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Part 2 book “Practical procedures in aesthetic dentistry” has contents: Indirect ceramic veneer restorations, partial removable prosthodontics, aesthetic management of tooth wear, tooth whitening, implants in the aesthetic zone.
199 Part VII Indirect Ceramic Veneer Restorations 201 7.1 Planning for Porcelain Laminate Veneers Christopher C.K Ho Principles Treatment Planning A comprehensive examination with a complete history and clinical assessment is a critical step in this treatment modality The prevention of disease and control should be considered a first priority, with planning for aesthetic improvement such as veneers considered after this has been completed The treatment planning begins with the following: ●● ●● ●● Discussion of a patient’s objectives and the ability of the dentist to achieve the desired outcomes Initial examination A systematic approach documenting clinical findings, including periodontal conditions, existing restorations, occlusion and so on A radiographic examination and study models should complete this initial examination A photographic series of the patient including extra-oral photos of the full smile and lateral smiles as well as intra-oral photos should be part of the documentation process Informed consent With the information gathered, discussions should be held to inform the patient fully about the treatment This should be done in a simple manner, detailing the treatment steps and limitations of treatment Care must be exercised not to over-promise the final outcomes, and also to determine whether the patient is expecting unachievable results It must be remembered that as health professionals we abide by Primum non nocere, a Latin phrase that means ‘First, no harm’ If a patient can be treated with conservative options, then this must be discussed and recommended to patients as part of the treatment planning process Here are some examples: ●● Crooked teeth and diastemas may be treated with orthodontic treatment, which would be advantageous, as there would be no preparation of teeth or long-term replacement required Orthodontics may also be a phase of treatment to position the teeth prior to veneers, allowing for less invasive preparation The introduction of new orthodontic techniques like Invisalign™ may help to remove some of the objections to conventional orthodontics Practical Procedures in Aesthetic Dentistry, First Edition Edited by Subir Banerji, Shamir B Mehta and Christopher C.K Ho. © 2017 John Wiley & Sons, Ltd Published 2017 by John Wiley & Sons, Ltd Companion website: www.wiley.com/go/banerji/aestheticdentistry 202 Practical Procedures in Aesthetic Dentistry ●● ●● Discoloured teeth might be bleached with vital bleaching or, in the case of a discoloured non-vital tooth, a non-vital ‘walking’ bleach may be carried out Small chips on teeth might be restored with direct resin Indications for Porcelain Veneers 1) Type I – Teeth resistant to bleaching: a) Tetracycline discoloration b) No response to external or internal bleaching 2) Type II – Major morphologic modifications: a) Conoid teeth b) Diastema and interdental triangles to be closed c) Augmentation of incisal length and prominence 3) Type III – Extensive restoration: a) Extensive coronal fracture b) Extensive loss of enamel by erosion and wear c) Generalised congenital and acquired malformations Contraindications for Veneers ●● ●● ●● ●● ●● ●● Minimal enamel for bonding Major changes in tooth colour Major changes in tooth positions, such as severe crowding Large restorations within tooth, minimal enamel and reduced tooth rigidity Bruxism (unprotected) or other parafunctional habits, for instance pen chewing, ice crushing Psychological Diagnostic Wax-Up or Mock-Up Utilisation of a diagnostic wax-up (Figure 7.1.1) can help plan the desired aesthetic appearance This should incorporate the patient’s wants that were expressed in the initial treatment planning discussions The diagnostic wax-up provides visualisation of the desired treatment and a blueprint of the final restorations Additionally, a wax-up allows the fabrication of putty keys for provisionalisation and reduction guides for the preparation process The contours and form of the final teeth can be transferred from the desired wax-up to the provisionals, allowing the patient to have a preview of their desired appearance and to re-confirm that they are happy with the planned changes It is certainly advantageous for a patient to view the changes prior to constructing the veneers, due to the cost of re-making restorations if patients are not happy Material Choices There are different types of ceramics available to fabricate veneers, but there are two basic types of materials used: low-fusing feldspathic porcelain and lithium disiliate or leucite-reinforced ceramics Feldspathic Porcelain This is also referred to as powder liquid or stacked veneers It is used in the layering or build-up technique of most modern porcelains This material contains mainly silica 7.1 Planning for Porcelain Laminate Veneers 203 Figure 7.1.1 Diagnostic wax-up on articulated models and feldspar Additional components include pigments and opacifying agents There is no outstanding inherent strength (up to 100 MPa flexural strength), but feldspathic porcelain is twice as strong as human enamel (50 MPa) In the form of a bonded veneer, it gains much of its strength from the underlying tooth structure, the so-called lamination effect One of the advantages