	What is the average time for a porcelain buildup? With all the studies and articles I have read throughout the years, I can honestly say “who knows.”

	I developed my No Cut Back Technique more than 20 years ago and have taught this technique throughout the United States at various dental conventions. This technique is designed to increase production and at the same time allow the ceramist to produce a much more esthetic restoration.

	I currently build on average a crown every 5-7 minutes in one bake. In the buildup process, I use seven different porcelain powders because natural dentition consists of more than just dentin and enamel-color comes from within a natural tooth. Having studied natural dentition as well as thousands of photographs throughout my career, understanding the layering of dentition is all part of my buildup technique. This technique can be used for any substructure regardless of the material. Having high-quality porcelain that you can control color and shrinkage makes it even better.

	If we as an industry have the ability to produce the most esthetic crowns and bridges and save time, everyone is satisfied. Just a few years ago, we had to compete among ourselves. Now, with technology (e.g., CAD/CAM) and some of the work going to overseas markets, we must make a change for a more esthetic product. I am not trying to take away from the amazing technology that has come into our industry. I just believe a layered buildup is the most esthetic approach we can offer our clients.

 Starting with an opaqued substructure, first analyze your working clearances (Fig. A). I am using black stone to enhance color of buildup technique for photography purposes.

 Build buccal cusp tips with dentin. This buildup is shade A2 (blotting from facial) (Fig. B).

 Apply lingual cusps with dentin while connecting porcelain to what was layered in Step 1, (blotting from facial) (Fig. C).

 Apply dentin porcelain to buccal surface (Fig. D).

 Apply dentin porcelain to lingual surface (Fig. E).

 Apply occlusal ACCENT that corresponds to prescribed shade: Example: A1 would be a YELLOW OCHER and an A4 would be OCCLUSAL ORANGE (Fig. F).

 Apply interproximal ACCENT T-BLUE for lighter shades going to T-GREY for darker shades (Fig. G).

 Apply buccal mamalon lobe (ACCENT MAMALON VANILLA) (Fig. H).

 Apply incisal porcelain (I prefer opalescent incisals OPAL E-2) following steps 01 through 04 (Figs. I and J).

 Apply ACCENT WHITE at middle of crown to highlight contour of restoration (Fig. K).

 Remove buildup from working model and add a slightly darker shade at the cervical 1/3 and apply a T-NATURAL to the marginal ridge area (Fig. L).

 Build crowns in sequences of three to five, and fire at manufacturer’s recommendations.

 Once fired, then start the finishing stage. Adjust contacts and occlusion, then begin contouring to your satisfaction.

 Create detailed anatomy using a #34 FG bur. Create an ideal surface texture, and then you are ready to glaze (Fig. M). The buildup, grind-in and staining per crown is approximately 12 minutes (excluding firing time).

	Fig. N shows the finished crown shade A2 next to a previously built crown shade A4 (Fig O).

	By using this technique, the time you spend staining also is expedited. On posteriors, occlusal stains are required to produce a much more esthetic crown that will harmonize with the oral environment. All natural dentition regardless of shade has more color than what appears on a shade guide. I believe that if your goal is to increase your lab’s ability to create a more esthetic restoration, ask your clients for photos. Although not all dentists have photography equipment, you as a lab technician should do the research in understanding the importance of this technology. Whether you receive a printed photo or an e-mailed photo, this is the best tool we have to create a higher quality restoration.

	I realize learning a new technique can be difficult. These methods will increase your volume, and equally as important, you will produce a much more esthetic restoration. I use Zeo CE Light porcelain on our entire metal substructure restorations from Base Metal to High Noble. I have never had a tear or crack since our lab started using Zeo CE Light. I also recommend using wet trays for your buildup. I have wet trays for every different type of porcelain used in our laboratory. They are set up by shades (e.g., A tray for bleach shades as well as for my entire A, B, C and D shades). Pre-mixed porcelain saves time, and there is no wasted material.

Douglas J. Frye, CDT, owns Functional Esthetics Dental Laboratory, a cosmetically focused laboratory in Farmington, Mo. Doug was chosen by 3M to study under Yamamoto, one of the best technicians in the world. Doug has lectured on all phases of crown and bridge and dental ceramics throughout the country. He is the developer of the No Cut Back Technique™. Doug and his wife, Muffy, also have a sister company, Re-Creating Nature not just another crown™, which is focused on providing continuing education, NBC approved seminars. He has worked with some of the industry’s leading manufacturers in research and development of new products. For more information visit re-creatingnature.com or call 866-760-8821.

Articles

 What is the average time for a porcelain buildup? With all the studies and articles I have read throughout the years, I can honestly say “who knows.”  I developed my No Cut Back Technique more than 20 years ago and have taught this technique throughout the United States at various dental conventions. This technique is designed to increase production and at the same time allow the ceramist to produce a much more esthetic restoration.

Step-By-Step: Zeo CE Light

	Designed specifically for the dental market, the open-platform DWX-30 CNC milling machine features three types of clamps, one for discs and two for blocks, making it easy to securely hold a wide variety of material sizes and thicknesses. Materials can be cut on the top, bottom and at ±20 degrees for complex geometry. Aided by a maximum machine speed of 3600 mm/min and a maximum spindle speed of 30,000 rpm, it cuts material quickly with precision, helping to reduce errors, saving time and money. It also has a virtual panel that makes it easy to create copings, crowns and bridges. Other features include an integrated dust collection system and a tool sensor that automates machine and tool setup, saving valuable time and eliminating errors.

