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2011;142;14S-19SJADA Daniel Edelhoff and Oliver Brixindications : A case seriesAll-ceramic restorations in different

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14S JADA 142(4 suppl) http://jada.ada.org April 2011

Clinicians use all-ceramic restorationsroutinely in dentistry today. Therapid rate of innovation with regardto materials, computer-aided design/

computer-aided manufacturing (CAD/CAM)technologies, and intraoral data acquisitionsystems has resulted in the need for dentalcare professionals to familiarize themselveswith a large body of knowledge to make useof the almost limitless possibilities that thesesystems offer.

Conventional steps, such as careful treat-ment planning in collaboration with the labo-ratory technician, selection of appropriateceramic materials, and adequate tooth prepa-ration and processing are essential to ensuringthe long-term survival of restorations. Fur-thermore, rapid advances in material tech-nology in the field of glass and oxide ceramics,as well as in adhesive technologies, have led tonew treatment options that are reflected in anextended range of indications and in less inva-sive tooth preparation designs. All-ceramicsystems are suitable for a wide range of indi-cations covering almost all areas of fixedrestorative dentistry, and they encompass adiverse range of materials.

We present five cases ranging from place-ment of veneer restorations to complex reha-bilitation to illustrate the scope of applica-tions and procedures used to achieve success-ful outcomes with all-ceramic restorations.Close collaboration between the patient, den-tist and laboratory technician is paramountto define and achieve the treatment goals. Ananalytic wax-up, a diagnostic templatederived from the study wax-up and modifi-able temporary restorations facilitated com-munication, decision making and subsequentpreparation procedures.

Dr. Edelhoff is an associate professor, Department of Prosthodontics, Ludwig-Maximilians-University, Goethestrasse 70, D-80336 Munich, Germany, e-mail“[email protected]”. Address reprint requests to Dr. Edelhoff.Mr. Brix is owner of Innovative Dental Design, Wiesbaden, Germany.

All-ceramic restorations in different indicationsA case series

Daniel Edelhoff, CDT, Dr Med Dent, PhD; Oliver Brix, CDT

AB ST RACTBackground. Encompassing a vast array ofmaterials, today’s all-ceramic systems are suitable for alarge range of indications in almost all areas of fixedrestorative dentistry.Methods. The authors describe five clinical casesinvolving different indications to illustrate the use of dif-ferent ceramic materials and combinations of materials.They describe the collaboration between the dentist anddental technician for single-tooth restorations and forcomplex cases, including all stages of the restorativeprocedures from treatment planning with an analyticwax-up to the selection of appropriate materials, toothpreparation and cementation.Results. The patients described experienced signifi-cant functional and esthetic improvement, even thosewho had severely discolored teeth. This was possiblebecause the authors executed the working steps in astrictly synchronized manner and selected the restora-tive materials carefully to meet the specific needs ofeach patient.Conclusions. All-ceramic systems have expanded therange of restorative treatment options significantly; atthe same time, their handling has been simplified sub-stantially. The use of lithium disilicate glass-ceramic–and zirconium oxide–based frameworks along with anidentical veneering ceramic enables the dental care pro-fessional to cover almost all indications in fixed prostho-dontics while achieving the same esthetic results.Key Words. Lithium disilicate glass-ceramic; zirco-nium oxide; fluorapatite veneering ceramic.JADA 2011;142(4 suppl):14S-19S.

Copyright © 2011 American Dental Association. All rights reserved.

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JADA 142(4 suppl) http://jada.ada.org April 2011 15S

VENEERS FABRICATED ON REFRACTORY DIESBecause of their excellent clinical performance,outstanding esthetics and minimally invasivecharacteristics, resin-bonded veneers offer anexcellent treatment option for a wide range ofindications.1 Porcelain veneers are consideredadvantageous for maintaining tooth vitality andpreserving hard tissues,2 especially if tooth prepa-ration is guided by a diagnostic template andincludes the use of an additive wax-up.3 Fullcrown preparations require removal of 63 to 72percent of tooth structure, while veneers requireremoval of only 3 to 30 percent of tooth structure.4

Case 1. A 30-year-old man visited his dentist(D.E.) because of general defects of his toothstructure. The patient requested to have thebrightness value of his teeth improved perma-nently and to undergo esthetic reconstruction toimprove the morphology and function of histeeth. After the dental technician (O.B.) createda study wax-up, the dentist and the techniciandecided to use all-ceramic single-tooth restora-tions to achieve the patient’s treatment goals.The diagnostic template, which had been cre-ated on the basis of the wax-up, served as aguide for preparation of the teeth.

