Functional Aesthetics: Predictable Techniques for a Complete Ceramic Rehabilitation

Every case, no matter how complex or simple, revolves around the synergy between the 3 parties involved: the dentist, the dental technician, and the patient. Dr. Mike Malone and Mike Bellerino (A Certified Dental Technician) have a relationship that has lasted for more than 20 years. Even though they live several hours apart, they communicate constantly by telephone and via the Internet. They also share a common interest in completing complex dental reconstructions, usually with predictably excellent results, both aesthetically and functionally.
They understand the importance of the doctor-technician relationship in achieving great outcomes and have more in common than just a desire for excellent dental restorations. They also share a passion for running. When together at dental meetings and when lecturing together they will often discuss cases and lecture development while running, usually in the early morning hours. They have run in locations all over North America and beyond.
The purpose of this article by Dr. Malone and Mr. Mike Bellerino is to describe the way they handle an aesthetic restorative case, working creatively and technically as a cohesive doctor-technician team.

TREATMENT GOALS COME FIRST

Before starting on a complex restorative case, the goals for the case must be spelled out in advance. The priority is to identify the patientÌs needs and desires by completing a very comprehensive examination that starts with a preclinical interview. In addition, the goal for every case is to create a natural smile that is pleasing to the eye yet preserves as much tooth structure as possible. Time between the doctor and dental technician should be spent to select the best materials for the case, and to discuss techniques that will ensure longevity of the completed restoration(s).
As a doctor-technician team, Malone and Bellerino have developed systems for virtually every step of the dental restoration process. The key for consistently predictable results is to leave nothing to chance. Every step of the entire process is planned so that either the dentist or the technician is ac-countable for the final result of that step. If there is ever a problem or misstep in the process, one or both must be willing to accept responsibility and to make the necessary correction(s).

