DT Middle East and Africa No. 3 (May-June), 2015

DT Middle East and Africa No. 3 (May-June), 2015

Dental Tribune MEA/CAPPmea - IDS Cologne success story / Henry Schein at IDS: Everything for digital dentistry / Bulk fill restorations in the posterior area / Interdisciplinary approach in aesthetic dentistry / From everyday dentistry to advanced photoacoustic endodontic applications (PIPS): Er:YAG & Nd:YAG dual wavelength laser / Total-etch vs. Self-etch adhesives a case-dependent choice / Establishing good oral care habits from the very first tooth / Beverly Hills Formula reveals the secrets of whitening toothpastes! / Impeccable esthetic results with ceramic restorations / New trends in restorative dentistry. Approach to posterior restorations. / The passive abutment / Super-high translucent zirconia Ceramill Zolid FX for highly aesthetic anterior and posterior restorations / Interview with Abdo Salem - Amann Girrbach Sales Manager MEA / The new dental care system proven to reverse the enamel erosion process / Clinical case study: esthetic anterior restoration with VITA SUPRINITY / Have fun everyday / The first ISO 9001 certified dental centre / Immediate implant placement long term success: a case report / Versailles dental clinic news / Midline diastema closure with direct-bonding restorations / Current guidelines for the use of nitrous oxide inhalation analgesia/anxiolysis in pediatric dentistry / CAPPMEA 10 Years' Anniversary / Endo Tribune / Practice Management / Industry / International Dental Show 2015 / Hygiene Tribune Middle East & Africa Edition / 10th CAD/CAM & Digital Dentistry International Conference

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Printed in Dubai

www.dental-tribune.me

Hygiene Tribune
Over 100 countries
celebrate World Oral
Health Day

Lab Tribune

10th CAD/CAM INT’L CONFERENCE
Happy 10th Birthday CAPPmea

2nd Dental Technician Forum
2016 Singapore
(Part of IDEM 2016)

CAD/CAM Digital Dentistry
in a milestone year

Organized by
Koelnmesse & CAPPmea

>Insertion

May-June 2015 | No. 3, Vol. 4

>Insertion

Dental Tribune MEA/CAPPmea - IDS Cologne
success story
By Dental Tribune MEA / CAPPmea

UBAI, UAE: The Dental Tribune
MEA license owner – Centre for
Advanced Professional Practices
(CAPPmea) - were amongst the “movers
and shakers” in the dental market during the 36th International Dental Show
(IDS), which took place in Cologne,
Germany, on 10-14 March 2015. The
event has become the biggest and most

successful “dental show” for all major
players in the field, including its organizer - Koelnmesse, dental industry representatives and other dental professionals
tasted the “newest spices” of the dental
development cuisine at IDS Cologne.
In the year of its 10th Anniversary, and
prior to the 10th CAD/CAM & Digital Dentistry International Conference, CAPPmea travelled to Cologne, for a 10-day

The Cologne cathedral

mission, to represent globally the Middle
East dental society, at the 36th International Dental Show and the 11th DTI Annual Publishers Meeting. CAPPmea provided information on its latest Continuing
Dental Education events in the Middle
East & Asia and distributed 2,500 up to
date publications of Dental Tribune MEA
at the 100m2 DTI Media Lounge stand
(D66/F65) situated in hall 4.1.
11th DTI Publishers Meeting 2015
As an IDS tradition, the DTI Annual Publishers meeting was held for the 11th
time. All 96 publishers from the DTI family came together at Hilton Dom Hotel
for the two days meeting. The 11th Annual Publishers Meeting welcomed attendees from Australia, the U.S.A., the
Middle East and many other countries.
DTI’s CEO, Torsten Oemus opened the
meeting with a motivational speech presenting the achievements of the last year
of all the partners. Together the group
evaluated, planned and strategized approaches. Amongst new projects of the
partners Dental Tribune MEA / CAPPmea
introduced two new innovative items:
‘Referral Clinic section’ and ‘Digital enewspaper’ incorporating the print publication as a digital copy into the e-newsletters. The 2015 Publishers Meeting helped
strengthen the global DTI platform and
announced plans for the coming years to
work in cooperation with the entire publishing group. Amongst the main subjects
discussed were the globalization process,
the digitalization of dental practices and
laboratories and the relevance of on-line
education and e-commerce for dentistry.
Dental Tribune International and its partners will continue to follow this path. On
its part, Dental Tribune MEA / CAPPmea
will join forces in asserting the same
trends for the MEA region in the coming
years.

> Page 25

NEWS
Henry Schein at IDS
Read more...

2
39

restorative
Bulkfill case
4
Read more...
5, 10-11, 14, 16-17

MEDIA CME
Interdisciplinary approach...
Read more...

6-7
8-9

oral health
Establishing good oral care...
Read more...

12
13

implant TRIBUNE
The passive abutment
Read more...

19
20-21

referral clinic
Have fun everyday
29
Read more...
30-32

pediatric TRIBUNE
Current guidelines for the use of ...
Read more...

36
45

endo tribune
FKG Dentaire launches first...
Read more...

40
41

practice management
The first impression is the final...
Read more...

ids

42
43

2015

Bigger than ever: IDS 2015...
46
Read more...
47-50

[2] =>

2 news

Dental Tribune Middle East & Africa Edition | May-June 2015

Henry Schein at IDS:
Everything for digital dentistry

Group Editor

Daniel Zimmermann
newsroom@dental-tribune.com
Tel.: +49 341 48 474 107
Clinical Editor

Magda Wojtkiewicz

Online Editor
social media manager

By Dental Tribune International

Claudia Duschek

OLOGNE, Germany: In
2013 the Henry Schein
launched an umbrella
brand, ConnectDental, bringing together the range of digital
products and services needed
to connect dental practices and
laboratories while integrating
open CAD/CAM systems and
materials. Tuesday’s IDS press
conference confirmed once
more that this is the only way to
establish a future-proof practice
and laboratory structure. It also
provided an overview of present
market developments, including
a strategic outlook on current
and future trends in dentistry.
According to Stanley M. Bergman, Chairman of the Board
and CEO, Henry Schein, the
truly relevant question to ask in
this context is, why not? After all,
this is what was in the minds of
Esther and Henry Schein when
they founded their company to
occupy a key position between

editorial assistants

Anne Faulmann
Kristin Hübner

Copy Editors

Sabrina Raaff
Hans Motschmann

Publisher/President/CEO

Torsten Oemus

Chief Financial Officer

Dan Wunderlich

Chief technology Officer

Serban Veres

Business Development Manager

Claudia Salwiczek

Junior Manager Business
Development

Sarah Schubert

Stanley M. Bergman, Chairman of the Board and CEO of Henry Schein, provided information on Henry Schein’s history
and future development. (Photograph: Claudia Duschek, DTI)

project manager online

Martin Bauer

Event Manager

the current health market and
the idealised vision they sought
to create. Now, the time has
come for practices and laboratories to demonstrate similar
courage and to view digitalization as a real opportunity.

In this context, Henry Schein
offers two concepts for complete digitalization of practice
work flows: ConnectDental and
CEREC+. Both concepts are entirely structured to deliver efficiency and profitability, and

are therefore trendsetting tools
in the hands of practices and
laboratories. The ConnectDental workflow brings together
the various digital system components to produce an open solution, covering 3-D diagnosis,
digital impressions, implant
planning and model production
using 3-D printers, while also
incorporating design and manufacture for restorative surgery
using grinding and milling machines.
Andreas Meldau, President,
European Dental Group, Henry Schein, and Managing Director, Henry Schein Dental
Deutschland, emphasised the
absolute prioritisation of continuous development for the
efficient treatment of patients.
“360°— digitale Zahntechnik
gestalten [shaping digital dental technology]”— this theme
describes a first-of-a-kind event
scheduled for June that is intended to offer laboratory owners and management, as well
as their customers, a 360° view
of the systems, components and
materials that are part of the
digital workflow. The event will
place particular importance on
providing a variety of perspectives: digital solutions according
to practices, the dental laboratory perspective and the academic
viewpoint. The two-day event
presented by Henry Schein will
feature speakers from the world
of science, practices, laboratories and industry, who will share
information on the opportunities
and limits of digital manufacturing technologies.
Attendees of the IDS are invited
to pencil in the 360° congress
scheduled for June.
Henry Schein, one of the world’s
leading providers of products
and services for doctors, dentists
and veterinarians is at the vanguard of progress in the establishment of new concepts in the
health care sector.

Lars Hoffmann

Marketing & sales Services

Nicole Andrä

Event Services

Esther Wodarski

Accounting services

Karen Hamatschek
Anja Maywald
Manuela Hunger

Media Sales Managers
Matthias Diessner (Key Accounts)
Melissa Brown (International)
Antje Kahnt (International)
Peter Witteczek (Asia Pacific)
Weridiana Mageswki (Latin America)
Maria Kaiser (USA)
Hélène Carpentier (Europe)
Barbora Solarova (Easten Europe)
Executive Producer

Gernot Meyer

advertising disposition

Marius Mezger

Dental Tribune International

Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48 474 302
Fax: +49 341 48 474 173
www.dental-tribune.com
info@dental-tribune.com
DENTAL tribune Asia Pacific ltd.

Room A, 20/F
Harvard Commercial Building
105–111 Thomson Road, Wanchai, HK
Tel.: +852 3113 6177
Fax: +852 3113 6199
The America, llc

116 West 23rd Street, Ste. 500, New York
N.Y. 10011, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185
Dental Tribune mEA
Edition Editorial Board

Dr. Aisha Sultan Alsuwaidi, UAE
Dr. Ninette Banday, UAE
Dr. Nabeel Humood Alsabeeha, UAE
Dr. Mohammad Al-Obaida, KSA
Dr. Meshari F. Alotaibi, KSA
Dr. Jasim M. Al-Saeedi, Oman
Dr. Mohammed Sultan Al-Darwish
Prof. Khaled Balto, KSA
Dr. Dobrina Mollova, UAE
Dr. Munir Silwadi, UAE
Dr. Khaled Abouseada, KSA
Dr. Rabih Abi Nader, UAE
Dr. George Sanoop, UAE
Aiham Farrah, CDT, UAE
Retty M. Matthew, UAE
Partners

Emirates Dental Society
Saudi Dental Society
Lebanese Dental Association
Qatar Dental Society
Oman Dental Society
Director of mCME

Dr. Dobrina Mollova
mollova@dental-tribune.me
Tel.: +971 50 42 43072
DIRECTOR

Tzvetan Deyanov
deyanov@dental-tribune.me
Tel.: +971 55 11 28 581
Designer

Kinga Romik
k.romik@dental-tribune.me

[3] =>

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[4] =>

4 restorative

Dental Tribune Middle East & Africa Edition | May-June 2015

Bulk fill restorations in the posterior area
By Dr. Abubakar Sheikh, Pakistan

ntroduction
Traditionally cavities in posterior teeth were generally
filled with amalgam. With the
advent of direct composites this
approach gradually changed,
but there were quite a few challenges that had to be overcome.
These challenges included reducing polymerization shrinkage and postoperative sensitivity, achieving tight contacts in
posterior teeth and sufficient
strength in load bearing areas.
With the improvement in adhesive bonding systems and composite materials most of these
challenges were addressed but
still it has always been recom-

mended to place composite in
increments due to a variety of
reasons. These include penetration of curing light to a limited
depth and placing composite in
increments will help reduce the
effect of polymerization shrinkage to a certain degree. From
a clinician’s point of view this
approach is certainly time consuming and there has always
been a desire to fill the cavity in
a single increment and get the
job done as fast as possible.
Considering the demand of the
dental practitioners, manufacturers such as 3M, have now
introduced bulkfill composites
which can be placed in cavities in a single increment and
yet can be cured effectively and

have good adaptability and reduced shrinkage. We tried bulkfill material in a clinical case in
which 3 posterior cavities were
filled with Filtek™ Bulk Fill Posterior composite.
Clinical Case
A female patient presented with
multiple cavities in her teeth.
There was a moderate sized cavity in the first molar, the first premolar had a large distal carious
lesion and the second premolar
had caries mesially. We decided
to manage the 3 adjacent large
cavities in her posterior teeth in
4th quadrant with bulkfill composite in a single appointment.
Fig. 1 to Fig 13.

About the Author

Conclusion
Previously with composites being placed in multiple increments, it would have been quite
time consuming and tedious to
do a number of such restorations in a single appointment.
Certainly bulkfill composites
made the job easier. Their handling and manipulation with
instruments are also quite user
friendly. With the composites
being applied in a single increment, an ideal shade match
might not be possible in all situations but in posterior restorations the effect can be masked to
a certain degree. Overall I would
say that bulkfill composites will
definitely speed up the work and
make things easy for the clinician.

Dr. Abubakar Sheikh
Associate Professor Operative
Dentistry & Head of Dept. of Endodontics & Supervisor for Fellowship Program for postgraduate
students in Fatima Jinnah Dental
College.
Practice owner and Specialist in
Restorative Dentistry at Dr. Abubakar’s Specialist Dental Practice.
Specialist in Restorative Dentistry
at Fatima Jinnah Consulting Clinics.

Fig. 1. Initial case 1: 44 large carious lesion distally, 45 large carious lesion mesially, 46 moderate size lesion occlusally.

Fig. 5. Single Bond Universal adhesive being
applied in the molar cavity.

Fig. 6. Single Bond Universal application in all
cavities.

Fig. 7. Adaptation of Filtek™ Bulk Fill Posterior
composite after completely placing in molar
cavity.

Fig. 8. Occlusal anatomy being carved on the
molar surface.

Fig. 9. Anatomy being carved after complete
filling of Filtek™ Bulk Fill Posterior composite
in both premolars.

Fig. 10. Finishing of the restorations.

Fig. 11. Polishing with 3M Spiral Polishing disc
and diamond polishing paste.

Fig. 12. Restorations after finishing and polishing.

Fig. 13. Completed restorations.

Fig. 2. Isolation of the affected teeth with rubberdam.

Fig. 3. Caries has been removed and cavities
prepared. Premolars have been separated by
sectional matrices and wedge.

Fig. 4. Selective etching done on enamel margins.

[5] =>

3M, ESPE, Elipar, Filtek and Sof-Lex are trademarks of 3M or 3M Deutschland GmbH.
© 3M 2015. All rights reserved.

Oneand done.
One step placement. One innovative material.
No expensive dispensing device.
No time-consuming layers.
Posterior restorations made simple.
and easier—however, productivity can be lost when using complicated
layering techniques or expensive dispensing devices. Filtek™ Bulk Fill
Posterior Restorative was designed to improve productivity by allowing
one-step placement up to 5 mm … as easy as “one and done.”

Filtek

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www.3Mgulf.com/espe

[6] =>

6 mCME

Dental Tribune Middle East & Africa Edition | May-June 2015

Interdisciplinary approach in aesthetic dentistry
mCME articles in Dental Tribune have been approved by:
HAAD as having educational content for 2 CME Credit Hours
DHA awarded this program for 2 CPD Credit Points

CAPPmea designates this activity
for 2 continuing education credits.

dontics and restorative or orthognathic surgery (Le Fort type I);
(c) Category 3: more than 8 mm
of gingival display, treated with
orthognathic surgery with or
without periodontal and restorative treatment.

By Dr. Sebastian Ercus, Belgium

ntroduction
In today’s dentistry, for rendering the best comprehensive dental services to our aesthetically driven patients, the
paradigm has shifted to an interdisciplinary team of specialists that work together steered
by a clinical co-ordinator. This
person should be either a multicompetence general dentist or a
specialist with additional training outside his or her specialty
area. This gives him or her the
ability to bring the surgical, orthodontic, restorative and technical teams together as a whole,
following treatment sequences
customised especially for the patients’ best interests and expectations.

Fig. 1. The level of the maxillary central incisors in the relaxed position
(2–4 mm in women and 1–2 mm in
men).

Fig. 2. A maximum of 2 mm from the
incisal edge to the lower lip during
smiling, example 1.

Fig. 3. A maximum of 2 mm from the
incisal edge to the lower lip during
smiling, example 2.

Fig. 4. The middle third of the maxillary central incisor should be perpendicular to the occlusal plane.

Fig. 5. Evaluating width to length
ratios.

Fig. 6. Altered passive eruption. The
enamel could be exposed by a gingivectomy in one appointment.

The challenge is making the
correct diagnosis and selecting
the appropriate treatment regimen. In order to achieve that,
the clinician has to follow certain guidelines and understand
the relations between teeth and
the adjacent structures. Establishing the correct position of
the incisal edge of a maxillary
central incisor in relation to
the lower lip, the correct ratios
between the tooth’s width and
length, and the level of gingival
margin when smiling are very
powerful diagnostic tools.

the gingival margin is located
incisal to the CEJ. Treatment
options depend on the amount
of attached gingiva and the position of the bone relative to
the CEJ (as a general rule, the
biologic width should be a minimum of 2 mm):
(a) gingivectomy;
(b) osseous resection (ostectomy) with or without flap surgery (without a flap, it is difficult
to control the osseous contour
driven by the new gingival margin);
(c) apically repositioned flap.

with osseous resection.

ly with crown lengthening only
or crown lengthening combined
with orthodontic intrusion of
mandibular incisors and possible minimally invasive restoration of maxillary teeth.

In order to aid memory, one may
remember it as the 42.2 rule:
(a) a maximum of 4 mm of
maxillary central incisor display
when the lips are at rest (a minimum of 2 mm; Fig. 1);
(b) a maximum of 2 mm of gingival display during smiling;
(c) a maximum of 2 mm from
the incisal edge of the maxillary
central incisor to the lower lip
during smiling (Figs. 2 & 3); and
(d) the middle third of the maxillary central incisor should be
perpendicular to the occlusal
plane and the incisal edge
should touch the plane (± 0.5
mm; Fig. 4).

2. Altered active eruption when
the osseous crest does not resorb to a level 2 mm apical to the
CEJ. The gingival margin is still
located incisal to the CEJ. This is
treated with periodontal surgery

The correct ratio between the
width and length of a maxillary
central incisor is 78 to 80 per
cent. With the incisal edge position already determined, we can
identify the position of the gingival margin (Figs. 5 & 6).

Fig. 7. Lower third smile showing
altered passive eruption.

Fig. 10. Lower third full smile design.

3. Compensatory eruption when
the tooth surface is lost, with the
reduction in facial height or vertical dimension of occlusion unaffected (short tooth syndrome).
Treatment is either restorative
or, in the case of hypermobility
of the lip, combined with a coronally positioned mucosal flap.
4. Delayed eruption followed
by early loss of primary maxillary incisors, delayed eruption
of maxillary permanent incisors
or overeruption of mandibular
incisors. Diagnostic features are
short maxillary incisors, overerupted mandi bular incisors or
a Class III maxillomandibular
relation. Bearing the 42.2 rule in
mind, treatment should follow
incisal reduction done selective-

Fig. 8. Delayed eruption.

Fig. 11. Relaxed position (/m/ sound
– ahhh).

Gingival margin positioning
should be in accordance with
the understanding of six conditions present in the oral cavity with different aetiologies and
treatment regimens:
1. Altered passive eruption when
the gingival margin does not recede to a level near the cemento
enamel junction (CEJ) during
tooth eruption. Diagnostically,

Fig. 13. Initial lower third when smiling.

Fig. 14. Findings in order of importance after establishing the incisal
edge position on the full smile photograph.

5. Vertical maxillary excess described as a hyperplastic growth
of the maxillary skeletal base
where teeth are positioned farther from the skeletal base, an
increased facial lower third
and excessive gingival display,
which is classified according to
three categories:
(a) Category 1: 2–4 mm of gingival display, treated with only
orthodontic intrusion, orthodontics and periodontics, or periodontics with restorative therapy;
(b) Category 2: 4–8 mm of gingival display, treated with perio-

Fig. 9. A hypermobile lip and a slight
vertical maxillary excess.

Fig. 12. Superimposed photographs
10 & 11. The red arrow indicates the
distance from the incisal edge to the
upper lip in the relaxed position. The
yellow arrow indicates the height of
the upper lip in the relaxed position
(~ 21 mm). The white arrow indicates mobility of the upper lip from
the relaxed to smile position.

Fig. 15. The wax-up duplicated in a
stone model.

6. Hypermobile upper lip—the
average mobility of the upper
lip is from 6 to 8 mm from the
rest position. More than 8 mm
represents hypermobility. Considering that the average distance from the lower margin of
the upper lip and the base of the
nose (subnasion) is 21 mm, one
could take two superimposed
photographs with the patient
at rest and the patient smiling
fully to calculate the lip mobility very easily using the 42.2
rule. Generally normal tooth
length is present and dental labial aesthetics is good to ideal.
The treatment regimen could
entail a coronally po - sitioned
mucosal flap, crown lengthening with osseous resection or a
combination of both (Figs. 8 &
9). Example: Photographs captured at the same magnification
opened in Adobe Photoshop:
Picture 10: Full smile—length of
the central exposed – measure
digitally in pixels distance from
incisal edge to the lower margin
of the upper lip in full smile.
Picture 11: Lips at rest – 2 mm
central incisor reveal + 21 mm
distance lower lip to base of the
nose. Incisal edge to base of the
nose 23 mm (incisal edge at the
correct position).
x = distance from the incisal
edge to the lower margin of the
upper lip in full smile
y = the amount of central incisor
exposed at rest 23 mm = 1,725
px; x = 900 px; mobility = x – y;
= [(23 × 900) / 1,725] – 2 mm; =
12 mm – 2 mm; = 10 mm (Figs.
10–12)
Since the aetiology is generally
multifactorial, by combining all
the clinical data gathered during
the initial examination, including facial, periodontal, orthodontic, endodontic and restorative data, as well as radiographs
and diagnostic photographs,
the clinician has the ability to
compose a very detailed and
comprehensive treatment plan
especially for a patient with high
aesthetic demands.
Following the digitally designed
smile concept, balancing the
relations between the teeth and
adjacent structures will help
the clinical co-ordinator and the
specialty team propose treatment planning to the patient.
Presenting the plan in Keynote

> Page 7

[7] =>

mCME

Dental Tribune Middle East & Africa Edition | May-June 2015

< Page 6
(Apple) or Microsoft PowerPoint
is a very powerful communication tool in obtaining treatment
acceptance.
Case presentation
A 32-year-old female patient
came to the dental office with
her chief complaints being short
teeth, an uncomfortable bite, too
much gingiva showing when
smiling, brown-coloured areas
of her teeth and insufficient contact points. The patient was in
good general health with a good
periodontal status and probing
depths of 2 to 3 mm. The aetiology of the excessive gingival display was multifactorial, a combination of delayed eruption,
altered passive eruption and
hypermobility of the upper lip.
From an evaluation of the teeth,
both clinically and from the diagnostic photographs, we made
the findings given in Table 1 in
order of importance (Figs. 13 &
14). We placed incisal edge position first in order of importance
because, in the majority of cases,
without proper placement whatever follows could result in a
tooth that tries to mimic nature
but is not properly exposed in a
full smile.
Based on the data gathered, the
treatment plan was then presented to the patient in 3-D on
models mounted in the articulator and in 2-D with a Keynote
presentation, allowing her to
understand the present situation, treatment proposed and
simulated final outcome.
Following the treatment proposal and acceptance, the case
was sent to the dental laboratory, where the dental ceramist
fabricated a wax-up and a stone
model based on the clinician’s
diagnostic findings (Figs. 15–17).

A crown-lengthening surgical
guide (a vacuum-formed Essix
appliance) was manufactured
on a duplicate model of the waxup for ideal osseous contouring
during the surgical procedure
(Fig. 18). The gingivectomy was
performed following exactly the
gingival margin of the wax-up
and then used for guiding the
osseous contouring, through
which a biologic width of a minimum of 2 mm was maintained
(Figs. 19–24).
The mock-up should be placed
before the surgical appointment
for an initial evaluation and
then ideally six to eight weeks
post-crown lengthening. If done
earlier, a very well-adapted indirect acrylic prototype would
be advised or the utmost care in
adaptation of the bisacrylic resin
(Figs. 25–27).
For the ultimate control and
when time management in a
private office is not an issue,
the osseous contouring is performed and the flap is closed,
followed by guided gingivectomy and mock-up placement
at the next appointment in two
to three months’ time. With this
approach, the risk of recession
or invasion of biologic width is
reduced to the minimum.
Controlled tooth preparation
was performed through the
mock-up using 0.6 mm depthgauge burs (Figs. 28 & 29). In
designing restorations, the diagnosis of the initial situation
and underlying tooth structure,
the new design proposal and
the patient’s expectations play
a very important role. The material of choice in this case was
feldspathic porcelain (VITA
Zahnfabrik) on a refractory die
in the anterior zone combined

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Fig. 16. The new design proposal in
wax.

Fig. 17. Very good communication
with the dental laboratory.

Fig. 18. The crown-lengthening surgical guide.

Figs. 19–24. Crown lengthening with osseous contouring. (Surgery performed by Dr Muriel Krischek, Belgium.)

Figs. 25–27. The bis-acrylic prototype.

Fig. 28. Controlled tooth reduction.

Fig. 29. Tooth preparation.

Fig. 30. Porcelain restorations on alveolar models.

Fig. 31. The try-in paste and organiser.

Fig. 32. Cementation.

Fig. 33. Situation before.

Fig. 34. Situation after. (Ceramics performed by Edwing Chung, Canada.)

Incisal edge position
Missing
Form Missing
Value Missing
Surface texture
Missing
Translucency Missing
Chroma Missing
Hue Present
Gummy smile evaluation
Missing
Teeth ratios
Missing
Contact points
Missing
Occlusal interferences
Present
Table 1. Findings.

Fig. 35. Initial situation.

with pressed lithium disilicate
(IPS e.max, Ivoclar Vivadent) in
the posterior zone (Figs. 30–33).
As a rule of thumb, when a material like feldspathic porcelain
is used, which filters the light
through to the underlying structure, a space of 0.2–0.3 mm is
needed per shade change.
The restorations were adhesively cemented using a total-etch
technique and initially tried in
with a translucent try-in paste
(CHOICE 2, BISCO, Inc.).
The occlusion was checked after cementation and a processed
acrylic night guard was delivered two weeks post-operatively.

Fig. 36. Situation five months postop.

The final result is shown in Figures 34, 36 & 37).
Reference
1. Rufenacht CR, Principles of Esthetic Integration:Quintessence
Books, Carol Stream, IL, 2000.
2. Kois JC, Altering Gingival Levels: The Restoration Connection.
Part 1: Biologic Variables J Esthet Dent 6:3-9, 1994
3. Stephen J. Chu: Short Tooth
Syndrome: Diagnosis, Etiology
and Treatment management
February 2004. VOL32. NO32.
CDA. Journal

Fig. 37. Final result.

About the Author
Dr. Sebastian Ercus graduated
from the dental faculty at Ovidius
University in Constan, in Romania. He subsequently obtained a
Master of Science degree in Public
Oral Health in 2005 from the same
institution.
He is in private practice in Brussels.
Dental Specialty Center
Av. Franklin Roosevelt 82 bte 1
Ixelles / 1050 Brussells, Belgium
smile@sebastianercus.com
www.sebastianercus.com

[8] =>

8 mCME

Dental Tribune Middle East & Africa Edition | May-June 2015

From everyday dentistry to advanced photoacoustic
endodontic applications (PIPS): Er:YAG & Nd:YAG
dual wavelength laser
mCME articles in Dental Tribune have been approved by:
HAAD as having educational content for 2 CME Credit Hours
DHA awarded this program for 2 CPD Credit Points
By Lawrence Kotlow DDS,
Enrico DiVito DDS and
Giovanni Olivi MD

ntroduction
Lasers provide an exciting
new technology that allows
the dentist the ability to give
patients optimal care without
many of the “fear factors” found
in conventional dental techniques. Used with proper understanding of laser physics, lasers
are extremely safe and effective.
Using lasers for caries removal,
perio treatment, endodontic
treatment, bone management,
cutting and shaping, and softtissue procedures can reduce
postoperative discomfort and infection, and provide safe, simple
in-office treatment. As a result,
we can improve our efficiency,
expand what we can do, achieve
better results and increase production.
Lasers represent a real quantum
leap forward in the treatment of
our patients, including the pediatric patient. The U.S. Food and
Drug Administration (FDA) gave
approval for the use of the Er:
YAG laser in 1997 for both hardand soft-tissue procedures. The
erbium doped (erbium particles
placed within the YAG crystal)
crystal of Yttrium-AluminumGarnet’s (Er:YAG) development and success has made the
treatment of children safer and
quicker.
Plainly stated, a laser is a piece
of equipment that creates a concentrated monochromatic beam
of visible or infrared light that
can be absorbed by a specific
target. Since then, laser-assisted
dental care has changed forever
the way dentists can prepare
diseased teeth, ablate bone and
treat soft-tissue abnormalities and disease. An entire new
standard of care is becoming a
reality.
Lasers and pediatric dentistry
are a perfect fit. There are a
wide range of hard and soft
dental procedures that may
be completed using lasers as
an alternative to conventional
dental care on adults and, especially, children. Many of these
procedures may be treatments
dentists historically refer out to
other specialists; however, if you
understand and use your laser
efficiently, you will discover that
many of these are procedures
that every dentist can easily
complete.
The question that is often the
major concern and barrier to in-

CAPPmea designates this activity
for 2 continuing education credits.

vesting in lasers is the how this
investment will pay for itself,
more recently described as return on investment (ROI). Will it
pay for itself? We prefer to speak
of this as the secondary effect. If
you understand your laser, it will
easily pay premiums on your investment, and the cost factor becomes a non-issue.
The purchasing of lasers is an
investment, not an expense, for
any dental practice.
Lasers represent a fundamental
change in the entire way dentistry has been taught. We can
now rethink and often modify
G.V. Black’s principle of extension for prevention with the
concept of minimally invasive
micro-dentistry. We need to
understand that laser dentistry
is one portion of an entire new
way of practicing conservative,
pain-free dentistry.
The laser that we call the “allpurpose” laser is the Lightwalker Er:YAG & Nd:YAG laser,
manufactured by Fotona and
distributed in the United States
by Technology4Medicine. The
Er:YAG produces its effect at
2940 nm and has as its primary tissue target water and
hydroxyapatite. It is very safe,
relatively quiet, eliminates the
smells and vibrations associated
with the dental handpiece and,
most importantly, is much more
comfortable for the patient, significantly reducing the need for
local anesthesia.
The use of the new generation
erbium lasers for repair of incipient hard-tissue disease allows
the dentist to provide a stressfree means of restoring teeth in
a minimally invasive manner,
most often with no shot and no
numb lip, without the need for
any local anesthetics.
The erbium laser can be used
for restoring primary and permanent teeth, eliminating or
reducing the amount of local
anesthetics. In most cases, the
patient will not require numbing
for Class 1, 2 (sometimes), 3, 4,
5, 6 restorative procedures using
bonded restorative materials.
Using the concept of minimally
invasive restorative procedures,
the Er:YAG laser allows the operator to remove only diseased
tissue and thus preserves much
more of the healthy, unaffected
tooth.
In cases where alloy is preferred, the laser’s analgesia effect may also allow the dentist to

Figs. 1, 2. Representative sample images of root canal dentinal walls irrigated with 17 percent EDTA and PIPS for 20
seconds. (Photos/Provided by Technology4Medicine)

create a restorative preparation
using a conventional handpiece
that is not meant for bonding.
The erbium laser is effective because of its effect on its target,
water within the tooth structure.
This effect occurs when the laser heats up water within the
target tissue, causing it to create
small microscopic explosions
(photothermal followed by photoacoustical effects). When applied to soft tissue, bone or teeth
and cavities, the explosions then
cause the areas to be vaporized.
Er:YAG laser 2940 nm: Softtissue procedures
There is a wide array of softtissue procedures that can be
completed using the all-purpose
laser: maxillary and mandibular frenum revisions, lingual
frenum revisions, treatment of
pericoronal pain or infection, removal of hyperplasic tissue because of drugs or poor oral care
in orthodontic patients, biopsies,
treatment of aphthous ulcers
and herpes labialis, pulpotomies, removal of impacted teeth
and, in adults, apicoectomies
and bone recontouring.
Pulpotomies
Parents often express concern
about the need to take radiographs because of the nature of
X-rays and their possible side effects on a child’s overall health.
They question the use of alloys because of the chemical
makeup of the alloy. Whether
these should be a real concern
in today’s dental care is open to
debate, depending on your individual beliefs. There are also
concerns by many, although not
as loudly, about the effect of various pulpotomy procedure medicaments used in pulpotomy
procedures, such as formocreosol.
Lasers provide a safe, nonchemical, effective and alternative treatment for pulpotomies.
During the span of eight years,
post-treatment results on more

than 4,000 pulpotomies using
the erbium (2940 nm) laser provide ample evidence that this
method is both effective and safe
for children without the need for
introducing chemicals or using
electrosurgery methods.
When the final result of orthodontic positioning of the front
teeth results in gingival hypertrophy, the laser can be a useful
tool to increase crown length
and give the patient a more esthetic smile. This may often be
accomplished without the need
for local anesthesia. Patients
who have medically induced
hyperplastic tissue, such as patients requiring dilantin, can
also have their tissue reduced
and reshaped with the erbium.
In addition to the many examples described in this article,
lasers can be used for additional
procedures not usually required
in pediatric dentistry, such as
revisions of the abnormal mandibular frenum, often avoiding
the need for soft-tissue grafts,
crown-lengthening procedures
where bone requires recontouring, apicoectomies, removal
of bony exostoses, removal of
third molar impactions, removal
of root remnants, incising and
draining soft-tissue infections,
advanced periodontal treatments and the latest in advanced
endodontic treatment via photoninduced photoacoustic streaming.
Photoacoustic endodontics using PIPS
The goal of endodontic treatment is to obtain effective cleaning and decontamination of the
smear layer, bacteria and their
byproducts in the root canal
system. Clinically, traditional
endodontic techniques use mechanical instruments, as well
as ultrasonic and chemical irrigation, in an attempt to shape,
clean and completely decontaminate the endodontic system
but still fall short of successfully

removing all of the infective microorganisms and debris. This is
because of the complex root canal anatomy and the inability for
common irrigants to penetrate
into the lateral canals and the
apical ramifications. It seems,
therefore, appropriate to search
for new materials, techniques
and technologies that can improve the cleaning and the decontamination of these anatomical areas.
Among the new technologies,
the laser has been studied in endodontics since the early 1970s13
and has become more widely
used since the ’90s.4-6
Different wavelengths have
been shown to be effective in
significantly reducing the bacteria in the infected canals, and
important studies have confirmed these results in vitro.7
Studies reported that near infrared laser are highly efficient
in disinfecting the root canal
surfaces and the dentinal walls
(up to 750 microns for the diode
810 nm and up to 1 mm for the
Nd:YAG 1064 nm). On the other
hand, these wavelengths did not
show effective results in debriding and cleansing the root canal
surfaces and caused characteristic morphological alterations
of the dentinal wall. The smear
layer was only partially removed
and the dentinal tubules primarily closed as a result of melting
of the inorganic dentinal structures.5,8
Other studies reported the ability of the medium infrared laser
in debriding and cleaning root
canal walls.9,10 The bacterial load
reduction after erbium laser irradiation demonstrated high on
the dentin surfaces but low in
depth of penetration because of
the high absorption of laser energy on the dentin surface.7 Also
the laser activation of commonly

> Page 9

[9] =>

mCME

Dental Tribune Middle East & Africa Edition | May-June 2015

< Page 8
used irrigants (LAI) resulted in
statistically more effective removal of debris and smear layer
in root canals compared with
traditional techniques (CI) and
ultrasound (PUI).11,12 Additionally, the laser activation method
resulted in a strong modulation
in reaction rate of NaOCl, significantly increasing production
and consumption of available
chlorine in comparison to ultrasound activation.13
A recent study has reported
how the use of an Er:YAG laser,
equipped with a newly designed
radial and stripped tip, in combination with 17 percent EDTA
solution, using very low pulse
duration (50 microseconds) and
low energy (20 mJ) resulted in
effective debris and smear layer
removal with minimal or no
thermal damage to the organic
dentinal structure through a
photoacoustic technique called
photon induced photoacoustic
streaming or “PIPS.”14,15 Also
the same photoacustic protocol
in combination with 5.25 percent sodium hypochlorite solution has been investigated and
shown to reduce the bacterial
load and its associated biofilm
in the root canal system three
dimensionally.16
Other similar studies are in progress for publication and the results are promising and suggest
a three-dimensional positive effect of this laseractivated decontamination (LAD) method.
The purpose of this article is to
present briefly the experimental
background of this laser technique and to introduce the clinical protocol.
Scientific background
The microphotographic recording of the LAI studies suggested
that the erbium lasers used in
irrigant-filled root canals generate a streaming of fluids at high
speed through a cavitation effect.17 The laser thermal effect
generates the expansion implosion of the water molecules of
the irrigant solution, generating
a secondary cavitation effect on
the intracanal fluids. To accomplish this streaming, it is suggested the fiber be placed in the
middle third of the canal, 5 mm
from the apex and stationary.18
This concept greatly simplifies
the laser technique, without the
need to reach the apex and to
negotiate radicular curves.
Also, the recorded video of the
new technique, PIPS, showed
a strong agitation of the liquids
inside the canals. It differs from
the already cited LAI technique
by activating the irrigant solutions in the endodontic system
through a profound photoacoustic and photomechanical phenomena. The use of low energy
(50 microsecond pulse, 20 mJ at
15 Hz, 0.3 W average power, or
less) generates only a minimal
thermal effect. The study with
thermocouples applied to the
radicular apical third revealed
only 1.2 degrees C of thermal
rise after 20 seconds and 1.5 degrees C after 40 seconds of continuous radiation.14
When the erbium laser energy
is delivered at only 50 micro-

Fig. 3. Representative sample image of root canal dentinal
walls irrigated with 17 percent EDTA and PIPS for 20 seconds.

second pulse duration through
a special designed tapered and
stripped 400 microns tip (Fotona LightWalker, Technology4Medicine), it produces a large
peak power of 400 watts when
compared to a longer pulse duration. Each impulse, absorbed
by the water molecules, creates
a strong “shock wave” that leads
to the formation of an effective
streaming of fluids inside the canal while also limiting the undesirable thermal effects seen with
other methodologies. The placement of the tip in the coronal
portion only of the treated tooth
allows for a more minimally enlarged canal preparation with
less thermal damage as seen
with those techniques placed
into the canal system.
The root canal surfaces irrigated
with 17 percent EDTA and laser
activated for 20 seconds showed
exposed
collagen
matrix,
opened tubules and the absence
of smear layer and debris (Figs.
1-3). The rinsing with 5.25 percent sodium hypochlorite and
laser irradiation for 20 seconds
produced a strong activation of
the solution, as reported by Macedo,13 improving the disinfecting
action of the sodium hypochlorite.16 The disinfecting action of
PIPS is very effective both on the
root surface, the lateral canals
and the dentinal tubules, as confirmed with SEM and confocal
studies (Fig. 4).
The profound and distant effect
of PIPS eliminates the need to
introduce the tip into the root
canal system. Unlike traditional laser techniques requiring
placement of the tip 1 mm from
the apex, or even 5 mm from the
apex as proposed for LAI18, the
PIPS tip is placed in the coronal
portion of the pulpal chamber
only and left stationary, allowing the photoacoustic effect to
spread into the openings of each
canal. A new tip design consisting of a 400-micron diameter,
12 mm long, tapered end is used
for this technique (Fig. 5). The
final 3 mm of coating is stripped
from the end to allow for greater
lateral emission of energy compared to the frontal tip.
This mode of energy emission
allows for improved lateral diffusion with low energy and enhanced photoacoustic effect.
Discussion
Laser irradiation is a common
technique used in endodontics
to improve the cleaning, the debriding and disinfection of the
root canal system. Many wavelengths and protocols are used.
Near infrared lasers are used for
the three-dimensional decon-

Fig. 4. SEM image of clean lateral canal.

tamination of the
endodontic
system. Nd:YAG and
diode lasers use
thermal
energy
to destroy bacteria. Observations
reveal a certain
grade of thermal
injury to the root
canal surface and
create a typical
m o r p h o l o g i c a l Fig. 5. New tapered tip design for this technique.
damage. Moreover, they are not able to thor- ration that can then be obturated
oughly remove the smear layer.
three dimensionally.
On the contrary, erbium lasers are used for their effective
smear layer removal while their
bactericidal activity is limited
to the root surface. The placing
of the tip close to the apex and
its back movement during the
activation process is related to
the risk of apical perforation,
ledging and surface thermal
damage, because of the ablation
ability of this wavelength. Also a
combination of the near and medium infrared lasers has been
proposed. A technique, called
twinlight endodontic treatment
(TET), uses the erbium laser energy first, to clean the root canal
surface and remove the smear
layer, and the Neodimium:YAG
laser second, used in dry mode
as the final disinfecting step. All
these techniques utilize traditional tips and fibers placed into
the canal, close to the apex (1
mm) with all the corresponding
thermal disadvantages observed
in long, narrow and curve canals.
The erbium lasers are also used
as a medium of activation of
commonly used irrigants (LAI),
avoiding the risk of thermal
damage, while increasing the
cleaning and disinfecting activity of the fluids. PIPS, in particular, reduces all these risks and
disadvantages, thanks to the
position of the tip in the coronal orifice only and to the use of
minimally ablative energy levels
of 20 mJ or less.
The findings of our studies demonstrated that PIPS technique
resulted in a safe and effective
debriding and decontaminating
of the root canal system. Our
clinical trials showed that PIPS
technique greatly simplifies root
canal therapy while facilitating
the search for the apical terminus, debriding and maintaining
patency.
As a result of the efficacy of PIPS,
the final size required for canal
shaping can be significantly reduced, often to a size 25/04, allowing for a more minimally
invasive and biomimetic prepa-

Conclusion
Lasers are an extremely versatile addition to the dental practice and can be used in many
instances instead of the conventional methods employed
by the vast majority of dentists.
Incorporating a laser in the dental practice should be viewed as
an investment rather than a cost.
When used with a good knowledge of laser physics, training
and safety, lasers provide our
patients a new standard of dental care.
References
1. Weichman JA. Johnson FM.

