Henry Schein Dental Solutions Nov-Dec 2024 by Henry Schein Australia

DENTAL SOLUTIONS

HENRY SCHEIN & ADA NSW PARTNERSHIP

ADA NSW welcomes new partnership with Henry Schein to support clinical education offering in NSW.

In 2020 Henry Schein launched the Dental Education Hub to help support the dental community with a centralised resourced for clinical and business education, which has since become a leading online platform for dental education and online training in the form of live and on demand webinars. The Dental Education Hub offers a broad array of clinical content for dental professionals, accessible anytime now with over 230 on demand webinars - most of which are free. Hosting over 50 courses and 80 live webinars annually across Australia, it serves as a premier digital resource for dental education. Stay informed about upcoming events and courses in your area through this central platform.

To continue our commitment to our customers and the broader dental community, in October 2024 Henry Schein and the Australian Dental Association NSW (ADA NSW) announced a landmark strategic partnership to elevate dental education and training for dental professionals.

This collaboration focuses on equipping ADA NSW’s clinical facilities with the latest dental chairs from KaVo and Planmeca as well as advanced dental technology, enhancing their comprehensive Continuing Professional Development (CPD) programs. Key upgrades include a new digital dentistry lab, equipped with cutting edge digital equipment including intra-oral scanners and 3D printers.

Henry Schein’s support will bolster ADA NSW’s mission to improve patient care through highquality, accessible education. This partnership also brings community benefits through philanthropic endeavours like “Filling the Gap,” providing dental services to vulnerable Australians.

ADA NSW President Dr. Dominic Aouad emphasized the partnership’s role in maintaining a state-ofthe-art training environment, enhancing learning accessibility via a new website and Learning Management System, expected in December.

CARRIERE MOTION 3D APPLIANCE

THE SAGITTAL FIRST REVOLUTION

The SAGITTAL FIRST™ Philosophy is a time-tested approach that standardises, simplifies, and shortens Class II and Class III treatment times. It employs the Carriere Motion 3D Appliance to treat the AP dimension at the beginning of treatment before placing brackets or aligners. By resolving the most difficult part of treatment first, you can achieve a Class I platform in 3 to 6 months, shortening total treatment time by a minimum of 6 months.1 You know how excited patients and parents become when you mention shorter treatment times!

- Sarah

INITIAL - 4/9/18

PROGRESS 1 - 19/11/18 - Placement of Motion 3D Class II Appliance

PROGRESS 2 - 11/12/18 - Class I almost achieved with Motion 3D Class II Appliance CLASS II

1 “Treatment Effects of the Carriere Distalizer (Motion 3D) Using Lingual Arch and Full Fixed Appliances”, Journal of the World Federation of Orthodontists, May 2014

PROGRESS 3 - 20/12/18 - Placement of SLX 3D Brackets with M-ONE .015 Cu Nitanium 27° archwire

PROGRESS 4 - 8/1/19 - With M-TWO .020 x .020 Cu Nitanium 35° archwire

PROGRESS 5 - 4/4/19 - With M-THREE.019 x .025 Beta Titanium wire with power chain

FINAL - 16/7/19 Before After

Provided by - Dr Dave Paquette

AN AESTHETIC AND BIOMIMETIC APPROACH WITH A GLASS HYBRID FOR DIRECT RESTORATIONS

The overall goal of this article is to provide the clinician with an overview of the information on a newly developed glass hybrid system (EQUIA Forte® HT) and as well as to give useful application tips based on results from clinical cases.

What differentiates glass hybrid from other conventional GI restoratives is its chemistry. The highly reactive fluoro-alumino-silicate (FAS) micronsized fillers (<4 μm) were added to the standard FAS glass filler particles of EQUIA Fil. The micron-sized filler particles release more metal ions, which improve the cross-linking of the polyacrylic acid matrix and the overall physical properties.

Additionally, EQUIA Forte HT Fil liquid comprises a high-molecular-weight polyacrylic acid, which helps to improve the chemical stability, acid resistance, and physical properties of the set cement.

The light-cured, nano- filled resin coating (EQUIA Forte Coat) was improved by incorporating a reactive multifunctional monomer that increases resistance to wear, has a higher polymerisation conversion and thinner film layer, and also provides a smoother surface to the final restoration.

EQUIA Forte® HT was used in a 34-year-old female patient for the emergency treatment of a vital lower first molar (tooth 36) with a deep, large carious lesion (Fig 1a). The vitality of the tooth was first determined by pulp testing and a radiograph was taken to check the depth of the lesion (Fig 1b).

Local anaesthesia was applied and caries was removed using tungsten carbide burs (Busch "AU" Carbide Burr - TF1AU). Infected dentine was removed with an excavator (Fig 1c). The cavity walls were cleaned with 20% polyacrylic acid (Cavity conditioner, GC) during to for for 10s (Fig 1d), rinsed thoroughly with water (Fig 1e) and dried gently (Fig 1f).

EQUIA Forte® HT capsules were prepared and mixed for 10 s, then restorative was directly applied into the cavity in a sufficient quantity using a bulk-fill technique with a special applicator (Fig 1g). EQUIA Forte® HT was condensed against the cavity with a plastic hand instrument and was allowed to set undisturbed for approx. 2.5 min (Fig 1h). This restorative does not require a special surface coating during the setting reaction.

The finishing process was performed with the use of rotary instruments in 2 steps: a) tapered trimming & finishing tungsten carbide burs were used for forming the fissures and occlusal anatomy of the restoration; b) flame-shaped rubber points (blue and gray) were used for polishing (Fig 1i). All burs and polishers were used under water irrigation to avoid over-drying the restorative. The occlusal contact points were checked (Fig 1j).

A final layer of the coating agent (EQUIA Forte® HT Coat) was applied on the surface of the restoration without air- blowing (Fig 1k), then it was light-cured for 20 s with a D-Light DUO LED curing device at 1400 mW/cm2 (Fig 1l).

The final clinical and radiographic views of the restoration are shown in Figures 1m-o, demonstrating excellent contour and aesthetics.

PROF. ZEYNEP BILGE KUTUK Turkey

G-CEM ONE ™

SELF-ADHESIVE UNIVERSAL RESIN CEMENT

The patient presented with defective restorations. After a comprehensive evaluation, recurrent decay was identified in the existing resin restorations on teeth 14 and 15. The patient also reported discomfort due to an open contact, leading to food trapping.

Tooth 14: It was decided to restore tooth 14 with a direct composite. GC Essentia Universal was used. Tooth 15: An indirect restoration was fabricated for tooth 15. The tooth was prepared and scanned. GC Initial LiSi Block was selected to mill the inlay.

The inlay was bonded using G-CEM ONE™ self-adhesive universal resin cement, chosen for its excellent bond strength, easy handling, and reliable long-term outcomes. After seating the restoration, excess cement was carefully removed, and the restoration was light- cured.

G-CEM ONE™ is a truly universal, non-technique sensitive, versatile and reliable product that gives the flexibility of being effective in all cementation procedures for any type of restorations; from metal- based to resin and allceramic inlays, onlays, crowns, bridges, and posts. It demonstrates excellent bond strength to enamel, dentin and all indirect restorations.

The final restoration demonstrated excellent aesthetics and functional integrity. The patient reported satisfaction with both the comfort and appearance of the restorations.

View products online SHOP NOW

BDS(Hons) U. Sydney, Australia

7. 15 - G-Premio BOND™ for tooth structure. G-Multi PRIMER™ & G-CEM ONE for restoration.

14 - G-Premio Bond for tooth structure. G-aenial Injectable A2 for proximal box/ marginal ridge. GC Essentia Universal for occlusal form.

8. Finished restorations.

1. Pre-operative Image - Recurrent decay in existing resin restorations 14,15. Open contact with food trapping.

2. Immediate Dentin Seal and Resin Coat for tooth 15 following caries removal G-Premio BOND™ + everX Flow + G-aenial Injectable A2.

3. Preparations air-abraded and ready for bonding protocol with G-Premio BOND™

4. 15 LISI Restoration + 14 Resin Restoration Polished restoration with EVE Diapol Twist Polishers + GC Diapolisher Paste.

5. Application of G-Multi PRIMER™ on LISI restoration.

Application of G-CEM ONE ready for cementation.

DR. LIANG LIANG

FACE MEETS FUNCTION

Optimising functional and esthetic parameters in veneer cementation using panavia ™ veneer lc

The use of both porcelain veneers to improve and restore the shape, shade and visual position of anterior teeth is a common technique in esthetic dentistry. The biomimetic aim in the restoration of teeth is not only the cosmetic domain, but also functional considerations. It is critical to note that the intact enamel shell of the palatal and facial walls with respect to anterior teeth are responsible for its innate flexural resistance. When dental structure has been violated by endodontic access, caries and/or trauma, every effort must be made to preserve the residual structure and strive to restore or exceed the baseline performance levels of a virgin tooth.

1. Background

A 55 year old ASA II female with a medical history significant only for controlled hypertension presented to the practice for teeth whitening. It was foreseen that dental bleaching would not have an effect on the shade of a pre-existing porcelain veneer on tooth 1.2, and that this would need to be retreated following the procedure especially if the shade value changes were significant. The patient started with a baseline shade of VITA* 1M1:2M1; 50:50 ratio in the upper anterior region and 1M1 in the lower anterior region. Following a nightguard bleaching protocol with 10% carbamide peroxide worn overnight for 3-4 weeks, the patient succeeded in achieving a VITA* 0M3 shade in both upper and lower arches. As a result, there was a significant value discrepancy between the veneered tooth 1.2 and the adjacent teeth, and also increased chroma noted on the contralateral tooth 2.2 due to a facially-involved Class Ill composite restoration. This latter tooth also did not match the contralateral tooth in dimension and thus the decision was made to treat both lateral incisors with bonded lithium disilicate laminate veneers. The canine adjacent (2.3) featured localized mild to moderate cusp tip attrition, but the patient did not want to address this until following the currently-discussed veneers were placed. The goal of smile design at this stage is to ultimately establish bilateral harmony with the

view to place an additional indirect restoration restoring the facial volume and cusp tip deficiency of tooth 2.3 in the near future.

2. Procedure

A digital smile design protocol was not required for the initial intention, which was individual treatment of the lateral incisors, as slight variation is permitted in this tooth type, being a personality and gender marker of the smile. Prior to anesthesia, the target shade was selected using retracted photos featuring both polarised and unpolarized selections. The photographs were prepared for digital shade calibration by taking reference views with an 18% neutral gray white balance card (Fig. 1).

The basic body shade was VITA* 0M2 with an ingot shade of BL2. The patient was anesthetized using 1.5 carpules of a 2% Lignocaine solution with 1:100,000 epinephrine before affixing a rubber dam in a split dam orientation. The veneer on tooth 1.2 was sectioned and removed from tooth 1.2 and a minimally-invasive veneer preparation completed on tooth 2.2 (Fig. 2). Partial replacement of the old composite resin restoration was completed on the mesioincisobuccopalatal aspect of tooth 12 with the intact segment maintained. Adhesion to old composite was achieved using both micro particle abrasion and a silane coupling agent (CLEARFIL™ CERAMIC PRIMER PLUS, Kuraray Noritake Dental Inc.).

Fig.1

Reference photograph taken with a 18% neutral gray card.

Margins were refined and retraction cords soaked in an aluminum chloride solution and packed. Preparation stump shades were recorded. Final impressions were taken using both light and heavy body polyvinylsiloxane in a metal tray.

The patient was provisionalized and sent away with instructions to verify the shade at the laboratory at the bisque bake stage. The models prepared by the laboratory verify the minimally-invasive nature of the case.

On receipt of the case, the patient was anesthetized and the provisionals removed. The preparations were debrided and prepared for bonding by abrading the surfaces using a 27 micron aluminum oxide powder at 30-40 psi. The veneers were assessed using a clear glycerin try-in paste (PANAVIA™ V5 Try-in Paste Clear, Kuraray Noritake Dental Inc.). Retraction cords were packed and the intaglio surface of the restorations treated using a 5% hydrofluoric acid for 20 seconds prior to application of a 10-MDP-containing silane coupling agent (CLEARFIL™ CERAMIC PRIMER PLUS, Kuraray Noritake Dental Inc.) (Fig. 3). The tooth surface was etched using 33% orthophosphoric acid for 20 seconds and rinsed. A 10-MDP-containing primer was applied to the tooth (PANAVIA™ V5 Tooth Primer, Kuraray Noritake Dental Inc.) (Fig. 4) and air dried as per manufacturer’s instructions.

Fig.2

Veneer preparation tooth 1.2, 2.2

Fig.3

Fig.4

PANAVIA™ V5 Tooth Primer application to etched tooth surfaces.

CLEARFIL™ CERAMIC PRIMER PLUS applied to intaglio surfaces of veneers.

Veneer cement was loaded (PANAVIA™ Veneer LG Paste Clear, Kuraray Noritake Dental Inc.) (Fig. 5) and the veneer seated. The excess cement featured a non-slumpy character and maintained the veneer well in place during all margin verification exercises prior to a 1 second tack cure (Fig. 6).

Veneer LC Paste immediately after seating. Note the viscous, non-slumpy nature of the cement, which allows for ease of removal under both wet and gel-phase options.

The cement was rendered into a gel state, which facilitated “clump” or en masse removal of cement with minimal cleanup required (Fig. 7). The margins were coated using a clear glycerin gel prior to final curing to eliminate the oxygen inhibition layer (Fig. 8).

Excess cement removal after tack curing for 1 second.

Final curing of veneers from both palatal and facial aspects simultaneously.

The margins were finished and polished to high shine and the occlusion of the restorations verified as conformative. The postoperative views show excellent esthetic marginal integration (Fig. 9).

Post-operative esthetic integration of veneers on 1.2 and 2.2.

Fig.5

PANAVIA™ Veneer LC Paste Clear shade loaded onto prepared intaglio surfaces of veneers.

Fig.6

PANAVIA™

Fig.7

Fig.9

Fig.8

On polarised photograph reassessment, the restorations are well-integrated into the new smile esthetically and functionally (Fig. 10), now awaiting esthetic augmentation of tooth 2.3 to match the contralateral canine.

3. Rationale for Material Selection

Porcelain is often the chosen material for prosthetic dental veneers due to its innate stiffness in thin cross section, ability to modify and transmit light for optimal internal refraction and its bondability by way of adhesive protocols to composite resin. This trifecta allows for a maximal preservation of residual tooth structure whilst bolstering its physical function relative to flexural performance (1). The elastic modulus of a tooth can be restored to 96% of its control virgin value if the facial enamel is replaced with a bonded porcelain laminate veneer (2). The elastic modulus of lithium disilicate is 94 GPa whereas that of intact enamel is 84 GPa.

The elastic modulus of dentin has been found to range from 10-25 GPa, whereas that of the hybrid layer can vary widely, indeed from 7.5 GPa to 13.5 GPa in a study by Pongprueska et al (3). This low flexural resistance range reflects that of deep dentin and not that of superficial dentin, which does not reflect an ideal situation where a laminate veneer is bonded in as much enamel as possible, or in the worst case to superficial dentin. Maximal flexural strength of the hybrid layer is invaluable from a biomimetic standpoint. PANAVIA™ V5 Tooth Primer (Kuraray Noritake Dental Inc.) incorporates the use of the original 10-methacryloyloxydecyl dihydrogen phos phate (10-MDP) monomer, which elicits a pattern of stable calcium-phosphate nanolayering known as Superdentin, an acid-base resistant zone that is about 600x more insoluble than the monomer 4-MET, which is found in many other adhesives.

Indeed, PANAVIA™ V5 Tooth Primer is used solely in conjunction with Kuraray Noritake Dental Inc. PANAVIA™ V5 cement and PANAVIA™ Veneer LC which both allow the primer to act as a bond without the need to cure the layer prior to cementation of the indirect restoration due to its dual cure potential when married together.

If a bonding agent would be preferred, CLEARFIL™ Universal Bond Quick (Kuraray Noritake Dental Inc.), a multi-modal adhesive that also contains the essential amide monomer and 10-MDP components created by Kuraray Noritake Dental Inc., can be used. Of note, CLEARFIL™ Universal Bond Quick features exceptional flexural strength due to the accentuated cross-linking during polymerization afforded by the amide monomers, on the order of 120 MPa by itself (4).

Fig.9

Final result with polarised photography on reassessment

Of note, CLEARFIL™ Universal Bond Quick features exceptional flexural strength due to the accentuated cross-linking during polymerization afforded by the amide monomers, on the order of 120 MPa by itself (4).

