DT Middle East & Africa No. 5, 2018

Celebrating 10 years of Dental Facial Aesthetics over 6 days – Dubai Dental Week November / News / Implant-based all-ceramic restoration using 3M Impregum Penta Polyether Impression Material / Industry / New Technologies—to improve root canal disinfection / Long-term clinical success in the management of compromised intertooth spaces utilizing small-diameter implants / Sticks to the teeth – not the instruments / Efficiency and esthetics in the posterior region / Chairside CAD/CAM immediate restorations / Restoring function and aesthetics with monolithic zirconia restorations / Anterior restorations with CAD/CAM veneers made of VITABLOCS Triluxe forte / Interview: “I believe that innovation is the engine of a company” / Interview: “Clear, step-by-step instructions are essential for long-term success” / News / Distributors / Endo Tribune Middle East & Africa Edition No. 5, 2018 / Lab Tribune Middle East & Africa Edition No. 5, 2018 / Hygiene Tribune Middle East & Africa Edition No. 5, 2018 / Implant Tribune Middle East & Africa Edition No. 5, 2018 / Ortho Tribune Middle East & Africa Edition No. 5, 2018

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www.dental-tribune.me

Published in Dubai

September-October 2018 | No. 5, Vol. 8

ENDO TRIBUNE

LAB TRIBUNE

HYGIENE TRIBUNE

IMPLANT TRIBUNE

ORTHO TRIBUNE

Internal resorption treatment
using MTA-based endodontic
sealer

Sunny prospects: Using power
to achieve brightness

Brushing your teeth just got
social

Mastering the implant
digital workflow

New study: 7 percent of children
in orthodontic care at risk for
sleep disorders

ÿA1-4

ÿB1-4

ÿC1-8

ÿD1-4

ÿE1-4

DENTAL TRIBUNE
The World’s Dental Newspaper Middle East & Africa Edition

Celebrating 10 years of Dental Facial
Aesthetics over 6 days
– Dubai Dental Week November
By Dental Tribune MEA/CAPPmea
DUBAI, UAE: The 2018 Dental Facial
Cosmetic Conference & Exhibition
will be celebrating its 10th anniversary this year on 09-10 November
2018. Total of 42 CME credits, over
38 international speakers and key
opinion leaders, 27 lectures, 21 hands-

on dental training courses, 10 poster
presentations and over 30 free CME
sessions will take place during Dubai
Dental Week (07-12 November 2018).
The term “cosmetic dentistry” was
invented in the 1990s, but it actually
dates back to the ancient times. It is
well known that wooden sticks were
used to clean their teeth for beauty

and not for health reasons, in early
3000 BC.
The Middle-East’s largest dental conference related to aesthetic dentistry
will once again open it’s doors on
09 November 2018 at the InterContinental Hotel Dubai Festival City.
The two day event will feature inter-

AD

From a patient to a fan:

Together we
make it happen!
wh.com

#patient2fan

active lectures, hands-on trainings,
seminars, trade show exhibition and
additional CME related events. Ten
years together – one decade, learning
through experience and exchange,
our dental communities come together to contribute on the evolution of cosmetic dentistry and development within the field. Thanks
to modern technologies and the fast
growing evolving of the materials
and techniques; cosmetic treatment
from teeth whitening, laser procedures, composite fillings, dental
bonding to veneers and dental implants, cosmetic dentistry is defining
a new epoch.

tal Education Academy will feature
the following at the 10th Dental Facial Cosmetic Conference & Exhibition:

It has been incredible to experience
the growth of this conference over
the past decade, to review progress
and challenges in cosmetic and aesthetic dentistry. The 9th edition in
2017 concluded with a record breaking attendance which exceeded
3,000 delegates. The 10th edition
will surpass the attendance as the
event has become ever so popular in
the Middle-East region

Topic focussed dedicated
trade show exhibition

CAPP is very proud to be part of this
progress for the last decade and to
contribute with high-quality education.
We invite all dental professionals to
be part of this memorable event on
09-10 November 2018 at the Intercontinental Hotel Festival City in
Dubai. During the event, CAPP Den-

Educational sessions with
industry experts
Dental Hygienist Seminar (DHS)
Poster Presentations
Pre and post hands-on courses with
industry experts
Face-to-face appointments with
suppliers of your choice
Networking opportunities with
industry peers and supplier representatives

Main Sponsors include Dentsply Sirona, Ivoclar Vivadent, 3M Oral Care,
Colgate, Oral-B, Invisalign, 3-Shape,
VITA, Coltene, Shofu, Carestream
Dental, Kulzer, EMS, Mectron, HuFriedy and more.

CAPP Events
The Leader in Continuing Dental Education
Onyx Tower 2 | Office P204 & P205
The Greens | Dubai | UAE
P.O. Box: 450355 | Dubai | UAE
Tel: +971 4 347 6747
E-mail: events@cappmea.com

[2] => DTMEA_No.5. Vol.8_DT.indd

news

IMPRINT
Publisher/President/
Chief Executive Officer
Torsten R. Oemus
Chief Financial Officer
Dan Wunderlich

Researchers find possible link between
bruxism and periodontitis
By DTI
OKAYAMA, Japan: In a recent
study, researchers from Okayama
University investigated whether
involuntary masseter muscle activity showed any specific pattern concerning the severity of
periodontitis. According to their
results, after performing detailed
measurements in a group of people
with various degrees of periodontal
disease, they found that bruxism
might be related to its acuteness.

A total of 31 participants took part
in the study, 16 of whom had no
or mild periodontitis (NMP), with
the remaining 15 having moderate
to severe periodontitis (MSP). To
ensure researchers were able to attain as in-depth results as possible,
participants were equipped with a
portable electromyography (EMG)
device and monitored both day and
night.
In addition to wearing the device,
participants of the study were also
required to keep a diary—noting ac-

tivities such as when they ate their
meals, which enabled researchers
analysing the data to filter out all
muscular activity not related to
involuntary teeth grinding. Teeth
movement due to speech was filtered out by monitoring voice activity from a microphone attached
to the EMG device.
According to the study’s results,
during both waking and sleeping
hours, the duration of masseter
muscle activity was significantly
longer in the MSP group than in the

DIRECTOR OF CONTENT
Claudia Duschek
Clinical EditorS
Nathalie Schüller
Magda Wojtkiewicz
Editor & social media manager
Monique MEHLER

NMP group. However, due to oral
conditions such as missing teeth or
the use of removable partial dentures not being taken into account,
as well as the limited capabilities of
the EMG setup, researchers stated
that bruxism leading to periodontitis could not be concluded.
The study, titled “Relationship between severity of periodontitis and
masseter muscle activity during
waking and sleeping hours”, was
published in the Archives of Oral
Biology on 1 March 2018.

EditorS
Franziska Beier
Brendan Day
Kasper Mussche
ASSISTANT & SOCIAL MEDIA MANAGER
Luke Gribble
Copy Editor
Ann-Katrin Paulick
Sabrina Raaff
IT & DEVELOPMENT
Serban Veres
Business Development & MARKETING
Manager
Alyson Buchenau
DIGITAL PRODUCTION MANAGER
Tom Carvalho
Junior DIGITAL PRODUCTION MANAGER
Hannes Kuschick
PROJECT MANAGER ONLINE
Chao Tong
IT & DEVELOPMENT
Serban Veres
GRAPHIC DESIGNER
Maria Macedo
e-learning MANAGER
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EDUCATION & EVENT MANAGER
Sarah Schubert
PRODUCT MANAGER SURGICAL TRIBUNE
& DDS. WORLD
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SALES & PRODUCTION SUPPORT
Puja Daya
Madleen Zoch
Accounting
Karen Hamatschek
Manuela Hunger
Executive Producer
Gernot Meyer
advertising disposition
Marius Mezger
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Prof. Paul TIPTON, UK
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Dr. Ninette Banday, UAE
Dr. Nabeel Humood Alsabeeha, UAE
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Dr. Mohammad Al-Obaida, KSA
Dr. Meshari F. Alotaibi, KSA
Dr. Jasim M. Al-Saeedi, Oman
Dr. Mohammed Al-DarwisH, Qatar
Dr. Dobrina Mollova, UAE
Dr. Ahmed KAZI, UAE
Dr. Munir Silwadi, UAE
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Dr. Ehab RASHED, UAE
Aiham Farrah, CDT, UAE
Retty M. Matthew, UAE
Partners
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©2018, Dental Tribune International GmbH.
All rights reserved. Dental Tribune
International makes every effort to report
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product news accurately, but cannot assume
responsibility for the validity of product
claims, or for typographical errors. The
publishers also do not assume responsibility
for product names or claims, or statements
made by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune International.

[3] => DTMEA_No.5. Vol.8_DT.indd

Solutions for better,
safer, faster dental care
Dentsply and Sirona have joined forces to become the world’s largest
provider of professional dental solutions. Our trusted brands have empowered dental professionals to provide better, safer and faster care in all fields
of dentistry for over 100 years. However, as advanced as dentistry is today,
together we are committed to making it even better. Everything we do is
about helping you deliver the best possible dental care, for the benefit of
your patients and practice.
Find out more on

dentsplysirona.com

[4] => DTMEA_No.5. Vol.8_DT.indd

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 5/2018

Implant-based all-ceramic restoration using 3M
Impregum Penta Polyether Impression Material
By Dr. Gunnar Reich, Germany

Open tray (pick-up) technique
Initial situation
Single implant in region 15 to replace missing tooth. Patient arrived
for impression taking appointment
with trans-gingival healing cap. Surrounding soft tissue shows excellent
healthy conditions (Fig. 1).

Treatment
After removal of the healing cap, the
impression post (Straumann implant system) for the open tray (pick-

up) technique was positioned (Fig. 2).
For impression taking Impregum
Penta Polyether Impression Material was selected. For the monophase
technique the same material is used
for tray loading and syringing the
impression post. While the assistant
was filling the tray, the dentist syringed the material thoroughly with
the elastomer syringe (Fig. 3).
The impression was taken using a
3M ESPE Impression Tray. The perforation was made according to the
individual situation (Fig. 4).
The accurate impression with the

fixed impression post (Fig. 5) was
then sent to the dental lab. Prior to
pouring the model, the laboratory
implant analog was exactly mounted (Fig. 6).
For highest esthetics, a custommade zirconia abutment (3M Lava
Plus) (Fig. 7) was delivered by the lab.
On top, an individualized monolithic 3M Lava Plus Zirconia crown was
placed (Fig. 8).

in the set impression upon removal
from the mouth. Once the impression has set, the screw holding the
coping on the implant is accessed
through the hole above/below the
implant in the open tray and unscrewed to allow removal of the
impression from the mouth. Once
outside of the mouth, the implant
analogue is connected to the transfer coping prior to pouring the stone
model.

Tips for making great implant
impressions
- Support tray until impression material is sufficiently set. Stabilize the
tray after seating, avoid any movements.
- Use enough material and keep the
tip permanently immersed in the
material during syringing to avoid
air entrapment and voids.
- Pick-up technique: Widen implant
windows in the tray to avoid trayabutment contact.

Open tray (pick-up) technique
In this technique, the direct transfer
coping gets “picked up” and remains

Fig. 1: Initial situation with healing cap.

Fig. 2: Open tray impression post mounted.

Fig. 3: Impregum Penta Polyether Material syringed
around impression post (Straumann) using elastomer
syringe (step 1 in monophase technique).

Fig. 4: Impression taking using Impregum Penta
Polyether Material and an individualized, perforated
3M ESPE Impression Tray (step 2 in monophase technique).

Fig. 5: Impression with fixed impression post to be
sent to dental lab.

Fig. 6: Impression with mounted laboratory implant
analog.

Fig. 7: Custom-made Lava Zirconia abutment.

Fig. 8: Final placement of Lava Plus Zirconia crown.

Closed tray (snap-on) technique
Initial situation
Single implant in region 15 to replace missing tooth. Patient arrived
for impression taking appointment
with trans-gingival healing cap. Surrounding soft tissue shows excellent
healthy conditions (Fig. 1).

Treatment
After removal of the healing cap,
the corresponding impression post
and the impression cap (CAMLOG
implant system) for the closed tray
(snap-on) technique were mounted.
For impression taking Impregum
Penta Polyether Impression Material was chosen since it offers dimensional accuracy and a secure impression cap fixation. The impression
was taken using a regular stock tray.
For the monophase technique the
same material is used for tray loading and syringing the impression
post. While the assistant was filling
the tray, the dentist syringed the material thoroughly with the elastomer
syringe (Figs. 2 and 3).
The accurate impression with the
fixed impression cap (Fig. 4) was
then sent to the dental lab. For highest esthetics, a veneered Lava Plus
all-ceramic crown was placed on an
individualized Lava Plus Zirconia
abutment (Fig. 5).

Fig. 2: Impregum Penta Polyether Material syringed
around impression post using elastomer syringe (step 1
in monophase technique).

Fig. 4: Impression with fixed impression cap to be sent to
dental lab.

Fig. 4: Impression with fixed impression cap to be sent to dental lab.

impression and is pulled off of the
implant abutment when the set
impression is removed from the
mouth. Once outside of the mouth,
the implant analogue is connected
to the transfer coping prior to pouring the stone model.

Closed tray (snap-on) technique
In this technique, the direct transfer
coping “snaps-on” to the top of the
implant abutment in the mouth.
Once the impression has set, the
coping becomes embedded in the

Fig. 3: Impregum Penta Polyether Material syringed
around impression post.

Fig. 1: Initial situation with healing cap (CAMLOG).

To learn more 3M Impregum Polyether Impression Material please visit:
www.3Mae.ae/dental (Gulf countries),
www.3m.com.sa (Saudi Arabia)

To request Pentamix ‘Test Drive’ or visit of
3M specialist please contact us at:
3MOralCareGulf@mmm.com
3M, ESPE, Impregum, Lava and Penta
are trademarks of 3M Company or 3M
Deutschland GmbH. Used under license in
Canada. All other trademarks are owned
by other companies.

Dr. Gunnar Reich
Munich, Germany.
Owner of Dr. Gunnar Reich Private
Dental
Practice
specialized in the
following focus areas: aesthetic restoration and reconstruction with plastic,
filling material in anterior and posterior
regions, complex dental prostheses and
implantology. Author of several publications in Germany and abroad.

Tips for making great implant
impressions
- Support tray until impression material is sufficiently set. Stabilize the
tray after seating, avoid any movements.
- Use enough material and keep the
tip permanently immersed in the
material during syringing to avoid
air entrapment and voids.
- Snap-on technique: Try-in the tray
prior to making impressions and ensure proper size to avoid

[5] => DTMEA_No.5. Vol.8_DT.indd

[6] => DTMEA_No.5. Vol.8_DT.indd

InduSTRy

Dental Tribune Middle East & Africa Edition | 5/2018

GUM PAROEX – professional plaque
control for optimal gum health
By Sunstar Europe
The combination of Chlorhexidine
Digluconate (CHX), professional
reference for plaque control and
Cetylpyridinium Chloride (CPC),
included in GUM Paroex products,
has the long-lasting ability to attack
the structure of existing plaque and
prevent the growth of bacteria and
toxins responsible for its formation.
The superior efficacy of GUM Paroex
in the plaque control was proven by
an independent study* with the following results:

Gingival Index

Fig. 1

Placebo
GUM PAROEX
0.12% CHX/CPC
0.12%
CHX/ALC
0.20%
CHX/ADS

• GUM PAROEX 0.12% CHX + 0.05%
CPC is clinically proven to have a
more pronounced effect in reducing
plaque (vs. CHX/ADS) and gum problems than other usual mouthrinses
containing CHX (Fig. 1, Fig. 2).
• The clinical efﬁcacy of GUM PAROEX 0.12% CHX + 0.05% CPC is signiﬁcantly superior to 0.12% CHX/ALC in
controlling gum problems (Fig. 1).
• 0.20% CHX/ADS efﬁcacy is comparable to a 0.05% Sodium Fluoride
mouthrinse, without any active anti-

bacterial agent (Placebo) (Fig. 1).
• GUM PAROEX 0.12% CHX + 0.05%
CPC clinical efficacy in helping control gum problems is significantly
superior to 0.20% CHX/ADS (Fig. 1).
• The taste of GUM PAROEX 0.12%
CHX + 0.05% CPC is well-accepted
and signiﬁcantly better than 0.12%
CHX/ALC and 0.20% CHX/ADS formulation. This promotes better patient compliance to treatment (Fig.
3).
• The staining of GUM PAROEX 0.12%

Plaque Index

Fig. 2

Placebo

A
B

GUM PAROEX
0.12% CHX/CPC

0.12%
CHX/ALC

0.12%
CHX/ALC
0.20%
CHX/ADS

odontal disease based on the severity
and location of the lesion.
Plaque Index (QHI) - an index for estimating the status of oral hygiene
by measuring dental plaque that occurs in the areas adjacent to the gingival margin.

Gingival Index (GI) - measure of peri-

Fig. 3

Placebo

* Per Ramberg et al. Effect of Chlorhexidine/Cetylpyridinium Chloride
on plaque and gingivitis: abstract
ID# 182859 IADR WCPD Budapest
2013

Subjective taste

GUM PAROEX
0.12% CHX/CPC

0.20%
CHX/ADS

CHX + 0.05% CPC is equivalent to the
staining produced by 0.12% CHX/
ALC or 0.20% CHX/ADS based on
subjective patient evaluation (Fig 4).

A
B

Subjective tooth staining
Placebo

GUM PAROEX
0.12% CHX/CPC

0.12%
CHX/ALC

0.20%
CHX/ADS

Fig. 4

Gingival Index (GI) - measure of periodontal
disease based on the severity and location of the
lesion.

Plaque Index (QHI) - an index for estimating
the status of oral hygiene by measuring dental
plaque that occurs in the areas adjacent to the
gingival margin.

Taste acceptance
(0- Non acceptance; 8 - High acceptance)

Staining evaluation
(0- No stains ; 8 - Strong stains)

Fig. 1: Mean Gingival index (GL) change Day 0 - Day
21 in 17 patients. Different letters indicate statistically
significant differences in the mean GL change Day 0 Day 21 between treatment groups.

Fig. 2: Mean QHI (plaque level) change Day 0 - Day
21 in 17 patients. Different letters indicate statistically
significant differences in the mean QHI change Day
0 - Day 21 between treatment groups.

Fig. 3: Subjective taste of the different mouth rinses
evaluated by the VAS method at Day 21 on 17 patients. Different letters indicate statistically significant
differences between treatment groups at Day 21.

Fig. 4: Subjective tooth staining of the different
mouth rinses evaluated bz 17 patients at Day 21.
Different letters indicate statistically significant differences between treatment groups at Day 21.

Dentsply Sirona’s new VPS impression
material – coming soon
By Dentsply Sirona
In keeping with a long tradition of offering meaningful innovation to the
market, Dentsply Sirona will proudly
introduce Aquasil Ultra+ Smart Wetting Impression Material to customers in October 2018. A completely
redesigned VPS offering, Aquasil
Ultra+ impression material merges
state-of-the-art intraoral hydrophilicity and intraoral tear strength to
deliver better-than-ever results, op-

timising performance in all areas,
not just one. The ‘+’ means clinicians
now do not have to choose between
wettability, tear strength, speed, and
delivery options.
Aquasil Ultra+ Smart Wetting Impression Material is a final VPS impression material indicated for use
in all dental impression techniques
and will be available for purchase
through approved Dentsply Sirona
distributors.

Aquasil® Ultra+ Smart Wetting® Impression Material

a no-Compromise Vps
solution
Aquasil Ultra+ provides clinicians
with a no-compromise solution to
their final impression needs with
market leading intraoral hydrophilicity and intraoral tear strength. Historically, the market has measured
impression material performance
outside of the clinical context in
which a dentist works. Leveraging
the latest technology, Dentsply Sirona tests and publishes clinically

relevant intraoral performance to
better empower clinicians to make
better clinical decisions.
Aquasil Ultra+ impression material’s
market leading intraoral hydrophilicity is designed to help clinicians
avoid trapping fluid from the moment the material is syringed into
the moist, humid environment,
helping clinicians alleviate voids
and bubbles at or near the margin.
Our extremely low contact angle—
while the impression material is uncured—helps ensure
an accurate impression in the presence
of natural hydration,
so over-desiccation of
the tooth prep isn’t
necessary. It also delivers ideal cured film
hydrophilicity, meaning the material continues to work well
with moisture after
it leaves your office,
delivering accuracy at
the lab to ensure properly fitting final restorations.
Market leading intraoral tear strength
delivers a material
designed to help clinicians reduce risks of
tears at the margin
which are the most
common impression

errors labs see. It is especially useful
while the material is in thin crosssections and when being removed
from the patient’s mouth, as well
as during pours at the lab. Our advanced formula accommodates a
wider set of cases, including those using retraction paste where minimal
retraction occurs.
Aquasil Ultra+ sets a standard of excellence with its ability to capture
and maintain detail thanks to its intraoral performance, and combines
this with a selection of clinically relevant work/set times and viscosity
choices to provide a no-compromise
product solution for single-unit
crown cases and more.

Learn more about how Aquasil Ultra+
impression material can benefit the dental office from your local Dentsply Sirona
sales representative or at www.AquasilUltraPlus.com

[7] => DTMEA_No.5. Vol.8_DT.indd

MyCrown

[8] => DTMEA_No.5. Vol.8_DT.indd

industry

Dental Tribune Middle East & Africa Edition | 5/2018

An exciting year for award winning brand
Beverly Hills Formula
By Beverly Hills Formula
Despite over two decades as one of
the world’s top oral care brands, Beverly Hills Formula continues to expand rapidly. 2018 has been a truly
tremendous year for BHF, with CEO
Chris Dodd catapulting the company to ground-breaking new heights.
Revolutionary new product development and a dedication to producing
safe and effective teeth whitening in
the home has allowed the brand to
enjoy continued success across the
globe, notably in the Middle East,
where popularity and demand has
soared.
Throughout 2017, the company
focused their attention on increasing their brand presence here and
merely one year later, Beverly Hills
Formula have firmly cemented their
position as market leaders in Oral
Care. They are currently stocked in
countries such as UAE, Saudi Ara-

bia, Oman, Qatar, Lebanon, Kuwait,
Jordan and Iran, and dental professionals raise no qualms when recommending the products to their
patients.
The brand’s mantra is to always be
innovators, not imitators, and 2018
saw the introduction of one of their
most cutting-edge ranges yet.
The Professional White Range was
showcased at 2018’s International
Dental Conference and Arab Dental Exhibition (AEEDE) and was met
with an exceptionally positive response.
Having debuted at 2017’s show, there
was definitely a buzz about the range
this year, and dental professionals
from across the globe eagerly visited
the stand to find out more about the
range.
The Professional White Range Black
Pearl Whitening Toothpaste, Pink
Pearl Sensitive Toothpaste, the
award winning Precious Pearl Enam-

el remineralising toothpaste and
Fresh Pearl Mouthwash. Their Precious Pearl Enamel remineralising
toothpaste scooped the award for
Best New Oral Beauty Product at the
2017 Pure Beauty Awards. The range
has been scientifically formulated
with Hydroxyapatite which has
been proven to form new protective
layers, giving teeth a smoother and
brighter appearance by repairing
micro-lesions and strengthening the
enamel in teeth.
Along with this highly sought after
range, the brand also showcased
their first Professional Whitening
Kit, which includes teeth whitening
strips and a handy on the go whitening pen. The company sought to
introduce a whitening kit to the market that not only offers exceptional
teeth whitening, but one that is also
safe to use and won’t damage teeth.
The kit was over two years in development. The main ingredient is

PAP – Phthalimido-Peroxy-Caproic
Acid, a non-peroxide teeth whitening ingredient which effectively
breaks down discolorations on the
teeth, without harming the enamel
of gums.
Also in their portfolio is the Perfect
White Range, which has been a major success for the brand. The range
includes Perfect White Black, one
of the most innovative products to
hit shelves. The brand were first to
market with their activated charcoal
toothpaste, which has been clinically
proven to remove tannins and surface stains from teeth. Also in this
range is Perfect White Gold, Perfect
White Sensitive and their new-formulated Perfect White Optic Blue.
The range also includes two mouthwashes and has been proven to remove up to 90% of surface stains.
In a highly competitive industry,
Beverly Hills Formula has remained

a highly respected brand within the
oral care industry. They have proved
themselves as forerunners in this
industry, and show no signs of giving up their place as leaders in this
industry. They have proven that you
don’t need to be the biggest company to make the most noise.
The brand looks forward to reaching
new heights in 2019, acknowledging
that this may well be their biggest
one yet.

Beverly Hills Formula
Unit P1/P2 North Ring Business Park.
Swords Road
Dublin, 9, Ireland
Web: www.beverlyhillsformula.com
E-mail: info@beverlyhillsformula.com
Tel: + 353 1 842 6611
Fax: + 353 1 842 6647

Translux Wave - For save,
sustainable polymerisation
By Kulzer
Translux Wave is a LED curing light
for the polymerisation of dental materials such as adhesives and composites.
It is developed to consistently produce high-quality fillings with an
optimum polymerisation depth in
the 440 – 480 nm Wavelength range.

Benefits at a glance
- Pen-style body: The light-weight
and ergonomic pen-style design
enables an effortless handling even
for small hands. Furthermore, the
advanced angle of the 360° rotatable
light guide allows a better access to
the molar regions.
- One-button operation: One convenient power/program button to
choose easily between 10 and 20

seconds. LED lights indicate the program change.
- Cordless design: The cordless design gives you maximum freedom
of movement.
- Reliable performance: Translux
Wave comes with a strong and long
life Li-ion battery. It requires very
little time to recharge and the battery can be exchanged quickly and
easily without tools. The built-in ra-

diometer ensures the performance
you need for the perfect restoration.
Translux Wave is a state-of-the-art
LED curing light to deliver an optimum polymerisation for all commercially available camphor quinone based dental materials.

Ivory – The complete system for tooth isolation
By Kulzer
We recommend Ivory Rubber Dams
for absolute isolation of the treatment area. We provide Ivory Rubber
Dam Clamps in a variety of sizes and
shapes. With the Ivory all-in-one system, you will master practically every application, ranging from routine
to challenging treatments.

