Henry Schein Dental Solutions Feb-Mar 2024 by Henry Schein Australia

D E N TA L S O L U T I O N S

FEB / MAR 2024

CONTENTS - CLICK CATEGORY TO VIEW HS ONE

SURGERY SETUP 4

COSMETIC & RESTORATIVE

PREVENTATIVE 30

ENDODONTICS

PAIN CONTROL 39

SURGICAL 56

EQUIPMENT

HANDPIECES & INSTRUMENTS

INFECTION CONTROL 78

3D PRINTING

PROSTHETICS 86

WELCOME TO OUR FEBRUARY EDITION OF DENTAL SOLUTIONS Embarking on the journey into the promising year that lies ahead, the Henry Schein team excited to partner with you and your dental practice even more. Our collective aim is to make 2024 your most successful year yet, and we are fully equipped with a dedicated team of Relationship Managers and Specialists who are committed to understanding and fulfilling the unique needs of your practice.

Looking ahead, our commitment to environmental sustainability takes centre stage in the form of Practice Green. We are dedicated to minimizing Henry Schein's impact on the environment by enhancing elements of our supply chain and partnering with suppliers to introduce innovative renewable and recyclable products. Discover more about Practice Green at https://henryschein.com.au/practice-green

In this edition of Dental Solutions, explore insightful articles that highlight how industry-leading products and clinical workflows in dentistry can enhance the experience for both your patients and staff. Delve into topics such as modifying approaches to oral care for the elderly, discovering the transformative potential of cutting-edge technologies like CAD CAM and 3D printing, and exploring advanced clinical approaches to restorations and oral surgery, among many other engaging subjects.

In a spirit of philanthropy, Henry Schein is set to double down on charitable commitments in 2024. We will expand our support for oral health initiatives and extend assistance to less privileged Australians. Our inaugural gesture includes a donation of over 5000 oral care kits to Ronald Mcdonald House. Learn more about our charitable endeavours at https://henryschein.com.au/hscares To witness firsthand the array of remarkable products tailored for you and your practice, join the Henry Schein Team at ADX in March. Explore Schein Online, Australia's most widely used ordering platform for dental professionals, and gain hands-on experience with the innovative solutions we have in store for you.

As we navigate the lingering shadows of economic uncertainty and contend with rising interest rates affecting disposable incomes and discretionary spending, Henry Schein is poised to intensify collaboration with our Business Solution providers. Our shared goal is to empower your practice with the finest tools, expert advice, and services for practice success. Stay tuned for exciting announcements about new additions to our HS360 loyalty program, set to be unveiled at ADX.

S TA ND 5 4 3 617 615 20 - 23 March 2024 International Convention Centre

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SURGERY SETUP SOLUTIONS

SURGERY SETUP SOLUTIONS SYNERGY | SIMPLICITY | SAVINGS

MARKET OVERVIEW Over the last 5 years, the number of start-up dental practices have increased significantly. Research suggests that, on average, a new dental practice commences operations every two days in Australia. That’s not even considering the expansion of services within established practices and the incorporation of new technologies. By the statements above, we can gauge, how dynamic & competitive the dental market is growing. And constantly changing. New technologies, new companies, new generations, have reshaped dentistry in unprecedented ways.

Serene Smiles Perth is one of the practices that have trusted Henry Schein to provide the full surgery setup solution, including Equipment, Start-up Consumables Package, and Dentally Practice Management Software.

The Challenge Understanding the complexity of all steps revolving around a surgery setup can be at times, overwhelming. Not to say, combining all those elements together into a an efficient, sustainable, and profitable business model that somehow will stand out & differentiate itself from others practices in this increasingly competitive market.

SURGERY SETUP SOLUTIONS

The events offer an exceptional opportunity to deepen your expertise in some of the fundamental aspects of establishing or growing your dental practice as well as networking with experts, peers and potential collaborators.

The Surgery Setup Solution Following dental market trends, Henry Schein has expanded the Surgery Setup concept to a holistic solution, combining educational initiatives, a supportive network, and innovative tools to help dental practitioners navigate the challenges of setting up and managing successful dental practices in a rapidly evolving market. Regardless which stage of the surgery setup process; from planning, designing up to selecting the right mix of equipment, the program is designed to bring in the right expert at the right time so you can take informed decisions every step of the way. Ultimately, the Surgery Setup Program offers a compressive and tailored solution, combining consumables, equipment and management software into one package that can save you up to AU$ 40,000 in the first years of the new practice. The program offers 3 different discount layers and the flexibility to choose from the largest range of world leading brands and products to create the perfect workflow, tailored exactly to your practice needs.

Turning good practices into great businesses: Henry Schein One Empowering dentists with the World’s leading dental practice management software and dedicated business coaching, Henry Schein One provides a compressive support, turning good practices into great businesses. Through advanced technology and innovative features, such Cloud based software, contactless reception, online booking, and automated recalls Henry Schein One delivers the tools to enable dental professionals to manage teams, administrate dental practices (from anywhere) and ultimately, provide the highest quality of patient experience. Upcoming Initiatives For 2024, Henry Schein has prepared a number of upgrades to boost the Surgery Setup Program. Amongst the initiatives, the team is bringing from the USA a new Business Plan tool which should take the planning process to the next level. Additionally, based on the success & feedback from the Surgery Setup Academy nights in 2023, the upcoming events will have a fresh dynamic, incorporating new topics, new partners and much more. Stay tuned!

Where the journey starts: Surgery Setup Academy Starting a new dental practice or managing an existing one can be both exciting and rewarding but knowing where to begin – as well as finding the right partners – can be challenging. The Surgery Setup Academy events offer an exceptional opportunity to learn with expert insight and advice on how to navigate the current challenges and opportunities of starting up or expanding a dental practice. Speakers cover a wide range of topics to help dentists and prospective practice owners through some of the many considerations when setting up a new practice. Topics range from finance, design up to state-ofthe-art equipment and the latest technological advancements.

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HENRY SCHEIN ONE

PRACTICE EFFICIENCY IN THE NEW YEAR

Stepping into the new year, naturally many businesses will be taking the opportunity to review current workflows to ensure that they’re putting their best foot forward. For dental practices, knowing how to streamline workflows to ensure they’re delivering the best possible care to their patients is a key consideration at this time, and one that goes hand in hand with revenue optimisation.

At Henry Schein One, we want to ensure practices are well equipped to optimise all areas of their practice, promoting business growth well into 2024 and beyond. Our cloud enabled software Dentally provides you with all the tools you need to take the stress out of daily practice management, ensuring you can make the changes you need to thrive without spending hours sifting through numbers or different software providers.

Automated patient communications in Dentally are simple to set up too, allowing you to send messages to patients that can be scheduled around certain events such as appointments, invoice creation or new estimates. There are many different scenarios when this feature can really help your practice, from sending out online medical history forms, appointment reminders and much more! This will free up your team’s time to focus on other elements of their role, whilst reinforcing the message that the oral health of your patients should remain prioritised.

Better environment for your staff Your team are the cogs of your business. Retaining your existing staff members by providing them with tools that empower them to do their work effortlessly and effectively is important, whether they are working on your practice admin, communicating with patients or are practitioners delivering clinical care in surgery. Practice management software for your dental practice can support your staff retention by removing the stress and burden of admin, while it can also help you to attract new members through its ease of use and the opportunity to earn more through a thriving patient base. And with Dentally, all of these tools are in one convenient, user-friendly platform. Managing workloads, setting tasks and good internal communication is all made simple with Dentally’s easy to use reporting, tasks lists and chat functionality. Using automation to optimise your practice efficiency is an essential tool, keeping everything running smoothly in your practice, taking care of day-to-day admin and ensuring your patient communication is consistent – ultimately, ensuring your team has more than adequate time to focus on caring for patients in-practice.

Business growth and efficiency Have you ever taken a step back from your role to take a look at all of the tasks you carry out day to day, many without you even realising? Did you know that Dentally has been designed with many of these tasks in mind, allowing you to automate them and drive revenue from streams that may otherwise be dormant, neglected or unoptimized. To set yourself up for success at the end of the year your workflows need to be reviewed and addressed now. Let's take a closer look at just a few of our tools that can help as you address your workflows...

HENRY SCHEIN ONE

Waiting lists

Task lists

We have developed waiting lists within Dentally, so that dental practitioners can easily track and report on patients that are waiting for an appointment, as well as being able to set this against your own specific practice targets for seeing patients. This functionality within Dentally will not only save you time managing different waiting lists, it will help you fill cancelled appointments with priority patients, manage your lab work, allow you to track who has an outstanding requirement for an appointment or examination and run your waiting lists more efficiently. In addition, it will allow you to improve the patient experience you’re delivering by ensuring that waiting lists times are closely monitored by the internal targets you have set for your team. It is also useful if you are planning to offer a new type of service or introduce a new practitioner to the practice, it helps you compile an initial target marketing list.

Task Lists were made with ease of use in mind - just like everything we do. With them, you can track and undertake a multitude of tasks from calls, correspondence to patient admin, so you know that all of the things that need doing will be done and promptly too. With Tasks Lists, you can keep track of must-dos, as well as manage workloads effectively, support staff by helping to carry out vital tasks and improve your patient communication and general practice management too. Discover more about how your practice can harness the power of cloud-enabled tools in 2024 to manage your practice more effectively at dentally.com

Recalls Another simple to use feature that again saves time is recall automation. Dentally will keep your recalls running smoothly, help you to retain your patients and keep them engaged and on top of their check-ups, encourage treatment plan completion and make sure your appointment is full, so you can optimise all aspects of your practice’s revenue potential.

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NEW PRODUCTS

STATIM B G4+ FULLY AUTOMATED SPACE-SAVING MIRACLE

Compact vacuum autoclave STATIM B G4+ optimises sterilisation process. Thanks to its smart configuration, the STATIM B G4+ is a high-performance vacuum autoclave that easily meets all current requirements for safety, flexibility, and efficiency. With the aid of modern G4+ Technology and a wide range of digital functions, this EN 13060 compliant steriliser enables the easiest instrument sterilisation of two large cassettes or up to 12 sterilisation pouches in as little as 27 minutes, which includes drying time. The compact design of the STATIM B G4+ fits seamlessly into all existing sterilisation rooms. The STATIM B G4+ has a large, 5-inch LCD touch screen. With an easy-to-clean glass surface and straightforward icon menu, it is easy to operate even with gloves on. The smart technology allows for traceable load release as well as printing of bar codes. The WiFi-enabled connectivity of the STATIM B G4+ ensures protected data transfer and continuously fast user interface software updates.

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NEW PRODUCTS

CANALPRO X-MOVE ENDOMOTOR ROOT CANAL TREATMENTS FROM A TO X

COLTENE expands product range with practical CanalPro X-Move endomotor. •

Adjustable reciprocation angles for higher preparation efficiency

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Lower noise levels of smooth rotation provides higher treatment comfort

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Very small fully isolated contra angle

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High performance brushless motor

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Apex locator built in

The novel, wireless X-Move endomotor is characterized above all by its simple handling and great flexibility. The “x” in the name stands for the variable choice of practically x different movement protocols and treatment methods. With a diameter of only 8 mm, the delicate, matt black head of the contra-angle ensures a better view of the working field and at the same time facilitates photo documentation. The integrated isolation of the contra angle eliminates the need for additional sleaves. Equally practical is the integrated Apex Locator for automatic length determination. With a speed of 2,500 rpm and a torque of up to 5.0Ncm, the flexible motor scores overall with a good price-performance ratio.

View product online

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CLICK HERE

COSMETIC & RESTORATIVE

IN-CHAIR & TAKE-HOME WHITENING IDENTIFYING THE BEST WHITENING SOLUTION FOR YOUR PATIENTS

Teeth whitening is one of the most commonly requested treatments by patients, and there are many reasons why patients will want to whiten their teeth.1 Tooth whitening provides a conservative means to improve a patient's smile, as well it can be used as an adjunct to an overall restorative treatment plan. Helping patients to understand the different whitening options available, and if they are a suitable candidate, are all important topics as you consider whitening.

Expectations of whitening

Choosing the appropriate procedure

Prior to recommending any whitening products for your patient, it is important to have a conversation with your patient about their expectations after whitening. Patients should understand existing restorations will not whiten, and that certain teeth shades are a little more resistant to whitening.2

Some of the biggest deciding factors for our patients, when considering whitening treatments, are time and cost. More and more patients are time poor, and many are unable to implement a structured routine for take-home whitening in order to achieve the results. For these patients, in-chair whitening treatment is ideal, as it enables them to achieve faster results.

The darker the teeth are at baseline, the longer the tooth whitening process becomes. Gray or blue staining is less amenable to bleaching than yellow staining.3 If your patient does have anterior teeth with restorations make sure you advise that after a whitening treatment these may appear darker and therefore will need to be replaced, as part of the overall treatment plan. It is also important to talk with your patient about what to do after they whiten their teeth as part of the maintenance of their whitening treatment, as they can experience relapse over time. Discussing diet with your patient is also important, as high staining foods and drinks such as red wine and coffee are notorious for staining teeth.

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The Colgate Optic White Light Up In-Chair system uses a unique 10% hydrogen peroxide serum and an Indigo LED device to achieve up to 5.9 shade whiter in just a thirty minute treatment*. This short treatment time is perfect for time poor patients, and it is also a plus for dental practitioners, as ﬁnding time in the dental schedule for traditional in-chair whitening treatments which can take up to two hours, can often be a challenge. In-chair whitening is, however, traditionally more expensive, so if cost is an issue for patients, at-home whitening is a great option to be able to offer your patients. The Optic White Light Up Take Home, is to be used for 10 minutes a day for ten days to provide up to 7 shades whiter teeth. Patients do need to be committed to implementing a structured routine, and use the whitening product for the indicated time to achieve the results.

COSMETIC & RESTORATIVE

Whitening Maintenance The Colgate Optic White Light Up In-Chair

After a whitening treatment, both in-chair and take home, patients will often ask how long their whitening results will last. This is always a diffcult question to answer, as there are many factors that can inﬂuence whitening relapse such as diet, oral hygiene behaviour and habits, such as smoking. As general guidance, the literature does state that results can last up to 18 months to two-years, however some patients may see regression in their results sooner than this.3

VIEW PRODUCT

The Optic White Light Up Take Home VIEW PRODUCT

There are different options you can offer your patients to assist with the maintenance of their whitening. There is a Reﬁll Pen available for patients to use as part of their at home maintenance with both the Optic White In-Chair and Take Home kits. This is a great way for patients to touch up their whitening results after treatment. In addition to this, a whitening toothpaste such as Colgate Optic White Renewal can assist with both intrinsic and extrinsic stain removal for patients.

Reﬁll Pen VIEW PRODUCT

Colgate Optic White Toothpaste VIEW PRODUCT

Take away Talking to your patient about the options available to them for whitening starts and ends with good conversation. Helping them to decide what to use and providing them with great resources to follow up with will ensure your patient is happy with their results. *Refer to leaﬂet for full instructions

Reference 1.

Carey CM. Tooth whitening: what we now know. J Evid Based Dent Pract. 2014 Jun;14 Suppl:70-6. doi: 10.1016/j. jebdp.2014.02.006. Epub 2014 Feb 13. PMID: 24929591; PMCID: PMC4058574.

Alqahtani MQ. Tooth-bleaching procedures and their controversial effects: A literature review. Saudi Dent J. 2014 Apr;26(2):33-46. doi: 10.1016/j.sdentj.2014.02.002. Epub 2014 Mar 12. PMID: 25408594; PMCID: PMC4229680.

Karina Irusa, Islam Abd Alrahaem, Caroline Nguyen Ngoc, Terence Donovan,Tooth whitening procedures: A narrative review,Dentistry Review, Volume 2, Issue 3, 2022,100055,ISSN 2772-5596, https://doi.org/10.1016/j. dentre.2022.100055.

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COSMETIC & RESTORATIVE

G-ÆNIAL A’CHORD SIMPLICITY, AESTHETICS AND PERFORMANCE IN YOUR HANDS

With more than 100 years of experience in serving dentistry and over one billion composite restorations worldwide, GC introduces its proprietary High-performance Pulverised Cerasmart (HPC) filler and Full Coverage Silane Coating (FSC) technologies with its latest universal composite G-ænial A’CHORD which brings together simplification, invisible fillings, natural fluorescence and advanced technologies in one composite. Class IV controlled layer concept utilising G-ænial A’CHORD in 3 shades

Pre-Operative presentation, exhibiting a failed direct composite restoration on the upper left central incisor (Tooth 21).

Tooth surface cleaned and prepared with 37% Phosphoric Acid prior to application of the adhesive with G-Premio BOND.

Completion of the palatal shelf and interproximal wall with the application of G-ænial A’CHORD composite, shade JE. The interproximal wall was formed with the use of a plastic myeloid strip and pull through technique to help develop an anatomical contour.

The dentine layer was then completed by the application of an opaque shade of G-ænial A’CHORD AO2. This is to provide the correct opacity and “block out” effect of the final restoration.

A chromatic body shade, G-ænial A’CHORD shade A2 was then applied and extended beyond the bevel to mask the transition line. Internal anatomy in the incisal third was also sculpted and formed in this increment of composite resin. White tints, Essentia White Modifier (WM) was then utilised to accentuate the mamelons and to replicate similar characteristics present in the adjacent right central incisor.

A final translucent shade of G-ænial A’CHORD shade JE was then placed to bring the anatomy to full contour.

Simplicity, aesthetics and performance in your hands

G-ænial® A’CHORD The advanced universal composite with unishade simplicity

G-ænial A’CHORD is a trademark of GC.

2-week review demonstrating the complete optical and functional G-ænial A’CHORD restoration on the tooth 21.

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Download the Product Brochure for more information MORE INFO

View products online VIEW PRODUCTS

Clinical images courtesy of Dr Anthony Mak, Sydney

COSMETIC & RESTORATIVE

LUTING PARTIAL COVERAGE CROWN

GC Inital LiSi Block restoration cemented with G-CEM LinkForce Strong, reliable and consistent. G-CEM LinkForce™ is a universal resin cement solution built on three strong links: G-Multi PRIMER, G-Premio BOND and G-CEM Linkforce cement - that ensure consistent and reliable adhesion.* Simple application steps

1. Before Defective occlusal filling and cracked tooth exhibiting symptoms of pain on biting

2. Tooth preparation Secondary caries and crack removal with conservation of buccal cusps

3. Immediate dentine sealing Immediate dentine sealing and resin coat with GC G-aenial Universal Injectable

4. Fabrication of the partial coverage crown milled partial coverage GC Initial LiSi Block

5. Pre-treatment Surface treated with hydrofluoric acid etch and G-Multi PRIMER

6. Apply G-Premio BOND Tooth treated with air abrasion, selective enamel etch and G-Premio BOND

View products online VIEW PRODUCT

7. Cementation G-CEM LinkForce applied to intaglio surface of restoration and seated

8. Final GC Initial LiSi Block partial coverage restoration adhesively bonded

*S. Akiyama, R. Akatsuka, K. Sasaki. Wear resistance evaluation of adhesive resin cement for esthetic restorations. JDR, 2016; 95B, abstract 1345. https://iadr.abstractarchives.com/abstract/16iags-2474915/wear-resistanceevaluation-of-adhesive-resin-cement-for-esthetic-restorations

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DR REINA YANG Melbourne

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COSMETIC & RESTORATIVE

KEY PROPERTIES OF MODERN ONE-STEP BONDING AGENTS AN INTERVIEW WITH DR TOMOHIRO TAKAGAKI DDS PHD

Due to its increased usability, one-step universal adhesives are becoming more popular and the choice of many clinicians all around the world. Nonetheless, some studies have shown a lower performance than previous generations. Jorge Espigares, DDS, PhD, Planning and Development Department at Kuraray Noritake Dental, interviewed Tomohiro Takagaki, DDS, PhD, lecturer and former assistant professor at Tokyo Medical and Dental University (TMDU), pioneer in the field adhesive dentistry, author of many publications and currently lecturer at Asahi University.

Dr. Espigares: Dr. Takagaki, in your opinion, what are the most important factors for a good and durable adhesion? Dr. Takagaki: Good resin infiltration (penetration) and good polymerisation are essential factors for good bonding. This is the basic concept for the formation of the hybrid layer. Additionally, there are other important factors such as low water sorption for bonding durability and the demineralization depth, which should be the same as the depth that the resin is capable of penetrating to. Dr. Espigares: Nowadays, the trend seems to be one-step universal adhesives. Do you believe that this reduction in steps has brought any limitations compared to previous generations? Dr. Takagaki: Traditionally, one-bottle adhesives are too hydrophilic. This hydrophilicity also brings high water sorption, therefore the durability of the interface is compromised. At TMDU, we did not accept one-step bonding agents in clinical use based on results we obtained in our research in that area.

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Water sorption/solubility of different bonding agents. Data provided by Tokyo Medical and Dental University.

Dr. Espigares: What do you think of the new MDP-Amide chemistry (included in CLEARFIL Universal Bond Quick) for overcoming such limitations? Dr. Takagaki: The MDP monomer has proved through research to be the best monomer for adhesion to tooth substrate. Nowadays, many manufacturers include MDP. Although the MDP purity and performance differs from Kuraray Noritake’s original one, in one-step bonding agents only MDP is not enough. The differential factor is the amide monomer that provides the desired high penetration and low water sorption.

COSMETIC & RESTORATIVE

Dr. Espigares: You and your work at TMDU, are very well known in the field of adhesive dentistry. Did your research show results that would support the abovementioned statements? Dr. Takagaki: In our research results, we observed indeed a lower water sorption compared to previous one-step generations. Actually, we were surprised to see water sorption levels equivalent to the two-step bonding agent gold standard: CLEARFIL SE BOND. The amide monomer behaves as hydrophilic before the polymerization and as hydrophobic after, which is the desired situation for one bottle, self-etching systems.

Dr. Espigares: Would you therefore recommend the usage of universal bonding agents in daily practice? Dr. Takagaki: Yes, but as mentioned, the MDP-amide chemistry is essential. It is noteworthy that another company is also using an amide monomer. However, our results at TMDU indicate that the performance in terms of penetration is not that good. Actually, we still saw lesion formation with that other company’s amide. Kuraray Noritake’s MDP-Amide chemistry is the only one that avoids lesion formation.

SEM (Scanning Electron Microscope) images of dentin-adhesive interface after acid-base challenge. OL: outer lesion; A/B: adhesive/bonding; D: dentin; R: resin; ABRZ; acid-base resistant zone. Although ADRZ was detected in the competitive universal adhesive (C), lesion formed at the bottom of the OL. No lesion formation was detected with CLEARFIL Universal Bond Quick. Images courtesy of Tokyo Medical and Dental University.

Dr. Espigares: Let’s get out of the laboratory. According to your clinical experience, is there any extra advice that you could provide for reliable adhesion? Dr. Takagaki: One important point that sometimes is missed is to properly air-dry the solvent for at least 5 seconds after the bond application. I also recommend selective enamel etch for achieving aesthetic margins, even if all universal bonding agents allow self-etching. Finally, I would like to talk about simplicity. We dentists tend to shorten the necessary time and sometimes the rubbing time is not respected. With Universal Bond Quick, our research showed no significant difference in bond strength with rubbing time is not respected. With Universal Bond Quick, our research showed not significant difference in bond strength and the rubbing time. Therefore, it reduces the risk of error, allowing consistent results. I believe that simplicity is required so the fact that Universal Bond Quick and PANAVIA SA Cement Universal can cover direct and indirect restorations is ideal for daily practice. Universal Bond Quick achieves what I am looking for in my practice: easy, quick, and reliable.

CLEARFIL Universal Bond Quick

CLEARFILSE BOND

Asterisks show no signifcant differences (p>0.05)

Bond strength upon rubbing time. Data provided by Tokyo Medical and Dental University.

Although the universal adhesive market is large, key properties like the above-mentioned may help in the complicated process of selecting a one-step adhesive that offers the best performance, simplicity, consistency and predictable results. DR TOMOHIRO TAKAGAKI DDS PhD

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COSMETIC & RESTORATIVE

KATANA UTML VENEERS AND CROWN ON ZIRCONIA IMPLANT CEMENTED WITH PANAVIA VENEER LC

Among the most common problems in modern dentistry is that of restoring a patient‘s lost aesthetic dental appearance. To do this, new technologies are available to practitioners. For anterior teeth where aesthetics are paramount, dentists prefer the least mutilating treatments possible, such as layered dental veneers (cut-back). In cosmetic dentistry, practitioners are often faced with cases requiring a multidisciplinary treatment plan or different types of restorative materials to be used at the same time. For cases of prosthetic restoration combining dental veneers, dental crowns and dental bridges, dentists are often faced with situations where the difference in shade is noticeable in the final result, this is explained by the difference in restorative material, product, adhesion technique, the thickness of the prosthetic element and the colour of the abutment, whether it is a living natural tooth, devitalized, or even an implant abutment 1-2. In the presence of a treatment plan requiring dental veneers, crowns and dental bridges, choosing zirconia as the only restorative material is no longer an option but an obligation. This is due to the limited mechanical properties of lithium disilicate and feldspar porcelain restorations, which contraindicate their use as dental bridges.

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There are different factors explaining the reluctance of practitioners to use the zirconia dental veneer technique3: One is the absence of the vitreous phase. It makes it impossible to create an optimal adhesion surface with hydrofluoric acid at the level of the intaglio of the zirconia veneers. Another is the lack of translucency of the first zirconia generations. Modern zirconia materials, however, are particularly well-suited for cases requiring a combination of veneers, crowns and dental bridges of the same optical appearance. This is due to their increased translucency and excellent mechanical properties. The following article describes and discusses the realisation of a clinical case treated with dental veneers and a crown using KATANA™ Zirconia UTML (Kuraray Noritake Dental Inc.). The veneers were placed with PANAVIA™ Veneer LC (Kuraray Noritake Dental Inc.). The patient presented an aesthetic problem at the level of an anterior implant-supported crown.

