cosmetic dentistry international No. 1, 2017
Cover
/ Editorial
/ Content
/ Eleven tips for success in your dental clinic Part II: CAPS & CLIMB
/ Lighting in dental surgeries — frequently neglected requirements of the standard on illumination
/ Cosmetic enamel restoration using naturomimetic layering technique—Part I
/ Complex direct ORMOCER composite restorations in the posterior region
/ ‘ No-prep’ interceptive rehabilitation —of tooth wear using a free-hand technique driven by a functional wax-up
/ Aesthetic composite layering of implant-supported restorations in an edentulous jaw
/ Non-ablative melanin depigmentation of gingiva
/ New treatment protocol for periodontal pocket treatment
/ Update on teeth whitening and remineralisation with nHAp— 5 years after the EU regulations
/ Evaluation of the effectiveness of the professional home whitening with the new ENA White 2.0
/ Manufacturer News
/ IMAGINA Dental— Digital technologies & Aesthetic dentistry congress
/ International Events
/ Submission guidelines
/ Imprint
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issn 2193-1429
Vol. 11 • Issue 1/2017
cosmetic
dentistry
beauty & science
1
2017
technique
Cosmetic enamel
restoration using
naturomimetic
layering technique
case report
Non-ablative melanin
depigmentation
of gingiva
practice management
Eleven tips for success
in your dental clinic
[2] =>
[3] =>
cosmetic dentistry editorial
|
Dear Colleagues,
Every 2 years, the world of dentistry prepares for its own Oscar Ceremony—the International
Dental Show (IDS) in Cologne. Companies from all over the world present their best and most
innovative products.
In the world of innovation, diversity feels at home and everybody is welcomed. Bright ideas and
brilliant minds are pushing forward the world of dentistry.
Dr Florin Lazarescu
At IDS, gala dresses and sharp suits are replaced by architect-signed booths, innovative products
and world class manufacturers compete to become the attraction of the exhibition. The Show
shapes the future of dentistry for the following 2 years.
Dental media prepares its best as well, and the proof of it is now in your hands—the latest
cosmetic dentistry issue. Prominent authors share their knowledge in this 64-page magazine.
Innovation and diversity are also present in the articles’ subject matter, covering everything from
general aspects, such as illumination in dental surgeries or practice management, to specialised
topics, such as new composite materials or advanced periodontal treatment.
Scientific aspects and innovations presented at the IDS will be debated in the months to follow
at the most important scientific events, organised all over the world.
As President of the European Society of Cosmetic Dentistry (ESCD) I would like to kindly invite
you to another important event in dentistry—‘Heart of Esthetics’—our annual congress, which
will take place from 21 to 23 September in Zagreb, Croatia. I have invited the world’s top speakers
in dentistry to Zagreb, who will provide a review of the scientific literature and present clinical
concepts for practitioners during two sessions. Parallel to the scientific sessions, a wide selection of workshops and live demonstrations will be organised; all that in an international,
vibrant atmosphere of friendship. You will find more details about the meeting on our website
www.heartofesthetics.eu.
I hope you will also find many innovative ideas in this issue of cosmetic dentistry!
Sincerely,
Dr Florin Lazarescu
President of the European Society of Cosmetic Dentistry
cosmetic
dentistry
1
2017
03
[4] =>
| content
page 14
page 32
page 46
| editorial
| industry report
03 Dear colleagues
40 New treatment protocol for periodontal pocket
treatment
Dr Florin Lazarescu, Guest Editor
Dr Kinga Grzech-Lesniak
| practice management
06 Eleven tips for success in your dental clinic –
Part II
Dr Anna Maria Yiannikos
| opinion
46 Update on teeth whitening and remineralisation
with nHAp–5 years after the EU regulations
Prof. Martin Jörgens
50 Evaluation of the effectiveness of the
professional home whitening with the new
ENA White 2.0
Dr Irene Franchi
10 Lighting in dental surgeries–frequently neglected
requirements of the standard on illumination
Antonín Fuksa
| manufacturer news
56 Products information
| technique
14 Cosmetic enamel restoration using
naturomimetic layering technique – Part I
Dr Sushil Koirala
| meetings
58 IMAGINA Dental–Digital technologies &
Aesthetic dentistry congress
60 International Events
| case report
22 Complex direct ORMOCER composite
restorations in the posterior region
Dr Clarence Tam
26 ‘No-prep’ interceptive rehabilitation
Dr Didier Dietschi
| about the publisher
61 submission guidelines
62 imprint
issn 2193-1429
Vol. 11 • Issue 1/2017
cosmetic
dentistry
beauty & science
1
2017
32 Aesthetic composite layering of implantsupported restorations in an edentulous jaw
Drs Patrice Margossian & Pierre Andrieu
36 Non-ablative melanin depigmentation of gingiva
Dr Kenneth Luk
04 cosmetic
dentistry
1 2017
technique
Cosmetic enamel
restoration using
naturomimetic
layering technique
case report
Non-ablative melanin
depigmentation
of gingiva
practice management
Eleven tips for success
in your dental clinic
Cover image courtesy of edelweiss dentistry products gmbh
(www.edelweiss-dentistry.com).
[5] =>
[6] =>
| practice management CAPS & CLIMB
Eleven tips for success
in your dental clinic
Part II: CAPS & CLIMB
Author: Dr Anna Maria Yiannikos, Germany & Cyprus
After the last issue of cosmetic dentistry, we have
begun a new journey with our brand new series
‘’Eleven tips to gain desirable success in our dental
clinics’’. In this publication, we are going to continue
exploring different parameters that can reinforce
our success and professional development as dental practitioners. Today I will share with you the
knowledge I have gained within the past 25 years of
managing and evolving my clinic so you can always
be one step ahead and avoid mistakes I have made
in the past.
The third very important tip that I am going to share
with you today in order to be and remain successful
06 cosmetic
dentistry
1 2017
at your clinics is how to regain your power. We learn
a lot of things during our studies in the dental
schools. We learn how to make the best fillings with
great contours and biocompatible materials; how
to treat a tooth that needs a root canal therapy, but
do we really learn anything on how to find the best
employee that will make our life and daily routine
easier?
Firstly we should make a job analysis by listing the
CAPS of the candidate. If we do not take the time to
complete this process, we will not know from the
beginning exactly what we are looking at and by this
we will increase the risk of making the wrong choice.
[7] =>
CAPS & CLIMB practice management
|
(physically capable) must the successful applicant be?
· Attitudes: such as customer service, orientation, team player, reliability, honesty, willingness to follow rules, problem-solving, loyalty,
safety-consciousness, ability to follow through—
Imagine having a receptionist who, although she
is doing the job without a mistake, complains
about everything all the time. Is that a person that
you would love to have as part of your team?
· Personality: traits such as competitiveness, assertiveness, attention to detail and sociability—Also
search whether the person will manage his or her
personality to get the job done, since as social scientists declare about 60 per cent of our personality traits are inherited and most of them are set by
age nine. In other words: personality can’t be
taught and it doesn’t change much over time.
· Skills: Expertise required to do the job—Skills are
the easiest job requirements to identify. We could
do that by asking the candidate to perform certain
tests. For example, if we are trying to find a receptionist we could ask her to translate an article, or
through role playing to check how she responds
in certain scenarios.
Have always in mind the quote ‘we hire them for the
skills but we fire them for their attitudes’!
So finally we found our A-star employees and now
what do we have to do in order to keep them? The
fourth very essential tip of today’s article that
I would love to share with you is the different ways
that we can use to retain our A-star employees.
Apply CLIMB to retain your team!
© Gajus/Shutterstock.com
If, for example, we go to the supermarket without our
shopping list, what will we end up doing? We will
most probably buy unnecessary things or even forget
the things that we went in the beginning there for.
My point here is that when we decide that we need
to hire an employee we should know upfront what
we are looking for, otherwise we might make mistakes that will cost us money and time!
Let’s have a look now what does CAPS stand for:
· Capacities: The mental and physical abilities required to do the job. How smart and how strong
Now let’s explain a little what does exactly the
acronym CLIMB stands for:
· Challenge: Studies have shown that the main
reason that our employees resign is that they are
dissatisfied with their tasks. That’s why we should
give them challenging duties to accomplish. And
what will the result be? They will feel useful and
they will find it difficult to leave from a job that
offers them different and unique experiences.
· Loyalty: Be human with your employees and do
not be afraid that you will lose your power. Show
interest in their problems and lay back in times
that they cannot handle any more pressure.
· Investment: Invest time and money to them so
they will feel appreciated. During my lectures I get
regularly the question that we reward them by
giving them bonus and still they are not motivated enough, what shall we do? My answer here
is that you must renew your reward system regularly. Sometimes you can give them cash (as
bonuses) or maybe you can offer them other kind
cosmetic
dentistry
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07
[8] =>
| practice management CAPS & CLIMB
© Syda Productions/Shutterstock.com
of incentives, like buying them a free trip for
vacation on Christmas, for example. Research
has proven that the more powerful and effective incentives are the ones that are specific,
tangible and noncash. Also please remember to
‘Reward not the best in sales but the best.’ A major
mistake that we usually do is to only reward the
ones that bring money to our clinics. Instead we
should reward the best in our practices, the ones
that are completing their tasks in excellence
unconditionally to what this task is.
· Measurement: Conduct a fair performance appraisal every six months.
· Building: Demonstrate your commitment to
them by showing them opportunities of career
development.
During the next issue we will analyse two new
tips that will reveal new opportunities and potential
of our dental clinics. Till then, remember that not
only are you the dentist in your clinic, but you are
also the manager and the leader.
08 cosmetic
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1 2017
You can always send me your questions and
request for more information and guidance at:
dba@yiannikosdental.com or via our Facebook
account. Looking forward to our next trip of business growth and educational development!_
Editorial note: This article is the second one from the
series. Part I appeared in Cosmetic Dentistry 1/2016.
contact
Dr Anna Maria Yiannikos
Adjunct Faculty Member
of AALZ at RWTH Aachen
University Campus,
Germany
DDS, LSO, MSc, MBA
dba@yiannikosdental.com
www.dbamastership.com
[9] =>
Heart of Esthetics
September 21-23, 2017 - Zagreb/Croatia (Sheraton Hotel)
www.heartofesthetics.eu
www.escdonline.eu
[10] =>
| opinion lighting
Lighting in dental surgeries
—frequently neglected requirements
of the standard on illumination
Author: Antonín Fuksa, Czech Republic
Fig. 1a
Fig. 1b
Fig. 1a: Typical situation in dental
surgeries in Eastern Europe:5
lighting is designed using
requirements for office workplaces.
Most of the requirements
are not met, see Table 1.
Fig. 1b: Balanced illumination of
d ental surgery employing a directional/
indirectional panel luminaire above
the chair and using additional ceiling
and furniture luminaires, see Table 2.
[11] =>
lighting opinion
Parameter
Fig. 1
Overall surgery illumination
Overall uniformity
Patient illumination
Instruments illumination
Material preparation area
illumination
Nurse’s desk illumination
Doctor’s desk illumination
Background illumination
General colour rendering index
Compliance with Standard
The model surgery has dimensions 5 x 6 m and
ceiling height of 2.8 m. The luminaire above the chair
is suspended in the height of 2.2 m above the floor.
Positions of the additional luminaires are a compromise between functionality and aesthetics.
Besides the visual task in the mouth cavity, many
other facets exist in the dental surgery that need to
be illuminated in order to carry out tasks: instrument
trays, controls and displays of diagnostic instruments, material preparation areas, PC table, filing
cabinet etc. Illumination requirements have to be fulfilled at all these places, too. A minimum overall room
illumination of 500 lx has to be maintained as well.
One of the principal items in the updated standard
is the background surrounding the dentist’s workspace, which is a stripe aligned to the surrounding
area of the dentist’s workspace, at least 3 m wide,
within the size of the room. According to the standard, this has to be illuminated 1/3 of the illumination
of the surrounding area. Installations according
to the older standard rarely meet this requirement.
A luminance of 5,000 lx directed at the patient can
be measured under a powerful luminaire. The back-
Fig. 2
20–500 lx
poor
300–500 lx
500–700 lx
50–200 lx
600–1,500 lx
very good
1,000–3,000 lx
500–700 lx
500–750 lx
20–200 lx
30–100 lx
20–500 lx
70–80
NO
500–750 lx
700–800 lx
600–1,000 lx
> 90
YES
|
Table 1: Comparison and evaluation
of very basic parameters
of illumination.
ground lighting in this case would be 1,670 lx, which
is quite expensive to achieve. This requirement has
not been met in any of tens of surgeries measured
where a powerful directional pendant luminaire
was placed above the chair. The updated standard
helps us to understand the room as a whole, not
just a set of task areas. Not only the illumination of
the patient, but also the uniformity and acceptable
contrast in the whole space is important.
The focused beam of the operating light provides
illumination of about 15,000 lx that is necessary
for the dentist’s task in the mouth cavity. The high-
output directional/indirectional panel luminaire
above the chair provides illumination of the task
background area of about 3,000 lx, providing a
1 : 5 contrast, which is already an acceptable level.
Colder tones of light further improve the perceived
contrast to about 1 : 4. Besides illuminating the
patient, the high-output directional/indirectional
panel luminaire serves as an ergonomic aid to ease
the visually demanding task of the dentist.
Measurements carried out in dental surgeries
across some Eastern European countries5 clearly
Symbol
Meaning
Purpose
Overall illumination
Patient
illumination
Em
Maintained Illuminance
Adequate level of light
500 lx
1,000 lx
UGRL
Limit of Glare index UGR
Glare limitation, acceptable contrast
19
–
Uo
Minimum illuminance uniformity
Acceptable distribution of light
0.6
0.7
Ra
Minimum general colour rendering index
Required color discrimination
90
90
–
Special requirements
According to selected task or area
Light should not
dazzle the patient
–
Table 2: Requirements on lighting
in dental surgeries, according
to table 5.48 of the standard.1
cosmetic
dentistry
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[12] =>
| opinion lighting
Fig. 2a: 3-D visualisation
of situation from Fig. 1a.
Lighting is designed using
requirements for office workplaces.
The installation does not respect
additional task areas.
Fig. 2a
Fig. 2b: 3-D visualisation
of situation from Fig. 1b.
An insight into a model room with
a directional/indirectional panel
luminaire and additional
luminaires to respect
additional task areas.
Fig. 2b
show that even the very basic requirement of task
illumination is often neglected. Also task background and overall illumination are often far too
low, which has both eye and overall fatigue im
plications. As little as 30 lx have been repeatedly
measured on the material preparation areas and
computer desks. Many surgeries installed in existing
buildings kept the original (office) luminaires, not
quite following the lighting project. These systems
were often projected according to an old standard
that required as little as 300 lx for office work.
Savings on lighting tend to generate much larger
expenses later. The need for light grows with age.
Other parameters of lighting like uniformity, glare,
colour rendering or non-visual effects of light and
lighting control will be discussed later in a dedicated
article.
Lighting the surgery with office luminaires only is
not sufficient to fulfil basic requirements. Lighting
using a single, powerful central luminaire provides
enough light in the visual task area, but may easily
fail to meet additional requirements. That is why
12 cosmetic
dentistry
1 2017
a dditional luminaires are needed to provide background area illumination and uniformity._
References
1. EN 12464-1:2011 Light and lighting—Lighting of work places—
Part 1: Indoor work places.
2. Czech Government Regulation No. 361/2007 establishing the
conditions of occupational health protection.
3. E N ISO 9680:2007 Dentistry—Operating lights (repl. 2014).
4.
FUKSA, Antonín. Lighting in dental surgeries. StomaTeam.
2/2014. ISSN 1214-147X.
5.
SVOBODA, Filip. Lighting in dental surgeries in Romania—
a summary report. Personal communication, 2015.
about
Antonín Fuksa graduated (MSc) in 2000 at the
Czech Technical University in Prague, Faculty
of Electrical Engineering in the field of study
Measurement and instrumentation. He currently
works as a developer of intelligent luminaires,
smart lighting systems and chronobiological
phototherapy devices in NASLI.
[13] =>
Science in Every Smile
Aesthetic Teeth
Straightening…
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of General Dentists.
