Restauraciones Esteticas Del Sector Anterior.-1

RESTAURACIONES ESTÉTICAS DEL
SECTOR ANTERIOR: EN BASE A LOS PRINCIPIOS DE PASCAL MAGNE
Dra. Karla Va ejo Vél
E ecial ta en Rehabilitación Oral
Docente de la Universidad Central del Ecuador

sp
is
ll
ez

-El uso consciente,

explícito y juicioso de la mejor evi-
dencia cientí ca clínica disponible
para tomar decisiones sobre el
cuidado del paciente individual.-
fi
1. Formulación de la pregunta.
2. Localización de la evidencia
disponible en la literatura.
3. Evaluación crítica.
4. Aplicación práctica de las
conclusiones obtenidas.
A Al menos un meta-análisis, revisión sistemática o ensayo clínico aleatorizado calificado como 1++ y directamente
aplicable a la población objeto, o
Una revisión sistemática de ensayos clínicos aleatorizados o un cuerpo de evidencia consistente principalmente en estudios
calificados como 1+ directamente aplicables a la población objeto y que demuestren globalmente consistencia de los
resultados.
B Un cuerpo de evidencia que incluya estudios calificados como 2++ directamente aplicables a la población objeto y que
demuestren globalmente consistencia de los resultados, o
Extrapolación de estudios calificados como 1++ o 1+.
C Un cuerpo de evidencia que incluya estudios calificados como 2+ directamente aplicables a la población objeto y que
demuestren globalmente consistencia de los resultados, o
Extrapolación de estudios calificados como 2++.
D Niveles de evidencia 3 o 4, o
Extrapolación de estudios calificados como 2+.
Tabla VI. Niveles de evidencia (CEBM)
Nivel de
evidencia Tipo de estudio
1a Revisión sistemática de ensayos clínicos aleatorizados, con homogeneidad.

1b Ensayo clínico aleatorizado con intervalo de confianza estrecho.
1c Práctica clínica (“todos o ninguno”) (*)
2a Revisión sistemática de estudios de cohortes, con homogeneidad.
2b Estudio de cohortes o ensayo clínico aleatorizado de baja calidad (**)
2c Outcomes research (***), estudios ecológicos.
3a Revisión sistemática de estudios de casos y controles, con homogeneidad.
3b Estudio de casos y controles.
4 Serie de casos o estudios de cohortes y de casos y controles de baja calidad (****)
5 Opinión de expertos sin valoración crítica explícita, o basados en la fisiología, bench research o first principles (*****)
Se debe añadir un signo menos (-) para indicar que el nivel de evidencia no es concluyente si:
• Ensayo clínico aleatorizado con intervalo de confianza amplio y no estadísticamente significativo.
• Revisión sistemática con heterogeneidad estadísticamente significativa.
(*) Cuando todos los pacientes mueren antes de que un determinado tratamiento esté disponible, y con él algunos pacientes sobreviven, o bien cuando algunos
pacientes morían antes de su disponibilidad, y con él no muere ninguno.
(**) Por ejemplo, con seguimiento inferior al 80%.
(***) El término outcomes research hace referencia a estudios de cohortes de pacientes con el mismo diagnóstico en los que se relacionan los eventos que suce-
den con las medidas terapéuticas que reciben.
(****) Estudio de cohortes: sin clara definición de los grupos comparados y/o sin medición objetiva de las exposiciones y eventos (preferentemente ciega) y/o sin
identificar o controlar adecuadamente variables de confusión conocidas y/o sin seguimiento completo y suficientemente prolongado. Estudio de casos y contro-
les: sin clara definición de los grupos comparados y/o sin medición objetiva de las exposiciones y eventos (preferentemente ciega) y/o sin identificar o controlar
adecuadamente variables de confusión conocidas.
(*****) El término first principles hace referencia a la adopción de determinada práctica clínica basada en principios fisiopatológicos.
Diagnó ico
st
Analizar
• Estado sistémico
• Estado psicológico
• Parámetros Faciales
• Parametros Dentales
• Parametros Dento - Faciales
• Cinemática Mandibular
• Plan de Tratamiento: materiales

indicados
• Perspectiva de vida (garantía)
Parametros Dento-labiales
Altura de la sonrisa
CLINICAL REVIEW opyrig

No C
t fo
ht
rP
by N
ub
lica
Q ui
tio
te n ot
Is the Smile Line a Valid Parameter sse nc e
n
fo r
for Esthetic Evaluation?

A Systematic Literature Review
Nicole Passia, DDS, Dr med dent

Assistant Professor, Department of Prosthodontics, School of Dentistry,
Albert-Ludwigs University, Freiburg, Germany
Markus Blatz, DMD, Dr med dent, PhD

Professor and Chair, Department of Preventive and Restorative Sciences,
School of Dental Medicine, University of Pennsylvania, Philadelphia, USA
Nicole Passia, DDS, Dr med dent; Is the Smile Line a Valid Parameter for Esthetic Evaluation? :A Systematic Literature Review; THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 6 • NUMBER 3 • AUTUMN 2011
Altura de la sonrisa PASSIA ET ALopyrig

No C
t fo
ht
rP
by N
ub
lica
Q ui
tio
te n ot
n
ss e n c e fo r Fig 1 Average smile line. Fig 2 Hig
Fig 1 Average smile line. Fig 2 Hi
Fig 2 High smile line.
Fig 3 Low smile line. Fig 4 Pa

Table 3 Smile line in relation to upper lip.
Comparison between
Smile line
male and female
Number of Age
Male Female High Average Low
Study subjects of subjects Male Female
(N) (N) (%) (%) (%)
(N) (years)
Significantly Significantly
Tijan et al29 454 20–30 207 247 10.57 68.94 20.48 more often a more often a
low smile line high smile line
Dong et al,12
citing Yoon 240 - 129 111 29 56 15 - -
et al19
Larger per- Larger per-

Maulik and
230 14–35 99 131 21 57 22 centage with centage with
Nanda30
low smile lines high smile lines
6.3 (2.3
with no
Desai et al31 261 15–70 - - 17.6 73.8 - -
dental
display)
41 35 24 Low smile line High smile line

15 (mean
Peck et al32 88 42 46 (with special definition of high as a male as a female
age)
and low smile line) lineament lineament
Significantly
Significantly
less gingival
Owens et more gingival Q ui
253 18–41 144 109 - - - display dur-
al28 display during n
ing maximum
maximum smile
fo
t
smile
r
s
fo r
s
P
en
ub
Fig 2 High smile line.
Fig 3 Low smile line. Fig 4
Linea de la Sonrisa
Low smile line. Fig 4 Parallel smile line.
Fig 4 Parallel smile line. Fig 5 Flat smile line. Fig 6
Flat smile line. Fig 6 Reverse smile line.
Table 4 Smile line in relation to lower lip.
Comparison between male

Smile line
and female
Number of Age of
Male Female Parallel Flat Reverse
Study subjects subjects Male Female
(N) (N) (%) (%) (%)
(N) (years)
Significantly
Tijan et
454 20–30 207 247 84.8 13.88 1.32 higher amount -
al29
of reverse smile
Dong et
al,12 citing
240 - 129 111 60 34 5 - -
Yoon et
al19
Higher amount
Maulik and Higher amount
230 14–35 99 131 40 49 10 of flat or reverse
Nanda30 of parallel smile
smile
3.6 (16.3
lower lip cov-
Desai et
261 15–70 - - 48.8 31.7 ering maxil- - -
al31
lary incisal
edges)
Krishnan More female subjects than male

60 18–25 30 30 - - -
et al15 subjects have parallel smile arcs
Parametros Dentales
Criterios Objetivos Fundamentales: (14)
1. Salud Gingival
SALUD GINGIVAL
:2·20
2. TRONERAS INTERDENTALES O LLENADO INTERDENTAL
Pascal Magne, PD DR MED DENT; Restauraciones de Porcelana adherida en los dientes anteriores. Método biomimético

Parametros Dentales
Criterios Objetivos Fundamentales: (14)
2. Troneras gingivales o llenado gingival
:2·20
2. TRONERAS INTERDENTALES O LLENADO INTERDENTAL

Parametros Dentales
3. Ejes dentales
3.
3. EJES
EJES DENTALES
DENTALES
2·2<:
2·2<:
4.
4. CENIT
CENIT DEL
DEL CONTORNO
CONTORNO GINGIVAL
GINGIVAL
Parametros Dentales
4.2·2<:
Cenit del contorno gingival
2·2<:
4.
4. CENIT
CENIT DEL
DEL CONTORNO
CONTORNO GINGIVAL
GINGIVAL
Parametros Dentales
5. Equilibrio entre los márgenes gingivales
S.EQUILlBRIOENTRE
S.EQUILlBRIO ENTRELOS
LOSMÁRGENES
MÁRGENESGINGIVALES
GINGIVALES
Parametros Dentales
6. Nivel del contacto interdental
66 .. NIVEL
NIVEL DEL
DEL CONTACTO
CONTACTO INTERDENTAL
INTERDENTAL
Parametros Dentales
7. Dimensiones relativas de los dientes
7 . DIMENSIONES RELATIVAS DE LOS DIENTES
2-3c
Proporción Anchura/Altura
FIGURA 2-3 ICONTINUACIÓN).EI cociente entre anchura y altura (anchura / altura) en incisivos y caninos es idén-
tica en ambos sexos." No se hallaron diferencias en la comparación de estas proporciones entre hombres y mujeres,
excep to poro los caninos (2-3c),
Pascal que
Magne, sonMED
PD DR más largos
DENT; en los hombres
Restauraciones (ver
de Porcelana también
adherida en los2-3f).
dientesDientes
anteriores.de igualbiomimético
Método anchura pero
Las coronas de incisivos centrales y caninos tienen la misma relación
anchura / longitud (entre un 77-86%)
Los incisivos centrales son de 2 a 3 mm más anchos que los incisivos
laterales
Los incisivos centrales son de 1 a 1.5 mm más anchos que los caninos.
Los caninos son de 1 a 1.5 mm más anchos que los incisivos laterales.
Los incisivos centrales y los caninos tienen una altura de corona similar
(varía sólo en 0 .5 mm), que será de media unos 1-1.5 mm más larga
que la corona de los incisivos laterales.
Parametros Dentales
7. Dimensiones relativas de los dientes
Altura media de la corona Anchura media de la corona
ular o redondeado pero se hará más regular
recto debido al desgaste funcional.
Parametros Dentales
8. Rasgos básicos de la forma de los dientes
8. FORMA DEL DIENTE
Triangular
Cuadrado
Ovoide

Parametros Dentales
,/i
.
\
\.
:
..... ..:E
(J
....'"
."
,/i
8. Rasgos básicos de la
forma de los dientes.
Parametros Dentales
sos (manchas, fisuras, lóbulos de ntinales, zonas de (F ig 2-70 ). A causo de lo presencio de pequeños
lo dentina infiltrados) y los efectos específicos de lo partículas, como los gotas de aguo, que interac-
Parametros Dentales con formación (atrición, abrasión). Todo ello deter-

mino lo sensación de eda d y cará cter del die nte.
cio nan con lo luz solar el cielo puede aparecer
azul (de noche) o ro jo (01 amanecer y 0 1atardecer).
Un efecto similar ocurre en el bo rde incisal, debido
Lo op a lescencia es una propiedad ó ptico del o lo dispersión de lo luz 01incidir en los microscó-
esma lte y se refiere o lo capacidad de transmitir picos cristales de hidroxiapa tita (Fig 2-7b).
9. Caracterización de los dientes
Parametros Dentales
OPALESCENCIA T R AN S P A R E N CI A
Opalescencia Transparencia
T R AN S P A R E N CI A
ar una amplia gama de efectos causa- en casos de abrasión y/o atrición. La estructura
a comb inación de la translucencia y la interna del núcleo dentinario y su compleja arqui-
encia.
Parametros Dentales
tectura se hacen visibles en forma de rayas,
mamelones, infiltraciones en la dentina, etc (Fig
tremo del espectro, como ilustran las 2-8). La fluorescencia propia de la dentina (ver
7b y 2-7 c, encontramos áreas de trans- criterio 11) es la base de este tipo de efectos.
EFECTOS DENTINARIOS
80
Parametros Dentales
10. Textura Super cial
Horizontal Vertical
HORIZONTAL VERTICAL
fi
1. COLOR
Parametros Dentales
11. Color BRILLO
Matiz
Croma
Valor
blan co co n la luz de l día Y Se define como la demuestran los estudios espectrales in vitro.33.34
ca paci dad de a bsorber la energía luminosa y Se usa n ha bitualmente las Tierras Rara s como
reemitirla en una longi tud de o nda d iferente. 29 La luminóforos (p. ej europio, terbio, cerio e iterbio)
Parametros Dentales
dentina par ece ser tres veces más fluoresce nte
que el esmalte, esto provoca una "luminiscencia
interior " . Por último es un medi o para conseguir
pero ninguna de ellas reproduce fielmente la
fluorescencia azul malva de los di entes natura les
(F ig 10-8). Para el clínico, un método simple y
una apariencia de di ente natural vivo , tamb ién eficaz de co mprobar la fluorescencia de una res-
se le conoce como "vita lescencia " (Fig 2-10f) . tauración (o de un material) in vivo es observar
Alguna s cerá micas se han perfeccionado en este su interacción óptica con un foco de luz mod ifi-
11. Color aspecto conc reto (Creación , Klema ; ver Figs 7-
9p a 7-9r y 7 -9q ).
cad a : luz negra (Sylvan ia S18W/ BLB u O sra m
L18W/ 7 3 , Figs 2- 10 f, 2-10i y 2-10 jl.35 Este
tipo de luz se usa a menudo para crea r efectos
Fluorescencia luminosos especia les.
FIGURA 2-1 O.ICONTINUACIÓNj . A pesar de tener una menor sa luración de co lor y un mayo r bri llo que la dentina
(2-10f, izquierda), el esmalte, efectivame nte, muestra una menor luminiscencia q ue la raíz (2-1 Of, derecha). Paciente
q ue presenta unos diente s co n manc has y restaura ciones (2-1 Og ). Las fotografía s en bla nco y negro (2-1 Oh) y co n luz
Pascal
negra (2-10i) Magne,
son PD para
muy útiles DR MED
la vaDENT;
loraciónRestauraciones de Porcelana
rápida de las restaura adherida
cio nes. La enrestaurac
deficiente los dientes anteriores.
ión de resina deMétodo biomimético
com posite C lase IV en el incisivo central superior derecho es eviden te, como lo son las manchas no-fluorescentes de
Parametros Dentales
12. Con guración de los Bordes Incisales
2 . BORDES INCISALES
Forma de "gaviotal " Curva invertida
fi
Parametros Dentales
ANGULOS INT ER INCISAL ES
2-l ld
FIGURA 2-11 (CO NTINUACIÓN): REGLA DE LA V INVERTI DA. Relacione s interincisivas. Adviértase el espacio
neg ro ("nega tivo ") entre los dientes maxilares y mandi bulares (2-1 1d).
90
Parametros Dentales
13. Línea labial inferior
13. LíNEA DEL LABIO I N F E RI O R
Parametros Dentales
14. Simetría de la sonrisa

14. SIMETRíA DE LA SONRISA
Plan de Tratamiento
Material Restaurador
Tabla 4-1 : Corocteristlcos clínicas de las resinas de composite y la porcelana.

