Director, Chairside CAD/CAM Dentistry, Department of Preventive and Restorative

1

Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia,

Pennsylvania, USA.
Clinical Professor of Restorative Dentistry, Department of Preventive and Restor-
2

ative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia,

Pennsylvania, USA.
Chairside Dental Technology, Department of Preventive and Restorative Sciences,
3

University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania,

USA.
Director, CAD/CAM Ceramic Center, Department of Preventive and Restorative
4

Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia,

Pennsylvania, USA.
Professor of Restorative Dentistry, Chairman, Department of Preventive and
5

Restorative Sciences, Assistant Dean, Digital Innovation and Professional Develop-

ment, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsyl-
vania, USA.

Correspondence to: Dr Julian Conejo, Department of Preventive and Restorative

Sciences, University of Pennsylvania School of Dental Medicine, 240 South 40th
Street, Philadelphia, PA 19104. Email: jconejo@upenn.edu
 Veneer and Crown
Shade Matching:
A Digital Approach

Julián Conejo, DDS MSc1

Leslie Stone-Hirsch, DMD MSc2
Sooryung Ann, CDT3
Michael Bergler, CDT, MDT4
Markus B. Blatz, DMD, PhD5

S
hade matching indirect restorations of central inci- incisors that require different types of indirect restora-
sors with different types of ceramic has always been tions.2
a challenge for clinicians and dental technicians.1 A This article presents key details of the clinical and labo-
digital approach implementing the latest dental applica- ratory steps for chairside CAD/CAM restorations and a
tions (apps) for mobile devices can simplify the treatment case that illustrates a technique to predictably match color
planning, accurate shade selection, and patient communi- and translucency of a laminate veneer and a full-coverage
cation involved in this treatment. The combination of new crown. The presented approach involves multilayer mono-
CAD/CAM software technology with improved design fea- lithic restorations with symmetric support structures and
tures allows clinicians and dental technicians to success- ceramic laminate veneers to achieve a good match and
fully address demanding clinical challenges such as natural appearance.
matching the appearance and shades of maxillary central

QDT 2020 3
 CONEJO ET AL

1 2

Fig 1 Dr Markus Blatz/Dr Julian Conejo Preparation System for CAD/CAM Restorations #K0394, Brasseler).
Fig 2 Intraoral view of the maxillary central incisor preparations.

MOBILE APPLICATIONS TOOTH PREPARATION

Mobile applications, commonly referred to as apps, are ap- When treating both maxillary central incisors with the same
plication software that run on mobile devices such as smart type of indirect ceramic restorations, clinical outcomes can
phones and tablets. Apps have become part of our daily be greatly improved by preparing the abutment teeth sym-
lives, providing valuable information and facilitating com- metrically with the same amount of 3D tooth reduction and
mon tasks. Their implementation in clinical and laboratory finish line position.5
protocols provides opportunities to streamline workflows Preparation design features for full-coverage CAD/
and surpass common communication challenges between CAM restorations on maxillary central incisors include:
clinicians, dental technicians, and the patient.
The Digital Smile Design (DSD) App is an advanced • F inish line with an internally rounded shoulder and sym-
tool for 2D and 3D treatment planning and patient educa- metric zenith levels
tion on a mobile device, based on preoperative STL files • Smooth transitions from interproximal walls to the incisal
from intraoral scans, specific intra- and extraoral photos, edge while avoiding sharp angles, corners, and under-
face scans, and videos.3 Shade selection and communica- cuts
tion are other key components of the workflow when re- • Same preparation design and amount of 3D tooth struc-
storing maxillary central incisors with indirect ceramic ture reduction for both abutment teeth
restorations. A small dental spectrophotometer (Easy
Shade V, VITA Zahnfabrik), controlled through the VITA Fine diamond burs with specific dimensions and shapes
mobileAssist App and supported by intraoral photos, sim- (eg, Dr Markus Blatz/Dr Julian Conejo Preparation System
plifies the shade-taking process and facilitates shade for CAD/CAM Restorations #K0394, Brasseler; Fig 1)
communication. Accurate shade taking and effective com- are necessary to carry out ideal tooth preparation designs
munication reduce the number of clinical appointments (Fig 2) for chairside CAD/CAM restorations, which are
and possible remakes.4 typically fabricated without any models. An ideal tooth

4 QDT 2019
 Veneer and Crown Shade Matching: A Digital Approach

3a 3b

5a 5b

Figs 3a and b Design of CAD/CAM restorations.

