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‘‘MULTI’’ple Shades of Aesthetics SPRING 2015
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A NEW WAY TO
CONDUC T BUSINESS
Carestream Dental’s CS 3500 intraoral scanner is a work of art – one that can create big opportunities for your lab. With our preferred lab program, you can help practitioners hit the right notes by providing a convenient method of submitting digital impressions to your lab at no fee. You’ll gain more control, save time and maximize profits by offering no update or license fees. We’ll even help you advertise your lab’s new capabilities, so you benefit from the perfect harmony of cutting-edge technology and increased business. READY TO GET STARTED? Find out how at www.carestreamdental.com/CS3500 or by calling 800-933-8031.
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contents
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The Rest Of The Story
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New Luting Composite: Variolink Esthetic On the cover
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Photograph of cover patient, prior to treatment.
cover story
Full Mouth Rehabilitation Using The New IPS e.max Multi Ingot
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Control of Tissue Contours In Implant Impressions EDITORIAL DIRECTOR
Catherine Wilson (416) 510-6785 cwilson@oralhealthgroup.com ASSISTANT EDITOR
PRODUCTION MANAGER
DENTAL GROUP ASSISTANT
Karen Samuels (416) 510-5190 karens@bizinfogroup.ca
Kahaliah Richards (416) 510-6777 krichards@oralhealthgroup.com
CIRCULATION
SENIOR SALES MANAGER
SENIOR PUBLISHER
Melissa Summerfield (416) 510-6781 msummerfield@oralhealth group.com
Jillian Cecchini (416) 442-5600, ext. 3207 jcecchini@oralhealthgroup.com
Barbara Adelt (416) 442-5600, ext. 3546 badelt@annexnewcom.ca
Tony Burgaretta (416) 510-6852 tburgaretta@oralhealthgroup.com
VICE PRESIDENT
ART DIRECTOR
DENTAL MARKETPLACE – CLASSIFIED
ASSOCIATE PUBLISHER
Jim Glionna
Mark Ryan
Karen Shaw (416) 510-6770 kshaw@oralhealthgroup.com
Joe Glionna PRESIDENT
Hasina Ahmed (416) 510-6765 hahmed@oralhealthgroup.com
ORAL HEALTH LABS IS A SUPPLEMENT TO ORAL HEALTH
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editorial
“THE REST OF THE STORY” For almost fourteen years I worked as a news reporter for Global Television in Canada’s largest news market, Toronto. The old cliché “if it bleeds it leads” is quite fitting in the news biz. Five days a week I was on the frontlines covering and reporting on the doom and gloom du jour in Toronto the great. City budget short falls, homicides, car accidents, corrupt cops, political boondoggles, there was a smorgasbord of news to cover. However, looking back with some introspection I can tell you it’s one big news blur. Year upon year of negative news stories tends to take a toll and after a while you don’t want to remember. I believe it’s a defense mechanism. A way to protect oneself from all the negative things seen over the years. I can say the fondest memories I do have as a news reporter were the “feel good stories” These were not usually stories that lead the newscast but they did uncover a kinder, gentler side of humanity; stories that were greatly needed in our newscasts to balance our perspective. Yes, these stories were typically buried at the end of the news line up. Often these pieces were about the disadvantaged and the rallying of a community to help. I always went to bed those nights feeling a little better, a little safer in our great city. Back in November I had the pleasure of meeting a woman by the name of Renata Gick. Her story reminds me of the generosity of spirit that miraculously still exists today and the news stories I longed to cover. Renata is a 48-year-old mother of two, who resides in a small town near London, Ontario. She was born with an inherited disorder called Ehlers-Danlos syndrome. It’s a connective tissue disorder whereby the tissue that provides support to many body parts, such as the skin, muscles and ligaments, Neha Narang graduated from the University of Toronto and later from Centennial College’s Radio and Television Arts program before embarking on her journalism career. Neha worked as a reporter for Global Television News in Toronto for 14 years. She left the network to raise her two daughters. It was a natural progression for her to join her husband in running their
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have a genetic defect and don’t produce the necessary amounts of collagen. Collagen acts like glue in the body, adding strength and elasticity to connective tissue. What that means is Renata is prone to frequent dislocations and hyperextensions of her joints. Her skin is also very soft and fragile, so it tears and bruises easily. Patients with EDS have widespread problems that manifest from collagen not being structured the way it should be or just a lack of it. Renata, like many with this syndrome, suffered for years before she was eventually diagnosed. One of the areas where Renata experienced a lot of pain was her mouth. Her gumsm lacked the normal levels of collagen which meant her teeth were prone to falling out. By the time she turned 41, she had lost most of her teeth and her dentist pulled out the few that still remained. I asked her how she felt when she was left with no teeth. She honestly replied that it was almost a relief because of the mouth pain, which she had suffered from for many years, had come to an end. However now she was left with no teeth. For the past eight years, Renata has survived without teeth, re-learning how to speak, eating unhealthy mushy foods and putting up with the whispers and stares from the unkind and curious. We can only imagine the emotional trauma of being completely edentulous at such a young age. Not only edentulous but also without any available prosthesis to assist her in any way. When in discussion with Renata, it becomes painfully obvious how difficult her life has been in our aesthetically minded society. Unfortunately, because of her EDS Renata’s gums are extremely soft and would tear if she wore any type of denture, so it’s not an option for her. What Renata needs are dental implants and a prosthesis which does not abrade the gums. Her attempts to get the costs of implants covered by the Ontario Health Insurance Plan have been fruitless. OHIP does not deem it to be medically necessary, both from a healthy eating routine or from any related detrimental emotional scarring. Resourcefully, Renata wasn’t
dental practices heading the HR, marketing & PR aspects of managing the practices. Neha has been successful at creating a presence in the local community for the dental practices. She also brought a philosophical aspect to the dental practices by introducing charitable and community outreach programs; such as raising breast cancer awareness, organizing dental hy-
giene tutorials at elementary schools, and setting up a program for abused and battered women needing dental treatment. Neha continues to keep the creative process alive by writing various articles, creating media scripts, overseeing production of television appearance, and overseeing production of ads. She is currently producing a documentary.
editorial
December, in a six-hour surgery, six upper and four lower dental implants were placed along with two sinus lifts. Dr. Psutka performed the high-risk procedure donating his time and expertise along with anesthesiologist Dr. Zbigniew Wajtasik. Oral radiologist Dr. Milan Madhavji donated the CAT scan and surgical guide services for the procedure. With Renata’s implants also graciously donated by BioHorizons Implants, healing well, Dr. Narang is preparing for the next chapter in Renata’s smile story. Enter Trevor Laingchild RDT. He will use his expertise as an accredited AACD dental technician and owner of dentalstudios, to fabricate the appropriate prosthesis and by working with Dr. Narang to make Renata’s long awaited dream of a smile, a reality. Over the coming weeks, it is hoped that the eight long years that Renata has had to endure without any teeth, will come to an end. It’s stories like this that don’t get the coverage they deserve. We do have great news stories taking place across this great country but without airplay or print, we have little or no idea how kind and caring people are towards those who need help. As Mahatma Gandhi so wisely stated, “A nation’s greatness is measured by how it treats its weakest members.” Renata’s story helps renew my faith in humanity after seeing the dark underbelly for far too long. Stay tuned for “The Rest Of The Story”.
ready to throw in the towel or toothbrush in this case. While scouring the internet looking to see if there was some way she could get teeth, she stumbled upon a Smile Story contest through the American Academy Cosmetic of. Dentistry. By submitting her picture and expressing what a smile make over would mean to her Renata was one of more than four hundred applicants who entered the contest this past June. The public was then able to vote for their favorite stories on the AACD’s Facebook page. The top twenty stories were identified based on a popular vote and finally five people were selected based on their smile evaluations by AACD member dentists. Renata was chosen in that group of five and was the only Canadian. On the AACD Facebook page, president elect Joyce Bassett states, “A beautiful smile has the power to change someone’s life and we couldn’t be happier for these individuals who now have an opportunity to grow personally and professionally with new found confidence.” That’s what Renata and the other smile story winners are banking on. But beyond that smile there is a bigger story, which brings me back to the spirit of giving. The AACD dentists who are performing the smile makeovers are donating their expertise and resources free of charge. Dr. Arun Narang, an AACD member dentist, was chosen to give Renata a full smile makeover. In order to do that, Dr. Narang enlisted the skills of oral surgeon Dr. David Psutka. This past
Guest Editor
Neha Narang
INTRODUCTION FROM THE EDITOR This issue I felt a guest editor would be timely and appropriate in order to showcase the human side of dentistry, which can be of an aesthetic nature, but occasionally with a more life changing agenda. The ability to help a person overcome physical, emotional and aesthetic challenges helps all of us in many ways. For this I welcome the editorial from Neha Narang and look forward to the rest of the story. The cover shot and subsequent article is a look into the procedure of a full mouth reconstruction,
from a laboratory perspective. The emphasis being on achieving good aesthetic results for the patient, while still undertaking to maintain a similar shape and contour from the pre-operative presentation. Dr. Stephanie Huth illustrates and visualizes cement able protocols, which are ever evolving and are of the utmost importance to both clinicians and technicians, to understand. Soft tissue management, especially with implant restorations, is so vital for the health and aesthetics of the patient, that a good procedure for laboratory communication and model replication is essential. Dr. Bill Turner showcases his protocols, with illustrations within this issue. Thanks to all the contributors, who share their expertise, thoughts and experiences, for the benefit of us all.
