cosmetic dentistry international

Cover / Editorial / Content / Midline diastema closure with direct-bonding restorations / Hemisection of a front tooth / Root recession coverage made predictable using resorbable barriers / The benefits of expanding and refurbishing your practice / Word-of-mouth 2.0 / “Once you’ve tried it - you can’t drink anything else” / An interview with Dr Sim Tang Eng - AAAD president / An interview with Hans Geiselhöringer - Head of Global Marketing & Products - Nobel Biocare / Opalescent composite resin / ‘Myth busting’ laser dentistry / Perfect Bleach: Effective and gentle / VITA Easyshade Compact: The new generation in digital shade-taking / CLEARFIL SA CEMENT: Top Self-adhesive Resin Cement of 2010 / The first South Asian cosmetic and aesthetic dental congress / All-ceramics works / Events / About the publisher

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CDE0109_01_Titel_CDE0109_01_Titel 26.04.10 10:19 Seite 1

issn 1616-7390

Vol. 4 • Issue 1/2010

cosmetic
dentistry
_ beauty & science

1

2010

| MICD
Midline diastema closure with
direct-bonding restorations

| business
Word-of-mouth 2.0

| feature
An interview with Dr Sim Tang Eng

[2] => untitled

BEAUTY – COMPOSE IT!
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r Two simple steps
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GLOB_CosmDentInt_0110_Amaris_210x297.indd 1

08.01.2010 12:59:41 Uhr

[3] => untitled

CDE0110_03_Editorial_CDE0110_03_Editorial 26.04.10 10:22 Seite 1

editorial _ cosmetic dentistry

Dear Reader,
_Welcome to this year’s first edition of cosmetic dentistry! With great pride, we
are able to look back at a successful year in 2009. cosmetic dentistry is now one of the
most popular aesthetic dental magazines in the Asia Pacific region. This success was greatly
due to the high standard of both printing and article selection. We were able to offer
free accessibility to the electronic version of the magazine on www.dental-tribune.com
and the official websites of the South Asian Academy of Aesthetic Dentistry (SAAAD) and
Asian Academy of Aesthetic Dentistry. Furthermore, various aesthetic continuing education
(CE) institutions have approached cosmetic dentistry in order to establish a professional
relationship for the promotion of the art and science of aesthetic dentistry in the Asia
Pacific region.

Dr Sushil Koirala
Editor-in-Chief

In my editorial in edition 1/2009, I discussed the scope of the minimally invasive concept
in cosmetic dentistry. In edition 4/2009, we published an article proposing the minimally
invasive cosmetic dentistry (MICD) concept and its treatment protocol. The concept, which
is now widely recognised, was tremendously well received. Various aesthetic and national
dental organisations have since invited me to lecture on the concept and its clinical application. It is my pleasure to mention that aesthetic academies now officially endorse the
MICD concept and its treatment protocol, introducing it at their scientific meetings and
in their CE programmes. For the past six months, I have lectured at the scientific meetings of the Nepalese Academy of Cosmetic and Aesthetic Dentistry, SAAAD, Philippine
Dental Association (PDA) and Malaysian Dental Association. Owing to the great response
at the PDA conference and at the special request of the Philippine Academy of Esthetic
Dentistry, we were encouraged to organise the first exclusive MICD symposium, offering
six CE credit points, in Asia on 21 February 2010. With six international speakers and nearly
400 attendees, the symposium was a great success.
Within a short period, the MICD movement has gained popularity and is being accepted
by clinicians globally. Keeping this recent trend in mind, we have created a section dedicated
to MICD-related clinical cases, with the first in this issue.
I would like to express my gratitude to our valued readers, authors, advertisers and everyone that has directly and indirectly supported cosmetic dentistry and thus helped to bring
the magazine to its current place. I hope you will enjoy this edition of cosmetic dentistry
and invite you to send your valuable feedback and ideas.
Sincerely yours,

Dr Sushil Koirala
Editor-in-Chief
President Vedic Institute of Smile Aesthetics (VISA)
Kathmandu, Nepal

cosmetic
dentistry 1
I 03
_ 2010

[4] => untitled

CDE0110_04_Content_CDE0409_04_Content 27.04.10 11:24 Seite 1

I content _ cosmetic dentistry

page 06

30

I editorial
03

Dear Reader
| Dr Sushil Koirala, Editor-in-Chief

Opalescent composite resin

37

‘Myth busting’ laser dentistry
| Fotona

I case report

I industry news

Hemisection of a front tooth
| Dr Steffen Hohl & Dr Anne Sofie Brandt Petersen

38

Root recession coverage made predictable using
resorbable barriers
| Dr David L. Hoexter et al.

Perfect Bleach: Effective and gentle
| VOCO

39

I special
14

An interview with Hans Geiselhöringer, Head of Global
Marketing & Products , Nobel Biocare

| Ulf Krueger-Janson

Midline diastema closure with direct-bonding restorations
| Dr Sushil Koirala

12

page 20

I industry report
34

I MICD
06

page 14

VITA Easyshade Compact:
The new generation in digital shade-taking
| VITA

40

CLEARFIL SA CEMENT:
Top Self-adhesive Resin Cement of 2010
| Kuraray Europe

I business
18

The benefits of expanding and refurbishing your practice
| Anne Levitch

20

I meetings
42

Word-of-mouth 2.0
| Dr Lorne Lavine

44
48

“Once you’ve tried it, you can’t drink anything else”
| Dr Jay B. Reznick

International Events

I about the publisher
49
50

I feature
28

All-ceramics works
| Manfred Kern

I digital dentistry
22

The first South Asian cosmetic and aesthetic dental congress
| Dr Suhit R. Adhikari

| submission guidelines
| imprint

An interview with Dr Sim Tang Eng, AAAD president

page 22

04 I cosmetic
dentistry

1_ 2010

Cover image courtesy of cardiae

page 28

page 34

[5] => untitled

3384E_210x297:Layout 1

05.03.2010

8:14 Uhr

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[6] => untitled

CDE0110_06-11_Koirala_CDE0110_06-11_Koirala 26.04.10 10:41 Seite 1

I MICD _ diastema closure

Midline diastema closure with
direct-bonding restorations
Author_ Dr Sushil Koirala, Nepal
crowns incline distally because of the crowding
of the roots. With the eruption of the laterals and
permanent canines, the MD reduces or even closes
completely.

Fig. 1

Fig. 1_MICD TP.

Fig. 2_Placement of plastic strip.
Fig. 3_Plastic strip is supported
with index finger.

06 I cosmetic
dentistry

1_ 2010

_Midline diastemata (MD) are spaces of
varying magnitude between the crowns of fully
erupted maxillary and mandibular central incisors.
Keene describes MD as anterior midline spacing
greater than 0.5 mm between the proximal surfaces of adjacent teeth. Incidences of maxillary
and mandibular MD are 14.8 and 1.6 %, respectively.1

Etiological factors
The etiological factors of MD are described by
various researchers. Angle concludes the presence
of an abnormal frenum to be the cause of MD,2
a view that has been supported by other researchers.3–5 According to Tait, the frenum is the
effect and not the cause of the incidence of diastemata.6 He reports causes such as ankylosed
central incisors, flared or rotated central incisors,
anodontia, macroglossia, dento-alvolar disproportion, localised spacing, closed bite, facial type, ethnic and genetic characteristics, inter-premaxillary
suture and midline pathology. Weber lists the causes
for spacing between maxillary incisors as the result
of high frenum attachment, microdontia, macrognathia, supernumerary teeth, peg laterals, missing
lateral incisors, midline cysts, habits such as thumbsucking, mouth breathing and tongue thrusting.7
Therefore, the etiological factors can be summarised as follows:

MD can occur in temporary, mixed or permanent dentition and may be considered normal for
many children during the eruption of the permanent maxillary central incisors. When incisors first
erupt, they may be separated by bone and the

1. developmental: microdontia, missing laterals,
mesiodens, macroglossia, macro-hypertrophic
fibrous frenum;
2. pathological: midline cysts, tumours and periodontitis;
3. neuromuscular: oral habits, such as tongue
thrusting during speech, swallowing or abnormal
pressure during rest.

Fig. 2

Fig. 3

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CDE0110_06-11_Koirala_CDE0110_06-11_Koirala 26.04.10 10:41 Seite 2

MICD _ diastema closure

Fig. 4_Injection of flowable resin
to create frame.
Fig. 5_Flowable resin ready
for light curing.

Fig. 4

Fig. 5

Clinicians must be prepared for patients visiting
the dental office with the aim of having their diastema closed in order to fulfil their psychological
(aesthetic and beauty enhancement), functional
(pronunciation of ‘f’ and ‘s’ sounds and cutting
foods with anterior teeth) and/or health (oralhealth maintenance) problems.

psychology, health, function and aesthetics of
the patient.”8 The MICD concept as the professional
movement that encourages all clinicians to select
diagnosis, treatment and maintenance modalities
that are the least invasive in order to preserve
healthy oral tissues while still achieving the natural
aesthetics outcome in the best interests of the
patient’s health and happiness.

_Treatment options for diastema closure
Treatment modalities depend on the etiological
factors and complexity of the MD. It is suggested
that treatment of a MD should be delayed until
the eruption of the permanent canines. However,
the pathological causes should be ruled out and
treated at an early stage, for example extraction
of supernumerary teeth (mesiodens) and surgical
treatment for the removal of midline cyst, tumour
and periodontal pathologies. Surgical, orthodontic
(comprehensive/short term), periodontal, directbonding and indirect restorations are the treatment
modalities that can be used alone or in combination
to achieve harmony in terms of a patient’s aesthetics, function and health.
MICD by definition is “a holistic approach that
explores the smile defects and aesthetic desires of
a patient at an early stage and treats them using the
least intervention options in diagnosis, treatment
and maintenance technology by considering the

Fig. 6

Following, I will demonstrate the clinical use of
MICD TP (minimally invasive cosmetic dentistry
treatment protocol) to close or reduce the diastema
in clinical practice (Fig. 1).8 The direct-bonding
procedure with the application of the Flowable
Frame Technique (FFT) is presented here as a special
technique.9

_Case presentation
A 20-year-old female patient presented with the
complaint that she did not like her smile because of
the large gap between her upper front teeth. The patient was very concerned about her smile aesthetics
and also aware of her speech difficulties.
Phase I: Understand
In the first step of Phase I, the patient’s perception, lifestyle, personality, and desires were explored
in a personal interview and through completion of
the MICD self smile-evaluation form. The patient,

Fig. 7

Fig. 6_Plastic strip is removed
after light curing; note beautiful
lingual frame.
Fig. 7_Lips at rest;
note MD is clearly visible.

cosmetic
dentistry 1
I 07
_ 2010

[8] => untitled

CDE0110_06-11_Koirala_CDE0110_06-11_Koirala 26.04.10 10:41 Seite 3

I MICD _ diastema closure

Fig. 8

Fig. 9

Fig. 8_MD in close-up view.
Fig. 9_Teeth #12 and 21 after
isolation with gingival
retraction cords.

who exhibited a high dental IQ, evaluated her smile
as below satisfactory.
After the interview, the disease, force element
and aesthetic defects of her smile were explored
clinically. Necessary digital photographs were taken,
along with diagnostic study models for further exploration of existing diseases, force elements and
aesthetic defects. The patient had good oral health,
normal function and no para-functional or other
destructive oral habits.
The collected clinical and diagnostic information,
such as extra and intra-oral digital photographs,
study models and X-rays, was further analysed to determine her smile aesthetic grading in terms of her
health, function and aesthetics, as well as to gain an
overview of the clinical problems and the macro-,
mini- and micro-smile defects. We found a high
frenum attachment and the space analysis of the
study model revealed a MD of 3.5 mm between teeth
#12 and 21. The tooth-size ratio of the centrals was
nearly 65 % and lacked central dominance.

Fig. 10_Light touch upon the enamel
surface of tooth #12 with diamond
point to enhance bonding process.
Fig. 11_Enamel etching with
phosphoric acid (FL-Bond Etchant)
for 20 seconds.

Fig. 10

Fig. 11

08 I cosmetic
dentistry

In the design step, a new smile with a closed gap
was designed. It is to be noted that the upper central
incisors are considered key to a smile10,11 and must
be given sufficient prominence.12 The aesthetically
acceptable width of the centrals is between 75 %
and 80 % of their length.12 In the presented case,

1_ 2010

it was logical to close the diastema completely by
increasing the width of the centrals. The types of
treatment involved, complexity, possible risk factors, complications and treatment limitation were
evaluated, and the tentative costs calculated and
presented to the patient.
The new smile was proposed through the modified digital photographs and aesthetic mock-up
of the study model. In order to correct her MD,
a frenectomy with non-invasive indirect partial
veneers was proposed as the first option and
a direct-bonding restoration without frenectomy
as the second option. However, because of financial constraints, the patient preferred the second
option.
All patient queries related to the proposed new
smile and treatment modalities were addressed in
detail. The informed consent form was signed prior
to proceeding to Phase II.
Phase II: Achieve
In the first step, the patient’s health, function and
a healthy lifestyle were established. The patient’s
smile was graded as Grade B.8 The established parameters of her oral health and function were within
normal limits, the aesthetic parameters were below
the accepted level and enhancement treatment was
to improve her aesthetic parameters further. Hence,

[9] => untitled

CDE0110_06-11_Koirala_CDE0110_06-11_Koirala 26.04.10 10:42 Seite 4

MICD _ diastema closure

Fig. 12

in this case, it was not necessary to undergo establishment treatment (like orthodontic, periodontal,
occlusal adjustment, etc.) before proceeding to the
aesthetic enhancement step. According to MICD TP,
the desire of the patient in this case was need-based
or naturo-mimetic smile enhancement.

flowable composite resin as frame material, a plastic
strip, composite brush and other usual instruments
for direct resin restorations.

_Direct-bonding restoration

_Step 1—After the completion of etching, priming
and bonding of the tooth surfaces, insert a simple
plastic strip to the level of gingival sulcus of the
tooth to be restored (Fig. 2).
_Step 2—Support the plastic matrix strip lingually
with your index finger to create a lingual contour
(Fig. 3).
_Step 3—Inject the flowable composite resin of desired shade (either opacious or translucent) and
smooth it to a thin layer with a hand instrument
or a composite brush if necessary (Fig. 4).
_Step 4—Light cure the flowable composite and
remove the plastic strip. A flowable frame is now
ready (Figs. 5 & 6). The length, shape and thickness
of the flowable frame can be adjusted using the
sharp edge of the hand instrument or a diamond
point if required.

