cosmetic dentistry international No. 1, 2015

cosmetic dentistry international No. 1, 2015

Cover / Editorial / Content / MiCD: Do no harm cosmetic dentistry—Part I / Aesthetic Digital Smile Design: Software-aided aesthetic dentistry—Part I / Technological innovation in professional home bleaching: the ENA White 2.0 system in only 2 minutes per day without tray / Direct resin restoration using the new V4-Ring matrix and the new Micerium Enamel Plus HRi Function composite / Impression of steeply angulated implants: A new method / Wireless digital sensors / Industry News / Meetings / International Events / Submission guidelines / Imprint

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CDE0115_01_Title 26.02.15 10:25 Seite 1

issn 2193-1429

Vol. 9 • Issue 1/2015

cosmetic
dentistry
_ beauty & science

1

2015

| review
MiCD: Do no harm
cosmetic dentistry—Part I

| case report
Direct composite resin restoration

| technology
Wireless digital sensors

[2] => Standard_300dpi

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CDE0115_03_Editorial 26.02.15 10:25 Seite 1

editorial _ cosmetic dentistry

I

Dear Reader,
_At the end of 2014, the Asian Academy of Aesthetic Dentistry (AAAD), which is
the pioneer aesthetic dental organisation in Asia, held its 13th biennial meeting and scientific
conference in Foshan in China jointly with the Foshan Academy of Esthetic Dentistry. During
the meeting, the new executive council committee for 2014–2016 was elected, and I am
honoured to have been elected as the 14th President of the AAAD.
Clinicians from Bangladesh, China, Hong Kong, Japan, Korea, Malaysia, Nepal, the Philippines,
Singapore, Sri Lanka and Taiwan attended the 44 lectures of the scientific programme
presented by invited speakers in various fields of aesthetic dentistry. At the conference,
Chinese clinicians learnt about the growing global trends in cosmetic dentistry and
participants from other countries learnt about the rapid development of China in the field of
aesthetic dentistry.

Dr Sushil Koirala
Editor-in-Chief

An international programme of this magnitude helps to promote professional collaboration,
friendship and opportunities to share knowledge and skills among clinicians and academics
in the region.
With the rapid development of information and communication technology, AAAD is
now planning to launch an e-learning platform to provide the most cost-effective aesthetic
dentistry educational opportunities to young dental professionals in Asia. This will be
developed with the active participation of member countries’ key clinicians and through joint
collaboration with various like-minded professional academies, dental schools and dental
experts, as well as dental companies around the world.

cosmetic dentistry being the official magazine of AAAD, I hope AAAD members will be
able to put the information to full use to improve and share their clinical knowledge and skills.
In this year’s first issue, we have two exclusive articles about digital smile design and
cosmetic dentistry practice philosophy and other clinical case reports. I hope readers will
enjoy them, and the cosmetic dentistry editorial team looks forward to your feedback.
Yours faithfully,

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

cosmetic
I 03
dentistry 1
_ 2015

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CDE0115_04_Content 26.02.15 10:26 Seite 1

I content _ cosmetic dentistry

I editorial

I technology

03

40

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

Wireless digital sensors
| Dr George Freedman

I review

I industry news

06

44

MiCD: Do no harm cosmetic dentistry—Part I
| Dr Sushil Koirala

14

Aesthetic Digital Smile Design:
Software-aided aesthetic dentistry—Part I
| Dr Valerio Bini

Technological innovation in professional home
bleaching: the ENA White 2.0 system
in only 2 minutes per day without tray
| Dr Luigi Leonardi

I industry report
30

Direct resin restoration using the new
V4-Ring matrix and the new Micerium Enamel Plus
HRi Function composite
| Drs Francesco Simoni & Lorenzo Vanini

Remedent NV launches major upgrade to
dental marketing software
| Remedent

I meetings
46

I technique
24

| Micerium

45

I special

ENA White 2.0—professional home bleaching

Regenerative endodontics and composite
as an all-rounder
| Coltène

48

International Events

I about the publisher
49
50

| submission guidelines
| imprint

issn 2193-1429

Vol. 8 • Issue 2/2014

cosmetic
dentistry
_ beauty & science

2

2014

I case report
36

Impression of steeply angulated implants:
A new method
| Profs. Gregory-George Zafiropoulos & Oliver Hoffmann

04 I cosmetic
dentistry

1_ 2015

| review
MiCD: Do no harm
cosmetic dentistry—Part I

| technology
Wireless digital sensors

| case report
Impression of steeply angulated
implants: A new method

Cover image courtesy of lenaer

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Today, cosmetic dentistry is a $ 4 billion industry.
With
you decide how much of that happens in your practice.

VISIT WWW.SMILEME.MOBI FOR A FREE WEB DEMO.
Hall 3.2
Stand A-041

C1 - 016B

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I review _ minimally invasive dentistry practice

MiCD: Do no harm
cosmetic dentistry—Part I
Author_Dr Sushil Koirala, Nepal

Fig. 1

Fig. 2

Fig. 3

_Introduction
The demand for cosmetic dentistry is a growing
trend globally. Increased media coverage, the availability
of free online information and the improved economic
status of the general public has led to a dramatic increase
in patients’ aesthetic expectations, desires and demands.
Today, a glowing, healthy and vibrant smile is no longer
the exclusive domain of the rich and famous; hence,
many general practitioners are now being forced to
incorporate various aesthetic and cosmetic dental treatment modalities into their daily practices to meet the
growing demand of patients.
Cosmetic dentistry is a sciencebased art guided by the desire of
the patient. Many young clinicians
who plan to incorporate it into their
practice are confused about what
they and their patients actually wish
to achieve. It is to be noted that the
treatment modalities of any health
care service should be aimed at the
establishment of health and the
conservation of the human body
with its natural function and aesthetics. However, it is worrying to
note that the treatment philosophy
and technique adopted by many
cosmetic dentists around the world
tend towards macro-invasive protocols, and millions of healthy teeth are
aggressively prepared each year for
the sake of creating beautiful smiles.

Fig. 4a

Fig. 4b

06 I cosmetic
dentistry

1_ 2015

The practice philosophy adopted by the clinic and
the professional team members generally guides the
overall output of the practice. Minimally invasive cosmetic dentistry (MiCD), a do no harm practice philosophy,
has four fundamental components: level of care, quality
of operator (dentist), protocol adopted and technology
selected, which must all be respected in daily clinical
practice. Adopting this holistic medical science practice
philosophy is not an easy task, as it requires a change in
the mindset of professionals.
In Parts I and II, I explain MiCD, do no harm cosmetic
dentistry, based on my Vedic Smile concept, which I have
been practising successfully in Nepal for the last 20 years,
and advocating globally since 2009 as the MiCD global
mission. It is to be noted that both parts are based
on fundamental science (truth and available evidence),
clinical experience and the common sense required in
holistic dentistry. Part II of the article will follow in the
next issue of cosmetic dentistry.

_Cosmetic dentistry, a global trend
The prevalence and severity of dental decay have
been declining over the last decades in many developed
countries and this trend is shifting towards developing
countries as well. With increased media coverage, the
availability of free online information, public awareness
has fuelled the demand for cosmetic dentistry globally.
Now, a glowing, healthy and vibrant smile is no longer
the exclusive domain of the rich and famous.1 The population of beauty- and oral health-conscious people is
increasing every year and data from various sources
shows that the coming generations of children, espe-

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review _ minimally invasive dentistry practice

cially from the middle- to higher-income population, will
have fewer decayed teeth and will need less complex
restorative dental care as they age. These changing patterns of dental care needs will bring about a major shift in
the nature of dental services from traditional restorative
care to cosmetic and preventive services.
The increased market demand for smile aesthetics
among patients is forcing general practitioners of today
to incorporate the art and science of cosmetic dentistry
into their practice. Cosmetic dentistry is not yet recognised as a separate clinical specialty like orthodontics,
periodontics or paediatric dentistry. Cosmetic dentistry is
synonymous with multidisciplinary dentistry, as its success and failure are related to the patient’s psychology,
health, function and aesthetics. Ethical, high-standard
cosmetic dentistry skill training of clinicians is essential
for the increased global market of cosmetic dentistry and
its promotion. It is widely seen that the treatment modalities of contemporary cosmetic dentistry are tending towards more-invasive procedures with an over-utilisation
of full crowns, bridges, dentine veneers, and invasive periodontal aesthetic surgery, while neglecting long-term
oral health, actual aesthetic needs and the characteristics
of the patient.2 These aggressive treatment modalities are
indirectly degrading social trust in dentistry, owing to the
trend of fulfilling the cosmetic demands of patients without ethical consideration and sufficient scientific background and promoting the “the more you replace, the
more you earn” or “more is more” mindset in dentistry.2
Changing the professional mindset of the practising
clinician is not an easy task; it is just like quitting smoking
for a heavy smoker. In order to practise healthy dentistry,
one must be groomed, starting from dental school education, with moral values, a high ethical standard, a positive attitude and a patient-centred practice philosophy.
A student reflects the mindset of his or her teachers, and
a teacher or mentor with comprehensive knowledge,
clinical skills, honesty and humanity is difficult to find in
today’s business-oriented dental education. I believe that
knowledge should be free and skill training must be useful
and easily affordable to our young practising clinicians
around the world. Compromised university dental education and expensive private skill training with biased
mentoring have been promoting health-compromising
treatment protocols and costly diagnostic, preventive
and treatment technologies. This highly business-oriented trend will promote a change in the mindset of
practising clinicians to adopt more-aggressive and invasive dental treatment modalities, leading to the practice
of unhealthy dentistry in the long term.

_Aesthetic versus cosmetic dentistry
The words “aesthetics” and “cosmetic” are viewed
as synonyms by many cosmetic dentists. However, it is
necessary to understand the core difference in meaning.

The Oxford dictionary2 defines
“aesthetics” as “the branch of
philosophy which deals with questions of beauty and artistic taste”
and “cosmetic” as “improving only
the appearances of something”.
In dentistry, “aesthetics” explains
the fundamental taste of a person
concerning beauty, whereas “cosmetic” deals with the superficial or
external enhancement of beauty.
Therefore, aesthetic dentistry falls
under need-based dental service,
and is generally guided by the
sex, race and age (SRA factors)
of the patient. However, cosmetic
dentistry, which is influenced by
perception, personality and desires
(PPD factors), can be categorised
as want- or demand-based dental
service. For example, a patient’s
request to replace old amalgam
restorations with tooth-coloured
restorative materials can be considered an aesthetic requirement
or demand. The request of an old
woman for pearly white teeth and
the ideal smile design is far more
than an aesthetic requirement,
and must be considered a cosmetic
demand or requirement.

Fig. 5a

Fig. 5b

Fig. 5c

In my clinical practice, I divide aesthetic and cosmetic
clinical cases into three different categories:
1. Preventive, or support based: treatment prevents or
intercepts the diseases, defects,
habits and other factors that
may adversely affect the existing
or the future smile aesthetics
of the patient.
2. Naturo-mimetic, or need based:
treatment is carried out to restore or mimic the natural aesthetics, bearing the SRA factors
of the patient in mind, and the
treatment generally enhances
the health and function of the
oral tissue.
3. Cosmetic, or desire based: treatment is performed to enhance or
supplement the aesthetic components of the smile; hence, the
treatment outcome of cosmetic
treatment may not be in harmony with the patient’s SRA factors as in nature-mimetic dentistry, and cosmetic treatment

Fig. 6a

Fig. 6b

cosmetic
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I review _ minimally invasive dentistry practice
understand that science and art in dentistry have no
meaning if practised by an unethical operator, who does
not respect the overall health of the patient. Any scientific advancement in technology has positive and negative sides; hence, if not applied properly, it may adversely
affect the profession and may become a threat.

Fig. 7a

Fig. 7b

I believe that a clinic or treatment centre must establish its practice philosophy according to its objectives.
What a clinician wants and the kind of services he or she
wants to deliver to his or her patients guides the clinic.
Practically, the practice philosophy in dentistry can be
classified into two different categories, depending on the
mindset of the operator.
Patient-centred

Fig. 8a

Fig. 8b

may not necessarily be beneficial to the health and
function of the oral tissue.