Ventajas Desventajas
Resinas • Adhesión • Contracción polimerización
Composites • Preservación del tejido dental • Coeficiente de expansión
• Dureza similar a lo dentina térmica
Porcelana • Estética • Fragilidad

• Durabilidad • Características del desgaste
• Dureza parecida a lo del esmalte
it is not applied. The reason for this is re- These are principles that should be ap-
lated to the complexity and time required plied universally in any comprehensive
for these steps, which are normally ap- treatment plan. The second goal is to
plied in indirect restorations like ceram- propose the application of these prin-
ics but not properly used in direct com- ciples to direct restorations even when
posite resin rehabilitations. Moreover, a no individualized articulator mounting
large portion of these patients, clinicians, or appropriate laboratory wax-ups are
and technicians in many countries may available – the anatomically driven di-
not have the resources and/or tools to rect approach (ADA).
undertake a full comprehensive ap-
proach. In order to aid clinicians to use (Int J Esthet Dent 2018;13:16–48)
Ca as Directas de
R ina
17
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
SPRING 2018
es
ri
ll
Indicaciones
• Pequeños correcciones de espacio (Diastemas)
• Problemas aislados
• Restauraciones Estéticas
• Pequeñas alteraciones de forma
• Pequeñas alteraciones de color
• Finalización de ortodoncia en pacientes jóvenes
TIPS Claves en Odontología Estética, Hirata R.; Editorial Medica Panamericana/Artes Medicas, 2011

Diastemas
213 211
214 212
213
205 y 206 I Caso inicial y final.
214 215
216
211 y 212 I Encerado realizado sobre el modelo inicial que guiará el

(Laboratorio Studio Dental/Curitiba - PR).
215
.
216
215 215
215 215
216 216
216 216
217 217
217
217
218 TIPS Claves en Odontología Estética, Hirata R.; Editorial Medica Panamericana/Artes Medicas, 2011
218 218
218
219
Asperice la super cie del

esmalte siempre antes de
acondicionamiento ácido
213 y 214 I Se coloca la matriz. Como se verá en el capítulo sobre dientes anteriores, se puede
utilizando el
confeccionar una reconstrucción de prueba (mock-up) para esta visualización. chorro con
oxido de aluminio
215 y 216 I Normalmente, se utiliza una aislación modificada (ocho perforaciones unidas) de
de 50um o
premolar a premolar. fresas diamantadas de
217 I Se prueba de nuevo la guía de silicona para verificar acabado
que la aislación a bajalavelocidad
no impida
adaptación de la matriz.
218 y 219 I Asperización de la superficie del esmalte que elimina el esmalte aprismático
superficial.
o se verá en el capítulo sobre dientes anteriores, se puede

trucción de prueba (mock-up) para esta visualización. TIPS Claves en Odontología Estética, Hirata R.; Editorial Medica Panamericana/Artes Medicas, 2011
fi
220
221
222
222
222
223
224
225
223
224
225
220 y 221 I Se coloca el hilo retractor (Sil-Trax 7/Pascal) sin tratam
222 I Obsérvese la retracción obtenida.
223 a 225 I Se comienza, en este caso, por el incisivo central más

226
227
226
228
227
228
229
230
229
231
230
231
232
233
232
233
232
232
233
233
234
234
235
235
236
236
237
238
239
240
241 TIPS Claves en Odontología Estética, Hirata R.; Editorial Medica Panamericana/Artes Medicas, 2011
240
241
242
243
244
243
244
236 I Examen oclusal.
237 a 239 I Con el uso de polvo para textura cerámica (texture marker/Benzer), se observa la
textura y la anatomía primaria y secundaria. Las modificaciones se hacen según estas
referencias obtenidas gracias al uso de ese polvo.
236 I Examen oclusal. TIPS Claves en Odontología Estética, Hirata R.; Editorial Medica Panamericana/Artes Medicas, 2011
240 a 242 I Terminación y pulido con sistema de tacitas de goma Jiffy (Ultradent).
7
245
246
48
49
247
Pulido
Cambio de Color
Carillas de dientes con oscurecimiento LEVE
1. Una capa de dentina (mas espesa)

2. Un halo blanco opaco con resina de efecto blanco
3. Colorante azul/gris para efecto incisal
4. Una capa de esmalte cromático
5. Una capa de esmalte acromatico (excepto para los
sistemas que no poseen esmalte cromático: saltar
el item 4)

Carillas de dientes con oscurecimiento INTENSO

1. Colorante opaci cador
2. Una capa de dentina
3. Un halo blanco opaco con resina de efecto blanco
4. Colorante azul/gris para efecto incisal
5. Una capa de esmalte cromático
6. Una capa de esmalte acromatico (excepto para los
sistemas que no poseen esmalte cromático: saltar
el item 4)
fi

R E S TA U R A C I Ó N C O N S E R V A D O R A D E L A D E N T I C I Ó N D E S G A S TA D A : E L
E N F O Q U E D I R E C T O I M P U L S A D O A N AT Ó M I C A M E N T E ( A D A )
(Int J Esthet Dent 2018;13:16–48)
a b c
d e f
g h i
Inter- Occlusal Occlusal Tooth Gingival Posterior
maxillary vertical plane display and levels tooth
Relation & dimension Phonetics anatomy
Guidance (OVD)
Los2ocho
Fig Theparámetros
eight basicbásicos que deben
parameters tenerse
that should be en cuenta para
considered el diagnóstico
for diagnosis y la planificación
and treatment planningdel
of
tratamiento
extensively worn de denticiones
dentitions: extensamente
intermaxillary desgastadas:
relation, mandibular relación
guidance,intermaxilar, guía mandibular,
occlusal vertical dimension, oc-
clusal plane, tooth display, phonetics, gingival levels, and posterior tooth anatomy.
dimensión oclusal vertical, plano oclusal, visualización del diente, fonética, niveles gingivales y
anatomía del diente posterior.
Normal alveolar bone
Possible bone
remodelation
with teeth intrusion
Dense alveolar bone
Maximum ↑ OVD
Difficult bone
intercuspation (MI)
remodelation,
= Muscle
fractures and
Centric relation (CR) stretching
symptoms
more likely
Increased
muscular activity
Posibles
Fig 3
consecuencias de aumentar la dimensión vertical en pacientes en los que
Possible consequences of increasing the vertical dimension in patients where MI and CR coincide,
based on Dawson. 36
coinciden el IM y el RC, según Dawson.

Maximum Posterior mandibular No increased
intercuspation (MI) rotation to CR muscular activity,
≠ reduced risk
Centric relation (CR) ↑ OVD
Muscle
shortening
Fig 4 Consequences of increasing the vertical dimension in patients where CR is significantly different
from MI, based on Dawson.36
Consecuencias de aumentar la dimensión vertical en pacientes donde CR es significativamente
diferente de MI, basado en Dawson
trichion
30%
glabella
30%
subnasale
stomion 45% 30%
40%
55% 70%
menton
Proporciones
Fig 5 Facialfaciales basadas
proportions ensoft
based on hitos delandmarks
tissue tejidos blandos
related torelacionados conin la
vertical dimension dimensión
females and
vertical en mujeres y hombres según mediciones antropométricas modernas

males according to modern anthropometric measurements.
a b
c d
Ilustración de los diferentes tipos de desgaste dental y sus efectos sobre los dientes y los niveles gingivales. (a)
dentición
Fig sin usar.of
6 Illustration (b)different
Desgaste generalizado
types y erupción
of tooth wear compensatoria.
and their (c)and
effects on teeth desgaste anterior
gingival levels.con
(a)erupción
Unworn
dentition. (b)compensatoria
Generalized wear anterior.
and (d) desgaste posterior
compensatory con(c)
eruption. erupción compensatoria
Anterior posterior
wear with anterior compensatory
Un cierto
Fig 7 grado de libertad
Some degree del
of freedom IMMIque
from that permite que los
allows mandibular incisivos
incisors mandibulares
to close slightly forward se cierren
without
causing horizontal forces on the maxillary anteriors (fremitus) is a well established and clinically relevant
ligeramente hacia adelante sin causar fuerzas horizontales en los anteriores maxilares (fremitus) es
concept.
un concepto bien establecido y clínicamente relevante.

While
is more
sion abo
choose
some fle
promote
zontal loa
create an
muscula
prevalen
inclined
to do in
or versus
Orientación anterior y contactos oclusales de función grupal logrados en la práctica clínica (izquierda) III pat
un
Fig 8 Anterior guidance and group function oc-
esquema oclusal ideal (derecha). Un esquema oclusal ideal es más un concepto para trabajar más que
plane).algo 73
clusal contacts achieved in clinical practice (left)
precisamente alcanzable en la realidad clínica.
MÁXIMA INTERCUPSIDACIÓN (MI) C O N TA C T O S S I M É T R I C O S B I L AT E R A L E S E N T O D O S L O S D I E N T E S , M E N O S I N T E N S O S E N L O S
DIENTES ANTERIORES
GUÍA ANTERIOR DESOCLUYE TODOS LOS DIENTES POSTERIORES DURANTE LOS MOVIMIENTOS PROTRUSIVOS
G U Í A L AT E R A L GUÍA CANINA DESOCLUYE TODOS LOS DIENTES POSTERIORES DURANTE LOS MOVIMIENTOS EXCURSIVOS.
M Á S F Á C I L D E I M P L E M E N TA R .
M Á S C O M Ú N E N PA C I E N T E S M Á S J Ó V E N E S Y D E C L A S E I I .
P O T E N C I A L PA R A R E D U C I R L A A C T I V I D A D M U S C U L A R E N A L G U N O S PA C I E N T E S
M AY O R E S T R É S E N L O S D I E N T E S C A N I N O S
FUNCIÓN EN GRUPO P R O G R E S I VA M E N T E D E S O C L U Y E D I E N T E S P O S T E R I O R E S D U R A N T E L A S E X C U R S I VA S .
M Á S D I F Í C I L D E I M P L E M E N TA R
M Á S C O M Ú N E N PA C I E N T E S M AY O R E S Y D E C L A S E I Y I I I
P O S I B I L I D A D D E D I S T R I B U I R M E J O R L A S C A R G A S E N VA R I O S D I E N T E S Y, P O R L O TA N T O ,
R E D U C I R E L E S T R É S E N L A S R E S TA U R A C I O N E S
L I B E R TA D E N E L M O V I M I E N T O M A N D I B U L A R P R O P O R C I O N A C I E R T O G R A D O D E M O V I M I E N T O D E S D E M I ( L I B E R TA D C É N T R I C A ) A N T E S D E
CUALQUIER DES OCLUSIÓN.
E L I M I N A L A S F U E R Z A S H O R I Z O N TA L E S D A Ñ I N A S E N L O S D I E N T E S A N T E R I O R E S C O N U N C I E R R E
MANDIBULAR RELAJADO
C O N F O R T E N E L PA C I E N T E , S I M P L I C I D A D Y D A D O Q U E N O E X I S T E N C L A R A S V E N TA J A S PA R A S E L E C C I O N A R E S Q U E M A S O C L U S A L E S
M Í N I M A M E N T E I N VA S I V O R Í G I D O S , L A C O M O D I D A D , L A S I M P L I C I D A D Y S E R M Í N I M A M E N T E I N VA S I V O O N O I N VA S I V O S O N
PRINCIPIOS ESENCIALES CUANDO SE PROPORCIONA UN ESQUEMA OCLUSAL.
Conceptos oclusales para implementar

1 2
3 4
Secuencia de9 tratamiento

Fig según according
Treatment sequence la ADA: Etapa 1: Dientes
to the ADA: mandibulares
Stage 1: Mandibular para
teeth to establecer
establish un nuevo plano
a new functional
occlusal plane. Stage 2: Maxillary posterior teeth establishing the new vertical dimension. Stage 3: Anterior
oclusalguidance.
funcional. Etapa 2: dientes posteriores maxilares que establecen la nueva dimensión vertical.
Stage 4: Esthetics on the buccal areas of the maxillary teeth.
Etapa 3: orientación anterior. Etapa 4: Estética en las áreas bucales de los dientes maxilares.
Stage Main goal Procedures
E V A L U A R L A D I F E R E N C I A D E C R A M I ; I D E N T I F I C A R E L PAT R Ó N D E
Evaluate difference from CR to MI; identify wear pattern;
Stage 0 Diagnosis and planning D E S G A S T E ; O B S E R VA R L A V I S U A L I Z A C I Ó N D E L D I E N T E Y L O S N I V E L E S
observe
G I N G I V A L Etooth
S display and gingival levels
•Restore
R E S TA Uthe
RARmandibular
L O S D I E N Tteeth
E S Mto
A Nestablish
D I B U L A Ra
E Snew
PA Rfunctional
A
occlusal plane
E S TA B L E CER UN NUEVO PLANO OCLUSAL FUNCIONAL
• LA VISUALIZACIÓN DEL BORDE INCISAL MANDIBULAR SE
Stage 1 Functional occlusal plane Mandibular incisal edge display can be used as a starting
PUEDE UTILIZAR COMO PUNTO DE REFERENCIA DE INICIO
•reference
E L PA C I Epoint
NTE QUEDA CON UNA DIMENSIÓN VERTICAL
PRO
The V I S I O NisAleft
patient L with a provisional vertical dimension
• R E S TA U R A R L O S D I E N T E S P O S T E R I O R E S M A X I L A R E S Y
Restore the maxillary posterior teeth and perform the occlus-
R E A L I Z A R L O S A J U S T E S O C L U S A L E S D E S D E U N A P E R S P E C T I VA
Stage 2 Vertical dimension al adjustments from a functional perspective, establishing
F U N C I O N A L , E S TA B L E C I E N D O L A D I M E N S I Ó N V E R T I C A L F I N A L
the
C Ofinal
N C Overtical
N TA C T Odimension
S O C L U S A Lwith
E S E Sstatic
TÁT I Cocclusal
OS contacts
•Construct
C O N S T R U and
YA Y adjust
A J U S T Ethe
L Apalatal
S S U P E Rsurfaces
F I C I E S PAof maxillary
L AT I N A S D E an-
LOS
Stage 3 Guidance A N T E Rfor
teriors IORaEcorrect
S M A X I Lanterior
A R E S PA guidance
R A U N C O Rwith
R E C Tposterior
O GUIADO tooth
ANTERIOR CON LA POSTERIOR DESOCLUSIÓN DE LOS DIENTES
disclusion
•AUdirect
N A M Amock-up
Q U E TA Dof
I R Ethe
C TA D E L O S incisal
maxillary B O R D E edges
S I N C I Sprovides
ALES a
S U P E R I O R E SofPthe
perspective R O PnewO R Cocclusal
I O N A U N plane,
A P E R S tooth
P E C T Idisplay,
VA D E L N UEVO
and
PLANO OCLUSAL, LA VISUALIZACIÓN DE LOS DIENTES Y LA
phonetics
FONÉTICA.
Stage 4 Esthetics and phonetics
S E H A C E N Aare
•Adjustments J U S made
T E S S I ifE needed
S NECESARIO
• U S A N D O U N A M AT R I Z D E S I L I C O N A M O D I F I C A D A H E C H A D E
Using
LA MA aQmodified
U E TA , L Osilicone
S BORDE matrix
S I N C Imade
S A L E S from
Y L Athe
S Á Rmock-up,
EAS
incisal
B U C A Ledges
E S M A and
X I L A maxillary
R E S F I N A Lbuccal
M E N T Eareas
S E R EareS TA finally
U R A N restored
a b c
Fig 10 Examples of generalized wear (a), anterior wear (b), and posterior wear (c).
Ejemplos de:
• desgaste generalizado (a)
• desgaste anterior (b)
the next appointment, at least one tooth accordingly. In most cases, these palatal
from each side should have • desgaste
simultan-posterior (c). are performed over intact,
restorations
eous contacts for mandibular stability at non-worn, palatal enamel to provide new