Laser use in endodontics. A
preliminary investigation. Oral
Surg Oral Med Oral Pathol. 1971
Mar;31(3):416–20.
2. Pini R. Salimbeni R. Vannini
M. Barone R. Clauser C. Laser
dentistry: a new application
of excimer laser in root canal therapy. Lasers Surg Med.
1989;9(4):352–357.
3. Shirasuka T. Wakabayashi
H. Debari K. Kodaka T. Ahmed
S. Matsumoto K. Morphologic
changes in human tooth enamel
by continuous-wave Nd-YAG laser irradiation. Showa Shigakkai
Zasshi. 1990 Jun;10(2):206–215.
4. Myers TD. Lasers in dentistry.
CDS Rev. 1991 Sep;84(8):26–29.
Full list of references is available
from the publisher.

About the Author
Lawrence Kotlow, DDS, has been
in private dental practice in Albany,
N.Y., since 1974.
He is board certified in pediatric
dentistry. He is a recognized standard proficiency course provider
for the Academy of Laser Dentistry.
Enrico DiVito, DDS, is an adjunct
professor at the Arizona School of
Dentistry and Oral Health.
He is in private practice at the
Arizona Center for Laser Dentistry
in Scottsdale, Ariz., in conjunction
with MDATG research group.
Giovanni Olivi, MD, DDS, is a professor of endodontics at the University of Genoa School of Dentistry,
where he is director for the Laser
in Dentistry Master Course with
Prof. S. Benedicenti. He is in private
practice in Rome, Italy.

[10] =>

10 restorative

Dental Tribune Middle East & Africa Edition | May-June 2015

Total-etch vs. Self-etch adhesives
a case-dependent choice
By Dr. Walter G. Renne, USA

dhesive dentistry with
direct and indirect restorations has advanced tremendously since the first etchand-rinse technique introduced
by Buonocore for enamel-only

adhesion. Enamel and dentin
are both now routinely etched
and bonded, procedures that
have been proven in multiple
studies to be safe and reliable
when proper technique is followed. As the procedures advanced, we now have adhesive

systems that offer either etchand-rinse (also known as totaletch) and self-etch options. The
total-etch technique is still considered the gold standard for
bond strength to enamel, and
self-etch adhesive systems have
been compared to these to as-

sess the relative bond strength
with each. Adhesion is the most
important step in all procedures
associated with adhesive dentistry and with so many options—
enamel or dentin or enamel
and dentin bonding; total-etch
or self-etch; and multi-bottle
or one-bottle systems—there is
much to consider before selecting one. Both total-etch and selfetch adhesives offer reliable and
repeatable results when properly selected, and the fewer steps
required, the more efficient the
procedure. This saves chairside
time for the clinician and the
patient, reducing the possibility
for error. Since the appropriate
technique is case dependent, the
type of case must be the first consideration. If there is a large area
of enamel available for bonding
and only a small area of dentin,
the total-etch technique is often
preferred, as it has been shown
to result in stronger bonding to
enamel than a self-etch technique. Conversely, if a preparation has a substantial area of
dentin available for bonding and
a lesser area of enamel (such as
a large Class II), then self-etch is
more frequently used. Whichever adhesive system is chosen,
it must provide for high bond
strength, durable marginal integrity, and be compatible with
the restorative material. The
cases below show the use of universal adhesives for direct composite and indirect restorations.

Fig. 1. Preparations

Fig. 2. Preparations isolated and after
application of 2-step etch-and-rinse adhesive.

Fig. 3. Final composite restorations.

Fig. 4. Old composite restoration with
poor marginal integrity.

Case report 1
Direct Class II Restoration
The patient in this case presented with approximal carious
lesions in teeth 12 and 13, which
breached the enamodentinal
junctions on the radiographs.
Old preventive resin restorations were also present occlusally. It was decided that direct
composite restorations would be
placed to restore the 2 bicuspids.
At the treatment appointment,
after giving the patient local
anaesthesia, a rubber dam was
placed to isolate the teeth before
preparation and provided a dry
field during placement of the
adhesive and composite restorations (Fig. 1). In this case, a totaletch technique was selected.

Fig. 5. Preparation completed.

During preparation of the teeth,
minimal width boxes were created that extended sufficiently
for caries removal but no further
and the old preventive restoration removed. Since adhesion
would provide for retention of
the bonding agent, there was
no requirement to ensure a retentive preparation form. For
this case, I chose OptiBond Solo
Plus (Kerr) as the adhesive. It
consists of a phosphoric acid gel
etchant and a separate primer/
adhesive that contains a filler to
help strengthen the bond at the
hybrid zone level, giving very
high bond strengths with just 2
steps. After etching the enamel
and dentin for 15 seconds, the
etchant was rinsed off and the
enamel and dentin gently dried
without desiccating the dentin. Next, the bonding agent
was applied and lightcured for
20 seconds (Fig. 2) before the
composites were placed as bulk
fills using the SonicFill System
(Kerr) and light-cured.
The composites were then
checked for occlusion, the margins checked for any excess, and

the composites were finished
and polished using Progloss
(Kerr) (Fig. 3).

Fig. 6. CAD scan of preparation.

Fig. 7. Proposed form of indirect restoration.

Case report 2
Indirect Ceramic
Inlay in this case, a new patient
presented with failed, old patchy
composite restorations in tooth
20 (Fig. 4). Several areas of different composites were present
that had been placed at various
times. On presentation, the patient complained of sensitivity in
this tooth when eating or drinking anything cold. On examination, the bond between the
restorations and the tooth had
failed and the composites were
found to lack marginal integrity.
In addition, the tooth was found
to have marginal leakage, staining, and recurrent caries in the
mesial box. This could have
been due to the technique used,
poor bond strength, or lack of
compatibility between the adhesive systems and composite
systems used at various times.

> Page 11

[11] =>

restorative 11

Dental Tribune Middle East & Africa Edition | May-June 2015
< Page 10

Fig. 8. Application of the bonding
agent to enamel and dentin after
primer had been used.

Fig. 9. Moderately air-drying the
bonding agent.

Fig. 10. Applying bonding agent to
the inlay’s intaglio surface.

self-etch adhesive,1 although
this may be due to overdrying
of the dentin and its desiccation
leading to transient sensitivity.
Self-etch adhesives inherently
leave less room for sensitivity to
occur. OptiBond XTR has a mild
pH of around 4 (versus a pH of
around 2 for phosphoric acid
etchants); it does not remove the
smear layer or open dentinal tubules, instead preventing tubule
exposure while still allowing for
hybridization. OptiBond XTR
contains proprietary chemistry
that helps to prevent sensitivity,
and its hydrophilicity ensures
that the primer and adhesive
can penetrate well into the dentin and seal off the surface of the
dentin, helping to prevent sensitivity. Before placement of the
ceramic inlay (LAVA Ultimate),
it was first air-abraded at 15
psi and ultrasonically cleaned.
It was then put aside while the

preparation was treated.
The primer was applied to the
enamel and dentin for 20 seconds with a gentle scrubbing
motion then air-dried for 5 seconds to remove the solvent.
Next, the bonding agent was
applied (Fig. 8), agitating the
brush gently over the enamel
and dentin surface for 15 seconds. The adhesive was then
gently air-dried (Fig. 9) and
light-cured for 10 seconds. The
bonding agent was then applied
to the intaglio surface of the indirect ceramic inlay (Fig. 10) and
gently air-dried for 5 seconds
and light-cured for 10 seconds.
NX3 Nexus (Kerr) resin-based
cement was then applied to the
intaglio surface, the inlay carefully seated, and excess cement
removed before light-curing all
surfaces for 20 seconds each.
NX3 Nexus resin-based cement

is fully compatible with OptiBond XTR, making it a superior
choice compared to other resinbased cements. The interproximal areas were checked for any
residual cement, and the occlusion was checked before the patient left. The result was an aesthetic, durable restoration with
excellent marginal integrity,
excellent bond strength, and a
satisfied patient (Fig. 11).
Summary
Our current adhesive system options are total-etch and self-etch
variants. Without a patent and
durable bond with high bond
strength, restoration failure will
occur with the breakdown of the
bond even if all other aspects of
the restoration are sound. Selecting a clinically proven adhesive
ensures that you are choosing
a material capable of performing under real-life conditions.

The adhesives used in the cases
presented offer reliable, durable
high-strength bonds, marginal
integrity, easy clean-up, and
ease of use.
Reference
1. Blanchard P, Wong Y, Matthews A, et al. Restoration variables and postoperative hypersensitivity in Class I restorations:
PEARL Network Findings. Part
2. Compend Contin Educ Dent.
2013;34(4):E62-8.v

About the Author
Dr. Walter G. Renne, DMD, USA
Dr. Walter runs the CAD/CAM
clinic at MUSC in addition to treating patients in faculty practice
where Dr. Renne maintains an
active general dentistry practice
utilizing both the CEREC AC and
E4D systems.

Herculite XRV Ultra
®

™

Fig. 11 Final restoration seated and
cemented.

After discussing the alternatives,
the patient opted for an indirect
ceramic inlay. At the treatment
visit, after anaesthetizing the
area, the old composites were
removed and the tooth prepared
to remove recurrent caries and
staining at the old margins (Fig.
5).
A digital impression was taken
of the preparation (Fig. 6) and
opposing arch using an E4D
digital scanner, the proposed
inlay form examined (Fig. 7),
and the scans transferred to
the laboratory where the ceramic inlay was fabricated using CAD/CAM. At the patient’s
seating appointment, the fit of
the inlay was assessed. In this
case, I selected OptiBond XTR
(Kerr) 2-bottle self-etch universal adhesive with separate
etch/primer and bonding agent,
which is suitable for direct composite and all types of indirect
restorations. I chose this adhesive system for 2 main reasons.
Due to its unique chemistry, the
high bond strength obtained
with this adhesive is as high as
that obtained with a traditional
total-etch adhesive, and it offers
high shear bond strength with
both enamel and dentin. The
OptiBond XTR adhesive system
primer etches enamel and dentin, and its hydrophilic nature
lets it better penetrate the dentin
to help provide increased bonding to dentin. OptiBond XTR also
has a thin film thickness, allowing for proper seating of the final
restoration.
A distinct consideration in
choosing OptiBond XTR, particularly since the preparation
was large and deep, was the
lack of post-operative sensitivity
found with this adhesive. Postoperative sensitivity is a relatively frequent occurrence following restoration placement,
and some studies have found
this more likely to occur with a
total-etch adhesive than with a

Kerr, making history
again

Your practice is our inspiration.™

[12] =>

12 oral health

Dental Tribune Middle East & Africa Edition | May-June 2015

Establishing good oral care habits from the very first tooth
By Jordan

t is important that we take
care of our teeth right from
the beginning and establish
good brushing habits.
Parents and children do not
share the same motivation when
it comes to choosing their toothbrush. Parents are concerned
about safety and look for quality products that they think their
children will like¹. As many as
45% of them buy “children’s
personal care” products because
their children are more excited
about using them². Children
are primarily motivated by fun
(much more than health)¹. Colours and design play an important role in making their brushing sessions positive. Older
children especially are attracted
to “new” features and functions
that they would like to try.
In a recent consumer study,² we
found that parents appreciate
information that will help them
make good decisions when selecting a toothbrush for their
child. In addition, parents welcome initiatives that will help
their children be more enthusiastic about brushing their teeth.²
To meet these needs, here are
some good tips to remember

when considering your next
toothbrush for your child are:
- Choose a soft toothbrush. Children have softer enamel than
adults do, and it is easy for them
to brush too hard. A soft toothbrush is gentle and safe for children’s teeth and gums.
- Children need a small toothbrush head as their mouths are
smaller and it is easier to navigate around the mouth with a
smaller head. A small head
makes it easier to reach and
clean properly all the difficult
areas in the mouth, especially
the back molars when they start
to develop. It is in these areas
that cavities are most likely to
start developing.
- Children have less dexterity and motor skill development
than adults do. It is easier for
them to control their brushing
movements with a handle that
has more volume. Their hands
are also much smaller than
adults are so choose a handle
that will fit comfortably in their
hands.
- Children should use a toothpaste that is formulated especially for them, and only a small
amount is sufficient (a good rule
of thumb is to think about the
size of the nail on your child’s
little finger and use a similar
amount of toothpaste). Children’s toothpaste have a lower

dosage of fluoride than adult
toothpastes. Most children prefer milder toothpastes that are
not “strong”. They tend to prefer other flavours like fruit flavoured toothpaste. Children
should not swallow toothpaste.
- Parents are advised to brush
their children’s teeth. In the
Scandinavian countries, the
National Dental Associations
recommended parental assisted brushing until children are
around 10 years of age.
- Brushing the teeth for 2 minutes gives the best results.
Brushing time is the most easily
controlled parameter of effective
everyday brushing. Increasing
time from 45 seconds to 2 minutes will increase plaque removal and contribute to significantly
improved oral health benefits.³
- In addition to brushing, the
American Dental Association
recommends that parents help
their children “floss” as soon
as two of their teeth touch each
other. This can be as early as

B RBU RS HU SAHL AL LTLE TE ET HE TWHEWL LE ,L L ,
A L AS OL STOH TEHNEE NWEOWNOESN ES

when they get their permanent
back molars (from 6 years of
age).
To keep teeth clean and healthy
it is recommended that both you
and your children avoid in-between meal snacking and foods
and drinks that can harm your
teeth’s enamel. Try rinsing your
mouth with water in between
brushing sessions to help wash
away food and help prevent
plaque build-up. Finally, regular

Jordan Step by Step. Follows your child´s development
Jordan
Step by
Step. Follows
yourtoothbrushes
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Jordan’s
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make brushing
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brushing
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For more information www.jordan.no
For moreenquiry@jordan-co.ae
information www.jordan.no
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References
¹TNS Gallup, Norway, 2010
²Teen and Tween Beauty and
personal care consumer research, USA, Aug 2013, Childrens personal care market is defined as children 6-11 years old.
³ The Jornal of Dentist hygiene,
volume 83, issue 3, 2009

Beverly Hills Formula
reveals the secrets
of whitening toothpastes!
By Dental Tribune MEA/CAPPmea

everly Hills Formula has
been working hard to
provide premium quality
6 - 9 Y EA R S
oral
care
products for the den6 - 9 Y EA
RS
S P EC I A L P Y RA M I D S H A P E D tal sector through their range
RALMESI D ESFHFAECT
P E IDV E LY C L EA N
3 - 5 Y EA RS PSEC I A L BPRYI ST
whitening toothpastes and
3 - 5 Y SEA
R S B R I ST L EST HEOFSF EECTH AI VREDLY- TOC-LREAEANC H P L A Cof
ES
O F T B R I ST LTES
mouthwashes
for more than 20
H O S E H A R D - TO - R EA C H P L A C ES
N DL GESO O D G R I P
0 - 2 Y EA R S S O F T B RAI ST
years. Dental Tribune Middle
GOOD GRIP
0 - 2 Y EX
EATRRAS S O F T B RAI STN DL ES
,
East & Africa speaks to Beverly
EX T RA STOEFET
T HBIRNIGSTRLI ES
,
NG AND
Hills Formula Managing DirecT E ET H I N GG OROI DN GG RA INPD F O R B OT H
tor Chris Dodd to reveal some
G O O D G RPAI PR FEON RT SB AOTN DH BA B Y
secrets that lie around whitenPA R E N T S A N D BA B Y
ing toothpastes!

G E N T LY
AND
G E N T LY
S AAF NE DL Y
S
BUILD
MSI N U T E
2
S A F E LY
E
E
G
T
A
U
G OBOU I L
N C O U2R M I N
G O O D R D RDO U T I N E SE N C O U RE A G E I N G T I M E
OUTINE
BI NRGU ST HI M E
S
H
S
U
BR

check-ups with your local dentist/hygienist will help you keep
your teeth healthy.

Dental Tribune MEA: Firstly,
can you give us some background on Beverly Hills Formula and its overall vision?
Chris Dodd: When Eric Peterson established the Beverly Hills
Formula brand back in 1992,
the majority of whitening toothpastes around were very abrasive and were responsible for
tooth sensitivity and damage to
the enamel.
And so it became the company’s
aim to provide whitening toothpaste that enabled everyone to
attain high stain removal and
effective tooth whitening results,
without damaging the enamel.
This was, and continues to be,
HANG ME
U P A N Dthe core vision of the compaH A N G KM E
E E UP P A
ny and Beverly Hills Formula
K E E P M E M EN HD Y G I E N I C
H YG I E N I C
brand.
Beverly Hills Formula whitening toothpaste has been in the
oral care health and beauty
sector for over 20 years now.
Where do you think the success lies?

We continuously strive to enhance our product offering and
one of our latest developments is
Perfect White Black toothpaste.
Ideally placed to compliment
the Perfect White range, Perfect
White Black helps those who
suffer from bad breath achieve
a Hollywood smile with its high
performance ‘activated charcoal’ whitening whilst experiencing a fresh breath feeling.
Innovation, high stain removal
but low abrasivity are key factors for Beverly Hills Formula
and it is important to us to always be using the highest quality of ingredients to ensure the
quality of our products are next
to none. This is why I believe
Beverly Hills Formula remains
successful over 20 years since
the brand was born.
Tooth whitening is one of the
fastest growing markets in
the dental sector. Why do you
think this is?
In today’s image-conscious
society, more and more celebrities are opting for tooth
whitening, veneers, or other
cosmetic procedures, in order to
attain a bright, white smile, aka
the “Hollywood Smile”. Quite
simply, if people aren’t happy
with their appearance, including their teeth, this can impact
on their confidence, self-esteem
and happiness. As a result, patients are increasingly turning to
their dentists and dental hygien-

> Page 13

[13] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

oral health 13

< Page 12
ists, asking “How can I achieve
whiter teeth?” Add to this, a recent survey that revealed, nearly
one in five (18%!) find stained
teeth a real turn off (1), it’s no
wonder why teeth whitening
has become a fast growing market within dentistry.
With an array of tooth whitening products on the shelves,
what makes your whitening
toothpaste stand out from the
crowd?
Taste, brand, image and ability
to combat common dental problems are all common factors
for choosing toothpaste, but not
many look beyond the attractive
packaging and into the ingredients. One of our core values is
to continue to spend resources
on enhancing the quality of the
product and ingredients going
inside the tubes instead of excessive packaging and spin marketing. The result? Low abrasion toothpastes with high stain
removal, helping to protect the
patient’s oral health whilst enhancing their smile.
Sensitivity is a common problem, especially after professional tooth whitening. Is
there anything dentists can do
to help alleviate this discomfort for patients?
After in-surgery tooth whitening treatment patients can be
experience sensitivity, this can
be anything from a mild twinge
to having severe discomfort
that can last for several hours,
or even days. Highly abrasive
toothpastes can add to this pain,
as they continue to wear away
the enamel. For this reason,
patients should use a low abrasion, desensitising, whitening
toothpaste that contains the
ingredient Potassium Nitrate.
Those who require extra sensitivity relief with an extra whitening boost will appreciate Beverly Hills Formula Perfect White
Sensitive toothpaste.
Combining the advanced Hydrated Silica for high performance whitening with Potassium Nitrate for rapid sensitivity,
patients can start to enjoy acidic
foods and drinks once again
whilst leaving teeth looking and
feeling brighter. Regular use
will also help to prevent tartar
build-up and relieve tooth sensitivity, effectively protecting and
whitening teeth whilst allowing
patients to maintain good oral
care.
There has been some speculation that whitening toothpastes aren’t effective. Is this
true?

Many dental professionals and
patients assume that all whitening toothpastes do not live up to
their claims but this is not true.
Contrary to this, it is important
that toothpastes, which safely
and effectively whiten teeth and
are proven to work, are brought
to your patients’ attention. In
2012 a UK Dental School performed an in-vitro laboratory
study. Its aim was to measure
stain removal in order to discover how effective various toothpastes were at removing dietary
stains from Perspex, compared
to water.
The laboratory tests revealed
that stain removal was performed after just one minute.
Of the products tested, Beverly
Hills Formula Perfect White
toothpaste scored exceptionally
well, removing nearly 91% of
stains over a five minute period
(2). Meanwhile other leading
brands of whitening toothpaste
and toothpolishes scored as low
as 41%, a remarkably low percentage considering water alone
removes 48% of staining.
How about their abrasivity?
How safe are whitening toothpastes?
There is a misconception that
to removal dental stains caused
by smoking and some foods and
drinks, patients need to resort
to products that contain harsh
abrasives. This is now the case.
We recommend that patients
use whitening toothpastes that
contain Hydrated Silica, like our
Perfect White range. This low
abrasive polishing ingredient,
which is frequently combined
with the softer calcium carbonate to provide a smooth gel-like
quality, works hard to remove
plaque and stains and whiten
the teeth.
This mild abrasive is harmless and is even listed by the US
Food and Drug Administrative
as “Generally Recognised as
Safe”. Toothpaste abrasiveness
is measured by RDA (relative
dentin abrasivity) value, and any
figure over 100 is considered
to be “abrasive”. In July 2012, a
USA-based independent testing
laboratory tested the abrasivity levels of 15 toothpastes. The
results confirmed that Beverly
Hills Formula’s whitening toothpaste is less abrasive than both
regular and whitening toothpaste brands. Some brands
scored as high as 138 whilst
Beverly Hills Formula scored 95
on the Abrasivity Index Table.
We at Beverly Hills Formula are
proud of our low abrasion products and use every opportunity

to include abrasivity information on the packs, as we believe
that consumers have the right to
make well informative choices.
Finally, can we expect to see
any new and exciting developments at Beverly Hills Formula over the coming months?
We continuously strive to enhance our product offering and
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References
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[14] =>

14 restorative

Dental Tribune Middle East & Africa Edition | May-June 2015

Impeccable esthetic results with ceramic restorations
By Dr. Nelson Geovane Massing, Brazil, Passo Fundo, Brazil,
and Alexandre Santos, Brazil

he aim of any restorative treatment in anterior teeth is to re-establish
proper function and a naturallooking smile. In addition to ensuring the function and longevity of the restoration, the esthetic
expectations of the patient have
to be fulfilled.
Materials that are based on biomimetic principles allow the
natural teeth to be faithfully
reproduced in many different
clinical situations. Furthermore,
biomechanical aspects and
light-optical characteristics have
to be taken into consideration in
the restoration process.
Clinical case study
The 33-year-old patient requested an esthetic makeover for his
front teeth. The slight gap (diastema) in the upper anterior dentition, which was visible when
he smiled, displeased him in
particular. The clinical examination also revealed dark stains
on tooth 21, which had been

Fig. 1. Preoperative smile: The patient was dissatisfied
with the a 12 lignment of his front teeth.

Fig. 4. After minimally invasive preparation of teeth
12 to 22

caused by endodontic treatment
and composite restorations (Figs
1 and 2). Models were created
and photos taken in order to
thoroughly analyze the existing
situation and plan the anticipated result. The photographic

Fig. 2. Close-up: Slight gaps are visible between the front
teeth, and tooth 21 is discoloured.

Fig. 5. Custom-layered veneers in the laboratory on
refractory dies

documentation included portrait
pictures of the patient as well as
intraoral close-ups.
Subsequently, the tooth shade
(Fig. 3) was determined. The
Digital Smile Design protocol

N
US O
CALL

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ENTA
D
0
0
8
RE

O
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O
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Fig. 3. Determination of the tooth
shade

Fig. 6: The veneers were made of fluorapatite leucite glass-ceramic (IPS d.SIGN). As a result, lightoptical qualities that are similar to those of natural
teeth were achieved.

was used and a wax-up was
fashioned on the basis of the information acquired during the
planning stage. A composite resin (Systemp® C&B) was used to
fabricate an intraoral mock-up
of the planned restorations.
Selection of the restorative
material
A suitable restorative system
was chosen on the basis of
general esthetic and functional
considerations. In the following
case, we decided to take advantage of the outstanding esthetic
potential of feldspathic ceramic
and the excellent biomechanical performance of the adhesive
cementation protocol on natural
tooth structure.
State-of-the-art adhesive luting
techniques involving ceramic
conditioning with hydrofluoric
acid and silane produce reliable
bonds between ceramic restorations and natural dentition.
Moreover, adhesive cementation requires less invasive preparation of the tooth structure
and it imparts the restoration
with excellent biomechanical
properties.
Preparation and impression
taking

As a result of sophisticated developments in dental ceramics
and adhesive dentistry, it is now
possible to fabricate delicate,
ultra-thin restorations showing
outstanding translucent properties. In the present case, teeth
12, 11, 21 and 22 were prepared
to receive veneers. Since tooth
11 showed some discolouration,
more tooth structure was removed from it during preparation (removal of approximately
1 mm of tooth structure; Fig. 4).
The other three teeth required
only minimal preparation. The
canines 13 and 23 remained
untouched, since they were to
be restored with veneers that
do not require any preparation.
A silicone matrix made according to the diagnostic wax-up was
used as an orientation aid during preparation. Tooth preparation was confined to the dental
enamel in order to ensure an
effective and long-lasting adhesive bond.
The impression was taken with
an addition silicone (Virtual®)
using the double-cord technique. Subsequently, the prepared teeth were photographed
together with the shade guide
samples in order to ensure the
best possible shade match in
collaboration with the dental

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Fig. 7. The delicate ceramic veneers were prepared for seating.

laboratory. The matrix which
had been fabricated according
to the diagnostic wax-up was
used to produce the intraoral
mock-up. The composite material (Systemp C&B) was used for
this purpose and for fashioning
the provisional restoration.

For more information on admissions, please call the Student Aﬀairs Oﬃce
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Fig. 8: The fit of the individual veneers was checked in the mouth
of the patient.

> Page 16

[15] =>

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[16] =>

16 restorative

Dental Tribune Middle East & Africa Edition | May-June 2015
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< Page 14

Fig. 9. The transitions between the ultra-thin
veneers and the canines were lightly finished.

Fig. 10. Final polishing

Fig. 13: Final picture: The upper tooth row looks esthetic and very natural.

In the dental laboratory
The ceramic restorations were
created on a refractory model
using a fluorapatite leucite glassceramic (IPS d.SIGN®). Prior to
this step, we selected the appropriate ceramic layering materials with the help of the shade
determination photos. Then the

veneers were conventionally
layered on refractory dies. After
the firing process, the restorations were carefully finished.
Subsequently, the delicate ceramic veneers were prepared
for placement (Figs 5 to 7).

ADVANCED
PRESS TM

Fig. 11. After seating of the six veneers on teeth
13 to 23

Placement
The provisional restorations
were removed and the prepared
teeth were cleaned. Then the
veneers were tried in the mouth
(Fig. 8).
Try-in sequence:
- Dry try-in of each individual
restoration for the inspection of
fit
- Dry try-in of all the restorations
together in order to check the
proximal contacts
- Try-in of the restorations with
glycerine paste (Variolink®
N Try-In) for determining the
shade of the luting composite
It is of utmost importance to try
in the restorations with a tryin paste in order to select the

ADVANCED PRESS
Process

Fig. 12. Inspection of the functional parameters

most suitable shade of the luting
composite. In principle, a translucent material is selected for
cementing ultra-thin veneers
(for example Variolink N Clear
Veneer), since the natural tooth
structure and the restoration are
expected to produce the tooth
shade. Nevertheless, if the shade
needs to be specially adjusted,
try-in pastes in other shades can
be tested and used.
Once the luting composite had
been selected, the try-in paste
was rinsed off with water and
the restorations were conditioned with nine-percent hydrofluoric acid (HF) for 90 seconds.
Then they were thoroughly
rinsed with air-water spray. The

The patented ADVANCED PRESS process ensures a uniform temperature distribution from the temperature sensor of the press furnace to the inside of the
press ring.
Pressing always takes place within the ideal temperature range for pressing lithium disilicate. Thus hardly any reaction layer is created on the surface. This is
enhanced by an extermely short press time.
The result is a smooth surface and an enormous time savings!
TM

prepared tooth surfaces were
cleaned with 35-percent phosphoric acid for 20 seconds. A silane solution (Monobond® Plus)
was applied and left to react for
one minute, followed by the adhesive (ExciTE® F). A light-curing composite (Variolink N Clear
Veneer) was used to cement the
restorations in place.
The restorations were seated
according to the corresponding
protocol. After the excess cement had been cleaned up, the
composite was polymerized for
60 seconds at high light intensity
(1,200 mW/cm2, Bluephase®).
Since the canines did not require preparation before they
received the ultra-thin veneers,
the transitions between the restorations and the teeth had to be
lightly finished with a diamond
polishing system (OptraFine®).
The surfaces were finished by
moving from the restoration to
the tooth structure in order to
prevent any damage being done
to the natural dental enamel
(Figs 9 and 10).
Conclusion
The adhesive cementation of
ceramic restorations offers
a proven treatment strategy,
which provides excellent biomechanical and esthetic results.
In the described case, the nat
ural-looking and esthetic result
speaks volumes. A satisfied patient with a beaming smile was
released from the dental practice (Figs 11 to 13).

Available only in the VARIO PRESS 300e Version

Contact Information

Exclusively by:

P.O.Box: 24476, Sharjah - United Arab Emirates, Tel. : +9716 5308055, Fax : +971 6 5308077
E-mail : dt_uae@eim.ae, www.dme-medical.com

Dr. Nelson Geovane Massing
XV de Novembro Street
260 Passo Fundo | Brazil
nelsonmassing@hotmail.com

[17] =>

interview 17

Dental Tribune Middle East & Africa Edition | May-June 2015

New trends in restorative dentistry.
Approach to posterior restorations.
Dr. Paulo Monteiro
By Dental Tribune MEA/CAPPmea

r. Monteiro is coming to
Middle East to lecture
on direct restorations
of anterior and posterior teeth,
with special focus on new bulk
fill resins and he shared with us
his opinion on modern dentistry
evolution and latest technologies used in dental materials.
Following the IDS Cologne we
see a big change in the dental
industry, towards which direction do you see dentistry
heading?
Dr. Monteiro: Modern Dentistry walks towards the maximum
conservation of dental tissues
(enamel and dentin). Accordingly, materials which are able
to emulate the natural tooth tissues in aesthetics and function
have been developed.
We have witnessed in recent
years a technological revolution in dentistry. With more and
more applications, technology
in dentistry open us new doors,
new ways to go. With no doubt
the technology is not only the
present but is the future of dentistry.
Being an international speaker, what is the most important
message you would like to por-

tray to the audience?
Dentistry is constantly developing and there is a need to update
regularly.
In this sense, we should not be
stuck in the past, trying to follow
new trends if properly supported
by scientific evidence.
Don’t be afraid of new technologies, new products, new dental
restorative techniques. All this
came to help us to simplify our
daily clinical world.

“‘With more and more
applications, technology
in dentistry open us new
doors, new ways to go.”
What is your impression of
Dentistry in the Middle East?
I have not had direct contact
with dentistry in Middle East, as
this will be my first time I will
travel to these countries. However, I have followed the work of
some colleagues in this region,
which have a very high level of
excellence. So I have a very positive opinion.
Can you tell us about your upcoming lecture in Saudi Arabia?
I am excited about the opportu-

nity to visit and lecture in Saudi
Arabia.
In these lectures we will discuss
the new materials and techniques for direct restorations
of anterior and posterior teeth,
with special focus on new bulk
fill resins. We will also discuss
simple techniques to make direct restorations with a high
aesthetic level.
You will love how simple it is to
make an aesthetic restoration.
What is your opinion regarding bulk fill posterior restorative materials? What are the
major advantages and disadvantages?
I really like the bulk fill resins.
Especially the newer ones.
As a main advantage - the possibility of using large thickness
of material, lower shrinkage and
easy application. The disadvantage… Honestly only to be slightly translucent material to allow
the light pass through.
In which case would you prefer to use bulk fill composite in
the posterior area?
To be honest, in direct restorations I currently use almost always the bulk fill resins in pos-

terior teeth.
What is the risk of post-operative sensitivity with bulk fill
posterior composites vs traditional composites using traditional layering technique?
With bulk fill the risk is much
lower, due to lower polymerization shrinkage.
What are the key success factors when working with bulk
fill posterior composites?
Choosing the right composite
resin and apply it correctly.
There are bulk fill resins that are
very fluid. Usually all these more
fluid resins need to be coated
with a conventional composite resin, due to suffering more
occlusal wear. This is not the
case with the latest versions, for
example with Filtek™ Bulk Fill
Posterior, as those are materials
that can be used with a lower occlusal wear.
I would choose a resin composite that is not so fluid and which
allows me in the same time a
good and proper compaction in
the cavity and an easy modeling.