Ivory Rubber Dams
The Ivory rubber dam is manufactured from natural latex and undergoes a special washing step during
the manufacturing process to reduce
surface proteins. Ivory Rubber Dam
has extremely high tear strength,
reducing waste from tearing during

By Marc Berendes, CEO Kulzer
“In our system solutions, materials,
technologies and services are interconnected from the very start.”

application. The Rubber Dam is thin
and pliable, allowing easy placement
in especially difficult areas.

Ivory Rubber Dam Clamps
We produce the Ivory rubber dam
clamps in various sizes and shapes.
Each Ivory clamp is die-cut, heat
treated, tempered and individually hand-set to ensure high performance. This is how we guarantee the
high performance of the stainless
steel clamps and confident fixation
of the rubber dam.

Ivory Punch
This precision instrument is made
from high quality stainless steel.

Marc Berendes, born on June 19,
1970, was appointed CEO as of July
1, 2018. He has been the Kulzer CSO
and member of the Management
since 2016. In this function, he was

The unique floating plunger strikes
all edges of the cutting disc evenly,
guaranteeing a perfect, tear-resistant
hole every time. The cutting disc rotates through a range of 6 hole sizes,
providing the correct opening for
the smallest anterior tooth to the
largest molar.

Ivory Forceps
The Ivory forceps are made from
high grade stainless steel to ensure
many years of use. The forceps will
reach around the bow of any clamp
without tilting, which is especially
important when reversing a clamp.
The straight head design allows
easy gripping and placement of any
clamp size.

The most popular stainless
steel clamps.

responsible for Sales, Service and
Marketing. Marc Berendes has over
20 years of experience in the medical
device industry. The Canadian looks
back on a successful career in vari-

ous management functions in Sales,
Marketing and Finance for a number
of renown healthcare companies.

- Available in a multitude of sizes and
shapes.
- Die-cut, heat-treated, tempered and
individually hand-set to ensure high
performance.
- Also available in wingless.

Aboubakr Eliwa
Area Manager Middle East
T: + 97 (1) 4 294 35 62 (Office)
F: + 97 (1) 4 294 35 63
M: +97 (1) 56506 89 76
E: aboubakr.eliwa@kulzer-dental.com
W: www.kulzer.com

[9] => DTMEA_No.5. Vol.8_DT.indd

[10] => DTMEA_No.5. Vol.8_DT.indd

10

InduSTRy

Dental Tribune Middle East & Africa Edition | 5/2018

EVO.15 – The world's safest contra-angle,
developed by Bien-Air
By Bien-Air
In response to public health authorities’ growing concern over patient
burns caused by rotary dental instruments, Swiss medical technologies
company Bien-Air Dental has developed the EVO.15, the safest contraangle on the market today.
In procedures involving contra-angles, the slightest contact between
the instrument’s push-button and
the inside of the patient's cheek may
cause the instrument to overheat,
resulting in possible burn injuries.
"While overheating can be an indication of a damaged or clogged instrument, laboratory evaluations reveal
that this hazard is just as prevalent

in new and properly-maintained
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[11] => DTMEA_No.5. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 5/2018

11

InduSTRy

Align Technology launches the iTero element
intraoral scanner in the Middle East
The iTero Element Scanner Offers General dentists and Orthodontists Enhanced Visualization Tools along with Advanced Invisalign and Restorative workﬂows
By Invisalign
Align Technology, Inc. (Nasdaq:
ALGN) today announced the launch
of its innovative iTero Element intraoral scanner in the Middle East.
The iTero Element scanner is synonymous with high-precision intraoral
scanning, and its launch in the region offers dentists and orthodontists alike a state-of-the-art digital solution, designed to enable scanning
in as little as 60 seconds* with high
accuracy, intuitive operation and exceptional visualisation capabilities.
The scanner will also allow dental
professionals to access new features
for intraoral assessment that facilitate proactive dialogue with patients regarding treatment options,
including Invisalign clear aligners.
Designed using advanced restorative workflows, the iTero Element
scanner also offers digital options for
traditional crown and bridge and implant treatments. The iTero Element
scanner is now available to doctors

in the United Arab Emirates, Saudi
Arabia and Kuwait.
“I’m delighted to announce the
launch of the iTero Element scanner in the Middle East - one of the
most digitally-advanced markets in
EMEA,” – commented Simon Beard,
Align Technology senior vice president and managing director, EMEA.
“The iTero scanner is a real gamechanger for doctors, combining the
fast scanning speed and great precision with a simple, intuitive operating system. It will help doctors deliver excellent treatment outcomes
and will significantly enhance patient experience. With this launch,
we are taking further steps towards
driving the growth of digital dentistry in the region and providing
our doctors with best-in-class digital
services."
The iTero Element scanner, engineered to capture 6 000 frames per
second, offers colour scanning to
clearly distinguish between gingival

and dental tissue for more precise
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To date, iTero scans have been used
in more than 2.7 million restorative
crown, bridge, and custom implant
cases and more than 7.7 million iTero
orthodontic scans, including more
than 3.7 million Invisalign treatment
related scans.**

The iTero Intraoral Scanner is now available in the UAE, Saudi Arabia and Kuwait.
For more information, visit www.itero.
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*Scan times vary and depend on individual experience. Data on file at Align
Technology.
**April 2018. Data on file.

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[12] => DTMEA_No.5. Vol.8_DT.indd

12

mCME

Dental Tribune Middle East & Africa Edition | 5/2018

New Technologies—
to improve root canal disinfection

CAPP designates this activity for 1 CE Credits

mCME articles in Dental Tribune have been approved by:
HAAd as having educational content for 1 CME Credit Hours
dHA awarded this program for 1 CPd Credit Points
By Drs Gianluca Plotino, Nicola M.
Grande & Prof. Gianluca Gambarini,
Italy

Introduction
The major causative role of micro-organisms in the pathogenesis of pulp
and periapical diseases has clearly
been demonstrated.1 The main aim
of endodontic therapy is to disinfect
the entire root canal system, which
requires the elimination of micro-organisms and microbial components
and the prevention of its reinfection
during and after treatment.
This goal is pursued through chemomechanical debridement, for which
mechanical systems are used with
irrigating solutions.

standard endodontic
irrigation protocol

Sodium hypochlorite
Sodium hypochlorite (NaOCl) is the
main endodontic irrigant used, owing to its antibacterial properties and
its ability to dissolve organic tissue.2
NaOCl is used during the instrumentation phase to increase its time of
action within the canal as much as
possible without it being chemically altered by the presence of other
substances.3 The effectiveness of this
irrigant has been shown to depend
on its concentration, temperature,
pH solution and storage conditions.3
Heated solutions (45–60 °C) and
higher concentrations (5–6 %) have
greater tissue-dissolving properties.2
However, the greater the concentration, the more severe the potential
reaction if some of the irrigant is
inadvertently forced into the periapical tissue.4 In order to reduce this
risk, the use of specially designed
endodontic needles and an injection
technique without pressure is recommended.5
EDTA
The main disadvantage of NaOCl
is its inability to remove the smear
layer. For this reason, combination of
NaOCl with EDTA (ethylenediaminetetraacetic) is recommended.2 EDTA
has the ability to decompose the
inorganic component of intracanal
debris and is generally used in a percentage equal to 17 %.
EDTA appears to reduce the antibacterial and solvent activity of NaOCl;
thus, these two liquids should not be
present in the canal at same time.6
For this reason, during mechanical
preparation, abundant and frequent
rinsing with NaOCl is performed,
while the EDTA is used for 2 min at
the end of the preparation phase to
remove the inorganic debris and
the smear layer from the canal walls
completely.
Ultrasonic activation of NaOCl
The use of ultrasound during and
at the end of the root canal preparation phase is an indispensable step
in improving endodontic disinfection. The range of frequencies used
in the ultrasonic unit is between 25
and 40 kHz.7 The effectiveness of ultrasound in irrigation is determined
by its ability to produce cavitation
and acoustic streaming. Cavitation
is minimized and limited to the tip

of the instrument used, while the
effect of acoustic streaming is more
significant.7
Ultrasound creates bubbles of positive and negative pressure in the
molecules of the liquid with which
it comes into contact. The bubbles
become unstable, collapse and cause
an implosion similar to a vacuum
decompression. Exploding and imploding they release impact energy
that is responsible for the detergent
effect. It has been demonstrated that
ultrasonic activation of NaOCl dramatically enhances its effectiveness
in cleaning the root canal space, as ultrasonic activation greatly increases
the flow of liquid and improves both
the solvent and antibacterial capacities and the removal effect of organic
and inorganic debris from the root
canal walls.7
Ultrasonic activation of NaOCl of
30–60 s for each canal, with three cycles of 10–20 s (always using new irrigant), appears to be sufficient time to
obtain clean canals at the end of the
preparation phase (Figs. 1 & 2).7 Ultrasound appears to be less effective
in enhancing the activity of EDTA,
although it may contribute to better removal of the smear layer.7 The
accumulation of debris produced by
mechanical instrumentation in inaccessible areas is preventable by using
ultrasonic activation of NaOCl even
during the preparation phase.8 The
use of a system of ultrasonic continuous irrigation might therefore
be advantageous.
It involves the use of a needle activated by ultrasound. With this method,
the irrigant is released into the canal
and is activated by the action of the
ultrasonic needle simultaneously.9
Chlorhexidine
A ﬁnal ﬂush with 2 % chlorhexidine
(CHX) after the use of NaOCl (to dissolve the organic component) and
EDTA (to eliminate the smear layer)
has been proposed to ensure good
results in cases of persistent infection, owing to its broad spectrum of
action and its property of substantivity.5, 10 However, the use of CHX is
hindered by the interaction between
NaOCl and CHX, which tends to create products that may discolor the
tooth and precipitates that may
be potentially mutagenic. For this
reason, CHX should not be used in
conjunction with or immediately
after NaOCl.11 This interaction can be
prevented or minimized by an intermediate wash with absolute alcohol,
saline or distilled water.12

activation systems
Mechanical instrumentation alone
can reduce the number of microorganisms present within the root
canal system even without the use of
irrigants and intracanal dressings,13
but it is not able to ensure an effective and complete cleaning.14 Irrigating solutions without the aid of mechanical preparation are not able to
reduce the intracanal bacterial infection significantly.15 For these reasons,
today research is oriented toward the
study of systems that can improve
root canal disinfection through me-

Figs. 1 & 2: Ultrasonic activation with a passive file (Fig. 1) and an active file (Fig. 2).

chanical activation of endodontic
irrigants, and in particular NaOCl.
Multiple agitation techniques and
systems for irrigants have been used
over time,16 demonstrating more or
less positive results.17
Manual agitation techniques
The simplest technique of mechanical activation of irrigants is manual
agitation, which can be performed
with different systems. The easiest way to achieve this effect is to
move vertically an endodontic file
that is passive in the canal. The use
of the file facilitates the penetration
of the irrigant, leads to a more effective delivery of irrigant to the untouched canal surfaces and reduces
the presence of air bubbles in the
canal space,18 but does not improve
the final cleaning.17 Another similar
technique moves vertically a guttapercha cone to working length with
the canal filled with irrigant. Even
this method, however, has not been
found to improve the intracanal
cleaning.9, 17 For this purpose, in each
case, well fitting gutta-percha cones
(increased taper) were more effective than cones with the standard
taper (0.02).9 The use of endodontic
brushes and of particular needles
for endodontic irrigation with bristles on their surface is another technique suggested in order to move
the irrigant more effectively within
the canals. These systems have been
shown to be valid in the removal of
the smear layer from root canal walls
and thus they can be recommended
during irrigation with EDTA to improve their efficacy at the end of the
preparation.
Machine-assisted agitation
systems
The evolution of manual systems led
to the introduction of instruments
that can be rotated in handpieces at
low speed inside the canal filled with
irrigant.
They are rotary brushes too large
to be brought close to the working
length; thus, they can be used effectively only in the coronal and middle thirds of the canal. Other similar
instruments are files in plastic with a
smooth surface and increased taper
or with a surface with lateral plastic
extensions, that have dimensions
appropriate to achieve the working
length if used after the canal preparation. Studies on these systems
have shown conflicting results.
In general, the results are better than
with hand irrigation with a syringe,
but lower than that of other more ef-

fective systems.16
Continuous irrigation during instrumentation
Recently, a new system for root canal
preparation has been introduced to
the market. This system uses a particular instrument with an abrasive
surface that enlarges the canal via
friction in a vibrating motion and
allows irrigant to flow through the
file itself. This system has shown
excellent results in terms of respecting the anatomy and cleaning of
difficult root canal anatomies, such
as difficult isthmuses, oval canals or
C-shaped canals.19 The low cutting
efficiency of this system in some
cases may limit its use in root canal
preparation, but makes it an excellent additional technique to enhance
the cleaning and disinfection of the
root canal system at the end of the
preparation.20 The concept of continuous irrigation was developed in
the past with the use of mechanical
instruments for sonic and ultrasonic
preparation that could concurrently
clean through the continuous release of irrigant. These techniques
were then abandoned for various
reasons related to the poor quality of
the preparation itself.
Sonic activation
Sonic activation has been shown
to be an effective method for disinfecting the root canals. The recent
systems use smooth plastic tips of
different sizes activated at a sonic
frequency by a handpiece.
The system seems to be able to clean
the main canal effectively, to remove
the smear layer and to promote the
filling of a greater number of lateral
canals.17 Another recently introduced
technique uses a syringe with sonic
vibration that allows the delivery
and activation of the irrigant in the
root canal simultaneously. Sonic activation differs from ultrasonic activation in that it operates at a lower
frequency (1–6 kHz), and for this
reason it is generally found to be less
effective in removing debris than are
ultrasonic systems.17, 21, 22
Apical negative-pressure irrigation
As the irrigant must be in direct contact with the micro-organisms and
canal walls to be effective, the accessibility of the irrigant to the whole
root canal system, in particular in the
apical third, is essential.
In order to deliver the irrigant into
the root canal for the entire length
and to obtain a good flow of fluid,
apical negative-pressure systems

have been introduced that release
and remove the irrigant simultaneously.
These systems consist of a macrocannula for the coronal and middle
portions and a microcannula for the
apical portion, and the cannulas are
connected to a syringe for irrigation
and the aspiration system integrated
with the dental unit (Fig. 3). During
irrigation, a tip connected with a
syringe delivers the irrigant to the
pulp chamber without the risk of
overflow, while the cannula placed
in the canal pulls irrigant into the canal, through the aspiration system to
which it is connected, and evacuates
it through the suction holes. This system is intended to ensure a constant
and continuous flow of new irrigant
into the apical third safely and with
a lower risk of extrusion.23 Most of
the studies on this technique have
shown that it is very effective at ensuring a greater volume of irrigant
in the apical third24 and excellent
removal of debris from this area25
and inaccessible areas,26 with results
in the majority of cases similar to
those of ultrasonic activation techniques.27–29 From a clinical perspective, apical negative-pressure systems can be effectively integrated
with ultrasonic irrigation techniques
because they act by different mechanisms. They can operate in synergy
with the objective to obtain cleaner
canals, especially in the apical third
and the most inaccessible areas.
Laser activation
The interaction between the laser
and the irrigant in the root canal is
a new area of interest in the field of
endodontic disinfection. This concept is the base of laser-activated irrigation (LAI) and photon-initiated
photoacoustic streaming (PIPS) technology.30
The mechanism of this interaction
has been attributed to the effective absorption of the laser light by
NaOCl. This leads to the vaporization
of the irrigant and to the formation
of vapor bubbles, which expand and
implode with secondary cavitation
effects.
The PIPS technique is based on the
power of the Er:YAG laser to create
photoacoustic shock waves within
the irrigant introduced into the canal.
When it is activated in a limited volume of liquid, the high absorption

ÿPage 13

[13] => DTMEA_No.5. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 5/2018

mCME

◊Page 12

Fig. 3: Apical negative-pressure irrigation system used to enhance
debridement.

of the laser in NaOCl combined with
the high peak power derived from
the short pulse duration employed
(50 μs) determines a photomechanical phenomenon.30 A study showed
that there was no difference in bacterial reduction achieved by NaOCl activated by laser compared with only
NaOCl.31 Another study investigated
the capability of LAI to remove a bacterial biofilm created in vitro on the
canal walls.32 This study found that it
did not completely remove the biofilm from the apical third of the root
canal and infected dentinal tubules.
However, the finding that laser activation generated a higher number of
samples with negative bacterial cultures and a lower number of bacteria
in the apical third was a promising
result regarding the effectiveness
of the technique, and has been confirmed by a more recent study.33

Additional disinfection
systems
In addition to the above-mentioned
systems that were able to activate
the endodontic irrigants and to improve their cleaning capability, endodontic research is oriented toward
the identification of alternative solutions that could further refine disinfection and assist in the destruction
of biofilms and the elimination of
micro-organisms.
For this purpose, different substances and technologies have been
investigated over time with different
results.
Photoactivated disinfection
A new method recently introduced
in endodontics is photoactivated disinfection. This technique is based on
the principle that the photosensitizing molecules (photosensitizer, PS)
have the ability to bind to the membranes of the bacteria.
The PS is activated with a specific
wavelength and produces free oxygen, which causes the rupture of the
bacterial cell wall on which the PS is
associated, determining a bactericidal action.
34 Extensive laboratory studies have
shown that the two components do
not produce any effect on bacteria
or on normal tissue when used independently of each other; it is only
the combination of PS and light that
exert the effect on the bacteria.34
An endodontic system called lightactivated disinfection (LAD) has been
developed based on a combination
of a PS and a special light source.
The PS attacks the membranes of micro-organisms and binds to their surface, absorbs energy from light and
then releases this energy in the form
of oxygen, which is transformed into
highly reactive forms that effectively
destroy microorganisms LAD is effective not only against bacteria, but
also against other micro-organisms,
including viruses, fungi and protozoa. The PSs have far less affinity for
the cells of the body; therefore, toxicity tests carried out did not report
adverse effects of this treatment.
Clinically, after root canal preparation, the PS is introduced into the
canal to working length with an endodontic needle and is left in situ for
60 s to allow the solution to come
into contact with the bacteria and
spread through any structures, such

Fig. 4: Disinfection activated by light to enhance root canal cleaning.

as biofilms.
The specific endodontic tip is then
inserted into the root canal up to
the depth that can be reached and
irradiation is performed for 30 s in
each canal (Fig. 4). This technique
has proven to be effective in laboratory studies at eliminating high
concentrations of bacteria present
in artificially infected root canals.35
Care should be taken to ensure maximum penetration of the PS, since it
is important that it come into direct
contact with the bacteria, otherwise
the effect of photosensitivity will not
occur. In addition, LAD appears to be
effective not only against the bacteria in suspension, but also against
biofilm.5 Research is now directed
toward evaluating the possibility of
increasing the antibiofilm effectiveness of LAD, combining the benefits
of photodynamic therapy with those
of bioactive glasses and nanoparticles, which will be described later.
Currently LAD is not considered as
an alternative, but rather as a possible supplement to standard protocols of root canal disinfection already
in use.5
Laser
One of the main disadvantages of
the current endodontic irrigants is
that their bactericidal effect is limited primarily to the main root canal.
In the endodontic field, several types
of lasers have been used to improve
root canal disinfection: the diode
laser, carbon dioxide laser, Er:YAG
laser and Nd:YAG laser. The bactericidal action of the laser depends on
the characteristics of its wavelength
and energy, and in many cases is due
to thermal effects. The thermal effect induced by the laser produces
an alteration of the bacterial cell wall
that leads to changes in osmotic gradients up to cell death. Some studies
have concluded that laser irradiation
is not an alternative, but rather a
possible supplement to existing protocols to disinfect root canals.36 The
laser energy emitted from the tip of
the optical fiber is directed along the
canal and not necessarily laterally toward the walls. In order to overcome
this limitation, a new delivery system of the laser was developed. The
system consists of a tube that allows
the emission of the radiation laterally instead, directed through a single opening at its terminal end. The
objective of this modification was to
improve the antimicrobial effect of
the laser in order to penetrate and
destroy microbes in the root canal
walls and in the dentinal tubules.
However, complete elimination of
the biofilm and bacteria has not yet
been possible, and the effect of the laser has been found to be less relevant
than that of the classical solutions
of NaOCl.37 In conclusion, strong
evidence is not currently available
to support the application of highpower lasers for direct disinfection of
root canals.38
Ozone
Ozone is an unstable and energetic
form of oxygen that rapidly dissociates in water and releases a reactive
form of oxygen that can oxidize cells.
It has been suggested that ozone
may have antimicrobial efficacy

without inducing the development
of drug resistance and for this reason it was also used in endodontics.
However, the results of the available
studies on its effectiveness against
endodontic patho gens are inconsistent,39 especially against biofilms.
The antibacterial effectiveness of
ozone was found not comparable
and less than that of NaOCl.39
Alternative antibacterial systems
Nanoparticles
Nanoparticles are microscopic particles between 1 and 100 nm in size
that have antibacterial properties
and a tendency to induce much lower drug resistance compared with
traditional antibiotics. For example,
nanoparticles of magnesium oxide, calcium oxide or zinc oxide are
bacteriostatic and bactericidal. They
generate active oxygen species that
are responsible for their antibacterial
effect through electrostatic interaction between positively charged nanoparticles and negatively charged
bacterial cells, resulting in accumulation of a large number of nanoparticles on a bacterial cell membrane
and a subsequent increase in its permeability associated with the loss of
its functions.
Nanoparticles synthesized from
powders of silver, copper oxide or
zinc oxide are currently used for
their antimicrobial activity. In addition, nanoparticles can alter the
chemical and physical properties of
dentin and reduce the strength of
adhesion of bacteria to the dentin
itself, thus limiting recolonization
and bacterial biofilm formation. In
any case, the possible success of the
application of nanoparticles in endodontics will depend essentially
on the manner in which they can be
delivered in the most complex root
canal anatomy.
Bioactive glass
Recently, bioactive glass or bioactive
glass-ceramics have been a subject of
considerable interest for endodontic
disinfection owing to their antibacterial properties, but conflicting results
have been obtained.5
Natural plant extracts
A current trend is the use of natural
plant extracts, taking advantage of
the antibacterial activity of polyphenolic molecules generally used
for storing food. These compounds
have been found to have poor antibacterial efficacy, but several demonstrate significant ability to reduce
the formation of biofilms, although
the mechanism by which this occurs
is not clear.5
Noninstrumentation techniques
The first trial of a method of cleaning
without canal preparation was the
noninstrumentation technique conceived by Lussi et al.40 This technique
did not provide for the enlargement
of the root canals because there was
no mechanical instrumentation
of the root canal walls. In fact, root
canal cleaning was exclusively obtained with the use of NaOCl at low
concentration, introduced and removed from the canal using a vacuum pump and an electric piston that
created fields of alternating pressure
inside the canal.

These caused the implosion of the
produced bubbles and hydrodynamic turbulence that facilitated the
penetration of NaOCl into the root
canal ramifications. At the end of
this procedure, the canals were filled
with a cement conveyed by the same
vacuum pump. This system did not
prove to be of substantial effectiveness and was never marketed.
Recently, a method has been developed for cleaning the entire root
canal system through the use of a
broad spectrum of sound waves
transmitted within an irrigating solution to remove pulp tissue, debris
and micro-organisms quickly.
One study showed that this technique was able to dissolve the tissue tested at a rate significantly
higher than that of conventional
irrigation.4 More research is needed
to determine whether this approach
is effective in the root canal system
with minimally invasive or no canal
preparation.

Conclusion
According to current knowledge, endodontic pathology is an infection
mediated by bacteria and in particular by biofilm. From a biological perspective, endodontic therapy must
then be directed toward the elimination of micro-organisms and the prevention of possible reinfection.
Unfortunately, the root canal system, with its anatomical complexity, represents a challenging environment for the effective removal
of bacteria and biofilm adherent to
the canal walls. Chemomechanical
preparation involves mechanical
instrumentation and antibacterial irrigation, and it is the most important
phase of the disinfection of the endodontic space. The technological advances of instruments have brought
significant improvements in the
ability to shape the root canals, with
fewer procedural complications. In
the management of the infected root
canal system, various antimicrobial
agents have been employed. Furthermore, some clinical measures,
such as an increase in apical preparation and a more effective system of
irrigant delivery and activation of ir-

rigant, can promote and make more
predictable the reduction of intracanal bacteria, especially in complex
anatomical and noninstrumented
portions of the root canal system.
Editorial note:
This article was published in the
2/2016 issue of roots_international
magazine of endodontology.
A list of references is available from
the publisher.

Dr Gianluca Plotino is
a senior lecturer in the
Department of Endodontics and adjunct
professor in the School
of Dental Hygiene at
the Sapienza University of Rome in Italy. He serves on the editorial boards of and is an official reviewer
for several journals, and has organized
several research groups worldwide. He is
the author and co-author of more than
70 articles in international scientific peerreviewed journals with high impact factors on different endodontic and restorative topics.

Dr Nicola M. Grande is Assistant Professor
of Endodontics at Università Cattolica del
Sacro Cuore in Rome. He completed his
PhD at the same university in 2009, with
a thesis on an innovative technique he
developed for the restoration of endodontically treated teeth. He has contributed
to the development of various instrumentation systems and new techniques, and
holds international patents in the fields of
endodontics and oral surgery. Dr Grande
has published extensively in international
peer-reviewed journals and has contributed to several books of endodontic interest.

