Oral Health Labs Fall 2013

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LABS

FALL 2013

Creating the “Tiffany” Smile

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contents

4 6

Building Blocks

CAD-CAM

Dentistry with Esthetics and Function “Today and Beyond”

On the cover The patient Tiffany with her new smile. IPS E-max crowns 14-24.

14

Custom zirconium abutment 11.

Osseous and gingival recontouring.

Function and Aesthetic Rehabilitation of a Patient with Hereditary Gingival Fibromatosis

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The Evolution of Screw Retained, Implant Supported Fixed Partial Dentures A BUSINESS INFORMATION GROUP PUBLICATION ORAL HEALTH LABS IS A SUPPLEMENT TO ORAL HEALTH EDITORIAL DIRECTOR

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from the editor

BUILDING BLOCKS In the last issue of Oral Health Lab, the discussion centered on the ever - crowded and the ever expanding technical landscape of dental implants. The cover photo shoot showcased the “ Urban Landscape” illustrating the many and varied componentry found in todays restorative options, at times a visual kaleidoscope of differing mechanical geometry, shapes and colors. Understanding this landscape is of the utmost importance when determining and planning a comprehensive treatment plan for the patient. This month we will continue with the implant theme and venture into the structural positioning of implants within an aesthetic protocol. Like constructing a building, the foundations are planned and designed along with the internal structures, to fit the proposed external shapes and forms of the structure. The external being the visual aesthetics, which require a precise adherence to the science of support engineering, in order to ensure longevity, of the chosen aesthetic materials. As in most restorative situations the external materials are mostly weaker in strength and compression than the sub-structure from which they obtain the necessary support. Therefore correct design principles are needed in order to give the appropriate support to these aesthetic materials for both final and framework masking aesthetics. The well-used phrase of designing from the end, backwards to the beginning, will ensure a carefully planned and executed sub-structure and aesthetic outcome.

Dr. Matt Illes continues with this theme in his article “Screw Retained Implant Supported Fixed Partial Dentures” on page 16 where he discusses and illustrates the structural design of milled sub-structures fabricated to the purpose of supporting individual aesthetic restorations. The article continues with a visual and fully documented showcase of the in-depth protocol required for a successful delivery of this type of restorative prosthesis.

I am honored and delighted to have Pinhas Adar MDT, CDT join us on page 6 to discuss and illustrate the many and varied material options available, along with their appropriate fabrication procedures, in order to obtain a successful aesthetic outcome. The role and interaction of the Dental Technician required in an aesthetic CAD-CAM environment is explained, along with the financial investment and the relationship partnership, which is required with the dental manufacturing companies.The dental laboratories of today have evolved into partnerships with these companies, hopefully offering mutual support and integrity.

On Page 14 Dr. Ed Philips showcases a clinical case of a patient with Hereditary Gingival Fibromatosis.

This issue of Oral Health Labs introduces and illustrates the case report with the treatment plan, along with the pre-op photographs and post-op photographs. This concise and exemplary article will be continued with full clinical and technical documentation in the next issue of Oral Health Labs.

In the last issue, I mentioned my upcoming trip to Seoul, South Korea where I was an invitee to the Seoul Dental Technology Symposium. For me it was an amazing experience not only to visit a truly vibrant and exciting city, but also to meet and to interact with my peers from a different international perspective. All the positives and negatives of our profession were discussed, essentially re-enforcing the mindset, that now we are truly in a global village, when it comes to technology and the sharing of the world’s knowledge, technology and the labor workforce. Participants from not only Asia, but also including Australasia, Europe and North America

Trevor Laingchild’s sense of adventure has taken him on an international road in his profession. After formal Dental Education in London, England, he managed a Dental Laboratory in Germany and served as Chief Dental Technician for an American Hospital in Saudi Ara-

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bia. Further experiences included, expanding his technical horizons whilst working in Norway, Scandinavia. He currently owns and operates dentalstudios in Burlington and in Yorkville, Toronto.

Trevor is an Accredited member and an Examiner within the American

Academy of Cosmetic Dentistry, in addition is a Certified LVI Master Aesthetic Technician. Trevor is very active lecturing and teaching whilst conducting numerous hands on courses in all aspects of restorative aesthetics, of which, he has had numerous articles published.

attended the meeting, which ensured a vibrant and multi-dimensional environment, within our global village.

The cover shot used in this edition illustrates the importance of designing a successful aesthetic outcome with the addition of an internal substructure, in this case an implant abutment on tooth number 11 within a maxillary smile redo/makeover. The patient had undergone several reconstructive procedures in the past without consideration being made to the final aesthetic outcome both from a tooth morphology perspective, in conjunction with the clinical peridontia situation. This had the detrimental effect, that during these past treatments, the patient, the clinician and finally the dental laboratory had no visualization of the final aesthetics.

This would include the aesthetic and functional tooth form and healthy aesthetic gingival framing. As we have discussed the importance of the correct support design for the reconstruction, in this case both clinical natural abutment design along with an implant-supported abutment are paramount for success.

The following images illustrate the successful results of inter-disciplinary dentistry, co - ordinated with the patient’s aesthetic and functional desires.

Post-op

Pre-op

CLINICAL TREATMENT General Dentistry Periodontal Surgery Technical Team Photography

Dr Rod Toms Dr. Bruno Girard Trevor Laingchild Trevor Laingchild

RDT,

Americo Henriques, Cristian Angelescu

RDT

In addition to various all-ceramic restoration techniques, the next issue will also focus on the ever -changing business environment within the dental technology landscape. Laboratory owners, technicians and laboratory staff, face challenges which include; the erosion of skill status, outsourcing, both internal and external, the multi -faceted position of our role within the direct restoration environment and the future of education within our profession. Where is dental technology going? What will be the role of technicians within a larger and more complex digital landscape? What will be the business ramifications within these questions for the dental laboratory of the future? The laboratory may not be going anywhere, but it is likely to be very different, from todays model. Then if so, how do we all adapt?

Every dental laboratory and dental office has a crystal ball somewhere. Take a look. I welcome your feedback.

Tell me what you see. Bye for now.

Editor Trevor Laingchild, RDT, AAACD FALL/WINTER

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CAD-CAM Dentistry with Esthetics and Function

“Today and Beyond”

by Pinhas Adar MDT, CDT

O

ur patients are learning more and more about the role they play in their own dental health thanks to the age of information that we live in that makes it but a click away. And in turn, their wishes and interests are driving the decisions that we as health care professionals make. Within this environment comes the need for information about options, products and the possible implications of dental care decisions. There are many differences in qual- how to process the relevant information from the anecdotal.

Given the onslaught of product introductions from manuity that exist in the dental field today.

However, if knowledge were the only req- facturers vying for the business of the dental market, dental uisite for success, virtually everyone would be professionals face the ongoing challenge of keeping up with successful. An action plan also is essential on the barrage in order to make informed selections of the best Pinhas Adar, MDT CDT Master Ceramist Pinhas Adar studied in Tel Aviv, Israel and did his residency with Mr. Willi Geller in Zurich, Switzerland. He has over 35 years of experience in all phases of dental laboratory technology. He is the founder of Adar Dental Network, Inc, a laboratory, educational and research company that is dedicated to setting a new standard in esthetics.

He is an Adjunct Clinical Professor at Tufts University School of Dental Medicine, past President of the Georgia Academy of Cosmetic Dentistry; on the PEC board of the American Academy of Cosmetic Dentistry as program co-chair for 2011, an Accredited member of the American Academy of Cosmetic Dentistry, a Fellow

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in the American Academy of Esthetic Dentistry, a board member as well as one of the commencing members of the International Oral Design group. He is also a center for Oral Design International. He is on the advisory board of the Amara Institute as well as on the editorial board of several dental journals.

