THE American JOURNAL OF DENTISTRY VOL UME 1 FA L L N UMB E R 2 0 1 1 1 The American Journal of Esthetic Dentistr
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THE American JOURNAL OF
DENTISTRY
VOL UME
1
FA L L
N UMB E R 2 0 1 1
1
The American Journal of Esthetic Dentistry
Volume 1 • Number 1
Fall • 2011 (1–84)
The American Journal of
DENTISTRY
Volume 1 • Number 1 • Fall 2011
ISSN 2162-2833 (print) ISSN 2162-2841 (online)
5
Editorial: Welcome aboard!
Richard J. Simonsen
10
Minimally Invasive Restorative Treatment of Hypoplastic Enamel in Anterior Teeth
Jussara Karina Bernardon
The Gray Zone Around Dental Implants: Keys to Esthetic Success
Iñaki Gamborena
Determining the Influence of Flowable Composite Resin Application on Cuspal Deflection Using a Computerized Modification of the Strain Gauge Method
Hamdi H. Hamama
26
48
60
7 8
All-Ceramic Crowns and Extended Veneers in Anterior Dentition: A Case Report with Critical Discussion
Renata Gondo Luiz Narciso Baratieri
Markus B. Blatz
Nadia M. Zaghloul Ossama B. Abouelatta Abeer E. El-Embaby
Júnio S. Almeida e Silva Juliana Nunes Rolla Daniel Edelhoff Élito Araujo Luiz Narciso Baratieri
Guidelines for Authors Mandatory Submission Form
Readers are invited to submit personal photographs for consideration for use in the journal. The number of photos may vary in each issue, but we hope the images will provide an interesting break between the outstanding papers within. This is an opportunity for you, the reader, to share with your colleagues some of the images you are proud of, that may otherwise never see the light of day. For this inaugural issue, we present images from Antelope Canyon, a slot canyon in northern Arizona, photographed by Richard J. Simonsen (http://www.richardsimonsen.com). At certain times of the year and day, the sun may shine through from the slot above that communicates to the surface. Such canyons can be dangerous, as they fill with rainwater quickly in the event of a thunderstorm upstream, sometimes trapping those who choose to ignore nature’s warnings. It is the effect of the running water over millions of years that makes the unique patterns on the walls of the soft sandstone rock walls.
The American Journal of
Publisher
H. W. Haase Executive Vice President
William G. Hartman
Director, Journal Publications
DENTISTRY
Lori A. Bateman
Managing Editor ISSN 2162-2833 (print) ISSN 2162-2841 (online)
Colleen E. O’Keefe Production Manager
Diane J. Curran
Director, Advertising Sales
Editor-in-Chief Richard J. Simonsen, DDS, MS Professor, Faculty of Dentistry Health Sciences Center Kuwait University PO Box 24923, Safat 13110, Kuwait [email protected]
Editorial Board
Joel H. Berg, DDS, MS Markus B. Blatz, DMD, PhD Jeff Brucia, DDS John R. Calamia, DMD Alexander Carroll, DDS, MBA David Chambers, EdM, MBA, PhD Gordon J. Christensen, DDS, MSD, PhD Theodore P. Croll, DDS Alessandro Devigus, Dr Med Dent Sillas Duarte Jr, DDS, MS, PhD Newton Fahl Jr, DDS, MS Jack L. Ferracane, PhD Ronald E. Goldstein, DDS Laura C. Kottemann, DMD Gerard Kugel, DMD, MS, PhD Tyler Lasseigne, DDS Pascal Magne, Dr Med Dent, PhD Tidu Mankoo, BDS Assad F. Mora, DDS, MSD Marc L. Nevins, DMD, MMSc Vijay Parashar, DDS, MS André V. Ritter, DDS, MS Richard D. Roblee, DDS, MS David D. Rolf II, DMD, MS
William G. Hartman
Editorial, Advertising, and Subscriptions Quintessence Publishing Co, Inc 4350 Chandler Drive, Hanover Park, IL 60133 Tel: (630) 736-3600. Fax: (630) 736-3633 Toll-free (US/Canada): (800) 621-0387 E-mail: [email protected] Introductory subscription rate (Vols 1 and 2, six issues; includes online version): Regular rate for North America is $248; $430 institutional. International rate (outside North America) is $278 regular; $460 institutional. International subscribers add $30 to international rate for air mail. Special student rate is $150 ($180 international); verification of student status required on submission of subscription order. AJED is published quarterly by Quintessence Publishing Co, Inc. Postmaster: Send address changes to Quintessence Publishing Co, Inc, 4350 Chandler Drive, Hanover Park, IL 60133, USA. Copyright © 2011 by Quintessence Publishing Co, Inc. All rights reserved. Printed in Germany. No part of this journal may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information and retrieval system, without permission in writing from the publisher. The publisher and editors assume no responsibility for unsolicited manuscripts. The views expressed herein are those of the individual authors and are not necessarily those of the publisher. Information included herein is not professional advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures, or practices. To the extent permissible under applicable laws, the publisher disclaims responsibility for any injury and/or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from the use or operation of any ideas, instructions, procedures, products, or methods contained in the material herein. Permission to photocopy items solely for internal or personal use, and for the internal and personal use of specific clients, is granted by Quintessence Publishing Co, Inc, for libraries and other users registered with the Copyright Clearance Center (CCC) Transaction Reporting Service, provided that the base fee of $5 per article plus $.10 per page is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923 (www. copyright.com). Identify this publication by including the fee code: 2162-2833/11 $5 + $.10.
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Printed in USA.
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Editorial
Welcome aboard!
I
am very pleased to welcome you to a new addition to Quintessence Publishing Company’s stable of fine
journals and books in dentistry. This is the first issue of The American Journal of Esthetic Dentistry, a journal dedicated to promoting the highest clinical standards of esthetic dentistry based on an evidence base and on a minimally invasive approach. We wish to share with our readers the research advances and clinical accomplishments of the profession over the past several decades. With our outstanding editorial board
readers. I may take a certain position
and many others who will aid in the re-
on an issue in order to stimulate con-
view of papers and ideas for the journal,
versation and responses such that a
we pledge to provide you with the high-
broad perspective of opinions can be
est standard of peer-reviewed informa-
aired. It will be my job as your editor to
tion in the form of papers submitted by
try to stimulate such debates and com-
you, the reader, and fellow dedicated
mentary, such as, for example, around
members of our profession.
the current overtreatment problems
The theme of “esthetic dentistry” is a
in the cosmetic dentistry arena. I also
broad one. One could argue that almost
welcome guest editorials from those of
all phases of clinical dentistry involve—
you who may wish to tackle a particular
directly or indirectly—esthetics, and we
subject of interest to the profession. An
will publish papers in most areas of
active and robust “Letters to the Editor”
clinical interest to the general dentist,
section is on my list of goals for devel-
who is faced with the enormous task of
opment as time goes on. I hope that
keeping up with new developments in
you will feel free to communicate with
all fields of the profession. You can ex-
me on any ideas or constructive criti-
pect many papers of the quality you
cism you may have.
see here in this issue from around the
Please enjoy the first issue of The
globe, and also you can expect excit-
American Journal of Esthetic Dentistry !
ing new developments in terms of being able to review your journal and read the papers online with your iPad or similar instrument in months to come. Future editorials will discuss themes and trends in our profession that I hope
Richard J. Simonsen, DDS, MS
will be of interest to a wide group of
Editor-in-Chief
5 VOLUME 1 • NUMBER 1 • FALL 2011
The American Journal of
DENTISTRY Guidelines For Authors Manuscript Submission Submit manuscripts via AJED’s online submission service: www.manuscriptmanager.com/ajed Manuscripts should be uploaded as a PC Word (doc) file with tables and figures preferably embedded at the end of the document. No paper version is required. Manuscript Preparation The Journal will follow as much as possible the recommendations of the International Committee of Medical Journal Editors (Vancouver Group) in regard to preparation of manuscripts and authorship (Uniform Requirements for Manuscripts Submitted to Biomedical Journals, updated October 2008; www.icmje.org). Manuscripts should be typed doublespaced with a 1-inch margin all around. Number all pages. Do not include author names as headers or footers. The first page must include the title of the article (descriptive but as concise as possible); the complete names, titles, addresses, and professional affiliations of the authors; and phone, fax, and email address for the corresponding author, who will be assumed to be the first author unless otherwise noted. If the paper was presented before an organized group, the name of the organization, location, and date should be included. A 150- to 200-word abstract of the article must be included. Trade names: When a trade name of a product is used, the name of the manufacturer must appear parenthetically at first mention. Tables: Each table should be logically organized, typed on a separate page at the end of the manuscript, and numbered consecutively. Table title and footnotes should be typed on the same page as the table. Legends: There should be an individual legend for each illustration. Figure legends should be typed as a group on a separate page at the end of the manuscript. Detailed captions are encouraged. For microphotographs, specify original magnification and stain. References: References should be included on a separate page in the manuscript. Cite all references
numerically, in order of appearance in the text. Limit references to those specifically referred to in the text. Use the following style for the reference list: Journals: 1. A l-Johany, SS, Alqahtani AS, Alqahtani FY, Alzahrani AH. Evaluation of different esthetic smile criteria. Int J Prosthodont 2011;24:64–70. Books: 1. G ürel G. Porcelain laminate veneers: Predictable tooth preparation for complex cases. In: Romano R (ed). The Art of Treatment Planning: Dental and Medical Approaches to the Face and Smile. Chicago: Quintessence, 2010:249–263. Review Process Manuscripts will be reviewed by the editor and editorial staff with expertise in the field that encompasses the article. Original articles are considered for publication on the condition that they have not been published or submitted for publication elsewhere. The publisher reserves the right to edit all manuscripts to fit the space available and to ensure conciseness, clarity, and stylistic consistency. Article Acceptance Article acceptance is pending receipt of images judged to be of sufficient quality for publication (see the guidelines below). Once a manuscript is accepted, authors should submit high-quality nondigital images or high-resolution digital image files (on disk) to: Managing Editor American Journal of Esthetic Dentistry Quintessence Publishing Co, Inc 4350 Chandler Drive Hanover Park, IL 60133 The disk/package should be labeled with the first author’s name, shortened article title, and code number assigned upon acceptance. Nondigital Image Format. When submitting nondigital images please consider the following points: • Clinical photographs/radiographs. Submit original 35-mm slides, high-quality glossy prints, or original film. If arrows, letters, or numbers need to be added to the images, submit black-and-white or colored prints of each transparency with the appropriate labels drawn.
