Inside Dentistry

March 2011
Volume 7, Issue 3

Repairing Worn Dentition with Lithium-

Disilicate Glass-Ceramic
This versatile restorative material provides a
predictable approach for achieving esthetics,
function, and patient satisfaction.
By Andre Michel | Hannah A. Lewis, DDS

In an era of highly publicized, media-driven dentistry, patients

often come to the dental office seeking the perfect
“Hollywood” smile.1 Dentists must approach such
procedures cautiously.1 Therefore, dentists and technicians
must openly communicate with their patients and each other
throughout all stages of treatment.3,4 By doing so, a higher
standard of care can be provided and the best in esthetics,
function, and patient satisfaction can be achieved.5

For example, diastemas, discolorations, and other

characteristics of a patient’s dentition may be viewed by a
dentist as defects or unesthetic.2 However, the patient may
desire to keep these traits to maintain their sense of
individualism.2 When proper communication between the
dentist, technician, and patient is not facilitated, the defining
characteristic of the patient may be lost during the
restorative process,2,6 which could lead to patient
dissatisfaction and possibly further restorative work.2

Material selection is also important in any restorative or smile

design case and must be undertaken carefully to provide
satisfactory long-term results for the patient.7 With the variety
of restorative materials available to dentists and technicians
today, dental professionals must be sure that the material
chosen will not only withstand the masticatory forces placed
upon it, but that it is indicated for use in the specific region of
the oral cavity being restored.7 Although proper function is a
necessity, esthetics must be considered as well because
restorations in the anterior and posterior do not always
require the same optical qualities.7

Lithium Disilicate
Lithium-disilicate glass-ceramic contains approximately 70%
by volume needle-like crystals in a glassy matrix.8,9 This
unique crystalline structure enables size, shape, and density
to be controlled, allowing for greater strength and durability.8-
10 With its relatively low refractive index, outstanding optical

properties, such as translucency, are easily achievable and

provide the optimal esthetics required for restoring anterior
teeth.8-10

Currently available in two different processing techniques,

lithium-disilicate glass-ceramic provides dentists a multitude
of options when using it to restore their cases. Fabricated
with a wax hot-press technique, pressable lithium-disilicate
restorations (IPS e.max® Press, Ivoclar Vivadent,
www.ivoclarvivadent.us) demonstrate a flexural strength of
400 MPa.9,11 Milled lithium-disilicate restorations (IPS e.max®
CAD, Ivoclar Vivadent) can be fabricated either in the
laboratory or chairside using CAD/CAM technology and
demonstrate a flexural strength of 360 MPa.9,11 Although all
other material properties are similar, the variation in strength
between the two processing techniques is due to the size
and length of the lithium-disilicate crystals. Furthermore,
because of the increase in strength and the presence of the
glassy matrix, lithium-disilicate restorations can be either
adhesively bonded or conventionally cemented, which
provides dentists even further flexibility.9,12,13

Lithium-disilicate materials exhibit high edge strength, low

viscosity, and superb dimensional stability, allowing pressed
restorations to be finished as thin as 0.3 mm. These qualities
make lithium disilicate ideal for no-preparation and minimal
preparation veneers.10,14,15 In addition to veneers and thin
veneers, pressable lithium disilicate can be used as an
effective treatment option to fabricate anterior three-unit
bridgework up to the second premolar, anterior and posterior
crowns, inlays/onlays, telescopic crowns, and implant
restorations.8 For posterior crowns, lithium disilicate does not
require a layering ceramic when pressed or milled to full
contour because of its monolithic strength of 360 MPa to 400
MPa.

Aside from providing improved function, pressable and CAD

forms of lithium disilicate also allow for characterization to
make the restorations indistinguishable from the patient’s
natural dentition, which is important when patients wish to
maintain their own unique characterizations. Available in a
variety of translucencies, high-translucency (HT) ingots are
ideal for anterior esthetic cases, while ingots with more
opacity are well-suited for cases involving dark teeth and
core build-ups that require masking. To further enhance
esthetics, dentists and technicians may also use either a
cutback-and-stain or stain-and-glaze technique.8,11

Smile Design
In an ideal setting, smile design cases would call for minimal
to no-preparation veneers on teeth with acceptable coloring
using translucent powder-liquid porcelain or pressed glass-
ceramic material to achieve an esthetic result. However, most
clinical situations often involve worn, broken-down, dark
teeth; old or unesthetic restorations; and/or missing teeth. In
these indications, a treatment plan must be developed that
incorporates a combination of different treatment modalities
and materials within the same arch.