of feldspathic porcelain is the ability to build within each veneer different colours, characteristics and even opacity Another advantage is the ability to use a minimal thickness veneer with a depth reduction of 0.3 mm This preparation is more conservative, and more likely to remain in enamel, especially if a reductive approach is required in the preparation Lithium Disilicate and Leucite-Reinforced Ceramics These ceramics were introduced in the 1990s and are made of pre-sintered ingots, which consist of silicate glasses containing a crystal phase They can be fabricated using a pressed approach, where the restoration is created in wax and the lost-wax technique is used to create the final restoration The pressing procedure consists of a homogeneous ceramic ingot being heated and then forced under pressure into a wax-formed void (investment) The process eliminates porcelain shrinkage, porosity and inconsistencies that may be present with brush build-up techniques The alternative technique is the use of CAD/CAM technology and milling the glass ceramics Two of the most popular materials include Empress, leucite containing (Ivoclar Vivadent, Schaan, Liechtenstein), and e.max, lithium disilicate containing (Ivoclar Vivadent) These materials have several advantages, including more flexural strength Due to this higher strength capability, it is possible even to increase incisal length It has been reported that up to mm of missing tooth structure can be restored with leucite-reinforced ceramic These materials have good marginal integrity and wear compatibility They are also available in different translucencies and opacities, allowing the ceramist better colour masking 204 Practical Procedures in Aesthetic Dentistry Periodontal Considerations The patient’s periodontal status must be optimal prior to treatment This ensures long-term stability of the periodontal apparatus and minimises any chance of marginal gingival recession Periodontal therapy should be completed as well as proper plaque control methods practised with the patient for long-term maintenance This also enables the clinician to work with healthy periodontal tissues and not to have excessive bleeding due to inflammation while working on the patient The concept of ‘biologic width’ should be respected, with preparation margins not invading the minimum space of mm between the most coronal level of the alveolar bone and the gingival level The surgical correction of gingival asymmetries, gingival recession, excessive gingival display (gummy smile) and altered passive eruption should be completed and time allowed for the maturation of the tissues prior to veneers being constructed (Figure 7.1.2) This may range from 3–6 months depending on the case Informed Consent Porcelain veneers are often an aesthetic and elective procedure and as such require a full discussion on the benefits and risks, with the functional and aesthetic objectives defined within this process Alternative means of achieving the patient’s goals must be mentioned and a discussion held on the procedures involved, including the steps from start to completion The patient must be educated on the care and maintenance of the veneers, and mention made of the longevity of the veneers and their eventual replacement Figure 7.1.2 Correction of gingival contours with measuring of biologic width and gingivectomy with diode laser 7.1 Planning for Porcelain Laminate Veneers 205 Figure 7.1.3 Complications with porcelain laminate veneer with fracture Maintenance and Complications The survival rate of porcelain veneers has been shown in the literature to be very high Friedman, in a review of 3500 veneers over 15 years, found a 7% occurrence of complications in clinical service, or a success rate of 93% (Figure 7.1.3) Of the 7% failures, fractures accounted for 67% of total failures, leakage 22% and debonding 11% Fradeani et al., in a review of 182 veneers, found a probability of veneer survival of 94.4% at 12 years, with a low clinical failure rate (approximately 5.6%) Procedures ●● ●● ●● ●● Treatment planning – comprehensive history taking with an understanding of the patient’s needs, and a complete medical and dental history identifying any possible risk factor(s) that may influence the long-term success of treatment Comprehensive examination – hard and soft tissue examination, including occlusal assessment and periodontal examination It is important to evaluate the patient’s dento-labial features and to understand features of smile design, addressing any that may be improved It may be that the patient does not understand what makes a smile beautiful; an example may include gingival asymmetry In many a case with uneven gingival contours, carrying out veneers would not give the patient an aesthetic result without addressing the gingival contours Records – photography (see Chapter 2.2) and radiography should be undertaken to assess the case prior to initiation of treatment Assessing the teeth to ensure that there is no pathology or attachment loss with periapical radiographs is an important step in treatment planning Other diagnostic tests – such as transillumination to assess teeth for fractures, pulpal sensibility testing and so on 206 Practical Procedures in Aesthetic Dentistry ●● ●● ●● Study models – these are articulated and assessed for occlusion, as well as planning Diagnostic wax-up or mock-up – used to plan the required changes as well as being transferred onto the patient’s teeth to allow a ‘test run’ or ‘trial