DT Asia Pacific No. 9, 2015

Asia News / World News / Treatment coordinator: The bridge to case acceptance / Interview: “Patients tend to go to court more often nowadays” / Tips and strategies for restoring large cavities using fibre-reinforced material / Direct anterior restoration placed with a modern composite

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DTAP0915_01-02_Title 08.09.15 09:29 Seite 1

DENTAL TRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition
www.dental-tribune.asia

Published in Hong Kong

Vol. 13, No. 9

CASE ACCEPTANCE

MALPRACTICE

ANTERIOR RESTORATIONS

The introduction of a well-trained
Treatment Coordinator can change
your entire approach to new patient
care, as well as increase profitability.
” Page 6

Dr Andy Wolff about the steady
increase in litigation in dentistry
and simple measures that can help
prevent many incidents in the first
place.
” Page 8

With modern materials, they can
be efficiently layered to produce
highly aesthetic results that are
virtually indiscernible from the
natural tooth structure.
” Page 14

Hypertension related to poor oral hygiene
By DTI

and hypertension may be linked
in that inflammation may lead to
blood pressure elevation, which
would allow for the conclusion
that oral hygiene may be considered an independent risk factor
for hypertension.

SEOUL, South Korea: High blood
pressure, or hypertension, is a
common but dangerous condition.
Untreated, it can lead to stroke,
damage to the heart and arteries,
and kidney defects. A recent South
Korean study has suggested that
the likelihood of developing hypertension may be linked to poor oral
hygiene habits.
In the study, the researchers
analysed clinical data from 19,560
participants, collected between
2008 and 2010 for the Korea National Health and Nutrition Examination Survey. High blood pressure
was determined by use of antihypertensive medication or an average blood pressure greater than
140/90 mmHg. According to these
criteria, hypertension was diagnosed in 5,921 persons.
In addition, oral hygiene habits
were evaluated by daily frequency
of toothbrushing, as well as the
use of oral health products, such
as dental floss, mouthwash, inter-

Hence, maintaining good oral
health habits may prevent and
control the condition.
“Although this subject may require further study, the association between hypertension and
periodontitis is reminiscent of
the link periodontal disease
shares with other systemic conditions, including diabetes and
heart disease,” remarked Dr Joan
Otomo-Corgel, President of the
American Academy of Perio dontology, on the research findings.
Hypertension may be related to oral health habits, the study suggests.

dental brushes and electric toothbrushes.
The analyses showed that frequent toothbrushing could be as-

sociated with a decreased prevalence of hypertension in individuals with and without periodontitis.
Generally, participants with poor
oral hygiene habits were found to

have higher hypertension frequency.
According to the researchers,
this suggests that periodontitis

The study, titled “Associations
among oral hygiene behavior
and hypertension prevalence and
control”, was published in the
July issue of the Journal of Periodontology.
AD

Potential biomarkers
for dental caries found
By DTI
ODENSE, Denmark/VALENCIA, Spain:
In order to determine potential
biomarkers for dental caries, an
international team of researchers
has taken a closer look at the human oral metaproteome, the most
prevalent proteins found in oral
biofilm. Their findings might enable scientists to develop a diagnostic caries test.
The researchers from the Department of Biochemistry and Molecular Biology at the University of
Southern Denmark in Odense and
from the FISABIO Foundation in
Valencia aimed to determine a
minimum set of proteins that allow for discrimination between
healthy and caries-affected dental
plaque samples. They identified

7,771 bacterial and 853 human proteins in 17 individuals.

exopolysaccharide synthesis, iron
metabolism and immune response.

The study’s metaproteomic
analyses of the oral biofilm provide the first protein repertoire of
human dental plaque, the researchers stated. Moreover, by using
different mass spectrometry approaches, they were subsequently
able to quantify individual peptides in healthy and caries-bearing
individuals.

By interpreting the potential
biomarkers collectively, the scientists were able to determine the oral
health status of the individuals
studied with an estimated specificity of over 96 per cent.

Their findings showed that
healthy individuals appeared to
have significantly higher amounts
of enzymes associated with a high
acid tolerance.
Other proteins found to be at
significantly higher levels in cariesfree individuals were involved in

Although validation of the findings in larger sample size studies
is necessary, the findings could be
of use for developing future caries
risk screenings, the researchers
concluded.
The results of the study were
published online ahead of print on
14 August in the PROTEOMICS journal in an article titled “The human
oral metaproteome reveals potential biomarkers for caries disease”.

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[2] =>

DTAP0915_01-02_Title 23.03.16 17:22 Seite 2

ASIA NEWS

Coconut oil pulling
reduces gingivitis
By DTI
KANNUR, India: A recent study has
shown that oil pulling using coconut
oil could be an effective method to
reduce plaque formation and plaqueinduced gingivitis. Coconut oil is an
easily usable and safe substance with
minimal side-effects and could thus
become an alternative to conventional

oral antimicrobial agents such as
chlorhexidine, the findings suggested.
The pilot study included 60 adolescents aged 16–18 with plaque-induced
gingivitis, half of whom performed
coconut oil pulling in addition to their
oral hygiene routine over the course
of 30 days, while the remainder served
as a control group. The researchers

observed a steady reduction in both
plaque and gingival index values already after one week of therapy. In
addition, they noted a 50 per cent decrease in these values in four weeks,
which is comparable to the decrease
produced by chlorhexidine.
A number of studies have shown
that oil pulling or swishing reduces

Dental Tribune Asia Pacific Edition | 9/2015

gingivitis. In 2007, for example, oil
pulling with sunflower oil was found
to reduce plaque and gingival indices
after 45 days. However, the current
study is the first to investigate the
benefits of coconut oil in this respect.

IMPRINT

To date, the mechanism by which
oil pulling works is not fully understood. According to the researchers,
its plaque-decreasing effect could be
attributed to mechanical shear forces
that can reduce adhesion of plaque.
Another possible explanation is the
composition of coconut oil. It contains
92 per cent saturated acids, approximately 50 per cent of which is lauric
acid, which has proven anti-inflammatory and antimicrobial effects.