He is a skilled communicator who has the ability to make the complex simple and to teach and inspire. As a speaker, author, and entrepreneur Pinhas has achieved success in empowering both individuals and organizations. His purpose is “To Live, Teach, and Empower Greatness.” He is the creator of educational DVD’s, numerous magazine article as well as a contributor to many chapters in dental esthetic publications.

1a

b 1a: Old crown that did not match the adjacent central 1b: Customizing the

internal effects during the patient’s appointment 1c: Final single central crown after glaze and polish

c products that not only meet their clinical and esthetic requirements but also patient demands.

The Plan of Action Dentists and dental ceramists are business owners, and in business, time is money. Yet, rather than just selling a product¬ — a crown, for instance — dental professionals are providing a service that requires considerable skill and time. Instead of asking their patients to purchase a product or procedure, dental professionals are asking for an investment in their expertise and time to exercise these skills and knowledge. Therefore, dental professionals must determine the

1d: Final single central

crown after cementation

d

types of products and systems to employ in their daily procedures in order to maximize their most valuable commodities — time and service.

Technology is a time saver and can present a rich profit source. However, before investing in any technology, it is important to consider five factors for success. They are as follows: 1. Favorable market trend 2. Product uniqueness (for dental professionals, this translates into their skill levels and how these can be utilized to marketplace advantage) 3. Partnerships with companies with proven longevity, reliability and quality (if dental professionals purchase costly equipment and/or FALL/WINTER

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technology, they want assurance the company and technology will be around if future services and/or upgrades are required) 4. Favorable return on investment (ROI) compensation (if laboratories or dentists invest $120,000, what can they expect as an ROI for their businesses?)

5. Perfect timing

Dental ceramists and their dentists should embrace technology, but they must not be ruled by it. Patients should feel as if technology is an enhancement — not a replacement — of a dental professional’s personal service, as “the personal touch” remains an important element of patient satisfaction and retention. We still need to remember that an informed consumer wants to get what they want – the first time. Communication is one of the key ingredients to achieving this. The topic of communication is one that has many turns and twists and that can become quite complicated particularly with geographical constrains. People use different key words in an attempt to communicate. But what exactly does the patient mean when they use the words “white”, “natural”, “straight”, “big” and “small”? Do these words have the same meaning from patient to patient, dentist to dentist and dental ceramist to dental ceramist? Communication is a complex issue, yet as in the rest of life, an essential part of a satisfactory outcome. Specific tools can be used to assist and support a consistent message traveling between everyone involved, so that the desired outcome can be attained with no surprises for anyone. The first step, no matter what type of enhancement is required, is proper diagnosis and treatment planning.

The assignment that we all have is to create an illusion of reality. And due to the new materials available to us in the market today, it is no longer an impossible task. With the proper ceramic selection and skills of the ceramist, an illusion of reality can be accomplished even with a single anterior crown. The blueprint is already there to copy. Figure 1-A is an old crown that did not match the adjacent central to the patient’s preference. A new single central crown was fabricated (figure 1-B). The blend is much more harmonious with the existing central incisor (figure 1-C & D).

ZIRCONIA and Lithium Disilicate Zirconia materials are a practical ceramic option for metal-free restorations. They are ideal for light transmission in certain clinical situations. Studies by the University of Zurich-Haemmerle and the University of Goettingen-Huels have backed up the strength and longevity of restorations using zirconia framework. Fixed partial denture frameworks made from all zirconia can now span up to 14 units on natural teeth and edentulous implant retained restorations (figure 2-A).

The fabrication process for an all-ceramic restoration using a zirconia core is similar to the process used for porcelain fused to metal restoration.

Compared to traditional all-ceramic materials, IPS e.max,

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composed of 70% needle-like crystals in a glassy matrix, affords optimal strength, durability and esthetics.1,2 It has a flexural strength of 360-400 MPa and is up to three times more durable than other glass-ceramic systems.3 IPS e.max incorporates true-to-nature shades while demonstrating a low refractive index, providing optimal optical qualities (e.g., lifelike translucency and high light transmission).4,5 Cutbackand-layer or stain-and-glaze techniques make it possible to further characterize IPS e.max restorations.4,5 Dental professionals can seat IPS e.max restorations using either conventional cementation or adhesive bonding methods.

Dual-curing adhesive luting cements can be used to create a bond between prepared teeth and IPS e.max restorations.4,5 Extremely versatile, IPS e.max is indicated for numerous restoration applications, including veneers, crowns, inlays, onlays and implants. IPS lithium disilicate can be pressed utilizing the hot wax technique (figure 2-B). (IPS e.max Press) or milled in the laboratory or chair side using CAD/CAM technology (IPS e.max CAD).4,5 These new technology and materials have certainly made their impact in the dental world. However we need to understand that the human touch still makes the epic difference.

All ceramic powders are purchased from the same manufacturers yet each technician ends up with different outcomes.

The challenge with CAD/CAM technology is that the higher strength materials can appear too chalky and not esthetic. Zirconia is the strongest all-ceramic material available in dentistry to date. However, not all Zirconia materials are created equal. For instance, the digitally fabricated Prettau Zirconia material is a more translucent product that can produce full contour single crowns (figure 3-A & B) as well as implant-supported, screw-retained restorations. These restorations can be fabricated for any number of implants. As a result, it’s a viable treatment option for single units and up to fourteen unit bridges (figure 3-C). This final restoration is fabricated using CAD/CAM technology (figure 3-D). This includes computer aided design (CAD) and milling of the restoration from a zirconia disk. Once milled, (figure 4-A) the “green state” zirconia is much softer making the human touch of contouring and anatomy surface enhancements (figure 4-B) as well as multi-shading for improved esthetics an easy possibility (figure 4-C & D). After the bridge is sintered at a high temperature for 8-13 hours, a skilled laboratory technician will custom stain the Zirconia and layer pink porcelain (figure 4-E) on implant-supported, screw-retained bridges to create the illusion of soft tissue. With many cases involving the mandibular arch, the monolithic option (figure 4-F) is common and will need minimal cut back enhancing esthetics by layering on non-functional areas only, as opposed to the upper which usually requires more layering (figure 4-G).

2a 3a

4a b

b

2a: Screw retained implant

Prettau Zirconia framework after milling 2b: eMax full monolithic

crown after glaze

3a-b: Monolithic full contour Zirconia crown process with a natural look

c

3d: Screw retained

implant Prettau Zirconia framework after sintering

3c: Screw retained implant CAD-CAM design

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b c

d

4a: Screw retained implant

CAD-CAM after milling 4b: Screw retained implant

CAD-CAM after milling and some human touch

d

4c-d: Prettau Zirconia framework staining with the human touch

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By emphasizing the importance and the role of the human touch with CAD/CAM technology digital solution along with unique concepts that create a signature line with more esthetics, consistency and efficiency all at an excellent value, can change the current rule of thumb for full monolithic crowns and bridges.

The process and protocol in fabricating large implant bridges is very important to follow because if any step is missed or done wrong the cost of redo is expensive and very frustrating. For example, if the impressions are not accurate and a verification jig was not provided before cementation (figure 4-H) of the titanium abutment in the lab, the implant bridge will break (figure 4-I), because as strong as Zirconia is, it is still very brittle.

One important thing to remember is that every Prettau Zirconia bridge must have a certificate of authenticity that comes with each Prettau disc – if you do not get one of these (figure 4-J) you have gotten a cheaper material.

