Cover / Editorial / Content / Case acceptance in complex-care dentistry / Use of an X-ray phantom in dental 3-D diagnostics in digital volume tomographs / Imaging in dentistry: A clinical perspective / Impression materials—Are there any REALLY new ones? / Radiant - beautiful anterior teeth / First whitener for fixed-braces orthodontics / Grandio®SO and Grandio®SO Heavy Flow / International Events / Submission Guidelines / Imprint
Cover
01 - 01 viewEditorial
03 - 03 viewContent
04 - 04 viewCase acceptance in complex-care dentistry
06 - 09 viewUse of an X-ray phantom in dental 3-D diagnostics in digital volume tomographs
10 - 12 viewImaging in dentistry: A clinical perspective
14 - 20 viewImpression materials—Are there any REALLY new ones?
22 - 24 viewRadiant - beautiful anterior teeth
26 - 28 viewFirst whitener for fixed-braces orthodontics
30 - 32 viewGrandio®SO and Grandio®SO Heavy Flow
34 - 34 viewInternational Events
36 - 36 viewSubmission Guidelines
37 - 37 viewImprint
38 - 38 viewArray
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CDE0310_01_Titel
CDE0310_01_Titel 29.10.10 12:53 Seite 1
issn 1616-7390
Vol. 4 • Issue 3/2010
cosmetic
dentistry
_ beauty & science
3
2010
| special
Case acceptance in complex-care dentistry
| opinion
Impression materials—
Are there any REALLY new ones?
| industry report
Radiant, beautiful anterior teeth
[2] =>
CDE0310_01_Titel
Ceramage Ad -CD.indd 1
8/23/10 2:29:41 PM
[3] =>
CDE0310_01_Titel
CDE0310_03_Editorial 29.10.10 11:56 Seite 1
editorial _ cosmetic dentistry
I
Dear Reader,
_I have been quite busy for the past six months, travelling to different countries to
attend various scientific conferences and official board meetings. I enjoy travelling the most
when I also have the opportunity to learn and share professional knowledge and skills while
doing so. Most of my national and foreign travels this year were related to my lectures and
official meetings, as well as to the promotion of aesthetic dentistry.
For the last ten years, I have advocated the Vedic Smile Concept and its protocol amongst
our colleagues and encouraged them to incorporate its core principles—health, honesty,
harmony and humanity (4H)—in their daily practice in order to ensure happy and healthy
patients, employees and practice owners. The concept adopts the naturo-mimetic principles
to harmonise the mind, body, behaviour and surroundings (MBBS) of a person by enhancing
his/her smile with minimal intervention.
Dr Sushil Koirala
Editor-in-Chief
During the course of my international lectures, I have always received many enquiries
about the concept. Most of these enquiries were from participants wishing to adopt it in their
daily practice, which encouraged me to start a five-day Vedic Smile Dentist Programme
in Nepal. The programme is part of the Dental Knowledge Tourism (DKT) initiative developed
by the Vedic Institute of Smile Aesthetics and offered as part of the Visit Nepal 2011 package.
DKT is a unique concept in continuing dental education programme (CDE) that creates a
wonderful opportunity for dental professionals who love travelling and wish to advance and
share their knowledge and skill for better patient care.
CDE is mandatory in developed countries; however, it is still in the process of approval in
South Asia. Dentists seeking to earn mandatory CDE points can now book a DKT package and
travel along with their family to Nepal, one of the world’s most popular tourist destinations.
I personally believe that the concept of DKT can help foster harmony between business and
family.
I am confident that you will enjoy reading this issue of cosmetic dentistry, which includes
a variety of clinical articles, and welcome your valued feedback!
Yours faithfully,
Dr Sushil Koirala
Editor-in-Chief
President Vedic Institute of Smile Aesthetics (VISA)
Kathmandu, Nepal
cosmetic
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I content _ cosmetic dentistry
page 6
I editorial
03
page 10
I industry report
Dear Reader
26
| Dr Sushil Koirala, Editor-in-Chief
Case acceptance in complex-care dentistry
I industry news
| Dr Paul Homoly
34
®
®
Grandio SO and Grandio SO Heavy Flow
| VOCO
I case report
Use of an X-ray phantom in dental 3-D diagnostics
in digital volume tomographs
| Dr Georg Bach et al.
I meetings
36
I clinical report
14
First whitener for fixed-braces orthodontics
| Dr Enrique Jadad et al.
I special
10
Radiant, beautiful anterior teeth
| Dr Stefen Koubi & Gérald Ubassy
30
06
page 14
International Events
I about the publisher
Imaging in dentistry: A clinical perspective
| Dr Claudio M. Levato
37
38
| submission guidelines
| imprint
I opinion
22
Impression materials—
Are there any REALLY new ones?
| Dr Michael B. Miller
Cover image courtesy of alias
page 26
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page 34
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I special _ practice management
Case acceptance in
complex-care dentistry
Author_ Dr Paul Homoly, USA
_I enjoy seeing the articles in cosmetic
dentistry in which clinicians recount their creation
of magnificent works of art through digital restorative dentistry. In most of the case studies I’ve read,
I am sure the patient fees reach well over US$15,000
or more.
Let me ask you this: what percentage of your
patients whose fee is US$15,000 or more are
ready to start care immediately after you present
their treatment plan? I have directed this question to thousands of my dentist audience members over the last decade and the overwhelming
response is “fewer than 5 per cent”. Is this because
patients do not understand dentists’ treatment
recommendations? Or is it that the fee does not
fit into their budgets? Chances are that both these
apply.
As dentists we are pretty good at helping patients
understand us and our treatment recommendations. What we are not good at is understanding our
patients and the manner in which our treatment
recommendations must fit into their lives. If you
have heard it once, you have heard it a thousand
times: the key to case acceptance is patient education. Go to dental seminars, read journals, listen
to consultants; most of it sounds the same―
educate, educate, educate. Now let me ask you this:
is it true? Is patient education the solution to case
acceptance?
If it is, then why do many new patients who have
been thoroughly examined, educated and offered
comprehensive treatment plans leave your practice
and never return for care? Is it that you did not
educate them sufficiently? Or is it that in the challenge of case acceptance, patient education is not
the only answer?
Let’s consider the new patient process and case
presentation and learn when patient education
works for us and when it chases patients out the
door.
06 I cosmetic
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_Inside-out versus outside-in
How do we get patient education to work for us?
Let’s first make the distinction between an insideout versus outside-in new patient process. The traditional new patient process is inside-out. It begins
by studying the inside of the patient’s mouth―
the examination, diagnosis and treatment plan. It is
after this inside look that we educate the patient
with regard to all his/her problems―how he/she got
them and what we can do about them, for example
case presentation. After case presentation, we
quote our fees and discuss financial arrangements.
It is only once we have gone through our inside
process that we discover what is happening outside
the patient’s mouth―his/her budget, work schedule, time and significant life issues.
The flow of conversation starts with insidethe-mouth conditions and ends with outside-themouth issues. I label this traditional way of managing the new patient the inside-out process (Fig. 1).
For patients with uncomplicated dental needs
―fees of US$3,500 or less―the inside-out approach with appropriate patient education works
well. Here’s why:
First, patients with minimal clinical needs are
often unaware of them. Patients with conditions
such as periodontal disease, asymptomatic periapical abscesses and incipient carious lesions must
be made aware of them and educated regarding
their consequences. Patient education is the driver
of case acceptance when patients are unaware of
their conditions.
Next, the inside-out process works well for
patients with fees of US$3,500 or less because the
outside-the-mouth issues―fees, time in treatment
and life issues―are such that most patients can
proceed with your treatment without undue
hardships or inconvenience. Dental insurance reimbursements, patient payment plans such as
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CareCredit and credit cards usually sooth the sting
of fees for US$3,500 or less. Fees at this level are not
insurmountable and usually do not anger or embarrass patients out of your office. But what if you
present complex dentistry for more than US$3,500?
Let’s suppose your fee is US$10,000 and it
involves multiple, long appointments and your
patient would lose time from work? Do outsidethe-mouth issues get in the way of case acceptance now? Yes, they do. Does patient education
make the unaffordable affordable? No, it does not.
How do I know? You have proven it, have you not?
It is with the patient whose fee is greater than
US$3,500 that I recommend an outside-in approach. Employing an outside-in approach involves
initiating your new patient procedures with conversations―telephone and the in-office new patient
interview―that focus on understanding what is
happening outside the patient’s mouth, such as significant life issues, budget and work obligations.
Later in this article, I’ll show you how.
I
She goes as far to recommend another appointment
with her so she can show you how to keep your
house clean before you buy one. She does all this
before she has any idea of what you can afford
and where you want to live. What would you think?
You would think about finding another estate agent,
would you not?
How many of your complex-care patients, after
experiencing your inside-out process, find another
dentist for the most likely reason that you spent
a bunch of time educating them on inside-themouth details before you had any idea what was
suitable for them? You educated them right out
your door.
After we have an understanding of outside-themouth issues, we do our examination. Then, during
the post-examination conversation and case presentation, we link our treatment recommendations
to the realities of their outside-the-mouth issues.
Let me show you how.
The flow of conversation starts with outsidethe-mouth issues and ends with inside-the-mouth
treatment recommendations. I label this an outsidein process (Fig. 2). An excellent example of an outside-in process is the purchase of a home. Imagine
you and your spouse decide to buy a new house.
You go to a real estate agent and, just a few minutes
into the conversation, you talk about price range,
neighbourhood, schools, proximity to work, financing and down payment. These are all big picture,
outside-the-home issues. Once you settled on the
broad outside-the-home issues then, and only then,
does it make sense to begin discussing the detailed
inside-the-home issues, such as room size, carpet
and tile selection, lighting, etc. Good estate agents
discover what the suitability factors of home buying
are (price, down payment, monthly payments, location, etc.) before they get into the inside details. In
other words, the flow of conversation is outside-in.
