Cosmetic dentistry international No. 1, 2018

Cosmetic dentistry international No. 1, 2018

Cover / Editorial / Content / The prosthetic revolution - Minimally invasive prosthetic procedures and new digital tools for the treatment plan / Aesthetic Digital Smile Design: 2-D-/3-D-assisted communication and software design / Digital vs. analogue workflow on ten ceramic veneers in the maxilla / Minimal invasiveness—maximal effectiveness - The paradigm of the present decade in restorative dentistry / TouchWhite Teeth Bleaching / Age-appropriate aesthetics - Creating natural effects with VITA VM materials / New materials for a classic indication - Cementation of all-ceramic restorations using Variolink Esthetic / Bioactivity in restorative dentistry: A user’s guide / Sometimes faster, sometimes safer, sometimes both—The digital practice at IDS 2019 / International Events / Submission guidelines / Imprint

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1/18

issn 2193-1429 • Vol. 12 • Issue 1/2018

cosmetic
dentistry
beauty & science

trends & applications
The prosthetic revolution

case report

Minimal invasiveness—
maximal effectiveness

industry report

New materials for a classic indication

[2] =>

[3] =>

editorial

Dr Florin Lăzărescu
Guest Editor

Dear readers,
The concept of aesthetic and cosmetic dentistry has
evolved during last several years, involving other new
concepts and trends in dentistry. At aesthetic dentistry
congresses all over the world, the topics are involving
concepts of minimally invasive dentistry and focusing on
the differences between analogue and digital workflows.
Implant placement in the aesthetic zone and soft-tissue
manipulation for achieving aesthetic results are mandatory subjects among the invited speakers. A broad range
of topics are taken into consideration when the scientific
committee decides on the invited speakers and topics.

This anniversary edition of the ESCD meeting will really be an outstanding one according to the complexity
of organisation and number of participants (more than
600). There will be two main podiums and two parallel
hands-on sessions over the three days. For the first time
at the event, there will be a live TV studio, from where
interviews with speakers, participants, members of
the industry and organisers will be broadcast live on
ESCD’s Facebook page. For those unable to come to
Lisbon, we offer the possibility of viewing the scientific
sessions online.

The same situation applies to publications in aesthetic
and cosmetic dentistry. In this issue of cosmetic dentistry,
the authors have approached the same concepts: minimal invasiveness in a case report of total rehabilitation
in centric relation combining indirect and direct restorative
solutions; looking at digital versus analogue in a case report on ceramic veneers in the anterior r egion; minimally
invasive prosthetic procedures and digital solutions for
treatment planning.

Self-registration will make the registration process a
smooth one and the social programme throughout the
event (ESCD & Friends, president’s dinner, Portuguese
night) will foster further cohesion among the members
of our society.

I am very pleased that this issue of cosmetic dentistry
will be distributed at the 15th annual meeting of the
European Society of Cosmetic Dentistry (ESCD), which
is being held in Lisbon in Portugal on 20 to 22 Sep
tember. It is gratifying that many of the authors in this
cosmetic dentistry issue are founding or active members of the ESCD, or invited speakers to the congress.

I wish you all an instructive read and that you will be
inspired by the topics addressed and be able to implement the methods in your day-to-day practice. I also wish
you three days of science and pleasure in Lisbon, together
with the ESCD and the Dental Tribune International
family.

Dr Florin Lăzărescu
Guest Editor

cosmetic
dentistry
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2018

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| content
editorial
Dear readers

03

Dr Florin Lăzărescu

trends & applications
The prosthetic revolution

06

Dr Mauro Fradeani
page 06

Aesthetic Digital Smile Design:
2-D-/3-D-assisted communication and software design

10

Dr Antonello Demartis, Luca Borro & Dr Valerio Bini

case report
Digital vs. analogue workflow on ten ceramic veneers in the maxilla

16

Dr Michalis Diomataris, Dr Stavros Pelekanos & Michalis Papastamos

Minimal invasiveness—maximal effectiveness

20

Dr Maciej Żarow
page 16

industry report
TouchWhite Teeth Bleaching

24

Dr Nguyen Linhlan

Age-appropriate aesthetics

26

Carolin Wehning

New materials for a classic indication

28

Drs Eduardo Mahn & Juan Pablo Sánchez
page 28

new materials
Bioactivity in restorative dentistry: A user’s guide

32

Dr Fay Goldstep

meetings
Sometimes faster, sometimes safer, sometimes both—
The digital practice at IDS 2019

38

International events

40

about the publisher
Cover image courtesy of
kiuikson/Shutterstock.com
1/18

issn 2193-1429 • Vol. 12 • Issue 1/2018

cosmetic
dentistry
beauty & science

trends & applications
The prosthetic revolution

case report

Minimal invasiveness—
maximal effectiveness

industry report

New materials for a classic indication

04 cosmetic
dentistry

1 2018

submission guidelines

41

international imprint

42

[5] =>

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Available only with

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www.lightwalkerlaser.com

TouchWhite Laser Assisted
Tooth Whitening
®

www.fotona.com

The medical power of light

[6] =>

| trends & applications

The prosthetic revolution
Minimally invasive prosthetic procedures
and new digital tools for the treatment plan
Dr Mauro Fradeani, Italy

Minimally invasive prosthetic procedures
Nowadays, the demand for prosthetic treatments owing to imperfect teeth is steadily rising. The importance
given to aesthetics in our society is growing, especially
among young people, and clinicians ought to be increasingly conservative in their treatments and take precautionary measures.
This type of approach allows the dentist to maintain
most of the remaining dental structure while re-establishing a proper relationship between function, aesthetics,
and duration of the prosthetic restoration. Minimising the
removal of enamel while aiming to satisfy the aesthetic
expectations of the patient represents a risk for the clinician, especially when the remaining tooth structure is
already partly worn. When treating a case extending to
both arches with a severely worn dentition, the goal of
the clinician should be to obtain micromechanical retention and mechanical strength though paradoxically limiting the amount of tooth preparation.
By preserving the maximum amount of enamel, the clinician will be able to reduce occlusal ceramic thickness
without compromising the resistance and aesthetic result
of the restoration. The use of a minimally invasive prosthetic procedure (MIPP) will help the dentist to reduce the
biological cost of enamel removal. The key steps of this
technique are the following:
1. Increase the vertical dimension of occlusion (VDO);
2. reduce the thickness of the monolithic ceramic material;

06 cosmetic
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3. preserve the enamel during tooth preparation;
4. adhesively bond the restorations.
1. Increase of the vertical dimension of occlusion
In prosthetic restorations extended to at least one full
arch, an increase in the VDO of the patient is important in
order to achieve a successful aesthetic and functional and
restorative result. This procedure will help the clinician to
reduce the amount of dental tissue removed in conventional preparation. By increasing the VDO, the clinician will
be able to avoid invasive dental and occlusal preparation
and thus be able to bond the ceramic restoration to the
remaining enamel. A permanent increase in the VDO is a
safe and predictable procedure if done up to 5 mm (considering the absence of disease affecting the temporomandibular joint and the presence of correct disc alignment); in any case, any discomfort related to the patient’s
new VDO ratio will last no longer than one to two weeks.
When determining a modification in the VDO vertical
dimension, the clinician may consider the use of the following techniques:
– Evaluation of the required space for restorative material;
– interocclusal rest space;
– evaluation of the facial proportions;
– phonetics (“m” and “s” sounds); and
– acrylic preoperative mock-up.
Among these techniques, the one most effective in
order to gain acceptance of the new VDO by the patient
is the evaluation of speech, particularly with regard to
sibilants or “s” sounds.

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trends & applications

2. Reduction of the thickness
of the monolithic ceramic
material
The reduction in the thickness of the ceramic material
used in the restoration is a
great advantage of the MIPP
technique. It has been proven
that minimally invasive lithium
disilicate occlusal restorations,
if supported by enamel, have
a high load-bearing capacity
and therefore a high resistance
to fracture. The key to the success of the restoration is its adhesive bonding, which must always be on enamel and involve
an etchable ceramic material.
3. Preservation of enamel
during tooth preparation
The preservation of enamel
during tooth preparation is
highly important in order to implement the MIPP technique. The recommended conventional thickness in the
occlusal area for porcelain restorations is 1.5 to 2 mm;
however, these values can be reduced by using an etchable monolithic ceramic material with a decreased thickness bonded to enamel.
4. Adhesive bonding of the restorations
Adhesion to enamel can influence the design of the
tooth preparation, allowing the clinician to maintain the
maximum amount of dental structure and thereby achieve
excellent treatment results, including lower post-cementation sensitivity, improved support of the ceramic restoration and avoidance of endodontic intervention. Moreover,
a correctly performed adhesive procedure can eliminate
the need for extensive tooth preparation, as well as the
use of anaesthesia. Success will depend on the ability
to establish good adhesion between the tooth structure
and the porcelain with correct performance of the etching procedure and appropriate use of adhesive materials.

The MIPP technique is characterised into six different
classifications, which can be divided into two main approaches:
1. Confirmatory approach when the patient’s occlusion is left in maximum intercuspation:
– MIPP 0: additional restorations (anterior, posterior)
with no preparation, mainly on enamel
– MIPP 1: partial restorations (anterior veneers, posterior restorations) with minimal tooth preparation,
mainly on enamel
2. Reorganisation approach in the case of a modification
of the VDO and centric relation (CR):
– MIPP 2A: partial restorations (veneers, posterior restorations) with minimal tooth preparation, mainly on
enamel in CR
– MIPP 2B: full-coverage veneers (patient with open
bite in CR) with minimal tooth preparation, mainly on
enamel

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– MIPP 3A: one arch in CR with VDO alteration and
tooth structure preservation, mainly on enamel
– MIPP 3B: two arches in CR with VDO alteration and
tooth structure preservation, mainly on enamel
The use of the MIPP technique in prosthetic restorations aids the clinician in achieving excellent functional
and aesthetic results, avoiding invasiveness in the reduction of the tooth structure and thus allowing a more physiological occlusion and a better distribution of occlusal
forces.