a b
c d
Fig 11 Details of the final stage. (a) Situation at the end of Stage 3, with composite resin on the palatal
Detalles de la etapasurfaces
final. (a) Situación
of the al final
maxillary anteriors. (b)de la Etapa
An esthetic 3, con
mock-up resinaand
is performed compuesta enislas
a silicone matrix con-superficies palatinas
structed to capture the incisal position. (c) The silicone matrix is adjusted with a bur to smoothen the tran-
de los anteriores maxilares.
sition between (b) Se realiza
the palatal anatomy una maqueta
and the estética
new incisal edge. y of
(d) Part setheconstruye una
previous palatal matriz de silicona para
restoration
is removed, and final restorations are performed with the adjusted silicone matrix. A small palatal chamfer
capturar la posiciónwith
incisal. (c)new
which the Lamaterial
matriz cande silicona
engage se ajusta
will probably improve con una fresa para suavizar la transición entre la
retention.
anatomía palatina y el nuevo borde incisal. (d) Parte de la restauración anterior del paladar se elimina, y las
restauraciones finales se realizan con la matriz de silicona ajustada. Un pequeño chaflán palatino con el que se
puede enganchar el nuevo
A silicone matrix is constructed with
material probablemente mejore la
incisal anatomy of the final esthet-
retención.
Fig 13 Initial situation: smile. Teeth seem to have
Situaciónworn
inicial:
around
sonríe.
20% to 30%
Los
of
dientes
their
Fig 13 Initial situation: smile. Teeth seem to have initial
parecen
length. Com-
haber
perdido
worn around 20%
Fig alrededor
pensatory
13to 30% eruption del
of their
Initial
also 20%
seems
initial
situation: altoTeeth
length.
smile. 30%
have de
Com- seemsu longitud
occurred.
to have
pensatory eruption also seems
worn around 20% toto30%have ofoccurred.
their initial length. Com-
inicial.pensatory
La erupción compensatoria
eruption also seems to have occurred.
también parece
haber ocurrido.
Fig 12 Initial situation: portrait. Fig 14 Initial situation: intraoral view.

Situación inicial: retrato.
Situación inicial: vista intraoral.

limited posterior area of the first contacts acceptable anterior guidance without
Situación
Fig 15 inicial: vista detallada
Initial situation: deoflaworn
detailed view dentición
maxillarymaxilar
dentition.desgastada.
Clinical historyLa historia
revealed thatclínica reveló
acid erosion
due to bulimic behavior, aggravated by parafunctional attrition and abrasion from aggressive toothbrush-
que la erosión ácida debida al
ing, were the most likely etiologic factors.
comportamiento bulímico, agravada por el desgaste
parafuncional y la abrasión del cepillado agresivo de los dientes, fueron los factores
etiológicos más probables.
Fig 16 Maxillary and mandibular occlusal views. Palatal surfaces of the anterior maxillary teeth and oc-
clusal surfaces were the most affected areas.
Vistas oclusales maxilares y mandibulares. Las superficies palatinas de los
dientes maxilares anteriores y las superficies oclusivas fueron las áreas más
afectadas.
dentin, involving all the teeth, with mini- surfaces of the maxillary teeth and the
mum wear on the mandibular anterior occlusal surface of the maxillary mo-
ifficult to determine if the OVD
in this case. Although the pos-
eth
re were worn, there seemed to
th
gree of compensatory eruption.
c-
this,
e- the treatment would have
de
he an increased vertical dimen-
on
ce no space could be created
al
R-MI
to difference.
case
er was approached accord-
ds
he guidelines described for a
u- Etapa
Fig 18 1:Stage
se restauran
1: The los dientes mandibulares
mandibular teeth from the
zed wear case. The mandibular
he Etapa 1: en la etapa inicial,
Fig 17 Stage 1: In the initial stage, the mandibu-
lar posterior teeth are restored up to their supposed first desde el primer
premolar to the premolar
first molarhasta el primer
on each quadrant
plane indicated an overerup-
original anatomy.
D los dientes posteriores are restored. After rubber dam removal, the patient
molar en cada cuadrante. Después de la
he anterior teeth. The cause for is left with a least one occlusal contact on each side
s-
elated mandibulares se restauran
to the Class II division 2 atextracción de lavertical
this provisional barreradimension.
de goma, el paciente
to
hasta suThe
n. pattern. supuesta
erosionanatomía
of the queda con al menos un contacto oclusal en
ve cada lado en esta dimensión vertical
surfaces of the
n-
original.
maxillary anter-
may also have played a role in An implant with provisional.
a provisional crown
ed
A second appointment was planned
for the direct reconstruction of the oc-
clusal surfaces of the maxillary poster-
ior teeth from the first premolar to the
first molar (Fig 16). Once the occlusal
contacts were adjusted, the new vertical
dimension was established.
During the third appointment, all
Fig 19 Stage 2: At the second appointment, the
the maxillary anterior palatal surfaces
direct reconstruction of the occlusal surfaces of the
maxillary posterior teeth to their original anatomy is
were reconstructed, with the new anter-
Etapa 2: en la segunda cita, se realiza la Fig 20 Stage 3: Palatal surfaces of the maxillary
ior guidance with posterior disclusion
done. Occlusal adjustments are then performed to
reconstrucción directaocclusion
de las superficies oclusales
Etapa
anterior teeth3:
arelas superficies
restored palatinas
to provide de at the
contacts
create a stable static at this new vertical (Figs
vertical17 and 18).
dimension created in the previous stage.
de los dientes posteriores maxilares a su anatomía
dimension. los dientes anteriores maxilares se
In the fourth appointment, the maxil-
original. Los ajustes oclusales se realizan para restauran para proporcionar
lary anterior gingivectomy and impres-
crear una oclusión estática estable en esta nueva sions contactos
for home en la dimensión
bleaching withvertical
10% car-
dimensión vertical. creada en in
la etapa
bamide were
to the first molar each anterior.
performed, since all the
quadrant were
dentin was
restored now
with protected. Two
a microhybrid weeks
direct com-
Fig 21 Stage 3: At the end of this stage, both static occlusion and anterior guidance have been created
Etapa 3: al final de esta etapa, se han creado oclusión estática y guía anterior para el
for the patient. The anterior guidance is adjusted to provide posterior teeth disclusion. From the buccal view,
paciente. La guía anterior se ajusta para proporcionar la desoclusión posterior de los dientes.
one can see that the transition between the palatal restoration and the buccal surface is still unrestored.
Desde la vista bucal, se puede ver que la transición entre la restauración palatina y la
superficie vestibular sigue sin restaurarse.
a a b b
Fig 22 Stage direct

4: Esthetic direct
tomock-up
evaluateto evaluate
incisalfinal incisal edge position. Incisal
at display
rest ac- at rest ac-
Etapa 4: maqueta directa estética para evaluar la posición final del borde incisal. La visualización incisal en
Fig 22 Stage
cording to age
4: Esthetic
cording
and to
lipage
mock-up
and lip movement
movement will the
will determine
final
determine the most
most natural
edge position.
natural
position
Incisal
forposition
display
for each patient.
each patient.
reposo de acuerdo con la edad y el movimiento del labio determinará la posición más natural para cada
paciente.
39
re
all mandibular movements (Fig 19). The b
primary anatomy, contours and line an- ch
gles, initial polishing, secondary anato- is
my (macro and micro-texture), and refin- m
ing polishing were distributed over two
b
appointments (Fig 20). The final results
were very satisfactory for the patient
un
(Figs 21 to 25).
tr
Fig 23 The silicone matrix, previously custom- an
La matriz de silicona,
ized with the direct mock-up, serves to guide the Discussion
Fig 24
After the palatal and incisal anatomy are
fin
final esthetic restorations. Después de establecer la
established in the palatal shell, the resin stratifica-
previamente personalizada con In is
tion this clinical case, a good esthetic re-
performed. p
anatomía palatina e incisal en
sult was achieved with direct composite la b
la maqueta directa, sirve para resin capa palatina,
restorations se26realiza
(Figs to 31).la
Since Th
guiar las restauraciones estéticas bulimia is a disorder with a strong psy- on
estratificación de la resina.
finales. chological component, a complete cure m
is difficult to achieve; therefore, higher d
maintenance is necessary. This should ce
Layering techniques
Overview
When considering the direct anterior restoration in composite, one needs
only to borrow from nature. If one studies and understands natural tooth
structure in color, form, and function, then composite mirroring becomes
the objective. Composite mirroring is the natural replacement of teeth
with minimal or no additional removal of the intact, health dentition to nor-
mal form and function with tooth-colored material. With this approach, the
restorative dentist must indulge the optical, anatomic, and functional char- Dent Clin N Am 51 (2007) 359–378
acteristics of natural teeth.
In composite mirroring, the restorative dentist chooses an enamel and
dentin replacement material that emulates the missing tooth structure in op-
Aesthetic Anterior Composite
tical properties and strength. Clinically, this can be oversimplified by using
a microhybrid in any area requiring strength or dentin replacement and a mi-
Restorations: A Guide to Direct
crofill for polishability and enamel replacement and effects (Fig. 1, Table 4).
Figs. 2–5 shows a more in-depth breakdown of the composite mirroring sys-
tem. Nanofillers, with more clinical data, may eventually eliminate the need Placement
for both systems.
a,b,c,*
When used properly, the composite mirroring system of layering is Brian P. LeSage, DDS
crucial in creating life-like restorations in strength and esthetics including a
polychromicity and incisal effects. The layering of composite material can Beverly b
Hills Institute of Dental Esthetics, CA, USA
UCLA Aesthetic Continuum, CA, USA
be simple, involving one or two shades, or advanced, mimicking the c ar-
Department of Restorative Dentistry, UCLA Dental School, CA, USA
tistic skills of the ceramic technician. When describing the four layering
technique, trying to simplify or categorize which layering technique is
Mastering anterior direct composite 366restorations is a necessity for the LESAGE
contemporary clinician who appreciates and understands the art and science
of cosmetic dentistry. In the esthetic zone, Table 4composite bonding procedures
are considered the most conservative and Overview of tooth structure
least invasive techniquereplacement
to return and classification of composite resins
missing, diseased, and unsightly toothTooth structure to enhanced color, form,
structure
and function. The attractiveness and popularitybeing replaced of composites are easyMicrohybrid
to Microfill
explain because these restorations have excellent
Enamel: esthetic area
stress-bearing potential, very
þþþþ þ (need support of tooth)
good to excellent prognosis, and a reasonable fee [1,2].
Enamel: pure esthetic area þþwþþþ þþþþ
Composites are the most versatile Dentin: restorative
pure material available to þþþwþþþþ
esthetic area the þþþwþþþþ (higher chroma
dental professional, especially for the(ie,esthetic-conscious
CL III, V) patients. The needed)
restorative dentist can use this versatile material
Dentin: in a mirage
stress-bearing of indications
area þþþþ þ (need support of MicroHybrid)
and techniques. It is used as a direct and (ie, indirect
CL IV) restorative material on an-
terior and posterior teeth, orthodontics attachments and bracket cement, in-
Abbreviations: w, not indicated; þ, least indicated; þþþþ, highly indicated.
direct restoration cements, correction of erosive and abfraction lesions,
Fig. 1. Simplified, generalized overview of the composite mirroring system. Brown area using mi-
crohybrid for the stress-bearing zone (strength for the long-term), and beigebases, liners,
area using core build-ups and post and cores, mock-up for anterior es-
a microfill
thetic
for esthetics (polishability for the long-term). (Courtesy of Brian LeSage, DDS, orHills,
Beverly posterior
CA.) best,
occlusal trial therapy, the clinician
splinting, needs to
provisionalization, consider the patient’s financial commitment
gingi-
val stabilization, and so forth. and the esthetic wants of the patient. Visualization, being able to see
For composite restorations to mimicand believe
natural toothin creating
structure, thethe end point, is critical. The purpose of compos-
clinician
must have a comprehensive understanding of theismaterial
ite layering sciencethe
to establish anddentin layer and dentinal lobes in a tooth
374 LESAGE
4 LESAGE Fig. 6. Shade Selection Technique. (A) Before picture at 1:1 showing worn and chipped areas
after lightly pumicing. (B) Highlighted gingival 1/3 for dentin shade selection. (C) Highlighted
Fig. 8. (A) Tint application internally showing lines and dot maverick colors in second-to-last
middle 1/3 for enamel shade selection. (D) Highlighted incisal 1/3 for translucent shade selection.
(E) Color mapping to aid in shade predictability. (F) Mock-up used for preliminary shade deter-
layer. (B) The final restoration. (Courtesy of Brian LeSage, DDS, Beverly Hills, CA.)
mination and 3-D spatial relations to fabricate putty matrix. (G) Putty Matrix trimmed properly
to the facial incisal line angle. Note bevel and star burst bevel. (H) Final restoration appearing
seamless and mirroring mother nature. (Courtesy of Brian LeSage, DDS, Beverly Hills, CA.)
Paint the desired colored tint on the walled area and clean the excess.
mirror the unique characterizations of the natural tooth, such as subsurface
staining or demarcations of any color, shape, or size.
Then light cure. The outer layer is unique and preplanned in this technique. If the desired
outcome is a brighter (higher value) shaded tooth, then the outer layer must
5. Anneal material over the tint: While placing
have enamel the most
color. Enamel outer
shade should enamel
be used or and the
a the outer layer
dentin layer create a notch or groove in the composite, preferably non-

straight. Paint the desired colored tint in the notched or grooved area
and anneal the composite toward and within itself, preferably in a non-
straight pattern. Then light cure.
g. 8. (A) Tint application internally
These showing
techniques lines
are andtodot
best maverick
learn colors in second-to-last
on extracted teeth or typodont teeth,
AESTHETIC ANTERIOR COMPOSITE RESTORATIONS 369
Fig. 5. (A) 3-D CharacterizedT É Layering

