dentistry beauty & science

cosmeticdentistry _ beauty & science

_case studyManagement of full mouthprosthodontic rehabilitation

_featureAesthetics and the brain

_industry reportTemporaries: Perfect provisional restorations

32009

issn 1616-7390 Vol. 3 • Issue 3/2009

light colored intense colored

Excellent flexural strength and no degradation in strength compared to white zirconia*

Certified for excellent material homogeneity and purity

Excellent esthetic results supported by

the coloring of the underlying framework

Innovative coloring technique

NobelProceraTM

Full zirconia product assortment in four colors.

white light medium intense

* Nordic Institute of Dental Materials (NIOM) NobelProcera™ Zirconia testing: S306269B, S306205B.** Products for NobelActive™ platform are currently under development.

Following the success of shaded NobelProcera Zirconia Crowns, the same colors are now available for the full assortment** – crowns, copings, bridges, abutments, implant bridges. The innovative coloring technique ensures excellent material homoge-neity, consistent color throughout frameworks. External studies show no degradation in strength compared

to white zirconia*. NobelProcera offers solutions for all indications –single crowns, bridges up to 14 units, cemented or screw retained, fixed or removable prosthetics on natural teeth and implants. NobelProcera provides extensive experience and access to a quality-assured central-ized industrial manufacturing.Precision of fit, quick turnaround

times, consistent and predictable results – you will enhance your customer sat isfaction and the efficiency of your practice. Nobel Biocare is the world leader in innovative evidence-based dental solutions. For more information, visit our website.www.nobelbiocare.com/nobelprocera

YOU CAN VISIT US AT FDI,

STAND Q01-10 OR

WWW.NOBELBIOCARE.COM

Nobel Biocare Asia +852 2845 1266, Nobel Biocare Singapore +65 6737 7967, Nobel Biocare Taiwan +886 2 2793 9933© Nobel Biocare 2009

NobelProcera Shad Zirc A4 HK FDI.indd 1 09-08-14 09.09.35

I 03

editorial _ cosmetic dentistry I

cosmeticdentistry 3_2009

Dr Sushil Koirala

Editor-in-Chief

_Since the beginning of the year cosmetic dentistry has shown a strong presence at various international seminars, conferences, trade shows, and scientific meetings. Theamount of positive feedback we have received thus far has encouraged us immensely andgiven more responsibility to our team in aiming to meet the expectations of our professionalcolleagues around the world. With the electronic edition of cosmetic dentistry now avail-able at www.dental-tribune.com, our readers across the globe now have 24/7 access to information on the latest developments in the field.

It is encouraging to note that various aesthetic events are now hosted in Asia. Addition-ally, general dental associations are demonstrating increasing eagerness to invite speakerson aesthetic topics to their scientific meetings. As the demand for aesthetic proceduresamongst our patients increases, so too does the demand for quality aesthetic dentistry lec-tures, training and accreditation programmes. Unfortunately, many Asian countries are stilllagging behind owing to the lack of such activities at a national level. Because of financialand time constraints, participation in international aesthetic dentistry activities is not viablefor many of our Asian colleagues. I suggest that a possible solution to this for our Asian den-tal professional associations, societies, academies and various educational centres is toutilise the advanced information technology available in the knowledge and skills dissemi-nation process.

It is my pleasure to announce here that the South Asian Academy of Aesthetic Dentistrywill launch its online aesthetic dentistry accreditation (fellowship) programme atwww.dentistrysouthasia.com on November 2009. We believe that this effort is a milestonein the development of voluntary professional accreditation systems in South Asia. In addi-tion, the Asia Pacific Dental Federation is planning to launch a two-year fellowship pro-gramme in aesthetic dentistry. The concept paper and syllabus for this programme werepresented at the ICCDE board meeting during APDC Hong Kong 2009.

As always, I hope you will enjoy this new edition of cosmeticdentistry, in which we pres-ent a combination of clinical cases, expert opinion pieces and product information. I lookforward to receiving your valuable feedback. Please feel welcome to share your clinical ex-pertise and experiences with us.

Sincerely,

Dr Sushil KoiralaEditor-in-ChiefPresident Vedic Institute of Smile Aesthetics (VISA)Kathmandu, Nepal

Dear Reader,

cosmeticdentistry 3_200904 I

I content _ cosmetic dentistry

I editorial

03 Dear Reader_ Dr Sushil Koirala, Editor-in-Chief

06 Welcome to our international colleagues_ Dr Suhit R. Adhikari

I case study

08 Immediate dentures: Are you missing out?_ Dr Craig Callen

12 Ceramic restorations—What is the key to success?_ Robert Michalik

16 Management of full mouth prosthodontic rehabilitation using high-strength CAD/CAMzirconium-oxide crowns_ Dr Ansgar C. Cheng et al.

I clinical technique

20 Anatomic stratification technique for lifelike anterior composites_ Dr Ratnadeep Patil & Dr Kavita Mahesh

I special

24 Smile Design Wheel™: A practical approachto smile design_ Dr Sushil Koirala

I feature

30 Aesthetics and the brain_ Dr David L. Hoexter

32 Ceramic instead of composite_ Manfred Kern

I industry report

34 Temporaries: Perfect provisional restorations_ Dr Hans Sellmann

38 Customised abutments for long-term aesthetics—software tools to meet clinical and laboratory requirements_ Hans Geiselhöringer & Dr Stefan Holst

I industry news

42 Ivoclar: Progress knows no clinical limitations

I lifestyle

44 Enjoy your trip and indulge in the journey!_ Annemarie Fischer

I meetings

48 Cosmetic events

I about the publisher

49 _submissions50 _ imprint

page 34 page 38 page 44

page 16 page 20 page 32

Anschnitt DIN A4 04.08.2009 11:15 Uhr Seite 1

06 I

I editorial _ welcome letter


I 07

editorial _ welcome letter I


Dr Suhit R. Adhikari

_The South Asian Academy of Aesthetic Dentistry (SAAAD) was founded in 2005as the first web-based, regional professional academy in South Asia. The academy is dedicated to advancing the art and science of aesthetic dentistry and to promoting highstandards of ethical conduct and responsible patient care, by institutionalising a stan-dard continuing professional development programme through the provision of rele-vant accreditation (fellowship) processes. In order to fulfil its mission, the academy con-ducts regional aesthetics meetings and skills-oriented aesthetic training programmesand aims to organise its biennial scientific conference on a rotation basis amongst itsmember countries.

It is my pleasure to announce here that Nepal, the home country of the SAAAD ini-tiator, is hosting the first SAAAD biennial scientific conference from 28 to 29 November 2009. The conference theme is Minimally Invasive Cosmetic Dentistry: A Holistic Approach. The conference is organised in collaboration with the Asian Acad-emy of Aesthetic Dentistry, the Nepalese Academy of Cosmetic and Aesthetic Dentistry(NACAD), the Sri Lankan Academy of Aesthetic and Cosmetic Dentistry, the BangladeshAcademy of Aesthetic Dentistry and the Esthetic Academy of Bangalore, India.

It will be the first meeting of its kind in South Asia, with many renowned regional andinternational aesthetic dentists meeting in one place to share their knowledge and skillsin order to promote the art and science of aesthetic dentistry. We believe that the con-ference theme demonstrates our interest in quality, health and ethical issues of aestheticdentistry in Asia. We look forward to bringing positive changes though our mutual col-laboration.

On behalf of the organising committee and the host country, I would like to cordiallyinvite you all to participate in the forthcoming SAAAD conference in Kathmandu to fos-ter great relationships as professionals and friends and to enjoy the hospitality, naturalbeauty and cultural richness of Nepal. To sign up for the SAAAD Nepal conference, pleasevisit www.saaad.org. I hope to see you in Kathmandu!

Namaste,Dr Suhit R. AdhikariSAAAD 2009 Conference Organizing ChairmanSAAAD Secretary GeneralNACAD President

Welcome to our international colleagues

08 I

I case study _ immediate dentures

_All of the courses advertised today toutthe productivity of porcelain facings, orthodon-tics, automated root canal and implants. Whileany of these treatments can be rewarding andprofitable, the often-overlooked area of treat-ment that is highly rewarding and profitable is that of removable prosthetics. Yes, I said it,dentures! Many of us became burnt out on making dentures in dental school and never recovered, but times have changed. Not only is

there a huge untapped market for high-quality dentures as the population ages,but it can also be one of the most re-warding and profi-table proceduresyou provide for your patients per hour.

In addition, with the materials avail-able to you today, this can be a relativelyeasy treatment. A lot of what we knowabout cosmetic dentistry came fromprosthodontics. Full denture treatmentused to be the ultimate in cosmetic den-tistry before periodontal care changedthe way dentists practice.

Prosthodontists were really the firstdentists to study things such as facialproportions as related to tooth size andshape.

_How to get denture patients

Our office offers a Free Aesthetic DentureConsult. This allows patients to meet us and seewhat we can do for them in a non-threateningenvironment. If a patient calls in requesting fees,they are offered the option of the free consult.The patient is scheduled for a 10-minute timeblock with a doctor in the consultation room. Heor she fills out a short form that pertains strictlyto dentures. Then the patient is given a printoutthat describes his or her denture options andprocedures. We also show the patient pictures ofour cases and how natural they look.

We just had two large discount denture cen-tres move into our area (and they tend to be morebait-and-switch than discount centres). We notonly had to compete, but also differentiate ouroffice by showing that we provide high quality,aesthetic dentures, not cheap ones.

Most of our dentures are set with Dentsply’sPortrait IPN denture teeth, which look amaz-ingly natural. We run a small advertisement in the local paper promoting aesthetically pleasing dentures. In addition, we belong towww.denturewearers.com, which is a great online informational site for denture patients

Fig. 1_After, full face.


Immediate dentures: Are youmissing out?Author_ Dr Craig Callen, USA

Fig. 1

I 09

case study _ immediate dentures I


and will help drive them toward your own Website and office looking for solutions (Fig. 2).

_Technique appointment No. 1

Randy is a typical patient who came in for afree consultation for immediate maxillary andmandibular dentures. He had been told a longtime ago that he had severe periodontal disease and that his teeth could not be saved. A busy contractor, he put off treatment for years.We were able to appoint him for a complete examination and X-ray films, which verified hisstory.

Financial arrangements were made and weset-up an appointment for impressions, shadeand bite (Fig. 3). At the next appointment, wetook about an hour to get nice impressions withthe Accudent dual alginate system with stocktrays.

If Randy had been edentulous, we would have used Accudent’s anatomically correcteddenture trays. This utilises a light and heavy

body alginate mixed in an alginator. The lightbody sets slower and is applied in a large syringe.Because Randy still had teeth to establish verti-cal and tooth position, we then took a bite with Discus Dental’s Vanilla Mousse, but you can, of course, use your material of choice. Ifthere are many missing teeth, you may also useDiscus Dental’s Impression Putty for a bite .

The shade was chosen using the Dentsply Portrait Shade Guide. As most people want tobleach their teeth, we see more and more pa-tients choosing lighter coloured teeth. We takeseveral clinical and portrait photos for ourrecords and the lab’s use in setting the case.

If the patient wants to change his or her smile,we use The Smile Style Guide, written by Dr LorinBerland and Dr David L. Taub to pick a new smile(www.Digident.com; +1 800 741 7966). It is agreat tool that contains a multitude of differentsmiles progressing from square, pointed, roundand flat as well as various length combinationsthat we include with detailed notes for the lababout exactly what we and the patient want.

Fig. 2_A screen shot of

www.denturewearers.com.

Fig. 3_Accudent immediate denture

impression.

Fig. 4_Before, close-up.

Fig. 2 Fig. 3

Fig. 4

10 I

I case study _ immediate dentures


Because Randy did not need to have posteriorteeth removed and prolonged healing time, weprogressed right to a wax try-in appointment intwo weeks. I do a split set-up to verify the biteand show the patient the set-up. Randy, and hiswife, approved the set-up and the aesthetics andwe scheduled the surgical appointment in an-other two weeks. The case is then sent to the labfor proper festooning and life-like base materialprocessing.


Fourteen periodontally involved teeth wereremoved with local anaesthetic and nitrous ox-ide and the dentures seated. I relined them witha temporary soft liner to aid in the fit (Fig. 5). Weuse a cartridge-based system, such as VOCO’sUFI Gel SC. When Randy and his wife saw his newsmile, they both cried (in a good way) (Fig. 1). Sheimmediately scheduled herself for an appoint-ment for dentures too. In six months we will pro-vide relines.


Randy was back the next day with minimalconcerns. I will generally see the patient on thefirst adjustment, and then delegate the simpleadjustments to my well-trained, experiencedstaff.

My total chair time with the free consultation,examination, impressions, try-in, extractionsand seating and the first healing check wasabout 2.5 hours. My per hour production washigher than what I make on a typical crown andbridge case, and I provided a life-changing treat-

ment for a patient who was a dental cripple. Ifthe patient has trouble wearing dentures, we canproceed to implants to help in retention. One ofthe keys to providing quality denture care foryour patients is to find a laboratory that also isinterested in quality. You will pay top dollar, butit will be well worth it.