08 cosmetic
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New digital tools for the treatment plan:
Guided Esthetic Treatment App
The need of clinicians all over the world for a tool that
supports them in formulation of the correct treatment
plan, combined with new technologies that simplify and
accelerate many prosthetic procedures, led us to develop a multimedia application that assists the dentist in
all of the phases of data collection and analysis. This app
is designed to interact with other available technological
tools (such as new-generation 3-D face scanners), thus

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trends & applications

facilitating an entirely digital workflow for prosthetic rehabilitation.
The GETApp (Guided Esthetic Treatment App) was
developed according to the systematic approach to data
collection created by Dr Mauro Fradeani. The app automatically analyses all of the values and information on the
patient collected by the clinician to determine the best
possible treatment to be chosen. The user can modify the
suggested treatment plan at any time, by adapting the selected parameters according to his or her specific needs.
The tool guides the dentist step by step through the
complete decision-making process, aiding him or her in
achieving optimal aesthetic and functional results. The
two main phases of data collection and processing offer
detailed clinical explanations, which contribute to making
GETApp a modern educational system for both simple
and complex prosthetic rehabilitation.
By the clinician following all of the suggested steps
and entering all of the requested values and parameters,
the app automatically generates a PDF file containing all
of the information provided by the clinician. This allows
him or her to easily share with the dental laboratory every
detail for the fabrication of the ideal prosthetic work.
In conclusion, the benefits and possibilities provided
by the GETApp to the clinician are as follows:
– Collection of data for patient anamnesis (the GETApp
system can replace the medical records);
– collection of all of the clinical data necessary for good
communication with the dental team (radiographs, periodontal chart, health of each tooth, tooth colour, previous dental treatments to be redone, stomatognathic
dysfunction);
– guided and predictable method for dental photography
and case documentation;
– collection of all aesthetic and functional values necessary for formulation of the treatment plan;

|

– complete and automatised support in formulation of the
treatment plan;
– effective communication with the dental laboratory; and
– effective communication with the patient.
Innovative operative protocols such as the MIPP, combined with the use of modern digital systems such as the
GETApp, represent a revolution in the approach to prosthetic treatment. These new procedures will undoubtedly
help the clinician to confidently perform comprehensive
treatments involving dentures, crowns and veneers on
natural dentition and implants, from simple to complex
full-mouth rehabilitation.

about
In 1979, Dr Fradeani graduated
in medicine and surgery from
the University of Ancona (now the
Università Politecnica delle Marche),
Italy, where he then completed
a specialisation in dentistry in 1983.
He is a past President of the European
Academy of Esthetic Dentistry
(2003/2004) and of the Accademia
Italiana di Odontoiatria Protesica (1999/2000), and was a
visiting associate professor in prosthetics at Louisiana State
University, New Orleans, US, from 1999 to 2008.
He is an active member of the American Academy
of Esthetic Dentistry and maintains membership
of the American Academy of Fixed Prosthodontics.
He is the founder and Director of the ACE Institute in Pesaro,
Italy. He is also the founder and Director of Fradeani Education,
an educational project developed together with a group of
expert speakers with the goal of promoting an Italian model
of excellence in dentistry throughout the world. He is the author
of the two-volume series Esthetic Rehabilitation in Fixed
Prosthodontics, translated into 11 languages (Quintessence,
2004 and 2008). He runs a private practice in Pesaro
limited to prostheses on natural dentition and implants.

cosmetic
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| trends & applications

Aesthetic Digital Smile Design:
2-D-/3-D-assisted communication
and software design

Fig. 1

Fig. 2

Introduction
The communication between dentist and patient is
important, especially in cases of partial or complete
aesthetic restoration in the anterior (smile makeover).
Nowadays, it is important not only to treat oral pathol-

ogy, but also to request an aesthetic evaluation of the
patient’s smile to obtain results that respect the patient’s
aesthetic expectation. The smile is our business card
and represents the first thing that distinguishes us in
human relationships, in work and in social life. It is necessary to know that a smile can appear unpleasant even
if there are no evident issues or pathology, influencing
people/patients’ psychologically. The clinician should
understand the psychological needs of desire, perception and personality to explain in a better way the necessary therapeutics and/or aesthetic choices. When a
smile is being designed, these parameters are fundamental and dependent on the communication with the
patient and they should be considered in the evaluation
of a 360° clinical approach. It often happens that patients are not able to identify their expectations, so dentists must be able to consider whether their exigencies
can be satisfied.
What does the clinician need to plan an aesthetic
dentistry treatment? What is needed to plan a smile
that is integrated into the face? The diagnostic history
of each clinical case must include anamnesis, analogue
and digital clinical models, radiographic examination, intraoral and extraoral photographs, functional analysis,
aesthetic dentofacial analysis, intraoral diagnosis, static

Fig. 3

10 cosmetic
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Dr Antonello Demartis, Luca Borro & Dr Valerio Bini, Italy

Fig. 1
Fig. 7a

[11] =>

trends & applications

Fig. 5

Fig. 4

and dynamic extraoral diagnosis, the psychological approach to the patient and informed consent.

Of benefit for the clinician, regarding the patient, is to
employ intuitive language in taking a subtle approach to
the patient, and he or she must subject himself or herself
to the expertise of aesthetic dentistry to become the real
protagonist of aesthetic dentistry. As patients’ requests
mainly relate to aesthetics, we must depend on the definition of “aesthetic smile” to know how to apply it appropriately. Is there a concept of “beauty” achievable in
aesthetic dentistry? In our opinion, a smile cannot lose
its meaning, attraction and personality; therefore, it has
psychological, sociological and communicative involvement. Only through effective communication can we answer to the needs of the evolution of the past 50 years.
Today, it is easy and possible to communicate regarding
aesthetics, owing to the instant availability of the digital
image and since the image is a universal language, easy,
immediate and decoded.
With the progress of technology and the introduction
of digital photography, programme and protocols have
been introduced to facilitate communication increasingly through the preview of the treatment result that the
patient will receive (smile design or oral design). More
generally, Digital Smile Design (developed by Dr Christian

Fig. 1
Fig. 7a

Fig. 6

Coachman) allows the use of presentation software
(Keynote, Apple, or PowerPoint, Microsoft) or software
specifically dedicated to dentistry. In addition to these,
regarding 2-D aesthetic pre-visualisation, it is possible
to use image editing software, such as Photoshop Smile
Design as described by Dr Edward McLaren and Aesthetic Digital Smile Design (ADSD) by Dr Valerio Bini.
A detailed smile analysis and its design are fundamental parts of this method and indispensable for the formulation of the treatment plan for the clinical case. The first
step involves the acquisition of images and video (static
and dynamic dentofacial) on the basis of the ADSD protocol (Figs. 1–3). The import of these important elements
into the aesthetic digital file of the patient is complementary to the anamnesis because they are integral to the
objective intra- and extraoral examination.

Fig. 2

Fig. 3
Fig. 7b

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| trends & applications

Fig. 8a

Fig. 8b

Fig. 8c

Fig. 8d

The second step involves the aesthetic analysis according to the main guidelines. Dynamic smile analysis
and dentolabial phonetic analysis are identified in their
characteristics through recording images caught during
sleep, speaking and smiling, allowing better understanding of the variation of the soft perioral tissue.

Nowadays, digital technology is a successful reality
and a confirmed part of daily life in wider society; consequently, the digital workflow in dentistry has become
suitable for all professionals.

Aesthetic Digital Smile Design
The dentist must communicate and explain to the patient how the smile can be improved and personalised;
therefore, it is necessary pre-visualise the outcome of an
ideal aesthetic treatment to show it to the patient using
images.
In order to satisfy the exigencies of both the patient and the team in a clinical case, the methodology
of ADSD allows the clinician to analyse and provide
an indication of the dimensional and morphological
aesthetics of the tooth volume, starting from the acquisition of 2-D elements useful to the aesthetic analysis
through photographs, an instrument we can all have
in our clinic. The smile design digitally realised in 2-D
offers the ability to obtain new and predictable compositions of aesthetic tooth design using images in 2-D
with visual perception in 3-D (picture-in-picture). Digi-

Fig. 7
Fig. 8e

12 cosmetic
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[13] =>

trends & applications

Author, Country
Fig. 9a

Fig. 9b

Fig. 9c

Fig. 9d

tal processing of the images can be done in different
ways according to the exigencies of the smile designer;
currently ADSD can be executed using the well-known
graphics editing programme Adobe Photoshop CC
(Adobe Systems).
ADSD uses a particular set-up dedicated to the smile
designer, through which it is possible to use this well-designed software in a simple way by the dental team. The
ADSD method provides a photographic result that as far
as possible reflects the clinical reality. Forms, colours,
disposition and aesthetic dental composition are inseparable from the aesthetic facial composition. They perform
a primary role through the 3-D visual perception that the
digital dental image editing yields. Once the images have
been imported into the work area of the software, the
frontal and lateral photographs (digital orthogonal projection planning) are aligned to develop the dentofacial
mapping related to all its main components (ADSD digital
face mapping; Figs. 4 & 5).

Fig. 10a

Fig. 10b

Through the visual information provided, the smile design or oral design is a useful way to communicate to
the patient the envisioned aesthetic dental composition
of the smile, synonymous with predictability. This offers
a great instrument for communication in a 360° clinical
approach, especially with the dental team. The modelling
and placement confer the aspect and the visual 3-D perception of the tooth morphology that the dental team will
copy in the CAD modelling phase (Fig. 6).

3-D modelling
In aesthetic dentistry, the role of 3-D has begun to assume greater importance both in the optimisation of the
clinical workflow and as an important improvement to
the efficiency in communication between dentist and
patient. 3-D modelling is a technical discipline that provides the virtual reconstruction in 3-D of an object in the
real world. This discipline, which has its origins in architecture and design, is used in unusual contexts, such

Fig. 10c

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| trends & applications

Fig. 10d

Fig. 10e

as biomedical field. Dentistry was the first discipline to
use 3-D modelling as an instrument perfectly integrated
into the work process. Other medical disciplines followed
and now this technique is frequently used in clinical and
research contexts.

Fig. 10f

Because of this, smile design could be defined as dental
specialisation that can certainly use 3-D as a significant
instrument of support for a large part of clinical and diagnostic activity. 3-D in smile design overcomes all of the
limits of 2-D technology. Currently, 3-D permits the user
to select teeth from a 3-D library, available in commercial
software, or to realise a personal database starting from
an intraoral scan (Figs. 7a & b).
The advantage that 3-D technology certainly can offer
is relevant: it allows the design of patient-specific teeth
directly in 3-D, allowing quick access to all production
systems, including rapid prototyping. There are many
software programmes available that facilitate working in
3-D, and among these, there is one that is appreciated for
a series of characteristics that are different from the others, such as its ease of use, being entirely free of charge
and its infinite versatility. The factotum software is called
Meshmixer and is from Autodesk, a leader in 3-D software. It allows the designer to work at 360° on the mesh,
generating an infinite series of modification (Figs. 8a–e).

Fig. 10g

3-D prototype
An important improvement to the workflow of smile
design is the printing of prototypes with the new 3-D
printers, facilitating an increase in the efficiency in the
modality of communication between dentist and patient.
From a clinical point of view, dentistry, more than the
others, is a discipline that permits a very concrete and
realistic use of 3-D printing. There are different printing
technologies now available, but in dentistry, the technologies mainly used are stereolithography (SLA) and
PolyJet (Stratasys).

Fig. 10h

SLA is a printing technology that uses photosensitive
resin to produce physical objects thorough the use of
laser light. This photosensitive resin contains photoactivators, such particular molecules that polymerise if
exposed to a luminous ray of a certain wavelength. A subgroup of SLA is digital light processing (DLP), a technology that uses light to polymerise resins as well, but the
luminous source is the beam emitted from a projector in
LED (not laser).

Fig. 10i

14 cosmetic
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Fig. 11a

[15] =>

trends & applications

Fig. 11a

Fig. 11b

PolyJet technology ejects drops of resin from nozzles
on to the build tray and the resin is polymerised by a diffused light of a determinate wavelength. Unlike SLA technology, PolyJet makes use of high-cost machinery without providing added value considering that the same is
obtainable with some low-cost technologies. Owing to our
experience, we prefer to utilise an SLA printer to realise a
3-D resin model, and based on this, a silicone key (negative reproduction) is fabricated, then we place the acrylic
resin into the silicone key and thereafter insert it into the
patient’s mouth and wait until it solidifies. In the meantime,
we remove any excess material from the silicone key. After
polymerisation, we remove the silicone key and finish the
resin plate as best we can. Once these steps have been
completed, we show to the patient our vision of the aesthetics of his or her smile, based on our earlier analysis
with digital analysis of photographs and successively prototyped in 3-D simulated in his or her mouth, and we evaluate with him or her the envisioned final result (Figs. 9a–d).

3-D model that is cost-effective and reproducible to obtain a prototype from a digital photograph of the smile.
Meshmixer software for 3-D design has the advantage of
being open source and using it requires minimal learning.
Moreover, with Meshmixer, one can create in an easy way
a personal digital dental database complementary to the
2-D library. The database can be modified following the
rules of smile design that has as its purpose 3-D printing of
a model in resin characterised by high accuracy of details.
This article originally appeared in DT France 6&7/2018.

about
Dr Antonello Demartis is a cosmetic
dentist in private practice.