C N I C A DTechnique.
E C A PA S CSame
A R A Cas
T E3-D
RIZA DA.
Advanced Layering technique
with the lingual enamel layerL O being
M I S MaOdistinct
Q U E (E)
L A layer.
T É C N IAnd
C A 3the- D addition
A D V A N Cof
ED L AY E R Ifacial
a second NG CON LA
C A PA D E E S M A LT E L I N G U A L S I E N D O U N A C A PA D I S T I N TA ( E ) . Y L A
enamel layer of differing chroma range to internally give depth to the dentinal lobes and create
A D I C I Ó N D E U N A S E G U N D A C A PA D E E S M A LT E F A C I A L D E
incisal effects mirroring mother nature. Not shown is the tint layer placed internally creating
D I F E R E N T E R A N G O C R O M ÁT I C O PA R A D A R P R O F U N D I D A D
maverick colors and effects.I N(B)
T E Sequential
R N A M E N T application
E A LOS LÓ and
B U Llayering
OS DEN starting
T I N A R Ifrom
O S Ythe
C Rlingual
EAR EFECTOS
and extending to the facial Iwith
N C I Smultiple
A L E S Qdentin
U E R Eand
F L E Jenamel
A N L Ashades,
N AT U Rand
A L Ia
DAtranslucent
D DEL CO shade.
LOR. NO SE
(Courtesy of Brian LeSage, M U E S Beverly
DDS, TRA LA C ACA.)
Hills, PA D E T I N T E C O L O C A D A I N T E R N A M E N T E
C R E A N D O C O L O R E S Y E F E C T O S I N C O N F O R M I S TA S . ( B )
A P L I C A C I Ó N S E C U E N C I A L Y E S T R AT I F I C A C I Ó N C O M E N Z A N D O
D E S D E E L L I N G U A L Y E X T E N D I É N D O S E H A S TA E L F A C I A L C O N
into their decision-making
M Ú L T I Pprocess.
L E S T O NTwoO S Dshaded
E D E N Tmaterials
I N A Y E S with M A L T Edifferent
, Y UN TONO
T R A N S Ldentin,
chromas are used to replace Ú C I D O . with an enamel layer for enamel effects
and another layer using incisal shaded material (Fig. 4).

E S T R AT I F I C A D A P O R C A PA S N AT U R A L E S ( O A N AT Ó M I C A S ) , C O N O C I D A
E N I N G L É S C O M O N AT U R A L L AY E R I N G T E C H N I Q U E . S O N P R E C U R S O R E S
D E E S TA T É C N I C A : D I E T S C H I , V A N I N I Y B A R AT I E R
P R O T O C O LCLINICAL
O C L N RESEARCH
I C O PA R A L A S R E S TA U R A C I O N E S
CON RESINA IV
CLINICAL RESEARCH PAOLONE
Direct composite restorations Abstract profiles, macro- and microsurface tex-

tures, and chromatic characteristics,
Direct
in anterior teeth. composite
Managing restorations
In direct restorations of anterior teeth,
particularly central incisors, symmetry
the result can often be unpredictable. A
step-by-step class IV restoration treat-
plays an important role. The clinician ment will be described, as well as a sim-
symmetry in central incisors
in anterior teeth. Managing can take advantage of silicone indexes
based on a wax-up to build palatal and
ple procedure to help reproduce, check
and correct symmetrically interproximal
incisal walls; however, when he has to re- wall contours and chromatic character-
symmetry in central incisors

Gaetano Paolone, DDS produce free-hand chair-side symmetri- istics.
Private practice, Rome, Italy cal items like interproximal emergence (Int J Esthet Dent 2014;9:12–25)
Gaetano Paolone, DDS

Private practice, Rome, Italy
Correspondence to: Gaetano Paolone, DDS

Viale dei Quattro Venti, 233, 00152 Rome, Italy;
A New Proposal to Optimize the Occlusal Margin in Direct Resin Composite Restorations of Posterior Teeth; Luís Henrique Schlichting, DDS, MS; THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 3 • NUMBER 4 • WINTER 2008
Tel: +39 3474425470; E-mail: gaetano.paolone@gmail.com
Í
P R O T O C O L O C L N I C O PA R A L A S R E S TA U R A C I O N E S
at presentation. Fig 2 CON RESINA IV
Radiograph at presentation. FigFig
3 3One week
One after
week initial
after periodontal
initial therapy. FigFig
therapy.
periodontal 4 4
wax-up.
Extra
wax-up.
hard
Extra plaster
hard casts
plaster and
casts diagnostic
and diagnostic
CLINICAL RESEARCH PAOLONE

PAOLONE
ter initial periodontal therapy. Fig 4 Extra hard plaster casts and diagnostic FigFig
5 5 Extra
Extra hard
hard plaster
plaster casts
casts andand diagnosticFigFig
diagnostic 6 6 Silicone
Silicone indexes.
indexes.
wax-up. wax-up.
wax-up.
Careful cleaning with a motivating oral

hygiene session was performed during
the first appointment. One week later, 15
15
no gingival inflammation was detected THE
THE INTERNATIONAL
INTERNATIONAL JOURNAL
JOURNAL OF OF ESTHETIC
ESTHETIC DENTISTRY
DENTISTRY
(Fig 3). VOLUME

VOLUME 9 •9 • NUMBER
NUMBER 1 •1 • SPRING
SPRING 2014
2014
Precision silicone impressions were

taken in order to make extra hard plaster
casts and a diagnostic wax-up (Figs 4
and 5). These plaster models were used
to create a series of laboratory-made
rigid silicone indexes, both palatal and
Figs 11 and 12
Figs 11 and6,
12 Rubber dam isolation.
Fig 7 Silicone indexes. sagittal (Figs 7).Rubber dam isolation.
These indexes are useful in building
plaster casts and diagnostic Fig 6 Silicone indexes. palatal and incisal walls and in check-
ing composite thickness while perform-
ing layering technique as described
by several authors.8-12 In the same ap-
pointment, a personalized color chart
Í
P R O T O C OPAOLONE
LO CL NIC O PA RRESEARCH
CLINICAL A L A S R E S TA U R A C I O N E S
CON RESINA IV
Figs 11 and 12 Rubber dam isolation.
Rubber dam isolation.
Fig 13 1.1 after old restoration removal. Fig 14 212 clamp allowed accessibility to cervi-
cal area.
Volumetric discrepancies of the pre- The old composite filling was removed
sent restoration can be detected remov- using a medium grain cylindrical dia-
ing color, using black and white or in- mond bur. (Diagram 1, step 2) The cer-
verted pictures (Figs 9 and 10). vical area was not completely exposed
On the third appointment, teeth 15 to by rubber dam isolation (Fig 13). The
25 were isolated with a thin weight rub- application of another clamp (modified
ber dam (Isolante, Natursint) and two “2” 212, Ivory) on 1.1 (Fig 14) allowed that
clamps (Ivory, Heraeus) (Figs 11 and 12). area to be accessible.
The rigid silicone palatal index was The 212 clamp did not allow the use of
d restoration removal. Fig 14 212 clamp allowed accessibility to cervi-
checked
cal area. to fit perfectly and passively. the palatal silicon index, so the cervical
For this purpose, interdental silicone area had to be treated before the rest
Diagram
A New Proposal to Optimize the Occlusal Margin in Direct Resin Composite Restorations of Posterior Teeth; Luís Henrique Schlichting,1
DDS, MS; THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 3 • NUMBER 4 • WINTER 2008
was removed from the index with a No. of the restoration before performing the
Í
P R O T O C OPAOLONE
LO CL NIC O PA RRESEARCH
CLINICAL A L A S R E S TA U R A C I O N E S
CON RESINA IV
Figs 11 and 12 Rubber dam isolation.
Rubber dam isolation.
Fig 13 1.1 after old restoration removal. Fig 14 212 clamp allowed accessibility to cervi-
cal area.
Volumetric discrepancies of the pre- The old composite filling was removed
sent restoration can be detected remov- using a medium grain cylindrical dia-
ing color, using black and white or in- mond bur. (Diagram 1, step 2) The cer-
verted pictures (Figs 9 and 10). vical area was not completely exposed
On the third appointment, teeth 15 to by rubber dam isolation (Fig 13). The
25 were isolated with a thin weight rub- application of another clamp (modified
ber dam (Isolante, Natursint) and two “2” 212, Ivory) on 1.1 (Fig 14) allowed that
clamps (Ivory, Heraeus) (Figs 11 and 12). area to be accessible.
The rigid silicone palatal index was The 212 clamp did not allow the use of
d restoration removal. Fig 14 212 clamp allowed accessibility to cervi-
checked
cal area. to fit perfectly and passively. the palatal silicon index, so the cervical
For this purpose, interdental silicone area had to be treated before the rest
Diagram
A New Proposal to Optimize the Occlusal Margin in Direct Resin Composite Restorations of Posterior Teeth; Luís Henrique Schlichting,1
DDS, MS; THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY VOLUME 3 • NUMBER 4 • WINTER 2008
was removed from the index with a No. of the restoration before performing the
Í
USA). Next, the composite
the teeth, and the restoring is inserted
space is ing with surface.
the lingual more precision how much
Note the e.xcellent resin plate.The composite lay
defined (height and width) for the composite adaptation to the bevel mar-
Clinical against Strategies
the lingual
composite for
plate
lingual surface.
Success
surface that isto in
corresponding the Proximoincisal
ofgins,
each
in this area.
shade
reducing is necessary
the finishing in each
procedures a pulse-delay or s
already cured (Figures 17 and 18). location. Figure 20 demonstrates to minimize shrink
Composite Restorations. Part II: Composite
The dentin layer should cover just several forms that the dentin
Application Teclmiqne
a part of or
the opaque dentin needed to be OB2 eled similarly to the initial drawn
theOA2bevel, not extending mamelons
visualization (eg, Filtek Supreme
(Charisma OB2; Fsthet-X plan (Figure can 19). Suchassume in the incisal
a drawing Insertion of the T
or GT, 3M ESPH, St. Paul, MN
until its end.
OA2, This helps mask
Dentsply/Caulk, the FTDE, third
IMilford,
Ki.ii'i'r; or map ofcan
teeth. The larger
be helpful the ma-
in determin- Dentin
USA; Esthet-X YH,Layer
Dentspiy/Ca
interface,
LUIS ANTONIO USA). Next,
resulting
EELIPPE, DDS, MSD"the
in an composite
impercep- is inserted melon ing withcontrast
more precision howincisal
is in the much third,The composite layers are cured u
SYLVIO MOfJTEIROagainst
JR. DDS, the
MSD,lingual surface that is
This layer comple
of each shade is necessary in each a pulse-delay or soft-start meth
tible composite-tooth
CESAR Al.VES CALDEIRA DE ANDRADA, DDS. transition. The the larger the opaque dentin exten- more opaque dent
already cured (Figures 17 and 18). location. Figure 20 demonstrates to minimize shrinkage. ^"^
ANDREdentin composite
V. RITTER, DDS, MSD* increment is mod-
The dentin layer should cover just sion
several is forms
to thethat incisal border. Not
the dentin cent dentin layer p
a part isofcovered
the bevel,
with not
a thinextending
layer of all patients
mamelons canrequire
assume in visible mame-
the incisal Insertion vitality
of the Translucent
to the dent
ABSTRACT until itsopaque
end. This helps
microfill mask the
composite. third of
If the lons, butteeth. The largernecessary,
whenever the ma- Dentin Layer
these
desired
interface,and final
resulting basic shade is Bl or BO,
opaque dentin is u
Reproducing the form, function, opticalincharacteristics
an impercep- of natural melon contrast
dental is in the incisal
structures
opaque dentin extensions should with third, This layer complements the inn
tible a lighter opaque resin should be
composite-tooth
direct composites in large and moderately transition.
largeSLO,
proximoincisal The the larger the opaque dentin
{Class IV) restorations represents a exten- ration looks
more opaque dentin. A translu-
dull,
masking used (eg, Durafill Heraeus be covered by a high translucent
dentin composite
great challenge for clinicians in Kulzer). increment
general.If Understanding
the final basic shade
is mod-
color sion is to the incisal
is is fundamental to achieving successborder. Not cent dentinopaque. Some optic
layer provides com
when restoring these defects, asuniversal (A2), an opaque
was discussed in PartOA2 I ofor thisenamel
all
two-part composite
patients require
article (Volumeto increase
visible mame-
16, itsvitality togreat variation
the dentin stratum.am If
micrafill surface Number 6). The proper restoration OB2 is used. This layer should be
of the functional lingual contour lons, but whenever
is also necessary,
a challenge that these opaque dentin is used, the resto
thin to not result in an opaque strip opaque dentin extensions should
cannot beopaque
overcome without close
dentin attention to the restorative
in the surface of the final restoration.
technique. In this second article, the ration looks dull, matte, and to
enamel be covered by aphotographs
high translucent
composite application techniqueA ismicrofill
discussed and presented
composite is the material in detail. Clinical opaque. Some composites offer
lingual enamel enamel composite to increase its
illustrate the proposed technique. of choice for this area owing to great variation among the opaq
dentin its brightness and polishability
high translucent CLINICAL SIGNIFICANCE (Figure 2 1).
enamel
The proposed
Figure 19. Schematic draiving shoiving clinica! protocol, including a try-in of the shades in a mock-up restoration to more
the location and
thicknesses of the layers of composites drafted for
accurately the restora-
define color and shape, and aofsilicone
tion of the teeth. When the mamelons need to be more evident, Insertion the Incisalguide to transfer the lingual and proximoincisal
contour
the opaque dentin should be extended to the of the border,
incisal mock-up to the final
Opaque restoration,
Border is of great help to successfully restore proximo-
creating a larger contrast with the translucent enamel.
incisal defects. When an incisal "halo" effect is de-
sired, an opaque hybrid or microfill
and regular dentin pastes. In the Masking of the Composite-Tooth composite should be applied as (/ a Esthet Restor Dent 17:11-21, 2005)
proximal areas and mamelon Junction thin line across the incisal border
ends, an Al composite (Charisma) Figure
To ensure that the composite-tooth (Figure view
16. Proximal 22). This
of optical phenome- Figure 17. Composites corresponding
the lingual to Figure 18. The opaq
was applied.
R estoring the junction
naturalis optical
and functional characteristics (in
ground,
resin plate.
not noticeable, this
young
to observeresin
whether
Tbe(3)non
area
teeth),
a translucent
proximal
and (4)
the proximal
plate. Tbe
viewincisal
is noted especially
Figure 16. Proximal view of the lingual
natural
translucent
edge during
isinused
young hoth refraction
the dentin and reflection
are applied to the resitt
Figure 17. Composites corresponding to
view is used oflingual
incident light.
plate.
the dentin However,
to thegood
The placement
are applied
Figure
resitt of these
reproduce the dentin mamelons.
18.reproduce
The opaque the dentin
dentin shou
ends, an Al composite (Charisma) To ensure that the composite-tooth (Figure 22). This optical phenome-
was applied. junction is not noticeable, this area non is noted especially in young increment is used, c
Figure 2L A smail amount of opaque Figure 22. After the opaque microfill taken to avoid the d
microfill composite is distributed in a resin is applied, it is possible to notice
strip form following the resin-tootb larger softness in the shade transition undesirable composi
junction over the bevel. Tbis resin is from resin to the tooth (in the area of
already positioned in tbe surface of the the bevel). Final Evaluation of
C I . I M C A I . S T R . A T E G I E . S P R O . \ 1 \l O 1 \ C Irestoration.
S A I. C O N f P The
O S I Tfinish
F H F and
. S T O Rdistribution
\TI(t\S:
\ P P L I (; .A T 1 0 N T E t; H N I Q I! E of this resin layer should he the hest and Polishing
possible, emphasizing the good The final shape is c
restoration shape.
all angles to certify
or lack of composit
natural teeth and can be reproduced tics of the adjacent enamel and/or
Figure 20. A, Schematic shoiving tbe most classic appearance of the incisal border. This format can he called tridigital because
it presents tbree defined mamelons. B, Tbis illustration indicates another way of showing tbe dentin mamelons. The digital (Figures 25-27). If an
C I . I M C A I . S T R . A T E G I E . S P R O . \ 1 \l O 1 \ C I S A I. C O N f P O S I T F H F . S T O R \ T I ( t \ S :
format comes bipartitc(it occurs when a single digit divides in two ends), creating dentin fillets that are projected in tbe
Figure 16. Proximal view of the lingual with composites.'^''''
Figure 17. Composites corresponding to Figureteeth.'^
18. TheThe
direction of the incisal border. C, The form of the incisal mamelons shown here is more difficult to recognize and reproduce.
Often it is necessary to create internal paintings in this restoration area to evidence these fine projections of the dentin in
color dentin
opaque selection should
should a curved scalpel blad
\ P P L I (; .A T 1 0 N T E t; H N I Q I! E
resin plate. Tbe proximal view is used
the direction of the incisal border.
the dentin are applied to the resitt paintbrushes
reproduce help
the dentin
be similar to thetomamelons.
distribute
enamel andand
layer, paper disks are used
to observe whether the translucent lingual plate. The placement
Insertion of the Enamel of theseLayer plane the composite
usually in theis surface.
just one color used be- restoration. Care sh
composite invaded the dentin area of increments is facilitated by the cured Thecause
application of this layer hasshould
the restoration. Proximoincisal restorations
Imgual increment. VOLUME 17. NUMBER I , 2 0 0 . 17 are lo- the desired tonality al- when applying the c
cated where the natural enamel is notready require
beenmore than The
inserted. threeproximal
in- because too much e
the thickest. The enamel composite crements, area hasalthough
a doublethe number of
convexity, facial in the operator remo
layer fills the spaces between the increments
to lingual depends
and on theto exten-
cervical incisal. acterization obtained
paintbrushes help to distribute and
mamelons and defines the final res- sion of thecomposite
Excess defect. If ismore than one
removed
plane the composite in the surface. and layering technique u
toration shape (Figures 23 and 24). increment is used, care should be
The application of this layer should
Figure 2L A smail amount of
J O U R N A L OE E S T H E T I C AND R E S T O R A T I V E DTheopaque Figure 22. After
E N Tthickness the opaque microfill
I S T R Y and degree of trans- taken to avoid the development of
microfill composite is distributed in a resin is applied, it is possible to notice not require more than three in-
strip form following the resin-tootb lucency
larger softnessof thein thecomposite used in
shade transition undesirable composite interfaces.
crements, although the number of
junction over the bevel. Tbis resin is from resin to isthedirectly
tooth (inproportional
the area of
already positioned in tbe surface of the this layer increments depends on Shape
the exten-
the bevel). Final Evaluation of the
restoration. The finish and distribution to the translucency characteristics sion of the defect. If more than one
of this resin layer should he the hest and Polishing
of the adjacent natural enamel increment is used, care should be
possible, emphasizing the good The final shape is checked from
restoration
Figure 2L Ashape.
smail amount of opaque and/or teeth. Likewise,
Figure 22. After the opaque microfill the tone taken to avoid the development of
microfill composite is distributed in a resin is applied,
of the composite it is possible notice the all angles to certify that no excess
should tofollow
strip form following the resin-tootb larger softness in the shade transition undesirable composite interfaces.
or lack of composite is present
junction over the bevel. Tbis resin is selection
from resin toofthethe enamel
tooth (in the tonality
area of of
natural positioned
already teeth and in cantbebesurface
reproduced
of the tics of patient's
the adjacent enamel and/or (Figures 25-27). If an excess is noted,
the
the bevel). teeth. Final Evaluation of the Shape
ered directly on the sili- Fig 19
Incisal, palatal and interproximal walls are
set in one single step.
CON RESINA IV FigFig
20 20
Sagittal silicone
Sagittal index
silicone on the
index wax-up.
on the wax-up. FigFig
21 21
Checking space
Checking for for
space dentin and
dentin enamel.
and enamel.
PAOLONE
PAOLONE CLINICAL RESEARCH
ndex on the wax-up. Fig 21 Checking space for dentin and enamel.
FigFig
22 22 Dentin
Dentin layering.
layering. FigFig23 23Finishing
Finishing and
and polishing
polishing was
was performed
performed
after
after final
final curing.
curing.
20
20
THE
THE INTERNATIONAL
INTERNATIONAL JOURNAL
JOURNAL OF OF ESTHETIC
ESTHETIC DENTISTRY
DENTISTRY
VOLUME
VOLUME 9 • 9 • NUMBER
NUMBER 1 •1 • SPRING
SPRING 2014
2014
Fig 24 Asymmetry between 1.1 and 2.1. Fig 25 Silicon index after buccal portion removal. Fig 26 A transparent matrix band is inserted in Fig 27 After several c
Fig 24 Asymmetry between 1.1 and 2.1. Fig 25 Silicon index after buccal portion removal.
the silicon index parallel to central incisors. pects are symmetrical.
Fig 23 Finishing and polishing was performed

