Smiles June 08

All Part of the Dental Family What’s a Lab to Do? Veneers The Latest Trends

June 2008

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Smiles is the official journal of the Dental Laboratory Association of the State of New York

In this issue…

Executive Board and Staff President Gary Spadaro, Jr. Liberty Dental Laboratory 518-344-5372 Vice President, Education Technician Relations Raymond Rayeski, CDT Highland Acres Dental Labs Inc. Secretary Mark Viscusi Viscusi Dental Lab

Treasurer/Budget & Finance Norm Friedman, CDT Crown Dental Laborator

President’s Message

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What’s a Lab to Do?

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George Obst

Veneers The Latest Trends August Brugera, MDT

Smiles Technical Market

Congress Bill Baum, MDT, CDT Bill Baum Dental Studio Inc. Membership Gary Spadaro Sr. Liberty Dental Laboratory

Constitution and Bylaws Robert Iuliano Adirondack Dental Ceramics Head of Legislative Committee Kevin Crane, CDT Crane Dental Lab Membership & Congress Coordinator Michelle Milazzo

DLANY Smiles

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How to contact us

Smiles US Office: 1436 Altamont Ave Suite 199 Schenectady, NY 12303 Tel: 518-355-3183 & 1-877-DLANY65

Professional Relations Gail Broderick, MDT Jason Kim Dental Laboratory

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Fax: 1-877-352-6965 E-Mail: [email protected]

Canadian Office: Palmeri Publishing 35-145 Royal Crest Court, Markham, ON L3R 9Z4 Tel. 905-489-1970 Fax 905-489-1971 E-mail: [email protected]

Design & Layout: Samira Sedigh Web site: www.dlany.org E-mail: [email protected] Congress Information: [email protected] SMILES is published four times a year by Palmeri Publishing Inc. Known office of Publication, 2424 Niagara Falls Blvd. Niagara Falls, NY, 14304. Application to mail at Periodicals Postage Rates is pending at Niagara Falls, N.Y. 14304 U.S. Postmaster send address correction to Palmeri Publishing, Box 1068 Niagara Falls, N.Y. 14304.

Contributions from clinicians, lab owners, suppliers, readers, etc., are solely the opinion of the writers and do not constitute the endorsement of this publication or its staff. SMILES makes every effort to report clinical information and manufacturer’s product news accurately but cannot assume responsibility for the validity of product claims or for typographical errors. The publishers also do not assume responsibility for product names, claims, or statements made by advertisers.

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President’s Message

Gary J. Spadaro Jr.

All Part of the

Dental Family

T

he Dental Laboratory Association of the State of New York is proud and thrilled to announce that our current legislative efforts are finally producing results!

In recent meetings with Assembly Members from around New York State, we have laid the foundation for a legislative bill officially creating the title of Denturologist in New York State, which will include provisions for licensure. The legal language in the original draft of the statue has been refined to address issues raised by legislators, gaining bipartisan support in both houses of the New York State Legislature, and is now being officially sponsored by Assemblyman Steven Englebright. The next step in the legislative process is the assignment of a bill number. We continue being in constant communication with Assemblyman Englebright and his colleagues, and have requested specific and detailed information with regard to when this might occur. As the Assembly is near the end of its current legislative session, we hope to see our bill voted upon when they reconvene in the fall of this year.

This is to be considered a historic accomplishment; the significance and future ramifications of these developments cannot be overstated.

This is to be considered to be a historic accomplishment; the significance and future ramifications of these developments cannot be overstated. As Denturologists all know, regulatory efforts to standardize the dental lab industry are long overdue. Upon enactment of this statute, licensure of the Denturologist will demand that requirements designed to protect the dental prosthetics consumer are met and maintained. DLANY Committee members recommend and encourage all of the members of our profession to support this historic endeavour, as it will finally afford us meaningful status in a unique industry with growing demands for our products and services.

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DLANY Smiles

IECDT fuses the traditions and beauty of Hawaii to reflect old technology and new modern technical applications within the dental technical profession.

