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QUALITY CONTROL QUALITY CONTROL in ESTHETIC DENTISTRY in ESTHETIC DENTISTRY Gerard Chiche L.L.C.

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Presentation on theme: "QUALITY CONTROL QUALITY CONTROL in ESTHETIC DENTISTRY in ESTHETIC DENTISTRY Gerard Chiche L.L.C."— Presentation transcript:

1 QUALITY CONTROL QUALITY CONTROL in ESTHETIC DENTISTRY in ESTHETIC DENTISTRY Gerard Chiche L.L.C.

2 SMILE BUILDER 1. PROPER LENGTH 2. DOMINANT CENTRALS 3. CONVEX SMILE LINE 4. INCISAL EMBRASURES 5. HIGH BRIGHTNESS

3 WHAT ARE THE STEPS? 1. Road map 2. Parameters 3. Confidence Builder SEVEN OBJECTIVES

4 DISCLOSURE Dept. Grants & Funding, Honorarium 3M-ESPE, Vident, Brasseler USA 3M-ESPE, Vident, Brasseler USA Nobelbiocare, 3I, Zimmer Nobelbiocare, 3I, Zimmer No Direct, indirect income or royalty from products discussed except No Direct, indirect income or royalty from products discussed except Paid Consultant NORITAKE co. Paid Consultant NORITAKE co. Teaching Faculty & Former Consultant PANKEY INSTITUTE Teaching Faculty & Former Consultant PANKEY INSTITUTE

5 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

6 I INCISAL PLANE

7 Incisal Plane. Convex. Flat. Flat. Concave. Concave. Too Convex. Too Convex Preview Length Adjustment

8 SMILE LINE 1. Record Shape 2. Record Lower Lip

9 Pitch of the upper anterior teeth should mirror the pitch of the lower anterior teeth Edge to Edge

10 PRECAUTIONS WITH SMILE LINE 1. Harmonize Anterior Guidance 2. Harmonize Pitches and Bevels 3. Smooth Crossover

11 II INCISAL PROFILE

12 PLAN 1. Incisal Length 2. Gingival Level 3. Implant Level

13 1. Harmony with Lower Lip + 2. Perpendicular Relation + 3. Final Restoration INCISAL PROFILE

14 III INCISAL LENGTH

15 Pleasing Display 3.5 - 4.5 mm. Pleasing Length 10 - 11 mm.

16 INCISAL LENGTH 1. Measure Display 2. Measure Length 3.Test Drive New Envelope 4.Do not Steepen Guidance when Increase Length without testing

17 IV TOOTH PROPORTION

18 Short-Fat Proportion Never Engineer Narrow-Long Proportion

19 PLAN 1. Preview 2. Check against Face 3. Involve Lat. & Can.

20 Mesial Additions Fat Central Incisor Distal Reductions

21 P roportion D isplay L ength RULE 1. Priority = Centrals

22 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

23 10 mm. L 7.5-8.0 mm 11 mm. L 8.5-9.0 mm

24 Central Incisors At Least 7.5 mm Width

25 V TOOTH to TOOTH PROPORTION

26 TOOTH-TO-TOOTH PROGRESSION Main Test ? DELICATE Lateral Incisor

27 PROPORTION CONTROL Precautions 1. Implants 2. Short Papillae 3. Canine Substitution 4. Orthodontic Planning

28 LATERAL INCISOR IMPLANT Deficient Papillae = Use Special Effects

29 SPECIAL EFFECTS 1. Decrease Reflection 2. Increase Deflection 3. Round Flatten

30 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

31 54 patients (36 F) (18 M) 16-72 years Average 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)

32 VI GINGIVAL PLANE

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

34 VII DESIRED FULLNESS

35 FULLNESS 1. Show on screen first 2. Mandibule Angle 3. Provide Canine Disclusion 4. Allow Cusps Escape

36 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. Patients Desires, Cost

37 GINGIVAL PLANE Follows UPPER LIP LINE

38 Break Time

39 ALL-CERAMIC CROWNS

40 REALITY RATINGS 2009 1.IPS Empress Ivoclar 1. Lava3M Espe 2.CerabienNoritake 3.HeraCeramHeraeus 4. EX-3Noritake 5. IPS D.SignIvoclar 5. Omega 900Vident 5. DuceragoldDentsply 6. VM7 / VM9Vident 6. CreationJensen 6. FinesseDentsply

