cosmetic dentistry international No. 1, 2011

cosmetic dentistry international No. 1, 2011

Cover / Editorial / Content / Reattachment and build-up of fractured maxillary central incisors / Laser-assisted cosmetic dentistry—A case report / Integration of aesthetics and function with composite resins / Restoring missing mandibular incisors with implants—What makes you hesitate? / An interview with Dr José Roberto Moura - IFED President / An interview with Olaf Sauerbier - CEO of VOCO GmbH / The Inman Aligner—Alignment - bleaching - bonding: A progressive approach to smile design (Part II) / CLEARFIL SA CEMENT—Easy to remove - hard to forget! / Aesthetic restoration created with composite / Class II fillings in everyday clinical work / Lithium disilicate meets zirconium oxide / International Events / Submission Guidelines / Imprint

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issn 1616-7390

Vol. 5 • Issue 1/2011

cosmetic
dentistry
_ beauty & science

1

2011

| clinical technique
Reattachment and build-up of
fractured maxillary central incisors

| case report
Laser-assisted cosmetic dentistry

| industry report
CLEARFIL SA CEMENT—
Easy to remove, hard to forget!

[2] =>

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...Delive r
like a flow

Beautifil flow Plus
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is an injectable hybrid aesthetic restorative that exhibits superior strength, durability
and aesthetics for enhanced applications in direct cosmetic dentistry.

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...

• Ideal density and stackability for effortless sculpting
• Remarkable mechanical properties
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• Extensive application capabilities including load-bearing surfaces
• Simulates life-like aesthetics with excellent shade match
• Benefits of fluoride with anti-plaque effect

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Tel: 65-6377 2722 Fax: 65-6377 1121 eMail: mailbx@shofu.com.sg www.shofu.com.sg

[3] =>

editorial _ cosmetic dentistry

Dear Reader,
_Welcome to this year’s first edition of cosmetic dentistry!
As we all know, the American Dental Association (ADA) has played an important role in
dentistry not only in America, but also worldwide. On 13 October 2010, Dr Raymond Gist was
installed as the 147th President of the ADA. Dr Gist made ADA history as the first AfricanAmerican President to serve in this role. In a recent interview, Dr Gist stated: “I am looking forward to continuing to create a history that will be embraced […] I see nothing but positives
for the future of dentistry.”

Dr So-Ran Kwon
Co-Editor-in-Chief

Likewise, I see many positives for the future of aesthetic/cosmetic dentistry. For the past
two decades, aesthetic dentistry has been well led by the International Federation of Esthetic
Dentistry (IFED). IFED’s ultimate purpose has been to contribute to the progress and development of worldwide aesthetics and oral health and to enhance communication between all
member academies. Amongst IFED members are the Asian Academy of Aesthetic Dentistry,
Japan Academy of Esthetic Dentistry, Korean Academy of Esthetic Dentistry, Taiwan Academy
of Aesthetic Dentistry, and Indian Academy of Aesthetic and Cosmetic Dentistry. Personally,
I hope more Asia-Pacific countries such as China, Singapore, Thailand, Nepal, Sri Lanka, Australia and New Zealand will join the Federation to contribute to dentistry and enhance
communication worldwide.
In February, Dr Dan Nathanson (USA) passed the IFED Presidency to Dr José Moura (Brazil)
with a new executive committee of nine members. Amongst the current executive committee members, Dr Akira Senda (Japan) and Dr Sushil Koirala (Nepal) will be representing Asia.
I am sure that this edition of cosmetic dentistry will meet your expectations in seeking
critical clinical tips to improve on your everyday clinical work especially in the area of bonding in the aesthetic zone. Please send your invaluable feedback and participate in improving
our journal’s quality to the highest level of excellence.
Yours faithfully,

Dr So-Ran Kwon
Co-Editor-in-Chief
President, Korean Bleaching Society
Seoul, Korea

cosmetic
dentistry 1
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_ 2011

[4] =>

I content _ cosmetic dentistry

page 6

I editorial
03

page 14

I MICD

Dear Reader

30

| Dr So-Ran Kwon, Co-Editor-in-Chief

Reattachment and build-up of fractured
maxillary central incisors

I industry report

| Dr Irfan Ahmad

36

Laser-assisted cosmetic dentistry—A case report

42

Aesthetic restoration created with composite
| Dr Anna Salat Vendrell

| Dr Hugh Flax

18

CLEARFIL SA CEMENT—
Easy to remove, hard to forget!
| Dr Jürgen Garlichs

I case report
14

The Inman Aligner—Alignment, bleaching,
bonding: A progressive approach
to smile design (Part II)
| Dr Tif Qureshi

I clinical technique
06

page 18

Integration of aesthetics and function
with composite resins

44

Class II fillings in everyday clinical work
| Dr Sylvain Mareschi

| Dr Rony Hidalgo Lostaunau et al.

20

Restoring missing mandibular incisors
with implants—What makes you hesitate?

I industry news
46

| Dr Chonghwa Kim & Sangwoo Lee

I feature
26
28

Lithium disilicate meets zirconium oxide
| Ivoclar Vivadent

I meetings

An interview with Dr José Roberto Moura,
IFED President

48

An interview with Olaf Sauerbier,
CEO of VOCO GmbH

I about the publisher

page 36

04 I cosmetic
dentistry

1_ 2011

International Events

cosmetic
issn 1616-7390

Vol. 5 • Issue 1/2011

dentistry _ beauty & science
1

2011

| clinical technique

49
50

| submission guidelines
| imprint

page 42

Reattachment and build-up of
fractured maxillary central incisors

| case report
Laser-assisted cosmetic dentistry

| industry report
CLEARFIL SA CEMENT—
Easy to remove, hard to forget!

Cover image courtesy of
Kuraray Europe GmbH,
www.kuraray-dental.eu.

page 44

[5] =>

[6] =>

I clinical technique _ fractured maxillary central incisors

Reattachment and build-up
of fractured maxillary
central incisors
Author_ Dr Irfan Ahmad, UK

Fig. 1

Fig. 2
Fig. 1_Dento-facial view, showing
immediate treatment of the two
maxillary central incisors,
following a sporting accident.
Fig. 2_Pre-op status, showing
extensive plaque deposits, acute
gingivitis, reattachment of the coronal
fragment on the right central incisor
and a defective composite build-up
on the left central incisor.
Fig. 3_Incisal pre-op view, showing
the reattached right fragment
on the right central incisor and
an over-contoured composite
build-up on the left central incisor.
Fig. 4_Peri-apical radiograph,
showing large defects between the
composite resin fillings and remaining
tooth substrate, with large pulp
chambers and immature, open apices.
Figs. 5–7_Post-scaling and polishing,
showing improvement of gingival

Fig. 5

Fig. 3

_Acute dental trauma of anterior teeth is
a common occurrence in children under the age
of 12. The most frequently fractured teeth are
the maxillary incisors, involving solely enamel,
enamel and dentine or, in extreme cases, pulpal
exposure, very often without root fractures.
Unlike the relatively slow tooth loss due to dental caries or tooth wear, acute dental trauma is
an immediate, often painful loss of natural tooth
substrate. Furthermore, involvement of the pulp
complicates initial and long-term treatment,
placing the affected teeth in jeopardy and requiring periodic monitoring.
The sequential treatment strategy for acute
dental trauma is restoring health (H), followed
by function (F) and lastly, achieving acceptable
aesthetics (A; the HFA triad). Contemporary dental composites and direct adhesive techniques
allow replication of the tooth morphology, as
well as optical (colour, translucency, opalescence, fluorescence) and mechanical properties.

Fig. 6

06 I

cosmetic
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Fig. 4

The advantage of a direct approach is that it
is minimally invasive, not requiring additional
removal of tooth substrate; however, it is technique sensitive, requiring patience and meticulous execution.

_Clinical case
A ten-year-old boy was involved in a sporting
accident that resulted in acute dental trauma
to the maxillary central incisors. The fractured
fragment of the left central incisor was lost,
while that on the right central incisor was located. The patient was treated at the accident
and emergency department of a local hospital,
where tetanus inoculation was verified and
composite resin used to reattach the right central incisor fragment and to build-up the left
central incisor (Figs. 1–3).
The patient presented to my practice a few
weeks later, complaining of poor aesthetics and

Fig. 7

[7] =>

clinical technique _ fractured maxillary central incisors

Fig. 9

Fig. 8

a dull ache in the buccal sulcus above the left
central incisor. Intra-oral examination revealed
poor contours of the composite fillings, with
incorrect colour and texture. In addition, the
patient’s oral hygiene was unsatisfactory, with
extensive plaque and calculus deposits causing
acute gingivitis. The left central incisor was sensitive to gentle percussion, as well as to hot and
cold stimuli.
Radiographs showed substantial defects between the composite filling and remaining tooth
substrate, allowing ingress of oral pathogens
(Fig. 4). The periodontal ligament was intact, no
root fractures were evident and a typical solid
cortical bone appearance, consistent with an
acute dental trauma, was apparent.

_Initial therapy
Before considering definitive treatment, the
initial items requiring attention are the periodontal and endodontic status. Assessing the
endodontic condition following acute trauma is
essential for treatment planning. Following an
accident, the patient is distressed, anxious and
mentally traumatised. In addition, the shock of
the physical trauma often results in a transient
anaesthesia or paraesthesia of the pulpal neural
fibres.
For these reasons, assessing pulp vitality
with thermal or electrical stimuli, which are
highly subjective, yields unreliable results. In addition, a false-negative result is often obtained
with traumatised teeth owing to the transient

Fig. 11

paraesthesia of nerve fibres. Conversely, a falsepositive result is elicited when necrosis of the
pulpal vascular tissues has occurred, leaving
vital nerve fibres, which are more resilient.
This may delay diagnosis and treatment of the
affected tooth, often leading to root absorption.
A reliable and objective method for determining pulp vitality is pulse oximetry. Pulse
oximetry measures the blood oxygen saturation levels or circulation within the pulp. The
pulse oximeter consists of light-emitting diodes
(LED) of two wavelengths (red light – 640 nm
and infrared light – 940 nm) and a receptor
for recording the spectral absorbance of the
oxygenated and deoxygenated haemoglobin
in the tooth pulp. A computer calculates the
percentage of oxygen saturation levels, which is
approximately 75 to 80 % for vital teeth, compared to values at the fingers or ear lobes of
98 %. The tooth oxygen saturation levels are
lower than soft tissues of the body owing to the
dentine and enamel, which scatters the LEDlight.
A reading of 78 % was obtained for this patient, indicating that there was adequate vascularity for eventual regeneration of the pulp.
At this stage, root-canal therapy was not necessary.
In order to resolve the acute gingivitis, the
teeth were scaled and polished, and the patient
counselled about home oral-hygiene procedures. Impressions for the diagnostic wax-up
were delayed until gingival health had improved.

Fig. 10
health and detachment of the
defective composite build-up on the
left central incisor. Notice the clearly
visible dentine mamelons and incisal
edge lobes of the reattached
fragment on the right central incisor.
Fig. 8_Dento-facial view with
VITA Classic shade guide.
Fig. 9_Dento-facial view with
VITA 3D Shade Guide.
Fig. 10_Photograph of patient before
the sporting injury. Notice the blatant
maxillary midline diastema.

Fig. 11_A large overjet of 7 mm,
making the maxillary incisors
vulnerable to external trauma.
Fig. 12_Facial view of pre-op
plaster model.
Fig. 13_Incisal view of pre-op
plaster model.

Fig. 12

Fig. 13

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I clinical technique _ fractured maxillary central incisors

Fig. 14

Fig. 15
Fig. 14_Facial view of
diagnostic wax-up.
Fig. 15_Right lateral view of
diagnostic wax-up.
Fig. 16_Left lateral view of
diagnostic wax-up.

Fig. 17_Incisal view of
diagnostic wax-up.
Fig. 18_Facial view of diagnostic
wax-up with silicone index in situ.
Fig. 19_Facial view of diagnostic
wax-up and palatal aspect of silicone
index, showing the palatal anatomy
with incisal ledge to support the
intra-oral composite build-up.

Fig. 17

_Diagnostic wax-up and silicone index
At the next appointment the following week,
the gingivitis had resolved but the composite
build-up on the left central incisor had detached
from the remaining tooth substrate (Figs. 5–7).
In order to prevent sensitivity and bacterial invasion, the exposed dentine on the left central
incisor was etched with 37 % phosphoric acid for
20 seconds and immediately sealed with a dentine-bonding agent (OptiBond Solo Plus, Kerr).
The gingival condition had improved following prophylaxis and oral-hygiene instruction,
and upper and lower impressions were taken
using an accurate, soft, distortion-free material
(AlgiNot FS, Kerr). Concurrently, reference photographs were taken with VITA Classic and
VITA 3D Shade Guides (VITA) for shade analysis
(Figs. 8 & 9).
The impressions were cast with hard plaster
for the diagnostic wax-up. The patient was asked
to supply photographs of his teeth prior to the
accident (Fig. 10), which are an invaluable guide
for assessing tooth anatomy and for guiding the
dental technician during the wax-up process.
The patient displayed a large overjet of 7 mm,
which obviously places the central incisors in
a precarious situation, highly susceptible to
traumatic injury (Fig. 11).
In the dental laboratory, the preoperative
models of the fractured incisors were waxed-up
to the proposed facial and palatal morphology
(Figs. 12–17). An index was fabricated, using
a heavy body, addition silicone impression ma-

Fig. 18

08 I cosmetic
dentistry

1_ 2011

Fig. 16

terial and sectioned at the incisal edge, ensuring
that a ledge was present at the incisal edge
to support the intra-oral composite build-up
(Figs. 18 & 19).