COSMETIC & RESTORATIVE CASE OBSERVATION Patient S, from the Tunisian Sahel, engineer in France, with no significant pathological history and aged 29, presented in January 2023 due to an aesthetic problem negatively affecting her smile. The extraoral examination was without abnormalities, while the intraoral examination showed good oral hygiene, healthy gums, a thin free gingiva and a protruded zirconia crown on an implant in the region of the maxillary right central incisor (figs 1 and 2). During the preliminary interview, it turned out that the implant in the region of the right central incisor had been placed in 2020. The patient’s former dentist had left Tunisian territory. The patient does not have any document or reference on the dental implant, and she wishes to “straighten” the crown and improve the aesthetics of her smile before her planned wedding ten days after her first consultation.

In the dental laboratory, virtual models were created based on the conventional impressions (fig. 4). Then, the zirconia restorations were designed in full contour, cut back for the veneering porcelain and finished by layering with CERABIEN™ ZR porcelain (Kuraray Noritake Dental Inc.). At try-in during the second session, we checked the insertion, the gingival margins, and the contact points between the veneers and the crown on the implant. Given the superior mechanical properties of the zirconia veneer, the shape and thickness of the veneers were modified chairside to have a harmonious anterior curve and a better aesthetic rendering. After determining the colour of the resin cement, the temporary crown was put back in place.

TREATMENT PLAN After having had the informed consent of the patient and after having asked the indication of dental veneers for aesthetic reasons, the treatment was initiated. According to the treatment plan, seven maxillary anterior teeth (from first premolar to first premolar) should receive an incisal overlap preparation (depth: 0.1 to 0.3 mm) for the placement of veneers made of KATANA™ Zirconia UTML. For the implant in the region of the right central incisor, it was planned to replace the existing crown by a crown made of KATANA™ Zirconia UTML without replacing the abutment. This was due to the lack of information about the implant type and the lack of time. TREATMENT After taking the preoperative photos (fig 3), choosing the color of the veneers and anesthetizing the maxillary anterior region, the incisal overlap preparation was carried out on the seven maxillary teeth and the zirconia crown was removed from the implant. A cylindrical diamond bur was used to separate the zirconia part from the abutment. Subsequently, a bite record and impressions were taken using the wash technique. In addition, a temporary crown was produced and placed on the abutment.

Figure 1: Initial clinical situation.

Figure 2: Occlusal view revealing the volume and position of the crown on the central incisor.

Figure 3: Preoperative picture.

Figure 4: Virtual model.

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COSMETIC & RESTORATIVE After glazing and preparation of the bonding surfaces in the dental laboratory, the upper veneers were cemented according to the PANAVIA™ Veneer LC protocol. We ended the session by removing excess cement. An occlusion check and postoperative photos were taken after three days. DISCUSSION In this case, the dental veneers and the crown on the implant were produced using a KATANA™ Zirconia UTML disc. This type of zirconia has an yttrium oxide proportion of 5 mol%, leading to about 70 % cubic zirconia phase, and therefore a higher translucency than earlier generations of zirconia. With a translucency of 51 % (light transmission, illuminant: D65, specimen thickness: 1.0mm. Source: Kuraray Noritake Dental Inc); this zirconia allows us to have remarkable optical properties (fig 5). The patient chose colour BL1 and requested a transparent incisal edge. For this reason, a cutback design of the zirconia (fig. 6) and porcelain layering was the technique of choice. Figure 7 shows the slight transparency in the incisal edge region of the new restorations. The zirconia veneers technique was chosen to avoid the colour difference between the crown on the implant and the veneers. The pleasant aesthetic appearance and a harmonious smile are confirmed by the post-operative picture (fig 8). According to the manufacturer, the flexural strength of KATANA™ Zirconia UTML is 557 MPa, which is higher than that of lithium disilicate and feldspathic porcelains. As zirconia veneers will be more resistant to shear forces, it is possible to eliminate contact points that interfere during try-in or even safely modify the shape of the restorations in vivo. This is done with specific burs adapted to zirconia during different stages of the fittings according to the wishes of the patient4.

However, the desired surface modification can be achieved with a different procedure: tribochemical silica coating. It was used in the present case to improve the adhesion of the zirconia veneers to the resin cement system. Indeed, it was found in an in-vitro evaluation that the tribochemical preparation technique and the application of MDP provide an optimized adhesive interface6. In this study, dualbeam focused ion-beam technology followed by scanning electron microscopy were used to compare the resin/zirconia bonding interface with tribochemical preparation/ MDP and the bonding interface between resin/zirconia without this preparation.

Figure 5: Remarkable optical properties of the final restorations.

Figure 6: Cutback design of the restorations.

In the present case, we were able to adjust the crown until we had a perfect anterior line. It was thus possible to optimize the inclination of the crown without replacing the dental implant, in just one week. Given the significant shear resistance, the dental laboratory technician made zirconia dental veneers with an average thickness of 0.3 mm. Such a thin veneer requires less preparation of the dental tissue, which will be limited to enamel instead of extending into the dentin, where the adhesion value is lower due to its low chemical composition in minerals5.

Figure 7: Slight transparency at the incisal edges of the restorations.

The expected difficulty in bonding zirconia veneers is explained by the absence of a vitreous phase given the poor adhesion of the crystalline phase to the bonding cement. Figure 8: Immediate post-operative picture.

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Figure 9: Treatment outcome.

Figure 10: New smile designed according to the individual desires of the patient.

The tribochemical process consists of an aeroabrasion of the zirconia surface with particles coated with silica combined with a silane primer containing MDP. The phosphate ester groups of this silane bind to the surface oxides of the zirconia, and the methacrylate group makes covalent bonds with the resin matrix of the PANAVIA™ Veneer LC cement7. In the present clinical cases, the KATANA™ Zirconia UTML veneers were abraded with silicon dioxide with the formula SiO2. As a primer, we chose CLEARFIL™ CERAMIC PRIMER PLUS (Kuraray Noritake Dental Inc.), because it contains the original MDP monomer, developed Kuraray Co., Ltd.8. To clean the veneers before applying CLEARFIL™ CERAMIC PRIMER PLUS, KATANA™ Cleaner (Kuraray Noritake Dental Inc.) was used. The presence of saliva and residues from fittings can alter the interface with the resin cement, which presents a risk of bonding failure of Zirconia veneers9. One of the most important challenges in this case was to be able to hide the greyish colour of the implant abutment which was visible through the zirconia crown. To hide the grey of the abutment, a resin opaquer was applied. These techniques combined with the PANAVIA™ Veneer LC white gave us an optimal result (figs. 9 and 10)10. CONCLUSION KATANA™ Zirconia UTML veneers have better mechanical properties than conventional veneers, so that the zirconia veneers technique allows users to combine bridges, crowns and dental veneers without a noticeable difference in shade. It offers acceptable translucency and aesthetics according to our observation. The technique of bonding the zirconia veneers with PANAVIA™ Veneer LC combined with a tribochemical treatment and the application of MDP on the adhesion surfaces allowed for a secure bonding, while the dyschromia caused by the implant abutment was effectively concealed.

References: 1. Restaurations esthétiques grâce à la technique du cut-back Par Fleur Nadal, Geoffrey Di Bacco, Julien Chesnot Publié le 01.06.2019. Paru dans L‘Information Dentaire n°23 - 12 juin 2019 (page 28-29). 2. Effects of ceramic layer thickness, cement color, and abutment tooth color on color reproduction of feldspathic veneers Christopher Igiel, Michael Weyhrauch, Barbara Mayer, Herbert Scheller, Karl Martin Lehmann PMID: 29379907 Int J Esthet Dent 2018;13(1):110-119. 3. Influence of Air-Particle Deposition Protocols on the Surface Topography and Adhesion of Resin Cement to Zirconia. Acta Odontol: Sarmento, H.R.; Campos, F.; Sousa, R.S.; Machado, J.P.B.; Souza, R.O.A.; Bottino, M.A.; Ozcan, M: Acta Odontol Scand . 2014 Jul;72(5):346-53. doi: 10.3109/00016357.2013.837958. Epub 2013 Oct 31. 4. Comparison of the Mechanical Properties of Translucent Zirconia and Lithium Disilicate:Kwon, S.J.; Lawson, N.C.; McLaren, E.E.; Nejat, A.H.; Burgess, J.O. J.Prosthet:: J Prosthet Dent . 2018 Jul;120(1):132-137. doi: 10.1016/j.prosdent.2017.08.004. Epub 2018 Jan 6. 5. The Success of Dental Veneers According To Preparation Design and Material Type:Yousef Alothman, Maryam Saleh Bamasoud: Open Access Maced J Med Sci. 2018 Dec 14;6(12):2402-408.doi:10.3889/oamjms.2018.353. eCollection 2018 Dec 20. 6. The Effect of Resin Bonding on Long-Term Success of HighStrength Ceramics: Blatz, M.B.; Vonderheide, M.; Conejo, J: J Dent Res 2018 Feb;97(2):132-139. doi: 10.1177/0022034517729134. Epub 2017 Sep 6. 7. Ultra-thin monolithic zirconia veneers: reality or future? Report of a clinical case and one-year follow-up: Rodrigo Othávio Assunção Souza, Fernanda Pinheiro Barbosa, Gabriela Monteiro de Araújo, Eduardo Miyashita, Marco Antonio Bottino, Renata Marques de Melo, and Yu Zhang :Oper Dent :2018 ;43(1) :3_11.doi :10.234/16-350-T. 8. Functional monomer impurity affects adhesive performance :Kumiko Yoshihara 1 , Noriyuki Nagaoka, Takumi Okihara , Manabu Kuroboshi, Satoshi Hayakawa, Yukinori Maruo, Goro Nishigawa, Jan De Munck, Yasuhiro Yoshida, Bart Van Meerbeek : Dent Mater : 2015 Dec;31(12):1493-501.doi: 10.1016/j.dental.2015.09.019. Epub 2015 Oct 28. 9. Effect of decontamination materials on bond strength of saliva-contaminated CAD/ CAM resin block and dentin Kei Takahashi, Tomohiro Yoshiyama, Akihito Yokoyama, Yasushi Shimada, Masahiro Yoshiyama : Dent Mater J 2022 Jul 30;41(4):601-607. doi: 10.4012/ dmj.2021-268. Epub 2022 Apr 13. 10. Masking ability of implant abutment substrates by using different ceramic restorative systems Pablo Machado Soares , Ana Carolina Cadore-Rodrigues , Maria Gabriela Packaeser , Atais Bacchi , Luiz Felipe Valandro , Gabriel Kalil Rocha Pereira , Marília Pivetta Rippe J Prosthet Dent 2022 Sep;128(3):496.e1-496.e8. doi: 10.1016/j.prosdent.2022.05.010. Epub 2022 Aug 16. Affiliations PMID: 35985853 DOI: 10.1016/j. prosdent.2022.05.010.

DR. BASSEM JAIDANE Sousse, Tunisia,

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INNOVATIVE RESIN CEMENTS FORMING THE BASIS OF MINIMALLY INVASIVE PROSTHODONTICS

High-performance adhesive resin cements are often the enablers of minimally invasive prosthodontic treatments. When the main aim is to save as much healthy tooth structure as possible, preparation designs that offer sufficient macro-mechanical retention for conventional cements are usually abandoned. The designs chosen instead need to rely on a strong and durable chemical adhesion established between the tooth structure and the restorative material – a task successfully accomplished by modern adhesive resin cement systems. An excellent example of a minimally invasive, nonretentive preparation and restoration design is the single-retainer resin-bonded fixed dental prosthesis (RBFDPs), nowadays usually made of 3Y-TZP zirconia. With its single cantilever bonded to the oral and proximal enamel surface of an adjacent tooth, it requires minimal to no healthy tooth structure removal. The RBFDP is often used to replace a congenitally missing tooth – in many cases a maxillary lateral incisor – in young patients with incomplete dentoalveolar development and narrow edentulous spaces unsuitable for conventional implant placement1 (Fig. 1 and 2). Additional factors hindering implant therapy – like an insufficient bone volume or angulated roots – are also not an issue for this type of restoration. And compared to orthodontic gap closure, the treatment approach with a RBFDP is less risky, as it does not affect the vertical jaw relationship, prevent canine guidance or compromise the aesthetic appearance2. Finally, it is much less invasive than conventional FDPs, which is usually not a treatment option for young patients in the anterior region. The level of patient satisfaction and the success rates of this treatment approach are impressive3-7. Despite the numerous advantages and excellent clinical performance – single-retainer RBFDP made of zirconia showed a survival of 98.2 percent and a success rate of 92.0 percent after ten years4 – many dental practitioners still opt for alternative treatment

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options. The reason may be a lack of trust in the bond strength and durability to zirconia. However, this bond can be very strong and durable – provided that a few rules are respected. How to establish a strong bond to the tooth structure

In order to decide whether a missing tooth may be successfully replaced by a single-retainer RBFDP made of zirconia, the abutment tooth should be examined carefully. It needs to be vital and largely free of caries or direct restorations, while the oral enamel surface must be large enough for resin bonding1. In addition, the space required for the placement of a retainer wing (thickness: about 0.7 mm) needs to be available, as a non-contact design is important for the success of the restoration. Among the preparation designs described in the literature is a lingual veneer and small proximal box preparation with retentive elements located in the enamel only1, or no preparation at all7. For restoration placement, the abutment tooth is treated as usual: after cleaning e.g., with fluoridefree prophylaxis paste, phosphoric acid etchant is applied to the bonding surface, which is then thoroughly rinsed and dried. How to establish a strong bond to the restoration The recommended pre-treatment for the bonding surface of the retainer wing made of zirconia is small- particle (50 µm) aluminium oxide air-abrasion at a low pressure (approx. 1 bar)8,9, followed by ultrasonic cleaning. Figures 3 (A-E) shows the sequence of surface treatment of zirconia restorations. As a visual aid for a controlled airabrasion treatment, the marking of the surface with a pen has proven its worth. The whole air-abrasion procedure should be carried out after try- in, during which the tooth surface and the restoration usually becomes contaminated through contact with saliva and sometimes blood.

COSMETIC & RESTORATIVE Proteins present in saliva and blood that contaminate the bonding surface are safely removed in this way, while the required surface modification necessary to establish a strong and durable bond to the selected resin cement system is achieved10. Which resin cement system to choose Subsequently, the components of the resin cement system are applied. Regarding the selection of the system, it is generally recommended to use a restoration primer or resin cement that contains 10-Methacryloyloxydecyl dihydrogen phosphate (10- MDP)11. In this way, a high-quality chemical bond is established. Among the resin cement systems used in the available long-term clinical studies is PANAVIA™ 21 (Kuraray Noritake Dental Inc.)4-6. Launched in 1993, this anaerobic-curing adhesive resin cement contains several important technologies like the MDP monomer and the Touch Cure Technology found in PANAVIA™ V5, the state-of-the art dual-cure multi-bottle adhesive resin cement system of the company. In order to further improve the bonding performance of this present product, however, the team of developers reviewed the basic composition, updated existing technologies and combined them with completely new ingredients.

Figure 3A: Cleaning of the restoration prior to luting with water steam cleaner

Even with PANAVIA™ 21 introduced 30 years ago, high success rates were obtained4-6. The few observed failures were mainly due to chipping of the veneering ceramic or debonding. Sometimes caused by traumatic incidents, the debondings resulted in no further damage and the restorations were simply rebonded using the same cementation system and procedure.

Figure 3B: Marking of the bonding surface as an visual aid for the air-abrasion

One might expect that with its improved formulation, PANAVIA™ V5 will offer an even stronger and more durable bond than predecessor products, so that it is even better suited for such demanding applications as the resin-bonded fixed dental prosthesis. In a pilot study, this assumption was confirmed7. Without any preparation of the abutment tooth, but a defined size of the bonding surface of at least 35 mm2, the team of researchers placed 24 monolithic zirconia resin-bonded bridges (made of KATANA™ Zirconia HT) to replace congenitally missing lateral incisors. The palatal sides of the central incisors were cleaned with pumice paste and treated with phosphoric acid, while the bonding surfaces of the restorations were sandblasted with aluminum oxide particles (50 µm, 2.5 bar pressure). Afterwards, twelve restorations were luted with PANAVIA™ V5, the other twelve with PANAVIA™ F2.0 (another earlier-version resin cement from Kuraray Noritake Dental Inc.).

Figure 1-2: Replacement of both congenitally missing maxillary lateral incisors with single-retainer zirconia RBFDPs after soft tissue augmentation and gingival margin correction.

Figure 3: Sequence of surface treatment of zirconia restoration.

Figure 3C: Air-abrasion with 50-µm Al2O3 particles with 1 bar pressure

Figure 3D: Application of a primer containing 10-MDP

Figure 3E: Application of the composite resin cement

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After an observation period of 32 to 50.47 months, the success and survival rates in the PANAVIA™ V5 group were 100 percent. In the other group, a connector fracture, a chipping and two debondings occurred. Based on these results, the authors of the publication concluded that “it has been seen that the new generation cement (PANAVIA™ V5) is more successful”7. Conclusion For many years, minimally invasive indirect restorative approaches like the replacement of missing incisors with resin-bonded fixed dental prostheses have been performed successfully by some dental practitioners. Many others, however, still seem to be hesitant whether these approaches will lead to the desired results in their hands. The available clinical study results, however, have confirmed that the procedure is highly advantageous and successful, while ongoing development efforts in the field of adhesive resin cements have led to products further decreasing the failure rates related to debonding. Even if a debonding occurs, however, no damage is usually done, so that the restoration can be rebonded again with little effort. These findings – together with the well-known benefits of minimally invasive dentistry in general – should encourage dental practitioners to start exploring the full potential of adhesive dentistry for themselves. In this context, PANAVIA™ V5 is definitely an excellent choice. References 1. Sasse M, Kern M. All-ceramic resin-bonded fixed dental prostheses: treatment planning, clinical procedures, and outcome. Quintessence Int. 2014 Apr;45(4):291-7. doi: 10.3290/j.qi.a31328. PMID: 24570997. 2. Tetsch J, Spilker L, Mohrhardt S, Terheyden H (2020) Implant Therapy for Solitary and Multiple Dental Ageneses. Int J Dent Oral Health 6(6): dx.doi. org/10.16966/2378-7090.332. 3. Wei YR, Wang XD, Zhang Q, Li XX, Blatz MB, Jian YT, Zhao K. Clinical performance of anterior resin-bonded fixed dental prostheses with different framework designs: A systematic review and meta-analysis. J Dent. 2016 Apr;47:1-7. doi: 10.1016/j.jdent.2016.02.003. Epub 2016 Feb 11. PMID: 26875611. 4. Kern M, Passia N, Sasse M, Yazigi C. Ten-year outcome of zirconia ceramic cantilever resin-bonded fixed dental prostheses and the influence of the reasons for missing incisors. J Dent. 2017 Oct;65:51-55. doi: 10.1016/j.jdent.2017.07.003. Epub 2017 Jul 5. PMID: 28688950. 5. Kern M. Fifteen-year survival of anterior all-ceramic cantilever resin-bonded fixed dental prostheses. J Dent. 2017 Jan;56:133-135. 6. Sasse M, Kern M. Survival of anterior cantilevered all-ceramic resin-bonded fixed dental prostheses made from zirconia ceramic. J Dent. 2014 Jun;42(6):660-3. doi: 10.1016/j. jdent.2014.02.021. Epub 2014 Mar 5. PMID: 24613605. 7. Bilir H, Yuzbasioglu E, Sayar G, Kilinc DD, Bag HGG, Özcan M. CAD/CAM single-retainer monolithic zirconia ceramic resin-bonded fixed partial dentures bonded with two different resin cements: Up to 40 months clinical results of a randomized-controlled pilot study. J Esthet Restor Dent. 2022 Oct;34(7):1122-1131. doi: 10.1111/jerd.12945. Epub 2022 Aug 3. PMID: 35920051. 8. Kern M. Bonding to oxide ceramics—laboratory testing versus clinical outcome. Dent Mater. 2015 Jan;31(1):8-14. doi: 10.1016/j.dental.2014.06.007. Epub 2014 Jul 21. PMID: 25059831. 9. Kern M, Beuer F, Frankenberger R, Kohal RJ, Kunzelmann KH, Mehl A, Pospiech P, Reis B. All-ceramics at a glance. An introduction to the indications, material selection, preparation and insertion techniques for all-ceramic restorations. Arbeitsgemeinschaft für Keramik in der Zahnheilkunde. 3rd English edition, January 2017. 10. Comino-Garayoa R, Peláez J, Tobar C, Rodríguez V, Suárez MJ. Adhesion to Zirconia: A Systematic Review of Surface Pretreatments and Resin Cements. Materials (Basel). 2021 May 22;14(11):2751. 11. Al-Bermani ASA, Quigley NP, Ha WN. Do zirconia single-retainer resin-bonded fixed dental prostheses present a viable treatment option for the replacement of missing anterior teeth? A systematic review and meta-analysis. J Prosthet Dent. 2021 Dec 7:S0022-3913(21)00588-6. doi: 10.1016/j. prosdent.2021.10.015. Epub ahead of print. PMID: 34893319.

DR. ADHAM ELSAYED

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RESTORATION

"Working with the AquaCare as part of my daily routine gives me the confidence that my bonding is the best it can be. Often excess hand piece oil can contaminate your cavity during preparation and if not removed can seriously compromise bond strength. Prior to bonding, decontaminating the cavity with 27μm Aluminium Oxide will help to ensure that the cavity with be clean and oil free.” Richard Field

Fig.1 Patient presented with food trapping mesial and distal to the Upper left 5. This was stemming from a poor medial and distal contact point from the adjacent defective restorations.

Fig. 2 Isolation was achieved with a non latex rubber dam.

Fig. 3 The old restorations and caries was removed from the upper right 4 6 and 7 reviewing a carious pulp exposure on the upper right 6

Fig. 4 Cavities were cleaned with 27μm Aluminium Oxide using the AquaCare unit to ensure bonding surfaces are clear of contaminants.

Fig. 5 An MTA plug was placed as a means of direct pulp capping over the exposure on the upper right 6.

Fig. 6 Direct composite was used to restore the Upper right 4 and 7 with a GIC core placed as a long term provisional on the upper right 6 in order to monitor pulp vitality prior to an indirect restoration.

View brochure online DR RICHARD FIELD United Kingdom

CLICK HERE

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ASSOCIATION OF RESIN INFILTRATION AND COMPOSITE RESIN ON THE TREATMENT OF SEVERE DENTAL FLUOROSIS.

Prof. Dr. Leandro Augusto Hilgert, Marília Bizinoto Silva Duarte.

Fig 1: Base status.

Enamel developmental defects may negatively affect esthetics and patients’ self-esteem [1]. This is particularly true for young patients. For these cases, treatments should be able to present an acceptable esthetic result without compromising much tooth structure (being minimally invasive). Resin infiltration has been shown to be a microinvasive treatment for white spot lesions, slight to moderate fluorosis and some other types of opacities [2, 3]. However, in more severe cases, in which tooth substance loss is already present and/or opacities are too opaque and deep, a combination of resin infiltration and composite resins may be an effective, fast and minimally invasive approach to improve esthetics (»deep infiltration«) [4]. Fluorosis is characterized by hypomineralization of the enamel [5]. In less severe cases the subsurface hypomineralized enamel may be resin inifiltrated only in a true microinvasive treatment approach. The aim of this case report is to present a severe case of fluorosis in which due to enamel loss and deep opacities an association of resin inifltration and composite resin restorations was used on the treatment a young patient.

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Case report A young female patient presenting a severe case of fluorosis reached the University clinic seeking for esthetic treatment. During anamnesis it was revealed that the child was shy and afraid of smiling, and episodes of bullying at school have already happened due to the enamel development defects. However, there was a concern by the child and her mother on the possible complexity, costs and invasiveness of the necessary treatment approach. Intra oral examination showed a fluorosis graded as TF6, presenting regions of white opacities as well as some enamel pitting with substantial amount of enamel loss. Transillumination suggested areas of deeper hypomineralization (where light transmittance was blocked) as well as some areas with more shallow lesions. Proposed treatment plan was resin infiltration and small additions of composite resin. Patient and mother were explained on the treatment steps and the possible need for some localized wear of the enamel on the regions that already presented enamel pitting and discoloration and on the areas with deeper opacities.

COSMETIC & RESTORATIVE

Fig 2

Fig 3 Fig. 1-4: Figures 1, 2 and 3 present different views of the clinical case in which the patient presents fluorosis (TF6). Observe that there are areas with diffuse and slight white opacities, areas with very opaque white opacities and areas that already present enamel loss and some discoloration. In Figure 4 transillumination was performed to check light transmittance through the enamel, that may be a useful diagnostic tool since the deeper the enamel hypomineralization, the more light is blocked. Some areas of the affected anterior teeth area were suggested to present deeper lesions, that may impair a more complete resin infiltration without some previous wear of the enamel.

Fig 4

Fig 5

Fig 6

Fig 7

Fig 8

Fig. 5-8: After isolation of the operatory field using lip retractors and a liquid dam to protect soft tissues (Fig. 5), Icon-Etch (hydrochloric acid) was applied on the surfaces for 2 mins (Fig. 6) aiming to remove the enamel surface layer and create access to the subsurface hypomineralized enamel (porous area). In Figure 7 it is possible to observe the matt appearance after the acid etching. In Figure 8, a drop of Icon-Dry (alcohol) was applied on the etched surfaces. After a few seconds, it is possible to see that some areas around the enamel pitting kept very white and opaque. This »optical test« after etching may be useful to indicate areas in which a more pronounced enamel wear is needed to create access to the hypomineralized layer. This extra step may be performed with repeated acid etchings or, in deeper lesions, with air abrasion or rotary instruments.