Laboratory Protocol SMILE DESIGNS: Fabricating entire smile designs are a lot different than doing a couple of crowns. Without adequate communication this could be a difficult procedure with an unpleasant surprise at the end. It is important that we understand the patients’ preconceived ideas of what they would like their smile to look like.

One of my favorite quotes is “Beauty is in the eye of the beholder, but so is ugliness.” What you or your ceramist might consider beautiful, your patient might consider ugly. That is why it is so important to involve the patient in the process. The patient should always be given options and alternatives so that they can make educated decisions. Make them aware of what the possibilities are.

The dentist must also be aware of what his laboratory is capable of and what their style is. As with all forms of art, all ceramists have a different style. If a dentist sends a case with the same instructions to several different laboratories he will get extremely different looks. That is because each laboratory interprets the same request with a different vision. The questions that the restorative dentist should ask are: “Which laboratory’s outcome will the patient like?” and “What kind of tooth preparation will this desired outcome require?” Each vision has the need for different tooth style preparations for space management.

Now with the CAD-CAM technology we can fabricate several temporary sets for our patient in exact duplicate by using a PMMA block (figure 5-A). So, for example one temporary can be customized with pink composite (figure 5-B) and delivered for the patient to test drive and the second set can be used as

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a communication tool to transfer between dentist and the laboratory (figure 5-C). This process is more efficient and cost effective than using conventional methods.

INDIRECT TRIAL SMILE: The removable Trial Smile method is an incredible tool for communication. The benefit of the utilization of a trial smile in the pre-treatment stage is to avoid patient disappointment and enhance communication between the entire dental team for a successful outcome. With the “Trial Smile” the patient can see and feel the teeth, as well as the color, in their mouth. The Trial Smile serves as a blueprint to allow the patient to experience all of these things. However, it is important and necessary that the ceramist who will be doing the final ceramics do a diagnostic wax up for the Trial Smile and/or the Trial Smile itself. A lot of detail needs to be put into these restorations.

Figure 6-A is a patient who was unhappy with her smile after orthodontic treatment. She disliked the size and proportion of her teeth as well as the spacing. An impression was taken without tooth preparation and a diagnostic wax up was made. A Trial Smile was fabricated using the cold curing acrylic Outline (AnaxDent). The patient was able to place the removable restoration in her mouth (figure 6-B) and visualize the outcome of the new smile (figure 6-C) prior to tooth preparation.

It is important that the patient make the final decision on the design of their Trial Smile. Esthetics is very subjective and a matter of personal preference, emotional feelings and personal opinion. There is no right or wrong in esthetics, just variations in opinion.

DIRECT MOCK-UP TRIAL SMILE: The patient shown in figure 7-A did not like her smile. She felt that the teeth were too short, the soft tissue lacked symmetry and the color was too yellow. The ceramist created a wax up of his vision of what the final outcome of the case should be. This is an extremely important first step to ensure success of the case. The wax was made to over-lap the soft tissue to lengthen the teeth cervically, simulating crown lengthening. The dentist made an impression of the wax-up and then created an acrylic mock-up or removable trial smile using DMG Luxatemp® (figure 7-B). The patient then put the mock-up Trial Smile in her mouth (figure 7-C) and could see and feel what her new smile would be like (figure 7-D). This ensures that the patient approves of the ceramist’s vision of the final outcome. The patient should always be involved and approve the outcome prior to tooth preparation. Once the wax up/Trial Smile is approved, the periodontist can then use this as a surgical guide and the dentist can prepare the teeth, when ready, minimally to insure the preservation of

4e f

4e: Screw retained

monolithic implant bridge with pink ceramic application

h

4f: Screw retained

monolithic implant bridge after stain and glaze 4g: Minimal cut back

on non-functional areas for ceramic application

i j

4h: Cementation with loops to ensure accuracy 4i: Broken full contour

Zirconia when not following the process and protocols

g

4j: Certificate of Prettau

Zirconia authenticity

5e 5a: Screw retained implant PMMA framework after milling

b

5b: Pink composite

application with GC gradia

5c: Screw retained implant PMMA bridges after the finish

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as much enamel as possible maximizing the bonding strength of the porcelain veneers.

COMMUNICATION TOOLS: There are critical communication tools that need to be used between the dentist and the laboratory technician to maximize success: 1. Preoperative study models of upper and lower arches 2. Preoperative clinical digital images – smile and retracted view with a shade tab of the natural color shown with it 3. Digital image of the unprepared teeth with the existing color shade tab next to it 4. Digital image of desired shade tab next to the prepped teeth. It is incredibly important for the technician to know the shade of the prepared teeth so that the correct ceramic system can be chosen.

5. Digital image of provisional restoration if used – smile and retracted view 6. Digital image of patient’s face 7. Three or more accurate impressions. The reason for 3 impressions is that certain distortions are very smooth and unrecognizable, but it would be very difficult to have the same type of distortion in 3 impressions. So the technician can check the restorations in all 3 models for accuracy, thus allowing for the best fit of the restoration.

8. List of the desired expectations of the patient and the dentist

Synergy between all the key players, the patient, periodontist, general dentist, prosthodontist, orthodontist and the ceramist should be a priority for treatment. This will integrate communication that will ultimately lead to success.

Understanding each restorative option is the key to achieving patient expectations. Clinical mastery depends mainly on the expertise of the dental team as well as the restorative materials chosen (figure 8-A). Esthetics is not about a particular product but about using the product with the same degree of success whether you have a case that is a single crown, multiple crowns or a combination case of veneers and crowns or implant (figure 8-B). To achieve success all members of the restorative team must work together using the same set of guidelines and protocols. In an ideal situation, the entire dental team, consisting of the restorative dentist, the specialist and the dental technician (figure 8-C) should be able to evaluate the patient during the treatment-planning phase. This can be done either in person or by video conferencing. However if this is not possible a very detailed protocol for communication is the next best thing (figure 8-D).

There is not one single product on the market today that can solve every restorative case. That is why material selection is so critical to reach success. You must consider the type of foundation that is used to have the optimal end result. As re-

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storative materials continue to progress, technicians will be able to create improved harmony which will directly increase overall patient satisfaction with a definitive end result.

Summary In summary let me quote what many people have heard me often say: “No man is an island.” We all need each other to pull off the ultimate in dentistry. No aspect of dentistry can survive this “CAD-CAM-ESTHETIC” rush if we think we can do it on our own. With digital solutions today we can create a signature line with more consistency and efficiency as well as pleasing esthetics and all at an excellent value, allowing us to serve more dentists and their patients. The importance is to understand that the human touch still makes the epic difference!! We must learn to communicate better and most of all, to respect the profession and our colleagues. L Dentistry by: Figures 1-A –1-B - Dr. Cathy Schwartz, private practice, Atlanta, Ga Figures 4-A – 4-D – Dr. Nancy Ray, private practice, Chicago, IL Figures 8-A – 8-D – Dr. Aldo Leopardi, private practice, Greenwood Village, CO Special THANKS to the Zirkon Zahn TEAM!! Alessandro Cucchiaro, LienHuynh, Admir Hujdur, Ashley Wayne Michalec and Hai Nguyen for their generosity and assistance with the screw retained implant Prettau Zirconia !!

References 1. M cLaren EA, Phong TC. Ceramics in dentistry: classes of materials. Inside Dent 2009; 5(9):94-103.

2. R eynolds JA, Roberts M. Lithium-disilicate pressed veneers for diastema closure. Inside Dent 2010; 6(5):46-52.

3. I voclar Vivadent. IPS e.max lithium disilicate: this changes everything. Amherst, NY: Ivoclar Vivadent; 2009:1-6.

4. C ulp L, McLare EA. Lithium disilicate: the restorative material of multiple options. Compend Contin Educ Dent 2010; 31(9):716-20,722,724-5.