_Practice philosophy in dentistry:
The mindset
The majority of dental schools around the world focus on teaching knowledge and skills in dental medicine
that are based on contemporary dental science and art.
Dental school education does not give due consideration
to healthy dental practice philosophy owing to various
factors, such as the right to chose one’s practice philosophy and the domination of business rather than
service-oriented dental practice in the global market.
However, quality and healthy clinical practice is always
a dream of a good clinician, and establishing such practice requires an unbiased vision, learning and serving
attitudes, and dedication from the dentist. We must

Clinicians with this kind of mindset generally have
a do no harm dental practice (Fig. 1). Professional
honesty and humanity are the fundamental principles
of such a practice. Operators with this mindset enjoy
sharing their clinical knowledge and skills with their
professional friends and junior colleagues to promote
patient-centred clinical practice in society. This group
of clinicians firmly believes in the word-of-mouth
approach to practice marketing and always thinks
of the patient’s long-term health, function and aesthetics. Clinicians practising do no harm dentistry
are generally cheerful, happy and healthy in their professional life.
Financially focused
Clinicians with this kind of mindset practise a financially focused dentistry and adopt various kinds of direct
marketing approaches to sell their dentistry like a commodity in the market rather than a health care service.
Practitioners in this group generally achieve a secure
financial position quickly; however, it is frequently seen
that they develop chronic stress, burn-out syndrome,
depression, frustration and professional guilt, leading
to compromised health and happiness in their professional life.
Dentistry and professional stress

Fig. 9a

Fig. 9b

Fig. 10a

Fig. 10b

08 I cosmetic
dentistry

1_ 2015

Dentistry has long been considered a stressful occupation. Dentists perceive dentistry as being more stressful than other occupations.3 Dentists have to deal with
many significant stressors in their personal and professional lives.4 There is some evidence to suggest that dentists suffer a high level of occupation-related stress.5–9
A study has found that 83 per cent of dentists perceived
dentistry as “very stressful”10 and nearly 60 per cent
perceived dentistry as more stressful than other professions.11 Stress can elicit varying physiological and
psychological responses in a person. Professional burnout is one of the possible consequences of ongoing

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review _ minimally invasive dentistry practice

professional stress. The effect of burn-out, although
work-related, often will have a negative impact on people’s personal relationships and well-being.12–13 Hence,
dentists need to take care of their staff’s health and focus
on professional happiness in daily practice.
A clinician has full right to adopt the practice philosophy that he or she prefers. However, it is always advisable
to apply oneself to understanding, analysing and comparing this philosophy with others. I am very fortunate to
have been brought up with the Vedic philosophy of the
law of nature and the first, do no harm consciousnessbased philosophy in my life at home, at school and in my
society. The spiritual guidance and mentoring I received
at an early age at home and school have helped me to
become a professional with a firm philosophy of do no
harm; hence, I started practising consciousness-based
dentistry early in my career. During my 21 years of private
practice, I have always experienced happiness and joy
with high patient satisfaction, which has given me complete confidence and faith in my practice philosophy and
the MiCD treatment protocol that I apply in my practice.
Since late 2009, I have been promoting my practice philosophy and clinical protocol in South Asia, and started
the MiCD Global Academy in 2012 with the help of likeminded friends, who also practise a similar kind of holistic dentistry around the world. The MiCD Global Academy
has a mission to share clinical knowledge and fundamental clinical skills free of charge with all clinicians
who desire to practise do no harm cosmetic dentistry for
better patient care and to enhance their happiness in
their professional life.

_Three-way test:
Questions for your conscience
Cosmetic dentists can make errors in practice in two
ways, first owing to a lack of the required professional
knowledge and skills, and second owing to a lack of
professional honesty and humanity. The first one can
be eliminated with good education and proper training,
but the second one demands a total shift in mindset, with a high level of consciousness in professional ethics, attitudes and respect towards the
patient’s long-term health, function and natural
beauty.
I apply a simple yet very powerful test to
keep myself stress- and guilt-free and within the
boundaries of professional ethics, honesty and
humanity when proposing a dental treatment
plan to my patient. Clinicians can apply the threeway test mentioned below just by taking a deep
breath and closing their eyes for few seconds and
analysing their answers (the true response that
comes to mind) with professional honesty and
humanity. If your conscience responds positively to all the questions, then it is advisable

for you to propose the treatment plan
and take up the case, but if you give
negative responses to the questions,
then you should rethink your proposed
treatment plan to safeguard your
and your patient’s long-term health,
function and aesthetics using a more
sensible and less destructive treatment
approach.
Fig. 11a

The three-way test consists of
three basic questions:
_Would I use this treatment for a member of my own family in this situation?
_Am I competent enough to take up the
case?
_Will the patient be happy with the
biological, financial and time costs of
the proposed treatment?

Fig. 11b

I have been using this simple test
since my early days of practice and
enjoying every moment of my clinical
practice without any mental stress
and post-treatment professional guilt.
Moreover, I have found that the endresult of my case has always brought
happiness to me and to my entire
supporting team with high patient
satisfaction. During all my MiCD international lectures, training, workshops
and seminars, I always encourage my trainees and audience to enhance the quality of their operator factors
(knowledge, skills, honesty and humanity) because it is
the pillar of successful MiCD. It is my personal belief that,
if a clinician adopts a habit of testing his or her treatment
plan with the three-way test before proposing it to the
patient, it can certainly help him or her to promote
overall happiness in his or her practice with high patient
satisfaction.

Fig. 11c

Fig. 12a

Fig. 12b

Fig. 13a

Fig. 13b

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I review _ minimally invasive dentistry practice

Treatment options

Treatment procedures

Biological cost

Non-invasive treatment:
when hard and soft tissue is
not prepared during smile
enhancement procedures

_Smile exercise
_Remineralisation of white spots
_Oral appliances and bruxism guard
_Dentures requiring no tissue preparation
_Gingival mask

None

Micro-invasive treatment:
when hard and soft tissue is
prepared at a micro-level during
smile enhancement procedures

_Cosmetic chemical treatment, such as
bleaching and micro-abrasion
_Cosmetic restorations with chemical tooth
preparation, such as direct bonding, ultra-thin
veneers, adhesive pontics and overlays

Very low

Minimally invasive treatment:
when hard and soft tissue is prepared
at a superficial or minimal level during
smile enhancement procedures

_Cosmetic contouring (teeth and/or gingivae)
_Cosmetic restorations with minimal tooth
preparation, such as thin veneers, modified
inlays and onlays, partial crowns,
partial dentures, and inlay bridges
_Non-extraction conventional and
MiCD orthodontic treatment
_Mini dental implants (small diameter)
_Gingival depigmentation

Low

Invasive treatment:
when hard and soft tissue is
prepared at a deeper level during
enhancement procedures

_Tooth preparation for crowns, bridge abutments
and deep veneers
_Orthodontic treatment with tooth extraction
_Dental implants
_Aesthetic surgical procedures, such as
periodontal, orthognathic and facial surgeries

High

Table I

Table I_Treatment options,
treatment procedures and biological
cost in cosmetic dentistry.

the approach of minimal intervention dentistry, which
has basically focused on the conservative management
of carious lesions, applying the concept of “minimal
extension for decay removal”. History clearly shows
that, since Dr G.V. Black era to the present day, we have
been applying the concept of “extension in dentistry” in
the name of prevention, retention, function, aesthetic
need and cosmetic desire, and caries removal. It is a clinical fact that this concept will remain the focus because
each clinical situation is different, as its treatment
modalities are guided by multifactorial issues such as
patient factors (mind, body, behaviour and surroundings), operator factors (knowledge, skills, honesty and
humanity), protocol factors (the truth, evidence, experience and common sense), technology factors
(health, reliability, affordability and simplicity). The use
of science and technology requires consciousness in
operators and awareness in patients; hence, the operator must use his or her professional knowledge and
skills with honesty and humanity to select the least
invasive procedure, protocol and technology in treatment, so that extension in dentistry is always minimal,
safe and healthy.

_Extension: Invasive dentistry
If we look carefully at the history of restorative
dentistry, the word “extension” (or “invasive”) has
always been a point of focus among clinicians.14 The
concept of “extension for prevention and retention”
was pronounced by Dr G.V. Black 100 years ago and
it was appropriate in relation to the restorative materials available at that time. However, with the development of porcelain-fused-to-metal technology in the
late 1950s, the concept of “extension for functional
aesthetics” was advocated, which is still very popular in
clinical practice. In the early 1980s, the concept of the
“Hollywood smile” was introduced, which established
the concept of “extension for cosmetics” in dentistry.
In 2002, the FDI World Dental Federation endorsed

The invasiveness of procedures selected in cosmetic
dentistry depends on the level of smile defect, type of
smile design, proposed treatment types and treatment
complexity. MiCD uses the most conservative smile
enhancement procedure possible. The level of invasiveness in cosmetic dentistry can be classified into four
types, namely non-invasive, micro-invasive, minimally
invasive and invasive, and the treatment options, various treatment procedures and their biological cost for
each are presented in Table 1. There is only one principle
in selecting treatment modalities in MiCD: always
select the least invasive procedure as the choice of the
treatment.2 Treatment procedures mentioned under
non-invasive, micro-invasive and mini-invasive are
used selectively in MiCD.

Fig. 14a

Fig. 14b

Fig. 14c

Fig. 14d

Fig. 14e

Fig. 14f

10 I cosmetic
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_MiCD treatment protocol
and clinical technique
Minimally invasive dentistry was developed over
a decade ago by restorative experts and founded on
sound evidence-based principles.15–24 In dentistry, it has
focused mainly on prevention, remineralisation and
minimal dental intervention in caries management
and not given sufficient attention to other oral health
problems. For this reason, I developed the MiCD concept
and its treatment protocol in 2009, which integrates
the evidence-based minimally invasive philosophy into
aesthetic dentistry in the hope that it will help practitioners achieve optimum results in terms of health,
function and aesthetics with minimum treatment intervention and optimum patient satisfaction. The MiCD
concept and treatment protocol are explained in an
article titled “Minimally invasive cosmetic dentistry—
Concept and treatment protocol”;25 hence, in the
current article, I only discuss the MiCD core principles
(Table 2), MiCD treatment protocol and clinical technique briefly (Fig. 2).
MiCD clinical technique:
Rejuvenation, restoration, rehabilitation and repair
The MiCD clinical technique focuses on the aesthetic
pyramid of the Smile Design Wheel1 (Fig. 3). Aesthetic
components in dentistry are divided in to three broad
groups:
1. macro-aesthetics,
2. mini-aesthetics; and
3. micro-aesthetics.
Each aesthetic group deals with different smile aesthetic components (Table 3) and each component must
be harmonised at the end of treatment. According to the
smile defect and patient’s desire, there are four different
techniques in MiCD to enhance smile aesthetics:
1. Rejuvenation: to rejuvenate in MiCD is to enhance
smile aesthetics with minor modifications in tooth
position, colour and form, also known as the MiCD
ABC principles, namely align, brighten and contour
(Figs. 4–9):
_Align: minor discrepancies between the facial and
dental midlines are acceptable in many instances.26
However, a canted midline would be more obvious27
and therefore less acceptable in cosmetic dentistry.
Similarly, the disharmony in natural progression of
axial inclination or the degree of tipping of anterior
teeth affects the aesthetic outcome of a smile. The
correction to the midline and axial inclination progression, and necessary changes to anterior tooth
position are carried out using cosmetic orthodontic
procedures with fixed or removable aligners. Once
the anterior teeth are in an aesthetically acceptable

Sooner is better

Follow early diagnosis, prevention and intervention approach

Smile Design Wheel approach

Understand psychology, establish health, restore function and
enhance aesthetics (PHFA—sequences of Smile Design Wheel)

Do no harm

Select the most conservative treatment options and procedures
to minimise the possible biological cost

Evidence-based selection

Select materials, tools, techniques and protocols based
on scientific evidence

Keep in touch

Encourage regular follow-up and maintenance

position, the aesthetic concerns of the patient generally shift towards the colour enhancement of the
dentition. It is to be noted that a well-aligned tooth
generally requires no or less tooth preparation
during tooth contour (shape and size) modification.
This helps the clinician to achieve aesthetic smiles
with micro- or minimally invasive procedures with
a very low biological cost.
_Brighten: tooth bleaching or colour modification in
MiCD is carried out once teeth are in acceptable
alignment but before the tooth form is modified.
The level of tooth colour modification depends on
the quality of the existing colour of the dentition
and the patient’s desire. Home and office bleaching
are popular methods for modifying tooth colour.
However, in some cases, procedures such as remineralisation, micro-abrasion, walking bleach and
thin enamel veneers are used.
_Contour: a contour is an outline of the shape or form
of something.28 In dentistry, cosmetic contouring
entails reshaping teeth or gingivae to an aesthetic
form. Cosmetic contouring can be performed in two
ways, additive and subtractive. Additive cosmetic
contouring entails changing the tooth form using
tooth-coloured restorative materials, such as a resin

Table II

Table II_MiCD core principles.

Table III_Aesthetic components
and smile design parameters.

Aesthetic components

Smile design parameters

Macro-aesthetics: deals with the overall structure
of the face and its relation to the smile. In order
to establish the macro-aesthetic components
of any smile, the visual macro-aesthetic
distance should be more than 1.5 m.

_Facial midline
_Facial thirds
_Interpupillary line
_Nasolabial angle
_Rickett’s E-plane

Mini-aesthetics: deals with the aesthetic correlation
of the lips, teeth and gingivae at rest and in smile position.
The aesthetic correlation can be established properly
when viewed at a closer distance than the visual
macro-aesthetic distance. The visual mini-aesthetic
distance is similar to the across-the-table distance,
which is normally within 60 cm to 1.5 m.

In M-position:
_Commissure height
_Philtrum height
_Visibility of the maxillary incisors

Micro-aesthetics: deals with the fine structure of dental
and gingival aesthetics (Fig. 8). Micro-aesthetics can
be established at a visual micro-aesthetic distance
of less than 60 cm or within normal make-up distance.

_Maxillary central incisors (tooth size ratio)
_Principle of golden ratio
_Axial inclination
_Incisal embrasures
_Contact point progression
_Connector progression
_Shade progression
_Surface micro-texture
Table III

In E-position:
_Smile arc (line)
_Dental midline
_Smile symmetry
_Buccal corridor
_Display zone and tooth visibility
_Smile index
_Lip line

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I review _ minimally invasive dentistry practice
4. Repair: the role of repair in restorative dentistry is very
important. The restoration cycle or each re-restoration
process generally increases the size of the smile defect
by 15 to 20 per cent per re-restoration. Hence, MiCD
protocol recommends performing repair wherever
aesthetically appropriate and possible using suitable
adhesive restorative materials so that the health of
the oral tissue will not be compromised, while maintaining function and aesthetics (Figs. 15a–c).