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Minimally Invasive Restorative Treatment of Hypoplastic Enamel in Anterior Teeth Jussara Karina Bernardon, DDS, MS, PhD Clinical Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Renata Gondo, DDS, MS, PhD Clinical Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Luiz Narciso Baratieri, DDS, MS, PhD Professor, Department of Operative Dentistry, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
Hypoplastic enamel can compromise the smile by altering the morphology and natural translucency of the teeth. To avoid performing iatrogenic procedures, etiologic knowledge of the enamel deficiency is essential to indicate the most appropriate treatment approach. In the case of white stains involving the enamel and dentin, a notable treatment option is a direct restoration with composite resin, which has excellent optical properties to reproduce the natural tooth structure and appropriate mechanical properties to ensure treatment longevity. In this article, a clinical case of a patient who reported dissatisfaction with her smile esthetics, prompted by the presence of hypoplastic enamel staining at the central and lateral incisors, is presented. Treatment consisted of composite resin restorations with the natural stratification technique. The final esthetic result proved the possibility of obtaining natural-looking restorations, while ensuring the esthetic and functional satisfaction of both the patient and clinician. (Am J Esthet Dent 2011;1:10–24.)
Correspondence to: Dr Jussara Bernardon Armaro Antônio Viera 2489, apto 403, Itacorubi, Florianópolis, Santa Catarina, Brazil. Fax: 55 048 38799226. Email: [email protected]
10 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Fig 1 Proximal view of the anterior teeth. Note the change in color and presence of white spots.
11 VOLUME 1 • NUMBER 1 • FALL 2011
Bernardon et al
S
everal factors may compro
to the natural shine and trans-
mise the esthetics of the
lucency of enamel. This opacity
hypoplastic
prevents light transmission in
enamel, which may affect the
the specific region of the lesion,
morphology, texture, and color of
providing a distinct difference
the tooth surface, the result of an
between it and the surrounding
incomplete or defective forma-
enamel. Several types of treat-
tion of the enamel organic ma-
ments may be recommended
trix. The intensity and duration
according to severity, and the
of stimulation on ameloblasts
least invasive technique should
reflect the extent and location of
always take precedence. There-
enamel defects.1 Lesions may
fore, the etiologic diagnosis is of
be triggered by hereditary or
paramount importance and aims
environmental factors. With he-
to prevent unnecessary treat-
reditary factors, generally only
ment of the hypoplastic teeth.
the enamel of primary and per-
For mild (smooth, light) and su-
smile,
including
Hy-
perficial lesions, tooth bleaching
poplastic enamel resulting from
can be performed, with or with-
environmental factors, however,
out abrasion of the enamel. This
can be caused by a variety of
is a minimally invasive technique
influences, including nutritional
and is limited to the enamel of
deficiencies, rashes (eg, mea-
the affected area.6 In the case
sles,
chickenpox,
of moderate or severe stains
ver),
syphilis,
manent teeth is
affected.2
scarlet
fe-
hypocalcemia,
with
dentin
involvement,
the
systemic disorders, ingestion of
preferred treatment is a direct or
chemicals (eg, fluoride), trauma,
indirect restorative procedure.
infections of the primary denti-
With the ongoing development
tion, or by idiopathic causes.2,3
of composite resins, which pre-
Environmental factors usually af-
sent a wide range of available
fect only one arch and can alter
colors and excellent mechani-
dentin.4
cal properties, it has been pos-
both the enamel and
the
sible to perform more esthetic,
etiology, stains resulting from
predictable, and conservative
hypoplastic enamel may have
restorations.7 The use of com-
systemic features, affecting a
posite resin has the advantage
group of teeth, or be localized,
of minimal reduction of the tooth
with asymmetric distribution and
structure and the completion of
isolated to specific teeth.5
the procedure in a single ap-
Therefore,
These
depending
spots
on
compromise
smile esthetics because they have an opaque, rough, and irregular appearance, compared
12 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
pointment.8
Bernardon ET AL
Fig 2 Initial appearance of the patient. At conversation distance, the spots, while clearly visible, can be left untreated if they do not bother the patient. However, in this case, the patient was concerned about the appearance of her teeth.
Clinical case
enamel areas at the incisal and middle thirds of the maxillary and mandibular
The chief complaint of the patient was
incisors, without functional involvement
esthetic dissatisfaction from discolora-
(Figs 3 and 4). The patient underwent
tion of the teeth and the presence of
radiographic examination, and no peri-
white spots on the incisors (Figs 1 and
odontal or periapical changes were
2). After taking the case history with a
evident. The affected teeth yielded a
clinical examination, it was determined
positive response to the vitality test.
that the teeth were naturally dark and that the white spots were hypoplastic
An additional recommended baseline
examination
is
transillumination,
13 VOLUME 1 • NUMBER 1 • FALL 2011
Bernardon et al
Fig 3 Preoperative labial view demonstrating yellow coloration of the teeth and the presence of white spots at the incisal and middle thirds of the maxillary central incisors and incisal third of the left lateral incisor.
Fig 4 Occlusal view of the maxillary incisors. Note the change in morphology and surface texture.
which involves the use of a transillumi-
termining the treatment approach: the
nator positioned along the palatal sur-
less the light propagation through the
face of the tooth being assessed (Figs
affected areas, the greater the depth
5a to 5c). This technique allows analy-
of the stain. If the dentin is involved, the
sis of the transmission of light through
most common treatment approach is a
the hypoplastic defects, identification of
direct restoration with composite resin
the thickness of the affected areas, and
and limited preparation of the compro-
verification of the degree of compro-
mised surface.
mised enamel (and dentin, if affected).
Initially, because of tooth discolora-
Thus, transillumination is effective in de-
tion, the patient was asked to perform
14 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Bernardon ET AL
a
b
c
Figs 5a to 5c Using a transilluminator placed on the palatal surface of the involved incisors, it was possible to visualize the stain depth and relate this to the depth of the hypocalcified area.
Fig 6 Frontal view after home bleaching with 10% carbamide peroxide gel for 4 weeks (2 hours/ day). Note that the stains remained visible, confirming the need for restorative intervention.
a supervised home whitening or bleach-
condition in terms of saturation and
ing
carbamide
brightness of the teeth to be restored.12
peroxide gel for 4 weeks (2 hours/day)
The restoration was performed 14 days
(Fig 6). Home bleaching is a relatively
after completion of the bleaching pro-
simple,
effective
cess to ensure that the adhesive proce-
treatment,9,10 with satisfactory results
dure and color selection were carried
regimen
obtained
with
10%
conservative, in
a
short
and time
period.11
out properly.13
Bleaching, associated with restorative
A microhybrid composite resin sys-
treatment, is a common approach that
tem (Opallis, FGM) with the appropri-
aims to establish a more homogenous
ate mechanical properties to ensure
15 VOLUME 1 • NUMBER 1 • FALL 2011
Bernardon et al
Fig 7 (left) Choice of color using the color scale positioned on the facial surface of the affected tooth. The enamel and dentin colors were selected separately. Fig 8 (right) By placing the dentin shade guide against the enamel shade guide, the final shade can be visualized.
strength and maintenance of polishing
chemistry of the different brands avail-
and surface brightness and sufficient
able. This is because the enamel and
optical properties to mimic the features
dentin shade guides vary in saturation
found in natural teeth was selected for
and translucency depending on the
procedure.14
A resin
system used. The color scale should
system with both enamel and dentin
be positioned as closely as possible to
shades is recommended because the
the tooth. The color selection for den-
natural tooth overlaps these structures
tin should be performed at the cervical
in different thicknesses, which creates
third of the affected tooth, where the
the polychromatic effect seen on natu-
dentin is thicker and more saturated,
the restorative
The selected system pre-
and enamel color selection should
sented several hues and saturations
occur at the middle third. The system
for enamel and dentin beyond the
used had separate scales for enamel
transparent resins, which reproduce
and dentin, which is an advantage be-
different degrees of translucency, opal-
cause it allowed for an individual evalu-
escence, and fluorescence.
ation of the structures. In addition, each
ral
teeth.15
When selecting the color for the res-
tab had a different thickness, and it was
toration, the teeth should be clean and
possible to predict the shade of the final
moist so that the natural translucency
restoration by altering the thickness of
is preserved.15 Color scales are essen-
the tab selected (Fig 7). By placing the
tial, and it is of paramount importance
enamel shade tab on top of the dentin
that they be of the same manufacturer
shade tab, it was possible to predict
as the resin system selected to avoid
how the resins would interact in the
potential discrepancies between the
future restoration (Fig 8). The operative
16 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Bernardon ET AL
Fig 9 After rubber dam was
Fig 10 Occlusal view of the
Fig 11 After preparation,
used to isolate the affected
preparation. Note the remaining
the white spot was still evident,
teeth, the white spot was re-
white spot that could compro-
which called for its removal
moved using diamond burs.
mise the restorative outcome if
with a diamond bur of smaller
not removed.
diameter.
