COME MEET YOUR NEW PATIENTS

One of the common claims clinicians or technicians have in a discussion of the

implementation of high-end esthetic dentistry in everyday practice or in the
laboratory is that their patients cannot afford that kind of dentistry. They often
use a similar example to emphasize the reality in which they work. It is the story
of the loyal patient with high dental awareness who was informed that an exist-
Avisbai Sadan
ing extensive restoration on one of his molars was failing and could not be re-
placed and that a full-coverage restoration was needed. The patient replied
that although he is fully aware of the poor prognosis of replacing the existing
failing restoration with another direct restoration, strict financial limitations made replacement the
only viable treatment option for him at that point The message of the story is clear. Cutting-edge
dentistry is a great thing, but most patients cannot afford it
Though this story has strong roots in reality, it is only a part of the picture. The same patient
would bring his 15-year-old son or daughter for a routine check-up, and in many instances the clin-
ician would refer the child for an orthodontic consult. Upon examination, the orthodontist would
indicate the need for orthodontic treatment at a cost of about seven times the amount of the full-
coverage crown the clinician had prescribed for the parent The end result would usually be an im-
mediate initiation of orthodontic therapy. Most patients, from their mid-20s to their late 50s, have
to budget their funds, putting their children's needs as a first priority. When it comes to our chil-
dren, we are willing to travel a long distance to seek the best treatment any profession has to
offer. Cost becomes secondary to state-of-the-art concepts, cutting-edge technology, and high-
end esthetic results.
We have to ask ourselves if in recent years a decline of young patients with trauma and other
complications to their anterior dentition has occurred in our practices or laboratories. If the answer
is yes. we must realize that the decline is contrary to the fact that the number of traumatic injuries
and other complications to the anterior dentition is increasing. The message is clear: Their parents
are taking them elsewhere to be treated.
By not updating our techniques and knowledge, we are giving up our next generation of pa-
tients who are willing to go the extra distance to receive state-of-the-art esthetic dental care. Keep
in mind that the cost of treating these cases is more. Extra laboratory time is required, and re-
makes for shade matching are common. The laboratory must charge and receive a fee that will re-
flect the time invested in the case, and the same is true for the clinical fee. Multiple sessions and
several provisional restorations may be required prior to finalizing the case. One may produce less
but will definitely not earn less.
Acquire the knowledge and skills necessary to practice high-end esthetic dentistry in your
practice or laboratory. You will find it very challenging but also very refreshing and rewarding. Re-
juvenate yourself, and come meet your new patients.

Avrshai Sadan, DMD

Editor-in-Chief
 OPERATIVE DENTISTRY/FIXED P R O S T H O D O N T I C S

Clinical and Laboratory Protocol for Porcelain

Laminate Restorations on Anterior Teeth

Alan V. Sulikowski, DMD, OdVAki Yoshida**

s we enter the 21st century, the fabrica- proach and an in-depth understanding of tooth
tion of esthetic, functional, and biocom- anatomy, dental structures, dental materials, and
patible dental restorations has become light behavior.
the objective of restorative dentistry. This phe- Contemporary materials allow the manipulation
nomenon has created a paradigm shift in which of light to mimic the natural dentition. However, a
function and esthetics are no longer two separate protocol should be established t o predictably
or antagonistic elements. However, creating es- achieve the desired results. This article will pre-
thetic restorations that are indistinguishable from sent a rationale based on color for the diagnosis,
the natural teeth can be a challenge.' tooth preparation, and laboratory protocol for the
To meet this challenge, all members of the restoration of anterior porcelain veneers.
dental team must take a myriad of factors into
consideration. They must have a very precise ap-
• DIAGNOSIS

A correct diagnosis, to recognize all the factors

that will play a role in the final outcome, is one of
the key steps in providing an adequate treatment
"Clinical Instructor, Postgraduate Prosthodontics, Harvard plan. Due to the quantity of factors that have to
School of Dental Medicine; Private Practice, Cambridge, be determined,^ this article will focus on the color
Massachusetts. evaluation of problem teeth that require porcelain
••Technical Instructor, Department of Postgraduate Prostho-
dontics, Tufts University, Boston; Technical Instructor, Non-
restorations.
tal<e Dental Supply Company; Dental Technician, Gnathos The existing color of the tooth will influence the
Dental Laboratory, Weston, Massachusetts,
technique used to achieve the final result. Often-
Reprint requests; Dr Alan V. Sulikowski, 181 Concord Av-
enue, Cambridge, MA 02133. times, the tooth to be restored is not the same
 Porcelain Laminate Restorations on Anterior Teeth ,

Fig 1 Diagram of three types of

preparations based on the color of
tbe tooth to be restored. Type I
sbows a space requirement of 0,3
mm, type II a space requirement of
0.6 mm, and type III a space re-
quirement of 0.9 mm.

color as the adjacent teeth. Three types of prepa- sired shade is A2 and the background color is
rations are proposed to better diagnose and pre- A3.5, the technician will utilize an Al shade to
pare a treatment plan for individual clinical cases create the desired result.
(Fig 1). Type HI Preparation: There are three shades or
more of difference between the proposed
• Type t Preparation: The shade of the restoration and the color of the tooth/teeth. In
tooth/teeth to be restored is similar to the this case, a masking effect is necessary to ob-
shade of the final restoration; there is usually tain the desired color. The porcelain restoration
no more than a shade of difference. In this sit- will mask the unwanted discoloration and will
uation, tooth preparation will provide a mini- provide the desired color. A space requirement
mal reduction of about 0,3 mm from the pro- of 0.9 mm is needed for tooth reduction. The
posed contours. The margin location will be margin location will frequently be subgingival.
supragingival. The restoration will take advan-
tage of the background color to achieve a nat-
ural look,
• Type It Preparation: The shade of the m SHADE TAKING
tooth/reet/i to be restored differs up to two
shades when compared to the proposed When taking a shade, we must pay careful atten-
restoration. In this situation, the final restoration tion to several points. The first and most impor-
will play an important role in modifying the tant point is to control the quantity and quality of
background shade to bring it to the desired light in the room. The light must be daylight, tem-
level. The space requirements for tooth prepa- perature must lie between 5O00''K and 55OO''K,
ration will be about 0,6 mm from the proposed and the intensity of the light should be 175 to 200
contours. Margin location will be at the gingival foot-candles [ft-c), especially in the zone around
crest. The resulting shade will be a combination the patient's face (Fig 2), Sometimes it is neces-
of the background and the desired shade of the sary to use bulbs of various temperatures to
porcelain restoration. For example, if the de- achieve this result. If there is a window in the

QDT 2001
 SULIKOWSKI/YOSHIDA

various shade tabs. Separate assessments are

made for the dentin and the enamel. Sometimes
only one of the two will have a different translu-
cency than the shade tab, but sometimes they
both will. One might be more translucent than the
tab and the other less than the tab. If only the
enamel layer has a different translucency than the
tab, then only the outer surface has to be adjusted
with translucent powders. If the dentin has a differ-
Fig 2 Color temperature meter is used to ent translucency than the tab, the dentin porcelain
check the lighting conditions around the pa- powder must be adjusted. If there is enough
tient's face.
space, further control of the translucency is possi-
ble by adjusting the thickness of the layers of
dentin enamel and translucent powders,^ This
method of shade taking, which involves the
unique order described and a crucial concept of
room, the daily fluctuations of the sky conditions developing a build-up strategy during shade tak-
will introduce unpredictable influences in the ing, makes it easier for the ceramist to accurately
process; closing the curtains and/or blinds is al- recreate the shade of the natural teeth.
ways recommended. If possible, the ceiling, walls, The chosen shade tab should be included in
and furniture should be neutral gray. Intense col- the photograph. The absolute shade of a slide will
ors throughout the operatory and dental labora- depend on the camera, the film, the flash system,
tory should especially be avoided.^ Because pa- etc, but if the tab is included, differences between
tients' teeth dehydrate during any examination, the tab and the teeth are accurately recorded.
shade taking is the first step in the process. If The differences recorded on the slide are then
white calcification occurs due to dehydration, it used to adjust the color. The tab should be edge
will take at least 2 hours for the shade to return to to edge and in the same plane as the teeth. If the
normal,'' If the cheek retractor is on for more than shade tab is held up against the labial surface of
a minute before the photographs are taken, the the preparation or an adjacent tooth, it will not be
teeth should be artificially moisturized. in the same plane and will look relatively higher in
When taking a shade, it is always necessary to value,' Depending on the case, it may be best to
develop a strategy for matching a shade that is include more than one shade tab. Also, be sure
cognizant of the multiple layers of various porce- that the tab labels are clearly visible.
lain involved in a build-up. The hue and chroma If the camera is held perpendicular to the labial
will be determined by the dentin porcelain pow- surface when photographing the mamelons, there
der. The overlay of enamel and translucent pow- will be too much reflected light. Therefore, the
ders primarily determines value, but custom char- camera should be held high and the photograph
acterization also influences value, as well as color taken downward at an angle of 30 degrees. To
and intensity. In the procedure used for this report, best record the translucency in the incisai edge,
the order of steps is to (1) choose the hue, (2) separate photographs should be taken to show
choose the chroma, (3) choose the value, and (4) the patient's teeth both clenched and open. If the
assess the translucency (an often overlooked step). photographs are taken from a 30-degree side
While making a restoration, careful attention must angle, the thickness of the enamel layer as well as
be paid to the translucency. Because there is no any crack lines will be revealed.
commonly accepted translucency guide, notes are Professional-grade color slide film should be
made comparing the translucency of the teeth and used and developed as soon after shade-takinq as

QDT 2001
 Porcelain Laminate Restorations on Anterior Teeth

possible. Before the build-up, a sketch of the

porcelain layering strategy is made. The powders
that will be needed during build-up may be mixed
if necessary (Fig 3), An accurate, written record of
the powder ratios should be kept in the event it
becomes necessary to reproduce the result or
communicate to someone else how to achieve
that particular shade. The need to remake one
unit of a multi-unit case a few years later is not un-
usual. If the shade needs to be adjusted after the
Fig 3 A measuring scoop set from the
oral try-in, a written record of the layering tech- Gnathos siiade set (Belle de St, Claire/Kerr,
nique and the mixing ratios will ease the process. Orange, CA). The relative volumes are 50,
25, 5, and 1. These scoops are used for mix-
ing custom powders.

RESTORATIVE CONTOURS

Restorative contours are evaluated by means of In addition to the factors mentioned above, the
computer-aided analysis and conventional wax- tooth preparation will be directly affected by the
up techniques. As a rule, emergence profiles and proposed contours of the final restorations.
contours found in natural teeth are often created. Enamel is preserved whenever possible. Geomet-
However, depending on the case, some charac- ric principles of tooth preparation for porcelain ve-
teristics may be accentuated to create a better neers are followed to maximize strength.'
outcome. This is often true when there is some Adequate three-dimensional tooth preparation
misalignment in a buccolabial or mesiodistal di- is confirmed with a silicone index, made of the di-
rection of the teeth to be restored. Tooth length agnostic wax-up, which is transferred to the pa-
is determined by esthetics and function. It is not tient's mouth,^ Although space requirements for
uncommon to change the length for a more es- porcelain veneers vary from 0.3 to 0.9 mm, that
thetic result. At this stage, tooth proportion is does not necessarily mean there will be the same
evaluated for each tooth, and as a whole, for reduction of dental structures. Final tooth con-
form, function, and relation to the lips. The pro- tours are designed to maximize tooth enamel
posed contours will then be confirmed with the preservation. Tooth position may vary the amount
temporary restorations. of reduction needed. For example, if a tooth is lin-
gually misplaced in the arch and the final restora-
tion will correct such misalignment, the space re-
• TOOTH PREPARATION quirements will be met with minimal to no
preparation of the tooth structures.
With the evolution of dental materials, the princi- Incisai reduction of about 1.5 to 2 mm of pro-
ples of tooth preparation have changed tremen- posed contours is designed following current re-
dously. The t o o t h preparation guidelines for search,' A final impression is then made and tem-
partial-coverage porcelain restorations are deter- porary restorations are fabricated following the
mined by the removal of diseased dental struc- diagnostic wax-up. Esthetics, phonetics, and func-
tures, quantity and quality of remaining tooth tional aspects are evaluated on the temporary
structure, and adequate space requirements for restorations,'" With all the information gathered,
the proposed restoration to provide form and the final restorations are fabricated and delivered
function. to the patient.

QDT 2001
 SULIKOWSKI/YOS H IDA

• I CLINICAL CASES the intensity, and the positioning of the patients

other individual characteristics were carefully stud-
Type I Preparation: Single Laminate Case ied and reproduced using the slides (Figs 14 to
17). Cervical translucency is an important aspect
In this patient, the maxillary left central incisor will of success in porcelain laminate veneers. Nor-
be restored with a porcelain laminate veneer (Fig mally, orange and pink modifiers are added to the
4). The shade, anatomy, and surface texture must dentin porcelain to adjust the color, and then
all be copied exactly. Obviously, reproducing the translucent powder is added to increase the
white calcification in the middle third will be a cru- translucency of the cervical area. The ratio is cho-
cial determinant of success in this case. Because sen on a case-by-case basis. The mixing ratio in
there is no discoloration, a type I preparation will the cervical area must be chosen carefully (espe-
be used to take advantage of the existing condi- cially if the margin is supragingival) and always
tions (Figs 5 to 7). The hue of the teeth is on the measured accurately and documented.
orange side of Vita Lumin A shade. The chroma When working with porcelain veneers, the lay-
matches A I . The value is lower than A I . The ering of porcelain and space control is critical. To
translucency of the right central incisor is about measure the thickness of the porcelain on the re-
25% less than the A I tab (Fig 8). To recreate this fractory die, the following method is used. Four
tooth, a layering technique illustrated by the points are marked on the facial surface of the re-
sketch in Fig 9 was used. Orange-colored dentin fractory die with a refractory pencil before final de-
modifier was mixed with dentin porcelain to shift gassing. On the lingual side, four small indenta-
the hue toward orange. If enough modifiers were tions are made directly opposite of the four pencil
added to match the desired orange hue, the re- marks (Figs 18 and 19), Then the thickness of the
sulting chroma would be higher than A I , even if refractory die is measured between each of the
Bl body porcelain was used. Therefore, BO body four pencil mark/indentation pairs before any
porcelain from the Noritake New Color Kit (Darby porcelain is built up and written records are made
Dental, Westbury, New York, USA) was used (Fig (Fig 20), The pencil marks will still be visible after
10). Also, some opacious dentin had to be mixed the porcelain is fired. Note that the pencil marks
to reduce the translucency. Surprisingly, even will not be visible in type III cases where masking
t h o u g h the laminate is very thin and highly porcelain is used; however, the thickness can still
translucent, the final result is quite sensitive to the be approximated by using the small indentations
mixing ratio. This is especially crucial with single- as a reference (Fig 21), Using this method, the
tooth restorations (Figs 11 to 13), thickness of porcelain laminate veneers can be
After some porcelain has been built up and controlled before the veneer is divested to help
fired, it is difficult to increase the value. It is much create better control of shade, hue, chroma, value,
easier to decrease the value. Therefore, the and translucency. Glazing temperature should not
enamel for a standard AI was chosen. After the control detail of surface texture. For best results,
first build-up was fired, the value was carefully de- the texture should be controlled by judicious
creased using the Internal Live Stain Technique." choice of burs, wheels, and polishing materials
The mamelons, the white calcification, the color. during mechanical polishing [Figs 22 to 25},

QDT2001
 Porcelain Lamiriate Restorations on Anterior Teeth I

CASE1 (Figs 4 to 25)

Fig 4 Pretreatment; Patient with chipped compos-

ite on the maxillary left central incisor was seeking
esthetic treatment.

Figs 5 and 6 The master cast. Tooth preparation

was designed as type I to achieve the best results.

Fig 7 Cross section of a silicone index impression

of the diagnostic wax-up placed over the cast to
show the tooth preparation and the build-up space.

OBBl-5
Fig 8 Shaae taking with A1 and Bl tabs. tBOB-25
Orangp-3
Pinl-5
LT0-3S

Fig 9 Diagram of the build-up strategy. Note espe-

cially the custom mixture of body and cervical
translucent porcelains.
SULIKOWSKI/YOSHIDA

Fig 10 Noritake New Color Kit.

Fig 11 Mamelon construction at tbe

body and enamel stage.

Fig 12 Translucent is added to tbe in-

cisal edge before tbe first firing.

Fig 13 Tbe incisai edge is sbifted

slightly to the lingual to compensate for
tbe firing shrinkage toward tbe labial that
is cbaracteristic of laminate cases.

Fig 14 After the first bake, smoothing by grinding Fig 19 Tbe indentations on the lingual side are
is needed before application of internal stain. used in conjunction with the pencil dots.
Fig 15 Noritske Internal Live Stain Kit, Fig 20 The thickness of the refractory die is mea-
sured between a dot and an indentation before any
Fig 16 After application of internal stain. build-up. Tbis method will guarantee that the differ-
ent layers of porcelain will remain identical after fin-
Fig 17 Fired internal stain. ishing tbe ueneer

Fig 18 Refractory pencil marks on the dies are Fig 21 Total thickness after firing. The porcelain
used to check the porcelain thickness of undivested thickness is calculated by subtracting the cast thick-
restorations. ness from the total thickness.
Porcelain Laminate Restorations on Anterior Teeth I

QDT 2001
SULIKOWSKIA'OSHIDA

Fig 22 Finished laminate on the master cast. Fig 23 The translucency of the laminate is illus-
trated by wetting it with stain liquid and setting it
on a fingertip.

Figs 24 and 25 Restoration cemented

in the patient's mouth. The diastema was
eft open at the patient's request.
 Porcelain Laminate Restorations on Anterior Teeth I

Type It Preparation: Laminate and cutback on the canine. There are important differ-
All-Ceramic Crown Comb/nation Case ences in lateral and central mamelons. Also, there
are no mamelons in the canine (Fig 32), The entire
This patient will receive a maxillary canine-to-canine surfaces were covered with Noritake luster porce-
six-unit anterior restoration in which the left central lain with natural opalescence and fluorescence to
incisor is a full crown and the others are porcelain beautifully harmonize with the natural dentition
laminate veneers (Fig 26). Because all six maxillary (Figs 33 to 36).
anterior teeth are being restored, we have the free-
dom to choose appealing anatomy and shade. The
patient, a young female whose esthetic priority was Type /// Preparation;
a natural appearance, wanted the restored teeth to Four-Unit Porcelain Laminate Veneer Case
harmonize with the other teeth. We tried to follow
her desire as much as possible. This patient presented with an esthetic problem in
If we use more than one kind of restoration in a the maxillary anterior area. An accident had
combination case, it is difficult to match the caused the fracture of both central incisors, one a
shade—especially if a different material is chosen horizontal fracture and the other an oblique frac-
for only one central. Therefore, a porcelain jacket ture. Root canal therapy was performed in the left
crown, rather than a porcelain-fused-to-metal central incisor. Several attempts were made in the
(PPM) crown or alternative all-ceramic system, was past to correct the dark color of the central incisors
selected for the left central. Since only one mater- using resin composite. This resulted in overcon-
ial is being used, all the units can be made at the toured restorations with an opaque and monotone
same time, Noritake EX-3 porcelain has high flex- appearance that caused esthetic and periodontal
ural strength (111 MPa), which is almost as high as problems such as gingivitis and recession.
that of the Optec all-ceramic system (Jeneric Pen- Both central incisors have discolored prepara-
tron, Wallingford, CT, U5A)(117 MPa). This type of tions, but the laterals do not (Figs 37 and 38). To
restoration is much stronger since the advent of match the centrals and the laterals, it was neces-
high bond strength resin cements. sary to use masking porcelain on the centrals and
In this case, no shade adjustment was deemed to prepare the teeth as type III (Figs 39 to 41). To
desirable (Fig 27), It was prepared as type II, with make suitable masking porcelain, Noritake creamy
a porcelain thickness of 0.6 mm to create enough white luster porcelain and opacious body porce-
opacity control to match the translucency of the lain were mixed, A greater amount of creamy
veneers and the jacket crown (Figs 28 to 30). From white is used when more masking power is
lateral to lateral, the shade is A I . The canines are needed. The particle size of luster porcelain is
A2. Because natural appearance was the priority, much smaller than that of conventional porcelain.
moderate incisai area characterization and match- The small particle size diffuses the light that re-
ing surface texture were the crucial factors for suc- flects off of the discolored preparation so that the
cess in this case {Fig 31). During the porcelain discoloration is not visible (Fig 42),'^'^ Thus, the
build-up in a six-unit anterior case, careful atten- color is masked while some translucency is main-
tion must be paid to the differences in the degree tained. Masking porcelain was built up to extend
of dentin cutback among the central incisors, lat- the short preparation to make the opacity of the
eral incisors, and canines to create appropriate core uniform (Fig 43). The patient's teeth had
differences in the value and chroma across the been bleached. To match the incisai e d g e .
arch. The largest degree of dentin cutback is on straight creamy enamel was used (Figs 44 to 46),
the lateral, followed by the central, with the least
SULIKOW5KI/YOSHIDA

Fig 26 Pretreatment. The incisai edge of this pa- Fig 27 Shade is taken with an Al tab.
tient's maxillary right central incisor was broken in
an automobile accident. The patient wanted func-
tion restored and esthetics enhanced.

Figs 28 and 29 The master cast. A type II preparation was used. Inter- Fig 30 Cross section of a silicon
proximal caries was addressed by the design of the preparation. index impression of the diagnos-
tic wax-up placed over the cast to
illustrate the tooth preparation
and bujid-up space.

Fig 31 Diagrani of the build-up strategy.

Fig 32 Note the difference in the mamelons be-

tween the centrals and the laterals and the absence
of mamelons in the canine.
 Porcelain Laminate Restorations on Anterior Teetb

Figs 33 and 34 The finished restora-

tions, A porcelain jacket crown was
constructed on the maxillary left central
incisor.

Fig 35 Noritake luster porcelain. Note tbe opales- Fig 36 Note the periodontal tissue response to tbe
cent effect with reflected light. atraumatic intervention.

QDT 2001
SULIKOWSKI/YOSHIDA

CASE 3 (Figs 37 to 46)

Fig 37 Pretreatment (type IN). Note the gingival in- Fig 38 The teeth had been bleached and both
flamrnation and recession caused by the overcon- central incisors were significantly more discolored
toured existing restorations. than the adjacent teeth.

Fig 39 The master cast. Fig 40 Cross section of a silicone index impression
of the diagnostic wax-up placed over the cast to illus-
trate the tooth preparation and the build-up space.
This required a type III preparation of approximately
0.9 mm on the facial surface. Incisai reduction was
guided by the remaining tooth structure under the
coniposite restorations.

Fig 41 Diagram of the build-up strategy.

Fig 42 Scanning electron micrograph of conven-

tional porcelain (/eft) and luster porcelain (right) at
5,000x magnification.
 Porcelain Laminate Restorations on Anterior Teeth

Fig 43 Restorations of the two lateral incisors were Fig 44 The cemented veneers. Note the blocking
placed on the cast to illustrate how short the two effect of the restorations compared to the high
central incisors are. chroma of the preparations.

Fig 45 Right lateral view of the fin-

ished case. Note the similar color
translucency and depth between the
central and lateral incisors. Masking
porcelain was only used in the centrals.

Fig 46 Left lateral view of the finished

case. The correct contours have been
restored. Note the improvement of
periodontal health.

QDT 2 0 0 1 ^
SULIKOWSKIA-OSHIDA

• i CONCLUSION • REFERENCES

This article discussed a new approach to treat- I. Piet.obon N, Paul S. All-reramic restorations: A challenge
iorantetioresthetics.JEsthet Dent 1997:9:179^180.
ment planning and treatment execution for the 2. Chiche G, Pinauit A. Esthetics oi AnteiK."' Fi«ed Prostho-
restoration of the anterior dentition, A new proto- dontics. Chicago: Quintessence, 1994
col is established based on color to facilitate the 3. Miller LL. Shade selection. J Esthet Dent 1994;6:'17-4e.
achievement of the desired outcome. Clinicians 4. Yamamoto M. Technical vjorl< and shade taking [in Japan-
ese). Quintessence Dent Technol 1984;9:42a-429.
should use their own judgment as they apply 5. Hegenbarth EA. Transparents |m Japanese]. Quintessence
these concepts to a specific situation to produce DentTechnol 1994;19|1):17-29.
accurate results. 6 Ban K. Dental Technology Library. St Louis: Ishiyaku,
1989 157-158.
7. Magne P, Douglas W. Design optimization and evolution
of bonded ceramics for the anterior dentition. A finite-el-
• ACKNOWLEDGMENTS emenl analysis. Quintessence Int 1999;30:661-671.
8. Belser U, Magne P, Magne M. Ceramic laminate veneers:
Continuous evoiution of indication. J Esthet Dent
The authors wish to express their gratitude to Dr Lloyd L,
1997;9:197-207.
Miller for his guidance on their professional development and
to Ms Kiyoko Ban for reviewing the draft. 9 Magne P, Douglas W. Porcelain veneers: Denlin bonding
optimization and biomimetic recovery of the crown. Int J
Rrosthodont 1999;12:111-121.
ID. Touati B Defining form and position Pracl Periodontics
AesthetDent1998;10:813-822.
I 1 . Aoshima H. A Collection of Ceramic Works. Chicago:
Quintessence, 1992.
12, Yamamoto M Metal Ceramics. Chicago: Quintessence,
1982:285-291
13. Cornell DF Porcelain veneer [in Japanese). Quintessence
DentTechnol 1997;22(7¡:ó9-77.
An Alternative Technique for Value Management
of Densely Sintered Alumina-Based Restorations

Larry Benge, DDS*/Russell Young, RDT'

he introduction of Procera densely sin- with low chroma, there is a need for a technique
tered alumina-based restorations' pro- that will enable the ceramist to predictably con-
vided the restorative team with an all-ce- trol and reduce the value upon the first firing. The
ramic core that possesses exceptional strength^ use of the laminating porcelain AllCeram (Ducera
and the unique ability to mask underlying dark Dental, Rosbach, Germany) has been recom-
substrates.- Also, initial evidence of good long- mended for laminating Procera copings. The All-
term survival is indicative of predictability." Ceram system provides the ceramist with a wide
Value is defined as the quality by which a light range of opaque liner powders that are fired as
color is distinguished from a dark color, the di- the first layer to control value and chroma. How-
mension of the color that denotes relative black- ever, the outcome of the application of these lin-
ness or whiteness [grayness or whiteness).^ In ers can be viewed only following the firing. If the
comparison to most ceramic materials, densely results are not satisfactory, the fired liner has to
sintered alumina copings have relatively high be removed by sandblasting and a new liner must
value. This high value may be beneficial in young be applied.
patients with light and bright teeth but may pre- This article describes an alternative technique
sent 3 challenge in highly chromatized teeth with to firing the first layer in order to control the value.
low value. In patients who require restorations This technique is based upon incorporating stains
into the first layer. The use of stains in the first
layer is an excellent method to visualize the value
of the coping even prior to the firing. The fact that
the applied stains look almost identical before
'Private practice, Melbourne, Australia.
and after the firing will increase predictability and
"Ceramist and Dental Prosthetist, Melbourne, Australia.
Reprint requests: Dr Larry Benge, 5 Bond Street, South
possibly minimize the need for removal and refir-
Yarra, 3141 Melbourne, Australia. Fax: (03) 9826 8857. ing of the liner.

QDT 2001
BENGE/YOUNG

Figi The opaque liner and liquid

(left) are tbe traditional ^PP'°^^\1
for first layer application. The IL.
powder and Prevu liquid are used
for the suggested technique (right).

Fig 2 Conventional opaque liner

mixture on left side of ps&, TC
mixed with stain and Preuu on
right.

Fig 3 Procera coping prior to lami-

nation.

Fig 4 Application of opaque liner.

The color outcome of this applica-
tion cannot be visualized prior to
firing.

Fig 5 Prefiring view of

stain/TC/Preuu mixture applied to
the buccal margins to control
value.

Fig 6 Postfiring view demonstrat-

ing reduced value of the coping.
Note the similarity between the
prefired and postfired views; this
allows the ceramist to evaluate tbe
outcome prior to firing.

Fig 7 Application of various

stains/TC/Prevu mixtures to differ-
ent areas of the coping to control
value and chroma.

Fig 8 Left coping presents tradi-

tional opaque liner application; the
rigbt coping presents the sug-
gested application technique.
 Value Management of Densely 5intered Alumina-Based Restorations

Fig 9 Preoperative view of existing porce I ai n-f used- Fig 10 Preoperative lateral view demonstrating the
to-metal restorations on central incisors. overcontoured restorations.

Fig 11 Central incisors after removal of the existing Fig 12 Prepared central incisors following build-up
restorations show insufficient labial reduction and refining of preparations.

The technique is based on the mixture of All- 5. Fire AllCeram according to manufacturer's
Ceram stains with AllCeram TC powder using recommendations of 92O''C at 60°C per
Prevu liquid (Jeneric Pentron, Wallingford, PA, minute in full vacuum; hold 1 minute,
USA) as a mixing medium. This is the first layer ap- 6. Evaluate results and repeat if additional mod-
plied to the coping. It is the authors' experience ifications of value are needed.
that use of the Prevu liquid results in a viscous and
uniform mixture. The steps of the technique are as The fired layer can be 0.05 to 0,1 mm or
follows: thicker. Also, combining this technique with thin-
ning of the buccal margins of the coping may
1, Mix AllCeram TC powder with the AllCeram eliminate the need for porcelain margins in most
stain of choice to a honeylike consistency. anterior cases.
The mixture is created using Prevu liquid. Figures 1 to 8 provide an illustrated comparison
2, Apply the mixture with a brush to the coping. demonstrating the visual advantages of the sug-
3, Place colors where necessary (eg, increased gested technique vs the traditional application of
chroma at cervical portion of coping, applica- opaque liners. Figures 9 to 21 present a case in
tion of violet on incisai third). which the suggested technique was used. Note the
4, Dry at 400°C for 10 minutes. challenging value and chroma of the patient's teeth.
BENGE/YOUNG

Fig 13 Close-up view of supporting tissues following Fig 14 Try-in of Procera restoration on right central in-
temporization. dsor. Note low value and high chroma at the buccal
margins.

Fig 1 5 Close-up view of seated restoration on right Fig 16 Try-in of left central incisor restoration.
central incisor at try-in.

Fig 17 Completed restorations.

Low value and high chroma at the
margin area were achieved without
the use of porcelain margins.
 Value Management of Densely Sintered Alumina-Based Restorations

Figs18and19 Preoperative srnile

and postoperative rest position
views.

Figs 20 and 21 Preoperative and

postoperative full-face views.

• CONCLUSION M REFERENCES

1. Andersson M, Oden A, A new all-ceramic crown: A

The article presented a simple method to control
dense-5intered, high purity alumina coping with porce-
the value of Procera restorations in the first layer lain. Acta Odontol Scand 1993;51:59-64,
application. In addition to the simplified ap- 2. Zeng K, Oden A, Rowcliffe D. Flexure tests on dental ce-
ramics. IntJ Prosthodont1996;9:434-439,
proach, it also enables the ceramist to evaluate
3. Oden A, Razzoog ME. "Masking ability" of Procera AllCe-
the outcome of the value even prior to firing. ram coping of various thickness [abstract]. J Dent Res
1997;76(special issue]:310.
4. Oden A, Andersson M, Krystek-Ondracek I, Magnusson
D. Five-year clinical evaluation of Procera AllCeram
crowns. J Prosthet Dent 1998;a0:450-45É.
5. Glossary of Prosthodontic Terms, ed 7. J Prosthet Dent
1999;81:105.

QDT2001
Indirect Resin-Based Restorations:
The belleGlass HP System

Didier Dietschi, DMDVNikolaos Perakis, DMD*/Dominique Vinci, CDT**/

Ivo Krejci, DMD, PD*

undamental changes have occurred in preparations, while medium-size cavities are bet-
treatment concepts for anterior and pos- ter restored with a direct composite technique.'
I terior teeth, due to the success of pre- The controversy surrounding the indication for in-
vention, development of new materials, and more direct ceramic restorations is more prevalent than
effective conservative clinical procedures.'-' As a ever, especially since a new category of compos-
result of these developments, placing direct ite materials entered the market. These materials,
restorations and preserving tooth vitality empha- as claimed by their manufacturers, can replace ce-
sizes biocompatibility in order to preserve the ramic or porcelain-fused-to-metal (PFM) restora-
biomechanical potential of the dental apparatus. tions in many of their traditional indications, with
For instance, the indications for Class I and II gold consideration given to preservation of tooth
or ceramic inlays are restricted to very large structure.
The objective of this report is to outline infor-
mation about one of these new laboratory com-
posites and to review its properties and indica-
tions for use.

•Department of Cariology, Eridodontics and Pedodontiqs,

School of Dentistry, University of Geneva, Geneva, Switjer-
land.
• CHARACTERISTICS QF AN IDEAL MATERIAL
••Vinii Odontotechnique s a.r.L, Acacias-G ene va, Switzer- FOR INDIRECT RESTORATIONS
land.
Reprint requests; Dr Didier Dietschi, Department of Cariol- An optimal restorative material for the fabrication
ogy, Endodontics and Pedodontics, School of Dentistry, Uni-
versity of Geneva, 19 Rue Barthélémy Menn, CH-1205, of indirect restorations should fulfill, at least, the
Geneva, Switzerland. following chief conditions:
 Indirect Resin-Based Restorations

• Ease of manipulation (fabrication and place- havior of resin composite indirect restorations.^'"'"
ment} However, some reports show promising results for
• Mechanical resistance, especially flexural the newest composite formulations.'"' Their satis-
strength and fracture toughness factory clinical behavior (in comparison to the for-
• Wear resistance mer generations of laboratory composites, micro-
• High surface gloss and smoothness filled and hybrids derived from clinical materials) is
• Esthetics {color, translucency/cpacity, opales- attributed to the following improvements:
cence, fluorescence)
• Reasonable system and restoration costs • Higher resin conversion = less chemical wear
• Repairability and surface discoloration; better color stability.
• Sufficient restoration longevity (10 years mini- • Higher flexura! strength and fracture toughness
mum) = better fatigue resistance and less chipping or
bulk fractures,
Ceramics used for the veneering of metal or • Better surface quality = better esthetics, wear
high-strength ceramic frameworks or as a single resistance, and less surface discoloration,
restorative material have demonstrated their po- • Optimized handling properties and shading for
tential in the past several decades. This is espe- laboratory application = better anatomy and
cially true regarding the esthetic quality of these esthetics.
restorations. However, these materials do not ful-
fill the cited list of characteristics. They actually
have common drawbacks, such as the complexity • I THE BELLEGLASS HP SYSTEM
and length of fabrication procedures with high
production costs, brittleness, and general abra- The belleGlass HP (Kerr, Orange, CA, USA) is a
siveness for opposing occiusal surfaces," This jus- complete system for the fabrication of metal-free
tifies improving some of these characteristics tooth-coiored restorations for anterior and poste-
and/or searching for alternative materials. Resin rior teeth. The material is a dual-cure composite
composites address some of these deficiencies; {light- and heat-activated) which was designed ex-
they are less brittle,' less abrasive,'"'" and normally clusively for use in the laboratory. It consists of
easier to manipulate. As a consequence, the four basic masses: cervical shades, opaque
shorter fabrication time allows composite restora- dentins, translucent dentins, and opalescent
tions to be introduced at a lower cost. This ex- enamels, with intensive colors completing the sys-
plains the growing interest of practitioners for tem (Fig 1), Special fibers (Connect) are to be
used for full-coverage crown and bridge work.
resin-based indirect restorations. However, com-
posites do not guarantee the same long-term
color stability and surface gloss, two properties of
critical importance in terms of esthetics. In fact, Material Composition
the "strong points" of resin composites lie in the
deficiencies of the ceramics, and the same is true The belleGlass HP is a fine hybrid composite,
conversely. We, therefore, need to define objec- based on a blend of urethane dimethacrylates
tive selection or judgment criteria to take advan- {UDMA) and other aliphatic monomers, both of
tage of both material categories and define their which are light- and h eat-activated. The light acti-
respective advantages.^ vation reaches about 50% of resin conversion,
Numerous papers describe laboratory compos- which helps in physically stabilizing the different
ite physical characteristics,"-'* related technical masses during restoration fabrication and facili-
procedures, and clinical indications"-™ while only tates the achievement of optimal esthetics and
sparse data are available regarding the in vivo be- anatomy. Heat curing at 147°C under nitrogen
DIETSCHI ETAL

Fig la Sampies of belleGlass HP made of three differ- Fig 1 b Same samples viewed under UV illumination.
ent enamels (from /eft: cuspal, clear, white) and A3 The material exhibits adequate fluorescence.
translucent dentin. Note the different tints and natural
opalescent effects.

Table 1 Physical Characteristics of the belleGlass HP System (Manufacturer's Data]

Flexura 1 Flexural Rockwell X-ray Filler Coefl themal Fracturs
tens strength strength strength modulus hardness opacity Wt% Shnriksge expansion toughness
IMPal (MPa) (MPa) IMPa) 15T (xAI) (vol %) (vol %) (ppm/°C)

TranslucerIt 63 41/ 142 13100 87 0 3- 7S 3.00 30.2 1.04

den tin (41 (34) (10) (700) (1 0) (56) (0.1) (0,8) (0.04)
Opaceouii 56 370 158 21000 89.1 3K 87,1 0,94 13.1 1.4B
dentin (4) (28) (111 (1400) (1,0) (72.5) (0.1) (0,7) (0.09)
Enamels Ó3 460 167 10700 39.6 11 72.9 3.10 26,4 0 96
(2) (50) (21) (200) (0,4) (59.5) (0.03) (0.3) (0.07)

Numbers in parenihe

pressure (5 bars, 75 psi) for 10 to 20 minutes al- 2, Translucent dentins use the same barium glass
lows resin to be almost 100% polymerized. This filler but with a narrower particle size and dis-
dual-cure mode was introduced in 1998. Prior to tribution (0.6 micron average] and slightly infe-
this time, dentins were light-cured materials while rior filler load (78% wt, 56% vol). Dentin
enamels were only heat-cured. masses are fluorescent (Fig 1b),
The filler composition differs in each of the 3, Enamels contain a borosilicate filler (Pyrex
three system constituents: glass] in a proportion of 72% wt and 59.5%
vol. This special filler allows the material to
1. Opaceous dentins have a trimodal filler parti- reach physical properties as good as translu-
cle size with "larger" barium glass particles (10 cent dentins but provides better translucency
microns average) and a high filler load (86% and opalescent effects. In addition, enamels
wt, 72% vol]. This allows for a low coefficient of exhibit a very smooth and shiny surface, even
thermal expansion (13,1 ppm/''C), low poly- after a prolonged time in the mouth. This is
merization shrinkage (0.94%), modulus of elas- probably due to the fine and soft filler, as well
ticity that closely adapts to dentin (21 GPa), as an optimal resin polymerization rate.
high flexural strength, and better microreten-
tion after internal surface preparation (etching Physical characteristics of the belleGlass HP
and/or sandblasting). system are summarized in Table 1.
 Indirect Resin-Based Restorations I

Table 2 Materials of the belleGIass System to Be Used in the

Different Clinical Applications
Materials In/on/overlays Veneers Crowns Bridges
Opaceous dentin - {i-) ^. +
Translucent denlin + +, 4. .j.
Enamels + + 4. 4.
Intensive colors + {+) + +
Connect fibers - - + .^.
+= Application recommended.
(+1 = Application possible.
- = Application not recommended.

The optical characteristics of the materials gas plasma treated and pre impregnated vi/ith resin
should cover the needs for uncompromised es- to facilitate handling. In addition to the fibers, spe-
thetic restorations, Opaceous dentins are to be cial tinted and filled fiowable materials are avail-
used to mask underlying discolored tooth struc- able for building up the restoration framework.
ture. They can also be used for full tooth structure
replacement to prevent the grayish effect result-
ing from excessive translucency. Translucent Indications
dentins maintain the restoration chroma, even in
rather thin restorations. Opalescent enamels pro- The clinical application of the belleGIass HP sys-
duce many of the subtle light effects found in nat- tem includes the following indications ¡Figs 2 to 7):
ural enamel, such as the "halo" and "opales-
cence" of the incisai third. Table 2 summarizes the • Semi-direct inlays/onlays
selection and application of the different elements • Indirect inlays/onlays/ouerlays and veneers
of the system according to the clinical situation. • Minimally invasive fixed partial dentures, adhe-
With this system, however, it is difficult to ob- sively cemented
tain restorations of optimal value. This is espe- • Crowns and bridges, adhesively cemented
cially true in young patients with a rather white
opaque, but highly opalescent, enamel (Fig la). These indications have been extensively cov-
Both enamels and dentins exhibit satisfactory fluo- ered in the literature with regard to clinical as well
rescence {Fig 1b). as laboratory procedures. The system also has a
potential application for semi-direct or "chairside"
fabricated inlays/onlays [Figs 4 and 5). Actually.
Fiber Reinforcement the surface quality and resistance to degradation
of a restoration made of a heat- and light-cured
Special fibers (Connect) made of polyethylene are material might be superior to what can be ob-
to be used to create substructures for full-cover- tained with conventional light-cured resin com-
age crowns or bridges.^^" When incorporated in posites used for direct restorations. Also, fabrica-
the belleGIass core, the resulting strength is largely tion time is not significantly extended. The
superior (flexural strength = 335 MPa; fracture specific heat-pressure curing process is completed
toughness = 12.9 MPa) to the nonlaminated ma- in 10 minutes, which lies within the timeframe of
terial (flexural strength = 126 MPa; fracture tough- postcuring treatment usually applied to semi-di-
ness = 1.48 MPa).^^° These fibers are now cold rect restorations^ (Fig 5),

QDT 2001
 IDIETSCHI ETAL

Figs 2a and 2b Young patient showing peg-shaped lateral incisors

Figs 2c and 2d Indirect veneers were fabricated for application without any preparation.

Figs 2e and 2f Postoperative situation.

Figs 2g and 2h Facial views, preoperatively and 1 year postoperatively.

IQDT2001

IL
 Indirect Resin-Based Restorations

Fig 3a Preoperative view showing edentulous space Fig 3b The radiograph shows insufficient bone height
with reduced mesiodistsi width. as well. Adjacent teeth have proximal restorations.

Fig 3c Minimally box-shaped preparations were Fig 3d View of the optimally consen/ative prepara-
made, which integrated preexisting restorations. tions.

Fig 3e The fixed partial denture is Fig 3f The restoration was fabri- Fig 3g Occlusal view of the
made of optimized resin composite cated on a hybrid hard stone-sili- restoration, ready for cementation.
with glass fiber-bonded framework cone cast for ease of manipulation; The adhesive approach facilitated
{belleGlass HP and Connect). dies are made of silicone (Fig 3e). the anatomic integration of the
The bridge was then reseated on a restoration.
nonseparated hard stone cast.

Fig 3h Postoperative view 1 month after cementation.

QDT 2001
. DIETSCHIETAL

Fig 4a Initial view of defective amalgam restorations. Fig 4b Teeth were conservatively prepared; undercuts
were suppressed and final geometry was achieved by
application of flowable composite.

Fig 4c Inlays were fabricated chairside on a bard sili- Fig 4d Postoperative situation 1 month after cemen-
cone material with translucent dentin and enamel from tation.
the belleGlass HP system. For ¡niays and onlays, fiber
reinforcement is not necessary.

Fig 5 Fabrication of semi-direct extraoral composite Fig 5e Tbe sectioned casts of the maxilla and mandible
inlays, step by step, with simplified layering technique. can be mounted on a simplified articulator if needed.

Fig 5a The cast is made of stiff and fast-setting sili- Fig 5f Tbe occiusal anatomy is tben completed, usually
cone materials (beige material for teetb: Mach2, with a very translucent material at the margins {light or
Parkell, Farmingdale, NY, USA; blue material for cast clear), while a more opalescent material is used for tbe
base: Blumousse, Parkell). Dies can be easily sepa- remaining surface [white or cuspal), A fine-pointed in-
rated with a blade. strument is used to sculpt tbe occiusal anatomy (Com-
posculp, Suter Dental, Chico, CA, USA),
Fig 5b The restoration is built up in three steps, Tbe
first step is tbe application of a bigh-cbroma composite Fig 5g Completed restorations after characterization of
for dentin replacement {cervical shade). the fissures with intensive colors {Kolor plus, Kerr). Note
tbat a thin layer of material covers the margins to pre-
Fig 5c The second step consists of completing the vent deformation and preserve optimal restoration fit.
restoration base witb translucent dentin.
Fig 5h Restorations are maintained on their dies during
Fig 5d Proximal surfaces and contact points are cre- heat and pressure postcuring treatment.
ated with translucent enamels.
Indirect Resin-Based Restorations I

QDT 2001
 DIETSCHI ETAL

Figs 6a and 6b Preoperative views of both upper lateral segments, which require the replacement of
multiple amalgam restorations and defective prosthetic restorations.

Fig 6c belleGlassHP inlays on the master cast. Fig 6 d Teeth to be restored under rubber-dam isola-
Restorations exhibit adequate anatomy and optical tion. This protection is mandatory for adhesive cemen-
characteristics. tation of indirect inlays and onlays.

Fig 68 View of the same quadrant 6 months after Fig 6f Initial view of the mandible, with amalgam
restoration placement. restorations on molars.

