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How to Use Virtual Impression Material by Jason Olitsky, DMD, AAACD

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Introduction
Dentists and laboratory ceramists often face complex and timeconsuming cases that require materials to simultaneously provide aesthetics and adequate strength. Accurate impressions are of paramount importance for achieving these goals and require the use of materials that capture excellent details for every step of the process, from diagnostic to master impressions.

Virtual impression material, a line of vinyl polysiloxane (VPS) material, simplifies the impression taking process for IPS e.max restorations (Ivoclar Vivadent, Amherst, New York) and expands the possibilities for conservative, minimally invasive smile design. Virtual impression material (Ivoclar Vivadent) can be used for fullarch impressions, eliminating additional steps and saving valuable chairtime. The fast-set wash materials and putty demonstrate exceptional adaptation characteristics that withstand the moist oral environment. The material’s precision and accurate detail reproduction ensure marginal integrity and remarkably well-fitting restorations.

Case Presentation
A 22-year-old female in excellent oral health came to the office for a cosmetic consultation with a chief complaint of having “baby teeth” (Figs. 1 & 2). She exhausted professional whitening trays, was not satisfied with the results, and requested inoffice professional whitening treatment. Her shade was a B1, and she wanted a much whiter and bigger smile to show off from the field when she cheered for the Jacksonville Jaguars. The patient had prominent facial features including large eyes, and felt her small teeth were over-powered by her other more prominent facial features (Fig. 3).

An initial clinical examination revealed altered passive eruption of the maxillary anterior teeth and short bicuspids; Class III occlusion, edge to edge on the left posterior side; minor wear to anterior tooth #7; and two missing molars, #3 and #19, which had been bone grafted for the next phase of implant placement. The patient’s maxillary central length was 8.5mm, and she demonstrated a reverse incisal curve, wide labial corridor and high smile line of approximately 2mm, with gingival exposure at full smile over the centrals. Gingival exposure of 7mm presented in the gingival margin of the premolars and the inferior border of the upper lip.

After reviewing pre-operative photographs and smile design principles on a computer with the patient, a treatment plan was discussed and agreed upon for closed flap osseous crown lengthening of teeth #4-13, followed by placing lithium disilicate (IPS e.max) veneers. Alternatives to the treatment plan were discussed, including orthodontics to minimize preparation to the posterior left side in edge to edge bite, crown lengthening without porcelain veneers and direct resin veneers.

At the diagnostic appointment, a full series of 12 American Academy of Cosmetic Dentistry (AACD) images were taken, as well as an upper alginate impression, which was immediately poured for fabricating a maxillary release appliance. The patient wore the appliance every night for two weeks to enable the TMJ to seat into its most anatomically stable position, the muscles to relax, and an open bite centric relation record to be taken at the subsequent visit. An appointment was made for closed flap osseous crown lengthening, as well as to obtain open bite centric relation records and VPS impressions for wax-up, stick bite and face bow.

At the next appointment, the bite was recorded and clearance was verified with articulating paper pulling through the posterior contact area. Next, the patient was appropriately anesthetized, the teeth isolated (Optragate), and bone sounded on the facials of all maxillary teeth receiving treatment to gauge the amount of bone to be removed with the er:YAG laser. The patient’s smile was digitally designed prior to performing the gum lift to anticipate the necessary gingival recontouring. Immediately following the crown lengthening procedure, upper and lower impressions were taken according to the following procedure.

Pre-operative Impressions Using Virtual Impression Material
Step 1: A stock tray was lined with Virtual adhesive, and Virtual putty was mixed and placed in the posterior and seated in the mouth.
Step 2: The tray was removed immediately to create a pseudo custom tray in the posterior, after which heavy body was immediately injected into the tray, and the light body was injected on top of the heavy body and around the facials of the dentition in the impressed arch. The tray was restored.
Step 3: The material was allowed to set for 2:30 and checked for accuracy. The author ensures that the diagnostic impressions of both arches are extremely accurate, since this is the first step of the smile design that sets the standard for the rest of treatment.
Step 4: An earless facebow was lined with Virtual adhesive and the face bow and stick bite were recorded with Virtual Bite Registration Material in the photo studio to facilitate laboratory communication.

The laboratory prescription indicated that the case would be minimal preparation, and some minimal preparation was anticipated on the facials of the central incisors. I prefer to place a fine margin on teeth that require minimal or no preparation for the ceramist. Teeth #12 and #13 would require preparations that wrapped over the buccal cusps to enable the ceramist to jump the edge-to-edge bite, lengthen the incisal edges and normalize the labial corridor. The maxillary canines would require some lingual wrap to control occlusion and provide immediate canine disclusion.

Discussion with the laboratory involved tooth shapes and sizes, as well as final length and other smile design principles. The laboratory was also instructed to mount the case using the enclosed centric relation open record bite and equilibrate interferences to full closure and wax in the new MIP. The laboratory would produce a reduction guide based on the wax-up for use during the preparation appointment.