The direct-bonding restoration technique represents the preferred therapeutic option in MICD.
It preserves maximal tooth structure and helps to
restore function and aesthetics in only a few clinical
visits. In addition, the technique is economical and
the possible need for sophisticated indirect restoration can be postponed. Direct-bonding restorations
demand excellent clinical skills. The clinician is required to incorporate various clinical techniques,
tips and tricks. Following, I would like to demonstrate a simple technique that I have applied since
2005 in various clinical scenarios and find helpful
for the upgrade of clinicians’ restorative skills.
The Flowable Frame Technique
The FFT is a simple restorative technique developed to speed up the placement and simplified
confinement of material when restoring challenging anterior aesthetic cases such as large Class IV
or Class III defects and diastema closure or reduction. As the name suggests, this technique requires

Fig. 13

Fig. 12_Uniform layer of bonding
(FL-Bond) application.
Fig. 13_Placement of plastic strip
for FFT.

Clinical steps in the Flowable Frame Technique
The following steps are to be taken:

The advantages of the FFT are:
_time and cost saving (no direct or indirect mockup required);
_thickness of the layer of restoring materials

Fig. 14

Fig. 14_Injection of flowable resin
(Beautifil Flow shade A3T).
Fig. 15_Adjustment of lingual frame
with sharp hand instrument.

Fig. 15

cosmetic
dentistry 1
I 09
_ 2010

[10] => untitled

CDE0110_06-11_Koirala_CDE0110_06-11_Koirala 26.04.10 10:42 Seite 5

I MICD _ diastema closure

Fig. 16

Fig. 17

Fig. 16_Application of Beautifil II
dentine shade A1.
Fig. 17_Dentine layer is smoothed
with a brush and light cured.

Fig. 18_Application of enamel layer
in Beautifil II shade Inc.
Fig. 19_Tooth #12 after final
restoration.
Fig. 20_Lingual frame
created on tooth #21.
Fig. 21_Teeth #12 and 21
after finishing and polishing.

(dentine, enamel and opacious group) can be
predicted;
_as with the silicone template method, an opaque
halo, mamelons, and translucent areas in the
proximal and incisal areas can be created;
_smooth palatal surface is achieved with minimal
finishing;
_smooth adaptation of the restorations can be
achieved even in the gingival sulcus; and
_it is the most suitable lingual frame creation technique for diastema reduction or closure.

_Material selection and clinical steps
for diastema closure
Material selection for diastema closure should
be guided by optical properties (light transmission

Fig. 18

Fig. 19

Fig. 20

Fig. 21

10 I cosmetic
dentistry

1_ 2010

and diffusion characteristics) and tissue responses
of the materials (restoration in diastema closure
normally touches the gingival tissue and sulcus).
Amongst the various materials available, Giomers are
amongst the latest category of micro-hybrid lightcured restorative materials and are touted as the
true hybridisation of glass ionomers and composite
resins, as they have the fluoride release and recharge
of glass ionomers and the aesthetics (shade, polish
and optical properties), handling and physical properties of composite resins. Giomer restorative and
adhesive systems have good bio-compatibility13 and
have been reported not to result in long-term post
operative sensitivity.14 They have also been found to
possess anti-plaque formation properties.15 Hence,
giomer direct-restorative materials and adhesive
systems were selected to close the MD in this case.

[11] => untitled

CDE0110_06-11_Koirala_CDE0110_06-11_Koirala 26.04.10 10:42 Seite 6

MICD _ diastema closure

Beautifil Flow Shade #A3T with giomer adhesive
system FL-Bond II (SHOFU Inc.) were used in FFT to
create the lingual frame. Beautifil II (SHOFU Inc.)
dentine shade A1 and enamel shade Inc. were used
to restore the defects using the bi-layered shading technique to achieve the desired aesthetics
with an invisible restoration. The Direct Cosmetic
Restoration Kit and the Super-Snap Rainbow Technique Kit (both SHOFU Inc.) were used to prepare the
teeth and to finish and polish the final restorations
(Figs. 7–22).
Phase III: Keep in touch
After completion of the treatment, the importance and role of the keep-in-touch concept to
the long-term success of aesthetic enhancement time and costs involved. The MICD TP guides the
procedures were briefly explained to the patient. clinician and the patient and helps both to underShe was advised to continue her normal oral stand, plan and complete the clinical case using
hygiene procedures and shown how to keep the diagnosis and treatment modalities that are the
interdental space of the closed diastema clean. least invasive in order to preserve sound tooth
In the final step of MICD TP, the patient was re- structure and achieve natural aesthetics, considerquested to fill out the MICD clinical evaluation form. ing the patient’s best interests._
The patient evaluated her new smile
as excellent and mentioned that MICD summary ten
she was fully satisfied with the over1. SMILE SELF-EVALUATION: BELOW SATISFACTORY
all clinical services at our centre.
2. SMILE GRADE: B
The MICD summary ten (Table I ➝)
3. TREATMENT CATEGORY: TYPE I
helps to evaluate the overall success
4. TREATMENT COMPLEXITY: GRADE I
of the case.

_Conclusion

Fig. 22

Fig. 22_Final smile.

Table I

5. PROPOSED TREATMENT: ACCEPTED
6. ESTABLISHMENT OUTCOME: NOT APPLICABLE (N/A)
7. SMILE RE-EVALUATION: N/A
8. ENHANCEMENT CATEGORY: NATURO-MIMETIC (NEED-BASED)
9. EXIT REMARKS: EXCELLENT
10. CLINICAL SUCCESS: SATISFACTORY

Diastema closure or reduction in
clinical practice requires detailed
case analysis. The successful treatment of diastemata depends on etiological factors, size and extent of the diastema,
and the patient’s affordability in terms of treatment

Editorial note: A complete list of references and the MICD
forms are available from the publisher.

_about the author

cosmetic
dentistry

Dr Sushil Koirala is the founding president
of the Vedic Institute of Smile Aesthetics and
the chief instructor of Comprehensive Aesthetic
Dentistry, a two-year training programme based
upon Vedic philosophy of beauty and aesthetics. He maintains a private practice
focusing primarily on MI cosmetic dentistry (MICD). Based on more than 17 years of
clinical experience in aesthetic dentistry, Dr Koirala developed the Vedic Smile Concept,
the Smile Design Wheel, the MICD TP, and various clinical techniques for direct
aesthetic restorations. He is the founding president of the Nepalese Academy of
Cosmetic and Aesthetic Dentistry and South Asian Academy of Aesthetic Dentistry.
He has published numerous clinical articles in aesthetic dentistry and authored A clinical guide to Direct
Cosmetic Restorations with Giomer, published by Dental Tribune International GmbH. In addition, Dr Koirala
serves as Editor-in-Chief of cosmetic dentistry_beauty & science. He frequently conducts hands-on
programmes and delivers lectures globally on smile aesthetics. He can be contacted at skoirala@wlink.com.np.

cosmetic
dentistry 1
I 11
_ 2010

[12] => untitled

CDE0110_12-13_Hohl_CDE0110_12-13_Hohl 26.04.10 10:46 Seite 1

I case report _ hemisection

Hemisection
of a front tooth
Authors_ Dr Steffen Hohl, Germany & Dr Anne Sofie Brandt Petersen, Denmark

_A 14-year-old girl greeted us in the treatment room with a friendly smile. Her aesthetically unpleasing tooth #21 was immediately
apparent. It appeared twisted and too wide.
The mother’s comment highlighted the severity
of the situation: “My daughter generally does
not smile like that. She is embarrassed and
avoids smiling.”
Fig. 1

Fig. 2

_Case report
The patient presented with two deformed
teeth in the region of tooth #21 that were fused
together, a deformity that occurs in 0.01 % of
the population. The central and lateral incisors
in the maxilla are most frequently affected. One
can distinguish between the fusion of the tooth
surface and the whole tooth with a joint pulp
chamber (partial versus complete fusion). Fusions in milk teeth are more frequent than those
in permanent dentition are. Fusions in milk teeth
are not determinants of fusion in the permanent
dentition.
The following treatment was planned for the
patient:
1. X-ray diagnosis to determine whether the
fusion was partial or complete;
2. hemisection of the teeth along the root separation line;
3. direct capping with calcium hydroxide, if necessary, to retain the vitality of tooth #21;
4. temporary crowns; and
5. orthodontic integration of the tooth into the
dental arch.

_Summary
The fusion of two teeth occurs in the nascent
period of the teeth. There are various courses
of action in therapy that address either partial

12 I cosmetic
dentistry

1_ 2010

(only the tooth enamel) or complete (with joint
pulp) fusion.
Since the young patient had two separate
pulp chambers, the vital tooth #21 could be
retained. Should pulp opening occur during
hemisection with complete fusion, an immediate application of a hydrogen peroxide pellet
would be recommend. After a short integration
period, calcium-hydroxide paste (e.g. Kerr Life,
Kerr) should be applied to the pulp wound.
This initial therapy—direct capping—is very likely
to help keep the part of the tooth to be retained
vital.
A temporary crown, as shown in this case,
completed the treatment. After a rest period of
at least three months and monthly vitality tests,
long-term tooth retention can be expected.
Orthodontics following the hemisection should
not be performed until a six weeks healing period
has elapsed._

_contact
Dr Steffen Hohl
Estetalstraße 1
21614 Buxtehude
Germany
Website: www.dr-hohl.de
Dr Anne Sofie Brandt Petersen
Kogade 4
6270 Tonder
Denmark
Website: www.dentist.dk

cosmetic
dentistry

[13] => untitled

CDE0110_12-13_Hohl_CDE0110_12-13_Hohl 26.04.10 10:46 Seite 2

case report _ hemisection

Fig. 1

Fig. 2

Fig. 3

Figs. 1 & 2_Fusion of teeth #21 and 21a (accessory tooth germ).—Fig. 3_Orthopantomograph with illustration of the fused teeth #21 and 21a. Seemingly, the accessory
tooth #21a does not have a proper pulp chamber.

Fig. 4

Fig. 5

Fig. 6

Fig. 4_Minimally invasive, marginal incision with discreet vertical relief distally to tooth #21a.—Fig. 5_Vestibular formation of a muco-periosteal flap to evaluate the fusion
between teeth #21 and 21a.—Fig. 6_The fused teeth were cut off from the crown right down to the root using a diamond-coated micro-cutter with a cutting disc.

Fig. 7

Fig. 8

Fig. 9

Fig. 7_The fused part of tooth #21a was removed by periotomy and the actual tooth #21 was retained.—Fig. 8_Openings in the pulp chamber were investigated using explorer sensors
and magnifying spectacles. The pulp chamber of tooth #21 appeared to be completely closed.—Fig. 9_Tooth #21 was carefully prepared for the incorporation of a provisional crown.

Fig. 10

Fig. 11

Fig. 12

Fig. 10_The empty alveolus of tooth #21a was filled with a collagen sponge to avoid quick resorption.—Figs. 11 & 12_Tooth #21a after exact hemisection of the fused teeth.

Fig. 13

Fig. 14

Fig. 15

Fig. 13_Plastic covering of the alveolus of tooth #21a. Wound closure was carried out with absorbable suture materials and through surface adhesion with cyanoacrylate.—
Fig. 14_Post-op view.—Fig. 15_Post-op view after one week.

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I special _ root recession

Root recession coverage
made predictable using
resorbable barriers
Authors_ Dr David L. Hoexter, Dr Nikisha Jodhan & Dr Jon B. Suzuki, USA
_Gingival recession is defined as the location
or displacement of the marginal gingiva apical
to the cemento-enamel junction (CEJ).1 Recession is the exposure of root surface, resulting
in a tooth that appears to be of longer length.
From a patient’s perspective, recession means an
unaesthetic appearance and is associated with
ageing.
The gingiva consists of free and attached gingival tissue, as seen macroscopically. The free
marginal gingiva, located coronal to the attached
gingiva (AG), surrounds the tooth and is not attached to the tooth surface. The AG is the keratinised portion of gingival tissue (KG) that is dense,
stippled and firmly bound to the underlying periodontium, tooth and bone. In ideal health, the most
coronal portion of the AG is located at the CEJ,
where the most apical portion is adjacent to the
muco-gingival junction (MGJ). The MGJ represents
the junction between the AG (keratinised) and
alveolar mucosa (non-keratinised).2
There are numerous aetiological factors that
may result in recession. Generally, the aetiology
can be categorised as either mechanical or as
a function of periodontal disease progression.
Recession usually occurs due to tooth malposition,3–5 alveolar bone recession,6,7 high muscle attachments and frenal pull,8 and iatrogenic factors
related to restorative and periodontal treatment
procedures.3,9
The detrimental effects of recession include
compromised aesthetics, an increase in root sensitivity to temperature and tactile stimuli, and an
increase in root caries susceptibility due to cementum exposure. Thus, the main therapeutic goal
of recession elimination is gingival root coverage
in order to fulfil aesthetic demands and prevent
root sensitivity.

14 I cosmetic
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1_ 2010

Miller classifies recession defects into four categories:
_class I: marginal tissue recession does not extend
to the MGJ;
_class II: marginal tissue recession extends to the
MGJ, with no loss of interdental bone;
_class III: marginal tissue recession extends to or
beyond the MGJ; loss of interdental bone is apical
to the CEJ but coronal to the apical extent of the
marginal tissue recession;
_class IV: marginal tissue recession extends beyond the MGJ; interdental bone extends apical
to the marginal tissue recession.10
A possible treatment modality for recession includes restorative/mechanical coverage, such as
cervical composite restorations. This kind of treatment may effectively manage root sensitivity and
root caries. However, such treatment entails a longterm compromise from an aesthetic perspective.
Composite restorations stain over time, and any
marginal leakage may lead to secondary caries,
recurrence of sensitivity and/or local inflammatory
changes. Additionally, colour matching can be difficult and such restorations may involve the undesirable removal of vital tooth structure in order to
create adequate retention form. Thus, clinicians
must determine whether the restorative benefits
outweigh the aesthetic shortcomings and whether
is it possible to employ a treatment modality with
few, if any, functional and aesthetic disadvantages.
Another treatment modality for recession is
muco-gingival surgery. Muco-gingival surgery refers to periodontal surgical procedures designed to
correct defects in the morphology, position and/or
amount and type of gingiva surrounding the teeth.11
In the early development of muco-gingival surgery, clinicians believed that there was a specific

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special _ root recession

BEFORE

Fig. 1

Fig. 2

Fig. 3

Fig. 4

In order to improve aesthetics and increase KG
for root coverage procedures, current periodontal
surgery largely involves the use of gingival grafts.
There are a multitude of surgical techniques, which
can be distinguished based on the relationship between the donor and recipient sites. Gingival graft
procedures involve either (a) pedicle soft-tissue
grafts, which maintains the pedicle blood supply, or
(b) free autogenous soft-tissue grafts. Techniques
involving the latter type require the clinician to prepare two surgical sites: one to harvest the tissue (1)
and another one to prepare the recipient site (2).
In this case, the autogenous soft-tissue graft has
a separate blood supply to the recipient site. Combinations of (a) and (b) have also been reported.22–24

Fig. 1_Pre-op labial view
of anterior teeth: recession
on tooth #6; tooth #7 surrounded
by a small adequate zone
of keratinised apical tissue.
Fig. 2_Flaps reflected preserve
the interproximal tissue,
which preserves the blood supply
and prevents black triangles
(unaesthetic interproximal
spaces).
Fig. 3_The GTR membrane
was shaped and placed over the
root surfaces of teeth #6 and 7.
Fig. 4_Gingival tissue was
coronally repositioned, covering
the membranes and the roots
of teeth #6 and 7,
and sutured in place.
Fig. 5_Post-op view:
the previously recessed roots
of teeth #6 and 7 are covered
with attached pink, keratinised
gingival tissue, with no pocket
depth upon probing.