Figs 69 and 6h Full arch views showing the excellent esthetic integration of the indirect composite
restorations {6-month postoperative situation). Restorations on the maxillary right second premolar
and first molar are PFM crowns.

QDT 2001
 Indirect Resin-Based Restorations I

Fig 7a Preoperative view of the lower right quadrant. Fig 7b Adhesive post and cores were made on the
second premolar, while the existing cast gold core was
maintained on the first premolar.

Fig 7c Three full composite crowns with fiber-rein- Fig 7d Postoperative view, 1 month after adhesive ce-
forced framework (Connect-Revolution, Kerr) were pre- mentation. Note that the restorations maintain a satis-
pared, according to the technique described in Figs 3 factory surface gloss, although Burface is not as shiny
and 5. as glazed porcelain, A slight discoloration is visible on
the second premolar occlusal surface due to the un-
derlying carbon-fiber post.

Clinical Findings and System Review pressing and curing the enamel underneath a sili-
cone key. The manufacturer presently is working
Some improvements in handling and application on filler modifications to address this material's
of the system are expected. Actually, all masses value drawback.
and enamels are quite sticky at room temperature, The problem of light diffusion and reflection in
and it can be difficult to form and sculpt the mate- enamels also needs to be investigated, because
rials in their uncured stage. As a consequence, single anterior restorations proved difficult to per-
significant corrections sometimes have to be fectly integrate, as value usually was too low. It
made with rotary instruments. Developing the will be of prime importance to compare the exact
restoration anatomy in this way is far less ideal optical characteristics of translucent dentins and
and is more time-consuming than forming the enamels with those of natural tissues and then to
restoration with appropriate hand instruments. fine-tune the relative thickness of each layer, or
Another approach, proposed by Jourdain-Her- perhaps even adapt the material structure (see
wyn,^' consists of waxing the restoration and then Figs2e and 2f),

QDT 2001
DIETSCHI ETAL

Also, we initially experienced difficulties in 15. Knobloch LA. Kerby RE. Seghi R, Van Putten M. Tv«ro-body
achieving ideal restoration fit. This might be at- wear resistance and degree of conversion of laboratory-
processed composite materials. Int J Prosthodont
tributed to deformation of the material when the
1999;! 2:432-438.
restoration is introduced in the oven and pressure 16. Msiyca A, Kobashigawa A, Shellard E Physical properties
is applied to the chamber. The still "soft" material of an improved indirect CS.B resin [abstract 288]. J Dent
Res 2000:79:179.
might slightly deform where it is very thin. A little
17. Chalifous PR. Treatment considerations for posterior labo-
overcontour build-up at the level of margins can ratory-fabricated composite resin restorations. Pract Peri-
prevent such distortions (Fig 5d). odontics Aesthet Dent 1998:10:969-978.
18. Dickerson WG, Rinaldi P. The fiber-reinforced mlay-sup-
ported indirect composite bridge. Pract Periodontics Aes-
thet Dent 1996:8 [suppi, August):2'-5.
• REFERENCES 19. Kreici I, Boretti R, Lutz F, Giezendanner P Adhesive
crowns and fixed partial dentures of optimized composite
I. Lutz F, Krejci 1, Odera M. Advanced adhesive reçtorations: resin with glass fiber-bonded framework. Quintessence
The post-amalgam age. Pract Periodontics Aesthet Dent DentTechnol 1999:22:107-127.
1996)8:385-394. 20. Miara P. Aesthetic guidelines for second generation indi-
2 Dietschi D. Dietschi JM. Current developments in com- rect inlay and onlay composite restoration. Pract Peri-
posite materials and techniques. Pract Penodontics Aes- odontics Aesthet Dent 1998:10:423^31.
thet Dent 1996:8 003-613. 21. Beuchat M, Krejci I, Schmutz F, Lutz F Klinischer Erfolg
3. Dietschi D, Spreafico R. Adhesive Metal-Free Restora- mit minimalinvasiven adhäsiven Kompositbrücken im
tions: Current Concepts for the Esthetic Treatment of Pos- Seitenzahnbereich nach einjähriger Funktionsdauer Acta
terior Teeth. Chicago- Quintessence, 1997.60-77 Med Dent Helv 1999:4:55-61.
4. Wiley FG. Effect of porcelain on occluding surfaces of re- 22. Christensen RP, Smith SL. Hein DK, Woolf SH. Clinical
stored teeth J Prosthet Dent 1989:61 133-137 performance of 3 filled polymer crowns with Ei without
5. Magne P, Oh WS. Pintado MR, DeLong R Wear of substructures [abstract 16311. J Dent Res 1999:78:309.
enamel and veneering ceramics after laboratory and
23. Givan DA, O'Neal SJ, Suzuki S. Eight-year clinical perfor-
chairside finishing procedures J Prosthet Dent
mance of heat and pressure cured indirect inlays [abstract
1999:82:609-679.
1523). J Dent Res 2000;79:334.
6. Dyer SR, Sorensen JA. Flexural strength and fracture
24. O'Neal SJ, Givan DA, Suzuki S. Five year clinical perfor-
toughness of fixed prosthodontic resin composites [ab-
mance of heat and pressure cured indirect composite (ab-
stract 434]. J Dent Res 1999:79.160.
stract 1628]. J Dent Res 1999,78:309.
7. Givan DA, O'Neal SJ. In vitro wear of enamel and poste-
25. Kreisler T. Behr M, Rosentritt M, Lang R, Handel G. Frac-
rior restorative materials [abstract 1655]. J Dent Res
1999:78:312. ture strength and marginal adaptation of molar-crowns
made of fibre-reinforced systems (abstract 1013]. J Dent
8. Knobloch L, Agarmala Y, Dorosti Y, Seghi R Simulated
Res 2000:79:270.
oral wear of laboratory processed and direct placement
composites [abstract 1648]. J Dent Res 2000;79:349. 26. Munoi CA, Torres J, Dunn JR, Yow W, Kobashigawa A,
Shellard E. Effect of fiber reinforcement on the breaking
9. Roe WD, Ramp MH. Wear of ename! opposing three es-
strength of crowns (abstract 11 77]. J Dent Res
thetic materials and one alloy [abstract 1090]. J Dent Res
1998:77:779.
2000:79:280.
10. Sorensen JA, Dyer SR. Condon JL, Ferracane JL In vitro 27. Munoi CA, Torres J, Dunn JR, Yow W. Kobashigawa A,
wear measurements of fixed prosthodontics composite Shellard E. Effect of fiber reinforcement on the strength of
resins [abstraa 432]. J Dent Res 1999;79:159. fined partial dentures [abstract 2220]. J Dent Res
1999;78:383.
II. Cesar PF, Miranda WG. Flosural strength of composites
for indirect restorations [abstract 2407]. J Dent Res 28. Dyer SR, Sorensen JA. Fiber-reinforoed composite and ce-
2000:79:444. ramometal fixed partial denture fracture comparison [ab-
12. Douglas RD. Color stability of new-generation indirect stract 925]. J Dent Res 2000:79:259.
resins for prosthodontic application. J Prosthet Dent 29. Kobashigawa A, Shellard E. Crack arresting properties of
2000:83:166-170. a fiber reinforced composite resin laminate (abstract 289].
13. Kerby R, Berlin J, Knobloch L. FractLire toughness of pos- J Dent Res 2000,79:180.
tenor condensable composite resins [abstract 415]. J 3D. Kolbeck C, Rosentfitt M, Behr M, Handel G. Examination
Dent Res 1999:78:157. of polyethylene-fiber-reinforced composite-FPDs after
14. KerbyR, Lee J, Knobloch L, Seghi R. Hardness and de- TCML [abstract 924]. J Dent Res 2000:79:259.
gree of conversion of posterior condensable composite 31. Jourdain-Herwyn JP La stratification des matériaux com-
resins [abstract 414]. J Dent Res 1999:78:157. posite. Proth Dent 1999;15:11-10.
 By Avisbai Sadan, DMD, and
Tbomas J Salinas, DOS

UNIFYING CLINICAL STANDARDS

Didier Dietschi is well-recognized in the field of esthetic and adhe-
sive dentistry. Together with Roberto Spreafico, he coauthored Ad-
hesive Metal-Free Restorations. This book and his many other publi-
cations exhibit application of the highest clinical standards for direct
and semi-direct clinical procedures.
The durable and stable nature of indirect materials such as cast al-
loys and dental ceramics enables professionals to apply stringent cri-
teria in assessing the clinical outcomes. This is especially true since
the specialized production is divided between the restorative dentist
and the technician.
In direct and semi-direct procedures, the outcome is primarily de-
Didier Dietschi pendent on the skill level of the clinician. Working with materials that
are comparably inferior in light transmission and color stability to
those used in indirect restorations make these procedures difficult.
The clinical assessment of such work was mainly evaluated as an af-
fordable alternative to indirect restorations with little expectation for
long-term intraoral service. Didier Dietschi's work is proof that uni-
form guidelines for outcome assessment can be applied for both in-
direct and direct restorations. The combination of superior clinical
skills and thorough understanding of direct materials enables him to
present not only immediate excellent results but also several years of
follow-up on these cases. The surge in esthetic dentistry has brought
forth a time to unify the direct and indirect clinical guidelines.
Long-Term Clinical Success of All-Ceramic
Posterior Restorations

Markus B. Blatz, DMD, PhD*

he high number of all-ceramic systems rates. Reliable scientific data and long-term suc-
available currently is due to an increasing cess rates should be decisive keys in treatment se-
demand for superior esthetics even in the lection. The clinician as well as the dental techni-
posterior regions of the mouth and the question- cian must follow the current literature, critically
able biocompatibility and inferior physical proper- evaluate its content, and compare data to provide
ties of alternative materials for posterior restora- patients with current but also evidence-based
tions, such as amalgam, composites, and certain treatment. Such an approach, however, poses a
alloys. It is an interesting fact that all-ceramic dilemma for dentists and dental technicians when
restorations in the posterior jaw have been part of they must decide between ceramic restorations
dental treatment for almost a century,'^ but the in- and alternative, sometimes more predictable and
herent brittleness of the ceramics available and clinically proven materials. Today, numerous im-
the kind of cements used for insertion caused frac- proved ceramic materials and all-ceramic systems
tures and, as a result, very high failure rates. How- are on the market and are widely used in molar
ever, recent developments of stronger ceramic and premolar areas for inlays, onlays, crowns, and
materials and the application of adhesive bonding even fixed partial dentures. However, it has been
techniques have led to acceptable clinical success suggested that new materials and techniques
should be followed up and their performance
proven for at least 5 years before they become
routine modalities of treatment^
'Assistant Professor, Department of Prosthodontics, Louisiana The purpose of this article is to review the cur-
State Uniuer5Jty Health Sciences Center, School of Dentistry,
rent literature and scientific data on the long-term
Nevir Orleans, Louisiana,
Reprint requests: Dr Markus B. Blatz, Department of success of all-ceramic restorations in the posterior
Pro5thodontics, Louisiana State University Health Sciences regions and to compare these results to alterna-
Center, School of Dentistry, 1100 Flonda Avenue, New tive treatment options. The cited clinical studies
Orleans, Louisiana 70119, Fa«: + (504) 619-8741.
E-mail: [email protected] are limited to observations of at least 5 years. The
 ;BLATZ

reader has to be aware, however, that only trends tion of a special heat process ("ceramming")
can be noted. Direct comparisons are difficult due achieves a controlled crystallization, which in-
to high variations in study designs, inclusion crite- creases strength. Dicor causes less wear on the
ria, criteria for success, and statistical analysis. opposing dentition than the reinforced conven-
tional porcelains. Esthetic considerations led to
the release of Dicor Plus, which offers a Dicor cop-
• CLASSIFICATION OF OENTAL CERAMICS ing and compatible veneering porcelain. A system
similar to Dicor is Gerapearl (Kyocera Bioceram,
In accordance with other publications on this San Diego, GA, USA), which uses hydroxy apatite
topic, ceramic restorations and materials avail- as the main crystalline phase.
able were classified by material composition and
fabrication.*-"
Machinable Ceramics

Conventional Powder Slurry Ceramics Computer-aided milling and copy-milling systems

were developed to eliminate microporosities, in-
To obtain higher strength, the crystalline content homogeneities, and shrinkage that accompany
of conventional feldspathic porcelains as tradition- high-temperature processing. Prefabricated ce-
ally used for porcelain-fused-to-metal (PFM) ramic ingots are milled to the desired shape. The
restorations was increased. The porcelain is ap- Cerec system ¡Siemens, Bensheim, Germany) uses
plied and built up directly on the model with the computer-aided design/manufacturing {CAD/
refractory die technique. Optec HSP (Jeneric/Pen- CAM) processing and ingots of the feldspathic
tron, Wallingford, CT, USA) is an example of a Vitablocks Mark I and II (Vita) or the glass ceramic
leucite-reinforced feldspathic porcelain. Other Dicor MGC. An optical impression of the pre-
manufacturers use higher contents of aluminum pared cavity is taken chairside, and a computer
oxide to fabricate strong ceramic cores (eg, Hi- transfers the information to the milling part of the
Ceram, Vita, Bad Sackingen, Germany).'^ The use unit. The milling of the ceramic ingots only takes a
of zirconia fibers is another way to reinforce felds- few minutes, enabling the dentist to deliver indi-
pathic porcelain (Mirage II, Mirage Dental Sys- rect ceramic inlays in a single appointment.
tems, Chameleon Dental Products, Kansas City,
Denzir (Dentronic, Stockholm, Sweden) is one
KS, USA). Further examples of conventional pow-
of the latest systems for computer-aided inlay fab-
der slurry ceramics are Ceramco and Ceramco II
rication. A laser scans the working die, and an
(Ceramco, Burlington, NJ, USA), Cerinate (Den-
inlay is milled accordingly from a zirconia ingot.
Mat, Santa Maria, CA, USA), and Duceram LCF
Essentially, the Procera AllCeram system (Nobel
(Degussa, South Plainfield, NJ, USA), Finesse
(Dentsply, York, PA, USA) was recently introduced Biocare, Yorba Linda, CA, USA) uses CAD/CAM
to the market. technology for the fabrication of sintered alu-
minum oxide ceramic crowns of high strength. The
dental technician scans the shape of the prepara-
tion from the master die, and the information is
Castable Ceramics transferred via modem to a remote production
unit, where a ceramic coping of densely sintered,
The best-documented member of this group is high-purity alumina is produced. Computerized
the Dicor system (Trubyte, Dentsply), which is a calculation of the dimensions necessary to fabri-
micaceous glass ceramic. Restorations are pro- cate well-fitting copings compensate for the high
duced with the lost-wax technique and centrifugal shrinkage of the material during firing. The cop-
casting of heat-treated glass ceramic. The applica- ings are sent back to the dental laboratory, where

QDT 2001
 All-Ceramic Posterior Restorations I

they are veneered with the compatible feldspathic stabilized zirconia improved flexural strength, frac-
porcelain. The Procera AllCeram veneer and ture toughness, and fatigue resistance, allowing
bridge were recently introduced to the market. the fabrication of posterior fixed partial dentures.
The Celay system (Mikrona Technologies, mar-
keted in the United 5tates by Vident, Brea, CA)
uses a contact digitizer. The shape of a laboratory- • LONG-TERM SUCCESS OF CERAMIC
made composite inlay is traced, and the informa- • INLAYS AND ONLAYS
tion is transferred to the milling part of the sys-
tem. Ingots can be the same as for Cerec. Ceramic inlays and onlays offer optimal esthetics,
biocompatibility, and durability When adhesive
bonding techniques and the use of composite
Pressable Ceramics resin cements for final cementation of all-ceramic
restorations were introduced, their clinical success
IPS Empress [Ivoclar Williams, Amherst, NY, USA) and fracture resistance increased significantly."^'''
uses precerammed, leucite-reinforced feldspathic Acid etching and a silane coupling agent create
ingots. The ingots are heated and pressed into a high bond strengths between feldspathic porce-
refractory mold made with the lost-wax technique. lain and composite resin cement.'^" With the in-
To achieve desired esthetics, restorations have to troduction of third- and fourth-generad on dentin
be stained or veneered. bonding systems, a predictable and sufficient ad-
To gain further strength, Ivoclar developed IPS hesive bond was achieved between the ceramic
Empress 2, A lithium disilicate glass ceramic is the restoration and pretreated tooth structures, A sta-
core, and a sintered glass ceramic is the veneering ble and d u r a b l e b o n d t o ceramics with low
material. Even fixed partial dentures have shown amounts of silica, such as aluminum or zirconium
promising short-term results when dimensional re- oxide ceramics, requires other surface pretreat-
quirements, especially at the connector areas, ment techniques or modified luting cements.""
were followed. Dual- or self-curing cements are used to overcome
Examples of other pressable ceramics are Cere- problems with depth of cure of light-curing ce-
store {Innotek Dental, Lakewood, CO, USA), which ments underneath ceramic restorations of in-
consists of a magnesium aluminate spinel, and creased thickness.'' Many in vitro investigations
Optec OPC, which contains an increased amount have addressed different aspects, such as fit, mar-
of small leucite crystals. ginal accuracy, microleakage, fracture resistance,
and performance, of different bonding systems.
Other important factors discussed in the literature
iniiltrated Ceramics are wear of ceramic and opposing enamel, wear of
cement, various insertion techniques, and postop-
With In-Ceram (Vita), a slip cast process fabricates erative hy perse nsitivity. The influence of prepara-
a porous alumina framework, which a molten lan- tion design on the long-term success of all-ce-
thanum aluminosilica glass infiltrates, In-Ceram ramic inlays and onlays was always questioned.
restorations are of high strength and they are ve- Because of various requirements in material thick-
neered with the compatible feldspathic porcelain. ness for different ceramics, the preparation design
In-Ceram Spinell is a spinel core (an oxide of mag- should follow manufacturers' recommendations
nesium and aluminum), which is weaker but more very closely. The use of rounded external and in-
translucent than the alumina core and is recom- ternal lines with deep chamfer or rounded shoul-
mended for esthetically challenging, single-unit der margins has been suggested': these should be
anterior restorations. The latest development was located in enamel. The most predictable situation
the In-Ceram Zirconia. The addition of partially for indirect ceramic inlays is Class I and II defects,^"

QDT 2001
 BLATZ

Table 1 Long-Term Clinical Success Rates of Ceramic Inlays and Onlays

No. of Observation
Study Material restorations period (y) Survival rate {%)

Feldenetal 1998^° Various 287 7 9 8 ' inlays

56* partial ceramic crowns
Van Dijken et al Mirage 115 6 88 cemented with dual-cure composite
1998" 74 cemented with glass-ionomer cement
Hayashietal 1998" Fired ceramics 49 6 92'
Fuzzi and Rappelli Fired ceramic 182 5.9 95
1999"
Roulet1997» Dicor 127 6 76'
Reiss and Walther Cerec 1011 6.6 91.3
1991«
Mörmann end Krejci Vita porcelain 8 5 100
1992" Mark 1 (Cerec)
Hofmann et al Cerec 59 5 90
1995"
Pallesen 1996'* Vita porcelain 16 6 91
Mark II (Cerec)
Dicor IVICG 16
Berg and Dérand Vita porcelain 115 5 97
1997" (Cerec)
5jögren é t a l Cerec 66 5 94 cemented with chemical-cure composite
1998^° 85 cemented with dual-cure composite
Studeretal 1998" IPS Empress 163 6 93 ;

'Estimate for sun/ival (Kapla n-Meier analysis}.

Because of the development of stronger and ramic inlay restorations. Fuzzi and Rappelli^^ ob-
better materials, new techniques, and an increas- served a success rate of 95% after an average of
ing demand, numerous papers on the clinical 5.9 years with inlays made of fired ceramics.
short-term success of ceramic inlays and onlays
have been published recently. However, the num-
ber of clinical studies on the long-term success of Castab/e Ceramics
such restorations with a specific material is small.
After a ó-year follow-up, Roulet^" observed a 90%
survival rate with 127 Dicor inlays.
Conventional Powder Slurry Ceramics

Van Dijken et al^' reported a failure rate of 12% Machinable Ceramics

after 6 years for Mirage inlays cemented with
dual-cure cement. Significantly higher failure rates Different long-term studies on the Cerec system
were observed when conventional glass-ionomer have reported success rates of between 9 1 % and
cement or light-cured composite resin was used 100% after observation periods of between 5 and
for cementation. Hayashi et al^^ estimated a 92% 6.6 years.^^^° In an intraindividual 5-year compari-
success rate after 6 years of evaluation of fired ce- son, a failure rate of 6% for inlays luted with a

1 QDT 2001
 All-Ceramic Posterior Restorations

chemical-cured resin composite and 15% for in-

lays luted with dual-cured resin composite cement I LONG-TERM SUCCESS OF POSTERIOR
ALL-CERAMIC CROWNS
was shown.^° Reiss and Walther^- reported higher
failure rates for inlays placed in molars compared The first report of the use of an all-ceramic crown
to premolars and for restorations placed in en- dates back to 1903,^^ The need for improved
dodontically treated teeth. strength and esthetics led to the development of
an aluminous porcelain core material that was ve-
neered with conventional porcelain," Only with
Pressab/e Ceramics the invention of a reinforced microstructure for
glass ceramics, eg, leucite, alumina, zirconia, was
Studer et al-' observed a 7% failure rate after 6 it possible to fabricate all-ceramic full-coverage
years with IPS Empress inlays. crowns strong enough for use in the posterior re-
Table 1 summarizes the results of long-term gions of the mouth, where they must withstand in-
studies on ceramic inlays and onlays. creased occiusal forces. Preparation designs must
follow manufacturers' instructions in order to pro-
vide adequate reduction and sufficient space ac-
Case 7 cording to the needs of the material. With many
systems, tooth reduction has to be more aggres-
A young patient presented with failing amalgam sive in comparison to conventional PFM restora-
restorations and ceramic inlays in her maxillary first tions. Long-term clinical trials are rare. However,
molars (Figs la to 1c), The mandibular first molars because of the many short-term studies published
had extensive carious lesions under existing recently, results of observations of 5 years or
restorations (Figs 2a to 2c), After excavation and longer should be available soon.
restoration with composite resin as a base mater-
ial, preparations for ceramic inlays and onlays were
made, and the final impression was made (Figs 3 Ccynventional Powder Slurry Ceramics
and 4) using a polyether-based impression mater-
ial (Permadyne, ESPE, Bad Seefeld, Germany), In- In 1983, McLean" published results of a study
lays and onlays were made of IPS Empress and in- with 679 aluminous ceramic crowns. Seven years
serted with Variolink II (Vivadent, Schaan, of observation showed success rates of between
Liechtenstein) dual-cure cement (Figs 5 and 6). 84.8% and 97,9%, depending on the location in
the mouth, Hankinson and Cappetta^' found that
after 5 years in function, 24,0% molar and 2.3%
Case 2 premolar crowns made of leucite-reinforced
porcelain {Optec HSP) had fractured.
Figure 7 presents failing composite restorations in
the maxillary right second molar to the right first
premolar and the left second premolar to the left Castafa/e Ceramics
second molar. Following the removal of the failing
restorations, preparations, and final impression Erpenstein et aP^ reported a failure rate of 30%
with Permadyne (Fig 8), IPS Empress inlays were after 7 years of following Dicor full-coverage
fabricated [Figs 9a and 9b). Adhesive bonding crowns in posterior regions. After a 14-year obser-
techniques require proper moisture control, which vation of 1,444 Dicor crowns, Malament and
a rubber dam can achieve (Figs 10a and 10b), The Socransky^' obtained an 87% overall success rate.
restorations were bonded with a dual-cure cement Survivor function at 14 years ranged between
(Fig 11), 79,5% and 96.3% for premolar crowns and

QDT 2001
F
CASE 1 (Figs 1 to 6)

Figs la to 1c Preoperative maxillary

view demonstrates open margins on
ceramic onlay and secondary caries
under amalgam restoration.

Figs 2a to 2c Preoperative occlusa I

view demonstrates occlusal lesion anc
extensive carious lesion around com-
posite inlay.

Figs 3a to 3c Occlusal view of prepa-

rations and final impression of maxil-
lary molars.
 All-Ceramic Posterior Restorations

Figs 4a to 4c Occlusai view of prepa-

rations and final impression of
mandibular molars.

Figs 5a to 5c Postoperative maxillary

occlusai view of bonded all-ceramic
inlay and onlay.

Figs 6a to 6c Postoperative
mandibular occlusa! view of bonded
all-ceramic inlay and onlay. {Ce-
ramist—H. Liebetanz, CDT, Freiburg,
Germany,)
p BLATZ

{Figs 7 to 11)

Fig 7 Preoperative occlusal view

of failing composite resin
restorations in the maxillary right
second molar to the right first
premolar and the left second
premolar to the left second
molar.

Fig 8 Final impression.

Figs 9a and 9b Occlusal view of

completed restorations on un-
sectioned cast.

between 48.3% and 74.1% for molar crowns. Acid CAD/CAM Ceramics
etching of Dicor crowns resulted in significantly
better clinical success. As with ceramic inlays and Excellent success rates with Procera AllCerarr
onlays, proper application of adhesive bonding crowns were reported by Oden et al.^* Succès;
techniques does significantly improve the fracture rates ranged between 93% and 100% after í
resistance of Dicor all-ceramic crowns, whereas the years of function.
type of preparation finish line seems to have no
significant influence on their clinical performance."

iQDT 2001
 All-Ceramic Posterior Restorations I

Figs 10a and 10b Occlusal view

of preparations prior to bonding
of final restorations.

Fig 11 Postoperative occlusal

view. (Ceramist—F. Ferraresso,
CDT, Freiburg, Germany.)

Pressable Ceramics Case 3

In all areas of the mouth, 1Ó8 Empress crowns had The mandibular left first molar of a 20-year-old
a total of 88.4% success in an abstract published patient was endodontically treated and built up
by Lehner et al.^' Crowns on canines had the high- with composite resin (Fig 12). The tooth was pre-
est incidence of failure. pared according to manufacturers' recommenda-
Table 2 summarizes the results of studies on all- tions to obtain sufficient space and adequate
ceramic crowns in posterior regions. preparation design for an all-ceramic restoration

QDT 2001
 BLATZ

Table 2 Long-Term Clinical Success Rates of All-Ceramic Crowns in Posterior Regions

No, of Observation
Study Material restorations period (y) Survival rate '•*•)
McLean 1983" Alumina 679 total 7 84.8 molars
93.6 premo ars
97,9 incisors
Hankinson and Optec HSP 159 total 5 76 molars
Cappetta 1994" 97,7 premolars
100 incisors/canines
Erpenstein et a 2000-'^ Dicor 173 total 7 70,0 molars/premolars
82.7 incisors/canines
' Malament and Dicor 1444 14 48,3-74,1* molars
• Socransky 1999^' 79,5-96,3* premo ars
80.6-100* incisors/canines
Oden et si 1998^ Procera AllCeram 97 tota 5 93 molars
96 premo ars
100 inciscrs/canines
; iLehnereta 1998" Empress 1Ó8 total 6 88.4 total
'Estimate for îuruival (Kaplan-Meier ana

(Fig 13), An all-ceramic crown (IPS Empress) was LONGEVITY DF ALTERNATIVE MATERIALS
fabricated (Fig 14) and adhesively cemented with FOR POSTERIOR RESTORATIONS
chemically curing composite resin cement (Figs
15a and 15b), Amalgam

Depending on the extent and location of a de-

LONG-TERM SUCCESS OF ALL-CERAMIC fect, amalgam has been the restorative material
MULTIPLE-UNIT FIXED PARTIAL of choice for more than 100 years, especially in
DENTURES Class I and II defects, A large number of long-
term studies have documented excellent long-
The vision of applying the all-ceramic concept to term success rates of between 87,4% and 95,8%
the area of fixed partial dentures to replace miss- for observation times of 5 to 20 years.'^ In a com-
ing teeth has always existed. From a mechanical parative clinical investigation, Roulet^" estimated
standpoint, its realisation was only possible with success rates after 6 years of 7ó% for Dicor inlays
new ceramic materials of very high strength, and 87% for amalgam restorations (control
which was evaluated in countless in vitro investi- group). The difference was not statistically signifi-
gations. Recently, some clinical trials on the short- cant. Even t h o u g h amalgam has excellent
term performance of all-ceramic fixed partial den- longevity and physical properties, its use is be-
tures were p u b l i s h e d , but no long-term coming more and more controversial due to es-
observations could be found. Results of those thetic and environmental concerns.
short-term studies show acceptable clinical suc-
cess rates, especially in the anterior regions."*'"' It
was emphasized, though, that the performance of Composite Resins
such bridges highly depends on the dimensions
of the connector areas and that it is crucial to fol- Wear characteristics and polymerization shrink-
low manufacturers' recommendations closely. age of composite resin materials, which affect
 All-Ceramic Posterior Restorations I

CASE 3 (Figs 12 to 15)

Fig 12 Preoperative view of mandibular left first

molar presents a buildup of the endodonticaliy
treated tooth prior to preparation for full-coverage
restoration.

Fig 13 Occlusal view of preparation.

Fig 14 Completed all-ceramic restoration on the

master cast.

Figs 15a and 15b Postoperative occlusal view,

(Ceramist—J. Kern, MDT, Bötzingen, Germany.)

QDT 2001
BLATZ

Fig 16a Preoperative view of fail- Fig 16c Postoperative view of d

ing amalgam restoration. rect composite restoration.

marginal behavior, have always been problematic It can be concluded that composite resin is the
for their application in premolar and molar areas. material of choice for Class I restorations if materi-
The introduction of new materials, such as highly pals and techniques are applied properly. An ex-
filled small-partide-size hybrid composites, and ample is given in a clinical case [Figs loa to lóc). A
advanced application techniques seemed to min- failing amalgam restoration was replaced with a di-
imize these problems. Welbury et al" showed rect composite resin restoration (Renamel, Cosme-
that minimal composite restorations in molars dent, Chicago, IL, USA). For Class II restorations,
performed after 5 years as well as amalgam fill- composite materials are more difficult to handle.
ings, but occupied an average of only 5% of oc-
clusai tooth surface compared to the 25% that
the amalgam occupied. Long-term studies--^' in- Cast-Gold Restorations
dicate relatively high success rates. Posterior
composite restorations were considered success- Conflicting results" on the longevity of cast-gold
ful after 10 years (84% success)"" and 17 years restorations range from success rates of 51% after
(77% success}." 6 years^" to 9 1 % after 10 years." Following 2,717
It is claimed that with indirect composite in- cast-gold inlay/onlay restorations for 10 years,
lays, wear resistance and marginal behavior can Fritz et al^* published survival rates of 70% for on-
be improved. Different techniques have been in- lays, 68% for mesio-occlusodistal inlays, and 60%
troduced to fabricate such inlays either in the for mesio-occlusal or occlusodistal inlays. Presem
laboratory or chairside, where the inlay is pre- and Strub" found similar results. A comparative
formed in the patient's mouth, polymerized in an study reported a median survival time of 20 years
extraoral curing unit, and cemented in the same for gold inlays and 12 to 14 years for amalgam
appointment. Long-term evaluations™'^' are rare, restorations.=' Westermann et al=' compared the
and a short-term clinical trial showed no or only performance of extensive amalgam fillings to cast-
minimal advantage over direct c o m p o s i t e gold crowns. After 8 years of service, about 50%
restorations." Compared to the longevity of ce- of the extensive amalgam fillings but only 12% of
ramic inlays, composite inlays are reported to be the crowns failed. Recently, Studer et a l " pub-
inferior.''^ lished a study on the long-term survival of cast-
 All-Ceramic Posterior Restorations I

gold inlays and onlays. The success rate was demanding insertion techniques. Despite poor
86.2% after a mean observation time of 18,7 performance in the beginning, some of the newer
years. Estimated Kaplan-Meier survival rates were all-ceramic crown systems offer acceptable clinical
96.1% at 10 years, 87,0% at 20 years, and 73.5% results, but to date, no clinical trials of 5 years or
at 30 years. Clinical data can differ tremendously, longer are available on the performance of all-ce-
and results seem to depend highly on the clinical ramic multiple-unit fixed partial dentures. Never-
setting, inclusion criteria, and experience of the theless, many all-ceramic systems have been in-
clinician. troduced to the market lately without this proof of
long-term clinical performance. Conventional
treatment options like PFM restorations have a
PFM Restorations long history, and their success has been extremely
well documented over long periods. Unfortu-
The number of published articles on clinical long- nately, most of the studies published on both op-
term survival of PFM crowns and bridges is high. tions are retrospective observations with poor
Success rates reported by different authors on study designs. In order for one to recommend any
fixed restorations vary between 77% and 99.5% technique or material for routine use in private
for 5 to 20 years.*" Kerschbaum and Gaa'° exam- practice or dental laboratories, controlled, ran-
ined 4,370 single crowns and 1,666 fixed partial domized, prospective, clinical long-term trials are
dentures {PFM and cast gold) after 8 years. Suc- necessary.
cess rates were 86,7% for crowns and 90.6% for
bridges. After 10 years, success rates for PFM
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34. Hankinson JA, Cappetta EG. Five years' clinical experi-
Int 1991:22:823-829.
ence with a leucite-reinforced porcelain crown system. Int
17. Lu R, Hartcourt JK, Tyas MJ. Alexander B. An investiga- J Periodontics Restorative Dent 1994:14:138-153.
tion of the composite resin/porcelain interface. Aust Dent
35. Erpenstem H, Borchard R, Kerschbaurn T Long-term clini-
J 1992;37:12-19. cal results of galvano-ceramic and glass-ceramic individ-
18. Kern M, Thompson VP. Bonding to glass infiltrated alu- ual crowns J Prosthet Dent 2000:83:530-534.
miria ceramic: Adhesive methods and their durability. J 36. Malament KA, Socransky SS. Survival of Dicor glass-ce-
Prosthet Dent 1995;73:240-249. ramic dental restorations over 14 years. Part I: Survival of
19. Kern M, Wegner SM. Bonding to îirconia ceramic: Adhe- Dicor complete coverage restorations and effect of inter-
sion methods and their durability. Dent Mater nal surface etching, tooth position, gender and age. J
1998:14-64-71. Prosthet Dent 1999:91:23-32
20. Felden A, Schmalz G, Federlm M, Hiller KA. Retrospective 37. Bernai G. Jones RM, Brown DT, Muño; GA, Goodacre CJ.
clinical investigation and survival analysis on ceramic in- The effect of finish line form and luting agent on the
lays and partial ceramic crowns: Results up to 7 years, breaking strength of Dicor crowns. Int J Prosthodont
din Qral Invest 1998:2:161-167. 1993:6:286-290.
21. van Dijken JWV, Höglund-Aberg C, Olofsson AL Fired ce- 38. Oden A, Andersson M, Krystek-Ondracek I, Magnusson
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1998;26:219-225. crowns. J Prosthet Dent 1998:80:450-456.
22. Hayashi M, Tsuchitani Y, Miura M, Takshige F, Ebisu S. 6- 39. Lehner G, Studer S, Scharer P Seven-year results of
year clinical evaluation of fired ceramic inlays. Oper Dent leucite reinforced glass ceramic crowns (abstr 1368J. J
1998:23:318-326. Dent Res 1998:77:802.
23. Fuizi M, Rappelli G. Ceramic inlays: Clinical assessment 40. Sorensen JA, Kang SK, Torres TJ, Knode H. In-Geram
and survivalrate. J Adiesive Dent 1999,1:71-79 fixed partial dentures: Three year clinical trial results. J
Calif Dent Assoc 1998:26:207-214.
24. Roulet J-F Longevity of glass-ceramic inlays and amal-
gam—Results up to 6 years. Clin Oral Invest 41. Sorensen JA, Cru2 M, Mito WT. Raffeiner Q, Meredith HR,
Foser HP A clinical investigation on three-unit fixed par-
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tial dentures fabricated with a lithium disilicate glass-ce-
25. Reiss B. Walther W. Überlebensanalyse und klinische ramic. Pract Periodontics Aesthet Dent 1999:11:95-106.
Nachuntersuchungen von zahnfarbenen Einlagefüllungen
42. Roulet J-F. Benefits and disadvantages of tooth-coloured
nach dem Cerec-Verfahren. Zahnarztl Welt
alternatives to amalgam. J Dent 1997;25:459-473.
1991:100:329-332.
43. Welbury RR, Walls AW, Murray JJ, McCabe JF. The fnan-
26. Mörmann WH, Krejci ;. Computer-designed inlays after 5
agement of occlusal caries in permanent molars. A 5-year
years in situ: Clinical performance and scanning electron clinical trial comparing a minimal composite with an amal-
microscopic evaluation. Quintessence Int gam restoration. Br Dent J 1990:169:361-366.
1992:23:109-115.
44. Bams DN, Blank LW, Thompson VP, Holston AM, Gingell
27. Hofmann N, Popp M, Klaiber B. Klinische und rasterelek- JC. A 5- and 8-year clinical evaluation of a posterior com-
tronenmikroskopische Nachuntersuchung von Gerec-in- posite resin. Quintessence Int 1991:22:143-151.
lays nach fünf Jahren Üegedauer Dtsch Zahnarztl Z
45. Wilson NHF Wilson MA, Wastell DG, Smith GA. Perfor-
1995:50:835-839. mance of Occlusin in butt-joined and bevel-edged prepa-
28. Pallesen U. Glinical evaluation of CAD/GAM ceramic rations' Five-year results. Dent Mater 1991:7:92-98.
restorations: 6-year report. In: Mörmann WH (ed). 46. Fukushima M, Setcos JG, Iwaku M. Posterior composite
CAD/CAM in Aesthetic Dentistry. Proceedings of the restoration failures in five-year clinical studies [abstr 792j.
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sence, 1996:241-253. 47. Gangler P, Hozer I, Langer K, Montag R. Surface micro-
29. Berg NG, Dérand T. A 5-year evaluation of ceramic inlays morphology of posterior GlC/composite restorations after
(Gerec¡. Swed Dent J 1997;21:121-127. six years labstr â30j. J Dent Res 1994;73:180.
 All-Ceramic Posterior Restorations I

48, Pallesen Ü, Quist V, Clinical evaluation of three posterior 56. Friti Ü, Fischbach H, Harke I. Langzeitverweildauer von
composite resins: 10 year report |abstr 30]. J Dent Res Goldgussfullungen. Dtsch Zahnarztl Zeitschr
1995:74:404. 1992:47:714-716,
49, Wilder AD, May KN, Bayne SC, Taylor DF, Leinfelder KF, 57. Presern ZF, Strub JR, Inlays versus onlay. Eine klinische
17-year clinical evaluation of UV-cured composite resins und röntgenologische Nachuntersuchung. Schweiz
in posterior teeth labstr 21601. J Dent Res 1996;75:290, Monatsschr Zahnmed 1983:93:154-162.
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2000;27:461-472. 62. Leempoel PJB, Eschen S, De Haan AFJ, Van't Hof MA, An
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55, Bentley C, Drake CN. Longevity of restorations in a dental sive amalgams and posterior crowns. J Dent
school clinic, J Dent Educ 1986:50:594-000. 1997:25:225-227.

QDT 2001
 Predetermining Factors Governing Calculated Tooth
Preparation for Anterior Crowns

Irfan Ahmad, BDS'

his article focuses on a number of scien- crowns. Following this discussion, a clinical case is
tific, research-based parameters govern- presented, applying theory to a practical situation.
ing anterior t o o t h preparation tech- An anterior prosthesis, similar to other dental
niques. Depending on the clinical situation, a restorations, is essentially a fusion of two dis-
variety of anterior crowns are advocated. These parate materials to form a single structure. This in-
include porcelain fused to metal, electroformed, tegration betvi/een biologic (tooth) and synthetic
all ceramic (with or without ceramic cores), and (restoration) components aims to repair or en-
the recently introduced polyglass materials (part hance a compromised dentition. Routinely, clini-
ceramic, part composite). Admittedly, there are cians are faced with a combination of treating
minor differences in preparation designs depend- decay and/or improving esthetics, both of which
ing on the type of final restoration, but the rules initially involve altering remaining tooth structure
governing tooth preparation, ie, biologic, me- to achieve a therapeutic goal. Any reconstructive
chanical, and esthetic,' still apply. The purpose of process inflicts some destruction for the attain-
this article is to emphasize a scientific basis for a ment of improved form and function, and tooth
universal tooth preparation protocol for anterior preparation is no exception. However, minimizing
biologic violation results in minimizing iatrogenic
insult, allowing a rapid recovery and ensuring
longevity of the restoration. Unfortunately, tooth
preparation is not always dictated by scientific
principles, but rather by a variety of factors. These
'Private Practice, North Harrow, Middlesex, United Kingdom. include recommendations by peers, advertise-
Reprint requests: Dr Irfan Ahmad, The Ridgeway Dental ments in journals, or a proprietary pitch for a par-
Surgery, 1 73 The Ridgeway, North Harrow, Middlesex, HA2
ticular product. Though meant sardonically, this
7DF, United Kingdom. Fax: + 44 20 8361 2517,
E-mail: [email protected] state of affairs is not too far from the truth.

QDT 2001
AHMAD

Fig 1 Midfacial dentogingival

complex measurement with a peri-
odontal probe. The linear measure-
ment is 2.0 mm, indicative of a
shallow sulcus and a high osseous
crest.

Fig 2 Mesial dentogingival com-

plex measurement with a peri-
odontai probe. The linear measure-
ment is 2.5 mm, indicative of a
shallow sulcus and high osseous
crest.

Fig 3 Distal dentogingival com-

plex measurement with a peri-
odontal probe. The linear measure-
ment is 4,5 mm, indicative of a
deep sulcus and low osseous crest.

Fig 4 Atraumatic retraction cord

placement within gingival sulcus of
maxillary right central incisor.

• MARGIN LOCATION was termed the biologic width. Since its introduc-
tion, a biologic width of 2.04 mm has been ubiqui-
The location of the crown margin on a tooth is im- tously quoted, reported in dental journals, and in-
portant to avoid gingival recession^ and periodon- delibly ingrained in clinicians' minds. Three factors,
tal pockets,^ prevent chronic inflammation,' allow however, need elaboration. First, the quoted mea-
long-term monitoring of the tooth-restoration surements are averages, not applicable to all indi-
seal, satisfy esthetic demands, expedite oral hy- viduals, all teeth, or all sites on a specific tooth.
giene maintenance procedures, simplify impres- Second, biologic width is not directly visible and
sion making, and create a correct crown emer- must be conceptualized around each tooth. Finally,
gence profile.'^ Often, one factor will conflict with the sulcus depth (0,69 mm) was obtained from ca-
another; for example, ideal esthetics are achieved davers, while clinical depths range from 1 to 3 mm^
with a subgingival margin, but at the possible ex- depending on prevailing inflammation, probing
pense to access for adequate oral hygiene proce- force, and location on a given tooth.
dures. The predominant consideration regarding It therefore becomes apparent that the greatest
crown margin location is the biologic width. variance in the dentogingival complex is that of
Ingber et al* coined the term biologic width in sulcus depth, while the least is that of the biologic
1977 based on original research by Gargiulo et al width.' Consequently, to accurately ascertain the
in 1961.' The concept of the biologic width envi- depth of the sulcus, it is prudent to measure the
sioned by the latter authors, based on autopsy and entire dentogingival length and deduct 2 mm (for
histologie findings, was a mean sulcus depth of the biologic width). As stated earlier, the length
0.69 mm, a junctional epithelial attachment of 0.97 from the free gingival margin to the alveolar crest
mm, and a connective tissue attachment from the varies depending on the site where it is measured.
cementoenamel junction to alveolar crest of 1,07 For example, at the midfacial aspect of a maxillary
mm. The sum of linear measurements for junc- incisor the measurement is typically 3 mm, while
tional epithelium and connective tissue (2.04 mm) interproximally it is 4.5 mm.'" At the midfacial as-
 Tooth Preparation for Anterior Crowns I

pect the sulcus depth would be 1 mm (indicative ing precedence, ie, esthetic, mechanical proper-
of a normal osseous crest height), while interproxi- ties of material, and fabrication or preparation
maliy it increases to 2.5 mm (indicative of a low considerations.
osseous crest height). A dentogingival complex of Several of the most popular designs are the
less than 3 mm implies a high osseous crest and a knife edge, shoulder, and chamfer (Figs 5 to 7).
shallow sulcus, ie, less than 1 mm (Figs 1 to 3). Marginal integrity in terms of opening at the tooth-
Crown margins can be placed supragingival, crown interface has varying clinical acceptance,
equigingival, or subgingival. When the patient has with reports citing discrepancies of 120 |jm," 100
a low upper lip line, the ideal choice is supra- or jjm,'^ and 50 |jm,'^ The knife-edge design with an
equigingival. With a high lip line and gingival ex- opening of 135 pm'" fails even the most lax ac-
posure during a smile, subgingival placement be- ceptability standards of 120 |jm, making its appli-
comes a necessity for optimal esthetics. As a gen- cation questionable. Additionally, the lack of tooth
eralization, intracrevicular margins should be reduction with this design can result in both verti-
placed at approximately half the width of the cal and horizontal overcontouring of the restora-
crevice depth. Aiming to place a margin at half tion, leading to changes in the bacterial flora with
the depth of the sulcus gives a degree of latitude ensuing chronic inflammation and attachment loss
so that, should the preparation inadvertently devi- of the surrounding periodontal ligament,"^
ate from the ideal, the additional depth still pre- The shouldered preparation also shows diver-
vents impingement into the epithelial attachment sity in geometry, with axiogingival angles of 90
part of the biologic width. Additionally, placing and 120 degrees. In a study using finite element
margins halfway in the crevice leaves sufficient analysis to ascertain total strain of porcelain
space for gingival cord placement, which acts as a stresses on shoulders of 90-degree, 120-degree,
buffer zone between the epithelial attachment and chamfer preparations, the latter showed the
and the bur {Fig 4-), most resilience." While limited in its conclusions,
Pitfalls to avoid are in the interproximal region this study does question the conventional teach-
where sulcular depth is generous (> 2,5 mm). ing of using shoulders when porcelain contacts
Margins could be placed deeper than at the mid- the prepared tooth margin. Other benefits of a
facial aspect, but this practice may result in chamfer finish line include a marginal opening of
"black triangles" due to interproximal recession, 68 |jm, facilitating scanning devices for computer-
leading to a compromise in "pink esthetics," aided design/manufacturing (CAD/CAM) copings,
Therefore, it is wiser to prepare a tooth mimick- expediting crown preparation," and preserving
ing the gingival scallop around its circumference more natural tooth in comparison to a 90-degree
at a fixed predetermined level. The second point shoulder (Figs 8 and 9). Also, a chamfer is estheti-
to observe isthat not only crown margins but also cally better than a shoulder since there is a grad-
other artifacts should be prevented from being ual color transition between the restoration and
introduced beyond the sulcus depth. These in- tooth substrate, avoiding an abrupt delineation
clude retraction cord, temporary or permanent between tooth and crown (Figs 10 and 11).'°
cement, as well as rotary or hand instruments for Finally, removal of serrated, overhanging
excess cement removal. enamel prisms, or the "enamel lip," is requisite to
obtaining a distinct and visible finish line. The ar-
mamentarium employed for this task includes
• MARGIN GEOMETRY enamel trimmers (hand instruments) and rotary
and reciprocating diamond tips. The smoothest
A variety of margin designs have been proposed finish line has been shown to be achieved by
and used for all-ceramic and bonded crowns. using diamond tips of progressively finer grits in a
Opinions are divided depending on the factor tak- reciprocating handpiece (Fig 12),"
 Fig 5 Knife-edge ma.g Fig 6 Ninety-degree shoulder Fig 7 Chamfer margin.
margin.

