The Journal of Cosmetic Dentistry

Fall 2007 Volume 23 Number 3

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Predictably Exceeding Patients
Expectations Using Pressed Ceramics
by
Brad Jones
Boise, ID
www.secondonlytonature.com
INTRODUCTION
This patient presented Dr. Jeffrey Burns and me with a perfect scenario for
instant orthodontics. Not only were the patients teeth far from being in per-
fect arch form, but they also were discolored and broken. The patient was not
willing to accept orthodontic treatment and, even if he had been, he would
still ultimately need veneers and years of retainers. This article presents a step-
by-step technique that will give the patient a predictable result.
I believe it is of great importance to utilize the patients own preparation
shade to inuence the nal restoration whenever possible.
CASE OBJECTIVES
The rst and most important objective for this case was to straighten teeth
##611 without orthodontics. The second was to ll out the buccal corridors.
The third objective was to brighten the patients smile (Figs 1-4).
NECESSARY TOOLS
I always start by requiring all the tools necessary to complete the case. This
begins with a diagnostic wax-up, which will be evaluated from the photographs
of the patients smile in the form of a provisional. I require a complete labora-
tory esthetic prescription, which includes the goals of the nal case; a checklist
of the items included with the case; teeth to be restored; type of restoration
desired; preparation shade; detailed shade mapping; type of light source used
to take the shade; shape desired; crown lengths (centrals, laterals, canines);
the amount and color of incisal translucency; surface texture; and any other
essential miscellaneous information (Figs 5 & 6).
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The items that must be included
with the case are as follows:
one or more master impressions
opposing impression
preoperative models
diagnostic wax-up
bite records
transfer jig
model or impression of the
approved provisionals
matrix for determining the
buccal-lingual position
of the centrals.
Equally important are these
items:
photographs of the preoperative
smile (the standard 12 AACD
views)
eyebrow-to-chin photos of stick-
bite
eyebrow-to-chin photos of the
natural smile with approved
provisionals (taken a couple of
days after the preparation ap-
pointment).
I use the Giroform System
(Amann Girrbach; Koblach, Austria)
plate and pins.
WAXING AND PRESSING
A silicone putty matrix was
formed over the model of the pro-
visional (a few modications were
made to improve symmetry between
the two centrals, even out the lengths
of the laterals, and perfect the buc-
cal corridors) and quickly placed
in a pressure chamber at 60 psi for
perfect adaptation. This matrix was
then used as a mold to inject wax
over the lubricated dies. This injec-
tion process perfectly reproduced
the patients provisionals (including
JONES
Figure 1: Full-face smile, preoperative. Figure 2: Retracted view, preoperative.
Figure 3: Natural smile, preoperative. Figure 4: Retracted view, preoperative.
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the minor improvements) on the
working model.
MATERIALS SELECTION
In nature we nd that centrals
are predominantly higher in value,
laterals lower in value, and canines
more chromatic and less translu-
cent.
1
Typically, if a doctor gives me
a Chromascop (Ivoclar Vivadent;
Amherst, NY) shade of 040, I will
use this shade for the laterals and
bicuspids. I generally go one shade
lighter, 030 in this case, for the cen-
trals; and one shade in the opposite
direction for the canines (such as
110 or Vita B1 [Vident, Brea, CA].)
In selecting a ceramic material I rst
look at the color of the preparations.
This patient had perfectly light-col-
ored stumps to work with (stump
shade 9).
Commonly, preparations are
naturally orange-pink in the cervi-
cal, khaki-colored in the gingival
interproximals, and sometimes
slightly translucent at the incisal tip.
I believe it is of great importance to
utilize the patients own preparation
shade to inuence the nal restora-
tion whenever possible. This allows
the cervical of the restoration to in-
tegrate seamlessly into the gingival
tissue.
I prefer Authentic pressable ce-
ramic (Jensen Industries; North
Haven, CT). This system has ingots
available in all the different shades
in three different values (a ++ is
an ingot equivalent to an opacious
dentin, a + ingot is equivalent to a
dentin material, and an ingot with-
out a + is equivalent to an enam-
el). For any given shade, there is an
appropriate ingot based on tooth
reduction.
For instance, if I were to make
a veneer for a minimally reduced
tooth (.5 mm) I would select an in-
got without a + because we are just
replacing enamel. For a 1-mm re-
duction veneer, three-quarter crown,
or even a full all-porcelain crown
I would select an ingot with a +.
Lastly, if we were taking off an old
porcelain-fused-to-metal restoration
(particularly if we are dealing with
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Figure 5: Detailed esthetic prescription (front). Figure 6: Detailed esthetic prescription (back).
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Figure 7: Horizontal plane guide reference. Figure 8: Preparation shade.
Figure 9: Wax-up. Figure 10: Pressed units tted to dies.
some dark dentin), I would select a
++ ingot.
There are patients who will auto-
matically choose the whitest shade
available simply because it is the
whitest, with no regard for how un-
realistic it will look in their mouth.
We, as experienced clinicians and
technicians, should be responsible
for showing the patient the shades
available for their particular age and
complexion.
In this case, my target shade was
a more natural-appearing (slightly
more translucent) 030 for the cen-
trals, a more translucent version of
040 for the laterals and premolars,
and an A1 cervical and B1 body for
the canines. I wanted the canine to
be denser (less translucent) in ap-
pearance.