Fig 4 Dry-milling preview.
Figs 5a and 5b Fully sintered monolithic polychromatic preshaded zirconia crowns.

preparation also simplifies the digital restoration design translucent multilayer preshaded zirconia blocks (eg, Katana
process and provides better design proposals (Figs 3a and STML, Kuraray Noritake) provide viable options in such
3b), especially for endodontically treated teeth, which have situations. The presintered zirconia blocks (Fig 4) are dry
less critical anatomical design considerations since they milled in a 4-axis milling machine (eg, MCXL, Dentsply
are not vital.6 Sirona) with carbide burs and are then fully sintered with a
When the abutment teeth reveal a noticeable color dif- speed sintering cycle in a small-footprint furnace (eg, Speed
ference after tooth preparation, the design proposals for Fire, Dentsply Sirona). In this manner, the entire fabrication
monolithic restorations should provide a minimum thick- process of a chairside full-contour monolithic zirconia
ness of 1.0 mm on the labial surfaces to mask any discol- crown takes only slightly more than half an hour (Figs 5a
orations and avoid discrepancies in the appearance of the and 5b).8 The restorations are tried in and delivered with
final restorations.7 A chairside digital workflow and high- the proper cementation materials and protocols (Figs 6a

QDT 2020 5
 CONEJO ET AL

6a 6b

7a 7b

Figs 6a and 6b Try-in and cementation of final restorations.

Figs 7a and 7b Postoperative extraoral views at rest and during a smile.

and 6b) with the goal to provide natural tooth morpholo- was calculated for ideal restorative space distribution (Figs
gies and shapes (Figs 7a and 7b). 10a to 10c). A 2D smile that included a proposal for the
maxillary central incisors was designed and used to ex-
plain the treatment and possible esthetic outcomes to the
patient for motivational purposes (Figs 11a and 11b). A
CASE PRESENTATION spectrophotometer (Vita Easyshade V) and App (Vita mo-
bileAssist) were used for shade communication with the
A 23-year-old male patient presented with an overcon- patient and the laboratory technician (Fig 12).
toured porcelain-fused-to-zirconia crown on the maxillary After approval of the 2D design, a digital 3D wax-up
left central incisor and a diastema between the maxillary and set-up were created with natural tooth shapes from
central incisors. Extraoral frontal, lateral, and anterior 12 the tooth and smile libraries in the DSD App. A resin mod-
o’clock views of the patient’s smile as well as intraoral pho- el was 3D-printed based on the digital wax-up, and a sili-
tographs were taken (Figs 8 and 9). These photographs cone index was made to serve as a guide for the tooth
and STL files of preoperative maxillary, mandibular, and preparations.
buccal intraoral scans were uploaded to the DSD App on a The maxillary right central incisor was prepared for a
tablet (iPad Pro, Apple). ceramic laminate veneer following common preparation
The maxillary intraoral scan was calibrated and posi- guidelines. The endodontically treated maxillary left central
tioned to the extraoral images to calculate the smile frame. incisor was prepared for a full-coverage crown (Fig 13).
The width/length ratio of both maxillary central incisors Digital and conventional impressions were made.

6 QDT 2019
 Veneer and Crown Shade Matching: A Digital Approach

8a 8b 8c

10a 10b 10c

Figs 8a to 8c Preoperative extraoral views.

Fig 9 Preoperative intraoral view.
Figs 10a to 10c Smile frame calculation and width/length ratio of maxillary central incisors with the DSD App.

QDT 2020 7
 CONEJO ET AL

11a 11b

12

13

Figs 11a and 11b Visualization of the anticipated 2D smile design.

Fig 12 Shade values from the spectrophotometer are uploaded to the mobileAssist
App through Bluetooth connectivity.
Fig 13 Tooth preparations for a veneer on the maxillary right central incisor and a
crown on the maxillary left central incisor.

8 QDT 2020
 Veneer and Crown Shade Matching: A Digital Approach

14 15

16a 16b

17a 17b 17c

Fig 14 Digital restoration design in full contour.

Fig 15 Design of two symmetric laminate veneers after split-file of the maxillary left central incisor.
Figs 16a and 16b Crown coping design on the maxillary left central incisor.
Figs 17a to 17c The crown coping was fabricated from a preshaded multilayer zirconia block, and laminate veneers were milled
from a polychromatic feldspathic ceramic.

Two symmetric monolithic restorations were designed spathic ceramic blocks (Vita Tri-lux Forte, VITA Zahnfabrik),
(Fig 14) and a split-file was created on the maxillary left shade A2, while the zirconia coping was milled from a mul-
central incisor to obtain symmetrically shaped veneers for tilayer preshaded zirconia block (Katana ML, Kuraray Nori-
both central incisors (Fig 15). In addition, a full-coverage take; Figs 17a to 17c).10 The block was selected to mimic
coping was designed for the crown preparation (Figs 16a the shade of the contralateral prepared central incisor with
and 16b) in a shape that imitated a veneer preparation the intent to achieve the best possible color match be-
symmetrically to the prepared maxillary right central inci- tween the two most visible teeth.
sor.9 The two veneers were milled from polychromatic feld-

QDT 2020 9
 CONEJO ET AL

18a 18b 18c

19a 19b 20a 20b

Figs 18a to 18c Intraoral views during try-in of the restorations.