smile’, giving them the ability to gauge whether they are happy with the prescribed changes Often a patient is unsure of the final aesthetics until given some time to accustom themselves to the changes Informed consent – the patient should be given all the available options, the advantages and disadvantages of each procedure, along with risks, complications and success rates It may also be at this stage that it is prudent to address where it may not be possible to meet the patient’s needs Tips ●● To communicate clearly the correct final orientation of the incisal plane of the planned veneers, it is important that the ceramist receives a ‘stick bite’ or ‘symmetry bite’ (Figure 7.1.4) This can be as simple as two sticks within the bite registration to register the midline Figure 7.1.4 Symmetry bite or stick bite – This allows the orientation of the facial vertical plane and the interpupillary line to be transfered to the dental ceramist, enabling the correct alignment of incisal edges relative to these planes in the final restorations 7.1 Planning for Porcelain Laminate Veneers 207 ●● ●● and the interpupillary line to the teeth There are also commercial tools available to carry out this procedure, including the Kois Dento-Facial Analyser (Panadent, Orpington, UK), and Symmetry Facial Plane Relator (Clinician’s Choice, New Milford, CT, USA) It is important to explain to patients that veneers can fracture; they are just like natural teeth in that they can chip and break Although veneer failures are rare, they are possible, although it should be explained that the veneers can easily be repaired or replaced It is important to explain to patients the aftercare needed with veneers An instruction sheet is seen in Table 7.1.1 Table 7.1.1 Post-operative instructions on the care of veneers Temporary changes in speech Your teeth will feel different to your lips and tongue when you first close your mouth This is normal and to be expected when changes have been made to the shape and size of the teeth Sometimes your speech may change or be affected in the beginning until your tongue adapts to the changes Even though the changes are slight (measurable only in millimetres), your mouth is extremely sensitive and will exaggerate those feelings at first Usually after a couple of days the feelings lessen and your mouth will feel normal again Daily hygiene We recommend that you brush with an ultra-soft toothbrush twice a day and floss nightly to extend the life of your veneer As with your natural teeth, the veneer may pick up stains from tobacco, coffee, tea, red wine, colas etc Having regular dental cleans will usually remove these stains Do not use baking soda or any abrasive toothpaste Avoid routinely rinsing with mouthwashes containing alcohol Alcohol softens bonding and weakens the bond of porcelain Select non-alcoholic mouthwashes or a solution made of hydrogen peroxide and water Diet and habits to avoid As with natural teeth, avoid chewing excessively hard foods on the veneered teeth, such as: Hard sweets Nuts ● Spare ribs ● Hard bread and rolls ● Ice ● Raw carrots ● ● This puts stress on the veneer and could result in a fracture or a chip Do not bite extremely hard objects with one tooth Avoid habits such as: Opening packages with your teeth Biting thread ● Chewing ice ● Nail biting ● Pipe smoking ● ● Playing sports Extreme force or trauma can break porcelain veneers, just as the same force can break natural teeth Use care when playing sports or other potentially traumatic situations We recommend wearing a sports mouthguard in these instances Continuing care Visit us for examinations and continuing care at regular six-month examination periods Often, problems that are developing with the veneers can be found at an early stage and repaired easily, while waiting for a longer time may require re-doing the entire restorations We will arrange your continuing care appointment with you at the end of your treatment 208 Practical Procedures in Aesthetic Dentistry References 1 Magne P, Belser U Bonded porcelain restorations in the anterior dentition: a biomimetic approach Berlin: Quintessence; 2003 2 Castelnuovo J, Tjan AH, Phillips K, Nicholls JI, Kois JC Fracture load and mode of failure of ceramic veneers with different preparation J Prosthet Dent 2000;83:171–80 3 Friedman MJ A 15-year review of porcelain veneer failure: a clinician’s observations Compend Cont Educ Dent 1998;19;625–32 4 Fradeani M, Redemagni M, Corrado M Porcelain laminate veneers: 6- to 12-year clinical evaluation – a retrospective study Int J Periodontics Restorative Dent 2005;25(1):9–17 11.7 Implant Maintenance and Review 345 (a) (b) (c) Figure 11.7.3 Excess cement on buccal and lingual Excess cement retained on the abutment and crown of the implant in the UR site (a and b); radiograph showing recurrent decay of the UR and peri-implant bone loss around the UR (c) The patient presented clinically with pain, swelling and suppuration from the implant sulcus consistent with peri-implantitis or peri-implantitis, peri-implant bleeding or suppuration, tobacco use and the needs of the remaining dentition When examined by the clinician or dental hygienist at a recall visit, the patient should be asked whether they are having any trouble with the implant rehabilitation, along with the rest of the dentition Prior to any instrumentation of the implant the site should be visually inspected, the clinician noting the appearance of the peri-implant soft tissues and checking for any signs