cosmetic dentistry No. 1, 2022
Cover
/ Editorial: MiCD knowledge philanthropy by Dr Sushil Koirala
/ Content
/ An interview with Dr Davinder Raju: “I hope that sustainable dentistry will soon reach critical mass and become the norm”
/ An interview with Dr Sumita Mitra: “Everyone has the power to become an innovator”
/ Direct restoration procedures simplified: Transforming dentistry with groundbreaking technologies by Kuraray Noritake Dental
/ Treatment of a carious lesion with a composite with a single posterior shade by Dr Nicola Scotti
/ Rethinking bonding in the adhesive dentistry era: Think universal by Dr Dimitrios Spagopoulos
/ New philosophies in ceramic layering by Joaquín García Arranz (Quini) & Dr Ramón Asensio Acevedo
/ Making a permanent difference with zirconia paediatric crowns; A five-year follow-up by Dr Ana Vînău
/ An interview with Dr Michał Nawrocki: Laser protocol for peri-implantitis treatment
/ Restorative aesthetics at the gingiva by Drs George Freedman & Paiman Lalla
/ The world’s first thermo-viscous restorative material: VisCalor—now available for all cavity classes
/ International events
/ Submission guidelines
/ Imprint
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[1] =>
issn 2193-1429 • Vol. 16 • Issue 1/2022
cosmetic
dentistry
1/22
beauty & science
interview
“Everyone has the power
to become an innovator”
case report
New philosophies
in ceramic layering
user report
Laser protocol for
peri-implantitis treatment
[2] =>
The Medical Power of Light
Facial Aesthetics with the
®
LightWalker Dental Laser
Now available for your dental practice
LipLase® – lip plumping without injectables
SmoothEye® – wrinkle reduction in the periocular region
Fotona3D™ – non-surgical facelift
Vascular and skin lesion treatments
Laser hair removal
Acne treatments
Skin rejuvenation
Committed to Engineering
The Highest Performance, Best Made Laser Systems in the World
www.fotona.com
109747 CE ENG/1
•
•
•
•
•
•
•
[3] =>
editorial
|
Dr Sushil Koirala
Editor-in-Chief
MiCD knowledge philanthropy
cosmetic dentistry has become one of the most popular clinical cosmetic dentistry magazines in the world.
This success has in large part been due to the high standard of clinical articles submitted by the authors, the article selection approach of the editorial team and the print
quality. Because of this, we were able to offer free accessibility to the digital version of the magazine on Dental
Tribune International’s (DTI’s) official websites and those
of partner academies, which was indeed a major step
forward. I appreciate this knowledge-sharing initiative of
DTI, which has facilitated my personal mission of promoting the knowledge philanthropy concept in the field of
dentistry.
I vividly recall that, in the editorial I wrote for cosmetic
dentistry 1/2009, I discussed the scope of the minimally
invasive concept in cosmetic dentistry, and in issue
4/2009, I wrote a comprehensive article proposing the
minimally invasive cosmetic dentistry (MiCD) concept
and its treatment protocol. The MiCD concept, as we
look back at it 13 years since its inception, has been
widely recognised and very well received by global clinicians.
It is my pleasure to report that, thanks to the overwhelming acceptance of the MiCD concept and treatment protocol in aesthetic dentistry, we have expanded
the clinical horizons of MiCD from cosmetic to comprehensive dentistry. The encouraging responses, suggestions and requests from clinicians, researchers and
academics around the world have led us to take MiCD
Global Academy management from a privately governed and exclusive sponsorship approach to a nonprofit and open sponsorship approach. From 1 June,
this new philanthropic approach began under the
philanthropic dental education wing of the Dental
Community for Humanity division of the Punyaarjan
Foundation in Kathmandu in Nepal to promote the
MiCD mission as an independent and non-commercial
initiative in dental education.
With this, the MiCD Global Academy has morphed into
the MiCD Knowledge Philanthropy Academy with the
support of many knowledge philanthropists and openminded dental companies. This has been done with the
objective of serving the global dental profession and humanity through the science and technology of MiCD.
To make MiCD knowledge and skills easy to understand
and apply in daily practice, I have broadly divided the
MiCD care and education system into four domains,
namely MiCD lifestyle dentistry, MiCD functional healthy
dentistry, MiCD cosmetic dentistry and MiCD practice
management. MiCD care and education in all these domains are based on the premise of the MiCD concept
that I proposed in 2009. Alongside the introduction of
these domains, related free MiCD educational materials
will be published in the upcoming MiCD clinical journals
and DTI publications according to the need of and demand by readers.
I hope that the global dental fraternity will greatly help us
foster our initiative of MiCD knowledge philanthropy,
and I urge all our readers to take the opportunity to be
part of the MiCD global mission.
I express my gratitude to our valued readers, esteemed
authors, advertisers and everyone who has directly and
indirectly supported cosmetic dentistry and thus
helped bring the magazine to where it is now. I hope you
will enjoy this issue of cosmetic dentistry, and I invite
you to send your valuable feedback and ideas.
Sincerely yours,
Dr Sushil Koirala
Editor-in-Chief
cosmetic
dentistry
1 2022
03
[4] =>
| content
editorial
MiCD knowledge philanthropy
03
Dr Sushil Koirala
interview
“I hope that sustainable dentistry will soon reach critical mass
and become the norm”
06
An interview with Dr Davinder Raju
page 10
“Everyone has the power to become an innovator”
10
An interview with Dr Sumita Mitra
technique
Direct restoration procedures simplified
14
By Kuraray Noritake Dental
case report
page 20
Treatment of a carious lesion with a composite
with a single posterior shade
18
Dr Nicola Scotti
Rethinking bonding in the adhesive dentistry era: Think universal
20
Dr Dimitrios Spagopoulos
New philosophies in ceramic layering
28
Joaquín García Arranz (Quini) & Dr Ramón Asensio Acevedo
page 28
Making a permanent difference with zirconia paediatric crowns
34
Dr Ana Vînău
user report
Laser protocol for peri-implantitis treatment
38
An interview with Dr Michał Nawrocki
Restorative aesthetics at the gingiva
42
Drs George Freedman & Paiman Lalla
manufacturer news
46
meetings
Cover image courtesy of
Monkey Business Images/Shutterstock.com
issn 2193-1429 • Vol. 16 • Issue 1/2022
cosmetic
dentistry
1/22
beauty & science
interview
“Everyone has the power
to become an innovator”
case report
New philosophies
in ceramic layering
user report
Laser protocol for
peri-implantitis treatment
04
cosmetic
dentistry
1 2022
International events
48
about the publisher
submission guidelines
49
international imprint
50
[5] =>
REGISTER FOR FREE
DT Study Club – e-learning community
THE GLOBAL DENTAL CE COMMUNITY
THE GLOBAL DENTAL CE COMMUNITY
THE GLOBAL DENTAL CE COMMUNITY
THE GLOBAL DENTAL CE COMMUNITY
THE GLOBAL DENTAL CE COMMUNITY
Dentistry's largest online
education community
webinars / live operations / online CE events / CE credits
www.dtstudyclub.com
@DTStudyClub
Tribune Group is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist
dental professionals in identifying quality providers of 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.This continuing education
activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition
Program (ADA CERP) through joint efforts between Tribune Group and Dental Tribune Int. GmbH.
[6] =>
| interview
“I hope that sustainable
dentistry will soon reach critical
mass and become the norm”
An interview with Dr Davinder Raju
By Iveta Ramonaite, Dental Tribune International
Dr Davinder Raju is the lead dentist at Dove Holistic
Dental Centre in Bognor Regis in the UK and the founder
of Green Dentistry, an online platform that helps dental practices become more environmentally conscious
and reduce their carbon footprint. In this interview with
Dental Tribune International, Dr Raju, an ardent advocate of sustainability, explains why he thinks apathy and
the fear of litigation are the greatest enemies of sustainable dentistry and how dental professionals often have
false beliefs about sustainability. He also discusses why
having an environmentally aware team with a can-do
attitude is essential in order to promote sustainable
practice and describes why the dental industry should
be transparent about the environmental impact of its
products.
06
Dr Davinder Raju
[7] =>
interview
|
“There has to be clear
leadership and a desire
to embrace sustainability
in order to promote
sustainable dentistry.”
healthcare, with a focus on prevention, early diagnosis
and management, using minimally invasive operative
procedures and having the best long-term interests of
patients at heart, while at the same time mitigating negative impacts on the planet so that we do not undermine
prospects for future generations.
© Iryna Mylinska/Shutterstock.com
Using a minimal intervention approach to dentistry
means that patients are less likely to enter the restorative
downward spiral, thus reducing the need to provide
resources such as dental restorative materials.
Dr Raju, what does sustainability mean to you
personally, and how would you define sustainable
dentistry?
I’m continually amazed at the abundance of life that
our planet has to offer, and it is something that future
generations should have the opportunity to enjoy. To
me, sustainability is about being a good custodian of
the environment and ensuring the well-being of future
generations. It’s about making decisions that reduce
environmental impact. I’m deeply concerned about the
fact that underprivileged children will suffer disproportionately more in light of the consequences of unchecked climate change.
As for sustainable dentistry, I would define it by combining
Gro Harlem Brundtland’s famous definition of sustainability with minimally invasive dentistry. Sustainable
dentistry involves delivering optimal oral and dental
You believe that great leaders should know not only
why they are running a practice but also how they
are running it. Could you elaborate on that?
We know that greenhouse gases emitted by human
activities cause climate change and that the effects of
climate change, some of which are already apparent,
pose a global health threat.
Now, “to do no harm” is one of the pillars of medical
ethics, yet globally, the health sector emits more carbon
dioxide than Japan, which is currently ranked as the fifth
highest emitter of all countries. Given its mission to protect and promote health, the health sector, including
dentistry, has a responsibility to reduce its own climate
footprint. This can only be accomplished by examining
how we are providing services. Only by scrutinising how
we operate can we consider the possibility of delivering
the same service, but by employing an approach that
has a lower environmental impact.
Climate change will become an increasing concern for
consumers, and the dental profession must take action
to reduce the harm that healthcare is causing.
To follow up on the previous question, what motivated you to found Green Dentistry, and how do you
promote sustainable development in your business?
I first need to explain why I set up an eco-friendly dental
practice. The catalyst came about when I was studying
for my master’s degree in advanced minimum intervention dentistry. I was struck by the ecological plaque
hypothesis. Inside a healthy mouth, there is a stable and
healthy community of cells—microbial homeostasis—
where a mutually beneficial equilibrium exists between
cosmetic
dentistry
1 2022
07
[8] =>
| interview
the microflora and the host. If this balance is upset,
disease ensues. Consequently, I started thinking about
the effects of my business on our host, namely the environment, and how I could mitigate that impact.
When I wanted to set up an eco-friendly dental practice,
information about sustainable dentistry wasn’t readily
available. Since there seemed to be a lack of practical
advice, I had to piece information together from other
industries. Green Dentistry came about when I was approached by other dentists who wanted to make their
practices greener but didn’t quite know where to start.
There has to be clear leadership and a desire to embrace sustainability in order to promote sustainable
dentistry, and having an environmentally aware team
with a can-do attitude is essential. As a practice owner,
I’m busy running the practice, and I don’t have the time
to manage day-to-day activities. Good ideas and strategies aren’t worth anything if you can’t implement
them, so I delegate the role of maintaining the changes
to a sustainability champion. However, we need the
entire team to be on the same page for both coherence
and creativity. The team needs to be willing to suggest
ideas to the sustainability champion and to ensure that
they are discussed at practice meetings.