Prof. Gianluca Gambarini is Professor of
Endodontics at the Sapienza University
of Rome’s dental school. He is an international lecturer and researcher, and actively collaborates with a number of manufacturers all over the world to develop
new technologies, operative procedures
and materials for root canal treatment.
Prof. Gambarini also works in a private
endodontics practice in Rome.

mCME SELF INSTRUCTION PROGRAM
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is international, drawn from the upper echelon of dental medicine, but also
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Membership
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[14] => DTMEA_No.5. Vol.8_DT.indd

mCME

Dental Tribune Middle East & Africa Edition | 5/2018

Long-term clinical success in
the management of compromised intertooth
spaces utilizing small-diameter implants
CAPP designates this activity for 1 CE Credits

mCME articles in Dental Tribune have been approved by:
HAAd as having educational content for 1 CME Credit Hours
dHA awarded this program for 1 CPd Credit Points

By Dr Paul S. Petrungaro, USA
Management of edentulous sites in
the oral cavity with dental implants
has been well documented in dental literature during the last 25 plus
years.1-3 Patients seeking tooth replacement for partial or totally edentulous situations have been able to
enjoy natural appearing and functioning prosthesis that are fixed, stable and, in some cases, so natural it’s
difficult to ascertain a dental implant
restoration for a tooth restoration.
Using dental implants to replace
the natural tooth system in the esthetic zone has also seen an increase
in restorative treatment plans and,
with the advent and perfection of
immediate restoration protocols
initially reported in the literature4-7,
achieving natural soft-tissue esthetics around dental implants can be
predictable and successful. However,
certain clinical situations can complicate or negate the procedure all
together.

One of these complications is insufficient intertooth spacing between
natural teeth and, most commonly,
congenitally missing lateral incisors
following orthodontic treatment8.
Often as a solution to this, the dentist chooses a removable partial denture or some type of resin-bonded
bridge, both of which may not be
appealing to younger individuals. In
extreme cases, the dentist may elect
to proceed with a fixed bridge, which
would cause excessive destruction
to the natural teeth serving as abutments and, for a young individual,
this could be devastating to these
teeth during a 40-50 year period, if
not sooner.8
Fig. 2. Pre-operative periapical radiograph

To properly form an ovate pontic
type emergence profile in the soft
tissue, which is required for a fixed
bridge to have a natural clinical appearance, consideration must be
given to the intertooth edentulous
space.9-12 This is also very important
when choosing dental implants for
natural tooth replacement. Wallace,

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its mCME - Self Instruction Program a quick and simple way to meet your
continuing education needs. mCME offers you the flexibility to work at your
own pace through the material from any location at any time. The content
is international, drawn from the upper echelon of dental medicine, but also
presents a regional outlook in terms of perspective and subject matter.
membership
Yearly membership subscription for mCME: 1,100 AED
One Time article newspaper subscription: 250 AED per issue. After the
payment, you will receive your membership number and allowing you to
start the program.
Completion of mCmE
•
mCME participants are required to read the continuing medical
education (CME) articles published in each issue.
•
Each article offers 2 CME Credit and are followed by a quiz
Questionnaire online, which is available on www.cappmea.com/
mCME/questionnaires.html.
•
Each quiz has to be returned to events@cappmea.com or faxed to:
+97143686883 in three months from the publication date.
•
A minimum passing score of 80% must be achieved in order to claim
credit.
•
No more than two answered questions can be submitted at the same
time
•
Validity of the article – 3 months
•
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•
Collection of Credit hours: You will receive the summary report
with Certificate, maximum one month after the expiry date of your
membership. For single subscription certificates and summary
reports will be sent one month after the publication of the article.
The answers and critiques published herein have been checked carefully
and represent authoritative opinions about the questions concerned.
Articles are available on www.cappmea.com after the publication.
For more information please contact events@cappmea.com or
+971 4 3616174
FOR INTERACTION WITH THE AUTHORS FIND THE CONTACT DETAILS AT
THE END OF EACH ARTICLE.

Fig. 1. Pre-treatment clinical view

Fig. 3. Ovate pontic type defect created

Misch and Salama, et al,9-11 stated that
an implant site requires, for a normal two-piece implant, the implant
should be placed at least 1.5 mm from
the adjacent teeth. As a result, using a
3.5 mm diameter implant, the minimum inter-tooth space to support
interproximal bone and natural softtissue papillary contours should be
6.5 mm, and with a 3.0 mm diameter
implant, 6.0 mm for the edentulous
space. Often, the intertooth space in
these types of cases is smaller than
6.0 mm.
Taking these parameters into account, small-diameter (or, mini) implants (3.0 mm is the smallest from
most dental implant manufacturers)
should not be used in cases with less
than 6.0 mm of inter-tooth space, to
prevent potential tooth root damage, crestal bone loss and unnaturalappearing gingival tissues and papillae.
Small-diameter implants were developed more than 20 years ago and,
initially, the recommended use was
to support temporary removable
prostheses during the healing phase
for advanced bone-grafting procedures and/or conventional implant
placement.12-13 Their use was later
expanded into immediate conversion of full dentures into implant-

Fig. 4. Dentatus ANEW implant seated minimally invasive protocol

supported dentures, support for
partially edentulous cases and for
anchorage of single tooth implant
restorations in compromised intertooth spaces.14-15
Implants are available from 1.8 mm
diameter to 2.8 mm diameter and
offer a fixed permanent tooth replacement option for patients that
otherwise would not be able to have
implants placed and restored. Their
ease of use and atraumatic placement utilizing a flapless approach,
with only one coring procedure, as
well as simplistic abutment transfer
and provisional construction, make
the use of these implants in the
aforementioned sites a must for the
dental implant practice.
The following case report will demonstrate the use of the Dentatus
ANEW (Dentatus USA, Ltd, New York,
N.Y.) implant for the management
of the compromised, congenitally
missing lateral space in a 17-year-old
teenage girl and a 10-year clinical follow up.

Case report
A 17-year-old, non-smoking female
presented for tooth replacement in
the congenitally missing maxillary
left lateral incisor site (Fig. 1). The pa-

tient had recently completed orthodontic therapy, and the orthodontist
and general practitioner had agreed
this was the final obtainable result in
regard to the remaining intertooth
space between the maxillary left
central incisor and maxillary left canine (Fig. 2). The resultant intertooth
space was less than 5 mm, and conventional two-stage implants with
abutment options were ruled out.
The patient and her parents ruled
out conventional tooth-replacement
options and chose the minimally invasive procedure: a small-diameter
implant, 1.8 mm in diameter, which
would allow for natural papillary
contours to be developed.
After administration of an appropriate local anesthetic, an ovate
pontic contour was created utilizing a football-shaped diamond in
the attached, keratinized tissue of
the edentulous site (Fig. 3). This scalloped-type tissue contour helps in
the creation of the natural-appearing
papillary contours.
The small-diameter implant chosen,
a 1.8 mm x 14 mm Dentatus ANEW
Implant was then placed after a sin-

ÿPage 13

[15] => DTMEA_No.5. Vol.8_DT.indd

mCME

Dental Tribune Middle East & Africa Edition | 5/2018

◊Page 14
or resin-bonded bridge, the luxury
of dental implants with no preparation and/or reduction to the adjacent
natural dentition.

Editorial note:
This article was published in the
4/2014 issue of implants_international magazine of implantology.

Proper placement procedures and
restorative techniques can lead to
very esthetic results, allowing for
natural tissue contours and emergence profile formation, reminiscent
of the natural tooth.

The full list of references is available
from the publisher.

references

Fig. 6. Immediate postoperative radiograph

Fig. 5. Immediate postoperative clinical view.

Fig. 7. Lab-processed, long-term provisional restoration

Fig. 8. 10-year postoperative clinical view

1. Branemark P-I, Zarb GA, Albrektson
T, eds. Tissue-Integrated Prosthesis:
Osseointegration in Clinical Dentistry. Carol Stream, IL: Quintessence
Publishing: 1985:11-81
2. Adell R, Lekholm U, Rockler B, et al.
A 15-year study of osseointegrated
implants in the treatment of the
edentulous jaw. Int J Oral Surg. 1981;
10(6):387-416.
3. Babbush CA. Dental Implants: The
Art and Science. Philadelphia, PA: WB
Saunders Co. 2001:201-216.
4. Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior single
implants: A surgical and prosthetic
rationale. Pract Periodontics Aesthet
Dent. 2000; 12:817-824.
5. Saadoun AP. Immediate implant
placement and temporization in extraction and healing sites. Compend
Contin Educ Dent. 2002; 23:309-323.

Paul S. Petrungaro, DDS, MS, FICD, FACD,
DICOI, USA. He is internationally recognized for his educational and clinical
contributions to modern dentistry. He
graduated from Loyola University Dental
School in 1986, where he completed an
independent study of periodontics at the
Welsh National Dental School in Wales,
U.K. He completed his residency in periodontics and has a specialty certificate in
addition to a master’s of science degree in
periodontics from Northwestern University Dental School.
He is the former coordinator of implantology, Graduate Department of Periodontics, Northwestern University Dental
School. Petrungaro has been in the private
practice of periodontics and implantalogy
since 1988 and holds a license in both Illinois and Minnesota.

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In Fulfillment of the Educational Requirement for the Examination
for Associate Fellow Membership and Fellowship for the
American Academy of Implant Dentistry
The Faculty are as follows:
Dr. Shankar Iyer, USA

Director, AAID Maxi Course®UAE
Diplomate AAID
Clinical Assistant Professor,Rutgers School of
Dental Medicine.

gle coring of the site with a 1.4 mm spade drill to full
depth, within the sculpted tissue emergence profile
previously created (Fig. 4). Conversion to an esthetic provisional restoration was completed by placing an abutment coping with a silicon retention screw (Dentatus
USA, New York, N.Y.).
An ion shell provisional crown was then hollowed out
and retrofitted to the abutment coping with flowable
composite. The margins of the provisional were corrected and provisional contoured out of the mouth. The
restoration was polished and seated with the set screw
from the palatal. The immediate postoperative clinical
view is seen in Fig. 5. The immediate postoperative periapical view is seen in Fig. 6.
The patient then went through the three-month healing
and observation phase prior to construction of a lab-processed provisional restoration (Fig. 7). One year later, the
patient underwent final restoration fabrication at the
left lateral incisor site. A 10-year postoperative clinical
image can be seen in Fig. 8 and a 10-year postoperative
CT scan of the implant in Fig. 9. Please note the beautiful
soft-tissue esthetic result obtained and excellent maintenance of the crestal and lateral contours.

Conclusion
The management of compromised intertooth spaces
presents a challenge for the contemporary dental implant team. These spaces have limits on how they are
handled and require implants 3.0 mm wide or less, as
was demonstrated in the text of this article. Availability of smaller-diameter implants allows patients that
normally would have to proceed with a fixed bridge,

Fellow, American Academy of Implant Dentistry
Diplomate ABOI

Dr. Robert Miller, USA

Dr. Jason Kim, USA
Diplomate of ABOI

Board Certified by the American Board of Oral
Implantology/Implant Dentistry
Honored Fellow American Academy of Implant
Dentistry

Co-Director AAID Maxicourse- Abu Dhabi,
UAE
Academic Associate Fellow AAID

Dr. Ozair Banday, USA

Dr. Philip Tardeu, France

Dr. Amit Vora, USA

Dr.Bart Silvermann, USA

Dr. Ninette Banday, UAE

Fig. 9. 10-year postoperative CT serial view

Dr.Burnee Dunson, USA

Prosthodontist

Diplomate of the American Board of
Periodontology
Professor (partime) ,JFK Hospital and the
Veteran Affairs (V.A.) Hospital

Diplomate, American Board of Oral
Implantology
Oral & Maxillofacial Surgeon

Dr. Jaime Lozada, USA

Diplomate American Board of Periodontics

Director of the Graduate Program in Implant
Dentistry
Fellow, American Academy of Implant
Dentistry

Dr. William Locante, USA

Diplomate of ABOI
Fellow of American Academy of Implant
Dentistry

Dr. Rachana Hegde, USA

Dr. Robert Horowitz, USA

Diplomate American Board of Periodontology
Clinical Assistant Professor New York
University

Dr. Stuart Orton-Jones, UK

Founder Member, The Pankey Association
Member, Alabama Implant Study Group

Founder and Author, Computer Guided
Implantology and the Safe System.

Dr. Natalie Wong, Canada

Diplomate, American Board of Oral
Implantology
Fellow, American Academy of Implant
Dentistry

Dr. Irfan Kanchwala, India

Implant Fellowship ( UMDNJ, USA)
Diplomate , American Board of Prosthodontics

Dr. Jihad Abdallah, Lebanon

Diplomate American Board of Oral
Implantology
Fellow AAID
Professor & Head of Implantology Division,
Faculty of Dentistry.Beirut Arab University

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[16] => DTMEA_No.5. Vol.8_DT.indd

restorative

Dental Tribune Middle East & Africa Edition | 5/2018

Sticks to the teeth – not the instruments

The direct restoration of multiple defects, in particular old restorations with secondary
caries, places considerable demands on both the clinician and the materials.

By Dr. Ralph Schönemann, Germany
Compared with indirectly fabricated
restorations, the effort is considerably less, as these generally require
a temporary restoration as well as a
second treatment session following
conventional impression-taking. The
fabrication of individual full ceramic
restorations after optical scanning
and subsequent automated fabrication is, of course, a single appointment alternative, does however, require investment in this technology.
A prerequisite for the successful, direct preparation of restorations with
purely light-curing composite materials in the layering technique, is
avoiding tension during volumetric
shrinkage which occurs during polymerisation.
The adhesives and hybrid composites should be compatible with each
other and offer good long-term performance. This is reflected both in invitro tests as well as in in-vivo longterm studies.
Sticks to the teeth and not the instruments. One of the requirements
for state-of-the-art adhesives and
composites is safe handling during
the preparation of the restoration.
This implies a good, uniform wetting
layer when applying the adhesive
and convenient modeling properties
of the hybrid composite which allow
the clinician safe adaptation to the
bonded tooth.
Submicron hybrid composites offer an impressive rapid and consistent gloss. The filler composition
should enable achieving 'an' impressive gloss of the surface during preparation and polishing.
Permanent protection against
leakage in the marginal region is a
prerequisite. Last but not least, the

result achieved with a composite
in terms of colour, gloss and abrasion has to be reliable in the long
term. This result is complemented
by a technically reliable adhesive
through permanent impermeability of the restoration margins. The
practical implementation of a direct
restoration, combining adhesive and
composite, and an evaluation of the
prerequisite material requirements,
are discussed in the following case
study.
In this case, the patient presented
with insufficient restorations (Fig.
1). The restoration margins revealed
leakage and discoloration. The gap
closure between 35 and 37 was particularly irritating for the patient.
The X-ray image (Fig. 2) revealed secondary caries and the approximal
situation. The teeth involved were
cleaned, as were the adjacent teeth,
while waiting for block anaesthesia
to come into effect. The placed Flexi
Dam permitted a good overview and
provided good conditions for drying
the work area and thus for a permanent adhesive bond between tooth
and restoration. The old restorations
were removed entirely and the secondary caries was excavated (Fig. 3).
ONE COAT 7 UNIVERSAL was used as
adhesive. ONE COAT 7 UNIVERSAL is
an MDP-based, light-curing singlecomponent bonding agent which
can be applied in self-etching, selective etching or total etch techniques.
The tooth surface is conditioned
with Etchant Gel S and an S.P.E.C. 3
LED lamp is used for polymerisation
(Fig. 4).
After excavation of the secondary
caries, the cavity floor of 35 is in close
proximity to the pulp chamber.
Pulpconserving acid conditioning
is indicated. Selective etching of the
enamel with Etchant Gel S for 30 seconds is followed by a shortened Total

Etch for 10 seconds (Fig. 5). Then the
etchant was removed thoroughly
by rinsing for 20 seconds and the
cavities were dried with care. Immediately afterwards, ONE COAT 7 UNIVERSAL was applied with a brush to
maintain adequate moisture and to
provide complete cover prior to placing the matrix (Fig. 6). The adhesive
is gently flushed with an air blower
and polymerised with the S.P.E.C. 3
LED lamp for 10 seconds.
A variety of partial matrix systems
are available for a sophisticated design of the approximal surfaces.
Here we used a ROEKO tension-free
steel matrix band and trimmed it to
the desired length as a partial matrix.
This band is available in different
widths and material strengths.
The nonelastic properties of the material make anatomical customisation extremely easy. The thickness
of the band in the area of the contact
point can be minimised effectively
by thinning. Fixation and basal sealing of the trimmed partial matrix is
performed with a wooden wedge,
and for lateral sealing the band edges
are pressed to the tooth surface using a clamping ring.
The design of the approximal surfaces (Fig. 7) with BRILLIANT EverGlow
A3/D3 (Fig. 8) is very simple. The
material keeps its shape and does
not stick to the instrument. Coated
instruments are of advantage here,
especially filling instruments work
better. There are no limits to creating
the morphology of the occlusal surfaces as the consistency of BRILLIANT
EverGlow offers excellent modelling
properties. Delicately modelled fissures (for example, using an endo
needle) remain open and do not
merge again, customisation is truly
enjoyable with this material.

After removing the matrix, the approximal surface is given a spherical
design using an EVA file, any bonding expressed basally from the matrix is removed, and the transition
from the tooth to the restoration is
brought to the same level. The matrix is applied distally to premolar
35 and sealed basally with a wooden
wedge and laterally with a clamping
ring. ONE COAT 7 UNIVERSAL is applied and gently air-cleaned after an
exposure time of 20 seconds. ONE
COAT 7 UNIVERSALis polymerised
with the S.P.E.C. 3 LED lamp for 10
seconds (Fig. 9). The matrix, which
has now been stabilised by bonding,
is then thinned out swiftly using a
zirconium round burr in anticlockwise rotation, yet without water.
At the same time, the partial matrix must be reliably fixated by the
wooden wedge. Metal chips were
avoided by using anti-clockwise rotation. Any metal chips that may still
be generated, are dispersed with air.
The desired result is a tight, spherical contact. Approximal convexity
can be customised very easily in this
manner. This is again followed by
designing the approximal surface
with BRILLIANT EverGlow A3/D3 as
well as the anatomical morphology
of the occlusal surface. Due to the
well sealed partial matrix and aided
by the clamping ring, the finishing
effort required after their removal is
minimal. Using the EVA file, the result is already very satisfactory (Fig.
10). An occlusal check and minor corrections were performed. Polishing
takes little time as BRILLIANT EverGlow delivers its gloss very quickly
(Fig. 11). Then the restorations are
brought to a high gloss using an occlubrush. In their final from, the restorations are more than satisfactory
(Fig. 12).
The applied layer method of the
BRILLIANT EverGlow submicron

filled hybrid composite in combination with the ONE COAT 7 UNIVERSAL adhesive delivers very good
results. The S.P.E.C. 3 LED polymerisation lamp provides reliable curing
of both restoration materials at high
conversion.
Conclusion and comments regarding the initially demanded material
properties:
Sticks the way it should, to the
tooth and not the instrument. Due
to the consistency-setting of the dental restoration material such as BRILLIANT EverGlow, application is easy
and results in anatomically correct
outcomes.
Submicron hybrid composites offer an impressive rapid and consistent gloss. Appropriate shades
and an easy to achieve gloss due to
intelligent filler design provide the
desired and sustainable aesthetics.
Permanent protection against
leakage in the marginal region is a
prerequisite. The high density and
composition of the filler particles of
the BRILLIANT EverGlow composite
optimise the results in terms of reducing shrinkage and the resulting
lower shrinkage stress.
The clinical long-term objective of
sealed restoration margins can be
achieved with even greater certainty
when using a reliable adhesive such
as ONE COAT 7 UNIVERSAL, which
was used here.

Dr. Ralph Schönemann
Bahnhofstrasse 10
86150 Augsburg
Tel. +49 8 21 - 3 49 77 77
Fax +49 8 21 - 3 49 77 78

Fig. 1: Insufficient restorations with secondary caries

Fig. 2: X-ray 3. quadrant, missing approximal contact
35/37

Fig. 3: Condition after removing the insufficient restorations

Fig. 4: ONE COAT 7 UNIVERSAL is used for adhesive
mounting of the direct restorations

Fig. 5: Filling the cavities with Total Etch for 10 seconds

Fig. 6: Application of ONE COAT 7 UNIVERSAL with a
brush

Fig. 7: Reconstruction of the approximal wall with
BRILLIANT EverGlow

Fig. 8: BRILLIANT EverGlow A3/D3 syringe

Fig. 9: Polymerisation of ONE COAT 7 UNIVERSAL with
S.P.E.C. 3 LED

Fig. 10: Restoration after removing the matrix

Fig. 11: Polishing of the restorations

Fig. 12: Finished restorations with BRILLIANT EverGlow

[17] => DTMEA_No.5. Vol.8_DT.indd

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[18] => DTMEA_No.5. Vol.8_DT.indd

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 5/2018

Efficiency and esthetics in the posterior region
Since bulk-fill composites have been on the market for a number of years, the time has
come to take a look back at the introduction, development, current trends and future options of these materials.

By Dr Eduardo Mahn, Chile
When bulk-fill composites first hit
the market, they were considered a
true innovation. We had been layering posterior composites for more
than 40 years, yet many of us were
not quite sure for what reasons the
layering technique was mandatory.
Understanding the reasons why a
certain technique is applied is crucial for the correct assessment of the
pros and cons of any technique.

Basically, the reasons were
four:
1. Aesthetics: It is obvious that a layering technique involving dentin,
enamel and effect shades leads to
a better final outcome than a technique that uses only a single layer in
a standard translucency. As regards
the bulk-fill technique, this reason
can easily be rejected because, objectively, most posterior restorations
are almost always placed using one

shade only and most patients are
satisfied with the result.
2. Reduction of volumetric shrinkage: The less composite we place, the
smaller the volumetric shrinkage.
3. Reduction of shrinkage stress:
This reason makes sense and is based
on the configuration factor. It is said
that the shrinkage stress is reduced
if the unbonded surface area of a
layer is larger than the bonded surface area. Although there is enough
in-vitro evidence on the relevance of
the C-factor, a clinical correlation has
not yet been shown. This point can
be easily illustrated by the fact that
Class-I restorations have an unfavourable C-factor but a high survival
rate while Class-V restorations have a
favourable C-factor but a low survival rate. This example shows that the
C-factor is only one of many factors
that determine the success of a direct
restoration - and frequently not the
most important one.
4. Depth of cure: This is probably
the most important factor because

increments of only 2 mm could be
applied before the advent of bulk-fill
composites. Some studies suggest
that the depth of cure of certain composites is even lower than 2 mm. This
was the reason why all layers were
restricted to a maximum thickness
of 2 mm. If not, the composite material placed in the deeper areas of the
cavity would never receive enough
light to cure adequately. Having
discussed all these factors, we may
realize that we are not so far from the
bulkfill technique. If a composite is
capable of reducing the stress when
applied in thick layers and, at the
same time, offers an increased level
of translucency and a more effective light-curing process, the bulk-fill
technique is feasible. In most cases,
shrinkage stress relievers are responsible for the reduction of shrinkage
stress. Shrinkage stress relievers are
fillers with a lower modulus of elasticity. Their function is to release the
stress as the composite polymerizes.
The second aspect, i.e. the depth of
cure, was achieved by making the
composites more translucent with
the effect of enhancing the passage
of light through the material. As a result, the depth of cure was increased.
This point has also been proven to be
true. In addition, some companies
such as Ivoclar Vivadent improved
the polymerization process in deeper areas by adding newly developed
initiators (e.g. Ivocerin) to the formulation.
Nowadays, all major dental manufacturers offer bulk-fill composites.
Bulk-fill composites can basically be

categorized into two main groups:
first, flowable bulk-fill composites requiring a final capping layer and, second, sculptable bulk-fill composites.
Generally, these materials increase
the efficiency of the restorative
workflow as they allow the fillings to
be placed with either a single-increment technique (sculptable composite) or a two-increment technique
(dentin replacement with flowable
composite and capping layer with
sculptable composite). These methods are obviously faster and easier to
perform than conventional layering
procedures. However, this advantage
is undermined by the fact that bulkfill materials are generally too translucent and allow discolourations
to shine through the restorations,
especially if they are used to replace
an amalgam filling. Nevertheless,
clinical evidence has shown that the
results achieved with the new bulkfill methods are comparable to the
results achieved with conventional
multi-layer techniques.
Fortunately, new developments often pave the way for new technologies. By this I mean the Aessencio
technology developed by Ivoclar Vivadent. The Aessencio technology allows a composite to be highly translucent prior to being light-cured and
causes a drop in translucency as it
polymerizes. Once polymerized, the
material exhibits a dentin-like translucency and is capable of effectively
masking most discolourations. Practitioners can follow a very efficient
procedure to accomplish fillings due
to the Aessencio technology of Tetric

EvoFlow Bulk Fill and the combination with Tetric EvoCeram Bulk Fill
as the final capping layer. Two steps
will be enough in most clinical situations. At the same time, patients will
receive a sufficiently aesthetic restoration. In addition, the entire adhesive restorative protocol has become
more predictable with the recent
introduction of universal adhesives,
as they have eliminated the need for
dentin etching. Dentin etching was
one of the reasons for the variability
and sensitivity of the adhesive technique in the past years. A recently
published meta-analysis showed the
importance of predictable clinical
protocols as the correlation between
in-vitro tests and clinical performance is poor. Furthermore, there
is growing evidence in clinical trials
and elsewhere that self-etch protocols show a favourable performance.
The clinical case below demonstrates
how these materials are used.

Clinical case

A 33-year-old patient presented with
a failing amalgam restoration on the
upper right 4 with no interproximal contact (Fig. 1). After the amalgam filling had been removed and
a rubber dam placed (OptraDam),
a matrix, wedge and ring were inserted (V4 Triodent). The enamel was
etched with phosphoric acid (Total
Etch) and then rinsed with water
(Fig. 2). Subsequently, the adhesive
(Adhese Universal) was applied with

Fig. 1: Pre-op situation

ÿPage 20

Fig. 2: Enamel etching with Total Etch

Fig. 3: Application of Adhese Universal with the VivaPen

Fig. 4:Tetric EvoFlow Bulk Fill was applied.

Fig. 5: Tetric EvoFlow Bulk Fill before light-curing. The high translucency
facilitates the penetration of light.

Fig. 6: Once cured, Tetric EvoFlow Bulk Fill exhibits a dentin-like translucency, masking discolourations.

Fig. 7: Tetric EvoCeram Bulk Fill was applied as a final layer. All excess was
removed before curing.

Fig. 8: Completed restoration after 1 week. Occlusal view

Fig. 9a-b: X-ray images before and after the restoration. Both the flowable and sculptable variants offer adequate radiopaque properties.