CLINICAL EDITOR:
Magda WOJTKIEWICZ

Study recommends disinfecting
toothbrushes regularly
By DTI
DAVANGERE, India: Toothbrushes are
prone to contamination by microorganisms originating not only from
the oral cavity but also from the surroundings in which they are stored.
Indian researchers have now investigated how different dental disinfectants affect bacterial colonisation.
In order to investigate the impact of
disinfectants such as chlorhexidine
gluconate, sodium hypochlorite and
water on the presence of streptococcal
micro-organisms, the toothbrushes
of 21 children aged 5–12 were evaluated after five consecutive days of
twice daily toothbrushing.
Following the five-day trial, the
brushes were incubated in Robertson’s
AD

cooked-meat broth for four to five
hours before immerging them
in the different disinfectants in groups of seven
toothbrushes. Group 1
was immersed in
0.2% chlorhexidine,
Group 2 in 1% sodium
hypochlorite, and
Group 3 in water only.
After 24 hours, all
of the brushes were
placed in Robertson’s
cooked-meat broth again
and then cultured.
The final analyses showed that
treatment with chlorhexidine resulted in a 100 per cent reduction of
streptococci colonies, while sodium
hypochlorite reduced the micro-organisms by 71 per cent. In contrast, the

toothbrushes that were immerged in water
only showed a 14 per cent reduction
in streptococci colonies.
The results indicate that both
chlorhexidine and sodium hypochlorite are effective disinfecting agents.
According to the researchers, the significant increase in contamination of
the toothbrushes in Group 3 suggests
that rinsing one’s toothbrush only in
water and air-drying could lead to
toothbrush contamination.
In light of the findings, the researchers concluded that it is essential

for every individual to disinfect his
or her brush at regular intervals, hence preventing
reinfection and helping maintain good
oral hygiene and
general wellbeing. Since
the present
approach did
not consider
all the varieties of microorganisms present in the oral
cavity, future research should focus on
the survival of other microorganisms, such as other bacteria,
fungi and viruses, the scientists
stressed. Moreover, they noted that
other antimicrobial solutions, such as
products of the neem plant or salt,
might be economical, non-toxic and
easy-to-use alternatives worth testing
for their disinfectant properties.
Contaminated toothbrushes are
associated with various oral health
problems, including dental caries,
gingivitis and stomatitis. Health organisations, such as the America Dental Association, recommend changing toothbrushes every two to three
months.

Asia-Pacific leads
market growth
According to a recently published
report by market research firm
MarketsandMarkets, the global orthodontic supplies market is expected to
reach about US$3.9 billion by 2020,
representing a compound annual
growth rate of 6.9 per cent over the
next five years. The Asia-Pacific region
is expected to be the fastest growing
market during the forecast period
owing to constant health care expenditure and increasing awareness
about orthodontic procedures, among
other factors.

Overall, the growth in the orthodontic supplies market is primarily
stimulated by the growing number of
patients with malocclusion, jaw diseases and tooth loss; technological
advances; the increasing popularity of
orthodontic treatment among adolescents and adults; and rising disposable
incomes in developing countries, such
as India, China and Brazil. As reported
by MarketsandMarkets, North America
is estimated to hold the largest share
of the orthodontic supplies market as
of 2015, followed by Europe.

PUBLISHER:
Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT AP & UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com

ONLINE EDITOR:
Claudia DUSCHEK
ASSISTANT EDITORS:
Anne FAULMANN, Kristin HÜBNER
COPY EDITORS:
Sabrina RAAFF, Hans MOTSCHMANN
PRESIDENT/CEO:
Torsten OEMUS
CFO/COO:
Dan WUNDERLICH
MEDIA SALES MANAGERS:
Matthias DIESSNER
Peter WITTECZEK
Maria KAISER
Melissa BROWN
Weridiana MAGESWKI
Hélène CARPENTIER
Antje KAHNT
MARKETING & SALES SERVICES:
Nicole ANDRAE
ACCOUNTING:
Karen HAMATSCHEK
BUSINESS DEVELOPMENT:
Claudia SALWICZEK
EXECUTIVE PRODUCER:
Gernot MEYER
AD PRODUCTION:
Marius MEZGER
DESIGNER:
Franziska DACHSEL
INTERNATIONAL EDITORIAL BOARD:
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany
Dr George Freedman, Esthetics, Canada
Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

Published by DT Asia Pacific Ltd.
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Fax: +49 341 48474-173
info@dental-tribune.com
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responsibility for the validity of product claims,
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expressed by authors are their
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[3] =>

DTAP0915_03_Root 08.09.15 09:30 Seite 1

WORLD NEWS

Dental Tribune Asia Pacific Edition | 9/2015

Case of amnesia linked
to root canal treatment
By DTI
LEICESTER, UK: In March 2005, a
38-year-old British soldier stationed
in Germany lost his ability to form
new memories after undergoing a
regular root canal treatment. To this
day, he is unable to remember anything for longer than 90 minutes, although his brain is completely intact
and he suffered no trauma that could
have caused the amnesia, according
to his doctors.

new long-term memories. In order
to further research his hypothesis,
Burgess is examining five similar
cases of mysterious memory loss
without brain damage from the med-

ical literature. These cases might provide an answer to why the root canal
treatment appears to have triggered
the man’s memory loss. All of the cases
are in some way related to a period

of psychological stress during a medical emergency. “It could be a genetic
predisposition that needs a catalyst
event to start the process,” Burgess
told the BBC.
“One of our reasons for writing up
this individual’s case was that we had
never seen anything like this before
in our assessment clinics, and we do
not know what to make of it, but felt
an honest reporting of the facts as we
assessed them was warranted, that

perhaps there will be other cases, or
people who know more than we do
about what might have caused the
patient’s amnesia,” Burgess stated.
The case report by Burgess, titled
“Profound anterograde amnesia following routine anesthetic and dental
procedure: A new classification of amnesia characterized by intermediateto-late-stage consolidation failure?”,
was published online in the Neurocase
journal on 15 May.
AD

LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED

“I remember getting into the chair
and the dentist inserting the local
anaesthetic,” the man, who wishes to
remain anonymous, told the BBC.
Since that moment, he remembers
nothing. Every morning, he wakes up
thinking that he is still a soldier stationed in Germany in 2005, waiting to
visit the dentist for root canal surgery.
The German dentist only realised
after the treatment, which was without complications, that something
was wrong with the patient. He was
pale, disoriented and struggled to
stand up. As his condition did not
improve, he was brought to hospital
where he stayed for several days. In
the beginning, he was not able to remember anything for longer than a
few minutes.
The doctors’first suspicion was that
a bad reaction to the anaesthetic had
caused a brain haemorrhage. However,
they could not find any evidence of injury. Finally, the patient and his family
returned to England, where Dr Gerald
Burgess, a clinical psychologist from
Leicester, took over the case.
According to Burgess, a form of
anterograde amnesia would have
been the most obvious explanation
for the man’s condition. In this case,
the hippocampi, the brain regions responsible for the consolidation of information from short-term memory
to long-term memory, are damaged
so that memories can no longer be
formed and stored correctly. Yet, the
man’s brain scans showed no abnormalities. Thus, another possible
explanation would have been a psychogenic illness. Burgess conducted
detailed psychiatric assessments in
order to determine whether the man
had suffered any trauma. However,
Burgess found that his patient was
emotionally healthy and his wife
confirmed that there had not been
any traumatic events in the man’s life
prior to his dentist visit in 2005.
Burgess continues to research his
patient’s rare case of amnesia, currently suspecting that the brain’s
synapses might play an important
role. Each time a memory is formed
and transferred to long-term memory, the synapses are rebuilt, which
involves the production of new proteins. This protein synthesis might be
blocked in the case of Burgess’ patient,
keeping him from generating any