“We’ve taken many steps
in the right direction,
but we never assume that
we’ve done enough. I want the
team to be forward-thinking
and future-oriented [...]”
Running a sustainable practice is about creating a
culture that consistently seeks new opportunities to
improve efficiency and environmental performance.
The right team is essential, and its members need to unite
and collectively participate. We’ve taken many steps
in the right direction, but we never assume that we’ve
done enough. I want the team to be forward-thinking
and future-oriented, almost as if the team members are
carrying out mini eco-audits as they’re walking through
the practice, carrying out their regular procedures while
thinking to themselves: “Is there a better way of doing
this? Is there another product we could be using?”
Sustainability is gaining increasing awareness in
dental practices worldwide. How would you explain
this trend?
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Programmes like David Attenborough’s television series
The Blue Planet and professional magazines such
as the British Dental Journal have all helped raise
awareness of sustainability. Still, there is possibly a disconnect between what we do at home and in our working environments. During the COVID-19 pandemic,
many dental professionals were alarmed by the large
amounts of extra personal protective equipment that
they had to use. This may have produced a cognitive
tipping point and made dental professionals realise
how much the dental sector negatively impacts the
environment.
I believe that sustainable dentistry is currently being
introduced to the dental curriculum at King’s College
London and hopefully at other dental teaching hospitals. I hope that sustainable dentistry will soon reach
critical mass and become the norm.
Why is it crucial that the dental industry is transparent about its supply chains and environmental
policies?
The lion’s share of carbon dioxide emissions produced
by the provision of healthcare are generated upstream
and are attributable to the supply chain through the
extraction of raw materials and the production, transport
and distribution of goods and services. If the dental
industry is transparent about the environmental impact
of its products, we, as end users of dental products and
materials, can make greener procurement choices. In
addition, industry-wide environmental policies that promote responsibility and accountability will help those
working in the dental profession to determine with
which companies they wish to align themselves and do
business.
What would you say is the greatest enemy of sustainable dentistry, and what are some of the barriers
to sustainability in dentistry?
The greatest enemy of sustainable dentistry is apathy.
It is the feeling that, since dentistry’s overall impact is
relatively small compared with, for example, coal-fired
power stations, there’s no point in making the necessary changes towards a more environmentally sustainable future within the dental environment. However, we
can’t be passive bystanders. We can’t stand back and
be spectators knowing that conditions that humans
have created, and are continuing to create, are a threat
to humanity and other life forms.
We are facing a climate crisis, ever-shrinking biodiversity and acidification of the oceans. We can vote for
policymakers who prioritise the environment and make
a move towards delivering sustainable dentistry now.
Regulatory change will come eventually, but we shouldn’t
wait for the government to take action. It’s immensely
satisfying to do the right thing.
[9] =>
|
© PopTika/Shutterstock.com
interview
The fear of litigation is also a barrier to embracing sustainability. In the UK, Health Technical Memorandum 01-05:
Decontamination in primary care dental practices has
resulted in a significant increase in the use of singleuse plastics and increased costs for dental practices.
Although aware of the importance of infection prevention, we seem to have tipped too far on the side of
caution. If used appropriately and recycled when possible, plastic is a valuable material. However, singleuse plastics are now ubiquitous in the dental environment.
It’s picking the low-hanging fruit that hopefully will spark
a change in behaviour towards sustainable practice.
There is also a common perception that the changes
necessary to achieve a more sustainable approach are
expensive to implement. Yes, you can spend a great
deal of money on capital expenditure by purchasing
solar panels, ground source technology or heat pumps,
but this isn’t the only way to achieve a more sustainable
approach to delivering dentistry. For example, if a practice wants to help reduce carbon dioxide emissions,
it can simply switch to a renewable energy provider.
As demand grows, renewable energy will increasingly
be sourced for the grid, thus reducing the supply generated from fossil fuels.
We have a wild flower garden at the front of our house,
which has never been mowed in order to help increase
biodiversity. It looks a mess for a few months of the year,
but it is delightful when the flowers appear. We also
recycle, of course, but more importantly, we’re not big
consumers. If we buy goods, we try to buy sustainably
sourced goods whenever possible.
What measures do you take outside of work to
minimise your impact on the planet?
We obtain our energy from a renewable energy provider
at home, don’t eat meat (for ethical and environmental
reasons) and buy organically grown food. Last year, we
started growing our own vegetables fed with homemade fertiliser made from comfrey and nettles. We also
compost.
Editorial note: More information can be found online at
www.greendentistry.co.uk.
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09
[10] =>
| interview
1
Fig. 1: Dr Sumita Mitra has dedicated more than 30 years to the development of dental materials. (All images: © European Patent Office)
“Everyone has the power to
become an innovator”
An interview with Dr Sumita Mitra
By Franziska Beier, Dental Tribune International
Dental Tribune International (DTI) interviewed Dr Sumita
Mitra, chemist and awarded dental materials inventor.
During her career at 3M, she developed a unique
nanomaterial-based dental filler, for which she received the
European Inventor Award 2021. This material and numerous other inventions of hers in the field of dental materials
have been patented. DTI spoke with Mitra about how a
bunch of grapes inspired her research efforts, about the
greatest advantages of her developed material and about
how she gives back to the next generation of inventors.
Dr Mitra, thank you for agreeing to this interview.
Could you tell us something about your background?
I grew up in India and had my early education there. I did
my BSc at Presidency College in Kolkata with chemistry
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honours. After my MSc in chemistry in India, I came to the
US and obtained a doctorate in organic/polymer chemistry in 1977 from the University of Michigan in Ann Arbor.
After a year of postdoctoral work at Case Western
Reserve University in Cleveland in Ohio I joined the
3M Corporate Research Laboratories in 1978 and later
moved to the 3M Dental Products Division (now 3M Oral
Care) in 1983. There I held positions of increasing responsibility and in 1998 was appointed corporate scientist, the
highest technical position at 3M. I led the new materials/
products research and development efforts until my
retirement in 2010. From 1999 to 2010, I also served as
the industrial director of the Minnesota Dental Research
Center for Biomaterials and Biomechanics at the School
of Dentistry at the University of Minnesota in Minneapolis.
[11] =>
interview
“From a very early age
I was fascinated by
different materials.
I often wondered what
makes one material
different from another.”
Currently I am a partner at Mitra Chemical Consulting, an
independent consulting firm, which I co-founded.
Why did you decide to go into chemistry and how did
you become concerned with dental materials?
From a very early age I was fascinated by different materials. I often wondered what makes one material different
from another—things like why paper is different from
wood, or why fabric is different from our skin. I learnt that
the answer is in the molecules—it is chemistry that is the
central science that defines materials. I was so awestruck
by the subject that I made up my mind to study chemistry
in depth. I would often visit my father in his laboratory and
peer over his shoulders as he did his chemistry experiments. After I joined the 3M company, I got an opportunity to join its Dental Products Laboratory to develop new
polymer matrices for dental composites. I jumped at that
prospect and spent most of my career there, developing
many new materials technologies, including the development of nanotechnology for use in dentistry.
You have developed a nanocomposite restorative
material (Filtek Supreme, 3M), that has already
been used for more than 1 billion tooth restorations.
How did you come up with the idea of using nanotechnology?
|
Until the late 1990s dentists wanting to perform naturallooking tooth repairs relied on a combination of two
separate materials. Microfills were aesthetically pleasing
but too weak to be used for stress-bearing regions of the
incisal edges and for filling teeth in the posterior region of
the mouth. Less attractive hybrid and microhybrid composites were stronger, but lost their shine and became
rough from brushing and chewing. This was both inconvenient and expensive for dentists and their patients.
So, we wanted to create one material that would not only
be strong and durable but also have the long-lasting
lustrous beauty of natural teeth.
Fig. 2: Dr Mitra at the 3M Innovation Center in Minneapolis in Minnesota in the US.
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[12] =>
| interview
3
Fig. 3: Together with scientists at 3M, Dr Mitra invented the nano-based filling material Filtek Supreme.
I realised that the key problem was that the existing filler
technology used to reinforce dental composites had
limitations. Around that time, nanotechnology was an
emerging science. I hypothesised that developing nanoparticle technology for use as dental fillers could allay
most of the problems and afford us a universal filling material. This is because nanoparticles are much smaller in
size than the wavelength of light and thus could provide
unique aesthetic properties. In addition, nanoparticles
had the potential of providing mechanically strong materials. With this idea, and with the help of a team of
3M scientists, I set about the task of developing suitable
nanofillers and incorporating them into a resin matrix to
generate nanocomposites with superior characteristics.
Our initial approach was to make tiny nanoparticles of
several sizes, but this approach was disappointing since
it did not provide all the desirable characteristics, especially the required rheology or handling properties needed
by dentists. I realised that this was because we needed
nanoparticles of a wide size distribution to get packing
efficiency in the composite. It sounds simple but was not
easy to achieve with the initial nanoparticles.
The decisive idea for the material was inspired by
a particular fruit. Could you tell us more about this?
The breakthrough moment came as I was looking at a
cluster of grapes in a bowl. If one observes a bunch of
grapes, there are grapes of different sizes, some small
12
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and some large, with the small ones fitting in between the
gaps created by the large ones, leading to optimum use
of space. Also, the sizes of the bunches can vary greatly—
there can be clusters of five, 20 or 100 grapes, and so on.
If one or two individual grapes are plucked out, the overall cluster doesn’t change that much. My theory was that
we could first assemble the nanoparticles into nanoclusters of wide size distribution and then combine them with
individual nanomeric particles to fill any voids to provide
a synergistic mix that could then be incorporated in a
dental resin to create the composite. This is what I set out
to do, with the help of the excellent team at 3M.
The end result of all that hard work is the universal filling
material 3M Filtek Supreme. Since the original material
was introduced in 2002, several updates have been made
and a family of Filtek products has been introduced for
the benefit of dentists and their patients.
Would you please explain how the material works
exactly and what some of its greatest advantages for
dentists and their patients are?
The 3M Filtek Supreme product is an uncured composite
paste, which comes in a number of shades that make
it possible to exactly match the patients’ dentition. After
using a dental adhesive, the dentist places the composite
and shapes it according to the required anatomy, finally
curing it in place by a short exposure to blue light. The
greatest advantage is that the material is very versatile
[13] =>
interview
and can be used in all areas of the mouth—anterior, posterior, and on incisal or molar surfaces. It is highly aesthetic and has the shine and opalescence of a natural
tooth. It is extremely durable and withstands the forces
of chewing and brushing without losing its shine for a
long time. Dentists all over the world have expressed their
enthusiasm and shared examples of their work, which is
very gratifying.
Your material has been patented. Aside from this
product, do you hold any other patents for dental
applications?
I hold 100 US patents, 58 European patents and their
corresponding equivalents in other countries. The majority of my patents are in the area of dental materials.
You have been awarded and honoured many times,
including being inducted into the US National Inventors Hall of Fame in 2018. Last year, you won the
European Inventor Award 2021—in the category
Non-European Patent Office countries. Congratulations!
How meaningful are these awards to you?
I feel greatly honoured to be recognised by organisations
like the National Inventors Hall of Fame, the American
|
Chemical Society and many others, including most recently the European Patent Office for this invention. It is
quite humbling to be included in the same league as so
many well-known inventors whose work has greatly benefited society. This type of recognition validates the importance of the scientific contributions of scientists and
increases public awareness of the pivotal role that science and technology play for the advancement of society. Another important aspect is that the award creates
role models for aspiring scientists who pursue careers
in science, technology, engineering and mathematics
(STEM)-related fields. Furthermore, awards like these
give a voice to science and help in influencing greater
funding for scientific research and policymaking.