Ten areas

Rating

1. Smile self-evaluation

Good

Satisfactory

Compromised

2. Smile HFA grade

Normal

Compromised A

Compromised HFA

3. Aesthetic category

Micro

Mini

Macro

4. Treatment complexity

Simple

Moderate

Complex

5. Proposed treatment

Accepted

Modified

Changed

6. Established outcome

Improved

No change

Deteriorated

7. Enhancement category

Preventive

Naturo-mimetic

Cosmetic

8. Biological cost

None

Very low

Low

High

9. Exit remark

Excellent

Good

Satisfactory

Below satisfactory

10. Clinical success

Excellent

Good

Satisfactory

Needs improvement

MiCD summary ten

Table IV

Table IV_The MiCD summary ten.

Fig. 15a

composite (direct and indirect restorations) or
ceramic (veneers), and changing the gingival shape
using graft materials. Subtractive cosmetic contouring entails removing dental tissue by grinding
or texturing, and gingival tissue by selective surgical
procedures—which are non-reversible in nature and
so proper care must be taken.

Fig. 15b

2. Restoration: restoration
is a process of replacing
missing dental tissue to
enhance health, function
and aesthetics. Restoration is performed using
micro- to mini-invasive
treatment options, such
as direct restorations,
veneers, inlays, onlays
or adhesive pontics, depending upon the extent and severity of the smile
defect (Figs. 10a & b & 11a–c).
3. Rehabilitation: rehabilitation is the process of complete reconstruction of the smile to enhance psychology, health, function and aesthetics using micro- or
minimally invasive treatment options to minimise the
possible biological cost. Direct and indirect composite
resin and feldspathic porcelain are the materials of
choice for rehabilitation in MiCD (Figs. 12–14).

Fig. 15c

12 I cosmetic
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1_ 2015

After completion of any MiCD clinical case, the
patient’s overall satisfaction and the clinical success
must be evaluated. In order to evaluate clinical cases
comprehensively and practically, in the MiCD protocol,
a clinician is advised to always summarise his or her
cases under the ten areas listed in Table 4, called the
MiCD summary ten.

_Conclusion
In order to practise do no harm cosmetic dentistry,
a clinician requires the desire, passion, dedication and
will-power to become an honest professional with humanity because honesty and humanity are the pillars of
do no harm cosmetic dentistry, since the mind controls
all other practice factors. The clinician must understand
that honesty and humanity are not scientific like knowledge and skills, which can be learned, copied and applied
immediately in the practice. Honesty and humanity
are inner qualities of a person and are deeply related to
the level of a person’s consciousness, which are generally expressed as habits and attitudes. Therefore, we need
to learn these qualities at home and school, and from the
profession and society.
Self-evaluation and the realisation of the level of
inner happiness that you obtain through your daily
professional work are vital to understanding and beginning to practise do no harm cosmetic dentistry in
your practice._
Editorial note: A complete list of references is available
from the publisher.

_about the author

cosmetic
dentistry

Dr Sushil Koirala
is the Chairman of and chief
instructor at the Vedic Institute
of Smile Aesthetics. He
maintains a successful private
practice in Kathmandu, Nepal.
He can be contacted at
drsushilkoirala@gmail.com.

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I special _ digital smile design

Aesthetic Digital Smile
Design: Software-aided
aesthetic dentistry—Part I
Author_Dr Valerio Bini, Italy

Fig. 2

Fig. 1

Fig. 1_Facial aesthetics medical
team and interdisciplinary vision.
Fig. 2_ADSD virtual planning.

Fig. 3_Photographs and
aesthetic plane.

Fig. 3

14 I cosmetic
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1_ 2015

_Introduction
The concept of aesthetics has been explored by
various authors and discussed by eminent philosophers. While their definitions are subjective, they
all agree on the natural origin of the term. For this
reason, I believe that the real objective of aesthetic
dentistry must be imitating nature, which is so simple to perceive yet so difficult to copy, particularly as
regards the aesthetics of the lower third of the face.
The skill and visual perception of the dental team are

essential in pursuing this goal, and the dentist acts
as architect and artisan of the oral and periodontal
tissue by moulding the physiology of the smile.

_Smile designer:
A new means of communication
Dental surgery is increasingly being forced to
adopt a multidisciplinary approach to treating the
face and smile, in which the dentist plays an influential if not primary role. A balance between the teeth,
inter-oral and perioral tissue, face, smile and person
creates an aesthetic ideal, and synergises the artistic
capacities and the expertise necessary to see the
design in the context of the face. Today aesthetics is
increasingly linked to measure, proportion and symmetry, which were all already present in ancient civilisations but today have been considerably perfected
by the digital age. Modern scientific knowledge puts
at the disposal of professionals various therapeutic
options. This along with collaboration between different specialists (orthodontists, implantologists,
periodontologists, dental technicians, maxillofacial
surgeons, plastic and cosmetic surgeons) and the
above-mentioned goal enable a treatment plan to be

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special _ digital smile design

developed with ever-greater precision (Fig. 1). Furthermore, images captured at locations far away
and viewed via video conferencing using Skype, for
example, give the dentist the role of the conductor of
an orchestra and provide him or her with a new way
of working together with other professionals.
Digital dentistry requires that one follow precise
protocols in order to obtain a standard, predictable
result that corresponds to an optimal clinical result
(virtual planning) in an ergonomic manner and with

I

Fig. 4a

Fig. 4b

Fig. 4c

Fig. 4d

a high level of quality. Today, the use of 2-D and 3-D
software for photograph editing and digital image
editing allows us to process data and customise
parameters for each specific clinical and aesthetic
requirement of the smile makeover. Modern digital
technology along with the experience and aesthetic
sensitiveness of the dentist, which are fundamental
to the success of smile design, offers greater predictability for the patient, as regards both the final
aesthetic results and the course of therapy agreed
upon.

Figs. 4a–d_Front view and
lateral views at 45 and 90 degrees.

Fig. 5a_Face Analogic
Transfer Support.
Fig. 5b_Transfer of analogue
measurements to digital calliper.

Fig. 5a

Fig. 5b

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I special _ digital smile design
The combination of terms such as “aesthetic dentistry”, “interdisciplinary vision”, “digital dentistry”
and “predictability” led me to consider that today a
new professional figure might be created: the smile
designer, whose fundamental role would be communicating with the patient and the aesthetics medical
team, whose members are crucial in virtual planning.
My ideal would be to have at my disposal a single
instrument that would serve the purpose of the
smile designer.
Using various software platforms, I have pursued
the development of a protocol for Aesthetic Digital
Smile Design (ADSD) to be used alongside other
important diagnostic elements useful for diagnosis
and prognosis, ultimately to improve the health and
well-being of the patient. Furthermore, it is advisable
to obtain prior consent regarding the aesthetic treatment to be undertaken using real clinical models,
such a mock-up, since this is also a predictable
method of simulating the aesthetic treatment plan.
It is useful to recall here the forensic dentistry provides that the dentist is obliged to comply with three
fundamental principles in carrying out his or her profession: prudence, diligence and technical expertise.

Fig. 5c

_ADSD method and protocol
Further to what has been said above, ADSD should
first be an instrument to improve communication
with the patient by showing the patient detailed
images. On the monitor, the before and after photographs allow an index of predictability and point
of comparison with the patient himself or herself.
A milestone is the innovation of aesthetic clinical
planning in aesthetic dentistry and prosthetic dentistry relating to dental technical analysis and planning, which, among other things, can be integrated
into diagnosis and planning for plastic and maxillofacial surgery (Fig. 2).

Fig. 6

The protocol first requires the acquisition of
full-frame digital images and videos of the patient.
Video especially is capable of capturing the dynamic
phases of the smile linked to its physiology (mimicry,
phonetics, relationship between the teeth and lips).
Importing this vital data into the digital clinical file
of the patient is complementary to the anamnesis
because it is an integral part of the intra- and extraoral objective examination, and will subsequently
be the subject of aesthetic analysis according to the
main guiding principles. Therefore, we could define
this as the third part of the methodology, which we
will call analytical processing, during which the
aesthetic composition of the smile, the determining
morphological features of the face and smile, including the fundamental points of reference to be

Fig. 7

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special _ digital smile design

obtained from software such as face makers, will be
mapped and processed.
The next phase in digital data processing is virtual
planning by means of digital image editing: wax-up,
digital and analogue diagnosis, mock-up, and provisional and definitive restorations. The digital methodology used for photograph and image editing is
very reliable, especially in communicating through
images the ongoing clinical case to dental laboratories concerning functional and morphological adjustments, which is made even easier if accompanied
by explanations and verbal comments. Compatibility
with other digital systems is very important, for
example being able to implement ADSD in digital orthodontic simulations, digitalisation of casts,
CAD/CAM, etc., thus adding to the methodology.

_Acquisition and import of
digital images

Fig. 8

As stated earlier, the first phase of ADSD entails the
acquisition and import of photographs of the patient.
If possible, these photographs should be taken with
a digital SLR camera with semi-professional features
and with a good illumination system (nowadays
there are a number of basic dental photography
courses and books available dealing with this fascinating subject). We must remember that in the
analytical phase the photograph is a clinical and
aesthetic diagnostic element that will form part of
the patient’s clinical history, which can be consulted
by other specialists to establish an interdisciplinary
vision. In view of this, the dentist/photographer must
capture the photographs with the patient’s head in
a position that can be replicated in the future to
verify topography in relation to smile design. The
Fig. 9
Fig. 5c_Activation of analogue
measurements with digital ruler.
Fig. 6_Focal length and analysis
of the aesthetic component.
Fig. 7_Facial analysis.
Fig. 8_Dental analysis.
Fig. 9_Dento-labial analysis.
Fig. 10_Gingival analysis.

Fig. 10

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I special _ digital smile design

Fig. 11a

Fig. 11b

Figs. 11a & b_Digital Dental
Design, outlines.
Fig. 12_Personal database
consisting of composite dentition
or single teeth.

Fig. 12

most reliable position in which to photograph the
patient’s face is that relative to the aesthetic plan
(Fig. 3), that is the plane perpendicular (frontal) to
the plane that runs at the centre of the angle formed
between the Frankfort horizontal plane and Camper’s
plane. The same position must be projected orthogonally at 45 and 90 degrees (Figs. 4a–d) because
photographs of the profile are of great importance in
the aesthetic dental and facial analysis of the profile
in relation to occlusal class, the relationship between
the lips, and aesthetic angles, according to studies
in orthodontics, maxillofacial surgery and cosmetic
plastic surgery.
ADSD imports the measurements of the photographed subject standardised and configured to
the scale of values expressed in pixels, the ordinary
unit of measurement of a digital photograph. In order to do this, it is possible to use technical drawing
tools, such as set squares and rulers (made of metal if
possible and thus easily cleaned and capable of being
sterilised, or other similar material). I have personally
built a measuring tool called Face Analogic Transfer

18 I cosmetic
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1_ 2015

Support (Fig. 5a), which consists of a ruler with graduated millimetre and centimetre scales, which the
patient can wear like a pair of glasses. Furthermore,
for new photographs for the fabrication of mock-ups
and PMMA models etc., it is useful to use a device
such as a craniostat fixed to the headrest, which is
integrated into our dental chair. If more accurate and
detailed measurements of the teeth and gingival
parameters are required, one can use digital callipers
whose tips are placed at the cervical margin and
incisal edge (the length of the tooth) or at the mesial
and distal margins relative to the dental line (width
of the tooth; Fig. 5b). These measurements when
transmitted can be very effective in communication
between the dentist and dental technician, whose
manufacturing skills and expertise will be the most
important to the end-result of this innovative
method (Fig. 5c). It is necessary to bear in mind that
the measurements expressed in millimetres in relation to the digital image produced by the digital processing, as well as the design of the dental contours,
are not of much interest to patients, who desire
a photograph of the first phase simulation, but

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special _ digital smile design

the measurements represented as 3-D wax models
and mock-ups tried in and analysed in the patient’s
mouth will give you an idea of the delicate psychoaesthetic approach to the clinical case very important
for aesthetic dentistry.

_Aesthetic analysis of a face and a smile
In relation to the manner in which to portray the
patient in a photograph, we should reflect on the
aesthetic component of the face and the smile.
For the objective aesthetic analysis, the focal length
is modified, starting from the first photograph
(Fig. 6). For this parameter, the following classification criteria could be applied:
_macro-aesthetics (extra-oral analysis of the face);
_mini-aesthetics (extra-oral analysis of the mouth);
and
_micro-aesthetics (intra-oral analysis of teeth and
gingiva).

Fig. 13a

Fig. 13b

Fig. 13c

Fig. 13d

Fig. 13e

Fig. 13f

As regards the aesthetic analysis of the smile,
the specific areas of the objective analysis that are
pertinent to dentistry are as follows, based on that
provided by a number of many authors:

Figs. 13a–f_Virtual modelling
of dental forms with DDID.