Applying New Technologies: Roland DGA Corp. DWX-30

	Fewer than half of the respondents to the October 2010 DPR Implant Survey said they are currently placing implants, but that doesn’t mean they shouldn’t be up to date on implant treatments and have a surgical partner in mind so they can offer implants as an option to their patients.

	“Not everyone will have the confidence to do both the surgical and restorative aspects of implant dentistry, but if implant dentistry truly has become the standard of care, all dentists must be involved in some capacity,” Dr. Robert Miller said.

	Getting started with implants involves training, and Dr. Miller advises turning to a professional organization or study club rather than an implant manufacturer for a well-rounded approach to the treatments.

	Still, if a clinician plans to work on restoring implants, but does not expect to place them, the techniques and knowledge needed to get started are not too different than techniques for placing a non-implant crown. Dr. Miller said gaining an understanding of how implants work and the parts involved in implant systems is really the only extra knowledge required.

	“If an implant is properly placed, it’s a very easy procedure to place an impression post and take and impression to send off to the laboratory with a proper prescription and have a beautiful crown made for that implant,” he said.

	In fact, the laboratory can serve a valuable resource for dentists new to implants. Dr. Brien Harvey said labs that work with a wide range of implant systems and a variety of types of implant cases usually have a broad base of implant knowledge to share.

	“Labs can be good resources and might even be able to point less-experienced clinicians in the right direction,” he said.

	With training being paramount, Dr. Miller said it is also important to gain an understanding of the types of implant cases you will be providing and to focus on learning the implant systems that are designed for those types of cases. This can help dentists new to implants avoid what he went through acquiring new implant systems because his practice would hit the limits of the care he could provide with one system and needed to find something else to address new treatment challenges.

	“There’s no reason for younger clinicians to go out and purchase system after system,” he said. “I wouldn’t want anyone to follow the path that I took. Over 25 years, I have incorporated 16 implant systems into my practice.”

	With so many resources available to help dentists along, adding implant offerings to a practice takes a commitment to education and a dedication to finding surgical and laboratory partners. Dr. Miller emphasized the best way to get started is to work with professional organizations dedicated to implants.

	“It is incumbent upon the younger clinician getting involved in implant dentistry to not just take a weekend course, but to get involved in an implant organization,” he said

    Fewer than half of the respondents to the October 2010 DPR Implant Survey said they are currently placing implants, but that doesn’t mean they shouldn’t be up to date on implant treatments and have a surgical partner in mind so they can offer implants as an option to their patients.

Getting started

	Laboratory ceramists and their dentists often are faced with restorative cases that demand the use of a singular material capable of simultaneously providing conservative esthetics and sufficient functional strength. Lithium disilicate is increasingly being used in clinical situations demanding the highest physical and optical characteristics.

	Unlike conventional PFM restorations, lithium disilicate ­restorations are uniformly strong and esthetic and allow dental professionals to provide highly cosmetic restorations in a conservative manner. Additionally, the enhanced strength and presence of a glassy matrix allows dentists to either conventionally cement or adhesively bond lithium disilicate restorations.

 line of ingots expands the restorative possibilities for smile design and is ideal for enamel replacement with minimally invasive preparations. The new Impulse ingots include three Value shaded ingots in an intermediate translucency and two Opal ingots that provide dental professionals with a high level of natural opalescence to beautifully mimic the look of ­natural dentition.

	Created to meet the demands of dental professionals around the world, IPS e.max Press Impulse ingots can be used in single tooth restorations, bridges in the anterior, implant super structures, veneers and thin veneers. With a strength of 400 MPa, IPS e.max Press Impulse ingots demonstrate the same flexural strength of the original IPS e.max Press ingots and can be reliably pressed to as thin as 0.3 mm for veneers.

	The IPS e.max Press ingot product line, originally available in four translucencies (High Translucency, Low Translucency, Medium Opacity, High Opacity) and two sizes, has been greatly expanded with the introduction of IPS e.max Impulse ingots. By providing translucencies and new shades with the same exceptional strength of the original IPS e.max Press ingots, Impulse ingots enable dental professionals to provide their patients with the most functional and life-like esthetics possible in restorations requiring the use of lithium disilicate glass-ceramics.

	Developed with the same quality of Ivoclar Vivadent materials, IPS e.max Ceram Impulse veneering materials are specially developed to create individual characterization. Pressable lithium disilicate restorations (IPS e.max Press, Ivoclar Vivadent) are fabricated utilizing a hot wax press technique, and due to crystal size and length, the flexural strength of pressable lithium disilicate is 400 MPa.

	A healthy 61-year-old woman presented with the intention of replacing the bridge spanning tooth Nos. 10-12 for cosmetic reasons, but didn’t want her otherwise healthy tooth Nos. 6-9 prepared (Fig. A). The right-hand bicuspids (Nos. 4 and 5) previously had been treated with titanium post and cores, but at the time of presentation, the patient was uninterested in post build-ups and desired only composite build-ups.