When faced with these difficult cases, dentists and

technicians may benefit from using either form of lithium
disilicate. With high strength, proven physical properties,
ease of fabrication, versatility, and predictable results,
lithium-disilicate glass-ceramics provide ideal functional and
esthetic outcomes.9 The following case represents how
lithium-disilicate glass-ceramic restorations (IPS e.max
Press) can be used in a variety of indications to complete a
full smile design case that satisfied the patient’s desire to
maintain the defining characteristics—chiefly the diastemas
—of his smile. Of paramount importance to this process was
communication among the patient, dentist, and laboratory
ceramist.

Case Presentation
A 45-year-old man who was a musician/entertainer
presented to the office with major problems of decay, broken
porcelain-fused-to-metal (PFM) restorations, excessive wear,
and isolated gingivitis (Figure 1). He also had a history of
bruxism and acid reflux that caused secondary decay on the
second molars. Upon further examination, the patient was
found to have a lack of cuspid guidance, over-closed vertical
dimension, uneven gingival architecture, and excessive
incisal wear (Figure 2). However, the patient’s midline and
gingival health were relatively acceptable.

The patient desired to restore his teeth to a more youthful

appearance with a natural shade appropriate for his skin tone
and that would match his unrestored lower anterior dentition.
Although the patient presented with a diastema between the
central incisors, he wished to keep it because he felt it was
part of his professional and personal identity.

Treatment Plan
After discussions with the patient, it was decided that
treatment would include laser recontouring of the gingival
zeniths on teeth Nos. 7 through 10. Full-coverage maxillary
posterior lithium-disilicate restorations (IPS e.max Press)
would be placed on teeth Nos. 2 through 5 and 12 through
15. Additionally, full-coverage mandibular posterior lithium-
disilicate restorations (IPS e.max Press) would be placed on
teeth Nos. 18, 19, and 30. Lithium-disilicate veneers (IPS
e.max Press) were planned for teeth Nos. 6 through 11 while
maintaining the diastema between his central incisors. The
treatment plan also included mandibular anterior
enameloplasty, direct bonding, and whitening. Due to the
lack of solid tooth structure, tooth No. 20 would not be
involved in the restorative treatment, and a dental implant
was planned for the future.

Clinical Protocol
Initially, diagnostic wax-up records were taken, along with
clinical photographs, facebow bite records, polyvinyl siloxane
(PVS) impressions, and a detailed laboratory prescription. To
begin designing the case, length was added to the centrals.
Coming to a compromise with the patient, spatial issues
caused by the diastema were addressed and the teeth were
made less triangular. After the centrals were completed, the
remaining teeth were developed.

Provisional restorations were then created from the

diagnostic wax-up and transferred to the preparations using
a silicone putty matrix (Sil-Tech®, Ivoclar Vivadent) (Figure 3).
The gingival tissues were recontoured using a soft-tissue
laser with the provisional restorations in place. During the
laser gingivectomy, recontouring was left incomplete on
tooth No. 9 because it demonstrated biological width issues
and could not tolerate further laser treatment (Figure 4).

The gingival architecture was idealized with the diagnostic

wax-up and transferred intraorally with temporary material
and a vacuum matrix (Figure 5). Measurements were then
taken with a periodontal probe. It was noted, however, that
the idealized gingival contour for tooth No. 9 would impinge
upon the biological width. Therefore, it was decided that the
laboratory technician would correct the issue in the
laboratory with a partial pontic. To create all other gingival
contours, excess tissue was removed with a soft-tissue laser.

Once recontouring was complete, bite records, a facebow,

clinical photographs, and a detailed shade map were
submitted to the ceramist. This information was essential for
fabricating restorations that would meet the patient’s
expectations in terms of esthetics, particularly maintaining
the natural characteristics of his dentition and matching the
maxillary and mandibular anterior teeth.

Laboratory Protocol
After the ceramist received the necessary case information
from the clinician, the laboratory was ready to create the final
restorations from pressable lithium disilicate (IPS e.max
Press). Wax was first injected through the matrix of the
provisionals onto the master dies. The margins were then
sealed, and form and function were developed in the wax.
The completed wax-ups were then sprued, invested, burned-
out, and pressed using the proper shade of pressable lithium
disilicate (IPS e.max Press). The pressed restorations were
then devested and placed in a dissolving liquid to eliminate
the surface reaction layer. The restorations were then cut
from the sprues, scrutinized against the model of the
provisionals, and ready for cutback and ceramic veneering
powders.