41 I WHAT SYSTEM ?

42 ALL CERAMICS TWO FAMILIES = TWO LOGICS

43 ALL CERAMICS FAMILY A

44 ALUMINA FAMILY A …The alumina particles did not show any surface alteration by the etchants... Della Bona A. & Anusavice K. 2002 ZIRCONIA

45 . Degussa Allceram Ceram S.Noritake Cerabien CZR, CZR Press.Jensen Creation AV Lava Ceram.Vident Alpha, VM7 VM9.Nobelbiocare Rondo Rondo Zirconia.Ivoclar EMax

46 ALL CERAMICS FAMILY B Etchable Crowns

47 Empress Esthetics Emax Lith. Disil. Authentic CZR Press Duceram LFC Finesse ProCad Mark II Examples

48 II WHAT CEMENT ?

49 REALITY RATINGS RESIN GLASS IONOMERS LUTING 1. FUJI PLUS 1. FUJI PLUS 1. FUJICEM AUTOMIX 1. FUJICEM AUTOMIX 2. RELY X LUTING PLUS 2. RELY X LUTING PLUS 3. RELY X LUTING 3. RELY X LUTING 4. FUJICEM 4. FUJICEM 5. KETAC-CEM 5. KETAC-CEM 2009

50 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

51 WHY Adhesive Cementation ? Suggested Reasons include 1. Increase Retention 2. Increase Strength 3. Decrease Microleakage 4. Best for Thin Cores

52 The Effect of Preparation Height and Luting Agent on the Resistance Form of Cemented Cast Crowns under Load Fatigue. The Effect of Preparation Height and Luting Agent on the Resistance Form of Cemented Cast Crowns under Load Fatigue. E.W. Lepng et al. E.W. Lepng et al. J. Prosthet Dent 102: 155, 2009 J. Prosthet Dent 102: 155, 2009 Mean Cycles to Failure Prep. Height Zinc Phosh. Panavia F 2 mm. 9,238187,347 3 mm. 120,895 215,998 4 mm. 200,375250,000 5 mm. 250,000 250,000

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

54 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)

55 REALITY RATING / DUAL CURE 1. 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!

56 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 Ceramics N. L. Clelland et al. J. Prosthet Dent. 2007; 97:18

57 No etch, no silane Unicem 9.6 +-1.9 Multilink 6.2 +-1.2 Panavia F 7.4 +-1.9 Doubles If etch and silane Unicem 18.8 +- 3.5 Multilink 17.4 +-3.0 Panavia 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

58 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…

59 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

60 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)

61 III WHAT PRECAUTIONS ?

62 . 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

63 . 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

64 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

65 Raigrodski AJ, Chiche GJ, Potiket N, Mohamed SE, Hochstedler JL, Mercante DE, Billiot S. The efficacy of posterior three-unit zirconia-based bridges A prospective pilot clinical study J Prosthet Dent 2006;96:237-44

66 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

67 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.

68 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;4-3 P. Guess Zirconia Posterior Fixed Partial Dentures Prospective Clinical 3-Year Follow-up Int J Prosthodont 2009;22:597 Schmitt J, et al

69 Int. J Prosthodont; 2009; 22: 553 Sailer I. et al J Prosthet Dent 2006;96:237-44 Raigrodski AJ, et al Int. J Prosthodont; 2009; 22: 597 Wichan & Holst

70 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

71 IV CERAMIC SELECTION

72 CRITERIA Alumina / Zirconia. 1 Discolored Teeth. 2 No Bonding Requirement. 3 Need Adequate Thickness. 4 Thinner Cores on Facial

