April 2009 â€“ Hawaii
Restoration of a Single Central Incisor Predictable & Precise Tooth Preparation Techniques Single Vital Tooth Whitening
Canadian Journal of Cosmetic Dentistry
Vol. 5 No. 1 • April 2009
Spectrum Cosmetic - Hawaii
Restoration of a Single Central Incisor Basil Mizrahi
Predictable & Precise Tooth Preparation Techniques Dr. Galip Gurel
Single Vital Tooth Whitening Linda Greenwall
departments 5 6 38
President’s Message — Steve Hill
Career & Practice Transitions — Nadean Burkett
From the Editor — Dr. Edward Lowe Recession Proof your Practice — Cathy Jameson
Canadian Journal of Cosmetic Dentistry I 3
Executive Board and Staff Editor in Chief Dr. Ed Lowe
Canadian Journal of Cosmetic Dentistry
Associate Editor Dr. Ron Goodlin
The Official Publication of the Canadian Academy of Cosmetic Dentistry
President Dr. Steven Hill
This Journal is the official journal of the Canadian Academy of Cosmetic Dentistry. The CACD is a non-profit organization affiliated with the American Academy of Cosmetic Dentistry. Bi-annual publication of this journal with the co-operation of the Toronto Academy of Cosmetic Dentistry occurs twice a year: April and September. There will be one annual Scientific meeting of the CACD each year, and moving to different locations within Canada. The Toronto Academy of Cosmetic Dentistry holds 4 meetings per year, 3 general sessions where leading speakers in the field of Cosmetic Dentistry present various topics of current importance. There is an additional Members Only night open to TACD members and corporate sponsors only. Both the CACD and the TACD membership is open to all Canadian Dentists with an interest in Cosmetic Dentistry. For more information, please contact the TACD or CACD via the Executive Director at 604-669-5550 or online at www.tacd-online.com or www.cacd.net. We encourage the development of regional Academies of Cosmetic Dentistry. For more information contact the CACD via Christine (Executive coordinator) at 604-669-5550, by e-mail at info@CACD.net or visit the website at www.cacd.net
Vice-President Dr. Deborah Cooper-Lall
Director Marek Bedynski, RDT
Director Dr. Robert Knudsen
Director Dr. Alain Methot
CACD Board of Directors Director Dr. Jeffery Norden
Director Dr. Stephen Phelan
Director Dr. Janet Roberts
Dr. Steven Hill, British Columbia – President Dr. Deborah CooperLall, Alberta – VicePresident, President Elect Dr. Robert Knudsen – Director Marek Bedynski, Ontario – Directors Dr. Stephen Phelan, Ontario – Director Dr. Alain Methot, Quebec – Director Dr. Jeffery Norden, British Columbia – Director Dr. Janet Roberts, British Columbia – Director Dr. Roderick Toms, Ontario – Director Christine Wyatt, British Columbia – Executive Director Telephone: 6046695550 Website: www.cacd.net
Disclaimer Director Dr. Rodrick Toms
Executive Director Christine Wyatt
Publisher Ettore Palmeri, MBA, AGDM, BEd., BA
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Articles published express the viewpoints of the author(s) and do not necessarily reflect the views and opinions of the Editor and Advisory Board. All rights reserved. The contents of this publication may not be reproduced either in part or in full without written consent of the copyright owner. Publisher: Palmeri Publishing Inc. 35-145 Royal Crest Court Markham, ON L3R 9Z4 Tel: 905-489-1970 Fax: 905-489-1971 Design and Layout: Lindsay Hermsen B.Des.Hon. Printed in Canada Canadian Publications Mail Product Sale Agreement 1033352
Steve Hill, President
few years ago, the new buzzword in health care was, “evidence-based practice”. This notion has now moved beyond buzzword and has become a feature of dental practice. Dentists are now required to possess the necessary skills to adhere to the many facets of “evidence based practice”, including but not limited to: 1. Formulating appropriate research questions 2. Employing efficient met hods to seek clinically relevant evidence 3. Critically appraising high quality peer-reviewed studies 4. Translating these concepts into clinical practice Conscionable dentists are also aware that other, often forgotten facets of “evidence based practice” must integrate the best available research, expert opinion and patient values. As specialized practitioners, we are entr usted with making accurate diagnoses and in selecting appropriate, conservative and safe treatments for our patients.1
Increasingly, our trend in searching out the latest research and new information involves the use of the internet. Educators that I’ve spoken to about this (including the publisher of this journal) predict a continued rise in the use of online services to provide us with much of our continuing educational requirement. While this can’t replace the camaraderie of a conferencestyle setting, it can be a great resource to help us keep up to date without incurring travel costs. During my last haircut, the stylist, whom I’ve known for a few years, commented that during this current economic crisis, being in school was the best investment of our time. If our practices indeed slow a little, an efficient use of our time might be to learn something new. In that spirit, enjoy this latest journal of ours. The C ACD has been researching t he cur rent online continuing education and will soon make available to our members the best source(s) of online dental CE we can find. We remain committed to your continued education in cosmetic dentistry.
References 1. Guyatt G, Rennie D. User’s guides to the medical literature: essentials of evidence-based clinical practice. Chicago: AMA Press; 2005
MASOUD NIKNEJAD, RDT 588 EDWARD AVE. UNIT #56, RICHMOND HILL, ON L4C 9Y6 TEL 905-883-9447
Canadian Journal of Cosmetic Dentistry I 5
Dr. Edward Lowe, Editor
Dental Offices are the Front Line Defense Against Oral Cancer
members of the public think of major health concerns that actually imperil their lives or overall health, they seldom give their dental provider more than a passing thought. Every medical doctor, clinic, or hospital emergency room ranks higher in their perceived importance. Oral cancer has changed all the rules, but in our professional community we have much work to do in patient education. Every hour of every day someone dies of Oral Cancer in the USA alone. Canadian figures add to this toll. Over 30,000 patients are diagnosed annually with oral cancer, and the survival rate is only 50% over 5 years. Primary causes are tobacco usage, heavy alcohol use, past history of cancer, and a compromised immune system. Recently, 25% of new cases do not fall within these high risk groups and they are occurring in patients younger than 40. Oral cancer survival ratios have not improved in the past 50 years, primarily due to the existing screening procedure. All that has changed, and dentists are in a great position to positively impact their patients and the general public at large. Velscope, a product developed jointly between LED Medical Diagnostics Inc. of Vancouver and the B.C. Cancer Agency, has made this step possible. Their technology is based on the direct visualization of human tissue fluorescence and the changes that occur when abnormal tissue is present. This machine is affordable for any practice, and allows you to screen a patient within minutes during your nor mal new patient exam or hygiene recare appointment. In my practice we have included this in all recall exams with no resistance to price (usually $35$45). Our patients appreciate the ‘clean bill of health’ and our team emphasizes that each patient has passed with an ‘A+’ grade! By the time most oral cancers are diagnosed they have progressed to symptomatic late-stage disease with at least 50% revealing regional cer vical metastases. This technology assists in early detection. If we detect any suspicious area, we have another terrific new weapon at our disposal. Oral Advance is a DNA analysis tool developed by Perceptronix Medical Inc. of Vancouver, and allows us to utilize a painless bristle brush technique to take a sample for analysis at their lab. We get our results in 6 I Canadian Journal of Cosmetic Dentistry
2-3 days without the necessity for a biopsy which is something most patients regard with apprehension. At this point we have undeniable proof that they are in no danger or they need immediate further examination. An interesting statistic is that 75% of oral cancers are discovered in the dental chair, and although this cancer kills 3 times the number of patients who die from cervical cancer, it is not receiving the attention it demands. You can change this within your practice. We ran an Oral Cancer Awareness Day recently in our building and had an overwhelming response from our corporate neighbours, including medical offices. One podiatrist was so impressed by this free event that my team, Velscope, Oral Advance, and Crest sponsored that he asked if it would be ‘OK’ if he recommended us to his patient base! In fact, it was astounding to see the number of participants who had lived in our city for some time and had not yet found a general dentist. Our intention was to give back to our community, and the reality was we ended up with a dozen great new patients who had no idea we were operating this type of practice right here in their own building. We made friends, reassured some folks who had previously been heavy smokers, and in fact booked regular dental treatment for some patients who had simply been procrastinating. Our team initially had some trepidation about how to run this ‘event’ in our practice, but it became quickly apparent that this was the easiest promotion we had ever experienced. It reminded me of the pediatric ward at the hospital – it is one of the only ‘happy’ places in that building. We followed up with a ‘report card’ we sent to all participants and in fact received thank you cards from some of our corporate neighbours. This was a terrific example of turning a serious issue into a great consumer awareness event, and I recommend it to any of our readers. Our corporate sponsors made this event possible, and it was very gratifying for my team. They were able to focus on this technology and patient education in such a manner that it is now a regular part of our patient care. The bottom line result is that in a reasonably sized practice you can add close to six figures by adding this screening to your armamentarium. There are precious few areas to positively affect your bottom line while performing an invaluable patient service. We can save lives!