AFTER

minimum apical-coronal dimension of AG that was
necessary to maintain periodontal health. However,
subsequent clinical12–15 and experimental studies16,17
have demonstrated that there is no minimum
numerical value necessary. However, for aesthetics,
a uniform colour and value of AG is desirable
amongst adjacent teeth.18
Some of the earliest techniques for correcting
recession involved extension of the vestibule.19
The subsequent healing usually resulted in an increase of AG. However, within six months, as much
as a 50 % relapse of the soft-tissue position was
reported.20,21 Thus, these techniques did not adequately address recession.

Fig. 5

The pedicle soft-tissue graft was first described by
Grupe and Warren in 1956.25 This involved raising a
full thickness flap and laterally positioning and then
suturing donor tissue into place from an adjacent area,
while maintaining a pedicle blood supply. This technique and others that followed were designed to increase the zone of AG. Later modifications of the technique included the double papilla flap26—introduced
by Cohen and Ross in 1968—the oblique rotational
flap27 and the rotational flap.28 Another type of gingival movement flap was described later as the coronally repositioned flap.29 This technique involves mobilising a full thickness flap and repositioning the tissue
to the CEJ, thereby covering the exposed recession.
The use of free gingival grafts was described in
the 1960s by Sullivan and Atkins.30 The free auto-

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I special _ root recession
genous graft can be made up of either epithelialised
gingiva or connective tissue. Initially, the therapeutic goal was to increase the zone of KG. The clinical
objective has now evolved to covering the recessed
root with a zone of attached KG. This can be achieved
in one or two stages. Initially, Sullivan and Atkins described a one-stage procedure in 1968. Its purpose
was to increase the zone of KG without concentrating on coverage of a recessed root. In the 1980s,
a two-stage modification was suggested for an
increase in root coverage, which proved to be more
successful with increased predictability. This involves first placing the free gingival graft or the
free connective tissue graft apical to the area of
recession, and using the coronally repositioned
technique after healing.
Free autogenous grafts are predominantly harvested from the palate. Recently, materials other
than gingival grafts have been explored. Using
a guided tissue regeneration (GTR) technique, an
acellular dermal matrix has been reported to yield
favourable outcomes in root coverage.31,32 This
material may provide the patient with a less invasive
alternative than a palatal donor site, in order to
achieve root coverage.
Procedures combining both free grafts and pedicle techniques have also been detailed. For instance, when a connective tissue graft is employed,
the graft is placed sub-epithelially with a coronal
advancement of the overlying keratinised tissue.
GTR techniques have also been developed more
recently. In 1992, Pino Prato et al. described a combination technique of sub-epithelial placement of
a membrane with coronal advancement of the flap,
such as e-PTFE.33 The function of the membrane is to
maintain space during the healing period for tissue
regeneration to occur. From a patient’s perspective,
biodegradable membranes with GTR might be preferable in order to avoid a second-stage surgery for
membrane removal.
The goal is to restore gingival health, colour and
aesthetics by covering the exposed root predictably with healthy gingival tissue and in doing so
decrease sensitivity. Using GTR and coronal repositioning techniques, we achieve predictably covered
roots.
Variations in muco-gingival procedures have
been developed to include root surface bio-modifications by treating the root surfaces with a variety
of materials. These measures enhance the regeneration process of a new connective tissue attachment. In order to increase root coverage, a new
clinical attachment is necessary. Root surface biomodification involves treating the root surfaces

16 I cosmetic
dentistry

1_ 2010

with citric acid, tetracycline or EDTA in order to
remove the smear layer and expose dentinal tubules
and thus facilitate a new fibrous attachment. An
enamel matrix derivative claimed to support the
action of enamel matrix proteins by inducing acellular cemetum, periodontal ligament and alveolar
bone formation is also available in the range of root
surface bio-modification materials.
The following case report considers predictable
aesthetic root coverage by comparing a GTR technique to a non-GTR technique in a split-mouth
procedure involving the same patient.

_Case report
A young, adult male patient presented with
recession bilaterally in his maxilla. The upper right
maxilla had extensive recession on teeth #6 and 7
(Fig. 1). The upper left maxilla had similar recession
on teeth #11 and 12. Additionally, tooth #11 had
a cervical groove, which was stained and hard but
not decalcified.
After local anaesthesia using lidocaine, the
desired flap design was completed. There was an
adequate zone of KG present before treatment,
which was preserved and repositioned coronally.
Upon reflection of the tissue, the full extent of the
underlying recession was evident (Fig. 2). The area
and recession were uncovered following removal
of debridement and granulomatous tissue. The
resorbable membrane material was shaped and
placed on the exposed roots. The membrane was
first placed on tooth #6 and thus the tooth appeared
darker as it absorbed blood. The membrane was
placed on tooth #5 second and thus the tooth had
not absorbed the blood at the time of the photograph, which accounts for the colour difference at
this time.
The coronally repositioned flap was sutured in
place with the flap covering the now submerged
membranes and previous recession (Figs. 3 & 4).
Periodontal dressing (Coe-Pak, GC) was utilised as
a bandage and placed over the surgical area. It was
removed a week later at the same time as the sutures. The patient then lavaged and returned to
the usual oral hygiene routine, initially lightly and
gradually more vigorously. Once healed and oral
health was maintained, the recession was covered
and health regenerated. Upon periodontal probing,
no pockets were present (Fig. 5). The final view presents a visual symmetry of health and colour that is
maintainable.
Recession was also present at the maxillary left
side (teeth #11 and 12; Fig. 6). After local anaes-

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special _ root recession

Fig. 6_Pre-op labial view
of anterior teeth.
Fig. 7_Cervical groove on
tooth #11 is solid, hard
and non-carious.

BEFORE

Fig. 6

Fig. 7
Fig. 8_GTR membrane placed
over the root surface of tooth #11
only; no membrane was placed
on the surface of the recession
of tooth #12.
Fig. 9_Gingival tissue coronally
repositioned to cover
the GTR membrane on
tooth #11 and tooth #12.

Fig. 9

Fig. 8

thesia of the areas involved, a full thickness mucoperiosteal flap was completed. This exposed the
extent of the recession defects (Fig. 7). Tooth #11
was treated, as was the other side of the mouth,
by utilising the GTR technique using an acellular
connective tissue membrane to preserve the space
for regeneration. Tooth #12 was treated the same
way, except that no membrane barrier, resorbable or
non-resorbable, was used (Figs. 8 & 9). Thus, there
was no use of a GTR technique on tooth #12. Both
teeth had the flap manipulated with the coronally
repositioned graft, covering the recessed root and
suturing to the CEJ level. Both sides were covered
with periodontal dressing. Antibiotics (tetracycline)
and an analgesic (Tylenol-Codeine) were prescribed
for the first week after the operation.
One week after the surgical phase, the dressing
and sutures were removed and the mouth lavaged.
Oral hygiene was restored to good, maintainable
habits following the healing phase of over two
months. Upon observation, tooth #11, for which
the GTR membrane had been employed, had reattached healthy gingiva that was not probable.
The recessed root and the stained cervical groove
were covered. In contrast, tooth #12, for which
no GTR membrane had been utilised, displayed
recession as prior to the surgery (Fig. 10).
In summary, this split-mouth technique demonstrated that using an acellular resorbable barrier

Fig. 10_Post-op view.

AFTER

Fig. 10

membrane is more predictable for achieving root
recession coverage than coverage of a recessed
root without such a membrane._
Editorial note: A complete list of references is available
from the publisher.

_contact

cosmetic
dentistry
Dr David L. Hoexter
654 Madison Avenue
New York, NY, USA

Tel.: +1 212 355 0004
E-mail: drdavidlh@aol.com

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CDE0110_18-19_Levitch_CDE0110_18-19_Levitch 26.04.10 10:54 Seite 1

I business _ practice management

The benefits of
expanding and refurbishing
your practice
Author_ Anne Levitch, Australia

_There are many benefits to refurbishing or
relocating your dental practice, and although the
decision to make such major physical changes to
your surgery is usually secondary to other financial
concerns, most practitioners find that they receive
more than the obvious benefits with a new surgery.
The opportunity to streamline the operation of your
practice and attract new patients can be immensely
Fig.business.
2
profitable to your
By increasing the functionality of your surgery, the productivity of your
staff will improve. Patients will also feel more comfortable in a fresh, well-organised, private practice.

Fig. 1

After about ten years, the furnishings and fittings
in most dental practices become worn. Fashions also

Fig. 1_Before.

18 I cosmetic
dentistry

1_ 2010

change—to such an extent that even the most stylish design in 1997 can simply highlight the age of
your practice today. Patients expect a clean, modern
surgery design and associate it with the highest
standards in health care. Most commercial leases
are for five years, so the end of your second lease is
often a convenient time to consider relocating your
practice. Generally, the life of your equipment is also
about ten years, considering changes in technology
and the availability of spare parts.
The main factors involved in the decision regarding a new surgery are room for expansion, practice
image, privacy for patients and staff, movement
and functionality, standards of hygiene, and the age

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business _ practice management

Fig. 2_After extension
into adjoining tenancy.

of equipment. Relocating to larger premises allows
for the expansion of your surgery and the facilities
to take on more staff, and therefore, more patients.
Space adjoining your existing premises may be
available, and awareness of such opportunities is
worthwhile.
Should you update the overall image of your practice during refurbishment, you could address aspects
such as the finishes, graphics, visibility, staff image
and the facilities in your practice. Major refurbishment or relocation gives you an opportunity to overhaul the image of your practice, which can help you
attract potential patients and retain existing ones.
The traffic flow in your practice should allow for
easy movement by staff and patients, whilst maintaining the privacy of both. Refurbishing gives you
the opportunity to redesign the layout of your practice, and make better use of the space available.
Moving into a new space means your surgery can be
designed based on the knowledge of your previous
layout—its benefits and disadvantages.
Your practice will ensure a higher standard of
infection control with new fit-out and streamlined
surfaces to clean. An advantage of relocation or a major
refurbishment is the opportunity to upgrade equipment and reassess storage needs. The size and accessibility requirements of new equipment and storage
can be integrated into the design of a new practice.

Relocation carries a greater financial risk than
refurbishment, owing to the time it may take to
secure new premises and an increase in short-term
expenses, but this is usually outweighed by an
increase in business. Fitting out a new space also
eliminates the inconvenience of an interruption to
the operation of your surgery, as you can continue
practising in your old premises until the new space
has been finished.
Should you consider relocating your surgery, start
looking around generally for commercial premises
in your area 18 months in advance, in order to better
determine the range of spaces available and learn of
future opportunities? Looking ahead of time will help
you to secure a space that is appropriate and affordable for your new surgery. Should you inform agents
and owners that you are looking for premises, these
opportunities may come to you._

_contact

cosmetic
dentistry
Anne Levitch
L2/280 Pacific Hwy
PO Box 216
Lindfield NSW 2070
Australia
E-mail: info@levitch.com.au

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CDE0110_20-21_Lavine_CDE0110_20-21_Lavine 26.04.10 10:56 Seite 1

I business _ online reputation

Word-of-mouth 2.0
How leveraging one’s
online reputation can
help attract new patients
Author_ Dr Lorne Lavine, USA

_It is an undisputed fact that in the world of
dentistry, no amount of expensive advertising or fancy
marketing can beat the power of word-of-mouth referrals from your satisfied patients. What your patients
say about you is the ultimate driver of your business
success. Today, consumers increasingly turn to the
Internet to locate and select a dental practice. Understanding this and using the right tools will help you create and maintain the most relevant, valuable practice
builder you’ll ever have: the experience and feedback of
your own patients shared with millions of prospective
patients actively seeking a new dental practice. It’s
up to you to choose: will your online reputation consist
of a single thread of random gossip, or will it become
your most valued asset, carefully managed and nurtured to give you the best return on your investment?
Everyone knows consumers will share a good experience with a few people, but they’ll make a point of
telling the world about a negative one. As a service
provider, you and your staff are your brand. You don’t
sell widgets; you sell your skills, experience, specialties,
personalities, hours and location—and your very existence and livelihood depend on your reputation.
We all work hard to ensure our patients have a good
experience and ask that refer us to friends and family
based on this. Now, take that most valuable scenario,
expand it to hundreds and even thousands of prospective patients, and you’ve just moved from the world of
offline word-of-mouth referrals to the sophisticated
new world of online reputation-based marketing—or
word-of-mouth 2.0.

20 I cosmetic
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1_ 2010

We know that in the growing world of online
reviews, consumers want and expect to find the local
user information they seek, whether it’s a great Italian
restaurant or a top-notch cosmetic dental practice.
As the Internet has come of age, our universe of availability for goods and services has exploded. The advent
of local reviews provides a return to neighbourhood
intimacy—and neighbourhood reputation.
It is highly likely you already have an online reputation, and may not even know it. Through online web
sites, consumers can review and rate your business.
There is no way to know whether their comments
are legitimate. In fact, these people may have never
seen your dental chair. Like it or not, these consumers
are establishing your online reputation—without your
knowledge, without your control—and there has been
nothing you could do to manage this exposure, until now.

_Driving patient volumes
As you probably know, the largest and most powerful search engine is Google. Today, 67 per cent of all
online searches are conducted using Google. Google
sees 3.2 billion visits per month. You can optimise your
web site to come up in the free, natural search results
when prospective patients google for a dental practice.
If you choose to pay for exposure, you can subscribe
to Google Adwords (https://adwords.google.com/
select/Login), paying for each ‘click’ generated from
Google to your web site. The higher you bid for a click,
the higher your placement in the sponsored section
of Google.

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business _ online reputation

There are many dental practices that bid more than
US$6 for every click, resulting in thousands of pounds
spent on Adwords each month. One particular practice
I am aware of spends more than US$3,000 a month on
Adwords and claims the cost is “worth every penny”. As
with all advertising, there are limitations, even beyond
expense. Ads are companies promoting themselves,
and today’s savvy consumer recognises this and filters
information accordingly. However, even the world’s
leading search engine recognises the extreme power
and relevance of word-of-mouth feedback. Google
recently expanded its offerings to enable consumers
to search for and compare local businesses online. Try
searching for a dentist in your area by typing in your
postcode followed by the word dentist in the Google
search box. A map with a listing of ten dental practices
will be displayed above the natural search results.
To the far right of each listing is a link to reviews.
This is where a consumer can view what your patients
say about your practice. With this Google has hit the
referral jackpot: this functionality leverages consumer
relationships and capitalises on the inherent credibility
of the first-person testimonial. This is a priceless intangible—something advertising dollars just can’t buy.