Now imagine you and your spouse go to the
estate agent, but this time she is a former dentist and
uses the traditional inside-out process she used as
a dentist. As soon as you sit down she begins educating you on the inside-the-house issues―the difference between cement slabs versus crawl space
foundations and vinyl siding versus brick exteriors.
Fig. 1
An outside-in process works best for complexcare patients. Here patient education is not the
driver of case acceptance. This is why: first, patients
with complex needs often come into your office
with a specific complaint―embarrassment about
their appearance, aggravation by their dentures
or fear of losing their teeth. They do not need to be
educated about their chief complaint. They may not
be aware of all their conditions, but it is most likely
that they have lived with the complaint that brought
them into your office for a long time.
Next, many complex-care patients have heard
the patient education lecture about plaque, pockets
and sugar many times before. It’s old news and
thus not a subject that distinguishes you. For many
patients, patient education efforts bounce off like
BB’s fired at icebergs. Expecting to influence them
into a US$10,000 treatment plan that does not fit
into their budget by showing them how to floss well
is naïveté.
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Let me be clear at this point: we are going to
spend some time on the patient education process
with complex-care patients, it is just not one of the
first conversations we will have.
The first conversations we will have with complex-care patients are about discovering outsidethe-mouth issues—just like the suitability conversation with the estate agent. The outside-the-mouth
issues of budget, time, work schedule, health issues
are what I call fit issues. These are the issues into
which your treatment plan must fit. Become good at
discussing fit issues and you will save an incredible
amount of time, you will sell much more dentistry
and you will no longer blow patients out of the
water—and out of your practice.
short, any issues dominating the patient’s energy
and attention. When you present complex-care
dentistry, it has to fit into the patient’s life.
Think about it. If you offer most patients a
US$10,000 treatment plan, something in their life
has to happen. People need to wait to receive their
tax refund, wait for a child to graduate from college, become more settled in their new job, or take
a much-needed vacation. Knowing the manner in
which your complex-care treatment plans fit into
the current or foreseeable circumstances of your
patient’s life is a mandatory skill for practising
complex-care dentistry. Without fit, there is no case
acceptance, regardless of the level of dental IQ or
your zeal for patient education.
_Discovering fit issues
Your team often knows what is going on in the
patient’s life. How do they know? They talk―they
chit-chat with the patients and they make friends.
Another purpose of chit-chat is to learn about
those fit issues in your patient’s life impacting their
treatment decision. When chit-chat is intentional,
I call it fit-chat—an indirect way of discovering
patient fit issues.
When you fit-chat, be curious and listen more
than talk. Listen to the manner in which patients
spend their time and what’s creating stress in their
life―health, money and/or family issues. If they
mention something you believe may influence
a treatment decision, be curious, listen attentively
and encourage them to talk more about it. Through
indirect fit-chat, you’re going to discover what’s
going on in patients’ lives.
Fig. 2
_Fit versus change
The earlier influencers in my dental career emphasised that a significant part of being a good
dentist is to get patients to change. Change the way
they clean their teeth, change what they eat and
change the priorities in their life and put dental
health at the top. It took me ten years and thousands
of patients to realise that patients change when
they are ready, not when I tell them to.
I learned to replace the concept of change with
the concept of fit. Instead of telling patients they
need to change to accommodate my treatment
plan, I learned to accommodate my treatment plan
to fit their life situation. Patients, especially the more
mature, complex-care patients, have complex fit
issues. These include finances, family hassles, work
schedules, special current events, travel, stressors,
health factors, significant emotional issues; in
08 I cosmetic
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Some patients do not fit-chat well. They are
simply not talkers. I am that way. When I get my hair
cut, the last thing I want is a chatty experience.
When you have a complex-care patient who will
not fit-chat, you can try a more direct approach to
discovering fit issues.
Here is an example of a direct approach: “Kevin,
I know from the line of work you are in that you are
busy and travel quite a bit. I also know you are aggravated by food trapping around your lower partial
denture. Let’s talk about your choices and how we
can best fit your dentistry into what is going on in
your life. Is now a good time to talk about this?”
Here is another example of a direct approach:
“Kevin, most people like you are busy, on-the-go and
have lots of irons in the fire. I need to know if any
of these irons are affecting the amount of stress
you are under, the amount of time you can spend
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I
here with us, or if there are financial issues I need to
consider when planning your care. I want to reassure you that I am very good at helping patients fit
their dentistry into what is going on in their life.”
Whether you are using an indirect fit-chat or
a direct approach to discovering fit issues, an absolute prerequisite to a comfortable conversation is
for you to have a connected communication style.
This means you hold good eye contact, listen carefully and patiently; you maintain a conversational
tone of voice and your speaking rate is relaxed.
Be sure to pause long enough to let what you are
saying sink in.
If you attempt to use a direct approach to fit
issues but have a disconnected style (do not look
the patient in the eye, speak too quickly, do not
listen attentively), your conversation may be perceived as being inappropriate, unprofessional and
seeking to diagnose their pocketbook sneakily.
_Advocacy
Advocacy is the experience of patients when they
realise that you are guiding them towards and not
selling them into dental health. To be an advocate is
to be a guide. To guide patients into complex care
effectively you need to take the fit circumstances
of their life into account and help them find a way
to fix their teeth in light of those circumstances. This
may mean fixing their teeth now, later, or over time.
Here is something you say that propels the advocacy experience. It occurs after the examination,
but before any detailed conversation about clinical
findings. Here is where you link the fit issues you
discovered to your clinical findings.
“Kevin, now that I have looked at your teeth,
I know I can help you. We treat many patients like
you with partial dentures that do not work well.
I know I can help. What I do not know is whether this
is the right time for you. You mentioned you travel
a lot and your company is in the middle of a big
reorganisation. Do you go ahead with your treatment
now? Do we wait until later? Or do we do it over time?
Help me understand how I can best fit your treatment
into everything that is going on in your life.”
This advocacy statement leads to a conversation about the patient’s fit issues. This conversation
reveals what treatment fits and what does not. You
will find that this approach results in many complex-care patients doing their treatment over time,
allowing them to stay within the limitations of their
fit issues. This is a good thing. I would rather treat
two patients for US$5,000 each than no patients
Fig. 3
for US$10,000. It also yields lifetime patients for
you. Patients will exhibit fierce loyalty to you when
they experience advocacy.
_The decision to educate
The decision when to educate and when to advocate is situational. Figure 3 demonstrates that
the impact of patient education on case acceptance
is highest when the complexity of the care (and its
associated fee) is minimal. Patient education is the
driver of case acceptance when a patient’s conditions and fees are minimal. However, when the complexity of care increases, the role of advocacy takes
over. Advocacy is the driver of case acceptance when
the patient’s conditions are complex and fees are
high. Copy Figure 3 and keep it in area where you will
see if often. Then, right before you go into case presentation, look at it and ask yourself: does this patient
need education or advocacy? Let the situation guide
you. When you do, you will discover how to keep
from educating your patients out the door._
_about the author
cosmetic
dentistry
Dr Paul Homoly is a world-class
leader in dental education.
As a comprehensive, restorative
dentist and acclaimed educator
for over 25 years, he is known
for his innovative and practical
approach to dentistry. Dr Homoly
is now offering YES! On-Line
as the solution for dentists and
their teams to excel at case acceptance. This on-line,
seven-module curriculum, which is supported by a
matching set of DVDs, takes your dental team step-by-step
through the essential dental team-patient conversations,
and has proven successful for over 30 years.
Distinguished by his focus on outcomes, Dr Homoly is
legendary for his ability to teach and lead in a practical
and engaging manner. For more information, visit
www.paulhomoly.com or call Homoly Communications
at +1 800 294 9370.
cosmetic
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I special _ 3-D diagnostics
Use of an X-ray phantom
in dental 3-D diagnostics in
digital volume tomographs
Authors_ Dr Georg Bach, Christian Müller & Alexander Rottler, Germany
Fig. 1a
Fig. 1b
Figs. 1a & b_DVT phantom
(the maxillary sinus floor and alveolar
nerve of the mandible are simulated
with radiopaque wire structures).
_Undoubtedly, digital volume tomography
has significantly expanded the range of dental
imaging diagnostics. Just as Paatero ushered in
a new era of dental radiology at the end of
the 1950s with the development of the orthopantomograph and the resulting introduction
of panoramic view imaging, 3-D processes will,
in turn, replace panoramic view imaging.
Although digital volume tomography has to
date been mostly used for pre-implantological
planning and in reconstructive surgery, now
other dental disciplines are beginning to appreciate the value of this process. It is in orthodontics,
endodontics, dental surgery and periodontics
that digital volume tomography represents a
significant improvement of the possibilities of
imaging processes. Its significance in the current
domain, pre-implantological diagnostics, can be
assessed as even greater.
_Available digital volume tomographs
Digital volume tomographs (DVTs) have been
on the market for a good decade, and the number
of suppliers of such devices has increased dramatically. When observing the device market,
10 I cosmetic
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two clear trends are evident: the trend towards
an all-in-one device (also called dual use) and the
trend towards DVTs of various volumes.
All-in-one devices
In addition to offering 3-D diagnostics, the majority of DVTs available on the market also provide
the option of producing panoramic view images
(real images, not reconstructed from a data record)
and sometimes even lateral cephalogram. These
devices thus cover the entire range of dental largescale diagnostics—in contrast with the first generation, which only offered the DVT option.
The DVTs of today’s generation are often similar in design and appearance to traditional DVTs.