Enjoy a great
start with an
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To find out more visit
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or come and see us at
200842 Rev A1
IDS Booth No. E/F
10/29, Hall 2.2
*Terms and conditions apply, which can be found online at www.invisalign-go.uk
[14] =>
| technique naturomimetic layering
Cosmetic enamel restoration
using naturomimetic
layering technique—Part I
Author: Dr Sushil Koirala, Nepal
Introduction
A human face takes
priority when de
termining physical
attractiveness. 1
If we group the
facial compo
nents accord
ing to their
influence on
appearance,
the mouth
takes prece
dence over the
others. Smiling is
one of the most
important facial ex
pressions and is essential
in expressing friendliness,
agreement and appreciation.2
A smile develops when a person senses
happiness, pleasure or humour.3 Whatever may be
the emotion, a smile plays an important role in so
ciety, and for a variety of psychological reasons
makes both giver and receiver feel good.4 The face,
gums (gingival complex), teeth (dentition) and
emotion are the four basic components of a smile.
A smile requires coordination of these four compo
nents with voluntary or involuntary stimulation by
various emotions; hence it is evident that every smile
is different and denotes a sense of individuality.5
Fig. 1: Attrition.
Fig. 2: Abrasion.
14 cosmetic
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1 2017
Fig. 1
The upper and lower lip frame displays the zone of a
smile, which can be linked to the frame of a painting.
Within this frame, the gums act as the canvas and
the teeth become the major substance of the smile
painting. As the lips separate during speech or a
smile, an image of the person is revealed, which may
indicate youth or age, harmony or disharmony, and
beauty or a compromised aesthetic appearance.
Healthy and well-aligned teeth have been shown to
have a positive effect on an individual’s confidence
and psychosocial wellbeing.6 Among the four com
ponents of a smile, it has been found clinically that
even minor defects or disharmony in alignment,
brightness or contour of anterior dental compo
nents can negatively affect the overall smile aes
thetic. This paper focuses on the role of the dental
hard tissues, especially the enamel in smile aesthet
ics, and presents minimally invasive technique to
rejuvenate the compromised enamel at minimal
biological cost.
Understanding dental enamel
Enamel is one of the most important structures of
the tooth, both from a functional and aesthetic
point of view. It is a uniquely organised nano-struc
tured material, which forms the outermost covering
of teeth.7 It is composed of crystalline calcium phos
phate, which is 96 per cent mineral with the remain
ing 4 per cent consisting of organic components and
water. The organic content consists of breakdown
Fig. 2
[15] =>
naturomimetic layering technique
|
products of major enamel
protein amelogenin.8 The
mature enamel is acellular
and does not regenerate
itself unlike other biomin
eralised tissues such as
bone and dentine.9
Enamel surface loss
affects smile aesthetic
Fig. 3a
Enamel, being the outermost coverage of coronal
portion of teeth, has to face various challenges of
maintaining its integrity with constant deminerali
sation and remineralisation within the oral environ
ment, and it is susceptible to tooth surface loss (TSL)
phenomenon. Tooth surface loss can be physio
logical, occurring as a normal aging process.10 This
process, accelerated by several endogenous and
exogenous factors, is termed pathologic. Depend
ing upon the cause, four types of surface loss have
been identified: attrition, abrasion, erosion and
abfraction.11-19
Each type of tooth surface loss and its effects on
overall health, function and smile aesthetics are
described below.
Attrition (Fig. 1) is the loss of the tooth substance
occurring as a result of mechanical wear between
the opposing surfaces of teeth during masticatory
and parafunctional activities.20-23 It is most often
seen on the occlusal surfaces of posterior teeth and
the incisal edges of the anterior teeth.
Abrasion (Fig. 2) denotes mechanical wear of teeth
due to causes other than tooth-to-tooth con
tact.24-26 It occurs due to friction between teeth and
exogenous agents like a hard toothbrush, abrasive
toothpaste, intensive horizontal brushing motions
etc.27, 28
Erosion (Figs. 3a & b) is the wearing of the teeth due
to chemical processes that may involve intrinsic
or extrinsic acids. The rate of the erosion is also
affected by the quality of saliva (salivary flow, pH,
and its constituents). The palatal surface seems to
be the most commonly affected site.27, 28
Fig. 5a
Fig. 3b
Abfraction (Fig. 4) is the pathologic process of tooth
surface loss in which repeated compression and
flexure of teeth under occlusal loading will lead to
fracture of thin enamel rods. It is mostly seen in the
cervical region of teeth.29-32
Fig. 4
Figs. 3a & b: Erosion.
Fig. 4: Abfraction.
Other than these four causes, developmental anom
alies (Fig. 5a–c), especially amelogenesis imperfecta
and dentinogenesis imperfecta, predispose teeth
to rapid wear.33-35 This is because the enamel is very
thin and/or friable in amelogenesis imperfect, while
in dentinogenesis imperfect, the attachment of the
enamel and dentine is weak, which results in easy
separation.36 Tooth surface loss affects tooth anat
omy, and various kinds of complications may arise if
it is left untreated. Loss of the mineralised tooth
substance results in a higher risk of tooth sensitivity,
pulpal complications, and discoloration.37, 38 Loss
of the vertical occlusal dimension (VOD) may result
in dentoalveolar compensation or an increased
interocclusal rest space.39
This will affect the neuromusculature, efficiency of
masticatory function, and aesthetics, as the posi
tion of the smile line, the horizontal occlusal plane
changes.38-40
Loss of canine guidance and canine protection may
increase horizontal stresses in the posterior occlusal
surface and thereby cause loss and fracture of res
torations.38 Moreover, instability of the occlusion
will decrease masticatory function and increase the
incidence of cheek and tongue biting.37, 41
The overall effects of tooth substance loss influence
not only teeth anatomy and masticatory system,
but also quality of life.42
Figs. 5a–c: Teeth with d evelopmental
defect: enamel hypoplasia (a),
amelogenesis imperfecta (b),
dental fluorosis (c).
Fig. 5b
Fig. 5c
cosmetic
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[16] =>
| technique naturomimetic layering
Optical characteristics of anterior teeth
As mentioned previously, teeth suffer modifications
over the years that directly interfere with their ap
pearance and colour. Due to an increase in thickness
of dentine and a decrease in thickness of enamel and
its surface texture bring changes in translucency
and opacity of dentine and enamel.
Understating optical properties of dental structures
is immensely important as enamel and dentine in
teract with natural light differently due to their vari
ations in composition and mineralisation. Enamel
allows 70.1 per cent average light passage, whereas
Figs. 6a–c: Childhood teeth.
Figs. 7a–c: Adolescent teeth.
Fig. 6c
Fig. 7a
Fig. 7b
Fig. 7c
While dealing with enamel, clinicians need to keep
in mind the orientation of the rods that comprise the
basic structure of the enamel. Generally, these rods
rise at right angles from the dentinal surface. In
cervical areas, the rods divert from their horizontal
orientation and lean apically. Near the incisal or
cusp tip, the rods change direction gradually, be
coming oblique and nearly vertical over the edges.48
Because of this orientation change, less light is
transmitted, which decreases the translucency of
the enamel.49 Enamel also modifies the chromatic
aspects of the teeth because of phenomena such as
reflection, transmission, refraction, thickness and
surface texture.
Moreover, enamel has the ability to attenuate
underling colours, which can affect the chromatic
aspect of teeth.50 Hence the properties of light
reflection, or transmission of enamel depend upon
its texture, orientation of enamel rods, and its ability
to refract light, in addition to histological character
1 2017
Dentine can be considered as the dental tissue of
higher relevance when concerned with color.46, 53
From an optical point of view, dentine is a low-
translucency structure with various chroma and
saturation variations. Dentine has a special property
of producing relative opacity, this is because the
dentinal tubule arrangement enables the dentine
Fig. 6b
Optical properties natural enamel
dentistry
Optical properties of dentine
Fig. 6a
52.6 per cent of light can be transmitted through the
dentine structure.43, 44 It can be said that dentine is
the colour and enamel is the colour modifier.45-47
16 cosmetic
istics. Enamel translucency may also be attributed
to variations in calcification levels, because the
more porous and less mineralised the enamel, the
larger the dispersion index.51, 52
to demonstrate selective light diffraction, as certain
rays are reflected, whereas others are absorbed.51
As age increases, primary dentine begins to evolve
or change, originating secondary and tertiary den
tines, which have different structure and compo
sitions, and affect optical properties of tissues.54
In elderly patients, the reduction in the diameter
of the dentinal tubules causes progressive dentine
sclerosis and high saturation.
Basic characteristics of teeth
The visual characteristics of teeth modify with age
and can be studied under four categories: child
hood, adolescent, middle-aged and aged teeth.
Childhood teeth (Figs. 6a–c)
At about the age of 10 years, enamel presents
an almost milk-white hue, the superficial enamel
layers are the most opaque and frequently appear
as though they have a white frost. Enamel generally
shows a clear opalescent effect, the prominent
enamel surface with micro- and macro-texture
has a very low surface lustre; the incisal edges
of the dentinal lobes are completely covered by
enamel.
[17] =>
naturomimetic layering technique
Adolescent teeth (Figs. 7a–c)
At about the age of 20 years, the enamel is less white,
enamel translucency becomes visible due to gradual
wearing off of the opaque top layers of the young
enamel. There is a presence of enamel surface mi
cro-texture and low gloss; dentinal lobes are still
covered by enamel but slightly blue and orange hues
become visible.
Middle-aged teeth (Figs. 8a–c)
There is reduced enamel surface micro- and mac
ro-texture, and an increased surface lustre. There
Cosmetic enamel restorations can be successfully
utilised to correct minor tooth misalignments,
changes in brightness, and enhance the contour of
a tooth.
As described earlier, enamel surface loss generally
affects visual alignment, brightness and contour of
the teeth, which negatively affects the overall smile
aesthetic. With enamel being a thin outer layer of
a tooth, the loss of enamel surface is generally as
sociated with the exposure or loss of dentine sub
stance. Hence restoring natural enamel requires
careful analysis of its dentinal substrate loss in
terms of its depth, colour and type.
Fig. 8a
Fig. 8b
Fig. 8c
Fig. 9a
Fig. 9b
Fig. 9c
is also increased enamel translucency; blue and or
ange hues become more prominent and dentine is
normally exposed in the region of the incisal edges.
Aged teeth (Figs. 9a-c)
There is an increased enamel translucency, changes
in hue to bluish to lilac and grey, a lack of enamel
surface micro-texture, with considerably reduced
macro-texture. There is a high surface lustre, dentin
is relatively darker and less opaque than of mid
dle-aged teeth, and on the incisal edges, the under
lying dentine structure appears as a flat wall.
Restoration strategy
After having a better understanding of the inherent
characteristics of dental tissues to light incidence,
it allows a more artistic restorative approach where
the light can be manipulated in each increment
of the resin, thus resulting in vivid and extremely
natural restorations.55, 56
Restoration strategies should follow proper under
standing of defects, right selection of restorative
materials and their proper application, finishing,
texturing and polishing.
|
Figs. 8a–c: Middle-aged teeth.
Figs. 9a–c: Aged teeth.
Selection of restorative materials based
on optical properties
Natural dentine and enamel have a rich composi
tion and details. Where dentine confers the basic
colour to the dental element, or the hue, this colour
is not entirely perceived by the observer, because the
enamel modulates the chroma and the value of hue
according to its greater or smaller thickness and
surface texture and level of polishing. Enamel does
not actually change the hue (colour), but only con
fers a greater or lesser saturation or chroma accord
ing to its thickness.56, 57
Placing the correct thickness of enamel layer over
dentine can positively increase or decrease the
value (brightness) giving the restoration its vivacity.
If the restoring tooth has lost both the enamel
and dentinal tissue, then proper colour selection of
dentine and enamel resin is paramount. It is because
the percentage of light transmission on enamel is
approximately 70.1 per cent, which gives this tissue
translucent characteristics. On the other hand, the
percentage of the dentine is 52.5 per cent, which
makes it more opaque.58 Hence, in order to obtain
natural lifelike restorations, more transparent res
ins should be used for the fabrication of the artificial
cosmetic
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[18] =>
| technique naturomimetic layering
Material category
Objective
Example
Opaque group
To mask discoloration
Beautifil Opaquer
Opacious dentine
To replace deeper dentine
Beautifil II A20 (Opacious dentine)
Normal dentine
To replace outer dentine
Beautifil II A2 (Universal dentine)
Translucent
To replace enamel
Beautifil II Enamel HVT
Effect group (stain)
To create special effect
Beautifil II Gum shade
Dentine group
Enamel group
Table 1: Materials category.59
enamel, whereas more opaque resins should be
used to reproduce artificial dentine.
There are varieties of composite resin materials
available in the global market, and dental manu
facturers are now developing resin with different
shades and opacities to mimic colour, translucen
cies and visual appearance of the natural tooth
structure and have come up with different grouping
systems.
D-Smile Style
I-Smile Style
Regardless of the method of restorative materials
grouping that is employed by manufacturers, all the
direct aesthetic restorative materials can be catego
rised into four groups59 based on its optical proper
ties (Table 1).
S-Smile Style
Smile Style and surface texture design
C-Smile Style
Table 2: DISCover Smile Style—
tooth characteristics.
The naturomimetic restoration technique follows
the patient’s psychology, as described in the Smile
Design Wheel concept.60 Smile Style and tooth sur
face texture should be selected based on patient’s
perception, personality and desire. However, select
ing the correct smile style requires knowledge about
the personality component of the Smile Design
Wheel in depth.
While discovering a patient’s personality (tempera
ment), the author used the concept of ‘DISC’, which
was introduced by the psychologist Dr William
Moulton Marston in his publication Emotion of
Normal People in 1928.61 Marston theorised that
people are motivated by four intrinsic drives
that direct his/her personality patterns. He used
four
descriptive behavioural tendencies, which
are represented by four letters of the alphabet:
D (dominance), I (influence), S (steadiness) and
C (compliance). Based on the DISC personality traits,
the author has categorised smiles into four cate
gories (Tables 2 & 3).
To achieve a naturomimetic enamel restoration, the clinician should understand age-related
natural tooth surface texture characteristics.
Generally, there is a decrease of surface texture
as patients increase in age.62 However, surface
texture should be designed on a case-by-case
basis to satisfy the patient’s need and desire.
The surface texture of a tooth is confirmed by three
factors.
1. Surface texture or degree of surface smoothness or roughness. This can be divided into two
categories.
2. Macro-texture (vertical and/or horizontal eleva
tion and depressions, or ridges and grooves seen
on the surface of a tooth).
Smile Style
Central
incisors
Canine
tips
Lateral
incisors
IAL
IAL
angle
Tooth
axis
D—Smile Style
Lack of
dominance with
square shape
Flat type
Flat and may touch
incisal aesthetic line
(IAL)
Straight or
R = reverse
90°–above
Straight or
slight divergent
I—Smile Style
Dominant type
with rectangular
shape
Rounded with
flat tips
Rounded and flat
incisal edges and
do not touch incisal
aesthetic line (IAL)
Slightly
descending
to straight type
85–90°
Straight
S—Smile Style
Dominant type
with oval shape
Rounded type
Delicate, rounded mesial
and distal incisal edges,
and do not touch incisal
aesthetic line (IAL)
Descending
type
75–85°
Slightly
conversing
C—Smile Style
Dominant type
with triangular
shape
Pointed type
Rounded distal and flat
mesial incisal edges, and
touch IAL
Descending
type
70–80°
Conversing
18 cosmetic
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[19] =>
naturomimetic layering technique
Micro-texture (small surface irregularities related
to the apposition and calcification of the enamel
matrix during tooth formation, pits, vertical lines
and perikymata).
3. Lustre or degree of shininess of the tooth also
known as gloss (Figs. 10 & 11).
Lustre will set the amount of the light reflection
of the crown surface and it is as important as
colour and contour in recreating the natural
appearance.63 It is to be noted that lustre is not
related to age and is genetically and congenitally
determined.
