Introduction:
This blog post continues the annual Before and After series, in which I present one clinical case each year (since 2008) on my website that I feel offers a meaningful challenge, insight, or point of reflection within contemporary aesthetic dentistry. Each case is selected for its own unique demands—whether technical, material-related, or aesthetic in nature.
In the previous post (Before and After 2024), the focus was on e.max ZirCAD Prime, exploring the aesthetic potential of high-strength translucent zirconia at a time when monolithic restorations were becoming increasingly dominant in everyday practice—while still highlighting the importance of controlled micro-layering techniques to meet individual expectations.
In this instalment, the discussion moves one step further with the introduction of e.max Ceram Art (released in Australia in late November 2025), a new-generation ceramic system designed to complement contemporary materials and workflows. As monolithic restorations have become more prevalent, liquid ceramics—such as e.max Ceram Illusion—have assumed a more significant role, allowing enhanced chromatic depth and three-dimensional colour modulation compared with earlier generations of surface staining alone.
While these developments have undoubtedly elevated baseline outcomes, the distinction between a competent result and a truly refined one continues to lie in the operator’s ability to control tooth morphology, colour dynamics—including degree of translucency and internal characteristics—and surface anatomy and lustre. This is where the newly introduced e.max Ceram Art Structure material becomes particularly relevant. Rather than functioning as a purely additive or corrective medium, the structure component enables the deliberate build-up of anatomical and optical architecture, creating a layer where individual craftsmanship and manual skill are most clearly expressed.
The structure material is available in two aesthetic domains: a white structure intended for hard-tissue characterisation, and a pink structure designed for soft-tissue integration. In this article, I will demonstrate how this additional layer can be incorporated seamlessly into an existing, well-established workflow—enhancing depth, texture, realism, and future potential—without requiring fundamental changes to the underlying protocol.
Pre-operative Overview:
At the initial smile design consultation, it was clear that this case would require a high level of aesthetic precision. The patient presented with strong expectations and a clear desire for an outcome that would be visually undetectable within the natural dentition—particularly on the right side of the smile.
To remain conservative, the restorative scope was limited to a three-unit reconstruction spanning teeth 14–12. The remainder of the dentition was in excellent condition, displaying a high degree of natural translucency and internal character—making material selection and integration especially critical. A diagnostic wax-up was therefore used to assess space distribution and tooth proportions, revealing a narrower available space in the upper right quadrant compared with the contralateral side. Rather than pursuing strict symmetry, the design focused on achieving optical balance and natural harmony within these constraints.
Tooth morphology was refined selectively. The existing form of tooth 12 was largely preserved in line with the patient’s preference, while adjustments were made to the canine and first premolar to reduce bulk and improve spatial balance. From a technical perspective, this created a scenario where precise control of form, transition, and surface character would be essential to achieving a seamless result.
Colour planning was approached in parallel, allowing final shade evaluation to be carried out on a stable baseline prior to definitive ceramic work. This ensured predictable material behaviour during the build-up phase and provided a reliable foundation for aesthetic integration.
From a technical standpoint, this case offered an appropriate platform to evaluate a high-strength zirconia workflow using e.max ZirCAD Prime, where translucency is derived primarily from the material itself, and refinement is achieved through controlled morphology, layering strategy, and surface characterisation.
Temporary Review and Design Validation:
The temporary review was conducted once bone grafting and soft-tissue healing had stabilised, allowing an accurate assessment of both form and gingival integration. The temporaries were fabricated directly from the diagnostic wax-up, providing a reliable reference for evaluating the proposed design in situ.
From a shape perspective, the patient was very comfortable with the overall form, and no major modifications were required. The presence of subtle natural imperfections was viewed positively, as these blended well with the adjacent dentition and supported a more authentic aesthetic outcome. The soft-tissue response following grafting was also favourable, contributing to a balanced and well-supported emergence profile.
Colour evaluation was carried out on a stable baseline following completion of whitening. At this stage, the patient was satisfied with the shade of her natural dentition, establishing a clear reference point for the definitive restorations. The increased chroma evident in the canine region—particularly when compared with the contralateral side—was acknowledged by all parties, reinforcing the importance of achieving a natural transition in colour and depth within the final restorations.
From a technical standpoint, the temporary phase also highlighted subtle spatial considerations within the interproximal zone, underscoring the need for careful control of form and surface transition during the definitive ceramic build-up. These observations further emphasised the importance of material choice and layering strategy in achieving seamless integration.