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DTAP0915_04_Morfis 08.09.15 09:30 Seite 1

WORLD NEWS

Dental Tribune Asia Pacific Edition | 9/2015

“I do not see how the situation can improve”
An interview with Dr Stefanos Morﬁs, Greece

Dental Tribune: Dr Morfis, with the
recent referendum on the austerity
measures proposed by the EU and
the resignation of Minister of Finance
Yanis Varoufakis, the debt crisis in
Greece has heated up again. Can you
describe what impact the crisis has
had on dentistry in your country?
Dr Stefanos Morfis: When one
looks back 10–15 years, dentistry
actually used to be quite a prosperous business in Greece. Since many
dentists received their education
in countries like England, Germany
or the Netherlands, the level of dentistry was quite high. What we have
seen during the last ten years or so
is that fewer people are visiting the

Dr Stefanos Morﬁs

ically, my practice will be taken over
by a dentist from Britain.

Educated in Manchester and a
dentist at heart, Dr Stefanos Morfis
opened his first practice in Athens
five years ago, right at the beginning of the debt crisis in Greece. Five
years later, he is selling it owing to
the economic circumstances and is
planning to register with the General Dental Council in order to start
working as a dentist in Britain.
Dental Tribune had the opportunity
to speak with him recently about
the situation of dentists in his home
country and the reasons he has
chosen to leave.

You are planning to work in the UK.
When are you going to leave?
I am currently in the process of
registering with the General Dental
Council and planning to leave Greece
in November. I did my postgraduate
studies at the University of Manchester’s School of Dentistry and I have
worked in several practices over there.

Photo showing protesters in Thessaloniki. The crisis has left Greece in turmoil. (© Aikaterini Mavromati, Greece)

dentist because of their financial
situation and they only go when
they are already in pain.
You have to know that, unlike in
the UK or other European countries,
most dental care here is private.
Since many cannot afford treatment in Greece, they travel to other
countries, like Macedonia, where
they receive cheaper, but lower
quality, treatment. Recently, I heard
of two patients who died after undergoing a tooth extraction there.
Owing to the lack of money for
treatment, caries levels are very
high and, although we are fully
aware of its benefits, there is very
little money for any kind of preventative dentistry. This is only done
at university level.

Consumer prices in Greece are soaring owing to the strict regulations.
Have prices for dental treatment
also gone up?
In contrast to everything else in
Greece, prices for dental treatment
have actually gone down in the last
five years. While one could charge
€50 or more for a composite filling in 2003/2004, today there are
quite a number of dentists who are
performing fillings for just €20.
This trend is facilitated by the
majority of patients, who are only
looking at price and not at what
kind of material is being put in
their mouth. Do not ask even me
what kind of fillings they use sometimes! But how can one work professionally and ensure quality for
patients at these prices?

With having to compete at such low
prices, can you actually live on your
income as a dentist in Greece?
Ten years ago, our income was almost double what it is now and the
cost of living, materials and education were much cheaper. Living in

The austerity measures will allow
Greece to stay in the EU. In your
opinion, is there any possibility of
the situation improving?
There are positive examples, like
Ireland and Portugal who were able
to recover from the recession a few
years ago. I hope to be proven wrong,
but I do not see how the situation
can improve in Greece. Politicians
come and go, but the people remain
the same. If we do not drastically
change how things are run in this
country, in a few years I guess it will
be impossible to recover.
Would you go back if things start to
improve?
I would like to, but I think it will be
very difficult. I have a family to look
after now and I want the best for my

“Living in Athens now is like living in London,
but with ﬁve times less income.”
Athens now is like living in London,
but with five times less income. That
is why many now meet their educational needs online by attending free
webinars. What is really troubling is
that more and more dentists are being forced to sell their practice for
half the price. That includes me. Iron-

little son. At 35, I am at the best age
to be productive and achieve things
in my live. I have always felt a love
for the dental profession and therefore want to dedicate my life to it.
Thank you very much for taking the
time and all the best for your future.

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[5] =>

DTAP0915_05_Amalgam 08.09.15 09:30 Seite 1

Dental Tribune Asia Pacific Edition | 9/2015

WORLD NEWS

05

European Commission alters opinion
on dental amalgam
Update recommends use of alternative materials for dental ﬁllings
By DTI
BRUSSELS, Belgium: Many countries around the world, European
countries in particular, have seen
a shift away from the use of dental
amalgam in oral health care and an
increase in the use of alternative
materials over the past years. The
European Commission recently
acknowledged this trend and published an updated version of its
opinion on the safety of dental
amalgam and alternative restoration materials.
The new document is an update
of the 2008 opinion and aims to
assess the safety and effectiveness
of dental amalgam and current
alternative materials by evaluating
the latest scientific evidence.
While in 2008 the European
Commission and the Scientific
Committee on Emerging and
Newly Identified Health Risks concluded that both types of material
are generally considered safe to
use, they now recommend that
the choice of material be based on
patient characteristics. In accordance with the objectives of the
Minamata Convention on Mercury,
the committee now recommends
using alternative materials in children and pregnant women.
The committee further stated
that the systemic effects of elementary mercury are well documented
and it has been identified as a
neurotoxin, especially during early
brain development by a number
of studies. Mercury has also been
associated with adverse health effects in the digestive and immune
systems, and in the lungs, kidneys,
skin and eyes. Nevertheless, the
evidence for such effects due to
dental amalgam is weak, according
to the committee.
The new recommendation is
also based on the findings that
dental amalgam fillings may cause
mercury poisoning in genetically
susceptible populations. Some
genetic variants appear to impart
increased susceptibility to mercury toxicity from dental amalgam.
Studies involving dental health
care personnel have indicated that
mercury exposure from dental
amalgam during placement and
removal may cause or contribute
to many chronic illnesses, as well
as depression, anxiety and suicide.
However, exposure of both patients and dental personnel could
be minimised by the use of appropriate clinical techniques, the
committee stated in its opinion
report.

However, current evidence does
not preclude the use of either

amalgam or alternative materials
in dental restorative treatment.