Smile Style
Personality charateristics
Suitable for
D—Smile Style
Goal oriented, competitive, direct,
extrovert, driven, ambitious,
strong willed—“Just Do It” type
Entrepreneurs, sales
anagement, legal or litigation,
m
operation management etc.
related professionals
I—Smile Style
People and person oriented,
talkative, spontaneous,
enthusiastic, warm, persuasive
“Have Fun Doing It” type
Advertisement, marketing,
public relations, training,
hospitality, tourism, retail sales
etc. related professionals
S—Smile Style
Stable, dependable, conservative,
loyal, relaxed, passive,
patient “Do it Together” type
Teaching, education, finance,
economics, human recourses,
support services, customer
services, manufacturing etc.
related professionals
C—Smile Style
Careful, detail oriented, logical,
Accounting, auditing,
organised, diplomatic, conventional, engineering, medicine,
exacting, “Do it Right” type
research and development,
agriculture, computer
programming etc.
related professionals
Naturomimetic layering technique (NLT)
Natural teeth are complex in structure and hard to
simulate due to the distribution of colours through
the enamel and dentins. Hence, in NLT it is important
to have a detailed examination of the colour, opac
ity, translucency, texture, surface gloss and pres
ence of any special characterisation of the tooth
to be restored. In NLT, the desired result is achieved
by applying the correct thickness of clear or trans
lucent enamel group of material over a saturated
and opaque dentine group of material which pro
duces a double effect layer and hence helps to mimic
natural optical properties of the tooth. There are
various clinical situations during enamel rejuvena
tion which are guided by the type of tooth defects
(anatomy, brightness/colour and contour) and de
sire level of the patient. Depending on the clinical
situation, the clinician should choose one of the
above NLT techniques. Naturomimetic layering
technique is based on new layered shading classifi
cation64 and is divided into the following types for
clinical conveniences.
|
shades of a similar group of material may be used
at different thicknesses (Fig. 12).
Table 3: DISCover Smile Style—
personality characteristics.
NLT—Bi-layer
Fig. 10: Macro-texture with low gloss.
Fig. 11: Micro-texture with high gloss.
Fig. 12: NLT—Mono-layer.
Fig. 13: NLT—Bi-layer.
Fig. 14: NLT—Tri-layer.
Fig. 15: NLT—Mono-Complex layer.
Fig. 16: NLT—Bi-Complex layer.
Fig. 17: NLT—Tri-Complex layer.
The Bi-layer technique is used when both dentine
and enamel are affected and two different groups
of materials are used to replace dentine and
enamel. Even in this layering technique, opaque
and effect group materials are not used. After
choosing the correct shade, opacity, and trans
NLT—Mono-layer
In the mono-layer technique, the tooth defects
are restored using only a single group of material.
The layering procedure does not entail the use
of opaque or any effect group. However multiple
Fig. 10
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 11
Fig. 16
Fig. 17
cosmetic
dentistry
1
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19
[20] =>
| technique naturomimetic layering
entails the use of opaque group of materials but
does not require effect resin and the opaque layer
should be covered with a suitable thickness of the
correct shade of dentine and translucent enamel
layer (Fig. 14).
NLT—Complex layer
In NLT, any restoration that demands the use of
effect group of materials either singly or in com
bination with enamel, dentine or opaque materials
is considered as a complex restoration of that
particular layer technique, such as Mono-Complex
layer, Bi-Complex layer or Tri-Complex layer. The
use of effect resin (to create opalescence, orange
or yellow hues, stain, enamel crack, white spot etc.)
requires detailed colour analysis and mapping be
fore application. This kind of restoration is basically
done in the incisal third area of the tooth, where the
range of translucency and opalescence is greater
(Figs. 15–17).67
The level of polish (smoothness) of a surface
changes the chromatic perception of the com
posite resins and is inversely proportional to
luminosity.68 The more polished the surface, the
larger the light transmission, and consequently,
the less luminosity (brightness).45 Conversely, the
lack of polishing (matte finish or presence of
more micro-texture) causes the surface to become
more reflective, making the restoration appear
more luminous.68
Conclusion
Fig. 18
Fig. 18: Naturomimetic layering
technique (NLT) step by step.
This article originally appeared in
the MiCD Clinical Journal, 2016,
Sept–Nov; 01(1):6-21. Reprinted
with permission from Vedic
Institute of smile Aesthetics (VISA).
20 cosmetic
dentistry
1 2017
lucency materials, it is important to consider the
thickness of the materials to be layered to mimic
natural dentine and enamel. Perception of higher
chroma and opacity is related to an increase in
thickness.45 The handling of composite layers is
crucial for obtaining the desired chromaticity,
translucency, and opacity.65 It is to be noted that
high-translucent enamel resin may create a greyish
restoration with a lower value; when the thickness
of translucent enamel resins increases, the value
decreases and chroma increases. However, by
increasing the thickness of the dentine group
(opacious composite) both value and chroma of
the restoration increase66 (Fig. 13).
NLT—Tri-layer
This is basically used to restore tooth defects where
major colour modification is desired, for example, a
non-vital discoloured tooth. The layering technique
Cosmetic dentistry is one of the fastest growing
trends in oral healthcare today. This has been fuelled
by increased public awareness, an increasing in pa
tients’ affluence, as well as the desire for beautiful,
stylish and healthy smiles. An aesthetic smile has
recently become one of the fundamental demands
of patients visiting dental practices._
Editorial note: A list of references is available from the
publisher.
contact
Dr Sushil Koirala is the
Chairman of and chief
instructor at the Vedic
Institute of Smile Aesthetics.
He maintains a successful
private practice in
Kathmandu, Nepal.
He can be contacted at
drsushilkoirala@gmail.com.
[21] =>
[22] =>
| case report direct composite restorations
Complex direct ORMOCER
composite restorations
in the posterior region
Author: Dr Clarence Tam, New Zealand
Fig. 1: Pre-operative situation
showing large restorations and
minimal residual tooth structure.
Fig. 2: Completed preparation with
strongly bevelled margins as an
alternative to straight cuspal height
reduction. The cusps were at least
3 mm thick at their base. The occlusal
shaping must be very thorough
to minimise the lateral excursion
load on the cusps.
Fig. 3: The teeth were micro air
abraded using 27 micron aluminium
oxide. A selective enamel etch
technique was then applied using
Futurabond U. The lingual cusps were
built-up with a purely ceramic-based
bulk fill ORMOCER (Admira
Fusion x-tra, shade U, VOCO).
Fig. 4: The marginal ridges were
built-up using a sectional matrix system
(V3, Triodent, Dentsply Sirona). In this
fashion, we have converted a complex
Class II into a Class I situation.
22 cosmetic
dentistry
1 2017
Fig. 1
Fig. 2
For reasons of cost, patients and dentists today
often find themselves obliged to use restorative
materials for the treatment of large structural,
functional and aesthetic defects. This case report
demonstrates how an innovative, organically modified ceramic composite with extremely low shrinkage stress and volume contraction can be used
to restore teeth while preserving tooth substance.
Occlusal functionality is key to the longevity of the
restoration.
sons, the patient also did not wish any prosthetic
treatment, e.g. in the form of ceramic restorations.
The patient was recommended a direct complex
resin onlay requiring functional and non-functional
cusp reduction. With this unconventional approach,
it was important that the occlusal design should
take into consideration the strengths and weaknesses of both the restorative material and the
residual tooth structure.
A 71-year-old female patient presented in my
practice requiring replacement of insufficient, excessively large composite resin restorations of
the lower right first and second molars (46 and 47).
The natural crown still retained a small amount of
residual structure, and the patient did not wish any
further removal of tooth substance. For cost rea-
The patient was given a local anaesthetic with one
cartridge of 4 % articaine with 1:100,000 adrenoline, and the teeth were isolated with a rubber dam
prior to removal of the existing restorations. In order
to ensure a caries-free, hard dentine base, three successive checks were performed with a caries detector (Caries Marker, VOCO). The thickness of the remaining cusps was measured, and found to be 3 mm
Fig. 3
Fig. 4
[23] =>
direct composite restorations case report
|
Fig. 5: The buccal lobes were
built-up individually, starting
with the mesiobuccal lobe.
Fig. 6: After all buccal lobes were
fully cured, FinalTouch brown shade
(VOCO) was added to the base
of the lobes as part of the Tam
interlobe staining technique.
Fig. 5
Fig. 6
at the base. The margins were strongly bevelled to
maximise the amount of the planned restorative
material with minimal reduction in the cusp region,
and thus achieve a large contact surface. No centric
contacts or other extensive functional contacts
were planned for the cavity areas being treated.
s taining technique was utilised (brown, FinalTouch,
VOCO) to customise the colour tone. In the next step,
the lingual cusps were shaped individually, thus
completing the design of the occlusal anatomy.
Following complete finishing of tooth 46, the
matrix system was placed on tooth 47 (Omnimatrix,
Ultradent: distal marginal ridge; V3 Triodent: mesial
marginal ridge). Tooth 47 was layered in a similar
manner, again using a universal shade bulk-fill
material (Admira Fusion x-tra).
The preparations were micro air abraded using
27 micron aluminium oxide. Then a selective enamel
etch technique using 33 % orthophosphoric acid was
performed, followed by bonding with Futurabond U
(VOCO). The lingual cusps of tooth 46 were created A small amount of white shade for customisation
free-hand using the universal shade Admira Fusion was applied to the triangular ridges of teeth 46 and
x-tra, a purely ceramic-based bulk-fill composite. 47 (FinalTouch, VOCO) to imitate the enamel hypoThe cusps were widened towards the centro- calcification. A glycerine layer was then applied,
occlusal aspect progressively in 2 mm increments. and the composite was polymerised fully through
The key factor here was not applying this bulk-fill the glycerine in order to avoid the oxygen inhibition
material in bulk, and thereby ensuring maximum layer. Only minimal occlusal adjustments were
necessary. Taking the material properties of the
depth of cure at all times.
ORMOCER into consideration (high compressive
The benefit of Admira Fusion x-tra is the increased strength and low flexibility), the occlusion was
depth of cure, which is inherent to this restorative. ground in to establish light centric point contacts
After curing of the base of the lingual cusps, a sec- without extensive lateral contacts or interferences.
tional matrix system (V3, Triodent) was used. In the The restorations were finished under water spray
gingival floor area of the proximal box, a small quan- with a single-stage polisher (Dimanto, VOCO) to
tity of the flowable Admira Fusion Flow (shade A3, a high lustre.
VOCO) was used in three 0.25 mm increments
(extremely thin) to ensure complete and maximum Rationale for material selection
marginal hybridisation and adaptation. The marginal ridges were then incrementally completed Geriatric dentistry is becoming an increasingly
using Admira Fusion x-tra (shade U).
prominent part of everyday general dental practice.
The main objective of treatment for this section of
The buccal lobes were layered individually with the population is essentially ‘to preserve function
Admira Fusion x-tra before the Tam interlobe without high cost’. The majority of older individuals
Fig. 7
Fig. 8
Fig. 7: The mesiolingual cusp was
shaped and finished with a brush
to create the infoldings into the
mesiolingual and mid-lingual lobes.
The brown stain was partially
covered, leaving it only slightly visible
and thus giving a natural appearance.
Fig. 8: The distolingual cusp was
shaped and finished with a brush to
create the infoldings into the other
surrounding lobes and to complete
the occlusal surface. The shade
is extremely natural. The marginal
ridges were finished before preparing
tooth 47. Selective etching, bonding
and restoration were performed
in a similar fashion to tooth 46.
cosmetic
dentistry
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23
[24] =>
| case report direct composite restorations
Fig. 9: Immediate post-operative
situation before application of
hypomineralisation details
on triangular ridges.
Fig. 10: Situation after application
of hypomineralisation details
to the triangular ridges
using FinalTouch white.
Fig. 9
Fig. 10
are not willing to invest a lot of money in their
teeth. In view of this, it is essential to understand
the physical properties of direct and indirect restorative materials in order to design the appropriate
restoration.
stress are two additional key factors with regard to
high marginal precision and integrity.
Composite resins have high compressive strength,
but only low tensile strength and flexibility.
The compressive strength of enamel is 384 MPa
and that of dentine is
297 MPa. In contrast,
the flexural strength of
dentine is 165.6 MPa.
The compressive strength
of Admira Fusion x-tra is
307 MPa, while its flexural strength is 132 MPa
—acceptable values when
compared to natural tooth
substance.
Fig. 11
Fig. 11: Final post-operative situation
showing light centric point contacts,
free of functional lateral excursive
interferences, and with full
aesthetic integration.
24 cosmetic
dentistry
1 2017
The extremely low shrinkage stress (3.71 MPa) of
this bulk-fill material, in combination with a high
depth of cure, ensures maximum marginal integrity,
especially if used in small increments like a conventional composite. In terms of avoiding gingival irritation, biocompatibility plays an important role, and
ceramic-based composites are less conducive to the
formation of biofilm than resin composites.
The remarkable chameleon effect of this material,
combined with optimal working properties, makes
it the go-to choice for 90 per cent of posterior restorations in my practice. When combined with the
easy-to-apply customisation shades in the FinalTouch range, it enables me to increase enormously
the efficiency, aesthetics, predictability and marginal integrity, essentially with just a single smart
material._
The major advantage of
Admira Fusion derives Reference
from its material composition, as it contains no conventional methacrylate 1. Arora, R., Kapur, R., Sibal, N., Juneja, S. Evaluation of Micromonomers, and therefore allows a more biocomleakage in Class II Cavities using Packable Composite Restopatible restoration (essentially a purely ceramic-
rations with and without use of Liners. Int J Clin Pediatr Dent.
based composite compatible with all bonding sys2012;5(3):178–184.
tems). At the same time, the composition gives an
extremely low volumetric shrinkage (1.25 per cent), contact
the lowest of any product currently on the market.
The ability to maintain an optimal marginal seal is
Dr Clarence Tam heads a
also critical in the Class II restorations shown, espepractice in Auckland, New
cially in the case of dentine-bound restoration marZealand, which specialises
gins below the cementoenamel junction (CEJ).
in cosmetic and restorative
dentistry. Born in Canada, she
Arora et al investigated the role of flowable comgraduated from the University of
posites with regard to the marginal integrity of subWestern Ontario and c ompleted
CEJ Class II restorations and found a significant reher residency at the University of
duction in microleakage when a flowable composite
Toronto. She is the chairperson
liner was used instead of a purely packable composof the New Zealand Academy
1
ite resin. The premise of this study is that the first of Cosmetic Dentistry (NZACD) and Certified Member
point of failure of Class II restorations is generally at of the American Academy of Cosmetic Dentistry (AACD).
the restoration margin, in the region of the proximal
box floor, especially when located subgingivally. clarence.tam@gmail.com
Thus, both volumetric shrinkage and shrinkage www.clarencetam.co.nz
[25] =>
EXCELLENCE IS IN THE SIMPLICITY
05
6 direct veneers in upper front teeth: Body i2 & Azur Effect & Skin White
SHADING
TECHNOLOGY
DOUBLE CONSISTENCY
SURFACE GLOSS
ERGONOMICS
Discover the unique advantages of this product
designed by Dr. Didier DIETSCHI
By EdelweissDR AG
Unter-Altstadt 28, Mercandor
6300 Zug / Switzerland
www.edelweissdr.com
Form enhancement of 6 anterior teeth: Body i1 & Skin Bleach
[26] =>
| case report aesthetic and restorative dentistry
‘No-prep’ interceptive
rehabilitation
—of tooth wear using a free-hand
technique driven by a functional wax-up
Author: Dr Didier Dietschi, Switzerland
Treatment rationale
Excessive abrasion (attrition) and erosion are two
common conditions affecting dental hard tissue
and occur in an increasing number of patients.1, 2 Both
can be considered growing challenges in dentistry,
because with such patients, especially in cases of
severe parafunction, the etiology can rarely be suc
cessfully and permanently eliminated.35 Therefore,
continuous monitoring to control related patholo
gies is required.
The most frequent causes of erosion are unbalanced
dietary habits with a high consumption of acidic food
or beverages (such as fruit, carbonated drinks, fruit
juices and vinegar), as well as abnormal intrinsic acid
production, such as in bulimia nervosa, acid reflux and
hiatal hernia. Insufficient salivary flow rate or buffer
capacity and, in general, salivary composition changes
induced by various diseases, medications and aging
are other etiological cofactors.69 As regards abra
sion, awake and sleep bruxism are two different forms
of parafunctional activities that can severely affect
tooth integrity.4, 5 Preventive and restorative mea
sures are therefore mandatory to correct and limit the
extent of further tissue and restoration destruction.
An important clinical finding is that a large number
of patients affected by hardtissue loss present
combined aetiologies, challenging the dental team
to determine a multifactorial preventive and restor
ative approach.1–9
The dental consequences of abrasion and erosion are
manifold and involve a loss of enamel, with progres
sive exposure of large dentin surfaces, which signifi
cantly affects the occlusal, facial and lingual tooth
anatomy and has biological consequences, too. Ob
jective symptoms or complaints reported by patients
are shortening of teeth, discoloration, tooth displace
Fig. 1
26 cosmetic
dentistry
1 2017
[27] =>
aesthetic and restorative dentistry case report
ment, dentin sensitivity, as well as an increased risk
of decay and premature loss of marginal adaptation
of the restoration. The significant impact of tooth
wear on occlusion, function and aesthetics leads the
patient to seek advice and intervention. The bio
mechanical challenge shall entail a range of treat
ments involving different specialties, from preventive
measures to full-mouth rehabilitation. Intermediate
stages (slight to moderate erosion or abrasion) re
quire other clinical measures, such as various forms
of adhesive and partial restorations. The aim of this
paper is to present a sound clinical concept for ad
dressing various forms of early restorative interven
tion and their potential to restrict ongoing tissue
destruction.
