REFLECTREFLECTREFLECTd e n t a l p e o p l e f o r d e n t a l p e o p l e 0 2 / 1 1

The three pillars of esthetics

An impressive outcome

New ways have to be taken sometimes

02

Editorial

Dear Reader

One of Ivoclar Viva -dent’s major objec-tives has been, andcontinues to be, thelaunch of newly devel-oped technologies ona world wide scale –ideally in all countriesat the same time. Tomake new productsavailable to the den-tal profession through-out the world is a verychallenging task. It de -

mands considerable effort on the part of the people involved inResearch and Development, Production, Logistics as well as inMarketing and Sales. The effects of globalization which nowinvolve all levels oblige us to continually adjust our plans ofaction to be able to meet the new demands with which we arefaced.

Everywhere in the world, Ivoclar Vivadent products enjoy areputation for being of extremely high quality – and this alsoapplies to Latin America. Our unflagging commitment to meet-ing, or even exceeding, customer expectations has certainlyhelped to achieve these results. However, the worldwide distri-bution of products is not our only concern. We organize as well

as endorse and financially support further education events andtraining courses in order to ensure that our customers have thelatest information at their fingertips as far as state-of-the-arttechniques and treatment modalities are concerned that helpachieve esthetic and durable restorative results. The samerationale lies behind our efforts to provide the dental communi-ty with scientific reports, research results and case report bymeans of publications such as Reflect magazine.

We hope that the articles contained in this issue of Reflect willserve exactly this purpose and that you, the readers, may derivebenefit from it for your practical work. The best results areachieved in practice if operators have undergone comprehen-sive training. This helps to ensure that they use the productsaccording to the instructions and recommendations, which weas the manufacturer make available to them.

With best wishes

German SarmientoGeneral ManagerIvoclar Vivadent Colombia

The cover picture shows an agate slab with amethyst, which exhibits an opalescent effect similar to that of natural tooth structure under fluorescent light (Photo: Eva Ilzer).

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Contents

03

Editorial Challenges in the age of globalization . . . . . . . . . . . . . . . . . 02

German Sarmiento (CO)

Dental medicine All filling materials are not alike . . . . . . . . . . . . . . . . . . . . . . . . 04

Dr Eduardo Mahn (SA)

The three pillars of esthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 07

Dr Julio Reynafarje Reyna and

Dr Gustavo Watanabe Oshiro (PE)

TeamworkAn impressive outcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

Prof Dr Daniel Edelhoff and Oliver Brix, DT (D)

Ultra-thin, but highly effective . . . . . . . . . . . . . . . . . . . . . . . . . .14

Dr Alejandro James Marti, Dr Rosa Antonia López

Parada and Francisca Hernández, DT (MX)

Dental technologyJust an everyday story . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Florin Stoboran, DT (RO)

New ways have to be taken sometimes . . . . . . . . . . . . . . . . 20

Szabolcs Hant, MDT (HU)

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17

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PUBLISHER'S CORNERPublisher Ivoclar Vivadent AG

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Publication 3 times a year

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Production teamwork media GmbH, Fuchstal/Germany

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04

Dental medicine

Glass ionomer cements (GICs) and composite resinshave been successfully used for a variety of indi-cations in direct filling procedures for many years.Both materials are considered to be excellent amal-gam alternatives, even though they both have theirrespective strengths and weaknesses. Over time, thespectrum of their applications has grown wider andmore sophisticated.

Glass ionomer cementsGlass ionomer cements chemically bond to the toothstructure and release fluoride over a period of time.Moreover, they are easy to use and biocompatible. GICsare composed of polyalkenoic acid and glass powder,mainly aluminium fluorosilicate glass. An initial acid-base reaction occurs when the powder and liquid aremixed. A salt gel matrix is formed and a completelycross-linked structure results, which assists in the settingof the cement [1,2].Conventional glass ionomers were introduced in 1972 [3],followed by metal-reinforced glass ionomer cements,containing either silver or gold, in 1977 [4]. Resin-modi-fied glass ionomer cements were developed in 1992 [5,6]. Current research efforts are focused on using acidswith a high molecular weight, which would heighten theviscosity of the product and accelerate curing.The applications of GICs range from cementation andlining procedures to the placement of Class V restora-tions and small deciduous tooth fillings. Nevertheless, itis important to note that the adhesive strength of glassionomer cements is relatively low (merely 3 to 7 MPa)[6,7]. Furthermore, the problem of marginal integrityand marginal seal must also be taken into considera-tion. Even though GICs demonstrate a thermal coeffi-cient of expansion similar to that of natural tooth struc-ture [1,6], glass ionomer fillings often show marginalleakage. A number of studies have found that com-posite resins achieve more successful results with regardto marginal integrity than GICs in dental enamel [8].

The most important characteristic of GICs is most prob-ably their ability to release fluoride. This action beginswhen the components are mixed and continues grad-ually without negatively influencing the mechanicalproperties of the material [9]. Moreover, GICs are capa-ble of absorbing topically applied fluoride and releasingthis component over an extended period of time [10].Therefore, GICs are considered to have a cariostaticeffect in clinical use [11]. Nevertheless, carious lesionsare often found along the margins of GIC restorations.The ability of GICs to release an adequate amount offluoride to successfully inhibit the growth of caries hasnot yet been established. The service life of GIC restora-tions is a further cause for concern. Numerous studieshave shown that the life time of these restorations isconsiderably shorter than that of composite resin andamalgam restorations. Therefore, GICs are more appro-priately used in the fabrication of long-term temporariesthan permanent restorations. A systematic analysis hasshown that the failure rate of GICs is above seven per-cent, while that of composite resins is lower than threepercent [12].Despite these drawbacks, many practitioners are tempt-ed to use GICs rather than composite resins as an alter-native to amalgam. GICs are easier to use and theirapplication protocol is faster than that of compositeresins. Furthermore, they are much cheaper and there-fore very popular in emerging markets.

Composite resinsAs a result of developments in the field of compositeresins, as regards the inorganic fillers [13] and monomersused [14] in particular, these materials now featurelower solubility and higher wear and fracture tough-ness. Therefore, the overall mechanical properties ofcomposite resins have improved. The interaction of thebonding agent and the tooth structure establishesmicromechanical retention [15-17], which ensures ahigh level of resistance.