If you are not providing denture treatment inyour practice and you have holes in your sched-ule, you should think again about this underserved area of cosmetic dentistry. As babyboomers age and lose teeth, there will be a realneed for quality denture care._

Fig. 5_After, close-up.


Dr Craig C. Callen is a full time practicingdentist in the small city ofMansfield, Ohio, USA, inthe centre of the rust belt.He graduated from CaseWestern Reserve School ofDentistry at the age of 23.Callen has written threebooks for dentists: The Cut-

ting Edge I, II, and III. He is the associate editor forThe Profitable Dentist Newsletter and has writtennumerous articles for national dental publications.Callen is a member of the ADA,AGD and the AACD.He has lectured internationally on clinical and ma-nagement topics in dentistry. His latest seminar istitled, The Million Dollar Blue Collar Dental Practice.Callen and his wife, Dee, have five children.Theylive on a farm where they raise horses, alpacas andllamas. In his spare time, he likes to spend time bo-ating and travelling.You can reach Dr Callen via E-mail at [email protected].

cosmeticdentistry

_author info

Fig. 5

It's digital, cable-free, lightweight and mobile – there are a good

many reasons for choosing the VITA Easyshade Compact. And

every one of these is in itself a winner. With the new generation

of digital shade measurement you determine and check the tooth

shade in a matter of seconds. The VITA Easyshade Compact is

designed for all shades of the VITA SYSTEM 3D-MASTER and the

VITAPAN classical A1-D4 shades. This high-tech instrument

impresses with a great accuracy of measurement using state-of-

the-art spectrophotometric measurement technology. See for

yourself. Find out more at www.vita-zahnfabrik.com.

3384

E

VITA Easyshade® Compact –The exact shade in the blink of an eye.

The new generation

of digital tooth shade determination

3384E_210x297 V09 28.11.2008 8:26 Uhr Seite 1

12 I

I case study _ ceramic restorations

_The issue I would like to address in this articleis one well known to many of the readers. How-ever, occasionally it can be beneficial for us to con-solidate and evaluate our knowledge. Therefore, I would like to set out my own experiences acquiredover many years of work as a dental technician. I hope that the majority of readers will share my

opinion that in order to guarantee a successful ceramic restoration it is important to choose theright material and construction and to ensure thatit is properly made. Prosthetic work carried out inthis way ensures an aesthetically pleasing appear-ance, perfect marginal seal and durability for the entire restoration. Naturally, it cannot be expectedthat crowns set on a non-precious metal will lookbeautiful and provide a natural distribution of light,for example.

Technicians will always face a dilemma when itcomes to choosing the right coping, and only a skil-ful consideration of all the arguments for andagainst any specific solution will guarantee a suc-cessful outcome. My observations primarily concernthe materials and technologies that I have most frequently used to make ceramic crowns.

The firing method used for a ceramic mainly de-pends on the material of the coping. In turn, the aes-thetic quality of the prosthetic restoration (trans-parency, opalescence, fluorescence) is mostly influ-enced by the type of coping used.

Fig .1_Ceramic crowns made

on a metal substructure (CrCo).

Figs. 2–4_Crowns made on

a zirconium dioxide substructure.

Figs. 5–7_Ceramic crowns

made on a substructure using

the press technique.


Ceramic restorations—What is the key to success?Author_ Robert Michalik, Poland

Fig. 1 Fig. 2

Fig. 3 Fig. 4

Fig. 5 Fig. 6 Fig. 7

I 13

case study _ ceramic restorations I


Ceramic prosthetic crowns differ both in the tech-nology used to construct them and in the materialsfrom which the restoration is prepared. Porcelain canbe fired on:

_ alloys: precious metals (alloys with high gold con-tent—above 75%, medium—50–70 %, low—up to50 %) and non-precious metals (chrome, cobalt);

_ galvanic structures;_ transparent zirconium dioxide ZrO2 (nanoceramic—

size of grain below 30 µm, purity of material99.9999 %, and opaque zircon—grain value above30 µm);

_ aluminium trioxide Al2O3;_ press porcelain; and_ feldspathic porcelain.

I will briefly outline the pros and cons of thecrowns we use most frequently in our office.

_Porcelain fired directly on refractory die

Advantages_ natural distribution of light in finished restoration_ optimal cohesion of material_ excellent aesthetic effect when making individual

crowns for anterior non-discoloured abutment teethor veneers and inlay/onlay restorations

_ physiological wear with the antagonist_ chameleon effect

Drawbacks_ a difficult restoration technology, as no adjustments

can be made once the refractory material is removed_ not possible to control and monitor individual stages

of the work_ limited application for making individual anterior

crowns to be placed on non-discoloured abutmentsor for inlay/onlay restorations


Fig. 11 Fig. 12 Fig. 13

Fig. 14 Fig. 15

Fig. 16 Fig. 17

14 I

I case study _ ceramic restorations

_ preparation is possible only with a simple, relativelyeven shoulder around the entire circumference

_Porcelain fired on zirconium dioxide ZrO2

Advantages_ reproducibility and accuracy of restoration (only in

CAD/CAM system)_ good light dispersion_ covers dark abutments and metal posts and cores

(opaque zircon)_ a wide range of applications (crowns, bridges, bars

and implant abutments, telescope crowns, ledges)_ possibility of preparation with limited shoulder and

chamfer/bevel_ individual stages of the work can be monitored,

even in the patient’s mouth_ construction retains shape when ceramic is fired

Drawbacks_ construction has limited elasticity_ micro chipping on active surface_ construction cannot be repaired_ liners must be used

_Porcelain fired on metal

Advantages_ chemical bonding of construction with porce-

lain_ construction can be repaired_ high elasticity_ a wide range of applications (bridges, crowns,

telescope prosthetics, posts and cores, bars andimplant abutments)

_ individual stages of the work can be monitored,even in the patient’s mouth

_ oligodynamic effects (in the case of gold)

Drawbacks_ no transparency in substructure_ oxidation necessary_ risk of margin deformation when firing ceramic_ external factors may influence construction (tem-

perature, proportion, refractory material)

I will present several cases in which various kindsof substructures were used to achieve the most nat-ural appearance possible.

_Case I (Figs. 8–17)

A 28-year-old patient presented with pronounceddiscoloration of the teeth, which was a result of med-ication from the tetracycline group taken during herchildhood (Fig. 8). There was also significant damageto the enamel of the patient’s teeth. The uneven cer-vical line had damaged the aesthetic appearance ofher dentition. The patient wished to change both theshape and appearance of her teeth.

The first task was to ensure a proper cervical lineand achieve an effect of longer teeth without chang-ing the occlusal line. Owing to the skilful work of thedentist and the ideal construction of the temporarycrowns made by the technician, it was possible to


Fig. 18 Fig. 19

Fig. 20 Fig. 21

I 15

case study _ ceramic restorations I


achieve excellent results in the red aesthetic zone. Figures 16 and 17 show that the gingiva formed in accordance with our expectations.

As I mentioned earlier, in order to guarantee success, it is important to choose the right technol-ogy for crown fabrication. In this case, I consideredtwo possibilities for making the restorations: eitheron a coping using press technology or fired directly onthe refractory material. I was faced with such adilemma because I was unsure whether the crownsmade using feldspathic porcelain would cover thedark abutments of the patient’s teeth. After thepreparation, however, it turned out that the stumps ofthe teeth were not as drastically discoloured as thecolour prior to the preparation had indicated.

The effect of the reconstruction is left to the ap-praisal of the readers. The use of a metal coping andeven a zircon solution would not have achieved thedesired aesthetic result.

_Case II (Figs. 18–21)

A 26-year-old patient presented with a dis-coloured tooth 11 (Fig. 18). Previously, the operationsperformed by the dentist on the patient had involvedmaking composite veneers, which had changedcolour over time.

The first stage of the work involved changing thefillings in teeth 21 and 22, then making the prepara-tion and taking the impression. In this case, I consid-ered three variants for the substructure: made usingthe press method, a zirconium dioxide coping or a galvanic structure. The patient wanted a naturalrestoration identical to the one on tooth 21.

The press method would have been too risky, as thestump of the tooth was severely discoloured. I wasconcerned that the dark colour would show throughthe cemented crown. A crown inserted on a galvanicgold coping, in spite of its warm tone and its ability tocover the dark abutments, would not have dispersedlight in such a way that when looked at from any

angle it would be impossible to notice any featuresdistinguishing it from a natural tooth. Hence, I de-cided to make a crown based on a zirconium dioxidesubstructure.

_Case III (Figs. 22–23)

A patient visited our surgery for a typical dentalcheck-up. After a preliminary examination, caries wasfound to be present in several teeth, including the pa-tient’s two lower premolar teeth (secondary cariesreaching the pulp chamber). Unfortunately, in clean-ing the zone affected with caries the dentist had todevitalise the tooth and perform endodontic treat-ment. On completion of the treatment, the remainingdental tissue was found not suitable for partialrestoration. Hence, the dentist decided to make ce-ramic crowns and place them on stumps strength-ened beforehand with gold alloy posts and cores. Thestumps prepared in this way were subjected to analy-sis that showed that the optimal solution in this casewould be porcelain crowns made on a zirconium diox-ide substructure. This would ensure an aestheticallypleasing appearance and durability. Such character-istics could not be achieved with crowns made usingthe press method or fired on a refractory material ora metal coping. Only using zirconium dioxide as a sub-structure guaranteed the intended effect, which isleft to the readers to judge.

In conclusion, I would like to thank the dentistswho helped me prepare the work presented here. Iwould also like thank Robocam for providing the zir-conium dioxide._

Robert MichalikINTER-DENT LaboratoryUl. Pustuleczki 23,WarsawPolandTel.: +48 22 651 5645E-mail: [email protected]

cosmeticdentistry

_contact

Fig. 22 Fig. 23

16 I

I case study _ prosthodontic rehabilitation

_Introduction

_Prudent clinical judgementand careful consid-eration of the risks and benefits of various treatmentoptions are essential for the treatment planning andlong-term success of prosthodontic treatment.1

It has been established that loss of the vertical dimension of occlusion (VDO) may pose significantclinical difficulties in prosthodontic treatment.2,3 Yet,the re-establishment and maintenance of a new VDOis seldom taught in undergraduate dental curricula.

VDO is defined as the vertical measurement ofthe face between two selected points superior andinferior to the oral cavity when the occludingmembers are in contact.4 Various methods havebeen proposed for the assessment and re-estab-lishment of the VDO.3 The difference between thevertical measurement of physiological rest posi-tion, which should have a higher value than theVDO, and the VDO is referred to as the inter-occlusal rest space,4 which is essential for normalpatient function.

Fig. 1_Pre-treatment frontal view

showing attrition, erosion,

discolouration and compromised

aesthetics.

Fig. 2_Pre-treatment maxillary

occlusal view showing general loss

of enamel on the occlusal surfaces.

Fig. 3_Pre-treatment mandibular

occlusal view revealing loss of

occlusal tooth structure and

differential erosion loss of dentine.


Management of full mouthprosthodontic rehabilitationusing high-strength CAD/CAMzirconium-oxide crownsAuthors_ Dr Ansgar C. Cheng, Dr Helena Lee, Dr Neo Tee-Khin & Ben Lim, Singapore

Fig. 2 Fig. 3

Fig. 1

I 17

case study _ prosthodontic rehabilitation I


As teeth are worn down, the alveolar bone mayundergo an adaptive process that may compensatefor the loss of tooth structure.5 The VDO should becarefully assessed before the initiation of restora-tive procedures.

Traditional porcelain-fused-to-metal anteriorcrown restorations require the placement of labialcrown margins below the free gingival margin, in order to mask the hue and value transition betweenthe root surface and porcelain-fused-to-metalrestoration. However, intra-crevicular placement of crown margins is technique-sensitive and relatedto adverse periodontal tissue response.6–9 From aperiodontal point of view, preparation margins arebest kept away from the free gingival margin.8,9

The dentition, masticatory muscles and tem-poromandibular joints form a Class 3 lever system.

In such a lever system, functional load is inverselyproportional to the length of the lever arm. Anteriorteeth are under a reduced functional load in com-parison with posterior teeth. Porcelain-fused-to-metal restorations are commonly used in theposterior teeth because of their well-documentedlong-term clinical track record in anterior and posterior teeth.10–17 Newer zirconium-oxide-basedmaterials are usually prescribed in the anterior region owing to their demonstrated promisingphysical properties18,19 and reasonable clinicallongevity.20 In vitro studies also show that the wearof metal occlusal surfaces against porcelain occlusal material is acceptable when there are nobruxing activities.21

This article describes the prosthodontic manage-ment of a mutilated dentition using high-strengthzirconium-oxide crowns.

Fig. 4_Panoramic radiograph

showing adequate alveolar support.

Fig. 5_Anterior view of the full

maxillary and mandibular diagnostic

wax-up.

