Daniel Vasquez, DDS

and restorative dentistry is to improve the health and integrity of the patient’s dentition as well as the patient’s self-image and confidence. I like to think of dentistry as a performance of sorts. In addition to my role as a cosmetic dentist, I also wear the hats of an artist and communicator, paying attention to every detail, beginning with the initial patient consultation through treatment planning, treatment, and follow-up care.

For this case, a wax up was created so the patient could see how the new teeth would look in his mouth. Giving the patient an opportunity to visualize the final restorative outcome helps with treatment acceptance and allows for discussion of any adjustments or fine-tuning prior to producing the restorations.

A 61-year-old healthy man presented with 20-year-old porcelain-fused-to-metal (PFM) crowns on both upper centrals with margin exposure (

). The shade of the PFMs was brighter than his surrounding natural dentition, and the patient also suffered from incisal and occlusal wear on the lateral incisors, canines, and bicuspids. Due to the incisal and occlusal wear, full-coverage crowns were recommended on teeth #4 through #13.

The patient was unhappy with the appearance of his teeth and reluctant to smile, so the treatment objective was foremost to protect the integrity of the patient’s dentition while also enhancing his confidence by changing the form, shape, and color of his teeth to result in a more esthetically pleasing smile.

Preoperative case photos and a full-mouth digital impression are taken with CEREC Primescan (Dentsply Sirona) (

). This information is important for better communication and understanding of the treatment plan and goals with the patient.

A 3D model of the digital impression is printed using a SprintRay Pro 55S (SprintRay Inc). The physical model is then used to create a wax up modifying the size, form, and shape of teeth as needed to visualize the treatment outcome and to produce a silicone key.

) is used to transfer the mock-up into the patient’s mouth (

)—a very important step—because the patient will make his final decision to proceed with treatment at this appointment. Once the case is accepted and all financials are taken care of, we are ready to schedule “The Big Day,” which I refer to as “Same-Day Personalized Smile Transformation.”

On the big day, we start with tooth preparation using the biologically oriented preparation technique, referred to as BOPT, which is a vertical preparation or feather-edge technique. The goal of BOPT is to achieve high-quality and esthetic results in terms of soft-tissue stability and prosthetic/tissue interface. Next, a digital impression of the preparations is taken with CEREC Primescan (

), and the restorations are designed on screen using CEREC SW 5.2 (

After designing the restorations for teeth #4 through #13, the crowns are milled using both a CEREC MC XL and CEREC Primemill (

). Because this case requires 10 restorations, using 2 milling machines in tandem greatly reduces the amount of time needed to complete the treatment. The crowns are milled from blocks of VITA Suprinity® PC, a high-strength, partially crystalized zirconia-reinforced lithium silicate material with excellent esthetic attributes. Once milled, the sprues are removed, and each restoration is shaped and texturized with Meisinger’s Twist Polishers (green and blue) (

) on a low-speed analog electric handpiece to eliminate any scratches on the ceramic before the staining and glazing process. Following texturization, CERABIEN™ ZR stain and glaze (Kuraray Noritake Dental Inc) are applied to each restoration to impart a natural appearance with lifelike vitality.

At A Glance

A 3D model of the preparations is produced by exporting an .stl file from the CEREC software to the SprintRay Pro 55S printer, allowing us to passively test the fit of each restoration on the model (

). This step ensures that the final restorations will fit perfectly before delivery.

“The Crowning Achievement”: We deliver the final restorations. Using a modified technique in isolation, a rubber dam is used for final cementation with PANAVIA™ V5 cement (Kuraray Noritake Dental Inc). First, PANAVIA V5 Tooth Primer is brushed onto all surfaces of each preparation (

). Next, each crown is prepared for final cementation by first applying CLEARFIL™ CERAMIC PRIMER PLUS (Kuraray Noritake Dental Inc) into the intaglio and allowing it to dry, followed by dispensing PANAVIA V5 cement into the intaglio and seating the restoration with uniform pressure, letting the paste flow evenly around the preparation (

). Excess cement is removed with a brush, followed by a tack-and-wave cure technique. Finally, floss is used to make sure we have solid interproximal contacts.

Upon seeing his new teeth in the mirror, the patient could not keep himself from smiling and admiring his new look (

Whether the procedure calls for a single crown or a full-smile restoration, CAD/CAM dentistry gives clinicians the power to provide fast, safe, and efficient same-day dentistry, delivering beautiful, individualized smiles that patients are proud to show off.

The last, but not least, piece of the puzzle is bonding. This step is crucial to achieving long-lasting restorative integrity. I prefer the Kuraray Noritake family of adhesives, cements, tooth primers, and ceramic primers because they have demonstrated exemplary outcomes in clinical practice over the years. The company is a pioneer in methacryloyloxydecyl dihydrogen phosphate, or MDP, adhesive technology, and in my experience, PANAVIA™ V5 cement provides great color stability and long-term bonding confidence.