KEY STEPS IN THE RESTORATIVE PROCESS

The first step in every case is to perform a comprehensive diagnostic examination. The doctor needs to take the time with every patient in a preclinical interview to thoroughly discuss the patientÌs chief concerns and establish their priorities. A complete periodontal charting and comprehensive clinical examination is accomplished, along with a thorough temporomandibular joint disorder (TMJ) evaluation. Next, every case is evaluated with study models mounted in centric relation, along with a complete series of diagnostic radiographs and photographs.
After determining that the patientÌs goals and the completed treatment plan is congruent with their needs/desires, the patient is appointed for a smile design appointment. Using either a computer imaging and a direct composite mock-up (or sometimes both), the patient is able to participate in the planning process and can then be asked to accept the final goals for the smile design.
Next, an “Esthetic Wax-up Checklist” is completed in the dental office. The purpose of this checklist is to make sure that the dental technician receives all the information that is needed (along with equilibrated, mounted study models, photographs, and computer imaging) in order to complete an ideal wax-up of the desired aesthetic and functional result. The dental technician then communicates with the doctor using digital photographs (by e-mail) to confirm that the wax-up satisfies all the identified requirements before mailing the case back to complete the prototype templates.
Before the patient arrives for the preparation phase in the dental office, the dental assistant uses the diagnostic wax-up models to fabricate accurate templates so that the patientÌs prototype restorations will become an exact replica of the waxed models. Preparation templates are also fabricated from the waxed models to allow precise tooth preparation with minimal tooth reduction.
A rubber dam is used to isolate an entire arch for removing all old restorations and bases. Next, core buildups using dentin-colored hybrid composite resin are done wherever needed. Then, the preparations are completed and multiple impressions are taken with a syringable hydrocolloid and water-cooled hydrocolloid material. (At least 4 impressions are taken for every case, but usually 5 or 6 full-arch impressions are taken.)
The first impression is poured immediately in a quick set dental stone, and by the time all impressions are completed, a model is available for making the provisional restorations (or prototypes). The provisional restorations are called prototypes because every effort is made to ensure that the prototypes match the desired outcome for the final restorations. All of the prototypes, except for one central incisor, are cemented or spot-bonded in place. Another final impression is then taken for the trial-unit model. Then, the last central incisor prototype is placed and the patient is dismissed. After about one week, the patient returns for a reevaluation of the prototypes. Changes are made to the prototypes as needed in order to satisfy both the doctor and the patient. When the patient accepts the prototypes, he or she will sign a “prototype approval” form to begin the fabrication of the final restorations. The prototypes are photographed and accurate impressions and bite records are taken.
Using bite records taken in centric relation at the predetermined vertical relation, the sectioned and trimmed die models and prototype models are all mounted on a semi-adjustable articulator. All models are approved and mounted in the dental office. The doctor then verifies the accuracy of the mounting before the case is sent to the laboratory. Three sets of models are sent for every case: mounted sectioned die models, solid die models, and mounted prototype models. The doctor writes a detailed prescription detailing the aesthetics, occlusion, materials, etc, and the dental technician will now have everything needed to fabricate an ideal finished case.
The trial unit model is used to fabricate a trial unit of a single central with the desired shade, texture, translucency, and shape. The patient returns for the trial unit appointment. The doctor then removes the provisional for the single central and places the trial unit in the mouth with tryin gel for patient approval. After accepting the trial unit, the patient signs a “trial unit acceptance” form. This trial unit is not used in the final case, but the case can now be completed with assurance that the patient will not change their mind and reject the case because of the shade.
The dental technician will then complete the restoration using the prototype models as a guide. Nothing is left to chance. The technician also uses the solid models to confirm the fit and interproximal contacts of each unit. If there are any questions, he will use digital photography and e-mail to communicate with the doctor for resolution.
When the case is returned to the doctor’s office, accuracy is confirmed using another unused solid model that was retained in the patientÌs case pan (called the “hold back model”). The occlusion and anatomy are also checked before appointing the patient for the insertion. When each of these steps is completed, it is extremely rare that the case is not cemented at the insertion appointment. The occlusion is perfected, the porcelain polished, and a hard acrylic nightguard is fabricated for every case.
The final step in the complex restoration process is the reward. In addition to the financial restitution that comes with the many hours of hard work, the doctor-technician team can both take pride in knowing they have collaborated in a complicated series of steps. These joint and carefully orchestrated efforts will result in a ceramic reconstruction that will serve their patient for many years to come.

Figure 1. Keith wanted to improve his smile and replace all his existing gold and silver amalgam restorations.	Figure 2. Mounted models used for diagnosis and treatment planning.

Study models mounted in centric relation (Figure 2) showed most of the severe wear was restricted to the anterior teeth, as most of the posterior teeth had little loss of tooth structure. The vertical dimension of the arches with the teeth in centric relation allowed enough room to be able to restore the anterior teeth in an ideal relationship. The accepted treatment plan included 16 posterior all-ceramic crowns using zirconium oxide cores (Lava [3M ESPE], to be layered with a compatible layering porcelain (e.max [Ivoclar Vivadent]); and 12 pressed and layered porcelain (Empress Esthetic [Ivoclar Vivadent]) veneers.
The first step was to complete the “Smile Design” appointment. Computer imaging was used to create an aesthetic facsimile of the completed reconstruction (Figures 3a and 3b). Keith wanted no metal to show but he also wanted a “natural” look for his age. He did not want “super” white or an artificial look in his smile. After the smile design appointment, the aesthetic wax guide was completed and then sent to the dental technician (along with photographs and the computer image) for the complete wax-up at the desired vertical dimension. The dental technician dedicated enough time to complete a detailed wax-up that incorporated not only the aesthetics desired, but also ideal occlusion with carefully detailed anterior guidance and posterior centric stops (Figure 4).

Figure 4. The completed diagnostic wax-up.