Fig 8 Curvaceous outline of a

chamfer preparation facilitates
CAD/CAM scanning of the stone
die (viewed by white light).

Fig 9 Curvaceous outline of a

chamfer preparation facilitates
CAD/CAM scanning of the stone
die {viewed by ultraviolet light).

Fig 10 Stone die of a 90-degree Fig 11 Stone die of a chamfer Fig 12 Enamei lip foiiowing tooth
shoulder preparation with crown preparation vuith crown outline preparation (left side) can be re-
outline shows an abrupt transition shows a gradual transition betvveen moved with diamond tips in a reci-
between crown and tooth margins. crown and tooth margins procating handpiece (right side).

3 QDT 2001
 Tooth Preparation for Anterior Crowns

P PREPARATION DESIGN The proverbial 1,5-mm reduction for porcelain-

fused-to-metal crowns is based on a 0,5-mm re-
The retention, resistance, and convergence taper duction for metal substructures and a 1-mm re-
triad influences tooth preparation design. Reten- duction for veneering porcelain. Structurally, a
tion is resistance to displacement along the path thinner labial porcelain shoulder {less than 1 mm)
of insertion of a restoration, ie, the force needed is better suited to withstand tensile stresses for
to remove a prosthesis. While retention has been both labially and palatally angled loads," Other
demonstrated to have a linear relationship to studies have further concluded that a thicker
preparation diameter and height,^°-^' it is less rep- porcelain layer has no effect on fracture resistance
resentative of forces generated in the oral envi- or longevity of crowns,^"•^^ Consequently, the rec-
ronment compared to resistance. Masticatory and ommended reduction (1,5 mm) is purely to obtain
parafunctional force vectors encountered are lat- depth of color to achieve the desired esthetics.
eral in nature, ranging from buccolingual to occlu-
sogingival to linguobuccal, and cause fatigue, de-
fined as cyclic loading over a period of time. MAINTENANCE OF DENTAL HARD TISSUE
Counterbalancing fatigue and improving the long- INTEGRITY
term success of a prosthesis are dependent on
the resistance, as opposed to retention form, of Tooth preparation, particularly for cosmetic rea-
an abutment tooth. Resistance also demonstrates sons, is essentially an assault on healthy tissue to
a linear relationship to the height or diameter of achieve a desired result. While in the majority of
tooth preparation. Additionally, variance of resis- cases the ends justify the means, precautions are
tance to fracture is dependent on the cement uti- necessary to reduce damage to the t o o t h
lized. For example, composite resin cement has (enamel, dentin, and pulp). Amount of tooth re-
three times the resistance of zinc-phosphate ce- duction is dictated by parameters such as esthet-
ment. ^^ Furthermore, using dentin bonding helps ics, obtaining a minimum thickness to avoid com-
to transfer occiusal and masticatory loads to the promising strength of the restorative material,
underlying tooth substrate.^^ occlusion, and pulp chamber size.
A 6-degree taper on each proximal wall, mak- Various studies have reported nonvitality of
ing a total convergence angle of 12 degrees, is teeth restored with artificial crowns.""™ Causes for
regarded as the standard norm,^" The total oc- nonvitality can be a dentin wound, dehydration of
ciusal convergence of the preparation shows a dentin, and temperature elevation during prepa-
linear,^^ as opposed to exponential, relationship ration stages. Thermal shock to the pulp is depen-
to resistance to dynamic lateral loading. There- dent on pulpal dimensions and size, amount of
fore, varying the convergence angle by ± 10 de- dentin calcification, and preparation techniques.
grees will increase or decrease resistance by 5% The first two factors are uncontrollable but should
to 10%, Additionally, taper has a bearing on the be visualized radiographically before preparation
compressive strength of the cement layer, A is initiated. The last factor is primarily operator de-
gradual taper exaggeration will progressively termined and can impact the vitality of a tooth.
cause the cement area under compression to While using coarser grit-sized diamond burs is
tend toward zero." Notice that the cement com- procedurally expedient, it does produce elevated
pression is progressive and does not exhibit a temperatures within the pulp chamber. For exam-
given cutoff point, or "limiting taper," depending ple, a 1 50-|jm diamond grit bur produces temper-
on the convergence angle," Therefore, although atures of 40.5°C (equivalent to a temperature in-
a taper increase will decrease resistance, there is crease of 3,2°C), precariously close to the critical
no finite total convergence angle below which limit of 41.5°C for pulpal necrosis. On the other
cement failure is inevitable. hand, a fine diamond of 30-|jm grit causes an in-

QDT 2001
 AHMAD

Fig 13a Using diamond burs of

coarse grits results in a rough sur-
face finish with microscopic enamel
cracks.

Fig 13b Completing the prepara-

tion with a tungsten carbide finish-
ing bur produces a smoother sur-
face finish with enhanced enamel
margin integrity.

trapulpal temperature increase of 2.5°C. Other are potential microundercuts causing failure in
culprits of temperature increase are increased complete seating of a restoration, inaccurate cast-
grinding time, relentless grinding, increased bur ings when a lost-wax technique is employed, and
pressure, lack of hydraulic cooling, and a cooling trapping air within the cement layer. Conversely,
water temperature in excess of 32°C. Finally, as excessively smooth surfaces may cause restoration
the dentin layer decreases with progressive stages dislodgment with traditional nonadhesive ce-
of tooth preparation, its heat absorption capacity ments. Considering the above points and the dis-
also diminishes. Therefore, in the final stages of cussion relating to increased temperature and
preparation it is prudent to use burs of finer grits, enamel subsurface damage with coarser grits, it is
as these cause less temperature elevation than probably better to veer toward a smoother prepa-
those of coarser grits.^' ration surface finish.
Another reason for sparingly using coarser dia-
monds is that the latter cause enamel cracks at
the preparation margins, resulting in reduced H CUTTING EFFICIENCY
enamel toughness. This inevitably lessens resis-
tance to crack propagation within the enamel. The cutting efficiency is dependent on a myriad
This problem is overcome by using diamonds of number of factors, including type of biologic or
progressively finer grits to remove the median- restorative material to be cut (ceramic, cast metal,
type cracks and microcracks between and within or resin composite, etc), operator kinesthetic
enamel rods, respectively. Adopting this protocol sense, handpiece speed, and rugosity and quality
means that the resultant preparation margins are of a rotary instrument. The belief that coarser-grit
stronger and have fewer cracks (Fig 13),^ diamond burs (> 150 ^im) are more efficacious is
The final surface roughness of the preparation fallacious, A recent study reports that there is in
has also been a topic of debate in the dental liter- fact no Increase in cutting efficiency using coarser
ature. While some studies have shown little vari- grits as compared to medium grits (100 |jm),^° The
ance in retentive forces between rough and force applied on the handpiece during prepara-
smooth preparations,""^' others have shown tion is another point of contention. Using light
greater retention when a tooth surface is prepared pressure tends to smooth a surface, while exces-
with coarser diamond stones,^°^' Roughness, mea- sive force can cause pulpal damage. Furthermore,
sured in terms of R^, of a 120-|jm diamond bur is increasing the handpiece load is self-limiting; be-
6,8 [jm, while that for a tungsten carbide finishing yond the normal clinical range of loads between
bur is 1.2 |jm. Disadvantages of a rougher surface 50 and 150 g,^' little improvement in cutting effi-

QDT 2001
 Tooth Preparation for Anterior Crowns I

Table 1 Factors Determining Tooth Preparation

Factor Protocol
Crown margin placement Dependent on varying sulcus depth;
ideally placed at half prevailing sulcus depth
Margin geometry Chamfer ^ ^
Preparation design 1 12-degree convergence angle
2. Maximize preparation height and
diameter
3. Minimize tooth reduction depending on
type of final crown
4. Use composite resin as luting cement
5. Mean reductions: PFM crown = 1.5 mm,
alt-ceramic crown = 1.3 mm
Dental tissue integrity 1. Determine size and location of pulp
2, Determine degree of calcification
3, Avoid using ultra-coarse burs
4, Use a water cooling temperature below
32°C
5. Prepare tooth in intervals to allow
cooling of tooth
6. Ensure final preparation surface
roughness is smooth J ^
Cutting efficiency 1. Use diamond burs of medium grit
{< 150 Mm)
2. Avoid excessive handpiece pressure
3. Discard degraded, damaged, or debris-
soiled rotary instruments

ciency is observed. What seems pertinent is was evident due to a previous history of bulimia
degradation and debris accumulation of the bur, (Fig 16). The substantial gap between the central
factors that both decrease cutting efficiency.'" incisors dictated fixed orthodontic treatment.
Table 1 presents a synopsis of factors determining After 12 months, the space between the central
tooth preparation. incisors was reduced to 2 mm and the roots were
paralleled to reduce the distal flaring (Figs 17 to
19). The situation after bracket removal and pro-
• CLINICAL SEQUELAE OF TOOTH phylaxis is shown in Figs 20 and 21. All-ceramic
^ PREPARATION crowns were prescribed to reduce spacing and
create a more favorable width-length ratio of the
A 22-year-old man presented to the office re- anterior teeth. Furthermore, the increased width
questing elimination or reduction of blatant di- of the proposed crowns could minimize orthodon-
astemae in both arches. Due to financial con- tic relapse.
straints and the fact that his lower lip concealed Prior to tooth preparation, sulcus depths were
the mandibular anterior teeth, the patient's pri- determined to ensure intrasulcular margin place-
mary concern was correcting esthetics pertaining ment (see Figs 1 to 3). Retraction cord was atrau-
to the maxillary arch. Preoperatively, the maxillary matically introduced around the circumference of
median diastema measured 5 mm with distal flar- the maxillary right lateral incisor [Fig 22). Since the
ing of the central incisors (Figs 14 and 15). Addi- final restorations were to be all ceramic, a depth
tionally, palatal erosion of the maxillary incisors gauge of 1.3-mm diameter was used to create

QDT 2001
 AHMAD

Fig 14 Preoperative view shows Fig 15 initial maxillary median di- Fig 16 Palatal erosion of the max-
spacing in both arches and poor astenia of 5 mm with distal flaring illary incisors.
oral hygiene maintenance. of the central incisors.

Fig 17 Facial view of fixed ortho- Fig 18 Reduction of median I Fig 19 Palatal view of fixed ortho-
dontic appliance in situ to reposi- astema to 2 mm. dontic appliance in situ to reposi-
tion maxillary anterior segment. tion maxillary anterior segment.

grooves mesiodistally and incisogingivally (Figs 23 completed preparations had sinuous outlines and
and 24), Throughout the ensuing stages of buccal smooth surface roughness with enhanced enamel
and palatal reduction, cylindric, chamfer-shaped, structural integrity. Distinct interproximal gingival
1.3-mm-diameter burs (Meisinger, Dusseldorf, papillae and stippling were also discernible (Figs
Germany) were utilized to conform to the initial 31 and 32).
depth cuts. The first diamond employed was of a Using a new type of vinyl polysiloxane impres-
grit size between 125 and 150 |jm (green band; sion material (Flexitime, Heraeus Kulzer, Dorma-
below the cntical 150-(jm grit to avoid excessive gen, Germany) in which the setting reaction is
pulpal temperature elevation). This was followed manipulated by intraoral temperature, the defini-
by diamonds of grits between 90 and 120 |jm tive impression was made (Fig 33), Plaster casts
(blue band), 20 and 40 |jm (red band), and 12 and with crown outlines emphasized the precise
22 |jm (yellow band), and reduction was com- chamfer margins plus the relationship of the
pleted with a tungsten carbide finishing bur (Figs preparations to the ceramic crowns (Figs 34 to
25 to 29). A reciprocating diamond was passed 36), The dies were scanned and using CAD/CAM
around the preparation to remove the enamel lip. computer software. Procera (Nobel Biocare,
In the present case, little palatal preparation was Göteborg, Sweden) copings were fabricated and
deemed necessary due to the existing erosion. subsequently veneered with porcelain (Figs 37 to
However, when required, a similar protocol using 39), Preoperative and postoperative facial com-
elliptical burs of varying grits should be used for positions displayed the reduction of the median
palatal concavity reduction. The distinct 1.3-mm diastema and realignment of the maxillary in-
chamfer margins are clearly visible in Fig 30. The cisors (Figs 40 and 41),

1 QDT 2001
 Tooth Preparation for Anterior Crowns I

Fig 20 Orthodontic appliance re- Fig 21 CenirsI incisors following Fig 22 Retraction cord around
moval and prophylaxis to improve orthodontic repositioning are maxillary right lateral incisor to pro-
periodontal health. ready for tooth preparation. tect gingival margins.

Fig 23 Mesiodistal grooves of 1.3

mm in depth act as guides for pre-
cise tooth reduction.

Fig 24 Mesiodistal and incisogin-

gival grooves of 1.3 mm in depth
act as guides for precise tooth re-
duction.

Fig 25 Tooth reduction is initiated Fig 26 Tooth reduction is contin- Fig 27 Tooth reduction is contin-
with a cylindric, chamfer-shaped, ued with a bur of 90- to 120-|jm ued with a bur of 20- to 40-jjm grit
1.3-mm-diameter diamond bur of grit (blue band). (red band).
125-to 150-|jm grit (green band).

Fig 28 Tooth reduction is contin-

ued with a bur of 12- to 22-|jm grit
(yellow band).

Fig 29 Tooth reduction is com-

pleted With a cylindric, chamfer-
shaped, 1.3-mm tungsten carbide
bur.
 AHMAD

Fig 30 Distinct chamfer enamel Fig 31 Right lateral view shows fa- Fig 32 Left lateral view shows fa-
margins on maxillary incisors. vorable tissue reaction following vorable tissue reaction following
tooth preparations. Distinct inter- tooth preparations. Distinct inter-
dental papillae and gingival stip- dental papillae and gingival stip-
pling are evident. pling are evident.

Fig 33 Definitive impression using

Flexitime material.

Fig 34 Plaster cast of preparations

with sinuous outlines.

Fig 35 Plaster cast shows tooth Fig 36 Plaster cast shows tooth Fig 37 Facial view of completed
preparation-to-crown relationships preparation-to-crown relationships Procera crowns viewed by ultravio-
viewed by ultraviolet illumination. viewed by mixed white and ultravi- let illumination.
olet illumination.

Fig 38 Palatal view of completed

Procera crowns viewed by ultravio-
let illumination.

Fig 39 Completed crowns viewed

by ultraviolet illumination. Notice
that the margins of the Procera
copings accurately conform to the
chamfer tooth preparations.

QDT 2001
 Tooth Preparation for Anterior Crowns I

Fig 40 Preoperative facial composition Fig 41 Postoperative facial composition of fitted

maxillary median diastema. crowns with a reduced maxillary median diastema of
only 0.5 mm.

P CONCLUSION p REFERENCES

1. Dykema RW, Goodacre CJ, Phillips RW, Johnston's Mod-

Clinicians carrying out tooth preparations are
em Practice in Fixed Prosthodontics. Philadelphia: WB
faced with a challenge. On one hand, adequate Saunders, 1982:22,
tooth reduction is mandatory for achieving the de- 2. Orkin DA, ReddyJ, Bradshaw D. The relationship of the
position of crown margins to gingival health. J Prosthet
sired esthetics for patient satisfaction, while on
Dent 1987:57:421-424,
the other hand, biologic integrity is essential to 3. Lang NP Feriodontal considerations in prosthetic den-
ensure reduced tissue insult and longevity of the tistry. Periodontol 2000 1995:9:118-131.
restoration. Often a compromise is unavoidable; 4. Müller HP The effect of artificial crown margins at the gin-
gival margin on the penodontal condition in a group of
either esthetics or tissue integrity is sacrificed. penodontal supervised patients treated with fixed
However, in the majority of cases, following a bndges, J Clin Periodontol 19Bó:13'97-lO2.
sound scientific protocol can help to overcome 5. Bruchmann K5, Buns C-E, Marginal periodontium and the
location of the crown margin. J Multidisciplinary Collabo-
these shortcomings. This article has endeavored ration Prosthodont 1999;1:177-183.
to present theoretical concepts for tooth prepara- 6. IngberJS, Rose LF, Caslet JG. The biological width—A
tions and apply these principles to a clinical case concept in periodontics and restorative dentistry. Alpha
Omegan 1977;70:62-é>5.
study. With advances in dental technology and
7. Gargiulo AW, Wentz FM, Ofban B. Dimensions and rela-
material properties, these protocols will no doubt tions of the dentogingival junction in humans. J Periodon-
need modifications to keep pace with evolving toM961;32:321.
8. Kois JC. New paradigms for antenor tooth preparation.
dental esthetic techniques.
Rationale and technique. Oral Heath 1998;88:19-30.
9. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prostho-
dontics. Chicago. Quintessence, 1994.
10. Spear FM. Maintenance of the interdental papilla follow-
P ACKNOWLEDGMENTS ing anterior tooth removal, Pract Penodontics Aesthet
Dent 1999:11:21-23.
Research was provided by BDA academic iervices, London, 11. McLean JM, von Frauhofer JA. The estimation of cement
Clinical work, art direction, and photography were performed film thickness by an in vivo technique, Br Dent J
by the author. Laboratory work was performed by Ernst
1971:131:107-111.
Hegenbarth, Germany.
12. May KB, Russell MM, Razzoog ME, Lang BR, Precision of
ft: The Procera AllCeram crown, J Prosthet Dent
1998;80:394-404.

QDT 2001
 AHMAD

13. Weil AJ,GoodacreCJ, Moore BK, Dykema RW. A com- 27. Parker MH, Gunderson RB, Gardner FM, Calverley MJ.
parisori of lour techniques for fabricating ccllarless metal- Quantitative determination of taper adequate to provide
ceramic crowns, J Prosthet Dent 1985;S4;636-6d2. resistance form: Concept of limiting taper J Prosthet
14. Lin M-T, Sy-Muño2 J, Muñoz CA, Goodacre CJ, Naylor Dent 1988:59:281-288,
WP, The effect of tooth preparation form on the fit of Pro- 28. Malament KA, 5ocransl<y SS. Survival of Dicor glass-ce-
cera copings. IntJ Prosthodont 1 993;11:5aO-59O. ramic dental restorations over 14 years. Part II: Effect of
thickness of Dicor material and design of tooth prepara-
15. Lang NP, Kiel RA, Anderhalen K. Clinical and microbiolog-
tion. J Prosthet Dent 1999:81 :ó62-667,
ical effects of subgingival restorations with overhanging
or clinically perfect margins, J Clin Periodontol 29. Bergenholt^ G, Nyman S. Endcdontic complications fol-
1983;10:563-578. lowing periodontal and prosthetic treatment of patients
with advanced penodontal disease. J Periodontol
16. Seymour KG, Taylor M, Samarawickrama DY, Lynch E.
1984,55:63-68
Variation in labial shoulder geometry of metal ceramic
crown preparations; A finite element analysis. Eur J 30. Spiering TA, Peters MC, Plasschaert AJ. Thermal trauma
Prosthodont Restorative Dent 1997;5:131-136. to teeth. Endod Dent Trau m ato I 1985:1:123-129.
17. Bishop K, Biggs P, Kelleher M. Margin design for porce- 31 Qttal P, Lauer H-C, Temperature response in the pulpal
lain fused to metal restorations which extend onto root. chamber during ultrahigh-speed tooth preparation with
BrDentJ 1996;130;177-184. diamond burs of different grit. J Prosthet Dent
1998:80:12-19.
IS. Burke FJT. Fracture resistance of teeth restored with
32. Xu HHK, Kelly ^R, Jahanmir S, Thompson VP, Reltow ED.
dentin-bonded crowns: The effect of increased tooth
Enamel subsurface damage due to tooth preparation witli
preparation. Quintessence int 1996:27:115-121.
diamonds. J Dent Res 1997:76:1698-1706.
19, KippaxAJ, Shore RC, Basi<er RM. Preparation of guide
33. Smith BG. The effect of the surface roughness of pre-
planes using a reciprocating handpiece. Br Dent J
pared dentine on the retention of castings. J Prosthet
1996:180.216-220.
Dent 1970:23:187-197.
20, Kaufman EG, Coehio DH, Colin L. Factors influencing the
34. Ayad MF, Rosenstiel SF, Salama M. Influence of tooth sur-
retention of cemented gold castings. J Prosthet Dent
face roughness and type of cement on retention of com-
1961:11:487-502.
plete cast crowns, J Prosthet Dent 1997;77:116-121.
21, Maxwell AW, Blank LW, PelleuGBJr. Effect of crown
35. Darveriia M, Basford KE, Meek J, Stevens L. The effect of
preparation height on the retention and resistance of
surface roughness and surface area on the retention of
gold castings. Gen Dent 1990;38:200-202.
crowns luted with zinc phosphate cement. Aust Dent J
22, WiskottHWA, NichollsJI, Belser UC. The effect of tooth 1987;32:446-457.
preparation height and diameter on the resistance of 36. Smyd ES, Dental engineering applied to inlay and fixed
complete crowns to fatigue loading. Int J Prosthodont
bridge fabrication. J Prosthet Dent 19S2;2:S36-542.
1997;! 0:207-215.
37. Tuntiprawon M. Effect of tooth surface roughness on mar-
23, Jensen ME, Sheth JJ, Tolliver D. Etched-porcelain resin- ginal seating and retention of complete metal crowns. J
bonded full-veneer crowns: In vitro fracture resistance. Prosthet Dent 1999;81:142-147.
Compend Contin Educ Dent 1989; 10:336-347.
38. Siegel SC, von Frauhofer JA. Assessing the cutting effi-
24, Burke FJ, Watts DC. Fracture resistance of teeth restored ciency of dental burs. J Am Dent Assoc
with dent in-bonded crowns. Quintessence Int 1996,127:763-772.
1994:25:335-340.
39. Eames WB, Nale NL. A companson of cutting efficiency
25, Jorgensen KD. The relationship between retention and of air-driven fissure burs. J Am Dent Assoc
convergence angle in cemented veneer crowns. Acta 1973:86:412^15,
Odontol Scand 1995:13:3S-40.
40. Siegel SC, von Frauhofer JA. Dental cutting with diamond
26, Hegdahl T, Silness J. Preparation areas resisting displace- burs: Heavy-handed or light touch? J Prosthodont
ment of artificial crowns. J Oral Rehabil 1997,4:201-207. 1999;6.3-9.

S]QDT2001
Fabrication of Fixed Partial Dentures with Special
Design Using Capillary Casting Technology

Ariel J, Raigrodski, DMD, MS*/Avishai Sadan, DMD*/

Pinhas Adar, CDT, MDT**/Hisham F, Nasr, DDS, MSc***

he Captek system (Precious Chemicals The Captek coping is composed of 88.2%

Inc, Altamonte Springs, FL, USA] was de- gold, 9% platinum-group metals {4% pure plat-
veloped as a restorative alternative to inum), and 2.8% silver.' It is composed of two
traditional metal-ceramic systems. The system metal components, Captek G and Captek P, which
uses capillary casting technology and can produce when combined create a composite material. The
restorations that combine strength properties ap- copings are fabricated on refractory dies using
proximating those of traditional metal-ceramic metal embedded in wax, not using the traditional
systems with superior esthetics and biocompatibil- lost-wax technique,' After the refractory die is
ity,' The Captek system displays prosthetic versa- painted with a special adhesive, strips of the
tility similar to that of traditional metal-ceramic Captek P material, a platinum-colored alloy, are
systems which use the lost-wax technique.^ The adapted to the die with light pressure and fired in
manufacturer recommends its use for fabricating the furnace to form a tri-dimensional network of
inlays, onlays, crowns, multiple-unit fixed partial capillaries. Captek G, a gold-colored material that
dentures, implant crowns, and implant-supported contains 97% gold, is applied over the Captek P
fixed partial dentures. and fired in the furnace so that the molten mater-
ial fills the Captek P capillary network through the
process of capillary attraction, creating a compos-
ite material.' Structure strengthening similar to
'Assistant Professor, Department of Prosthodontits,
that created with other composite materials is ob-
Louisiaria State University School of Dentistry, New
Orleans, Louisiana, tained in the process of the fabrication of the
"Oral Design Center, Atlanta, Georgia, Captek coping.^ Since no oxide layer is formed on
•"Private practice. New Orleans, Louisiana, the coping, the connection between the porcelain
Reprint requests: Dr Ariel J. Raigrodski, Department of
Prosthodontics-222, LSU School of Dentistry, 1100 Florida
and the metal substructure is formed with a spe-
Avenue, New Orleans, LA 70119. Fax: 504-619-8741. cial bonding material, the Capbond.' An in vitro

QDT 2001
 RAIGRODSKI ETAL

Study has demonstrated that the shear bond vitro study found a significant reduction in the
strength of the veneered porcelain to the Captek marginal gap of Captek crowns and bridges in
copings is at least as strong as the shear bond comparison to traditional metal-ceramic restora-
strength of the veneered porcelain to traditional tions with a chamfer margin design,' The system
metal-ceramic alloys.' Any porceiain suitable for can be used with various metal margin designs;
use with precious cast-ceramic metals may be with porcelain margins; and with various finish line
used for veneering Captek restorations.' designs, such as a chamfer, a chamfer with bevel,
The copings are designed with a thickness of a shoulder, a shoulder with bevel, or a knife edge.'
0.25 mm for anterior teeth and premolars and As with traditional metal-ceramic systems, stan-
0.35 mm for molars. Thus, additional room is pro- dard cementation procedures can be used and
vided for the veneering porcelain, and the possi- the adhesive bonding cementation is optional.
bility of overcontouring the restoration at the cer- The color of the coping, resulting from a com-
vical areas, which might result in compromising bination of metals in the alloy, creates a favorable
both the emergence profile and the periodontal background for the veneering porcelain as com-
health of the abutment teeth, is reduced.^' The pared to a pure gold color.* Its lack of oxide layer
thinness of the coping promotes achieving es- enhances its color as well, thus promoting the es-
thetic restorations without compromising the thetic result. This result can be evaluated not only
thickness of the veneering porcelains and thus al- by the ability of the coping to present superior
lows the use of a relatively conservative tooth color interaction with the veneering porcelain, but
preparation. This feature can also prove advanta- also by enhanced light reflection at the restora-
geous in cases of anatomic limitations such as re- tion-soft tissue interface as compared to the gray-
stricted interocclusal distance or mandibular In- ish gingival appearance traditional metal-ceramic
cisors. For severely restricted interocclusal systems can cause.^^ The warm color of the metal
distance, a Captek alloy occlusal surface can be coping may be reflected through the soft tissue,
fabricated.' Moreover, the system allows the cop- especially if subgingival preparation is required
ing to be thickened to the desired dimensions as and the patient presents with thin, translucent gin-
required at different areas, using materials that giva. In addition, the color of the coping allows
are designed for that purpose: Captek Repair for the application of a thinner layer of opaque
Paste and Capfil. To prevent the formation of un- material, eliminating the high-value appearance of
supported porcelain, the coping can be thick- the veneered porcelain at the cervical area.'
ened selectively to the required dimensions to The oxide-layer-free coping also contributes to
create a lingual collar or to increase the coping the excellent biocompatibility of the system. An in
thickness at the palatal surfaces, incisai edges, vivo study showed that Captek alloy harbored a
occlusal surfaces, and interproximal extensions.' lower number of bacteria, particularly streptococci
After the coping has been fabricated, one can and periodontal pathogens, than natural teeth.'"
further add to it and increase its thickness where This biocompatibility, exhibited by the lack of gin-
necessary. There is no need to make a new final gival reaction and discoloration at the free gingival
impression and fabricate a new coping, as re- margin, may make the use of the system more at-
quired by systems that use the lost-wax tech- tractive for cases of periodontally involved teeth.
nique; the ceramist can add directly to the origi- Fixed partial dentures can be fabricated with
nal coping. the Captek system. An in vitro study showed that
The system can produce extremely accurate the load-bearing capacity of Captek fixed partial
restorations because when the clinician chooses to dentures was equivalent to that of a traditional,
use metal margins, these margins are burnishable. high-noble, metal-ceramic system." This capabil-
The copings can be formed directly on a refractory ity to fabricate fixed partial dentures is similar to
die and then finished on the master die. An in that of traditional metal-ceramic systems and is

aQDT2üO1
 Fixed Partial Dentures Using Capillary Casting Technology

not restricted to three-unit fixed partial dentures

or to specific clinical scenarios. In addition, the
system offers the capability to fabricate fixed par-
tial dentures with special designs for relatively
complex clinical situations. The availability of 17
prefabricated metal pontics made of palladium-
based or gold-based alloys, with one, two, or four
units in a row, and the ability to join them to the
copings, promotes that capability,' Moreover, like
traditional metal-ceramic systems, the Captek sys-
tem can be used as a treatment alternative in the Fig 1 Preoperative frontal view of the patient in maxi-
following cases: mum intercuspation. Mote the grayish color of the
metal framework of the Maryland fixed partial den-
tures reflected through the facial aspect of the right
1. Multiple-unit fixed partial dentures canine, central incisors, and left first premolar.
2. Fixed partial dentures with double splinted-
abutments
3, Telescopic copings
4, Fixed partial dentures with a nonrigid connec- smile (Figs 2 to 5), After clinical and radiographie
tor such as a key and a keyway examination, a multidisciplinary treatment ap-
proach was deemed appropriate.
The finished copings and the pontics are joined An orthodontic and periodontal consultation
in wax, invested with a special investment material contributed to the following treatment plan: the
(Captek soldering investment), and soldered using left canine was treatment planned for extraction;
special soldering materials (Capeón and Capfil), the left first premolar would be orthodontically ro-
Furthermore, Captek single units can go through tated distobuccally to improve its position in the
a post-ceramic soldering procedure as can tradi- arch in order to use it as the abutment replacing
tional metal-ceramic restorations,' the canine and to allow enough space for a pontic
In the following clinical report, the authors will replacing the first premolar (Fig 6), Two fixed par-
demonstrate the use of the Captek system as an tial dentures would be fabricated as the definitive
alternative to traditional metal-ceramic systems restorations using the Captek system. The first, a
for fabricating a multiple-unit fixed partial denture three-unit fixed partial denture, included the right
with a nonrigid connector. canine and central incisor as prospective abut-
ments, with the lateral incisor serving as the pon-
tlc. The second, a five-unit fixed partial denture,
• CASE REPORT included the left central incisor and second pre-
molar as the prospective mesial and distal abut-
A patient presented to the clinic with two Maryland ments, with the first premolar serving as a
fixed partial dentures in the maxilla, one on the prospective pier abutment. The position of the
right incisors and canine, and the other on the left left first premolar in the arch dictated the use of a
incisors and first premolar. The prostheses re- nonrigid connector with a precision attachment on
placed congenitally missing lateral incisors and the its distal aspect of the pier abutment. To achieve
left canine, which was ectopically erupted distal to favorable stress distribution on the abutment
the first premolar {Fig 1), The patient complained teeth, the general recommendation is to position
that her teeth had a dark-gray appearance and the the female part of the attachment on the distal as-
right canine presented a severe esthetic problem, pect of the pier abutment and the male part on a
and she indicated that she wanted to improve her mesial extension of the distal pontic,'^-'^

QDT 2001
 RAIGRODSKI ET AL

Fig 2 Preoperative view of the patient's smile. Note Fig 3 Preoperative view of the patient at rest. Note
that the incisai edges of the maxillary central and lat- the lackof display of the incisai edges of the maxillary
eral incisors do not follow the lower lip and that the central incisors.
left first premolar does not successfully simulate the
canine.

Fig 4 Preoperative left lateral view of the patient in Fig 5 Preoperative occlusal view of the patient. Note
maximum intercuspation. Note that the left canine is the Maryland fixed partial denture ori the left side
ectopically erupted distal to the left first premolar, cre- using the left first premolar as the distal abutment to
ating a severe esthetic problem. simulate the ectopically erupted left canine.

Fig 6 Occlusal vjew of the maxillary arch after the ex- Fig 7 Frontal view at maximum intercuspation. Note
traction of the left canine and at the initial phase of that the left first premolar crown was lengthened fa-
the orthodontJc treatment. Note the lack of adequate cially to improve its length-to-width proportions in
space for a pontic simulating the left first premolar. order to enhance the simulation of a canine.

QDT 2001
 Fixeij Partial Dentures Using Capillary Casting Technology

Fig 8 Occlusai view after finalizing the orthodontic Fig 9 Frontal view at maximum intercuspation. Note
treatment and removing the Maryland fixed partial that the gingival level of the left first premolar is similar
dentures. Note the favorable position of the left first to that of the right canine.
premolar in the arch.

Follovuing the orthodontic treatment, the ieft

first premolar was crown iengthened faciaily to im-
prove its length-to-width proportions, enhancing
the simulation of a canine (Fig 7). The Maryland
fixed partial dentures were removed (Figs 8 to 10)
and the abutment teeth were initially prepared
and provisions I ized. To promote the natural ap-
pearance of the pontics, a ridge augmentation
procedure was performed at the lateral-incisor
pontic sites. Creating an ovate pontic site would
enhance the shape and emergence profile of the
future pontics." In this case, a hard and soft tissue Fig 10 Left lateral view at maximum .ntercuspatiün.
grafting approach to the ridge augmentation was Note that an adequate space was created for the pon-
tic serving to replace the first premolar.
used (Fig 11). Upon completion of the healing
process, the pontic sites were prepared using a
football-shaped, high-speed diamond bur, and
the provisional pontics were relined with self-
cured acrylic resin exerting pressure on the pontic was waxed up separately and then fabricated
site." Tooth preparations were refined (Figs 12 to (Figs 19 and 20). The fit of the framework was as-
14). a final impression was made, and the master sessed and verified in the patient's mouth (Figs 21
and opposing casts were mounted on a semi-ad- to 23). The ceramist built up the porcelain (Fig
justable articulator (Figs 15 to 17). 24), and during the bisque bake stage the fixed
The Captek copings were fabricated on refrac- partial dentures were assessed for proximal con-
tory dies according to the previously described tact points, tissue surface of the pontics, and oc-
technique. The copings were seated on the mas- clusai contacts. The glazed definitive prostheses
ter cast (Fig 18), and the correct selected pontics were reassessed for fit, proximal contact points,
were j o i n e d t o the copings with wax. The tissue surface of the pontics, and occlusai contacts
prospective framework was invested in Captek (Figs 25 and 26), Minor adjustments were made,
soldering investment and connected using Cap- and the prostheses were cemented in the pa-
con and Capfil materials. The nonrigid connector tient's mouth to her satisfaction (Figs 27 to 30).

QDT 2001
 RAIGRODSKI ETAL

Fig 11 Frontal view of the initially prepared teeth at Fig 12 Occlusal view of the definitive tooth prepara-
maximum intercuspation immediately following the tions demonstrates the successful buccal augmenta-
ndge augmentation procedure. tion.

Fig 13 Frontal view of the prepared incisors shows Fig 14 Frontal view of the prepared teeth shows how
the prepared ovate pontJC site. the prepared left first premolar simulates the appear-
ance of a prepared maxillary canine.

Fig 15 Occlusal view of the master Fig 16 Lateral view of the master Fig 17 Frontal view of the master
cast demonstrates the 360-degree and opposing casts mounted on a and opposing casts mounted on a
shoulder preparation and the scor- semi-adjustable articulator demon- semi-adjustable articulator shows
ing of the pontic site. strates the Angle Olass III dental the adequate occlusal clearance.
relations.

QDT 2001
 Fixed Partial Dentures Using Capillary Casting Technology!

Fig 18 Frontal view of the master cast shows the ex-

cellent fit of the Captek copings to the dies.

Fig 19 Occlusal view of the framework on the master

cast. Note the pontics and connector areas cast in
noble metal alloy.

Fig 20 Occlusal view of the completed framework on

the master cast after the application of Capfil over the
connectors and pontic areas. Note the cast nonrigid
connector with the keyway positioned on the pier
abutment retainer and the key positioned at the distal
pontic.

Fig 21 Frontal view of the framework try-in in the pa-

tient's mouth.
Figs 22 and 23 Occlusal views of the framework try-in
in the patient's mouth.
 RAIGRODSKI ETAL

Fig 24 The silicone matrix fabri- Fig 25 Note the metal margins of Fig 26 Note the incisai translu-
cated with a cast of the provisional the restorations and the connected cency and the nonconnected non-
restoration is used in building up nonrigid connector. rigid connector.
the porcelain.

Figs 27 and 28 Frontal view of the pontics (right and left lateral incisors) shows how they blend
well with the surrounding soft tissue. Note the enhanced length-to-width proportions of the pon-
tics in comparison to the preoperative view.

Fig 29 Postoperative view of the patient at rest. Note Fig 30 Postoperative view of the patient smiling.
that the incisai edges of the maxillary central incisors Note how the incisai edges of the maxillary incisors
are barely touching the lower lip. follow the curvature of the lower lip.

QDT 2001
 Fixed Partial Dentures Using Capillary Casting Technology I

• CONCLUSION 10. Standard cementation procedures can be

used.
To determine whether the Captek system can be 11. The system provides excellent biocompatibility.
used as a complete substitute for traditional
metal-ceramic systems, further studies on the me-
chanical properties of the system, accompanied
by long-term clinical trials, are required. However, • ACKNOWLEDGMENTS
the versatility of the Captek system enables its use
The authors would like to thank the following people for their
in various prosthetic situations that might dictate support: Alvin Fulastre Mi, CDT, Frank Loegel, CDT; and
special framework designs, eg, when the need to Aharon Whitman, CDT

use a nonrigid connector arises, as in the case de-

scribed in this article. In addition, the properties
of the Captek system enhance the ability to • REFERENCES
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This prosthetic/esthetic versatility is achieved be- DentTechnol 1995:18:9-20.
cause of the following factors: 2 Giordano RA. Dental ceramic restorative systems. Com-
pend Contin Educ Dent 1996:17:779-794.
3. Zappala C, Shoher I, Battami P. Microstructural aspects of
1. Thinness or thickness of the framework can be Captel; alloy for porcelain-fused-to-metal restorations, J
controlled or modified in different areas of the Esthet Dent 1996:8:151-150,
4. Juntavee N, Giordano R, Nathanson D. Porcelain shear
coping according to the required dimensions. bond strength to a new ceramo-metal system (abstract
2. Nonrigid connectors can be waxed up to the 1181|.JDentRe5Î995:74:159
Captek framework. 5. Youdelis RA, Weaver JD, Sapkos S. Facial and lingual con-
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3. The oxide layer present in traditional metal-ce- fects on the periodontium. J Prosthet Dent 1973;
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on adolescents. J Periodontol 1976:47:320-323.
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color of the coping and the soft tissue at the stract 167|. J Dent Res 1995:74:421.
6. Shoher I. Vital tooth esthetics in Captek restorations. Dent
restorative-gingival interface. din North Am 1993:42:713-718.
5. There is a favorable interaction between the 9. Bichacho N, Cervical contouring concepts: Enhancing the
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1995;8:241-2S4.
lain. A thinner layer of opaque is required be-
10 Goodson M, Shoher I, Iniber S, et al. Captek alloy re-
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ceramists more latitude by allowing them Res 1999:78:138.
more room for the veneering porcelain, thus 11. Juntavee N, Giordano R, Nathanson D. Load bearing ca-
pacity of Captek crowns and bridges [abstract 565|. J
enhancing the capability to achieve an es- Dent Res 1995;74471.
thetic result. 12. Shiilingburg HT, Hobo S, Whitsett LD, Jacobi R, Bracket
Ó. The copings have excellent fit and may be SE. Treatment planning for the replacement of missing
teeth. In: Fundamentals of Fixed Prosthodontics, ed 3.
burnished when metal margins are used. Chicago: Quintessence, 1997:85-103.
7. Any type of finish line and margin design can 13. Shillinburg HT, Fisher DW, Nonrigid connectors for fxed
partial dentures, J Am Dent Assoc 1973:87:1195-1199.
be used.
14. Garber DA, Rosenberg ES. The edentulous ridge in fixed
8. Conservative preparation designs are an op- prosthodontics. Compend Contin Educ Dent
tion. 1981;2:212-224.
9. The system can be used in areas presenting
with anatomic limitations, such as reduced in-
terocciusal space and small teeth.
 A Systematic Approach to Full-Mouth Rehabilitation;
Clinical and Laboratory Guidelines

Brian S. Vence,

he purpose of this article is to illustrate a and make a preliminary assessment of his or her
step-by-step approach to full-arch fixed condition to determine the necessary diagnostic
rehabilitation. The article will discuss the procedures. After the interview, the following di-
basic concepts applied during these procedures agnostic procedures are essential for an accurate
through a clinical report. In addition, it will outline assessment of the patient's status: diagnostic pho-
the sequence of appointments required for com- tographs (Figs 1 to 12), complete periapical radi-
pleting a full-arch fixed reconstruction [Table 1). ographs, diagnostic impressions, and a clinical
evaluation. The comprehensive evaluation in-
cludes a clinical dental examination, a clinical peri-
DIAGNOSTIC PROCEDURES odontal examination, temporomandibular joint
ANO PATIENT AGREEMENT (TMJ) and occlusai evaluations, and a radi-
ographie evaluation. If the TMJ and occlusai eval-
Diagnostic Phase uations reveal any evidence of occlusai pathology,
an additional appointment is scheduled for ob-
As in any major dental procedure, the first step is taining maxillary and mandibular full-arch impres-
for the clinician to agree with the patient on the sions, centric relation interocdusal records, and a
nature of the problem and to discuss treatment al- facebow transfer, followed by a functional analy-
ternatives.' The dentist must interview the patient sis.^ At this stage, the patient's "type" should also
be determined^:

• Type I. Healthy patient without oral health is-

sues other than maintenance: Esthetically
"Private practice. West Dundee, Illinois,
pleasing dentition; physiologic occlusion;
Reprint requests; D[ Brian S, Vence, 700 Willow Lane, Suite
G, West Dundee, IL 60118. Fax: -[847)426-1581. E-msil: structurally sound teeth; biologically healthy
[email protected]. Website: www.vencedds.com periodontium, pulps, and third molars.

JQDT 2001
 A Systematic Approach to Full-Mouth Rehabilitation I

Table 1 Sequence of Appointments for a Full-Arch Fixed Reconstruction

I. Telephone screening (first contact) • Discover essential and meaningful treatment

• Purpose • Help connect the emerging meaning derived
• Questions from the patient consultation with the restorative
dentist to the technique for a shared purpose
II. Initial consultation—dental interview • Help patient understand what the choice means
• Purpose in terms of time, money, energy, and outcome
• Questions
• Create a context for the patient's dentistry VI, Action plan—implementation
" Determine patient type (I, II, III, or IV; see text) • Narrative
- Explicitly state diagnostic findings and the pa-
II. Diagnostic services tient's preferred future in terms of the shared
• Clinical evaluation purpose (meaning + technique)
- Comprehensive examination (periodontal • Phases
exam, occlusal exam, dental exam) • Financial arrangements
- Full-mouth radiographs • Appointments
- Diagnostic photographs
• Records appointment VIL Active treatment
- Diagnostic casts • Follow scheduling procedures in office manual
- Jaw records and mounted diagnostic casts • Laboratory systems
- Functional analysis • Mailing systems
• Procedure systems
IV. Treatment planning session—patient education
• Determine where you are VIIL Preferred outcome
• Co-discovery • Stable, healthy, esthetic mouth
• Review diagnostic findings
- What we are seeing IX. Maintenance
- What we consider ideal • Occlusal splint
- What we think will likely happen if nothing is • Continuing care program
done
- What would patient like to do? X. Referrals
• Internal marketing
V. Obtaining a future of choice—negotiation • External marketing
• Decide on a preferred future; how the patient
wants to resolve the findings

Type (/, Healthy patient with limited restora- Type IV. Patient with a dentition that is
tive needs: Structurally compromised teeth in breaking down, with multiple issues in need
need of isolated restorations that may in- of complex restorative care: Esthetic, oc-
clude amalgams, composites, inlays, onlays, clusal, structural, periodontic, endodontic ,
crowns, bridges, or single implants; physio- o r t h o d o n t i c , a n d / o r oral surgery; esthetic
logic occlusion; biologically healthy peri- desires; pathologic occlusion because of a
odontium (may need isolated endodontics or combination of bruxism, malaligned teeth,
oral surgery); maintenance. lost tooth form from previous dental work or
Type III. Healthy patient who has esthetic de- wear, and/or missing teeth; structurally com-
sires and cioes not fiave occtusal or periodon- promised teeth in need of individual restora-
tal issues: Esthetic desires in terms of compo- tions that may include amalgams, compos-
sition, arrangement, shape, contour, or color; ites, inlays, onlays, and crowns; b i o l o g i c
physiologic occlusion; structurally sound issues resulting in an inflammatory process
teeth; biologically healthy periodontium, from periodontal disease or necrotic pulps;
pulps, and third molars; maintenance. maintenance.