Fig 12 Final aspect of the
Fig 13 Etching of the hard
Fig 14 Application of the ad-
hydrated cavity preparation,
tissue with 37% orthophosphoric
hesive system according to the
which was restricted to removal
acid (15 seconds for dentin,
manufacturer’s instructions.
of the white spot.
30 seconds for enamel).
field was isolated to ensure a clean and
There is no need to bevel the cavo-
suitable environment for the bonding
superficial angle, preserving as much
procedures.
healthy tooth structure as possible (Fig
The cavity preparation should be
12). The absence of preparations en-
restricted to removing the hypoplastic
sures a reversible treatment without
enamel using diamond points com-
compromising esthetics or the adhe-
patible to the size of the lesion under
sive bond. After the preparation was
constant irrigation to avoid heating of
complete, conditioning was performed
the structure (Fig 9). The entire depth
with 37% orthophosphoric acid for 15
of the hypoplastic enamel should be
seconds on the dentin and 30 seconds
removed. Otherwise, the resulting dif-
on enamel (Fig 13), followed by appli-
ference in opacity between natural and
cation of the adhesive system, accord-
affected tooth structure can negatively
ing to the manufacturer’s instructions
affect the outcome of the restoration
(Fig 14).
(Figs 10 and 11).
17 VOLUME 1 • NUMBER 1 • FALL 2011
Bernardon et al
Fig 15 Composite resin was
Fig 16 Mamelons must be
Fig 17 Frontal aspect after
placed in the preparation to
defined when applying the
placing the second dentin resin
reproduce the dentin layer.
composite resin.
layer for bleached teeth. Note the design of the mamelons.
The restorative procedure was per-
an “orange” appearance. This is the
formed using the stratification tech-
counter-opalescence feature of dentin.
nique, based on the techniques of
To reproduce this effect, an opalescent
building ceramics. This new trend is
and highly translucent resin (T-Blue,
also referred to as the anatomical tech-
Opallis) was placed on the tips of the
nique.16,17 In this technique, layers of
mamelons and between the dentin and
selected materials are used to repro-
incisal edge of the tooth (Fig 18).
duce the enamel and dentin structures
Then, artificial enamel was recon-
while also respecting their thickness
structed using a single enamel resin
and anatomical contour.
layer (E-Bleach) (Fig 19). In the stratifi-
The artificial dentin reconstruction
cation technique, it is important to con-
was performed using the dentin resin
sider that the artificial enamel thickness
DA1 (Opallis). This resin was applied
should correspond to one third of that of
covering the deepest portion of the cav-
natural enamel18 to avoid value reduc-
ity to sculpt the shape of the mamelons
tion of the restoration. This means that
(Figs 15 and 16). Dentin mamelons can
a thicker layer of artificial enamel results
have various shapes and determine
in a gray and more monochromatic res-
the
characteristics
toration.14 This is because the refrac-
of the tooth (Fig 17). Each layer was
tory index of the natural tooth structure
photopolymerized for 40 seconds. To
is different from that of the composite
complete the artificial dentin, a resin for
resin.14 The enamel surface was final-
bleached teeth was applied at the tip
ized at this time, avoiding use of dia-
of the mamelons (D-Bleach, Opallis).
mond points (Fig 20).
translucent
halo
In a natural tooth, dentin presents as
The same procedures were per-
an intense and very reflective opaque
formed for the maxillary right central
white color on the tip of the mamelons.
(Figs 21 to 24) and left lateral inci-
However, when light penetrates the
sors (Figs 25 to 28). After complete
dentin through the enamel, it results in
polymerization and at a later session,
18 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Bernardon ET AL
Fig 18 A highly translucent
Fig 19 Positioning of the final
Fig 20 Proximal view of the
resin was placed on the opal-
enamel composite resin layer.
vertical development and lobes
escent areas of the incisal third
Care was taken to cover all
shaped in the definitive restora-
region of the tooth.
preparation margins.
tion.
Fig 21 Removal of the white
Fig 22 After hydration, the
Fig 23 Incremental tech-
spots on the right central inci-
preparation was completed
nique for resin application:
sor with a diamond bur.
with removal of the white spot.
DA1, D-bleach H, T-Blue, and Bleach (Opallis).
Fig 24 Final aspect of the
Fig 25 Removal of the hypo-
Fig 26 Final aspect of the hy-
restoration of the maxillary right
plastic enamel on the left lateral
drated cavity preparation, which
central incisor.
incisor.
was restricted to removing only the hypoplastic white spot.
Fig 27 (left) Mamelon design using dentin resin (DA1 and DBleach, Opallis). Fig 28 (right) Final aspect of restoration. Note the contrast between the restoration and the natural tooth, which is dehydrated as a result of absolute isolation.
19 VOLUME 1 • NUMBER 1 • FALL 2011
Bernardon et al
Fig 29 A surface enhancer was used to identify the differ-
Fig 30 Vertical development and
ent reflection areas of the teeth.
the edges were completed with an oval format extra-fine diamond bur.
Fig 31 Note the similarity in morphology between the cen-
Fig 32 The restoration was pol-
tral incisors after texturing.
ished to make the surface bright and smooth.
the surface of the restoration was tex-
an irregular surface provides light dis-
tured, and finishing and polishing were
persion. Lobules and development
completed (Figs 29 to 32). Surface tex-
grooves (vertical texture), horizontal
turing is indispensable in ensuring a
grooves, and perikymata should be
natural-looking
reproduced using extra-fine diamond
restoration
because
20 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Bernardon ET AL
a
b
c
Figs 33a to 33c A transilluminator was again used to visualize the similarity in light transmission between tooth and restoration (compare to Figs 5a to 5c).
Fig 34 Final aspect of restorations, frontal view. Fig 35 (right) Final aspect of restorations, palatal view.
burs. Finishing was completed using
result showed that composite resin
flexible disks and rubber tips. Polish-
provides a suitable material to produce
ing with felt disks and polishing pastes
esthetic effects similar to that of the
ensures surface brightness and de-
natural tooth structure (Figs 33 to 39).
creases plaque retention. The final
21 VOLUME 1 • NUMBER 1 • FALL 2011
Bernardon et al
Figs 36 to 38 Final smile after bleaching and restorative treatment. Note the correct merging of the dental substrate with the composite resin and reproduction of the optical aspects in the incisal third region.
22 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Bernardon ET AL
Fig 39 The patient was satisfied with the end result. Note the naturalness and harmony of the smile with the facial esthetics.
23 VOLUME 1 • NUMBER 1 • FALL 2011
Bernardon et al
Conclusions and guidelines for practitioners
properties, and reproduction of the natural tooth color and characteristics.19 Proper color selection is not enough; satisfactory resin system selection and
In cases of hypoplastic enamel, a correct
proper realization of the stratification
diagnosis is indispensable for an appro-
technique must also be accomplished.
priate treatment prognosis. In lesions
Following this protocol is critical to the
with dentin involvement, direct compos-
quality of treatment received.
ite resin restorations promote satisfactory results with conservation of a healthy dental structure, excellent mechanical
This article is based on a chapter in the book Clinical Vision: Cases and Solutions by Dr Baratieri and was originally written in Portuguese.
References 1. Elcock C, Smith RN, Simpson J, Abdellatif A, Bäckman B, Brook AH. Comparison of methods for measurement of hypoplastic lesions. Eur J Oral Sci 2006;114(suppl 1): 365–369. 2. Clarkson J. Review of terminology, classifications, and indices of developmental defects of enamel. Adv Dent Res 1989;3:104–109. 3. Ribas AO, Czlusniak GD. Anomalias do esmalte dental: Etiologia, diagnostico e tratamento. Biol Health Sci 2004;10:23–26. 4. Bendo CB, Scarpelli AC, Novaes JB Jr, Valle MPP, Paiva SM, Pordeus IA. Enamel hypoplasia in permanent incisors: A six-month follow-up. RGO 2007;55:107–112. 5. Sensi lG, Marson FC, Strassle H, Duarte SJ. Recuperação Cosmética de Deformidades Dentais. Pro-odont Estética, ed 2. Porto Alegre: Artmed, 2008: 156–178. 6. Croll TP. Enamel Microabrasion. Chicago: Quintessence, 1991. 7. Simonsen RJ. Developmental defect restorations. In: Simonsen RJ. Clinical Applications of the Acid Etch Technique. Chicago: Quintessence, 1978:63–70.