_Facial analysis: Frontal/lateral, determining morphological features, horizontal/vertical reference
lines, vertical/horizontal facial proportions, golden
ratio, horizontal/vertical dimensions, analysis of the
facial profile, and analysis of the lips, nose and eyes
as regards position and size (Fig. 7).
_Dental analysis: Dental composition, dental arrangement and position, dimensions, proportions,
shapes, contours, margins, textures, surfaces, axial
inclinations, inter-incisal angles, interproximal
contacts and colour (Fig. 8).
_Dento-labial analysis: Labial dynamics, smile line,
width of smile, labial corridors, occlusal plane, midline, and inter-incisal and commissural lines (Fig. 9).
_Phonetic analysis: This is complementary to the
dento-labial analysis and involves the recording

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I special _ digital smile design

Fig. 14a

Fig. 14b

Fig. 15a

Fig. 15b

Figs. 14a–c_DDID, vectorial
deformation of the length of teeth.
Figs. 15a–e_DDID applied
to teeth 12, 11, 21 and 22.

of the phonetics with particular attention to consonants and their combinations. In addition, the
analysis of the phonemes “/m/” and “/i/” ( sometimes
also the phoneme “/e/”) is of great importance for
detecting and determining the position of the lips
and the maxillary incisors relative to the age and
sex of the subject being analysed. Furthermore,
it is important to bear in mind the extent to which
the central incisors are the visual focal point of the
smile architecture.
_Gingival analysis: Architecture, shape parallelism,
symmetry, zenith, papillae, biotype and colour (Fig. 10).
In general, it can be stated that considering all of
these very important values and parameters in detail
requires comprehensive planning and competence
that cannot be contained in only a few lines. These
have been scientifically established by a number of
authors and further information can be found in
books and scientific articles.

_Dental digital image editing
Digital image editing can be performed in various
ways (Fig. 2) according to the requirements of the
smile designer and with various software packages
(both freeware and for purchase) easily obtained from

20 I cosmetic
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1_ 2015

Fig. 14c

Figs. 15c–e

the Web. Their main use includes generic image and
photograph editing for both amateur and professional graphic designers. Some of the packages available
have been developed by dentists. An important contribution to these packages is offered by some authors,
who through the use of Keynote (a presentation application developed by Apple for Mac OS X and iOS)
have made smile design easier with results that provide a schematised dental design with real outlines.
In addition to Digital Dental Design (Figs. 11a & b),
ADSD offers important processing functions: the
import, conversion and editing of dental shapes and
types of dentition in the form of real images. In order
to carry out these important functions, it is necessary
to create a real dental library, which we shall call the
Digital Dental Photos Database (DDPD). This might
include:
_Dental shape library, which might be the best form
of database, in which five types of dentition could
be captured relative to anatomical form and possibly colour according to the quality and amount of
light in the photograph as observed by the operator.
The photographs of the teeth in this library should
be taken at a frontal projection, and at 45 and 90 degrees laterally, that is a profile, so that they can be

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special _ digital smile design

Figs. 16a & b_DDCT.

Fig. 16a

incorporated into the photographs and images of
the patient in ADSD. The dental shapes contained
in the library must correspond to nature itself, such
as triangular, oval or rectangular with variables,
like square or trapezoidal (Fig. 13f).
_Libraries of dentition containing aligned and aesthetically ideal complete mouths: There are some
libraries, such as that of Digident, in which the teeth
are already preformed according to the morphology
of the incisal edges (flat, square and round).
_Personal case reports database, that is the collection
of our clinical cases concerning the fabrication of
prostheses, aesthetic dentistry, virtual wax-ups,
mock-ups and the healthy dentition of patients
(with their permission). Dental technicians in laboratories could also exchange data thanks to the
goodwill of colleagues who supply them with images. An ADSD images community would be of
great scientific advantage. This library should consist of images of complete and partial dental arches
(eight anterior teeth, six anterior teeth). These might
be single maxillary arches, the primary object of
smile design, or maxillary and mandibular arches
with normal occlusion (useful for partially or totally
edentulous patients). The images might also contain
the gingiva according to photographic requirements;
indeed, they may be integrated as a whole into the
virtual oral cavity or else one might isolate single
teeth (Fig. 12) in order to be able to adapt them
according to shape, alignment, emergence, ideal contour and contact points respecting the aesthetics.
_Dental libraries of removable prostheses: These are
available on the Web from leading companies in the
industry, such as Ivoclar Vivadent, Heraeus Kulzer
and Candulor.
_Smile library, consisting of photographs with faces
of models smiling, which can be useful if in high
resolution. The teeth can be selected and extrapolated from the face of the subject, generally
photographed by professional photographers. These
images can be downloaded from stock photography

sites at a fee (such as 123RF.com,
Fotolia.com, Shutterstock.com
and Fotosearch.com).
Another very important feature
of this method of smile design is
Digital Dental Image Distortion
(DDID; Figs. 13a–f), which allows
the modification of the morphology of the teeth to be processed.
This function is of great utility for
the formation of the teeth in the
DDPD. It must be applied to length
and width (Figs. 14a–c), as well as
in every direction both along the
contours and on the dental surfaces, and especially along the lines
of transition. This processing is often very useful for light reflected on
the dental surfaces characterised
by micro- and macro-textures, and
is effective in the analysis and processing of the interproximal contact points and inter-incisal angles.
Moreover, it is effective in the
morphological classification of the
incisal edges, transitional lines, etc.,
often reference points specific to
the age, sex and personality of the
patient (morphopsychology). From
my point of view, this part of dental
digital image editing is the most
important because it is not possible
to give a prefabricated smile to a
patient; while such a smile might
be made up of teeth that are in
themselves perfect, it is necessary to
know how to modify, model, shape,
deform, increase, diminish or eliminate everything in contrast with the
harmony of form (Figs. 15a–e).

Fig. 16b

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I special _ digital smile design
feedback for the implantologist, prosthetist and
orthodontist, with all of whom it is necessary to
communicate radiological findings (DICOM and
Tac3D—the latter is compatible with ADSD). Only
after having decided on the final positioning of the
teeth can the smile designer pay greater attention
to the improvement of the aesthetic aspects by
further modifying the images with DDID. The same
is true for the integration of the orthodontic simulation data from sophisticated applications such as
ClinCheck (Align Technology), which can be implemented in the virtual planning towards an integrated
aesthetic and prosthetic solution to an orthodontic
problem (Figs. 17a–d)._
Editorial note: This is the first of a two-part article based on
a paper presented by Dr Valerio Bini to the 15th International
Congress of Aesthetic Medicine in Milan in October 2013
during the session titled “Aesthetic dental surgery of the
lower third of the face”. Part II of the article will appear in
cosmetic dentistry 1/2015.
Fig. 17a

_about the author
Figs. 17a–d_Implementation
in ClinCheck, ADSD.

Fig. 17b

In many aesthetic clinical cases, it is useful to perform Digital Dental Calibrated Transposition (DDCT),
a transposition of the teeth necessary for the simulation of orthodontic movements, some of which
apply to the situation prior to aesthetic treatment,
prosthetic treatment, implants, etc. (Figs. 16a & b).
The transposition must be calibrated, that is must
move the teeth into the desired position and maintain the measurements and anatomical dimensions.
This makes it easier to calculate more predictably
the future dental composition, not only aesthetically
but also functionally, as well as the relative spacing
(mesialisation/distalisation) necessary for the insertion of the prosthetic implant. It gives important

Fig. 17c

22 I cosmetic
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1_ 2015

cosmetic
dentistry

Valerio Bini, DDS, graduated from the University
of Genoa in Italy. He is a specialist in prosthodontics
and aesthetic dentistry. He has presented papers
at international conferences on aesthetic dentistry
and aesthetic medicine, and is the author of many
articles published in national and international
journals. Dr Bini is a member of the European
Society of Cosmetic Dentistry, a fellow of Società
Italiana di Estetica Dentale (Italian society of
aesthetic dentistry) and a fellow of the Italian Academy
of Esthetic Dentistry. He is Invisalign certified.
Dr Bini may be contacted at info@studio-bini.com.

Fig. 17d

[23] => Standard_300dpi

2 minutes
instead of 6/8 hours
per day

New professional home
bleaching without tray
with special accelerator
XS151™ which activates

The special
brush with
dispenser
contains the
bleaching gel,
sufficient for a
treatment of
about 20 days

6/8
hours

while brushing, increasing
the absorption rate of
hydrogen peroxide
exponentially

4
hours

2
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Ena
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MICERIUM S.p.A.
Via Marconi, 83 - 16036
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Tel. +39 0185 7887 880
www.micerium.com
hfo@micerium.it

esteti
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Other bleaching systems with tray

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I industry report _ professional home bleaching

Technological innovation in
professional home bleaching:
the ENA White 2.0 system in only
2 minutes per day without tray
Author_Dr Luigi Leonardi, Italia
_74 % of adults think that an unpleasant smile may
have a negative influence on career opportunities.
We are also aware that the desire of having
a bright smile with white teeth has existed for
centuries, but the research in this sector has only
stepped notably forward during the past few
decades.
This happened especially at the end of ‘80s,
thanks to Dr Eyneman and Dr Aiwood,1–4 who conceived the idea of home bleaching treatment with
the use of the well-known bleaching trays, customised or not, adequately filled with low-percentage hydrogen peroxide and worn for some hours
a day or even all night long.
Fig. 1

Fig. 1_ Bleaching system ENA White
2.0: toothbrush with dispenser
containing hydrogen peroxide
bleaching gel with special activator
XS 151, which increases its
absorption rate exponentially.

_Introduction
The desire for whiter teeth has considerably increased in the last few years. The demand for tooth
bleaching as a cosmetic treatment is increasing
more and more, despite the recession, which only
marginally affected aesthetics and cosmetics.
Nowadays, we live in a world where appearance
is extremely important in any field; according to
independent studies conducted for the American
Association of Cosmetic Dentistry:

24 I cosmetic
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1_ 2015

Afterwards, the companies of the dental field
worked hard to improve these procedures, such as
designing pre-filled trays or changing the flavour of
the gel. The method is substantially the same, only
the percentage of hydrogen peroxide (also available
as carbamide peroxide) may vary from 10 % to
30 %.6–7 This influenced the contact period, which is
at least from a couple of hours a day (for percentages that are onlyallowed for cosmetic bleaching)
to all night long. All of them start from a single
assumption: the bleaching action of peroxide needs
a variable contact period to penetrate through the
enamel prisms and the dentinal tubules, releasing
active oxygen and allowing the free radicals to
attack the chromophobe particles and reach the
desired effect.9

_99.7 % of Americans are convinced that a bright
smile is an important social factor;

_Materials and methods

_96 % of adults are convinced that an unpleasant
smile may have a negative influence on career
opportunities;

After years of attempts and experimentations
used to improve the current methods and the
result, I have managed to refine a new method,

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industry report _ professional home bleaching

GROUP 1

Age

Initial shade

Target shade

Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8
Patient 9
Patient 10
total

25–35
25–35
25–35
25–35
25–35
36–45
36–45
46–55
46–55
46–55

3
2.5
2.5
2
3
3
2
3.5
4
3.5

1
1
1
1
2
1
1
2
3
2

Shade check 21 days Shade check 35 days
1
1.5
2
2
1.5
2
2
2.5
3
2

I

Satisfaction

–
–
1
–
–
–
–
–
–
–

yes
no
yes
no
yes
no
no
no
yes
yes
50%

–
0.5
1
–
–
1
–
–
–
–

yes
yes
yes
yes
yes
yes
yes
no
yes
yes
90 %

in red: suspended treatment

GROUP 2
Patient 11
Patient 12
Patient 13
Patient 14
Patient 15
Patient 16
Patient 17
Patient 18
Patient 19
Patient 20
total

25–35
25–35
25–35
25–35
25–35
36–45
36–45
46–55
46–55
46–55

2
2
3
2
3
3.5
2
3.5
4
3.5

making it easy and above all reducing the daily
duration of the treatment to only two minutes
instead of 6–8 hours of the traditional cosmetic
home bleaching: I have optimised the method in an
extreme way.

1
0.5
1
1
1
2
1
2
2.5
2

1
1
2
1
1
2.5
1
2.5
2.5
2

After several tests, I deduced that peroxide,
if activated by a special accelerator (XS 151) could
penetrate in a faster way, exploiting the action of
mechanical pressure generated by a special toothbrush with nozzle-doser and a dispenser filled with

Table I

Table I_ Group 1 treated
with tray and 6 % hydrogen peroxide.
Group 2 treated with
the new system ENA White 2.0.
In red: suspended treatments.
AD

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I industry report _ professional home bleaching

GROUP 1

Age

Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8
Patient 9
Patient 10
total

25–35
25–35
25–35
25–35
25–35
36–45
36–45
46–55
46–55
46–55

effects8: inflammation of soft tissues, hypersensitivity, risk of swallowing the gel and so on. There is also
an improvement of some psychological aspects, due
to the need of wearing the tray for hours or all night
long5 with interferences with normal interpersonal
relationships both in private life and at work.

Hours of treatment
120
160
240
24
160
160
24
120
160
160
1,328 hours

GROUP 2

Minutes of treatment

Patient 11
Patient 12
Patient 13
Patient 14
Patient 15
Patient 16
Patient 17
Patient 18
Patient 19
Patient 20
total

25–35
25–35
25–35
25–35
25–35
36–45
36–45
46–55
46–55
46–55

40
60
60
40
40
60
40
40
40
40
460 minutes

8 hours

Table II

this special bleaching substance (Fig. 1). This special
bleaching toothbrush has been designed with a
smaller head if compared to the most common toothbrushes in order to reduce the contact with oral mucosa.
Soft blunted bristles activate the accelerator (XS 151)
contained in the gel while brushing and guarantee a
faster absorption of the bleaching gel; it also improves
the procedure by drastically reducing the application
time: from 6–8 hours to two minutes per day! The advantages are amazing, because reducing the contact
period means reducing enormously the undesirable

Table II_Total time of treatment:
Group 1 treated with tray and
6 % hydrogen peroxide,
Group 2 treated with ENA White 2.0.