QDT 2001
 VENCE

Fig 1 Preoperative view of the patient's smile. Fig 2 Preoperative frontal view in maximum intercus-
pation.

Fig 3 Preoperative frontal view in protrusion. Fig 4 Preoperative view of the maxillary incisors. Note
the incisai translucency of the right central incisor.

Figs 5 and 6 Preoperative lateral views in maximum intercuspation.

ifl QDT 2001

 A Systematic Approach to Full-Mouth Rehabilitation

Fig 7 Preoperative view of the maxillary arch Fig 8 Preoperative view of the mandibular arch.

Figs 9 and 10 Preoperative views

of the maxillary posterior teeth.

Figs 11 and 12 Preoperative

views of the mandibular posterior
teeth. Note the non serviceable
margins of the amalgam restora-
tions and leakage.
 VENCE

Treatment Planning Phase lation in patients who present with joint or muscle
pain. Specific esthetic and occlusal parameters
A treatment planning session that consists of pa- must be followed to achieve esthetic and func-
tient education follows the diagnostic phase. In a tional harmony in the final restoration^-'°;
process called co-discovery, the restorative dentist
and patient evaluate the diagnostic records to- Esthetic treatment planning must include
gether. The dentist groups the findings into four tooth position, gingival levels, arrangement,
main components—esthetics, occlusion, structural contour, and color.
integrity of the teeth, and biologic parameters— Attention must be paid to the "five esthetic
and he or she presents them to the patient in a keys," the midline, incisai edge position, in-
"nonjudgmental reporting" manner. By educating cisal plane/smile line, occlusal plane/incisal
the patient, the restorative dentist is able to pro- plane, and gingival levels.
vide clinical reasoning behind the issues that are The occlusion must be assessed; signs of a
essential to address in the treatment. The patient pathologic occlusion are joint pain, muscle
has to provide interpretive reasoning as to which pain, tooth wear, tooth fracture, tooth mobil-
issues in the treatment plan are the most impor- ity, and tooth sensitivity.
tant to him or her. The dentist and the patient A differential diagnosis of tooth wear must in-
must discuss the relevant issues to reach an clude bruxism, habits, diet, occupation, med-
agreement on the nature of the problems and the ical considerations, deflective-contact inter-
methods of care. ference, avoidance-pattern interference,
parafunction-inducing interference, and joint
pain.
Diagnostic Wax-up and Fabrication
of Templates After completing the diagnostic wax-up, fabri-
cate a set of templates. The templates consist of a
The proposed esthetic and occlusal changes must copyplast press-formed mold [Great Lakes Ortho-
be determined from the diagnostic records and dontics) made on the Biostar pressure-forming
transferred into the prototypical restoration using machine (Great Lakes Orthodontics] and a silicone
the diagnostic wax-up. The diagnostic pho- putty matrix such as Coltoflax {President
tographs help relate dentofacial relationships to ColteneAWhaledent, Mahwah, NJ, USA), Use the
the diagnostic casts." In the diagnostic appoint- matrices to fabricate the provisional restorations
ment, two sets of mounted casts are necessary for and to verify adequate tooth structure reduction
the fabrication of the diagnostic wax-up, the first for the definitive restorative materials.
set for data collection and the second for fabricat-
ing the diagnostic wax-up. To accurately transfer
the patient's dentofacial relationships to the artic- • TREATMENT SEQUENCE
ulator, make a facebow transfer with the patient
Standing up with his/her head in an upright pos- The goal of the treatment sequence is to transfer
ture, with the facebow leveled to the horizon, and the proposed esthetic and functional occlusal
mount the maxillary cast. Record centric relation changes from the diagnostic wax-up via the provi-
using the bimanual manipulation technique, an sional restoration to the patient's mouth, which is
anterior déprogrammer, or a leaf gauge and a the key to a successful definitive restoration (Figs
hard wax (DeLar bite registration wax wafer. Great 13 to 24),'''^ While fabricating the provisional
Lakes Orthodontics, Tonawanda, NY, USA), and restorations, care must be taken to achieve excel-
mount the mandibular cast. Splint therapy may be lent marginal integrity and positioning, a well-
indicated prior to recording an accurate centric re- planned emergence profile, esthetic contact areas.

QDT 2001
 A Systematic Approach to Full-Mouth Rehabilitation |

Figs 13 and 14 Preopcative shade matching for the

provisional and definitive restorations.

Figs 15 to 17 To allow restoration of the maxillary left

second premolar with a crown, it was orthdontically
extruded to gain an adequate amount of tooth mater-
ial for achieving a ferrule effect.

Fig 18 Occiusal view of the maxillary provisional Fig 19 Maxillary left second premolar after extrusion
restorations. and restoration with a cast post and core.

QDT 2001
 VENCE

Figs 20 to 24 Lateral and frontal views of the provisional restorations. Note the surface texture
transferred from the diagnostic wax-up and the shade characterizations.

adequate thickness for the proposed restorative prefers to prepare the teeth one sextant at a time,
materials, incorporation of the esthetic goals, and vi/ith appointments 1 week apart. Include canines
maintenance or establishment of a physiologic in the preparation of posterior teeth to coordinate
and functional occlusion. In addition, the provi- anterior guidance and posterior disclusion. The
sional restorations are used for soft tissue man- following sequence of tooth preparation estab-
agement, as bicfeedback devices, and as the pro- lishes the maxillary occlusal plane first, which pro-
totypes for function and esthetics for the definitive motes a functional result without compromising
restoration. esthetics. Esthetics are established first with the
Prepare the teeth with a 3óO-degree shoulder incisai edge position of the maxillary anterior
finish line for 360-degree porcelain margin design. teeth and the buccal cusp position of the maxillary
Verify sufficient reduction of tooth structure for the posterior teeth. Optimal function can then be es-
future restorations by using the pressure-formed tablished when the mandibular arch is restored':
and silicone templates as preparation guides. The
first step in this procedure is to ensure complete 1. Use the patient's lips at rest and active smile
seating of the template; reduce teeth that are out to establish incisai edge position of the max-
of alignment with the diagnostic wax-up in the illary central incisors.
areas that do not allow a complete seat of the 2. Using the esthetic parameters described
template.'^ above, determine or adjust the incisai edge
For patient comfort and because of the amount position of the lateral incisors and the buccal
of time required to prepare teeth and to fabricate cusp position of the canines, premolars, and
excellent provisional restorations, the author molars.

QDT 2001
 A Systematic Approach to Full-Mouth Rehabilitation

3. Determine the mandibular incisai edge posi- late cement from adhering to the tooth prepara-
tion based on OVD for facial esthetics, over- tion. Seal the intaglio surface of the provisional
jet, and overbite requirements for anterior restoration with a diluted mix of minute stain
guidance and "s" position. glaze and thinner to prevent the polycarboxylate
4. Assess the overbite and overjet relationship. cement from adhering to the provisional restora-
5. Assess the lingual aspect of maxillary anterior tions. A crown remover {Miltex Temporary Crown
teeth {the dental envelope of motion we de- Remover, Miltex Instrument, Bethpage, NY, USA)
termine to harmonize with the patient's neu- can easily flex the Triad provisional restorations
romuscular envelope of motion). and remove them. It is easy to clean the polycar-
6. Assess the mandibular buccal cusps. boxylate cement from the previously sealed tooth
7. Assess the maxillary palatal cusps. preparations and from the provisional restorations
8. Assess the mandibular lingual cusps. with a cavitron.
9. Assess the fossa depth.

Healing Phase and Esthetic and Functional

Tootfi Preparation Sequence Re-evaluation

During the first appointment, prepare and provi- The occlusion obtained with the provisional
sionalize the maxillary right canine and maxillary restorations is maintained or adjusted in centric
right posterior teeth. At the second appointment, relation during this phase. The dentist can only
prepare and provisionalize the maxillary left ca- work within the patient's dental envelope of func-
nine and maxillary left posterior teeth. During ap- tion to harmonize it with the neuromuscular enve-
pointments three to six, respectively, prepare and lope of function and parafunctional envelope of
provisionalize the maxillary incisors, the mandibu- function. The TMJs, the muscles of mastication,
lar right canine and mandibular right posterior the periodontal tissues, and the puipal tissues are
teeth, the mandibular left canine and mandibular monitored for approximately 3 months. The gin-
left posterior teeth, and the mandibular incisors. gival tissues are evaluated for inflammation to
Fabricate the provisional restorations from the rule out lack of oral hygiene maintenance, bio-
template of the diagnostic wax-up with Triad logic-width infringements, recessions, inadequate
(Dentsply, York, PA, USA). Adjust the occlusion at free gingival margin levels, and inadequate inter-
each appointment. To increase the occlusal verti- proximal papillae levels. This periodic monitoring
cal dimension, between posterior preparation ap- establishes correct tooth size and a pleasing
pointments use an acrylic resin shim cemented tooth arrangement {Figs 20 to 24). The incisai
with polycarboxylate cement [Durelon, ESPE, Nor- plane and smile line relationship, and the occlusal
ristown, PA, USA) on the side of the arch opposite plane-incisal plane relationship are refined at this
the side being provision a I ized. This allows the pa- time. Finally, the provisional restorations are stud-
tient to bilaterally maintain the new vertical di- ied to evaluate how the proposed occlusion is
mension of occlusion. The author also uses poly- functioning with the patient's particular envelope
carboxylate cement between appointments to of function and speech patterns, defined as fol-
cement the provisional restoration after treating lows':
the preparations for pulpal protection with a 15-
second etch with a dentin desensitizer {Gluma, • Envelope of motion: the maximum range of
Heraeus-Kulzer, South Bend, IN, USA) and sealing motion in all directions
the preparations with a dentin sealer (Tubulitec, • Dental envelope of motion: the range of mo-
Global Dental Products, North Belimore, NY, tion determined by the guiding inclines of
USA). The dentin sealer prevents the polycarboxy- the teeth
 VENCE

Figs 25 to 27 Occiusal views of the pre-

pared mandibular teeth and the impres-
sion post. Note the excellent gingival
health.

• Neuromuscu'ar envelope of function: the be impeccable if the provisional restorations' mar-

range of motion for functional purposes with- ginal integrity and emergence profile are precise
out dental interference (It is important to and the patient maintains oral hygiene procedures
note that the dental envelope of motion can at home (Figs 25 to 30),
be more restrictive than the neuromuscular Using the double-cord technique, first pack a 0
envelope of function.) retraction cord (Gingibraid, Van R Dental Prod-
• Envelope of parafunction: the pattern of ucts, Oxnard, CA, USA), and modify any margins
mandibular motion for nonfunctional pur- that need to be placed subgingivally. Place a sec-
poses ond, larger (1 or 2) retraction cord (Ultrapak, Ultra-
dent, South Jordan, UT, USA) to retract the gingi-
The provisional restorations relate the patient's val tissues at the level of the margins (Figs 31 to
dentofscial relationships to the articulator and fix 33), If in the process of packing the second cord,
the dynamic occiusal function and speech pat- the gingival tissue Still touches a margin some-
terns into a static representation for physiologic where around the tooth, place a small piece of
harmony.'"" cord in the sulcus below the second cord to sup-
port the second cord position at the level of the
margin. Leave the cord in the sulcus for 4 minutes.
Final Impressions Modify disposable impression trays (Master
Trays, Teledyne Getz, Elk Grove Village, IL, USA)
During appointments seven and eight, respec- with heat to fit the patient's arch form. Tape over
tively, maxillary and mandibular full-arch impres- the outer surface of the tray with transparent tape,
sions are made, Alginate impressions of the provi- and coat the inner surface of the tray with the ap-
sional restorations are poured with a type 111 stone propriate tray adhesive. Remove the wet second
(Fuji Rock EP, GC Europe, Leuven, Belgium), cords from the sulcus, and air dry the teeth. The
These will be used to cross mount with the master cords are removed wet because drying the cords
casts in the clinical-laboratory phase of treatment. and teeth prior to removal can tear the delicate
Remove the provisional restorations and residual epithelial attachment and promote bleeding. The
cement from the teeth. The tissue health should tray is loaded with heavy-body impression material

QDT 2001
 A Systematic Approach to Full-Mouth Rehabilitatii

Figs 28 to 30 Occlusal views of the pre-

pared maxilla^ teeth. Note the excellent
gingival health.

Figs 31 to 33 Occlusal views of the pre-

pared maxillary teeth with the retractron
cords placed in the sulcus.

while the dentist injects refrigerated low-viscosity Inspect the impression for accuracy, with the
polyether impression material (Permadyne Penta goal of capturing a 360-degree circumferential
H, ESPE) into the sulcus around the prepared intrasulcular impression of all of the prepared
teeth. Use a light air stream on the impression ma- teeth in the arch (Figs 34 to 37), Gapturing this
terial to force it into the sulcus. Seat the fitted tray, information over several impressions is not ac-
loaded with heavy-body polyether impression ma- ceptable for complete-arch reconstruction. Pour
terial, over the light-body material on the teeth the impressions three times with a type III stone.
and allow it to set for 6 minutes. Gare must be This allows the technician to have a virgin set of
taken when making a mandibular impression be- dies for margin correction, a Pindex master cast
cause extreme mandibular opening will result in a (a pinned cast], and a solid cast with soft tissue
flexure of the mandible and a distorted impression. simulation.
VENCE

Figs 34 to 37 Full-arch maxillary impression. Note that preparation margins are cor
pletely reproduced for all preparations

Jaw-Relation Records and Mounting Clean the tooth preparations of cement to obtain
an accurate interocdusal record. Leave the maxil-
During appointment nine, facebow transfer and lary anterior provisional restorations cemented in
centric relation interocdusal records are made. place. Use them as an anterior déprogrammer, with
The centric relation records will be used to cross the mandibular anterior provisional restorations at
mount the casts of the provisional restorations the established vertical dimension of occlusion.
and the master casts. A centric relation record of Make three centric relation records with wax to re-
the provisional restorations is made with a small late the maxillary master cast to the mandibular
amount of polyvinyl siloxane recording medium in cast of the provisional restorations (Fig 39).
the grooves of the posterior teeth. This record will Third, remove the mandibular posterior provi-
be used when mounting the provisional restora- sional restorations. Clean the tooth preparations
tion casts.'^ of cement to obtain an accurate interocdusal
First, make a facebow transfer of the maxillary record. Leave the mandibular anterior provisional
provisional restorations in the same manner as in restorations cemented in place and use them as
the diagnostic phase. Second, remove the maxil- the anterior déprogrammer, with the maxillary an-
lary posterior provisional restorations (Fig 38). terior provisional restorations at the vertical di-
 A Systematic Approach to Full-Mouth Rehabilitation

Figs 38 and 39 Posterior maxillary provisional restorations are removed and a centric relation record is made

mension of occlusion. Make three centric relation Try-in Phase

records with wax to relate the maxillary master
cast to the mandibular master cast. During appointment 10, try-in and adjustments
Fourth, cross mount the casts in the laboratory. are performed. The completed restorations are
Mount the maxillary provisional cast with the face- tried in intraorally with a polyvinyl siloxane disclos-
bow to the upper member of a semi-adjustable ing agent (Fit-Checker, GC). Evaluate and adjust
articulator Mount the cast of the mandibular pro- the proximal contact points, and evaluate the
visional restorations either by hand articulation or restorations for marginal integrity. Because of the
by using the polyvinyl siloxane centric relation inevitable inaccuracies that result from flexure of
record previously obtained. Then, use the first the mandible during impression making, mount-
centric relation record made between the ing errors, and stone expansion, occlusal adjust-
mandibular provisional restorations and the maxil- ments are usually necessary to achieve a mutually
protected articulation occlusal scheme. Therefore,
lary prepared teeth to mount the maxillary master
the occlusion and the esthetics of the restorations
cast and the maxillary solid cast with the soft tis-
are evaluated and refined. Once this has been ac-
sue simulation to the mandibular cast of the provi-
complished, polish the restorations with the Bras-
sional restorations. Use the second centric relation
seler (Savannah, GA, USA) porcelain polishing kit
record of the maxillary prepared teeth to the
and with fine pumice.
mandibular prepared teeth to mount the
mandibular master cast and mandibular solid cast
with the soft tissue simulation to the mounted
maxillary master cast and solid cast. Cementation Procedures
Send the case to the dental laboratory with the
preoperative diagnostic casts and the casts of the During appointments 11 and 12, respectively, ce-
diagnostic wax-up. The ceramist should also re- mentation of the mandibular and maxillary arches
ceive slides showing preoperative views, the pre- is performed. First, cement the maxillary right
pared teeth, the teeth with shade tabs, and the segment (canine to second molar] and the maxil-
provisional restorations. lary left segment (canine to second molar). Then,
 VENCE

Figs 40 and 41 Anterior prepared maxillary teeth during the try-in phase

Figs 42 and 43 Rubber dam is used in the bonding procedure of the mandibular veneers. The
excess cement is removed with a No. 12 surgical blade.

cement the mandibular arch in the following

order; mandibular right segment (canine to sec-
ond molar), mandibular left segment (canine to
second molar), and mandibular anterior restora-
tions. The author prefers resin-modified glass-
ionomer cement for cementing metal-ceramic
restorations {Vitremer, 3M, St Paul, MN, USA), and
a more translucent cement (Pro Tec CEM, Ivodar
Vivadent, Buffalo, NY, USA) for cementing anterior
restorations (Figs 40 and 41). Bond all veneers or
all-ceramic crowns with a clear composite resin ce-
Fig 44 Postoperative view of the mandibular veneers. ment; with all-ceramic crowns, use a catalyst with
the cement and dentin bonding agent [Variolink,
Ivodar Vivadent) (Figs 42 to 44).

QDT 2001
 A Systematic Approach to Full-Mouth Rehabilitation i

Figs 45 to 50 Frontal and lateral views of

the completed restorations in maximum
intercuspation.

Figs 51 to 53 Postoperative view of the

patient's smile. The free gingival margins
of the maxillary anterior teeth follow the
outline of the upper lip, whereas their in-
dsal edges follow the curvature of the
lower lip.
 VENCE

Fig 54 Postoperative view of the patient at rest Fig 55 Postoperative view of the patient's smile.

Postoperative Procedures 6. Mack MR. Vertical dimension: A dynamic concept based

on facial form and oropharyngeal function. J Prosthet
Dent 1991,66:478-485.
Appointment 13 consists of re-eualuation and 7. KOIS JC, Phillips KM. Occlusal vertical dimension: Alter-
documentation. Dedicate this last appointment ation concerns. Compend Contin Educ Dent
1997;18:1169-1177
for a final check of the occlusion, re-evaluation of
a. Shauell HM. The art and science of complete-mouth oc-
esthetics, and documentation with photographs clusal reconstruction: A case report. Int J Periodontics
of the definitive restorations (Figs 45 to 55). Restorative Dent 1991;! 1:439^59,
9, Spear F, Facially Generated Treatment Planning, Work-
shop, The Seattle Institute for Advanced Dental Educa-
tion, March 22-24, 2000.
m ACKNOWLEDGMENTS 10. Spear E Occlusion I & II Workshops, The Seattle Institute
for Advanced Dental Education, April 12 and June S-7,
The author would like to thank Mr Donald Cornell for fabricat- 2000.
ing the restorations presented in this article, and Frank M. 11. Shavell HM. The periodontal-restorative interface in fixed
Spear, DDS, MS, for his generous teaching and shaiing of prosthodontics: Tooth preparation, provisionalization, and
knowledge. biologic final impressions. Part I. Pract Penodontics Aes-
thet Dent 1994:0:33-44.
12. Shavell HM The periodontal-restorative interface in fised
prosthodontics: Tooth preparation, provisionalization, and
m REFERENCES biologic final impressions. Part II. Pract Periodontics Aes-
thet Dent 1994:6:49-60.
1, Lipkin M Jr (ed). The Medical Interview: Clinical Care, Ed- 13. Vence BS. Sequential tooth preparation for aesthetic
ucation, and Research, New York: Springer 1995:11-14. porcelain full-coverage crown restorations, Pract Peri-
2, Daw5Dn PE. Evaluation, Diagnosis and Treatment of Oc- odontics Aesthet Dent 2000;! 2:77-84.
clusal Problems, ed 2. St Louis: Mosby, 1989, 14. Spear FM. Occlusal considerations for complex restora-
3, Spear F, The Practice of Excellence, Workshop, The Seat- tive therapy. In: McNeill C (ed¡. Science and Practice of
tle Institute for Advanced Dental Education, July 8-10, Occlusion. Chicago: Quintessence, 1997:437.
1999, 15. Dawson PE. A classification system for occlusions that re-
lates maximal intercuspation to the position and condi-
4, Roblee C. Interdisciplinary Dentofacial Therapy. Chicago:
tion of the temporomandibular joints. J Prosthet Dent
Quintessence, 1994.
1996:75:60-66.
5, Spear FM. Fundamental occlusal considerations. In: Mc-
Neill C (ed). Science and Practice of Occlusion. Chicago:
Quintessence, 1997:421,

I QDT 2001
Expanding the Possibilities of Esthetic Restorations
with the AGC System

Carlo Zappalà, MD, DDS*/Luig¡ Lucernini, CDT**

ll-ceramic crowns are considered state of tion of chemical and mechanical retention caused
the art in esthetic full-coverage restora- by both the oxidation film and sandblasting pro-
tions. However, efforts are still put forth motes an ideal interface between the alloy and
by manufacturers to create ceramic crowns that the veneering ceramics.
have higher fracture resistance and will be able to One disadvantage of the noble-metal alloy is
function in any given condition in the oral environ- its relatively increased thickness, which is required
ment. At the same time, since many dentists still for maintaining the strength of the framework to
prefer to use traditional metal-ceramic restora- prevent its distortion. The other disadvantage is
tions, researchers are striving to create a metal-ce- the formation of a low-value ceramic due to the
ramic restoration with a framework functionally metal oxides contained in the alloy. In addition,
and esthetically superior to the traditional ones with the lost-wax technique, uneven distribution
fabricated with the lost-wax technique. of the base metals, which causes grouping of is-
lands; areas of contamination: alloys with a high
percentage of palladium, which causes gas emis-
sions; and the formation of bubbles between the
• NOBLE-METAL ALLOYS
alloy and the veneering ceramics contribute to the
reduction of the bond strength between the alloy
The traditional noble-metal alloys generally con-
and the veneering ceramics.
tain a high percentage of gold, platinum, and pal-
ladium.' Small quantities of base metals such as
indium and tin, which form a thin film of oxides,
are added to the alloy to enhance the metal-ce- W Base-Metal Alloys
ramic bond. The ideal thickness of this oxide film
is 1 to 5 [im.^ Furthermore, these base metals also Fabricated with the lost-wax technique, base-
harden the alloy and refine its grains. A combina- metal alloy substructures have high hardness, high
castability, and an excellent resistance to sagging.
Minimal metal thickness allows more room for the
'Prrvate practice, Bergamo, Italy. veneering porcelain and thus promotes the fabri-
"Dental technician, Bergamo, Italy.
cation of an esthetic restoration. Base-metal alloys
Reprint requests: Dr Carlo Zappall, 4 Via Petrarca, 24121
Bergamo, Italy Fax: +39 (035) 23592.
have the following disadvantages:
 I ZAPPALÀ/LUCERNINI

quired in the lab,'-' It eliminates the disadvan-

tages of the lost-wax technique while reducing
laboratory time and costs (Fig 1), The gold cop-
ing is produced by an electroforming process and
offers the highest degree of precision and supe-
rior fit. With the following case, this article will
describe the laboratory procedures for fabricating
AGC restorations.

• Case Report

A patient presented with a severe discoloration of

Fig 1 Intaglio surface of the AGC coping. the maxillary right central and lateral incisors (Fig
2). After preparing the teeth for full-coverage
restorations (Fig 3), fabricating provisional restora-
tions, and making definitive impressions, a master
cast was fabricated in the traditional manner. The
1, The production of a thick film of oxides be- laboratory procedures are as follows;
tween the alloy and the veneering porcelain
may lead to a lower bond strength and an in- 1. After determining and marking the finish line
creased risk of detachment of the porcelain on the master die, prepare the base of the
from the alloy. master die itself to eliminate undercuts (Fig
2, Their large production of oxides lowers the 4). In this particular case, we also used the
value of the restoration, creating an unsatisfy- AGC block-out wax to eliminate some un-
ing esthetic result. dercuts, cavities, and surface roughness that
3, Their biocompatibility is questionable, and might interfere with the duplication process
the risk of allergy has been reported.^ of the master die (Fig 5), Apply die spacer
on the master die in the traditional manner.
To overcome the problems that the traditional 2. To duplicate the master die, make an impres-
noble-metal and base-metal alloys present, re- sion of the master die with AGC duplication
search has focused on new materials that will not material (Dubli-Gum). Pour the impression
only eliminate esthetic problems and create func- with AGC Super Hard Plaster Twelve minutes
tional and biocompatible restorations, but will after pouring, remove the duplicated die
also reduce the working time and, consequently, from the mold and allow it to dry for 90 min-
the costs of the fabrication of the restoration. utes at room temperature,
3. Grind the base of the duplicated die to make
it as small as possible (Fig 6). Make a chan-
W Auro Galvano Crown AGC nel, 2 to 3 mm in length, in the base of the
duplicated die with a tungsten carbide bur.
The Auro Galvano Crown [AGC) (Weiland Edel- The opening of the channel should be 1 to 2
metalle, Pforzheim, Germany) presents with a mm under the margins of the preparation
minimum coping thickness made of 24k gold. (Fig 7), Insert a copper rod into the channel,
The system assures fracture resistance compatible attach it with cyanoacrylate, and leave it to
to that of traditional alloys, enhances esthetics, dry (in the case of Speed Unit, use a titanium
and reduces the materials and equipment re- rod micro/micro plus) (Fig 8),

iQDT 2001
 Esthetic Restorations with the AGC System I

Fig 2 Preoperative view of the anterior maxillary den- Fig 3 Facial view of the prepared teeth.
tition. Note the severe discoloration of the right cen-
tral and lateral incisors.

4. Apply AGC Conductive Silver Lacquer over alloy, where all the grains are the same. The
the duplicated die in the desired shape of adhesion of the veneering ceramic to the
the final coping and over the part of the die electroformed structure is achieved by me-
in proximity to the copper/titanium rod to chanical retention exclusively. Sandblasting
connect between them {Fig 9). the electroformed surface with aluminum
5. Determine the power level, electroforming oxide particles (110 |jm) at a maximum of 1
thickness, and quantity of gold electrolyte re- bar is extremely important for enhancing the
quired. Assemble the electroforming head, adhesion.
distance piece, and silicone seal. Pull the 10. Steam clean the copings, and apply AGC
copper rods through the appropriate holes Gold Bonder to enhance further the reten-
and arrange the parts as indicated by the tion. The bonder must be spread homoge-
arrow. neously over the surface of the coping using
6. Carefully follow the manufacturer's instruc- a shorthaired brush. The bonder contains
tions. The electroforming process takes 5 to spherical microparticles of pure gold and ce-
7 hours in the AGC Micro System and 1 to 2 ramic powder. Baking at 920° C for 1 minute
hours in the AGC Speed System {Figs 10 promotes the adhesion of the spherical gold
and 11). microparticles to the electroformed coping.
7. Once the electroforming process is completed As a result of firing, the spherical microparti-
and the copings are formed, remove the cop- cles flow and sinter into the roughened sur-
per rod with a twisting motion, and dissolve face of the coping. The increased surface
the plaster die in gypsum remover in an ultra- roughness of the coping forms a mechanical
sonic cleaner {Fig 12). For the complete elimi- bond between the electroformed coping and
nation of the conductive silver layer, place the the veneering ceramics. The bonder must be
copings in a nitric acid solution in the ultra- applied carefully to prevent the creation of
sonic cleaner. Any residual silver lacquer will air bubbles caused by gas emission that
cause gas emission or discoloration when the might compromise the bond between the
porcelain is baked. Therefore, its complete re- coping and the veneering porcelain.
moval is absolutely necessary. 11. The copings are ready to be built up with
8. Refine the margins of the copings with a sili- porcelain. Use any type of commercially
cone polisher {Fig 13). available porceiain to build up the restora-
9. The surface of the electroformed copings ex- tions (Fig 14).
hibits the typical surface of a monophase
 ZAPPALA/LUCERNINI

Fig 4 The base of the master die Fig 5 Undercuts, cavities, and sui- Fig 6 The base of the duplicated
IS prepared, and undercuts are face roughness are blocked out. die is ground and is minimized as
eliminated. much as possible.

Fig 7 A hole is drilled 1 to 2 mm Fig 8 Cyanoacrylate is applied on Fig 9 AGC Conductive Silver Lac-
under the margins. the copper rod, which is then in- quer is applied over the duplicated
serted into the hole and left to dry. die in the desired shape of the final
coping and over the part of the die
in proximity to the copper/titanium
rod.

Fig 10 Electroforming equipment. Fig 11 Electroformed coping on Fig 12 Duplicated die dissolved in
the duplicated die immediately a gypsum removing acid in an ul-
after the completion of the electro- trasonic cleaner.
forming process.

Fig 13 The margins of the copings

are ground with a silicone polisher.

Fig 14 Facial view of the copings

tried-in the patient's mouth.

QDT 2001
 Esthetic Restorations with the AGC System

Figs 15 to 18 Facial view of the completed restorations cemented in the patient's mouth.
Note the blending of the restoration with the soft tissue at the restoration-gingival interface.

Figs 19 and 20 Facial view of the patient's smile. Note the excellent blending of the restorations-
 ZAPPALA/LUCERNINI

• Oiscussion M References

The AGC System is a well-documented prosthetic 1. Leinfelder KF. An evaluation of casting alloys used for
restorative procedures, J Am Dent A5S0C
system,* and high, long-term success rates have 1997;128(1):37-45.
been reported for the use of the system for ante- 2. McLean JW, Reproducing natural teeth in dental porce-
rior and posterior crowns and anterior fixed partial lain. In: The Science and Art of Dental Ceramics. Vol II:
Bridge Design and Laboratory Procedures in Dental Ce-
dentures." The fabrication process with the use of ramics. Chicago: Quintessence, 1982:21-44.
24k gold offers the following functional, biologic, 3. Lamster IB, Kalfus DI, Steigerwald PJ, et al. Rapid loss of
and esthetic advantages (Figs 15 to 20): alveolar bone associated with nonprecious alloy crowns in
two patients with nickel hypersensitivity. J Periodontol
1987:58:486-492.
1. The system allows the fabrication of crowns, 4. Vence B. Electroforming technology for galvanoceramic
inlays and onlays, fixed partial dentures, and restorations. J Prosthet Dent 1997,77:444-449.
5. Raigrodski AJ, Malcamp C, Rogers WA. Electroforming
telescopic ridge prostheses with excellent
technique. J DentTechnol 1998;15(6):13-16.
fit.' '^'° 6. Wir7 J, Hoffmann A. Biological dental prosthetics In:
2. Due to the excellent biocompatibility of the Electroforming in Restorative Dentistry: New Dimensions
in Biologically Based Prostheses. Chicago Quintessence,
electroformed coping, it is possible to leave
2000:13^4.
the margins of the restoration in gold without 7. Erpenstein H, 6orchard R, Kerschbaum T Long-term clini-
the risk of discoloration of the free gingival cal results of galvano-ceramic and glass-ceramic individ-
ual crowns. J Prosthet Dent 2000;83:530-534.
margin resulting from metal corrosion.'•^•'"^
8. Koutayas SO, Kheradmandan S, Bernhard M, et al. Frac-
3. The gold color raises the value of the veneer- ture strength of different types of antenor 3-unit fixed
ing porcelain, promoting its natural appear- partial dentures (abstract 1599). J Dent Res 20O0;79:343,
ance.'" 9. Holmes RJ, Pilcher ES, Rivers JA, Stewart MR, Marginal fit
of electroformed ceramometal crowns. J Prosthodont
4. The reduced thickness (0.2 to 0.3 mm) of the I996;5{2):ni-114.
electroformed gold coping esthetic restora- 10. Set: J, Diehl J, Wever H. The marginal fit of cemented
tion can be achieved with minimum tooth re- galvanoceramic crowns. IntJ Prosthodont 1939;2:61-64.
11. Giezendanner P Suitability of electroforming for ordinary
duction while reducing the risk of pulp devi-
use: Experience with the Hafner HF 600. Quintessence
talization. In addition, an esthetic restoration DentTechnol 1998;21:39-S6.
can be achieved in cases such as restricted 12. Stewart RM. Electroforming as an alternative to full ce-
ramic restorations and cast substructures. Trends Tech
interocctusal space and mandibular incisors.^
Contemp Dent Lab 1994;! 1:42-47.
5. Working time is reduced, and consequently
the cost of the lab is, too. In fact, the fabrica-
tion of an AGC electroformed crown saves at
least 50% of the metal in comparison t o the
traditional metal-ceramic crown, and the en-
ergy required t o produce an AGC electro-
formed crown is 100 times less.

JQDT 2001
Clinical and Laboratory Case Presentations Using
Lithium Disilicate Glass-Reinforced Ceramics

Oliver Brix, ZT*/Horst Mayer, Dr Med Dent**/Kathrin Stryczek***

ll-ceramic restorations have become in- proved m ate rial-related properties compared to
dispensable. Their field of indication is the original Empress were deciding factors, espe-
increasing constantly, and the reluctance cially with regard to all-ceramic fixed partial den-
toward adhesive cementation is decreasing con- tures and posterior restorations. This article will
tinuously. Only the selection of the "proper" all- not focus on the physical and chemical properties
ceramic system remains difficult, given that there of Empress 2, since they have already been de-
are so many systems on the market with different scribed in detail in previous articles. The intent of
fabrication processes. this article is to show the practical aspects, paying
The authors decided to begin using the new close attention to the esthetic appearance and
IPS Empress 2 system (Ivoclar, Amherst, NY, USA) the easy handling of this new material. The es-
in 2000. Its easy laboratory processing and im- thetic possibilities and the day-to-day suitability of
Empress 2 will be demonstrated through three
progressively more extensive clinical cases.

m SYSTEM FUNDAMENTALS

'Technician, Innovatives Dental-Design, Frankfurt/Mam, The system comprises two components. The first
Germany.
is a pressed substructure material made of a
"Private practice, Mayer/Stryczek/Dunsch, Frankfurt/Main,
Germany, lithium disilicate glass ceramic with a flexural
***Private practice, Mayer/Stryczek/Dunsch, Frankfurt/Main, strength of 350 MPa. Thanks to this high resis-
Germany, tance as compared to the original Empress, the
Reprint requests: Mr Oliver Brix, Innovatives Dental-Design, range of indications has been extended to small
Eschersheimer Landstrasse 18, D-60322 Frankfurt/Main, Ger-
many, fixed partial dentures and posterior teeth. This
 BRIX ET AL

material can be cemented either with adhesives • i CASE 1

or conventionally with glass-ionomer cement. The
second component of the system is the new layer- In this case the maxillary right lateral incisor was
ing material, which is made of a fluoroapatite nonvital and showed a strong discoloration in its
glass ceramic. These apatite crystals provide a marginal area {Fig 1). After inserting an all-ceramic
balance between opacity and translucency identi- post and core {constructed with the Cosmopost
cal to that found in nature. system), the tooth was restored with an Empress 2
How does this new material perform in the single crown [Fig 2). Within 1 week of its cementa-
mouth, and what color and esthetic possibilities tion, it already showed favorable adaptation to its
do we have in regard to its practical use? The surroundings.
first clinical case provides information about The color harmony and its optical properties
these issues. speak favorably of this material. Figure 3 shows a
section of an Empress 2 crown and allows one to
perfectly visualize the integration of the coping in
the layered crown.

CASE1

Fig 1 Preoperative view of maxillary right lateral in- Fig 2 Postoperative viev
cisor

Fig 3 Section of an Empress 2 crown.

QDT 2001
 Lithium Disilicate Glass-Reinforced Ceramics I

• CASE 2 tion. Figures 7 and 8 show the completed crowns

on the cast. At this stage, it is already possible to
The second clinical case is more comprehensive; it observe the intimate fit and the light transmission
required the restoration of the four maxillary in- of this material. What is suggested on the model,
cisors (Fig 4), To construct all-ceramic crowns, the ie, the harmony in the oral surroundings, appears 1
dinidan has to pay attention to a series of factors. week after cementation in the mouth (Figs 9 to
An atraumatic shoulder preparation with enough 12). In other words, neither single crowns nor more
reduction of tooth structure {Figs 5 and 6) is a complex restorations of the anterior teeth pose
basic prerequisite for the success of such a restora- any type of problem for all-ceramic treatments.

CASE 2 (Figs 4 to 12)

Fig 5 Adequate reduction is achieved by using a re- Fig 6 Prepared anterior teeth. (Clinician, Kathrin
duction guide. Stryczek.)

Figs 7 and 8 Definitive restorations on the cast.

QDT 2001
 Figs 9 and 10 Integrated restoratio

Fig 11 Favorable adaptation between the gingival tis- Fig 12 Close-up view of the incisai details.
sues and the crowns.

• CASE 3 Restoration Process

This patient, who required a full-mouth rehabilita- First, the mandibular anterior teeth were restored
tion (28 teeth), was treated with Empress 2, This with porcelain laminate veneers (Figs 14 to 1ó},
case involved esthetic as well as functional as- The next steps consisted of the removal of old
pects, and was used to determine the limits of restorations, as well as the new preparation and
what can be done with this material. restoration of the abutments. Figures 17 and 18
The steps involved in this rehabilitation are pre- show the situation in the mouth prior to the im-
sented on the following pages, providing insights pression taking with Permadyne. These images
into the specific details of the system. Figure 13 demonstrate that the case may not be ideal for
presents the pretreatment diagnostic casts. As all-ceramic restorations. The challenge involved
mentioned, the functional and esthetic considera- the presence of metal posts in the maxillary right
tions involved resulted in a full-mouth rehabilita- central incisor and left lateral incisor and premolar,
tion treatment plan. a pontic replacing the right first premolar, and
heavily discolored abutments. The patient's re-
quest for metal-free restorations was the main rea-
son for selecting the all-ceramic option.
 Lithium Disilicate Glass-Reinforced Ceramics i

CASE 3 (Figs 13 to 81)

Fig 13 Preoperative view. Fig 14 Preparation for the restoration of the mandibu-
lar anterior teeth with porcelain laminate veneers.

Figs 15 and 16 Postoperative view of bonded veneers.

Figs 17 and 18 Newly prepared and previously treated abutments after removal of the old
restorations. (Clinician, Dr Horst Mayer.)
 BRIX ET AL

Figs 19 and 20 Master casts.

Figs 21 and 22 Articulated casts

Laboratory Procedures (Figs 26 to 29). Figure 30 shows a cast on which

both the prepared anterior teeth and the dupli-
The solid casts were articulated with respect to cated waxed posterior teeth are present. This
the position of the cranium (Figs 19 to 22), A diag- method is beneficial in reducing a full-arch case to
nostic wax-up was completed (Figs 23 to 25). This smaller segments. The overall picture is not lost
wax-up was used as a guide to the fabrication of while trying to achieve function and esthetics.
the ceramic frameworks, After these preparatory steps, the all-ceramic
A common challenge in full-mouth rehabilita- frameworks were waxed up. As already mentioned,
tion is the proper three-dimensional orientation in this step the silicone putty index of the previous
during the layering of the teeth. Aspects such as wax-up served as a reference for the framework
the canine rise/anterior guidance, curve of Spee, construction (Figs 31 and 32). In the fabrication
and a "point centric" indentation, for example, process of the frameworks, a minimum thickness of
pose some difficulties. These problems can be ad- 0.8 mm is required. The wax patterns were sprued
dressed by duplicating the wax-up, and thus ob- on the Empress base following the manufacturer's
taining anatomic casts that can be articulated instructions (Fig 33). For the investment and press-
against the master casts after eliminating the wax ing process, a speed-investment material (Granisit

H QDT 2001
 Lithium Disilicate Glass-Reinforced Ceramics

Figs 23 and 24 Full-contour wax-up for both func-

tional and esthetic orientation.

Fig 25 Design of the anterior teeth.

Figs 26 and 27 Duplicated casts of the wax-up pro

vide information.

Figs 28 and 29 Duplicated casts used as anatomic

cast.
 Fig 30 Special cast in which only the waxed posterior
teeth have been duplicated to fabricate the maxillary
anterior crowns to control the vertical dimension at all
times.

Figs 31 and 32 Silicone putty index for a precise

modeling of the frameworks.

Premium, Siladent, Munich, Germany) was used. The Layer'mg Technique

Within 30 minutes of the investment, the pressing
process can be initialized. Figure 34 shows the The first layers to be applied were interproximal
muffle after the pressing procedure. Figure 35 opaque orange dentin and a horizontal band made
shows the copings after being divested using glass with an opaque white ceramic to control the value
beads and before being etched with Invex acid so- (Fig 41), The dentin buildup was performed with
lution. The copings were sectioned using water dentins of different values and chromas. An incisai
cooling and fitted under the microscope. Figures edge was created using different incisais (Fig 42) to
36 and 37 demonstrate the intimate fit obtained. achieve internal color nuances that were analogous
The next step consisted of a wash bake made out to the selected shade (Fig 43). Eventually, the lay-
of thin layers of dentins and stains. In this process, ering was completed with enamel and translucent
the surface is infiltrated and the previously white ceramics (Fig 44). Figure 45 shows the finished
coping turns translucent and gains saturation. bisque bake on the special cast. Overall, this layer-
Next, the anterior teeth were layered: first, the ca- ing technique does not differ from the one used in
nines were fired, followed by the central incisors, conventional porcelain-fused-to-metal restorations;
and finally the lateral incisors {Figs 38 to 40). Some thus, no alterations in the layering are required.
details of the layering are shown on the left central After completing the maxillary anterior teeth,
incisor {Fig 41), the frameworks of the posterior teeth were con-
 Lithium Disilicate Glass-Reinforced Ceramics

Fig 33 Wax patterns are sprued following the manu-

facturer's instructions.

Fig 34 Muffle after the pressing procedure.

Fig 35 Blasted copings prior to the acid etching with

Invex liquid.

Fig 36 Sectioned copings, fitted onto the cast.

Fig 37 Convincing fit.

Fig 38 Layering sequence: first, the canines.

Fig 39 Next, the central incisors are layered.

Fig 40 Maxillary anterior teeth. The lateral incisors are

the last to be layered.

QDT 2001
 BRIX ET AL

Fig 41 For demonstration of the layering technique,

tho maxillary ieft central incisor is built up again. The
first layers are composed of an interproximal orange
opaque dentin and a honzontal band to control the
value.

Fig 42 Incisai edge.

Fig 43 Integration of shade effects.

Fig 44 Overbuilding with enamel and translucent ce-

ramics.

Fig 45 View of the maxillary anterior teeth on the spe-

cial cast.

l QDT 2001
 Lithium Disilicate Glass-Reinforced Ceramics í

Figs 46 and 47 Fabrication of the pos-

terior frameworks using the anatomic
cast as a reference.

Fig 48 Design ofthe framework forthe

all-ceramic fixed partial denture with V-
shaped connectors.

structed (Figs 46 and 47). The only daring ele- bake try-in is recommended and was performed
ment consisted of the fabrication of the fixed par- on this patient (Fig 58). At this stage, the results
tial denture from the right second premolar to of the comprehensive planning were shown to be
the second molar, because, especially in all-ce- fruitful.
ramic fixed partial dentures, the stability of the Next, Stains-Fluid was applied to the anterior
framework is of utmost importance. For this rea- crowns to control the shade details (Fig 59). At the
son, the manufacturer prescribes a minimum di- try-in, the gingival status had been judged to be
mension of 16 mm^ for the connectors of fixed favorable. Adequate previous treatment and a
partial dentures. To fulfill this requirement, V- properly contoured emergence profile had con-
shaped connectors (Fig 48) were introduced that tributed to this fact, which meant not having to
would later integrate into the shape and shade of question the esthetic success. After the try-in, the
the fired fixed partial denture. The layering of the restoration, which can be observed in detail in
posterior teeth was started on the mandibular Figs 60 to 72, was completed. In a last appoint-
arch (Figs 49 to 55). ment, the restoration was cemented with adhe-
The occlusion was adjusted by performing ex- sjves using the Variolink-2 system.
cursive movements against the anatomic cast, The patient was seen 1 week later for a follow-
ideally preparing the mandibular incisors for the up visit. The gingival response and the color result
coupling of their antagonists (Figs 56 and 57). were esthetically pleasing despite the presence of
After completing the mandibular quadrants, the metallic posts and cores. This demonstrates the
maxillary master cast with the finished anterior ability to succeed with the Empress 2 system even
teeth was again inserted in the articulator and the in challenging situations. Figures 73 to 81 present
remaining quadrants were produced. A bisque the postoperative results.

