Esthetic, Biological and ... - Dental Creation s.n.c TW vol 5 n.4 De Stefano.pdf · Implantology”...

Dr. Mario De Stefano obtained a Degree in Medicine and Surgery with a score of 110/110 cum laude. Subsequently, he achieved a Degree in Dentistryand certification with honors. He is an ordinary member of AIOP, AISI, an active member and manager of IBC (Group for Implant Research), andan active member of AIOM (Italian Association of Microscopic Dentistry). He is a tutor for “Advanced Techniques and Biological Aspects inImplantology” Dental Medicine, at the University of New Jersey, and an Adjunct Associate Professor in New Jersey Dental School. He is also a tutorand lecturer at the Post-Graduate Course of Implantology at the University of Guarulhos, Sao Paulo, Brasil. He is the author of several publications in

national and international journals. He participates as a speaker at numerous national and foreign congresses. Presently, he works on implantology and oralrehabilitation at this office in Montevarchi (AR).

Attilio Sommella was born in Pozzuoli (ITA) on May 23rd, 1966. He owns in partnership and manages the Dental Creation SNC prostheticdentistry laboratory located in Naples. His main focus is with aesthetics in fixed prosthodontics. Attilio has lectured in several Italianuniversities. He is the author of numerous articles that have been published both in national and international journals. As well, he is thecreator of a simplified work system for ceramic. Attilio is also the author of “The Incisal Edge, the strong point in the expression of anincisor” and co-author of the book “Veneers - Mini-invasive Reconstructions. Techno-Clinical Aspects”. He is a member of the scientific

committee for Dental dialogue and TeamWork and winner of the AIOP - ANTLO “Roberto Polcan” prize (2006).

Authors:

Esthetic, Biological and Functional Integration withMini-Invasive Reconstruction

Cosmetic Dentistry

14 TEAMWORK Vol.5-No.4 - April 2012

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Abstract

This clinical case places particular emphasis on prostheticrehabilitation of the elements of the front group through mini-invasive reconstructions using veneers. The great evolution ofceramic materials, combined with considerable development ofadhesive bonding techniques, has greatly increased the demandfor these restorations, with the possibility of satisfying thedesire for esthetic and functional improvement in a non-traumatic and durable manner, with considerable biologicalsavings. The following clinical case ends with prostheticrehabilitation using feldspar ceramic veneers on the frontupper and lower group and an intervention to estheticallycorrect the face using fillers.

Introduction

In recent years, esthetics has taken on an increasinglyimportant role, especially in prosthetic dentistry, and todaypatients requires not only adequate functional results, but alsoincreasingly excellent restorations to improve their appearance.White, shiny and smooth teeth are attractive, and arerecognized as a sign of vitality and bodily health. Indirectreconstruction of the front sector, functional restoration,maximum preservation of healthy dental tissue and overallesthetics of the smile, are indivisible and inalienable principlesin conservative restoration of tooth structure. Ceramic veneersmeet all these requirements and are now, in most cases, themost complete answer in the restoration of the frontal area. Agreat contribution to this reconstruction technique comes frommodern methods of enamel dentine adhesion, which haveexpanded what was originally defined as the range ofindications for use of porcelain veneers. This has made itpossible to achieve two major objectives of modernconservative dentistry: proper regard for sound tooth structureand maintaining the vitality of restored teeth.Careful analysis of literature on the topic of veneers points

out how this method is reliable over time: Calamia reports98% success in a sample of about 5000 porcelain veneerscemented over ten years (Calamia JR, Philipp J Dent Assoc.1996; Mar-May, 47:35-41). Friedman presented a clinicalobservation for a period of fifteen years on a sample of 3500restorations with failures of less than 10% (Friedman MJ,Compend Contin Educ Dent. 1998 Jun; 19 (6) :625-8, 630,632.). In Italy, Fradeani presented a clinical review on theplacement of 83 porcelain veneers made from EmpressIvoclar® ceramic, with a survival of six years for over 98.8% of

the restorations (Fradeani M. Int J Periodontics RestorativeDent. 1998 Jun; 18(3):216-25). Another very interesting studyis that of J.F. Roulet who demonstrated, in vitro, how porcelainveneers are no less durable than full ceramic crowns, if theywere cemented to the enamel; in fact, the resistance valueswere significantly higher than the latter (Restoring Chun YH,Raff elt C, Pfeiff er H, Bizhang M, Saul G, Blunck U, RouletJF. J Adhes Dent. 2010 Feb;12(1):45-54). This data, combinedwith our clinical experience, indicate porcelain veneers as a firstchoice method in the restoration of the front region.The application of these techniques allows us to preserve, in