Editor
Trevor Laingchild, RDT, AAACD SPRING 2015
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sponsored case study
A NEW CLASS OF RESTORATIVE MATERIAL Bobby Chaggear B.Sc., DDS Restorative dentistry requires practitioners to identify restorative materials which balance esthetic appeal with the durability required for intra-oral function. Three companies, DeguDent (A Dentsply Company), Fraunhofer and Vita Vident participated in a study to improve dental materials being used in both CEREC Chairside and Commercial Laboratories. These three companies brought their pre-eminent researchers to Germany to review current restorative materials and to discuss new dental material innovations. The key result of the collaboration was the creation of a new class of restorative material – ZLS. The name is short for Zirconia reinforced Lithium Silicate. ZLS is a glass ceramic produced out of Silicon Dioxide, Phosphates, Alumina, Lithium composition, Terbium Oxide, Ceria and Zirconium Dioxide. It was the addition of 10% Zirconium Dioxide being completely dissolved in the glass matrix that led to the creation of this new class of material. The incorporation of the Zirconia had the added effect of creating a crystalline structure that was smaller than the one that is present in a Lithium Disilicate material. (Figure 1a) This effect has had an effect upon polishability, machinability and esthetics (being flouresence, translucence and opalescence). The smaller crystalline structure, which was a result of the incorporation of zirconium dioxide in the glass matrix, allowed for excellent extra-oral and intra-oral polishability of the final restoration. No zirconium dioxide crystals are visible. (Figure 1b) The restoration can also be stain and glazed in a porcelain furnace and further polished manually. The incorporation of the Zirconia had the added effect of creating a crystalline structure that was smaller than the one that is present in a Lithium Disilicate material. (Figure 1a) This effect has had an effect upon polishability, machinability and esthetics (being flouresence, translucence and opalescence).
Figure 1a - Lithium Disilicate Crystalline Structure
Figure 1b - ZirconiaLithium Silicate Crystalline Structure (Celtra Duo)
ZLS also has a flouresence of natural teeth and due to the smaller crystalline structure, has remarkable translucence and opalescence. This structure has allowed the material to have a chameleon like effect with the natural dentition as it allows for an almost imperceptible colour transition from restoration to tooth. An interesting phenomenon occurred when the material was tested after crystallization. The material had a flexural strength of up to 420 MPa, yet the material was machinable in the CEREC milling chamber. This ability to be milled in the crystallized form in the CEREC milling chamber is due to the smaller crystalline structure that occurred from the incorporation of the zirconia in the glass matrix. The advantage of having a ZLS CEREC block in the crystallized stage (called Celtra DUO, developed by Dentsply) is that once it is milled, it can be tried in the mouth to check marginal fit, contacts and esthetics. The colour of the restoration can be verified next to the adjacent teeth. At this point one has 2 choices of either manually polishing the restoration or glazing the restoration in the porcelain furnace. Under testing, it has been shown that the flexural strength of the ZLS material drops to approximately 200 MPa after milling. This flexural strength rises to approximately 210 MPa after manual polishing. This flexural strength of 210 MPa is remarkable as it is 25 to 80 percent higher than other glass ceramics presently available for Chairside use with CEREC. In addition, one has the option to glaze this final restoration in the porcelain oven and see a dramatic rise of the flexural strength to approximately 370 MPa due to surface enforcement independent from glaze which is needed to get a glossy surface.
Figure 2
In the demonstrated case (Figure 2), tooth #14 has been endodontically treated and in need of full coverage, tooth #15 has decay both mesially and distally and tooth #16 has decay mesially. Both teeth #15 and #16 do not require full coverage with a crown. After excavation of the decay, it became apparent that tooth #15 had a substantial amount of tooth structure removed and tooth #16 had a minimal amount removed. (Figure 3a and 3b)
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A NEW CLASS OF RESTORATIVE MATERIAL Bobby Chaggear B.Sc., DDS
Figure 3a
Figure 3b
Figure 4
Figure 5
The decision was made to fabricate an onlay for #15, inlay for #16 and crown for #14 and have the restorations fabricated with CELTRA Duo. The proposals for the restorations with the CEREC are presented (Figure 4). After fabrication of the restorations, they were checked intra-orally for marginal fit and contacts. Due to the size of the restorations, the restorations on teeth #14 and #15 were further stain and glazed in a porcelain oven. This was done to increase the flexural strength of the material to 370 MPa. A decision on tooth #16 was made to polish the inlay. The inlay had not compromised the cusps of the tooth and as such did not need to be glazed in the oven. After polishing of the inlay at tooth #16, we felt the flexural strength of 210 MPa would allow for a very successful restoration. The cemented restorations are demonstrated in Figure 5. All the restorations were first cleaned in an ultrasonic bath prior to try-in intra-orally. The inlay on tooth #16 was polished utilizing a porcelain polishing system. Diamond polishing bodies with a size of less than 60microns is recommended. Care was taken to polish the occlusal surface with the porcelain polishing wheels only. The use of tungsten carbide burs on the material is contraindicated. Celtra Stains and Glazes were utilized to finish the restorations on teeth #’s 15 and 14. Due to the fact that Celtra Duo does not have a dimensional change after firing, the restorations may be placed directly on the firing tray or on a firing pad when being placed in the porcelain oven. The use of metal pins is contraindicated during the firing process. Prior to cementation, the restorations were etched with a hydrofluoric acid etch for 30 seconds. Following this porcelain etch, the restorations were thoroughly rinsed and silane was applied for 60 seconds. Calibra resin cement was utilized to cement the restorations.
THE ADVANTAGES OF CELTRA DUO ARE: 1. Shade verification and contact check of the restoration before stain and glazing or polishing. 2. Clinician choice is present to insert the restoration glazed or polished. The flexural strength is 370 MPa for glazed and 210 MPa for polished restorations. 3. A material that can both be used in the anterior esthetic region or in the posterior. With the incorporation of CELTRA Duo in their practice, one has the ability to incorporate a Zirconia Lithium Silicate (ZLS). This material allows for the fabrication and utilization of a highly esthetic and functional material for both the anterior and posterior regions of the oral cavity. Dr. Bobby Chagger, B.Sc., DDS, FICOI graduated from the University of Waterloo, and obtained a DDS from University of Toronto. Bobby later graduated from the Misch International Implant Institute and studied Advanced Functional Esthetics at LVI. He became a CEREC Educator, CEREC Software BetaTester, and traveled across North America, Asia and Europe to work with companies like Sirona to understand how new technology is changing possibilities in dentistry. He has published articles on CEREC technology and now trains other dentists in both basic and advanced dentistry utilizing CEREC 3D. Bobby’s clinical gains from innovation, and specific interests in cosmetic dentistry, dental implantology and CEREC have led him to create a new model for practice management. Bobby is a Fellow of the ICOl, is certified in IV Sedation and professionally affiliated with The CDA and ODA. He is a proud father and supports numerous community and charitable organizations in the Halton-Peel Region.
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Feature
LUTING Variolink Esthetic
Dr. Stephanie Huth Ivoclar Vivadent, AG
Stephanie.huth@ivoclarvivadent.com
V
ariolink Esthetic, the light and dual-curing luting composite, allows the dental professional to adhesively cement highly esthetic ceramic and composite restorations thanks to its flexible and well-structured Effect shade concept. Pre-polymerized excess material can be easily and efficiently removed.
Dr. Stephanie Huth is research associate in the internal clinic of Ivoclar Vivadent`s research and development department. She is responsible for clinical studies concerning restorative dentistry and prosthodontics, particularly adhesives and zirconia restorations.
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She started her career at the Julius-Maximilians-University in WĂźrzburg, Germany (20052010), where she passed the examination with distinctions and earnd a doctorate in the department for functional materials in medicine and dentistry.
Cementation materials establish a durable bond between the tooth structure and the restorative material, and therefore contribute significantly to the long-term success of indirect restorations. Cementation materials are classified into three different types: conventional luting cements, self-adhesive and adhesive resin cements. The advantage of conventional cements (e.g. Zinc phosphate or glass ionomer cements) lies in the ease of use and more forgiving properties in adverse clinical conditions like excessive saliva or bleeding. However, these luting cements adheres mechanically to the tooth structure, hence retentive tooth preparation is required and esthetically are easily discernible due to its opaque shade. The advent of adhesive resin cements has contributed to the rising importance of innovative restorative materials. Adhesive resin cements bonds chemically with highly esthetic all-ceramics restorations – such as IPS e.max Press/CAD and hence can be used even if no retentive preparation has been performed. It is essential in such cases, however, that a luting material of an appropriate shade and translucency level is selected in order to obtain excellent esthetic results. This applies in particular to restorations with a low material thickness. An additional advantage of adhesive luting composites over conventional cements represents the enhanced long-term integrity of the restoration margin. The low solubility and high resistance to wear of these luting composites lead to a reduced washing out of the cement gap. Adhesive resin cements use adhesive to ensure a reliable bond to the tooth structure. The adhesive penetrates into the dentin tubuli and forms a hybrid layer by bonding to collagen fibres. Etching of the tooth structure removes the smear layer and exposes the dentin tubuli, resulting in an increased micro-retention. The luting composite forms a chemical bond with the hybrid layer and therefore adheres well to dentin and enamel. Although the pre-treatment time of wellestablished self-adhesive composite ce-
Fig. 1 Preoperative situation: Tooth 19 with an insufficient composite filling
Fig. 2 Proposed design of the e.max CAD restoration
Fig. 3 T ry-in of the IPS e.max restoration with Variolink Esthetic Try-In Paste Neutral
Fig. 4 Placement of the anatomically shaped OptraDam rubber dam
Fig 5 A cid-etching of the prepared tooth surface with 37% phosphoric acid (Total Etch)
Fig. 6 A pplication of Adhese Universal
Clinical case:
A 25-year-old patient presented to our practice with a compromised resin composite restoration and secondary caries on tooth# 19 (Fig. 1). Since the defective area was very large, treatment with an IPS e.max CAD restoration was decided in order to achieve an efficient and esthetic result. After placement of the core build-up and preparation of the tooth, the tooth was scanned intraorally and a partial crown was designed (Fig. 2). Subsequently, the non-crystallized restoration in blue stage was tried in in the patient’s mouth to check the contact points and the fit of the restoration. In order to assess the esthetic appearance and the shade effect, the characterized and fired restoration was again tried in using Variolink Esthetic Try-In Paste Neutral (Fig. 3). During these trial placements, care was taken that the tooth was sufficiently moist to ensure a lifelike shade impression. An anatomi-
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case continued cally shaped rubber dam (OptraDam Plus) was used for absolute isolation during the final placement of the restoration (Fig. 4). First, the enamel was etched for 15 seconds (Fig. 5), followed by the entire cavity for another 15 seconds (Fig. 5). Then, Adhese Universal was scrubbed onto the prepared tooth surface for 20 seconds and dispersed with a stream of air (Fig. 6). Special care was taken that no material pools formed at the cavity floor. Subsequently, the restoration was light-cured with a polymerization light (Bluephase Style) for 10 seconds. To obtain an optimum bond, the IPS e.max CAD restoration was etched with hydrofluoric acid (IPS Ceramic Etch Gel) for 20 seconds and conditioned with Monobond Plus 60 seconds followed by air-drying. In a next step, Variolink Esthetic DC was applied on the restoration which was subsequently positioned on the tooth. After pre-polymerization of the excess material using the quarter technique (two seconds per quarter surface) (Fig. 7), the gel-like excess material could be easily removed using a scaler (Fig. 8). Glycerine gel (Liquid Strip) was applied to prevent the formation of oxygen inhibition layer. In a final step, each segment of the restoration was light-cured for 10 seconds (Fig. 9), the composite gap was finished and polished (Astropol) and
the occlusion was checked.