single central incisor with an all-ceramic crown: Restoration of a
a case report
Basil Mizrahi illustrates and discusses the use of a resin bonded, glass based all-ceramic crown to restore a single central incisor
Abstract Optimum aesthetics can be obtained using an etchable, glass based ceramic crown (Empress) in combination with a resin cement. The specific stages in treatment are described, as are the stages for actual bonding of the crown. The importance of a good temporary crown is also emphasised and discussed.
he restoration of a single central incisor is a demanding procedure. The patient’s aesthetic expectations are normally very high and the final result is heavily dependant on the dental technician. It is usually necessary for the technician to spend time with the patient at various stages while fabricating the crown and it is not uncommon for the crown to be remade if the aesthetic objectives are not achieved at first. These factors may increase the treatment time and patient needs to be made aware of this from the outset. The dentist needs to understand the technical difficulty and skill required to match a single crown to natural adjacent teeth and the high costs involved. Besides creating the optimal hard and soft tissue environment for the crown, the dentist needs to facilitate the opportunity for the technician to meet with the patient on one or more occasions if necessary. The initial meeting between the patient and dental technician should be at one of the patient’s dental appointments. This allows for any meaningful discussion to take place between all three parties. Another important factor for success in these cases is the temporary crown. A well made temporary crown will immediately satisfy the aesthetic, functional and biologic requirements of the patient and dentist. Once this has
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been accomplished, time becomes a friend rather than an enemy and can be utilised by both dentist and technician to ensure success in all aspects of the final restoration good things take time. In order to utilise the temporary crown to its full potential, the dentist needs to ensure that it is an improvement on the existing situation. Failure to do this will be detrimental to treatment and will increase the patient’s anxiety, reduce their confidence in the dentist and limit the time available for treatment. The dentist therefore needs to be able to create a temporary crown with good form, function and colour and be skilled in the use of materials that allow for this. Methylmethacrylate acrylic resin is the author’s material of choice for the fabrication of all temporary restorations. The advantages of acrylic resin over the more popular bisacryl automix products include (Mizrahi 2007): • Increased versatility in modification of shape and colour. Acrylic resins consist of a powder and a liquid t hat can be combined in var ious different consistencies and applied in various ways. • More amenable to remargination which allows for the creation of well fitting margins that in turn create healthy gingival tissue. • Better polishability and resistance to long-term discolouration. Surface glazes should not be used as they create a rough surface and tend to stain after a short period of time. • Because of their lower modulus of elasticity they can be easier removed from the underlying tooth without damage.
Fig 1: Pre-op view of discoloured composite restoration on tooth # 21
Early on in treatment, a decision needs to be made as to what type of crown to fabricate and the temporary crown will aid in this decision making process. Factors such as effect of the underlying tooth colour and the space available for restorative material can be assessed via the temporary crown. When attempting to match natural adjacent teeth, all ceramic crowns offer better potential for colour match than traditional porcelain fused to metal crowns (Douglas and Przybylska 1999). Much work has been carried out by Burke et al who have shown good longterm success with ‘dentine bonded crowns’ (Burke et al 1995, 1998, 2007, Burke and Qualtrough 2006, Burke 1999, 2000). There are two families of all-ceramic crowns to choose from: • Low strength, etchable, glass based ceramics. • High strength, non-etchable alumina or zirconia based ceramics. The following case outlines the technique involved in restoring a single central incisor with a resin bonded, etchable, glass based ceramic crown (Empress, Ivoclar Vivadent, Liechtenstein) in order to achieve a predictable aesthetic and functional result with a good long-term prognosis.
Fig 2: Palatal view of a large defective composite restoration in tooth # 21
Fig 3: Silicone putty matrix formed on study model and used in intra-oral fabrication of the temporary crown
Fig 4: Tooth preparation with equi-gingival margins in enamel. Note smooth preparation with no sharp angles
The patient was a 33 year-old female in good health. Her main complaint concerned tooth #21 (Figures 1 and 2). Fifteen years previously, the tooth received a traumatic blow and was root treated and restored with a composite restoration. Over the years, the composite restoration was replaced and the patient now requested a restoration with improved longevity and aesthetics. On the study cast, the shape of the tooth was minimally modified with wax. A matrix was then made using silicone laboratory putty in an impression tray to be used for fabrication of the chairside temporary crown (Figure 3). The existing composite restoration was removed and due to the favourable colour of the underlying tooth substrate and the possibility of keeping the margins equi-gingival in enamel, it was decided to utilise a resin bonded, etchable, glass based ceramic crown (Empress Emax). Tooth preparation edges for all ceramic crowns should be rounded with no sharp angles to create internal stresses in the crown (Figure 4). In addition, margins should be extremely smooth and uniform to allow the technician to fabricate precise, well fitting and strong ceramic margins. Any unevenness on the ceramic margins will lead to increase fragility of the margin with an increased susceptibility to cracking. After tooth preparation, especially when existing restorations are removed, the gingivae are often inflamed or traumatised and bleeding is usually present. As such, making the impression should be delayed until a subsequent appointment (about two weeks later) once tissue health has been re-established in the presence of a temporary crown with precisely fitting and highly polished margins. Following tooth preparation, a methylmethacrylate acrylic resin (Palavit 55VS. Heraeus Kulzer, GMBH), Canadian Journal of Cosmetic Dentistry I 9
Fig 5: Silicone putty matrix with methylmethacrylate acrylic resin being applied over the tooth
Fig 9: Tooth with single retraction cord in place ready for impression. The cord is removed just prior to the impression
Fig 6: Initial form and colour of acrylic resin temporary crown as matrix is removed
Fig 7: Internal surface of temporary crown
temporary crown was fabricated, utilising the silicone matrix formed on the modified study model (Figures 5-8). The temporary crown was cemented with a non-eugenol containing temporary resin cement (TempBond Clear. Kerr, Orange County, USA) and the patient returned two weeks later for the definitive impression. Shade selection should be done at the beginning of the impression appointment before the teeth have had time to dehydrate and change colour (become brighter). For single tooth colour matching, the dental technician should be present at the appointment to select the correct shades. Prior to making the impression, the level of the healthy gingival margin should be re-evaluated and if necessary, it should be re-prepared to the desired level. The impression was made using a polyether impression material (Impregum, 3M ESPE, St. Paul, MN, USA) in a custom impression tray. Despite the fact that the margins were equi-gingival, a single retraction cord was placed in order to allow impressing of additional tooth structure beyond the margins to aid the technician in creating the correct emergence profile (Figure 9). Adequate time should be allowed for the technician to fabricate the crown and neither patient nor dentist should place pressure on the technician to complete the crown. A good temporary crown will remove any time constraints from the technician.