complex cases, the integrity of the pulp and makes it possible toreconstruct teeth without endodontic treatment, withoutreconstruction with fiber implants, and preserving a largeamount of healthy tissue, compared to normal techniques forprosthetic reconstruction.In certain situations, as in our case report, for an overall

concept of esthetics, for some facial areas specialists resort tomini-invasive filling techniques, using fillers that can providesatisfactory results without resorting to more invasivetechniques. In this intervention, the material of choice isagarose, a saccharide polymer formed by repeated units of3,6-anhydro-L-galactose and D-galactose which, for its physicalproperties, is a highly biocompatible material.

History of Veneers

Veneers are considered an innovative technique, but in factprototypes already existed before this era; they were introducedby Charles Pincus in Hollywood in the '30s (1938) to improvethe appearance of actors during movie close-ups. These thincoatings were applied with an adhesive denture powder, andthen removed every day when shooting was concluded, since atthat time there was no way to fix them permanently. ThenSimonseen and Horn created metal-free porcelain veneers,without silanization, which were cemented on the buccalsurfaces of the upper front group.

Case Report

The patient comes to us complaining of a lack of esthetics inthe upper and lower front group as an after-effect of whiteningtechniques.

General medical historyFemale, 49 years old, non-smoker, mild iron deficiency anemia,in good health.

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Dental historyAn examination of the front teeth shows: discoloration fromfluorosis, previous crown in zirconium oxide at 2.2, abrasionsdue to wear, diastema of the lower front group due todisturbance of biostatic balance. The parameters to consider are:the patient's expectations, the esthetic parameters of the face, thesmile line, the tissue biotype, the mouth area to be rehabilitated,dyschromia, dento-periodontal reports, dental malposition andparafunctions. Collecting this information is essential not onlyfor the clinician, but also for successful communication with thedental laboratory, which could gain useful benefits when makingevaluations and decisions within its competence.

Overall treatment planAfter a careful general and dental medical history, the overalltreatment plan is summarized in:

Step 1: Diagnosis and preliminary treatment plan1. First visit:

• Initial photographic documentation• Primary modeling, wax, color, model analysis• X-rays (OPT, Intraoral X-Ray, etc.. )• Clinical dental exam

• Periodontal exam• Stomatological exam

2. Evaluation of plaque index with negative compliance:• Hygienic rehabilitation• Diagnosis

Step 2: Final treatment plan1. Specific therapy:

• Periodontal

Step 3: Prosthetic rehabilitation1. Temporary:

• Clinical provisional2. Final:

• Rehabilitation with feldspathic ceramic veneers

X-ray examination (Fig. 11) of the elements concerned(front group) shows a root canal therapy of the 2.2 withreconstruction and Zirconium oxide crown and class IVconservation of 1.1 and 2.1.X-ray observation of remaining elements deserves careful

analysis, but the patient only requires an evaluation of the upperand lower front group. A periodontal examination of the

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Fig. 4 Fig. 5

Fig. 3Fig. 1 Fig. 2

Figs. 1 to 10: Initial functional esthetic situation of the front group Impaired with pronounced interdental spaces in the lower sector.

Fig. 6 Fig. 7

Fig. 10Fig. 8 Fig. 9



elements of the upper front group (Fig. 13) shows a probingdepth of no more than 2 mm (1.1,1.2,1.3, 2.1, 2.2, 2.3); a plaqueindex of 0 (1.1, 1.2, 1.3 , 2.1, 2.3) and a plaque index of 1 (2.2); ableeding index of 0 (1.1,1.2,1.3, 2.1, 2.2, 2.3). The periodontalexamination of the elements of the lower front group (Fig. 14)shows a gingival recession of approximately 1 mm (3.1, 3.2, 4.1,4.2); a probing depth of about 2 mm (3.1, 3.2, 3.3, 4.1, 4.2, 4.3);a plaque index of 0 (3.1, 3.2, 3.3, 4.1, 4.2, 4.3); a bleeding indexof 0 (3.1, 3.2, 3.3, 4.1, 4.2, 4.3).

Analysis of master models in the first session (time 0)During the diagnostic phase great attention is paid to resolvinggingival asymmetries in quadrants # 1 and # 2, adequatelyrestoring dental volumes, a parameter that is necessarilycorrelated with standards such as: a) re-configuration of gumparables, b) correct dental-facial relationship. The duplicationof master models is essential (Figs. 15 and 16).