The committee acknowledged
that there is a need for further research, particularly with regard to
neurotoxicity of mercury from
dental amalgam and the effect of
genetic polymorphisms on mercury toxicity. In addition, the
committee concluded that there
is a need for the development of

new alternative materials with a
high degree of biocompatibility.
The full report, titled “The safety of
dental amalgam and alternative
dental restoration materials for
patients and users”, can be accessed
on the website of the Scientific
Committee on Emerging and Newly
Identified Health Risks.
AD

[6] =>

DTAP0915_06_Craven 08.09.15 09:31 Seite 1

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 9/2015

Treatment coordinator:
The bridge to case acceptance
By Lina Craven, UK
You might think that in financially challenging times the last thing you need is
a new member of staff. For a practice to
thrive and prosper in a difficult financial climate, however, it has to become
more efficient, more competitive and
more profitable. One way to do that is
to introduce a treatment coordinator
(TC) into the team or if you already have
one then to offer appropriate training.
This is a relatively new role to the European market, but in the US, where the
role is a central part of any practice, it
has proven to dramatically add value to
the patient experience, reduce in chair
time and increase case acceptance.
The introduction of a well-trained
TC will change your entire approach
to new patient care, as well as increase
profitability. While many practices
know how to attract patients, their
case acceptance ratio is low. The first
contact, first visit and follow-up are
the most important elements of the
new patient process, yet they frequently represent a wasted opportunity because of a lack of skill, focus,
time or all three.
In my experience, a major downfall of practices is the unwillingness of
practitioners to delegate the new patient process to staff, or what we call
the TC role. This is often due to a wide
range of factors, including the prac-

Too many new patients are lost due
to lack of follow-up. A good TC follows
up and provides monthly information on patient conversions to assist
with strategic planning. All practices
should have a patient journey tracker.

titioner’s perception that the patient
wants communication on his or her
treatment to come from the practitioner, the perception that patients
pay to see the practitioner, a lack of
trust to empower staff or time to train
staff, and the financial implications
of introducing the new role.

has been limited in Europe. However,
patients’ expectations, competition
for private work and the team’s demand for career progression and job
satisfaction are key drivers for introducing the TC role.

Relinquishing new patient management to well-trained staff is not
a new trend, although its application

A TC is someone in your practice
who, with the right skills and training,
will facilitate the new patient process.

The TC concept

FDI BA
T
A
S
U
EE

N G KO K

AV I L I O N
P
N
A
M
GER
A83
BOOTH

NEW
Bodenseeallee 14-16 • 78333 Stockach / Germany
Tel.: +49 7771 64999-0 • Fax: +49 7771 64999-50
www.kohler-medizintechnik.de

The TC carries out the case presentation, reiterates the treatment
options available to the patient, discusses these, answers any questions
the patient may have, and clarifies
proposed treatment. He or she also
discusses the informed consent,
shows before and after photographs
of similar cases, and addresses any
barriers or concerns the patient may
have. The TC also explains the financial options and determines the most
suitable payment method for the patient’s needs, as well as prepares the
walk-out pack. The value of a walk-out
pack should not be underestimated
and should reflect the values of the
practice, including all information the
patient needs, the finance agreement
or contract, diagnostic report, photographs of the patient (an excellent
marketing tool), informed consent
and anything else the practitioner
feels adds value to the consultation.

Instruments for conventional endodontics
and endodontic surgery

He or she bridges the gap between
the new patient, the practice and the
staff. The TC promotes and sells the
practice and its services by demonstrating their true value to prospective patients, frees up the practitioner’s time, increases case acceptance ratios and, resultantly, increases
practice profits.
Consider the time spent by the
practitioner with the new patient and
calculate how much of that time is
non-diagnostic. A TC can often reduce
up to 60 per cent of practitioner–
patient time. Rather than this being
a barrier to patients—which is indeed
what many practitioners perceive to
be the case—in my experience, patients actually feel much more at
ease with the TC and therefore better
informed. Doctor time is not always
doctor time. As a typical example: if an
new patient appointment is 30 minutes, but the clinical part is actually
only 15 minutes, there is potentially
15 minutes still available. Think about
the impact an additional 15 minutes
for every new patient in the appointment diary could have.
A good TC will manage all aspects
of the patient journey, from referral
to case start, and potentially increase
your case starts. He or she is the first
point of contact. People buy from
people, so the development of a relationship and establishing of rapport
between the TC and the new patient
are crucial to the success of your
conversion from referral to start of
treatment. The TC informally chats to
the new patient prior to consultation.
This helps not only to foster rapport
but also to gain a better idea of the
patient’s needs and wants.
I recommend to all my TCs to be
present at the consultation to listen
and understand clinically what is and
is not possible in order to allow the TC
to determine how he or she will conduct a top-notch case presentation.

Filling the role:
An internal solution?
There are no hard and fast rules. It depends upon the size and aspirations of
your practice and the qualities of existing members of your team. If you have
a team member who fulfils the characteristics of a TC and he or she wants the
challenge, then the answer is yes. Keep
in mind that you may well need to fill
that person’s current position.
Some practices streamline job descriptions allowing them to create the
new role without having to hire another staff member. Whether it is a fulltime role or not depends upon various
factors, including the size of the practice; the number of practitioners,
chairs and patients; and the profit aspirations. Many practices implement
the role and monitor its progress and
impact. This often helps the team to accept the change and gives the practitioner the opportunity to assess any
training needs of the TC and to access
how remuneration will be affected.
The role of your TC should fit in
with your practice’s culture and aspirations for patient care. However
you choose to implement the role,
the only guarantee is that you will
benefit enormously. Augmenting
your team with a well-trained TC can
reap tremendous rewards for you, the
team and your patients. A TC’s tailored
and personal approach to care, followup and communication with patients
fosters trust and increases patient
satisfaction and retention.

Lina Craven is
founder and Director of Dynamic Perceptions,
an orthodontic
m a n a g e m e nt
consultancy and
training ﬁrm in
Stone in the UK,
and has many
years of practice-based experience. She
can be contacted at info@linacraven.com

[7] =>

[8] =>

DTAP0915_08-09_Wolff 08.09.15 09:46 Seite 1

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 9/2015

“Patients tend to go to court more
often nowadays”
An interview with Dr Andy Wolff, Israel
I have seen many cases over the
years, but nothing quite like that.
In another case, a dentist extracted a third molar without the
requisite training. He should have
referred the patient to a specialist,
but he chose to do it himself—possibly because it earned him another
US$200–300
(£130–190)—with the result that
the patient now has to live with
chronic pain for the rest of her life.