5. I voclar Vivadent. Ips e.max lithium disilicate: the future of all-ceramic dentistry-material science, practical applications, keys to success. Amherst, NY: Ivoclar Vivadent; 2009: 1-15.

6. K ahng LS. Patient-dentist-technician communication within the dental team: using a colored treatment plan wax-up. J Esthet Restor Dent. 2006;18(4):185-93; discussion 194-5.

7. J ournal of Esthetic Dentistry, Volume 9, number 6, Adar – Avoiding Patient Disappointment with Trial Veneer Utilization 8. N anchoff-Glatt M. Clinician-patient communication to enhance health outcomes. J Dent Hyg. 2009;83(4):179.

9. T erry D.A. Aesthetic & Restorative Dentistry Material Selection & Technique. Everest Publishing Media. 2009:152-3.

b

6a

b

c

6a: Patient who was unhappy with her smile after orthodontic treatment 6b: Patient placing the

7a

b c

removable Trial Smile restoration in her mouth

6c: Smile with Trial Smile in the mouth

8a

b

d

7a: Pre-operative smile

7b: Mock up fabricated

from a wax up 7c: Patient smile with

mock up

7d: Smile with mock up

8a: Pre-operative smile

c

8b: The process of cementation with MO1

Multilink implant resin based

full-face picture has more impact on the patient

d

8c: Delivery of the screw retained implant bridges in the articulator 8d: Final smile with the screw retained Prettau

Zirconia implant bridges

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Function and Aesthetic Rehabilitation of a Patient with Hereditary Gingival Fibromatosis

by Dr. Ed Philips B.A., DDS

Abstract

Hereditary gingival fibromatosis (HGF) is a rare benign, slowly progressive, noninflammatory fibrous hyperplasia of the maxillary and mandibular gingivae that occurs generally with the eruption of the permanent dentition, more rarely of the primary, or even at birth. It presents as a localized or generalized, smooth or nodular overgrowth of varying severity of the gingival tissues. It can be isolated with

autosomal dominant inheritance or as part of a syndrome.

This clinical report presents the diagnosis, treatment planning and prosthetic rehabilitation of a 37 year old male patient with HGF. The patient was rehabilitated with 10 maxillary and 10 mandibular IPS Emax Veneers.

The patient is currently being observed for adaptation of the gingival tissues with regular follow-up. The patient is satisfied with the aesthetic, function and phonation of his prostheses.

Hereditary gingival fibromatosis is a hereditary, typically characterized by generalized gingival fibrous hyperplasia.It can vary in degree from site to site and have various histological characteristics. It may also be associated with morphologic or malformative changes elsewhere in the body such as Cowden’s Syndrome. It may produce migration of the teeth as a result of an often associated enlarged tongue and associated constriction.

The following clinical report describes the rehabilitative procedure experience by this patient affected by HGF.

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Case Report A 37 year old man presented with a chief complaint of unpleasant aesthetics related to the spacing of his teeth and the overgrowth of his gums. His general medical history is non-significant. His stature and appearance were suggestive of a hereditary condition. Panorex findings did not show any specific abnormality that could be associated with the gingival hyperplasia. Consultations with University Periodontal and Oral Surgical members confirmed by clinical appearance and history a diagnosis of Hereditary gingival fibromatosis.

The patient was treated with a soft tissue laser over numerous appointments and adaptive temporization to create gingival contour. Final restorations consisted of 10 IPS Emax maxillary and 10 mandibular IPS Emax veneers.

Editors Note The full and progressive detail of the management of this case will be highlighted in the April 2014 issue. L

Dr. Philips is author of the

Director for Aesthetic Dentistry at the Univer-

Dentistry for the Ontario Dental Association

recently published book

sity of Toronto, Faculty of Dentistry, Depart-

and Professor for the Faculty of Health Sci-

Your Guide To The Perfect

ment of Continuing Education; Senior Clinical

ences, George Brown College. Dr. Philips limits

Smile. His past teaching ap-

Instructor for Millennium Aesthetics in Niagara;

his practice at The Studio for Aesthetic Den-

pointments include Course

Continuing Education Course on Cosmetic

tistry in Toronto.

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Unretracted Smile Pre-op :1 Retracted Closed Bite Pre-op :2 Retracted Open Bite Pre-Op :3

4: Post-Op Unretracted 5: Post-Op Retracted Closed Bite 6: Post-Op Retracted Open Bite

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The Evolution of Screw Retained, Implant Supported Fixed Partial Dentures

by Matt Illes HBSc, DDS FAGD, FICOI

Synopsis:

The following article serves as the second half of a two part composition dedicated to a discussion on the construction and clinical application of the screw retained, implant supported, fixed partial denture (ISFPD) using modern methodology. The first paper reviewed the literature available to support computer assisted design/computer assisted manufacturing (CAD/CAM) technology in lieu of traditional casting. It also provided a report on CAD/CAM materials and contemporary fixed framework design with a summary of the key scientific data. The author will review a protocol in this follow up piece for the fabrication and delivery of a maxillary anterior, screw retained, ISFPD in maximum intercuspation occlusion (MIP). The ISFPD will feature a titanium milled frame and individual, cementable crowns with screw access holes (SAH).

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abrication of the ISFPD using CAD/CAM technologies can be performed using either virtual design or copy milling. The virtual technique is a two appointment process characterized by a computer generated framework design and computer numeric controlled (CNC) milling. This approach has the potential to be used with a high level of predictability for the rehabilitation of short edentulous spans (2-4 units). However, virtual design can become problematic when used with patients whom have high esthetic expectations. It can also be- tients diagnosed with suspected mandibular dysfunction or come troublesome for the construction of ISF- parafunction to permit an occlusal assessment and anterior PDs in the anterior maxilla when the occlusal guidance development. Provisionalization should always be plane is not level. The addition of a third ap- used for patients with high esthetic expectations.  The initial prosthodontic appointment includes the selecpointment to serve as an intermediary, esthetic check would address the aforementioned issues tion of shade, alginate impressions, a final impression, a facebut it would conflict with the primary asset of bow or ear-bow record and possibly an MIP interocclusal record.

Digital photography is used to communicate shade. A CAD which is its expeditiousness. Furthermore, digital framework development using software single lens reflex camera equipped with a macro lens and extools has not gained widespread acceptance ternal flash are necessary to capture colour information acwith dental laboratories. This is partly a result curately. The camera’s exposure compensation feature, in comof the challenge CAD presents with respect to bination with the correct f-stop, external flash power setting controlling the contours of the frame without a and lens reproduction ratio, is used to achieve underexposed photos (figure 5). Higher exposure levels result in the loss of physical inspection.

F

In contrast, copy milling is a three appointment process distinguished from the virtual technique by a try-in procedure using a full contour jig which serves the role of a prototype (figure 1). The jig can be made using a combination of wax and acrylic or epoxy resin. It offers the clinician and the laboratory technician the benefit of greater control of all aspects of the permanent prosthesis framework tissue fit, esthetics and occlusion. It also provides improved control of permanent framework contours through manual cut back using silicone matrices of the jig for guidance (figures 2-3). The cut back acrylic jig is later duplicated into the final framework using scanning technology and CNC machining (figure 4).

The clinical procedure for manufacturing an ISFPD might include a provisionalization phase of treatment incorporating the use of a temporary ISFPD. Provisionalization should be given consideration in situations offering the opportunity for peri-implant soft tissue development to circumvent the use of pink restorative materials. It might also be used for pa-

colour information.