_Composite build-up on the left central
incisor
Choice of composite
The two basic criteria for selecting an appropriate composite filling material are satisfaction
of function (resilience, mechanical and thermal
properties) and aesthetics (replicating enamel,
dentine and characteristics such as translucency, opalescence and fluorescence). In this
instance, the new Herculite XRV Ultra (Kerr)
was chosen for its superior mechanical and optical properties. Herculite XRV Ultra is a nanohybrid composite, updated from its predecessor
Herculite XRV, which was introduced over two
decades ago.
The endearing feature of nano-composites
is the very small particle size of the filer, 25 to
75 nm smaller than in micro-hybrids. The reduced
filler size particles confers superior aesthetics
by allowing excellent surface gloss after polishing, as well as advantageous optical properties,
such as opalescence and fluorescence. In addition, Herculite XRV Ultra offers favourable
wear resistance, compressive strength, fracture
toughness and flexural strength with good
adaptability, sculptability and thixotropic properties. Furthermore, it is available in a large
range of enamel, dentine and incisal shades for

Fig. 19

[9] =>

clinical technique _ fractured maxillary central incisors

Fig. 20

incremental layering or stratification placement.
The latter techniques are commonly utilised to
reduce polymerisation stresses by lowering the
C-factor and for emulating the shade nuances
and characterisations within natural teeth, for
example incisal halos, mamelons and translucencies.
Clinical technique
After two weeks, the symptoms associated
with the left central incisor had subsided (that is,
sensitivity and buccal tenderness), and no response was elicited with gentle percussion.
In addition to the preoperative colour analysis with shade tabs carried out earlier, small
beads of Herculite XRV Ultra shades Incisal,
Enamel A1, and Dentine A2 were directly placed
on the tooth and light-cured to ensure a precise
shade match (Fig. 20). This method allows a direct comparison of set composite on the natural
tooth substrate and is an excellent method for
selecting the correct enamel and dentine shades
of composite. Next, the silicone index was placed
against the teeth to confirm correct location and
exact seating (Fig. 21).
Isolation is essential for composite resin fillings to accomplish a moisture-free environment. Various methods are available, including
gingival retraction cords, cotton wool rolls,
aspiration and a rubber dam. Several techniques
are advocated for rubber dam use, including
complete isolation of individual teeth (Fig. 22)
and the split-dam technique for isolating a

Fig. 23

Fig. 21

number of teeth (Fig. 23). However, when building-up anterior teeth, for which aesthetics is
of paramount concern, using a rubber dam can
be disadvantageous owing to excessive dehydration of teeth, making accurate shade assessment challenging. Therefore, for this patient,
a dry retraction cord was carefully eased into
the gingival sulcus to absorb the crevicular
fluid, together with cotton wool rolls in the sulci
and continuous aspiration to maintain a dry
field. This protocol prevented desiccation of
the teeth, allowing a precise shade assessment
during the layering placement of the composite
build-up.
After composite shade selection, silicone index verification and tooth isolation, the tooth
was prepared for resin build-up. The reattached
fragment on the right central incisor was left untouched and served as a guide to mimic shape,
colour and characterisations of the build-up on
the left central incisor (Fig. 20). Several designs
are suggested for preparing the tooth substrate,
including no preparation, simple chamfer or
the stair-step chamfer. In this instance, a simple
1 mm chamber was created on the buccal and
lingual surfaces using a tapered round-ended
diamond bur (Fig. 24). The prepared tooth was
etched with phosphoric acid and dried (not
desiccated), and OptiBond Solo Plus was applied
according to the manufacturer’s instructions
(Figs. 25 & 26). The stages for the layered composite build-up are as follows:
_Step 1: Using the CompoRoller (KerrHawe SA),
a thin layer (1 to 1.5 mm) of Herculite XRV Ultra

Fig. 22
Fig. 20_Beads of different shades
of Herculite XRV Ultra (Kerr) placed
and set directly onto the left central
incisor (from left: Incisal, Enamel A1,
Dentine A2 shades).
Fig. 21_Silicone index placed
onto placed surfaces of incisors
to ensure correct seating.
Fig. 22_Complete isolation of each
tooth with a rubber dam.

Fig. 23_Split-dam technique used to
isolate the anterior maxillary sextant.
Fig. 24_A 1 mm chamfer being
prepared around the circumference
edge of the fracture. Notice the
visible gingival retraction cord on
the mesial aspect.
Fig. 25_Enchant is applied for
20 seconds using the total etch
technique.

Fig. 24

Fig. 25

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I clinical technique _ fractured maxillary central incisors

Fig. 26

Fig. 27
Fig. 26_Dentine bonding agent is
applied on all surfaces and light-cured.
Figs. 27 & 28_The CompoRoller
(KerrHawe) is used to form a thin
layer (1 to 1.5 mm thick) of incisal
shade to place into the silicone index,
which is used as a template to guide
placement of the palatal incisal layer
and ensure the correct length
of the tooth.

Fig. 29_Silicone index removed,
showing the initial build-up layer.
Fig. 30_A thin layer of dentine shade
is placed at the mesial, incisal
and distal edges to simulate
an incisal halo.
Fig. 31_A rounded conical-shaped
hand instrument is used to create
dentine mamelons.

Fig. 29

Incisal shade was rolled out (Fig. 27) and placed
into index to build-up the palatal aspect and incisal edge, and subsequently light-cured with
the index in situ (Fig. 28).
_Step 2: The index was removed and the palatal
incisal layer inspected to ensure that it was not
too thick and that sufficient space was available for the remaining layers (Fig. 29), and subsequently light-cured from the palatal aspect.
_Step 3: A thin layer of Herculite XRV Ultra Dentine A1 was placed at the incisal edge, mesial
and distal aspects to re-create the incisal halo
effect (Fig. 30).
_Step 4: Using a suitably shaped instrument,
Dentine A2 shade was used to copy the
mamelon effect of the reattached fragment on
the right central incisor (Fig. 31).
_Step 5: CompoRoller tips of various shapes,
for example conical and cylindrical, were used
to sculpt the Enamel A1 covering layer (Figs.
32–34).
_Step 6: The reconstruction was completed with
a thin covering layer (0.5 mm) of Incisal shade
at the incisal third of the build-up (Fig. 35).
The final contouring and finishing were postponed for one week. This allows re-evaluation
of the shade and characterisations by both
the patient and clinician. Necessary changes
were performed before proceeding with the
finishing and polishing. Composite layering is
a lengthy and painstaking process, requiring
meticulous attention by the operator and protracted endurance by the patient. Both these
factors contribute to tiredness and loss of
concentration, and finishing and polishing after

Fig. 30

10 I cosmetic
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1_ 2011

Fig. 28

a long treatment session is inadvisable. The
shade and characterisation of the build-up a
week later was satisfactory, ready for adjusting morphology and finalising surface texture
(Figs. 36 & 37).

_Reattachment of fractured tooth
segment
The reattachment of fractured segments is a
conservative approach to restoring health, function and aesthetics. It is particularly advantageous for aesthetic appearance, since the natural tooth fragment is used to restore the original
morphology and colour. However, if the remaining tooth substrate has discoloured owing to
breakdown of the pulpal blood vessels, there
may be a colour transition between the tooth
and the reattached fragment. Depending on the
amount of remaining tooth, this is usually not
a concern, since the cervical aspects of teeth are
darker than the incisal aspects.
Clinical technique
The procedure for reattaching a fragment is
similar to a free-hand composite build-up but
with the following differences. Firstly, the colour
transition of the sandwiched composite between the remaining tooth and reattached fragment should be a seamless. Secondly, to improve
the fracture strength of the repaired complex
(remaining tooth/composite/fragment), it is advisable to re-hydrate the fragment for at least
30 minutes prior to bonding with the resin composite. The sequence was as follows:

Fig. 31

[11] =>

clinical technique _ fractured maxillary central incisors

Fig. 32

_Step 1: The fractured fragment was carefully
removed without damaging the remaining
tooth or the fragment (Fig. 38) and hydrated in
sterile water for 30 minutes.
_Step 2: The silicone index was placed onto the
teeth and aided the correct location of the
dislodged fragment (Fig. 39).
_Step 3: The retraction cord was placed around
the right central incisor, and both the remaining tooth and fragment were etched and
coated with OptiBond Solo Plus. A thin layer of
Herculite XRV Ultra Incisal shade was placed
into the index to ‘link’ the tooth and fragment
and subsequently light-cured. The index was
removed, and the position of the fragment
verified from both facial and palatal aspects
(Figs. 40 & 41).
_Step 4: The chasm between the tooth and fragment was filled with a combination of Dentine
A2 and Enamel A2 shades to create an unnoticeable colour transition (Figs. 42 & 43).

_Finishing and polishing
The final stage of a composite filling is finishing and polishing, which ensures longevity and
superior aesthetics. The finishing procedure,
which ensures a high gloss and smooth surface
roughness (Ra), is important not only to prevent
surface discolouration, but also to ensure oral
health by reducing plaque accumulation and
gingival irritation. Furthermore, polishing is also
beneficial for achieving good marginal adaptation, reduced micro-leakage and for retaining
morphology and occlusal contacts owing to
improved wear resistance. The type of inorganic

Fig. 35

Fig. 33

filler, particle size and the degree of loading
influence the polishability of a composite. Furthermore, the difference in hardness between
the resin matrix and filler content and amount
of conversion of the polymer also contribute to
the degree of surface roughness.
Other factors affecting the finish are the
flexibility and hardness of the finishing materials, force applied, speed and cooling of rotary instruments, and duration of the polishing
procedure. However, contemporary light-cured
composites with finer particles (for example,
nano-filled) and fine grit rotary instruments
allow a durable, smooth and high lustre texture
to be readily attainable.
Although using cellulose acetate matrices or
Mylar strips mitigates the finishing procedures,
most free-hand composite build-ups usually require finishing and polishing to remove excess
composite and alter morphology and occlusion.
In addition, the superficial oxygen inhibition
layer requires removal to improve the surface
hardness of the composite for resilience and improved aesthetics. But how smooth is smooth?
The degree of micromorphology irregularities to
which a filling should be finished is debatable.
Some authorities suggest that the microscopic
surface irregularities should be smaller than
the critical bacterial adhesion threshold of Ra =
0.2 µm, while others state that it should equal
the Ra of natural enamel-to-enamel occluding
surfaces. Another threshold for smoothness is
that in order for a filling surface to appear
smooth optically, its Ra value should be less than

Fig. 34
Fig. 32_The CompoRoller with
a conical tip is used to sculpt
the surface anatomy.
Fig. 33_The CompoRoller with
a cylindrical tip is used to sculpt
the surface anatomy.
Fig. 34_The dentine mamelon effect
created by using a dentine shade is
clearly visible at the mesial aspect
before being covered with an enamel
shade overlay.

Fig. 35_The completed reconstruction
with a thin overlying incisal shade
at the incisal third of the build-up.
Fig. 36_A week later, the colour of
the build-up on the left central incisor
is acceptable and ready for finishing
and polishing.
Fig. 37_Incisal view of the build-up
on the left central incisor, one week
later. (The cervical gingival margin
of the left central incisor shows
a trapped cornhusk, which was
subsequently removed.)

Fig. 36

Fig. 37

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I clinical technique _ fractured maxillary central incisors

Fig. 38

Fig. 39
Fig. 38_Removal of the fractured
segment on the right central incisor.
Fig. 39_After re-hydration, the
fragment is correctly located in
position with the silicone index.
Fig. 40_Facial view of the fragment
secured to the existing tooth with
Herculite XRV Ultra Incisal shade.

Fig. 41_Incisal view of the fragment
secured to the existing tooth with
Herculite XRV Ultra Incisal shade.
Fig. 42_Facial view of reattached
fragment with remaining tooth
substrate. Observe the seamless
colour transition.
Fig. 43_Incisal view of reattached
fragment with remaining tooth
substrate. Observe that the cornhusk
at the cervical gingival margin of the
left central incisor has been removed
(compare with Fig. 37).

Fig. 41

1 µm, which is similar to natural enamel surface
roughness of Ra 0.3 µm to 0.5 µm.
Many methods have been advocated for
finishing and polishing composite restorations,
including multi-fluted (16 to 30) tungsten carbide burs, fine grit (<25 µm) diamond burs,
aluminium oxide (Al2O3) coated abrasive discs,
silicone and rubber points, felt discs with diamond paste, and unfilled resins to coat the
surface layer of the restoration. The type of
polishing system depends on the type of composite, the degree of contouring required for
aesthetics and occlusion, and the operator’s experience and familiarity with a specific finishing
system.
Generally, micro-filled and nano-filled composites can be polished to a very high gross
finish compared to hybrid and condensable varieties. If the contours of the restoration require
extensive alteration, a diamond bur is preferable
(rather than a fluted carbide) followed by silicone tips, discs and polishing pastes. Conversely,
if the morphology and surface topography require little modification, the ideal starting point
is with fluted carbide burs, followed by silicone
tips, discs and polishing pastes. Also, condensable composites may require more abrasive
instruments compared to micro-filled or nanofilled composites.
Clinical technique
The polishing system used for this case study
was the Hawe Composite Surface Treatment Kit

Fig. 42

12 I cosmetic
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1_ 2011

Fig. 40

(KerrHawe SA) consisting of OptiDisc, Al2O3coated inter-proximal strips (Fig. 44), fluted
finishing burs, HiLuster tips, and brushes for
diamond polishing paste. The sequence was as
follows:
_Step 1: All rotary instruments were copiously
irrigated with water at a speed not exceeding
50,000 min–1 and gingival retraction cord was
placed around the teeth to prevent laceration
of the soft tissues. Excess composite was removed and the anatomy refined with OptiDisc,
starting with the black centre super coarse
disc and ending with the blue centre coarse/
medium disc. The discs were also used to create
the incisal lobes of the build-up on the left
central incisor, guided by the incisal lobes of
the reattached fragment on the right central
incisor.
_Step 2: The facial and palatal topography (undulations) was formed with the fluted finishing
burs and polished with the HiLuster tips.
_Step 3: Inter-proximal composite excess and
overhangs were smoothed with Al2O3-coated
inter-proximal strips of varying coarseness.
_Step 4: The restoration was polished with diamond paste for a high gloss and lustre.
The finished and polished restoration demonstrates correct anatomical form; seamless
colour transition between the composite buildup/reattached fragment and the remaining
tooth structure; incisal lobes on the left central
incisor, mimicking those of the incisal edge of
the right central incisor; and correct lustre and
texture (Fig. 45). The patient was supplied with

Fig. 43

[13] =>

clinical technique _ fractured maxillary central incisors

Fig. 44

a mouth guard and advised to attend for periodic
review appointments, or earlier, if endodontic
symptoms developed. In addition, oral-hygiene
procedures were re-enforced.

