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Reproducing Optical Properties of AnteriorTeeth after Ultra-Conservative Preparation VICTOR CLAVIJO, DDS, MS, Phd*, LEONARDO BOCABELLA, CDT†, LUISA SCHERTEL CASSIANO, DDS, MS‡, SILLAS DUARTE JR, DD, MS, PhD§ ABSTRACT Objective: Selecting the appropriatematerial is essentialwhenrestoringcolor and appearance of esthetically compromised anterior teeth. Clinical considerations: Mostofthe conventionalrestorative techniquesrequire toothreduction in order tomimicoptical properties of a natural tooth.Fortunately, bonding techniques associatedwith improvements on dental ceramics esthetics allow forhighlyconservative treatmentoptions inwhichmaximumpreservation of dental tissues canbe attained.An analysis of differentceramicmaterials available and differenttypes oftooth preparation is presented in a formatof a decisiontree for treatmentplanning. Conclusions: The suggested decision-makingaims to facilitate clinicians’selection ofthemost appropriate restorative technique for reproducingcolor and appearance of anterior teeth after ultra-conservative preparation and according to differentclinical scenarios CLINICAL SIGNIFICANCE The selection ofthe appropriate ceramicmaterial foreachcase is ofmajor importance, since the entire treatmentplan willbe determinedbasedonthe type ofceramicmaterial thatwillbe used for the f|nalrestoration.Eachrestorative materialhas a specif|c toothpreparationrequirement, indications, andlimitations that shallberespected formaximum estheticaloutcomes. (JEsthet Restor Dent 28:267^276, 2016) INTRODUCTION Mastering the concepts of optical properties, form, and function are important in reproducing the natural tooth structure adequately with dental materials.1,2 Esthetic restorative materials and more conservative tooth preparation methods are constantly being developed with the goal to simplify the daily practice.3 When preparation techniques that aim to preserve enamel are used, it has been documented that a higher success rate can be expected for bonded porcelain veneers.4 However, the optical properties and overall esthetic outcome is directly dependent upon the amount of remaining tooth structure as well as the appropriate restorative material selection.1–3,5–7 Thus, it is important to carefully analyze each clinical situation and to evaluate which is the most adequate treatment option prior to treatment. *Visiting Professor, Advanced Program in Operative and Adhesive Dentistry, Division of Restorative Sciences, Herman Ostrow School of Dentistry,University of Southern California, Los Angeles,California,USA �Dental Technician,Campinas, SP, Brazil `Private Practice, Brasilia, DF, Brazil ‰Associate Professorand Chair, Division of Restorative Sciences, Director, Advanced Program in Operative and Adhesive Dentistry, Herman Ostrow School of Dentistry,University of Southern California, Los Angeles,California,USA Journal of Esthetic and Restorative Dentistry Vol 28 � No 5 � 267^276 � 2016VC 2016 Wiley Periodicals, Inc. DOI 10.1111/jerd.12266 267 CLINICAL ARTICLE Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 The most challenging situation for anterior bonded porcelain veneers is regarding the material selection when missing tooth structure is presented. Fractured tooth, diastema, caries with dentin exposure, and space discrepancies between teeth are some examples of clinical scenarios in which the material selection and the restorative technique become highly important in order to mimic the optical properties of different dental structures.5,8 Composite resins, feldspathic porcelain, leucite-reinforced glass-ceramic, lithium disilicate glass-ceramic, zirconia-reinforced lithium monosilicate glass-ceramics are few examples of materials that can be used for esthetic rehabilitation using conservative bonding techniques. However, the restored areas where dental structure is missing may pose a challenge for the clinician when compared to the restored areas supported by remaining dental structure. Providing the dental technicians with more space for ceramic layering through tooth preparation may overcome this deficiency. However, it may not necessarily solve the problem, in fact, it would create another problem on bonding exposed dentin that can negatively affect the longevity of the restoration.9 The material selection for conservative esthetic restorations is not a straightforward decision. Thus, one of the biggest challenge is how to perfectly reproduce the natural teeth characteristics while simultaneously preserving pristine dental structures. The aim of this article is to reflect on the decision- making process of how to reproduce the optical properties of natural tooth while maintaining the integrity of the tooth by using a conservative dental preparation