 6 veneer fractures.

Survival of Procera AllCeram Ceramic Crowns in Students Clinics.

J. Hochstedler et al. 2004

. Survival of Procera AllCeram Ceramic Crowns in Students Clinics

J. Hochstedler & A. Sadan 2004

1. Core Integrity

2. Short Preparations

3. Marginal Ridge Support

4. Anatomical Cores

Adequate Support May Increase Restoration Strength by 30%

Fischer et al. JIADR 2006, Abstract 546

“…Copings for crowns must be designed to minimize tensile loading of

veneering porcelain…”

Marschak et al. J Prosthet Dent 2008

99: 169

Raigrodski AJ, Chiche GJ, Potiket N, Mohamed SE,

Hochstedler JL, Mercante DE, Billiot S.

The efficacy of posterior three-unit zirconia-based bridgesA prospective pilot clinical study

J Prosthet Dent 2006;96:237-44

ZIRCONIA FPD

1. Patient Selection

2. Insure Thick Connectors

3. Facial Shoulder

4. No Lateral Interferences

5. Fine Diamonds – Reglaze

6. Slow Cooling Cycle

7. Zirconia – Veneer Interface

Marginal Fit of Zirconia Crown Copings on chamfer and Shoulder preparations

IADR 2007, # 0885 J Dent. Research Vol 86, Special Issue A

D. Augusti, G. Augusti

Chamfer Preparation 21 mic. (6 mic.) Shoulder Preparation 11 mic. (6 mic.) Difference was significant.

Shear Bond Strength of Veneering Ceramics to Zirconia J Dent Res 2006;85:Abstr 0888

Blatz MB, Chapman L, et al

Effect of veneering Techniques on Damage and Reliability of Y-TZP Trilayers

European J Esthet Dent 2009;4-3P. Guess

Zirconia Posterior Fixed Partial Dentures Prospective Clinical 3-Year Follow-up

Int J Prosthodont 2009;22:597 Schmitt J, et al

NO NEW CHIP SINCE FIRST YEAR

Int. J Prosthodont; 2009; 22: 553 Sailer I. et al

ZIRCONIA CERAMICS FPD’S SIMILAR 3-YR SURVIVAL RATE TO METAL CERAMIC FPD’S

J Prosthet Dent 2006;96:237-44Raigrodski AJ, et al

100% RETENTION AT THREE YEARS PRECAUTIONS WITH SECOND MOLARS

Int. J Prosthodont; 2009; 22: 597 Wichan & Holst

Main Precautions

1. Patient Selection

2. Insure Thick Connectors

3. Facial Shoulder

4. No Lateral Interferences

5. Fine Diamonds – Reglaze

6. Slow Cooling Cycle

7. Zirconia – Veneer Interface

IV CERAMIC SELECTION

CRITERIA

Alumina / Zirconia . 1 Discolored Teeth

. 2 No Bonding Requirement

. 3 Need Adequate Thickness

. 4 Thinner Cores on Facial

CRITERIA

Etchable Crowns • 1 Best Translucency• 2 Reduced Facial Thickness• 3 May be Equigingival• 4 Plan Masking Strategy

DISCOLORATIONS&

SYSTEM SELECTION

1. CREATE BONUS SPACE

2. MATCHED PAIRS

3. INGOT SELECTION

4. AVOID EXCESSIVE TRANSLUCENCY

M. Roberts 2007

“The Common Denominator must NOT be the most discolored

tooth”

VOCCLUSAL

PRECAUTIONS

1. Test-Drive New Envelope.

2. Transfer Existing Guidance.

3. Custom Guide Table.

4. Half try-in when Feasible.

5. Passive Anteriors – No Fremitus

Static: 3 positions & Dynamic: Chew

6. Maintain Guidance if shorten.

DETERMINE ANTERIOR GUIDANCE

Protection Strategy

1. Assess Risk

2. Discover What they are Likely to do with their Teeth

3. Do not Put Teeth in the Way of Habitual Function and Envelope of Parafunction

J. Fondriest & M. Fling

… :

Move Tooth to

Safe Position First

…:

Shallower

Cuspid Guidance

For every 100 change in the angle of disclusion, there is a 35% change in force applied.

L. Weinberg

The flatter the angle of guidance, the lower the muscle activity.

G. Williamson J. Prosthet Dent 1983

T. Tanaka 2008

“…The resultant closure forces of the mandible are upward and forward. This produces a mesial force between the interproximals resulting in anterior

teeth more vertical and a constricted envelope…”

VIPORCELAINVENEERS

A 15-Year Review of Porcelain Veneer Failure A Clinician’s Observations

FRIEDMAN M.J.

COMPENDIUM. 19, 1998

FAILURES (7%)

1. FRACTURES

(67%)

2. MICROLEAKAGE

(22%)

3. DEBONDING

(11%)

Cervical Dentin + Heavy Occlusion

=

CONTROL FLEXURE

LONG-TERM BONDING

Canines Management

1. Contact Intensity 2. Contact Location

3. Steepness of Guidance

VIIPREPARATION

SYSTEM

. LVS 4 . LVS 3

. 8392 016

. 828 026

INCISAL REDUCTION

Unrestored Tooth

2 mm.

4 mm.

FRACTURE STRENGTH

31.0 Kg. (10.38 s.d.)

27.4 Kg. ( 9.63 s.d.)

19.2 Kg. ( 6.18 s.d.)

Fracture Strength and Failure Mode for Different Ceramic Veneer Designs.

