Dental Asia January/February 2019

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User Report intraoral scanner Carestream 3500 and the new vertical dimension of occlusion (VDO) was achieved respectively through the wide opening of the virtual articulator in the CAD/CAM software. The dynamic documentation protocol of the Digital Smile Design (DSD) was used: videos were recorded with a smartphone from four different calculated angles to achieve harmonious facial smile symmetry: a frontal video of the smiling face with and without the lip and cheek retractor, a profile video, a 12 o’clock video and an anterior occlusion video perpendicular to the occlusal level without a mirror. Four supplementary videos were recorded for the functional, structural and facial analysis: a consultation that matched the patient’s expectations, a 180° phonetic video, an intraoral functional and intraoral structural video with lip and cheek retractor (Fig. 5). The information was transmitted to the DSD laboratory. The main goal of the DSD technique is to reconcile the photos from the three views (occlusal, frontal and 12 o’clock) with a digital ruler in order to recreate the correct smile proportions by means of a video analysis (Smile Frame). Fig. 5: DSD protocol: image of patient smiling wearing a lip and cheek retractor. Cupid’s bow and jaw curve. The 2D proportions of the smile were converted in the CAD software into a digital 3D simulation model. The resulting 3D file in STL format was transmitted to a printer which created the model with the new design. It was then used to produce a matrix made of Bis-acryl (Structur; VOCO) for the motivational mock-up (Fig. 6). Fig. 6: Motivational mock-up made of Bis-acryl (Structur 3, VOCO) The vertical dimension (VD) was increased in the new model and for this reason the patient tested the mock-up over the course of two weeks to ensure the new bite height met his expectations. The bite trial showed no stability problems and the patient was happy with the result. As such, there was no need for further deprogramming of the occlusion and definition of a new centric relation. The patient felt comfortable with this new VD and experienced no pain in the TMJ. The treatment plan was presented yet the patient chose not to continue treatment for financial reasons. (Structur; VOCO) using a vacuum formed matrix (V-print Ortho clear; VOCO). The abutment teeth were minimally prepared on the basis of the mock-up (Fig. 8). Figs. 8: No preparation of the posterior teeth, minimal preparation of the bottom anterior teeth, with the exception of 11, 12, 13, 21, 22, 23, which were already prepared. The old teeth preparations in the second sextant were retained; the upper posterior teeth (14–17, 24–27) and the lower posterior teeth (34, 35, 36, 37, 44, 45, 46, 47) were not prepared and the lower anterior teeth were minimally prepared. A new intraoral scan was produced. The information was transmitted to the DSD laboratory (Fig. 9) which created an STL file with virtual models which were produced in the laboratory (Anatomic Lab). These 3D models (V-Print model; VOCO) were created in a 3D printer (SolFlex 650; VOCO). The Smile Frame was then created as follows, taking the facial symmetry into account: digital face bow, form and position of the smile curve, determination of width using the recurring esthetic dental (RED) correlation, length proportions, gingival curve, papillary curve, Fig. 7: Two years later, prior to treatment (2017) The patient returned to the practice in 2017 to resume treatment (Fig. 7) and a new intraoral scan (Carestream 3600) was produced. A new mock-up for the tooth preparation was printed on a 3D printer (SolFlex; VOCO) with Bis-acryl Fig. 9: DSD planning The final veneers and crowns were digitally prepared using the design software Ceramill ® mind (Amann Girrbach) and produced in a milling machine (Ceramill ® Motion 2, Amann Girrbach) from machinable lithium disilicate ceramic blocks (VITABLOCS ® TriLuxe forte for Ceramill ® Motion 2, Amann Girrbach) (Fig. 10). After confirming the marginal seal and the visual properties through trial insertion, a lip and cheek retractor 52 DENTAL ASIA JANUARY / FEBRUARY <strong>2019</strong>