Fig. 7 Pre-polymerization of excess luting cement using the quarter technique, i.e. each quarter surface is light-cured for two seconds with the polymerization light held at a maximum distance of 10 mm.
Fig. 9 After the application of a glycerine gel (Liquid Strip), each segment of the restoration is light-cured.
Fig. 8 Removal of gel-like excess luting cement material using a scaler.
Fig. 10 One week post-op.
Shade Comparison Variolink Esthetic
Light+
Light
Neutral
Warm
Warm+
Variolink Veneer
HV+3
HV+2 HV+1
MV0
LV-1 LV-2
LV-3
White opaque
Bleach XL
Transparent White
Yellow
Brown
Variolink II
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ments is considerably reduced, as no conditioning is required, they demonstrate lower bond strength values. The high strength of IPS e.max lithium disilicate allows clinicians to choose conventional, adhesive, or self-adhesive composite cement for cementation. However, due to lower bond strength, it is recommended that self-adhesive and conventional cements be utilized in clinical situations with retentive prep design (less than 8 degree taper and minimum 4 mm height), adequate thickness (greater than 1 mm for anterior and 1.5 mm for posterior) and tight fit. Although adhesive cements (e.g., Variolink Esthetic) are also indicated for these conditions, adhesive cements compliment IPS e.max lithium disilicate’s high strength in a variety of additional indications, including all types of restorations, any preparation design, and any thickness of restorations. With no minimum requirements for adhesive cementation, adhesive cementation provides higher immediate bond strengths and a better marginal seal with IPS e.max restorations. Optimum esthetics for a broad range of indications Variolink Esthetic is a light and dual-curing luting composite for the permanent cementation of ceramic and composite restorations. The light-curing version (Variolink Esthetic LC) is suitable for high translucent restorations where a longer working time is desired. This allows the dental professional to position, secure and subsequently light-cure all-ceramic veneers without any time constraints. The dual-curing version (Variolink Esthetic DC) is suitable for ceramic and composite restorations for which a complete polymerization with light cannot be ensured due to the material’s opacity or strong wall thickness. In such cases, complete polymerization of the luting composite is achieved by the material’s combination of light and self-curing properties, resulting in a reliable adhesion of the restoration. Variolink Esthetic is available in five
different shades.. Variolink Esthetic Neutral, which features the highest level of translucency, does not affect the brightness value of the restoration and is colour neutral. “Warm” and “Warm+” increase the chroma of the restoration and therefore result in a gradual darkening of the overlying ceramic and composite restoration. The shades “Light” and “Light+” have a gradual brightening effect on the restoration. Utilizing the Variolink Esthetic Try-In pastes ensure that the ideal shade is selected to flow seamlessly with the adjacent dentition. Easy excess removal In the past, the time-consuming removal of excess luting cements before and after polymerization represented a disadvantage of the adhesive cementation technique. Variolink Esthetic has been further developed and sets a new standard for easy removal of excess material making esthetic cementation simple. Excess material can be easily removed while still in a gel-like consistency due to the material’s optional pre-polymerization feature. For the pre-polymerization, Variolink Esthetic DC is light-cured using the quarter technique, i.e. each quarter surface (mesiooral, disto-oral, mesio-buccal, disto-buccal) is polymerized with light for two seconds. In case of Variolink Esthetic LC, the entire cement gap is pre-polymerized fortwo seconds (circular technique). Controlled Viscosity The consistency of Variolink Esthetic has been optimally adapted to the requirements ofdental practitioners. It has a convenient level of flowability and can be effortlessly and precisely extruded from the syringe. Furthermore, excess material smoothly flows from the cement gap, but remains stable at the cementation joint so that it can be readily removed after successful pre-polymerization. Combination with Adhese Universal The adhesive material Adhese Universal ideally complements Variolink Esthetic.
The optional etching step with phosphoric acid is part of the “selective-etch” and the “etch & rinse” technique and results in an enhanced adhesion to enamel and optimized marginal seal. Adhese Universal is applied onto the tooth surface to be treated, starting with the enamel margins, and agitated for at least 20 seconds. Subsequently, the ad-
hesive is dispersed with oil- and waterfree air until a glossy, stable film results. Due to the adhesive’s adapted thixotropy, the film thickness is kept to a minimum so that the fit of the restoration is not affected. The material is polymerized with a light intensity of ≥ 500 mW/ cm2 for ten seconds before the placement of the indirect restoration.
Variolink Esthetic Indications Variolink Esthetic LC
Variolink Esthetic DC
X
XX
XX
XX
---
XX
XX
XX
XX
XX
Inlays/onlays/partial crowns
X
XX
Crowns
---
XX
3-unit bridges
---
XX
Oxide-ceramics (zirconia/alumina) e.g. Zenostar®, IPS e.max ZirCAD
---
---
Indirect composites, e.g. SR Nexco® Inlays/onlays
X
XX
Crowns
---
XX
Root posts
---
---
Glass-ceramic e.g. IPS Empress® Inlays/onlays/partial crowns Veneers Crowns Lithium disilicate e.g. IPS Occlusal veneers
e.max®
Thin veneers/veneers
XX Recommended product information --- not recommended X Use Variolink Esthetic LC only for restorations with a low material thickness of <2 mm and with sufficient transparency.
Frequently Asked Questions 1. Can veneers be cemented using either Variolink Esthetic materials? Both Variolink Esthetic DC and Variolink Esthetic LC can be used to cement veneers. Variolink DC is recommended since it defines the time of curing of the composite and not the composite itself. 2. Should a bonding agent be used prior to application? It is recommended to pretreat the bonding surface of the restoration with a primer (e.g., Monobond Plus) and utilize a universal adhesive (e.g., Adhese Universal) on tooth surface to ensure a reliable and strong bond between the adhesive and the cement. 3. What aspects need to be considered when determining the optimum shade for cementation when using Variolink Esthetic? The shade effect of Variolink composite pastes should be simulated in vivo with the corresponding Variolink Esthetic Try-In pastes and performed prior to isolation or drying of the tooth structure.
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PREDICTABILITY WITH IMPLANTS USING
PLANNED GUIDED IMPLANT SURGICAL TECHNIQUES.
T 12
he replacement or a single tooth, multiple teeth or removing all natural dentition and placing dental implants is a surgical and restorative challenge. Diagnosis and treatment planning can be combined with the use of a CBCT
(Cone Beam Computer Tomography) and 3-D software to achieve predictable results. SmartFusion is the merging of 2 databases, the CT Scan and the information scanned from the master cast. The Nobel Procera 2G optical scanner automatically merges these date sets.
Dr. Michael Dove is in Solo General Practice in Barrie, Ontario. He has a special interest in providing treatment for dental patients using sedation. He also has a special interest in comprehensive dentistry including the use of implants. Dr. Dove has been in practice for more than 25 years and is a graduate of the University of Toronto and General Practice Residency Program at Mount Sinai Hospital in Toronto.
His practice includes progressive technology and strong interest in continuing education.
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Ms. Teresa Maltese is a registered restorative dental hygienist who has a special interest in technology and comprehensive general dentistry. She is a graduate of George Brown College in Toronto where she won top academic and clinical awards.
What does SmartFusion allow me to do in my practice? NobelClinician supports efficient treatment planning by linking with the NobelProcera 2G System, allowing the capture of digitized prosthetic information for the current and desired situations, eliminating the need for a radiographic guide. - NobelClinician Viewer or Communicator facilitates collaboration with all treatment partners and the iPad ® app allows the clinician to present patient - specific treatment options in a way that is visual and easy to understand for increased patient acceptance. NobelConnect is Nobel Biocare’s secure online storage space where you can share information seamlessly between NobelClinician, the NobelProcera 2G System, NobelClinician Communicator and OsseoCare Pro. During the first visit, the (CB)CT scan and the dental impression are done by the qualified dental assistant, preferably by the clinician. The dicom files can immediately be uploaded into the NobelClinician Software along with the 3D model being created in the NobelClinician Software by the dental assistant. They can also upload additional supporting files like clinical pictures and X-rays into the software. After everything has been prepared, the clinician can immediately start diagnosing, check if implant
treatment is a possible solution and decide whether bone grafting or other surgical procedures are required. After the first appointment and the treatment acceptance received by the patient, the clinician starts detailed planning by sending the impression taken during the first visit to the lab for the tooth setup. The lab scans the dental cast and the diagnostic tooth setup with the NobelProcera 2G System, and the data is uploaded via NobelConnect to NobelClinician Software. Efficient and predictable treatment outcomes - Thanks to the accuracy and flexibility of the NobelProcera 2G System, which accurately and easily captures all the critical surface information of the plaster model and of the diagnostic tooth setup, the data can easily and quickly be obtained. It is easily shared between dental lab and clinician to support efficient treatment planning which leads to predictable treatment results. - No additional (CB)CT scan with radiographic guide is needed (minimizing the radiation dose and avoiding additional costs). Combination of hard and soft tissue information thanks to NobelClinician’s SmartFusion technology. This unique technique combines 3D X- ray data from the (CB)CT scanner and surface data from the NobelProcera 2G System.