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Fig 9

Fig 10

Fig 11

Fig 12

Fig 13

Fig 14

Fig 15

Fig 16

Fig. 9-12: In this case we opted for diamond burs to wear the surface. Localized preparations were performed, removing the superficial part of the more affected enamel and areas of discoloration (where enamel pitting was already present) (Fig. 9). Then, Icon-Etch was applied once more for 2 mins (Fig. 10). Figure 11 shows the aspect after localized enamel wear and acid etching. It possible to see that there are still whitish areas that could be infiltrated. After etching Icon-Dry was dropped onto the surfaces (Fig. 12). Observe the more uniform aspect after alcohol application, indicating that a better access to the porous areas was achieved. Once the result was good, Icon-Dry was left for 30s and surfaces thoroughly dried.

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Fig. 13-16: Icon-Infiltrant (the low-viscosity resinous infiltrant) was applied according to manufacturer’s instructions (3 min, excess removal, light-curing; 1 min, excess removal, light-curing) (Fig. 13). In Figure 14 it is possible to see the aspect immediately after infiltration in which a uniform color was achieved and most of the whitish opacities were adequately masked. This uniform substrate eases composite resin stratification and improves final result since there is no need for masking white spots with opaque composites. Areas of worn enamel and previous enamel pitting where restored using only body and enamel shades (Fig. 15). It is interesting to say that after resin infiltration, if the surface was not contaminated, it is not necessary to apply an adhesive. Methacrylate-based composites effectively adhere to the infiltrant [6]. Figure 16 shows that tooth anatomy was correctly recovered. After composite resin application a careful finishing and polishing procedure was performed on the infiltrated and restored surfaces using abrasive disks, rubber cups and polishing pastes.

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Fig 17

Fig. 17-18: Figures 17 and 18 show the immediate results achieved after association of resin infiltration and composite resin. Esthetics were significantly improved. Patient and mother were very satisfied. Even though some enamel wear was needed, we considered this a simple, cost-effective, fast, and minimally invasive approach to deal with the clinical situation. Compare posttreatment pictures with Figures 1 to 3.

Fig 18

The presented treatment shows that an association of resin infiltration and composite resin may be an interesting approach to severe cases of fluorosis or other enamel defects that are nonresponsive to resin infiltration only. The localized wear performed with abrasive instruments removes the highly affected enamel and exposes the underlying porosities that are, then, able to be adequately infiltrated (technique known as »deep infiltration«). The advantage of infiltrating the (still porous) subsurface enamel before covering it with composites is that a uniform substrate is achieved, avoiding the need to use opaque dentin shades, that in thin thicknesses either do not mask de whitish underlying enamel or do not present the expected life-like esthetics and translucency of the enamel. Learning from cases like this on limitations of using resin infiltration alone, but its usefulness when associated with localized preparations and composite resin restorations allow the dentist to have new treatment possibilities that aim on a highly esthetic outcome with a minimally invasive approach.

REFERENCES 1. Martínez-Mier EA, Maupomé G, Soto-Rojas AE, Ureña-Cirett JL, Katz BP, Stookey GK. Development of a questionnaire to measure perceptions of, and concerns derived from, dental fluorosis. Community Dent Health. 2004;21(4):299–305. 2. Hilgert LA, Leal SC. Resin Infiltration: A Microinvasive Treatment for Carious and Hypomineralised Enamel Lesions. In: Eden E, editor. Evidence-Based Caries Prevention. Springer; 2017. p. 123–41. 3. Gugnani N, Pandit IK, Gupta M, Gugnani S, Soni S, Goyal V. Comparative evaluation of esthetic changes in nonpitted fluorosis stains when treated with resin infiltration, in-office bleaching, and combination therapies. J Esthet Restor Dent. 2017;29(5):317–24. 4. Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. Taches blanches de l’émail: protocole de traitement par infiltration superficielle ou en profondeur (partie 2). Int Orthod. 2014;12(1):1–31. 5. Aoba T, Fejerskov O. Dental fluorosis: chemistry and biology. Crit Rev Oral Biol Med. 2002 Mar;13(2):155–70. 6. Wiegand A, Stawarczyk B, Kolakovic M, Hämmerle CHF, Attin T, Schmidlin PR. Adhesive performance of a caries infiltrant on sound and demineralised enamel. J Dent. 2011;39(2):133–40

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STELA SELF CURE COMPOSITE THE FUTURE OF COMPOSITES

“The combination of Stela Primer and the self-curing Stela restorative generates low polymerisation stress, which enables this bulk-fill composite system to create a gap-free bonding interface.”

STELA AT A GLANCE Gap-Free Interface Stela features innovative technology that enables a gap-free interface. Unlike standard light cured composites, Stela polymerisation is accelerated along the restoration interface. This enables a gap free interface, reducing post operative sensitivity and the risk of premature failure.

STELA BONDING INTERFACE (SELF ETCH) A confocal micrograph of a gap-free Stela-dentine interface, using the self etch Stela Primer. Note the penetration depth of Stela Primer (yellow) within the dentine tubules. Pre-test failure rate: 0%

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Unlimited Depth Of Cure

High Strength

Stela is a new generation composite that will self cure to an unlimited depth. This allows full cure certainty for all restorations.

Stela has an impressive combination of compressive and flexural strength. This is the result of the initiator system that starts a snap set fast cure to convert monomers into polymer chains.

COMPRESSIVE STRENGTH - 328 MPa

UNLIMITED DEPTH OF CURE

Chameleon Aesthetics Great for a wide range of clinical indications: • • • •

Class I, II, III and V Core build-ups Base or liner Sealing endodontic access cavities

FLEXURAL STRENGTH - 143 MPa Cavity prepared and ready to be isolated with rubber dam

Final aspect Cavity prepared and ready to be after finishing and polishing

15 SECOND PREPARATION IN JUST 2 SIMPLE STEPS While traditional composite systems can take up to 120 seconds to prepare, Stela restorations are ready for placement in just 15 seconds. With Stela, clinicians can benefit from reduced in-chair time and a simplified protocol.

PROF DR SALVATORE SAURO Professor of Dental Biomaterials and Minimally Invasive Dentistry - University CEU Cardenal Herrera – Valencia - Spain Editorial board member Dental Materials Journal - Elsevier

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PREVENTIVE

ORAL HEALTH CARE FOR THE ELDERLY AND MODIFYING APPROACHES

Oral health not only refers to the absence of dental diseases but its contribution to general well-being and quality of life (QoL), which is more difficult to achieve with advancing age (Lamster and Northridge, 2008). Learning about the characteristics of this population can give helpful insights into oral health care for the elderly and how to modify approaches to suit individual needs. Demography of Aging: Australia and New Zealand

Senior Living Spectrum

Due to medical advances, socioeconomic development and improved public health measures, the average lifespan has improved, and mortality/fertility rates have reduced. In New Zealand (NZ) the number of people aged 65+ doubled between 1991 and 2020, to reach 790,000. This number is projected to double again by 2056 with a significant increase in the 85+ age group, which will be approximately 320,000 in 2048 (Stats NZ, 2021). In Australia, from 1999 to 2019, the population of those aged 65+, increased from 12.3% to 15.9%, with a 2.5% increase in the age group 85+ in the same period (Australian Bureau of Statistics, 2019).

All elderly are not subject to the same living circumstances. We must appreciate the wide spectrum of senior living and levels of senior care (National Caregivers Library, 2019). At one end of the spectrum are individuals who are more independent, perhaps requiring some form of home assistance, but who are able to carry out dental homecare themselves. Even so, there may be opportunities for oral health practitioners to make suggestions for an improved homecare routine with a focus on preventative strategies.

The New Zealand 2018 census results show that the changing demography consists of a more diverse cultural makeup (Statistics NZ, 2021). Furthermore, poor oral health statistics are represented disproportionally in both countries by the indigenous population and minority groups. Collectively, these statistics highlight the burden on oral health services because more people are living longer and are more likely to retain natural teeth. However, the elderly population is made up of distinct groups and this can affect the way a treatment plan is formulated. Below are the estimated age groups and their different characteristics:

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65-74 are considered as young elderly who are relatively healthy and active

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75-84 are mid-elderly who could vary from being healthy and active to being dependent with chronic diseases

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85+ are the frail group with one or more medical conditions (Razak, Jose Richard, Thankachan, Abdul Hafiz, Nanda Kumar, Sameer, 2014).

On the other end of the spectrum individuals may live in aged-care facilities in which healthcare assistants and/or nurses provide the necessary care. Moreover, in institutionalised facilities care resistant behaviours may be more common and add further complications. Evidence reveals that institutionalised individuals are at greater risk of developing dental diseases than the non-institutionalised, as reported in a study of several rest homes in Adelaide in 2005 (Lamster and Northridge, 2008). Determinants of Oral Health in Elderly Treating the elderly population poses many challenges for oral health professionals especially when implementing preventative strategies. Clinicians have to consider deterioration of physical and mental health, medical condition(s) and polypharmacy when managing this cohort. The elderly population is a unique group of vulnerable individuals who become the main consumers of primary health care services and are more likely to access multiple services such as medical clinics, outpatient hospital services, pharmacies, dental care and supportive care (Lamster and Northridge, 2008).

PREVENTIVE Oral health practitioners in collaboration with allied health services can achieve better oral health outcomes and continuation of care. With individuals keeping their natural teeth further into life there is a greater need for support, preventative dental treatment and restorative work. The oral-health concerns during ageing can include one or more of the following:

Recommendations for oral health interventions and other suggestions •

Diet and nutrition counselling should be considered as an integral part of the oral health assessment. Refer to GP, nutritionist or dietician if necessary

•

Toothbrushing: Use an electric toothbrush with an ergonomic handle. This makes it easier to grip and move around. Alternatively, the way you hold a toothbrush can be changed (refer to resource below) as well as the shape and size of the handle to suit individual needs. Soft or extra soft bristled toothbrushes with bass or modified bass brushing technique using light pressure are best

•

Mouth rinses: either fluoride rinses or chlorhexidine rinses can help control plaque and prevent decay important for those with physical or mental disability. A small bottle spray can help if the individual is unable to swish around the liquid

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Reduced chewing efficiency

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Poor nutritional status

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Denture-related issues - such as ill fitting, damaged/cracked dentures

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Edentulism or tooth loss

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Reduced sensitivity to pain

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Tooth Sensitivity

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Reduced salivary function or xerostomia

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Changes in teeth such as erosion, attrition and recession

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Changes in oral mucosa - less regenerative capacity

Adaptive dental aids: special handles for floss, toothbrush, or interdental aids

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Water flossing - not a replacement to flossing but helps those with reduced dexterity

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Use high fluoride toothpaste

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Apply fluoride varnish regularly

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Communicate: Keep oral health instructions simple, use easy to understand language and visual aids. Speak at a volume they can hear clearly but not raising your voice

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Counsel and educate caregivers or families to support with homecare

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Provide denture care instructions

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Use tell-show-do method

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Employ preventative counselling

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Make referrals to other health care professionals as required

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Work with allied health professionals

• •

Coronal Dental caries - higher rate

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Root caries - higher rate

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Periodontal disease - more prevalent

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Oral cancer

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Complications by comorbid conditions such as hypertension, heart disease, cancer and diabetes mellitus

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Age-related physiologic changes

(Razak et al., 2014; Gil-Montoya, Ferreira de Melli, Barrios, Gonzalez-Moles, Bravo, 2015)

Other factors that can affect oral health in the elderly are barriers to accessing dental care resulting in irregular dental visits due to cultural views, ethnic background, inability to travel, fear and anxiety, and financial strain.

(Razak et al., 2014; Lamster and Northridge, 2008).

Resources 1.

Modifying toothbrush: https://www.mytoothbetold.com/modify-toothbrush-arthritis/

Better oral health in residential care - A toolkit: https://www.sahealth.sa.gov.au/wps/wcm/connect/77fd7a004b3323958834ad e79043faf0 BOHRC_Professional_Portfolio_Full_Version%5B1%5D.pdf?MOD=AJPERES&amp;CACHEID=ROOTWORKSPACE77fd7a004b3323958834ade79043faf0-nKKIuxl 2.

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References Australian Bureau of Statistics. (2019). Australian Demographic Statistics: Twenty years of population change. Retrieved September, 2021, from https://www.abs.gov.au/ausstats/abs@.nsf/0/1cd2b1952afc5e7aca257298000f2e76. Gil-Montoya, J. A., Ferreira de Melli, A. L., Barrios, R., Gonzalez-Moles, M. A., & Bravo, M. (2015). Oral health in the elderly patient and its impact on general well-being: A nonsystematic review. Clinical Interventions in Aging,10, 461–467. Lamster, I. B., & Northridge, M. E. (2008). Improving oral health for the elderly: An interdisciplinary approach. Springer Science + Business Media. Lauritano, D., Moreo, G., Della Vella, F., Stasio, D., Carinci, F., Lucchese, A., & Petruzzi, M. (2019) Oral Health status and need for oral care in an aging population: A systematic review. International Journal of Environmental Research and Public Health, 16(22), 4558. https://doi.org/10.3390/ijerph16224558 National Caregivers Library. (2019).The long-term care spectrum. Retrieved September, 2021, from http://www. caregiverslibrary.org/Caregivers-Resources/GRP-Care-Facilities/The-Long-Term-Care-Spectrum-Article Razak, P. A., Jose Richard, K. M., Thankachan, R. P., Abdul Hafiz, K. A., Nanda Kumar, K., Sameer, K. M. (2014). Geriatric oral health: A review article. Journal of International Oral Health, 6(6),110-116. Stats NZ (2021). National population projections: 2020(base)–2073. Retrieved September, 2021, from https:// www.stats.govt.nz/information-releases/national-population-projections-2020base2073

Christine Murthi Christine Murthi is an Oral Health Therapist based in New Zealand. She is currently studying a Masters in Health Science at Auckland University of Technology. Prior to this she had secondary teaching/tutoring experience spanning more than ten years. Through this teaching experience combined with her diverse cultural background she has developed a passion for promoting diversity in clinical practice, overcoming communication barriers and connecting with the community. As a member of the Colgate Advocates for Oral Health: Content Community, her contributions to the dental community aim to promote good oral health for all and keeping a healthy smile for life.

CHRISTINE MURTHI New Zealand

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DENTAL EDUCATION HUB

UPCOMING WEBINAR SERIES

In recent years, the increasing challenges on global supply, economic instability, have changed the way of acquiring new equipment, consumables, and dental products in general. With this new scenario, Henry Schein has prepared a package of actions & tools to ensure you purchase dental equipment timely and capitalises on the current Government Stimulus. From expert advice, up to flexible finance options and aggressive pricing, Henry Schein has on offer a tailored mix of solutions that makes NOW the perfect time to purchase world class equipment in the recent years. Tune in to the Surgery Setup Solutions Webinar Series being held throughout the month of March. Log in to the FREE Live webinars to gain insights on an array of topics including finance, fitout, surgery set up considerations and marketing.

Ensuring access to dental services in the environment of declining discretionary spending Tiffany Wright-St Clair & Ayelet Mendel Girin 27 FEB 1 Non Clinical CPD READ MORE

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Endodontic Access and Locating Canals: A practical approach

Sabine Friedlaender

Dr. Shalin Desai

TUES 12 MARCH 1 CPD Point

TUES 5 MARCH 1 CPD Point

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MANAGING DENTINE HYPERSENSITIVITY WITH MI VARNISH™

Superior Durability MI Varnish™ features a hydrogenated rosin matrix that ensures high fluoride, calcium and phosphate ions availability, combined with translucency and exceptional durability. This enhanced formulation means MI Varnish™ can provide exceptional protection from dentine hypersensitivity. MI Varnish™ contains NaF and RECALDENT™ (CPP-ACP) dispersed in a rosin and ethanol solution. When MI Varnish™ is applied, it adheres to the tooth and seals exposed dentine tubules. Contact with saliva sets the varnish and starts the slow dissolution process, driving the release of fluoride and RECALDENT™ (CPP-ACP). Fluoride ions that are released bind with calcium ions in pellicle and plaque, to form globules of calcium fluoride. These globules deposit on the tooth surface, providing additional blockage of exposed dentine tubules, enhanced acid resistance and promote calcium and phosphate-enriched saliva. MI Varnish Technique Guide

1 . Tooth surfaces should be cleaned and completely dried before application of MI Varnish™. A prophylaxis is not required.

2. Peel off the foil lid of the unit dose container of MI Varnish™.

4. Apply a thin, uniform layer to minimise clumping. Only apply one layer.

5. MI Varnish™ sets when in contact with water or saliva; if desired, once MI Varnish™ is applied, wet tooth surfaces using triplex syringe to accelerate MI Varnish™ setting.

3. Stir MI Varnish™ with the disposable brush before application.

After Application MI Varnish™ should remain undisturbed on the teeth for four hours. Instruct patients to avoid hard, hot or sticky foods, tooth brushing and flossing, products containing alcohol (oral rinses, beverages, etc.) during this time period.

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Q&A

7. Are there any contra-indications?

1. What is the shelf life of MI Varnish™?

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MI Varnish™ has a 3 year shelf life from manufacturing date.

MI Varnish™ contains RECALDENT™ (CPP-ACP) which is derived from milk casein.

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Do not use MI Varnish™ on patients with proven or suspected milk protein allergies.

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Do not use MI Varnish™ on patients with ulcerative gingivitis and stomatitis.

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The ingredient rosin used in MI Varnish™ is a processed pine tree extract and not an extract of pine nut. A patient with recognised allergies should consult his/her medical professional for guidance.

•

If any allergic reaction occurs, this may indicate sensitivity to a component of the product. In this event, discontinue use of the product and contact patient’s physician.

2. How much material is there in a unit dose? MI Varnish one unit dose package contains 0.4ml (enough for a full adult dentition). ™

3. Are fluoride varnishes suitable for all patients? According to the American Dental Association Council on Scientific Affairs, fluoride varnish applications every three to six months are recommended for children younger than 6 years, adolescents and adults, who are at elevated risk of developing caries.** 4. Can MI Varnish™ be used on patients with crowns and veneers? Yes, MI Varnish™ can be applied to the margin area of crowns or veneers.

References ** Weyant RJ et al. Topical fluoride for caries prevention: executive summary of the updated clinical recommendations and supporting systematic review. J Am Dent Assoc. 2013 Nov;144(11):1279-91.

5. Is prophylaxis (cleaning) required before the application of MI Varnish™? View MI VarnishTM Online

No, MI Varnish™ does not require a prophylaxis treatment prior to application.

VIEW PRODUCT

6. Why is a thin application better? The best outcome when applying MI Varnish™ is prolonged retention on tooth surfaces. A thick application means a higher chance of clumping – if clumping occurs, this tends to be less comfortable and patients might feel the need to pull on pieces of the set material. Applying one thin layer of MI Varnish™ provides the best outcome for protecting tooth surfaces and for patient’s comfort.

View an On-Demand Webinar which focuses on CPP-ACP New prebiotic and biomimetic approaches for treating oral disease

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Presented by Professor Eric Reynolds & Professor Ian Meyers VIEW WEBINAR

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IMPLANT CARE KIT

A newly launched oral care kit helps people with implants Having a dental implant installed in the mouth is becoming increasingly common worldwide since it is a solution for patients with missing teeth or severe periodontitis. Australia seems to be a fast-expanding market for dental implant treatments, and general dental practitioners are increasingly carrying them out.1 Getting a dental implant is a relief for many patients and improves their quality of life. However, it is important to note that the implant and surrounding tissue must be cared for thoroughly to stay healthy. TePe, a Swedish oral hygiene company with a multinational presence, has launched an implant care kit in Australia. We are asking Michaela von Geijer, Doctor of Dental Surgery and employee of TePe, more about the products in the kit, how to use them properly and the issues surrounding having dental implants. Some patients with dental implants will get peri-implant diseases. How common are these diseases? Very common. According to the latest Clinical Practice Guideline from 2023 nearly half of our patients (43%) will get peri-implant mucositis and 1/5 (22%) will get the severe form peri-implantitis, with bone loss.2 “Dental implant treatment is a relief for many patients and improves their quality of life. The implant and surrounding tissue need to be taken care of daily and thoroughly to stay healthy” Dr Michaela von Geijer

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What are peri-implant diseases? “Peri-implant diseases are inflammatory conditions that affects the peri-implant tissues and are induced by peri-implant biofilms.” This definition was stated in the Clinical Practice Guidelines from 2023.3

Implant with peri-implantitis. Cleaning with TePe Compact Tuft™

I see, so plaque accumulation is the cause of the disease. Are there other risk factors? Yes, even though plaque accumulation is the etiological factor for the disease, certain risk factors contribute to the progression, such as a history of severe periodontitis.3 Other risk factors are, for example, smoking, not well-managed diabetes, low socio-economic status, location of the implant, bone quantity and quality, and potentially genetics.4 How can we treat implant diseases? The first stage, peri-implant mucositis, should be treated with professional cleaning and thorough cleaning at home. The second stage, peri-implantitis, is really challenging to treat. The Clinical Practice Guidelines from 2023 recommend a step-wise approach. The fact is that we don’t really know how to treat it. There are different suggestions on how to approach the disease, but we can’t guarantee a successful outcome for the patient. In the worst-case scenario, we need to remove the implant. That is why prevention is so important.

PREVENTATIVE What can the patient do to minimize the risk for implant diseases?

Can you please go through the products available in the kit?

Number 1: thoroughly cleaning at home along the gumline. Number 2: attend maintenance care regularly at the dental office. Number 3: contact the dental office if bleeding occurs or if the tissue close to the implant looks or feels strange.

Let’s start with TePe Universal Care™. In my opinion, this is a must for all patients with implants because of its unique angle neck. It can be challenging to clean lingual along the gumline, and with this tool it is easier to reach that hard-to-reach area.

“We must inform our patients about the importance of daily plaque removal along the gumline. We also need to recommend suitable products and share our knowledge about daily cleaning at home. The daily cleaning will make the difference between having a healthy implant or one affected by disease.”

Cleaning along the gumline with TePe Universal Care™

Dr Michaela von Geijer Do you have any tips on motivating patients to take good care of their implants and oral hygiene? That is a tough one to answer in a few sentences. Encourage them at every session. A plaque discloser might be a good educational tool to use. We must share our knowledge and try to find the patient’s internal motivation to keep the implant healthy. Every improvement matters. How often should a patient attend maintenance care?

Depending on risk factors, that must be tailored individually, but at least twice a year is recommended. TePe has launched a care kit for patients with implants. How do you use the kit at the practice? The Implant Care Kit is really useful for patients who want to try out which tools they prefer and can handle. Since all the useful tools are collected in one kit, it makes it easier; no need to collect them from different sources. It also makes for a nice gift to hand out. For me, it is an easy and quick way to collect speciality products for the patient. It is so important to take good care of the implants from the start. Like all TePe’s products, this kit is developed in collaboration with dental experts.

The TePe Compact Tuft™ is also included in the kit, what are the benefits? Sometimes there is a need for a very firm, dense and rounded tuft for precision cleaning along the gum line or around implant surfaces.

Different suitable situations for using TePe Compact Tuft™

There is a very thin toothbrush with only two rows of filament, TePe® Implant Orthodontic Brush. Where should this brush be used? This is perfect for buccal cleaning. The slim brush head aids cleaning outside the implant surfaces along the gumline.

Cleaning with TePe® Implant Orthodontic Brush

Is it easy for the patient to understand how to use the products in the kit at home? The kit contains a leaflet with instructions and illustrations on how to use the products. But our role as professionals is very important, we must show, guide and instruct the patient on how to use the products. Practice with the patient during every maintenance visit. In this way we encourage the patient and can pinpoint and adjust the way the products are used.

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PREVENTATIVE The interdental brushes in the Implant Care Kit are softer than usual, how come? Initially, the tissue might be sensitive, so these extra soft brushes are very comfortable to start with. Cleaning in-between implants is even more important than cleaning in-between teeth because the tissue around implants is more sensitive to plaque accumulation. Studies show that interdental brushes are the most effective way to disturb the plaque layers. The kit includes six sizes with an extra soft-bristled brush with plastic-coated wire and a user-friendly handle design for gentle and safe cleaning. Later, when the tissue is less sensitive, it is possible to switch to the original interdental brushes, which come in 9 sizes, and TePe Angle™, in 6 sizes.

Check out Tepe Implant kit here

CLICK HERE

References 1.

Guo et al. (2017). Implant dentistry in Australia: the present and future. A survey of Australian dentists and specialists. Australian Dental Journal/2010; 55: 329-332.

Derks & Tomasi (2015). Peri-implant health and diseases. A systematic review of current epidemiology. Journal of Clinical Periodontology. 42(Suppl 16), S158-S171.

Herrera et al. (2023). Prevention and treatment of periimplant disease – The EFP S3 level clinical practice guideline. Journal of Clinical Periodontology. Jun;50 Suppl 26:4-76.

Darby (2022). Risk factors for periodontitis & peri‐implantitis. Periodontology 2000. Oct; 90(1): 9–12.

Six brush sizes of extra-soft interdental brushes are included in the kit

“Daily plaque removal is even more important around implants than teeth” Dr Michaela von Geijer How is the TePe Bridge & Implant Floss used? ®

This floss is ideal for cleaning under the pontics, and is also an option for cleaning proximal sites or to combine it with interdental brushes. The sturdy ends facilitate insertion, and the spongy mid-section effectively removes plaque.

The floss is used for cleaning under the pontic and for proximal cleaning, as shown in the picture

Thank you! Anything more you would like to add? Really take the time to instruct your patients on how to use the products, it will pay off in the long run. It will give more success for the clinic, us, and most importantly, the patients.