All filling materials are not alikeThe first choice for posterior restorationsDr Eduardo Mahn, Jeddah/Saudi Arabia

Today, composite resins have only two shortcomingscompared with glass ionomer cements: They takelonger to place and the application protocol is moretechnique sensitive. This time difference, however, isnot really significant if the entire restorative procedureis taken into consideration: examination, diagnosis,anaesthetic, excavation, preparation, isolation and fin-ishing and polishing. The development of self-etchingadhesives – irrespective of one-step or two-step sys-tems – has reduced the entire treatment time quite con-siderably. The introduction of self-etching adhesives hasalso helped to reduce technique sensitivity and increasethe reproducibility of results [18]. The dentin tissue isnot etched and the smear layer is not removed; instead,infiltration takes place. As a result, the dentin tissue iseasy to dry and post-operative sensitivity is reduced[19]. Furthermore, the evaporation of the solvent afterthe application is not a critical issue. As is the case withmany total-etch adhesives, a mixture of different sol-vents, rather than just one, is used. In this context, it isimportant to note that strong adhesion to dental enam-el can only be achieved with phosphoric acid etching[20,21]. This step is always recommended, regardless ofthe method used.In the following case study, a self-etching adhesive ofthe latest generation was used (Tetric® N-Bond Self-Etch). Due to its innovative pen-shaped delivery form,this material can be directly applied, which saves time.Despite all of these advances and developments, how-ever, composite resin users must have in-depth knowl-edge of materials. The procedure recommended by themanufacturer must be strictly observed.

Case studyA 31-year-old female patient presented to our sur-gery after a lengthy absence. A thorough examinationrevealed that several aspects required attention, in par-ticular a highly opaque, damaged filling in tooth 47.The filling in question had the distinct appearance of aglass ionomer cement. Secondary caries had formedin the distal area. According to the patient, it had beenplaced less than two years previously. Furthermore, wetook note of a filling in tooth 46 that had been placedin our surgery more than eight years ago (material:Tetric® Ceram). The restoration was clearly worn afterall this time. Nevertheless, the margins were still intact(Fig 1).We recommended that the filling in tooth 47 be replaced.Figure 2 shows the working field isolated with a rubberdam (OptraDam® Plus). Proper isolation ensures cleanand safe placement of the restorative material. The oldfilling was removed and carious tissue was excavated.An adhesive (Tetric N-Bond Self-Etch) was placed direct-ly on the tooth structure and scrubbed in for 30 seconds(Figs 3a and b). The solvent was evaporated with astrong stream of air. Next, the surface was light-curedfor 10 seconds with a third-generation LED polymeriza-tion unit (bluephase®).First, a layer of flowable composite resin (Tetric® N-Flow)was placed in the cavity (Fig 4) and light-cured for 10 sec-onds. Subsequently, the filling was built up with shadeA2 of the universal composite resin Tetric N-Ceram®. Anon-stick modelling instrument (OptraSculpt®) was used,with which the cusp slopes and tips were faithfullyreproduced. This instrument is supplied with various

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Fig 1 Preoperative view Fig 2 Proper isolation of the operative field with a rubber dam

Figs 3a and b Application of the self-etching adhesive for 30 seconds

working tips to satisfy the different indications. In thepresent case, the chisel shape was used. The pointedend of the tip was used to sculpt the fissures.The restoration was built up in four steps. One cuspwas modelled and light cured at a time. Figure 5 showsthe situation after the distal cusps were polymerized.In Figure 6, a mesial cusp is sculpted. Only as muchcomposite resin as was necessary was applied and light-cured. As a result, very few occlusal adjustments werenecessary. Figure 7 shows an occlusal view of the fillingbefore polishing. The natural-looking anatomy is clear-ly evident as well as the worn eight-year-old filling intooth 46 and its intact margins. After occlusal grinding,the restoration was polished with OptraPol® Next Gen-eration rubber tips (Fig 8), which contain a high dia-mond crystal content (72 wt%). This high diamond con-tent achieved excellent polishing results in only one step.

Figure 9 shows the finished filling with the marked con-tact points. q

A bibliography is available from the editors on request.

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Fig 6 Sculpting of the mesial cusps Fig 7 Occlusal view of the filling before polishing

Fig 8 Final polishing in one step with a large “flame” tip Fig 9 Result of the occlusal inspection

Fig 4 Application of a flowable composite resin as the first layer Fig 5 View of the distal cusps after light-curing

Dr Eduardo MahnSamaya ClinicsPO Box 10703 Jeddah 21443 Saudi Arabiaedomahn@hotmail.com

Contact details:

have the tooth prosthetically restored with ceramicmaterial and expressed her desire to receive minimallyinvasive treatment. We decided to apply a direct restora-tive technique using state-of-the-art composite resin(IPS Empress Direct).

Initial steps and tooth preparationAs the degree of tooth discolouration varied from mildto medium, a preparation depth of 0.3 to 0.5 mm wassufficient. Following minimally invasive preparation, aretraction cord was placed to prevent contamination ofthe working field with sulcus fluid (Fig 3). When fabri-cating layered restorations, the application of the adhe-sive is the step most prone to error. Therefore, it isadvisable to use an adhesive system that is easy-to-use,but provides reliable adhesion. In the case presented,we decided to use ExciTE® F adhesive. After having con-ditioned the enamel with phosphoric acid gel (TotalEtch) for 30 seconds, the adhesive was brushed intothe tooth structure for 10 seconds (Fig 4) and blownto a thin layer with a weak stream of air. Subsequently,the adhesive layer was light-cured for 10 seconds withthe bluephase® curing light using the Low Powermode. Then the first composite layer was placed. Inorder to achieve optimum masking, we chose to usethe opaque B2 shade from the IPS Empress range ofDentin materials.