Patient #1: 65 year old female with non-restorable teeth #35 and 36. This patient was not interested in having a having a bridge and definitely not interested in having a denture and had a short but reasonably wide alveolar ridge. Solution: We used a fully guide SmartFusion technique to place implants using a flapless surgical technique.
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Patient #2: 35 year old male with a fractured upper anterior central and a broad smile. Adjacent tooth is restored by an implant supported crown. Solution: A fully guided SmartFusion case to both properly position( both in angle and for platform depth consideration) the implant to obtain maximum aesthetics for both gingival margin and the papilla formation.
Patient #3: 45 year old female with locator retained mandibular denture. The patient was looking for a nonremovable solution for the maxilla.
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Solution: A fully guided technique to allow placement of the properly angled implants for an all-on-four solution with the screw retained temporary prosthetic.
Patient #4: 75 year old female who had an upper previously restored with a locator style implant supported denture. She had nine remaining lower teeth and was looking for a non-removable immediate denture solution. Solution: A fully guided TWO STENT SmartFusion technique. A two stent system where we removed nine madibular teeth in two stages and placed four implants and proceeded with placement of a screw retained prosthetic. The modification of the traditional SmartFusion
technique allowed us to remove some of the teeth in order to get the properly positioned posterior implants in place. We then, using a different stent, removed some of the remaining teeth to get the properly positioned anterior implants in place. We then completed the extractions. Finally we were able to (using a pick up impression technique) place a screw retained immediate load highly aesthetic and functional complete lower denture in a very efficient manner with no alteration of the lower prosthesis.
ALL LAB WORK PERFORMED BY:
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FULL MOUTH REHABILITATION USING THE NEW
IPS e.max MULTI INGOT by Trevor Laingchild, RDT, AAACD
W
hen considering an aesthetic restoration case, many considerations need to be undertaken, in order to satisfy the patients functioning and aesthetic demands. Within the constraints of the functioning intra-oral environment, choices need to be made when deciding the choice of fabricating materials. Those materials need to be of an ideal to maintain strength and longevity as the first priority. Intra-oral situations often dictate the selection of materials, especially in situations of varying occlusal demands, load dissipation and varying edentulous spacing. All fabricating materials have limitations and recommendations for use in the restorative process and it is imperative the laboratory, understands those limitations and fabricates the restorations within those recommendations. In conjunction with the engineering parameters required, a material or materials, which are selected, are required to be of the optimum in aesthetics. The desired balance between the physical and aesthetic demands of the restorations can often be demanding, especially when selecting the appropriate materials for use. The material choices available to the laboratory and the clinician, for a successfully engineered and an optimized, aesthetic outcome, have become more complex and varied. Occasionally various allergies and personal resistance to certain materials, complicates the decision making process, further. It is my opinion that the least variation of materials used within a patients treatment plan should be adhered to. With
restoration failures, it is often found that the restoration failure is found at the junction between two dissimilar materials. When combining two dissimilar materials in the fabricating process, every consideration has to be ideal for the continued success of the restoration. Dissimilar Considerations •F ramework design, shape, fit and ideal molecular homogeneity. • Positioning of the framework and the aesthetic materials within the intra-oral environment. • Framework fabrication. • Framework finishing, non-contamination with both material and gaseous contaminants. • Framework compatibility to layering /esthetic materials. • Framework behavior during heating /cooling phases of aesthetic layering. • Considerations of thermal incompatibility. It can be seen that there is an increased possibility of material failure due to the complex design and fabrication process, used technically – especially after prolonged intra-oral usage. The use of a single material in the restorative process is becoming more widespread. Many of these materials have adequate or good mechanical and physical properties. Their use as a single material for restoration purposes is economical and prevents issues arising as listed above. However, they often do not
Trevor Laingchild’s sense of adventure has taken him on an international road in his profession. After formal Dental Education in London, England, he managed a Dental Laboratory in Germany and served as Chief Dental Technician for an American Hospital in Saudi Arabia. Further experiences included, expanding his technical horizons whilst working in Norway, Scandinavia. He currently owns and operates
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dentalstudios in Burlington and in Yorkville, Toronto. Trevor is an Accredited member and an Examiner within the American Academy of Cosmetic Dentistry, in addition is a Certified LVI Master Aesthetic Technician. Trevor is very active lecturing and teaching whilst conducting numerous hands on courses in all aspects of restorative aesthetics, of which, he has had numerous articles published.
exhibit natural tooth aesthetics. Natural teeth do not include biological materials with only one aesthetic or optical property. Occasionally, the posterior intra-oral situation allows for a single material restoration. However, the situations allowing for the anterior restoration to be fabricated with a single material are extremely limited. The aesthetic demands dictate the majority of these restorations require additional aesthetics. Hence historically, laboratories have layered various layering ceramics of differing optical and aesthetical properties, in order to achieve the “NATURAL LOOK”. This is both applicable when using a supporting framework for ceramic support or when the framework is not required. The challenge for dental manufacturing companies has been to produce a single material, which has the required strength, but exhibiting within that single material, varying aesthetic and optical properties. The result that when utilized correctly, offer the benefits of single material properties within the intraoral environment, along with the enhanced optical properties that single materials do not exhibit. There have been various milling blocks available for many years that have offered these properties, but never as a pressing ingot. Digital fabrication processes are increasing in popularity but the use of ingot pressing is still extremely popular, especially when using Lithium Disilicate. Becoming more popular is the use of Cad-Cam technology to mill a burnout material, which can be used in the pressing technique. This is due to the quality control and efficiency aspect of the Cad-Cam design protocols, combined with the accuracy of the pressing technique. A recent arrival in the one-material/multiple optical properties has been the Multi-ingot from Ivoclar Vivident. It is the first pressing ingot with varying optical properties. “One Material, Multiple Aesthetics.” In addition to the milling blocks, which have been available for some time, the addition of the pressing ingots, allow the laboratory more selection and opportunities, within the fabricating process. These ingots have the advantage of being Monolithic, yet polychromatic. By positioning the variance of the optical properties of the Lithium Disilicate material within the restoration, optimization of the aesthetics can be achieved. This may or may not necessitate further aesthetic layering. Should it require further layering, the underlying framework will exhibit an improved aesthetic platform for harmony, for which to do so. In addition, the layering will be of a decreased volume, further enhancing the durability of the restoration. Due to the polychromatic nature of these ingots, the varying Chroma within these restorations will still exhibit aesthetic advantages to a monolithic restoration, even after both have endured lengthy intra-oral exposure and possible surface abrasion. The surface stain may be abraded in the monolithic restoration, but the polychromatic composition of the Multi–ingot will continue to exhibit variances in
its aesthetic properties, even after possible surface abrasion. The following clinical case describes and illustrates the new IPS e.max Multi-ingot in use, as the material of choice, for a full-mouth rehabilitation. Clinical Case Study The patient whom we shall call “Patient A” presented for clinical examinations with Dr. Rod Toms of Burlington, Ontario. After lengthy discussions within the consultative and diagnosis process, combined with the patient’s aesthetic and functional demands, a full-mouth rehabilitation was decided as the treatment plan. Fig. 1 This image shows the smile view, illustrating the aesthetic smile zone with the lips present. The patient requested during the consultation process a desire for an improved anterior arch architecture and slightly longer maxillary incisors, in order to harmonize with the lower lip. The aesthetics requested, included a higher value look, with a soft incisal opalescent translucency. Fig. 2 This image illustrates the retracted view, showcasing the shapes and contours of the individual teeth. The patient requested that the individual and highly personalized “DNA” of her teeth were to be maintained but with a more ideal and symmetrical look. Fig. 1.
Fig. 2.
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Fig. 4.
Fig. 3.
Fig. 5. Fig. 3. This image, illustrates the diagnostic wax-up. This was fabricated on duplicate models cross- mounted on the articulator, which already had been mounted with the patients pre-op maxillary model by utilizing the John Kois Facial Analyzer in conjunction with full face photographs. It is extremely important to have the maxillary pre-op model mounted on the articulator in the corresponding orientation to the horizontal, as presented biologically by the patient. The use of the Analyzer and proof checking with a correctly taken full-face shot of the patient, allowed us to do so. This patient also required a very slight opening of the vertical as to allow for posterior occlusal table correcting. This was clinically established with the use of establishing a centric relationship, which the patient was comfortable with. The posterior second molars were opened by only 0.5mm and the anteriors by approximately 1.5 mm. It was extremely important to include the patients natural “DNA” for the individual restorations, amongst the aesthetic demands, when designing the full-mouth rehabilitation.
