vol. 1, no. 3, 2001 esthetic technique - brasseler...

Producing Preparation Designs in PatientsWho Require Simultaneous, DifferentRestorative ProtocolsLarry Rosenthal, DDSPeter Rinaldi, DMD

Sponsored by Brasseler USA 2 Hours of Continuing Education Credit

from Dental Learning Systems

A Supplement to Contemporary Esthetics and Restorative Practice® An MWC Publication

© 2001. Medical World Business Press, Inc.

Esthetic Technique™

Clinical Case Studies and Technique Review

Vol. 1, No. 3, 2001

Dear Reader:

With the expanded options for esthetic restorations today, practi-tioners have the challenge of choosing rotary instrumentation that willallow them to prepare teeth for the variety of restorations available. Weno longer have a “one size fits all” option when it comes to the type anddesign of finish line margins and amount of tooth reduction for esthet-ically bonded restorations. For example, ceramic veneers require a sig-nificantly different preparation than ceramic crowns. For posteriorrestorations, it is now possible to conserve tooth structure with eithercomposite or ceramic inlays and onlays when only partial-coveragepreparations are needed. The posterior crown has requirements differentfrom anterior crowns.

In this issue of Esthetic Technique, Drs. Rosenthal and Rinaldidescribe a rationale and approach to the preparation of esthetically bond-ed anterior and posterior restorations using The Rosenthal GroupAesthetic Design Kit. This kit offers the clinician a compact, well-orga-nized set of rotary instruments that fulfills the criteria for preparing teethfor all types of esthetically bonded restorations. Instead of spending timesearching for rotary burs and abrasives, one only has to reach for one kitof rotary instruments. As dentistry becomes more complex, having a kitsuch as this makes it easier for everyone.

Dental Learning Systems would like to thank Brasseler USA forsponsoring this teaching series for the dental clinician.

Best regards,

Howard E. Strassler, DMDProfessor and Director of Operative DentistryDepartment of Restorative DentistryDental School, University of MarylandBaltimore, Maryland

The Esthetic Technique™ series is made possible through an educational grant from Brasseler USA,

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Bruce Crispin,DDS, MS

Nasser Barghi,DDS

Lee Culp, CDT

John Kois,DMD, MSD

Gerard Kugel,DMD, MS

Edward A.McLaren, DDS

Larry Rosenthal,DDS

Howard E. Strassler, DMD

Douglas A.Terry, DDS

Thomas F.Trinkner, DDS

ADVISORY BOARD

Dental Learning Systems is an ADA Recognized Provider

Academy of General Dentistry Approved National Sponsor. FAGD/MAGD Credit

7/18/1990 to 12/31/2002

3ESTHETIC TECHNIQUE VOL. 1, NO. 3, 2001

LEARNING OBJECTIVESAfter reading this article, the reader should be able to:

• discuss a specific protocol for preparation design.• understand smile design preparation and material

preparation.• identify new techniques for tooth preparation for dif-

ferent materials.• describe the benefits of the new bur system that sim-

plifies esthetic procedures.

As new materials enter the marketplace, dentalprofessionals are continually supplementingtheir knowledge and skills to enhance the quali-

ty and functionality of the restorations and esthetictreatments they provide. As they incorporate the newergenerations of products into their repertoire, itbecomes necessary to identify the clinical techniquesassociated with placing such materials that will ensureconsistent quality and restorative longevity.1-3

Among the techniques requiring evaluation and, per-haps, modification based on the restorative materialselected, are those involving the preparation of dentition.Full-coverage ceramic restorations require one type oftooth reduction, while minimally invasive procedures,such as indirect inlays or veneers, require tooth prepara-tions that follow different guidelines. As such, cliniciansshould become keenly familiar with the proper protocolassociated with various restorative modalities, as well asthe instrumentation that should be used.4-6

It seems obvious, then, that clinicians are facedwith a challenge when a patient presents for multiplerestorations, each requiring a different preparation proto-col. The challenge, specifically, is to quickly and appro-priately identify those instruments and methods that will

ABSTRACTAs dentists incorporate new materials into

their treatment regimen, they must become

knowledgeable in the armamentarium available

for completing specific esthetic preparation

design techniques, and they must become

skilled in performing such procedures. This

article features a case presentation that high-

lights the clinical protocol associated with

using a recently introduced, functionally organ-

ized tooth preparation kit designed for simplic-

ity and maximum step-by-step consistency.