07

Dental medicine

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How often do we encounter heavily stained ante-rior teeth in dental practice? Nearly every clinicianhas come across that problem at least once. In suchcases, an invasive approach is usually required, iethe teeth need to be prosthetically restored withceramic veneers or even crowns. However, since theconcept of “minimal invasiveness” has attainedquite a following recently, it might be a good ideato start rethinking our ways of dealing with stainedanterior teeth. Today’s state-of-the-art compositesenable dental professionals to use minimally inva-sive treatment protocols and achieve outstandingrestorative results.

Training courses held on the subject of esthetic den-tistry usually focus on three basic aspects: shape, shadeand surface texture. These are the three indispensablepillars without which the esthetic restoration of anteri-or teeth would be impossible. However, in most casesattention is only paid to one of the aspects, namelyshade. Why is this so? This article will show how all thethree elements can be taken into account in order toachieve an esthetic outcome.

Preoperative situationA female patient presented to our dental practice witha stained central incisor (Figs 1 and 2). She refused to

The three pillarsof esthetics

Fig 1 Starting situation: severely stained tooth 11 Fig 2 A close-up of the upper anterior teeth shows that theesthetic appearance is inadequate.

Directly placed composite restorations using IPS Empress Direct®

Dr Julio Reynafarje Reyna and Dr Gustavo Watanabe Oshiro, Lima/Peru

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Fig 11 Final polishing of the restoration with the Astropol system

Fig 8 Shade A1 Dentin was chosen for the central portion ofthe tooth (mamelon area). The incisal edge was covered withtranslucent opalescent material.

Fig 9 Layering scheme showing the masking composite layers

Fig 4 The adhesive was brushed into the tooth structure for10 seconds.

Fig 5 In the gingival portion, composite was applied in an “arch”shape to follow the gingival outline (B2 Dentin).

Fig 6 The composite was adapted to the natural tooth structure.

Fig 7 Placement of composite in the proximal portion of the tooth.Also in this region, an “arch” was moulded.

Fig 3 Situation after minimally invasive preparation of the tooth

Fig 10 Application of the enamel layer (B1 Enamel)

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LayeringMimicking the shape and shade of natural teeth is ahuge challenge and requires considerable attentionto detail. In order to achieve the same reflections asthose of natural teeth, the dentin shade was appliedin an arch-like fashion. As the composite materialreadily adapted to the preparation margins, only lightpressure with the modeling spatula (Fig 5) had tobe applied. The composite increment was deliberate-ly moulded with a slight taper towards the centre ofthe tooth. In this way, an invisible transition to thesubsequently placed increments was ensured (Fig 6).Then the composite was light-cured with the blue-phase curing light for 15 seconds using the Soft Startmode. After having moulded the gingival “arch”, which out-lined the gingival margin of the veneer, the proximalportions were moulded in a similar fashion. As eachlayer was thinned out, the different shades and shapesblended well into each other (Fig 7). Once the mamel-on-type increment had been placed in the centre, thediscolouration was completely masked. Both in theproximal and central areas, Shade A1 Dentin was used.To copy the appearance of the adjacent teeth, a translu-cent opalescent material was applied along the incisaledge. Finally, the entire composite build-up was cov-ered with a layer of IPS Empress Direct B1 Enamel asindicated in the layering scheme (Figs 8 to 10).

FinishingIn order to closely reproduce the morphology andanatomy of natural teeth, just as much effort shouldbe applied in finishing the restoration as in layering it.Following polymerization, attention was paid to creat-ing an optimal surface texture. First, the restorationwas pre-contoured with fine-grit burs to remove pos-sible composite excess. Fine-grit instruments provid-ed the advantage of allowing an optimal shape to beachieved in a controlled fashion. Moreover, the inad-vertent creation of undesirable retentions or depres-sions was avoided. After pre-contouring the restora-tion, finishing and polishing was performed using theAstropol® system (Fig 11).

ConclusionWith state-of-the-art composites such as IPS EmpressDirect, natural-looking restorations can be created. Easy-to-use materials in combination with individual layeringschemes enable minimally invasive treatment proce-dures to be employed, even in cases where indirectrestorations would normally be indicated. By choosinga suitable restorative and following the treatment pro-tocol described in this article, the three pillars of esthet-ics can be taken into account in the restoration of ante-rior teeth (Figs 12 and 13). q

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Contact details:

Dr Julio Reynafarje ReynaJr Grimaldo del Solar 231 Of 101Miraflores, Lima 18Perucda_peru@live.com

Dr Gustavo Watanabe OshiroMiguel Angel 220San Borja, LimaPerugustavowatanbeo@hotmail.com

Figs 12 and 13 The final result: esthetic reconstruction of tooth 11involving minimum loss of tooth structure

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Fig 2 The severe discolouration of tooth 11 also caused a discolouration of the marginal gingival area.

Fig 3 The asymmetrical tooth axes of the central incisors areclearly visible.

Fig 1The pronounced

discolouration and the inadequate tooth position of

the upper central incisorsimpaired the esthetic

appearance.

Endodontically treated incisors may entail seriousesthetic deficiencies as a result of severe dis-colouration and present a challenge to the restora-tive team. The objective of the treatment is toreconstruct the biomechanical and optical proper-ties of the affected teeth, at the expense of as lit-tle natural dental tissue as possible. By following aclearly coordinated procedure, the treatment teammay achieve satisfactory results with an internalbleaching method, an adhesive post build-up anda preparation technique that suits the require-ments of the restorative material. The invasivenessof this approach is considerably reduced as com-pared with conventional restorative techniques.

This article discusses the rehabilitation of two uppercentral incisors by placing fibre-reinforced compositeposts, using build-up materials and subsequently restor-ing the teeth with 360° veneers made from lithiumdisilicate ceramic (LS2).

Initial situationA 28-year-old male patient came to the practice andexpressed the wish to have his endodontically treatedand severely discoloured upper central incisors restored.He said that he had not experienced any problems sincethe resection of the root some years previously; how-ever, he was dissatisfied with the impaired estheticappearance caused by the affected teeth (Figs 1 to 3).