Figs 19a and 19b A ceramic primer that contains both a silane and the zirconia-binding MDP monomer was applied to the bonding
surfaces of the veneers and the zirconia coping after air-particle abrasion and to the feldspathic ceramic after hydrofluoric acid
etching.
Figs 20a and 20b Extraoral cementation of the veneer to the coping ensures a simplified bonding procedure, excess cement
removal, and polishing process. The same clear composite resin cement was used for the veneer.

After try-in and esthetic evaluation (Figs 18a to 18c), the CONCLUSION
feldspathic ceramic veneers were etched with 5% hydro-
fluoric acid for 60 seconds, followed by ultrasonic clean- Matching a veneer and a crown in the esthetic zone is one
ing. Following the APC technique,11–13 the zirconia coping of the great clinical challenges, especially when the abut-
was air-particle abraded with 50-micron aluminum oxide ment teeth present variations in stump shades. The reported
particles for 10 seconds. A ceramic primer that contains approach was applied in an attempt to match the restora-
both a silane and the zirconia-binding MDP monomer tions of the two central incisor teeth in a most ideal man-
(Clearfil Ceramic Primer Plus, Kuraray Noritake) was applied ner despite the variations. Matching the crown coping to
to the bonding surfaces of the veneers and the zirconia the tooth prepared for a veneer in terms of both shade and
coping (Figs 19a and 19b).11 The zirconia coping and ce- 3D design allows for the fabrication of two symmetrically
ramic veneer were cemented extraorally with an adhesive designed ceramic laminate veneers that offer the exact
resin system (Panavia V5 Clear, Kuraray Noritake; Figs same material, shade, shape, thickness, and translucency.
20a and 20b). Extraoral cementation of the veneer to the A fully digital approach that includes all treatment steps
coping ensures a simplified bonding procedure, easy ex- from design to completion and even allows for chairside
cess cement removal, and ideal polishing process.12 The restoration fabrication is highly supportive of achieving the
ceramic laminate veneer for the maxillary right central inci- esthetic and functional goals in a variety of challenging
sor and the and bilayered crown on the maxillary left cen- clinical situations. Novel tools such as mobile smile design
tral incisor were inserted with the same resin cement (Figs applications further simplify these processes and improve
21 and 22) after proper pretreatment of the restoration communication with the patient and between clinical and
and tooth bonding surfaces.13 laboratory teams.

10 QDT 2020
 Veneer and Crown Shade Matching: A Digital Approach

21

22

Fig 21 Postoperative intraoral situation 4 weeks after insertion.

Fig 22 Postoperative extraoral view.

REFERENCES 7. Lee Y-K, Yu B, Lee S-H, Cho M-S, Lee C-Y, Lim H-N. Shade compat-
ibility of esthetic restorative materials—A review. Dent Mater 2010;
26:1119–1126.
1. Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. 8. Blatz MB, Conejo J. The current state of chairside digital dentistry
Chicago: Quintessence, 1994. and materials. Dent Clin North Am 2019;63:175–197.
2. Blatz MB, Chiche G, Bahat O, Roblee R, Coachman C, Heymann HO. 9. Gamborena I, Sasaki Y, Blatz MB. Novel approach for predictably
Evolution of Aesthetic Dentistry. J Dent Res 2019;98:1294–1304. matching a veneer to an implant crown. Quintessence Dent Technol
3. Coachman C, Calamita MA, Sesma N. Dynamic documentation of the 2019;42:6–14.
smile and the 2D/3D digital smile design process. Int J Periodontics 10. Tezulas E, Yildiz C, Kucuk C, Kahramanoglu E. Current status of
Restorative Dent 2017;37:183–193. zirconia-based all-ceramic restorations fabricated by the digital ve-
4. Igiel C, Lehmann KM, Ghinea R, et al. Reliability of visual and instru- neering technique: A comprehensive review. Int J Comput Dent
mental color matching. J Esthet Restor Dent 2017;29:303–308. 2019;22:217–230.
5. Goodacre CJ, Campagni WV, Aquilino SA. Tooth preparations for 11. Blatz MB, Alvarez M, Sawyer K, Brindis M. How to bond zirconia: The
complete crowns: An art form based on scientific principles. J APC Concept. Compend Contin Educ Dent 2016;37:611–617.
Prosthet Dent 2001;85:363–376. 12. Blatz MB, Conejo J. Cementation and bonding of zirconia restora-
6. Baba NZ1, Goodacre CJ, Daher T. Restoration of endodontically tions. Compend Contin Educ Dent 2018;39(suppl 4):9–13.
treated teeth: The seven keys to success. Gen Dent 2009;57:596– 13. Blatz MB, Vonderheide M, Conejo J. The effect of resin bonding on
603; quiz 604-5, 595, 679. long-term success of high-strength ceramics. J Dent Res 2018;97:
132–139.

QDT 2020 11