Discussion
In our opinion, photography provides the ideal mor
phological indication of the new smile that should be
communicated to the patient. With ADSD 2-D methodology, we obtain some indication useful also for the team
that can develop, through 3-D modelling, a prototype silicone key to test in the mouth with resin. The purpose of
aesthetic pre-visualisation with ADSD is to demonstrate
to the patient what we can obtain from the aesthetic
analysis of photographs and the possible treatment plan
(Figs. 10a–i). The problem today, in this communication
with 3-D, is the absence of a texture that looks similar to
that of the natural dentition, so when the model is shown
to the patient, it may evoke a negative reaction owing to
what may appear to be a very poor integration. Such visualisation of a natural texture can at present be obtained
only with photography (Figs. 11a & b).

Conclusion
A series of technical procedures have been proposed
that involve digital smile design, ranging from 2-D to 3-D.
This article has described an alternative method for a

Luca Borro is a specialist architect
in medical 3-D modelling and
multidisciplinary innovation in medicine.

Dr Valerio Bini is a prosthetic and
cosmetic dentist. He is the author of
numerous articles published in national
and international journals on digital and
cosmetic dentistry and has presented
papers at international conferences on
aesthetic dentistry and aesthetic medicine.
He is the developer of Aesthetic Digital
Smile Design, an aesthetic virtual
planning method helpful for aesthetic dentofacial analysis.
Dr Bini is an active member of the Digital Dentistry Society.
He can be contacted at info@studio-bini.com.

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| case report

Digital vs. analogue workflow
on ten ceramic veneers in the maxilla
Dr Michalis Diomataris, Dr Stavros Pelekanos & Michalis Papastamos, Greece

Fig. 1

Fig. 2a
Fig. 1: Initial photograph of the anterior teeth prior to orthodontic treatment.
Fig. 2a: Anterior teeth after orthodontic treatment. Fig. 2b: Extraoral photographs after orthodontic treatment.
Fig. 2b

Introduction
Different materials and treatment options are available in
aesthetic and restorative dentistry for the anterior region.
The conventional protocol, including an analogue impression with polyether or polyvinylsiloxane, a master cast and
die fabrication, waxing and pressing of ceramic materials,
requires exceptional skills and is technique-sensitive. Intraoral scanning and digital impression taking provide an accurate alternative method for transferring information from
the mouth to the dental laboratory.1 The digital file is always
on the computer and can be immediately processed or at
any time, unlike with the conventional procedure.
Regarding materials, various newer products, such as
pressed or milled ceramics, offer enhanced strength and

functionality; however, in thinner dimensions, they lack the
inherent aesthetic beauty of conventional materials such as
feldspathic porcelain. As patient demand for better aesthetics has increased in recent years so too has the need for
restorative materials that closely mimic the patient’s natural dentition. Initially used for the creation of porcelain dentures, feldspathic porcelain has emerged as the premier
aesthetic material for custom veneer restorations. In recent
years, the use of hand-layered powder/liquid feldspathic
porcelain has been revived based on its highly aesthetic
values and little to no preparation requirements. By keeping
preparation to a minimum, less tooth structure is removed
and procedures are much less invasive, which is exactly
what patients desire.2

Fig. 3

Fig. 6a

Fig. 4

Fig. 5

Fig. 6b

Fig. 7

Fig. 3: Digital smile design indicating crown lengthening of teeth #13, 12, 11 and 21 and restorative treatment of the ten anterior teeth. Fig. 4: Wax-up on
the stone model concerning the restorative treatment of the ten anterior teeth. Fig. 5: Three-dimensionally printed model of the digital smile design planning,
bearing a mock-up shell. A cervical opening was introduced for surgical access and guidance for crown lengthening. Figs. 6a & b: Intraoral fit of the surgical
guide for crown lengthening. Fig. 7: Periodontal tissue of the anterior teeth six months after crown lengthening.

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case report

In contrast, the conventional methods of
ceramic fabrication have been described
as time-consuming, technique-sensitive and
unpredictable owing to the many variables,
and thus CAD/CAM may be a good alter-

Fig. 9a

native for both dentists and laboratories.3
CAD/CAM may also reduce the fabrication time of high-strength ceramics by up to
90 per cent.1 Furthermore, industrially fabricated blocks are more homogenous, with
minimal flaws, and CAD/CAM restorations
have been found to compare favourably
with other restorative options.4, 5
As far as optical properties and CAD/
CAM are concerned, the fact of complex optical illusion phenomena in anterior aesthetics cannot always be met with
monochromatic aesthetic materials without the need for final characterisation by
a dental technician. In order to overcome
such aesthetic disadvantages of a monochromatic restoration, multichromatic ceramic blocks have been developed to create a 3-D layered structure. These ceramic
blocks offer a gradient of chroma from the
cervical to the incisal areas that replicate
dentine and enamel in the same block.6–8
The aim of this case report is to compare
the analogue versus the digital workflow on
ten ceramic veneers in the maxilla, in terms
of aesthetic outcome, length of procedures
and technical sensitivity for both the dentist
and the dental technician.

Fig. 15a

Fig. 8a

Fig. 8b

Fig. 9b

Fig. 9c

Fig. 10

Fig. 11

Fig. 12a

Fig. 12b

Fig. 13

Fig. 14

Fig. 8a: Mock-up silicone index. Fig. 8b: Intraoral photograph of the mock-up. Fig. 9a: Preparation through
the mock-up. Fig. 9b: Check of the preparation depth, with the use of the silicone guide, palatal aspect.
Fig. 9c: Final preparation of the teeth. Fig. 10: Analogue impression with polyvinylsiloxane. Fig. 11: Digital impression with TRIOS. Fig. 12a: Digital planning of the provisional restorations. Fig. 12b: Provisional restorations
intraorally (Telio CAD). Fig. 13: Analogue workflow (refractory dies, built-up veneers, adjustments, staining/
glazing). Fig. 14: Digital workflow (3-D printed model, CAD/CAM veneers, adjustments, staining/glazing).

Fig. 15b

Fig. 15c

Fig. 15a: Feldspathic veneers with try-in paste. Fig. 15b: CAD/CAM veneers with try-in paste. Fig. 15c: First quadrant feldspathic veneers and second
quadrant CAD/CAM veneers simultaneously with try-in paste.

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| case report

Fig. 16a

Fig. 16b

Fig. 16c

Fig. 16d

Fig. 16e

Fig. 16f

Fig. 16a: Isolation field and try-in of the fit of the veneers on teeth #11 and 21. Fig. 16b: Etching of the enamel for 30 seconds with a 32 % orthophosphoric acid.
Fig. 16c: Application of the bonding agent. Fig. 16d: Final polymerisation of the veneers. Fig. 16e: Veneers in situ before finishing and polishing procedures.
Fig. 16f: Final outcome immediately after removal of the rubber dam.

Case report
A 35-year-old patient presented at the office with the chief
desire that the aesthetics in the anterior region be changed
(Fig. 1). A diagnostic wax-up was performed, followed by
mock-up fabrication, in order to obtain a preliminary visualisation of the final outcome. Orthodontic treatment was
proposed in order to align the teeth in a more favourable
position for veneers requiring minimal preparation and to
reduce the overbite. One year after treatment, the patient
returned for the final prosthetic rehabilitation (Figs. 2a & b).

Fig. 17a

Fig. 17b

Fig. 17c

Fig. 17e

Fig. 17d

Methods and materials
Digital smile design according to Coachman and
Calamita9 was performed, from which a treatment plan of
crown lengthening and veneers on teeth #15–25 (Fig. 3)
was proposed. A conventional diagnostic wax-up was also
produced (Fig. 4). Both digital and conventional mockups were applied, and agreement was attained concerning tooth shapes and proportions. Crown lengthening was
performed, guided by the digital mock-up, with the use of
an acrylic transparent double crown lengthening guide that
indicated the borders of the gingivectomy and alveolectomy
needed in periodontal surgery for aesthetic rehabilitation (Figs. 5 & 6).10
After six months of tissue stabilisation
(Fig. 7), a mock-up was produced with
Telio CS C&B (Ivoclar Vivadent) chairside
(Figs. 8a & b), and tooth preparations with
silicone guides were performed (Figs. 9a–c).
Both conventional impressions with polyvinylsiloxane (Fig. 10) and digital impressions
(TRIOS, 3Shape) were taken (Fig. 11).
Provisionalisation was executed digitally,
using Telio CAD (Ivoclar Vivadent) in the
Wieland Select CNC milling machine. The
design was performed with the 3Shape
DentalDesigner 2015 software (Figs. 12a & b).
Two sets of final restorations were fabricated.
The set of feldspathic veneers was fabricated
on a stone model using IPS Style (Ivoclar
Vivadent), while IPS Empress CAD Multi
(Ivoclar Vivadent) was used for the digital
set (Figs. 13 & 14). Both sets were examined
intraorally with a try-in paste to compare the
optical properties of the feldspathic and the
CAD/CAM veneers (Figs. 15a–c).

The subjective decision of the clinician and
Fig. 17a: Final outcome one week later. Fig. 17b: Final outcome one week later, frontal view. Fig. 17c: the patient was to cement the feldspathic veLips at rest, exposure of the incisal edges. Fig. 17d: Wide smile. Fig. 17e: Extraoral final photographs. neers, owing to slight differences in the length

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case report

about

Fig. 18a

Dr Stavros Pelekanos graduated
School of Dentistry, National and
Kapodistrian University of Athens in
Greece and received Doctoral promotion
Dept. of Prosthodontics, School of
Dentistry, Albert-Ludwigs University
of Freiburg, Germany. He was a clinical
instructor, Dept. of Prosthodontics,
School of Dentistry, National and
Kapodistrian University of Athens from 1994–2001. He has
published many scientific articles and abstracts, one chapter
in a book, and received 2nd prize at the scientific award
competition of the EAED in Madrid, Spain, 2008.
Dr Pelekanos is in private practice in Athens (AthinaSmile,
www.athenasmile.gr) with emphasis on prosthodontics, aesthetic
dentistry, pre-prosthetic periodontology and implantology.
He is Asst. Professor, Dept. of Prosthodontics, School of
Dentistry, National and Kapodistrian University, Athens.

Fig. 18b
Fig. 18a: Subjective comparison criteria per step between analogue and
digital workflows. PVS = polyvinylsiloxane. Fig. 18b: Laboratory duration per
step between analogue and digital workflows. PVS = polyvinylsiloxane.

of the central incisors between the two sets. Adhesive procedures followed (Figs. 16a–f), and final intraoral and extraoral photographs were captured one week later (Figs. 17a–e).
Results
Intraoral digital scanning is a perfect alternative clinical
procedure compared with the conventional impression
technique. The digital planning and mock-up procedure
is a powerful communication tool for the dentist, although
special skills in using computer software are required. Regarding the laboratory workflow, most of the analogue procedures require more time (refractory dies, built-up veneers,
adjustments), except the staining/glazing (Figs. 18a & b).
Although the aesthetic outcome of the feldspathic veneers
was subjectively chosen in this case, the analogue workflow
is much more demanding. The digital approach, because
of the reduced difficulty, speed, complexity and patient discomfort, tends to be preferable (Figs. 18a & b).

Conclusion
Knowledge and application of virtual smile design procedures, coupled with innovative dental laboratory technologies, allow dentists to diagnose, plan, create and deliver
aesthetically pleasing new dental compositions. Furthermore, advances in CAD/CAM technology have catalysed
the development of aesthetic veneer restorations with industrially produced materials possessing superior biomechanical properties and good aesthetics.