In your opinion, what are the essential characteristics that a person needs in order to start an innovation?
Basically, it is a combination of curiosity, exploration and
imagination. Of course, you need a scientific training, but
above all, you have to try new ways of doing things—
a way that is more convenient and or easier. The other
thing is to have passion coupled with persistence. The
first attempts may not be successful, but failures should
never discourage us. They only
show us that there is another pathway toward achieving a goal.
How do you inspire young people
and what would you tell the
next generation of potential innovators?
After my retirement, I have spent
many hours volunteering and teaching at a number of local organisations, encouraging STEM education
at all levels, primary school to postgraduate. It is a way for me to give
back to society for all the opportunities I have had.
Everyone has the power to become
an innovator. The important thing
is to understand that a solid foundation in STEM-related fields gives
young people the toolset to unleash their creativity and design
better approaches to improving the
well-being of society. I always tell
young people, “Believe in yourself,
seek help when needed, and never
give up.”
Fig. 4: Dr Mitra loves art and enjoys painting
with watercolours in her free time.
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[14] =>
| technique
Direct restoration procedures
simplified
Transforming dentistry with groundbreaking technologies
By Kuraray Noritake Dental
Some companies mainly make use of basic technologies developed by others to improve their products and
introduce new ones, while other companies conduct
fundamental research and technology development inhouse. Is this difference relevant for someone who uses
the resulting products in the dental practice or laboratory
on a daily basis? It is. Companies that develop everything
from scratch usually have a deeper understanding of
the products and their production procedures, making it
easier for them to modify specific features, solve existing
problems and respond to market needs. This article describes the impact of several basic technologies developed by Kuraray Noritake Dental on the workflow for
creating direct composite restorations.
Direct restorations—from complex to simple
Adhesive restorative dentistry using high-performance
dental adhesives and resin composites is currently one
of the most popular approaches to treating teeth with
carious lesions. Nowadays, a single-bottle universal
adhesive and one or two shades and opacities of universal
composite are usually enough to create beautiful and
durable outcomes, provided that the right materials are
selected.
This, however, has not always been the case. For a long
time, the techniques used to create direct restorations
“The original MDP monomer
creates a strong chemical
bond to enamel, dentine,
metal alloy and zirconia.”
were quite complex. Adhesives were technique-sensitive
multi-bottle and multistep systems with long application
times. Composite filling materials only produced lifelike
outcomes when many different shades and opacities
were combined in the right way. Even if the complex
procedures were carried out correctly, the risk of microleakage, discoloration and eventually secondary caries
was comparatively high. Kuraray Noritake Dental focused
on solving these issues quite early on, starting with the
utilisation of the original MDP monomer developed
in 1981.
Optimising bonding performance
The original MDP monomer addressed the issue of
limited long-term bonding performance of adhesive
systems. MDP’s hydrophilic (phosphate) group forms a
particularly strong and long-lasting chemical bond with
1
Fig. 1: The bactericidal mechanism of MDPB is presumed to be similar to that of the well-known antibacterial agent cetylpyridinium chloride, which is in many
toothpastes and mouthrinses.
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[15] =>
technique
calcium found in hydroxyapatite. The MDP–Ca salt
formed provides the basis for a stable, strong and
durable hybrid layer. In combination with the resin in
the bonding agent, a tight seal of the cavity after lightpolymerisation is the result. To date, MDP is still an essential component of any adhesive product from Kuraray
Noritake Dental, and it is the key component that made
CLEARFIL SE BOND the gold standard self-etching
adhesive system.
However, convinced that dental adhesives should
provide for more than a strong and long-lasting bond,
Kuraray Noritake Dental started to focus on solving another issue: the risk of demineralisation and cavitation
caused by bacteria remaining in the cavity. Based on its
experience in developing other adhesive monomers,
Kuraray Noritake Dental invented the MDPB monomer, which has an antibacterial cavity-cleansing effect.
Different from antibacterial agents that might impair
the bond strength of a subsequently applied adhesive,
the MDPB monomer kills remaining bacteria without
affecting the bonding performance. It is contained
in the primer of the two-bottle self-etching adhesive
CLEARFIL SE Protect and is immobilised by polymerisation (Fig. 1).
While two-bottle self-etching adhesives have already
simplified the adhesive procedure, single-bottle universal
adhesives go the extra mile. It is a challenge to bring
together components distributed in multistep systems
in one bottle without compromising the stability of the
product. Current technology now makes this possible.
To seal the surface as soon as possible after application,
the penetration of the monomers into the dental tissue
must be fast and efficient.
However, the penetration is usually slowed down by
monomers that need time to penetrate the tooth structure—especially wet dentine—and sometimes even
need to be rubbed into it. That is why Kuraray Noritake
Dental focused on developing the rapid bond technology. It utilises the original MDP monomer combined
with newly developed hydrophilic cross-linking amide
monomers and is integrated in CLEARFIL Universal
Bond Quick. The hydrophilic amide monomers provide for rapid, deep and complete penetration of the
dentine and form upon polymerisation a densely
cross-linked polymer network responsible for a strong
and durable bond. Hence, waiting and rubbing
times are eliminated, and a tight and long-lasting seal
of the cavity is established after light-polymerising
(Figs. 2a & b).
Because of their hydrophilicity (water affinity), these
amide monomers penetrate dentine very well. After lightpolymerising, the bond exhibits low water absorption
and therefore high ageing resistance.
2a
|
2b
Fig. 2a: Prepared dentine with smear layer. Because of its hydrophilicity, very hydrophilic bonding is needed in order to be able to optimally
penetrate the dentine. Fig. 2b: Dentine bonded with CLEARFIL Universal
Bond Quick. During polymerisation, CLEARFIL Universal Bond Quick creates
a highly cross-linked polymer network. As a result of this network, the
bonding has very low water absorption, which produces a long-lasting
restoration.
Optimising direct restorative materials
Combining multiple layers, shades and opacities—the
use of highly complex layering techniques for the creation of lifelike composite restorations is luckily a thing of
the past in many clinical situations. The reason for this is
highly developed resin composites that blend seamlessly with the adjacent tooth structure. To provide for
this favourable feature, Kuraray Noritake Dental developed its proprietary light diffusion technology. The technology is incorporated in special prepolymerised fillers
that act like millions of microprisms that transmit and
refract light and colour from the surrounding tooth
structure. Optimised in size, distribution and refractive
index in relation to the matrix, the fillers offer unsurpassed natural blending.
The whole CLEARFIL MAJESTY composite line-up
employs this proprietary filler technology. Its latest
product—CLEARFIL MAJESTY ES-2 Universal—in
which Kuraray Noritake Dental uses next-level light
diffusion technology, allows for a single-shade technique with simplified shade selection (Fig. 3). It is
3
Fig. 3: Refracting and transmitting light for great optical integration: light
diffusion fillers of CLEARFIL MAJESTY ES-2 Universal.
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[16] =>
| technique
4a
4b
Figs. 4a & b: Example of a single-shade restoration made of CLEARFIL MAJESTY ES-2 Universal. Before (a). After (b).
available in two shades for the anterior and a single
shade for the posterior region, but blends in so well that
it covers virtually every shade of the VITA classical A1–
D4 shade guide.
As a great optical appearance is not only dependent on
optical integration and undetectable restoration margins,
Kuraray Noritake Dental also developed fillers that provide for the rest—a natural surface gloss and long-term
polish retention. The solution, integrated in CLEARFIL
MAJESTY ES Flow with its three levels of flowability, is
called submicron filler technology. It makes use of glossy
submicron-sized fillers that are so small that light reflections show a natural effect even after wear. Kuraray
Noritake Dental’s exceptional silane technology is used
to join millions of those submicron fillers and keep them
together over time. It allows for high filler loads in the
low-viscosity composites and limits water uptake that
5
Fig. 5: CLEARFIL MAJESTY ES-2 Universal products.
16
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would otherwise lead to degradation of the polymerised
composite. The perfect balance between the glossy
submicron fillers, light diffusion fillers, resin matrix and
proprietary silane technology is responsible for an optimal combination of mechanical and optical properties
(Figs. 4a & b).
Conclusion
Adhesive monomers, filler technologies and silane technology providing for a solid combination of fillers, clusters
and resin matrix—CLEARFIL MAJESTY ES-2 Universal
clearly is a trusted line of products in the field of adhesive
restoration (Fig. 5). The proprietary technologies developed during the past decades have definitely contributed
to a better (long-term) performance of direct restorations
and to reliable and aesthetic outcomes that are more
easily achieved.
[17] =>
EDITION
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THE HYBR
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EXHIBITION AND CONFERENCE
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[18] =>
| case report
Treatment of a carious lesion
with a composite with
a single posterior shade
Dr Nicola Scotti, Italy
“It offers good marginal
adaptation, low shrinkage
stress and high wear
resistance, necessary for
great long-term results.”
1
Fig. 1: Initial situation.
When restoring posterior teeth with resin composite,
functional aspects such as tight and anatomically correct
proximal contacts and a naturally shaped occlusal surface that is wear-resistant and antagonist-friendly are
even more important than perfect optical integration. This
is why every dental practitioner should avoid spending a
great deal of time on shade selection in these cases and
focus on the factors that have an impact on the reliability
and longevity of the restoration. Great support in accomplishing this task is offered by CLEARFIL MAJESTY ES-2
2
Universal (Kuraray Noritake Dental), a resin composite
with a single universal shade (U) for the posterior region
that eliminates the need for shade taking and selection.
It offers good marginal adaptation, low shrinkage stress
and high wear resistance, necessary for great long-term
results.
The initial situation presented a wide primary carious
lesion in the distal aspect of the second premolar (Fig. 1).
The working field of the premolar was first isolated with a
dental dam, and caries excavation and cavity preparation
were performed (Fig. 2). A sectional matrix and a wedge
were then placed to optimise the fit. Both were held in
place with a separation ring, which increases the interproximal space and hence ensures tight, anatomically
correct proximal contacts (Fig. 3). Build-up of the proxi-
3
Fig. 2: The premolar after isolation with a dental dam, caries excavation and cavity preparation. Fig. 3: Placement of a sectional matrix and a wedge to optimise the fit.
18
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[19] =>
case report
4
5
6
7
|
Fig. 4: Build-up of the proximal wall with CLEARFIL MAJESTY ES-2 Universal (Shade U). Fig. 5: A thin layer of flowable composite (CLEARFIL MAJESTY ES
FLOW High) applied to the cavity floor. Fig. 6: Restoration completed with CLEARFIL MAJESTY ES-2 Universal (Shade U). Fig. 7: Treatment outcome
immediately after removal of the dental dam.
mal wall with CLEARFIL MAJESTY ES-2 Universal (Shade U)
was then done, after selective enamel etching with
phosphoric acid (K-ETCHANT Syringe, Kuraray Noritake
Dental) and bonding with CLEARFIL SE BOND (Fig. 4).
After that, a thin layer of flowable composite (CLEARFIL
MAJESTY ES Flow High) was applied to the cavity floor
to act as a resin coat (Fig. 5). Restoration was completed
with CLEARFIL MAJESTY ES-2 Universal (Shade U).
Although this composite blends in very well with the
surrounding tooth structure, the natural look was finished
off by adding a tiny bit of brown tint to the fissure
(Fig. 6).