approach, assuming that the shade of the remaining dental tissues is favorable. FUNCTIONAL ESTHETIC REHABILITATION OF FRACTURED TEETH A 28-year-old woman presented at the office for regular maintenance appointment. It was noticed that the anterior teeth presented a peculiar anatomy, so photographs (Figure 1a,b) were taken to keep a digital record of her natural teeth. After 16 months, the patient returned to the office presenting both #8 and #9 fractured (Figure 2a) due to a motorcycle accident. Clinical and radiographic examinations were performed together with percussion and thermal tests, and the teeth were also checked for mobility. The teeth presented no mobility, but it was detected the need of endodontic treatment (Figure 2b) in both teeth due to pulpal necrosis. Intra-radicular posts were not indicated because there was sufficient remaining coronal structure and the endodontic access opening was minimal, so only the filling with composite was performed. The previous photos taken before the teeth were fractured were used to aid the treatment planning. As there was no reference of the actual height of the teeth, the width of the remaining crowns was measured and, in association with the previous photos and the models, it was possible to use the concepts of the Digital Smile FIGURE 1. a, Preoperative view of intact maxillary anterior teeth before the patient was involved in a motorcycle accident. b, Observe the exquisite optical properties of the maxillary anterior teeth. FIGURE 2. Fracture maxillary central incisors from the same patient teeth on Figure 1. RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Vol 28 � No 5 � 267^276 � 2016 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12266 VC 2016 Wiley Periodicals, Inc.268 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 Design (DSD)10 to determine the height of �10 mm of the fractured teeth. Based on that measurement, the diagnostic wax-up (Figure 3) was performed. Before performing the teeth preparation, photos were taken to provide a more accurate reference for the color selection, since the photos were taken before teeth dehydration. MINIMALLY INVASIVE ULTRA- CONSERVATIVE ADHESIVE TOOTH PREPARATION Material selection and tooth preservation not necessarily have a reciprocal relationship. Tooth reduction, as advocated by different types of ceramics, may lead to complete eradication of gingival enamel leaving the margins on dentin. The long-term clinical success of bonded porcelain veneers is highly dependent on the quality and amount of enamel for bonding.4 Therefore, the need for tooth preparation should be carefully evaluated and conservative techniques such as ameloplasty, enamel recontouring, or minimally invasive ultra-conservative enamel preparation were highly selected as the first options for treatment.3 Table 1 depicts a decision-making process used to define the most appropriate restorative approach. In the present case, the teeth were then meticulously and minimally prepared bucal-lingually, without FIGURE 3. Diagnostic wax-up based on the initial anatomical features.DSD was used to determine the original width/length ratio of the teeth before fracture. TABLE 1. Decision-making process when restoring anterior tooth using ultra-conservative tooth preparation RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Journal of Esthetic and Restorative Dentistry Vol 28 � No 5 � 267^276 � 2016VC 2016 Wiley Periodicals, Inc. DOI 10.1111/jerd.12266 269 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 breaking into the contact points, aiming for a 0.3 mm chamfer margin (Figure 4a–d).7 A 0.3-mm ultra- conservative tooth preparation allowed adequate enamel preservation, appropriate path of insertion for the restoration as well as space for the dental ceramist to restore the optical characteristics of the two central incisors. Thus, the characteristics of the preparation were crucial for the selection of the restorative material. An ultra-conservative preparation, averaging maximum of 0.3 mm in thickness, can provide the ceramist with a reduced space for working. In such minimal space, zirconia-based materials may not be the material of choice because of limitation on milling to its proper thickness and the lack of appropriate bonding effectiveness.11 Thus, etchable ceramics or composites should be the materials of choice for minimally invasive ultra-conservative tooth preparations. After the preparations were performed, photographs (Figure 5) were taken to provide the ceramist with a reference for the color of the teeth abutments. An impression was taken using double cord and two-step technique. After taking the impression, the provisionals were made. A discussion among the restorative team was then made to select the appropriate material