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

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

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

4. No Direct, indirect income or royalty from products discussed except
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

5. DISCLAIMER
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.

6. I INCISAL PLANE

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

8. SMILE LINE
Record Shape
2. Record Lower Lip

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

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

11. II INCISAL PROFILE

12. PLAN Incisal Length
2. Gingival Level
Implant Level

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

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
Test Drive New Envelope
Do not Steepen Guidance
when Increase Length
without testing

17. IV TOOTH PROPORTION

18. Short-Fat Proportion Never Engineer Narrow-Long Proportion

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

20. Mesial Additions Fat Central Incisor Distal Reductions

21. Proportion Display Length
RULE Priority = Centrals
Proportion Display Length

22. RULE Create Reference Points
Display
Length : At least 10 mm.
3. Width: At least 7.5 mm.
4. Midline : Must be Vertical
Lateral Incisor: 2mm. rule
6. Canine: 1mm. rule

23. 10 mm. L mm
11 mm. L 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
Implants
Short Papillae
Canine Substitution
Orthodontic Planning

28. LATERAL INCISOR IMPLANT
Deficient Papillae =
Use Special Effects

29. 1. Decrease Reflection 2. Increase Deflection 3. Round Flatten
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. Pract Proced Aesthet Dent 2007; 19 (4)
54 patients (36 F) (18 M) 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 – (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
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. Patient’s Desires, Cost

37. GINGIVAL PLANE Follows UPPER LIP LINE

38. Break Time

39. ALL-CERAMIC CROWNS

40. REALITY RATINGS 2009
IPS Empress Ivoclar
1. Lava 3M Espe
Cerabien Noritake
HeraCeram Heraeus
4. EX-3 Noritake
5. IPS D.Sign Ivoclar
5. Omega 900 Vident
Duceragold Dentsply
VM7 / VM9 Vident
6. Creation Jensen
6. Finesse Dentsply

41. I WHAT SYSTEM ?

42. ALL CERAMICS
TWO FAMILIES =
TWO LOGICS

43. ALL CERAMICS
FAMILY A

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

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
FUJI PLUS
1 . FUJICEM AUTOMIX
2 . RELY X LUTING PLUS
RELY X LUTING
FUJICEM
KETAC-CEM
2009

50. Shear Bond Strength to LAVA
9 MPA
6 MPA
FUJICEM MAXCEM NEXUS 2 UNICEM
Shear Bond Strength of Self-Adhesive Resin Cements: A comparative Study
R. Aljouni et al, 2006 (Abstract 329)

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

52. Prep. Height Zinc Phosh. Panavia F
Mean Cycles to Failure
Prep. Height Zinc Phosh. Panavia F
2 mm. 9, , mm , , mm , , mm , ,000
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

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

54. M.B. Blatz 2003 SBl. (10 sec.) 11.58 Mpa (4.13) Rocatec soft+Silan
SBl +CPA / CSE
16.58 Mpa (3.17)
LAVA Zirconia
(6 months testing)
M.B. Blatz 2003

55. REALITY RATING / DUAL CURE
1 . INSURE / INSURE LITE
2 . NX3
VARIOLINK II
VITIQUE
LUTE-IT!
CALIBRA
1 . RELYX UNICEM
1 . EMBRACE WETBOND
1. G-CEM
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!
2009

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
No etch, no silane Unicem Multilink Panavia F Doubles If etch and silane Unicem Multilink Panavia F
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
Auto Pol. Light Pol. Rely ARC (14.3) (21.7) Unicem Translucent (114) (19.6) Unicem A (5.9) (18.2) Maxcem Clear (9.5) (10.8) Maxcem Yellow (8.3) (17.7)
“…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…”
E. Saskalauskaite et al
Flexural Strength, Elastic Modulus and pH profile of Self-etch Resin Luting Cements.
J. Prosthodontics 2008: 262

59. Bond Strength, f Self-adhesive Cementing agents to dentin and enamel
Bond Strength to Enamel (Unetched) Rely Unicem Aplicap (2.0) Rely Unicem Clicker (2.8) Maxcem (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 4. Neutral Shade
Glass Ceramics
1. Etch
2. Silane
Dual-Cure Cements
3. Light-Cure
4. Neutral Shade
Marginal Enamel
Etch in selective situations (Varies with Cement – Check with manufacturer first)

61. III WHAT PRECAUTIONS ?

62. 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. Marginal Ridge Support Anatomical Cores
Core Integrity
Short Preparations
Marginal Ridge Support
Anatomical Cores
. Survival of Procera AllCeram Ceramic Crowns in Students Clinics
J. Hochstedler & A. Sadan 2004

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 Insure Thick Connectors
Facial Shoulder
4. No Lateral Interferences
Fine Diamonds – Reglaze
Slow Cooling Cycle
Zirconia – Veneer Interface

67. IADR 2007, # 0885 J Dent. Research Vol 86, Special Issue A
Chamfer Preparation 21 mic. (6 mic.) Shoulder Preparation 11 mic. (6 mic.) Difference was significant.
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

