Continuing Education

Volume 33 No. 10 Page 102

Treating Discolored
Anterior Teeth:
Ingot Selection and Cementation Protocol
for Lithium Disilicate Restorations
Authored by Arthur R. Volker, DDS, MSEd; Paul A. Springs, DMD; and
Steven Romanzi, CDT
Upon successful completion of this CE activity 2 CE credit hours will be awarded

Opinions expressed by CE authors are their own and may not reflect those of Dentistry Today. Mention of
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Continuing Education

Treating Discolored
Anterior Teeth:

to bridging the gap between technician and dentist and is

focused on bringing laboratory education to the forefront of his
business. He can be reached via e-mail at the address
alldent85@gmail.com.

Ingot Selection and Cementation Protocol

for Lithium Disilicate Restorations
Effective Date: 10/1/2014

Disclosure: Mr. Romanzi reports no disclosures.

Expiration Date: 10/1/2017

INTRODUCTION
Restoration of the maxillary central incisors, especially when
one is severely discolored, can be one of the most difficult
challenges a clinician faces. The need to create visual
harmony between the 2 maxillary centrals often dictates a
more invasive approach than would otherwise be necessary.
Historically, the only option available was to crown both
centrals, even when the nondiscolored tooth was not in need of
a full-coverage restoration. With the advent of materials that
allow bonding to glass ceramics, preparation of the
nondiscolored tooth can be done more conservatively. The
pairing of an opacious PFM or all-ceramic metal oxide crown on
the discolored tooth, with a feldspathic porcelain veneer on the
other central, has been a common solution to this problem.
While this approach was less invasive than what was
previously employed, use of 2 dissimilar materials on the
central incisors can result in an optical disharmony. The
case illustrated in Figure 1 demonstrates such a situation.
There is a difference in color saturation (chroma) and
brightness (value) between the PFM crown on tooth No. 8
and the feldspathic porcelain veneer on tooth No. 9.
Although both restorations are VITA shade A2, their
appearances differ due to the variation in light reflected by
the underlying structures.
Though there are many all-ceramic material choices
available, favorable physical and aesthetic properties make
glass-based lithium disilicate an excellent material for
anterior restorations.1-3 This material currently has more
options available for shade as well as light transmittance
(translucency/opacity) than any other available ceramic
system. There are currently 47 ingot selections available for
the e.max Press system (Ivoclar Vivadent).4 The selection of
an appropriately opacious ingot will allow for the masking of
a discolored tooth and can achieve optical uniformity
between multiple teeth of varying colorations.
The following case will demonstrate proper ingot selection,
based on the desired final shade and preparation design, as

ABOUT THE AUTHORS

Dr. Volker graduated from the Columbia
University School of Dental and Oral
Surgery. He is the chairman of the New
Dentist Committee and a member of the
Continuing Education Committee for the
New York State AGD. Additionally, he is a
clinical attending at the Coler-Goldwater Specialty Hospital
and Nursing Facility on Roosevelt Island, and is in private
practice in New York. He has published articles and lectures
on such topics as cosmetic dentistry, minimally invasive
dentistry, dental materials, and implants. He can be reached
via e-mail at volkerdds@gmail.com.
Disclosure: Dr. Volker reports on disclosures.
Dr. Springs graduated from New Jersey
Dental School, formerly the University of
Medicine and Dentistry of New Jersey. A
former student president of the New
Jersey AGD, he is currently a resident
member of the New York AGD New
Dentist Committee, and a general practice resident at
Coler-Goldwater Specialty Hospital and Nursing Facility
on Roosevelt Island. He can be reached via e-mail at
paul.a.springs@gmail.com.
Disclosure: Dr. Springs reports no disclosures.
Mr. Romanzi has more than 33 years of
experience as a certified dental lab
technician. The owner of All Dent
Ceramic Studios, a full-service dental
laboratory and educational center
located in Glen Cove, NY, he is dedicated
1

Continuing Education

Treating Discolored Anterior Teeth: Ingot Selection and Cementation Protocol for Lithium Disilicate Restorations
well as the details of an adhesive
cementation protocol. Advantages
of bonding glass ceramics using
resin cements include additional
optical flexibility for the clinician and
the demonstrated reliability of their
high bond strengths.5 However,
additional considerations related to
cement selection must be weighed
by the judicious clinician, and will
be discussed in conjunction with
this case as well.

Figures 1a and 1b. Color saturation (chroma) and brightness (value) differences observed when 2
dissimilar materials are used.