Tooth Preparation
At the preparation appointment, the patient was anesthetized. Small adjustments were made to posterior inclines recorded on the CR open bite mounted models from the equilibrated models on a semi-adjustable articulator. Utilizing reduction guides fabricated off the laboratory wax-up, proper reduction and ideal room for the IPS e.max minimal preparation veneers was verified (Fig. 4). Once the reduction guide cleared the facials of the teeth, there was enough room to fabricate the intraoral mock-up from the Siltec impression of the wax-up.

The Siltec impression of the wax-up was filled with a temporary crown and bridge material and seated in the mouth to fabricate a mock-up. After allowing the provisional material to set for two minutes, the matrix was removed, and the bulk flash was cleaned. Aesthetics of the mock-up were reviewed prior to preparation and determined to look excellent.

The mock-up was prepped with .3mm reduction in three facial plains, and 1.5mm on incisal reduction to allow room for the laboratory to cut back and layer the incisal edges (Fig. 5). The mock-up was prepped as if it was actual enamel and, once completed, excess flash was removed and shallow chamfer margins were placed equi-gingival. The author prefers to create a slight margin, enough for the ceramist to delineate as a finish line for the restorations (Fig. 6).

Bite Record and Final Impressions Using Virtual Impression Materials
Step 1: The bite was checked and recorded with Virtual bite, and photographs were taken to record preparation shade ND1 with Ivoclar Vivadent ND shade guide.
Step 2: With a custom tray lined with Virtual adhesive, a maxillary impression was taken using fast set Virtual Heavy Body and Virtual Light Body material. No retraction cord or materials were used prior to impressing the case.
Step 3: After the impression was checked for final set, it was removed and carefully scrutinized for marginal details that are crucial for excellent fitting restorations.
Step 4: The impression was disinfected with CaviCide surface disinfectant spray and packed for shipment to the laboratory (Figs. 13 and 14).

Provisionalization
The teeth were provisionalized with a bleach-shaded temporary crown and bridge material. The final shade of the temporaries material on an ND1 prepared tooth approximates a Chromoscope 020/030 shade. The teeth were conditioned with Concepsis (Ultradent Products, Inc., South Jordan, Utah), then spot etched in the center of the teeth, which enhances the strength of the provisional material. The etch was rinsed and the teeth dried and coated with a desensitizer (Telio CS Desensitizer, Ivoclar Vivadent). A primer was then placed on the preparations with a microtip brush and air dried with an Adec Warm Air Tooth Dryer.

The Siltec matrix of the wax-up was filled with a provisional material and seated in the mouth for two minutes. After setting, the matrix was removed and excess flash was cleaned with a sharp instrument. After final setting, the provisional material was trimmed to margins with an eight-fluted carbide flame on the facial and a football-shaped eight-fluted carbide on the lingual. The margins were polished, the incisal edges were rounded, and the incisal embrasures deepened to produce a more youthful smile. The incisal embrasures were opened with a small diamond disk, and the mesial and distal line angles were modified with an eight-fluted-carbide-flame-shaped bur. These areas was further polished, and the provisional then glazed. The provisional was cured with an LED curing light (Bluephase Style, Ivoclar Vivadent) for 10 seconds per tooth.

Laboratory Fabrication
The laboratory poured the impression in stone and created a working model of the IPS e.max veneers (Fig. 15). Each veneer was carefully inspected for exceptional aesthetics while preparing the case (Fig. 16). The details of the impression facilitated laboratory fabrication of exceptionally well-fitting restorations (Figs. 17 and 18).

Final Cementation
At the cementation appointment, the provisional (Fig.19) was removed. The IPS e.max veneers were carefully evaluated for aesthetics and fit (Fig. 20).The preparations were cleaned with chlorohexadine, and the IPS e.max restorations were tried in one at a time for fit, then two at a time for contacts. Once full seating was confirmed, all veneers were tried on together with try-in paste Variolink Veneer HV+1 shade, Ivoclar Vivadent) (Fig. 21).

The veneers were removed and prepared for adhesive bonding using Variolink veneer light-cured cement, then bonded using the “tack and wave” method. Excess cement was cleaned, the margins were covered with a glycerin gel, and the restorations given a final 40-second cure per surface. The occlusion was adjusted in protrusive and lateral protrusive and confirmed to have immediate canine disclusion.

Conclusion
Using Virtual impression material facilitates laboratory communication and also the fabrication of exceptionally well fitting lithium-disilicate restorations, such as minimal preparation IPS e.max veneers. The Virtual line of VPS impression materials ensures accurate impressions throughout the restorative process, from diagnostic to master impressions.
Author's Bio
Dr. Jason Olitsky, The Smile Stylist, is an accredited member of the AACD, as well as president of the Florida Academy of Cosmetic Dentistry. He was a clinical mentor with the Hornbrook Group and is currently faculty with the Gold Dust Clinical Mastery Series. Jason currently works three days a week with his wife and partner, where 80 percent of their production is based off large cosmetic cases. They started Wallsmiles.com, a site that sells wall art for the dental office and teaches dentists how to get their own patients’ pictures on their walls. They created Smile Stylist, a brand committed to promoting, providing and maintaining beautiful smiles for the fashion-forward customer. He is also coauthor of The Naked Tooth: What Cosmetic Denists Don’t Want to Know. Check out Olitsky’s technique via his OnDemand Webinar on Dentaltown.com.
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