after final curing.
were used, with the aid of a conditioner Once the final layer was applied and
Í
between the matrix and the labial sur-
face of the element. Tracing the path on
the matrix band with one probe and with Fig 30 Pressing gently on the transparent matrix
PAOLONE
light pressure, it was possible to transfer
band with a probe.
PROTOCOLO CL
the N I C O PA
information R stripes’
on the A L ApathS RonE S TA U R A C I O N E S
SEARCH
CON RESINA IV
1.1 (Figs 30 and 31; Diagram 1, steps 9
and 10). FigFig
26 26A transparent
A transparentmatrix band
matrix bandis inserted in in Fig
is inserted 2727After
Fig several
After comparisons,
several the
comparisons, distal
the as-
distal as-
Small
thethe
silicon
silicondiameter
index parallel
index multiblade
to
parallel central burs (H1 pects
incisors.
to central incisors. are
pects symmetrical.
are symmetrical.
and reinserted into the index. Referenc-
314 006, Komet) were used to create
es of distal portions and midline were
space for effect masses (Fig 32). Once
used for a correct matrix repositioning.
these masses were applied, the element
The pattern of horizontal stripes of 2.1
was polished once again and the dental
was then on 1.1 (Fig 29).
dam was removed (Fig 33).
In order to transfer the pattern of hori-
One week after treatment, the teeth
zontal stripes, a small piece of 8 microns
were rehydrated (Fig 34). Seventeen
articulating paper, coated on one side
months after the end of the treatment,
(Arti-fol BK-21, Bausch), was interposed
the restoration showed a good integra-
between the matrix and the labial sur- Fig 31 Horizontal stripes path is transferred on
PAOLONE tion with the marginal tissues (Fig 36). 1.1.
face of the element. Tracing the path on
Cold and EPT tests produced positive
the matrix band with one probe and with Fig 30 Pressing gently on the transparent matrix
responses. The patient appeared mo-
band with a probe.
light pressure, it was possible to transfer
tivated and has changed his attitude
trix band is inserted intheFig
information on the
27 After several stripes’ path
comparisons, onas-
the distal FigFig
28 28Horizontal
Horizontal stripes
stripes areare outlined
outlined in black.
in black. Fig
Fig 2929Horizontal
Horizontal stripes
stripes are
are now
now onon 1.1.
1.1.
toward oral hygiene, causing gingival
central incisors. 1.1pects
(Figsare
30symmetrical.
and 31; Diagram 1, steps 9
e index. Referenc- inflammation to disappear.
and 10).
and midline were
Small diameter multiblade burs (H1
atrix repositioning.
314 006, Komet) were used to create
ntal stripes of 2.1 With the same scalpel blade anydiscrepancies
discrepanciesbetween betweenthe thedistal
distal
space for effect masses (Fig 32). Once With the same scalpel blade anan inci- any
inci-
29). portions
these masses were applied, the element sion of 5 mm of depth was made bucca-
sion of 5 mm of depth was made bucca- portions ofofthethecentral
centralincisors.
incisors.Based
Based
the pattern of hori- lly, in the front of and parallel to the labial onon this reference index andchecking
checkingit it
was polished once again and the dental lly, in the front of and parallel to the labial this reference index and
piece of 8 microns continuously, the distal portion
dam was removed (Fig 33). surfacesurface of of the the incisors.
incisors. In In this
this incision continuously,
incision the distal portion ofof the
the res-
res-
oated on one side a transparent matrix band was inserted toration toration (Diagram
One week after treatment, the teeth a transparent matrix band was inserted (Diagram 1,1,step
step7)7)was
wasmodi-
modi-
h), was interposed (Fig 26) (Diagram 1, step 5). fied (using diamond bursand
anddiscs)
discs)inin
were rehydrated (Fig 34). Seventeen (Fig 26) (Diagram 1, step 5). fied (using diamond burs
and the labial sur- With a green felt pen, the midline and order order to improve the symmetrywith with2.1
2.1
months after the end of the treatment, With a green felt pen, the midline and to improve the symmetry
racing the path on the distal portion of 2.1 was marked (Di- asas much as possible (Fig 27).
16
16
theFig
restoration showed the distal portion of 2.1 was marked (Di- much as possible (Fig 27).
one probe and with 30 Pressing gently onathe good integra-
transparent matrix Fig 31 Horizontal stripes path is transferred on Fig 32 Space for effect masses is created.
agram 1, step 5). Removed and flipped, Using the same transparent matrix,
tion with
band withthe a probe.marginal tissues (Fig 36). agram 1, step 5). Removed and flipped, Using the same transparent matrix,
possible to transfer 1.1.
the band was then reinserted centering the pattern of horizontal stripes was
Cold and EPT tests produced positive the band was then reinserted centering the pattern of horizontal stripes was
e
arestripes’ path
outlined in on
black. Fig 29 Horizontal stripes are now on 1.1. the midline; the distal portion of 2.1 was marked with a black permanent marker
responses. The patient appeared mo- the midline; the distal portion of 2.1 was marked with a black permanent marker
Diagram 1, steps 9 marked onceDDS, again (Diagram
JOURNAL OF 1, step 6). VOLUME
(Fig 28)4 •(Diagram 1, step 8). The matrix
marked once again (Diagram 1, step 6). (Fig 28) (Diagram 1, step 8). The matrix 23
A New Proposal to Optimize the Occlusal Margin in Direct Resin Composite Restorations of Posterior Teeth; Luís Henrique Schlichting, MS; THE EUROPEAN ESTHETIC DENTISTRY 3 • NUMBER WINTER 2008
tivated and has changed his attitude
Í
NICAL RESEARCH
Fig 33 After dental dam removal, rehydration is Fig 34 One week after treatment.
remarkable.
CLINICAL
CLINICALRESEARCH
RESEARCH CON RESINA IV
Fig 33 After dental dam removal, rehydration is Fig 34 One week after treatment.
remarkable.
Fig 35 Palatal aspect. Fig 36 Follow-up after 17 months.