Dr Michalis Diomataris received his
DDS in 2009 from the University
of Athens Dental School, Greece.
In 2017 he received his master
specialty from the postgraduate
programme of Operative Dentistry of
the University of Athens. Since 2011,
he is supervisor in the education of the
undergraduate dental students, in the
contemporary principles of aesthetic and restorative dentistry.
In 2013 he received the first award of a national competition
between the postgraduate students of Operative Dentistry
of the national Dental Schools, presenting a case with
the topic of “class IV restoration of a maxillary central incisor”.
Since 2014, he is a member of the team of Stavros Pelekanos’
Dental Clinic—AthinaSmile, in Athens, Greece, practising in
aesthetic and restorative dentistry and prosthodontics.
Michalis Papastamos completed
his studies in 1983 and ever since
he is active on the dental field.
Since 1989 he is the owner of the
“Dental Aesthetic” dental laboratory,
which is specialised in aesthetic
restorations. He attends seminars
of well established dental technicians
and dentists in Greece and abroad,
investing in the upgrading of his knowledge and educational
level. Moreover, he organises and delivers seminars and
demonstrations himself and has participated, in collaboration
with Greek and foreign dentists, in complete live dental
rehabilitation programmes, being in charge of the dental part.
He cooperates with the dental school of the National and
Kapodistrian University of Athens, in the field of Prosthodontics.

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| case report

Minimal invasiveness—
maximal effectiveness
The paradigm of the present decade
in restorative dentistry

© MichaelJayBerlin/Shutterstock.com

Dr Maciej Żarow, Poland

Introduction

Case report

This article describes a case in which severe tooth
damage was presented and complex oral rehabilitation
was planned. Part of the rehabilitation had been completed more than a decade before, and the rest only recently. Although there was only ten years between these
two treatments (upper arch in 2005 and lower arch in
2015), a significant paradigm shift was evident concerning the treatment planning and with respect to the
amount of tooth reduction.

A 25-year-old female patient reported to the dental office 12 years ago in order to improve her smile (Figs. 1–3).
Her anterior maxillary and mandibular teeth were severely damaged owing to a past chronic eating disorder. In 2005, complex oral rehabilitation was planned for
the patient, starting from the upper arch. For the maxillary posterior teeth, full-ceramic onlays were planned and
placed, while for the maxillary anterior teeth, full-ceramic
crowns were fabricated (Figs. 4–6). A decade ago, this

Fig. 1

Fig. 2

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Fig. 3

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case report

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9

was the standard procedure in such a
case of structural damage.
The patient, happy with the appearance
of the maxillary teeth when smiling, did not
present for the completion of the complex rehabilitation until 2015. During the
past ten years, some of the full-porceFig. 10
lain crowns had sustained minor chipping
(Figs. 7–9), which was a result of the unfinished rehabilitation. After a decade of advances in dental
technology and treatment planning, we could propose to
the patient a new option, one that was minimally invasive
and without the extent of tooth reduction associated with
the work carried out ten years earlier.
Treatment planning
The Kois deprogrammer was employed in order to register the centric relation and articulate the models in this
position. A wax-up of the lower arch was obtained, and
the vertical dimension of occlusion (VDO) was slightly increased, based on aesthetic analysis. The obvious benefit of the VDO increase was also the fact that there would
then be enough space for the restorative material without
additional tooth reduction. The appropriate mock-up procedure and phonetic analysis were performed to confirm

Fig. 12

Fig. 13

Fig. 11

this. In the posterior area, lithium disilicate onlays were
used, while direct composite resins were planned for the
anterior teeth.
Restorative phase: Posterior teeth
For the mandibular posterior teeth, minimally invasive
preparation took place, generally only in order to produce sharp, visible borders for the laboratory preparation procedures. The entire preparation surface was
meticulously polished, with the exception of the borders,
to remain sharp and evident for the dental technician.
In order to ensure sufficient occlusal volume for the
restorative space, a pattern resin jig was fabricated on
the articulated study models with increased VDO and
transferred to the mouth for control (Fig. 10). Impressions
were taken, and the lithium disilicate (IPS e.max, Ivoclar

Fig. 14

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Fig. 15

Fig. 16

Fig. 17

Fig. 18

Fig. 19

Fig. 20

Vivadent) onlays were fabricated in the laboratory (Fig. 11).
At the next appointment, the onlays were tried in for
correct marginal adaptation and adhesively luted under
rubber dam isolation (Figs. 12–20).
Restorative phase: Anterior teeth
The teeth were cleaned with pumice, and the incisal
parts were abraded with 50 µ aluminium oxide particles.
On the incisal vestibular edge, a 1 mm chamfer was obtained using a diamond ball tip (001-006-2, Olident), and
the lower part of the chamfer was delicately elongated
using an 80° bevel (around 0.5 mm; Figs. 21 & 22). The
mandibular anterior teeth were found to be tight and

Fig. 21

Fig. 22

Fig. 24

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The enamel and dentine were etched with 38% phosphoric acid for 20 seconds, then OliBOND adhesive (a
fifth-generation prime and bond adhesive, Olident) was
meticulously applied to the dentine and enamel, rinsed
with water, air-dried and light-cured for 20 seconds.
The restorative phase of the anterior teeth consisted
of creating an external box, placing inside a layer of inner composite followed by a final outer composite layer.
The procedure does not have to be too complex to

Fig. 23

Fig. 25a

22 cosmetic

crowded; consequently, the operator found it easier to
restore the teeth without rubber dam isolation.

Fig. 25b

Fig. 25c

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case report

Fig. 26

Fig. 27

Fig. 28

achieve a predictable result; one can obtain correct layering with only two syringes
of composite resin (Fig. 23).
Based on the wax-up (Fig. 24), a silicone index was made and cut in the frontal
plane. With the lingual part of the index, the Fig. 29
back shell of the reconstruction was created using a thin layer of nano-filler composite (OliREVO, Shade A3, Olident). In the next stage,
the approximal surfaces were built up with the same composite material, and by means of the BlueView VariStrip
(Garrison), which provides an anatomical shape mesially
and distally (Figs. 25a & 26). When all of the boxes had
been prepared, the inner, more opaque layer (OliREVO,
Shade OA2) was applied, and the mamelons were shaped
before polymerisation in order to create natural internal
characterisation (Figs. 25b, 27 & 28). The inner layer
was polymerised, and finally the outer layer of composite
(OliREVO, Shade OA2) was applied in a thickness of more
or less 0.5 mm (Figs. 25c & 29). This layer was meticulously brushed with the modelling brush and finally polymerised with slight time extension (40 seconds for each
of the surfaces). After minor bite corrections, the final
characterisation was done. First, the primary anatomy
was achieved by contouring the transition
angles and incisal edge. The next step was
to start reproducing the secondary anatomy: the division of the lobes. These were
drawn in pencil (Fig. 30) and formed with a
diamond bur (831-204-012, Komet Dental/
Brasseler; Fig. 23). Next, a rubber point
was used to smooth the rough surface left
by the bur. The rubber point was also used
to give an initial gloss to the restoration.
The restoration was polished with 1 µm di- Fig. 31
amond paste applied with a natural goat
hair brush used at 1,000 to 10,000 rpm.
The satisfactory clinical result of the
lower arch restorative rehabilitation can be
seen in Figures 31 to 33. The 24-month
clinical control showed excellent clinical
behaviour with respect to the lithium disilicate onlays and anterior composite resin
restorations (Fig. 34).

Fig. 33

Fig. 30

Conclusion
By increasing the VDO, it is possible to achieve additional space for the restoration, and in this way to minimise
the tooth reduction and maximise the adhesion owing
to residual enamel. Correct treatment planning and utilisation of a wax-up and silicone index allow predictable
results for the final shape and shade of the composite
restoration.

contact
Dr Maciej Żarow (DDS, PHD) is in private practice
and runs a dental education centre in Cracow in Poland
(www.kursydentist.pl). He can be contacted at
maciej.zarow@dentist.com.pl or facebook: Maciej Zarow.

Fig. 32

Fig. 34

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TouchWhite Teeth Bleaching
Dr Nguyen Linhlan, Australia

Introduction
Discolouration of teeth is a common aesthetic problem and bleaching is the most conservative treatment
option when compared to other restorative techniques
used to change tooth colour. The mechanism of the
bleaching process is based on the penetration of different
oxygen radicals, which occurs during the decomposition of hydrogen peroxide (H2O2) into discoloured dentine,
thus modifying the dentine colourant molecules through
an oxidation reaction.1 Most of the in-office bleaching
gels contain hydrogen peroxide and these agents are frequently used with an activator such as heat or light. Light
sources accelerate the bleaching procedure by heating

24 cosmetic
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the bleaching gels to increase the decomposition rate
of oxygen to oxygen-free radicals and raise the release
of stained molecules.2 The Er:YAG laser wavelength has
been described as a safe and effective light source option
for office bleaching treatment.1–4
TouchWhite patented tooth whitening makes use
of the fact that the Er:YAG laser wavelength has an
absorption peak in water, which is the major component
of aqueous bleaching gels. This eliminates the need for
any additional absorbing particles in the bleaching gels.
More importantly, taking into account thermal burden
considerations, the TouchWhite procedure represents
the most effective and least invasive laser whitening

© wavebreakmedia/Shutterstock.com

| industry report

[25] =>

industry report

Fig. 1

Fig. 2

Fig. 3

Fig. 1: Before treatment. Fig. 2: During treatment. Fig. 3: After 18 days.5

method possible. Due to its high absorption in bleaching
gels, the Er:YAG laser beam is fully absorbed in the gel
and does not penetrate to the hard tissue or the pulp. All
of the laser energy is thus effectively used for the heating
of the gel. There is no direct heating of the dental tissue
and the pulp, as is the case with other laser-assisted whitening methods. There is also no risk of accidentally damaging the hard dental tissue as the laser fluence of every
laser pulse is set significantly below the ablation threshold for dental tissues. As a consequence, the procedure
can be performed with a minimal undesirable thermal
burden on the tooth and the tooth whitening speed can
be safely increased by 5 to 10 times.1, 4

Case report
A male patient in his late thirties suffered a sporting
accident some fifteen years ago that left his upper left
central incisor with necrotic pulp, which discoloured after
root canal therapy. The aim of treatment was to lighten
the tooth colour in preparation for a ceramic veneer using
the TouchWhite protocol (LightWalker laser system,
Fotona).

Treatment
The palatal resin restoration was removed. The GP
was removed to the cervical dentine level. A layer of
GIC lining was placed to protect the cervical dentine.
Clear hydrogen peroxide (35%) was used as the bleaching
gel. The Fotona TouchWhite protocol was used to activate the bleaching process. We used the R16 handpiece with the following parameters: VLP, 0.75 W,
10 Hz. The gel was placed in the pulpal chamber and on
the labial surface. The laser beam alternatively activated
the gel for 20 seconds on the labial surface and on
the pulpal chamber (three applications on each side).
The gel was washed off and replaced with a fresh gel
coating before administering another three applications.
The discolouration subsided significantly after six activations. Before the session ended a cotton pellet soaked
with bleaching gel was placed in the pulp chamber.
It was activated three times, each time for 20 seconds
with 20 seconds rest in between activations. A tempo-

rary restoration was placed with the cotton pellet remaining in the chamber.