QDT 2001
 BRIX ET AL

Fig 49 Wash bake and shade modification in one

step.

Fig 50 Control of the value and the chroma from the

inside out.

Fig 51 Dentin buildup to the original size.

Fig 52 Overbuilding with different incisais.

Fig 53 Occlusal reduction of the dentin until reaching
the coping.

Fig 54 Integration of opaque orange dentin.

Fig 55 Completion of the occlusal surface with an

enamel-dentin blend and incisais.

QDT 2001
 Lithium Disilicate Glass-Reinforced Ceramics I

Figs 56 and 57 Constant cont'ûl of Ihe occlusion and the excursive movomonts with tho
anatomic cast. Using this method, one segment after another is completed.

Fig 58 Bisque bake try-in. Fig 59 Close-up view of the anterior restorations at
the bisque bake try-in.

Figs 60 and 61 Frontal ano lingual views of the glazed and polished restorations.
BRIX ET AL

Figs 62 and 63 View of both arches {compare to Figs 23 and 24).

Fig5 64 and 65 Lateral view of the posterior teeth.

Figs 66 to 69 Close-^o view of the different quadrants.

 Lithiurn Disilicate Glass-Reinforced Ceramics I

Figs 70 to 72 Satisfactory resuits are achieved with

the Empress 2 system despite the challenging situa-
tion.

Figs 73 and 74 Bonded restorations 1 week following

insertion.

Fig 75 Symbiosis among form, shade, and structure.

QDT 2001
 BRIX ET AL

Figs 76 and 77 Lateral view of the completed full-mouth rehabilitation

Figs 78 and 79 Completed rehabilitation.

Fig 80 Palatal ose-up view ofthe maxillary anterior Fig 81 Orar harmony.
teeth.

QDT 2001
Seteded Cície
Innovations in Esthetic Restorations Using Porcelain Laminate Veneers
Masao Yamazaki, DDS*
Satoshi Tsuchiya, MDT**
Case 1 Preparation is extended to the lingual surface to compensate for the lack of enamel on the labial side.
Case 2 The tooth was prepared after completion of a composite resin restoration. Tooth structure was missing
st the incisai edge due to bruxism. Thus, this surface was not reduced any further.
Case 3 Modification of gingival levels by orthodontic treatment.

i I ' 1.

Positioning of orthodontic brackets using

the free gingival margins, not to the incisai
edge position, is the key factor.

...^X.i='.,M,„.^-r.^.

Since laminate veneer restoration is

planned after the orthodontic treatment,
definite anterior guidance is provided.

Teeth-gingivae-lip relationships are well balanced.

Masao Yamazaki, DDS, Harajuku Dental Office, ** Satoshi Tsuchiya, MDT, Dentcraft Studio, 3-18-
5-? 2, Jingumae, Shibuya-ku, Tokyo, Japan. 4-201, Minamiaoyama, Minato-ku, Tokyo,
Japan.
 stabirshing Harmony Between Dental Restorations and the Perio
""" .: . Yoshinori Shimizu, MDT* .'à
' ' -' • Kenji Tsuchiya, DDS** --M

The need to fabricate dental restorations that combine

harmony between function and esthetics is extended
also to include harmonious relationships between the
restoration and periodontium. The periodontal tissue
is delicate and will keenly respond to invasive stimuli;
thus, knowledge of the healthy periodontium is
mandatory. This knowledge enables the restorative
team to treatment plan Ejnd deliver restorations that
will exist in harmony with the periodontium.

Fig 1 The preoperative challenging clinical situa-

tion includes uneven gingival levels due to gingival
recession, black triangles, and discoloration of the
devitalized maxillary left canine.
Fig 2 Minor tooth movement is an effective
method to alter gingival levels.
Figs 3 and 4 Mandibular posterior quadrants were
restored with dental implants and a conventional
fixed partial denture. Both mandibular lateral in-
cisors were restored with porcelain laminate ve-
neers, and the rest of the teeth were restored with
porcelain-fused-to-metal fixed partial dentures {ex-
cept for the maxillary left canine, which is a natural
tooth).
Figs 5 and 6 The thickness of the mucosa is measured and trimmed, leaving 1 mm thickness of tissue
from the crest of bone to provide the ovate shape for the pontic.

Figs 7 and 8 The pontic site is developed with the provisional restoration and transferred to the master
cast.

Figs 9 and 10 No sign of inflammation is

observed.
 Fig 11 Lack of embrasure space will re-
sult in Inflamed papilla.

Fig 12 Five millimeters of embrasure space was provided

from the crest of the bone with the provisional restoration.

Fig! 3 The embrasure space

is filled with interdental
papilla.

Figs 14 and 15
Final restorations
demonstrating
healthy gingival
response.

' Yoshinori Shimizu, MDT, YS Dental Lab, 31-7-402,

Kitamine-cho, Ota-ku, Tokyo, Japan.
Kenji Tsuchiya, DDS, Tsuchiya Dental Clinic, 9-10-3F,
Niban-cho, Chiyoda-ku, Tokyo, Japan.
 Osaka Ceramic Training Center, Miyazaki Branch
Award winners of the 2000 Technical Contest

First Place Award

Fukufumi Kuroki
Uekubo Dental Clinic, Miyazaki, Japan

The teeth presented are not fired i n , . , , , .

exercise demonstrates the ability to reproduce form, morphology, and shade in wax, thus cre-
atina a three-dimensional object that enables the restorative tear^ to v,bud,,.t; m^ ut..M.u u .
finitive result and to enhance communication with the patient. (Materials; Creation Wax from
Yeti; Color Toning Wax from Shofu.)
Comments from the judge. Shigeo Kataoka. Osaka Ceramic Training Center: The work pre-
sented is an outstanding example of reproducing tooth morphology and color in wax. I v/ish
the contestant all the best and hope that such devotion and attitude will be carried out in his
ceramics as weil.
 Yamamoto Shogo Award
Takafumi Josen
Jasons Crown and Bridge, Napier, New Zealand

fr

The goal of the exercise was to improve my ability to express proper tooth morphology. The mod-
els and teeth presented are representative of an Asian female in her late 20s. Emphasis was placed
on reproducing accurate transition from antenor to posterior teeth, and accurate occlusal anatomy.
(Material: Creation.)

Comments from the judge. Shogo Yamamoto, Esthetic Laboratory, MASA: The applicant was able

the best and hope he keeps developing in mastering color tone and light transmission. Despite his
r e m o t e tocatior^ (New Zealand), the universal language of dentistry enables him to share and ex-
press similar concepts and philosophies.
 The Judge Award
Koichi Ishimi, Dental Creation Art. Osaka. Japan

f I

This case presentation is a reproduction of natural middle-age dentition (including root area) in
porcelain. The mandible and the maxilla were fabricated in clay, I feel that my results in proper
color reproduction are lacking due to my relative inexperience. (Material: Vintage Halo, Shofu,)

'A*
-.-r

Comments from the judge, Yoshimi Nishimura: The contestant has a good understanding of basic
natural tooth morphology. This knowledge is well reproduced in his work, which demonstrates at-
tention to detail and a balanced transition in morphology from anterior to posterior teeth. Although
the clayjaws are the weakest link, the overall result is impressive.
On March 19, 2000, a t a special lecture series organized by OCTC graduates, MrShogo Yamamoto presented "Bianncoe
rosso," and MrYutaka Yamamoto, Mr Makoto Miyajima, and Mr Stoshi lizuka presented their clinical cases. Along with
these presentations, a technical contest and final presentation by new graduates were held, celebrating the fifth anni«er-
saiy of the OCTC Miyazaki branch. Mr Yoshimi Nishimura stated that overall, the projects presented, although simple,
were supported a by solid concept. It appears that Mr Kataoka's concept of "Nature's Morphology" is well understood by
the students and graduates. (Mr Shoji Sasab, Osaka Ceramic Training Center, Miyazaki branch)

T •

Shinya Ishida (Takashiro Dental Seiichi Matsumoto (Hasegawa Den- Tokuichi Shigeyoshi (Tsuchida Dental
Clinic, Miyazaki, Japan) tal Clinic, Miyazaki, Japan) Clinic. Miyazaki, Japan)

Shoichiro Nakamura (Dental Square Takeshi Arimura (Dental Accel, Mr Kawazoe (Osaka Ceramic Train-
Success, Miyazaki, Japan) Kagoshima, Japan) ing Center, Miyazaki branch)

Masayuki Shimoda (Ceram Art Shi- Tochihiko Iwata (M.D.L, Kumsmoto, Hirohito Taira (Dental Acrcl,
moda, Miyazaki, Japan) Japan) Kagoshima, Japan)

Kazunori Matsumoto (Ceramotec Akira Odawara (Cergmic-Dental, Akihito Suzuki ÇTsuchida Dental
System, Fukuoka, Japan) Kagoshirna, Japan) Clinic, Miyazaki, Japan)

Yasuo Inoue (Tsuchida Dental Clinic, Makoto Fujimoto (Tsuchida Dental

Miyazaki, Japan) Clinic, Miyazaki, Japan)
 DR GRUNDER received his training in periodontat prosthesis at the University of Zurich.
His private practice in ZoHii<on, Switzerland, wtth his partner Dr GaberThüeís, places a
strong emphasis on implant dentistry and iixed prosthodontics. His shii :n both placing
and restoring implants (surgical and superstructures) combined with the presence of
Hans Peter Spielmann, the master dental technician whose laboratory is in the same
building, provides Dr Grunder with a wide perspective. He is a prolific author who pub-
lishes both clinical and research articles. An international iecturer, he is recognized world-
wide in the field of implant dentistry. In recent years, many developments and advance-
ments have occurred in the field of impiant dentistry. His work is a combination of careful
planning, based on vast ciinical experience, and meticu'ous surgical and clinical execu-
tion. This interview provided us with a unique opportunity for an update from a ciinician
who is an authority in this fi'e'd.

In recent years, changes in socket as with the traditional risky, especially from an esthetic
surgical and restorative two-step method. Also, the non- standpoint. Bone résorption and
protocols enabled the submerged protocol for implant soft-tissue shrinkage following
orative team to combine placement, in which the implant tooth extraction happen in vary-
many steps that had traditionally is connected to the oral environ- ing degrees and can signifi-
been achieved in many separate ment from the moment it is cantly compromise the esthetic
appointments. How did such placed, has proven to be as pre- results. The key to minimizing
changes affect the collaboration dictable as the traditional sub- complications that may be asso-
between the clinician and the merged protocols in which the ciated with reduced-appoint-
dental laboratory? implant was placed, covered, ment protocols is proper case
and uncovered in a second- selection. In my opinion, only
First, I would like to ad- stage surgery. With the available very few cases are appropriate
dress the issue of select- data it is clear that immediate for immediate implant place-
ing the appropriate surgi- temporization and/or immediate ment.
cal protocol and the trend of loading of implants will become The combination of immedi-
reducing the number of treat- a routine treatment modality in ate implant placement with the
ment steps. We know that it is the near future. However, we traditional two-stage (sub-
possible to achieve the same have to understand that treat- merged) protocol does not
success rates when placing an ment approaches such as imme- make sense to me as a clinician,
implant immediately after tooth diate placement with immediate because the benefit of such
extraction into the extraction temporization/loading are more an approach is minor and the

QDT 2001
 An Interview with
Conducted by
UELI GRÜNDER Avishai Sadan, DMD

disadvantages, such as more jaws, the immediate placement tion must be reinforced using a
difficulties with soft tissue han- with immediate loading proto- metal framework. Fabricating a
dling or a higher risk when cols have a lot of advantages full-arch transitional prosthesis in
using membrane techniques, for patients. They do not have one day (the implants are
are obvious. to wear a complete denture as placed and immediately loaded)
The delayed immediate-im- a transitional prosthesis for sev- is a challenging task for the den-
plant protocol, which is based eral months, and they do not tal laboratory. Such cases re-
on placing the implant about 8 go through the discomfort of quire close collaboration at the
weeks following the extraction, being without dentures 2 weeks treatment-planning stage, fabri-
after the healing of the soft tis- postsurgically. Also, fewer ap- cation of a precise surgical stent
sue at the extraction site is com- pointments are necessary. by the dental laboratory, and
pleted, seems to me to be (in The clinical approaches of im- maxillomandibular records by
most cases) the m e t h o d of mediate temporization or load- the clinician. Close collaboration
choice. For single tooth replace- ing require close collaboration is essential because some ad-
ment, if one can accept some with the dental laboratory. In the justments are expected at the
soft tissue shrinkage and if there case of a single-implant restora- delivery of the full-arch transi-
is no bony defect, the immedi- tion, the abutment and the tem- tional restoration. In my case,
ate implant placement with the porary crown must support the the dental laboratory, under the
nonsubmerged technique, soft tissue adequately to avoid leadership of Mr Hans Peter
maybe even with immediate tissue shrinkage. Thus, a cus- Spielmann, and our clinic are in
temporization, can be a wonder- tomized abutment and tempo- the same building. Our close
ful protocol. It is a very good ser- rary crown have to be prepared collaboration as a team, from
vice to the patient and the best in advance and adjusted on the treatment planning to comple-
way to preserve healthy papillae. day of surgery. tion, is routine.
For fixed implant-supported In full-arch reconstructions,
reconstructions in edentulous the provisional acrylic restora-

QDT 2001
GRUNDER

Fig 1 This patient's maxillary right Fig 2 The flap design should not Fig 3 Guided bone regeneration
central incisor had to be extracted leave visible scar tissue. The im- procedure is performed using a
due to trauma. An ovate-shaped plant IS placed, and it is obvious Gore-Tex membrane and BioOss.
temporary was used to preserve that although the buccal bony
the papilla. plate is present, it is not thick
enough for esthetic reasons.

Fig 4 Perfect tension-free flap Fig 5 Six months after implant Fig 6 Four weeks after the mem-
adaptation is a key factor for the placement, the membrane is re- brane was removed and a soft tis-
success of the membrane tech- moved. Adequate bone volume is sue graft completed, sufficient tis-
nique. now available on the buccal side of sue is present in the implant area.
the implant head.

Growing demands from tissue and its reaction t o me- contribution for enhancing es-
patients for esthetic res- chanical pressure. In the case of thetic results. This breakthrough
ftorations affect the implant a single-implant restoration, we in the use of ceramic materials
fiela as well. What are the signif- start by placing our first tempo- started with the alumina-ceramic
icant changes that you have no- rary restoration, with an ovate a b u t m e n t d e v e l o p e d by Drs
ticed in this context in recent pontic design, into the extrac- Prestipino and Ingber. Currently,
years? tion site. It will support the soft zircon oxide {zirconia) seems to
tissue at the extraction site and be a very promising material.
We have learned our limits will preserve the papilla. Follow- However, this technique needs
from failures. Years ago, ing implant placement we apply more improvements before it
the introduction of GBR pressure using individualized can be utilized routinely in every
{guided bone regeneration) abutments, provisional restora- practice. It is up to the manufac-
techniques was a significant tions, and the final crown to turers and dental laboratories to
step in our ability to achieve es- shape and support the dental keep improving this material so
thetic results in implant den- papillae and create the perfect that more dentists will be able
tistry. However, some limitations soft tissue result. to benefit from it.
still exist regarding the amount On the prosthetic side I see Another new technology that
of tissue that can be regener- the development and introduc- allows us t o work wit h n o n -
ated or augmented. We also tion of ceramic-based restora- castable materials is CAD/CAM.
learned to carefully handle soft tive components as a significant Using CAD/CAM technology, Mr
 Perspectives in Implant Dentistry I

Fig 7 Abutment connection is ac- Fig 8 The Impression is made di- Fig 9 An alumina-ceramic abut-
complished through minor soft tis- rectly from the implant, and the ment is prepared at the laboratory.
sue opening and insertion of a abutment is selected on the master
healing post. cast at the laboratory.

Fig 10 During intraoral insertion of Fig 11 Insertion of the fixed transi- Fig 12 After 6 months, when no
the abutment, additional pressure tional restoration. more changes in soft tissue are ex-
is applied to the soft tissue to pected, the abutment is re-pre-
shape the papilla. pared and a new impression is ob-
tained.

Fig 13 The definitive Empress crown is cemented. Fig 14 No soft tissue discoloration is present as a re-
Perfect papillae are present, and a harmonious soft tis- sult of the different augmentation procedure.
sue margin is established.

QDT 2001
GRUNDER

spielmann is able to produce far orally may adversely affect proper implant placement. This
customized abutments and both phonetics and esthetics. is not the case in complex cases,
frameworks, up to full-arch Placing the implant too far labi- even if they seem to be rela-
bridges, made completely of zir- ally will result in soft-tissue re- tively simple—from an implant-
con oxide. It is our belief that cession. Placing adjacent im- positioning standpoint—at first
the esthetic outcome using plants too close to each other glance. Once an extensive mu-
metal-free restorations is worth will eliminate any hope for the coperiosteal flap is raised, all
the effort. f o r m a t i o n of inter-implant the landmarks that made the
papilla. This all comes down to case look simple disappear, and
With the advancement of the conclusion that there is only it becomes even worse if addi-
techniques and technolo- one proper position for implant tional steps, such as grafting,
gies, not much is being placement, and the surgical are required. It becomes ex-
recently about proper treat- stent is the tool guiding us to tremely challenging to properly
ment planning, especially in the this position. Also, a properly place the implants without a
context of well-designed surgi- designed stent provides us with stent. The information provided
cal stents. Why do you find the additional information, such as by the stent is very useful, even
surgical stent so important? the position and length of the for a very experienced surgeon,
future crowns, the expected because it enables the clinician
We have to keep in mind emergence profile, functional to visualize the desired pros-
that there is no way to aspects, and information for lip thetic result. Also, it is important
prosthetically correct a support. that the surgeon is familiar with
poorly positioned implant. Im- The only exception for the the prosthetic options, such as
proper mesial or distal implant use of a surgical stent is single- the use of different abutments.
placement will adversely affect implant placement by the expe- The clinician who is not willing
the shape of the crown and will rienced clinician. In such cases, to use surgical stents is not striv-
significantly compromise the the adjacent and o p p o s i n g ing for the best possible results.
shape and appearance of the teeth provide the clinician with
papilla. Placing the implant too
the required information for
 IMPLANT DENTISTRY

Predictable Precision, Function, and Esthetics

in Implant Dentistry

Hans-Peter Spielmann, ZT,

ince the introduction of osseointegration, Well-placed implants are a prerequisite to the

the successful application of implant- achievement of a functional as well as an estheti-
supported restorations in edentulous cally successful implant-supported restoration.
and partially edentulous patients has been well Restorations that end up with a ridge-lap design
documented.'"" However, the esthetic outcome of are no longer acceptable. In addition to sufficient
implant-supported treatment was sometimes ne- bone volume, various factors, such as a harmo-
glected, lacking coordination between surgical nious gingival line, sufficient soft tissue volume,
and prosthetic treatment planning. Today, estheti- and the exact emergence site, play an important
cally oriented treatment attracts more attention role in achieving an optimal result in the final
due to patients' requests, especially in partially restoration.''"'^•^'' Predictability in precision, func-
edentulous situations or for single-tooth replace- tion, and esthetics in implant-supported restora-
ment. A single-tooth implant-supported restora- tions is a primary challenge for the dental treat-
tion in the anterior region is indeed the utmost ment team.
challenge for the treatment team. This is espe- Clinicians and dental technicians apply different
cially true when patients display a high smile line components and materials to enhance esthet-
ics.""^'' The most common request from patients is
to maintain or to regain a natural smile (Fig 2).
New knowledge regarding hard and soft tissue re-
construction extends the indications for the place-
ment of osseointegrated implants and encour-
ages surgeons and periodontists to optimize the
*Master Dental Technician, ZollJkon, Switzerland. treatment of the peri-implant tissue.'^^' A success-
Reprint requests: Mr Hans-Peter Spielmann, Dufourstrasse
7a, CH-e702 Zollikon, Switzerland. Fax: + 41(0)1-392 01 13. ful restoration must be not only well integrated in
E-mail: [email protected] size, shape, color, and translucency with the sur-
 Precision, Function, and Esthetics in Implant Dentistry i

Fig 1 All-ceramic Empress crown^' on a CerAdapt

abutment demonstrates a harmonious relationship
among the restoration, the tissue, and the papillae to
create a naturally esthetic silhouette.

Fig 2 Most patients desire to maintain or restore a

natural and harmonious smile.

Fig 3 Implant-supported ceramometal restoration''

emerges perfectly from the peri-implant sulcus; for an
optimal result, the gingival crest should be placed
more apically.

rounding dentition, but also well integrated with thetic result. These circumstances should be taken
the surrounding soft tissue. This integration will into consideration during the vertical and sagittal
provide a harmonious relationship between the positioning ofthe implant according to the size of
restoration and soft tissue, particularly a harmo- the root and crown to be restored later.^^ The co-
nious gingival line (Fig 1), which is not always easy ordination of the surgical, prosthetic, and labora-
to accomplish (Fig 3). The tooth morphology of tory procedures is definitely one of the most im-
natural teeth dictates great discrepancies in root portant goals in achieving optimal esthetic results
and crown width, whereas the transmucosal com- and patient satisfaction. The long-term pre-
ponents of osseointegrated implants are all of ap- dictability for implant-supported restorations de-
proximately the same diameter t o support pends on some essential principles:
restorations of teeth of different dimensions (Fig
4)," This is exemplified in the esthetic region • Anatomic features
when teeth of a small diameter have to be re- • Surgical procedures
placed by implants (Figs 5 to 8), • Prosthetic procedures
Anatomic discrepancies of implants influence • Laboratory procedures
the root and crown contour of the final restora- • Biocompatibility of materials
tion, and therefore will have an impact on the es- • Patient collaboration

QDT 2001
 SPIELMANN

'ßi ^
Figs 4 and 5 Framework of
restoration with gold cylinders of
even diameter to support teeth of
various anatomic shapes.

Figs 6 to 8 Anatomic discrepancies of root and crown contour, compared with implants and
transmucosal components. When teeth of small diameters have to be restored with implants, spe-
cial attention must be given to the hygiene accessibility when designing the restoration.

• PLANNING THE RESTORATION, POSITION, (3) hygiene accessibility, and (4) esthetics. These
^ AND OIRECTION OF THE IMPLANTS four requirements depend merely on implant po-
sition and direction, vertical and sagittal.
Well-placed implants are the key to the achieve-
ment of a functionally as well as an estheticaily
successful implant-supported restoration.^^ The Implant Position
implants should be placed within the long axis of
the restoration to respect the aspects of biome- To achieve proper implant placement, it is manda-
chanics (Figs 9 and 10). Long-term results may be tory to plan the future restoration by means of a
influenced by the loading condition of the restora- wax-up or set-up of the teeth (Figs 11 and 12),
tion, and especially by the stress magnitude that This wax-up or set-up, which represents the
is placed on the individual implants. Overload in anatomic design of the future restoration, is con-
this biomechanical system can lead to marginal comitantly verified by a radiographie or surgical
bone loss or mechanical failure.*'^"' Restorations guide stent {Figs 13 and 14). This individual guide
that end up with a ridge-lap design should be stent indicates to the surgeon the favorability of
avoided. Ridge lap-shaped restorations are diffi- the implant site in reference to the proposed
cult to clean, which in most cases results in tissue restoration (Figs 15 and 16),
inflammation."-^''" Planning the position of implants and restora-
The essential requirements for an implant-sup- tions is a prerequisite to achieve functionally as
ported restoration are: (1) function, (2) comfort. well as estheticaily successful restorations. It is

QDT 2001
 Precision, Function, and Esthetics In Implant Dentistry j

Figs 9 and 10 Restoration and im-

plants are in perfect axial align-
ment to ideally support the oc-
ciusal forces.

Figs 11 and 12 Wax-up or set-up,

a must for planning the restoration
and implant placement.

Fig 13 Radiographic and surgical

guide stent with steel pins as indi-
cators for proper implant sites.

Fig 14 Master cast with analogues

of optimally placed implants ac-
cording to the surgical stent.

most important that the implants, regardless of in the peri-implant sulcus should be maintained
their size and number, are placed within the axis at the lowest possible level (Figs 8 and 17),^"' If
on the center position of a crown or bridge abut- in a multiple-unit restoration, for any anatomic
ment, marked by steel pins on the individually reason, an implant cannot be placed within the
designed guide stent (Fig 14), If two or more im- marked site through the guide stent (eg, if the
plants are placed, care should be taken to place root of an adjacent natural tooth is inclined too
them as parallel as possible to each other to much toward the implant site and impedes
avoid jeopardizing the final esthetic result. If the proper placement), we must consider a can-
implants are placed according to the preplanned tilevered restoration. In many cases, surgeons
restoration, emergence profiles and embrasures tend to move the implant site just a few millime-
can be properly created by the dental technician, ters more distal or mesial or change the axis of
which facilitates adequate oral hygiene proce- the implant, jeopardizing the proper location for
dures by the patient. For biologic reasons and the screw access holes as well as the final es-
long-term success, plaque and calculus formation thetic result.
5PIELMANN

Figs 15 and 16 Radiographic diagnosis with guide

stent to determine implant sites.
Fig 17 Proper placement of implants prior to plan-
ning enables embrasures and ideal emergence profiles
as well as hygiene accessibility

For screw-retained restorations in the posterior edge (Fig 10), Implant restorations in the ante-
region, the implants must be placed in such a way rior region are rather challenging for the dental
that the screw access holes are positioned in the team. In the treatment of maxillary edentulous
occlusal central fissure of the restoration (Figs 10 arches, desirable esthetic results could be much
and 14). Already, slight variances in implant direc- more easily achieved if biomechanical consider-
tion will cause malfunction as well as a poor es- ations permit a pontic-designed restoration in
thetic result. Screw access holes located in maxil- the region between the canines. However, im-
lary palatal cusps or in the mandibular buccal plant-supported single-tooth restorations are
cusps are therefore undesirable for occlusal func- the most demanding challenge where adjacent
tion since these are working cusps. Location of natural teeth with supporting soft tissue are
the screws in the maxillary buccal cusp region is clearly visible; in these cases, we should achieve
also not preferred because of an undesirable es- esthetic standards compatible with conventional
thetic result. restorative dentistry, with excellent gingival har-
For screw-retained restorations in the anterior mony and the restoration itself blending in per-
region, the screw access holes should be lo- fectly between the neighboring teeth (see Figs 1
cated in the palatal or lingual third to the incisai and 2),^^'"-'=
 Precision, Function, and Esthetics in Implant Dentistry \

Fig 18 Perfect implant position

sagittslly between labial and
palatal emergence lines.

Fig 19 Peri-implant SUICÜS on soft

tissue model after anatomic
buildup of restoration. Note the
difference from Fig 18.

Figs 20 to 22 Ideal implant position sagittally as well as vertically to obtain a cemented restora-
tion that enables buildup of an ideal anatomic contour arid ernergence profile.

Figs 23 to 25 Implant position sagittally more to the palatal emergence line angle to obtain a
transocclusal screw-retained restoration. Insufficient apical placement in the vertical direction com-
promises an ideal crown contour.

Sagittal Versus Vertical Placement planned, the ideal placement of the implant is in
the center of the labial and palatal emergence line
The undesirable configuration between the im- of the adjacent teeth {Figs 20 and 21). This will
plant/abutment and the root/crown to be replaced allow elaborating an ideal labial emergence con-
requires a very precise placement of the implant tour (Fig 22). However, if a screw-retained restora-
(Fig 18). According to the tooth to be replaced, tion is projected, the implant is placed near the
we must compensate more or less for the discrep- palatal emergence line (Figs 23 and 24). This posi-
ancy between the implant diameter and the great- tion has some disadvantages for the labial emer-
est diameter of the tooth (Fig 19). If we restore a gence contour of the restoration and therefore
central incisor where a cemented restoration is must be compensated for in the vertical place-
SPIELMANN

Figs 26 to 28 Optimal emergence of an all-ceramic Empress crown" on a CerAdapt abutment

concludes a strict follow-up ofthe clinical and laboratory protocols.

ment to avoid a labial ridge lap-like contour (Fig rected by using angulated abutments or possibly
25). This poses more submarginal depth, allowing by modifying abutments (Figs 29 and 30), An an-
achievement of a continuous proper anatomic gulation of up to 15 degrees calls for a cemented
shape of the restoration, which starts at the abut- restoration. Angulations of more than 15 and up
ment junction and must emerge labially on the to 35 degrees allow transocclusai screw-retained
same line at the height of the adjacent teeth. restorations. However, if implants are placed too
A harmonious gingival line requires a precise close to the labial emergence line, the use of an-
emergence site. If the implant is not sufficiently gulated abutments may have some negative im-
apical but more palatal, we cannot build up an pact labiatly on the soft tissue. With increased
ideal emergence profile (Fig 24), The achievement angulations, the abutments have a more pro-
of well-positioned implants as well as good es- nounced forward direction before they angle, thus
thetic results mandates the position of the restora- creating excessive pressure against the soft tissue
tion-abutment margin labially to be 2 to 4 mm and consequently leading to tissue recession and
submarginal (Fig 21),"-" However, for wider teeth, esthetic failure (Figs 31 and 32).
this depth is sometimes not sufficient to permit an
The precise placement of the implants to fulfill
optimal root and crown contour. Smaller teeth
anatomic and esthetic needs of the teeth to be re-
need less submarginal placement ofthe implants
stored is often not an easy task. In most cases,
since there is a smaller diameter to be created.
bone and soft tissue regeneration is a prerequisite
The vertical position ofthe implants depends also
to restore an ideal anatomic site for implant place-
very much on the size of the tooth to be restored.
ment.""'^'''° However, hard and soft tissue recon-
An ideal combination of sagittal and vertical
structions do not merit the effort if ultimately the
placement will permit creation of an optimal
implants are not placed as accurately as possible
emergence profile, and hence a harmonious gin-
gival outline (Figs 26 to 28). within the anatomic features of the restoration
and in harmony with the neighboring teeth, A
thorough presurgical diagnosis reveals the possi-
ble angulations of implants, and thus the need to
Implant Direction use angulated abutments. Surgeons have to be
fully aware o f t h e anatomic characteristics and
Maxillary anterior teeth emerge at an angle of 15 consequences of the various transmucosal abut-
to 35 degrees to the occlusal plane. Angulations ments, particularly when angulated abutments are
of implants within this range can easily be cor- imperative."'''
 Precision, Function, and Esthetics in Implant Dentistry í

Fig 29 Implant direction in the Fig 30 Angulated abutments on Figs 31 and 32 Clinical impact of
maxillary anterior region often en- implants placed too close to the an angulated abutment exerting
countered because of the labial emergence line can produce excessive pressure on the tissue is
anatomic situation of the bone. adverse effects on the soft tissue. a recession of the tissue.
Orientations like this can be cor-
rected by using angulated abut-
ments.

PROSTHETIC AND LABORATORY ity (Fig 34). A record base is made on the master
• RESTORATION PROCEOURES cast resting on the healing abutments, A minimum
of two of the healing abutments are removed to
Full-Arch Restorations be replaced by either standard or EsthetiCone
abutments (Nobel Biocare, Göteborg, Sweden],
After successful implant placement according to allowing for screw retention intraorally through
the planned restoration, a healing period is al- gold cylinders attached to the record base {Figs
lowed, 3 months in the mandible and 6 months 35 and 3Ó).
in the maxilla. After the appropriate healing pe- After mounting on the articulator with a face-
riod, the second-stage surgery with abutment bow transfer, an anatomic tooth set-up is per-
connection is performed, allowing another few formed (Figs 37 and 38). The set-up is tried in the
weeks of healing after the second-stage inter- patient's mouth {Fig 39). Corrections are made
vention. In the meantime, custom trays are pre- until functional and esthetic satisfaction is ob-
pared for final impressions. In most cases, the tained regarding vertical dimension, incisai length,
impressions are made directly from the level of lip support, and phonetics (Fig 40). Over the final-
the implants." ized set-up on the master cast, an index is made
Master casts with removable soft tissue with silicone putty {Fig 41). Only now can we se-
iVestogum, ESPE, Seefeld, Germany) are fabri- lect the abutments, utilizing the silicone index of
cated (Fig 33). Healing abutments identical to the set-up as a reference (Fig 42). The criteria for
those in the patient's mouth are utilized for the the appropriate abutment are the availability of
master cast tissue molding to obtain the same tis- the interocclusal space, the depth of the peri-im-
sue situation on the master cast as in the oral cav- plant sulcus, and the implant direction.

QDT 2001
SPIELMANN

Master Cast and Soft Tissue Fabrication

Figs 33 and 34 Master cast with
removable soft tissue mask.

Figs 35 and 36 Preparation of the

record base, with the acrylic base
resting on the healing abutments
that are of identical height to those
in the patient's mouth, fixed with
two screws on trial abutments.

Anatomic and Diagnostic Set-up

•MM»

Figs 37 and 38 Anatomic and diagnostic set-up, prior thetic satisfaction is reached regarding vertical dimen-
to the try-in. The abutments are not selected at this sion, incisai length, lip support, and phonetics.
stage. Only two abutments are in place for intraoral tri-
als and to screw retain the acrylic base with the set-up Figs 41 and 42 Abutment selection on the master
on the master cast. cast with the aid of the silicone indox made over the
anatomic set-up. Type and size of the abutments se-
Figs 39 and 40 Intraoral try-in of the anatomic set-up. lected depend on the interocclusal space, the peri-im-
Corrections are made until functional as well as es- plant sulcus depth, and the implant orientation.
 Precision, Function, and Esthetics in Implant Dentistry I

Framework Waxing, Investing, Casting

Figs 43 to 45 Waxing up of the framework. Prior to the wax-up, the gold or plastic cylinders are
splinted together with pattern resin. After polymerization, the splint is separated in several places
and reconnected after a few hours.

Figs 46 to 48 The waxing, investing, and casting protocol permits a high reproducibility of pas-
sive-fitting frameworks.

In most cases the anatomic set-up is further To obtain well-fitting frameworks of any span, it
processed to a long-term metal-reinforced provi- is indispensable to follow strict laboratory proce-
sional restoration that patients will wear for up to dures, such as the selection of the appropriate
1 year or more, allowing them to accommodate to investment material, which has to be highly com-
the new oral situation and giving proof of func- patible with the alloy in use (Fig 46). The powder-
tional and esthetic comfort. The resin provisional to-liquid ratio must always be measured accu-
restoration will then be replaced by a permanent rately. An adequate setting time for the
porcelain-fused-to-metal restoration. investment is followed by a long and slow heating
The silicone index made from the provisional procedure in the furnace, between 3 and 4 hours
restoration is used for building up a proper frame- depending on the size of the investment cylinder.
work design (Fig 43), Prior to the wax-up of the The melting of the alloy is performed with an
framework, the gold cylinders are splinted to- open flame and by means of a gas-oxygen mix-
gether with self-curing pattern resin (Fig 44). After ture. After the casting procedure, the cylinders are
the polymerization of the resin, the splint is sepa- gradually cooled down to room temperature to
rated in three to four places on the full arch, de- promote a grain structure formation and a more
pending on the number of cylinders (Fig 45). Be- rigid casting. Quenching a casting in cold water to
fore reconnecting the separations, the splint will speed up the cooling procedure can be very de-
sit for several hours. Following this procedure, structive to the framework and must be avoided
tension is avoided in the splint by the setting con- by all means. By respecting this waxing, investing,
traction of the resin. and casting protocol, a very high reproducibility of
 SPIELMANN

Porcelain Application and Laboratory Verification

Figs 49 to 51 Porcelain is applied after color selection on the patient. According to the color and
the characteristics of the teeth to be restored, different internal stratification techniques are used
to reach optimal natural appearance.

Figs 52 and S3 Restoration is veri-

fied at all stages of the work to
grant hygiene accessibility to the
patient.

Figs 54 and 55 Proper planning

and 3 precise implant placement
enable design and creation of an
ideal occlusion.

well-, passive-fitting frameworks can be achieved in the laboratory, the hygiene accessibility must
(Figs 47 and 48). Fitting and verification of the also be verified (Figs 52 and 53). A thorough plan-
framework on the analogues and on the master ning of the anticipated restoration prior to the
cast are done under magnification. placement of the implant enables the laboratory
Before applying the porcelain, the metal frame to create a functional restoration in terms of occlu-
is verified on the patient. A color layering and sion, anatomic design, and hygiene accessibility
stratification technique to reach an optimal natural (Figs 17, 54, and 55). A strict clinical and labora-
appearance is followed (Figs 49 to 51). There is a tory protocol will finally result in long-lasting
first, and when necessary a second, bisque try-in restorations as well as patient satisfaction (Figs 56
on the patient. Before the restoration is finalized to 59).

QDT 2001
 Precision, Function, and Esthetics in Implant Dentistry \

Final Restoration
Figs 56 to 59 The effort of following up a clinical and laboratory procedure protocol results
in a high standard of predictability in precision, function, and esthetics, and in patient satis-
faction.

Síng/e-7ooí/i Restoration in the Esthetic pearance (Fig 60). Missing papillae require in most
Region cases an extraordinary effort by either surgical in-
terventions or unconventional prosthetic acrobat-
Single-tooth implant restorations in the anterior ics. This can include overcontouring a restoration
region are still the ultimate challenge, especially in with dental porcelain or long contact areas to
cases where patients display a high smile line. The achieve the illusion of papillae, especially be-
size, shape, color, and translucency ofthe restora- tween neighboring implants (Fig 61). Many times
tion have to be well integrated with the neighbor- all efforts fail, resulting in an esthetically unaccept-
ing dentition. The soft tissue contour and intact able solution. Another option could be to add on
papillae must also be harmonious with the gingi- pink porcelain in the tissue area. However, this is
val outline.'^"'"" It is mandatory to achieve high more a solution for bridgework. Special care must
esthetic standards that are compatible with con- be given to the hygiene accessibility for this type
ventional restorative dentistry. Besides an optimal of restoration (Figs 62 and 63).
placement of the implant vertically as well as The technique of pressure to support and pre-
sagittally, the presen/ation ofthe interdental papil- serve the soft tissue around implant-supported
lae and gingival contour presents a difficult chal- restorations is in many cases the crucial key for
lenge for most clinicians. It is the mismanagement long-term esthetic results. The part of the restora-
of soft tissue that often results in a displeasing ap- tion reaching into the submucosal area must be

QDT 2001
SPIELMANN

Preservation of Gingival Contours

Fig 60 Preservation of natural-looking Fig 61 Missing interdental papillae require

gingival contours as well as interdental in most cases unconventional prosthetic
papillae is for most clinicians a difficult tricks, like the overcontouring of a restora-
challenge. It is the mismanagement of soft tion to get the illusion of papillae.
tissue that often results in a displeasing
appearance

Figs 62 and 63 One option for

restoring missing tissue is to add
pink porcelain. This option is more
often used for fixed partial denture
restorations. In the case of such so-
lutions, special attention must be
given to proper hygiene accessibil-
ity.

designed with a flat, wide contact surface sup- A provisional removable prosthesis becomes a
porting the tissue and giving gentle, appropriate very important part in preserving the papillae after
support to the tissue (Figs 64 and 65). Excessive careful extraction by the clinician. The laboratory
pressure or a sharp pinpoint contact can be prepares the prosthesis for the tooth to be ex-
harmful, cutting off the blood supply and result- tracted, creating an ovate rather than long-shaped
ing in tissue recession. The submucosal tissue can pontic design, allowing the clinician to adapt and
be supported through the anatomic shaping of fit it into the extraction socket (Figs 74 to 76). This
the abutment, particularly when ceramic abut- ovate pontic shape will help with appropriate pres-
ments are used, or with the cervical part of the sure to support and preserve the soft tissue during
crowns reaching into the peri-implant sulcus. the healing period, resulting in a perfect condition
With a continuous anatomic shaping of the prior to the implantation {Figs 77 and 78).
restoration that starts at the abutment or implant Impressions are made at the level of the im-
junction as far as the emerging line at the height plant as mentioned above {Fig 79). The labora-
of the adjacent teeth, the contour is created until tory produces the master cast with a removable
it and the emergence profile are optimal {Figs 66 soft tissue mask (Fig 80). This allows the techni-
to 71). This submucosal contouring in a mesiodis- cian to make a proper selection of the abutment
tal as well as labiopalatal direction will finally re- according to the tissue s i t u a t i o n and the
sult in an optimal tissue and papillae condition anatomic needs of the specific tooth to be re-
(Figs 72 and 73). placed (Figs 81 and 82).
 Precision, Function, and Esthetics in Implant Dentistry I

Papillae and Soft Tissue Support

Figs 64 and 65 Cervical part of a restoration reaching Figs 68 to 71 Peri-implant contouring of a restoration,
into the peri-implant sulcus has to be shaped with starting at the implant or abutment junction in s
great care to avoid overcom pressin g tissue and labiopalatal as well as a mesiodistal direction, reaches
papillae. full anatomic contour at the proper emergence site.

Figs 66 and 67 Technicians must learn how to build Figs 72 and 73 Esthetic result of a rather compro-
up a restoration, from implant diameter to the ideal mised implant site with insufficient submarginal im-
anatomic contour, respecting the possibilities of tissue plant placement for this specific size of tooth.
and papillae support.
 SPÍELMANN

Provisional Prostheses Prior to Implantation

Figs 74 and 75 Provisional remov-
able prostheses with long-shaped,
ovate pontic designs.

Figs 76 to 78 After the extraction

of the tooth, the clinician will adapt
and fit the ovate pontic into the ex-
traction socket to support and pre-
serve the soft tissue during the
healing period

Impression and Master Cast

Figs 79 and 80 Impression made
at the implant level, followed by
master cast fabrication with remov-
able soft tissue mask.

Figs 81 and 82 Selection of the

proper abutment according to the
tissue situation and the anatomic
needs for the specific tooth to be
restored.

QDT 2001
 Precision, Function, and Esthetics in Implant Dentistry

Abutnnent Selection, Provisional Crown

Figs 83 and 84 Anatomic-shaped zirconia abutments. Figs 85 to 88 Abutment is prepared according to the
The greater part of the submarginal tissue will be sup- information on the anatomic landmarks of the soft tis-
ported by the anatomic-shaped abutment, and mini- sue mask, following the gingival crest.
mally to not at all by the crown.

Final Restoration

Figs 89 and 90 After the provisional period, a final preparation of the abut-
ment takes place intraorally, followed by making the impression and master
cast, to produce the final all-ceramic Empress restoration.

Figs 91 and 92 Esthetically emerging implant-supported all-ceramic IPS Empress restoration, ce-
mented over the emerging CerAdapt abutment

QDT 2001
 SPIELMANN

With the introduction of all-ceramic abutments

made of aluminum oxide (CerAdapt, Nobel Bio-
care; Fig 82) or zirconia oxide (Metoxit, Thayin-
gen, Switzerland; Figs 83 and 84), we could
greatly improve the quality of esthetics for im-
plant-supported restorations. Most ofthe titanium
abutments demonstrate a nonanatomic shape (Fig
82). This discrepancy has an influence on the root
and crown contour, and finally on the esthetic re-
Fig 93 DCS CAD/CAM unit.
sult. In many cases, a gray, unpleasant shadow ap-
pears through the tissue because of the color of
the titanium abutments. Alumina or zirconia allows
creation of individually and anatomically shaped
abutments, which are much more physiologic, like With the DCS CAD/CAM/CNC system (computer-
natural tooth abutments (Figs 83 and 84). Accord- aided design/manufacturing and computer-nu-
ing to the information of the anatomic landmarks meric controlled system)" (DCS Dental, Allschwil,
from the soft tissue mask on the master cast, the Switzerland; Fig 93), the possibility to process
abutment is prepared in the laboratory following bridge frameworks in zirconia oxide (Metoxit) for
the gingival crest of the tissue mask (Figs 85 to all-ceramic restorations is available (see Figs 99
S8). The submucosal part of the abutment is and 100). The ZrO^-TZP BIO-HIP (tetragonal zirco-
shaped carefully to give an ideal morphology nia polycrystals biological heat isostatic pressed) is
(Figs 83 and 84), A provisional crown, which the known for its high biocompatibility and outstand-
patient will wear from 3 to 6 months, is fabricated. ing fracture strength, which so far has not been
Thanks to the careful anatomic shaping of the pro- reached by any all-ceramic material for use in the
visional crown and the abutment as well as the ad- field of restorative dentistry. Zirconia bridges bear
equate pressure induced on the papillae, we can the high loads (< 1,280 N) in the molar region with
expect to achieve an optimal gingival crest and a very high degree of reliability,'^^^ In the field of
papillae (Fig 91)." medicine, zirconia is used for orthopedic devices,
After the provisional period, when a stable and namely hip prostheses.^' It was discovered as a new
harmonious soft tissue contour is established, a root post material and, as already mentioned, for
final preparation of the abutment will take place abutments in implant dentistry. For about 2 years
orally, followed by making the impression and fab- we have been using zirconia for fabricating bridge
ricating the master cast (Figs 89 and 90), In most frames as well as single crown copings.
cases, the material of choice for the fabrication of The DCS system is designed for infrastructure
the all-ceramic crown is IPS Empress (Ivoclar, milling of crown and bridge work of metallic or
Amherst, NY, USA; Fig 92), nonmetallic materials. Three-dimensional (3-D)
data from the master cast with the previously pre-
pared zirconia abutments are obtained through an
• CAD/CAM TECHNOLOGY optical 3-D scanning or the mechanical digitizing
system (Fig 94), From the 3-D data obtained from
The use of high-tech materials like zirconia oxide in the master cast with either prepared teeth or im-
the field of restorative dentistry opens up new di- plant abutments, we continue with the CAD pro-
mensions in fabricating esthetic restorations in the cessing of the framework on the computer screen
laboratory, since many patients express the desire (Figs 95 and 96), The thickness of the copings or
not only to get nonmetallic single-tooth restora- bridge abutments can be varied, as can the con-
tions but also nonmetallic fixed partial dentures. nectors, according to the specific material to be

QDT 2001
 Precision, Function, and Esthetics in Implant Dentistry I

Fig 94 Three-dimensional digitiz Figs 95 and 96 CAD processing of the framework for zirconia milling by
ing of the individually produced the DCS CAM unit.
zirconia abutments.