8. Machado FC, Ribeiro RA. Defeito de esmalte e cárie dentária em crianças prematuras e/ou de baixo peso ao nascimento. Pesq Bras Odontoped Clin Integr 2004; 4:243–247. 9. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintessence Int 1989;20: 173–176. 10. Leonard RH Jr, Bentley C, Eagle JC, Garland GE, Knight MC, Phillips C. Nightguard vital bleaching: A long-term study on efficacy, shade retention, side effects and patients’ perceptions. J Esthet Restor Dent 2001;13:357–369. 11. Joiner A. The bleaching of teeth: A review of the literature. J Dent 2006;34:412–419. 12. Hirata R. Tips: Dicas em Odontologia Estética. São Paulo: Artes Médicas, 2011:576. 13. McGuckin RS, Thurmond BA, Osovitz S. Enamel shear bond strengths after vital bleaching. Am J Dent 1992;5:216–222 14. Baratieri LN, Belli R. Resinas compositas. In: Baratieri LN. Clinical Solutions—Fundamentals and Techniques. Florianópolis: Editora Ponto, 2008:131–142.
24 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
15. Baratieri LN, Belli R. Colo: Fundamentos básicos. In: Baratieri LN. Clinical Solutions—Fundamentals and Techniques. Florianópolis: Editora Ponto, 2008:21–55. 16. Ardu S, Krejci I. Biomimetic direct composite stratification technique for the restoration of anterior teeth. Quintessence Int 2006;37:167–174 [erratum 2006;37:408]. 17. Vanini L. Light and color in anterior composite restorations. Pract Periodontics Aesthet Dent 1996;8:673–682. 18. Vanini L, Mangani F, Klimovskaia O. Colour in dentistry. In: Vanini L, Mangani F, Klimovskaia O. Conservative Restoration for Anterior Teeth. Viterbo, Italy: ACME, 2005:97–200. 19. Bernardon JK, Gondo R. Restorative treatment of hypoplastic stains in anterior teeth. In: Baratieri LN. Clinical Vision: Cases and Solutions. Florianópolis: Editora Ponto, 2010:62–101.
The Gray Zone Around Dental Implants: Keys to Esthetic Success Iñaki Gamborena, DMD, MSD, FID Private Practice, San Sebastian, Spain; Clinical Assistant Professor, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.
Markus B. Blatz, DMD, PhD Professor and Chairman, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.
Correspondence to: Dr Iñaki Gamborena Resurecccion mª de Azkue, 6 20018 San Sebastian, Spain. Email: [email protected]
26 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Single-implant restorations in the anterior maxilla have become a routine treatment option. While customized tooth-colored prosthetic components show greatly improved clinical outcomes, esthetic success relies not only on the restorative result, but also on the condition of the soft tissues. A common esthetic shortcoming is the grayish appearance of the peri-implant soft tissues, which are difficult to manipulate around dental implants. The parameters and clinical guidelines that should be used to influence esthetic success and avoid the gray zone around implant restorations can be categorized into five key factors: (1) optimal threedimensional implant placement for functional and esthetic long-term implant success; (2) maximized soft tissue thickness to conceal the implant-restorative interface; (3) proper abutment selection to improve biocompatibility, tissue stability, color, translucency, and fluorescence; (4) careful crown restoration to imitate the natural teeth; and (5) awareness of the lip line, which may greatly influence the final outcome. Mimicking the inherent optical properties, especially fluorescence, of natural teeth with implant components and crown materials is fundamental for ideal restorative and soft tissue esthetics. (Am J Esthet Dent 2011;1:26–46.)
27 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
T
he esthetic success of a dental
and restorative esthetic success with
restoration is judged by its inte-
maxillary anterior implant-supported
gration with the surrounding dentition
restorations presents a great challenge
in respect to position, angulation, di-
for the entire dental team and depends
mensions, proportions, shape, surface
on a variety of parameters.10–14
morphology, and shade.1–3 Other cru-
The parameters and clinical guide-
cial esthetic parameters that are often
lines that should be used to influence
overlooked include the morphology,
esthetic success and avoid the gray
texture, and ultimately the color of the
zone around implant restorations can
surrounding gingiva.3,4 The soft tissue
be categorized into five key factors: (1)
is the natural frame of the teeth and
optimal three-dimensional (3D) implant
any dental restoration and is, therefore,
placement for functional and esthetic
a fundamental parameter for esthetic
long-term implant success; (2) maxi-
success.1,3,5 This aspect is often ne-
mized soft tissue thickness to conceal
glected because successful soft tissue
the implant-prosthetic component inter-
outcomes—including handling, manip-
face; (3) proper abutment selection to
ulation, and healing—are very demand-
improve biocompatibility, tissue stabil-
ing, time intensive, and unpredictable.5
ity, and color to provide a perfect blend
described a prevalence
with surrounding tissues and teeth; (4)
of grayish soft tissue discolorations
careful crown restoration to imitate the
around tooth-supported full-coverage
natural teeth; and (5) awareness of the
porcelain-fused-to-metal and even all-
lip line, which may greatly influence the
ceramic restorations. Interestingly, oth-
final outcome.
Magne et
al6
er perioral facial parameters such as position of the upper lip and height of the smile line7–9 also seem to influence
3D implant placement
the degree of gingiva discoloration. The authors note that “this problem is
The fundamental factor for long-term
particularly evident in the presence of
functional and esthetic success as well
the upper lip, which can generate an
as soft tissue color and stability is opti-
‘umbrella effect’ characterized by gray
mal 3D implant placement.18 A simple
marginal gingivae and dark interdental
but essential guideline is to position the
papillae.”6
implant as close as possible to where
This umbrella effect is magnified with
the natural tooth was or ideally would
dental implant restorations in the an-
be.10 If a line is drawn at the center of
terior maxilla because the supporting
the implant along its long axis and ex-
hard and soft tissues are often com-
tending through the tooth restoration,
promised even before restorative treat-
it should run through the center of the
ment and are influenced by the color
incisal edge of the prospective tooth
and design of the implant, its prosthetic
(Fig 1). The greater the 3D mismatch
components, and the definitive resto-
between the crown and implant body,
ration.10–17 Therefore, ideal periodontal
the poorer and less stable the final
28 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Gamborena and Blatz
Fig 1 (right) Maxillary anterior implants should be positioned and angulated so that a virtual line through the center of the implant along its long axis would run through the center of the incisal edge of the prospective crown.
outcome will be. The incisal edge is also the target for the angulation of the implant. An implant that is angulated too far to the buccal aspect will result in greater tissue recession under functional load. Conversely, a palatally placed implant leads to a more extreme emergence profile, resulting in increased bone resorption and thinning of the tissues. Both situations will lead to an intensified grayish appearance of the soft tissues at the gingival margin. The third dimension is determined by the depth of the implant in respect to the marginal bone and soft tissue. An implant placed at the proper depth allows for the development of an ideal emergence profile and a soft tissue collar void of a gray zone. It is impossible to create a proper emergence profile when the implant is placed too shallow, while an implant placed too deep is difficult to manage clinically and increases the possibility of peri-implant infection, inflammation, and bone loss. A surgical guide fabricated from the diagnostic wax-up/setup is an indispensible tool to ensure proper 3D implant placement. The anticipated incisal
Soft tissue thickness
edge position of the final tooth restoration determines the position, angulation,
Even in cases where ideal implant
and depth of the implant in all three di-
placement was achieved, the esthetic
mensions, which directly influence the
outcome may become compromised
position, height, and thickness of the
over time due to resorption of the mar-
surrounding hard and soft tissues.10,12
ginal bone and soft tissues.5,19
29 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 1
Figs 2a and 2b A modified metal abutment was used after im-
Fig 3 Postoperative situation
mediate implant placement at the maxillary right central incisor site
showing the implant-supported
without bone or soft tissue augmentation.
crown.
Fig 4 (above left) Follow-up view after several years reveals a grayish appearance of the soft tissues. Fig 5 (above right) Follow-up view after 11 years showing soft tissue discoloration due to the metal abutment. Fig 6 (left) Periapical radiograph after 11 years reveals loss of buccal bone.
Case 1 (Figs 2 to 6) illustrates a situa-
inserted (Figs 2 and 3). A follow-up
tion where a single implant was placed
photograph taken several years post-
immediately after extraction of the
operatively reveals a grayish appear-
maxillary right central incisor without
ance of the soft tissue surrounding the
any hard or soft tissue augmentation. A
implant restoration (Fig 4). This discol-
modified metal abutment was fabricat-
oration becomes increasingly evident
ed, and the definitive restoration was
11 years after completion as a result of
30 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Gamborena and Blatz
the resorption of the buccal bone and
connective tissue grafting, is another
surrounding soft tissues, revealing the
critical issue. Connective tissue grafts
unfavorable gray color of the metal im-
(CTGs) are placed around implants to
plant abutment (Figs 5 and 6).
enhance gingival margin stability and
To avoid this result, it is advisable
create a more fibrous and less mobile
to maximize tissue thickness in every
tissue complex.19–22 In dentistry today,
case and for both delayed and imme-
the clinician’s search for soft tissue
diate implant placement.19–22 In fact,
abundance in the early stages of im-
the mucosal characteristics of the peri-
plant treatment means creating a large
implant tissues necessitate connective
amount of soft tissue during or soon af-
tissue grafting for long-term esthetic
ter implant placement and manipulat-
success.21 With clear surgical objec-
ing these tissues during the prosthetic
tives, a modern approach should al-
phase. This is a shift from traditional ap-
ways include the most conservative
proaches in which multiple subsequent
procedure that satisfies the esthetic
soft tissue grafts are performed until
and functional requirements. For ex-
the desired thickness was achieved.
ample, if a bone graft is unnecessary,
Multiple surgical interventions, how-
stage-one surgery should always be
ever, are less predictable because
performed with a minimal flap incision,
the scarring and compromised blood
such as a split-thickness flap or even
supply make every subsequent graft-
no flap, to avoid unnecessary exposure
ing
of the underlying bone. Several authors
ideal prosthetic soft tissue manipula-
have indicated that flapless surgical
tion, the healing abutment should be
implant placement using computer-
significantly narrower than the tooth to
assisted
attempt
more
challenging.