Treatment Design Considerations • Improve centric occlusion. • Improve cuspid left and right function. • Fabricate slightly longer maxillary, central and lateral incisors. • Maintain the strong distal lobes. • Improve the length to width ratio. • Idealize maxillary arch form, with good symmetry and harmony. • Maintain soft mid-facial deflective surfaces on the maxillary incisors (not flat facials). • Although gingival architecture was not ideal, it was felt not necessary to change. • Idealize the mandibular arch into good centric occlusion and function. • Increase value and reflective components of the facial aspects of all anterior restoration. • Maintain phonetics within the Neutral Zone. From this diagnostic wax–up, the required matrixes for the provision restorations and the appropriate preparation guides were fabricated.
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Fig. 6. Fig. 4. Illustrates the provisional in place. A period of trial and approval was undertaken. Fig. 5. The treatment plan dictated the maxillary restorations were to be completed initially. They would be cemented into place and subsequently the mandibular restorations would be completed. Therefore the wax-up of the maxillary restorations were completed with the patients and clinical directions for shape, contour and aesthetics, into occlusion with the lower diagnostic wax-up. Considerations were given to the aesthetics and function of the provisionals, in conjunction with the established design principals for this clinical case. Fig. 6. The spru-ing technique is different for the Multi-ingot pressing technique. This image illustrates this technique. It is important to realize that the ingot although monolithic, is polychromatic and that the molten material needs to enter the space left by the burned out wax in a certain direction, as to correctly result in the placement of the polychromatic material within the restoration. The positioning within the spru- technique can be varied according to the required ratio and level of chroma, required in the restorations. The waxed restorations can be moved vertically within the spru-ing technique as to vary the resulting chroma in the pressed restoration. This image illustrates the positioning protocol necessary as too accomplish this.
Fig. 7.
Fig. 8.
Fig.7. As above but with a different view. The two maxillary incisors are positioned within the sprue-base, prior to investing. The recommended investing, burnout, and pressing protocols are then completed as required by Ivoclar Vivodent, using the IPS e.max Multi ingot. Fig. 8. This image illustrates the divested central incisor showing the attachment of the sprue prior to removing, shaping and fitting. It should be noted that the positioning of the sprue to the restoration is important. Ideally the thicker of the mesial or the distal surfaces should be the location. However, when fabricating large cases, such as multiple units, it is beneficial to have the sprue on the distal surface. The mesial contacts between the two maxillary incisors are very important and therefore a location not to have sprues attached. As in this case, initial development of a perpendicular midline to the horizontal, should not interfered with. All subsequent restorations should be sprued from the distal as to obtain a consistant fitting efficiency. Distal lobes often are more bulbous than mesial line angles and are slightly fuller, therefore distal placement of sprues I feel is more ideal. This image illustrates the sprueing on the mesial surface. Subsequent working with this technique, allows me to conclude that distal sprueing in large multiple restoration cases such this, allows for increased efficiency when fitting and Fig. 10.shaping restorations on the model. With single unit restoration cases, this is not the case.
Fig. 9.
finished restorations, whether they are aesthetically layered or not. “Monolithic and Polychromatic”. Depending on the clinical situation and the patient’s demands, that decision can be made accordingly. Fig .10. The divested restorations are fitted to the individual dies and checked for fit, shape and occlusion. Fig. 11. Once the restorations have been seated, the shaping and development of the mesial and distal line angles is undertaken. By inverting the model and utilizing a black background, shapes of restorations can be easily identified and modified if necessary. The visualization of the incisal embrasures, within the labial arch form is improved when model and restorations are inverted, giving assistance when developing the progression from mesial to distal. This image shows the polychromatic effects within the restoration, highlighted by the lowering of chroma within the incisal area. Fig. 12. This image illustrates the line angles being developed, it is important to view from a facial aspect, while shaping the facial surfaces. Fig. 11.
Fig.9. It can be seen from this image that the pressed restoration has a polychromatic look. There is less chroma and more translucency in the incisal region. This will greatly help with the aesthetic outcome of the Fig. 10. Fig. 12.
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Fig. 13.
Fig. 15.
Fig. 14.
Fig. 16.
Fig. 13. & 14. For maximum opalescent incisal effect, an incisal cutback is undertaken with the use of rotary instruments. A matrix is always used to verify the incisal edge position and for the efficient layering of ceramics. The polychromatic effect, along with the increased translucency in the incisal area, assist as an aesthetic platform for the addition of aesthetic ceramics. Fig. 15. A wash firing utilizing a paste and/or and any appropriate thin layer of ceramics to develop the bond surface with any subsequent ceramic layering is the initial ceramic firing. Fig. 16. Any opalescence or incisal translucency should be layered onto the wash baked restorations. i.e. e.max OEI, e.max OE2, e.max NEUTRAL. All translucency materials should be layered under an enamel bake of higher value enamel, as not to lower the value of the restoration.
shapes. All enamels layered over the window should be of a higher value, and slightly more opaque. The underlying window should be slightly camouflaged, as to not show the outline of the cutback. Fig. 18. This image illustrates continuation of the enamel layering, using e.max INCISAL BLEACH. The addition of additional opaque white enamels can be mixed with the enamel, when a high value restoration is being fabricated. i.e. e.max OE2, e.max OE3, and e.max OE4 Fig. 19. Shaping and re-establishing shapes and contours after enamel bake. By the use of facial markings, the separation and contouring of the reflective and deflective Fig. 18.
Fig. 17. After completion of the window/opalescent translucency bake, additional characterizations can be included at this stage with any subsequent enamels layered over into ideal contour Care should be taken to maintain the shapes of the restorations at this stage of ceramic layering, for time efficiency. Efficiency comes with layering small increments, whilst maintaining facial contours, to the desired Fig. 17.
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Fig. 20.
Fig. 22.
Fig. 21.
Fig. 23.
surfaces is more visible, predictable and efficient. Surface texturing should be visible at this stage and appropriate for the patient. Remember rotary polishing will diminish some aspects of the surface texture.
Torsion of the restoration can be viewed and developed when viewed from this angle. Torsion of the restoration gives the restoration a slight rotation within itself and produces a natural curve, slightly changing the long axis. The restoration will exhibit a slight change of direction of the long axis, giving a more natural appearance. This is especially important when fabricating high value restorations. This technique varies slightly the reflective properties of the restoration and removes the “White Flat Look”
Fig. 20. At this stage is extremely important to invert the model with the restorations and hold as shown in this image. By rotating the model away and back, it is possible to view the facial contours and the flow of the mesial and distal line angles. Any discrepancies of symmetry are easily visualized by using this technique. This patient required facial deflective surfaces, as to accentuate the roundness of the distal lobes and line angles, both on the centrals and the laterals of the maxillary arch. Fig. 24.
Fig. 21. Along with the shapes, facial anatomy, surface texture, the reflective and deflective surfaces are established with the mesial and distal line angles. After cleaning the restorations are ready for glazing. Rotary polishing is completed in order to achieve the appropriate surface luster, shine and reflection after glazing. Fig. 22. Maxillary incisors finished. Fig. 23. Maxillary restorations on model. Fig. 24. Maxillary restorations on model. Fig. 25. Maxillary restorations on model (Inverted) Fig. 26. Post-Op Image (maxillary and mandibular restorations inserted)
Fig. 25.
Fig. 26.
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Fig. 4.
Fig. 3.
Fig. 27. Post-Op Image Fig. 28. Post-Op Image (Inverted) Fig. 29. Post-Op Image
Conclusion A successful clinical outcome is dependent on many factors. The communication between the patient, clinician and the laboratory, being of the utmost importance. The application of a wellstructured treatment plan requires an understanding of the working and functional capabilities of the required dental materials used in the restorations. Functional and aesthetical properties working in conjunction with each other, ensuring longevity and satisfaction for the patient. The patient was extremely happy with the completed result, especially the atten-
Fig. 27.
tion to detail relating to the primary shapes and contour of her smile. Without the communicative process it may have been possible to miss the required “personalized “ DNA that the patient desired. The use of the new IPS e.max Multi ingot with both Monolithic composition and polychromatic aesthetics was invaluable for the aesthetic outcome. It allowed for limited aesthetic layering of ceramics, with an option not to layer ceramics on adjacent restorations, yet still have similar harmonized restorations. It is beneficial for occlusal loading on restorations to be monolithic, allowing for only one material to be taking the increased loads and forces. This patient’s treatment concluded with the finishing of the mandibular arch restorations using the IPS e.max Multi-ingot. The ability to layer ceramics whereever required and to be able to leave the restoration monolithic and un-layered is a distinct advantage within a treatment plan. Using Lithium Disilicate IPS e.max Multi-ingot pressing material allows this, with the result that, the aesthetics of the adjacent restorations will be in harmony with each other whether they are aesthetically layered or not. I would personally like to thank “Patient A” for the use of her clinical photographs, without compromising her anominity. Also, Mr. Americo Henrique’s for his dedication and professionalism during the laboratory procedures. Once again, Dr. Rod Toms showed his fabulous skills as a clinician and for that, I thank him. Clinician: Dr. Rod Toms Burlington, Ontario. Technicians: Mr. Trevor Laingchild, RDT A AACD Mr. Americo Henriques Ms. Joanna Klisowska, RDT Fig. 29.
Fig. 28.
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XRay- Panorex of the Mouth at Treatment Phase
EVALUATIONS AND PRE-SURGERY TREATMENT PLAN AND SELECTED RESTORATION OVER IMPLANTS by Dr. Ariel B. Cohen DDS (Cloverdale Dental Group) and Carmella Angus BScN.,MSc,MBA (Nova DenTech Inc)
T
he success of any restoration is primarily due to the pre-treatment evaluations and consequent treatment plan. At Nova DenTech Toronto Inc. we work as a team with our dental centres to make sure prior to us fabricating any restoration the case has been discussed with the dentist and there are no obvious clinical reasons that may predict implant failure. Our general dentists and/or prosthodontists work as a team with Nova DenTechâ&#x20AC;&#x2122;s implant technicians during case planning to ensure the best possible outcome for their patients. A woman in her sixties presented with high blood pressure, high cholesterol and diabetes which were well-controlled with medication. An oral and radiographic examination together with a periodontal consultation revealed the patient did not have any need for pre-implant orthodontic treatment. The patient did present with overall symptoms of moderate chronic periodontitis (PD) with severe localized infection on tooth 37. In addition, 35 had a fracture to the gum line while tooth 36 was missing and 37 had a post perforation on the mesial. Both the Periodontist and treating dentist concluded teeth 35 and 37 could not be salvaged and would need to be extracted (XRay-1).