Figs 97 and 98 Milling unit with

blank holder to receive blanks of
metallic or nonmetallic material.

Figs 99 and 100 Zirconia frame as

milled from the inside out.

Figs 101 and 102 Zirconia frame

adapted over the abutments on
the master cast.

Figs 103 and 104 Cenyical view of

zirconia frame before and after
porcelain application.
SPIELMANN

Figs 105 to 107 Final oral insertion of the

individualized zirconia abutments supporting
a cemented zirconia-frame all-ceramic
bndge restoration.

processed, Pontics are set and designed to the master cast and to the single abutments (Figs 99
appropriate size. The data of the final frame are to 102), Final refining of the surface is performed
transferred to the processor of the milling ma- to receive porcelain application (Figs 103 and
chine. Copings with vertical dimensions of up to 104), The case procedure follows according to the
15 mm and frames that will fit in the blanket size previously described clinical and laboratory proto-
of 50 mm X 80 mm can be milled (Figs 97 and col until the final oral insertion takes place (Figs
98). The milled frame must be adapted to the 105 to 107),
 Precision, Function, and Esthetics in Implant Dentistry I

m CONCLUSION 2. Adell R, Lekholm U, Rockler B, Brânemark P-I. A 15-year

study of osseointegrated implants in the treatment of the
edentulous jaw. Int J Oral Surg 1981;! 0:367-416.
The aim of this article was to elaborate on implant-
3. Brânemark P-I, Zarb GA, Albfektsson T (eds). Tissue-Inte-
supported restorations that fulfill the requirements grated Prostheses: Osseointegration in Clinical Dentistry.
of natural teeth. Proper diagnosis and planning of Chicago: Quintessence, 1965.
implant placement and restoration are prerequi- 4. Albrektsson T, Bergmann B, Polmer T, Henry PJ, Higuchi
K, Klineberg I, et al. A multicenter report of osseointe-
sites for predictably functional and esthetic grated oral implants, J Prosthet Dent 1988;60:75-84.
restorations, and for optimal oral hygiene by pa- 5. Zarb GA, Schmitt A. The longitudinal clinical effectiveness
tients. Implant placement must be as optimal as of osseointegrated dental implants: The Toronto study.
Part I: Surgical results. J Prosthet Dent 1990,63:451-457.
possible in sagittal as well as vertical positions, ac-
6. van Steenberghe D, Lekholm U, Bolender CL, Folmer T,
cording to the size of the tooth to be restored. Henry PJ, Hermann 1, et al. The applicability of osseointe-
This is especially true in the anterior region, where grated oral implants in the rehabilitation of partial eden-
tulism: A prospective multicenter study of 558 fixtures. Int
esthetics becomes the utmost challenge to the
J Oral Maxillofac Implants 1990;5:272-261,
dental treatment team. The more palatally an im-
7. Gunne J, Jemt T, Linden B. Implant treatment in partially
plant is positioned, the more apical placement in edentulous patients: A report on prostheses after 3 years.
the vertical direction should be to enable a correct Int J Prosthodont 1994,7:143-148.
emergence profile. The larger the tooth, the more 8. Laney WR, Jemt T Harris D, Henry PJ, Krogh PH, Polizzi
G, et al. Osseointegrated implants for single-tooth re-
apical placement should be, in contrast to smaller placement: Progress report from a multicenter prospec-
teeth with smaller root and crown circumferences. tive study after 3 years. Int J Oral Maxillofac Implants
1994:9:49-54.
An angulation of 15 degrees to the occlusal plane
9. VJedgewood D, Jennings J, Cntchlow HA, Watkinson AC,
is ideal if a cemented restoration is planned. How- Sheperd JP, Franco JW, et al. Experience with ITt osseoin-
ever, for a screw-retained restoration, an angula- tegrated implants at five centres in the UK. Br J Oral Max-
illofac Surg 1992;30:377-361.
tion of more than 15 degrees is required. The
10. Buser D, Mericske-Stern R, Bernard JP, Behnekc A,
strict observance of the treatment and laboratory
Behneke N, Hirt HP, et al. Long-term evaluation of non-
protocols enables the treatment team to maintain submerged ITI implants. Clin Oral Implants Res
a high level of reproducibility. Cooperation among 1997:8:161-172.
11. Avivi-Arber L, Zarb GA. Clinical effectiveness of implant-
the treatment team, surgeon, restorative dentist,
supported single-tooth replacement: The Toronto study.
and technician is mandatory to achieve a pre- Int J Oral Maxillofac Implants 1996:11:311-321.
dictable functional as well as an esthetic perfor- 12. Henry PH, Laney WR, JemtT, Harris D, Krogh PH, Polizzi
mance of long-lasting restorations that blend in G, et al. Osseointegrated implants for single-tooth re-
placement: A prospective 5-year multicenter study. Int J
perfectly and emerge from the peri-implant sulcus Oral Maxillofac Implants 1996,11:450-455.
in harmony with the neighboring teeth. 13. Andersson B, Odman P, Lindvall AM, Brânemark P-I. Ce-
mented single crown on osseointegrated implants after S
yeafs: Results from s prospective study on CeraOne. Int J
Prosthodont 1998;! 1:212-218.
• ACKNOWLEDGMENT 14. Levine RA, Clem DS, Wilson TG, Higginbottom FL, Saun-
ders SL. A multicenter retrospective analysis of the ITI im-
plant system used for single-tooth replacements: Prelimi-
The cases illustrated in this publication have been performed
nary results at 6 or more months of loading. Int J Oral
in cooperation with Dr U. Gründer, Zollikon/ZH, Switzerland.
Maxillofac Implants 1997;!2:237-242.
15. Gründer U. Einzelzahnimplantat: Zur Indikation fur ein
Einzelzahnimplantat—Case report. Schweiz Monatsschr
Zahnmed 1989,99:445^51.
• REFERENCES
16. Grunder ü, Gaberthüel T, Spielmann HP Implantate bei
ästhetisch schwieriger Ausgangslagc—Casereport. Im-
1. ßrenemark P-i, Breine U, Adell R, Hanson B-0, Ohisson A.
piantologie 1993;1:59-67,
Intra-osseous anchorage of dental prostheses. 1. Experi-
17. Spielmann HP, Grunder U, Das Smiüne CeraOne System,
mental studies. Scand J Plast Reconstr Surg
Systemreport. Impiantologie 1993:1:95-97.
1969;3:81-100.
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18. Gründer U, Spielmann HP, Gaberthüel T. Implant-sup- 36. Rangen: B, Krogh PM. Langer B. van Roekel N. Bending
ported single tooth replacement in the aesthetic region overload and implant fracture: A retrospective clinical
A complex challenge. Pfact Periodontics Aesthet Dent analysis. IntJ Oral Maxillofac Implants 1995;! 0:320-334.
1996:3:835-842. 37. Rangert B. Practical guidelines based on biomechanical
19. Belser UC. Bernard JP, Buser D. Implant supported principles. In: Palacci P, Ericsson I, Engstrand P, Rangert B
restorations in the anterior region: Prosthetic considera- [eds]. Optimal Implant Positioning and Soft Tissue Man-
tions. Pra« Periodontics Aesthet Dent 199ó;8:e75-884. agement for the Bránemark System. Chicago: Quintes-
20. Buser D, Belser UC, Schroeder A. Fortschritte und ak- sence, 1995:21-33.
tuelle Trends m der oralen Implantologie. Schweiz 38. Beumer J. Implant overload and bone response. Pract Pe-
MonatsschrZahnnied 1998; 108:326-350. riodontics Aesthet Dent 1999;11:680-682.
21. Prestipino V, (rgber A. Esthetic high-strength implant 39. Zarb GA, Schmitt A. The longitudinal clinical effectiveness
abutments: Parti. J Esthet Dent 1993:5:29-35. of ossec inte g rated dental implants: The Toronto study.
22. Prestipino V, Irgber A Esthetic high-strength implant Part III: Problems and complications encountered. J Pros-
abutments: Part II. J Esthet Dent 1993:5:63-68. thet Dent 1990;64:185-194.
23. Wohlwend A, Studer S, Schärer P Das Zirkondioxidabut- 40 Jemt T, Linden B, Lekholm U. Failures and complications
merit ein neues vol I keramisch es Konzept zur ästhetischen in 127 consecutively placed partial prostheses supported
Verbesserung der SupraStrukturen in der Implantologie. by Bránemark implants: From prosthetic treatment to first
Quintessen! Zahntech 1996;22:364-381. annual checkup. IntJ Oral Maxillofac Implants
24. Watson PA. Development and manufacture of prostho- 1992;7:40^4.
dontic components: Do we need changes? Int J Prostho- 41. Walton JN, MacEntee Ml. Problems with prostheses on
dont 1998:11:513-516. implants: A retrospective study. J Prosthet Dent
25. Ericsson I. Biology and Pathology of Peri-Implant Soft Tis- 1994:71:283-288.
sue. Chicago: Quintessence, 1995 42. Kallus T, Bessing C. Loose gold screws frequently occur in
26. Palacci P Peri-implant soft tissue management Papilla re- full-arch fixed prostheses supported by osseointegrated
generation technique. In: Palacci P, Ericsson 1, Engstrand implants after 5 years. Int J Oral Maxillofac Implants
P, Rangert B (edsj. Optimal Implant Positioning and Soft 1994:9:169-178.
Tissue Management for the Bránemark System. Chicago: 43. Haack JE, Sakaguchi RL, Sun T, Coffey JP Elongation and
Quintessence, 1995:59-70. preload stress in dental implant abutment screws. IntJ
27. Bahat O, Fontanesi RV, Preston J. Reconstruction of the Oral Maxillofac Implants 1995:10:529-536.
hard and soft tissues for optimal placement o! osseointe- 44. Dixon DL, Breeding LC, Sadler j p McKay ML. Compari-
grated implants. IntJ Periodontics Restorative Dent son of screw loosening and deflection among three im-
1993;! 3:255-275. plant designs. J Prosthet Dent 1995:74:270-278.
28. Hürzeler MB, Strub R. Guided bone regeneration around 45 McClumphy EA, Robinson DM, Mendel DA. A compari-
exposed implants: A new bioresorbable device and biore- son of ultimate failure force. Int J Oral Maxillofac Implants
sorbable membrane pins. Pract Periodontics Aesthet 1992;7:35-39.
Dent 1995:7:37-47. 46. Binon P. The effect of eliminating implant/abutment rota-
29. Listgarten M. Soft and hard tissue response to en- tional misfit on screw joint stability. IntJ Prosthodont
dosseous dental implants. Anat Rec 1996;245:410-425. 1996:9:511-519.
30. Augthun M, Conrads G. Microbial findings of deep peri- 47. Spielmann HP, Hagmann A. Neue Möglichkeiten der
implant bone defects. Int J Oral Maxillofac Implants Gerüstherstellung dank CAD/CAM/CNC-gesteuerten An-
1997;12:106-n2. lagen, dargestellt am Beispiel des DCS-Systems. Swiss
31. Keller W, Bfägger U, Mombelii A. Peri-implant microflora Dent2O0O;21:5-18.
of implants with cemented and screw-retained suprastruc- 48. Rieger W. Aluminium- und Zirkonoxidkeramik in der
tures. Clin Oral Implants Res 1998;9:209-217. Medizin. Industrie-Diamanten-Rundschau 1993;2:2-6.
32. Wheeler RC. Wheeler's Alias of Tooth Form. Philadelphia: 49. Filser F, Kocher P, Lüthy H, Schärer P Gauckler U. All-ce-
Saunders, 1984. ramic dental bridges by the direct ceramic machining
33. Spielmann HP. Influence of implant position on the aes- process. Proceedings of the 10th International Sympo-
thetics of the restoration. Pract Periodontics Aesthet Dent sium on Ceramics in Medicine, Paris. Bioceramics
1990:8:897-904. 1997:10:435^36.
34. Quirynen M, Naert I, van Steenberghe D. Fixture design 50. Tinschert J, Nat; G, Doose B, Fischer R, Marx R. Seiten-
and overload influence marginal bone loss and fixture zahnbrücken aus hochfester Strukturkeraniik. Dtsch Zah-
success in the Bránemark system. Clin Oral Implants Res nai^tl Z 1999:54:545-550.
1992;3:104-ni. 51. RiegerW, Weber W. Ex pen en ce on Zirconia Femoral
35. Hoshaw S, Brunski J, Cochran G. Mechanical loading of Heads. Thaymgen, Switzerland: Metoxit, 1999.
Bránemark implants affects interfacial bone modeling and
remodeling. Int J Oral Maxillofac Implants
1994,9:345-360.

JQDT 2001
 By Avishai Sadan, DMD, and
Thomas J Salinas, DDS

PRECISION AS A KEYSTONE
The master dental technician Hans-Peter Spielmann has been on
the forefront of dentistry for many years. In collaboration with Dr Ueli
Gründer, he has explored new clinical and laboratory avenues; to-
gether they have created one of the leading teams in implant den-
tistry. They were also one of the first teams to implement CAD/CAM
zirconia-based restorations and to utilize them on natural teeth and
dental implants.
In the field of implant dentistry, manufacturers have created com-
ponents to compensate for malplaced implants. This enables the
restorative team to work more easily in less than ideal situations. Al-
though a wide range of components is available, it will not be able
Hans-Peter Spielmann to predictably bring about satisfactory results in a poorly planned sit-
uation. Although carious lesions are not a concern in cases of poorly
sealed margins on implant restorations, the tissue response and the
unfavorable stress that may be transferred to implants, or the stress
involved in misfit, can result in a fracture of the supporting frame-
work. The time and effort Mr Spielmann dedicates to achieve preci-
sion fit is impressive,
Mr Spielmann's approach demonstrates that the drastic change in
materials and technologies eliminated some concerns related to tra-
ditional materials and technologies, but also created new concerns.
Persistence in the basic principles of dedication, conscientiousness,
and precision will be the key to success in any era.
 A Fixed Whole-Mouth Rehabilitation Utilizing
Natural Abutments and Implants:
Treatment Concepts and Clinical Realization

Nitzan Bichacho, DMDVRafi Lahav, MDT**/Cobi J. Landsberg,

* Private practice limited to prosthodontics, Tel Aviv, Israel.

•'Master Dental Technician, Tel Aviv, Israel.
***Private practice limited to periodontics, Tel Aviv, Israel.
Reprint requests: Dr Nitzan Bichacho, Miriam Hahashmoriait 1Ó,
Tel Aviv 62665, Israel. Fa«: + 972 [3¡ 54Ó-0415. Email: [email protected]

QDT 2001
 Whole-Mouth Rehabilitation I

Figs la to 1c A 45-year-old female patient pre-

sented to the clinic with a request to treat her dete-
riorating dentition that had been reconstructed 15
years ago with fixed restorations. Clinical examina-
tionrevealedfixed partial dentures cemented to
natural abutments in the maxilla, whereas tele-
scopic restorations were cemented to natural abut-
ments bilaterally in the mandible. The treatment
plan included a whole-mouth rehabilitation utilizing
natural teeth and implants. As the patient declined
any surgical augmentation procedure, the hopeless
teeth (maxillary right first premolar and mandibular
bilateral third molars) were removed and following
the alveolar ridge maturation, a surgical guide for
implant placement was fabricated. However, due to
anatomic jaw limitations and the patient's rejection
of advanced bone augmentation procedures, ideal
prosthetically driven implant placement could not
be implemented. Three implants (Sten-Oss, Yorba
Linda, CA, USA) were placed in the right maxilla,
four implants in the right mandible, and three in the
left mandible. The patient presented to the
prosthodontist's clinic with the implants already in
place, and the treatment plan was re conceptualized
according to the existing situation from this stage.

Figs 2a to 2c The mandibular abutments consisted

of four implants and two prepared premolars {from
the previous rehabilitation) on the right side, and
three implants and two telescopic copings on the
premolars on the left side. Due to massive résorp-
tion of the edentulous ridge and implant placement
according to the existing anatomic conditions, the
left mandibular implants were placed with a pro-
nounced lingual inclination. In the maxilla, the im-
plants were again placed according to existing
anatomic limitations. The esthetic zone exhibited
six anterior maxillary teeth with composite resin
restorations, an uneven and straight incisai line, and
gingival recession of the right canine and lateral in-
cisor. Adjacent to the mandibular incisors, labial
gingival recession was noted.
 BICHACHO ET AL

QDT 2001
 Whole-Mouth Rehabilitation

Figs 3a to 3c The lateral views of both sides de-

pict overeruption of the previously restored maxil-
lary molars, which resulted in decreased intermaxil-
lary space and accentuated curves of Spee. The
treatment plan at this stage would include a signifi-
cant reduction of the maxillary molars' vertical
height, with or without surgical crown elongation,
and possible extraction of the inclined right first
molar. The vital anterior maxillary teeth should be
modified in shape and color either by full-coverage
crowns or porcelain veneers, whereas the nonvital
left lateral incisor and canine should be crowned.
The mandibular incisors' recession should be
treated by conservative periodontal treatment. To
assess the different treatment steps for achieving
an optimal prosthetic result, articulator-mounted di-
agnostic models are required.

Figs 4a to 4c The diagnostic wax-up revealed that

correction of the curves of occlusion was possible
only by prosthodontic redesigning, with minimal to
no need for surgical modification of the posterior
maxillary teeth. Together with the laboratory techni-
cian, with the patient present, an esthetic analysis
was conducted at this stage. Because of a low
upper lip line and a restricted gingival display, it
was decided not to treat the gingival asymmetry of
the maxillary anterior teeth. However, it was de-
cided that the incisai line of these teeth should be
corrected and the color of ali teeth enhanced.

Figs 5a to 5c The diagnostic wax-up models

served to create the external form of the provi-
sional acrylic restorations through silicone matrices
as well as constructions of custom-made gold trans-
mucosal abutments to be connected to the im-
plants. The implant abutments were designed such
that their gingival part would blend with the sur-
rounding soft tissue [with a pronounced chamfer
finish line configuration), whereas their coronal part
was designed to match the crown forms as dupli-
cated from the optimal shape of the diagnostic
models. In normal treatment planning, the implants
would have been placed according to the diagnos-
tic models as well, thus enabling the use of prefab-
ricated abutments to support the overlying crowns.
However, to bridge the discrepancies between the
existing implants' platform location and orientation
to that of the planned crowns, the connecting abut-
ments had to be custom-designed for each crown.

QDT 2001
ßlCHACHO ET AL

1 Ideal Treatment Planning (I) 3 Optima! Treatment

• Planning (11)

2 3D Diagnostic Models ^ 4 Provisionalization

 Whole-Mouth Rehabilitation I

Figs 6a to 6c The custom-made gold abutments

were carried within an acrylic positioner to facilitate
their delivery intraorally as well as to secure the
abutments when screvuing and connecting to the
implants. Each abutment was shaped with a flat in-
terproximal surface to avoid rotation of the abut-
ments within the acrylic positioner and to have a
definitive seating of each crown. Due to its superior
esthetic, biologic, and physical properties, the
Captek system (Precious Chemicals Inc, Altamonte
Springs, FL, USA) was used to create all definitive
restoration copings. The implant copings were fab-
ricated directly onto the abutments to facilitate a
later pick-up impression together with the natural
teeth abutments using a full-arch impression tech-
nique.

Figs 7a to 7c The outer forms of the diagnostic

provisional acrylic restorations were duplicated
from the diagnostic wax-up. As for the inner as-
pects, the implant crowns were matched precisely
to the implant gold abutments, whereas thin acrylic
shells were created for the natural teeth abutments,
to be relined after preparation. It was not yet deter-
mined whether the anterior maxillary teeth would
be crowned or laminated. The overall provisional-
ization procedure of such treatment should be exe-
cuted in one treatment appointment.

Figs 8a to 8c The transmucosal abutments were

connected intraorally to the implants utilizing the
acrylic positioner, and the natural abutments were
re-prepared. The provisional crowns were adjusted
intraorally several times while the patient was moni-
tored fora period of 5 months. The provisional
restorations were occasionally reexamined and
readjusted to provide adequate function when as-
sessing the supporting tissue reaction and when an-
alyzing their esthetic appearance. It was then de-
cided to restore the four vital maxillary teeth with
bonded porcelain veneers (Creation, Klema GmbH,
Meiningen, Austria]. Despite potential periodontal
involvement, it was also decided to use all of the
right maxillary molars, including the steep mesially
inclined second molar (which replaced the missing
first molar). This was decided because the provi-
sional restorations were functioning satisfactorily;
they were properly cleaned and an excellent tissue
reaction was maintained.

Fig 9 The diagram describes the treatment con-

5 Intraoral Modifications cept to this stage. The ideal treatment plan should
always be verified by three-dimensional diagnostic
models. The models are a key factor in analyzing
the different possibilities of the initial treatment
planning, and they ensure that an optimal treat-
ment plan can be executed. The diagnostic models
are then duplicated into provisional restorations to
6 Realistic Treatment be placed intraorally. Depending on the case, a di-
Plan (III) agnostic period for analyzing function, esthetics,
phonetics, and tissue reaction has to be set up, and
the patient should be regularly monitored and
treated if needed. This stage might last from 2 to
18 months, depending upon the initial status of the
BICHACHO ET AL
 Whole-Mouth Rehabilitation i

supporting tissues and abutments, as well as the

patient's cooperation and "dental IQ." The reaction
and adjustment of the oral tissues to the provisional
restorations and the necessary treatments that
might arise accordingly are also looked for in the
provisional stage Only after complete healing of
the oral tissues, and full satisfaction of the patient
and the treatment team, is a realistic treatment plan
determined. The definitive stage of the treatment
can then take place.

Figs 10 to 13, a to c Single Captek copings were

manufactured and verified for individual seating in-
traorally. The copings were then connected accord-
ing to the definitive treatment plan, and a Captek
wax-pontic was added for the missing maxillary left
second premolar. An occlusal supportive ring was
constructed over the mandibular copings according
to the Captek metal design, and tubes for trans-
verse 5crews were added to the implant-supported
retainers. To achieve the final desired metal form,
Capcon-Capfil materials (Captek system. Precious
Chemicals Inc) were added where indicated. The
metal substructures were designed to support the
veneering materials and to minimize stress build-up
between the metal and the veneering materials,
thus minimizing metal deformation. The connected
retainers were again verified for their seating intrao-
rally, and pick-up impressions were made to con-
struct the definitive working casts and to provide
the correct relationship between the restoration
margins and the surrounding gingiva.
 BICHACHO ET AL

QDl 2001
 Whole-Mouth Rehabilitation I

Figs 14 and 15, a to c In the authors' team experi-

ence with full-mouth rehabilitation treatment, the
use of a semi-adjustable articulator is sufficient for
transferring the intermaxillary and intraoral data to
the laboratory, with minimal intraoral adjustments
required, A spring-loaded universal face-bow (Face
BowAEA, Dentatus, New York, NY, USA) has been
used to record the orientation data and transfer it
to the articulator (Dentatus Articulator ARH), and
the casts were mounted.
BICHACHO ET AL
 Whole-Mouth Rehabilitation I

Figs 16 to 18, a to c The veneering outer forms of

the definitive restorations have been duplicated
from the intraoral modified acrylic provisional
restorations after serving for 5 months. The natural
teeth crowns were veneered with porcelain (Cre-
ation) fused to the Captek copings. The implant-
supported crown copings were veneered with a
laboratory composite resin (ArtGlass, Heraeus
Kulzer, South Bend, IN, USA). It has been the au-
thors' experience that the Captek system provides
maximum support and adherence to laboratory
composite resin veneering materials, and that a
composite resin veneer in transverse screw-retained
crowns is more durable and long lasting than a ce-
ramic veneer. It should also be noted that the im-
plant-supported crowns, in addition to their trans-
verse screw connections, are cemented with
provisional cement (Improv, Steri-Oss) and are re-
trievable, if needed, for possible future repairs and
enhancements. The restorative three-dimensional
shape was initialized with an optimal design in the
diagnostic models, duplicated into provisional
acrylic restorations, modified intraorally as needed
during the diagnostic monitoring phase, and then
duplicated in form to the definitive restorative ma-
terials.
BICHACHO ETAL

Bichacho N, Landsberg CJ. Single implant restorations:

• ACKNOWLEDGMENT Prosthetically induced soft tissue topography, Pract Pe-
riodontics Aesthet Dent 1997:9:745-752.
The authors would like to thank Aharon F. Whiteman, Bichacho N, Landsberg CJ, Silberstein S. Comprehensive
MDT, for his most valuable consultation throughout. rehabilitation of severely traumatized anterior teeth
utilizing a gold alloy-ceramic bridge. Lab Digest
1998;Spring:7-11
Blatz iWB, Kern J, A new composite resin veneering mater-
ial bonded to telescopic crowns. Quintessence Dent
• BIBLIOGRAPHY Technol 2000:23:149-158.
Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prostho-
iichacho N, Achieving optimal gingival esthetics around dontics. Chicago: Quintessence, 1994.
restored natural teeth and implants: Rationale, con- Kopp FR. Esthetic principles for full crown restorations:
cepts and techniques Dent Clin North Am Part II. Provisionalization. J Esthet Dent
1998:42(4]:763-780. 1993:5.258-264.
¡¡chacho N, Landsberg CJ. A modified surgical/prosthetic Magne P, Douglas WH. Optimization of resilience and
approach for an optimal single implant-supported stress distribution in porcelain veneers for the treat-
crown: Part II. The cen/ical contouring concept, Pract ment of crown-fractured incisors. Int J Periodontics
Periodontics Aesthet Dent 1994;6:35-41. Restorative Dent 1999:19:543-553.
 Whole-Mouth Rehabilitation |

Figs 19 and 20, a to c During a routine recall visit,

18 months postoperatively, the implant crown
restorations were retrieved for examination of the
provisional cement status and the gingival reaction
surrounding the transmucosal prosthetic units. Sat-
isfactory results were observed, and marked func-
tional and esthetic improvements to the preopera-
tive status were noted. The various types of
definitive restorations—the porcelain veneers of the
anterior maxillary teeth, the porcelain-fused-to-
Captek crowns over the natural abutments, and the
A rtG I ass-fused-to-Captek retainers connected to
the (gold custom-made abutments screwed to the]
implants—exhibited complete integration with
healthy surrounding tissues.

Morris RB. Strategies in Dental Diagnosis and Treatment Shoher I. Vital tooth esthetics in Captek restorations. Dent
Planning. London: Martin Dunitz, 1999. d i n North Am 1998:42(41:713-718.
Natfianson D, Riis D, Goldstein R. In vitro capacity of a Shoher I, Whiteman AF. Captek—A new capillary casting
technology for ceramometal restorations. Quintes-
new bridge system [abstract 1 ó39|. J Dent Res
sence DentTechnol 1995:18:9-20.
1991:70.
Touati B, Miara P, Nathanson D. Esthetic Dentistry & Ce-
Rieder C. Customized implant abutment copings to
ramic Restorations. London: Martin Duniti, 1999.
achieve biologic, mechanical, and esthetic objectives.
Zappala L, Shoher I, Battaini P Microstructural aspects of
IntJ Periodontics Rostorative Dent 1996:16:21-29.
the Captek alloy for porcelain-fused-to-metal restora-
Schärer P, Rinn LA, Kopp FR. Esthetic Guidelines for tions. J Esthet Dent 1996:8:151-153.
Restorative Dentistry. Chicago: Quintessence, 1982.
Shoher I. Reinforced porcelain system: Concepts and tech-
niques. Dent Clin North Am 19e5;29(4):489-496.
 EMPHASIZING ONE'S STRENGTHS
Nitzan Bichacho is the president of the European Academy of Es-
thetic Dentistry and an editorial board member of several peer-re-
viewed journals, A prolific author and teacher, he expands his focus
on esthetic dentistry in a flourishing full-time private practice.
His teamwork concept is slightly different from the accepted
norm. He prefers to collaborate with several laboratories rather than
working with one exclusively. The concept according to Dr Bichacho
is simple, and he explains it by using his own practice as an example:
"Although I practice all facets of fixed prosthodontics, my main
strength is complex fixed cases on natural teeth and dental implants.
Nitzan Bichacho Colleagues know that this is my principal sphere of treatment and
refer relevant patients to me, A similar rule can be applied for dental
technicians. Whereas most dental laboratories encompass all angles
of restorative dentistry, they have certain areas that they emphasize.
Even within the field of fixed prosthodontics, some technicians spe-
cialize in all-ceramic restorations; others specialize in fixed implant
restorations, or single units, or complex crown and bridge restora-
tions, etc. Since I am utilizing a very wide range of systems, materi-
als, and technologies in my practice, the selection of my technician
partner is primarily based on his expertise within the case specifica-
tions. Custom tailoring a dentist and a technician-partner to the
treatment plan specifications is a concept that entails working with
one's strengths, and this is a predictable recipe for elevating success
rates."
Zygomaticus Implants: A New Treatment Modality
for the Edentulous Maxilla

Thomas Salinas, DDSVAvishai Sadan, DMD **/Tom Peterson, CDT, MDT***/

Bundhit Jirajariyavej, DDS, MSc****/Michael Block, DMD*****

atients who present for prosthetic reha- Lekholm show that using osseointegrated im-
bilitation of an edentulous maxilla can plants in the edentulous maxilla can display rea-
often present a challenge when osseoin- sonably successful outcomes with fixed partial
tegrated implants are chosen to assist a pros- dentures.' Many times, the maxillary sinus cavities
thetic reconstruction with retention, stability, and can become quite enlarged in those who become
support. Obstacles to placement of implants are edentulous at an early age, which precludes
the endemic porous quality of bone in the max- placement of a full complement of osseointe-
iila, enlarged sinus cavities, and inadequate bone grated implants into the maxilla. To overcome this
volume. Fifteen-year studies by A d e l l and problem, Boyne and James introduced a concept
of adding bone to the sinus cavity to provide an
additional volume into this critical area.^ Many of
these patients were initially treated with the
'Associate Prcifessor, Department of General Dentistry,
Louisiana State University Health Science Center, School placement of a bone graft into the sinus; then
of Dentistry, New Orleans, Louisiana. after a 6- to 8-month consolidation period, 6 to
**AssÍ5tant Professor, Department of Prostho don tics, 10 implants were placed into the entire arch for
Louisiana State University Health Science Center, School
of Dentistry, New Orleans, Louisiana. rehabilitation at a later time. Success rates ranged
•"Master Dental Technician. Owner, Northshore Dental from 70% to 89% over 70 months.
Laboratories, Lynn, Massachusetts. This can be a formidable treatment option for
•"•Fellow, Maxilbfacial Prosthetics, Department of Prostho- those who cannot wear conventional dentures.^"
dontics, Louisiana State University Health Science Cen-
ter, New Orleans, Louisiana, instructor. Department of However, the time delay is a disadvantage in
Prosthodontics, Mahidol University, Bangl<ok, Thailand. these patients, since up to 1 year may pass before
""•Professor, Department of Oral and MaKillofacial Surgery, any of the prosthetic phases can be initiated.^ Pro-
Louisiana State University Health Science Center, New
Orleans, Louisiana. tocols of using immediate placement of implants
Reprint requests: Dr Thomas Salinas, Department of General into these bone-grafted maxillas began to be-
Dentistry, Louisiana State University Health Science Center, come popular in the interest of reducing the time
School of Dentistry, Box 127, 1100 Florida Avenue, New Or-
allotted for both of these surgical phases. Some
leans, LA 70119.
SALINAS ETAL

-. Zygo malic Zygomatic n

\\ y irnp'^"' ' implant 2 . //

Branemark //S
\\ Branemark implant 4 /Mñ
/ \ \\ implant 3

'<2l y// Loadpointlll

V""^ Load point II

Load point 1

Fig 1 Schematic diagram of Zygomaticus Fig 2 Vector diagram indicating mechanical consider-
implant being placed through maxilla and ations for the use of the Zygomaticus implant.
into the zygomatic process. (Adapted from R, Skalak's work with PI, Branemark, Zy-
goma Training Manual, Nobel Biocare, Yorba Linda,
CA, USA,)

studies indicate that this practice can also be fa- priate bar and superstructure height after casts
vorable. However, a native maxillary alveolar bone are mounted and a diagnostic set-up has been
height should approach 8 mm to adequately sta- verified on the patient (Figs 3 and 4),
bilize the implants,' which often does not exist. Controversies still exist that place doubt on the
A recent technique investigated by Branemark success rate of implants supporting overdentures
involves the use of an extended-length osseointe- compared to those supporting fixed prostheses.
grated implant from the maxillary alveolar ridge However, failures associated with poor bone qual-
through the sinus and engaging the dense corti- ity, relatively short implants, and extreme atrophy
cal bone of the zygomatic process' (Fig 1), Graft- are often cases in which overdentures were the
ing of the sinus cavity is avoided with this sce- treatment chosen. Some studies comparing im-
nario since two zygomatic implants engage dense plants supporting fixed prostheses to those sup-
cortical bone and each opposes each other's load porting overdentures have found similar success
with an angular vector (Fig 2). This procedure is rates when both are placed in bone of similar
indicated for a completely edentulous maxilla quality and quantity,'-'"
with bilateral placement of two Zygomaticus im- A stable attachment mechanism is indicated
plants and at least two additional auxiliary con- for overdentures that are implant supported. The
ventional root-form implants in the anterior max- combination of electrical discharge machining
illa. Compatibility of titanium implants through and milling a connecting bar can create a very
the sinus has been investigated and actually stable superstructure/infrastructure relation."
found to be favorable." The integration time is a However, the costs of spark erosion machining
standard 6 months, after which a stabilizing bar may be prohibitive. Alternative techniques of ta-
attachment is placed at uncovering to minimize pered milling (Figs 5 and 6) with careful super-
forces on the zygomatic implants, A second bar structure fabrication can be applied to a greater
attachment is made in the traditional fashion to number of cases with easier methods of fabrica-
accurately develop attachment sites and appro- tion and servicing,'^
 Zygomaticus Implants: A New Treatment Modality for the Edentulous Maxilla I

Fig 3 Master casts ready for mounting and fabrication Fig 4 Master casts mounted on semi-ad|ustable artic-
of diagnostic wax-up. uiator with diagnostic wax-up.

Figs 5 and 6 Vacuum-rcriTied matrices indicating available restorative dimension for bar attach-
ment fabncation.

P TECHNIQUE was confluent with the floor of the mouth, and

the quality and quantity of saliva were thin and
The use of this technique is illustrated in a patient scant, respectively. A panoramic radiograph re-
with maxillary atrophy and inability to wear con- vealed an atrophie maxilla with pneumatized pos-
ventional prosthetics. A 72-year-old African terior segments. The mandible measured about
American woman presented to the dental clinic 18 mm from superior to inferior margins. After
complaining of difficulty in wearing maxillary and casts were mounted and a determination of the
mandibular complete dentures. Her medical his- interarch restorative dimension was made, plans
tory was noncontributory with the exception of for making maxillary and mandibular overden-
hypertension controlled with beta-blocker medi- tures were contemplated. The patient was ad-
cation. Oral examination showed an atrophie vised of the plans for the surgical and restorative
maxilla with redundant tissue anteriorly and lim- phases, including all pertinent risks, and was
ited to no vestibule. The mandibular vestibule eager to proceed with treatment.

QDT 2001
SALINAS ET AL

Fig 7 Manual placement of Zygomaticus implant at

surgery.

Fig 8 Completed placement of all implants at the end

of the first surgery.

Fig 9 Placement of abutments after tissue punch un- Fig 10 Luting of semi-burnable copings with light-
co very. cured resin and resin bar for fabrication of provisional
bar.

The patient was placed under general anesthe-

sia for placement of two Zygomaticus implants
and three (3.8-mm) nonhexed lock implants in the
maxilla, and five (4.3-mm Replace) tapered im-
plants in the mandible (Nobel Biocare, Yorba
Linda, CA, USA) (Rgs 7 and 8), The patient toler-
ated the procedure well and was allowed to heal
for 6 months to permit integration to occur for 6
months.
After this time the patient was prepared for
second-stage surgery. PME abutments {Nobel
Fig 11 Placement of provisional bar to splint Zygo- Biocare) were placed on all maxillary implants and
maticus and other root-form implants. torqued to 32 Ncm to affirm integration (Fig 9].
 Zygomaticus Implants; A New Treatment Modality for the Edentulous Ma>

Fig 12 Maxillary master cast after final impressio Fig 13 Mandibular master cast after final impression.

Fig 14 Mounted master casts after diagnostic wax-up

has been completed.

Fig 15 Verification of wax-up on patient for esthetics

and phonetics.

Plastic/gold copings were luted together with pre- a transitional denture may be made to rest over
fabricated round bars (Attachments International, the transitional bar attachment.
San Mateo, CA, USA) and Triad gel (Caulk/ After soft tissues were given a chance to heal
Dentsply, York, PA, USA) splinting all maxillary im- properly, transfer copings were placed on all abut-
plants (Fig 10). The assembly was gently removed ments and a diagnostic impression was made with
from the mouth, attached to analogs, and imme- irreversible hydrocolloid for fabrication of custom
diately placed into a stone patty for stable trans- trays. A final impression was made with polyether
port. The subsequent framework was then in- to transfer the position of implants in making a
vested and cast in gold alloy and delivered to the master cast (Figs 12 and 13), Occlusion rims were
patient 24 hours later [Fig 11), The use of an im- fabricated and teeth were set to proper vertical
mediate splint of this type reduces the amount of dimension (Fig 14). The set-up was verified for es-
lateral loads placed upon the zygomatic implants. thetics and phonetics (Fig 15), and then diagnos-
During the time taken for definitive prosthesis fab- tic cores were fabricated to aid in constructing bar
rication, the existing denture may be modified or attachments for both arches. Vacuum-formed ma-

QDT 2001
SALINAS ETAL

Fig 16 Clear vacuun^.-formed matrix shows site selec- Fig 17 Vacuum-formed matrix is placed on master
tion for Swis5-Loc NG attachment. cast to ghost silhouette of external contour of prosthe-

trices were made on duplicate casts of the wax-up The metal-based superstructures were made
to "ghost" the silhouette of the final external on the refractory duplicates from a conventional
prosthetic contours to plan placement of the at- method of cobalt-chromium casting. Incorpo-
tachment mechanism (Figs 16 and 17). rated into these superstructures were Swissloc
The bar attachments were made of pattern NG attachments [Attachments International) from
resin splinting plastic/gold copings and were the original design. The superstructures were
milled with a 2-degree taper on a parallel milling retrofitted to the bars with disclosing media, and
machine. The bars were then placed into the the teeth were attached with baseplate wax using
mouth for verification indexing (Figs 18 and 19). previously constructed matrices on the original
Several areas were sectioned and re-relation was master casts. The cast bars were attached again
made with pattern resin. The bar fit was then veri- in the mouth (Figs 27 and 28), and the wax-up
fied radiographicaliy {Fig 20). The resin bars were was then verified again on the patient to ensure
placed into a transfer index using analogs and low ideal occlusal relationships (Fig 29). Clearance for
expansion stone. Both bar attachments were cast hygiene procedures is evident in a frontal view of
in gold alloy and placed on the transfer indices to both bar attachments (Fig 30). After successful
verify fit (Figs 21 and 22). Custom trays were try-in and minor modifications, the superstruc-
made on the bar/master cast to properly recon- tures were free pattern invested and wax elimi-
struct corrected master casts after bar sectioning. nated; silicoating/opaquing procedures were
Both bars w& = returned to the mouth with long then carried out followed by conventional pro-
screws for a pick-up impression with polyether cessing procedures.
material in the custom trays (Figs 23 to 26). Cor- The prostheses were remounted in the labora-
rected master casts were constructed from these tory and finished. The insertion appointment in-
impressions, and both bars were duplicated in re- cluded instructions for placement, removal, and
fractory material on which superstructures were care. Both prostheses were stable upon delivery
fabricated. and allowed the patient improved function (masti-
cation and speech) and esthetics (Figs 31 to 33).
 Zygomaticus Implants: A New Treatment Modality for the Edentulous Maxilla |

Fig 18 Resin pattern is placed over all maxillary im-

plants.

Fig 19 Resin pattern is placed over all mandibular im-

plants.

Fig 20 Radiographic verification of all semi-burnable

copings and abutments for accurate fit.

Figs 21 and 22 Cast bar attachments on verification

indices with long abutment screws.
 SALINAS ETAL

Figs 23 and 24 Bar attachments with long abutment screws are placed for transfer impression.

Figs 25 and 26 Transfer impressions with polyether material to make more accurate master casts

Figs 27 and 28 Cast bars are placed for support of secondary superstructure.

(QDT 2001
 Zygomaticus Implants: A New Treatment Modality for the Edentulous Maxilla I

Fig 29 Wax try-in of secondary prosthesis for esthet- Fig 30 Frontal view of bar attachrrents showing clear-
ics/phonetics and centric relation. ance.

Figs 31 and 32 Occiusal views of completed

prostheses with disengaged attachments.

Fig 33 Frontal view of both prostheses en-

gaged in centric relation.