CASE REPORT
Findings
A 46-year-old female with a
noncontributory medical history
presented with a chief complaint
of, I dont like the look of my front
teeth. Examination revealed Figures 2a and 2b. Initial presentation. Patient was concerned with the appearance of her anterior teeth.
either fractured or failing restorations of teeth Nos. 7, 9, and
10. Tooth No. 8 had a ceramo-metal crown with an open
facial margin as well as an incisal edge extending 1.0 to 1.5
Figure 3. Final tooth
preparations. Note
mm beyond that of No. 9 (Figure 2).
the discolored stump
Periodontal evaluation revealed probing depths of 1.0 to
of tooth No. 8.
3.0 mm, with minimal bleeding upon probing. Additionally,
the gingival zeniths of the central incisors were noted to be
1.0 to 2.0 mm apical to those of the lateral incisors.
Figure 4. Grayscale
photo of stump and
shade selection. The
use of 3 shade tabs
allows the ceramist
to more easily
compare the relative
shades.

Clinical Protocol
The PFM crown on tooth No. 8 was removed. A dark stump,
with an intact cast metal post, was noted. Prior restorations
and any decay were removed from teeth Nos. 7, 9, and 10.
These teeth were then prepared for veneers or three quarter
crowns, with no preparation of their lingual surfaces. Final
impressions were taken with a vinyl polysiloxane impression
material (Aquasil [DENTSPLY Caulk]). Figure 3 shows the
final preparations. A detailed prescription, along with
preoperative and shade photos, were sent to the dental
laboratory.
Figure 4 demonstrates a grayscale photograph provided
to communicate the brightness (value) of the desired
restorations to the laboratory team, as well as of the

prepared teeth. The use of black and white photography has

been shown to be a reliable way to accurately match tooth
shades that is especially valuable when evaluating and
matching value.6 The teeth were then temporized with a bisacryl provisional material (Integrity [DENTSPLY Caulk]).
A medium opacity (MO) ingot was used to fabricate
all of the restorations. To create a polychromatic
appearance to optimize aesthetics, the ceramist cut back
the incisal edges (Figure 5), then microlayered them using
2

Continuing Education

Treating Discolored Anterior Teeth: Ingot Selection and Cementation Protocol for Lithium Disilicate Restorations
a fluoroapatite ceramic (e.max Ceram [Ivoclar
Vivadent]). The final lithium disilicate
restorations were then hydrofluoric acid
etched (per manufacturers directions) on their
intaglio surfaces to optimize the cement-toceramic adhesive bond strength (Figure 6).
On the day of cementation, the restorations
were tried in with both opaque and transparent
try-in pastes (Multilink Automix Try-in Paste
[Ivoclar Vivadent]) to observe the effects that the
different cements would have on the
appearance of the restorations. No influence
from either paste was noted, and no show
through of the body of tooth No. 8 was evident,
indicating that the dark stump and metal post
had been satisfactorily masked. The teeth were
then cleaned with medium-grit plain pumice. The
try-in paste was cleaned off the restorations, and
then they were placed in an ultrasonic with
distilled water, as per the protocol of Martins et
al.7 The restorations were dried, and a thin layer
of universal primer (Monobond Plus [Ivoclar
Vivadent]) was painted onto the intaglio surfaces
(Figure 7), allowed to set for 60 seconds, then
air-dried.
Restorations Nos. 7, 9, and 10 were primed
for cementation via preparation with a self-etch,
self-cure, bonding agent (Multilink A and B
[Ivoclar Vivadent]); this was done before dualcure resin cement (Multilink Automix Adhesive
Cement [Ivoclar Vivadent]) was used to
adhesively lute the restorations. Tooth No. 8
received a slightly altered protocol. Only the
remaining tooth structure was prepared with the
Multilink A and B (Figure 8), then a layer of the
universal primer (Monobond Plus) was coated
on the metal post (allowed to set for 60
seconds, and then air-dried) (Figure 9). Finally,
the crowns were filled with the dual-cure resin
cement (Multilink Universal Adhesive Cement)
and seated into place (Figure 10).
Figure 11 demonstrates the immediate
postoperative view. Figure 12 is a grayscale
photo of the final result 10 days later, demon-

Figure 5. Monolithic veneer made from a

medium opacity ingot, undergoing an incisal
cutback (shown here) and ceramic layering
(e.max Ceram [Ivoclar Vivadent]) procedure
for optimal polychromatic aesthetics.

Figure 6. Completed restorations that have

been pre-etched by the laboratory team.
Note the frosty appearance of their intaglios
after etching.