68. Effect of veneering Techniques on Damage and Reliability
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. ZIRCONIA CERAMICS FPD’S SIMILAR 3-YR
SURVIVAL RATE TO METAL CERAMIC FPD’S
Int. J Prosthodont; 2009; 22: 553
Sailer I. et al
100% RETENTION at THREE YEARS
PRECAUTIONS WITH SECOND MOLARS
Int. J Prosthodont; 2009; 22: 597
Wichan & Holst
No NEW CHIP SINCE FIRST YEAR
J Prosthet Dent 2006;96:237-44
Raigrodski AJ, et al

70. Main Precautions 1. Patient Selection Insure Thick Connectors
Facial Shoulder
4. No Lateral Interferences
Fine Diamonds – Reglaze
Slow Cooling Cycle
Zirconia – Veneer Interface

71. IV
CERAMIC SELECTION

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

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

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

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

76. V OCCLUSAL PRECAUTIONS

77. DETERMINE ANTERIOR GUIDANCE
Test-Drive New Envelope.
2. Transfer Existing Guidance.
3. Custom Guide Table.
4. Half try-in when Feasible.
Passive Anteriors – No Fremitus
Static: 3 positions & Dynamic: Chew
6. Maintain Guidance if shorten.

78. Protection Strategy Assess Risk
Discover What they are Likely to do with their Teeth
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. The flatter the angle of guidance, the lower the muscle activity.
G. Williamson J. Prosthet Dent 1983
For every 100 change in the angle of disclusion, there is a 35% change in force applied.
L. Weinberg

81. “…The resultant closure forces of the mandible are upward and forward
“…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…”
T. Tanaka 2008

82. VI PORCELAINVENEERS

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

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

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

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

87. VII PREPARATION
SYSTEM

88. . LVS LVS

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

90. “Maxillary restored with the 3 types of IPS Empress 1 Veneers showed fracture resistance similar to that of unprepared incisors …”
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,

91. VIII VENEER SELECTION

92. Making a Six-Unit Smile Design “Disappear” in the mouth
using feldspathic porcelain
B. Jones
Jrl. Cosmetic Dentistry 2007, 22 (4)
Conservative Aesthetic Enhancement of the
Maxillary Anterior Using Porcelain Laminate Veneers.
J.M. Lerner
Pract Proced Aesthet Dent 2006; 18 (6)
Permanent Diagnostic Provisional Restorations for Predictable Results when Redesigning the Smile. G. Gurel, N. Bichacho Pract Proced Aesthet Dent 2006; 18 (5)

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

94. IX SHADING SYSTEM

95. A.J. Raigrodski & G.J. Chiche. 2004
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
Incisal Shade
Basic Shade
Mix Colors
Two Tabs

97. SHADING EFFECTS CHECKLIST
HALO
TRANSPARENT
STREAKS
PROXIMAL CLEAR

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

99. Bleached Shades
A B M M3 0M2
NW05 NW0
BL3 BL2
PW4 PW7

100. X CLINICAL VARIATIONS

101. Set Goals
. Increase Brightness
Increase Length
Fuller Smile

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

103. INCREASE LENGTH and FULLNESS
Mock-up for Length
Wax-up for Fullness
Instant Mock-up
4. Show First on Screen !
Preparation Guide
Always Augment
7. Verify Gingival Levels

104. 1. Preop. Silicone Impression 2. Undercontour Cervical Wax
VENEER PROVISIONALS
1. Preop. Silicone Impression
2. Undercontour Cervical Wax
3. Duplicate Wax-up, Pour Model
4. Score Cervical with Cleoid
5. Spot Etch & Bond Preps
6. Fill Matrix with Bis-Acryl
7. Trim with ET3, ET4 & #12

105. 6 mm 56% 7 mm 27% Contact to Bone crest Interdental Papilla
Base of Proximal Presence of
Contact to Bone crest Interdental Papilla
5 mm %
6 mm %
7 mm %
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. Following Denudation Procedures
“… 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. Healthy Papilla = 5 mm. Healing Papilla = 4 mm. J. Kois
PAPILLA HEIGHT
Healthy Papilla = 5 mm.
Healing Papilla = 4 mm.
J. Kois

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

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

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. Advanced Esthetics & Interdisciplinary Dentistry 2006; 2 (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)

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
1 . RELY X VENEER CEM.
2 . VARIOLINK VENEER
3. DA VINCI
4. ACCOLADE PV
5. CHOICE 2
2009

114. Clear
White
(Thin Veneers)

115. 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
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

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

117. XII PROTECTION
STRATEGY

118. Functional Considerations
MIP coincident with CR
Night-time Appliance
Envelope of Function
Custom Guide Table
Dentin Bond Technique
Porcelain Selection
Incisal Extension

119. J. Kois, B. Filder. Compendium, 30; 7: 420 September 2009
Three-Dimensional Assessment of Dental Occlusion. (Occlusal Fencing) A Clinical Technique.
N. Mehta, E. Abdallah et al , Advanced Esthetics & Interdisciplinary Dentistry
Clinical Case Report. Anterior Wear: Orthodontic and Restorative Management.
J. Kois, B. Filder. Compendium, 30; 7: 420 September 2009

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

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

122. THANK YOU