_Build your reputation
So how do you, as a dentist, take advantage of this
new tool to guide and shape your online reputation?
It is important to remember that this is not a practice
snapshot in time, but rather a reputation built and
sustained over time. Your best chance of securing and
maintaining a ‘top-ten’ placement is to be amongst
the first to populate your Google profile—and to keep
a steady stream of relevant reviews and quality practice information flowing in to Google. You can do this
one of two ways: passively or actively.
The passive approach: you can hope the patients
who visit your practice have the wherewithal to create
a Google account, find your Google profile, and submit
a review. This requires time and effort on your patients’
part, and staff time to inform patients and promote the
process. Even if your staff are dedicated to making your
patients aware of the online review process, you can only
hope patients remember to follow through once they get
back to their busy schedules at home and work. If history
is any guide, a passive approach will result in one or two
reviews posted over the course of several months.
The proactive approach: today, the only integrated
approach to proactively managing your online reputation on Google is through companies such as
Demandforce (http://demandforce.com/), an online

patient-communication company. They recently announced a data integration agreement with Google
that enables dental practices to populate their Google
profiles easily, including posting reviews directly from
data originating from their communication systems.
With Demandforce, each patient is automatically
sent a thank-you e-mail message after each appointment. As part of the thank-you, they can choose to
submit a confidential survey of their visit, as well as
a public review. You can read the reviews of your
practice and post a response or ask for a review to be
removed if it does not meet standard posting requirements. After seven days, the data is automatically sent
to Google to populate your profile.
This proactive approach results in dozens of reviews
being posted to your profile every month. In addition to
Google review management, Demandforce will optimise
your profile by submitting additional information such
as specialties, languages spoken, insurance accepted,
hours of operation and affiliations. You can also choose
to integrate online scheduling directly into your profile.
The new Google review functionality is included at no
additional cost with a standard monthly subscription.
Whether you opt to take a passive approach or a
proactive approach to building your online reputation,
I highly recommend you take charge to ensure it accurately reflects and therefore benefits your practice.
Your online reputation is your business and those
practices that realise this early on will have a significant head start over their peers.
Solicited or not, online reviews are here to stay.
Our patients’ satisfaction and their resulting word-ofmouth referrals will always be our bread and butter;
only the serving plate has changed. What are you doing to shape your online reputation? Have you googled
your practice or your competitors lately?_

_about the author

cosmetic
dentistry

Dr Lorne Lavine is
founder and president
of Dental Technology
Consultants, a company
that aims to address the
specialised technological
needs of the dental
community. He can be
contacted at DrLavine@
TheDigitalDentist.com.

cosmetic
dentistry 1
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_ 2010

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CDE0110_22-26_Reznick_CDE0110_22-26_Reznick 26.04.10 10:57 Seite 1

I digital dentistry _ CT-guided implant surgery

“Once you’ve tried it, you
can’t drink anything else”
Author_ Dr Jay B. Reznick, USA
This was an enlightening moment for me, as I saw the
potential in this technique. As soon as it was available in
the US and the cost became more reasonable, I vowed
to bring this technology into my practice so that my
patients could benefit from this amazing innovation.

Fig. 1

Fig. 2

Fig. 1_Pre-op view of failing tooth
#10 in a 70-year-old female patient.
Fig. 2_Pre-op radiograph showing
a horizontal fracture, root canal
treatment and a cast post.

Fig. 3_CEREC 3D virtual model with
proposal of provisional restoration.

These two pioneering systems opened the door
for the current tidal wave of CT-guided implant surgeries. For those of you not familiar with the concept,
CT-guided implant surgery uses 3-D CT imaging to
evaluate the bony anatomy of the edentulous jaw, uses
this for implant planning, and then accurately transfers the treatment plan to the patient at surgery using
a custom surgical guide that controls the position, angle, and depth of each drill and implant fixture. It is so
accurate that a custom provisional or even final prosthesis can be made that is delivered with minimal, if
any, adjustment needed. It is a panacea for the restorative dentist because implant placement is completely
prosthetically driven, not dictated by the surgeon’s
whim if there are anatomical surprises when the tissue
is flapped open. The anatomy is known with 3-D accuracy before surgery, and should bone or tissue augmentation be necessary to position the implants properly,
this information is known ahead of time and additional
procedures are planned. The result is perfectly placed
implants in ideal bone that are straightforward to restore and function properly nearly all of the time.
Even though I did not use CT-guided surgery for
every implant case, I probably completed a hundred
cases or more in those first two years. It was a very
time-consuming process. I had to have the laboratory
make a radiographic template, arrange for the patient
to have a CT scan, have the scan redone should the
technician not have followed the protocol exactly,

Fig. 3

22 I cosmetic
dentistry

_Way back in 2005, I was listening to a speaker
discuss a new way of placing dental implants that
would revolutionise the process. He showed a video
of an elderly Swedish man strolling into a dental clinic
with a bag full of ill-fitting dentures, and walking out
later that same day with fully implant-supported final
prostheses. The process used 3-D computed tomography (CT) imaging to plan the implant placement, and
then a custom surgical guide was made that facilitated
the flapless placement of a dozen or so implants so
precisely that only minimal adjustments would be
necessary to the prefabricated fixed bridges. The cost
of this treatment was about US$100,000, rendering
it beyond reach for the majority of patients.

Early in 2006, I flew to Chicago and took the NobelGuide training course, and within a short time I had
half a dozen cases under my belt. I was amazed by how
quickly and accurately I could place multiple implants,
and that most patients needed only a few post-operative ibuprofens and were back at work the next day.
Soon thereafter, I acquired SimPlant software and
began using both methods for treatment planning
and placing implants.

1_ 2010

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digital dentistry _ CT-guided implant surgery

import the DICOM files into the software program,
clean up the scatter, treatment plan the implants, and
then see the patient for a second consultation to review the treatment plan. Because of the significant
time and effort required to complete a computerised
treatment plan, I generally reserved this process for
the more complicated cases or those for which accurate implant placement was critical. Most cases were
done the ‘old-fashioned way’ during this period.
My next revelation came in 2007, when I first saw
the GALILEOS cone-beam computed tomography
(CBCT) scanner and started thinking about incorporating this into my practice. The beauty of it was not the
scanner itself, as most CBCT scanners on the market
render a good image; it was the software. GALAXIS and
GALILEOS Implant were developed with the dentist in
mind, as opposed to most other CT viewing and implant-planning programmes, which were modified
from existing medical CT software. With very little instruction, I was able to navigate through the images
and start planning implant surgery like an expert.
Sirona, the manufacturer of GALILEOS, hit a home
run, in my opinion, when they considered the entire
work flow in designing the software suite that was
included with their machine. With the simple click of
a tab, the same software programme used for viewing
the scan diagnostically could quickly and easily be
used for treatment planning implants, and then ordering a custom surgical guide.
Once I had brought GALILEOS into my office, life became easier. Now, as soon as my patient was scanned,
using a radiographic template, the images could be
brought up on the monitor, and then implant planning
could begin immediately. What previously took at least
30 minutes of my time and two patient visits was now
possible in less than 5 minutes in a single appointment.
As a result, cases that I previously considered to be too
simple to treat using CT-guided surgery techniques
were now suitable candidates. Before I knew it, I was
utilising this technology for practically every implant
case. The only exception was a case in which a patient
could not wait the seven working days that it currently
takes to have the surgical guide manufactured. CTguided implant surgery has the benefits of increased
accuracy of implant placement through a smaller,
minimally invasive incision. Another major benefit to
the implant surgeon is decreased surgical time, which
allows one to schedule more patients and more procedures in the day. Of course, this is of little benefit
if treatment planning becomes very time-intensive.
The beauty of the GALILEOS Implant/siCAT system is in
the integration of work flow that makes the implant
planning phase rapid and effortless. An additional plus
is improved inventory control. Instead of requiring
a variety of implant sizes for a single case, the exact

Fig. 4

fixture diameter and length are predetermined, so only
a single fixture has to be ordered per site.
We have traditionally relied on panoramic radiographs and study models to plan our implant placement. Surgical stents have always been used in implantology to aid in this process. The traditional surgical

Fig. 4_GALILEOS treatment planning
report demonstrating position
of implant in relationship
to existing restoration.

Fig. 5

Fig. 6

Fig. 7

Fig. 5_Placement of implant through
siCAT surgical guide using
Facilitate Surgical Guide.
Fig. 6_Provisional abutment
attached to immediately
placed implant.
Fig. 7_Provisional crown on implant
immediately after placement.

cosmetic
dentistry 1
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I digital dentistry _ CT-guided implant surgery
Anatomical variations also pose challenges, such as
a high lingual mylohyoid concavity, a surprise pneumatised sinus, or a divergent root that came a little too
close to the implant fixture. We do not like to have to
deal with these complications, but even the best of us
have faced them more than we like to admit.

Fig. 8

Fig. 9

Fig. 8_Post-implant cross-sectional
CBCT image demonstrating good
position and angulation in
relationship to provisional prosthesis.
Fig. 9_Tangential slice CBCT
showing implant and provisional
restoration immediately after
placement.

Fig. 10_Clinical photograph of
provisional restoration at three
months after surgery.
Fig. 11_Panoramic CBCT
reconstruction of a 62-year-old male
patient missing multiple teeth
in the maxilla. Bilateral sinus-lift
procedures had been performed
six months prior.

Fig. 10

guide is made from a wax-up on a stone model that does
not allow representation of the true bony anatomy of
the underlying edentulous ridge nor the position of
adjacent tooth roots. There are various styles of surgical
guides that have been in use, ranging from thermoplastic sheets to solid acrylic replicas of the final prosthesis.
These guides only estimate the position for the initial
drill, leaving this up to the discretion of the surgeon,
and do not control the depth of drilling. Sequential
osteotomies are then generally drilled free hand. This
introduces many opportunities for aberrant implant
positioning. Even in the hands of the most experienced
implant surgeons, up to 20 % of implant placements
vary from their intended position. Dentists need only
look in their favourite implant textbook or journal to find
examples of textbook cases that are less than perfect.
And, I have never met a restorative dentist who has not
had his or her share of similar experiences.
Often, these restorative challenges can be managed with custom abutments and other prosthetic
tricks, which significantly increase the dentist’s laboratory bill and affect the profitability of the case.
However, in some cases, the only solution is either to
not restore the fixture or to remove it and start over.

Fig. 11

24 I cosmetic
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1_ 2010

Many of my surgical colleagues are of the opinion
that CT-guided surgery is unnecessary because they
have been placing implants for many years using the
technique they learned 15 or more years ago. I completed my surgical training in 1990, and have done more
implants than I can count since then. And for the most
part, I have a very high success rate, with minimal problem cases of which to speak. But, am I perfect? Of course
not. Are my colleagues any better? I don’t think so.
I strongly believe that CT-guided techniques will become the standard of care for implantology within the
next ten years, or sooner. Those clinicians reading this
article have already demonstrated an understanding
of what new technologies can do for the practice of
dentistry. I’m sure that few of you who own dental
CAD/CAM systems could imagine practising without
them and the benefits that this technology gives to
your patients and your practice. The same holds true
for CBCT and guided implant surgery.
In September 2009, I was honoured to be the surgeon for the introduction and first live demonstration
of the integration of GALILEOS CBCT data with that
from a CEREC digital impression and prosthetic proposal. CEREC uses surface-scanning technology to
capture a digital impression of the hard and soft tissues
around an area where a dental implant is being considered. GALILEOS uses a radiographic source and sensor to image the bony anatomy in the area of interest.
The multiple views are then processed by a computer
to create a 3-D image of the teeth and bone, which can
be viewed in an infinite number of cross-sectional cuts.
Both types of images are nothing more than a set of
digital data translated into an image that can be viewed
on a monitor. Merging these two sets of numbers
appears to be a simple process. However, I am not
a software engineer; I am just a dentist. Luckily for us,

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digital dentistry _ CT-guided implant surgery

Fig. 12_3-D image reconstruction
from GALILEOS Implant software
showing implant planning for tooth
#15, based on imported CEREC
virtual model and prosthetic proposal.
Fig. 13_3-D image reconstruction
from GALILEOS Implant software
showing implant planning
for teeth #2 to 5, based on imported
CEREC virtual model and
prosthetic proposal.

Fig. 12

Fig. 13

there are some smart people at siCAT, Sirona’s software
subsidiary in Germany, whose mandate was to do just
that. Their efforts have changed implant dentistry
forever. With the integration of CEREC and GALILEOS,
we now have the opportunity to practise real digital
implantology. The restoration of a patient’s missing
dentition can be treatment planned in virtual reality,
without the need for physical impressions, pour-up
study models or wax-up prostheses. The ability to visualise the patient’s bony- and soft-tissue anatomy in relationship to the proposed prosthesis is a tremendous
advantage in attempting to follow the principles of
prosthetically driven implant dentistry. This facilitates
restoration, optimises functional forces on the implant
fixture, and improves long-term implant success.

time saved can be used by the surgeon to schedule
another consultation, surgery, or recreational activity.

Another benefit of CT-guided implant surgery is the
ability to perform the procedure through a minimal incision. This is possible because the underlying 3-D bony
anatomy is known preoperatively. Also, since the surgical guide directs the position, angulation and depth
of each drill, the surgical time is significantly reduced.
This translates to an easier post-operative course for
the patient. Because the implant is placed in the ideal
position, functional loads on the implant fixture are
more ideal. This helps maintain optimal peri-implant
bone levels and reduces the failure rate. The resulting

The following cases demonstrate the types of
implant treatment plans that can be treated using
3-D CT-guided surgical techniques through the integration of GALILEOS and CEREC.

_Case I
This first patient was a 70-year-old woman with a
failing maxillary left lateral incisor. The tooth had been
treated endodontically many years before and had
a post-retained fixed prosthesis that was subject to
repeated failures (Fig. 1). The tooth was not restorable
and a decision was made to remove the tooth and replace it with an immediately placed dental implant and
provisional prosthesis (Fig. 2). The patient understood
and agreed that the immediate implant and prosthesis would not be placed in function for three months
after placement.
A stone study model was made, and the crown
of tooth #10 was removed. This modified model was
captured by CEREC in order to create a digital model
that represented the site after tooth extraction.
The opposing dentition was captured in a Futar D

Fig. 14

Fig. 14_Panoramic reconstruction
of CBCT showing proposed implant
positions and abutment screw paths.
Fig. 15_Prepared siCAT surgical
guide for Facilitate Surgical Guide.