[19] => DTMEA_No.5. Vol.8_DT.indd

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[20] => DTMEA_No.5. Vol.8_DT.indd

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◊Page 18
the help of the new VivaPen delivery
form and carefully scrubbed into the
tooth structure of the entire cavity
for 20 s (Fig. 3). Next, the solvent was
evaporated until a shiny immobile
film resulted. Then, the material was
lightcured using a Bluephase Style
third-generation curing light.
Tetric EvoFlow Bulk Fill was applied
to the proximal box and cavity floor
(Fig. 4). Initially, the material was as
translucent as most other flowable
bulk-fill materials. This translucency
makes it difficult to mask discolourations (Fig. 5).

Figure 6 shows how the translucency
altered in the course of the curing
process and the material started to
mask the discolourations underneath it. Then, a final composite layer of Tetric EvoCeram Bulk Fill was
applied. Excess composite was carefully removed and the filling contoured to an adequate anatomical
shape prior to undergoing final polymerization (Fig. 7). This was all accomplished in a single step, as most
of the cavity had already been filled
before with Tetric EvoFlow Bulk Fill.
After final curing, the restoration was
polished with OptraPol. Then, Fluor

Protector S was applied. The completed restoration rather closely resembles the natural tooth structure.
It is virtually impossible to detect the
margins from the occlusal and frontal view (Fig. 8). The X-rays show the
excellent radiopaque properties of
both materials, i.e. the flowable and
sculptable variant (Figs 9a and b).

Conclusin

To sum up, the “bulk-fill technique”
using Tetric EvoFlow Bulk Fill and
Tetric EvoCeram Bulk Fill allows us
to be more efficient with almost no
compromises compared to the con-

ventional layering technique. The
C-factor is no longer an issue due to
the shrinkage stress relievers. As expected, marginal gaps do not occur
more frequently and are not larger
compared to the conventional layering technique. Application is clearly
quicker and the aesthetic effect is in
most cases similar to that of conventional composites. The differences
in the translucency of materials for
conventional posterior composite
restorations are no longer of relevance due to the Aessencio technology. This sets a new standard in this
group of composite.

Dr Eduardo Mahn
Director of Clinical Research and of
the Aesthetic Dentistry
Post-Graduate Program,
Facultad de Odontología,
Universidad de los Andes, Chile
Monseñor Álvaro del Portillo 12455, Las
Condes, Santiago, Chile
Private practice:
Clínica CIPO, La Dehesa, Santiago
E-mail: emahn@miuandes.cl

Chairside CAD/CAM immediate restorations
Anterior no-preparation ultrathin veneers
By Drs Feng Liu & Xing Liu, China

Introduction
No-preparation ultrathin veneer is
one of the most minimally invasive
restorations. Its thickness ranges
from 0.3 to 0.5 mm. In the right circumstances (Figs. 1 & 2) it can show
excellent aesthetic appearance, and
provide long-term stability and
health of soft- and hard-tissue.
The overall structure of ultrathin
veneer is flexible, in that its neck can
gradually change from thick to thin,
and the border can be knife edge-like
or thin round-convex (Figs. 3 & 4).
Manufacturing
inlays,
onlays,
crowns and veneers chairside with
a CAD/CAM system has become established in most dental offices. This
technique can produce immediate
scan, design, milling and restoration quickly and conveniently. It is
the same for the no-preparation ultrathin veneer. For chairside CAD/
CAM systems, CEREC is the most developed system.
The biocopy mode, which is widely
used for restoration design, has target contours such as wax-up. In this
mode, the operator should scan the
original tooth shape in the mouth or
on the model first, then wax up and
re-scan the wax-up shape into the
CEREC system. Both optic impressions will transfer into the virtual
model, and match to each other to

obtain the restoration contour information. Depending on the 3-D data,
chairside milling can be complete in
few minutes. Post-milling processes
usually contain shaping and polishing. In some conditions, it may be
necessary for additional staining and
glazing.

Case report
A 57-year-old female patient presented, whose dentition had apparent
colour changes and abrasions that
had occurred gradually over time.
These problems resulted in an unaesthetic smile and made her appear
older than her age. She also made a
request for a highly comfortable and
minimally invasive treatment plan,
and expected an improvement in
the colour and shape of her upper
anterior teeth, which would rebuild
her smile and self-confidence (Figs.
5 & 6).
It was found that due to the abrasion
which had occurred over several decades, the labial surface was plane and
flat, the incisors had been worn to a
straight line and also had abrasionassociated defects (Figs. 7 & 8). The
no-preparation veneer that would
occupy the “outer space” of the teeth
would eliminate the slight wrinkles
around the lips. These effects were
part of the patient’s expectations
and the treatment plan was accepted.
Taking the treatment requirement

Fig. 1: No-preparation veneer is adapt to the teeth with flat surface.

Fig. 2: When the teeth have apparent curvature, no-preparation veneer may have weak contact area. Micropreparation veneer is more
appropriate.

Fig. 3: Ideal gradual thinning no-preparation veneer.

Fig. 4: Acceptable round-convex no-preparation veneer margin
with a little thickness.

and oral condition into consideration, the patient was prepared for
the ultrathin no-preparation veneer.
Digital Smile Design (DSD) was done
based on the pre-operation photos
(Figs. 9 & 10), and the patient was satisfied with the aesthetic appearance
of the design.

The patient wanted her teeth colour
to seem natural and to disguise the
discoloration. The treatment plan
was confirmed as CEREC designed
and manufactured Mark II (VITA) veneer of 0.3 mm thickness, 1M1 shade,
and the material was chosen for its
excellent aesthetic performance and

translucency.
The manufacture of no-preparation
veneer could depend on the precise
wax-up of pre-operation. This step

Fig. 5: Frontal view pre-operation.

Fig. 6: Frontal smile view pre-operation.

Fig. 7: Upper-anterior dentition view pre-operation.

Fig. 8: Upper jaw view pre-operation.

Fig. 9: DSD dentition view pre-operation.

Fig. 10: DSD smile view pre-operation.

ÿPage 22

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Fig. 11: Precise pre-operation model.

Fig. 12: Pre-operation scan.

Fig. 13: Wax-up based on pre-operation model.

Fig. 14: Biocopy model.

Fig. 15: Biocopy optic model accurately match with pre-operation model.

Fig. 16: Setting the insertion direction and margin of the restoration.

Fig. 17: Finished restoration design.

Fig. 18: Designed restoration prepared to mill.

Fig. 19: Ready veneers before cementation.
Fig. 20: The thickness of the finished restoration is 0.3 mm.

Fig. 21: Try-in: frontal view of upper anterior dentition.

Fig. 22: Try-in: incisal view of upper anterior dentition.

Fig. 23: Try-in: lateral view of smile.

Fig. 24: Try-in: lateral view of smile.

Fig. 25: Four-year follow-up: frontal view of upper anterior dentition.

Fig. 26: Four-year follow-up: frontal view of smile.

Fig. 27: Four-year follow-up: lateral view of upper-anterior dentition.

Fig. 28: Four-year follow-up: lateral view of upper-anterior dentition.

Fig. 29: Four-year follow-up: lateral view of smile.

Fig. 30: Four-year follow-up: lateral view of smile.

Fig. 31: Four-year follow-up: frontal view of face.

Fig. 32: Four-year follow-up: lateral view of face.

ÿPage 24

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◊Page 22
could save the patient’s chairside
waiting time; the biocopy technique
can simplify the design process;
milling the restoration with a 0.5
mm original thickness and polishing
after milling will decrease the risk of
milling defect.

The exact process can be
concluded as:
1. Obtain a precise pre-operation impression, and make the model. Use
a CEREC scan to obtain information
about the abutment teeth (Figs. 11 &
12).
2. Depending on the DSD result,
make a wax-up on the pre-op model.
The thickness of wax-up should be
from 0.3 mm to 0.5 mm. Get the biocopy scan of the wax-up model, and
match accurately with the pre-op
model (Figs. 13–15).
3. Setting the margin of the abut-

ment teeth, the marginal edge line
is not fixed because of the no-preparation technique. The direction of insertion should be defined first, which
can cover most areas of the labial
surface, incisor edge and adjacent
surfaces. The border of the covered
area should be the margin of the restoration (Fig. 16).
4. Shape formation of the restoration: Copy the target shape of the
biocopy model, the restoration
should be calculated automatically.
If there is any defect, it can be adjusted and corrected by the tools. If
there are any areas not thick enough
for 0.5 mm, it should be added to 0.5
mm to avoid fractures during the
milling process (Figs. 17 & 18).
5. Modification and polishing of the
initial restoration to 0.3 mm thick after milling. And fine polishing of the
final restoration (Figs. 19 & 20).

6. Intraoral try-in, fine adjustment
and cementation (Figs. 21–24).
7. Four-year follow-up and recheck.
The restorations are as excellent as
before and the margins are tightly
sealed, the colour is stable, there is
no margin colorised or whole colour
changing. The patient is very satisfied with the aesthetic performance
and function. A charming smile appearance has given her more confidence and vigour (Figs. 25–32).

Conclusions
The no-preparation veneer is a kind
of restoration with high precision
requirement and manufactured difficulty. t is usually finished in laboratory. Getting benefit from chairside
CAD/CAM techniques, immediate
restorations in one appointment
can be achieved; dentists can invite
the patients to observe the process

of restoration design and manufacture, and even get involved into the
design. Patients may feel that they
are participating in the treatment,
establishing an emotional connection with the restoration, which may
also make them more easily accept
and love their restoration. The value
of increasing the satisfaction should
not be ignored.
Biocopy design is the combination of
traditional aesthetic design and digital virtual design. It is also the most
convenient and fast technical route.
Nowadays, 3-D virtual technique is
becoming more and more established. Using 3-D techniques directly
to make a virtual design may also get
wonderful restoration performance,
it can be predicted that this pattern
will become the mainstream of digital aesthetic design in future.

Editorial note:
This article was published in the
1/2018 issue of CAD/CAM_international magazibe of digital dentistry

Dr Feng Liu
is a Clinic Professor and Vice Director
of Clinical Division of Peking University
School and Hospital of Stomatology.
He is also the director of the Clinical Division Esthetic Dentistry Training Center
and member of many scientific associations worldwide.
Dr Xing Liu
is a dentist, working at Peking University Hospital of Stomatology. He is also a
member of many scientific associations
worldwide.

Restoring function and aesthetics with
monolithic zirconia restorations
By Dr Ara Nazarian, US
With greater public awareness about
cosmetic dental reconstructions,
the dentist is often challenged with

greater demands from the patient.
This increased demand for aesthetic
restorative treatment challenges the
dentist, laboratory technician and
dental manufacturers to develop

techniques and materials to satisfy
the discerning patient. Utilising digital planning, modern materials and
effective techniques, the restorative team can succeed in restoring a

smile to proper form, function and
health. The case presented in this
article demonstrates the significance
of a systematic approach to planning, preparation and material selection in full-mouth reconstruction of
a patient’s dentition.

Case presentation
A woman in her early forties was
referred to my practice by her dental provider because she was dissatisfied with the appearance of her
smile. The patient explained that she
felt that her existing teeth and restorations were unattractive because of
recurrent caries, wear and colour (Fig.
1). Most importantly, she mentioned
that she was suffering from tension
headaches, grinding and a limited
range of function.

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length-to-width ratio and create a
less worn appearance.
As a result of the information gathered from the diagnostic wax-up,
it was determined that aesthetics
and function could be enhanced by
restoring the entire dentition. The
final treatment plan would consist of
crown restorations, placing composite cores where needed from teeth
#17–27 in the upper arch and teeth
#37–46 in the lower arch.
The material of choice for these
crown restorations would be Zenostar (Wieland/Ivoclar Vivadent).
According to the manufacturer, this
translucent zirconia material combines excellent flexural strength
with the aesthetics of natural tooth
shades.

Initial diagnostic evaluation at the
first appointment consisted of a
series of digital images with study
casts, a centric relation bite record,
a facebow transfer and a fullmouth
set of radiographs. In the maxillary
arch, the patient had several teeth
with worn composite and veneer
restorations, as well as abfractions
with cervical caries. In the lower arch,
several existing composite restorations had worn and exhibited caries
on the facial cervical areas. Although
there were no restorations present in
the mandibular anterior teeth, there
was severe wear of the incisal edges,
possibly due to grinding and other
parafunction.

With full-contour Zenostar restorations, there are two methods of
achieving the desired shade: the Zenostar brush infiltration technique
or the Zenostar staining technique.
Six pre-shaded zirconia blanks—
pure, light, medium, intense, sun
and sun chroma—form the basis
for reproducing the patient’s natural
dentition. Owing to their warm, reddish nuance, Zenostar Zr Translucent
sun and sun chroma are suitable for
restorations with individual colour
characterisation and can therefore
be used for patients whose own
natural dentition deviates from the
classical tooth shades.

planning

preparation

After reviewing the clinical findings
and the mounted models, the patient was diagnosed with a restricted
envelope of function and decreased
vertical dimension from continuous
wear. In order to develop a treatment
plan and determine whether the vertical dimension could be increased,
a diagnostic 3-D White Wax-Up (Arrowhead Dental Laboratory) was fabricated (Fig. 4).
In the wax-up, the vertical dimension was increased by 1.5 mm. Also,
based on information gathered from
the initial consultation and digital
images, it was determined that the
maxillary central incisors could be
lengthened by 1.3 mm to improve
the aesthetics. The canines would
also be lengthened to restore canine guidance in lateral excursions.
Regarding the mandibular anterior teeth, the goal was to correct the

Once informed consent had been obtained from the patient, treatment
was initiated.
After anaesthetic had been administered, the existing veneer and crown
restorations were removed and the
teeth cored with composite if there
was any indication of recurrent caries remaining in the respective tooth.
Adhese Universal bonding agent
(Ivoclar Vivadent) was applied following the manufacturer’s protocol
and cured using the Bluephase LED
curing light (Ivoclar Vivadent). Using MultiCore Flow Light (Ivoclar
Vivadent), build-ups were accomplished on the teeth that required
cores. A Clear Reduction Guide (Arrowhead Dental Laboratory) pro-

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restorative

Using 3Shape Communicate, images
of the proposed reconstruction were
forwarded to my office by e-mail.
Any minor adjustments in tooth
shape and contour were communicated with the technical adviser to
achieve the ost ideal aesthetics. Once
approved, the milling process was
begun (Fig. 8).

Cementation
Figs. 1–3: Pre-op retracted view.

vided with the White Wax-Up was
used to ensure adequate reduction
for the definitive restorations. Using a coarse-grit chamfer diamond
bur (Komet), the entire dentition was
prepared for Zenostar crowns, starting from teeth #17–27 and then teeth
#37–46.

that she no longer experienced discomfort in her temporomandibular
joint and that her bite had never
felt better. Since no adjustment or
modification of the temporary was
needed, the dental laboratory was instructed to replicate the White Wax-

Up when fabricating the definitive
restorations.

Laboratory considerations
The White Wax-Ups, colour photographs, impressions and bite relations were forwarded to the dental

laboratory (Arrowhead Dental Laboratory). A scan of the White Wax-Ups
was used to select an appropriate
arch form, tooth size and occlusion
from the library of teeth available in
the 3Shape software (Fig. 7).

Before try-in of the definitive restorations, the provisional restorations
were removed using the Easy Pneumatic Crown and Bridge Remover
(Dent Corp) and any remaining provisional cement was cleaned off the
prepared teeth. The maxillary and
mandibular zirconia restorations
were tried to verify fit, form and
shade. After the patient had been
shown the retracted view for acceptance, the cementation process was
initiated.

A full-arch impression was taken
using Instant Custom Trays (Good
Fit). Made of a proprietary material
(PMMA) that becomes mouldable
when heated in boiling water, these
trays provide a quick, efficient way of
capturing a dimensionally accurate
impression with uniform thickness
of the impression material.
Once moulded and customised to
the patient’s maxilla and mandible,
full-arch impressions were taken
using a heavy and light polyvinylsiloxane impression material (Panasil,
Kettenbach).
After the impressions had been completed, a bite relation jig fabricated
on the White Wax-Up models was
tried in the mouth. Medium-body
impression material (Panasil) was
placed into the relation jig and seated in the patient’s mouth on to the
prepared teeth (Figs. 5 & 6).
The patient was asked to bite into
the relation jig until she reached
the vertical stops and the material
set. Instructions for the size shape
and colour of the final restorations
was forwarded to the dental laboratory (Arrowhead Dental Laboratory), as were the White Wax-Up
models. Also, a stump shade (Ivoclar
Vivadent) was selected for shade
matching of the preparations to assist the laboratory technician in creating natural-looking restorations.

SEAMLESSLY MERGING

Provisionalisation
Provisional restorations, which
would aid in determining the best
size, shape, colour and position for
the definitive restorations, were
made from Sil-Tech (Ivoclar Vivadent) impressions of the White
Wax-Ups provided by the dental
laboratory.
Using the B1 shade of Visalys Temp
(Kettenbach), the Sil-Tech mould
was quickly filled and placed on the
patient’s prepared dentition. Within
minutes, the provisional restorations were fabricated and effortlessly trimmed with trimming burs
(Komet). Once the teeth had been
desensitised with Systemp.desensitizer (Ivoclar Vivadent) and dried,
the provisional restorations were
temporarily cemented using TempBond Clear (Kerr). The patient was
instructed about their care and use
in eating, speaking and biting.
A few weeks later, the patient returned for evaluation of aesthetics, phonetics and bite. Already, she
exhibited excitement about and
confidence with her provisional restorations, commenting that all her
coworkers had remarked that she
looked younger and happier.
Most importantly, the patient said

digital scans and conventional impressions.
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[26] => DTMEA_No.5. Vol.8_DT.indd

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◊Page 25
dried to the extent that they were
still slightly moist. At this time, the
cement capsules were depressed
consecutively to activate and placed
in the ultramat 2 (SDI) amalgamator
for only ten seconds for trituration.

Fig. 4: White Wax-Up. Bite jig relined, capturing full-arch
bite.

Using the applicator dispenser (SDI),
the cement was loaded into the restorations (Fig. 8), starting from the
midline and working distally. With a
very low film thickness and creamy
consistency, riva luting plus cement
was dispensed into the restorations
with easy insertion and seating.

Figs. 5 & 6: Impression.

Removal of excess cement was
cleaned up in about two minutes at
the gel phase. After the cement was
fully set at five minutes, the occlusion was verified and adjusted.
The overall health and structure of
the soft tissue and restorations were
very good. The patient was extremely satisfied with the definitive results
(Figs. 10–12).

Fig. 7: 3Shape virtual design

Fig. 8: Zenostar monolithic restorations on model.

Fig. 9: riva luting plus cement.

The occlusion was checked and verified with T-Scan (Tekscan) to make
sure that all of the proper points of
contact were in their ideal positions
to ensure longevity of the reconstruction. The patient no longer experienced pain and was very pleased
with her new enhanced smile (Fig.
10).

Conclusion

Figs. 10–12: Post-op retracted view.

riva luting plus (SDI), a resin-modified, self-curing glass ionomer luting
cement, was used for the cementation of these zirconia restorations because it can be used without special
preparation using cleaning agents,
nor does it require any bonding
agent (Fig. 9).
According to the manufacturer, riva
luting plus utilises SDI’s proprietary
ionglass filler. Ionglass is a radiopaque, high-ion-releasing reactive
glass used in SDI’s range of dental cements. riva luting plus releases substantially higher levels of fluoride to
assist with remineralisation of the
natural dentition. This higher level
of fluoride has a proven antimicrobial activity against three cariogenic
bacteria: Streptococcus mutans,
Streptococcus sobrinus and Lactobacillus.1 In addition, riva luting plus
has low solubility in the oral environment, increasing the material’s ability to resist degradation and wear at
the margins caused by oral acidity.
The preparations were washed and

In conclusion, having a systematic
method for treatment planning,
material selection, tooth preparation
and cementation, the dental provider will be able to address the needs
of the patient more effectively and
efficiently. Because of this and more,
the final outcome will be much more
predictable aesthetically and functionally.

Acknowledgement
Special thanks to Chris Barnes and
his staff at Arrowhead Dental Laboratory for the fabrication of the restorations depicted in this case.
Editorial note:
This article was published in the
2/2018 issue of CAD/CAM_international magazibe of digital dentistry

Dr Ara Nazarian
He maintains a private practice in Troy
in the US with an emphasis on comprehensive and restorative care. He is a diplomate of the International Congress of
Oral Implantologists and Director of the
Ascend Dental Academy.
He has conducted lectures and hands-on
workshops on aesthetic materials, grafting and dental implants throughout the
US, Europe, New Zealand and Australia.

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restorative

Dental Tribune Middle East & Africa Edition | 5/2018

Anterior restorations with CAD/CAM veneers
made of VITABLOCS Triluxe forte
By Dr. David Jäger, Dr. Martin Hammer
& Carmen Scheibling, Germany
Prosthetic restoration of the maxillary incisors is a challenging task
for dentists and dental technicians.
In the following case study, the authors Dr. David Jäger, Dr. Martin
Hammer and Carmen Scheibling
(dental technician), describe how
they treated a complex initial clinical
situation step-by-step with the CAD/
CAM feldspar ceramics VITABLOCS
TriLuxe forte (VITA Zahnfabrik, Bad
Säckingen, Germany).

Case study
A patient presented in the dental
practice with severe discoloration
caused by a course of tetracycline
given to her as a child. The psychological strain on the 38-year-old patient was increased by the palatal
inclination of teeth 11 and 21. She was
looking for a quick and efficient solu-

tion which would meet her expectations in terms of aesthetics without
having orthodontic pretreatment.
The practitioners, the dental technician and the patient therefore decided on a digital workflow with the
feldspar ceramics VITA TriLuxe forte.
The material allows for a natural look
in the anterior tooth area thanks to
its integrated shade gradient.

Mock-up phase
A wax-up was made using dental
impressions and used as the foundation to discuss the treatment goals
with the patient. Using a silicone index and composites, mock-ups were
produced similarly in the laboratory.
The severely discolored middle incisors were modified, as well as the
length and gradient of the incisal
edges for 12 and 22. “During the trial,
the patient was quickly convinced of
the potential positive results and decided on four veneers,” dental tech-

nician Carmen Scheibling reported
at the final planning meeting. This
was followed by a minimally invasive preparation of the teeth and impressions being taken.

CAD/CAM process
“I corrected and duplicated the mockup and scanned in the plaster model
in the laboratory,” said Scheibling,
explaining the next steps. The master
model made during the preparation
was also digitalized. “In order to
cover the severe discoloration, we
decided on the multi-chromatic
VITABLOCS TriLuxe forte blank, due
to its integrated harmonic shade
gradient,” the dental technician said,
justifying the choice of material.
Thanks to the mock-up data set, the
restorations could be created in the
lab using the CEREC SW 3.8 design
software and milled using the CEREC
MC XL milling system (Sirona Dental,
Bensheim, Germany).

Individualization
and integration
“To deepen the chroma in the cervical area even more, I worked with a
well-balanced mixture of VITA VM 9
CHROMA Plus 2 and CP3 during the
individualization. I was able to achieve
more light dynamics on the distal and
mesial edges with EFFECT OPAL 2,”

said the dental technician, describing
the formative and shading individualization steps. After the try-in, small
corrections and the glaze firing, the
final adhesive integration came next.
Carmen Scheibling concludes that
“the result was a happy and satisfied
patient.”

Fig. 1: Initial situation with severe tetracycline discoloration on 11 and 21.

Fig. 2: Mock-up on 11 and 21 for defining the goal with the patient.

Fig. 3: Mock-ups on all incisors for leveling the gradient of the incisal
edges.

Fig. 4: Plaster model for digitalization similar to the intraoral mock-ups.

Fig. 5: Preparation is as minimally invasive as possible and limited to the
enamel with retention grooves for the best adhesive bond possible.

Fig. 6: Targeted reduction to harmonize the dental arch.

Fig. 7: The removal of tooth substances ensures that the discoloration is
covered.

Fig. 8: Computer-aided design of veneer 21 using mock-up data.

Fig. 9: Computer-aided design of veneer 11 using mock-up data.

Fig. 10: Virtual position of the restoration in VITA TriLuxe forte block from
mesial.

Fig. 12: Try-in of the completed restorations with glycerin gel.

Fig. 13: The esthetic results after adhesive integration.

The article was originally published in das dental labor 2/2018, Verlag Neuer Merkur, Germany.
Fig. 11: Lumen-side view of the virtual veneer restoration.

VITA and other VITA products mentioned are registered trademarks of VITA Zahnfabrik H. Rauter GmbH & Co. KG, Bad Säckingen, Germany.

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[30] => DTMEA_No.5. Vol.8_DT.indd

interview

Dental Tribune Middle East & Africa Edition | 5/2018

Interview: “I believe that innovation
is the engine of a company”
By Dental Tribune International
Founded in 1890, W&H today operates globally as a leading manufacturer of dental instruments and
devices. With over 1,200 employees
worldwide, the company exports its
products to over 110 countries. The
family-owned business runs two
production sites in Bürmoos and
one in Brusaporto in Italy, as well
as 19 subsidiaries in Europe, Asia
and North America. Recently, W&H
President Peter Malata sat down with
Dental Tribune to discuss the enduring success and philosophy of the
company.

Only a few dental companies
worldwide can look back at
a 125-year history. In your
opinion, what are the main
reasons for the long-standing
success of W&H?
There are several factors to which I
would attribute our successful participation in the dental market for
such a long time. Firstly, innovation:
W&H’s history is a story of numerous technological developments and
innovations, such as the Roto Quick
coupling; the first push-button
chuck system for turbines; the first
high-speed contra-angle handpiece
for preparation up to 200,000 rpm;
Assistina, the world’s first cleaning
and maintenance unit; Lisa, the first
Class B steriliser available on the
market; Synea Vision, the first turbine with 5× ring LED+; and our latest innovation, the Primea Advanced
Air turbine. We have continuously
provided products and services—
tailored customer solutions made
in Austria—that not only support
dentists and their teams on a daily
basis, but also make their daily work
easier. Our products are used in dental practices, dental clinics, dental
laboratories, and oral and maxillofacial surgeries in over 110 countries
around the world.
Secondly, our internal apprenticeship programme is of particular
priority to us. We regard this as
an investment in the future. With
our comprehensive training programme, we not only focus on the
professional education of young
people, but also support their personal development.
Third, we rely on continuity: we put

an enormous amount of trust into
our employees. Team spirit is of utmost importance to us. The level of
education of our workforce is very
high and expertise is passed on from
colleague to colleague. Additionally,
we rely on a generational mix within
our teams and a long-lasting staff
membership, enabling continuity
and thus productivity at a very high
level.

intelligent solutions for our customers and partners. The goal is optimal
support for dentists in their day-today work with advanced hardware
and software solutions. The close cooperation between the development
and manufacturing departments
has allowed W&H to respond quickly
to changes in the market and incorporate customer requirements into
new, sustainable solutions.

