A clinical case by our Community member Dr. Gilbert Jorquera
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The use of digital tools and CAD-CAM equipment has become a reality in dentistry. A completely digital workflow and teamwork with technicians allows fast and high-precision treatments with amazing aesthetic results.
The full-digital workflow, together with the technician allows us to transform an entire smile in the shortest possible time, using materials that perfectly reproduce the mechanical and optical properties of natural teeth. The different softwares available on the market have incorporated many of the digital smile design tools in their chairside or laboratory workflows, which allows the patient to participate in their own treatment by having the possibility of evaluating with a digital or physical mock up, how the final result would be and give an opinion regarding
its appearance, generating an emotional link during the treatment.
In this clinical case, we will see how the transformation of a smile is carried out with a completely digital flow that includes clinical photography, intraoral scanner, digital design software and ceramic milling machines and the most importantly without any impression material.
Fig.1
Initial smile situation, middle-aged female patient, with some misalignment and numerous defective restorations in the upper anterior teeth, who also didn’t like the shape, size or color of her teeth. She has had many previous dental treatments with bad experiences, so in this case it is very important to make the patient participates in the treatment to achieve the esthetic and functional goals in a reliable and efficient way.
Fig.2
Complete intraoral view of initial situation. You can see more easily the difference in size and shape of teeth, different zenith positions and multiple restorations with varying colors.
Fig.3
On the first appointment, the digital flow included a classic photographic record for digital smile design, and complete intraoral scanning, including the occlusion for a complete diagnosis of the patient. A digital intraoral scanner was used to perform the complete record which was then sent to the laboratory.
Fig.4
With the information from the intraoral scan and the patient’s photos, the technician can work on a digital wax-up proposal according to the instructions sent, using shapes from the InLab 20 software library or individualizing these shapes. Once the design is approved by the dentist and the patient, we can print plastic models to make a physical mock up or treatment simulation.
Fig.5
A silicone key of two consistencies was made on the 3D model of the printed design. It’s very important that this silicone key doesn’t have bubbles, to obtain a simulation as perfect as possible.
Fig.6
Physical mock-up with bis-acryl resin, but only in the teeth in which additive can be made. No test material was loaded in the misaligned canines. In this second appointment, the patient can be an active part of her treatment and give feedback on the new shape of her teeth, which gives great potential to the mock-up, and facilitates acceptance by the patient in what is also known as emotional dentistry.
Fig.7
Once the mock up was approved, we moved on to the dental preparation phase. During this stage it’s very important to record the color of the preparations and the final color that you want to achieve, because with this information the technician will select the correct material according to color and opacity. This photograph must be well taken and be true to reality,
which is why lighting is very important and equipment such as Smile Lite MDP 2 facilitates its registration together with a good smartphone.
Fig.8
After finishing preparations, an intraoural scan is taken, as well as that of the occlusion. Also the
printed dental shapes can be scanned to record the patient-approved project.
Fig.9
The software automatically matches the models under the biogeneric copy function and then presents the occlusal contacts to be able to check and then send everything to the technician.
Fig.10
For this case, the laboratory technician used the InLab 20 software to modify details and refine the design proposed by the software. With the color information the technician selected Emax Cad MT A1 blocks to mill the ceramic laminates, which were then crystalized and and given a natural appearance.
Fig.11
For the final integration of ceramic laminates it is essential to correctly select the cementation agent, especially when the thickness and opacity of the veneer can cause the cement to take a leading role at the time of cementation. For this reason, there are many light-curing cement alternatives on the market with a range of different colors and try-in pastes that simulate the color of the cement for try-in. The Relyx Veneer try-in paste by 3M was tested in its shades TR and A1 to find the best option for this case.
Fig.12
Relyx veneer TR was selected. The cementation protocol for feldspathic ceramics included conditioning of the veneers with hydrofluoric acid prior to cementation. Scotchbond Universal (3M) was selected, as it contains silane within its composition, to be a bonding agent between the ceramic and the resin cement. The justification for the choice of cement for a ceramic laminate is fundamentally centered on its thickness and opacity, that allows or not the passage of light. As long as laminates are less than 1 mm thick and of medium translucency, the cement of choice is a photoactivated one, as it ensures higher conversion and chromatic stability.
Fig.13
Final smile situation after cementation, using a multiwave curing light (Curing Pen by Eighteeth).
Fig.14
Before and after smile, at 1-month check-up, with ceramic veneers perfectly integrated into the patient’s smile. The aesthetic and functional requirements of the patient were successfully resolved in three sessions thanks to the Complete Digital Work Flow.
Fig.15
Conclusions
The full-digital flow allows us to significantly the number of appointments, allows us to work as a team even if the technician is at a far location, and it allows the patient to be an active part of their treatment and provide real-time feedback in the mock-up stage. Last but not least, the precision of the CAD/CAM equipment in the digitalization of the patient allows us for clean, quick and efficient work, minimizing the errors that could occur in intermediate stages, such as the making of cast models. Digital flow achieves happy patients in a short time.
Bibliography
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2. Christian Coachman, Marcelo Calamita. Digital Smile Design: A tool for treatment planning and communication in esthetic dentistry. Quintessence of Dental Technology. 2012.
3. Juan Pablo Sánchez, Eduardo Mahn, Gilbert Jorquera, Vanessa Bernasconi. Mock-Up An Old Tool Renewed. Clinical Research in Dentistry. 2018; 1 (1): 1-5.
4. Pablo Atria, Camila Sampaio, Ronaldo Hirata, Gilbert Jorquera. Preliminary evidence for the complete digital esthetic rehabilitation treatment: case report and 1-year follow-up. J Evid Base Dent Pract 2017: (76-82)
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