Diagnostic wax-upAt this stage the dental technician proposes a preliminary projectusing a wax model (Fig. 17), on the basis of information gathered insynergy with both the team and the patient. If necessary, byremoving or adding wax the clinician notifies the technician of anychanges. This image (Fig. 18) shows the relationship between theactual position of the cusp for element 1.3 and the new location ofthe latter according to the new smile line proposed. Construction ofa resin template (enamel) for the mock-up clinical stage (Fig. 19),generated from information received from the diagnostic wax-uppreviously discussed and approved by both the clinician and thepatient. Details are shown regarding the cusp of tooth element No.1.3 (red arrow) and the new structure of the gingival parables ofquadrants 1 and 2 (blue arrows). The indirect mockup is positioned(Figs. 20 and 21), rebased (if necessary), and stabilized with resincement. In this phase, the volume, shape and length of the teethmust be approved. Subsequently these are used as provisional.

Fig. 11: Initial OPT Fig. 12: Pre-existing situation

Fig. 13: Upper periodontal chart Fig. 14: Lower periodontal chart

Figs. 15 and 16: Technical laboratory phases. Initial models

Fig. 15 Fig. 16



Periodontal therapyProceed with improving the periodontal tissues, restoringa proper biological width and giving the gingivalparables greater symmetry through gingivectomy carriedout by laser (Figs. 22 and 23).

Prosthetic preparationAfter placing a retraction cord to slightly move the freemargin of the gum, the cervical portion is preparedusing a red ring diamond cut bead with a diameter of0.12 mm, tilting the cutter at 45°.

Reduce the incisal edge with a black ring chamfercutter with a 0.12 mm diameter according to thepredetermined pattern. The preparation is carried out

Fig. 20 Fig. 21

Figs. 17 and 18: Technical laboratory phases. Diagnostic wax-up

Fig. 19: Technical laboratory phases – Mock-up

Figs. 20 and 21: Mock-up in oral cavity

Fig. 19Fig. 18

Fig. 17

in two ways: window preparation for canines; butt-joint preparation forthe incisors.

The window preparation, although there is favorable data in literatureregarding its performance, from a biomechanical point of view, it findslimited use in clinical practice.

The benefits are minimal in relation to the elements to restore in thelingual version, but are important when only buccal-palatal thickness isincreased or if minor morphological and/or color changes are required.

Clinically, this type of technique, requires highly accurate preparation,in order not to undermine the prisms of enamels not affected by thepreparation. Butt-joint preparation provides for a clean cut of the incisaledge that, in light of information obtained before the diagnostic wax-upand then validated by the patient with a mock-up, may result in areduction of about 2 mm.

The cut must be at a vestibular angle to allow insertion of horizontalveneers. This type of preparation is easily reproducible during the imprintphase and is an advantage in the laboratory due to the ease with which thetechnician can see it, and realize the finishing line of the veneer. Theinterproximal regions are finished with abrasive disks or streep to make itpossible to remove the impression material. The extent of the reductionmust be absolutely dictated by the template guide built on the diagnosticwax-up initially accepted by the patient. After achieving the requiredthickness, a final step is performed using silicone paste and pumice tomake the surface very smooth (Figs. 24 and 25).



Final facial archThe tool that makes it possible to adequately reproduce thestatic and dynamic relationship of the masticatory system is

the articulator, while the facial arch is a device that makes itpossible to transfer the position of the arches on thehorizon from the patient to the articulator (Figs. 26 and 27).

Fig. 24a Fig. 24b

Figs. 22 and 23:Periodontalintervention

Figs. 24a and 24b:Initial preparation on

model and in oralcavity of the upper

incisors

Fig. 22 Fig. 23


To correctly transfer information to the laboratory, the branches ofthe facial arch must be parallel to the horizon (in the articulator thecondyles are aligned on a horizontal plane).

Color interceptionColor interception by individual ceramic specimens to evaluatethe shades of color produced, are received from the laboratory(Figs. 28 and 29).

Final impressionAfter having preserved the tooth substrate, the final imprint of theelements prepared is revealed. The technique is similar to that usedto construct full crowns. The impression includes the double wiretechnique, the first with a defined compression diameter of 00 (Figs.30 and 31), loaded with astringent liquid inserted into the gingivalsulcus, the second with a diameter of 0, called deflection (Figs. 32and 33), inserted in the sulcus with high viscosity polyethers,positioned in the individual impression tray, and subsequently withlow viscosity polyethers injected into the sulcus (Figs. 34 and 35).