A comprehensive treatment approach
The modern approach to the treatment of tooth wear
aims to stop its progression before full prosthetic re
habilitation becomes indicated, which would require
the removal of large amounts of additional tooth sub
stance with potential biological complications10, 11
and a rather inadequate biomechanical rationale.
The approach involves three steps:
patterns observed with conventional prosthetic res
toration,10, 11 using more conservative restorations,
such as partial direct and indirect restorations, ap
pears to have irrefutable advantages and promising
outcomes in the treatment of severe abrasion and
erosion.12–14
Dahl’s concept and controlling
the vertical dimension of occlusion
The idea of increasing the vertical dimension of occlu
sion (VDO) to treat or restore patients with abnormal
tooth wear has been described and applied for a long
time; one of the first clinicians to promote this tech
nique was Dahl, who published many articles on this
topic.15 His approach was to use a metal appliance to
elevate the occlusion and allow teeth to move pas
sively until they are again in occlusion and then create
space to restore the teeth stabilised by the appli
ance.15 The dental movements are intended to occur
by combined supra-eruption of occlusally free teeth
together with simultaneous alveolar growth and in
trusion of teeth maintaining contacts. It was shown
that such phenomena would occur in a significant
proportion of patients treated according to this con
cept16 and the outcomes of such treatment have been
|
Fig. 1: Comprehensive treatment
scheme for anterior and posterior
tooth wear or erosion. The length
of the anterior teeth is reduced
by combined wear or erosion (1).
The VDO needs to be augmented (2).
On the models and based on
a wax-up, a new anterior guidance
and smile line are established (3),
from which an index is made and
transferred to the mouth when
proceeding with posterior restorations (4).
Three different conditions are
encountered in the posterior areas:
(a) no or minimal tooth loss
(occlusal stops are made with
composite of any type);
(b) moderate tooth loss and/or small
to mediumsized restorations (occlusal
morphology is re-established with a
hybrid composite and direct technique);
and (c) severe tooth loss and large
metal-based restorations (occlusal
morphology is re-established with
indirect tooth-coloured restorations
—overlay).
1. a comprehensive etiological clinical investigation,
including diet analysis and identification of gen
eral/medical and local risk factors;
2. treatment planning and execution, including a
proper functional and aesthetic wax-up defining
the new smile line and tooth anatomy, transferred
then to the mouth with a combination of direct
and indirect restorations; and
3. a maintenance program, including a protective
night guard and, potentially, repair or replacement
of restorations over a medium- or long-term time
frame.
The restorative options at hand comprise direct par
tial composite restorations, indirect partial compos
ite or ceramic restorations, and indirect full-ceramic
restorations. Considering the more dramatic failure
Fig. 2a
Figs. 2a–c: Pre-op situation showing
moderate to severe tooth wear, due
to combined abrasion and erosion
aetiologies. However, the amount of
tissue loss does not speak in favour
of a conventional prosthetic solution;
rather, an interceptive solution using
direct composite restorations would
be used in this case.
Fig. 2b
Fig. 2c
cosmetic
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1
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27
[28] =>
| case report aesthetic and restorative dentistry
Fig. 2d
Fig. 2e
Figs. 2d & e: Pre-op diagnostic
wax-up, creating a new and improved
occlusal and anatomical posterior
scheme. The full-mouth wax-up
is made prior to treatment
and establishes the new VDO.
Silicone indexes can serve to
build-up lingual and buccal cusps
to the correct level if needed.
Figs. 2f–l: Details of the treatment
performed in the lower left and upper
corroborated by several recent papers and review ar
ticles.15-19 Increasing the VDO is a key parameter for
reversing and preventing the consequences of patho
logical wear and erosion.20-25 The passive eruption
that accompanies the continuous tissue destruction
and loss, tremendously restricts the space available
for restorations, which due to their limited thickness,
would be very fragile or otherwise require unneces
sary removal of the residual tooth structure. Recent
clinical reports have largely validated this treatment
approach.23-25
Fig. 2f
Fig. 2g
Fig. 2h
Fig. 2i
28 cosmetic
dentistry
1 2017
Treatment outline
and restorative options
The decision regarding the optimal restorative choice
is usually based on the pre-existing dental condition
(presence of decay, restoration, vital or nonvital sta
tus), as well as the amount and localisation of tissue
loss. This means that various restorative options have
to be considered and that treatment planning is
highly individual (tooth-specific). The therapeutic
scheme is logically oriented toward re-establishing
[29] =>
aesthetic and restorative dentistry case report
Fig. 2j
|
Fig. 2k
left quadrants, respectively. After
rubber dam placement, amalgam
fillings were removed and tooth
surfaces prepared and cleaned
with sandblasting, before applying
composite. A highly filled homogenous
nanohybrid material (inspiro) was
used and sculpted before light curing,
enabling proper anatomy and function
to be established.
Fig. 2l
first proper length of the central incisors and anterior
guidance, governing thereafter the new VDO. Proper
anterior tooth anatomy and function are designed
according to objective aesthetic guidelines,26 existing
and former tooth anatomy, as well as functional and
phonetic components. The first step entails produc
ing study casts in the form of a partial (in the case of
moderate posterior tissue loss) or full-mouth wax-up
(in the case of advanced generalised tooth wear or
erosion; Fig. 1).
Figs. 2m & n: The same treatment
sequence was applied to all of
the lower and upper quadrants.
These images show that composite
serves both to fill existing cavities
and to replace eroded or worn tissue,
creating better function, restabilising
proper anatomy and aesthetics,
and finally protecting damaged
tissue from further degradation.
This is an ideal treatment protocol
for moderate tooth wear combined
with small Class I and II cavities.
Fig. 2m
Fig. 2n
cosmetic
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29
[30] =>
| case report aesthetic and restorative dentistry
Figs. 2o-q: Smile and occlusal views
of this full-mouth rehabilitation,
using only direct restorations.
Such an approach is highly
conservative, comfortable for the
patient owing to the short treatment
time, and cost-effective.
Fig. 2o
composite restoration are its highly conservative
approach, the ability to replace or reshape small
portions of the tooth, reparability, simplified replace
ment and relatively limited cost (Fig. 2). Conversely,
it is more technique sensitive and might result in
thin layers of material over some surfaces, placing
them mechanically at risk. When using a sculpting
technique, proper anatomy can be created also
with a direct technique, favouring the selection of
a highly filled material with a firm consistency.27-29
In the case illustrating this treatment modality, a highly filled homogenous nanohybrid material (inspiro,
Edelweiss DR) was used owing to its firm consistency,
favourable for free-hand sculpting and modelling
(Figs. 2f-l).
Fig. 2p
Indirect composite option
The indirect option is logically preferred when larger
restorations or tissue destruction of a greater severity
is present. It also provides greater control of the anat
omy and occlusion in complex or advanced cases.
Nevertheless, one should not neglect the direct op
tion only in favour of this last parameter, as occlusion
seems not to play a major role in the origin of para
function.4, 5, 30-32 Since direct and indirect techniques
can be used together to treat the same patient, when
indirect restorations are chosen, they have to be fab
ricated first, at the new VDO, and then direct compos
ites placed.
Fig. 2q
Direct composite option
Material selection
The direct composite option is logically indicated
for all forms of moderate to intermediate tissue loss
or destruction.13-16 Among the benefits of a direct
30 cosmetic
dentistry
1 2017
Today, the debate about whether ceramics or com
posite is best indicated for such restorations is some
[31] =>
aesthetic and restorative dentistry case report
|
times based on personal experience and belief, rather
than on scientific or clinical evidence. The rather
abundant clinical literature dealing with the clinical
behaviour of composite and ceramic inlays and on
lays has not shown a major advantage of either ma
terial.33, 34 I clearly favour composite in the context of
tooth wear. Were ceramics to be chosen, the Empress
material (Ivoclar Vivadent), which has shown limited
annual failure rates,35 and, of course, today’s new
lithium disilicate pressed ceramic (IPS e.max Press,
Ivoclar Vivadent), with improved flexural strength
and fatigue resistance,36 would be considered the best
choice.
Longevity of restorations placed to
correct severe tooth wear and erosion
Clinical studies have demonstrated that the perfor
mance of composite in the treatment of advanced
tooth wear is adequate and that partial fractures
represent the most likely complication. These can be
corrected by a repair or uncomplicated replacement
of the restoration.37-39 The ten year survival rate of
porcelain-fused-tometal crowns has been proved to
be slightly superior to that of composite restorations,
but with much more severe complications: Porce
lain-fused-to-metal failures led mainly to endodon
tic treatments or to extractions, while composite fail
ures or fractures could be either repaired or replaced.40
This again demonstrates the reason the conservative
and adhesive approach is favoured for treating all
kinds of mild to moderate forms of tooth wear and
erosion.
Fig. 2r
Conclusion
Fig. 2s
The incidence of tooth wear represents an increasing
concern for the dental team and has multifactorial
origins. Behavioural changes, an unbalanced diet,
various medical conditions and medications inducing
acid reflux or influencing salivary composition and
flow rate trigger erosion. In addition, awake and sleep
bruxism are widespread functional disorders that
cause severe abrasion. It is then increasingly import
ant to diagnose early signs of tooth wear so that
proper preventive and, if necessary, restorative mea
sures are taken, with the focus on biomechanics and
long-term tissue preservation.
Acknowledgments
I would like to thank Serge Erpen (Oral Pro, Geneva,
Switzerland) for the fabrication of the wax-ups
presented in Figures 2d and f._
Editorial note: This article was first published in Clinical
Masters magazine 1/2016.
A complete list of references is available from the publisher.
contact
Dr Didier Dietschi, is a senior
lecturer at the Department of
Cariology and Endodontics at
the University of Geneva School
of Dental Medicine, Switzerland.
He is also an adjunct professor
at the Department of Comprehensive Care at Case Western
Reserve University School of
Dentistry, Cleveland, Ohio, USA.
Dr Dietschi also works at the Geneva Smile Center,
a private practice and education centre, in Switzerland.
He can be contacted at ddietschi@genevasmilecenter.ch.
Figs. 2r & s: Five-year recall.
The patient never did wear a night
guard despite it being recommended.
We can observe some additional
tooth wear, mainly of an erosive
nature (see, for instance, the cervical
areas of the mandibular premolars).
The restorations however show
minimal wear or volume loss, apart
from microfractures of a few margins
(i.e., teeth #46 and 47).
Geneva Smile Center
Quai Gustave-Ador 2
1207 Geneva
Switzerland
cosmetic
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[32] =>
| case report implant-supported restoration
Aesthetic composite layering of
implant-supported restorations
in an edentulous jaw
A good option for the lifelike recreation of gingival tissue
Authors: Drs Patrice Margossian & Pierre Andrieu, France
dental team has to involve the reconstruction of
the dental and the gingival tissue. The flawless
reconstruction of gingival tissue requires sound
teamwork, as well as excellent materials and exceptional skill. Layering with the light-curing laboratory composite SR Nexco (Ivoclar Vivadent) takes
this procedure to a new level.
A 37-year-old female patient presented to our
practice with her teeth and the surrounding
bone structure in very poor condition (Figs. 1 & 2).
Numerous teeth were missing from both the upper
and lower jaws. In addition, the upper jaw showed
considerable bone and gingival resorption. The
patient wished to have her teeth restored to regain
an attractive appearance. Owing to the extensive
damage, complete restoration of both jaws with
implants was indicated.
Surgical phase
Fig. 1
Fig. 1: Initial photograph
of the patient.
Fig. 2: Extremely poor oral condition:
The teeth could not be saved.
The alveolar ridge in the upper jaw
was considerably atrophied.
Fig. 3: After bone augmentation,
ten implants were placed.
The photograph shows the situation
prior to the prosthetic phase.
32 cosmetic
dentistry
1 2017
Careful planning is indispensable in the treatment
of an edentulous jaw with implant-supported restorations. The axes and positions of the implants
must correspond to the given biological, mechanical and aesthetic conditions. In situations in which
severe bone recession has occurred, the work of the
Owing to the sufficient bone structure in the lower
jaw, this part of the mouth could be restored at once
with four immediately loadable implants. During
the reconstructive phase, the upper jaw had to
be treated with a provisional removable denture
owing to the atrophied alveolar ridge. The tooth
extractions from the upper and lower jaw were
Fig. 2
Fig. 3
[33] =>
implant-supported restoration case report
Fig. 4
|
Fig. 5a
performed on one day. At the same time, four
mandibular implants were placed and loaded.
An immediate denture was seated in the upper jaw.
During the osseointegration period of the man
dibular implants, the maxillary bone was reconstructed. The maxillary sinus and the alveolar ridge
were augmented in one appointment. At a later
appointment, ten implants were placed according
to the treatment plan and exposed after six more
months. As a result of well-planned soft-tissue
management, adequate firm keratinised tissue had
formed. The permanent restorations for the upper
and lower jaws were fabricated two months later
(Figs. 3 & 4).
The determination of the occlusal plane and the
ideal incisal line allows the dental arches to be
integrated more easily in terms of aesthetics and
function. Open-tray impressions were taken with
a special plaster (Snow White, Kerr Dental) and
unsplinted impression posts. The considerable stiffness of the impression material completely immobilised the impression posts, thereby preventing any
errors in the casting of the study models.
An articulator allows the kinematics of the jaw to
be correctly simulated. The goal of this part of the
treatment is of a functional nature. It is intended
to ensure optimal occlusal integration of the restorations and the proper jaw movements during mastication, speaking and swallowing. In this particular
Fig. 5b
case, the maxillary model was positioned with the
help of a facebow. Four impression posts were
screwed on to the implants in order to provide
strong support and enhanced reliability.
Alternatively, this step can take place directly on
the immediately loaded provisional restorations.
For this purpose, however, the model has to be
mounted in the articulator. In the present case, the
masticatory model was positioned in correct relation to the hinge axis-orbital plane. Subsequently,
we adjusted the bite patterns in order to record the
vertical dimension of occlusion.
The centric relation is regarded as the reference
position for adjusting the muscles to the centric
and functional jaw relation. The mandibular model
was mounted in the articulator with the help of an
antagonist jaw relation record. If the centric relation
and the vertical dimension of occlusion are correct,
the immediately loaded provisional restorations
can be used for this purpose. The restorations have
to be immobilised when they are mounted in the
Fig. 4: Four implants were placed
in the lower jaw. Bone augmentation
measures were not necessary
in this case.
Figs. 5a & b: Recording of the
aesthetic facial axes with
the Ditramax system.
Fig. 6: The denture was set up with
prefabricated teeth (SR Phonares II).
Fig. 7: Try-in of the
CAD/CAM-fabricated titanium
framework in the upper jaw.
Fig. 6
Fig. 7
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| case report implant-supported restoration
Fig. 8
Fig. 9
Fig. 8: The ground-down composite
resin areas were conditioned for
receiving the light-curing laboratory
composite SR Nexco.
Fig. 9: Application of the coloursaturated intensive gingiva materials
(SR Nexco Paste Intensive Gingiva).
Fig. 10: The application of various
translucent materials imparted
the prosthetic gingiva with
the desired depth effects.
Fig. 11: Lifelike, vital, aesthetic—
the white and pink aesthetics
were optimally imitated.
Fig. 12: The restorations on the
implants in the upper and lower jaws.
Fig. 13: Close-up view: the macroand microstructure of the teeth and
the characteristic play of colour
of the gingiva is clearly visible.
Fig. 11
articulator. The Artex system (Amann Girrbach)
allows the articulator of the dental practice and
that of the laboratory to be synchronised.
The Ditramax system was used to transfer the precise data on the aesthetic facial axes to the maxillary
model (Figs. 5a & b). Two axes were marked on the
plaster base of the model (vertical and horizontal).
The vertical axis represents the midsagittal plane.
From the front, the horizontal axis is aligned parallel to the interpupillary line and from the side to
Camper’s plane. These markings, which should be
very close to the working area, function as a guide
for the dental technician in setting up the teeth.