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The Treatment Plan Phase 1: The first phase was to restore oral health and so a dental hygiene plan (Q 3 months) with periodic antibiotic treatment (as required) was started. The plan was not to perform any restorative treatments until the inflammation of the gums and localized infection was reversed. The initial recommendation to the patient was either a tooth supported bridge or implant supported bridge. The Treatment Plan Phase 2: Concurrently with Phase 1 treatments; Dr. Ariel Cohen in conjunction with a periodontist (Dr. Fayaaz Jaffer) started a full evaluation of the bone structure and its suitability for implant placement using Computerized Tomography Scan (CT). The CT scan revealed the need for bone grafting on teeth 35 and 37 and possible ridge augmentation on tooth 36. A tooth supported bridge was ruled out and plans were made together with the patient to place 2-3 implants depending on the success of the bone grafts. Treatment Plan Phase 3: Dental hygiene treatments were continued until the extractions and bone grafting could be done simultaneously. Thus 18 months after the initial screen
XRay-3 Multibase Abutments (RC SR-0º-4.5 and NC SR-0º-3.5)
XRay-2 Post op XRay of Strauman Implants with Healing Caps in Place
the patients oral health was such that teeth 35 and 37 could be extracted and the site could be packed with Straumann Bone Allograft (#1118928-0503). Furthermore, tooth 36 was augmented on its ridge.
Treatment Plan Phase 4: Six months after extraction and bone grafting it was determined there were no further signs of inflammation and there was full bone integration of the bone grafts. The patient was finally ready for implant placement in a site free of PD which is known to increase the risk of implant failures. A successful treatment plan was achieved and patient was now ready for the implants selected. Implant placement seen in XRay-2 to Xray-4) Treatment Plan Phase 5: The CT scan and impression models were used for Nova DenTech Inc. to prepare surgical guide stents for implant placement. Straumann implants were torqued to 35 N/cm. Healing abutments were placed (XRay-2). No bone grafting was required around the implants. Once the
1
2
XRay-4 Screw Retained Splinted PFM Bridge
PA showed complete osteo integration around the implant the materials for this implant supported bridge was discussed with one of Nova DenTech’s Implant Technician (Patrick A. Harrison). Figures 1 to 5 show the complete post wax-up preparation and restoration by Nova DenTech Toronto Inc. BROUGHT TO YOU BY
3 Figures 1 to 5 - Bridge Over Implant Fabrication by Patrick A. Harrison (Nova DenTech’s Implant Technician) Figure 1 On 35/36 Strauman 3.5 mm Bone Level NC and on 37 Strauman 4.5 mm Bone Level RC Figure 2 Placement of 2 NCSR 0º Gingival height 1 mm and 1 RCSR 0º Gingival height 1 mm Figure 3 RC and NC SR Multibase Abutments with placed screws and tissue in position Figure 4 Splinted and Retrievable Gold Plastic Castable Figure 5 Buccal View of Finished PFM Bridge
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Control of Tissue Contours in
Implant Impressions Fig 1.
I
mplants are arguably the most significant development in the history of dentistry. The ability to replace a missing tooth by placing an artificial root and tooth was just an impossible dream not that long ago. Implants will remain state of the art in tooth replacement until someone figures out how to grow a natural tooth in place, within the patient’s jaw.
Fig 2.
Fig 3.
Dr. Bill Turner earned his dental degree from the University of Manitoba in 1981 and a certificate of Proficiency in Esthetic Dentistry from the State University of New York at Buffalo in 2001. Dr. Turner is a member of the American Society for Dental Aesthetics and holds Fellowships in the Academy of General Dentistry, the Academy of Dentistry International, and the In-
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ternational Academy of Dental-Facial Esthetics. He has lectured and published numerous articles on a variety of esthetic techniques and authored the chapter on direct fiber reinforced bridges in Freedman’s textbook “Contemporary Esthetic Dentistry”. Dr. Turner maintains a fulltime general and esthetic dental practice in Thunder Bay, Ontario, Canada.
Fig 7.
Fig 4.
Fig 5.
Fig 6.
Titanium mplants are arguably the most significant development in the history of dentistry. The ability to replace a missing tooth by placing an artificial root and tooth was just an impossible dream not that long ago. Implants will remain state of the art in tooth replacement until someone figures out how to grow a natural tooth in place, within the patient’s jaw. The problem with implants is they do not reproduce the anatomy of the natural root. Implants are, of necessity, cylindrical. Tooth roots are not. We as dentists have to figure out how to simulate the natural emergence profile, and by so doing, simulate the appearance of a natural tooth. D.B. found her way to our office because she was unhappy with the appearance of the porcelain fused to metal crowns on her maxillary anterior teeth. Treatment at the time was to replace the porcelain fused to metal crowns with all ceramic. A diagnostic wax up was performed, the existing crowns removed, and the teeth re-prepared for all-ceramic crowns. Provisional restorations were placed using the diagnostic wax up as a pattern. Once everyone was happy with the esthetics of the provisionals, photographs were taken and models made to guide the technician. Six Empress crowns were fabricated and inserted. The patient was very pleased with the result. That was eight years ago.
Recently the patient presented with a chief complaint of a “loose crown” on the left maxillary lateral incisor. Radiographic examination revealed a vertical root fracture (Figs. 1 & 2). The patient was advised that the prognosis for the tooth was hopeless, and that the treatment of choice would be replacement of the tooth with an implant supported crown. In order to preserve as much bone as possible it was recommended an elective extraction be performed as soon as possible. She agreed and was referred to her periodontist for consultation regarding extraction and implant placement. The periodontist agreed with the proposed treatment, and advised that he would attempt immediate implant placement, but this might not be possible. A surgical guide and transitional partial denture were fabricated and delivered to the periodontist. Upon extraction of the tooth it was determined that immediate placement was not advisable, so he performed Fig 8.
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Fig 9.
Fig 10.
a ridge augmentation procedure, and sutured the site closed. After three months healing, he reevaluated the site and determined that there had been more resorption than expected, and placement of the implant in the original location was no longer possible. In discussion with the patient, it was determined that she was not willing to proceed with a block graft. With that in mind, a compromise implant position was selected and a new surgical guide fabricated. Upon opening the surgical site, the periodontist determined that there was only enough bone to place a small diameter implant, and the position would be less than ideal. As the patient was rapidly running out of options, a Nobel Active 3.0x15 mm. implant was placed. Following three months of healing, the periodontist performed integration testing and reported that the implant was successfully integrated, and referred the patient back to my office for final restoration (Fig. 3). Fig 13.
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Fig 11.
Fig 12.
As the implant position was less than ideal, and gingival contours would be visible, it was decided to place a provisional restoration to guide the tissue into the most esthetic contour possible. To that end, a provisional abutment was placed and built up to simulate a tooth prepared for an all-ceramic crown. Margins were placed in an ideal location, the provisional abutment was removed, and the subgingival contours modified in direct composite to establish a desirable emergence profile and to create support for the soft tissue (Figs. 4-8). Over the next month the tissue contours were re-evaluated and the provisional abutment modified as required. The final result was not perfect, but under the circumstances was better than expected. The tissue was well supported with no â&#x20AC;&#x2DC;black holesâ&#x20AC;&#x2122; and the gingival contour of the tooth was only slightly greater than the natural tooth (Figs. 9&10).
Fig 15.
Fig 13. Fig 16.
Fig 17.
The next challenge was to provide the laboratory with an impression, which accurately reproduced the tissue contours created with the provisional (Fig. 11). This was done using a custom impression coping technique. Simply making an impression of the soft tissue would not be ideal as the tissue begins to collapse within minutes of removing the provisional restoration. At the appointment for the fixture level impression, the provisional crown and abutment were removed. An implant analog was attached to the abutment, and the analog/abutment assembly was inserted into polyvinyl bite registration material to record the contour of the provisional abutment (Figs. 12&13). Bite registration material was used rather than impression material for its rapid set. Once the polyvinyl material was set, the provisional abutment was removed, leaving the implant analog imbedded in the impression material. An impression coping was then attached to the analog (Figs. 14&15). Fast set acrylic was
flowed into the space left in the polyvinyl material to duplicate the contours of the provisional abutment on the impression coping (Fig.16). Once the acrylic was set, the now custom impression coping was trimmed of flash, transferred to the mouth, and an open tray implant impression was completed in the usual manner (Figs. 17-20). The completed impression with the custom impression coping was then delivered to the laboratory for fabrication of the final implant abutment and crown. It is not possible to use a zirconium abutment with 3.0 mm. Nobel Active implant. As the plan was to use the same material and shade map as was used for the adjacent crown, the titanium abutment was opaqued to facilitate proper colour match. The completed abutment and crown were inserted for tryin. Photographs were taken of the result, and the crown and implant returned to the laboratory for final shade revision. Post-op
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oralhealth guidelines manuscript submission
Oral Health wants to hear from you! We are actively seeking original article submissions from all of our valued readers. Here’s what we need from you: MANUSCRIPTS Manuscripts should run between 1,000 to 5,000 words; any manuscripts submitted on disc or flashdrive should be PC compatible (i.e., Micro soft Word). Should you have concerns with the compatibility between your word software and that of Oral Health’s, simply save your file as raw text (i.e., Text Only files, ASCII text files, etc.)