PANAVIA™ Veneer LC is a cement system that features cutting edge technology that provides excellent esthetics and adhesive stability of your indirect restorations, whilst allowing a stress free workflow. It is a cement system that is a game changer; one that allows you to restore confidence in the patient, strength in the tooth-restoration interface, and bolsters your clinical confidence in the delivery of biomimetic excellence.

References

1) Magne P, Douglas WH. Rationalization of esthetic restorative dentistry based on biomimetics. J Esthet Dent. 1999;11 (1):5-15. doi: 10.1111/j.1708-8240.1999.tb00371.x. PMID: 10337285.

2) Magne P, Douglas WH. Porcelain veneers: dentin bonding optimization and biomimetic recovery of the crown. lnt J Prosthodont. 1999 Mar-Apr;12(2):111-21. PMID: 10371912.

3) Pongprueksa P, Kuphasuk W, Senawongse P. The elastic moduli across various types of resin/dentin interfaces. Dent Mater. 2008 Aug;24(8):1102-6. doi: 10.1016/j. dental.2007.12.008. Epub 2008 Mar 4. PMID: 18304626.

4) Source: Kuraray Noritake Dental Inc. Samples (beam shape; 25 x 2 x 2 mm): The solvents of each material were removed by blowing mild air prior to the test.

HBSc, DDS, FIADFE, AAACD Auckland, New Zealand

DR CLARENCE TAM

ZERO IN ON

Fig.1 Initial frontal view. Patient was unhappy with the black triangle between #8 and 9 (11 and 12).

Fig.2 Taking shade.

Fig.3 Retracted view.

Fig.4 Rubber dam view after air abrasion. The matrices will help to retract the dam further at the operative site.

addressed after discussion with the periodontist.

Note the resultant contours from the matrices, as well as the palatal volume at #8 due to the unusual positioning of the teeth.

Fig.5 Scope photo. Note the unusual position of the matrices, due to the overlapping of the teeth.

Fig.6 Scope pic with filter.

Fig.7 Immediate result following gingivectomy of #8 (11). Needs some refinement, which will be

Fig.8 Post-operative radiograph.

ARTHUR VOLKER USA

DEEP INFILTRATION FOR TRAUMATIC HYPOMINERALIZATION

AN ESTHETIC AND CONSERVATIVE TREATMENT

Deep Infiltration for traumatic hypomineralization: an esthetic and conservative treatment.

Fig. 1-2: Initial intra oral picture and initial

• Fig. 1-2: Initial intra oral picture and initial polarized picture.

In everyday practice, dental surgeon, under increasing pressure from patients with esthetic concerns, is more and more often called on to treat abnormalities in tooth color.

The presence of a visible white area on the tooth surface is due solely to a defect in the enamel. This patient present a deep traumatic hypomineralization of a permanent tooth (Fig. 1-2). This is a consequence of periodontal trauma affecting the deciduous teeth. This may involve displacements of all kinds (concussion, subluxation, luxation, intrusion, extrusion, extraction). Traumatic hypomineralizations can present a wide variety of clinical expressions differing in color, shape, and outline. They are often limited to one tooth and sometimes associated lesions can often be found on mandibular opponents. Medical history is not one of the leading criteria on account of its uncertain utility (it is difficult to remember a shock that occurred several years previously). It is the elective nature of traumatic hypomineralizations rather than their clinical presentation that provides the most useful diagnostic information [1]. So the diagnosis of traumatic hypomineralization remains essentially diagnosis by exclusion (with Fluorosis, White spots and MIH).

• Fig. 3

• Fig. 4

• Fig. 5

• Fig. 3-5: First step after Isolation with rubber dam placement is a prophylactic polishing. The deep cycle protocol is then : sandblasting with alumine oxyde 27 microns (Fig. 3). Erosion with Icon-Etch (15% HCl) 2 minutes (Fig. 4) Deshydratation with Icon-Dry (application of alcohol) (Fig. 5). At this step we have to control if the spot is always present. If yes, a second same cycle is necessary [3]

Dr. Marie Clement

•

polarized picture.

Fig. 1-2 Initial intra oral picture and initial polarized picture.

• Fig. 3

Dr. Marie Clement

Fig. 3-5 First step after Isolation with rubber dam placement is a prophylactic polishing. The deep cycle protocol is then : sandblasting with alumine oxyde 27 microns (Fig. 3). Erosion with Icon-Etch (15% HCl) 2 minutes (Fig. 4) Deshydratation with Icon-Dry (application of alcohol) (Fig. 5). At this step we have to control if the spot is always present. If yes, a second same cycle is necessary [3].

• Fig. 6

Fig. 6 The third times Icon-Dry application (after 3 cycles). For our patient 3 deep cycles have been necessary: the optical change now concerns all lesions in totality and infiltration is possible.

• Fig. 7

• Fig. 6: The third times Icon-Dry application (after 3 cycles). For our patient 3 deep cycles have been necessary: the optical change now concerns all lesions in totality and infiltration is possible. • Fig. 7: Infiltration is performed with Icon-Infiltrant during 3minutes [4]. Use of dental floss before light curing is recommended. A second infiltration is necessary for 1 minute and light curing too. • Fig. 8: All the lesions are translucent. If the hollow left by milling or sandblasting is significant, the slight loss of hard tissue can be made up with composite. After light-curing of the infiltrate, the resin will be used as an adhesive support. For this reason, glycerin should not be used before composite application. Several studies have shown that bonding between the resin infiltrate and composite is of very good quality [5]. So the application of a thin composite build-up to this tooth is performed with one single shade of enamel composite resin. No stratification is required : only a work of surface texture with different brushes. A last light curing is necessary under glycerin to avoid the inhibited layer because of oxygen.

Fig. 7 Infiltration is performed with IconInfiltrant during 3minutes [4]. Use of dental floss before light curing is recommended. A second infiltration is necessary for 1 minute and light curing too.

• Fig. 6: The third times Icon-Dry application (after 3 cycles). For our patient 3 deep cycles have been necessary: the optical change now concerns all lesions in totality and infiltration is possible. • Fig. 7: Infiltration is performed with Icon-Infiltrant during 3minutes [4]. Use of dental floss before light curing is recommended. A second infiltration is necessary for 1 minute and light curing too. • Fig. 8: All the lesions are translucent. If the hollow left by milling or sandblasting is significant, the slight loss of hard tissue can be made up with composite. After light-curing of the infiltrate, the resin will be used as an adhesive support. For this reason, glycerin should not be used before composite application. Several studies have shown that bonding between the resin infiltrate and composite is of very good quality So the application of a thin composite build-up to this tooth is performed with one single shade of enamel composite resin. No stratification is required : only a work of surface texture with different brushes. A last light curing is necessary under glycerin to avoid the inhibited layer because of oxygen.

References

1. White spots on enamel: treatment protocol by superficial or deep infiltration (part 1).

• Fig. 8 Fig. 8 All the lesions are translucent. If the hollow left by milling or sandblasting is significant, the slight loss of hard tissue can be made up with composite. After light-curing of the infiltrate, the resin will be used as an adhesive support. For this reason, glycerin should not be used before composite application. Several studies have shown that bonding between the resin infiltrate and composite is of very good quality [5]. So the application of a thin composite build-up to this tooth is performed with one single shade of enamel composite resin. No stratification is required : only a work of surface texture with different brushes. A last light curing is necessary under glycerin to avoid the inhibited layer because of oxygen.

In the case of white spots involving deep lesions of the enamel superficial infiltration is not sufficient and a new technique has been developed the deep infiltration [2].

The concept of deep infiltration involves paying a price in the form of mild mutilation of the enamel through preparation by sandblasting or milling so as to ensure that the infiltration can spread through almost the whole of the lesion if the latter is deep.

Key Learnings

• Traumatic hypomineralization of a permanent tooth is a consequence of periodontal trauma affecting the deciduous teeth

• The diagnosis of traumatic hypomineralization remains essentially diagnosis by exclusion (with Fluorosis, White spots and MIH).

• A last light curing is performed under glycerin to avoid the inhibited layer because of oxygen.

REFERENCES

Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. Int Orthod. 2014 Mar;12(1):1-31 j.ortho.2013.12.011. Epub 2014 Feb 3. English, French.

2. White spots on enamel: treatment protocol by superficial or deep infiltration (part 2).

1. White spots on enamel: treatment protocol by superficial or deep infiltration (part 1).

Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. Int Orthod. 2014 Mar;12(1):1-31 j.ortho.2013.12.011.

Epub 2014 Feb 3. English, French.

3. Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series. Tirlet G, Chabouis HF, Attal JP.

2. White spots on enamel: treatment protocol by superficial or deep infiltration (part 2).

• Fig. 9: Final intra oral picture. After two months the result is satisfactory.The beauty of this internal dentin stratification has been conserved!

The histopathology of traumatic hypomineralization involves subsurface hypomineralization under a relatively wellmineralized surface layer. The surface layer is the result of post-eruptive ionic reprecipitation. It is due to inconsistent angles that the results of treatment of traumatic hypomineralization by erosion-infiltration are difficult to predict. In the case of white spots involving deep lesions of the enamel superficial infiltration is not sufficient and a new technique has been developed : the deep infiltration [2]. A deep infiltration treatment is proposed to our patient. Before the treatment the patient is informed a composite resin will be probably use on the teeth to mask concavity and alteration of enamel. Even if it remains a very conservative treatment. The concept of deep infiltration involves paying a price in the form of mild mutilation of the enamel through preparation by sandblasting or milling so as to ensure that the infiltration can spread through almost the whole of the lesion if the latter is deep.

4. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration-a clinical report. Quintessence Int. 2009 Oct;40(9):713-8.

• Fig. 10: Final polarized picture

Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. Int Orthod. 2014 Mar;12(1):1-31 j.ortho.2013.12.011.

Epub 2014 Feb 3. English, French.

5. Wiegand A1, Stawarczyk B, Kolakovic M, Hämmerle CH, Attin T, Schmidlin PR. Adhesive performance of a caries infiltrant on sound and demineralised enamel. J Dent. 2011 Feb;39(2):117-21. Oct 17.

3. Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series. Tirlet G, Chabouis HF, Attal JP.

KEY LEARNINGS

References

4. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration- a clinical report. Quintessence Int. 2009 Oct;40(9):713-8.

1. White spots on enamel: treatment protocol by superficial or deep infiltration (part 1).

Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. Int Orthod. 2014 Mar;12(1):1-31 j.ortho.2013.12.011.

5. Wiegand A1, Stawarczyk B, Kolakovic M, Hämmerle CH, Attin T, Schmidlin PR. Adhesive performance of a caries infiltrant on sound and demineralised enamel.

J Dent. 2011 Feb;39(2):117-21. Oct 17.

A deep infiltration treatment is proposed to our patient. Before the treatment the patient is informed a composite resin will be probably use on the teeth to mask concavity and alteration of enamel. Even if it remains a very conservative treatment. The concept of deep infiltration involves paying a price in the form of mild mutilation of the enamel through preparation by sandblasting or milling so as to ensure that the infiltration can spread through almost the whole of the lesion if the latter is deep.

Key Learnings

• Traumatic hypomineralization of a permanent tooth is a consequence of periodontal trauma affecting the deciduous teeth

Epub 2014 Feb 3. English, French.

2. White spots on enamel: treatment protocol by superficial or deep infiltration (part 2).

DR. MARIE CLEMENT

Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. Int Orthod. 2014 Mar;12(1):1-31 j.ortho.2013.12.011.

Epub 2014 Feb 3. English, French.

Dr. Marie Clement – Private Practice, Lyon, France 2005 - 2011 Studies of dentistry at the University of Lyon – France

Since 2011 Private practice in Lyon France (specialist in aesthetic and restorative dentistry)

3. Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series. Tirlet G, Chabouis HF, Attal JP.

2013 Post-Graduated in aesthetic dentistry in Strasbourg University France

• The diagnosis of traumatic hypomineralization remains essentially diagnosis by exclusion (with Fluorosis, White spots and MIH).

• A last light curing is performed under glycerin to avoid the inhibited layer because of oxygen.

2012 - 2016 Assistant professor at the Department of Prosthetic Dentistry - University of Lyon –France

• The diagnosis of traumatic hypomineralization remains essentially diagnosis by exclusion (with Fluorosis, White spots and MIH).

4. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration-a clinical report. Quintessence Int. 2009 Oct;40(9):713-8.

Since 2016 Digital Smile Design Instructor

Since 2017 Style Italiano Silver member

Main areas of work: Aesthetic, conservative and prosthetic dentistry

5. Wiegand A1, Stawarczyk B, Kolakovic M, Hämmerle CH, Attin T, Schmidlin PR. Adhesive performance of a caries infiltrant on sound and demineralised enamel.

Contact: Dr. Marie Clement, 8 avenue Maréchal Foch, 69006 Lyon, France

J Dent. 2011 Feb;39(2):117-21. Oct 17.

• Fig. 9: Final intra oral picture. After two months the result is satisfactory.The beauty of this internal dentin stratification has been conserved!

• Fig. 10: Final polarized picture

• Fig. 6 • Fig. 7

• Fig. 8

Fig. 9 Final intra oral picture. After two months the result is satisfactory.The beauty of this internal dentin stratification has been conserved!

Fig. 10 Final polarized picture

INTRODUCTION

Dental diastemas are openings or spaces between two adjacent teeth in the same dental arch. Many patients dislike the aesthetics of these spaces and search for a dental surgeon to solve this through a clinical solution. Different techniques can be used to close the diastema, such as orthodontic or restorative treatment using dental ceramics or composite resin. In less extensive cases, such as unitary diastema, the restorative technique with composite resins can be considered a viable option.

CLOSING DIASTEMA WITH COMPOSITE RESIN

AN EFFECTIVE AESTHETIC AND FUNCTIONAL METHOD

“Closing diastemas using composite resins is a reversible and conservative treatment with an excellent aesthetic result.”

Dr Leonardo Fernandes Cunha

Dr Fernanda Raposo

“Closing diastemas using composite resins is a reversible and conservative treatment with an excellent aesthetic result.”

Different techniques can be used to close the diastema, such as orthodontic or restorative treatment using dental ceramics or composite resin. In less extensive cases, such as unitary diastema, the restorative technique with composite resins can be considered a viable option.

The current stage of the direct adhesive systems allows an excellent clinical performance as well as presenting great optical properties, being able to not only reproduce the colour but also the translucency, texture and shine of the natural teeth. Therefore knowing the materials is essential. However, the technique must also be practiced to obtain success in treatment.

Hence, the objective of this work is to describe, through a clinical case, the technique for direct restorative treatment to close the diastema

Hence, the objective of this work is to describe, through a clinical case, the technique for direct restorative treatment to close the diastema.

CASE STUDY

A 26-year-old patient, male, sought treatment for the restoration of the front teeth where there were diastema between teeth 21, 22 and 23. Through radiography, it was confirmed that the support and pulp structures were normal. Taking into consideration the possibility of reversibility of the procedure, time and cost, we opted to restore the teeth with a direct adhesive restorative system Aura composite (SDI).

The prophylaxis of the tooth was performed then the shades for the dentin and enamel were selected. The shades DC1 for dentin and E1 for enamel were chosen. The modified isolation of the operation field was carried out through a dental dam.

A tape made of polytetrafluoroethylene was positioned on the lateral incisor to avoid etching the tooth. The enamel surface was etched with phosphoric acid (SDI). After that, the adhesive was applied (Stae SDI) and the light-curing process began according to the manufacturer’s instructions on the buccal and lingual surfaces, with Radii Plus (SDI).

The composite to simulate the shade of the dentin in the cervical line and medium third was condensed. After curing of this element, the contour of the emergence profile is established.

Surgery – UNESP – Araraquara; Indiana University School in Restorative Dentistry –School of Dentistry

FERNANDES CUNHA Master and Doctor of by FOB-USP

RAPOSO

Dental Surgery by UnB

Dr Ubiracy Gaião

Initial aspect

Final aspect

Initial Aspect

Final Aspect

CASE STUDY

was positioned on the lateral incisor to avoid etching the tooth. The enamel surface was etched with phosphoric acid (SDI). After that, the adhesive was applied (Stae SDI) and the light-curing process began according to the manufacturer’s instructions on the buccal and lingual surfaces, with Radii Plus (SDI).

the assistance of a polyester strip and brush.

Each increment was cured with an LED device (Radii Plus – SDI) based on the time recommended by the manufacturer, continuously. The same procedures were carried out for the left canine.