Prior to the first appointment, the clinician must determine the type of final impression. The impression can be registered at the level of the fixture platform or at the level of an abutment. Abutment level impressions for ISFPDs are a consideration in situations characterized by internal connection fixtures which exhibit questionable divergence radiographically. The addition of abutments such as the UniAbutment (Astra Tech), Multi-Unit Abutment (Nobel) or Multi-Base Abutment (Straumann) serves to convert an internal connection interface into an external connection interface. The use of abutments thereby reduces potential issues related to the inability to obtain a path of draw for the framework. The author has received an unsubstantiated report from personal communication with one of the largest milling centers in North America advising him that it is a rare event for fixture divergence to prohibit the fabrication of a milled, screw retained, implant bridge or bar framework. Consequently, the

Dr. Matthew Illes, is a graduate of the University of Western Ontario and serves as a prosthodontic consultant at the University of British Columbia. He is a fellow of both the AGD and International Congress for Oral Im-

plantologists. Dr. Illes has a practice limited to prosthodontics in Vancouver, B.C. He is a sponsored speaker for Nobel Biocare and Ivoclar and serves as current president of the BC AGD. FALL/WINTER

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primary benefit of using abutments is arguably one of convenience related to the elevation of the fixture platforms. The creation of equigingival or supragingival margins decreases complications with potential tissue impingement and patient discomfort during framework try-in and delivery procedures.

Abutment level impressions have multiple drawbacks including the need to have a stock of assorted abutment heights. This is due to the difficulty in predicting the most appropriate abutment for each fixture. Abutments also add a significant cost to the laboratory fee with current prices hovering around the $300 mark per unit. In addition, abutments can create technical issues for the laboratory technician because of their height. Fixtures which do not have ideal position and, or, angulation have the potential to create significant problems when abutments are utilized. The abutments might not lie within the confines of the desired prosthesis with sufficient space for restorative materials therefore compromising the design.

Hjalmarsson published a recent report demonstrating that there was no significant differences in clinical outcome in comparing abutment level to fixture level ISFPDs after 5 years of follow up.1 The author favours the use of fixture level impressions for all of the above reasons.

Implant impression technique for multiple units has many variables ranging from impression tray selection to impression coping selection. A review of the literature indicates that the consensus of data supports splinting (figure 6) and use of the direct, pick-up technique as more accurate than nonsplinting and use of the indirect, transfer technique. Lee reported that the previous finding was not unanimous and thus controversy continues to exist with respect to the optimal impression procedure.2 Splinting protocol has been another related topic of contention with variations in materials and techniques. GC pattern resin (GC America) was observed to be superior to Duralay II (Reliance Dental Manufacturing) for use as a splinting material due to significantly lower levels of microstrain generated with former.3 Recent evidence has also shown that the use of floss to connect impression copings for splinting is potentially detrimental due to high levels of tension.4 The author currently uses flowable resin to spot bond a monofilament material (Butler GUM Eez-Thru floss threaders) to negate the potential negative tension effects of floss and uses GC pattern resin to connect the impression copings (figure 7).

Polyether and polyvinyl siloxane (PVS) have been reported in the scientific literature as being the most accurate materials for implant impression registration. A review of the literature reveals that there is very limited information available to support one specific technique over another in comparing puttywash (1 step and 2 step) to heavy body-light body (or extralight body) to medium body only for the two materials.5,6

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Mounting of the maxillary working model requires an upper alginate and either a face-bow or ear-bow record of the provisional ISFPD, or the removeable interim partial denture. The provisional model facilitates improved accuracy in positioning of the working maxillary model on the articulator as the anterior teeth aid in registering a precise face-bow or ear-bow record. The lower model is then mounted to the provisional model through hand articulation, or use of a PVS, MIP record.

The resultant three dimensional orientation of the mounted lower model acts as the foundation upon which the working maxillary model can be cross mounted using a MIP record.

In the event that provisionalization is performed to develop the peri-implant soft tissues, a PVS impression of the tissue surface of the provisional restoration is needed to attempt to mimic its contours and transfer them to the permanent ISFPD (figure 8).

The second prosthodontic appointment is optional and is used by the author for the sole purpose of bite registration.

An implant supported, PVS, MIP record is taken using a lab fabricated, acrylic bite jig. The jig serves to improve the accuracy of the mounting (figure 9).

A full contour, copy mill jig is then constructed using nonhexed, titanium temporary copings connected with acrylic incorporating tooth coloured wax in esthetic areas (figure 10).

The jig can also be developed using epoxy resin exclusively.

The copy mill jig is tried in at a third prosthodontic appointment. It is used to evaluate the potential design of the ISFPD including its dental esthetics. The incisal plane cant and levelness of the occlusal plane can be assessed along with the midline cant and vertical incisal edge position of the anterior teeth in the patient’s face prior to framework production. These specific areas of esthetics can not be judged using the two appointment virtual protocol.

The copy mill jig allows the clinician an opportunity to identify potential peri-implant oral hygiene issues related to the ease of floss threading so that changes to the framework, or the tissue, can be managed at this stage.

An assessment of the adaptation of the jig frame to the soft tissues can be performed to ensure proper fit with the absence of undesirable spaces caused by impression inaccuracies. The jig also offers the dentist an opportunity to visualize maxillary lip support in cases whereby a patient wishes to have an implant supported, fixed denture instead of a conventional implant supported, bar overdenture.

The static and dynamic aspects of occlusion of the prosthesis can be evaluated prior to further processing using the copy mill jig. Adjustments to the jig for the purpose of remounting can easily be performed through subtraction with a bur or addition with autopolymerizing acrylic.

The prototype also serves an important role in its use as a verification jig to judge the accuracy of the impression and workFALL/WINTER

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ing model. A clinical exam is conducted under magnification to evaluate the connection between the framework cylinder seats and the fixture platforms. This procedure has significant limitations. The visual evaluation is greatly impaired by being limited to those areas which can be accessed. In some situations these are minimal to non-existent. Gauging the precision of framework fit for the increasingly popular platform shift implant fixture has created new challenges. Platform shifting refers to a connection characterized by an implant fixture which is of greater outer diameter at its most coronal point than the prosthodontic component which attaches to it. This component could be a framework, cylinder interface or a single unit, abutment interface (figure 11).

Non platform shift fixtures with flat disc platforms (i.e. Nobel Replace Select) or bevelled collar platforms (i.e. Straumann Standard) offer an advantage in facilitating the dentist’s ability to detect discrepancies in fit. The author prefers the use of 6x magnification loupes for this purpose. The verification protocol must further rely on a radiographic assessment of the fixtures which is also adversely affected by platform shift implants.

The copy mill jig is duplicated into acrylic, unless made from epoxy resin, then cut back and scanned using positional indicator analogues or scan bodies. Scan bodies are used to relate the jig to the scan of the working model. The information taken from the scan is then relayed to a CNC milling machine which cuts the ISFPD framework from a disc of titanium alloy.

The frame is then inspected for accuracy. This process is accomplished using varying approaches in accordance with the milling center. Some corporate production facilities have invested in metrology technology such as a coordinate measuring machine (CMM) to perform part of this assessment.

CMMs are reported to be able to evaluate a framework using a touch probe sensor to as close to 3um of its design dimensions (figure 12). Other less sophisticated methods are often used alone, or in combination with the CMM, including the in vitro Sheffield test. An unverified report from one major corporate milling center in North America claims to achieve an accuracy of fit for screw retained, implant supported, bridge frameworks or bars to be less than 20um with a misfit rate at the factory approximating 0.05%.