Fig. 45

Fig. 46

than many indirect approaches that remove
additional tooth substrate, which further compromises the damaged tooth. The free-hand
build-up, guided by a silicone index, is conservative and minimally invasive, but requires

Fig. 44_OptiDiscs of varying
coarseness with an inter-proximal strip.
Fig. 45_The finished and polished
restorations, showing correct
anatomy and surface texture,

_Post-operative results
Figures 46 to 48 demonstrate the post-operative results at two weeks. Observe the impeccable gingival health; correct anatomical form
of the composite build-up on the left central
incisor; a seamless transition between the composite and natural tooth substrate; dentine
mamelons in the coronal build-up on the left
central incisor and an incisal halo, opalescence,
incisal edge translucency within the build-up on
the left central incisor, mimicking the reattached
natural tooth fragment on the right central incisor.
It is important to note that the composite
build-up on the left central incisor is similar but
not identical to the right central incisor. It is clinically difficult to produce a facsimile by direct
free-hand composite build-up, and it is unusual
to find identical teeth in any one individual dentition, and slavishly copying an existing tooth
appears contrived and artificial, which is rarely
observed in nature. Nature is creative, rather
than perfect. Finally, any artificial prostheses or
restoration should broadly conform to the existing dentition by blending with the surrounding
teeth.
The full-face images show restitution of
dental aesthetics that are in harmony with the
surrounding lips (Figs. 49 & 50).

_Conclusion
Acute dental trauma is distressing for the patient and challenging for the clinician. Following
initial emergency treatment to alleviate pain and
sepsis, the goal is salvaging as much natural
tooth as possible. The restoration of health,
function and aesthetics is achievable with direct
composite restorations and is less destructive

Fig. 47

Fig. 48

Fig. 49

a degree of patience and expertise of the operator, and endurance of lengthy appointments by
the patient. Salvaged and usable fragments of
fractured teeth are ideal for reconstructing teeth
to their former morphology and aesthetics._

_contact
Dr Irfan Ahmad
The Ridgeway Dental Surgery
173 The Ridgeway
North Harrow
Middlesex, HA2 7DF
UK

cosmetic
dentistry

Fig. 50
as well as seamless transition
between the remaining tooth and
composite fillings.
Fig. 46_Post-op facial view
(compare with Figs. 2 & 5).
Fig. 47_Post-op incisal view
(compare with Figs. 3 & 7).
Fig. 48_Post-op dento-facial view
(compare with Fig. 1).
Fig. 49_Pre-op full-face view.
Fig. 50_Post-op full-face view.

iahmadbds@aol.com
www.irfanahmadtrds.co.uk

cosmetic
dentistry 1
I 13
_ 2011

[14] =>

I case report _ dental lasers

Laser-assisted cosmetic
dentistry—A case report
Author_ Dr Hugh Flax, USA
_As aesthetics are absolutely critical to a patient’s external appearance and inner emotions,
orchestrating a bio-aesthetic result is mandatory.
Too often, this is complicated when aesthetic desires
infringe on the health of the periodontal complex.
This is often true when biologic width violations
have occurred iatrogenically.
Many factors may contribute to these failures;
the two main culprits are intra-crevicular margin
location and over-contoured restorations. Not only
is plaque accumulation problematic, but the supracrestal fibres also become interrupted, causing the
tissues to become further inflamed and aesthetically unmanageable. Kois’ landmark study defined
the total dento-gingival complex (DGC) as clinically
predictable at 3 mm on the direct facial aspect and
at 3 to 5 mm inter-proximally when measured from
the free gingival margin to the osseous crest.

Fig. 1
Fig. 1_Visualising the entire
oral-facial composition helps to
diagnose less harmonious
features of the smile.
Fig. 2_Close-up photography
is essential to planning
periodontal-restorative care.
Fig. 3_A mounted diagnostic
wax-up is a critical guide for
planning a realistic result.
Fig. 4_Outlining the desired gingival
margins prior to anaesthesia
communicates a blueprint to the
patient and restorative team.

Fig. 2

It is critical anteriorly that the gingival margin
mimics the osseous scallop while maintaining the
DGC.1 Further complicating these complex situations is the degree of inflammation in the soft tissue, affecting the clinical development of health
and aesthetic symmetry.

dentistry

1_ 2011

Fortunately, dental lasers have evolved considerably as an adjunctive and alternative treatment to
safely, conservatively and reliably decrease bacterial
levels and improve the hard and soft-tissue contours. Studies of Er:YSGG lasers by Rizoiu and others
have shown that thermal coagulative results and
bony ablation characteristics are similar to those
resulting from use of a dental bur.2 From a patientfriendly standpoint, less need for suturing and
shorter healing times improve case acceptance for
doing ideal dentistry. In selected cases, such as the
one presented in this article, minimally invasive laser
procedures, with precise restorative planning and
technique, can satisfy aesthetic and functional parameters. Furthermore, patients can enjoy optimal
results more comfortably and within a shorter time.
For this case, a conservative strategy was devised
that would allow us to correct the problems and
causes by completing multiple task simultaneously.

_An ideal result

_Case presentation

Often, the patient is frustrated with his/her previous poor cosmetic results. However, to improve
the periodontal framework in order to create an
ideal result, they must be referred to yet another
doctor. Even more challenging is the extended

A 38-year-old female patient presented for correction of what she termed her “tilted smile” (Fig. 1).
Given that she was starting a new sales career, she
also wanted to make her teeth brighter and her smile
much broader. The patient shared her frustration

Fig. 3

14 I cosmetic

healing time created by reflective mucoperiosteal
surgery. This not only affects the chronology of final
restorative care, but also delays the patient’s ultimate satisfaction and happiness for a minimum
of two to three months.

Fig. 4

[15] =>

case report _ dental lasers

Fig. 5

about previous dental consultations that had focused solely on orthodontic or surgical solutions
without considering a more practical approach that
would suit her busy lifestyle.
Her smile analysis established a collapse of the
bicuspids in the buccal corridor. Furthermore, the
axial inclinations, irregular gingival margins and
incisal edges created a downward tilt to the patient’s
right owing to tooth positioning. Close-up imaging
demonstrated healthy gingival tissues, as well as a
right central incisor weakened by a large composite
(Fig. 2).

_Findings
A full clinical examination with radiographs and
mounted models revealed the following:
_biomechanically, the majority of her teeth remained strong despite previous dental care;
_periodontally, soft and hard tissues were healthy;
_occlusally, load testing was normal (after muscle
relaxation) and there was obvious CR-CO anteriorvertical slide due to premature contact at tooth
#30;
_aesthetically, the width-to-length ratio of the
upper centrals was 1:2, far from the ideal range of
0.75:1.0, and tooth shade was VITA A2.

Fig. 6

vative strategy was devised that would allow us to
correct the problems and causes by conducting
multiple tasks simultaneously:
_muscle and bite therapy with a Tanner appliance,
followed by careful equilibration aided by the
T-scan (Tekscan System);
_3-D wax-up on a Stratos articulator (Ivoclar Vivadent; Fig. 3);
_home bleaching of the lower teeth with Opalescence 15 % (Ultradent);
_‘closed flap’ periodontal modification with the
Waterlase Er,Cr:YSGG (Biolase), while the first
three items were being accomplished (the combination of these four steps was a tremendous time
saver and allowed us to monitor progress carefully
on a weekly basis); and
_definitive restorative care with porcelain veneers
and a crown on tooth #8.

Fig. 8

Fig. 7
Fig. 5_A stick-bite helps to verify
that incisal and gingival planes
will be parallel.
Fig. 6_The tissues are treated
atraumatically with the Waterlase.
Fig. 7_Using the black mark as
a reference following the gingival
scallop, a very tight up-and-down
movement is performed to modify
the bone.

_Treatment
For the initial closed periodontal lift, the Er,Cr:YSGG
laser was used in three modes (gingival sculpting,
osseous recontouring, and bio-stimulation). Prior
to anaesthesia, the desired framework was planned
and outlined using a fine marker (Fig. 4). Furthermore, a stick-bite was used, not only to establish
an ideal incisal plane, but also to align the gingival
margins properly (Fig. 5).

_Treatment plan
Given the patient’s previous history and her
desire for minimally invasive dental care, a conser-

With the settings at 2.0 W, 20 pulses per second,
20 % air and 20 % water, a G-6 tip (600 µm in
diameter) was used to shape the labial gingival

Fig. 8_A curette helps clean and
smooth the sulcus of any debris.
Fig. 9_A ‘laser bandage’ is placed
along the treated area to improve
the healing time and decrease
the patient’s discomfort. Note
the immediate improvement
of the geometric progression of
gingival embrasures.
Fig. 10_Detailed information helps
the laboratory to translate clinical
results to the porcelain restorations.

Fig. 9

Fig. 10

cosmetic
dentistry 1
I 15
_ 2011

[16] =>

I case report _ dental lasers
region. No tissue necrosis or significant
bleeding occurred as a result of using the
laser’s relatively lower settings. All areas
were ‘sounded’ using a periodontal probe
(Fig. 6).

Fig. 11
Fig. 11_The great improvement
in aesthetics boosted the patient’s
self-confidence and pride in
her dental hygiene.
Fig. 12_Ideal proportions and
emergence profiles will create
long-term healthy tissues
and bio-aesthetics.

At the facial margins, osseous sculpting
required great precision in order to maintain a 3 mm DGC. A specially tapered T-4
tip (400 µm in diameter) was used at a
25 % higher wattage of 2.5 W. Prior to
usage, the tip was measured and marked
to 3 mm in order to maintain controlled
adjustments within the gingival sulcus
during periodontal probing movement of
the tip (Fig. 7). The resection was smoothed
with a 7/8 curette (Fig. 8). Using low-level
laser therapy at a setting of 0.25 W, a
decrease in the release of inflammatory
histamine and increased fibroblasts for
junctional epithelial growth was achieved
by ‘frosting’ the outer epithelium and injection sites (Fig. 9). The patient was placed
on a vigorous home-care regimen (Oxygel,
Oxyfresh) and closely monitored for a month, while
occlusal therapy and bleaching procedures were
performed.
Four weeks after surgery, the tissues had healed
and restorative care could be initiated. The patient’s
teeth were prepared for veneers and a crown with
mild soft-tissue reshaping in order to make adjustments to our previous treatment. After taking
impressions and bite registrations, prototype provisionals (Luxatemp Plus, Zenith DMG) were fabricated using the ‘shrink-wrap’ technique. The patient
was sent home with the same home-care regimen
as mentioned previously and instructed to ‘testdrive’ her new smile for aesthetics and function.
She returned in a week for the prototype’s occlusion,
colour and morphology to be perfected. Photographs and models were sent to the laboratory,
providing a final blueprint for the porcelain restorations (Fig. 10).

_Satisfied patient
Four weeks later, the provisionals and cement
were carefully removed from the teeth. All restorations were tried in individually and as a group to
verify fit and aesthetics. After the patient’s enthusiastic approval, the porcelain was bonded using the
two-by-two technique and isolation. Margins were
smoothed and polished and occlusion balanced
with the T-scan. A protective night-time appliance
was created to bring longevity to the rehabilitation.
Our very satisfied patient said that we had exceeded
her expectations (Figs. 11 & 12).

16 I cosmetic
dentistry

1_ 2011

A hard- or soft-tissue laser is a wonderful adjunctive tool for cosmetic and restorative dentistry.
The case discussed here demonstrates that this
type of laser technology gives dentists the ability
to make significant hard- and soft-tissue changes
while being minimally invasive. These changes not
only improve the final aesthetic outcome of the
case, but also provide the physiological functional
parameters required for successful dentistry.

Fig. 12

_Acknowledgments
I would like to thank my office team and laboratory technician, Mr Wayne Payne (Payne Dental Lab),
for continually enhancing the lives of many patients
such as the one presented here. I am also thankful
to my family, who allow me to contribute to the
education of other dentists and their teams._
Editorial note: This article is reprinted with permission
from the Journal of Cosmetic Dentistry, © 2010 American
Academy of Cosmetic Dentistry (Tel.: +1 608 222 8583;
Fax: +1 608 222 9540; www.aacd.com). All rights reserved.
A list of references is available from the publisher.

_about the author

cosmetic
dentistry

Dr Hugh Flax has been an
Accredited Member of the
American Academy of Cosmetic
Dentistry (AACD) since 1997.
He served as Co-chair of the
AACD’s Conference Advisory
Committee for the 2003 and
2008 Annual Scientific Sessions.
He served on the AACD Board of Directors, serves on
the editorial board of the Journal of Cosmetic Dentistry
and chair the AACD’s Disaster Relief Fund in 2005 and
2006. Dr Flax is also a member of the American Dental
Association, Academy of General Dentistry, Academy of
Laser Dentistry, L.D. Pankey Alumni Association and Pierre
Fauchard Academy. He is a Fellow of the International
Academy for Dental Facial Esthetics. Dr Flax practises
full time in Atlanta, USA, focusing on functional and
aesthetic conditions and advanced laser dentistry.

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[18] =>

I case report _ aesthetics & function

Integration of aesthetics and
function with composite resins
Authors_ Dr Rony Hidalgo Lostaunau & Rafael Barrantes Alarcon, Peru

Fig. 1

Fig. 2

_Careful integration of the different dental
specialties is the basis of modern dentistry, especially when the treatment goal is an aesthetic
and functional oral rehabilitation of the patient.1,2
Today, aesthetic oral rehabilitation integrates three
basic concepts—bio-compatibility, mechanics and, of
course, beauty—in order to preserve the anatomical
structures of the stomatognathic system and to fulfil functional purposes. At the same time, utmost
attention is paid to achieving aesthetic goals in accordance with the current trends in aesthetic dentistry and thus fulfilling the patients’ expectations.3
With comprehensive oral rehabilitation as our
main goal, utilisation of the different areas in
dentistry becomes extremely important in order to
establish a precise diagnosis, treatment plan and
finally treatment. Orthodontics, for example, has
clearly defined objectives, such as the establishment of a functional occlusion, the preservation of
periodontal health and the achievement of a stable
result within the boundaries given by physiology
and dentofacial harmony.4,5 When the case is pre-

Fig. 4

Fig. 5

18 I cosmetic
dentistry

1_ 2011

Fig. 3

sented to the patient prior to any intervention, individual limitations of that particular case must be
considered in order to avoid unreal expectations. The
patient needs to have a clear idea of the treatment
plan, realistic expectations with regard to the final
result, and previous and posterior dental needs. Therefore, meticulous examination and good communication with the patient are of utmost importance.4,5
There are a number of different cases in which
the combination of orthodontics and restorative
dentistry is advisable, such as Bolton’s and vertical discrepancies, peg-shaped teeth, discrepancies
in height and width, diastemas, agenesia, malformations, extrusions, intrusions, attrition, etc.6–8
Not solving the problems mentioned above might
result in failure of the orthodontic therapy due to
relapse, periodontal complications, occlusal instability or overall dissatisfaction.9,10 However, the careful
planning and combination of aesthetics and orthodontic functionality in combination with the new
restorative materials available today enable us to
obtain harmonic results.2,11

Fig. 6

[19] =>

case report _ aesthetics & function

Fig. 8

Fig. 7

This article seeks to demonstrate the manner in
which the goals of an orthodontic treatment were
fulfilled in a clinical case. A multidisciplinary approach is indispensable for the achievement of the
therapeutic goals of functionality and aesthetics,
which are obtained thanks to modern direct restorative dentistry as part of a comprehensive treatment
plan and followed by an aesthetic and functional
execution of that plan.