	However, during a discussion of treatment options, the patient was informed that it would be possible to create a uniform appearance to her smile (i.e., including Nos. 6-9) by keeping tooth preparation to a minimum (e.g., only 0.3 mm). After demonstrating the proposed changes using intraoral mock-ups, she accepted the proposed treatment plan.

	The need to provide patients with minimal preparations while simultaneously addressing esthetic and color blocking issues (e.g., old dark tooth structure from root canal therapy) can require a combination of restorations that range from thin, for esthetics and conservation of tooth structure, to thick, for adequate strength. In this case, the restorative material of choice was lithium disilicate (IPS e.max), and in particular the recently introduced Opal ingot.

	Based on the diagnostic wax-up (Fig. B) and final impressions of the provisional restorations, the laboratory ceramist followed the following protocol to fabricate the lithium disilicate (IPS e.max Press Opal) veneer and bridge restorations:

 A wax-up for pressing was created using a matrix of the provisional model, which was trimmed to remove any areas without clear tissue detail, leaving a small piece of the palatal area to stabilize the matrix during injection.

 The matrix was placed on the model, wax was injected, and the wax was allowed to set for 3 minutes, after which the matrix was removed from the model.

 Using a scaler (Hollenbeck, Kerr Corporation), the margins were exposed, wax removed from the gingival area and any flash from waxing removed.

 After observing the clinical photographs, the midline of the provisional model was marked, along with the incisal edge positions of all teeth, and the width was checked with an electronic caliper (6425A Caliper, Central Tools Inc.).

 The stick-bite photograph then was studied to ensure the midline was in the proper position, and wax was added to create lobes to work with and reinforce the dominant line angle.

 The mesial and distal line angles were built-up with hot wax, followed by the emergence lobes. The middle was then filled, allowing the wax to flow to the newly established areas, ensuring that the middle lobe was high and that the mesial reflected more forward.

 Surface morphology was refined using a wax carving instrument (Premier Dental). After shaping the facial areas, the mesial and middle lobes were refined and their boundaries established.

 The incisal embrasures were worked and opened. Utilizing the back side of the carving instrument, the mesial lobe symmetry was refined. The emergence profile was controlled by building out just enough to set the facial plane and vertical axis.

 At this time, the contacts were checked to ensure they ran all the way to the papilla. To prevent the formation of black triangles, the interproximal areas were extended.

 To separate the embrasures, the contact was melted with the waxing instrument and cut through with a thin porcelain slicing blade (Tanaka Dental Products). The wax was then cut back to allow room for layering ceramic on the facial incisal aspect. Margins were resealed and the ­restorations were sprued for pressing. 

	After the interproximal embrasures were complete, the wax model (Figs. C and D) was sprued, invested and pressed with the appropriate shade of IPS e.max Press Impulse ingot. Then, the following ceramic layering protocol was followed:

 The midline was marked, the incisal edges were refined using a diamond bur (854 Bur, Brasseler USA), and the sprues were removed.

 Utilizing a sharp diamond (Brasseler USA) with light pressure and high speed, a rough reduction was completed to remove any scale layer left from investment. Every surface area of the restorations was freshened with the diamond, since lithium disilicate cannot be sandblasted, as per manufacturer instruction.

 A football-shaped diamond (Brasseler USA) was used to set up the dentin lobes and remove the reaction layer up to the contacts. With a diamond bur (863 Bur, Brasseler USA), the emergence profile and surface was worked to remove any remaining reaction layer and reestablish the desired morphology.

 Once the desired surface morphology was achieved, the color of the restorations was modified using a ceramic stain (IPS e.max Stain, Ivoclar Vivadent) and brush (Tanaka Dental Products), and color was added from the gingival to incisal. A ceramic glaze (Ivoclar Vivadent) was then applied to the restorations, which were fired at 770°F (Fig. E).

 To begin esthetic development, it was necessary to separate the lobes and extend slightly past the cut-back (Fig. F).

 Effect enamels (IPS e.max Ceram) were placed, beginning with Opal (OE 1) to create a silhouette, while translucency was reduced with a translucent incisal (TI 1) ceramic. Keeping the midline straight, the silhouette shape was built with incisal ceramic enamel. To create the mammelon effects, a light-colored ceramic (MM Light) was feathered on the tips of the dentin lobes. Salmon effect enamel (MM Salmon) also was used and carried to the incisal edge (Fig. G).

 Prior to firing, shape, color and value were evaluated and corrections made. The restorations then underwent the first bake (Fig. H).

 After baking, the lithium disilicate restorations underwent full contouring with an Opal enamel ceramic (OE 1) to replace what was cut-back during waxing (Fig. I). The lobe structures were filled and rebuilt to final anatomy prior to the second bake, after which any deficient areas were corrected, beginning at the midline and working out. The incisal embrasures were then reopened and the restorations fired a third time.

 After baking, the lithium disilicate restorations underwent a corrective procedure utilizing adjusting diamonds (Brasseler USA) to modify the contacts at the midline, based on the stick-bite. Excess ceramic was removed from the surfaces, and the incisal was blended into the surface morphology and embrasure form with an 863 diamond bur. Lines from the gingival two-third were extended into the incisal, without over-grinding the stained and glazed pressed ceramic (Fig. J).