For
minimizes
be replaced. At first, the tissue will not
bone resorption, preserves soft tissue
have the same scalloped architecture
architecture, and improves the healing
as found around natural teeth. How-
process.23 While some of these results
ever, when the provisional restoration
still need to be verified in long-term clin-
is placed, its subgingival contour and
ical trials, the positive effects of flapless
shape will determine the position and
implant placement on patient comfort
scallop of the soft tissue margin.10,13 It
due to the minimally invasive nature
also seems advantageous to connect
evident.23
the definitive abutment as early as pos-
The key components of this surgical
sible and not to remove it after that time.
surgical
guides
of the procedure are clearly
process are maintenance of the inter-
Thicker
peri-implant
soft
tissue
proximal bone, minimal bone exposure
masks the implant-abutment-restoration
only on the implant site, precise coro-
interface and provides a better color
nal graft suturing central to the implant
match between the soft tissues around
axis, and tension-free flap closure and
the implant and those around the neigh-
adaptation.
boring teeth.15–17 Some basic guide-
The design of the healing abutment, which can be placed during or after
lines for tissue thickness and abutment selection are as follows:
31 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 2
Fig 7 Thin peri-implant soft
Fig 8 A custom-colored
Fig 9 Colored zirconia abut-
tissue of only 1 mm was
zirconia abutment (Procera, No-
ment and alumina crown
evident on the buccal aspect.
bel Biocare) was fabricated to
(Procera Crown Alumina, Nobel
optimize the esthetic outcome.
Biocare).
Fig 10 Intraoral occlusal view
Fig 11 Postoperative buc-
showing the soft tissue support.
cal view. The tooth-colored abutment and all-ceramic crown blend favorably with the adjacent teeth and surrounding soft tissue despite the compromised soft tissue thickness.
Fig 13 (left) Occlusal view of
Fig 12 Postoperative peri
the definitive implant-supported
apical radiograph.
restoration.
• A soft tissue thickness greater than
along with the adequate soft tissue sup-
3 mm allows for the use of titanium or
port and contour, provided a satisfying
zirconia abutments without negative
outcome.
esthetic implications. • A thin soft tissue of less than 2 to 3 mm requires either a CTG or zirco-
Abutment selection
nia abutment. • A dentin-colored abutment is always preferred.
In an evaluation of the soft tissue around single-tooth implant crowns, Fürhauser et al24 showed that the color of the peri-
In Case 2 (Figs 7 to 13), a colored in-
implant soft tissue matched that of the
stead of a white zirconia abutment was
reference tooth in no more than one-
placed due to the presence of less than
third of cases. Another study found that
1 mm of labial soft tissue. This approach,
all-ceramic implant abutment and crown
32 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Gamborena and Blatz
Case 3
Fig 15 Preoperative intraoral situation.
Fig 16 Lateral tomogram showing the extent of the ridge defect.
Fig 14 Preoperative periapical radiograph of the missing maxillary left central incisor.
Fig 17 Intraoral view of the edentu-
Fig 18 Virtual
lous ridge topography.
implant placement for guided surgery.
materials provide a better soft tissue
dental implant (Figs 14 to 18). Ideal 3D
color match with neighboring teeth than
implant placement was planned on the
do conventional metal-alloy compo-
computer and transferred via guided
nents.16 Zirconia has been shown to be
surgery.
the preferred implant abutment material
the implant (3.5 × 13 mm, NobelAc-
due to its high strength13,25,26 and ex-
tive, Nobel Biocare) was inserted, and
biocompatibility.27–29
During
stage-one
surgery,
The short-
a CTG harvested from the maxillary
comings of zirconia include its higher
tuberosity was placed to increase tis-
cost and unfavorable optical properties
sue thickness (Figs 19 to 23). Figure
in regard to color and fluorescence.30
24 shows the augmented edentulous
cellent
Case 3 (Figs 14 to 55) includes all
ridge 6 months postoperatively. Next,
previously described factors and treat-
a zirconia abutment was connected to
ment parameters. The missing maxillary
the implant, and a provisional restora-
left central incisor was replaced with a
tion was fabricated, relined in the oral
33 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 3 Continued
Fig 19 Implant placement (3.5 × 13 mm,
Fig 20 A subepithelial CTG was harvested
NobelActive, Nobel Biocare).
from the maxillary tuberosity to augment the deficient ridge.
Fig 21 After placement of the CTG, the flaps
Fig 22 Labial view of the adapted flap after
were adapted without tension and sutured with thin
suturing.
suture material to limit trauma.
Fig 23 Intraoral situation 1 week postopera-
Fig 24 Postoperative situation after 6 months
tively.
reveals improved ridge morphology.
cavity, and cemented (Figs 25 to 29).
Figs 30 to 33 reveal the optical short-
The different lighting conditions (natu-
comings of these materials, especially
ral and ultraviolet [UV] light) shown in
the lack of natural fluorescence. Figure
34 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Gamborena and Blatz
Case 3 Continued
Fig 25 Definitive zirconia abutment and provisional restoration. Fig 26 (right) Insertion of the colored zirconia abutment.
Fig 27 (above left) Try-in of the provisional crown. Fig 28 (above right) Precision of fit was verified extraorally. Fig 29 (right) Periapical radiograph used to verify fit.
34 shows the detailed optical charac-
applied to zirconia abutments even af-
teristics of natural enamel and dentin
ter milling and finishing have recently
under different light sources.
been developed.30 The abutment or
Fluorescence is a crucial property for natural
esthetics.30–32
framework is dipped into a fluores-
Colorants
cent coloring liquid before sintering
and fluorescent modifiers that can be
to infiltrate the zirconia (Colour Liquid
35 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 3 Continued
Fig 30 Optical properties of the provisional
Fig 31 Optical properties of the provisional
crown under natural light.
crown under UV light. Note the lack of fluorescence.
Fig 32 Optical properties of the zirconia abut-
Fig 33 Optical properties of the zirconia abut-
ment under natural light.
ment under UV light reveals a lack of fluorescence. Fig 34 Color characteristics of natural enamel and dentin: (a) The three basic color zones; (b) areas of brightness/value; (c) enamel characteristics under a polarizing filter; (d) color characteristics of dentin; (e) degrees of dentin fluorescence under UV light.
Fluoreszenz, Zirkonzahn). The abutment is blow dried after the dipping
In addition to the regular zirconia, a more
translucent
zirconia
process to remove the excess and then
Zirconia
placed under a drying lamp to prevent
along with 16 coloring liquids (Zirkon-
damage to the heating elements of the
zahn) are available. Figures 35 to 37
sinter furnace.
illustrate the infiltration process and its
36 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
“Translucent,”
(Prettau
Zirkonzahn)
Gamborena and Blatz
Case 3 Continued Fig 35 Three different abutments were fabricated with conventional zirconia, a more translucent zirconia (Prettau Zirconia “Translucent”), and fluorescent colorants (Colour Liquid Fluoreszenz): colored translucent zirconia with fluorescence (transl + fluoresc) and without fluorescence (translucent), and conventional zirconia with fluorescence (Zr + fluoresc). Natural light reveals the chroma characteristics.
Fig 36 Fabrication of a fluorescent abutment: (a) Provisional composite abutment; (b) duplicated zirconia abutment before the sinter process; (c) dipping of the zirconia abutment into fluorescent colorants before sintering; (d) definitive abutment after sintering.
Fig 37 The three different abutments under UV light. Conventional colored zirconia and fluorescing liquid (Zr + fluoresc) reveal the most favorable effect.
effect on the optical appearance under
tient’s favorable soft tissue thickness
different light sources. Three different
and the clinical try-in of the three differ-
abutments were fabricated: translucent
ent abutments under regular and UV
zirconia with and without fluorescence
light. Interestingly, the translucent abut-
and conventional zirconia with fluores-
ment provided the best match in natu-
cence. Figures 38 to 40 show the pa-
ral light but the worst under UV light.
37 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 3 Continued
Fig 38 (above left) Intraoral try-in of the three abutments under natural light. Fig 39 (above right) Ideal soft tissue thickness (> 3 mm). Fig 40 (left) Intraoral try-in of the three abutments under UV light.
The most favorable fluorescent effect was achieved with colored conventional zirconia and fluorescing liquid. In summary, the selection of zirconia
value,
translucency,
and
shade
(chroma and hue). • Color of the intended crown restoration (alumina versus zirconia).
implant abutments should be based on the following factors:
For optimal stability and fit of the coping, the preparation margin of the
• 3D implant position: The screw-
implant abutment is generally a circum-
access opening in the abutment
ferential chamfer or rounded shoulder.
should not compromise mechani-
On the labial aspect, the margin is typi-
cal strength, and the circumferential
cally placed deeper than on the palatal
thickness should be at least 0.8 mm.
aspect, but should not extend more than
• Soft tissue thickness: A minimum of 3 mm is ideal.