Result
The treatment was reviewed after 18 days showing
a complete recovery. The palatal composite resin was
placed and the patient no longer needed a ceramic veneer. Many factors contributed to a successful result:
1. A high concentration bleaching gel with higher pH.
2. The optimum level laser energy provided.
3. Adequate removal of the lining/GP (to the cervical
dentine).
4. Activated bleaching gel left in the pulpal chamber to
continue working.5
TouchWhite Er:YAG teeth bleaching can be a safe and
effective teeth whitening method for vital and non-vital
tooth discolouration.
References
1. CASE REPORT: Office Bleaching with Er:YAG Laser. Tugrul Sari, Aslihan
Usumez. J LA&HA; 2013(1):55–57.
2. In vitro comparison of an Er:YAG laser-activated bleaching system
with different light-activated bleaching. Yazici A, Kalender B, Usumez A,
Ertan A, Gorucu J, Sari T. Lasers Med Sci. 2018 Jun 2.
3. TouchWhite™ Er:YAG Laser-Assisted Tooth Whitening. Jugoslav Jovanovic.
J LA&HA, Vol.2011 (1):S14.
4. A Novel Er:YAG Laser-Assisted Tooth Whitening Method. Norbert Gutknecht,
Rene Franzen, Jorg Meister, Matjaz Lukac, Samo Pirnat, Janez Zabkar,
Boris Cencic, Jugoslav Jovanovic. J LA&HA; 2011(1):1–10.
5. TouchWhite® Teeth Bleaching. Nguyen Linhlan. J LA&HA; 2017(1):CB07.

contact
Dr Nguyen Linhlan
Kaleen Dental Care & Facial Aesthetics
149 Maribyrnong Ave,
Kaleen ACT 2617, Australia
kaleendentalcare@gmail.com
www.kaleendentalcare.com.au

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| industry report

Age-appropriate aesthetics
Creating natural effects with VITA VM materials
Carolin Wehning, Germany

Fig. 1

Fig. 2
Fig. 1: Initial situation: Composite restoration of tooth #21 after distal transverse fracture of the tooth crown. Fig. 2: After matching the wax-up with the master
model, the functional crown was designed.

For dental technicians, it is especially challenging to
produce natural-looking, age-appropriate reconstructions in the visible area of the mouth in older people. It is
recommended to follow a systematic procedure based
on the characteristics of the natural teeth for the individualisation and characterisation of such a restoration.
This is the only way results can be achieved that blend
harmoniously with the remaining dentition. In this case
study, I show how such a complex case can be solved
with VITA VM 9 veneering ceramics and VITA INTERNO
materials (both VITA Zahnfabrik) for internal characterisation.

Fig. 3

Assessment and planning
A 77-year-old patient presented to the dental practice after a coronal transverse fracture of tooth #21
that had already been treated with a direct composite. Clinically, the results were morphologically and aesthetically inadequate (Fig. 1). On the adjacent natural
tooth (#11), age-related discolourations, initial white and
brown spot lesions in the cervical area, and a vestibular
transverse dark-brown crack were apparent. The dentist
and patient decided on restoration of the tooth with a
full-ceramic crown for long-term stabilisation, on which

Fig. 4
Fig. 3: The crown framework, prepared for veneering. Fig. 4: After determining the basic tooth shade of 5M2 with the VITA Toothguide 3D-MASTER
(VITA Zahnfabrik), the layering scheme was sketched.

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Fig. 5

Fig. 6

Fig. 5: After a dentine firing, VITA INTERNO can be used for a second time to give depth with individual shade nuances. Fig. 6: The VITA INTERNO stains allow
for a multifaceted and age-appropriate reproduction of the natural teeth.

the colour effect of tooth #11 was to be reproduced
in detail. In order to achieve a predictable result, the
situation was moulded and a model was developed for
a wax-up. Tooth #21 was prepared for a full crown and
a master model was produced using a precision mould
(Fig. 2).

CAD/CAM fabrication and veneering
The crown framework was made of CAD/CAMsupported VITA YZ HT zirconium dioxide (Fig. 3). For
a deep initial fluorescent effect, a wash firing was performed with EFFECT LINER 5 (orange) and EFFECT
LINER 6 (green-yellow). Layering with VITA VM 9 was
the foundation for reproducing the basic shade (Fig. 4).
The VITA INTERNO materials then enabled intensification of the deeper individual shade nuances after the
wash and dentine firings (Figs. 5 & 6). Int 04 (orange)
and Int 11 (grey-brown) were used in the cervical and interdental areas; Int 05 (terracotta) was used in the centre. The inside areas were nuanced with Int 08 (blue),
Int 05 (terracotta) and Int 07 (anthracite), and the incisal
edges with Int 02 (sand). Cracks and brown spots were
reproduced with Int 10 (brown), and white spots with
Int 01 (white).

Fig. 7

Fig. 8

Finalisation of the restorations
After establishing the basic morphology with a stone and
the details with a fine diamond-coated bur, the interior crack
was recreated from the outside with a fissure bur to achieve
a 3-D effect. The surface texture was kept as smooth as
possible, in accordance with the patient’s age. After the
glaze firing, only a goat hair brush and diamond polishing
paste were used to slightly reduce the gloss effect. After trying out the full-ceramic crown, the patient was very satisfied
with the result (Fig. 7), and a self-adhesive bonding agent
was applied. The shade and form of the restoration integrated harmoniously with the other teeth (Fig. 8). The veneering ceramic, in combination with two stain firings, made
it possible to achieve age-appropriate aesthetics (Fig. 9).

about
Carolin Wehning
is a dental technician
in Bocholt in Germany.

Editorial note:
This article was
first published
in Dental Barometer 6/17.

Fig. 9

Fig. 7: The patient was very satisfied with the final aesthetic result. Fig. 8: The shading and lighting of the restoration fitted in perfectly with the overall picture.
Fig. 9: The final full-ceramic crown had an age-appropriate morphology, surface texture and shading.

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| industry report

New materials for a classic indication
Cementation of all-ceramic restorations
using Variolink Esthetic
Drs Eduardo Mahn & Juan Pablo Sánchez, Chile

Fig. 1

Fig. 2
Fig. 1: Pre-op situation. Fig. 2: Situation after composite build-up (Tetric N-Ceram Bulk Fill) and preparation.

Zinc phosphate cements are seen as classic luting materials for the cementation of metal-ceramic crowns. Along
with all-ceramic materials, glass ionomer cements (GICs)
and resin-modified glass ionomer cements (RMGICs)
were introduced. Generally, luting cements are expected
to meet certain requirements: they should provide an optimum bond to the tooth structure and restorative material,
must not be soluble in water, should be suitable for application in thin coatings and should offer long-term stability. This is in contrast to the properties of classic cements,
which are water soluble and do not establish an adhesive
bond to the enamel or dentine (zinc phosphate cements)
or establish only a minimally adhesive bond and only to the
dentine (GICs and RMGICs). Nonetheless, these cements
show reasonable survival rates if used for the appropriate
indication even if they have certain limitations.

Problem 1: Opacity
The opacity of the luting material is a critical issue for
all-ceramic crowns, as well as ceramic inlays and onlays.

Fig. 3a

Almost any colour can theoretically be reproduced with
ceramics by exploiting their natural translucent properties.
Using an opaque luting material appears to be counterproductive in achieving this. Further critical issues are the
limitations involved in the anterior region and the location
of the cement line in the visible area for inlays and onlays.
For instance, if a tooth is restored with a veneer, the basic
shade of the tooth is maintained; only the enamel is replaced, usually by using a translucent ceramic that covers
the natural dentine. In such a case, it is essential to use a
translucent luting material to achieve a favourable result.

Problem 2: Adhesion
The comparatively low bond strength of conventional
cements is also problematic. Classic preparations around
the tooth create a high degree of friction and retention.
However, the retention is significantly reduced with partial
crowns, veneers or onlays. It is therefore advisable to use
a luting material that is capable of providing a strong adhesive bond. Both problems led to the widespread use of

Fig. 3b
Figs. 3a & b: Crown design in the software suite (inLab) and try-in before crystallisation firing (IPS e.max CAD).

28 cosmetic
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[29] =>

industry report

Fig. 4

Fig. 5

Fig. 7

Fig. 6

Fig. 8

Fig. 4: Characterised and glazed crown. Fig. 5: Etching and silanating with Monobond Etch & Prime. Fig. 6: Enamel etching prior to application of the adhesive.
Fig. 7: Applying Variolink Esthetic DC into the crown. Fig. 8: Placing the crown.

luting composite materials. Perhaps their only disadvantage
is the removal of excess material. These luting materials are
hard and solid and not water soluble, and they have a high
adhesive strength, making removal of excess difficult. Early
luting composites were equipped with a self-cure mechanism. Users had to wait a few minutes until the composite
was almost fully set before they could remove the excess
material. This period was risky because of the moisture in
the mouth. Blood or saliva could come into contact with the
non-polymerised composite and cause damage.

Dual-curing luting composites
These issues led to the rise of dual-curing composites for
the cementation of all-ceramic crowns. Dual-curing luting
composites are usually delivered in double-push syringes
with a mixing tip. During extrusion, the base and catalyst
are automatically mixed. The material can be applied directly. The main advantage is that the curing process can
be accelerated with light and excess material can easily be
removed. At the same time, the self-cure mechanism ensures a reliable cure, even with relatively thick or opaque
ceramic layers. Nonetheless, there are some situations in

Fig. 9

Fig. 10

which excess material cannot be removed all that easily
because the setting reaction takes place too quickly or the
material does not cure down to the depth of the composite layer. After one second of light curing, the surface is
set and excess can be broken off, but the material is still
paste-like at the interface to the crown or tooth. Excess
can be polymerised en bloc and pulled off as a ring in one
go with no uncured material left in contact with the tooth
or crown. In addition, the luting composite does not contain amine, which is another advantage, since amine may
be implicated in discolouration of the cement line over time.

One material, five shades
Variolink Esthetic (Ivoclar Vivadent) is based on the value
shade concept. The shades are classified according to the
effect to be achieved with the cement. Five shades are available: Light+, Light, Neutral, Warm and Warm+. In this way,
the shade spectrum ranges from an opaque white tone
(Light+) to an opaque yellow-brownish shade (Warm+). In
between lie shades such as a coconut water white and a
neutral tone (very translucent) and a warm tone (comparable to A3). In addition, the luting composite is available

Fig. 11

Fig. 9: Excess removal is easily achieved owing to the new technology based on the Ivocerin photoinitiator. Fig. 10: Final curing. Excess luting material was
removed beforehand (quarter technique). Fig. 11: Seated crown after excess removal.

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| industry report

Fig. 12a

Fig. 12b
Figs. 12a & b: Lateral and occlusal views of the completed restoration.

in an LC (light-curing) and a DC (dual-curing) version. The
LC version is designed for relatively thin restorations, such
as inlays, onlays and veneers. The DC version is suitable
for more extensive and opaque restorations. The luting
composite is used in conjunction with the light-curing single-component Tetric N-Bond Universal (Ivoclar Vivadent).

Fig. 13a

ceramic material (Fig. 7). The luting composite was applied
into the crown. The restoration was then seated (Fig. 8) and
light-cured from each side for two seconds. Excess composite was easy to remove owing to the Ivocerin photoinitiator (Ivoclar Vivadent), which provides a fast and thorough
cure with a minimum amount of energy (Fig. 9). For final
polymerisation, the restoration was light-cured from each
quarter for 20 seconds (Fig. 10). Figures 11 and 12a & b show
the oral situation after placement of the crown. Although the
cement line was located above the gingival margin, it was
not visible owing to the favourable tone and opacity of the
luting composite. Figures 13a & b show radiographic control images of the restoration: the radiopaque build-up material and cement can easily be distinguished from the tooth
structure. This aspect is particularly important in situations
where excess cement cannot be seen with the naked eye.

Fig. 13b
Figs. 13a & b: Radiographic control images before and after the treatment.