 After smoothing the lingual incisal, functional movements were checked with an articulator and articulator paper. Once occlusion was verified, the distal line angle was softened, the lobes began to take form, and a natural flowing contour was created, with incisal spacing smallest at the midline and the dental lobes flowing into the incisal edge. The lobes were smoothed and shaped with soft angles to achieve ideal esthetics (Fig. K).

 Excess material was removed, the restorations were glazed (IPS e.max Glaze, Ivoclar Vivadent), and a final firing was completed at 725°F (Fig. L).

 After firing, excess glaze was removed from the surface with a diamond bur (850-016 Bur, Brasseler USA), beginning at the midline and working out. Minimal adjustments to the contacts were made to ensure a proper seal from the tip of the papilla to the incisal embrasure (Fig. M).

 A polishing wheel (Brasseler Gray, Brasseler USA) and light rubber wheel were used to smooth the surface of the restorations. A diamond strip was used to adjust the interproximal contacts, without pulling it all the way through, which would damage the restorations (Fig. N).

 To achieve a natural appearance, a rubber wheel was used to polish and smooth any high points in the restorations, which were then placed back on the articulator for assessment of functional movements. A diamond paste (Diashine, VH Technologies Ltd.) and a soft bristle brush (Robinson Brush, Bolton Dental Manufacturing Inc.) brought the surface to high luster, making the restorations ready for final cementation (Fig. O).

	Lithium disilicate restorations (IPS e.max) can be conventionally cemented or adhesively bonded. The patient was anesthetized, the provisionals removed, and the preparations thoroughly cleaned. After try-in of the restorations, the internal aspects were conditions with a single-component bonding agent (Excite F single), after which the selected shade of resin cement (Variolink Veneer +3) was applied. Proper isolation and gingival retraction was accomplished, and the preparations were conditioned with the single-component bonding agent (Excite F), desensitized (Gluma, Heraeus Kulzer), and cured. The restorations were seated individually, cured into place, and cleaned with glycerin and dental floss.

	Lithium disilicate restorations (IPS e.max Press) enable dentists to offer patients a conservative alternative for replacing previously placed PFM restorations and transforming the appearance of their smiles. In the case presented here, the patient was very pleased with the function and esthetics of the IPS e.max Press restorations (Fig. P), as well as the fact that only minimal tooth reduction was required.

	For a video of this technique, visit the Team Aesthetics and CMR Dental website at 

 Laboratory ceramists and their dentists often are faced with restorative cases that demand the use of a singular material capable of simultaneously providing conservative esthetics and sufficient functional strength. Lithium disilicate is increasingly being used in clinical situations demanding the highest physical and optical characteristics.

Step-By-Step: IPS e.max Press Impulse

	We sometimes struggle to match a patient’s tissue color. The tough connective gingiva, which lines the base of the teeth, is part of the lining of the mouth. Not only does it surround the teeth, it also produces a seal. Unlike the soft tissue linings of the lips and cheeks, most of this gingiva is tightly bound to the underlying bone, which aids in resistance of the chafing of food as it’s chewed.

	This tissue color is not always definitive, but if healthy, it is often called “coral pink.” Colors such as red, white or even blue may indicate inflammation due to plaque. However, we must also consider racial pigmentation, because this can make the tissue appear darker. The most significant issue then is color homogeny. Pockets of different colors, lighter or darker, could indicate a concern.

	In texture, healthy gingiva is firm, does not move, and often exhibits stippling, or a speckled appearance. Unhealthy gingiva, on the other hand, will often present as puffy and spongy.

	Yet if the tissue color does not blend properly, it ruins the effect of the final restoration. Tissue color also affects the size of the teeth and the tint of our combined porcelain colors. When we recreate tissue, we have to keep in mind that a patient’s smile is in large part influenced by that color.

	In the past, we could only mimic tissue color by adding or mixing together modified colors with pink porcelain. But the GC Initial™ Zr Gum Shade Set System (

) now includes the Zr and MC gum shades with six color choices. Included are Frame Modified Gum, Base Dark, Intensive Red, Intensive Violet, Base Light and Intensive Cream. The individual steps can be divided between different firings, according to the standard layering techniques.

	As mentioned above, from the different skin types people exhibit, we can safely assume their tissue color also will be unique. When I am assigned a restoration such as the one we see in Fig. A, I will match tissue color by overlaying the solid porcelain color with a pink tone.

	In my newly updated Chairside Shade Guide™ System (

), there are nine total tissue colors all created, categorized and photographed. With the three possible soft-tissue colors we see here, I am attempting to match this patient’s shade, which appears to be a light pink with slightly darker tones at the gingival. Ultimately, that dark color will be covered when the restoration is completed.