The pressings were fitted to the solid model (Figure 6). It was
determined from the pressing of the restoration for tooth No.
9 and through evaluation of the clinical photographs and
provisionals that gingival symmetry could be achieved with
the contour of the partial pontic design (Figure 7). Once this
was established, the restorations were marked with a red
pencil and underwent a 0.5-mm vertical cutback (Figure 8).
Additionally, the incisal edges of the restorations were
marked with the red pencil and given a 0.5-mm facial taper
(Figure 9 and Figure 10).

Using the red pencil once again, outlines of the material to be

troughed in order to mimic natural translucency were made
on the restorations (Figure 11). Using the matrix, a final
cutback was then completed and the mamelon structures
developed (Figure 12).

To facilitate shading and create restorations that were

indistinguishable from the patient’s natural dentition, internal
stain (I1, IPS e.max, Ivoclar Vivadent) was placed in the
mesial and distal trough, with vanilla, silver, and orange on
the middle lobes (Figure 13). MM Light (IPS e.max) was
placed on the mesial and distal lobes, followed by further
characterizations to the middle lobes with OE4 (IPS e.max)
and Salmon (IPS e.max) (Figure 14). OE1 (IPS e.max) was
then placed in the mesial and distal troughs and in between
the mamelons (Figure 15).

Once the restorations were brought to full contour with TI1

(IPS e.max), they were bisque-baked and ready for final
contouring (Figure 16 and Figure 17). Then, prior to delivery
to the dentist for placement, the lithium-disilicate restorations
were glazed and polished (Figure 18).

Final Seating
After receiving the completed restorations from the
laboratory, the provisionals were removed and the teeth were
polished with flour pumice. All definitive restorations were
then seated with a temporary try-in paste. After margins were
verified, the teeth were re-polished, treated with a
desensitizing agent (Gluma® Desensitizer, Heraeus,
www.heraeus.com), and prepared with multi-purpose
adhesive bonding cement (Multilink® A/B, Ivoclar Vivadent).
The restorations were then re-etched with a hydrofluoric acid
solution and prepared with a universal primer (Monobond,
Ivoclar Vivadent). After all preparation work was complete,
the definitive restorations were cemented in place with self-
curing luting cement (Multilink).

Upon final seating of the definitive restorations, the patient

demonstrated a natural-appearing smile that retained his
personal characteristics, specifically his diastema (Figure 19).
Additionally, gingival symmetry was created, the occlusion
was protected with canine guidance, his vertical dimension
was increased, and the restorations were seamless (Figure
20). Overall, the patient’s expectations for lifelike
characterization and shade were far exceeded by the
restorative treatment.

Conclusion
When patients seek restorative dentistry, they expect to
receive exactly what they desire, even if their esthetic
preferences contradict conventional solutions.2 Although
proper protocol must be followed at all times, including
informing patients of the advantages and disadvantages of
treatment or non-treatment, dentists must still take into
consideration the individual goals of the patient before any
restorative procedures can begin.2 When the dentist,
technician, and, most importantly, the patient openly
communicate through all phases of treatment, the best in
function, esthetics, and standard of care can be provided in
the most comprehensive and conservative manner.3-5

References
1. Ahmad I. Risk management in clinical practice. Part 5.
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12. Dudney TE. Unlock that combination. Dental Products

Report. 2009;43(3):60-62.

13. Fabianelli A, Goracci C, Bertelli E, et al. A clinical trial of

Empress II porcelain inlays luted to vital teeth with a dual-
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Adhes Dent. 2006;8(6):427-431.

14. Ritter RG, Rego NA. Material considerations for using

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Today. 2010:29(5):80-86.

About the Authors

Andre Michel
Private Practice
Dana Point, California
Member, Board of Directors
American Academy of Cosmetic Dentistry

Hannah A. Lewis, DDS

Private Practice
Dana Point, California

Figure 1 Figure 2

Figure 3 Figure 4

Figure 5 Figure 6

Figure 7 Figure 8

Figure 9 Figure 10

Figure 11 Figure 12

Figure 13 Figure 14

Figure 15 Figure 16

Figure 17 Figure 18

Figure 19 Figure 20

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