The position of the patient with these and other
frame devices is typically standing or sitting,
while the once dominant supine patient position
of the first-generation device is passé, except for
that required by one DVT manufacturer.
Various volumes
The first-generation devices featured very large
volumes that required time-consuming reworking
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special _ 3-D diagnostics
Fig. 2
_small volume (4 x 5 cm) for oral surgery and dental procedures;
_medium-sized volume (8 x 10 cm and higher) for
oral surgery and reconstructive surgery; and
Fig. 3
_large volume (18 x 20 cm and higher) for oral
surgery and reconstructive surgery.
Problems with small and medium-sized
volume devices
Small- and medium-sized volume devices
are generally used for pre-implantological diagnostics, oral surgery, and orthodontic and
endodontic procedures. The limited volume
size requires careful device setting and patient
Fig. 2_DVT phantom in a DVT
(Kodak 9000 3D, small volume)
fixated on the original patient
biting aid.
Fig. 3_Device settings: with the
aid of the light visors, the volume
is placed on the region to be
captured (here region 26 and
the maxillary sinus floor).
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of the immense data record for problems beyond
large and reconstructive surgery in order to be able
to evaluate the relevant data and/or regions in a
target-oriented manner. Today, numerous manufacturers offer devices with small and mediumsized volumes. Three types of devices are available:
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I special _ 3-D diagnostics
images using the preview function and check whether the
setting was correct. In the
event of incorrect settings, a
better image can immediately
be generated. In this manner,
there is a direct learning curve.
Using the DVT phantom for
preparing a patient image
Fig. 4
For new users and those who only take volume
tomograms once in a while, this correct setting
can pose difficulties, which was our motivation
for developing a DVT phantom that can be used
for training purposes and for direct preparation
of an image with a patient.
Time-consuming and tedious setting (aiming) of the
DVT on a patient who is already
in the device is likely to be
uncomfortable for the patient. This is where
presetting the device with the aid of the DVT
phantom comes in handy. The desired region is
captured with the phantom and, if needed, is
checked with the preview function. Then, the
phantom is removed and the patient is positioned
in the device. Generally, only one device setting
for the patient’s body size and small fine-tuning
are required before the image is set.
_The DVT phantom and its application
_How to obtain a DVT phantom
The DVT phantom is an X-ray phantom that
depicts a medium-sized mandibular and maxillary dental arch with the teeth positioned in ideal
denticulation.
A DVT phantom can be produced in cooperation
with practising dental technicians. The plastic teeth
containing barium sulphate are available on the market and a phantom can be made in the manner described above. An easier option is to send a DVT positioning aid of your device to dtcmfreiburg@aol.com
or through www.dtcmfreiburg.de. Master Dental
Technician Christian Müller will then mount a prepared DVT phantom on your positioning aid. Industrially manufactured plastic teeth containing
barium sulphate (SR Vivo Tac/SR Ortho Tac, Ivoclar
Vivadent) will be used, which are then incorporated
into a mandibular and maxillary model made of
transparent plastic.
Fig. 5
Fig. 4_DVT phantom image of the
maxilla with the DVT phantom.
Fig. 5_DVT phantom image of the
mandible with the DVT phantom.
positioning so that the relevant structure is accurately captured.
The phantom, which consists of a mandible
and maxilla, is mounted on the individual bite
or positioning support of the respective device.
Barium sulphate is added to the plastic teeth so
that they are visible in the X-ray image. These
teeth are made by the manufacturer especially
for X-ray applications. The DVT platform is then
mounted on the device with the original bite
support instead of a patient. The device setting
can be done in two different ways:
a) The desired volume is preset using the device
programme and then manually fine-tuned.
b) The device is manually set directly upon the
region to be captured with the aid of the light
visors.
Thereafter, the set positioning is saved.
Using the DVT phantom for training and practice
With the aid of the DVT phantom and the abovementioned setting techniques, new users, who are
training to become dentists or dental technicians,
can learn how to set the device for the regions
to be examined, generate one or more individual
12 I cosmetic
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3_ 2010
We hope that the fascinating field of 3-D diagnostics will establish itself quickly in dentistry and
remain an imaging procedure that significantly
expands upon the hitherto range of dental X-ray
diagnostics in the long term._
_contact
Dr Georg Bach
Rathausgasse 36
79098 Freiburg/Breisgau
Germany
E-mail: doc.bach@t-online.de
cosmetic
dentistry
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I clinical report _ imaging
Imaging in dentistry:
A clinical perspective
Author_ Dr Claudio M. Levato, USA
_Digital imaging in dentistry is a field of
expanding possibilities and applications. Within
the broad context of imaging, there are diagnostic,
clinical and administrative applications. Diagnostic imaging can be radiographic, ultrasound, visible
light and laser fluorescence. The clinical applications include surgical microscopes, magnified video
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
Figs. 1a–e_Our different websites
over the years: 1993 (a); 1998 (b);
2005 (c); 2007 (d); and 2010 (e).
14 I cosmetic
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3_ 2010
systems and optical impression systems. The administrative applications are concerned with digital
record-keeping, computer simulation, consultative
and communication applications. In considering
the number and types of imaging applications and
the number of companies who manufacture and
market these to dentistry, it is not surprising that
many dentists are frustrated and confused as to the
efficacy, implementation and financial implications
associated with incorporating these technologies.
This article will address the clinical perspective of
these technologies, and the manner in which our
office has incorporated many of these applications
over the last few decades.
_History
A brief history of our office is necessary to put all
this in perspective. Our private practice is 34 years
old and has been a leading-edge practice since its
inception. As with many other early adopters, our
decisions were not always well thought through
and return on invested dollar was not always
considered and not always successful. I have used
our office environment as a learning laboratory,
which has fuelled my lectures, and published articles on technologies and leading-edge applications
for over 20 years. The journey began in 1982 with
our first computer, which served as a billing and
Fig. 1e
accounting system. From there we transitioned to
a mini-mainframe (Alpha Micro system) with server
and operatory workstations in 1985. Fast forward to
today; we have two office locations in suburban
Chicago, connected by a T1 line and a single Eaglesoft dental software database (Patterson Dental) in
a completely chartless environment.
Our early technology environment did not become complicated until we wanted to add clinical
applications to our system. There were many challenges with technology integration, not the least
were the cart delivery systems used by most of the
companies. The first intra-oral camera system was
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clinical report _ imaging
analogue, which came on a cart with a video printer
and monitor. When digital radiology was first introduced, it too came on a cart with a PC, monitor and
thermal printer; shortly after that you were able to
link the intra-oral camera to the same PC as the
digital radiology system. This evolved further by
putting PCs in all the operatories so that you could
eliminate the carts for image acquisition and make
room for the lasers and CAD/CAM applications,
which also came on wheels. We have worked with
numerous digital radiology systems: Schick Technologies, DENTSPLY NI-DX (no longer available), Welch
Allyn Reveal sensor (no longer available), Gendex
Dental Systems, Planmeca sensors, DMD sensors (no
longer available) and Myray X-pod wireless sensor
(Cefla Dental Group). Having multiple sensor systems has its complications and it is most efficient to
use whatever sensor systems integrates best and
seamlessly with your dental software program.
Fig. 2a
Once the patient has selected your office, everything that they experience will be measured by their
expectations. It seems that today’s society, especially those under forty, is always connected and
in search of the immediate gratification of needs
and wants. Technology is a tool that can facilitate
meeting those expectations.
I
Fig. 2b
Fig. 2a_iPhone application
for Lighthouse PLZ.
Fig. 2b_Patient history screen on
phone through Lighthouse PLZ.
_Attracting new patients
It is a fair description that the ideal technologyfocused dental office is one that is in a perpetual
state of change. The continuous flow of evolving
applications makes it essential that all systems are
designed to be sufficiently flexible to allow future
integration with minimal interruption. One thing that
we must remember is that we are in the business of
providing oral health care, and technology should be
incorporated if it helps us better serve our patients.
_The World Wide Web
In today’s economy, we have to assume a more
global perspective of the impact of digital imaging on
your practice. We have to realise that even before your
patient makes that first call for an appointment, their
decision was probably influenced by the Internet.
Dental consumers are using the Internet in greater
numbers to find the right fit for their dental and
medical needs. So a web presence is becoming a key
component for attracting and keeping your patients.
The Internet has changed the way we use images
and information. Years ago, we would work with a
marketing company to produce a practice brochure
with some direct mail pieces. The process would take
months to create and implement, the downside to this
approach is that it is costly and not easily amenable to
changes. In today’s Internet age, we can launch a simple website in hours and make changes whenever we
need to. It is important to understand this new medium
because creating a website that is not interactive is in
some cases worse than no website at all. We have only
a matter of seconds to attract and keep someone’s
attention, and if we do not have something to address
their agenda, they move onto the next site. So website
optimisation is actually more important than creating
a beautiful site with animation and flash features that
do not address the wants of your potential clients.
There are numerous companies that have been
helping dentists navigate these waters successfully.
Fig. 3a
Fig. 3a_Initial digital
photograph series.
Fig. 3b_Initial full series
of digital X-rays.
Fig. 3b
cosmetic
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I clinical report _ imaging
Fig. 4a
Fig. 4b
Fig. 4a_ProMax 3D (Planmeca):
small scan imported into InVivo5.
Fig. 4b_MyRay Skyview
(Cefla Dental Group): medium scan
imported into InVivo5.
Fig. 4c_i-CAT (Imaging Sciences
International): large scan imported
into InVivo5.
We have used Curtis Marketing Group, Sesame
Communications and Connect to Patients for creating and optimising our websites (Figs. 1a–e).