Fig 8: Finished temporary crown. Note accurately trimmed and well fitting margins. A highly polished surface has been created without the use of a surface glaze
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An aesthetic try-in of the crown should be made before final staining and glazing is carried out. This allows verification of the crown morphology and colour both of which can still be modified at t his stage. The technician should be present at this try-in appointment and depending on the results, the next step will range from simple finishing of the crown to a total remake of the crown. If the crown does need to be remade, a good temporary will alleviate any time constraints as neither patient nor dentist will have any problem with leaving the temporary crown in place until a satisfactory result can be achieved.
Fig 10: Internal surface of Empress crown being etched with 9% hydrofluoric acid
Fig 11: Internal surface of crown after etch. Note white precipitate which needs to be removed
Fig 12: Removal of precipitate with 36% phosphoric acid. This should be agitated with a microbrush
Once the technician has completed the final crown, it should be returned to the dentist in an unetched state. This allows for optimal preparation of the internal ceramic surface by the dentist after the crown has been tried in and approved for final cementation. The crown should be tried in with a clear medium such as glycerine. Aspects such as contact points and occlusion are assessed and adjusted. Only once the aesthetics, fit and function of the crown have been approved by the patient, dentist and technician can the cementation process begin. The cementation protocol for a resin bonded, glass based ceramic crown is similar to that of a porcelain veneer. Following the try-in, the internal surface of the crown should be thoroughly rinsed with water and cleaned with alcohol and then treated as described by Magne and Cascione (2006) as follows: • 90 second etch with HFl (9%) (porcelain etch) (Figure 10) • Rinse thoroughly with water and check for white precipitate (Figure 11) • Scrub internal surface with 36% phosphoric acid (tooth etch) (Figure 12) and then rinse thoroughly. • Ensure that white precipitate has been removed and a frosty porcelain surface exists (Figure 13) • Apply fresh silane, leave for 60 secs and then dry thoroughly with hot air (hairdryer). • Apply bonding agent and protect from light.
Preparation of the tooth for resin bonding • Apply rubber dam. A butterfly shaped rubber dam clamp (Ash 212) is used and can be stabilised on the adjacent teeth with warmed impression compound (Kerr) (Figure 14) • Etch tooth with 36% phosphoric acid (Figures 15 and 16) • Apply bonding agent – do not cure A dual cured resin luting cement was used for bonding the crown in place (Variolink II. Ivoclar Vivadent, Liechtenstein). Cementation of the final crown under rubber dam ensures a dry field for resin bonding and facilitates direct vision and access for cleaning of excess cement. All cement should be removed before polymerisation and any residual cement remaining after polymerisation should be removed with a sickle scaler or a #12 scalpel blade (Figure 17). No rotary instruments should be used on the margins of the restoration after cementation. Once all the excess cement has been carefully removed, the rubber dam clamp is removed. Initially the gingivae around the area will appear however, this is a temporary phenomenon and when used carefully, rubber dam clamps will not cause any permanent gingival recession. Gingival health should return to the area within 7 – 10 days (Figure 18).
Fig 13: Well etched, clean, internal surface after removal of white precipitate. Compare to Figure 11
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A common reason for replacement of anterior crowns is gingival recession and exposure of the crown margins. In certain situations, utilising adhesive technology, it is possible to create invisible margins that are not dependent on concealment by the gingival margins. Criteria necessary for achieving these imperceptible margins are:
Fig 14: Rubber dam applied to tooth using 212 clamp stabilised with impression compound. Note exposure of all margins and engagement of clamp jaws on tooth and not gingivae
Fig 15: Etching of the entire tooth surface for 30 seconds with 36% phosphoric acid
Fig17: Cleaning of excess cement after polymerisation with sickle scaler. Note the access and good vision made possible by the rubber dam retraction
• Use of a translucent and etchable glass based ceramic crown to allow blending with the underlying and adjacent tooth margins. • Enamel margins for optimal resin bonding • Access for rubber dam application to ensure optimal resin bonding • Good underlying tooth colour • Minimal tooth destruction at the marginal level so that margins do not need more than 1mm reduction. The presence of all these factors offers the most favourable chance of obtaining a good match between a single anterior crown and the adjacent natural teeth. However, despite these favourable factors, the dentist needs to ensure that sufficient time is allowed for the technician to produce the single crown. Often this may require multiple try-ins and even remaking of the crown. A well fitting and aesthetic temporary crown allows this time to be created and allows the dentist and technician to continue on with treatment until success is achieved.
Acknowledgement Dennis Mostert of Ceramiart, London, UK for the excellent technical work.
About the Author Dr Basil Mizrahi graduated as a dentist from the University of the Witwatersrand, South Africa in 1989. In 1993, he obtained an MSc in Dentistry at the University of the Witwatersrand majoring in Periodontics. After five years in general practice, he moved to the USA to specialise in Prosthodontics at Louisiana State University (LSU), School of Dentistry. In June 1998, Basil graduated from a three-year full time Prosthodontic program at LSU under the leadership of Dr Gerard Chiche a world leader on anterior aesthetics. Basil is registered as a Specialist in Restorative Dentistry and runs a full time, referral practice in London’s West End. He runs hands-on courses in ‘Advanced Restorative and Aesthetic Dentistry’ and is a Clinical Lecturer at UCL, Eastman Dental Institute. Fig 16: Etched tooth surface
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Figure 18: Final restoration 10 days after cementation. Note healthy gingival margin despite use of rubber dam clamp
References Burke FJ, Fleming GJ, Abbas G, Richter B. Four year performance of dentinebonded all-ceramic crowns. Br Dent J. 2007 Mar 10;202(5):269-73.
Douglas RD, Przybylska M. Predicting porcelain thickness required for dental shade matches. J Prosthet Dent. 1999 Aug;82(2):143-9
Burke FJ, Qualtrough AJ. Effectiveness of a self-adhesive resin luting system on fracture resistance of teeth restored with dentin-bonded crowns. Eur J Prosthodont Restor Dent. 2006 Dec;14(4):185-8.
Magne P, Cascione D. Influence of post-etching cleaning and connecting porcelain on the microtensile bond strength of composite resin to feldspathic porcelain. J Prosthet Dent. 2006 Nov;96(5):354-61
Burke FJ. Follow-up evaluation of a series of dentin-bonded ceramic restorations. J Esthet Dent. 2000;12(1):16-22.
Materdomini D, Friedman MJ. The contact lens effect: enhancing porcelain veneer esthetics. J Esthet Dent. 1995;7(3):99-103
Burke FJ. Maximising the fracture resistance of dentine-bonded all-ceramic crowns. J Dent. 1999 Mar;27(3):169-73.
Mizrahi B. Temporary Restorations: The Key to Success. Alpha Omegan, 2007, 100, 2, p81
Burke FJ, Qualtrough AJ, Hale RW. Treatment of loss of tooth substance using dentine-bonded crowns: report of a case. Dent Update. 1998 JulAug;25(6):235-40.
Vichi A, Ferrari M, Davidson CL. Influence of ceramic and cement thickness on the masking of various types of opaque posts. J Prosthet Dent. 2000 Apr;83(4):412-7
Burke FJ, Qualtrough AJ, Hale RW. The dentine-bonded ceramic crown: an ideal restoration? Br Dent J. 1995 Jul 22;179(2):58-63.