One must also check if there is space for the enamel composite in the buccal and lingual surfaces. A layer of the E1 composite for the enamel was applied on the buccal and lingual surfaces and spread with the assistance of a polyester strip and brush.

Each increment was cured with an LED device (Radii Plus – SDI) based on the time recommended by the manufacturer, continuously. The same procedures were carried out for the left canine.

After the isolation was removed, the excess was also removed and the incisal adjustment was made. In the following session, the finishing and final polishing were carried out with abrasive discs of sequential granulometry, rubbers and polishing paste, which were all used to promote the final shine. (Pictures 1 and 4).

The final aspect of the composition of the smile can be seen in picture 5.

The composite to simulate the shade of the dentin in the cervical line and medium third was condensed. After curing of this element, the contour of the emergence profile is established. One must also check if there is space for the enamel composite in the buccal and lingual surfaces. A layer of the E1 composite for the enamel was applied on the buccal and lingual surfaces and spread with

The final aspect of the composition of the smile can be seen in picture 5.

After protecting the tooth next to it, the etching was performed throughout the entire tooth to avoid the application of resin in non-conditioned areas. Application of the adhesive according to the instruction of the manufacturer and the curing of the adhesive with an LED device.

Fig 1a. Initial aspect of the patient

Fig 2a. Selection of shades through the application of a small amount of composite on the tooth and curing for 5 seconds

Fig 3a. ondensation of the dentin composite. Insertion of the DC1 shade to characterize the opacity of the dentin

Fig 1b. Initial aspect of the smile

Fig 2b. Acid conditioning (etching)

Fig 3b.

Fig 1c. Initial aspect of the patient Front view

Fig 2c. Initial aspect of the patient Frontal view

Fig 1a.

Fig 2a.

Fig 3a.

Fig 1b.

Fig 2b.

Fig 1c.

Initial aspect of the patient

Initial aspect of the smile

Acid conditioning (etching)

Initial aspect of the patient - Front view

Selection of shades through the application of a small amount of composite on the tooth and curing for 5 seconds

Condensation of the dentin composite. Insertion of the DC1 shade to characterize the opacity of the dentin

Fig 2c.

Initial aspect of the patient - Frontal view

Fig 3b.

adhesive various good durability relatively

various durability relatively The results discussed in in closing can The age into the indirect treatments, of the cannot favour the with increase time. patient, appointments important. composite conservative aesthetic

The results discussed in demonstrated in closing can The age taken into making the indirect future treatments, resistance of the structure. cannot favour the with increase time. patient, appointments very important. composite conservative excellent aesthetic

DISCUSSION

Moreover, as demonstrated in the aforementioned case, closing diastemas with composite can be considered reversible. The age of the patient must be taken into consideration when making the treatment plan (direct or indirect restorations) to allow future approaches for other treatments, without losing the resistance of the remaining dental structure.

are

the specialised literature.

The current direct adhesive restorative systems have various advantages. They have good durability are low cost, and it is a relatively fast treatment to perform. The mechanical and aesthetic results have also been widely discussed in the specialised literature. Moreover, as demonstrated in the aforementioned case, closing diastemas with composite can be considered reversible. The age of the patient must be taken into consideration when making the treatment plan (direct or indirect restorations) to allow future approaches for other treatments, without losing the resistance of the remaining dental structure. The finishing and polishing cannot be neglected, they also favour the longevity of the restoration, with less loss of gloss and less increase in surface roughness over time. Nonetheless, advising the patient, aftercare and follow-up appointments to assess the work are very important.

The finishing and polishing cannot be neglected, they also favour the longevity of the restoration, with less loss of gloss and less increase in surface roughness over time. Nonetheless, advising the patient, aftercare and follow-up appointments to assess the work are very important.

CONCLUSION

Closing diastemas using composite resins is a reversible and conservative treatment with an excellent aesthetic result.

the edges with a pencil to start the finishing with a diamond bur and polishing discs

PRODUCT REFERENCES

Closing diastemas using composite resins is a reversible and conservative treatment with an excellent aesthetic result.

Marking the

Detail of the restorations Lateral and frontal view

Marking the edges with a pencil to start the finishing with a diamond bur and polishing discs

Closing diastemas using composite resins is a reversible and conservative treatment with an excellent aesthetic result.

Fig 5a. Detail of the restorations Lateral and frontal

CONCLUSION

Fig 5b. Detail of the restorations Lateral and frontal view of the restoration

of the restorations Lateral and frontal view of the restoration

To learn more about the products used in this case please visit www.sdi.com.au

PRODUCT REFERENCES

Final aspect of the smile. Notice the harmony between the colour and contour provided by the direct adhesive restorations

Fig 5c. Final aspect of the smile. Notice the harmony between the colour and contour provided by the direct adhesive restorations

Closing diastemas using composite resins is a reversible and conservative treatment with an excellent aesthetic result

UBIRACY GAIÃO

To learn more about the products used in this case please visit www.sdi.com.au

Doctor of Dental Surgery – UNESP – Araraquara; Master of Dentistry – Indiana University School of Dentistry; Specialist in Restorative Dentistry – Indiana University School of Dentistry

REFERENCES

LEONARDO FERNANDES CUNHA

FERNANDA RAPOSO

Master and Doctor of Dental Surgery by UnB

Final aspect of the smile. Notice the harmony between the colour and contour provided by the direct adhesive restorations

Professor at UnB, Master and Doctor of Restorative Dentistry by FOB-USP

Fig 4a.

Fig 5a.

Fig 4b.

Fig 5b.

Fig 4c.

Fig 5c.

Marking the edges with a pencil to start the finishing with a diamond bur

Marking the edges with a pencil to start the finishing with a diamond bur and polishing discs

Lateral and frontal view of the restoration

Polishing with rubber disc

Final aspect of the smile. Notice the harmony between the colour and contour provided by the direct adhesive restorations

Detail of the restorations Lateral and frontal view

Fig 4a. Marking the edges with a pencil to start the finishing with a diamond bur

view

Fig 4a.

Fig 5a.

Fig 4b.

Fig 5b.

Fig 4c. Fig

Marking the edges with a pencil to start the finishing with a diamond bur

edges with a pencil to start the finishing with a diamond bur and polishing discs

Detail of the restorations Lateral and frontal view of the restoration

Polishing with rubber disc

Final aspect of the smile. Notice the harmony between the colour and contour provided by the direct adhesive restorations

Detail of the restorations Lateral and frontal view

Fig 5a.

Fig 5b.

Fig with a pencil with a

with a pencil with a polishing discs

Detail of the restorations Lateral and frontal view of the restoration

Fig 4a.

Fig 5a.

Fig 4b.

Fig 5b.

Fig 4c.

Fig

Marking the edges with a pencil to start the finishing with a diamond bur

Marking the edges with a pencil to start the finishing with a diamond bur and polishing discs

Detail of the restorations Lateral and frontal view of the restoration

Polishing with rubber disc

Final aspect of the smile. Notice the harmony between the colour and contour provided by the direct adhesive restorations

Detail of the restorations Lateral and frontal view

Fig 4a.

Fig 5a.

Fig 4b.

Fig 5b.

Fig 4c.

Fig 5c.

Marking the edges with a pencil to start the finishing with a diamond bur

Marking

Polishing with rubber disc

Fig 4b. Marking the edges with a pencil to start the finishing with a diamond bur and polishing discs

Fig 4c. Polishing with rubber disc

Fig 4a.

Fig 5a.

Fig 4b.

Fig 5b.

Fig 4c.

Fig 5c.

Marking the edges with a pencil to start the finishing with a diamond bur

Detail

Polishing with rubber disc

Detail of the restorations Lateral and frontal view

PRO-MATRIX CASE STUDY

An 87 year old gentleman attended as a new patient and was unconcerned about aesthetics but wanted a functional solution to two teeth which had become fractured and had become symptomatic and were found to be carious. These were LL5 LL6 (lower left second premolar and first molar).

X-rays were recorded, LA delivered and the teeth were isolated with Unodent latex-free rubber dam, Hygienic clamp & Triodent V-ring wedges.The existing amalgam restorations and underlying caries were removed and the cavities were then sandblasted with 50μ aluminium oxide. This was rinsed off, VOCO Vococidacid etchant applied and agitated then rinsed once more.

DR JAMES ROBSON BDS Principal Dentist, Identity Individual Dental Care

Qualified in Newcastle 1998 James has worked in private practice since 2004 and became a practice owner in 2010. James works with VOCO providing lectures and hands-on training for dentists, hygienists and therapists and enjoys writing for the dental or local press. He is most passionate about tooth coloured fillings, preventive care and the links between periodontal status and systemic health and wellbeing.

The Pro Matrix was placed on LL6 and the wedges adapted (1). The band was burnished/shaped with an American Eagle teardrop to ensure good tight contacts and the VOCO Futurabond U applied then agitated, air thinned and cured with an Ultradent VALO curing light.

Basic shaping was then performed with an NSK X600L air turbine using fine diamond burs (yellow band) and polished with VOCO Dimanto points run at slow speed with water spray in an NSK Z25L. (3)

The rubber dam was then removed and occlusal checks performed with 40μ Dr Bausch articulating paper and final adjustments made. Contacts were cleared with floss and polished with GC Epitex tapes. (4)

VOCO Grandio SO Flow flowable nanohybrid composite was applied to the box up to the band in a very thin layer then cured. VOCO Grandio SO nanohybrid composite was applied to each proximal contact independently and cured on each occasion, converting the cavity into an occlusal (Black’s Class 1). The band was then removed and the stages were repeated on LL5. (2) The tooth morphology was then restored on a cusp by cusp basis with American Eagle titanium nitride instruments and a VOCO Single Tim microapplicator, gently drawn up towards the cusp tips.

THE RARELY SPOTTED PULPOTOMY

BY DR PETER RAFTERY, ENDODONTIST, HAMPSHIRE ENDODONTICS

Article and remarks written under the sole responsibility of Dr. Peter Raftery

In his Hampshire practice, endodontist Dr Peter Raftery frequently saves patients (and himself) time and money by offering BiodentineTM pulpotomy as an alternative to root canal treatment, much to their delight. However, he often finds that general dentists can be hesitant to follow suit, with pulpotomy a vastly overlooked option.

Here, Dr Raftery makes the case for why BiodentineTM (*) pulpotomies are more beneficial, more lucrative, and easier to perform than you think…

Does VPT have an image problem?

Yes. I think that Vital Pulp Therapy (VPT) in permanent teeth has an image problem -- literally.

In terms of eye-catching Instagram updates, BiodentineTM pulpotomy post-ops just don’t compete with a sealer-filled apical delta. And so, outside of a textbook, you probably haven’t seen any pulpotomy cases in years. Which in turn means you probably aren’t aware of how incredibly useful a treatment option it is. In fact, in their 2022 paper on the evidence concerning pulp therapy, the British Endodontic Society (BES) suggests that this procedure might represent “a paradigm shift in how we manage pulpal disease.” (reference 1). Now that is attention-grabbing.

BiodentineTM pulpotomy – the win-win treatment approach

When patients are referred to me, they arrive already knowing our root canal treatment fee. If, following consultation, I am then able to recommend a pulpotomy (which I charge at two thirds of the full fee), patients are delighted with the prospective financial saving. And the savings don’t end there.

We all know that molars typically get crowns after root canal treatment. Most of my work is on molar teeth and so, if we are avoiding a root canal treatment via BiodentineTM pulpotomy, it seems reasonable that there is a chance of avoiding a crown, too. Having done many now, I am confident enough in the predictability of the procedure.

I reassure patients that, in the unlikely event the pulpotomy doesn’t work, I’ll complete the root treatment for the remaining third of the fee. As such, patients perceive that there is no financial penalty preventing them from trying pulpotomy.

Patients soon start to love the idea of BiodentineTM pulpotomy. Still, some might question whether this novel pulpotomy is as ‘tried and tested’ as a full root canal treatment and ask: “Would it not be better to spend a little more time and money for a more certain outcome?”

Forget the Dycal pulp caps you did in dental school; current evidence shows pulpotomies are predictable, with high success rates for pulpotomies in adult teeth with signs and symptoms indicative of irreversible pulpitis. (reference 2) Further, these success rates are no lower than those of more invasive and costly conventional endodontic treatments. (reference 3)

There are plenty of reasons for the operator to love this approach, too. Pulpotomy is a less technically demanding treatment to perform than full root canal treatment, avoiding most of the headline-grabbing risks (e.g. irrigant extrusion) and taking significantly less chair time. I find pulpotomy to be the most enjoyable treatment to perform and, when I consider the fee structure mentioned, probably the most lucrative, too. Pulpotomies, I feel, are the win-win treatment modality.

The rationale for BiodentineTM pulpotomy

It used to be the case that if the pulp of a permanent tooth became exposed by caries (or by caries removal), root canal treatment was indicated. Direct pulp caps with materials like Dycal were as unreliable as they were unpredictable.

The development and uptake of modern materials in the UK such as BiodentineTM in 2010, alongside a better understanding of pulp biology, means that VPT of inflamed mature teeth is now approaching the routine. With the increased acceptance of Minimal Intervention (MI) principles in dentistry, I would suggest all conservative-minded dentists ought to be offering BiodentineTM pulpotomies.

Patients instantly grasp the rationale. They instinctively understand that if, say, a diabetic patient develops irreversible foot complications, surgeons would best address the problem by amputating at the ankle, rather than cutting off the whole leg. By that token, if their dental problem comprises toothache or an extensively carious but vital tooth, they will understand the rationale behind removing that unviable portion of pulp and leaving behind the healthy, unaffected tissue.

To quote the BES paper on pulpotomy: “Maintaining pulp vitality preserves the tooth’s circulatory defence system, the full proprioceptive function of the tooth is maintained, and the tooth will be less mechanically weakened and hence less prone to fracture.” (reference 1)

Case selection

Teeth that are suitable for consideration for pulpotomy include:

• Vital teeth with no caries but symptoms of irreversible pulpitis.

• Vital teeth with caries extending into the pulp with or without pulpitis symptoms (reversible or irreversible).

Cases not suitable for consideration include:

• Caries not extending into the pulp of teeth with no symptoms or with symptoms of reversible pulpitis. These teeth should be restored conventionally.

• Non-vital teeth and teeth with apical areas of rarefaction. These pulps are dead and the pulp space is infected. With necrotic pulps, there is no tissue to preserve and root canal treatment (mature apices) or revascularisation (immature apices) are the endodontic options of choice.

Case selection does not hinge entirely on the irreversible/reversible pulpitis categorisation. Despite improvements in the understanding of pulp biology, pulp histology still correlates poorly with clinical symptoms.

If symptoms can correlate poorly with the true condition of the pulp, then patients must be cautioned that “the goalposts may move” during the pulpotomy procedure. If no viable pulpal tissue is found intra-operatively, then there is nothing to preserve, and a fuller clean-out of the pulp space is necessary. Patients need to be quoted (and appointment times need to allow) for pulpotomy or root treatment.

For a proposed pulpotomy to remain an option intra-operatively, I say: “I need to see red stuff on the inside of the tooth.” I will always take an image to justify doing (red stuff) or not doing (no red stuff and/or a smell) the pulp therapy and for this reason, I think that intra-oral imaging is a medicolegal musthave.

The European Society of Endodontology (ESE) says that: “The colour and intensity of pulp bleeding on exposure intra-op may provide a surrogate marker of inflammation and capacity to recover after treatment.” (reference 4)

Only with injectable anaesthetics do I feel I have a hope of getting inflamed pulps numb. Rubber dam use is necessary because bacterial contamination of the pulp space spells certain failure. After clearing caries, I will deroof the pulp. It is necessary to remove the vital pulp with a diamond bur. A slow handpiece will entangle and rip out the very pulp you’re trying to preserve.

Drilling away pulp is a skill to be learned on the job. A light touch (and good vision) is needed to discern the ‘feel’ of pulp and to avoid gouging out the pulp chamber dentine. Once I’ve drilled away the coronal pulp down to orifice level, I will take a photo for the record. I need to see red circles (not pus, not empty orifices, and not a gushing, hyperaemic pulp).

I will clean out the pulp chamber with a cotton pledget or small piece of sponge soaked in sodium hypochlorite. I will apply some pressure to the cut pulp through the pledget for a minute. Pressure will help stop the bleeding from a healthy pulp stump and the hypochlorite will kill bacteria and gently dissolve any necrotic pulp.