following the decision-making guidelines described in Table 1. FIGURE 4. a, An ultra-conservative 0.3 mm reduction full- veneer preparation was selected. Determination of the marginal finishing chamfer with a round diamond bur (801.314.016, Komet, USA) and 0.3 mm depth grooves were created to ensure maximum preservation of enamel using the following formula: C 5 (BD 2 SD)/2 where, C 5 chamfer, BD 5 bur diameter, and SD5 shank diameter. b, After creating the depth grooves to guide the ultra-conservative preparation, the full-veneer preparation was carefully completed using a round end cylindrical diamond bur (8881.314.012, Komet, USA) to ensure 0.3 mm overall enamel reduction and preservation of gingival enamel. c, The preparation was finishing using finishing carbide burs (H375R.314.012, Komet, USA) at 4000 rpm. d, Evaluation of minimal enamel reduction with a periodontal probe. FIGURE 5. Shade selection of the abutment and adjacent teeth was performed before and after tooth preparation. RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Vol 28 � No 5 � 267^276 � 2016 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12266 VC 2016 Wiley Periodicals, Inc.270 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 REPRODUCING OPTICAL PROPERTIES IN ULTRA-CONSERVATIVE PORCELAIN VENEERS The models were made following the Geller Model technique and the refractory dies were created. The ceramic application was guided using a silicone guide as a reference for the orientation of the height of the restorations. A decision was made to use layered feldsphatic porcelain to restore dentin chromaticity, and translucency and value of natural enamel. An opaque dentin (Figure 6a–c) was applied to reestablish missing dentin structure in the middle and incisal thirds of the restoration. The stratification using the dentin body powder (Figure 7a) was performed in the middle and incisal thirds. Importantly, dentin porcelain was not used at the cervical third of the veneers, since this area exhibited appropriate chroma and value to impart a natural optical outcome. Cut back (Figure 7b) was performed using burs to reproduce the mammelons and to create space for the incisal characterization. The FIGURE 6. a, Fabrication of a layered feldsphatic full-veneer in refractory die: Application of an opaque dentin powder. b, Feldsphatic ceramic opaque dentin layer immediately after crystallization. c, The opacity of the ceramic opaque dentin layer visualized through a transmitted light. FIGURE 7. a, Application of a body dentin layer at middle and incisal thirds. b, Cutback of the dentin body layer to create the mammelons. FIGURE 8. a, Application of opalescent and mammelons effects in the incisal third to reproduce the incisal edge optical properties. b, Opalescence of the incisal third visualized through transmitted light. RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Journal of Esthetic and Restorative Dentistry Vol 28 � No 5 � 267^276 � 2016VC 2016 Wiley Periodicals, Inc. DOI 10.1111/jerd.12266 271 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 transition area between the enamel and dentin was performed with incisal effects and the opalescent layer at the incisal edge was reproduced using a ceramic powder with opalescent effect. The mammelons were then covered with an enamel powder with an orange effect and the connection between the mammelons and the incisal edge was reproduced with mammelons effects (Figure 8a), the last layer applied, over the dentin and the previous effect layers, was a translucent and opalescent enamel powders (Figure 8b). The cervical third was covered only with an enamel powder with pink undertone to reproduce the interaction between the natural teeth and the gingival tissue. No dentin powder was applied to the cervical third, once this area had a favorable chroma and opacity. Thus, the enamel ceramic powder was used to recreate value and translucency. FIGURE 10. a, Correction of the reflection areas. b, Confection of the primary and secondary anatomy using diamond burs. c, Finishing with appropriate ceramic burs. d, After glaze, polishing was manually performed with diamond paste and polishing discs. FIGURE 9. a, Application of translucent enamel powder. b, Confection of the maxillary central incisor morphology. FIGURE 11. a, Morphological characteristics reproduced as they were found in the natural teeth (compare with Figure 1a). b, Translucency, opalescence, and opacity were individualized using feldspathic ceramic over refractory die. FIGURE 12. Veneers were bonded under rubber dam, resin excesses were removed with scapel 12, and the final polishing is performed. RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Vol 28 � No 5 � 267^276 � 2016 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12266 