_Case report
The patient was unhappy with her dental aesthetics after completion of fixed orthodontic treatment.
In addition, she did not like the appearance of her
incisal edges, nor the texture or translucency of the
incisal third of her central incisors (Figs. 1 & 2).
After gaining a clear understanding of the patient’s expectations and having informed her of the
therapeutic possibility of treating the case with composite resin, it was decided to make a diagnostic waxup, elongating the height of the clinical crowns to
correct the irregularities of the incisal edges. We then
proceeded to take a pattern of the future restorations
with putty polyvinyl siloxane (PVS). This pattern was
then tried in to gain a better idea of the quantity of
composite needed to restore the teeth (Fig. 3).
Following adequate cotton roll isolation, and after gaining complete cooperation from the patient,
the adhesive protocol for the enamel was followed
and restoration with composite resin AMARIS (VOCO)
was decided upon. The first increment of restorative
material was placed in the PVS pattern and seated
with gentle pressure on the palatal aspect of the
pattern. AMARIS Translucent was placed in such a
way that all the palatal surfaces of the restoration
were completed on teeth #11, 21 and 22. In order to
restore the central incisors simultaneously, a partially
thinned matrix (OptraMatrix, Ivoclar Vivadent) was
lodged in the PVS pattern and each incisal edge was
light-cured for 30 seconds (Figs. 4–6).
The pattern that rapidly gave us all the anatomic
features of the lingual aspect was then removed to

Fig. 9

continue stratifying the layers of
this composite (AMARIS Opaque),
seeking to insinuate the mamelons
very slightly at the incisal third
but close to the incisal edge itself,
and at the same time spreading
the composite onto the surface
of the enamel, in order to hide the
excessive translucent aspect that
these teeth showed naturally (Fig. 6).
In addition, we applied several
brushstrokes of AMARIS Flow High Opaque (VOCO) in
areas where it was necessary to hide the translucency,
and at the same time it was useful for us to generate
small areas of hypoplasia of enamel, resembling the
natural characteristics of the lateral incisor.

Fig. 10

Finally, the whole surface of the incisal edge
and the facial surface were covered with AMARIS
Translucent again. Thereafter, the whole restoration
was brushed up and light-cured for 60 seconds.
Next, the occlusion was adjusted and the composites
finished (Figs. 7 & 8).
The patient was very pleased with the final result
and was informed of the necessary appointments for
follow-ups and maintenance, occlusion check-ups, as
well as photographic monitoring. The accompanying
photographs were taken three months post-operatively, the first one with dried teeth and the second
in natural conditions during smile (Figs. 9 & 10)._
Editorial note: A complete list of references is available
from the publisher.

_contact

cosmetic
dentistry
Dr Rony Hidalgo Lostaunau
Alameda del Crepúsculo 195
Alborada – Surco
Lima 33
Perú
hidalgo@endoroot.com

cosmetic
dentistry 1
I 19
_ 2011

[20] =>

I special _ implants

Restoring missing mandibular
incisors with implants—
What makes you hesitate?
Authors_ Dr Chonghwa Kim & Sangwoo Lee, Korea
Preparing mandibular incisors for bridge abutments is an extremely delicate procedure that
often leads to root-canal treatment due to pulp
damage that might occur during the procedure.
Even without the risk of pulp damage, it is still
quite a challenge to recreate natural contour and
shade on such tiny dentition.

Fig. 1

Fig. 2

Fig. 1_Pre-op.
Fig. 2_Pre-op peri-apical X-ray.

Fig. 3_Resin-bonded provisional
restoration.
Fig. 4_Lingual view.

20 I cosmetic
dentistry

1_ 2011

_Mandibular incisors can be vulnerable to
early loss due to their inherently weak periodontal
support and high prevalence with respect to periodontal disease. What are the most common
treatment options for missing mandibular incisors? Aside from removable prosthetic options,
the restorative options for a fixed prosthesis
include a conventional bridge, a resin-bonded
bridge (Maryland Bridge) and implants. For a case
in which one or two mandibular central incisors
are missing, a three- or four-unit bridge has often
been the treatment of choice. A resin-bonded
bridge, in these cases, can be a reasonable alternative to a conventional bridge; whereas implant
treatment, more often than not, is not suitable due
to insufficient space. When more than two incisors are missing, the implant option may become
the first choice for most clinicians these days.

Fig. 3

Dental implants have, in many cases, become
the treatment of choice for restoring missing
teeth and have been documented to have a high
degree of success. With implant therapy, the
preparation of healthy teeth adjacent to the
edentulous area can be avoided. An additional
advantage to the implant restoration is the maintenance of the alveolar bone, which otherwise
would undergo resorption with other restorative
options, hence, often complicating aesthetics.
What’s happening in the real world? Are we
comfortable enough placing implants in the
mandibular anterior region? In spite of understanding both the disadvantages of conventional
fixed bridgework and the advantages of implant
restorations, we often make the treatment choice
for missing mandibular incisors in favour of the
bridge. Why is that? What hinders us from providing an implant option for patients in such
cases? Restoring mandibular incisors with implants can be one of the most difficult dental

Fig. 4

[21] =>

special _ implants

treatments to perform due to the limited amount
of bone and interdental space. Placing implants
in the mandibular anterior region can be challenging due to:
1. insufficient facio-lingual bone volume;
2. insufficient mesio-distal space between adjacent teeth;
3. insufficient height of remaining alveolar bone;
4. the presence of mento-labial depression, which
limits the facio-lingual angulation of implants;
and
5. the preservation or recreation of the interdental papilla being an extremely delicate procedure.
One of the prerequisites for the successful
placement of an implant is the presence of adequate bone volume. Tarnow et al. stated that
a submerged implant, following the delivery of
the prosthesis, will create circumferential or horizontal bone resorption of 1.3 to 1.4 mm. Grunder
et al. also stated that at least 2 mm of lateral alveolar bone must be present beyond the body of the
implant to compensate for the effects of bone remodelling. If this amount of bone is not present,
part or all of the facial or buccal bone plate will
be lost after remodelling, with the subsequent risk
of soft-tissue recession. This amount of bone
around an implant rarely exists in the mandibular
anterior region. Therefore, ridge augmentation
procedures are often required to create adequate
bone volume to maintain a 2 mm alveolar thickness following implant placement.
Another prerequisite for successful implant
treatment is sufficient interdental space. The
creation of a natural-looking implant restoration largely depends on the appropriate placement of the implant during surgery. In order to
achieve this goal, careful planning and precise
implant placement are essential. An implant requires a minimum distance of 1.5 mm between
the implant and adjacent tooth to maintain
interproximal bone and interdental papilla. Standard diameter implants of 4 mm or greater there-

Fig. 5_Twelve weeks
post-extraction.

Fig. 5

fore require a mesio-distal space of at least 7 mm
to place an implant. For an interdental papilla between two adjacent implants to be established,
the inter-implant distance should be more than
3 mm. Thus, a minimum mesio-distal space of
14 mm is required to place two standard-diameter implants adjacent to each other.
Implant manufacturers have introduced
narrow-diameter implants (3.0 to 3.5 mm) in an
attempt to solve these problems. However, these

Fig. 6_Following implant placement.
Fig. 7_Peri-apical X-ray
at implant insertion.

Fig. 6

Fig. 7

implants still require a minimum mesio-distal
space of 6.0 to 6.5 mm to allow adequate implant-to-tooth distance. With the exception of
mandibular incisors, narrow-diameter implants
present a solution for the aforementioned requirements of adequate bucco-lingual bone
volume and proper implant spacing. For missing
mandibular incisors, it would be beneficial to
use implants with an even smaller diameter than
narrow-diameter implants.

Fig. 8_Immediate provisionalisation.
Fig. 9_Modification of provisional
Fig. 8

Fig. 9

restoration.

cosmetic
dentistry 1
I 21
_ 2011

[22] =>

I special _ implants
Fig. 10_Eight weeks
post-implant placement.
Fig. 11_Friction-fit impression caps.

Fig. 12_Working cast.
Fig. 13_Top view.
Fig. 14_Final prosthesis.

Fig. 12

Fig. 10

Fig. 11

Mini-diameter implants (MDI) are not synonymous with narrow-diameter implants. MDIs are
smaller in diameter than narrow implants and
have a diameter of 2.7 mm or less. Because of their
smaller diameters, MDIs require minimal interdental space while preserving more of the alveolar bone following the osteotomies for implant
placement. MDIs were initially developed to support transitional prostheses and were ultimately
intended to be removed. However, these implants

MDIs of less than 3 mm in diameter are fundamentally challenged as two-piece designs due
to the insufficient strength of their component
parts. When the diameter of an implant approaches 3 mm or less, either the abutment
screw becomes too small or the internal axial
walls of the implant become too thin to withstand the functioning load. These concerns
can be overcome with a one-piece design. Onepiece implants have recently received substantial

Fig. 13

Fig. 15_Thirteen-month follow-up.
Fig. 16_Peri-apical X-ray.

Fig. 14

exhibited a bone-to-implant contact similar to
that of implants with conventional diameters.
Numerous studies have indicated that MDIs
appear to be an effective treatment option for
missing mandibular incisors. Nevertheless, one of
the primary disadvantages of MDIs is the reduced
resistance to occlusal loading. The retention of
an implant, however, is correlated to the length of
the implant and not the diameter. This implies
that MDIs may be used in situations where excessive occlusal loading is not present.

Fig. 16

Fig. 15

22 I cosmetic
dentistry

1_ 2011

attention in implant dentistry; yet, one-piece implants are not new to implant dentistry. While the
use of one-piece implants has been controversial,
they have been used for decades with reasonable
clinical success.
Recent variations from early designs have
created a renewed interest in this old, but not
obsolete concept. Most one-piece implants are
composed of three portions—the bone-anchoring (fixation thread) portion, transmucosal portion and prosthetic abutment portion.
The primary disadvantage of one-piece implants is related to the fact that these implants
must be placed with a one-stage protocol.
Therefore, the angulation of the abutment
cannot be altered and only minimal modification of the abutment is possible. Without the
prosthetic freedom of the abutment choices,
the initial surgical positioning of one-piece implants becomes critical in obtaining an optimal
result.

[23] =>

special _ implants

Fig. 17

Fig. 18

The advantages of one-piece implants include
minimally invasive surgery, simple restorative
procedures and no screw loosening. Furthermore,
the amount of crestal bone resorption may be
minimised, since there is no micro-gap or micromovement between the implant and its abutment.
This becomes even more critical for long-term
aesthetic results in the anterior region. In order
to demonstrate the successful use of one-piece
implants, this article describes the restoration of
mandibular incisors with one-piece MDIs.

_Case reports
Case I
A 67-year-old female patient presented with
occasional throbbing pain in the mandibular
anterior region. The patient’s medical history was
non-contributory. Clinical and radiographic evaluation revealed two separate peri-apical lesions
on teeth #23, 25 and 26 (Figs. 1 & 2). The patient
reported that tooth #24 had been extracted
15 years ago. The incisors were deemed nonrestorable and treatment planned for extraction.
Owing to the size and duration of the peri-apical
lesions, delayed placement of implants was
planned. The teeth were carefully luxated with
a periotome and atraumatically extracted, preserving the thin facial bone. A wire-embedded
provisional restoration was fabricated and bonded
to the adjacent canines with flowable resin (Figs.
3 & 4). After ten weeks of healing, the provisional
restoration was removed. The distance measured

Fig. 19

between the two mandibular canines was 15 mm
(Fig. 5).
A crestal incision was made and a limited softtissue flap was reflected to expose the alveolar
crest of bone. In this fashion, the patient experiences reduced post-operative swelling and
discomfort. With a 1.6 mm twist drill and copious
irrigation, osteotomies were performed at a speed
of 1,500 rpm. The angulation of the twist drill was
carefully monitored throughout the osteotomies.
Following completion of the prepared implant
sites, visual and tactile inspection of the internal
bony walls was performed to ensure the absence
of any fenestration or dehiscence at the cervical
area. Two 2.5 mm-diameter implants (MS implant,
Osstem) were then placed in the ideal 3-D position and torqued to 25 Ncm with a manual torque
wrench. The superior margin of the transmucosal
portion was positioned 2 mm apical to the softtissue margin (Figs. 6 & 7). Immediately following
implant placement, provisional restorations were
fabricated at chairside using prefabricated temporary abutments and acrylic resin.

Fig. 17_Pre-op X-ray.
Fig. 18_Resin-bonded provisional
restoration after extraction
of teeth #23 and 24.
Fig. 19_Eleven weeks
post-extraction.

The provisional restorations were snapped into
position using the friction-fit temporary abutments, eliminating the use of cement (Figs. 8 & 9).
This could remove the risk of cement being forced
into the gap between the implant fixture and
soft tissue. The provisional restorations had no
centric or eccentric occlusal contacts. The patient
was instructed to avoid any function of the implant for eight weeks.

Fig. 20_Papilla preservation
with ovate pontics.
Fig. 21_Eight weeks post-implant
Fig. 20

Fig. 21

placement.

cosmetic
dentistry 1
I 23
_ 2011

[24] =>

I special _ implants
Fig. 22_Modified impression caps.
Fig. 23_Indexing jig.

Fig. 24_Final prosthesis.
Fig. 25_Eleven-month follow-up.
Fig. 26_Peri-apical X-ray.

Fig. 22

Fig. 23

After a healing phase of two months, a final
impression was produced using friction-fit impression caps (Figs. 10 & 11). Definitive restorations were then fabricated on the working cast
and adjusted to have slight occlusal contacts

altered cast was made, and a definitive prosthesis
was fabricated. The clinical and radiographic
evaluation at 11 months demonstrated a good
aesthetic result with no significant peri-implant
bone loss (Fig. 24).