Paulo Monteiro, DMD, MSc
Dr. Paulo Monteiro obtained his
degree as a Doctor of Dental Medicine at the Instituto Superior de
Ciências da Saúde-Sul and his Master’s Degree in Dental Medicine at
the Instituto Superior de Ciências
da Saúde Egas Moniz (ISCSEM) in
Caparica, Portugal. He completed
post-graduate training in Aesthetic
and Restorative Dentistry at ISCSEM.
Currently, he works there as an
Assistant Professor responsible
for the post-graduate program in
Aesthetic and Restorative Dentistry
and is occupied in a dental practice.
In addition Dr. Monteiro is a PhD
student in Dentistry at the University of Santiago de Compostela,
Spain. He is involved in research
of new dental materials, including composite resins, dental adhesives, dental ceramics and new
digital technologies.

CopraSintec K

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[18] =>

18 implant tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

The passive abutment
For assembly, the titanium interfacial component is clamped
to the analogue on the master
model by means of the luting
screw. The luting screw ensures
that the interfacial component is
held in full contact with the implant analogue.

By Dr. Petros Yuvanoglu, Greece
and Dr. Ero Pandelias, Greece

ne of the main problems
faced by both prosthodontists and dental technicians, with regards to implant
supported dental prostheses is
the problem of producing a repeatable passive fit which would
eliminate the need for complex
and intense laboratory procedures, usually undertaken to
improve the fit of castings e.g.
sectioning and soldering.
The Passive Abutment (Fig.
1) is unique to Southern Implants and has been in clinical
use since 1998. It allows one to
achieve a predictable passive fit
of cast structures in a practical
way.
The unsatisfactory fit of prosthodontic work on implants is due
not only to the distortion caused
by the physical process of investing, casting and sandblasting,
but also from the distorting forces which develop when the casting is exposed to repeated high
temperature cycles while baking porcelain. All these parameters cause the collection and entrapment of energy resulting in
tensions, which are then transferred to the prosthetic screws.
Consequently we have fractures
of screws, destruction of the
prosthesis (porcelain fracturing)
and perimplantitis. Finally there
is breakdown of relationship between the patient and the dental
practitioner and tension among
members of the implantology
team as well (technician/dentist/prosthodontist/surgeon).
After years of research by Southern Implants, the first prosthetic
abutment with a passive fit was
presented to the dental implant
market in 1994.
The philosophy of the passive
abutment is innovative in the
field of dental implantology and
has reduced the stress experienced by the technician and the
dentist, especially when it comes
to the fit of the prosthesis.
By reviewing data from x-rays
of patients who have dental implants with fixed prostheses, one
can see marked differences between those with passive abutments and those without.
Passive fit is achieved by luting a
premachined titanium interface
component onto the finished
prosthesis, using the laboratory
master model as the blueprint
for fit. The luting takes place in
the dental lab by the dental technician. No additional clinical
steps are required.
The discrepancy between the
passive ring and implant reaches
as low as 2 microns, independent of the length of the span of
the bridge. The titanium interfacial component is kept separate
from the manufacturing of the
casting and is therefore not subjected to degradation by heatcycles or devesting and finishing procedures as a cast-to gold

Fig. 1. The Passive Abutment
Fig. 2. The Passive Abutment Assembly

Fig. 3. Comparing Fitting Surfaces

Fig. 4. Different Radiographic Appearance Of The Same Miss Fit Depending On
X-Ray Beam Angulation/Orientation

cylinder would. The integrity of
the machined part is therefore
maintained in the original condition.
The passive abutment kit includes a titanium ring, which
will not be subject to external
physical forces and is cemented
to the porcelain superstructure
after the aforementioned is cast
and polished.
Description
The Passive Abutment consists
of four components (Fig. 2)
1. Plastic cylinder - this component is incorporated into the
wax-up of the structure and thus
becomes part of the casting.
2. Titanium interfacial component (6 mm) - this pre-machined
component forms the final interface between the casting and the
implant.
3. Luting screw - this small
screw is used to clamp the interfacial component onto the
laboratory analogue during the
process of luting the casting onto
the interfacial component.
4. Prosthetic screw - this screw
retains the completed prosthesis
to the implant at final placement
and provides a compressive
force across the cement line.
Overview of use
The plastic cylinder is incorporated into the wax-up and becomes part of the cast structure.
The casting may then undergo
further laboratory processing
e.g. ceramic firing, finishing
and polishing before being assembled with the interfacial
component. The titanium interfacial component is kept separate from the manufacturing of
the casting and is therefore not
subject to degradation by heatcycles or de-vesting and finishing procedures as a ‘cast to gold’
cylinder would.
The integrity of the machined
part is therefore maintained in
its original condition.
The finished cast structure is assembled with the interfacial ring
by luting before placement in
the patient’s mouth by the dental
technician. Both titanium ring as
well as the prosthesis, need to be
sandblasted and cleaned by air
pressure and not with a ultrasonic bath.

Fig. 5. Cast Plastic vs. Passive Abutment

The finished prosthesis is then
luted to the clamped interfacial
ring using a dual-cured resin cement.
In this way the resin cement
serves as a space filler between
the casting and the interfacial
ring, thus compensating for any
minor casting and finishing discrepancies, so eliminating misfit of the casting to the implant.
At placement in the mouth, the
prosthetic screw retains the
completed prosthesis (both casting and interfacial ring together)
to the implant and maintains a
compressive force over the cement line. This is achieved because the prosthetic screw engages onto the casting and not
onto the interfacial ring. The
cement is therefore not responsible for retention of the prosthesis, but is merely a space filler.

> Page 20

[19] =>

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Diplomate American Board of Prosthodontics

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[20] =>

20 Implant tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

< Page 19
The luting screw is discarded.
The Application
The Passive Abutment is intended for the fabrication of implantsupported SCREW RETAINED
CASTINGS (e.g. crowns, bridges, mezzo-structures, cast bars,
custom posts) on one or more
implants where excellent prosthetic fit is desired. The use of a
burnout plastic cylinder allows
freedom of choice in choosing
the casting alloy. The complexity of laboratory procedures is
greatly reduced when compared
to complex casting procedures
with gold cylinders.
The Passive Abutment System is
available for direct connection
to all Southern Implants product
ranges.
Passive Abutments are also
available for Compact Conical
Abutments.
For direct connection to Externally Hexed, IT, Tri-Nex, Deep
Cone and Internally Hexed connection
Implants, both non-engaging
and engaging versions are available:
1. Non-hexed or non-engaging
versions are indicated for multi
implant case (bridges).
The non-hexed (non-engaging)
interfacial component has an internal taper fit to allow for nonparallelism of implants of up to
14 degrees per abutment i.e. 28
degrees between 2 implants.
2. Hexed or engaging versions
are indicated for single implant
cases and multi-unit custom
abutments cases.
Problems of Conventional
Cast Structures
Frameworks
incorporating
cast to gold cylinders are very
commonly used in implant reconstruction, as are castings
fabricated using plastic burnout cylinders. These castings
however are subject to signifi-

cant difficulties. Significant deterioration of the fitting surface
of the cast structure occurs as a
result of laboratory procedures
i.e. (Fig. 3)
- sandblasting of the casting
- the casting is subjected to repeated high temperature cycles
during casting and porcelain firing procedures. This results in
oxidation of the fitting surfaces
and further deterioration of fit.
- the gold fitting surface is deteriorated by multiple “fittings” on
the model, especially if the analogues are not kept clean.
The larger and more complex
the casting, the greater the likely degree of discrepancy of fit.
Hence, larger castings with fit
discrepancies are often cut and
soldered, or laser-welded. It is
commonly reported that these
attempts to improve the fit result
in even greater fitting problems
and may be amplified by porcelain firing.
Clinical implications of misfitting implant structures
Discrepancies in fit are extremely difficult to detect clinically, if not impossible where the
interface in-between implant
and superstructure is subgingival. Vertical misfits will only be
detected on x-ray, if the misfit
occurs interproximally and the
x-ray beam is oriented perpendicular to the interface.
If the discrepancy is in the bucco-lingual plane, it will not be
detected on x-ray.
Even gross discrepancies may
be missed where x-ray techniques are not optimal (Fig. 4).
Most importantly, poorly fitting
prostheses can result in:
-bacterial accumulation at the
prosthetic/implant
interface,
which will result in bone loss
around the implants (Fig.5)
-mechanical strain being ap-

plied to the implant, which may
result in bone loss
-poor preload of retaining
screws and thus more frequent
screw loosening
-fatigue loading of the retaining
screws, resulting in screw fracturing.
The Laboratory Procedure
1. Model preparation:
The appropriate analogues must
be selected and the model prepared using a silicon or rubber
soft tissue mask. The highly
recommended use of a removable soft tissue mask will allow
easy access to the analogues for
further lab procedures and will
greatly ease later assembly procedures.
2. Wax-up:
The Titanium Ring and Waxing
Sleeve are assembled on each
implant analogue, using the
brass equivalent of the prosthetic screw to hold them in place
(Fig.6). Do not over tighten, so
as to avoid distortion of the plastic sleeve. The waxing sleeve
can be cut back or added to as
needed.
The wax-up is completed and
sprued before removing the
wax-up from the model.
3. Investing and Casting:
The retaining screw must be
removed to allow the wax-up
with plastic cylinders to be lifted
from the model, leaving behind
the loose titanium interfacial
component (Fig.7). Standard
procedures are used for investing and casting. An appropriate
casting alloy must be chosen,
depending on whether a ceramic veneered bridge or cast bar is
being manufactured. Alloys that
are commonly used are:
Degunorm, Argipal, Begopal
300, Begocer-G, Pors-on 4, Degudent G etc.
Complete burn-out. The plastic
cylinder requires an oven tem-

Fig. 6. Waxing onto the plastic cylinder

Fig. 7. Removal of the wax up, ready to be casted

Fig. 9. Luting screws and interfacial rings

Fig. 10. The application of cement onto the titanium ring

Fig. 8. Refining the screw seat

perature of about 820°C for at
least 45 minutes.
As with all implant work, it is
best to de-invest ultrasonically
as opposed to blasting with sand
or glass beads. This helps preserve the sharp edges and fitting
surfaces of the casting.
4. Refining the screw seat:
The “screw seat” is the internal
ledge in the casting where the
head of the screw will seat (engage). The cast surface of the
screw seat will likely be rough
due to the casting procedure and
must therefore be refined using
special hand-held reamers (Fig.

8). (LT18-2.4, LT18-2.6 or LT182.8)
The correct diameter of reamer
must be chosen.
This is an important step to ensure proper seating and tightening of the prosthetic screw.
5. Fitting the casting to the model:
The titanium interfacial components are secured to the analogues using the small luting
screws. Do not over tighten, as
this may result in the head of the
Peek luting screw breaking off.
The casting can then be placed
over the secured interfacial
components (Fig. 9). The casting
can be easily fitted and removed
from the model without the need
to remove and replace the luting
screws. If the prosthesis needs to
be screw-retained on the model,
then one or more of the small
luting screws can be exchanged
for a prosthetic screw (the prosthetic screw secures the prosthesis to the analogue, while the
short luting screw has a smaller
head and can only retain the titanium interfacial component to
the analogue.)
6. Luting the prosthesis to the
titanium interfacial component:
After completing the fabrication of the prosthesis, sandblast
the fitting surface of the casting
and the top surface of the titanium ring. The titanium ring is
best clamped to an analogue by
the short luting screw for ease
of handling while sandblasting.
This also protects the fitting surface of the titanium ring. Avoid
sandblasting the polished collar
of the titanium ring.
After sandblasting, it is very important to disassemble and ultrasonically clean the following:
- the titanium interfacial components
- the short luting screws
- the fitting surfaces of the prosthesis
Also clean the analogues (Implant Replicas) of the model by
brushing with soap and water or
steam cleaning to remove any
debris, which may interfere with
perfect seating of the interfacial
components.
Luting of the prosthesis to the titanium rings will now take place
on the master model.
- attach the titanium rings to
the model with the short luting
screws
- apply self cure resin cement
or dual cure resin cement to the
sandblasted surface of all of the
titanium rings. Refrigeration of
self-cure resin cements will usually lengthen working time for
ease of use on multi-unit structures.
Important: Limit the amount
of resin cement being applied
to the angle between the sandblasted horizontal plane and
vertical plane of the titanium
ring (Fig.10). This will avoid excess cement extruding upwards
through the screw hole in the
casting and so inadvertently
locking the luting screw into the
cement. Definitely avoid placing
any cement in the area immediately around the head of the luting screw.
Fit the prosthesis over the titani-

um rings and settle the prosthesis firmly into place with finger
pressure to extrude excess cement. Arch castings can be left
seated under their own weight
to allow cement to harden.
Smaller bridges or single units
need to be held lightly in place
by using one or more prosthetic
screw in place (instead of using
a luting screw), to allow cement
to harden. (e.g. use the middle
screw in a three-unit structure)
IMPORTANT: Do not over tighten the prosthetic screw being
used to retain the prosthesis
during cement hardening as
this may lead in distortion of the
multi-unit structure.
7. Finishing & Polishing:
Once resin cement has hardened, remove all luting screws
and then remove any prosthetic
retaining screws so that the
prosthesis can be lifted from the
model (Fig. 11).
Attach polishing protectors or
implant lab analogs, of correct diameter to each of the fitting surfaces of the cemented
titanium rings. Remove excess
extruded resin cement using a
sharp blade, probe or hand scaler. Polish the remaining cement
line using a fine edged, lens
shaped rubber wheel and blend
the casting into the titanium ring
where needed. You will notice
that the cement line is often not
of constant thickness.
This variation is indicative of the
extent of casting misfit, which
existed and has now been corrected by the cement space of
the Passive Abutment.
Once polishing is completed,
remove the protector caps or
implant lab analogs (Fig.12)
and replace the casting on the
cleaned model analogues to inspect and verify the quality of fit
obtained. Resin cement is best
cleaned from analogues using
a brush with alcohol. The fit
would be expected to be excellent in all areas.
A titanium ring can easily be
removed by forcing a sharp
blade into the cement line, or
by punching out the ring using
the shaft of a lab handpiece drill
applied through the screw access hole (place the bridge rings
down on a folded towel for padding and give the drill shaft a
sharp tap).
Important: As this technique relies absolutely on the accuracy
of the master model to achieve
passive fit of the prosthesis, it is
vital that accurate impression
techniques be used and that
the quality and condition of the
model and analogues be maintained at all times.
Try-in procedures
Should it be necessary to try-in
a passive abutment case (i.e. the
rings are not yet cemented into
the framework) the following
method may be followed:
a. Remove the temporary abutments from the implants.
b. Place some petroleum jelly
(“Vaseline”) or chlorhexidine
gel around the head of each

> Page 21

[21] =>

implant tribune 21

Dental Tribune Middle East & Africa Edition | May-June 2015
< Page 20

It is an advantage of the Passive
system that the fitting surfaces
can be removed from the casting
to avoid damage by heat cycles
during the repair process and
then be refitted.
Delivery of the Final Prosthesis
Once the final prosthesis is
placed into the patient’s mouth,
peri-apical X-rays should be
taken in order to verify the positive fit onto the implants. The
x-ray beam should be oriented
perpendicular to the implant/
prosthesis interface in older to
increase the chances of detecting a potential discrepancy (miss
fit).
Eliminating a Miss Fit
In case that a miss fit is detected,
make sure that no soft or hard
tissues are interfering with the
positive sitting of the prosthesis.
As mentioned above Passive
Abutments can eliminate all discrepancies introduced into the
prosthesis during the laboratory
steps of the manufacturing.
If a miss fit is detected, this is attributed to one of the following
reasons:
a. distorted implant impression
b. increased implant component
tolerance
c. distorted plaster implant model
In order to eliminate a miss fit, a
new implant impression should
be taken and a new plaster implant model should be poured
again. The laboratory technician
is going to use the new implant
model as a blueprint in order to
recement the passive abutments
(Fig. 13).

Contact Information

Dr. Petros Yuvanoglu D.M.D.
summa cum laude, Cert. Prosth.
(TUFTS U.S.A.). Prosthodontist.

Dr. Ero Pandelias BDS (Wits)
Dr. Ero Pandelias qualified as a
dentist in 1987 from the University
of Witwatersrand , Johannesburg
in South Africa. After 10 years private practice experience in the
restorative phase of implants she
became the CEO of Southern Implants Greece in 1998 & the Director of Southern Implants JLT
in Dubai in 2012. She is married to
the Oral & Maxillofacial Surgeon
Dr Costa Nicolopoulos & they have
2 daughters Andriana & Eleni who
are both medical students.

Dr. Petros Yuvanoglu is co-director of the Branemark Osseointegration Center Dubai. He qualified
as a dentist in 1995, receiving his
dental degree summa cum laude
from Semmelweis University in
Budapest, graduating with exceptional high grade, top of his class
as valedictorian. He has lectured
extensively on the “Same Day
Implants & Teeth” reconstruction protocol. Together with Dr.
Costa Nicolopoulos (Oral & Maxillofacial Surgeon), they are the
cofounders of “Same Day Dental
Implants” Clinic in Dubai Health
Care City, U.A.E.

Fig. 11. Removing the prosthesis from the model

Fig. 12. The Passive Abutment is
cemented, protected with a lab analogue and polished

Contact Information

Fig. 13. Eliminating a Miss Fit

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implant using a syringe with a
blunt delivery tip.
c. Place the loose Passive rings
individually into position on the
implants and press the down
into place using a flat-ended
“plastic” instrument. When the
rings are seated, the gel helps
hold them in place. The soft tissue surrounding the rings also
holds them in place quite well.
d. Place the metal structure over
the rings in the mouth, taking
care to align the casting properly
so as to not disturb the rings.
e. Screw retain the structure by
placing a few prosthetic screws
in strategic places.
f. When removing the frame,
take care of any rings that may
drop. Some rings may be found
on the removed frame while others may be left on the implants.
Count the rings to make sure
you have all of them.

• Weight only 70g.

As a result of those actions the
new radiographic examination
should reveal no discrepancies
to the fitting of the prosthesis
onto the implants.
Conclusion
The Passive Abutment from
Southern Implants allows one to
achieve a predictable passive fit
of cast structures in a practical
way. It’s easy to use, cost effective and has repeatable results,
which eliminate the need for
complex and intense laboratory
procedures like sectioning and
soldering.

For further information,
contact your local dealer
or B.A. International
www.bainternational.com
Lithium Battery

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Northampton, NN2 6NE, England. info@bainternational.com

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60mm

30/03/2015 13:40

[22] =>

22 industry

Dental Tribune Middle East & Africa Edition | May-June 2015

Super-high translucent zirconia Ceramill
Zolid FX for highly
aesthetic anterior and
posterior restorations
By Amann Girrbach

eramill Zolid FX – this is
the strong alternative to
lithium disilicate, as the
super-high translucent zirconia
blanks from Amann Girrbach
can now be used to fabricate
highly aesthetic monolithic or
anatomically reduced restorations in the anterior region and
up to 3-unit bridges in the molar
region without having to forego
the excellent material properties
of zirconia. In addition, Ceramill
Zolid FX does not age, which
ensures long-term strength
and stability of the restoration.
Ceramill Zolid FX is processed
and fitted in the patient’s mouth
without additional expense and
also using standard luting material, as is the usual practice with
zirconia restorations.

The STRONG alternative
to lithium disilicate.

In accordance with the integrated product philosophy of Amann
Girrbach, Zolid FX is not a single product but a whole system
solution consisting of material
and method.

Ceramill Zolid FX

A coordinated staining concept
will therefore soon be available
for Zolid FX Classic, which enables precise, reliable staining
according to the VITA classical
shade guide.
Amann Girrbach will also soon
supply the super-high translucent zirconia blanks Ceramill
Zolid FX Preshades for restorations, which are fabricated as
efficiently as possible without a
staining process.

By Dental Tribune MEA/CAPPmea

E EXP
IV

mann Girrbach started
its activities in the Middle
East region in 2010 and
has been growing ever since.
Dental Tribune MEA / CAPPmea
has the pleasure to interview
Mr. Abdo Salem, Sales Manager
MEA to find out more about the
company in the area.

Interview with
Abdo Salem Amann Girrbach
Sales Manager MEA

10th CAD/CAM
Conference Dubai
8 - 9 May

Dubai

Safinah Ballroom,
Booth no. 12“

Super-high translucent
zirconia – now also for
anterior restaurations.
Beirut | Lebanon I Fon +961 3133911
mea@amanngirrbach.com
www.amanngirrbach.com

Dental Tribune_ET1504_Zolid FX_376x146mm_4c_AG4837_EN_v04.indd 1

09.04.15 08:50

Dental Tribune MEA: Mr. Abdo
Salem, congratulations on the
continuous achievements at
the innovative Amann Girrbach. How do you explain
the constant success to innovate and serve your customers in the MEA region over the
years?
Abdo Salem: Amann Girrbach
started its sales activities in MEA
in 2010 and has strengthened its
presence here by having a dedicated team based in Beirut offering Helpdesk support in Arabic,
French and English speaking

Abdo Salem, Sales Manager MEA

languages as well as a technical support and assistance team.
Furthermore we established
an AG training center based at
the Antonin University where
a professional instructor with
dental technician educational...

Lab Tribune
Note:

Continuation in Lab Tribune
(Insertion)
> Page 2C

[23] =>

interview 23

Dental Tribune Middle East & Africa Edition | May-June 2015

The new dental care system proven to
reverse the enamel erosion process
ByDentalTribuneMEA/CAPPmea

UBAI, UAE: Monday
16th of February 2015,
over 180 dental professionals gathered at the Armani
Hotel Downtown Dubai, UAE
for the launch of the new dental care system which proves to
help reverse the early and invisible stages of the enamel erosion
process. Dental Tribune MEA/
CAPPmea interviews Unilever
expert Dr. Fred Schafer on his
views.
Dental Tribune MEA/CAPPmea: Dr. Fred Schaefer, what
is NR-5 or rather Regenerate?
Dr. Fred Schaefer: Regenerate
Enamel Science™ is a dental
care system. It is the first system
able to help rev erse the early,
invisible stages of the erosion
process, and regenerate enamel
with exactly the same mineral
of which tooth enamel is made.
The Regenerate system contains
the exclusive NR-5™ technology
with 5 international granted and
pending patents.
Regenerate Enamel Science™ is
a completely novel way to apply
effective anti-erosion enamel
care because it combines an
Advanced Toothpaste for daily
brushing with a Boosting Serum for direct application of the
NR-5™ technology onto tooth
enamel on three consecutive
days once a month.
The NR-5™ technology is a
unique combination of calcium
silicate, sodium phosphate and
fluoride. Whilst standard fluoride toothpastes help to protect
from enamel erosion, clinicallyproven Regenerate Enamel Science™ is the first system able to
help reverse the early invisible
stages of the erosion process and
regenerate enamel with exactly
the same mineral (hydroxyapatite) from which tooth enamel is
made.
How has Unilever’s new NR5™ dental care system been
proven to reverse the enamel
erosion process?
To answer this question we
need to understand first how
the NR-5™ technology works.
When brushing calcium silicate
and sodium phosphate combine
with saliva to form hydroxyapatite. Firstly the calcium silicate
particles deposit (stick) onto the
surface of enamel. The calcium
silicate particles then trigger
the formation of crystals of hydroxyapatite on the tooth surface.
Therefore the first step in proving the NR-5™ technology was
to investigate the formation of
hydroxyapatite crystals. Detailed measurement and analysis of the deposited layer – using
sophisticated microscopy and
x-ray technology – did indeed
prove that the deposited layer is
hydroxyapatite.

be very effective. Given the similarity in the mineral of which
bones and teeth are made we
postulated that the same technology could prove beneficial
in regenerating acid-damaged
tooth enamel.

The second step was
to study in the laboratory whether the invisible erosive damage of tooth enamel
could be restored. A
series of studies using small pieces of
enamel were carried out according
to
internationally
accepted protocols
and procedures. The
enamel
samples
were analysed and
measured to determine the beneficial
effect of the NR-5™
toothpaste and the
direct
application
boosting serum.
The results of these
studies showed:
the
combined
treatment of NR-5™
toothpaste and NR5™ boosting serum Dr. Fred Schaefer - Unilever expert
provided 82% recovery of enamel hardness after
erative benefit to acid-damaged
three days.
- the NR-5™ boosting serum tooth enamel than a normal
gave a 43% benefit compared to toothpaste.
the NR-5™ toothpaste alone.
- the combined treatment of NR- What was the motivation and
5™ toothpaste and NR-5™ boost- inspiration to produce such a
ing serum provided significantly formulation over ten years of
greater recovery of enamel sur- research and development?
face micro-hardness in compar- The motivation was to give the
consumer an improved denison to a normal toothpaste.
tal care system specifically deFinally, the NR-5™ toothpaste signed to help against the chaland NR-5™ boosting serum lenges our modern, healthy
were tested in human volun- diet pose to tooth enamel, The
teers. The results confirmed that inspiration came from research
the combined use of the NR-5™ into the repair of bone in which
toothpaste and NR-5™ boosting a calcium silicate – phosphate
serum provided a greater regen- technology had been shown to

How will Unilever convince
dental professionals that the
new NR-5™ Regenerate System is better than its predecessors and that is should replace
the everyday regular toothpaste used?
Unilever has carried out extensive basic and applied scientific
research on this new technology and provided clear proof of
the effectiveness of the NR-5™
toothpaste and NR-5™ boosting serum. The main results
have been published in a peerreviewed scientific journal
and are available to academic
researchers and dental practitioners worldwide. We are convinced that the daily use of the
NR-5™ toothpaste combined
with the direct application of
NR-5™ boosting serum – a completely novel and unique way of
using an oral care product – will
significantly help consumers in
protecting their tooth enamel
from damaging effect of the erosive acid challenges our modern
diets and life styles bring.

NR-5™ boosting serum together.
Serum is for 190 AED and Toothpaste for 60 AED.
What is your view on Dentistry in the Middle East and do
you think the NR-5 will be successful in this region?
The dental profession in the
Middle East is highly sophisticated and of world-class standard.
Likewise, the consumers in the
Middle East represent a global
picture of dental care needs and
oral hygiene practices. As noticed in other regions, the relatively high living standard has
increased the risk of dental erosion from modern diet and lifestyle, for example consumption
of carbonated drinks and fresh
fruit such as oranges. For these
reasons, we see a clear need to
give the consumer an improved
product system to help maintain
healthy teeth able to withstand
the challenges of modern life.
We are convinced that NR-5™
toothpaste and NR-5™ boosting
serum will therefore have a big
role to play in this and be a success also in this region.

Is it so that the advanced
toothpaste also has to work in
conjunction with a Boosting
Serum to get the full effect? If
so what are the prices for both
the toothpaste and serum for
the MEA region?
Our studies have shown that the
best effect can be achieved by
using the NR-5™ toothpaste and

Contact Information
For further information, please
contact:
Rola Awad
PR Executive, Unilever
E-mail: Rola.Awad@unilever.com
Nikhita Phulwani
PR Executive, Unilever
E-mail: Nikhita.Phulwani@
unilever.com

Your Practice. Our Priority.
This upcoming great event will take place in Dubai
at the Jumeirah Emirates Towers with international Speakers:

Save
the Date!

Dr. Stuart Frost (USA)
How about Finishing beautifully with the Damon System!
●●●● ●

Dr. Jeff Kozlowski (USA)
Enhancing Efficiency and Effectiveness through
Digital Orthodontics
●●●● ●

Dr. Philippe Van Steenberghe (Belgium)
Early Elastics : a new world to explore
●●●● ●

Dr. Hans Seeholzer (Germany)
Marketing in orthodontics: tips and tricks to be a
successfull and modern orthodontist today

2
MENA SYMPOSIUM
DUBAI - DECEMBER 3rd to 5th - 2015
ND

●●●● ●

Dr. Andrey Tikhonov (Russia)
Misunderstandings concerning Damon System
●●●● ●

Dr. Zakaria Bentahar (Morocco)
How to improve efficiency with passive self-ligating brackets?
●●●● ●

Detailed program coming soon on our websites:
www.ormcoeurope.com / www.ormco.com

Pre-congress December 3rd: Hands-on

[24] =>

24 clinical

Dental Tribune Middle East & Africa Edition | May-June 2015

Clinical case study:
esthetic anterior restoration with VITA SUPRINITY
By Daniel Carmona Cando,
MDT, Spain

nitial situation
The case documentation
shows a 39 year old patient
who presented at Dr. Diego Alexander Cardenas’ practice in
Barcelona, Spain, with two aging metal-ceramic crowns and
loss of soft tissue in regions 11
and 21 (Fig. 1).
Following comprehensive consultation, she opted for a new
crown restoration fabricated
using VITA SUPRINITY. Crucial
in this respect was the unique
characteristic of this new material that combines the esthetic
potential of a glass ceramic with
the improved strength provided
by reinforcement with zirconia.

Fig. 1. Initial situation

Fig. 2. Preparation for the post abutment fabricated using VITA ENAMIC

Fig. 3. Virtual design of the anterior
crowns

Fig. 4. Try-in of the milled VITA SUPRINITY crowns prior to crystallization

Fig. 5. Following reduction using cutback technique

Fig. 6. Try-in of the crystallized, and
as yet unveneered VITA SUPRINITY
crowns

Fig. 7. Crowns veneered using VITA
VM 11 successfully cover the dark
stumps

Fig.8. Final result

Complexity and material selection
Just how complex this case actually was only became apparent

following removal of the inadequate restorations for preparation: the tooth stumps were
strongly discolored and fitted

with gold metal abutments. The
question needed to be addressed
as to whether the planned restoration could mask this suf-

ficiently in order to achieve a
satisfactory result from a visual
perspective. In the LABORATORIO DENTAL FONTCAR laboratory, we met this challenge by
combining the esthetic possibilities afforded by VITA SUPRINITY using the cutback technique
with the low-melting fine-structure feldspar ceramic VITA VM
11.
Milling and reworking
The inLab MC XL system (Sirona Dental GmbH, Wals, Austria)
was used for virtual design and
milling of the crowns. Following
the CAM process, reworking of
the new high-performance glass
ceramic should only be carried
out at low pressure using finegrained diamond-tipped milling
tools as well as special polishing
instruments. For cost-effective
surface processing that is gentle on the material, the technical and clinical versions of the
VITA SUPRINITY Polishing Set
are recommended. For crystallization firing, any vacuum furnace that supports slow cooling
can be used. The crowns can be
placed directly on to honeycomb
firing trays with platinum pins,
without using firing paste.
Final result
Despite the unfavorable initial
situation, VITA SUPRINITY enabled a comparatively good final
esthetic result to be achieved in
highly efficient fashion, restoring the patient’s natural smile.
The expectations and hopes of
the patient and the entire treatment team were met in full.
We would like to thank master dental technician Thomas
Gausmann for his enormous local support!

About the Author
Daniel Carmona Cando
A master dental technician from
Barcelona, Spain, uses the following complex patient case to
report on how laboratory users
can achieve excellent results with
VITA SUPRINITY restorations.
This article provides a step-bystep explanation of how VITA
SUPRINITY and the VITA VM 11
veneering ceramic can be used to
achieve esthetic results in a challenging clinical scenario.

[25] =>

EVENTS 25

Dental Tribune Middle East & Africa Edition | May-June 2015
< Page 1

Torsten Oemus further pointed
out that one of the main implications of these trends was the
growing importance of communities working in the field
of dentistry. This development
offers promising opportunities
for Dental Tribune International
as well. The digital, educational,
and event-related elements of
the company’s product portfolio are becoming increasingly
important in this context. In response to the growing demand
for digital dentistry technologies,
Dental Tribune MEA / CAPPmea
intends to apply its extensive expertise in organizing CAD/CAM
& Digital Dentistry International
Conferences, in order to provide
support to the Digital Dentistry
Show (DDS) launched by DTI
in Milan, Italy. Altogether, there
will be six Digital Dentistry
Shows in 2015 carried out in
cooperation with similar major
events in Athens, Moscow, Budapest, Shanghai, Istanbul, and
New York.

Dental Tribune MEA / CAPPmea
on-line page for the Middle East.
The hard working day finished
with a delicious partner dinner
where networking and discussions continued. On the second
day, workshops in different topics took place helping the new
partners who recently joined get
up to speed.

Another fresh development that
has become part of the DTI portfolio is the innovative e-commerce plug in for the dental-tribune.com website. Its layout now
features selected products in the
company profile and in news
articles by including external
links to local on-line retailers. In
this way, the company is offering dealers and manufacturers
a platform to show their products and thus generate leads
and sales. The facility is already
functional and being used on the

Dental Tribune MEA / CAPPmea, covers the third largest region in the DTI Portfolio and has
grown with tremendous speed
over the three years. The company provides the largest dental media distribution in MEA
through bi-monthly printed
publications, daily on line news
and e-mailed newsletters. The
Dental Tribune MEA / CAPPmea
media reaches regularly over
45,000 dental professionals in
the MEA region and, together
with DTI, provides information

Ritter
made in germany

DT Publishers meeting, Cologe, Germany

services to over 800, 000 dental
readers worldwide.
Impressions from the IDS
Week – CAPP in Cologne
As usual, Dental Tribune was
the best performing Media at
IDS. DTI further published five
today publications – the IDS official trade show newspaper, an
ultimate business guide for visitors and exhibitors.
Oemus Media Group, which is
the German counterpart of Dental Tribune, broadcasted live
news events with active 24/7
coverage of the International
Dental Show during the whole
period of 10-14 March. As part of
the duty, a dedicated on-site editorial team was equipped with
live studio tools and a production team operating from within
the soundproof walls of the Dental Tribune Media Lounge edito-

rial room. Dental Tribune MEA
/ CAPPmea, as part of the team
worked closely with the organizers and dental societies to cover
IDS press conferences, lectures,
presentations and contests. In
addition, exclusive interviews,
industry reports and image
galleries have been published
in newspapers and on-line at
www.dental-tribune.com. Subscribers to the Dental Tribune
MEA / CAPPmea enewsletters
and social platforms have received exhibition highlights and
news every day. Furthermore,
an e-paper version of the respective daily issue was sent out
through e-newsletters. All press
conferences have been covered
by Dental Tribune representatives and published live in over
24 languages.

industry with the cozy friendly
atmosphere and excellent ambience for networking. From
morning until evening, the
lounge welcomed B2B industry “movers and shakers” and
dentistal professionals to meet,
network, plan new marketing
tools and advance their business interests. Dental Tribune
International further invited its
partners to a number of cocktail receptions to the DTI Media
Lounge. During the receptions,
attendees received business updates on international markets
and had the opportunity to connect with their peers and leaders
from the dental industry. The
feature events included a Russian Night, a CHANNEL 3 Night,
a Chinese Night, and a Brazilian
Night. These evenings underlined key points in the respective dental markets focusing on
latest movements. The DTI Media Lounge was once again the
host of the elite dental industry
professionals and high-end international dentists.
CAPPmea at IDS 2015
For the third time CAPPmea
experienced a very successful
presence at IDS Cologne sparking up large interest within
the industry through its Dental
Tribune MEA Media and CAPPmea’s educational programs.
CAPPmea is the only UAE based
company to exhibit for the last
6 years at IDS Colgone. With its

Once again, the Dental Tribune
Media Lounge surprised the

,
t
h
g
i
sr !
´
t
i
,
t
f mate
e
l
s
´
It s Ulti
it´

> Page 28

Ritter Ultimate Comfort
left and right swivable version
l Complete water unit can be shifted on the fly to left
and right hand treatment

l Strong and heavy patient chair with 5 programs
l Assistant element with 4 holders and control panel
for all chair movements

l Delivery system with hanging hoses,

Borden or Midwest, 6 inserts/positions for instruments

l Water unit with cuspidor movable, made of porcelain

Henry Schein Dental, Dr. Ghassan Nasser Hussein, Sales
and Marketing Director (Henry Schein)
Middle East and North Africa, Mobile: +971 50 4813292,
Tel: +971 6 5252842, Fax: +971 6 5531291
E-mail: ghassan.nasser@henryschein.com
Ritter Concept GmbH, Germany, Christian Findeisen
Sales and Key Account Manager , Middle East/ Africa
Ritter Concept GmbH, Mobile: +971 56 9578689
E-mail: christian.findeisen@ritterconcept.com
www.ritterconcept.com

*** Exclusively distributed by Henry Schein Middle East ***

[26] =>

Maintain your patients’ confidence and
satisfaction with their dentures by helping
them overcome daily social, emotional and
physical challenges.
Help your patients eat, speak and smile
with confidence with the Corega® denture
care regime.
Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For reporting any Adverse Event/Side Effect related to GSK product
please contact us on contactus-me@gsk.com.
Date of preparation: June 2014, CHSAU/CHPLD/0008/14b
We value your feedback
Saudi Arabia: 8008447012
All Gulf and Near East countries: +973 16500404

[27] =>

Dentures contain surface pores in
which microorganisms can colonise.1
Corega® cleanser is proven to penetrate the biofilm*
and kill microorganisms within hard-to-reach surface pores.2

Help your patients eat, speak and smile with
confidence with the Corega® denture care regime.

