Anterior Esthetics with APT: Are CAD-CAM

Systems Ready for the High-End Anterior

Esthetics Challenge?
$0,

Galip GOrel, DDS, MS'

Adriano Shayder, CDT2
3 BraulioPc,DS
ichacho, DMD 4

sthetic dentistry is a delicate combination of sci-

dental team must then incorporate their own personal

entific principles and artistic abilities. Mathemati-

artistic abilities and their subjective feelings into cre-

cal parameters used by the dentist and the lab-

ating a smile. The creativity of the procedure makes

oratory technician combine to produce an attractive

each treatment unique and the dentist's job pleasingly

esthetic appearance. However, these geometric laws

varied and rewarding.

must not be used mechanically but rather should act

As

the popularity of esthetic dentistry increases,

as guidelines for each individual clinical restoration. 1-3

growing numbers of patients are seeking treatment

Because general esthetic rules are not entirely ob-

for the improvement of unesthetic anterior dentition.

jective, the dentist must also consider the subjective

Whereas patients previously focused on the mere res-

concerns of the character and the inner being of the in-

toration of traumatized, periodontally involved, or cari-

dividual patient when designing the new natural smile.

ous teeth, today the focus has shifted to treatment for

Taking these criteria into account, the dentist and the

enhancement of the esthetic appearance of existing

healthy teeth as well. In addition, the professional approach to dentistry has changed dramatically. Acceleration in the development of dental ceramic systems,

'Private Practice, Istanbul, Turkey; Visiting Professor, New York

University, New York, USA.
2 Dental
3 Private

Technician, Sao Paulo, Brazil.

Practice, Barbacena, Brazil.

'Professor, Department of Oral Rehabilitation, Faculty of Dental

Medicine, Hebrew University, Jerusalem; Private Practice, Tel Aviv,
Israel.
Correspondence to: Dr Galip Gurel, Tevikiye Cad Bayer Apt no.
143 Kat:6, Nisantasi 34365, Istanbul, Turkey.
Email: galipgurel@galipgurel.com

bonding materials, and CAD-CAM (computer-aided

design, and computer-assisted manufacturing) technologies has made conservative tooth preparation
and restorative procedures controllable in a way never
before imaginable.
Digital dentistry has also been changing the profession. Diagnosis, treatment planning, dental procedures,
and the laboratory technical phases are all being reshaped by the many aspects of digital CAD/CAM

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OPEL ET AL

Fig 1 The patient's short maxillary anterior teeth cannot be

seen with lips at rest position.

dentistry as more and more dentists adopt this meth-

of artistic visual language with disciplines such as psy-

odology. Advances in the milling of block materials

chology, neurobiology, anthropology, and sociology.

have significantly increased clinical reliability, efficien-

Visagism makes it possible to determine which emo-

cy, economy, and esthetic results in both the clinical

tions and personality traits patients wish to express

and laboratory applications of CAD/CAM. These new

through their appearance and, specific to dentistry,

techniques enable the clinician to achieve esthetic im-

through their smiles. The aim is to create a smile design

provements and more predictable, esthetically pleas-

that expresses the patient's personality and lifestyle,

ing results. Some of the more progressive dental

ensuring harmony between the restorations and the

patient's physical appearance, values, and attitudes. 56

schools have been implementing CAD/CAM in their

curriculum, and most probably these young dentists
will not even know how to treat a patient without having these technologies as an adjunctive tool.

A mock-up is a method for creating the length, position, volume, and shape (as well as the surface texture
in specific indications) of the teeth to be restored or the
Esthetic procedures have the ability to alter the entire

new smile design in three dimensions (3D) directly in

appearance of the patient by providing them with an

the patient's mouth.' In today's esthetic dental world,

attractive smile. Patients gain not only an improved

it is almost impossible to assess the final structural and

appearance but also a potential morale boost that acts

esthetic result without a mock-up, especially from the

positively on their mental health and self-esteem. Any

patient's point of view. This procedure requires precise

high-end esthetic restoration must take into account

knowledge of the tooth anatomy along with intuition,

the personality of the patient and interpret and inte-

sensitivity, and a good perception of the patient's indi-

grate it into the procedure. 4 The importance of psy-

vidual personality (Figs 1 to 3).