62nd Annual International Education Congress of Dental Technology The IECDT evolution continues in 2008 Tailored education to help achieve all your dental lab and technician goals

Friday and Saturday, September 19 – 20, 2008 NEW location: Hyatt Regency, 1800 East Putnam Ave, Old Greenwich, CT

“Ancient Wisdom, ModernApplications” 2008 Program to include: • George Obst • Dan Nathanson, DMD • Lee Culp, CDT • Romeo Pascetta, MDT ( Italy) • Francesco Ferretti, MDT (Italy) • Trevor Laingchild, RDT • Horst Koining, MDT (Austria) • and many more… Check the web for session updates

Over 110 commercial exhibits Over 1000 dental technicians in attendance Over 40 educational sessions Free Floor Passes

5 star resort hotel Minutes from Manhattan Bring your family; bring your lab for a getaway weekend of learning Parking and meals included Hawaiian Luau Cocktail Reception, Family Welcome.

For more information call 518-355-3183 or visit: www.dlany.org

Become a part of something beautiful.

What’s a Lab to Do?

C

hanges in dental laboratories are coming so swiftly and are so significant that it is difficult for dental laboratory owners, managers, technicians, customer service and sales staff to keep up to date. Most importantly, it’s most challenging to figure out what actions should be taken and when they should be made. You are undoubtedly aware of the biggest factors impacting dental laboratories today: • Automation • Worldwide competition • Double digit growth in implants • A surge in demand for cosmetic dentistry • New product introductions • Increased awareness and potential involvement by the FDA • Expanded use of high level magnification and illumination Although change is always with us, its current magnitude, speed, and depth are unlike what most of us have experienced in our lifetime. To deal effectively with these changes and keep our competitive edge we need to develop new skill-sets that will help us decide what actions to take. Some of these skills are described in a book entitled, Know-how: The Eight Skills That Separate People Who Perform From Those Who Don’t, by Ram Charan a gifted author and management consultant. This article highlights four skill-sets: • Pinpoint external changes • Position your laboratory • Set goals • Set laser sharp priorities One of the most important exercises for every dental laboratory is to pinpoint the external changes that affect the business. This involves keeping up on changes through reading dental publications and most importantly by talking to customers and finding out what’s on their minds. Yes, it’s also important to try and speak with customers you may have lost over the past 12 months. Detecting patterns of change early in the cycle of change will help put your laboratory or department on the offensive. Another skill that needs to be mastered is the idea of positioning or repositioning your laboratory or department. Once you have identified external changes you need to find and develop the ideas that will best meet customer demands. You have to decide how you will respond to each change. For example, with automation will you invest in equipment for your laboratory or out-source products to another laboratory where they can be made more efficiently with quality and service? With substantial growth in implants and cosmetic dentistry how will you position your laboratory? Will you develop and improve your expertise in these specialties? Thus, with each external change the objective is to evaluate what internal actions should be considered. A third skill-set, setting goals, needs to be mastered to 6

move your organization forward. What are the goals that best balance what your laboratory can become and what it can George Obst realistically achieve? Selecting the right set of goals and making them achievable is quite a challenge. Before goals are set a thorough analysis must be done to examine internal strengths and weaknesses. This should be coupled along with the external changes that are impacting the business. During periods of rapid change as we are experiencing today, the very nature and magnitude of your goals may need to be very different from traditional goal setting activities. To set and accomplish worthwhile goals, significant dialogue needs to take place between management and the staff, before goals are set and subsequent to goal setting. When goals are stated clearly and communicated effectively they have a powerful effect on people’s behavior and results. A fourth skill is setting laser sharp priorities. Priorities are the specific pathway for accomplishing the goals. They are the road map that organizes and directs the laboratory toward its goals. The right priorities, combined with relentless follow-up, keep the truly important things from being driven off the radar screen in the day-to-day work activity world where everything seems urgent and important. Priorities are the specific and most important actions that need to be taken to accomplish the goal. If the laboratory has a goal of growing 10% during the next year, management needs to articulate the “right” four or five priorities or action steps that must be taken to achieve the goal. Applying these skill-sets result in ownership and management taking new, different, intensive and specific actions to solve problems as opposed to continuing to talk about problems. More on these skill-sets in the next issue of Smiles.

