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Natural
Esthetics Comes Easy by Dr. Montri Chantaramungkorn
DDS
Esthetic
dentistry has become an integral part of
everyday practice in a dental clinic. With
the increasing patient demand, it has also
become a challenging job for our profession.
Fortunately, with the armamentarium at our
disposal we can meet the various needs of
patients quite satisfactorily. While all
ceramic crowns are arguably one of the best
alternatives in indirect esthetic restorations,
composite are not no doubt the best material
for direct esthetic restorations.
In
recent years, many dental manufacturers
have introduced composites with new formulations
that allow us to create excellence in this
field. Unsurpassed physical properties permit
the utilization of more and more composites
in stress-bearing areas. Good polishability
provides near-ceramic quality esthetic results.
There are, however, several dilemmas, that
seem to be common to all these modern-day
composites; and that is, every one of them
has many shades and opacities. In order
to be prepared for different circumstances,
we often have to stock 30 or more different
shades in multiple opacities, some of which
may never see the light of day before expiry.
The other "problem" is that no
manufacturer seems to be able to tell us
how thick each opacity should be. In the
end, we are left to "expand our artistic
minds". Only after numerous trials
and errors can we master the art of this
so-called layering technique. In essence,
experience counts.
Dentsply,
one of the leaders in composite technology,
has recently introduced a composite - Ceram X ,
that addresses these issues very effectively.
First of all, instead of 30 or 40 shades,
it only has 7 shades. With these 7 shades,
it already covers the entire Vita1
range. Is it possible, you may wonder? The
answer is a surprising "yes".
Apparently, if we group the 16 Vita shades
according to their lightness & chroma,
we can roughly categorize them into 7 groups.
Try this experiment yourself: group A1 &
B1, then A2 with B2, A3 & D3; can you
tell much difference? If you are thinking
of what I was thinking when I first encountered
this material: does it mean that I can reduce
the inventory of my clinic substantially?
Then the answer will again be a happy "yes".
The
other thing that CeramX
tackles is the thickness issue. How thick
should the dentin and enamel layers, respectively,
be? According to the manufacturer, this
material can replace dentin with a composite
of dentin-like opacity and high chroma while
the enamel can be replaced with something
having similar translucency as that of natural
enamel. To be honest, I had my doubts in
the beginning. As with all dentists, there
is only one way to find out: to try it in
an actual case. And the results were again
amazingly natural. In fact, come to think
of it, the so-called layering technique
is no longer as complicated as it used to
be. When I see dentin, I use the dentin
shade; when I see enamel, I switch to the
enamel shade. And we can always distinguish
between dentin & enamel, right?
You
may also ask, "Do I have to use two
opacities in all my cases?" The answer
is: no. CeramX
is available in 2 versions - Mono &
Duo. Although it is advisable to use the
afore-mentioned Duo version for Class IV's,
diastema closures and other more esthetically-demanding
cases, the Mono version is recommended for
posterior restorations, Class V's &
smaller Class III's.
Let
me share with you one of the cases that
I've done recently.
During
routine oral examination of a 37-year old
female patient, it was discovered that the
composite restorations on her two maxillary
central incisors had discolored and had
in fact become quite unsightly. Upon explanation,
the patient agreed to have them replaced
with a more advanced, longer-lasting composite
material. (Figure 1)
CeramX
was decided as the
material of choice. Obtaining the shade
for CeramX
proved
to be very easy. As usual, the Vita1
shade guide was used. After matching the
shade (in this case, A2), it was cross-referred
to the CeramX
i-shade guide, a sticker label that could
be adhered the back of any Vita1
shade guide. (Figure 2)
For
those of you who do not use Vita1
shade guides, CeramX
shade guides made of the original material
are also provided with the kits.
To
ensure proper isolation, the rubber dam
was applied to the involved teeth. (Figures
4 & 5)
Slight
bevel preparations were done on both the
labial & palatal surfaces. This step
was mainly to ensure that there would be
a more gradual blend of the composite into
the surrounding tooth structures. It also
increased the effectiveness of etching and
bonding procedures. (Figure 6)
Normal
etching and bonding procedures were done.
We may choose the total-etch technique (with
Dentsply's Prime&Bond NT ,
for example) or self-etch technique (with
Dentsply's XenoIII,
for example). (Figure 7)
CeramX
Duo
D2 was first placed on the palatal surface.
Because of the non-slumping characteristic
of this material, free hand buildup of this
layer was entirely possible. I know some
colleagues who also use their free thumb
to act as support during the initial placement.
This first layer was crucial as it would
fulfill the role of a firm backing for subsequent
layering of other layer(s). It also replaced
the palatal dentin. (Figure 8)
Due
to higher chroma of CeramX
Duo
dentin shades, it is an ideal material for
replacement of the more opaque natural dentin.
We should also use our clinical judgement
when determining the thickness of the dentin
layer in incisal fracture & diastema
closure cases. For instance, a thicker dentin
layer must be used if the surrounding natural
teeth are not so translucent (like in elderly
patients). Yet, as mentioned above, the
"guessing" work is very much kept
to a minimal when it comes to this material.