Upon removal, I have a clean, vital, nonbleeding pulp directly onto which I will pack some BiodentineTM (not MTA). In their 2022 Pulp Therapy Evidence Guidelines, the BES describes BiodentineTM as the single best pulp therapy material. Calcium hydroxide induces a poorer, less predictable pulpal response and the bismuth oxide in MTA irreversibly discolours teeth. (reference 1)

Septodont’s procedure allows me to fill the entire cavity with one BiodentineTM capsule (the Bio BulkFill procedure). Septodont advise that BiodentineTM can be used as an enamel restoration material for up to six months. I don’t see any argument for taking a post-pulpotomy x-ray.

Post-op management

Having manipulated the densely innervated tissue, I supply the patient with two days of oral steroids as a potent anti-inflammatory. After six months, I review the case. To determine success clinically, I use an absence of swelling or draining sinus. Radiographically, I require an absence of apical rarefaction. In successful cases, I request the General Dental Practitioner (GDP) resurface the BiodentineTM, ideally cutting back the outer 2mm of BiodentineTM and flowing something harder-wearing and aesthetically suitable on top. I can accept that some cases still need a casting (crowns or onlays) despite a successful pulpotomy.

Failures are rare, characterised by clinical and/ or radiographic signs of infection. I also deem as failures those very rare cases where the patient cannot wait until six months due to worsening pain symptoms.

A common concern from dentists is how to complete a root filling when you’ve packed BiodentineTM down. Having progressed a few of my own pulpotomies into root fillings, I can say that it is not as hard as one might think to visually discern between white BiodentineTM and yellow dentine when drilling. Nor is it hard to discern between the two from a tactile perspective when drilling with a Goose Neck bur.

Conclusion

Pulpotomies are soon to be routine. I find the most disgruntled patients at my endodontic practice are those who experience an agonising Bank Holiday weekend after a ‘deep filling’ at their dentist (such as a deep amalgam or composite in a deep cavity close to the pulp). I would argue that placing a deep filling in a carious molar and hoping for the best is asking for trouble (and complaints). I would argue that being slightly more proactive with deeply carious cavities, excising the inflamed pulp and placing a BiodentineTM restoration onto uninflamed pulp, will be the proverbial “stitch in time, saving nine”.

(*). Biodentine is marketed by Septodont laboratory (58 r Pont de Créteil, 94100 Saint Maur des Fossés – France)

References

1. British Endodontic Society (BES) https://britishendodonticsociety.org.uk/_userfiles/pages/files/ a4_bes_guidelines_2022_hyperlinked_final.pdf

2. Asgary & Eghbal 2013, Asgary et al. 2015, 2017, 2018, Galani et al. 2017, Linsuwanont et al

3. Ng Y-L, Mann V, Rahbaran S, Lewsey J, Gulabivala K. Outcome of primary root canal treatment: systematic review of the literature – Part 1. Effects of study characteristics on probability of success. International Endodontic Journal, 40, 921–939, 2007.

4. European Society of Endodontology (ESE) https:// britishendodonticsociety.org.uk/_userfiles/pages/files/duncan_et_ al2019international_endodontic_journal.pdf

APEX LOCATION

AN ENDODONTIST’S PERSPECTIVE

“We’ve always bought and used Morita ZX apex locators and the Dentaport ZX that we are currently using is a number of years old now. Apex locators are manufactured by a lot of different companies and there are many models on the market. I’m sure they’re all good instruments, however, I prefer the Morita apex locators because of their reliability and longstanding track record.”

Dr John Barbat, North Shore Endodontic Services, Chatswood, NSW

The History

Prior to the early ’90s, electronic apex locators were notoriously unreliable. They used a single current that would often complete the electronic circuit when the file wasn’t at the apex.

The Morita ZX system eliminates this electronic variability by using two currents of different wave frequencies simultaneously.

The relationship between these two currents changes as the biologic constriction is approached.

The Research

There’s a plethora of research into this particular instrument. It’s a favourite of endodontic master’s students to investigate and write their thesis.

Most of the research shows that this apex locator is highly accurate to within 0.5 and 1mm of the biologic constriction of the tooth.

The Benefits

It improves efficiency, saves time and reduces patient radiation. The locator gives a very accurate length measurement that is confirmed with an X-ray.

This means you know where you are before taking the X-ray. Without the locator reading, it’s highly likely that a succession of X-rays would be needed to achieve the same result.

Recommendations

There is a degree of technique sensitivity when using this instrument. Care must be taken that short circuits aren’t created by metal restorations. Irrigants used in canals are electrolytic, so if there is any leakage it can also create false readings.

However, any errors are pretty obvious and these can usually be overcome.

DR JOHN BARBAT, North Shore Endodontic Services, Chatswood, NSW

TIPS FOR WARM VERTICAL CONDENSATION

1. You need two devices –one heated plugger and one back fill unit. (e.g. B&L SuperEndo Alpha and Beta) and to take your treatment to the next level we suggest endodontic pluggers such as B&L’s NiTi/SS Kondensors.

2. Ensure the canals are prepared adequately, disinfected and dried. True warm vertical obturation works consistently with small apical size and larger taper preparation techniques eg. #25 .06.

3. Select your master GP point based on the minimum size of the apical constriction and ensure there is adequate tug back.

4. Select a plugger tip that goes within 4-5mm of your working length. Mark the depth at which it binds to the canal with a rubber stopper.

5. Insert your sealer coated master GP point into the canal and trim off the excess at orifice level using the B&L Alpha heated plugger.

6. Condense your GP at the orifice level using the large SS end of your B&L Kondensor.

7. Activate the heated plugger and Insert into the canal, applying firm pressure. Stop 1mm from the marked stopper.

8. De-activate the heat, whilst still maintaining apical pressure for approximately 8-10 seconds.

9. Activate the plugger again and push 1mm apically and swiftly pull the plugger out along the curvature of the canal. Do this step quickly in 1-2 seconds. This will leave an apical plug.

10. Condense the apical GP with the fine NiTi end of the B&L Kondensor.

11. Place the pre-heated needle of the backfill unit (B&L Beta) into the canal, resting on the apical portion of the GP. Extrude the warmed GP and let the pressure of the extruded GP push the tip out of the canal. Do not pull back as this can create voids!

12. Condense the expressed GP into the canal carefully with an endodontic plugger.

It is recommended that you practice on extracted teeth first to gain confidence.

Beta unit

Alpha unit

B&L Kondensors

SUCCESSFUL ROOT CANAL TREATMENT OUTCOMES

HYFLEX EDM – OGSF SEQUENCE

Initial presentation and background

VISIT 1

The patient was a referral for root canal treatment (RCT) on the LL6, following the referring dentist having difficulty in locating the root canal orifices. The patient reported being advised by her general dentist that she required RCT as she had extensive decay on the tooth. She had been in continuous pain after the GDP tried to find the nerves; however, this did not help. The patient told me that the tooth hadn’t felt right since the treatment was initiated and that she would like the pain to stop. She had been taking painkillers and prescribed a course of antibiotics.

Results of examinations

Extra-orally, no abnormality was detected. Intraoral exam on LL6 revealed an attempted extirpation, however gross mesial caries had not been removed. Mobility was grade 0. The tooth was slightly tender to percussion, also there was mild buccal tenderness to palpation. There was no endo-related pocketing when the probe was walked around the gingival crevice. No evidence of a sinus tract or intraoral swelling were found.

A pre-operative radiograph showed extensive mesial caries with a previous attempt at locating the canals. There was no obvious apical pathosis radiographically (Fig 1).

Diagnosis

A diagnosis was made for the LL6 of symptomatic apical periodontitis with previously initiated treatment.

The options regarding this tooth were:

1. Do nothing. However, the patient was warned that, if left untreated, it could cause an acute flare up at any time and have a reduced prognosis due to persistent infection.

2. Root canal treatment (RCT) with cuspal coverage. The patient was informed initially that we would have to investigate the restorability of the tooth due to the extensive mesial caries, and if unrestorable then an extraction may be required.

3. Extraction.

The patient was happy to proceed with RCT. Consent was discussed, with the risks and benefits explained, including the risk of re-infection and the complex anatomy. The consent form was duly signed, witnessed by me and the dental nurse.

Treatment pathway

Local anaesthesia was administered: 4.4 ml lidocaine hydrochloride, 2% 1:80,000 adrenaline via buccal infiltration and inferior dental block (IDB).

A rubber dam was placed over LL7 LL6 LL5 LL4, with a Hygienic Fiesta 7 clamp and double floss ties used to provide a tight seal (Fig 2). The tooth was reassessed with caries removal having been carried out (Fig 3), and four orifices located. The mesial cavity margin was deemed restorable, however deep marginal elevation (DME) would be required. A decision was made to carry out the DME following cleaning and shaping of the root canal system (RCS), to improve/maintain access to the RCS.

Fig 1. Preoperative Radiograph.

A glidepath was created using K-Flex Files 06, 08, 10. Throughout the procedure, the canal was irrigated with an enhanced sodium hypochlorite solution applied using Irriflex syringe irrigation.

Working lengths were established using a Morita Root ZX apex locator: Mesiobuccal (MB), 21 mm (reference point, distobuccal cavity wall); Mesiolingual (ML), 22.5 mm (reference point, distobuccal cavity wall); Distobuccal (DB), 21.5 mm (reference point, distobuccal cavity wall) and Distolingual (DL), 21 mm (reference point, lingual cavity wall).

Cleaning and Shaping was completed using Coltene’s HyFlex EDM OGSF file sequence and CanalPro X-Move motor sequentially. These files know their way around curves. Due to their controlled memory, the files follow the anatomy of the canal, thus significantly reducing the risk of ledging, transportation or perforation of a canal. Like stainless steel files, HyFlexTM files can be pre-bent, facilitating access to the RCS. Used in combination with the CanalPro X-Move motor, which enables monitoring of working length throughout shaping due to the inbuilt apex locator, I was able to navigate the RCS to achieve a safe, effective and predictable mechanical preparation.

The new HyFlex EDM OGSF sequence includes a new Orifice Opener and Glidepath file for achieving an effective glide path, as well as a Shaping file for shaping the root canal over the full length. The canals were prepared to the Finisher file (30/04) using Tactile Controlled Activation, with continuous irrigation using the sodium hypochlorite solution

throughout the procedure. The defined treatment procedure makes the preparation easy and keeps the learning curve short.

Following apical gauging, matching Hyflex EDM Gutta-Percha points were placed in situ and a mastercone long cone periapical radiograph (LCPA) of the LL6 was performed (Fig 4), to assess the apical extent of the master gutta percha cones. Reporting showed a potential obturation to within 2 mm of radiographic apex.

The canals were dried with paper points, a calcium hydroxide paste placed in them and PTFE tape used in the pulp chamber space. In order to improve the fracture resistance of the tooth in between appointments, deep marginal elevation was carried out with composite for the mesial marginal ridge, utilising a band in band technique. The tooth was temporarily restored with a GIC restoration, occlusion and contacts checked (Fig 5-7).

Fig 2. Rubber Dam Isolation

Fig 3. Caries Removal with deep mesial margin.

Fig 5. Band in Band technique using a sectional matrix within a DME band to restore the marginal ridges.

Fig 4. Mastercone Radiograph.

Fig 6. Post Deep Marginal elevation and restoration of the marginal ridges of the LL6.

The patient was told to expect some post-op pain and tenderness and advised to take painkillers and avoid having anything hard on the tooth, due to the risk of fracture. She was also advised about the possibility of an acute flare-up and/or swelling in the area, alongside the possibility of tenderness from the jaw joint. If any of these scenarios were to occur, she was to use anti-inflammatories, cold compresses and contact the dental practice. The patient understood these instructions and left happy.

VISIT 2

For her next visit, the plan was to obturate and provide a coronal seal with a direct permanent restoration.

The patient was able to report that since the last visit she’d experienced no pain or discomfort, so would like the treatment completed. She was made aware of the risks and confirmed consent, as before.

I was then able to proceed with the continuation of the RCT on LL6. Once again, it was delivered under local anaesthesia: 4.4ml lidocaine hydrochloride, 2% 1:80,000 adrenaline via buccal infiltration and IDB. A rubber dam was placed over LL7 LL6 LL5 LL4, with a Hygienic Fiesta 7 clamp and double floss ties used to provide a tight seal. The tooth was accessed, and four orifices relocated, using a microscope and ultrasonics. Working lengths in each canal were re-established using COLTENE’s HyFlex EDM Finisher file (30/.04) (Fig 8), with continuous irrigation throughout using sodium hypochlorite solution applied through an Irriflex needle.

I performed mechanical agitation of the irrigant, with well-fitting gutta percha cones using long vertical strokes and 30 seconds ultrasonic activation of the irrigant in each canal. I then gave a penultimate rinse with EDTA 17% for one minute, followed by sodium hypochlorite as the final rinse. The canals were dried with Hyflex EDM 30/04 paper points (Fig 9).

The canals were obturated using a single cone bioceramic technique. One-Fil bioceramic sealer was delivered into the canals using an MST tip (Fig 10). Matching master cones with sealer were placed to working length and a heat source was used to remove the coronal portion of the cones (Fig 11-13).

The tooth was etched bonded and restored with a composite restoration (Fig 14). Occlusion and contacts were checked.

Fig 7. Interim GIC restoration placed to re-establish access to the canals at the next visit.

Fig 8. Hyflex EDM Finisher 30/04 in situ, using Tactile Controlled Activation as method of use.

Fig 9. Canals dried using Hyflex EDM 30/04 paper points.

Fig 10. MST tip used to deliver One-Fil Bioceramic sealer within the canals.

Fig 11. Placement of Hyflex EDM gutta percha mastercones to working length.

The tooth was etched bonded and restored with a composite restoration (Fig 14). Occlusion and contacts were checked.

The patient was advised to take painkillers to relieve any discomfort and to expect some pain and possible tenderness of the tooth. As per visit one, she was also advised about the possibility of an acute flare-up and/or swelling in the area, or the possibility of tenderness from the jaw joint. If any of these scenarios occur, she was to use anti-inflammatories, cold compresses and contact the dental practice. The patient understood these instructions.

A LCPA radiograph was taken, justified for postoperative assessment of endodontic treatment and to check that a coronal seal was provided. Reporting showed the RCT well condensed and within 2 mm of the radiographic apex The patient was advised to see her GDP for review and left happy (Fig 15).

ABOUT THE AUTHOR

Dr Dhiraj Arora qualified in 2007 from Kings College London and after five years as an associate dentist, is now the owner of two practices. Having completed his Masters in Endodontic Practice from QMUL, he now principally works as an endodontist across multiple practices in London. Dhiraj has been involved in the mentorship educational supervisor within the London Deanery. This, along with being an Honorary Lecturer in Endodontics (QMUL) allows him to combine his enthusiasm for endo and teaching. He has recently set up Evo Endo to provide postgraduate endodontic courses to general dental practitioners.

DR DHIRAJ ARORA

Dr Dhiraj Arora

Fig12. Cutting of coronal aspect of Gutta percha cones using a System B Heat Source.

Dr Dhiraj Arora

Fig 13. Post Obturation.

Dr Dhiraj Arora

Fig 14. Post composite core build up.

Dr Dhiraj Arora

Fig 15. Postoperative radiograph showing well condensed obturation to within 2 mm of the radiographic apex and an adequate coronal seal provided by a composite restoration.

THE KAVO UNIQA, A NEW CLASS OF TREATMENT UNITS.

Kavo Dental has set many milestones in modern dentistry over its 110 year history

After the introduction of pioneering premium treatment units such as the ESTETICA series and the popular PRIMUS models, the company is now continuing its long-standing, unique success and innovation story, heralding a new era with the KaVo uniQa: this treatment unit sets a new standard in the mid-range price segment, the generation of the premium compact class. Better design, more comfort and more pleasure come together to create a unique product experience for dentists and patients. Developed for more enjoyment in modern everyday practice. The modern dental practice is characterised by diverse demands and requirements that are becoming more and more relevant. On the one hand, dentists value quality, precision, efficient workflows and high-quality design. On the other hand, it is no longer just the quality of treatment that is important for patients; the need to feel comfortable and safe is also becoming more important. With this change, the practice rooms are also taking on a new role, as they are beginning to mirror individual practice management. And as the heart of the dental practice, the treatment unit is even more important. The new KaVo uniQa was developed to meet these very unique requirements in terms of design and practitioner and patient comfort today and in the future, in all areas of application, and thus represents a comprehensive technological and emotional success story for everyday practice.