SEM images of denture surface.
*In vitro single species biofilm after 5 minutes soak
References: 1. Glass RT et al. J Prosthet Dent. 2010; 103(6): 384-389.
2. GSK Data on File, Lux R. 2012.

Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For reporting any Adverse Event/Side Effect related to GSK product
please contact us on contactus-me@gsk.com.
Date of preparation: June 2014, CHSAU/CHPLD/0008/14c
We value your feedback
Saudi Arabia: 8008447012
All Gulf and Near East countries: +973 16500404

[28] =>

28 events

Dental Tribune Middle East & Africa Edition | May-June 2015

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< Page 25
ten years experience in the Middle East and having facilitated
over 250 CME dental meetings
with over 52,000 international
participants, the company presented its latest innovative dental solutions to new and existing
industry partners.
IDS Cologne has once again illustrated the importance of Digital Dentistry hosting the latest
trends and developments in the
industry. The show has served
as yet another reminder that
digitalization
is taking over in
14ER3194 Dental Tribune_A4_Layout 1 12/2/14 4:15 PM
Page 1
Dental Tribune Media Lounge
dentistry in all fields. More and

more companies are bringing
out digital systems.
For the first time after IDS, the
upcoming 10th CAD/CAM &
Digital Dentistry Int’l Conference on 08-09 May 2015 in
Dubai will showcase the latest
trends and developments in Digital Dentistry in the Middle East
region. In December 2015, CAPP
will also organize the 3rd AsiaPacific, CAD/CAM & Digital
Dentistry International Conference in Singapore, bringing the
latest systems to the AP region as
well bundled with education.

Yearly, CAPPmea hosts four iconic events in MEA and Asia-Pacific. CAD/CAM & Digital Dentistry
Int’l Conference and Dental-Facial Cosmetic Int’l Conference
in Dubai and the newly developed CAD/CAM & Digital Dentistry Int’l Conference and Dental Technician Forum – Part of
IDEM in Singapore(December
2015 & April 2016).
Amongst the new trendsetters,
CAPPmea further presented its
extended dental media outreach
in Iran (bi-lingual English/Farsi), adding an additional 25,000

print run to its portfolio and
distribution reaching a total of
65,000 dental professional readers of Dental Tribune MEA and
800, 000 worldwide.

Contact Information
Dr. Dobrina Mollova
Managing Director
Dental Tribune MEA / CAPPmea
dr.mollova@cappmea.com
www.cappmea.com
www.dental-tribune.me

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[29] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

Have fun everyday
just some of hte challenges.
You know what I am talking
about, remember what you
think about the accuracy of the
shape, the shade, I cannot even
mention the labs that tell you
that the restoration is wrong because of your print. This annoyance happens everywhere in the
world, maybe it does not bring
any consolation to you, but you
might feel less lonely.

Dr. Dominique Caron

By Dr. Dominique Caron, France

had a dream. In 1989 you
still might have been a small
child but I was already running my own practice for 2 years
and I was facing what many of
you, dentists, are facing today:
I was wasting my time with temporaries. The Lab always took
too long and was not always on
time. The prosthesis done were
not always fitting. These were

I had a dream. A dream to be
in sole command of my boat! A
dream? You don’t need a fairy
godmother for that, just keep in
touch with the profession and
the wise people who will give
you the necessary information
(Dental Tribune MEA / CAPPmea is doing the ground work
for you, enjoy).
Once upon a time, 26 years ago,
we already had electricity (yes
we did), Sirona was still Siemens
and I was told about a strange
saga that started in 1985 in Switzerland. In a valley, between
trolls and cows, some kind of
Steve Jobs, Dr. Mormann and
Brandestini were developing a
system to make your prosthesis
in minutes from 100% ceramic,

referral clinic 29

“In 1989 in France, we were 85 dentists having CEREC
amongst 42.000 dentists at the time.”

in one session chairside. Aliens
were amongst us and I did not
know about it: The flying saucer was called CEREC 1. It was
slow, raw, compared to the latest
CEREC it was like comparing
the first Macintosh 128k to the
latest Macbook.
You had to believe in it; anyway,
it was the rise of a new era in
front of your eyes. The time to be
aware was in 1989 when came
the CEREC 2, first machine
bringing efficiently from the lab
in to your hands: A flying saucer you can actually drive. This
could have been just one more
tool, one amongst the many new
ones you see every year, except
the fact that you soon understand that this particular one
will change so much of your
behavior, it will make you jump
into another world.
As for same cutting-edge innovations, you are dealing with
people who target quality, ethics,
safety, improvement more than
short-term business; this might
be appealing to some of you.
Once using this system, you become part of some kind of club
gathering colleagues who look

out for the best of their patients.
In this “club”, there is a kind of
friendly ethics between fellows
who have the same aims, nothing to prove to each other, without the need to show off. They
share information with a very
open mind. No competition,
rather family minded atmosphere. Is that the actual life that
you have now? Does it sound too
good to be true? No, it is not. It
has been my actual fairy tale story for 26 years now. Beyond the
nice story however, what might
be your expectation?
With Sirona, you draw your own
ceramic yourself with the shape,
the shade, the translucency
you want. Who better than you
knows what you want? Regarding accuracy, the lab will not
spoil your skills: You choose the
width of the gap for the bonding.
Mine have 30 microns (a bacteria: 5 to 10 microns). Never forget your best foe is bacteria.
Be accurate and get the means
for it. Take some minutes of your
time, imagine that you are the
patient, what can be the most
upsetting thing? As a patient you
do not feel any pain but behind
you, a hidden guy is looking inside of your mouth to say: Wow,
it is awful, you need an inlay
here and there, terrible, how can
you stand this, you need crowns
there, there and there but maybe
you do not feel you need it. Easy
to become suspicious, isn’t it? If
you as a patient see step by step
what your problem is, don’t you
think you will understand better
and feel more relaxed?
I always draw the reconstruction
in front of the patients it is an entertainment for them. When you
show and explain what you do,
your patients will trust you even
more.

Dr. Dominique Caron and CEREC BLUE CAM

Dr. Dominique Caron CEREC 3D
Omnicam

When Sirona Galileos 3D Scan integrates CEREC
CEREC 1
CEREC 2

Their crown, the one and only,
just for them, is drawn and
carved in front of their eyes: it is
magic. You are no longer just a
dentist you become a magician.
Your patients are happy and so
are you.
You are working in the dental
field, the only medical field in
which you can keep the whole
process under your control: You
do the diagnosis, the treatment
plan and the actual treatment,
including the prosthesis. You
must enjoy the “do it yourself”
part. Enhance your skills; your
patients will love to see an artist.
I invite you to a little time travel
again, remember the laptop
(if any) that you had when you

were a student, your mobile
phone? You see the world is
moving fast, don’t be late.
Match the expectations, with this
“state-of-the-art” technology : It
is a state of mind your patients
will appreciate, they will ask for
the treatment themselves.
CEREC may be a smart tool
for you: 28 million restorations
already done, metal free, no
chemical, non-allergic, no biological issues. For 26 years now,
after thousands of restorations,
many lectures, and presentation
to the French Academy, I work
more and more with CEREC.
For 26 years every morning, I
am happy to come to the clinic
and work with the best tools.
When you know you do the best,
your patients feel it, a better life
for everybody. It is what is called
in French “L’art Dentaire”: Dental art, it is beyond technical.
When you grow up, only the cost
of your toys is changing but it is
worth it. Be proud of what you
do, be ethical.
In the UAE we are lucky, our
outstanding colleague, Dr. Dobrina Mollova built a unique
structure CAPPmea that organizes the best dental meetings,
don’t miss the opportunity, come
to the next CAD/CAM event and
join the CEREC team.
In 1989 in France, we were 85
dentists having CEREC amongst
42.000 dentists at the time. We
preserved from that time a kind
of family spirit you can still feel
when you visit the Sirona booth.
Nowhere else, you will see colleagues coming and staying
just to hear and talk about what
they like. Have a look yourself
next time. Everyday I make 5
or 6 CEREC restorations and after the prints are taken I say to
my patients who looking at the
screen: “Tea? Coffee? Now enjoy
your holidays, and for me time to
use my play station.”
Join the family. Stop working
and start playing!
Editorial note: Further details
available from the author.

Contact Information
Versailles Dental Clinic
Al Razi Building 64, Block A ,
First Floor , 1006
Dubai Healthcare City
Dubai, UAE
www.versaillesdentalclinic.com
+971 4 4298288

[30] =>

30 referral clinic

Dental Tribune Middle East & Africa Edition | May-June 2015

The first ISO 9001 certified dental centre
By Dr. Ammar Alekri, Bahrain

osmetics is a necessity.
We then start talking
about the cosmetic treatment of teeth of which Dr. Alekri
said explaining: “There is a misconception about what is called
teeth cosmetics that it is some
sort of luxury. This is not accurate because most of these treatments are necessary.”
Dentist, oral and dental surgeon
Dr. Ammar Alekri stressed that
most of the treatments the teeth
need are necessary to achieve
the perfect health of the mouth
and teeth, and that is what is
called “a cosmetic treatment”,
also necessary to maintain
healthy teeth.
He further explained that the
role of dentists is preventive in
the first place and therapeutic
in the second. He continued:
“Yet, the general culture that we
have now directs the individual
not to resort to the dentist until
after feeling pain. We are aiming
at changing this cultural pattern
and are trying persistently to
persuade everyone of the importance of maintaining the periodic examinations, especially
dental examinations.”
Prevention is better than cure
Dr. Ammar Al-Ekry started his
speech talking about hopes of

“Cosmetic Dentistry is a
necessity”

Dr. Ammar Alekri, Bahrain - owner of the first ISO 9001 certified dental centre

vide the appropriate treatment
for them.
Dr. Ammar further mentions
that many of those who are treating themselves from tooth decay
or gum disease or other diseases
believe that the treatment ends
at the last session of the therapeutic program, thus neglecting
the periodic examinations. They
only resort to the dentist when
they feel pain again.
He pointed out that implanting
missing teeth due to a disease
or a symptom is very necessary
for a proper chewing process of
food. He said: “From a general
image prospective, losing teeth

at maximum. “Another example that illustrates the need for
“cosmetic dental treatment” is
obvious for any patient who underwent nerve treatment. The
treated tooth becomes rigid,
similar to an object made of
glass and prone to break, it becomes very important to protect
the tooth by cocooning it with
what is commonly called “a
crown”. Dr. Ammar added: “it
is ironic that insurance policies
cover nerve treatment as a disease, while not covering the second part of the treatment which
is protecting the tooth with “a
crown” from any break. The
insurance policy covers removing the broken tooth, yet doesn’t

Dr. Ammar Alekri Dental Centre in Bahrain. ISO 9001 certified.

dentists to take a more preventive than therapeutic role with
patients of dental clinics. He said
that: “The general culture in
our society creates a correlation
between consulting a physician
and the disease. This concept
is incorrect, and this pattern of
thinking should be changed.”

distorts the general image of the
face, and from a practical prospective, this leads to weakening
the chewing process and speech
in which the integrated teeth
system represents the main part.
Thus, it becomes necessary to
implant a tooth to compensate
for the lost one.

He pointed out that it is very important for the person to visit the
physician to perform the necessary examination periodically.
He explained: “When a person
specifies a periodic schedule
to visit the dentist once every 6
months, this will allow the dentist to examine the mouth and
teeth, and remove lime from the
gum and teeth as well as other
accumulations if needed. At the
same time, the dentist will be
able to identify any medical conditions in an early stage and pro-

He pointed out that teeth implants are very easy and the
chances of pain are little with
the development of treatment.
He added: “Especially that the
center possesses the 3-D panoramic X-ray machine which
diagnose and facilitate the planning process of the treatment
with the optimum accuracy.”
Dr. Ammar further stressed that
the process of implanting the
artificial tooth in its place takes
a period between 5-10 minutes

cover teeth implanting considering this to be cosmetic surgery.
He pointed out the importance of
validating insurance responsible
and reconsidering this topic very
well to define the difference between treatment and cosmetics
in mouth and teeth diseases.
Modify your life style
When addressing the issue of
disease prevention, Dr. Alekri
said: “An individual can protect
himself from a lot of teeth and
gum diseases by modifying his
life style, which causes a lot of
health problems at the level of
oral health and overall health”.
Dr. Alekri added: “Dietary habits
and quality of food that we eat,
generally, lack adequate servings of vegetables, fruits, milk
and milk products. These food
types contain a small percent-

age of sugars and rich with basic
components that human body
needs.” He also added: “In contrast, a food and beverages that
we eat daily are rich in sugars,
acids and industrial colors and
the most prominent example of
this are soft drinks. I have found
that it the cause behind a lot of
the mouth and teeth diseases
that afflict Center clients in the
age group between 12-22 years.”
Dr. Alekri said: “The habit of eating dinner late is very bad and
affects the teeth in the long run
even while maintaining washed
before going to sleep.”
Dr. Alekri also expressed his dissatisfaction with the significantly spread of the habit of smoking
among Bahrainis between males
and females, indicating negative
effects on the teeth and mouth.
He hoped that the society could
change the dietary patterns and
trend towards healthy dietary
patterns and quitting unhealthy
habits as such mentioned.
Tooth Engineering
As for his objectives that made
him open the Dr. Ammar Alekri
Dental Centre, Dr. Alekri said:
“The opening of a private clinic
or medical center is considered
the ambition of every doctor and
the financial capability contributes to acceleration or slowing
down the achievement of this
dream.” He added: “Tamkeen
Program, that supports small
and medium enterprises, contributed in with my support,
developing my clinic that was
built on the philosophy of paying attention to the patients before the start of treatment, as it
supplied the clinic with the latest high-quality devices in the
field of dental treatment, which
included Lasers, X-ray equipments and assistive devices in
dentistry.” Dr. Alekri added:
“Comes before the equipments,
the medical staff that specializes
in various dental treatments, especially the cosmetic treatment
of all kinds, which offers on
my hands and the hands of Dr.
Mohamed Ismail.” Referring to
that they had received many of
the necessary courses of beauty therapy at the University of
UCLA (one of the most prestigious American universities).
Dr. Ammar said: “The centre
departments are equipped with

an electronic network linking
all departments with each other
from the Department of Registration and Reception to the six
clinics, then to the Radiology Department. Today, our centre has
become “A paperless work environment”. He explained: “Our
commitment to our patients to
comply with the highest professional standards in the field
of oral health and dental care,
has qualified us to get the quality certificate ISO: 9001: 2008,
the certificate that enhance the
confidence of our clients to our
center, and assured to us the
progress of work in the organization.
According to the highest professional standards and certified
by accredited party. Alekri said:
“That made us very happy, the
consulting body (Jafcon) revealed to us that the centr had
applied a lot of technical and
administrative matters that
matched the requirements for
the adoption of quality certification, according to the testimony
of Bureau Veritas, the accredited
party of the issuance of the certificate in the world.”
He also added: “This is what
makes us proud and determined
to provide the best services according to the highest standards
of quality, also leads us to accelerate the application of our
future plans to obtain quality
certification in other areas, especially the environment.”
He also revealed his ambition to
manufacture dentures inside the
centre, he said: “Big advances in
the world of medicine quoted
treatment for advanced stages
on both the treatment methods
and the devices used.” He added: “Recently, the acquisition of
the necessary devices for manufacturing dental dentures at clinics has become easy. Currently, I
have the ambition to acquire the
devices used to design the dental
dentures.”
He explained: “The device will
also enable me to make the design of tooth dimensions which
I want to plant for the patient,
then it will send the data to the
company specialized in the dental industry. This will save the
time and will ensure that the
dental implants process will be
done by structures that I have
done, which means higher quality.” He said that he seeks to fulfill his dream of establishing a
specialized hospital in dentistry
which offers the best services to
the highest standards.

[31] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

referral clinic 31

Immediate implant placement long term success:
a case report

Dr. Bernard Alliot, UAE

By Dr. Bernard Alliot DDS, DOS,
PhD, CES, DU, UAE

ummary
Immediate implant placement is sometimes a risky
procedure particularly when
we are replacing front teeth,
patients are always expecting
quick aesthetic results. This case
report will try to show you how
this procedure can be provided
with a reduced risk for the patient.
Key words
Immediate implant placement,
patient selection, aesthetic results, long term success, case
report.
Introduction
In case of immediate implant
placement, the selection of the
patient and the site are of primarily importance. This selection will have to integrate anatomical and pathological factors.
The following factors will have
to be taken in consideration as it
has been recommended by the
ITI consensus (EVANS & CHEN
/ 2009):
- medical status
- smoking habits
- patient’s aesthetic expectations
- lip line
- periodontal biotype
- shape of teeth crowns
- infection at implant site
- bone level at adjacent sites
- restorative status of neighbouring teeth
- width of edentulous space
- soft tissue anatomy
- bone anatomy of alveolar crest
One of the most important considerations will be the difficult
detection of the patient periodontal biotype!

Fig. 1. Thin periodontal biotype

Fig. 5. Patient at first consultation

Soft tissue biotype was previously called gingival biotype
or morphotype (OLSSON &
LINDHE / 1991), but since the
advent of implants, this has been
renamed to encompass tissue
around both teeth and implants
(KAN & al / 2003). The term refers to a composite or aggregate
of four features of the soft tissues
and the teeth they surround that
build up to a specific picture:
- gingival width (keratinised tissue width)
- gingival thickness (thick or
thin)
- papilla height and proportion
- crown width and height ratio.
Thin scalloped periodontal biotypes (Fig. 1 & 2) are characterized by:
- highly scalloped soft tissues
and bone contours
- delicate and friable soft tissues
- narrow band of keratinized tissue
- thin bone with dehiscences
and fenestrations
- long pointy papilla
- long tapered teeth
whereas thick flat periodontal
biotypes (Fig. 3 & 4) are presenting:
- relatively flat soft tissues and
bone contours
- dense and fibrotic soft tissues
- wide band of keratinized tissue
- bone thick with ledges
- short blunted papilla
- short square teeth
This detection is important more
particularly to prevent aesthetic
complications.
Inflammation
generated by accumulation of
plaque on the root surface extends into the tissue for a distance of 2 mm in all directions
(KAN & al /2010):
- concerning thin biotypes, the
distance from the root surface
to the oral epithelial surface can
be less than 2mm, inflammation
will involve all the structures
(cementum, periodontal ligament, bone and gingiva) rapidly
resulting in a recession. Bundle
bone (lamina dura) is very likely
to be the buccal plate; we can
expect considerable collapse of
the socket, resulting in a contour
deficiency; bone grafting and
compromised position / angulation of the implant, especially if
patient is getting implant treatment in the aesthetic zone.

- concerning thick biotypes,
due to a thick alveolar housing
around the teeth, the 2mm radius of inflammation will damage cementum, ligament and
bundle bone only, producing
a periodontal pocket. Patients
may end up with less alveolar
deficiency; restorative treatment
can be viewed as being more
predictable and less demanding.
Peri-implant tissue health seems
to depend to there being immobile keratinized tissue around
the emergent restoration:
- thin peri-implant soft tissues
seems to be more prone to recession and less likely to develop
nicely formed papillae around
implant restorations.
- tissue recessions around implants seems to result in absence of immobile keratinized
tissue more quickly that around
natural teeth, possibly because
the shoulder of most implants
are placed more apical to the
cemento-enamel junction of the
teeth they replace.
- mobile tissue around an implant is associated with increased risk of development of
peri-implant diseases and authors recommend an augmentation of the keratinized tissue as
one of the treatment strategies
in managing peri-implantitis.
A thick soft tissue biotype is a
desirable characteristic that will
positively affect the aesthetic
outcome of an implant supported restoration because thick
soft tissue is more resistant to
mechanical and surgical insults,
is less susceptible to mucosal
recession and has more tissue
volume for prosthetic manipulation (COOK & al / 2011). Therefore, although tissue biotype is
an inherent trait that varies from
patient to patient, it can be transformed through precise management of the implant position,
implant design and prosthetic
design such that a desired aesthetic outcome is achieved (FU &
al / 2010). Most of the literature
on implant success rates has not
identified a correlation with the
gingival biotype, although it is
increasingly accepted that the
biotype and tissue volume have
an important impact on the aesthetic outcome and minimizing
the risk for post-restoration tissue instability.

Fig. 2. Triangular teeth, long pointy
papilla & thin periodontal biotype

Fig. 3. Thick periodontal biotype

Fig. 6. Radiograph at first consultation

Fig. 7. Extracted tooth with root resorption

Management of aesthetic risk
AESTHETIC RISK FACTORS

LEVEL OF RISK
LOW

MODERATE

HIGH

Medical status

Healthy, cooperative patient with an
intact immune system

Smoking habits

Non smoker

Light smoker (< 10 cigarettes / day)

Heavy smoker (> 10 cigarettes / day)

Patient’s aesthetic expectations

Low

Medium

High

Lip line

Low

Medium

High

Periodontal biotype

Low scalloped, thick

Medium scalloped, medium thick

High scalloped, thin

Reduced immune system

Shape of tooth crowns

Rectangular

Infection at implant site

None

Chronic

Acute

Bone level at adjacent teeth

≤ 5 mm to contact point

5.5 to 6.5 mm to contact point

≥ 7 mm to contact point

1 tooth (< 7 mm) / 1 tooth (< 5.5 mm)

2 teeth or more

Horizontal bone deficiency

Vertical bone deficiency

Restorative status of neighbouring teeth

Virgin

Width of edentulous space

1 tooth (≥ 7 mm) / 1 tooth (≥ 5.5 mm)

Soft tissue anatomy

Intact soft tissue

Bone anatomy of alveolar crest

Alveolar crest without bone deficiency

Triangular

Restored

Soft tissue defects

Dr. Bernard ALLIOT - GMC Clinics / Dubai - U.A.E.

Table 1

Case report
Patient is a man, 45 years old;
he is presenting good health,
he is non-smoker and his oral
hygiene is good. He complained
five years ago (in 2010) about
the presence of a recent diastema between 11 and 21, and
about a slight mobility tooth 21
(Fig. 5)
After complete examination, we
detected the presence of a root
resorption (Fig. 6), so it has been
decided to extract this central incisor and to replace it by a dental
implant. A complete aesthetic
risk assessment of the patient
and the site has been done and
the results are presented in red
inside of Table 1.
An extraction without incisions
has been done using periotome
in order to preserve the surrounding bone and soft tissues.
A Straumann® bone level implant (length 12mm / diameter
4.1mm) has been placed inside
the socket in a palatal position
and the remaining gap (around
1.5mm) between the implant
and the buccal bony wall has
been filled with a bone graft Bio
Oss®, and the top of the socket
has been protected with a Collacone® without sutures (Fig. 7 &
8) (CORDARO / 2014).
Then at the end of the same appointment, the extracted tooth
(full crown and 3 mm of the
root) has been used as temporary restoration and fixed to the
adjacent teeth using a metal
grid. The presence of this previous tooth was of primarily
importance in order to support
the surrounding soft tissues and
more particularly the papilla on

Fig. 4. Square teeth, short papilla &
thick periodontal biotype

Fig. 8. Implant and bone graft covered with collagen sponge

both sides of the implant (Fig. 9
& 10).
Before to restore the implant
with a final crown we took
in consideration the latest
recommendations
concerning cementation on dental
implants (I.T.I. / 5th Consensus
2013):
- after bone level implants placement, if the depth of the mucosa
margin is deeper than 1.5mm,
screw-retained prosthodontics
are highly recommended,
- reduce the quantity of cement
used to cement prosthetic restorations,
- if the patient has been treated
previously for periodontal diseases, use only temporary cement, you will have the possibility to remove the superstructure
in order to treat an eventual
peri-implantitis.
At the time of the final restoration, it is also very important to
keep in mind predisposing factors leading to cement retention
around dental implants:
- the soft tissue connection
around dental implants (epithelial adhesion with hemidesmosomes and absence of
connective tissue attachment)
which is different from natural
teeth (epithelial attachment and
connective tissue attachment),
- the sub-gingival placement of
the implant more or less deep
than the cemento enamel junction of the natural teeth,
- the abutment selection: abutment with a fixed restorative
margin 2-3 mm to the implant
neck or one-piece implant with
a built-in restorative margin,
- the radiographs are unable to
show the presence of retained
cement on buccal and palatal /
lingual sides,
- the cementation issues: excessive quantity and unsuitable
type of cement used,
- the maintenance controls not
always respected by a majority
of patients.
At the end of a period of healing of 10 weeks, you can see
the very good positioning of the
soft tissues (Fig. 11), the implant
has been exposed (Fig. 12), the
depth of the sulcus was more

> Page 32

[32] =>

32 referral clinic

Dental Tribune Middle East & Africa Edition | May-June 2015

< Page 31
than 2mm and it has been decided to place a permanent ceramic crown directly screwed
on the implant. You can see also
the lower position of the lip, gum
above the final reconstruction is
never exposed during patient’s
smile (Fig.13).
The last pictures showed the
aesthetic result after 5 years (in
2015), aesthetic expectations
of the patient has been fulfilled
and we can consider that the patient has been also successfully
rehabilitated on a functional
point of view (Fig. 14, 15 &16).
Conclusion
Soft tissue and bone managements will have to be done after
a complete evaluation of the ratio benefit / risk of the patient;
best results will be dependant of
the choice of the procedure the
most adapted to the patient.
Healing time for soft tissues as
well as for bone tissue are of primary importance to obtain successful aesthetic prosthodontic
restorations.
References
1. Evans C., Chen S., 2009, The
Sac Classification In Implant
Dentistry, Pages 120-125
2. Olsson M., Lindhe J., Periodontal Characteristics In Indi-

Fig. 9. Extracted tooth placed as temporary restoration

Fig. 10. Extracted tooth fixed using
metal grid

Fig. 11. Temporary restoration after
10 months

Fig. 12. Implant exposure after 10
months

Fig. 13. Low smile with permanent
crown

Fig. 14. Permanent restoration after
5 years

Fig. 15. Permanent restoration
screwed retained after 5 years

Fig. 16. radiographic control after 5
years

viduals With Varying Form Of
The Upper Central Incisor, Journal Of Clinical Periodontology,
1991, Vol.18, Issue 1, Pages 78-82
Kan J.Y., Rungcharassaeng K.,
Umezu K., Kois J.C., Dimensions
Of Peri-Implant Mucosa: An
Evaluation Of Maxillary Anterior Single Implants In Humans,
Journal Of Periodontology 2003,
Vol. 74 (4), Pages 557-562
3. Cordaro L., 2014, Iti Treatment Guide, Vol 7, Ridge Augmentation Procedures In Implant Patients, Pages 14-28
4. Kan J.Y., Morimoto T.,

Rungcharassaeng K., Roe P.,
Smith D.H., Gingival Biotype Assessment In The Aesthetic Zone:
Visual Versus Direct Measurement. International Journal Of
Periodontics Restorative Dentistry, 2010, Vol. 30(3), Pages 237243.
5. Cook D.R., Mealey B.L., Verrett R.G., & Al. Relationship Between Clinical Periodontal Biotype And Labial Plate Thickness:
An In Vivo Study. International
Journal Of Periodontics Restorative Dentistry, 2011, Vol. 31(4),
Pages 345-354.

6. Fu J.H., Yeh C.Y., Chan H.L.,
Tatarakis N., Leong D.J., Wang
H.L., Tissue Biotype And Its Relation To The Underlying Bone
Morphology. Journal Of Periodontology 2010, Vol. 81(4), Pages
569-574.
7. Wismeijer D., Bragger U., Evans C., Kapos T., Kelly J.R., Millen C., Wittneben J.G., Zembic
A., Consensus Statements And
Recommended Clinical Procedures Regarding Restorative
Materials And Techniques For
Implant Dentistry, The International Journal Of Oral & Maxil-

lofacial Implants Volume 29,
Supplement, 2014 pages 137-140
Editorial note:
Contact detail available from the
publisher.

Contact Information
GMC Jumeirah - Dental
Box 11962
Dubai, U.A.E.
M: 055 4503329
T: 04 344 9150
www.groupgmc.com

Versailles dental clinic news
By Dental Tribune MEA/CAPPmea

f you say French expat community in Dubai, you say Versailles Dental Clinic.

Dr. Dominique and his wife, Veronique Caron, founders of Versailles Dental Clinic in Dubai are
very present in the French expat
scene in the Emirates. They
sponsor many French community events including the “pinnacle” French Business Council
Gala Dinner.
Along with other distinguished

companies, Versailles Dental
Clinic was the Silver Sponsor of
the Gala Dinner this year.
“Supporting the French Community in the UAE and providing them and all residents of the
UAE with outstanding dental
care is one of our main priorities” confirms Veronique Caron.
Along with the founder of CAPPmea, Dr. Dobrina Mollova, the
Versailles Dental Clinic team
are establishing the standards
for excellence in dentistry in the
region.

Dr. Dominique Caron and Mr. Obaid Al Swaidi CEO of
Emirates Delta Investment Abu Dhabi

Madame Veronique Caron

Versailles Dental Clinic team and guests

Mr. Obaid Al Swaidi CEO of Emirates Delta Investment
Abu Dhabi, Mr. Hussain Al Jaziri FBC Honorary President
and Dr. Dominique Caron
Officials at the Gala Dinner

Dr. Dominique Caron, Mr. Obaid Al Swaidi CEO of Emirates Delta Investment Abu Dhabi, Madame Veronique Caron

[33] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

aesthetics 33

Midline diastema closure with
direct-bonding restorations
By Dr. Sushil Koirala, Thailand

patient’s aesthetics, function and
health.

idline diastemata (MD)
are spaces of varying
magnitude between the
crowns of fully erupted maxillary and mandibular central incisors. Keene describes MD as
anterior midline spacing greater
than 0.5 mm between the proximal surfaces of adjacent teeth.
Incidences of maxillary and
mandibular MD are 14.8 and 1.6
%, respectively.1
MD can occur in temporary,
mixed or permanent dentition
and may be considered normal for many children during
the eruption of the permanent
maxillary central incisors. When
incisors first erupt, they may
be separated by bone and the
crowns incline distally because
of the crowding of the roots.
With the eruption of the laterals and permanent canines, the
MD reduces or even closes completely.

Fig. 2. Placement of plastic strip.

Fig. 4. Injection of flowable resin to
create frame.

Fig. 6. Plastic strip is removed after
light curing; note beautiful lingual
frame.

Fig. 1. MICD TP.

Etiological factors
The etiological factors of MD are
described by various researchers. Angle concludes the presence of an abnormal frenum to
be the cause of MD,2 a view that
has been supported by other researchers.3–5 According to Tait,
the frenum is the effect and not
the cause of the incidence of

Fig. 3. Plastic strip is supported with
index finger.

Fig. 5. Flowable resin ready for light
curing.

Fig. 7. Lips at rest; note MD is clearly
visible.

Fig. 8. MD in close-up view.

Fig. 9. Teeth #12 and 21 after isolation with gingival retraction cords.

Fig. 10. Light touch upon the enamel
surface of tooth #12 with diamond
point to enhance bonding process.

Fig. 11. Enamel etching with phosphoric acid (FL-Bond Etchant) for 20
seconds.

diastemata.6 He reports causes
such as ankylosed central incisors, flared or rotated central
incisors, anodontia, macroglossia, dento-alvolar disproportion,
localised spacing, closed bite,
facial type, ethnic and genetic
characteristics, inter-premaxillary suture and midline pathology. Weber lists the causes for
spacing between maxillary incisors as the result of high frenum attachment, microdontia,
macrognathia, supernumerary
teeth, peg laterals, missing lateral incisors, midline cysts, habits
such as thumbsucking, mouth
breathing and tongue thrusting.7
Therefore, the etiological factors
can be summarised as follows:
1. developmental: microdontia,
missing laterals, mesiodens,
macroglossia, macro hypertrophic fibrous frenum;
2. pathological: midline cysts, tumours and periodontitis;
3. neuromuscular: oral habits,
such as tongue thrusting during
speech, swallowing or abnormal
pressure during rest.
Clinicians must be prepared for
patients visiting the dental office
with the aim of having their diastema closed in order to fulfil
their psychological (aesthetic
and beauty enhancement), functional (pronunciation of ‘f’ and
‘s’ sounds and cutting foods with
anterior teeth) and/or health
(oralhealth maintenance) problems.
Treatment options for diastema
closure Treatment modalities
depend on the etiological factors and complexity of the MD.
It is suggested that treatment of
a MD should be delayed until
the eruption of the permanent
canines. However, the pathological causes should be ruled
out and treated at an early
stage, for example extraction
of supernumerary teeth (mesiodens) and surgical treatment
for the removal of midline cyst,
tumour and periodontal pathologies. Surgical, orthodontic
(comprehensive/short
term),
periodontal, directbonding and
indirect restorations are the
treatment modalities that can be
used alone or in combination to
achieve harmony in terms of a

MICD by definition is “a holistic
approach that explores the smile
defects and aesthetic desires of
a patient at an early stage and
treats them using the least intervention options in diagnosis,
treatment and maintenance
technology by considering the
psychology, health, function and
aesthetics of the patient.”8 The
MICD concept as the professional movement that encourages
all clinicians to select diagnosis,
treatment and maintenance modalities that are the least invasive in order to preserve healthy
oral tissues while still achieving
the natural aesthetics outcome
in the best interests of the patient’s health and happiness.
Following, I will demonstrate
the clinical use of MICD TP
(minimally invasive cosmetic
dentistry treatment protocol) to
close or reduce the diastema in
clinical practice (Fig. 1).8 The
direct-bonding procedure with
the application of the Flowable

Frame Technique (FFT) is presented here as a special technique.9
Case presentation
A 20-year-old female patient
presented with the complaint
that she did not like her smile
because of the large gap between her upper front teeth.
The patient was very concerned
about her smile aesthetics and
also aware of her speech difficulties.
Phase I: Understand
In the first step of Phase I, the
patient’s perception, lifestyle,
personality, and desires were
explored in a personal interview and through completion of
the MICD self smile-evaluation
form. The patient, who exhibited a high dental IQ, evaluated
her smile as below satisfactory.
After the interview, the disease,
force element and aesthetic defects of her smile were explored

> Page 34

[34] =>

34 aesthetics

Dental Tribune Middle East & Africa Edition | May-June 2015

< Page 33

Fig. 12. FL Bond II and not FL Bond.

Fig. 14. Injection of flowable resin
(Beautifil Flow shade A3T).

Fig. 13. Placement of plastic strip
for FFT.

Fig. 15. Adjustment of lingual frame
with sharp hand instrument.

Fig. 16. Application of Beautifil II
entine shade A1.

Fig. 17. Dentine layer is smoothed
with a brush and light cured.

Fig. 18. Application of enamel layer
in Beautifil II shade Inc.

Fig. 19. Tooth #12 after final restoration.

Fig. 20. Lingual frame created on
tooth #21.

Fig. 22. Final smile.

clinically. Necessary digital
photographs were taken, along
with diagnostic study models
for further exploration of existing diseases, force elements and
aesthetic defects. The patient
had good oral health, normal
function and no para-functional
or other destructive oral habits.
The collected clinical and diagnostic information, such as
extra and intra-oral digital photographs, study models and Xrays, was further analysed to
determine her smile aesthetic
grading in terms of her health,
function and aesthetics, as well
as to gain an overview of the
clinical problems and the macro-, mini- and micro-smile defects. We found a high frenum
attachment and the space analysis of the study model revealed
a MD of 3.5 mm between teeth
#12 and 21. The tooth-size ratio
of the centrals was nearly 65 %
and lacked central dominance.
In the design step, a new smile

Fig. 21. Teeth #12 and 21 after finishing and polishing.

with a closed gap was designed.
It is to be noted that the upper
central incisors are considered
key to a smile10,11 and must be
given sufficient prominence.12
The aesthetically acceptable
width of the centrals is between
75% and 80% of their length.12 In
the presented case, it was logical
to close the diastema completely
by increasing the width of the
centrals. The types of treatment
involved, complexity, possible
risk factors, complications and
treatment limitation were evaluated, and the tentative costs
calculated and presented to the
patient.
The new smile was proposed
through the modified digital photographs and aesthetic mock-up
of the study model. In order to
correct her MD, a frenectomy
with non-invasive indirect partial veneers was proposed as the
first option and a direct-bonding
restoration without frenectomy
as the second option. However,
because of financial constraints,
the patient preferred the second
option.
All patient queries related to the
proposed new smile and treatment modalities were addressed
in detail. The informed consent
form was signed prior to proceeding to Phase II.

