Gurel • Esthetic Dentistry

Fig 1-12a-c (a) Iatrogenic factors may affect the smile. Two porcelain-f used-to-metal restorations exhibit an unesthetic
appearance, (b) They have been replaced by all-ceramic crowns and the remaining teeth bleached, (c) Even though the
asymmetrical gingival levels are not altered, an overall esthetic integration of the crowns into the facial appearance is
achieved through the use of correct placement, texture, color and form. In order further to improve the esthetics, the
inciso-mesial embrasure of tooth #23(11) could have been closed with a restorative material. However, since the
patient has asked to retain his natural-looking smile, it is kept as it is.

able to recognize the presence of a replacement The author's philosophy on natural-appearing

(Fig 1-11). The patient and the observer should
perceive the restorative result as entirely natural. 48
The continuing esthetic evolution has fostered
a growing need for materials and application
techniques that can augmentthe armamentarium
for esthetic design. Some patients may complain
that their new restorations are not "esthetically
pleasing" owing to the fact that their friends or rel•
atives failed to notice their new teeth from "miles
away". The reason for this is that we have suc•
ceeded in achieving esthetic harmony by adher•
ing to the natural morphologic state. Some
patients may go as far as to ask the clinician to
spoil this naturally pleasing smile. Therefore, it is
essential to keep in mind that "esthetic values"
vary not only from nation to nation but from
individual to individual as well. 49 ' 5 0
esthetics is that even if treatment necessitates
drastic changes in the dental composition, it
should not be obvious to the observer that alter•
ations were made but rather the observer should
simply recognize a very positive improvement in
the smile and overall facial appearance (Fig 1-12).
Ceramics
The utilization of porcelain as a restorative mate•
rial began a new era in esthetic dentistry. By
today's standards, the early porcelains were
rather primitive and of low value. Upon recogni•
tion of the potential use of porcelain in esthetic