An impressive outcomeRestoring severely discoloured anterior teeth using minimally invasive proceduresProf Dr Daniel Edelhoff, Munich, and Oliver Brix, DT, Wiesbaden/both Germany

Teamwork

Fig 4 Leaking composite restorations and secondary caries inthe endodontically treated teeth 11 and 21

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to achieve an optimum esthetic outcome, the veneerswere to be fabricated in the cut-back technique.

Preliminary treatment and preparationAfter the coronal pulp chamber of the two incisorshad been cleaned, an additional seal was placed atthe cemento-enamel junction using a small amount ofphosphate cement. This measure ensured that thebleaching agent which would be applied later did notdiffuse into these sensitive areas (Fig 5). For the inter-nal bleaching, a mixture of sodium perborate powderand distilled water was applied using the walkingbleach method. The palatal access to the coronal pulpchamber was sealed with cotton pellets soaked inbonding agent (Heliobond) and a low-viscosity com-posite (Tetric EvoFlow®). The next appointment wasscheduled one week later. The desired tooth shadehad not yet been achieved, and therefore fresh bleach-ing agent was applied. After another week with thebleaching agent in place, a satisfactory brightness valuewas observed on both abutment teeth (Fig 6). A calci-um hydroxide preparation (CalciPure®) was inserted intothe pulp chamber and left in place for a week in orderto neutralize the bleaching agent.

After the neutralization phase, we proceeded to thepost-endodontic build-up of the abutment teeth. Forthis purpose, the coronal sealing of the root canalfillings was removed and standardized holes for thefibre-reinforced composite posts (FRC posts) weredrilled. The posts were luted with Variolink® II (dual-curing, low viscosity, shade: white-opaque) and amulti-step adhesive (Syntac®). After the posts hadbeen covered with a low-viscosity composite (TetricEvoFlow), a bright, highly filled viscous composite(Tetric EvoCeram®, Bleach XL) was applied to createthe direct build-up (Fig 7). A high-power curing light(bluephase® G2 with > 1,000 mW/cm2) was used forthe final polymerization of the cementation and build-up materials. A diagnostic pattern was employed forthe minimally invasive preparation. This template wasfabricated on the basis of the wax-up and contained all

The clinical and radiological evaluations revealed tightand properly executed root canal obturations in teeth11 and 21. There were no signs indicating the presenceof root canal posts, but the extensive composite restora-tions in both teeth were leaking and showed secondarycaries (Fig 4). At the time of the clinical evaluation, therestorations were already five years old. The specificchallenges facing the treatment team was the patient’swish to have the esthetic appearance of his teethrestored in a timely fashion. The patient required thathis natural tooth shade and position be restored and, tothe extent possible, that the remaining tooth structurebe stabilized in the long term.

Treatment planningBefore we proceeded to planning the permanent restora-tion, the inadequate fillings of the anterior teeth as wellas the secondary caries were removed. This allowed usto assess the extent to which the teeth had been dam-aged. In addition, a possible contamination of the tworoot canals with microorganisms – resulting from theinadequate fillings which had been in place for years –had to be ruled out.

Both root canal fillings had been tightly sealed at thecemento-enamel junction with separate fillings. Thecanals therefore did not have to be re-opened. Internalbleaching of the crown portions of both teeth usingthe walking bleach technique was planned.

After an initial technical and clinical evaluation, the fol-lowing treatment plan was determined: First, the toothposition and proportions should be corrected by meansof an analytic wax-up. The brightness of the affectedteeth was then to be adjusted by internal bleaching tomatch the brightness of the neighbouring teeth dur-ing a preliminary treatment phase. Given the extensivelesion, we opted for a direct adhesive build-up afterendodontic treatment with cemented fibre-reinforcedcomposite posts. For the final restoration of the severe-ly destroyed anterior teeth, we decided to use 360°veneers based on a lithium disilicate material. In order

Fig 5 The root canal fillings were checked prior to the internalbleaching procedure, and the cemento-enamel junction wasadditionally sealed. The cavities were now ready for the appli-cation of the bleaching agent.

Fig 6 Two weeks later: The severe discolourations were almostentirely removed by the internal bleaching treatment.

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Fig 9 The optimum masking of the extensively built-up abutmentteeth achieved by an MO ingot coping and a try-in paste in theshade white-opaque became evident already during the try-inof the veneers.

Fig 11 The 360° veneers were seated with the luting cementthat corresponded to the try-in paste used; a multi-step dentinadhesive system was used. Thus, an excellent esthetic outcomecould be achieved reliably and predictably.

Fig 12 The restorations in transmitted light. By combiningtranslucent build-up materials and glass-ceramic veneers, alight transmission that matches the properties of natural teeth was achieved.

Fig 10 Frontal view of the veneers during try-in. The use oflithium disilicate as the basis of the restoration ensured ahomogeneous appearance regardless of the substructure.

information relating to the correction of the tooth posi-tion and the outer contour of the final restoration.

Temporization and fabrication of the final veneersThe diagnostic template was also used for creating thedirect veneer temporaries. The temporary restorationscould thus be fabricated in a fairly straightforward man-ner using a Bis-GMA-based temporary material (Telio®

C&B, A2). A bonding agent (Heliobond) was applied tothe finished, non-etched preparation surfaces and tothe inner side of the temporaries and light-cured afterremoval of excess material.

After a four-week evaluation phase of the tooth shapeand position, which both were determined by the wax-

up and transferred to the temporaries, a precisionimpression of the prepared teeth and an impression ofthe antagonist jaw were taken. This information wassent to the laboratory together with the facebow, theregistration of the jaw relation and an image of theprepared abutment teeth. The image showing the prepa-rations helped the laboratory to assess the requireddegree of opacity for the framework structure. Giventhe different levels of translucency, the different build-ups of the abutment teeth and to ensure an improvedmasking capability in case of a relapse of the discoloura-tion, the treatment team chose to use press ceramicingots with a medium opacity level in shade 0 (MO 0).The IPS e.max® Press frameworks were veneered withthe IPS e.max® Ceram veneering ceramic in the shadeA2 (Fig 8).

Fig 8 Lithium disilicate-based 360° veneers made of IPS e.maxPress. In order to better mask the dental structure with a mini-mum layer thickness, an MO ingot was selected.