Phase II: Achieve
In the first step, the patient’s
health, function and a healthy
lifestyle were established. The
patient’s smile was graded as
Grade B.8 The established parameters of her oral health and
function were within normal
limits, the aesthetic parameters
were below the accepted level
and enhancement treatment
was to improve her aesthetic parameters further. Hence, in this
case, it was not necessary to undergo establishment treatment
(like orthodontic, periodontal,
occlusal adjustment, etc.) before proceeding to the aesthetic
enhancement step. According
to MICD TP, the desire of the
patient in this case was needbased or naturo-mimetic smile
enhancement.
Direct-bonding restoration
The direct-bonding restoration technique represents the
preferred therapeutic option
in MICD. It preserves maximal
tooth structure and helps to restore function and aesthetics in
only a few clinical visits. In addition, the technique is economical and the possible need for sophisticated indirect restoration
can be postponed. Direct-bonding restorations demand excellent clinical skills. The clinician
is required to incorporate various clinical techniques, tips and
tricks. Following, I would like to
demonstrate a simple technique
that I have applied since 2005 in
various clinical scenarios and
find helpful for the upgrade of
clinicians’ restorative skills.
The Flowable Frame
Technique
The FFT is a simple restorative
technique developed to speed
up the placement and simplified
confinement of material when
restoring challenging anterior
aesthetic cases such as large
Class IV or Class III defects and
diastema closure or reduction.
As the name suggests, this technique requires flowable composite resin as frame material,
a plastic strip, composite brush
and other usual instruments for
direct resin restorations.
Clinical steps in the Flowable
Frame Technique
The following steps are to be
taken:
Step 1
After the completion of etching, priming and bonding of the
tooth surfaces, insert a simple
plastic strip to the level of gingival sulcus of the tooth to be restored (Fig. 2).
Step 2
Support the plastic matrix strip
lingually with your index finger
to create a lingual contour (Fig.
3).
Step 3
Inject the flowable composite
resin of desired shade (either
opacious or translucent) and
smooth it to a thin layer with a
hand instrument or a composite
brush if necessary (Fig. 4).
Step 4
Light cure the flowable composite and remove the plastic strip.
A flowable frame is now ready
(Figs. 5 & 6). The length, shape
and thickness of the flowable
frame can be adjusted using the
sharp edge of the hand instru-

MICD summary ten
1. SMILE SELF-EVALUATION: BELOW SATISFACTORY
2. SMILE GRADE: B
3. TREATMENT CATEGORY: TYPE I
4. TREATMENT COMPLEXITY: GRADE I
5. PROPOSED TREATMENT: ACCEPTED
6. ESTABLISHMENT OUTCOME: NOT APPLICABLE (N/A)
7. SMILE RE-EVALUATION: N/A
8. ENHANCEMENT CATEGORY: NATURO-MIMETIC (NEED-BASED)
9. EXIT REMARKS: EXCELLENT
10. CLINICAL SUCCESS: SATISFACTORY
Table 1

ment or a diamond point if required.
The advantages of the FFT are:
- time and cost saving (no direct
or indirect mockup required);
- thickness of the layer of restoring materials (dentine, enamel
and opacious group) can be predicted;
- as with the silicone template
method, an opaque halo, mamelons, and translucent areas
in the proximal and incisal areas
can be created;
- smooth palatal surface is
achieved with minimal finishing;
- smooth adaptation of the restorations can be achieved even in
the gingival sulcus;
- it is the most suitable lingual
frame creation technique for diastema reduction or closure.
Material selection and clinical
steps for diastema closure
Material selection for diastema
closure should be guided by optical properties (light transmission and diffusion characteristics) and tissue responses of the
materials (restoration in diastema closure normally touches
the gingival tissue and sulcus).
Amongst the various materials
available, giomers are amongst
the latest category of micro-hybrid lightcured restorative materials and are touted as the true
hybridisation of glass ionomers
and composite resins. They
have the fluoride release and
recharge of glass ionomers and
the aesthetics (shade, polish and
optical properties), handling and
physical properties of composite
resins. Giomer restorative and
adhesive systems have good biocompatibility13 and have been
reported not to result in longterm post operative sensitivity.14
They have also been found to
possess anti-plaque formation
properties.15 Hence, giomer
direct-restorative materials and
adhesive systems were selected
to close the MD in this case.
Beautifil Flow Shade #A3T
with giomer adhesive system
FL-Bond II (SHOFU Inc.) were
used in FFT to create the lingual
frame. Beautifil II (SHOFU Inc.)
dentine shade A1 and enamel
shade Inc. were used to restore
the defects using the bi-layered
shading technique to achieve
the desired aesthetics with an
invisible restoration. The Direct
Cosmetic Restoration Kit and the
Super-Snap Rainbow Technique
Kit (both SHOFU Inc.) were used
to prepare the teeth and to finish
and polish the final restorations
(Figs. 7–22).

Phase III: Keep in touch
After completion of the treatment, the importance and role of
the keep-in-touch concept to the
long-term success of aesthetic
enhancement rocedures were
briefly explained to the patient.
She was advised to continue her
normal oral hygiene procedures
and shown how to keep the interdental space of the closed
diastema clean. In the final step
of MICD TP, the patient was requested to fill out the MICD clinical evaluation form. The patient
evaluated her new smile as excellent and mentioned that she
was fully satisfied with the overall clinical services at our centre.
The MICD summary ten (Table
1 ) helps to evaluate the overall
success of the case.
Conclusion
Diastema closure or reduction
in clinical practice requires detailed case analysis. The successful treatment of diastemata
depends on etiological factors,
size and extent of the diastema,
and the patient’s affordability
in terms of treatment time and
costs involved. The MICD TP
guides the clinician and the patient and helps both to understand, plan and complete the
clinical case using diagnosis
and treatment modalities that
are the least inva sive in order to
preserve sound tooth structure
and achieve natural aesthetics,
considering the patient’s best
interests.
Editorial note:
A complete list of references and
the MICD forms are available
from the publisher.

Contact Information

Visiting Professor , Faculty of
Dentistry Thammasasrt
University, Thailand.
President: Vedic Institute of Smile
Aesthetics ( VISA)
President: Asian Academy of
Aesthetic Dentistry ( AAAD)
Chairman: National Dental Hospital , Kathmandu , Nepal
Global Coordinator: MiCD
Global Academy
E: drsushilkoirala@gmail.com

[35] =>

[36] =>

36 pediatric tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

Current guidelines for the use of nitrous
oxide inhalation analgesia/anxiolysis
in pediatric dentistry
By Dr. Manal Al Halabi, UAE

bstract
Nitrous oxide/oxygen inhalation analgesia and anxiolysis as a behavioral management intervention in children
has maintained an excellent
safety record and is, therefore,
utilized widely by pediatric dentists. As is true of any diagnostic
or therapeutic dental intervention, however, its usage merits
periodic review, especially when
it is routinely applied. When nitrous oxide/oxygen is used in
combination with other sedatives, such poly-pharmacy can
produce potentially serious side
effects. Bioenvironmental risks
to patients and staff can be encountered if proper use of the
gas and appropriate dispensation of exhaled nitrous oxide is
not monitored. Using historical
publications, current empirical
articles, professional usage policies, and educational textbooks,
the purpose of this article was
to review indications and contraindications of nitrous oxide/
oxygen inhalation analgesia
and anxiolysis and discuss various factors that should or should
not be considered about its use.
Even though today’s parents
may be more accepting of pharmacologic approaches such as
nitrous oxide, the choice to use
it should always be made with
the child’s best interest in mind
and with adequate training and
understanding.
Introduction
After the analgesic qualities of
nitrous oxide were determined
in the 19th century, dental practitioners experimented with
nitrous oxide as a general anesthetic for almost a century, frequently pushing beyond physiologic tolerance levels. Its usage
then shifted to that of an analgesic and subsequently to an inhalation sedative. The significantly
reduced dosages needed to
elicit sedation rendered the drug
much safer and enabled dentists
to administer nitrous oxide with
ever-greater frequencies. Consequently, by the dawn of the
21st century, N2O had become
a routine component of dental
care among many dentists.
Nitrous oxide/oxygen inhalation
is considered a safe and effective technique to reduce anxiety,
produce analgesia, and enhance
effective communication between a patient and health care
provider. The essential need to
properly diagnose and treat, as
well as the safety of the patient
and practitioner, should be carefully measured before using
nitrous oxide1. In medicine, nitrous oxide has long been used
as an inhalation anesthetic for
both the induction and maintenance of general anesthesia.
More recently, nitrous oxide
protocols have been established
for pediatric patients undergoing diagnostic procedures such

Class I

No organic, physiological, biochemical or psychiatric disturbance.

Class II

Mild to moderate systemic disturbance, e.g. mild diabetes, moderate anemia, well-controlled asthma, not disabling.

Class III

Severe systemic disease, e.g. severe diabetes with vascular complications, severe pulmonary insufficiency, disabling.

Class IV

Severe systemic disorders that are already life threatening, e.g. signs of cardiac insufficiency.

Class V

The moribund patient who has little chance of survival without operative intervention.

Table 1. ASA Classification. American Society of Anesthesiologists.

as computer tomography, endoscopy, electroencephalography and bone marrow biopsies2.
All children should be able to
expect painless, high quality
dental care. While anxiety and
pain can be modified by behavior management psychological
techniques, additional pharmacological approaches may be
necessary. Analgesia/anxiolysis is defined as diminution or
elimination of pain and anxiety
in a conscious patient2. The pa-

tient responds normally to verbal commands. All vital signs
are stable, there is no significant
risk of losing protective reflexes,
and the patient is able to return
to pre-procedure mobility. In
children, analgesia/anxiolysis
may be helpful to expedite the
delivery of procedures that are
not particularly uncomfortable,
but require that the patient not
move3. By reducing or relieving anxiety, the patient may be
able to tolerate unpleasant procedures, discomfort, or pain.
The outcome of any pharmacological approach especially mild
ones is variable and dependent
upon patient’s response to different drugs. The clinical effect
of nitrous oxide/oxygen inhalation, however, is relatively more
predictable among the majority
of the population.
Mechanism of action
Nitrous oxide is a colorless and
nearly odorless gas with an indistinct, sweet smell. It is an
effective
analgesic/anxiolytic
agent producing central nervous
system (CNS) depression and
euphoria with slight effect on
the respiratory system3. Nitrous
oxide has multiple mechanisms
of action. The analgesic effect
of nitrous oxide appears to be
initiated by endogeneous opioid
peptides release from neurons
which results in activation of
opioid receptors and descending Gamma-aminobutyric acid

type A (GABAA) receptors and
noradrenergic pathways that
modulate nociceptive processing at the spinal level. The anxiolytic effect involves activation
of the GABAA receptor both directly and indirectly through the
benzodiazepine binding sites4,5.
Nitrous oxide demonstrates rapid uptake, it is absorbed quickly
from the alveoli and held in a
simple solution in the serum. It
is relatively insoluble, passing
down a gradient into other tis-

sues and cells in the body, such
as the CNS. It is excreted quickly
from the lungs. As nitrous oxide
is 34 times more soluble than
nitrogen in blood, diffusion hypoxia may occur.
Studies have shown that children desaturate more rapidly
than adolescents, and administering 100 percent oxygen to the
patient once the nitrous oxide
has been terminated is important6.
Nitrous oxide causes slight
depression in cardiac output
though peripheral resistance is
marginally increased, thereby
sustaining the blood pressure3.
This is of particular advantage
while handling patients with
cerebrovascular system disorders.
Nitrous oxide is absorbed quickly, allowing for both rapid onset and recovery (two to three
minutes). It causes negligible
impairment of any reflexes, thus
protecting the cough reflex3. It
exhibits a superior safety profile with no recorded fatalities
or cases of serious morbidity
when used within recommended concentrations7. Studies have
reported negative outcomes associated with use of nitrous oxide greater than 50 percent and
as an anesthetic during major
surgery8. Although rare, silent
regurgitation and subsequent
aspiration need to be considered
with nitrous oxide/oxygen seda-

tion. The concern lies in whether pharyneal-laryngeal reflexes
remain intact. This problem
can be avoided by not allowing
the patient to go into an unconscious state9.
Nitrous oxide has been associated with bioenvironmental
concerns because of its contribution to the greenhouse effect.
Bacteria in soils and oceans emit
nitrous oxide naturally; it is produced by humans through the
burning of fossil fuels and forests and the agricultural practices of soil cultivation and nitrogen fertilization. Altogether,
nitrous oxide contributes about
five percent to the greenhouse
effect11. Only a trivial fraction of
this five percent (0.35 to two percent), however, is actually the
result of combined medical and
dental applications of nitrous oxide gas11.
The decision to use nitrous
oxide/oxygen inhalation analgesia
Nitrous oxide/oxygen inhalation
analgesia should be offered to
children with mild to moderate
anxiety to enable them to accept
dental treatment better and to
facilitate coping across sequential visits. The decision to use
nitrous oxide/oxygen analgesia/
anxiolysis must always utilize
alternative behavioral guidance
modalities, the patient’s dental
requirements, the effect on the
quality of dental care, the patient’s emotional development,
and the patient’s physical considerations. Nitrous oxide generally is acceptable to children and
can be titrated easily. Most children are enthusiastic about the
administration of nitrous oxide/
oxygen; many children report
dreaming, floating or being on a
“space-ride”9. For some patients,
however, the feeling of “losing
control” may be troubling and
patients suffering from claustrophobia can find the nasal hood
restraining and disagreeable10.
Fitness for nitrous oxide/oxygen inhalation analgesia
Review of the patient’s medical
history should be performed prior to the decision to use nitrous
oxide/oxygen analgesia/anxiolysis. This assessment should
include:
1. Allergies and previous allergic
or adverse drug reactions.
2. Current medications including dose, time, route, and site of
administration.
3. Diseases, disorders, or physical abnormalities and pregnancy status.
4. Previous hospitalization to in-

clude the date and purpose.
5. Recent illnesses (eg, cold or
congestion) that may compromise the airway.
Children who are ASA I or II
(Table 1) can be deemed fit to
undergo nitrous oxide/oxygen
inhalation sedation in general,
community or specialist (pediatric) practice. Those who are
not in these categories requiring conscious sedation should
be treated in a hospital environment with due consideration to
their individual needs and medical condition, involving the assistance of medical colleagues
where appropriate12.
The objectives of the Use of nitrous oxide/oxygen inhalation
analgesia
The objectives of nitrous oxide/
oxygen inhalation include:
1. Reduce or eliminate anxiety.
2. Reduce untoward movement
and reaction to dental treatment.
3. Enhance communication and
patient cooperation.
4. Raise the pain response
threshold.
5. Increase acceptance for longer appointments.
6. Aid in treatment of the mentally/physically disabled or medically compromised patient.
7. Reduce gagging.
8. Potentiate the effect of sedatives.
Disadvantages of nitrous oxide/oxygen inhalation analgesia:
Disadvantages of nitrous oxide/
oxygen inhalation may include3:
1. Weak potency.
2. Significant dependence on
psychological reassurance.
3. Interference of the nasal hood
with injection to anterior maxillary region.
4. Patient must be able to breathe
through the nose.
5. Nitrous oxide pollution and
potential occupational exposure
health hazards.
Indications for the use of nitrous oxide/oxygen inhalation
analgesia
Indications for use of nitrous oxide/oxygen analgesia/anxiolysis
include:
1. A fearful, anxious, or disruptive patient.
2. Certain patients with special
health care needs.
3. A patient whose gag reflex interferes with dental care.
4. A patient for whom profound
local anesthesia cannot be obtained.

> Page 45

[37] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

anniversary 37

10 Years of Successful “Continuing Dental Education”
by CAPPmea
ByDentalTribuneMEA/CAPPmea

UBAI, UAE: May 2015
will mark a significant
milestone in the history
of the Centre for Advanced Professional Practices (CAPPmea)
in Dubai, which has come to celebrate its 10th anniversary. This
event is a landmark not only for
CAPPmea but also for the entire
Dental Society in the Middle
East, who have participated in
CAPPmea’s Continuing Dental
Education programmes. The
dentists are those who are at the
forefront, driving the industry
in the right direction through
valuable feedback, experience
and increasing demand for high
level technology and education.
Thanks to the hard work of
our colleagues, sponsors, partners and supporters for the last
10 years, CAPPmea has built a
frontrunner standard commit-

ted to the highest echelons of
continuing dental education. A
big “Thank You” is owed to all
participants, followers and partners, having helped CAPPmea
develop the professional training tools adjusted to the specific
needs of the region.
CAPPmea has been an American Dental Association (ADA)
C.E.R.P Recognized Provider
for the last 3 years, specializing
in CME and CPD dental programmes – conferences, handson courses, workshops and selfinstruction events. During the
past 10 years, CAPPmea facilitated over 350 CME programmes
with over 52,000 international
participants taking part. With
the opening of CAPPmea Asia
in 2012, the professional reach
of CAPPmea expanded to the
Asia-Pacific region and beyond.
In 2012 CAPPmea also joined a
global family of 96 publishers

by becoming the proud license
owner of the Dental Tribune
Middle East & Africa edition.
Over the last 3 years, CAPPmea
has delivered yearly six print
and digital newspaper publications to over 45,000 dental professionals in the MEA region, 24
newsletters to more than 45,000
active online subscribers, and
through an international website the latest industry news and
scientific articles are reaching
the largest dental community
worldwide – an audience of over
800,000 dental readers.
A Decade of Education – Passion for Quality and Perfection
“It is unimaginable how fast
time has passed. It is already 10
years that I started CAPPmea as a
center for professional training,
quickly growing into the creation of two very important international conferences, namely
CAD/CAM & Digital Dentistry

and Dental-Facial Cosmetic International Conferences. Today,
even if I would want, it is not
possible to stop these events.
There is a huge demand for
the education and showcasing
of the fast developing dental industry.” – Dr. Dobrina Mollova,
Managing Director CAPPmea,
emotionally commenting on the
achievements.
The 10th CAD/CAM & Digital
Dentistry International Conference will be celebrated jointly
with CAPPmea’s 10-year anniversary. The journey in the
last decade came along with
many challenges related to the
incredible pace of growth of industry and new technologies,
particularly in digital dentistry.
Ten years ago, one could not
imagine that such opportunities existed. They are now able
to change dentistry and improve
dramatically the patient care. All

from diagnostics, planning to
the treatment in term of precision, time consuming and aesthetic treatments.
What has been accomplished
in the past 10 years is truly significant. CAPPmea would like
to express its highest appreciation of the role of our business
partners, industry, sponsors and
supporters in helping CAPPmea
make the success story that it is
today. Thanks to all who have
worked with CAPPmea, sharing the challenges and the passion that come along. Thanks to
all dentists, dental technicians,
dental hygienists and assistants,
who followed us in this decade
of fast development of dental industry and technology. We look
forward to another decade of being together.
For more information please visit
www.cappmea.com

CAD/CAM & Digital Dentistry significant growth in
Middle East in last decade
By Dental Tribune MEA/CAPPmea

UBAI, UAE: Behind
great achievements are
great people. Over the
last 10 years the Centre For Advanced Professional Practices
(CAPPmea) International Conferences have hosted some of
the finest dentists in the dental
profession. Dental Tribune MEA
managed to catch their opinion
on the milestone 10 year anniversary of CAPPmea prior the
10th CAD/CAM & Digital Dentistry Int’l Conference on 08-09
May 2015.
Dental Tribune MEA/CAPPmea: Where was CAD/CAM &
Digital Dentistry 10 years ago?

Dr. Julian Caplan,UK: 10 years
ago CAD CAM was being heavily
used by laboratories but still had
limited capabilities chairside.
The limitations of the camera
and the software reduced the
clinical options and the interplay
between CAD/CAM technology in-surgery and CAD/CAM
technology in-lab. The software
was “3D” but there were still few
“players” in the market. There
were a number of competitors
beginning to enter the arena
and this would be a catalyst for
established companies to make
radical changes to their systems.
Prof. Atef Shakar, Egypt: CAD/
CAM & Digital Dentistry was
dealt with as if it came from
Mars in our region 10 years ago.

Many dentists were dealing with
this topic as “Not for every dental
field”. But with such a specialized event like CAD/CAM & Digital Dentistry Int’l Conference
in Dubai, the awareness of this
highly important field of Dentistry become more and more know
and developed.
Dr. Munir Silwadi, Canada: 10
years ago CAD/CAM dentistry
was more or less in its infancy
stage. Though chairside systems, such as the CEREC chairside system from Sirona, were
well in a reasonably advanced
stage, most of the dental laboratories oriented systems were
just learning to crawl. Very few
dental manufacturers ventured

Lutz Ketelaar, Germany, 6th CAD/CAM & Digital Dentistry Int’l Conference

into this technology. A side from
some high precision milling
units, such as the Everest Milling Unit from KaVo, both hardware as well as software did not
enjoy the required features to
warrant predictable and precise
restorations.
Dr. Mark Morin, USA: CAD/
CAM was available but only
provided a limited scope. The
number of users was very small.
There was only one company
that made the machine. It could
only do limited types of restorations and there were limited
materials available to make the
restorations.
Lutz
Ketelaar,
Germany:
Digital dentistry was driven by
closed systems, networking and
sharing of capacities not implemented, not even at most in
people’s mind. The major driver
for CAD/CAM were full ceramic
restorations, ZrO2 an upcoming
material with a lot of hope and
trust - not always fulfilling all
expectations technicians did -

Dr. Munir Silwadi, Canada, th CAD/CAM & Digital Dentistry Int’l Conference

this was mainly driven through
a lack of understanding on the
lab side though. I remember the
Procera days, where a scanner
which just could create single
restorations was enough to win
fans all around the world with a
central manufacturing solution
using Al2O3, on the other hand
a DCS in-house system which
was on exhibitions, grinding
restorations out of hip-material.
The switch came with the ZrO2
green stage material, as it allowed to mill economically ceramic materials.
Even though there was no
movement for open systems, the
industry made the implementation of CAD/CAM possible,
due to support and training of
dental technicians. Information
Technology was never part of
the dental world and the majority of dental technicians did
not even believe that soft- and
hardware would change their

> Page 38

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38 Anniversary

Dental Tribune Middle East & Africa Edition | May-June 2015

< Page 37
better than conventionally produced restorations. They can
be manufactured in a faster and
better reproducible way. CAD/
CAM technology saves time, offers safer treatment methods,
and makes practicing dentistry
less stressful and more enjoyable.
Dr. Mark Morin, USA: The advantages that CAD/CAM offers
to the dental practice over conventional technologies are numerous. The first one is efficiency. The ability to do crowns in
one visit helps increase the profitability of the dental office. It allows us to participate in more of
these PPO type insurance plans
since it helps us control our cost

whole working environment.
Even just a couple of years ago,
lab owners told me that they are
still waiting for the right system
to go for, unless there was the
perfect system. I believe there
is still no perfect digital solution, but we are getting closer.
We have to admit however that
hand craft was neither perfect but we adapted perfectly to the
conditions.
Rik Jacobs, The Netherlands:
10 years ago, the dental industry in terms of CAD/CAM was in
an exploring stage, definitely in
terms of economies of scale. It
was the time that the first dental design software came on the
market as far as I can remember
it was transferred from the hearing aid market on the one hand
and on the other 3D systems like
CERE were just launched. However the first serious milling machine came shortly after in 2007.
Dental Tribune MEA: Today,
which aspects of dentistry
have been altered most due
to the rapid development of
CAD/CAM?
Dr. Julian Caplan, UK: In-surgery restorations, particularly
for posterior indirect restorations, have become simplified
and far less technique sensitive
to finally make this technology a more mainstream option.
Dentists can now visualize how
they can integrate this technology into their everyday dental
practice. The ability to morph
CAD/CAM scans into CT scans
is simplifying computer-guided
surgery. Pre-planning for accurate implant placement utilizing
CAD/CAM and CT scans will
become the industries standard
although the necessary surgical
skills will still be a requirement
- the computer has not replaced
the surgeon – yet.
Prof. Atef Shaker, Egypt: Well,
development of CAD/CAM and
its speed progress, have touched
every dental field. Of course
Restorative and Fixed Prosthodontics fields have gained
the highest advancement, but
Orthodontic, Surgical, Removable Prosthodontics & Radiology branches of dentistry have
been included in the CAD/CAM
developments. In my opinion,
within 5 years from now, CAD/
CAM & Digital Dentistry will be
covering all specialties of the
dental science.

Rik Jacobs, The Netherlands, 6th CAD/CAM & Digital Dentistry Int’l Conference

Dr. Munir Silwadi, Canada:
Almost every single discipline of
dentistry had its share of CAD/
CAM technology. Probably the
fields of Aesthetic, Restorative
and Prosthetic Dentistry got
the lion’s share. Indirect Restorations are more precise and
predictable when fabricated
through CAD/CAM systems.
Guided Implant Surgery made
the field of Implantology an easier and safer procedure. CAD/
CAM driven orthodontics as well
is getting more and more utilized.
Dr. Mark Morin, USA: I feel
that today the aspects of dentistry that has been altered the most
in our profession by CAD/CAM
is the implant and the lab world.
The lab world is now almost all
digital and connected to the office through the internet. Dentists have learned how to work
with these labs differently than
they did in the past. The implant
world has now been simplified
with cone beam technology. It
has made it easier for the dentist
to treatment plan, place, and restore the implants.
Lutz Ketelaar, Germany: I am
often surprised how quick the
old values of manual dentistry
have been changed for the new
solutions and how the markets
adapt this opportunity worldwide. For me personally, the
direction of monolithic restorations with the opportunity to go
model-free and virtual adaptations, without losing esthetics
out of the view, is a big change
and can be seen on the materi-

als that are being offered - simple ZrO2 has been replaced for
translucent variations in 16
shades, classical porcelain has
a successor in high strength
technical glass materials which
natural opalescence and fluorescence.
CAD/CAM is not limited by its
opportunities, but of economic
aspects - not everything that is
possible makes sense. The trust
into the investment of new technologies with an open end is
limited - The price for machines,
materials and dental restorations is very much under pressure, knowledge and service
are underestimated and almost
ignorant behind the pricing policies.
Rik Jacobs, The Netherlands:
So many aspects, it is based on
imagination what happened only
10 years ago. Certain treatments
can be completely planned and
executed by CAD CAM, consider Cone Beam CT, the success of CEREC at the practice of
the Doctors, the transformation
from a handicraft into a high
tech virtual planned 3D working environment, the start of the
Milling centers, the overproduction of the total number of milling centers in certain countries,
the total acceptance of Zirconia
for Crown & Bridge applications
and shortly 3D Printing which
will become more and more accepted in the profession.
Dental Tribune MEA: What
advantages do CAD/CAM systems offer for the dental practices versus conventional tech-

Dr. Mark Morin, USA, 7th CAD/CAM & Digital Dentistry Int’l Conference

nologies?
Dr. Julian Caplan, UK: In-surgery CAD/CAM systems allow
the dentist immediate evaluation of their preparations - specifically clarity of their margins
and occlusal clearance. In fact
many universities are utilizing this technology for their
undergraduate teaching. The
wonderful progression of this
pre-manufacture
assessment
using digital scanners is that
the preparation can be altered
where there are deficiencies
in the preparation, the altered
parts removed from the original
scan and only this part need be
rescanned. This comes into a
world of its own when a dentist
is involved with multiple preparations which previously would
require a completely new impression if one of the preparations did not fulfill the required
criteria. CAD/CAM scanning
is not only time efficient it also
greatly reduces a dentist stress.
Prof. Atef Shakar, Egypt: CAD/
CAM systems added many advantages to the dentists as well
to the dental patients. Speeding
up the dental treatments was a
recognition which was not possible without CAD/CAM systems.
High quality of precision has
transferred the dental field to
another spectrum of perfection.
Technology-based treatments
have increased our patients’ expectations, which are now possible, thanks to the versatility of
Digital dental products.
Dr. Munir Silwadi, Canada:
CAD/CAM generated restorations are more precise and fit

Dr. Julian Caplan, UK, 5th CAD/CAM & Digital Dentistry Int’l Conference

by eliminating the lab expense
and a second appointment. Studies have also shown how the use
of digital impressions are much
more accurate and predictable
than the traditional impression
technique. It also benefits the
patients because it makes the
treatment predictable and convenient.
Lutz Ketelaar, Germany: CAD/
CAM allows a constant high
quality of restorations, not only
depending on manual skills in
dental education - this is not
the end of the classical dental
technicians, otherwise we could
also expect PC-gamers who play
flight simulators to take over
your next flight to Europe. Dental knowledge allows to use the
instrument of CAD/CAM to become a perfect solution for an
efficient workflow in high, mid
and low price segment.
Rik Jacobs, The Netherlands:
Predictable output, workflow
management, relieving the client & saving costs.
Dental Tribune MEA: Given
the proven positive results,
what are the reasons why
some dental practices are remaining on the sidelines when
it comes to CAD/CAM technology?
Dr. Julian Caplan, UK: There
are many reasons but the main
reason is perceived cost of the
systems to purchase. However
this is only because the practitioner has not understood the
savings that they would make in
materials and laboratory costs.

> Page 39

[39] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

ANNIVERSARY 39

< Page 38
Understanding how to integrate
this technology into their busy
practice can also be daunting.
The systems are becoming incredibly user friendly and this
hurdle is becoming far easier to
overcome.
Prof. Atef Shakar, Egypt: I believe, no one can still deny the
importance of CAD/CAM technology in every dental practice,
but still the high cost of the
recent CAD/CAM systems in
comparison to traditional technologies, have pushed some
dental practices to stick to the
old fashioned technologies until
now. In addition, the computerbased software are considered
a dilemma towards many older
dentists with limited computer
skills. But my opinion is, it is
the era of CAD/CAM & Digital
Dentistry, so every dentist has to
catch it, otherwise, the train of
development will pass by leaving them in a dark and isolated
spot.
Dr. Munir Silwadi, Canada:
The most common reason for

some dentists not being involved
in CAD/CAM technology is probably lack of proper exposure.
CAD/CAM dentistry is still more
or less considered a feature of
“elite dentistry”. The second
most common reason may be
that quite few dental practitioners do not realize the full positive
impact of CAD/CAM technology
on their daily practices. Manufacturers, organizers, and educators have to put more effort to
bring this technology to the average dental practice.
Dr. Mark Morin, USA: The
number one reason keeping
practices on the sidelines is cost.
Dentists still do not think they
can justify the cost of the technology. This absolutely false. By
just doing one crown a day the
dentist can pay for the technology in the first year. I also see
dentists who are scared of using the technology. Dentists find
it difficult to learn how to use
CAD/CAM. Over the years this
technology has become easier
and easier to use and it can be
delegated in most areas to the

assistant.
Lutz
Ketelaar,
Germany:
There is no point in drawing
black-and-white. The manual
skills of an educated and experienced dental technician using
precious alloys is outstanding,
if he gets the time and the payment to do “his art”. There are
still dentists and labs who manage to keep this offer available
for people who are willing to
pay for manual made quality.
We can see the same for luxury
goods such as watches - the
majority of sold watches worldwide will be comparably cheap,
but there are still manufacturer,
where people can buy manually
made “art work”.
Rik Jacobs, The Netherlands:
For these practices, CAD/CAM
systems have to become more
Plug & Play, that’s the industry’s
full responsibility; CAD/CAM
should be fully integrated into
dental education on all levels as
well.
Dental Tribune MEA: What

further innovations in CAD/
CAM what is the future you
foresee?
Dr. Julian Caplan, UK: There
are numerous future possibilities for CAD/CAM. One of my
major interests is giving patients
a new smile in one day. At the
moment this is labor intensive
and requires a broad knowledge
of micro and macro tooth morphology. My hope is that there
will be an integration of CAD/
CAM with photography and
imaging linked with intelligent
software. This will allow the
dentist to set parameters specifying smile design requirements
and then simply press a button
for a multitude of smile designs
to be created which will be ready
to be milled immediately.

of restorations that are esthetically and functionally pleasing
to everyone, patient, dentist, and
dental laboratory technicians. As
for the future of CAD/CAM technology, I believe that the “Sky is
the limit”.

Prof. Atef Shaker, Egypt: Well,
as a professional in the CAD/
CAM field, I am so ambitious
about what is ahead of us, we
hear a lot about what is coming and what will be possible
in dental materials, hardware
& software. This places a big
weight on the shoulders of the
manufacturing companies and
their R&D departments and we
are relying on the professional
organization of “CAPPmea” to
be the link chain between the
innovations of such and an advanced career to the majority of
dentists worldwide.

Lutz Ketelaar, Germany: The
future will bring dentist and
labs closer together for a better,
faster and more economic service towards the patient. Necessary patient data and scheduled
appointment can be shared between both parties, manufacturing sites involved and their
status shared - the workflow
gets lean. The dental field of
restorations is limited, but it still
needs innovations and progress
in finding proper solutions - possible technical approaches also
need to be affordable - Dental
treatment is in direct competition with luxury goods, vacation
or even affording standard of living. We can learn a lot from the
US about marketing the beauty
business of dentistry, but should
not forget that we also need
highly educated and trained
dental technicians to achieve future success.

Dr. Munir Silwadi, Canada:
This is a very rapidly developing field. What was a wishful
thinking few years ago is now a
reality. Digital intraoral and extraoral scanners will definitely
replace conventional impression techniques in the very near
future. Most of Indirect Dental
Restorations will be CAD/CAM
produced. Dentists will be able
to digitally connect with dental laboratory technicians. This
should allow for a rapid and
precise exchange of information to facilitate the production

Prof. Atef Shaker, Egypt, 9th CAD/CAM & Digital Dentistry Int’l Conference

Dr. Mark Morin, USA: The
future is bright for CAD/CAM.
I think we are going to see a
complete digital platform in
dental offices with full connectivity to all technologies. I also
see the ability of the CAD/CAM
technology to help us diagnose
and treatment plan our cases.
By taking a picture before we
start and doing a 3D analysis it
can help us determine whether
treatment is necessary and what
procedure is best.

Rik Jacobs, The Netherlands:
The next revolution will be the
total integration of newly developed Dental 3D printers for
a wide range of Dental applications.

SIRONA LLC founded in Dubai to support a direct
operation for UAE private market
By Sirona

UBAI, UAE: IDS Cologne
was once again a record
breaking trade-fair. Sirona presented itself to industry
professionals as an experienced
specialist in the field of digital
technologies for dentists and
dental technicians. This was
borne out by spectacular innovations in radiography, laser
therapy as well as pioneering
new developments for CEREC
and treatment centers. For the
Middle East region, dental professionals will be able to see
these latest innovations during
the anniversary upcoming 10th
CAD/CAM & Digital Dentistry
Int’l Conference in Dubai on 08-

09 May 2015 – Jumeirah Beach
Hotel.
As the dental market leader and
a technology pioneer, all at Sirona are passionate about enhancing our products and services.
We are permanently investing
in research and development,
as well as our global sales and
service structures. Being close
to our customers is essential,
which is why we have 28 sites
around the world where we
work together to advance global
dental health.
In May 2015, Sirona LLC will
be founded in Dubai in order to
support a direct business operation towards the private customers market in UAE. The big suc-

cess of previous years has been
recorded through increasing
sales and services experienced
by Sirona in the region. This is
an important step for Sirona in
improving the delivery of professional sales, after sales and
dental education to the UAE
market. Sirona LLC will continue to work alongside MPC in
order to fully service the needs
of the Government sector which
remains equally important.
With UAE being a significant
hub for its business and education in GCC, the setting up
of Sirona LLC underlines the
constant commitment to research, development and better
servicing of the end-user with

surpassed quality to the dental industry whilst reinforcing
the image of Sirona worldwide.
This will be achieved through
a fully dedicated Sirona sales
and technical team and Product
specialists who will work closely
together to deliver premium services to the private market in the
UAE.
As you can imagine we have
much more to share, so Sirona
encourages you to browse our
website and review the highlights of 2014 and novelties of
IDS 2015. You will enjoy diving
into our world of innovation and
reading about some of Sirona’s
advancements, both within this
issue of Dental Tribune MEA

and on our official website as
well as through all of our online
channels.
Make sure you visit Platinum
Sponsor Sirona at the upcoming
10th CAD/CAM & Digital Dentistry International Conference
on 08-09 May 2015, Jumeirah
Beach Hotel where we will present the latest trends and developments for the first time in
Middle East after IDS Cologle.