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Dr. Galip Gurel
Predictable & Precise Tooth Preparation Techniques
for PLVs in complex cases
hen it comes to restoring the mouth with porcelain in order to improve the aesthetics, the PLVs are one of the most conservative and aesthetic techniques that we can apply. The longevity of the veneers are quite long and durable especially if the right indications are chosen and the correct techniques are applied (Horn 1983). The main idea in any restorative case is to keep it simple and concentrate on one idea which is the conservation of the sound tooth structure. The dentin-enamal junction (DEJ) where they get together is very important in the structural strength of the tooth. The explanation lies in the most fascinating feature inherent to the natural tooth-a complex fusion at the DEJ, which can be regarded as a fibre-reinforced bond (Lin et al 1993). When we limit our preparations on enamel, the tooth will not flex and it will stay as rigid as a tooth can be (Magne and Douglas 1999). Even if our preparation line passes through the DEJ margin and enters into dentin, it won’t create a major problem for minor invasions. However, if we end up finishing our preparation on large amounts of dentin, we very well may end up with other kind of problems. This will not only create complex bonding issues on dentin, but will also free the ‘flexing’ factor on the tooth structure. Over preparing the rotated or aggresive preparation of protrusively placed teeth will cause us to end up in the dentin structure which will lower our bonding values as well as causing the flexing of the tooth structure. When we end up in the dentin structure, it’s not only lowering our bonding values (Noack and Roulet 1987, Van Meerbeek et al. 1996, 1998) but it also causes the flexing of the tooth structure. And when the tooth starts flexing, a different phenomena occurs as this situation. First of all, we have the tooth which is agressively prepared that wants to bend, to flex, and on top of it we’re bonding a veneer, a porcelain material, which is very rigid and in between those two structures we’ll be using the adhesive luting resin which will stay in between and will try to absorb all the stresses. If the tooth receives some
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Fig 1a: Teeth exhibiting large composite fillings.
Fig 1b: Teeth are bleached. Note the colour difference between the bleached parts of the incisors and the existing composite fillings.
Fig 1c: Note the existing large composites and cavity on the palatal side.
www.burlingtondentalstudio.com Burlington Dental Studio Inc., ● 905.632.0102 ● 1.800.342.1508 Yorkville Dental Studio ● 416.607.5984
Fig 2a Fig 3a: Retraction cord is placed in the sulcus to prevent any possible soft tissue damage during tooth preparation and for beter magrin displacement during impression making. First the depth cutters are used for exacting the depth of the preparation.
Fig 2b Figs 2a & 2b: Finished and bonded veneers with facial and lingual view after two years. Fig 2c: Full smile and its integration with the face
different occlusal forces and keeps on flexing, the luting resin at the margin will start peeling off slowly. So at these situations we will most probably end up with some microleakage or de-lamination. In order to minimise those effects and problems, we have to be very precise and careful about case selection and tooth preparation (Besler et al 1997). The ideal cases which we would want to place the veneers are when the teeth are aligned perfectly on the dental arch and maintaining their original facial volumes which means that the facial structures of the teeth isnâ€™t worn as it happens by ageing. That means, we exactly need to remove the tooth structure equivalent to the thickness of the veneer that we will be placing on the tooth itself. For that reason we can simply use our standard tooth preparation techniques (Figures 1a-c).
Standard preparatÄąon technique In those situations, since we will not be changing mostly the shape, the volume or the contours of the tooth, then it is a standard preparation which makes it easier for us to 20 I Canadian Journal of Cosmetic Dentistry
Fig 3b: Standard tooth preparation.
execute (Strub et al 1999). Shortly, what we needed to do is to remove the exact depth that we would need our porcelain to be built up and when these steps are followed, finishing the final restorations will never be a problem (Figures 2a-c). First we start with the depth cutter (Garber et al 1988, Garber 1993, Nixon 1990) which indicates the exact depth that we want to prepare and that basically depends on the material selection or the colour of the tooth that we want to restore (Figure 3). Once this is established, we paint the surface of the tooth onto a different colour and then use our round-ended fissure bur to finalise the facial reduction. The important factor here is that we have to use our bur in three different angulations in order to be respectful to the facial convexity of the tooth structure. Only in that way, can we achieve the same thickness from all around the porcelain material or, porcelain build-up. Once this major reduction is carried out, then we finish our preparation on the gingival margins and then extend it towards the papilla to finish our interproximal elbow preparation. This is actually very important, especially when we are dealing with discolourations. If the depth is not prepared correctly, when we look at those teeth from an angle, we will see the joint/connection between the dark coloured tooth and the light coloured porcelain which will not be aesthetically pleasing. In order to prepare this dog leg preparation we hold our burs almost 60 degrees towards the pallet. Once we decide that we have achieved the exact depth that we needed to prep, then we upright our burs and finish our interproximal preparation (Morley 1999). Finally we would need the butt joint preparation of the incisal edge to give enough room to the lab technician to build up all his artistic translucence opalescense effects, incisal silhouette, etc. (Figures 4a and b). As in every PLV case the direct or
prefabricated provisionals are placed after impression making (Figure 5).
What if the teeth are not aligned properly? One of the major indications of utilising PLV is space management. We should be dealing with spaced dentitions, crowded teeth or both. It becomes more of a challange if the teeth are spaced or the teeth are not aligned properly on the dental arch, such as crowding. There are two problems which come along when the teeth are not aligned properly on the dental arch: a) visualising the aesthetic outcome, b) tooth preparation.
Fig 4a: Last reduction is from the incisal edges. First the necessary depth is created with a fissure bur of choice by creating some ditches and then these are connected to each other in order to create a butt joint.
Aesthetic communication Creating natural-looking smiles When considering an approach for a new smile design, the dentist undertakes the creation of a new but natural aesthetic effect. With each restoration, the patient must be considered as a whole instead of focusing merely on one or two teeth. Each tooth exists as part of the mouth and face, assisting in creating a smile that reflects the patient’s personality. To create a restoration, harmony in the size, shape and arrangement of the teeth are required in order to enhance each patient’s facial features. When the teeth, the surrounding soft tissue and the patient’s facial charasteristics are taken into consideration, a three-dimentional canvas is examined. The dentist must be aware of the ratio between the anterior teeth and the surrounding tissue and analyse them to arrive at the desired result. A combination of only a few teeth may create an impact larger than the sum of the parts and an aesthetic case may vary from a simple aesthetic contouring of a corner of a single tooth to the complete recreation of a new smile involving the entire dentition. The mouth and its physiological make-up for each individual patient must be studied carefully by the aesthetic dentist; analysing and anticipating any problems that may arise in carrying out the treatment. The first problem is about handling the aesthetic desires of the patient. Owing to these types of situations, we would be creating a new smile design which needs to be communicated perfectly with the patient. This cooperation and communication between the patient and the dentist will determine the success or failure of the treatment. The aesthetic dentist needs to be completely ‘in tune’ with the attitude of the patient, the verbal requests, and the lessobvious non-verbal cues. The dentist who is able to generate a confident, competent and observant attitude makes the patient feel relaxed, and inspires confidence in him or herself and in the proposed treatment. The dentist’s perception of a desirable smile and the style of design should be discussed with the patient and be considered along with the patient’s personal thoughts on their appearance. The patient may wish to reinstate the appearance that has been established over a long period of time or may request an alteration that is totally unrealistic for their face. Perhaps one of the most difficult task is to select the right treatment in order to achieve success in 22 I Canadian Journal of Cosmetic Dentistry
Fig 4b: After the actual preparation is finished on the existing composites, they are removed and the margins are rounded to finish the final preparation.
Fig 5: Previously built shell provisionals tried in the mouth and then filled with composite and temporarily bonded on the prepared teeth.
Fig 6: The unaesthetic appeareance of the smile with relatively dark in colour, short crowns, uneven gingival levels, crowded incisors, uneven incisal silhouette and a decidious canine on the second quadrant.