Fig 7 The built-up and prepared incisors. Given the severe degreeof destruction, adhesively cemented fibre-reinforced compositeposts combined with mouldable composite materials were used.

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Try-in and seatingAfter removal of the temporary restorations, residuesof the bonding agent were removed with cleaningbrushes and a fluoride-free cleaning paste. In order tocheck the shape and shade of the veneers in thepatient’s mouth, the restorations were tried in with ashaded glycerine gel (Try-in Paste, Variolink II, white-opaque). A perfect masking of the abutment teeth wasalready achieved at this stage and the resulting situa-tion showed a harmonious appearance regardless ofthe substructure (Figs 9 and 10).

The inner aspects of the glass-ceramic veneers wereetched with a hydrofluoric acid gel (< 5% IPS® CeramicEtching Gel) for 20 seconds. Subsequently, a bondingagent (Monobond Plus) was applied. Only the multi-step dentin adhesive system Syntac was applied to thetooth. The restorations were luted into place with theVariolink II system (white-opaque) (Fig 11).

ConclusionA light transmission which corresponds to that dis-played by natural teeth was achieved by using translu-cent build-up materials in conjunction with glass-ceramic lithium disilicate veneers (Fig 12). The final out-come with regard to functional and esthetic parame-ters was found to be very satisfactory at the final eval-uation. The tooth shade was in perfect harmony withthe surrounding dentition. In addition to removing thesevere discolouration of the hard and soft tissues, wewere able to correct the tooth position and adjust thetooth proportions (Fig 13). The patient was fully satis-fied with the esthetically pleasing outcome and did notexperience any phonetic problems resulting from thecorrection of the tooth position (Fig 14). q

Fig 13 Postoperative view with mandible in protrusion. The final check of the functional and esthetic parameters was satisfactory. Thetooth shade excellently matched the adjacent teeth.

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Fig 14 Portrait image of the final outcome: The discolourationswere removed, the tooth posi-tion corrected and the toothproportions adjusted (for com-parison, see Figs 1 and 2).

Contact details:

Prof Dr Daniel EdelhoffTenured Associate ProfessorDepartment of ProsthodonticsLudwig Maximilian University of MunichGoethestr 70 80336 MunichGermanydaniel.edelhoff@med.uni-muenchen.de

Oliver Brix, DTInnovatives Dental DesignDwight-D-Eisenhower-Str 965197 WiesbadenGermany

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Fig 1 Chipped distal incisal edge of tooth 21 Fig 2 Plaster cast according to Geller with removable die

As a result of the wide selection of dental restora-tives available today, clinicians are able to userestorative procedures involving minimal or nopreparation, which take both functional andesthetic aspects into account. Due to the reliablebonding effect achievable with state-of-the-artadhesives, heavily invasive preparation schemesare being increasingly avoided. One of the majorgoals in modern dentistry is to maintain as muchof the natural tooth structure as possible. In somecases, we can even do without any preparationof the tooth, as will be illustrated by means ofthe clinical case shown below.

Case reportA male patient presented to our office, whose tooth21 had a chip on the distal portion of the incisal edge.The clinical examination revealed several worn areaswhich were due to occlusal disharmony (Fig 1). Themandibular position was restabilized in line with thecentric occlusion of the teeth in order to prevent fur-ther damage due to functional disorder. We decided torestore tooth 21 with a non-prep veneer. The state-of-the-art materials available today gave us the option ofusing this procedure which involved minimal invasive-ness. After taking an impression with Virtual® additionsilicone material, a photographic record was made and

the tooth shade was determined. Subsequently, the datawere sent to the dental laboratory.

Dental laboratory procedureA working model was fabricated using the Gellertechnique, which served as the working basis. In otherwords, tooth 21 was designed as a removable die(Fig 2). The die was duplicated using Double Takeduplicating material and then reproduced in refractorydie material. Based on a layering scheme set up before-hand, the veneer was built up with IPS d.SIGN® fluor -apatite glass-ceramic (Figs 3 to 7).

Clinical procedure conducted in the dental practiceUsing Variolink® Veneer Try-In pastes, the veneer wastried in the mouth. Try-in pastes allow the right shadeof the luting material to be determined and thus ensurean optimum esthetic result. We recommend using posi-tioning aids such as OptraStick®, as they make handlingof the laminate veneer a lot easier (Fig 8). After havingchecked the fit of the restoration, the try-in paste wasrinsed off with water and the laminate veneer placedin an alcohol solution in an ultrasonic cleaner to removeall the contaminants. Then the veneer was thoroughlyrinsed again with water. Subsequently, the inner sur-faces were etched with 5-per cent hydrofluoric acid(IPS® Ceramic Etching Gel) for 60 seconds (Fig 9). By

Ultra-thin, but highly effectiveMinimally invasive treatment with non-prep ceramic veneers Dr Alejandro James Martí, Dr Rosa Antonia López Parada and Francisca Hernández, DT, León/Mexico

Teamwork

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enamel surface was rinsed with water for 5 seconds toremove the etching gel and subsequently air-dried foranother 5 seconds. Next, a coat of adhesive was applied.In the case presented, we used ExciTE® adhesive.Then Variolink Veneer luting composite was applied tothe inner surfaces of the veneer directly from thesyringe with the application tip. We positioned theveneer on the tooth (Figs 12 and 13) and applied slightpressure in a vertical direction to squeeze out anyexcess material. Subsequently, the inserted restorationwas light-cured from the vestibular and palatal aspectsfor 10 seconds each. Removal of excess material wasaccomplished with scalpel no. 12 (Fig 14). To prevent anoxygen-inhibited layer from forming on the compositesurface, the margins were covered with glycerine gel(Liquid Strip) and light-cured again from both aspectsfor 30 seconds (Fig 15). Finishing and polishing of the

means of this etching procedure mechanical retentionswere created. After having removed the hydrofluoricacid with water, the laminate veneer was cleaned in analcoholic bath in the ultrasonic unit and rinsed againwith copious amounts of water. Then the veneer wasdried. We applied Monobond Plus to the inner surfacesand left it to react for 60 seconds (Fig 10).When laminate veneers are adhesively cemented, itis essential to establish a completely dry treatmentfield. Normally, the placement of a rubber dam is rec-ommended (eg OptraDam®) to avoid any kind of con-tamination. As a next step, the enamel was etched withTotal Etch (37-per cent phosphoric acid gel) for 15 to30 seconds. We recommend protecting the adjacentteeth with Teflon tape during this procedure (Fig 11), asthis will prevent the teeth from being etched inad-vertently. Moreover, excess gel is easier to remove. The

Fig 3 Layering of the laminateveneer on the refractory die

Figs 4 and 5 Repositioning of the ultra-thin veneer on the model

Figs 6 and 7 The laminate veneer is translucent and as thin as a contact lens.