Dr Andy Wolff talking to Group Editor Daniel Zimmermann. (© Kristin Hübner/DTI)

Be it a careless error or a case of
misjudgement, even the most experienced practitioner can make a mistake. In fact, statistics indicate that it is
likely that every general dentist will be
involved in a malpractice suit at some
point in his or her career. Israeli-based
dentist Dr Andy Wolff has worked as a
medical expert in dental malpractice
litigation for many years and has
seen almost everything, ranging from
slight negligence to severe overtreatment. Dental Tribune had the opportunity to speak with him recently about
the steady increase in litigation in the
field and simple measures that can
help prevent many malpractice incidents in the first place.
Dental Tribune:Dr Wolff,you have been
a medical expert in dental malpractice
litigation for many years now. Why is
it so important to increase awareness
of this topic?
Dr Andy Wolff: So much literature
out there tells dentists how to do
things—whether it is placing implants or improving efficacy with
the newest technology—but there
are no books on how not to do things
or, more precisely, what can happen
when something has gone wrong.
This aspect is no less important, both
for the patient affected and for the
clinician, who might be facing legal
consequences.

expert, I am confronted with many
instances of damaged nerves caused
while placing an implant, during
tooth extractions or through an injection. It is common and it happens
quickly. Typically, it is an inadvertent
mistake, because the clinician was either in hurry or impatient. However,
the consequences for the patient are
mostly very dramatic and often beyond repair.
Aside from nerve damage, is there an
area where mistakes are more likely?
If I had to choose one, I would say
it is implants. I recently had a very
disconcerting case where an oral surgeon did all the preliminary examination work meticulously, the CT
scan, the radiographs, everything. For
that reason, he knew for certain that
he was working with a bone structure
of 11 mm, yet he used an implant that
was 13 mm long in the treatment.
Maybe he was just mistaken or the
assistant handed him the wrong implant and he did not recheck it, but the
result was that he hit a nerve.
In this particular case, the dentist
was a specialist, an experienced surgeon. Without raising the question
of guilt—although the surgeon was

without a doubt responsible for the
damage—cases like this show that
mistakes really can happen to anybody.

Can injured nerves regain normal function eventually?
Mostly, damage is irreversible.
There are exceptions, of course, either
if the damage was not too severe or if
the nerve was inside a canal. Potentially, an injured nerve can regain
function over time. However, if it is an
exposed nerve, such as the lingual
nerve, the damage is generally irreversible, although there are some
microsurgery procedures that may
improve the situation. Interventions
like this, however, carry extremely
high risks themselves and might even
aggravate the situation.

Have malpractice incidents become
more common over the last decades?
I would say so. At least, litigation
has increased. Of course, there have
always been cases of malpractice, but
patients tend to go to court more often nowadays. Perhaps you could call
it an “Americanisation” phenomenon:
almost every problem is taken to court,
with the result that dentists are paying increasingly higher insurance
fees because the treatment risks are
so high today.
How common is legal action in dentistry and what is the compensation
amount paid compared with other
medical disciplines?
It is perhaps comparable to plastic
surgery. There are many complaints
filed for cases in which the result was
not what the patient expected it to
be. Compensation payments range
from US$10,000 to 100,000, which
is much lower than those in other
medical disciplines.

Do more cases of overtreatment or
“I am confronted with many
cases of error on behalf of the dentist
end up in court?
instances of damaged nerves
These cases have an almost equal
occurrence. Of course, overtreatleaves the dentist in a bad pocaused while placing an implant, ment
sition. It raises the question of why
he or she treated the patient unnecduring tooth extractions or
essarily in the first place and did so
poorly in the second; it leaves him
through an injection.”
or her doubly guilty. If a mistake

So expertise does not preclude mistakes, but there are undoubtedly also
cases that result from negligence and
hubris.
I certainly see many cases in
which dentists have carried out a
treatment for which they were not
qualified. I remember an incident
in which a general practitioner injured nerves on both sides of the
mouth during an implant treatment. That is truly unbelievable.

With the consequence that patients
partially lose sensation in the mouth
or face?
Yes. Another consequential damage, of which I only recently learnt,
is loss of sense of smell. Patients
whose sinus has been injured often
lose their ability to smell. Sometimes,
they may not even realise it initially,
because the sinus runs on both sides
of the face and the unaffected side
often functions normally. Imagine

Many may think that it is not relevant to them, but every smart physician knows that things occasionally
go wrong and no one is immune. By
documenting dental malpractice incidents and by talking and writing
about these, I aim to raise awareness
and therefore help prevent future
incidents.
In your experience, what types of malpractice are most common?
There are definitely many cases in
the neurological field. As a medical

losing your sense of smell completely
owing to a defective bilateral sinus
lift procedure—that would be a fairly
serious impairment of a person’s
quality of life.

Displacement of dental implant into the maxillary sinus of a 70-year-old male patient. (© Dr Andy Wolff)

occurred after a reasonable treatment plan had been formulated, it
is comparatively less bad. Sometimes, even if a patient dies while
undergoing therapy, this does not
need to involve a distinct fault of
the clinician.
An American dentist was recently
charged because his patient died after
he extracted 20 teeth in one procedure.
I have performed such extensive
treatment in the past; it depends
on the need for the treatment and
how it is done. Probably, that case in
the US was the result of a combination of many things. For instance,
did the dentist act in accordance
with state-of-the-art practice? If
not, he is at fault. If he did, one has
to remember that dentists cannot
rise above today’s level of knowledge and technology. Let us say an
impaired patient files charges for
something that happened to him
20 years ago that would have been
preventable with the latest medical
treatment. He can, of course, make
a claim, but the dentist could not be
sued for it if he or she treated the patient according to the best knowledge available at that time.

[9] =>

DTAP0915_08-09_Wolff 08.09.15 09:47 Seite 2

Dental Tribune Asia Pacific Edition | 9/2015

TRENDS & APPLICATIONS

09
aiming to avoid disappointing patients.

That is a very important aspect
when writing expert reports on dental malpractice: did the dentist act
to the best of his or her ability and
according to the current knowledge
or with gross negligence? That is what
makes the difference.
What can medical professionals do
to protect themselves against legal
disputes arising from high-risk procedures they intend to perform?
Patients should not only be warned
of the possible consequences of a
certain procedure, but also be advised
of the alternatives—and one of those
alternatives is not proceeding with
treatment at all. In my opinion, the
patient should always understand
both options: the risks of a particular
treatment and what could happen if
nothing is done. Only then should the
patient be asked to sign a declaration
of consent.
Unfortunately, the reality is often
quite different. Patients are often
asked to sign declarations of consent
on their way into surgery or while
already on the dental chair. Even if
they had questions then, there would
be no time to answer them properly.
Although it should be of major concern for every dentist to thoroughly
inform the patient of the risks, as well
as alternative treatment methods,
before he or she is asked to sign a
consent form, I am constantly confronted with the opposite.