Fig 7: Analysing the smile at an angle clearly shows the crowding of the centrals.
aesthetic dentistry. The ability to say ‘no’ will save the dentist sleepless nights and it should also be remembered that one setback can easily erase many brilliant and successful procedures. If the aesthetic dentist and patient find it difficult to agree on the objectives, it is in the best interests of both parties not to begin the treatment. Analysing the smile In order to have a solid understanding about the visualisation of the final outcome, the existing smile should be analized carefully from a three-dimensional aspect. Facial view When the smile is analysed from a facial view we can only deal with the mesia-distal or vertical problems that we can see. In this particular case we can easily see that the centrals are overlapping. This causes a vertical canting of the midline which actually can be easily seen by the lay people. The existing teeth are basically short for the face proportionaly and the gingival levels are uneven (Figure 6).
buccally or bring the tooth # 11 lingually? Aesthetic Occlusal Plane (AOP) The third dimension to be checked in our aesthetic evaluation is the AOP. This can simply be done from a sagital view and in this particular case the area where there is still a decidious canine (tooth # 63) which creates a problem related to AOP since it is too short (Figure 8). At this point the angulation of the centrals is prefered to be perpendicular to the AOP. Functional evaluation The restorations we should be delivering should be long lasting and for that we have to be careful about the foundations. When we check the root of the deciduous tooth # 63 on the x-ray, it is obvious that it won’t be able to withstand the lateral forces during occlusion especially and it won’t be able to survive if a canine guided occlusion is to be planned.
Treatment planning 45 degree angle view (checking buccal-lingual dimension) This angle gives us t he oppor tunity to check t he crowding in a more solid way. In this case we can see that the mesial incisal tip of # 11 is more buccally placed relative to tooth # 21 (Figure 7). However at this very beginning stage, we may not know which incisal edge position we can use as a reference point in a buccallingual dimension. Should we build up the tooth # 21
And at this stage, how can somebody be sure about the final outcome just by looking at this case intra or extraorally? It’s almost impossible. Now, with all these problems or imperfections in our mouth, the first step is to try to visualise and realise the aesthetic final outcome and share this knowledge or information with the patient. The answer to that starts with the composite mock-up (Dietschi 1995, Vanini 1996, Baratieri 1998).
Canadian Journal of Cosmetic Dentistry I 23
Fig 8: AOP (Aesthetic Occlusal Plane) from this view it can easily be evaluated; the decidious canines displaying a distinct concavity
Fig 9: First of all the incisal edges are aligned with a composite mock-up and the incisal edge position is defined. Then a reverse mock-up is applied over the soft tissues in order to determine where the soft tissues should be after the perio operation. Meanwhile the length to width ratio of the teeth are carefully watched out.
Fig 10: After perio surgery, a new mock-up is produced in order to get the new proportions and relations amongst the teeth in a beter way.
Fig 11: Teeth are bleached after the crown lengthening. Note the altered gingival margins
Mock-up Simply, a free hand carved composite can be used for us to visualise the final outcome of those veneers and one can try to see how the smile will look like when we place these composites (Figure 9). At that time this should not be as precise as a wax-up but rather it would give us the idea on how/where the length of these teeth should be; about where to place the facial bulkiness and it’s effects on the lip structure, on phonetics and to a stand, on occlusion (Peumans et al 1998, Chiche et al 1994, Romano et al 2005). This mock-up will be a great tool or guide for the lab technician to build up his wax-up. And at the end, we will be sharing this information with the patient so that first step of functional and aesthetic outcome is proved by the dentist and the patient (Dawson et al 1989).
Second mock-up However, in the cases where we need to alter the gingival levels which will change the length of the crown apicaly, it is always more reliable to make a second mock-up. This will show the new proportions and the smile design a lot better than a reverse mock-up. So, after the periosurgery is finished and six to eight weeks pass, a new mock-up is produced (Figure 10). This second mock-up after the periosurgery will help the dentist and the ceramist for precising the teeth proportions relative to where the new gingival margins are. The new impression made out of this mock-up is sent to the ceramist for the wax-up. This new mock-up will provide more solid information to the ceramist for his final wax-up. Another decision that we can make at this point is to prepare the deciduous canine # 63 and tooth # 24 for crowns and connect them to each other 24 I Canadian Journal of Cosmetic Dentistry
Fig 12: The final wax-up
for better support and eventually end up with a small group function (instead of canine only) through the canine and first premolar which will also effect the design of the final wax-up. If necessary during this period, the teeth can be bleached as well (Figure 11). We can now actually realise that the incisal mesial corner of the tooth # 11 has to be positioned and restored lingually. The best choice of treatment would be pulling it back with ortho first and then continue with our minimal invasive techniques. However, time limitation for this specific case won’t allow for such a treatment planning. But in any case, this situation has to be communicated to the lab so that he would know he has to trim that corner slightly inwards during his wax-up. What we do at that stage is that, we have to make two impressions out of the patient’s dental arches. One is the original existing tooth structure with all these diastemas and unproperly aligned teeth and the second one is the impression with the mockup. Now, the lab technician should relate those two together, using a silicone index and finalise his wax-up
Fig 13: A silicone index (SI) according to this wax-up is built to be used during the preparation stage. This SI is tried on the teeth. Note that SI can not be seated on the arch passively, due to the protruded position of the mesio-incisal corner of tooth # 11 (# 8)
Fig 14: In such situations APR (Aesthetic Pre Recontouring) is done. The protruding surfaces of teeth that are positioned labially â€“ relative to the final contours of the finished PLVs â€“ are trimmed down until the silicone index can be passively seated ont he dental arch. Note the trimmed mesio-incisal edge of tooth # 8 (# 11) and how passively the index is seated on the arch after the APR. In order to test the final outcome of the proposed smile design the APT (Aesthetic Pre-evaluative Temporaries) has to be tested.
with all the details as if he is building up the porcelain restorations. The technician is now free to do reduction on the facial surface of the protruding teeth (in this case tooth # 11) and then finish his wax-up according to the guidelines of our mock-up (Figure 12).
APR (Aesthetic pre recontouring) During the next appointment when the patient comes to the clinic for the tooth preparation, the dentist should be provided with a silicone index that is made from the waxup model which will indicate the final contours of the teeth. The index is then placed over the dental arch in order to visualise the existing positions of those teeth on the dental arch, relative to the final outcome of the wax-up and veneers (Figure 13). One problem that can be seen at this stage is that, one or few teeth may touch or push the silicone index bucally indicating that these teeth are either rotated or positioned labially than the expected final outcome. At this stage those teeth have to be trimmed down in order to place the silicone index passively on the dental arch. The process is named as APR (Aesthetic Pre Recontouring) (Gurel et al 2003) (Figure 14).
APT (Aesthetic pre-evaluative temporaries) We can now apply the wax-up on the tooth structure as we are making the provisionals. The technique is that we make a transparent silicone impression from the wax-up and in the mouth, we fill this up with the flowable composite, then place it on the unprepared teeth; light cure it and take the translucent impression material out of the mouth (Figures 15a and b). This would not have been possible had we rotated or buccally positioned the teeth and had they not been recontoured with APR, simply because the transparent impression wouldnâ€™t have fit on those teeth. We then trim the gingival margins slightly and what we have now created is the exact final outcome of the porcelain that is expected at the end but now made out of plastic. At this stage, because the patient is not being
Fig 15b Figs 15a & b: An impression made out of the wax-up is filled with a flowable composite (or any material of choice) and placed on the unprepared teeth.
numbed, it is the best way to evaluate the aesthetic outcome (Figure 16).The lip support of these restorations and the aesthetic length can be easily evaluated and should be approved by the patient. Also, we want to evaluate the functional movements of the patient to see whether it would create an anterior constriction or not, and the phonetics that may be a problem in the future. And when this is approved by the patient, then we can step onto our second next stage. These plastic teet h have been named as APT (Aesthetic Pre-evaluative Temporaries) which is nothing Canadian Journal of Cosmetic Dentistry I 25
Fig 16: Completed smile design, before any tooth preparation is done (APT). This should now mimic the exact final contours, texture and shape of the final PLVs.