The fourth prosthodontic appointment for a framework try-in is an optional appointment and one which is routinely performed by the author. Verification of both clinical and radiographic framework fit is performed, as per the technique used for the copy mill jig. Peri-implant floss threading (anterior segments) and, or, proxabrushing (posterior segments) is then evaluated to ensure ease of assess.

The framework is returned to the lab for fabrication of the individual crown restorations following its evaluation.

The author prefers the use of monolithic, e.max, lithium disilicate crowns in all patients whom demonstrate no evidence of functional or parafunctional occlusal disorders. E.max has

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very good short term scientific data and has demonstrated a fracture resistance which exceeds the average occlusal force in the posterior of the mouth.7 It is always used in a monolithic form in the posterior and is layered on the facial, for improved depth of esthetics, in the anterior. The cut back in this area is restricted to the incisal region of the crown extending to the incisal edge but not onto the lingual surface to minimize the potential incidence of chipping or fracture.

Zirconia can also be used as an alternative to e.max. Issues related to the esthetics of the former in its monolithic form, coupled with the concerns about porcelain chipping when layering is employed, along with the inability to produce a full contour restoration with a built-in SAH, limit its use in the author’s practice.8 Silicone matrices and an anterior guide table of the copy mill jig are fabricated to replicate the esthetic and occlusal components of the prototype and used during construction of the permanent ISFPD. A provisional ISFPD can also be cloned into a copy mill jig, if used, to incorporate the contours developed and tested intra-orally. This duplication process is employed to elevate the level of predictability for manufacturing of the permanent prosthesis.

All crowns are fabricated through the classic lost wax technique with ceramic ingot pressing rather than CAD/CAM because of the incorporation of SAHs. These holes can be drilled through milled e.max but concerns arise regarding the introduction of subsurface cracks and their potential impact on restoration survival. No data is available which investigates this matter.

A light cured, white, resin opaquer is selectively applied to the framework following application of the self curing, metal adhesive SR Link (Ivoclar Lab). This strategy is employed to minimize the effect which the grey titanium has on the porcelain esthetics when using all ceramic crowns such as e.max. Traditional porcelain opaquer is not used due to the issue associated with titanium oxide formation from exposure to heat.

The fifth prosthodontic appointment is for the purpose of final prosthesis delivery, unless the patient has high esthetic expectations. In such circumstances a dedicated try-in can be performed. The framework is seated, the abutment screws are hand tightened and the crowns are tried in. The use of individual crowns allows for a systematic approach for occlusal adjustment with each crown tried in and adjusted independently.

This strategy assists in maintaining MIP through repeated verification of reference MIP occlusal contacts following the insertion of each crown. KY jelly is used to facilitate the assessment and occlusal adjustment of the crowns. Its cellulose component offers sufficient viscosity to retain the crowns with predictability and its water soluble nature expedites its removal.

Abutment screws are torqued to their appropriate setting following patient approval of esthetics. Although the majorFALL/WINTER

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12 13 14 References 1. H jalmarsson L, Jemt T et al; Int J Prosthodont. 2011 Mar-Apr;24(2):158-67 2. Lee H et al; J Prosthet Dent. 2008 Oct;100(4):285-91 3. Cerqueira NM, et al; Int J Oral Maxillofac Implants. 2012 Mar-Apr;27(2):341-5 4. Lopes Junior I et al; J Oral Implantol. 2011 Dec 30 5. Reddy S et al; Niger J Clin Pract. 2013 Jul-Sep;16(3):279-84 6. Wenz HJ et al; Int J Oral Maxillofac Implants. 2008 JanFeb;23(1):39-47 7. Kim JH et al; Implant Dent. 2013 Feb;22(1):66-70 8. Larsson C et al; Acta Odontol Scand. 2012 Dec 4 9. Choi JH; Int J Oral Maxillofac Implants. 2011 SepOct;26(5):1016-23 10. Wilson TG Jr; Periodontol. 2009 Sep;80(9):1388-92

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ity of implant systems have screws engineered to be torqued to 30-35 N-cm, some implant companies, such as Astra Tech, use considerably lower torque values which can range from 15-25 N-cm. Knowledge of the implant system used is therefore imperative to success. Selection of the proper driver with regard to the dimension of height is also important as it permits for finger control at the top of the torque wrench. This technique is critical to prevent stripping of the abutment screw during application of torque. Abutment screw torque application sequence for implant bars or bridges has been shown to be inconsequential.9 Crown cementation can be performed intra-orally or extraorally (figure 13) using the SAH crown design. The author prefers intra-oral cementation. This is partly due to the ability to limit potential cement perfusion apical to the soft tissues using a framework design featuring supragingival margins in all nonesthetic areas. This design feature serves to significantly reduce the risk of deposition of excess subgingival cement and negates its potential inflammatory ramifications.10 The SAH porcelain must first be air abraded after cementation to remove the residual cement. Hydrofluoric acid etching is then performed for e.max (20s) or feldspathic porcelain (60s) to prepare the porcelain for application of the resin coupling agent. Silane (e.max or feldspathic porcelain) or a metal primer (zirconia) is subsequently applied to finalize porcelain preparation for a composite restoration. The author uses a single piece of teflon tape to obturate the majority of the SAH leaving the coronal 2-3mm unfilled. The coronal space is restored with an opaque, microhybrid composite (figure 14) to minimize the presence of the SAH. The SAH is typically evident as a distinct grey zone in the surface of the crown when using non-opaque composite materials.

Static occlusion is rechecked in both a supine position and an upright position due to mandibular protrusion as a result of a postural change. Failure to examine the upright static occlusion has the potential to result in undiagnosed anterior interferences into MIP. The author then checks dynamic occlusion using exercises involving the chewing of food and enunciation of the sibilant speech sounds. This particular approach to dynamic occlusion is antithetic to the traditional protocol which focuses on assessing and adjusting excursions with mandibular movements starting from the MIP position.

Copy milling and CNC technology for the manufacturing of screw retained, ISFPD frameworks designed for individual, cementable crowns with SAHs represents the pinnacle of fixed, implant prosthodontic engineering. This contemporary technique offers the clinician the opportunity to achieve unparalleled precision of prothesis fit with highly predictable esthetics and occlusion. It provides the patient with the benefit of single crown replacement in the event of fracture and the option for unobstructed prosthesis retrievability, if required. L

Oral Health

CALENDAR OF EVENTS 2014 To list YOUR Canadian or International dental event, send information to: Catherine Wilson at cwilson@oralhealthgroup.com

JANUARY

January 29 - February 1 Yankee Dental Congress 38 Boston Convention & Exhibition Center Boston, MA P. (877) 515-9071 F. (508) 480-0002 www.yankeedental.org FEBRUARY

February 20 - 21 American Prosthodontic Society 86th Annual Meeting Swissôtel Chicago Chicago, IL P. (312) 981.6780 F. (312) 981-6787 www.prostho.org www.swissotelchicagod.com February 20 - February 22 The 149th Chicago Dental Society Midwinter Meeting Chicago, IL P. (312) 836-7300 F. (312) 836-7337 www.cds.org February 27 - March 1 The Academy of Laser Dentistry’s 21st Annual Conference & Exhibition Scottsdale, AZ P. (954) 346-3776 F. (954) 757-2598 Toll Free: (877) 527-3776 E. memeberservices@ laserdentistry.org www.laserdentistry.org MARCH

March 6 - 8 Pacific Dental Conference Vancouver, BC P. (604) 736-3781 E. info@pdconf.com www.pacificdentalonline.com March 19 - 22 43rd Annual Meeting & Exhibition of the AADR 38th Annual Meeting of the CADR Seattle, WA P. (703) 548-0066 F. (703) 548-1883 E. research@iadr.org www.dentalresearch.org March 26 – 30 2014 IAO Annual Meeting (International Association for Orthodontics Ann. Mtg.) Kissimmee, FL