About Michaela von Geijer, Doctor of Dental Surgery Dr von Geijer works part-time at a private dental office in Sweden and TePe HQ in Malmö, Sweden. She has long clinical experience and is particularly interested in prevention and oral health. She has always placed a high value on working with preventive care. Dr von Geijer has held temporary preclinical positions as amanuensis at the University of Lund, including basic research and assistance with education/training at the medical and dental schools. She also has experience lecturing to professionals when employed by pharmaceutical companies and companies within the dental industry. Since 2015 Dr von Geijer has been employed by TePe and been a lecturer at universities worldwide.

MICHAELA VON GEIJER Sweden

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PAIN CONTROL

THE WAND/STA IT’S PRECISE, IT’S PROFITABLE IT’S PROVEN

Milestone Scientific‘s WAND/STA “All Anaesthesia system”, the only Computer controlled anaesthetic delivery system, that has been proven to help you and grow your practice. The technology behind WAND/STA enables:

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Increased Practice Productivity

- Reduces time spent calming anxious patients - Achieves profound anaesthesia within 2 minutes - Reduces injections per patient - Allows for bilateral procedures in a single appointment

- Reduces appointment cancelations (in dentistry this typically accounts for up to 30% appointments)

- Increase patient visits per day •

Increased patients’ referrals

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Reduced and/or eliminated mandibular block injections

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Increased precision and consistent flow of anesthetics below the patient’s pain threshold

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Improved tactile control

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Increased ergonomic ease and comfort

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Increased access and visibility

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Reduced anxiety

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Increased comfort and confidence in using alternative injection techniques

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Increased practice value/revenue

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Eliminates the barrier of hypodermic syringe in your practice

Testimonials from other dental practitioners

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View Product Online

CLICK HERE

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ATRAUMATIC RESTORATIVE TREATMENT (ART)

Minimizing droplet & aerosol generation with ART technique and Biodentine™

Why choose biodentine™ with art procedure?

To protect the health of dental practitioners around the globe, some procedures such as the Atraumatic Restorative Treatment can be preferred in order to avoid the spread of virus particles (aerosol generation). Atraumatic Restorative Treatment (ART) is based on the minimal intervention dentistry approach that provides Several benefits • • • •

Avoid aerosol generation Save the tooth Reduce the chance of odontogenic infection Manage pain

What is ART Procedure? •

Remove dental caries using only hand instruments (no drill/no turbine)

•

Restore the cavity with a filling material

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Save the tooth rather than extracting it (Minimally invasive therapy) Maintain the vitality of the pulp, as supported by the European Society of Endodontology (ESE)

Biodentine™ can be placed from the pulp to the top of the cavity (bio bulk fill). For ART procedure, it is recommended to place the final enamel restoration in the same session.

83.3%*

positive success rate

Biodentine™ has a positive success rate of 83,3%* during pulp capping procedure with manual removal of the soft dentin and round carbide burs on a slow speed hand-piece. *Hedge et al: Clinical evaluation of Mineral Trioxide Aggregate and Biodentine™ as direct pulp capping agents in carious teeth (2017).

Photos from Dr Rocio Lazo

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Recommended procedure*in 1 session 1.

Examination with x-rays if necessary. If the tooth can be restored (as in a cavitated lesion with reversible pulpitis), an ART can be considered.

Rinse with 1.5% hydrogen peroxide or a povidone-iodine oral rinse.

Administer local anesthesia as indicated.

Place rubber dam for isolation.

If there is access to the lesion begin excavation of the caries using surgical curettes or spoon excavators, to remove as much of the lesion as is appropriate from clinical judgment. Place matrix if appropriate in preparation for the restoration.

Mix Biodentine™ and bulk fill the cavity with Biodentine™. The total handling time of Biodentine™ is 12 minutes (6 minutes for mixing and placement, and 6 minutes for setting in the mouth).

After complete setting of Biodentine™, the cavity may be covered in the same session with a composite filling in combination with a selfetching dentine adhesive if desired.

Remove the rubber dam and verify occlusion.

Patient can be dismissed with chewing, care and maintenance instructions.

*By Mark Roettger DDS, Chief of Dentistry, University of Minnesota Medical Center

10. Set up appropriate phone follow-up.

Learn more about Biodentine

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CLICK HERE

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HOW TO BETTER MANAGE YOUR PATIENT'S PAIN

Undeniably, dentists who can provide informed pain management are highly sought after. Because pain is complex and specific to each person, there is no easy solution. Your goal is to create a sustainable and pleasant relationship with your patient through optimal care. We’ll see that many prejudices can hinder effective treatment, however some new approaches can support you in your daily practice. Today, pain management is not only drug-based, it strongly involves the way you communicate.

Pain is a question of perception Pain is a phenomenon produced by the brain, and there are as many ways to express pain as there are different people. Many factors contribute to pain’s variability: genetic inequality, gender, education, social background, culture, etc. Since pain expression varies so much and depends on all of these components, empathy becomes trickier: people tend to only recognise pain they can identify with personally. Practitioners need to overcome certain prejudices in order to avoid leaving a part of their patient base on the sidelines. Pain experienced by women in particular is systematically underestimated and consequently, under-treated. When suffering from an identical medical case, women receive less morphine compared to men. Gender bias or misconceptions in relation to biological differences are a common occurrence inside the medical system, and have led doctors to believe that women exaggerate their pain reports. These differences have been highlighted in a number of studies. 1 What’s more, a recent study has now confirmed that women are actually more sensitive to certain types of pain. For instance, they have twice the number of receptors in their face: women have 34, compared to 17 for men. This difference may support the claim that women exhibit a different sensitivity to pain. 2 Pain levels are also often underestimated for black patients and other ethnic minorities, notably due to misconceptions about biological differences, leading to a gap in treatment and patient care.

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For example, one retrospective study found that black patients were significantly less likely than white patients to receive analgesics for extremity fractures in the emergency department (57% versus 74%), despite similar self-reported pain.3 Individuals may also express pain differently due to their cultural background. For instance, stereotypes on masculinity may prevent some men from expressing their pain effectively.4 Consequently, as a dentist, it’s crucial to remain attentive while delivering the highest degree of care. However, it is not always easy to know what to recommend in each situation. Recent studies have introduced new avenues for pain management in patient care. New pain treatments To ensure that your patients receive optimal pain management in your practice, there is now a whole range of new techniques for you to discover or explore in greater detail. Your patients are the only ones who can tell you what they are feeling. Their participation is crucial in assessing the intensity of the pain and the effectiveness of the proposed treatments. Accordingly, new ways of managing pain take the patient into account as a whole, by calling on all their physical but also mental resources. Good communication is now the key to optimizing the therapeutic relationship. In order to succeed in this challenge, here are some guidelines that will put you on the right path.

PAIN CONTROL Using scales to express pain

Use active listening to relieve pain This technique covers two aspects:

You may use some tools to help a patient express their feelings of pain. Among the most frequently used 3, 4

Empathy It is absolutely necessary to believe what your patient tells you about their pain. There is nothing imaginary in their perception, even if it seems exaggerated to you, it is their own experience of the pain, which may be amplified by emotion. Knowledge sharing As a dentist, it is best to establish a partner relationship with the patient. When you share your knowledge with them and explain procedures in detail, you involve them in their care and reassure them. So, before initiating a treatment procedure, explain its purpose, the different stages and subsequent treatment plan to your patient. Finally, invite them to ask you questions which you will respond to in a simple and precise manner. By gaining their overall trust, you can co-create an authentic and viable care plan that lowers patient anxiety so it has less of an impact on pain expression.

The Visual analogue scale (VAS) A small ruler on which patients are asked to indicate their pain intensity by moving a cursor from one end to the other. The back of the ruler, designed for the assessor, has a scale from 0 to 10 (or 0 to 100 mm). However, just because two patients rate their pain between 7 and 10 does not mean that they will experience the same intensity. This assessment must be accompanied by a dialogue between the carer and patient. The numeric rating scale (NRS) The healthcare provider asks the patient to self-assess the current level of pain by circling the number from 0 to 10 that best describes their level of pain. A score of 0 is "no pain." A score of 10 is the "worst pain imaginable." Both methods can be used to assess pain but can also be used to express a level of anxiety.

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Soothing behavior and language Learn to calm the patient's anxiety by being mindful of your choice of words. Healthcare received during childhood, or a bad experience can lead to unfounded fear. Your language, both verbal and non-verbal, will reassure the patient by being consistent. If you say, "I'm listening" your attitude should confirm this: don’t look out of the window or consult another file at the same time. This becomes obvious when you consider the "3V rule," based on studies published in 1967 by Professor Albert Mehrabian, according to which only 7% of communication is verbal (spoken word), 38% of this communication is vocal (tone and sound of voice), 55% is visual (facial expression and body language). This means that 93% of communication is non-verbal.5

to get past the acute episode. On the other hand, it enables an in-depth study of patterns in the person's life. This in-depth work will not only lead to the understanding of the problems and their roots, but also to the modification of the dysfunctional patterns. CBT is worth exploring both for patient comfort and practice productivity. This is because dental phobia can lead to repeated cancellations, constant rescheduling of appointments, or the inability to treat or reassure a very anxious patient. It may be a good idea for your practice to inform some patients about this type of behavioural therapy. Conducted by a psychologist, it is generally short and effective because it is tailored to a specific objective. The integrative approach

However, words do have real power, especially when used in medical hypnosis. This is an increasingly popular technique in dental surgeries. This technique allows you to induce a state of relaxation in the patient, by fixing their attention elsewhere using a calibrated rhythm in your speech. How to step out of your role During your training, you may have learned to maintain a clinical distance and an even temperament. You may also have been advised not to get too close to your patients, for fear of absorbing their suffering and taking it on yourself. However, you have everything to gain by listening to your patients and exploring their needs by asking them questions. Cognitive behavioural therapy (CBT) When the pain has no discernible physical cause, how do you proceed as a practitioner? It might be of interest to explore its origin by using psychological therapies such as cognitive behavioural therapy. On the one hand, CBT focuses on relieving the manifestations of a psychological problem in order

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When medication alone no longer helps patients, the aim is to help them become more autonomous in understanding and managing their pain. Integrative medicine combines standard treatments with alternative therapies 6 such as acupuncture, mindfulness, massage or Qigong practice 7. The first step is to educate and raise awareness of these techniques. Training courses are available for those who want to go further and integrate them into their practice. References 1

https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC3690315/

https://www.vidal.fr/maladies/douleurs-fievres/prise-chargedouleur/femme.html https://journals.lww.com/plasreconsurg/ Abstract/2005/ 10000/ Increased_Cutaneous_Nerve_Fibers_in_Female.31.aspx

https:/www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6157457

http://www.kaaj.com/psych/smorder.html

https://www.cairn.info/revue-hegel-2015-4-page-346.htm

Qigong, traditional Chinese gymnastics that combines slow movements, breathing exercises and concentration in the control of vital energy

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ENDODONTICS

BIOCERAMIC TECHNOLOGY THE GAME CHANGER IN ENDODONTICS

Dr Ken Koch and Dr Dennis Brave take a look at the increased use of bioceramic technology in endodontics, what they believe is changing the game as we know it.

Recently, we have seen a great rush to condemn teeth and place implants among both general dentists and specialists. While these recommendations may be somewhat questionable, we want all clinicians not to forget the many benefits that well done endodontics can bring to their patients. Furthermore, this desire to have dentists understand the benefits of good endodontics is critical to having the natural tooth remain a key component of restorative dentistry.

(www.realworldendo.com). The basic EndoSequence file system has given all clinicians the ability to machine predictable shapes that ultimately lead to synchronicity between the preparation and the master cone fit.

Fortunately, over the past two decades, new techniques and technology have been developed that allow the majority of dentists to perform better endodontics.

Activ GP is a system which utilizes improved glass ionomer technology (both as a sealer and as a special glass ionomer coated gutta percha cone) to create a true single cone obturation. This is very significant because a true single cone technique will allow us, for the first time, to create a hermetic seal within the root canal space. A hermetic seal has been a goal of endodontics for more than 50 years. Furthermore, a true single cone technique is a method that is now clinically achievable as a result of improved material science. Most importantly, such a technique (when performed properly) will give the greatest percentage of clinicians (due to the ease of technique) the ability to produce superior obturation results (Koch, Brave, 2006).

Significant among these changes is the introduction of advanced material science. However, we have only recently witnessed significant changes in endodontic material science. The good news is that the arena of endodontic material science is continuing to evolve and, in fact, the game has changed. The game changer is the increased use of bioceramic technology in endodontics; more specifically in endodontic obturation. It has been a continuing goal of Real World Endo to develop products and techniques that will deliver excellent endodontic results in the most efficient manner. Furthermore, it has been an additional goal to design these techniques in such a manner that the greatest majority of practitioners will be able to perform these procedures successfully and in a predictable manner

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Embracing this concept of synchronicity, and taking it to a more sophisticated level in obturation are sealerbased obturation systems such as the Activ GP Obturation System and EndoSequence BC Sealer (Brasseler USA, Savannah, Georgia).

In fact, in a study published in the Journal of Endodontics in 2008, Fransen et al at Baylor University compared the sealing ability of single cone Activ GP with glass ionomer sealer to the warm vertical compaction of gutta percha with AH Plus sealer and to the warm vertical compaction of Resilon with Epiphany sealer. Their conclusion was:

ENDODONTICS ‘In summary, there were no statistically significant differences for any of the parameters tested between the three obturation systems tested. Based on these results, the single cone Activ GP /GI sealer system has potential as an obturation system to provide a seal comparable to that achieved with other popular obturation systems.’ (Fransen et al, 2008).

A diplomate of the American Board of Endodontics, and a member of the College of Diplomates, Dr Dennis Brave received his DDS degree from the Baltimore College of Dental Surgery, University of Maryland and his Certificate in Endodontics from the University of Pennsylvania. Along with having authored numerous articles on endodontics, Dr Brave is a co-founder of Real World Endo. For more information, please visit www.realworldendo.com.

Also Russell and his colleagues at Fort Bragg (US Army) conducted ‘a study utilizing a fluid filtration method which showed no statistically significant difference in leakage between the Activ GP Obturation system and gutta percha (and AH Plus sealer) using a warm vertical continuous wave of condensation technique.’ (Russell et al, 2007).

Figure 1 EndoSequence BC Sealer

These two non-sponsored studies are offered as evidence that a single cone obturation technique can be very effective if performed properly and with the correct materials. However, gaining acceptance for a true single cone technique has taken a number of years and has had its challenges. In the original pursuit of achieving a hermetic seal in endodontics, glass ionomer (Ketac Endo) was selected because of its superior biocompatibility and its physical properties. However, a problem historically with the early generations of glass ionomer, and resin sealers, was that neither method was able to develop a true monobloc.

Figure 2 The tip of the syringe should be inserted into the canal no deeper than the coronal one third

Although there were advocates on both sides of the argument, research showed that both the glass ionomer and resins sealers each had some advantages and some limitations. However, one thing that both the resin and glass ionomer advocates could agree on was that obturation was headed in the direction of sealer based techniques rather than the mechanical packing and melting of gutta percha. It is also very interesting to see how the two materials differed. The resins were shown to have a good seal between the sealer and the gutta percha cone but their seal to the canal wall was questionable. The glass ionomer cements, on the other hand, displayed an excellent seal to the canal wall but their seal to the gutta perha was less than ideal. So as the 20th century came to a close, we still found ourselves searching for a technique that could consistently deliver a true monobloc obturation (Koch, Brave, 2006).

This made sense from both the technical and science sides. Dr Ken Koch received both his D.M.D. and Certificate in Endodontics from the University of Pennsylvania School of Dental Medicine. He is the founder and past director of the new program in Postdoctoral Endodontics at the Harvard School of Dental Medicine. In addition to having maintained a private practice limited to endodontics, Dr Koch has lectured extensively worldwide and is the author of numerous articles. Dr Koch is a co-founder of Real World Endo.

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ENDODONTICS Activ GP obturation is, in fact, a single cone technique that requires a minimal amount of sealer, rather than the excess that is utilized in other methods. This is because the system is precisionbased. As previously mentioned, precision-based endodontics requires accuracy between the file and the master cone. Similar to the regular EndoSequence gutta percha, all Activ GP points are laser verified (and calibrated) to precisely match the preparations made by the .04 or .06 tapered EndoSequence file system. The precision matching of the primary cone to the preparation (endodontic synchronicity) is very important with any single cone technique because the accuracy of the cone fit to the preparation minimizes the amount of sealer and any dimensional change. Although dimensional change can occur with all sealers, glass ionomer is very stable and does not shrink. Furthermore, due to the predictability of shape associated with constant tapers, it may be stated that a true single cone technique should be accomplished with a constant tapered preparation such as a .04 or .06. A variable taper technique is not recommended because its lack of shaping predictability (and its corresponding lack of reproducibility) will lead to a less than ideal cone fit. This lack of endodontic synchronicity is why all variable taper preparations are associated with thermoplastic techniques. While glass ionomer has been a huge help in establishing a true single cone filling technique, there has always been practitioners who question the handling characteristics of glass ionomer. While respecting those questions about handling characteristics, the obturation equation has further changed with the introduction of a new material – bioceramics. This new bioceramic technology is the basis of EndoSequence BC Sealer. But, before we discuss how this specific sealer is changing obturation, we need to address some of the merits associated with bioceramics. The first question we need to ask ourselves is, ‘what are bioceramics?’ Bioceramics are ceramic materials specifically designed for use in medicine and dentistry. They include alumina and zirconia, bioactive glass, glass ceramics, coatings and composites, hydroxyapatite and resorbable calcium phosphates, and radiotherapy glasses (Best, Porter, Thian, Huang, 2008; Dubok, 2000; Hench, 1991).

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It is also very interesting to see how the two materials differed. The resins were shown to have a good seal between the sealer and the gutta percha cone but their seal to the canal wall was questionable. The glass ionomer cements, on the other hand, displayed an excellent seal to the canal wall but their seal to the gutta perha was less than ideal. So as the 20th century came to a close, we still found ourselves searching for a technique that could consistently deliver a true monobloc obturation (Koch, Brave, 2006). There are numerous bioceramics currently in use in both dentistry and medicine, although more so in medicine. Alumina and zirconia are among the bioinert ceramics used for prosthetic devices. Bioactive glasses and glass ceramics are available for use in dentistry under various trade names. Additionally, porous ceramics such as calcium phosphate-based materials have been used for filling bone defects. Even some basic calcium silicates such as ProRoot MTA (Dentsply) have been used in dentistry as root repair materials and for apical retrofills. However, we must ask ourselves another question, ‘what are the advantages of bioceramics in dental applications?’ Clearly the first answer is related to physical properties. Bioceramics are exceedingly biocompatible, non-toxic, do not shrink, and are chemically stable within the biological environment. Secondly (and this is very important in endodontics) bioceramics will produce little, if any, inflammatory response if an over fill occurs during the obturation process or in a root repair. A further advantage of the material itself is its ability (during the setting process) to form hydroxyapatite and ultimately a bond between dentin and filling materials. While the properties associated with bioceramics make them very attractive to dentistry, in general, what would be their advantage if used as an endodontic sealer? From our perspective as endodontists, some of the advantages are: enhanced biocompatibility, possible increased strength of the root following obturation, high pH (12.8) during the setting process which is strongly anti-bacterial, sealing ability, and ease of use (Hichman, 1990). The introduction of EndoSequence BC Sealer (Figure 1) allows us, for the first time, to take advantage of all the benefits associated with bioceramics but to not limit its use to merely root repairs and apical retrofills. This is possible because of recent nanotechnology developments (the particle size of BC Sealer is so fine, it can actually be used with a .014 capillary tip). When viewed in the overall context of obturation techniques, EndoSequence BC Sealer is a game changer.

ENDODONTICS to facilitate access to the root canal. Also, because the particle size has been milled to such a fine size, a capillary tip (such as a .014) can be used to place the sealer.

Furthermore, this material has been designed as a non- toxic calcium phosphate silicate cement that is easy to use as an endodontic sealer. In addition to its excellent physical properties, the purpose of BC Sealer is to improve the convenience and delivery method of an excellent root canal sealer while simultaneously taking advantage of its bioactive characteristics (it utilizes the water inherent in the dentinal tubules to drive the hydration reaction of the material, thereby shortening the setting time). Dentin is composed of approximately 20% (by volume) water (Koch, Brave, 2008) and it is this water which initiates the setting of the material and ultimately results in the formation of hydroxyapatite.

Following this procedure, insert the tip of the syringe into the canal no deeper than the coronal one third. (Figure 2). Gently and smoothly dispense a small amount (1-2 calibration markings) of EndoSequence BC Sealer into the root canal by compressing the plunger of the syringe. Using a #15 hand file or something comparable (such as the master cone), lightly coat the canal walls with the existing sealer in the canal. Then coat the master gutta percha cone with a thin layer of sealer and very slowly insert it into the canal. The synchronized master gutta percha cone will carry sufficient material to seal the apex. The precise fit of the EndoSequence gutta percha master cone (in combination with a constant taper preparation) creates excellent hydraulics and, for that reason, it is recommended that the practitioner use only a small amount of sealer. Furthermore, as with all obturation techniques, it is important to insert the master cone slowly to its final working length. Finally, here’s more good news. The glass components in the bioceramic sealer bond to the Activ GP glass ionomer coated cones. So, in essence what we have is a bond to the canal wall as a result of the hydroxyapatite that is created during the setting reaction and we also have a bond between the ceramic particles in the sealer to the ceramic particles in the glass ionomer coated cone (Activ GP). In a sense, the bioceramic cement, with its ease of use, can replace the glass ionomer sealer.

EndoSequence BC sealer setting reactions The calcium silicates in the powder hydrate to produce a calcium silicate hydrate gel and calcium hydroxide. The calcium hydroxide reacts with the phosphate ions to precipitate hydroxyapatite and water. The water continues to react with the calcium silicates to precipitate additional gel-like calcium silicate hydrate. The water supplied through this reaction is an important factor in controlling the hydration rate and the setting time as following: The hydration reactions (A, B) of calcium silicates can be approximated as follows: (A) (B) The precipitation reaction (C) of calcium phosphate apatite is as follows:

Case studies

(C)

The following five cases evidence the importance of maintaining endodontic synchronicity, particularly when doing a single cone technique. Also, please notice the radiopacity of BC Sealer. It’s excellent.

For clinical purposes, the advantages of premixed endodontic cement (sealer) should be obvious. In addition to a significant saving of time and convenience, one of the major issues associated with the mixing of any cement, or sealer, is an insufficient and non homogenous mix. Such a mix may ultimately compromise the benefits associated with the material. Keeping this in mind, BC Sealer has been designed as a premixed bioceramic sealer that hardens only when exposed to a moist environment (such as that produced by the dentinal tubules).

EndoSequence BC Sealer in combination with Activ GP cones creates an excellent single cone obturation technique. But, when we talk about a true single cone technique let’s think about what this really means. The easiest way to comprehend this is to compare a single cone technique to carrier based methods. Recently, many in the endodontic community have come to the conclusion that excessive coronal enlargement (of the radicular dentin) can adversely affect the long-term prognosis of a tooth. While various thermoplastic techniques have contributed to the problem of over enlargement of the radicular dentin (and subsequent weakening of the tooth), the recent use of carrier based obturation

The technique with this material is straightforward. Simply remove the syringe cap from the EndoSequence BC Sealer syringe. Then attach an intra canal tip of your choice to the hub of the syringe. The intra canal tip is flexible and can be bent

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ENDODONTICS (both gutta percha and Resilon) has also resulted in wider than ideal orifice enlargement. The rationale behind this is again quite simple. The larger the hole at the top of the canal, the less likely it is to strip (denude) the carrier of gutta percha (or Resilon). This has been one of the challenges associated with carrier based obturation (stripping the carrier at the orifice during insertion) (Koch, Brave, 2006). Certainly, one can get good obturation results with carrier-based techniques (as with other methods) if done properly, but this issue of stripping a carrier remains a significant one in endodontics. In these techniques, you heat the obturator and then insert it into the tooth, delivering it to a point just shy of the working length. Basically, you are using a hard plastic carrier to deliver heated gutta percha, or resin, into the root canal system. In addition to the concern of stripping (or denuding) the carrier of gutta percha (or resin) when inserted, is the lack of apical control that is the result of using heated gutta percha or resin. This concern about stripping the carrier at the orifice is often addressed by simply making the hole larger at the top of the canal. However, the concept of filling a root canal with a device that you can ‘feel’ makes sense. It is essentially the same with an Activ GP cone and BC Sealer, but with a few differences. Again, think what you are doing. You are, in essence, EP USA April Koch.qxd 10/3/09 17:27 Page 4 using a stiff carrier (but one that is actually a stiffer gutta percha cone, not a plastic carrier) to deliver a non-shrinking bioceramic sealer into the root canal Clinical system. So while you get the ‘feel’ of a carrier-based technique, you have the advantage of using gutta percha as a carrier to deliver sealer. After all, it is the sealer that creates the seal in obturation, not heated gutta percha (which shrinks significantly when Koch.qxd 10/3/09 17:27 Page 4 EP USA April Koch.qxd cooled). 10/3/09 17:27 Additionally, Page 4EP USA April postpreparation will be a lot easier because you are now removing gutta percha not cutting plastic. It just makes sense!