As a member of the Malata
family, you have headed the
company for over 20 years.
Looking back, what have been
the most significant developments or achievements during
that time?

At W&H, “People have Priority”. Would you please explain
the philosophy behind this
slogan?

I took over the business from my
father, Consul DI Peter Malata, in
1996. My goal was not only to grow
the business, but also to keep our
processes lean. That’s why I decided
in 1998 to introduce a team-oriented
structure in the company, just to
name one significant measure of
many. Today, about 700 employees
at our headquarters in Bürmoos are
organised into over 100 teams.
Another important cornerstone was
the internationalisation of W&H.
Today, we operate three production
sites—two in Bürmoos and one in
Brusaporto—and 19 subsidiary companies around the globe.

How do you approach innovation at W&H?
The basis for W&H’s steady growth is
the consistent employment of stateof-the-art technologies and a dedicated focus on research and development. I believe that innovation is the
engine of a company and my personal goal is to create more room for
it. The continuous expansion of our
R & D department involves not only
the hiring of additional staff, but also
the creation of workspaces that allow
for and foster creative collaboration
and communication. In addition, we
focus on collaboration with universities and research centres, as well as
obtaining ongoing feedback from
users regarding their experiences.
Currently, around 13 per cent of our
employees work in the R & D department at our headquarters. The focus
of their activities is on innovative,
high-quality medical devices and

As a global dental company, we
serve all people in maintaining and
improving dental health. We are a
family business and have been family-owned for 60 years. We strive for
long-term, trusting and appreciative
relationships with patients, customers, partners and employees, relationships on which one can depend.
Our corporate values—reliability,
expertise, openness and sustainability—are therefore not just on paper,
but actually realised.

In March 2018, you launched a
new image campaign, “From
a patient to a fan”. How has
this influenced the perception
of your company by partners
and customers?
We have received very positive feedback on our new image campaign,
directly from customers and partners, as well as via our social media
channels. We want to make it clear
to dentists and their practice teams
that W&H is there for them as a solutions provider and does its utmost
to support them in overcoming their
daily challenges.
In practice, this means that our
products offer true added value to
the treatment process. By optimising and streamlining workflows, we
want to enable dentists and their
teams to give their undivided attention to patients throughout the
treatment process. Since the light
conditions in the mouth are usually
poor, it is our task, for example, to ensure that our products provide sufficient light. When the dentist’s hands
ache after a long day’s work, it’s up to
us to create lighter, more ergonomic
instruments.

W&H President Peter Malata. (Photograph: Gregor Sams/PunktFormStrich)

In addition, of course, the products
have to work intuitively, reliably and,
above all, precisely.
Our products are characterised not
only by innovative solutions, but
also by many small details that make
a real difference in the daily work of
our customers.

You recently announced your
acquisition of Swedish company Osstell. How has this
step complemented your offering?
Osstell and W&H have successfully
worked together since 2016. The first
result of this cooperation was the
new Implantmed with the integrated Osstell ISQ module.
Osstell is known for its implant stability measurement and osseointegration monitoring products. The
acquisition was part of our strategy
to expand into the surgical segment.
Our aim is to broaden our competence and strengthen our position as
a leader in the field of implantology.

In addition to your production facilities in Austria and
Italy, you currently maintain
subsidiaries in 19 countries
around the world. What are
the key markets for you, and
where do you see most potential for growth in the future?
W&H is active globally and our efforts are extended to all markets.
We do of course have specific goals
for the different markets according to their needs. To identify these,
we have our 19 subsidiaries, 16 area
managers, and a vast number of outstanding and reliable partners, who
allow W&H to guarantee rapid delivery and seamless technical service
anywhere in the world.
In recent years, we have also estabW&H’s production site. (Photograph: W&H)

lished subsidiaries in China and India and strengthened our sales activities in the Asia Pacific region. These
are the markets in which we see the
greatest potential at the moment.

The dental market is changing
faster than ever before. What
are your strategies for staying
ahead in this challenging environment?
Our main goal is to provide true added value to our clients with all our
products and services. As mentioned
before, we are focused strongly on
R & D and—I am personally very
proud to say—doing so with great
success. The Primea Advanced Air,
for example, recently received the
Staatspreis Innovation [national innovation award] from the Austrian
Ministry of Economy.
With the Primea Advanced Air turbine, the rotation speed of the bur
can now be set precisely and as a result of electronic regulation remains
constant even when the contact
pressure increases during the treatment. In addition to the innovative
drive technology, the turbine offers
all the advantages of a W&H Synea
Vision turbine.
Finally, the interconnectivity of our
products and services is playing an
increasing role, for example the option to control our tools via a smartphone or tablet, and automated
inventory management and service
scheduling.

Where do you see W&H in the
next ten to 20 years?
W&H has further expanded its position in the global dental market—appreciated by customers and respected by competitors.

Thank you very much for the
interview.

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[32] => DTMEA_No.5. Vol.8_DT.indd

interview

Dental Tribune Middle East & Africa Edition | 5/2018

Interview: “Clear, step-by-step instructions
are essential for long-term success”
By Kasper Mussche, DTI
Dental professionals should be empowered to instruct and motivate
their patients to maintain proper
oral hygiene. ITOP, short for individually trained oral prophylaxis,
is a hands-on training programme
developed by Dr Jiří Sedelmayer and
organised by Swiss oral health company Curaden that teaches dental
professionals to set up patients
for a lifetime of perfect oral care
through practice, correct tools and
techniques, and motivation. Dental
Tribune Online spoke to iTOP TopLevel International Lecturer and Instructor Dr Mia Girotto—a driving
force behind iTOP’s success—who
has been training professionals
and students worldwide for over 12
years.

ITOP gives knowledge to
dental students and professionals. What do you expect
them to take from a session?
Visitors to an iTOP training session can expect to finally learn
how to brush their teeth correctly.

Our aim is for dental students and
professionals to realise that they
are patients as well and should incorporate the correct use of tools,
techniques and knowledge taught
during our seminars into their own
oral health regimens. They should
realise one needs many iTOP sessions to get to the desired level of
knowledge and practice, and retain
this. As such, clear, step-by-step
instructions are essential for longterm success. It is based on practising our knowledge on a daily basis
for ourselves and, eventually, on
motivating and setting up patients
for a lifetime of optimal oral health.
Secondly, we want them to get interested and involved in iTOP, and
get them to realise the potential of
iTOP’s philosophy for their work. So
in short: practise what we preach,
recall for us as well. We are patients
too; the rules apply to us as well.

What is the advantage of an
iTOP session for professionals?
In many things dentistry, you can
do the perfect job, whether it be as

In addition to her activities as a dentist, periodontist and implantologist, Dr Mia Girotto (second from the left) is spreading a revolutionary prophylaxis paradigm as an iTOP Top-Level International Lecturer and Instructor. (Image: Mia Girotto)

a general dentist, specialist or technician, but if there is no compliance
from the patient, restorations or
other medical procedures will end
up in failure. Regardless of the excellence of the work that was put in,
patients should be correctly trained
and motivated to maintain good
oral hygiene after a procedure. If
dental professionals taught their
patients the correct techniques,
and gave them the correct tools and
knowledge, this would definitely set
them apart from other professionals and would also prevent failure.

Aside from your iTOP activities, you work as a periodontist and implantologist. How
does that influence your vision for iTOP?
ITOP has definitely been very useful in complementing these two
fields. In both, success rates are very
dependent on proper oral hygiene
maintenance and patient motivation.

How can dental professionals motivate their patients?
There are many ways to motivate
a patient. There are even documented schools and methods, but
some of the basic advice would be:
do not argue with the patient, find
out what his or her own reason is
for the visit and stick with that. Try
to be as supportive as possible and
keep in mind that this is a process
that needs time—even the smallest
progression deserves acknowledgement.

Creating natural smiles

Since 1995

www.mdentlab.com - info@mdentlab.com
+971 4 3329201 - whatsapp: +971 557590217

You have been an iTOP trainer and teacher since 2006.
How have you seen the programme and prevention in
general change?
If I have to be very honest, the biggest changes I have seen are in the
market. When I first started giving
iTOP lectures, I would often joke
about the market following the
iTOP lead. Ten years later, we are
witnessing this exact thing happening. As for the iTOP programme
itself, it has adapted to certain cultural and national specifics, but

other than that, the core really has
not changed much, as it is easy and
understandable. Of course, we still
discuss, debate and always strive to
improve.

How has your personal experience as an instructor
been so far?
ITOP has changed my life, in every
sense. Since I have been included
from the very beginning of its international programme, I have gained
a “new family”, and made many
friends and met so many wonderful people and colleagues along the
way. It has become a passion, an
inseparable part of me both professionally and privately. I really do
enjoy giving lectures on iTOP and
training people.

How does iTOP fit in with the
Curaden philosophy?
When I say I have gained a new
family through iTOP, part of that
feeling is also being well connected
with the Curaden company. The
company is incredible at listening to the inputs we give, as well
as being flexible and adaptable to
the needs of professionals and endconsumers. The level of honesty in
approaching this dynamic market
makes the Curaden company and
the iTOP philosophy very, very
compatible—a winning team, really.

What about your vision for
the future? Where do you
want to see iTOP go personally?
A long time ago, I jokingly said,
“It’s time for iTOP to conquer the
world.” What I meant by that is that
I want iTOP’s benefits, knowledge
and techniques to become available to every person in the world,
not only dental professionals.

[33] => DTMEA_No.5. Vol.8_DT.indd

The winning combination

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[34] => DTMEA_No.5. Vol.8_DT.indd

nEwS

Dental Tribune Middle East & Africa Edition | 5/2018

How to avoid back pains in dental work
By Veli-Jussi Jalkanen, Finland
The pains caused by the common
back degeneration, which is the result from traditional ergonomics,
are the constant nuisance in dental
work. Avoiding this threat is relatively easy with the new better posture
that can be achieved by sitting on a
divided swaying saddle chair, using
looser clothes, and positioning oneself closer to the patient.

tal ergonomics and health problems, rying their part, and the pressure on
and is spreading it around the world. the discs is 30% bigger. The increased
one-sided disc pressure is the main
reason for disc prolapse (Fig. 1).

Why are lower back degeneration and pains so common? The roundness of the back also
Normal 90/90 sitting (90 degree
angles in hips and knees) is actually
C/90 sitting with the rounded back.
Thus the facets are open and not car-

stretches the back muscles and
makes them tense, slowing down
the blood and lymph circulation. The
weakened oxygen and nutrient in-

This concept includes also numerous other advantages. The leading
Finnish ergonomics company has
developed the solution for the den-

Fig. 1: Poor posture opens the facets
and the discs starts to degenerate and
prolapses may appear.

Fig. 2: Rounded back holds many potential health risks and speeds up degeneration.

Fig. 3: The natural and balanced sitting, with no need to lean back.

take and waste removal degenerate
all tissues in the (lower) back, causing
numerous impacts and pains.
The missing vertebral arteries
around the L5 halves the flow of nutrients and oxygen for the L4 and L5,
and that is why they are the first to
degenerate (Fig. 2).

Dental work is challenging
due to our anatomy
We humans still have the Stone
Age hunter-gatherer anatomy and
physiology. Slouched and immobile
sitting is very unnatural and a great
health risk. The musculoskeletal
system is well and healthy when the
back is in a good posture and mobile.

Swayfit

Sway

The spine and vertebrae are not only
holding the body upright, the vertebrae are systematically also connected to the health of many organs.
Poor spine care and problems in it
trigger also other health issues.

solution: How to keep the
posture good and the back
healthy

Stretching
Support

The divided swaying saddle chair
restores the posture and keeps the
back undegenerated, healthy, and

without pains. The keys for the new
ergonomics is to raise the patient
chair higher, to sit closer to the patient, and to wear looser and more
comfortable clothes (Fig. 3).
This new ergonomics is very friendly
and healthy also for the genital and
internal pelvic health (prostate, erectile functions, female infections), and
knee and hip health as well. The 135
degree angle is so much better for
the knees and hips than 90 degrees.
If you can treat every 4th patient
standing it would improve health
and productivity even more (Fig. 4).
Mr. Veli-Jussi Jalkanen
He is the Chairman of the Board of Salli
Finland and CEO of Salli China. Being
a specialist in work environment and
preventive health, and having a riding
background, he developed the Salli Saddle Chair and Salli sitting health concept.
He has found strong connection between
traditional / poor sitting and many common degenerative illnesses. The unique
swinging and divided Salli seat is exported to over 60 countries.
Editorial note:
The article was originally published in
Dental Asia Magazine, January/February
2018.

Elbow Rest
SWAN-DMCC
Mazaya Business Avenue, Dubai,UAE
info@swanmedsupply.com
+971-43-699059
+971-5285-38713
Fig. 4: Balanced sitting in the natural posture without pains or health problems.

[35] => DTMEA_No.5. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 5/2018

nEwS

Philips to launch
ProtectiveClean
range at BDIA
Dental Showcase
By DTI
LONDON, UK: The BDIA Dental
Showcase, was held from 4 to 6 October at ExCeL London, provided
the backdrop for the latest product
launch by Philips Oral Healthcare.
The ProtectiveClean toothbrush
range features Sonicare’s sonic cleaning technology at its core, producing
32,000 brush sweeps a minute and
creating the dynamic fluid activity
necessary for a penetrative clean, according to the company.
The ProtectiveClean range also features a 2-minute timer and a pressure sensor. The latter of these provides real-time feedback to ensure
that users are not brushing too hard,
thereby minimising their risk of gingival damage and recession. Owing
to its Optimal Plaque Control brush
head, ProtectiveClean has been
clinically proven to remove seven
times more plaque than a manual
toothbrush, according to Philips. The
brush head also features new BrushSync radio-frequency identification
device technology. This is intended
to monitor usage and alert the patient when it is time to replace the
brush head.

Philips' ProtectiveClean 6100 toothbrush includes three
cleaning modes —clean, gum care and white—along
with three intensity settings. (Image: Philips)

The ProtectiveClean range addresses
multiple price points, making good
oral hygiene more accessible to a far
wider cohort of patients. The ProtectiveClean 4300 includes one inbuilt
cleaning mode, with two intensity
settings to provide users with a tailored clean. The handle comes with
an Optimal Plaque Defence brush
head, charger and travel case, features BrushSync technology and is
available in a range of colours, including pastel pink, light blue and
black grey.
The ProtectiveClean 6100 includes
three cleaning modes—clean, gum
care and white—and three intensity
settings. The brush also includes two
BrushSync features: a brush head replacement reminder and brush head
mode pairing to provide users with
a tailored clean. The handle comes
with two Optimal White brush
heads, a travel case and charger.
Philips exhibited at Stand J22 at the
BDIA Dental Showcase. There, visitors were be able to find a number
of key opinion leaders conducting
a series of workshops and carrying
out light-activated tooth whitening
demonstrations, while introducing
the latest clinical evidence for Zoom
chairside.
More information can be found at
www.philips.co.uk/sonicare.

Alan Atlas, DMD

Calibra® Cements

There’s no margin for excess.
Especially when it comes to successful cement cleanup. One out of five crowns fail because of secondary caries
caused by biofilm accumulation.1 Even a tiny bit of cement left behind can cause big problems. The Calibra
family of definitive cements offers a wide tack cure window of up to 10 seconds and a 45-second gel phase,2
giving clinicians the time needed for thorough cleanup. And prescriptive selection based on required bond
strength and material helps ensure successful restorations. Meet the family at dentsplysirona.com.

1. Morphology and Bacterial Colonisation of Tooth/Ceramic Restoration Interface and Different Excess Removal Techniques, Journal of Dentistry 40 (2012) 742-749
2. 10-second tack cure window equals five-second wave cure per surface. For excess cement cleanup, monowave output LED lights with a single peak output around
470nm are recommended. High power, dual or broad spectrum lights may cause premature hardening of excess cement. Check curing light effect on mixed cement
in the laboratory prior to clinical use. Calibra Veneer cement, as a visible light cured cement offers virtually unlimited cleanup time.
ML070011A (7-26-17)

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news

Dental Tribune Middle East & Africa Edition | 5/2018

A Dentsply Sirona predominant practice
Class II Solution
By Dr. Ahmed Soliman Idris, Egypt
Dr. Ahmed Soliman Idris is the
founder of Welldent Clinic which
was established six years ago in Cairo. Two branches are now open, one
in Dokki and one in Fifth Settlement.
Dr. Ahmed Soliman Idris graduated
with a MSc & PHD in Fixed Prosthodontics. He is a lecturer at the Faculty
of Dentistry Cairo University since
2001 and a lecturer at the Faculty of
Dentistry British University in Egypt
since 2013.
Dr. Ahmed Soliman Idris started using the Dentsply Sirona Class II Solution 2 years ago. We caught up with
him to find out how the Class II Solution has helped him better manage
restorative performance and give his
patients an improved Class II experience.

Please explain briefly why
you choose a career in dentistry?
For me, dentistry is a science combined with art and this is what I like.
The passion of changing a person`s
life by creating a beautiful, healthy
smile is one of the most intangible
rewards of being a dentist.

What does “Class II” mean to
your practice?
Class II restorations are part of my
daily work. On average, I am filling
around 5 to 6 cavities per day which
represents around 30% of the total
restorations I am doing - getting this
procedure right the first time is essential.

In your opinion, what is the
most challenging part of a
Class II composite restoration?
I think the most challenging part of a
Class II restoration is the creation of
a proper contact. The main difficulty
is to make a proper contouring of the
contact area in a short time and with
great precision to avoid food accu-

Dr. Ahmed Soliman Idris, Egypt

Class II Solution: Optimisation of each procedural step for predictable outcomes

mulation and subsequent periodontal problems later on.

For how long have you been
using the Dentsply Sirona
Class II Solution?
I have been using the Palodent V3
sectional matrix system with great
success for 2 years. 8 months ago, my
Dentsply Sirona sales representative
visited my clinic and conducted a
demo on the new Prime&Bond universal. He also gave me a sample of
SDR and ceram.x SphereTEC which
enabled me to try and see if the products stacked up against the current
system I was using. Since then, I have
been using the complete Dentsply
Sirona Class II Solution daily and I
am totally satisfied with the results
I achieve.

There is a variety of Class
II materials on the market.
Why do you choose to use the
Dentsply Sirona Class II Solution?
I chose the Dentsply Sirona Class II
Solution because of the precision
and the simplicity it offers. Dentsply

Sirona provides you with the complete solution and takes in consideration the fine details of each step
of the Class II restoration to make the
overall restoration a success.

Which product from the
Dentsply Sirona Class II Solution do you prefer most and
why?
Palodent V3, because it completely
solved the main challenge of a Class
II restoration which is creating a
proper contact. Palodent V3 is not
just a ring but a full solution including the matrices, wedges and the
wedge guards, which when used together saves a lot of time.

Success factors for a dental
practice are profitability, image and safety. How has using
the Dentsply Sirona Class II
Solution enabled you to reach
these 3 keys success factors
for your practice?
Dentsply Sirona’s Class II Solution
provides me with an academic and
professional dental practice with
perfect clinical longevity and mini-

mal post-operative complications.
Complaints of postoperative pain
has dramatically decreased after using the proper equipment to restore
contacts and allows for the proper
isolation protocol to be followed.
My patients receive a better treatment in a shorter timeframe and
excellent results. The satisfaction of
my patients has a positive impact
on the overall health of my practice.
Most of my patients are now referred
through word of mouth.

Class II is a critical player in
practice’s success. What advice would you give to colleagues to perform these restorations with confidence?
It is really important to have proper
cavity isolation and use suitable instruments and materials. Some clinicians are using a mix of products
and materials from different companies. While this approach can play
out successfully, it can also lead to
unpredictable outcomes. Using the
full Dentsply Sirona Class II Solution
makes the procedure more efficient
and the outcome more predictable.
I have already recommended the

Class II Solution to many colleagues.

Dentsply Sirona is the world’s
largest manufacturer of professional dental products and
technologies – Besides from
the Class II Solution do you
recommend any other products?
Yes I do. I would recommend CEREC
as I have already been using it in my
clinic since 2007. CAD/CAM technology has conquered its position in the
world of dentistry, and now we can
see the difference in term of quality
and time consumption when we use
digital dentistry in place of the traditional methods. For me, the advantages of CEREC are:
- User friendly software.
- Innovative and new updates that
we receive directly from Dentsply
Sirona.
- The quality of the scanners which
give us accurate optical impressions.
- From the patient point of view, they
can get their crown in the same day
with no need for unpleasant impressions in their mouth. This is a real
comfort for them.

[37] => DTMEA_No.5. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 5/2018

37

news

King’s College London celebrates research
awards at July’s IADR in London
By King's College London
King’s researchers were presented
with two prestigious awards during
the Opening Ceremonies of the 96th
General Session of the IADR, held in
conjunction with the IADR Pan European Regional Congress (PER), at the
ExCeL London Convention Centre.

Professor Gordon B. Proctor received
the 2018 IADR Distinguished Scientist Award in Salivary Research, one
of the 17 IADR Distinguished Scientist Awards, representing one of the
highest honours bestowed by the
IADR. The IADR Salivary Research
Award is designed to stimulate and

recognize outstanding and innovative achievements that have contributed to the basic understanding of
the salivary gland structure, secretion, and function, or salivary composition and function.
Proctor is a leading salivary researcher with specific expertise in salivary
secretion, the interaction of saliva
with oral surfaces and the significance of salivary biomarkers.
"It is a pleasure to work with talented
colleagues, students and collaborators to answer research questions
that impact on health and disease.
Receiving this award from the IADR
is marvellous and a great recognition
of our endeavours," said Professor
Proctor.
Professor Paul Sharpe and co-authors
Liu Yang, Ana Angelova Volponi and
Yvonne Pang received the William J.
Gies Award, for the best paper published in the IADR/AADR Journal of
Dental Research in the Biomaterials
and Bioengineering Research category. Their article “Mesenchymal Cell
Community Effect in Whole Tooth
Bioengineering” ( J Dent Res 96: 186–

Professor Gordon Proctor IADR 2018

5 place in
Shanghai
rankings for
Dentistry & Oral
Sciences
th

By King's College London
Dentistry & Oral Sciences research
at King’s has been ranked 5th in the
world in the 2018 Shanghai Global
Rankings, up from 7th place last year.
King’s College London is the only institution outside the United States
to have made the top five in the academic ranking of world universities.
Executive Dean Professor Mike Curtis says: “It’s a tremendous accolade
for the Faculty at King’s to be ranked
as one of the world’s top five institutions for research in dentistry along-

side four of our competitors in the
United States. This achievement reflects the commitment, enthusiasm
and excellence of a large number of
academic and professional services
staff in the Faculty and I wish to both
congratulate and thank all of them
for their achievements.”

William Gies Award IADR 2018

191) was identified as work which has
very significantly advanced knowledge in dental research.

tion. King’s College London is at the
forefront of this field and this award,
for the second time, is another recognition for our Centre of Excellence.'

Ana Angelova Volponi says: 'Our
research focuses on the underlying
mechanisms of repair and regenera-

AD

Blended learning courses
for working dentists

Explore our sample content online
Range of subjects open for January 2019 entry
• Advanced Minimum Intervention Dentistry MSc
• Aesthetic Dentistry MSc

RANKED NUMBER TWO IN THE
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UNIVERSITY RANKINGS 2018

• Dental Cone Beam CT Radiological Interpretation
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• Maxillofacial Prosthetic Rehabilitation MSc
Part-time | Online teaching | Face-to-face intensive training

Shanghai Ranking Consultancy is a
fully independent organization dedicating to research on higher education intelligence and consultation. It
has been the official publisher of the
Academic Ranking of World Universities since 2009.

For exclusive taster content

visit kcl.ac.uk/distancedentistry
email distancedentistry@kcl.ac.uk

KCL DI BLENDED LEARNING A5 PRESS AD AW.indd 1

@KingsDentistry

22/08/2018 11:24

[38] => DTMEA_No.5. Vol.8_DT.indd

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www.dental-tribune.me

Published in Dubai

September-October 2018 | No. 5, Vol. 8

The new Swiss Endo Academy
Training Centre

SUBSCRIBE NOW
https://me.dental-tribune.com/e-paper/
Vol. 13 • Issue 4/2017

issn 2193-4673

roots
international magazine of

endodontics

4

2017

FKG Dentaire is proud to announce the opening of its new Training
Centre in Dubai
By FKG Dentaire
FKG Dentaire SA (La Chaux-de-Fonds,
Switzerland), leader in innovation
and production of high-tech rotary
Ni-Ti systems, is highly committed in
worldwide Continuing Education for
dentists.

Training table with 24 seats, monitors, FKG training kits, Endo motor and Apex Locator,
Labomed Microscopes, Phantom Heads, Surgery LED lights, Dental Stools

After having set up its Training Centre in 2014 (Swiss Endo Academy),
based at the company’s headquarters, FKG Dentaire is proud to announce a new Continuing Education
Centre, located at its representative
office, FKG Dentaire DMCC (Dubai,
UAE).