Fig. 24

Fig. 26

Fig. 25

in centric occlusion and excursive movements
(Figs. 12–14). The clinical re-evaluation demonstrated a minimal gingival change around the
prosthesis, and a stable horizontal bone level
was observed radiographically at the 13-month
follow-up (Figs. 15 & 16).
Case II
A 58-year-old male patient presented with
severe mobility and peri-apical lesions on teeth
#23 and 24 (Fig. 17). A provisional restoration was
fabricated and bonded to the adjacent natural
teeth immediately following extraction (Fig. 18).
The provisional restoration was left undisturbed
for 11 weeks and the interdental papillae were
preserved with ovate pontics (Figs. 19 & 20).
The interdental distance measured between teeth
#22 and 25 was 8 mm, and two 2.5 mm-diameter
implants were placed in position. The superior
margin of the transmucosal portion was positioned sub-gingivally, and the height of the
abutments was reduced to ensure adequate
incisal clearance (Fig. 21). Owing to the limited
interdental space, the impression caps were modified (Fig. 22). An indexing jig was used to avoid
any undue stress applied to implant fixtures
during the impression procedure (Fig. 23). An

24 I cosmetic
dentistry

1_ 2011

_Conclusion
Based on the clinical cases presented in this
article, the utilisation of one-piece MDIs appears
to be a good treatment option for replacing missing mandibular incisors. Considering the simplicity, ease of implant placement and immediate
provisionalisation, this treatment offers a new
option for patient care._

_about the author

cosmetic
dentistry

Dr Chonghwa Kim specialises
in prosthodontics and
implantology. He works in
a private practice in downtown
Seoul, Korea. He graduated
from the University of
Michigan School of Dentistry
in 1997 and completed
prosthodontic training at the University of
Minnesota. Dr Kim is Co-director of the Global
Academy of Osseointegration and serves as
a Director of international relations for the Korean
Academy of Esthetic Dentistry. He can be
contacted at kimchonghwa@hotmail.com.

[25] =>

[26] =>

I feature _ interview

“The philosophy of dental
treatment is very important”
An interview with Dr José Roberto Moura, IFED President
_Dr José Roberto Moura graduated from
the University of Taubaté (Brazil) in 1983 with a
specialty degree in Restorative Dentistry. He later
completed his master’s degree in Prosthodontics
at the same university. Dr Moura served as President of the Brazilian Society of Esthetic Dentistry
(BSED) from 1999 to 2000 and from 2002 to 2003.
He is currently President of the International
Federation of Esthetic Dentistry (IFED).

Dr José Roberto Moura

_cosmetic dentistry: Dr Moura, you have
been actively involved in aesthetic dentistry since
your first BSED presidency in 1999. Would you
please tell us how you became involved in dentistry?
Dr Moura: Actually, I have been involved in
aesthetic dentistry for much longer. In 1990,
I started to work with adhesive dentistry using
some materials and techniques that I had brought
to Brazil from the USA. In 1994, my friend
Dr Marcelo Fonseca started the BSED and invited
me to join its board of directors, as we were already
working in that area even though it was something new in Brazil at that time.
_Cosmetic dentistry is guided by patient desires, contemporary fashion and trends. However,
the majority of cosmetic dental treatments are
invasive in nature and not always in line with oral
health and ethical standards. What is your take
on this?
I disagree with that statement. I think that aesthetic dentistry is also based on, for example, direct
composite restorations, which are very conservative and able to improve smiles while preserving
sound dental structure. Even bonded ceramic
restorations have become more conservative over
the years with the improvement of these materials,
which are becoming more resistant even at small
thicknesses. Besides that, there are very conservative aesthetic techniques such as bleaching,
cosmetic contouring and micro-abrasion. The philosophy of dental treatment is very important in
this matter and this, in turn, is directly influenced
by the way dentists are trained and taught.

26 I cosmetic
dentistry

1_ 2011

_In your opinion, what are the most important
considerations for dentists interested in introducing cosmetic dentistry into their general practice?
What are the largest obstacles?
Cosmetic dentistry is the use of dental materials that not only restore the function of the tooth,
but also its appearance. These materials, mainly
composites and ceramics, are already largely in
use in many practices. Besides, in many countries,
aesthetic dentistry is one of the main reasons that
patients come to dental offices nowadays. The
bottom line is that every dentist doing cosmetic
dentistry in his or her practice needs to go about
this very seriously, taking high quality hands-on
courses, especially those that value conservative
treatments and patient health.
_You are currently serving as IFED President.
Would you please briefly highlight the main goals
and activities of IFED, as well as what you wish to
achieve during your presidency?
The main goal of IFED is to bring aesthetic dentistry academies from all over the world together
to interact with one another in seeking to promote
the exchange of experience and knowledge. IFED
has one General Assembly that takes place in
Chicago during the Midwinter Meeting, where
new ideas are presented to IFED by the representatives of the academies. We also have a World
Meeting every two years, which is hosted by one of
the member academies. The next one will be held
in Brazil from 2 to 5 November 2011 in the beautiful city of Rio de Janeiro.
_What are IFED’s current challenges in expanding its membership and activities in the AsiaPacific region?
We need active members that can really help us
contact representatives of aesthetic dentistry
groups all over Asia who are willing to join us in
our task. We have had great help from people like
Dr Peter Tay (Singapore), Dr Seok-Hoon Ko (Korea),
Dr Akira Senda (Japan) and Dr Sushil Koirala
(Nepal), and I personally hope we can expand the
IFED representation in Asia.

[27] =>

feature _ interview

_How can a national academy become part of IFED?
In order to apply as candidate, they need to fill out a
form, which can be requested
from our secretary through our website. The applications will be reviewed by a members committee and discussed during the annual Executive
Council meeting in Chicago. If the criteria are met,
they will be voted in at the General Assembly as associate members. Following three years of activity, they are voted to become active members and
also part of our great world family.
_Next year’s IFED meeting will be held in your
home country Brazil. How are preparations coming along and what will the major attractions
be?
The BSED is working very hard in order to promote a great meeting with presentations by the
great masters from all over the world, and also a
good social programme that promotes interaction
amongst participants. We will be proud to have
Dr Adriana McGregor (USA), Prof Bart van Meer-

beek (Belgium), Dr Christian Coachman (Brazil),
Dr Dinos Kountouras (Greece) and Dr Tidu Mankoo
(UK) as speakers, amongst others. Additionally, the
beautiful and charming city of Rio de Janeiro will
certainly be a wonderful host city.
_Information technology has changed the
way dentists are educating themselves. Internetbased webinars and study clubs have become
standard practice for dentists worldwide. How is
IFED using this technology to educate professionals and the public globally?
We intend implementing an e-learning section
on our website with articles and videos as soon
as possible. We are also seeking to establish online
journals. There are also many other ideas that
the Executive Committee is currently discussing,
but I must say, this is not an easy task, but one that
I am personally committed to._

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[28] =>

I feature _ interview

“Foreign markets are
very important to us”
An interview with Olaf Sauerbier, CEO of VOCO GmbH

Olaf Sauerbier (left) in talks with
DT Group Editor Daniel Zimmermann.

_VOCO, based in Cuxhaven on the northern
coast of Germany, is an established international provider of high-quality dental materials. In
addition to products for restorative dentistry, it
offers a wide range of materials and preparations for the fields of prosthetics and prophylaxis.
cosmetic dentistry spoke with Olaf Sauerbier,
CEO and chief of Marketing and Sales, about
new products and aesthetic trends in restorative
dentistry.

_cosmetic dentistry: The Association of Dental Dealers in Europe (ADDE) has recently predicted growth rates above three per cent for most
European dental markets. Do you see any signs
of recovery in your company?
Olaf Sauerbier: To be honest with you, the
recession never really caught us. We usually tend
to perform slightly better than the overall market
and expect to be no different for this business
year. The year 2010 started off better than last
year ended, and we saw some significant growth
in most of our business segments in the first and
second quarters.
Although we have invested significantly in our
German businesses by extending our sales team

28 I cosmetic
dentistry

1_ 2011

by 15 new employees, foreign markets are very
important to us. At the moment, we are expanding our existing businesses worldwide, especially
in North America. It will be a while before we
are able to take full advantage of the enormous
potential this market has to offer.
_Did the products you introduced two years
ago at IDS Cologne meet your expectations?
The most important product we introduced at
IDS in terms of sales was definitely the non-run,
non-drip NDT syringe. This new delivery form
helped us to increase sales of most of our highly
flowable materials like Grandio Flow, Grandio Seal
and Ionoseal. Our gingiva-shaded restoration
system Amaris Gingiva has also shown good performance. We have to admit that the market for
such a product is still small but, on the other hand,
we see the demand for aesthetic restorations of
exposed necks of teeth increasing owing to demographic changes and people ageing. Those
who have highly aesthetic requirements will find
it hard to pass this product by.
Another bestseller has been the one-component, light-curing, nano-reinforced, self-etch bond
Futurabond M that we launched in SingleDose
and in a three-bottle value pack. Not to forget the
Rebilda Post System, an award-winning complete
system for placing 15 posts in post-endodontic
treatment, that sold successfully in Germany and
abroad within a short amount of time.
_Some segments in dentistry, dental implants
in particular, have shown decreasing sales. What
is the situation in the market segments you are
involved in?
The recession might have had devastating
effects on companies offering upscale materials
and equipment but the situation in restorative
and preventative dentistry looks far more promising. In the segments in which we are actively involved, such as prosthetics, prophylaxis or dental
cements, we have been able to achieve growth
rates between 10 and 20 per cent.

[29] =>

feature _ interview

Filling materials did not perform very well
owing to increased market competition. There are
plenty of new and innovative filling materials on
the market right now and we have to invest a great
deal in order to stay ahead with new developments and products.
_What current trends have you observed in
the industry?
All manufacturers are striving for
a product that offers almost ideal
properties for a filling material and
exhibits the same physical properties
as natural tooth substance. All our
competitors are moving towards this
ideal but I see us far ahead. We have
been working with nanotechnology since the early
2000s and based on the results of this launched
our first nanohybrid composite Grandio in 2003.
This product is still in high demand in Germany and
many other markets.
But we did not stop there. With GrandioSO,
we are now able to present another nanohybrid
composite to the dental community that has
outperformed our original expectations. In terms
of its physical properties, it is probably the most
tooth-like material on the market.
_When and where will it be available?
It is already available in Germany and other
selected European markets. Like its predecessor,
GrandioSO is universally applicable but a little
more translucent, so it can be used for restorations in the maxillary anterior region.

This is not
the direction we
wish to take. Teeth have a natural translucency
and we want to keep it that way. I believe that with
our current portfolio we offer dentists viable
solutions to achieving long-lasting and natural
aesthetic restorations.
_Some European companies develop their
products especially for the North American market. Do you do the same?
We sell exactly the same products in North
America as we sell in Europe. Usually, most products are launched there six months after they
have been placed on the European markets. The
only difference is the type of shade. In Germany,
for example, the majority of dentists use Shade
A3.5, which does not play any significant role
in markets like the US, where Shade A2 is more
common.

We will still offer Grandio to our customers
worldwide. In the end, it is the dentists who decide
which product they prefer.
_Do aesthetics play a more prominent role
in the development of a composite like VOCO’s
GrandioSO?
The primary goal is function. There is a place
for aesthetics too, but it must not compromise
functionality or the stability of the filling. There
are different points of view in dentistry regarding this matter right now but for us the primary
goal cannot be highly opaque teeth that might
be currently en vogue amongst Hollywood stars.
In the US, for example, we found that dentists
were using the white opaque shade of our
flowable composite Grandio Flow for anterior
restorations, as this is the typical shade of highly
bleached teeth in the US. Normally, we recommend it only be used to whiten dark spots or
in cases in which dentists absolutely need an
opaque layer.

_Will GrandioSO be the main focus of your
presentation at IDS this year and are you planning
to introduce more products there?
GrandioSO will indeed be the main focus of
our IDS presentation, but there are other products that we plan to launch at IDS 2011._

Areal view of the VOCO headquarters
in Cuxhaven, Germany.

cosmetic
dentistry 1
I 29
_ 2011

[30] =>

I MICD _ Inman Aligner

The Inman Aligner—Alignment,
bleaching, bonding: A progressive
approach to smile design (Part II)
Author_ Dr Tif Qureshi, UK

Fig. 1

Fig. 2

_The following article is Part II in a series discussing the use of the Inman Aligner as a tool for
MICD.1 The first article (published in cosmetic
dentistry 2/10) demonstrated that standalone treatments offer patients an alternative to fixed braces,
which are unsightly and have long treatment times,
and to expensive clear aligner treatments in suitable
cases.
This article will demonstrate that patients who
desire a more traditional smile makeover can achieve
beautiful results in a more progressive manner that

allows them to make their choices along the way.
This often results in virtually no removal of tooth
structure and a treatment result with the responsibility of decision-making shared between dentist
and patient.
Moreover, the subject matter of this article could
potentially start one of the most controversial debates in cosmetic dentistry for years. We are not only
discussing a radically different approach to smile
makeovers, but critically a sharply different approach to the traditional methods of planning smile
design.

_What would you choose?

Fig. 3

Fig. 4

30 I cosmetic
dentistry

1_ 2011

Patients entering cosmetic practices are often assessed at the initial consultation. They have digital
photographs taken and perhaps study models are
made. Normally, dental imaging software is used
to show patients what can be achieved. These ingenious programmes can help patients realise what
is possible. Naturally, care must always be taken
when promising treatment results that are viewed
digitally.
While computer imaging can be a very powerful
tool to help the patient see the potential in his/her
smile, I believe it also can make a patient focus on a
certain prescribed goal that may not be the only way
of satisfying his/her wishes. Dentists using imaging
would ideally create a set of five to ten different out-

[31] =>

MICD _ Inman Aligner

Fig. 5

comes of varying degrees of improvement to allow
the patient to make a more informed decision. While
ideal, it is not certain that dentists actually present
different levels of treatment to their patients digitally. Even if they were able to see various images
of their teeth, it can still be difficult for a patient to
really see and feel the suggested changes in their
mouth. One can question the ethics of allowing
patients to commit to a potentially irreversible procedure based on 2-D photographs.
Three-dimensional wax-ups can also be very
useful at this stage. If a patient is keen on the image,
going to an additive wax-up can sometimes allow for
a direct preview try-in using a silicone stent taken
from set-up. Temporary material of variable shades
can be tried in directly, without any bonding to allow
the patient to see the proposed outline, form and
overall aesthetics.
Despite this, veneers are often used to treat alignment issues and it is very difficult for patients to
appreciate the alignment of their own teeth with
wax-up or imaging. By approaching these cases
with a different protocol in mind, a dramatically
less invasive treatment plan becomes evident.
The first step is to look at the patient’s tooth
alignment. Misaligned teeth often cause issues in
gum heights, line angles, light reflections, shades
and tooth length. Correcting the misalignment first
can create a completely different perception of
the apparent problems. Next, the teeth should be
bleached. This can be done either immediately after
the teeth have been aligned or preferably simultaneously. After alignment and bleaching, edge bonding
(we term this the ABB concept) should be offered to
improve the incisal edge outline.
This combination of treatments also works well
because the Inman Aligner is a removable appliance
and only needs to be worn 16 to 18 hours a day. This
means simultaneous bleaching is very possible and
straightforward. A recent study from Sweden indicates a cost-benefit advantage of treating patients
with removable appliances in general dental clinics,

Fig. 6

rather than with fixed appliances at specialist orthodontists.2 The conclusion of this study is significant,
since a popular choice amongst aesthetic dentists in
the UK is removable orthodontics.
The cases outlined below highlight patients who,
either at the start of treatment or for years, had originally wanted veneers and had a specific result in
mind that only veneers could have offered quickly.
They were all concerned about the degree of preparation required, so undertook alignment first.
Then, part of the way through, started bleaching and
very quickly changed their minds about what they
wanted once they saw their own teeth improve.