Retreatment of bioceramics Bioceramic sealer cases are definitely retreatable yet the issue of retreating these cases (and all the associated misinformation) is not unlike that of glass ionomer. Historically there has been confusion about retreating glass ionomer endodontic cases (glass ionomer sealer is definitely retreatable when used as a sealer (Friedman,Moshonov, Trope, 1993)) and, similarly, there has been confusion concerning the retreatability of bioceramics. The key is using bioceramics as a sealer, not a filler. This is why endodontic synchronicity is so important and again, why the use of constant tapers makes so much sense (it minimizes the amount of endodontic sealer thereby facilitating retreatment). The technique itself is relatively straightforward. The key in retreating bioceramic cases is to use an ultrasonic with a copious amount of water. This is particularly important at the start of the procedure in the coronal third of the tooth. Work the ultrasonic (with lots of water) down the canal to approximately half its length. At this point, add a solvent to the canal (chloroform) and switch over to an EndoSequence file (#30 or 35 /.04 taper) run at EP USA April Koch.qxd 10/3/09 17:27 Page 4 an increased rate of speed (1,000rpm). Proceed with this file, all the way to the working Clinical length, using solvent when indicated. An alternative is to use hand files for the final 2-3mm and then follow the gutta percha removal with a rotary file to ensure synchronicity. Case 1: Four canal mandibular molar (courtesy of Dr Ali Nasseh)

Case 1: Four canal mandibular molar (courtesy of Dr Ali Nasseh)

Case 2: Three rooted maxillary premolar (courtesy of Dr Ali Nasseh)

Case 6 demonstrates the retreatment of BC Sealer. Case 3: Mandibular molar with a large mesial curvature (courtesy of Dr Ali Nasseh)

Case 3: Mandibular molar with a large mesial curvature (courtesy of Dr Ali Nasseh)

Case 4: Maxillary molar with obturated palatal delta demonstrating how BC Sealer can fill three dimensionally (courtesy of Dr Alex CaseFleury) 1: Four canal mandibular molar (courtesy of Dr Ali Nasseh)

Clinical

Case 1: Four canal mandibular molar (courtesy of Dr Ali Nasseh) Case 2: Three rooted maxillary premolar (courtesy of Dr Ali Nasseh)

Clinical

Case 4: Maxillary molar with obturated palatal delta demonstrating how BC Sealer can fill three dimensionally (courtesy of Dr Alex Fleury)

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Case 2: Three rooted maxillary premolar (courtesy of Dr Ali Nasseh)

Case 3: Mandibular molar with a large mesial curvature (courtesy of Dr Ali Nasseh) Case 4: Maxillary molar with obturated palatal delta demonstrating how BC Sealer can fill three dimensionally (courtesy of Dr Alex Fleury)

Case 3: Mandibular molar with a large mesial curvature (courtesy of Dr Ali Nasseh) Case 4: Maxillary

molar with obturated EP EPEP USA USA USA April April April Koch.qxd Koch.qxd Koch.qxd 10/3/09 10/3/09 10/3/09 17:27 17:27 17:27 Page Page Page 55 5 2 palatal delta 3 1

demonstrating how BC Sealer can fill three dimensionally (courtesy of Dr Alex Fleury)

Case 1 Four canal mandibular molar (courtesy of Dr Ali Nasseh)

Case 3: Mandibular molar with a large mesial curvature (courtesy of Dr Ali Nasseh)

Case 4: Maxillary molar with obturated palatal delta demonstrating how BC Sealer can fill three dimensionally (courtesy of Dr Alex Fleury)

Case 2: Three rooted maxillary premolar (courtesy of Dr Ali Nasseh)

Moshonov, Trope, 1993)) and, similarly, there has been Moshonov, Trope, 1993)) and, similarly, there has been 4 confusion concerning the retreatability of bioceramics. confusion concerning the retreatability of bioceramics. The key is using bioceramics as a sealer, not a filler. The key is using bioceramics as a sealer, not a filler. This is why endodontic synchronicity is so important This is why endodontic synchronicity is so important of favorable characteristics, including a pH of 12.5 which and again, why the use of constant tapers makes so of favorable characteristics and again, why the use of constant tapers makes so is anti-bacterial. However, the game has also changed in much sense (it minimizes the amount of endodontic is anti-bacterial. However, much sense (it minimizes the amount of endodontic terms of root repairs and apico retrofills. sealer thereby facilitating retreatment). terms of root repairs and a sealer thereby facilitating retreatment). The game changer is the new EndoSequence Root The technique itself is relatively straightforward. The The game changer is th The technique itself is relatively straightforward. The Repair material, which comes premixed in a syringe just key in retreating bioceramic cases is to use an ultrasonic Repair material, which com key in retreating bioceramic cases is to use an ultrasonic like BC Sealer. This is a tremendous help not just in with a copious amount of water. This is particularly like BC Sealer. This is a tre with a copious amount of water. This is particularly terms of assuring a proper mix but also in terms of ease important at the start of the procedure in the coronal terms of assuring a proper important at the start of the procedure in the coronal of use. We now have a root repair material with an easy third of the tooth. Work the ultrasonic (with lots of of use. We now have a roo third of the tooth. Work the ultrasonic (with lots of and efficient delivery system. water) down the canal to approximately half its length. and efficient delivery syste water) down the canal to approximately half its length. 3 Actually, EndoSequence Root Repair material has At this point, add a solvent to the canal (chloroform) Actually, EndoSequence At this point, add a solvent to the canal (chloroform) been created as a white premixed injectable cement for and switch over to an EndoSequence file (#30 or 35 /.04 3 been created as a white pre and switch over to an EndoSequence file (#30 or 35 /.04 both permanent root canal repairs and apico retrofillings. taper) run at an increased rate of speed (1,000rpm). both permanent root canal taper) run at an increased rate of speed (1,000rpm). Moshonov, Trope, 1993)) and, similarly, there has been Proceed with this file, all the way to the working length, It is an insoluble, radiopaque, and aluminum-free 4 Proceed with this file, all the way to the working length, It is an insoluble, radiopaq confusion concerning the retreatability of bioceramics. material based on a calcium phosphate silicate using solvent when indicated. An alternative is to use Moshonov, Trope, 1993)) and, similarly, there has been material based on a calcium using solvent when indicated. An alternative is to use The key is using bioceramics as a sealer, not a filler. composition. The setting and hardening reactions of this hand files for the final 2-3mm and then follow the gutta 4 concerning the retreatability of bioceramics. composition. The setting a hand files for the final 2-3mm and then follow the gutta This is why endodontic synchronicity is so important confusion material also require the presence of water from the percha removal with a rotary file to ensure Thesynchronicity. is using bioceramics including as a sealer, notofa 12.5 filler.which tissue or dentin tubules. As a bioceramic cement, the material also require the p percha removal with a rotary file to ensure ofkey favorable characteristics, a pH and again, why the use of constant tapers makes so is is anti-bacterial. However, the game has also changed in much sense (it minimizes the amount of endodontic This why endodontic synchronicity is so important tissue or dentin tubules. A synchronicity. advantages of this new repair material are (again) its Case 6 demonstrates the retreatment of BC Sealer. of why root repairs apico retrofills. sealer thereby facilitating retreatment). advantages of this new rep Case 6 demonstrates the retreatment of BC Sealer. of favorable including a pH of 12.5 andterms again, the useand of constant tapers makes so 5c 5c 5c high pH (pH characteristics, >12.5), high resistance to washout, no- which5d 5a 5a5a 5b 5b 5d 5b 5d The game changer is the new EndoSequence Root The technique itself is relatively straightforward. The much high pH (pH >12.5), high is anti-bacterial. However, the game has also changed in sense (it minimizes the amount of endodontic Bioceramics as a root repair material shrinkage during setting, excellent biocompatibility, and Repair which premixed in a as syringe key in retreating bioceramic cases is to use an ultrasonic sealer Bioceramics as a root repair material shrinkage during setting, e terms root repairs and apico retrofills. thereby facilitating retreatment). We are material, all familiar withcomes the success of MTA a rootjust superbofphysical properties. In fact, it has a compressive Case Case Case 5: 5: Maxillary 5: Maxillary Maxillary like BC Sealer. This is a tremendous help not just in with a copious amount of water. This is particularly We are all familiar with the success of MTA as a root superb physical properties The game changer is the new EndoSequence Root The technique itself is relatively straightforward. The repair and apico retrofilling material. Furthermore, we strength of 50-70MPa, which is similar to that of current terms of assuring a proper mix but in terms of ease important at the start of the procedure in the coronal repair and apico retrofilling material. Furthermore, we strength of 50-70MPa, whi premolar premolar premolar case case case Repair material, which comes premixed in a syringeand just keyrealize in retreating cases is also to use anand ultrasonic that it isbioceramic a modified Portland cement because root canal repair materials, ProRoot MTA (Dentsply) of asuch use. Weorigin, now have aofroot repair material third of the tooth. Work the ultrasonic (with lots of realize that it is a modified Portland cement and because root canal repair materials of an it has some limitations in with termsanofeasy BioAggregate (Diadent). a significant like BC Sealer. This is a However, tremendous help not upgrade just in with copious amount water. This is particularly demonstrating demonstrating demonstrating the thethe and efficient water) down the canal to approximately half its length. of such an origin, it has some limitations in terms of BioAggregate (Diadent). H handling It procedure does not come premixed with this material is its particle the of ease of assuring a proper mixsize butthat alsoallows in terms important atcharacteristics. thedelivery start ofsystem. the in the coronal(and terms initial initial initial placement placement placement of of of Actually, EndoSequence Root Repair material has At this point, add a solvent to the canal (chloroform) handling characteristics. It does not come premixed (and with this material is its par therefore must be mixed by hand), is difficult to use on premixed material to be extruded through a syringe of use. We now have a root repair material with an easy third of the tooth. Work the ultrasonic (with lots of BC BCBC Sealer Sealer Sealer (a,b) (a,b) (a,b) and and and been created as a white premixed injectable cement for and switch over to an EndoSequence file (#30 or 35 /.04 retrofills, therefore must be mixed by hand), is difficult to use on premixed material to be ex such large particle size cannot rather than mixing by hand and then placement with a and efficient delivery system. water) downand thehas canal toaapproximately halfthat its itlength. then then then the the the final final final both permanent root acanal repairs andYet apico retrofillings. taper) run at an increased rate of speed (1,000rpm). retrofills, and has such a large particle size that it cannot rather than mixing by han be extruded through small syringe. it has a number hand instrument. Actually, EndoSequence Root Repair material has At this point, add a solvent to the canal (chloroform) Proceed with this file, all the way to the working length, It is an insoluble, radiopaque, and aluminum-free placement placement ofthe of thea number hand instrument. be extruded through a placement small syringe. of Yet itthe has been created as a white premixed injectable cement for and switch over to an EndoSequence file (#30 or 35 /.04 material based on a calcium phosphate silicate using solvent when indicated. An alternative is to use single single single cones cones cones (c,d) (c,d) (c,d) both permanent root canal repairs and apico retrofillings. run at anThe increased of speed (1,000rpm). PRACTICE 2009 composition. setting rate and ENDODONTIC hardening reactions of this APRIL hand files for the final 2-3mm and then16 follow the gutta taper) (courtesy (courtesy (courtesy ofofDr of DrAli Dr AliAli Proceed with this file, all way toofthe working length, It is an insoluble, radiopaque, and aluminum-free 16 ENDODONTIC PRACTICE APRIL 2009 material also require thethe presence water from the percha removal with a rotary file to ensure Nasseh) Nasseh) Nasseh) material based on a calcium phosphate silicate using solvent whentubules. indicated. alternative is to the use tissue or dentin As a An bioceramic cement, synchronicity. composition. The setting and hardening reactions of this hand files for the final 2-3mm and then follow the gutta advantages of this new repair material are (again) its Case 6 demonstrates the retreatment of BC Sealer. material also require the presence of water from the percha with a rotary file to ensure high removal pH (pH >12.5), high resistance to washout, noand and and Case Case Case 6:6:Pre6: PrePre-

Clinical Clinical Clinical

Case 5 Maxillary premolar case demonstrating the initial placement of BC Sealer (a,b) and then the final placement of the single cones (c,d) (courtesy of Dr Ali Nasseh)

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Dubok Dubok VA, VA, (2000) (2000) Bioceramics Bioceramics Yesterday, Yesterday, Today Today Tomorrow, Tomorrow, Powder Powder Metallurgy Metallurgy and and Metal Metal Ceramics, Ceramics, 39(7-8) 39(7-8)

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Friedman S, Moshonov J, Trope M, (1993) Residue of gutta percha and a glass ionomer sealer following root canal retreatment, Intl Endo Jour, 26(3): 169-172

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Bioceramic Bioceramic Bioceramic technology technology technology isisaisaof game agame game As a bioceramic cement, the advantages this new Bioceramics Bioceramics Bioceramics ininEndodontics in Endodontics Endodontics Dentaltown Dentaltown Dentaltown changer! changer! changer! repair material are (again) its high pH (pH >12.5), high Pashley Pashley Pashley DH, DH, DH, (1996) (1996) (1996) Dynamics Dynamics Dynamics ofofthe of thethe Pulp Pulp Pulp Dentin Dentin Dentin Complex, Complex, Complex, Crit Crit Crit Rev Rev Rev resistance to washout, no- shrinkage during setting, References References References Oral Oral Oral Biol Biol Biol Med Med Med 7(2): 7(2): 7(2): 104-133 104-133 104-133 excellent biocompatibility, and superb physical etal. et al.(2007) al. 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ENDODONTICS

RESTORING DAMAGED TEETH USING GUTTAFLOW, PARAPOST FIBER POSTS, AND PARACORE BUILD-UP MATERIALS

“Using new Adhesive materials and technology, clinicians can bond a post securely to the dentin in the root canal space, the core build-up to the post, and the final crown restoration to the core and tooth” By Ricardo Caicedo, Doctor Odont; Paulino Castellon, DDS; and Joseph Fullmer, BA It is generally accepted that the successful treatment of a severely damaged tooth with pulpal disease depends not only on good endodontic treatment, but also on good prosthetic restoration of the tooth immediately after root canal treatment is completed. It is recommended that a post-andcore system is used to restore an endodontically treated tooth that has suffered significant loss of coronal structure. The post-and-core systems contain three components of different rigidity: the post, the cement, and the core material. As the most rigid component, the post is able to resist forces without distortion; as a result, stress is transferred to the least rigid substrate, the dentin, and may lead to failure.1 The difference between the elastic modulus of dentin and post material is a source of stress for the root structures. Metal cast posts have been used to restore endodontically treated teeth, but ideal canal preparation is paramount for the success of this type of post.2 As a result, the use of composite, glass ionomers and amalgam cores has been advocated to avoid the insertion of metal posts into the root canal.3 Using new adhesive materials and technology, clinicians can bond the post securely to the dentin in the root canal space, the core build-up to the post, and the final crown restoration to the core and tooth, with all components having similar physical properties bonded together as one unit. Retention between bonding systems and the core material is vital to the longevity of the restoration. For optimum bond strength, adhesive and core materials must be compatible.4 ParaPost® Fiber White, ParaPost Fiber Lux, ParaCem®, and Para- Post ParaCore (Coltene

052

Whaledent) materials all meet these criteria. It is important to remember that the success of a postand-core restoration hinges upon many factors, one of which is the success of the endodontic procedure. In this article we will discuss the GuttaFlow® method of root canal treatment with which the cases presented were treated. The GuttaFlow system is a new self-curing filling system for root canals that combines two products in one: gutta percha in particle form (less than 30 μm) and sealer. This injectable system provides a reliable and time-saving obturation. The flowable gutta percha is composed of polydimethylsiloxane, guttapercha powder, zinc oxide, zirconium dioxide, silicone oil, paraffin-base oil, colloidal silver (preservative), hexchioroplatinic acid (catalyst), and colouring. Properties of GuttaFlow include: high sealing ability requiring only one master gutta-percha point, homogeneously mixed flowable gutta percha that flows into isthmuses and lateral canals, and radiopaqueness. GuttaFlow consists of two components in one capsule that are activated by compression. The capsule is mixed for only 30 seconds in a standard triturator. Removal of the GuttaFlow, in preparation for post insertion, is similar to that of traditional gutta percha. This article describes a post-and-core technique previously used in 17 cases over a period of 24 months where a severely damaged molar was restored.5 During that period, there were no failures on the restored teeth due to root fracture, debonding, or core failure.

ENDODONTICS

Figure 1. Preoperative radiograph of teeth 32-42. Note the loss of coronal tooth structure.

Figure 2. Preoperative radiograph of tooth 11 showing the previous metal post and failed root canal treatment.

Figure 7. ParaPost Fiber White posts adapted and ready for cementation.

Figure 8. Radiograph of 11 showing ParaPost Fiber Lux before cementation.

Figure 3. Metal post removed with ultrasonic energy from failed restoration.

Figure 4. Radiograph of tooth 11 showing canal space after post was removed using ultrasonic energy.

Figure 9. Postoperative view of the final restoration using ParaPost Fiber White system

Figure 10. Postoperative photograph of finished restoration of 11 using ParaPost Fiber Lux aesthetic system.

Figure 5. Root canal treatment of teeth 32-42 using GuttaFlow.

Figure 6. Treatment of 11 using GuttaFlow with gutta-percha master cone.

Figure 11. Post-op radiograph of final restoration of 11.

Figure 12. Prepared canals ready for placement of Fiber White glass fiber posts

Figure 13. Occlusal view of teeth 32 through 42, showing acid-etching with 37% phosphoric acid after the posts have been cemented in each canal.

Figure 14. Postoperative radiograph of teeth 32 through 42 shows Fiber White posts are cemented to adequate length and periapical lesions are healing.

Figure 15. Core material cured and ready for preparation for the final restoration.

Figure 16. Prepared teeth 32-42.

Figure 17. Temporary restorations using the ParaPost Fiber White system.

Figure 18. Radiograph showing cemented ParaPost Fiber Lux in place in tooth 11 and prepared core.

Figure 19. The prepared tooth with ParaPost ParaCore.

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053

ENDODONTICS

Case One A 62-year-old man needing treatment of teeth 32 through 42 was referred to our clinic for evaluation due to periapical radiolucencies in the aforementioned teeth (Figure 1). He reported a period of cold and hot sensitivity 8 months prior but had not had any temperature tenderness for several months. The pulpal and apical diagnosis was necrosis in addition to chronic apical periodontitis. Case Two A 53-year-old woman who had had previous root canal treatment and a prefabricated post-andcore restoration on tooth 11 (Figure 2) was referred because of periapical radiolucence. The patient reported throbbing pain in the maxillary central incisor region for several weeks. The apical diagnosis was chronic apical periodontitis because of root canal failure. The post was removed using ultrasonic energy (Figures 3 and 4). Case treatments Root canal treatments using the crown-down technique and GuttaFlow filling material were performed on the canals of each case (Figures 5 and 6). The crown structure of the teeth in Case One was restored with Para- Post Fiber White, and in Case Two with ParaPost Fiber Lux after post removal (Figures 7 and 8). The posts were cemented with ParaCem, and the build-ups with ParaPost, ParaCore and full metal-ceramic crowns were posteriorly cemented as a part of the patients’ general treatment plan (Figures 9 through 11). Both cases were clinically monitored for 12 months. On the final periapical radiograph following obturation, the apical space, width and length of the root canals were checked (Figures 5 and 8). The working field was isolated with a rubber dam. Two thirds of the total canal length of the canals was used for the post

054

space. The GuttaFlow was removed to the desired depth using a Touch’n Heat 5004 instrument (SybronEndo) leaving 5 mm of GuttaFlow in the canals (Figures 8 and 12). A rotary reamer was selected according to the canal thickness on the radiograph using a template provided in the post system in both cases. The canals were prepared using a low-speed handpiece. For Case One, a 4.5mm rotary reamer was selected for the canals. ParaPost Fiber White drills were used with a slow-speed contraangle. The 4.5mm ParaPosts Fiber White were cut at the apical aspect to the required length with a diamond-finishing bur (Figure 7) in Case One. A 5.5mm ParaPost Fiber Lux was used in Case Two (Figure 8). After try-in and before cementation, the posts were cleaned gently with an alcohol swipe. The canals were cleaned and disinfected using a chelating agent with an ultrasound activation for 30 seconds and thorough irrigation of sodium hypochlorite. 6,7 At that point, the canals were etched for 15 seconds with 37% phosphoric acid, rinsed with water and dried with paper points, leaving the surface slightly moist. ParaBond Non-Rinse Conditioner from the ParaPost Cement Intro Kit was applied. Equal parts of adhesive conditioner ParaBond A and ParaBond B were mixed, applied to the canals with an endodontic paper point, and air-dried for 3 seconds. Conditioner was applied along the posts. The ParaCem base and catalyst were mixed in equal parts and layered uniformly along the canals using an endodontic file. Cement was applied along the canals, using an endodontic file of the same size as the canals, and the posts were placed into the canals to full depth, allowing excess cement to vent. Excess cement was cleaned; at that point, the dentin and coronal portions of the posts were etched for 15 seconds with 37% phosphoric acid, rinsed with water, and blotted dry, leaving a moist surface (Figure 13).

ENDODONTICS A ParaForm matrix was adapted, and ParaCore was injected around the post, tooth structure, and matrix form. Excess ParaCore was removed with an explorer, and each surface of the tooth was photocured for 30 seconds. At that point, the tooth was ready to be prepared for prosthetic restoration (Case One: Figures 14 through 17; Case Two: Figures 18 and 19).

References 1.

Sorensen JA, Martinoff JT. Clinically significant factors in dowel design. J Prosthet Dent. 1984;52(1):28-35.

Shillingburg HT, Hobo S, Whitsett LD, et al. Fundamentals of Fixed Prosthodontics, 3rd edition. Chicago, IL: Quintessence Publishing Co.;1997:194-204.

Sorensen JA, Engelman MJ. Effect of post adaptation on fracture resistance of endodontically treated teeth. J Prosthet Dent. 1990;64(1):419-424.

Dietschi D, Romelli M, Goretti A. Adaptation of adhesive post and cores to dentin after fatigue testing. Int J Prosthodont. 1997;10(6):498-507.

Caicedo R, Castellon P. Using ParaPost Tenax fiberglass and ParaCore build-up material to restore severely damaged teeth. Gen Dent. 2005;53(3):200-203.

Standlee JP, Caputo AA. Endodontic dowel retention with resinous cements. J Prosthet Dent. 1992;68:913-917.

Serafino C, Gallina G, Cumbo E, et al. Ultrasound effects after post space preparation: An SEM study. J Endod. 2006;32 (6):549-552.

Caicedo R, Clark S, Rozo L, et al. Guidelines for access cavity preparation in endodontics. Dental CE Digest. 2006;3(2):13-20.

Discussion Straight-line access of the canal system is desirable in endodontic treatment to minimize unnecessary instrumentation and removal of root-dentin structure.8 The most important consideration regarding the use of a post system are the following principles: 1.

Removal of the smear layer, debris, and sealer/ gutta-percha remnants in order to increase retention with a pretreatment of the dentinal canal wall with a chelating agent, ultrasound activation, and sodium hypochlorite before the etching procedure and post cementation; Adequate length;

3. Adequate resistance form and adequate strength to allow preservation of dentin structure; and 4.

An adequate ferrule. If these principles are followed, most post systems will perform well.7 The ParaPost Fiber White and ParaPost Fiber Lux translucent fiber-reinforced post-and-core system, together with an adhesive cementation procedure, may reduce the incidence of root fracture compared to metal posts. However, posts differ among brands, making careful selection very important. Although this new generation of bonded fiber posts seems promising, long-term clinical data are still accumulating, and other fiber post-andcore systems merit investigation.

About the authors

Disclaimer

Dr Ricardo Caicedo is Professor and Director, Advanced Endodontics at the- University of Louisville School of Dentistry, Louisville, Kentucky.

The authors have no commercial affiliation with the company manufacturing the products used in these clinical cases.

Dr Paulino Castellon is Assistant Professor, Department of Prosthodontics, Louisiana State University School of Dentistry, Baton Rouge, Louisiana. Joseph Fullmer is an Assistant Researcher and Student, University of Louisville School of Dentistry, Louisville, Kentucky. Reprinted from Inside Dentistry Volume 3 Number 1, Pages 94-99, January 2007. Copyright 2007. Reprinted with permission from Aegis Publications, LLC.

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DR RICARDO CAICEDO Louisville, Kentucky

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R.T.R.+ IN PRACTICE MANAGING THE EXTRACTION SOCKET

Pierre Koumi shares a dental practice with his colleagues in Brussels, where they specialise in periodontology and implantology, so this was the perfect environment to get feedback on the use of the innovative R.T.R.+ formula, a synthetic bone substitute made from tricalcium phosphate (ß-TCP) and hydroxyapatite (HA). During our interview, we also spoke about the challenges in dentistry and the importance of patient education. Why did you choose to specialise in periodontology and implantology? For me, dentistry is a real crossroads of several different aspects: intellectual, manual, scientific, medical, human, artistic and creative. Before specialising in periodontology and implantology, I worked for 8-9 years as a general practitioner, which I call “Comprehensive Dentistry”, which allowed me to have an overall, critical view of dentistry. This is an essential base to analyse complex cases, which often require a multidisciplinary approach. I am also lucky enough to work with colleagues who share the same passion and conviction as me, which has allowed us to progress and to learn from each other, which plays an important part in us feeling fulfilled professionally. I am particularly passionate about the surgical aspect of periodontology because that allows me to use creativity, based on rigorous scientific and medical principles, to work with living human tissue and to rebuild lost tissue, which is simply magical.1 Each intervention is a challenge that relies on the practitioner and their skill but also depends on the patient and their specific physiology and their cooperation. I also enjoy the educational aspect with my patients, to raise their awareness about periodontal disease, which patients often don’t know about, or underestimate how serious it can be. I love sharing my experience with my colleagues and learning from their criticism, comments, and their specialities. It is a profession that keeps changing, and we need to keep learning all the time…

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What are the challenges you face, and how do you prepare for the future? The time of the pandemic made us think about our weaknesses in the face of nature. Covid alerted us to our daily practice, which is extremely high-risk. The challenge is treating our patients in record time, with a surgical intervention which is as non-invasive as possible in order to limit the complications and reduce post-operative recovery, as well as the risk of contamination. This goes alongside advances in IT technology, which allows us to plan more and more cases virtually, preparing the different kinds of surgical guide matrices in advance (implant surgery guide, a matrix in the form of a grid or metal post for bone grafts…), or digital imprints, this can reduce the number of surgical stages or operating time, and thus reduces post-operative complications and even the risk of contamination. In which situations do you use an R.T.R.+ solution? R.T.R.+ is a synthetic biomaterial, made from hydroxyapatite and beta-tricalcium phosphate (ß-TCP), which are used as bone substitutes to fill in or reconstruct the bone, thus acting as a bone graft. There are different kinds of bone grafts: autografts (autogenous bone from the patient), allografts (bone from cadavers), xenografts (bone from another species, bovine or porcine…), and alloplastic grafts (synthetic grafts).