Fig. 15

cosmetic
dentistry 1
I 25
_ 2010

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I digital dentistry _ CT-guided implant surgery

Fig. 17

Fig. 16

Fig. 16_Post-op panoramic CBCT
reconstruction showing position
of placed implants.
Fig. 17_3-D reconstruction of post-op
CBCT showing placed implants in the
right maxillary posterior region.

(Kettenbach) bite registration and the prosthetic proposal was created in CEREC (Fig. 3). The digital model
and prosthetic proposal were then imported into
GALILEOS. The ideal implant size and position were
determined within the GALILEOS scan, based on the
bony anatomy data, as well as the mucosal surface
and prosthetic data from CEREC (Fig. 4). The treatment planning data, along with the stone model and
a special scanning template were sent to siCAT, and
a custom surgical template was returned.
This template was used in surgery once the tooth
had been atraumatically extracted in order to direct the
placement of the implant fixture into the site of tooth
#10. The position, angulation, and depth of implant
placement were all controlled by the guide, so that the
implant was placed exactly where it had been planned
in the 3-D imaging software (Fig. 5). A provisional abutment was placed (Fig. 6), and the patient was sent to
her dentist for a digital impression and fabrication of
a CEREC-produced provisional crown (Fig. 7). The
procedure to remove the tooth and place the implant

_about the author

cosmetic
dentistry

Dr Jay B. Reznick is a Diplomate of the American Board of Oral and
Maxillofacial Surgery. He received his dental degree from Tufts University,
and his MD degree from the University of Southern California, and trained
in Oral and Maxillofacial Surgery at LA County-USC Medical Center. His
special clinical interests are in the areas of facial trauma, jaw and oral
pathology, dental implantology, sleep disorders medicine, laser surgery
and jaw deformities. He also has expertise in the integration of digital photography, 3-D imaging, and CT-guided implant surgery in clinical practice.
He frequently lectures at continuing education meetings, and has published articles in the
Journal of the American Dental Association; Journal of the California Dental Association; Oral
Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology; Compendium of
Continuing Education in Dentistry; DentalTown Magazine; CE Digest; and Gastroenterology.
Dr Reznick is a founder of OnlineOralSurgery.com, which educates practising dentists in basic
and advanced oral surgery techniques. He serves on the editorial and advisory boards of
a number of journals and organisations. He is the Director of the Southern California Center
for Oral and Facial Surgery (www.sccofs.com) in Tarzana in California, and a consultant
for various dental and surgical manufacturers. He can be contacted at jreznick@sccofs.com.

26 I cosmetic
dentistry

1_ 2010

took under ten minutes. Post-operative GALILEOS
scan images indicated accurate implant placement
(Figs. 8 & 9). At the three-month follow-up appointment,
the provisional restoration was stable. The gingival
architecture and tissue health were excellent (Fig. 10).

_Case II
This second case illustrates the tremendous power
of the integration of GALILEOS and CEREC for treating
the partially edentulous patient. This patient was a 62year-old man with moderate bone loss due to smoking.
He was otherwise healthy. He was missing teeth #2 to
5 and 15, and had undergone bilateral sinus-lift surgery to augment the bony deficiency in the posterior
maxilla (Fig. 11). In preparation for implant placement,
a GALILEOS CBCT scan was performed with a siCAT
scanning template. A full-arch digital impression was acquired with the CEREC AC unit, and then prosthetic proposals were designed for teeth #2 to 5 and 15. This data
was then imported into GALILEOS for implant planning
(Figs. 12 & 13). The position of the implants was verified
(Fig. 14) and the surgical guide was ordered from siCAT
(Fig. 15). This was used to place four Astra Tech dental
implants accurately using the Facilitate Surgical Guide
(Astra Tech). Post-operative radiographs demonstrated
that all four implants were accurately placed and in
accordance with the treatment plan (Figs. 16 & 17). The
patient had an uneventful post-operative course.
One of my favourite cocktails is the Vesper Martini,
which was introduced to the world in the novel Casino
Royale when James Bond asked the bartender to mix
him this variation on his standard drink. Bond named
the drink after Vesper Lynd, his love interest in the story
because, he confessed, as with her, once you've tasted it,
that's all you want to drink. CT-guided implant surgery
is no different for me. After years of planning and placing dental implants the old-fashioned way I learned in
residency, I was given a taste of a new way to do so. It
was a radical change at first, but once I knew the recipe,
I realised that it was a faster, better and more accurate
way to treat my patients. Now, I can’t drink anything
else. Hopefully, you will give it a taste too and agree._

[27] => untitled

MiCD ad (lady)-DT.indd 1

2/9/10 5:35:26 PM

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I feature _ interview

Patients demand
instant aesthetic results
An interview with Dr Sim Tang Eng, AAAD president

Dr Sim Tang Eng

_cosmetic dentistry: Dr Sim, would you please
tell us a bit about yourself, your background and your
initial involvement in dentistry?
Dr Sim Tang Eng: I graduated from the University of Malaya in 1985 and obtained my MFGDP(UK)
in 1997. I undertook clinical attachment in Oral Implantology at Goethe University Frankfurt and was
awarded the Certificate in Oral Implantology in 2001.
I served as part-time clinical supervisor and lecturer
in the Faculty of Dentistry at the University of Malaya
and was a lecturer of the Oral Implantology course organised jointly by the University of Malaya and Goethe
University Frankfurt. I am now in a private group practice and my work is focused on aesthetic dentistry and
implantology.
_How was the Asian Academy of Aesthetic Dentistry
(AAAD) established and who qualifies to be a member?
The AAAD was established as an umbrella body for
the various aesthetic dentistry academies/associations/societies in the many Asian countries. Following
a preliminary meeting in Korea of interested representatives from Korea, Japan and Singapore in 1989, a formal meeting was convened at the Prince Philip Dental
Hospital in Hong Kong for the founding of the AAAD on
15 January 1990. At this historic meeting, which was
chaired by Prof Stephen Wei, the founding officers
were unanimously elected, with Prof Michio Haga from
Japan as Founding President of the AAAD. Since then,
the Academy has grown annually and the number
of member countries has increased from the original
three to include China, Hong Kong, India, Indonesia,
Malaysia, Nepal, the Philippines, Taiwan and Thailand.
In order to become a member of AAAD, one must
hold a university dental degree. One can become a
member through the institutional membership of an
aesthetic dentistry organisation in one of the member
countries, or privately. The AAAD aims to have all member countries register as institutional members in order
to simplify the logistics of keeping track of membership
records.
_The 11th biennial AAAD meeting is going to be held
in May. What objectives would you like to fulfil through
this year’s meeting?

28 I cosmetic
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1_ 2010

In accordance with the objectives of AAAD, the main
objective will be the promotion of the art and science
of the disciplines in aesthetic dentistry. This is the first
time that the biennial AAAD meeting will be held in
Malaysia and it certainly is an opportunity for many
of our dental colleagues to experience the meeting
and visit beautiful Malaysia. I hope the meeting will
foster greater understanding amongst Malaysian and
other Asian dentists, besides providing an opportunity
to experience the excellent scientific meetings that
AAAD organises biennially in this region.
This year’s biennial meeting boasts some of the best
speakers and clinicians in aesthetic dentistry in the
world. It is very difficult to book them and we thus
had to plan their lecture schedules way in advance. This
meeting will be a golden learning opportunity for our
colleagues in Asia, particularly in Malaysia. Thanks to
this meeting, our colleagues will not have to fly half way
around the globe and pay hefty registration fees in
order to hear these top speakers at meetings in USA
and Europe. I am sure it will be an eye-opening and
rewarding experience to see and hear the level of
aesthetic dentistry presented by the four keynote
speakers, Dr Galip Gurel, Dr Mauro Fradeani, Dr Didier
Dietschi and Dr Rhys Spoor. In the process, I hope
attendees will be inspired and never look at aesthetic
dentistry the same way again.
_In your opinion, how important is continuing
education in the field of cosmetic dentistry?
Very important! In fact, I strongly believe that
all dental professionals who profess to practise
aesthetic or cosmetic dentistry must keep up-to-date
with the developments in dental materials, technology
and clinical techniques, as this clinical discipline
changes dynamically and rapidly. They have to possess
knowledge of sound scientific theories and clinical
practice. They owe it to their patients who entrust them
with the responsibility of providing quality aesthetic
dentistry. This is only possible if the dentists keep
abreast of developments through continuing education.
_What options for continuing education are
available for Asian dentists?

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feature _ interview

There are basically two options available. Firstly, besides the biennial AAAD meetings, dentists can attend
the numerous scientific meetings and hands-on workshops organised regularly by the various national
aesthetic dentistry organisations in the Asian region.
Those who are really eager can attend the meetings
organised by the International Federation of Esthetic
Dentistry, American Academy of Esthetic Dentistry,
European Academy of Esthetic Dentistry and American
Academy of Cosmetic Dentistry. These are excellent
meetings but dentists will have to travel great distances
to the meeting venues. Secondly, dentists can attend
the structured programmes organised by universities.
Several US universities offer courses, on part-time
or full-time basis, tailored for aesthetic dentistry. In
addition, it is extremely important for dentists to read
journals and textbooks regularly in order to enrich their
knowledge. I find that most dentists want to take the
easy route by depending only on lectures and fellow
colleagues for information.

on the rise for obvious aesthetic
reasons. The trend for quick fix with
veneers or crowns in mildly crowded dentition instead of conventional orthodontic
treatment is also gaining in popularity, especially amongst working adults. Patients demand
instant aesthetic results with
the least amount of interference in their lives.
Even in orthodontics,
I understand that
patients request invisible braces. More
patients are also aware of the
appearance of their gingiva
instead of just their teeth and
this has invariably resulted in
increasing demand for periodontal plastic
surgery as well. The list goes on and on.

_Standards and education vary greatly throughout
the region. Do you see your organisation as a representative for the profession?
I certainly think this is the way forward. The AAAD
can act as an accreditation body by conducting courses
and examinations regionally for aspiring dentists
who wish to be proficient in aesthetic dentistry. Those
qualified can then be awarded a fellowship so that patients can recognise them as having achieved a certain
acceptable standard.

_Asians tend to be guided by Western stereotypes
in terms of aesthetics. Have you witnessed this pattern
in dentistry?
Rightly or wrongly, I think it is generally true.
Just ask any dentist who has been practising aesthetic
dentistry long enough. It is not uncommon to have
patients coming into the office with close-up photographs of Western models or film stars with the request
to have their teeth done the same way.

_What are the objectives of the AAAD and what role
does the Academy play in Asia?
This is best summarised by the objectives of the
AAAD as stated in the constitution. The Academy
is a non-profit and non-political organisation and shall
not discriminate against creed or race. The Academy
shall promote the art and science of disciplines in aesthetic dentistry, and popularise and advance the science and practice of aesthetic dentistry by organising
regular scientific meetings. Furthermore, the Academy
shall encourage research in Aesthetic Dentistry and inform the public of aesthetic dentistry and its practices
through periodic news releases.
_Driven by patient demand, the field of aesthetic
dentistry has gained much prominence in recent years.
What are the current trends in aesthetic dentistry in
Asia?
With greater exposure to the media and the Internet, as well as increasing affluence, Asians have followed trends in the West when it comes to demands
in aesthetic dentistry. Increasingly more patients now
chose veneers or have their teeth bleached in order
to obtain their ideal set of sparkling white teeth. The
preference for full-ceramic crowns instead of the traditional porcelain-fused-to-metal crowns is definitely

_What is perceived as an attractive smile in Asia?
I think the general rules governing an aesthetic
smile apply universally. Tooth proportion of the anterior teeth is generally the exception. Asians tend to have
narrower anterior teeth, i.e. lower width-to-length
ratio compared to Caucasians.
_As witnessed at all major dental exhibitions last
year, digitalisation is the new trend in dentistry. What
has the effect of this increasing digitalisation been?
It certainly is a boon to the practice of aesthetic
dentistry. It makes communication and presentation
so much easier. The archiving of clinical photographs,
which is of utmost importance, is now an easy task
thanks to digitalisation.
_What are your plans for the future?
My term as the AAAD President ends with my handing over of office to Prof Hisashi Hisamitsu at the
biennial meeting this coming May. I will continue to
contribute in whatever way I can to the progress of the
AAAD, particularly in the areas of sharing my clinical
knowledge with the various national aesthetic dentistry organisations. I will remain active in my clinical
practice, as I believe one can only teach and share
meaningfully if one has the experience and regular
practice._

cosmetic
dentistry 1
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_ 2010

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I feature _ interview

Digital dentistry is finally
becoming a reality
An interview with Hans Geiselhöringer, Head of Global Marketing & Products, Nobel Biocare
exchange of data and information among all partners involved in the treatment process is an important criterion for success. In this way, NobelProcera
is breaking ground in dentistry.
_These are challenging economic times. Why
should dentists and dental laboratories change to
NobelProcera?
Dentistry will see significant changes through
these new technologies in the years to come. We have
indeed reached the moment at which ‘digital dentistry’ is finally becoming a reality and I am convinced
that this is the time to change from conventional to
CAD/CAM technologies. NobelProcera was designed
to grow with the rising demands of the user through
regular updates of the system and the software.
Fig. 1_Hans Geiselhöringer at
a NobelProcera symposium
in Singapore.

_NobelProcera, which was first introduced to
the public in March 2009 at the International Dental
Show, is the most comprehensive prosthetic solution
in the history of Nobel Biocare. According to the company, it can design and fabricate prosthetics for every
clinical indication and treatment option, from single
tooth to full mouth. cosmetic dentistry spoke with
Hans Geiselhöringer, Head of Global Marketing &
Products, Nobel Biocare, about the system and how it
will affect the dental lab sector in the years to come.

With the new generation of CAD software, the
construction of frameworks is no longer necessary,
which is another important element. Automated
processes no longer provide only a recommendation for the later framework production after scanning the master model or the impression. Moreover,
ideal dimensioning can be achieved through only an
additional scan of the setup with the help of lateral
scans. Working processes that once took hours to
complete can now be achieved in a few minutes.

_cosmetic dentistry: The new NobelProcera
scanner has been available since June 2009. How
is it intended to influence the workflow between
dentists, technicians and patients?
Hans Geiselhöringer: The new NobelProcera
system has to be considered as a single unit. By combining high-precision scanning technology, intuitive design software and industrial manufacturing
processes, excellent product quality is guaranteed
for almost every clinical indication whether it be on
natural teeth or dental implants.

I know that it is difficult to introduce new systems into the daily work routine of a laboratory and
to keep technicians up-to-date with new developments, but from my point of view, it is better and
more efficient to have one system for all indications.
In addition, a system like NobelProcera gives users
the opportunity to outsource production, which
saves time and the need for continued special training of technicians. NobelProcera also helps to reduce costs for each step in production.