INTERVIEW

The KaVo uniQa reaches a new milestone in the treatment unit segment, defining a new class of treatment units, the premium compact class. Armin Imhof, Director of R&D for treatment units and instruments, and Jürgen Hinderhofer, Designer and Managing Director of SLOGDESIGN, explain what exactly this is all about and how the KaVo uniQa lives up to its name.

With the new KaVo uniQa, the name says it all – the focus on individuality. What does this individuality relate to?

Armin Imhof (AI): With regard to the product itself, there is one essential aspect in particular: with the uniQa, we have brought the premium level into the medium price segment. Many of the features of our new treatment unit used to only be available in the higher-price segment. That means we have moved into a new class with the uniQa, the premium compact class. Furthermore, there are four things that largely determine the uniQa’s unmistakable character: the patient chair, the hygiene functions, the touch controls and of course the style with its clear, compact design language. And of course the workflow, applied to all KaVo products, was also the focus, because KaVo customers should already feel at home with the new uniQa. The overall package is simply unique – from both a technological and design perspective. In addition, the uniQa can be individually customised, making it a unique piece for every practice.

KaVo products stand for the highest quality –with a focus on precision and durability. How is this guaranteed, especially with new treatment units?

AI: Developing a new treatment unit requires years of intensive research and development. Various stress and endurance tests are part of this. The final test phase lasts more than a year. The recurring and final practice and acceptance tests carried out with our dentists also make up an essential part of the process. KaVo products undergo intensive testing.

Jürgen Hinderhofer (JH): In the course of development, a large number of prototypes are created that ensure the correct tech-nology, ergonomics, design concept and choice of materials. We are also continually reassessing and researching new aspects of the design in order to sharpen and improve the concept. It is precisely these findings, directly from the dental practice, that are extremely important and are incorporated into the development.

In addition to the qualitative aspects, an effortless workflow that promotes health is extremely important for dentists and their practice teams. KaVo is known for its focus on ergonomics and design. How do these two aspects interact, especially from the point of view of individualisation?

JH: Enabling fatigue-free, concentrated work at the treatment unit is the backbone of a successful ergonomic concept, which allows a certain degree of flexibility for personal requirements and circumstances. The individual setting options and the optimisation of the reach areas are particularly important. The patient chair also plays a central role here; it is compact, offers plenty of legroom and supports good posture. We also attached great importance to a smart design evolution. All in all, we believe that with the KaVo uniQa we have succeeded in creating a treatment unit that simply makes you feel good.

Digitisation is also an increasingly essential part of modern practice processes. To what extent does the KaVo uniQa support digital workflows?

JH: The digital transformation offers us great, new opportunities in the dental practice. The opportunity to integrate software and the ease of use via the touchscreen on the dentist element, for example, provide a lot of leeway for improving the workflow, and allows for more transparent, simple and quick communication with patients.

Finally, can you summarise for us the difference between “a real KaVo” like the uniQa and other treatment units?

AI: Outstanding ergonomics in their most beautiful form... that’s how I would sum it up: the KaVo uniQa is a premium tool with a beautiful appearance. For me, these two characteristics, ergonomics and design, are the fundamentally and distinguishing

features of a KaVo treatment unit. JH: It is the well thought-out details and a high degree of functionality that set the uniQa apart and enable intuitive work on the unit. The degree of compactness that we have achieved for maximum ergonomic improvement is also unique. I think that we have created a new benchmark for elements such as the parallelogram chair and the base plate, for example. The reduction in dimensions has really made a big difference.

AI: To sum up: the uniQa is simply a pleasure!

Pleasure is a good keyword. What did you personally enjoy most during the development phase?

AI: It’s been great to watch the project develop over the years. But what I was most pleased about was that the uniQa today looks almost exactly like the first prototype! This is really a fantastic achievement and proof that we set the right goals and were and still are on the right track. JH: That’s correct. And as a design team, that gave us the opportunity to continue working on the product in a very focused and consistent manner. I personally enjoyed the high level of acceptance and the open, constructive exchange between the KaVo developers, KaVo product management and us designers. Excellent.

That sounds like a fantastic team effort. You have both worked for KaVo for many years. What still fascinates you?

AI: With our work we contribute to people’s health and quality of life as well as to a healthy, radiant smile; what could be better? We get to work with great products for a premium manufacturer. The treatment units, which are the heart of the practice, express this best. For some years now, there has also been an increasing number of design aspects, which I personally enjoy. Yes, a treatment unit is a piece of work equipment, but as a design element it also evokes a great deal of emotion, sort of like a piece of furniture. JH: I second that. The patients are always at the centre of everything we do. That means improving the quality of treatment, workflows and ergonomics. Our team is passionate about medical technology – and the mix of young and experienced colleagues creates a particularly exciting dynamic that leads to innovative and exciting solutions. We are passionate about the industry!

With so much enthusiasm, we are sure to see great things in the near future. What can we expect next from the KaVo world?

AI: Here in Biberach we are the competence hub for treatment units and instruments. The KaVo pipeline is full and we will be presenting exciting innovations in both areas in the near future. We are working at a fast pace and the dental world can look forward to a display of product fireworks from us.

EQUIPMENT SOFTWARE

THE NEW AI TOOLS: PLANMECA ROMEXIS®

The new AI tools for Planmeca Romexis® optimise daily tasks and boost patient communication. By visualising cases better than ever before, these tools both help save time for clinicians and promote patient education and communication.

The Planmeca Romexis® software platform is a comprehensive solution for dental imaging, diagnosis and treatment planning. It supports a wide range of imaging modalities from 2D and 3D to CAD/CAM and is suitable for clinics of all sizes and specialities. The software has now been complemented with new tools for 2D and 3D imaging that harness the potential of artificial intelligence. The tools utilise AI to generate proposals, but the ultimate decisionmaking authority always remains with the clinician.

Romexis® Smart is an optional feature available for the Romexis 3D imaging module. It automatically segments and recognises anatomies such as the skull, soft tissue, teeth, nerves, jaws, airways and sinuses. Thanks to the new feature, the software is even easier and faster to use, and the visualisation of anatomies makes it an excellent tool for patient communication.

AI helps save time in the implant planning and implant guide design as CBCT images and intraoral scans are automatically fitted. Romexis Smart also streamlines the CMF surgery workflow: the automated jaw segmentation, nerve detection and fitting of CBCT images and intraoral scans generate time-savings and allow surgeons to focus on the essential, i.e. the surgery planning, which optimises the return on their time invested.

Additionally, segmented anatomies offer an effective means to explain treatment plans to patients. This can help patients gain a better understanding of their treatment options, which often leads to increased case acceptance rates.

The Romexis software also offers another advanced AI-based tool, which is optionally available for the 2D imaging module. As a result of a collaboration between Planmeca and Pearl, the global leader in dental AI solutions, Romexis users can now benefit from the seamless integration with Pearl’s Second Opinion® radiologic detection aid service and receive AI detections created by the service directly in Romexis.

The automatic 2D image analysis for panoramic and intraoral X-rays provides a second pair of eyes, which can help dentists make better diagnoses, boost patient communication and improve oral health outcomes. The AI analysis helps to identify signs of various dental pathologies and other treatable conditions found in dental radiographs, including hard-to-spot issues such as incipient caries or the early signs of a periapical radiolucency. Findings are highlighted in colour and text, establishing an easy-to-understand independent opinion that helps gain patient trust. This allows for timely interventions and long-term health benefits through increased patient retention.

“Artificial intelligence is not only the future but already the present of dentistry. Our unwavering commitment remains: to simplify the lives of our users and unlock value through intuitive software tools. With Planmeca Romexis, we’ve now taken this mission to new heights. By seamlessly integrating artificial intelligence, Romexis not only accelerates data analysis but also elevates precision. Clinicians can now navigate their tasks more efficiently, allowing them to focus on what truly matters – patient care,” states Helianna Puhlin-Nurminen, Vice President of Digital Imaging and Applications at Planmeca.

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CBCT IN ACTION: ENDODONTICS

HOW CBCT CAN BE USED IN ENDODONTIC WORKFLOWS

For 25 years, cone beam computed tomography (CBCT) has transformed the way doctors practice dentistry. The advancement of this technology has become a valuable asset for patient diagnosis in many workflows, as well as in treatment planning where traditional radiography falls short.This is particularly true for complex endodontic cases in which a conventional radiograph hasn’t produced enough information.

By using CBCT imaging for diagnosis, endodontists can find extra canals and unusual anatomy that might not be visible using 2D imaging and plan a patient’s care ahead of time. CBCT scans are useful for detecting periapical lesions, root canal anatomy and the spatial relationship of roots to nearby anatomical structures. There is also a better view of the location, type and shape of structures within the root.

How CBCT can be used in endodontic workflows

A CBCT unit is about the size of a panoramic machine and doesn’t have a large footprint in a dental practice. Generally, dental team members take 3D images while a patient is seated or standing in the exam room or in a dedicated imaging area. Using software, they can process that data into a scan within minutes. The images can be displayed in the axial, sagittal and corona planes simultaneously.

There are a number of situations where using CBCT imaging may be helpful to endodontists:

• Detecting apical periodontitis: CBCT scanning allows for the detection of radiolucent endodontic lesions before they show up on a conventional radiograph.6 One study found that using 3D scans allowed for the detection of 62% more periapical lesions than two-angled periapical radiographs. This can allow for earlier detection of periodontal disease.

• Pre-surgical assessment: Endodontists often use CBCT imaging to identify the anatomical relationship of the root apices to important neighboring anatomical structures, such as the inferior dental canal, mental foramen and maxillary sinus. This can help prevent injuries during surgery. It is possible to use a CBCT scan to accurately determine the thickness of the cortical plate, the cancellous bone pattern, fenestrations and the inclination of roots involved in periapical surgery. Practitioners may also use a CBCT scan to assess the root morphology, bony topography and the number of root canals.

• Evaluating dental trauma: A 3D scan can be used to assess the severity of alveolar and luxation injuries. A CBCT scan can also be used to find horizontal root fractures. In one study, it performed better than the 2D intraoral scan or digital radiographic methods.7

• Studying root canal anatomy: It is not always possible to spot the number of root canals with a conventional radiograph. The CBCT unit can reconstruct images to allow for the view of resorption lesions, revealing the point of entry and the exact location, as well as lesions that were not previously discovered.

Clinical situations where CBCT has proven to be highly beneficial.

While CBCT is not necessarily warranted for routine endodontic diagnosis or for screening purposes when patients aren’t presenting with clinical signs and symptoms, practitioners are advised to use CBCT when “the need for imaging cannot be met by lower-dose twodimensional radiography.”

Common clinical situations include:

• During endodontic treatment / assessment / applications

If a comprehensive diagnosis has been completed and an endodontist needs more information, a CBCT scan can be a useful adjunct.2

• Surgical assessment

Several recent studies show that CBCT imaging has an impact on surgical assessment. One, for instance, found that CBCT imaging was more precise than 2D images when it came to determining the size of a lesion.3

• Evaluating pathosis

Research shows that using a CBCT scan in combination with a magnetic resonance imaging (MRI) scan can provide a more precise diagnosis of complex periapical pathosis than either one alone.4

• Temporomandibular joint (TMJ) assessment

According to recent research, CBCT is an effective imaging technology for diagnosing a variety of TMJ conditions.5

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Comparison of 2D to 3D images

CBCT provides a true 3D representation of the patient’s dentoalveolar facial structures. These scans show excellent soft tissue detail, enabling improved patient planning for surgeries, as well as enhanced diagnostic capability for many conditions.

3D images take a few more seconds to complete than a 2D X-ray, but can provide a greater wealth of knowledge and are widely considered a good use of that extra time. Think of a pan as just “one page of the encyclopedia” in regard to a patient, and a CBCT scan as “the entire encyclopedia.”

2D Images

• Caries Dental issues in the jaw and skull

• Abnormal growth near roots

• Cysts and tumors

• Bone loss surrounding teeth

• Salivary gland issues

• Analyzing a child’s developing teeth

• Teeth alignment

3D Images

• Surgical planning and treatment of impacted teeth

• Assessment of osteoarthritic changes in temporomandibular joints

• Locating the origin of pain or disease

• Identification of cysts, surface erosion, osteophyte or generalized sclerosis

• Developmental abnormalities

• Trauma, including identification of fracture lines

• Canal relationships Airway analysis for potential obstructive sleep apnea

• Periapical and periodontal findings

• Orthodontic applications

• Pathological findings Planning for root canal therapy

• TMJ issues

Impact of adding CBCT to a practice’s return on investment

regard to a patient, and a CBCT scan as “the entire encyclopedia.”

CBCT can pay for itself on numerous fronts, including:

• Faster, more accurate diagnosis, resulting in more efficient patient treatments in fewer visits — with more of these treatments kept “in-house” — plus practicing more dentistry with more confidence and increased referrals.

• Attracting patients seeking an office that uses the most advanced equipment and techniques.

• Ability to expand into new areas of dentistry and to better collaborate with medical colleagues when it comes to the head and neck areas. Some clinicians find that using CBCT increases their referral network of ear, nose and throat (ENT) practitioners and orthopedic surgeons.

• More walk-ins due to technology-focused branding; e.g., “Smith Dentistry” becomes “Smith 3D Dentistry.”

• Better retention of patients who seek second opinions; many like the visibility that 3D dentistry affords.

Case Study: Use of CBCT in Endodontic Diagnostics

40-year-old-patient came to Dr. Herrmann’s practice because of a maxillary anterior tooth, concerning a possible tooth preservation by endodontic therapy. The tooth #21 in question had been clinically inconspicuous after an accident trauma several decades ago, and to this day it is still completely free of complaints.

Endodontic therapy had not become necessary until then. Compared to a control X-ray about five years ago, the conventional X-ray showed a radiolucent change in the hard dental substance in the coronal third of the root, which is why the patient was referred to Dr. Herrmann’s practice by her family dentist with the suspected diagnosis of “internal resorption.” In a digital dental film carried out by Dr. Herrmann and his team, the typical picture of an external resorption was shown (e.g., decentralized whitening; moth-eaten appearance; the root canal can still be suspected in the X-ray image).

A high-resolution CBCT scan performed with the Morita Veraview X800 device impressively confirms the diagnosis and shows the extent of tooth structure destruction with a still intact root canal and perfect apical conditions.

Equally impressive (as a secondary finding) is the representation of several side canals on both tooth #11 and tooth #21.

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HARNESSING THE POWER OF 3D X-RAY IMAGING

With an upgradable platform, the DEXIS ORTHOPANTOMOGRAPH OP 3D x-ray imaging system enables general and specialty dental practices to leverage state-of-the-art 2D and 3D images for greater diagnostics, case acceptance, and patient convenience.

3D imaging is opening up new possibilities in the quality of care delivered at dental practices nationwide. With this technology, dentists have access to clear, high-resolution scans that show a level of detail not possible with 2D systems, allowing for more accurate diagnoses and better treatment planning— ultimately elevating patient care. 3D technology is the gateway to perform in-house services such as implants, endodontics, orthodontics, airway analysis, and more, enabling the general practice to offer more procedures so that it can provide the best-possible patient experience.

The Complete X-Ray Platform

The Benefits of Cone Beam Imaging

Designed for advanced imaging needs, the OP 3D features four resolutions for 3D (Low Dose Technology™, Standard, High, and Endo) and an edge-preserving noise reduction (EPNR) that softens soft-tissue noise patterns while retaining sharp edges, improved bitewing view, and a nextgeneration focusing technology that helps to ensure that the focal layer is aligned for each patient and their specific anatomy. These, along with the existing automated metal artifact reduction (MAR) function, work together to adapt to the ever-changing practice needs. It also comes with four predefined volumes that are freely positionable and height adjustable, for a total of 36 possible FOV sizes. The platform is designed to increase practice efficiency, with fast scan times and 3D programs for general dentists and specialists.

Beyond the advantages of improved diagnostics and treatment planning, adding CBCT imaging also gives your practice an edge over others that don’t use 3D imaging or that send patients to another site for image capture. Patients appreciate the convenience of taking the scans in your office. Many are impressed with the technology and the level of detail it provides—creating the opportunity for enhanced patient education and treatment acceptance. If you’re not ready for 3D just yet, you can take the first step by investing in the OP 3D upgradable panoramic. This system can grow with your practice, allowing you to easily add cephalometric and/or 3D capabilities when it makes the most sense. The configurable device platform has options for 2D panoramic; panoramic with cephalometric; panoramic with 3D imaging; and panoramic with cephalometric and 3D imaging.