Overall, the temporary phase served its intended purpose: validating the proposed design, confirming tissue behaviour, and establishing a precise aesthetic reference. This allowed the focus to shift confidently toward material execution and refinement during the final ceramic build-up.
Shade Taking Protocol:
As usual, shade taking was approached as a multi-reference process rather than relying on a single tab or viewing angle. In my workflow, three different shade tabs (with corresponding gingival holders) are assessed from two primary perspectives—frontal and lateral—with the patient positioned edge-to-edge. This approach allows for a more reliable evaluation of both value and chroma, particularly in cases where the surrounding dentition displays high translucency and natural variation.
The lateral view is especially important, as it reveals colour transitions and depth that are often underestimated from a frontal perspective alone. This becomes critical when attempting to integrate a restoration seamlessly into an existing dentition rather than creating a uniform or over-simplified appearance.
Photographs taken using polar_eyes filters form a key part of the protocol. By eliminating surface reflections, these images make it significantly easier to assess the degree of translucency, internal saturation, and natural characteristics of the enamel and dentine structure. In my experience, polarised images provide a more accurate and repeatable reference than conventional photography, particularly when subtle optical differences matter.
The eLAB protocol was used as an additional reference point to support shade communication and verification. While not relied upon in isolation, it serves as a useful cross-check—helping to minimise interpretation errors and reduce the risk of disappointment or colour mismatch at the try-in stage.
Taken together, this layered approach to shade taking establishes a stable and predictable foundation for ceramic build-up, allowing material behaviour and surface refinement to be guided by accurate visual data rather than assumption.
The Fabrication of Final Restorations and Ceramic Build-up:
In today’s restorative landscape, the increasing dominance of monolithic, CAD/CAM-manufactured restorations has brought undeniable efficiency and consistency—but often at the expense of individuality. As workflows become increasingly standardised, many restorations begin to share a similar visual language, regardless of case-specific nuance. For ceramists aiming to position themselves at a high-end or master level, the ability to differentiate work beyond digital uniformity has become more important than ever.
The fabrication of the final 14–12 restorations in this case followed a deliberately conservative and controlled approach. The primary objective was to achieve refinement through additive ceramic control, rather than relying on excessive post-firing shape adjustment. By maintaining anatomical intent throughout the build-up phase, internal characteristics and optical depth could be developed organically rather than imposed retrospectively through trimming and surface gloss alone.
The core ceramic build-up was completed using Noritake CZR, which remains my preferred system for establishing natural colour and primary aesthetics on zirconia restorations. Its handling behaviour and optical predictability provide a stable foundation, particularly in cases where subtle transitions are required to match complex adjacent natural dentition. At the semi-completed stage, the restorations could have been finalised conventionally. However, closer evaluation revealed a minor interproximal challenge: the separation between the pontic and the abutment created a small zone of negative space in the 13–12 region, visually exposing root form—an outcome that is rarely ideal when the goal is a youthful, highly aesthetic result.
When working on bridge cases, particularly when the separation must terminate directly over an abutment surface, the use of gingival ceramic should be considered a legitimate aesthetic option. In this context, pink ceramic is not applied to disguise error, but to enhance the continuity of the soft-tissue illusion and improve visual integration. As with any intervention at this level, the decision must be deliberate, discussed, and clinically validated—often through provisional assessment (for example, controlled application of pink composite on the provisional restoration)—before being finalised.
This is where e.max Ceram Art becomes particularly relevant. Rather than replacing an existing ceramic system, Ceram Art functions as a complementary refinement layer. The combination of Ceram Art Illusion and Ceram Art Structure allows both optical depth and physical architecture to be addressed independently, expanding the expressive potential of the restoration without disrupting an established workflow.
A key advantage of Ceram Art is its compatibility. Despite being part of the Ivoclar ecosystem, both Illusion and Structure integrate well with a wide range of ceramic systems due to their adaptable CTE range. In this case, they were layered over Noritake CZR without compromise. The firing protocol further supports this integration: the Ceram Art program operates at a significantly lower temperature than the primary CZR cycle, allowing refinement to be added with minimal risk of disturbing the underlying ceramic architecture.
From a behavioural standpoint, the Structure material offers an additional advantage. Its handling characteristics—stable yet mouldable—allow controlled sculpting of micro-anatomy and subtle shape refinement in a manner that feels closer to composite than conventional ceramic powders. This proved essential in this case, where the adjacent natural dentition exhibited complex surface texture and nuanced transitions that could not be convincingly replicated through colour application alone.
