a new height for esthetic creativity in smile makeovers

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A NEW HEIGHT FOR ESTHETIC
CREATIVITY IN SMILE MAKEOVERS
Creating natural-looking high- and low-value zones in
specific anterior lithium disilicate tooth restorations
W
Brad Jones, FAACD
WHEN CREATING a natural-appearing smile
makeover, the author typically uses three different ingots. For this he needs the doctor and
patient to allow him to use some “creative license”
in designing the maxillary central incisors to be
predominant both in value and in position to the
mandibular centrals. Likewise, the upper laterals
should match the lower laterals’ lesser value, and
the upper cuspids also should match the lower
cuspids’ high chromatic warmth.
A lesson in value mandates that value not
be considered as a gray scale. For oil painters
painting on canvas, a gray-scale concept would
be appropriate. However, because dental technicians are recreating natural teeth, what they are
creating must take on light internally in order
to appear like natural dentition. In other words,
it must assume the optical qualities of a natural
tooth. It is only by understanding this that it is
possible to better and more accurately design
restorations that demonstrate vitality.1
The area of a tooth that is high value should be
considered an area of light reflection. In fact, the
light is reflecting so much in some cases that it
appears to have its own light source. Therefore,
the areas of a tooth that are low value should be
considered areas of light absorption. Here, in
some cases, the light is absorbed so much that
About the author
Brad Jones, FAACD
Owner
Smiles, Inc.
Boise, Idaho
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no light is reflected back, as if it is being absorbed
like a sponge.1
When a clinician removes 0.6 mm or 0.5 mm
of the facial tooth surface of an anterior tooth, he
or she has removed mostly enamel.2-4 Why, then,
would technicians select an ingot that is more
opaque and then cut it back to a thin coping (ie,
0.3 mm) and begin layering it? The answer is that
since enamel/dentin tooth structure has been
reduced, it makes sense to choose an enamel/
dentin ingot (IPS e.max® Impulse ingots, Ivoclar
Vivadent, www.ivoclarvivadent.com).
In the case demonstrated here, after the shade
comparison photographs were evaluated, the
author determined that the patient was basically
a B1 shade (ie, IPS e.max Impulse V1), which is
a medium translucency B1. This is the shade the
author would use for the laterals and posteriors.
However, he will typically use one shade lighter
or higher in value for the centrals (IPS e.max
Impulse V2, 040 medium value). In this case,
he selected one shade more chromatic for the
cuspids (HTA1).
However, ingot selection is only part of the
equation. To understand how to mimic a natural
anterior tooth, it also is important to first imagine what a central incisor would look like after
0.5 mm of facial enamel is removed. Ceramists
must have an idea of this in order to reproduce or
mimic the vitality of a natural tooth.5,6
This is due to the fact that once a full-contoured
IPS e.max tooth (ie, core) is created, the 0.5 mm of
space that enamel would take up must be removed.
Next, the internal effects that mimic a natural
tooth must be placed. Lastly, enamel must then
be layered back over these internal effects.5,6 In
this case, the enamels would be layered again to
mimic a natural tooth using Opal Incisal powders.
Case Presentation
A 17-year-old patient (Figure 1) recently
completed orthodontic treatment (Figure 2
and Figure 3) to create room for fuller, more
adult-sized teeth in the esthetic zone (Figure 4).
Impressions were taken during the consultation, and a preoperative model was created and
mounted with a Kois facebow on a Stratos 200
articulator (Ivoclar Vivadent, www.ivoclarvivadent.com) (Figure 5). When clinicians use an
earless facebow record (Kois) combined with
an articulator-mounting table, concern about
the records being distorted during shipping is
eliminated.
After the maxillary preoperative model was
mounted, the lower model was mounted using
centric occlusion bites. A diagnostic wax-up was
then developed and subsequently used to create
a Sil-Tech® matrix (Ivoclar Vivadent) for use in
fabricating provisional restorations. An eyebrowto-chin photograph of the patient’s natural smile
with the provisionals in place was taken (Figure
6). Based on an analysis of this photograph, the
cast of the provisionals was modified for fabricating the definitive restorations.
A new Sil-Tech matrix was made based on
the modified provisional cast and formed under
60-psi pressure using a Wiropress SL pressure
chamber (BEGO USA, www.begousa.com). This
will enable creation of incisal edges and occlusion in exactly the same position as the working,
approved provisionals. It also facilitates fabrication of predictable final restorations.
