Getting Great Esthetics—No Matter What Tools You Use

Beauty, artistry and esthetics cover a lot of territory. If you ask 10 different technicians what makes a case esthetically pleasing, you’re likely to get 10 different answers. To be sure, they will all include the same components, including tooth shape, color, translucence and the like, but the ratios in each technician’s particular recipe will likely differ.

But beyond ascribing which individual constituents are the most important, there are larger forces by which you can be guided.

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Functionality, Fit AND Esthetics?

For many years, esthetic restorations were tough to achieve while still maintaining strength, fit or cost-effectiveness. Happily, that no longer seems to be the case, thanks to better quality materials.

“Twenty-five years ago, I would have said, ‘You can either have it look good or you can have it be strong, but you can’t have both,’” says Dr. David Hornbrook, DDS, clinical director of education at Keating Dental Arts in Irvine, Calif. “Now I would say, the way the materials are, whether it’s multilayer zirconia or lithium disilicate, there’s no reason why we can’t have restorations that are absolutely beautiful and strong. If I look at a porcelain-fused-to-metal crown, which used to be the best esthetic thing we could do, we have materials that’ll look better and are actually stronger than a PFM. When clinicians look at choosing restorative materials, there really should be no question about, ‘Can it look good and can it be strong?’”

“I feel like we finally have the materials available where we aren’t compromising fit or durability to achieve esthetics,” says Matt Roberts, CDT, owner of CMR Dental Lab in Twin Falls, Idaho. “Some of the new, higher strength ceramic materials have very good biocompatibility numbers, and we are seeing super high success rates now, much more than we ever did with porcelain-fused-to-metal restorations.”

While materials are certainly improved, the abilities of the techs working on the cases also matter.

“Long-lasting, well fitting esthetic restorations are certainly obtainable and readily available,” says Bob Cohen, CDT, president of Custom Automated Prosthetics in Stoneham, Mass. “There is a combination of essential elements: Materials, a tech’s technical ability, technical knowledge and discipline are all key. Without these critical elements, there will likely be compromises.”

To get all the features you want out of your restorations takes the best efforts of everyone involved in the case.

“That all starts with the doctor’s office making sure to follow the prep guidelines for the products,” says Alex Thomas, general manager of DAL DT Technologies in Davenport, Iowa. “You can use lower strength products that are going to be more esthetic, as long as the doctor is meeting the guidelines and using the product for the appropriate indications.”

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Instructing doctors is key so they know which materials they can use and how to use them.

“As a laboratory or as a ceramist, I think one of our obligations is to educate our doctors, as well,” Dr. Hornbrook says. “Because what’ll happen is doctors will continue just to write prescriptions for the materials they’re familiar with or they’ve used in the past. We, in the dental laboratory, have the opportunity to have more experience and explore the use of different materials, and we can become great educators for a doctor.”

Looking good is important, but, ultimately, the restorations need to perform properly.

“The functionality of esthetics is really important because something can look good, but if it doesn’t function right, there’s really no point in having it,” says Lien Huynh, CAD/CAM specialist and lab manager at Zirkonzahn. “Esthetics, for me, is what Mother Nature has given you, and in today’s society, a lot of people want that gorgeous, shiny, Hollywood smile, but then everybody’s smile starts looking the same.”

CAD/CAM + Good Techs = Great Esthetics

Ultimately, CAD/CAM is a tool, and the quality of the restoration is in the hands of whoever wields that tool.

“With correct planning and advanced software, dental technicians can easily create high esthetic restorations,” says Tais Clausen, CTO and cofounder of 3Shape. “In most cases, high esthetics are a matter of how the technician uses the available information, such as scan data, photos, etc., and how they combine this with the options related to the materials.”

There seem to be two schools of thought on CAD/CAM. Some favor it, while others prefer to make their cases by hand, employing traditional, analog techniques.