The minimum reductions in tooth structureduring tooth preparation were as follows: cervicalarea, 0.4 millimeter; equatorial area, 0.7 mm; andincisal area, 1.2 mm (Figure 1A). The laboratorytechnician used a fluorapatite-based veneeringceramic (IPS e.max Ceram, Ivoclar Vivadent,Amherst, N.Y.) and layering technique to producethe veneers on refractory dies. The dentist per-formed try-in by using tooth-colored pastes (Vari-olink Veneer Try-In Paste, High Value +2, IvoclarVivadent), and he performed the final adhesivecementation procedure by using a multistepdentin adhesive system (Syntac Primer andSyntac Adhesive, Ivoclar Vivadent) combined

with a light-curing luting composite for veneers(Variolink Veneer, High Value +2, IvoclarVivadent) (Figure 1B).

ALL-CERAMIC INDICATIONS IN THE ESTHETIC REGION

Esthetically demanding cases requiring the useof different all-ceramic framework materialspresent a challenge for the dental restorativeteam.

Case 2. A 42-year-old man who exhibited sev-eral anterior defects of varying degrees ofseverity and had lost tooth no. 6 required a func-tional and esthetic rehabilitation of the maxil-lary anterior region from tooth no. 5 to tooth no.11. Because of varying degrees of damage to theteeth and the patient’s high esthetic expecta-tions, the treatment team (including D.E. andO.B.) opted to place the following restorationsand materials (Figure 2):dright first premolar to right lateral incisor:zirconium oxide–based three-unit fixed dentalprosthesis (FDP) (IPS e.max ZirCAD, IvoclarVivadent);dcentral incisors: circular prepared veneerswith a minimum thickness of 0.3 mm composedof lithium disilicate glass-ceramic (IPS e.maxPress, LT, Ivoclar Vivadent);dleft lateral incisor and left canine: full-crownrestorations composed of lithium disilicateglass-ceramic (IPS e.max Press, LT).

Because the dental team used the sameveneering ceramic (IPS e.max Ceram) for all ofthe restorations, they were able to achieve auniform esthetic appearance throughout thedentition. Consequently, an observer would be

ABBREVIATION KEY. CAD/CAM: Computer-aideddesign/computer-aided manufacturing. FDP: Fixeddental prosthesis. VDO: Vertical dimension of occlusion.

Figure 1. A. Try-in of veneers in the anterior region of the mandible fabricated on refractory dies by using a fluorapatite-basedveneering ceramic (IPS e.max Ceram, Ivoclar Vivadent, Amherst, N.Y.). Preparation was guided by a mock-up, fabricated according to ananalytic wax-up. B. Postoperative view after definitive placement of the veneers with the use of a multistep dentin adhesive system(Syntac Primer and Syntac Adhesive, Ivoclar Vivadent) combined with a light-curing luting composite for veneers (Variolink Veneer, HighValue +2, Ivoclar Vivadent).

A B


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unaware of the fact that various ceramicmaterials had been used for the frameworks(Figure 3). The clinician used the followingluting materials for adhesive cementation of therestorations: primarily chemical curing lutingmaterial containing phosphonic and acrylic acidmonomers (Multilink Automix, MultilinkPrimer A and B, Monobond Plus, IvoclarVivadent) for the zirconium oxide–based three-unit FDP; light-curing resin cement for theglass-ceramic full veneers (Syntac Primer andSyntac Adhesive, Variolink Veneer, High Value+2, Ivoclar Vivadent) and dual-curing resincement for the glass-ceramic crowns (SyntacPrimer and Syntac Adhesive, Variolink II Baseand Variolink II Catalyst, transparent white110/A, Ivoclar Vivadent).