Figure 7. A universal primer (Monobond

Plus [Ivoclar Vivadent]) was applied into the
intaglio of the restorations, left in place for
60 seconds, then air-dried.

Figure 8. Placement of a bonding agent

(Multilink A and B [Ivoclar Vivadent]) on the
tooth structure.

Figure 9. Applying the universal primer

(Monobond Plus) onto the metal post of
tooth No. 8.

Figure 10. The restorations, including the

crown on tooth No. 8 shown here, were
seated with dual-cure resin cement
(Multilink Universal Adhesive Cement
[Ivoclar Vivadent]).

Figure 11. Immediate postoperative photo.

Figure 12. A 10-day postoperative

grayscale view, demonstrating not only
improved papillary fill, but also uniformity of
value (relative darkness/brightness) with the
lithium disilicate (IPS e.max Press [Ivoclar
Vivadent]) restorations.

Continuing Education

Treating Discolored Anterior Teeth: Ingot Selection and Cementation Protocol for Lithium Disilicate Restorations
strating not only improved papillary fill, but also a uniform
value among all the restorations.

(MO) ingot was that it offered sufficient opacity to block out

the dark stump of No. 8; at the same time, less aggressive
preparations of teeth Nos. 7, 9, and 10 were required. The
uniform final result achieved here would have been
impossible with a less opaque ingot.
Although unrelated to material selection, another
aesthetic compromise in this case requires discussion. As
mentioned previously, the gingival zeniths of the central
incisors were noted to be 1.0 to 2.0 mm apical to those of
the lateral incisors. This created the appearance of shorter
central incisors relative to the laterals, with a minimal
interproximal papilla. In this case, this could have been
corrected via osseous crown lengthening. The patient
opted to forego this procedure as her low lip-line masked
the discrepancy. To compensate, a long contact was
created in the final restorations.
It is evident that the range of opacities available in
todays restorative materials, combined with the proper
products for adhesive cementation, will yield a satisfactory
aesthetic result in many cases while allowing less
aggressive tooth preparation. In cases involving the
restoration of more than one adjacent tooth, many
combinations of indirect materials could block the varying
underlying stump shades. However, the differing optical
properties inherent in the dissimilar materials could cause
inconsistencies in the overall final appearance. Selection of
a suitably opacious material for all involved teeth allows the
clinician to achieve a more ideal optical match.

DISCUSSION
Selection of the restorative material, application of various
principles in tooth preparation, and cement selection and
application, all enabled a good result in the case shown
here. Attention to the color and transmittance of the
restorative material resulted in a consistent appearance
across all of the treated teeth, despite the significant
differences of the underlying tooth structure.
The thinner and/or more translucent a restoration is, the
greater the impact the cement shade can have on the final
result.8,9 Conversely, cement color becomes less critical
with a decreased ability to influence the shade/value
outcome as the thickness and opacity of the restoration
increases.10
In the case shown here, dual-cure resin cement was
selected due to the opacity of the restorations. However, this
seemingly straightforward decision can be complicated
somewhat by additional factors. For example, an inverse
correlation exists between the opacity of an indirect
restoration and the degree of conversion and polymerization
of light-cure resin cement.11 The clinician can take
advantage of this by using dual-cure resin cements under
opaque restorations as was done in this case. However, this
needs to be balanced with complications commonly seen
with dual- or self-cure cements, including lower initial bond
strength and the potential for post-cementation yellowing
throughout time.12,13 This latter complication was not a
salient factor in this case, because of the selection of a
suitably opacious ingot.
One compromise required in this case involved selection
of an opacious ingot for the restorations, even though 3 of the
4 restored teeth had stumps that were close to the final
shade. Had tooth No. 8 not been severely discolored, a more
translucent ingot could have been chosen. This would have
resulted in a better optical interaction between the restoration
and the underlying tooth structure, but the consistent
appearance across all of the teeth would have been
sacrificed. In this case, the advantage of a more opaque

CLOSING COMMENTS
Many options now exist that enable clinicians to go beyond
the traditional emphasis placed on tooth shade, final
restoration shade, and cement color. The ability to control
the translucency or opacity of the material enables more
control over the final aesthetic outcome. This increased
control allows achievement of a more ideal aesthetic result
in a compromised dentition. This case involving the
maxillary central incisors, where bilateral symmetry is of
paramount importance, provides a good illustration of the
more complicated decision-making process that must now
be performed.