Our years of experience with NobelProcera
are helping users not only to begin using digital dentistry but also to achieve immediate success in mastering the new technology. Of course, CAD/CAMsupported work processes contribute to the improvement of efficiency and precision, but the quick

30 I cosmetic
dentistry

1_ 2010

Our systems, products and concepts are certainly
validated by scientific research, as we want to be
a reliable partner for our clients.
_NobelProcera utilises conoscopic holography
technology. What are the advantages of this technique over comparable systems?

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feature _ interview

There is no truly comparable system available on
the market yet; NobelProcera is the only scanner
that exclusively utilises conoscopic holography
technology. Most other systems are based on triangulation, which does not offer the same amount
of applications offered by NobelProcera. These disadvantages have already been discussed in several
publications and, therefore, I won’t discuss them
here.
The conoscopic holography technology of
NobelProcera is based on a particular type of
polarised light interference process that has been
proven in several long-term trials and in other
fields of industry. The main advantage over
conventional CAD/CAM systems is that the conoscopic system is based on collinear measurement,
which means that the light source and the detector are not arranged at the same angle. The
collinearity offers not only higher accuracy of
measurement and sensitivity robustness against
optical defects, but also the ability to scan a wide
range of geometric figures and shapes, including
cavities. Besides high accuracy, productivity in

dental laboratories can be further increased by
batch scanning.
However, it is the precision of NobelProcera that
gives the ability to scan several implants or whole
implants systems in a patient in order to realise
supra-constructions like the NobelProcera Implant
Bridge or the new NobelProcera Overdenture solutions. I think the sheer amount of applications
cannot be achieved by any other system on the
market right now, with the exception of highprecision industrial scanners.
_Although a wide range of materials is available
for almost all indications, the focus is often only
on zirconium oxide. What other materials are available, and what are the main differences between
them?
You are talking about something that has been
on my mind for quite some time and it is something
I see everyday in my own laboratories here in
Munich. Zirconium oxide is an excellent material
for many clinical indications but not for all. Longterm stability is not the only decisive factor; the

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CDE0110_30-32_GeiselhInt 26.04.10 11:04 Seite 3

I feature _ interview
warns users if requirements for dimensional stability are not met.
_Critics say that the automated fabrication of
dental restorations may be the death of dental
technology as we know it. What is your response?
Definitely not. In a tough market environment
like the one we are operating in now, large-capacity
laboratories, as well as small- and medium-sized
companies gain significant advantages from using
CAD/CAM. Improved efficiency and rationalisation
do not automatically result in a reduced workforce.
In fact, there are new opportunities for specialisation. Human resources, for example, can be used
more economically, as uneconomical and timeconsuming production steps, such as cast fabrication and moulding, are eliminated.

Fig. 2_The NobelProcera Scanner.

requirements and preferred treatment methods
of the practitioner involved, and the financial costs
to the patient have to be considered as well.
Besides zirconium oxide in four different colours
for restorations on natural teeth, implant abutments and screw-retained prosthetic solutions,
aluminium oxide is available as the material of
choice in aesthetically demanding areas, for example in the anterior dentition. Titanium can be used
in all cases in which zirconium oxide is not clinically
acceptable.
We are also going to extend the material offering in the upcoming weeks with cobalt-chrome
alloys and acrylics. I expect our laboratory clients
will appreciate this offering, as they can pass this
on to their clinical partners for support of all clinical indications.
_How do these developments benefit the longterm success rates of conventional and implantsupported restorations?
For Nobel Biocare, long-term success is primarily connected to the safety and quality standards
we offer our patients and customers. Owing to our
many years of experience in the CAD/CAM field and
our high requirements of material and product
quality, we are able to offer a five-year warranty on
all our products, based on the harmonised working
processes and the support we give the user regarding optimal construction design. For example, the
software takes material-related specifications during the virtual framework design into account and

32 I cosmetic
dentistry

1_ 2010

The answer to whether it would be profitable to
run an own milling system in the laboratory is also
no. Only large-capacity milling centres can do this.
Ongoing observation of all production processes,
constant surrounding conditions and freedom of
choice of materials and their complementary
milling systems are only a few reasons that speak
for a centralised fabrication of frameworks. In
addition, time-consuming maintenance, updating
and the need to change milling heads are eliminated, which can only be economical under full
capacity.
However, we do not only talk about shortening
and simplifying the production processes but also
about minimising risks that could result from
CAD/CAM-produced restorations. Remaking incorrectly fitting restorations no longer strains the
budget of laboratories because if these systems are
utilised correctly, free remakes are usually included
in the warranty.
_What consequences will arise from these
developments for dental technicians?
In the near future, we will see further specialisations and the rise of new professional categories,
for example dental designers and dental engineers.
These new professionals will play a pivotal role in
dentist–patient communication. By eliminating
inefficient and error-prone working processes,
more resources will be available for such important
aspects as treatment planning and communication
with practitioners, as well as the functional and
aesthetic finish of the restoration.
Needless to say, this new CAD/CAM technology
won’t be able to replace the individual experience
and expertise of dental staff. However, it is a useful
addition to ensuring our patients the best quality
and safety._

[33] => untitled

emax_2010_ad_kataoka_e+IND+SING_A4.qxd

22.2.2010

16:16 Uhr

Seite 1

“IT’S AN
EASY
DECISION.”
Shigeo Kataoka, Dental Technician, Japan.

If durable all-ceramic crowns are required, the
decision is easy: IPS e.max lithium disilicate. With
this material, you can fabricate robust crowns
quickly and efficiently. Given the material’s high
esthetics, veneering in the posterior region is
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[34] => untitled

CDE0110_34-36_Ivoclar_CDE0110_34-36_Ivoclar 26.04.10 11:07 Seite 1

I industry report _ composite resin

Opalescent
composite resin
Author_ Ulf Krueger-Janson, Germany

Fig. 1

Fig. 2

Fig. 1_Initial findings: defective
restorations in teeth 11 and 21.
Fig. 2_Incisal view.

Fig. 3_View after removal
of the old fillings.

Aesthetic integration is accomplished by
placing special optical effects. Composite materials with a high opacity (similar to dentine)
and relative translucency (similar to enamel) are

required for this. Composite restorative systems
that additionally include an opalescent material
that allows the bluish areas (frequently observed
along the marginal ridges) and yellowishwhitish portion of incisal edges to be reliably
mimicked, offer just about everything the clinician needs to restore a case aesthetically.
The new IPS Empress Direct system (Ivoclar
Vivadent) includes such an opalescent material,
which enables the reproduction of the abovementioned optical phenomena owing to its
shade effects.
Opalescence is an optical effect exhibited by
some substances. It is caused by the refraction of
the various wavelengths of visible light due to
the small structures in the substance. As a result,
the substance exhibits an intensive bluish tinge
in incident light, whereas it has milky yellowish
appearance in transmitted light, just as is the
case in natural opal stone. In restorations, the
light that strikes the composite material and is
reflected from it appears bluish. Against the
light, however, the composite has a slightly milky
appearance with a yellowish tinge. The incisal
edge of natural dentition often has this appearance.
The clinical case described here involved the
replacement of two defective proximal restorations (Fig. 1). An initial analysis of the various
shade layers of which the natural teeth were

Fig. 3

34 I cosmetic
dentistry

_Experience has shown that aesthetically
pleasing composite restorations in the anterior
region can only be created, if the clinician succeeds in achieving a near-perfect shade match
between the restorative material and remaining
dentition. In general, state-of-the-art composite restoratives should be easy to handle, adapt
to cavity walls and offer good surface finishing
qualities. At the same time, however, it is essential that they allow the restoration to blend harmoniously into the natural oral environment.

1_ 2010

[35] => untitled

CDE0110_34-36_Ivoclar_CDE0110_34-36_Ivoclar 26.04.10 11:07 Seite 2

industry report _ composite resin

Fig. 4

composed demonstrated that the optical incisal
edge effects described above were particularly
eye-catching in this case. Moreover, the bluishwhitish line extended far into the interproximal
area. The challenge was to create a highly aesthetic restoration. We strove to achieve this by
means of a slight reduction of the diastema and
the application of opalescent effects. Following,
I describe the way improved restorative results
can be achieved if an opalescent material is also
available (IPS Empress Direct Trans Opal, Ivoclar
Vivadent).
The incisal view of the teeth shows the undulating contour of the incisal edge (Fig. 2). As secondary decay was diagnosed, the old fillings
were completely removed (Figs. 3 & 4). A perforated, one-sided diamond abrasive strip was

Fig. 9

Fig. 5

used to bevel the preparation margin (Fig. 5).
Thus, minimally invasive roughening and bevelling of the enamel surface were ensured in the
equi-gingival cervical region. Following etching
with phosphoric acid and conditioning with
ExciTE bonding agent (Ivoclar Vivadent), a matrix
band was placed (Fig. 6). The band was slid into
the sulcus along the proximal tooth surface
and secured with a transparent wedge from the
palatal side (Fig. 7). The anaemic appearance of
the surrounding gingiva indicated that nontraumatic compression of the tissue had been
achieved. In the palatal view, the size-1 wedge is
clearly visible. Owing to the pressure it exerts, the
interdental space was slightly enlarged. The matrix band was secured once in an optimum position. Then the first layer of composite material
(IPS Empress Direct Dentin Shade A3) was placed

Fig. 6

Fig. 4_Defects viewed from
the vestibular aspect.
Fig. 5_Bevelling of the preparation
margin using diamond abrasive strips.
Fig. 6_Placement of the matrix band.
Fig. 7_Palatal view.
Fig. 8_Application of the first
composite increment.
Fig. 9_Further IPS Empress Direct
Dentin Shade A3 increment.
Fig. 10_Completion of the dentine
core using IPS Empress Direct
Dentin Shade A2.
Fig. 11_Coverage with IPS Empress
Direct Enamel Shade A2.
Fig. 12_Contouring of the final tooth
shape using IPS Empress Direct
Trans Opal.

Fig. 7

Fig. 10

Fig. 8

Fig. 12

Fig. 11

cosmetic
dentistry 1
I 35
_ 2010

[36] => untitled

CDE0110_34-36_Ivoclar_CDE0110_34-36_Ivoclar 26.04.10 11:07 Seite 3

I industry report _ composite resin

Fig. 13

Fig. 14

Fig. 15

Fig. 16

Fig. 13_A matrix band has been
inserted in the interdental space
between teeth 11 and 21; etching
gel has already been applied.
Fig. 14_A layer of IPS Empress Direct
Trans Opal was applied to complete
the composite build-up.
Fig. 15_Situation immediately after
completion of treatment.
Fig. 16_Final photograph taken
one week after the treatment,
showing complete closure
of the interdental gap.

and adapted in such a way that it created a preliminary outline of the proximal contours (Fig. 8).
Subsequently, a further layer of composite
was added (Fig. 9). This was followed by a layer
of Dentin Shade A2 (Fig. 10), which served to
optimise the shade adjustment. Next, a layer of
Enamel Shade A2 (Fig. 11) was placed and the
build-up was completed with Trans Opal. Figure
12 demonstrates the building up of the composite materials to create the final tooth shape,
which also simplified morphological contouring
during the finishing procedure. For finishing, an
EVA tip handpiece was used. This handpiece performs oscillating movements. Owing to the fine
tip, completely non-traumatic finishing was ensured, particularly along the transition between
the filling material and sulcus. The fine reduction, which was achieved by means of suitable
grit size (the green or blue ring is used for prepolishing), enables targeted finishing. Therefore,
over-contouring of the composite restoration
was not necessary. The surface was finished
exclusively with an EVA tip and subsequently
polished with a pre-polisher and high-gloss
polishers (Astropol, Ivoclar Vivadent). Polishing
brushes (Astrobrush, Ivoclar Vivadent) were
used to finish the surface with a final high-gloss
sheen.
In tooth 11, a matrix band was used to shape
the proximal surface (Fig. 13). The band also
served to protect tooth 21 from the etching

36 I cosmetic
dentistry

1_ 2010

gel that was applied immediately afterwards.
The wedge was placed with tension in order to
establish a perfect separation of the teeth.
The intention was to reduce the diastema substantially. The primary composite increments
were applied according to the protocol described above. The final layers were also placed
based on the previously mentioned criteria.
Also, in this case, Trans Opal material was used
to complete the build-up (Fig. 14). After polishing the restoration to a high lustre, a slight
colour discrepancy due to the dryness of the
superficial enamel portion was recognisable.
The interdental papilla was still slightly compressed owing to the wedge (Fig. 15). The final
photograph (Fig. 16), which was taken one
week after placement of the restoration, shows
a completely healthy papilla and virtually
invisible composite restorations with lifelike
opalescence._

_contact

cosmetic
dentistry
Ulf Krueger-Janson
Stettenstraße 48
60322 Frankfurt/Main
Germany

E-mail:
ulf.krueger-janson@email.de

[37] => untitled

CDE0110_37_Fotona_CDE0110_37_Fotona 26.04.10 11:13 Seite 1

industry report _ Fotona

‘Myth busting’
laser dentistry
_Lasers are fairly new in mainstream dentistry. Their benefits are still not known to many
dentists and patients, and several myths about
lasers still exist. Therefore, we would like to do
a little bit of ‘myth busting’.

four quadrants during
the same appointment.

_Lasers are a bad
investment

_Lasers cut slower than
high-speed burs

Lasers are not inexpensive,
but so is every investment in
your future. Once you understand
the benefits of lasers, the return on investment is obvious.
With less need for anaesthesia, more treatments
in multiple quadrants during shorter visits can be
performed, increasing pervisit productivity. Dual
laser systems, such as AT
Fidelis, allow you to treat
more conditions efficiently and less invasively, even
those you were previously
not able to treat. Combined
with more patient referrals and added exposure
by setting your practice
apart from others, it is
evident that lasers are indispensable to a modern
practice._

This can be true for laser systems
that deliver the laser through
an optical fibre. In order to
protect the expensive fibre,
laser energy must be kept
low. In order to circumvent
this, Fotona’s Fidelis dental
laser systems utilise an articulated arm and advanced VSP
Technology that allow the laser
to deliver much more energy
for efficient laser drilling. These
lasers cut at comparable and
even higher speeds than conventional high-speed burs.1
A recent study has demonstrated that Fotona’s hard-tissue
Er:YAG laser cuts 3 times faster
through dentine and 4.2 times
faster through enamel than
an Er,Cr:YSGG laser delivered
through an optical fibre
(Waterlase MD, Biolase).2

_Lasers are 100 % painless
Ninety per cent of patients feel no discomfort
at all during Er:YAG laser treatments.3 Fotona’s
Fidelis lasers are thus predominantly used
without anaesthesia. Some procedures and
certain patients require local anaesthesia and
usually a topical anaesthetic suffices for some
soft-tissue procedures, while larger hard-tissue procedures may require a local injection.
Nevertheless, patient comfort is dramatically
improved—no needles, no noise, no vibration,
no numbness. In cases in which no anaesthesia
is used, patients can receive treatments in all

Editorial note: A complete list of
references is available from the publisher.