RECONSTRUCTION OF VERTICAL DIMENSION OF OCCLUSION

Case 3. Tooth wear is an increasing problem allover the world.5 A 28-year-old man wanted toimprove the esthetics and function of his denti-tion, which had been damaged severely by abrasive-erosive processes. He complainedabout experiencing hypersensitivity whileeating. In addition, he had noticed that the

shapes of his teeth appeared to be changingincreasingly.

The dentist (D.E.) performed an intraoralexamination, the results of which revealedsevere enamel loss that had led to extensivedentin exposure in the posterior region (Figure4A). If we assume that the enamel layer shouldhave been at least 1 mm thick in the posteriorregion, a considerable reduction in the verticaldimension of occlusion (VDO) had alreadyoccurred. After eliminating the nutrition-relatedcauses of the erosive processes, the clinicianreplaced all of the patient’s existing restorationswith resin-based composite restorations. Thisapproach allowed the dental team to gain aclear picture of the extent of the defects, thecondition of the abutment teeth and the amountof enamel remaining.

After conducting a technical (that is, evalu-ation of function in static and dynamic occlusionand of tooth proportions in the articulator) andclinical analysis, the dental team and thepatient decided on the following treatment plan:dfabrication of an analytic wax-up to aid thedental team in reconstruction of the estheticsand function of the dentition, as well as for thecreation of a transparent, hard elastic diag-nostic template (Duran, 0.5 mm, Scheu Dental,Iserlohn, Germany);dintraoral esthetic evaluation of the wax-upwith the help of the diagnostic template;dtransfer of information about the requiredincrease in the VDO gained with the wax-up toa modified Michigan splint to enable the clini-cian to evaluate the functional effectiveness ofthe reconstruction; dpreparation of the affected teeth, startingwith the opposing quadrants, by using the diag-nostic template as a guide and recording themaxillomandibular relationship with the aid ofa Michigan splint split in half;dinsertion of the direct temporary restorationsfabricated on the basis of the wax-up; devaluation of the clinical performance of thetemporary restorations on the basis of the ana-lytic wax-up, and any needed adjustments;dmaking of impressions and prompt fabricationof final restorations in the dental laboratory;dtry-in and placement of the final all-ceramicrestorations.

Treatment began with the patient’s wearing amodified Michigan splint for 12 weeks. Duringthis phase, the required increase in the VDOwas transferred accurately to the patient’s oralcavity and was identical with the VDO increasecreated by the wax-up. In addition, the diag-nostic template, which had been fabricated on

Figure 2. Different indications for all-ceramic restorations in theesthetic zone of the maxilla: full-crown preparations on teethnos. 5 and 7 for zirconium oxide–based fixed dental prosthesis;circular veneer preparations for glass-ceramic restorations on cen-tral incisors; full-crown preparations for glass-ceramic restorationson teeth nos. 10 and 11.

Figure 3. Try-in of the final restorations fabricated with the IPSe.max (Ivoclar Vivadent, Amherst, N.Y.) all-ceramic system. Zirco-nium oxide–based three-unit fixed dental prosthesis (IPS e.maxZirCAD) replaced tooth no. 6. Circular veneers (IPS e.max Press, LTframework) on central incisors and full crowns (IPS e.max Press, LTframework) on teeth nos. 10 and 11. An identical veneering ceramic(IPS e.max Ceram) was used for both framework types; conse-quently, the esthetic appearance of the restorations is the same.


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the basis of the wax-up, enabled the patient toobtain a first impression of the treatment goal.

The diagnostic template served as a guidethroughout treatment and as an orientation aidduring preparation of the onlays, which the clini-cian contoured in full anatomical shape by usinga lithium disilicate glass-ceramic (IPS e.maxPress, HT, with the staining technique) with aminimum thickness of 1 mm (Figure 4B).6 As aresult, the dentist had to remove little toothstructure in accordance with the intended outercontours of the restorations.7 The dentist pre-pared all teeth and recorded the maxillomandib -ular relationship at the same appointment.

The clinician fabricated the temporary resto-rations chairside with the help of the diagnostictemplate and a bisphenol A-glycidyl methacry-late–based temporary restorative material(C&B Provilink, Ivoclar Vivadent [this productis no longer on the market; the authors now useTelio CS C&B, Ivoclar Vivadent]). In the pos-terior region, the minimally retentive tempo-rary onlays were left splinted. The clinicianplaced the temporary restorations with the useof a bonding agent (Heliobond, Ivoclar Vivadent)without any etching of the tooth structure.