Articles

Using a CAD/CAM workflow gave the patient the opportunity to visualize the final restorative outcome.

How to Rehabilitate a Maxillary Arch Using a Digital Workflow for Same-Day Smile Transformation

When seating esthetic posterior metal-free restorations, the ultimate success of the treatment depends on the adhesive techniques and materials used for placement. 

Many materials can be challenging to handle, demonstrate low bond strengths and/or produce an inharmonious shade match in the final restoration compared to the adjacent dentition.

 The protocol could require multiple steps to achieve predictable bond strength and increase chair time due to cumbersome tasks associated with excess cement cleanup.

Fortunately, a variety of adhesive luting materials can be selected and used in combination to simplify indirect restoration placement while avoiding the challenges associated with the adhesive cementation process. 

For example, chemically conditioning restoration surfaces using a silanating agent (

) contributes to predictable and long-lasting bonds between all-ceramic materials and preparations. Similarly, a single-component, light-cured universal adhesive (

 Ivoclar Vivadent) that can be placed precisely in a fast and convenient manner contributes to less waste, more effective treatments and ease-of-use. These benefits are further enhanced when the adhesive is compatible with all etching techniques (e.g., self-etch, selective enamel-etch and total-etch) and prevents solvent evaporation over time for greater bond predictability.

However, what can significantly contribute to overall esthetic cementation predictability and simplicity is a light- and dual-curing adhesive luting composite (Variolink Esthetic, Ivoclar Vivadent) indicated for the permanent cementation of ceramic and composite restorations. Variolink Esthetic enables precise shade matching of the restoration to surrounding dentition due to its “Effect” shade system. This new approach to esthetic adhesive cementation includes five different shades for color-neutral cementation yet provides brightening or darkening of the restoration, as needed.

Furthermore, exceptional shade stability is realized based on the material’s reactive and patented 

, which also ensures fast and reliable curing of the material during subsequent light polymerization. The smart combination of light initiator and light sensitivity filter in Variolink Esthetic also promotes easy cleanup of excess cement because dental professionals can easily remove excess material following successful prepolymerization with light. The cement’s viscosity controller contributes to the material’s good flow properties and stability so it can be easily extruded from the syringe.

Among the indirect restorative materials ideal for cementation with Variolink Esthetic is lithium disilicate (e.g.,

). This glass ceramic material’s monolithic properties exhibit high strength.

 When lithium disilicate restorations are milled in-office and placed using efficient and predictable adhesive cementation techniques, they contribute to treatments that demonstrate improved strength and greater esthetics and require less chairside time.

Check out this video to see how Dr. Vasquez used Variolink Esthetic to perfect a restoration:

A 45-year-old female patient presented with a large mesial-occlusal-distal (MOD) composite restoration on tooth No. 13 and complaints of slight discomfort when chewing. A thorough examination was performed, and 

and clinical photographs were taken. The composite restoration was worn down and exhibited fractures, marginal linkage and decay around and underneath it. Based on the clinical findings, the treatment recommended to the patient was a full-coverage CAD/CAM restoration to restore and protect the integrity of  tooth No. 13.

The patient was anesthetized, and rubber dam isolation was established using an 

 (Ivoclar Vivadent) to promote good access while keeping the working field clean and dry.

 After removing the defective restoration and decay  it was determined a buildup was necessary. A universal adhesive (Adhese Universal, Ivoclar Vivadent) was applied by scrubbing for 20 seconds on the dentin, after which the adhesive was light cured for 10 seconds. Then, a flowable nanotechnology composite (Tetric EvoFlow, Ivoclar Vivadent) was used to build up the preparation,then light cured for 10 seconds.

Why one dentist raves about Adhese Universal from Ivoclar Vivadent

 Selecting this flowable composite was based on the material’s clinical performance, outstanding handling properties and high radiopacity (measured at 280 percent Al). The composite’s well-balanced filler technology combines fillers of various types and sizes, as well as color pigments and modifiers, which ultimately results in optimized handling properties for creating restorations and buildups that can be polished quickly and easily for an excellent chameleon effect.

 Building up the preparation in this manner was important for ensuring a successful milled CAD/CAM restoration. The buildup created a preparation demonstrating nice round and smooth surfaces without any sharp edges or line angles. This would facilitate a well fitting restoration and eliminate the potential for stress-concentrating areas.

The preparation was digitally scanned, along with the adjacent teeth, opposing dentition and bite registration. The scans were transferred to the computer to enable digital design of the proposed crown restoration. 

The shade for the final lithium disilicate CAD/CAM block was selected (IPS e.max CAD, HT D2) based on what would provide the greatest beauty and strength.

 The full-coverage crown restoration was milled using an in-office milling unit, after which it was tried in the mouth to verify fit. The monolithic restoration was then removed from the mouth, at which time it was characterized using glaze  and universal stains (IPS Empress Universal Stains, Ivoclar Vivadent), then fired in a fast cycle (Programat CS Furnace, Ivoclar Vivadent).