A 1.5-mm hole was drilled from the insides
of the matrix in the incisal edge area. Using a
jeweler’s wax-injector, Yeti beige wax (Keystone
Industries, www.keystoneind.com) was injected into the matrix and onto the untrimmed,
Fig 1. Preoperative view of a 17-year-old patient
following orthodontic treatment.
Fig 2. Retracted front view of the patient
during orthodontic treatment.
Fig 3. Maxillary arch view during orthodontic
treatment.
Fig 4. Post-orthodontic retracted front view.
Fig 5. Preoperative model mounting.
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Fig 6. Eyebrow-to-chin view of the patient’s
natural smile with provisionals.
Fig 7. A 1.5-mm hole was drilled into the incisal
edge of the incisors, and Yeti beige wax was
injected into the matrix.
Fig 8. Wax-up after removing the matrix.
Fig 9. The wax restorations were separated
using a Smile Line ultra thin knife.
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lubricated master dies (Figure 8). The injected
wax was left to cool for 5 minutes before the
matrix was carefully removed. Excess flash
was minimized and removed using a small
Hollenbeck wax carver (Pearson Dental, www.
pearsondental.com).
The master dies were lubricated but not
trimmed for two reasons. First, the injected
wax restorations demonstrated an accurate fit
to papilla and surrounding gingiva. Secondly, by
leaving all the papilla and gingival landmarks the
author saves time not second guessing himself in
getting the final shape and contour.
After the wax-up was finalized, the waxed
restorations were separated using an ultra-thin
knife (Smile Line, www.smilelineusa.com),
which facilitated their removal (Figure 9). The
master dies’ margins where accurately trimmed
under magnification, sealed, re-lubricated, and
ready for spruing and investing.
The restorations were pressed from HTA1
ingots for the cuspids, V1 ingots for the laterals,
and V2 ingots for the centrals, creating a natural
scenario (Figure 10). After pressing and divesting,
the sprues were cut and then removed using a
Cardinal 932-250-1 rotary instrument (www.
cardinalrotary.com) (Figure 11).
The restorations were carefully fitted to the
master dies, after which they were then fitted
to a hard-tissue model using a modified highspeed FG-57 burr (Benco Dental, www.benco.
com) (Figure 12). It was particularly important
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Fig 10. The restorations were pressed.
Fig 11. The sprues were cut and removed using
a Cardinal 932-250-1 rotary instrument.
Fig 12. The restorations were carefully fitted to
the master dies and then to a hard-tissue model.
Fig 13. Labial view of the fitted restorations on
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the hard-tissue model.
Fig 14. A Cardinal DB-15M rotary stone was
used to remove 0.3 mm of vertical structure
to only remove the stone where necessary in
order to fully seat the individual restorations.
This provided the ceramist with the gingival
architectural landmarks while cutting back and
layering the restorations (Figure 13).
After marking the incisal facial edge with a red
pencil, a 0.3-mm Eversharp lead pencil was used
to mark the vertical reduction at 0.3 mm below
the incisal edge. A Cardinal DB-15M rotary stone
was used to carefully remove 0.3 mm of vertical
structure from the incisal edge (Figure 14). After
using a 0.3-mm Eversharp lead pencil to mark
0.5 mm lingually from the facial red mark, a
red pencil was used again to re-mark the newly
reduced facial incisal edge (Figure 15). Then, using a Cardinal DB-15M rotary stone, the 0.5 mm
of facial core was carefully removed (Figure 16).
A 0.3-mm Eversharp lead pencil was used to
mark the mesial/facial and distal/facial low-value
areas found in a natural tooth. Then, the internal
lobe details were marked. Cuts then were made
using a sharp Cardinal 940 220 (ie, double-sided
diamond disk). This was carefully removed to
make a trough in the outermost mesial/facial
and distal/facial aspects. This troughed out area
would be stained to absorb light (ie, low value)
and mimic a natural tooth (Figure 17). Vanilla
Universal stain was modified with Universal Red
to accent a little incisal lobe detail (Figure 18).
Much of the beauty found in natural teeth
comes from their ability to act as an optic fiber. As
they take on light, it travels apically to illuminate
the gingiva from within. Therefore, dental technicians typically see a transference of a pinkish
color into the warmer colored cervical of natural
teeth, which imparts an orange/pink hue to the
neck of a natural tooth.
Therefore, a mixture of Universal Red and
Universal 110-120 stain was carefully added to
the cervical of the restorations. The troughed areas that need to absorb light (ie, low value) were
carefully stained with a mixture of IPS e.max
Incisal 2 (violet) and Universal Grey (Ivoclar
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off the incisal edge.