	The temporary implant crown on tooth No. 8, demonstrated in Fig. B, is long compared with tooth No. 9. The two will need to be matched at the gingival area (Fig. C), which is the reason for the pencil line I drew-to mimic what is adjacent. GC Initial™ created five different pink tissue color possibilities (Fig. D). Shown here are numbers GM 23, 24, 34, 35 and 36-tissue-colored, light-curable micro-composites-Gradia Gum Shades that allow the technologist to naturalize the existing restoration to give it the color, texture, translucency and veining of natural gum tissue. The line of gum shades is offered in three composite viscosities: a liquid, a gel and a paste. These alternatives afford the user almost unlimited combination of colors and textures and even allow the anatomy of the restoration to be enhanced in terms of root structure, tissue connectors and rugae. Gum fibers are even available to imitate the natural blood vessels in the oral cavity.

	In Fig. E, we are given a view of the implant titanium abutment in the mouth, post-operatively. I decided to use GC Initial™ 23, 24 and MC – C-LF for this particular restoration to match the patient’s gum color (Fig. F). Fig. G demonstrates the process of applying each shading layer to the restoration to accomplish the color goal I had set out to complete. Over the top of this, I then applied the GC C-LF (clear fluorescent) (Fig. H).

	There are five possible powder colors for the gum area, with shade tabs and opaque (Fig. I) available for the technician, opening up multiple possibilities when it comes to creating a beautiful and life-like restoration. On a mirror, the shade tabs are given a more detailed appearance (Fig. J). Post-operatively, the patient’s retracted view provides us a good view of the gum area (Fig. K).

	The technician will find this product to be especially beneficial for use with restorations such as the implant crown we demonstrated, or for denture work as well. There is no mixing involved, which makes it easy to use. Maximum results can be achieved with very little effort necessary. And, as we can see from the photos, the end result is pleasing to the eye.

 We sometimes struggle to match a patient’s tissue color. The tough connective gingiva, which lines the base of the teeth, is part of the lining of the mouth. Not only does it surround the teeth, it also produces a seal. Unlike the soft tissue linings of the lips and cheeks, most of this gingiva is tightly bound to the underlying bone, which aids in resistance of the chafing of food as it’s chewed.

Chameleon qualities

	Photo: RubberBall Productions/Getty Images

	Just about every day, a dentist asks Steve Killian, CDT, to use a material he knows won’t work for the cosmetic case in front of him. Maybe the dentist didn’t provide him with all the information he needs to use that particular all-ceramic material, or maybe the dentist’s material of choice just isn’t strong enough for the type of restoration he’s creating. Regardless of the problem, he has to explain to the dentist why it won’t work and why another material is better.

	“If I’m asked to use something and I disagree then I’ll explain why. We usually end up doing it my way. They (dentists) trust my technical ability,” said Killian, who owns Killian Dental Ceramics. “Nobody wants to risk it not turning out. They want to make sure I’m successful for them.”

	Your dentist clients depend on you to choose the best material for their cases. It’s often left to the technician to educate the clinician about those materials, and the number of options just keeps growing, with many of them combining both strength and esthetics to help you create more natural-looking, more functional cosmetic restorations. That’s why it’s so important for you-and everyone at your lab-to really know your stuff, to keep up-to-date on what’s available and to attend the latest CE courses. You need to be able to decide when to use what material and then explain your decision to your clients. That’s a huge part of creating successful cosmetic restorations.

	As more options have become available in the last five years or so, many doctors have become confused about what should be used when, said Daxton Grubb, President of R-dent Dental Laboratory, and it falls to the lab to lead them in the right direction.

	All too often, they expect you to use a certain material but don’t give you the information you need to make it work, Grubb said. If they don’t give you the proper prep design and stump shade, you either have to go back to them to get the information you need or tell them what you can successfully do with what you’ve been given.

	When a case is underprepared, Killian said he’ll call and ask the doctor if he wants him to adjust the prep or provide another restoration. It may be a slight compromise over what the doctor asked for originally, but it saves time and money. The doctor still can get a high-quality restoration without bringing the patient back in. Not only that, there will be a much greater chance for success than if you went forward without making that call.

	“We’re getting more involved. The pressure is getting put more on labs to learn the products. It gives us more credibility,” Grubb said. “We can give options. It’s saying I can’t do an e.max but I can do another all-ceramic that will look beautiful. Here are the options. It boils down to giving doctors more options and not just telling them yes or no.”

	When you first get a case in, there’s a lot to think about before you decide what type of material to use, including if the restoration is going in the anterior or posterior and how strong it needs to be. But regardless of what else is involved, it all comes down to doing what’s best for the patient.

	“The first thing we all need to think about is using the most conservative material that will satisfy esthetics and durability,” said Dr. Ed McLaren, Director of the UCLA Center for Esthetic Dentistry. “It doesn’t matter how good it looks if it breaks, but it also doesn’t serve the patient if you could have used a conservative veneer and the dentist did crowns everywhere. I’m going to use the most conservative material I can.”

	Porcelain is the most conservative material for anterior restorations, Dr. McLaren said, and is his first choice for veneers when there is 50 percent of enamel or more remaining on the tooth and a thickness of 0.8 mm or less. If that’s not what you’re working with, Dr. McLaren recommends the second most conservative choice: glass ceramics, which include the leucite-based IPS Empress from Ivoclar Vivadent and Jensen Dental’s Authentic. Both are esthetic, conservative choices for veneers and crowns.