of oedema or tissue recession The soft tissues around the implant should be gently compressed to check for any signs of suppuration from the sulcus, which would indicate pathology Following this, gentle periodontal probing can be conducted Because of the differences in the attachment of natural teeth and implants and the prosthetic transition from implant to clinical crown, the absolute probing depth around implants is not comparable to that of teeth What is more important is the presence or absence of bleeding on probing and the relative changes in probing depths over time associated with the implant The implant can be percussed to check for mobility or pain The static and dynamic occlusion should also be re-evaluated with thin articulating paper and a ribbon of shim stock to ensure its stability and fidelity to the prescribed occlusal scheme The patient should also be screened for parafunctional activity Professional mechanical debridement with gold or titanium scalers, and/or ultrasonic or piezoelectric scalers with plastic or carbon tips, is suitable for debridement of the restored implant While some standard metal scalers may be too hard or abrasive for debridement of the implant, many plastic hand scalers are not sufficiently rigid to remove plaque or calculus effectively A second pre-scripted radiograph, taken in the same fashion as the baseline radiograph, should be conducted year following restoration of the implant (Figure 11.7.4) The capture of a similar high-quality image allows the clinician to evaluate the stability of the bone levels visible on the radiograph when compared to the baseline In the absence of clinical and radiographic signs of peri-mucositis or peri-implantitis, the radiographic interval can be extended to match that of the remaining dentition If those conditions are not met, then an interventive treatment should be initiated promptly or the patient referred to a specialist colleague for further management Tips ●● Discuss with the patient the expectations for maintenance and review prior to initiating treatment Be sure that the patient understands the potential for biological and technical complications associated with implant rehabilitation, the importance 346 Practical Procedures in Aesthetic Dentistry (a) (c) (b) (d) (e) Figure 11.7.4 Series of radiographs and photographs from the author’s clinical practice permitting evaluation of peri-implant hard and soft tissues High-quality repeatable radiographs demonstrating the stability of the crestal bone relative to the implant over time: baseline (a), 1-year follow-up (b) and 6-year follow-up (c) Subsequent photographs depict the stability and health of the peri-implant soft tissues over the same 6-year interval (d and e) ●● ●● ●● of at-home and professional debridement, and the responsibility for the cost of future maintenance Develop an individualised maintenance plan for the patient focusing on disease prevention and review the effectiveness of and compliance with the plan frequently Recognise the clinical and radiographic signs and symptoms of peri-mucositis or peri-implantitis early and intervene or refer to a specialist colleague for further care Re-assess occlusion on implant restorations frequently, particularly if there have been changes to the dentition References 1 Jung R, Zembic A, Pjetursson B, Zwahlen M, Thoma D Systematic review of the survival rate and the incidence of biological, technical, and aesthetic complications of single crowns on implants reported in longitudinal studies with a mean follow-up of years Clin Oral Implants Res 2012;23 (Suppl 6):2–21 2 Pontoriero R, Tonelli M, Carnvale G, Mombelli A, Nyman S, Lang N Experimentally induced peri-implant mucositis: a clinical study in humans Clin Oral Impl Res 1994;5:254–9 3 Esposito M, Grusovin M, Worthington H Treatment of peri-implantitis: what interventions are effective? A Cochrane systematic review Euro J Oral Implant 2012;5 (Suppl):S21–41 347 Index a abfraction tooth wear 237 abrasion tooth wear 237 abutment design 186 abutment selection principles 308–311 material selection 311 procedures 311–312 tips 312 abutments 308 angulated abutments 310–311 castable abutments 309 computer-generated abutments 309–310 custom abutments 308 multiple unit abutments 310 prefabricated abutments 310 stock abutments 310 temporary abutments 310 acute stage management 39 Adam cribs 73 additive fashioning 124 adhesion, definition 109 adhesive dentistry principles 109–111 procedures 111 tips 112 aesthetic, definition aesthetic zone 18 aesthetic zone evaluation 11 principles 18–19 procedures 19–21 altered eruption types 88 alveolar bone 162 amelogenesis imperfecta 286 anatomical reference points 51 anterior de-programming device 57 anterior guidance 49 anterior reference point 51 anterior restorations principles 122 procedures 122–126 tips 127 appraisal for cementation 172–174 arbitrary facebows 51 arcon articulator 52 astringents 163 attrition tooth wear 237 b balanced occlusion 50 base/liner materials 129 Basic Periodontal Examination (BPE) 83 Bennett angle 61, 62–63 using lateral records 63 bevelling of enamel margins 117–118 beverage pH 237 bilaterally balanced occlusion 50 bimanual manipulation 57 biodentine 130 bisphosphonate-related osteonecrosis of the jaw (BRONJ; ARONJ) 303 bite fork 52, 60 procedure 60–61 Bennett angle 62–63 Bennett angle using lateral records 63 condylar guidance angle 62 condylar guidance angle using protrusive records 64 custom-made incisal guidance table 64–65 