Patient access to schedule, account information
and to paying bills online is provided by Sesame
Communications as well. Lighthouse PLZ is another
example of web-based solutions that work with
your existing practice management software. We
use this application to handle our re-care reminders
(by text, e-mail or regular mail), electronic newsletter and our direct mail marketing, and to monitor
practice statistics. They also have a smart-phone
application to allow you to check patient schedule
or history from your phone (Figs. 2a & b).
_Initial visit
During our initial visit, we review the medical
history that the patient filled out on paper, which
we scan into their digital chart, or we have them
Fig. 5_XCPT 2-D implant planning
and consultative tool.
Fig. 5
fill it out on a tablet PC, which can be signed
directly. We also have signature pads attached to
all our administrative workstations. After the dentist has met the patient and reviewed the concerns,
we have our assistant gather the necessary photographic and radiographic images. We use a digital
camera to take a series of digital photographs,
which will serve as documentation of existing
conditions and for Invisalign records, if required,
16 I cosmetic
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3_ 2010
Fig. 4c
for cosmetic imaging or for referral communication (Figs. 3a & b).
Depending on the patient’s concerns and existing condition, the radiographic imaging may be an
intra-oral set of digital radiographs, a panoramic
and bite wing set of digital radiographs, a CBCT
(cone-beam computed tomography) scan for implant assessment and treatment planning. After acquiring the radiographic and photographic images,
the clinical examination begins with an intra-oral
video camera tour of the mouth, which the patient
is able to view with the dentist, and examples of
problem areas, as well as healthy areas, are shown
in this co-discovery or co-diagnostic exercise.
The initial examination is in actuality a two-way
street where we, as well as the patient, get to know
and evaluate each other. Anything that will facilitate
communication and provide options and solutions
for the patient will go a long way towards building
a trusting relationship. Technology is a double-sided
sword; if it is used to impress or pressure a patient
into accepting care, it can become a very negative
experience, whereas if it is used as a vehicle to address their concerns and to help them co-diagnose
their condition, the patient will most likely move
forward with care.
Many practices have also incorporated standalone applications, such as VELscope (LED Dental,
Inc.) and the Identafi 3000 (Trimira Remicalm), for
help in oral-cancer screening by using high-energy
light sources to visualise tissue fluorescence. Giving
the patient an opportunity to see what we see is
a very powerful tool in helping them own their
dental condition and allowing us to become their
advocate for care.
_CBCT
CBCT has been available since 2000; the driving
force for this technology has been implant therapy.
The cost for this technology has come down somewhat with the introduction of newer technology
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I clinical report _ imaging
Fig. 6a
Fig. 6c
Fig. 6b
Fig. 6a_Pre-op CBCT scan with
radiographic guide.
Fig. 6b_NobelGuide guided
surgery plan.
Fig. 6c_Post-op implants seated
with surgical guide prior to seating
laboratory-processed provisional.
Fig. 6d_Post-op CBCT scan with
implants and immediate
provisional prosthesis.
and increased competition. There are currently at
least 20 CBCT scanners available in the US, with
more undergoing the FDA approval process.
All CBCT units provide 3-D information; however,
each manufacturer approaches the project differently regarding its choice of patient positioning,
scanning parameters and viewing software. CBCT
units are most commonly categorised by their X-ray
detection system, image-intensifier detector (II) or
flat panel detector (FP). IIs are an older and less expensive technology that generally result in more
noise than FPs and need to be preprocessed to reduce geometric distortions inherent in the detector
configuration. The radiation beam is 3-D in shape
Before
After
Fig. 6d
tact a fluorescent screen that emits light captured
by a charge couple device camera. The software then
reconstructs the sum of exposures using proprietary algorithms calculated by the manufacturers
into as many as 512 axial-slice images.
Many CBCT units have a variable field of view
(FOV) that allows the clinician to limit the radiation
exposure to the region of interest. The limiting factor is the size of the image detector, which comes in
a number of sizes depending on the manufacturer,
but for the sake of simplicity we will categorise them
into small (<15 cm), medium (15 cm), large (23 cm)
and extra-large (30 cm) FOVs. The maximum image
of a small FOV usually can accommodate most of
the adult dentition. The maximum medium FOV can
accommodate all the adult dentition extending into
the condyles and sinuses. The maximum large FOV
image encompasses the maxillo-facial anatomy, including the condyles and most of the orbits. Finally,
the extra-large FOV can accommodate the full skull
in most cases. Regardless of the volume capacity of
the unit, it is important to restrict the FOV for the
region of interest, which has a significant effect on
the amount of radiation absorbed.
Fig. 7a
Fig. 7a_Prosthodontic simulation
using Dental GPS.
Fig. 7b_Models being waxed up in
the laboratory using Dental GPS.
Fig. 7c_Finished provisional
restorations using Dental GPS.
Fig. 7d_Competed provisional
reconstruction.
Fig. 7b
Fig. 7c
and similar to photon energy used in digital or conventional dental radiology.
The receptor captures 2-D images either directly
through the FP, which absorbs the photons that are
converted to an electric charge, which is measured
by the computer or with the II, which captures the
photons and converts them to electrons that con-
18 I cosmetic
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Fig. 7d
DICOM format images are standard for handling,
storing, printing and transmitting information in
medical imaging, including those from CBCT. In 3-D
imaging, this becomes a great asset in exporting
this data set to third-party software programs that
will facilitate image renderings, implant-planning
programs and making surgical guides to assist in
implant placement (Figs. 4a–c).
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clinical report _ imaging
_Consultative and
treatment planning
Once the examination and diagnostic records
have been collected, the process of interpretation,
diagnosis, treatment planning and consultation
come into play, with a myriad of applications to
facilitate those processes. Current state-of-the-art
systems are based on 3-D applications, but there
are systems even for those who have been most
conservative with technology applications. With
a minimum investment in a laptop computer, a digital camera and software, a dentist can incorporate
digital treatment planning and interactive consultation by using XCPT (XCPT, LLC). XCPT provides
visuals of proposed treatment, such as crowns,
bridges and implants on the patient’s X-rays, CT
scans, or photographs. The software saves time,
reduces paperwork, streamlines workflow in the
office and allows patients to grasp treatment concepts quickly and intuitively (Fig. 5).
When it comes to working in 3-D, there are
a number of software applications that import
DICOM files from any CT or CBCT unit, and then allow
you to plan your case more accurately and many
of these programs will also allow you to have a surgical guide made for guided implant surgery and
immediate prosthetic restoration.
I
Fig. 8_Multiple open windows
of different file types in Transnet.
Fig. 8
_Cosmetic imaging
Cosmetic imaging has been around for over
20 years, but recently a company has taken this application to the next level. Dental GPS (Dental GPS,
Inc.) can simulate anything, from whitening to fullmouth reconstruction, with the subtle twist that it
can morph the teeth into the existing soft-tissue
envelope. What this means is that it can facilitate the
predictability of your provisional and final prosthesis
from the photographic simulation. By using the Kois
Dento-Facial Analyzer System (Panadent) with face
bow, the simulation can give the laboratory a guide
to waxing up the case for provisionals (Figs. 7a–d).
Programs such as InVivo (Anatomage, Inc.), Dolphin
Imaging and Management Solutions, NobelGuide
(Nobel Biocare) and SimPlant (Materialise Dental,
Inc.) will all help you analyse your CT or CBCT scan
and plan your implant treatments, but surgical
guide construction can be influenced by which implant system you choose to work with.
If you work primarily with Nobel Biocare implants, NobelGuide—their proprietary software application—will allow you to format the DICOM data
file from any CT or CBCT unit, design the case and
directly order the surgical guide along with all the
implant surgical, prosthetic hardware needed to
complete the case. By working with a laboratory
that has the NobelGuide software, your provisional
prosthesis can also be constructed from the CT or
CBCT data set (Figs. 6a–d).
There is a growing trend towards guided implant
surgery. The benefit for the patient is that the surgical placement of implants and the insertion of
the prosthesis can be done during the same visit.
This is more costly but there is always a premium
for the convenience. The challenge is that there is
no room for error, so the dentist has to be prepared
with a back-up plan, should there be complications
during surgery.
Fig. 9b
Fig. 9a
_Imaging communication
One of the most significant advantages of digital
imaging is the ability to share images with colleagues for referral or second opinions. It facilitates
interdisciplinary care and can save patients significant time and money. In today’s fast-paced society,
time is becoming a very limited commodity. Once
you have examined the patient and have uncovered
conditions that require other input, you can upload
any kind of digital file and send it to any number of
colleagues for input. We have been using an application called Transnet (Transcend) since 2000,
which has significantly reduced the need for specialty consultation prior to treatment.
Figs. 9a & b_Example of radiographic
report and report images returned
by radiologist.
We have been using the same network of specialists for years and know the information they
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I clinical report _ imaging
Fig. 10a
Fig. 10b
Fig. 10a_Assistant in one of our
operatories taking optical
impression with iTero.
Fig. 10b_Milled model from iTero
scan that was sent to laboratory.
Fig. 10c_Finished restorations
on iTero model.
would need to render an opinion and determine
a fee for the procedure. They respond to our communication and we inform the patient and review
the treatment and fee. Then the patient merely calls
and sets up the treatment visit. This works extremely
well for routine referrals, but complex cases still
warrant separate specialty examinations (Fig. 8).
With CBCT’s dramatic impact on diagnostic imaging, Internet data transfers are becoming more
important. Most dentists are still unfamiliar with
reading 3-D radiographic images and in the US,
many dentists use the services of oral and maxillofacial radiologists to interpret those images in order
to rule out possible pathologies. These image files
are very large and thus usually need to be uploaded
to an FTP site (Figs. 9a & b).