Contact Information
Dr. Amro Adel
Area Manager GCC & Pakistan
Country Manager Saudi Arabia
Sirona Dental GmbH
E : amro.adel@sirona.com

[40] =>

40 endo tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

FKG Dentaire launches first
anatomic finisher for root canal treatments
By FKG

he latest innovation from
FKG Dentaire lets practitioners treat complex root
canal systems and clean once
impossible-to-reach areas with
minimal impact on the dentine.
Made with a highly flexible NiTi-based alloy, the XP-endo Finisher follows the contours of the
canal with an improved reach of
6mm in diameter—or 100-fold
that of a standard instrument of
the same size.
“With the XP-endo Finisher,
we can finally solve a com-

while limiting the impact on the
dentine.

mon problem for dentists,” said
Thierry Rouiller, CEO of FKG
Dentaire, one of the world’s
leading manufacturers of endodontic instruments. “They’ll
now be able to reduce the risk
of future infection by offering
patients a deeper cleaning for a
better root canal treatment.”
Studies using micro CT technologies show that standard
NiTi files manage to clean just
45 to 55 per cent of the canal

walls, leaving debris and bacteria to accumulate in areas left
untouched. However complex
the morphology of the canal,
dentists can use the XP-endo
Finisher following a root canal
preparation starting at diameter
ISO 25. A unique FKG alloy, the
MaxWire (Martensite-Austenite
electropolish-fleX), gives the
instrument unparalleled flexibility so it can remove debris
from those hard-to-reach areas,

“Now (the canal) is cleaner,
perhaps two to three times compared to the conventional techniques we have today,” said Dr.
Gilberto Debelian, Norway.
The instrument also features a
strong resistance to instrument
fatigue, thanks to its zerotaper
design, and is simple enough for
dentists to quickly learn to use.
The XP-endo Finisher joins a
growing list of innovative highprecision products patented by

FKG Dentaire to meet the most
demanding needs of general
practitioners and endodontists
around the world.

Contact Information
For further information, contact
the team at:
FKG Dentaire SA
Crêt-du-Locle 4
2304 La Chaux-de-Fonds
Switzerland
T +41 32 924 22 44
info@fkg.ch
www.fkg.ch

Interview with Dr. Martin Trope
ByDentalTribuneMEA/CAPPmea

ental Tribune MEA has
the pleasure to interview Dr. Martin Trope,
past Endo program director at
University of Pennsylvania, and
chairman of the Endo division
at Temple University Dental
School and University of North
Carolina Dental School. Dr.

Trope was also the Director of
the American Board of Endodontics.
Dental Tribune MEA: Dr. Martin Trope, you have lectured
and provided training in the
Middle East several times.
What is your experience and
feeling of the level of Endodontics in the MEA region?

Dr. Martin Trope: The level of
the dentists who have attended
my courses is very high. I don’t
really know the general level
of endodontics in each country.
The variability comes in what
the dentist can afford in terms
of cutting edge technology. In
some countries the fees charged
for root canal treatment limits
what the dentist can afford. This

is a universal problem so not
limited to the Middle East.
How important is it for a dentists to specialize, particularly
in Endodontics and what is
the reason you chose to do so?
There are some cases that require additional expertise. I
don’t think it is important for a
dentist to specialize but to rec-

ognize those cases where a specialist is needed. I like to do one
thing well so endodontics suits
my character although I must
admit sometimes it can be very
tedious.
How do you stay up to date
with the latest technologies

> Page 41

3D efﬁciency_
optimal cleaning while preserving dentine

FKG Dentaire SA
www.fkg.ch

[41] =>

endo tribune 41

Dental Tribune Middle East & Africa Edition | May-June 2015
< Page 40
being developed in dentistry?
I am a faculty at the University
so the students keep my up to
date by making me read and
challenging me all the time.
Known for your research and
development in material development for root canal fillings, can you share with us
specifically your philosophy
of Biological Endo?
Endodontics is simply microbial
control and all the research and
technologies I have developed
are directed at either removing
microbes from the root canal or
sealing the canal after the instrumentation and irrigation is
completed.
What are the main advantaged of Bioceramic sealers
like TotalFill BC Sealer?
These sealers do not shrink and
wash out so they have tremendous advantage over traditional
sealers that do. Because of these
advantages the sealer does not
have to be in a thin layer which
changes the entire philosophy of
root filling.
There are different products
in the range, what are their
difference and purpose?
Bioceramics are a specific class
of material. MTA is the first bioceramic material for endodontic use. It is mixed to a putty consistency and used for vital pulp
therapy and endodontic surgery
as a root filling material. Newer
bioceramics are similar in properties and have better handling
properties and are used for similar purposes. Presently there is
only one premixed bioceramic

Dr. Martin Trope, past Endo program director at University of Pennsylvania, and chairman of the Endo
division at Temple University Dental
School and University of North Carolina Dental School

(TotalFill) that has the consistency that is suitable for a root
canal sealer and this is the one
that is revolutionizing the way
we think of how a root filling
should be done.
Due to your extensive academic background and clinical experience, you have started Next Level Endodontics,
can you share with us more
information on this?
I am trying to combine my academic expertise with the need
for efficiency and profitability in
private practice. Next Level Endodontics is my private teaching center that will remind the
dentist of what is essential for
success in root canal treatment
and evaluates new technologies
in order to achieve this aim predictably and in a reasonable of
time. We offer a wide range of
courses to fit the level and time

TotalFill BC GP Points

TotalFill BC Obturation Kit

TotalFill BC Pellets

TotalFill BC Points

TotalFill BC RRM Jar

TotalFill BC RRM on Spatula

TotalFill BC Syringe

Root canal anatomy

Obturation with TotalFill

commitment that the dentist has
available.

file in order to make it flexible
enough to move in all directions
and so clean areas unreachable
in the past.

Dental Tribune MEA?
My advice is always the same:
the biologic requirements for
successful root treatment always
stay the same. The technology
continues to change but is not always useful to reach the biological goals. An educated dentist
can evaluate new technologies
in the context of the biological
requirements and change only if
there is an improvement in this
direction.

Do you plan to extend Nexte
Level endodontics course in
the MEA region?
Yes – hopefully we will have a
branch in Dubai in the next year
How came the idea of the new
XP-endo Finisher?
We have understood the need to
clean the canal in all dimensions
but have been limited because
the files are round but the canals
are oval. The engineers and research people at FKG were able
to manipulate the martinsite
and austenite phases of the NiTi

What are the advantages of
the XP-endo Finisher and did
it change your vision of endo
treatments?
The advantage is that it reaches
areas that were previously left
untouched by round files. In
addition it causes the disinfecting irrigants to work in a turbulent fashion which makes them
much more effective.
Would you like to share anything else with the readers of

TotalFill range is available in
FKG Dentaire distributor network: http://fkg.ch/dealer

YOUR GENERATION OF BONE REGENERATION.
TODAY’S DENTAL PROFESSIONALS RELY ON NUOSS ANORGANIC BOVINE BONE.

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• NuOss® is one of the most reliable bone substitutes used by dental professionals
• Natural anorganic bovine bone matrix; available in 6 different forms to best suit your surgical needs

Contact Your Local ACE Surgical Dealer.

[42] =>

42 practice management

Dental Tribune Middle East & Africa Edition | May-June 2015

The first impression is the final impression, but…?
By Dr. Ehab Heikal

even the eggs have hatched!

rom a fancy looking clinic
to a friendly smile, first
impressions are no doubt
the most vital impression you
will ever make in business so it
is important to get it right first
time.

To prevent any loss of patient
reassurance it is important to
make sure that your story and
message of who you are and
what you do is in harmony with
each other. There is no room for
discrepancies.

But no, this does not just mean
making sure that your feet aren’t
on the desk when serving a customer or making sure there is a
permanent smile imprinted on
your face at all times. It is more
about the other details.

All the expenditure we do to stay
in business is dependent upon
patients going ahead with our
diagnosed treatment recommendations. Our clinical skill is
of no consequence if we do not
get the opportunity to benefit
our patients with it. So, to grow
our businesses we need our stories to comply with patient perceptions.

First impressions are really important in any industry, but in
the current economic climate
they are more important than
ever before. Our patients are
continually faced with making
so many decisions, that we have
to make the right impressions in
their minds to make it easier for
them to choose us. This is a vital
part of any dentist practice management program.
Shifting away from an obsession
with first impressions is vital as it
can be all encompassing, so shift
well clear of only treating your
patients extremely well on your
first ever contact with them. We
all know that in the current economic situation it can be very
easy to lose some of your most
valued customers, so be sure not
to count your chickens before

Once created, first impressions
are very difficult to change or
eliminate. These mindsets then
affect every subsequent decision
that patient makes. It will either
make your future dealings with
the patient easy or difficult; this
is why any comprehensive dental practice management strategy should consider this.
It is vital not to take any chances.
Everything your patients experience as a result of doing business with you must be exceptional. Everything you and your
team, say and do must match up
and be the same thing. For example, if your sign and exterior
of your practice looks good and

you are based in a good location
but your team and your services
are not up to that limit of quality,
then you will always reach below patient expectation.
It is important to note that your
patient’s expectations are created primarily by several attributes, from past experience, to
word of mouth, to the effectiveness of your marketing campaigns. If you do not at the very
least meet those expectations,
you will always disappoint your
patients. For this reason, it is vital to deliver what you promise
in your marketing. If you exceed
the expectations your patients
walk into your practice with,
then you will have developed a
fan for life!
Incorporating a “WOW” customer service experience whilst
your patients are with you often
exceeds the good impression
process. Taking positive steps to
developing a good solid reputation is the way to gain customer
confidence and this can be built
by using a series of techniques.
Create A Good First Impression At Your Clinic:
- Make sure you know how you
are portraying yourself to your
patients. What is the message
you are sending to your market.
- If you do not know your message, create one and define it.

The foundation of this usually
involves creating a unique selling advantage.
- Then create a good marketing strategy, which will attract
the right type of patients to your
practice. The kind of patients
who are more likely to be interested in your specific type of
dentistry or service.
- You need to get your entire
team in on the action of what
you are trying to do.
- Create systems within the clinic on accomplishing the unique
experience for your patients,
which complies with your marketing message.
- Customer service is a key element to excellent provision of
your dentistry.

- Educate your patients on their
conditions so that they are more
involved in the process of co-discovery. This will make it easier
for you to give options and advise.
- Make it easier for your patients
to be able to afford the dentistry.
Consider all options.
- Make sure you have a process
in your clinic, which continues
to provide a consistent experience for your patients. (Check
my book, Quality & Standardization section)

Contact Information
Dr. Ehab Heikal
BDS.MBA.DBA
Practice Management consultant
eheikal@eheikal.com

How are we doing? Getting the best from your staff
By Fiona Stuart-Wilson

complish. For example your receptionist might make appointments with unfailing accuracy.
Their performance might be
described as good. However this
receptionist might be routinely
unfriendly to patients. In the latter case we are highly unlikely
to describe their performance as
‘good’, as we are measuring it on
how they do their job (their behaviour) and not solely on what
they do (their activity).

f we lived in an ideal world
where nothing ever went
wrong, patients always took
up treatment plans and arrived
for their appointments on time
and staff never went sick we
probably wouldn’t need to talk
about managing performance.
Although we might want to believe that staff know what they
need to do and will get on with
it to the best of their ability at all
times, we all know this is unlikely to happen.
The success of your practice is in
the hands of everyone within it
and depends on their delivering
a good service. Any weak link in
the chain will have a negative effect on your practice and on your
ability to deliver a world-class
service to patients and run a
successful dental business. The
point of managing performance
is to make sure that the performance of your team contributes
to the goals of the practice, and
taking action to improve things
when this does not happen.
If you manage performance effectively it will mean that everyone in your practice understands
• what the practice is trying to
achieve
• their role in helping the practice achieve its objectives

• what they need to know and
what they need to be able to do
to fulfil their role
• the standards of performance
required
• how they can develop their
own performance and contribute to development of the practice
• how they are doing, and if there
are performance problems what
can be done about them.
However, good performance
management looks at how people do their job as well as what
they get done. So, how a person
approaches their job, or the way
they behave as part of a team or
communicate with patients and
the rest of the team is just as
important as what tasks they ac-

Performance management however is more than simply trying
to get staff to do things which
will help the practice achieve its
objectives. Handled well it can
encourage both the giving and
receiving of feedback, and unlock ideas for improvement and
innovation, clarify standards,
and foster greater communication.
Clarify and communicate the
aims of the practice
You want people to deliver the
objectives you have set for your
practice. Your staff’s performance can only be measured
in terms of the practice’s performance. Things often fall down
and business performance can
falter because the objectives of
the practice have not been clarified and established by the practice owners. Everyone needs to
know what the practice objectives are, and you need to re-

mind people of them frequently
to keep them focused. As you
achieve certain milestones,
don’t forget to tell your staff
about what they have achieved!
Clarify people’s roles
Make sure that you have clear
and detailed job descriptions
and person specifications and
update them when working
practices change. Job descriptions describe what you expect
people to do. Person specifications should outline the qualities
and qualifications that your staff
need to have in order to fulfil
their roles effectively and focus
on the ‘how’ people carry out
their role.
Make sure that you have clear
policies
Your policies are your ‘book of
rules’, clear statements about
the way your practice should
operate. If you do not tell people
what they should be doing you
cannot complain if they don’t do
it.
Know how to get good performance
Make sure that you know how
to help people improve through
training, coaching and development opportunities to get them
to the standard you want.
Provide honest and constructive feedback

Give open, honest and direct
feedback regularly so that people know what they are doing
well just as much as what they
are not doing well, and establish
a performance review system
which allows for two way discussion.
We all want staff who are engaged, take pride in their job
and show loyalty towards the
practice. If your team can see
the bigger picture and how their
role contributes to the success of
the practice they are more likely
to do their best for you. Performance management is about
continuously improving the
performance of individuals and
in so doing improving practice
performance.
And that’s not just good for the
practice – it’s good for patients
too.

Contact Information
Fiona will be presenting a great
seminar on the Dental Business
Management Conference in
Dubai – 12th June, 2015
For more information please
email to info@dbmc.ae
Fiona Stuart-Wilson, Director,
UMD Professional Ltd
fiona@umdprofessional.co.uk

[43] =>

Dental Tribune Middle East & Africa Edition | May-June 2015 practice management 43

Look at the bigger picture
By Eniko Simon

nalyse data to understand the performance
of your dental business
There are many important decisions we have to make when
managing a dental clinic- we
make these decisions on gut instinct or based on previous experiences or by analysing data
that is available for us.
Most of the dental clinics I have
been working with had some
understanding of the power that
data can add to their business.
It is essential that you regularly
track a wide range of data across
your clinic to allow you to have
a good understanding of your
business. Now days there are
fantastic dental software such
as Software of Excellence or R4
very well known on the market.
These dental software can assist
dental businesses to analyse important key performance indicators gain a better understanding
of their business.
Some data that you need to look
at – who are your patients, how
did they hear about your clinic,
nationality, age group, your
chair occupancy in your clinic,
the hourly turnover your associates generating, how many new
patients you have monthly and
many more KPI’s we can look at.
Undeniably collecting clean and
reliable data and analysing it in
a consistent way is part of 21st
century management.
Data is the fundamental ingredient in decision making, figuring
out where to focus your resources, create your targeted marketing approach.
Taking control of your data
The data on its own has no
meaning, it can not provide the
full picture, it does not take into
account the values you stand
for and the culture you trying to
create in your dental business or
your patients’ personal feelings
they feel about your clinic.
Practice data alone can not be
used to guide the success of the
clinic. In order to fully utilize the
facts and figures they need to
be put into context. Hours spent
collecting data is wasted if the
bigger picture not taken into
consideration.
The clinic`s short and long term
goals needs to be agreed upon
and once you are on your journey the collected data can demonstrate if you are on the right
track to achieve your goals.
The numbers provide an effective tool to help manage and
control the growth and development of your dental business but
do not set the strategy you need
to adopt.
Constantly analyse your data
– look at how your clinic is performing. The right data at the
right time will aid your decision
making process regarding your
finances, marketing, operations

of your clinic – but be ensure
that you control your data and
put it into context.
Always understand the “whys”
to know the way forward to the
“hows”.

Contact Information
Eniko Simon
Clinic Manager/Consultant
Dr Roze & Associates Dental
Clinic
eniko@dradubai.com

[44] =>

44 industry

Dental Tribune Middle East & Africa Edition | May-June 2015

The winning combination – CAD/CAM work
and 3D CBCT data in one software
By Planmeca

new doors in creating
a new standard of care
for patients – offering
high-quality features
for different specialities, all available
through one software
interface.

he field of digital dentistry
is rapidly evolving, with
new dental technologies
emerging as part of a more efficient and comprehensive workflow. By pairing Planmeca CAD/
CAM solutions with X-ray units
in the Planmeca ProMax® 3D
family, dental professionals can
bring together a wide range of
detailed information for treatment planning and diagnostic
purposes. This seamless com-

Planmeca PlanMill

bination of CAD/CAM and 3D
CBCT technology has opened

Planmeca Romexis®
is the only dental software platform in the
world to combine all imaging
and the complete CAD/CAM
workflow. This powerful solu-

tion is at the heart of the Planmeca ecosystem, as it provides
dental professionals with the
ability to acquire more detailed
data sets than ever before. Planmeca Romexis includes advanced tools for all specialities,
such implant planning and other restorative treatments. The
software presents dental clinics
with a superior way to increase
their patient flow and improve
the level of care offered.
Seeing more than ever before
Planmeca ProMax

Bringing together CBCT data
and CAD/CAM work provides a
comprehensive level of clarity.
Planmeca ProMax® 3D imaging units reveal intricate information on soft and hard tissue
structures, including the mandibular nerve canal, while the
Planmeca PlanScan® intraoral
scanner captures precise data
above the gum line. This combination of these data ensures a
complete understanding of any
case and makes 3D prosthetic
designing quick, accurate and
easy. Clinics are able to operate
more flexibly, as restorations
can either be milled at a clinic
with the Planmeca PlanMill® 40
milling unit, or easily sent to a
dental lab in an open STL data
format.

The Dental Tribune International
C.E. Magazines
www.dental-tribune.com

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The rise of same-day dentistry
A more active role in the manufacturing of restorations opens
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[45] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

pediatric tribune 45

< Page 36
5. A cooperative child undergoing a lengthy dental procedure.
Contraindications for the use
of nitrous oxide/oxygen inhalation analgesia:
Contraindications for use of nitrous oxide/oxygen inhalation
may include:
1. Some chronic obstructive pulmonary disease13
2. Common cold, tonsillitis, nasal blockage
3. Pre-cooperative children
4. Severe emotional disturbances or drug-related dependencies14
5. First trimester of pregnancy15
6. Treatment with bleomycin
sulfate16
7. Methylene tetrahydrofolate
reductase deficiency17
8. Cobalamin deficiency5
Whenever possible, appropriate
medical specialists should be
consulted before administering
analgesic/anxiolytic agents to
patients with significant underlying medical conditions (eg,
severe obstructive pulmonary
disease, congestive heart failure,
sickle cell disease, acute otitis
media, recent tympanic membrane graft, and acute severe
head injury.
Technique of nitrous oxide/

oxygen administration
Only appropriately licensed and
trained pediatric dentists must
administer nitrous oxide/oxygen. The practitioner responsible for the treatment of the patient and/or the administration
of analgesic/anxiolytic agents
must be trained in the use of
such agents and techniques
and appropriate emergency response.
Selection of an appropriately
sized nasal hood is very important. A flow rate of five to six L/
min generally is appropriate for
most patients. The flow rate can
be adjusted after observation
of the reservoir bag. The bag
should pulsate gently with each
breath and should not be either
over- or underinflated. Introduction of 100 percent oxygen
for one to two minutes followed
by titration of nitrous oxide in
10 percent intervals is recommended. During nitrous oxide/
oxygen analgesia/anxiolysis, the
concentration of nitrous oxide
should not normally exceed 50
percent. Studies have demonstrated that gas concentrations
dispensed by the flow meter
vary significantly from the endexpired alveolar gas concentrations; it is the later that is responsible for the clinical effects18. To

achieve sedation, care should be
taken that the scavenging vacuum is not so strong as to prevent
adequate ventilation of the lungs
with nitrous oxide19.
A review of records of patients
undergoing nitrous oxide-oxygen inhalation sedation demonstrate that the typical patient
requires from 30 to 40 percent
nitrous oxide to achieve ideal sedation19. Nitrous oxide concentration may be decreased during
easier procedures (eg, restorations) and increased during
more stimulating ones (eg, extraction, injection of local anesthetic). The use of a dental dam,
whenever possible during restorative procedures is essential
to minimize the concentration
of needed nitrous and increase
the potency of the gas. The practitioner should continue with
communicative techniques during the administration of nitrous
oxide as patients become highly
suggestible. The level of nitrous
oxide can be titrated down at
subsequent visits due to its considerable placebo effect.
During treatment, it is important
to continue the visual monitoring of the patient’s respiratory
rate and level of consciousness.
The effects of nitrous oxide are
largely dependent on psychological reassurance. Therefore, it is
important to continue traditional
behavior guidance techniques
during treatment. Once the nitrous oxide flow is terminated,
100 percent oxygen should be
delivered for five minutes14. The
patient must return to pretreatment responsiveness before discharge.
Monitoring
The response of patients to
commands during procedures
performed with analgesia/anxiolysis serves as a guide to their
level of consciousness. Clinical
observation of the patient must
be performed during any dental procedure. During nitrous
oxide/oxygen analgesia/anxiolysis, continual clinical observation of the patient’s responsiveness, color, and respiratory
rate and rhythm must be performed. Spoken responses provide an indication that the patient is breathing20. If any other
pharma-cologic agent is used in
addition to nitrous oxide/oxygen
and a local anesthetic, monitoring guidelines for the appropriate level of sedation must be followed21.
Adverse effects of nitrous oxide/oxygen inhalation
Nitrous oxide/oxygen analgesia/
anxiolysis has an excellent safety record. When administered by
trained personnel on carefully
selected patients with appropriate equipment and technique,
nitrous oxide is a safe and effective agent for providing pharmacological guidance of behavior
in children. Acute and chronic
adverse effects of nitrous oxide
on the patient are rare. Nausea
and vomiting are the most common adverse effects, occurring
in 0.5 percent of patients22. A
higher incidence is noted with
longer administration of nitrous
oxide/oxygen, fluctuations in nitrous oxide levels, and increased
concentrations of nitrous oxide3.
Typically, if a child appears restless during the course of ad-

ministration of nitrous oxide/
oxygen, they might be ready to
vomit or they might be entering
into a deeper stage of sedation.
Fasting is not required for patients undergoing nitrous oxide
analgesia/anxiolysis. The practitioner, however, may advise that
only a light meal be consumed
in the two hours prior to the
administration of nitrous oxide.
Diffusion hypoxia can occur as a
result of rapid release of nitrous
oxide from the blood stream into
the alveoli, thereby diluting the
concentration of oxygen. This
may lead to headache and disorientation and can be avoided by
administering 100 percent oxygen after nitrous oxide has been
discontinued3.
Documentation
Informed consent must be obtained from the parent and documented in the patient’s record
prior to administration of nitrous
oxide/oxygen. An explanation of
the sedation technique proposed
and of appropriate alternative
methods of pain and anxiety
control must be given In advance
of the procedure, the child and
their parent or guardian must be
given clear and comprehensive
pre- and postoperative instructions in writing. The practitioner
should provide instructions to
the parent regarding pretreatment dietary precautions, if indicated. In addition, the patient’s
record should include indication
for use of nitrous oxide/oxygen
inhalation, nitrous oxide dosage
(ie, percent nitrous oxide/oxygen and/or flow rate), duration
of the procedure, and post treatment oxygenation procedure.
The record should also include
documentation of the patient’s
response to the use of nitrous
and the postoperative instructions. Any adverse effects of the
procedure should be also documented.
Facilities/personnel/equipment
All newly installed facilities for
delivering nitrous oxide/oxygen
must be checked for proper gas
delivery and fail-safe function
prior to use. Inhalation equipment must have the capacity for
delivering 100 percent, and never less than 30 percent, oxygen
concentration at a flow rate appropriate to the child’s size. Additionally, inhalation equipment
must have a fail-safe system that
is checked and calibrated regularly. If nitrous oxide/oxygen
delivery equipment capable of
delivering more than 70 percent
nitrous oxide and less than 30
percent oxygen is used, an inline
oxygen analyzer must be used.
The equipment must have an
appropriate scavenging system
to minimize room air contamination and occupational risk.
A thorough check of the equipment should be carried out in
advance by the dental personnel
any time nitrous oxide/oxygen
analgesia is to be used.
The practitioner who utilizes nitrous oxide/oxygen analgesia/
anxiolysis for a pediatric dental
patient shall possess appropriate training and skills and have
available the proper facilities,
personnel, and equipment to
manage any reasonably foreseeable emergency. Training and
certification in basic life support are required for all clinical

personnel. These individuals
should participate in periodic
review of the office’s emergency
protocol, the emergency drug
cart, and simulated exercises to
assure proper emergency management response.
An emergency cart (kit) must
be readily accessible. Emergency equipment must be able
to accommodate children of all
ages and sizes. It should include
equipment to resuscitate a nonbreathing, unconscious patient
and provide continuous support
until trained emergency personnel arrive. A positive-pressure
oxygen delivery system capable
of administering greater than
90 percent oxygen at a 10 L/
min flow for at least 60 minutes
(650 L, “E” cylinder) must be
available. When a self-inflating
bag valve mask device is used
for delivering positive pressure
oxygen, a 15 L/min flow is recommended. There should be
documentation that all emergency equipment and drugs are
checked and maintained on a
regularly scheduled basis22.
Occupational safety
In the medical literature, longterm exposure to nitrous oxide
used as a general anesthetic has
been linked to bone marrow
suppression and reproductive
system disturbances5. Exposure
to nitrous oxide can result in
depression of vitamin B12 activity resulting in impaired synthesis of RNA. Dental surgeons
and their staff are particularly
at risk as they are exposed to
high concentrations in the confined space of a dental surgery,
especially if scavenging is inadequate24. In an effort to reduce
occupational health hazards associated with nitrous oxide, it is
recommended that exposure to
ambient nitrous oxide be minimized through the use of effective scavenging systems and
periodic evaluation and maintenance of the delivery and scavenging systems25.
References
1. AAPD Reference Manual.
Guideline on Use of nitrous oxide for pediatric dental patients.
http://www.aapd.org/media/
Policies_Guidelines/G_Nitrous.
pdf
2. American Dental Association.
Guideline for the use of sedation and general anesthesia by
dentists. 2007. Available “http://
www.ada.org/sections/about/
pdfs/anesthesia_guidelines.pdf”.
3. Paterson SA, Tahmassebi JF.
Pediatric dentistry in the new
millennium: Use of inhalation
sedation in pediatric dentistry.
Dent Update 2003;30(7):350-6,
358.
The full list of references is
available from the publisher.

Contact Information
Manal Al Halabi BDS MS
Associate Professor & Programme
Director, MSc Programme in Paediatric Dentistry
Hamdan Bin Mohammed College
of Dental Medicine
Dubai Healthcare City
P.O. Box 505097 Dubai UAE
T: 97144248602 | F: 97144248687
E: manal.halabi@hbmcdm.ac.ae

[46] =>

46 IDS 2015

Dental Tribune Middle East & Africa Edition | May-June 2015

Bigger than ever: IDS 2015 reports visitor, exhibitor and
area increase
By Dental Tribune International

OLOGNE,
Germany:
On 14 March, the 36th International Dental Show
(IDS) in Cologne closed after
five days with a record result.
The organisers reported that
about 138,500 visitors from 151
countries attended the most important trade fair in the dental
industry, which represents an
increase of nearly 11 per cent
compared with the 2013 IDS.

A new record was also set with
regard to the number of exhibitors and exhibition space. A total of 2,201 companies (+6.9 per
cent) from 56 countries presented their latest innovations, product developments and services
over 157,000 m² (+6.2 per cent).
More than 70 per cent of the exhibitors came from abroad (+2
per cent). In addition, the number of visitors from Germany increased by 4.3 per cent.

PRINT
L
DIGITA N
TIO
EDUCA
EVENTS

The next IDS will take place in March 2017. (Photograph: Claudia Duschek, DTI)

The 2015 IDS took place from 10 to 14 March.

“We managed to make the International Dental Show in Cologne, both nationally and internationally, even more attractive,
making it the most successful
IDS ever,” concluded Dr Martin
Rickert, Chairman of the Association of German Dental Manufacturers (VDDI).
Katharina C. Hamma, Chief
Operating Officer at IDS organiser Koelnmesse, stated: “The
increasing international attendance once again underlines
the character of the IDS as the
world’s leading trade fair for
the dental industry. Particularly
strong growth was recorded at
the International Dental Show in
the number of visitors from the
Near and the Middle East, the
US and Canada, Brazil, as well as
China, Japan and Korea. We also
noticed re-emerging business in
the southern European market,
especially Italy and Spain.”
The 2015 IDS focused on intelligent networking of components
for computer-based dentistry. As
computerised processes have
gained increasing importance,
digital systems in diagnostics
and production today span the
entire workflow from the practice to the laboratory.

The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.

A visitor survey showed that
more than 75 per cent of attendees interviewed were either satisfied or very satisfied with the
show. Overall, 95 per cent of the
visitors surveyed would recommend visiting business partners
at IDS and 77 per cent plan to attend the show in two years’ time.
The next IDS will be held from
21 to 25 March 2017.

[47] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

ids 2015 47

DTI Media Lounge Where movers and shakers in the
dental market meet
By Dental Tribune International

C

OLOGNE,
Germany:
Over the past week, the
International
Dental
Show (IDS) drew thousands of
people from all over the world
to Cologne. As an IDS tradition,
Dental Tribune International
(DTI) invited its partners to a
number of cocktail receptions
to the DTI Media Lounge. During the receptions, attendees
received business updates on
international markets and had
the opportunity to connect with
their peers and leaders from the
dental industry.
The traditional Russian Night
was celebrated at the DTI booth
on the first day of IDS. The event
was organised in collaboration with the Russian Dental
Association, the Moscow Dental University, and Dentalexpo.
Ilya Brodetski, General Director
of Dentalexpo, provided some
insights into the Russia dental
market and its importance for
the global dental industry. Currently, there are 85,000 dentists
and 25,000 dental technicians in
Russia. The market has a yearly
supply turnover of US$ 1 billion.

surgeons, with which DTI entered into an international media agreement in 2013. Under
the contract, DTI’s today trade
show newspaper became the official and exclusive publication
at the Congresso Internacional
de Odontologia de São Paulo
(CIOSP), one of the leading congresses worldwide.

CHANNEL3 Night was attened by almost 100 guests. (Photograph: Robert Strehler)

FDI 2015BANGKOK
Annual World Dental Congress
22 - 25 September 2015 - Bangkok Thailand

Deadline for early bird registration
15 June 2015

On the second day of IDS, DTI
hosted the CHANNEL3 Night,
which was orgainsed together
with Exit Strategies, for the first
time. About 80 key opinion leaders from 15 countries gathered
on Wednesday at DTI’s MEDIA Lounge for their annual
meeting. As part of the event,
Harvard professor Myron Nevins received the first annual PI
Brånemark Award. The number
three in CHANNEL3 signifies
the three channels of sales in the
dental industry: sales by dealer,
direct sales and sales resulting
from the work of key opinion
leaders. The group consists of
leaders from all three areas.
On 12 March, industry partners
of DTI gathered for the DDS
WORLD and Chinese Night in
Hall 4.2. In 2014, DTI launched
its Digital Dentistry Show, the
first exhibition to focus solely on
digital products and applications
for dentistry, in Milan in Italy as
part of International Expodental.
The show will travel around the
world and be present in all major dental markets. Participants
of the night were informed that
the next DDS World show will
take place in Athens from 22
to 24 May 2015 and will be organised in collaboration with
OMNIPRESS. Further shows in
2015 are planned in Moscow,
Budapest, Istanbul, Shanghai
and New York. The event on
Wednesday was also attended by
representatives of the Chinese
Stomatological Association.
The Brazilian Night on 13 March
attracted many people. The
event was a joint project of DTI
and Associação Paulista de Cirurgiões-Dentistas (APCD), the
São Paulo association of dental

www.fdi2015bangkok.org
www.fdiworldental.org

[48] =>

48 ids 2015

Dental Tribune Middle East & Africa Edition | May-June 2015

SHOFU celebrates, announces change of management
By Dental Tribune International

OLOGNE,
Germany:
No Thursday during the
IDS would be complete
without the traditional SHOFU
evening programme—and this
year was no different. The festive setting of the Cologne Hyatt
Hotel served as backdrop for
news about a number of important matters. These included the
announcement that Martin Hesselmann will succeed Akira Kawashima as managing director
of the company on 1 April 2015.

Noriyuki Negoro, President of SHOFU Japan. (Photograph: Christin Bunn,
OEMUS MEDIA)

Thursday evening provided several reasons for the global Japanese company SHOFU to enjoy a
special sense of satisfaction. By
this time, the company’s team
had not only enjoyed three suc-

cessful days at the IDS, it had also
seen a positive start to the year,
as Akira Kawashima, Managing
Director of SHOFU Dental, and
Noriyuki Negoro, President of

SHOFU Japan, announced during their welcoming comments
while also offering a strategic
outlook on the coming year.

As in the past, some 300 guests
from home and abroad, consisting of sales partners, SHOFU
staff and representatives of the
media, were invited to share in
an evening of excellent food,
pleasant conversation and a fairminded exchange of views in a
stylish atmosphere. The guests
at this year’s event also included the general managers from
Singapore and the US, together
with their staffs, who contributed to making the evening a
success through their experience and their insights into the
market—presented in a spirit of
friendly cooperation and professional exchange. SHOFU places
considerable importance on the
event as a way of showing appreciation for productive teamwork while also using the occa-

sion to provide a look ahead to
future projects.
Martin Hesselmann, resposible for Sales and Marketing at
SHOFU Dental, had two reasons
to be pleased. He was not only
celebrating his 50th birthday, it
was also announced that he had
been chosen to succeed Akira
Kawashima. The sincere congratulations offered by numerous guests was an indication that
the company has found an ideal
successor in Mr Hesselmann,
who stands out not only in terms
of his professional skill and market expertise but who also possesses the right human element
necessary to lead this venerable
company successfully into the
future.

Planmeca presents real-time visualisation of jaw
movement and other highlights
By Dental Tribune International

OLOGNE, Germany: Incomparable visualisation
and measurement data of
mandibular 3-D movements in
real-time are possible with the
new Planmeca 4D Jaw Motion
system now on display by Finish
dental equipment manufacturer
Planmeca in hall 11.1 at IDS
in Cologne. According to Vice
President of the Group, Tuomas
Lokki, to whom Dental Tribune
International had the opportunity to speak on Tuesday morning, the system is available for
the camera feature of Planmeca
ProMax 3D Mid and Max X-ray
units and requires no additional
hardware.
“The solution is unique in the
sense that you can see in real
time whatever movement the
patient is making with the jaw

and what happens when the patient is moving or biting,” he explained. “Afterwards we can use
that to analyse the bite and the
situation around it and combine
that with the CAD/CAM data to
have the bite analysis.”
Besides this innovation, Planmeca also has its complete renewed Planmeca Romexis 4.0
on display, as well as the Planmeca Romexis Smile Design
software that allows dentists to
create harmonious new smiles
for patients, among other things.
The company’s overall presentation is bigger and better this year
with about 200 sqms additional
booth space compared to 2013.

Tuomas Lokki, Vice President of the Planmeca Group. (Photograph: DTI)

Connectivity and digital workflow are a particular focus of this
year’s presentation, Lokki said.

bring it into practice so that dentists can efficiently work and get
the benefits of all that technology,” Lokki said.

“We have a very good technology range. The challenge is to

Lokki added that in the future,
practices will be an all-around

connected system, for which the
IDS is a good example.
“We have seven kilometres of
cable here connecting everything. Every single product here
is connected, and that is the way

it goes. It is all about productivity, whether it is CAD/CAM or
imaging.”

Imaging expert Carestream Dental introduces latest
trends at IDS
By Dental Tribune International

OLOGNE,
Germany:
Global manufacturer of
imaging solutions Carestream Dental presented the
latest trends in oral imaging and
CAD/CAM technologies yesterday at their stand at the International Dental Show (IDS) in
Cologne. The company is one of
few that offer a complete product range in the field of dental
imaging.
“With our products, dentists are
able to experience the whole
world of dental imaging because
we are the only company in the
field of radiographing that offers
a complete portfolio from film to

3-D imaging,” said Frank Bartsch, Trade Marketing Manager
at Carestream Dental.
The company introduces several novelties at this year’s IDS,
one of them being the compact
intra-oral scanning system CS
7200. The new scanner offers
dentists all the advantages of the
digital storage phosphor imaging technology without them
having to change their normal
workflow.
In addition, Carestream Dental announced the release of its
new imaging system CS 8100SC,
an advancement of its renowned
system, CS 8100, for the second
half of 2015.