Fig. 6_Completed maxillary anterior

teeth preparations for full coverage

restorations. Note the equi-gingival

preparation margins.

Fig. 7_Completed mandibular

anterior teeth preparations for full

coverage restorations. Less than

1.5mm of tooth structure was

removed at the cervical third, owing

to smaller tooth size.

Fig. 8_Definitive maxillary cast.

No die-spacer was required in the

CAD/CAM manufacturing process.

Fig. 4 Fig. 5

Fig. 6 Fig. 7

Fig. 8 Fig. 9

18 I

I case study _ prosthodontic rehabilitation

_Clinical report

A 63-year-old fully dentate male patient pre-sented with discoloured teeth and multiple areas ofloss of tooth structure. The patient desired therestoration of function and aesthetics. He presentedclinically with defective restorations, insignificantloss of VDO and compromised aesthetics (Figs. 1–3).There were signs of loss of enamel at the occlusal andlabial surfaces of most of the teeth. The pre-treat-ment radiograph was within normal limits (Fig. 4). In spite of the overall condition, the natural teethwere free of active dental caries and oral hygiene wasgood. An occlusal examination revealed a stablemaximal inter-cuspation position with insignificantcentric relation to maximal inter-cuspation slide at the teeth level. No para-functional habit was reported.

A diagnostic dental wax-up on mounted maxillaryand mandibular casts in a semi-adjustable articula-tor was performed (Hanau Wide-vue, Teledyne Waterpik; Fig. 5). The proportions of the anteriorteeth were corrected to the estimated 0.618 width-to-height ratio of central incisors using the goldenproportion22–25 as a guideline. The results indicatedthat no increase of VDO was needed at the incisal pinlevel in order to restore proper incisal anatomy andanterior guidance. The overall treatment plan in-cluded placement of fixed, high-strength zirconium-oxide base restorations in the maxilla and mandible.

The maxillary and mandibular teeth were preparedin the usual manner for complete coverage crownrestorations (Figs. 6 & 7). The margins of the toothpreparations were prepared at the gingival level under magnification, and no gingival displacementprocedures on the prepared teeth were necessaryprior to definitive impression making. High-viscosityvinyl polysiloxane material (Aquasil Ultra Heavy,

DENTSPLY DeTrey) was carefully injected onto alltooth preparations, ensuring that all teeth surfacesincluding the margins were recorded. A stock trayloaded with putty material (Aquasil Putty, DENTSPLYDeTrey) was seated over the entire dental arch to makethe definitive impression. A jaw relation record wasmade with a vinyl polysiloxane material (Regisil PB,DENTSPLY DeTrey). The maxillary and mandibular definitive casts were mounted in the centre of the articulator using standard settings.26,27 Provisionalcrown restorations (Luxatemp Automix, Zenith/DMG)were placed on the prepared teeth at the estab-lished VDO.

The development of the planned definitive crownrestorations was carried out using CAD/CAM. Themaxillary and mandibular definitive casts (Figs. 8 & 9)were scanned (Zeno Scan, Wieland) and the crowncopings were designed using a software programme(3Shape D700). The copings were milled in zirconiumbase material (ZENO ZrBridge, Wieland) with a millingmachine (ZENO 4030 M1, Wieland; Fig. 10). The copings were sintered according to the manufac-turer’s recommendations. Subsequently, overlayinglow-fusing porcelain material (IPS e.max, Ivoclar Vivadent) was manually applied onto the exterior tocreate proper anatomic form. All maxillary andmandibular anterior teeth were fabricated using thesame process. The completed restorations were cemented in resin-modified glass-ionomer lutingagent (RelyX Unicem, ESPE; Figs. 11–12 & 15).

The patient was evaluated post-operatively. Ante-rior guided occlusal schemes were verified intra-orally before and after prosthesis cementation (Figs.13 & 14). The patient reported no discomfort andadapted well to the new restorations. No abnormalclinical signs were noted.

_Discussion

The maintenance and re-establishment of the VDOis a crucial element in full mouth fixed prosthodonticrehabilitation. It was necessary to make impressionsthat registered all teeth preparations at once.

As the patient desired a high level of aesthetics, fullceramic restorations were chosen for all restorations.The minimum core thickness for this full ceramic system is 0.4mm, this enabled conservation of toothstructure and achievement of reasonable aestheticssimultaneously.

By prescribing full ceramic restorations, intra-sulcular placement of crown margins on the labialsurfaces become less important from an aestheticpoint of view. In this report, the teeth were essentiallycaries free, teeth preparation margins were made at

Fig. 9_Definitive mandibular cast

Tooth reduction was generally more

conservative when compared with

conventional porcelain-fused-

to-metal restorations.

Fig. 10_Coping milling machine

Zeno 4030 M1 (Wieland).


Dr Ansgar C. ChengSpecialist Dental Group™3 Mount Elizabeth #08-10Singapore 228510Republic of Singapore

E-mail:[email protected]

cosmeticdentistry

_contact

Fig. 10

I 19

case study _ prosthodontic rehabilitation I


gingival level and gingival retraction procedures wereeliminated. As gingival retraction cord placement wasnot required, there was less physical trauma to thegingival tissues and less clinical time was needed. Thisis particularly beneficial for thin gingival biotypes.

Full mouth rehabilitation using fixed prosthesesusually requires longer-term provisional restoration in order to facilitate a predictable treatment outcome.In this patient, owing to his busy travel schedule, long-term provisional restoration for verifying his adaptabil-ity and multiple professional clinical adjustments of provisional restorations were not feasible. The anterior teeth were restored based on the diagnosticwax-up without long-term provisional restoration before definitive cementation of the definitive crownrestorations. This treatment sequence left almost noroom for clinical errors in the execution of the plannedtreatment.

Intra-oral verification of the new occlusal schemeand detailed in situ clinical adjustment of the restora-tions on the day of prostheses insertion are essential forproper treatment execution. In this unique treatmentapproach, the patient should be informed of the poten-tial financial and time implications should any need forre-fabrication of the definitive restorations arise.

_Conclusion

The functional management of complex prostho-dontic rehabilitation is a clinical challenge. A rela-tively new restorative material was used in this case.The use of high-strength full ceramic restorations en-hances the overall aesthetic outcome and functionalpredictability over the long-term._

Editorial note: A complete list of references is available from the publisher.

Fig. 11_Occlusal view of completed

definitive maxillary full ceramic

crown restorations.

Fig. 12_Occlusal view of completed

definitive mandibular full ceramic

crown restorations.

Fig. 13_Side view at right

latero-trusion, canine-guided

occlusion.

Fig. 14_Side view at left

latero-trusion, posterior teeth were

out of occlusion during eccentric

movement.

Fig. 15_Anterior view of the

completed maxillary and mandibular

crown restorations. The crown

margins were placed at the gingival

margin with no sub-gingival

extension.

Fig. 11 Fig. 12

Fig. 13 Fig. 14

Fig. 15

20 I

I clinical technique _ anatomic stratification technique


_Introduction

_Direct composite resin restoration is a viabletreatment option for an aesthetic restoration withminimal tooth reduction, especially in the case ofuncomplicated tooth fractures.1,2 Such fractures arequite common amongst children and teenagers andmay cause aesthetic and psychosocial problems.3

In the past, the outcome of direct resin restora-tions was compromised as they reproduced theoptical properties of natural teeth poorly. Recentadvances in adhesive technology and materialproperties, as well as improved understanding of theoptical properties of the natural tooth, have helped

achieve improved vitality and depth of a restoration.The direct resin build-up of a Class IV restorationbased on a contemporary layering technique allowsclinicians to provide conservative treatment and avirtually imperceptible blend with adjacent toothstructures.4

_Case report

A 19-year-old male patient presented with a frac-tured upper-left central incisor and a chipped upper-right central incisor from a sports injury (Fig. 1).Radiographic examination and the cold test did not reveal any pulpal damage. After discussing var-ious treatment options with the patient, conserva-

Anatomic stratificationtechnique for lifelike anterior compositesAuthors_Dr Ratnadeep Patil & Dr Kavita Mahesh, India

Fig. 1 Fig. 2

Fig. 3 Fig. 4

I 21

clinical technique _ anatomic stratification technique I


tive restoration using direct composite resin was selected.

Shade selectionThe tooth shade was analysed before tooth prepara-

tion and thereafter evaluated for each layer of compos-ite. Shade selection involves the dentist visually com-paring the natural teeth shade to standard dental shadeguides.8 Such selection does not ensure that the same-shade composite will yield the desired outcome, as the

inherent opacity and layer thickness will determineshade outcome. Shade matching, on the contrary, is ahighly technical process, but also with an unpredictableoutcome because it depends on individual skill andknowledge.8 Shade matching has to be an integral partof the layering technique.

Using the Tetric N-Ceram shade guide system(Ivoclar Vivadent), the shade was determined to be A3,with a high incisal edge translucency and an orange-red

Fig. 6

Fig. 8

Fig. 10

Fig. 12

Fig. 5

Fig. 7

Fig. 9

Fig. 11

22 I

I clinical technique _ anatomic stratification technique

final effect. Occlusal view of the fractured teeth revealsthe difference in opacity and translucency of dentineand enamel in tooth 21 (Fig. 2). Dentine is an opaque andfluorescent tissue that determines the tooth’s hue andchroma by reflecting light through the enamel. Enamelis a translucent and opalescent tissue that determinesthe tooth’s value.3,6 As the patient is young, the incisalmamelons were intact (Fig. 1).

Preparation designA 1mm bevel was placed along the margin of the

chipped enamel surface of tooth 11 (Fig. 3). An envelopepreparation design extending 2 mm with a 1 mm bevelwas prepared on the buccal surface of tooth 21 (Figs. 3& 4). On the palatal surface of tooth 21, a rounded buttmargin was prepared (Fig. 4).

The cavity preparation was disinfected using a 2 %chlorhexidine antibacterial solution. Etching was donefor 15 seconds using 37 % phosphoric acid (Fig. 5).Thereafter, the etchant (Total Etch, Ivoclar Vivadent) wasremoved and the tooth surface rinsed with water spray

for 30 seconds, followed by air drying, taking care not todry the tooth surface excessively (Fig. 6). A fifth-gener-ation nano-optimised adhesive (Tetric N-Bond, IvoclarVivadent) was placed in the preparation and agitated for10 seconds, then gently air-thinned (Figs. 7 & 8) andpolymerised for 20 seconds (Fig. 9).

Composite layeringComposite layering was accomplished using the

anatomic stratification technique, which aids the natu-ral appearance of restorations. Each layer has differentshades and opacities when stratified, giving a polychro-matic effect with a more realistic depth of colour by creating an illusion of the way light is reflected, refracted, transmitted and absorbed, to simulate that ofdentine and enamel. This is crucial to overcome the disadvantage of ‘shine through’ (silhouette of the frac-tured area is highlighted by the darkness of the oral cavity) of traditional single- or two-layer techniques.6

Current composite resin systems use dentine mate-rials that reproduce the fluorescence of natural dentineand enamel materials that mimic the opalescence andtranslucence of natural enamel.4

Although there is no exact formula for stratificationwith such results, as shade layering varies from case tocase, the general rules are:

1. Replace palatal/lingual wall with an opaque compos-ite. As they have higher colour saturation, when lightstrikes the optically dense layer more light is reflectedback to the eyes, which contributes to the hue andchroma by optically replacing dentine.6,7


Fig. 13 Fig. 14

Fig. 15 Fig. 16

Fig. 18 Fig. 19

Fig. 17

I 23

clinical technique _ anatomic stratification technique I


2. Use thin increments and observe shade after curingeach layer, so that the shade of the next layer can beplanned. An advantage of this technique is that itminimises the negative effects of shrinkage by creat-ing small incremental shrinkage.5

3. Use translucent composites to encapsulate the den-tine core. This alters the quantity and quality of thelight reflected and thus determines the value of therestoration by optically replacing enamel in therestoration.6,7

4. Finish and polish to replicate natural tooth textures.

In this case, a nano-composite resin (Tetric N-Ceram)was selected as the material of choice for restoringthese teeth. Stratification was initiated with a thin layer of flowable resin (Tetric N-Flow, Ivoclar Vivadent;Fig. 10) and thereafter 1 mm of Bleach light shade (Tetric N-Ceram) was placed and cured to replicate theopaque dentine layer (Fig. 11). A metal matrix strip wasplaced interdentally and a triangular, mesio-incisallayer of the A2 and A3 dentine shades (Tetric N-Ceram)was placed and sculpted to reconstruct the proximalsurface (Figs. 12 & 13).

Next, increments of A3 enamel shade (Tetric N-Ceram) were layered (Figs. 14–16) with a long-bladedinstrument and texture lines created with a sable brushbefore curing (Fig. 17). The mamelon effect was com-pleted using the highly translucent Incisal shade (TetricN-Ceram) at the inciso-lingual matrix, and two notcheswere placed to duplicate the external contours of themamelons. The last increment was done using a thinlayer of Translucent Opal Shade (Empress Direct Com-posite, Ivoclar Vivadent).