Introducing the DEXIS OP 3D LX

Now, the next generation of DEXIS cone beam technology is here. Built on OP 3D technology, this multimodality imaging platform expands your 3D diagnostic capabilities with a wide range of clinical applications that support your evolving practice and enhance diagnostic confidence.

Featuring an optional 15x20 field of view—the largest view option available on a DEXIS OP 3D platform to date— and 5 other FOVs, OP 3D LX offers high-resolution scans and shorter scan times while capturing the maxillofacial complex and large diagnostic areas in one non-stitched scan. OP 3D LX features 96 additional customizable FOV options, along with 4 resolutions, including endo and low dose modes. In addition to panoramic, extraoral bitewing, and 3D imaging, OP 3D LX offers an optional cephalometric modality, as well as a host of implant planning tools and noise reduction filters embedded into the system software that minimize artifacts and noise.

WHAT YOU CAN DO WITH EACH VIEW

6x9 for Single Arch/Jaw:

5x5 for Localized Diagnostics: endodontic evaluations, single implant sites, and pathologies.

implant planning site evaluations, surgical guide creation, and single-arch periodontal analysis.

8x8 for Compact Dual-Arch: mandible and maxilla; treatment planning of dental implants with opposing arch visualization.

10x10 for Dual-Arch: mandible and maxilla with third molar region and lower maxillary sinuses; ideal for multiple implants or periodontal evaluations.

12x15 for Entire Dentition: mandible and maxilla, bilateral TMJ, and sinus and oropharyngeal airway.

15x20 for Maxillofacial Complex: bilateral TMJ, airway, tip of nose, oral/maxillofacial surgery, orthodontic analysis.

Powerhouse Imaging

DTX Studio™ Clinic software streamlines the digital diagnostic and treatment planning process while seamlessly integrating with your existing imaging hardware and fostering clinical collaboration throughout your office and beyond. From image acquisition to diagnostics and treatment planning, DTX Studio Clinic brings all your x-rays, photos, 2D and 3D, extraoral and intraoral imaging formats into one clear, comprehensive view.

Here are 5 ways DTX Studio Clinic takes 3D imaging to a new level:

• SmartFusion™ is the intelligent way of directly combining surface models from all intraoral and desktop scanners with any CBCT scan using proprietary voxel-based algorithms— for accurate information of surfaces and underlying anatomy in 3D.

• SmartFocus™ uses tooth positions as your reference. You can browse across your various patient images from different devices and sessions with just one click.

• DTX Studio Implant allows you to plan implants for major implant systems according to the patient’s anatomy and prosthetic requirements during the first visit. You can turn the plan into reality by using a surgical template or 3D-navigated implant surgery.

• DTX Studio Lab brings labs and clinicians together from treatment planning to final restoration.

• DTX Studio Go connects you to labs and other service providers in your area. For example, it’s easy to outsource implant planning with a connected clinician using the DTX Studio suite, or to order a prosthetic restoration or a TempShell at a connected lab.

DEVELOPMENT OF THE MORITA TORQTECH 1:5 RED BAND HANDPIECE (PART

1)

Morita released the Torqtech Red Band Handpiece Ultra Mini in October 2022 in response to requests from many dentists. This product was finally developed despite many difficulties through the high technological skills and persistent creative efforts by engineers at J. MORITA MFG. CORP, 12 years after the first release of the Torqtech series.

We interviewed Mr. Hitoshi Tanaka, one of the engineers at J. MORITA MFG. CORP., for his insight into the development of the Torqtech Red Band Handpiece in Part 1 and the Torqtech Red Band Handpiece Ultra Mini in Part 2.

The Evolution of the Torqtech Red Band Handpiece

First, what was the background of developing the Torqtech Red Band Handpiece?

Tanaka : Dental handpieces are categorized into air turbines and motor handpieces. Air turbines are capable of fast rotation with high cutting efficiency, while motor handpieces enable precise cutting adjustment and polishing. Morita has held a large share in the air turbine market, releasing TwinPower Turbine in 2000, followed by the TwinPower Turbine X series with an anti-drawback mechanism in 2007, and the TwinPower Turbine Ultra series (Powerful Micro Head) achieving a compact turbine head in 2010.On the other hand, there were increasing needs from dentists for red band handpieces, among other motor handpieces, for fast rotation that combined efficiency and precise control. In those days, the development of Red band handpieces had been delayed in Morita. To develop a motor handpiece with competitiveness in the global market, we started the development of the red band handpiece to become a flagship product in our handpiece product range.

In the 2000s, in contrast to the smooth and ergonomic body shape of air turbines, red band handpieces were made with a square and rugged design without considerations for ergonomics or easy access. It was a common understanding in the industry that this design aspect could not be avoided due to the gear system constraints.

However, as a latecomer in the red band market, Morita needed to develop a feature that could make our product stand out and be truly competitive. This is why we decided to rigorously pursue the development of a red band handpiece with a body shape closer to that of air turbines. Inside its body, the red band handpiece increases the input rotation five times from 40,000 rpm to 200,000 rpm. This rotation is nearly 100 times faster than that of an automobile engine, which rotates at several thousands of rpm, indicating how durable the gear system incorporated in the product needs to be.

HITOSHI TANAKA Associate Engineer, Research and Development Group 1

A red band handpiece in the 2000s had a square and rugged shape, which was common in the industry.

Could you describe in more detail why the red band handpiece in those days had such a rugged shape?

Tanaka : In those days, a red band handpiece was built with two gears. The five times speed increase was achieved by about 3.7 in the body angle part, and about 1.3 inside the head. In designs based on this conventional concept, it could not be avoided to design a product with a protruding lower angle part, which interfered with front teeth during access to the molar. This was a substantial disadvantage of the red band handpiece, which could not have an ideal body shape due to more complex internal mechanisms compared to turbines.

That was the reason all other competitors' models had similarly rugged shapes?

Tanaka : Yes. As I mentioned earlier, Morita was rather late to the market of red band handpieces. Therefore, our product needed to have a distinctive feature to be accepted in the market. This is why we started development focusing on a turbine-like smooth body shape and durable gear system.

How did

the actual development proceed?

Tanaka : Usually, the design of a gear system starts with the gear part, and the body was shaped to suit the gear structure. However, this procedure only led to shapes similar to those of conventional products. Therefore, we decided to determine an ideal body shape first, and subsequently figure out how to contain the gear system inside it. With this reverse concept in mind, it was a considerable process of trial and error.The double internal bevel gear system was developed through this process. We succeeded in laying out a gear system inside the body designed as above by increasing from two to three gear sets and slightly inclining the central axes.

Development was achieved through reverse thinking to determine an ideal body shape first and subsequently exploring how to contain the gear system inside it as illustrated (the dotted lines indicate the conventional shape of red band handpiece).

This substantially improved ergonomics and access to the molars, making great advancements in practitioner and patient comfort. We are confident that this is the most ideal shape achievable at present, because further reduction in the gear size would compromise durability due to technological obstacles.

Could you describe the double internal bevel gear system in more detail?

Tanaka : To contain the gear system inside the predetermined body shape, it was essential to increase from the conventional two to three gear sets, as I mentioned earlier. By dividing gears into two stages, we could lay out the gears in steps, thereby achieving reduction in the protruding lower part, which had been the conventional problem. However, it was impossible to contain the gear system in the body shape if the first axis and second axis were laid out in parallel, because of difficulty in reducing the size of the upper angle part. We examined many gear layouts, and finally developed a double internal bevel gear system, which had an inclined second axis and used an internal gear mechanism advantageous for speed increase for the first and second gear stages.

It became possible to contain the gear system inside the predetermined body shape by increasing from two to three gear sets and laying them out with respectively inclined axes.

What is the internal gear mechanism?

Tanaka : The external gear mechanism is a common gear structure, where gears mesh externally with each other. In contrast, internal gear mechanisms have a structure where a gear meshes against another gear that has teeth inside it. This structure achieves larger teeth in a smaller space, with increased gear strength and durability. On the other hand, it causes difficulties in processing. In particular, precise processing is considered extremely difficult for internal gears with inclined axes. The outer circumference of usual gears can be processed using a cutter. On the other hand, this usual processing is difficult for a gear with internal teeth, which needs be cut out using a pencil-like tool called a “ball end mill.” It had been unthinkable in common understanding to use this method for two gear sets, because it took so much time and labor.

The double internal bevel gear system was a challenge to this preconception.

benefits both dentists and patients.

Torqtech red band handpiece achieved a turbine-like smooth body shape, thereby providing efficient access to the treatment area while reducing contact with the opposing teeth.

However, because the double internal bevel gear system was extremely specialized, there had been no means for measuring whether the processed shape conformed to the design. Therefore, we needed to develop a dedicated shape measuring device in collaboration with a device manufacturer. In those days, there were opinions in the company that doubted the commercialization of a high-quality red band handpiece. An unprecedented investment also became necessary to develop a measuring device in addition to the design of the Torqtech unit. (The double internal bevel gear system has been evaluated for its innovativeness and awarded Patent No. 5645447.)

Does the Torqtech Red Band Handpiece have any other features you want to emphasize?

Tanaka : Just like turbines, Torqtechs need lubrication, but are not continuously immersed in oil, unlike automobile gears. Therefore, we needed to design the gears to withstand friction with only a thin layer of oil. This really highlights the importance of the precision and durability of gear teeth. Torqtech red band handpiece use an involute tooth profile based on involute curves for all its gears. An involute curve is a curve formed when a string is wrapped around a circle and then unwrapped. A gear processed in this shape minimizes slipping, rotates smoothly and efficiently, and reduces friction. Nevertheless, the gear would rapidly wear out if made of a common material. We use a special material that is extremely hard and withstands friction.

Torqtech red band handpiece use an involute tooth profile based on involute curves, thereby achieving smooth rotation that minimizes stress.

The Torqtech red band handpiece uses double internal gear sets. By using internal gears with inclined axes, despite the extreme difficulties in processing, the product achieves increased gear strength, durability, and access, thereby prioritizing precise treatment that

Structure of the gear system

HUFRIEDY – KOL SERIES

(1995)* 1998 ∙ RONALD GOLDSTEIN ∙ GOLDSTEIN EXTRA FLEX SPATULA

In the mid-1960s, Michael Buonocore, co-developer of the first composite resins, asked Goldstein to help him in the creation of esthetic techniques for the material. The instruments Goldstein had at the time were too bulky, inadequately shaped and too thick. This led to the development of new, much more ergonomic composite instruments with extremely thin blades that were able to be used subgingival as well. Goldstein’s new composite instruments had a very flexible design, with a reversed flared paddle designed for shaping and placement of Class III, IV and V restorations. Throughout the years, Goldstein has continued to develop more efficient operative instruments including the restoration protective crown removers and the reverse composite carvers for additional ease when contouring posterior composites.

In 2000, Hu-Friedy introduced the XTS™ Composite Instruments line. Stainless steel instruments coated with AITiN (aluminum-titanium nitride), which became the new standard for performance in non-stick composite instruments. Goldstein preferred the black finish as it made it much easier for the dentist to see due to the enhanced contrast between the instrument, composite material and tooth structure. Because of this, all of his XTS™ Composite Instruments are produced using AlTiN coating.

*the first samples were developed with American Dental that Hu-Friedy acquired in 1998.

INSERT MAINTENANCE CHECKLIST

How to properly care for your ultrasonic inserts

Did you know a hygienist spends 2 hours per day on average power scaling? With so much usage and often a different insert for many procedures, you must regularly evaluate your inserts to ensure they continue functioning properly. Ultrasonic inserts combine the power, efficiency, and comfort you need to treat a wide range of patients, but they can also be delicate. Below is a checklist to help you properly use, care for, maintain and therefore extend the useful life of your Ultrasonic Inserts.

1) Check Tip Condition

Just like your hand scalers, ultrasonic insert tips wear with use. Worn insert tips can significantly diminish your scaling efficiency. One millimeter of tip loss results in a 25% loss of efficiency. Two millimeters? That’s a 50% loss of efficiency.

When an insert tip is worn, the “sweep” of the instrument is reduced. The insert tip doesn’t travel as far on its’ optimal path. When using a worn tip, generally more pressure is applied, or generator power is increased to compensate for the efficiency loss—often leading to patient discomfort and increasing the possibility of tip bending/breakage. When using a worn insert tip, the clinician will likely feel the need to increase the power setting on the generator to facilitate debris removal. However, scaling efficiency will not increase, and more heat will be generated, especially if the power setting exceeds the recommendation for the insert tip.

Using worn tips can result in inefficient scaling, inferior tip performance, handpiece overheating, and more discomfort for you and your patient. So, be sure to measure tip wear on a weekly basis and replace inserts as they wear and lose efficiency.

2) Evaluate Pressure Applied

When it comes to the amount of pressure one should use when ultrasonic scaling, light pressure is all you need to allow the tip of the insert to vibrate efficiently, this results in fracture or removal of deposits. Applying more pressure dampens the tip vibration, leading to poor deposit removal, operator hand fatigue, and patient discomfort. Ultrasonic inserts are designed to work with a light grasp and light lateral pressure – let the insert do the work for you.

3) Double Check Power Settings

Each ultrasonic insert has a recommended power range for optimal performance. Robust tips, such as the HuFriedyGroup #10, #1000, and Beavertail inserts, are intended to remove heavy debris and can be used on higher power settings. It is recommended that thinner tips, designed for effective deposit removal, be used on low to medium power. Thin inserts with water flow to the tip have narrower water flow channels. If used on high power, the water flow rate may not be enough to cool the insert tip— resulting in handpiece overheating. Use the lowest effective power settings for each insert for maximum scaling and patient comfort. It is highly recommended to adhere to the power ranges specified on the insert packaging for optimal effectiveness.

4) Match Insert Type to Clinical Application

Ultrasonic inserts are designed for specific applications since complex oral anatomy, and debris type/location prohibit an effective “universal” insert. Robust inserts are for moderate to heavy/tenacious deposits and stains in supragingival and accessible subgingival areas. Thin inserts allow enhanced access to narrow subgingival areas, tight pockets, interproximal concavities, and other difficult-to-access areas. Using thin inserts as “universal” inserts—particularly on moderate/heavy supragingival deposits—can result in excessive tip wear, inefficient deposit removal, and tip bending/breakage. Much like using the correct power setting, matching the right insert to each clinical application is vital. And remember, more than one type of insert may be needed for each clinical procedure.

5) Don’t Compromise Instrument Shape

Bending or reshaping insert tips is not recommended. Aside from voiding the warranty, reshaping the tip can result in poor tip performance and make the tip susceptible to breakage. Insert tips are designed with precise bends to optimize the elliptical vibration path—bending the tips disrupts this vibration pattern, rendering the tip inefficient at debris removal.

6) Proper Sterilization and Maintenance

Sterilizing inserts in a cassette will protect them and extend their useful life. If your office uses sterilization pouches instead, always use caution when placing the insert in the ultrasonic bath or autoclave, as heavier instruments placed on top can cause bending/ breakage of the tip and/or stack. Cassettes provide the best long-term protection for your ultrasonic inserts. For a thorough step-by-step process, click here.

7) Prevent Overheating

Sometimes your handpiece can begin to feel warm. You may want to believe that it may cool down on its own, but sometimes it doesn’t. You may reach the point where you need to put it down to either change the ultrasonic insert or switch to hand instrumentation. Overheating can happen, and in addition to a couple of points mentioned earlier, there is more you can do to prevent such occurrences.

You may experience overheating due to air bubbles trapped in the handpiece. Trapped air can prevent water from contacting the vibrating stack—resulting in heat build-up. The entire insert stack must be completely submerged in water to operate efficiently. To eliminate/minimize trapped air, be sure the handpiece is filled to the top with water and held vertically when placing the insert. To further prevent trapped air, it is advisable to run water through the handpiece for at least 2 minutes at the start of each day and for 45 seconds each time you seat an insert into the handpiece.

Another reason for overheating may be that your waterline filter is clogged. Check the waterline that extends from the generator to the wall connection or the operatory unit. This waterline typically has a filter that should be monitored and changed routinely. A clogged filter will disrupt the water flow through the generator and result in less flow to the insert tip. Regularly changing the filter is an inexpensive, quick maintenance procedure that can help ensure unobstructed water flow.

Your practice makes an investment in its ultrasonic inserts. Any investment needs to be kept up to continue producing an ROI. If properly used and shown the proper care, your ultrasonic inserts will help keep you the Best in Practice no matter the patient or procedure.

For more helpful information, insights and resources for Ultrasonic Inserts, click here.