The restoration and soft tissue looked natural and healthy
immediately after removal of the dental dam. The proximal contact was tight, and the occlusal anatomy well
shaped for the patient’s individual masticatory dynamics.
The margin of the restoration was virtually invisible, but
the buccal cusp appeared lighter because of dehydration
of the natural tooth structure (Fig. 7). The final treatment
outcome was very satisfying (Fig. 8).
Conclusion
The case presented demonstrates that the selected
composite is well suited for simplified restorative procedures in the posterior region. The material handles well,
offers the same mechanical properties as other materials
from the CLEARFIL MAJESTY ES-2 series and blends in
harmoniously with the surrounding structures without
being too translucent. This way, it is possible to waive the
8
Fig. 8: Final situation.
shade taking process without compromising the treatment outcome. The time saved in this context may be
spent on functional aspects—or even on another patient.
about
Dr Nicola Scotti is an associate
professor at the Department of
Surgical Sciences at the University
of Turin’s dental school in Italy.
His main interests are dental
biomaterials, resin-based composites,
CAD/CAM materials
and adhesive dentistry.
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[20] =>
| case report
Rethinking bonding in the adhesive
dentistry era: Think universal
Dr Dimitrios Spagopoulos, Greece
Introduction
When Buonocore presented the benefits for acid etching
on bonding in the 1950s, it was the beginning of adhesive
dentistry.1 Direct composite restorations have evolved
over the years, and contemporary materials offer versatile solutions in a variety of direct or indirect restorations.
The vast progress that composites have undergone has
made this material the most popular choice among
restorative materials.
1
Fig. 1: A tooth prepared for an overlay. The outer enamel layer and inner
dentine are optically easily distinguishable.
The key point for the restorative dentist is to achieve
the best possible bond between dental substrate and
the composite. Hereto, the anatomy of the tooth must
be considered. In particular, it is important to examine
the structure and composition of the two main tissues,
enamel and dentine, to understand how they affect
adhesive bonds (Fig. 1).
2
Fig. 2: G2-BOND Universal, consisting of 1-PRIMER and 2-BOND. Their yellowish colour reveals the presence of photoinitiator in both components. This colour
disappears after the polymerisation reaction.
20
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[21] =>
Dental
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magazines
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webinars
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dental news
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DENTAL WORLD
Media | CME | Marketplace
www.dental-tribune.com
[22] =>
| case report
3
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6
7
8
9
10
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Fig. 3—Case 1: Mesial caries was discovered on the first mandibular molar after radiographic examination. The occlusal surface was scored as Code 3
according to the International Caries Detection and Assessment System II.5 Fig. 4: A typical Class II mesioocclusal cavity was prepared. Fig. 5: In this case, the
total-etching technique was chosen. Prior to applying 1-PRIMER to enamel and dentine, a 35% phosphoric acid gel was applied. Fig. 6: Etching of the dental
substrate gives it a frosty appearance. Fig. 7: It is recommended to use maximum air pressure to dry 1-PRIMER. Immediately after application of 2-BOND,
a gentle stream of air is applied, and the adhesive is light-polymerised for 10 seconds. Fig. 8: G-ænial Universal Injectable (GC) was applied at the cervical
margin of the restoration, followed by G-ænial A’CHORD in Shade JE in order to create a bubble-free approximal surface without voids at the margins.
Both materials were co-polymerised at this stage. Fig. 9: One mass of G-ænial A’CHORD in Shade A4 was applied to replace the missing dentine.
Fig. 10: A final layer of G-ænial A’CHORD in Shade JE was used in order to create natural morphology with the proper hue and value to replace occlusal enamel.
Fig. 11: Stains can be used to give the look of a natural tooth, making the restoration inconspicuous.
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Dentine differs from enamel in that it contains organic
material and liquid within the dentinal tubules. In addition,
the density of the dentine varies with depth. The water
content of the dentine is lower in the superficial dentine
and higher in the deep dentine.2 Bonding to these surfaces is challenging.
Adhesives are composed of both hydrophilic and
hydrophobic monomers. The main difference between
hydrophilic and hydrophobic adhesives is the chemical
composition of their monomers and solvents. The
most commonly used monomers in adhesive systems
are hydroxyethylmethacrylate (HEMA) and bisphenol
A-diglycidylether methacrylate. HEMA converts the adhesive to a more hydrophilic system by absorbing water from
the dentine or the oral environment,3 consequently causing
more discoloration at the margins of the restoration.
Any adhesive system that emerged during the past
decades falls into one of two categories, based on its
application: etch-and-rinse adhesives and self-etching
adhesives. Universal adhesives have recently been introduced, and they are distinguished by their multi-mode
application.
|
“On enamel, the best adhesion
is still obtained by first creating
a micro-retentive pattern
by means of acid etching.”
is present in both components. Even though the primer
contains photoinitiator, it is not meant to be polymerised
separately. The function of the photoinitiator is to ensure
that the infiltrated resin can efficiently polymerise in all
areas, including the deeper parts of the hybrid layer.
The bonding protocol
On enamel, the best adhesion is still obtained by first
creating a micro-retentive pattern by means of acid etching.
The benefits of acid etching on dentine are more ambiguous. Two cases are discussed here in which different
etching modes were chosen for specific reasons.
First clinical case: Total-etching mode (Figs. 3–11)
G2-BOND Universal (GC) is probably the best option
when efficiency is desired without sacrificing bond longevity (Fig. 2). Based on thorough research, it contains all
elements that are needed for an optimal adhesive performance.4 The primer (1-PRIMER) allows it to be used as a
total-etching adhesive or a self-etching adhesive system.
1-PRIMER contains MDP, providing enhanced chemical
bonding to the tooth structure and indirect substrates
such as zirconia and non-precious metals. Two additional
functional monomers, 4-MET and MDTP, further ensure
bonding to the tooth and precious metals, respectively.
Unlike other adhesives, 2-BOND is hydrophobic and free
of HEMA and MDP, what makes it very resistant to hydrolytic degradation and staining. However, a photoinitiator
12
In this first case, the preparation of the cavity was rather
shallow, and all margins were located in enamel. In such
circumstances, it is important that a tight seal is obtained
on the enamel margins, especially on the approximal surface which is most prone to recurrent caries. Therefore,
a total-etching approach was chosen in this situation.
Second clinical case: Selective-etching mode (Figs. 12–22)
When a considerable amount of dentine is present in the
cavity and especially on its margins, it is important that
the adhesion to dentine is durable and prone to water
degradation. Rigorous etching would expose the wet
13
Fig. 12—Case 2: Initial situation, showing a supra-crestal external resorption at the central incisor. The tooth was still vital, giving the option of a direct
restoration after raising a flap. Fig. 13: The cavity and the soft tissue were visible after the gingival flap had been raised, making it easy to clean the area
and place a dental dam.
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15
14
16
17
18
S
19
20
21
22
Fig. 14: Dental dam isolation protects the operative field from humidity and contamination. Fig. 15: It is important to remove the unsupported enamel in order
to avoid cracks during light polymerisation. Fig. 16: Selective etching of the enamel with 35% phosphoric acid. The thickness of the dentine overlying the pulp
was not more than 0.3 mm. Fig. 17: Prior to light polymerisation, 1-PRIMER and 2-BOND were applied to both the enamel and dentine in accordance with the
manufacturer’s instructions. Fig. 18: Application of G-ænial A’CHORD in Shade A4 to replace the missing volume of dentine. Fig. 19: G-ænial A’CHORD in Shade AE
was placed to complete the restoration. Fig. 20: It is important to finish and polish restorations—especially close to the periodontium—in order to obtain
a smooth surface, which is vital for promoting healthy periodontal tissue. Fig. 21: Immediately after the completion of the direct restoration and flap closure.
Fig. 22: The tooth was re-evaluated nine months after the surgery. The tissue had healed, and the restoration seemed completely integrated.
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collagen in its protective mineral envelope. Moreover,
etching dentine that is close to the pulp might cause
irritation and inflammation of the latter. For these reasons,
a selective-etching approach seems safer in such cases.
Here, the enamel was etched at the incisal cavity margin
to optimise micromechanical interlocking and to avoid
discoloration, whereas on the cervical margin, the dentine was bonded after a self-etching approach.
Conclusion
G2-BOND Universal ensures a strong, durable bond
and is versatile in its use. As a consequence, dentists can
reduce their armamentarium and do not need to remember the different protocols that need to be used for different adhesives, yet can still count on maximal bonding
performance. It is a valuable asset for any dentist unwilling to accept a trade-off.
Editorial note: A list of references is available from the
publisher.
|
about
Dr Dimitrios Spagopoulos
graduated from the School of Dentistry
of the University of Athens in Greece
in 2012 and the next year completed
an MSc in aesthetic and restorative
dentistry at the same university.
Since 2012, he has been a clinical
instructor at the dental school.
Since 2015, he has practised
at the Periocare Goumenos dental clinic in Athens,
where he exclusively focuses on aesthetic dentistry,
prosthodontics, restorative dentistry and implants.
He also practises in these fields in his own private clinic.
Dr Spagopoulos is part of the editorial team of the dentorama
and dental journal magazines (Omnipress) and is
a member of the European Academy of Esthetic Dentistry
and the European Association for Osseointegration.
He is a key opinion leader for Hu-Friedy.
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New philosophies in ceramic
layering
Joaquín García Arranz (Quini) & Dr Ramón Asensio Acevedo, Spain
1a
1b
1c
Figs. 1a–c: Initial situation. Frontal view (a). Right lateral view (b). Left lateral view (c).
Introduction
Diagnosis and treatment plan
Micro-layering is a solution that combines full-contour
ceramics with a very thin layer of veneering ceramic
in the buccal aesthetic zone. With current CAD methods, a buccally reduced restoration is quickly modelled. With the right materials, colour deepness and
natural translucency can be obtained within a space of
about 0.2–0.6 mm. Hence, the strength of the framework remains where needed, and within this small
space, colour, shape and microtexture are easily
controlled.
The patient consulted because he was dissatisfied with
his smile. He also mentioned pain in the maxillary anterior
area. During the clinical examination, it was noted that left
lateral incisor was absent, which had resulted in a large
midline shift in the upper jaw. A fixed porcelain-fusedto-metal restoration was present on teeth #12, 11 and 21.
Tooth #21 had suffered a periodontal loss of attachment,
and a large vestibular gingival recession was present
(Figs. 1a–c). The dental situation was causing occlusal
instability, inadequate function and poor aesthetics.
2a
Figs. 2a & b: Digital planning of the surgical phase.
28
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2b
The treatment plan consisted of an initial prophylactic phase, including oral hygiene instructions, and
extraction of tooth #21, and all necessary actions
would be taken to stabilise periodontal health. Once
stabilised, a second phase would be carried out,
in which orthodontic aligners would be used to correct the midline shift and to redistribute the spaces
for placing an implant at the locus of tooth #21
(Figs. 2a & b).
The last phase would consist of the prosthetic rehabilitation of the maxillary anterior teeth with veneers on
teeth #13 and 23, a cantilever bridge from tooth #12 to
a pontic in the locus of tooth #22 (Figs. 3a & b).
In such a case as this one that combines teeth and
implants in the anterior region, it is important to select
the most suitable restorative material in terms of strength
and aesthetics and to carefully consider the restorative design, obtaining the maximum implant integration
and efficiency.
3a
“With the right materials,
colour deepness and
natural translucency can be
obtained within a space
of about 0.2–0.6 mm.”