Finishing and polishingFinishing focuses on contouring, adjusting, shaping,

texturing and smoothing the restoration (Fig. 18), whilepolishing concentrates on producing a surface lustre(Fig. 19) and highly reflective surface.6 For creating tex-ture in finishing, various areas on the buccal surface ofthe tooth were highly polished to give a lifelike effect tothe restoration.1,2 Eminence of the proximal convexity,the horizontal and vertical ridges, the lobe effect and facial flattening were effectively projected. The black

and white image of the finished restoration shows thatthe value of the tooth and restoration is similar (Figs. 20& 21).

_Conclusion

The success of the anatomic stratification techniquelies largely in the fact that it draws inspiration from thenatural layering of dentine and enamel. Continuoustechnological advances have provided us with materi-als that can successfully replicate tooth characteristicsand retain the characteristics built into them throughlayering them on tooth surfaces. With this technique, it is possible for clinicians to provide more conservative,yet functional and aesthetic, treatment to their patients._

Editorial note: A complete list of references isavailable from the publisher.

Dr Ratnadeep Patil has maintained a successful private practicespecialising in aesthetic and implant dentistry in Mumbai since1988.He is a diplomate of the International College of Oral Implan-tologists and an active member of the International Association forDental Research.He has authored a clinical textbook on aestheticdentistry (Esthetic Dentistry:An Artist’s Science) and been activelyinvolved in conducting continuing dental education programmes.

Dr Kavita Mahesh has been in clinical practice since she gradua-ted from the Government Dental College and Hospital in Mumbai in2002.Since 2003,she has been a member of the team at SmileCare in clinics and been involved in continuing dental education pro-grammes and clinical research.She completed her Post-GraduateCertificate in Implant Dentistry at New York University in 2005.

Smile Care13,Geetanjali,234,S.V.Road Tel.:+91 22 2643 1670/71Bandra (West),Mumbai – 400 050 E-mail: [email protected] www.smilecareindia.com

_author info cosmeticdentistry

Fig. 21Fig. 20

24 I

I special _ smile design

_Modern trends in cosmetic dentistry andmedia coverage of smile makeovers have in-

creased public awareness of dental aesthetics.People now know that smile aesthet-

ics plays a key role in their senseof well-being, social accept-

ance, success at work andin relationships, and

self-confidence. Theaesthetic expecta-tions and demands ofdental patients haveincreased substan-tially. Now, a glow-ing, healthy and vi-brant smile is no

longer available onlyto millionaires and

movie stars. Therefore,many dentists are incorpo-

rating various smile designprotocols in their daily practices

to meet the increasing aesthetic de-mands of their patients.

_Smile aesthetics

A smile is a facial expression that is closely re-lated to the emotions and psychological state ofa person. A smile is exhibited when a person ex-presses happiness, pleasure or amusement.1 It isthe most important of facial expressions and isessential in expressing friendliness, agreementand appreciation.2 A smile requires the coordina-tion of facial, gingival and dental componentsthat are stimulated voluntarily or involuntarily byvarious emotions. It is evident that each smile is

different and particular to each individual.3 Animpaired smile on the other hand, has been asso-ciated with higher incidences of depression.4

Aesthetics deals with objective and subjectivebeauty.5 Objective beauty is based on the appre-ciable properties possessed by the object itself.However, subjective beauty is relative to the per-ception and emotion of the observing person.Perception, however, in smile aesthetics is basedon personal beliefs, cultural influences, aesthetictrends and fashion, and input from the media.Hence, smile aesthetics is a multifactorial issue,which needs to be adequately addressed for anyaesthetic treatment. The objective beauty of asmile can be established with the application ofvarious principles of smile design, and the cre-ation of subjective beauty may enhance cosmeticvalue.5,6

_Smile design

Smile design has been defined in various waysin the literature; I would like to summarise it asfollows: “Smile design is a systematic processgoverned by the psychology, health, function andrules of natural aesthetics to bring about somechanges in soft- and hard-oral tissue withinanatomical, physiological and psychological lim-itations, thereby creating a positive influence onthe overall aesthetics of a person’s face and per-sonality as a whole”.7

We all appreciate a beautiful smile when we see it, but it is difficult to explain exactly whatmakes a smile beautiful. It is evident that a pleas-ing smile depends on the following features: the


Smile Design Wheel™:A practical approach tosmile designAuthor_ Dr Sushil Koirala, Nepal

Fig. 1

I 25

special _ smile design I


quality of the dental and gingival components,their conformity to the rules of structural beauty,the relationship between teeth and lips, and theirharmonious integration with the facial compo-nents.8 Overall facial beauty and smile aestheticsare normally judged by psychological aspects—perception, personality, desire—the state of health,the mathematical ratio of the facial, dento-facialand dento-gingival components. The psychologi-cal aspects are highly subjective and fluctuateconstantly because of identity, peer and mediapressure. Hence, the only objective method of aes-thetic analysis is mathematical.

Indeed, mathematics has been considered theonly frame of reference for comprehending na-ture.8 Therefore, the cosmetic dentist needs to befamiliar with various mathematical and geomet-ric concepts for achieving smile aesthetics andtheir clinical protocols.

_The Smile Design Wheel

For any smile design procedure, the clinicianneeds to consider the elements of the smile de-sign pyramids—psychology, health, function andaesthetics (PHFA), listed here according to orderof importance.7 It is necessary to determine thepatient’s psychological status, establish a healthyoral environment, restore function and then giveattention to enhancing the aesthetic aspect. Allfour pyramids should be accorded equal impor-tance to achieve a desirable clinical result.

By integrating these PHFA pyramids, I devel-oped the Smile Design Wheel (Fig. 1), in whicheach pyramid is subdivided into three relatedzones. The Smile Design Wheel was devised as asimple guide to the most important componentsof smile design, their clinical significance and se-quence to be maintained during the smile designprocedure. I believe that the Smile DesignWheel will help clinicians to easily compre-hend the ‘complex’ smile design proceduresof aesthetic dentistry. In the next section, I briefly explain the Smile Design Wheelprotocols with PHFH pyramids assess-ment and their basic objectives.

_Step I: Understand—The pyramid of psychology

According to Prof. Robert A.Baron, psychology is best definedas the science of behaviour and cognitiveprocesses. Behaviour deals with any action orreaction of a living organism that can be observedor measured. Cognitive processes deal with every

aspect of our mental life: our thoughts, memories,mental images, reasoning, decision-making, andso on, in short, with all aspects of the human mind.

In smile design, we normally try to understandthe second part of psychology, i.e. the human mindor rather the minds of our patients. There are threefundamental zones we consider in detail for thepsychological pyramid assessment: perception,personality and desire.

Perception

Perception is the process through which a per-son can select, organise and interpret input fromtheir sensory receptors. A person cannot imaginebeauty and aesthetics without some input in ad-vance. The media is the most common source ofinformation at present regarding beauty and aes-thetics. A patient usually conceives his or her ownperception of smile aesthetics based on his or herown personal beliefs, cultural influences, aes-thetic trends within society and information fromthe media.

Dentists need to communicate with their pa-tients to determine such information during theinitial consultation, which helps in understandingthe patient’s perception of the treatment result.The use of questionnaires, visual aids, such as pre-vious clinical cases or smiles of various celebrities,can aid immensely in this process.

Personality

According to the human psychology, person-ality is an individual’s unique and relatively sta-ble pattern of behaviour, thoughts and emotions. It is to be noted that each patient’s

problem or concern should be comprehen-sively evaluated with respect to his or her

personality type. According to Roger P.Levin,9 there are four personality

types:

_ Driven: This type of personfocuses on results, makes

decisions quickly and dis-likes small talk. They

are highly organised,like details in con-

densed form,are businesslike

and assertive._ Expressive: This type of person

wants to feel good, is highly emotional,makes decisions quickly, dislikes details or pa-perwork, and likes to have a good time.

Fig. 2

26 I


_ Amiable: People with this personality type areattracted by people with similar interests, fearconsequences, are slow in decision-making, re-act poorly to pressure, are emotional and slowto change.

_ Analytical: This type of person requires endlessdetails and information, has an inquiring mind,is highly exacting and emotional. This type is themost difficult to convince and takes the longestto reach a decision.

Desire

Desire is a subjective component. Increasedpublic awareness of smile aesthetics through themedia has lead to a rapid increase in patients’ de-sires and levels of expectation. Patients are nowwilling to pay for the enhancement of their smileaesthetics. Therefore, the ethical responsibilitiesof cosmetic dentists in identifying the need- orwant-based desires of patients have also in-creased. The desires and levels of expectation inmany patients are higher than what is clinicallyachievable, and it is the clinician’s duty to explainand guide patients towards a realistic aestheticgoal.

The psychological assessment of any person isvery subjective; however, aspects like perception,personality, expectation or desire are importantfor the smile design procedure. Patient satisfac-tion is closely related to these aspects. Hence, understanding the pyramid of psychology is anintegral aspect in smile design.

_Step II: Establish—The pyramid of health

The pyramid of health is divided intothree zones: general health, specific

health and dento-gingival health.The health pyramid assessment

and its management play a vi-tal role in most cases, as pa-

tients may have certainlimitations owing to their

health, like uncontrolled dia-betes, soft-tissue pathology, poor bone

structure, poor oral hygiene, tooth decay, peri-odontal disease etc., which should be addressedprior to functional and aesthetic treatment.

The health pyramid assessment process in-cludes patient history (medical, dental, nutri-tional), examinations (extra-oral, intra-oral) andinvestigations (radiographs, pulp vitality test,study models analysis). Various types of ques-tionnaires and clinical examination and investi-

gation protocols can be used to obtain the neces-sary information relating to the patient’s health.The clinician can use this information to preparea personalised treatment protocol. All three com-ponents of the pyramid of health should be es-tablished within normal limits before starting anyaesthetic restorative procedure on a patient.

_Step III: Restore—The pyramid of function

Function is related to forceand movement. Hence, for the pyramid of function as-sessment, the existing oc-clusion, comfort and phonetics are properlyexamined with theevaluation of para-functional habits,level of comfortduring chewingand degluti-tion, and tem-poromandibu-lar joint movement.The clarity of normal speechand pronunciation are also examined. The occlu-sion, comfort and phonetics components of thefunctional pyramid should be restored and main-tained at an acceptable level before starting thetreatment of any aesthetic component.

_Step IV: Enhance—The pyramid of aesthetics

The pyramid of aesthet-ics is the last but mostsensitive pyramid of theSmile Design Wheel, asaesthetics has bothsubjective and ob-jective aspects. Theassessment ofthe subjectiveaspects—per-ception, per-sonality, de-sire—is car-ried out dur-ing the pyramid ofpsychology assessment.It is to be noted that the assessment of the objec-tive aspects depends on the distance (focallength) used to visualise the aesthetic compo-nent. Hence, the aesthetics pyramid can broadlybe divided into three major zones: macro, miniand micro.


Fig. 3

Fig. 4

Fig. 5

I 27

special _ smile design I


Macro-aesthetics

Macro-aesthetics deals with the overall struc-ture of the face and its relation to the smile (Fig. 6). To appreciate the macro-aesthetic com-ponents of any smile, the visual macro-aestheticsdistance should be more than 5 feet. However, inclinical practice the assessment of the macro-aesthetic components is done using various facialphotographs with geometric and mathematicalappraisals, using reference points and their inter-relation. Various facial reference points andguidelines are used for aesthetic assessment for orthognathic and facial cosmetic surgery;however, in smile design the following macro-aesthetic guidelines are considered fundamental:

_ facial midline;_ facial thirds;_ interpupillary line;_ naso-labial angle; and_ Rickett’s E-plane.

Mini-aesthetics

Mini-aesthetics deals with the aesthetic corre-lation of the lips, teeth and gums at rest and insmile position (Fig. 7). The aesthetic correlationcan be appreciated properly when viewed at acloser distance than the visual macro-aestheticsdistance.

The visual mini-aesthetics distance is similarto the across-the-table distance, which is nor-mally within 2 to 5 feet. There are various guide-lines in aesthetics based on the relationship andratio between lips, teeth and gingival tissue. Thesecan be analysed during mini-aesthetic assess-ment using frontal, vertical and transverse char-

acteristics of the smile. Clinical photographs arethe basic tools for mini-aesthetic analysis. Thesmile can be analysed at rest (M-position) or smile(E-position).

In the M-position, the following references aremeasured and analysed:

_ commissure height;_ philtrum height; and_ visibility of the maxillary incisors.

In E-position the following references shouldbe analysed:

_ smile arc (line);_ dental midline;_ smile symmetry;_ buccal corridor;_ display zone and teeth visibility;_ smile index; and_ lip line.

Micro-aesthetics

Micro-aesthetics deals with the fine structureof dental and gingival aesthetics (Fig. 8). Mini-aesthetics can be appreciated at a visual micro-aesthetic distance of less than 2 feet or withinnormal make-up distance. For the clinical assess-ment of micro-aesthetic components of the teethand gingival tissue, appropriate illumination andmagnification tools are required for intra-oral examination. Necessary clinical intra-oral photo-graphs should be taken for documentation andfuture reference.