fter dental dam removal, rehydration is Fig 34 One week after treatment.
Fig 35 Palatal aspect. Fig 36 Follow-up after 17 months.
Fig33
Fig 33 After
Afterdental
dentaldam
damremoval,
removal,rehydration
rehydrationis
is Fig 34
Fig 34 One week
One week after
after treatment.
treatment.
remarkable.
remarkable.
Conclusions
Conclusions
Reproducing
Reproducing“specular sym
“specular symm
rather
rather difficult,especially
difficult, especially whe
w
to be done freehand chairsid
to be done freehand chairs
some aspects can be planned
some aspects
boratory, cancannot.
others be planne
In thi
boratory, others
a simple and cannot. In te
inexpensive t
helpful in reproducing symmet
a simple and inexpensive
acteristics has been described
helpful in reproducing
guides symm
like this one could be p
Fig 37
acteristics hasand
in advance,
Periapical radiography of 1.1 at the end
been
in adescribe
more prec
of treatment. fromlike
guides the this
wax-up
oneorcould
with phot
be
Fig 37 Periapical radiography of 1.1 at the end in advance, and in a more pr
Fig 35 Palatal aspect.
Fig 35 Palatal aspect.
Fig 36
Fig 36
Follow-up after 17 months.of treatment.
Follow-up after 17 months.
from the wax-up or with ph
alatal aspect. Fig 36 Follow-up after 17 months. 24
THE INTERNATIONAL JOURNAL OF ESTHETIC DENTISTRY
A New Proposal to Optimize the Occlusal Margin in Direct Resin Composite Restorations of Posterior Teeth; Luís Henrique Schlichting, DDS, MS; THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY9
VOLUME VOLUME 3 • NUMBER
• NUMBER 1 4•• SPRING
WINTER 20082014
Í
The present a
on the direct
ment of functi
dentition. Alth
cept,16,17 the
thought proce
evidence-bas
essential step
to achieve a p
The propo
disadvantage
based strate
Fig 25 Final occlusal adjustment should provide
El ajuste centric
oclusalstops
final on
debe proporcionar paradas cian’s
céntricas en technic
all teeth (stronger on posteriors)
pointments, a
todos los dientes (más fuertes en los posteriores) y una guía
and an anterior guidance that provides posterior
disclusion. definition (Ta
anterior que proporciona una disclusión posterior.
R E S TA U R A C I O N E S R E S TA U R A C I O N E S T R ATAtreatment
MIENTO DIRECTO
Wax-up-based Wax-up-based Direct
D I R E C TA S B A S A D A S I N D I R E C TA S B A S A D A S
direct restorations indirect restorations S I N E Nwax-up
without C E R A D O(ADA)
(ADA)
EN UN ENCERADO EN UN ENCERADO
SE DEBE REALIZAR UNA
EAV Adetailed
L U A C I Ó anatomical,
N C L Í N I C A func-
• L A P L A N I F I C A C I Ó N D E L T R ATA M I E N T O S E
Ational
N AT ÓandMICA , F U N C I clinical
esthetic ONAL Y
F A C I L I TA
Treatment C O N Mis
planning O facilitated
DELOS MO N TAmounted
with D O S , YA Eevaluation
S T É T I C A Dneeds
E TA L L Ato
D AbeAN TES
Treatment per-
Q U Esince
casts H AY there
U N A is MaE Jbetter
O R V Ivisualization
S U A L I Z A C I ÓofNavail-
DEL D E C O M E N Z A R L A E TA PA D E
planning formed before starting the re-
E S PA
able C I O and
space D I S Pdistribution
O N I B L E Y of
L Arestorative
D I S T R I B Uvolumes
CIÓN R E S TA U R A C I Ó N P O R Q U E N O
storative stage because there
D E V O L Ú M E N E S R E S TA U R AT I V O S H AY I N T E N T O S D E R E A L I Z A R E L
is
E Nno
C Etry-in
R A D Oof
. the wax-up
R E S TA U R A C I Ó N D I R E C TA D E L
• EL ENCERADO SE REALIZA EN BASE A Direct restoration of the man-
Wax-up is made based on clinical indications, usu- ARCO MANDIBULAR UTILIZANDO
Starting INDICACIONES CLÍNICAS, USUALMENTE dibular arch using the man-
LA VISUALIZACIÓN DEL BORDE
ally using the desired maxillary incisal edge display
point U T I L I Z A N D O L A PA N TA L L A D E L B O R D E I N C I S A L Idibular
N C I S A L incisal
M A N D I Bedge
U L A R display
COMO
as a reference
MAXILAR DESEADA COMO REFERENCIA Ras
E FaE Rreference
ENCIA
CInON order
E L F Ito
N D provide
E PROPO aRlogical
CIONAR
• EL ENCERADO SE PRUEBA EN LA BOCA
Uand
N F Loptimized
U J O D E T R Aworkflow,
B A J O L Ó G the
ICO Y
A wax-up
The T R AV É S is D E U NinA the
tested M Amouth
Q U E TA C O Na
through O P T I M I Z A Dis
principle O ,that
E L Pcompos-
RINCIPIO ES
Í N D I C Ewith
mock-up S Dsilicone
E S I L I Cindexes
O N A Abefore
N T E S initiating
DE the Q U E L A R E S I N A C O M P U E S TA S E
ite resin is added until the
Possibility of A G R E G A H A S TA L A A N AT O M Í A
I N I C I A R L A R E H A B I L I TA C I Ó N
rehabilitation
Ddesired
E S E A D A anatomy
Y L U E G O Sand
E R Ethen
DUCE
corrections
• TA N T O L O S C A M B I O S A D I T I V O S C O M O PA R A A D A Pto
reduced TAaccommodate
RSE A LAS oc-
S U BbyS T the
R A Cclinician
T I V O S orP Udental
E D E Ntechnician
SER HECHOS Lclusal
I M I TA Climitations;
I O N E S O C L Utherefore,
S A L E S ; P O Rno
made L O TA N T O , G E N E R A L M E N T E N O S E
P O R E L C L Í N I C O O E L T É C N I C O D E N TA L additive changes are usually
N E C E S I TA N C A M B I O S A D I T I V O S
needed

R E S TA
made byUthe
RAC I O N E S or dental
clinician R Etechnician
S TA U R A C I O N E S clusal limitations; therefore, no
Wax-up-based Wax-up-based T R ATAtreatment
Direct MIENTO DIRECTO
D I R E C TA S B A S A D A S I N D I R E C TA S B A S A D A S additive changes are usually
direct restorations indirect restorations S I N E Nwax-up
without C E R A D O(ADA)
(ADA)
EN UN ENCERADO EN UN ENCERADO needed
C
AOdetailed
N O C I M I Eanatomical,
N T O D E L A func-
H A B I L I D A D PA R A T R A B A J A R C O N A R T I C U L A D O R E S , Knowledge of anatomy, and
Ational
N AT OandM Í A esthetic
Y L A C A PA CIDAD DE
Technical UAbility
N A R Cto work with articulators, a facebow, impres-
O Fplanning
A C I A L , I MisP facilitated
R E S I O N E S with
Y clinical
demand
Treatment
sions, and eventually preparations
mounted Ethe
S C Uability
L P I R YtoE sculpt and
S T R AT I F I C A stratify
R
Treatment E V E N T U A L M E N T E P R E PA R A C I O N E S evaluation needs to be per-
casts since there is a better visualization of avail- R E S I N A S C Oresins
composite M P U E S TA S
planning formed before starting the re-
able space and distribution of restorative volumes
storative stage because there
Occlusal PisOno
T Etry-in
N C Iof
A Lthe
M Ewax-up
NTE MÁS
P O Thigher
Potentially ENCIALMENTE M Á S A LT O Potentially lower
precision BAJO
MÍNIMAMENTE
Minimally invasive or D E P E N D EonDthe
Depends EL D ISEÑO
prepar- M Í N I Mrestoration
Minimally
Direct A Minvasive
E N T E of
IN Vnon-
A Sman-
orthe IVO
Invasiveness I N V Ais
Wax-up S I made
V O O Nbased
O on clinical indications, usu-
Starting noninvasive
I N V A S I V O
D E Ldesign
ation A P R E PA R A C I Ó N O N O I arch
invasive
dibular N VA S I V O the man-
using
ally using the desired maxillary incisal edge display
point dibular incisal edge display
as a reference
DEPENDE DE LA as a reference
Esthetic
Depends on the wax-
CALIDAD DE ENCERADO L O M Á S A LT O C O N D E P E N Don
Depends E D E clinical
the LA ap-
up Y
quality
L A A Pand
L I C Aclinical Highest with ceramics
outcome CIÓN CERÁMICA A PLICACIÓN CLÍNICA
plication
application
CLÍNICA
In order to provide a logical
and optimized workflow, the
MÁ S P R O PisE N S O A in the mouth M • MÁS PROPENSO A
The wax-up tested
More prone to fractures AY O Ra
through principle
More is that
prone compos-and
to fractures
F R A Cwith
mock-up T U R silicone
AS Y indexes before initiating the FRACTURAS Y
and staining L O
HighestN G E V
longevityI D A D Y
and ite resin is added until the
staining
Possibility of
Longevity MANCHAS
rehabilitation M A N C H A S
desired anatomy and then
corrections A E S TA Bwith
R E Q U E R I M I E N T O stability
LT O maintenance I L I Dceramics
AD CON
High A
•HighLT O R E Q
maintenanceU E R
reduced to accommodate I M I E N Toc-
require- O
DE MANTENIMIENTO
requirement CERÁMICA ment
DE M ANTENIM I E N T O no
made by the clinician or dental technician clusal limitations; therefore,
additive changes are usually
M AY O R E S TA R I F A S D E LOS HONORARIOS DE M AY O R E S TA R I F A S D E T I E M P O
Costs Higher laboratory fees Highest laboratory neededchair time fees
L A B O R AT O R I O L A B O R AT O R I O M Á S E L E fees
VA D O S Higher
CONSUMIDO
Fig 27 Final result: smile frontal view. Fig 28 Final result: smile lateral view.
Resultado final: sonrisa vista Resultado final: vista lateral de la

frontal. sonrisa.
Fig 29 Final result: intraoral view of maxillary anteriors.
Resultado final: vista intraoral de los anteriores maxilares.

Fig 30 Occlusal view at 2 years showing some wear and small areas of chipping, common in extensive
restorations with composite resin. An implant with a provisional restoration was placed on tooth 25.
Vista oclusal a los 2 años que muestra cierto desgaste y pequeñas áreas de
astillado, común en restauraciones extensas con resina compuesta. Se
colocó un implante con una restauración provisional en el diente 25.
THE INTERNATIONAL JOURNAL OF ESTHETIC DE
SPR
Mechanical limitations in c
resins make these restorations
tible to fractures, and they req
maintenance.85 In fact, both
and small repairs should be ex
the esthetic zones during the f
years.86 It is a common assum
the same incisal thickness s
provided in the composite m
the original volume of the intac
tooth. Although this can be reco
able with ceramic veneers, fro
thor’s experience it is not advis
ceramic, for example, has a

modulus similar to enamel,87 w
of composite resin is much low
makes it susceptible to fractur
cially when applied in extensi
ations. To increase its cohesiv
resistance, the authors recom
large a volume as possible of c
Fig 31 Final result: portrait view.
resin in the incisal edge, within
Available online at www.sciencedirect.com
ScienceDirect
journal homepage: www.intl.elsevierhealth.com/journals/dema
Review
Anterior composite restorations: A systematic

review on long-term survival and reasons for
failure
Flávio F. Demarco a,∗ , Kauê Collares a , Fabio H. Coelho-de-Souza b ,

Marcos B. Correa a , Maximiliano S. Cenci a , Rafael R. Moraes a ,
c
Niek J.M. Opdam
a Graduate Program in Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, RS, Brazil
b School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
c Department of Restorative and Preventive Dentistry, Radboud University Nijmegen Medical Centre, Nijmegen,
The Netherlands
a r t i c l e i n f o a b s t r a c t
Table 3 – Reasons for failure of anterior composite restorations reported in the included studies. Number of failures (% of total restorations evaluated).
Fracture of Caries Endodontic Restoration Marginal Color Anatomical Surface
tooth or complication loss adaptation form stain
restoration
Restorations in worn teeth
Al-Khayatt et al., 2013 [33]
Smales and Berekally, 2007 [39] 28 (17.7) 2 (1.2) 2 (1.2) 14 (8.5) – – – –
Restorations for aesthetic reasons

Gresnigt et al., 2012 [14] 5 (5.2) – – 6 (6.3) – 1 (1.0) – –
Peumans et al., 1997 [17,18] – – - – 4 (4.6) 2 (2.3) 9 (10.3) –
Frese et al., 2013 [40] 20 (11.4) 3 (1.7) – 2 (1.1) – – 2 (1.1)
Alonso et al., 2012 [31] 1 (4.8) – – – – – – –
Restorations due to caries, fractures, and replaced restorations

de Moura et al., 2011 [4]a 7 (4.1) – – 15 (8.8) – – – –
van Dijken, 1999 [41] 4 (2.7) 3 (2.0) – – – 1 (0.7) – –
Spinas, 2004 [23]
Millar et al., 1997 [42]
Kubo et al. 2011 [25]
van Dijken and Pallesen, 2010 [30] 11 (25.6) – – – – – – –
Smales and Hawthorne, 1996 [24]
Baldissera et al., 2013 [6] 5 (2.3) – – – 2 (0.9) 5 (2.3) 6 (2.7) 5 (2.3)
Studies that did not report specific reasons for failure were not included in the table [21,23,42].
a
Reasons for failure of Class III and Class IV restorations were inserted together.
Ca as de
Porcelana
ri
ll
Tabla 4-1 : Corocteristlcos clínicas de las resinas de composite y la porcela na.
Ventajas Desventajas
Tabla 4-2. Nueva Clasificación de la Indicaciones de las Carillas de Porcelana
Resinas • Adhesión • Contracción polimerización
Indicaciones de las
Composites • Preservación del tejido dental • Coeficiente de expansión
• Dureza similar a lo dentina térmica TIPO I
Porcelana • Estética • Fragilidad
• Durabilidad • Características del desgaste
DIENTES RESISTENTES AL BLANQUEAMIENTO
Cari as de Porcelana
• Dureza parecida a lo del esmalte
GRUPO lA Coloración por tetraciclina de grado 111 y IV
ESPECTRO . . . GRUPO lB Cuando no hay respuesta al blanqueamiento interno o externo
TI PO 11
MODIFICACIONES MORFOLÓGICAS MAYORES
GRUPO IIA Dientes conoides
GRUPOIIB Cierre o reducción de diastemas y espacios interdentales
GRUPOIIC Aumento de la longitud y del relieve incisal
TIPO 111
RESTAURACIONES EXTENSAS (ADULTOS)
GRUPO lilA Fracturas extensas de la corona
GRUPO IIIB Pérdida extensa de esmalte por erosión y desgaste
DE INDICACIONES GRUPO IIIC Malformaciones generalizadas congénitas y adquiridas
ll
Este documento es elaborado por Medigraphic
Tiempo de vida de las restauraciones dentales libres de metal: revisión sistemática; Anayely del Rocío González-Ramírez ; Revista ADM 2016; 73 (3): 116-120
et al.
www.medigraphic.org.mx et al.
et al.
et al.
et al, et al.
et al, et al.
et al.
et al, et al.
Diversos reportes han encontrado que el tiempo de vida de las restauraciones libres de
metal y metal- porcelana es del 83.9 al 100% y del 92.3 al 95.5% a los ocho años de
seguimiento clínico, respectivamente. Al comparar estos datos, las coronas libres de
metal muestran una supervivencia clínica menor que las restauraciones de metal-
porcelana. Sin embargo, como se mencionó anteriormente, su biocompatibilidad con los
8
tejidos dentales debe ser un aspecto importante a tomar en cuenta en las restauraciones
protésicas.
Moke Up
PASCAL .MAGNE, PHD, DR MED DENT ; vel Porcelain Laminate Preparation Approach Driven by a Diagnostic Mock-Up ; / Esthet Restor Dent 16:7-18, 2004 ; VOL,UME 16, NUMBER 1, 2004

\OVFL POliC 1- \ \ 1 | \ \TK !• [i I • I' \ H \ i I () N \ ]• I'H 11 \ (. 11 l ) l i l \ L
Figure 4. A, PreliminaryFigure 4.cast A, of upper anterior

Preliminary cast of teetb
upper sbowing
anterior teetb sbowing
Figure 4. A, Preliminary
severe erosions (BPR cast
indication of upper
type anterior
IIIB), teetb
enameltype sbowing
wear, and enamel wear, and
severe erosions
severe
(BPR indication
erosions type
(BPR indication
IIIB), enamel wear,
IIIB),
and to
breaching. B, Wax-upbreaching. obtained B, by by
Wax-up a slight addition
obtained of
byofawax wax
slight addition of wax to
breaching. B, Wax-up
restore ortgi?ial volumes obtained a
of enamelvolumes slight addition
on teetbofno. 6 to 11. to
This no. 6 to 11. This
restore ortgi?ialmust restore
volumes ortgi?ial
of enamel on teetb beforeenamel
no. 6 to on teetb
11. prepa-
This
configuration be assessed
configuration intraorally
must be assessed tootb
intraorally before tootb prepa-
configuration must be assessed intraorally
rations are made. C, Silicone index from a wax-up to be used before tootb prepa-
rations are made. rations
C, are made.
Silicone index C, Silicone
from a wax-up index to from
be useda wax-up to be used
for fabrication of a mock-up; the silicone must extend onto
for fabrication of for
a fabrication
mock-up; the of a mock-up;
silicone must the silicone
extend onto must extend onto
teeth no. 4 and 5 and 12 and 13 for improved intraoral stabil-
teeth no. 4 and teeth12no.
5 and and4 and 5 and
13premature
for 12 andintraoral
improved 13 for improved
stabil- intraoral stabil-
ity. Palatal clearance facilitates removal of excess
ity. Palatal clearance ity. Palatal
facilitates clearance
premature facilitates
removal
resin. D, Tbe facial aspect of tbe silicone index is first sectioned
premature
of excess removal of excess
resin. D, Tbe at
borizontally I resin.
facial mmaspectofD,the
ofTbetbefacial
silicone
gingival aspect of isA
indexE,
sulcus. tbe silicone
first
scalpelsectionedindex is first sectioned
is used
borizontally at I mm
to remove silicone borizontally
of the gingival
material fromat Iinterdental
mm of the
sulcus. gingival
E,papillae
A sulcus.
is used E, A scalpel is used
scalpelbetween
to remove
teetb to 11.to¥,
no. 6silicone remove
material
A largefrom silicone
diamond material
interdental fromat interdental
bur is papillae
used low speedpapillae between
abetween
teetb no. removal
for fine 6 to 11. of teetb
¥, A no.
tbelarge 6diamond
silicone to covering
11. ¥,bur A large
is used
tbe diamond
at a low
gingiva. G, bur is used at a low speed
speed
Tbe
for fine removal
completed siliconeoffortbe fine
index removal
silicone
follows of tbe
covering
tbe silicone
tbe
facial gingiva.
gingival covering
G, Tbe tbe gingiva. G, Tbe
contour
completed siliconecompleted
witbout exposing index
tbe follows
teeth; this tbe facial
silicone index gingival
facilitates follows contour
premature tberemoval
facial gingival contour
witbout
of excessexposing tbe teeth;exposing
resin. witbout this facilitates premature
tbe teeth; removal premature removal
this facilitates
of excess resin. of excess resin.