P. (414) 272-2757 F. (414) 272-2754 E. worldheadquaters@iaotho.org www.iaortho.org March 27 - March 29 102nd Thomas P. Hinman Dental Meeting Georgia World Congress Center Atlanta, GA P. (404) 231-1663 F. (404) 231-9638 www.hinman.org APRIL

April 10 - 13 25th Annual Meeting on Special Care Dentistry Westin Michigan Ave. Chicago, IL P. (312) 527-6764 F. (312) 673-6663 www.scdonline.org April 12 - 13 39th Annual Technorama Canada’s Largest Dental Technology & Denturism Convention Hilton Suites Toronto/Markham Markham, ON P. (519) 221-3144 E. denisetechnorama@gmail.com www.technoramadiac.ca April 30 - May 3 30th AACD Annual Scientific Session Orlando, FL Toll Free: (800) 543-9220 P. (608) 222-8583 F. (608) 222-9540 E. info@aacd.com www.aacd.com MAY

May 8 - 10 147th ODA Annual Spring Meeting Metro Toronto Convention Centre (South Building) Toronto, ON P. (416) 922-3900 F. (416) 922-9005 E. info@oda.on.ca www.oda.on.ca May 22 - 25 67th AAPD Annual Session Hynes Convention Center/ Sheraton Boston Hotel HQ Boston, MA P. (312) 337-2169 F. (312) 337-6329 www.aapd.org

May 23 - 27 43rd Annual JDQ Convention Montreal, QC P. (514) 875-8511 E. congres@odq.qc.ca www.odq.qc.ca JUNE

June 18 - 24 American Dental Hygienists Association ADHA’s CLL 91st Annual Session Las Vegas, NV P. (312) 440-8900 E. mail@adha.net www.adha.org.

June 25 - 28 91st General Session & Exhibition of the IADR Cape Town, South Africa P. (703) 548-0066 F. (703) 548-1883 E. research@iadr.org www.dentalresearch.org June 26 - 29 2014 Academy of General Dentistry (AGD) Annual Meeting & Exhibition Detroit, MI P: 1 (888) AGD-DENT or (888) 243-3368 E. meetings@agd.org www.agd.org JULY

July 19 - 20 2014 AAE/ AAP/ ACP Joint Symposium Swissôtel, Chicago T. 800-282-4867 (for U.S. and Canada), or 312-787-5518 (for attendees outside the US and Canada) E. meetings@perio.org W. www.perio.org AUGUST

August 5 - 8 American Academy of Esthetic Dentistry (AAED) 39th Annual Meeting The Bacara Resort & Spa Santa Barbara, CA P. (312) 981-6770 F. (312) 265-2908 E. info@estheticacademy.org www.estheticacademy.org SEPTEMBER

September 8 - 13 AAOMS 95th Annual Meeting

Scientific Sessions and Exhibition in Conjunction with the Japanese Society and Korean Association of Oral and Maxillofacial Surgeons Hawaii Convention Center Hilton Hawaiian Village Honolulu, HI P. (847) 678-6200 T. (800) 822-6637 F. (847) 678-6286 www.aaoms.org September 19 - 22 100th Annual Meeting Exhibition of the AAP (American Academy of Periodontology) San Francisco, CA T. 800-282-4867 (for U.S. and Canada), or 312-787-5518 (for attendees outside the US and Canada) E. meetings@perio.org W. www.perio.org OCTOBER

October 3 - 5 ICOI World Congress XXXI Int’l Congress of Oral Implantologists Tokyo Convention Center Tokyo, Japan P. (973) 783-6300 F. (973) 783-1175 T. (800) 442-0525 www.icoi.org NOVEMBER

November 5 – 8 2014 Annual Meeting American Academy of Implant Dentistry (AAID) Implant Dentistry’s 63rd Annual Education Conference Peabody Orlando, FL P. (312) 464-1550 T: (877) 335-AAID (2243) E. info@aaid.com www.aaid.org November 29 - December 4 The Greater New York Dental Meeting Scientific Session Jacob Javits Convention Center New York, New York P. (212) 398-6922 F. (212) 398-6934 E. infor@gnydm.com www.gnydm.com DECEMBER

No Meetings set for this month.

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oralhealth guidelines manuscript submission

Oral Health wants to hear from you!

We are actively seeking original article submissions from all of our valued readers. Here’s what we need from you: MANUSCRIPTS Manuscripts should run between 1,000 to 5,000 words; any manu­scripts submitted on disc or flashdrive should be PC compatible (i.e., Micro­ soft Word). Should you have concerns with the compatibility be­tween your word software and that of Oral Health’s, simply save your file as raw text (i.e., Text Only files, ASCII text files, etc.)

AUTHORS Biographical information regarding the author(s) should be included with the manuscript. The author’s name and degrees, as well as any association the author may have with any institution should be in­cluded. The author’s address, including city and province/state should also be included.

These requests for standardized submission of material are necessary for correctness of publication.

The Editorial Board looks forward to your submission. Please mail original manu­scripts to: ORAL HEALTH, 80 Valleybrook Drive, Toronto, ON M3B 2S9

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ILLUSTRATIONS The quality of the line drawings and photographs supplied contribute directly to the quality of reproduction in Oral Health. Therefore, when making a submission, please consider the following:

> All photographs/illustrations should be carefully indexed and marked as to proper viewing (i.e., slides should be marked which side is the appropriate viewing angle, etc.). X-rays should be mounted individually and marked on the front of the frame with the corresponding figure number.

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Price Reduced! Downtown office in well managed high rise. Close to professional offices and retail stores. Private parking facility. Large office with beautiful city views. Lots of natural light. Gross $1.4m/yr.

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NEWMARKET, ON

2000 SQ FT PRIME DENTAL LOCATION available for lease. Existing modern, high tech and computerized dental office located in an expanding area of Newmarket. Digital x-ray & pan equipment, 3 ops fully furnished with space for 3 add’l ops.

Please reply to off.oppor@gmail.com

ASSOCIATE BUY IN – CENTRAL BC

Opportunity for EXPERIENCED associate to purchase a busy, established dental office by working it off over time. 5 ops., hygiene, good income.

Professional evaluation done. Price negotiable.

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Practices & Offices RICHMOND HILL & NEWMARKET, ON

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Bayview & Elgin Mills in Richmond Hill. 1st & 2nd floor available. Anchor tenants are Shoppers Drug Mart & Tim Hortons.

Contact Michael Pearlman 416-567-5101 Email: pearlmanmichael@gmail.com.

Bayview & Stonehaven in Newmarket.

3000 sq ft next to Shoppers Drug Mart.

Contact Steve Babor 905-737-6222 Email: steve@sitelinesrealty.com

MASSEY, ON

Practice for sale, 4 hours from Toronto.

Relaxed ground level layout, busy family practice, experienced unique keen staff to ease transition.

Contact 705-869-4564 at home or e-mail: liongord@gmail.com

NEWMARKET, ON

PRIME DENTAL OFFICE for lease. Modern, 6 op Newmarket location with 2000 sq ft. Great potential to grow an existing or build a new practice.

Please reply to dental.locations@gmail.com

Associateships KITCHENER, ON FULL TIME ASSOCIATE

PETERBOROUGH ASSOCIATE

Looking for a full time dentist for a busy practice in Kitchener.