QDT 2001
SALINAS ET AL

• ACKNOWLEDGMENTS 6, Block MS, Kent JN, Simultaneous maxillary sinus floor

bone grafting and placement of hydroxyl apatite-cos ted
The authors would like to thank the teams at Northshore Den- implants, J Oral Maxillofac Surg 19a9;47:23e-242.
tal Porcelain Laboratory, Lynn, Massachusetts, and RPD inc of 7, Branemark PI. Zygomaticus fixture presentation at the An-
North Lauderdale, Florida, for their efforts in providing the nual Meeting ofthe Academy cf Osseointegration, March
laboratory work in this article. 1999, Palm Springs, CA,
8, Branemark PI, Adell R, Albrektsson T, Lekholm U, Lind-
strom J, Rockier B. An experimental and clinical study of
osseointegrated implants penetrating the nasal cavity and
• REFERENCES maxillary sinus, J Oral Maxillofac Surg 1984;42:497-505.
9, Chan MF, NarhiTO, de Baat C, Kalk W, Treatment of the
1, Adell R, Lekholm U, Rockier B, Branemark PI. A 15-year atrophie edentulous maxilla with implant-supported over-
study ot osseointegrated implants in the treatment of the dentures: A review ofthe literature, Int J Prosthodont
edentulous jaw, IntJ Oral Surg 1981 ;10:387-416, 1998;11:7-15,
2, Boyne PJ, James RA. Grafting of the maxillary sinus floor 10, Zitzmann NU, Marinello CP Treatment outcomes of fixed
with autogenous marrow and bone J Oral Surg or removable implant-supported prostheses in the eden-
1980;38:613-616, tulous mamila. Part II: Clinical findings, J Prosthet Dent
2000:33:434-442,
3, Watzek G, Weber R, Bernhart T, Ulm C, Haas R. Treatment
of patients with extreme rTa>;illary atrophy using sinus 11, Salinas TJ, Finger IM, Thaler JJ II, Clark RS, Spark erosion
floor augmentation and implants Preliminary results. J implant-supported overdentures: Clinical and laboratory
Oral Maiillofac Surg 199S;27:428^34. techniques. Implant Dent 1992,1:246^51,
4, Blomqvist JE, Alberius P, Isaksson S. Two-stage maxillary 12, ErcoliC, Gräser GN,TallentsRH, Hagan ME. Alternative
sinus recorïstruction with endosseous implants: A procedure for making a metal suprastructufe in a milled
prospective study, Int J Oral Maxillofac Implants bar implant-supported ouerdenture, J Prosthet Dent
1998;13:758-766. 1998:80:253-258,
5, Adell R, Lekholm U, Grondahl K, Branemark PI, Lindstrom
J, Jacobsson M. Reconstruction of severely resorbed
edentulous maxillae using osseointegrated fixtures in im-
mediate autogenous bone grafts, Int J Oral Maxillofac Im-
plants 1990;5:233-246,
 A Practical Approach for Retrieving
Cement-Retained, Implant-Supported Restorations

Vincent Prestipino, DDS*/Abraham Ingber, DDS**/Joseph Kravitz, DDS, MS***/

George M. Whitehead, DDS****

here are two different but prevalent tech- giene, design modifications, fracture repairs, and
niques for restoring dental implants. The abutment-screw tightening,^ Screw-retained de-
superstructure prosthesis can be screw- signs make all of these modifications possible with
retained or cement-retained to the implant abut- safety, simplicity, and predictability.
ments.''^ The choice of cementation versus screw Screw-retained restorations, however, require
retention seems to be primarily the clinician's pref- precise implant placement for optimal location of
erence.' There is no evidence that one method of the screw-access hole; deviations from the opti-
retention is superior to the other mal position and angulation can lead to an unes-
The greatest clinical advantage of screw reten- thetic restoration.' Also, it is difficult to obtain pas-
tion is the convenience factor for retrievability.** sivity of screw-retained frameworks due to
During the life of an implant prosthesis, the clini- dimensional discrepancies inherent in the fabrica-
cian may need to remove the restoration for hy- tion process.' While there is a lack of experimental
evidence demonstrating any detrimental effect of
misfit on osseointegration and the issue of misfit
as a biologic risk for implant success remains a
major question, evidence exists that inaccurate
'Private practice, Bethesda. Maryland. Assistant Clinical prosthesis fit can be the cause for component
Professor. University of Maryland at Baltimore. complications such as mechanical loosening
•"Private practice, Sethesda, Maryland. Adjunct Assistant
and/or fracture.'
Clinical Professor, Boston university, Boston, Massachu-
setts. However, cement-retained implant restorations
""•Private prartice, Bethesda, Maryland. Clinical instructor. have certain advantages, such as better esthetics
University of Maryland at Baltimore.
and occlusion, simplicity of fabrication, and re-
'"•"Private practice, Lynwood, Washington.
Reprint requests: Dr Vincent Prestipino, 7630 Old George- duced component and construction cost." An-
town Road, Suite 260, Bethesda, MD 20614 other advantage is the potential for complete pas-

QDT 2001
 Cement-Retained, Implant-Supported Restorations

sivity when a cemented restoration is placed in

the mouth.'" The absence of a screw to draw
poorly fitting components together with a clamp-
ing force would tend to eliminate strain that the
tightening force of the screw would introduce into
the restoration/implant assembly. If a restoration
could be seated passively on multiple abutments,
then the introduction of cement into the space
between prosthesis and abutment would not by
itself introduce stresses into the system. This po-
tential advantage, coupled with the others men-
tioned, makes cement-retained implant restora- Fig 1 Illustration of slot placed at the marginal area of
tions increasingly popular.^ the crown-abutment interface, which receives the end
of a flat-headed driver that will be rotated.
Advocates of cement-retained implant restora-
tions frequently state that retrievability of the
restoration can be maintained if a provisional ce-
ment is used. Unfortunately, little evidence
demonstrates predictable retrievability of various
provisional luting agents when cementing two or ered at the presurgical treatment planning stage.
more metallic or ceramic components together. It Cooperation between the surgeon, restorative
is likely that a cement that functions well as a pro- dentist, and the laboratory technician is needed
visional cement for restorations cemented to to maximize the successful esthetic and functional
teeth may, in fact, be a permanent luting agent for outcome of the implant reconstruction.
metal cemented to metal," A standard test for de-
termining the retention strength of crowns to
abutments is not available. However, Covey et al » RETRIEVAL SLOTS
have shown that the relationship between the
height and width of the abutment is more impor- Safe and efficient removal of cement-retained im-
tant than the total surfece area of the abutment in plant restorations requires the elimination of ten-
determining crown retention of teeth and implant sion on the abutment-retaining screw. Pushing
abutments,'^ Due to the resulting increase of verti- down on the abutment while at the same time
cal abutment clinical crown and preparation pulling up on the prosthesis can eliminate this
height, cement-retained implant crowns can be tension. The challenge is to hold the abutment
very difficult to remove. Should an abutment down while pulling up on the prosthesis, A ratio-
screw loosen or any restoration repair become nal approach would actually be to push down on
necessary, the restoration may be destroyed dur- the abutment and at the same time to push up on
ing the removal procedure if the cement seal can- the prosthesis with a flat-headed instrument that
not be broken easily. When an abutment screw would fit between the two components. A slot
loosens under a cemented multiple-unit implant placed at the marginal area of the crown-abut-
restoration, the restoration is usually uncemented ment interface, which is designed to receive the
from abutments, firmly seated to implants, and end of a flat-headed driver that would be rotated,
firmly attached to the loosened abutment(s). Any can accomplish this approach (Fig 1). The result-
force applied to a restoration on a loosened abut- ing torque force created by rotating the driver
ment has the potential to damage the internal would push down on the abutment and at the
threads of the implants. Thus, the clinical decision same time push up on the prosthesis, resulting in
on retention technique must be carefully consid- the release of the cement seal.

QDT 2001
 PRESTIPINO ET AL

Fig 2 Wax-up of a custom implant Fig 3 Premanufactured cement- Fig 4 The submarginal metal
abutment with a horizontal slot on able abutment with the midlingual below the slot is at least 3 mm in
the midmarginal position of the lin- margin altered to a slot design with height, and the profile of the lin-
gual surface. cutting or milling tools. gual abutment surface is relatively
flat.

Fig 5 The porcelain-fused-to-metal Fig 6 The abutment and crown fit Fig 7 Confirming "lift off" of the
crown with the slot design oppo- together on the master implant crown from the abutment with the
site the slot on the abutment has at cast with confirmation of the fit of rotation of the driver.
least a 3-mm rim of fully contoured the head of the driver.
metal on the lingual surface.

• TECHNIQUE The crown that will eventually cover this abut-

ment is waxed with a similar metal slot design op-
The first consideration during the fabrication of posite in position to the slot on the abutment's lin-
the cement-retained abutment is design. For cus- gual surface. At least a 3-mm rim of fully
tomized waxed-abutment patterns, the conven- contoured metal on the lingual crown surface is
tional techniques are employed for preparation retained without porcelain coverage. The cast
design with the addition of a horizontal slot on the metal crown is finished with porcelain application
mid-marginal position of the lingual surface of the if indicated and traditional polishing instrumenta-
abutment. The slot is at least as wide and deep as tion (Fig 5).
the end of the flat-headed driver used for re- The abutment and crown are fitted together in
trieval, typically 3 mm deep, 2 mm high, and 5 the laboratory. The tip of the flat-headed driver is
mm wide (Fig 2). For premanufactured abutments, placed within the void created between the two
the midlingual margin is usually contoured with a components (Fig 6). The ability of the crown to lift
deep chamfer from the manufacturer and only off of the abutment with the rotation of the driver
slightly altered with cutting or milling tools to cre- is confirmed in Fig 7.
ate a shoulder (Fig 3). The submarginal metal Clinically, the abutment is placed on the im-
below this slot is at least 3 mm in height, and the plant and its proper seating and position are con-
profile of the lingual abutment surface should be firmed intraorally. Then the retaining screw is
relatively flat in this area (Fig 4). The abutment is tightened to the proper torque force (Fig 8). The
completed with the necessary technical require- crown is tried over the abutment and adjusted for
ments to fabricate the superstructure crown. proper seating, approximal contacts, occlusion,

QDT 2001
 Cement-Retained, Impíant-Supported Restorations I

Fig 8 Custom implant abutment Fig 9 Crown seated onto the cus- Fig 10 Luting agent placed be-
delivered intraorally. tom implant abutment intraorally. tween the crown and abutment.

Fig 11 Luting agent cleaned Fig 12 The tip of the driver is Fig 13 Pressure is applied to the
around the crown and left within placed within the slot between the driver into the crown-abutment
the slot. abutment and crown for retrieval. complex slot. The driver is rotated,
lifting the crown off the abutment.

Fig 14 An electric torque driver is

used to hold and control the flat-
headed driver.

and esthetics (Fig 9). The crown is luted to the ial filling the slot is removed, and the tip of the
abutment with the cement of choice. The lingual slotted driver is placed into the slot (Fig 12). A
slot provides a vent hole for the cement to ensure mechanical or electric torque driver will provide
complete seating of the restoration (Fig 10). Ex- greater rotational control force (see Fig 14). Pres-
cess cement is removed after hardening. The ce- sure is applied to the driver into the crown-abut-
ment can either be left to fill in the lingual slot or ment complex slot, and the driver is rotated, thus
removed, and a composite resin is then placed in lifting the crown off the abutment [Fig 13). The re-
the slot for a smooth surface (Fig 11). quired maintenance and/or repair can be per-
formed and the abutment and crown cleaned and
Whenever crown removal is desired, this tech-
recemented with the cement of choice.
nique is simple, safe, and predictable. The mater-
 PRESTIPINO ETAL

Fig IS Lingual slot design on mul- Fig 16 Multi-unit, fixed partial Fig 17 Slot design incorporated
tiple abutments for a multi-unit denture on the custom implant into a multi-abutment subframe.
fixed partial denture. abutments.

Figs 18 and 19 Final superstructure design with the slot design opposite the slots in the subframe.

Fig 20 Tip of a traditional fiat- Fig 21 Tip of the traditional flat-

headed driver. headed driver modified to create
flat parallel sides.

• DISCUSSION incorporated into the lingual surfaces of the sub-

frame to allow for distribution of removal force on
Dr George Whitehead has used this technique for the superstructure. The slots are placed into the
individual implant abutments on single units and subframe between abutments allowing the
multiple units with great success since 1988 (Figs thinnest subframe design possible {Fig 17), The
15 and 16). Another possible use of this technique final superstructure metal framework is fabricated
is for a single subframe connecting multiple im- with the same slot designs at the appropriate lo-
plant abutments. A sufficient number of slots are cations opposite the slots in the subframe (Figs 18

iQDT 2D01
 Ce ment-Retained, Implant-Supported Restorations I

and 19). The prosthesis is completed, and the • ACKNOWLEDGMENT

subframe/superframe prosthesis is placed in the
mouth with the cement of choice. The authors would like to acknov^ledge Morty Ingber, CDT,
David Preîtipino, CDT, Tony Prestipino, and Robert M. Raffel.
Cements that have been used successfully with CDT, for their technical assistance and in the fabncation of the
this retrieval technique include traditional tempo- restorations presented in this article.
rary cements (Tempbond, Kerr, Orange, CA, USA),
zinc oxide-eugenol cements (Temrex, Freeport,
NY, USA), zinc phosphate cements {Mizzy, Cherry • REFERENCES
Hill, NJ, USA), and polycarboxylate cements
(Durelon, ESPE, Norristown, PA, USA). The glass- 1. Albrektsson T, Dahl E, Enbom L, et al. Osseointegrated
oral implants. A Swedish multicenter study of 8139 con-
ionomer and resin cements are indicated in this secutively inserted Nobelpharma implants. J Periodontol
technique when the prepared surface of the abut- 1988:59:287-296.
ment is highly polished. 2. Hebel KS, Gajjar RC. Cement-retained versus screw-re-
tained implant restorations: Achieving optimal occlusion
The end of a traditional implant-slotted screw- and esthetics in implant dentistry. J Pro5thet Dent
1997:77(l):28-35.
driver can be modified for improved resistance
3. Taylor TD, Agar JR, Vogiatzi T. Implant prosthodontics:
force within the slot. The end of the driver has a Current perspective and future directions. Int J Oral Man-
sloped contour, which can be modified with a rub- illofac Implants 2000:15(11:66-75.
ber wheel to create flat parallel sides (Figs 20 and 4. JemtT, Linden B, Lekholm U. Failures and complications
in 127 consecutively placed fixed partial prostheses sup-
21). This modification prevents the driver from ported by Brinemark implants: From prosthetic treatment
"jumping out" of the slot when rotational forces to first annual checkup. Int J Oral Maxillofac Implants
1992;7:40-44.
are applied.
5. Sones AD. Complications with ossEointcgrated implants.
J Prosthet Dent l989;62:5B1-585.
6. Vi/alton JN, MacEntee Ml. Problems with prostheses on
• I CONCLUSION implants: A retrospective study J Prosthet Dent 1994;71:
283-288.
7. Jemt T, Lie A. Accuracy of implant supported prostheses
Asimple, safe, and predictable method that allows in the edentulous jaw. Clin Oral Implants Res 1995:6:
the clinician to use all of the advantages of the 172-180.
8. Tan KB, Rubenstein JE, Nicholls Jl, Youdelis RA. Three-di-
custom, cementable implant abutment technique mensional analysis of the casting acCLirac of one-piece,
and to ensure retrievability of the prosthesis is put osseointegrated implant retained prostheses. Int J Pros-
for^ in this article, A slot design is initiated during thodont 1793:6:346-363.
9. Lewis S, Beumer J III, Homburg W, Moy P. The "UCLA"
the construction of the custom implant abutment abutment. Int J Oral Maxillofac Implants 1988;3:183-189.
and followed through to the final prosthesis. This 10. Chee W, Felton DA, Johnson PF, Sullivan DY. Cemented
complex can be completely fabricated on the mas- versus screw-retained implant prostheses: Which is bet-
ter? (current issues forum|. Int J Oral Maxillofac Implants
ter implant cast if one is confident of its accuracy. 1999,-14(1):137-141.
Another option is to connect the abutment to the 11. Kent DK, Koka S. Froeschle ML. Retention of cemented
implant intraorally and to make a final impression implant-supported restorations. J Prosthodont 1997;6:
193-196.
of the abutment with a traditional technique, while
12. Covey DA, Kent DK, St. Germain HA Jr, Koka S. Effects of
using a die stone cast for fabrication of the final abutment size and luting cement type on the uniaxial re-
prosthesis. tention force of implant-supported crowns J Prosthet
Dent 20OO;83:344-348.
The Versatile Use of Titanium in Implant
Prosthodontics

Achim Michael Renner, MDT*

n the 1790s, W, Gregor discovered tita- Sponge that could be melted in an induction cast-
nium as a dioxide in a titanium-iron oxide ing furnace Into a solid alloy and produced in
dust. In 1795, Martin Klapproth named long, cast solid bars.
this dioxide titanium. However, impure metallic ti- Titanium represents only 6% of the earth's
tanium would not be produced until 1925, when crust. Titanium deposits can be found in Canada,
Brezelius, using sodium, subjected titanium diox- Brazil, and the United States as a pure ore. Tita-
ide to a deoxidization process. In 1926, Van Arkel nium is found naturally in a wide variety of ores,
and De Boel reduced titanium to a 99% pure such as ilmenite (FeO-TiO^), rutile (92% TiO^),
state, producing ductile titanium sticks from tita- anatase, brookite, perovskite (CaO-TiOj), pyro-
nium iodine. phanite (MnO-TiO^), and titanite (CaO-TiO^-SiO^),
Dr Wilhelm Kroll, who is considered to be the Rutile, although less available in its pure form as a
father of the titanium industry, developed metal- titanium oxide, is preferred to ilmenite ore be-
lurgical processes for the commercial production cause a complicated separation and melting
of titanium in the late 1930s, He successfully de- process is required to extract titanium oxide from
veloped the deoxidization process of titanium ilmenite,'
tetrachloride through a reduction procedure with
magnesium and sodium. The result was a titanium
GENERAL CHARACTERISTICS

Titanium and titanium alloys can be classified in 18

different grades, according to the American Soci-
'Master Dental Technician, West Palm Beach, Florida. ety for Testing and Materials (ASTM) standards
Reprint requests: Mr Achim Michael Renner, RCK Dental
Laboratory Inc. 1622 Donna Road, West Palm Beach, FL
published in 1993 (Table 1). Grades 1 to 4 of com-
33409. Fax: (501)686-4103. mercially pure titanium differ among each other
 Use of Titanium in Implant Prosthodontics I

Table 1 ASTM Grade Classifications for Titaniur • BIOCOMPATIBILITY

According to Standards Published in 1993

Grade Classification Biocompatibility tests, based on localized cyto-

toxicity and on systemic response tests, are used
1,2,3,4 Commercially pure titanium
to identify whether a material intended for a clini-
5 Titanium alloy: 6% Al, 4% V (Ti-6AI-4V)
cal use causes a mutagenic or allergic response,
6 Titanium alloy: 5% Al, 2.5% Sn
7,11 Commercially pure titanium +
which may be defined as the response of a host
0,12-0.25% Pd to a biomaterial interacting in a sound biological
9 Titanium alloy: 3% Al, 2.5% V tissue.' Some of the requirements for a material
12 Titanium alloy: 0.3% Mb, 0.8% Ni to be classified as biocompatible are listed
13,14, 15 Titanium alloy: 0.5% Ni, 0.05% Ru below^:
16,17 Commercially pure titanium +
0.04-0.08% Pd
18 Titanium alloy: 3% Al, 2.5% V, 1. It must not cause damage to the surrounding
0.04-0.08% Pd tissues.
2. It must not contain toxic substances that could
be absorbed and released in the circulatory
system, causing a systemic toxic reaction.
due to the addition of small quantities of O2, Fe, 3. It must be free of potential agents that might
N, H, Ca, and other ions during the purification create an allergic response.
process. Titanium is a diomorph; it appears in the 4. It must not induce a carcinogenic response.
form of a hexagonal a-titanium at a temperature of
885°C ± 2°C 11625°F ± 3.6°F) and above this tem- In terms of biocompatibility, titanium is the ma-
perature, it transforms into the shape of a cubical terial of choice for many different applications (in-
body centered, the ß-titanium.' cluding the metal frameworks used in fabricating
Titanium alloys are formed into interim materi- dental prostheses) for two reasons. First, titanium
als by 3 process known as shaping. A head con- is a highly reactive material; once it contacts air,
version process changes the hexagonal a-tita- water, or other electrolytes, it spontaneously
nium phase into the cubical ß-titanium phase. forms a corrosion-resistant oxide layer. This very
The cold conversion process milling and drilling dense layer protects the metal from attack by the
remolds technically pure titanium. The cold con- acids and ions that are present in the oral environ-
version process then produces thin wire sheets ment. Second, titanium is an inert material. Its
and tubes. W e l d i n g and s o l d e r i n g are d o n e
oxide layer is nonsoluble; therefore, no free ions
that could react with organic molecules are on its
under vacuum or with noble gases. However, the
surface.
titanium has to be kept under a veil until it is fully
cooled.
The most commonly used alloy is TÍ-6AI-4V. It
excites in three forms: alpha; alpha-beta; and • LABORATORY CONSIDERATIONS
beta. Aluminum is known to be the stabilizer of AND PROCEDURES
the alpha phase. Once i n c o r p o r a t e d into t he
alloy, it reduces the alloy's total weight and in- The physical and chemical properties of titanium
creases its strength. Vanadium is known to be the make it one of the most versatile metals for al-
stabilizer of the beta phase, and once incorpo- most every use in the dental laboratory (Table 2).
rated into t he alloy, it inhibits corrosion. The The mechanical strength and high shear strength
modulus of elasticity of the TÍ-ÓAI-4V alloy is 10 of titanium are especially ideal characteristics for
times greater than that of the commercially pure long-span fixed partial dentures and bars for im-
titanium. plant overdentures.^
 RENNER

Table 2 Physical and Chemical Properties of Titanium

Periodic table #22
Composition/pure titanium 99.5-99.7 pure
Density 4.5 g/m^
Ultimate tensile strength (UTE) 734-882 N/mm'
Elastic module 90,000-100,000 N/mm'
Elongation on fracture 15%-20%
Temper 180-250 HV (Vicker's hardness test)
Crystallization > 883"C[1653.4T)
< 882'C11651.6T)
Melting point 1668°C(306ó.4T)
Boiling point 3ó20"C [Ó580T)
Electrical resistance 47-55 (j ohm cm
Coefficient of expansion 96
Thermal conductivity 0.04 cal/cm-s"C

Due to its characteristics, titanium gained inter- 1. Use dean titanium carbides only.
est from the dental laboratory sector in the mid- 2. Grind excess without pressure at the speed of
1980s. Different manufacturers attempted using 15,000 rpm.
different casting, investing, and spruing tech- 3. Avoid creating sharp edges.
niques but did not get predictable results. There- 4. Sandblast with 129-jjm particles of aluminum
fore, in 1992, Schuetz Dental (Rosbach, Germany) oxide at 2 bars pressure.
introduced the Biotan titanium casting system. It 5. Use only clean and disposable aluminum oxide
was the first dental laboratory casting system to (Alpj).
use a melting procedure with a high-vacuum at- 6. Allow for 5 minutes of passivating time after
mosphere. The arch melting and casting are car- each procedure.
ried out in a closed two-chamber system. Argon,
an inert gas, makes the oxidation-free casting pro- The surface of the titanium is hardened by the
cedure possible, and the Biotan titanium casting diffusion of elements. The reaction of the molten
system makes the dental use of titanium pre- titanium with the ingredients of the investment
dictable for commercial production.'' compound causes this progression of hardness.
The marginal layer becomes strongly embrittled
and impure. The a-layer must be removed as a
• THE BIOTAN TITANIUM CASTING SYSTEM preparatory measure before veneering the frame-
work with special titanium ceramics.^
Biotan titanium is a pure 99.8% grade-1 titanium. Titanium castings are indicated for the follow-
The Schuetz DOR-A-MAT universal casting ma- ing restorations:
chine is a compact tabletop unit that melts any
type of metal, including titanium, with a high in- 1. Any type of porcelain- or co m po site-fuse d-to-
tense arch under pressure in a protective argon titanium restorations.
environment. The following technical procedures 2. Full cast crowns, inlays, and onlays.
are recommended to finish the titanium metal 3. Titanium frameworks for removable partial
framework for metal-ceramic restorations: dentures.

QDT 2001
 Use of Titanium in Implant Prosthodontics I

4, Cemented and screw-retained implant restora- • i CASE 1

tions.
A patient presented with missing left mandibular
Titanium castings are biocompatible and do premolars and molars. The patient was treatment
not induce any galvanic corrosion, are relatively planned for implant-supported, fixed detachable,
lightweight, are cost effective, do not induce any metal-ceramic fixed partial dentures to restore the
thermal sensitivity, and present superior mechani- edentulous area (Fig 1), An initial set-up was
cal properties, Biotan titanium metal frameworks made (Fig 2) and used for fabricating a surgical
eliminate galvanic corrosion between the implants template made of clear acrylic resin (Fig 3), Four
and the prostheses. They can be successfully used osseointegrated implants were placed according
for fabricating infrastructures, such as screw-re- to the surgical template. They were uncovered
tained implant bars for implant overdentures or after 5 months, definitive impressions were made
fixed detachable prostheses, or for fabricating 4 weeks after the second-stage surgery, and a
metal frameworks for screw-retained metal-ce- master cast was poured with the implant analogs
ramic or composite veneered crowns and fixed (Fig 4), The master and opposing casts were
partial dentures. More than 2,000 implant cases mounted on a semi-adjustable articulator (Fig 5),
have been successfully completed in the last 6 A diagnostic wax-up was made to determine the
years with the Schuetz Biotan casting system in space available for materials and components of
the United States, the final restoration [Fig ó). With the diagnostic
The Vita titanium porcelain system is compati- wax-up, a buccal silicone matrix was made to de-
ble and has been successfully used with the termine the available space for the restoration (Fig
Biotan system. The recommended technical pro- 7), The wax-up of the infrastructure was com-
cedures for firing the Vita titanium porcelain to the pleted and the bar was milled with a 2-
Biotan metal are as follows: degree-taper wax-cutter (Fig 8), A key-slide at-
tachment (Schuetz Dental) was placed on the
1, Steam clean, no degassing is necessary. waxed bar (Fig 9), which was invested and cast in
2, Wash and bond at 800'C, Biotan pure titanium metal (Fig 10), The fit of the
3, Opaque at 7 9 0 r , casting was verified in the patient's mouth and it
4, First and second bake the restoration at 77Q°C. was re-milled in the milling machine on the master
5, Glaze the restoration at 7OO''C, cast [Fig 11),
The master cast with the bar in place was dupli-
The Vita titanium porcelain is gentle to the op- cated with a silicone material (Fig 12), and an in-
posing dentition; transfers less load to the im- vestment refractory cast was poured and mounted
plants; is homogenous and biocompatible; offers on the articulator (Fig 13), The superstructure was
natural opalescence and translucency, resulting in waxed up with the guidance of the original sili-
excellent esthetics; is easy to adjust and polish; cone matrix, leaving sufficient space for the ve-
and has a low firing temperature and a high frac- neering porcelain (Fig 14), It was cast in Biotan
ture resistance. pure titanium and fitted to the primary bar on the
The following three cases demonstrate the ver- master cast [Fig 15), Porcelain was applied to the
satility of titanium as a restorative material for superstructure, and the prosthesis was finished.
fabricating frameworks for various types of pros- For proper hygiene access around the implants,
theses. the patient can remove the superstructure by
pressing on the buccal aspect of the key-slide at-
tachment (Figs 16a and 16b], The lingual aspect
from the key-slide attachment was sealed with a
light-cured composite resin (Fig 17),

ODT 2001
RENNER

(Figs 1 to 17)

Fig 1 Occlusal view of the Fig 2 Diagnostic cast with the Fig 3 A surgical template is fab-
mandibular preliminary cast initial set-up mounted on the ar- ricated in clear acrylic resin.
showing the edentulous area ticulator.

Fig 4 Occlusal view of the man- Fig 5 Casts mounted with a bite Fig 6 Buccal view of the diag-
dibular master cast. record on a semi-adjustable ar- nostic wax-up.
ticulator.

Fig 7 Lingual view of the bucea Fig 8 Wax-up of the bar milled Fig 9 A key-slide attachment is
silicone matrix demonstrating with a 2-degree-taper wax-cut- positioned on the waxed bar.
the available space for the mate ter.
rials and the components of the
restoration.

Fig 10 Intaglio surface of the Fig 11 The casting is remilled Fig 12 The master cast with the
cast bar on the master cast. primary bar is duplicated with a
silicone material.
 Use of Titanium in Implant Prosthodontics

Fig 13 An investment refractory Fig 14 The superstructure is Fig 15 The superstructure cast-
cast is poured and mounted on waxed up in reference to the ing is fitted to the primary bar on
the articulator. original silicone matrix. the master cast.

Figs 16a and 16b Buccal and occiusal views of the veneered super- Fig 17 Lingual view of the com-
structure showing the open key-slide attachment. Porcelain is applied pleted prosthesis. Note the key-
to the superstructure. The patient can press on the buccal aspect of the slide attachment sealed with a
key-slide attachment to remove the superstructure for proper hygiene light-cured composite resin.
access around the implants.

• CASE 2 The spark erosion process was used to achieve

an absolute passive fit of the bar to the master
A patient presented to the clinic with an edentu- cast. During this process, an electrolyte was used
lous mandible. The treatment plan was to restore for cleaning and enhancing the flow of electricity
the mandible with a spark-erosion bar and an im- (Fig 23),
plant-supported prosthesis using Biotan pure tita- Using the single-screw test, the spark-eroded
nium. Four osseoin teg rated implants were placed bar was bolted down to the master cast, and each
between the metal foramina. The healing abut- gold coping demonstrated a perfect passive fit on
ments were replaced with transmucosal abutments its designated analog (Fig 24), The metal super-
after the healing period was completed for the structure was fabricated, silicoated, and opaqued.
second-stage surgery (Fig 18). A custom tray was The teeth were set up, and the prosthesis was fin-
fabricated, and a definitive impression was made ished with Futura Jet Acrylic (Schuetz Dental) (Fig
using the closed-tray impression technique. The 25), Friction pins were used for additional positive
implant analogs were attached to the impression retention between the primary bar (the infrastruc-
copings, and a master cast was fabricated (Fig 19), ture) and the superstructure {Fig 26), The primary
The infrastructure was waxed up on the master bar was fixed in the patient's mouth. Swivel-latch
cast, invested, and cast in Biotan pure titanium (Fig attachments were placed on the lingual aspect of
20), The cast bar was spark-eroded using the Spark the second premolar and the first molar for reten-
Erosion EDM Type 2000 machine. First the milled tion (Fig 27), The superstructure was inserted on
bar was connected with a resin to the cradle of the top of the primary bar and locked in place with
EDM Type 2000 (Fig 21) and then the copper elec- the latches (Fig 28),
trodes were placed on the master cast and
torqued down with a wrench at 20 Ncm (Fig 22),
 ¡RENNER

CASE 2 (Figs 18 to 28)

Fig 18 Frontal view of the pa-

tient's mandibular residual alveo-
lar ridge showing the transmu-
cosal healing abutments in place.

Fig 19 Intaglio surface of the de-

finitive impression showing the
implant analogs attached to the
impression copings.

Fig 20 Occlusal view of the mas-

ter cast with the waxed bar.

Fig 21 The milled bar is con-

nected with resin to the cradle of
the EDM Type 2000.

Fig 22 Copper electrodes are

placed on the master cast and
torqued down with a wrench at
20[Mcm.

Fig 23 During the spark erosion

process, an electrolyte is used for
cleaning and enhancing the flow
of electricity.

Fig 24 The passivity of fit of the

spark-eroded bar is verified on
the master cast using the single
screw test.

QDT 2001
 Use of Titanium in Implant Prosthodontics

Fig 25 Occiusal view of the com-

pleted restoration on the master
cast.

Fig 26 Intaglio surface of the su-

perstructure. Note the friction
pins used for additional positive
retention between the primary
bar and the superstructure.

Fig 27 Open swivel-latch attachment on the lin- Fig 28 Occlusai view of the completed prosthesis.
gual aspect of the second premolar and the first The superstructure is inserted anci locked in place
molar. with the latches to the primary bar

• CASE 3 ter cast (Fig 31). The master cast with the tele-
scopic copings was then duplicated and poured
The patient presented to the dental office par- up in a refractory material (Fig 32). The secondary
tially edentulous and with severe periodontal bridgework was waxed up on the master cast,
problems. He was treatment planned for a peri- transferred to the refractory cast, sprued, and in-
odontal prosthesis with telescopic-retained vested (Figs 33a and 33b). It was cast in Biotan
bridgework that could be removed to allow for pure titanium and divested (Fig 34). The sec-
proper hygiene and retrievability. The prosthesis ondary bridgework was fitted to the telescopic
was fabricated using Biotan pure titanium. Spark- copings on the master cast and finished (Fig 35).
eroded friction pins were used as precision at- The secondary bridgework metal framework was
tachments. Steam cleaned, silicoated, and opaqued. Light-
The teeth were prepared, an impression was cured composite resin was applied to veneer the
made, and a Pindex-die cast was poured (Fig 29). secondary bridgework metal framework (Fig 36).
The telescopic copings were fabricated, and a Spark-eroded friction pins provided additional re-
master cast was poured (Fig 30). The telescopic tention between telescopic copings and the sec-
copings were re-milled and polished on the mas- ondary bridgework (Fig 37).
RENNER

Fig 29 Occlusal view of the Pin Fig 30 Occlusal view of the tele- Fig 31 Occlusal view of the tele-
dex-die cast. scopic copings seated on the scopic copings re-milled and
master cast. polished on the master cast

Fig 32 Occlusal view of the re- Figs 33a arid 33b Secondary bridgework is waxed up on the master
fractory cast. cast, trans-erred to the refractory cast, sprued, and invested.

Fig 34 Secondary bridgework Fig 35 Occlusal view of the sec- Fig 36 Occlusal view of the
cast in Biotan pure titanium. ondary bridgework fitted to the completed secondary prosthesis,
telescopic copings on the master
cast.

Fig 37 Intaglio surface of the

completed secondary prosthesis.
Spark-eroded friction pins were
used to provide additional reten-
tion between telescopic copings
and the secondary bridgework.
 Use of Titanium in Implant Prosthodontics i

• CONCLUSION • REFERENCES

The general characteristics and the biocompatibil- 1. Wirz J, Bischotf H. Titanium in Dentistry. Berlin: Quintes-
senz, 1997:63-126.
ity of titanium render it useful for fabricating den-
2. Kappert HR Titan als Werkstoff fuer die zahnaerztliche
tal restorations. The use of the Biotan titanium Prothetik und Implantologie. Dtsch Zahnarztl 2
casting system promotes the predictable produc- 1994:49:573-583.
tion of Biotan pure titanium for fabricating these 3. Paessler K. Der dentle Titanguss-G rund langen, technolo-
gie und werkstoffice Bewertung. Quintessenz
restorations. Through the three cases presented, 1991:17:717-726.
this article has demonstrated the versatile and 4. Sommer E, Aussems H. Titanium Superstructures—Con-
predictable use of the Biotan titanium casting sys- sequences in Implantation. Quintenssenz 1991;17:9-16.
tem for the fabrication of Biotan pure titanium-
based restorations.

UCLA Center for Esthetic Dentistry

UCLA CENTER FOR ESTHETIC DENTISTRY announces
the CENTER FOR ESTHETIC DENTAL DESIGN. Next pro-
gram starts July 1. 2001. This laboratory training facility,
(opened July 1, 2000), has 1-and 2-year programs featuring:

» Specific training in esthetic laboratory procedures

• Hands-on patient experience with all-ceramic
systems
Mastership » Esthetic metal-ceramic systems
Training • New polymer fiber-based restorative systems
for Laboratory i Courses taught by Dr. Ed McLaren, DDS,
Technicians Joe Weisz, CDT, and adjunct faculty
For more informalion, con-
Mark Anderson, CDT, and Vincent DeVaud, MDT
tad UCLA Continuing Additional Courses for Technicians fhroughoul the year,
Edtjcation at next available course:
3i0-206-8388or Dr. Ed
Advanced Anterior Ceramic Workshop
McLaron, Diteclor UCLA
Center for Esthetic Dentistry, March 1 - 4 Dr. Ed McLaren Joe Weisz CDT
at 310-794-4858 Call UCLA Continuing Education al:
Í310) 206-8388
 Providing Clinical and Laboratory Solutions
for Common Dilemmas in Remote Tooth-Supported
Overdentures

Yossi Azuelos,

everal longitudinal studies have demon- Thus, the construction of a natural tooth-sup-
strated that the complete removal of nat- ported overdenture should be considered a treat-
ural teeth and the long-term wearing of ment option when an inadequate number of peri-
complete dentures generally result in a marked ré- odontally acceptable teeth to support a fixed or
sorption of the residual alveolar ridges.''^ With removable partial denture are present. Despite
overdentures, on the other hand, a decrease in the recent developments in the field of dental im-
progressive résorption of the residual alveolar plantology, the conservative approach to root
ridges has been reported,^" In addition, restoration preservation in both jaws is still valid.' Therefore,
with overdentures contributes to the periodontal an overdenture should also be considered for
health of the abutment roots, increases the masti- those individuals with a poor prognosis for im-
catory performance, and has a psychologic plant-retained prostheses. Natural dentition, fixed
benefit,' Therefore, overdentures can be used as a prostheses, or implant-supported fixed prosthe-
preventive measure to maintain severely compro- ses opposing an overdenture will have a less
mised teeth and have become a predictable treat- detrimental effect on the residual alveolar ridge
ment alternative to complete dentures. (Figs 1 to 4). However, the overdenture is not a
panacea; it demonstrates no special immunity
from the many inherent negative factors pre-
sented in most prosthodontic modes of treat-
ment. The ultimate overdenture failure occurs
when all abutments are lost and the overdenture
becomes a complete denture.
'Certified Prosthadontist, Tel A«iv, Israel.
Several studies have identified and evaluated
Reprint requests: Dr Yossi Azuelos, 11 Helsinki Street, Tel
AVIV 62996, Israel. the causes of tooth loss. Since 1975, several cross-
 AZUELOS

Figs 1 and 2 A 5-year study by Crum and Rooney' demonstrated that mandibular vertical bone
loss is more than eight times greater in conventional complete denture wearers than in patients
treated with an overdenture.

^^^M¿^^^
Figs 3 and 4 Retention of the maxillary canines or premolars is particularly indicated when the
overdenture is opposed by natural dentition or a fixed prosthesis.

sectional and longitudinal overdenture studies or immediate. It is usually constructed for inser-
have been published'"''; however, none of these tion at some time that is "remote" from the re-
studies evaluated specifically the incidence of moval of hopeless natural teeth. It is implied,
tooth loss in an overdenture population. In 1988, then, that the remote overdenture is placed over
Ettinger'* reported that abutments might be lost a well-healed residual alveolar ridge." A remote
mainly as a result of caries and periodontal dis- overdenture with a definitive restoration of the
ease. Both, with equal percentages, were the abutment teeth is the optimal treatment option
most common causes of failure (85.7%) and con- following a satisfactory interim (immediate or tran-
tinue to be the major factors impairing the long- sitional) overdenture experience. It is important
term success of overdentures. that the patient realizes that the remote overden-
The purpose of this article is to focus on clinical ture is not just a step toward a conventional or im-
and laboratory procedures that may enhance the plant-supported complete denture. It is the defini-
maintenance of root integrity and periodontal tive treatment, which, with g o o d patient
health of abutment teeth under a remote over- cooperation, has a predictable and reasonable
denture. A remote overdenture is not transitional long-term prognosis.^"

iQDT 2001
 Solutions for Common Dilemmas in Remote Tooth-Supported Overdentures

• ABUTMENT PREPARATION ments because they have several advantages:

they reinforce the endodontically treated abut-
Coronal amputation is the first step in the restora- ment, enable the prosthodontist to maintain or
tive phase of the treatment. Sufficient tooth struc- produce specific abutment contours, and protect
ture is removed from the retained abutment teeth tooth structure from a parafunctional habit. Cop-
to create a favorable clinical crown-to-root ratio ings provide considerable caries protection, but in
and to support a complete denture with usual the presence of poor oral hygiene they will not
contour The height and contour of the abutment protect the abutment root against marginal caries.
teeth are determined by their health and desired Thus, the routine placement of copings on sound
function. If the roots are to serve only for the sup- abutments is questionable.
port of the denture, a dome-shaped abutment is Keeping a bare root surface underneath a re-
usually advocated; the roots are shortened to 1 to mote overdenture may be the restoration of
2 mm above the free gingival margin and recon- choice in a caries-resistant patient when sound
toured to follow the shape of the edentulous tooth structure is present and home care is impec-
ridge. If the roots are intended to resist lateral cable. The orifice of the root canal can be obtu-
forces, at least 3 mm of coronal height should be rated with a glass-ionomer restoration, amalgam,
maintained, and the natural contour of the abut- or low-viscosity composite resin. The mean sur-
ments should be kept. The influence of overden- vival rate of amalgam and c o m p o s i t e resin
ture-abutment tooth contour upon the periodon- restorations is significantly higher than that of
tium is insignificant as long as the gingiva glass-ionomer restorations.^^ The dentinal tubules
conforms to the prepared abutment tooth as it of the exposed root surfaces should be restored
did before the removal of the crown.^' The dome- with low-viscosity unfilled resin to reduce the risk
shaped preparation is commonly used because it of bacterial invasion of the radicular dentin; other-
minimizes lateral stresses on the abutment while wise, the tubules may act as reservoirs for patho-
maximizing support for the overdenture. However, genic micro-organisms.
care should be taken not to overreduce the tooth The main problem with overlaid root caries is
because gingival tissue will tend to creep over the that it appears to occur in the deeper dentin
margins of the abutment, resulting in trauma to around the margin of the restoration rather than at
the gingiva and predisposing the area to peri- the root surface. The author's preference is to seal
odontal breakdown. the canal orifice with a hybrid composite resin and
plug the exposed dentinal tubules with low-vis-
cosity unfilled resin. This layer will probably wear,
• ABUTMENT RESTORATION but it can be restored at any time. The restoration
and the remaining dentin are polished to a
Preparation of teeth to serve as overdenture abut- smooth, glass-like finish, leaving a surface that will
ments usually results in the exposure of a consid- accumulate minimal plaque and can be easily
erable amount of dentin surface to the oral envi- cleaned (Figs 5 to 8).
ronment. Dentin surfaces are susceptible to caries
and contour alterations through vigorous tooth
brushing or occiusal wear (tooth to tooth, tooth to Coping Contour
denture base). The occlusai dentin surface is more
susceptible to demineralization than root-surface To date, no long-term studies have been pub-
dentin because the dentin adjacent to the pulp is lished on the best form of the coping for both
less calcified and more porous than the dentin ad- ease of oral hygiene maintenance and the protec-
jacent to the root surface.^' The use of copings is tion of the integrity of the free gingival margin
recommended for most remote overdenture abut- from dental plaque accumulation. Coronal reshap-
AZUELOS

Figs 5 and 6 Bare-root abutments may be used in a cari es-resistant patient for long-term treat-
ment if sound tooth structure is present and home care is impeccable.

Figs 7 and 8 In a caries-susceptible patient, the placement of copings with subgingival margins is
an additional preventive measure.

Figs 9 and 10 Nearly parallel outline form is the best contour for the coping for both
biomechanical and hygiene reasons.
 Solutions for Common Dilemmas in Remote Tooth-Supported Ouerdentures

ing of the abutment root remains an empiric pro- interim Coping

cedure based upon the experience of the
prosthodontist (Figs 9 and 10), The author has se- The bare-root face approach is normally em-
lected three common coping shapes: ployed for interim-insertion prostheses, even if
copings are to be employed at a later stage. Cop-
• Shape A; divergent walls create a wide coro- ings are usually constructed at least ó months fol-
nal surface, which is particularly impodrantfor lowing extraction of the last tooth, when the resid-
the use of an attachment system or magnets. ual alveolar ridge has matured and the tissue
This form may protect the free gingival mar- levels around the roots have stabilized. This lag
gins from being traumatized by the overden- period may be critical for root integrity in caries-
ture base; however, it will encourage plaque susceptible patients.
accumulation and impair oral hygiene main- Because caries can develop in a short period (2
tenance. Therefore, plaque control require- to 8 months) after the insertion of an interim over-
ments dictate that the coping must not be denture," using an interim resin coping to provide
overcontoured in any respect. protection for abutment roots and their surround-
• Shape B: almost-parallel walls provide bio- ing tissues becomes of paramount importance.
mechanical advantage as well as easy cleans- The interim coping should be designed and con-
ability, structed in the manner discussed above to permit
• Shape C: convergent walls create a narrow the patient to keep the abutments plaque free
occlusal surface. Enhanced plaque control is and to serve as a "healing matrix" for surrounding
the main advantage of this form, which al- gingivae, as a predictor of the end result, and as
lows easy access for cleaning even when pa- an oral hygiene training device.
tient's dexterity is impaired. However, it does An interim resin coping with a short retaining
not conform to the use of attachment sys- post is employed to: (1) obtain an acceptable con-
tems and contributes poorly to magnet re- tour on tooth surfaces that would be otherwise
tention. In addition, because of the reduced unobtainable, (2) produce specific abutment con-
occlusal surface, the support gained from the tour, (3) control caries that more conservative
abutment tooth is reduced as well and more means cannot, (4) control caries that develop
support is obtained from the residual alveolar shortly after the interim denture is placed, or (5)
ridge. Thus, the main rationale for retaining guide tissue healing after hemisection or root am-
tooth roots to support the denture and pro- putation (Figs 11 to 14),
tect the residual alveolar ridge is weakened.

Because a major objective in overdenture treat- Root Proximity

ment is to maintain structures that the patient can
maintain,' shape A for the coping is contraindi- When two adjacent teeth are being considered as
cated. Shape B is preferred over shape C when prospective abutments, the clinician must evalu-
the use of a magnet retention or gold copings ate the amount of keratinized tissue between
with stud attachments is planned. When the tooth them. If, after coronal reduction, the teeth are so
root will be restored with gold copings only, ti^e close that the possibility of papillary strangulation
clinician may choose between shapes B and C ac- exists, the weaker tooth should be extracted to
cording to the amount of support required and minimize the risk of periodontal breakdown in the
the patient's dexterity. interproximal area,^"" However, if the use of two
crowded roots is absolutely required, the use of
an elastic separator can achieve an adequate
amount of space between the roots. To prevent

QDT 2001
AZUELOS

Figs 11 to 14 To ensure favorable tissue response as well as to protect the abutment roots from
caries during the delay period, the interim resin coping with short retaining root is used as a
"healing matrix" following hemisection and root resections of molars.

relapse of these orthodontically treated roots, Transferring Biologic Information

connecting the adjacent interim copings until the
periodontal fibers of the supra-alveolar group re- The interface between the tooth and the support-
organize is mandatory. Permanent retention via ing tissues is a region of special concern. The rela-
adjacent gold coping connection is advisable only tionship of the abutment roots to the periodontium
if there is sufficient space between the abutments must be recreated in artificial restorations to impart
to allow adequate plaque control at the proximal biologic health. Reproduction of the appropriate
surfaces and sufficient space for sound overden- emergence profile is essential to accurately replace
ture construction (Figs 15 to 20), missing tooth structure, and preservation of the
original sulcus morphology with the intrasulcular
contours of the restoration is important.
 Solutions for Common Dilemmas in Remote Tooth-Supported Overdenture

iimize the risk of periodontal breakdown in the interproximal area where

. particularly restricted, a próxima I ization technique should be first con-

Ditching the die below the finish line and saw- not require the incorporation of attachment sys-
ing the master cast are not advisable because tems. However, if the clinician thinks that more re-
they eliminate the necessary information of the tention would be advantageous, an attachment
relation between the soft tissue and the margins system could be placed at a later time. As a rule
of the restoration. The use of this information will of thumb, the use of attachments should be
enhance the health of the periodontium. One avoided whenever possible because they increase
cast must transfer the emergence profile and soft the potential of detrimental force transmission to
tissue position, providing the information re- abutment roots, thus impairing their longevity.
quired for the establishment of the equilibrium Moreover, attachments must be applied selec-
between the copings and the gingival tissues tively to the roots after their capacity for bearing
(Figs 21 to 26). additional loads has been determined during the
preparatory and transitional stages of treatment.
The retentive force of a connecting element
• ATTACHMENT SELECTION should amount to at least 400 g to ensure ade-
quate retention for a denture. However, it must
There is general agreement that the overdenture not exceed 1,000 g because excessive tensile
patient should receive an interim (transitional or forces on the abutment teeth may result in dam-
immediate) overdenture before the remote over- age to the periodontium. The combined retentive
denture is considered. An interim overdenture ini- force of the anchors should be just enough to pro-
tially could function as a conventional complete vide retention to the overdenture; the greater the
denture, using the roots in a passive manner. In number of attachments included in a design, the
many instances, patients will express satisfaction lower the retentiveness of each individual element
with an overdenture without attachments and may should be.