This Centre exhibits the latest generation of high-end equipment (operating microscopes, phantom heads,...)
and offers a real simulation laboratory, allowing general dentists and
specialists, to enhance their clinical
experience while exposed to the latest endodontics Ni-Ti systems, more
particularly to 3D Ni-Ti treatments
range: the XP-Endo® sequence.
The centre of the Swiss Endo Academy in Dubai has been inaugurated
on February 5, just before the AEEDC
congress, in the presence of the top
management of the mother-company and the entire IMEA team of FKG
Dentaire.

research
Photodamage of dental pulpa stem cells
during 700 fs laser exposure

case report
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interview
Understanding sonic-powered irrigation

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[42] => DTMEA_No.5. Vol.8_DT.indd

endo tribune

Dental Tribune Middle East & Africa Edition | 5/2018

Internal resorption treatment using
MTA-based endodontic sealer
Clinical Case Report
By Dr. Fábio Duarte da Costa Aznar,
Brazil
Male patient, 32 years old, presented with clinical classification
of pulp necrosis of dental elements
11 and 12 (Fig. 1), associated with
the presence of internal resorption, being subjected to endodontic
treatment on both elements. He reported a history of dental trauma in
childhood, and had previously undergone an urgent intervention in
element 21 by another professional,
due to edema and pain in the apical region. Due to the presence of
fistula in this region, it was traced
and found to originate from dental
element 21 (Figs. 2 and 3).

After the initial approach of the
patient, he was anesthetized and
absolute isolation was prepared.
Afterward, the coronary access was
made, during which the pulp necrosis of both teeth was clinically identified. A crown-down disinfectant
penetration was done, using NaOCl
at 5% as an irrigating agent, with odonometry performed by the X-ray
method (Fig. 4) due to the infeasibility of using a foraminal locator in
these anatomical conditions, which
could influence its precision. The
preparation was done by the stepback preparation technique, using
K Files (Maillefer/Switzerland) and

NaOCI 2.5% as an irrigating agent,
seeking to dilate the whole root
canal formation. With each change
of instrument, ultrasonic irrigation
was done with smooth inserts (Irrisonic/Helse/Brazil) using the PUI
and CUI concept (Fig. 5). As a complement to the intra-canal decontamination process, two fifteen-day
exchanges of calcium hydroxide
were done (Ultracal/Ultradent/
USA), also aiming at analysis of the
quality of cleaning obtained in the
area of resorption by the radiopacity of this medication (Fig. 6).

chanical technique (Figs. 7 and 8),
through the use of GutaCondensor (Maillefer/Switzerland), cones
of TP gutta percha (Dentsply/Brazil), and Fillapex MTA-based sealer
Angelus/Brasil) (Fig. 9). After the
thermocompaction, the cut of the
obturation, vertical condensation
with the use of CLC, cleaning of the
pulp chamber, and immediate provisional restoration were done (Fig.
10). The sealing of the ramifications
and resorptive areas was observed
radiographically, as well as the presence of silent postoperative.

The obturation was done using
the Tagger Hybrid thermome-

The proservation was done after
three months. It demonstrated re-

sorption of the Fillapex sealer and
new bone formation in the apical
region of both teeth (Fig. 11).

Dr. Fábio Duarte da Costa Aznar
Specialist in Endodontics
HRAC(Centrinho)/USP/Bauru
Master’s in Endodontics SLMandic/
Campinas
Coordinator of the Program of Specialization in Endodontics FACESC/Chepecó-SC,
FAIPE/Goiânia-GO & GOE-Macapá

Fig. 1: Initial radiographic as- Fig. 2-3: Tracing of fistula of dental element 21.
pect of teeth 11 and 21.

Fig. 4: Odontometric radiog- Fig. 5: Complementation of the cleaning process using ultraraphy.
sonic irrigation.

Fig. 6: Radiographic aspect of Fig. 7-8: Wearing down of the cone and technique of thermomechanical obturation.
the intracanal filling with Calcium Hydroxide.

Fig. 9: Fillapex M.T.A.- based Fig. 9: Final radiography.
endodontic sealer.

Fig. 10: Proservation after 3
months.

Interview: “Endodontic treatment is an
invaluable therapeutic technique”
By DTI
From 4 to 7 October, the world of
endodontics will be meeting in the
South Korean capital of Seoul for the
11th International Federation of Endodontic Associations (IFEA) World
Endodontic Congress (WEC). In light
of the event, which has attracted dental professionals from all around the
world for many years, Dental Tribune
Online spoke with IFEA WEC 2018
Chairperson Dr Andy Euiseong Kim.

Dr Kim, how would you describe your experience as
chairperson of the IFEA WEC
2018 Seoul local organising
committee?
First of all, it is my great honour and
privilege to act as chairperson of
the local organising committee. I’ve
learnt so much while preparing for
this gathering. I would like to express

my sincere appreciation to everyone
for the support they’ve shown us so
constantly. I feel so blessed, and it
could not have been done without
that cooperation and support.
Second, I have been pleased to see Korean dentists demonstrating their excellent capability. They perform excellent endodontic treatment, even
in poor environments, and all the
techniques of endodontic treatment
are controlled under the government-led health insurance system.
I can confirm that these researchers
are conducting world-class research.
Finally, it has been a valuable experience to feel the unity of the members
of the Korean Academy of Endodontics.

The theme of this year’s meeting is “Endodontics: The utmost values in dentistry”. Can
you explain what is behind

this and how you identify
with it?
Endodontic treatment is an invaluable therapeutic technique that can
keep natural teeth healthy. The reach
of its use depends on the country,
and I have felt sorry that endodontic
treatment has been more neglected
than other fields, given its importance. We have various difficulties,
especially with the limited choices
for dentists, because of the government’s medical insurance system.
With this point of view, we came to
the idea of going back to the basics
and asked ourselves a fundamental
question: what is most important for
national oral health? A fancy building may be nice to look at, but it will
not last long if the groundwork is not
done properly. Likewise, our efforts
to keep our natural teeth healthy for
the long term should never be underestimated.

Why do you think meetings
such as IFEA’s WEC are important for the endo community?
This is an absolutely necessary meeting. The American Association of
Endodontists meeting, the European
Society of Endodontology meeting
and the WEC of IFEA are the standard
meetings of international endodontic societies, but while the meetings
arranged by the first two associations
are locally constrained, the IFEA gathering is the only academic congress
that covers international endodontic
treatment. Membership of IFEA continues to increase, and 36 countries
have enrolled in IFEA as member
countries.
It is natural that there’s level of difference depending on the country,
and I believe everyone will level up
through this kind of meeting. By doing so, we can contribute to the positive development of human beings,

which is IFEA’s primary value. Also,
the meeting promotes fellowship
among endodontists and exchange
of experiences and ideas. We will
maximise synergy in our field by
sharing information with one another.

What are your expectations/
hopes for the meeting, and
what are you most looking
forward to personally?
I am so excited about the meeting.
The largest number of participants
of all of past IFEA WECs will come to
Korea from 70 countries all over the
world. Personally, I am thrilled to
meet endodontists from all over the
world. I know that it will be a wonderful experience to meet participants
from far away and from closer to
home. Furthermore, I hope that IFEA
will continue to grow into a global
organisation representing the whole
world.

[43] => DTMEA_No.5. Vol.8_DT.indd

[44] => DTMEA_No.5. Vol.8_DT.indd

endo tribune

Dental Tribune Middle East & Africa Edition | 5/2018

Diagnosis and Outcome in Endodontics in
the 3D Imaging era
Professor Francesco Mannocci, specialist in endodontics and restorative dentistry,
discusses how 3D Imaging is streamlining the endodontic workflow.

By Dentsply Sirona
In recent years, a team at King’s College London has completed a number of clinical trials highlighting the
importance of CBCT (Cone Beam
Computed Tomography) in diagnosis and outcome assessment in endodontics. As endodontists, we are
all now familiar with the benefits of
using CBCT scans to identify where
the problems are within the tooth.
We use this technology to help us
view trauma such as tooth fracture
or examine where a root canal treatment has failed.

may be. The final 3D representation
can be rotated 360° and allows us to
determine the working length, analyse the natural shape of the canal
and select the appropriate files using
the integrated file database.
In root canal treatment, there is always a need for strict infection control to prevent bacteria getting into
lesions and creating infection that
can lead to failures. A tight coronal

seal is especially important to prevent bacteria penetrating the tooth
at a later stage. if the tooth is particularly damaged it is more difficult to
achieve an adequate coronal seal
and makes the tooth more prone to
failure through bacterial infection.
CBCT imaging plays a vital role in
such cases, as these teeth are likely
to be more prone to small cracks and
fractures, which are difficult to detect
using traditional scanning methods.

In conclusion | CBCT is essential:
• In diagnosing external/internal resorption.
• In diagnosing traumatic injuries of teeth.
• In the assessment of endodontic outcomes in the context of clinical trials.
• For pre-surgical assessment.
• In detecting small radiolucencies in teeth with deep caries.
• As a pre-treatment radiograph before the endodontic treatment of molars,
lower incisors and retreatment of premolars.
• For looking more closely at the loss of tooth structure and the success of
root canal treatment.

It is well known that the presence of
radiolucencies at the apex of a root
is symptomatic of endodontic infection such as granulomas or cysts. in
the majority of endodontic cases, the
assessment of outcomes is reliant on
the detection of these apical radiolucencies or exposing any change in
their size.
A radiographic technique (CBCT)
demonstrates far better sensitivity
and specificity at detecting radiolucencies than traditional periapical
radiographs. With periapical radiographs, it has been demonstrated
that the number of roots cannot be
seen clearly, so we are not just missing radiolucencies at the apex of the
root, but missing entire root canals.
it is important to remember that the
radiation dose delivered to the patient must also be considered, when
assessing treatment modalities. A
periapical radiograph delivers 0.14%
of annual background radiation, rising to 0.2% with panoramic, whilst a
conventional CT scan delivers 39%.
A small field of view CBCT scan delivers barely 1%, which although
around 7 times higher than a traditional scan, is in fact, much less than
taking a long-haul flight, say from
Paris to Tokyo, that delivers 4 times
this radiation dose.
Preserving the vitality of the pulp
helps to preserve the structure of the
tooth. indirect pulp capping works
better than direct pulp capping and
we can use CBCT to help determine
when indirect capping is likely to
be a success or failure. indirect pulp
capping guided by CBCT can help
avoid the loss of tooth structure, significantly improving the success rate
of this procedure and potentially increasing the chances of survival for
the tooth.
We can now also use CBCT in the
actual design of root canal treatment, effectively planning access
to the pulp chamber, and 2017 sees
the launch of 3D endo, a new software by Dentsply sirona, which will
improve individual treatment planning using CBCT. This software will
help us to visualise the direction and
position of the canal and the ideal
shape of the access cavity. 3D endo
enables the user to isolate the tooth
being treated and locates the orifice
and apex of the canals. This makes
it possible to add more points to the
computer image, resulting in more
precise tracking of each individual
canal, no matter how curved they

Complex cases,
nothing left to hide?
The first CBCT based software designed to improve
endodontic treatment planning for more predictability.

3D Endo™
Software

[45] => DTMEA_No.5. Vol.8_DT.indd

PUBLISHED IN DUBAI

September-October 2018 | No. 5, Vol. 8

www.dental-tribune.me

Sunny prospects:
Using power to achieve brightness
The layering concept using IPS e. max Ceram power materials

SUBSCRIBE NOW
https://me.dental-tribune.com/e-paper
CAD/CAM Italian Edition, anno 7, vol. 2
supplemento n. 1 di Dental Tribune Italian Edition, anno XIV n. 9

Settembre 2018

CAD/CAM
digital dentistry
international magazine of

DWOS Chairside

2018

cmf marelli s.r.l.

By Bastian Wagner, Germany
The most important factor when
imitating the light-optical properties
of natural dentition is brightness.
It is important to be able to control
this factor selectively during the production of the ceramic restoration.
The new power materials in the IPS
e. max Ceram range allow the dental technician to be the maestro of
brightness.
The work routine in the dental laboratory and dental practice has changed
a lot in recent years. Co-operation
between dentist and dental technician has become multifaceted and
complex. This enables the patient’s
individual needs to be fulfilled on an
even higher level. A prosthetic treatment plan is still an essential and
fundamental factor. Contact with
the patient is of great importance
for the dental technician, in order to
ensure a high-quality result. In addition, the dental technician should be
a master of his/her craft and understand the anatomical, functional and
esthetic factors of natural dentition.

Working
with all-ceramic materials

Another important aspect for successful prosthetic treatment is the
use of appropriate materials. In
modern dentistry, permanently
fixed restorations made entirely
from all-ceramic material are highly
relevant in the clinical routine. The
ceramic layering materials and the
multitude of framework materials
available on the dental market offer a
wide range of choice for a successful
treatment concept – according to the
different indications and the respective cases. However, due to the wide
variety of products it is not always
easy to select the best material. The
dental technician’s job is to produce
prosthetic restorations that have a
long service life. Functional, biological and esthetic perfection should be
adapted to the individual needs and
requirements of the patient. For this,
it is essential to become familiar with
the material properties of the various different materials and know
the specific features of the respective ceramic range. For example, it is
advisable to make individual shade
samples so that the light-optical
properties of the ceramic material
can be seen. The materials to be used
should be ideally coordinated with
one another in terms of biocompatibility, stability, esthetics, processing,

This article is an introduction into
the new IPS e. max ® Ceram power
materials. The new ceramic material’s indications and advantages will
be presented using a patient case as
an example.

- Reproducible natural brightness on
translucent frameworks
- Controllable brightness
- Vibrant alternating layering to imitate natural teeth with a high brightness value
- Stable value in thin layering thicknesses

The power concept

Patient case

The well proven IPS e.max Ceram
range has been extended with the
Power Dentin and Power Incisal
materials. The new power ceramic
materials have a higher brightness
value. The IPS e.max Ceram range
now includes three different brightness values and small variations of
opacity and chroma.

One of the biggest challenges for the
treatment team is the reconstruction of minimally invasively prepared anterior teeth. This situation
requires a great amount of attention
from the dental technician. There
has to be a high level of understanding for the light-optical analysis of
natural teeth and the ability to implement this in ceramic in an individual layering concept. In order to
achieve an esthetically harmonious
restoration, it is imperative to understand the light-dynamic characteristics of the respective ceramic range.
The power ceramic materials widen
the selection range and with their
high brightness value, they represent a clear added value to the IPS e.
max Ceram range. The brightness
value can be controlled significantly
better. The dental technician can adjust the brightness throughout each

chroma, brightness value and hue.

A comparison shows that the dentin
materials have the lowest brightness value and that the new IPS e.
max Ceram power materials enable
the highest values to be achieved. In
particular, a wider spectrum is available for creating a specific esthetical
reproduction in a single-tooth restoration.
The power materials are specifically
designed for the following situations:

Fig. 2: Determining the basic tooth shade
Fig. 1: Starting situation. The upper right 1 and the upper left 1 are to be restored with
veneers

Fig. 3: Determining the light-optical characteristics with a special shade sample (in
this case Opal Effect materials)

| formazione

I vantaggi della diagnosi radiologica 3D (CBCT) in Odontoiatria

| expert article

Ruolo della posizione degli incisivi
nella preparazione ortodontica pre-chirurgica

| special

Il “mandato psicologico” in odontoiatria estetica

of the various steps.
The versatility of the enhanced ceramic range is shown through a patient case. In this case, the patient’s
two upper anterior teeth were to be
restored with ceramic veneers (Fig. 1).
The plan was to esthetically improve
both the tooth shade and shape. The
natural teeth were prepared using a
minimally invasive technique. This
created space for the ceramic veneers.

Determining the shade
After a joint analysis of the initial situation and desired target, the tooth
shade and the light-optical characteristics were assessed.
The shade guide from the respective ceramic range is important for
determining the shade (hue), colour saturation (chroma) and colour
brightness (value). The preoperative
shade analysis showed a high brightness value in the body area of both

Fig. 4: Determining the tooth shade of the
prepared teeth

teeth. The ceramic materials, which
were selected through the shade
determination, were set in an individual layering concept. Figs 2 to 4
illustrate the importance of targeted
shade analysis with photographic
documentation.
The power ceramic materials are especially well suited for tooth shades
with a high brightness value. They
make the reconstruction of young
or bleached teeth easier. The advan-

Fig.5: Geller model with refractory dies

Fig. 6: Building the veneers up for the first firing

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tages of the power ceramic materials
can be seen in this minimally invasive situation.
If the brightness value cannot be
helped by the framework material,
it is all the more important to use
a high value ceramic. A “greyness”
within the restoration is therefore
prevented. A grey shimmer can occur for example, when a translucent
framework material is used or in
situations where no framework is
required.

Producing the veneers
In order to esthetically restore the
anterior teeth, the veneers were
individually built up on refractory
dies (Figs 5 and 6). In this case, the
prepared teeth have a slight discolouration, which needs to be masked
by the ceramic layer. The high degree
of reflection (value) made it possible
to achieve the required brightness
in a minimal layer thickness. Effect
materials were used in the buildup to achieve a vibrant appearance.
This way, the natural light-optical
characteristics were imitated (Figs
7 to 9). An alternating layering concept, using the Power Incisal and the
conventional incisal ceramic materials from the IPS e.max Ceram range,
gave the ceramic veneer a very high
light-dynamic effect with relatively
little effort (Fig. 10). The interaction
of the different brightness values
created a natural in-depth effect
within a minimal layering thickness
(Figs 11 to 13).

Fig. 7 & 8: Alternating the layers with the materials chosen during shade determination

Fig. 9: Prepared for the second firing

Fig. 10: The veneers with a high light dynamic on the model

Conclusion
To create a harmonious shade reproduction of natural teeth, it is
important to imitate the information obtained during shade analysis
using the light-dynamic characteristics in the material. The most important characteristic is the brightness
(value). If this is not implemented
exactly, even a non-professional will
see the ceramic restoration at a short
speaking distance. If the value is too
high, the restoration will appear to
be too white; if the value is too low,
the restoration will seem too grey.
It is important for the dental technician to be able to influence the
brightness value of a veneer. This
requires suitable ceramic materials and a patient-oriented working
method. The new IPS e. max Ceram
power materials are a big plus in
everyday laboratory life when translucent framework materials are
used and with minimally invasive
restorations. The brightness value
can even be altered at a later stage

Fig. 11 & 12: Veneers on the UR 1 and UL 1: The brightness value of the adjacent teeth has been reproduced exactly. There is a natural in-depth effect within a minimal layering
thickness.

with these materials, e.g. if the tryin shows that the brightness has to
be increased. This gives the dental
technician a high degree of safety,
because improvements are easy to
achieve. A total remake of the veneer
due to correction of the brightness
can be avoided in many cases.
The power ceramic materials offer
more safety in imitating the brightness value of natural dentition.

Bastian Wagner
Implaneo dental ceramic
Richard-Strauss-Strasse 69
81679 Munich, Germany
wagner.zahntechnik@gmail.com

Fig. 13: Harmony in shade and shape: Both upper anteriors appear significantly stronger
and have the desired lighter tooth shade.

Dental Technician Int’l Meeting
12 April 2019 in Dubai, UAE
By Dental Tribune MEA / CAPPmeaa
The Dental Technician International
Meeting (DTIM) is the continuation
and growth of CAPP’s Dental Technician Sessions during the last 11 years.
These Dental Technician Sessions
were accomplishments not only for
dental laboratory owners and dental
technicians but for the entire dental
technology profession.
The DTIM will be held on the 12 April
2019 at the Madinat Jumierah Conference Centre. Over 200 dental technicians, clinical dental technicians
(CDTs), lab owners, trade visitors and
more are expected to attend.

The DTIM takes place in conjunctions with the 14th CAD/CAM & Digital Dentistry Conference & Exhibition which will be attended by over
2,000 dental professionals.
Who Should Attend
– Dental technicians
– Clinical Dental Technicians (CDTs)
– Dental lab owners

CAPP Events
Tel: +971 4 347 6747
Web: www.cappmea.com
E-mail: events@cappmea.com
Round table presentations with hands-on training with dental technicians

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Dental Technicians during the scientific programme

Free hands-on training at the round tables

Lecture during the scientific programme of DTIM

Dental Technicians during the scientific programme

Interview: “I try to bring dentists
and technology together”
By Nathalie Schüller, DTI

We work directly with our customers or through companies. We have,
for example, an implant company
distributing our software, and CBCT
and 3-D printing manufacturers
and distributors using our system,
and direct sales through the web
and social networks. We no longer
have sales persons visiting dentists’
offices. It does not make sense for
us; the investment is too high. Our
customer segment is dentists who
already have an idea of how to use
the technology available, and word
of mouth brings us new customers
as well.

3DIEMME provides guided surgery
software developed for dentists,
radiologists and dental technicians
for the complete management of
the digital dentistry workflow. The
company’s offices, manufacturing
facilities and training centre are
located in Cantù, Italy. In this interview, CEO Alessandro Motroni talks
about the program, training users
and the possibilities the software
offers.

Mr Motroni, your software
analyses and replicates in
3-D complete parts of the
body to operate on bone, soft
tissue, muscles, and vascular
parts. Can you tell me more
about it?
We focus on dentistry because
of the technology allowing us to
mix printing and CAD/CAM, and
put all the technology available
together to plan the digital workflow. With the latest version of the
software, we use the cloud to bring
all the team members of the planning process (technicians, dentists,
laboratories) together in the same
loop through mobile technology as
well, allowing the dentistry team to
plan on a mobile phone or an iPad,
share the project, chat on the same
application and produce the surgical guides, models and results with
the possibility of being continuously in touch with one another. It
is therefore much easier compared
with standard software versions
for which you need to have a computer, and many dentists hate computers.

There is an issue of safety

It has become a new world,
one where one’s social media presence is primary.

Photograph: Alessandro Motroni

concerning putting personal
information in the cloud.
It is said to be secure and
then one reads about hackers accessing what are believed to be some of the safest websites. How does the
older generation feel about
putting information in the
cloud using your application?
They are open to it because it is
much easier to use for them and
they like to rely on somebody else to
collect data from their patients and
share this data with a technician
through a secure connection via
our web server, which has the highest security possible. The laboratory
can prepare a draft of the project,
share it with the dentist, who can
request changes, and this can be
done with only a couple of clicks by

the dentist. Therefore, even if they
are not used to new technologies,
they can still collaborate with other
members of the team and exploit
the benefits of digital dentistry. We
also offer training of course.

You teach dentists how to
use the software at the Lake
Como Institute in Italy, for
example.
We started working with Dr Tiziano
Testori 12 years ago. I am involved
now in the courses offered at the
Lake Como Institute, in teaching
the aspects related to imaging and
guided surgery. I try to bring dentists and technology together, by
using the latest version that we
have developed to leverage the level of dentistry in digital dentistry.

How do you market your
software?

Definitely! We sell in 18 countries,
including India and Chile, countries
where access to the Internet is not
easily available to everyone. We use
traditional distribution channels as
well.
We also customise the software for
companies. We now offer a special
service for companies: connecting
the project with their ERP [enterprise resource planning] or CRM
[customer relationship management] systems so that the integration between the software and the
internal ordering or management
system runs smoothly. For the dentists, it becomes just about planning; for the companies, it becomes
easier for an order to be placed and
facilitates the connection with the
sales force. One data set is in the
cloud and shared with all the people who work with and need this
data. You do not have to enter the
data all the time or wait for the order and input it manually, which of
course brings with it the possibil-

ity of mistakes. Furthermore, each
time you have to do something
manually, you lose time, and time
is money.
We are now waiting for US Food and
Drug Administration approval for
the software because it is certified
as a Class II medical device. We invest a lot of time showing potential
customers at major events, such as
congresses, what we are doing and
promoting the software on social
networks.
The word is spreading fast; we
have a lot of followers on Facebook.
When we have something new, our
followers start sharing the information and we receive requests from
dentists in Russia, China, etc.

It is quite mind-boggling.
Of course, you cannot go
against evolution and technology, but considering the
pace of development the
Internet has fostered, the
possibilities it creates, it is
a wonder we can keep up.
What will come next do you
think?
It is so true. For example, the mobile version allows things never
before possible. The dentist may
be in Rome, the dental technician
in Milan, and the implantologist
in Venice, yet they can all work on
a case without ever meeting. One
might think it is something bad,
but I think it increases the connection they have because the dentist
in Rome might not have been able
to manage the case alone.

Thank you very much for the
interview.

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www.dental-tribune.me

Published in Dubai

September-October | No. 5, Vol. 8

Brushing your teeth just got social
Oral-B launches the Oral-B FunZone, a gamification and social experience that makes brushing fun
for people of all ages.
By Oral-B
DUBAI, UAE: Oral-B, the worldwide
leader in oral care, has upgraded the
Oral-B App to feature the Oral-B FunZone, a unique gamification feature
that makes each brushing session a
more rewarding experience for users
of all ages.
The perfect solution for health-conscious people seeking a fun, enjoyable and dentist approved brushing
experience, the Oral-B FunZone is an
interactive in-app technology. The
function simulates features from
popular social sharing platforms,
to encourage users to achieve their
brushing goals through a fun-filled
scoring system that unlocks unique
photo filters.
“We know that people tend to accomplish their health goals when
they can gauge their progress
through an exciting social media or
wearable experience,” says Dr. Ashhad Kazi - Professional & Scientific
Relations Manager – P&G Oral Care,
“With this in mind, we’ve upgraded
our current mobile app offering to
include the Oral-B FunZone, a feature that allows users to track and actively share their brushing journeys,
encouraging proper brushing habits
for all in a unique way.”
The Oral-B FunZone helps improve
users’ oral care habits with a fun-

filled social media sharing and reward system, making each brushing
session the ultimate oral care experience.

Oral-B FunZone: An Easy Way
to Make Brushing Enjoyable
With the Oral-B FunZone, users gain
points during each brushing session
to unlock new FunZone themes: Jungle, Anime, Cats and Haunted House.

The app comes pre-loaded with the
Jungle theme, and the three additional themes can be unlocked by
acquiring points for improved oral
care habits such as brushing for the
dentist recommended time of two
minutes or a pressure free session.

Oral-B FunZone:
How it Works
• Users access the Oral-B FunZone

in the Oral-B App and unlock new
themes as they brush correctly.
There are four themes to unlock,
starting with Jungle
• Users select one of the unlocked
themes, and the app will automatically capture their filtered brushing
session, generating a “selfie” gif
• Users share FunZone experience
with friends on social media with a
specially curated “selfie”

The Oral-B App experience paired
with Oral-B GENIUS offers consumers a truly personalized oral care experience, so they can brush like their
dentist recommends – and have fun!