SURGICAL All these filling materials have different properties on bone formation: -

osteogenic properties (living osteocytes present in the material),

osteoinductive properties (stimulates bone formation through the activation of the differentiation of mesenchymal cells into osteoprogenitor cells),

osteoconductive cells (the material plays a role that supports bone formation).

Their physicochemical properties (resorbable or not, porosity…) will also influence the behaviour of osteogenic cells. R.T.R.+ is an osteoconductive biomaterial, so it will play a part in supporting bone formation to a predefined limit. For me, the indications are the management of the extraction socket, bone regeneration, which is guided in horizontal and vertical bone increase, bone grafts under the sinus membrane (sinus lift), filling cystic cavities, filling in bone craters in periodontology and implantology. “R.T.R.+ is an osteoconductive material, and plays a part in supporting bone formation to a predefined volume.” Why do you choose tricalcium phosphate (ß-TCP) and/or hydroxyapatite? We choose hydroxyapatite because it is an osteoconductive biomaterial that is not resorbed, or only very, very slowly. This will give the bone cells enough time to form in sufficient volume, maintained by the hydroxyapatites. However, the ß-TCP particles, which also play an osteoconductive role, are resorbed gradually, soon leaving room for the bone to form, and in theory, it will lead to a bone graft that is richer in living bone cells. I think that it is an original idea to combine the 2 products, as I believe this will give a bone graft with a higher percentage of living bone than if we just use hydroxyapatites… this could be the subject of a comparative study. a.

When do you decide to use the 80/20 formula (more ß-TCP than hydroxyapatite) In cases where the volume that we want to fill will not undergo a significant structural change (cystic cavity, intraosseous periodontal or implant craterisation).

When do you decide that it is better to use the 40/60 formula (more hydroxyapatite than ß-TCP) In cases where the volume that we want to fill could undergo rapid structural changes due to its nature, such as the extraction socket, or due to its function, like the sinus and its Schneider membrane, which is constantly under pneumatic pressure.

In the case of sinus lifts, I prefer biomaterials that are not resorbed quickly, which will also hold the sinus membrane in place and thus allow time for osteogenesis. What were your first impressions when you used R.T.R.+? I still haven’t had enough time to use this product, but my first impressions are rather positive. For example, in one of the clinical cases where I performed guided bone regeneration (GBR) in a horizontal bone graft, to widen the ridge and place the implant in the ideal prosthetic position, I used R.T.R.+ mixed with drilling auto bone generator to increase the osteogenic potential through vascular supply from the drill holes and through living osteocytes in the recovered bone boring. Then I covered and stabilised the mixture of RTR+ and bone boring with a membrane of resorbable collagen. After 6 months of healing, I opened the site in order to position the implant. My first impression was very positive, the graft had taken very well, despite the presence of a few grains of R.T.R.+ which were still visible on the bone surface, but attached and fixed to the bone, without being surrounded by and isolated from the bone. I think that this is a product that deserves a comparative scientific study more detailed than just a “clinical impression”. Moreover, the fact that R.T.R.+ is 100% synthetic reassures patients regarding the risk of contamination.

Pierre Koumi He was awarded his master’s degree in dental sciences from the University of Brussels (ULB), where he also specialised in periodontology and implantology. At the University of New York, he followed the “Linhart International Continuing Dental Education”, a two-year dental course entitled “Current Concepts in American Dentistry, Advances in Implantology and Periodontics”. He was hired by the University of New York as international program director for Belgium. He joined the University of Liege (ULG) in Belgium for a further two-year training course and obtained his European Inter-university Certificate of competence in implantology. He runs a private practice focusing on periodontics and implant surgery in Brussels, Belgium

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CLINICAL CASE on managing the extraction socket with R.T.R.+ and a connective tissue graft Any dental extraction brings about inevitable tissue alterations (soft and hard tissues). These alterations often result in bone loss after extraction of 20% to 60% in volume horizontally and 11% and 20% vertically. 1 So, this bone loss is massive and can reach 50% of the volume if we allow healing to take place spontaneously without the addition of biomaterials, which complicates the three-dimensional positioning of the implant and making the prosthesis. Studies show that the use of low bone resorption biomaterials associated with atraumatic surgery (extraction without flap) and the use of collagen matrices could reduce this bone loss by up to 10-15%, which would allow optimal positioning of the implant in the second surgical phase. 2 Other studies 3 show that the use of an osteoconductive material with a low resorption rate and the application of a connective graft over the socket could reduce horizontal and vertical bone resorption even further and thus compensate for this bone loss by a thickening of the soft tissues, which would facilitate the optimal placement of the implant and give an aesthetic gingival contour without loss of volume, which would improve the emergence profile of the crown. This is the technique described in this clinical case with the use of R.T.R.+ (80/20 formula) and connective tissue.

The presence of this connective tissue will ensure that the R.T.R.+ will stay in place, and more importantly, it will compensate in vestibular terms for the loss of volume of soft tissue which occurs despite filling. Clinical case 54-year-old patient in good general health. The request was both aesthetic and functional and she presented with a gingival smile and a root fracture of tooth 21. This clinical case took place in 2021 and used the R.T.R.+ 80/20 formula. The fitting of the implant is due to take place in January 2022, around 6 months later.

Sources 1.

TanWL et al;"A systematic review of post-extraction alalveolarhardand soft tissue dimensional changes in humans' ClinOralImplantsRes. 2m2; 23(Suppl 5):1- 2t

Ju REetal: "Radio graphic evaluatiooafdi!Erent tec hniqoosklrridgeinservatianaflErb:Xlth extraction:a rnndamiZOIODltrolleddinCill trial' J ClinPerOOanml 2m3 Jan;4[Xl):9D-8.drn: l(lllll/jc:pe.12027

Darbyletal:'Ridge preservation:what is it and when should it be considered rAustralian Dental Journal 2008:53:l1-21

PIERRE KOUMI Belgium

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Tooth 21 cracked with a periapical lesion: requiring a treatment plan that consists in extracting tooth 21 and replacing it with an implant.

Preparation of a half-thickness ‘pocket’ to house the connective tissue graft

The graft will be placed with its two edges in the pockets prepared in the vestibular and palate areas

Preparation of the syringe (by aspirating a little of the patient’s serum and blood) and filling the extraction socket with R.T.R.+

Atraumatic extraction without flaps, in order to preserve the vascularisation of the socket bone as much as possible 3

R.T.R.+ in place 9a

Sample of soft tissue from the palate

Suture of the graft after having slid it into the vestibular pocket 9b

Suture of the other side of the connective tissue graft on the palate

Expected resorption times

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KOMET SURGICAL TRAINING QUIZ

Surgical drill. Philippe Tramba, University lecturer and hospital doctor (MCU-PH), University of Paris Descartes Department of Dentistry, Charles Foix Hospital, Paris Public Hospital (AP-HP) Today’s quiz is intended to recall some essential principles of surgical procedures, even though they might be considered “simple”. Among the various surgical recommendations already proposed in the issues (see ZI No. 3/4, 23 January 2013, pages 19- 27), 3 aspects have turned out to be particularly important: preservation of the surrounding periodontal tissues, preservation of the vestibular bone plate and adherence to the essential surgical principles. Therefore, a comprehensive analysis of the situation is definitely still required and concerns the clinical and radiographic examinations, the patient and his or her (medical or psychological) condition/history, the practice team (practitioner and assistant), the practitioner’s ability to carry out the surgical procedure (skills, experience) and the technical field/instruments to be used. This is exactly where the use of the surgical bur H162ST.314.016 by Komet comes into play. The specific shape of this rotary bur with high cutting efficiency contributes to the reduction of vibrations during use (in the turbine) and thus ensures comfortable use. It is available for highspeed micromotors and handpieces with short and long chucks.

Bone cutter H162ST.314.016 made by Komet

Question 1. Can all surgical burs considered to be roughly identical, and do they have the same functions? Question 2. Can surgical burs cut through different materials for tooth reconstruction (metal-ceramic crown, metal crown, resin, amalgam)? Question 3. Are the vibrations inversely proportional to the speed of the instruments? Question 4. Can the surgical drill H162ST.314.016 by Komet be used for: • cutting roots? • bone windows? • apical surgery with apical ectomy? • alveolotomy for ankylosis? Question 5. Does this new instrument represent an improvement on surgical burs with comparable shapes and sizes?

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Answers

Clinical situations (photos) Situation 1

1. No. They are all different, regardless of the brand and their manufacturing origin. There are differences regarding the quality of the materials, calibration (especially at high speeds), resistance to wear and sterilisation cycles, and shapes in terms of efficiency and cutting precision.

Extraction of tooth 45 due to severe caries decay. Goal: preserve as much healthy tissue (gum and bone) as possible

2. Yes and no. Given that the burs are not designed for all materials, the instrument can only cut prosthetic crowns made of gold. However, it can cut amalgam and resin. Likewise, reconstruction with plugging materials is not a contraindication for using these types of burs, unlike the cast materials, except for gold (which is rarely used nowadays).

Mesial use of the surgical bur at the expense of the root of tooth 45 while preserving as much of the alveolar bone as possible.

3. Yes, because every practitioner has his or her own habits of use. For my part, I work at very high speeds with FG chucks (turbine), but the product range meets all requirements.

4. Yes and no. The instrument can be used for cutting of the root, bone windows and apical surgery with apicectomy. With regard to alveolotomy for ankylosis and all related aspects, it is preferable to use finer surgical instruments with a shorter working part to ensure greater precision and above all to minimise bone loss (see clinical situation no. 3).

Use of the surgical bur at the expense of the root of tooth 45, cutting the root longitudinally.

5. Yes. Even if the conventional instruments have already proven their worth, it is always possible to improve them. Over time, bone cutters have undergone numerous developments and the blade geometry has been constantly improved. For Komet’s new ST design, the drills used in craniotomy served as a model, with an improved cutting behaviour to ensure smoother operation and increased efficiency, without the uncontrolled micro- vibrations that can occur (in the turbine).

The alveolar bone is preserved and the soft tissue can be prepared. Suture with absorbable thread 4-0 (Assufil fast

Extraction of tooth 45 due to severe caries decay. Goal: preserve as much healthy tissue (gum and bone) as possible

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Situation 2

Another clinical situation with extraction of tooth 36 due to an existing carious infection of the cavity floor associated with an interradicular injury. Use of the surgical bur to separate the mesial roots from the distal root. Very short treatment time to ensure preservation of the vestibular and lingual cortical bone. Depending on the clinical situation, a flap might be recommended as a visible opening to the root furcation.

Extraction of the mesial roots by slightly rotating them in posterior direction.

The alveolus and interradicular septum are preserved and a dental implant can be inserted under optimal conditions (if the extraction and immediate placement option is chosen). If placement is not immediate, sutures are used for controlled wound healing.

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The distal root is pulled out with a slight rotation in anterior direction. The cut of the tooth is perfectly visible. This procedure looks very simple but requires specific analysis of the clinical situation by the surgeon.

Removed anatomical parts

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Situation 11

Teeth 13 and 14 are to be extracted due to infection and the patient’s medical condition. Due to the bone density and the infection of the crowns, the procedure has to be done

Removal of the mucosa at the site of operation improves visibility.

The 3 root fragments from 14.

Longitudinal section of the root (with the instrument H162ST, in this case size 016) usually facilitates mobilisation of the root fragments and removal while preserving the alveolus.

This article was published in L’INFORMATION DENTAIRE N0 31 – 21 septembre 2016 in its original French language with the title “Fraise chirurgicale”, Philippe Tramba, Université Paris Descartes”

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BONE CUTS: MED, FINE, SUPERFINE AN INTERVIEW WITH DR BULATOVIC

The material, size and geometry of bone drills is adapted to the requirements of different indications. Sonic instruments are also an option in this context. Oral and maxillofacial surgeon Djuza Bulatovic tested various models from the range of Komet instruments and described his experience in an interview. Dr Bulatovic, for which indications do you choose bone drills from your drawer? Our dental clinic focuses on implantology, prosthetics, aesthetic dentistry, children’s dentistry, endodontics as well as plastic and aesthetic oral and maxillofacial surgery. We cover the entire range of applications in dentoalveolar surgery. Generally speaking, I use a bone cutter when I need space. For example, this might be necessary when it comes to removing impacted teeth, exposing teeth during the removal of root fragments from the extraction alveolus, or as part of special techniques for alveolar ridge extension or for bone window preparation during an external sinus lift. Depending on the indication, large or small-dimensioned drills are required. Let us focus on fine bone drills. What effect do fine bone drills have? A small/fine drill will naturally produce fine incisions. This can reduce trauma to such an extent that healing can take place quickly, without complications and with a good prognosis. The benefit of fine or small instruments is best explained in a bone structure where the bone bed must be preserved. In other words, my primary goal is to prevent damage to the vestibular lamella during the procedure and to preserve the width of the bone ridge. To illustrate this, let’s imagine the cross section of bone. Only if I manage to penetrate the area between the tooth and the bone with a fine/ slender instrument, the outer bone wall can be preserved, and I can create optimal conditions for subsequent implant insertion. Likewise, I also perform a sinus lift or apicoectomy only with smalldimensioned bone drills in accordance with state-ofthe-art requirements.

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You tested the smallest bone drills from the Komet range, i.e., the H254E and the H255E. What was your impression? The H254E is a small, tapered bone drill with a blue ring marking (length 6 mm, size 1.2 mm at full insertion depth). The penetration depth is only 3 mm and the working part has a diameter of only 0.9 mm. It penetrates the bone gap quickly under optimal control. I have the impression that, thanks to its tapered shape, it adapts to the tooth root more easily than the cylindrical H255E with with black ring. But the latter is also good: thanks to its cylindrical shape, the rotational speed at the tip is higher. The instrument is able to continuously remove 1.2 mm of bone substance, no matter how deep it works. Dr. Bulatovic, please give your opinion regarding the aspect "view" The advantage of bone drills with small dimensions is the fact that I do not necessarily have to open the operating field with a flap to ensure clear view. Let me explain this with the example of a tooth that has broken off at bone level and needs to be extracted. In such a case, no forceps will help me. With the H245E or H255E, however, I can carefully penetrate and enlarge the gap, palpate the tooth fragment easily and work precisely, even though I don't have an unobstructed view at that moment. Then I use a luxation elevator in the cavity I have created. The mucosa and the vestibular lamella will remain intact. This procedure fully complies with the requirements of minimally invasive surgery. How stable did you find the two bone drills H254E and H255E despite their small dimensions? I was amazed at how stable both instruments are. Neither instrument broke during use. However, it has to be made sure that under no circumstances they are used as a lever.

HANDPIECES & INSTRUMENTS

Easy to identify: H254E with staggered toothing and blue ring marking.

Tapered bone drill H254E – fine working part with high cutting efficiency, also suitable for extremely thin cuts.

Bone drill type Lindemann (H162ST) with innovative Komet ST toothing. The instrument is also available as enhanced version with ZrN coating.

Sonosurgery sonic saw SFS101 axial – for minimally invasive bone cuts under optimal control

Now let's talk about a medium-size model, the H162ST. The H162ST (working length 9 mm, size 1.6 mm) impressed me very much due to its ST toothing. The special toothing geometry ensures smooth operation without vibrations. The bone drill has no tendency to “jump”. This allows me to work safely under optimal control, and the treatment is also much more comfortable for the patient who can keep calm.

They are particularly gentle on the neighbouring structures due to their oscillating mode of operation. There is no risk of any soft tissue unintentionally wrapping itself around the instrument. They also do not make the typical drilling sound and are used without exerting contact pressure, which is particularly helpful for patients with dental anxiety. However, the treatment takes longer. I always have to consider which patients are eligible for this kind of treatment.

Any vibration of the instrument would mean a highly unpleasant sound conduction for the patient. I use the H162ST when I'm working on hard bones, when I want to create space effectively and when I want to work quickly.

I would also like to point to the learning curve: The use of sonic instruments needs to be practiced! Given that sonic instruments used in surgery work better on angled structures than on straight structures, a combination of sonic instruments and bone cutters is probably the best option for chairside treatment!

What influence do instruments with high cutting efficiency have on the handpieces and contraangles including the motor? Instruments with high cutting efficiency are gentle on the handpieces and contra-angles and the motor. Therefore, the practitioner and the practice team are obliged to check the bone drills for damage/wear after reprocessing and, if necessary, replace them by new ones in due time. All mentioned bone drills can be used in the handpiece as well as in the red or green contraangle. What does that mean for you in terms of practical use? As a specialist in dental, oral and maxillofacial surgery, my background is in medicine. Therefore, I am used to working with the handpiece. Dentists, on the other hand, usually prefer working with the contra-angle. It is therefore good to have both options at hand. Do you also have experience with sonic instruments in surgery? Bone cuts with sonic instruments create incredibly thin bone cuts of only 0.25 mm, such as the sonic tip SFS100/101/102 from the range SonicLine developed by Dr. Ivo Agabiti (Komet Dental).

Thank you very much for the interview. Djuza Bulatovic 2000 State examination Dentistry at the Johann Wolfgang von Goethe Universität, Frankfurt 2006 State examination Medicine at the Johannes GutenbergUniversität 2007-2012 Advanced training assistant at the central German army hospital, Koblenz 2012-2015 Senior physician at the central German army hospital, department of oral and maxillofacial surgery; further training in the field of plastic surgery Responsible for hygiene, transfusion and DRG in the department of oral/maxillofacial surgery Many years of activity in the training of oral surgical assistants in the field of implantology, dental alveolar surgery, traumatology and dysgnathia surgery 2015 Locum doctor at the Marienhausklinikum St. Elisabeth Neuwied and in different practices in the region of Koblenz 2015 Registered doctor in the joint practice Dr. Milinko Bulatović and Djuza Bulatović in Ebhausen Since 1st January 2019 Registered doctor in the practice Dr. Dortmann & Bulatović, Mühlheim-Kärlich

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CHU’S AESTHETIC GAUGES THE START TO A PERFECT FINISH

INSTRUMENTATION AND PROCEDURAL PRODUCTS THE PROPORTION GAUGE - PROGS Precise Color-Coded Measurements •

Provides quick, accurate diagnosis of tooth proportion

•

Provides accurate results and reduces chairside adjustment time

•

Easy to read—reduces visual fatigue

Common reference guide between clinicians and labs Results in effective communication to reduce the incidence of errors and repeated adjustments Compatible with IMS™ Cassettes and can be easily sterilized along with other instruments2 Reduces incidence of cross-infection

8.5mm

11mm 11mm

INLINE TIP The Inline tip has a short and long vertical arm. This helps to measure the length and width, independently, in cases of crowding where the use of the T-bar tip may be difficult.

T-BAR TIP The T-bar tip has a vertical and horizontal arm. This measures length and width at the same time.

2) Color bands will wear with normal use; simply dispose of the tip. Tips last for approximately 5-10 sterilization cycles. Replacement tips are available in packs of three.

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THE CROWN LENGTHENING GAUGE - CLGS Precise Color-Coded Measurements •

Provides quick, accurate measurements and better results

•

Easy to read—reduces visual fatigue

Compatible with IMSTM Cassettes and can be easily sterilized along with other instruments Reduces incidence of cross-infection

11mm 14mm

BEFORE

BLPG TIP The BLPG tip has predefined measurements to help achieve the proper mid-facial clinical crown and biologic crown length during a crown lengthening procedure.

AFTER 6.5 mm

10.5 mm

PAPILLA TIP The Papilla tip has predefined measurements to help establish the correct aesthetic position of the interdental papilla from the incisal edge before the flap is closed and sutured.

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HANDPIECES & INSTRUMENTS THE SOUNDING GAUGE - SOUNDG •

Bone sounding made simple and quick

•

Sounding tip curvature and sharpness allows easy manipulation and access into deeper areas to analyze the level of the bone crest

3mm

1mm 5mm

SOUNDING TIP The Sounding tip helps determine the sulcus depth, mid-facial osseous crest location and inter-proximal osseous crest location.

CASE SYNOPSIS A 29-year-old Caucasian female presented with congenitally missing teeth #6 and 10 with horizontal impaction of tooth #11. Consequently, her upper arch width was constricted and deficient due to the lack of the development and eruption of the permanent teeth. The patient had ‘cosmetic’ bonding in an effort to create a pleasing outcome, but failed due to the lack of objective instrumentation to help guide the dentist in treatment. Chu’s Aesthetic Gauges, which define ranges of individual tooth size, was used to create the proper individual tooth proportion based upon width once the incisal edge position was established. The maxillary central incisors for this patient were found to be slightly deficient in length. The aesthetic restorative therapy entailed correction of tooth dimensions of all the maxillary anterior teeth through crown lengthening using the gauges as a guide for reconstruction of size and shape with ceramic laminate veneers as well as full crowns on teeth and implants. The centrals were corrected first, then the canines for occlusion, and then the lateral incisors. With Chu’s Aesthetic Gauges, predictable and swift diagnosis and correction can be accomplished with a minimum amount of1stress and a maximum amount of patient gratification1.

1) The techniques described herein are for illustrative purposes only. The technique(s) actually employed in each case must always depend upon the independent medical judgment of the doctor as to the best mode of treatment for each patient.

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Satin Steel Handle SKU

Resin Handle SKU

Description

PROGS

PROG

Proportion Gauge (1 Handle, 2 T-Bar Tips, 2 Inline Tips)

CLGS

CLG

Crown Lengthening Gauge (1 Handle, 2 BLPG Tips, 2 Papilla Tips)

SOUNDGS

SOUNDG

Sounding Gauge

SCHUSET

CHUSET

1 Proportion Gauge, 1 Crown Lengthening Gauge, 1 Sounding Gauge, 1 Five-Instrument IMS™ Cassette

PROCLHDLS

PROCLHDL

Proportion and Crown Lengthening Gauge Handle

Refill SKU

Description

TBARREF

T-Bar Tip Refill (3 tips)

INLINEREF

In-Line Refill (3 tips)

BLPGREF

Biological Periogauge (BLPG) Refill (3 tips)

PAPREF

Papilla Refill (3 tips)

For more information about Chu’s Aesthetic Gauges visit HuFriedyGroup.com/ChusGauges Hu-Friedy Mfg. Co., LLC, 1666 E. Touhy Ave., Des Plaines, IL 60018 | HuFriedyGroup.com All company and product names are trademarks of Hu-Friedy Mfg. Co., LLC its affiliates or related companies, unless otherwise noted. Marks not registered in all jurisdictions.©2023 Hu-Friedy Mfg. Co., LLC. All rights reserved. HF-5627/1123

Dr. Stephen Chu received his undergraduate degree from Brown University and his Doctor of Dental Medicine degree from the University of Pennsylvania. He obtained his Master’s of Science degree in Restorative Dentistry and completed the Certificate Program in Fixed Prosthodontics at the University of Washington, in Seattle. Dr. Chu subsequently became a board-certified dental technician in ceramics and obtained a Master’s degree in Dental Technology from the New York University College of Dentistry (NYUCD). He is the former Director of the Continuing Education Program in Advanced Aesthetic Dentistry at NYUCD. He is also presently an Associate Clinical Professor in the Department of Periodontics and Implant Dentistry at New York University College of Dentistry. Dr. Chu has authored two textbooks on color and recently on aesthetic restorative dentistry and has contributed chapters to several others. He has published numerous articles in the dental literature and is on the editorial board of several peer-reviewed journals. He is a worldwide lecturer in aesthetic/cosmetic restorative dentistry and implant dentistry.

DR. STEPHEN CHU

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HANDPIECES & INSTRUMENTS

BEST IN PRACTICE EVOLUTION CELEBRATING 115 YEARS

It’s not every day when a company can celebrate over a century in business, but that’s what makes this year so special for HuFriedyGroup. This marks 115 years of dental instrumentation excellence and dental industry evolution. Proud Partners with Henry Schein for over 54 years We’re also celebrating National Dental Hygiene Month and how the registered dental hygienist (RDH) role has evolved. Hygienists play a critical role in every dental practice. That was made abundantly clear during the pandemic when hygienists demonstrated how vital they are to the dental industry. Hygienists modeled infection prevention best practices for peers and patients, their feedback pertaining to ergonomic challenges help shape instrumentation changes and they have demonstrated a resilience and love for the profession that is nothing short of inspiring. This is certainly a cause for celebration! Empowerment of the RDH Profession The RDH profession has evolved over the years, with one of the most notable changes being the expansion of RDH practices. Previously restricted to a narrow set of duties, today’s RDH is now responsible for an array of procedures – a testament to their skill set, trustworthiness, and the recognition of their integral role in dental care. The Rise of RDH Influencers RDH empowerment has sparked the emergence of an “influencer” era for the dental hygienist profession. Starting with early KOLs (key opinion leaders) such as Anna Pattison, Karen Davis, Nancy Miller, Mary Govoni, and Dr. Paul Levi who were among the first RDH influencers to inspire CE courses, research and write educational articles, and perform essential training.