KAVO EXPERTMATIC E25

A HANDPIECE THAT’S MADE FOR THE LONG HAUL

The EXPERTmatic E25 high-speed attachment provides a low-maintenance alternative to air-driven handpieces, delivering maximum cutting performance while keeping heat, noise, and vibration to a minimum.

Choosing a dental handpiece is an important decision—after all, they’re practice workhorses that are on the front lines of many dental procedures. The question often comes down to air-driven vs electric. While air-driven handpieces are more common among restorative dentists in the U.S., in part due to their lighter weight and moderate price tag, they do have their downfalls—among them, greater noise and less consistent torque, vibration, and versatility. It's perhaps for these reasons that electric handpieces are gaining popularity in everyday dentistry.

The Expertmatic E25 at a glance

KaVo EXPERTmatic E25 high-speed handpieces are available without cellular optics (E25 C), as well as with a glass rod light conductor that delivers up to 25,000 lux of perfect, glare-free lighting (E25 L). Other features and benefits of both the EXPERTmatic E25 C and E25 L include:

• Speed increasing 1:5 transmission ratio

• EXPERTgrip surface

• Replaceable spray microfilter

• Reduced head size

• Chuck retention force up to 30 N

• CoolHead technology

• High-tech ceramic bearings

• 3-port spray

• Low, 57 dB(A) operating volume

• Thermo-disinfectable & sterilizable up to 275°F (135°C)

Stronger & Safer Than Ever

Ever innovating and improving upon their products, KaVo recently updated the EXPERTmatic E25 with 2 smart features that elevate patient safety and extend instrument service life:

• New KaVo CoolHead technology actively prevents excessive heating of the instrument head if the push button is pressed unintentionally while the bur is rotating (such as when touching the patient’s cheek). Integration of this feature assures greater patient safety, while giving clinicians one less thing to worry about during treatment.

• KaVo-exclusive high-tech ceramic ball bearings are now not only lighter and more resistant to wear, but also offer greater resistance to corrosion and fluctuations in temperature due to less friction. These bearings additionally incorporate optimized cage geometry and cage material to ensure a longer service life for EXPERTmatic instruments.

Problem-Free Performance

After experiencing persistent noise, chuck, and bur concentricity issues with her office's older air-driven handpieces, Krista Kappus, DDS, decided to follow the recommendation of a trusted colleague and try the EXPERTmatic E25, a high-speed attachment from KaVo. Dr. Kappus quickly found that going electric virtually eliminated her previous pain points, and 4 years later, the EXPERTmatic E25 has become her handpiece of choice at her Healdsburg, CA, practice.

“Overall, there's a lot more torque and smoother cutting efficiency,” she said. “We’ve phased out most of our air-driven handpieces because we like this one so much better.

More Comfort, Less Maintenance

Compared to her other handpieces, Dr. Kappus discovered that the EXPERTmatic E25 affords quieter, cooler operation and produces less vibration, making every procedure more comfortable for her and her patients. “No patient wants to feel like their head is being rattled around,” Dr. Kappus quipped. “So, the smoother a handpiece performs, the better.”

She also noted that, owing to its minimal vibration, smaller head size, and EXPERTgrip surface, the EXPERTmatic E25’s handling and ergonomics were a noticeable improvement over her previous handpieces. What’s more, both the contra-angle’s cutting performance and the precision of its multiport spray have lived up to her expectations: “It’s better at maintaining its temperature and the water stream seems a lot more consistent,” she shared.

Thanks to its quality stainless-steel construction, hightech FG chuck with carbide guide bushing, ceramic ball bearings, and a durable, dent-resistant head, the EXPERTmatic E25 is built for the long haul. And when it’s time to replace parts like the spray microfilter, the EXPERTmatic E25 makes things as easy as possible: “Every handpiece has its issues over time, but this one is really simple to repair and maintain,” affirmed Dr. Kappus.

DR KRISTA KAPPUS DDS Healdsberg, CA

KAVO DENTAL – BIBERACH

DENTAL EXCELLENCE ENGINEERED FOR YOUR PRACTICE

By experts, for experts - KaVo instruments are created from the best materials according to your requirements.

An Interview with Wolfram Halder – Senior Global Product Manager KaVo Dental, Biberach.

In fact, everything starts with what you need

The development of a KaVo instrument often begins in dental practices like yours. During numerous technical discussions around the world, we take note of your requirements and suggestions and, from those, derive the features for new KaVo instruments. For example, a refined instrument head size for a better view of your work, easier hygiene and any specific requirements from your specialist area of work: what you come up with sets the goals pursued by our product developers.

Over 6 million instruments sold worldwide are proof of dental excellence

The future is made in Biberach

To ensure new KaVo instruments not only meet the highest requirements, but also far exceed them, innovations at KaVo are all about teamwork. Specialists in design, development, marketing and sales all work together on-site in Biberach throughout the entire product development phase. Preliminary drawings become 3D data, and initial material samples become final prototypes.

Once everyone is satisfied, production tests begin for the KaVo instruments that you will later be thrilled to use every day at your practice.

WOLFRAM HALDER Senior Global Product Manager KaVo Dental,

Biberach.

Tested in Biberach, proven in practice

To ensure KaVo instruments can cope with the tough conditions they will face in practice, they have to pass some very rigorous tests. In our development laboratories, we simulate the kind of stress that equipment will encounter during years of use. Can the instrument complete several billion rotations with no problems? Is the retention force at the bur really as high as 30 newtons? Does the turbine still stop in less than a second after being used for the thousandth time thanks to Direct Stop Technology? Once the quality and performance of our instruments is beyond any doubt, pre-production testing is concluded and serial production can begin.

KaVo - Made in Biberach - Everything is made by us! Biberach — the home of quality.

Ultra-clean quality inside, dust kept outside

400 highly qualified employees ensure the instruments produced deliver the quality associated with KaVo

11,500 m2 space for the narrowest of margins (in the μ range)

Other suppliers still have their head office in Germany, but outsourced their production long ago. KaVo, however, insists on a 100% ’Made in Germany’ approach for its instruments. This means all our instruments are made exclusively at the main plant in Biberach. But the most important factor in ensuring the legendary KaVo quality is our ’vertical integration’ of at least 95%. This means almost all components (of which there can be up to 50) in a KaVo instrument are also manufactured in Biberach and are therefore subject to the same stringent quality control.

From delivery of the raw materials to the final inspection of the finished instruments, the 400plus highly qualified employees at the 11,500 m2 production facility are focused on the tiniest details.

Ultra-precise production, based on tolerances in the μ range (one μ equals 0.001 mm), ensures that you in turn can work with real precision at your practice.

The final assembly of many KaVo instruments is performed in special dust-free rooms. To stop even the smallest dust particle impairing the great quality associated with KaVo, the air is constantly cleaned and purged. Temperature, humidity and air pressure are also kept constant. This is the only way that each individual KaVo instrument can pass its thorough final inspection prior to delivery.

Quality pays — every single day

KaVo has now sold over 6 million instruments worldwide. This includes the KaVo EXPERTmatic E25 L, which is one of the most successful instruments ever (with over 100,000 units produced). But for KaVo, quality both today and in the future is more important than previous sales figures. And this is why every single instrument undergoes final testing — and a final polish — prior to delivery.

So it can make a dazzling impression at your practice for the whole of its working life!

98% Repurchase rate for instruments shows how satisfied our customers are

95% of all parts for KaVo Instruments are produced in Biberach 100% Quality, from the raw materials to the finished instrument. All from a single source

100 YEARS OF PREPARATION FOR TOMORROW

KOMET MOVE THINGS FORWARD SO YOU CAN SUCCEED

Special selection of instruments for work on zirconium oxide as suggested by Jan-Holger Bellmann, Dental Technician

In collaboration with the dental technician JanHolger Bellmann, Komet have compiled a handy little instrument set containing all the instruments required to work on crown copings and bridge frameworks made of high-performance ceramics, such as zirconium oxide and aluminium oxide.

The coarser grinding instruments contained in the set are suitable for eliminating stumps, whereas those with an extra long, slim neck are particularly suited for adjusting the fit – even in the case of long crown copings and bridge frameworks, like for example in the anterior area.

The set is completed by grinding tools with long working parts and finer grits which are particularly recommended for finishing surfaces and for carrying out interdental corrections, if necessary.

Helpful hint by Jan-Holger Bellmann: Generally speaking, grinding in the inter-proximal area is not recommended.

If this cannot be avoided, make sure to use the finest grinding tools possible, in order to keep the notch effect caused by machining to a minimum.

JAN-HOLGER BELLMANN Dental Technician

Kit contains:

Bur Holder

ZR6856.314.025

ZR6881.314.016

ZR862.314.016

ZR8850.314.016

ZR8881.315.016

ZR8379L.315.014

ZR8801L.315.010

Application Guide:

1. Elimination of stumps by means of instrument Zr6856.314.025.

2. Reduction of anatomic structures with the tool Zr6881.314.016.

3. Reworking the connecting elements with instrument Zr862.314.016 and ...

4. subsequent smoothing by means of instrument Zr8850.314.016.

5. The instrument Zr8881.315.016. is recommended for fine retouching of larger surfaces.

6. Zr8801l.315.010 and/or Zr8379l.315.014 are particularly suited for adjusting long crowns.

7. The long, slender neck of the instruments permits excellent vision

Recommendations for use:

• Recommended speed: the instrument is at its peak performance at (160 000 rpm.

• Use in the laboratory turbine with water cooling.

• Apply low contact pressure (< 2N).

WHY DENTAL PRACTICES NEED THE BEST CLEANING DETERGENTS

BIODEGRADEABLE | ENVIRONMENTALLY FRIENDLY | SUSTAINABLE CHOICE

Effective instrument reprocessing using the appropriate cleaning methods is a vital part of the Infection Prevention and Control Program in dental practices today. Inadequate cleaning of reusable medical devices has the potential to severely compromise the success of the sterilisation process and increase the risk of cross infection amongst patients and staff.

With the newly released Australian Standard AS 5369:2023 – Reprocessing of reusable medical devices and other devices in health and non-health related facilities, in the spotlight, and more recently important key updates in the fifth edition of the Australian Dental Association (ADA) Infection Prevention and Control (IPC) Guidelines, the sterilisation process is now being explored more closely than ever before.

Its important to note though, like any product category, not all enzymatic detergents are as effective as others. Dental clinics need to understand what products work best in meeting the cleaning & reprocessing needs within their clinic environment.

Enzymes

Enzymes are proteins that function as catalysts, they dramatically speed up biochemical reactions. Each enzyme has a specific action depending on where they are found. They are necessary in all areas of life and are produced in nature by all living organisms.

Enzymes work fast at variable temperatures with moderate pH levels and being biodegradable makes them an environmentally friendly choice in the dental practice.

Examples of how enzymes work in everyday life are in our bodies where there are over 3,000 different enzymes at work for example to aid in digestion, in our saliva to break down sugars and fats and in nature, plant photosynthesis would not be possible without enzymes, thus life as we know it on our wonderful planet would not exist. They are used to ferment wine and make cheese. Even fruit such as mangoes and bananas have amylase (enzymes) which help the fruit to ripen.

Cleaning Instruments with Enzymes

Enzymatic Cleaners offer the dental practice an efficient and environmentally friendly way to clean instruments traditionally crowded with harsh and unsafe chemicals. These cleaners include specific enzymes such as proteases, amylases, and lipase, with a near neutral pH levels (slightly alkaline) in most cases, and with minimal energy required, enzymes quickly get to work to break down and digest the most complex and hardest organic deposits whilst preserving the integrity of the most delicate of instruments.

When formulated with surfactants, enzymatic cleaners, quickly lift soil and organic deposits easily from dental instruments that other harsh cleaners struggle to do

Proteases break down protein-based residues found in blood and saliva and tissue left on instruments after treatment.

Amylases and Cellulase enzymes digest all carbohydrate, sugar and starch-based residues that are found in food particles left behind on instruments after treatment.

Lipases attack fatty deposits that originate from lipids or oils left on dental instruments after treatment.

If instruments are not cleaned thoroughly prior to sterilisation, they may not be correctly sterilised. Reuseable Medical Devices (RMD’s) , instruments and equipment must be clean before they can be sterilised, therefore effective pre-cleaning is critical.

Readily biodegradable Enzymatic Cleaners used in conjunction with ultrasonic baths and washer disinfectors are the sustainable choice for busy dental practices, reinforcing the need for safer and more efficient cleaning practices prior to sterilisation and to mitigate risks associated with cleaning instruments and equipment to ensure patient safety.

Introducing Optizyme Ultra- D

Optizyme Ultra D is a multi-enzymatic liquid detergent concentrate with an added biocide (disinfectant active) that is effective in killing bacteria within the water bath solution during a standard wash cycle and help to ensure that the surfaces of the cleaning unit remain hygienic even at very low concentrations providing a very economical and effective wash.

Optizyme Ultra D has been specifically formulated for dental instrument cleaning and uniquely optimised for cleaning superiority across all three cleaning modalities – static water / manual bath, ultra-sonic and auto-washer cleaning with a near neutral pH (slightly alkaline) for enhance cleaning performance.

Optizyme Ultra D in solution quickly and efficiently removes biological and inorganic deposits, irrespective of water type and is shown to also be effective at ambient water temperatures. Highest cleaning cycle speed and efficacy is at a water temperature of 40degC.

Advantages

• Cleans instruments & sanitises bath/water solution

• Removes Biofilm

• Independent studies confirm highest optimal cleaning efficacy

• Suitable for manual, ultrasonic & auto washer applications

• Contains rust & corrosion inhibitor

• Class I Medical Device product

Optizyme Ultra D complies with AS 5369:2023 requirements and is made in Australia.

Resources

1. https://www.cleaninginstitute.org/sites/default/files/documents/ Enzymes-factsheet.pdf

2. https://my.clevelandclinic.org/health/articles/21532-enzymes

3. ADA Guidelines for Infection Prevention and Control Fifth Edition

4. Enzymatic detergents for the effective cleaning of surgical instruments – Novapharm Research Australia View the product online CLICK HERE

Always follow the manufacturer’s instructions regarding appropriate cleaning and decontamination methods.

EMMA ROLFE

Infection Prevention and Control Professional Henry Schein

TERMINAL STERILISATION:

THE GOLD STANDARD

The dental anaesthetics developed by Septodont are the result of several decades of investment and expertise and provide the highest level of sterilisation guarantee, a key aspect for both patient and dentist.

The main aim of any conscientious dentist will be to provide his or her patients with the best quality of care, using the safest and least painful anaesthetics. Even though anaesthesia procedure accounts for only 5% of the consultation time, the dentist will nonetheless be judged by its success. Patient anxiety must be taken into consideration as much as pain itself during the administration of the anaesthetic. A painful injection may cause the patient to lose all confidence in the practitioner. Successful anaesthesia and, by the same token, correct product choice is therefore crucial.

Contamination : a “life-threatening risk to a patient”

Even in their generic forms, not all injectable dental anaesthetics are similar in all aspects. Their characteristics differ as a result of their pH, their composition in terms of excipients, their manufacturing process, their sterilisation method, etc. When it comes to injecting a drug to a patient, assurance of sterility comes in very first line. Health authority recommendations in this respect are particularly explicit: “Sterile drug manufacturers should have a keen awareness of the public health implications of distributing a nonsterile product. Poor CGMP conditions at a manufacturing facility can ultimately pose a life-threatening health risk to a patient.” according to an FDA recommendation(1) entitled “Sterile Drug Products Produced by Aseptic Processing -Current Good Manufacturing Practice”.

There are currently two sterilisation processes for injectable products available to the pharmaceutical industry, including the dental sector. These are aseptic filling and terminal sterilisation.

Terminal sterilisation, the highest guarantee

In contrast with aseptic filling, which filters bacteria from the solution upstream, the terminal sterilisation step takes place at the very end of the process. A local anaesthetic prepared with its various components will admittedly pass through filters smaller than 0.22 micron, which will retain viruses, bacteria and other contaminants by both methods. Sterilizing filtration will therefore trap and separate microorganisms from the solution, which will be packaged in cartridges and then capped and sealed. Both methods need very strict environmental conditions, but for sterilisation by aseptic filling they are particularly stringent in order to prevent any contamination during the anaesthetic production and packaging process. Unlike aseptic filling, terminal sterilisation, as its name suggests, takes place at the end, on cartridges that have already been sealed. In contrast with the other sterilisation method, no pharmaceutical operations will be carried out on the solution after sterilisation. Unless the cartridge is faulty, the solution cannot therefore be contaminated after the removal of bacteria and viruses, since it will already have been sealed. Moreover the sealing operation involves heat. Heating the solution at 122 degrees for 15 minutes will destroy all the microorganisms that it still contains. For all of these reasons, terminal sterilisation provides the highest level of sterility guarantee today.