Producing Preparation Designs inPatients Who Require Simultaneous,Different Restorative ProtocolsLarry Rosenthal, DDS

Peter Rinaldi, DMD

Larry Rosenthal, DDS

Director

Peter Rinaldi, DMD

Clinical Director

Aesthetic Advantage Inc.

The Rosenthal Group

New York, New York

Figure 1—The Rosenthal Group

Aesthetic Design Kit.

Figure 2—Preoperative retracted view

of smile. Note discrepancy in gingival

height.

Figure 3—Preoperative occlusal

view of affected dentition.

4 VOL. 1, NO. 3, 2001 ESTHETIC TECHNIQUE

ensure overall treatment success,patient comfort, and esthetic value.Using a system of rotary instrumentsdeveloped in recognition of clini-cians’ needs will enable dentists tomeet the criteria necessary to con-sistently achieve esthetically excel-lent direct and indirect restorations.

ARMAMENTARIUMA recently introduced system

of preparation armamentarium,The Rosenthal Group AestheticDesign Kita (Figure 1), is simplify-ing the process and enabling den-tists to complete each type of toothreduction in a more step-by-step,yet still clinically sound and appro-priate, manner. Using the uniquedesign elements of specific instru-mentation, clinicians can easilyachieve the desired preparationdesign and subsequent restorativeform and function in a predictablemanner.

The kit fulfills all of the require-ments for preparing esthetic restora-tions. The instruments are grouped

according to preparation design (ie,ceramic inlay/onlay, indirect res-torations, all-ceramic veneers, full-coverage crown restorations, andcomposite provisionals). The kitmostly consists of diamond burs ofvarious grits for inlay/onlay, veneer,and full-coverage crown (both all-ceramic and metal-supported) prep-arations. A recently introduced car-bide bur is also included for grossreduction and shaping of directlyplaced provisional composite res-torations. There are two depth cut-

ters in the kit, one 0.5 mm and one0.7 mm, in addition to several bursfor finishing.

CASE PRESENTATIONA 53-year-old woman present-

ed with concerns regarding herworn dentition (Figures 2 and 3).She also expressed concerns re-garding her tooth color. On exami-nation, it was noted that severalteeth were malpositioned in theanterior region, and decay was pres-ent in the upper left premolar andmolar. Recurrent decay was alsopresent under an existing porce-lain-fused-to-metal (PFM) full-cov-erage crown on tooth No. 4. Fur-thermore, the patient was begin-ning to lose canine guidance,which would require proper recon-struction to regain occlusal pro-tection. It was decided that reha-bilitation would be completed byplacing veneer restorations andreplacing the existing PFM with an all-ceramic restoration. The inter-proximal decay would be removedand replaced with indirect inlayrestorations.

As new materials

enter the market-

place, dental profes-

sionals are continually

supplementing their

knowledge and skills to

enhance the quality and

functionality of the

restorations and

esthetic treatments

they provide.

TABLE 1—THE ROSENTHAL GROUP AESTHETIC DESIGN KIT

Veneer Preparation

#828-026 0.5-mm depth cutter—creates initial depth cutat cervical third forfeldspathic porcelainveneer

#828-030 0.7-mm depth cutter—creates initial depth cutat cervical third forpressed porcelainveneer

#6844-016 Two-grit preparationdiamond defines porce-lain veneer preparationto depth determined bydepth cutter

Crown Preparation

#5847KR-016 Facial reduction andmargins for porcelaincrown (supercoarsegrit)

#6368-023 Occlusal reduction forporcelain crown(coarse grit)

Margin Finishing

#8392-016 Finishing diamondfor cervical margins(fine grit)

#3392EF-016 Finishing diamondfor cervical margins(extrafine grit)

aBrasseler USA®, Savannah, GA 31419; 800-841-4522


CLINICAL PROTOCOLPreliminary impressions were

obtained and used for the creationof the diagnostic wax-ups. Duringthe initial visit, restoration shadeswere discussed, and the patientwas informed that the interimrestorations would serve as a guidetoward her final shade selection.