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

74 DISCOLORATIONS & SYSTEM SELECTION 1. CREATE BONUS SPACE 2. MATCHED PAIRS 3. INGOT SELECTION 4. AVOID EXCESSIVE TRANSLUCENCY

75 M. Roberts 2007 The Common Denominator must NOT be the most discolored tooth

76 V OCCLUSAL PRECAUTIONS

77 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

78 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

79 … : Move Tooth to Safe Position First …: Shallower Cuspid Guidance

80 For every 10 0 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

81 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…

82 VI PORCELAINVENEERS

83 A 15-Year Review of Porcelain Veneer Failure A Clinicians Observations FRIEDMAN M.J. COMPENDIUM. 19, 1998 COMPENDIUM. 19, 1998

84 FAILURES (7%) 1. FRACTURES (67%) (67%) 2. MICROLEAKAGE 2. MICROLEAKAGE (22%) (22%) 3. DEBONDING 3. DEBONDING (11%) (11%)

85 Cervical Dentin + Heavy Occlusion = CONTROL FLEXURE LONG-TERM BONDING LONG-TERM BONDING

86 Canines Management 1. Contact Intensity 2. Contact Location 3. Steepness of Guidance

87 VII PREPARATION SYSTEM

88 . LVS 4. LVS 3. 8392 016. 828 026

89 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

90 Longevity and Failure Load of Ceramic Veneers with Different Preparation Designs after Exposure to Masticatory Stimulation C. F. J. Stappert et al J. 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 …

91 VIII VENEER SELECTION

92 Permanent Diagnostic Provisional Restorations for Predictable Results when Redesigning the Smile. G. Gurel, N. Bichacho Pract 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)

93 Pressed vs. Feldspathic Veneers 1. P Combination with Crowns. 2. P Complex Occlusal Rehabs. 3. P Better Cost. 1. F Better Esthetic. 2. F More Conservative, No Prep. 3. F Contact Lens Effect, Varying Trsl

94 IX SHADING SYSTEM

95 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

96 Cervical Shade Basic Shade Incisal Shade Mix Colors Two Tabs

97 SHADING EFFECTS SHADING EFFECTS CHECKLIST HALO TRANSPARENT STREAKS PROXIMAL CLEAR

98 Incorporate for Natural - Driven Soften or Eliminate for Perfect - Driven Incisal Effects

99 A1 B1 1M1 0M3 0M2 NW05 NW0 BL3 BL2 PW4 PW7 Bleached Shades

100 X CLINICAL VARIATIONS

101 Set Goals. Increase Brightness. Increase Length. Fuller Smile

102 INCREASE FULLNESS 1. Set Perpendicular Relation + 2. Check Harmony with Lip

103 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

104 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

105 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

106 … 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

107 PAPILLA HEIGHT Healthy Papilla = 5 mm. Healing Papilla = 4 mm. J. Kois

108 1. Short Papilla < 4 mm 2. 4 mm Esthetically Acceptable 3. Healing from Trauma PAPILLA COME BACK 3 QUESTIONS

109 3. Unilateral Pair D. Tarnow 2004 1. Maximize Symmetry 2. Special Effects

110 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)

111 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)

112 XI BONDING UPDATE

113 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

114 Clear Clear White White (Thin Veneers)

115 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

116 BONDING PRECAUTIONS 1. Rubber Dam 2. Glistening Preparation 3. Agitate Primers 4. Evaporate Solvent J. Burgess 2005

117 XII PROTECTION STRATEGY

118 1. MIP coincident with CR 2. Night-time Appliance 3. Envelope of Function 4. Custom Guide Table 5. Dentin Bond Technique 6. Porcelain Selection 7. Incisal Extension Functional Considerations

119 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

120 Deep Bite Over-retracted Bulky Crowns Misalignment Retrusion Restricted Envelope S. Ratcliff

121 2. Crowns with Proper envelope 3. Reposition Teeth before Veneers 4. Restore or Increase VDO 5. Occlusal Guard Optimize Anterior Guidance 1. Constriction Involved ?

122 THANK YOU


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