At its booth, Carestream Dental
offers individual consultations
for interested visitors in order
for them to find out which imaging solution is the right one for
them and how they can optimise
their own workflow. Moreover,
the manufacturer offers dentistry students the opportunity to
download its 3-D diagnosis software, “3D Viewer” and “Demovolumen,” for free during IDS.
To learn more about Carestream
Dental’s products, IDS attendees
can visit the company’s booth
(T040/U049/T043/T049) in Hall
10.2.

Carestream Dental’s booth at IDS can be found in Hall 10.2 (T040/U049/
T043/T049). (Photograph: Dental Tribune International)

[49] =>

ids 2015 49

Dental Tribune Middle East & Africa Edition | May-June 2015

KaVo Kerr Group Prepares to Present 35 + New
Products at the 36th IDS in Cologne
By KaVo

N

ew products in Digital
Imaging,
CAD/CAM,
Equipment and Consumables further cement organization’s role as global innovation
leader.

KaVo Kerr Group, a global portfolio of leading dental brands,
presented 35+ new products at
the 36th International Dental
Show (IDS) in Cologne. KaVo
Kerr Group delivers products
and solutions to 99% of dental practices worldwide, making IDS — the world’s leading
trade fair for the dental industry
— the ideal stage to share the
latest KaVo Kerr Group has to delivering complete workflow
offer. The meeting, March 10- solutions and introduce its own
14, 2015, expected more than sophisticated approach to digital
125,000 attendees from 149 dif- dentistry.
ferent countries.
The 35+ launches include brand Among the 35+ products intronew products, products released duced at IDS, highlights includin North America but new to the ed:
global market, and updates de- - The KaVo Lythos Intraoral
signed to take legacy products Scanner is designed to replace
to the next level. These releases traditional impressions, facilitatwill cover everything from Digi- ing a fully integrated workflow.
tal Imaging, to CAD/CAM, Op- Dentists can capture highly
eratory Units, Handpieces, and detailed images quickly, witha wide range of Consumables. out powder, in an intuitive and
The breadth and depth of prod- flexible scanning workflow that
uct development on display not offers the clinician maximum
only reinforces the role of KaVo flexibility: easily rescan anytime
Kerr Group as a leader in inno- during the scanning process,
data at any point during
vation, but will highlight the or- review
IDEM16 297x210mm Dental Tribune Middle East.ai
1
23/2/15
11:30 pm
ganization’s unmatched role in or after processing the scan, or

use the touch screen to rotate
the model in an infinite number of ways for heightened visibility of captured data. Dentists
can proceed to complete design
in-office or outsource complex
design cases to KaVo’s unique
Remote Design Service by wirelessly uploading scan data to the
cloud.
- The KaVo MASTERmatic Series offers excellent visibility
and access for speed increasing instruments, combined with
maximum precision and durability. Its new design and product features — including a 20%
reduction in head size — make
it the ideal replacement to the
12-year leader in the Premium
series, GENTLEpower.

- Kerr elementsfree: Kerr Endodontics is proud to introduce
its latest innovation in endodontic obturation, the cordless
elementsfree obturation system.
Designed for use with the warm
vertical condensation technique,
the elementsfree obturation system offers both downpack and
backfill capabilities in a cordless
design – giving dentists and endodontic specialists the freedom
of movement to perform endodontic procedures anywhere
without restrictions.
- The KaVo ESTETICA E70/E80
Vision is a delivery system designed to help dental professionals get in touch with their vision
for optimized chairside treatment. Product features include
sensitive touch screens with a
completely new user interface;
hygiene center with automated
cleaning programs; a modern
patient communication system
with integrated intraoral camera and hi-res KaVo HD screens;
and unique system software
CONEXIO for direct access to all
relevant patient data. Its innovative suspended chair concept
features new arm rests and the
ability to accommodate patients
up to 180 kg.

and global media to see many
of the new products up close.
This first-class event took place
at the Flora Köln, an historic formal park and botanical garden
located adjacent to the Cologne
Zoological Garden.
“It was just over a year ago
that KaVo Kerr Group formally
brought together our world class
dental brands under one identity,
with shared values and a lasting
commitment to the dental profession,” said Henk van Duijnhoven, Senior Vice President of
the KaVo Kerr Group. “We have
started the work of taking more
than 500 years of combined experience among these market
leading brands and translating
that expertise into leading product innovation that improves patient care and enhances clinical
workflows for dental professionals. We can’t wait to showcase
our unmatched global brand on
this one-of-a-kind global stage.”

On the evening of March 10,
2015, KaVo Kerr Group hosted
the “Art of Innovation” event, inviting dental professionals, dealer partners, industry leaders,

Contact Information
Visit www.kavokerrgroup.com for
more information.
Media Contact
KaVo Kerr Group
Thais Carter, Senior Manager
Global PR and Media Relations
+1 (312) 399-0953
thais.carter@kavokerrgroup.com

www.idem-singapore.com

THE BUSINESS OF DENTISTRY
INTERNATIONAL DENTAL
EXHIBITION AND MEETING

APRIL 8 - 10, 2016
Suntec Singapore Convention & Exhibition Centre

at
s
u
t
i
s
Vi
,
V006 0/11
ge 1
Passa

Now Open for Exhibition Applications,
Sponsorship Opportunities
Supporting Forums

Endorsed By
Ms. Stephanie Sim
Tel: +65 6500 6723
Fax: +65 6296 2771
s.sim@koelnmesse.com.sg

Supported By

Held In

In Cooperation With

Co-organizer

Singapore Dental Association

[50] =>

50 interview

Dental Tribune Middle East & Africa Edition | May-June 2015

Sirona introduces broad digital product line-up at IDS
By Dental Tribune International

OLOGNE,
Germany:
Under the motto “Proven
Digital Solutions”, global
dental manufacturer Sirona presented many product novelties
for the modern dental practice
and laboratory on 10 March at
the International Dental Show
in Cologne. Sirona’s new products aim to support the work of
dentists with innovative instru-

ments and equipment, as well
as provide efficient digital workflows and optimal comfort during treatment.
The company sees itself to be
one of the main drivers of digitalisation in the dental industry.
“Sirona quite simply is digital
dentistry,” said Jeffrey T. Slovin,
President and CEO of Sirona. To
digitalise and thereby simplify
dentistry, the global manufac-

turer developed several integrated digital solutions for efficient workflows in implantology,
endodontics, orthodontics and
prosthetics that are presented at
this year’s IDS.
Sirona looks back at a long history of developing digital solutions
to improve dental workflows.
“Twenty years ago, not only did
we put the first digital panoramic X-ray machine on the
market, but as many as 30 years
ago with CEREC, we made digital impressions and computeraided dental restoration suitable
for office practice,” Slovin said.
“Our path and the history of the
company stand for successfully
clinically tested and scientifically proven technologies that set
quality standards.”
Among other things, the company aims to set standards in
the field of digital imaging by introducing a completely updated
product range for intraoral, 2-D

Sirona press conference on 10 March

Jeffrey T. Slovin, President and CEO of Sirona spoke about the product novelties Sirona is introducing at IDS. (Photograph: Dental Tribune International)

and 3-D radiography as well as
the novel SIDEXIS 4 software
for capturing, processing and
archiving X-ray images. With its
innovative digital X-ray technology and the perfect interplay between hardware and software,
Sirona’s imaging systems ensure
a reliable diagnosis, even in
complicated cases, and yield Xray images of the highest quality
and free of noise.

Sirona employs a workforce of
3,300 at 29 locations worldwide
and markets its products in more
than 135 countries on all continents. The company develops,
manufactures and markets a
complete line of dental products,
including CAD/CAM restoration
systems (CEREC), digital intraoral, panoramic and 3-D imaging systems, dental treatment
centers and dental handpieces.

An Interview with Torsten Oemus, CEO of DTI
By Dental Tribune MEA/ CAPPmea

UBAI, UAE: In this interview, Dental Tribune
MEA speaks with Torsten Oemus, CEO and founder
of Dental Tribune International
(DTI), who shares his views on
dentistry and the dental industry
as a whole, placing particular
emphasis on the Middle Eastern
region. It has already been three
years since CAPPMEA became
the official licence owner of
Dental Tribune Middle East and
Africa (MEA).
Dental Tribune MEA/CAPPmea: Mr. Oemus, it is a rare
occasion for us to have you on
the other side of an interview
table. Could you tell us how
you began DTI and the motivation behind it?
Mr. Torsten Oemus: It all started
20 years ago as a family business.
My father was an orthodontist,
my mother and my grandmother were general dentists, and,
therefore, dentistry and the
challenges it presents to dentists
were daily discussion topics in
my family. While I was studying economics, I realised the
need for more business-oriented information and training for
the dentist as an entrepreneur,
something that was not taught
in dental schools. We launched
a business magazine and a business school for dentists in Germany, an idea that took off immediately. Within ten years, our
German operation had become
the leader in German-speaking
markets and created a strong
basis for an unprecedented international expansion. About ten
years ago, I founded DTI to create a global platform for dentists
to share their knowledge and
experience—from dentists for
dentists. What started as a dental
newspaper has today become a

multimedia powerhouse, reaching over 650,000 dentists in 27
languages in over 90 countries.
My vision was to create a network for dentists to serve their
information and education
needs 24/7 based on best practices from around the world, but
in their local language.
How does DTI differentiate itself from other dental media
in the market?
DTI’s greatest differentiator is
its global perspective combined
with local relevance. We invite
the best publishers to join our
global network and provide
them with a vast database of
globally produced materials.
The local editor is in charge of
choosing and supplementing the
best materials for local market
needs and of presenting them
in the local language and style.
Furthermore, we strive to be as
innovative as practically possible and to invest in content production for all channels: print,
e-papers, e-newsletters, online,
mobile, events and e-learning.
A good example of how this distinguishes us from other publishers is our highly successful
e-learning community brought
together via the Dental Tribune
Study Club, offering over 600
free continuing education programmes. Over 200,000 dentists
worldwide have already signed
up and are fulfilling their continuing education requirements
online. This comprehensive approach is rather unique in dental media because it requires a
great deal of resources and constant innovation.
At the end of 2012, a new edition enriched the DTI portfolio, a partner for the MEA
region. Why did you chose
CAPPMEA as your partner for
the MEA edition?

We had been trying to enter the
MEA market for several years,
but simply lacked a well-established professional partner, such
as CAPPMEA. When I met and
talked with Dr. Dobrina Mollova
in 2012, I immediately became
convinced that this would be a
perfect relationship. Dr. Mollova
and her business partner, Mr.
Tzvetan Deyanov, had earned
an excellent reputation for convening world-class events, conferences and continuing education programmes throughout
the Middle Eastern region, and
they worked very hard for the
success of their clients. This was
exactly the kind of partner we
had been looking for. They have
proved to be the right choice.
What are your thoughts on
the dental market in the Middle East and the change in activities seen over the last three
years since Dental Tribune
MEA began its operations?
Despite the unfortunate political turmoil in some parts of the
region, the MEA dental market
has seen solid growth over the
few last years and has become a
focus of investment for the international dental community. All
major competitors have opened
regional offices, showrooms,
training centres and even new
dental schools. Major international conferences and trade
shows have also been organised
in the region. These activities
demonstrate the increased importance of the region and are
the drivers of the need for modern communication channels
and educational content. Dental
Tribune MEA serves these needs
via its very popular print edition,
show dailies at major dental
meetings, and daily newsfeeds
online. No other publisher offers
the dental community across the
Middle Eastern region up-to-

date and comprehensive media
like Dental Tribune does. Even
within the Dental Tribune network, the Dental Tribune MEA
edition is famous for its early
adoption of new projects. It has
contributed multiple innovative
ideas, such as the implementation of e-papers into e-newsletters and the editorial feature of
specialist dental clinics for market referrals.
This year, CAPPMEA is celebrating its tenth anniversary
during the tenth CAD/CAM
and Digital Dentistry International Conference in Dubai.
What is your impression of
the rapidly developing digital
market?
Firstly, I wish to congratulate
CAPPMEA on reaching this important milestone! The CAD/
CAM and Digital Dentistry International Conference in Dubai
is one of the largest global gatherings concerning the latest
developments in digital dental
technologies. The conference
has certainly paved the way
for the high acceptance of the
digital workflow in dental offices across the region and
worldwide. Digital dentistry is
not simply a trend, but it will
continue to change the entire
workflow in dental offices and
is certainly changing the way
all service and product providers interact. Thousands of new
digital products have recently
been introduced at the International Dental Show. Their commercial success and acceptance,
however, highly depend on the
effective communication of their
benefits and on the training of
dental professionals on how to
integrate them into their daily
routines. Product innovation is
not an issue; changing long-established workflows certainly is.
I am fairly sure that dental pro-

Mr. Torsten Oemus, CEO DTI

fessionals will adapt to competitive advantages. We might even
see entirely new professions being created, combining clinical,
technical and engineering skills,
which are needed to operate
complex CAD/CAM devices.
How will DTI continue to develop, improve and better
serve its clients?
We regard these dramatic
changes in the marketplace undoubtedly as an opportunity for
our business to grow, as communication, information and
education are key drivers of the
market. We will further develop
our media portfolio, together
with our reach, in response to
the market. Our main growth
areas right now are the further
expansion of our e-learning
community (www.dtstudyclub.
com), the new event formats,
such as the Digital Dentistry
Show
(www.ddsworldshow.
com), and our high-end Tribune CME programmes (www.
tribunecme.com). All these initiatives serve the purpose of creating strong global communities
and marketplaces with a critical
mass through a global reach,
where dental professionals and
product and service providers can effectively interact and
achieve their goals.

[51] =>

Sensodyne
Repair & Protect
Presenting a new layer of protection

Sensodyne Repair & Protect harnesses advanced NovaMin® technology to help build
a robust hydroxyapatite-like layer over exposed dentine and within dentine tubules.1–5
With Sensodyne Repair & Protect, you can do more than treat the pain of dentine
hypersensitivity – you can repair and protect your patients’ exposed dentine.

Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For further information please contact your doctor/healthcare professional.
For reporting any Adverse Event/Side Effect related to GSK product
Please contact us on contactus-me@gsk.com.
Date of Preparation: June 2014, CHSAU/CHSENO/0063/14
We value your feedback
Saudi Arabia: 8008447012
All Gulf and Near East countries: +973 16500404

Think beyond pain relief and recommend
Sensodyne Repair & Protect

References: 1. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 2. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 3. West NX et al. J Clin Dent 2011; 22(Spec Iss):
82-89. 4. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 62-67. 5. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. Prepared December 2011, Z-11-516.

[52] =>

Ultra-low abrasion for your patients who need
sensitivity relief and seek gentle whitening
Clinically proven to relieve your
,
patients dentine hypersensitivity*1-4
Active lifting and prevention
of extrinsic dental stains5-7
Ultra-low abrasive formulation
appropriate for your patients
with exposed dentine8

Recommend Sensodyne – specialist expertise
for patients with dentine hypersensitivity

*With twice-daily brushing
References.. 1. Jeandot J et al. Clinc (French) 2007; 28: 379–384. 2. Nagata T et al. J Clin Periodontol 1994; 21(3): 217–221. 3. GSK data on
file. DOF Z2860473. 4. Leight RS et al. J Clin Dent 2008 19(4) 147-153. 5. Schemehorn BR et al. J Clin Dent 2011 22(1) 11-18. 6. Shellis RP
et al. J Dent 2005 33(4) 313-324. 7. GSK data on file. DOF Z2860415. 8. GSK data on file. DOF Z2860435.
Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For further information please contact your doctor/healthcare professional.
For reporting any adverse event/side effect related to GSK product,
please contact us on contactus-me@gsk.com
Prepared: July 2014, Item Code: CHSAU/CHSENO/0034/14
We value your feedback
Saudi Arabia: 8008447012
All Gulf and Near East countries: +973 16500404

[53] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

hygiene tribune 1B

Over 100 countries celebrate World Oral Health Day
in Times Square in New
York. A collage was
shown of pictures that
were individually created by users of a poster
application specially introduced by the FDI for
WOHD.

On World Oral Health Day, 20 March, the “Smile for life” campaign poster was shown via the famous NASDAQ screen
in Times Square in New York. (Photograph: FDI World Dental Federation)

By Dental Tribune International

ENEVA,
Switzerland:
World Oral Health Day
(WOHD), which takes
place annually on 20 March,
inspired many national dental
associations, dental students
and other participants around
the globe this year to organise
a wide range of awareness-raising activities. According to the
FDI World Dental Federation,
reports are only just coming
in from around the world and

signs are that the event has exceeded expectations.
Over 300 students gathered in
Amsterdam in the Netherlands
for the second edition of the
ToothCamp, a theatrical informational event that seeks to educate children and adolescents
about dental issues. The participants were able to try out dental
tools, as well as learn more about
the benefits of eating healthily
and about the importance of optimal oral health through excit-

ing chemical experiments with
acid and lime or porcelain and
abrasives under the supervision
of biology, chemistry and physics
experts.
Hong Kong’s Department of
Health organised an oral health
carnival, which attracted an
audience of about 2,300 local citizens. Through interactive games, exhibitions on oral
health information and teethcleaning demonstrations, the
public were reminded of the importance of taking care of one’s
oral health from an early age
by adopting good oral self-care
habits and seeking regular professional oral care.
In Costa Rica, the second edition
of Lavatón was organised by the
Colegio de Cirujanos Dentistas
de Costa Rica, the local dental
association. Dental professionals participating in this initiative
visited more than 35 schools to
educate students on toothbrushing, disease prevention and important oral hygiene habits. On
20 March, thousands of students
across the country brushed their
teeth simultaneously as part of
Lavatón.

Children had the opportunity to try out dental tools in Amsterdam.

In Vietnam, over 6,000 people
participated in the Run for Life
WOHD 2015 race, which was
sponsored by the Vietnam Odonto-Stomatology Association,
Unilever and the Vietnamese
Ministry of Health.
Unilever Kenya’s Closeup toothpaste brand and the Kenya
Dental Association kicked off a
new partnership in the town of
Naivasha to support the WOHD
“Smile for life” campaign with
free dental check-ups and toothbrushing lessons that they will
be rolling out across the country.

In Costa Rica, dentists educated students at 35 schools about brushing techniques

The “Smile for life” message
was also broadcast to the world
via the giant NASDAQ screen

As the official media partner of WOHD 2015, Dental Tribune International
provided comprehensive
coverage of the FDI’s
message. Among other
activities, the publisher
helped promote WOHD
2015 through news articles, banners and advertisements in its various
international print publications and on its website, www.dental-tribune.
com, including a topic
page solely dedicated to
WOHD 2015.
Oral health carnival in Hong Kong

[54] =>

2B hygiene tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

Shape and colour – factors in sectional matrices as well?
By Prof. Claus-Peter Ernst

irect composite restorations can now be considered a proven standard
treatment method in the posterior region [1, 3]. However, treatment can differ significantly with
regard to extension and stress,
and this can have a definite influence on long-term survivability. There are many factors that
determine the long-term success of a composite restoration:
tightly sealed edges are primarily guaranteed by the adhesive
technique [2]. For dental materials, besides low shrinkage stress
[4, 11], the material also has a
high flexural strength [6, 10] in
order to minimise the risk of the
restoration undergoing a cohesive-type failure. A fractured
filling is clearly a more dramatic
event for the patient than a discoloured edge. For the patient,
the success of direct posterior
tooth treatment with composites thus depends on its stability.
Besides the adhesive technique
and the selection of materials for
the restoration, the crucial key
function of correct light polymerisation also playes a decisive
role [5]. It is completely possible
to double the flexural strength of
one’s own composite just by using the correct light curing and
light curing technique. A further
possible influence on the stability of a posterior tooth composite
restoration is less well-known:
the correct anatomical shape of
the interproximal surface. If this
is shaped like a natural tooth,
the interproximal contact is at
the height of the tooth equator
and the marginal ridge is not too
excentric. This reduces the risk
of ridge fractures – both purely
cohesive chipping fractures as
well as more complex, mixed
cohesive/adhesive failure patterns. Lohmanns et al. [8] were
able to show that the stability of
an interproximal composite restoration can be increased significantly by using an anatomically
shaped matrix. The correct positioning of the interproximal contact also facilitates the achievement of sufficient contact
strength – provided clamping
rings are used correctly. Surprisingly, the interproximal contact
strength is not the result of the
pressure of a wooden wedge; it
is primarily caused by the separation force of the sectional matrix ring [7, 9]. Automatically – as
a side effect - fewer interproximal food impactions occur as a
result.
For this reason, sectional matrices are now the first choice
when it comes to correctly designing interproximal contact
surfaces. Circular matrices,
even when they are anatomically shaped, should be used
when it is not possible to fix sectional matrices in place. This is
the case, for instance, for distal
cavities on the last tooth in a
row, as well as for teeth that are
not in an anatomically correct
position as for example a rotated
tooth. The general acceptance of
sectional matrix systems is also

shown by the extensive range
of sectional matrices and rings,
which are now available. In general, sectional matrices can be
roughly divided into two groups:
dead-soft matrices and stable
steel versions. The supporters
of dead-soft sectional matrices
like their easy mouldability and
adaptability to the tooth. However, critics dislike their lack of sta-

what more safely used sectional
matrix systems.
Clinical case 1: Upper right
2nd premolar
The 48-year-old patient was
treated six months ago with a
Biodentine (Septodont) filling
to the 2nd upper right premolar
15 (Fig. 1). The temporary filling is now to be replaced with

ed and positioned in the contact
area. One benefit of this matrix
system is the almost black colour, which has been achieved
using a special dyeing process
(no coating!) for the metal carrier foil. This produces an outstanding contrast in the transition to the hard tooth tissue. This
makes it much easier to inspect
the cervical seal, as there is no

Fig. 1: Biodentine temporary treatment the upper right 2nd premolar.

Fig. 6: The treated upper right 2nd
premolar at a further follow-up appointment one year later.

Fig. 11: Lower right 1st molar with
MIH, which needed a restorative
treatment.

Fig. 2: The cavity margins can easily
been identified by means of the Polydentia LumiContrast sectional matrix in combination with the associated sectional ring under rubberdam
isolation.

Fig. 7: Cohesive type fracture in the
mesio-occlusal amalgam filling in a
lower right 2nd molar.

Fig. 12: The excavated, prepared cavity equipped with the LumiContrast
sectional matrix system under rubberdam.

Fig. 8: The excavated, prepared cavity, isolated under rubberdam and
equipped with the LumiContrast sectional matrix system.

Fig. 13: Completed, direct composite
restoration to the lower right 1st molar.

Fig. 3: Conditioning of the cavity with
phosphoric acid gel.

Fig. 4: Sealing of the cavity with a traditional two-bottle adhesive.

Fig. 5: Finished and polished restoration (tooth 15).

bility if an interproximal contact
that is left untouched and has to
be surpassed by the matrix or if
a wooden wedge, cannot be optimally placed and thus the sectional matrix presses it into the
cavity.
Three clinical cases are presented below in which a new
sectional matrix system is applied that, because of the special
dyeing method despite deadsoft steel, belongs in the second
group of stable and thus some-

Fig. 9: The finished composite restoration.

Fig. 10: The lower right 2nd molar once treated with the resin composite
- one year later: possibility of conducting a clinical-visual inspection of the
interproximal surface of tooth due
to the fracture of the amalgam filling
the 1st molar.

a permanent filling. The subsequent excavation of the very
deep occlusal-mesial cavity was
possible without any problems;
it was possible to avoid a pulp
opening using this two-step approach. Figure 2 depicts the
cavity with the Polydentia LumiContrast sectional matrix in
combination with the associated
ring under rubberdam isolation.
The extremely stable and thus
“wrinkle-resistant”
sectional
matrix can be easily manipulat-

disruption caused by reflections
in the metal film. A traditional
wooden wedge was used cervically to tighten the cervical margin there. The LumiContrast
separation ring can be used in
two versions: firstly, as shown
in the figure, corresponding to
a classic Silver separation ring.
However, there is also the possibility of fitting small triangular silicone sleeves that enable
improved interproximal sealing of the sides, as they better
press the sectional matrix films
to the sides of the interproximal
preparation surfaces. However,
this was not necessary in the
present case. Figure 3 shows the
cavity conditioned with phosphoric acid gel, figure 4 shows
the adhesive surface sealed with
a traditional two-bottle adhesive
(Optibond FL, Kerr). The restoration was built out of a nano hybrid composite (Venus Diamond
A3, Heraeus Kulzer, Hanau,
Germany) using an oblique layering technique (Fig. 5). Figure
6 shows the same tooth at a further follow-up appointment one
year later.
Clinical case 2: 2nd lower right
molar
The 50-year-old patient presented with a cohesive type fracture
in the mesio-occlusal amalgam
filling of his lower right 2nd molar (Fig. 7). In the distal marginal

ridge, a minor amount of abfractured enamel was visible . After
explaining all possible treatment
options to the patient, there was
consent, that the best option
might be the directly placed resin composite restoration. Figure
8 shows the excavated, prepared
cavity, isolated with rubberdam
and also equipped with the LumiContrast sectional matrix system (Polydentia, Switzerland). In
contrast to case 1, the interproximal sides were far more open
compared to case 1. For this
reason, the triangular silicone
sleeves were fitted to the LumiContrast separation ring. This
made it possible to better adapt
the sectional matrix foil to the
sides of the preparation and thus
consequently minimise the material overhang, resulting in less
finishing and polishing work.
Due to the silicone sleeves that
can be fitted individually from
case to case, e.g. only one ring
foot may need to be fitted with a
sleeve, the others meay remain
free. This significantly increases
flexibility in using the clamping ring and also simplifies the
preparation procedure in that
there is no need to prepare the
ring separately as were permanent silicone inlets have to be
taken care of. Figure 9 shows
the finished composite restoration (Optibond FL /Kerr, Venus
Diamond A3/Heraeus Kulzer);
figure 10 shows the situation after another year: the distal portion of the amalgam filling in the
1st lower right molar fractured –
this offered the rare opportunity
for a clinical-visual inspection of
the interproximal surface of the
2nd right lower molar created
one year earlier.
Clinical case 3: 1st lower right
molar
The 20-year-old patient exhibited molar-incisor hypomineralisation (MIH). His lower right
1st molar required restorative
treatment in the region of the
occlusal-buccal surface (Fig.
11). For cost reasons, as well as
from the viewpoint of minimally-invasive caries treatment, it
was agreed with the patient to
initially undertake direct treatment in the form of a resin
composite restoration. Figure
12 shows the excavated, prepared cavity equipped with the
LumiContrast sectional matrix
system under rubberdam. In the
present case – similar to case
1 – it was again not necessary
to fit the silicone sleeves to the
LumiContrast clamping ring.
Sufficient moulding and adaptation of the sectional matrix foil
was possible there. The excellent contrast between the almost
black sectional matrix foil and
the interproximal -cervical tooth
enamel margin can once again
be seen. The direct composite
restoration was again made out
of the nano hybrid composite
Venus Diamond (Heraeus-Kulzer), this time in the shade A2,5
using a traditional two-bottle
adhesive system (Optibond FL,

> Page 4B

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4B hygiene tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

< Page 2B
Kerr) (fig. 13). A colour characterisation of the occlusal surface
was intentionally avoided, as the
application of dyes in the fissure
in the worst case could even put
at risk to the overall integration
of the restoration [12]. In general, most patients like to avoid
such colour-stains; for them, it
is important that the restoration cannot be identified as such
at a normal speaking distance.
This is the case in the present
restoration. With complex findings such as MIH, the stability of
the restoration primarily takes
priority. This request was taken
into account in that all sectional
aspects – adhesive sealing with
a proven adhesive, the use of
a stable and shrinkage stressreduced resincomposite, the
anatomical shaping (sufficient
sectional matrix system) and the

correct light polymerization –
were satisfied.
References
1. Geinzer E, Muschweck A,
Petschelt A, Lohbauer U. Mechanical fatigue degradation of
ceramics versus resin composites for dental restorations. Dent
Mater 2014; 30: 424-432.
2. Ernst CP: Die 20 beliebtesten
Fehler beim Kleben. DFZ 2010;
11: 66–83.
3. Ernst CP: Komposit im Seitenzahnbereich: Möglichkeiten und
Grenzen. Quintessenz 2010; 61:
545-557.
4. Ernst CP, Rullmann I, Janssen
B, Willershausen B. Polymerization shrinkage stress of bulk
fill resin composites. Lecture
at the IADR Annual Meeting
2014. https://iadr.confex.com/
iadr/13iags/webprogram/Pa-

per170911.html.
5. Ferracane J, Watts DC, Barghi N, Ernst CP, Rueggeberg FA,
Shortall A, Price R, Strassler H.
Der effiziente Einsatz von Lichtpolymerisationsgeräten – ein
Leitfaden für Zahnärzte. ZMK
2014; 30: 166-180.
6. Hahnel S, Henrich A, Bürgers R, Handel G, Rosentritt M.
Investigation of mechanical
properties of modern dental
composites after artificial aging
for one year. Oper Dent 2010; 35:
412-419.
7. Loomans BA, Opdam NJ, Roeters FJ, Bronkhorst EM, Burgersdijk RC Comparison of proximal contacts of Class II resin
composite restorations in vitro.
Oper Dent 2006; 3: 688-693.
8. Loomans BA, Roeters FJ, Opdam NJ, Kuijs RH The effect of
proximal contour on marginal

ridge fracture of Class II composite resin restorations. J Dent
2008; 36: 828-832
9. Loomans BA, Opdam NJ, Roeters JF, Bronkhorst EM, Plasschaert AJ Influence of composite
resin consistency and placement
technique on proximal contact
tightness of Class II restorations.
J Adhes Dent 2006; 8: 305-310
10. Rosentritt M, Behr M, Kolbeck C, Handel G. Flexural
strength of restorative composites after different aging conditions. Lecture at the IADR Annual Meeting 2014. https://iadr.
confex.com/iadr/13iags/webprogram/Paper171330.html
11. Rullmann I, Schattenberg A,
Marx M, Willershausen B, Ernst
CP: Spannungsoptische Messungen der Polymerisationsschrumpfungskraft schrumpfreduzierter Komposite. Schweiz

Monatsschr Zahnmed 2012; 122:
8-12.
12. Pucci CR, Barcellos DC, Palazon MT, Borges AB, da Silva MA,
de Paiva Gonçalves SE. Evaluation of the cohesive strength between resin composite and lightcuring characterizing materials.
J Adhes Dent 2012; 14: 69-73

Contact Information
Prof. Dr. Claus-Peter Ernst
University Medical Centre
of the Johannes Gutenberg
University Mainz
Department for Operative
Dentistry
Augustusplatz 2, 55131 Mainz
ernst@uni-mainz.de

Reflecting on oral-health’s good old iodine days
By Patricia Walsh, RDH, USA
While anxiously waiting for the
“Downton Abbey” television series to start up again, I got my
English history fix by reading
the history of Wentworth Castle.
The book covered the trials and
tribulations of an aristocratic
family in a home three times
the size of Buckingham Palace. I
was taken by surprise when the
author mentioned the cause of
death of a high-ranking nobleman as “quinsy throat.”
In modern times, with the arrival of antibiotics, you wouldn’t
hear of this — at least not in a
developed nation. The more I
thought about it, I don’t think
I had heard the term “quinsy
sore throat”for a very long time.
Around here, if your throat is
starting to close off, you’ve probably gotten yourself to an emergency room “pronto.” It is an
abscess in the peritonsillar area
that often needs drainage.
While tonsillitis is more common in children, both kids and
adults are susceptible to quinsy.
One can only assume that if the
breathing restrictions don’t kill
you, the resulting septicemia
might later. A quinsy sore throat
can infect both the blood supply
and individual organs.
I can recall having my tonsils painted with iodine by the
school nurse when I was starting to “come down with something.” A tall canister of extra
long cotton swabs were one of
the staples of her office.
I can’t say whether there’s any
scientific proof that tonsil painting reduced cases of severe tonsillitis. But I do know that some
homeopathic remedies call for
gargling with a watered down
Betadine solution even today.
I’ve also heard that eating three
or four marshmallows helps to
soothe a sore throat. Apparently
it has something to do with the

gelatin. I suppose if you’re not
eating at all, any caloric intake
will do, so it might as well be fun!

while the glycogenfree attached gingiva
remains
unstained.
Measure the total
width at the unstained
gingiva and subtract
the
sulcus/pocket
depth from it to determine the width of the
attached gingiva.”

Washington’s epiglottitis
George Washington’s physician mentions his quinsy sore
throat prior to his death at age
63. He was thought to have suffered from a quinsy sore throat
that quickly turned into epiglottitis — most likely his cause of
death. The swelling of his epiglottis cut off his air supply. He
also suffered from malaria, TB
and smallpox during his lifetime. How sad that it may have
been a very bad sore throat that
got him in the end. The bloodletting technique that was used
at the time probably hindered
his recovery as well.
When I was a dental hygiene
student, we were occasionally
brought to a local city clinic to do
checkups on grammar school
children. These children were
the poorest of the poor and were
seen on old WWII wooden field
chairs. There was no money in
the budget for fancy things like
“disclosing tablets.” Instead,
we used iodine on long cotton
swabs to paint the teeth and disclose the plaque. Our instructor
kept the large bottle of iodine.
The iodine that a physician uses
is water-based as opposed to the
alcohol-based type available for
home use. We used eye droppers
to fill up our little green-glass
dappen dishes for each patient.
I would think the taste alone
would put children off dentistry for some time to come. We
rinsed their mouths with a rubber ball syringe, and they expectorated into a kidney basin. Considering the number of patients I
currently see with known iodine
allergies, it’s amazing we never
heard of any children having a
reaction. Then again, people are
now more “allergy aware” then
they once were. There is probably an equal number of children with red-dye allergies who
would have done no better with

Patricia Walsh, RDH, (Photo: Hygiene Tribune
U.S. Edition)

the modern disclosing tablets.
In spite of iodine’s unpleasant
taste, I have been known to recommend subgingival irrigation
with a Betadine solution (brand
name for povidone-iodine).
The key to this is the dosage. I
tell the patient that if the water
turns brown, they’ve added too
much. There is a huge temptation to use too much because
most drug stores sell only very
large bottles. But between the
bad taste and the potential for
staining, it’s easy to see why less
is more. Iodine kills the gram
negative bacteria that live in the
darker recesses of a deep perio
pocket.
There is another clinical application for iodine in dentistry. An
iodine staining test used to assist
in discerning attached gingiva
as mentioned in “Periodontics
Revisited” by Shalu Bathla, MD.
The clinician can: “paint the gingiva and oral mucosa with Lugols solution (iodine,water and
potassium iodide). The aveolar
mucosa takes on a brown color
owing to its glycogen content

In the Chernobyl disaster, some Lugols
solution was used as
an emergency source
of iodide to block radiation iodine uptake,
simply because it was
widely available as a
drinking water decontaminant, and pure potassium iodide without
iodine (the preferred
agent) was not available.

Mama don’t take my Mecurochrome away
Mecurochrome and merthiolate
were also very popular in my
childhood. We proudly wore our
hot pink tinctures over scraped
knees like playground battle
scars. When it was determined
that mercury was detrimental
to one’s overall health, Mecurochrome was banned from general use. The U.S. Food and Drug
Administration put very strict
limitations on the sale of Mercurochrome in 1998 and stated that
it was no longer considered to be
a GRAS (generally recognized as
safe) over-the-counter product.
Merthiolate was another commonly found antiseptic and antifungal agent that was banned
because of its mercury content.
Iodine was determined by the
U.S. Justice Department to
have a roll in the production of
methamphetamine and is now
a restricted purchase. I wouldn’t
recommend bringing back anything more than 4 fl. oz. of tincture of iodine from your next
Mexican vacation. Scrape your
feet on a coral reef, and you

might find yourself detained at
customs for questioning about
your toiletry kit.
While iodine crystals are the
form of choice for illegal drug
labs, some smaller manufacturers are known to combine
tincture of iodine with hydrogen peroxide. Some businesses
have removed iodine from the
shelves, while others are simply
restricting large quantity sales
— i.e., more than $100 worth.
When I asked my local pharmacist about Walgreen’s policy, he
pointed to the surveillance cameras above the tincture of iodine
shelf. Legitimate medical laboratories that do gram staining
now have additional paperwork
due to the restrictions on iodine
strengths and quantities.
Iodine getting harder to find
The old-time iodine bottle with
the skull and crossbones sitting in the medicine cabinet
has come and gone. In this new
age of communication and entertainment, I wonder if a child
would even be put off by the
sight of a poison label. Children
are exposed to cartoon pirates
at such an early age. In the mid
19th century, cobalt blue bottles
or raised glass lettering were
used to help in the identification
of poison.
While there is no federal mandate for small quantities, iodine
has disappeared from a few
pharmacies and department
store shelves the way Sudafed
did most recently. Home brewers take heart, these pharmacists just require that you sign
a poison-control statement and
list the reason for your purchase. For those of you who still
buy your beer in the traditional
manner, iodine is often used as a
test for starch conversion in the
mash.
This article was published in Hygiene Tribune U.S. Edition, Vol. 8
No. 2, February 2015 issue.