 An Optrastick was placed to hold the restoration while the intaglio surface was etched with a 5 percent hydrofluoric acid for 20 seconds.

 Monobond Plus silanating agent was then scrubbed onto the intaglio surface and allowed to react for 60 seconds, after which the restoration was air dried.

To ensure optimal access and a clean, dry working field, an Optragate isolation was placed.

 The built-up preparation was then selectively etched using 37 percent phosphoric acid for 15 seconds to treat the enamel, after which it was rinsed and lightly dried.

Trending article: The latest hourly and annual salary information for dentists, dental hygienists and dental assistants

 A universal bonding agent (Adhese Universal, Ivoclar Vivadent) was scrubbed onto the preparation for 30 seconds (Fig. 23), then air thinned and light cured for 10 seconds using an LED curing light (

 An esthetic light- and dual-curing cement (Variolink Esthetic) in shade DC was placed into the restoration (Fig. 25), after which it was seated. This cement was selected based on its ability to facilitate easy cleanup of excess cement, shade/color stability as a result of the patented Ivocerin and high bond strengths.

 After the restoration was seated, it was tack cured from the buccal and lingual aspects for three seconds each.

The now gel-like excess cement was removed using a scaler, and the restoration received a final full cure from all angles for 10 seconds each using an LED curing light (Bluephase Style). The occlusion was checked and adjusted as needed, and the restoration was polished. 

The indirect CAD/CAM all-ceramic restoration (IPS e.max CAD) placement process can be simplified by using a combination of advanced luting materials that work together to provide immediate and long-lasting bond strengths, esthetics and durability. Significantly contributing to overall esthetic cementation predictability and simplicity is Variolink Esthetic light- and dual-curing adhesive luting composite. When used to place IPS e.max CAD lithium disilicate restorations, Variolink Esthetic promotes precise shade matching of the restoration to surrounding dentition, exceptional shade stability, fast and reliable curing and easy clean-up of excess cement.   

 has been in private practice since 1999 in San Diego. Since acquiring his CEREC

 Redcam system in 2008, he has focused on esthetics and digital dentistry. His passion for CAD/CAM dentistry led him to become a trainer for Patterson Dental and an international speaker for Sirona Dental. As a CEREC trainer, he has found Ivoclar Vivadent dental products fit his professional needs. 

 When seating esthetic posterior metal-free restorations, the ultimate success of the treatment depends on the adhesive techniques and materials used for placement. 

Using esthetic adhesive cement to blend CAD/CAM posterior restorations to surrounding dentition

I remember when Andrew Allison (our SoproLIFE rep) came to my office for an intraoral camera demonstration in the fall of 2009. He said, “Dr. Vasquez, I’m going to show you a breakthrough in dental technology-an intraoral camera and caries detection device all in one.”

He explained how the camera works: using auto fluorescence technology, the user can easily switch lighting from white LED (or Daylight mode) that allows you to use SoproLIFE as a normal intraoral camera with quality images, to blue LED (light-induce fluorescence evaluator) caries detection mode.

While enabling the detection of caries more easily missed by eye or x-ray, SoproLIFE works with three different settings in imaging taking:

I told Andrew I needed to see the product in use on real patients, and I can say that after seeing SoproLIFE in action, I was sold.

I want my diagnosis to be the most accurate and I want my patients to understand the diagnosis and treatment proposed. This process has been simplified by the excellent images taken with SoproLIFE.

Now one of the most important diagnostic tools in my practice, SoproLIFE is my go-to for the detection of early caries, defective amalgams or composites and broken restorations; and part of my armamentarium during treatment using the Macro mode for the detection of cracked teeth, broken cuspids.

Our case acceptance, productivity, patient satisfaction and insurance payments all increased in 2011, in no small part because of the impact of SoproLIFE.


	With this technology, I can practice minimally invasive dentistry-where the principal philosophy is to be more conservative and preserve more tooth structure-by early detection of decay and repairing the effects of old, fractured and defective restorations, large cavities and cracked teeth (Figs. 1-3).


	A 43-year-old male came to the office for a routine checkup. After taking an x-ray and intraoral images we detected an asymptomatic broken tooth and restoration (Fig 4). After removal of the restoration we detected a horizontal fracture from mesio to distal of the crown (Fig. 5), changing the treatment plan to endodontic treatment and possible extraction. After accessing the pulp chamber and using SoproLIFE in Macro mode (Fig. 6) we determined how best to finish the root canal, build up and crown. Risk, benefits and options were given and the patient understands if he starts having any pain or infection, extraction and implant will be the next step.


	A 37-year-old female patient came in for a routine exam and cleaning. FMX and intraoral images are taken, and tooth No. 2 presented with a large composite filling and crack (Fig 7). We recommended full coverage. Images from preparation (Fig. 8) and for the final delivered crown (Fig 9).
	 

I remember when Andrew Allison (our SoproLIFE rep) came to my office for an intraoral camera demonstration in the fall of 2009. He said, “Dr.