Another expanding 3-D technology that was first
introduced 25 years ago was the original Cerec CAD/
CAM system (Sirona), a 3-D optical impression system.
There are several major companies that use different
imaging technologies with similar results that exceed
the accuracies of traditional impression materials—
3M Lava COS uses streaming video, iTero (Cadent, Inc.)
uses laser optics, Cerec AC (Sirona) uses Blucam—and
there are some companies ready to introduce confocal digital impression technology (Figs. 10a–c).
_Conclusion
Hopefully this article has painted a realistic picture of what is actually possible in a clinical practice.
Dr Omer Reed, a dentist visionary from Phoenix,
Arizona, said over 40 years ago, “If something has
been done, it is probably possible.” There are dentists
all over the world solving clinical issues for their
patients by expanding the applications of existing
technology in unique and different ways, pushing
the envelope of science and art beyond the original
intention and capability. Technology should not be
the focus of the dental practice, but should be transparent and used when it provides solutions for your
patients’ concerns. The focus of technology is to
allow us to provide better and more cost-effective
services. As Dr Gordon Christensen, founder of Clinical Research, has been saying for decades: “Better,
20 I cosmetic
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Fig. 10c
faster and cheaper is the mantra for justifying the
investment expense for technology integration.”
So it is evident that imaging in dentistry has become an integral part of every phase of dentistry.
Unfortunately at this time, there is no single source
that provides all these applications in a neat package; thus, the challenge of total seamless integration remains elusive and may never be fully realised.
If I have learned anything from my personal
journey in technology implementation, it is that as
soon as I have incorporated any new application,
there undoubtedly will be limitations with new and
different solutions right around the corner._
“The only constant is change, continuing change,
inevitable change that is the dominant factor in
society today. No sensible decision can be made any
longer without taking into account not only the
world as it is, but the world as it will be.”
—Isaac Asimov
_about the author
cosmetic
dentistry
Dr Claudio M. Levato is in a private
practice that has invested heavily in
leading-edge technologies for over
30 years, spanning five computer
systems and transitioning different
operating systems to create a fully
integrated digital patient record
shared in two locations. Dr Levato
is an author and lecturer on leading-edge technology and
serves on several clinical advisory boards for radiology and
restorative dental companies. He can be contacted at:
Comprehensive Dentistry, Ltd.
183 S. Bloomingdale Road, Suite 200
Bloomingdale, IL 60108
USA
Tel.: +1 630 529 2522
Fax: +1 630 529 2270
E-mail: clevato@comprehensivedentistry.com
Website: www.comprehensivedentistry.com
[21] =>
CDE0310_01_Titel
Bella Center
Copenhagen
APRIL 7- 9, 2011 s "%,,! #%.4%2 s COPENHAGEN s $%.-!2+
Welcome to the 44th Scandinavian Dental Fair
The leading annual dental fair in Scandinavia
The 44th SCANDEFA invites you to exquisitely meet the Scandinavian dental market and
sales partners from all over the world in springtime in wonderful Copenhagen
SCANDEFA, organized by
Bella Center, is being held in
conjunction with the Annual
Scientific Meeting, organized
by the Danish Dental
Association
(www.tandlaegeforeningen.dk).
More than 200 exhibitors and
11.349 visitors participated at
SCANDEFA 2010 on 14,220 m2
of exhibition space.
Reservation of a booth
Book online at www.scandefa.dk
Sales and Project Manager, Jo Jaqueline Ogilvie
jjo@bellacenter.dk, T +45 32 47 21 25
Fotos from Bella Center, Wonderful Copenhagen
2011
Travel information
Bella Center is located just a 10 minute taxi drive from Copenhagen
Airport. A regional train runs from the airport to Orestad Station,
only 15 minutes drive.
Book a hotel in Copenhagen
www.visitcopenhagen.com/tourist/plan_and_book
www.scandefa.dk
Scandefa_Ann_A4_ENG_2011.indd 1
14/06/10 12:01:50
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I opinion _ impression materials
Impression materials—
Are there any REALLY new ones?
Author_ Dr Michael B. Miller, USA
absorb the fluid and continue with its mission of
registering an accurate and detailed impression.
This property also goes hand-in-hand with the
ability of the impression material to ‘wet out’ on
the preparation and capture better detail. This
latter property has enhanced my own personal
experience over the years with PE, especially
Permadyne (3M ESPE), which has long been one of
my favourite materials.
Dr Michael B. Miller
_The most popular classifications of impression materials for precision restorations such
as inlays, onlays, crowns and bridges are polyethers (PE) and vinyl polysiloxanes (VPS). But
would you be amazed to know that PE were first
introduced by ESPE (before the company was purchased by 3M) in 1965? Yes, Impregum has been
around that long! How about DENTSPLY Caulk
leading the way with VPS materials by bringing
Reprosil to the market in 1982? A quick math
check shows that there have been no other major
category advancements on the material side of
impression-taking in 28 years!
So what has changed and which of these
changes really affect your chances of taking the
perfect impression the first time?
_Hydrophilicity
One of the main advantages of the PE over VPS
products is the inherent hydrophilicity of the former. Actually, hydrocolloid, which still shares a
very small segment of the market, is the epitome
of this type of material. It is generally considered
that the more hydrophilic a material is, the less
likelihood that fluid in the sulcus or really anywhere else on the preparation will distort the
impression. The hydrophilic material will merely
22 I cosmetic
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But DENTSPLY Caulk trumped the market again
with the first ‘hydrophilic’ VPS (Aquasil) in 1997.
Since that time, there has been a race amongst
manufacturers to create their VPS materials with
as much hydrophilicity as found in PE. Note that
hydrophilic properties in VPS products need to be
additives, since these materials are not inherently
hydrophilic as are PE. This race has escalated
recently by several manufacturers showing what
happens when you place a drop of water on a
set or even unset mix of impression material.
Presumably, if it beads up like water on a freshly
waxed car, the material is not hydrophilic. But if
it flattens out, it will do the same on a preparation in the mouth, showing it has enhanced
hydrophilicity and wetting out ability.
The Reality Research Lab (RRL) has developed
a more clinically relevant test, albeit more labour
intensive. An acrylic model with prepared and
intact extracted teeth is impressed with different
materials after the teeth have been dried, coated
with a glistening layer of water, or coated with
a rather thick film of freshly captured saliva. Not
only are the impressions and models from them
examined closely, but full cast crowns are fabricated and marginal gaps measured under a stereomicroscope at 50x. A recent product comparison
demonstrated virtually no differences between
two popular materials.
On the other hand, bucking the hydrophilicity
trend is one VPS marketed as ‘hydrokinetic’, which
breaks down to simply mean ‘moving water’. Well,
you can’t move water if you also love it, which is
the essence of the meaning of ‘hydrophilic’. There-
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opinion _ impression materials
fore, another way of describing ‘hydrokinetic’
would be ‘hydrophobic’. In other words, this product essentially returns to the early days when all
VPS materials were hydrophobic. The RRL also
tested this product, but the manufacturer did not
specify another product as a control. This makes
interpreting the data more difficult, although
there were virtually no differences between the
experimental groups, indicating that this product
will perform as the manufacturer claims it will.
Does any of this matter when you are trying to
take an accurate impression? Well, if the sulcus is
filled with fluid, including blood, that is obscuring
your margin, then it could definitely make a difference. If you are using a supremely hydrophilic
material, you hope that the product will literally
soak up the fluid similar to a sponge and, at the
same time, register the impression.
On the other hand, if the material is hydrokinetic, the aim is to move the fluid out of the sulcus
first and then capture the margin. Is this a better
strategy? The answer is probably yes, since there
is less chance that the fluid will distort the material, as it may do if it was absorbed. But if this
strategy is preferred, why have virtually all manufacturers opted for the hydrophilic route?
One reason could be the mob mentality. If it
works for one company, then other companies
produce the same item with some slight tweaks.
Another reason is that the concept flies in the
face of the trend. Hydrophilic is the in concept,
from bonding agents to cement to sealants. Why
should impression materials be any different?
And hydrophilic PE followed in the successful
footprints of hydrophilic hydrocolloid. Finally,
only one company thought of it.
So should you switch to a hydrokinetic impression material? Not necessarily. There are numerous other factors to consider, such as working and
setting time, flow and availability in different
delivery systems. All these criteria may be as or
even more important than hydrophilicity.
And, of course, none of this matters at all if you
use proper soft-tissue management BEFORE you
even lay a diamond on the tooth. Preventing a
bloody sulcus is much more effective than having
to deal with it after the fact. This is my own personal mantra. I obsess over tissue management.
However, although this is an admirable goal,
it doesn’t always happen. Therefore, finding an
impression material that will be ‘forgiving’ has
significant value. This is why PE continues to
I
garner kudos from its devotees—these products
tend to be less sensitive to moisture and have
a terrific ability to wet out the preparation under
adverse conditions.
_Viscosity and flow
This is an issue that goes back to how you prefer to take an impression. I personally prefer a very
light body/heavy body combination. Therefore,
I look for a light body material that syringes easily
and flows well without being too runny, combined
with a heavy body tray material that will push the
syringe material firmly against the preparation
and, at the same time, not run down the patient’s
throat. Less popular is a monophase material for
both the syringe and tray.
But very low viscosity syringe materials combined with heavy body tray materials is not new,
although the RRL tests on flow using the Shark Fin
device developed by 3M ESPE have found more recent selections with high flow. This means if you’re
like me, you no longer have to stick with one or two
brands to get better flow in your syringe material.