immediate side shift 62 setting articulator controls 61 Practical Procedures in Aesthetic Dentistry, First Edition Edited by Subir Banerji, Shamir B Mehta and Christopher C.K Ho. © 2017 John Wiley & Sons, Ltd Published 2017 by John Wiley & Sons, Ltd Companion website: www.wiley.com/go/banerji/aestheticdentistry 348 Index bite registration 56 bleaching discoloured teeth non-vital teeth principles 294–295 procedures 295–298 tips 298 vital teeth principles 289 procedures 290–292 tips 292–293 bleaching trays 291 body dysmorphic disorder (BDD) 10 bonded-base technique 129 bonding agents 110–111 bonding resins 110 bridges (fixed partial dentures; FPDs; FDPs) principles 184–186 abutment design 186 design 185 occlusion 184–185 pontic design 186 resin-bonded bridges (RBBs) 186 procedures 186–187 tips 187 bridges, adhesive principles 178 resin-bonded bridges (RBBs) 178 procedures 179–182 tips 182 bucket handle effect 185 business aspect of dentistry butt-joint enamel margins 118 c canine guidance 49 canine rise 73 canine rise restoration, direct principles 241–242 canine-guided occlusal scheme 241 mutually protective occlusal scheme 241 procedures 243–245 tips 245 canine riser 242 canine-guided occlusal scheme 241 capacity for consent carbamide bleaching 289, 294 procedure 290–292 cavity preparation principles 117–121 procedures 121 tips 121 cement retained implant-supported restorations principles 320 aesthetics 320–321 clinical performance 323 compared with screw implantsupported restorations 323 hygiene 321 interarch space 322 occlusal material fracture 322 occlusion 322 passivity 321 peri-implant tissue health 322–323 provisionalisation 323 retrievability 320 procedures 324–325 tips 326 cementation 159–160 principles 172–175 conventional cements 174 hybrid cements 174 resin cements 174–175 procedures 175–176 tips 177 cemento-enamel junction (CEJ) 87–88, 93 alveolar bone 162 gingival recession 100–101 positioning 95–96 centric occlusion (CO) 49, 275 centric relation (CR) 49, 55–58, 274 centric relation contact position (CRCP) 56 ceramic posts 167 ceramic repair principles 194–196 chemical bonding 195–196 micro-mechanical retention 195 options for repair 194–195 procedures 196–198 glass ceramics 196 metal oxide ceramics (zirconia) 198 preparation of materials 198 tips 198 C-factor 130 chairside copy abutment 326 chemical astringents 163 chroma 20, 34–35 circumferential matrix systems 120 Index 349 clinical occlusion assessment principles 47 procedures 48–50 tips 50 clinical photography benefits before-and-after image libraries 14 improved patient communication 13 laboratory communication 13–14 medico-legal considerations 14 planning 14 self-improvement 14 compositions contrasters 17 full face 16 full smile 17 upper and lower teeth 17 digital smile evaluation 27 equipment 14 backgrounds 16 camera body 16 flash 15–16 lenses 15 mirrors 16 retractors 16 periodontal tissue examination 83 principles 13 procedures 14–17 tips 17 closed sandwich application 129 closed-tray impressions 315 coercion 4 colour mapping 138 colour rendition 34 communicating with patients clinical photography 13 treatment planning 39 competence, definition complaint, nature of complications 205 composite posts 167 computer-aided design (CAD) techniques 31–32 principles 188–190 procedures 190–192 tips 192–193 computer-aided manufacturing (CAM) principles 188–190 procedures 190–192 tips 192–193 condylar guidance angle 61–62 using protrusive records 64 cone beam computerised tomography (CBCT) 87, 98, 304–305, 330 conflict of interests connective tissue graft (CTG) 337–338 consent 4 consent, informed 204, 206 contact points 69 cores principles 167 procedures 170–171 tips 171 cosmetic, definition cross-pinning 325–326 crown lengthening with osseous reduction principles 93 removal or repositioning of soft tissue 94 procedures 94–98 attached gingiva 96–97 bone level and CEJ 95–96 final incisal edge and gingival position 94–95 suturing and healing 97 tips 98 crown lengthening without osseous reduction principles 86–89 procedures gingivectomy 89–90 lasers 90 tips 91 crowns appraisal 172–174 cementation conventional cements 174 hybrid cements 174 resin cements 174–175 full coverage 268 partial coverage 268 procedures 175–176 tips 177 custom-made incisal guidance table 64–65 d Dahl concept 248 dams 113 colours, consistencies and materials 114 350 Index dark polymerisation 134 definitive complex restorations 43 definitive restorations 42 deflective contacts 56 dental aesthetic imperfections dental dam clamps 114 dental dam frames 114 dental dam punches 114 dental dams 113 colours, consistencies and materials 114 dental history of patients 10 dental surveyor 230 dentine cone 262 dentinogenesis imperfecta 286 dentogingival complex, clinical assessment 81 keratinised tissue 82–83 periodontal biotype 81–82 denture-bearing areas, potential 11 denture design 27 diagnosis 11 diastema closure 139–140 diet history of patients 10 dietary analysis 238 digital impressions 164 digital smile evaluation See also smile evaluation principles 27 procedures calibration 31 chewing 32 cloud-based file sharing 28 dento-facial references 29 digital diagnostic wax-up 31–32 facial references 28 functional relationships 32 photography 27 tooth alignment 31 tooth colour 31 tooth form 31 tooth proportion 29–30 video in digital smile evaluation 31 tips 32–33 diluents 110 dimensions of teeth 18–19 direct abutment impressions 315 direct resin veneers principles 137–138 advantages 137 drawbacks 137–138 