Fig 9 Etching of the restorationfor 60 seconds

Fig 10 Silane is applied. Fig 11 Prior to etching the enamel with Total Etch, theadjacent dentition was protected with Teflon tape.

Fig 8 To achieve an esthetic outcome, theshade of the luting composite needs to bedetermined. Placement instruments simplifythe handling of the veneer.

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Fig 15 The cement joint was coated withglycerine gel and then light-cured.

Figs 16 and 17 Finishing and polishing of the margins

restoration was performed with the Astropol®/Astro-brush® system (Figs 16 and 17).

ConclusionIn the case presented, we were able to reconstruct thechipped distal portion of the incisal edge of tooth 21without prior tooth preparation (Fig 18). Modern treat-ment concepts and the dental materials availabletoday allowed us to successfully apply this type ofprocedure, which helped to preserve as much naturaltooth structure as possible. It is definitely a valuableaddition to our range of treatment options, particu-

Fig 14 Following light-curing, excesscement was removed.

Fig 13 OptraStick was used to positionthe veneer on the tooth.

Fig 12 Application of the luting compositeto the inner surfaces of the veneer

Fig 18 The restoration in situ: We succeeded in perfectly mimick-ing the shape and shade of the natural tooth and concealing thetransition between the ceramic and the natural tooth structure.

Dr Alejandro James MartíBlvd Juan Alonso de Torres 2219 Col PanoramaLeón, Gto CP 37160Mexicodoctor@alejandrojames.com

larly when it comes to restoring worn down or chippedteeth. However, prior to performing such a procedure,the cause of the chipping should be established as func-tional therapy may be required. q

Contact details:

Dr Rosa Antonia López ParadaBlvd Venustiano Carranza 613 Col San MiguelLeón, Gto CP 37390MexicoRalp_odonto@yahoo.com.mx

Francisca Hernández, DT Astronautas 802 Col PanoramaLeón, Gto CP 37160Mexicoart-dent@live.com.mx

rial, because the esthetics of the results made all effortsworthwhile.

Today, the IPS e.max Press lithium disilicate (LS2) glass-ceramic ingots afford dental technicians a range ofmaterials which allows them to meet all require-ments in terms of mechanical properties and esthetics.Chipping, as it tended to occur under time pressure, isa thing of the past, thanks to the outstanding strengthof 400 MPa. The IPS e.max Press range comprises fiveingot types with different translucencies. Of these, I usethe LT, HT and Impulse ingots for inlays and onlays(LT = low translucency, HT = high translucency).

Shade determinationShade determination is a crucial step in the fabricationof ceramic restorations. I use the canine as a reference,as this tooth shows a very high dentin portion. In thepresent clinical case, an LT ingot in the shade B3 wasselected due to the size and depth of the lesion (Figs 1and 2). The shade of the cervical area of the tooth wasB3, and a somewhat brighter shade was selected forthe cusps (B2). I wanted the restoration to show a shadesaturation from the inside. Given the depth of the defect,an LT ingot with lower translucency and a lifelike bright-

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Dental technology

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Lab-fabricated ceramic inlays, onlays or table topsare an alternative to the direct restoration of pos-terior teeth with composite resin. These restora-tions fabricated by the dental technician offer someadvantages, such as the possibility to design adetailed morphology and to create a lifelike shadedesign. This article discusses the fascinating possi-bilities offered by IPS e.max® Press and IPS e.max®

Ceram in the fabrication of all-ceramic inlays.

Around seven years ago, I discovered a special all-ceramic system: IPS Empress® 2 and the layering ceram-ic IPS Eris® from Ivoclar Vivadent. The company adver-tised the highly esthetic results that could be achievedwith this system, particularly with regard to the shadedesign in single crowns as well as inlays and onlays. Iwas eager to find out for myself and so I tried the sys-tem. The material fulfilled my expectations, but I foundone aspect to be unsatisfactory: The material’s strengthwas still not optimal for the fabrication of inlays andonlays. Great care had to be taken while sandblastingthe restoration margins in order to prevent the thinmargins from breaking. The entire processing there-fore became rather time-consuming. However, this didnot keep me from continuing to work with the mate-

Just an everyday story

Fig 1 Initial situation: extensive and deep lesion after endodontictreatment

Fig 2 The canine was used for shade determination. The antag-onist served for comparison.

Restoring extensive coronal lesions with IPS e.max®

Florin Stoboran, DT, Oradea/Romania

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Fig 9 Result after theglaze firing and polishing

Fig 7 The fully anatomi-cally pressed restorationis ready for the stainingtechnique.

Figs 8a and b Characterization with stains and glazematerial

Figs 4a to e Characterization with stains and shades

Figs 5a to d Anatomical layering with various ceramic materials

Figs 3a to d For the wash firing, the framework was wetted with glaze liquid and sprinkled with Dentinpowder (B3).

Fig 6 The result after thefinal firing cycle and pol-ishing

ness value and chroma was selected instead of an HTingot. An inlay of this size might have shown a grey-ish shade effect if an HT ingot had been used. After theshade group had been determined on the basis of thecanine, all subsequent work steps were completedwithin this shade group. In this case, B was determinedas the shade group. To illustrate this: The canine in thiscase had the shade B3; consequently, all the work wasdevised so as to lighten up or darken this shade accord-ing to the specific requirements.

To document this patient case, two different approach-es were pursued: On the one hand, a cut-back IPS e.max

Press framework was layered with IPS e.max Ceram, andon the other hand, a fully anatomical inlay was pressedand characterized during the glaze firing.