Bilateral mental and labial paraesthesia in a 62-year-old female patient due to bilateral mandibular canal perforation. (© Dr Andy Wolff)

So, you are saying that consultation
should be of similar importance to
treatment?
Absolutely. In my opinion, building mutual trust between doctor
and patient is key for avoiding malpractice and consequential charges. If
patients feel that their condition is
being properly treated, and that
money is not the dentist’s first concern, this alone can prevent litigation
in many cases. Of course, if a nerve is
damaged, there needs to be a settlement of some kind, but if a bridge
fails, for example, instead of filing
charges the patient will return for
further treatment if there is a solid,
trust-based relationship.
Time, communication, trust—what
else is important when it comes to
preventing malpractice?
One more basic rule every dentist
should follow is adhering to evi-

dence-based dentistry. This means
not performing a certain treatment
just because in the dentist’s experience it is considered to be right. External scientific evidence should be implemented. Also, every single finding
should be taken into account in determining how to treat the individual
patient: diagnosis, radiographs, periodontal analyses, age, health status,
literature and so on. Neglecting these
related aspects can very likely lead to
misconduct.
Do you see basic problems in dentistry
that need to change?
Nowadays, we face the problem
of “cheap” dentistry. Owing to the
amount of competition with the
large number of dentists in the
market, there are many cases of
overtreatment. Cheap dentistry
needs to be fast, yet I have documented cases in which patients

have returned for retreatment of a
simple problem up to 70 times in
two years. If you add up the time
those patients invest only to have a
poor outcome, it is striking. However, it is not possible for there to be
elite dental practices solely. For legal purposes, dental treatment
does not need to be exquisite, but it
has to be reasonable.
Maybe it is a problem of today that
patients have increasing expectations
regarding the service or technologies
their dentist should be using.
That is certainly part of the same
problem. Advertising that promises
people a new Hollywood smile in
2 hours forms the basis of patients’
beliefs or expectations regarding
treatment. Dentists should not be
tempted to involve themselves in
this kind of misguided pressure.
Honest communication is key when

Measures to prevent malpractice
should begin as early as possible, but
where should prevention start?
Personally, I think legal regulation
should be extended, such as specific
laws or by-laws concerning the
amount of experience and training,
for example, required in order to perform certain procedures. Basically, it
is just what common sense calls for
and everybody will agree with if they
think about it: should one be allowed
to place an implant after attending
a speakers’ corner talk or looking over
a colleague’s shoulder? No, yet this is
often what happens.
A second measure could focus on
undergraduate education. Dental
schools should devote more time to
prevention of lawsuits. This aspect
is neglected in the curriculum, although it is an essential part of
dentistry. General awareness of the
subject needs to be raised and this
alone would help prevent mistakes. As
I said earlier, mistakes are not always
avoidable, but they should at least not
arise out of negligence, hubris or
greed. Apart from that, there will always be cases of medical malpractice.
Dentists are humans too; only he who
does nothing makes no mistakes at all.
Thank you very much for the interview.
AD

[10] =>

DTAP0915_10-12_Browet 08.09.15 09:35 Seite 1

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 9/2015

Tips and strategies for restoring large
cavities using ﬁbre-reinforced material
By Drs Stephane Browet, Belgium, & Javier Tapia Guadix, Spain
Evidence has shown that one of the
biggest challenges facing dentists
today is restoring severely damaged
teeth. In order for these restorations
to be long lasting, certain biomechanical and biochemical criteria
need to be met. Even the smallest of
cavities can result in dramatic failure
owing to poor material choice and
incorrect biomechanical interaction
between the tooth and the material.
We often see cases where a small
cavity was restored with amalgam
a few years prior. The amalgam itself meets the material criteria but
the biomechanical issues are clearly
evident and cause severe cracks to
develop. These cracks could lead to
complete failure of the restoration
with loss of vitality of the tooth,
and possibly even loss of the tooth.
Amalgam has long been relied upon
as a durable restorative material.
But what value is a restoration itself
that lasts for 20 years if the tooth
fails? The final objective should be
preservation of the tooth and not
necessarily preservation of the
restoration.

Cavity design
When it comes to restorations of
this nature there are two goals: to
stop crack propagation and stopping
new cracks from forming. To achieve
this you will need a good material
and a sound approach. When it comes
to cavity preparation, the sharper
the angles, the higher the stress created in the cavity. The difficulty today is that as dentists we often have
to redo restorations with existing

cusps. Even with a bonded restoration, this fatigue will eventually
cause the wall to fracture. The following clinical situations call for
cuspal coverage:
1a

Fig. 1a: Pre-operatory.—Fig. 1b: Preparation.—Fig. 1c: Bonding.—Fig. 1d: Enamel wall.—Fig. 1e: everX build-up.—Fig. 1f: Enamel
built-up.—Fig. 1g: Staining ﬁnal.—Fig. 1h: Polishing.—Fig. 1i: Final.

cavity designs for amalgam but restore those cavities with another
material.
In addition, the tooth will also be
damaged to some extent. Our challenge is to minimise this damage
by making good choices in cavity
design and material. The principles
of cavity design are well established:
the width of the cavity should not
exceed half of the intercuspal width.
This means the surrounding tooth
structure is strong enough to function with the restorative material
inside. It is recommended that you
need between 2–2.5 mm of wall thickness in order to maintain good in-

trinsic strength. It is clear that if we
don’t respect these criteria and the
cavity ends up with very thin and
undermined walls, biomechanical
failure will occur.
Our biggest problem here is that we
get cavities like this
to start with. It’s
not necessarily our
choice to drill a cavity like this for caries removal. Often times an old
amalgam restoration can
lead to this type of cavity and the
temptation is to keep the remaining tooth structure to enable a di-

rect restoration. The tendency is to
keep those cusp tips, as references
for occlusal morphology and to preserve as much tooth tissue as possi-

ble. Because the walls are clearly
not thick enough the load bearing
forces will create fatigue within the

1. A wide isthmus and thin walls.
2. If there is no dentinal support and
cusps are undermined—blocking
out the unsupported enamel will
not solve the problem because
curing a composite inside a shell
will fracture it.
3. A horizontal crack in the undermined base of the cusp.
4. A longitudinal MOD crack.
5. Any crack inside the pulp chamber.
6. An endodontically treated tooth
with MOD restoration requires
coverage for all cusps.
7. An endodontically treated tooth
with a crack in the pulpal floor requires all cusps to be covered.

everX posterior
What is needed for these restorations is a material that will bond to
the tooth. This is not a guarantee
that the restoration will work, but
some sort of adhesion is required
that is not mechanically retained
like amalgam. What is needed is a
material that behaves like tooth
structure, something that
resists fatigue and also increases the load bearing capacity of the total restorative complex of the tooth
with the restoration.
everX Posterior (GC) fibre-reinforced composite material offers

Fig. 2a: Pre-operative view.—Fig. 2b: Occlusion and articulation should be considered, they guide the layering for ﬁnal morphology. Isolation with a rubber dam is recommended for a controlled protocol, optimal view
and access.—Fig. 2c: Cavity after removal of the old restoration shows decay.—Fig. 2d: Another view of the decay under the old amalgam restoration.—Fig. 2e: Caries removal and ﬁnalisation of the cavity preparation.—Fig. 2f: Cavity after the bonding procedure.—Fig. 2g: Sectional matrix placement and separation ring, a wedge adapts the matrix to the tooth in the cervical area.—Fig. 2h: Build-up of the mesial wall in two consecutive separately light cured layers.—Fig. 2i: Internal build-up with everX Posterior.—Fig. 2j: Finalised occlusal morphology.—Fig. 2k: Final result.—Fig. 2l: Follow up.