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6B hygiene tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

Infection control in an era of emerging
infectious diseases
By Eve Cuny, USA

ore than three decades
have passed since the
emergence of human
immunodeficiency virus (HIV)
as a global pandemic. More
than any other infection, it is
possible to single out HIV as the
primary stimulus for changing
infection control practices in
dentistry. Prior to the mid-1980s,
it was uncommon for dentists
and allied professionals to wear
gloves during routine dental
procedures. Many dental clinics did not use heat sterilisation,
and disinfection of surfaces was
limited to a cursory wipe with an
alcohol-soaked gauze sponge.
This was despite our knowledge
that hepatitis B virus (HBV) had
been spread in clusters in the
offices and clinics of infected
dentists and that dentists were
clearly at occupational risk for
acquiring HBV.
Today, many take safe dental
care for granted, but there is
still reason to remain vigilant
in ensuring an infection-free
environment for providers and
patients. HIV has fortunately
proven to be easily controlled in
a clinical environment using the
same precautions as those effective for preventing the transmission of HBV and hepatitis C
virus.[1] These standard precautions include the use of personal
protective attire, such as gloves,
surgical masks, gowns and protective eyewear, in combination
with surface cleaning and disinfection, instrument sterilisation,
hand hygiene, immunisations
and other basic infection control

precautions. Sporadic reports
of transmission of blood-borne
diseases associated with dental care continue, but are most
often linked to breaches in the
practice of standard precautions.
[2]
Emerging and re-emerging infectious diseases present a real
challenge to all health care providers. Three of the more than
50 emerging and re-emerging
infectious diseases identified by
the Centers for Disease Control
and Prevention and the World
Health Organization (WHO) include Ebola virus disease (EVD),
pandemic influenza and severe
acute respiratory syndrome.
[3, 4] These previously rare or
unidentified infectious diseases
burst into the headlines in the
past several years when they exhibited novel or uncharacteristic
transmission patterns.
Concern about emerging infectious diseases arises for several
reasons. When faced with a particularly deadly infectious disease such as EVD, which can be
spread through contact with an
ill patient’s body fluids, health
care workers are naturally concerned about how to protect
themselves if an ill patient presents to the dental clinic. With
diseases such as pandemic influenza and severe acute respiratory syndrome, which may
be spread via inhalation of aerosolised respiratory fluids when
a patient coughs or sneezes, the
concern is whether standard
precautions will be adequate.
In addition to standard precau-

Infection control in the dental practice includes washing hands, wearing gloves, using disposable supplies, and disinfecting reusable materials properly. (Photograph: Bork/Shutterstock)

tions, treating patients with
these diseases requires the use
of transmission-based precautions. These encompass what
are referred to as contact, droplet and airborne precautions
for diseases with those specific
routes of transmission. Transmission-based precautions may
include patient isolation, placing
a surgical mask on the patient
when he or she is around other
people, additional protective attire for care providers, and in
some cases the use of respirators and negative air pressure in
a treatment room. In most cases,
patients who are contagious for
infections requiring droplet or
airborne precautions should not
be treated in a traditional dental
clinic setting.
Updating a patient’s medical
history at each visit will assist
dental health professionals in
identifying patients who are
symptomatic for infectious diseases. Patients with respiratory

symptoms, including productive
cough and fever, should have
their dental treatment delayed
until they are no longer symptomatic. Additionally, health care
professionals who are symptomatic should refrain from coming to work until they have been
free of fever without taking fever-reducing medication for 24
hours.
In most cases, a patient with
symptoms as severe as those
experienced with EVD will not
present for dental care and
therefore extraordinary screening and protection protocols are
not recommended. If a patient
is suspected of having a highly
contagious disease, he or she
should be referred to a physician, hospital or public health
clinic.
Dental professionals should take
action to remain healthy by being vaccinated according to accepted public health guidelines,

understanding that the recommendations may differ according to country of residence.
Performing hand hygiene procedures at the beginning of the
day, before placing and after removing gloves, changing gloves
for each patient, wearing a clean
mask and gown or laboratory
coat, and wearing protective
eyewear are all positive actions
that help prevent occupational
infections. In addition, cleaning and heat sterilisation of all
instruments and disinfection of
clinical surfaces ensure a safe
environment for patients. There
is solid evidence that dental care
is safe for patients and providers when standard precautions
are followed, but patients and
dental health care workers are
placed at risk when precautions
are compromised and breaches
occur.
Editorial note: A complete list of
references is available from the
publisher.

Tackling poor oral health around the globe
By Dental Tribune International

OPENHAGEN,
Denmark: Researchers from
the University of Copenhagen have examined the benefits of enhanced oral health promotion combined with a closely
supervised toothbrushing programme in schools in southern
Thailand. The two-year study
aimed to establish an effective
model for the fight against the
increasing burden of tooth decay among children in Asia.
The research project, which
was based on the World Health
Organization’s Health-Promoting Schools concept, focused on
increasing awareness of the importance of oral health in order
to foster a healthy school environment and encourage regular dental care habits in young
children, including the use of
effective fluoridated toothpaste.
Over 24 months, the researchers
compared the effects of closely
supervised toothbrushing with
a toothpaste containing 1,450
ppm fluoride and 1.5% argi-

The research project in southern Thailand focused on increasing awareness of
the importance of oral health in order to foster a healthy school environment
and encourage regular dental care habits in young children. (Photograph:
Stephane Bidouze/Shutterstock)

nine to customary oral hygiene
practices in the control group.
The study was conducted in
the Songkhla province in Thailand and involved 15 schools
and 3,706 preschool students, of
whom 1,940 were in the intervention group and 1,766 in the
control group.
During the course of the study,
dental plaque scores significantly improved among the children
in the intervention group. Ac-

cording to the researchers, the
project achieved a caries reduction of up to 34 per cent for all
schools included in the study
and a reduction in new carious lesions of up to 41 per cent
for the most compliant schools.
This points to the positive effect
of the use of fluoridated toothpaste administered by schoolteachers via an enhanced school
oral health programme.
“This project emphasises the ne-

cessity of engaging the school as
well as family and schoolteachers,” said lead researcher Prof.
Poul Erik Petersen, from the Department for Global Oral Health
and Community Dentistry at the
university’s School of Dentistry.
“Globally, very few school health
programmes are evaluated scientifically. This research project
has provided sound information
and will thus contribute to the
promotion of preventive measures in school oral health programmes,” Petersen concluded.
According to Petersen, the experience gained from the study
could offer new insight into the
global fight against poor oral
health in children. Furthermore, he expressed the hope
that the research results would
assist ministries of health, public health administrators and
oral health planners in low- and
middle-income countries in Asia
in developing evidence-based
school health programmes.
In Asia, the number of children
suffering pain and discomfort

resulting from poor oral health,
in addition to missing school
lessons, is increasing. High levels of tooth decay in developing
countries such as Thailand are
primarily related to poor living
conditions, the high intake of
sugars, poor oral hygiene practices, low exposure to fluoride
for disease prevention, as well
as limited availability of and accessibility to preventive dental
health services.
According to figures of the FDI
World Dental Federation, between 60 and 90 per cent of
schoolchildren worldwide have
caries but the majority of dental
decay remains untreated due
to inappropriate, unaffordable
or unavailable oral health care
services.
The study, titled “School-based
intervention for improving the
oral health of children in southern Thailand”, was published in
the March issue of the Community Dental Health journal.

[59] =>

[60] =>

Ultra-low abrasion for your patients who need
sensitivity relief and seek gentle whitening
Clinically proven relief from the pain
of sensitivity*1-4
Gently lifts stains and help prevent
new stains from forming5-7
Ultra-low abrasive formulation
appropriate for your patients
with exposed dentine8

Recommend Sensodyne – specialist expertise
for patients with dentine hypersensitivity

*With twice-daily brushing
References.. 1. Jeandot J et al. Clinc (French) 2007; 28: 379–384. 2. Nagata T et al. J Clin Periodontol 1994; 21(3): 217–221. 3. GSK data on
file. DOF Z2860473. 4. Leight RS et al. J Clin Dent 2008 19(4) 147-153. 5. Schemehorn BR et al. J Clin Dent 2011 22(1) 11-18. 6. Shellis RP
et al. J Dent 2005 33(4) 313-324. 7. GSK data on file. DOF Z2860415. 8. GSK data on file. DOF Z2860435.
Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For further information please contact your doctor/healthcare professional.
For reporting any adverse event/side effect related to GSK product,
Please contact us on contactus-me@gsk.com
Prepared: July 2014, CHSAU/CHSENO/0034/14
We value your feedback
Saudi Arabia: 8008447012
All Gulf and Near East countries: +973 16500404

[61] =>

lab tribune 1C

Dental Tribune Middle East & Africa Edition | May-June 2015

Translucent Zirconia...
Can it be esthetic enough for
the esthetic zone?
By Aiham Farah, CDT, Syria

he ongoing evolution of
restorative materials is
bringing dentists more
options than ever before to
achieve the most desirable mix
of properties. In the field of lab-

Fig. 1.

popular in recent years, thanks
to its high performance in the
aesthetic category.
Today, Zenostar Zirconia is one
of the top ranked high esthetic
Zirconia, in our current test on
the material below. I used all the

LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED

/ T. 1200mpa), and fracture
toughness of double that of the
glass infiltrated ceramic. Milling
is carried out with an enlargement factor of approx. 20-25%.
Zenostar offers a versatile range
of processing options, providing

Fig. 2.

IPS e.max PRESS MULTI
®

THE WORLD’S FIRST POLYCHROMATIC PRESS INGOT

8
amic
all cer need
u
all yo

• Monolithic LS2 restorations showing a lifelike shade progression
• Exceptional combination of strength, esthetics and efficiency
• For crowns, veneers and hybrid abutment crowns
• Coordinated with high-precision Programat press furnaces
• Maximum cost effectiveness in the press technique

Fig. 3.

oratory-fabricated restorations,
clinicians and their lab partners
have long been seeking to balance aesthetics, strength, and
ease of use.
While the concepts of strength
and ease of use are well understood, aesthetics are of course

working techniques instructed
by the material manufacturer
(staining tech on one set, and
cut-back tech on the other), but
I implemented my own experience in order to pull out its esthetic optical properties, and display it for you in this case report,
so you can be the judge whether

maximum flexibility and reliability.
For instance, IPS emax ZirPress
can be pressed onto it, or IPS
emax Ceram can be veneered
onto it. Or even the shade and
stains (from IPS emax Ceram
kit or Zenostar Art Modul) can
be used to characterize a full
contour restoration to their high
translucency and enhanced esthetic properties.
What’s the concept behind the
disks (T & MO)?
Zenostar T discs are particularly suited for the manufacture of monolithic restorations,
supplied in pre-shaded basic
shades, allowing easy reproduction of all the 16 shades and 4
bleach (Fig.2).
The fact that Zenostar disks are
matched to the IPS emax press
ingot range, is important to the

Fig. 4.

more subjective, yet can still
be discussed in some objective
terms. When we speak of aesthetics in this category, we typically mean two things: color and
translucency. In order to best
mimic natural tooth structure, a
restoration must reflect, scatter,
and absorb light similar to the
way that a natural tooth does.
Lithium disilicate has proven

it’s esthetic enough for the esthetic zone!
What is Zenostar?
Zenostar materials are partly
sintered (chalk-like) zirconia
disks, in both pre-shaded and
non-shaded versions (Fig. 1),
when sintered to full density, it
demonstrates strength of more
than 900 Mpa ((MO. 1150mpa
Fig. 5.

www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstrasse 2 | 9494 Schaan | Liechtenstein
Tel.: +423 235 35 35 | Fax: +423 235 33 60

success of full dental rehabilitation, (for instance; IPS emax
veneers on anterior teeth and
Zenotar full contour bridges
on posterior teeth), to guarantee the shade match. IvoclarVivadent made it simple by having
relevant coding for the Zenostar
T (Translucency) to the emax
press LT (Low Translucency).
Never the less, Zenostar MO
(Medium Opacity) disk is also
available and particularly suitable for esthetic frameworks
on discolored preparation and
metal components, where a full
masking even with a thin layer is
guaranteed.

1st set: Working steps after the
milling (Fig. 3).
Brush infiltration Tech
- With the correct grinding
instrument, we separate the
milled object. With no vibration.
- With a fine rubber polisher
(white rubber for example), we
smooth out the attachment point
of the holding pins.
- With a polishing brush disk
(LISKO for example), we smooth
out the milling fades exist on the
outer surface
- With a soft brush (Micro brush

> Page 3C

[62] =>

2C lab tribune
Dental Tribune
Note:

Continuation from
Dental Tribune MEA
> Page 22

...background gives lectures and
courses on site at the customers
and at the training center; this
has led to a close relation and a
trust from our customers that is
based on the fact that AG delivers functional solutions and not
just promises - as all our releases throughout the years have
shown stability in function and
results.
Last but not least we have a
competent distributor network
throughout the MEA region. In
combination with direct local
AG interaction we have a wellaccepted and appreciated mix of
education and support.

This 08-09 May, the 10th CAD/
CAM & Digital Dentistry Int’l
Conference by CAPPmea will
be held in Dubai, how do you
see the progression of CAD/
CAM over the last ten years
and what has it meant for you
and the company?
CAD/CAM is the technology that
determines the dental business
today and changed the job description of a dental technician
immensely and within a very
short time. If we take a look on
the use of CAD/CAM in the dental business ten years ago and
what can be realized today is
that we recognize a revolution
of a complete industry which
happened and is still happening. Ten years ago the amount
of CAD/CAM-systems for dental labs has been very manageable, today a dental technicians

Dental Tribune Middle East & Africa Edition | May-June 2015
is faced with a jungle of systems to fabricate its frameworks
and restorations. At this point
Amann Girrbach benefits from
its more than 35 years of experience in CNC technology and we
do not offer single products but
these complete processes just
mentioned. The combination of
both makes us able to offer one
of the most versatile and technically adapted CAD/CAM-system
in the market.
This experience values and
knowledge in mechanical engineering and CAD/CAM makes
it possible to produce our products with a high proportion of
in-house manufacturing which
includes also the in-house production of the control units
as the core of the machines.
Thus we can adapt our system
components to the very spe-

cific requirements of the dental
markets. We hope that we can
remain in this leading position
also in the future.
Amann Girrbach continues to
grow in the region. How important is education for you
and getting your newest technologies across to your customers and potential clients?
Education and knowledge transfer is essential for dental technicians in general as well as for
our customers. Although our
systems can be used intuitively
we are talking about complex
systems consisting of soft- and
hardware components that can
be combined with various materials and techniques to get
the best results. Furthermore
our customers come from different generations and differ

9 - 10 APRIL

2016

sometimes strongly regarding
the access to modern technologies. For these reasons we offer
a wide variety of education and
training either by our local training centers or online by webinars or video tutorials that can
be downloaded from our homepage.
IDS 2015 once again whitnessed many novelties, which
new systems will AG be exporting to the MEA region?
How will you educate your clients to see the benefits?
As we have seen at the IDS this
year our inhouse milling machines Ceramill Motion 2 and
Ceramill Mikro – a new small
4-axes unit for dry millable material - in combination with the
diversity of CAD/CAM materials
is of great interest to our customers in MEA region.
In addition to our presence in the
CNC technology we are working
on new materials such as the
super-high translucent zirconia
Ceramill Zolid FX that could
be quite successful in MEA. It
is easy to process but it is also
a perfect material to achieve
high aesthetic results in the anterior regions as it was previously only possible with lithium
disilicate. At the same time this
zirconia does not undergo ageing but maintains it strength
over the long term. In accordance with the integrated product
philosophy of Amann Girrbach,
Ceramill Zolid FX is not a single
product but a whole system solution consisting of materials and
method. A coordinated staining
concept will therefore soon be
available which enables precise,
reliable staining according to
the VITA classical shade guide.
Customers who want to process
this material can visit our training course or take a look in our
video tutorials or step-by-step
guidelines.
What are the plans for the
rest of this year and 2016 for
Amann Girrbach in the MEA
region?
Surely we strive to strengthen
our sales activities so we will
continue supporting our customers in the region and provide
them with the latest knowledge
and updates on our novelties.
This year we will be renewing
our training center at the Antonin University and have a complete new setup that can match
the demand and the growth of
the region. This way we will be
able to receive more and more
of our customers. At the moment
the project is already in process
and we will announce it as soon
as it has reached its final stage.
Additionally we are planning
to have a helpdesk based in
the Kingdom of Saudi Arabia to
be able to assist our biggest installed base in the region in parallel with our local distributor.

Contact Information
Abdo Salem | Area Manager
Middle East & Africa
Amann Girrbach AG
Herrschaftswiesen 1
6842 Koblach | Austria
Mob: +961 3133911
Fax: +961 1877079
Email: abdo.salem@amanngirrbach.com
Web: www.amanngirrbach.com

[63] =>

Dental Tribune Middle East & Africa Edition | May-June 2015

lab tribune 3C

< Page 1C
for example), we remove all the
trace of milling dust and residue
from the inner surface, then we
can use the oil-free compressed
air. But we never use steamer or
water bath to clear non-sintered
restoration.
- With a fine grinders head, and
diamond bars, we could leave a
natural texture on the labial surface of some high esthetic restoration. Note that the hand peace
speed should be low.

- With the coloring liquid and
(Brush) infiltration technique,
and with the help of the VisualiZR we can map-shade the
white stage, like enhance the
translucency in the incisal third
by using Violate-gray.
- With the infrared lamp or drying cabinet, The infiltrated restorations must be fully dried before they are sintered, less than
140oC.

Further staining after sintering using Zenostar Art Moduls
stains
One first bake (880C for 2min
hold) for fixing the stain, and
one another bake (880C for
2min hold) for glaze.
Note in (Fig. 4) the final outcome
after glaze of Zenotar T0, being
shifted by stain to BL1 color.
2nd Set: Working steps after

Fig. 6. Translucency

Fig. 7. Zirliner

the milling (Fig. 5).
Cut-back tech & characterizing using brush infiltration
tech.
- If our CAD design not chosen
to be (reduced) design first, and
we decided to do the cut-back
later after milling, we have to do
it manually on the white-chalk
stage. (In our case, a cut back
was done on one central all the
way to the cervical, and the other one was left full contour to be
stained).
- With the correct grinding instrument, we reduce on the incisal third of the labial surface of
the restoration.
- With a sharp rubber polisher,
and on a low speed, we create
the suitable mamlon cut.
- With a polishing brush disk
(LISKO for example), we
smooth the fades left by the rubber wheel.
- With the coloring liquid and
(Brush) infiltration technique,
and with the help of the VisualiZR we can map-shade the
white stage, like enhance the
translucency in the incisal third
and between the mamlon fingers by using Violate-gray, and
highlight the mamlon fingers by
using Ivory. (Fig. 6 shows the results after sintering).
- With the infrared lamp or drying cabinet, The infiltrated restorations must be fully dried be-

fore they are sintered, less than
140oC.
Layering with IPS emax
Ceram
After applying the Zirliner on
the labial cut-back area (Fig.7)
and slightly glaze and stain the
other central, we bake on (960oC
for 1 min), then we proceed with
layering over the central (Fig. 8):
1. 1st Wash & foundation layer
(baked on 750oC for 1min)
2. 2nd Internal (Impulse) layer
(baked on 750oC for 1min)
3. 3rd Transpa Incisal (Ti1) layer
(baked on 750oC for 1min)
4. 4th Final glaze on both centrals is conducted on (725oC for
1min)
Manual polishing on both centrals is necessary after glaze for
perfect gloss match (Fig.9).

Contact Information
Aiham Farah. CDT, Syria
Technical Training
Consultant
Near East & Orient
Ivoclar Vivadent
Email:
aiham.farah@ivoclarvivadent.com

Fig. 8

LiSi
from GC
Master your

lithium disilicate

challenges

GC EUROPE N.V.
Head Office
Tel. +32.16.74.10.00
info@gceurope.com
http://www.gceurope.com

Fig. 9.
186262-GC-LiSi-ADV-210x297-E.indd 1

11/03/15 14:49

[64] =>

4C lab tribune

Dental Tribune Middle East & Africa Edition | May-June 2015

A ceramic furnace that leaves nothing to be desired
By Ivoclar Vivadent AG

OLOGNE, Germany /
SCHAAN, Liechtenstein:
The new Programat P710
ceramic furnace incorporates a
digital shade analyzer and telephone functionality. Packed
with innovative features, the
new Programat P710 can do
more than just fire. The innovations include a Digital Shade Assistant (DSA) for accurate shade
selection, telephone capabilities
and infrared technology for enhanced process reliability.

Digital Shade Assistant (DSA)
The patented Digital Shade Assistant (DSA) enables users to
determine the exact tooth shade
in a snap. The user preselects
the three closest shades and
takes a photograph of the teeth
and the selected shades. This
information is transferred to
the furnace via SD card, WLAN
or USB flash drive. On the furnace, the user selects the shade
analysis mode to import the
photographs and start digital
shade selection. In addition to
the shade, the brightness and

saturation values (L-, A- and Bvalues) can be determined. The
software compares the shade of
the tooth to be analysed with the
three pre-selected tooth samples from the shade guide. Special image processing software
automatically recognizes which
tooth to analyse and displays the
best shade match. The software
also allows users to manually select specific aspects of the tooth
for shade analysis. No further
appliances are required.
The new Programat P710 ceramic furnace leaves nothing to be desired.

inLab MC X5:
DENTAL LAB
FREEDOM OF CHOICE.

Telephone functionality
The new ceramic furnace comes
with integrated telephone capabilities. This allows users to
discuss individual patient cases
with the clinician directly at the
furnace at any time, without
having to change workstation.
Both hands stay free to carry
on working. The user’s mobile
phone connects to the furnace
via Bluetooth wireless technology and transfers the user’s contact list to the furnace screen. A
built-in hands-free system and a
microphone ensure a high level
of call quality.
Infrared technology
The integrated infrared technology represents another milestone achievement in the design
of dental furnaces. The use of infrared technology heightens the
process reliability and the overall speed of the process. This
increases the cost-effectiveness
of the furnace and offers users
a twofold advantage: the firing process can be completed
up to 20 per cent quicker and
the quality of the fired objects
is superior compared with the
results achieved with conventional ceramic furnaces. Cleverly devised software uses a
thermographic camera to calculate the most suitable pre-drying
and closing parameters for each
firing cycle. Sensor controlled
measurements ensure that the
furnace recognizes at which
point the objects have been
optimally pre-dried. Potential
fluctuations in quality resulting
from the individual adjustment
of firing programs are therefore
eliminated.

Experience new freedom in your lab processes breaking the chains of
former dependencies with inLab and the new 5 axis milling and grinding
unit inLab MC X5. Open for all restoration data, combining the largest
material range and the possibility to machine both wet and dry disks
and blocks – for no limitations to your production. Enjoy every day.
With Sirona.

INLABMCX5.COM

Ease of operation
In addition to several new features, the Programat P710 offers
a high level of user friendliness.
The furnace is easy to operate by
means of a large, swivelling colour touchscreen. The most important functions, however, are
selected on the proven membrane-sealed keypad.
Proven portfolio
The firing and press furnaces
from Ivoclar Vivadent are based
on long-standing success. The
company has been designing
high-quality dental furnaces for
discerning customers for many
decades.
Programat is a registered trademark of Ivoclar Vivadent AG.

[65] =>

10th CAD/CAM & Digital Dentistry International Conference
8-09 MAY 2015 · Jumeirah beach hotel, dubai, uae

10 CAD/CAM & Digital Dentistry
International Conference

event

5-201
00

08-09 May 2015

Jumeirah Beach Hotel, Dubai, UAE
Dubai, UAE

www.cappmea.com/cadcam10

Show Edition

Happy 10th Birthday CAPPmea
CAD/CAM Digital Dentistry in a milestone year
By CAPPmea

n the year of IDS, important for all dental industry,
another significant dental
meeting in digital dentistry will
take place in Dubai at Jumeirah
Beach Hotel on 08-09 May 2015.
This will mark the 10th Anniversary of CAD CAM & Digital
Dentistry International Conferences in Dubai.
Almost 20 years after the first
CAD/CAM system was presented on the market with big enthusiasm, passion and belief in
digitalizing of dentistry, CAPPmea started its first CAD/CAM
and Computerized Dentistry
Int’l Conference in Middle East
ten years ago. Together with a
group of believers such as Dr.
Munir Silwadi, Dr. Aisha Sultan, Dr. Omar Adeeb, CAPPmea
started the unique event with
the support of 3M ESPE, Sirona,
KaVo, Etkon and the UAE Ministry of Health. Through the passion of these leaders and supporters, what has been achieved
today is the result of ten years
of continuing dental education
focused on Digital Dentistry. Today more than 15,000 dentists
and dental technicians have
been educated in digital dentistry by CAPPmea over the past
decade.
When I started the CAPPmea
over a decade ago, I couldn’t
have imagined that I will be
writing this post to all of you. But
here we are, greater and stronger than ever before. It is really
10 years since we organized
our 1st CAD/CAM & Computerized Dentistry International
Conference and invited our first
contributors to join us, most of
which are still with us.
Back in 2005, I had a vision for
what I wanted CAPPmea to become – a company that was
professionally close to the client, fun, recognizable and innovational. I can say that we
have achieved this through the
hard work of our colleagues,
sponsors, partners and supporters. CAPPmea has been able to
establish a first-class standard
for continuing dental education programs in Dubai for the
MEA region. Our very 1st CAD/
CAM & Computerized Den-

tistry International Conference
summed it up successfully. I am
proud to say that we have established and achieved a balance
during all those years and continue to do so with every organized event.

2nd CAD/CAM & Digital Dentistry Int’l Conference

4th CAD/CAM & Digital Dentistry Int’l Conference

3rd CAD/CAM & Digital Dentistry Int’l Conference

Those attending the upcoming 10th edition of the symbolic
CAD/CAM & Digital Dentistry
Int’l Conference will have the
pleasure to see for the first
time the new dental high-technologies post IDS. The event is
packed with 17 international
Key Opinion Leaders, 19 breathtaking scientific presentations
and 8 hands-on courses where
attendees will be able to practice on topics such as Advanced
Anterior Composites, Indirect
Inlays, Onlays & Partial Crowns,
Non-Prep Veneers, Emergence
Profile, Tibases, Abutment Selection, proper Temporization,
Bone Tissue, Indirect Veneers,
Biological Preparations for
CAD/CAM and non CAD/CAM
Restorations as well as Chairside Economical Restoration of
Esthetic Ceramics and Implant

The long journey to the 10th
Anniversary came along with
plenty of challenges of running behind the incredibly fast
growing industry and technological developments. A decade

6th CAD/CAM & Digital Dentistry Int’l Conference

crown/abutment design.

5th CAD/CAM & Digital Dentistry Int’l Conference

dividual courses or instructors,
nor does it imply acceptance of
credit hours by boards of dentistry. During the two day agenda the Jumeirah Beach Hotel
podium will become the centerpiece for 17 top dental educators
including Prof. Daniel Wismeijer, ACTA University The Netherlands, Prof. Richard Simonsen
(USA), Prof. Paul Tipton (UK),
Dr. med. Dent Jan-Frederick
Guth (Germany), Dr. Morten
Worsoe (Denmark), MUDr. Petr
Hajny (CZ), Dr. Munir Silwadi
(Canada), Dr. Andrea Gandolfi
(UK), Dr. James Russell (UK),
Dr. Harald Huskens (Germany),
Dr. Jochen Kania (Germany),
Dr. Nawaf Aldousari (Kuwait),
Dr. Safa Tahmasebi (USA), Dr.
Biju Krishnan (UK), Dr. Eduardo Mahn (Chile), Dr. Gary Severance and Angela Severance
(USA).

The scientific program has accreditation from three important bodies, HAAD, DHA and
ADA C.E.R.P. Centre for Advanced Professional Practices
(CAPP) is an ADA C.E.R.P. Recognized Provider. ADA C.E.R.P.
is a service of the American
Dental Association to assist dental professionals in identifying
quality providers of continuing
dental education. ADA C.E.R.P.
does not approve or endorse in-

ago one could not even imagine such kind of opportunities
which are now available and
changing the face of dentistry,
whilst improving patient care.
All from diagnostic, planning to
the treatment in terms of precision, improved efficiency in order to change the outcomes and
aesthetic needs of patients.
During the upcoming Anniver-

> Page 2D

[66] =>

2

event

10th CAD/CAM & Digital Dentistry International Conference
08-09 MAY 2015 · Jumeirah beach hotel, dubai, uae

< Page 1D

2nd CAD/CAM & Digital Dentistry Int’l
Conference

3rd CAD/CAM & Digital Dentistry Int’l Conference

7th CAD/CAM & Digital Dentistry Int’l Conference

sary, CAPPmea will award our
sponsors, speakers and dentists
who have been with us for 10
years of our dental meetings in
Dubai. The event will provide
us the opportunity to thank our
business partners, industry,
sponsors and supporters for
achieving the success we have
today together. A big appreciation goes out to all who have
worked with CAPPmea during
this period and sharing the challenges and passion. And to all
the dentists, dental technicians
that have followed our continuing dental education programs
for the last decade, we would
like to express our gratitude
for following us throughout this
period of ten years of fast development in the dental industry,
technology and dental profession.

CONFERENCE DAY / MAIN AUDITORIUM

Friday / 08 May 2015

BREAKFAST WITH THE SPONSORS, REGISTRATION

08:00 - 09:00
09:00 - 09:45

Dr Munir Silwadi, UAE

CAD/CAM & Digital Dentistry: A Ten – Year Journey

09:45 - 10:30

Dr Morten Worsoe, Denmark

Adhesive Bonding - Made Simple
Meet the Sponsors, Coffee Break

10:30 - 10:45
10:45 - 11:30

Dr Safa Tahmasebi, USA

Implant success in the Esthatic zone.

11:30 - 12:15

Dr Petr Hajny, CZ

IVD in One Day by Dr. Hajný
Lunch, Prayer Time

12:15 - 13:45
13:45 - 14:30

Dr. Jochen Kania, Germany

The Digital Dental Office 2.0

14:30 - 15:15

Dr Andrea Gandolfi, Italy

All ceramic restoration in the daily clinical practice

15:15 - 16:00

Dr. Nawaf Aldousari, Kuwait

CAD/CAM History and Beyond Part 1

16:00 - 16:30

Dr. Nawaf Aldousari, Kuwait

CAD/CAM History and Beyond Part 2

When I think of all events that
we have done with our CAPPmea team and what wonderful
opportunities were given to me
during all those years, tears of
happiness are coming to my
eyes. It really demonstrate the
volume of people, topics and
events that can be simply described as ‘worthy’.

Discussions

16:30 - 16:45
16:45 - 17:30

Gary & Angela Severance, USA

Changing the Dental Experience with Chairside CAD CAM Dentistry

17:30 - 18:15

Prof. Paul Tipton, UK

Treatment Options for The Wear Patient
Discussion

18:15 - 18:30

Meet the Sponsors, Coffee Break
Saturday / 09 May 2015

CONFERENCE DAY / MAIN AUDITORIUM

09:00 - 09:45

Dr. Harald Hueskens, Germany

CAD/CAM-State Of The Art

09:45 - 10:30

Dr. Morten Worsoe, Denmark

From good to great! - are CAD/CAM dentist more predetermined for succes?

10:30 - 11:15

Dr. Petr Hajny, CZ

Chairside Implant Prosthetics
Meet the Sponsors, Coffee Break

11:15 - 11:30
11:30 - 12:15
12:15 - 13:00

It gives me a thrill every day
when receiving emails showing
how much CAPP has grown and
what a wonderful job we have
been doing for all those years! It
always inspires me to do everything we can to keep CAPPmea
being your #1 choice for continuing dental education – we
strive to continue for at least another 10 years and beyond.

BREAKFAST WITH THE SPONSORS, REGISTRATION

08:00 - 09:00

Jan-Frederik Güth,
Dr. med. dent., Germany
Prof. Dr. Daniel Wismeijer,
The Netherlands

Digital Dentistry - connecting technologies for higher predictability
Digital Dentistry: “Milling so 2014”

All information on continuing education dental meetings, courses and workshops in
Dubai and the region organized
by CAPPmea can be found on
the official website.

Lunch, Meet the Sponsors

13:00 - 14:15
14:15 - 15:00

Prof. Richard Simonsen, USA

Commerce vs. Care: the Ethics of Elective Dental Treatment

15:00 - 15:45

Dr. Eduardo Mahn, Chile

Designing Smiles in The Dental Practice

15:45 - 16:30

Dr. Biju Krishnan, UK

Cosmetic Orthodontics - The Missing Link in Minimally Invasive Cosmetic Dentistry

16:30 - 17:15

Dr. James Rusell, UK

Progressive Smile Design
Discussions

17:15 - 17:30

Yours Sincerely
Dr. Dobrina Mollova, MDS
Managing Director
CAPPmea / Dental Tribune MEA

HANDS ON COURSES
Wednesday / 06 May 2015

Hands On Courses

Dr. Eduardo Mahn, Chile
Thursday / 07 May 2015
Dr Munir Silwadi, UAE

Advanced Anterior Composite (Direct Veneer and Diastema Closure)

JBH

Hands On Courses
Indirect Inlays, Onlays & Partial Crowns

3M

09:00 - 18:00

Dr. Eduardo Mahn, Chile
Friday / 08 May 2015

Non-Prep-Veneers and Modified Non-Prep-Veneers
Hands On Courses

JBH

09:00 - 18:00

Dr. Eduardo Mahn, Chile

Emergence Profile, Tibases, Abutment Selection and Proper Temporization

JBH

09:00 - 18:00
09:00 - 18:00

Saturday / 09 May 2015
14:30 - 18:30

Dr. Harald Hüskens, Germany

13:00 - 17:00

Dr. Morten Worsøe, Denmark

Hands On Courses
Bone or Tissue - What's the Issue?

09 :00 - 17:00

Dr Munir Silwadi, UAE

Chairside Economical Restoration of Esthetic Ceramics and Implant
Crown/Abutment Design
Hands On Courses
Indirect Veneers

09 :00 - 17:00

Dr. Eduardo Mahn, Chile

Biological Preparations for CAD/CAM and Non CAD/CAM Restorations

Sunday /10 May 2015

JBH
JBH
3M
JBH

Contact Information
Dr. Dobrina Mollova, MDS
Managing Director
CAPPmea/Dental Tribune MEA
E: dr.mollova@cappmea.com
T: +971 504243072
www.cappmea.com
www.dental-tribune.me

[67] =>

3

game plan

platinum sponsor

main product

10th CAD/CAM & Digital Dentistry International Conference
08-09 MAY 2015 · Jumeirah beach hotel, dubai, uae

crystal sponsor

gold sponsor

gold sponsor

gold sponsor

SILVER sponsor

main product

main product

main product

main product

main product

official sponsor

official sponsor

official sponsor

official sponsor

official sponsor

main product

main product

main product

main product

main product

other industry player

other industry player

other industry player

other industry player

other industry player

main product

main product

other industry player

other industry player

main product

other industry player

main product

main product

other industry player

main product

main product

other industry player

main product

other industry player

main product

other industry player

other industry player

main product

other industry player

main product

other industry player

main product

main product

main product

main product

other industry player

other industry player

other industry player

other industry player

main product

main product

other industry player

main product

Instructions:
1. Exchange Business Cards with Company
2. Find out the Main Product - Ask for Stamp in return
3. Complete the Gameplan with products & stamps
4. Submit your contact details to the reception

main product

other industry player

main product

main product

other industry player

main product

[68] =>

A completely digital workflow
from scanning through design to milling

Share images
and expertise securely via the
Planmeca Romexis Cloud
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Planmeca Romexis®

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Planmeca Romexis Smile Design
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• An intuitive software program for efficient smile designing,
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• Increase case acceptance and improve information sharing
• Try FREE for 30 days – no credit card required

DOWNLOAD YOUR
FREE TRIAL TODAY!
www.planmeca.com/online

Find more info and your local dealer www.planmeca.com
Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com

[69] =>

11 - 15 November 2015
Jumeirah Beach Hotel Dubai, UAE

Joint Meetings

Inman Aligner Symposium
AAID 4th Global Conference
TARGET AUDIENCE:
These events are designed for
Dentists, Dental Technicians & Dental Team

www.cappmea.com/aesthetic2015

[70] =>

04-05 December 2015
Singapore

Hands-On Courses
03 December
Conference
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[cover] => DT Middle East and Africa No. 3 (May-June), 2015

Table of contents

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