Figure S. A, Preliminary intraoral view. B. Palatal tootb surfaces and facial gin
facial enamel is spot etcbed with H_]PO4 for a few seconds (then rinsed and d
up. C, Silicone index loaded witb A} dentin-tike acrylic resin. D, Silicone index
tbe level of tbe premolars; because of tbe silicone sbape, facial (and palatal) ex
is cooled with water and maintained until complete curing of resin. E, Clinical
index. F, Brownisb Ugbt-curing stains are mixed with glaze liquid and inserted
for optical enbancement ofthe interdental contact. G, The mock-up is glazed w
(Skin Glaze). H, General view of tbe mock-up after complementary light curin
ment at 2 weeks reveals a barmony between the incisal edge positions and tbe
tootb surfaces and facial gingiva have been isolated with petrolatum; tbe
w seconds (then rinsed and dried) to secure tbe retention of the future mock- 12 JOURNAL OF ESTHETIC: AND RESTORATIVE DENTISTRY
crylic resin. D, Silicone index positioned intraorally witb axial pressure at
ary intraoral
sbape, view.
facial (and B. Palatal
palatal) excesstootb
resin surfaces and facial
can be removed gingiva have
immediately. Silicone been isolated with petrolatum; tbe
etcbed
e curingwith H_]PO4
of resin. for a few
E, Clinical secondsjust
appearance (then
afterrinsed and dried)
tbe removal tbeto.MAGNE,
of PASCAL secure
silicone tbe retention of the future mock-
PHD, DR MED DENT ; vel Porcelain Laminate Preparation Approach Driven by a Diagnostic Mock-Up ; / Esthet Restor Dent 16:7-18, 2004 ; VOL,UME 16, NUMBER 1, 2004
loaded
ith glazewitb
liquidA}and
dentin-tike acrylic
inserted with resin.atD,
a scalpel theSilicone
level of index
cervicalpositioned
embrasuresintraorally witb axial pressure at
.lars; because
G, The mock-up of tbe silicone
is glazed withsbape, facial (and palatal)
a very-low-viscosity excessliquid
Ugbt-curing resin can be removed immediately. Silicone

Ta ado
ll

for "deprogramming" ofthe mock-up. The most critical step of
dl dl DC 0,7 mm DC 0,7 mm DC 0.7 mm DC 0.7 mm
DC 0.7 mm DC 0,5 mm jL
DC 0.7 mm DC 0,5 mm jL
\l \ ( : \ F A N D BKl.SFR
DC
DC
Toolh preparation driven by Tooth preparation driven by
Toolh preparation driven by
existing toothTooth preparation driven bymock-up
surface
DC = (di - d 2 ) / 2 DC 0.5 mm DC 0.7 mm
existing tooth surface
DC = (di - d 2 ) / 2 DC 0.5 mm DC 0.7 mm B and singie depth cuttermock-up and differentiai depth cutter
B and singie depth cutter and differentiai depth cutter
Figure 6. A, Simple round diamond burs represent ideal deptb cutters. The depth of cut (DC) is easily calculated with formula
shown diamond
Figure 6. A, Simple round by measuring
burs tbe diameter
represent of the
ideal deptb burcutters.
(dl) andThetbedepth
diameter of the
of cut (DC) sbank (d2).calculated
is easily A DC of 0.5 withmm is recommended for
formula
cervical preparations and 0.7 mm for tbe incisal ttuo-tbirds. B, Preparation of tbe tootb with thin diagnostic
initial enarnel.approach
Left, and require a
Omis-
shown by measuring tbe diameter of the burDentin (dl) andexposure Enamel preservation
tbe diameter of the sbank (d2). A DC of 0.5 mm is recommended for
cervical preparations sion
and ofthe
0.7 mmadditive diagnostic
for tbe procedures B,
incisal ttuo-tbirds. and the use of aofsingle
Preparation deptbwith
tbe tootb cutter caninitial
thin lead to total enamel
enarnel. high
Left, loss
Omis-level
(redof communication
dotted line). with
Right, Useprocedures
sion ofthe additive diagnostic of differential
anddepth ctttters
the use of a insingle
combination witb can
deptb cutter an additive mock-up
lead to total enamel(redloss
additive line)the
(red dotted sbould
line).
dentalmaintain most oftechnician. In
laboratory
tbe enamel
Right, Use of differential depth (red dotted
ctttters line).
in combination witb an additive mock-up (red additive line) sbould maintain most of
tbe enamel (red dotted line). these cases the BPR aims to restore
the original (not the existing) vol-
ume of the tooth, especially in the
presence of thin initial enamel.
Such cases typically involve
patients with altered existing tooth
Tooth preparation driven by Tooth preparation driven by VOLUME shape 16, (ie,NUMBER
indicated 1, for2004BPR 13 types
existing tooth surface final volume of restoration
VOLUME 16, NUMBER II and 1, 2004111, according13 to Magne
(baseline) (additive wax-up and mock-up]
and Belser).'•^'i-'-'"
figure 2. Two tootb preparation strategies illustrated in bori-
zontally sectioned incisors. Left, Use of tbe existing tootb sur-
A diagnostic wax-up that represents



Fracturo previo Facturo previo

moderado severa

Diente delgado Diente curvado y

y plano grueso
y plano grueso
Diente delgado Diente curvado y

y plano grueso

Recubrimiento lotal Recubrimiento totol

No recubierto Recubrimiento porc íol con marjen plano con chomfer

Vio de inserción oblicua Se requiere convergencia
FIGURA 6-20 , Vio de inserción horizontal

: PREPARACiÓN DENTAL PARA EL CIERRE Compatible con divergencia
DE DIASTEMAS. El cierre de triángulos interdentales o de
dia stemas son situaciones excepciona les en las que se requiere una máxima penetración en la superficie próximal, para
permitir que el técnico dental co nfeccio ne unas "mini-aletas" interdentales, con un perfil prog resivo, que compensen la
pérdi da de tejido bla ndo o la a narmal posición del diente (6-20 0). Aspecto típico de las RPA, en estos casos; la s "mini-
a letas", q ue forman una línea de transición angular muy precisa (morcada en rojo), están hechas con una po rcelana de
mayor croma para evitar el aspecto abombado del diente (6-20 b). Los dientes son con frecuencia más anchos en lo
zona inci sa l (6 -20 c 1) que en la zona cervica l (e) . La penetració n proximal máxima debe co mbinarse con un margen
pala tino plano que permitirá la inserción horizontal de la carilla (6-20 c). La divergencia natural de las paredes axiales
se respeta , co nsiguiendo la máxima preservación de esmalte (6-2 0 d, mó s fotografías de este caso se pueden encontrar
en la Fig 4 -5) . C uando la penetración proximal máxima se co mbina co n un chamfer pa latino, sólo permite la inserción
obl icua de la car illa (6-20e) . La divergencia natural de las paredes axiales no se respetará , lo que lógi ca mente con-
duce a una preparación más invasiva del diente ya un mayor riesgo de exposición dentinaria oxial co mparado con la
preparación de la Fig 6-20c . (la Fig . 6 -20 b se ha reimpreso con la autorización de Belser y col. \0 l.
266
Vio de inserción oblicua

Se requiere convergencia

FIGURA 6-21: MARGEN INTRASULCULAR PARA UN CIERRE INTERDENTAL ÓPTIMO. Los márgenes intrasulcula-

cil.
cil.E,
E, Remtiants
Remtiants of
of acrylic
acrylic from
from the
the mock-up
mock-up are
are eliminated
eliminated
witb
witb aasealer.
sealer.
2-week-
2-week-
aa bur
bur to
to
middle
middle
hee depth
depth
C,
C, Tbe
Tbe
AA
ghtly
ightly
nd
nd cer-
cer-
h pen-
th pen-
inated
minated

Figure Figure
7 continued. F, Traditional
7 continued. burs (round
F, Traditional ended,ended,
burs (round slightlyslightly Figure 7 c
tapered) are used
tapered) arefor thefor
used removal of remaining
the removal tooth tooth
of remaining substance
substance tapered) a
betweenbetween
reduction grooves;
reduction sufficient
grooves; space space
sufficient shouldshould
he created
he created between r
automatically when tbe
automatically when pencil marks marks
tbe pencil disappear. G, Horizon-
disappear. G, Horizon- automatica
tally sectioned siliconesilicone
tally sectioned index from
index tbefromwax-up (with (with
tbe wax-up marked marked tally sectio
occlusal stops on
occlusal premolars)
stops is usedistoused
on premolars) double-check for facial
to double-check for facial occlusal st
clearance. H, Incisal
clearance. edge preparation
H, Incisal edge preparationis controlled with the
is controlled with the clearance.
palatalpalatal
index. index.
More reduction
More reductionis required (pencil(pencil
is required marks)marks) palatal ind
to reachto the
reachminimum
the minimuml.S mml.Sincisal clearance.
mm incisal I, Finishing
clearance. I, Finishing to reach th
steps include a slighta proximal
steps include separation
slight proximal with ultrathin
separation with ultrathin steps inclu
diamond disks (Vision
diamond Flex) to
disks (Vision enhance
Flex) marginmargin
to enhance definition.
definition. diamond d
J, Coarse flexibleflexible
J, Coarse disks are
disksused
aretoused
remove all sharp
to remove transition
all sharp transition J, Coarse
line angles. (Completed
line angles. preparations
(Completed are shown
preparations in Figure
are shown 1). 1).
in Figure line angles
eduction grooves (see Figure proximal separation (see Figure 71;

other steps are traditional. Vision Flex® disk, Brasseler, Savan-
nah, GA, USA) to enhance proximal
ontally sectioned silicone margin definition during the impres-
recommended for double- sion and to facilitate the subsequent
g the available space (see fabrication of stone dies during lab-
G), and a palatal index is oratory procedures. Ail transition
assess the 1.5 mm incisal line angles are finally rounded with
e {see Figure 7H). More flexible disks at a low speed (see
e must be removed, as out- Figure 7J). A last but essential pro-
dentin, that
dentin, that is,
is, the
the identification
identification of
of cementation should
cementation should bebe required
required The authors thank attendees of var-
possible dentin
possible dentin exposures
exposures andand sub-
sub- because the
because the friction
friction fit
fit (resin
(resin shrink-
shrink- ious lectures and hands-on courses
sequent sealing
sequent sealing of of these
these areas
areas with
with aa age) and
age) and existing
existing proximal
proximal undercuts
undercuts who have shared their ideas and
dentin
dentin (owing to
(owing to gingival
gingival retraction)
retraction) should
should inspired the content of this work.

bonding for indirect composite and porcelain restorations. More than 30 articles were reviewed,
most of them addtessing the specific situation of dentin bonding for indirect restorations. It
appears that the combined results of this data plus clinical experience suggest the need for a revi-
sion in the dentin bonding procedure. Immediate application
Tniinediate Deiitiii Sealing: A Fundamental and polymerization of the dentin
bonding agent to the freshly cut dentin., prior to impression taking, is recommended. This new
Procednre for Indirect Boiuhnl Restorations
application procedure, the so-called immediate dentin sealing (IDS), appears to achieve improved
bond strength, fewer gap formations, decreased bacterial leakage, and reduced dentin sensitivity.
PASCAL MAtiNi;, DMI),
The use of filled adhesive resins (low elastic modulus liner) facilitates the clinical and technical
aspects of IDS. This rational approach to adhesion also has a positive influence on tooth struc-
ture preservation, patient comfort, and long-term survival of indirect bonded restorations.
AI5STRACT
The purpose of this article is to review evidence-based principles that could help optimize dentin
CLINICAL SIGNIFICANCE
bonding for indirect composite and porcelain restorations. More than 30 articles were reviewed,
Tooth preparation for indirect
most of them addtessingbonded
the specificrestorations (eg, composite/ceramic
situation of dentin inlays, onlays,
bonding for indirect restorations. It and
appears that the combined results of this data plus clinical experience suggest
veneers) can generate significant dentin exposures. It is recommended to seal these freshly cut the need for a revi-
sion in the dentin bonding procedure. Immediate application and polymerization of the dentin
dentin surfaces with a dentin bonding agent (DBA) immediately following tooth
bonding agent to the freshly cut dentin., prior to impression taking, is recommended. This new
preparation,
before takingapplication
impression. A three-step
procedure, the so-calledtotal-etch
immediate DBA
dentin with
sealinga(IDS),
filledappears
adhesive resinimproved
to achieve is recom-
mended for bond strength, fewer
this specific gap formations,
purpose. The major decreased bacterial leakage,
advantages, as well and reduced
as the dentin sensitivity.
technical challenges of
The use of filled adhesive resins (low elastic modulus liner) facilitates the clinical and technical
this procedure, are presented in detail.
aspects of IDS. This rational approach to adhesion also has a positive influence on tooth struc-
ture preservation, patient comfort, and long-term survival of indirect bonded restorations.
(/ Esthet Rc'sto!- Dent 17:144-155, 2005}
Tooth preparation for indirect bonded restorations (eg, composite/ceramic inlays, onlays, and
DKNTINOF.NAMEL JUNCTIONveneers)
AS leaguessignificant
can generate in the 1980s,'
dentin
PASCAL .MAGNE, PHD, DR
the principle
exposures. It is
MED DENT ; vel Porcelain recommended
Laminate
can betoby regarded
Preparation Approach Driven aseal these
Diagnostic
as a perfect
Mock-Up ; freshly
fibril
cut16:7-18, 2004 ; VOL,UME
/ Esthet Restor Dent 16, NUMBER 1, 2004
A MODEL. FOR DFNTIN HONDINCi of with

dentin surfaces which is tobonding
a dentin createagent an interphase
(DBA) immediatelyreinforced following tooth bond.''"'
preparation, It is composed