6/8
ore
250 h

3
1st GROUP PATIENTS

200 h

2

150 h

5

6

10

19

20

TRADITIONAL TRAYS

8

1

100 h

9

50 h
20 h
10 h
5 h
12

1 h

11

13

14

15

16

2nd GROUP PATIENTS

17

18

ENA WHITE 2.0

0 h
Patients: numeration indicated in tables 1 and 2

Total time of whitening treatment:
first group treated with tray and 6% hydrogen peroxide,
second group with ENA WHITE 2.0.
N.B. The Patients 4 and 7 have not been inserted into the graph because they have interrupted the treatment.

Graphic I

26 I cosmetic
dentistry

1_ 2015

The new method, as said before, considers reduced
application times of about two minutes per day; it is
easy to understand how this can encourage the user
to apply tooth bleaching. The average total contact
period of the whole treatment is less than one hour
(two minutes for 20 days). This corresponds to less
than one-fifth of the time that a single application
with the tray technique takes, which is currently the
most common mode. Furthermore, this special
toothbrush with dispenser is extremely easy to carry
thanks to its pocket-size and can be used for one
minute in the morning and one minute in the evening
anywhere, after one’s usual oral hygiene routine. The
treatment lasts about 15–20 days on average, and
this duration is sufficient to obtain an excellent result,
achieving a reduction of 1–2 chromes of the VITA
shade guide depending on the subject with a minimum commitment. Wherever you want, whenever
you want: you can choose the place and time of
application, which makes it different from other
methods. The here-analysed method respects all the
recent UE laws about the use of hydrogen peroxide
as a cosmetic bleaching treatment, accepting a
maximum percentage of 6 %, specifying that the
bleaching kits must be delivered to the user only
by the dentist as a professional treatment, after an
accurate visit and the evaluation of each single case.
It is also important to underline that advice and
protocols are the fundamentals of what has been
stated so far. First of all, the dentist must undertake
thorough plaque removal, advise the patient about
correct oral hygiene use, which means brushing the
teeth with adequate toothpastes with special characteristics, for example, the Enamel Plus toothpaste,
which has a low abrasion formula and desensitising
action: this enhances and maintains the bleaching
effect reached with this system. It is also important
to limit the consumption of food with a high acid pH,
such as citrus fruit, tomatoes, tea, tobacco etc, in order to preserve the achieved result. We also recommend to: schedule regular visits with your dentist in
order to monitor the condition of teeth and mucosa
and point out any irritation or inflammation of mucosa10; repeat the bleaching treatment regularly to
maintain the results, considering that the repetition
of this method decreases the undesirable effects
thanks to the limited contact period of 1 hour maximum for the whole complete treatment of about
15–20 days, in comparison to the 120–150 hours or
more of the traditional bleaching with tray method.

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industry report _ professional home bleaching

_Comparative analysis
with traditional bleaching systems
We carried out a comparative study performing 20 bleaching treatments in the same period:
10 cases were treated according to the traditional
technique with tray and 6 % hydrogen peroxide,
and the other 10 patients with ENA White 2.0. The
patients were aged between 25 and 55, and were
divided into three age groups.
The first group were treated with bleaching
trays and 6 % hydrogen peroxide:
_Five were satisfied with the result;
_Three were not satisfied with the treatment and
decided not to extend the treatment of a further
15–20 days;
_Two abandoned the treatment because they
considered the application times to be too demanding; they didn’t have time to carry out the
treatment as it clashed with their hours of
workingand/or because they felt discomfort and
annoyance wearing the tray at night.

Fig. 2

The inconveniences reported during the
bleaching treatment with tray include the fact
that in some cases, it was very difficult or even impossible to keep the tray in the mouth—which has
a recommended time of action of several hours or
all night—due to illness, for example flu, bronchitis with coughing fits, also with phlegm and colds.
This was a further complaint that sometimes contributed to demotivate the user in such a decisive
way as to suspend the treatment.
The second group of 10 people who used the
new system ENA White 2.0 proposed by me:
We could verify the total satisfaction in nine
subjects, only one of them was not completely

Fig. 2_30-year-old male patient
with discolouration on the central
and lateral teeth; shade A3
of VITA shade guide.
Fig. 3a_Unscrew and remove
the cap of the toothbrush.
Fig. 3b_Unscrew the toothbrush
and remove it from the dispenser.
Fig. 3c_Remove the seal from the
base of the toothbrush with tweezers.
Fig. 3d_Screw the toothbrush again.
Fig. 3e_Rotate the ring
anti-clockwise towards the direction
‘UP’ until the gel comes out
from the hole among the bristles.
Fig. 3f_It is necessary to use
a small lentil-sized dose of the gel.
Fig. 3g_The patient must brush the
teeth to be bleached for about
30 seconds with horizontal
movements, avoiding contact
with the gums as much as possible.
Fig. 3h_Rinse the bristles
with running water.
Fig. 3i_Brush again for further
30 seconds and rinse accurately.

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 3d

Fig. 3e

Fig. 3f

Fig. 3g

Fig. 3h

Fig. 3i

cosmetic
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I industry report _ professional home bleaching
satisfied because he expected a more evident effect and did not want to extend the treatment.
With regard to motivation, all of them showed
a huge satisfaction, especially for how the kit had
been introduced, considering it as very innovative, handy and with no limits of use. For the
result details of this comparative analysis, please
see Tables 1 and 2.

_Clinical cases

Fig. 4_Check after 4 days.
Fig. 5_Check after 7 days.
Fig. 6_Check after 10 days.
Fig. 7_Check after 12 days.
Fig. 8_Check after 16 days.
Fig. 9_Check after 21 days.
Fig. 10_Check after 28 days.
Fig. 11_Check after 35 days:
the chromaticity at the end
of the treatment corresponds
to A1 of VITA shade guide.

The case report in the pictures shows a 30year-old male with an apparently optimal health
condition, who was unhappy with the discolouration on the central and upper- and lower-lateral
teeth near the cervical area. After an objective examination of the oral cavity, the subject showed a
normal gingival biotype, good gingival health and
good oral hygiene. For the verification of the initial and final colour (hue and croma) I used the
VITA shade guide, starting from A3 (Fig. 2).
After a session of professional prophylaxis
I proposed to the patient the bleaching treatment
Ena White 2.0 and advised him to perform it after
his oral hygiene routine in the morning and in the
evening. When he realised how easy the system
was to use, he immediately accepted the treatment that I explained, as shown in the pictures.

First of all you show the patient how to open
the toothbrush by unscrewing the cap (Fig. 3a).
Then the head of the brush must be unscrewed
too (Fig. 3b) to remove the seal from the base of
the toothbrush (Fig. 3c). After screwing the final
part of the toothbrush on the dispenser again (Fig.
13d), you must rotate the ring on the base of the
toothbrush anti-clockwise towards the direction
‘UP’ until the bleaching gel comes out (Fig. 13e).
For the first application, a couple of rotations are
required, until the tube is filled up to the bristles.
Explain to the patient that for the following applications it will be sufficient to rotate the ring of
2–3 marks to obtain the needed quantity of gel,
like a small lentil, as shown in the picture (Fig. 13f).
Show the patient how to proceed with brushing:
make a horizontal movement for about 30 seconds (Fig. 13g), avoiding brushing the gums as
much as possible; the blunted shape of the bristles helps the patient to avoid this contact, which
does not cause irritations anyway, considering
the short application period. At this point it is necessary to rinse the toothbrush with water (Fig.
13h) and brush the teeth again for a further 30
seconds (Fig. 13i). In this way the residual gel on
the teeth is diluted before the final rinse.
You can notice the evolution of the bleaching
action in pictures from Fig. 4 to Fig. 11, where you
can appreciate the final result of the treatment

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

28 I cosmetic
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1_ 2015

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industry report _ professional home bleaching

Fig. 12

after 35 days with a shade corresponding to A1
of VITA shade guide. Halfway through treatment,
a lighter chromaticity, almost equal to A2 of VITA
shade guide, had been achieved, as shown in Fig. 9
(this is case No 13 in the statistic table).
The second case (No 15 of the statistic table)
shows a 25-year-old female patient who was not
satisfied with a bleaching treatment performed
with a tray six months before, which irritated her
gums. With the new treatment, she reported no
discomfort and appreciated the result, as you can
see in the pictures she changed from shade A3
of VITA shade guide (Fig. 12) to shade A1 (Fig. 14)
in about 20 days (after 10 days, the result was
already equal to A2 (Fig. 13).

_Conclusion
Dental discolouration is an important factor of
psychological discomfort for the patient, which
leads to an increase in cosmetic bleaching requests. The new method explained here makes
the bleaching procedure easier, considerably reducing the side effects that can appear with other
techniques, thanks to the shorter contact period
between gel and tooth.
This method allows to reach very satisfying
results and produces a growth in the request of
bleaching from the patient: this is attributable to
both the time which is reduced (2 minutes a day)
thanks to the special accelerator XS 151 contained in the hydrogen peroxide gel, which activates while brushing, and its portability, which
means it can be performed anywhere and not exclusively at home, thanks to the new pre-filled
brush.

Fig. 14

Fig. 13

I also thank my son Marco for supporting
me during my work with his knowledge in the
chemical and pharmaceutical field, acquired with
his degree in CFT and the doctorate at Madrid
Conplutense University._

_References
1. Eyneman, Haywood (infodent 4/2005)
2. I.Franchi, S Bartolini, U Consolo. Lo sbiancamento
dei denti vitali (teamwork media 2010).
3. Haywood VB1 (1992), Bleaching of vital and nonvital teeth Curr Opin Dent. Mar;2:142–9 (3).
4. Haiwood VB(1992) History, safety, band effectiveness or current bleaching techniques band applications or the nightguard vital bleaching techniques.
(Quintessence International. 23,47–88)
5. CondòSG Sbiancamento dei denti: come e perché.
Bologna: edizioni martina,76–9.
6. Leonard RH jr, Garland GE, Eagle JC, Caplan DJ.
Safety issues when using 16 % carbamide peroxide
whitening solution. J Esthet Restor Dent, 2002,
14(6):358.67.
7. Alma K, Al-Harbi M, Al-Gunaim M. The effect a
10 % carbamide peroxide tooth whitening agent.
Compend Continua Educ Dent 1988,19(10):968–
72,977–8.
8. Franchi Malaguti, Bianchi, Vanini, Bortolini, Consolo, Sbiancamento Professionale Ambulatoriale
Con Ena White System, Teamwork Clinic 5-09
9. Goldstein R. Metodiche di sbiancamento totale dei
denti, Utet.
10. Mangani FM, Sigalot C, Galattini L,Vanini L. Modificazioni dello smalto indotte da diverse metodiche
di sbiancamento. Dentista Moderno 2000:117–119.

_Acknowledgements

_author

I would like to thank Micerium S.p.A. for the
kind collaboration and for the material that was
provided, in particular Dr Eugenio Miceli for his
attention and availability.

Dr Luigi Leonardi
Private practice in Terni
Italia

Fig. 12_A 25-year-old female
patient, unsatisfied with a bleaching
treatment with tray; initial colour of
teeth was A3 of the VITA shade guide.
Fig. 13_Check after 10 days:
the result corresponds to A2
of the VITA shade guide.
Fig. 14_Check after 21 days:
she reached shade A1
of the VITA shade guide.

cosmetic
dentistry

cosmetic
I 29
dentistry 1
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I industry report _ direct resin restorations

Direct resin restoration using
the new V4-Ring matrix
and the new Micerium Enamel
Plus HRi Function composite
Authors_Drs Francesco Simoni & Lorenzo Vanini, Italy

Fig. 1

Fig. 2

Fig. 1_Clinical view of carious
lesion on 24 distal.
Fig. 2_X-ray view of carious
lesion on 24 distal.
Fig. 3_First access to carious lesion
on 24 distal with the protection
on 25 by matrix and wedge.
Fig. 4_Removing decay using
a medium-grained diamond bur
on a red ring hand piece.

Fig. 3

_Introduction
In restorative dentistry, as in all dentistry fields,
in order to obtain a correct diagnosis it is essential to perform a proper clinical analysis, to take
at least bite wings X-rays or preferably full mouth
X-rays and to use a magnification system.1
Once a correct diagnosis has been obtained,
the first treatment phase is to eliminate gingival

Fig. 4

30 I cosmetic
dentistry

1_ 2015

inflammation by teaching the patient proper oral
hygiene methods, followed by simple scaling,
or complete non-surgical periodontal therapy.2
It is then possible to proceed with the removal
of the carious lesion.
This paper describes the most important steps
in performing a correct class II restoration using
the new V4-Ring matrix and the new Enamel Plus
HRi Function composite (Micerium).

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industry report _ direct resin restorations

I

Fig. 5

_Case study
After careful clinical and X-ray examination of
the tooth decay on the second upper left premolar (Figs. 1 & 2), we carried out a local anaesthesia
with articaine 1:100,000. Before proceeding with
the removal of the carious lesion, the adjacent
tooth must be protected with a matrix and a
wedge (Fig. 3). The access to the cavity is then
provided and a rubber dam is placed. Once the
operative field has been isolated, the decay is removed first by using a medium-grained diamond

bur mounted on a red ring hand piece (Fig.4) and
then a round (rosette) bur on a blue ring hand
piece (Fig. 5). The preparation of the cavity is
finished with a fine-grained diamond bur on a red
ring hand piece (Fig. 6) and with a red rubber on
a blue ring hand piece (Fig.7). In order to optimise
the preparation of the cavity at the marginal level
metal strips are first used (Fig. 8) followed by
paper strips (Fig. 9).