Therefore, the incisal line has a predictable parallel
alignment with the interpupillary line. The incisal
axis is aligned parallel with the midsagittal plane.
The Camper’s plane markings indicate the alignment
of the occlusal plane. All these elements provide
a sound rationale for the tooth set-up according
to aesthetic and functional principles.
We selected the tooth shade and the teeth on
the basis of the SR Phonares II tooth mould chart
(Ivoclar Vivadent). Holding the teeth up against the
lips of the patient quickly revealed whether they
were in harmony with her facial features. The set-up
of the teeth according to the Ditramax markings
(Fig. 6) allows the situation to be clinically validated.
In this case, attention was given in particular to the
aesthetic integration of the dentogingival complex
when the patient was smiling. The lip dynamics were
shown with video clips. The functional criteria were
also checked. The vertical dimension of occlusion
had to be harmonious in order to achieve a balanced
lower facial third and proper phonation.
Fig. 12
34 cosmetic
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1 2017
Fig. 10
We felt that a CAD/CAM-fabricated titanium framework (NobelProcera, Nobel Biocare) would best
fulfil this indication. The double-scan technique
allowed the implant model to be superimposed on
the tooth set-up to construct the framework. In the
next step, the framework was machined and then
tried on the model and in the patient’s mouth (Fig. 7).
The cast impression and the high-performance
processing systems significantly contributed to
providing the optimal passive (tension-free) fit of
the framework, which is decisive for the long-term
success of the restoration.
The areas that needed to be built-up with gingival
materials were blasted with aluminium oxide at
200 to 300 kPa pressure. Subsequently, the SR Link
bonding agent (Ivoclar Vivadent) was applied, followed by a thin layer of the light-curing SR Nexco
Gingiva Opaquer to mask the metal framework.
The Opaquer was polymerised and then a second
coating was applied and polymerised. The resulting
inhibition layer was removed.
The conventional flask technique with a heatcuring denture base material (ProBase Hot, Ivoclar
Vivadent) was used to produce the denture. After
the polymerisation process, the denture base was
ground and space was made for building up the
Gingiva composite. The surface was conditioned by
blasting it with aluminium oxide (50 µm) at 200 kPa
(Fig. 8). A bonding agent was then applied and left
to react for three minutes before it was light cured.
In order to achieve very lifelike results in the layering
of the gingival tissue, saturated (intensive) materials (SR Nexco Paste Intensive Gingiva) were used
Fig. 13
[35] =>
implant-supported restoration case report
|
first (Fig. 9). Next, translucent, light-curing gingival
materials (SR Nexco Paste Gingiva and SR Nexco
Paste Basic Gingiva) were used to impart the gingival areas with the desired depth (Fig. 10). The colours
of the Gingiva composites range from pale pink
through reddish and orange to purple. A certain
amount of time and effort are necessary to master
the necessary mixing techniques and achieve a harmonious interplay of the intensive and the trans
lucent materials. Practical experience is essential.
With some technical skill, the gingival areas can be
naturally reproduced in terms of shape, texture and
shade.
All the individual layers were pre-cured (Quick
curing light, Ivoclar Vivadent) in segments. A high-
performance curing light was used for the final
polymerisation. Prior to this step, a coating of
glycerine gel (SR Gel, Ivoclar Vivadent) was applied
to the surfaces to prevent oxygen inhibition, which
could lead to an unattractive result that is difficult
to polish. The surfaces of the teeth were characterised with a vertical and horizontal macrostructure.
Particular attention was paid to mechanical polishing. Once the glycerine gel had been removed, the
restorations were finished with different polishing
instruments (various grit sizes, pumice, leather
buffing wheels and universal polishing paste;
Fig. 11). In the present case, mechanical polishing
was preferred to glazing with a light-curing composite in order to prevent premature ageing of the
surface.
The dentures were seated manually with the help of
multi-unit abutments from Nobel Biocare (Fig. 12).
The screw channels were sealed with Teflon and
light-curing composite resin. The position of maximum intercuspation was checked and the occlusal
pathways were adjusted to the protrusive and laterotrusive movements. In addition, the restorations
were checked in terms of the ability to clean them
with interdental brushes, and the patient was given
special instructions regarding her oral hygiene.
Conclusion
For a long time, ceramics were considered to be
the aesthetic benchmark. With the introduction
of state-of-the-art industrially fabricated acrylic
teeth specially designed for implant applications,
the bar for aesthetics has been raised in this category of materials. The teeth used in this case exhibit
a true-to-nature morphology, which allows the restoration to be functionally integrated without any
problems. Using the laboratory composite SR Nexco
to recreate gingival tissue is an effective restorative
approach. In contrast to ceramic materials, the
composite resin is easy to handle and delivers
Fig. 14
exceptionally aesthetic results (Fig. 13). The light
weight of the material is an added benefit. An allceramic restoration (zirconium dioxide framework,
layering ceramic, gingival mask) weighs almost
twice as much as a titanium and composite resin
denture. Another advantage of the type of restoration described here is its long service life. The success of an implant-supported denture depends on
the systematic coordination of all the surgical and
prosthetic requirements. A strict procedure needs to
be followed from the treatment plan to the final
outcome. Layering gingival portions with a laboratory composite represents a genuine improvement
on previous materials and methods with regard to
aesthetics, handling and hygiene (Fig. 14)._
Fig. 14: The complex restoration
gave the patient a new lease on life.
contact
Dr Patrice Margossian
maintains a private practice
specialising in implantology
and prosthetics in Marseille in
France. He can be contacted at
pm@patricemargossian.com.
Dr Andrieu Pierre
is a practising prosthodontist
in Aix-en-Provence in France.
He can be contacted at
andrieupi@wanadoo.fr.
cosmetic
dentistry
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[36] =>
| case report laser dentistry
Non-ablative melanin
depigmentation of gingiva
Author: Dr Kenneth Luk, Hong Kong
Introduction
Melanin depigmentation of gingiva using various
laser wavelengths have been reported for over ten
Fig. 1: Depigmentation by ablation.
Fig. 2: Depigmentation by absorption
of melanin and haemoglobin.
Fig. 1
Fig. 2
36 cosmetic
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1 2017
years.1–5 Layer by layer, the mucosa is ablated to
the basal layer of the epithelium where the melanocytes are located. The use of lasers have been
compared with the use of scalpel and diamond bur
[37] =>
laser dentistry case report
(Fig. 1).6–9 By incorporating the optical properties
and absorption characteristics of 810 nm together
with specific power parameters, a non-ablative
technique was developed (Fig. 2).10, 11
Another similar non-ablative technique described
as microcoagulation was also reported using
a 20 W 980 nm diode laser.12 The 445 nm blue
wavelength was introduced in the dental market
in 2015. By using 320 μm uninitiated fiber delivering 1 W continuous wave of 445 nm, the same
non-ablative procedure and result can also be
realised.
Fig. 3
Fig. 4
Fig. 5
Fig. 6
A constant movement must be performed in
order to avoid thermal damage deep into the
tissue. Water irrigation can be used as coolant
during the treatment. There is no surface ablation
of the pigmented mucosa but rather the haemoglobin and melanin absorbing the laser energy
(Fig. 2). This technique (Figs. 3–6) showed a
treatment time of two minutes compared to the
ablative technique time up to 30 minutes in an
|
Figs. 3–6: Depigmentation on upper
arch using 810 nm at 30 W, 20 kHz,
16 μsec, pre-op (Fig. 3),
immediate coagulation (Fig. 4),
three weeks post-op (Fig. 5),
eight years post-op (Fig. 6).
Fig. 7: Absorption Spectra
of biological materials.
(Courtesy of J. Meister)
Background with
non-ablative technique
Diode laser at 810 nm is poorly absorbed in water,
but it is well absorbed by pigment such as haemoglobin and melanin. The use of high power, short
pulse duration concentrated the thermal e nergy on
the surface over deep tissue thermal conduction
with lower power and long pulse.13, 14
The author has used the 810 nm wavelength
(elexxion claros 810 nm diode laser, elexxion AG,
Singen, Germany) with the power parameters of
30 W, 20 kHz, 16 μsec giving an average power
of 10 W. Under local anaesthesia, a non-initiated
600 μm fiber was used. The fiber was placed at
a distance of 2 mm to 5 mm from the pigmented
mucosa. Coagulation can be observed with immediate effect upon irradiation.
Fig. 7
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[38] =>
| case report laser dentistry
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Figs. 8–11: Depigmentation of
lower arch using 445 nm at 1 W cw,
pre-op (Fig. 8), immediate post-op
(Fig. 9), one day post-op (Fig. 10),
one day post-op laser peel
between 31, 41 (Fig. 11).
area of first premolar to first premolar of one
dental arch.
The wavelength of 445 nm is much better absorbed by melanin and haemoglobin than 810 nm
(Fig. 7). Hence, a much lower power density may
be used to produce the same effect.
Case outline
Fig. 12: Three days post-op
(photo taken by patient on holiday).
Fig. 13: Two weeks post-op.
Fig. 12
A 26-year-old female patient of Chinese ancestry presented with melanin pigmentation in
2007. Congenital melanin pigmentation of the
labial gingiva was diagnosed. Depigmentation
on the upper arch using 810 nm at 30 W, 20 kHz,
16 μsec was carried out. Eight years post-op
showed mild relapse of pigmentation, but the
Fig. 13
38 cosmetic
dentistry
1 2017
patient was satisfied with the cosmetic appearance (Figs. 3–6). She now wanted the melanin pigment on her lower anterior segment to be removed
(Fig. 8).
Purpose
Pigment removal in the requested sites was discussed using 445 nm diode laser. The same technique would be used and the patient consented to
the treatment.
Material and method
SIROLaser Blue (Dentsply Sirona) with an emission
wavelength of 445 nm was used at 1 W, cw delivered through a 320 µm fiber.
[39] =>
laser dentistry case report
Fig. 14
Procedure
Depigmentation technique is the same as d escribed with the 810 nm wavelength (above).
Under local anaesthesia, a non-initiated 320 μm
fiber delivers the energy at a distance of 2 mm to
the pigmented area with constant movement.
Immediate change to pink colour without surface
ablation of the pigmented mucosa was observed.
The procedure took approximately 40 seconds
to complete between lower left and right canine
region.
Results
In this case, the mucosa turns pink without any
signs of surface mucosal ablation except one spot
between teeth 31, 32 (Fig. 9). Sub-surface coagula
tion of blood vessels gave a pink coloured appearance. There was very mild post-op discomfort for
about one hour after loss of the anaesthetic effect.
No analgesics were required as the discomfort
feeling disappeared fast.
Laser peeling of mucosa between 31 and 41 was
noted during photograph taking at one day post-op
review (Figs. 10 and 11). The three day post-op
photo taken by the patient showed that the laser
peel disappeared with new gingival mucosa formation (Fig. 12). Two weeks post-op showed complete recovery of the gingival mucosa without
melanin pigmentation (Fig. 13).
Discussion
There has not been much information on this new
wavelength. From Fig. 7, the absorption coefficient
for haemoglobin is estimated at 7 x 10²/cm–1 and
10³/cm-1 for melanin. Penetration depth for haemoglobin is calculated at 140 μm and 10 μm for
melanin. The penetration depth of haemoglobin
and melanin with 810 nm are 2 mm and 0.1 mm respectively. Furthermore, scattering curve showed
higher tissue scattering effect with 445 nm than
810 nm.
|
Fig. 15
Fig. 14: Diagram 3.
Fig. 15: Diagram 4.
In comparison with the NIR diode lasers, the absorption of collagen and scattering increases in the
blue light spectrum. In view of the above together
with high absorption of haemoglobin and melanin
to 445 nm, 1 W cw was used. Power density of
88 W/cm² (Fig. 14) delivering at 88 J/cm² fluence
at 2 mm distance was calculated. Although the
power density of 1,697 W/cm² (Fig. 15) delivering
543 J/cm² fluence used by 810 nm is higher than
445 nm delivered, the eight years post-op showed
stable gingival contour with no recession (Fig. 6).
The understanding of the optical properties of the
wavelength, power parameters and laser tissue
interaction are important information for the clinician to achieve the desired treatment outcome.
Conclusion
The use of 1 W cw 445 nm blue diode laser is
effective in non-ablative depigmentation of oral
mucosa. This non-ablative technique provide immediate aesthetic result with very short procedure
time. To the author’s knowledge, this is the first
case presented using 445 nm for melanin depigmentation._
Editorial note: A list of references is available from
the publisher.
Dr Luk reports no potential conflicts of interest.
contact
Dr Kenneth Luk
502, Winway Building,
No. 50 Wellington Street
Central
Hong Kong
Tel.: +852 2530 2837
laserdontic@me.com
cosmetic
dentistry
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[40] =>
| industry report laser dentistry
New treatment
protocol for periodontal
pocket treatment
Combination of Er:YAG and Nd:YAG lasers
Author: Dr Kinga Grzech-Lesniak, Poland
Periodontitis is the most common chronic inflammatory disease in adults of European populations.
Eight out of ten over 35-year-olds suffer from some
kind of gum complaint. It is associated with systemic
diseases including type 2 diabetes, cardiovascular
disease and stroke. Although they are so common,
periodontal diseases are not very well acknowledged.1, 2
To date, mechanical therapy has been the general
treatment for plaque-induced periodontal disease.
A lot of studies have shown that mechanical treatment itself does not lead to a complete healing because it does not eliminate the periopathogenes.3
Laser therapy may constitute an efficient alternative to surgical treatment. Based on research, data and
experience of many practitioners, we can enumerate
potential advantages of laser therapy, such as bactericidal, detoxification and homeostatic effects and
biostimulation. It is also easy to use, provides good
access to anatomically difficult areas and makes a
comfortable treatment for patients. Laser treatment
provides for eradication of bacteria and better wound
healing.4, 5
High-energy lasers are applied in periodontal procedures as adjunctive therapy or alternative conventional procedures have become standard treatment
Figs. 1a–d: a) Initial state;
b) the situation of the
gingival-tooth in the jaw;
c) orthopantomographic image;
d) the dental-gingival situation
in the mandible.
40 cosmetic
dentistry
1 2017
Fig. 1a
Fig. 1b
Fig. 1c
Fig. 1d
[41] =>
laser dentistry industry report
|
Figs. 2a–f: a) Clinical improvement
of the gum after hygienisation,
reduction of swelling, bleeding
and bacterial plaque;
b) clinical view of the periodontal
treatment, electronic probe testing
(pa-on, orangedental);
c) electronic probe, pa-on view
and molecular-biological test;
Fig. 2a
Fig. 2b
Fig. 2c
Fig. 2d
Fig. 2e
of periodontal pockets. Their effectiveness in eliminating periodontal pathogens and decreasing pocket
depth is widely documented. Neodymium:Yttrium–
Aluminum Garnet (Nd:YAG) laser with a wavelength
of 1,064 nm can decontaminate periodontal pocket
without causing necrosing or carbonisation of the
underlaying connective tissue.6 Periodontopathogens can persist within cells outside the pocket epithelium after mechanical conventional mechanical
periodontal debridement, and Gianelli et al. reported
that the Nd:YAG is capable of eradicating periodontopathogenic bacteria trapped within gingival epithelial
cells.7
Erbium:YAG (Er:YAG) with a wavelength of 2,940 nm
has been applied for effective elimination of granula-
Fig. 2f
tion tissue, gingival melanin pigmentation and gingival discoloration. This laser is also used for contouring
and cutting of bone with minimal damage and enhances healing.8 In addition, irradiation with the
Er:YAG laser has a bactericidal effect with reduction
of lipopolysaccharide, is efficient in calculus removal,
with the effect limited to a very thin layer of the surface and is effective for implant maintenance.
d) the result of pocket-depth probing
(PD) and clinical attachment level
(CAL), bleeding on probing (BOP),
mean value of PD = 38; RC = 1.19;
AT = 3.57; BOP = 33 %;
e) plaque index (PI), PI = 11 %;
f) baseline values of molecular-
biological test (PET Plus test,
MIP Pharma, Germany).
A case report
A 47-year-old female patient was diagnosed with
advanced generalised periodontal disease, numerous missing teeth, lack of prosthetic supplements
in the posterior region, periapical lesions, and an incomplete endodontic treatment. The patient required
cosmetic
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[42] =>
| industry report laser dentistry
Figs. 3–7: Sterilisation of
the periodontal pockets
and decontamination.
Figs. 8–12: Removal of
subgingival stone.