chological factors that may enhance or detract from

A mock-up assumes even greater importance when

the esthetic appearance should never be underesti-

porcelain laminate veneers (PLVs) are being designed

mated.

because of their relative thinness and the need for a

In dentistry, visagism is a novel concept that ap-

conservative preparation approach, since the tooth

plies the principles of visual art to the composition of

preparation will be determined directly by the position

a customized smile. Visagism involves the creation of a

and volume of the definitive restoration.' Also, during

customized personal image that expresses a person's

the buildup of the mock-up, the more additive the ap-

sense of identity. The method used to apply this con-

proach, the more minimally invasive it will be.

cept is derived from the association of the principles

78

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2b

2c

3a

3c

Fig 2a to 2c The patient's short lateral and central incisors (and diastema that did not please him). Together with the incisal
attrition, the teeth went through passive eruption over the years, shifting the gingival level coronally.
Fig 3a Incisal attrition extends to the palatal surface, which also needs to be covered with the definitive restorations.
Fig 3b Due to ongoing eruption of the teeth and full contacts, space needs to be created for the restorations to partially
cover the affected palatal surfaces of the teeth.
Fig 3c Orthodontic treatment was initiated to intrude the maxillary anterior dentition to open space between the maxillary
and mandibular incisors as well as align the soft tissues.
Fig 3d After orthodontic treatment there is adequate space between the incisors. The smile was re-evaluated, and PLV
restorative treatment was chosen to improve the proportions and optical properties of the six maxillary anterior teeth.

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GORE' ET Al
Fig 4 Direct mock-up placed on the
teeth after orthodontic treatment
defines the new incisal edge position and the facial contours.
Figs 5a and 5b Full-face smile
photos before and after mock-up.

80

Starting Point: Incisal Edge Position

Tooth Morphology and Surface Texture

The position of the incisal edge acts as the parameter

The challenge to emulate nature and establish oral

upon which the rest of the design is built. Elongation

harmony is an extraordinarily complex issue, particu-

of the incisal edge is often indicated to correct incisal

larly in anterior restorations. Knowledge of the inter-

wear, inadequate tooth display, or a displeasing tooth

play of shape, function, and surface texture is the basis

or crown proportion. Once it is set, the incisal edge

for esthetically appealing restorations and will have an

serves to determine the proper tooth proportion and

gingival level, making it especially important. Several

immediate effect on the integration with the surrounding gingiva. 4,10-14

teeth should serve as the reference line for the cor-

Surface texture interrelates with the size, shape, and

rect incisal edge position of the treated teeth. How-

position of the teeth. In esthetic restorations, the sur-

ever, the incisal edge of the maxillary central incisor is

face texture of the anterior teeth and their enamel,

the first determinant in the creation of the new smile

which becomes abraded over time, are important fac-

design.

tors to consider.

Determining the incisal edge position is critical be-

Once the incisal edge position is defined, the tooth

cause it will affect the whole design and proportion

morphology and surface texture should be built up

of the mock-up in three dimensions, and therefore it

with an additive approach. This will not only be a great

must be verified both vertically and horizontally. For

tool for dentist-patient communication but also will

example, the horizontal (buccolingual) component of

help the ceramist tremendously either for the wax-

the mock-up will directly affect the facial contouring of

up or subsequently in the porcelain buildup. The pa-

the new teeth design (Figs 4 and 5). 9

tient will have a better understanding of the potential

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Anterior Esthetics with APT: Are CAD-CAM Systems Ready for the High-End Anterior Esthetics Challenge?

Fig 6 The wax-up is created based on the mock-up data.

shape, form, texture, and alignment of the final design

This concept was introduced as the aesthetic pre-

as well the new lip posture. 15,16 And if both the patient

evaluative temporaries (APT) technique,' and it has

and the dentist are happy with this outcome, the teeth

proved to be extremely beneficial for addressing the

can be prepared through this mock-up.

key factors even before treatment has been initiated

and, most importantly, for ensuring minimally invasive
tooth preparation.