_Case I (Figs. 1–8)
Laura was concerned about her very prominent
central incisors. She wanted to have them straightened and had considered veneers. She had ruled out
conventional orthodontics and invisible braces be-

Fig. 7

Fig. 8

cosmetic
dentistry 1
I 31
_ 2011

[32] =>

I MICD _ Inman Aligner

Fig. 9

Fig. 10

cause she wanted a quick treatment and did not want
anything stuck to her teeth, which is the reason that
she had refrained from orthodontic treatment. Several years ago, she may well have had veneers placed.
On viewing her teeth before the occlusal photograph, it was quite clear that this would have involved massive preparation of the upper central
teeth. Preparation would have been well into dentine
and may have even involved elective endodontics.
Her lateral teeth would have needed little preparation, but the emergence profiles would have been
poor, creating unrealistic aesthetics and a possible
periodontal risk later on. Instead, the alignment was
completed with an Inman Aligner in ten weeks. Her
treatment sequence is detailed below.
BACD-style digital photographs were taken and
the amount of crowding was calculated using an

Fig. 11

Fig. 12

Fig. 13

32 I cosmetic
dentistry

1_ 2011

electronic crowding calculator, which can also be
done by arch evaluation of the patient’s study models. We measured the ideal curve and subtracted this
measurement from the total mesio-distal widths of
the teeth being moved.3 The results showed that
there was only 1.6 mm crowding. This seemed less
than one would have expected; the reason for this
was that because the laterals were being pushed
out, the arch was being expanded, thus creating
space.
It was clear from the photographs that despite
the obvious crowding, there was some less obvious
irregular tooth wear. It was important to indicate this
to the patient, as this would become more evident
once the misalignment had been corrected. The
patient was quoted for three incisal composite tips.
She opted for an Inman Aligner with an incorporated
expander. These expanders are a very handy way of
creating extra space either to treat cases that are
more complex or to use instead of performing interproximal reduction (IPR).
In this case, no IPR was performed. We planned
to get nearly all space by using the midline expander.
The patient was instructed to turn the midline screw
once a week after one week of wear. Each turn is
1/4 of a revolution and equates to 0.25 mm. At week
six, bleaching was started with soft rubber sealed
trays. After nine weeks, the patient had expanded
1.8 mm and her teeth were in alignment. (As a rule,
less than 2.5 mm expansion with an incorporated
expander is easily tolerated.)
Looking at her post-alignment result, the golden
proportion, gingival heights and axial-inclinations
had improved dramatically, all without a handpiece
being picked up and in the space of nine weeks.
What was very clear to the patient at this point was
that she only needed some simple bonding to improve the incisal edge outlines. Without the use
of an anaesthetic, the edge outlines were prepared
with very slight roughening of the edge, bonding
of hybrid composite on the load bearing edge and
a micro-fill on the facial surface. The edges were then
polished.

[33] =>

MICD _ Inman Aligner

Fig. 14

The patient was thrilled with the result we
achieved using an Inman Aligner and some simple
bonding. She described that when she had once
considered having veneers, she had hoped for a
similar result. There are still minor imperfections,
but, in my opinion, these contribute to her natural
beauty.
There is a stark contrast between the treatment
selected and the potential treatment approaches in
this case. Where once a patient, who refused orthodontics, would have consented and received highly
aggressive tooth preparations to achieve correct alignment with veneers, now a removable aligner and
some simple bonding were able to achieve a similar
and arguably better result in less than three months
with not a micrometer of tooth reduction needed.

Fig. 15

Interestingly, the patient’s perception of her smile
had changed dramatically. Owing to the improved
line angles, whiter teeth and balanced gum heights,
her eyes were now only drawn to the irregular outline caused by chipping and differential wear.
The patient then enquired about fixing the edges.
We offered to bond the incisal edge with virtually no
preparation. A hybrid composite (Tetric Flow, Ivoclar
Vivadent) was placed palatally and incisally with
a micro-fill on the facial surface. This was done in B0
and B1 shades to match the bleaching. The patient
was delighted with the result and a wire retainer was
bonded immediately.
Despite some clear deviations from her ideal
simulated smile, the patient explained that she felt
her smile after alignment was better than she had

_Case II (Figs. 9–17)
This young lady had been attending my practice
for some time and was aware of porcelain veneers,
having seen our previously advertised cases. We had
spoken about the aesthetic benefits of veneers years
before. However, on reviewing her case, it was clear
that we could improve her alignment dramatically
with an Aligner in a short period.
We took an occlusal image of her anterior teeth
and outlined the amount of tooth structure that would
have to be removed to produce veneers that would look
aesthetic. It was immediately apparent to the patient
that alignment of her teeth would offer a possibly better treatment outcome. Her case was suitable for an
Inman Aligner and as only 2.5 mm crowding was present, this meant it could be treated quickly and simply.
Her Inman Aligner was fitted and IPR performed
progressively over three visits. At week eight, upper
and lower bleaching trays were constructed even
though her alignment was not yet complete. Home
whitening was begun with clear and concise instructions. We used rubber trays with a deep seal
cut into the model to create a tight dam effect. Over
two weeks, her teeth whitened nicely and at week
ten, she returned for a review.

Fig. 16

Fig. 17

cosmetic
dentistry 1
I 33
_ 2011

[34] =>

I MICD _ Inman Aligner

Fig. 18

Fig. 19

imagined her veneers would have been. Had veneers
been placed, we could perhaps have corrected the
golden proportion more fully, balanced the zeniths,
improved the canine outlines, widened the buccal
corridors, etc. However, that was clearly not what
the patient desired. Should she later decide that she
does need further improvements, we can proceed
with already straightened teeth. The ABB smile design is progressive and not sudden or rushed. In this
manner, the patient is given the opportunity for decision-making in his/her treatment and the responsibility in choice is shared.

_Case III (Figs. 18–26)
This patient presented with what she described
as a “wonky smile”. She had previously looked into
the possibility of having porcelain veneers placed so
understood some of the aims of smile design. However, on studying her teeth, it became clear that there
was potential to pre-align first. Her upper right central was mesially rotated by approximately 30° and
her laterals were slightly in-standing and mesially inclined. Furthermore, she had fairly stained teeth, with
the canines two shades darker than the centrals.

34 I cosmetic
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1_ 2011

On examining the occlusal view, the patient became aware of the extent of aggressive tooth preparation that would be required to place a veneer.
She understood that her teeth needed to be aligned
first before we decided on the next step in design.
An Inman Aligner was used over the period of eleven
weeks to de-rotate the front tooth and to tip out the
laterals. At week eight, bleaching was begun using 35to 45-minute a day H2O2 gels. Simultaneous whitening
is a very attractive part of aligner treatment, as it helps
with patient motivation. After alignment, the case was
re-examined. Once her teeth had been straightened, it
became evident to the patient that her problem concerned edge shape, which had actually worsened with
alignment owing to differential wear. In fact, the left
central was 2.5 mm shorter than the right. It was very
clear to the patient that only these incisal edges needed
building in order to achieve the smile she desired.
For placement of the incisal edges at week twelve,
no local anaesthetic was administered. Other than
slight roughening of the worn incisal edges of the upper left 1 and 2, no other preparations were needed.
A tetric hybrid composite (Tetric Flow, Ivoclar Viva-

Fig. 20

Fig. 21

Fig. 22

Fig. 23

[35] =>

MICD _ Inman Aligner

Fig. 24

dent) was built up free-hand on the incisal edge and
palatal surface to match the outline of the other central. A small amount of white opaquer was dotted in
to match the facial surface and was simply filled with
a nano-hybrid composite (Venus Diamond, Heraeus)
for high polish. The composite was polished vertically
using rubber sticks (PoGo, DENTSPLY DeTrey) to try to
blend in with surface anatomy to mask the join.
The process was repeated on the lateral.
The patient was held in retention using her aligner
and an impression was taken for a wire retainer to be
fitted two weeks later. It was especially nice to retain
the natural aesthetic characterisation of this patient. Ceramic work, as beautiful as it can be, would
certainly have changed her appearance more—some
may say for the better, but that was not what the patient actually wanted. She wanted her own teeth to
have correct length and look straighter and whiter.

Fig. 25

I believe this approach firmly sits alongside MICD
core principles, which recommend a more minimally
invasive and patient-led approach.

_Conclusion
I understand the controversy in challenging the
traditional approach to smile design, but the new
mantra of progressive smile design is vital when we
are looking to give our patients what they actually
want. Previously, pre-whitening was always a way
of giving our patients an alternative view of their

_Shared responsibility of treatment
The ABB concept can truly be described as minimally invasive. At the same time, it actively involves
the patient in the treatment, giving him/her a feeling
of being in control and taking responsibility for
his/her treatment. This has been proven to be of great
significance when measuring patient satisfaction of
treatment results.4
There are many anecdotal stories about patients
who had technically beautiful veneers placed but
found that these simply did not meet their desires. The
problem is that even with no-preparation veneers, an
irreversible procedure has been undertaken and this
has been done mainly based upon the treating dentist’s opinion, with the patient having very little input.
In my experience, every patient that I have treated
according to the ABB concept has accepted the result
happily, even though technically it might not be perfect
from a smile design point of view. Nowadays, with rising levels of litigation, one would have to question the
wisdom of selecting a treatment path that could result
in conflict over one in which the patient participates
in key decisions and sees his/her own teeth improve.

Fig. 26

teeth. Now, and more significantly with alignment
techniques, patients can make their own decisions
and massively reduce the risks by breaking down
the process of a smile makeover into stages and reassessing at each point.
With ABB, it is possible to align, whiten and bond
a case in less than twelve weeks, which previously
might have required eight to ten veneers, four times
the cost and significant tooth preparation. Thus,
a dramatic contrast in pathways has been created. If
a patient is happy after alignment, whitening and
minimal bonding, then this has to be viewed as a success. This UK technique is now a significant new
treatment discipline in itself and cosmetic dentistry
will be better for it. After all, what would you choose
to have?_
Editorial note: A complete list of references is available
from the publisher.

_contact cosmetic
dentistry
Dr Tif Qureshi
Straight talks Seminars
40–44 Clipstone Street,
Ground Floor East
London, W1W 5DW
UK
info@straight-talks.com
www.straight-talks.com

cosmetic
dentistry 1
I 35
_ 2011

[36] =>

I industry report _ CLEARFIL SA CEMENT

CLEARFIL SA CEMENT—
Easy to remove, hard to forget!
Author_ Dr Jürgen Garlichs, Germany

_In past years, adhesive technology has
progressed substantially, especially in the area
of direct, aesthetic composite restorations. The
basis for enamel adhesion through acid etching
was laid by Dr Michael Buonocore in the 1950s.
Since then, the procedure has established itself
as a safe and permanent method for adhesion
in dentistry. For a long time, dentine adhesion
was not able to provide even nearly as good
results as enamel adhesion. Only in the 1990s
were products developed that enabled reliable
dentine adhesion.

Fig. 1

_CLEARFIL SA CEMENT
CLEARFIL SA CEMENT is a self-adhesive, dualcuring composite cement for the cementation
of indirect restorations, such as crowns and
bridges; inlays and onlays made of metal, ceramic and composite; as well as root-canal
posts. The material is applied directly from the

Fig. 2

Fig. 1_Initial situation. Tooth #13
with approximal caries, apical
osteitis and poor cervical restoration.
Prosthetic provision planned after
endodontic treatment.
Fig. 2_Prepared situation before
insertion. Adhesive build-up fillings
were placed in the cervical and
disto-incisal areas. A retraction
cord was used in order to ease
cementation and drying.

Owing to the great results with direct adhesive techniques, they were also implemented for
the adhesion of indirect prosthetic restorations.
The aim was to combine the simple and quick
handling properties of conventional cements
with the good adhesion of modern composite
provisions. This first led to the further development of classic composite cements and finally
to the development of self-adhesive composite
cements that do not require extensive pre-treatment of tooth structures.
The reasons for focusing on self-adhesive
cements include numerous clinical trials, which
prove that the bond and stability of metal-free
crowns on prepared teeth are significantly
higher with adhesive composite cements than
with conventional cements, such as zinc phosphate, glass ionomer or polycarboxylate ce-

36 I cosmetic
dentistry

ments. Furthermore, most all-ceramic systems
require an adhesive bond with the hard tooth
substance to stabilise the ceramic framework.

1_ 2011

Automix delivery syringe without prior etching or bonding to the hard tooth substance.
Furthermore, CLEARFIL SA CEMENT releases
fluoride ions into the surrounding tooth substance. Compared with other fixing cements,
CLEARFIL SA CEMENT provides an excellent
bonding strength to enamel (23.2 MPa) and dentine (18.1 MPa),1 as well as mechanical stability,
in addition to its easy handling properties.
Owing to its self-adhesive ability, the dentine
tubules are sealed and hypersensitivities thus
prevented.
CLEARFIL SA CEMENT mainly contains BisGMA, TEGDMA, hydrophobic dimethacrylate
and MDP. Its self-adhesive ability is achieved
reliably and effectively through the unique
adhesive monomer MDP as tried and tested in
CLEARFIL bonding cements and PANAVIA (both

[37] =>

industry report _ CLEARFIL SA CEMENT

Kuraray). Owing to the affinity of CLEARFIL SA
CEMENT to and good wettability of the tooth
surface, the MDP penetrates into the tooth
structure effectively and ensures even adhesion. Multifunctional monomers and the dualcuring catalyst system provide a high crosslinking rate and good polymerisation characteristics. The mixed, uncured cement has a mildly
acidic pH value. After application, the pH value
rises until it is neutral in its polymerised state.
CLEARFIL SA CEMENT contains 66 wt% (45
vol%) of filler material in and below the micrometre range with an average size of 2.5 µm,
and therefore has exceptional mechanical properties in combination with a thin layer of only
19 µm.

metal posts and glass-fibre posts. CLEARFIL SA
CEMENT is available in Universal (A2) and White
colour shades.