Figs. 13 & 14: Bleeding stop.
Fig. 3
Fig. 5
Fig. 4
Fig. 6
Fig. 7
Fig. 9
42 cosmetic
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1 2017
Fig. 8
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
[43] =>
laser dentistry industry report
|
Fig. 15: Situation immediately
Fig. 15
Fig.16b
Fig.16a
after surgery, subgingival plaque
removal and sterilisation
of the periodontal pocket.
Figs. 16a–c: Clinical view
during inspection after three
and six months.
Fig. 17: Comparison of the clinical
condition at microbiological/
molecular baseline (a)
and after six months (b).
Figs. 18a–f: Clinical situation
after 16 months.
Fig.16c
Fig.17a
Fig.17b
Fig.18a
Fig.18b
Fig.18c
Fig. 18d
a comprehensive dental treatment. To create a preliminary treatment plan, it is necessary to implement
initial treatment (hygienisation) to check the patient's motivation to continue the highly specialised
treatment and assess the prognosis of her teeth.
Detailed clinical examination should include,
among others, data on the periodontal pocket depth
(PD), bleeding on probing (BOP) and plaque index (PI).
In the case of a significantly severe disease, high tooth
mobility, numerous missing teeth, it is recommended
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[44] =>
| industry report laser dentistry
Fig. 18f
Fig. 18e
Fig. 19
Fig. 19: Molecular-biological test
results after 16 months
(PET plus, MIP Pharma Germany).
to carry out a molecular-biological test to assess
periopathogens quantitatively and qualitatively.
Before the treatment the patient underwent supragingival hygienic procedures done with ultrasound scaler (EMS, Piezon). After hygienisation, the
clinical condition of the patient improved. Additional
examination was carried out to determine the stage
of the periodontal disease. Then, a Nd:YAG laser
was applied for periodontal pocket sterilisation
and decontamination (Figs. 3–7) and Er:YAG laser to
remove subgingival calculus (Figs. 8–12). For final
decontamination and stabilisation of the fibrin clot,
the Nd:YAG laser was applied again (Figs. 13 & 14).
Figure 15 shows the situation immediately after surgery by Er:YAG and decontamination of the perio
dontal pocket by Nd:YAG (LightWalker, Fotona).
Summary
Er:YAG and Nd:YAG lasers have become the tool of
choice in the treatment of periodontal diseases.
They effectively reduce bleeding (BOP) and a pocket
depth (PD) and are less time-consuming in comparison to conventional methods. Another advantage
44 cosmetic
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1 2017
is the increased access of laser light to anatomically difficult areas compared to conventional hand
tools, such as deep narrow pockets or furcations.
Lasers broaden the range of treatments offered
in the dental office, increasing precision, enabling
minimally-invasive treatments and better wound
healing. The introduction of laser methods to the
dental practice compels us to further learning,
improving professional qualifications and special
isation in the field. This in turn extends the range of
non-surgical treatments of periodontal diseases._
Editorial note: A list of references is available from
the publisher.
contact
Dr Kinga Grzech-Lesniak DDS, PhD
Oral Surgery Department,
Medical University of Wroclaw, Poland
Specialist Periodontist
President of the Polish Society of Laser Dentistry, PTSL
ptsl@laser.org.pl
kgl@periocare.pl
[45] =>
[46] =>
| industry report teeth whitening and remineralisation
Update on teeth whitening and
remineralisation with nHAp—
5 years after the EU regulations
Author: Prof. Martin Jörgens, Germany
Consider this the new era of painless teeth whitening and the end to soft tissue damage caused by
hydrogen peroxide. Developments in the past five
years have made a huge impact on the daily work of
dentists, dental hygienists and well-trained dental
nurses in the EU regarding the parameters for in-
office teeth whitening and the purchase of teeth
bleaching products containing hydrogen peroxide
or carbamide peroxide.
Impact of EU regulations for teeth
whitening professionals
In 2011, a new EU regulation called the EU directive
2011/84/EU brought about massive changes in
teeth whitening across the blossoming industry in
Europe. Following the new EU regulations, patients
must be under constant dentist supervision and
see the dentist before, during and after the teeth
whitening process. Delegated, supervised and welltrained dental assistants are still allowed to perform
teeth whitening procedures if supervised by a dentist on-site.
could only be performed by dentists and supervised
by dental assistants and/or dental hygienists. In
Germany specifically, teeth whitening in cosmetology studios where cosmeticians, dental students
and dental assistants were employed, had to stop
their non-regulated businesses or had to hire dentists for supervision.
Professional products banned
in EU countries
Professional teeth whitening products above 6 %
hydrogen peroxide and 16 % carbamide peroxide
were banned from the market and are no longer
available in all restricted EU countries. The only cosmetic products available to consumers for at-home
teeth whitening contain less than 0.1 % hydrogen
peroxide and can only be purchased online.
Reactions have been varied in different EU countries. Most of the countries are following and
monitoring EU regulations completely. Several
EU countries are only allowing teeth whitening by
the dentist or dentist supervised dental assistants.
The same countries are no longer allowing teeth
Economic effect on dental hygienists
whitening products above 6 % hydrogen peroxide
and cosmetologists
or above 16 % carbamide peroxide. The current
In the Netherlands and other EU countries, self- countries following these regulations are: the
employed dental hygienists have been severely eco- Netherlands, Belgium, Luxembourg, United Kingdom,
nomically affected. Professional hygienists are no Ireland, Slovenia, Croatia, France, Romania, Sweden,
longer allowed to whiten teeth as they did for many Finland, Norway and Denmark.
years as independent business owners. To continue
teeth whitening therapy and running their own Different guidelines in Germany
local clinics, self-employed dental hygienists had to
hire dentists for supervision purposes to fulfil the Missing from this list is Germany. Usually Germany
new EU regulations.
is the first country to follow new restrictive guidelines, no matter where they come from. However,
Cosmetologists and cosmetology studios were also hydrogen peroxide is still being used in higher conrequired by the EU regulations to remove their teeth centrations and is still available in Germany.
whitening practice. Even before the new EU regulations, some courts had already ruled that teeth At the moment, the German government allows
whitening belonged in the dental field only and higher concentrations above 6 % hydrogen peroxide.
46 cosmetic
dentistry
1 2017
[47] =>
teeth whitening and remineralisation industry report
|
Figs. 1a & b: Scanning electron
microscope (SEM) images of
unprotected open dentine tubuli
before treatment with nHAp agent
by PrevDent.
Fig. 1a
Fig. 1b
But patients receiving the bleaching therapy should
have medical purposes and not cosmetic reasons for
such a special, highly concentrated teeth whitening
treatment.
along with the products with officially higher concentrations of the teeth whitening agents.
The state control system has not yet detected the
use of higher concentrations of hydrogen peroxide
in Germany and these products should also be
banned from the market because of EU directive
2011/84/EU. But, we expect German regulations to
follow the EU directive for this year.
Off the market in France
France had some special reactions on the EU directive and control mechanisms. All teeth whitening
products—even the ones that should have only 6 %
hydrogen peroxide—were taken off the market for
some months and went into a state control system.
The Health Ministry of France wanted to be sure that
all products contained the exact concentrations
of the teeth whitening agents that were displayed
on the packages. All teeth whitening products were
analysed and double checked by a governmental
state control.
After this analysis, some products failed the new
restrictions; in reality they contained a higher concentration than what was printed on the packages.
Of course these products were taken off the market,
Fig. 2a
Other reactions from EU countries
In countries like the Netherlands or the United
Kingdom, the new rules have led to a massive
change to teeth whitening treatments. Market
shelves were completely empty because of all the
banned products and the dentists were sending patients away from in-office teeth whitening to home
teeth whitening. Products containing only 16 %
carbamide peroxide for home teeth whitening had
a massive increase in sales.
The UK market also had an increase in home teeth
whitening products. For in-office teeth whitening,
UK dentists no longer saw a safe and effective alternative therapy. In general, the market appeared confused and nervous based on a lack of alternative new
teeth whitening products and lack of information.
The UK’s Commonwealth States had similar reactions to the regulations and availability of products.
India and Australia adapted the EU regulations to
the local market and made plans to reduce hydrogen
peroxide concentration down to 3 % instead of 6 %.
By following the EU regulations like the UK, the market opportunities in these countries are growing
more in the home teeth whitening business.
Fig. 2b
Figs. 2a & b: Scanning electron
microscope (SEM) images of sealed
and protected dentine surfaces
after treatment with nHAp agent
by PrevDent.
cosmetic
dentistry
1
2017
47
[48] =>
| industry report teeth whitening and remineralisation
Fig. 3
Fig. 4
Fig. 3: nHAp agent by PrevDent
can be used also during
orthodontic treatment.
Fig. 4: Initial situation.
Fig. 5: Final result, after bleaching
and remineralisation with nHAp
by PrevDent.
Studies and new product compliant
with EU regulations
To put professional teeth whitening therapy back
into the hands of qualified dentists, new technology
had to be developed to deliver great and safe results
and still comply with the EU regulations. This applied not only to whitening agents with just 6 %
hydrogen peroxide, but also finding new additives
to increase the value and results of teeth whitening
treatment, and on challenging cases with hyper
sensitive teeth and gums.
The regulations made it necessary to go back to
studies carried out in 2010 by a Japanese University
(Kawamata et al.) as well as the University of Indianapolis to find a new product. All over the world,
teeth whitening scientists were waiting for the
discovery—or rather, rediscovery—of the additive
nHAp: nanohydroxyapatite.
Discovery of nHAp—
nanohydroxyapatite
Multiple studies had previously shown several positive effects of nHAp on solid tooth structures as
enamel, dentine and on gingival soft tissues leading
to reduction of tooth decay and periodontitis or
gum disease.
The application of nHAp provides a remineralisation
of the tooth surface and seals sensitive dentine tubules. The nHAp remineralisation is an active agent
against white spots and early enamel lesions. Nano-
hydroxyapatite helps to effectively remineralise the
erosions on teeth caused by soft drinks, for example.
With a new smoother tooth surface, bacterial adhesion is decreased and fewer periodontal infections
occur.
As result of the studies, the World Health Organi
zation (WHO) announced that nHAp could become
the effective and economical prevention therapy
for third world countries. Thanks to the University
of Indianapolis for discovering that teeth whitening
with 6 % hydrogen peroxide simultaneously with
nHAp reduces all the well-known painful and nega-
48 cosmetic
dentistry
1 2017
Fig. 5
tive side effects of teeth whitening. Currently, their
studies are leading to brilliant teeth whitening results without sensitivities during and after the teeth
whitening process. This is a massive breakthrough
in teeth whitening over the past few decades.
Results of nHAp
From these results, the Dutch company PrevDent
created patents for teeth whitening combined with
nHAp, the first EU-legal teeth whitening product
with an intensive simultaneous remineralisation.
The new developments and changes by this technology for the sensitive patient are visible, detectable and remarkable.
In the past, hypersensitive patients with exposed
dentine structures had severe challenges with teeth
whitening products. To make these conditions possible to treat, patients visited the clinic several times
for desensitisation therapy before the teeth whit
ening appointment. Multiple fluoridations of the
tooth surface and multiple use of amorphic calcium
phosphate (ACP) started weeks in advance of the
treatment and were standard procedure.
Before, during and after the teeth whitening pro
cedure, the patient had to consume painkillers and
anti-inflammatories as a recommended therapy.
Without any kind of preventive desensitisation programme, teeth whitening therapy was not possible.
Now even patients with sensitive teeth and exposed
dentine can have painless teeth whitening without
other side effects. The combined teeth whitening
therapy is called ‘In-Office Repair Whitening’ by
PrevDent.
How to achieve excellent results
with only 6 % hydrogen peroxide
PrevDent did their homework, used scientific research, and patented a device to arrive at the best
and safest results while at the same time meeting
EU regulations. The active ingredients in in-office
repair whitening create an interactive reaction
between 6 % hydrogen peroxide combined with a
[49] =>
teeth whitening and remineralisation industry report
special stabilising molecule, which bonds with the
surface of the teeth and is applied with a special
mixing device and container that seals and preserves both liquids—nHAp and hydrogen peroxide.
Technical evolution
For each patient, the solution is mixed to freshly activate the ingredients into a foam with a solid structure that physically adheres to the tooth surface.
This foam mixture is another technical evolution.
Because of the way it bonds with the tooth surface,
the teeth whitening process works immediately
and actively.
Time and sequence of results
PrevDent’s standard application is six times every
ten minutes. In each sequence, the foam is always
mixed and freshly applied and fully concentrated.
Applying the fresh foam mixture with those extremely active ingredients each time is key in reaching
the predictable perfect results within the estimated
time of one hour. When necessary, a few extra ap
plications are possible.
Therapy for sensitivities
and remineralisation
Using results based on scientific research, PrevDent
also developed DeSensiDent—a tooth serum of
highly concentrated nHAp. DeSensiDent has become the universal desensitising tool and is used for
all kinds of treatments against dental sensitivities
and for tooth surface remineralisation.
In the field of orthodontic treatment, PrevDent
has opened doors for intensive preventive therapy,
which is being studied and discussed by the World
Health Organization (WHO). Before, during and after the orthodontist performs corrective treatments
with braces, the tooth surface is treated with the
highly concentrated nHAp. PrevDent’s OrthoCare
products help prevent tooth decay and remineralises enamel erosion occurring at the contact points
between teeth and braces.
Medical treatment
Preventive therapy with nHAp is a focused medical
treatment and not an aesthetic, cosmetic treatment. This therapy is not based on aesthetical
indications or patients’ wishes, and is therefore
considered a medical treatment without additional
taxes for the dental and orthodontist businesses.
In some countries like Germany, similar surface
sealant therapy is paid by insurance as a preventive
|
therapy for every single tooth before, during and
after orthodontic treatment with braces (GOZ No.
2000a).
Mineral restoration and surface sealant therapy
follows the GOZ No. 2000a, which is the fissure sealant and surface sealant therapy of healthy tooth
surfaces. The general office of the German private
insurances declares that such a treatment is medically necessary and will be covered by all German
private insurance companies.
Availability for professional t reatments
facilities
The DeSensiDent product line is currently available
on the market, meets EU regulations, and is the
number one professional product developed by
PrevDent for mineral restoration and surface sealants. PrevDent has opened a big and important
scientific door for dental professionals performing
orthodontic procedures and who want to include
remineralising and desensitising treatments into
their preventive and restorative therapy portfolios.
To summarise, based upon scientific results
PrevDent’s in-office repair whitening is a combined teeth whitening and remineralisation product that is fulfilling all national and international
restrictive parameters that occurred out of the
EU directive 2011/84/EU. As additional complementary products, they developed new desensitising
and remineralisation tools based on the usage
of nHAp for intermediate short-term applications
and intensive long-term applications as sealant
products.
As another future perspective, this nHAp technology of PrevDent can become a successful partner for
surface sealant technology in the perioprevention
concept._
Images courtesy of Dr Skander Ellouze.
contact
Prof. Martin Jörgens
Dental specialists Düsseldorf,
Germany
Profesor Invitado University
of Sevilla, Spain
www.prevdent.com
www.periopreventionnetwork.com
www.dentalspecialists.de
cosmetic
dentistry
1
2017
49
[50] =>
| industry report effectiveness of the professional home whitening
Evaluation of the effectiveness
of the professional home whitening
with the new ENA White 2.0
Analysis of results measured with spectrometer
6 months after treatment
Author: Dr Irene Franchi, Italy
Introduction
The ideal smile has always been considered as an expression of health and beauty.1, 2 The Romans consecrated the tradition of having teeth that were white
in colour and perfect in shape; Patrician women used
to try to bleach their teeth by rubbing them with tissues soaked in urea-based natural mixtures.
Table 1: Arithmetic mean of chroma,
hue and value of the treated elements
of the selected study group.
surface of the tooth and is of exogenous nature as
it is caused by external agents (e.g. food, drinks,
plaque, tartar, smoke, products with chlorhexidine)
and can be easily eliminated by using a specific
toothpaste and professional abrasive techniques.
According to some recent statistics,3 about 50 per
cent of the world population are not satisfied with
the colour of their own teeth, and adopt all the possible methods to make them whiter and brighter,
just like all advertising models suggest.