WAX-UP

Step 1: Evaluation of the APT

The first step is to use the silicone index (duplicated

Once agreement about the general dimensions of the

from the wax-up) over the patient's teeth before the

design has been reached by the dentist (technically,

case is started. No tooth preparations have been done

ie, form, function, and esthetics) and the patient (es-

yet. Because the patient is not anesthetized, this cre-

thetics), this information is sent to the ceramist in the

ates a good opportunity for the dentist, patient, and

form of conventional alginate, elastomeric, or digital

ceramist to evaluate the esthetic, phonetic, and func-

impressions accompanied by clinical photographs and

tional outcome, which will be identical to the planned

videos if necessary. One of the major considerations of

definitive restorations. 17-19

a ceramist should be to turn this mock-up into a wax-

If any alterations or changes are needed, they are

up following the exact guidelines that were provided

done at this stage to make sure the patient is com-

(Fig 6).

pletely satisfied with the final outcome. Even if no

In the past, a precise silicone index would be fabri-

changes are needed, it may even be very helpful not

cated from this wax-up, which in turn would be used

to start the treatment until the patient accepts this out-

for the fabrication of the provisional restorations (ie,

come instead of hoping the ceramist can create mira-

veneers, crowns, or acrylic shells). The provisionals

cles in the lab on a design the patient disliked from the

would allow the patient to "test drive" the esthet-

beginning (Figs 7 and 8).

ics, phonetics, and function of the new design. The

problem is that occasionally the patient will be dis-

Step 2: Tooth preparations through the APT

pleased with one or more factors (esthetic, phonetic,

Because it ensures and mimics the planned final out-

or functional) after the dentist has completed the tooth

come and represents the planned final contours of the

preparation (mostly guesswork) and the impression

actual restorations, the major advantage of using the

making. To avoid this problem, the authors conceived

APT is that the dentist can prepare the teeth directly

the idea of using these provisionals in two additional

and very precisely through it. 2 The facial thickness

clinical steps, not only for the provisionals to be made

of the APT and the use of depth cutters (the depth

but even before the treatment planning is completed.

of which will depend on the color changes that are

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GORE ET AL
Figs 7a and 7b A silicone index is
fabricated from the wax-up, and the
inside is filled with flowable self-cure
composite resin (DMG Luxatemp Star,
Hamburg, Germany), to be placed in
the mouth as an APT.

7a

8b

1 8c

18d

Fig 8a The thin shell and the APT in the patient's mouth before polymerization. Note that as yet there have been no injections or tooth preparations carried out.
Fig 8b If necessary, the APT can easily be removed from the mouth since it has not been bonded to the teeth. The additive
design in this case means that preparations will be less invasive.
Figs 8c and 8d The patient with the new APT. Since no anesthesia was used, it is easy to evaluate the esthetic integration
of the new smile design and the patient's facial features.

planned) will dictate the amount of facial reduction

ing the ultimate esthetic dental approach should never

that is needed. With this technique, the dentist will

forget that a critical factor concerning the nature of ce-

avoid any unnecessary loss of enamel and dentin as-

ramic restorations is that they cannot be thinned down

sociated with excessive tooth preparation and be able

or shortened without impacting the outer surface, in-

to perform the ideal preparation depth and volume

cisal edge, or general esthetics of the restoration (Figs

for the intended restoration production. Those seek-

9 to 11).

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Figs 9a to 9h Preparation of the teeth through the APT.

9a

9b

90

9c

1 9e

9h
Fig 9a APT over the untouched tooth surfaces.
Fig 9b The depth cutter is used through the APT.
Fig 9c The thickness of the depth cutter is indicated by the color markings, which will be directly related to the thickness of
the planned PLVs.
Fig 9d Vertical incisal edge depths are created for the butt joint incisal design. The horizontal depths were marked with a
pencil to orient the exact depth for the final facial preparation after the APT is removed.
Fig 9e Partially removed APT from the left side of the incisors demonstrates the minimally invasive approach. Note that
even though a 2-mm depth was created vertically through the APT's incisal edges, there are no preparation marks on the
teeth.
Fig 9f When the entire APT is removed, the areas that need further preparation are easily detected. The pencil markings
will guide the dentist in the minimally invasive facial preparation.
Fig 9g Facial tooth reduction should be continued only until the pencil marks disappear, indicating that the depth needed
for the porcelain thickness has been reached.
Fig 9h Facial and incisal preparation are roughly completed.