VC 2016 Wiley Periodicals, Inc.272 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 Transmitted light (Figure 8c) was used to verify the correct position of the ceramic layers in the means of translucency and opacity, after the first bake. The palatal guide was placed to check the height. Internal staining was then performed to reproduce the small horizontal striaes and to evidence the mammelons. A transmitted light was used again to check the opalescence effect. Before performing the second bake, a neutral value enamel layer was confectioned aiming to reproduce the final morphology (Figure 9a,b). To reproduce the opaque halo in the incisal edge, an opaque powder was applied in the incisal-palatal region. The second bake was then performed. The areas of light reflection were then evidenced and corrected (Figure 10a). Diamond burs (Figure 10b) were used to create the primary and secondary anatomy. Finishing strips (Figure 10c) were used for the finishing and polishing. Functional occlusal adjustments were made using an articulator. The final glaze was then performed. For the final polishing, a diamond paste was applied and manually polished with ceramic polishing discs (Figure10d). FIGURE 13. a, Final outcome of the bonded full-veneer restorations. b, Close up of the restorations. c, Aspect of the restorations under transmitted light. Note the translucence, opalescence and opacity effects created and the integration thanks to bonded technique. d, Distal view of the restorations. e, Note soft tissue response and the morphology created. RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Journal of Esthetic and Restorative Dentistry Vol 28 � No 5 � 267^276 � 2016VC 2016 Wiley Periodicals, Inc. DOI 10.1111/jerd.12266 273 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 The final result (Figure 13a–d) shows that is possible to achieve an acceptable esthetic result using the feldspathic ceramic over a refractory model. ADHESIVE BONDING TECHNIQUE The ceramic restorations (Figure 11a,b) were tried-in and some minor adjustments at the contact points had to be performed. The layered feldspathic porcelain veneers were etched following the manufacturer recommendations: 9% hydrofluoric acid for 90 seconds; cleansing at the ultrasonic cleaner with alcohol for 5 minutes; application of a thin layer of silane and waiting for 60 seconds; application of a thin layer of adhesive and air-thinned and left uncured. The teeth were isolated with rubber dam. The remaining dental structures were roughened using aluminum oxide jet with 50 mm size particles (bar). Then the teeth were etched using phosphoric acid at 37% for 30 seconds in enamel and for 15 seconds in dentin. A universal adhesive system was applied actively with a micro-brush for 20 seconds and then air-thinned. The adhesive was left uncured. A light curing resin cement was inserted into the intaglio of the restorations, placed into the correct position, and the cement excess carefully removed using a fine sable brush. The restorations were light- cured for 40 seconds on each tooth side (lingual and buccal). The remaining cement excess was removed using a 12D blade. The polishing of the margins (Figure 12) was performed with ceramic diamond points and polishing inter-proximal strips. The final outcome (Figure 13a,b) showed that it is possible to achieve a natural esthetic result using the feldspathic ceramic over a refractory model. DISCUSSION The selection of the restorative approach is of paramount importance for long-term success of treatment planning proposed and execution of the case. The method of delivery of the restoration (adhesive or cemented) and type of ceramic guide the tooth preservation and preparation. The latter must be clearly observed to establish the ideal space for the ceramist to be able to create the restoration, reproducing the characteristics of natural teeth and obtaining satisfactory esthetic outcome. Maximum preservation of enamel is essential for long- term success of bonded restorations. Techniques such as direct composite restorations, partial bonded veneers, bonded porcelain veneers, or full veneers are preferable than conventional crown preparations since these aforementioned techniques are highly conservative. 