For micro-aesthetics, the detail of the individ-ual tooth structure and its relation to the sur-

Fig. 6 Fig. 7

28 I


rounding gingiva and the adjacent teeth shouldbe analysed. The following are the major pointsto be considered:

_ upper centrals (tooth size ratio);_ principle of golden ratio;_ axial inclination;_ incisal embrasures;_ contact point progression;_ connector progression;_ shade progression; and_ surface micro-texture.

In smile design, the aesthetic conditions re-lated to gingival health and appearance are anessential component. The gingival shape, posi-tion, embrasure, and contour in relation to theteeth are interdependent. The following are ma-jor aspects that should be addressed duringsmile design to achieve gingival or pink aesthet-ics:

_ gingival shape;_ gingival contour;_ gingival embrasure;_ gingival zenith; and_ gingival height (position or level).

To achieve higher patient satisfaction andlong-lasting treatment results, the followingshould be the sequence in any smile design pro-cedure: proper comprehension of psychologicalaspects, the establishment of health and therestoration of function within its normal limit,and the subsequent enhancement of aestheticcomponents.

_Conclusion

Today, various protocols of smile design areavailable in cosmetic dentistry. However, most cli-nicians wish to use the simplest protocol with themost predictable results. It is to be noted thatsmile design should always be a multifactorial decision-making process that allows the clinicianto treat patients with an individualised and inter-disciplinary approach.

The Smile Design Wheel presented in this articleclearly indicates the most important components(PHFA pyramids) of smile design, their clinical sig-nificance and sequence to be maintained duringthe smile design procedure. I believe that theSmile Design Wheel is a simple and practical pro-tocol in smile design that can help the clinician toeasily comprehend the ‘complex’ smile designprocedures of aesthetic dentistry._



Dr Sushil Koirala, VISA president, can be reachedat [email protected].

cosmeticdentistry

_contact

Fig. 8

IPS

e.m

ax®

“e.max LITHIUMDISILICATE IS THEMOST ROBUSTCERAMIC SYSTEMTESTED TO DATE.”*

This changes everything.

The durability of lithium disilicate glass-ceramic crownsis higher than that of veneered zirconium oxide. Lithiumdisilicate is therefore the material of choice for singlecrowns: strong, esthetic, economical. Try it yourself. 350 N*1

1,000 N*2

all ceramic

all you need

zirconiaveneered

IPS e.maxlithiumdisilicate

*Mouth Motion Fatigue and Durability StudyPetra C Guess, Ricardo Zavanelli, Nelson Silva and Van P Thompson,New York University, March 2009

1 90% failure by 100,000 cycles2 No failures at 1 million cycles

www.ivoclarvivadent.comIvoclar Vivadent AGBendererstr. 2 | FL-9494 Schaan | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60

Ivoclar Vivadent Marketing Ltd. (Liaison Office) India503/504 Raheja Plaza | 15 B Shah Industrial Estate | Veera Desai Road, Andheri (West) | Mumbai 400 053 | IndiaTel.: +91 (22) 2673 0302 | Fax: +91 (22) 2673 0301 | E-mail: [email protected]

Ivoclar Vivadent Marketing Ltd. Singapore171 Chin Swee Road | #02-01 San Centre | Singapore 169877 | Tel.: +65 6535 6775 | Fax: +65 6535 4991

emax_ad_quote_NYU_eIND+SING_A4.qxd 22.7.2009 13:21 Uhr Seite 1

30 I

I feature _ opinion

_The age-old question as towhat constitutes beauty has beensubjected to yet another wrinkle. Re-search has been presented showingthat left-sided brain people perceivebeauty differently than right-sided ones.Beauty is and has been perceived throughthe ages through individual eyes. Perhapsdifferent cultures encourage differentzones of desire and contentment; also, peo-ple of different ages may have different views.Whatever the cause or conditioning, our vi-sions encourage that beautiful zone. Is it dueto our youth’s environment, perhaps where ourmother’s left side of the brain influenced our con-cepts early, relating to beauty?

When I was presenting cosmetic periodontal tech-niques in Sicily, Italy, at a congress dedicated to aesthet-ics in dentistry, Dr DeLucca, an exquisite prosthodontistwith exceptional aesthetic prosthetic results, broughtup factors and questions regarding the effects of aes-thetics from the right and left sides of the brain as wellas the male/female dominance in their respectivespheres.

The brain has been relegated to different functionson its left and right side in several factors. The right sideis said to be more analytical, more detailed, as well asmore scientific, mathematical, computeristic, logicaland analytical. In general, the right side is usually relatedto males. The left side of the brain is, in general, attrib-uted to the female gender. Its characteristics are said tobe non-verbal, intentional, emotional, excellence inspacial relationships, and good colour perception.

In the past 20 plus years of dentistry, aesthetics haschanged the face of the profession. This is not meant tobe a pun but an actual fact. The desire by patients to elec-tively choose to have dentistry is a huge leap from its im-age of yesteryear. Not relying on motivation from painor trauma, patients are eagerly trying to improve their


Aesthetics and the brainAuthor_ Dr David L. Hoexter, USA

I 31

feature _ opinion I


appearance orally. A wonderful bright smile canlight up the face and the public is now aware ofthis fact. At about the same time that cosmeticimprovement was encouraged by our profes-sion, the profile of the dental school popula-tion started to change. The number of femaledental students became more predominantthan ever before in the United States. Wasthis the left side of the brain making itsmark?

The initiating pioneers in the dental aes-thetic field, Drs Irwin Smigel and Ron Gold-stein, forged awareness to the public aswell as dentists, and encouraged the pa-tient to request looking better orally. Inturn, they encouraged the dentist to pro-vide the services that stimulated dentalcompanies to research and provide betteraesthetically appearing, yet formidable,restorative materials. Did it take these pio-neers the use of the right side of their brainto forge this field of aesthetics?

In other countries throughout the world,the number of female dental school graduates

has been higher than males for years. In addi-tion, 85 per cent is the common percentage of fe-

male dentists practicing in many such countries. In theUS, that number hovers at about 50 per cent.

Does the right side of the brain dominate our fieldwith the necessary precision that is demanded? Havethe materials in dentistry today improved so much thatthere is compensation in techniques to allow the leftside of the brain’s activity to transcend and emit an aes-thetic sensitivity for the patient’s appearance? Can theindividual dentist utilise the left and right side of his orher brain as noted in today’s terminology by the expres-sion ‘crossover’?

Will the economic turmoil of today affect the demandby patients for cosmetic dentistry beyond the necessaryhealth requirements? I know that for me to find the answer regarding the male/female, left and right brainrelationships, I should smilingly have to ask my wife._

Dr David L. Hoexter is director of the International Academy forDental Facial Esthetics, an organization that combines physiciansand dentists with other related fields in research and relates its fin-ding to clinical practice. He lectures throughout the world and has published internationally. He has been awarded 11 fellowships in-cluding FACD,FICD and Pierre Fauchard.He maintains a practice inNew York City, limited to periodontics, implantology and aestheticsurgery.He can be reached at [email protected].

cosmeticdentistry

_author info

Fig. 1_Dr Otto and his team have

worked with CEREC for 18 years.

(Photo: Manfred Kern)

32 I

I feature _ practical experience

_Dr Tobias Otto, a dentist in private practice inAarau in Switzerland, witnessed the ‘death’ ofamalgam as a student at the University of Zurich.The University was reacting in response to the prohibition of amalgam in Sweden. Compositesand the adhesive technique were the new hopefuls

for treatment with fillings. The tooth-colouredrestorations met the patients’ aesthetic desires. Dr Otto learned how to perform this time-consuming procedure, which includes rubber dam,dentine adhesives, the composite layering tech-nique and light polymerisation. He also saw howtwo- to four-surface composite restorations soonfractured under masticatory loading due to in-sufficient contact points and porosities, becamediscoloured and abraded after longer service, orneeded replacement because of recurrent caries.

Inspired by natural aesthetics, patients nolonger found cast gold fillings attractive. The newalternative, such as laboratory-manufactured ceramic inlays, taught Dr Otto that this restorationtechnique too failed to provide the hoped-for,long-term survival quality and was too expensive.He found that the fracture resistance of the delicate edges of pressed silicate ceramic inlays leftmuch to be desired, as did the colour stability of the surfaces. Dr Otto dreamt of an industrially sintered, dense, stable ceramic. But how could thisbe milled?

While he studied hard for his licensing exams,the first CEREC machine, which could mill an inlayfrom an industrially produced ceramic blank, wasbeing developed in the clinic one floor above his office. The protagonists of this method were con-fronted by many sceptics who denied the new system their support because of the adhesive jointbetween ceramic and enamel. However, Dr Ottorecognised that here was a highly resilient silicateceramic, whose flexural strength surpassed that ofboth composites and laboratory-layered sinteredceramics.


Ceramic instead ofcompositeAuthor_ Manfred Kern, Germany

Fig. 1

I 33

feature _ practical experience I


He began working with CEREC 1 in 1989 in apartner practice in Zurich. He wished not only toprovide his patients with aesthetic and long-lasting restorations, but also to prove to the hesi-tant university and the professional communitythat this method, together with adhesive bonding,was capable of providing the basis for highly resilient ceramic restorations. With typical Swissthoroughness, he documented all of the CERECtreatments he performed and recorded all findingsfrom recall appointments. “I was convinced that inthe long run, ceramic would be more durable andeconomical than composite,” remembers Dr Otto.“For three and more surfaces, composite is, in myopinion, a poor compromise and, if recurrent cariesdevelops or the filling has to be replaced a shorttime later, the patients will consider me a bad dentist. In terms of long-lasting dental aesthetics,we Swiss are very particular; we don’t accept com-promises.”

Time would prove him right. After ten years,data from his practice demonstrated a survival rateof 90.4% for CEREC inlays and onlays. Thus, theseresults corresponded to those of the gold standard,that is, cast gold fillings.1 The study was publishedinternationally and the media acknowledged thefindings for ceramic restorations in private prac-tice. Meanwhile, Dr Otto has been working with

a CEREC 3 unit, and the study is now in its 18th year.The consistently applied multistep adhesive tech-nique has proven to be sufficient, even with an adhesive joint of 150µm. With a survival rate of88.7 per cent after 17 years, Dr Otto has set the newgold standard with his restorations.2

He satisfies his patients’ dental and aestheticdesires using CEREC thanks to the material, whichcombines excellent aesthetics with stability, and to the longevity, which makes the restoration economical. “What my patients appreciate aboutCEREC is that their tooth-coloured ceramicrestoration is manufactured and inserted in onesitting, and for an average yearly cost of 47 SwissFrancs—based on the minimum expected servicelife—they really get tailor-made aesthetics.”_


Fig. 2_Patients appreciate that the

complete treatment requires just one

sitting. (Photo: Dr Otto)

Manfred Kern, Wiesbaden, GermanyGerman Society of Computerized Dentistry –International Society of Computerized [email protected]

cosmeticdentistry

_author info

Fig. 2

34 I

I industry report _ provisionals

_Temporaries are indeed only an interim solution.They do, however, fulfil important functions until thepermanent restorative is available and thus have a last-ing effect on the success of the treatment in restorativedentistry.

The quality of the temporary restorations has greatimportance with respect to their protective functionuntil the integration of the permanent restoration. Tem-porary crowns and bridges combined with luting ce-ments protect the dentine and pulp from thermal,chemical, mechanical and bacterial damage. Today,modern temporary crown-and-bridge materials facili-tate the fabrication of temporary restorations that meetthe highest medical standards of reliability and provideincredible, natural aesthetics.

_The challenge of fabricating temporaries

The fabrication of temporary crowns and bridgesthat provide an accurate fit is not easy. Much effortgoes into it, as building a perfectly integrated protec-tion for the prepared abutment requires extreme pre-cision. For the clinical success of a temporary, there areseveral aspects of the fabrication to consider.

One such aspect is the quality of the marginal seal;the temporary must sufficiently close the preparationborder so that the patient does not suffer from sensi-tivity. Additionally, care must be given to provide aconsistent occlusion and appropriate contact pointsto the neighbouring teeth; ultimately, the teeth shouldnot wander until the definitive restoration is inserted.

Fig. 1_The initial situation: teeth 11,

21 and 22 cannot be preserved.

Fig. 2_Plaster model for making

a formed component for the long-

term temporary.

Fig. 3_The post-extraction alveoli

after removing teeth 11, 21 and 22.

Fig. 4_Processing the miniplast tray.

Fig. 5a_Filling the shaped piece with

a highly aesthetic provisional

crown-and-bridge material

(Structur Premium).

Fig. 5b_Structur Premium: complete

set with dispenser (application gun)

for fabricating perfect temporary

restorations.