The clinician tried in the restorations with theuse of a tooth-colored glycerine gel (Try-In Paste,Variolink II) to inspect their shape and shade.He examined the marginal seal and checked thestatic and dynamic occlusal contacts carefullywith the help of a low-viscosity silicone.

Before placing the glass-ceramic restorations,the dentist etched their inner surfaces withhydrofluoric acid (< 5 percent IPS CeramicEtching Gel, Ivoclar Vivadent) for 20 secondsand then conditioned them with silane(Monobond-S, Ivoclar Vivadent). The clinicianused Syntac Primer and Syntac Adhesive on theteeth. He placed all of the onlays by using asingle light-curing luting composite (Variolink IIBase, shade 110) and used a high-performancecuring light (bluephase G2, with > 1,000 milli-

watts per square centimeter, Ivoclar Vivadent)for the final cure. The patient’s esthetic expecta-tions were satisfied completely with reconstruc-tion of the lost tooth structure (Figure 4C).

REHABILITATION OF DENTINOGENESISIMPERFECTA WITH MONOLITHIC POSTERIOR CROWNS

Case 4. A 15-year-old boy visited his dentist(D.E.) together with his parents because hewished to have his severely discolored and mal-formed teeth restored. He said that he was painfree but complained about the severe social stressthat he felt because of the appearance of his teeth(Figure 5). After conducting an intraoral exami-nation and obtaining a medical history, the den-tist diagnosed the patient as having dentinogen-esis imperfecta type II (hereditary opalescentdentin). The specialist dental literature refers tothe importance of early therapeutic interventionto stop the destruction of tooth structure and pre-vent the development of inadequate occlusal func-tion.8 Some authors have described the use of all-ceramic crowns as a possible restorative approachand have recommended adhesive cementation.9,10

The challenge faced by the dental team in thiscase was the young age of the patient, who wasstill growing, and his request for an immediateimprovement in his oral condition. In addition,the dental team had to establish an appropriatemorphology of the teeth, adjust the VDO andensure reliable retention of the restorations onthe damaged tooth structure.

Against such a background, a study wax-upwas created and evaluated with regard toesthetics and function. On the basis of the wax-up, the dental technician (O.B.) manufacturedfull crowns composed of high-density polymer byusing CAD/CAM technology and seated them aslong-term (12 months’ duration) temporary restorations.

The clinician performed the final restorativeprocedures section by section, first in the max-

A CB

Figure 4. A. Preoperative view of the combined abrasive-erosive defects on the posterior teeth on the right side of the mandible. Thevertical dimension of occlusion (VDO) was affected significantly by severe loss of enamel. B. After fabrication of an analytic wax-up andthree months’ successful therapy with a modified Michigan splint for reconstruction of the VDO, onlays with a minimum thickness of 1 millimeter were fabricated (IPS e.max Press, HT, Ivoclar Vivadent, Amherst, N.Y., with the staining technique). C. Postoperative view ofthe final onlays after adhesive placement with a light-curing low-viscosity resin cement (Variolink II Base, transparent, Ivoclar Vivadent).The onlays exhibited an enamellike appearance and the color adapted well to the surrounding tissues owing to a high degree oftranslucency.


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illa and then in the mandible. In the anteriorregion, he fabricated the definitive crowns byusing a layering technique (IPS e.max PressMO 2/Ceram A2) and in the posterior region, hefabricated the full anatomical crowns by using apressing and staining technique (IPS e.maxPress, LT, A2) (Figure 6).

The prolonged temporary phase providedample time to test the patient’s new VDO, thereby

enabling the treatment team to predict accuratelythe outcome of the final restorations.

