A METAL-FREE BRIDGE TO THE FUTUREOF OF STUNNING RESTORATIVE

AESTHETICS

The demand for natural-looking metal-free restorations, which closely match the
Patient’s existing dentition, is increasing rapidly. In order to achieve this, Dentists
and Dental Technicians must constantly stay abreast of new materials and
develop techniques which maximize their use.

Heraeus Signum Ceramis

New Signum Ceramis from Heraeus is the first composite specifically developed
to meet the requirements of metal-free restoration work. The material
composition has extremely high fatigue strength, impact resistance and a high E-
modulus.

The unique matrix composite formula allows the technician to achieve

unparalleled aesthetic results, previously only possible with high end ceramics.
This material offers especially long lasting, brilliant colours and abrasion resistant
restorations without the use of metal.

This article highlights the ease of use, excellent functionality and the stunning
aesthetics that are achievable with Heraeus Kulzer’s new Signum Ceramis range
of nano hybrid composites and Dentapreg’s Smart Fibres.

The young patient in this case presented with avulsed upper right central and
lateral teeth, with associated loss of gingival tissue in the adjacent area (Fig.1)
The Dentist consulted Vision Dental Laboratory with a view to achieving:

a. a minimally invasive restoration;

b. materials which, whilst providing sufficient tensile strength, would result

in low wear of the opposing dentition; and

c. natural looking tooth and gingival aesthetics.

It was agreed that these requirements would be well achieved by means of a

Maryland Bridge, constructed from Dentapreg Smart Fibres (for the framework)
and Heraeus Kulzer’s new Signum Ceramis and Signum Matrix composite.

The method employed to construct the Maryland Bridge is explained below:

1. The first step was to construct a diagnostic wax setup using acrylic
denture teeth of a similar size, shape and surface character to that of the
patient’s natural teeth (Fig 1.a). In this particular case, it was necessary to wax
over the acrylic teeth in order to achieve a good anatomical match (shape and
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surface character). Once satisfied with all aspects of the wax diagnostic setup,
the next step was to make a suitable mould / matrix of the setup.

2. Construction of Clear Silicone Matrix / Mould. Bearing in mind that

the composite to be used for this restoration would need to be light-cured, it was
necessary for the matrix to be transparent. Making a clear, bubble-free matrix,
which is well adapted to the diagnostic setup (and without using large amounts of
clear silicone), is not as simple as might be imagined. The method used in this
case was as follows:

a. Apply a thin (3-4mm) first layer of Lab Putty over the diagnostic
setup (Fig. 2), and allow it to set;

b. Apply a suitable Separator (e.g Vaseline) over this first layer of Lab
Putty;

c. Envelope the first layer of Lab Putty and separator with a second,
thicker (+-10mm) layer of Lab Putty (Fig. 3), and allow it to set. This
second layer will provide the necessary rigidity to support the clear
silicone matrix;

d. Once it has set, separate the first layer of lab putty from the thicker,
more rigid second layer (Fig. 4) and discard the first layer. This first
layer will have served its purpose by creating a void space in the
second layer, into which the clear silicone can be injected.

Note: In order to facilitate a sufficiently rigid and accurate

replication of the diagnostic wax setup, the clear silicone to be used
for the matrix should have a Shore-A hardness of at least 65. In this
case, Heraeus Kulzer’s Memosil 2 (Vinyl Polysiloxane) was used.

e. Memosil 2 was then injected into the void space formed by the
removal of the first layer of Lab Putty from the second layer (Fig. 5).
The lab putty matrix containing the clear silicone was pressed over
the diagnostic wax setup (forming a mould / matrix) and the silicone
left to set (Fig. 6).

f. Once the Memosil 2 clear silicone had set, it was separated (Fig 7)
from the Lab Putty Matrix, which – having served its purpose – was
then discarded. The resulting clear silicone matrix produced a
highly accurate, sufficiently rigid mould – through which the
composite could be light cured.