	Of course, there will be times when you’re working in a higher-stress environment where you’re more worried about fracture or bruxing. This is when you might want to think about IPS e.max lithium disilicate, Dr. McLaren said. This works better than pure porcelain if you have to bond to dentin, which is more flexible than enamel and requires something stronger when bonding to it. Empress also is a good choice in this situation, but you do get more strength from e.max and less chance of fracture.

	At Grubb’s lab, the three most common materials used are Ivoclar’s e.max, Lava Zirconia from 3M ESPE and his own R-brux in-house brand, which are all great choices for single-unit posteriors. He typically uses e.max for veneers and Lava Zirconia for bridges. Those are his materials of choice, but it’s important to remember that every lab is different and has different strengths. Communicate that to your clients, and don’t try to sell them on a certain material because you like to use it; focus on what’s best for the patient.

	Dentists don’t have a lot of spare time, and some of them may not be willing to return your calls or e-mails to discuss a case. But you can’t miss out on the opportunity to educate those who do. If they wanted you to use Lava or e.max but didn’t provide you with enough information, let them know what you need next time.

	Labs should have a technical team that focuses on quality control, Grubb said. Have people on staff who are capable of talking to doctors about preps and making suggestions for improvements. But you have to be consistent. If you call about a case today but miss one tomorrow, it sends a mixed message to the dentist.

	Grubb also sends prep models to doctors to give them something they can actually see. His lab even sends doctors the burs he’d like them to prep with, introducing them to a product they may otherwise never have used. This helps get you and your doctors on the same page, and it is a way to build that all-important technician/doctor relationship.

	“Labs are inventorying certain things from the clinical side, which is something they didn’t do before. Ten years ago it was paper,” Grubb said. “When you send the same sheet of paper versus putting that instrument or that model in their hand, generally speaking people pick up faster that way. It’s more personal,too. You touch the customer then.”

	Even though labs tend to know more about the materials they’re using, the doctor still should be involved in the decision, said Gary Hult, Professional Relations Manager at 3M ESPE. The dentist and lab technician should come to a collaborative decision about what restoration is best for the patient.

	“Unfortunately, dentists too often delegate that to the lab and just tell them what shade they want. They don’t get into a discussion about the benefits and limitations of different restorations in terms of what they’re trying to clinically accomplish,” Hult said. “Labs and dentists should understand enough based on the patient’s situation and overall clinical needs to determine what would be the optimal choice for the patient.”

	The dentist knows the patient the best, 3M ESPE Marketing Manager Angie Hadrits said. They’re going to know individual patient circumstances and any special health concerns. They can provide you with relevant information as well as photos to help the lab create a restoration that the lab, the dentist and the patients are happy with-and an open dialogue is key to making that happen.

	“Ultimately, a great ceramist can make an average dentist look great. A bad ceramist can make a great dentist look bad. The ceramist is an important part of the team,” Dr. McLaren said. “There needs to be a close dialogue between the two. It’s not 100 percent the dentist prescribing to the technician.”

	And as patients become more and more informed about their options, they may have an opinion about what’s going in their mouth, too, Dr. McLaren said. For instance, many patients don’t want metal restorations, and zirconia is a strong, esthetic option that can meet that need.

	Choosing the wrong material can lead to a variety of problems and is just another reason it’s so important to work in partnership with your dentist to determine the best restoration for the patient, said Dr. George Tysowsky, VP of Technology at Ivoclar Vivadent. If you make the wrong decision, it’s the patient who suffers.

	“When choosing a material there is always a fine balance of strength and esthetics that one must consider. If we choose materials that have the highest strength often times they don’t provide the optimum esthetics, and the final outcome can be opaque and not esthetically pleasing to the patient,” Dr. Tysowsky said. “On the other hand, if we choose a low-strength translucent material, it may not have the final strength requirements to support the function that is required in the appropriate clinical situation. We want a material with a naturally esthetically pleasing result but yet ultimately survives and provides the appropriate function for the appropriate area.”

	Making the right material choice is especially important when it comes to all-ceramics; the wrong choice can mean complete disaster, Killian said. There is such a variation on strength and translucencies that using the wrong material can lead to fracture or esthetic failure.

	With many all-ceramic materials, the manufacturers make it clear what you’ll need to be successful, Grubb said. If you go forward without exactly what you need from the prep, including stump shade, your chances of being successful go way down-and that’s even before the restoration leaves the lab.

	“It may make it past production, but in one of the next few steps it’s going to fail,” Grubb said. “So if it does make it out the door, if you sacrificed on requirements with that material there’s a great chance it will fail during seating or after seating.”

	Materials development for esthetic restorations is an exciting area, Dr. Tysowsky said, with many new technologies on the horizon. And with all the materials that are coming out, it’s more important than ever to keep up to speed on what’s available and to know what works best in different situations, to make sure you and your clients are providing the best possible restorations with the best esthetic and functional results.

	There are now materials like IPS e.max that offer strength and esthetics, something that hasn’t always been available, but is a trend that experts expect to see continue.

	As the options continue to grow, dentists will depend on their labs more and more to steer them in the right direction-especially when it comes to using something new.

	This is your time to become that trusted expert your clients turn to, the one who keeps them from a mistake that will cost them time and money and leave them with an unhappy patient.