Fig 17: Since the APT resembles the exact facial contours of the proposed smile design, now the tooth operation can be done through the APT. This will give the dentist and the ceramist the exact volume of reduction, hence being minimally invasive.
Fig 18: Incisal reduction finished through the APT.
Fig 19: The final preparation. Note how the mesio-incisal corner of the tooth # 11 (# 8) had to be reduced more than all the other teeth due to its protrusive position. Hence all the other teeth are minimally preped with almost all the enamel left on their surfaces.
different than making a provisional on the tooth structure before the teeth have been touched (Gurel 2003 a, b, c). These provisionals can then be double checked with silicone index to make sure that they are placed in the mouth correctly.
if for example, the tooth is too palately placed (i.e. More than 0.6mm away from the facial contours of the APT). Once we make our major reduction with the depth cutters followed by the round ended fissure burs, our major facial volume reduction will be finished. Then we can proceed and finish the gingival margins and interproximal lines. In rare occasions like in this case, if we did a substractive correction on the wax-up stage, that means that we should be removing much more tooth structure than a standard preparation depth and tooth # 11 gets a substractive correction. So, the mesial incisal corner is prepared aggressively in order to align it properly while the facial contours of the expected dental arch form we want to create after the veneers are finished. As mentioned previously the best way of handling such a case is to prealign the position of such teeth orthodonticaly before our preparations.The same reduction will be carried out in the incisal edge and most of the time, which is very surprising that, we really do not need to prepare too much incisal healthy tooth structure (Castelnuovo et al 2000) (Figure 19). In PLV preparation we tend to finish the gingival champher supra gingival unless we are dealing with a severe discolouration or with spaced dentition. After finishing the tooth preparation for the veneers, deciduous canine (#63) and first premolar tooth #12 (#24) can be prepared for the all ceramic crowns. They will then be connected to each other for the functional support and a small group function for the lateral excursions (Figure 20). Once the preparation is finished, the same silicone index is
Tooth preparatıon in complicated cases The second problem at this stage is what if we cannot use the standard preparation technique? In other words, when the teeth are not aligned properly on the dental arch which means the teeth may have rotations, or may be placed lingually or buccally, how can we assess the final success of that case and prepare the teeth precisely and predictably every time?
Tooth preparatıon through APT The beauty of these Aesthetic Provisional Temporaries, besides the evaluation of aesthetic functions and phonetic aspects, is that we have a great tool in our hands now to prepare the teeth. We can simply use these APTs as a guideline to prepare tooth structure. Since this APT resembles the exact final contours of the final outcome such as the incisal edge position, and the facial volume (contours) of the the teeth, now we can start preparing the teeth through the APT as if we are dealing with a very simple case in which the teeth are aligned properly, since evertything is already set in advance. At this point we wouldn’t really mind how the teeth underneath are aligned (Gurel 2003). (Figures 17 and 18). In some situations we may not end up preparing the tooth surface, 28 I Canadian Journal of Cosmetic Dentistry
Fig 20: The decisious canine # 63 and the premolar # 24 (# 12) is preped to receive crowns connected to each other in order to support the functional loads especially during the excursions. Note the 360 degrees champher all around the gingival magrin.
Fig 21: The final check for preparation depth of the veneers as well as the crowns with the SI.
used once again to check and verify the correct preparation depths (Figure 21), then the impression is made and the provisionals are fabricated. The provisionals will be exactly the same as the APT. This will be a second chance for the patient to evaluate the final outcome during the fabrication (Figure 22).
Laboratory procedures Basically the veneers can be fabricated with feldspathic porcelain on a refractory die, or on platinum foil. The other ways are either using pressable ceramics with external staining or layering techniques.
Fig 22: Provisional temporarily bonded in the mouth, replicating exactly the final result.
Canadian Journal of Cosmetic Dentistry I 29
Figs 23a & b: Smile from different angles.
In this case the pressable porcelain will be used with the layering technique. Whichever technique is used, the most important issue is that the ceramist uses the same silicone index that we used in the mouth that fits perfectly on the APT, which was the approval of the final outcome. The rest is his/her knowledge, ability and talent of integrating the colours, form, shape and texture.
Try-in When the veneers are received from the lab, they should be first tried out in the mouth. Preferably the provisionals should be taken out and PLVs are tried in without anesthesia. That way it will be a lot easier to check the lip support and the incisal edge position relative to the upper lip. The veneers should be tried out one by one in order to check the margin fit accurately, and then together, to see their overall integration with each other, with the lips and finally, the face.
Bonding The author prefers a sectional rubber dam placed in the mouth. Once the teeth and the inside of the veneers are surface treated they can now be bonded two by two. Preferably, the bonding should start with the centrals, proceeding with the lateral, canine on one side and the other lateral, canine on the other side. The soft tissues should be handled very gently. The easier way to do that is to place the veneer on the tooth and once it is completely seated, spot tack it from the 1/3 middle with a 2mm turbo tip. This will hold the veneer intact in place and then switch the tip of the light source to a larger diameter such as 13mm. Light cure the excess flesh around the gingiva for only one or two seconds. This will not fully polymerise the luting resin but bring it to a jelly consistency. That will be very easily cleaned with an explorer which was dipped into an adhesive liquid. Then, go in between the veneers with a dental floss to cleanse the interproximal contacts. Once 30 I Canadian Journal of Cosmetic Dentistry
everything is finished, now you can fully polymerise the luting resin. In order to finalise the bonding procedure a # 12 blade will help a lot to cleanse the undetected left over composite on the margins. And if needed, the margins can be polished with a rubber cup, but never, ever with a diamond bur which will totally ruin the glaze and the polish of the porcelain on the margins. Final PLV position, form, phonetics, lip support etc. will never be guess work. The same aesthetic, functional and phonetic results that are established during the APT and provisionalisation will be the same after the PLVs are bonded (Figures 23a and b).
Summary PLVs have been one of the most used restorations for aesthetics. Even though it is one of the most conservative of the treatment options, some rules have to be followed. Aesthetics is a subject that is very objective and necessitates excellent communication between the dentist, patient and ceramist. The case has to be carefully selected and treatment planned. The use of the mock-ups, followed by a wax-up, APT and silicone index will not only allow us to get the best aesthetic, phonetic and functional outcome, but to communicate this with the patient and more importantly, end up with minimum invasion on the recipient tooth. Further to all the techniques explained above which will help this communication to get more reliable, solid and helpful to get the best aesthetic results with minimal tooth reduction, the use of PDP (Permanent Diagnostic Provisionals) will have a further impact on this solid communication. That way, the patient will have a chance to evaluate the aesthetics, function and phonetics not only by him/herself but with their immediate circles as well if he/she wishes to do so.
Acknowledgements Special thanks to, Ulrich Werder, MDT for the first case and Shigeo Kataoka, RDT for the second case.
About the Author Dr. Galip Gurel graduated from the University of Istanbul, Dental School in 1981. He continued his education at the University of Kentucky, Department of Prosthodontics. He is the founder and current president of EDAD (Turkish Academy of Aesthetic Dentistry). He is a member of the American Society for Dental Aesthetics (ASDA) and the honorary diplomate of the American Board of Aesthetic Dentistry (ABAD) as well as a member of the American Academy of Cosmetic Dentistry (AACD) and an active member of European Academy of Esthetic Dentistry (EAED). He is the author of â€˜The Science and Art of Porcelain Laminate Veneersâ€™ published by Quintessence in 2003. He has been practicing in his own clinic in Istanbul, specialising in Aesthetic Dentistry, since 1984.