Temporaries: Perfectprovisional restorationsAuthor_ Dr Hans Sellmann, Germany


Fig. 4 Fig. 5a Fig. 5b

I 35

industry report _ provisionals I


The temporary should also be easy to polish andexhibit good surface quality in the interdentium andregion of the crown boundary. The gingiva is alreadyirritated from the preparation and shaping andshould not become infected and retract because of atemporary’s rough edge. Owing to these require-ments, materials for the fabrication of temporariesshould not only permit safe and quick handling, butalso facilitate an optimal medical and aesthetic result.

_The clinical case

A female patient presented who had to have hermaxillary anterior teeth removed and a bridge had tobe prepared for her. The initial situation showed thatteeth 11, 21 and 22 could not be preserved (Fig. 1).Normally, we would extract the teeth, insert a re-movable temporary (or an expensive one made by alaboratory) and prepare accordingly, after the post-extraction alveoli have healed. This procedure, how-ever, is accompanied by the problem that the ponticsare always recognised as such, as there is no emer-gence profile or papilla formation typical of the nat-ural tooth.

In contrast, a procedure is used in the followingcase that permits the fabrication of a bridge with themost naturally appearing bridge pontic area possible.To begin with, a plaster model is fabricated for mak-ing a formed component for the long-term tempo-rary (Fig. 2). After the preparation and extraction ofthe teeth to be removed, we went with the fabrica-tion of a long-term temporary with pontics for theformation of the alveoli, for which we use the post-extraction alveoli (Fig. 3). In this manner, the emer-

gence profile of the bridge pontics could be made sothat it appears that they are emerging from the gin-giva and thus have the appearance of natural teeth(keyword ‘red aesthetics’).

We used a deep-drawn miniplast splint made froma soft foil for the impression and processed it with aninstrument especially for this purpose from the prepa-ration kit (Komet; Fig. 4). The shaped piece offers theadvantage that it is not sensitive to external influences(shrinkage etc.), can be stored longer and is more hy-gienic than a precast.

In the next work step, the mould was filled with ahighly aesthetic provisional crown-and-bridge ma-terial (Structur Premium, VOCO; Figs. 5a & b). Thequality of the margin was assessed after removingthe temporary bridge from the formed component(Fig. 6). The temporary was subsequently finishedwith tools from the preparation kit. First, a one-sidedsandpaper disc was used for rough finishing (Fig. 7),followed by the smooth finishing of the edges with across-cut carbide bur (Fig. 8). We segmented the pon-tics with the diamond disc from the finishing set (Fig. 9) and used a rubber cup for the pre-polish onthe temporary (Fig. 10). Small irregularities or defects(‘bubbles’) were corrected with Structur PremiumQM in incisal shade (Figs. 11a & b).

We carried out the subsequent high-gloss polishwith the equally fast and effective fibre-buffing disc(Fig. 12). For a perfect finish, we applied a nano-filledprotective varnish to seal the surface (Easy Glaze,VOCO; Figs. 13a & b), which we light-cured after-wards (Fig. 14). The protective varnish provides a

Fig. 6_Assessing the quality of the

edge before finishing.

Fig. 7_Rough finishing of the

temporary bridge with the one-sided

sandpaper disc.

Fig. 8_Smooth finishing of the edges

with the cross-cut carbide bur.

Fig. 9_Segmenting the pontics with

the diamond disc.

Fig. 10_Pre-polishing with

the rubber cup.

Fig. 11a_Correcting small irregulari-

ties and defects with a highly aes-

thetic provisional crown-and-bridge

material in incisal shade (Structur

Premium QM).


Fig. 9 Fig. 10 Fig. 11a

36 I

I industry report _ provisionals

naturally shiny, smooth and aesthetic surface thatprotects against more than just discolouration.

A smooth surface is especially important for thepontics that rest on the alveoli, in order to preventplaque retention and the potential resulting inflamma-tion (Fig. 15). The completed long-term temporary wasfinally integrated (Fig. 16). It created an ideal initial sit-uation for an aesthetic emergence profile for the futurepontics (Fig. 17).

_Billing for the long-term temporary

In contrast to a removable long-term temporary, afixed long-term temporary is not covered by insurance.My patients gladly pay the difference, however, becauseof the increase in comfort. This is especially the casewhen I describe the positive aesthetic results to them.

Successful creation of durable long-term tempo-raries is ensured with the provisional crown-and-bridgematerial I used here. Structur Premium is not just forlong-term temporaries, it is also my first choice for fab-ricating ordinary, routine temporaries._

Fig. 11b_Structur Premium QM:

highly aesthetic provisional crown-

and-bridge material in incisal shade.

The QuickMix syringe permits perfect

handling and exact application.

Fig. 12_High-gloss polish with the

fibre-buffing disc.

Fig. 13a_A protective varnish (Easy

Glaze) is applied for the perfect finish.

Fig. 13b_Easy Glaze: nano-filled,

light-curing protective varnish

for surface sealing.

Fig. 14_Light-curing the

protective varnish.

Fig. 15_A smooth surface on the

pontics is especially important for

the alveoli because the temporary

will rest on them.

Fig. 16_The finished long-term

temporary.

Fig. 17_The integration of the tem-

porary created an ideal initial

situation for an aesthetic emergence

profile for the future pontics.


Dr Hans Sellmann studieddentistry at Westfälische Wilhelms-Universität in Mün-ster,Germany,and has practi-sed as a general dentist since1976.He is the author ofbooks on dental entrepre-neurship,managing problempatients and microbiological

diagnostic methods,and of DVDs for continuing profes-sional development in the fields of anaesthetic treatment,cranio-mandibular dysfunction,halitosis,paedodonticsand risk diagnosis in the dental practice.He has develo-ped several instruments for dentistry, is an expert lectu-rer in CPD courses and has published over 100 articles.

Dr Hans SellmannLangehegge 33045770 Marl,GermanyE-mail:[email protected]

cosmeticdentistry

_author info

Fig. 11b Fig. 12 Fig. 13a

Fig. 13b

Fig. 16 Fig. 17

Fig. 14 Fig. 15

_The expectations are increasing for highly aesthe-tic treatments. This equally applies to provisional crowns and bridges, especially in the anterior region. Temporary restorations must not only provide superior aesthetics, but also durable protection for the prepared teeth until the defi nitive restoration is inserted. Therefore, the mechanical stability is especially an important quality feature for crown and bridge materials. With Structur Premium, VOCO offers a highly aesthetic provisional crown and bridge material that equally fulfi lls all of the different requirements and it can also be used universally.

_Durable and naturally aesthetic

Structur Premium is characterised by its ingenious material composition. It has the proven material properties of a nano-particle composite and provides the tempora-ries with excellent stability and a brilliant shine. Structur Premium is available in seven shades (A1, A2, A3, A3.5, B1, B3 and BL). All shade versions exhibit natural fl uores-cence and thus provides the temporaries with exceptional brilliance in all lighting conditions. The optical properties of the temporaries in the anterior area can be improved even more with Structur Premium QM (QuickMix) in the shade I (incisal).

_Simple and economical application

With its excellent product characteristics, Structur Premium permits a comfortable applica-tion and effi cient fi nishing with simple grinding and subsequent polishing to a tooth-like shine. The proven 1:1 cartridge facilitates precise work with the especially small mixing tips and it provides an economical application and frugal use of the material. Structur Premium, the provisional crown and bridge material for perfect handling and perfect aesthetics.

Structur Premium – Prime advantages for users and patients

_Advertorial

Structur Premium – The Highly aesthetic provisional crown and bridge material from VOCO

AESTHETIC LIKE PORCELAIN, AS HARD AS ENAMEL, EASY TO HANDLE – EXPERIENCE STRUCTUR PREMIUM!Return this coupon by fax +49 4721 719-140 or by mail until 30 Sept, 2009 to enter the draw for three free Intro Sets Structur Premium:

Practice/Doctor’s Name:

Street Address:

ZIP, City, Country:

E-Mail: Phone:

Signature:By completing and submitting this coupon, I give VOCO GmbH permission to contact me using the information provided above. I understand that no purchase is necessary to participate in this sweepstakes promotion and I do not have to submit to a sales presentation. Check here to opt out of being contacted. Drawing held 30/09/2009. Void where prohibited. ©2009 VOCO GmbH – CDI0309StrPre

VOCO GmbHDept. MarketingP.O. Box 76727457 CUXHAVENGERMANY

Cosmetic Dentistry_Advertorial_0709.indd 1 24.06.2009 13:49:50 Uhr

38 I

I industry report _ abutments

_Replacing missing single teeth with dentalimplants has become routine, yet restoring ante-rior teeth with implant-supported restorations isa technique-sensitive task for which aestheticand functional success remains a challenge forthe surgical-restorative team.

Indispensable factors for success are theamount of available alveolar bone, morphologicalsoft-tissue type, correct positioning of the im-plant in all three dimensions, and a successfulprovisional phase. In addition to establishing anadequate implant recipient site and a harmonious

and natural blending of the restoration with thesurrounding tissues and dentition, the long-termstability of the peri-implant tissue architecture isa significant challenge. The selection of suitablematerials and an optimal design are paramountfor the success of the definitive restoration. Thisis where the advantages of CAD/CAM technologyand all-ceramic materials become evident.

These technological advancements have had aconsiderable impact in various areas of dentistryand will continue to do so into the future. Advan-tages related to material and manufacturing

Figs. 1a & b_Virtual design of an

implant abutment (NobelProcera sys-

tem software, Nobel Biocare).

The display of the surrounding

anatomy provides detailed informa-

tion on the ideal design and retentive

contour. The abutment height and

taper must be idealised to provide

functional stability. Suggested

contour by software (a) and

customised height (b).


Customised abutments for long-term aesthetics—software toolsto meet clinical and laboratory requirementsAuthors_ Hans Geiselhöringer & Dr Stefan Holst, Germany

Fig. 1a Fig. 1b

I 39

industry report _ abutments I


processes will promote the ongoing adoption ofCAD/CAM systems in preference to conventionalcasting and manufacturing techniques. This isbecause CAD/CAM technology offers numerousbenefits compared to conventional frameworkfabrication, including reproducible precision,material homogeneity, individual customised design, and ease of fabrication. At the same time,industrialised fabrication methods guaranteestandardised quality and reduce cost-intensivemanual labour. In addition, the availability of homogeneous, bio-compatible materials willminimise material incompatibilities and corro-sive phenomena arising from dissimilar metal alloys and interfaces between cast and machinedcomponents.

Ongoing research in ceramic materials develop-ment has led to the use of high-strength, non-silica-based ceramics in dentistry with beneficialproperties in terms of bio-compatibility, aesthet-ics and long-term clinical function that have beeninvestigated in numerous scientific investiga-tions. Aluminium oxide (Al2O3) and zirconiumdioxide (ZrO2) ceramics are the most common oxide ceramic materials used today. Owing to itsmaterial properties and strength, ZrO2 is appliedwhenever high loads are expected (e.g. posteriorfixed dental prosthesis frameworks, implantabutments and multi-unit implant restorations).In addition to its strength, the greatest advantage

of ZrO2 is its excellent tissue integration. Variousstudies have demonstrated the successful appli-cation of zirconia abutments in terms of stabilityof soft tissue and marginal bone. Results indicatethat the type of material used affects both theamount and quality of the surrounding tissues(when comparing zirconia to cast alloys). Also, ceramic abutments minimise bacterial and plaqueadhesion and prevent soft-tissue inflammation.

_Customised abutments: manufacturingoptions

The clinician may choose between prefabri-cated or customised abutments for implant-retained single or multi-unit restorations. Theprimary objective must always be proper supportof the surrounding tissues, optimal morphologyto support the restoration without impairing hy-giene maintenance, and anatomic design to allowfor proper support of the veneering ceramics incase of screw-retained restorations. These goalscan easily be achieved if an abutment is custom-made. Using prefabricated abutments, on thecontrary, has several disadvantages. Customisingis a time-consuming and highly unpredictableprocess in the laboratory, requiring additionalfinishing procedures in the dental office. Post-sintering manipulation of oxide ceramic compo-nents significantly increases the risk of micro-cracks that could result in subsequent failure

Figs. 2a–d_The intuitive software

helps simplify the design process.

Occlusal and lateral view of the

margin radius that can be homoge-

nously adapted at the click of a

button (a & b). Note the location of the

abutment-crown margin at the

cervical margin (c & d).

Fig. 2b

Fig. 2d

Fig. 2a

Fig. 2c

40 I

I industry report _ abutments

under clinical function. Scientific investigationshave revealed that the reaction of cells towardsmaterials with a corrosive potential such as cast-alloy components or veneering porcelain is infe-rior to homogenous materials such as titanium or zirconia.

_Fast and intuitive design of implantabutments

Work processes to fabricate an individual abut-ment that in the past required significant amountsof time can be realised within minutes today. Thenewest generation of CAD software eliminates theneed for a wax-up to achieve the desired definitiveabutment shape. While an automated software

function suggests a superstructure or abutmentfollowing a model or impression scan, the dentaltechnician can easily adapt the contour and formvirtually to any desired shape (Figs. 1a & b). In addition, one software programme offering an intuitive software interface and the ability to re-store using different implant systems is a very interesting alternative to conventional fabrica-tion, for which cast-on components have to be ordered for the respective implant system and then customised.