The Oral-B App 5.0 is available on iTunes
and Google Play. For more information
about the Oral-B App and Oral-B products, please visit https://oralb.com/en-us

Interview: “Prevention is not just for children
and young people”
By DTI

symptoms of which, in the form of
decaying lesions, are still some of the
most common reasons for extractions. I am aware that I am speaking against the common teaching
opinion, which treats caries and periodontitis as non-communicable diseases, but it would be too much for
this interview to explain the reasons
for this stance in detail.

Three years ago, Professor of Cariology and Endodontology Ivo Krejci
from the University of Geneva, Switzerland, published an article in which
he made the case that professional
motivation, instruction and checkups, as well as precise, non-invasive
therapies, should be the core competence of a practice team in order to
maintain oral health. Dental Tribune
International spoke with him about
his assertions.

Prof. Krejci, what is your main
message when it comes to
modern caries prophylaxis?
The aim of modern dentistry is not
the temporary repair of heavy clinical symptoms in the form of large
decaying lesions and deep periodon-

Prof. Ivo Krejci recommends an approach to caries prevention that is focused on lifelong
dental coaching. (Photograph: Ivo Krejci)

tal pockets, but rather the lifelong
dental health of the population,
which I define as the absence of clinical symptoms. My article focused on

one aspect of this concept, namely
the causes, symptoms and treatment of caries, a chronic lifelong
infection of the biofilm, the clinical

Besides increasingly criticised fluoridation, bioavailable calcium, acid
neutralisation and harmless sugar
substitutes can be identified as important factors in preventing caries
symptoms in so far as the patient
doesn’t want to curb excess sugar
consumption. Three further measures are at least just as important:
firstly, early diagnosis of the initial
caries; secondly, the lifelong, periodical professional motivation, instruc-

tion and monitoring of an efficient,
atraumatic home dental care routine
in the sense of primary prevention;
and thirdly, the use of non-invasive
adhesive composite restoration to
stop or at least delay subclinical caries symptoms in the sense of secondary prophylaxis. Direct and indirect
minimally invasive composite restorations complement this philosophy
in patients entering into this concept
with existing large decaying lesions
or with existing restorations.

Why do we still separate periodontitis prophylaxis and
caries prophylaxis?
It’s difficult to say, as both problems
have to do with immunology and a

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pathogenic biofilm. This separation
makes no sense at all. We should always speak of simultaneous caries
and periodontitis prophylaxis, not
of separate problems. Depending
on the individual patient’s situation,
the focus may be more on caries
and/or periodontitis prophylaxis,
but it shouldn’t be forgotten that a
lifelong prevention-orientated concept should take not just caries and
periodontitis into account, but also
erosion, abrasion, trauma, dental
misalignment and infraction.

You mentioned pathogenic
biofilm. What do you recommend: completely remove or
disrupt the biofilm?
The biofilm actually protects our
teeth, so is vital for survival. Its permanent removal from the mouth
would therefore be counter-productive. Through its currently unpreventable infection with bacteria
that cause caries and periodontitis,
it becomes potentially pathogenic.
This pathogenicity can only develop
if two conditions are present: firstly,
the biofilm must be sufficiently
structured, which requires around
24 to 48 hours after its formation,
and secondly, certain parameters
must be present. An example of this
is the repeated excess of sugar in the
caries process.
These deductions form the basis of
the preventative concept: we accept
the infected and potentially pathogenic biofilm and do not remove it
permanently from the mouth. We
acknowledge that a change in the
conditions—for example, through a
drastic reduction in sugar consumption—would be very welcome, but
difficult to implement in the long

term in practice. We therefore approach the structure of the biofilm
and prevent its pathogenicity from
developing. The solution is simple:
we just have to regularly, that is
every 24 hours, disrupt the structure of the biofilm intensively on all
surfaces of the tooth. Chemicals and
medications don’t help a great deal,
as the biofilm has very potent defence mechanisms.

In your article, you spoke
about lifelong dental coaching.
What do you mean by that?
Prevention is not just for children
and young people. As caries and periodontitis are lifelong infections and
decaying lesions, periodontal pockets, erosion, abrasions, trauma and
dental infractions can arise at any
age, lifelong prophylaxis is unavoidable. This lifelong dental coaching is
based on the preventative measures
already mentioned, complemented
by regular professional monitoring
with high-tech diagnostics to catch
symptoms in the subclinical stage,
thereby allowing non-invasive therapy where needed.

Therapy, diagnostics, prevention—what are your concrete
recommendations?
We cannot predict reliably enough
how much of a risk a patient has of
developing symptoms in the form
of decaying lesions or periodontal
pockets. It is even more difficult
to do this for specific areas of the
tooth. And even if we could, things
can change at any time. The risk of
too little or too much prevention
on the wrong tooth surface is therefore very high. This applies to ero-

sion, abrasions and infractions in
the same way. That’s why it is more
efficient in today’s dentistry to wait
for symptoms to develop, providing
site-specific risk information. However, if we wait long enough for the
symptoms to be clinically visible, it’s
already too late and we fall back on
dentistry from the nineteenth century. If one has the diagnostic opportunity to recognise symptoms long
before their clinical manifestation,
such a concept suddenly becomes
very interesting.
We know that it takes years for clinically evident symptoms to develop
in caries and periodontitis alike. If
diagnostics are carried out with sufficient reliability and if diagnostic
methods are available that catch
symptoms in the subclinical stage,
one will have enough time to tackle
these with non-invasive methods.
As dentists, we only tackle the symptoms of caries with our restorative
methods. For technical and practical
reasons, we used to only treat symptoms at a later stage, when the decaying lesions had already developed
into cavities, because diagnostics
weren’t as advanced and restorative
therapy was based on macro-mechanical principles. We needed the
hole so that we had something to
fill. Today, this concept hasn’t really
changed in principle. From a professional perspective, we are still treating symptoms, but we have other
diagnostic tools and therapies, so we
don’t need macro-retentions for restoration. This lets us act much earlier
and use non-invasive therapies.

Should we be concentrating on
primary or secondary prophylaxis?
Individual primary prophylaxis is
the foundation of everything, but
nobody’s perfect. With the primary
prophylaxis tools we have today
alone, we will not be able to save
humanity; despite our best efforts,
symptoms will arise. That’s why our
concept is not solely based on primary prophylaxis. It also integrates
secondary prophylaxis, which aims
to halt symptoms non-invasively
in the early stages so that they do
not become more clinically serious.
Non-invasive secondary prevention
seems to me the tool of choice, given
our current circumstances and the
resources we have available today.

What role does individual
home oral hygiene play in caries prophylaxis in your opinion?
Individual home oral care by the patient is the most important aspect
for me. It might sound presumptuous, but many people can’t brush
and don’t know which tools, products and techniques are the best and
most efficient for their individual
situations. I am convinced that oral
care at home can only have a longterm effect when it is overseen by
a dental professional. This professional cannot heal the patient, and
it wouldn’t make sense for the professional to perfectly remove the
patient’s biofilm each day, as this
would require that the patient come
to the practice every day. Even if he
or she could afford this, it would lead
to public transport chaos and would
make very little sense. Therefore, it

is more sensible to delegate this job
to the patient and inform, educate
and monitor him or her as needed,
as well as correct and motivate when
necessary, not just once, but again
and again.
Manual or electric toothbrush, floss
or interdental brush, toothpaste with
or without fluoride—the individual
case should stipulate what tools are
needed. As dental professionals, we
have the knowledge to provide the
correct diagnosis and to advise the
patient on which tools, products and
techniques would be the most effective, quickest and cheapest for his
or her individual circumstances. We
can still get involved if professional
therapy is needed and before clinically visible symptoms arise.

Finally, how’s your own oral
hygiene?
Very good. Although I had to live
through the dentistry of the 1960s
as a child, I still have all my own vital teeth and they’re all doing well.
It helps that my wife is a dental
hygienist. She’s the best thing that
could have happened to me in many
respects.

Thank you very much for the
interview.
Editorial note: Prof. Krejci’s article, titled “Lebenslanges ‘DentalCoaching’
anstelle ästhetischer Zahnmedizin”
[lifelong dental coaching instead of
aesthetic dentistry], was published in
the January/February 2015 issue of
Bayerisches Zahnärzteblatt.

Emirates – Kenya outreach success
By EDHC
In August 2018, Emirates Dental
Hygienists Club (EDHC) and Faircare, an initiative by Goumbook,
partnered to deploy a team of
dental professionals and a general
volunteer to Aitong in Kenya. The
group was led by Rachael England,
President of the EDHC. Faircare is
a Dubai-based organisation that
provides dental care to low income
workers for just 10% of the usual
cost, ensuring equitable access to
quality dental care.
England had previously visited Aitong in 2015, when she rendered a
dental hygienist service and gave
oral health lessons, while a team of
dentists carried out basic restora-

tive treatment and pain relieving
extractions. This time, with the support of an amazing team of 11 volunteers from four countries, they
planned to go a step further and
establish an ongoing service.
Following one missed flight, two
cancelled flights, a brief struggle to import 2000 toothbrushes
and 2000 tubes of toothpaste and
a bone shaking 6-hour bus ride,
the team finally met in Aitong in
Kenya, where they set up the mobile dental clinic within the village
medical centre.
Sterilisation and cross-infection can
be an issue in developing countries
when carrying out humanitarian
work, but careful planning by Hi-

lary Browne meant the team were
well prepared with an entire decontamination process and two pressure cookers, ensuring both clinician and patient safety.
A dental hygiene clinic was set up
with two portable ultrasonic scalers
and oral hygiene aids. Here, Hasna
Hafsi, Yasmeen Arafsha, Hanan
Abdalla and Dr Shaima Obaid Bin
Rabeeha carried out dental screenings for the local school children,
preventative treatment and prophylaxis scaling. Abdalla and Arafsha
also held fun and interactive oral
health lessons for groups of children, where they sang and learned
about toothbrushing and healthy
snacks. Patients often request
cleaning to remove the brown

Getting up close with elephants on the Maasai Mara

Back row L-R: Hilary Browne, Hasna Hafsi, Karina Carniato, Dr Jamshed Tairie, Zohra Tairie, Lisa Hicks. Front row L-R: Shaima Obaid bin
Rabeeha, Yasmeen Arafsha, Hanan Abdalla, Stephany Gardner, Me (Rachael England), Maddie Tucker, Simi Senegey (local host)

stains seen frequently in the Mara,
however this discolouration is due
to the high levels of fluoride found
in the ground water. Despite community efforts, filters to remove
such high concentrations are expensive to maintain and following
generations continue to be afflicted
with severe fluorosis.

triaged by dental hygienists Karina
Carniato and Stephany Gardner
who used their full skills sets to
assess and anaesthetise patients
ready for dental therapist Madalyne Tucker and dentist Dr Jamshed
Tairie to carry out basic restorative
care and extractions. Dr Tairie’s

In the main surgery, patients were

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wife, Zohra oversaw the surgery,
tracking the treatments that had
been carried out and helping with
patient care.
Outside, the general volunteer
Lisa Hicks registered patients and
created a basic filing system to
ensure future expeditions have
patient treatment records. Four local young men were recruited to
assist in translation and clinic organisation, one of whom, Delama,
had been both deaf and mute since
childhood when he contracted an
illness, yet the whole community
were able to do sign language with
him.
The first day in clinic went smoothly as word spread throughout the
community that a dental team
was in town. The local host, Simi
ensured the welfare of the team
and also managed to secure hotel

accommodation-an upgrade from
the expected campsite.
It was not all work and no play for
the team. Sunday, Wednesday and
Thursday were spent in the Maasai
Mara National Park, where they
were lucky enough to see elephants,
lions, leopards, buffalo and cheetahs amongst the spectacular scenery inhabited by these incredible
animals. They were also welcomed
by the village elder at a local Manyatta (Maasai village) with traditional singing and dancing. Maasai
are great pastoralists, living seminomadic lives that have remained
unchanged for hundreds of years.
They are easily recognised by their
colourful clothes, elaborate beaded
jewellery, stretched earlobes and removal of the lower central incisors.
Their diet mostly consists of milk,
meat, vegetables and maize, leading to low rates of dental caries and

Dr Jamshed works in the background assisted by Karina, Maddie triages
a patient with anaesthetic assisted by Stephany

virtually no heart disease!
Monday and Tuesday were long
days in the clinic, working from
08:30 to the last light of the day.
Although it was school holidays,
the local Head Teacher, Mr Ndarasi
Dismas had arranged for local children to return for the day to have a
dental screening and any treatment
needed. Fortunately, about 150 children made the trip back, who then
in a huge surprise performed songs
for the team.
Many children live at the school
to avoid the perilous walk across
the Mara to reach their lessons. Facilities are basic, but clean and safe
with wonderful, enthusiastic teachers. England and the team will be
working with the school in future
to ensure more children are able
to receive an education that costs
$20 per month-insurmountable to

some families on the Mara. St. John
Paul II School receives no government funding and relies solely on
community support and external
donors. Currently 394 children reside at the school, yet there are approximately 2000 children living
in the zone.
Rags to Riches UAE are an amazing
group of volunteers who recycle
bed sheets into reuseable sanitary
pads. These pads help reduce the
stigma of menstruation, allowing
girls to stay in school throughout
the year. Rags to Riches UAE generously donated 270 kits that the
team distributed during this visit.
Clinically, the team experienced
many cases of severe crowding
that, naturally, the children and
their families wanted corrected.
Sadly, this was unachievable at
this time, carious #6 teeth in very

Hasna and Shaima carry out dental hygiene treatment, buckets become
spittoons!

young children and carious #8
teeth in everyone else. Overall, the
clinic carried out 77 extractions, 19
fillings, 26 prophylaxes and dozens
of oral health lessons. St. John Paul
II School received toothbrushes and
toothpaste to ensure all children
would start the year able to brush
twice daily, 270 sanitary packs were
distributed and great friendships
were forged.
The EDHC and Faircare would like
to publicly extend their gratitude
to their generous sponsors: Oral
B, Beverley Hills Formula, Henry
Schein and Colgate.

The next expedition to Aitong will be in
July 2019. For more details and to register your interest, email: maasaimolar@
gmail.com or rachaelenglandrdh@gmail.
com

Enaitoti Hotel staff and the team

09 Nov 2018 | Preliminary Programme

Lisa Hicks registers patients visiting the dental clinic

PROF. ANDREA MOMBELLI
SWITZERLAND

MARY MOWBRAY
NEW ZEALAND

AMANDA GALLIE
UK

DR. PENELOPE JONES
AUSTRALIA

Periodontal Therapy and
Care Today. The Essential
Points for the Dental
Hygienist

Management and
Prevention of Peri Implant
Disease

ICDAS and Caries Risk
Assessment

Sitting is a Health Hazard
— How the Dental Team
Can Prevent and Recover
from the Damage of Poor
Sitting Posture

ROBYN WATSON
AUSTRALIA

DR. NADIA MOHD SALEH
UAE

Tools for Periodontal
Assessment, Diagnosis
and Treatment planning

Oro Facial Pain

SAWSAN JAFFER
ALTHAQAFI
BAHRAIN
Dental Assisting Course,
Establishing Vocational
Health Programs in the
GCC Region

InterContinental Hotel Dubai Festival City
DUBAI, UAE
Part of 10th Dental Facial Cosmetic Conference & Exhibition
ORGANISED BY

IN PARTNERSHIP WITH

Emirates Dental Hygienist's Club

www.cappmea.com/dhs
Dr Jamshed and Zohra meet the Maasai Chief and his son

[52] => DTMEA_No.5. Vol.8_DT.indd

hygiene tribune

Dental Tribune Middle East & Africa Edition | 5/2018

Evaluation of an ex vivo porcine model to
investigate the effect of low abrasive airpolishing

Glycine (1)

Erythritol (1)

Ultrasonics (2)

Hand Instrumentation (3)

Control

By Gregor Petersilka, Ralph Heckel,
Raphael Koch, Benjamin Ehmke,
Nicole Arweiler

using glycine of 25 μm (EMS Perio
Powder, EMS, Nyon, Switzerland).
Group B: Low Abrasive airpolishing
using erythritol powder of 14 μm
EMS PLUS Powder, EMS, Nyon, Switzerland).
- EMS Air Flow Master was used with
a standard handpiece at a distance of
5mm to the gingival tissue in a continuously sweeping way for 5 s like
subgingival biofilm removal
Group C: Piezoceramic scaling using
Perio Slim PS instrument (EMS)
- EMS Piezon Master was used at medium power and water setting
- The instrument was kept parallel to
the root surface at a pressure of approx. 1 N for 10 s
Group D: 7/8 Gracey Curette (Deppeler, Rolle, Switzerland)

- Five strokes of curette applied with
a pressure of approximately 3 N
Group E: Untreated biopsy samples
served as negative control
- Following instrumentation, the soft
tissue alongside the tooth was removed and graded.

Results

Conclusion

- Hand instrumentation had the
most pronounced damage
- Hand instrumentation and ultrasonic scaling caused higher tissue
destruction than both airpolishing
powders
- Ultrasonics was slightly less traumatic than hand instrumentation
with no statistically significant difference
- Between the low abrasive airpolishing powders, glycine showed
slightly lesser destruction, however,
no statistically significant difference
was observed between glycine and
erythritol
- The porcine model is apt for use in
histological evaluation

- Pig jaws could be used to assess
the histological effects of different
instrumentations on periodontal
tissues before conducting studies on
humans
- Low abrasive airpolishing powders
had an overall low potential of soft
tissue damage and could be used
safely to remove biofilm subgingivally.

Aim
To assess the usability of pig jaws
periodontal treatment model for low
abrasive air polishing and to histologically gauge the effect of various
instrumentation techniques.

Material and methods
- From 120 Pig mandibles, the buccal
part of one molar was chosen randomly and fixed in a way allowing
controlled instrumentation.
- Four modes of instrumentation
were evaluated.
Group A: Low Abrasive airpolishing

1 - No lesion: undamaged epithelium
and connective tissue
2 - Minor lesion: disruption of superficial epithelial layers, undamaged
basal membrane
3 - Medium lesion: superficial layers
of the epithelium removed, basal
membrane partially damaged
4 - Severe lesion: epithelium and basal membrane completely removed,
connective tissue exposed

Dr. Fábio Duarte da Costa Aznar
Specialist in Endodontics. HRAC (Centrinho)/USP/Bauru Master’s in Endodontics
SLMandic/Campinas
Coordinator of the Program of Specialization in Endodontics FACESC/Chepecó-SC,
FAIPE/Goiânia-GO & GOE-Macapá

Clinical Oral Investigations, https://doi.org/10.1007/s00784-018-2536-5

Sitting is a health hazard – an innovative way for
the dental team to avoid workplace problems
By Dr. Penelope Jones, Australia

Dr Jones has been teaching her
unique workshops for almost 30
years, both in Australia and internationally. Her workshop has helped
people to prevent and recover from
workplace injuries caused by chronic
poor sitting at work.

We have known for years that dental
offices face a general problem. Millions have been spent trying to address this problem, yet the literature
is still full of articles confirming, “Sitting for long periods increases your
risk of cardiovascular disease, diabetes and even cancer.”

Working Posture uses easy gentle
movement lessons along with good
breathing techniques to allow you to
unwind your old muscular tension
and learn to align yourself with far
better skill. You will learn how to find
good balance with strength as well as
greater flexibility for the fine work of
dentistry. It is easier and more enjoyable than you would imagine and
does not involve strenuous exercise.
It teaches you how to feel and understand good posture from within.

Inroads have been made by members of the dental team by increasing their fitness levels and making a
point of moving around as often as
they can during the day.
Unfortunately, the basic problem
has not been properly addressed.
The problem, as expressed by Dr
Penelope Jones of the “Working
Posture” programme, is how we sit.
Jones has been helping people turn
this around successfully for over 25
years.
Have you ever noticed what happens when you concentrate, need
to perform intricate work or even
just deal with a stressful situation?
You tend to reduce your breathing.
You are unaware of it and, as time
goes on, your breathing muscles (intercostal muscles and diaphragm)
become tighter. As you can imagine,
doing this every day is eventually
going to lead to tighter and tighter
muscles and a more rigid chest. Our
other unconscious responses to
stress are raised shoulders (part of
our natural startle reflex) and shortening our torso at the front (also part
of the reaction to protect ourselves
from emotional stress). At the end

Dr Jones has restored many a dental
career. She is an international speaker and has been teaching in the faculty for over 26 years.
Dr. Penelope Jones, Australia

of the day so many muscles that are
not needed to perform our work are
chronically tight and we feel “uptight”. No surprises there.
These tight muscles are sabotaging
our comfort, and we are completely
unaware of how it happens. We rest
and do exercises and the tightness
relaxes slightly, but in most cases
the muscles never completely relax,
so it is almost as if we are wearing a
neurological strait jacket, even when
we sleep.
These unconscious tight muscles

pull our posture out of alignment
and create chronic pain in our backs,
necks, shoulders and arms.
Posture is not a static thing. Our
nervous system controls which muscles contract and which ones relax, as
well as the timing of this process-it
is a continually adjusting mechanism. Ideally, when the muscles can
continually adjust to the need to dissipate energy from our movements,
we have good posture. But chronically tight muscles do not allow for
this continual adjustment. Great

athletes and martial artists have
trained themselves to do this continual adjustment. They can strike a
fatal blow or a shot with minimum
effort as they are very aware of how
their bodies function.
Dr Jones uses this understanding
and the brilliant tool of neuroplastic
learning to help you find a way to
align yourself from the inside. You
then very quickly become aware
when you are tense and out of alignment, allowing you to correct your
posture.

Dr Jones workshops run mainly in Sydney
in Australia, but she will be lecturing and
running workshops at the CAPPmea conference in Dubai on 10 and 11 November
2018.
Visit www.workingposture.com.au
https://www.youtube.com/
watch?v=xoS7RqcgI8I for more details on
Working Posture.
Visit https://www.cappmea.com/dhs/ for
details on the CAPPmea conference.

[53] => DTMEA_No.5. Vol.8_DT.indd

THE GAME CHANGER
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Apadana Tak

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Imeco

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MAKE ME SMILE.

[54] => DTMEA_No.5. Vol.8_DT.indd

hygiene tribune

Dental Tribune Middle East & Africa Edition | 5/2018

Interview: “BlueM supports the body’s
own healing process”
By Franziska Beier, DTI
Awareness of the importance of oral
care during pregnancy has been increasing, and this is also apparent in
the dental products available today.
Dutch company BlueM, for example,
offers an oral care range that is safe
for pregnant women and children.
Denise Leusink, oral health adviser
at BlueM, spoke to Dental Tribune
International about the rationale behind development of the BlueM line,
its effects on oral health and particular concerns for pregnant women regarding oral care.

Ms Leusink, the founding of
the BlueM brand was somewhat of a coincidence arising
from Fokke Jan Middendorp
sustaining an injury during a
hockey game. Can you elaborate a bit on this story?
Ha, I love this story! Fokke Jan is a
former international hockey player
and one day was injured during a
game. Dr Peter Blijdorp, a maxillofacial surgeon, was watching the game.
He came to Fokke Jan and asked him
if he could apply a gel on his knee to
relieve the pain. It turned out that Peter was determined to achieve a new
and different way of practising dentistry—not one that was unhealthy
or aggressiv e, but one that was gentle on the body. All he wanted for his
patients was minimally invasive surgery, meaning a minimal amount of
pain and the fastest recovery possible. During his quest, he discovered
the power and beneficial effect of
oxygen and developed a gel based
on active oxygen that accelerated
wound healing. Fokke Jan was so enthusiastic that he wanted to help Peter and together they started BlueM.
The first product they launched was
the oral gel, which is the perfected
version of Peter’s oxygen gel.

What was it that motivated
you and your team to develop
the blue m product line?
BlueM is different from other oral
care brands. Peter wanted to make a
difference for his patients and help
as many people as possible with
body-friendly solutions. The realisation of Peter’s dream is what drives
us as the BlueM team. We receive
many, many stories from BlueM users from all around the world and
we are constantly impressed by the
remarkable, almost magical results.
It is both exciting and humbling and
as a team we feel grateful to continue on the journey started by our
founder.

What active agents do the
products contain and how do
they work?
The basis of BlueM is sodium perborate, honey, xylitol and lactoferrin.
Sodium perborate slowly releases
a body-friendly amount of active
oxygen. Oxygen plays a key role in
wound healing because it accelerates the wound healing process.
Active oxygen kills anaerobic bacteria, which are the cause of most
oral problems. Honey is a carrier of
oxygen and has many antibacterial
functions. Xylitol stimulates salivary
flow, helps remineralisation and
kills Streptococcus mutans. Last but
not least is lactoferrin, an immuneboosting protein that stimulates
bone regrowth.

Photo: Nathan Reinds

Does BlueM toothpaste contain fluoride?
We have two toothpastes: one without fluoride and one with 1,000
ppm calcium fluoride. When BlueM
started, we focused on patients with
implants. Fluoride corrodes the titanium surface layer of implants,
which means that one should rather
use fluoride-free toothpaste. Since
many people without implants are
using our products nowadays and
dental professionals asked for a fluoride toothpaste, we created one.

Does the toothpaste contain
sugar because of the added
honey?
The sugar in the biological, cold-extracted honey is converted into water and oxygen when it comes into
contact with liquids. The catalyst in
this process is called glucose oxidase.
The sugar in honey is completely
converted, which means there is no
risk of caries.

Why is this product suitable
for pregnant women?
BlueM supports the body’s own healing process. Because of the products’
natural effects, they are suitable
for long-term use. Other products,
which are mostly chemical, can only
be used for a short period. Blue m
products are safe for children and
pregnant women.

of this correlation might be of
particular concern for pregnant women?

What oral hygiene measures
do you recommend to pregnant women?

Periodontitis causes an increase in
the prostaglandin level, which induces contractions. Studies show
that women with periodontitis have
a two to seven times greater chance
of preterm birth due to this high
level of prostaglandin. It also works
the other way around: treatment of
periodontitis can reduce the chance
of preterm birth.

Make sure that you do not have gingival bleeding! So, brush twice a day
and use toothpicks or interdental
brushes on a daily basis. Especially
during the second trimester, prevalence of gingivitis and anaerobic bacteria increases. That makes it even
more important to work on your oral
hygiene. The BlueM products can be
a great addition to your routine.