Clinical case reports have proven the excellent material properties of CLEARFIL SA CEMENT.
In an investigation, Dr Cornelis Kleverlaan at
the Academic Centre for Dentistry Amsterdam
recorded a flexural strength of 81 MPa for
CLEARFIL SA CEMENT. A trial by Yamamoto et al.
at the University of Osaka demonstrated that

CLEARFIL SA CEMENT was developed on the
basis of PANAVIA, a gold standard adhesive composite cement, whose properties have already
been proven over a long period of time. The handling parameters were the main focus during the
development of CLEARFIL SA CEMENT. The resulting advantages are undoubtedly its simple

Advantages of CLEARFIL SA CEMENT
The most significant clinical advantage is good
adhesion through the MDP monomer and the
resulting secure mechanical and chemical bond
to enamel and dentine. CLEARFIL SA CeMENT is
a universally applicable material and, owing to
the thin layer it creates, allows for an adhesion
cement layer of only 19 µm and thus high dimensional stability. The low water resorption in combination with excellent margin qualities supports
long-term stability.

Fig. 3

CLEARFIL SA CEMENT has a low linear expansion rate (0.26%) and low water absorption
(27.7 µg/mm³).2 A survey on the quality of the
margins by Sadr et al. at Tokyo Medical and
Dental University found perfect margins on
all samples even after 3,500 thermal cycles.3
(For complete trial results, please refer to the
detailed scientific product information of the
manufacturer.)
Application range
CLEARFIL SA CEMENT is suitable for a wide
range of indications involving indirect restorations and a wide range of materials, such as the
cementation of crowns, bridges, inlays, onlays
made of ceramic (zirconia, alumina, silica-based
ceramic, etc.), hybrid ceramics, composite resin
and metal, as well as metal cores, resin cores,

handling properties, the quick implementation
of the treatment steps, the Automix application
and flexible working times.
CLEARFIL SA CEMENT can be applied exactly
portioned into the prepared restoration or
onto the prepared tooth, directly after fitting
the mixing tip. According to an internal trial,
the relative moisture of the hard tooth substance
is of secondary importance. CLEARFIL SA CEMENT
provides very good bonding values on both dry,
moist and wet enamel and dentine. Thanks to the
dual polymerisation mechanism, the curing time
can be controlled. After a short initial polymerisation of two to five seconds with the curing
lamp, excess material can be easily removed.

Fig. 4
Fig. 3_Bubble-free application of
CLEARFIL SA CEMENT (Universal)
directly from the Automix syringe into
the silane-treated, lithium-disilicate
glass-ceramic crown. The hard tooth
structure requires no conditioning.
Fig. 4_Ceramic crown directly
after insertion. Excess CLEARFIL SA
CEMENT can be easily squeezed out
and remains at the crown margin
without flowing away.

After light-curing the margin for 20 seconds,
the restoration will be set tight and saliva-proof

cosmetic
dentistry 1
I 37
_ 2011

[38] =>

I industry report _ CLEARFIL SA CEMENT

Fig. 5

Fig. 6

Fig. 5_After two to five seconds
of light-curing, the excess material
becomes gel-like and can be easily
removed in one piece without
leaving any residue.
Fig. 6_The approximal spaces are
carefully cleaned with SuperFloss.
The final light polymerisation phase
takes 20 seconds.

in situ. Cement not reached by the light will
polymerise within five minutes. Owing to the
thinness of the CLEARFIL SA CEMENT layer, the
cement will not alter the natural colour of the
ceramic restoration. In general, the Universal
(A2) colour shade is used. White, which shows
a better contrast with the gingiva when removing excess material, is used to shield against
dark dentine colours or under metal restorations.

Prior to definitive stump preparation, the
provisional distal and cervical crown parts received adhesive build-up fillings. For the restoration, we used the universal composites CLEARFIL
MAJESTY Esthetic and CLEARFIL MAJESTY Flow.
The self-etching, two-step adhesive CLEARFIL SE
BOND was used for the adhesive pre-treatment
of the dentine. The preparation was completed
and the colour of the crown defined using a VITA
shade guide.

_Clinical case

The impression was taken as a one-step,
putty-wash impression. Tooth #13 received a
temporary crown until the ceramic crown was
inserted. The temporary crown on tooth #13 was
removed and the core thoroughly cleaned directly before the crown was inserted. A retraction cord was used in order to ease the insertion
of the crown, as well as for contamination control purposes.

A 65-year-old patient presented with pain in
tooth #13. After examination and X-ray analysis, profound approximal caries and apical osteitis were diagnosed. Furthermore, the existing
cervical filling showed an insufficient marginal
seal (Fig. 1). The neighbouring teeth #12, 11 and
22 had already been treated with ceramic
crowns.

Fig. 7_Situation directly after
insertion of restoration and removal
of retraction cord.

After fitting the mixing tip, CLEARFIL SA
CEMENT in Universal (A2) was directly applied
into the crown with the Automix syringe (Fig. 3).
CLEARFIL SA CEMENT is supplied bubble free in
the container. Ideally, the mixing tip of the
Automix syringe should remain in the cement
during application in order to avoid incorporating any air bubbles. After application of the
cement into the restoration, the dentist has one
minute of working time in which to insert the
restoration. When cementing inlays, onlays or

Fig. 7

38 I cosmetic
dentistry

Tooth #13 first received endodontic treatment in several sessions. After all signs of inflammation had ceased, the root canal was permanently filled and a provisional crown placed
in order to ensure a non-irritated state of the
root-canal filling before placing the permanent
crown.

The gingiva appeared to be free of any irritation, the resin core was free of any clefts and
the preparation margin was exactly and clearly
defined (Fig. 2). An IPS e.max Press (Ivoclar
Vivadent) crown was provided by the laboratory
ready to use (Fig. 3). Try-in showed that the fit
was good so that the crown could be inserted
permanently. The crown was cleaned and treated
according to manufacturer’s instruction. The
stump was cleaned with water and any excess
water removed (Fig. 2).

1_ 2011

[39] =>

[40] =>

I industry report _ CLEARFIL SA CEMENT
root-canal posts, CLEARFIL SA CEMENT can also
be applied directly into the cavity. Owing to the
higher temperature in the oral cavity, the available working time is thus reduced to approximately 40 seconds.
The thixotropic properties of CLEARFIL SA
CEMENT enable easy insertion and positioning
into the final position, as the material flows under
pressure (Fig. 4). Nevertheless, excess material
will remain at the crown margin without flowing

Fig. 8

In the case described, IPS e.max Press,
a lithium-disilicate glass-ceramic restoration,
was inserted with the self-adhesive composite
cement CLEARFIL SA CEMENT. This product is
distinguished by its efficient Automix application and its dual polymerisation mechanism.
The application of the material and the insertion
of the restoration are made easier thanks to the
thixotropic effect.

Fig. 9

Figs. 8 & 9_One week after insertion
of the ceramic crown on tooth #13
the gingiva appears to be free of
irritation. The marginal fit is tight and
the transition cannot be seen with the
naked eye. The natural colour of
the ceramic is not influenced
by CLEARFIL SA CEMENT.

away and can be coagulated slightly by applying
a polymerisation lamp for two to five seconds,
depending on the lamp’s power, so that it can be
easily removed with an instrument, usually in
one piece (Fig. 5). It is important that while removing the excess material, the crown be held
fast in its final position.

CLEARFIL SA CEMENT provides secure mechanical and chemical bonding to tooth structures and restorations. It can be used in many
application areas ranging from metal, ceramic
and composite restorations to root-canal posts.
The thin layer of CLEARFIL SA CEMENT and low
solubility ensure long-term prosthetic success._

For ceramic and composite crowns, light
polymerisation occurs for 20 seconds from
both sides after removal of excess material. As
CLEARFIL SA CEMENT is dual-curing, the final
chemical polymerisation of the areas that cannot be reached by light is achieved after five
minutes, meaning that CLEARFIL SA CEMENT
can also be used under metal restorations.

_References

Cleaning of the approximal spaces with
SuperFloss (Oral-B) and the removal of the retraction cord are carried out after complete
light- and chemical curing (Fig. 6). CLEARFIL SA
CEMENT ensures a tight marginal fit and does
not influence the colour shade of the ceramic or
composite restoration.
Figure 7 shows the completed restoration
in situ directly after insertion and removal of
the retraction cord. Figures 8 and 9 show the
non-irritated state at one week after insertion
of the prosthetic provision for tooth #13. The
marginal fit is tight and the transition cannot
be seen with the naked eye.

40 I cosmetic
dentistry

_Summary

1_ 2011

1. Iwamoto N, Uctasli S, Ikeda M, Nakajima M, Tagami J. Shear
Bond Strength of New Self Adhesive Cement to Enamel and
Dentin. International Symposium for Adhesive Dentistry 2008 in
Kanazawa. Abstract #P-24.
2. Yamamoto H, Nakamura T, Wakabayashi K, Okada A, Kinuta S,
Yatani H. Mechanical Properties of New Self-adhesive Resin
Based Cement. International Symposium for Adhesive Dentistry
2008 in Kanazawa. Abstract #P-28.
3. Sadr A, Shimada Y, Tagami J. Micro leakage of Class-V Inlays using an Experimental Self-Adhesive Resin Cement. IADR Meeting in Toronto, 2008. Abstract #0404.

_contact
Kuraray Europe GmbH
BU Medical Products
Hoechst Industrial Park/F 821
65926 Frankfurt/Main
Germany
dental@kuraray.eu
www.kuraray-dental.eu

cosmetic
dentistry

[41] =>

[42] =>

I industry report _ IPS Empress Direct

Aesthetic restoration created
with composite
Author_ Dr Anna Salat Vendrell, Spain

Fig. 1

Fig. 2

Fig. 1_Pre-op situation.
Fig.2_Absolute isolation of the
operating field with a rubber dam is
the ideal form of moisture control.
Fig. 3_Preparation of a small
circular chamfer.

_The new generation of resin composite materials in combination with modern layering techniques allows today’s practitioners to treat their
patients with minimally invasive, highly aesthetic
direct restorations. Owing to their enhanced properties, these materials produce results that are
hardly distinguishable from natural dentition, especially with regard to colour, which is particularly
desirable in anterior teeth.
The new composite IPS Empress Direct (Ivoclar
Vivadent) enables us to create restorations that
are almost invisible to the human eye. The appropriate increment technique together with correct
handling of the materials and high-gloss polishing produces predictable, aesthetic results directly
in the mouth. Owing to its nano-hybrid structure,
the material can also be used to restore posterior
teeth.

Fig. 4_Etching with 37 %
phosphoric acid.
Fig. 5_Application of the adhesive.

42 I cosmetic
dentistry

1_ 2011

Fig. 3

steps of the technique used to place IPS Empress
Direct are described in this article.

_Clinical case: Step-by-step restorative
procedure
A young patient presented with a defective
resin composite filling in tooth #11. The margin
was no longer tight and the interface between the
tooth structure and the restoration exhibited
staining. What is more, the chroma, opalescence
and shade of the filling did not correspond to that
of the natural dentition (Fig. 1).

IPS Empress Direct materials are available in
various levels of opacity, translucency and brightness. By combining the different materials, toothlike light scattering can be achieved. The working

According to the treatment plan, the filling
would be removed, the cavity prepared along minimally invasive principles and the tooth restored
with a direct resin composite. In order to achieve
impeccable integration of the restoration in the
oral environment and an aesthetic smile line with
a uniform colour, the composite would have to
be placed using the increment technique. As the
cavity had walls on all sides, there was no need to
create a wax-up or a silicone template to restore

Fig. 4

Fig. 5

[43] =>

industry report _ IPS Empress Direct

Fig. 6_Application of the dentine
material in the appropriate shade,
that is, the appropriate
translucency/opacity.
Fig. 7_Application of the opalescent
material in the enamel part
of the tooth.
Fig. 8_Application of the enamel
material on the entire facial part
of the restoration.
Fig. 9_Restoration one week
after it was placed.

Fig. 6

Fig. 7

Fig. 8

Fig. 9

the tooth shape. A layering scheme was established before the treatment was begun.

opaque strips (IPS Empress Direct Bleach XL) were
applied over the dentine segment to enhance the
brightness. Finally, an appropriately shaded enamel
material (IPS Empress Direct Enamel A2) was placed
over the entire facial surface of the restoration to
cover all the previously placed materials (Fig. 8). The
creation of surface texture as well as finishing and
polishing are important working steps in imparting
a restoration with a true-to-nature appearance. As
a result, they have to be given due attention. In the
present case, the surface texture was created with
diamond burs at low speed. This allowed the procedure to be precisely controlled. A three-step silicone polishing system (Astropol) was used to finish
and polish the restoration. Finally, the restoration
was polished to a high gloss finish using aluminium
oxide, diamond pastes (Shiny System, Micerium),
brushes and felt wheels.

During the dental examination, the general
preoperative situation, the natural colour of the
patient’s teeth and individual characteristics were
photographically documented. The layering scheme
was prepared on the basis of the photographs.
The different materials that would be used for
the restoration were established in the process.
In order to reproduce the special characteristics
of the patient’s tooth anatomy, the appropriate
dentine and enamel shades were selected along
with an opalescent material and a white-opaque
material (from the IPS Empress Direct range).
At a second appointment, the operating field
was isolated with a rubber dam, since absolute
moisture control is indispensable in the placement
of resin composites (Fig. 2). The outer margins of
the old filling were traced with a pencil. This was
done to highlight the transition between the filling
and the tooth structure in the removal of the
old filling. A small chamfer was prepared on the
vestibular side, as this is indicated for this type of
restoration (Fig. 3). Next, the enamel and dentine
were etched with 37 % phosphoric acid (Total Etch)
and a three-component adhesive (Syntac) was
applied (Figs. 4 & 5).
In order to obtain the desired tooth shade, the
dentine part of the restoration was built up first
with dentine material (IPS Empress Direct Dentin
A2; Fig. 6). A translucent and opalescent material
(Trans Opal from the IPS Empress Direct range) was
used to build up the enamel part (Fig. 7). Thin white-

It is worthwhile recalling the patient for a third
appointment to ensure that the restoration blends
into the natural environment when the tooth is
moist and to establish whether any shape or colour
adjustments need to be made (Fig. 9)._

_contact

cosmetic
dentistry
Dr Anna Salat Vendrell
C/ Frederic Corominas nº 48
Torrelles de Llobregat
08629 Barcelona
Spain
annasalat@hotmail.com

cosmetic
dentistry 1
I 43
_ 2011

[44] =>

I industry report _ FenderMate

Class II fillings in
everyday clinical work
Author_ Dr Sylvain Mareschi, France

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 1_Previous amalgam filling.
Fig. 2_Composite filling.
Fig. 3_FenderMate matrix in place.
Fig. 4_Filling before initial polish.
Fig. 5_Previous amalgam restoration.
Fig. 6_Class II composite restoration.
Fig. 7_Completed restoration.