Clinical case
A 45-year-old male patient presented to the practice with
a restoration on tooth #46. The tooth had been endodontically treated and temporised with a filling (Fig. 1). The temporary was removed, the tooth built up with Tetric N-Ceram
Bulk Fill (Ivoclar Vivadent) and then prepared for the crown
restoration (Fig. 2). An impression was taken with a onestep, two-phase impression technique using a putty and
light-body silicone. After scanning the model, the crown
was designed in the software suite (inLab, Dentsply Sirona)
and milled from an IPS e.max CAD lithium disilicate block
(Ivoclar Vivadent; Figs. 3a & b). After the crystallisation firing, the crown was stained and glazed (Fig. 4). The next
step was to etch and silanate the ceramic crown with the
new glass-ceramic primer Monobond Etch & Prime (Ivoclar
Vivadent). This primer combines a ceramic etching and
silanating component in a single material and therefore
eliminates the need for the ceramic to undergo hydrofluoric acid etching (Fig. 5). After the etching and silanating step, the crown was rinsed with water and dried. The
isolated enamel was then etched (Fig. 6). The adhesive
(Tetric N-Bond Universal) was applied and dispersed with a
strong stream of air. The dual-curing version of the Variolink
Esthetic luting composite was used for seating owing to
the thickness of the crown and the low translucency of the

30 cosmetic
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Conclusion
The cementation methods used in conjunction with
all-ceramic materials have changed for single-crown restorations. Variolink Esthetic is a protagonist of the latest
generation of luting composites. Excellent bond strength
values, coupled with user-friendly handling characteristics and highly aesthetic properties, make this material an
asset in day-to-day dental restorative care.

contact
Dr Eduardo Mahn is a certified
implantologist and the Director of
Clinical Research, and the Director of
the Program of Esthetic Dentistry at the
Universidad de los Andes in Santiago
in Chile. He can be contacted at
emahn@miuandes.cl.
Dr Juan Pablo Sánchez is a dental
surgeon. He holds a postgraduate
degree in oral rehabilitation from the
Universidad de los Andes and lectures
on this field at the university.
He can be contacted at
drjpsanchez@gmail.com.

[31] =>

6th Biennial Meeting of ADSS

|

15th Biennial Meeting of AAAD

Pre-Congress Day: 27 September 2018
Main Congress: 28-29 September 2018
Post-Congress Day: 30 September 2018
Level 4, Marina Bay Sands, Singapore

LEARNING | COLLABORATION | INSPIRATION

REGISTRATION NOW AVAILABLE ONLINE!

2018 SPEAKERS

LUCKY DRAW

Frank Milnar

Stefen Koubi

Hilal Kuday

Shamsul Alam

Cheung Lai Chun

Ratna Dissanayake

Onny Eryanto

Ho Feng Chuan

USA

Philippines

France

Sri Lanka

Turkey

Indonesia

Bangladesh

REGISTER AS A
DELEGATE FOR
DAMA 2018 AND
STAND A CHANCE
TO WIN!

Taiwan

NEWLY LAUNCHED
Kim Ki-Seong
South Korea

Jerry Lim
Singapore

Joan Lim Zhi Yin
Malaysia

Paulo Monteiro
Portugal

EYESPECIAL C-III
worth SGD 3,500.
The EYESPECIAL C-III
is sponsored by Shofu
Dental Asia-Pacific
Pte Ltd

Park Chul-Wan
South Korea

Organiser

Giulio Pavolucci
Italy

Rita Singh
Nepal

Co-host

Kazunobu Yamada

www.dama.sg

Japan

Event Manager

[32] =>

| new materials

Bioactivity in restorative dentistry:
A user’s guide
Dr Fay Goldstep, Canada

Introduction
The word “bioactivity” is one of the latest buzzwords
in the dentistry. It is highlighted as a feature in many restorative products with different and conflicting claims.
This has stirred up confusion and controversy surrounding the concept. This article will attempt to provide clarity
for the practising restorative dentist regarding the following: What is bioactivity? What are bioactive products?
How can they be used to provide the best dental care?
The term “bioactive material” originated with Dr Larry
Hench in 1969. He was looking for an improved graft material for bone reconstruction needed by injured returning
soldiers of the Vietnam war. Hench was searching for a
material that could form a living bond with tissues in the
body. All the available materials at the time were rejected
by the body. He developed bioglass (calcium silicophosphate glass), a completely synthetic material that chemically bonds to bone.1 Hench defined a bioactive material
as “one that elicits a specific biological response at the
interface of a material which results in the formation of a
bond between the tissues and the material”.2
Today, there are many different definitions of bioactivity
found in the dental literature, dependent on the research
and on the researcher. The definition fits the research,
whereas it should fit the concept. In order to achieve clarity of meaning, it is best to go with what can be most eas-

Table 1: Examples of bioactive restorative materials by their mechanism
of action. Bioactivity increases with each mechanism: materials that
remineralise, only remineralise; materials that deposit hydroxyapatite also
remineralise; materials that stimulate pulpal regeneration also remineralise
and deposit hydroxyapatite.

32 cosmetic
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ily understood by clinicians and patients alike, the definition found in the dictionary: “bioactivity”, noun: any effect
on, interaction with or response from living tissue.
Historically, dental materials were designed to have a
“neutral” effect on the tooth.3 Many current dental materials are not neutral. They are “active”, not “passive”, participants in the restorative process. New materials are being
developed to harness this potential behaviour. These are
“bioactive” materials.
For simplification and clarity in discussing bioactive
restorative materials, it is best to separate them according to their mechanism of action. There are three separate mechanisms that are demonstrated by bioactive
restorative materials (Table 1 lists examples of bioactive
restorative materials by their mechanism of action). A bioactive restorative material can display one or more of the
following actions:
1. Remineralises and strengthens tooth structure through
fluoride release and/or the release of other minerals;
2. forms an apatite-like material on its surface when immersed in body fluid or simulated body fluid over time;4
3. regenerates live tissue to promote vitality in the tooth.

Materials that remineralise
Dental caries is the cumulative result of consecutive cycles of demineralisation and remineralisation at the interface between biofilm and the tooth surface. Oral bacteria
excrete acid after consuming sugar, leading to demineralisation. Hydroxyapatite crystals are dissolved from the
subsurface. Remineralisation is the natural repair process for non-cavitated lesions. It relies on calcium and
phosphate ions, assisted by fluoride, to rebuild a new surface on the existing crystal remnants in the subsurface.5
Under normal physiological conditions at a pH of 7,
saliva is supersaturated with calcium and phosphate
ions, making caries progress slow. As the pH is lowered,
higher concentrations of calcium and phosphate are required to reach saturation with respect to hydroxyapatite.5 This is called the “critical pH”, the point where equilibrium exists and there is no mineral dissolution and no

Fig. 3a

[33] =>

new materials

Fig. 1

Fig. 2

Fig. 1: Cycling of oral pH during cariogenic challenges in naturally occurring hydroxyapatite. Fig. 2: Cycling of oral pH during cariogenic challenges in fluoridated
hydroxyapatite.

mineral precipitation. The critical pH of hydroxyapatite is
around 5.5 and that of fluorapatite is around 4.5. This varies with individual patients. Below critical pH, demineralisation occurs, while above critical pH, remineralisation
occurs (Figs. 1 & 2).43
If fluoride is present in the plaque fluid, it will penetrate the enamel, along with the acids at the subsurface,
adsorb to the apatite crystal surface and protect the
crystals from dissolution.6 This coating makes the crystals similar to fluorapatite (critical pH of 4.5), ensuring that
no demineralisation takes place until the pH reaches this
point. Fluoride present in solution at low levels among
the enamel crystals can markedly decrease demineralisation.7, 8
When the pH returns to 5.5 or above, the saliva, which
is supersaturated with calcium and phosphate, forces
minerals back into the tooth.8 Fluoride increases remineralisation by bringing calcium and phosphate ions
together and is preferentially incorporated into the remineralised surface, which is now more acid-resistant.

Fig. 3a

Fig. 5a

The benefits of fluoride are maintained long term
through the mechanism of fluoride reservoirs. Fluoride is
retained intraorally after fluoride treatments, such as fluoridated toothpaste and fluoride varnish application, and
is then released into the saliva over time.9, 10 Fluoride can
remain on teeth, mucosa or dental plaque or within bioactive restorative materials. Fluoride retention is clinically
beneficial, since it can be released during cariogenic
challenges to decrease demineralisation and enhance
remineralisation.5
When the enamel and dentine no longer have adequate structure to maintain their mineral framework,
cavitation takes place and simple remineralisation is an
insufficient treatment. Tooth preparation and restoration
are now required.
Bioactive restorative materials replace dental hard
tissue and help to remineralise the remaining dental
structures. Glass ionomer cements and their derivatives,
such as resin-modified glass ionomers, compomers and
giomers, fall into this category.

Fig. 3b

Figs. 3a & b: Examples of glass ionomers, riva self cure (SDI) and EQUIA Forte (GC). These are bioactive materials that remineralise.

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| new materials
ing benefits, dental researchers have produced an assortment of glass ionomer derivatives: resin-modified
glass ionomers, compomers and giomers. Two product
lines in this category are ACTIVA BioACTIVE-RESTORATIVE (Pulpdent; Fig. 5) and the Beautifil giomer family
of restorative materials, including Beautifil II and Beautifil
Flow Plus (SHOFU; Fig. 6). Studies have shown ACTIVA’s
remineralisation potential through fluoride release and
recharge and calcium release.14, 15 Giomers are used in
restorative dentistry as equivalent to composite resin, in
all their applications.
Fig. 4: Glass ionomers create an ion-enriched, harder dentine surface
adjacent to the glass ionomer surface.

Glass ionomer cements
Glass ionomer cements were developed in the early
1970s. They are particularly valuable for caries control in
high caries risk patients and in areas where location or
isolation create restorative challenges (Figs. 3a & b). Glass
ionomers have a true chemical bond with dental tissue.
They encourage remineralisation of the surrounding tooth
structure and prevent bacterial microleakage through
ion exchange adhesion with both enamel and dentine.11
A new, ion-enriched layer is created at the tooth–glass
ionomer interface. This layer contains phosphate and
calcium ions from the dental tissue, and calcium (or strontium), phosphate and aluminium from the glass ionomer
cement.11 The remineralisation process creates a harder
dentine surface (Fig. 4).12, 43 Restoration fracture is usually
cohesive, leaving the ion exchange layer firmly attached
to the cavity wall. The dentinal tubules are sealed and
protected from bacterial penetration.13
In order to eliminate the physical property disadvantages of glass ionomers and harness their remineralis-

Fig. 5

Giomers
Giomers represent the hybridisation of glass ionomer
and composite resin properties: the fluoride release and
recharge of glass ionomers, and the aesthetics, physical properties and handling of composite resins.16 The
giomer concept is based on PRG (Pre-Reacted Glass)
technology: a glass core, surrounded by a glass ionomer
phase enclosed within a polyacid matrix. Studies show
that dentine remineralisation occurs at the preparation
surface adjacent to the giomer.17
Giomers, through the creation of fluoride reservoirs, release and recharge fluoride efficiently, significantly better
than do compomers18 and composite resins, although
not as well as glass ionomers.19 The clinical performance
of giomers has been tested against those of hybrid resin
composites. Giomers have been found to compare positively for all criteria.20

Materials that deposit hydroxyapatite
Some bioactive materials not only remineralise by adding minerals to tooth structure, but also create an apatite-like material on their surfaces when immersed in
body fluid or simulated body fluid over time.4 There are

Fig. 6
Fig. 5: ACTIVA BioACTIVE-RESTORATIVE is a bioactive restorative material that remineralises. Fig. 6: The Beautifil giomer family of restorative materials,
including Beautifil II and Beautifil Flow Plus, are bioactive restorative materials that remineralise.