Keith was appointed for 2 (full) consecutive days for the preparation and provisionalization phase of treatment. On the first day, the entire upper arch was anesthetized (Articaine [Septodont]) and isolated with a rubber dam. All teeth were reduced with the aid of a silicone reduction guide fabricated from the diagnostic wax-up. All of the existing restorations and old bases were removed. Several teeth had recurrent decay, which was removed, and buildups were then placed with a dual-cured composite (CosmeCore [Cosmedent]) with a dual-cure dentin adhesive system (Clearfil Liner Bond 2V [Kuraray]). The posterior crown preparations were completed allowing 1.0 mm of axial reduction and 2.0 mm of occlusal reduction (Figures 5a and 5b). The anterior veneer preparations were prepared conservatively, leaving the cingula intact and staying in enamel on the facial surfaces. Six hydrocolloid impressions were taken, 3 with Identic (DUX Dental) syringable bonding hydro and Identic (DUX Dental) alginate, and 3 with Slate (DUX Dental) reversible hydrocolloid in a water-cooled tray.
One of the alginate-to-hydrocolloid impressions was poured immediately with an ultra-fast setting stone (Snap Stone [Whipmix]). All the provisional restorations (crowns and veneers) were fabricated on the stone model with templates made from the wax-up model, using a recently introduced material called Radica (DENTSPLY). Radica is a highly aesthetic provisional material with excellent physical properties that make it ideal for long-term provisional applications. It comes in many shades and can be layered to create a prototype restoration that rivals the final in aesthetics and durability (Figures 6a and 6b).

Figure 8. Building the trial-unit veneer.	Figure 9. Patient accepts trial-unit veneer.

Figure 10. The completed case is tried on solid (“hold back”) models.

The provisionals for the posterior were temporarily cemented (Temp-Grip [DENTSPLY Caulk]) and the veneer provisionals were spot-bonded in place (Insure Yellow-Red Light resin cement [Cosmedent]). Since Keith flew into see us from out-of-state, he returned the next day (instead of the normal one week follow-up) for his post-op check to verify that the occlusion and aesthetics of the prototype restorations were acceptable. He was very comfortable and happy with the aesthetics of his new smile, so no changes were necessary (Figures 7a and 7b). Alginate impressions were taken of both arches, along with a bite record and digital photographs. After reviewing flossing and home care instructions, along with careful advice about eating with the temporary restorations, Keith was released and appointed to return a few weeks later for a trial unit try-in.
When placing the provisional restorations, all but one central incisor was cemented and an Identic (DUX Dental) Syringable impression was taken. The model was sent to the laboratory to fabricate one trial-unit veneer following the patientÌs desire for an aesthetic, but natural looking restoration. The dental technician chose an ETC1 (Empress Esthetic [Ivoclar Vivadent]) ingot shade to give this case the natural look that Keith desired. After waxing and pressing the veneer to full contour, he cut back the incisal portion of the veneer and developed the internal color characteristics with the porcelain layering material (Empress Esthetic [Ivoclar Vivadent]) (Figure 8).
Keith returned for the trial-unit appointment and the provisional veneer was removed. Next, the trial veneer was placed with a try-in gel (Prevue yellow-red light [Cosmedent]) and both the doctor and the patient evaluated the color, translucency, anatomy, and surface texture. The joint decision was to accept the trial unit as the dental technician had created it (Figure 9). Keith signed a “Trial Unit Approval Form” accepting the shade and agreeing to move forward with the full reconstruction using the trial as a guide. A series of digital photographs were taken with the trial veneer in place with the appropriate shade tabs. Then, the provisional veneer was recemented. (Note: The dental technician used the trial unit to help with the fabrication of the entire case, but he did not deliver the trial unit veneer back to the doctor for use as a final restoration. A new, final veneer was fabricated.)
While the trial unit was being fabricated, the doctor and his office team used the records taken earlier to mount the models on a semi-adjustable articulator (Artex [Jensen Industries]). These articulators allow the doctor and dental technician to accurately calibrate their respective instruments so that the models would be completely interchangeable. Since the final pinned die models and the models of the accepted provisionals were all interchangeable, the dental technician could duplicate the provisionals aesthetically and functionally. In this case, the doctor also included separate solid models to aid the technician in the fabrication process.
When the completed case was returned to the dental office, a fourth solid model was used to confirm the fit and interproximal contacts (Figure 10). The occlusion was also examined on the articulator before scheduling Keith for insertion. Using multiple impressions for multiple models helps eliminate mistakes, misfits, and remakes. This system also eliminates finger pointing in the rare instances when there are fit problems. Once it is confirmed that that the case fits all the models, and the occlusion is correct for the models mounted in his office, then the doctor accepts that the dental technician has followed the prescription correctly. If there is a problem with the fit or the occlusion when the case is delivered, then the doctor accepts the responsibility for the error (When the system is followed properly, errors are rare).
At Keith’s final insertion appointment, the maxillary provisionals were removed after anesthetizing the entire arch (Articaine [Septodont]). The individual restorations were tried on dry for fit and then they were all tried in with the try-in paste (Prevue Yellow-Red Light [Cosmedent]). Keith accepted the restorative aesthetic try-in and signed the approval form before the restorations were finally cemented. The posterior restorations were cemented with a self-etching, dual-cured resin cement (RelyX Unicem [3M ESPE]). The anterior veneers were cemented with a light-cured resin cement (Insure Yellow-Red Light [Cosmedent]). All teeth were treated with a dentin-enamel primer (Clearfil LinerBond 2V [Kuraray]) and Clearfil PhotoBond (Kuraray) prior to cementation. The lower arch was inserted using the same protocol.