George Obst will be a Key note speaker at the International Education Congress of Dental Technology with a presentation titled, "Shaping Pathways to the Future", to be held on September 19-20 2008. Take control of your future.....ponder the following questions and plan to attend if you are interested in your career success. • In one sentence describe the biggest problem you face in your lab, department, and or Job. • In one sentence describe and important change you made in the past year. • In one sentence describe a change you are considering making in the next 6 months. See you at the Congress.

DLANY Smiles

Veneers The Latest Trends August Brugera, MDT

hen discussing veneers, everyone understands that they are highly esthetic restorations. Ceramic veneers have become hugely popular in recent years and this is due, undoubtedly, to their excellent biochemical behavior and esthetics after bonding. With these traits and the minimal tooth preparation needed for success, it is no surprise that they are so popular. This article reviews the evolution of veneers and shows some first experiences with Empress Esthetic and e.max, new materials from Ivoclar.

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Advantages:

Conventional Veneers

Figure 1 shows how light transmits through a bonded metal free restoration. This feature is very important for successful integration. When restoring one translucent material with another, the final shade will be the sum of the shade of the natural tooth plus the shade of the veneer. This feature makes the laboratory technician’s work much easier. This would not be the case with a porcelain metal crown (Fig. 2). The metal core eliminates light transmission and requires a cumbersome layering technique to hide the substructure. To say that porcelain veneers are esthetically superior to metal-ceramic crowns is questionable, since comparable esthetics can be developed with both types of restorations. The main difference

For many years, teeth have been restored using the conventional refractory model technique. Without a doubt this technique has given, and does give great results. Yet, it still has its pros and cons:

Disadvantages: • Length of time needed to prepare models. • Slight loss of precision from duplicating methods. • Precision loss from using removable models. 8

• Develops a highly esthetic and very thin restoration. • Uses adhesive bonding technique. • Controls shade and opacity of the teeth depending on the needs of each case. • Causes little trauma to the natural tooth. • Controls final shade of the restoration well. • Bonds with excellent biochemical properties. • Highly translucent

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Fig.1: A translucent core always transmits light allowing better integration.

Fig.3: After the veneer on #7 is bonded, the crowns on #8, 9, 10 can be matched to it.

Fig.4: Bonded veneers and crowns. The diverse types of restorations are not an impediment to anterior integration and harmony.

Fig.2: A metal core eliminates light making integration more difficult.

Fig. 5a: The patient presented with moderate to heavy tetracycline discoloring.

between the two is the difficulty in obtaining a good esthetic result. In Figure 3, the patient had three old metal ceramic crowns removed from teeth # 8 and #9, and #10, and an old labial composite was removed from #7. Treatment consisted of a ceramic veneer on #7, two Empress II crowns, taking advantage of the excellent tooth color on #8 and #9, and a metal-ceramic crown on #10 to cover a pre-existing cast post and core. Figure 4 illustrates the fine esthetic result independent of the type of restoration used. Making the veneer was extremely simple compared to the effort involved in making the metalceramic crown. One of the advantages of veneers is the high translucency but this is a disadvantage when the teeth are severely discolored. Figure 5a depicts a woman who presented with tetracycline discoloring plus areas of severe color saturation that emerged during tooth preparation (Fig.5b). At first, it would seem too difficult to restore this case with veneers because they are so translucent. However, it can be accomplished successfully by increasing the opacity of the layering materials, thus neutralizing the internal discoloration. DLANY Smiles

Fig. 5b: The veneer preparations show severe internal discoloration that will have to be eliminated.

When dealing with slight discoloration, a small amount of opaque dentin added to the initial dentin layer would usually be sufficient. In this case, however, due to the intensity of the discoloration, a more opaque wash mixture of 75% dentin and 25% IO opaque (d. sign, Ivocalr Vivadent, Amherst, N.Y.) was needed (Figs. 6 and 7). This first layer completely neutralizes the discoloration of the preparation, and then the remaining contours are finished with a traditional layering of dentin and enamels (Fig. 8). 9

Fig.6: Applying a mixture of 25% IO and 75% dentin will eliminate the discoloration.