In an era where monolithic restorations risk visual homogenisation, the selective use of structure and illusion ceramics provides a means of restoring individuality to ceramic work. For ceramists seeking to differentiate themselves, this approach offers a practical and controlled way to elevate outcomes—bridging the gap between digital efficiency and handcrafted refinement.
Try-in and Clinical Evaluation:
The clinical try-in proceeded smoothly and predictably, confirming the accuracy of fit, overall aesthetics, and integration with the surrounding dentition. Both the seated evaluation and initial visual assessment aligned well with the objectives established during the planning and fabrication stages.
As is often the case during try-in appointments, the use of local anaesthetic resulted in a temporary alteration of soft-tissue appearance, with the gingival tissues appearing lighter than their resting condition. While this is a normal and unavoidable clinical variable, it can limit the precision with which soft-tissue colour transitions are assessed at that specific moment.
Rather than viewing this as a limitation, this stage highlighted an important consideration for future case planning—particularly when gingival ceramics and soft-tissue illusion play a role in the final aesthetics. One option in such cases is provisional or short-term temporary cementation of the restoration, allowing the tissues to return fully to their natural state before definitive aesthetic evaluation.
Alternatively, a dedicated follow-up appointment—conducted without local anaesthesia—can offer an ideal opportunity for further refinement. In this context, the handling behaviour of Ceram Art Structure becomes especially relevant. Due to its composite-like viscosity and sculptability, minor adjustments to the gingival architecture can be carried out clinically (with appropriate equipment, including a ceramic furnace) in a controlled and deliberate manner, allowing the soft-tissue transition to be fine-tuned directly in response to clinical conditions.
From a broader perspective, this reinforces the importance of considering material behaviour at the planning stage, not only during fabrication. As structure ceramics continue to evolve, they open new possibilities for extending aesthetic control beyond the laboratory bench and into carefully staged clinical evaluation—particularly in complex cases where hard- and soft-tissue harmony must be assessed together.
In this case, the try-in confirmed that the established workflow was sound, while also highlighting additional avenues through which the full potential of structure materials can be explored and leveraged in future treatments.
Post-operative Outcome and Reflections:
The post-operative review confirmed a highly successful outcome—clinically, technically, and aesthetically—and, ultimately, emotionally and psychologically from the patient’s perspective. The patient was visibly pleased with the result, which is always rewarding, particularly in cases where expectations are high and the technical demands are significant. Considering the initial constraints, the complexity of integration with the adjacent natural dentition, and the level of scrutiny applied throughout the process, the final outcome was more than satisfying.
However, the value of this case extends beyond the immediate result. It reinforces why I continue to do what I do: not simply to meet expectations, but to exceed them, while remaining invested in the ongoing refinement of skill, judgement, and material understanding. In an era where dentistry is becoming increasingly digitised, efficient, and systematised, there is a genuine risk that human nuance—listening, interpretation, restraint, and artistry—can be diminished. This case serves as a reminder that technology and material innovation should support, not replace, the human element of aesthetic dentistry, where artistic judgement and, most importantly, communication remain central.
While digital workflows and measurements provide useful structure, they are ultimately tools and reference points, not determinants of what can be achieved for a patient. Meaningful aesthetic outcomes are shaped by decision-making, experience, and a willingness to engage critically with each case rather than defaulting to standardised solutions. That mindset does not change with age, career stage, or background. Continuing education, curiosity, and openness to evolving materials and techniques remain essential—regardless of where one sits professionally.
This case also highlights the importance of resisting complacency. Even when outcomes are successful, there is always room to reflect, refine, and explore how emerging materials—such as structure ceramics—can further expand aesthetic potential when integrated thoughtfully into established workflows. The goal is not perfection, but progress.
For this reason, this case will be developed further for upcoming publication. Beyond documenting a result, it provides an opportunity to contribute meaningfully to the broader conversation around contemporary aesthetic dentistry—particularly at the intersection of digital efficiency and handcrafted refinement. It reflects how experienced ceramists can continue to evolve, adapt, and contribute to the future of the profession.
Acknowledgement:
I would like to sincerely thank Dr Sophie Lee of The Paddington Dental Surgery for her clinical excellence, thoughtful case planning, and collaborative approach throughout the treatment process. Her attention to detail and commitment to achieving a refined aesthetic outcome were integral to the success of this case.
I would also like to acknowledge Jay Woo of Mowbray Dental for the precise CAD/CAM production of the zirconia framework, which provided a reliable and accurate foundation for the subsequent ceramic work.