The preoperative photographswere taken using a Yashica DentalEye III camerab and a Polaroid Macro5c. The instant photographs wereessential for proper communicationwith the laboratory regarding thepreexisting condition of the patient’soral environment. An impressionwas made with a polyvinylsiloxanematerial, such as Honigumd, and biteregistrations were made.

Local anesthetic was adminis-tered, the old crown restoration wasremoved, and the affected teethwere prepared using the armamen-

tarium included in The RosenthalGroup Aesthetic Preparation DesignKit (Table 1). The inlay restorationswere prepared independently.

Smile Design Preparation

To initiate the preparation pro-

tocol, a diamond bur (#6856-029a)was used first to facilitate smiledesign, create arch form, andrealign axial inclinations, in addi-tion to gross reduction (Figures 4and 5). To open gingival embra-sures and allow for proper emer-gence profiles of the plannedveneer restorations—as well as tofacilitate accessibility for cleans-ing—the #132F-008 diamond burwas used (Figure 6).7,8

Veneer Preparation

When the smile design prepara-tion was completed (Figure 7),depth cutters were used. Depend-ing on the material selected for the veneer restorations (pressedceramic or feldspathic porcelain),either a 0.5-mm bur (#828-026) or a0.7-mm bur (#828-030) may be cho-sen (Figures 8 and 9).

Material choice for a restora-tive procedure depends on several

Figure 4—Initial development of

arch form and correction of axial

inclinations.

Figure 5—Alternate view of arch

form development and correction of

axial inclinations.

Figure 6—Enhancement of smile

relation and improved gingival

embrasures.

Figure 7—Completed smile design

preparation, left side.

Figure 8—Depth cuts were made with

either the 0.5-mm or 0.7-mm bur.

Figure 9—Alternate view of depth

cut preparation.

b Kyocera International, Inc, San Diego, CA 92123;858-576-2600

c Polaroid Corporation, Cambridge, MA 02139;781-386-2000

d Zenith Dental/DMG, Englewood, NJ 07631; 800-662-6383

Among the tech-

niques requiring

evaluation and, perhaps,

modification based on

the restorative material

selected, are those

involving the prepara-

tion of dentition.

factors. For example, when prepara-tions are to be kept to a minimum,feldspathic porcelain is the materialof choice, because it inherentlyrequires less bulk of material forstrength. If the stump shade of theprepared tooth is dark (ie, St 5 of theChromoscope shade guide), thenfeldspathic porcelain will block outthe color better than the moretranslucent ingots of a pressedceramic. On the other hand, if agreat deal of tooth structure needsto be removed, as in full-mouthreconstructions or severely crowd-ed dentition, or if there are largeexisting fillings that need to beremoved, waxing and pressing maybe the appropriate technique to use.

A diamond bur (#6844-016) wasused for the initial veneer prepara-tion (Figure 10). A diode laser

(Biolase Twilightf) was used forcontouring the gingival height andzenith over teeth Nos. 8 and 9(Figure 11), and the #6844 bur wasused again to define the margins andfinish the preparations (Figure 12).9

Crown Preparation

After completion of the veneerpreparations, the defective PFMcrown on tooth No. 4 was removedwith a cross-cut fissure carbide bur(#H32-012) (Figure 13), and the

crown preparation was redefinedwith a diamond bur (#5847KR-016).Overall occlusal reduction was alsocompleted with a diamond bur(#6368-023). The final restorationwas an all-ceramic crown. Theauthors try to restore the areabetween the premolars, particular-ly the first premolars, with all-ceramic restorations as often aspossible because this area is con-sidered the anterior part of themouth and nonmetal restorationswill not show dark lines if gingivalrecession occurs.

The inlay/onlay portion of thekit was used to remove the inter-proximal decay on teeth Nos. 13and 14, first using the #H32-012 bur.The inlay/onlay preparations wererefined with two burs (#845KR-45and #845KR-018). An end-cuttingdiamond bur (#10839) was used tosmooth the gingival floor of thepreparation. Final smoothing of theline angles and points was accom-


C linicians should

become keenly

familiar with the proper

protocol associated

with various restorative

modalities, as well as

the instrumentation

that should be used.