Intrinsic discolouration is caused by a deposit of
pigments in the organic or mineral structure of the
tooth, accumulated during the development and/or
the mineralisation of dental germs; specific products or appropriate techniques are required to solve
them. From a chemical point of view, bleaching
means the destruction of the chromophore groups
in the organic and inorganic compounds.1
Discolouration is a very important aesthetic problem: extrinsic discolouration affects the external
Through a chemical reaction of oxide reduction,
the bleaching agent can discolour a substratum
ARITHMETIC MEAN OF CHROMA, HUE AND VALUE
PATIENT N. 2
PATIENT N. 1
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
66,88
70,12
15,00
13,76
88,01
88,12
cervical third
71,91
72,21
72,22
20,45
20,56
68,88
69,91
69,98
70,27
24,18
77,91
22,61
middle third
69,86
69,29
69,46
18,58
18,91
17,55
84,21
86,12
86,20
middle third
69,82
71
71,03
21,55
20,98
20,96
71,21
73,24
73,44
incisal third
64,31
65,93
66,08
14,81
13,97
13,88
88,45
88,89
88,09
incisal third
70,08
71,72
71,88
19,98
19,12
19,11
68,79
71,23
71,28
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
65,28
67,66
68,12
25,01
20,34
20,44
77,41
84,64
84,39
cervical third
69,89
71,99
71,12
20,1
19,2
19,27
68,23
70
70,01
middle third
64,25
61,01
61,00
19,01
17,32
16,98
83,12
85,13
85,03
middle third
70,01
71
71,1
20,1
19,3
19,22
68,28
70,10
70,12
incisal third
64,55
69,12
68,85
13,96
12,26
12,46
86,90
88,01
88,00
incisal third
69,12
70,23
70,22
69
tooth element 12
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 12
L before L after
20,23
19,83
19,86
L 6 m. later c before
c after
c 6 m. later h before
70
70,03
h after
h 6 m. later
70
cervical third
68,99
69,23
69,21
22,21
17,15
17,56
77,92
87,94
88,06
cervical third
69
70
70,08
26
25,12
25,1
69,90
70
middle third
68,51
69,78
70,45
24,77
24,65
25,64
83,14
81,94
82,64
middle third
69,82
71,10
71,66
26,12
25
25,2
70
71
71,1
incisal third
64,23
67,36
68,98
17,15
13,87
14,46
87,94
87,59
88,01
incisal third
68,89
71
71,10
25,89
25,34
25,12
70
71,1
71,1
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
64,58
68,22
23,21
23,76
79,90
79,28
cervical third
68,8
72,2
26
25,33
25,23
71,14
71,2
67,89
25,67
80,97
72
71
middle third
65,37
68,11
68,15
19,88
22,77
23,08
84,30
83,94
83,99
middle third
69,15
68,64
68,44
25,49
24,56
24,45
72
72,98
72,99
incisal third
64,04
64,66
64,81
19,06
19,87
19,97
85,12
86,99
86,76
incisal third
69
68,12
68,15
24
23,32
23,44
71
71,15
71,15
tooth element 22
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 22
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,19
70,40
19,45
19,67
75,39
75,76
cervical third
70,12
71,54
71,44
21,12
21,02
71
72,12
72,14
70,38
20,21
75,22
22
middle third
69,80
71,18
71,67
19,58
18,45
18,47
75,18
71,94
73,27
middle third
70,01
71,56
71,54
22,02
22,00
22
72,02
72,99
72,77
incisal third
69,36
70,98
71
19,81
17,12
17,11
76,69
77,54
78,19
incisal third
69,76
70,12
70,22
21,12
21
20,98
71,12
71,45
71,48
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
65,78
67,41
67,61
23,55
21,75
21,11
80,91
82,19
82,23
cervical third
69,98
70,14
70,45
23,09
22,12
22,15
72
72,34
72,38
middle third
67,36
69,11
69,45
19,88
18,17
18,99
83,98
83,99
84,15
middle third
69,11
69,99
70,01
22,98
21,09
21,10
73
73,99
74
incisal third
65,36
68,33
68,87
18,87
17,02
17
85,59
85,69
85,97
incisal third
69,78
71
71,01
23
22,01
22
74
74,98
74,76
50 cosmetic
dentistry
1 2017
[51] =>
effectiveness of the professional home whitening industry report
PATIENT N. 3
|
PATIENT N. 6
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,88
71,33
71,41
27,3
26,7
26,55
74,08
76,8
76,9
cervical third
70,11
74,55
74,65
27,12
23,98
23
80,98
82,87
83,90
middle third
69,38
71,38
71
26,91
24,18
24,19
75,13
78,01
88,2
middle third
72
76,09
77
28,12
22,98
23
81,12
86,89
87
incisal third
69,13
73,55
73,2
25,22
24,85
24,6
75,9
76,15
76,96
incisal third
70,12
74,67
75
29
26,89
27
80,98
83
83,87
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,3
72
23,89
23
78,13
80,1
80,6
cervical third
68,98
74,23
75
28
25,98
26
83
86
86,87
71,91
25,89
middle third
68,1
71,22
72,11
24,71
23,51
23,12
78,33
84,57
84,7
middle third
70,76
75,78
76
27,98
25,98
26
82,22
87
88
incisal third
68,3
71,48
72
22,17
21,32
21
79
85
86
incisal third
71,12
75,09
76,01
25
23,32
23,98
83,34
86,89
87
tooth element 12
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 12
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,8
71,43
23,17
23
78,67
79,27
80,01
cervical third
73,12
76,98
77
28
26,12
26,11
79,09
83,12
83,76
71,21
25,3
middle third
71,81
75,16
76,7
26,58
20,6
20,03
78,97
81
81,12
middle third
71
75,05
75,98
27,78
25,1
26
80,08
84,88
85
incisal third
71,33
73,98
74
25,35
22,23
21
83
85
84,77
incisal third
70,87
74,98
75
28,35
26,12
26
78,89
79,98
80
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
72
73,12
73,24
25,90
22,32
22,12
79
79,12
79,23
cervical third
68,25
75,81
77
27,12
22,11
22
75
82,12
82
middle third
71
72
72,12
25
22
22,12
80
79,12
79
middle third
70,98
72,99
73
29,98
26,98
27
88
89,99
90
incisal third
69,87
71
71,12
26
23
23,12
79,12
80
80,12
incisal third
71,88
75,98
76,09
30
27,12
27,45
87
88,89
89
tooth element 22
L before L after
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 22
L before L after
c after
c 6 m. later h before
h after
h 6 m. later
87,88
L 6 m. later c before
L 6 m. later c before
cervical third
69,78
71
71,12
25
23,12
23,44
79,99
82
82,12
cervical third
71,34
75,89
76
26,98
22,12
22,89
80,09
87,23
middle third
71
72
72,1
26
25,12
25,11
80,99
83
83,43
middle third
72,23
75
75,15
23
21,19
21
83
85,01
85,99
incisal third
70
72
72,12
26
23,12
23
81
81,98
81,76
incisal third
71,87
75,98
76
23,98
21,01
20,81
82
78,98
79
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,91
72,12
23
23,11
78
78,98
78,99
cervical third
70,98
75,89
76
25,89
21,98
21
80,98
87,34
88
72
25,12
middle third
69,12
73
73,17
22
21,98
21,12
82
83,99
84
middle third
71,87
75,23
76,89
26,98
22,87
23
83,67
89,87
90
incisal third
70,28
74
74,22
25
23,32
23,12
83
83,88
84,01
incisal third
72,98
75,87
76
25,98
21,87
22,76
84
87,89
88,09
PATIENT N. 4
PATIENT N. 7
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,42
71,6
26,12
26,01
78,12
79,35
79,89
cervical third
70,23
75,89
76,88
23,89
21,89
22
80,99
83,87
84
71,77
28,45
middle third
70,12
76,12
76,6
28,19
25,55
25,95
79,82
80,88
81
middle third
71,89
75,98
77
24,87
23,21
22,98
81,89
85,98
86
incisal third
69,89
72,34
72,89
29,08
26,87
27,01
80,76
81,11
82
incisal third
69,98
76,23
77
25,98
22,34
23
85,98
88,65
88,98
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,12
73,98
74
28,99
27,87
27,89
78,12
79
79,12
cervical third
69,87
73,87
74
27,45
23,21
21,90
79,90
85,34
86
middle third
70,78
73,21
73,98
29
27,05
27
80
80,78
81
middle third
71,09
74,87
76,00
28,12
23,87
24
82
85,89
86
incisal third
71,34
73,23
73,99
26
25,98
25
78,09
79
79,99
incisal third
70,99
74,67
75
26,12
23,12
22,65
83
86,12
87,09
tooth element 12
L before L after
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 12
L before L after
c after
c 6 m. later h before
h after
h 6 m. later
86
L 6 m. later c before
L 6 m. later c before
cervical third
63
67,87
67,90
26,78
24,12
24,00
77,98
79
79,56
cervical third
72,12
75,54
76,78
27,98
26,12
26
80,98
85,32
middle third
65
65,98
66
27
25,12
24,66
78,34
79
79,12
middle third
73,12
76,98
75,99
26,12
22,67
23
79,12
83,12
84
incisal third
66,67
70
70,87
28
27,11
27,01
79
80,12
80,22
incisal third
72,76
76,12
77
27,12
23,78
24
81,98
83,87
84
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,34
72,17
24,12
24,98
87,01
89,09
89,39
cervical third
71,12
75,98
76
26,12
24,76
24
78
83,98
84
72,12
26,99
middle third
71,98
73
73,87
28
27,12
26,76
79,34
76,33
76,19
middle third
69,12
73,3
75
23,12
21,98
22
81,98
84,98
85
incisal third
69,38
72,98
72,99
29,20
27,12
27
79,23
81,97
82
incisal third
72,12
75,78
76,98
21
18,98
19,09
83
86,02
87
h 6 m. later
tooth element 22
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 22
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
cervical third
66,12
71,78
72,98
18
16,98
16,12
89,34
91,56
92
cervical third
71,12
75,98
76
23,98
22,1
21,78
78,90
83,78
84
middle third
68,45
73,98
74
19,76
17,45
16
88,76
90,87
91
middle third
69,12
73,89
74
21
19,87
19
80,98
85,12
86
72,87
73
73,87
84
86
incisal third
70,98
20,09
19,12
19
88,73
91,7
91,5
incisal third
71,89
25,09
23,98
24
83,23
85,98
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
67,78
75
24,95
25
78,98
79,45
79,67
cervical third
71,12
74,12
74
25,98
26
80,98
88,65
88
74,23
26,11
21,87
middle third
69,23
73,07
73,17
27
23,97
24
80,01
82,76
83
middle third
70,12
75,76
76
25
21,01
21
79,12
86,88
87
incisal third
70,98
74,87
75
26
23,21
23,12
82,67
84,98
85
incisal third
68,01
72,90
73,87
26,01
22,9
23
78,98
83,12
83
PATIENT N. 5
PATIENT N. 8
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 11
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
69,98
72,98
24,76
24,98
78,98
79,99
80,76
cervical third
69,98
75,67
76,12
24,89
22,76
22
85,09
85
72,87
26,09
78,98
middle third
70,87
73,12
73,55
24,12
22,87
22,99
79
81,87
82
middle third
71,34
75,12
76
25,98
21,87
21,99
79,98
84,32
84,12
incisal third
72
75,03
75,99
23,45
22,12
22,45
79,87
83,99
84
incisal third
71,89
74,98
75,09
25,45
22,98
21,12
80,98
82,12
82
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 21
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
72,57
76
25,45
25,89
82,76
84,78
85
cervical third
71,98
73,56
73,99
23,12
23,23
79,09
82,89
83,76
83,98
75,78
27,87
27,98
middle third
70,76
75,76
75,99
26,45
22,87
23
86,89
88
88,11
middle third
72,78
74,87
75
26,23
22,87
21,87
78,67
83,12
incisal third
68,89
73,89
74,99
25,77
23,23
23
88,34
89,98
90
incisal third
71,98
76,09
76,10
24,21
21,98
21
79,98
82,87
82,98
tooth element 12
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 12
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
68,78
73,67
74
27,12
24,54
25
78,88
83,23
84
cervical third
72,98
74,09
74,82
27,23
23,98
24,09
81,12
86,87
87,09
middle third
70,45
74,43
76,10
29,23
26,78
27
80,01
83,78
84
middle third
69,98
71,18
71,87
19,09
17,07
17,77
78,88
79,99
80,09
75,54
76
74,56
75
86
incisal third
72,12
30,02
26,78
27
81,23
83,23
83,67
incisal third
71,67
21,98
19,12
19
81,99
85,89
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 13
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
70,93
74
25,78
26
78,98
82,98
83
cervical third
71,34
75,77
76
26,12
26
77,96
79,90
80,09
73,23
25,78
28,88
middle third
71,56
75,09
75
26
24,77
25
83,21
85,23
85,87
middle third
72,09
76,09
75,78
28,65
26,12
25,77
78,88
81,98
82,01
incisal third
70,28
75,34
68
24
23,46
24,12
84,09
85,12
86
incisal third
72,01
73,98
74
25,89
22,89
23
77
81,09
81,17
tooth element 22
L before L after
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 22
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
L 6 m. later c before
cervical third
71,45
73,98
74
24,67
23,1
23
78,23
84,23
84,78
cervical third
72,98
74,99
75
28,76
26,23
25,66
77,56
81,09
81,10
middle third
70,87
73,78
74
25,89
22,78
23
79,98
83
83,78
middle third
73,12
76,09
77
19,99
17,77
17,99
78,99
81,45
82,99
74,23
75
26,12
83
72,9
73,09
84
incisal third
72,12
22,12
23
85,08
85,10
incisal third
69,87
26,98
24,21
24,90
79,99
83,88
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
tooth element 23
L before L after
L 6 m. later c before
c after
c 6 m. later h before
h after
h 6 m. later
cervical third
70,09
75,67
24,45
25
80,12
82,78
83
cervical third
71,34
75,78
76
24,87
24,12
79,98
83,23
84
75,3
26,98
28,54
middle third
71,12
73,67
74
28,89
24,89
23,89
81,98
84,89
85
middle third
70,12
74,23
74
29,87
25,88
25,12
80,98
85,12
85,93
incisal third
72
73,98
74
26,12
25,11
25
82,08
86,89
87
incisal third
71,98
75,87
76,01
27,78
24,12
24,01
81,98
82,99
83
cosmetic
dentistry
1
2017
51
[52] =>
| industry report effectiveness of the professional home whitening
Table 2: Results from the clinical
diary of the patients: the column on
the left shows the patients, while the
other columns show the hours and
days passed from the application
of the bleaching product. Each
patient had to report the level
of post-operative sensitivity at each
period: value 1 indicates a very low
level, value 2: low, 3: moderate,
4: heavy, 5: very heavy (implicating
problems with the assumption of cold
liquids or the contact with air
and pain during chewing).
Patient
1h
3h
6h
12 h 24 h 2 d
3d
4d
5d
6d
7d
10 d
1
4
4
2
2
1
0
0
0
0
0
2
1
2
5
5
4
4
2
2
1
0
0
0
0
0
3
4
4
4
3
2
1
0
0
0
0
0
0
4
4
3
2
1
2
2
1
1
1
1
0
0
5
3
3
3
2
2
1
0
0
0
0
0
0
6
3
3
2
1
0
0
0
0
0
0
0
0
7
4
3
2
1
0
0
0
0
0
0
0
0
8
4
4
3
1
0
0
0
0
0
0
0
0
containing double conjugated links, aromatic systems and quinolonic systems.1, 3
Many bleaching products for outpatient or home
bleaching that are currently on the market are based
on hydrogen peroxide and carbamide peroxide at
different concentrations.1, 4
For outpatient bleaching, the professional applies
the mixture on the teeth to be treated, while for at
home bleaching, a special resin tray is made to be
worn by the patient with the product inside during
the night.
The new bleaching product ENA White 2.0 (Micerium
S.p.A., Italy; Fig. 2) is an innovation in this field as the
bleaching product is not applied with a tray or in office but supplied by a toothbrush with a dispenser.
The aim of this study is to verify the efficacy of the
bleaching treatment ENA White 2.0 through spectrophotometer analysis, on a group of 10 patients
6 months after the clinical results, excluding pos
sible side effects such as sensitivity.
Fig. 1: SpectroShade picture of
element 11 shows the difference of
the chromatic measurements while
varying the extension of the reference
area can be noticed. The window
on the top left of the picture shows
how the program can provide the
extent of value (L), chroma (C) and
hue (h) for each portion of the tooth
and compare it with the colour
on the market (left and right
column respectively).