GUREL ET AL

10b

11a

11c

11d

Figs 10a and 10b Due to the incisopalatal attrition, the preparation borders need to be extended just beyond these areas.
Figs 11 a and 11 b Invested and pressed e.max (Ivoclar Vivadent, Schaan, Liechtenstein) cores for the monolithic

application.

Fig 1 1 c Finished pressed monolithic veneers (e.max LT Al). Note the supragingival margin location, making margins almost
invisible from a speaking distance even with lips retracted.
Figs 11d to 1 1 f Integration with the lips.

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11g

11h

Fig 11g Close-up view. Ceramist: Hilal Kuday, Istanbul, Turkey.

Fig 11 h Postoperative smiling patient.

ENTERING THE DIGITAL ERA

We can all take advantage of today's high-tech tools in

a conventional impression, this mock-up is then sent

to the laboratory via digital scanning together with the

our daily esthetic treatments. Digital impression mak-

original digital impression of the patient's preoperative

situation.

ing (in place of conventional elastomeric impressions)

On the other side of the computerwhether that

and CAM techniques are now widely available. Yet we

means next door or in another city or even continent

still need to create our smile design in the patient's

the ceramist receives the virtual data in a matter of

mouth via mock-ups, laboratory wax-ups, and the APT

minutes via the Internet. This eliminates all the prob-

for an exacting final outcome and tooth preparation

lems of transporting the silicone impressions, stone

guide. With the restoration of six teeth, we can com-

casts, and facebow transfers, which under normal cir-

pletely plan and create a new smile design (Figs '12 to

17). 21

cumstances would take at least a day if not more.

High-Tech Digital Dentistry

Three-Dimensional Printing
In today's high-tech world, we are not only able to

Following basic esthetic principles, we start designing

email 3D images, we also have access to 3D printing

the case in the patient's mouth with the mock-up, which

of the virtual images that we have emailed. Thus, the

already creates a very positive change in the patient's

digital impressions of the patient's existing teeth and

facial appearance. One of the most challenging tasks

the mock-up can be printed in 3D in the ceramist's vi-

in esthetic rehabilitation is establishing a harmonious

distribution of tooth shapes, sizes, and proportions.

cinity, as if the actual stone casts are sent to or poured

by him.

Maxillary anterior teeth are considered the key ele-

The associated sharing of stereolithography (STL)

ments in a pleasant smile. Some studies have shown

files creates an instant collaboration between the den-

differences in the widths, lengths, and width-length

tist and laboratory. STL is an interchange file format

ratios of maxillary anterior teeth. 21 Instead of making

used for rapid prototyping technology to produce

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11 3

12

115

14

16

Figs 12 and 13 The patient exhibits short maxillary

incisors and crowded dentition in both arches.

Fig 14 Orthodontic treatment was carried out for

9 months to align the teeth and move them to their
ideal position.
Fig 15 After orthodontic treatment, the situation is
re-evaluated for the PLV restorations.

Fig 16 Before the mock-up, the intended outcome is

double-checked with the digital smile design concept.
Fig 17 The mock-up in the patient's mouth, defining
the final length and facial contours of the intended
PLVs.
17

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118c
Fig 18a The mock-up design is transferred to the laboratory as virtual data in a matter of minutes via the Internet.
The ceramist can print this in a 3D printer to obtain the same mock-up model in real sizesimportant especially if a
cutback/layering technique is to be used.
Figs 18b and 18c The wax-up is more refined by using the dimensions of the mock-up as a reference.