indications 137 procedures 138–140 colour mapping 138 diastema closing 139–140 malformed tooth 140 tooth length increase 140 tips 140 disclusion 241 discoloured tooth assessment principles 283–286 procedures 286–288 tooth whitening assessment form 287 tips 288 discoloured tooth bleaching principles 289, 294–295 procedures 295–298 tips 298 dual-point flash 16 dynamic occlusal components 47 examination 49 e earbows 51 embrasures 68 emergence profile 68 envelope formation 124, 256 erosion tooth wear 237 eruption, altered 86–88 essential patient data etchants 110 ethics informed consent 204, 206 principles 3 procedures 3–4 examination aesthetic zone evaluation 11 Basic Periodontal Examination (BPE) 11 diagnosis 11 extra-oral features 10 gingival tissues 11 initial examination 10 intra-oral examination 10 occlusal assessment 11 oral hygiene 10 potential denture-bearing areas 11 principles 9 Index 351 procedures 10–11 soft tissues 10 special tests 11 tooth wear 11 extractions 41 extra-oral features 10 f face apportioning 19 frontal aspect 19 lateral profile 19 photography 28 shape of 19 skin 19 symmetry 19 well-proportioned face 19 width of 19 facebow analysis 28–29 facebow fork 52 facebow recording principles 51–52 procedures 52–53 tips 53 facio-lingual (FL) dimensions 148 feldspathic porcelain 202–203 ferrules 168 fibre-reinforced resin posts 168 fifth-generation bonding agents 110–111 finishing resin composites 134 fixed partial dentures (FPDs) See also bridges, adhesive principles 184–186 abutment design 186 design 185 occlusion 184–185 pontic design 186 procedures 186–187 resin-bonded bridges (RBBs) 186 tips 187 flowable composites 130 fluoride application, topical 238–239 fluorosis 284 fourth-generation bonding agents 110 free full-thickness connective tissue grafts 101–102 freehand sculpting 217, 248 freeway space (FWS) 48, 274 fricative sounds 32 full coverage restoration tooth preparation principles 147–150 auxiliary retention 150 circumferential morphology 148 line angle form 150 margin design 148 margin location 148 occluso-cervical (OC)/inciso-cervical dimension 147 occluso-cervical (OC)/inciso-cervical dimension to facio-lingual (FL) dimensions 148 preparation requirements 149–150 reduction depths 148–149 surface roughness 150 total occlusal convergence (TOC) 147 procedures 150–151 sequence 151 tips 151–152 functional diagnostic waxing up principles 67–68 procedures 68–70 contact points 69 details 69 embrasures 68 emergence profile 68 prominent areas 69 tips 70 g generation of introduction of bonding agents 110 gingival aesthetics 21 gingival biotype 333 gingival display, excessive 86–87 gingival exposure during smile 79–80 gingival margins 80–81 gingival recession management principles 100–101 procedures 101–104 graft harvesting 101–102 receptor area 102–104 tips 104–105 gingival tissue examination 11 gingivectomy 89–90 glass ceramics 196 glass ionomer cements (GICs) 109, 129 Golden Proportion 18, 24 graft harvesting 101–102 352 Index group function 49 gummy smile 86 h high-volume suction techniques 113 hingebows 51 Hippocratic oath hue 20, 34–35 hybrid layer 110 hybrid, visible light-cured resins 130 hydrofluoric acid etching 195, 221 i ideal occlusal scheme 47 implant case evaluation 306 implant maintenance and review principles 341–344 complications 343 procedures 344–345 tips 345–346 implant positions 334 apico-coronal position 334–335 buco-lingual position 335 mesio-distal position 335 implant provisionalisation principles 327–328 aesthetic zone strategies 328 procedures 329–332 optimisation modification 332 tips 332 impression taking principles 314–317 abutment-level impression copings 315 customised impression copings 316 implant-level impression copings 315–316 multiple unit impressions 316–317 open- and closed-tray impressions compared 315 procedures 317–319 tips 319 impressions principles 161 chemical astringents 163 digital impressions 164 high, normal and low crest 161–162 impression materials 163–164 impression trays 164 retraction 162 subgingival margins 161 tissue biotype 162 tooth and periodontal health 161 procedures 164–166 tips 166 incisal edge reduction 210–213 incisal guidance table, custom-made 64–65 inciso-cervical dimension 147–148 incremental technique 130 indications for anterior restorations 128 indirect abutment impressions 315 informed consent 204, 206 injection moulding technique principles 260–261 procedures 261–266 tips 266 intercondylar width 51 intercuspal position (ICP) 49, 55 intermediate composite resin restorations 268 interocclusal clearance 247 interocclusal records principles 55–56 procedures 56–59 tips 59 interproximal pillar 123, 256 interproximal wall 132 intra-oral examination 10 intra-oral mock-up 22–23 intra-oral repair 141 k keratinised tissue 82–83 kinematic facebows 51 l laboratory communication 13 shade guides 14 laminated resins 130 laser techniques 90 lateral excursive mandibular records 55 lateral set-screws 325–326 leaf gauge 57 legal considerations 14 leucite-reinforced ceramics 203 light reflection and dispersal from restorations 135 light-curing units 131 Index 353 lips lip line 20 mobility 19 smile arc 20 smile line 20 smile width 20 symmetry 19 thickness 19 listening to patients lithium disilicate 203 Lucia Jig 57 m macro-texturing 135 maintenance programme 43 Maryland bridge 178 matrix bands 120 matrix metalloproteinases (MMPs) 111 matrix systems 120–121 maximal intercuspal position (MIP) 49, 55 medical history of patients 9–10 mesial tilt 24 metal