3,12–14 Different restorative materials result in differences on optical properties. Composite resin restoration may be employed for anterior teeth esthetic rehabilitation; but, in order to restore translucency, chroma, and value, composite stratification techniques should be used. Unfortunately, layered composite restorations are time consuming and the clinicians, as well as patients, should be aware of the limitations encountering with composite stratification techniques as well as their longevity.15 Conversely, the costs for direct composite restorations are usually lower than that of indirect restorative procedures and easier to color match. Ceramics are also appropriate materials to esthetically restore anterior teeth, but the myriad of ceramic with different compositions and properties can make the process of material selection complex. When correlating enamel preservation and ceramic selection, glass-ceramics are ideal materials since their intrinsic characteristics are to be etched and bonded. Glass- ceramics are also highly translucent; however, its translucency depends on their crystalline composition and thickness.16 For instance, feldspathic porcelains have higher translucency than that of milled lithium disilicate or leucite-reinforced glass-ceramics. Another important decision regarding ceramic selection is the method of fabrication of the restoration: layered or monolithic, pressed or CAD/CAM milled. A recent study found no statistical differences in the L*, a*, and b* values between monolithic lithium disilicate glass- ceramic pressed (e.max Press) or milled lithium RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Vol 28 � No 5 � 267^276 � 2016 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12266 VC 2016 Wiley Periodicals, Inc.274 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26 disilicate glass-ceramic (e.max CAD), but they differed significantly from the feldspathic porcelain commonly used for layering (IPS e.max Ceram).17 Milled ceramic restorations may also be translucent depending on the composition, thickness, and inherent translucency of the CAD blocks.18 An increase in lithium disilicate glass-ceramic thickness may minimize the influence of background color due to an increase in opacity of the restoration.19 However, any increase in restoration thickness would require more aggressive tooth preparation. Sacrificing intact dental structure because of dental materials own limitations does not justify nowadays and alternative techniques that can benefit from bonding strengthening techniques should be the first choice of treatment when planning esthetic rehabilitations. Feldspathic glass-ceramics using refractory die technique may be the most esthetic restorative material considering that these ceramics allow the ceramist to layer translucent and opaque areas adequately, even if the space for the restorative material is reduced.9 Conversely, porcelain stratification techniques require years of training for a skilled ceramist to attain superior optical properties. It is interesting, however, to note that patients not necessarily would perceive the differences in translucency, chroma, and value when different veneers fabricated with different ceramic systems (pressed followed with stratification or monolithic and stained) are tried-in.5 However, ceramic layering techniques would allow the ceramist to reproduce the natural dentition with more fidelity by incorporating different optical properties such as fluorescence, translucency, and opalescence of enamel and dentin into the restoration. Clinical scenarios where the discrepancies between different opacities and translucencies are found are still challenging for clinicians and ceramists. Fractured tooth, diastema, caries with dentin exposure, and restoration of space discrepancies between teeth requires the restorative team to wisely analyze the advantages and limitations of different restorative approaches before deciding on a treatment sequence. Any selected restorative technique must be discussed with the patient, who should be clearly educated on the anticipated esthetic outcomes. The clinician, ceramist, and patient should agree as a team to maximize the esthetical outcomes and to provide realist expectations to all team members. Ultra-conservative minimally invasive preparation should be employed as frequently as possible to ensure long-term bonding effectiveness to enamel. DISCLOSURE The authors do not have any financial interest in the companies whose materials are included in this article. REFERENCES 1. Chu SJ, Trushkowsky RD, Paravina RD. Dental color matching instruments and systems. Review of clinical and research aspects. J Dent 2010;38 (Suppl2):e2–e16. 2. Chu SJ, Mieleszko AJ. Color-matching strategies for non- vital discolored teeth: part 1. Laboratory ceramic veneer fabrication solutions. J Esthet Restor Dent 2014;26(4):240–6. 3. 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Reprint requests:Dr.Victor Clavijo,Rua Cerqueira Cesar,1078 Indaiatuba,S~ao Paulo,Brazil13330-005; email: vc_028@usc.edu RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al Vol 28 � No 5 � 267^276 � 2016 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12266 VC 2016 Wiley Periodicals, Inc.276 Rodolfo Nunes - rodolfodamasio@hotmail.com - IP: 85.245.102.26