_contact

cosmetic
dentistry

Fotona d.d.
Stegne 7
SI-1210 Ljubljana
Slovenia
Tel.: +386 1 5009 178
Website: www.fotona.com

cosmetic
dentistry 1
I 37
_ 2010

[38] => untitled

CDE0110_38_Voco_CDE0110_38_Voco 26.04.10 11:14 Seite 1

I industry news _ VOCO

Perfect Bleach:
Effective and gentle
_Simple and user friendly

_With Perfect Bleach, VOCO offers a home
whitening system that meets all of the requirements of modern tooth whitening and thus the
highest aesthetic demands in an equally simple
and cost-effective way. Vital teeth that are discoloured because of ageing or diet-related accretion can be whitened quickly and effectively.
Devitalised teeth can also be whitened externally
and internally. The treatment of tetracycline discolouration, superficial enamel discolouration
from fluorosis, and discolouration caused by
trauma due to bleeding is also possible. Perfect
Bleach is a carbamide peroxide-based home
whitening material. Depending on the type of
discolouration, either a 10 % or 17 % concentration can be used.

_Gentle and effective
Distinct whitening success can be achieved
with whitening gels containing low concentrations of carbamide peroxide and with a simultaneous gentle treatment of the tooth substance.
The carbamide peroxide concentration in Perfect
Bleach is sufficiently high to provide effective
and gentle treatment of discolouration. The
sodium fluoride and potassium in 17 % Perfect
Bleach ensure that hypersensitivity is prevented
during and after the treatment. Perfect Bleach
provides a thorough oxidation of accumulated
pigments without damaging the tooth substance or existing restorations.

38 I cosmetic
dentistry

1_ 2010

The application of Perfect
Bleach is uncomplicated and
user friendly: the patient simply fills the custom-fabricated and optimal fitting
trays with the high viscosity
gel and wears them as instructed. Wearing the trays
for two hours is sufficient for
the gel to achieve full effect.
Initial results are already evident
after the second application. As the
viscosity of the gel ensures it does not run out
of the tray, gingival irritation is prevented.
The fresh mint flavour is also pleasant for the
patient. Furthermore, the concentration of the
carbamide peroxide gel remains stable even if
the cold chain is interrupted.

_Complete Set and Patient Kit
The Perfect Bleach Complete Set contains all
the components needed: six 2.4 ml syringes of
whitening gel, two deep-drawing films, one
1.2 ml syringe of Block Out Gel LC for the fabrication of the trays, application pictogram
card, shade guide to verify treatment success,
storage case for the trays, and a cosmetic bag.
The Patient Kit contains four 2.4 ml syringes
of whitening gel, application pictogram card,
shade guide, storage case for the trays, and a
cosmetic bag._

_contact
VOCO GmbH
P.O. Box 767
27457 Cuxhaven
Germany
Website: www.voco.com

cosmetic
dentistry

[39] => untitled

CDE0110_39_Vita_CDE0110_39_Vita 26.04.10 11:16 Seite 1

industry news _ VITA

VITA Easyshade Compact:
The new generation
in digital shade-taking
_Since its introduction in 2003, VITA
Easyshade, the optoelectronic shade-measuring
unit, has convinced dentists and dental technicians by its simple handling and high degree of
accuracy in the objective shade determination
of natural teeth and dental restorations. With
the arrival of VITA Easyshade Compact, the
second generation of the measuring device, the work of dentists and dental
technicians will now be even further
facilitated. VITA is proud to present
VITA Easyshade Compact at upcoming international trade shows.
VITA Easyshade Compact is the
lightweight and ergonomic form of
the previous model. The advanced
spectrophotometric technology ensures precise and swift results in
the determination of natural tooth
shades and the shades of dental
restorations. Results are displayed in the shade codes of
the VITA classical shade guide
A1 to D4 or the VITA 3D-Master.
Other key improvements include
its cordless design, which allows
users to move freely, and a durable state-ofthe-art LED light. In addition, VITA Easyshade
Compact offers storage capacity for 25 measurements that remain stored when the unit is
switched off.
VITA Zahnfabrik, headquartered in Bad Säckingen at the foot of the Southern Black Forest
region in Germany, is an independent, familyowned enterprise. For over 80 years, the company has been doing justice to the principle upon
which it was founded, namely, product development with the goal to provide better prosthetic
restorations.
VITA develops materials and technologies
for the fabrication of high-quality dental restorations. Numerous pioneering achievements

in the fields of ceramics, artificial teeth and the
determination and reproduction of human tooth
colours have obtained worldwide recognition
in the branch._

_contact

cosmetic
dentistry

VITA Zahnfabrik H. Rauter GmbH & Co. KG
Spitalgasse 3
79713 Bad Säckingen
Germany
Tel.: +49 77 61 5 62 0
Fax: +49 77 61 5 62 299
E-mail: info@vita-zahnfabrik.com
Website: www.vita-zahnfabrik.com

cosmetic
dentistry 1
I 39
_ 2010

[40] => untitled

CDE0110_40_Kuraray_CDE0110_40_Kuraray 26.04.10 11:20 Seite 1

I industry news _ Kuraray

CLEARFIL SA CEMENT:
Top Self-adhesive Resin Cement of 2010
Kuraray, established in Kurashiki in
Japan in 1926, was originally involved in
the industrial production of synthetic
fibres from viscose. Through intensive
research and development work, the
company has created a broad base of
experience and technology in the sectors
of polymer chemistry, chemical synthesis
and chemical engineering.

_As science and society continue to develop,
new questions and challenges arise for dental
materials. With the innovative self-adhesive
resin cement CLEARFIL SA CEMENT, which was
first presented in Europe at IDS 2009, Kuraray
Europe introduced a new dualcuring, self-etching resin cement
that meets the demands of today’s
dental practice.
CLEARFIL SA CEMENT was recently
voted the Top Self-adhesive Resin
Cement of 2010 by The Dental Advisor.
Excess paste can now be removed in one piece
or in larger bits with little effort. Kuraray’s unique
adhesive monomer (MDP) ensures a consistent,
strong bond strength and low technical sensitivity.
The high mechanical stability ensures an excellent
marginal seal, while the auto-mix syringe and the
optional dispensing gun (CLEARFIL DISPENSER)
provide a direct and comfortable way of using the
material without the necessity of mixing. A precise
application, even directly into the root canal, is
possible with the use of the Endo Tip.
According to the company, CLEARFIL SA CEMENT
can be used for the adhesive attachment of fullceramic, composite, metal or zirconia crowns,
bridges, inlays and onlays.

40 I cosmetic
dentistry

1_ 2010

Thanks to its technological strength and
comprehensive experience, Kuraray has
developed in no va tive
products for many different branches of business such as the dental
industry. In 1978, for
example, the company introduced the
first bonding system
CLEARFIL BOND SYSTEM F that marked the
beginning of the age of adhesive dentistry. At the
same time, the company developed the total-etch
technique for enamel and dentin.
Today, Kuraray continues to produce innovative high-quality products such as PANAVIA F 2.0,
CLEARFIL PROTECT BOND or CLEARFIL SE BOND.
Between April and July, Kuraray will be exhibiting at international meetings such as the AACD
Annual Meeting 2010 (booth 1110), at Amici di
Brugg (pavilion C7, booths 66–95, lanes 2 & 3),
Dental 2010 (hall 1.0, booth C011, Oraltek) and
IADR in July (halls 1–8, booth 506, MAB Dental)._

_contact

cosmetic
dentistry

Kuraray Europe GmbH
Hoechst Industrial Park, Building F 821
65926 Frankfurt/Main
Germany
Tel.: +49 69 305 35 825
E-mail: dental@kuraray.eu
Websites:
www.kuraray-dental.eu / www.sa-cement.eu (Europe)
www.kuraraydental.com (USA)

[41] => untitled

The best of two worlds.
®
Identium.
Polyether

A-Silicone

Identium®

For more information: Kettenbach GmbH & Co. KG, Im Heerfeld 7, 35713 Eschenburg · Germany

Phone: +49 (0) 2774 7050, www.kettenbach.com

020819_1409

Utilizing the best characteristics of two well-known
impression materials, Kettenbach has developed an
entirely new one: Vinylsiloxanether.® Designed especially
for the one-step impression technique: Identium.®

[42] => untitled

CDE0110_42_SAAAD_CDE0110_42_SAAAD 27.04.10 11:43 Seite 1

I meetings _ SAAAD 2009

The first South Asian cosmetic
and aesthetic dental congress
Author_ Dr Suhit R. Adhikari, Nepal

Fig. 1

Fig. 2

Fig. 1_Inauguration of the SAAAD
meeting with the lighting
of the traditional Nepalese lamp.
Fig. 2_Participants.

Fig. 3_From left to right: Dr Sandesh
Mayekar (India), Dr Vijayaratnam
Vijayakumaran (Sri Lanka), Dr Sim
Tang Eng (Malaysia) and Dr Sushil
Koirala (Nepal) after receiving their
SAAAD inaugural fellowship.
Fig. 4_Japanese delegates singing
a Japanese song at the gala dinner.
Fig. 5_AAAD President Dr Sim Tang
Eng with traditional Nepali cap.

Fig. 3

_The South Asian Academy of Aesthetic
Dentistry (SAAAD) held its first biennial scientific
meeting Minimally invasive cosmetic dentistry—
A holistic approach from 28 to 29 November 2009,
at Radisson Hotel in Kathmandu in Nepal. The
conference, which was organised in collaboration
with the Asian Academy of Aesthetic Dentistry
(AAAD), Sri Lanka Academy of Aesthetic and Cosmetic Dentistry, Bangladesh Academy of Aesthetic
Dentistry and Nepalese Academy of Cosmetic and
Aesthetic Dentistry, was attended by 225 South
Asian delegates.
The meeting was inaugurated by the presidents
of the AAAD, SAAAD and Nepal Dental Association by lighting the traditional Nepalese lamp.
The President and Prime Minister of Nepal, Dr Ram
Baran Yadav and Madhav Kumar Nepal, offered
their best wishes for the conference. As a conference
memento, the SAAAD published Dentistry South
Asia. Speakers from Bangladesh, Greece, India,

Fig. 4

42 I cosmetic
dentistry

1_ 2010

Japan, Malaysia, Nepal and Singapore presented
clinical talks on various aspects of aesthetic and
cosmetic dentistry.
The SAAAD was founded in 2005 as the first
online, regional professional academy in South Asia.
The academy is dedicated to advancing the art
and science of aesthetic dentistry and to promoting
high standards of ethical conduct and responsible patient care, by institutionalising a standard
continuing professional development programme
through the provision of a relevant accreditation
(fellowship) process.
At the gala dinner, the SAAAD awarded its
inaugural fellowship to Dr Sushil Koirala (Nepal),
Dr Sandesh Mayekar (India) and Dr Vijayaratnam
Vijayakumaran (Sri Lanka) for their outstanding
contribution to the promotion of aesthetic dentistry
in their respective countries. The next SAAAD biennial meeting will be held in Sri Lanka in May 2011._

Fig. 5

[43] => untitled

Anschnitt DIN A4

29.03.2010

11:19 Uhr

Seite 1

“Zirconia - The Truth”
Open Discussion Forum
* Panel participants - researchers, clinicians, manufacturers

4th CAD/CAM &
Computerized Dentistry
International Conference

www.cappmea.com/cadcam4

13-14 May 2010, Dubai UAE
The Address Hotel Dubai Marina

20 % Discount
for the Readers

Dr. Andreas Kurbad, Germany
CAE – Computer Aided Esthetics

Dr. Atef Shaker, Egypt
Understanding Machinable Blocks

Dr. Ilan Preiss, UK
Clinical and Laboratory Case
Presentation using the Lava
Chairside Oral Scanner

Ralph Riquier, Germany
The Digital Therapeutic ChainFrom the Patient to the Production

Dr. Dusko Gedosev, Germany
Cerec Meets Galileos

Josef Hintersehr, Germany

Dr. Philippe Tardieu, France
Proper Cementations to Proper
Objectives

Dr. Khaled Abouseada, Egypt/KSA
Computerized Orthodontics

Dr. Benoit Philippe, France
Twelve Years of Experience in
Computer-Guided Pre-implant
Reconstructive Surgeries

Prof. Georges Tehini, Lebanon
Clinical Steps And Clinical
Performance Of Crowns
Raffi Khanjian, Lebanon

Dr. Nadim Aboujaoude, Lebanon
The Tooth Preparation for
CAD CAM Technology

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[44] => untitled

CDE0110_44-47_Kern_CAD0110_44-47_Kern 26.04.10 11:24 Seite 1

I meetings _ 9 Ceramics Symposium
th

All-ceramics works
Author_ Manfred Kern, Germany

_The Society for Dental Ceramics (SDC) has
followed the development of all-ceramic materials and CAD/CAM technology for the last ten
years, reviewing and commenting on the clinical
results in the professional community, supported
by experience from its own field studies in private
practices. During this period, the number of inserted all-ceramic inlays, onlays, crowns and
bridges has increased steadily to over 5.5 million
restorations per year, thus attaining 20 % share of
the treatment volume indicated for long-term
restorations.

Fig. 1a–f_Cusp overlay, indicated
for weakened cusps.
(Photographs courtesy of
Prof Karl-Heinz Kunzelmann, Germany)

At the 9th Ceramics Symposium All-Ceramics
at a glance, which was held from 4 to 5 November 2009 in Munich in Germany, the moderator
Dr Bernd Reiss (Germany) called attention to the
results of the Tele-Dialog Survey, which demonstrated that 87 % of the symposium attendees

judged the quality of polycrystalline oxide ceramic frameworks to be better than or at least
equal to that of porcelain-fused-to-gold. Prof
Sven Reich (RWTH Aachen University, Germany)
supported this assessment and presented a thematic tour of millable CAD/CAM ceramics.
Thanks to a combination of different properties, today there is a suitable ceramic for every
indication. Silicate ceramic, known for its translucent chameleon effect, has established itself
for inlays, partial crowns, veneers, and crowns,
chiefly in the anterior-tooth and premolar regions. For extended aesthetic demands, as well as
crowns and three-unit fixed dental prosthesis (FDP)
up to the second premolar, lithium disilicate (LS2)
ceramic is available in graded opacities for press
and CAD/CAM techniques. Framework ceramics
of aluminium oxide (Al2O3) and zirconium dioxide

Fig. 1a

Fig. 1b

Fig. 1c

Fig. 1d

Fig. 1e

Fig. 1f

44 I cosmetic
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CDE0110_44-47_Kern_CAD0110_44-47_Kern 27.04.10 15:37 Seite 2

meetings _ 9 th Ceramics Symposium

Fig. 2

(ZrO2) have an opaque structure and require veneering. Owing to its partial translucency, Al2O3 is
especially suitable for crown and FDP frameworks
in the anterior and premolar regions. ZrO2 is indicated for use not only in the posterior dentition,
but also as a framework with wings for adhesive
FDPs. Prof Reich discussed the veneering fractures on ZrO2 frameworks, which have been under
discussion in the professional community for
some time. The underlying problem is that up until
a few years ago, thin-walled crown copings were
covered with thick veneer layers, and the bridges
lacked anatomically designed frameworks with
cusp support.

cusp tips or contact points. Occlusal surface veneers of pressable ceramic, suitable for the treatment of occlusal defects and vertically increasing
occlusion, do not require a chamfer and conserve considerable substance. In partial crowns
with cusp reconstruction, a substance-conserving supporting area in the enamel-dentine region
is preferable to a supporting shoulder. An overlay
is indicated when cusps are very thin (<2 mm cusp
thickness). According to Prof Kunzelmann, the
reimbursement for overlaying cusps should be
adjusted because the statutory health insurance
criteria for the partial-crown indication require
that all cusps be sacrificed. However, this contradicts the principle of substance conservation.