Fig.7: This mixture is applied as a wash without going all the way down to the end of the preparation.

Fig.8: Appearance with the bonded veneers.

Fig. 9: A natural appearance was obtained.

By neutralizing the discoloration found during preparation it is possible to obtain a result that is esthetic and well balanced with the patient’s appearance (Fig.9). One of the problems with traditional veneers on a refractory model is that it is impossible to perform a bisque bake try-in. This test can be essential when trying to restore anteriors where precise shade is extremely important. Figure 10 shows a patient who was not satisfied with the esthetics of tooth #9. The diagnosis and subsequent treatment plan called for this tooth to be veneered. Upon observation of the patient from a distance, however (Fig. 12a), it was apparent that both #8 and #9 lacked the prominence that the patient’s expression required. The labial volume and incisal length of both teeth needed to be increased to obtain greater morphological contrast. Therefore, it was decided to place veneers on teeth #8 and #9. Figure 11 shows 10

Fig. 10: The case before restoration.

the finished veneers before bonding. A second look at the patient from a distance shows how, with a very simple treatment, the shade defect on tooth #9 is corrected and how his overall appearance was improved (Figs. 12a-12d).

Veneers without Tooth Preparation Often, during a diagnostic wax-up, it becomes clear that the patient only needs some added structure in areas that does not require preparation of the natural tooth (Figs. 13a &b). Often these cases can be treated with direct composite reconstructions. However, another excellent choice is to bond indirect porcelain veneers onto the unprepared teeth. Figures 14a-g show a typical anterior tooth fracture. However, this fracture was repaired without preparing the entire tooth. Instead, the clinician prepared a slight bevel on DLANY Smiles

Fig. 11: The veneers with Ivoclar Try-in.

Fig. 12a: The two centrals lack harmony with the patient’s expression.

Fig. 12c: Unbalanced

the border of the fracture to obtain a better esthetic transition and greater support. To mimic the natural enamel, this zone must be constructed with pure transparent opalescence (E1,d.sign). The shade is then obtained from the natural tooth to avoid undesirable chromatic contrasts. In this case, a mini veneer with little preparation was a good esthetic solution and less traumatic. Figures 15a-c illustrates a patient with composite restorations on the facial of the two central incisors. Perhaps the specialist who performed the restorations tried to give greater labial contour and incisal length to the central incisors. However, after a few years the patient no longer liked the shade. In this case, two veneers were constructed without tooth preparation. To do this, the clinician removed the composites, polished the enamel surface, and took an impression. 12

Fig. 12b: Now the centrals are more prominent and follow the lower lip line.

Fig. 12d: Balanced

The patient’s natural tooth shade must be acceptable when making a veneer without tooth preparation, because the veneer material will be too thin to make any major chromatic changes. The transparency of the veneer allows the natural tooth to provide the desired hue, chroma and value of the final restoration (Figs. 16-19). If needed, the value and translucency of the tooth could be manipulated slightly, however, the ability to manipulate shade in very thin veneers is certainly limited. The restorations are layered with an enamel shade that is closest to that of the patient’s (in this case TS1, d.sign, Ivoclar Vivadent). The final veneers are extremely thin (Fig. 20). Figures 21 and 22 show how these restorations integrate before bonding and after bonding and final polish (Fig. 23). The long-term prognosis for the treatment is good because porcelain restorations do not change shade or morphology over time. The supragingival preparation on these restorations ensures DLANY Smiles

Fig 13a: Before the diagnostic wax-up is finished, it is impossible to know the treatment plan.

Fig. 13b: The diagnostic wax-up shows what to restore and what type of restoration is most indicated.

Fig. 14a: Patient presents with a typical impact fracture.

Fig. 14b: During preparation, the tooth is slightly beveled, giving more support to the veneer and favoring integration.

Fig. 14c: The position of the veneer…

Fig. 14d: …Increases the illusion.

Fig. 14e: With the veneer almost in place, integration already becomes evident.