The layering techniqueFirst, residues of the investment material were removedfrom the framework with aluminium oxide (110 µm, 2 bar/29 psi). Subsequently, the surface of the frame-work was sandblasted with glass polishing beads. Giventhe excellent strength of the lithium disilicate material,the risk that the restoration would break at the marginswas eliminated. After sandblasting, glaze liquid wasapplied in a thin layer and Dentin powder in the same

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shade as the ingot was sprinkled onto the framework.This step improves the bond between the layeringceramic and the lithium disilicate material and fur-thermore creates a “diamond effect” under incidentlight (Figs 3a to d). After the initial firing cycle at 750°C (1382°F), a stains firing was conducted, in the courseof which fine, more detailed characterizations weredesigned. For this purpose, highlights were created withstains materials: Darker colours were used in the deep-er areas of the restorations (central fossa) and lightercolours in the elevated areas (cusp tips) (Figs 4a to e).

The layering diagram applied after stains firing was fairly straightforward: Dentin (B2) for the cusps, someOpal Effect 2 (OE2) between the cusps towards thecentral fossa (depth effect) and some Transpa Incisal(TI1) to imitate the anatomy of the posterior tooth; thislayer, however, was restricted to 0.2 mm below thefinal restoration outline in order to leave some roomfor OE4 material. This material is capable of reflectinglight to some extent, which is why it is often used toimitate the whitish effect seen on the cusp tips (Figs 5ato d). After layering and another firing cycle at 750°C(1382°F), I focussed on the design of the surface tex-tures, which I created with rotary grinding instrumentsand sealed by means of a glaze firing conducted at 715°C (1319°F). Subsequently, the restoration was pol-ished with rubber polishers and a diamond paste (Fig 6).

The staining techniqueAll morphological properties of this molar, including thesurface texture, were already designed in the wax-up.After the ceramic inlay had been pressed and divested,the surface was slightly ground and the contact pointsas well as the occlusion were checked (Fig 7).

The same stains as the ones used in the layering tech-nique were applied and subsequently fired in a stainsand characterization firing (Figs 8a and b). Care shouldbe taken not to apply the stains too excessively in orderto prevent a “mirror” effect; if the material is appliedtoo thickly, the light is reflected from the restoration sur-face and does not penetrate it. As a result, the desired

translucency is not achieved. The shape and the mar-ginal adaptation were checked with silver powder beforeand after the glaze firing. Finally, the restoration waspolished to a high gloss with a rubber polisher and dia-mond paste (Fig 9).

ComparisonBoth restorations were tried in intraorally, and bothshowed a nearly perfect marginal fit. Therefore, therestoration which was actually to be cemented intoplace had to be selected on the basis of esthetic con-siderations. The monolithic structure and the fact thatonly pressed lithium disilicate, the strongest pressableceramic tested to date, was used would have been areason to use the stained restoration (Fig 10). From thepoint of view of mechanical and functional properties,this restoration would have been preferred; however, itdid not show the desired translucency. If the two restora-tions were compared, the layered restorations clearlyshowed a superior shade effect (Fig 11), and thus thisrestorations was permanently seated (Fig 12).

ConclusionIPS e.max Press and Ceram in conjunction with an adhe-sive cementation protocol represent a valuable assetfor dental technicians. For instance, the system allowsyou to fabricate highly esthetic inlays with an excellentstrength. It is thus a highly attractive alternative to directinlay restorations, offering advantages to patients, clini-cians and dental technicians alike. q

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Fig 10 Try-in of the fullyanatomically pressed andstained inlay

Fig 11 Try-in of the ceramic-layered inlay

Fig 12 The inlay in place

Florin Stoboran, DT S. C. STOBY DENTAL S.R.LHategului / 39A410257 Oradea/BihorRomaniaflorinstoboran@yahoo.com

Contact details:

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Dental technology

In the case below the author describes two meth-ods of creating an anterior restoration: a conven-tional method where the veneers are layered andfired on an investment die and an unconvention-al method involving layered veneers on a pressedceramic substrate.

Initial situationTeeth 11 and 21 should be esthetically corrected in thisdiscerning male patient. He was particularly concernedabout the palatal position of the teeth and the dis-coloured composite restorations (Fig 1). The aim was tofind a treatment option that would involve as little lossof healthy tooth structure as possible in line with theprinciples of conservative dentistry.

An analytical evaluation of the diagnostic model showedthat a minimally invasive esthetic modification could onlybe achieved with ceramic veneers (Fig 2). At this stage,we were still considering the possibility of using a total-ly non-invasive treatment option. The palatal position ofthe upper two central incisors afforded enough spaceto accommodate a layered non-prep veneer. Already atthis stage we decided to use two different methodsand compare them with each other: one of them con-ventional and the other one still relatively unknown inour market.

Conventional methodFor the conventional method we opted for a metal-ceramic system (IPS d.SIGN®), which involves firing of theveneers in an investment ring. The veneers were mod-elled on investment dies (GC Orbit Vest) that had beenprepared beforehand (Figs 3 to 6). When applying thelayers, I masked the areas of the composite restorationwith Deep Dentin to prevent it from shining through theceramic layers. I generally use a translucent material forthe cervical region, unless the underlying tooth structureis completely discoloured. For the present case, I appliedTranspa Neutral and Opal Effect 1 materials. The advan-

tageous translucent properties of Transpa Neutral andthe incisor-like opalescence of Opal Effect 1 provide asuitable combination for this region. In my experience,this technique has proved to be successful, allowing thetransition in the cervical region to be effectively camou-flaged.

It is essential to work in small steps when working withan investment die. The mechanical and chemical bondbetween the investment material and ceramic material isnot as strong as the bond between the opaquer andceramic material when a conventional layering technique

New ways have to betaken sometimesVeneer restorations layered onto pressed ceramic substratesSzabolcs Hant, MDT, Budapest/Hungary

Fig 1 Initial situation: The patient is unhappy about the discolouredcomposite restorations and the uneven alignment of the teeth.