1 mm subgingivally to avoid difficulties during cement removal. The abutment
• Interocclusal space: Sufficient abut-
should support approximately 90% of
ment height is required for ideal
the total surrounding soft tissue con-
strength and resistance.
tour, with the crown supporting no more
• Implant abutment color: The order of priority should be fluorescence/
38 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
than 10%.30
Gamborena and Blatz
The provisional restoration generally
while enamel has low fluorescent prop-
remains in place for 4 to 6 weeks until
erties.30–32 Ceramic coping materials
the position of the tissue is stable. A
such as alumina37 and zirconia39 do
final impression of the abutment should
not provide natural fluorescence and,
then be made to transfer this informa-
therefore, are treated with fluorescent
tion to the laboratory for fabrication of
modifiers and/or veneered with fluores-
the definitive restoration.
cent dentin stains, liners, and shoulder porcelains.30,37,39 As in natural teeth, the fluorescent effect is most prominent
Crown restoration
in the gingival third of the restoration. Therefore, natural fluorescence does
The definitive crown material is se-
not only influence the optical effects of
lected based on its core structure to
the restoration itself, but also greatly in-
enhance the optical characteristics of
fluences the color and appearance of
the intended restoration. The coping
the surrounding soft tissues.30
is chosen by its ability either to mask
Figures 41 to 55 show the selection
underlying structures or to complement
of the definitive coping material and the
the underlying abutment color. Zirconia
final outcome of Case 3. Figures 41 and
is increasingly used as a coping ma-
42 reveal the influence of fluorescent
terial due to its versatility in respect to
stains on the value and chroma of alu-
strength, thickness, color, and translu-
mina and zirconia copings under natu-
cency, but especially due to its inherent
ral and UV light. The impact of using a
brightness and options for fluorescence
fluorescent (Fig 43) versus a nonfluo-
through infiltration.13–17,30 It seems only
rescent coping (Fig 44) is quite obvious
logical that when a fluorescent abut-
on the stone cast (Figs 45 and 46) and
ment is used, the material selected for
even more so in the oral cavity (Figs 47
the definitive crown should also offer a
to 55). The definitive implant-supported
certain degree of fluorescence to match
crown shows optical and fluorescent
It is
properties that ideally match the exist-
important to evaluate the optical prop-
ing natural dentition under various light
erties of the coping in relation to the
sources.
the adjacent natural
dentition.30–32
remaining natural dentition under different light sources. UV light reveals the dramatic effects of fluorescence, which
Lip line
provides the vitality and brightness exhibited by natural teeth.
A high lip line or “smile line” that reveals
Fluorescence is an inherent property
all anterior teeth and large amounts of
of natural teeth31,32 but is rarely found
gingival tissue7,8 is a great challenge
in “esthetic” dental
materials.33–40
In
for the dental team since it is impossible
natural teeth, the root and coronal den-
to hide the implant-restorative interface.
tin show the highest degree of fluores-
A high smile line may be due to vertical
cence, especially in the gingival third,
maxillary excess or a hypermobile lip.
39 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 3 Continued
Fig 41 The influence of fluorescent stains on
Fig 42 Fluorescent properties of alumina and
the value and chroma of alumina and zirconia
zirconia copings under UV light: (a and c) without
copings under natural light: (a and c) without
fluorescence; (b and d) with fluorescence.
fluorescence; (b and d) with fluorescence.
Fig 43 Definitive fluorescent abutment on the
Fig 44 Nonfluorescent coping on the cast
stone cast demonstrating ideal fluorescence
under UV light.
under UV light.
Fig 45 Fluorescent coping on the cast under
Fig 46 Definitive crown showing fluorescent
UV light.
properties under UV light.
It is a common rule that, besides be-
canines, while the margins of the lateral
ing symmetric, the most cervical aspect
incisors should be approximately 1 mm
of the gingival margins of the central in-
below an imaginary line drawn from
cisors should be at the same level as the
the canine-centrals-canine.1 It seems
40 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Gamborena and Blatz
Case 3 Continued
Fig 47 Intraoral try-in of definitive crown under
Fig 48 Intraoral try-in under UV light demon-
natural light shows an excellent blend with the
strates ideal blending of the fluorescent properties
shade of the adjacent teeth.
of the definitive crown with the adjacent teeth.
Fig 50 Postoperative occlusal view showing the soft tissue support and contour.
Fig 49 Definitive implant restoration. Fig 51 (right) The definitive abutment and restoration provide the same degree of fluorescence as a natural tooth.
advisable for central incisor implant
extremely helpful to counterbalance
restorations to initially place the gingi-
tissue recession typically seen over
val margin slightly more incisally. This
time. The CTG now becomes an essen-
slight “overcompensation” will prove
tial aspect for functional and esthetic
41 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 3 Continued
Fig 52 Postoperative view under natural light
Fig 53 Postoperative view under UV light
showing the color match of the implant-supported
showing the ideal blend of fluorescent properties
crown with the natural dentition.
between the restoration and natural dentition.
Fig 54 Postoperative intraoral situation. No gray zone is evident.
Fig 55 One-year postoperative periapical radiograph of the implant at the left central incisor site.
integration of the implant-supported
natural and implant-supported teeth.
restoration, especially in the presence
The added connective tissue causes
of a high lip line.
the fibrotic mucosa around the implant
Occasionally, unfavorable changes
to migrate more coronally. In rare cas-
of the gingival margin levels may occur
es, the additional soft tissue becomes
at the teeth adjacent to the implant res-
so abundant that a gingivectomy fol-
toration. These are based on the dis-
lowed by a fibrotomy becomes neces-
tance between the free gingival margin
sary to establish ideal crown lengths
and the supporting bone and may re-
and gingival margin contours.
quire more extensive tissue grafting
The unfavorable umbrella effect is
to control gingival levels at both the
most prevalent in patients with a high
42 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Gamborena and Blatz
Case 4
Fig 56 Intraoral view of the definitive zirconia
Fig 57 A CTG was placed earlier to ensure
abutment.
ideal soft tissue thickness.
Fig 58 Intraoral situation after 1 year reveals
Fig 59 Preoperative view showing the patient’s
differences in peri-implant soft tissue color and
high lip line.
morphology.
Fig 60 Postoperative situation. An unfavorable
Fig 61 A high smile reveals the gray zone
gray zone is visible during an average smile.
through the umbrella effect.
smile line.6 The gray zone may become
the upper lip, causing a shadow on the
visible at the implant restoration site
soft tissue and the light to be reflected
even when all of the key factors are im-
and transferred in a different manner.
plemented perfectly. Differences in soft
Case 4 (Figs 56 to 61) demonstrates
tissue thickness and volume may cause
a situation in which the maxillary left cen-
these color dissimilarities, which are
tral incisor was replaced with an implant-
then amplified by the shear presence of
supported crown in a patient with a high
43 VOLUME 1 • NUMBER 1 • FALL 2011
Gamborena and Blatz
Case 5
Fig 62 Intraoral view of the crown prepara-
Fig 63 UV light reveals the natural fluores-
tion of the right central incisor and the definitive
cence of the modified zirconia implant abutment.
colored zirconia implant abutment at the left central incisor.
Fig 64 Preoperative intraoral view of the failing
Fig 65 Postoperative intraoral situation show-
central incisor crowns.
ing the color and soft tissue match.
Fig 66 Initial situation. Note the high lip line.
Fig 67 Successful implementation of the five key factors prevented the appearance of a gray zone despite the high smile line.
smile line. A CTG was placed to en-
In contrast to the previous case,
hance the soft tissue contours. While all
Case 5 (Figs 62 to 67) exemplifies
of the key aspects were implemented
successful implementation of these
successfully, the slight differences in
key factors in a patient with a high lip
soft tissue volume created an unfavora-
line for long-term esthetic and func-
ble grayish effect (Figs 60 and 61).
tional success.
44 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Gamborena and Blatz
Conclusions
Acknowledgments
Five key factors were identified to avoid
The authors would like to thank Iñigo Casares for the beautiful porcelain work featured in this article and Fernando Zozaya for the detailed fabrication on the zirconia abutments.
the gray zone around maxillary anterior implant restorations: 3D implant placement, soft tissue thickness, abutment selection, crown restoration, and lip line. Mimicking the inherent optical properties, especially fluorescence, of natural teeth with ideal prosthetic implant components and crown materials is fundamental for ultimate restorative and soft tissue esthetics.
References 1. Chiche G, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Chicago: Quintessence, 1994. 2. Matthews TG. The anatomy of a smile. J Prosthet Dent 1978; 39:128–134. 3. Fradeani M. Esthetic Analysis: A Systematic Approach to Prosthetic Treatment. Chicago: Quintessence, 2005. 4. Bitter RN. The periodontal factor in esthetic smile design—Altering gingival display. Gen Dent 2007;55:616–622. 5. Blatz MB, Hürzeler MB, Strub JR. Reconstruction of the lost interproximal papilla—Presentation of some surgical and non-surgical procedures. Int J Periodontics Restorative Dent 1999;19:395–406. 6. Magne P, Magne M, Belser U. The esthetic width in fixed prosthodontics. J Prosthodont 1999;8:106–118. 7. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent 1978;39:502–504. 8. Passia N, Blatz MB, Strub JR. Is the smile line a valid parameter for esthetic evaluation? A review of the literature. Eur J Esthet Dent (in press).