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Today, hygienists are continuing to leverage their education, knowledge, and expertise in a multitude of ways: Patient educators: Hygienists are helping dispel long-held myths about oral care and diet to help improve the dental health of the populations they serve. Mentors: Hygienists are assisting their peers to better understand and consistently utilize best practices to ensure a safe and productive work environment for dental teams and their patients. Motivators: Hygienists are often inspiring their peers to work together and create healthier, happier work environments. Clinical leaders: Hygienists are leveraging their education and training to help dentists and practice owners identify and implement protocols and processes for a more efficient practice. This amplification of RDH voices is gaining them recognition from their colleagues and improving the oral health and oral care practices of their patient population. HuFriedyGroup fosters and features these RDH “influencers” as key contributors for depth of their knowledge and the breadth of their potential. In fact, HuFriedyGroup has elevated RDH voices to make them active contributors to the discourse on dental health, practices, and innovations. Their expertise is sought, their opinions valued, and their roles revered. From clinical practice, research, and academia to consultancy, entrepreneurship, and digital influencing, hygienists now have myriad choices that weren’t available when HuFriedyGroup was founded. HuFriedyGroup’s influence and empowerment of the dental hygiene industry didn’t just happen. This company had fairly modest beginnings and grew to become an industry leader thanks to a commitment to innovation and excellence.

HANDPIECES & INSTRUMENTS

Rooted in Tradition, Driven by Innovation

The Distributor-Driven Paradigm

HuFriedyGroup’s story dates back to 1908, when a Viennese immigrant named Hugo Friedman founded the company. Friedman, along with Dr. Clayton Gracey designed one of HuFriedyGroup’s most popular group of instruments, Gracey curettes in 1945. This series of double-sided, area-specific instruments have stood the test of time and are ideal for the successful removal of deposits from root surfaces.

Saslow’s faith in distributor channels was pivotal in shaping the company’s trajectory. An episode with Litton Dental Products, which culminated in a surge in sales, underscored the profound influence of distributors. This experience fortified Saslow’s conviction in nurturing robust distributor relationships, a philosophy that has remained integral to our operations.

In 1959, when Richard Saslow acquired the company, the company was already a beacon of craftsmanship. With Friedman’s unexpected passing, Saslow combined his innate drive for excellence with the counsel of his brother and dental distribution expert, Dan Saslow to steer the company to even greater heights. Cultivating Quality and Commitment Central to Saslow’s vision was a desire for impeccable quality. His mantra was simple: “How do we make it better?” This question permeated every aspect of the company’s endeavors – from instrument design to craftsmanship to growth of the profession. Saslow also fostered a culture that prized teamwork and pooling expertise. He aligned with brilliant minds like Howard Wax, who excelled in sales and marketing, to ensure that the company remained dynamic, versatile, and ahead of the curve.

The First Dedicated RDH Platform: Friends of Hu-Friedy In 1997, when the internet was still in its early stages, the idea of a dedicated platform for dental hygienists seemed both novel and ambitious. Yet, HuFriedyGroup recognized the potential of creating community for registered dental hygienists. FriendsofHuFriedy.com – a website dedicated to the RDH community – was launched from that idea. More than just a site; it is a virtual home and hub where RDHs worldwide can learn, collaborate, and contribute to the industry. Engaging the Next Generation In a strategic masterstroke, Saslow began courting dental schools and students, aiming to instill brand loyalty early on. The intent was clear: to have newly graduated practitioners specifically request our products. This dedication to encompassing the entire professional life cycle of a dental professional solidified HuFriedyGroup’s prominence in the industry.

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HANDPIECES & INSTRUMENTS

Today, HuFriedyGroup provides dental instrument to 97% of dental schools in the country and more than 97% of dental hygiene schools. HuFriedyGroup also sponsors The Golden Scaler Award, which honors one dental hygiene student at each school for their overall achievements. The HuFriedyGroup/ADAA Merit Scholar Award is given to dental assisting students for outstanding accomplishments. A History of Instrumentation Excellence HuFriedyGroup’s Best in Practice heritage brings together world-class products, services, education, and communities to facilitate superior clinician performance, clinical outcomes, and safety for clinicians and patients. Our 10,000-plus products are hand-crafted by highly skilled artisans, making them known for their precision, performance, longevity, reliability, and quality. •

1978 - Launched First Restorative Line of Immunity Steel® Instruments: Made from a resilient material that results in longer instrument life and allows for autoclave steam sterilization.

• 1982 - Introduced First Instrument Management System (IMS) Cassettes: A foundational “best in practice” product, IMS cassettes save time, prolong the life of instruments, and prevent sharps injuries.

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For further information

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• 1996 - Launched Line of Ultrasonic Inserts: Designed for both subgingival and supragingival debridement with a range of tip designs, handle styles, and water delivery methods. •

2008 - Introduced Nevi™ line of sickle scalers: Named for the late, legendary master craftsman, Neville Hammond, these instruments are specially designed to improve access to the tooth surface for scaling.

• 2016: Introduced EverEdge 2.0 Scalers: Superior edge retention and wear characteristics last the entire life of the instrument and cannot be removed through use or sharpening. • 2018: Launched GreenLight Dental Compliance Center™: Helps dental professionals and practices create customized infection prevention and instrument reprocessing protocols and internal audits to help them protect patients and staff. • 2020: Launched Harmony™ Ergonomic Scalers and Curettes: Designed with TrueFit™ Technology to offer a truly ergonomic scaling solution backed by scientific innovation. To find out more about HuFriedyGroup’s history and full line of products, visit HuFriedyGroup.com.

PRODUCT DISPLAY IMPROVEMENT We are making it easier to shop - products ranges have been consolidated now with fields to choose attributes like size, shade and shape.

SEARCH IMPROVEMENTS Now with advance filtering - use the boxes on the left of the search screen to search multiple brands, categories and other options.

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HANDPIECES & INSTRUMENTS

AEROSOL DRAWBACK IN HANDPIECES CAN IT BE ELIMINATED?

The COVID-19 pandemic has awoken a sense of urgency and concern in the dental world. Dental practices and schools are changing the way they operate by enhancing their cross-contamination response. Many dental equipment manufacturers are moving to provide their customers with effective solutions to assist them respond to this new normal. One of those solutions has been to reduce the propagation of aerosols during dental procedures. Consideration of contamination from retraction and suck back into the handpiece lines has also been a topic of heightened interest. Here we discuss this with J Morita Manufacturing Corporation engineer, Mr David Sleeman to seek clarification on the difference between anti-retraction and Zero-Drawback. Retraction versus drawback. What is the difference? There has been a lot of talk about anti-retraction and anti-suckback features but little clarification about what they are and how they work” Mr Sleeman said.

Most major manufacturers, including Morita, include them within handpieces, couplings and the treatment unit. This technology has been around for a while and the ISO 7494-2 standard requires your treatment unit to include it” Mr Sleeman explained. According to “Transmission routes of 2019-nCoV and controls in dental practice”, “high-speed dental handpieces without antiretraction valves may aspirate and expel debris and fluids during the dental procedures. More importantly, the microbes, including bacteria and virus, may further contaminate the air and water tubes within the dental unit, and thus can potentially cause crossinfection.” “Should retraction occur, you can still flush and disinfect your waterlines as needed, so we can say that the potential for cross-contamination here is relatively low” Mr Sleeman said.

“Many manufacturers, including Morita, have already solved this problem by introducing anti-retraction valves throughout the system.

What is drawback and can we eliminate it? Zero-Drawback is the solution. When asked to explain what the term Zero-Drawback means (or zero-suckback as it is sometimes known), Mr Sleeman said, “Unlike retraction, drawback is related to the air lines. Aerosols, created during dental treatment, can be drawn back into the handpiece, your air lines and eventually into your treatment unit.

One common type is called a duckbill valve which is held open by water pressure and clamps shut when the water stops which blocks any fluids from travelling back into the water lines.

When the drive air stops, the turbine continues to spin. This creates negative pressure in the system and begins to draw aerosols back into the system, kind of like a vacuum.

Mr Sleeman further clarified that “Retraction is essentially related to water being pulled back into the system through the water lines. So, retraction is strictly related to fluids and debris within those fluids”

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These can be present in your treatment unit and even in your handpiece or coupling. Usually, you will find multiple anti-retraction valves as fail-safes.

HANDPIECES & INSTRUMENTS

Morita TwinPower Highspeed Handpiece with Zero-Drawback and anti-retraction

Top tier brand with anti-retraction and drawback reduction technology. Reduction is not enough.

This is also known as suck back. This effect is cumulative. Each time you activate the drive air, the draw back forces any contaminates further into the handpiece, past the coupling and eventually into your air lines and your treatment unit.

According to “In vitro study of anti-suck-back ability by themselves on new high-speed air turbine handpieces”, some manufacturers will introduce a labyrinth system to reduce draw back, but these will not eliminate the drawback effect. Only the Morita Zero-Drawback system was found to eliminate draw back through this study *

Keep in mind that you cannot disinfect and flush the air or exhaust lines of your treatment unit. Many manufacturers will include a braking system to reduce the spinning motion of the turbine once the drive air stops. Terminology for these types of braking systems may vary but at Morita, we call it Quick Stop.”

Anti-Suckback Diffuser (ASSD) Exhaust tubing

Product Link henryschein.com.au/ handpieces/high-speed/ twinpower-turbine-ultra4huex-o-optic-morita Morita TwinPower Highspeed handpieces available in 5 models References

“A quick stop braking system can help reduce draw back but not eliminate it. The turbine continues to rotate after the drive air stops and, like any braking system, we cannot force the turbine to stop instantaneously.

Ozawa T, Nakano M, Arai T. In vitro study of anti-suck-back ability by themselves on new high-speed air turbine handpieces. Dent Mater J. 2010;29(6):649-654. doi:10.4012/ dmj.2010-008 Peng, X., Xu, X., Li, Y. et al. Transmission routes of 2019nCoV and controls in dental practice. Int J Oral Sci 12, 9 (2020). https://doi.org/10.1038/s41368-020-0075-9

It takes time and during that time, draw back is occurring. In addition, smaller handpiece head sizes create less inertial force which also contributes to reducing stopping times.” Mr Sleeman said.

Quan, Yingjun & Lim, Joong-Yeon & Kim, Kyoung-Nam & Kim, Yang-Soo. (2015). A testing methodology for suck-back behavior of high-speed air-turbine dental handpiece. Korean Journal of Dental Materials. 42. 10.14815/kjdm.2015.42.1.29.

Smaller head sizes or quick stop braking mechanisms will help stop the turbine faster and reduce the number of possible contaminants from being drawn back into the system. But reduction is not enough as the effect is cumulative, and even minor draw back can be pushed back into the exhaust lines and contaminate your system” Mr Sleeman emphasised.

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HANDPIECES & INSTRUMENTS

KAVO EXPERT SERIES PRODUCT UPDATES & EXTENSION OF THE STANDARD WARRANTY TO 24 MONTHS

The KaVo EXPERTmatic E25 L and E25 C high speed contra-angles are two of the best-selling KaVo products and impress with efficiency, durability and high-quality workmanship. Now with CoolHead technology and exclusive ball bearings make these instruments even more robust and safe - for even more patient safety.

CoolHead technology for even more patient safety The new KaVo CoolHead technology actively prevents excessive heating of the instrument head if the push button is pressed unintentionally during treatment while the burr is rotating, e.g. when touching the patient’s cheek. This way, practitioners can avoid painful contact. That is the level of patient safety and user comfort that KaVo customers are used to.

The CoolHead technology reduces the contact area between the push button and the rotating drive insert, resulting in less friction if the push button is pressed accidentally during operation. The potential heating of the instrument head is thus significantly reduced.

Temperature with CoolHead without CoolHead

Time

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HANDPIECES & INSTRUMENTS

Optimised KaVo exclusive high-tech ball bearings for an even longer service life

More Power, significant Noise Reduction EXPERTtorque turbines

Ball bearings in dental high speed contra-angles must be able to withstand extreme speeds and loads. Ceramic ball bearings are not only lighter and more wear-resistant, but also bring advantages such as corrosion resistance, low friction and thermal shock resistance.

EXPERTtorque turbines stand for performance, reliability and proven quality. More power and a significant reduction in noise make the instruments even more attractive. More power for even more efficient work EXPERTtorque turbines impress with even more power:

With the exclusive KaVo ball bearings, both the cage geometry and the cage material have been optimized, reducing wear in the ball bearing and further increasing the service life of the E25 L/C high speed contra-angles.

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E680 turbines – maximum power approx. 29 watts at 3.5 bar

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E677 mini turbines – maximum power approx. 27 watts at 3.5 bar

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Noise reduction of 26% – for a relaxed everyday practice

By implementing technical optimizations, the running noise of EXPERTtorque turbines has been significantly reduced. KaVo was able to reduce the running noise by 2 dB(A) – this corresponds to a noise reduction of 26% and ensures a pleasant working atmosphere in the dental practice. The average value for all EXPERTtorque turbines is now approximately at 59 dB(A).

NOTE: In this context, KaVo would like to point out once again that this level of quality can only be guaranteed if original spare parts are used.

Book in your FREE Handpiece Care & Maintenance Session to learn how to maintain Ultimate Handpiece Performance CLICK HERE REGISTER

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EQUIPMENT

DIAGNOCAM VISION FULL HD THREE INSTANT DIAGNOSTIC IMAGES FROM ONE SHOT

Imagine taking three different diagnostic images with one camera — sharp quality

images of the same object shortly before and

every time, in less than one second, as easy

after the shutter release, and automatically

as one, two, three. You call it amazing —

selects the sharpest image and displays it on

we call it the DIAGNOcam Vision Full HD.

the screen.

Intraoral images for the first visual caries diagnostic, true insight views into the dental structure via transilluminating technology and fluorescence images — all captured in a single shot and instantly displayed in Full HD resolution on your screen.

Tooth decay is the most frequent type of infectious disease. Almost everyone is affected by it at least once in their lifetime. Tooth decay is often invisible from the outside, and similar to icebergs, 90% of carious lesions are hidden beneath a tooth’s

Create remarkably clear and distortion-

surface. Often, no damage is visible on the

free Full HD photographs in real time. In

outside, while the tooth is destroyed from

addition, all images, from face to macro

within. In order to recognize caries early on,

shots, are optimised to keep their natural

mechanical examinations are insufficient. For

colour tones and to remain clear even when

this purpose, the use of the DIAGNOcam is

enlarged — enabling you to easily view the

an effective and, at the same time, non-

smallest details. From extraoral portrait or

invasive alternative. The principle is very

smile images, from a row of teeth to macro

simple: when DIAGNOcam shines through

shots, the KaVo autofocus feature guarantees

a tooth, carious lesions become visible

precise, clinically relevant images, every time.

as dark spots. The tooth functions as a

And without delays due to separate focusing.

conductor of the light; a camera captures

This is new, because existing intraoral

the light and transmits a real-time image

cameras often have a fixed-focus lens,

to a monitor. And without any X-rays. Thus,

meaning that a certain distance is necessary

the procedure may be repeated as often as

for a distortion-free image. With a classic

necessary.

autofocus the user usually also must press a button. With the DIAGNOcam Vision Full HD, this is done automatically: the continuous autofocus feature delivers a sharp image every time, whatever the distance and with no need to press a button.

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To do this, the camera generates additional

The fluorescence mode of the DIAGNOcam Vision Full HD is a particularly useful supplement to the assessment of occlusal surface caries as well as for a final caries check before placing a filling.

EQUIPMENT

This fluorescent light stimulates the metabolic

The KaVo DIAGNOcam Software is designed so

products of (e.g. cariogenic) bacteria on the tooth´s

that all procedures are intuitive and carried out in

hard substances.

seconds flat. Integrated functions such as the 3-in-1 shot, the recording assistant and the clear structure

Emitting different colours, the tooth´s hard substance is displayed greenish and metabolic products of cariogenic bacteria are shown reddish.

with self-explanatory symbols make diagnostics almost as easy as recording itself.

This allows the user to detect caries activity, making it possible to diagnose pathological findings. The mode enables the recording of images in the fluorescence range, in order to diagnose occlusal

View KaVo DiagnoCam Vision Full HD

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caries and plaque.

View KaVoTreatment Units

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INFECTION CONTROL

MAINTAINING YOUR STATIM STERILISER

Keeping the STATIM cassette clean is good clinical practice and assists in the proper functioning of the unit. It is recommended that the interior surface be cleaned at least twice a week. Cleaning the inside of your cassette is very important if you regularly sterilise lubricated instruments. Use dishwashing soap or a mild detergent that does not contain chlorine. Scrub the inside of the cassette with a cleaning pad designed for use with Teflon™ coated surfaces. Rinse thoroughly with water to remove all traces of the detergent. Coating the entire inside surface of the cassette with STAT-DRI drying agent induces water to form an even coat on the inside surface, without beading. The water in contact with the hot cassette surfaces also evaporates much more efficiently. Spotting is minimized and instruments dry much better. STAT-DRI should be applied every 10 cycles and after every cassette cleaning. Some offices use it as often as every morning. Spray it on the inside surfaces of the cassette and use a paper towel or gloved hand to spread it around, so that you have covered the inside of the cassette - top and bottom. STAT-DRI Plus with sprayer is available from Henry Schein, with item code SCI-2OZPLUS. To ensure optimum performance of your STATIM cassette steriliser, change the cassette seal every 500 cycles or every six months, whichever comes first. Do not wait until there is steam pouring out of the cassette before replacing the seal. Item codes for replacement seals are STATIM 2000 - SCI-01100028S and STATIM 5000 - SCI- 01101649S. During the first cycle after changing the seal, steam may appear between the lid and the tray as the seal seats. If this persists, remove the cassette and check that the seal is correctly installed. For both the 2000 & 5000 models, make sure that the port inside the cassette back left corner, does not have any debris.

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The bubble on the front right corner of the STATIM should be in the 4 to 5 o’clock position, NOT in the centre of the circle. This allows any water to flow to the back left corner of the cassette where it is vented out. This will allow the water to flow to the exhaust port much easier. Use the STATIM’s three adjustable feet to change the level, with the front right leg extended fully. Check that there are not any kinks in the exhaust tubing running from the back of the STATIM to the waste bottle. Kinks in this tubing will significantly reduce the STATIM’s ability to dry instruments. If there is a kink that cannot be straightened out, replace the tubing with SCI-01100204S.

INFECTION CONTROL

It is very important to change the microbiological air filter on the back of the STATIM 2000S & 5000S every 6 months, or at least every time you change the cassette seal. Some older STATIM units do not have this filter. To verify whether your STATIM 2000 or 5000 has this filter, look at the back of the machine. If there is a rectangular clear plastic filter with 2 grey hoses coming off it, your machine has the filter. The microbiological air filter is an extremely fine filter. It is fine enough that it may be significantly plugged up but may not look dirty. Oftentimes, offices have never changed these filters, which results in poor drying capabilities. To order a replacement STATIM Biological Filter use item code SCI-01102119S. On the STATIM 2000 there is also an air filter on the air compressor. This is a doughnut-shaped filter that should be replaced every six months. Part # SCI-01100207S. It is located at the rear of the machine, under the round silver cap with a screw in the middle of it. Simply remove the screw to access the filter. The key to optimal drying in any steriliser is to load it according to the manufacturer’s instructions. Through a series of tests, maximum load weights are determined at manufacture, and the values are included in the operator’s manual. To complete a successful cycle with dry loads, special care must be taken when loading your instruments. It’s important to note that drying cycles have a pre-set time that is determined before the cycle begins. If there are instances when water droplets are present at the end of the cycle, then the operator should increase the pre-set drying time. For proper loading of your STATIM, place instruments that are in pouches, paper side down. This allows water to “wick” out through the paper and improves drying. Pouched instruments in the STATIM 5000 should be placed on the STAT-DRI Plates (SCI-01103935) to ensure the heat from the plates helps evaporate any moisture in the pouches. Lay the pouches’ paper side towards the plate. The STATIM needs airflow through the cassette to dry the instruments, therefore you must use the flat wire rack inside of the STATIM cassette. For optimum drying, make sure that the feet on the rack are facing down to give the maximum amount of airflow under the instruments. Do not overstuff the cassette.

Scan here To reach out to our service department to enquire about the maintenance parts discussed in this article.

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INFECTION CONTROL

AEROSOL & SPATTER REDUCTION EFFICACY OF MR.THIRSTY® AND ALTERNATIVE PRODUCTS

Purpose A pilot study to compare the aerosol and spatter reduction efficacy of various hands-free high-volume evacuation (HVE) systems during an ultrasonic scaling procedure. Challenge Device Mr. Thirsty® , an intraoral hands-free high-volume evacuation (HVE) suction device.

from the patient’s mouth and a TSA Settling Plate placed on the patient’s chest 8 inches from their mouth (Chest SP).

Experimental Design Independent Variables: Use of a standard HVE, Mr. Thirsty® , Isodry® (Zyris),

The positioning of each plate was consistent for all testing for the duration of the study. For each ultrasonic scaling procedure, all quadrants of the mouth were treated, anterior and posterior, buccal and lingual. After 2 minutes, 30 seconds the devices were used on the opposite side of the mouth.

Dry Shield® (DryShield), or Ivory® ReLeaf ™ (Kulzer) Materials Mr. Thirsty® (Zirc Dental Products), Isodry® (Zyris), Dry Shield® (Dry Shield), Ivory® ReLeaf ™ (Kulzer), Cavitron ultrasonic scaling unit with Cavitron FSI 10S 30K insert (Dentsply Sirona), HVE with standard suction tips, SAS Super 180 Bioaerosol Sampler, TSA with Lecithin and Poly 90 Contact plates, TSA Settling plates, patient volunteers (A, B, and C), licensed dental hygienist volunteer wearing a face shield, and Level 3 mask.

An ASP in the SAS Super 180 Bioaerosol sampler and HS Chest SP were used to routinely collect air quality samples for 5 minutes during each procedure and were replaced between each new condition.

Methods Each ultrasonic scaling procedure was completed while the office was closed, and all procedures were completed in one designated operatory. Prior to the first patient, HVE lines were cleaned with an evacuation line cleaner and traps were changed. An additional saliva ejector line plus two HVE lines were running during the study to simulate a four operatory practice using a dual vacuum pump. The same dental hygienist performed all ultrasonic scaling procedures in this study. The ultrasonic scaler was consistently set to 60Hz and set to the highest water spray level. A control sample of the operatory air was taken for 5 minutes while patient A and the dental hygienist were seated in the room, prior to any aerosol generation. The control air sample was taken using the SAS Super 180 Bioaerosol Sampler with a TSA with Lecithin and Poly 90 Contact Plate (ASP, air sampling plate) placed 18 inches

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Control: Chest (CFU = 2)

INFECTION CONTROL Five separate conditions were utilized for comparison purposes on each patient volunteer. The first condition utilized a standard HVE, the second condition utilized Mr. Thirsty® , the third condition utilized Isodry®, the fourth condition utilized Dry Shield® , and the fifth condition utilized Ivory® ReLeaf ™. There was a 10-minute room turnaround time between each patient, during which appropriate clinical contact surface cleaning and disinfection and other recommended protocols were followed. After each test run, the exposed plates were immediately processed and incubated at 37°C for 48 hours. Microbial growth was analyzed and recorded for all plates. All testing procedures were repeated on a total of three patient volunteers. Before testing, all volunteers agreed to participate in the study and to having their photos taken. Results Air sampling plate (ASP) data and chest settling plate (Chest SP) data is presented below, showing individual data for the three patients.

Discussion Overall, the data show a trend that the use of Mr. Thirsty® performed most similarly to HVE when considering both ASP and Chest SP results. It should be noted that all HVE devices used in this study reduced air sample bacterial counts when compared to the control air sample. With respect to the Chest SP, an outlier was observed for Ivory® ReLeaf ™. Among the remaining hands-free devices, more variability was seen across the three patients with IsoDry® than for the other devices. Use of IsoDry® resulted in lower ASP CFU and the greatest variability was found for DryShield® . Use of any HVE device holds clinical advantage; hands-free devices seem to be preferred by hygienists. There were some limitations in this study, including the limited number of patients. A larger sample size could provide a better representation of the population, may reduce variability, and would enable determination of statistical significance. In addition, standardized laboratory testing in conjunction with clinical testing would be useful in future research. Conclusion Preliminary data in this pilot study showed Mr. Thirsty® to perform most similarly to a standard HVE in both air sampling and chest spatter plates while also giving the dental professional the advantage of utilizing a hands-free high-volume suction.

Read the full article CLICK HERE

DARLENE FINNERTY B.S., RDH USA

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ACCESSORIES

BENEFITS OF CLINICAL EFFICIENCY AND ORGANIZATION FOR DENTAL PRACTICES

Efficiency and organization measurably benefit dental practices in both administrative and clinical aspects. In dental practice management, we know the value of maintaining patient flow. Reserving and protecting specific time each month for a dedicated team member to manage the recare system is necessary for a full schedule. With a full schedule comes the opportunity to treatment plan and generate positive case acceptance. Similarly, cash flow of a dental practice needs an organized system of accounts receivable follow-up. The negative impact of diminishing returns without follow-up and financial arrangement plans underscores the importance of organizing such business systems. While there may be less attention and focus on such systems for clinical areas of a dental practice, the value is still measurable. In my on-site consulting

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experience as a dental practice management coach, I have witnessed the positive impact in wellorganized clinical dental operatories and labs as well as the detriment to those that are less organized. One example of a practice that was able to make improvements was a two doctor practice with one newly graduated dentist and one retiring dentist. The new dentist grew frustrated while waiting on materials during procedures to come from another operatory or the lab, holding him back from his full production capacity. The practice had been working with an old system that was established long ago and worked fine for the retiring dentist. The team had been working together for a long time and was limited in their experience of how other dental offices might do things differently.