Fig. 6
Fig. 5_Removing decay using a
rosette bur on a blue ring hand piece.
Fig. 6_Finishing using a fine-grained
diamond bur on a red ring hand piece.

Once the preparation is finished the matrix
V-Ring 4 is placed (Figs. 10 & 11) using the pin
AD

ENAMEL HRi®
Function
plus

/-2+$(/2-('(/#/2$+$('/-2$2/-2+#-/
ENAMEL PLUS HRI FUNCTION IN DENTAL OFFICE

Enamel-composite system subject to low abrasion that is comparable to natural
enamel. Ideal for use in posterior areas with direct or indirect technique and especially
to restore the function in a micro-invasive way respecting the neuromuscular system
and getting an excellent aesthetic integration.

  

 

 

ENAMEL PLUS HRI FUNCTION IN LABORATORY

+'-' +2(..#.20!2+!*0 21"2%"2#)2- 2'! 2 2/).2"2%12&11&211%2 2! 2"2%12&11&2&%2 2.,0*)0,.*,2 2,0*)0,,0*)0,.0

esteti

ENAMEL HRI FUNCTION = NATURAL ENAMEL = WEAR = AESTHETICS = UNIQUE!

ca

®

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I industry report _ direct resin restorations

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 7_Polishing enamel with a
rubber red on a blue ring hand piece.
Fig. 8_To optimise cavity preparation at
the marginal level, metal strips are used.
Fig. 9_To optimise cavity
preparation at the marginal level,
paper strips are used.
Fig. 10_Cavity preparation is completed.
Fig. 11_Once the preparation
is finished matrix V-Ring 4 is placed
with its proper tweezers, which are
placed in the little hole on the matrix,
making its insertion easier.

Fig. 11

tweezers, which are placed in the hole on the
matrix itself making insertion easier (Fig. 11).
After checking proper assembly, the wedge and
the transparent tines of the V4-Ring are inserted
(Figs. 12–15). This allows light to pass through for
360° polymerisation.
After the matrix has been positioned, ENAetch
is applied for 30 seconds evenly with a brush to
distribute the etching agent (Figs. 16 & 17), and
the area is washed with water for 30 seconds and
with 0.2 % chlorhexidine digluconate (Fig.18).3
Ena Bond is then applied for 60 seconds (Fig.19).

Fig. 12

32 I cosmetic
dentistry

1_ 2015

It must be polymerised for 40 seconds4 (Fig. 20) and
at the end ENAseal is brushed on for 30 seconds
(Figs. 21–22).5 Finally the cavity is polymerised
again for 40 seconds (Fig. 23).6
Every step has to be done properly, from
carious lesion removal to cavity surface finishing. Any approximation may compromise
long-term outcome and restoration aesthetics.7
With adhesive techniques it is mandatory to
respect all protocols in order to prevent secondary tooth decay and ensure a long lasting
restoration.8

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industry report _ direct resin restorations

Fig. 13

Fig. 14

Fig. 15

Fig. 16

Once the adhesive step is finished, the interproximal wall is built up9 with Enamel Function 2
(Fig. 24) and finally, due to the new V4-Ring
matrix special design, it is possible to polymerise
the buccal, palatal and occlusal aspect of the
composite reconstruction.

polished restoration is less likely to attract plaque
adhesion, and is more respectful of periodontal
tissues, while also maintaining better aesthetics
over time (Fig. 27).3–12_

Once the restoration has been completed with
Enamel Plus HRi Dentine UD3 and Enamel Plus
HRi Function EF2, the fissures are characterised
with Stain brown 2 and the marginal ridge with
Intensive White.10, 11

1. Ricci G. Chapter 1 Diagnosis from the book “Periodontal Diagnosis and Therapy” Quintessence 2012.
2. Ricci G. Chapter 2 Non Surgical Periodontal Therapy
from the book “Periodontal Diagnosis and Therapy”
Quintessence 2012.
3. Breschi L, Cammelli F, Visintini E, Mazzoni A, Vita F,
Carrilho M. Influence of chlorhexidine concentration on the durability of etch and rinse dentin
bonds: a 12-month in vitro study. J Adhes Dent
2008.

After modelling, the restoration is finished
on the interproximal level with paper strips.
An occlusal check (Fig. 25), X-ray control (Fig. 26),
and careful polishing are mandatory. A well-

_References

Fig. 17

Fig. 12_After checking the proper
assembly of the wedge and the
transparent ring of V-Ring 4 are inserted.
Fig. 13_The transparent ring
of V-Ring 4.
Fig. 14_V-Ring 4, note light passing
through the matrix.
Fig. 15_The wedge
of the transparent V-Ring 4.
Fig. 16_ENAetch, Micerium.
Fig. 17_Etching for 30 seconds
with ENAetch, a brush is used
to evenly distribute etching.
Fig. 18_Washing with water
for 30 seconds and with
0.2% chlorhexidine digluconate.
Fig. 19_ENAbond for 60 seconds.

Fig. 18

Fig. 19

cosmetic
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dentistry 1
_ 2015

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I industry report _ direct resin restorations

Fig. 20

Fig. 21

Fig. 22

Fig. 23

Fig. 24

Fig. 25

Fig. 26

Fig. 27

Fig. 20_Polymerisation
for 40 seconds.
Fig. 21_ENAseal for 30 seconds.
Fig. 22_ENAbond
and ENAseal, Micerium.
Fig. 23_Polymerisation
for 40 seconds.
Fig. 24_Enamel Plus HRi
Function 2 Micerium.
Fig. 25_An occlusional check.
Fig. 26_An X-ray check, note the
maximum integration of restoration.
Fig. 27_Occlusal view of restoration.

34 I cosmetic
dentistry

1_ 2015

4. Vanini L.from the book “Conservative restoration
of anterior teeth” Chapter 3.8 Composites and adhesion: polymerization. ACME 2003.
5. D’Arcangelo C, Vanini L et al. The clinical influence
of adhesive thickness on the microtensile bond
strength of three adhesive systems J Adhes Dent.
2009 Apr;11(2):109–15.
6. Van Meerbeek B, De Munk J, Yoshida Y, Inoue S,
Vargas M, Vijay P et al. Buonocore memorial lecture.
Adhesion to enamel and dentin: current status and
future challenges. Oper Dent 2003; 28: 215–235.
7. Vanini L. from the book “Conservative restoration
of anterior teeth” Chapter 5.5 The Shape in conservative restoration: finishing, polishing and buffing
of the conservative restoration” ACME 2003.
8. Drummond JL. Degradation, fatigue, and failure of
resin dental composite materials. J Dent Res. 2008
Aug; 87(8): 710–719.
9. Magne P., Dietschi D., Holz J. Esthetic restorations
for posterior teeth: pratical and clinical considerations. Int J Periodontics Restorative Dent 1996;
2:105–119.

10. Vanini L. from the book “Conservative restoration of
anterior teeth” Chapter 4.9 The layering tecnique:
costruction of “intensive” ACME 2003.
11. Vanini L. from the book “Conservative restoration
of anterior teeth” Chapter 4.11 Anatomic layerying
tecnique: construction of the characterizations
ACME 2003.
12. Vanini L. from the book “Conservative restoration
of anterior teeth” Chapter 7.3 Aesthetic and gingival architecture: gingival contour and adhesive
restorations. ACME 2003.

_contact
MICERIUM S.p.A.
Via Marconi, 83
16036 Avegno, Italy
www.micerium.com

cosmetic
dentistry

[35] => Standard_300dpi

1 Year Clinical Masters Program
TM

in Aesthetic and Restorative Dentistry
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Three sessions with live patient treatment, hands-on practice, plus
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Learn from the Masters of Aesthetic and Restorative Dentistry:

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CDE0115_36-38_Zafiropoulus 26.02.15 10:38 Seite 1

I case report _ impression of steeply angulated implants

Impression of steeply
angulated implants:
A new method
Authors_Profs. Gregory-George Zafiropoulos & Oliver Hoffmann, Germany

Fig. 1_The panoramic radiograph
at the initial examination.
Note the angulation
of the implants and the proximity
to the inferior alveolar nerve.

Fig. 2_Simulated position
of the impression posts.
Fig. 3_Try-in of abutments
with different angles.

Fig. 2

Fig. 1

_In the present case report, a new method
that allows impression taking of implants inserted at a steep angle is presented.
The use of implants for the rehabilitation of the
partially or fully edentulous patient has become

Fig. 3

36 I cosmetic
dentistry

1_ 2015

a routine treatment modality. Improvements in
the field of implant surgery and in implant prosthetics allow for functionally and aesthetically
satisfying treatment results in the vast majority
of cases.1, 2 However, implants may have been
placed at an incorrect angle or in excessive

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CDE0115_36-38_Zafiropoulus 26.02.15 10:38 Seite 2

case report _ impression of steeply angulated implants

Fig. 4

proximity to another tooth or the natural teeth.
Although rather rare, these situations render impression taking and the consequent restoration
of the placed implants difficult.3, 4 In the present
case report, a method to allow for treatment in
such a situation is described.

_Case report

Since the implant was placed in proximity to
the inferior alveolar nerve, removal of the integrated implant was not advisable.

A 60-year-old male patient reported to our
office for restoration of two implants placed in
regions 29 and 30 three months earlier at a different office (Fig. 1).

The following approach was used to solve this
problem:

According to the records obtained from the
previous treating dentist, a surgical guide was
not used when placing the implants.

Fig. 6

Fig. 5

Implant 29 had been placed at an inadequate
angle. Owing to the angulation of the implant, the
simultaneous placement of two impression posts
was not possible, rendering it impossible to take
an impression (Fig. 2).

_Implant 30 presented with a minor mesial tilt.
Therefore, a prefabricated impression post,
together with the corresponding impression
coping, could be placed (Fig. 3).

Fig. 4_The 25-degree angulated
abutment used.
Fig. 5_CAD/CAM-fabricated impression
coping placed on the abutment.
Fig. 6_The coping covered
with resin to increase retention.
Fig. 7_Impression posts
with copings in place.
Fig. 8_Impression with
implant analogues in place.
Fig. 9_Custom-made abutments
in place on the cast.
Fig. 10_Metal–ceramic crowns
in place on the cast.
Fig. 11_Panoramic radiographs
with the abutments in place.
Fig. 12_The final restorations in place.

Fig. 7

Fig. 8

Fig. 9

Fig. 10

Fig. 11

Fig. 12

cosmetic
I 37
dentistry 1
_ 2015

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CDE0115_36-38_Zafiropoulus 26.02.15 10:38 Seite 3

I case report _ impression of steeply angulated implants
Editorial note: A complete list of references is available
from the publisher.

_about the authors

Fig. 13

Fig. 13_The panoramic radiograph
after placement of the
final restorations.

_Various prefabricated angulated abutments
were tried on implant 29. An abutment with
a 25-degree angle was chosen because it was
comparatively parallel to the impression post on
implant 30 (Figs. 3 & 4).
_The selected abutment was scanned and an impression coping was fabricated from non-precious metal (cobalt–chromium alloy; Zenotec NP,
Wieland Dental) using CAD/CAM technology
(Fig. 5). The coping was covered with a thin
layer of resin (PATTERN RESIN, GC) and small
spheroids were modelled coronally, labially and
lingually to increase retention (Fig. 6).
_The impression post, together with the coping,
was placed on implant 30. The 25-degree angulated abutment, functioning as an impression
post, together with the coping, was placed on
implant 29 (Fig. 7).
_An impression was taken using a polyether
material (Impregum, 3M ESPE; Fig. 8).
_Two custom abutments were fabricated, as
well as two individual porcelain-fused-to-metal
ceramic crowns (Figs. 9 & 10).
_The abutments were placed on the implants
using a custom-made key and torqued to 35 Ncm
(Fig. 11). The crowns were then cemented on
to the abutments using provisional cement
(Figs. 12 & 13).

Gregory-George K.
Zafiropoulos, DDS, Dr. dent.,
is a specialist in periodontology
certified by the German
Society of Periodontology.
He received his PhD in
Periodontology from the
Philipp University of Marburg in
Germany. He has been in private practice in Düsseldorf
in Germany since 1993 and is a professor at the
Università Cattolica del Sacro Cuore in Rome in Italy.
Prof. Zafiropoulos has completed postgraduate
studies in preventive dentistry (University of Athens
in Greece), periodontology (Saarland University
and Philipp University of Marburg in Germany),
oral implantology (University of Göttingen/German
Association of Dental Implantology) and implant
prosthodontics (RWTH Aachen University in Germany).
He worked as an adjunct professor at the University
at Buffalo in the US. He is a diplomate of the
International Congress of Oral Implantologists
and a specialist in implantology certified by the
German Society of Oral Implantology, and has
published 130 articles internationally in the fields
of periodontology and implantology.
Oliver Hoffmann, DDS, MS,
Dr. med. dent., received his
dental and doctoral degrees
from the University of Würzburg
in Germany in 1997. He received
his certificate in Periodontics
and his master’s degree from
Loma Linda University in the
US. Furthermore, he is an associate professor at the
Department of Periodontics at Loma Linda University
and is an associate along with Prof. Zafiropoulos at
a practice in Düsseldorf. Prof. Hoffmann is a diplomate
of the American Board of Periodontology and an
active member of the American Academy of
Periodontology and the Academy of Osseointegration.
_contact:

_Conclusion

38 I cosmetic
dentistry

1_ 2015

cosmetic
dentistry

The method described allows for the successful restoration of malpositioned implants.