Fig. 14f: Shade try-in

Fig. 14g: The bonded and polished veneer in place. (Clinical case Dr. Erika Tellez, Barcelona).

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that the patient will enjoy impeccable hygiene and otherwise good periodontal health.

Empress Esthetic One of the most difficult applications of the veneer technique occurs when only one central incisor is restored. As mentioned above, it is not possible to perform a bisque-bake try-in with the refractory model technique and this makes it very difficult to achieve error free tooth integration on the first attempt. For this type of restoration, the new Empress Esthetic system (Ivoclar Vivadent, Amherst, N.Y.) is very helpful.

This system employs the lost wax technique without duplicate models or refractory material. The patient in Figure 24 had a fracture of the incisal edge and the clinician made a direct provisional with composite on tooth #9. An Empress Esthetic veneer was chosen to restore this tooth. The first thing that we must determine is the appropriate shade of the pressing ingot. The ingot must be very similar in shade to the adjacent tooth. Using the shade guide, look for the shaded ingot that appears closest in hue, chroma, value and very importantly translucence. Once we know the shade of the pressed ingot, the porcelain layering can be mapped out.

Fig. 15a-c: Typical case where the labial of the central incisors lack sufficient contour.

Fig.16: When restoring a tooth without preparation…

Fig. 17: … there must be an adequate basic shade...

Fig. 19: A veneer without preparation on a lateral during a shade try-in (clinical case Dr. Erika Tellez, Barcelona). Fig. 18: … because the natural tooth provides the shade.

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Fig. 20: Veneers without preparation can be very thin, from 0.1-0.2mm

Figs. 21 and 22. Veneers from the case in Fig. 15 at the shade try-in.

Fig. 23. Bonded veneers (Clinical case Dr. Erika Tellez, Barcelona)

First, a full contour wax-up of the crown is achieved; this is similar to the technique required with Empress II (Figs. 25-28). The wax-up is then reduced in the incisal areas to allow for future enamel layering (Figs. 29a and 30). The resulting dentin core is then pressed using the previously selected shaded ingot. Observation of the Empress Esthetic core under transmitted light ( Fig. 31) illustrates that the translucency of the material is

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very similar to Empress II. However with the Empress Esthetic system a wide range of shaded ingots are available. The porcelain layering begins by reproducing some of the shade characteristics with internal stains. (Figs. 32-33). The second phase involves the conventional layering of enamels and translucencies to finalize the incisal characteristics and overall tooth form.

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Fig. 24: Direct composite provisional

Fig. 25: View of the preparation on the working model.

Fig.26: Occlusal view

Fig. 27: Full wax-up of the veneer.

Fig. 28: Occlusal view of the full wax-up

After-firing, a bisque try-in is made with Variolink II Try-in paste (Ivoclar Vivadent) in order to examine the future shade after bonding (Fig. 34). Try-in is an ideal bonding simulator to test the effect on the final shade (Figs. 35-38). If everything is correct, mechanical surface finishing can proceed to see the result of the finished veneer (Fig. 39).

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Figures 40 and 41 show another example of a veneer on a central incisor restored with Ivoclar's Empress Esthetic system. The ability to perform a bisque try-in of the veneer is very helpful, since it allows for direct evaluation in the patient's mouth and subsequent firings if necessary, something that is impossible with conventional veneer systems. Empress Esthetic is also a good material for anterior restorations where crowns

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Fig. 29: Reduction of the incisal area.

Fig. 30: Occlusal view of the reduction. Fig. 31: The Esthetic is very translucent which favors veneer integration.

"The porcelain layering begins by reproducing some of the shade characteristics with internal stains."

Fig. 32: The Esthetic core has been checked and is ready for stain application.

Fig. 33: The stains will be applied internally to reproduce shade characteristics.

Fig. 34: Empress Esthetic allows a bisque-bake try-in and subsequent corrections without undergoing any distortion from the process.

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DLANY Smiles

Fig. 35: Ivoclar Try-in allows testing before bonding to see what shade is the most appropriate.

Fig. 36: The shade of the preparation before try-in.