I selected a B00+ (medium value
020 in color) ingot for the incisors,
a B0 (lower value B1 in color) ingot
for the laterals and pre-molars, and a
B1+ (more chromatic and less trans-
lucent) ingot for the canines. This
sets up the case to have a natural
scenario even before I begin cutting
back and layering. This color and
value shift is subtle and emulates
nature (Figs 9-11).
CUTBACK AND LAYERING
After divesting and tting each
unit, I was ready to do my typical
cutback. This started with a mini-
mal .3-mm vertical reduction (Fig
12). I outlined the perimeter of this
reduced area with a red pencil and
drew a line .5 mm in from the facial
edge using an extra-ne pencil (Fig
13). Then I beveled back the incisal
edge halfway down the facial using a
contouring stone (Komet; Rock Hill,
SC).
I cut in a straight groove in the
mesial-incisal edge and then a
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Figure 11: Preoperative model, occlusal view. Figure 12: Pressings on dies, occlusal view.
Figure 13: Minimal .3-mm vertical reduction. Figure 14: .5-mm incisal facial bevel.
Figure 15: Softening sharp cuts. Figure 16: Cutback in matrix.
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Figure 17: Blue-gray stain in grooves, orange-pink between lobe
details.
Figure 18: Powder effects.
Figure 19: Powder effects after ring. Figure 20: Opal lled to full contour.
curved groove in the distal-incisal
using a knife-edge contour stone
(Komet) (Fig 14). These grooves, or
troughs, will hold both gray-blue
stain and porcelain. I then carefully
cut in the internal lobe formations
with a fresh double-sided diamond
disk (Komet).
Then I used a tapered ame
diamond (Komet) to soften the
mechanical-looking cuts. Lastly, I
checked the cutback in the matrix
before staining (Figs 15 & 16).
STAINING AND EFFECTS POWDER
Using a low-fusing color stain,
I detailed the gingival interproxi-
mals, and lightly stained the out-
ermost mesio-incisal and disto-
incisal edges with a gray-blue stain.
I used a hairline brush to apply an
orange-pink highlight to a sliver de-
tail that I cut in between the mesial
and middle lobe with the diamond
disk (Fig 17).
Because the stain I used was a
paste, I was able to place my effect
powders in the same bake. I placed
the Authentic effect powder over the
core lobe detail, using mostly Pearl
(white dentin) with a thin segment
of Orange-Flour (color tag blue)
over the middle lobe. Then I used
the same Pearl powder to create a
high-value lter band through the
middle incisal of the tooth, which I
brushed out in both directions, in-
cisally and cervically (Fig 18).
When baking Authentic in the
porcelain furnace, it is essential to
work with an oven that is well cali-
brated. The fusing temperature of
the Authentic powders is 765 Cel-
sius. After staining and building up
the effect powders, I baked the resto-
ration under full vacuum at a rate of
climb of 60 degrees a minute, and a
one-minute high temperature hold
without vacuum (Fig 19).
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Figure 21: Bisque bake. Figure 22: Pre-glaze, texture, and polish.
Figure 23: Glazed and polished. Figure 24: Natural smile, postoperative.
Figure 25: Lateral view, postoperative. Figure 26: Retracted view, postoperative.
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OPAL POWDERS FILLED TO CONTOUR
After evaluating the effects, in-
cluding the high-value lter band, I
was ready to ll in the mesio-incisal
and disto-incisal edge grooves and
build them to full contour using
Opal 3, a low value opal, (color tag
blue) powder. Between the lobes I
used Opal 2 powder (color tag yel-
low). The Opal 2 is a medium-low
value powder and contrasts well
with the effects (Fig 20).
After using the same ring cycle,
I was able to evaluate my bisque
bake (Fig 21).
GENERAL INFORMATION
This cutback and layering tech-
nique is the basis for almost ev-
ery case I do. The internal dentin
lobe formations and staining and
powder effects can vary to achieve
different results. The Pearl high-
value lter band gives the ceramist
complete control over the value of
the restoration.
FINAL GLAZE
I nalized the shapes and con-
tours, paying close attention to the
reective and deective zones. Then
I added back in the surface texture
and lobe formations. After I rubber-
wheeled the surface (Komet), I cut
in the perikymata with a pointed
ame diamond (Komet). Finally, I
brushed on a thin, consistent layer
of Pulse (Jensen) uorescent glaze
paste to the restorations and then
air-red them at 765 Celsius with a
one-minute high temperature hold.
(To make the surface reection ap-
pear natural, I rst take down the
highly glazed restoration with the
knife-edge rubber wheel.) Lastly, I
used a large felt wheel and diamond
paste to bring up the luster on the
heights of the lobes (Fig 23).
SUMMARY
Using Authentic pressable ceram-
ic, I was able to achieve the objec-
tives of the clinician and the patient,
while satisfying my own objective of
making this case appear natural in
the mouth (Figs 24-26).
Reference
1. Ubassy G. Analysis: The New Way in Den-
tal Communications. Brescia, Italy; Editrice
MEA; 1999.
______________________
v
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Figure 27: Full-face view, preoperative and postoperative.