[11] =>

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[12] =>

DTAP0915_10-12_Browet 08.09.15 09:35 Seite 2

TRENDS & APPLICATIONS

Additional tips for using everX Posterior
• everX Posterior should be completely enclosed by the other material.
• First close the proximal, then the occlusal.
• Use a ball plugger or microbrush to adapt the material to the ﬂoor and take
your time.
• Light-cure in layers of 2mm thickness.
• When adding the ﬁnal layer of regular composite, use air block during the
ﬁnal light-cure to create a surface with a good ﬁnish and without an oxygen
inhibited layer.
• Always respect manufacturer guidelines for maximum rotation speed for
polishing points – avoid heating because it will change the properties of the
material.
• For ﬁnal lustre a goat hair brush with diamond paste will create a glossy result
for surface polishing.

many solutions to the type of problems we have discussed in this article. It is made up of three sections:
an interpenetrating polymer network (IPN) resin matrix, e-glass fibres and fillers, initiators and inhibitors. What is really important
in a material like this, is the way in
which the e-glass fibres and the IPN
matrix interact with each other because this makes it possible to absorb the loading forces. This transfer of pressure from the matrix to
the fibres on a microscopic scale

Dental Tribune Asia Pacific Edition | 9/2015

means that crack propagation can
be stopped while at the same time
giving the restoration the capacity
to resist very high loading forces.
The maximum bite force for humans is about 1,000 N. A conventional composite has a similar resistance. However, if you compare a
combination of everX Posterior,
which is a base material that should
be covered with an overlaying composite, the total load bearing capacity is much higher than with composite alone, even “almost double”.

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Fracture prevention
Some dentists are misguided
when they think that a tooth can be
saved by using a very strong material.
In actual fact, when using such a
strong material, the tooth inadvertently becomes the weaker part of the
restorative complex. This means that
if failure occurs, the tooth will be lost.
With this everX Posterior, in the case
of failure, the damage can be contained. Cracks can be deviated along
the material inside the tooth, resulting in fractures which are more
above gum level, instead of running
through the entire tooth leading to
catastrophic failure. It will still lead to
failure, but will allow for further
restoration because the fracture line
is still visible and accessible. Fracture
toughness is another physical property which is twice as high in everX
Posterior than in conventional composites. The flexural modulus is
closer to that of natural dentine, so it
behaves like natural tooth structure.
While the build-up procedure of the
material allows for a well-functioning restorative complex, it’s how the
material shrinks that matters. The
volumetric change and shrinkage
stress of the material after and during setting is similar to that of conventional composite, but a very big
difference is the presence of the fibres. By placing the material in the
cavity and by pushing it down you
are able to align the fibres into a more
longitudinal direction which reduces
linear shrinkage. With the vertical
shrinkage you can expect the entire
restoration to shrink down, but this
won’t create the same stress as a regular composite. The linear stress and
shrinkage on the walls is lower, giving
you a more predictable outcome and
minimised damage. By using everX
Posterior as dentine replacement and
layering it with a regular composite,
the total load bearing capacity of the
tooth complex will increase significantly. Therefore it makes sense in
both direct and indirect approaches
to have the support from a fibre-reinforced composite underneath.
Editorial note: This article was first published
in GC get connected (www.gceurope.com/
news/newsletter/index.php).

Stephane Browet
attended dental
school at the Free
University of
Brussels in 1995
and completed
the Post Graduate programme
Aesthetic Dentistry. Nationally
and internationally he lectures on rubber dam isolation, microscope dentistry,
posterior and anterior composites as well
as indirect restorations.He also maintains
a private practice focused on microscope
aided restorative dentistry. He can be
contacted at info@stephanebrowet.com.
Javier
Tapia
Guadix currently
owns a private
practice specialised in prosthetic
and restorative
dentistry in Madrid, Spain, and
frequently presents lectures on
topics such as composite stratiﬁcation
techniques, dental photography and
computers in dentistry.

[13] =>

[14] =>

DTAP0915_14-16_Ozoglu 08.09.15 09:36 Seite 1

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 9/2015

Direct anterior restoration
placed with a modern composite
Lifelike aesthetics achieved with minimally invasive methods
By Dr Ali H. Ozoglu, Turkey

Fig. 1: Initial situation with tooth #22 discoloured as a result of endodontic treatment.—Fig. 2: Minimally invasive preparation of tooth #22 for the placement of a composite restoration.—Fig. 3: The prepared tooth
surface is covered with IPS Empress Direct Color in white.—Fig. 4: The tooth is completely coated with a layer of IPS Empress Direct in A2 Dentin.—Fig. 5: Internal play of colours: IPS Empress Direct Color in blue in the
incisal area and IPS Empress Direct Color in honey yellow in the cervical area to match the neighbouring teeth.—Fig. 6: Contouring of the composite with an OptraSculpt Pad instrument.

The possibilities of restoring teeth
have grown immensely over the past
few decades owing to the development of innovative dental composites. In the past, dentists had to rely
on indirect veneers to produce highly
aesthetic results, but today advanced
materials are available that offer a
suitable alternative in many cases.
Composite resins have undergone
considerable changes in recent times.
The dental research community and
industry have reacted to the emerging demand among practitioners and
patients for these materials, and as
a result composite resins are now at
a level where they are regarded as
state of the art.
With modern materials such
as IPS Empress Direct (Ivoclar
Vivadent), anterior restorations can
be efficiently layered to produce
highly aesthetic results that are virtually indiscernible from the natural
tooth structure. Consequently, dental practitioners can benefit from the
convenient handling properties of
composites without having to make
any compromises in terms of aesthetics. In our opinion, IPS Empress
Direct is the best material of its kind
available for satisfying exceptionally
high aesthetic requirements. Owing
to the material’s lifelike opacity, fluorescence and opalescence, true-tonature restorations can be fabricated
using a very efficient method.
Generally, the filler composition
of composites is more significant in
anterior than in universal materials.
A composite resin has to meet special
physical property requirements with
regard to volume shrinkage, surface
hardness, flexural strength, polisha-

bility and wear resistance. Furthermore, the optical characteristics
have to be carefully balanced. IPS
Empress Direct fulfils all of these
major requirements. The monomers
contained in the composite determine its reactivity, strength, shrinkage and handling. The monomer matrix incorporates fillers that determine the wear resistance, strength,
polishability, surface gloss, radiopacity and translucency of the material.
A coarse barium glass filler imparts
the Dentin shades with high strength,
while the finer barium glass filler

contained in the Enamel shades
ensures excellent polishability, high
gloss and low susceptibility to
wear.
The composite system comprises
32 shades and five translucency levels. The properties of fluorescence,
translucency and opalescence are decisive for the aesthetic appearance of
the restoration. IPS Empress Direct
obtains its lifelike fluorescence from
special pigments and owes its exceptional optical characteristics to its
composition. The Dentin shades ex-

hibit a higher opacity and colour saturation than the Enamel materials.
Therefore, the aesthetic effect is enhanced from within the restoration.
The translucency of the Enamel
shades allows the Dentin materials
to scatter light in a manner similar
to natural tooth structure. Furthermore, the Trans Opal shade gives
the restoration a true-to-nature
opalescence. In reflected light, it appears bluish and in transmitted light
reddish-orange, which corresponds
to the appearance of natural tooth
structure.