User Report (OptraGate, Ivoclar Vivadent) were placed in the patient’s mouth. Fig. 10: Final veneers and crowns digitally prepared using the design software Ceramill ® mind and produced in a milling machine (Ceramill ® Motion 2) from machinable lithium disilicate ceramic blocks (VITABLOCS ® TriLuxe forte for Ceramill ® Motion 2) The abutment teeth and ceramic veneers and crowns were prepared in accordance with the manufacturer’s recommendations: The ceramic surface was prepared with 50 μm aluminium oxide and for 20 seconds with hydrofluoric acid 5%, it was then rinsed for 20 seconds before being treated with phosphoric acid 37% (Total Etch, Ivoclar Vivadent) and alcohol 96% in order to be cleaned and finally conditioned for 20 seconds with silane (Monobond Plus, Ivoclar Vivadent). Fig. 11 Fig. 12 Figs. 11-12: The crowns (11, 12, 13, 21, 22, 23) and veneers (14, 15, 16, 17, 24, 25, 26, 27, 31, 32, 33, 34, 35, 36, 37, 41, 42, 43, 44, 45, 46, 47) were secured to the abutments using a light-curing, polymerising resin adhesive (Futurabond U and Bifix QM, VOCO, Germany) The crowns (11–13, 21–23) and veneers (14, 15, 16, 17, 24, 25, 26, 27, 31, 32, 33, 34, 35, 36, 37, 41, 42, 43, 44, 45, 46, 47) were secured to the abutments using a light-curing, polymerising resin adhesive (Futurabond U and Bifix QM; VOCO). A high-performance LED light curing device (Celalux 3; VOCO) was used for polymerisation (Figs. 11-12). Excess luting material was removed and the occlusion was adapted and checked with the T-scan technology (Tekscan). A removable acryl splint was used to protect the final restorations. The final restorations were checked after six months. It was still stable and showed no signs of fractures (Figs. 13-15). The patient also reported that he no longer suffered from headaches with the new bite height. Fig. 13 Fig. 14 Figs. 13-14: Intraoral photo following treatment Fig. 15: Panoramic image at the end of treatment Conclusion Thanks to dental technological developments, fully digitalised treatment was possible, which can successfully solve problems such as a loss of bite height. However, further clinical studies are necessary in order to arrive at reliable results with regards to the digital work process compared to conventional techniques in the event of loss of bite height. The functionality of permanent restorations must also be assessed in the long term. DA References: 1. Coachman C, Van Dooren E, Gürel G, Landsberg CJ, Calamita MA, Bichacho N. Smile design: From digital treatment planning to clinical reality. In: Cohen M, editor. Interdisciplinary Treatment Planning. Vol 2: Comprehensive Case Studies. Chicago: Quintessence; 2012. p. 119–74. 2. Coachman C, Calamita A, Sesma N. Dynamic documentation of the smile and the 2D/3D digital smile design process. Int J Periodontics Restorative Dent. 2017;37:183–93. 3. Pimentel W, Teixeira ML, Costa PP, Jorge MZ, Tiossi R. Predictable outcomes with porcelain laminate veneers: a clinical report. J Prosthodont. 2016;25: 335–40. 4. Lin WS, Zandinejad A, Metz MJ, Harris BT, Morton D. Predictable restorative work flow for computer-aided design/computer-aided manufacture-fabricated ceramic veneers utilizing a virtual smile design principle. Oper Dent. 2015;40: 357–63. 5. Arias DM, Trushkowsky RD, Brea LM, David SB. Treatment of the patient with gummy smile in conjunction with digital smile approach. Dent Clin N Am. 2015;59:703–16. 6. Coachman C, Calamita MA, Coachman FG, Coachman RG, Sesma N. Facially generated and cephalometric guided 3D digital design for complete mouth implant rehabilitation: a clinical report. J Prosthet Dent. 2017;117:577–86. 7. Zimmermann M, Mehl A. Virtual smile design systems: a current review. Int J Comput Dent. 2015;18:303–17. 8. Edelhoff D, Liebermann A, Beuer F, Stimmelmayr M, Güth JF. Minimally invasive treatment options in fixed prosthodontics. Quintessence Int. 2016; 47:207–16. https://doi.org/10.3290/j. qi.a35115. 9. Culp L, McLaren EA. Lithium disilicate: the restorative material of multiple options. Compend Contin Educ Dent. 2010;31:716–25. 10. Zarone F, Ferrari M, Mangano FG, Leone R, Sorrentino R. Digitally oriented materials: focus on lithium disilicate ceramics. Int J Dent. 2016;2016:9840594. 11. Soares PV, Spini PH, Carvalho VF, Souza PG, Gonzaga RC, Tolentino AB, et al. Esthetic rehabilitation with laminated ceramic veneers reinforced by lithium disilicate. Quintessence Int. 2014;45:129–33. https://doi.org/10.3290/j. qi.a31009. 12. Morimoto S, Albanesi RB, Sesma N, Agra CM, Braga MM. Main clinical outcomes of feldspathic porcelain and glass-ceramic laminate veneers: a systematic review and meta-analysis of survival and complication rates. Int J Prosthodont. 2016;29:38–49. 13. Sulaiman TA, Delgado AJ, Donovan TE. Survival rate of lithium disilicate restorations at 4 years: a retrospective study. J Prosthet Dent. 2015;114:364–6. 14. Tarantili VV, Halazonetis DJ, Spyropou-Los MN. The spontaneous smile in dynamic motion. Am J Orthod Dentofac Orthop. 2005;128:8–15. JANUARY / FEBRUARY <strong>2019</strong> DENTAL ASIA 53
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