3D parts. It allows CAD software to communicate to

die assembly, margin trimming, and articulation. How-

the additive manufacturing systems, much like a PDF

ever, the disadvantage of these 3D printers, for now, is

does in 2D printing. These systems allow the user to

their price tag, which can range from $10,000 to more

transmit the data file via email in an STL format for

than $100,000.

fabrication of accurate, articulated CNC 5-axis milled

Once the 3D printing is completed, the ceramist

or stereolithographic (SLA) plastic polymer models for

can easily start to build the wax-up using conventional

fabrication of dental restorations.

techniques (Figs 18a to 18c), paying close attention to

The advantages of 3D printing are obvious: no need

all the details such as tooth morphology and texture,

for mixing and pouring of dental stone into the impres-

and then either ship or email it (through 3D printing)

sions, and no bubbles or inaccuracies in the stone cast.

to the dentist.

Also, savings are realized by the reduced amount of

The wax-up needs to be transferred to the mouth

packaging needed and its associated shipping costs.

so that the APT can be verified by the dentist and the

The dentist is relieved of the tasks of model base and

patient. Because this wax-up is so similar to the first

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120

Fig 19 APT, which is an exact copy of the wax-up, is produced and placed over the unprepared teeth
before the patient is anesthetized. This is the best time to evaluate all aspects of the smile.

Fig 20 Patient smile prior to preparation of the teeth: pretreatment, mock-up, after wax-up and APT.
Fig 21 Final preparations through the APT. Note the minimal invasiveness of the prepared incisors,
where only the finishing configuration is more pronounced. The canines were kept prep-less.

mock-up previously verified by the patient, esthetic

will be aware of the subtle changes in 3D. A major

problems rarely arise. However, if the patient or the

advantage of using the APT is to ensure that the final

dentist is not happy with this outcome, simple altera-

outcome is accepted by both the dentist and the pa-

tions can be made until both are satisfied with the

tient (Figs 19 and 20).

result. This will require rescanning so that the ceramist

88

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Anterior Esthetics with APT: Are CAD-CAM Systems Ready for the High-End Anterior Esthetics Challenge?
Fig 22 Digital impression is made of the prepared teeth
from second premolar to second premolar with the new
Omnicam camera.

Tooth preparations through the APT

sions, and for clinicians it eliminates one of the most

The teeth can be prepared very precisely through the

tedious and error-prone experiences of the dental

APT since it represents the final contours of the actual

visit. Digital scanning results in lower overall expens-

restorations. The exact facial thickness can be verified

es for the dentist due to a more efficient workflow,

with the help of a silicone index. The facial thickness

elimination of the need for remakes, and less material

of the APT and the use of depth cutters through it

usage. With intraoral digital impressions, there is no

will dictate the necessary facial reduction. In this way,

need for an impression tray, tray adhesives, alginate,

the dentist will avoid the unnecessary loss of enamel

elastomeric impression materials, impression material

and even dentin associated with uncontrolled exces-

disinfection, or occlusal registration material. 27 They

sive tooth preparation and will be able to produce the

also eliminate the need for a staff member to secure

ideal preparation depth and volume for the restora-

the tray in position, time lost in waiting for materials to

tion production. The use of the APT is not limited to

set, and the additional lab and clinical steps required

preserving and exacting the final facial volume; it is

when sectional impressions are being used to register

also used to determine the exact incisal length and

a full arch. Digital impressions do not require the clini-

the amount of reduction that is necesarry at the incisal

cian to wait for an impression cast in dental stone to

edge. Reduction during the preparation should be car-

set; instead, an instant 3D replica is available as soon

ried out through the APT to ensure the exact prepared

as the recording is completed.

incisal edge position (Fig 21).