9. Fradeani M. Evaluation of dentolabial parameters as part of a comprehensive esthetic analysis. Eur J Esthet Dent 2006;1:62–69. 10. Gamborena I, Blatz MB. Current clinical and technical protocols for single-tooth immediate implant procedures. Quintessence Dent Technol 2008;31:49–60. 11. Holst S, Blatz MB, Hegenbarth E, Wichmann M, Eitner S. Prosthodontic considerations for predictable single-implant esthetics in the anterior maxilla. J Oral Maxillofac Surg 2005;63(suppl 2):89–96. 12. Kois JC, Kan JY. Predictable peri-implant gingival aesthetics: Surgical and prosthodontic rationales. Pract Proced Aesthet Dent 2001;13:691–698. 13. Blatz MB, Bergler M, Holst S, Block M. Zirconia abutments for single-tooth implants— Rationale and clinical guidelines. J Oral Maxillofac Surg 2009;67(suppl):74–81. 14. Yildirim M, Edelhoff D, Hanish O, Spiekermann H. Ceramic abutments—A new era in achieving optimal esthetics in implant dentistry. Int J Periodontics Restorative Dent 2000;20:81–91.
15. Jung RE, Sailer I, Hämmerle CH, Attin T, Schmidlin P. In vitro color changes of soft tissues caused by restorative materials. Int J Periodontics Restorative Dent 2007;27:251–257. 16. Jung RE, Holderegger C, Sailer I, Khraisat A, Suter A, Hämmerle CH. The effect of all-ceramic and porcelainfused-to-metal restorations on marginal peri-implant soft tissue color: A randomized controlled clinical trial. Int J Periodontics Restorative Dent 2008;28:357–365. 17. van Brakel R, Noordmans HJ, Frenken J, de Roode R, de Wit GC, Cune MS. The effect of zirconia and titanium implant abutments on light reflection of the supporting soft tissues [epub ahead of print 20 Jan 2011]. Clin Oral Implants Res. 18. Garber DA. The esthetic dental implant: Letting restoration be the guide. J Am Dent Assoc 1995;126:319–325. 19. Grunder U. Crestal ridge width changes when placing implants at the time of tooth extraction with and without soft tissue augmentation after a healing period of 6 months: Report of 24 consecutive cases. Int J Periodontics Restorative Dent 2011;31:9–17.
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20. Linkevicius T, Apse P, Grybauskas S, Puisys A. The influence of soft tissue thickness on crestal bone changes around implants: A 1-year prospective controlled clinical trial. Int J Oral Maxillofac Implants 2009;24:712–719. 21. Speroni S, Cicciu M, Maridati P, Grossi GB, Maiorana C. Clinical investigation of mucosal thickness stability after soft tissue grafting around implants: A 3-year retrospective study. Indian J Dent Res 2010;21:474–479. 22. Wiesner G, Esposito M, Worthington H, Schlee M. Connective tissue grafts for thickening peri-implant tissues at implant placement. Oneyear results from an explanatory split-mouth randomised controlled clinical trial. Eur J Oral Implantol 2010;3:27–35. 23. Esposito M, Grusovin MG, Maghaireh H, Coulthard P, Worthington HV. Interventions for replacing missing teeth: Management of soft tissues for dental implants. Cochrane Database Syst Rev 2007;(3):CD006697. 24. Fürhauser R, Florescu D, Benesch T, Haas R, Mailath G, Watzek G. Evaluation of soft tissue around single-tooth implant crowns: The pink esthetic score. Clin Oral Implants Res 2005;16:639–644. 25. Att W, Kurun S, Gerds T, Strub JR. Fracture resistance of single-tooth implant-supported all-ceramic restorations after exposure to the artificial mouth. J Oral Rehabil 2006; 33:380–386.
26. Nothdurft FP, Merker S, Pospiech PR. Fracture behaviour of implant-implantand implant-tooth-supported all-ceramic fixed dental prostheses utilising zirconium dioxide implant abutments. Clin Oral Investig 2011;15: 89–97. 27. Scarano A, Piattelli M, Caputi S, Favero GA, Piattelli A. Bacterial adhesion on commercially pure titanium and zirconium oxide disks: An in vivo human study. J Periodontol 2004;75:292–296. 28. Rimondini L, Cerroni L, Carrassi A, Torricelli P. Bacterial colonization of zirconia ceramic surfaces: An in vitro and in vivo study. Int J Oral Maxillofac Implants 2002;17: 793–798. 29. Degidi M, Artese L, Scarano A, Perrotti V, Gehrke P, Piattelli A. Inflammatory infiltrate, microvessel density, nitric oxide synthase expression, vascular endothelial growth factor expression, and proliferative activity in periimplant soft tissues around titanium and zirconium oxide healing caps. J Periodontol 2006;77:73–80. 30. Gamborena I, Blatz MB. Fluoresence—Mimicking nature for ultimate esthetics in implant dentistry. Quintessence Dent Technol 2011;34:7–23. 31. Benedict HC. A note on the fluorescence of teeth in ultra-violet rays. Science 1928;67:442. 32. Araki T, Miyazaki E, Kawata T, Miyata K. Measurements of fluorescence heterogeneity in human teeth using polarization microfluorometry. Appl Spectrosc 1990;44:627–631.
46 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
33. Lee YK, Lu H, Powers JM. Fluorescence of layered resin composites. J Esthet Restor Dent 2005;17:93–100. 34. Tani K, Watari F, Uo M, Morita M. Discrimination between composite resin and teeth using fluorescence properties. Dent Mater J 2003;22:569–580. 35. Sant’Anna Aguiar Dos Reis R, Casemiro LA, Carlino GV, et al. Evaluation of fluorescence of dental composites using contrast ratios to adjacent tooth structure: A pilot study. J Esthet Restor Dent 2007;19:199–206. 36. Monsénégo G, Burdairon G, Clerjaud B. Fluorescence of dental porcelain. J Prosthet Dent 1993;69:106–113. 37. Komine F, Blatz MB, Yamamoto S, Matsumura H. A modified layering technique to enhance fluorescence in glass-infiltrated aluminum oxide ceramic restorations: Case report. Quintessence Int 2008;39: 11–16. 38. Marchack BW, Futatsuki Y, Marchack CB, White SN. Customization of milled zirconia copings for all-ceramic crowns: A clinical report. J Prosthet Dent 2008;99:169–173. 39. Nik Mohd Polo Kinin NM, Wan Mohd Arif WI, Zainal Arifm A. Study on the effect of Y2O3 addition to the fluorescent property of dental porcelain. Med J Malaysia 2004;59 (suppl B):23–24. 40. Ferreira Zandoná AG, Kleinrichert T, Analoui M, Schemehorn BR, Eckert GJ, Stookey GK. Effect of two fluorescent dyes on color of restorative materials. Am J Dent 1997;10:203–207.
Determining the Influence of Flowable Composite Resin Application on Cuspal Deflection Using a Computerized Modification of the Strain Gauge Method Hamdi H. Hamama, BDS, MDS Assistant Lecturer, Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
Nadia M. Zaghloul, BDS, MDS, PhD Associate Professor, Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
Ossama B. Abouelatta, BEng, MSc Engg, PhD Associate Professor, Production Engineering and Mechanical Design Department, Faculty of Engineering, Mansoura University, Mansoura, Egypt.
Abeer E. El-Embaby, BDS, MDS, PhD Lecturer, Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, Mansoura, Egypt.
Correspondence to: Dr Hamdi H. Hamama Conservative Dentistry Department, Faculty of Dentistry, Mansoura University, PO Box 35516, Mansoura, Egypt. Email: [email protected]
48 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
This study evaluated the influence of the application of flowable composite resin on cuspal deflection using a computerized modification of the strain gauge method. Forty sound extracted mandibular molars, which received a mesioocclusodistal slot preparation, were divided into two groups of 20 molars each based on the type of restorative materials used. Each group was further divided into two subgroups of 10 molars each relative to the application of flowable composite resin at cavity internal line angles. Cuspal deflection was measured using a new computerized modification of the strain gauge method. The mean cuspal deflection values (µm/m) and standard deviations were calculated and subjected to normality and homogeneity of variances tests. If they passed the tests, they were subjected to parametric statistical analysis (independent sample t test). The results showed that groups containing flowable composite resin exhibited higher cuspal deflection values than groups without flowable composite resin. The application of flowable composite resin at the internal cavity line angles increased cuspal deflection, possibly due to the material’s high volumetric shrinkage levels, which exerted more stress at the tooth-restoration interface. Further, the validity of the new computerized modification of the strain gauge method was proven by the agreement found between the output results and those of previous studies of cuspal deflection. (Am J Esthet Dent 2011;1:48–59.)