That is why it is so important to
be aware of the effects of your oral
health when you are pregnant.

Does BlueM have a unique
position on the dental market
because it specifically offers
oral health products for pregnant women?

Why is the topic of oral care in
pregnant women not as widely discussed as it should be?
I think that many midwives are not
aware of the risk of poor oral health
for the unborn child, as it is not a part
of their protocol. Luckily, I see that
more and more pregnant women
are being referred to dental hygienists by their midwives. This is a good
thing and I believe that this interprofessional cooperation should
become part of the protocol. I truly
hope this awareness grows in the
future.

Gain a child, lose a tooth—
truth or myth?
It is true that many women develop
caries after their pregnancy. During
pregnancy, there are many changes:
fluctuating levels of calcium and
magnesium, altered nutrition resulting from consuming more snacks,
hormone fluctuations and even less
time for oral hygiene. All these external factors can lead to caries. Therefore, I believe it to be a myth because
the development of caries is caused
by many factors beyond pregnancy.

Periodontitis is associated
with systemic diseases such
as diabetes and heart disease.
What adverse consequences

Photo: Nathan Reinds

BlueM products have not been specifically developed for pregnant
women, but it is true that the products are safe to use during pregnancy, in contrast to many other oral
health products.

Do you recommend the use of
BlueM also for non-pregnant
people?
BlueM products have a wide range
of use. We see that blue m is most
commonly used by people with im-

plants, periodontal problems or oral
wounds. Since it accelerates wound
healing, it has many indications.
For example, the elderly use our
oral foam to take care of their gingivae and clean their dentures. Our
oxygen fluid is often used by cancer
patients to support wound healing
after chemo- or radiotherapy.

What sets BlueM apart from
other products?
BlueM supports the body’s own
healing process. That’s unique in oral
care.

Where is the product available, and how much does it
cost?
BlueM is promoted by top dental
professionals in more than 40 countries. You can buy it online, in various
clinics and in many pharmacies. We
have distributors worldwide; for an
overview, see our website https://
www.bluemcare.com/internationaldistribution/. The price ranges from
€5.95 for a mouth spray to €24.95 for
the oxygen fluid, which is a medical
product.

Thank you very much for the
interview.

[55] => DTMEA_No.5. Vol.8_DT.indd

[56] => DTMEA_No.5. Vol.8_DT.indd

A soft
approach
for tough areas.
Enamel is hard. Harder than steel, even.
And it should stay that way. Enamelfriendly brushing means: pampering
your teeth and gums with tender loving
care. Like with the gentle CS 5460 ultra
soft. Mmmm, let’s do that again.

curaprox.com

[57] => DTMEA_No.5. Vol.8_DT.indd

Published in Dubai

September-October 2018 | No. 5, Vol. 8

www.dental-tribune.me

Mastering the implant
digital workflow

SUBSCRIBE NOW
https://me.dental-tribune.com/e-paper/
issn 1868-3207 • Vol. 19 • Issue 3/2018

3/18

implants
international magazine of oral implantology

case report
Minimally invasive implant dentistry

industry
Implant retreatment

interview
Measuring implant stability

Fig. 1: Dental Wings intraoral scanner

Fig. 2: Printed models

Fig. 3: 2-D X-ray

Fig. 4: 3-D X-ray

By Dr Ross Cutts, UK

would be less so than the perceived
iPhone generation.

through shifting workflows in dental
laboratories, even where more traditional clinical practices are followed
chairside. Quite often, wet impressions are poured and stone models
are scanned to produce STL files for
laboratories to process during crown
and bridge unit manufacturing.

ratories can provide these services.
However, having these tools at one’s
disposal greatly increases one’s efficiency and means one is not reliant on external services for one’s
patients.

Whether we like it or not, we are embracing the digital era in our brave
new world. Many dental practices
are now becoming paper-free – a
digital innovation – and even using
tablet computers to record patient
details and medical histories. We are
continually surprised by the rising
age of the technologically savvy patient, particularly those of a certain
generation who perhaps we assume

Fig. 5: CodiagnostiX

Fig. 7: Printed guide and sleeves

This change in the patient demographic and attitude towards technology is filtering through to us in
the dental profession. The nuts and
bolts of implant dentistry tends to
lend itself more readily to the digital revolution of dentistry in the UK
and now globally. Many practitioner
opposed to or reluctant to embrace
it are actually being influenced by it

As an implant clinician, one does
not have to invest in a CT scanner or
chairside intraoral scanner—there
are ways that other centers and labo-

So how do we begin the implant
digital workflow? Successful implant
treatment begins with thorough
case assessment and planning of the
proposed restoration. This is important for all cases, not just what we

Fig. 6: CodiagnostiX surgical guide

Fig. 8: Postoperative radiograph of implant placement

deem the complex ones. Even the
most experienced implant clinician
can miss a potential treatment planning hazard, especially during a busy
day. Accurate study model casts
are an essential part of this; however, we can now use intraoral scans
preoperatively to begin the digital
workflow. We take a scan rather than
impressions to form digital models.
Our laboratory can then use these to
create digital wax-ups of proposed
treatment outcomes.
We are routinely used to 2-D radiographic imaging techniques in dentistry, but with the availability and
access to CBCT scanning devices
now, we are able to assess bone quantity and quality of proposed implant
surgical sites. ith ever-reducing doses
of 3-D imaging and improving accuracy, we are able to use CBCT scans,
combined with clever software packages such as coDiagnostiX (Dental
Wings), to plan safe and accurate
implant placement and restoration.
We are able to preoperatively plan
precise implant placement with safe
surgical margins away from important anatomical structures, such as
the inferior alveolar nerve or maxillary sinus. From this, we are then
able to design and either mill or print
a surgical guide to use for precise implant placement.

ÿPage 2

[58] => DTMEA_No.5. Vol.8_DT.indd

implant tribune

Dental Tribune Middle East & Africa Edition | 5/2018

◊Page 1
If soft tissue-supported, mobility
completely negates any accuracy of
the guide, so it should only be used
for a pilot drill and then a more conventional surgical protocol adopted.
If bone-supported,
· raising of a very large surgical flap
is likely.
· it is very difficult to ensure accurate full seating of a bone-supported
guide in the precise planned position and this relies upon external
fixation.

Fig. 9: Surgical placement of LL67 implants

Fig. 11: Tissue level implants

Fig. 13: Implant crowns in situ

Once the implants are placed in
situ and fully integrated, we then
have a choice of conventional wet
impression techniques versus digital intraoral scanning. For the majority of cases, intraoral scanning
is extremely predictable and reliable—more so than conventional
techniques—with milled (and lately
printed) models having excellent
properties and less accumulation of
processing errors. However, deeply
placed implants relative to adjacent
teeth with deep contact points are
very difficult to scan and pick up.
Straumann tissue level implants offer a very straightforward restorative
platform to scan from.

Fig. 10: Scanbodies in situ

With greater numbers of implants
and fewer teeth to act as reference
points, intraoral scanning becomes
less reliable—particularly across the
arch—so we need to exercise caution
and be aware of its limitations. We
have used composite flow stuck to
the soft tissue to increase reference
points for our scanners, increasing
their ability to stitch images more accurately together. With this in mind,
we cannot assume the scan is accurate and any framework fabricated
would be non-passive; therefore, we
must use other methods to verify
the scan’s accuracy. We have found
locking temporary abutments within a composite framework intraorally the easiest and most reproducible
way to do this. It then allows us to design and mill a truly passive framework by Createch and a temporary
acrylic bridge.

Fig. 12: Crowns on printed model

Fig. 14: Scanbodies with composite flow material to increase scan accuracy

Conclusion
There are many opportunities to
opt in and out of using technology
regarding the digital implant workflow. For anyone considering capital
investment, the most important
question to ask is, how will or can
this improve the outcomes I provide
to my patients, and then determine
whether that warrants the expenditure. Too often are we subjected
to sales pitches of the next biggest
thing by company sales representatives and gadgets and gizmos end up
by the wayside.
Acknowledgements to Andy Morton
and Ian Murch, the fantastic laboratory technicians at Borough Crown
and Bridge that I work closely with.

Fig. 15: Verification jig locked in situ to gain implant passivity

Fig. 16: Createch framework fit surface

Even with assisted surgery or guided
surgery, there are sometimes certain
restrictions that prevent us from
achieving the most ideal implant
placement, such as this case shown
where posterior access in the second
molar region was reduced, so achieving the perfect parallel was extremely difficult.

Fig. 17: Finished screw-retained bridge in situ

There are fully guided systems available that allow for absolutely precise implant placement, but these
ar fraught with complexities and
should be reserved for experienced
clinicians. The accuracy of surgical
guides should not be used to make
up for a lack of surgical competency
however.

There are many factors to be considered when using surgical guides, including whether the guide is tooth,soft tissue- or bone-supported.
Tooth-supported allows the greatest
degree of accuracy.
If tooth-supported, · are there windows in the guide that direct full
seating of the guide?
· are the teeth that support exact positioning of the guide mobile? Any
mobility adds a degree of inaccuracy.
· is the guide made from a direct
intraoral scan or a scan of a study
model? If scanning a study model,
is this an accurate stone model representation? Otherwise, there is the
risk of poor seating and inaccuracy
of the guide.

Editorial note:
This article was published in the
2/2018 issue of CAD/CAM_international magazine of digital dentistry.

Dr Ross Cutts
He is the principal dentist at Cirencester
Dental Practice in Cirencester in the UK.
He can be contacted at cuttsrg@aol.com.

[59] => DTMEA_No.5. Vol.8_DT.indd

implant tribune

Dental Tribune Middle East & Africa Edition | 5/2018

Astra Tech Implant System
and Atlantis Case report
By Prof. Clark M. Stanford, USA &
Ass. Prof. Gustavo Avila-Ortiz, USA
Single tooth immediate placement
using the Astra Tech Implant Sys-

tem EV and Atlantis Abutment. The
patient presented with a fractured
maxillary right lateral incisor (#12)
with a dislodged endodontic post.
Due to crown-to-root ratio and short

remaining root, extraction and immediate implant placement was
elected. Care was provided with an
OsseoSpeed EV 3.6 diameter implant
placed towards the palate following

the 3x2 rule. Following eight weeks
of healing, stage-II was performed
and the final restoration completed
within six weeks using an Atlantis
Abutment in gold-shaded titanium

with concave emergence shape selected. The final crown was an allceramic zirconia crown.

Fig. 1: Clinical pre-treatment situation. Root fracture on maxillary right
lateral incisor.

Fig. 2: Radiographic image of the pre-treatment situation.

Fig. 3: Immediate implant placement after tooth extraction starting
with the Twist Drill EV Ø1.9.

Fig. 4: Direction Indicator EV showing the forthcoming position of the
implant.

Fig. 5: Implant placement using Implant Driver EV 3.6.

Fig. 6: OsseoSpeed EV 3.6 S x13mm placed in the correct position.

Fig. 7: Radiographic image after implant placement showing the OsseoSpeed EV 3.6 S x13mm placed epicrestally with a Cover Screw EV 3.6.

Fig. 8: Stage-II was performed after eight weeks of healing. A triangular
HealDesign EV 3.6 Ø5-3.5mm is placed in the implant.

Fig. 9: The triangular design pre-shapes an esthetic profile for the final
restoration.

Fig. 10: The self-guiding Implant Pick-Up EV 3.6 is used for
impression taking.

Fig. 13: Atlantis Abutment
in situ after six weeks of additional healing. The oneposition-only indexing feature simplifies the abutment
placement.

Fig. 14: Radiographic image
after placement of the Atlantis
Abutment and the crown.

Fig. 15: All-ceramic crown
(ZrO2) after three months.

Fig. 11: Implant Replica EV 3.6 is connected to the Implant Pick-Up in the
impression material.

Fig. 12: An Atlantis Abutment in
gold-shaded titanium is ordered
through Atlantis WebOrder.

Fig. 16: Anterior incisal plane and final clinical appearance three months after installation.

[60] => DTMEA_No.5. Vol.8_DT.indd

Dentsply Sirona does not waive any right to its trademarks by not using the symbols ® or ™. 32670635-USX-1612 © 2016 Dentsply Sirona. All rights reserved.

Astra Tech Implant System®

Simplicity without
compromise
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– Unique interface with one-position-only placement
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[61] => DTMEA_No.5. Vol.8_DT.indd

PUBLISHED IN DUBAI

September-October 2018 | No. 5, Vol. 8

www.dental-tribune.me

New study: 7 percent of
children in orthodontic care at
risk for sleep disorders

Photograph: Africa Studio/Shutterstock

By DTI
CLEVELAND, Ohio, U.S.: Researchers at Case Western Reserve University’s School of Dental Medicine have
found that about 7 percent of children between ages 9 and 17 in orthodontic care are at a high risk for sleepdisordered breathing. This disorder
can lead to restlessness, hyperactivity and concentration problems.
For the study, 303 children or their
parents completed a questionnaire
about sleep and symptoms. About
7 percent responded with enough
“yes” answers to put them at a high
risk for sleep-disordered breathing.
“The rate is higher than we expected,” said Prof. J. Martin Palomo, a
professor in the Department of Orthodontics at the dental school, and
senior author of the study. The researchers note that sleep-disordered
breathing in children may be underrecognized and underreported. They
also suggest that the same portion
of adolescents in orthodontic care in
the general population could similarly be at risk.
However, according to Palomo, orthodontists are well-positioned to
help affected patients because they
see children whose facial development or jaw alignment has been
impacted by breathing problems.
When spotting a potential problem,
they can make a referral to a sleep
specialist.

When adults get tired, they typically
show signs of sleepiness: yawning,
heavy eyelids and sitting down to
rest. In contrast, children tend to get
hyperactive. They also might snore,
breathe through the mouth during
the day, awake with dry mouth or
become easily distracted.

DUBAI | UAE 6-8 DECEMBER
PALAZZO VERSACE

Palomo hopes the study will help educate both the public and orthodontists. He also believes, based on published reports, that many children
with sleep disorders are misdiagnosed with attention deficit hyperactivity disorder (ADHD), given that
the symptoms of both are strikingly
similar. “I think it’s important to rule
out sleep disorders before a patient is
medicated for ADHD,” he added.
The study, titled “Sleep disordered
breathing in children seeking orthodontic care”, was published in the
July 2018 issue of the American Journal of Orthodontics and Dentofacial
Orthopedics.

DR. SONIA PALLECK

DR. MATIAS ANGHILERI

DR. BILL DISCHINGER

DR. SKANDER ELLOUZE

DR. ANMOL KALHA

DR. BADER BORGAN

DR. FIRAS HAMZEH

DR. KIRILL ZERNOV

Featuring Six Hands-On Workshops

SUBSCRIBE NOW
https://me.dental-tribune.com/e-paper
issn 1868-3207

OUR SPEAKERS

Estimated 18 CE Credits (ADA CERP)/ 18 CME HAAD/ 15 CME DHA

Vol. 2 • Issue 2/2017

ortho
international magazine of

orthodontics

2017

“Sleep is a tightly regulated and
well-organized biologic process affecting daily functioning as well as
physical and mental health,” Palomo
said. “Sleep, or a lack of sleep, affects
adults and children differently.”

Sleep-disordered breathing describes several conditions—including apneas—characterized by abnormal breathing patterns.

Tongue star 2 (TS2) –
System for rapid open bite closure

case report
Use of diode laser in the treatment of gingival
enlargement during orthodontic treatment

industry report
Sensorimotor training with RehaBite
during orthodontic treatment

early bird fees starting $550
(until 30 September 2018)
normal fee starting $650
(after 30 September 2018)

For more information, please contact :
marketing.emeai@ormco.com
For hotels, visa and other registration
information, please contact:
ormco2018@teamtroika.net
+971 50 879 9035

[62] => DTMEA_No.5. Vol.8_DT.indd

2

ORTHO tribune

Dental Tribune Middle East & Africa Edition | 5/2018

Insignia Resolves Adult Open Bite with
Straight-Wire Finishing
Case study
INITIAL

By Dr. David González Zamora,
Spain

Pretreatment Diagnosis
Adult female, mesofacial, skeletal class I, open bite. Patient suffered
Insignia
Adult
Open Bite with Straight-Wire Finishing
fromResolves
frequent
headaches.
™

™

FINAL

Treatment Plan Objectives
Close her open bite while maintaining vertical
relationship of upper anterior incisors.

Appliance Used
Insignia SL

FINAL

Treatment plan notes submitted with this case:
• Insignia Archform
• Laterals should be shorter than centrals
• Align marginal ridges
• 3mm of overbite
• Expansion through molars and premolars
• IPR between premolars
TREATMENT SEQUENCE
TREATMENT
SEQUENCE
Appointment

Archwire

Notes

1

U: .014 Damon CuNi-Ti*
L: .014 Damon CuNi-Ti*

Bonding
Triangle elastics

2
Week 10

U: .014 x .025 CuNi-Ti
L: .014 x .025 CuNi-Ti

Triangle elastics

3
Week 22

U: .018 x .025 CuNi-Ti
L: .018 x .025 CuNi-Ti

Triangle elastics

4
Week 34

U: .018 x .025 CuNi-Ti
L: .018 x .025 CuNi-Ti

Triangle elastics
Rebond 27

5
Week 38

U: .019 x .025 SS
L: .019 x .025 SS

Anterior box elastics

6
Week 46

U: .019 x .025 SS
L: .019 x .025 SS

Triangle elastics
Anterior box elastics
Elinks to close spaces

7
Week 57

U: .019 x .025 SS
L: .019 x .025 SS

Triangle elastics
Anterior box elastics
IPR 2-2
Elastic chain 3-3
Occlusal adjustment

8
Week 62

U: .019 x .025 SS
L: .019 x .025 SS

Debonding
Fix retainer 2-2, 3-3
Occlusal splint

INITIAL

*Stock round wire
Appointment photos featured in this case study

APPOINTMENT 3 | 2 WEEKS

24 vol. 20 | no. 01 | summer 2017

FINAL 62 WEEKS
ormco.com/ci

APPOINTMENT 7 | 57 WEEKS

Treatment Discussion
The patient had a complete open
bite due to the habit of atypical swallowing.

molars and molars. The key to making a bite close quickly and easily is
applying forces mesial to the arcade
center of resistance, just so get a rotation of both occlusal planes.

of cementation. The patient also
followed a rehabilitation treatment
neuromuscular speech pathologist,
to ensure the future stability of the
case.

To perform a bite closure, it is necessary to achieve perfect alignment
and leveling of the teeth as well as
obtaining accurate torque. Only then
can we face the upper and lower occlusal planes. In addition, the two
arches have been expanded at pre-

Despite using an extrusive mechanics with previous elastics, you can see
in the photo finish smile that the relationship of the upper incisors has
not worsened, thanks to the relative
position of the brackets at the time

Finishing Notes
No debonds, no wire bends. Just occlusal adjustment.

[63] => DTMEA_No.5. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 5/2018

ORTHO tribune

Use of diode laser in the treatment of gingival
enlargement during orthodontic treatment
Case report
By Prof. Carlo Fornaini, Drs Aldo Oppici, Luigi Cella & Elisabetta Merigo,
Italy

Introduction
In recent decades, we have witnessed
the substantial development and
expansion of the use of fixed orthodontic appliances. While their application has many advantages, several
problems related to the health of the
soft tissue may sometimes appear
during treatment. In fact, the use of
fixed orthodontic appliances may
provoke labial desquamation,1 erythema multiforme,2 gingivitis3 and
gingival enlargement.4
Gingival enlargement is a very common complication during orthodontic treatment,5 but fortunately, it
seems to be transitory and generally
resolves after orthodontic therapy,
even if sometimes incompletely.
Gingival overgrowth induced by orthodontic treatment shows a specific
fibrous and thickened gingival appearance, different from fragile gingiva with marginal gingival redness
common in allergic or inflammatory
gingival lesions.6
Several clinical studies suggest that
orthodontic treatment may be associated with a decrease in periodontal
health, causing a hypertrophic form
of gingivitis. However, the actual
pathogenesis of gingival enlargement is not yet completely understood, although probably involves
increased production by fibroblasts
of amorphous ground substance
with a high level of glycosaminoglycans. Increases in mRNA expression
of Type I collagen and up-regulation
of keratinocyte growth factor receptor could play an important role in
excessive proliferation of epithelial
cells and increased development of
gingival enlargement, on the basis
of some studies, in cases of poor oral
hygiene status.7 However, there is no
clear definition on its aetiology, although it is probably associated with
the inflammatory response induced
by the corrosion of orthodontic appliances, particularly those of nickel,8
linked to an inflammatory response
considered a Type IV hypersensitivity and manifested as nickel-induced
allergic contact stomatitis, even if its
aetiology has not yet clearly been defined.9
The treatment of these conditions
is surgical. Histological and histochemical studies have demonstrated
that the removal of the gingival papilla can promote the formation of
normal connective tissue.10 Because
the classic intervention performed
by scalpel has some disadvantages,
mainly linked to the discomfort for
the patient (e.g. anaesthesia by injection and sutures), there has been
great interest in the utilisation of laser technology.

Case report
A 14-year-old female patient was referred to our department by the orthodontics unit because, at the end
of fixed orthodontic treatment, she
had developed gingival enlargement
in the upper arch (Fig. 1), probably related to the fast closure of the spaces
associated with very poor oral hygiene due to bleeding during tooth-

Fig. 1: Clinical view, showing gingival enlargement, just
before the debonding procedure.

Fig. 2: Application of a topical anaesthetic.

Fig. 3: Surgical laser-assisted treatment via laser gingivectomy.

Fig. 4: Clinical view just after surgery.

Fig. 5: Healing five days after surgery.

Fig. 6: One month follow-up.

brushing. Just after the removal of
the appliance, a topical anaesthetic
(EMLA, AstraZeneca) was applied to
the gingivae (Fig. 2) and a gingivectomy was performed using a diode
laser (XD-2, Fotona) according to the
technique of removal of the inter
dental papillae (Fig. 3). The parameters used were as follows: a wavelength of 808 nm, 3 W in continuous wave, a 320 μm fibre in contact
mode. The intervention had a duration of 375 seconds, and the patient
did not feel any pain (Fig. 4). After the
intervention, the patient did not take
any kind of pain medication, and the
healing process was completed in
five days (Fig. 5).

Diodes, the last generation of laser
used in dentistry, have several advantages, such as reduced cost and
size, and offer the operator the possibility to work both in continuous
and chopped mode. Based on our

experience, we can confirm that this
technology may represent a new approach to the resolution of gingival
enlargement during orthodontic
treatment, with better comfort for
the patient during and after surgery.

Discussion
The first laser appliance was built
by Maiman in 1960, and some years
later, it was successfully employed
in medicine and in oral surgery with
several advantages. It may provide
excellent incision performance with
sealing of small blood and lymphatic
vessels, resulting in haemostasis
and reduced postoperative oedema.
Furthermore, target tissues are disinfected as a result of local heating
and production of an eschar layer,
which results in a decreased amount
of scarring owing to decreased postoperative tissue shrinkage, allowing
one to avoid the use of sutures.

AVAILABLE SOON
Prof. Carlo Fornaini
He is a lecturer at the MICORALIS Laboratory of the Côte d’Azur University in Nice,
France. carlo@fornainident.it
Dr Elisabetta Merigo
She is a lecturer at the MICORALIS Laboratory of the Côte d’Azur University in Nice,
France. elisabetta.merigo@gmail.com

Just scan the QR code and to get further details.

Dr Aldo Oppici
He is the Head of “Special Needs and
Maxillofacial Surgery Unit” of the “Guglielmo da Saliceto” hospital in Piacenza,
Italy. A.Oppici@ausl.pc.it
Dr Luigi Cella
He is a maxillofacial surgeon at the “Special Needs and Maxillofacial Surgery Unit”
of the “Guglielmo da Saliceto” hospital in
Piacenza, Italy. L.cella@ausl.pc.it

Editorial note:
This article was originally published
in the 2/2017 issue of ortho_international magazine of orthodontics.
A list of references is available from
the publisher.

ormco.eu

[64] => DTMEA_No.5. Vol.8_DT.indd

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[cover] => DT Middle East & Africa No. 5, 2018

[toc] => Array ( [0] => Array ( [title] => Celebrating 10 years of Dental Facial Aesthetics over 6 days – Dubai Dental Week November [page] => 01 ) [1] => Array ( [title] => News [page] => 02 ) [2] => Array ( [title] => Implant-based all-ceramic restoration using 3M Impregum Penta Polyether Impression Material [page] => 04 ) [3] => Array ( [title] => Industry [page] => 06 ) [4] => Array ( [title] => New Technologies—to improve root canal disinfection [page] => 12 ) [5] => Array ( [title] => Long-term clinical success in the management of compromised intertooth spaces utilizing small-diameter implants [page] => 14 ) [6] => Array ( [title] => Sticks to the teeth – not the instruments [page] => 16 ) [7] => Array ( [title] => Efficiency and esthetics in the posterior region [page] => 18 ) [8] => Array ( [title] => Chairside CAD/CAM immediate restorations [page] => 20 ) [9] => Array ( [title] => Restoring function and aesthetics with monolithic zirconia restorations [page] => 24 ) [10] => Array ( [title] => Anterior restorations with CAD/CAM veneers made of VITABLOCS Triluxe forte [page] => 28 ) [11] => Array ( [title] => Interview: “I believe that innovation is the engine of a company” [page] => 30 ) [12] => Array ( [title] => Interview: “Clear, step-by-step instructions are essential for long-term success” [page] => 32 ) [13] => Array ( [title] => News [page] => 34 ) [14] => Array ( [title] => Distributors [page] => 38 ) [15] => Array ( [title] => Endo Tribune Middle East & Africa Edition No. 5, 2018 [page] => 41 ) [16] => Array ( [title] => Lab Tribune Middle East & Africa Edition No. 5, 2018 [page] => 45 ) [17] => Array ( [title] => Hygiene Tribune Middle East & Africa Edition No. 5, 2018 [page] => 49 ) [18] => Array ( [title] => Implant Tribune Middle East & Africa Edition No. 5, 2018 [page] => 57 ) [19] => Array ( [title] => Ortho Tribune Middle East & Africa Edition No. 5, 2018 [page] => 61 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

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