_Hardness/stiffness
With the increasing popularity of closedmouth impressions, especially with sideless trays,
a more rigid or stiff material should work better
by providing lateral support, although to my
knowledge, this has never been shown in a clinical comparison. Nevertheless, there have been
a few materials that the RRL has measured using
a digital durometer that are indeed stiffer than
the rest. Just don’t be tempted to use a very rigid
material for a full-arch impression, especially if
you are using a well-fitting custom tray—you may
need a ‘knee-on-chest’ manœuvre to remove it
from a patient’s mouth!
_Dispensing options
Another area with some significant changes
is mixing/dispensing. The hand-mixing of tubebased products in the past has been largely replaced with cartridge-based products mixed and
dispensed using a ubiquitous automix gun. However, these guns are no longer exactly cutting
edge, look like you bought them in a home-improvement store, and can make filling a full-arch
tray a real challenge for an auxiliary due to the
hand and forearm strength required for heavy
body materials.
To overcome the disadvantages of guns, ESPE
introduced the first electronic mixer in 1995.
cosmetic
dentistry 3
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I opinion _ impression materials
There have been tweaks and speed improvements
in these machines, which have been cloned by a
handful of competitors over the ensuing 15 years,
but the overall design is largely the same as the
original version.
For syringe materials, at least two VPS products have unidose versions. While I like unidose
packaging, it doesn’t seem to have caught on with
impression materials and has not been a real
factor in product selection.
_Intra-oral working time
Our thirst for speed has resulted in the availability of a number of very fast setting materials,
which can be a real time-saver when you impress
one or two teeth. The problem is when you try
to stretch the use of fast-set materials for more
than the aforementioned one to two units. The
intra-oral working time of these fast-set materials
then becomes a major issue.
Unfortunately, the working times provided by
manufacturers are typically determined at room
temperature. While this provides somewhat of
a comparison between products, it doesn’t really
give you much indication about how much time
you have between the inception of syringing
the material around your preparation and when
you need to seat the tray. For example, if you
are taking a ten-unit impression, how much time
do you have from when you syringe material
around the first preparation and when you need
to seat the tray? This is critical to know because
the material syringed around the first of the
ten preparations is already starting to set, which
is accelerated by the heat and moisture of the
mouth. If it sets too fast, the tray material will
not bond adequately to the syringe material and
you’ll most likely end up with wrinkles or other
types of distortion.
24 I cosmetic
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3_ 2010
pression material from locking into them and
tearing on the way out of the mouth. But I was
using an ‘improved’ formula of a well-known
material that had claims of high tear strength.
Therefore, on this case, I decided to go for it and
dispense with the block-out procedure. Sure
enough, the impression tore. I took a second impression and it also tore.
The guru of tear-strength testing in my opinion is Dr Alan Boghosian, a member of the REALITY
Editorial Team. Dr Boghosian and his colleague
recently completed a test of eight impression
materials for the RRL. The material I used that
tore in the mouth scored in the middle of the
pack, not quite matching the strength forecast
by the manufacturer. To be fair, even though
the impressions I took did indeed tear, the margins were still captured and the veneers seated
beautifully.
Nevertheless, since a torn impression can ruin
an otherwise perfect effort, it would be wise not
to tempt fate and block-out areas that could
cause tears, such as the aforementioned open
embrasures, assuming, of course, these areas
don’t need to be captured.
_What to use?
Many aspects of taking an impression are personal. For example, you get to select the material
that meets your flow and set-time requirements.
But beyond that, don’t get too caught up with
marketing slogans such as “vinyl polyether silicone” or “polyeasier”. There are still only two real
classes of impression material, same as they’ve
been for the past 28 years. And remember—no
impression material can do it all. To get the best of
all worlds, you probably need to stock two or three
different types to cover all clinical situations as
efficiently and productively as possible._
To my knowledge, there are only two extended
working time VPS materials on the market, both
of which were introduced in recent years. For
large cases, it would be prudent to consider using
one of them.
Editorial note: This article originally appeared in the March/
April 2010 issue of General Dentistry. It is published with
permission by the Academy of General Dentistry. © 2010
by the Academy of General Dentistry. All rights reserved.
_Tear strength
_about the author
If you have ever removed an impression from
a patient’s mouth and found that it has torn on
a critical marginal area, you know how important
this property is. I recently took an impression for
ten veneers in a patient who had open gingival
embrasures. Normally, I would block out these
embrasures from the lingual to prevent the im-
Dr Michael B. Miller is President of the
REALITY Publishing Company and Editor-in-Chief
of its publications. He also maintains a general
practice in Houston, Texas, USA.
Website: www.realityesthetics.com
cosmetic
dentistry
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CDE0310_26-28_Koubi 29.10.10 12:03 Seite 1
I industry report _ IPS e.max Press
Radiant, beautiful
anterior teeth
Authors_ Dr Stefen Koubi & Gérald Ubassy, France
Fig. 1_Pre-op view.
Fig. 2_Mock-up.
Fig. 1
Fig. 2
_The loss of the interdental papillae is a grave
consequence of periodontal disease. Surgical
reconstruction is still not feasible. There are
several approaches to reducing or masking the
black triangles that occur as a consequence of
the missing papillae. Conventional restorations
are an option if the teeth also show increased
mobility. If this is not the case, that is, if the
periodontal tissue is healthy, it is crucial to find
a biomimetic solution, meaning that the restoration should take aesthetic, biomechanical and
biological factors into account.
_gingiva: healthy periodontal tissue; interdental
papillae are missing; the teeth are stable; recess
at tooth #12; and
_radiological examination: regular alveolysis in
the cervical third.
_Initial situation
The treatment of missing papillae by means
of ceramic veneers will be presented on the basis of a clinical case. A female patient around
the age of forty was unhappy with the look of
her smile, which she described as “disgraceful”.
The aesthetic diagnosis consisted of an analysis
of the features of the face, the smile, the teeth
and the gingiva. The analysis (Fig. 1) revealed the
following findings:
_face: tense and shy look due to self-consciousness about her teeth;
_smile: considerable aesthetic compromises due
to the black triangles;
_teeth: healthy triangular, curved teeth; the
margins of the roots are visible;
26 I cosmetic
dentistry
3_ 2010
_Procedure
The following procedure was determined on
the basis of the analysis:
_surgical intervention at tooth #12 in order to
increase the gingiva (transplantation of connective tissue);
_fabrication of a mock-up in order to visualise
the final result;
_tooth preparation on the basis of the mock-up;
_temporisation;
_try-in of the veneers (adaptation, shape and
shade); and
_incorporation of final restoration.
_Treatment course
Surgical intervention to increase
the gingiva
Connective tissue was removed from a lobe
that was moved towards the tooth crown. Before
further treatment was conducted, a four-month
healing phase was necessary.
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industry report _ IPS e.max Press
I
Preparation of the mock-up
A silicone matrix was fabricated on the basis
of the wax-up, which was based on the findings
of the aesthetic analysis. The temporary restorations were fabricated with the help of the matrix
from a self-curing, flowable Bis-GMA-based
composite. This allowed us to discuss the
restoration beforehand with the patient, who
provided her input and approved of the restoration (Fig. 2).
Preparation
In order to keep the depth in check and observe the biological concept, the drill was placed
directly on the mock-up. With this procedure,
a uniform thickness of approximately 0.5 mm is
achieved on the basis of the volume of the final
restoration.1 After removing the preparation key
(mock-up), the presence of larger, non-prepared
enamel areas is observed. In the present case,
the treatment protocol was slightly varied in
view of the cervical preparation margins: usually, the preparation margins are located above
the gum line for veneer preparations; in this
case, however, the margins had to be designed
sub-gingivally (Fig. 3).
Fig. 3
contact surface with a soft transition from the
edge of the root to the margins of the contact
surface could be designed to mask the missing
papillae (Fig. 4).
The all-ceramic veneers were fabricated with
the IPS e.max Press (MO1) lithium-disilicate
glass-ceramic material and the incisal third was
veneered with IPS e.max Ceram (both Ivoclar
Vivadent). The pressed veneers, which showed
a minimum thickness of 0.3 mm, feature a high
stability and outstanding accuracy of fit on the
one hand and excellent light-optical properties
on the other.
Try-in of the IPS e.max Press veneers
This approach was chosen for various reasons: in order to eliminate the black triangles,
meet the biological requirements (cleaning and
soft edges) and consider the biomechanical
properties of the ceramic (prevention of nonsupported areas in the ceramic), only one single
After removing the temporary restorations,
all veneers were tried in simultaneously. This
enabled the overall appearance to be visualised.
Subsequently, the accuracy of fit was checked.
Variolink Veneer Try-In paste (Ivoclar Vivadent)
was used for this procedure in order to simulate
Fig. 4
Fig. 5
Fig. 6
Fig. 3_Preparations with
sub-gingival margins in the
proximal region.
Fig. 7
Fig. 4_Checking the relation
between the preparations and the
volume of the final restoration with
the help of a silicone matrix.
Fig. 5_Isolating individual teeth in
order to achieve optimum bonding.
Figs. 6 & 7_Lateral view of the
IPS e.max Press veneers from right
(Fig. 6) and left (Fig. 7).
cosmetic
dentistry 3
I 27
_ 2010
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I industry report _ IPS e.max Press
Fig. 8
Fig. 8_Frontal view of the restorations;
an expansion of the interdental
papillae can be observed.
Fig. 9_View of the maxillary teeth;
the optical properties of IPS e.max
Press material are particularly
highlighted in this image.
Fig. 9
the effect of the cementation material on the
shade of the restoration.
Clinical procedure
The veneers were individually cemented using
the adhesive technique, starting with the inci-
the distance between the contact point and
the tip of the papilla had to be less than 5 mm in
order to allow the papilla to grow back.2 After
some months, the papilla will have grown and
filled the small spaces that were reserved for it.