34 cosmetic
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[35] =>

new materials

|

two chemical classes of these bioactive restorative materials: calcium silicates and calcium aluminates.21, 22 These
materials are non-resin-based. Both materials set with
an acid–base reaction and produce an alkaline pH after
setting. High pH levels (7.5 or higher) appear to stimulate
more active and complete bioactivity.4
Ceramir (Doxa Dental; Fig. 7) is a calcium aluminate
material developed for cementation. An in vitro study
found that this apatite-forming bioactive cement can
occlude artificial marginal gaps. This is beneficial clinically at the margin of the prepared tooth and cemented
restoration. It suggests that bioactive dental materials
may significantly improve clinical outcomes and longevity of dental restorations.23
Calcium silicates have also been shown to deposit
hydroxyapatite.23 Even more importantly, they can stimulate the regeneration of live tissue: dentine, pulp, blood
vessels and bone.24–26

Materials that can regenerate live tissue
Some bioactive materials not only remineralise and
form hydroxyapatite, but also regenerate live tissue.
This is crucial in many restorative and pulp-related treatments. One major example is vital pulp therapy. The
goal of vital pulp therapy (direct pulp capping and pulpotomy) is to treat reversible pulpal injury arising from
trauma, caries or restorative dentistry. These injuries destroy the normal tissue architecture at the pulp–dentine
interface, but can be healed if the wound is properly
protected.27
Treatment must maintain pulp vitality and function
and restore dentine continuity below the injury through
hard-tissue bridge formation.28 Optimal quality of this
hard-tissue bridge is essential to the long-term success
of vital pulp therapy.29, 30 There is a pulp tissue-specific
response to the capping material, and this determines
the quality of the dentine bridge.28

Fig. 7: Ceramir is a bioactive cement that remineralises and deposits
hydroxyapatite.

MTA is a calcium silicate-based material (derived from
Portland cement) with high sealing ability and excellent
biocompatibility. MTA-based materials stimulate faster
formation of dentinal bridges that are of better quality
than those of calcium hydroxide.35, 36 Since the mid1990s, MTA has been recognised as the standard in
conservative pulp vitality treatment.37 MTA-based materials have limitations however:
– Long setting time;38
– weak mechanical properties; 38
– difficult handling; 38
– may produce tooth discolouration;39
– may contain heavy metals.40
Much research has followed to build on the advantages
of MTA while eliminating most of the disadvantages.
One such material is Biodentine (Septodont; Fig. 8).
It was formulated by improving the physical and handling properties of MTA-based endodontic repair cement
technology and creating a dentine replacement material
with significant reparative qualities.

Calcium hydroxide products have been used in vital
pulp therapy for many years. The ability of calcium hydroxide to promote dentine bridge formation and enhance wound healing is well established.31 However,
calcium hydroxide has inadequate physical properties
and produces poorly formed dentinal bridges containing tunnels.32 This has directed research to seek out new
materials for this therapy.

Biodentine can be used as a complete dentine replacement material to treat damaged dentine in both
the crown and the root with clinical indications that
exceed those of MTA and other related Portland cement
calcium silicate products.21 Biodentine can be used
as a:

The first of these materials created for practical clinical use was mineral trioxide aggregate (MTA).33 MTA
was originally developed as a root end filling material for
apicectomy procedures and to repair root perforations.34
Indications for its use have expanded broadly within restorative dentistry and paediatric dentistry.21

– cavity base/liner in deep carious lesions;
– pulp capping agent in vital pulp therapy (both direct
pulp capping and pulpotomy);
– root repair material for perforations, resorptions, apexification and root end filling material in endodontic
surgery; and

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35

[36] =>

| new materials
– restorative material to replace missing or defective
dentine.

The calcium silicate setting reaction is as follows:

It cannot be used to replace enamel.
The advantages of Biodentine over MTA and modified
MTA materials include:
– Ease of handling;
– high viscosity;
– shorter setting time (12 minutes);
– better physical properties;41
– composition containing raw materials with known degree of purity;42 and
– good colour stability, so there is no discolouration.43
Biodentine is a tricalcium silicate-based material. Its
mechanical properties compare to those of dentine, and
it can be used as a dentine substitute in both the crown
and the root.44–46 It stimulates deposition of hydroxyapatite when exposed to tissue fluids.47 It is non-toxic as
tested on human pulp cells.48 Studies have shown complete dentinal bridge formation after six weeks in human
teeth.49
Biodentine provides a hermetic seal that protects the
dental pulp by preventing bacterial infiltration. This creates
a protected environment where healing can take place.
The seal is created through micromechanical retention
by infiltrating the dentine tubules and by stimulating odontoblasts to deposit dentine.25
It is the calcium-releasing ability of pulp capping materials that induces pulp tissue regeneration. Tricalcium
silicate-based materials like Biodentine produce calcium
hydroxide as a product of hydration.50

Calcium silicate in the powder interacts with water, leading to the setting and hardening of the cement.
This produces hydrated calcium silicate gel and calcium
hydroxide. Calcium hydroxide can now stimulate pulp
regeneration within a gel-like material that is strong and
not porous; this harnesses the regenerative powers of
calcium hydroxide without its physical disadvantages.
Biodentine in vital pulp therapy, through the action of
calcium hydroxide in this enhanced physical state, boosts
the deposition of reparatory dentine by odontoblasts.
This creates a dense dentine barrier,51, 52 as well as heals
damaged pulp fibroblasts.53 Clinical results have confirmed Biodentine’s ability to preserve pulp vitality even
in very difficult cases. It has the potential to heal pulps,
avoiding what may have been inevitable endodontic
involvement in the past.
Resin-modified calcium silicates
Studies have shown that the presence of a resin
matrix modifies the setting mechanism and calcium
leaching of calcium silicates.54 A partial pulpotomy clinical
study compared TheraCal (BISCO), a light-cured, resinmodified calcium silicate base/liner designed for direct
and indirect pulp capping, with non-resin-containing materials Biodentine and ProRoot MTA (Dentsply Sirona).
The results showed that Biodentine achieved complete dentinal bridge formation in all teeth. The rates for
bridge formation were 56 % for ProRoot MTA and 11 %
for TheraCal.55 Normal pulp organisation was seen in
66.6 % of the teeth in the Biodentine group, 33.3 %
of the ProRoot MTA group and 11.1 % of the TheraCal
group. The study concluded that the non-resin-based
partial pulpotomy materials perform better than the
resin-based materials and present potential for the best
clinical outcomes.55
Another recent study compared Biodentine with
TheraCal with respect to how they each affect inflammation and regeneration of the pulp in a direct pulp capping in vitro model. TheraCal was shown to increase
inflammatory cells and decrease the regenerative processes of the pulp, whereas Biodentine did not increase
inflammation and supported the regenerative processes
of the pulp.56

Fig. 8: Biodentine is a bioactive restorative material that remineralises, deposits
hydroxyapatite and regenerates live tissue.

36 cosmetic
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These two studies seem to suggest caution in using
resin-based materials for vital pulp therapy. Biodentine
has good biocompatibility and bioactivity for use in vital
pulp therapy.

[37] =>

new materials

Calcium silicates as endodontic sealers
The ability to deposit hydroxyapatite and regenerate
live tissue has brought calcium silicate technology into
the scope of endodontic sealers. After obturation, there
is generally contact between the obturating materials and
the periapical tissue. The success of treatment greatly
depends on the integrity of the obturated seal to prevent
recurrent infection of the periapical space.
The introduction of bioactive endodontic sealers has
changed the concept of obturated seal from hermetic
sealing with inert materials to biological bonding with
bioactivity.57 The sealer becomes a filler, not only a sealer.
Calcium silicates are well suited to endodontic obturation owing to the following properties:58
– High pH (antibacterial);
– hydrophilic (use moisture present in dentinal tubules to
initiate set);
– biocompatible;
– do not shrink or resorb;
– excellent seal (bond chemically and mechanically to
dentine); and
– ease of use (can be used with many methods of condensation).
Furthermore, they are bioactive:
– Remineralise hard tissue;
– deposit hydroxyapatite to improve the seal over time;
– regenerate and heal surrounding periapical tissue.
BioRoot (Septodont; Fig. 9) has been developed to
incorporate these bioactive traits. Research has shown:
– Hydroxyapatite formation upon setting reaction: Bioceramic sealers bond to dentine through the process
of alkaline etching. This is due to the alkalinity of the
sealer. A mineral infiltration zone develops between the
dentine and the sealer.59
– Tissue healing: A study that compared the effects of
BioRoot RCS on human periodontal ligament cells
with the standard zinc oxide eugenol-based root canal
sealer, Pulp Canal Sealer (Kerr Dental), showed BioRoot to have fewer toxic effects on periodontal ligament
cells and that it induced greater secretion of angiogenic
and osteogenic growth factors. These properties are
essential in periapical tissue regeneration.60, 61 BioRoot
also showed excellent biocompatibility when compared
with many other contemporary endodontic sealers.62

Conclusion
With a bit of simplicity and focus on the essentials of
bioactivity in dentistry, it becomes clear that bioactivity
is now an essential part of the practice of clinical den-

Fig. 9: BioRoot is a bioactive endodontic sealer that remineralises, deposits
hydroxyapatite and regenerates live tissue.

tistry. Dentists can now harness the potential to remineralise and generate tooth material and heal biological
structures for their ultimate objective: attaining the best
possible clinical outcomes for their patients.
Editorial note: A list of references is available from the
publisher.

contact
Dr Fay Goldstep has been an ADA
(American Dental Association) Seminar
Series Speaker and lectured at the
ADA, Yankee, American Academy
of Cosmetic Dentistry, Academy of
General Dentistry and Big Apple dental
conferences. She has lectured nationally
and internationally on proactive/minimal
intervention dentistry, soft-tissue lasers,
electronic caries detection, healing dentistry and innovations
in hygiene. Dr Goldstep has served on the teaching faculties
of the postgraduate programmes in aesthetic dentistry at the
State University of New York at Buffalo, universities of Florida
and Minnesota, and University of Missouri–Kansas City in the
US. She sits on the editorial boards of the Oral Health Journal
(healing/preventative dentistry), Dental Tribune U.S. Edition and
Dental Asia. She is a fellow of the American College of Dentists,
International Academy for Dental-Facial Esthetics and American
Society of Dental Aesthetics. Dr Goldstep has been a contributing
author to four textbooks and has published more than 60 articles.
She has been listed as one of the leaders in continuing
education by Dentistry Today since 2002. Dr Goldstep
is a consultant to a number of dental companies
and maintains a private practice in Toronto in Canada.
She can be contacted at epdot@rogers.com.