Technical laboratory phasesThe working model is ready forstratification (Fig. 36). The stumpsreproduced in refractory mass, areproperly positioned within the artificialcells. It should be noted that with theresult obtained after the second firingof the ceramic-refractory interface, itwas decided to realize a first layer ofceramic that is stable, precise andperfectly adherent to the underlyingsurface. With the first firing of thefeldspar ceramic, the dental skeletonundergoes morphological andchromatic structuring (Fig. 37). Thetemplate guides the stratification


Fig. 29Fig. 28

Fig. 27Fig. 26

Figs. 25a and 25b: Initial preparation on model and in oral cavity of thelower incisors

Figs. 26 and 27: Facial arch

Figs. 28 and 29: Color interception

Figs. 30 and 31: Insertion of compression wire

Fig. 30 Fig. 31

Fig. 25b

Fig. 25a



(silicone) generated by the approval of the mock-up, a greathelp during this practice run.

Figures 38 and 39 show a global view of the wholereconstruction completed and still anchored to the underlying

Fig. 32 Fig. 33

Figs. 32 and 33: Insertion of deflection wire Figs. 34 and 35: Details of final impression

Fig. 34 Fig. 35



refractory mass. A slight surface texture characterizes thisreconstruction. Figure 40 illustrates details of the entire model(without removable stumps) accurately produced byduplicating the working model on which the feldspathicporcelain veneers were made.Figures 41 to 43 display porcelain veneers, now free from

the coating mass and accurately mounted on the entire model(sectoral model) for control of contact surfaces. This phaseanticipates the clinicians intraoperative session. Porcelainveneers are freed from the refractory mass and are ready to beetched with hydrofluoric acid HF 5% for 120 sec. The plot ofetching increases the resistance of the bond between cementand ceramics (Fig. 44).

Notes on the use of FillerThe use of fillers is now universally recognized as a validmethod for preventing and correcting imperfections caused byall those factors that cause or promote skin aging.If the thing that matters the most is the shape of the lips and

the naturalness of the result, no technique can compete with

temporary fillers. The use of non-resorbable fillers is notcurrently recommended because of the scarcity of publishedscientific data regarding their long term safety (more thanthree years after implantation).The temporary fillers allow modeling of very thin lips, and

guarantee extremely natural results, while the results obtainedwith permanent fillers are generally inferior. The price to pay forthe naturalness of the result is therefore the need to periodicallyrepeat the treatment, a feature, however, that makes it possible toreturn to the previous situation by suspending infiltrations. Themost common temporary fillers are constituted by hyaluronicacid, which gives an aesthetic result for several months.These products are so easy to use that they provide

absolutely natural results. Although substantially similar tothe previous one, fillers containing hyaluronic acid producedby extraction from animal tissues represent a second choice,both due to the potential risk of contracting pathogens, andbecause they seem to have a shorter duration. Animal-derivedcollagen, which forms the basis of many fillers, is used mainlyin the USA and very little in Europe.

Fig. 36: Model ready for stratification

Fig. 37: Morphological structuring and polishing

Figs. 38 and 39: Full reconstructions completed anchored to theunderlying refractory mass

Fig. 40: Entire model without removable stumps

Fig. 38

Fig. 40

Fig. 39

Fig. 36 Fig. 37


It exposes to the risk of allergic reactions (a test is required onemonth before the actual treatment), potential transmission ofpathogenic agents (BSE) and its duration is less than that ofhyaluronic acid.Lastly, temporary filler based on heterogeneous substances are

used, such as a synthetic hydrogel containing polylactic acid anda gel containing hyaluronic acid and cross-linked dextran, with aduration of the result comparable to that of hyaluronic acid.

Easy Filler with agarose gelIn our clinical case, the material of choice is represented byagarose, a saccharide polymer consisting of repeated units of3.6-anhydro-L -galactose and D-galactose. Because of itsphysical properties, agarose in water forms a gel extrudable bya needle, a true rigid mesh gel consisting of a plastic, threedimensional, slow resorption grid.