Fig. 3

Fig. 2_Fracture of a veneered ZrO2
bridge. The framework was ground
in palatinally (pointed droplet shape)
and did not support the veneer
adequately. The over-dimensioned
veneering layer became subject
to tensile forces.
(Photograph courtesy of
Prof Ulrich Lohbauer, Germany)
Fig. 3_Cusp-supporting coping form
prevents veneering fractures.
(Photograph courtesy of
Prof Joachim Tinschert, Germany)

_Substance conservation as the goal
Prof Karl-Heinz Kunzelmann (Ludwig Maximilian University of Munich, Germany) lectured
on Ceramic inlays and partial crowns: New
preparation concepts, pointing out that current
preparation criteria are still heavily influenced
by—the limitations of early ceramic materials and
CAD/CAM systems. Today, given the good fitting
accuracy of ceramic restorations, the enlarged
divergence angles of the gold era are no longer
necessary (Figs. 1a–f). Thus, classical divergence
angles of 6 to 10° are to be avoided, owing to the
risk of the cavity margin ending in the area of the

Dr Andreas Kurbad (Germany) covered the
range from Classical crown to minimally invasive.
In the preparation of a fully anatomical ceramic crown with a circular chamfer, up to 64 %
of the hard dental tissue can be conserved.1 In
contrast, metal-supported full crowns consume
at least 70 % in preparing the necessary retention
surfaces.2
A sure positioning of the crown is facilitated
by clear margins. It should be tactilely perceptible
when the ceramic body has reached its correct
position. Further, the advantage of adhesive

Fig. 4

Fig. 4_Embedding the
CAD/CAM-milled wax-up in order
to obtain a pressed veneer.
(Photograph courtesy of
Volker Brosch, Germany)
Fig. 5_Pressed veneers
(IPS e.max Press) with final firing
on ZrO2 framework.
(Photograph courtesy of
Volker Brosch, Germany)

Fig. 5

cosmetic
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CDE0110_44-47_Kern_CAD0110_44-47_Kern 26.04.10 11:24 Seite 3

I meetings _ 9 Ceramics Symposium
th

Table I _Failure rates of all-ceramic
bridges. ZrO2 frameworks remained
largely fracture-free; chipping
interfered with clinical success.
(Table courtesy of
Prof Matthias Kern, Germany)

Failure rates of all-ceramic fixed dental prosthesis
FIRST AUTHOR

CERAMIC

TIME
(IN MONTHS)

Pospiech 2004c

Lava

–

Suárez 2004c

In-Ceram Zr

0°

Raigrodski 2006c

Lava

–

Sailer 2007a

DCM

–

Molin 2008a/c

Denzir

Tinschert 2008a/c

DSC

0°

Wolfart 2008c

Cercon

–

Wolfart 2008c

Cercon ext-br.

–

8.1°*

Beuer 2009c

Cercon

–

9.5

Eschbach 2009c

In-Ceram Zr

–

Wolfart 2009a/c

e.max Press

0°

adhesive luting

conventional luting

° up to 25 % additional fractures

luting is that no retention forms are necessary
whatsoever. Depending on the type of material,
ceramics have translucent properties; thus, according to Dr Kurbad, dark fillings can be a difficult foundation. Pronounced discolouration
of the crown stump requires greater substance
removal, in order to allow the ceramic a greater
thickness.

_Toughness versus resistance
“The fracture toughness of the ceramic is more
important than its resistance,” explained Prof Ulrich Lohbauer (University of Erlangen-Nürnberg,
Germany) in his talk on Fracture mechanics of
all-ceramic restorations. Hence, it is an important
accomplishment that in the structure of zirconium dioxide ceramic (ZrO2), volume-expanding
compressive forces block the propagation of
micro-cracks. The fracture toughness explains
the high survival probability of crown and FDP
frameworks of ZrO2 in clinical long-term studies.
However, there has been recent discussion about
veneering fractures on ZrO2 frameworks3 because
the veneer ceramic (feldspar) has a much lower
crack toughness than ZrO2. In designing the
crown copings, it is therefore important to ensure
that cusps support the veneering layer (Figs. 2 & 3).
After grinding (fine diamond), Prof Lohbauer recommended polishing the restoration’s surface
(check with loupes) during insertion or, better yet,
sending it back to the dental laboratory for final
firing. In selecting the ZrO2 blank, Prof Lohbauer
advised using only original materials from quality-conscious ceramic manufacturers and with
proven clinical suitability, and adhering to the

46 I cosmetic
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1_ 2010

FAILURE RATES (IN %)
ANT.
PM
M
–

0°
5.5

0*
26.1°*

–

3.2*
6.7*

* 2.2–4.8 % structural fractures

procedure for the veneers. This is to ensure that
framework and veneering materials match.

_From wax knife to mouse
Master Dental Technician Volker Brosch (Germany) demonstrated the switch from wax knife
to electronic framework design, comparing the
workflow in conventional dental engineering
with the CAD/CAM technique. The digitally constructed datasets can be used to construct both
the temporary and definitive restorations. Fully
anatomical anterior and posterior crowns can be
made from the millable LS2 blanks, and multi-unit
bridges up to the second premolar can also be
manufactured from this pressable ceramic of
increased strength. Where aesthetic demands
are particularly high, the cut-back procedure is
used—the fully anatomical crown is anatomically
ground down by the thickness of the enamel layer
and then fuse-on veneered. Recently, Brosch has
made singly designed veneers of fluorapatite
pressable ceramic, digitally modelled and then
sintered onto the ZrO2 frameworks (Figs. 4 & 5).
Unique in dentistry is the multi-centre field
study by the SDC, in which dentists in private
practice can compare their findings/results on
all-ceramic restorations anonymously and individually with other participating practices. At
the time, over 5,700 restorations from more than
200 practices constituted the basis of the results.
After evaluating over 3,000 follow-up examinations, Dr Reiss, who heads this quality-control
study, recapitulated that the survival rate of inlays, onlays, partial crowns, and crowns of silicate

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meetings _ 9 th Ceramics Symposium

ceramic lies at 83 % after 13 years of observation,
putting them on par with cast restorations as
described in the literature.4 He explained that
participating dentists enter their results online
on the platform www.csa-online.net and receive
an individual, graphic treatment profile.

_ZrO2 not always necessary
Speaking on the Clinical testing of all-ceramic
restorations, Prof Matthias Kern (University of
Kiel, Germany) made it clear that ceramics must
measure up to the survival rates of metal-supported restorations. The literature demonstrates
that ceramic inlays and onlays have a clinical
durability similar to that of cast restorations.
CAD/CAM restorations demonstrate a longer
service life than pressed or laboratory-constructed restorations.5 Owing to its semi-translucency, Al2O3 is particularly well suited for crowns
in the aesthetically sensitive anterior dentition.
According to Prof Kern, it is thus not necessary
to manufacture single crowns from ZrO2. FDPs
with ZrO2 frameworks have demonstrated encouraging results; in observation periods of
up to five years, framework fractures occurred
rarely, even in multi-unit FDPs. However, some
studies described veneering fractures (chipping;
Table I). The reason for this is that originally,
trusting in the high fracture-flexural strength of
the material, ZrO2 frameworks were delicate constructions, milled out with thin walls onto which
thick veneering layers were applied, which became subject to tensile force. Prof Kern recommended wall thicknesses of no less than 0.8 mm
for ZrO2 frameworks and advised designing them
anatomically, so that the veneering is supported
by the cusps.
From the papers submitted for this year’s
Research Award in All-Ceramics, the jury selected
three studies of equal merit. The presenter of
the award thus decided to recognise all three
researchers: Dr Frank Nothdurft (Germany) for his
study Clinical testing of a prefabricated all-ceramic implant build-up of zirconium dioxide in the
posterior dentition, Dr Andreas Rathke (Germany)
for his In vitro examination of the effectiveness of
the dentin bond of ceramic inlays using different
luting concepts, and Falk Becker (Germany) for his
study Press-on and layering technique, chipping
behaviour of all-ceramic anterior crowns.

_CAD/CAM workshop reflects practical
experience
During the concluding CAD/CAM workshop
at the Clinic for Dental Prosthetics in Munich,

Fig. 6

Prof Daniel Edelhoff, Dr Florian Beuer, dentist
Peter Neumeier, dental technician Marlis Eichberger and dental technician Josef Schweiger
helped familiarise participants with the functioning of CAD/CAM systems. The clinic is equipped
with representative CAD/CAM systems (C.O.S.,
3M ESPE; Cercon, DeguDent; DigiDent, GirrbachAmann; etkon, Straumann; Everest, KaVo; inLab,
Sirona Dental Systems; Lava, 3M ESPE; Procera,
Nobel Biocare; ZENOTEC, Wieland), which are
used in scientific projects and for practical work
in patient treatment.

Fig. 6_The feldspathic veneer,
ground with CAD/CAM,
was ceramic sintered to
the ZrO2 crown framework.
(Photograph courtesy of
Josef Schweiger, Germany)

In terms of the achievable quality and precision of fit of the milled all-ceramic frame-works,
Prof Edelhoff emphasised that these are of a high
level in every respect. Schweiger pointed out that
the computerised milling systems for all-ceramic
restorations employ various grinding strategies
that are especially designed for the original blanks
of the manufacturer. ZrO2 frameworks that were
manufactured in manual copy-milling processes
(pantograph) had a worse fit and a critical structure, according to Schweiger. Prof Beuer and
Schweiger demonstrated a new way to avoid
veneering fractures: sinter veneering (Fig. 6).
In this, single veneer structures of feldspathic
ceramic are computer milled and sintered onto
the ZrO2 framework._
Editorial note: A complete list of references is available
from the publisher.

_contact

cosmetic
dentistry

Manfred Kern, Wiesbaden, Germany
Society for Dental Ceramics (Arbeitsgemeinschaft
für Keramik in der Zahnheilkunde e.V.)
E-mail: info@ag-keramik.de
Website: www.ag-keramik.eu

cosmetic
dentistry 1
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_ 2010

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CDE0110_48_Events_CDE0110_48_Events 26.04.10 11:25 Seite 1

I meetings _ events

International Events
2010
26th AACD Anniversary Scientific Session
Where:
Grapevine, TX, USA
Date:
27 April–1 May 2010
E-mail:
pr@aacd.com
Website: www.aacd.com
11th Biennial AAAD Meeting
Where:
Kuala Lumpur, Malaysia
Date:
14–17 May 2010
E-mail:
medident@streamyx.com
EAED Spring Meeting
Where:
London, UK
Date:
27–29 May 2010
E-mail:
info@eaed.org
Website: www.eaed.org
3rd International Congress for
Aesthetic Surgery & Cosmetic Dentistry
Where:
Lindau, Germany
Date:
17–19 June 2010
E-mail:
event@oemus-media.de
Website: www.oemus.com
IADR 88th General Session & Exhibition
Where:
Barcelona, Spain
Date:
14–17 July 2010
E-mail:
sherren@iadr.org
Website: www.iadr.org

IACA Annual Meeting
Where:
Boston, MA, USA
Date:
22–24 July 2010
E-mail:
info@theIACA.com
Website: www.theiaca.com
AAED 35th Annual Meeting
Where:
Kapalua, HI, USA
Date:
3–6 August 2010
E-mail:
meetings@estheticacademy.org
Website: www.estheticacademy.org
FDI Annual World Dental Congress
Where:
Salvador da Bahia, Brazil
Date:
2–5 September 2010
E-mail:
congress@fdiworldental.org
Website: www.fdiworldental.org
AACD & ESCD Joint Meeting
Where:
London, UK
Date:
23–25 September 2010
E-mail:
info@aacd.com
Website: www.aacd.com
Veneersymposium
Where:
Leipzig, Germany
Date:
5 & 6 November 2010
E-mail:
event@oemus-media.de
Website: www.oemus.com
7th Annual DGÄZ Meeting
Where:
Rottach-Egern, Germany
Date:
19 & 20 November 2010
E-mail:
info@dgaez.de
Website: www.dgaez.de
Greater New York Dental Meeting
Where:
New York, NY, USA
Date:
26 November–1 December 2010
Website: www.gnydm.org

2011
34th International Dental Show
Where:
Cologne, Germany
Date:
22–26 March 2011
E-mail:
ids@koelnmesse.de
Website: www.ids-cologne.de
7th IFED World Congress
Where:
Rio de Janeiro, Brazil
Date:
21–24 September 2011
Website: www.ifed.org

48 I cosmetic
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CDE0110_49_Submission_CDE0110_49_Submission 26.04.10 11:27 Seite 1

about the publisher _ submission guidelines

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cosmetic
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_ 2010

[50] => untitled

CDE0110_50_Impressum_CDE0110_50_Impressum 27.04.10 13:59 Seite 1

I about the publisher _ imprint

cosmetic
dentistry _ beauty & science
Publisher
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Claudia Salwiczek, Managing Editor

cosmetic

dentistry _ beauty & science
is the official publication of:

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Dr Michael Miller, USA
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Editorial Board
Dr Anthony Au, Australia
Dr Bao Baicheng, China
Dr Helena Lee, Singapore
Dr Hisashi Hisamitsu, Japan
Dr Jiraporn Charudilaka, Thailand
Dr Mostaque H. Sattar, Bangladesh
Dr Ratnadeep Patil, India
Dr Sim Tang Eng, Malaysia
Dr Suhit Raj Adhikari, Nepal
Dr Takashi Nakamura, Japan
Dr Vijayaratnam Vijayakumaran, Sri Lanka

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_cosmetic dentistry_ beauty & science is published by Oemus Media AG and will appear in 2010 with one issue every quarter. The magazine
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50 I cosmetic
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[51] => untitled

[52] => untitled

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13.04.2010 15:28:01 Uhr

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[cover] => cosmetic dentistry international

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