Impr ión De nitiva
es
fi

HILO DE COMPRESiÓN
HILO DE RETRACCiÓN
HILO DE RETRACCiÓN
HILO DE RETRACCiÓN




Prov ionalización
is

U N P A S O I D O B L E MEZCLA

Cementación

J Indian Prosthodont Soc (Apr-June 2010) 10(2):79–88

DOI 10.1007/s13191-010-0022-0
REVIEW ARTICLE
Conventional and Contemporary Luting Cements: An Overview

Komal Ladha • Mahesh Verma
Received: 18 June 2010 / Accepted: 3 August 2010 / Published online: 12 December 2010
! Indian Prosthodontic Society 2010
Abstract Long-term clinical success of fixed prosth- of a proper luting agent and the cementation procedure.
odontic restorations is influenced by many factors, one Loss of crown retention was found to be the second leading
important factor being the selection of an appropriate luting cause of failure of crowns and fixed partial dentures [1]
agent. No single luting agent is capable of meeting all the while a study listed uncemented restorations as the third
stringent requirements, which is one reason why there is leading cause of prosthetic replacement with failure
such a wide choice of luting agents currently available occurring after only 5.8 years of service [2].
86 J Indian Prosthodont Soc (Apr-June 2010) 10(2):79–88
Table 3 Luting agents for different fixed prosthodontic restorations
Restoration Reinforced Zinc Zinc Glass- Resin- Adhesive resin

zinc-oxide phosphate polycarboxylate ionomer modified
eugenol glass-ionomer
Cast metal Only crowns and
crowns, FPD’s, short-span FPD’s
inlays, onlays
Metal-ceramic -do-
crowns and FPD’s
Aluminous all-
ceramic crowns &
other reinforced
core all-ceramic
systems
Pressable glass
ceramic crowns
Ceramic veneers
Resin-retained
FPD’s
Ceramic inlays
and onlays
Cast post & core
Partial veneer
crowns/ and
retainers for
FPD’s
Implant-supported
crowns
Multiple-unit
implant-supported
prosthesis
cements indicated, cements not indicated, cement most preferred, cement not preferred
Sources: Refs. [36, 86]
by the affinity of these monomers for the metal oxides Commercially available C&B Superbond (Parkell,
TABLE 1
Resin Cements by Polymerization Mechanisms
RESIN CEMENT CURING METHOD CHARACTERISTICS INDICATIONS

Light-Cure • Photo-initiators, activated • Increased working time • Esthetic restorations
by light • Decreased finishing time • Metal-free restorations
• Color stability • Cementing thin,
translucent ceramic
Dual-Cure • Chemicals and light • Bond strength • Cementing thick.

• Esthetics opaque ceramic
• Ease of use • Metal-free restorations
Chemical-Cure • Chennical reaction of two • Useful in areas where light- • Metal restorations
materials mixed (self-curing) curing is difficult • Endodontic posts
• Ceramic restorations
that prohibit curing unit
from adequately polymer-
izing the resin cement
Cementation of Indirect Restorations: An Overview of Resin Cements; Catherine Stamatacos, DDS; and James F. Simon, DDS, Med;
www.dentalaegis.com/cced
COMPENDIUM January 2013; Volume 34, Number 1 January 2013 COMPENDIUM 43
ments have been shown to produce fairly strongbonds to dentin.^^-^*^ cements.'^'™ However, self-etch and total-etch resin cements tend to
Resin Cements by Adhesive Scheme
RESIN CEMENT ADHESIVE SCHEME CHARACTERISTICS
Total-Etch 30% to 40% phosphoric acid-etch. • Excellent cement-to-tooth bond strength

then adhesive is applied • Reduced microleakage
• Long-term predictability
• Requires multi-step application technique
Self-Etch Self-etching primer, then mixed • Ease of use

cement is applied • Less technique sensitivity
• Good bond strength
Self-Adhesive "One component" phosphoric acid • Able to bond to untreated tooth surface
grafted into resin • "Selective etching" can be incorporated
for improved bond strength
44 COMPENDIUM January 2013 Volume 34, Number 1
Cementation of Indirect Restorations: An Overview of Resin Cements; Catherine Stamatacos, DDS; and James F. Simon, DDS, Med;
COMPENDIUM January 2013; Volume 34, Number 1
I CARLOS JOS£ SOARES, DDS, MS, P H D *
PAULO VINlCIUS SOARES, DDS'
JANAlNA CARLA PEREIRA, DDS+
ROnRIGO BORGES FONSECA, UDS. MS
Surface Treatment
ABSTRACT
Protocols in the Cementation
The clinical longevity of indirect restorations made of ceramics or indirect composite resins
Process of Ceramic
depends and
on their successful Laboratory-Processed
treatment and cementation. The cementation technique is determined
by the type of restorative material—ceramics or indirect composite resins; thus, their intaglio sur-
Composite Restorations:
face treatment should be performedA Literatme
according Review
to their particular compositions. The aim of this lit-
erature review was to define surface treatment protocols of different esthetic indirect restorative
materials. A PubMed database search was conducted for in vitro studies pertaining to the most
common treatment protocols of tooth-colored materials. Articles that described at least the surface
CARLOS JOS£ SOARES, DDS, MS, P H D *
treatment procedure, its effects on adhesion, its relationship with the material's composition, clini-
PAULO VINlCIUS SOARES, DDS'
cal aspects,
JANAlNA CARLA and expectedDDS+
PEREIRA, longevity were selected. The search was limited to peer-reviewed articles
published in English between
ROnRIGO BORGES FONSECA, UDS. MS 1965 and 2004 in dental journals. Sandblasting, etching techniques,
and silane coupling agents are the most common procedures with improved results.
ABSTRACT Tooth-colored restorative materials vary considerably in composition and require different proto-
cols for of
The clinical longevity adhesive cementation.
indirect restorations made of ceramics or indirect composite resins
depends on their successful treatment and cementation. The cementation technique
(J Esthet Restor is determined
Dent 17:224-235, 2005)
by the type of restorative material—ceramics or indirect composite resins; thus, their intaglio sur-
face treatment should be performed according to their particular compositions. The aim of this lit-
erature review was to define surfaceCeramic
treatment protocols of different toesthetic
fractureindirect restorative
T he advances
materials.
tistry have
of adhesive
A PubMed
an increasing
den-
database search
materials
was conducted
important
have some
properties, for
suchinasvitro studies
propagation.-^-^
Thosepertaining
properties to the most
indicate
"
that
TABLE 1. CERAMICS COMPOSITION AND SURFACE TREATMENT PROTOCOLS
Restorative Material Composition* Surface Treatment Protocols
Feldspar ceramics: Noritake EX3 SiOj; K2O, AI2O3, 6SiO:; 9.5% hydrofluoric acid for 2 to 2.5 min;
(Noritake, Nagoya, japan), Na2O, AizO,?, 6SiO2 application 1 min washing; silane application
Duceram {Degussa Dental/
Dentsply, Hanau, Germany)
Leucite-reinforced ceramics: SiO2, AI2O3, K2O, NaiO, CeO2, 9.5% hydrofluoric acid for 60 s;
IPS Empress, Cergogold other oxides 1 min washing; silane application
Lirhium di-silicate-reinforced SiOz (57-80%), Li2O (11-19%), 9.5% hydrofluoridric acid for 20 s;
ceramic: IPS Empress II MiOi (0-5%), La2O3 (0.1-6%), 1 min washing; silane application
MgO {0-5%), P1O5 (0-11%),
ZnO (0-8%), K2O (0-13%)
CiUiss-infiltrated aluminum oxide AUO3 (82%), L&1O3 (12%), Sandblasting: synthetic diamond particles
ceramic: In-Ceram alumina SiO2(4.5%), CaO(0.8%), (first choice) or 50 ^ini AI2O1 particles;
other oxides (0.7%) restoration by washing with water for
1 min; or retentive preparation design
Cements: phosphate-monomer-containing resin
cement (first choice), conventional resin
cement, glass ionomer, or zinc phosphate
Zirconium-reinforced ceramic: UzOi (62%), ZrO2 (20%), Retentive preparation design; alternacive:
l-Ccram zirconium
^Jn-Ccrai La2O3(12%), SiO2(4.5%), sandblasting with 50 jini Al2O,i particles
CaO (0.8%), other oxides (0.7%) Cements: phosphate-monomer-containing
resin cement (first choice), conventional resin 1
Densely sintered, aluminum AI2O3 (99.5%) Retentive preparation design; alternative:
Jde ceramic: Pmccr.! AllC'cram sandblasting with .^{) ym AI2O3 particles
Cements: phosphate-monomer-containing resii
cement (first choice), conventional resin
ACTIVACIÓN DEL SILANO PRUEBA GRABADO HF + LIMPIEZA
ACTIVACIÓN DEL SILANO PRUEBA GRABADO HF + LIMPIEZA
8-50 8-5b S-Se

8-50 8-5b S-Se
SILAN IZACIÓN + SECADO CON AIRE SECADO AL HORNO
SILAN IZACIÓN + SECADO CON AIRE SECADO AL HORNO
APLICACiÓN DE LA RESINA ADHESIVA APLICACiÓN DE LA RESINA ADHESIVA

----..---=-- - - - - - -, ----..---=-- - - - - - -,
TIP: utilizar aire caliente a 75 grados para

mejorar las propiedades
_5/
del silano fl 'ji _5/ fl 'ji
APLICACiÓN DEL COMPOSITE DE RES INA APLICACiÓN DEL COMPOSITE DE RES INA
8 Si 8-Sk 8-'i1 8 Si
8-Sk 8-'i1
TIP: acido ortofosfórico autolimitante
LAVADO Y SECADO CON ALCOHOL LAVADO Y SECADO CON ALCOHOL
-61-. 8-6:
-61-. 8-6:
APLICACiÓN DE LA RESINA ADHESIVA
APLICACiÓN DE LA RESINA ADHESIVA

INICIO DE lA CIMENTACIÓN Y ELIMINACIÓN DEL GRUESO DEL EXCEDENTE

INICIO DE lA CIMENTACIÓN Y ELIMINACIÓN DEL GRUESO DEL EXCEDENTE
8-7.-: 8-7h B-/ e

8-7.-: 8-7h B-/ e
RETIRADA DE lAS MATRICES Y CEMENTACiÓN FINAL .....----,- --- ..
RETIRADA DE lAS MATRICES Y CEMENTACiÓN FINAL .....----,- --- ..
fl-7h fl-7h
POLIMERIZACiÓN , GLICERINA Y lAVADO ..,.--,.--.-:---=------

POLIMERIZACiÓN , GLICERINA Y lAVADO
..,.--,.--.-:---=------
B-/ i S-Ik 87! B-/ i S-Ik 87!


ACABADO
ACABADOMANUAL
MANUAL
AJ
AJAJ U
UAJ
ST
AJUST
ST
ES
U ES
ES
ST OC
ES OC
OC
OC
U ST ES OC LU SA
LU LU
LULU
SA
SA SA
LES
SA LES
LES
LES
LES
8-70
8-70 8-7p
8-7p B-7q
B-7q
8-70
8-70
8-70 8-7p
8-7p8-7p B-7q
B-7qB-7q
Caso clínico 1
Lateralidad Derecha
Lateralidad Izquierda
Caso clínico 2
Gracias

Restauraciones Esteticas Del Sector Anterior.-1

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Restauraciones Esteticas Del Sector Anterior.-1

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RESTAURACIONES ESTÉTICAS DEL

SECTOR ANTERIOR: EN BASE A LOS PRINCIPIOS DE PASCAL MAGNE

Dra. Karla Va ejo Vél

E ecial ta en Rehabilitación Oral

Docente de la Universidad Central del Ecuador

-El uso consciente,

Tabla VI. Niveles de evidencia (CEBM)

1a Revisión sistemática de ensayos clínicos aleatorizados, con homogeneidad.

• Parametros Dento - Faciales

• Plan de Tratamiento: materiales

• Perspectiva de vida (garantía)

CLINICAL REVIEW opyrig

for Esthetic Evaluation?

Nicole Passia, DDS, Dr med dent

Markus Blatz, DMD, Dr med dent, PhD

Altura de la sonrisa PASSIA ET ALopyrig

Fig 1 Average smile line. Fig 2 Hi

Fig 2 High smile line.

Fig 3 Low smile line. Fig 4 Pa

Larger per- Larger per-

41 35 24 Low smile line High smile line

Low smile line. Fig 4 Parallel smile line.

Fig 4 Parallel smile line. Fig 5 Flat smile line. Fig 6

Comparison between male

Krishnan More female subjects than male

2. TRONERAS INTERDENTALES O LLENADO INTERDENTAL

2. TRONERAS INTERDENTALES O LLENADO INTERDENTAL

Altura media de la corona Anchura media de la corona

8. FORMA DEL DIENTE

Parametros Dentales con formación (atrición, abrasión). Todo ello deter-

9. Caracterización de los dientes

11. Color BRILLO

Forma de "gaviotal " Curva invertida

13. Línea labial inferior

13. LíNEA DEL LABIO I N F E RI O R

14. Simetría de la sonrisa

Tabla 4-1 : Corocteristlcos clínicas de las resinas de composite y la porcelana.

Porcelana • Estética • Fragilidad

• Pequeñas alteraciones de forma

• Pequeñas alteraciones de color

• Finalización de ortodoncia en pacientes jóvenes

211 y 212 I Encerado realizado sobre el modelo inicial que guiará el

Asperice la super cie del

o se verá en el capítulo sobre dientes anteriores, se puede

222 I Obsérvese la retracción obtenida.

223 a 225 I Se comienza, en este caso, por el incisivo central más

236 I Examen oclusal.

1. Una capa de dentina (mas espesa)

Carillas de dientes con oscurecimiento INTENSO

Dense alveolar bone

coinciden el IM y el RC, según Dawson.

stomion 45% 30%

vertical en mujeres y hombres según mediciones antropométricas modernas

un concepto bien establecido y clínicamente relevante.

Conceptos oclusales para implementar

Secuencia de9 tratamiento

Fig 12 Initial situation: portrait. Fig 14 Initial situation: intraoral view.

Fig 12 Initial situation: portrait. Fig 14 Initial situation: intraoral view.

Situación inicial: vista intraoral.

Fig 22 Stage direct

Mastering anterior direct composite 366restorations is a necessity for the LESAGE

dentin layer create a notch or groove in the composite, preferably non-

Fig. 5. (A) 3-D CharacterizedT É Layering

and another layer using incisal shaded material (Fig. 4).