Nevertheless, ideal physical and
optical properties alone are not
enough to ensure an aesthetic result. Skill and expertise are required on the part of the dental
practitioner who has to impeccably layer and shape the restoration, as well as faithfully reproduce the shade and optical characteristics of the tooth.
For this purpose, a composite
should be convenient to handle. IPS
Empress Direct is applied according
to an intuitive method.

Fig. 7: After ﬁnal shaping of the restoration and polymerisation.—Fig. 8: Finished and polished restoration on tooth #22.—Fig. 9: Two months after treatment: the result is
stable.—Fig. 10: Examination of the functional situation two months after treatment.

[15] =>

Proven
Unrivaled innovation, thoughtful design, lasting integrity: A-dec 500
is based on decades of collaboration with dentists worldwide.
Such cooperation has led to pressure-mapped patient comfort,
robust integration of handpieces and technology to minimize reach,
and a touchpad that provides single-point system control.
In a world that demands dependability, A-dec delivers
a proven solution without a single compromise.

Contact A-dec at +1.503.538.7478 or visit a-dec.com to learn more.

©2015 A-dec Inc.
All rights reserved.

[16] =>

DTAP0915_14-16_Ozoglu 08.09.15 09:36 Seite 2

TRENDS & APPLICATIONS

16
Case study
A 28-year-old patient was referred to our practice. He was dissatisfied with the colour and position of the maxillary left lateral
incisor (Fig. 1). The examination
showed that tooth #22 had been
endodontically treated, which explained its substantial discolouration. The shade of the existing composite restoration considerably
deviated from that of the natural
tooth structure. In addition, the po-

restoration would involve minimally invasive preparation and
could be placed in a single appointment. The patient accepted this proposal, and we proceeded to prepare
tooth #22 for a modified veneer and
to remove any discoloured dental
tissue.

sition of tooth #22 contributed to
the suboptimal overall appearance
of the dentition. It was inclined towards the palatal aspect and therefore looked very small compared
with the adjacent teeth. The patient
desired an aesthetic result that
could be achieved in one appointment. This was the ideal indication
for IPS Empress Direct.

In the process, as little as possible
of the healthy tooth structure was
ground. Since minimally invasive
criteria were being followed, the
existing composite restoration was

We suggested that the patient
consider having the tooth restored
with a direct composite. This type of

Dental Tribune Asia Pacific Edition | 9/2015

not completely removed (Fig. 2). The
tooth was conditioned and a bonding agent was applied. Next, the discoloured dentine was concealed with
IPS Empress Direct Color in white.
The material was applied to the tooth
surface in such a way that the restoration would not appear completely
opaque (Fig. 3). The tooth surface
was then entirely covered with IPS
Empress Direct in A2 Dentin (Fig. 4).
In order to impart a lifelike appearance to the incisal part of the

ENDO POWER
with COLTENE innovations!
1

HyFlex™ EDM

> Up to 700% higher fracture resistance
> Specially hardened surface
> Less ﬁlling required for treatment success

The excess material was removed with finishers and fine-grit
diamond burs. The occlusion and
function of the restoration were
checked. The restoration was then
polished to a high-gloss finish with
silicone polishers and polishing
discs in a few easy steps.

CanalPro™ Syringe Fill Station

> One-hand dosing
> Thought-out design

The patient was thrilled with the
new appearance of his anterior
teeth (Fig. 8). The shape and shade
of tooth #22 blended in smoothly
with the existing teeth. The optical
characteristics of the restoration
were comparable to those of the
natural dentition. Two months after the treatment, the patient returned to the practice for a recall
appointment. On this occasion, the
restoration showed excellent integration. Its shape and shade completely fulfilled our expectations
(Figs. 9 & 10).

GuttaFlow® bioseal

> Actively supports regeneration in the root canal
> Excellent ﬂow properties

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Bioactive obturation
material
Not just ﬁlling,
but also healing!

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tooth, we applied IPS Empress Direct
in A2 Enamel in layers and imitated
the enamel areas of the adjacent
teeth. The natural incisors exhibited
several dark incisal areas as a result
of their relatively high translucency. These areas were imitated
with IPS Empress Direct Color in
blue. Owing to the thin enamel
layer, the cervical areas of the natural teeth had a yellowish tinge.
This feature was recreated in tooth
#22 using IPS Empress Direct Color
in honey yellow (Fig. 5). The enamel
layer was completed with IPS
Empress Direct in A2 Enamel. This
layer was shaped with the help of an
ingenious contouring instrument
called OptraSculpt Pad (Ivoclar
Vivadent; Figs. 6 & 7). This instrument was used to form the final
contours of the restoration. The
foam pad attachments allow composites to be shaped quickly and
without sticking. This instrument
has become an indispensible tool
in our daily work. Finally, a thin
layer of IPS Empress Direct in Trans
Opal was applied and the restoration was shaped again with OptraSculpt Pad. The Trans Opal material
allowed us to imitate the natural
optical properties of the tooth surface. Subsequently, the restoration
was polymerised according to the
manufacturer’s recommendations.

Conclusion
IPS Empress Direct is a nano-hybrid composite for direct restorative
procedures. It features lifelike opacity, fluorescence and opalescence.
Aesthetic anterior restorations can
be skilfully created with the material in a very short time. Given the
appropriate conditions, this material can be used to offer patients an
adequate alternative to laboratoryfabricated ceramic veneers.

3
Dr Ali H. Ozoglu
is a dentist from
Adana in Turkey.
He can be contacted at aliozoglu@
yahoo.com

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[cover] => DT Asia Pacific No. 9, 2015

[toc] => Array ( [0] => Array ( [title] => Asia News [page] => 01 ) [1] => Array ( [title] => World News [page] => 03 ) [2] => Array ( [title] => Treatment coordinator: The bridge to case acceptance [page] => 06 ) [3] => Array ( [title] => Interview: “Patients tend to go to court more often nowadays” [page] => 08 ) [4] => Array ( [title] => Tips and strategies for restoring large cavities using fibre-reinforced material [page] => 10 ) [5] => Array ( [title] => Direct anterior restoration placed with a modern composite [page] => 14 ) ) [toc_html] =>

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