References Baratieri LN et al (eds). Direct Adhesive Restorations on Fractured Anterior Teeth. Sao Paulo: Quintessence, 1998: 135-205 Besler UC, Magne P, Magne M. Ceramic laminate veneers: Continious evolution of indications. J Esthet Dent 1997;9:197-207 Castelnuovo J, Tjan AH, Phillips K, Nicholls JI, Kois JC. Fracture load and mode of failure of ceramic veneers with different preparations. J Prosthet Dent 2000;83:171-180 Chiche GJ, Pinault A. Esthetics of Anterior Fixed Prosthodontics. Carol Stream, IL: Quintessence Publishing, 1994;33-52 Dawson PE. Evaluation, Diagnosis and Treatment of Occlusal Problems, ed 2. St Louis: Mosby, 1989:274-297 Dietschi D. Free-hand composite resin restorations: A key to anterior aesthetics. Pract Periodont Aesthet Dent 1995;7:15-25 Garber DA, Goldstein RE, Feinman RA, Porcelain Laminate Veneers. Chicago: Quintessence, 1988)(Nixon RL. Porcelain Veneers. An esthetic therapeutic alternative. In: Rufenacht CR. Fundamentals of Esthetics. Chicago: Quintessence, 1990:329-68
Gurel G, The Science and Art of Porcelain Laminate Veneers. Quintessence 2003;7:246) Gurel G. Predictable, precise and repeatable preparation for porcelain laminate veneers. Pract Proced Aesthet Dent 2003;15(1):17-24 Gurel G. Predictable tooth preparation for porcelain laminate veneers in complicated cases. Quint Dent Tech 2003;26:99-111 Gurel.G. QDT + PPAD Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am 1983;27:67-684 Lin CP, Douglas WH, Erlandsen SL. Scanning electron microscopy of type I colagen at the dentin-enamel junction of human teeth. J Histochem Cytochem 1993;41:381-388) Magne P. Douglas WH. Porcelain veneers: Dentin bonding optimization and biomimetic recovery of the crown. Int J Prosthodont 1999;12:111-121 Morley J. The role of cosmetic dentistry in restoring a youthful appearance. J Am Dent Assoc 1999;130:1166-1172 Noack MJ, Roulet J-F. Rasterelelektronenmikroskopische Beurteilung der Atzwirkung verschiedener Atzgele auf Schmelz. Dtsch Zahnarztl Z 1987;42:953-959 Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G, Quirynen M. The influence of direct composite additions for the correction of tooth form and/or position on periodontal health: A retrospective study. J Periodontal 1998;69:422-427 Romano R, Bichacho N, Touati B, eds. The Art of the Smile. Carol Stream, IL: Quintessence Publishing Publishing; 2005: 7-24 Strub JR, T, rp JC. Esthetics in dental prosthetics. In: Fischer J, Esthetics and Prosthetics. Chicago: Quintessence, 1999:11 Van Meerbeek B, Perdigao J, Lambrechts P, et al. The clinical performance of adhesives. J Dent 1998;26:1-20 Van Meerbeek B, Peumans M, Gladys S, et al. Three-year clinical effectiveness of four total-etch dentinal adhesive systems in cervical lesions. Quint Int 1996;27:775-784 Vanini L. Light and color in anterior composite restorations. Pract Periodont Aesthet Dent 1996;8:673-682
Garber DA. Porcelain laminate veneers: Ten years later. Part 1. Tooth preparation. J Esthet Dent 1993;5:56-62)
Canadian Journal of Cosmetic Dentistry I 31
Single Vital Tooth Whitening any patients more than ever are requesting tooth whitening. There are several reasons for this. Patients are adopting a healthier lifestyle and thus want to whiten their teeth to give the appearance of being healthier. White teeth are equated with youthfulness and many patients would like to look younger. The continued interest by the media in this subject has led to more information available about tooth whitening and thus patients are requesting these services from dentists. Some patients have started researching tooth whitening on the internet and are starting to gain a basic working knowledge about the subject. Some patients when requesting whitening treatments are concerned that the teeth will become too white as they have seen comedy television programmes about this occurrence. These patients request natural enhancement of their existing shade, only a few shades lighter. Others request to have the whitest teeth and want the â€˜Hollywood Whiteâ€™ look. It is thus important to ascertain from patients what they are trying to achieve with whitening and what is a realistic whitening goal. Some patients who have tetracycline staining have such dark discolouration that any improvement will be a bonus for them. These patients have a threshold of acceptability to be able to accept any minor improvements in the shade. Some patients have just one tooth which has discoloured which could be the result of calcific metamorphosis (West 1997). The colour may vary from being subtly different from the adjacent tooth or there can be a marked contrast in the colour of the adjacent tooth. Some patients may not even be aware of the colour difference and it is important for the dentist to detect these colour differences.
History and diagnosis Some patients when questioned as to the history of the discolouration will report some type of minor trauma that had occurred some years previously. The trauma could have been as simple as knocking the front tooth on the handle of a bicycle 10 years previously. The patient does not normally experience any pain from this discoloured tooth and the normal progression is that the tooth gradually became more yellow than the adjacent tooth over a period of years. Some patients may not be able to give a history of the tooth or may have forgotten any traumatic episode on the tooth. At the second appointment they may report that they vaguely recollect an incident of trauma. 32 I Canadian Journal of Cosmetic Dentistry
Fig 1: Mild trauma hitting the tooth
Fig 2: Toot h yellowing laying down of secondary dentine
Fig 3: Single dark tooth: pathological process. Tertiary dentine being laid down
Intra-oral inspection of the tooth will normally reveal a yellow tooth with the colour either being uniform in colour or slightly darker at the cervical margin. The tooth is not normally tender to percussion or palpation.
These teeth are normally vital but due to the trauma, the pulp chamber may be calcified or reduced in size. As a result there will be a slower response from the electric pulp tester. Normally the dial is turned right up to the end reading before the patient reports that they can feel the electric current vaguely. It is important to take time in testing the response of the patient as the patient will take time to register the reading. The same is true for the cold or ice test when placed on the tooth. It will eventually respond and the patient will report that they can feel the cold cotton wool on the tooth.
Fig 4: Bleaching tray design. A: Full arch tray. Single tooth bleaching can be undertaken in a full arch tray. B: Depending on the location of the single yellow tooth, windows can be cut adjacent to the dark tooth to prevent the adjacent teeth from getting too light, before the single dark tooth has managed to lighten sufficiently
A periapical radiograph will normally demonstrate the presence of pulp chamber and canal calcification or obliteration. The whole tooth is present and there is no evidence of any type of fracture in the tooth either in the crown of the root of the tooth. There is normally no periapical area present. The root of the tooth is intact and t here is no evidence of exter nal or inter nal root resorption.
Fig 5: Start of bleaching treatment
Fig 6: This figure shows the process of whitening as the oxygen moves through the tooth and through the pulp canal which has been narrowed due to t he formation of secondary and tertiary dentine being laid down. After a period of about six weeks, t he tooth starts to lighten
Fig 7: Radiograph of case 1 showing complete obliteration of the pulp chamber and the upper right central incisor due to trauma
Canadian Journal of Cosmetic Dentistry I 33
Fig 8: Case Number 1: This patient had two central incisors that were traumatised due to minor trauma from a swimming pool incident. See the radiograph which shows obliteration of the upper right central incisor and dentine bridge formation on the upper left incisor. The treatment involved using 10 % carbamide peroxide for a period of two weeks on all the upper teeth and then 20% carbamide peroxide on the two central incisors for a period of three weeks. The patient experienced very little sensitivity during the bleaching treatment
Fig 9: Case Number 1: The result after three weeks
The pathological process
It is normally not necessary to do root canal treatment for these teeth. Most of the literature does not support endodontic intervention unless periradicular pathosis is detected or the involved tooth becomes symptomatic (Amir et al 2001). It may be advisable to manage cases demonstrating CM through observation and periodic examination and radiograph as necessary. However, the discolouration in teeth with obliterated pulp chambers is not always caused by pigments from the blood degradation products but from the presence of the secondary and tertiary dentine which has been laid down after the trauma (according to Dahl and Pallensen 2007). It may be that the light being transmitted through such a tooth gives the appearance of it being darker.