REHABILITATION OF MISSING CENTRALINCISORS WITH ZIRCONIUM OXIDE–BASEDFIXED DENTAL PROSTHESIS

Case 5. A 45-year-old woman visited her dentist(D.E.) because of a trauma to the anterior max-illa. Clinical and radiographic examinationrevealed deep root fractures of the two maxil-lary central incisors. Because implants were notthe treatment option of choice and all anteriorteeth had been restored with metal-ceramic fullcrowns, the subsequent treatment consisted ofpreparation of the lateral incisors and caninesas abutment teeth, extraction of the two centralincisors and insertion of a provisional six-unitFDP, fabricated directly with the aid of a diag-nostic template created according to the wax-up.

The dentist conditioned the ovate ponticrecipient sites with a relineable long-term provi-sional restoration (Figure 7A).11 After a healingperiod of about 12 weeks, the clinician per-formed the final tooth preparations andobtained precise impressions. The design of theframework included a minimum dimension of 9 square millimeters for the connector cross-section and sufficient support of the veneeringceramic.

During try-in of the final restoration, thedental team paid special attention to ensuringthe correct interaction between the ovate ponticrecipient sites and the FDP area of the ovatepontics. For esthetic reasons, the clinicianreduced the zirconium oxide–based framework(IPS e.max ZirCAD) in the facial cervical aspectof the abutments and applied shoulderveneering ceramic to increase light transmis-sion into the surrounding soft tissues and thetooth structure (Figure 7B). To stabilize theshoulder ceramic, the clinician performed selec-tive etching with hydrofluoric acid and used anadhesive luting material (Monobond Plus, Mul-tilink Automix) for the final insertion. Afterplacement, a harmonious interaction betweenthe soft tissue and the all-ceramic FDP wasaccomplished.

CONCLUSIONSSilicate-based all-ceramics have been proveneffective in numerous long-term clinical studiesas an appropriate material for esthetic single-tooth restorations. They are well suited for awide variety of applications, from direct lay-ering of veneering ceramics on refractory dies tothe veneering of high-strength glass-ceramicframeworks for anterior crowns or extensive

Figure 5. Preoperative view of amber-shaded posterior teethwith extended deformation caused by dentinogenesis imperfectatype II.

Figure 6. Postoperative view of monolithic full crowns (IPS e.maxPress, LT, A2, Ivoclar Vivadent, Amherst, N.Y.) made with thestaining technique and placed adhesively with a dual-curing resincement (Variolink II, Ivoclar Vivadent) in a white opaque shade.

Figure 7. A. Conditioning phase of the ovate pontic recipientsites in the esthetic zone of the maxilla. B. Six-unit zirconiumoxide–based fixed dental prosthesis with ovate pontics replacingthe central incisors.

A

B


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veneer restorations, as well as full anatomicalmonolithic reconstructions without veneeringfor posterior inlays, onlays, partial crowns andfull-crown restorations.12-15 Veneered lithiumdisilicate glass-ceramic full crowns have demon-strated satisfactory long-term clinical stabilityin the anterior aspect, as well as in the load-bearing zone.16,17 Given their favorable mechan-ical properties, lithium disilicate glass-ceramic–based restorations seem to require less invasivepreparation designs as they exhibit greaterstrength than do conventional leucite-reinforcedglass ceramics.6 Furthermore, researchers inclinical midterm (about three years) trials havereported that monolithic lithium disilicate partial-coverage restorations and full crownsoffered appropriate stability and did not causemore wear in the opposing dentition than didconventional metal-ceramic crowns.18-20

Polycrystalline ceramics (for example, zirco-nium oxide) are well suited for restorative com-ponents that are exposed to high loads andstress concentrations, such as all-ceramic bridgeframeworks and implant abutments.21-23 Thesurvival rates of zirconium oxide–based FDPs(up to four units) are promising. However, sig-nificant improvement in the veneering systemwith regard to long-term stability is required.14,24

Insufficient data are available regarding FDPscomposed of more than four functional units.Therefore, further randomized, controlled clin-ical trials are needed.24

Our case series demonstrated that virtuallyall types of fixed restorations—ranging fromveneers to bridges—can be accomplished withmodern all-ceramic systems. From an estheticpoint of view, a single veneering ceramic usedfor both glass- and zirconium oxide–basedframework types has been proven to be advantageous. ■

Disclosures. Dr. Edelhoff and Mr. Brix have received honorariafor educational programs and research funding for projects withIvoclar Vivadent, Amherst, N.Y.

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