QDT 2001
AZUELOS

Figs 21 to 26 Interim coping, indi-

vidual impression technique, emer-
gence profile transfer, and soft tis-
sue simulation are employed to
maintain the delicate equilibrium
between copings and the gingival
tissues beneath the denture base.

Overdentures require adequate space for the Simplicity in design, ease of maintenance, and
components and materials used for their construc- minimum leverage are additional factors para-
tion. One has to consider the space between the mount in selection. Generally, the vertical space
occiusal plane and the abutment as well as the re- available governs the choice. For this reason, stud
quired shape of the denture before selecting the attachments are sometimes preferred over bar at-
attachment system. It is the vertical and faciolin- tachments, and small, slender retentive elements
gual space that determines the maximum dimen- may be selected instead of larger ones.
sion of any restoration that is placed upon the Many stud attachments are available. However,
abutment tooth. Ignoring the space restrictions it is better to limit oneself to a few types of attach-
might prove to be detrimental to the final pros- ments and accumulate experience with them than
thesis. In most cases, the final selection of the ap- to experiment with many different types. The non-
propriate attachment can be made only after the resilient, nonrigid Rothermann and Dalbo (Cen-
trial denture has been tried in the patient's mouth. dres et Métaux, Biel-Bienne, Switzerland) stud at-
The amount of space available for an attachment tachments reflect the author's personal preference
can then be reliably evaluated for the first time. based on clinical experience.
 Solutions for Common Dilemmas in Remote Tooth-Supported Overdentures |

Figs 27 and 28 Shortest stud attachment is the Rothermann nonresilient form. Retention is pro-
vided by a C ring incorporated into the denture base.

Figs 29 and 30 Dalbo Bona ball anchor Retention is provided by adjustable lamellae. If the
housing is shimmed during processing, 0,4 mm of tissue resilience and rotation will exist.

The Rothermann nonresilient attachment is the resistance force is 1,000 g force [ION), Bending the
shortest extraradicular attachment available, and lamellae activates this attachment (Figs 29 and 30).
its overall height is 1,1 mm. It has a minimal resis- The concept behind the nonrigid, nonresilient
tance force of 420 g force (4.2 N), which can be attachment systems is the reduction of the torque
reduced by spreading the retention ring. The at- that the prosthesis exerts on the periodontium of
tachment can be aligned on teeth divergent as the abutment teeth. By shortening the clinical
much as 10 degrees from the long axis. This at- crowns of the abutment teeth (flush with the gin-
tachment is recommended when the vertical giva) and providing a loose connection between
space is limited, teeth are divergent, and light re- the overdenture and the remaining roots, this con-
tention is essential [Figs 27 and 28), cept of prophylactic shortening is applied.^'
If the patient presents with an adequate inter- Magnetic retainers have the theoretic advan-
arch space and more retention is desired, the tage of not transmitting any lateral loads to the
Dalbo (Bona-Ball) attachment system is the recom- abutment teeth because they resist shear loads
mended choice. Its overall height is 4 mm, and its only to a small extent. However, they cannot be

QDT 2 0 0 1 ^
AZUELOS

Figs 31 and 32 Dyna magnet system (Dyna Dental Engineering BV, The Netherlands) is incorpo-
rated into a denture base opposing the mandibular canines.

universally recommended at this time because of • DENTURE BASE

their low resistance to corrosion and the rapid loss
of retention [Figs 31 and 32), The construction of an overdenture must follow
Directly mountable prefabricated retentive ele- the same biomechanical and physical principles as
ments are devices without copings that can be complete denture construction. The ideal over-
screwed and cemented directly into endodonti- denture has inherent support, stability, and a bor-
cally treated roots. The Dalbo-Rotex system (Cen- der seal that enhances retention. The additional
dres et Métaux) is a good representative of this retaining devices, when incorporated, must be re-
type of system,^' The overall height of the short- garded only as an additional safety valve,'^ Unfor-
neck type is about 2 mm, and the breakaway re- tunately, too often, these principles are forgotten
tention is about 700 g. The Dalbo-Rotex root because clinicians rely completely on the mechan-
canal-anchor system was originally designed for ical retention that the attachment system pro-
questionable roots with a guarded prognosis, but vides. We must understand that attachments are
they are well suited for the temporary retention of not a substitute for a correctly designed prosthe-
interim overdentures. The Dalbo-Rotex attach- sis, and they cannot compensate for poor pros-
ment can replace a gold coping and a concealed thetic construction. A poorly constructed overden-
precision attachment when a bare root face is evi- ture with attachments will move around the roots,
dent. It should be realized, however, that the risk leading to damage of the gingivae, periodontal
of root fractures is increased because these sys- breakdown, and failure of the entire restoration."
tems iack the ferrule effect. An attachment system for enhancing retention is
The use of composite resin cement and an ad- usually not required for maxillary overdentures
hesive syster might provide a partial solution to when normal border extensions can be achieved.
this problem. Zinc phosphate cement is still the Unfortunately, anatomic, hygienic, and esthetic
author's choice because the ability to retrieve the considerations may sometimes dictate the reduc-
canal-anchor system is maintained when the male tion of a flange, thus compromising the border
component is worn to the point that its retentive seal. However, the use of stud attachments to pro-
properties are lost. To decrease this wear, it is vide additional mechanical retention promotes
recommended that the female component be re- the construction of a good overdenture even with-
placed annually (see Figs 6 and 37). out a perfect border seal,'
 Solutions for Cornrtion Dilemmas in Remote Tooth-Supported Overdentures |

Figs 33 to 38 Use of attachments

does not authorize the abandon-
ment of basic principles of com-
plete denture construction.-' How-
ever, with the use of stud
attachments, it is possible to re-
duce the interfering flanges apica
to the abutment roots. This must
be done in an esthetic and hy-
gienic way.

Because an overdenture should be designed Path of Insertion

with the concept of sharing the occiusal forces be-
tween abutment roots and the remaining denture- Areas of undercuts must be identified and treated
bearing areas, maximal coverage of the tissue- prior to denture base construction. In the maxilla,
bearing area will benefit both the periodontium the undercut relationship of the canine emi-
and residual alveolar ridges. It Is support from the nences and the tuberositles must be considered,
buccal shelves in the mandible that is so impor- A similar problem may be found in the mandible,
tant if the underlying roots are to be shielded where anterior undercuts around prominent ca-
from excessive forces, and complete palatal and nines and bilateral posterior undercuts in the
tuberosity coverage in the maxilla play a similar retromylohyoid fossae produce a similar problem.
role (Figs 33 to 38), Altering the path of insertion of the overdenture
may solve the problem. If conflicting undercuts
AZUELOS

Figs 39 and 40 Conflicting areas of undercuts.

Figs 41 and 42 Maximum coverage is possible only if

a common path of insertion is found. Moreover, stud
attachments work best when they are aligned with one
another and the path of insertion of the denture.
Reprinted from Preiskel,^'

still remain, it will be necessary to reduce the depression in the acrylic base, which the root
buccal flange of the overdenture base. Ideally, restorations occupy, should be designed and ad-
the attachments should be aligned with one an- justed during the insertion visits to fit accurately
other after the path of insertion of the overden- on the underlying roots and surrounding tissue.
ture has been selected. Stud attachments work The ideal is that the root chamber is in direct oc-
best when they are aligned with one another and clusal contact with the root abutments, but only
with the pal of insertion of an overdenture^' in passive contact with the free gingival margin
(Figs 39 to 42). under occlusal loading. Failure to follow these
guidelines will result in irritation of the gingivae,
leading to rapid downgrowth of the epithelial at-
Root Chamber tachment and loss of attached gingiva. At the
same time, spaces between the denture base and
The term root chamber refers to the intaglio sur- the gingiva must be avoided because additional
face of the denture base around abutments. This plaque tends to accumulate in that space, and
 Solutions for Common Dilemmas in Remote Tooth-Supported Overdentures I

Figs 43 and 44 When the intaglio surface of the denture is not well adapted to the root surface,
plaque accumulation and irntation of the gingivae are likely to occur The root chamber should be
designed during the impression stage and adjusted during the insertion visits.

the gingivae can sometimes hypertrophy to fill fied during the recall appointments. Visibility of
this space (Figs 43 and 44). Finally, the impor- cracks should prompt a search for their cause, for
tance of a cautious, gentle insertion of the over- they are evidence of extreme stresses within the
denture must be emphasized to the patient. The denture base.
gingiva and the bone enveloping the abutment
teeth are often thin and can be irreparably dam-
aged by improper insertion.^" • ORAL HYGIENE REGIMEN
It is often thought that the insertion of the over-
Cast Reinforcing Framework denture represents the final step of prosthodontic
therapy. However, the critical long-term factor in
The overdenture base is similar to that of a com- successful management of the abutment roots
plete denture, but is much thinner around the and the overdenture base is keeping them
abutment teeth. Therefore, risk of fracture through plaque free. Covering teeth and soft tissues with
the abutment root or adjacent to it exists. Cutting overdentures probably is not conducive to the
away the labial flange overlying the copings or the maintenance of a plaque-free environment" be-
stud attachments renders the base even more cause the conditions beneath a well-fitting over-
prone to fracture. As a result of ridge résorption, denture resemble those of an incubator. There-
abutment teeth may act as fulcrum points, allow- fore, the wearing of overdentures is particularly
ing :he denture to rock on the resilient muco- associated with a high risk of caries and progres-
periosteal foundation,' exposing the base to re- sion of periodontal disease. Longitudinal studies
peated fractures. Thus, a cast-metal reinforcing have shown that, irrespective of which technique
framework within the overdenture base is recom- is used for abutment teeth restoration and over-
mended as a routine procedure in a remote over- denture construction, the periodontal health of
denture construction, especially if cast copings the abutment roots can be successfully main-
containing precision attachments are used. The tained and dental caries prevented by good
cast-metal framework will not necessarily prevent plaque control.^'•^'•^' Developing and maintaining
the formation of cracks in the overdenture base. meticulous oral and overdenture hygiene seem to
However, usually those cracks do not propagate be the key for success in extending the service-
and cause fractures, and they are usually identi- ability of overdentures.

QDT 2001
AZUELOS

The responsibility for maintenance must be cal plaque control methods; chemical means can-
shared between dentist and patient. The prostho- not replace mechanical plaque control. Fluoride
dontist has four basic responsibilities: (1) to pre- applied as a gel or varnish directly to exposed
pare the tissue and structures to be easily accessi- roots, or indirectly in each root chamber in the
ble for patient maintenance; (2) to smooth and clean overdenture before placing it in the mouth,
polish the tooth and the restoration as well as the retards the carious process and inhibits plaque
root chamber so that the surfaces will accumulate activity,
minimal plaque; (3) to educate, instruct, and moti- Chlorhexidine may be used as a gel or varnish
vate the patient on oral hygiene; and (4) to enroll in very small amounts inside the intaglio surface of
the patient in a recall system. The oral hygiene the overdenture and the female attachments,
procedures that the patient practices following when present. However, chlorhexidine should not
the insertion of overdentures should be an unin- be used as a routine preventive measure for over-
terrupted continuation of the home care measures denture wearers because of the side effects asso-
learned during the preparatory and transitional ciated with its prolonged use. The author's experi-
stages. The oral hygiene regimen must be tailored ence is that the application of chlorhexidine for 1
according to the needs of each patient. Preven- week with fluoride the following week is a winning
tive measures include mechanical and chemical combination. Fluoride and chlorhexidine may be
plaque control, administration of fluoride, applica- used in a solution for rinsing, and a periodic im-
tion of antimicrobial agents against cariogenic mersion ofthe denture in a disinfectant solution is
bacteria, and introduction of appropriate denture- recommended.
wearing habits. Finally, the patient should be instructed to
The clinician must teach the patient a careful leave the prostheses out of the mouth at night. If
and atraumatic brushing technique with a soft, leaving the denture out at night is not feasible for
rounded brush. This brushing takes care of only psychologic or parafunctional reasons, a suitable
the occlusal surface of the coping and the gingiva. time during the day might be acceptable. If the
It must be followed with a single, tufted interden- patient prefers not to remove the prostheses dur-
tal brush to clean the axial surfaces of the coping ing the night, chlorhexidine gel application at
ofthe sulcus. Electric toothbrushes are equally or night is mandatory." It is the prosthodontist's
more effective than manual brushing in removing duty to inform day-and-night wearers of overden-
supragingival plaque. Brushing should be done tures that continuous denture wear is a major risk
twice a day to reduce the risk of bacterial invasion factor in promoting periodontitis and caries (Figs
o f t h e radicular dentin. Special attention should 45 and 46),
be given to anterior teeth with extensive buccal Despite these efforts, caries-susceptible indi-
gingival recession. Dental floss should be used viduals may develop root caries, and progression
only to clean between root copings that are of periodontal disease also is likely to take place.
splinted together. Hence, it is important that patients with a high
The patient should also be instructed to brush risk for caries and periodontai disease be recalled
the intaglio surface of the overdenture with spe- frequently. The patient should be recalled every 3
cial denture brushes with bristles arranged in tufts to 4 months during the first year. At the 1 -year re-
to facilitate cleaning of the intaglio surfaces of call appointment, the dentist should be able to
the denture, including the narrow root chamber. gauge the patient's skills and cooperation and
A disclosing solution on both the abutments and determine the frequency of future recall appoint-
the inner surface of the denture helps to demon- ments. Because most patients seem to revert to
strate to the patient any residual bacterial plaque. their previous habits, the preventive measures
Chemical means to control dental plaque should must be re-emphasized and reinforced
be introduced only as a complement to mechani- frequently-' [Figs 47 to 50), As stated by Dr R, H,
 Solutions for Common Dilemmas in Remote Tooth-Supported Overdentures

Figs 45 and 46 Highly motivated patients who present with good dexterity can use a plastic cu-
rate that will not damage the gold coping, and they can irrigate the sulcus with 0.2% chlorhexi-
dine using an irrigation syringe.

Figs 47 and 48 Labial preoperative and postoperative views of abutment teeth for a mandibular
overdenture. Note the excellent health of the gingivae.

Figs 49 and 50 Ocdusal preoperative and postoperative views of abutment teeth for a mandibu-
lar overdenture. Note The excellent health of the gingivae, indicating the excellent oral hygiene
maintenance by the patient.

QDT 2001
AZUELOS

Boitel almost 30 years ago in one of his presenta- 15. Davis RK, Renner RP, Antos EWJr, Schlissei ER, Baer PN.
tions, "The dentist of the future will not be A two-year longitudinal study of the periodontal health
status of overdenture patients. J Prosthet Dent
judged only by the excellence of his margins, but 1981:45:358-363.
also by how well he motivates his patients to 16. Renner RF, Gomes BC, Shakun ML, Baer PN, Davis RK,
practice correct oral hygiene." Camp F, Four-year longitudinal study of the periodontal
health status of overdenture patients, J Prosthet Dent
1984:51:593-598,
17. Ettingcr RL,Taylor TD, Scandrett FR. Treatment needs of
ACKNOWLEDGMENT overdenture patients in a longitudinal study: Five-year re-
sults. J Prosthet Dent 1984:52:532-537.
18. Ettinger RL Tooth loss in an overdenture population. J
All laboratory work presented in the article was completed by Prosthet Dent 1988:60:459-462,
Abraham Eisenberg, MDT, Tel Aviv, Israel, The author extends
his profound gratitude to Prof Anselm Langer, a mentor, a true 19. Morrow RM. Remote overdentures. In: Brewer AA, Mor-
friend, and a mentsch. row RM (eds), Overdentures, ed 2. St Louis: Mosby,
1980:132-163.
20. Budt!-Jergensen E. Prosthodontics for the Elderly: Diag-
nosis and Treatment, Chicago: Quintessence,
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21. Craser GN, Caton JG, Influence of overdenture abutment
tooth contour on the periodontium: A preliminary report,
1. Atwood DA, Reduction of residual ridges A major oral J FrosthetDent 1983:49:173-177.
disease entity. J Prosthet Dent 1971 ;2ó:266-279,
22. Fenton AH. The decade of overdentures: 1970-1980. J
2. Tallgren A. The continuing reduction of the residual alveo-
Fröstlet Dent 1998:79:31-36.
lar ridges in complete denture wearers: A mixed longitu-
dinal study co\iering 25 years, J Prosthet Dent 23. Ettinger RL. Evaluating the longevity of restorative materi-
1972;27:120-132, als that seal the root canals of overdenture abutments, J
Am Dent Assoc 1995:126:1420-1425,
3. Tallgren A. The effect of denture wearng on facial mor-
phology: A 7-year longitudinal study. Acta Odontol Scand 24. Schwartz IS, Morrow RM, Overdentures: Principles and
1967:25:563-592, procedures. Dent Clin North Am 1996:40:169-194.
4. Crum RJ, Rooney GE Jr, Alveolar bone loss in overden- 25. Preiskel HW, Overdentures Made Easy: A Guide to Im-
tures: A 5-year study, J Prosthet Dent 1978:40:610-613. plant and Root Supported Frostheses. London: Quintes-
sence, 1996.
5. Loiselle RJ, Crum RJ, Rooney GE Jr, Stuever CH Jr. The
physiologic basis for the overlay denture. J Prosthet Dent 26. Geering AH, Kundert M, Kelsey CC. Complete Denture
1972:28:4-12. and Overdenture Frosthetics. New York: Thieme, 1993,
6. Langer Y, Langer A. Root-retained overdentures: Part I— 27. Dalla Bona H. A new anchor system for the fixation of par-
ßiomechanical and clinical aspects. J Prosthet Dent tial or complete dentures. Quintessence Int
1991:66:784-789. 1989:20:13-19.
7. Frantz WR. The use of natural teeth in overlay dentures, J 28. Mensor MC Attachments for the overdenture. In: Brewer
Prosthet Dent 1975;34:135-140. AA, Morrow RM {eds), Overdentures, ed 2 St Luuis
Mosby, 1980:208-251.
8. Fenton AH, Hahn N, Tissue response to overdcnturo ther-
apy. J Prosthet Dent 1978:40:492^98. 29. Preiskel H, Precision Attachments in Prosthodontics:
Overdentures and Telescopic Prostheses, Vol 2, Chicago:
9. Reitz PV, Weiner MG, Levin B. An overdenture survey:
Quintessence, 1985.
Preliminary report. J Prosthet Dent 1977:37:246-258,
30. Robbins JW. Success of overdentures and prevention of
10, Reitz PV, Werner MG, Levin B. An overdenture sun/ey:
failure. J Am Dent Assoc 1980:100:858-862.
Second report. J Prosthet Dent 1980:43:457-462,
31. Renner RP, Gomes BC, McNamara TF, Baer PN, Shakun
11, Toolson L8, Smith DE, A 2-year longitudinal study of over-
ML, Overdenture sequelae: A nine-month report, J Fros-
denture patients. Part I: Incidence and control of caries
thet Dent 1982:48:377-384,
on overdenture abutments. J Prosthet Dent
1978:40:486-491. 32. Renner RP, Gomes BC, McNamara TF, Shakun ML, Baer
PN, Hackett D, Feriodontal health, prosthodontic factors
12, Toolson LB,f nith DE, Phillips C. A 2-ycar longitudinal
and microbial ecology of patients treated with overden-
study of overdenture patients. Part II: Assessment of the
tures—A 2 1/2-year report. Quintessence Int
perjodontal health of overdenture abutments. J Prosthet
1984,15:645-652.
Dent 1962:47:4-11.
33. Budtz-J argen sen E. Effects of denture-wearing habits on
13, Toolson LB, Smith DE. A five-year longitudinal study of
periodontal health of abutment teeth ir- patients with
patients treated with overdentures. J Prosthet Dent
overdentures, J Clin Periodantol 1994:21:265-269.
1983:49:749-756.
34. Lord JL, Teel S. The overdenture: Patient selection, use of
14, Toolson LB, Taylor TD. A 10-year report of a longitudinal copings, and follow-uo evaluation. J Prosthet Dent
recall of overdenture patients. J Prosthet Dent 1974:32:41-51.
1989:62:179-181,
 TECHNIQUES AND MATERIALS

Management of Limited Vertical Dimension

of Occlusion for Maxillary Removable
Partial Dentures

Oskar Sykora, CDT, DDS, PhD, FADP

n some partially edentulous situations, • CASE 1

esthetic considerations must be planned
at the time of framework design, wax-up, A 24-year-old female was treated for a functional
and selection of artificial teeth. The harmony of and esthetic problem mainly due to the loss of her
the gingival and incisal/occlusal crest height of the maxillary right first premolar, second premolar,
natural and artificial teeth has to be maintained to and first molar. She was also missing her maxillary
give the prosthesis a natural appearance. Further- right second molar; her maxillary left second pre-
more, excessive vertical overlap of the maxillary molar and second molar; her mandibular right first
anterior teeth combined with a limited interarch and second molar; her mandibular left second
space in the posterior ridge area presents an addi- molar; and all of her third molars, which had been
tional challenge to creating an acceptable esthetic extracted 4 years prior to this treatment. The re-
smile. This article describes the treatment of two maining teeth were in good condition with some
patients with these partially edentulous situations. minor interproximal stains between the maxillary
anterior teeth. The patient refused to consider re-
placements for her missing mandibular posterior
teeth.

Upon examination of the patient and mounting

of the diagnostic casts, it became apparent that
•Professor of Prosthodontics, Department of Dental Clinical the excessive vertical overlap of the anterior teeth
Sciences, Faculty of Dentistry, Dalhousle University, Halüax, combined with the limited posterior interarch
Nova Scotia, Canada.
Reprint requests: Dr Oskar Syko.a, Department of Dental
space would not provide sufficient room for an es-
CImlcal Sciences, Faculty of DentiM^j, Dalhcusie University, thetic placement of the maxillary premolars (Fig 1).
Halifax, Nova Scotia B3H3J5, Canada.
Therefore, two anterior teeth, canines, were se-
SYKORA

CASE 1

Fig 1 A limited interarch space Fig 2 With proper planning, the

combined with an excessive verti- esthetic requirements can be
cal overlap creates an esthetic achieved using reshaped maxil-
challenge for the placement of lary canines rn lieu of premolars.
maxillary premolars.

CASE 2

Fig 3 Mounted casts show re- Fig 4 Section of framework Fig 5 Initial try-in; note the short
duced interarch space for the shows a proper lattice design posterior teeth and the lack of
placement of posterior partial with the soldered wrought wire harmony between the maxillary
denture teeth and large vertical retentive arm. anterior and posterior partial
overlap of the anterior teeth. denture teeth.

Figs 6a and 6b Final try-in. Reshaped maxillary canines were used in

lieu of premolars, and the lingualized second molar occlusion will be
produced on the future denture base.

Fig 7 Centric occlusion contacts Fig 8 Centric occlusion contacts

at the final try-in appointment. at the first insertion of the pros-
thesis.
 Maxillary Removable Partial Dentures |

lected and appropriately shaped to resemble the wrought wire retentive arm was soldered to the
buccal surface of a maxillary premolar t o o t h . framework on the lingual side of the crest of the
These teeth were set strictly into an esthetic, non- ridge. An acrylic resin record base with an oc-
functional position to replace the missing premo- clusal wax rim was added to the framework, and
lars. Thus, the esthetic illusion of posterior teeth of the records, mounting, and set-up were made in
compatible length with the anterior teeth was the normal manner However, at the try-in stage,
achieved (Fig 2), The maxillary right first molar and the patient objected to the short posterior teeth
the left premolar were set into occlusion in the [Fig 5), Figure 5 also displays the crossblte place-
normal manner, and the removable partial denture ment of the second maxillary molar, which was
was completed. done to tingualize the occlusion in order to im-
Upon the initial insertion of the prosthesis, a prove the stability of the distal extension base of
functional "chew-in" was made to produce opti- the prosthesis.
mal masticatory efficiency. The functionally gener- To gain additional space gingivally, the acrylic
ated tooth surface can be cast in metal and cured resin record base was removed from the lattice,
to the acrylic resin base lingual to the previously A tinfoil was placed directly on the cast and
positioned veneers. An alternative treatment, luted with the wax rim to the framework. Two
which is presented in Case 2, involves producing a maxillary canines were reshaped and placed in
functionally generated path template at the final the maxillary right first and second premolar po-
try-in stage and finishing the generated occlusal sitions, A new first molar was selected, and the
surface to the acrylic resin base. lingualized occlusion for the second molar was
provided with a wax-up for the future denture
base (Figs óa and 6b), A functionally generated
m CASE 2 path template was produced at the final try-in
stage (Fig 7). Figure 8 shows the occlusal sur-
The patient in this case, similar to Case 1, pre- faces at the first insertion stage.
sented with an excessive vertical overlap with a The use of reshaped maxillary canines instead
limited interarch space for the posterior artificial of premolars satisfied these patients' esthetic re-
teeth [Fig 3), Figure 4 shows the design of the quirements, and the use ofthe functionally gener-
partial denture framework. The lattice was placed ated path fulfilled the masticatory needs of the
lingually from the crest of the ridge, and the patients in these two cases.

QDT 2001
Development of Dental Laboratory Composites

Giuseppe Isgro*/Richard van Noort, BSc, DPhil**/

Giuseppe Cannavina, Cert Ed, BEd, LCGI***

ver the past 20 years, dental manufactur- lays and veneers, metal-free fixed partial dentures,
ers have developed resin composite and as veneering material for fixed partial den-
products for clinical use. Major develop- tures because they enable the dental technician
ments of the resin composites have occurred in to achieve esthetic results similar to those of ce-
the areas of polymerization techniques and new ramic systems.
filler technology.' Gradually, these materials have In this article, the background to the introduc-
become popular for use in the dental laboratory tion of resin composites will be outlined. Then,
because of the associated improvement in wear the composition of resin composites and the
resistance, bond strength of resin to metal, esthet- major laboratory composites used will be de-
ics, and composition. In recent years, these newer scribed. The chemical bonding systems that have
resin composites have been used in a wide variety been introduced to improve performance will be
of applications. These include resin composite in- considered as well as recent developments and
new applications.

• BACKGROUND
"Piotessor and Director, Centre for Biomateriais am
Engineering, University of Sheffield, Great Britain. The first introduction of resin in the dental labora-
""Lecturer arid Course Co-ordinator, Department of Restora-
tory was in 1936 for denture base materials.^ This
tive Dentistry, University of Sheffield, Great Britain.
Reprint requests: Mr Giuseppe Carinavina, Department of resin system was based on polymethyl methacry-
Restorative Dentistry, Schooi of Clinicai Dentistry, University late/methyl methacrylate (PMMA/MMA). In the
of Sheffield, Ciaramont Crescent, Sheffield S 10 2TA, Great
early 1940s, this polymeric material was also used
Britain.
This article is a result of a task undertaken by G. isgro as part in veneers for crown-and-bridge frameworks.- The
of his BMedSci course requirements. resin PMMA/MMA system was attached to metal

QDT 2001
ISGRO ET AL

by mechanical retention," The disadvantage of forcing filler to the resin matrix.' The organic resin
polymeric materials for veneers was the poor matrix consists of a monomer system that can be
adaptation on the metal base because of a rela- a bisphenol-A and glycidylmethacrylate (bis-GMA)
tively large polymerization shrinkage, which or a urethane dimethacrylate resin system
caused serious problems with microgaps between (UDMA),' an initiator system for free radical poly-
the metal framework and polymers,^ lack of color merization, and stabilizers for maximizing the stor-
stability, porosity because of insufficient mixing or age stability of the uncured resin composite,'' The
excess of monomer liquid, low abrasion resis- filler consists of hard particles such as glass,
tance, and loosening or fracture of the facing ma- quartz, and fused silica' or prepolymerized fillers
terial,^ With the advent of ceramometal crowns, containing silica microfilier,'
many of these problems were addressed. In fact, Studies have shown that the properties of resin
the ceramic facings did not wear, the marginal composites depend on the three basic compo-
leakage was not a problem, and most importantly, nents of the material. In fact, some of the proper-
the ceramic did not discolor." Moreover, the ce- ties are mainly related to the filler and the cou-
ramic also tolerates occiusal forces, eliminating pling agent, whereas other properties are related
the need for the incisai or occiusal metal protec- to the resin matrix,' It has been observed that the
tion required with resin-veneered restorations.* fillers increase properties such as hardness and
However, the ceramic has some limitations: (1) the compressive strength and abrasion resistance,'
coefficients of thermal expansion should be simi- whereas color stability depends on the organic
lar in both ceramic and metal; (2) the ceramic is resin matrix.' Because of these qualities, a number
brittle, flow sensitive, subject to crack propaga- of these materials have become commercially
tion, and abrades natural teeth; and (3) the melt- available and are being used in dental laborato-
ing point of the metal should be higher than the ries. These materials vary in their composition and
fusing temperature of the ceramic,^ physical properties. Principal variations in chemi-
To overcome these problems, new resins were cal composition are monomer composition and
developed. These materials, differing in chemical concentration and size of filler particles (eg,
composition, amount and type of filler particles, macro, micro, and hybrid),^ The polymerization of
and mode of cure, are used as veneering materi- these composites is initiated by light curing or
als in dental laboratories.' These new materials, heat and pressure polymerization.
which are classified as resin composites, offer im-
provement over the traditional acrylic resin ve-
neering materials in esthetic and mechanical m EVOLUTION OF DENTAL LABORATORY
properties after the addition of microfillers to the RESIN COMPOSITES
resinous mass,'
The first resin composite introduced in dental lab-
oratories was SR-lsosit-N by Ivoclar (Schaan,
H RESIN COMPOSITES Liechtenstein). The SR-lsosit-N system contains 33
wt% inorganic microfilled particles of silica that
The resin composites have been introduced to the are embedded in particles of prepolymerized or-
dental laboratory as an alternative veneering ma- ganic material, while the monomer is a mixture of
terial to ceramic' and acrylic resin.' The word com- methacrylates based on a UDMA system. The SR-
posite means a mixture of two or more materials'; lsosit-N system had an unfilled MMA opaque that
thus, the resin composite consists of a mixture of did not have bonding properties and depended
hard, inorganic particles bound together by a soft on mechanical retention,' The polymerization of
resin matrix and a coupling agent, which is usually this composite was initiated by heat and pressure
an organosilane that chemically bonds the rein- (Fig 1). The curing process of the paste-based SR-
 Development of Dental Laboratory Composites

isosit-N is unique in that it is initiated by applica-

tion of a thin layer of benzoyi peroxide-containing
monomer liquid before each heat polymerization
of the pastes.= Another composite processed in
dental laboratories is Biodent Multiplus
(Dentsply/De Trey, York, PA, USA), which contains
30 wt% macrofiller,^ The polymerization of this
composite system, as in SR-isosit-N, is initiated by
heat and pressure.
The bonding of these two composites on the
metal is by mechanical retention. This retention
requires beads, wires, or loops in the metal de- Fig 1 Ivoclar SR-lsosit-N processing system
sign. However, this process results in a bulkier
framework that is difficult to make opaque be-
cause of the pooling around the beads, resulting
in a decrease in retention' and a variable thickness
of opaquing resin. As a result, failure often occurs
at the resin-opaquer junction.'^ Moreover, the me-
chanical retention does not restrict the creation of
a marginal gap at the resin-metal interface, which filler; the monomer system is based on UDMA.^
can cause discoloration or detachment because of This composite uses blue light to photo cure, with
infiltration of debris in the marginal gaps of these curing times on the order of 90 seconds."
composites. It has been shown that the SR-lsosit- Shortly afterward, another composite system
N system gives the widest fissures between itself was marketed under the name Visio-Gem (ESPE,
and gold castings compared with other resin com- Bad Seefeld, Germany]. The Visio-Gem composite
posites.^ As a consequence, the use of these com- system contains 33 wX% inorganic microfilier, and
posites remains limited. Another factor that limits the monomer system consists of a bis-GMA deriv-
composite use is poor esthetics; these composites ative.^ This composite system employs two lights,
require incisai or occlusal metal protection to the alpha and beta light units. The first source
avoid detachment, loosening, fracture of the fac- contains a 1,500-W xenon light with a wavelength
ing and abrasion of the material. of 406 nm; with this light the initial curing of the
In light of these disadvantages, alternative composite is obtained. The final curing of the
composites were developed; they are classified as resin is accomplished in the beta light unit. The
light-cured resins because their polymerization is beta light is a complex system that uses a halogen
initiated by light curing. These new materials are light source and a dedicated vacuum. The advan-
microfllled composite resins with higher filler con- tage of the vacuum technique is that it eliminates
tent than other laboratory composites such as SR- the oxygen-inhibited surface layer that forms
Isosit-N, and the monomer is based on bis-GMA when the resin is in contact with air.^
and UDMA.^ Two other composites introduced in dental lab-
The first introduction of these new resin veneer- oratories are Triad K-tB (Dentsply/DeTrey) and the
ing systems was in 1984, when a new composite Elcebond composite (Schuetz Dental, Rosbach,
called Dentacolor (Kulzer, Wehrheim, Germany) Germany). The Triad K+B resin system contains 56
was introduced in dental laboratories as a substi- wt% inorganic hybrid filler particles of silicate
tute for ceramic veneers." The Dentacolor com- glasses and 4 wt% organic filler The monomer
posite system contains 51 vJt% inorganic microfilier system is t r i e t h y l e n e g l y c o l dimethacrylat e
particles of silicate glasses and 25 wt% organic The Elcebond system contains 49
ISGRO ET AL

vrt% inorganic microfilier particles of silica and 16 other prosthetic applications. In fact, it can be
wt% organic filler. The monomer system is based polymerized without teeth and used as base
on UDMA.^ plates or in the construction of special trays.
The development and improvement of these These resin composites are now used for many
composites allowed the dental technician to ex- prosthetic applications. The applications of resin
tend their range of application in the dental labo- composite in the dental laboratory include pontics
ratory. In addition to their low cost, these compos- for resin-bonded fixed partial dentures, fixed par-
ites give excellent esthetics with color stability, tial dentures, overlay removable partial dentures,
abrasion similar to natural tooth structure, bio- single crowns, inlays-onlays, esthetic veneers,"
compatibility with intraoral tissue, the ability to be fixed partial dentures subject to flexing forces," ar-
readily repaired (even in the mouth), and compati- tificial teeth, veneered telescopic dentures, den-
bility with most dental casting alloys." The major ture base resins, special trays, and base plates.
advantages of these resin composite-bonded
fixed partial dentures are that they give the dental
technician unlimited working time, eliminate ma- m CHEMICAL BONDING SYSTEMS
terial waste, and are more easily workable than
ceramic. Another advantage of these materials is A major improvement associated with the new
the minimal preparation needed on teeth adja- composites used as a veneering material for fixed
cent to the pontic that act as supports. Studies partial dentures is the development of adhesive
have indicated that the clinical impact on the peri- systems that allow chemical bonding of the com-
odontal condition is very good, comparable to posite to metal surfaces. However, the pretreat-
the response of other types of restorations. How- ment of the alloy surface and the application of
ever, although resin composites have been im- coupling agents are necessary. Studies have
proved, the disadvantage of these materials re- shown that the most significant factor in resin ve-
mains the retention of the material on the surface neer-to-metal adhesion is the metal surface treat-
of the metal. The reasons for such failures appear ment.* As a result, the chemical adherence of the
to be the sensitivity of the technique and suscep- opaque layer on the metal substructure reduces
tibility to marginal deterioration.'^ Moreover, the the creation of a marginal gap, which is caused by
use of these composite veneering materials in the polymerization shrinkage of the resin. As a
areas of heavy occiusal contact should be avoided consequence, the color of these composites is
because they still have low wear resistance." more stable." Moreover, studies have shown that
Another important evolution, and consequently with a chemical bond of composite on metal al-
a new application, of resin composites in dental loys, mechanical retention devices such as beads
laboratories is their use for the construction of and wire can be avoided.^ This makes the system
denture bases. This resin composite has a matrix especially favorable in cases in which there is not
of UDMA microfine silica and high-molecular enough space for mechanical retention'^ and lim-
weight acrylic resin monomers. Acrylic resin beads its the amount of tooth structure required.' It has
are present as an organic filler.'^ This material is been shown that without mechanical retention,
supplied in premixed sheets having a clay-like the esthetics are also improved because there is
consistency. The sheet of resin composite is more space available for a dentin/enamel layer,
adapted to the cast, the teeth are added to the especially in areas with limited access.^
base with additional material, and the anatomy is These new bonding systems can be classified
sculpted, all while the material is still plastic. After into three main groups according to chemical ad-
that, it is polymerized in a light chamber with blue hesion on metal frameworks: (1) silicate
light of 400 to 500 nm from high-intensity quartz layer-silane coupling, (2) tin oxide layer,^ and (3)
halogen bulbs."" This new material is also used in bifunctional monomers.
 Development of Dental Laboratory Composites

Silicate Layer-Siiane Coupling

These systems provide bonding through a ceramic

layer (silica) on the alloy surface." The first adhe-
sive bonding system classified in the first group
was the Silicoater technique (Kulzer), introduced in
1984 by Tiller and Musil'» (Fig 2), The system con-
sists of fusing a thin, flexible glass on the surface
of the alloy, and the resin is bonded to the glass
via 3 silane coupling agent,-" The basic element of
this bonding system is a silicate layer [SiO^-C),'
After that, a silane coupling agent is brushed on Fig 2 Silicoater processing syste
the metal,' The newer-generation Silicoater MD
[Kulzer) fuses the silicate layer using a special oven
rather than a flame," The disadvantages of sili-
coating include the expensive equipment re-
quired. With this new bonding system, it has be- After that, the layer is oxidized in a strong hydro-
come possible to bond any resin, MMA, bis-GMA, gen peroxide solution that results in a thin film of
or UDMA to the surface of any commonly used tin oxides,^
dental alloy. The silicoater adhesive can be used
with different veneers of composites such as Den-
tacolor, SR-lsosit-N, Cromasit (Ivoclar), and Visio- Bifunctional Monomers
Gem,'° It has been seen that the Silicoater system,
in combination with the Dentacolor composite As the name implies, a bifunctional monomer has
and Visio-Gem composite, gives a higher bond a dual role. One end of the monomer is designed
strength compared to other resin composites. to bond to the metal while the other end will bond
Moreover, the Silicoater system produces a signifi- to the resin, thus acting as a coupling agent be-
cantly stronger bond than either the Ag-Pd or Au tween the metal and resin.' In this group are the
alloys when it is used with Ni-Cr and Cu-AI alloys,' Spectra-Link bonding system [Ivoclar), in which the
Another bonding system classified in the first layers of bonding agents applied on the surface of
group is the Rocatec system (ESPE), In this sys- metal are active acrylate monomers and polyfluo-
tem, the silicate layer is formed by sandblasting romethacrylates^; and the 4-methacryloxyethyl
the surface of the metal with a silicate-quartz trimellitate anhydride [4-META) monomer, which is
medium. When sandblasting particles contact contained in New Metal Color light opaque bond-
metal surfaces, their mechanical energy is trans- ing liner (Sun Medical, Shiga, Japan) and was in-
formed to thermal energy, which makes the glass troduced in Japan to replace etching of the
stick in the metal surface. After that, a silane solu- metal," The 4-META primer is a single liquid ap-
tion is also applied, acting as a coupling agent^ plied directly to the dental alloy,'' followed by the
between the glass layer and the resin composite. application of the polymer and monomer opaque
by using a brush-on technique and curing for 8
minutes. The advantage of this bonding system is
Tin Oxide Layer that only a thin layer of opaque is necessary be-
cause the 4-META material is opaque. It has been
There is one available system, called OVS observed that the 4-META provides superior
[Dentsply/De Trey). In this system, the layer is strength adhesion to cobalt chromium (Co-Cr)
formed by electroplating the metal framework. alloy. In addition, this bonding is improved by oxi-
ISGRO ET AL

dation of the metal surface by immersion in 1% RECENT DEVELOPMENTS AND NEW

potassium permanganate and 3% aqueous sulfuric • APPLICATIONS
acid for 2 minutes. After that, it is washed in an ul-
trasonic bath with distilled water." Recently, new filled composites have been devel-
Recently, more adhesive primers for base met- oped and introduced in dental laboratories by
als containing different functional monomers have several major companies. First was Artglass (Her-
become commercially available, and these are still aeus Kulzer), introduced in Germany in March
improving the bond strength between resin com- 1995.^' This new material is a polyglass, and it fills
posites and metal. One of these is Cesead Primer the gap between ceramic and resin composite
Opaque (Kuraray, Osaka, Japan), which contains materials. The advantages of the Artglass system
10-methacryloxydecyl dihydrogen phosphate are that it can be bonded to nearly all types of
(MDP) bifunctional monomer." Cesead Primer metal because of the new adhesive primer called
Opaque has been shown to improve the bond be- Kevloc," which is probably of the bifunctional
tween the prepared opaque resin and Co-Cr alloy. monomer variety. Because of the Improvement in
This is because when a layer of metal oxides or resistance to wear, it can be used on all occlusal
passive film is created on the casting metal sur- surfaces of the restoration in patients with heavy
face, the MDP monomer has more affinity with occlusal contact areas without incisai or occlusal
this layer than 4-META.^' metal protection. The procedures are relatively
However, these monomers have never pro- simple; in tact, after basic instruction and a little
duced a strong bond to precious alloys because it practice, most technicians can produce an accept-
is more difficult to coat the surface of precious- able crown, and the laboratory costs should be
metal alloys with an oxide layer.^' Therefore, new substantially lower. Artglass is used in dental labo-
types of functional monomers containing sulphur ratories to construct single crowns, fixed partial
have been developed and used successfully as dentures, and Maryland bridges, but mainly Art-
primers for bonding to noble alloys,^" These are ó- glass is used over metal restorations supported by
(4 vinylbenzyl-n-propyl)amino-1,3,5-triazine 2,4 implants. It also can be used in restorations with-
dithione (VBATDT] monomer, which is contained out metal, such as esthetic veneers, inlays, and
in V-Primer (GC/Sun Medical), and the methacry- onlays. It is necessary to use a new cement system
loyloxyalkyl thiophosphate derivatives (MEPS) called 2 Bond 2 (Heraeus Kulzer), which is a light-
monomer, which is contained in Metal Primer (Sun curing resin composite luting agent. This results in
Medical), Studies have shown that a methyl a bond between these restorations and the nat-
methacrylate-trin-butylborane (MMA-TBB) resin ural teeth, providing adequate strength.^' More-
bonds strongly to noble metals with the use of over, Artglass can be repaired intraorally with the
use of Charisma (Heraeus Kulzer),
The development and introduction in dental Other composites recently introduced in dental
laboratories of these adhesive primers have im- laboratories are belleGlass HP (Kerr/Belle de St
proved the bonding of resin composites with dif- Claire, Orange, CA, USA) and the Targis and Con-
ferent dental alloys. In addition, the use of adhe- cept systems (Ivodar), Although the formulations
sive primers has simplified the procedures for and techniques of these new composites differ, all
surface preparation. In fact, they are applied with are polymer-based restorations,^'
a brush onto the surface of metal. All of these The Targis system is a composite that contains
chemical bonding systems have been developed new reinforced fillers called ceromers. The charac-
to give a significantly stronger bond between the teristic of the ceromers is a very high particle con-
metal and the resin composites. As a result, these tent of inorganic filler of 75 wt% to 85 wt%. This
new composites are widely used in the dental lab- compact filling is achieved with fine ceramic parti-
oratory as veneering material. cles. This material has the same applications in
 Development of Dental Laboratory Composites I

Fig 3 Composite crown. Fig 4 Composite veneers.

the dental laboratory as Artglass, The most impor-

tant feature of this new composite is that it can be
used in the construction of small fixed partial den-
tures without a metal substructure. In fact, a new
material, Vectris (Ivoclar), has been developed as
a substitute for the metal; it is supplied in two
forms: Vectris Single for crowns and Vectris Pontic,
This material is composed of several layers of fiber
wafers as well as uniaxially oriented fiber bundles.
The material ensures a certain degree of elasticity
and a distribution of strain in situations in which
permanent loads are applied.
Because the latest generation of fiber-rein-
forced composite systems is giving excellent re- Fig 5 Implant and composite crown
sults, they are finding wide use in dental laborato-
ries to an even greater degree than other
composites ¡Figs 3 to 5]. In fact, with these new
materials, optimal esthetics, a natural effect similar and different skills in the use of these materials.
to that of the ceramic systems, and antagonist One problem is that the improvements of these
suitability have been achieved. composites are occurring in a very short time. As a
consequence, when dental technicians invest in a
new system of composite, they must be selective.
M CONCLUSION It is probable that a new system will be introduced
before they have had enough time to recoup their
This article has analyzed the resin composites capital. On the other hand, the improvement of
used in dental laboratories. Thanks to research, these composites gives the patient a better
these composites have been improved since they restoration at a lower cost than a restoration in
were introduced, and the result is better esthetic metal ceramic or all ceramic. The future of es-
and mechanical properties. The continual intro- thetic materials in dental restoration is likely to be
duction of new composites by several companies yet more new composites with improved chemical
has meant that technicians need new knowledge compositions.

QDT 2001
 ISGRO ET AL

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