ILLUSTRATIONS The quality of the line drawings and photographs supplied contribute directly to the quality of reproduction in Oral Health. Therefore, when making a submission, please consider the following: > All photographs/illustrations should be carefully indexed and marked as to proper viewing (i.e., slides should be marked which side is the appropriate viewing angle, etc.). X-rays should be mounted individually and marked on the front of the frame with the corresponding figure number. > Any artwork submitted on disc should be MAC compatible, and should be saved at the highest resolution possible (266 pixels per inch or greater). We cannot accept any digitized photographs/illustrations that have been created in a word processing, spread sheet or presentation package such as Microsoft Office, Powerpoint or Corel Office Suite. > Do not embed photos within the article.
AUTHORS Biographical information regarding the author(s) should be included with the manuscript. The author’s name and degrees, as well as any association the author may have with any institution should be included. The author’s address, including city and province/state should also be included. These requests for standardized submission of material are necessary for correctness of publication. The Editorial Board looks forward to your submission. Please mail original manuscripts to: ORAL HEALTH, 80 Valleybrook Drive, Toronto, ON M3B 2S9
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> T he editorial board reserves the right to not return photos that do not meet quality standards. > Each illustration provided by the author should be identified and described by a short caption; and this list of figures should follow at the end of the article.
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Contact: Karen Shaw • tel: 416-510-6770 • fax: 416-510-5140 • e-mail: kshaw@oralhealthgroup.com Toll free: CDA 1-800-268-7742 ext 6770 • Toll free: USA 1-800-387-0273 ext. 6770
Lab For Sale
This well established dental laboratory relocated to its current locaton four years ago. This 1250 square foot lab has a strong steady customer base. A valuation report prepared by a highly reputable dental appraisal firm is available. For more information please call Graham Flanagan at 416-801-9470 or 613-563-6363 or e-mail: graham.flanagan@tierthree.ca
Practices & Offices
WATERLOO, ON
Fully equipped modern dental office to lease or buy in a beautiful commercial plaza. Ample parking, digital xrays, Adec chairs. Perfect for dental GP or specialist. For more information please call 519-570-1001 or email highland.dental@rogers.com
TORONTO, ON
Small Toronto practice with great potential for sale. Ability to speak Spanish a plus. E-mail: Practicesale@minnaar.ca
RICHMOND HILL, ON
Brand New (2014) fully equipped dental office available for rent. 3 brand new operatories with Sirona equipment. Office in a free standing building with plenty of free private parking in front, located on very busy King Rd and walking distance to Yonge St. Great opportunity. Please email: wzigan@brightlifedental.com
TORONTO, ON
Fully equipped dental office, Toronto east end for sale. In an established storefront location (over 40 years). On the Danforth, just steps to a subway stop. Current dentist set to retire. Email to inquire: dental-practice@outlook.com
MODERN TURN KEY KAWARTHA 3 OP PRACTICE FOR SALE Unique Opportunity for associate to own or principal second office. Fully digital, remote log in, remote surveillance, everything less than 1 year old. Only dental office in community’s largest medical/professional building. Exclusivity in the building. Former dental office goodwill transferred to this practice last year. (was grossing 700k) 30-40 New patients each month – lots of walk in traffic. Revenue estimate 400k for next 12 months with 3 days of hygiene (24 hrs of hygiene) (10 hrs) currently on Fridays for dentistry. Could be up to 3 days per week of dentistry. Currently Everything is referred out even simple extractions. Appraised at 512k by ROI corporation – over 550 active patients growing to 800 by end of year. Open house scheduled – by appt with confidentiality agreement. Letter of intent will be available on site, offers must be registered within 24 hrs. Closing ASAP. Associate ran practice. Low overhead.
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DENTAL LAB FOR SALE OTTAWA, ON
Practices & Offices EDMONTON, AB PRACTICE FOR SALE
5 op practice with low overhead and good potential for growth in Edmonton for sale. For details email: designdental13@gmail.com
BARRIE, ON
Available new retail space on busy Mapleview Dr. West. Ideal for Professional Dental Office. Attractive lease rates. Surrounded by residential. National brands in plaza. Contact Michael Pearlman at (416) 567-5101 or pearlmanmichael@gmail.com
VANCOUVER, BC
Busy Practice in Vancouver. Excellent gross. Low overhead. Well established patient base with strong new patient flow. 3 fully equipped ops and 1 more plumbed & ready to go. Digital radiography, Panorex, Biolase laser, Digital scanner, state of the art sterilization center and laboratory. Potential for growth is outstanding. Contact: VancouverDentalForSale@gmail.com STATE OF THE ART CLINIC FOR SALE — NORTH EASTERN ALBERTA
Large General Practice, 3000+ sqft, 8 ops. Fully updated Adec equipment, 3D conebeam, digital x-rays. Strong Hygiene Program. High grossing. Loyal patient base with many new patients every month. Great location with lots of new development in the area. Significant growth potential, clinic can accommodate 2-3 dentists simultaneously. DentalClinicSale@gmail.com
MONTREAL, PQ Orthodontist Wanted ASAP
Orthodontist needed for partnership buyin. Highly successful senior practice with an excellent income. Experienced staff will stay. Equipment includes 7 dental chairs, CBCT, state of the art sterilization center, office is fully computerized and paperless. Appraisal done and available upon request. Reason for sale: Owner would desire a smooth transition to retirement. Contact office manager: tonyamugford2015@gmail.com SPRING 2015
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Practices & Offices
LABRADOR CITY, NL OFFICE FOR SALE
Looking for someone dedicated to his career who wants to have not only above-average income but the desire to become the best dentist they can be. Must have a great personality and be highly driven. Busy practice with 3 fully-equipped operatories, digital radiography, state-of-the-art sterilization centre and laboratory, potential of growth is outstanding. Practice is owned by a Pediatric dentist & Orthodontist who desires to keep providing Pedo and Ortho care to the population on a part-time basis. Reason for sale: The office was built to provide only Pedo and Ortho care (part-time) but the need for a General dentist is screaming in the area. Contact our office manager: Tonyamugford2015@gmail.com
WATERLOO, ON
Orthodontic specialty office for sale. 9 years established in Waterloo. Great for new grad or existing orthodontist to add as satellite office. Or convert to dental clinic with orthodontist as associate. Call for further details: 778-985-6507
GTA NORTH
Dental practice for sale. Established practice grossing $500K and 800 patients. Owner selling due to other commitments. Email gtadentist2015@yahoo.com
Equipment
Associateships OTTAWA, ON ORTHODONTIST NEEDED
An exciting opportunity for an Orthodontist in Ottawa. You will work with an experienced team of dentists and specialists in a dynamic environment with the state-of-art digital and dental equipment including Sirona Pan Ceph. A healthy flow of new patients seeking Ortho treatment are waiting for you! New Grads and/ or Orthodontists who enjoy performing Ortho treatment without the stress of running an office or being stressed about getting new patients are welcome to apply. Please send your resume to: associates2020@gmail.com
ORILLIA, ON
Part time associate required 1-2 days per week for busy general family practice. Please forward resume to dental_2010@live.ca
ASSOCIATES FOR HAMILTON & WATERLOO, ON
Associates required, for TWO VERY busy and modern practices with VERY strong new patient flow. E-mail: associatedentist@ymail.com Fax CV: 888-880-4024
THOMPSON, MB
Westwood dental clinic in Thompson, MB team looking for experienced dentist full time or part time. Decent income plus accommodation . E-mail: westwooddental@hotmail.com
SUDBURY, ON
Busy new Sudbury dental office looking for a new associate to fill the shoes of a retiring associate with a full patient load. The individual must have excellent communication skills, be compassionate and a team player. Please e-mail resume to: krista123@eastlink.ca
FOR SALE
Sirona CEREC MC XL 2 years old, like brand new. Only 40 restorations milled. 4.0 software, Bluecam. Selling complete set up: Ivoclar furnace, staining and glazing kit 120 emax blocks and 150 Empress blocks in a variety of shades. $85,000. Contact nknight@sasktel.net for further information
Associateships KINGSTON, ON Looking for an associate to work 3 days a week in a very busy, well established, modern practice with good patient flow. Please submit your resume to dgouettreferrals@gmail.com
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NORTH SCARBOROUGH, ON Busy Dental Office in north Scarborough is looking for a FT/PT Dental Associate. Saturdays and weekdays available. Canadian graduate is preferred, Chinese speaking a must. E-mail: dentistassociates@gmail.com TOTTENHAM, ON
Very large family practice 1 hour north of GTA, seeking orthodontist 3-4 days per month. Currently referring all ortho out 100 to 150 cases per year. Please send all inquiries or resumes to office@queenstreetdental.ca
SCARBOROUGH & BRAMPTON, ON ASSOCIATE OPPORTUNITY
Experienced associates and pedodontist required to work in supportive and progressive practice in Scarborough and Brampton on weekdays and weekends. Candidates should enjoy every aspect of dentistry. Fax resume to 416-443-9090 or e-mail: rose-2010@live.ca
SASKATOON, SK Associate required for modern, very busy practice with strong new patient flow. Great opportunity in a University setting. E-mail: associatedentist@ymail.com Fax CV: 888-880-4024.
ORANGEVILLE, ON Established Orangeville office seeking a full-time associate. Canadian experience an asset. Email resume: Progressivedental16@hotmail.com
OSHAWA, ON Progressive growing practice in Oshawa is looking for an associate dentist for Fridays and alternating Saturdays. Please forward resume to dentaloshawa@yahoo.ca.