Currently there are several proven systems on the

After the teeth are prepared and the surrounding

market offering intraoral digital impression capabilities,

gingiva is stable and healthy, the impression can be

in which the virtual and actual worlds are being com-

made either by traditional means or digitally. The digi-

bined (see Fig 1): Lava Chairside Oral Scanner COS (3M

tal impression technologies currently available to the

ESPE, St Paul, Minnesota, USA), iTero digital scanner

dentist are satisfactory provided the exact conditions

(Align Technology, formerly Cadent, San Jose, California,

needed for traditional elastomeric impression making

USA), CEREC (Sirona, Bensheim, Germany), and E4D

are provided (ie, healthy nonbleeding supporting tis-

Dentist (D4D Technologies, Richardson, Texas, USA).

sues, moisture control, retraction cords if necessary,

The CEREC system, with its Omnicam, for instance,

etc). Under these ideal circumstances, the digital im-

offers the dentist digital scanning of the anterior seg-

pression making captures the visible tooth and tissue

ment from second premolar to second premolar in less

in detail, matching or even surpassing the capabilities

than 30 seconds, in full color and with no need to use

of elastomeric impression materials. 22-26

a powder. The same procedure and timing can be applied to the opposing arch as well, and then the occlusion is registered digitally (Fig 22).

Advantages of Digital Impression Making

A virtual impression of the prepared teeth is emailed

to the lab. Meanwhile, the ceramist scans the wax-up

For patients, digital impression making avoids what of-

model (already approved by the patient in the form

ten turns into the taking of multiple unpleasant impres-

of an APT) and superimposes the two on top of each

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GORR. ET AL.

123b
Fig 23a The image is immediately sent via the Internet to
the laboratory, no matter where in the world it is located.
Fig 23b The wax-up, which is the foundation of the APT, is
also digitally scanned either chairside or in the laboratory
so every detail related to the final esthetic design is copied.
Fig 23c The two imagesthe prepared teeth and the APT
(wax-up)are superimposed with special software. This will
define the exact CAM procedure for the PLVs made out of
e.max CAD ingots.
Fig 24a The same procedure is animated by the Keynote
software.
Fig 24b Bonded CAD/CAM PLVs in the patient's mouth.
Note the minimal cutback on the central incisor veneers,
which are layered with feldspathic porcelain; monolithic
CAD PLVs on the lateral incisors and on the prep-less
canines.
Fig 25a Close-up intraoral and full-face views of definitive
restorations. Ceramist: Adriano Shayder, Sao Paulo, Brazil.
Fig 25b Pre- and postoperative smiles.

other. As simple as that, the restorations are ready to

High-strength ceramics feature substantial flexural

be digitally milled from one of several choices of ma-

strength and fracture toughness compared to the old

terials (Fig 23).

esthetic ceramic materials. IPS e.max CAD (Ivoclar Vivadent, Schaan, Liechtenstein) was introduced in 2006

CAM procedure

as a lithium-disilicate CAD/CAM material with flexural

The materials to choose from include esthetic and

strength (360 MPa) two to three times that of feld-

high-strength ceramics, composite resins for both pro-

spathic ceramic materials, which is etched and adhe-

visional and definitive restorations, and nanoceramics

sively bonded to the tooth (Figs 24 and 25). 28-3

(Lava Ultimate, 3M ESPE) that offer ease of handling

and a glossy surface finish.

Lithium disilicate for use as a monolithic restoration

in chairside CAD/CAM systems or as a core under feldspathic porcelain is available in block form in nine AD
shades, two translucencies, and four bleach shades.

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OPEL ET Al

EXPECTATIONS FOR THE NEAR

FUTURE

The software is excellent for inlays, onlays, and full

crowns in the posterior zone (premolar or molar site).
Although it offers advantages in the anterior zone,

When attempting to deliver monolithic crowns or ve-

use of the Biogeneric software is limited to designing

neers specifically in the anterior zone, the challenge

a single central or lateral incisor in situations where the

to emulate nature and establish oral harmony is highly

contralateral tooth is intact. Its design capabilities are

complex, particularly if a new smile design is being es-

inadequate in situations where a contralateral tooth is

tablished. Knowledge of the interplay of shape, func-

missing or unesthetic, especially if the aim is the chair-

tion, and surface texture is the basis for esthetically

side fabrication of the monolithic crowns or veneers.

appealing restorations. Surface texture affects the size

perception, shape, and position of the teeth, and yet
with the current digital CAD/CAM technologies, each
of these factors still depends on the clinician's and ce-