In the analysed clinical case, element
11 is similar to colour A2 for chroma,
hue and value. On the right, the
discrepancy between A2 and the
examined tooth is reported on a scale:
the extent of chroma is higher
than A2 while the hue is lower.
Starting from A2, this indicates a total
colour that is more saturated
and tending to red.
52 cosmetic
dentistry
1 2017
Fig. 1
Materials and methods
Eight patients who required the cosmetic treatment
of outpatient bleaching were selected. The criteria
to be included in the group of the study were: to be
non-smokers, aged between 18 and 50 years old, not
periodontally compromised and without any prosthetic element or aesthetic restoration on anterior
teeth. Some pregnant women were excluded, as it is
advisable to postpone treatment until after the birth
as it is a cosmetic treatment, despite no side effects
being documented for the foetus nor the mother.
Before starting the clinical bleaching session, all
patients were submitted to an accurate treatment of
oral hygiene and spectrophotometer analysis of the
six frontal superior elements (from canine to canine).
For each dental element (from 1.3 to 2.3), the variables L (value), C (chroma) and h (hue) in the cervical,
medium and incisal sections were observed (Fig. 1
and Table 1).
The three above-described parameters were observed before the treatment and after 6 months,
with the aim of evaluating the maintenance of the
colour.
All patients used the toothbrush twice a day: once
in the morning and once in the evening. The patients
were given instructions on how to use the device
as follows:
[53] =>
effectiveness of the professional home whitening industry report
|
Fig. 2: ENA White 2.0 by Micerium.
Fig. 2
·· First remove the cap, unscrew the head of the
brush from the dispenser and remove the seal at
the base of the toothbrush.
·· Then screw the head on the dispenser again,
rotate the ring on the lower part anti-clockwise
towards the direction ‘UP’ until the gel comes
out.
·· The first time you perform this operation, a couple
of rotations of the ring are required as the tube
that takes the gel to the bristles must be filled.
(The patient must be informed that a rotation of
a couple of marks is enough to make the right
quantity of product come out.)
·· The brushing must be performed with a horizontal movement, for about 30 seconds, avoiding the
gums as much as possible; then rinse the toothbrush with water and brush again for another
30 seconds.
Figs. 3 & 4: Didactic pictures
showing results of use of the bleaching
product: Figs. 3a & b: clinical case 1:
before (a) and after bleaching (b);
Figs. 4a & b: clinical case 2:
before (a) and after bleaching (b).
Fig. 3a
Fig. 3b
Fig. 4a
Fig. 4b
cosmetic
dentistry
1
2017
53
[54] =>
| industry report effectiveness of the professional home whitening
The patients were asked to evaluate the post-operative sensitivity, indicating its extent with a number
(from 5, maximum intensity, to zero) immediately
after the session and 10 days after (Table 2).
Discussion
At the end of the 1980s, some home bleaching techniques were conceived, with the use of customised
or not-customised trays, adequately filled with hydrogen peroxide at a low rate, worn for some hours
per day, or even all night long. The active ingredient
had a concentration from 10 to 30 per cent and the
time of contact (from a couple of hours to the whole
night) varied accordingly.
The aesthetic result obtained is based on the variation of the colour; to define the colour from the
psychosensorial point of view three parameters1-23
were used:
·· Hue (h) is the base colour of the tooth, the most
difficult parameter to identify, which comes from
the dentine and is defined with four gradients:
A (red-brown), B (orange-yellow), C (green-grey),
and D (pink-grey).
·· Chroma (c) represents the level of saturation, the
pigmented portion of a shade. Vita Shade Guide
has 4 levels of chroma: 1, 2, 3 and 4.
·· Value (L) represents the level of brightness, it separates light and dark colours. Black is the minimum value, white is the maximum value.
Through the SpectroShade colorimeter, the value,
hue and chroma of the upper frontal elements were
measured; the main feature of this device is that
it shows the value of the sample of the required
shade guide, which is more similar to the colour of
the examined tooth, thanks to a comparison of the
delta E of the samples.
The delta E of the data is the square root of the
sum of the squares of the colorimetric data of
the obtained evaluation points:1
DE= [(Lfin – Liniz)2 + (Cfin – Ciniz)2 + (hfin – hiniz)2]1/2
After the analysis of 10 clinical cases, it was
shown that the value (L) of the treated elements
increased, so that the dental element acquired
a lighter aspect. Analysing the literature1-23, we
can deduce that in order to have a visual perception
of the difference of brightness between the two
treated elements DL must be at least identical or
higher than 1.
The results obtained for the parameter of chroma (C)
were excellent, with values that were lower than at
54 cosmetic
dentistry
1 2017
the start of the study, meaning that a lower level of
saturation was attained.
Six months after the end of the treatment, the analysis with the spectrophotometer was repeated and
it was noticed that the studied parameters remained unvaried, without any significant change.
The excellent aesthetic result achieved with ENA
White 2.0 bleaching is visually admirable and confirmed also by the analysis with the colorimeter.
The balance of chroma, hue and value was also
maintained after 6 months.
Concerning post-operative progress, this study
confirms what has been stated by the literature:17-22
sensitivity is particularly marked during the first hour
after the treatment, but it disappears in 24 hours.
After 3 days, only four people reported some problems of sensitivity (described as very bearable),
which persisted in only one case even after 7 days.
On the 10th day no problem was reported.
Conclusion
The new method with ENA White 2.0 allows excellent aesthetic results to be obtained with only 2 minutes a day of application of the bleaching product
for about 20 to 30 days, a time period corresponding
to less than 1/5 of the time necessary using the classic tray; the toothbrush with dispenser is easy to use,
handy, it can be brought and used anywhere for
1 minute in the morning and 1 minute in the evening.
If the aesthetic result is not achieved at the end of
this treatment, a second cycle can be performed
without any negative effect on the dental structure.
The described treatment respects the EU regulation
for the use of 6 % hydrogen peroxide, clarifying that
the bleaching kits can be directly delivered to the
user by the dentist as a professional treatment after
an accurate visit and evaluation of every single case.
The accelerator XS 151 is contained into the bleaching, it activates with brushing and allows the patient
to use it easily and everywhere._
Editorial note: A complete list of references is available
from the publisher.
contact
Dr Irene Franchi is working as a dentist
in Levizzano Rangone in Italy.
She can be contacted at franchiirene@virgilio.it.
[55] =>
[56] =>
manufacturer news
clear aligner
Align extends Invisalign offering for GDPs
With its Invisalign system, Align Technology provides one of the leading solutions on the clear
aligner market. The company has now introduced
Invisalign Go, a new aesthetic tooth-straightening
product, with which it aims to make the solution
accessible to more clinicians in the UK.
Designed specifically for general dentists, Invisalign
Go can treat mild crowding, spacing, orthodontic relapse and other aesthetic tooth misalignment cases. It will be available for single-arch or dual-arch
treatments, ranging from £655 to £875, making it
a realistic treatment option for GDPs, the manufacturer said.
Align promises that patients can achieve Invisalign smiles in as little as seven months with
Invisalign Go. Users will be able to easily identify
suitable patients for treatment with new case
assessment software that can be fully integrated
into an existing digital dental workflow and works
both with polyvinyl siloxane impressions and
Align Technology’s intra-oral scanner, the iTero
Element, as well as 3M True Definition and
CEREC Omnicam (Dentsply Sirona).
As part of the new Invisalign Go system, dentists
are provided with an appointment plan that gives
task-level guidance with specific and
detailed processes to be performed at
each appointment. Owing to a progress
assessment tool, the technology furthermore allows clinicians to upload new
intra-oral photographs and receive confirmation of whether the case is progressing as
planned at any time during treatment.
clinicians access to an extensive continuing education
program that is aimed at
supporting them throughout their Invisalign Go
treatments.
A specially set-up website at www.invisalign-go.
co.uk provides more information for those practitioners interested in signing up for the system. Invisalign also offers a training program, available to
users and non-users of the system, that includes
both online and live sessions that provide hands-on
tips and techniques on Invisalign Go digital photography, impressions, interproximal reduction and
attachments. Furthermore, the company gives
The Invisalign product family includes Invisalign,
Invisalign Teen, Invisalign Lite, and Vivera Retainers. In addition to the Invisalign System, Align Technology manufactures and markets 3-D digital
scanning products and services for orthodontic
and restorative dentistry, including the iTero including the iTero element intraoral scanner and
OrthoCAD software. For additional information,
please visit www.invisalign.com.
patient education website
Website pushes technology for cosmetic treatment simulation at home
Polls have shown that a significant number of Brits are considering cosmetic procedures to improve their appearance. In order to guide them in
their decision-making process, patient education website Comparethetreatment.com has recently launched a new simulation tool that promises to
show consumers what they would look like after treatment.
According to the website, the Visualizers are the only technology in the UK
that can simulate cosmetic surgical and non-surgical treatment outcomes
with or without clothes. Users simply select the treatment option, upload a
current photograph and enter their contact information. They then receive a
free digitally created before and after photograph by e-mail within 24 hours.
The company said that the tool was developed for prospective patients who
are thinking about having procedures such as cosmetic dentistry done, but are
not ready to commit to a consultation with a professional for various reasons.
“Aesthetic procedures are becoming mainstream in consumer consciousness. Yet many people who could benefit from treatment don’t because they
simply can’t imagine how they’ll look afterwards, so don’t pursue it,” said
the website’s founder, Tim Molony. “With our aesthetic treatment visualizers, people get a better understanding of what they could achieve before
committing to the procedure. It’s simply an extension of our aim to help
consumers to make confident treatment decisions.”
“We also aim to take away the fear factor in choosing cosmetic treatments
and clinicians by providing people with face-to-face contact with surgeons
and evidence-based web information,” he further explained.
The Visualizer tool will be available exclusively on www.comparethetreatment.com. Launched in 2015, the website claims to be a safe and informative platform for everything concerning cosmetic surgery, covering over
250 treatments, ranging from smile makeovers to all-out plastic surgery.
56 cosmetic
dentistry
1 2017
© iko / shutterstock.com
[57] =>
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– no time away from the practice
– interaction with colleagues and
experts across the globe
– a growing database of
scientific articles and case reports
– ADA CERP-recognized
credit administration
www.DTStudyClub.com
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Join the largest
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in dentistry!
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
[58] =>
| meetings IMAGINA Dental
IMAGINA Dental—
Digital technologies &
Aesthetic dentistry congress
The 6th IMAGINA Dental edition, Digital technologies & Aesthetic dentistry congress will be held from
13 to 15 April 2017 at the Grimaldi Forum in Monaco.
IMAGINA Dental is the industry's leading event for
new digital technologies, 3-D and CAD/CAM in dentistry.
of just a few years ago, including individualised bone
grafts and trachea replacements for cancer patients.
However, it is important to realise that these technologies do not replace knowledge or conventional
treatments; rather, they open up new treatment
avenues, he said.
IMAGINA organizers invite dentists to a new generation of congress designed to help them better understand, learn and share experiences and clinical cases
about how digital technologies could change their
daily practice. From 3-D imagery and 3-D diagnostic
tools to guided surgery, treatment planning, implantology, CAD/CAM, aesthetic restoration and Digital
Smile Design, IMAGINA Dental brings a unique educational experience in an intimate setting, to discover
and find out more how enjoyable innovative dentistry
can be.
“Innovations in implantology” was the theme of the
second day and started with a presentation by Drs Luc
Manhès and Guillaume Fougerais titled “At the dawn
of artificial intelligence, how to leverage technologies
to keep hold of our dental treatments?” The speakers
demonstrated that using CBCT technology, it is possible to obtain perfect treatment planning in 3-D.
They pointed out that very few dentists use the
technology and emphasised the value of using CBCT.
Only 3 per cent of dentists use surgical guides to place
implants, but Manhès and Fougerais encouraged the
use of a surgical guide even for a simple case “to see
the technology through”.
After last year’s edition (7–9 April 2016) it was apparent that IMAGINA has maintained its reputation
as the leading congress for digital technology. In
particular, participants emphasised the quality of the
presentations and remarked that IMAGINA is more
personal, giving the opportunity to engage with the
presenters. More than 600 visitors from 26 countries
attended the event, which received positive feedback
from both the presenters and attendees.
Highlights of 2016 meeting
IMAGINA 2016 focused on CAD/CAM dentistry and
microscopy, innovations in implantology and digital
smile design.
The guest of honour at the opening session was
Dr Marcus Abboud, Founding Chair of the Department
of Prosthodontics and Digital Technology and Director of Continuing Education at Stony Brook University’s School of Dental Medicine in New York in the US.
The title of his lecture was “Innovations in CAD/CAM
and digital workflow for the daily practice”. Abboud
pointed out that digital dentistry and 3-D printing
have rendered possible what could only be dreamed
58 cosmetic
dentistry
1 2017
Dr Joseph Choukroun was the guest of honour of the
second day. In his presentation, titled “A-PRF and
i-PRF: the latest innovations with the use of mesenchymal stem cells in the dental office”, he explained
how it is possible today to treat patients who have lost
bone, cartilage and collagen by regenerating the lost
tissue with stem cells. In the past, harvesting stem
cells and treating them were very difficult to achieve.
However, today, stem cells can be extracted directly
with a blood sample, and Choukroun presented the
technique for quickly extracting stem cells and injecting them where needed.
The theme of the last day of the congress was “Digital
smile design”. The room was full for Prof. Angelo
Putignano’s presentation, titled “Simplexity in dentistry: The StyleItaliano approach”. He began by explaining the guiding foundation for his work—colour
and details—and went on to demonstrate this, taking
the attendees on a magical trip to see what can be
achieved in aesthetics.
Save the date and join IMAGINA Dental in 2017!
[59] =>
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[60] =>
| meetings events
International Events
2017
37th International Dental Show
21–25 March 2017
Cologne, Germany
www.ids-cologne.de
Dental Digital Marketing Conference
28–29 April 2017
Las Vegas, USA
www.dentalmarketingconference.com
12th CAD/CAM & Digital Dentistry
International Conference
5–6 May 2017
Dubai, UAE
www.cappmea.com
Dental Technology Showcase
12–13 May 2017
Birmingham, UK
www.the-dts.co.uk
Art of Esthetics
14th International Congress
of Esthetic Dentistry
18–20 May 2017
Bucharest, Romania
www.sser.ro
EAED 31st Annual Meeting
25–27 May 2017
Milan, Italy
www.eaed.org
Cologne, Germany © Arndale
IMAGINA Dental
6th Digital Technologies &
Aesthetic Dentistry Congress
13–15 April 2017
Monaco
www.imaginadental.org
60 cosmetic
dentistry
1 2017
FDI Annual World Dental Congress
29 August–1 September 2017
Madrid, Spain
www.world-dental-congress.org
Heart of Esthetics
14th ESCD Annual Meeting
21–23 September 2017
Zagreb, Croatia
www.heartofesthetics.eu
© 06photo
AACD 33 Annual Congress
18–21 April 2017
Las Vegas, USA
www.aacd.com
rd
Interdisciplinary Summit of the
American Academy of Esthetic Dentistry
3–5 August 2017
San Diego, California, USA
www.estheticacademy.org
[61] =>
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cosmetic
dentistry
1
2017
61
[62] =>
| about the publisher imprint
cosmetic
dentistry
beauty & science
Publisher/President/CEO
Torsten R. Oemus
t.oemus@dental-tribune.com
Editor-in-Chief
Dr Sushil Koirala
drsushilkoirala@gmail.com
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soran-kwon@uiowa.edu
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m.wojtkiewicz@dental-tribune.com
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Barbora Solarova (Eastern Europe)
Editorial Board
Dr José Roberto Moura (Brazil)
Prof. Akira Senda (Japan)
Dr Dinos Kountouras (Greece)
Dr Valerio Bini (Italy)
Dr Florin Lazarescu (Romania)
Asst. Prof. Pavinee P. Didron (Thailand)
cosmetic
dentistry
beauty & science
is the official publication of:
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62 cosmetic
dentistry
1 2017
[63] =>
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[64] =>
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)
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/ Complex direct ORMOCER composite restorations in the posterior region
/ ‘ No-prep’ interceptive rehabilitation —of tooth wear using a free-hand technique driven by a functional wax-up
/ Aesthetic composite layering of implant-supported restorations in an edentulous jaw
/ Non-ablative melanin depigmentation of gingiva
/ New treatment protocol for periodontal pocket treatment
/ Update on teeth whitening and remineralisation with nHAp— 5 years after the EU regulations
/ Evaluation of the effectiveness of the professional home whitening with the new ENA White 2.0
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