Prof. Gregory-George K. Zafiropoulos
Blaues Haus
Sternstr. 61, 40479 Düsseldorf
Germany

However, proper treatment planning should
precede any implant placement to guarantee the
ideal position and thus eliminate any additional
treatment steps._

zafiropoulos@prof-zafiropoulos.de.
www.prof-zafiropoulos.de

[39] => Standard_300dpi

DTSC_A4_EN_Layout 1 04.02.14 14:23 Seite 1

www.DTStudyClub.com

Y education everywhere
and anytime
Y live and interactive webinars
Y more than 500 archived courses
Y a focused discussion forum
Y free membership
Y no travel costs
Y no time away from the practice
Y interaction with colleagues and
experts across the globe
Y a growing database of
scientific articles and case reports
Y ADA CERP-recognized
credit administration

Register for

FREE!

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

[40] => Standard_300dpi

CDE0115_40-43_Freedman 26.02.15 10:39 Seite 1

I technology _ dental radiography

Wireless
digital
sensors
Author_Dr George Freedman, Canada

Fig. 1_Wireless digital sensor
technology is the most popular digital
radiography process worldwide.
Fig. 2_Wired chip sensors
with bitewing images.
Fig. 3_The PSP sensor is quite
pliable and has a reasonable flex
upon insertion into the mouth.

_When digital dental radiography was first
introduced in the late 1980s, conventional X-rays
had been in use for almost a century. The radiograph had, over the years, expanded the dentist’s
investigative capacity in many ways; it was possible to confirm health, or to detect disease, in
many previously invisible areas of concern to the
profession, including coronally, pariapically, and
periodontally. Visual access, complemented by

Fig. 2

radiographic interpretation, provided a comprehensive environment for earlier and more accurate
diagnosis.

_Advantages of digital radiography
For the practitioner, the lost production of the
conventional X-ray’s developing downtime (5 to
10 minutes) has always been a very costly break in
the production day. The virtually immediate computer-generated radiographic image eliminates this
irritating issue. For the dental team, the elimination
of the darkroom, its chemicals, solution replenishment
routines, foul odours, and increasingly complicated
environmental liabilities are welcome changes.
Modern digital radiographic systems today
provide highly accurate and clinically relevant diagnostic information. Their many advantages include:
virtually immediate results, clinical accuracy, expanded diagnostic options, decreased patient radiation, convenient data storage and communication,
ease of clinical use by auxiliaries, decreased consumable costs, and a more environmentally friendly
profile.

_Digital radiography options
Fig. 1

Fig. 3

40 I cosmetic
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1_ 2015

Several categories of innovative dental radiographic imaging technologies have been intro-

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technology _ dental radiography

Figs. 4a & b_In some cases,
effective imaging requires a greater
radiation exposure for the patient.

Fig. 4a

Fig. 4b

duced into the dental marketplace. In general, they
can be used with existing X-ray units. As a major
benefit to dental patients, a significant decrease in
radiation emission is required. Practitioners looking to update and upgrade their traditional (silver
halide) radiographic systems have excellent clinical options. One of the most important selection
criteria is the sensor-to-computer data transfer
mode. Some digital chip sensors, such as the CCD
(Charge Coupled Device) and CMOS (Complementary Metal Oxide Sensor), are hardwired to the
computer through a USB or utilise a Bluetooth
connection. The digital PSP (Phosphor Storage Plate)
sensors (ScanX, Air Techniques, Melville, NY, USA)
are wireless, and are most similar in appearance,
function and convenience to traditional radiographic film. Wireless digital sensor technology
(Fig. 1) is the most popular digital radiography
process worldwide, with more than 50,000 dentists having incorporated PSP into their practices.
The three types of sensors, CMOS, CCD, and PSP are
equivalent in terms of the data that they accumulate per square millimetre during their very brief
exposure to ionizing radiation, and then transfer
to a digital image format.

gingival areas and the crestal bone. This often
necessitates a vertical reorientation of the sensor
and/or more radiographs, requiring a greater radiation exposure for the patient (Fig. 3).
Sensor thickness
The thickness of the sensor can be a major barrier to patient comfort and proper positioning of
the sensor. A traditional size 2 film, at approximately 1.0 mm of thickness, can be rather uncomfortable for some patients, particularly individuals
with small mouths or conditions such as lingual
tori. Wired digital sensors range from 5.5–8.3 mm
in thickness. Their thickness makes them more difficult position in the mouth and more difficult
for the patient to retain comfortably. The ScanX
wireless digital sensor is less than half as thick as
a conventional X-ray film at 0.4 mm. Furthermore,
unlike the rigid, wired sensors, the PSP sensor

Fig. 5_ScanX wireless digital sensors
are available in different sizes.

Sensor diagnostic surface area
Sensor dimensions are crucial to diagnostic
utility. The larger the active surface (or image) area,
the greater the amount of information the sensor
provides to the practitioner. A traditional size 2
film provides about 1,100 mm2 of diagnostic area.
Similarly, a size 2 ScanX wireless digital sensor
offers 1,080 mm2 of diagnostic area. Digital chip
sensors typically have a smaller active area, providing correspondingly less diagnostic information. There is a further complication for the wired
chip sensors with bitewing images (Fig. 2). The sensor wire must be placed between the posterior
teeth, preventing their complete intercuspation.
Unlike a thin cardboard or plastic bitewing tab, the
wire is 4–6 mm in diameter, leaving the teeth that
distance apart. The resulting empty interocclusal
space is non-diagnostic for dental structures, and
in fact, prevents the effective imaging of the

Fig. 5

cosmetic
dentistry 1
_ 2015

I 41

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CDE0115_40-43_Freedman 26.02.15 10:39 Seite 3

I technology _ dental radiography

Fig. 7

Fig. 6

Fig. 6_ScanX wireless digital sensors
for standard bitewing.
Fig. 7_ScanX wireless digital sensors
periapical.
Fig. 8_ScanX wireless digital sensors
endodontic.

is quite pliable and has a reasonable flex upon
insertion into the mouth (Fig. 4), significantly increasing patient comfort.
Wireless sensor size range
ScanX wireless digital sensors are available in
a range of sizes (Fig. 5): #0 and #1 for smaller and/
or constrained mouths, #2 for standard bitewing,
(Fig. 6) periapical, (Fig. 7) and endodontic (Fig. 8)
images, #3 for long bite wings, #4 for occlusals,
panoramic, (Fig. 9) cephalometric, (Fig. 10) and TMJ.
Each sensor is a reusable plate that is inserted into
a disposable protective barrier sleeve, positioned
as required, briefly exposed, scanned and the data
is immediately transmitted to the computer for image display. During the scanning, the data is automatically erased from the sensor, preparing it for
immediate re-use in a new protective barrier sleeve.
The intraoral sizes are fabricated of a flexibly
soft, reusable plastic that can be curved extensively
to better fit the patient’s mouth. If the digital sensor is bent to the point where the surface cracks,

Fig. 9_ScanX wireless digital sensors
panoramic.
Fig. 10_ScanX wireless digital
sensors cephalometric.

Fig. 8

the broken portion of the sensor surface can no
longer provide diagnostic information. With reasonable care, each sensor should last for thousands of images.

_Digital sensor replacement cost
Most breakdowns of chip sensors occur at the
wire-sensor interface. While this should be easily
(and inexpensively) repairable, there is a general
reluctance to refurbish this connection, and the
dentist is placed in a position where new sensors
must be acquired. Whether the problem is a
crushed chip or a frayed lead cable, wired digital
sensors are very expensive to replace (often US$
5,000–10,000 or more).
In fact, it is highly advisable to have a replacement (insurance) policy with the manufacturer or
dealer to cover these eventualities. The replacement warrantee is typically more than US$1,000
per year per sensor. Wireless sensors, on the other
hand, are far less costly; a size #2 replacement
sensor costs about US$40. Moreover, there are no
wires to break. Considering a lifespan of thousands
of exposures, the per-use cost of a PSP digital
sensor is negligible.

_Developing/scanning time

Fig. 9

Fig. 10

42 I cosmetic
dentistry

1_ 2015

Conventional X-rays were developed to image
viewability through chemical baths, water rinses
and air dryers. The process was long and frustrating,
particularly if the results were needed quickly. After
intraoral exposure, a single film might be ready in
5–6 minutes, but a full mouth series took 10 minutes or longer. Wired digital sensors transmit the
ionization data to the software immediately, and
the images are ready for viewing as soon as they are
processed (typically a very minimal delay).
ScanX wireless digital sensors are placed in the
small footprint scanning unit, ScanX Swift (Fig. 11)
and the images are available for viewing momentarily. The first PSP image is ready within 11 seconds,
and subsequent one take 4 seconds each. Thus, a

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technology _ dental radiography

4-bitewing series is ready for viewing in less than
30 seconds, and a full mouth series within 2 minutes. The unit automatically erases all the data
on each wireless sensor, readying it for the next
radiograph.

Fig. 11_ScanX wireless digital
sensors are placed in the small
footprint scanning unit, ScanX Swift.

_Image enhancement
Digital radiographs have higher resolution
than conventional film, and are thus clearer and
more accurately diagnostic. The ScanX software has additional image enhancement tools
that allow dentist to manipulate the acquired
raw images (brightness, contrast, false colour,
reversal) for additional analytic data without
re-exposing the patient to additional radiation.
These investigative tools are very valuable in
pinpointing issues more specifically and far
earlier than ever before. The software is intuitive
and easy to use.
Viewing digital images on a screen has significantly improved both the way that practitioners diagnose their patients and the means whereby they
develop simple and extensive treatment planning.
The size of the monitor offers on-screen co-diagnosis and co-treatment planning that actively involve the patient in the dental treatment process.

_Data storage
The practice’s radiographic data is ideally stored
in a single location on the office server computer
from where it is readily accessible to all the operatory. Since radiographic image files are rather large
(and compression may cause the loss of important
details), it is important to dedicate adequate storage space that can accumulate at least 3 years’
worth of data. Cephalometric and panorex images
are particularly space consuming. Off-site and multiple location backups are good safe-computing
practices that eliminate the unlikely, but potentially disastrous results of fire, flood, or a total
irreversible failure of the storage drive.

_Conclusion
Digital dental radiography is faster, cleaner,
more effective and better than silver-based film.
More than 99 per cent of dentists who use digital
radiography recognize that it was a good investment. The obvious advantages include: immediacy
of the images, decreased radiation exposure, image
enhancement, digital storage, and the elimination
of chemicals. The mainstream acceptance of digital
radiography has been slowed by high start-up
costs, however. Some of the earlier objections such
as rigidity and bulkiness of sensors, sensor cord

Fig. 11

damage, and ongoing maintenance and repair have
been eliminated by the PSP wireless digital sensors.
While the initial costs of conversion to digital
radiography may be high at first, the long-and
short-term clinical and financial benefits of digital
radiography are well worth the investment._

_about the author

cosmetic
dentistry

Dr George Freedman is a founder
and past president of the American Academy of Cosmetic Dentistry, a co-founder of the Canadian
Academy for Aesthetic Dentistry
and a Diplomate of the American
Board of Aesthetic Dentistry. His
most recent textbook, “Contemporary Aesthetic Dentistry” is published by Elsevier.
Dr Freedman is the author or co-author of 12 textbooks, more than 700 dental articles, and numerous
webinars and CDs and is a Team Member of REALITY.
Dr Freedman was recently awarded the Irwin Smigel
Prize in Aesthetic Dentistry presented by NYU College
of Dentistry. He lectures internationally on dental
aesthetics, adhesion, desensitization, composites,
impression materials and porcelain veneers.
A graduate of McGill University in Montreal, Dr
Freedman is a Regent and Fellow of the International
Academy for Dental Facial Aesthetics and maintains
a private practice limited to Aesthetic Dentistry in
Toronto, Canada.
epdot@rogers.com

cosmetic
dentistry 1
_ 2015

I 43

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CDE0115_44_Micerium 26.02.15 10:40 Seite 1

I industry news _ Micerium

ENA White 2.0
—professional home bleaching
the 6 per cent hydrogen peroxide bleaching
gel and the special accelerator XS151, which
activates while brushing; the absorption rate of
hydrogen peroxide is increased exponentially if
compared to a traditional bleaching with tray.
The unique properties of ENA White 2.0 reduce the daily application time to only 2 minutes,
instead of 6–8 hours of the traditional cosmetic
home bleaching with tray. For a treatment plan
of 10 days, the patient’s teeth would remain
in contact with hydrogen peroxide for about
60/80 hours, against only 20 minutes with our
innovative product.
The risk of irritation and sensitivity is reduced
thanks to the shorter contact period between
the tooth and the bleaching gel, and the possibility of swallowing the gel during the treatment
is lower.
ENA White 2.0, avoiding the use of trays, allows
you to save up on the cost of impressions, model
with block out resin, thermoplastic sheet, printing
and finishing.
The special mini-head (GUM CARE) has been
designed to protect gums and the innovative
packaging allows you to perform the treatment
even when not at home.

_The new European regulation about bleaching products allows the use of cosmetic bleaching
substances with a maximum of 6 per cent hydrogen peroxide.

44 I cosmetic
dentistry

1_ 2015

ENA White 2.0 is a system based on a new technology, which makes the bleaching procedure
easier with unique advantages in the market._

_contact

Micerium S.p.A. worked hard to conceive a way
of simplifying home bleaching, with the aim to
provide dentists and patients with a rapid and
effective treatment. White teeth are not only a
trend, but they can help to smile and face life in
a happy, positive and outgoing way.