This is also a confirmation of the bio-compatibility of the lithium-disilicate glass-ceramic
IPS e.max Press (Figs. 9 & 10).
By strictly observing the treatment strategy
and using materials that show optimum optical and biomechanical properties, the patient’s
smile was modified and restored in accordance
with the principles of minimally invasive dentistry.
I would like to thank Gérald Ubassy for his
cooperation and his exceptional talent._
Fig. 10
Fig. 10_Light transmission through
IPS e.max Press veneers.
sors (Fig. 5), followed by the lateral incisors and
canines and so on, thus allowing the clinician
to carry out corrections on the proximal areas
of the less prominent teeth (distal surfaces of
canines or premolars). The restorations were
conventionally placed with Variolink Veneer
(Ivoclar Vivadent). In a last step, the composite
joints were carefully finished with a scalpel in order to maintain the surface gloss of the ceramic
and the excellent fit in the periodontal tissue
(Figs. 6–8).
Editorial note: A list of references is available from the
publisher.
_contact
cosmetic
dentistry
Dr Stefen Koubi
51, Rue de la Palud
13001 Marseille
France
E-mail:
koubi-dent@wanadoo.fr
_Conclusion
Clear communication between the dentist
and the dental technician is mandatory in clinical cases such as this to allow as much information as possible to be exchanged (models,
images of the initial situation, images of the
preparations and their shade, impression of
the temporary restorations in place, shade determination). In the present case, the ceramist
designed the margins of the contact surfaces on
the stone model 2 mm from the papilla because
28 I cosmetic
dentistry
3_ 2010
Gérald Ubassy
Centre de Formation
International
Route de Tavel
Impasse des Ormeaux
30650 Rochefort du Gard
France
E-mail: contact@ubassy.com
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CDE0310_30-32_Jadad 29.10.10 12:04 Seite 1
I industry report _ Opalescence Treswhite Ortho
First whitener for
fixed-braces orthodontics
Authors_ Dr Enrique Jadad, Dr Jaime Montoya & Prof Gonzalo Arana, Colombia
Fig. 1
Fig. 2
Fig. 1_Patient under
orthodontic treatment.
Fig. 2_Close up of patient under
orthodontic treatment.
Fig. 3_Treswhite Ortho
ready to be used.
Fig. 4_Treswhite Ortho tray
in the upper maxillary.
Fig. 5_Removing the external
bleaching tray allows the internal
bleaching tray to remain in position.
Fig. 6_Upper and lower bleaching
trays in position with H2O2 in
close contact with the teeth.
Fig. 4
_The following article describes the use of
a new dental whitening product based on hydrogen peroxide (H2O2). The effect of this compound
whitens dentine in multidirectional angles, reaching areas covered by brackets, making it possible
to achieve teeth whitening under braces. Patients
are very willing to use this whitening procedure,
both in-office and at home, because they want
to achieve white teeth while under orthodontic
treatment. The result is a whitening technique that
also achieves a marked increase in patients’ oral
hygiene habits.
The use of the H2O2 as a dental whitening agent
was first described by Kingsbury in 1861. The dentists’ desire to provide fast and effective teeth
whitening procedures was described by Abbot in
1918, when he introduced a wonderful and revolutionary in-office dental whitening technique—
a 35 % H2O2 concentration together with heat
emission from a lamp to increase oxidation.1 In
Fig. 5
30 I cosmetic
dentistry
3_ 2010
Fig. 3
1989, Haywood and Heymann described a technique for daily use that used a low carbamide peroxide concentration to remove deeper teeth stains,
which increase with age.2
_Dental whitening popularity
The success of H2O2-based teeth whitening
products has been accepted and validated by
research. The successful use of H2O2 for dental
whitening, using different techniques for in-office
and at home treatment, has been described by
many authors.3 Messages on TV and in newspapers, magazines and other media have popularised
dental pigments and teeth-stain removal, caused
by age, food, cigarettes, tea, and beverages with
colorants, amongst others causes. People ask for
dental whitening treatments to achieve better
aesthetics, improve their smile and their selfesteem, all of which are closely related to dental
pigmentation.4
Fig. 6
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industry report _ Opalescence Treswhite Ortho
Fig. 7
Patients under orthodontic treatment are
convinced they must maintain their oral health
regarding colour and aesthetics. Dentists and
patients understand that there is the possibility
of generating gingival irritations and dental pigmentation alterations caused by bacterial plaque
accumulation around orthodontic devices, such
as brackets, bands and arches, which adds to the
process of decalcification and to long-term adverse
factors, such as a poor oral hygiene. Conventional
home care includes tooth brushing (mechanical
or manual), irrigation devices, fluoride mouth
rinses, topical fluoride applications and dental
floss. But even with all this armamentarium, there
is low motivation on behalf of patients.5
Fig. 8
implement parallel treatments that will maintain
optimal periodontal health and at the same time
protect teeth by increasing enamel micro-hardness
and making teeth less decay prone. Owing to the
new dental whitening that contains fluoride and
potassium nitrate ions, this is possible.5
For these patients, we helped developed a product called Opalescence Treswhite Ortho (Ultradent,
Opal Orthodontics) that prevents decalcification
resulting from bacterial attack, which is responsible
for carious lesions, and increases enamel microhardness.
_Health and aesthetics
Treswhite Ortho is applied with an entrenched
external tray, which holds another very flexible one
for home or in-office use, and is easily adaptable
to teeth and brackets topography. This flexible tray
contains an 8 % concentration of H2O2, fluoride
and potassium nitrate. The flexible tray containing
H2O2 should be kept on the brackets for 45 minutes
in order to achieve adequate contact time between whitening gel, teeth and brackets. After
each 45-minute daily session, the soft tray is easily
removed from the mouth and discarded, and after
that the patient removes any remnants of gel by
brushing.
Oral health and hygiene are important factors
to keep in mind for patients who are being treated
with orthodontic devices; excellent oral hygiene is
associated with the desire for appropriate dental
aesthetics during and after treatment. By appealing to this desire for optimal aesthetics, we can
Treswhite Ortho is the first dental whitening
method that works on fixed orthodontic devices
and on preventing enamel demineralisation. The
use of H2O2 for bacterial and plaque removal, and
gingival tissue healing or scarring removal was
proved more than 35 years ago.6–9 Bacteria such
The vast majority of these devices and techniques used for oral health and hygiene are not
implemented by the majority of patients that go
at least twice per year to the dental office, and
therefore benefits and results are not really significant. We should emphasise other alternatives that
add to the above and that with patient awareness
could help us improve the oral health of patients
undergoing orthodontic treatment.
Fig. 10
I
Fig. 9
Fig. 7_After ten days of whitening
treatment we started the removal
of the orthodontic devices.
Fig. 8_Brackets over the teeth,
ready to be removed.
Fig. 9_Notice teeth colour in the area
in which the bracket was located
after the first bracket is removed.
Fig. 10_Regular colour under bracket,
no colour differences were found.
Fig. 11_Colour matching using the
VITA Easy Shade spectrophotometer.
Fig. 12_Colour matched (B2)
showing in the Easy Shade screen.
Fig. 11
Fig. 12
cosmetic
dentistry 3
I 31
_ 2010
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I industry report _ Opalescence Treswhite Ortho
Fig. 13
Fig. 14
Fig. 13_Colour matching using
the VITA Classical (Lumin Vacuum).
Fig. 14_Final result after ten days’
use of Treswhite Ortho and
brackets removal.
Fig. 15_Patient smile shows uniform
colour in all the anterior teeth.
as Streptococcus mutants and Lactobacillus are
responsible for the white spot lesions caused
by enamel demineralisation. Both types of bacteria
are anaerobic, meaning that they need a dark, warm
and oxygen-free environment to survive, because
their organisms are unable to eliminate or detoxify
in the presence of oxygen radicals.10 Conversion
of H2O2 to nascent oxygen causes tissue and oral
environment oxygenation, and subsequently creates an inadequate environment for bacteria
growth and reproduction.
Fig. 15
ally, dental whitening increases the responsibility
for maintaining a good oral hygiene.
An 18-year-old patient is more receptive to a
treatment based on a dental whitening product
than to brushing with fluoride toothpaste or using
anti-plaque mouth rinses. This is quite evident when
removing the soft Treswhite Ortho tray, since teeth
must be vigorously brushed to remove the remnants
of the viscous H2O2-based whitening gel. The result
is chemical and mechanical removal of filaments
and bacteria from the teeth surface and brackets.
_Overcoming reluctance
Many young and adult patients are reluctant
to wear fixed orthodontic brackets because of
their unattractive aesthetic appearance. Adequate
oral hygiene is more difficult to achieve when
wearing these devices, and after months or years
of treatment, patients’ teeth usually become dark
or pigmented, thus increasing patient rejection of
orthodontic treatments.
The use of pre-medicated, adaptable and
malleable trays for home or in-office treatment is
an excellent and easy way to offer patients the
opportunity to have sparkling white teeth during
orthodontic treatment.11 Treswhite Ortho whitening power has a predictable benefit. H2O2 has a low
molecular weight of 32 mg/m, which allows its easy
diffusion through enamel to dentine.12 Once it
spreads to the dentine, oxygen molecules act upon
the dark pigments rotating and fragmenting them,
creating a whitening effect in the dental structure.13 In addition, Treswhite Ortho H2O2 conversion
to oxygen is highly beneficial for eliminating gingivitis, owing to the ability to provide the extra oxygen required during the high-oxygen consumption
by the inflamed gingival tissues.12,14
H2O2 whitens poly-directionally inside the teeth,
even underneath places covered by orthodontic
devices such as brackets, making it possible to obtain homogeneous whitening on patients wearing
orthodontic devices.12 Patients are very receptive
and keen to use this whitening product. Addition-
32 I cosmetic
dentistry
3_ 2010
As oral health professionals, we desperately
seek to increase patients’ awareness of functional,
healthy and aesthetic orthodontic treatments.