matrix bands 120 metal oxide ceramics (zirconia) 198 metallic wing retainer 178 Michigan splint 71–73 procedure 73–75 micro-mechanical retention 142, 195 Miller’s classification of gingival recession 100–101 minimally invasive methods mirrors 16 modified templates 261 monitoring programme 43 mutually protective occlusion 49 canine rise restoration 241 stabilisation splints 71 n non-vital bleaching principles 294–295 procedures 295–298 tips 298 non-vital teeth 284 o oblique layers 131 occlusal assessment 11 occlusal index 131 occlusal interferences 50, 55 occlusal stabilisation splints 239 principles 71–73 procedures 73–75 tips 75 occlusal vertical dimension (OVD) 48–49 occluso-cervical (OC) dimension 147–148 opaque cements 225 open sandwich application 129 open-tray impressions 315 oral fluids, isolation against 113 oral hygiene of patients 10 overlay restorations 268 p palatal enamel wall 256 palatal grafts 103 palatal shelf 123 palatal silicone index 254 partial coverage restoration tooth preparation principles 153–154 procedures adhesive preparations 159 cavity design and configuration 154–155 cementation 159–160 depth reduction 154 indirect techniques 159 margin design 154 tips 155, 160 path of insertion (POI) 230 patient communication clinical photography 13 treatment planning 39 patient history body dysmorphic disorder (BDD) 10 dental history 10 diet history 10 essential patient data medical history 9–10 nature of complaint principles 9 procedures 9–10 social habits 10 patient protection 113 peri-mucositis 341–342 periodontal biotype 81–82 Periodontal Examination 11 periodontal plastic surgery 101 354 Index periodontal tissue clinical assessment dentogingival complex 81–83 keratinised tissue 82–83 periodontal biotype 81–82 principles 79–81 gingival exposure during smile 79–80 gingival margins and zenith points 80–81 gingival papillae 81 procedures 83 photography 83 probing 84 video 83 tips 84 personal development and clinical photography 14 pH of common beverages 237 phonetic tests 32 photography, see clinical photography pick-up impressions 315 pink aesthetics principles 333–335 gingival biotype 333 implant position 334–335 papilla 333–334 procedures 335–338 bone augmentation 337 flap design and wound closure 336–337 implant placing timing 337 second-stage surgery and soft-tissue augmentation 337–338 tips 338 planning treatments clinical photography 14 plastic surgery, periodontal 101 polishing resin composites 134 polychromatic nature of teeth 35 polyvinyl siloxane (PVS) 56 pontic 178 pontic teeth 185 porcelain laminate veneer (PLV) appraisal principles 220 procedures 221 porcelain laminate veneer (PLV) cementation principles 220 procedures 221–226 bonding veneers 222–224 cementation 222 finishing and polishing 225–226 haemostasis 222 isolation 222 opaque cements 225 treating fitting surface 221–222 tips 226 porcelain laminate veneer (PLV) planning principles 201–205 contraindications 202 diagnostic wax-up 202 indications 202 informed consent 204 maintenance 205 material selection 202–203 periodontal considerations 204 treatment planning 201–202 procedures 205–206 tips 206–207 post-operative instructions 207 porcelain laminate veneer (PLV) provisionalisation principles 216 procedures 217–219 freehand sculpting 217 silicone template 217–219 tips 219 porcelain laminate veneer (PLV) tooth preparation principles 209 procedures 210–214 cervical margin 213–214 existing restorations 214 finishing the preparation 214 incisal edge reduction 210–213 labial preparation 210 proximal preparation 213 tips 214–215 posterior facebow 51 posterior restorations principles 128–129 merits and drawbacks 128 procedures 129–132 tips 133 posts principles 167–168 ceramic posts 167 composite posts 167 fibre-reinforced resin posts 168 procedures 168–171 tips 171 Index 355 predictability in planning 39 premature tooth contacts 56 pre-operative evaluation principles 301–302 flow diagram 302 procedure 303–305 tips 305–307 implant case evaluation 306 pre-preparation wedging 120 pressure-formed templates 261 preventative stage management 40 primers 110 Protemp crown 158 protrusive mandibular records 55 provisionalisation principles 156–157 procedures 157 direct techniques 157–159 r reference point locator 52 reference points 51 relative axial movement 248 removable dental prosthetics (RPDs) principles 229 transitional use 229 procedures 229–233 dental surveyor 230 major connector design 232 path of insertion (POI) 230 precision attachments 232 rest seats 231 retention 231 stability of appliance 232 support selection 231 telescopic crowns 232 tips 233 resin composite restoration, finishing and polishing principles 134 procedures 134–136 tips 136 resin composite restorations, repair and refurbishment principles 141–142 intra-oral repair 141 micro-mechanical retention 142 sandblasting 142 successful rebonding 142 procedures 142–143 abrading fractured area 143 surface sealer 143 tips 143 resin composites 128 resin injection moulding technique 261 resin tags 110 resin-based cements 109 resin-bonded bridges (RBBs) 178, 186 dulling effect 179 procedures 179 wrap-around design 179 resin-modified glass ionomer cements (RMGICs) 129 rest seats 231 resting vertical dimension (RVD) 48–49 retraction 162 retraction devices 113 retractors 16 retruded arc of closure 49 retruded contact position (RCP) 49, 56 ring flash 15 Rochette bridge 178 rotational movement 49 s saliva, isolation against 113 sandblasting 142 screw retained implant-supported restorations