_Virtual design of transgingival contour and positioning of the crown-abutment margin

When designing an abutment, the followingtwo major criteria supporting long-term successshould be considered: the contour and shape of theabutment in the sub-gingival area and the height,angulation and taper to provide adequate reten-tion for a cement-retained crown. There is no scientific evidence that supports a more concaveor a convex peri-implant abutment contour. Communication and close collaboration betweenthe dental technician and the dentist are needed,taking the individual clinical situation into consid-eration. This includes the position of the implant in relation to the definitive crown contour, thethickness and biotype of the surrounding tissue,and location within the arch.

It is generally agreed that the abutment-crownmargin should always be located at or slightly be-low the gingival crest in order to allow for completeremoval of cement (Figs. 2a–d). If remnants of thecementation media remain, peri-implant inflam-mation and adverse tissue reactions are very likely.Here another advantage emerges. While metalabutments or porcelain-fused-to-metal crownshad to be positioned deep underneath the gingivalmargin in order to minimise the risk of discoloura-tion, utilising oxide ceramic materials eliminatesthis concern and improves the aesthetic outcome.

Figs. 3a & b_The anatomic tooth

library is an extremely useful tool that

eliminates the need for a wax-up and

ensures an homogenous veneering

porcelain thickness using an

automated reduction tool (see dark

green contour of the definitive

abutment and the transparent

morphology of the anticipated

final restoration).


Table 1_Biological advantages of customisedCAD/CAM abutments:

• formation of an intimate soft-tissue contact• long-term clinical stability through

bio-compatible and homogenous materials

• eliminates the risk of corrosion in contact areasof dissimilar metals and alloys

• maximises aesthetic results through application of shaded Zirconia

Table 2_Customised CAD/CAM abutments: design advantages

• free-virtual design options• screw- or cement-retained restorations• optimal support of peri-implant soft tissue

through individual abutment profile• round contours, no sharp edges• ideal positioning of cement line

Fig. 3a Fig. 3b

I 41

industry report _ abutments I


_Mechanism of retention

A significant disadvantage of screw-retainedrestorations in the past compared to cementedrestorations was the aesthetic closure of thescrew access channel. Using metal-based frame-works and composite resin for closure resulted inimpaired aesthetic outcomes on the occlusal surface. Zirconium-dioxide-based frameworkseliminate this disadvantage. If white or shadedsubstructures are used, easy and fast closure ofthe screw access channel can be achieved withconventional composite resin materials. The retrievability and the absence of cement betweenthe abutment and the crown are amongst thegreatest advantages compared to cemented solutions or cast abutments.

Porcelain is fired directly onto the abutmentand the abutment-crown complex can bescrewed onto the implant. Here again CAD tech-nology supports the dental technician in the design of the final abutment shape. Numerouspublications emphasise the need for an homo-genous veneering material thickness in order to minimise the potential problem of chipping(Figs. 3a & b). Utilising a software system thatmakes use of an anatomic tooth library supportsthe user in designing the later contour of the final restoration (taking occlusal and functionalaspects into consideration). Whether an implant-

retained crown is cemented or the abutment-crown complex is screw retained depends on the dentist’s preference and the positioning ofthe implant (Figs. 4 & 5a–c). A cement-retainedrestoration on an individual ceramic abutmentallows for simple compensation of misalignedimplants and can be treated like a natural tooth.The main disadvantage of cemented prosthesesis irretrievability._

The authors acknowledge Dr M. Thorwardt fromFriedrich Schiller University Jena for conductingthe implant surgery.

Editorial note: A complete list of references isavailable from the authors.

Fig. 4_The combination of the

strength of a zirconia abutment and

the aesthetic advantages of an

alumina crown (NobelProcera crown

alumina, Nobel Biocare) demonstrate

the advantages and versatility of the

NobelProcera system.

Fig. 5a–c_The clinical advantages of

custom-designed CAD/CAM

abutments are unrivalled. Homoge-

nous and bio-compatible materials

allow for correction of implant

angulation and ensure long-term

clinical tissue stability (NobelProcera

zirconia abutment, Nobel Biocare; a)

Initial clinical situation with an

unacceptable provisional restoration

replacing the lateral incisor (b).

Definitive clinical outcome following

implant treatment (c).Hans GeiselhöringerDental TechnicianDental X Hans Geiselhöringer GmbH & Co. KGLachnerstraße 280639 Munich, Germany

Dr Stefan HolstUniversity Clinic Erlangen Dental Clinic 2 – Department of ProsthodonticsGlückstraße 1191054 Erlangen, Germany

cosmeticdentistry

_contact

Fig. 5a

Fig. 5c

Fig. 4

Fig. 5b

42 I

I industry news _ Ivoclar Vivadent

_Second generation LED lights are notorious foroffering a much narrower emission spectrum than thegold standard halogen lights. For this reason, severalbleach shade composites, adhesives and protective varnishes cannot be entirely cured owing to the photoinitiator used. This is where bluephase and itsspecifically developed poly-wave LED come into play.

_Simply clever: The new poly-wave LED

Reliable polymerisation of composites and lutingmaterials is a crucial step in the dental practice. This isexactly where the new bluephase family—bluephase C8,the classic bluephase and bluephase 20i—show theirstrength. The specifically developed poly-wave LED activates all photoinitiators. The four LEDs—three blueones (dominant wavelength: approximately 410nm)and a violet one (dominant wavelength: approximately470nm) that operate simultaneously—allow unlimiteduse in the dental practice and are thus suitable for allphotoinitiators and materials (Figs. 1 & 2).

_Bluephase C8: On an economical mission

The mains-operated curing light bluephase C8, featuring a light intensity of 800mW/cm2 and three programmes—high power for fast polymerisation, low

power for polymerisation close to the pulp and soft startfor stress-reduced polymerisation, is relatively cost-effective (Figs. 3 & 4). Owing to the 10 mm light probe,which offers an enlarged treatment field, time-consuming multiple polymerisations are a thing of thepast. In addition, proximal boxes can easily be cured using this elegant light (Fig. 5).

_Continuous cooling: A must-have for LED lights

Does this sound familiar? If a certain temperature isexceeded, the LED light switches off in order to preventdamage. The light is only operational again after severalminutes. The virtually noiseless, invisible fan of the bluephase family allows continuous operation with-out clinical limitations, even when used for extensive indirect restorations.

_Conclusion

The cordless bluephase has proven its value with its functional properties and ergonomic concept (Fig. 6). The more compact basic edition bluephase C8 is a more economical option. Now the versatile bluephase model featuring a poly-wave LED is availablefor every practice._


Progress knows no clinical limitations

Ivoclar Vivadent AGBendererstrasse 29494 SchaanLiechtensteinwww.ivoclarvivadent.com.

cosmeticdentistry

_contact

Fig. 1

Fig. 2

Fig. 3

Fig. 4 Fig. 6

Fig. 5

It really would have been possible to meet each other much sooner, because in 1955 we were already the firstcompany worldwide to supply elastomeric, condensation-curing impression materials. And by now the newshas made the rounds internationally that our research department is responsible for ground-breaking developmentsin the A-silicone sector. Thus, our partners in laboratories and dental practices are always a bit ahead of theirtime. You don't know us yet? Then please invite us in and test the Kettenbach precision products.

www.Kettenbach.com

Allow us to introduce ourselves:Kettenbach. In Germany we areworld-famous.

0204

47_1

208

www.Kettenbach.com

Anschnitt DIN A4 12.06.2008 14:44 Uhr Seite 1

_The road trip is a constant nar-rative in US-American pop culture and is synonymous with escape, freedom, and inde-pendence from borders and boundaries. In theland of the free and the home of the mobile, theAsphalt Nation of America, as observed by JaneHoltz Kay, is built around automobiles and cher-ishes the ideal of mobility. Some road—enthusi-asts, referring to themselves as road trippers—

have developed the scienceof a road trips, roadology,that explores the effects ofroads on societies.

A true American roadtrip starts at the firstcrossroads, not knowing

if you would like to gostraight, left or right,and not planningahead too much. It is about impromptu‘moseying’ down theroad rather than fol-lowing a strict sched-ule.

This road trip com-bines two routes, thehiker-favourite Ap-palachian Trail, starting in Pennsylvania and exploring Southern Atlanta, and the NYC–MiamiAtlantic Coast Route to Florida. The routes explore the historical birthplace of the UnitedStates in Philadelphia, the impressive nature

of the Shenandoah, Great Smoky Mountainsand Everglades National Parks, Ivy Leagueuniversity campuses of Cornell, Princetonand Pennsylvania University, the cradle of the African-American civil rights movementand global news in Atlanta, the Kennedy SpaceCenter in Cape Canaveral, and the colourfulMiami.

Enjoy your trip andindulge in the journey!

Author & Photographer_ Annemarie Fischer, Germany


““TThhee AAmmeerriiccaann RRooaadd TTrriipp iissnn’’tt jjuusstt aa ppaassttiimmee;; iitt’’ss aa bbiirrtthhrriigghhtt,, aa nneecceessssiittyy,, aa rriittee ooff ppaassssaaggee,,iitt’’ss aa wwaayy ooff lliiffee..”” (Erin McHugh, The Little Road Trip Handbook)


For outlanders, a well-kept rental car, suffi-cient insurance coverage, a working mobilephone and a good map, as well as credit cards andsome dollar bills to secure cash-flow are enough.In local supermarkets, one can get a regular sup-ply of water, fresh fruit and chopped veggies. Insome states, one might be lucky to find on-the-road selling stations of local produce. With mostrentals nowadays, you get access to hundreds ofdigital radio stations that complete the roadtrack with the perfect sound track. Jamie Jenson,author of Road Trip USA, offers a road trip blogand podcast at www.roadtripusa.com.

Motels are available easily down the road;with the Days Inn as well as Jamestown being onthe (more) pleasant side. However, their early nutrition consists mostly of a crime called Con-

tinental Breakfast. The Waffle House, for exam-ple, offers a more decent way to start the day andis open-all-night to savour fresh waffles withmaple syrup, eggs’n’bacon and grits in enormousportion sizes. For a decent dinner, one should always ask for the best local diner on the way, andfast food branches offer a quick snack to go.

The concept of Park and Ride is not compul-sory in most cities. Most downtown areas arequite car-friendly, with most sights offering freeparking or at rates for a couple of dollars perhour. Park and Ride is only mandatory in citymolochs like New York.

_Going green

Nature parks in theStates truly signify thegorgeousness of thiscountry, and functionas an oasis from civi-lization—no gigan-tomanic malls andno fast food restaurantsdisturb the scenic nature. A small entrance fee isvalid for a couple days up to a week. Hotels orcamping facilities offer a place to stay for thenight.

Being thrown into nature, one is to respect the speed limit in order not to hurt an animal. A 35-mile-speed limit in Skyline Drive exploresShenandoah National Park. Down the AppalachianTrail, the fog-covered mountains name the GreatSmoky Mountains Na-tional Park and amaze vis-itors in the most popularpark in the United States.Alligators, pythons andvultures come close inthe Florida EvergladesPark, and protectionfrom mosquitoes ismandatory!

_Going Ivy

American elite Ivy League Universities—Cornell, Pennsylvania University and Princeton—are always worth the trip, since their cam-

puses blend in with the nature and offer an

impressive architecture. Univer-sity bookstores are tea’n’coffee havens to in-dulge in the oeuvres of university lecturers,for instance novelists Vladimir Nabokov inCornell, Philip Roth at PennU, and JeffreyEugenides at Princeton.

The campuses also own captivat-ing museums: The University ofPennsylvania, that claims to beAmerica’s First University, pos-sesses in Museum of Archaeologyand Anthropology one of thefinest ethnology collections inthe world.

_Shopping in the USA

Since consumption of goods hasbeen elevated to a true art form in theUnited States of America, a typical

road tripper goes shopping. In times of crisis, outlet shopping centresfunction as a holy grail for an al-most guilt-free indulgence. It ismore fun to explore the less-crowded centres in the South,such as in nomen est omenCommerce.

_Rocking Philly

Philly forms the perfect symbiosis betweenhistory and relaxation. The City of Brotherly Loveis the historical birthplace of the United Statesand welcomes you with American historical sitesin the Independence National Historical Park,home of the Liberty Bell, as well as the Betsy Ross

House, where histori-ans still debate if thefirst US-Americanflag had been indeeddesigned there. ThePhiladelphia Mu-seum of Art offersone of the most

impressive art collections. Film legendRocky Balboa turned its stairs into an Americanpop culture icon—to climb and conquer the

stairs and to cheer on tophas become a verb, “to dothe Rocky (Balboa)”. Cruis-ing South Philly is evenmore amazing–it unravelsgraffiti buildings, outdoorneighbourhoods and fam-ily businesses. Geno’s andPat’s just face each otherto win the culinary com-petition over the BestPhilly Cheese Steak, asandwich filled with steakand cheese sauce.