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[38] =>

Sometimes faster, sometimes
safer, sometimes both—
The digital practice at IDS 2019
DTI
The digital world is creating numerous opportunities
for dental practices. To the practitioner, these may seem
countless and it may not be easy to keep pace with relevant developments. The 2019 International Dental Show
(IDS), which is to be held from 12 to 16 March in Cologne
in Germany, will present the state-of-the-art technology
and help clinicians determine the most suitable solutions
for their practices and focus of work following the motto
“It depends on which innovation brings me and my practice forwards here and now.”
The impetus for digital processes is often triggered as
a consequence of today’s patient. A typical situation: the
patient needs a crown replaced; however, his time constraints demand same-day treatment. One solution could
be a chairside system and another a particularly fast digital workflow that includes the practice and the laboratory.
Considerations regarding the ideal restorative materials
also play a role. IDS will present the entire palette of options to the visitor and thus also lays the basis for wellfounded investment decisions.
Whereas in the above-mentioned case, the priority
was above all speed, digital technologies assist with both
complex and difficult treatments. For example, in the
field of implantology: a patient requires a fixed prosthesis for his edentulous mandible. Based on radiographs
and model scan data, the dentist–dental technician team
plans the treatment together in the scope of backward
planning from the final prosthesis to the positions of the
individual implants. The digital availability of the data fa-

38 cosmetic
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cilitates this process and if necessary also enables a further professional to be involved—even at short notice.
There are various ways of implementing the planned
treatment, including many options that involve digital
support. For example, for a safe surgical treatment, drilling templates can be ordered from the dental laboratory
or from an industry partner that provides the service. External support is also available for the virtual design and
production, so that the individual work steps can be more
flexibly divided up among the team (surgeon, prosthodontist, dental technician) today than ever before. In this
way, the practice aims to achieve quality assurance or,
indeed, an improvement in the quality, while at the same
time possibly saving time and money. Experts predict a
pace of progress that will mean that by IDS 2019 or IDS
2021 at the latest more digital implant treatments will take
place than analogue treatment using standard products.
“The current trends for the digital technologies for the
practice, as well as extensive workflows for surgeons,
prosthodontists and dental technicians, will be presented in a unique form at IDS,” said Mark Stephen Pace,
Chairman of the Board of the Association of the German
Dental Industry. “The opportunities of digital dentistry
have now arrived in all disciplines—from implantology
and prosthetics, through to endodontics and orthodontics. As such, it is certainly worthwhile for representatives from all specialised areas to experience the current
innovations at IDS in a diversity that can be found in no
other place.”

| meetings

[39] =>

[40] =>

| meetings

International Events
Extended Deadline

15 May
2 018

The 11th

October 4lThul -7lSunl, 2018

Expo And Symposium
Kong International Dental

Hong Kong

Deadline

Endodontic Associations

Coex, Seoul, Korea

Values in Dentistry
Endodontics : The Utmost

G U ST
26 AandUExhibition
24–Convention
Centre

EARLY-BIRD REGISTRATION

International Federation of

IFEA 2018 Seoul

HKIDEAS
Hong

31 May
2018

www.ifea2018korea.com

2018

CALL FOR ABSTRACT

www.hkideas.org

NEW MILLENNIUM OF ORAL HEALTH

Overview

W www.ifea2018korea.com
eoul
www.facebook.com/ifea2018s

Confirmed
Invited
Speakers

Is there still a role for medicaments
in endodontics?

trauma Root resorption after dental
findings and treatment possibilities

Gustavo De-Deus

(Sweden)

Organizer

HKIDEAS

curvatures and
Management of severe
memory
complex anatomy with controlled
files: A new approach

Italy
3D endodontics: Shaping
in 3 dimensions

Mo K. Kang
Challenges

USA
endodontic
“Past, present and future oftechnology
files”: Where science meets

Tara Mc Mahon
Belgium
Does heat treated NiTi facilitate
endodontic therapy?

Cliff Ruddle
USA
Endodontic Disinfection:

root canals

3D Irrigation

Michael Solomonov
Israel
to
Contemporary approaches root canals
instrumentation of non-round

Yoshi Terauchi
Japan
invasive
Predictable and minimally
file
method to retrieve a separated

Long term prognosis of
Tx vs. Implant Tx

A potential

Italy

Korea
predictor for

Soft tissue management in
microsurgery

endodontic

Yosef Nahmias

Zvi Metzger

Canada

Israel
of

breakage
How to prevent instrument
by creating a mechanical reproducible
glide path (don’t rotate, reciprocate)

Hagay Shemesh

Frank Setzer

The Netherlands

USA
errors by
Management of iatrogenicretreatment.
non-surgical and surgical

Asgeir Sigurdsson
USA

fillings.
A realistic look at root canal
performance.
Trends, evidence and clinical

Ibrahim Abu Tahun
Jordan

pain

order in
Re-establishing biological
complex
reengineering the pulp-dentin

pulp therapy

Management of second mesio-buccal,
with only one
narrow and curved canals
reciprocating instrument.

Is it toothache? non-odontogenic
presenting as dental pain

Martin Trope
USA
The expanding role of vital

Nanomaterials in endodontics:
game changer

IFEA 11th World Endodontic
Congress 2018

Francesco Maggiore

Seung Jong Lee

Early diagnosis and biomechanics
vertical root fractures

invasive

Canada

endodontic

Are the viable cells the only
delayed replantation?

The paradox of minimal
endodontics

Anil Kishen

Syngcuk Kim
USA

USA

Sergio Kuttler

24-26 August 2018
Hong Kong
www.hkideas.org

Nick Grande
Gianluca Plotino
Italy

Gianluca Gambarini

USA

Pulp tissue regeneration:
and new outlook

Franck Diemer
and heatHow asymmetric geometry
of
treatment influence the behavior
rotary root canal instrument

The relationship among reciprocation,
glidepath and canal scouting

Samuel O. Dorn
alternative
Extraction-Replantation: An
surgical technique

and cleaning:
Solutions to simplify shaping
root canal treatment
improving the quality of the

France

Brazil

Greece

Professor Tomas Albrektsson
Dr. David Craig (UK)
Dr. Michel Dard (USA)
Dr. James Foster (UK)
Dr. Christopher Ho (Australia)
Dr. Jerry Hu (USA)
Dr. Sabrina Huang (Taiwan)
Dr. Terence Jee (Singapore)
Dr. Alfred Lau (Hong Kong)
Dr. Donald Li (Hong Kong)
Dr. Jingping Li (Mainland China)
China)
Professor Xiaobing Li (Mainland
Dr. Edmond Pow (Hong Kong)
Dr. Alan Reid (Australia)
Dr. Mario Roccuzzo (Italy)
Dr. Frankie So (Hong Kong)
Dr. Chong-meng Tay (Singapore)
Professor Wim Teughels (Belgium)
Kong)
Professor Maurizio Tonetti (Hong
Dr. Victoria Yu (Singapore)

Italy

The Netherlands

Australia

Antonis Chaniotis

PRELIMINARY FACULTY

Filippo Cardinali

Andreas K. Braun

Paul Abbott

Ghassan Yared
Canada

Lecture titles are tentative and

subject to change.

4–7 October 2018
Seoul, Korea
www.ifea2018korea.com

BUENOS AIRES 2018

Buenos Aires

World Dental Congress

Argentina

5-8 September 2018

ENT
ITM
OMM
A PASSION FOR MANY, A C

FO

LL
RA

Scientific Programme
now online

ss.org
www.world-dental-congre

FDI World Dental Congress

DenTech China –
Exhibition & Symposium

5–8 September 2018
Buenos Aires, Argentina
www.world-dental-congress.org

31 October – 2 November 2018
Shanghai, China
http://www.dentech.com.cn

ESCD Annual Meeting

JADR Annual Meeting

20–22 September 2018
Lisbon, Portugal
www.soulofesthetics.eu

17–18 November 2018
Hokkaido, Japan
http://jadr66.umin.jp

2018-2019
Dental-Expo
September 24-27, 2018

Dental Salon
April 22-25, 2019

Crocus Expo exhibition grounds
550 exhibitors
30000 visitors

www.dental-expo.com
com
international@dental-expo.

40 cosmetic
dentistry

1 2018

Dental-Expo

GNYDM

24-27 September 2018
Moscow, Russia
www.dental-expo.com

25–28 November 2018
New York, USA
www.gnydm.com

BDIA Dental Showcase

ADF

4–6 October 2018
London, UK
www.dentalshowcase.com

27 November – 1 December 2018
Paris, France
www.adfcongres.com

[41] =>

© 32 pixels/Shutterstock.com

submission guidelines

|

How to send us your work?
Please note that all the textual components of your submission must be combined into one MS Word document.
Please do not submit multiple files for
each of these items:
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and
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e-mail address, etc.).
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
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We can run an unusually long article in
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In short, we do not want to limit you in
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Any formatting contrary to stated above
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· We require images in TIF or JPEG format.
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· These image files must be no smaller
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Larger image files are always better,
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Also, please remember that images
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You may submit images via e-mail, via
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contact us for the mailing address, as
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Please also send us a head shot of
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short biographical sketch may precede
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with the necessary information (60 words
or less).

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

cosmetic
dentistry
1
2018

41

[42] =>

| international imprint

Imprint
Publisher/President/CEO
Torsten R. Oemus
Director Content Creation
Claudia Duschek
Editor-in-Chief
Dr Sushil Koirala
drsushilkoirala@gmail.com

International Administration
Chief Financial Officer
Dan Wunderlich
Chief Technology Officer
Serban Veres
Junior Business Development & Marketing
Alyson Buchenau

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

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Designer
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Hannes Kuschick

Copy Editors
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Lars Hoffmann

Editorial Board
Dr José Roberto Moura (Brazil)
Prof. Akira Senda (Japan)
Dr Dinos Kountouras (Greece)
Dr Valerio Bini (Italy)
Dr Florin Lazarescu (Romania)
Asst. Prof. Pavinee P. Didron (Thailand)

Official publication of:

Education Director Tribune CME
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Sarah Schubert
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Executive Producer
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Advertising Disposition
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International Offices
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cosmetic dentistry beauty & science is published by Dental Tribune International (DTI) and appears in 2018 with one issue. 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
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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.

42 cosmetic
dentistry

1 2018

[43] =>

DESIGN A SMILE
AND MAKE IT A REALITY
Use the Planmeca Romexis® Smile Design software to design beautiful smiles
and bring them to life with the Planmeca FIT® chairside CAD/CAM system.

Download your free trial today!
www.planmeca.com/online

Find more info and your local dealer!
www.planmeca.com

Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com

[44] =>

THE ONLY ARGUMENT
AGAINST
ADMIRA FUSION
COULD COME
FROM YOU.

New: pure ceramic for direct fillings.
Nothing but impressive advantages:
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3) Universal range of applications and completely
familiar handling!
Maybe you can now tell us what argument might speak
against this - if you can find one.

VOCO GmbH · Germany · www.admira-fusion.dental

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[cover] => Cosmetic dentistry international No. 1, 2018

[toc] => Array ( [0] => Array ( [title] => Cover [page] => 01 ) [1] => Array ( [title] => Editorial [page] => 03 ) [2] => Array ( [title] => Content [page] => 04 ) [3] => Array ( [title] => The prosthetic revolution - Minimally invasive prosthetic procedures and new digital tools for the treatment plan [page] => 06 ) [4] => Array ( [title] => Aesthetic Digital Smile Design: 2-D-/3-D-assisted communication and software design [page] => 10 ) [5] => Array ( [title] => Digital vs. analogue workflow on ten ceramic veneers in the maxilla [page] => 16 ) [6] => Array ( [title] => Minimal invasiveness—maximal effectiveness - The paradigm of the present decade in restorative dentistry [page] => 20 ) [7] => Array ( [title] => TouchWhite Teeth Bleaching [page] => 24 ) [8] => Array ( [title] => Age-appropriate aesthetics - Creating natural effects with VITA VM materials [page] => 26 ) [9] => Array ( [title] => New materials for a classic indication - Cementation of all-ceramic restorations using Variolink Esthetic [page] => 28 ) [10] => Array ( [title] => Bioactivity in restorative dentistry: A user’s guide [page] => 32 ) [11] => Array ( [title] => Sometimes faster, sometimes safer, sometimes both—The digital practice at IDS 2019 [page] => 38 ) [12] => Array ( [title] => International Events [page] => 40 ) [13] => Array ( [title] => Submission guidelines [page] => 41 ) [14] => Array ( [title] => Imprint [page] => 42 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

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