Surgical intervention
After orthodontic treatment with aligners, the marked
bone defect caused by a long-evolving infection at
the locus of tooth #21 was regenerated. For this intervention, autologous bone was chosen for the guided
bone regeneration, being considered the gold standard. The split bone block technique, initially described
by Khoury and Hanser, was used.1 This technique
3b
Figs. 3a & b: Digital planning of the prosthetic restoration. Frontal view (a). Left lateral view (b).
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4a
modifications were made that were of great importance. The abutment was customised by undercontouring the subcritical area as much as possible, modifying the margins, especially the mesial
margin, and lengthening the distal area to have sufficient support for the secondary structure to rest on
(Fig. 6b).
4b
5a
5b
Figs. 4a & b: Horizontal ridge augmentation with autologous bone using the
split bone block technique.1 Figs. 5a & b: Guided implant surgery, during (a)
and after (b) surgical procedure.
consists of obtaining a bone graft of the mandibular
ramus that is subsequently divided into two cortical
sheets that are fixed in the defect area by screws, and
then autologous bone scraped from the bone graft is
placed between the two sheets. The intervention is
concluded with a tension-free closure using sutures
(Figs. 4a & b).
Four months after the horizontal ridge augmentation,
the implant was placed in the regenerated area using
guided surgery (Figs. 5a & b). When this area was
exposed, a horizontal gain of bone was found. After
implant placement, the volume of soft tissue was optimised by two connective tissue grafts; one from the
palate and one from the tuberosity region.
Zirconia was chosen for the restoration framework
from tooth #12 to pontic #22. This material allows
under-contouring of the design in the subcritical area
of the emergence profile as much as possible, following
the design of the abutment interface to create a fully
polished, seamless profile and thereby providing a
smooth surface in contact with the mucosa. In the
design, the full volume was kept on the palatal side
to ensure a durable restoration over time and to avoid
chipping due to protrusive or lateral movements.
Coloured zirconia of the same substrate or nuance of
the patient’s base dentine, which was Shade A3, was
used. A micro-reduction of about 0.2–0.3 mm was created at the vestibular side for future microstratification
(Fig. 7). Once sintered, the framework was prepared on
the model and the occlusion verified. It was then ready
for micro-layering.
Characterisation: Internal staining
Restorative design
Nowadays, a wide range of possibilities exist for the
characterisation of ceramic restorations. The combination of GC Initial IQ Lustre Pastes ONE and GC Initial
Spectrum Stains provides the ability to establish all
colour effects, both internally and externally. A great
difference can be seen in comparison with the older
paints and stains, there being much more luminosity
and incredible fluorescence (Fig. 8).
A standard prefabricated abutment that could be
modified by grinding was chosen (Fig. 6a). Small
The internal staining was done with this combination to
intensify some colour details. To mimic the mamelon
6a
6b
Figs. 6a & b: The standard abutment prior to modification (a) and after modification (b).
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|
7
Fig. 7: Digital design of the restoration framework in zirconia.
“A great difference
can be seen in
comparison with the older
paints and stains,
there being much more
luminosity and incredible
fluorescence.”
structure, a combination of SPS-13 (Twilight) and
SPS-16 (Midnight) was used. Next, the incisal halo was
accentuated using a mixture of SPS-1 (Ivory White) and
SPS-2 (Melon Yellow).
Mesial and distal of the incisal edge, L-A (Body A) mixed
with either SPS-2 or SPS-4 (Light Terracotta) was
applied alternately for bright contrast and saturation,
respectively. Further mesially and distally up to the cervical margin, L-6 (Dark Blue) was used. In the middle
and cervical thirds, L-B (Body B) was used to give the
zirconia framework a bit more saturation. Here, SPS-13
was used on either side of the centro-facial lobe to
further accentuate the developmental depressions
towards the cervical aspect.
Layering: Form and texture
Once the Lustre Pastes have been fired in the furnace,
all colours are fixed in place and serve as a connection
layer. Depending on the chosen shade, this can be
done in multiple firings. After the internal characterisation, a texturising ceramic material (GC Initial IQ SQIN)
that was introduced together with Lustre Pastes and
Spectrum Stains as a new innovative concept was used
to add shape, texture and gloss. A great advantage of
this concept is that the same ceramic can serve for different restorative materials, such as zirconia and lithium
disilicate.
The area of the mamelons was layered with Translucent TO (Opal Booster) combined with the enamels
E-57 to E-59. Translucent TO was also used for the
line angles of the teeth. Since the zirconia was pre-
8
Fig. 8: Fluorescence of the GC Initial IQ Lustre Pastes ONE.
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9a
9b
10
11b
11a
Figs. 9a & b: Zirconia framework after adding colour with a mixture of GC Initial IQ Lustre Pastes ONE and GC Initial Spectrum Stains. Frontal view (a).
Close-up (b). Fig. 10: The finished zirconia restoration, characterised with the GC Initial IQ ONE SQIN system. Figs. 11a & b: Lithium disilicate veneers for
teeth #13 and 23, characterised with the GC Initial IQ Lustre Pastes ONE and GC Initial Spectrum Stains from the same GC Initial IQ ONE SQIN system
as was used for the zirconia bridge. On the model (a). Individually (b).
12
13
14
15
Fig. 12: Occlusal view after removal of the provisional screw-retained restoration, showing the gingival architecture obtained. Fig. 13: Frontal view after placement of the restorations. Fig. 14: Transillumination of the restorations. Fig. 15: Frontal view of the final result, showing natural-looking and harmonious dentition.
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|
coloured in the base colour, there was no need to add
dentine ceramic; only a thin enamel layer was applied
(Figs. 9a–10).
The SQIN ceramics are much easier to handle than
conventional ceramics, as the feeling on the brush
is very consistent. Owing to the Form & Texture liquid,
it remains on any surface on which it is placed, and
compared with other ceramics, there is virtually no
shrinkage. In the case of zirconia, the restoration is fired
at a temperature of approximately 760 °C, depending
on the furnace.
In the final phase, lithium disilicate veneers were made
on the canines, combining the Lustre Pastes with the
Spectrum Stains (Figs. 11a & b).
The great advantage of the micro-buccal layering is
that adding texture is much easier than on full-body
lithium disilicate or zirconia, which is more difficult to
manipulate because of its extreme hardness, even
though SQIN is denser than conventional veneering
ceramics. It allows control of the luminosity and
the fluorescence, creating a noticeable difference in
black light or fluorescent light after the surface has
been finished, making it resemble the natural tooth
(Figs. 12–15).
16a
16b
16c
Figs. 16a–c: Adding colour to the gingival area with GC Initial IQ Lustre
Pastes NF GUM shades (a). Adding texture with the GC Initial IQ SQIN GUM
shades (b). The finished gingival area showed a desirable orange peel
effect (c).
Gingiva
The SQIN gingival shades enable the use of ceramics
for atrophied jaw restorations for which pink aesthetics
are needed. Combined with the Lustre Pastes gingival
shades, the main colour is intensified first (Fig. 16a).
This system enables micro-layering with the same
philosophy as for the white aesthetics with different
shades of colour, adding subtle contrasts by employing
differently shaded masses and adding details to the
surface (Fig. 16b), such as an orange peel effect
(Fig. 16c).
Conclusion
The Lustre Pastes characterisation serving as a connection layer, the SQIN ceramics refining the form and
texture, and the Spectrum Stains enabling infinite
shade variations, only a minimal cutback on the vestibular part is needed to control the texture, fluorescence
and transillumination in order to mimic natural teeth.
Following the same concept for pink aesthetics by
employing the gingival shades provides a complete
layering concept.
Reference
1. Khoury F, Hanser T. Three-dimensional vertical alveolar ridge augmentation in the posterior maxilla: a 10-year clinical study. Int J Oral Maxillofac
Implants. 2019 Mar–Apr;34(2):471–480. doi: 10.11607/jomi.6869.
about
Joaquín García Arranz (Quini)
is the founder of the Ortodentis dental
laboratory in Madrid in Spain, director
of the Dental Training Center in Madrid
by Quini and founding partner of the
Fresdental fabrication centre in Alicante
in Spain. He lectures in the master’s
degree programme in implants
at the European University of Madrid
and in the master’s degree programme in prosthetics for dental
technicians at Vericat Formación’s training centre in Madrid.
He is an opinion leader for GC Iberica.
Dr Ramón Asensio Acevedo
holds a DDS from the Alfonso X el
Sabio University in Madrid in Spain and
a master’s degree in aesthetic and
restorative dentistry and a master’s
degree in interdisciplinary aesthetic
rehabilitation, both from the Universitat
Internacional de Catalunya in Barcelona
in Spain. He is in private practice in
Madrid, Barcelona and Toledo in Spain and an assistant professor
in the aesthetic dentistry, endodontics and restorative dentistry
department at the Universitat Internacional de Catalunya.
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Making a permanent difference
with zirconia paediatric crowns
A five-year follow-up
Dr Ana Vînău, Romania
Patricia first came to our clinic with her mother when
she was 7 years old. She was quite shy, and I could tell
that she felt very uncomfortable. Her mother told me that
her daughter had experienced a great deal of dental pain
before at another dental clinic and did not want to endure
a similar experience again.
When examining Patricia, I could see that several of her
teeth were affected by caries. I could see that teeth #75
and 85 were the most affected, showing evidence of
massive dental destruction. I noticed that tooth #85 also
had a vestibular abscess. I was almost certain that we
would need to extract those teeth owing to the extensive
damage. Furthermore, the lesions had already led to
infection.
34
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At the next appointment, I examined the panoramic
radiograph so that I could see all of Patricia’s teeth and
assess the amount of root resorption in order to know
how to treat her teeth. Upon viewing the radiograph, I was
surprised, disappointed and challenged all at the same
time. I saw that the respective permanent teeth were
missing and noted accompanying extensive bone damage
(Figs. 1 & 2). Patricia’s parents were shocked and discouraged when they found out that she had hypodontia
in addition to caries-affected primary second molars.
I knew right away that I needed a second opinion on
this case, so I asked orthodontic specialist Dr Teodorina
Secara for some advice. She advised me to try to keep
the two damaged teeth in Patricia’s mouth if at all pos-
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1
|
2
Fig. 1: Initial situation, panoramic radiograph. Fig. 2: Initial situation, clinical photograph.
sible, given the fact that she already had too much space
between her teeth. The loss of these two primary molars
would disrupt the relationship between the rest of her
teeth and, in the end, impact her entire occlusion.
I took on the task of resolving this case as a personal
challenge. Because the permanent adult teeth were
missing, we could not afford to lose the primary second
molars. I did not know how this case would end up, so
I started by taking it one step at a time. In the beginning,
I treated the root canals of the two damaged and infected teeth with antibiotics and anti-inflammatory medication.
After ten days, I filled the root canals of both teeth using
the standard procedure for permanent teeth. On tooth
#75, I also encountered a furcal perforation, and although
it was very difficult to stop the haemorrhage, we managed eventually to place mineral trioxide aggregate on
the perforation. We filled tooth #75 with EQUIA (GC) and
tooth #85 with GRADIA DIRECT (GC).
Two weeks later, while I was treating the rest of Patricia’s
teeth, I saw through the enamel that tooth #75 had begun
to turn black underneath the EQUIA filling. Also, tooth
#85, owing to the extensive filling and the small amount
of healthy dental structure remaining after removing the
carious tissue, had begun to exhibit fissure lines. It was
just a matter of time until that tooth would break, requiring
an extraction, in spite of all the hard work done to save it.
This was not a scenario I was willing to accept. At that
point, I knew I had to come up with an alternative idea in
order to help retain the primary second molars, and I had
to do it fast.