Continuing Education

Treating Discolored Anterior Teeth: Ingot Selection and Cementation Protocol for Lithium Disilicate Restorations
8. Chaiyabutr Y, Kois JC, Lebeau D, et al. Effect of
abutment tooth color, cement color, and ceramic
thickness on the resulting optical color of a CAD/CAM
glass-ceramic lithium disilicate-reinforced crown. J
Prosthet Dent. 2011;105:83-90.
9. Niu E, Agustin M, Douglas RD. Color match of
machinable lithium disilicate ceramics: effects of
cement color and thickness. J Prosthet Dent.
2014;111:42-50.
10. Wang F, Takahashi H, Iwasaki N. Translucency of
dental ceramics with different thicknesses. J Prosthet
Dent. 2013;110:14-20.
11. Archegas LR, de Menezes Caldas DB, Rached RN, et
al. Effect of ceramic veneer opacity and exposure time
on the polymerization efficiency of resin cements.
Oper Dent. 2012;37:281-289.
12. Kilinc E, Antonson SA, Hardigan PC, et al. Resin cement
color stability and its influence on the final shade of allceramics. J Dent. 2011;39(suppl 1):e30-e36.
13. Al Ben Ali A, Kang K, Finkelman MD, et al. The effect
of variations in translucency and background on color
differences in CAD/CAM lithium disilicate glass
ceramics. J Prosthodont. 2014;23:213-220.

REFERENCES
1. Guess PC, Zavanelli RA, Silva NR, et al. Monolithic
CAD/CAM lithium disilicate versus veneered Y-TZP
crowns: comparison of failure modes and reliability
after fatigue. Int J Prosthodont. 2010;23:434-442.
2. Della Bona A, Kelly JR. The clinical success of allceramic restorations. J Am Dent Assoc.
2008;139(suppl):8S-13S.
3. Fasbinder DJ, Dennison JB, Heys D, et al. A clinical
evaluation of chairside lithium disilicate CAD/CAM
crowns: a two-year report. J Am Dent Assoc.
2010;141(suppl 2):10S-14S.
4. Smith J. Ingot and block selection for IPS e.max.
ivoclarvivadent.us/update/labs/september2012/ingotand-block-selection.php. Accessed May 16, 2014.
5. Marocho SM, Ozcan M, Amaral R, et al. Effect of resin
cement type on the microtensile bond strength to
lithium disilicate ceramic and dentin using different test
assemblies. J Adhes Dent. 2013;15:361-368.
6. Gmez-Polo C, Gmez-Polo M, Celemin-Viuela A, et
al. Differences between the human eye and the
spectrophotometer in the shade matching of tooth
colour. J Dent. 2013 Oct 16. [Epub ahead of print]
7. Martins ME, Leite FP, Queiroz JR, et al. Does the
ultrasonic cleaning medium affect the adhesion of
resin cement to feldspathic ceramic? J Adhes Dent.
2012;14:507-509.

Continuing Education

Treating Discolored Anterior Teeth: Ingot Selection and Cementation Protocol for Lithium Disilicate Restorations
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1. With the advent of the materials that allow bonding

to glass ceramics, preparation of the nondiscolored
tooth could be done more conservatively.
a. True

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b. False

2. Though there are many all-ceramic material choices

available, favorable characteristics make zirconium
oxide the only choice for anterior restorations.
a. True

b. False

3. The selection of an appropriately opacious lithium

disilicate ingot will allow for the masking of a
discolored tooth and achieve optical uniformity
between multiple teeth of varying colorations.
a. True

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b. False

4. Advantages of bonding glass ceramics using

conventional cements, such as glass ionomers, include
additional optical flexibility for the clinician and the
demonstrated reliability of their high bond strengths.
a. True

b. False

5. The use of black and white photography has been

shown to be a reliable way to accurately match tooth
shade that is especially effective when evaluating
and matching value.
a. True

b. False

6. In this case, after the try-in paste was cleaned off the
restorations, they were placed in an ultrasonic with
distilled water, as per the protocol of Martins et al.

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a. True

b. False

7. Cement color becomes more critical as the thickness

and opacity of the restoration increases.
a. True

This CE activity was not developed in accordance with

AGD PACE or ADA CERP standards.
CEUs for this activity will not be accepted by the AGD
for MAGD/FAGD credit.

b. False

8. An inverse correlation exists between the opacity of

an indirect restoration and the degree of conversion
and polymerization of light-cure resin cement.
a. True

b. False

Continuing Education

Treating Discolored Anterior Teeth: Ingot Selection and Cementation Protocol for Lithium Disilicate Restorations
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