MICERIUM S.p.A.
Via Marconi, 83
16036 Avegno
Italy

ENA White 2.0 is a patented system for cosmetic home bleaching, which is made up of a
special toothbrush with a dispenser containing

hfo@micerium.it
www.micerium.com

Tel.: +39 0185 7887 880

cosmetic
dentistry

[45] => Standard_300dpi

CDE0115_45_Remedent 26.02.15 10:52 Seite 1

industry news _ Remedent

Remedent NV launches major
upgrade to dental marketing software
_Remedent NV is delighted
to announce a major upgrade
to the SmileMe Mirror, their
successful dental marketing
software. Previously used only
in 50 GlamSmile Clinics worldwide as a beta test, SmileMe
Mirror V2 is now available to
dentists worldwide.

_Attracting the right
cosmetic patients
The SmileMe Mirror is a
proven concept for practices
to attract more cosmetic patients. By assisting the dental
team with every step of the
consultation, it is a software that
has the power to grow dental practices by changing the way they communicate.
In fact, SmileMe was designed so that every single
patient receives the same information about the
treatments the clinic has to offer. More specifically,
it consists of three complimentary modules that
spark a valuable 10-minute conversation between
the practice and the patient. The end goal is to motivate the patient to move forward with the proposed
treatment.

_Complete communication:
awareness, possibilities, and solutions
The first step is for the patient and dental nurse
to go through the Smile Analysis. This is a carefully
crafted questionnaire that helps the practice understand what their patient wants. The goal of asking
these 14 questions is to make the dental team aware
of their patient’s desires. Depending on the outcome of the analysis, the practice can then respond
with an appropriate cosmetic treatment.
Smile Sketch is the second module and allows
a member of staff to make the patient realise that a
new smile can be life-changing. In under 2 minutes,
a before and after can be simulated so that the patient understands the potential of cosmetic dental
treatments. Especially now with version 2, SmileMe
has become the quickest and most comprehensive
dental simulation software available.

Last but not least, the protocol ends with a
concise explanation of all relevant treatments.
The Treatment Pages serve as a menu in the dental
practice to make sure that the patient is familiar
with all solutions available. To do so, SmileMe uses
interactive content and digital animations so that
all explanations are quick and easy to understand.

_A must-have for cosmetic dentists
Thanks to this update, SmileMe can now confidently position itself as world leader in marketing
technologies and services for cosmetic dentists. With
a concept that is easy to integrate and has proven its
success in hundreds of practices and dental chains
across the planet, the SmileMe Mirror is an investment any practice looking for growth should make.
Schedule a web demo at our website or come meet
us at the IDS (Hall 3.2, Stand A041) or at ScanDeFa
(C1–016B), to learn how SmileMe can grow your
practice today._

_contact

cosmetic
dentistry

SmileMe
Zuiderlaan 1–3, bus 8, 9000 Gent, Belgium
www.smileme.mobi

cosmetic
I 45
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_ 2015

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CDE0115_46-47_Coltene 26.02.15 10:53 Seite 1

I meetings _ review

Regenerative endodontics and
composite as an all-rounder
European COLTENE Key Opinion Leader Meeting
sheds light on the future of dental medicine
_The St Gallen football stadium is where various
past matters of international importance have been
settled. This November, the well known sports facility
became the venue for a summit meeting of European
dental medicine. The Swiss dental specialist COLTENE
invited respected opinion leaders and distinguished
researchers to the Key Opinion Leader Meeting on its
home territory. Over 80 renowned experts from research
and practice spent two days discussing the future of
endodontics and restorative dentistry. Among the participants were representatives of leading European universities and research laboratories, as well as numerous
dentists who have made a name for themselves, also internationally, with their innovative treatment concepts
and unusual patient cases. Specialists from countries
including Germany, Finland, Greece, Great Britain, Italy,
Norway, Switzerland and the USA took part in numerous
presentations and lively discussions.

_The chameleon of restorative dentistry
Following a few words of introduction from
COLTENE Managing Director Martin Schaufelberger,
the first part of the congress focused on the creative
use and advancement of composite as an all-rounder
in restorative dentistry. To start the congress, the chairman, Prof. Ivo Krejci, Head of the Division of Cariology
and Endontology, as well as President of the Ecole de
Mèdecine Dentaire at the University of Geneva, presented his own concept developed for lifelong dental
coaching. Minimal invasive treatment with direct and
indirect adhesive techniques still represent one the
best alternatives for long-term patient restoration.
‘Thanks to growing life expectancy in Western Europe,
there is an increasing demand for sustainable dental
care and therapy, starting with the small child well into
old age’, according to Krejci. In the second presentation
section, the emphasis was on the current state of material research. Prof. Jorge Perdigão from the Department of Restorative Sciences at the University of
Minnesota spoke about the latest approaches for improving dentine adhesion with the aid of adhesives.
Also, Simon Sutter allowed the international guests
exclusive insights into the latest innovations from

46 I cosmetic
dentistry

1_ 2015

COLTENE's Research and Development department under the title ‘How can the gloss retention of composites
be improved?’ Tips and special ideas on the use of
composite veneering systems, such as the worldwide
established COMPONEER treatment concept, were
presented by dentists in private practice and aesthetic
specialists Dr George Gomes from Lisbon and Dr Mario
Besek from Zurich. Industrially prefabricated nanohybrid composite shells offer the modern practitioner
a wealth of options for anterior restoration, rectifying
misalignment, diastema and tooth fracture through
to gap closure and classical caries therapy. Dr Monik
Vasant from London illuminated the fine art of highly
aesthetic anterior restoration using the freehand
technique using the MIRIS system, for a direct comparison with ceramic restorations. The programme was
rounded off with an exciting outlook on the perspectives of new solutions in restorative dental medicine.
The discussion covered the skilful exploitation of
3-D printing in dental medicine, the use of CAD/CAMgenerated composite blocks as real alternatives for
ceramic, as well as crowning of implants with composite and the use of composite cement for bridges. Prof.
Mutlu Özcan from the University of Zurich concluded
the round of presentations with her own spectacular cases, in which prosthetic freehand constructions
composite were used, and the enormous potential of
composite as an all-rounder became abundantly clear.

_New approaches in endodontics
The second day of the congress dedicated to
endodontics was no less lively. Under the motto
‘Pulp Fiction—beyond today’s limitation of Endodontic
treatment’, the participants researched new ways of
achieving regenerative orientation in the supreme
discipline of conservative dentistry, leading away from
the conventional, purely surgical approach. The congress chairmanship was shared by Prof. Dag Ørstavik,
Head of the Department of Endodontics and the
Postgraduate Programme at the University of Oslo,
and Dr Antonis Chaniotis who works at the University
of Warwick and has his private practice in Athens.
To start, Prof. Håvard Haugen from the University of

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meetings _ review

Oslo explained the principles of morphogenesis
and the special role of intrinsic disorder proteins
(IDPs). The possibilities of developing a method
for systematic regeneration of the dental pulp in
the idea of tissue engineering was impressively
illustrated by Dr Kerstin Galler from the University
of Regensburg. The chairman Prof. Ørstavik himself demonstrated the basic principles and limitations in effective testing of dental materials.
At the same time, he referred to the importance
of clinical studies before using innovative materials in the clinical field. ‘Understanding biological
processes must not mutate into an end in itself.
Firstly it is important to define which objectives
the investigations of new materials have and are
then presented in the studies. At the end of the
day, new treatment methods should also actually benefit the patient and be deployed intelligently", Ørstavik
strongly stressed. Konstantinos Simatos, who also
travelled from Athens, offered creative enrichment.
During the lunch break, all manner of percussion instruments were handed out in the lecture hall and
the dedicated Greek managed to persuade the congress participants to work together as an orchestra for
40 minutes. A task that served for relaxation and evidently sounded like fun for all involved at the same time.
Dr Antonis Chaniotis had already complemented
the insights from basic research with his experience
from routine clinical work, and presented a series of
long-term observations in the treatment of children
in the regenerative part of the day's programme. In his
second contribution, he demonstrated why and how
he came to use intelligent endodontic working aids,
and how modular NiTi systems and endodontic
aspirator tips significantly simplify obturation of
a perfectly prepared canal for dentists today already.
In the so-called ‘negative pressure technique’, fluid
gutta-percha is transported in the temporarily sealed
canal, even into the smallest lateral canals, through the
skilled use of an aspirator tip. Mechanical preparation
is still easiest with an almost unbreakable NiTi file.
Taking the example of HyFlex CM and the new HyFlex
EDM system, the endo expert demonstrated how
high precision canal shaping can be achieved within
a short time. As quoted by Dr Chaniotis on the current
progress in the industry: ‘Thankfully we don't have
to wait for the future for high quality treatment and
confident working! Nowhere is current technical development advancing so rapidly as in endontology.’
The eventful day was rounded off by Dr Barbara
Müller, Head of the COLTENE Endo Business Unit.
She introduced the upcoming new products, such as
GuttaFlow bioseal and the Hyflex EDM files and illustrated that their special manufacturing process yielding
a new generation of NiTi files, whereby the reduction in
the number of files used is not at the expense of the

quality of the endodontic treatment. The contribution
was impressively complemented by Dr Ginaluca Fumei
and Dr Thomas Rieger, who both presented cases from
their practices, which were treated with Hyflex EDM.

_Important impetus for material research
The host COLTENE was entirely satisfied with the
results of the symposium and the ideas put forward
by the various opinion leaders. The innovation-driven
company will also consider the countless suggestions
and ideas from the seminar within its own development work. The close cooperation with dentists from
around the world and leading universities plays a crucial role in designing and shaping practical products.
This is the only way of ensuring that clever working aids
and dental materials optimally support dentists in
their day-to-day therapeutic practice. Today's visions
from the dental specialists may then have already
become common treatment in practice by the time of
the next Key Opinion Leader Meeting.
The initial responses from the audience were also
full of praise. For instance, Prof. Brian Millar from
London and Dr Hagay Shemesh from the Netherlands
emphasised the balanced mix between scientific and
clinical contents. Participants such as Dr Michael Leski,
Poland and Dr Sylvia Rahm, Germany, found the interdisciplinary presentations extremely enriching and
also appreciated the perfect organisation of the event._

_contact

cosmetic
dentistry

Coltène/Whaledent GmbH + Co. KG
Raiffeisenstr. 30, 89129 Langenau, Germany
Tel.: +49 7345 805-0
Fax: +49 7345 805-201
info.de@coltene.com / www.coltene.com

cosmetic
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CDE0115_48_Events 27.02.15 10:11 Seite 1

I meetings _ events

International Events
10th CAD/CAM & Digital Dentistry
International Conference
8–9 May 2015
Dubai, UAE
www.cappmea.com

2015
36th International Dental Show
10–14 March 2015
Cologne, Germany
www.ids-cologne.de
Academy of Osseointegration 30 Annual Meeting
14–12 March 2015
San Francisco, USA
www.osseo.org
th

IMAGINA DENTAL
4th 3D & CAD/CAM Digital Dentistry Congress
1–3 April 2015
Monaco
www.imaginadental.org
APDC 37th Asia Pacific Dental Congress
3–5 April 2015
Singapore
www.apdc2015.sg

White & Pink Esthetics
12th International Congress of Esthetic Dentistry
14–16 May 2015
Bucharest, Romania
www.sser.ro
EAED 29th Annual Meeting
28–30 May 2015
Florence, Italy
www.eaed.org
EuroPerio 8
3–6 June 2015
London, UK
www.efp.org
AAED 40th Annual Meeting
4–7 August 2015
Telluride, USA
www.estheticacademy.org
FDI Annual World Dental Congress
22–25 September 2015
Bangkok, Thailand
www.fdi2015bangkok.org
ESCD Annual Meeting
1–3 October 2015
Cannes, France
www.escdonline.eu
IFED 2015—The 9th World Congress of the
International Federation of Esthetic Dentistry
5–7 November 2015
Cape Town, South Africa
www.ifed-2015.com

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CDE0115_49_Submission 26.02.15 10:54 Seite 1

about the publisher _ submission guidelines

submission guidelines:
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I

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In addition, please note:

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Please consider this when formatting your document.

Questions?
Magda Wojtkiewicz (Managing Editor)
m.wojtkiewicz@dental-tribune.com

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CDE0115_50_Impressum 26.02.15 10:54 Seite 1

I about the publisher _ imprint

cosmetic
dentistry
_ beauty & science

asia pacific edition

Publisher
Torsten R. Oemus
t.oemus@dental-tribune.com
Editor-in-Chief
Dr Sushil Koirala
skoirala@vedicsmile.com

International Media Sales
Matthias Diessner (Key Accounts)
m.diessner@dental-tribune.com
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m.brown@dental-tribune.com

Co-Editor-in-Chief
Dr So Ran Kwon
soran-kwon@uiowa.edu

Peter Witteczek (Asia Pacific)
p.witteczek@dental-tribune.com

Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com

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w.mageswki@dental-tribune.com

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Copy Editors
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International Administration
Chief Financial Officer
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Sales Services
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Executive Producer
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h.carpentier@dental-tribune.com

Advisory Board
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Dr Seok-Hoon Ko, Korea

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 Suhit Raj Adhikari, Nepal
Dr Takashi Nakamura, Japan
Dr Vijayaratnam Vijayakumaran, Sri Lanka

Barbora Solarova (Eastern Europe)
b.solarova@dental-tribune.com

cosmetic

dentistry _ beauty & science
is the official publication of:

International Offices
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50 I cosmetic
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PRINT
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A
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U
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The DTI publishing group is composed of the world’s leading
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in more than 90 countries.

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