Treswhite Ortho is effective in removing bacteria
and achieving enamel hardness, leaving patients
with bright and sparkling teeth. But more importantly, it leaves teeth healthy and free of fissures.
This type of result must form the basis for our new
maintenance and care methodology for modern
orthodontic therapies._
Editorial note: A complete list of references is available
from the publisher.
_about the authors
cosmetic
dentistry
Dr Enrique Jadad is a specialist in Oral
Rehabilitation and Associate Professor
at the University of Cartagena and Santiago de Cali
University in Colombia. He is also an international
visiting professor at Viña del Mar University, Chile.
He can be contacted at ejadad@gmail.com.
Dr Jaime Montoya is an orthodontic specialist
in private practice in Barranquilla, Colombia.
He can be contacted at jamontoya72@gmail.com.
Prof Gonzalo Arana is a Professor at Santiago
de Cali University, and a researcher in aesthetics
and biomaterials who leads the BEO Research Group.
He can be contacted at gonzalo.arana@usc.edu.co.
[33] =>
CDE0310_01_Titel
Register & More Information at:
Contact in Athens:
Lito Christophilopoulou
Τel: +30 210 213 2084, +30 210 222 2637
E-mail: lito@omnipress.gr, omnipress@omnipress.gr
Web:www.omnicongresses.gr
Contact in the US:
Nena Puga
Tel.: +1 310 696 9025
E-mail: nena@gidedental.com
website: www.gidedental.com
Media Partner:
SPONSORS
coltene
whalledent
Unbenannt-10 1
21.10.2010 18:03:34 Uhr
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CDE0310_34_Voco 29.10.10 12:04 Seite 1
I industry news _ VOCO
®
®
Grandio SO and Grandio SO Heavy Flow
_GrandioSO, the new, universal nano-hybrid
restorative for all classes of cavity, meets the highest
demands for restorations in anterior and posterior
regions. GrandioSO is suitable for Class I to V restorations, reconstruction of traumatically injured anterior teeth, interlocking and
splinting of loosened teeth,
corrections of shape and
shade to enhance aesthetic
appearance, core build-up
for crowns, and the fabrication of composite inlays.
As it offers superb material properties, GrandioSO
is a most toothlike
material with regard to its physical parameters. It
allows for equally durable and
aesthetic restorations, owing to
a very high filler content (89 w/w%) and low shrinkage (1.61 %), a high compressive and flexural
strength (439 MPa and 187 MPa, respectively),
an E-modulus (16.65 GPa) and thermal expansion
behaviour (␣ = 27.3 x [10–6 x K–1]) similar to dentine,
a very high surface hardness (210,9 MHV), low abrasion (18 µm, ACTA with 200,000 cycles), as well as
the optimal balance of translucence and opacity.
GrandioSO polishes very well and owing to its
outstanding abrasion resistance the restoration
remains permanently lustrous. With 16 different
shades, including the new shades VCA3.25 and VCA5,
the entire spectrum relevant to dentistry is covered.
_contact cosmetic
dentistry
VOCO GmbH
P.O. Box 767
27457 Cuxhaven
Germany
Website: www.voco.com
34 I cosmetic
dentistry
3_ 2010
GrandioSO Heavy Flow, a high-viscosity flowable
universal nano-hybrid restorative, has a very high
filler content (83 w/w%) and exceptional stability
in comparison with conventional flow composites,
as well as excellent wetting properties. Thus, it
is recommended for any type of treatment
that requires these qualities. For composite restorations that are directly modelled
in the mouth, the increased viscosity
results in simplified and stress-free placement of the composite layers. GrandioSO Heavy
Flow is suitable for minimally invasive restorations
of all types; restorations of small Class I cavities and
extended fissure-sealing; Class II to V restorations,
including treatment of cuneiform defects and cervical caries; blocking-out of undercuts; repair of fillings and veneers; luting of translucent prostheses
(for example, full ceramic crowns); and interlocking
and splinting of teeth with glass-fibre strands such
as GrandTEC. It can also be used as base material, in
combination with glass-fibre strands, for the fabrication of semi-permanent crowns and bridges.
_Optimal handling
Owing to its smooth consistency, GrandioSO is
readily packable and sculpts well without sticking
to the instrument. In addition, it combines exceptionally long workability under ambient light with
very short setting times during subsequent polymerisation. It is possible to cure the material reliably
in 10 seconds per 2 mm increment. GrandioSO is
available in easy-to-use rotating syringes and particularly economical caps.
GrandioSO Heavy Flow is subject to far lower
shrinkage than conventional flow materials during
polymerisation (2.96 %). It also features high
compressive and flexural strength (417 MPa and
159 MPa, respectively), an E-modulus that is extremely high for a flowable material (11.85 GPa), a high
surface hardness (175 MHV), as well as low abrasion
(40 µm, ACTA with 200,000 cycles). This slow flowing composite, which complements flowables with
conventional viscosity, offers users many advantages. On the one hand, it offers a longer working
period during which the material can be placed
in the cavity and distributed before polymerisation;
on the other hand, less time is required for the removal of any excess due to running of the material.
Owing to its reduced flowability, GrandioSO
Heavy Flow is well suited to all fillings that do not require elaborate sculpting. Its excellent material and
handling properties make GrandioSO Heavy Flow
superior to many packable composites. GrandioSO
Heavy Flow is available in a non-run, non-drip NDT
syringe in ten shades and as caps in five shades.
GrandioSO and GrandioSO Heavy Flow may also
be used in combination._
[35] =>
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Unbenannt-5 1
11.10.2010 15:29:21 Uhr
[36] =>
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CDE0310_36_Events 29.10.10 12:05 Seite 1
I meetings _ events
International Events
2010
2011
Dental-Facial Cosmetic
International Conference
Where:
Dubai, UAE
Date:
5 & 6 November 2010
E-mail:
info@cappmea.com
Website: www.cappmea.com
IADR General Session & Exhibition
Where:
San Diego, CA, USA
Date:
16–19 March 2011
E-mail:
sherren@iadr.org
Website: www.iadr.org
Veneersymposium
Where:
Leipzig, Germany
Date:
5 & 6 November 2010
E-mail:
event@oemus-media.de
Website: www.oemus-media.de
DGÄZ Annual 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
International Dental Show
Where:
Cologne, Germany
Date:
22–26 March 2011
E-mail:
ids@koelnmesse.de
Website: www.ids-cologne.de
AACD Boston 2011
Where:
Boston, MA, USA
Date:
18–21 May 2011
E-mail:
pr@aacd.com
Website: www.aacd.com
EAED Spring Meeting
Where:
Istanbul, Turkey
Date:
2–4 June 2011
E-mail:
info@eaed.org
Website: www.eaed.org
IACA 2011
Where:
San Diego, CA, USA
Date:
28–30 July 2011
E-mail:
info@theiaca.com
Website: www.theiaca.com
AAED Annual Meeting
Where:
San Juan, Puerto Rico
Date:
2–5 August 2011
E-mail:
meetings@estheticacademy.org
Website: www.estheticacademy.org
FDI Annual World Dental Congress
Where:
Mexico City, Mexico
Date:
14–17 September 2011
E-mail:
congress@fdiworldental.org
Website: www.fdiworldental.org
IFED World Congress
Where:
Rio de Janeiro, Brazil
Date:
21–24 September 2011
Website: www.ifed.org
36 I cosmetic
dentistry
3_ 2010
[37] =>
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CDE0310_37_Submission 29.10.10 12:05 Seite 1
about the publisher _ submission guidelines
submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
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address, e-mail address, etc.).
I
Image requirements
Please number images consecutively throughout the article
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Please place image references in your article wherever they
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If you do not directly refer to the image, place the reference
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In addition, please note:
In addition, images must not be embedded into the MS Word
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We can run an unusually long article in multiple parts, but this
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In short, we do not want to limit you in terms of article length,
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cosmetic
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I 37
_ 2010
[38] =>
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I about the publisher _ imprint
cosmetic
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38 I cosmetic
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3_ 2010
[39] =>
CDE0310_01_Titel
CDE_Abo_A4_CDE_Abo_A4 29.10.10 12:19 Seite 1
cosmetic
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[40] =>
CDE0310_01_Titel
“I need a
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VOCO_CDI_0410_GrandioSO_210x297.indd 1
03.09.2010 9:58:28 Uhr
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Editorial
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Content
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view
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Case acceptance in complex-care dentistry
06 - 09
view
-
Use of an X-ray phantom in dental 3-D diagnostics in digital volume tomographs
10 - 12
view
-
Imaging in dentistry: A clinical perspective
14 - 20
view
-
Impression materials—Are there any REALLY new ones?
22 - 24
view
-
Radiant - beautiful anterior teeth
26 - 28
view
-
First whitener for fixed-braces orthodontics
30 - 32
view
-
Grandio®SO and Grandio®SO Heavy Flow
34 - 34
view
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International Events
36 - 36
view
-
Submission Guidelines
37 - 37
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-
Imprint
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/ Content
/ Case acceptance in complex-care dentistry
/ Use of an X-ray phantom in dental 3-D diagnostics in digital volume tomographs
/ Imaging in dentistry: A clinical perspective
/ Impression materials—Are there any REALLY new ones?
/ Radiant - beautiful anterior teeth
/ First whitener for fixed-braces orthodontics
/ Grandio®SO and Grandio®SO Heavy Flow
/ International Events
/ Submission Guidelines
/ Imprint
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