ACCESSORIES

Sometimes it is wise to question why we are doing things the same way that we always have and if it still makes sense to do it the same way. The practice I visited prepared a sandwich bag containing the expected materials for each patient and their procedures at the beginning of each day. If the procedure changed, or the bag fell over and spilled the contents, witnessed what looked like an automotive pit crew as team members left the operatory in search of the needed instruments and materials. Instead, we introduced a color-coded tub and tray organization system for procedure set-ups. With this system, they were able to efficiently complete procedures in less time. In the time they were able to save, they found that the team could perform at least one additional procedure per day or see additional patients. The team was less stressed since the dentist was less frustrated and able to work again at his natural speed rather than being delayed. The team was able to quickly establish the tub and tray system that decreased room set-up and turnover time.

The end-of-day restocking was also more efficient, made easier by the color-coding of the system. The benefits of clinical organization in a dental office are many. Overall practice production increases with as little as one additional procedure per day. As a conservative estimate, a practice may produce $500 per hour restoratively. If a 45-minute composite procedure is added to each day at $375 per day, the practice works 4 days per week, and the practice is open 48 weeks per year, the practice can potentially add $72,000 more production per year. Decreased staff overhead can result from fewer end-of-day tasks, as efficient restocking and procedure set-up allow tasks to be completed throughout the day. Team members can use their time in the operatory to increase referral request opportunities and build patient loyalty as well. Examining your dental practice for potential efficiencies, whether administrative or clinical, can improve doctor and team morale, patient customer service and ultimately profitability.

Remember the story of the roast? The story begins with three generations gathered in the kitchen to prepare the holiday roast. The mother told her teenaged daughter to make sure she cut the end off of the roast before putting it in the roasting pan. The daughter questioned why she should do that. The mother answered for her to ask her grandmother, as it was her mother who taught her. The grandmother answered that their first roasting pan was too small for a full-size roast, so she had to cut the ends off to make it fit. She never questioned why her daughter had followed the same routine.

KAREN BURNETT, RDH, MA

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3D PRINTING

6 REASONS FOR DENTISTS TO START 3D PRINTING TODAY

Dentistry – like the rest of the healthcare industry – has been moving away from an analog system towards a digital workflow, and 3D printing is quickly becoming the new standard of care. Clinicians are more aware of the benefits of integrating a digital workflow into their practice – lower costs, a faster turn-around time, high-quality outputs – and are making the transition to digital dentistry. Transitioning to digital dentistry can be challenging without professional guidance. This article will help guide dentists and clinicians through the different advantages of adopting 3D printing in their practice, and what resources are available to get started. Going Digital The development of digital technology is centered around core challenges in the dental sphere that labs and clinicians, and ultimately patients, are facing – long waiting times, inaccurate results, and higher costs. The introduction of intra-oral scanners in combination with advancements in subtractive and additive manufacturing, and increasingly powerful software, has revolutionized the turnaround time for the most essential workflows – including crowns, inlays/onlays, bridges, and much more. An effective digital workflow brings many improvements to any practice, but the most important question to ask, according to Dr. Russell Schafer, is: What problem is this solving for me and my practice? Your transition to digital most likely does not simply stem from a wish to deliver faster results, but also from a desire to control the entire

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workflow, manage increasing lab costs, produce same-day results, and more. It is imperative to identify the issue that your practice is currently facing – and whatever that reason, let it guide the decision of which type of printer and additional tools you choose. What can 3D printing bring to your practice? Time Time is money, and a dentist’s time is best spent with their patients. If excessive time is wasted on preparing materials, this will become detrimental to patients and the practice. One of the biggest advantages of adopting a digital workflow is reducing the time spent on producing crown, splint, or denture, and maximizing contact with patients. An intraoral scanner, for example, can get a more accurate image of a patient’s mouth in under 5 minutes than an analog impression can get in 15 minutes. A crown can be created from start to finish in under an hour. Dentures can be produced in a week rather than a month. This additional time allows for better interactions with your patients, and maximizes the efficiency of your clinic. Cost While the initial cost of purchasing a digital workflow may seem high, there is a significant return on investment (ROI), and that return can come in as quickly as a few weeks. Splints, for example, have a very fast ROI, when comparing lab costs with inhouse chairside production.

3D PRINTING

Dr. Schafer, who is experienced with both analog and digital workflows, frequently uses 3D printed mock-ups to sell highly profitable restorative cases - a 3D printed mock-up and try-on smile only takes around 50 minutes to produce, and gives patients a real experience of what their smile would look like with a permanent milled restoration. The ability to quickly and concretely show this to a patient encourages them to adopt a treatment – in situations like this, ROI goes beyond simply money. 3D printing resins for permanent restorations are also showing an even higher potential yield for lasting, aesthetic results – possibly eliminating milling from the equation altogether in a few years’ time. Overall, these strategies create a more cost-effective workflow. Quality and accuracy With constant improvements in the resins available on the market, dentists can print increasingly highquality outputs to meet the needs of their patients

– permanent crowns and bridges, in addition to models, splints, surgical guides and more. Over the past 10 years, the greatest improvements in the 3D printing industry have been with the materials – in other words, resins. This trend will continue, and thus 3D printing will become increasingly efficient and profitable to a clinic. In addition to the quality of the resins, precision and accuracy of the prints mean that a patient is able to get an excellent solution the first time – without having to go back for adjustments due to errors. This improved quality thus greatly benefits the practice, the clinicians and the patients. Ease of use Many of today’s digital workflows offer ‘plug & play’ solutions, so that dentists are able to begin printing as soon as possible. The SOL, for example, has an open system that comes fully calibrated and validated with over 150 resins, which means that no trial-and-error is required on the clinician side.

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3D PRINTING It is easy to input the print parameters, and know that the final output will be successful. Learning fully digital workflows is a step-by-step process, and there are numerous resources available to support dental professionals on their journeys. Workshops that focus on specific applications teach users each step of the workflow, from scanning through the design, print, and finishing process, as well as provide additional expert tips. The growing community of online users who provide feedback and advice on their experiences with digital dentistry is another excellent source of information. Additional articles and videos are also available, which address a wide variety of topics related to digital dentistry and a 3D printing workflow.

Patient Experience The patient’s main priority is getting their problem solved as quickly as possible. While the methods for obtaining that are not significant to them, time and cost are important. When a patient approaches a dentist with something about which they are concerned and would like fixed or aesthetically improved, dentists can show patients their possible smile by providing a photo book with images of possible future smiles, or with a wax-up. Wax-ups are a much more effective tool, as they empower the patient to truly visualize that their smile could be – and allowing the patient to take home that smile for a week to really try it out is much more persuasive than looking at a picture. Once they see what the dentist can offer them, they will be more likely to choose the treatment – more benefits for the dentist and clinic.

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Where a traditional analog workflow could get a crown to a patient in a week, a digital workflow can have that done in an hour. When a denture might take more than a month to prepare outside the clinic, a dentist could now have that ready in a week – and make any necessary adjustment within another week. Dentists such as Dr. Schafer are now able to provide aesthetic temporaries at a very low cost, giving patients the best experience. Increased Expertise and Professional Growth

With many ‘plug & play’ solutions and support systems, the transition to a digital workflow is optimized and dentists are able to take this next step with confidence.

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Chairside solutions allow for a one-hour workflow – patients can be in and out with their solution the same day, rather than waiting a week or more to receive the care and results they want.

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Continuing Education is a key element allowing dental professionals to continue to provide the best care and patient experience. Additionally, there are a certain number of required credits that must be completed each year to maintain a dentist’s credentials. As the dental field becomes increasingly digital, learning and integrating these more advanced tools into a practice’s workflow allows a clinician to stay relevant, progress their practice, and learn the latest techniques to help patients get the results they want. In addition to personal professional growth, digital tools also allow for clinic growth – through consistent successful outcomes for patients, and increased awareness of these new technologies in the field. By adopting a digital workflow and creating more time to focus on faster and improved care, dentists are able to expand their offices. And marketing strategies that promote a more streamlined workflow for patients can add top and bottom line revenue for dentists.

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CADCAM

DOUBLE TRIUMPH FOR VHF AT THE GREEN DENTAL AWARDS 2023

EASE CLASS wins in the sustainability categories Best Product and Best Lab The Die Grüne Praxis (green practice) initiative voted vhf the winners with two accolades at the Green Dental Award 2023. The expert panel of judges voted the vhf dental milling machines E5 and E4 in the EASE CLASS and the AIRTOOL the winners in the two sustainability categories of Best Product and Best Lab. The official award ceremony was held on 13 October 2023 at the Fachdental Südwest trade fair in Stuttgart and was attended by numerous specialists, industry experts and representatives from the media. In addition to the Gold at the German Innovation Award 2023, the EASE CLASS, which was only launched by vhf in the spring of 2023, has also won the Green Dental Award 2023, which was presented for the first time. The independent panel of judges recognized in particular the positive environmental and sustainability aspects of the EASE CLASS, which were developed by vhf with technical innovations and additional measures. “We knew we had a good chance of winning the Green Dental Award with the EASE CLASS. We were surprised and of course delighted that we received two awards,” says Lucas Kehl, Head of Product at vhf camfacture AG. “The Green Dental Award is a wonderful accolade and another great success for vhf and the EASE CLASS. The prize represents a true recognition of our work, and is also an incentive and motivation for us to continue taking into account issues around the environment and resources when developing ideas and to promote them in the product development process.”

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The vhf EASE CLASS represents a new generation of dental milling machines that is a unique combination of technical innovation and a minimal use of resources. The innovative AIRTOOL plays a key role here: The turbine blades in the milling tool generate a powerful airflow thanks to the impressive speeds of the high-frequency spindle. This ensures that the workpiece remains free of chips and dust during processing. Significant energy is saved by eliminating the need for an air compressor: This is all the more remarkable, as compressed air is one of the most expensive forms of energy and can easily account for half of the total electricity consumption in dental practices and laboratories. The E4 and E5 dental milling machines were recognized at the Green Dental Award 2023 and, similar to all vhf products, are manufactured in Germany with verifiable 100% certified green electricity. In addition, as customary from vhf, they are characterized by the highest quality:

CADCAM

The best manufacturing results made in Germany paired with high-quality industrial components from leading manufacturers guarantee a long service life for the dental milling machines. vhf’s technologyneutral complete solutions also enable a long-term and flexible usage phase and offer users maximum flexibility and products that can be combined with components from other manufacturers such as intraoral scanners and CAD software. The light weight of the E4 (28 kg) and E5 (43 kg) and the compact dimensions of these two dental milling machines are also crucial for maximizing resourcesaving logistics and environmentally friendly shipping. Finally, vhf seized the opportunity of the launch of the new EASE CLASS to develop the technical documentation for the E5, E4 and E3 dental milling machines in digital format and to make it even more intuitive for users. The digital operating instructions save valuable resources and help protect the environment.

The impact-resistant denture base Vita Vionic Base Disc HI has recently become part of the comprehensive Vita Vionic Solutions product portfolio for the digital fabrication of partial and full dentures. The new composite disc Vita Vionic Dent Disc multiColor for denture teeth has also been added. These top-quality and esthetic products have been validated on the vhf R5, S5, K5+, K5 and E5 milling machines and offer users greater efficiency. This means that dentures can be reliably produced digitally that meet the usual requirements of analog prosthetics.

Validated workflow for the fabrication of milled partial and full dentures with vhf milling machines

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High-quality materials have a decisive influence when it comes to the efficient production of precise prostheses. The manufacturing processes and workflows tailored to these products are just as important. This is why vhf combines its technological expertise with the material expertise of Vita Zahnfabrik.

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PROSTHETICS

A NEW ENDO-RESTO APPROACH IN DIGITAL DENTISTRY DR. SIMONA CHIRICO & PROF. MASSIMO MARIO GAGLIANI, ITALY

Introduction

Exclusions criteria consist in:

The endodontic treatment of severely compromised teeth and their restoration represent an everyday challenge in the clinical dental practice. The advent of increasingly high-performance endodontic instruments, CAD / CAM technologies by chairside systems and the related materials drastically reduced the rehabilitation times of these teeth, allowing the treatments to be performed in a single visit.

•

Invasion of the supracrestal attachment during the margins preparation;

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Acute or chronic periapical abscess;

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Temporomandibular disorders (TMD);

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Vertical root fracture

This procedure might be an interesting alternative to the usual one; it discloses a new way of thinking in which restorative preparation and digital impression, has made before the endodontic treatment; in fact, right after a complete removal of carious tissues or damaged restorations, the clinician should orient the whole preparation, except the access cavity, to seal dentin and prepare the tooth for the indirect restoration. At the end of this phase a digital impression should be taken and addressed to the milling procedure; during this period the root canal treatment might be accomplished and, at the end, the restoration could be cemented, sometimes without removing the rubber dam. Inclusions criteria consist in: •

Carious lesions with pulp involvement (need endodontic treatment);

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Carious lesions that have caused the loss of at least one cusp (need indirect restoration);

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Inappropriate endodontic treatment (need endodontic retreatment);

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Presence of apical lesions (need endodontic treatment/retreatment)

•

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Willingness of the patient to undergo a long appointment;

The potential advantages of this procedure should be summarized: •

Immediate Dentin Sealing before the usage of irrigating solutions might guarantee a better sealing by the adhesive systems

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The access cavity might be better controlled during the shaping and sealing steps

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Adverse effects on adhesion process generated by any kind of sealer might be avoided

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The single visit procedure reduces time for patient and clinician

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In a single visit procedure, the restoration might enhance the overall sealing of the endodontic space.

The use of COLTENE endodontic instruments, which have features suitable for this procedure, is clearly recommended to obtain a conservative shaping of the root canal system. The use of the resin composite CAD/ CAM block BRILLIANT Crios, as a material for partial indirect restorations, guarantee excellent performances both for mechanical resistance and aesthetics, with the integration of this with the surrounding tissues. The luting of the restorations can be accomplished either with the BRILLIANT EverGlow composite in a paste or flow composition, making the steps of removing the material and its polymerization easier.

PROSTHETICS Case 1 A female 38-year-old patient had an emergency appointment due to pain and high sensitivity of heat and cold in the fourth quadrant. After carrying out the physical and radiographic examination, the presence of a large carious lesion with pulp involvement first lower molar, which had an old composite restoration, was clinically and radiographically assessed. A poor oral hygiene and gingivitis in the acute phase was also detected (Figures 1, 2). Since the patient was pregnant and would have given birth after 3 weeks, a single session procedure was encouraged and the new protocol “Endo-Resto approach in digital dentistry” was chosen.

A part of teflon was placed in the bottom of the pulp chamber, for a height of about 1.5 mm. This tool was used to simulate the subsequent covering of the floor with the flow, after finishing the endodontic treatment. Once the correctness of the canal closure was verified, the chair-side digital protocol started with the use of Cerec Primescan. After selecting the tooth (46), the type of restoration (inlay / onlay) and the material to be used (Coltene - BRILLIANT Crios), the impressions of the upper and lower hemiarches and the bite were recorded (Figures 5, 6, 7). In this way the milling machine was able to produce the endocrown, during the execution of the endodontic treatment. Once this procedure was completed, the margin preparation of 46 was drawn (Figure 8), ready to be restored with an endocrown, and the final project previewed (Figure 9). When everything was finished, the process continued with the milling of the BRILLIANT Crios A2 HT composite block (Figures 10, 11). PHASE 3 – Endodontic treatment The root canal shaping was carried out with the Hyflex EDM instruments - Shaping set medium 25 mm, alternating the use of CanalPro sodium hypochlorite at each step (Figures 12, 13). After completing the root canal instrumentation and drying the canals using Paper Points Greater Taper .04 COLTENE paper cones, GuttaFlow bioseal root canal cement was applied and closed by vertical hot condensation with Hyflex EDM Guttapercha points. (Figures 14, 15, 16).

Figure 1: Radiographic evaluation of tooth 46

PHASE 4 – Restoration

Figure 2: Clinical evaluation of tooth 46

PHASE 1 – Isolation and cavity preparation After applying the rubber dam to isolate the fourth quadrant, the removal of the old restoration to evaluate the extent of the carious extension was accomplished (Figure 3). Later a full toilette of the dentine was completed, the margin relocation performed and the cavity refined for proceed with the endodontic treatment (Figure 4). All the margins were perfectly visible and the contour of the future endocrown should not be modified by the root canal treatment procedures. The root canal system at this time should be already prepared. (Figure 4) PHASE 2 – Impression In this case, to give a little rest to the patient, the rubber dam was removed but most of the time it should be left in place during the digital impression procedure.

After the endodontic treatment (Figure 17), a layer of BRILLIANT EverGlow Flow (Figure 18) was applied to the bottom of the pulp chamber (Figure 19). Once the milling of the block was completed (working time about 9 minutes), a try-in check was done. Afterwards, the Endo crown was finished and polished (Figures 20, 21). We continued with the conditioning phases of the restoration, carrying out, in the order: sandblasting (Figure 22), application of the adhesive ONE COAT 7 UNIVERSAL (Figure 23). After applying the rubber dam again, isolating the fourth quadrant, the conditioning of tooth 46 was performed: etching (Figure 24), ONE COAT 7 UNIVERSAL adhesive (Figures 25, 26). At this point, the luting of the Endo crown took place using the heated composite BRILLIANT EverGlow A2/B2 (Figures 27, 28). After removing all the excesses, the polymerization took place for a time of 90 seconds per surface (occlusal, buccal, lingual). Post luting polishing was performed using the DIAT¬ECH ShapeGuard Composite Polisher Kit (Figures 29, 30).

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PROSTHETICS After removing the rubber dam, a post-luting clinical check of the Endo crown was performed (Figure 31). The execution time of this new protocol “Endo-Resto approach in digital dentistry” was 2 hours and 30 minutes.

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10 days after the endo-resto treatment, the patient is seen for both a clinical and radiographic control to evaluate the integration of the restoration with the surrounding tissues (Figures 32, 33).

Figure 3: Initial removal of the old restoration on Figure 4: Tooth 46 with completed and tooth 46 to assess the extent of the carious lesion finished cavity

Figure 5: Digital impression (lower hemiarch)

Figure 6: Digital impression (upper hemiarch)

Figure 7: Digital impression (buccal bite)

Figure 8: Drawing of the preparation margin to accommodate the endocrown

Figure 9: Preview of the endocrown of 46

Figure 10: Preview of the milling phase

Figure 11: BRILLIANT Crios A2 HT block

Figures 12: Hyflex EDM files

Figure 13: CanalPro (NaOCl 3 %)

Figure 14: ROEKO Paper Points Greater Taper 0.04

Figure 15: GuttaFlow bioseal

Figure 16: HyFlex EDM Guttapercha Points

Figure 17: Endodontic treatment completed

Figure 18: BRILLIANT EverGlow Flow

Figure 19: Layer of flow applied to the bottom of pulp chamber.

Figure 20: Resin composite endocrown at the end of characterization and polishing

Figure 21: Resin composite endocrown at the end of characterization and polishing

Figure 22: Sandblasting

Figure 23: Application of adhesive ONE COAT 7 UNIVERSAL

PROSTHETICS

Figure 24: Etching

Figure 25: Application of the universal adhesive

Figure 26: ONE COAT 7 UNIVERSAL

Figure 27: BRILLIANT EverGlow A2/B2

Figure 28: Luting of the endocrown

Figure 29: DIATECH ShapeGuard Polishers

Figure 30: Endocrown after polishing and finishing

Figure 31: Clinical view of the endocrown of 46, after removing the rubber dam

Figure 32: Clinical evaluation of endocrown integration

Figure 33: Radiographic evaluation of the integration of the restoration and endodontic treatment

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PROSTHETICS Case 2

points. (Figures 17, 18, 19).

A male 62-year-old patient had an emergency appointment due to pain and high sensitivity of heat and cold in the third quadrant. After carrying out the physical and radiographic examination, the presence of a large carious lesion with pulp involvement first lower molar, which had an old amalgam restoration, was clinically and radiographically assessed (Figures 1, 2). The patient was offered to treat this tooth in a single visit with the new protocol “Endo-Resto approach in digital dentistry”, which he accepted.

After the endodontic treatment (Figure 20), a layer of BRILLIANT EverGlow Flow (Figure 21) was applied to the bottom of the pulp chamber (Figure 22).

PHASE 1 – Initial digital impression The session began immediately with the digital impression, concerning the left lower arch, the upper one and the buccal bite (Figures 3, 4, 5). It is important to start with the impression because, after having prepared the tooth under the rubber dam and recorded the new impression, the software is able to match and recognize the two components. PHASE 2 – Isolation und preparation After applying the rubber dam to isolate the third quadrant (Figure 6), the amalgam was removed and the mesial margin was relocated. Then, the cavity was prepared, according to the endo crown, and the pulp chamber was opened according to the endodontic treatment (Figure 7). PHASE 3 – Final digital impression and procedures

PHASE 4 – Endo crown luting procedure Once the milling of the block was completed (working time about 11 minutes), the endo crown was tried in, finished and polished (Figures 23, 24). We continue with the conditioning phases both of the restoration and the tooth. For the first one it consisted in: sandblasting (Figure 25), application of the universal adhesive ONE COAT 7 UNIVER¬SAL (Figure 26). For the second one: etching, ONE COAT 7 UNIVERSAL adhesive (Figures 27, 28). At this point, the luting of the Endo crown took place using the heated composite BRILLIANT EverGlow A2/B2 (Figures 29, 30). After removing all the excesses, the polymerization took place for a time of 90 seconds per surface (occlusal, buccal, lingual). Post luting polishing was performed using the DIATECH ShapeGuard Composite Kit (Figures 31, 32). After removing the rubber dam, a post-luting clinical and radiographic check of the endo crown was performed (Figures 33, 34). The execution time of this new protocol “Endo-Resto approach in digital dentistry” was 2 hours and 20 minutes.

Before the digital impression, teflon was applied on the pulp floor, with the aim of simulating the thickness of the subsequent layer of flow that will be applied at the end of the endodontic treatment (Figures 8, 9). Once the correctness of the canal closure was verified, the chair-side digital protocol continued. Tooth 36 was cut out from the previous scan, and the preparation under rubber dam was recorded, with the adjacent teeth as reference (Figure 10). Once this procedure was completed, the margin preparation of 36 was drawn (Figure 11), ready to be restored with an endocrown, and the final project previewed (Figure 12). When everything was finished, I continued with the milling of the BRILLIANT Crios A2 HT composite block (Figures 13,14) and then the endodontic treatment.

Figure 1: Clinical evaluation of tooth 36

PHASE 4 – Endodontic treatment The root canal shaping was carried out with the Hyflex EDM instruments - Shaping set medium 25mm, alternating the use of CanalPro sodium hypochlorite at each step (Figures 15, 16). After completing the root canal instrumentation and drying the canals using Paper Points Greater Taper .04 Coltene paper cones, GuttaFlow bioseal root canal cement was applied and closed by vertical hot condensation with Hyflex EDM Guttapercha

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Figure 2: Radiographic evaluation of tooth 36

PROSTHETICS

Figure 3: Digital impression (lower arch)

Figure 4: Digital impression (upper arch)

Figure 5: Digital impression (buccal bite)

Figure 6: Isolation of the third quadrant

Figure 7: Tooth 36 after cavity preparation and removal of the pulp

Figure 8: With the use of a probe, the thickness of the teflon was measured, which must be between 1 and 2 mm, in order to emulate the flow layer after the endodontic treatment.

Figure 9: Applied teflon

Figure 10: Digital impression of tooth 36 after the application of rubber dam and cavity preparation

Figure 11: Drawing of the dental preparation margin to accommodate the endocrown

Figure 12: Preview of the endocrown of 46

Figure 13: Preview of the milling phase

Figure 14: BRILLIANT Crios A2 HT block

Figure 15: HyFlex EDM Files

Figure 16: CanalPro (NaOCl 3 %)

Figure 17: ROEKO Paper Points Greater Taper 0.04

Figure 18: GuttaFlow bioseal

Figure 19: HyFlex EDM Guttapercha Points

Figure 20: Endodontic treatment completed

Figure 21: BRILLIANT EverGlow Flow

Figure 22: Layer of flow applied to the bottom of pulp chamber.

Figure 23: Resin composite endocrown after characterization and polishing

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PROSTHETICS

Figure 24: Resin composite endocrown after characterization and polishing

Figure 25: Sandblasting

Figure 26: Application of ONE COAT 7 UNIVERSAL

Figure 27: Application of the universal adhesive

Figure 28: ONE COAT 7 UNIVERSAL

Figure 29: BRILLIANT EverGlow A2/B2

Figure 30: Luting of the endocrown

Figure 31: DIATECH ShapeGuard Polishers

Figure 32: Endocrown after polishing and finishing

Figure 33: Clinical evaluation of endocrown integration

Figure 34: Radiographic evaluation of the integration of the restoration and endodontic treatment

DOCTOR SIMONA CHIRICO DDS, MSc • Graduated in Dentistry at University of Milan in 2016. • Master in Restorative and Aesthetic Dentistry at University of Bologna in 2021. • Active in Restorative Dentistry, Endodontics and Digital Dentistry since 2017. • Private practice in Milan and Desio (MB). • Scientific coordinator of “Dentistry33 – Edra”.

PROF. MASSIMO GAGLIANI • Active in Restorative Dentistry and Endodontics since 1990. • Became Researcher at the University of Milan in 1992; was upgraded to Associate Professor in the same University in 2000. • Member of the major international and national societies on Restorative & Endodontics and one of the five founders of the Digital Dental Academy (DDA). • Published several papers on Restorative & Endodontics topics in all the major international journals. • Since 2014, Scientific Coordinator for Editorial Group Edra.

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