_Making proximal cavity
fillings requires a rigorous
clinical procedure that must
be easily reproducible. The
aim is to obtain a dental
morphology that reconstructs
a tight contact point and
avoids future food impaction.
Another very important goal is
respecting the anatomy and
physiology of the patients’
interdental papillae, as well
as guaranteeing the balance
and integrity of the proximal
space.

_Compression of the
papillae
It is much more difficult to obtain a good contact
point with composite compared to amalgam because
of the way composite material needs to be light-cured.
If the proximal matrix does not have a good adaptation to the tooth, then too much compression on the
composite filling material will result in cervical overhang. This in turn will compress the interdental papillae
and may cause periodontal damage to the patient’s
tooth (Figs. 1 & 2).

_The matrix

Fig. 5

Fig. 6

Fig. 7

44 I cosmetic
dentistry

1_ 2011

It is easy to understand
the importance of the role of
the matrix both in forming the
filling proximately and channelling the filling material to
the correct position. Directa’s
FenderMate matrix perfectly
fulfils the clinical needs of completing Class II cavities
(Figs. 3 & 4). The concept of a steel plate and plastic interdental wedge in one piece was initially introduced
by Directa in the concept of FenderWedge, a device for
protecting the adjacent tooth during preparation, and
replicated under the name FenderMate as a matrix
system. The aim is to facilitate the insertion of a wedge
and an anatomically adapted matrix at the same time.

The matrix can be removed in two stages. The
interdental wedge, which separates from the steel
matrix, can be taken out first and the steel matrix can
then be removed next. The matrices are available in two
sizes—narrow and regular—and for right and left
application. They are colour-coded—green and blue—
for ease of identification. FenderMate may be applied
either buccally or lingually.

_The contact point
The interdental wedge with a flexible wing keeps
the lower part of the matrix in contact with the cervical walls of the cavity. This causes a slight separation of the teeth so that when the filling is made, it is
slightly larger than usual in the proximal direction.
Once the matrix has been removed, the patient’s teeth
will return to their natural position, assuring tight
contact between the proximal spaces with the adjacent tooth.
The matrix’s convex shape positions the interdental contact point in the highest third of the tooth
and creates a papillary splay compatible with the physiology and the natural interdental space for cleaning.
The curved shape of the combined matrix and interdental wedge forms the matrix around the buccal and
lingual limits of the cavity box, and the pre-shaped
contact former creates a natural contact point on the
patient’s tooth (Figs. 5–7)._
Editorial note: This article was first published in DENTOSCOPE 58/10, 2009.

_contact
Directa AB
Box 723
194 27 Upplands Väsby
Sweden
info@directadental.com
www.directadental.com

cosmetic
dentistry

[45] =>

[46] =>

I industry news _ Ivoclar Vivadent

Lithium disilicate
meets zirconium oxide
framework made of IPS e.max ZirCAD and
a lithium-disilicate superstructure made of
IPS e.max CAD. Both parts are designed using
the new and intuitive inLab V3.80 software
from Sirona and milled with the Sirona inLab
MC-XL unit.
The IPS e.max ZirCAD framework is then
subjected to a quick sintering process in the
Programat S1. Subsequently, a homogeneous
all-ceramic bond between the two individually
milled parts is established by means of an innovative fusion glass-ceramic that has been
developed especially for the purpose. The fusion
process occurs simultaneously with the crystallisation of IPS e.max CAD.

_Treatment goals are reached more
quickly and efficiently
The IPS e.max CAD-on technique.
Front: IPS e.max CAD superstructure,
IPS e.max ZirCAD framework and the
completed IPS e.max CAD-on bridge
restoration. Centre: IPS e.max
CAD Crystall/Connect fusion glassceramic. Back: Ivomix vibrator unit.

_The IPS e.max CAD-on technique allows
dental laboratories to utilise lithium-disilicate
glass-ceramics in the fabrication of highstrength, zirconium-based bridges.
What makes the new CAD/CAM-based processing technique IPS e.max CAD-on so special is that it involves a combination of lithium
disilicate and zirconium oxide. The lithiumdisilicate glass-ceramic IPS e.max CAD offers
high strength and aesthetics. It has already
been used successfully for the fabrication of
single-tooth restorations such as monolithic
crowns.
IPS e.max ZirCAD zirconium oxide is used to
create high-strength frameworks, primarily for
bridge restorations. By means of the IPS e.max
CAD-on technique, three- to four-unit posterior
bridges that consist of aesthetic, high-strength
lithium-disilicate superstructures on a zirconiumoxide framework can be produced.

IPS e.max CAD-on takes the fabrication of
tooth- or implant-borne posterior bridges to
the next level with regard to efficiency and
productivity. This new technique enables dental
laboratories to create zirconium-based IPS
e.max CAD restorations within a day and with
little manual effort. The results leave nothing to
be desired in terms of strength, economy and
aesthetics.
The IPS e.max CAD-on technique can be used
as an alternative to the layering or press-on
technique. From this autumn, IPS e.max CAD
blocks and accessories for the IPS e.max CAD-on
technique will be available worldwide._

_contact
Ivoclar Vivadent AG
Bendererstrasse 2
9494 Schaan
Principality of Liechtenstein

_The production procedure
The CAD-on technique involves the fabrication of two components: a zirconium-oxide

46 I cosmetic
dentistry

1_ 2011

info@ivoclarvivadent.com
www.ivoclarvivadent.com

cosmetic
dentistry

[47] =>

[48] =>

International Events
2011
IADR General Session & Exhibition
San Diego, CA, USA
16–19 March 2011
www.iadr.org
International Dental Show
Cologne, Germany
22–26 March 2011
www.ids-cologne.de
ACE Tampa 2011 Conference on
Social Media & Marketing for Dentistry
Tampa, FL, USA
1 & 2 April 2011
www.acesthetics.com

CAD/CAM & Computerized Dentistry
International Conference
Dubai, UAE
12 & 13 May 2011
www.cappmea.com
AACD Boston 2011
Boston, MA, USA
18–21 May 2011
www.aacd.com
EAED Spring Meeting
Istanbul, Turkey
2–4 June 2011
www.eaed.org
IACA 2011
San Diego, CA, USA
28–30 July 2011
www.theiaca.com
AAED Annual Meeting
San Juan, Puerto Rico
2–5 August 2011
www.estheticacademy.org
FDI Annual World Dental Congress
Mexico City, Mexico
14–17 September 2011
www.fdiworldental.org
IFED World Congress
Rio de Janeiro, Brazil
21–24 September 2011
www.ifed.org
Dental-Facial Cosmetic
International Conference
Dubai, UAE
27 & 28 October 2011
www.cappmea.com

cosmetic
dentistry 1
_ 2011

[49] =>

about the publisher _ submission guidelines

submission guidelines:
Please note that all the textual components of your submission
must be combined into one MS Word document. Please do not
submit multiple files for each of these items:
_the complete article;
_all the image (tables, charts, photographs, etc.) captions;
_the complete list of sources consulted; and
_the author or contact information (biographical sketch, mailing
address, e-mail address, etc.).

I

Image requirements
Please number images consecutively throughout the article
by using a new number for each image. If it is imperative that
certain images are grouped together, then use lowercase letters
to designate these in a group (for example, 2a, 2b, 2c).
Please place image references in your article wherever they
are appropriate, whether in the middle or at the end of a sentence.
If you do not directly refer to the image, place the reference
at the end of the sentence to which it relates enclosed within
brackets and before the period.
In addition, please note:

In addition, images must not be embedded into the MS Word
document. All images must be submitted separately, and details
about such submission follow below under image requirements.
Text length
Article lengths can vary greatly—from 1,500 to 5,500 words—
depending on the subject matter. Our approach is that if you
need more or less words to do the topic justice, then please make
the article as long or as short as necessary.
We can run an unusually long article in multiple parts, but this
usually entails a topic for which each part can stand alone because it contains so much information.
In short, we do not want to limit you in terms of article length,
so please use the word count above as a general guideline and if
you have specific questions, please do not hesitate to contact us.
Text formatting
We also ask that you forego any special formatting beyond the
use of italics and boldface. If you would like to emphasise certain
words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers.
Please do not use underlining.
Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line between paragraphs. Please do
not add tab stops.

_We require images in TIF or JPEG format.
_These images must be no smaller than 6 x 6 cm in size at 300 DPI.
_These image files must be no smaller than 80 KB in size (or they
will print the size of a postage stamp!).
Larger image files are always better, and those approximately
the size of 1 MB are best. Thus, do not size large image files down
to meet our requirements but send us the largest files available.
(The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more
space should there be room available.)
Also, please remember that images must not be embedded into
the body of the article submitted. Images must be submitted
separately to the textual submission.
You may submit images via e-mail, via our FTP server or post
a CD containing your images directly to us (please contact us
for the mailing address, as this will depend upon the country from
which you will be mailing).
Please also send us a head shot of yourself that is in accordance
with the requirements stated above so that it can be printed with
your article.
Abstracts
An abstract of your article is not required.

Should you require a special layout, please let the word processing
programme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes
or endnotes, please let the word processing programme do it for
you automatically. There are menus in every programme that will
enable you to do so. The fact is that no matter how carefully done,
errors can creep in when you try to number footnotes yourself.

Author or contact information
The author’s contact information and a head shot of the author
are included at the end of every article. Please note the exact
information you would like to appear in this section and format it according to the requirements stated above. A short
biographical sketch may precede the contact information
if you provide us with the necessary information (60 words
or less).

Any formatting contrary to stated above will require us to remove
such formatting before layout, which is very time-consuming.
Please consider this when formatting your document.

Questions?
Claudia Salwiczek (Managing Editor)
c.salwiczek@oemus-media.de

cosmetic
dentistry 1
I 49
_ 2011

[50] =>

I about the publisher _ imprint

cosmetic
dentistry _ beauty & science
Publisher
Torsten R. Oemus
oemus@oemus-media.de
CEO
Ingolf Döbbecke
doebbecke@oemus-media.de
Members of the Board
Jürgen Isbaner
isbaner@oemus-media.de
Lutz V. Hiller
hiller@oemus-media.de
Editor-in-Chief
Dr Sushil Koirala
skoirala@wlink.com.np
Co-Editor-in-Chief
Dr So-Ran Kwon
smileksr@hotmail.com
Managing Editor
Claudia Salwiczek
c.salwiczek@oemus-media.de
Executive Producer
Gernot Meyer
meyer@oemus-media.de
Designer
Franziska Dachsel
f.dachsel@oemus-media.de
Copy Editors
Sabrina Raaff
Hans Motschmann

Published by
Oemus Media AG
Holbeinstraße 29
04229 Leipzig, Germany
Tel.: +49-341/4 84 74-0
Fax: +49-341/4 84 74-2 90
kontakt@oemus-media.de
www.oemus.com

Printed by
Messedruck Leipzig GmbH
An der Hebemärchte 6
04316 Leipzig, Germany

Claudia Salwiczek, Managing Editor

cosmetic

dentistry _ beauty & science
is the official publication of:

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

Copyright Regulations
_cosmetic dentistry_ beauty & science is published by Oemus Media AG and will appear in 2011 with one issue every quarter. The magazine
and all articles and illustrations therein are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable
to prosecution. This applies in particular to duplicate copies, translations, microfilms, and storage and processing in electronic systems.
Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to
check all submitted articles for formal errors and factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited
books and manuscripts. Articles bearing symbols other than that of the editorial department, or which are distinguished by the name of the author, represent
the opinion of the afore-mentioned, and do not have to comply with the views of Oemus Media AG. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed
for information published about associations, companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty
representation are excluded. General terms and conditions apply, legal venue is Leipzig, Germany.

50 I cosmetic
dentistry

1_ 2011

[51] =>

cosmetic
dentistry _ beauty & science

You can also subscribe via
www.oemus.com/abo

"

Subscribe now!

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Holbeinstraße 29, 04229 Leipzig, Germany, Tel.: +49 341 48474-0, Fax: +49 341 48474-290, E-mail: grasse@oemus-media.de

[52] =>

BEAUTY – COMPOSE IT!
Highly aesthetic restorative
• Two simple steps
• Layers like in nature
• Brilliant results

Please visit us at
Cologne
22.-26.03.2011
Stand R8/S9 + P10, Hall 10.2

VOCO GmbH · P.O. Box 767 · 27457 Cuxhaven · Germany · Tel. +49 (0) 4721 719-0 · Fax +49 (0) 4721 719-140 · www.voco.com

Now also available
in gingiva shades

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[cover] => cosmetic dentistry international No. 1, 2011

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => Reattachment and build-up of fractured maxillary central incisors [page] => 06 ) [4] => Array ( [title] => Laser-assisted cosmetic dentistry—A case report [page] => 14 ) [5] => Array ( [title] => Integration of aesthetics and function with composite resins [page] => 18 ) [6] => Array ( [title] => Restoring missing mandibular incisors with implants—What makes you hesitate? [page] => 20 ) [7] => Array ( [title] => An interview with Dr José Roberto Moura - IFED President [page] => 26 ) [8] => Array ( [title] => An interview with Olaf Sauerbier - CEO of VOCO GmbH [page] => 28 ) [9] => Array ( [title] => The Inman Aligner—Alignment - bleaching - bonding: A progressive approach to smile design (Part II) [page] => 30 ) [10] => Array ( [title] => CLEARFIL SA CEMENT—Easy to remove - hard to forget! [page] => 36 ) [11] => Array ( [title] => Aesthetic restoration created with composite [page] => 42 ) [12] => Array ( [title] => Class II fillings in everyday clinical work [page] => 44 ) [13] => Array ( [title] => Lithium disilicate meets zirconium oxide [page] => 46 ) [14] => Array ( [title] => International Events [page] => 48 ) [15] => Array ( [title] => Submission Guidelines [page] => 49 ) [16] => Array ( [title] => Imprint [page] => 50 ) ) [toc_html] =>

Table of contents

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