“There’s a huge argument out there over, ‘Is CAD/CAM better? Is it worse? Do we have to do it? Is it a compromise?’ and people have very, very strong opinions,” Roberts says. “I haven’t seen the industry so polarized in many, many years. The truth of the matter is it’s in the hands of the user, not the tools being used. It still requires someone who understands tooth shape and tooth form and how they relate to facial features and how the color of the underlying dentition relates to the color of the final restoration. Through that whole process-whether you are building feldspathic porcelain on foil, refractory or PFM; waxing by hand and pressing lithium disilicate; doing CAD design with zirconia; or milling wax from a CAD design and pressing it with lithium disilicate-all of those can produce very, very high levels of esthetics in the right person’s hands, if you know what you’re doing with the materials and the equipment that you’re working with.”

Step-by-step technique: How to foresee the final esthetic outcome of a restorative case

“The only difference we’re going to see from one machine to the next is the designer,” Dr. Hornbrook adds. “In the past, where it used to be the ceramist or a waxer that would design the particular case, now it’s going to be someone that’s going to be more computer literate and is going through the design process on the computer. I could sit here and I could show you two different restorations that looked exactly the same-same translucency, same esthetics, same strength-and one could be traditionally waxed and then invested and pressed and the other could be designed on CAD/CAM and milled.”

CAD/CAM + Good Materials = Great Esthetics

It’s not news that CAD/CAM has changed the face of lab work; but, to a certain degree, it has also affected esthetics. That impact is because digital and traditional lab work utilizes different materials.

“This started with the advent of CAD/CAM, [with] Lava zirconia frameworks,” Cohen says. “Eliminating metal from restorations immediately enabled ceramists to more easily fabricate more lifelike restorations.”

While CAD/CAM is largely heralded as a positive for the dental lab industry, in some cases, CAD/CAM has had negative impacts, specifically on esthetics, Cohen observes.

“The development and acceptance of full-contour zirconia was initially a step backward in esthetics but a step forward in fit and durability,” he says. “At the time, there was a move in the industry to ‘good enough’. Honestly, I’m not sure where this started, but given a weak economy, pricing pressure and the current state of materials for digital applications, full-contour zirconia seemed just adequate esthetically and became a highly prescribed restoration. Many of these full-contour zirconia restorations fit well and will likely last as long as the remaining tooth but were a step backwards esthetically. This is due to the inherent opacity of the material, making it difficult to obtain proper value and translucency.”

That seems to have changed, and now esthetics are flourishing in the CAD/CAM world.

“More recently, the advent of a new generation of full-contour zirconia materials, like cubeX², has greatly increased the esthetics of full-contour zirconia restorations,” Cohen continues. “Historically, zirconia has been more opaque than natural teeth. This latest-generation zirconia matches the translucency of natural dentition, more closely resulting in much more esthetic restorations. Keep in mind, the most esthetic full-contour zirconia restoration does require a skilled technician to enhance form and color after milling.”

“CAD/CAM allowed for us to produce zirconia restorations,” Thomas adds. “e.max and Empress were available, as well as some other products, but just a metal-free restoration is going to be a more esthetic product. And with the introduction of zirconia having to be done via CAD/CAM changed the game of being able to offer higher strength restorations that were still metal-free, making them more esthetic than a PFM or a full-cast crown option.”

Ultimately, patients are reaping the benefits of those materials.

“As a clinician, I can offer my patients something that looks great, fits great and is strong, and [they] have a lot of options,” Dr. Hornbrook says. “The fastest growing restoration, and probably the number one restoration, certainly here at Keating, is monolithic zirconia. It’s always been very opaque and bright white and kind of flat looking, but the improvements with that now are that we have multilayered zirconia, which is our strongest restoration. It’s more translucent and has literally no compromise-it’s unbreakable, highly esthetic and fits great.”

This article originally appeared in the June 2015 issue of Dental Lab Products.

Top photo: Studio-Pro / Getty Images