I knew I had to reinforce these damaged molars if we
wanted to keep them, but what I most wanted for Patricia
was an aesthetic solution for her situation that would
prove durable over time, because these primary molars
would never be replaced by permanent teeth. In addition to being aesthetic, the ideal restoration would need
to be extremely strong, able to withstand all occlusal
forces over a lifetime. At the time, we only had stainlesssteel crowns available in our clinic, but they would
not be an option. I refused to believe that I had reached
the end of the road, so I began doing some research
to find out what aesthetic paediatric options were
available.
I discovered that such a restorative option with all the
characteristics that I had been hoping for did in fact exist.
EZCrowns (Sprig Oral Health Technologies) would satisfy
both the needs of my patient and the desires of her parents. Usually, when you diagnose a young patient with
“I was impressed by the
fact that both crowns looked
so natural that you could
barely notice any difference
between the zirconia crowns
and natural teeth.”
hypodontia and talk to the parents about it, they perceive
the diagnosis as a handicap, or they feel ashamed for
having done something wrong that led to the situation.
Now, however, it was such a joy and a relief to be able to
share the option of using zirconia crowns when faced
with such a difficult circumstance.
After assessing Patricia’s situation, I shared the good
news of my discovery with her parents and proposed
using EZCrowns. They were excited about the fact that
the crowns had the same colour as natural teeth and
gave me permission to proceed. I told Patricia that she
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would perform over time. Would my patient be able to
retain these two crowns over the long term?
3a
3b
3c
3d
Therefore, I monitored the crowns to see how they would
hold up after prolonged use. I saw Patricia regularly for
follow-up examinations and carefully examined her. At the
six-month and 18-month follow-up appointments, I took
photographs and radiographs of her teeth (Figs. 3a–d).
They still looked impeccable. Her permanent first molars
had erupted in their right places. I could not detect any
wear of the opposing teeth, and the crown margins were
subgingivally placed, revealing healthy surrounding tissue. The radiographs showed that the bone had remineralised and healed.
Figs. 3a–d: Eighteen-month post-op clinical photographs (a & d) and
radiographs (b & c).
would no longer feel any pain. She was excited to learn
that instead of two damaged teeth, she would be getting
two beautiful pearl-like teeth.
Anticipating the treatment, I was nervous because this
would be the first time I had ever used zirconia crowns.
However, I managed to seat both crowns in the same
session. In the end, Patricia was extremely excited with
the result. During the entire process of discovering zirconia crowns and preparing for the treatment, I found the
Sprig team to be most helpful and responsive in communicating with me.
I now feel confident recommending zirconia crowns to
parents, and these crowns enable me to honour the trust
which parents have placed in me by providing the best
available solution when treating special dental conditions
such as hypodontia. By incorporating all the benefits of
zirconia crowns into your practice, you too will increase
your chance of success. Above all, you will have the professional satisfaction of knowing that you can overcome
even the most difficult situation.
At Patricia’s two-week check-up, I was surprised to see
how beautifully the gingival margin had healed and to discover that the crown contour was nearly perfect. I was
impressed by the fact that both crowns looked so natural
that you could barely notice any difference between the
zirconia crowns and Patricia’s natural teeth. I was thrilled
with the result and so were her parents, but what I most
anxiously wanted to see was how well these crowns
Every time, a patient revisits our clinic for a check-up
appointment after a long absence, I feel a sense of excitement. I am eager to check each patient’s dental status
to see how the treatment plan we adopted has impacted
his or her quality of life. Now, almost five years later, our
choice to use zirconia crowns has been rewarded, and
Patricia’s teeth continue to look astonishingly natural
(Figs. 4–6). Based on the latest radiographs taken during
4
5
Figs. 4–6: Five-year follow-up clinical photographs.
36
In summary, Patricia uses her new crowns as if they are
her natural ones. After we placed the zirconia crowns,
Patricia began taking personal responsibility for and paying more attention to proper dental hygiene. She now enjoys coming to her appointments because she knows we
will take photographs every time. I think zirconia crowns
are a necessity in this kind of situation with missing
permanent teeth.
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7
Fig. 7: Five-year follow-up panoramic radiograph.
a recent follow-up examination (Fig. 7), I can confirm that
the final results continue to look amazing, despite the
rough start. Patricia, who is almost 12 years old now, is
no longer shy, and I can tell by the brightness of her smile
that she is full of confidence. Since her initial visit, she has
developed into a young girl with abundant enthusiasm
and is not the timid child who first stepped into our office
(Fig. 8).
As the pièce de resistance of the treatment, the EZCrowns
have literally demonstrated their quality. Although both
primary second molars were treated endodontically as
if they were permanent teeth and the mesial root of
tooth #85 shows evidence of resorption, Patricia has experienced no clinical symptoms.
The contour of the gingival margin is still placed at a physiologically appropriate height. Compared with Patricia’s
natural teeth, there are only insignificant signs of gingival
inflammation, likely due to her still superficial personal
dental hygiene habits.
One of my greatest concerns when I initially placed
Patricia’s zirconia crowns was how they would hold up
over the long term. Would they be abrasive and damage
the opposing natural teeth? Although zirconia crowns are
glazed and smoothly polished, they still have a harder
surface than natural teeth do. However, to my surprise,
every time Patricia arrived for a clinical examination, I was
unable to observe any notable pathological sign of dental
abrasion on her opposing teeth.
Today, Patricia has no difficulties with her mastication
or occlusion. Furthermore, and most importantly, she
enjoys the amazing aesthetics of a beautiful smile. She
has excellent oral health, and when I talk to her, I sense
her feeling of well-being at having a beautifully restored
smile. Although both molars had a guarded prognosis,
five years later, we are still pleased with the results of her
zirconia restorations.
8
Fig. 8: Happy patient with her dentist.
about
Dr Ana Vînău received her dental
degree from the “Victor Babeș”
University of Medicine and Pharmacy
in Timișoara in Romania and holds
a master’s degree in periodontics.
She is also currently studying for
another master’s degree in orthodontics.
She works as a paediatric dentist at the
DENT ESTET 4 KIDS clinic in Timișoara.
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Laser protocol for peri-implantitis
treatment
An interview with Dr Michał Nawrocki
By Dental Tribune International
insufficient for me, and to be honest my knowledge of
lasers, physics, indications and procedures was incomplete at the time. Then in January 2016, I invited Dr Ilay
Maden to my clinic to conduct a course and teach my
colleagues and me about various Er:YAG and Nd:YAG
procedures with the LightWalker laser. A few months
later, I decided to extend my knowledge about lasers by
attending the Master of Science in Lasers in Dentistry
presented by Prof. Norbert Gutknecht in Aachen. Now,
I cannot imagine continuing my daily practice and treatments without having LightWalker. Sometimes, I use it
as an additional tool during certain procedures, but very
often it’s a crucial and necessary tool for me to use to
conduct a particular procedure.
What procedures do you perform with laser?
Laser can be used in all fields of dentistry; however,
I am mainly focused on implantology and surgery, as well
as prosthodontics. In prosthodontics, it can be used for
sulcus conditioning, preparation for veneers and removal
of complete ceramic crowns, as well as during more challenging procedures like crown lengthening before tooth
preparation. We can use it in gingivectomy (Nd:YAG laser)
and bone recontouring (Er:YAG laser).
Dr Michał Nawrocki
Laser is becoming essential for every modern dental
practice. Moreover, from an educational standpoint,
there are many benefits in terms of the personal and professional development of the practitioner. In this interview, Dr Michał Nawrocki explains how laser dentistry
has helped to advance his practice and career and why
dental laser, and Fotona’s LightWalker in particular, has
become an essential part of his daily practice.
Dr Nawrocki, you have been using laser technology
since 2016. Looking back at your journey as a laser
dentist, how has LightWalker impacted your everyday practice?
I started my great adventure with Fotona’s LightWalker
in 2016. Before that I had used a diode laser, but it was
38
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All my surgery cases are finished with photo-biomodulation
using the Nd:YAG Genova handpiece. I have observed
that wound healing is much faster and better in such
cases owing to pain reduction, disinfection, reduction of
oedema and the laser’s analgesic function. Sometimes,
I have to conduct an endodontic treatment during the
procedure (which is quite rare and normally done by my
colleagues), in which case I really appreciate the deep
disinfection with Nd:YAG, which offers the highest bacterial reduction in comparison with other wavelengths,
and the Er:YAG SWEEPS (shock wave-enhanced emission
photoacoustic streaming) procedure, which provides the
most effective cleaning and disinfection. With surgical
treatments, I use both wavelengths in almost all cases.
Even when performing an easy and fast tooth extraction,
I can use Er:YAG for granulation tissue removal, followed
by Nd:YAG for disinfection, clot stabilisation and finally
photo-biomodulation. Of course, I use laser before implant insertion, as well as when complications appear.
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user report
One of your main fields of specialisation is implantology. Where does the laser fit in this field?
We can use LightWalker for all implantology cases. Sometimes, it’s only needed for better and faster wound healing
(photo-biomodulation with the Nd:YAG laser), but very often
it is necessary to conduct the treatment. For me, it’s the
most important device during immediate implantation with
immediate loading, especially when the bone must be very
precisely cleaned of granulation soft tissue and disinfected.
In the meantime, we can also provoke bleeding of the bone
using the Er:YAG laser for superficial bone ablation. I also
really appreciate the use of laser during bone grafting with
the Khoury method. Sometimes, I combine this technique
with immediate implantation, especially in the aesthetic
zone. Then, after bone shield fixation, I can use the laser for
bone recontouring. With the Er:YAG laser, it’s done very
precisely—I remove sharp edges and create an emergence
profile for the crown—and most importantly, everything is
safe for the shield (almost no vibration, so we don’t lose
stability) and the implant (no thermal effect).
Of course, we can also use the Er:YAG laser for more
common and “easy” procedures—like implant uncovering
(Er:YAG). The healing is faster and we avoid suturing, but of
course, even with the thin chisel tip, some amount of soft
tissue is vapourised—so it cannot be conducted in all cases.
In 2018, you defended your master’s thesis at RWTH
Aachen University titled Comparison of Two Methods of
Periimplantitis Treatment with the Use of Nd:YAG and
Er:YAG Laser. Can you tell us more about that research?
Owing to the increasing number of implants being placed,
the development of peri-implantitis is a growing concern
and one of the primary challenges in present-day dentistry.
In cases of inflammation, it is necessary to implement
treatment, or risk implant loss. However, until now, no
uniform protocol or procedure has been defined which
could be considered the best and the most effective
solution. Different methods of treatment of tissue inflammation around the implant are used, depending on the
extent of inflammation, method availability, type of defect,
and skills and experience of the dental surgeon.
We know that laser can be used for the treatment of
inflammation in soft and hard tissue around implants,
such as mucositis and peri-implantitis. I wanted to investigate what kind of procedure would be the most effective
and minimally invasive—so the question was whether we
could use a minimally invasive, flapless procedure for
proper treatment and solve the problem of inflammation.
“I really appreciate the deep
disinfection with Nd:YAG,
which offers the highest
bacterial reduction [...]”
The procedures were conducted with Er:YAG and Nd:YAG
lasers. In the first group of patients, a mucoperiosteal flap
was elevated in order to gain better access to the operative
area, while the second group of patients was treated using a
more minimally invasive procedure without the flap method.