_Hotlanta

Temperatures and heartiness rise as onereaches the capital of the Peach State Georgia,Atlanta. Hotlanta is the home of Coca-Cola and CNN, and of Martin Luther King Jr, who wasborn and raised here. The King Center and his birthplace blend in unpretentiously with the neighbourhood. King’s powerful rhetoric accompanies insightful information on his life path that reflects the struggles of the civilrights movement, and on current human rightsmovements around the world in this living me-

morial.

When Hotlanta makes hungry, TheVarsity is considered as the best Drive-In hot dogs, greeting the customerswith the legendary “What’ll ya have?”.


The CNN Headquarters satisfies an appetitefor information, where the longest escalator ofthe world guides one to the CNN studios, wherevisitors can see directly into studio windows.News is today a highly-complex and digitalisedproduction. CNN anchormen and -women workdirectly from news bureaus, endowed withhighly-sensitive microphones that block sur-rounding noises, and are digitally beamed intofuturesque studio settings.

_Bienvenidos a Miami!

Miami truly cites its Miami Vicepop culture reference, shimmeringin pleasant pastel colours, andglowing as the vibrant and volup-tuous as the eighties era. Pastel-blue daytime skies change intodramatic evening shades. The Art Déco districtcan be explored with guided tours, and it is thesight of a tragedy: Gianni Versace was murderedat Ocean Drive 1116 in his Casa Casuarina.

The Magic City merges into a true meltingpoint and is the largest and most vibrant out-of-Latin America community, visible in Little Ha-vana. Two-thirds of Miami people cite Spanish astheir mother tongue. Those Latin, Carribean,Central and South American as well as Europeaninfluences melted into the unique New World, orNuevo Latino, cuisine. In the Las Vegas Restau-rant, one can get a taste of the Cuban Fusion cuisine. After sun-bathing at South Beach, syn-onymous to “showing what you’ve got”, mostrestaurants turn into nightclubs. Coconut Groveoffers after-dinner cocktails in outside cafés andbars, where one cannot only indulge in tastes,but also sounds of Latin America and the Car-ribean. Cubans brought the conga and rumbato Miami from their homelands, instantly pop-ularising it into US-American culture. Domini-cans carried bachata, and merengue into thebars, while Caribbeans brought reggae, soca,

calypso sound. The Spanish chur-ros pastry, along with hot chocolate, drench thenight.

_Going up

The Kennedy Space Center is financeduniquely with entrance fees, and is the most gi-gantic PR measure to promote aerospace. The

spacy center is located in a gigantic

nature reserve and isnot only a high-tech playground,visitors can’witness work in progress on the working facil-ities.

For outlanders, an All-American road trip is the path to understand that theUnited Statesof America is a gathering of civilizations and cultures, flora and fauna, images and sounds,flavours and aromas, styles, and feelings; and “to get the feel of the road”, notes Erin McHughin The Little Road Trip Handbook, “remember that it’sthe journey, not the destination.”_


2009

FDI Annual World Dental CongressWhere: Singapore, SingaporeDate: 2–5 September 2009Tel.: +33 450 4050 50E-mail: [email protected] site: www.fdiworldental.org

ESCD 6th Annual MeetingWhere: Paris, FranceDate: 25–27 September 2009Tel.: +33 495 09 38 00Web site: www.escdonline.eu

ACE 2009 Symposium on Esthetic DentistryWhere: Scottsdale, AZ, USADate: 11–14 November 2009Tel.: +1 800 701 6223E-mail: [email protected] site: www.acesthetics.com

SAAAD Aesthetic Dental ConferenceWhere: Kathmandu, NepalDate: 28–29 November 2009Tel.: +977 142 425 64Email: [email protected]

Greater New York Dental MeetingWhere: New York, NY, USADate: 27 November–2 December 2009Tel.: +1 212 398 6922Web site: www.gnydm.org

2010

26th AACD Anniversary Scientific SessionWhere: Grapevine, TX, USADate: 27 April–1 May 2010Tel.: +1 800 543 9220E-mail: [email protected] site: www.aacd.com

EAED Spring MeetingWhere: London, UKDate: 27–29 May 2010Tel.: +39 02 295 236 27E-mail: [email protected] site: www.eaed.org

IACA Annual MeetingWhere: Boston, MA, USADate: 22–24 July 2010Tel.: +1 866 669 4222E-mail: [email protected] site: www.theiaca.com

AAED 35th Annual MeetingWhere: Kapalua, HI, USADate: 3–6 August 2010Tel.: +1 312 981 6770E-mail: [email protected] site: www.estheticacademy.org

48 I

I meetings _ events


Cosmetic events

I 49

I about the publisher _ submissions I


submissions:formatting requirements

_Please note that all the textual elements ofyour submission:

_the complete article, _all the figure captions, _the complete literature list, and _the contact info (bio, mailing address,

E-mail address, etc.)

must be combined into one Word document.Please do not submit multiple files for eachof these items.

In addition, images (tables, charts, photo-graphs, etc.) must not be embedded into theWord document. All images must be submit-ted separately, and details about how to dothis appear below.

Text lengthArticle lengths can vary greatly—from a mere1,500 to 5,500 words—depending on thesubject matter. Our approach is that if youneed more or less words to do the topic jus-tice then please make the article as long or as short as necessary.

We can run an extra long article in multipleparts, but this is usually discussing a subjectmatter where each part can stand alone be-cause it contains so much information. In ad-dition, we do run multi-part series on varioustopics.

In short, we do not want to limit you in termsof article length, so please use the wordcount above as a general guideline and if youhave specific questions, please do not hesi-tate to contact us.

Text formattingPlease use single spacing and un-indentedparagraphs for your text. Just place an extrablank line between paragraphs.

We also ask that you forego any special for-matting beyond the use of italics and bold-face, and make sure that all text is left justi-fied.

If you would like to emphasize certainwords within the text, please only useitalics (do not use underlining or a largerfont size). Boldface is reserved for articleheaders.

Please do not ‘center’ text on the page,add special tab stops, or use underling asall of this must be removed before lay-out. If you require a special layout, pleaselet the word processing programme youare using help you to do this formattingrather than doing it by hand on yourown.

If you need to make a list, or add foot-notes or endnotes, please let the Wordprocessing programme do it for you au-tomatically. There are menus in everyprogramme that will help you to do this.The fact is that no matter how carefulone might be, errors have a way of creep-ing in when you try to hand numberfootnotes and literature lists.

Image requirementsPlease number images consecutivelythroughout the article by using a newnumber for each image. If it is imperativethat certain images are grouped to-gether, then use lowercase letters to des-ignate the images in a group (ie, 2a, 2b,2c).

Please put figure references in your arti-cle wherever they are appropriate,whether that is in the middle or end of asentence. If you are not directly men-tioning the figure in the body of your ar-ticle, when it appears at the end of thesentence the figure reference should beenclosed within parenthesis and be in-side the sentence, meaning before theperiod.

In addition, please note:

_We require images in TIF or JPEG for-mat.

_These images must be no smaller than 6 x 6 cm in size at 300 DPI.

_Images cannot be any smaller than 80KB in size (or they will print the size of apostage stamp!).

Larger images are always better, andsomething on the order of 1 MB is best.Thus, if you have an image in a large size,do not bother sizing it down to meet ourrequirements but send us the largest filesizes available. (The larger the startingimage is in terms of bytes, the more lee-way the designer has in terms of resizingthe image to fill up more space shouldthere be room available).

Also, please remember that you shouldnot embed the images into the body ofthe text document you submit. Imagesmust be submitted separately from thetextual submission.

You may submit images through a zippedfile via E-mail, unzipped individual filesvia E-mail, or post a CD containing yourimages directly to us (please contact usfor the mailing address as this will de-pend upon where in the world you will bemailing them from).

Please do not forget to send us a headshot photo of yourself that also fits theparameters above so that it can beprinted along with your article.

AbstractsAn abstract of your article is not required.However, if you choose to provide us withone, we will print it in a separate box.

Contact infoAt the end of every article is a ContactInfo box with contact information alongwith a head shot of the author. Pleasenote at the end of your article the exactinformation you would like to appear inthis box and format it according to thepreviously mentioned standards. A shortbio may precede the contact info if youprovide us with the necessary informa-tion (60 words or less).

Questions?Please contact us for our Author Kit, or ifyou have other questions:

Managing EditorClaudia [email protected]

cosmeticdentistry _ beauty & science

I about the publisher _ imprint

cosmeticdentistry 3_200950 I

asia pacific edition

cosmetic dentistry_Copyright Regulations_cosmetic dentistry asia pacific edition is published by Dental Tribune Asia Pacific Ltd. and will appear in 2009 with one issue every quarter. The magazine

and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liableto prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.

Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to theeditorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right tocheck all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicitedbooks and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, representthe opinion of the afore-mentioned, and do not have to comply with the views of Dental Tribune Asia Pacific Ltd. Responsibility for such articles shall be borneby the author. Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibilityshall be assumed for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccu-rate or faulty representation are excluded. General terms and conditions apply, legal venue is North Point, Hong Kong.

PublisherTorsten R. Oemus [email protected]

Editor-in-ChiefDr Sushil [email protected]

Co-Editor-in-Chief Dr So-Ran [email protected]

Managing EditorClaudia [email protected]

Product Manager Bernhard [email protected]

Executive ProducerGernot [email protected]

Designer Nadine [email protected]

Copy EditorsSabrina RaaffHans Motschmann

International AdministrationPresident/CEOPeter [email protected]

Executive Vice PresidentFinanceDan [email protected]

International Media SalesEuropeAntje [email protected]

Asia Pacific Peter [email protected]

North America Humberto [email protected]

International OfficesEuropeDental Tribune International GmbHContact: Nadine ParczykHolbeinstr. 2904229 Leipzig, GermanyTel.: +49 341 484 74 302Fax: +49 341 484 74 173www.dti-publishing.com

Asia PacificDental Tribune Asia Pacific Ltd.Contact: Tony LoRoom A, 26/F, 389 King’s RoadNorth Point, Hong KongTel.: +852 3113 6177Fax: +852 3113 6199www.dti-publishing.com

The AmericasDental Tribune America, LLCContact: Anna Wlodarczyk213 West 35th Street, Suite #801New York, NY 10001, USATel.: +1 212 244 7181Fax: +1 212 244 7185www.dti-publishing.com

Advisory BoardDr Michael Miller, USADr Seok-Hoon Ko, Korea

Editorial BoardDr Anthony Au, AustraliaDr Bao Baicheng, ChinaDr Helena Lee, SingaporeDr Hisashi Hisamitsu, JapanDr Jiraporn Charudilaka, ThailandDr Mostaque H. Sattar, BangladeshDr Ratnadeep Patil, IndiaDr Sim Tang Eng, MalaysiaDr Suhit Raj Adhikari, NepalDr Takashi Nakamura, JapanDr Vijayaratnam Vijayakumaran, Sri Lanka

I hereby order 10 issues of DENTAL TRIBUNE

AUSTRIAN EDITION for 55 € (1 year)*❏I hereby order 20 issues of DENTAL TRIBUNE

GERMAN EDITION for 70 € (1 year)*❏I hereby order 4 issues of COSMETIC

DENTISTRY for 35 € (1 year)*❏I hereby order 4 issues of ROOTS

for 35 € (1 year)*❏ I hereby order 10 issues of DENTAL TRIBUNE

ASIA PACIFIC EDITION for 55 € (1 year)*❏

PAYMENT OPTIONS

❏ [email protected]

❏ Bank TransferCommerzbank LeipzigAccount No.: 11 40 201Bank Code: 860 400 00BIC: COBADEFFIBAN: DE57860400000114020100

*plus shipping and handling. Your personal data will be recorded and retained by Dental TribuneInternational GmbH, which has its registered office in Holbeinstr. 29, 04229 Leipzig, Germany. Yourpersonal data is used for internal purposes only. After the payment has been made, the shipping pro-cess for the subscribed publication(s) will start. The subscription will be renewed automatically everyyear until it is cancelled six weeks in advance to the renewal date.

PERSONAL DETAILS/SHIPPING ADDRESS

Name

Position

Department

Organisation

Address

Country

Telephone

Facsimile

E-mail

Date/Signature

Dental Tribune International GmbH | Contact: Nadine ParczykHolbeinstraße 29 | 04229 Leipzig | Germany

Tel.: +49 341 484 74 330 | Fax: +49 341 484 74 [email protected] | www.dental-tribune.com

Fax form to: +49 341 484 74 173 or subscribe online at www.dental-tribune.com

AESTHETIC. DURABLE. PERFECT.

Superior temporaries for the most ambitious demands

Aesthetic like porcelain

GB_DT-UK_0909_StructurPremium_210x297.indd 1 23.03.2009 15:53:50 Uhr

dentistry beauty & science

Documents

Transcript of dentistry beauty & science