(Figure 9)
This
first layer could then be cured with either
a halogen light or LED light. In this case,
I used the Dentsply SmartLite
IQ LED light. Curing time was 40 seconds
(due to the more opaque nature). (Figure
13)
CeramX
Duo
E2 was then used for replacement of the
more translucent enamel. (Figure 10)
The
handling of this material is also terrific
- not sticky at all. This is regardless
of whether I am using a Teflon-coated or
stainless-steel instrument or even a plastic
one. The non-slumping nature of
CeramX
also
makes carving, sculpting & recreation
of tooth morphology very easy, not to mention
tremendous chairtime saving. (Figure 11)
Prior
to curing the enamel layer, I used a flat-end
artist brush to smoothen the restoration
surfaces. This helps blending of the material
into the surrounding tooth structures. This
seemingly-extra step actually makes the
finishing & polishing procedures easier
& faster. (Figure 12)
The
enamel layer was then cured. Curing time
was only 10 seconds with the SmartLite
IQ LED light. (Figure 13)
After
curing, it was noticed that composite surfaces
seemed to be more translucent than the adjacent
natural tooth surfaces. This was due to
dehydration under prolonged rubber dam isolation.
(Figure 14)
The
restoration was then finished using routine
methods. (Figure 15)
Dentsply's
PoGo
one-step diamond micro-polisher was used
next. (Figure 16)
The
final polish was accomplished using Dentsply's
Enhance Prisma Gloss polishing paste. This
step allowed the CeramX
restoration
to blend invisibly into the adjacent natural
tooth structures. (Figure 17)
CeramX
really makes my life more enjoyable! I
hope it will to you too!
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Fig.
1: Preoperative picture of 37-year old
female patient with 2 unsightly old
Class IV composite resin restorations
on teeth #11 & #21. |
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Fig.
2: CeramX
Duo is designed to have easy manipulation
and is dentist-friendly. Shade matching
with Vita1
shade guide prior to restorative procedures
can be easily cross-referred to the
I-shade label for proper CeramX
shade selection. In this case, A2 Vita1
shade was was the closest match, equivalent
to the I-shade label for CeramX
Duo shade E2 and D2. |
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Fig.
3: Preoperative picture (tooth # 11
& 21). |
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Fig.
4: After rubber dam placement |
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Fig.
5: Preoperative picture under rubber
dam (palatal view). |
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Fig.
6: Tooth reduction (bevels are created
for better esthetic purposes). |
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Fig.
7: Acid etching. |
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Fig.
8: CeramX
Duo dentin shade placed first on the
palatal side of the cavity to act as
a support and also to replace dentin
at the same time. |
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Fig.
9: CeramX
Duo dentin shade replaces dentin with
dentin-like opacity and high chroma
nature of natural dentin.
Clinical Tips: The thickness of dentin
shade layer depend on opacity of the
restoring tooth; use thicker layer of
dentin shade when tooth being restored
appeared less translucent. |
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Fig.
10: A layer of corresponding:
CeramX
Duo enamel shade E2 (according to the
I-shade label) replaces enamel with
enamel - like translucency. |
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Fig.
11: The non-sticky, no-slump properties
of CeramX
(as proven by a handling evaluation,
performed in private practice and university)
makes sculpting to appropriate tooth
contour very easy thus saving much chair-time
& makes a dentist's life more enjoyable! |
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Fig.
12: Clinical Tips: Flat-end artist
brush helps smoothen restoration surfaces
and blends the restoration nicely into
the surrounding tooth structures prior
to light curing, thus making finishing
and polishing more efficient, faster
and easier. |
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Fig.
13: Light cure the restoration with
Dentsply SmartLite
IQ LED Light Curing system.
For
dentin shade light curing time is
40 sec. For enamel shade light curing
time is only 10 sec.
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Fig.
14: CeramX
Duo restoration after light-curing but
prior to finishing. (Note that the restoration
is a bit more translucent than the adjacent
tooth structures because the involved
teeth have been dehydrated during rubber
dam isolation) |
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Fig.
15: The finished CeramX
Duo restoration on teeth # 11 &
21 after rehydration |
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Fig.
16: The CeramX
Duo restoration after polishing with
PoGo one-step diamond micro-polisher |
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Fig.
17: The CeramX
Duo restorations after final polishing
with Enhance polishing paste will blend
nicely with adjacent shiny natural enamel. |
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Fig.
18: CeramX
Duo Class IV restorations (immediate
postoperative picture). |
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Fig.
19: CeramX
Duo Class IV restorations at 3-week
recall. |
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| Dr.
Montri Chantaramungkorn
(DDS) is a successful full-time
private practitioner specializing
in Comprehensive Restorative
and Cosmetic Dentistry in
Chiangmai, Thailand. He
has been teaching Esthetic
Dentistry at Chiangmai University
since 1985 and was the Chairman
of Department of Restorative
Dentistry at Chiangmai University
from 1993 to 2002. He is
also a Diplomate of the
Thai Board of Operative
Dentistry and enjoys giving
lectures on current materials
and techniques on newly
developed material in Restorative
Dentistry. |
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of VITA Zahnfabrik Rauter GmbH & Co.
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