It is removed from the site of application by macrophages, andthen, after enzymatic destruction of the polymer (via agalactosidase, an enzyme belonging to the family of glycosidases),it is destroyed in the pentose cycle by the macrophages, theplatelets, and the reticulo-endothelial cells.The biocompatibility of the agarose is well known; the gel,

in fact, is well tolerated by cells and tissues, it does notstimulate foreign body reactions, which frequently occurs withother vehicles suspended in solvents, nor induces responsesfrom the immune system.Because of its characteristics, agarose is used as a

biocompatible vehicle in many different fields of preclinicaland clinical applications.From the wide bibliographic documentation on the use of

agarose it is clear that it is biocompatible in clinical use, somuch so that this hydrogel is used in the bioengineering forthe growth of tissues in three dimensions and in the clinicalfield to form the substrate for systems with controlledrelease of drug substances.The product is injected with pre-dosed syringes in dermal

tissue to provide a viscoelastic supplement to the intracellularmatrix of connective tissue.This action is aimed at correcting skin imperfections caused

by wrinkles, folds and sunken scars or to enlarge lips, as in thiscase (Figs. 45a to 45c).

Final cementation of veneers Cementation is one of the most delicate phases of treatmentwith porcelain veneers. After testing in the mouth and havingmounted the dam, proceed with superficial treatment offeldspathic ceramics to combine the effects of micromechanicalconnection (obtained by etching with hydrofluoric acid) withthose of chemical coupling (obtained by silanization).


Fig. 43 Fig.44

Fig. 42

Fig. 41: Ceramic veneers free for coating mass

Fig. 42: Reconstruction in centric occlusion

Fig. 43: Occlusal details of reconstruction

Fig. 44: Completed veneers

Fig. 41



Fig. 46 Fig. 47

Fig. 48 Fig. 50Fig. 49

Fig. 52Fig. 51 Fig. 53

Figs. 46 to 53: Finalizing the case

Fig. 45cFig. 45a Fig. 45b

Figs. 45a to 45c: Phases of treatment with Easy Filler



Figs. 54a and 54b: Finalsmile

Figs. 55 and 56: Initialsituation and final situation

Figs. 57a and 57b: Initialsituation and final situationafter treatment with Filler

Fig. 55 Fig. 56

Fig. 57a Fig. 57b

Fig. 54a Fig. 54b

The protocol for the cementation of feldspar porcelainveneers provides for applying hydrofluoric acid at 10% for 90seconds on the inner surface of the restoration.After rinsing, remove the residues of ceramic and any

remineralized salts by emerging the restoration in an ultrasonictank with 95% alcohol. The next step involves applying silane,the heat treatment at 100° for 1 minute and applying a thin layerof bonding on the inner surface of the veneer. At this point, anytooth surface that is different is treated, if we are faced withenamel only or there is extensive dentin exposure. In thisclinical case the enamel is etched with ortho phosphoric acid for30 seconds and dentin for about 15 seconds; the surface is

cleaned and dried with air for 5 seconds. An adhesive is appliedto the dentin, enamel and to the inner surface of the veneerleaving it to evaporate for 15 seconds with air; apply a thin layerof the color cement selected directly with a syringe to theadhesive surface of the veneer, place in position by exerting agentle pressure allowing any excess cement to extrude around theedges, the position is blocked and polymerized for 20 seconds onthe front surface, then proceed with interproximal-occlusalphoto-polymerization for another 30 seconds.Remove any excess and the dam, and proceed with

finishing the marginal areas with finishing and polishingdiscs (Figs. 46-53).



Fig. 58: OPT Post treatment

Figs. 59 and 60: Final periodontal record

Final evaluation of the case• Dental examination

No pathological conditions are observed (Figs. from 46 to 53).• Occlusal exam

Occlusion in PIM reconfirms initial occlusion despiteconditioning by new front guide

• Periodontal examPeriodontal tissues show a probe depth of no more than2 mm and signs of inf lammation on some elements(Figs. 59 and 60).

• X-ray examNo periapical rarefaction of rehabilitated elements isobserved (Fig. 58).

Final remarks and acknowledgments

At the end of rehabilitation with prosthetic veneers the incisal planis adequately realigned with bipupillary line, parallel to the horizon,thus restoring correct orientation of the levels, determining idealaesthetic and functional integration (Figs. 54-57).

The patient is fully satisfied with the aesthetic, phonetics andmasticatory rehabilitation, all aspects of the function appearstable, plaque control is satisfactory and motivation forperiodic inspection is persistent.

We could not avoid thanking the team of dentists-dentaltechnicians who contributed admirably to the implementationof this rehabilitation, and special thanks to the patient whomade it possible to write this article.

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