Figure 10—The #6844 diamond

bur was used for veneer prepara-

tions.

Figure 11—Zenith positions were

corrected with a diode laser.

Figure 12—The veneer prepara-

tions were finalized.

Figure 14—Diamond strips and

sandpaper disks were used to

smooth contact points and angles.

Figure 15—The anterior prepara-

tions are ready for final impres-

sions.

Figure 13—The existing crown

was removed, and the underlying

tooth structure was re-prepared.

e Ivoclar Vivadent, Inc, Amherst, NY 14228; 800-533-6825

f Biolase Technology Inc, San Clemente, CA92673; 888-424-6527

plished with sandpaper disks anddiamond strips (Figure 14).

Temporization

After impression-making (Fig-ures 15 and 16), a matrix—whichwas made over the diagnostic wax-up—was subsequently employedfor the fabrication of the provision-al restorations. After placement,the provisional restorations (Luxa-tempd) were grossly refined using anew carbide bur (#H375-R-016),and the overall shape was devel-oped (Figure 17). The gingivalembrasures were opened up forhealing and ease of cleansing(Figures 18 and 19), and facial andincisal embrasures were createdusing the diamond bur (#8392-016).Sandpaper disks and rubberwheels were used to polish andrecontour the provisional restora-tions after placement (Figure 20).

The preoperative photographs,along with stump shades of the pre-

pared dentition and approved tem-poraries, were forwarded to the lab-oratory and helped the ceramist to

fabricate the final restorations. Thepatient was seen the day after thetemporary restorations were placedto check for proper occlusion and toreview any esthetic considerations.

PLACEMENT OF THE FINALRESTORATIONS

The patient returned to theoffice the following week for

placement of the finished porce-lain veneers. The temporary res-torations were removed by gentlyslicing vertical cuts with the #132diamond bur (Figure 21). This bureasily cut through the compositematerial, yet provided sufficienttactile sense to ensure that theunderlying tooth structure was noteasily marred. A crown separatorwas then applied in a gentletorquing action to “pop” the sec-tioned temporary (Figure 22).Interproximal composite remnantswere removed with floss and a dia-mond strip.

The teeth were then cleanedusing Consepsisg. The veneerswere tried in to verify fit and over-all appearance, after which theywere cleaned, silanated, and inter-nally coated with a bonding agent(OptiBond™ 2 Flh). A rubber dam


Figure 16—The posterior prepara-

tions are ready for final impres-

sions.

Figure 17—The provisional res-

torations were grossly reduced and

shaped.

Figure 18—Gingival margins were

recontoured and blended.

Figure 21—Vertical slices were

made in the provisional restora-

tions to facilitate removal.

Figure 20—Glaze was placed over

the polished provisional restora-

tions.

Figure 19—Development of lingual

contours and adjustment of occlu-

sion.

g Ultradent Products, Inc, South Jordan, UT 84095;800-552-5512

h Kerr® Corporation, Orange, CA 92867; 800-537-7123

C linicians are faced

with a challenge

when a patient presents

for multiple restora-

tions, each requiring a

different preparation

protocol.

was placed, the prepared teethwere etched and washed thorough-ly, and excess water was removedwithout dehydrating. The teethwere collectively adhesively pre-pared (Figure 23), and the restora-tions were placed sequentiallyfrom right to left (Figure 24).

After placement, excess ce-ment was removed with cottonrolls and brushes, and the restora-tions were spot-cured with a 3-mmturbo tip (Demetronh) for 4 sec-onds at the gingival collar (Figure25). All excess hardened lutingagent was then gently removedwith scalers and interproximallywith saws and floss (Figure 26).

Final curing was completedfor 9 seconds for each side on boththe lingual and facial aspects usinga plasma arc curing light (Apollo™

95Ei).

POLISHING AND FINISHINGAfter final curing, the gingival

margins were finished with dia-mond burs (#8392, #392EF, #379F,and #379EF) (Figures 27 and 28).Interproximal smoothing wasaccomplished with diamond stripsand floss. The lingual contours andocclusal adjustment were complet-ed using the Ceramist Porcelain

Polishing Systemj in the frictiongrip style.