Terminal sterilisation, the gold standard for health authorities

This highest level of sterility assurance explains why health authorities around the world are agreed on choosing this method. According to the US Food and Drug Administration (FDA) most recent guidance(2), “… It is a well-accepted principle that sterile drugs should be manufactured using aseptic processing only when terminal sterilisation is not feasible…”. The European authorities echo this when they state “Those products intended to be sterile should be terminally sterilized in their final container as clearly stated in the European Pharmacopea”(3) . Meanwhile, the Canadian health products and food branch inspectorate (HPFBI) concludes that “terminal sterilisation, where practicable, is currently considered the solution of choice for obtaining sterility”.

It is not by chance, then, that this method has been opted for by all these health authorities around the world. A manufacturing process including a terminal sterilisation stage has become the gold standard for them.

Septodont

has chosen Terminal Sterilisation

One of the major features of the unique Septodont process is that it includes this terminal sterilisation stage. All the local anaesthetics in the group, including Septanest, are produced by this method. But the corollary of these advantages is that terminal sterilisation is particularly difficult to carry out in the case of dental anaesthetics. This is because some vasoconstrictors such as adrenaline, contained in the formulations to make anaesthesia last longer, are sensitive to heat. But in order to take into consideration the authorities’ requirements, for which nothing is more important than the sterility guarantee, a pharmaceutical company must therefore make every effort to obtain the highest level of sterility guarantee, that is to achieve highquality production including a terminal sterilisation process. Mastering this process has been the result of huge investment by Septodont. It has taken decades of research to develop this gold standard applied to injectable dental products. Septodont is a unique and responsible pharmaceutical company.

Septodont, the world leader in anaesthetic procedures

• High-quality products, safety at the highest level

• The greatest capacity worldwide: production area of over 9000 square metres

• 2 manufacturing sites (France and Canada)

References

(1) FDA :“Sterile Drug Products Produced by Aseptic Processing Current Good Manufacturing Practice”

(2) FDA Guidance for Industry: Sterile Drug Products Produced by Aseptic Processing – Current Good Manufacturing Practice; Sept 2004

• 500 million cartridges produced annually

• 4 Septanest injections every second worldwide

• 600 marketing authorizations

(3) EMEA Guidance “Decision Tree For The Selection of Sterilisation Methods (Annex to Note For Guidance on Development Pharmaceutics)”

WAND STA

FOR PAEDIATRIC DENTISTRY

The Milestone Wand STA is clinically proven to significantly reduce disruptive pain behavior, as demonstrated in multiple independent university trials. A clinical study conducted by the University of Nebraska’s Department of Pediatric Dentistry found that pediatric patients were five times less disruptive when the Wand handpiece was used compared to a traditional dental syringe. With proper technique, the pediatric patient often doesn’t even realize that anesthetic has been administered until after the injection.

The non-threatening design of the Wand handpiece helps reduce a child’s fear and anxiety, resulting in a more manageable patient.

The STA Intraligamentary (PDL) injection technique also eliminates the challenges and risks associated with performing a mandibular block on pediatric patients.

Furthermore, collateral anesthesia of the cheek, lip, and tongue is avoided, making the procedure more comfortable for the patient.

The feather-light handpiece provides a better grip for the clinician and easier access to the oral cavity. Additionally, the ability to snip off the handpiece allows for discreet concealment, which is especially beneficial for treating anxious patients.

Reference: https://europepmc.org/article/med/11132503

Bilateral Restorative Dentistry

Feather light HP can be snipped off for better access & discreet concealment

FIND OUT MORE

Learn more about the Wand STA

BRIGHT SMILES, BRIGHT FUTURES

(BSBF) RELAUNCHED IN AUGUST 2024

To celebrate Colgate’s flagship Corporate Social Responsibility program being live once again across Australia, Colgate® hosted an event at a Sydney school which included a visit from Colgate’s very own Dr. Rabbit and Australian Football League (AFL) star Isaac Heeney, as well as being featured on Channel 7’s Sunrise segment to highlight the importance of oral health education at a young age. Both stars, Dr. Rabbit and Heeney, took part in dental health themed activities with students of the school, as well as Dr. Rabbit leading an oral health lesson.

The BSBF program originally launched in Australia and New Zealand in 1996 and has reached over 14 million children and their families in our region and more than 1.7 billion globally.

Colgate’s approach for the relaunch of the BSBF program involved a more sustainable approach, enabling the educational resources for teachers & dentists previously sent out via mail, to be hosted digitally on Colgate’s website.

The revised approach still allows teachers & dental professionals to order key materials to provide to students and patients alike, provided in newly branded ‘Smile Boxes’.

Each Smile Box contains 30 individual take-home envelopes or ‘Smile Packs’ for children to take home which include a brushing chart, oral health tips and stickers for dental professionals to give to patients and additional brushes and paste for teachers to give to their students. Each envelope has a QR code which links to the educational resources.

As dental professionals Colgate advises you to ask a teacher to order a Smile Box for their class if you are going to host a classroom lesson. You can use the online educational resources to create your lesson plan and ask the teacher to assist you in delivering the content to the class.

You can order a Dental Professional Smile Box to be able to use the resources in your practice to encourage your young patients to improve their oral health habits at home.

Access the educational material and place your order for a dental professional pack below:

MOLAR HYPOMINERALISATION

CHALKY TEETH - A SILENT EPIDEMIC DAMAGING 1 IN 5 CHILDREN’S TEETH*

What is Molar Hypomineralisation?

Molar Hypomin is a common developmental condition affecting primarily one or more first permanent molars.1-3 Central incisors may be affected as well, but this usually occurs to a lesser extent.1-3 Hypomineralisation of the second deciduous molars (HSPM) or canines may also occur.1-3 Molar Hypomin enamel presents low levels of calcium and phosphate. Molar Hypomin is characterized by whiteyellow enamel patches and dentine hypersensitivity. Variations in severity exist, ranging from mild opacities to post eruptive enamel breakdown. While Molar Hypomin affects patients’ quality of life, it also creates treatment challenges, which can lead to ongoing restorations and more complex care.1-4

What causes Molar Hypomin?

Recently published new research findings showed that serum albumin plays a direct role in the pathogenesis of molar hypomin.4 For more info visit: www.ncbi.nlm.nih.gov/pmc/articles/PMC7303361/

What are the Molar Hypomin clinical challenges?

• Molar Hypomin teeth are formed with less mineral, which makes them more prone to break down during chewing and tooth brushing.

• Once erupted, Molar Hypomin teeth may start to break down, even without excess sugars or acids in the diet.

• Tooth sensitivity and pain are common, which might lead to poor oral hygiene and therefore, increased caries risk.

• Difficulty in achieving anaesthesia, which are possibly related to chronic pulp inflammation

• Limited cooperation of young patients, due to dental fear and anxiety.

• Repeated marginal breakdown of restorations, leading to dentine exposure and risk of pulp involvement.

Tooth

Surface Protection

It is particularly important that Molar Hypomin teeth are looked after carefully to limit problems. Management of Molar Hypomin teeth should include long-term prognosis, as well as management of the presenting concerns, such as pain.

1.

Tooth Surface Protection at the practice

a) Reduce hypersensitivity: MI Varnish™ a 5% NAF varnish containing 2% RECALDENT® (CPP-ACP). When MI Varnish™ is applied, it adheres to the tooth and seals exposed dentine tubules.

b) Shield Molar Hypomin enamel surface: Surface protection with GC Fuji® VII or GC Fuji® VII EP creates a hardened outer layer which prevents plaque accumulation and facilitates tooth brushing.

2. Tooth Surface Protection at home:

Daily extra protection - Promote the importance of oral hygiene with a fluoride containing toothpaste and application of GC Tooth Mousse™ or GC Tooth Mousse™ Plus for daily extra protection.

An erupting Hypomin first permanent molar showing occlusal breakdown.

Completed surface protection using GC Fuji® VII. Images courtesy of Dr Jamie Lucas.

References

1. Schwendicke F., Elhennawy K., Reda S., Bekes K., Manton DJ., Krois J. Global burden of molar incisor hypomineralization. J Dent, 2018; 68: 10–18.

2. Zhao D., Dong B., Yu D., Ren Q. & Sun Y. The prevalence of molar incisor hypomineralization: evidence from 70 studies. Int J Paediatr Dent, 2018; 28: 170-179.

3. Garot E., Denis A., Delbos Y., Manton D., Silva M., Rouas P. Are hypomineralised lesions on second primary molars (HSPM) a predictive sign of molar incisor hypomineralisation (MIH)? A systematic review and a meta-analysis. J Dent 2018;72:8-13.

4. Terms of Use: This work, Copyright © 2020 Williams, Perez, Mangum and Hubbard, is licensed under the terms of the Creative Commons Attribution License (CCBY) (http:// creativecommons.org/licenses/by/4.0/). It is attributed to Williams R, Perez VA, Mangum JE, Hubbard MJ. Pathogenesis of Molar Hypomineralisation: Hypomineralised 6-Year Molars Contain Traces of Fetal Serum Albumin. Front Physiol. 2020; 11:619. Published 2020 Jun 12. doi:10.3389/fphys.2020.00619. The original version can be found at https://www.ncbi.nlm.nih. gov/pmc/articles/PMC7303361/.

* For 2-year and 6-year molars: https://www.thed3group.org/prevalence.html

*Arrow P. Prevalence of developmental enamel defects of the first permanent molars among school children in Western Australia. Aust Dent J. 2008; 53(3):250-9.

IMPORTANCE OF INTERDENTAL CLEANING

A RECOMMENDATION GUIDE FOR DENTAL PRACTITIONERS

Efficient cleansing and removal of plaque biofilm from tooth and restoration surfaces is key to ensuring our patients have good dental health. In addition to brushing twice daily, we must also encourage patients to clean interdentally equally as frequently given plaque tends to accumulate between the teeth more, compared to other tooth surfaces. Hence, dental diseases like caries and periodontal disease occur more interdentally.1 Given there are plenty of different interdental cleaning tools available for patients to use, which tools are best for their situation, is one of the frequently asked questions of dental professionals. In this article, each of the interdental cleaning tools will be explored to better guide clinicians on recommending the ideal tool for their patients to support their oral health.

Why Interdental Cleaning

As dental professionals, it is our responsibility to help educate our patients on how to best maintain healthy teeth, implants and restorations for a lifetime. Studies have shown that tooth brushing alone only removes around 60% of plaque from the oral cavity.2 Therefore interdental cleaning is an important adjunctive step to ensure the remaining 40% of plaque that is missed can be effectively cleaned to reduce the risk of dental diseases and promote good dental health.

Dental Floss

There are different types of dental floss available for patients and dental clinicians to use - regular string floss, dental tape and floss holders/flossettes. Although dental floss as an interdental cleaning tool was conceptualised almost two centuries ago, the evidence on its effectiveness remains ambiguous.

DR KAEJENN TCHIA Darwin, Northern Territory

A recent Cochrane systematic review suggested flossing combined with toothbrushing may reduce gingivitis compared to toothbrushing alone however the overall certainty of evidence was low.4 This is likely due to the technique-sensitive nature of flossing leading to ineffective interdental cleaning and thus lack of patient compliance.

Floss thread or tape can either be waxed or unwaxed; the former providing a smoother surface to glide between teeth surfaces. One major advantage of floss is that it is relatively cheap and travel friendly. Especially in the case of very tight interdental spaces or crowding of teeth, floss is usually the best tool to access these narrow areas. Sho. Like floss, they are quite affordable and travel friendly. From a utility point of view, most flossettes also have the handle designed as a toothpick to remove food debris interdentally.

Wood Sticks/Toothpicks

Wooden toothpicks are one of the earliest devices used by humans historically to remove food debris. Wood Sticks tend to be triangular in shape whereas toothpicks are round in shape. Whilst these are relatively cheap, easy to use and tend to be used particularly by the elderly who have a habit of removing food with them, they can cause gingival trauma and splinters.

In some cases, toothpicks can also cause attritional tooth surface loss interdentally with long term aggressive force; usually characterised in intraoral radiography by circular radiolucencies under the contact point.4 To counteract the disadvantages of wood, there are now soft, flexible, plastic toothpicks available which have a perforated design with a thin, triangular cross-section to better cleanse interdentally compared to round wooden toothpicks. These are a much better solution for patients who prefer to use toothpicks without traumatising the gingiva.

Interdental Brushes

Interdental brushes initially were designed to be used by patients who had lost their interdental papillae as a result of periodontal disease, leading to wider embrasures and food and plaque still being trapped after flossing.

Whilst patients with intact and healthy dental papillae were encouraged to use floss, interdental brushes now come in a variety of standardised sizes to fit a range of embrasure spaces to facilitate better interdental cleaning. Compared to toothpicks, the bristled, wire brushes or soft, flexible, rubber nibs tend to pick up more plaque; thus, leading to more effective plaque removal.5 Since they do not need to pass through an interdental contact point and are therefore easier to use than floss, compliance is better amongst patients. However, patients must still be warned against aggressive use as they can cause gingival trauma. Most importantly, interdental brushes need to be correctly sized with a sizing probe by dental practitioners for each interdental space in the mouth. Therefore, an individual patient may need to use a multitude of different-sized interdental brushes to effectively clean between their teeth. Aside from periodontal patients, interdental brushes are also useful for patients undergoing orthodontic treatment with traditional fixed brackets and wires. Floss is blocked by the orthodontic wire, but interdental brushes can easily slip under the wire to effectively clean the interdental spaces.

Oral Irrigators

Oral irrigators are electric, interdental cleaning tools that either use water or air to clean around and between the teeth. Water flossers use a jet stream of water to clean whereas air flossers use jets of air combined with water droplets to remove food debris interdentally.6 Their mechanical mode of action relies on a combination of pulsation and pressure to remove supragingival plaque, subgingival plaque and other debris whilst stimulating the gingival tissues. There are two zones of hydrokinetic energy produced by the pulsating action - the impact zone and the flushing zone. The impact zone is where the solution initially contacts the gingival margin whereas the flushing zone is where the water reaches subgingivally.3 A pulsating water jet regulates the water pressure in the device and relies on the fact that attached gingiva can sustain pressure of up to 160 psi (pounds per square inch) for 30 seconds resulting in no permanent damage. Some studies estimate that for undamaged or healthy gingival tissues, a pressure of 90 psi is acceptable whereas for inflamed or ulcerated gingival tissues, a pressure of 50-70 psi is recommended.7

Like interdental brushes, oral irrigators are indicated for patients who have wider embrasure spaces resulting from the loss of interdental papillae. However, they are also indicated to maintain good periodontal health around dental implants, bridges and patients wearing orthodontic appliances such as fixed braces. The main advantage of oral irrigators is the ease of use for patients with limited manual dexterity such as patients with disabilities, arthritis or the elderly. Patients can also mix adjunctive therapeutic mouth rinses in the water tank reservoirs of oral irrigators to better manage periodontal disease. However, these appliances can be costly and given they require water, a sink and power to charge their batteries, they are therefore less travel friendly compared to interdental brushes and floss.

Since patients have a number of interdental cleaning tools available to them to use, dental practitioners should continue to recommend personalised interdental cleaning tools for their patients based on their individual needs. More importantly, this should also extend to determining the ideal tools based on their manual dexterity or capability to achieve a safe and high standard of interdental cleaning. When the appropriate tool is matched to the patient’s specific needs and ability to easily maintain this habit in the long term, this allows us as dental practitioners to optimise a patient’s dental hygiene and health.

Biography

Dr Kaejenn Tchia is a recent graduate working in a corporate private practice in Darwin, Northern Territory. He is the current President of the Australian Dental Association NT Branch Inc. He has also served leadership positions for Bupa Dental Corporation including the Clinical Advisory Panel, Clinical Procurement Committee and currently the Graduate Committee. He is passionate about helping and collaborating with fellow dental colleagues, recently embarking on a new journey to help recent graduates eliminate burnout through a 6-step B.E.L.I.E.F System through his motivational coaching platform, The Limitless Dentist. Kaejenn is a member of the Colgate Advocates for Oral Health Editorial Community and hopes to use this platform to raise awareness of the importance of mental health in dentistry and provide mindset tools, which can help his colleagues unlock their next level of growth and success.

References upon request

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