Fig 2 A model of the initial situation shows the palatal deviationof the central incisors.

on a framework is used. It is imperative to bear this inmind since it is very difficult to mend the restoration ifceramic material has detached itself from the investmentdie because it was applied in too thick a layer. For the

present case, a comparatively thin layer of dentin mate-rial was sufficient because this restoration did not involvea metal framework masked with opaquer. Consequently,more space was available for the enamel materials.

Upon completion of the firing process, the investmentdies were removed and the veneers were tried in. Anoptimal result was achieved in the cervical region. Theuse of a matching try-in paste (Variolink® Veneer Try-In) was helpful in this respect. The shade of the incisalarea also appeared to be successful; the tooth’s inher-ent shade was shining through the translucent layersof the incisal area. However, things often turn out tobe different than expected: Upon close examination,we spotted the shortcoming that was unacceptableto our esthetically discerning patient: The incisal wasslightly brighter than that of the neighbouring teeth, ascan be seen in pictures 7 to 9. In addition, the veneers

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Fig 3 Deep Dentin is applied in layers to achieve an appropriatemasking effect.

Fig 4 Transpa and Opal materials complete the layeringprocedure.

Fig 5 Veneers layered on investment dies Fig 6 Veneers after divesting

Fig 7 When the veneers were tried in … Fig 8 … neither the patient nor the treatment team were satis-fied with the outcome.

Fig 9 The incisal was too bright and the veneers appearedslightly oversized.

were oversized and failed to integrate harmoniouslyinto the surrounding dentition.

An innovative methodI had to find a treatment option which would enableme to provide the patient with a satisfactory result. Inresponse to this situation, I opted for a technique thatwas based on a similar approach as the one above butinvolved different materials: The range of IPS e.max®

press ceramics includes highly translucent HT ingots.Strictly speaking, these materials were developed forfull-contour inlays, onlays, veneers and crowns. Giventheir high viscosity and high flexural strength (400 MPa),they are, however, also suited for ultra thin (0.3 mm)veneers.

For the present case, the veneers were pressed from HT A2 ingots and then ground down to a thickness of 0.3 mm (Fig 10). A try-in on the patient showed that thismaterial was capable of closely imitating the naturaltooth shade (Fig 11).

When I applied the layering ceramic, I again had to takethe existing composite restorations into account. I usedthe try-in pastes to simulate the shade effect and tocheck if the composite restorations were sufficientlycamouflaged. Enough space was available to design theincisal, which meant that I was able to control the

translucency in this area appropriately. To mask the dis-coloured areas in the proximal regions of the restorations,I used opaque materials. The IPS e.max® range offers twochoices to achieve this: Deep Dentin and Mamelon mate-rials – both of them are characterized by comparativelystrong masking capabilities. However, the Mamelonmaterials should be used only sparingly for applicationin this area. Except for the “light” shade, these mate-rials demonstrate fairly distinct shading characteristicsand may therefore have a visible effect on the restora-tion. Subsequently, the Dentin and Transpa materialswere applied in layers in the customary manner. Therestoration in progress could be directly checked in theoral cavity between the individual firing cycles andthe materials could be selected accordingly, which pre-sented a decisive advantage (Fig 12).

As aforementioned, the veneers which I designed firstwere not satisfactory because of their shape. I thereforecreated a slightly narrower incisal this time and, conse-quently, was satisfied with the result (Fig 13). The patientalso approved of the shape and I therefore proceeded toincorporate the veneers (Fig 14).

IncorporationThe use of two different ceramic materials provides aconvenient opportunity to point out the differences inetching techniques. Etching the ceramic veneers with

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Fig 10 The pressed veneers were ground down to a thin materialthickness and were used as a substrate for the subsequentapplication of ceramic layers.

Fig 11 Try-in of the pressed veneers before the layeringprocedure

Fig 12 Evaluation of the shade effect after the first firing Fig 13 The veneers layered onto a substrate made of IPS e.maxpress ceramic

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hydrofluoric acid (IPS® Ceramic Etching Gel) presents anessential and critical stage of the adhesive technique.The etching time depends on the ceramic material. Inthe present case, the reaction times for the individualceramic materials were different from one another. Themanufacturer recommends an etching time of 60 sec-onds for the IPS d.SIGN fluorapatite ceramic, whilstthe recommended etching time for the IPS e.max Presslithium disilicate ceramic is 20 seconds. Users shouldnot deviate from these recommendations.

After the etchant has been allowed to react, the sur-faces should be thoroughly rinsed with water. I usuallyuse an ultrasonic device to optimally clean the surfaces.Whilst etching of the veneer can be deferred to thedental technician, it is absolutely essential to be awareof the fact that the surfaces that are already etchedhave to be cleaned again after the try-in in the oral cav-ity, before the veneer is silanized (Monobond Plus). Studyresults have shown that contaminations from salivaryfluids remain on the surface and adversely affect thebond strength, particularly if glycerine-based try-in pastesare used.

ConclusionVeneers made of IPS d.SIGN ceramic materials have beenused to design restorations that provide exceptionalesthetic results for several years. However, today’s range

of products includes various other materials and meth-ods that enable you to achieve equally pleasing or evenbetter results in certain cases. The IPS e.max system is acase in point. It is worthwhile considering new routes offabricating a restoration, depending on the requirementsof the individual patient case, and allowing some scopefor creativity. In the process, however, the specific prop-erties and possible restrictions of the material used shouldnever be ignored. q

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Fig 14 The veneers in situ. Both the patient and treatment team are satisfied with the outcome. Sometimes it takes more than oneattempt …

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Contact details:

Szabolcs Hant, MDTMadarász Viktor utca 131131 BudapestHungarydensnatura@gmail.com

www.ivoclarvivadent.comIvoclar Vivadent AGBendererstr. 2 | FL-9494 Schaan | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60

Healthy teeth produce a radiant smile. We strive to achieve this goal on a dailybasis. It inspires us to search for innovative, economic and esthetic solutions fordirect filling procedures and the fabrication of indirect, fixed or removablerestorations, so that you have quality products at your disposal to help peopleregain a beautiful smile.

Distinguished by innovation

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