30

dentistry, various modifications and enhance•
ments were made to render the material applica•
ble for dental restorations. The history of porce•
lain follows a specific direction in approach.51 The
first major improvement in esthetic materials,
especially in the translucency of all porcelain
crowns, was introduced by Vines et al. in 1958. 52
He developed porcelain powders suitable for
vacuum firing or low-pressure air firing. Weinstein
et al. first discovered the bonding of porcelain-to-
gold alloys by means of vacuum firing in the early
1960s.53 In addition to these developments, the
introduction of gap-graded finer powders, that
could be vacuum fired, started a new era in den•
tal esthetics. Owing to the ability to layer and carve
porcelain, clinicians and laboratory technicians
became more aware of the esthetic significance
of light transmission as well as the changes in
refractive indices and reflection from opaque
porcelains.54
In 1965, McLean and Hughes described
sintered alumina that was originally used for the
fabrication of crowns, small fixed partial dentures,
and individual and custom-built pontics for use in
restorative dentistry in the form of prefabricated
profiles.55 Owing to excessive shrinkage, it was
impossible to manufacture custom-made high
alumina copings for porcelain crowns. The first
commercial porcelain was marketed in 1966, and
more than 30 years after its introduction porce•
lain still remains on the market today.51 In 1968,
MacCulloch, who first described the methods
used for making artificial teeth, veneers and
crowns in glass ceramic, utilized this approach. 56
The desired shade modifications, however, were
only possible with surface colorants that had a
tendency to erode after a certain period of time.
Despite its esthetic appearance, porcelain was
prone to fracture and required direct resin bond•
ing with an acid-etch technique.
In the 1970s, colorless metal ceramic crowns
were fabricated with newly improved techniques,
and commercial shoulder porcelains were devel•
oped. They had higher firing temperatures and
increased resistance to pyroplastic flows that
caused minimal distortions when the veneer
porcelains were fired.51 At that time, the goal of
eliminating the gold coping and replacing it with
Ceramics
high-strength ceramic was not yet achieved. In
1976, McLean and Seed developed the first com•
mercially possible foil-reinforced crown system.57
The dental porcelain could be strengthened by
the dispersion of ceramic crystals of high strength
and elastic modulus within the glassy matrix.
McLean and Hughes used this method to devel•
op the first aluminous porcelains for the fabri•
cation of crowns.55 These reinforced porcelains
had strengths of up to 180 MPa - approximately
double that of the more conventional feldspathic
materials. Electroforming and the use of tin oxide
coatings for the attachment of a conventional
metal-bonding porcelain was reported by Rogers
in 1979, and a number of foil systems were mar•
keted in the 1980s.58
Slip casting, or the science of preparing stable
suspensions and fabricating structures, was
accomplished by building a solid layer on the sur•
face of a porous mold where the capillary forces
absorb the liquid. Sadoun refined Count von
Schwerin's slip casting technique 59 in a paper
given at the International Conference on Dental
Ceramics held at Leeds Castle, England in 1989.
These changes produced high-strength coping,
and was marketed under the name of In-Ceram.
It was not a pure ceramic and represented a step
forward in achieving strengths of upto 630 MPa.60
In-Ceram made it possible for the laboratory
technicians to make advancements in the esthet•
ics of anterior crowns, without losing strength.
Undoubtedly, this work deserves a notable place
in the history of dental ceramics.
In 1993,/\nc/ersor? and Oden described a tech•
nique for manufacturing individual all-ceramic
crowns made up of densely sintered high-purity
alumina. 61 However, the color of sintered alumina
may vary according to the firing conditions,
presenting a serious disadvantage. Similarly,
when compared to regular or aluminous dental
porcelains, the sintered alumina is a more difficult
material to control.
At the Dental Institute of the University of
Zurich, Wohlwend developed and marketed a
material for the bonding of porcelain that used
the principle of leucite crystal dispersion. 62 This
material, Empress, consists of leucite crystals that
are only a few microns in size and are produced
31
Gurel • Esthetic Dentistry
by controlled crystallization in a special glass that
contains nucleating agents.
Ceramic materials have now become the main•
stay of esthetic dentistry. Rapid advances in the
quality of ceramics and ceramic technology have
made it possible forthe manufacturers to emulate
nature more effectively than ever before. Despite
the rapid advances in ceramic technology, the ulti•
mate failure or success of a ceramic restoration is
related directly to the expertise of the dentist and
his team of technicians. Ceramic material that is
used for all ceramic restorations is bonded to the
teeth without the support of a metal substructure.
Typically, it is reinforced porcelain, designed to
withstand the forces of occlusion. 63
Porcelain Laminate Veneers
Translucent ceramics were first used for clinical
purposes as early as 1862, and ceramic veneers
were used more frequently in the 1920s and
1930s.64*65 |n 1938, Pincus actually attempted to
use a denture adhesive to bond the veneers to the
teeth,66 but at that time they were too fragile, as
the adhesives available were neither strong nor
durable. 67 In 1955, Buonocore published an
article describing the "acid-etch technique", 6 8
where a micro-chemical "interlock" was achieved
through "acid-etching" the enamel and forming
a resistant bond between the composites and
inorganic enamel. Subsequently, transparent lut•
ing resins replaced the plaque zinc oxyphosphate
cement for ceramic inlays. Without any distur•
bance from an opaque material, light transmis•
sion improved, and esthetically pleasing results
were achieved.69
All-Ceramic versus Porcelain-Fused-to-
Metal Restorations
From the initial introduction of porcelain, the use
of it in porcelain-fused-to-metal (PFM) applica•
tions has achieved the most popularity. Through
the years, this system has proved to be beneficial
32
not only for use in the posterior region but also in
the anterior, where esthetics are an especially
important issue. Even today, there are a consid•
erable number of dentists who are still using
PFMs in the anterior regions to achieve better
esthetics. However, this technique, or the metal
used, impairs the transmission of light.70 If the
gingival tissues are thin, the marginal soft tissues
near the metal collars that have been placed sub•
gingival^ may appear to be dark (Fig 1-13). Since
the ceramic layer is quite thin and opaque, this is
a common occurrence, interfering with the trans•
mission of light through the labial gingival tissues,
owing to the shadows created by the porcelain-
fused-to-metal restorations with labial butt joint
designs. When there is no metal coping, natural
teeth, all-porcelain jackets, and cast glass ceram•
ic crowns allow light transmission. All-ceramic
restorations require the removal of large amounts
of sound dental tissue in order to provide
adequate space for the placement of the jacket
crown of optimal thickness over the prepared
tooth. 70 '71
Until the 1980s, esthetic dentistry was con•
cerned primarily with the close replication of the
tooth structure. In the last two decades, several
modifications of porcelain-fused-to-metal crown
restorations were developed and incorporated
within the all-porcelain systems. 53 ' 72 The im•
proved physical properties of these systems, com•
bined with advancements in adhesive tech•
nology, such as enamel bonding, 6 8 dentin
bonding, 7 3 porcelain etching, and silaniza-
tion 74 - 7 5 facilitated the reproduction of new
prosthodontic treatment modalities.76 Clinicians,
ceramic technicians, manufacturers, and re•
searchers have striven to produce a substitute arti•
ficial enamel, intimately bonded to the dental tis•
sue, for teeth that lack shape, color, or structure,
while attempting to retain the maximum amount
of healthy intact tooth structure and not exceed•
ing a reasonable financial expenditure.77
PLVs
With the recent increase in patients' demands for
esthetic restorations in the anterior as well as