49 VOLUME 1 • NUMBER 1 • FALL 2011
Hamama et al
R
apid development of resin-based
line angles is one of the most contro-
dental composites is one of the
versial topics in dentistry. Some stud-
main characteristics of modern esthetic
ies support its use due to its stretching
dentistry. Resin-based composite is now
capability (ie, its low Young modulus
widely used as an alternative to amal-
of elasticity), which provides sufficient
gam in stress-bearing areas.1 Consider-
elasticity to relieve polymerization con-
ing the polymeric nature of composite
traction
resin, it has an inherited volumetric po-
some studies suggest that the appli-
lymerization
that
cation of flowable composite resin in-
leads to contraction stresses at the
creases contraction stresses due to the
shrinkage
restoration-cavity
property
interface.2
This poly
stresses.5,10–14
In
contrast,
material’s high resin content.15–17
merization shrinkage has been reported
Cuspal deflection is a common bio-
to be one of the factors directly respon-
mechanical phenomenon observed in
sible for marginal leakage at the com-
teeth restored with composite resin. It
interface.3
results from the interactions between
The interaction of the polymerization
the polymerization shrinkage stresses
shrinkage stresses and the adhesive
of the composite resin and the com-
bond plays a large role in the long-term
pliance of the cavity wall.18 There are
function of a composite resin restora-
many methods to measure cuspal de-
tion. At sites where these stresses are
flection, including noncontact methods
higher than the bond strength between
(photography,19 microscopy,20,21 laser
the restoration and dental substrate, a
scanning,22
microgap will form, increasing the prob-
microcomputed
ability of postoperative sensitivity and
contact
recurrent caries.4,5 On the other hand,
interferometers,25
if the bond strength is higher than the
able
polymerization
stresses,
Because these methods depend pri-
the stresses will transfer to the cusps,
marily on measuring the difference
posite restoration–cavity wall
contraction
resulting in cuspal
deflection.2,6–8
A class of low-viscosity composite
and
three-dimensional
tomography23)
methods
differential
(strain and
and
gauge,6,24 linear
vari-
transformers26–29).
between precuring and postcuring values, they have not provided detailed
“flowable”
data regarding how cuspal deflection
composite resins, has been commer-
happens in relation to time. However,
cially introduced for restorative dentist-
the present authors introduce a modi-
ry. Flowability is regarded as a desirable
fication of the strain gauge method,
handling property because it allows the
which was developed in cooperation
material to be injected through small-
between the engineering and dental
gauge dispensers, thus simplifying the
teams of this study.
resins,
commonly
called
placement procedure and amplifying
This study was designed to evaluate
the range of applications suggested
the effect of the application of flowable
by the manufacturers.9,10 The effective-
composite resin on cuspal deflection of
ness of flowable composite resin as an
mesio-occlusodistal (MOD) composite
intermediate layer at the internal cavity
restorations. Cuspal deflection was
50 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Hamama ET AL
Table 1 Composite resin systems used in this study Material
Scientific classification
Trade name
Batch no.
Manufacturer
Tetric EvoCeram HB
J13387 J14049
Ivoclar Vivadent
Composite resin Restoration
Nanohybrid
Restoration liner
Nanohybrid
Bonding system
Filled, light-curing single component bonding agent for enamel and dentin in conjunction with the acid etch technique Etching gel containing 37% phosphoric acid
VOCO
Grandio Tetric EvoFlow
K15010
Grandio Flow
Ivoclar Vivadent VOCO
Excite
J25791 J25793
Ivoclar Vivadent
Total Etch
J25470 K20207
Ivoclar Vivadent
measured using the new modification
distance. The collected molars were
of the strain gauge method. The null
observed under magnification (×10) in
hypothesis was that application of flow-
a binocular stereomicroscope (LOMO
able composite resin does not increase
SF-100 Binocular Stereo Microscope,
the cuspal deflection of MOD compos-
MBC-10). Teeth with preexisting cracks,
ite resin restorations.
caries, or attrition were discarded. The selected molars were carefully cleaned using
Materials and methods
an
ultrasonic
scaler
(UDS-J
Ultrasonic Scaler, Ningbo Sunglow Imp & Exp) and then debrided with pumice
The materials used in this study are
(Americos Industries) using a rotary
listed in Table 1.
brush (Merssage Brush, Shofu). The molars were disinfected with 0.2% so-
Tooth selection and preparation
dium azide solution for 48 hours.30 To prevent dehydration, they were stored
A total of 40 sound extracted mandibu-
in physiologic saline for a period of no
lar molars were collected from the Oral
more than 1 month at 37°C until the
Surgery Department, Faculty of Den-
time of the test.
tistry, Mansoura University, Mansoura,
The molars were randomly divid-
Egypt. The patients were informed that
ed into two groups (20 molars each)
the voluntarily donated extracted teeth
based on the restorative material used
would be used for research purposes.
(Tetric EvoCeram or Grandio). Next,
To be included in the study, the mo-
each group was randomly subdivided
lars were required to have the following
into two subgroups (n =10) relative to
crown dimensions: 9-mm buccolingual
the application of flowable composite
distance and 10- to 11-mm mesiodistal
resin at the internal cavity line angles.
51 VOLUME 1 • NUMBER 1 • FALL 2011
Hamama et al
Each specimen received a nonreten-
connected to the gauge so that the
tive MOD slot preparation with the fol-
gauge constituted one-half of a Wheat-
lowing criteria: occlusogingival depth
stone bridge, with the other half internal
of 4 ± 0.3 mm without an axial wall and
to the strain gauge indicator. One layer
a buccolingual diameter of 3 ± 0.3 mm.
of the Excite universal bonding system
The remaining buccal and lingual cav-
was applied and cured using a light-
ity walls were measured using an elec-
curing
tronic digital caliper (MAX-CAL) after
Vivadent) at 800 mW/cm2 for 20 sec-
preparation for verification of the buc-
onds. The light intensity was checked
colingual diameter. The preparation
by
was carried out using a no. 59 carbide
Ivoclar Vivadent) prior to performing
bur (Komet Dental).
the test to confirm that the light inten-
unit
(Bluephase
radiometer
C8,
(Bluephase
Ivoclar
Meter,
sity was not less than 700 mW/cm2.
Cuspal deflection test
The teeth were restored with resinbased composite materials in shade
A 3-cm polyvinyl chloride tube was filled
A2 according to the following groups:
with acrylic resin (Rapid Repair, Dentsply) in the dough stage. The molar’s
• Group A: Flowable composite resin
roots were positioned at the tube center
(Tetric EvoFlow) was applied at the
and parallel to its long axis, leaving the
internal cavity line angles with a
crown and 2 mm of the root below the
small-gauge needle and cured for
cementoenamel junction uncovered to
20 seconds. Tetric EvoCeram was
accommodate the leads of the strain
inserted horizontally in increments.
gauge. A dental surveyor was used to
Each increment was approximately
verify that the tooth was parallel to the
2-mm thick and cured for 60 sec-
tube. After setting of the acrylic resin,
onds: 20 seconds from the occlusal
the parallelism of the cavity buccal
aspect, 20 seconds from the mesial
and lingual walls was confirmed by the
aspect, and 20 seconds from the
same surveyor.
distal aspect.
All prepared cavities were etched
• Group B: This group was similar to
using Total Etch for 15 seconds accord-
group A, except it did not receive
ing to the manufacturer’s instructions.
flowable composite resin prior to in-
Two precision strain gauges (KFG-2N-
sertion of Tetric EvoCeram.
120-C1-11L1M2R, Kyowa Electronic
• Group C: Flowable composite resin
Instruments) were attached to the buc-
(Grandio Flow) was applied at the
cal and lingual surfaces of each unre-
internal cavity line angles with a
stored specimen and bonded with
small-gauge needle and cured for
epoxy adhesive resin (Strain Gauge
20 seconds. Grandio was inserted
Cement, Kyowa Electronic Instruments)
horizontally in increments. Each in-
to the middle third of the cavity’s exter-
crement was approximately 2-mm
nal buccal and lingual walls (Fig 1). The
thick and cured for 60 seconds: 20
leads of the strain gauge indicator were
seconds from the occlusal aspect,
52 THE AMERICAN JOURNAL OF ESTHETIC DENTISTRY
Hamama ET AL
Personal computer Strain indicator program AD card Tooth fixation 3-channel amplifier Curing unit
a Fig 1 (above) Buccal view of the strain gauges bonded to the middle third of the external cavity wall. Fig 2a to 2c (right) The strain measurement system.
b
c
20 seconds from the mesial aspect,
The present study is based on the data
and 20 seconds from the distal as-
range, ie, the difference between the
pect.
maximum and minimum strain values.
• Group D: This group was similar to group C, except it did not receive
However, the data curves will be analyzed in detail in future studies.
flowable composite resin prior to in-
Strain measurement system
sertion of Grandio. During
polymerization,
the
strain
The strain measurement system con-
gauge recorded the changes in volt-
sisted
age signals, which were then amplified
circuit (Metrology Lab, Faculty of En-
by the recording system. The ampli-
gineering, University of Mansoura), an
fied signals were transferred using an
AD card, and a personal computer with
analog-to–digital converter (AD) card
the Strain Indicator Program (SIProg),
to a specially designed computer pro-
which was designed for this study by
gram (SIProg) for analysis. The results
Dr Abouelatta (Fig 2).
of
a
three-channel
amplifier
appeared as a curve between the time
SIProg was fully written in house us-
(seconds) and strain values. These
ing Matlab packages. The main inter-
readings for the Wheatstone bridge
face is shown in Fig 3. It consists of
are directly proportional to the internal
a title bar, menu bar, measuring infor-
cuspal deflection of the buccal and
mation panel, processing panel, option
lingual cusps of tested specimens.31
panel, and display area. To calibrate
53 VOLUME 1 • NUMBER 1 • FALL 2011
Hamama et al
Title bar Menu bar Display area
Fig 3 Graphical user interface of the Strain Indicator Program (SIProg).
the strain measuring system, specific
microstrain (με) values were applied
statistically significant when P < .05 with a confidence level of 95%.
on a sample tooth. The strain measurements were recorded using P-3500 Strain Indicators and SB-10 Switch and
Results and discussion
Balance Units (Vishay Measurements Group). The same values were record-
The independent sample t test showed
ed by the system in millivolts. A graph
a statistically significant difference (P