CONCLUSIONThe rationale of this systematic

approach toward unique instrumen-tation enables the clinician to con-sistently produce the patient’s antic-ipated esthetic, clinical, and func-tional results (Figures 29 and 30).

The clinical protocol associat-ed with placing multiple restora-tions of different modalities usinga recently introduced, functionallyorganized tooth preparation kithas been greatly simplified intostep-by-step procedures. As aresult, dentists can now quicklyand appropriately identify thoseinstruments and methods that willensure overall treatment success,patient comfort, and esthetic valuewhen preparing teeth in a singlevisit for a variety of restorativealternatives.


The challenge is to

quickly and appro-

priately identify those

instruments and meth-

ods that will ensure

overall treatment suc-

cess, patient comfort,

and esthetic value.

Figure 24—The final veneer restora-

tions were seated sequentially.

Figure 23—Occlusal view of com-

pleted preparations demonstrating

corrected arch form. Preparations

were then ready for adhesive.

Figure 22—The provisional res-

torations were gently torqued

using a Brasseler crown separator.

Figure 27—Remaining gross excesscement was removed from the gin-gival margins.

Figure 26—An interproximal saw

was used for initial clean-up.

Figure 25—The restorations were

spot-cured at the gingival margins.

iDental/Medical Diagnostic Systems, Inc,Woodland Hills, CA 91367; 818-595-0226

jSHOFU® Dental Corporation, Menlo Park, CA94025; 800-827-4638

REFERENCES1. Trinkner TF: Treatment and material consid-

erations for veneer restorations. Signature

7(1):2-7, 1998.2. Goldstein RE: Diagnostic dilemma: to bond,

laminate or crown? Int J Periodontics

Restorative Dent 7(5):8-29, 1987.3. Crispin BJ: The full veneer as an alternative

to the full crown. Curr Opin Cosmet Dent

4:6-10, 1997.

4. Shavel HM: The periodontal-restorativeinterface in fixed prosthodontics: toothpreparation, provisionalization, and biologicfinal impressions—part II. Pract Perio-

dontics Aesthet Dent 6(3):49-62, 1994.5. Shillingburg HT Jr., Grace CS: Thickness of

enamel and dentin. J South Calif Dental

Assoc 41(1):33-36, 1973.6. Crispin BJ: Evaluation of enamel thickness

and instrumentation as it relates to porce-lain veneer preparation. J Esthet Dent

5(1):37, 1993.7. Becker CM, Kaldahl WB: Crown contours

that promote access for oral hygiene.Quintessence Int 12(2):233-238, 1981.

8. Kois JC: The restorative-periodontal inter-face: biologic parameters. Periodontol 2000

11:29-38, 1996.9. Trinkner TF, Rosenthal L: Esthetic restora-

tion of anterior dentition with metal-freerestorative material. Compend Contin Educ

Dent 19(12):1248-1255, 1998.


WARNING: Reading an article in Esthetic Technique™ does not necessarily qualify you to integrate new techniques or procedures into your practice. Dental Learning Systemsexpects its readers to rely on their judgment regarding their clinical expertise and recommends further education when necessary before trying to implement any new pro-cedure.

The views and opinions expressed in the article appearing in this publication are those of the author(s) and do not necessarily reflect the views or opinions of the editors, theeditorial board, or the publisher. As a matter of policy, the editors, the editorial board, the publisher, and the university affiliate do not endorse any products, medical tech-niques, or diagnoses, and publication of any material in this journal should not be construed as such an endorsement.

Figure 30—View of the fine detail of

the veneer restorations, demonstrat-

ing lifelike luster and characteriza-

tion.

Figure 29—The final restorations

displayed proper tissue and tooth

esthetics and harmony.

Figure 28—View of occlusal adjust-

ments and finishing.

Dental Learning Systems is an ADA Recognized Provider

Academy of General Dentistry Approved National Sponsor FAGD/MAGD Credit

7/18/1990 to 12/31/2002


6. What was subsequently employed for thefabrication of the provisional restorations?a. a matrixb. copper tubec. no provisional was usedd. alginate impression

7. The temporary restorations were removed:a. with a spoon excavator.b. with sticky wax.c. by gently slicing vertical cuts.d. with hydrophilic eugenol solvent.