Anterior Single Tooth Restorations

ramist's expertise and in-depth knowledge of shape,

The CAD-CAM systems can be easily modified with

function, and surface texture of the teeth.

a library of different tooth morphologies, shapes, and

Although nearly all CAD software programs have

especially surface textures, including different vertical

integrated case management/tracking and design

and horizontal axes, that can be designed and config-

systems, unfortunately they are not yet equipped to

ured in their 3D forms. These new software programs,

create new smile designs and tooth shapes for the es-

with their very user-friendly and simple-to-deliver de-

thetic zone that look real. The options for the dentist/

signs, enable the dentist or ceramist to simply copy

ceramist are either to copy the adjacent teeth (which

and paste a 3D tooth design (changing their length-

may be adequate for single tooth replacements) or to

width ratio and sagittal positioning as necessary) over

possess the knowledge and skills necessary to design

the digitally scanned, nonprepared teeth to be re-

the restorations yourself.

stored for use as an actual esthetic test drive such as

For now, the high quality of the final esthetic results

of CAD/CAM machining alone for the anterior maxilla

an APT, or on the prepared tooth for the final monolithic CAM procedures.

is not quite high enough, especially when milling and

finishing of the monolithic restoration is completed
chairside, because of the limitations of the existing
software programs. Anterior teeth that are initially ma-

Multiple Anterior Tooth Restorations

chined, either with a chairside or laboratory CAD/CAM

Creating the new smile design in the anterior region

system, greatly benefit from the attention of skilled

with multiple restorations is one of the most challeng-

laboratory ceramists who can perform an additional

ing tasks in esthetic dentistry, whether it is performed

layering step. The monolithic veneers or crowns require

manually in the patient's mouth (ie, mock-up, wax-up,

either the dentist's or ceramist's artistic and esthetic

and APT) or digitally on a computer. Recently, two ma-

touches.

jor concepts were introduced to the world of esthetic

One of the advanced features available to dentists

today is CEREC Biogeneric software (Sirona), which

dentistry: the digital smile design (DSD) conceptm"

and visagism. 3334

takes the patient's intact tooth structure into account

The DSD concept is based on enhanced visual com-

and identifies the exact morphology of the missing

munication in daily treatment planning, better integra-

tooth structure using algorithms based on natural hu-

tion of the interdisciplinary team, and improved inter-

man tooth morphologies. The program collects exten-

action with the patient.

sive optic measurements of the preparation site and

Photographic and video facial esthetic analyses of

adjacent teeth, analyzing the patient's natural denti-

the patient are performed to understand the relation-

tion to create a crown proposal customized for the

ship of the teeth, gums, lips, and face in motion. With

individual patient. Measurements include mesial and

the use of a simple software program designed for

distal neighboring teeth as well as the opposing arch

slide presentations (Keynote for Mac or Powerpoint

dentition for the proper form, function, and occlusion.

for PC), these images are then manipulated to create

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Anterior Esthetics with APT: Are CAD-CAM Systems Ready for the High-End Anterior Esthetics Challenge?
the digital smile design.The DSD is an attractive pre-

with the strength and surface finish of ceramics. Two

sentation of the treatment plan that can be shared with

types of composite resin blocks are available. One

other specialists through the Internet and shown to the

brand is designed for final restorations with higher fill-

patient. When combined with the APT, the DSD can

er ratios employing new filler strategies" and for per-

be transformed into something that can be tested and

manent indirect composite veneers. Lava Ultimate Re-

approved by the patient before the treatment itself

begins. 31," Dedicated imaging software was recently

storative is a nanoceramic material available in eight

introduced (Dental Magic; dentalmaster.net ) that fur-

both CEREC AC and E4D chairside CAD/CAM system s."-43

ther facilitates the simulation/imaging of a new enhanced smile design.