BRAMPTON, ON
Associate needed part time for busy, established, family oriented Brampton Office. Graduates of North American Dental programs preferred with a 1 year GPR experience. Please send cover letter and CV to solidassociate@gmail.com
VICTORIA, BC PART-TIME associate required for ever growing practice in the beautiful Westshore of Victoria. Position could become full time as required. Please email dawn@westshoredental.com
WATERLOO, ON
Full time associate needed for modern established practice in Waterloo. New graduates welcome. For more information please call 519-570-1001 or email highland.dental@rogers.com
TRENTON, ON
We are looking for a motivated pediatric dentist and a general dentist who enjoys all aspects of dentistry. Come work in a busy, state of the art facility with new technologies. We have an excellent and very friendly team and looking for the right fit to join our practice. Please email us at ryounes@sympatico.ca
LONDON, ON (and surrounding area) Dove Dental Centres is looking for full time associates for their progressive, modern, multi-location group of dental practices in London, Ontario and surrounding area. Interested candidates should forward resume and cover letter to: dovedental@ody.ca
MARKHAM, ON Associate position part-time is available in busy mall location. Will be busy from day one. Position best suited to Cantonese or Vietnamese speaking. Can begin immediately. Friendly and personable is preferable. Please email to Oral Health Labs Box 26 e-mail: kshaw@oralhealthgroup.com
HIGH PRAIRIE, AB Full-time associate dentist needed for our wellestablished family practice in High Prairie, AB. Position available immediately. Very busy practice with above average remuneration. Accommodations provided. Please email: drroy04@telus.net if interested.
COBOURG, ON ASSOCIATES WANTED
GRANDE PRAIRIE, AB
Busy family practice requires full and part time associates. E-mail: andyc@coradixgta.com
ARE YOU READY?
Focus on the dentistry without the admin burden. Looking for a dynamic, experienced practitioner for a well established, busy practice in Regina. ReginaDentalOffice@gmail.com
CORNWALL AND/OR HAWKESBURY(ALFRED), ON AND/OR VALLEYFIELD, PQ
Very busy family dental practices looking for a part time/full time associate. E-mail: lucleboeuf291@hotmail.com
ASSOCIATE TORONTO
P/T associate for modern, growing practice in south Etobicoke with special interest in Cosmetic Dentistry and Periodontics needed. Must be able to do molar endo. Minimum 2 years of practical experience a must. Fax resume to 416-255-6414.
STOUFFVILLE, ON
Full time associate dentist required for busy family practice. Looking for highly motivated associate. Our practice includes the latest in technology (IOC camera, digital x-rays, paperless etc.). Large existing patient base. Current associate moving, team in place to help. Please send resume to pmdcgp@telus.net 780-538-2992.
WEST MISSISSAUGA, ON
Part time Dental Associate required for a Maternity leave position mid May thru Mid October (Tuesday-Thursday-Friday). www.parkdrivedental.com Submit Resume to: drbobboadway@yahoo.com
EDMONTON, AB
OSHAWA, ON
Looking for a part-time associate in an Oshawa Office Mondays 9:30–5 (with the later option to extend to longer hours) Thursdays 9–5. We prefer an associate with minimum 2 years experience. We are a large office with the potential of more working hours in the future. E-dental: ocdental@rogers.com
Part-time Pediatric Dentist required to work in state-of-the art General Anaesthesia dental office located in West Mississauga. Please send resume to sunnydaydental@gmail.com
ST. JOHN’S, NL PEDIATRIC DENTIST WANTED ASAP
Great opportunity for a motivated associate with some experience. $80,000-$100,000 per month, in a beautiful office with new equipment and a great team. Current associate is moving to another province. Potential of earning up to 45% and longterm buy-in for the right candidate. Experience is an asset but not required. Please email: EdmontonDentalCareer@gmail.com
Very busy office providing services in Pediatric dentistry and Orthodontics. We are now looking for another pediatric dentist to join our team. Digital x-rays (pan-ceph-3-D), paperless office, nitrous oxide, large operatory rooms available. The office has an easy going atmosphere, a well trained staff and modern equipment. Very generous remuneration structure based on individual and/or clinic performance. Schedule is flexible. Part-time or full-time would be considered. Contact our office manager: Tonyamugford2015@gmail.com
VANCOUVER ISLAND, BC
WOODSTOCK, ON
Enjoy the most ideal lifestyle in Vancouver Island and step into a full time – 4 day per week practice as our associate dentist. We are offering 40% of collections and a full time patient base. The practice is a state of the art facility and is located in Courtenay, BC. The business systems and the hygiene clinical program is established and the practice is a paperless practice. We are looking for the perfect fit. Position is available in July or August of 2015. We require 2 years clinical experience. We offer mentorship and CE. Please email: kim@watermarkdentalgroup.com or call Kim Graham at 604-787-0176.
Just 30 minutes from London or Kitchener, a great opportunity for an associate at a prosperous family practice offering all modes of dentistry. Approaching our 8th year in this modern and beautiful facility, we are having difficulty keeping up with the demand for quality dentistry and our tremendous growth rate. Potential for future buy in. Please send your resumes to woodstockdental@yahoo.com or contact David at 416-219-2513. A seasoned practitioner who is comfortable treating children as well as adults, is preferred — endodontic and orthodontic experience would be an asset, however, all candidates will be considered. Part time leading to full time in very near future. SPRING 2015
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RED DEER, AB
Situated in between Edmonton and Calgary, Red Deer is a bustling city with great opportunities. We are in need of an associate for our established, friendly, prosperous and growing family practice offering all modes of high quality/contemporary dentistry. Our successful candidate will have at least 3 years experience and should be comfortable with most disciplines of dentistry including pediatrics. Experience with conscious sedation preferred. Great opportunity to buy in and become part of this lucrative practice!!! E-mail resumes to: bianca@practicesmadeperfect.ca
CRANBROOK, BC Full-time Associate needed immediately. Live and work in a year round recreational paradise, Cranbrook, BC. Rather than plan vacations you can plan your evenings and weekends. Our recent associate laments leaving the area and a full patient base. Our digital office is strong on team dynamics, continuing education and patient care. Enjoy available hospital privileges, a cooperative dental community, city amenities and a small town lifestyle. Future buy-in possible. New Grads welcome! Please respond to Dr.Harris@shaw.ca
MISSISSAUGA, ON
Part-time dental associate required for multidisciplinary dental office in Mississauga. Position may lead to full-time for the right candidate. Please send resume to sunnydaydental@gmail.com
TORONTO, ON A newly built dental clinic located on Wilson ave in Downsview with a modern dental laboratory on side is looking for part-time dentists to work as associates. It’s a unique opportunity for new graduate to become a Principal Dentist. The clinic will be open 7 days a week. We can start booking new patients from the last week of March, 2015. Tel: 416-258-5697 or e-mail: dental_la@yahoo.ca
SARNIA, ON Seeking 2 Full Time Associates
An excellent opportunity to work in a modern, digital family practice in Sarnia, with a large patient base and an amazing new patient flow. We are looking for 2 full time associates. We have a fantastic team of professionals who are focused on providing excellent patient care. If you are interested, please send your resume to Corinne@practiceadvantage.ca
GTA AND SOUTHWESTERN ONTARIO Full-Time And Part-Time Associates Needed Smiles First is growing rapidly and we are looking for dental associates who want to join our team and practice dentistry without administrative and management responsibilities. We have numerous locations in GTA and Southwestern Ontario and are looking for full-time and part-time associates. If you are interested, please send your resume to admin@smilesfirst.org
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OTTAWA, ON Well established, extended hours, busy and fast-growing, multi-disciplinary dental practice looking for an energetic and patient-oriented associate. This is an excellent opportunity to work with a great support team. Please email your resume to: cmontgomery@adcottawa.com
RED DEER, AB ASSOCIATE REQUIRED
Here is the opportunity! We are looking for a PERSONABLE, PATIENTORIENTED individual to join Red Deer’s fastest growing new dental office. Schedule will be busy from day one as office has a very high volume of new patient flow. Please email resume/CV to drnar@clearviewmarketdental.ca. Talk to you soon!
STONEY CREEK/BRANTFORD, ON
TORONTO, ON ASSOCIATE REQUIRED
Established office, a large loyal client base with multiple locations, is seeking an Associate who is passionate about Dentistry to join our team that thrives on patient experience and excellence. This ideal candidate must be enthusiastic, dynamic and conscientious. Polish speaking would be an asset. Come join our family and help us create a new frontier in Dentistry. E-mail: audrey@sterlingdental.com
BRANTFORD, ON Associate needed for very busy family practice in Brantford. We are looking for long term relationship — 2–3 days to start. Please e-mail your resume to apply4@rogers.com
CAMROSE, AB
A great community only 50 minutes from Edmonton. Full time associate required for our busy, progressive, digital x-ray office. Existing associate is moving. Applicant must have excellent communication skills. Be busy from day one. Send C.V to smilesbyus@hotmail.com or fax to 780-672-4700
VANCOUVER, BC
Or thodontic specialty office seeks orthodontist as associate in Vancouver. Call for further details: 778-985-6507
BOLTON, ON
Looking for a highly motivated dentist. PT/ FT skilled in most aspects of dentistry for a busy, modern practice with an established patient load. Excellent remuneration. Please reply to: hamiltondentist50@gmail.com
Part time associate required for busy and growing modern general practice. E-mail: dent.associate@gmail.com
TORONTO, ON SPECIALIST REQUIRED
KINGSTON AND/OR TRENTON, ON
Established office, a large loyal client base with multiple locations, is seeking a Periodontist, and an Oral Surgeon who is passionate about Dentistry to join our team that thrives on patient experience and excellence. This ideal candidate must be enthusiastic, dynamic and conscientious. Come join our family and help us create a new frontier in Dentistry. E-mail: audrey@sterlingdental.com
We are looking for a PT and/or FT DDS to join our team at King’s Town Dental and/or Mike the Molar Dental Centre, both well-established dental offices and member of Teeth First Dental Group. This is a great opportunity for professionals that prefer to practice dentistry with flexibility and without administrative responsibilities. If you are interested please call Heather: 613-453-6985.
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