Fig. 37: The veneers positioned without try-in. (Clinical Case Dr. Sydney Kina, Maringa- Brasil)

Fig. 38: Try-in allows us to individually select the appropriate bonding material for each veneer.

Fig. 39: The veneer from Fig. 34 already bonded and finished.

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Fig. 40: Another case with a typical impact fracture.

Fig. 41: No. 8 is restored with an Empress Esthetic veneer. (Clinical Case Dr. Erica Tellez Barcelona, Spain)

Fig. 42: This patient will be rehabilitated with....

Fig. 43: .... Empress Esthetic veneers on 5, 6 & 7.

Fig. 44: Empress Esthetic veneer on 10. Ceramo-metal crown on implant on 11, metal-ceramic on 12.

Fig. 45: The two centrals are restored with e.max press crowns from Ivoclar Vivadent.

and veneers must be combined. Since it is possible to perform an esthetic evaluation, Empress Esthetic simplifies shade matching, from one tooth to another. In this last case, teeth #5 through #12 were restored. Empress Esthetic veneers were chosen for # 5,6,7,and 10. The central incisors were restored using Ivoclar Vivadent's pressed ceramic material e.max. Metal-ceramic crowns were fabricated for #12 and the implant abutment at #11. Figure 42 shows the initial situation. Figure 20

43 and 44 show the bonded Empress Esthetic veneers and the implant supported crown on #11. The two e.max crowns are not bonded yet. If the bisque try-in is done with the two e.max crowns next to the previously bonded veneers, it is much simpler to integrate them, since the veneers already exhibit their final shade. Figure 45 shows the two finished crowns in the shade try-in. The finished restoration is seen in Fig. 46. DLANY Smiles

Fig. 46: The integration of the diverse materials utilized is very acceptable. (Clinical case Dr. Monica Vicario, Dr. Oriol Llena and Dr.Jaime Llena, Stoma Clinic, Barcelona.)

Conclusion Treatment with bonded veneers has been hotly debated in recent history, but today the biomechanical and esthetic excellence has been clearly demonstrated and justified. For the laboratory, this type of treatment is really simple and predictable. Working with the lost wax technique considerably reduces the preparation time in the laboratory, while it allows as many bisque firing tests as necessary before finishing the veneers. Without a doubt Empress Esthetic was the right choice.

• Prof. Urs Belser. Quintessence book 2003. • Shadows, a World of Shades, August Bruguera, Teamwork 2003. • Clinical and Laboratory Aspects in Preparing Porcelain Veneers: science and practice.Inaki Gamborena- Maxilares 2002. • Ultra– conservatively Esthetic Veneers, Alejandro James, Eladio Gonzales, Inaki Gamborena, Dental Dialogue Spain 4, 2004. • Esthetics of Anterior Fixed Prosthodontics, G. Chiche, A Pinault, Quintessence 1994.

Appreciation

Smiles Product List I would like to thank Dr. Erika Tellez ( Barcelona, Spain), Dr. Monica Vicario ( Barcelona Spain), Dr. Sydney Kina ( Maringa Brazxil), Dr. Oriol Llena and Dr. Jamie Llena (Stoma Clinic Barcelona, Spain) for their invaluable collaboration on the clinical cases.

Bibliography

Indication Befestigungskomposite Farbsimulation Verblendkeramik Vollkeramiksystem

Name Variolink II Variolink II Try-In IPS d.SIGN IPS Empress Esthetic IPS Empress 2 IPS e.max PRESS IPS e.max Ceram

Manufacturer/ Distributor Ivoclar Vivadent Ivoclar Vivadent Ivoclar Vivadent Ivoclar Vivadent

• Bonded porcelain restorations in the anterior definition, Pascal Magne.

About the author August Brugera, is author of several articles published in national and international magazines. Author of the book "Shadows a World of Shades" Lectures at courses and conferences in national and international conventions. Consulting member of the US magazine Signature International; Former professor of the Dr. Thomas Escuin Postgraduate School of the University of Barcelona, Golden Scapel award 2003. Contact: August Bruguera, Disseny Dental ben. e-mail: [email protected]

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