Figure 12. The protective nightguard, occlusion adjusted and ready for delivery.	Figure 13. The completed case.

The occlusion was perfected and equilibrated (after the cementation) using a football-shaped fine-diamond [Neo Diamond, A128-1923F] (Figures 11a and 11b). For a case like KeithÌs to last predictably for years, the final occlusion must be ideal. Keith also agreed to sleep in a protective nightguard every night to help protect the porcelain surfaces from wear and chipping (Figure 12). All margins and the adjusted porcelain were polished using the Dialite Ultra (Brasseler USA) porcelain polishing system.
Even though the reconstruction process was long and intense, Keith was extremely happy with the outcome (Figures 13 to 14b). He said that he would not hesitate to recommend this type of treatment to anyone who may need it.

CLOSING REMARKS

To achieve a predictable and successful result in a complex all-ceramic reconstruction, many protocols must be developed and followed. After more than 20 years of working together, Dr. Mike Malone and Mike Bellerino, CDT, have developed systems for every step in the reconstruction process. When starting a reconstruction case, they always follow every step in every system to help insure predictability in function and aesthetics.

Dr. Malone earned his master’s degree from Louisiana Tech University and his dental degree from the Louisiana State University (LSU) School of Dentistry. He received a Fellowship in the Academy of General Dentistry, and is a member of the ADA, American Equilibration Society, the Pierre Fauchard Academy, and the Pankey Alumni Association. After serving 6 years on the Board of Directors of the American Academy of Cosmetic Dentistry, he was elected to serve as President of that organization for 2003 to 2004. In addition, he is on the advisory committee and is a clinical instructor and featured presenter in the Cosmetic Dentistry Con-tinuum offered by the Continuing Education Department of LSU School of Dentistry, where he is also an assistant clinical professor in Prosthodontics. He lectures and teaches dentists internationally about the latest advances in clinical cosmetic dentistry. He maintains a full-time dental practice with an emphasis on cosmetic and reconstructive dentistry in Lafayette, La. He can be reached at (337) 989-1269 or mike@mikemalonedds.com.

Disclosure: Dr. Malone has given lectures sponsored by Dex Dental and DENTSPLY.

Mr. Bellerino is a graduate of the Dental Technology Program at Louisiana State University School of Dentistry, where he currently serves as assistant clinical professor in the Department of Prosthodontics. He is one of 20 technicians in the world accredited with the American Academy of Cosmetic Dentistry. He also serves on the advisory board of Quintessence of Dental Technology. He is an active member and past president of the Louisiana Dental Laboratory Association. He can be reached at (504) 887-7765 or mike@trinident.com.

Disclosure: Mr. Bellerino owns Trinident Dental Laboratory in Metairie, La.