The assessment of treatment effectiveness involved clinical
and radiographic examination before the surgical procedures
and three months after the laser procedures. After conducting the intra-oral examination and defining plaque, probing
depth and bleeding on probing indices, photographic documentation of a given area was performed, bitewing and
occlusal surface radiographs were taken, and professional
scaling and root planing were subsequently carried out.
Based on my research, we know that non-surgical treatment
of peri-implantitis is effective and very often reduces inflammation. Of course, when we have severe defects, it’s impossible
to avoid a surgical procedure to elevate a flap to get proper
access to the defect. In such cases too, we should use a nonsurgical procedure as a first step to decrease the inflammation
and, after two to three weeks, perform the flap procedure.
Can you describe your standard laser protocol for
peri-implantitis treatment?
Firstly, we have to distinguish mucositis from peri-implantitis
with a radiovisiograph and with the use of a periodontal
probe. If possible, I remove the prosthetic restoration to get
better access for the treatment. In our surgical protocol,
we have five steps: (1) removal of granulation tissue with the
use of the Er:YAG laser (cylindrical tip); (2) decontamination
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© AlanVec/Shutterstock.com
In your opinion, what are the main benefits of choosing a laser system that includes two complementary
wavelengths, such as Er:YAG and Nd:YAG, especially
in the field of oral surgery?
Very often, we combine these two wavelengths to conduct
treatment in a fast, safe and predictable way. For me, it’s
crucial to use these two complementary wavelengths—
the interaction between the tissue and laser beam is quite
different, and owing to these differences in absorption,
transmission and scattering, we obtain different actions.
For example, during root apicectomy, after flap elevation,
I remove granulation soft tissue with the Er:YAG laser using
the H14 handpiece with a cylindrical tip (or when I want to
be more precise—a Varian tip) and the apicectomy is done
with the H02 non-contact handpiece. As the next step,
I conduct deep disinfection with the Nd:YAG laser (transmission in hydroxyapatite and absorption in pigmented
bacteria) before bone augmentation. Finally, I finish the
treatment with photo-biomodulation using the Nd:YAG laser.
As you can see from this example, I need both of these
two complementary wavelengths to achieve final success
with fast healing and proper bone regeneration.
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1
2
4
3
5
6
7
Fig. 1: Initial situation. Fig. 2: Pocket depth measurements. Fig. 3: Bleeding on probing. Figs. 4 & 5: Use of the Er:YAG laser Varian tip for granulation tissue
removal, implant surface decontamination and surface ablation of infected bone. Fig. 6: Photo-biomodulation with the Nd:YAG laser. Fig. 7: Final results
after three months. No sign of inflammation.
of the implant surface with Er:YAG; (3) surface ablation of
infected bone with Er:YAG; (4) reduction of bacteria in the
bone with the Nd:YAG laser; and (5) photo-biomodulation
with the Nd:YAG laser (after flap closure).
In our non-surgical procedure, there are only four steps—I skip
deep disinfection with the Nd:YAG laser owing to the 1,064 nm
wavelength’s high absorption in titanium (it’s not possible
without elevating a flap to disinfect only the bone and not
harm the implant surface). As I mentioned, the flapless procedure is most often my first option, and when the defect is
severe, I decide on a surgical procedure as the second stage.
After the procedure, the same restoration is generally
placed in the mouth (after corrections if necessary). Some-
8
9
10
11
times, depending on the type of bone defect, I decide to
conduct bone regeneration with the use of bone substitute
and collagen membranes. In such cases, I have to remove
the restoration and, after peri-implantitis treatment with the
use of laser and bone augmentation, close the flap with
cover screws, leaving the patient with no restoration (posteriorly), not even a temporary one, for two to three months.
What are the benefits of LightWalker for the treatment
of peri-implantitis in your everyday practice?
As I mentioned, the treatment of peri-implantitis is a huge
challenge nowadays; statistically, in 20% of cases periimplantitis develops and in 40% of cases mucositis develops
around inserted implants. Treatment with the use of Er:YAG
and Nd:YAG lasers is very effective, fast and comfortable
12
Fig. 8: Initial situation. Fig. 9: Granulation tissue visible after flap elevation. Fig. 10: Granulation tissue removal with Er:YAG laser. Fig. 11: Bone augmentation.
Fig. 12: Final results with restoration two years post-op.
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user report
13
15
|
14
18
19
16
17
20
Fig. 13: Initial situation. Visible fistula one year after loading. Fig. 14: Bone defect of 9.27 mm in diameter. Fig. 15: Flap elevation. Fig. 16: Granulation tissue
removal with Er:YAG. Fig. 17: Implant resection. Fig. 18: CBCT scan on the day of surgery. No bone augmentation. Fig. 19: CBCT scan 1.5 years post-op.
Visible bone regeneration. Fig. 20: Situation 1.5 years post-op. No sign of inflammation.
for both patients and practitioners. We can use a minimally
invasive, non-surgical treatment, which very often is highly
effective, and thus avoid a surgical procedure. However,
it’s very important that we use our lasers with proper parameters to protect the soft and hard tissue and not alter
the implant surface. We can thoroughly remove bacterial
biofilm from the implant surface without altering it, and
we have the possibility of re-osseointegration. Of course,
we have to be aware of risk factors and aim to avoid them,
understand what the reason for the disease was and solve
the underlying problem. Sometimes, it’s only improper oral
hygiene, while other times, we must change or correct
the restoration. Each case is individually treated.
Could you share with us some of your more challenging cases of peri-implantitis and explain how the
treatment was performed?
Case 1 was a patient who presented with deep pockets
(9 mm), bleeding on probing and visible purulent effusion
(Figs. 1–7) and was treated with a non-surgical protocol.
In Case 2, the patient preferred a surgical procedure with
bone augmentation, as a consequence of bone graft
complication and graft exposure (Figs. 8–12).
The implant apicectomy in Case 3 shows that one year
after the immediate implantation with immediate loading
there was inflammation around the implant apex. The rest
was properly integrated (Figs. 13–20).
What advice would you give to your dental colleagues
who may be considering whether to incorporate laser
technology into their practice?
I can only advise them to use laser; there is no reason to
hesitate. Laser technology really changes dental practice.
Laser use provides new possibilities, new treatment
protocols and many advantages in dental procedures.
Our treatments are more comfortable, less painful (sometimes even painless) and very often less invasive and
more predictable. We have a great advantage of selective
tissue removal based on the chosen laser wavelength
and settings. Last but not least, it is better for our marketing, and patients now expect newer technologies.
Editorial note: A shortened version of this interview was
published in implants—international magazine of oral
implantology, vol. 23, issue 1/2022.
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| user report
Restorative aesthetics at the gingiva
Drs George Freedman & Paiman Lalla, Canada & Trinidad and Tobago
1
2
Fig. 1: Normal-length maxillary central incisors—expected appearance. Fig. 2: Maxillary incisors with apparent length increased by 30%—very unnatural and unaesthetic.
Aesthetic dilemma of the gingival margin
The data is clear: porcelain and composite resin are both
biocompatible at the gingival margin and well tolerated.1–3
The caveat is that composite tends to cause tissue irritation if it directly impinges on the gingiva.4–6 This ultimately
causes unesthetic gingival recession. Porcelain is less
problematic, but marginal plaque build-up, initiated by the
thin layer of resin cement, leads to a similar irritation of the
free gingiva and eventually recession.7, 8
Even skilful subgingival margin placement will typically,
within three to five years, because of ageing, gingival irritation or lack of home maintenance on the patient’s part,
lead to unesthetic recession and full visible exposure of the
darker dentinal tissue.9, 10 Thus, the restorative conclusion
is location of the composite margins supragingivally,3, 11
placing the resin material a reasonable distance (0.25–0.50 mm)
from soft periodontal structures and thereby unlikely to
cause tissue irritation.
Today’s adhesives and restorative materials make this a
rather straightforward task.12–19 Newer-generation adhesives
bond equally well, and predictably, to both enamel and dentine.14, 15 Significantly, seventh- and eighth-generation adhesives have similar bonding strengths to both enamel and
dentine, eliminating the potential stresses caused by unequal
polymerisation contraction.17–19 It is clinically possible to create a continuous restoration through the dentino-enamel
junction (DEJ), covering as much of the enamel and the
dentine as necessitated by caries or abfraction (or both).
A significant aesthetic predicament quickly presents, however. Dental restorative materials are designed to match the
shade of the enamel position of the tooth. Although some
manufacturers offer dentine shades, these hues typically
do not closely match the darker coloration of exposed dentine, particularly those observed in endodontically treated
teeth. A typical central incisor measures approximately
10.5 mm cervico-incisally.20 A substantial increase in the
apparent length of a tooth, specifically in the anterior labial
region, detracts from the aesthetic smile.
3
Fig. 3: Beautifil II Gingiva shades. (Image: © SHOFU)
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When restoring a tooth with Class V caries or abfraction, or
perhaps a small gingival recession, an enamel-coloured
resin is commonly placed at the labial DEJ. Increasing the
maxillary central incisor’s vertical aspect (Fig. 1) by a mere
3 mm adds 30% to the apparent vertical dimension, significantly altering the cervico-incisal–mesiodistal ratio, totally
upsetting the aesthetic parameters of the smile (Fig. 2).
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4
Fig. 4: The five shades of Beautifil II Gingiva. (Image: © SHOFU)
Solving the gingival aesthetic dilemma
In situations where there is moderate recession, the visual
imbalance is even further impaired. The impact of the cervico-incisal–mesiodistal ratio is even greater on maxillary
lateral incisors and mandibular incisors (average of 9 mm
cervico-incisally). Maxillary and mandibular canines (average of 10–11 mm cervico-incisally) are often the teeth most
affected by gingival recession and are highly visible, both
anteriorly and laterally.
Beautifil II Gingiva (SHOFU) has been specifically designed for
the rebalancing of pink aesthetics in the cervical areas of the
dentition (Fig. 3). It is indicated for wedge-shaped defects,
cervical caries, the aesthetic rectification of gingival recession, shielding exposed cervical areas and splinting of
mobile teeth. The resin material is available in five tones
(Dark Pink, Light Pink, Brown, Orange and Violet; Fig. 4), which
can be layered and/or blended to achieve custom shades
that allow the treatment of patients with various hues of gingival pigmentation, according to their clinical needs (Fig. 5).
Individuals who have gingival recession, abfraction and/or
caries tend to look older than they really are (long in the
tooth). Covering the darker root dentine with an enamel-like
resin simply makes their teeth more visible, seemingly longer,
and correspondingly less aesthetic.
Beautifil II is a highly aesthetic, fluoride-releasing composite
resin material indicated for all classes of restorations. Numerous studies over the past 20 years have shown no secondary
caries, no failures, no postoperative sensitivity and a high retention of both shade matching and surface lustre. The material
is based on SHOFU’s proprietary giomer technology. The significant advantage of the giomer class of resins is not only that
they release fluoride to protect the tooth at the restorative margin,
but that their fluoride content can be recharged by toothpastes, fluoride rinses and varnishes (Fig. 6). Thus, a giomer’s
fluoride-releasing capacity does not decrease over time.
The practitioner must solve this problem practically, aesthetically and with minimum invasiveness. The restoration
must be functional, replacing missing dental structures
to natural dimensions and contours. The restoration should
replace lost enamel with enamel-shaded composite resin
and receded gingiva with gingiva-shaded composite resin.
By creating an artificial enamel–gingiva junction in composite restorative material, the patient’s aesthetics and
smile can be restored.
5
6
Fig. 5: Mixing chart showing the resins layered and/or blended to achieve custom gingival shades (1:1 mixing ratio). (Image: © SHOFU) Fig. 6: Fluoride release and recharge from giomers.