3. Dentapreg Smart Fibre Bridge Framework. The next step was to

construct the Smart Fibre framework over which the composite could be applied.
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Dentapreg produce user friendly “smart fibre” packs for a wide variety of dental
applications, including perio and trauma splinting, post-orthodontic retainers,
bridge frameworks, repair or reinforcement of removable dentures and other
acrylic dental devices, anatomical stress free posts and for strengthening large
composite restorations.

This material is very easy to work with, in that it does not require special cutting
tools or pre-soaking before use. It can simply be removed from its sealed foil
packaging, cut to length, adapted (in this case) to the lingual surfaces of the
abutment teeth on the model (Fig.9) and hardened through light curing.

Signum Matrix Gel composite was then applied to the abutment teeth on the
model; the preformed, hardened fibre strip was then placed over the composite
on abutment teeth and light cured together in order to form the framework for the
Maryland Bridge (Fig. 10).

4. Initial Build-up of Signum Composite (Dentine) over Dentapreg Smart

Fibre Framework. Shade A2 Dentine was selected and the tube placed in
warm water to soften and improve the flowability of the composite. The Dentine
was then manipulated into the clear silicone matrix using rubber tips (Fig. 11). If
so desired at this stage, a number of different Dentine layers can be applied to
match the shade of the patient’s natural teeth and to create a natural-looking
colour gradient in the composite teeth.

Signum insulating gel was then applied, as a separator, to the areas of the model
over which the composite-filled matrix was to be applied.

The clear silicone matrix, filled with layered Dentine composite, was then pressed
onto the model (Fig. 12) and light-cured in line with the manufacturer’s
specifications (Fig. 13).

Once the composite had fully cured, the clear silicone matrix was removed,
revealing an accurate composite replica of the original diagnostic wax setup (Fig.
14).

5. Cutting-back, Layering and Intrinsic Colour Build-up and

Characterisation. Using a diamond cutting disc, the Dentine was then cut
back in order to form mamelons and to create space for the application of
Enamel Matrix Gels (Fig 15).

The next step was to apply some higher-value (lighter) horizontal banding to the
teeth (Fig. 16) and to increase the value of the mamelons (to match the patient’s
natural dentition). This was done using thin layers of Signum Matrix Value
composite (VL 2 and VL 3).
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The chroma (colour) around the cervical of the teeth was increased by lightly
cutting back and applying a wash of yellow- tinted Signum Matrix Opal
Transparent composite (OTA) in this area (Fig. 17).

Light blue- tinted Signum Matrix Opal Transparent composite (OTB) was then
applied to the mesial and distal surfaces of the teeth (Fig 18).

White- tinted Signum Matrix Opal Transparent composite (OT1) and pale orange-
tinted Signum Matrix (OTA) respectively, were applied to create clear incisal tips
with a slight touch of orange. Deeper white Signum Matrix Transparent
composite (OT10) created a white incisal halo, which added to the required
youthful appearance of the teeth.

A reduced overall value was required for the lateral tooth and this was achieved
by applying a small quantity of light coloured Signum Matrix Opal Transparent
composite (OT6).

Finally, clear Matrix Gel and a layer of pale yellow-tinted Signum Matrix Opal
Transparent (OTY) was applied and cured to the buccal surfaces of the teeth to
increase the chroma and replicate the slightly yellow enamel appearance of the
Patient’s natural teeth.

6. Gingival Replication. The loss of bone and gingival tissue in this

case dictated the requirement for accurate matching of the Patient’s gingival
tissue in this case. This was achieved using Heraeus Kulzer’s light cured Cre-
active Gingiva colour-fluid system.

Conclusion. As can be seen from the final photographs (Fig.19 and 20),
an excellent aesthetic result was achieved with relative ease in this case. The
materials used were easy to work with and they provided sound, predictable
results. Both Patient and Dentist were delighted with the final restoration.

For more information on this very special composite for metal free restorations:
Telephone: 01635 30500.

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