Please forward resume to dr.deman@rogers.com

AIRDRIE AND EDMONTON, AB

Excellent Airdrie and Edmonton location in Alberta; FT Associate positions available with buy in option. Owners are team of excellent experienced clinicians who are fun to work and you can expect ample vacation and balance between family and work with above average income.

Please apply in confidence to doffice05@gmail.com

THOMPSON, MB Westwood dental clinic in Thompson, MB team looking for enthusiastic dentist full time or part time. Decent income plus accommodation.

E-mail: westwooddental@hotmail.com or tel 204-677-4526.

BARRIE, ON

Dentist Needed asap for busy office.

Full time, in Barrie. Fridays and Saturdays a must, plus 2 additional days.

Email resume to barriedentist@gmail.com

4 – 5 days available for General Dental Associate for Two different high-tech offices. Potential Partnership for a right person. Above average remuneration.

Please send your CV to dental.associate.east@gmail.com

BURLINGTON, ON

We are looking for a friendly, out­ going, experienced dentist to join our team. We are a family practice and we’re looking for someone who will treat our patients like family.

Please forward CVs to assoc.wanted@gmail.com

SASKATOON, SK

Full and part time associate opportunities in very busy modern family practice.

Fax CV to 866-764-1860 or call Bob in confidence at 306-260-6919.

KW AREA ASSOCIATE

Busy, generational practices with great new patient flow. We offer a full schedule, great hours and energetic, friendly & knowledgeable staff to work with.

Please reply to: dentistsreply@yahoo.ca

Associateships LLOYDMINSTER, ALBERTA (Population 32,000 – 2hrs drive from Edmonton or Saskatoon).

Direct flights available from Lloydminster to Calgary

Full time position available for a quality-conscious, motivated associate wishing to practice in a modern, well-established family oriented practice with well established clientele.

Monday to Friday daytime hours. Excellent team and patient-oriented, energetic staff. Adherence to recent ADA regulatory standards and dedication to patient care is our first priority. New grads welcome. If interested in joining our welcoming community, please contact: Mimi McMaster at 780-871-4550 or e-mail: mimimcmaster@shaw.ca

VERNON, BC

Cornerstone Dental Group is seeking a full time associate to take over an existing associate position in Vernon BC. The successful applicant will be an enthusiastic, energetic individual, have more than 2 years experience in all areas of general dentistry and have an appetite for continuing education. Our newer, well equipped office is fully computerized (paperless/digital radiographs) and has a Cerec machine, microscope and 2 soft tissue lasers. We have a committed staff and a large, loyal patient base.

For more information call 250-260-0281 or email dr.rex@shaw.ca

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oralhealthLABS •

FALL/WINTER

www.oralhealthgroup.com

WOODSTOCK, ON Just 30 minutes from London or Kitchener, a great opportunity for associate position and/or buy into a prosperous family practice offering all modes of dentistry. Approaching our 7th year in this modern and beautiful facility, we are having difficulty keeping up with the demand for quality dentistry and our tremendous growth rate.

Please send your resumes to woodstockdental@yahoo.com or contact Bianca at 416-244-5544. A seasoned practitioner who is comfortable treating children as well as adults, is preferred — endodontic and orthodontic experience would be an asset, however, all candidates will be considered.

EDMONTON, AB Looking for an associate (part/full time) to join our group of multidisciplinary practices which are focused on the highest quality of patient care and using the latest technology available. We are looking for a self-motivated, high-energy, clinically strong candidate who is interested in learning and continuing education. This is a great opportunity for the right candidate to grow with our expanding group and to work in a great environment. Buy-in opportunities are also available for the long-term associates.

If you are interested, please email your CV in confidence to edmontondentalcareer@gmail.com

Associateships

EDMONTON, AB A full time associate dentist required to take over an existing full patient load from the current associate who is leaving. This truly is a very unique opportunity for a new associate to be immediately busy from day one.

The office is bright, modern and very well equipped and is continually updating the core systems to better position the office for the future. If your primary focus is the needs and well being of the patients, and if you are willing and able to work with others in a larger group practice environment then this clinic is right for you. A positive attitude, a sense of humor and some flexibility in scheduling will lead to a very successful and rewarding position for the right individual.

Email: qdental@shaw.ca Email: bay1chelsea@gmail.com 780-965-3787.

YONGE AND EGLINTON SPECIALIST NEEDED

Excellent opportunity for a “specialist” to join a successful and well established specialty practice at Yonge and Eglinton. Our facility (8500 sq feet) provides ample operatory and private space combined with educational facilities to help keep your practice current.

We provide experienced and knowledgeable support staff and in-house lab support.

All interested candidates who currently own a fully “established” practice and wish to practice without the administrative responsibilities can contact us at mgonzalez@buildyoursmile.com.

SASKATOON, SK Associate required for modern, very busy practice with strong new patient flow.

Great opportunity in a University setting.

E-mail: associatedentist@ymail.com Fax CV: 888-880-4024.

Miscellaneous TORONTO, ON

New and unused Safeguard Business Systems file/charts and other accessories for immediate sale.

Photos and list of items are available upon request.

Will consider a reduced price if purchasing all materials.

Please contact Lilly at 416-789-1372 or email info@aestheticsindentistry.com

NORTH SCARBOROUGH, ON Busy Dental Office in north Scarborough is looking for a FULL TIME Dental Associate. Mon to Sat, Canadian graduate is preferred, Chinese speaking a must.

E-mail: dentistassociates@gmail.com

BRAMPTON, ON

Dental associate required for general practice. Well experienced in endodontics and restorative procedures. Monday and every other Saturday to start possibility for full time. Must have a passion for dentistry. New grads welcome to apply.

Please send cover letter and resume to dentalfcdo@gmail.com

OTTAWA, ON

ASSOCIATE WANTED to work between two busy dental offices in west end Ottawa.

Once a caring, ethical, good-conversationalist associate is hired, one of the two dentists plans to retire, leaving behind almost 5,000 active patients. Both offices feature modern facilities, friendly patient bases and efficient, hard-working staff.

Phone: (613) 224-7885 E-mail: ottawadentist@live.ca

PEMBERTON, BC

Raise your family 20 minutes from Whistler, BC. Full time dental associate position available in the young, vibrant community of Pemberton, BC. Incentive package to the right individual willing to make a long term commitment.

Contact seatoskyortho@gmail.com with contact information, resume, and references.

BARRIE, ON

Associate required in busy Barrie office. Well established practice looking for an associate to work one to two days to start, moving to 3 or 4 days next June. Associate will have the opportunity to buy into the practice.

Interested candidates should apply to barrieassociate@gmail.com

ORILLIA, ON

Part time associate required 1-2 days per week for busy general family practice.

Please forward resume to dental_2010@live.ca

Are you having enough fun at work?

With the core values of Health, Growth & JOY, Sierra is expanding and accepting applications for experienced Neuromuscular Orthodontists, Pediatric Dentists & General Practitioners in Calgary, Alberta.

Why Calgary?

This beautiful city sees more days of sunshine than any other major Canadian city. Home to 1.3 million people, Calgary is diverse and community-minded.

It is also the mecca of business & financial growth with the strongest economy in the entire country.

Why Sierra Dental?

Because you deserve to feel joy at work! Sierra believes in cultivating and sharing positive energy and strives for a joy-filled environment for all staff & patients. If you are clinically strong, high energy, and self-starting, we look forward to meeting you.

With over 12,000 active patients and a tremendously successful internal referral program we are excited to welcome the right doctor. If you are passionate, clinically committed and seeking happiness in your work environment, send resume & cover letter to lavonne.keal@sierracentre.com

FALL/WINTER

• oralhealthLABS

www.oralhealthgroup.com

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