8. Restorations were spot-cured for 4 seconds at the:a. gingival collar.b. lingual.c. incisal.d. mesial and distal.

9. Final curing was completed for:a. 9 seconds.b. 15 seconds.c. 45 seconds.d. 1 minute.

10. Interproximal smoothing was accomplished with:a. diamond burs.b. carbide burs.c. scalers.d. diamond strips and floss.

1. How many depth cutters are included in thekit?a. oneb. twoc. threed. four

2. What was essential for proper communica-tion with the laboratory regarding the pre-existing condition?a. written descriptionb. full-mouth radiographsc. instant photographsd. final impressions

3. To initiate the preparation protocol, a dia-mond bur was first used to:a. facilitate smile design.b. create arch form.c. accomplish gross reduction.d. all of the above

4. What was used to contour the gingivalheight and zenith over teeth Nos. 8 and 9?a. scalpel bladeb. diode laserc. electrosurgeryd. free gingival graft

5. What type of diamond bur was used tosmooth the gingival floor of the preparation?a. end cuttingb. football shapedc. inverted coned. a hybrid diamond/carbide round bur

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To receive credit, complete the enclosed answer form, and mail with a check for $20, payable to DentalLearning Systems, to Dental Learning Systems CE Dept., 405 Glenn Drive, Suite 4, Sterling, VA 20164-4432.

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Whatever the ultimate restorative goal,removal of nonserviceable or obsoleterestorations is frequently a time-consuming

step in the preparation sequence. Choosing instru-ments designed and adapted for the removal of spe-cific materials facilitates rapid and atraumaticremoval.

The time required to remove amalgam restora-tions can be greatly reduced with the use of the #H32-012 carbide bur. The transverse blade on the tip of thebur allows axial drilling. The pyramidal blade geome-try permits passage of water to reduce heat and mini-mizes the release of mercury vapor. Amalgam isremoved by drilling into the restoration in an axialdirection. Several longitudinal and transverse separa-tion grooves are cut. By dividing the filling into sec-tions, large fragments of the filling detach. This instru-ment provides quick, health-conscious removal of oldamalgam restorations.

The new diamond rotary instrument, #5985-012,is ideally adapted to the specific application ofremoving composite restorations. The innovative tiphas a transverse blade to improve axial drilling capac-ity. This makes it possible to remove large amounts ofcomposite from the first rotation of the instrument.The multiangled lateral surface increases chip space

for quick material reduction and minimal clogging(Figure 1).

For efficient removal of nonfunctioning porcelain-fused-to-metal crowns and bridges, the #5985-012supercoarse diamond is used first to cut through theporcelain. Placing the diamond at the buccal gingivalmargin, cut occlusally until the metal is exposed(Figure 2). Continue cutting over the occlusal surface,exposing the metal substructure. Then place the dia-mond instrument at the lingual gingival margin andcut occlusally until the cuts meet (Figure 3). Whenmetal is exposed from the buccal margin to the lingualmargin, the newly developed #H34L-012 carbide willeasily cut through precious or nonprecious metalswith minimal vibration (Figure 4). The crown-spread-er #EB134 hand instrument is placed in the separationgroove and rotated to spread and release the metalsubstructure from the tooth (Figure 5).

Cutting through the dense, hard substructures ofall-ceramic crowns generates extreme heat, whichmay cause iatrogenic damage to supporting hard andsoft tissue. Use of the 180-µm CRF diamond with copi-ous amounts of water (water syringe in addition tohandpiece spray) will save the clinician valuable chairtime and ensure comfortable treatment when remov-ing all-ceramic crowns.

This information is provided by Brasseler USA.

Removal of Nonserviceable or Obsolete Restorations

PREP STEPS

Figure 2—Sectioning the

porcelain on a porcelain-

fused-to-metal crown.

Figure 3—Sectioning

the porcelain on the lin-

gual gingival margin.

Figure 5—

Spreading

sectioned

crown with

the #EB134

hand

instrument.

Figure 1—Removing

composite with a #5985-

012 diamond rotary

instrument.

Figure 4—

Sectioning

the metal

with the

#H34L-012

carbide.

vol. 1, no. 3, 2001 esthetic technique - brasseler...

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