shades in both low- and high-translucency forms for

The other marketed composite resin blocks (Vita

With the visagism concept, clinicians can design a

CAD-Temp, Vident; Telio CAD, Ivoclar Vivadent; Para-

smile that even further blends the patient's physical

digm MZ100, 3M ESPE), which are designed for long-

appearance, personality, and desires and translates

term provisional restorations, 44,45 also have the advan-

them into natural tooth shapes in psychodentofacial

tage of being able to be rapidly fabricated, adjusted,

harmony. When observing maxillary anterior teeth, a

and polished chairside. Within the parameters of the

number of reference lines should be considered, such

visagism concept, these composite resin blocks can

as those that unite the gingival zeniths, incisal embra-

easily be milled chairside in advance (based on a se-

sures, gingival papillae, and incisal plane. These lines

lection from a 3D digital library), tried in the patient's

are archetypal symbols, which means specific varia-

mouth, and positioned correctly in 3D. Upon accep-

tions in their composition will arouse different emo-

tance by the patient, the new design is digitally re-

tions in the observer. 5,33-36

corded and then the teeth are prepared through the

Clinicians must understand the emotional message

new APTs. Next, the prepared teeth are digitally re-

behind any smile design they create and should dis-

corded, and a virtual model of the prepared teeth is

cuss this aspect with the patient before treatment. Ver-

created. Superimposed over this virtual model will be

tical, horizontal, inclined, straight, and curved lines in-

the CAM design used to mill the earlier composites.

teract in infinite ways to create the diversity of natural

Monolithic PLVs or crowns can then be milled out of a

tooth shapes. These lines contain their own power of

wide array of porcelain blocks.

expression and emotional significance. If this concept

were applied to the new upgraded software programs,
which could automatically add the 3D value to the new
smile design, it would be a significant improvement.

Advantages of Monolithic PLVs or Crowns

The dentist could then easily select the tooth forms,

Monolithic restorations created using a chairside

or even a combination of different tooth shapes," from

CAD/CAM system are fabricated from a single homo-

a 3D digital library and place them over the digital im-

geneous material rather than a bilayered restoration

pression of the existing dentition as an APT. In this way,

consisting of a coping base and a veneer layer. The

he or she could avoid the learning curve of reshap-

industrial material fabrication process provides a ho-

ing the tooth form and changing the texture using the

mogeneous, dense material without porosity or voids,

complex digital tools to lengthen, smooth, or add vol-

which maximizes the material's physical properties. 4',"

ume, as proposed by the existing software programs.

If, in the anterior esthetic zone, the tooth morphology, shape, and especially surface texture can be selected using the anticipated new upgraded softwares,

Nanoceramics: Composites

monolithic esthetic restorations can then be produced

chairside by dentists of varying skill levels in a single

Manufacturers have recently introduced composite res-

appointment requiring only a single injection to anes-

in blocks made of nanoceramic materials for milling

thesize the patient both for the tooth preparation and

crowns and veneers. These materials offer the benefits

the bonding of the veneers or crowns.

of easy handling similar to composite resins combined

DDT 2013

93

GUREL ET AL

Need for Replacement of the Feldspathic

Porcelain
Restorations that would satisfy the requirements for
areas that need minimal- to zero-preparation veneers
(or mini or sectional veneers) would continue to pose
a challenge for dental CAM processes because of the
paper-thin nature typically required of the restorations
that replace, for example, an incisal corner, until further improvements are made on the material side of
the technology.

CONCLUSION
The CAM machines are now precise enough to mill
every detail within micrometers, such as line angles
and characteristics of form (and texture to a certain
extent). Upgrades to the new software programs will
allow clinicians to become involved in analyzing data
and programming the machines about what to do,
and chairside to create monolithic veneers or crown
designs without the need for extensive lab work.
It appears that the dental CAD/CAM technologies
are undergoing promising improvements limited only
by the visions and imaginations of the dentists, ceramists, dental community, and the technical breakthroughs of the engineers in charge. Innovations will
continue to explode endlessly into the future.
Nevertheless, databases will never completely replace
the human factor. Machines can perform very delicate
tasks and make proposals based on information, but a
skilled person is ultimately needed in the decisionmaking procedures and to perform final touchups to
the CAD/CAM-produced restorations.

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