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Fig. 7: Maxillary left lateral incisor with caries and recession (photograph taken using the EyeSpecial, SHOFU). Fig. 8: BeautiBond seventh-generation dental adhesive.
(Image: © SHOFU) Fig. 9: Maxillary left lateral incisor with mesial restoration and gingival restorative rectification (photograph taken using the EyeSpecial, SHOFU).
Another important consideration is that the gingival margin
of the restorative material (whether pink or enamel in
colour) must be kept supragingival and slightly away from
the free gingival margin.3, 4, 6 Although a very narrow band
of darker root structure may be visible towards the apex,
the restoration’s enamel (coronal) and pink gingival (radicular) coloration will focus attention away from this area.
With gingivally blended restorations, the dental professional can deliver both aesthetic and supragingival margins within the same restoration. A supragingival margin
facilitates ready access and effective home maintenance
for the patient.
Clinical cases
Visible recession and caries
Remarkably, the patient’s chief concern was the gingival recession on the maxillary left lateral incisor, not the mesial caries
(Fig. 7). Fortunately, the patient’s oral hygiene was relatively
good, and restoring the MLB caries was straightforward using
BeautiBond (SHOFU; Fig. 8) and Beautifil Flow Plus X. The steps for
the aesthetic rectification of the buccal recession are as follows:
It is imperative that a restoration that is so close to the free
gingival margin be placed under conditions controlling
moisture and bleeding. Dental dam placement is impractical (the target area is positioned apically), and retraction
cord may physically or chemically compromise the working
area. Ideally, the patient’s oral hygiene would have created
a healthy gingival microenvironment with minimal pocketing and no bleeding on probing. In most cases, however,
the practitioner must modify the actual situation to increase
the likelihood of clinical success. The easiest and best
technique for predictable tissue sculpting is the use of the
diode laser.21–23 Utilising low power (1.0–1.5 W), the dentist
can produce an ideal —dry, clean and blood-free —working
area in less than a minute.
1. Gently micro-abrade the receded area and the apical
enamel to remove food debris and plaque. The nozzle of
the abrader should be angled incisally to prevent gingival irritation and bleeding. Rinse thoroughly and lightly
air-dry, leaving the surface slightly moist (although the
degree of moistness is not critical).
2. Apply BeautiBond, a seventh-generation dental adhesive, and leave on for 10 seconds. Thoroughly air-dry
the adhesive (very critical). Light-polymerise with the
FUSION 5 curing light (DentLight), offering deep polymerisation of composite resins within 3 seconds with a
uniform 4,000 mW/cm2 output.
3. Select the appropriate Beautifil II Gingiva shade (Light Pink
and Violet for this patient), apply to the receded area to restore the buccal dimension and contour of the original soft
tissue, and light-polymerise. It is important to leave a small
(0.25–0.50 mm) gap between the apical margin of the
10
11
Fig. 10: Mandibular anterior teeth with labial gingival recession. Fig. 11: Mandibular anterior teeth close-up. (Photographs taken using the EyeSpecial, SHOFU).
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restoration and the free gingival margin (Fig. 9). This space
prevents gingival irritation, is easily maintainable by the patient
and is generally not visible even with close-up photographs.
Mandibular anterior recession
This is the most commonly encountered recession in the
oral cavity. The mandibular anterior teeth are small, close
together and not effectively cleaned at the tongue and the
lower lip (Fig. 10). Owing to gravity, food debris and plaque
tend to accumulate labially and interproximally (Fig. 11). In
this case, the major culprit of the recession was the frenum
pulling the attached gingiva apically. The preliminary process is a diode laser frenectomy to eliminate the muscular
forces.21–23 The steps for the aesthetic rectification of the
buccal recession are as follows:
1. Gently micro-abrade, in an incisal direction, the receded
areas and the enamel nearest to the DEJ to remove food
debris and plaque. Rinse thoroughly and lightly air-dry,
leaving the surface slightly moist.
2. Apply BeautiBond and leave on for 10 seconds. Thoroughly air-dry the adhesive and light-polymerise.
3. Select the appropriate Beautifil II Gingiva shade (Light
Pink in this case), apply to the receded area to restore
the buccal dimension and contour of the original soft tissue, and light-polymerise. Leave a small (0.25–0.50 mm)
gap between the apical margin of the restoration and
the free gingival margin (Fig. 12). This procedure restores
the expected gingival height and contributes to making
the patient’s smile look younger.
Long-term at-home maintenance is best accomplished
with procedures that are familiar to the patient and easy to
implement. Regular toothbrushing is effective and practised by most dental patients, interdental string flossing
less so. Though the advantages of flossing are well established, patient resistance to the process and irregular application limit its benefits. Water flossing (Waterpik) not only
facilitates the interdental cleaning process, but has been
shown to improve the results.24 There are several models
available, but the Sonic-Fusion offers simultaneous water
flossing and sonic toothbrushing.
Conclusion
Beautifil II Gingiva enables the practitioner to overcome the
gingival aesthetic dilemma. The gingival rectification technique is predictable and can typically be accomplished without the need for local anaesthetic and without discomfort
to the patient. These restorations are completely functional
and replace both hard and soft missing dental structures to
natural dimensions and contours with minimum invasiveness.
The restoration of the coronal anatomy with tooth-coloured
composite resins is well established. The development of an
artificial enamel–gingiva junction and the reconfiguration of
missing gingival structures with composite resins is a novel
solution that restores the patient’s smile and facial aesthetics.
12
Fig. 12: Mandibular anterior teeth with gingival restorative rectification
(photograph taken using the EyeSpecial, SHOFU).
about
Dr George Freedman maintains
a private practice in Toronto
in Canada limited to aesthetic dentistry.
He is adjunct professor of dental
medicine at Western University
of Health Sciences in Pomona in
California in the US and a visiting
professor and director of the MClinDent
programme in restorative and cosmetic
dentistry at BPP University in London in the UK.
He is the author or co-author of 14 textbooks,
and of more than 800 dental articles and numerous webinars.
He serves on the editorial team of REALITY and is the
international editor-in-chief of 3D printing—international
magazine of dental printing technology. Dr Freedman
is a regent and fellow of the International Academy for
Dental-Facial Esthetics and a diplomate and chair of the
American Board of Aesthetic Dentistry. He is a founder and
past president of the American Academy of Cosmetic Dentistry
and a founder of the Canadian Academy for Esthetic Dentistry
and the International Academy for Dental-Facial Esthetics.
Dr Freedman is a recipient of the Smigel Prize in Aesthetic
Dentistry (New York University College of Dentistry).
Dr Paiman Lalla, a graduate of the
University of the West Indies, practises
dentistry in Trinidad and Tobago and
has a special focus on cosmetic and
implant dentistry. After completing
the Advanced Education in
General Dentistry program at
Lutheran Medical Center in
Wheat Ridge in Colorado in the US,
he was awarded fellowships in the International Congress of
Oral Implantologists and the American Academy of Implant
Prosthodontics. Dr Lalla serves on the medical panel of Trinidad
and Tobago’s ministry of national security.
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| manufacturer news
The world’s first thermo-viscous restorative material
VisCalor—now available for all cavity classes
The world’s first thermo-viscous composite, VisCalor, now comes
in a bulk fill variant. While VisCalor bulk is indicated for simple and
quick posterior restorations, the VisCalor universal variant is indicated for all cavity classes and makes highly aesthetic anterior
restorations possible, thanks to its large range of VITA shades,
including a new translucent shade.
areas that are difficult to reach, as well as bubble-free application,
which contributes to the durability of the restoration. The longevity
and stability of the material are the result of its excellent physical
properties. With a filler content of 83.0% by weight and very low
shrinkage of only 1.4% by volume, VisCalor is in a class of its own
among composite materials.
Both products are based on unique thermo-viscous technology.
VisCalor reaches a low viscosity through extra-oral heating, allowing for an application that resembles that which you are used to
with flowable materials. The material flows optimally on to cavity
walls and undercut regions. It then cools down to body temperature quickly, becomes highly viscous and can be modelled like a
classic packable composite without any delay. Uniting two different viscosities in one product guarantees fast and easy handling,
since the separate steps of placing lining and covering layers
are no longer required. In addition, VisCalor is compatible with
all conventional bonding agents. Thus, VisCalor offers not just a
high-quality and aesthetic restoration, but also an economical
alternative to conventional composites.
The Caps Warmer is ideally suited for heating VisCalor and allows
for up to four caps to be heated at the same time. This is especially
advantageous when working with multiple increments or also with
multiple shades.
VisCalor single-dose caps have particularly long and slender
cannulas, allowing direct application, even in narrow cavities and
46
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Thanks to its unique technology, VisCalor creates the ideal preconditions for excellent handling, simple application, and high-quality
and long-lasting restorations of highly aesthetic appearance—
for all cavity classes.
www.voco.dental/en/home.aspx
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| meetings
International events
Envista Summit
EMEA 2022
19th ESCD Annual Meeting
7–10 September 2022
Vienna, Austria
www.envistaco.com/en
13–15 October 2022
Rome, Italy
https://escdonline.eu
AAID Annual Conference 2022
12th World Congress
of Esthetic Dentistry—
IFED 2022
21–24 September 2022
Dallas, USA
www.aaid.com
27–29 October 2022
Abu Dhabi, UAE
https://ifed2022.com
EAO 2022
Annual Congress
ADF 2022
29 September–1 October 2022
Geneva, Switzerland
https://congress.eao.org/en
22–26 November 2022
Paris, France
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48
cosmetic
dentistry
1 2022
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[49] =>
|
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submission guidelines
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Please note that all the textual components of your submission must be combined into one MS Word document.
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Questions?
Magda Wojtkiewicz
(Managing Editor)
m.wojtkiewicz@dental-tribune.com
cosmetic
dentistry
1 2022
49
[50] =>
| about the publisher
Imprint
Publisher and Chief Executive Officer
Torsten R. Oemus
t.oemus@dental-tribune.com
International Administration
International Headquarters
Chief Financial Officer
Dan Wunderlich
Dental Tribune International GmbH
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www.dental-tribune.com
Editor-in-Chief
Dr Sushil Koirala
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Claudia Duschek
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Copyright Regulations
All rights reserved. © 2022 Dental Tribune International GmbH. Reproduction in any manner in any language, in whole or in part, without the prior written permission of Dental Tribune International GmbH
is expressly prohibited.
Dental Tribune International GmbH makes every effort to report clinical information and manufacturers’ product news accurately but cannot assume responsibility for the validity of product claims or for
typographical errors. The publisher also does not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect
those of Dental Tribune International GmbH.
50
cosmetic
dentistry
1 2022
[51] =>
[52] =>
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/ An interview with Dr Sumita Mitra: “Everyone has the power to become an innovator”
/ Direct restoration procedures simplified: Transforming dentistry with groundbreaking technologies by Kuraray Noritake Dental
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/ Rethinking bonding in the adhesive dentistry era: Think universal by Dr Dimitrios Spagopoulos
/ New philosophies in ceramic layering by Joaquín García Arranz (Quini) & Dr Ramón Asensio Acevedo
/ Making a permanent difference with zirconia paediatric crowns; A five-year follow-up by Dr Ana Vînău
/ An interview with Dr Michał Nawrocki: Laser protocol for peri-implantitis treatment
/ Restorative aesthetics at the gingiva by Drs George Freedman & Paiman Lalla
/ The world’s first thermo-viscous restorative material: VisCalor—now available for all cavity classes
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