	“Dentists may take a material and try to fit the clinical situation to the material, adapt the patient to the material. That’s not what we should be doing,” Dr. McLaren said. “We evaluate the clinical situation and choose the best material or technique or combination of the two that allows us to treat patients consistent with our philosophy of treatment. People want bright, beautiful teeth. I get that. But how do we get there the least destructive way for the best esthetics and biologic health? There’s usually a clear winner in every situation.” 

   Photo: RubberBall Productions/Getty Images

Choices, choices

	The surface texture of laboratory-manufactured restorations is an important aspect in esthetic dentistry. Texture (micro-geography) often is neglected by laboratory technicians who create unnecessary translucent effects and artificial cracks during the porcelain layering.

	I have been observing, studying and copying natural teeth for more than 20 years. I believe, without a doubt, that surface texture that captures an authentic look is the key element in any successful restoration. Surface texture is the “finger print” of a tooth and makes crowns or veneers unique. It reflects the age and personality of each patient, and shows the “history” of a tooth. Grooves can be deep for a rough surface or thin (almost non-existent) for a smooth surface. Those subtleties help a restoration appear more natural. Experienced technicians can mimic those effects using the correct instrumentation before the final glaze. KOMET USA recently introduced a kit to the industry that is designed to create shapes and textures in ceramic restorations that best mimic the design of natural teeth.

	The very best technician can use texture to create the illusion of a shorter/longer or narrower/wider tooth; therefore surface texture can change the appearance of any restoration.

	In this article, I will demonstrate my protocol of the surface texture development using a new Diamond Ceramic Series Kit from KOMET USA, which contains 11 high-end KOMET rotary instruments to create the absolutely finest ceramic restorations.

 The last layer of ceramic has been fired (Fig. A). The final contour and surface texture will be achieved by using a few selected KOMET burs from the Diamond Ceramic Series Kit.

 First, we remove the shiny aspect of the firing by grinding the surface of the ceramic using the 850.104.023 diamond. Line angles are then traced with red and blue pencils-a red pencil is used to show the actual line angle, and a blue pencil represents the desired line angles (Fig. B). Line angles are modified and controlled by grinding the red line away. Line and transitional angles are important in the contour of a tooth, because they reflect light and determine the width of each tooth.

 A 862.104.018 diamond is used to modify the line angles (Fig. C). A 863.104.012 can be useful for smaller areas.

 After the line angels are modified, we confirm that both the blue and red lines match (Fig. D).

 A regular pencil is used to map the restoration’s surface texture (Fig. E).

 A 850.104.016 diamond is used to create the main vertical depressions (Fig. F). For additional grooves, the tip of a 862.104.018 can be used (Fig. G).

 Thinner horizontal lines are created with a 860.104.012. These growth lines can be created one at a time using the sharp tip of that bur. Because those effects are parallel, we can create a few at the same time just by changing the angle of the bur and by having a wider contact with the material’s surface.

 Very thin fissures observed in natural teeth are difficult to make on the material’s surface. Without using the right instrument, fissures will look artificial. To mimic this effect, I like to use KOMET’s H97.104.010 carbide because it is designed with a three-edged wedge (Fig. H).

 After creating the texture prior to the final glaze, we must finish the margins. Using a diamond instrument such as the 847.104.014 flat-end taper diamond allows us to cut the porcelain from the investment with precision (Fig. I). We then use a 8863.104.102 fine-flame diamond (Fig. J) to refine the ceramic all around the margin. It’s best to use a microscope when performing this step.

 Using a double-sided diamond disc (3 mm of diamond coating) like a 911H.104.180 is a great way to match the micro chips observed on incisal edges of worn teeth (Fig. K).

 While glazing the porcelain, we must control the amount of paste used during this step. We need to avoid filling the textures we took the time to create (Fig. L).

 After the restorations are glazed, I use a rubber wheel to soften the texture on convexities only (Fig. M). The luster is adjusted using a diamond paste (Diamante high-luster diamond paste) and a felt wheel (Fig. N).

 The finished veneers are adjusted on a master cast (Fig. O). The porcelain veneers created in this case are displayed one year after they were placed in the patient’s mouth (Fig. P).

	Restorations with an authentic life-like appearance are created when technicians use a combination of quality restorative materials with well adapted form and personalized surface texture and innovative instruments. This makes the process easier and more successful. 

Olivier Tric began his studies in France at the College of Leonardo Da Vinci and the University of Pharo while pursuing an apprenticeship in dental technology. After a 5-year apprenticeship, he launched a 15-year career devoted to a thorough understanding of the principles of dental esthetics and the mastery of specialized techniques in dental laboratory technology. His specialties include all facets of porcelain restorations on both natural teeth and osseo-integrated implants. He is recognized by his peers as a pioneer in the dental industry by developing new and unique methodologies that are taught worldwide. He is widely published on the topic of ceramic layering techniques and esthetic dentistry in journals such as Dental Dialogue, Practical Procedures & Aesthetic Dentistry and Quintessence Dental Technology. He also serves on the editorial board for Spectrum Dialogue and Teamwork. His professional affiliations include Design Technique International, Oral Design International Foundation and others. He is a highly respected lecturer and educator, teaching hands-on courses to dentists and technicians throughout the United States, Canada and Europe. He is regularly consulted by leading dental manufacturers and laboratories for input on new product development. He currently operates the Olivier Tric Dental Laboratory and Educational Center. He can be reached at oliviertric@ameritech.net. For more information, please visit oliviertric.com.
	