Fig 15. The newly reduced facial incisal edge
was re-marked.
Fig 16. The 0.5 mm of facial core was carefully
removed.
Fig 17. The troughed out area will be stained
to absorb light.
Fig 18. Vanilla Universal stain was modified
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with Universal Red to accent incisal lobe detail.
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Fig 19. Troughed areas were carefully stained
with a mixture of IPS e.max Incisal 2 (violet)
and Universal Grey.
Fig 20. The internal powders were selected
and mixed on a stay-wet porcelain tray.
Fig 21. The mesial mamelon piece was then
carefully placed onto the internal surface of
the central core.
Fig 22. A BL3 high-value “bow tie” or band
was placed (color tagged light yellow for the
photograph).
Fig 23. View of the internal powder effects.
Fig 24. View of the fired internal effects.
Fig 25. An exact piece of OE1 (Opal Clear) was
placed in the outermost interproximal incisal
troughs.
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Vivadent). Care was taken to ensure the grey
stain remained inside the trough so it would not
negate the interproximal halo effect (Figure 19).
A4 Universal stain then was used to imitate the
natural color found in the lingual fossa.
After the internal stain effects were fired,
internal powders were selected and mixed on a
stay-wet porcelain tray. BL2 dentin was mixed
50/50 with each individual mamelon powder (ie,
salmon, yellow-orange, and light) to make three
different, smooth, level segments of porcelain
(Figure 20). Using a moist culinary sponge, a
Tanaka Big Brush (www.tanaka.de) was formed
into a flat blade, with the tip trimmed straight to
pick up the mamelon porcelain.
The specially formed big brush tip easily picked
up the perfect mamelon piece in its form. The
mesial and distal internal lobes were formed from
the light mamelon/BL3 dentin 50/50 mixture for
all four incisors. This formed mesial mamelon
piece was then carefully placed onto the internal
surface of the central core (Figure 21).
After the internal lobes were added using the
mamelon mixtures, a BL3 high-value “bow tie” or
band was placed (Figure 22). This was feathered
over the mamelons (Figure 23 and Figure 24).
Using the formed big brush, an exact piece of
OE1 (Opal Clear) was placed in the outermost
interproximal incisal trough (Figure 25). TI1
(high-value enamel) was placed in between the
lobe details, taking care not to trap air.
The fired internal effects were evaluated and
compared to how a natural tooth would look with
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Fig 26. The fired, internal effects were evaluated.
Fig 27. TI1 (high-value enamel) was placed over
the effects to full contour.
Fig 28. These enamels were then placed into a
P500 to fire.
Fig 29. The bisque bake restorations were then
evaluated.
Fig 30. The side of a red lead pencil marked
the heights of contour.
Fig 31. The preoperative model was used to
evaluate and duplicate the patient’s natural
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tooth surface.
its enamel removed (Figure 26). In this case, it
was determined that some additional halo effects would be added using the light MM/BL3
mixture. The internal effects of the six anterior
restorations were evaluated, after which it was
determined that enameling could proceed.
TI1 (high-value enamel) was placed over
the effects to full contour (Figure 27), fired,
and then evaluated (Figure 28). A Cardinal
ZLD8842R-018-1 diamond was used to adjust
the enameled surface to the correct thickness
(Figure 29).
Using the side of a lead red pencil, the heights
of contour were found and marked. These deflective and reflective zones were corrected where
necessary to mimic the patient’s preoperative
dentition. The preoperative model was used to
evaluate and duplicate the patient’s natural tooth
surface, including deflective surfaces (Figure 30).
The surface lobes of the patient’s preoperative
model were carefully copied onto the restorations (Figure 31).
The surface lobes were added using OE1 (Opal
Clear) powder. Then, the thicknesses of the
powder surface lobes were evaluated by looking from the incisal view. After evaluating the
fired surface lobes, it was determined that their
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Fig 32. Perikymata was cut into the
restorations.
Fig 33. Articulating film was used to mark the
surface texture to evaluate the perikymata.
Fig 34. The gingival and incisal interproximals
were refined.
Fig 35. The lingual incisal edge bevel was cut to
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duplicate the preoperative model.
Fig 36. The left cuspid rise was checked and
adjusted.
Fig 37. The right cuspid rise was checked and
adjusted.
Fig 38. The protrusive function was evaluated,
adjusted, and smoothed.