aesthetics 320–321 clinical performance 323 compared with cemented implantsupported restorations 323 hygiene 321 interarch space 322 occlusal material fracture 322 occlusion 322 passivity 321 peri-implant tissue health 322–323 principles 320 procedures 324 lateral set-screws 325–326 provisionalisation 323 retrievability 320 tips 326 sculpting, freehand 217, 248 sectional matrix systems 120 356 Index semi-adjustable articulators principles 60 bite fork 60 procedures 60–65 Bennet angle 62–63 Bennet angle using lateral records 63 condylar guidance angle 62 condylar guidance angle using protrusive records 64 custom-made incisal guidance table 64–65 immediate side shift 62 setting the controls 61 tips 66 seventh-generation bonding agents 111 shade guides 14 shade selection principles 34–36 illuminant 34 object 34 shade guides 35–36 surface texture 36 translucency 36 procedures 36–37 stump shade selection 37 tips 37–38 shared anterior guidance 49 shell crowns 157 shrinkwrap technique for silicone templates 217 sibilant sounds 32 silicone key 122–123, 125, 254 sixth-generation bonding agents 111 size of teeth 18–19 smear layer 110 smile arc 20 smile evaluation See also digital smile evaluation principles 22 procedures 22–26 tips 26 smile line 20 smile width 20 smile zone 18 social habits of patients 10 special tests 11 splints occlusal stabilisation splints 239 principles 71–73 arch 71 consistency 71 level of coverage 71 Michigan splint 71–73 mutually protected occlusal scheme 71 repositioning the mandible 71 stabilisation splint 71 Tanner appliance splint 71–73 procedures 73–75 tips 75 spot etching technique 218–219 stabilisation 40–42 stabilisation splint 71 Standard Tessellation Language (STL) 189 static occlusal components 47 static occlusal examination 48–49 Stuart lift 242 study casts 56 subepithelial connective tissue grafts 101–102 subgingival margins 161 successive cusp build-up technique 131 sulcus depth 81–82 probing 84 supra-occlusion 248 surface sealer 143 surface texture of teeth 36 t tacking technique for cementation 223 Tanner appliance splint 71–73 teeth alignment 31 anterior maxillary teeth 22–24 axial inclination 20, 24 canine rise 73 colour 31 connectors 21 contact areas 21 discoloured 139 embrasures 21 evaluation 20 form 20, 31 isolation principles 113 procedures 114–116 tips 116 length increase 140 Index 357 malformed 140 non-vital 284 polychromatic nature 35 proportion 29–30 size of 18–19 surface texture 36 symmetry 20 translucency 36 temporomandibular joints 48 terminal hinge axis 49, 51 tetracycline discolouration 284, 286 tooth preparation full coverage restorations principles 147–150 procedures 150–151 tips 151–152 partial coverage restorations principles 153–154 procedures 154–155 tips 155 tooth wear (TW) 11 tooth wear (TW) direct build-up with indices principles 253–254 procedures 254–258 tips 259 tooth wear (TW) direct build-up injection moulding principles 260–261 procedures 261–266 tips 266 tooth wear (TW) freehand direct restoration principles 246–248 advantages 247 Dahl concept 248 freehand technique 248 interocclusal clearance 247 relative axial movement 248 supra-occlusion 248 procedures 248–252 features to note 249 tips 252 tooth wear (TW) management principles 237–238 abfraction 237 abrasion 237 active intervention 238 attrition 237 beverage pH 237 erosion 237 passive management 238 procedures 238–239 acute conditions 238 dietary analysis 238 exposed dentine 239 generalised wear 238 habit changes 238 localised wear 238 location of wear 238 occlusal stabilisation splint 239 referral 239 severity of wear 238 topical fluoride application 238–239 tips 239 tooth wear (TW) occlusal vertical dimension (OVD) evaluation and management principles 274–275 procedures 276–277 tips 277–279 tooth wear (TW) posterior management principles 268–270 eruptive potential 268 intermediate composite resin restorations 268 occlusal table 268 preventative approach 268 riser restoration 268 procedures 270–273 tips 273 tooth whitening assessment form 287 topical fluoride application 238–239 total occlusal convergence (TOC) 147 transfer impressions 315 translational movement 49 translucency of teeth 36 transparent plastic matrices 120 treatment planning clinical photography 14 porcelain laminate veneer (PLV)s 201–202 principles 39 procedures 39–43 tips 43 true macro lenses 15 tuberosity grafts 103 358 Index u unilaterally balanced occlusion 50 universal concepts in dental aesthetics 18 v vacuum-formed templates 261 value (of colour) 20, 34–35 video examinations digital smile evaluation 31 periodontal tissue clinical assessment 83 vital bleaching principles 289 procedures 290–292 tips 292–293 w wave technique for cementation 176, 223 waxing up, see functional diagnostic waxing up working casts 55 z zenith points 80–81 zirconia 198 WILEY END USER LICENSE AGREEMENT Go to www.wiley.com/go/eula to access Wiley’s ebook EULA ... restoration Provide a definite margin, so that the ceramist has a finishing line, allowing correct emergence of the veneer from the gingival margin Maintain the preparation within enamel wherever possible... Provide a finished preparation that is smooth and free of any sharp internal line angles Provide definite seating landmarks, allowing proper seating of the veneer Practical Procedures in Aesthetic. .. Figure 7 .2. 7 Silicone index seen from the occlusal view 7 .2 Tooth Preparation for Porcelain Laminate Veneers 21 5 Figure 7 .2. 8 Silicone index assessing the vertical reduction ●● ●● During the final