	Disclosure: Mr. Tric receives royalties from KOMET USA.

 The surface texture of laboratory-manufactured restorations is an important aspect in esthetic dentistry. Texture (micro-geography) often is neglected by laboratory technicians who create unnecessary translucent effects and artificial cracks during the porcelain layering.

Step-By-Step: Diamond Ceramic Series Kit

	Engineered to make dental welding easier, faster, efficient and more user-friendly, the third-generation phaser as2 micro pulse arc welding unit features improved micro-electronic pulse shapes, individually defined for the specific alloys, to eliminate potential welding spot cracks. Special pulse shapes in combination with high-frequency overlapping further facilitate welding of palladium and titanium alloys. With 40 preset programs for a range of welding procedures, the user simply selects the alloy type and the energy level with the turn and push controller and starts welding safely and reliably. Power and pulse duration are freely adjustable for precise control of the welding spot diameter and penetration depth.

Applying New Technologies: Primotec USA phaser as2

	The popular phrase
	“a ­picture is worth a thousand words” is commonly thought to be a Chinese proverb attributed to Confucius. A Google search will lead you to a number of ­interpretations of the actual origin of this phrase; however, the meaning does not change. An image, photo or picture will go hand in hand with words to convey a meaning or purpose without having to provide an explanation using a handful of words-let alone one thousand words. Good images and photos will help gain the reader’s attention and interest, as well as help the ad or article get noticed.

	Since the first widespread use of photographic images by the press in the early 1920s, marketers have included images to help sell products and services to consumers. Imagery alone is not enough, for if you were to just look at a picture without words, you might not know what the intended message is. Now, combine imagery with words and you can convey a powerful message when selling products and ­services, especially to your dentist ­customers as most are very visual.

	In every dental publication, almost all of the articles and advertisements use imagery to convey a thought and to help explain what the article or author is trying to communicate. Advertisements, technical and non-technical articles use lots of photos and images because most readers would not read text-heavy articles.

	Esthetic dentistry and cosmetic cases are all about visualization, and it is what you see that counts. Imagine how difficult it is to talk about your skills as a cosmetic technician without being able to provide samples or photos of your work. Yet many laboratories try to accomplish this without photos of their work.

	Yes, it can be time-consuming and expensive to develop samples of your work; however, pre-planning and making a commitment to document cases through photography is an excellent alternative, and might be the best option because it won’t add much extra time to your workflow. Photos of actual cases, along with some explanation, tell the best story and just might get you the best results in selling your skills.

	Manufacturers will provide product photos of their dental materials in use, and these can be helpful to use in promoting your overall portfolio of products and services. But while many laboratories use these in their marketing collateral and on their websites, these stock photos from a manufacturer only help you to convey the types of products and services you offer, but are not representative of the quality of your actual work. If the desire is to promote your expertise in esthetic or cosmetic dentistry, having your own images will do a better job for you and your laboratory.

	One of the most effective uses of photography for dental laboratories is before-and-after images of actual cases. By providing these photos, you are showing your technical and creative abilities. As mentioned, dentists can be very visual, and by showing your actual work they can get an idea of what you might be able to do for their patients and practice.

	Every dentist has a number of patients who might have similar cosmetic challenges. By presenting your cases, you just may interest them enough to give you a call or try out your laboratory with a challenging case.

	Here are a few suggestions on how to get started, and are not necessarily in chronological order.

	Get trained in dental photography: The main goal is to take photos that tell a story, are visually appealing and are of high quality. There are educators and companies that can help you learn more about taking good photos of cases, what equipment is best, how to take before-and-after photos, and how to put together a photo album of your best cases.

	Work with a good clinician: Having a dentist who is not only a good clinician but a good marketer is ideal. These dentists can be effective in getting the right patient for before-and-after photos.

	If you are using photos for marketing purposes and not to support a clinical or technical article, consider ­eliminating cheek retractors and use smiling lip photos (where you just show lips in a smile position and showing teeth). Also include a full-face smiling photo (this helps to show the difference of the before and after). Don’t forget to get a photo-release form from the patient prior to taking the photos.

	Select your advertising medium: How and where you will use the photos should be decided prior to getting started. You should definitely include them on your website, and you also could include dentist or patient testimonials. Your corporate brochure and direct mail brochures are another effective means of getting the message out to existing and prospective customers. If you exhibit at trade shows, your booth graphics and a computer presentation also would be effective uses for your photos.

	Successful marketing today means taking advantage of different strategies to get your message out to the right audience. Attracting the attention of your audience through direct marketing pieces as well as your website is critical to that success. The photos or images you use will have a significant impact on the success of your efforts. Make it the impact you want.

	Good imagery combined with proper messaging helps you fulfill the meaning and intent of the phrase “a picture is worth a thousand words,” and should help your messaging stand out.

 November 2010 | Dental Lab Products     

Dental Lab Products-2010-11-01