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thickness required reduction. Using a Cardinal
T5856.104.023 (ie, spiral-cut diamond), perikymata was cut into the restorations to mimic the
patient’s preoperative tooth surface (Figure 32).
A piece of articulating film was used to mark
the surface texture to evaluate the perikymata
(Figure 33). The gingival and incisal interproximals were refined using a flexible double-sided
diamond disc (ie, Cardinal 918B 220) (Figure
34). The lingual incisal edge bevel was cut
using a Cardinal ZLD 850 diamond to duplicate
the same edge found on the preoperative
model (Figure 35).
Using the Stratos articulator, the left and
right cuspid rise were checked and adjusted
(Figure 36 and Figure 37). Additionally, using
the articulator, the protrusive function of the
restorations also could be evaluated (Figure
38). They were then adjusted and smoothed to
ensure no anterior interferences.
To glaze the IPS e.max restorations, one-third
of a tube of IPS e.max non-fluorescent glaze
paste was placed into a small empty mixing
jar with one-to-two drops of glaze liquid. This
precise measurement of glaze and liquid was
thoroughly mixed with a non-metallic spatula
to a stringy consistency before applying. With
the restorations on the solid model, this glaze
mixture was first applied liberally to each restoration (Figure 39). Excess glaze in and around
the interproximal areas was removed. Due to the
perikymata, it was necessary to clean all excess
glaze from these horizontal details. This was accomplished using the glaze brush with horizontal
strokes, making sure there was no excess glaze
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while still seeing the surface gloss back over with
each passing horizontal stroke.
The restorations were then fired. The glassy
look of the artificial glaze was removed using a
white knife-edge rubber wheel (ie, Cardinal G322),
paying close attention to maintaining the desired
amount of perikymata (Figure 40). It is important
to note that the natural surface of a tooth is neither
all high-shine nor dull. The lip naturally polishes
the top surface of the lobes, while in between these
high surfaces, the tooth is usually less polished or
dull. To imitate this effect, a large polishing wheel
(ie, Cardinal 6625-250-1) was used to highly shine
the highest surfaces (Figure 41 and Figure 42).
Fig 39. The glaze mixture was applied liberally
to each restoration on the solid model.
Fig 40. View of the glazed and fired IPS e.max
restorations.
Fig 41. A large polishing wheel was used to
highly shine the highest surfaces.
Fig 42. View looking straight on to the glazed
and polished surfaces.
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Fig 43. Postoperative portrait in outdoor light.
Conclusion
Today’s ceramic materials, such as the IPS e.max
lithium disilicate Impulse ingots, enable dental
ceramists to take their esthetic creativity to new
heights to create truly natural- and vital-looking
restorations for the anterior region. Dental professionals can now treat more patients in more
satisfactory ways, matching shades not only to
adjacent natural teeth, but also as they would
progress naturally from anterior to posterior,
and from upper to lower. In the case described
here, multiple postoperative views confirm the
natural esthetics, form, and texture achieved using the selected IPS e.max Impulse ingots and the
cutback and layering technique demonstrated
(Figure 43 through Figure 51).
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Acknowledgements
The author would like to acknowledge Dr. John
Workman, Glen Ellyn, Illinois, for his excellence in
dentistry. He would also like to thank a few of his
mentors—Matt Roberts, Don Cornell, Tom Trinkner,
David Hornbrook, and Wayne Payne.
References
1. Sieber C. Voyage: Visions in Color and Form. Chicago,
IL: Quintessence Pub.;1994.
2. Rufenacht CR. Fundamentals of Esthetics. Hanover
Park: Quintessence; 1990:329-332.
3. Terry DA. Aesthetic & Restorative Dentistry Material
Selection & Technique. Houston, TX: Everest Publishing
Media; 2009:152-153.
4. Chiche GJ. Esthetics of Anterior Fixed Prosthodontics. Hanover Park, IL: Quintessence; 1994:42-48.
5. Ubassy G. Analysis of anatomic occlusal surface
condition. Dent Labor (Munch). 1990;38(4):493-500.
6. Ubassy G. Fabrication and natural stratification of dental ceramics 1. Rev Fr Prothes Dent.
1990;(14):61-70.
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Fig 44. Postoperative retracted center view.
Fig 45. Postoperative retracted right lateral view.
Fig 46. Postoperative retracted left lateral view.
Fig 47. Postoperative upper arch view.
Fig 48. Postoperative natural smile center view.
Fig 49. Postoperative natural smile right lateral view.
Fig 50. Postoperative natural smile left lateral view.
Fig 51. Postoperative portrait in indoor lighting.
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