Castelnuovo J. et al. J. Dent. Res. 77; Abstract 1373

Longevity and Failure Load of Ceramic Veneers with Different Preparation Designs after

Exposure to Masticatory Stimulation

C. F. J. Stappert et alJ. Prosthet. Dent. 2005, 94, 132-139

“Maxillary restored with the 3 types of IPS Empress 1 Veneers showed

fracture resistance similar to that of unprepared incisors …”

VIIIVENEER SELECTION

Permanent Diagnostic Provisional Restorations for Predictable Results when Redesigning the Smile.

G. Gurel, N. BichachoPract Proced Aesthet Dent 2006; 18 (5)

Conservative Aesthetic Enhancement of the Maxillary Anterior Using Porcelain Laminate Veneers.

J.M. Lerner Pract Proced Aesthet Dent 2006; 18 (6)

Making a Six-Unit Smile Design “Disappear” in the mouth

using feldspathic porcelain B. Jones

Jrl. Cosmetic Dentistry 2007, 22 (4)

Pressed vs. Feldspathic Veneers

1. P Combination with Crowns.

2. P Complex Occlusal Rehabs.

3. P Better Cost.

4. F Better Esthetic.

2. F More Conservative, No Prep.

3. F Contact Lens Effect, Varying Trsl

IXSHADING SYSTEM

Efficacy of a computerized shade selection system in matching anterior metal-ceramic crowns. A double-blind

clinical pilot study.

A.J. Raigrodski & G.J. Chiche.

2004

Cervical Shade

Basic Shade

Incisal Shade

Mix ColorsTwo Tabs

SHADING EFFECTS CHECKLIST

HALO

TRANSPARENT

STREAKS

PROXIMAL CLEAR

Incorporate

for Natural - Driven

Soften or Eliminate

for Perfect - Driven

Incisal Effects

A1 B1 1M1 0M3 0M2

NW05 NW0

BL3 BL2

PW4 PW7

Bleached Shades

XCLINICAL

VARIATIONS

Set Goals

. Increase Brightness

. Increase Length

. Fuller Smile

INCREASE FULLNESS

1. Set Perpendicular Relation

+

2. Check Harmony with Lip

1. Mock-up for Length 2. Wax-up for Fullness 3. Instant Mock-up

4. Show First on Screen !

5. Preparation Guide

7. Verify Gingival Levels

INCREASE LENGTH and FULLNESS

6. Always Augment

1. Preop. Silicone Impression 2. Undercontour Cervical Wax 3. Duplicate Wax-up, Pour Model 4. Score Cervical with Cleoid

5. Spot Etch & Bond Preps

7. Trim with ET3, ET4 & #12

VENEER PROVISIONALS

6. Fill Matrix with Bis-Acryl

Base of Proximal Presence of

Contact to Bone crest Interdental Papilla

5 mm 98%

6 mm 56%

7 mm 27%

The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla

D. Tarnow et al 1992

“… Results showed a mean distance of 4.33 mm. between the

location of the gingival margin post-treatment and the bone level

during surgery…”

Regeneration of the Interdental Soft Tissues Following Denudation Procedures

U.Van Der Velden 1982

PAPILLA HEIGHT

Healthy Papilla = 5 mm.

Healing Papilla = 4 mm.

J. Kois

1. Short Papilla < 4 mm

2. 4 mm Esthetically Acceptable

3. Healing from Trauma

PAPILLA “COME BACK”

3 QUESTIONS

3. Unilateral Pair

D. Tarnow 2004

1. Maximize Symmetry

2. Special Effects

Unilateral Pair

1. Select Cantilever

2. Forced Eruption

3. Sequential Placement Interimplant Papilla Preservation in the Esthetic Zone. Report

of six consecutive Cases J. Kan, K. Rungcharassaeng

Internaltional J. Perio Restor Dent 2003; 23 (3)

Forced Eruption

“…0.5 mm to 1 mm. per month of eruption and then maintain this position 1 month

for each millimeter of coronal movement…”

Advanced Esthetics & Interdisciplinary Dentistry 2006; 2 (3)

XIBONDING UPDATE

REALITY RATING

LIGHT CURE DUAL CURE LIGHT CURE ONLY

1 . INSURE / INSURE LITE

2 . NX3

2. VARIOLINK II

3. VITIQUE

4. LUTE-IT!

5. CALIBRA

2009

1 . RELY X VENEER CEM.

2 . VARIOLINK VENEER

3. DA VINCI

4. ACCOLADE PV

5. CHOICE 2

Clear

White (Thin Veneers)

Influence of post-etching cleaning and connecting porcelain on the microtensile bond strength of composite resin to feldspathic

porcelain. P. Magne and D. Cascione

J. Prosthet Dent. 2006; 96:354

8 Authentic Block pairs all air abraded and etched with HF

“…Omission of the post-etching cleaning resulted in more than 50% loss in bond strength

BONDING PRECAUTIONS

1. Rubber Dam 2. Glistening Preparation 3. Agitate Primers 4. Evaporate Solvent

J. Burgess 2005

XIIPROTECTION

STRATEGY

1. MIP coincident with CR2. Night-time Appliance3. Envelope of Function4. Custom Guide Table5. Dentin Bond Technique6. Porcelain Selection7. Incisal Extension

Functional Considerations

Three-Dimensional Assessment of Dental Occlusion. (Occlusal Fencing) A Clinical Technique.

N. Mehta, E. Abdallah et al , Advanced Esthetics & Interdisciplinary Dentistry. 2006

Clinical Case Report. Anterior Wear: Orthodontic and Restorative Management.

J. Kois, B. Filder. Compendium, 30; 7: 420 September 2009

Deep Bite

Over-retracted

Bulky Crowns

Misalignment

Retrusion

Restricted Envelope

S. Ratcliff

2. Crowns with Proper envelope

3. Reposition Teeth before Veneers

4. Restore or Increase VDO

5. Occlusal Guard

Optimize Anterior Guidance

1. Constriction Involved ?

THANK YOU