The usual process is that the minor trauma caused some type of bleeding within the tooth. This bleeding causes the formation of secondary and tertiary dentine to be laid down within the pulp canal. The secondary dentine is laid down regularly along the dentinal walls as a response to the trauma to protect the sensitive pulp tissue from further damage. This causes the pulp chamber and canal to gradually diminish in size until only a narrow root canal remains. It becomes calcified or sometimes even obliterated. Histologically, the pulps had an increase in the amount of collagen and varying cell sizes (Lundberg and Cvek 1980). There seems to be no justification for root canal treatment of these teeth Cvek (2007). Periapical radioluscencies have only been reported in 13-16% of teeth with traumatically induced pulp canal obliteration during observation periods of up to 20 years according to Jacobsen and Kerekes (1977). According to Cvek (2007) the periapical radioluscency which occurs later is associated with caries, inadequate crown restoration or new trauma. Calcific metamorphosis (CM) can also be known as dystrophic calcification. It is seen commonly in the dental pulp after traumatic tooth injuries and can be recognised clinically as early as three months after injury. Calcific metamorphosis is characterised by deposition of hard tissue within the root canal space and yellow discoloration of the clinical crown. According to Amir et al (2001), opinion differs among practitioners as to whether to treat these cases upon early detection of CM or to observe them until symptoms or radiographic signs of pulpal necrosis are detected. 34 I Canadian Journal of Cosmetic Dentistry
The research and incidence of the occurrence The response to minor trauma that occured many years previously can result in 3.8% -27% of traumatised teeth and can develop Dystrophic calcification (Amir et al 2001). Up to 16% of cases can develop pulp necrosis (according to Amir et al 2001). There were 51% which responded to normal Electric Pulp Testing and 40% were clinically and radiographically sound (Robertson et 1996) with Tertiary dentine formation occurring (Torneck 1990).
The treatment It is important to decide whether only the single dark tooth or the entire arch is to be bleached. It is more difficult to bleach the single dark tooth to get it to match and is easier to try to bleach the entire arch using a special protocol. If it is decided that only the single tooth should be bleached then a specially designed bleaching tray needs
Fig 10: Case Number 2: This patient reported receiving a minor blow to the jaw due to a bicycle incident. She noticed over two months that the lateral incisor started yellowing, although she had initial pain for a week, the pain resolved. She visited her dentist who said no treatment was needed. She had naturally dark canine teeth present. Treatment undertaken: Whitening all teeth for two weeks on the upper teeth 20% on 2 to lighten to match the other teeth. 20% gel was also placed on the 3 3 for the same time period to lighten and blend in with all the other upper teeth. This way even lightening of all the teeth was achieved
Fig 11: The result after whitening for Case 2
to be made. A full arch tray is first made and then a window is cut adjacent to the dark tooth on either side of the tooth to be bleached. If this is not done then the tooth next door will lighten quicker as the bleach moves rapidly to the adjacent tooth. This will result in the adjacent tooth being bleached quicker than the dark tooth and uneven bleaching will result. Although some authors have suggested removing the coronal sclerotic dentine and utilising internal and external bleaching as necessary (Pedorella et al 2000), such extreme methods are not deemed to be necessary.
The protocol for bleaching the single tooth and the full arch Normally a full arch scalloped bleaching tray is made. The upper teeth are bleached for two weeks using 10% carbamide peroxide to evaluate the speed and progress of the bleaching of the whole arch. Thereaf ter 20% carbamide peroxide gel is placed in the tray adjacent to the single tooth for a period of four to six weeks or until the single tooth is matching all the upper teeth and they are all the same shade. Sometimes it may be necessary to continue whitening for a further two weeks after this. The
Canadian Journal of Cosmetic Dentistry I 35
progress of whitening the single tooth can be slow because of the nature of the dentine, which had been packed very densely from the secondary and tertiary dentine depositions. However, there is little or no sensitivity experienced on this vital tooth during the whitening treatment.
Follow-up and monitoring It is important to undertake the appropriate monitoring at intervals which are deemed necessary to follow the progress of the whitening. This may be at two weekly or three weekly intervals or until the patient and dentist are satisfied with the result. Normally the shade of the single bleached tooth will retain well and regression is unusual and slow. It may be necessar y to do a top up or maintenance treatment for the whole arch about three years later.
About the Author Linda is a specialist in Prosthodontics and Restorative Dentistry and runs a multi disciplinary private practice in Hampstead, London. She is editor in chief of Aesthetic Dentistry Today magazine and has written a book called â€˜Bleaching Techniques in Restorative Dentistry an Illustrated Guideâ€™ which was awarded Best New Dental Book of the Year 2001. Linda lectures all over the world on all aspects of combining Bleaching with Aesthetic and Restorative Dentistry. She also has a new book and interactive learning DVD called the Bleaching Business.
References Cvek M (2007) Endodontic Management and the use of Calcium Hydroxide Chapter 22 in Traumatic Injuries to the teeth. 4th Edition Edited by Andreasen JO, Andreasen FM, Anderssen. Blackwell, Munksgaard Oxford London. Denehy GE, Swift EJ Jr (1992) Single tooth whitening. Quintessence Int Sep;23(9):595-8. Dahl JE and Pallesen U (2007) Bleaching of the Discoloured Traumatised Tooth. Cahpter 33 in the Text book and Colour Atlas of Traumatic Injuries to the teeth. 4th Edition Edited by Andreasen JO, Andreasen FM, Anderssen. Blackwell, Munksgaard Oxford London. Greenwall L.H ( 2001) Bleaching Techniques in Restorative Dentistry. Martin Dunitz Taylor and Francis Publishing, London Jacobsen I and Kerekes K. (1977). Long- term prognosis of traumatised permanent anterior teeth showing calcifying process in the pulp cavity. Scan J Dent Res 85: 588-98. Lundberg M and Cvek M (1980) A Light Micrsoscopy Study of pulps from Traumatised permanent incsiors with reduced pulp lumen. Acta Odont Sacn 38:89-94. Pedorella CA, Meyer RD, Woollard GW (2000) Whitening of endodontically untreated calicified anterior teeth. Gen Dent May-Jun;48(3):252-5. Torneck (1990) The clinical significance and management of calcific pulp obliteration. Alpha Omega 83(4):50-4. Amir FA, Gutmann JL, Witherspoon DE (2001) Calcific Metamorphosis: a challenge in endodontic diagnosis and treatment. Quintessence Int Jun;32(6):447-55 West JD (1997) The Aestthetic and endodontic dilemmas of calcific metamorphosis. Pract Periodontics Aesthet Dent .Apr;9(3):289-93; Robertson et al. J Endondontics 1996
36 I Canadian Journal of Cosmetic Dentistry
n his book, Broken Windows, Broken Business, author Michael Levine, says ‘The smallest remedies reap the biggest rewards.’ It’s the little things that make the big difference. Levine notes that perception is everything. If there is a ‘glitch’ in a system or a ‘crack’ in the window, speaking metaphorically, one must stop the crack before it breaks. This concept works two ways: on the one hand, the smallest of customer service courtesies, like listening, make the biggest of differences. On the other hand, not paying attention to the details and not focusing on the customer service protocols that make a patient’s visit with you comfortable can make a negative difference. Levine speaks about the unmistakable power of observation, attention to detail and a focus on customer service so you can fix any potential weaknesses in your organization before it’s too late. In today’s challenging economic times, it is imperative that your patients see a reason to invest their money in the dental care you are recommending. People are being cautious about spending and for obvious reasons. You have to do everything you are already doing a bit better than ever before. No matter how well you are doing things now, taking things up a notch will encourage people to come, to stay, and to invest. Perception is reality. People often make a decision about the quality of the dental care by everything but the dentistry itself. What is your patient experience like? What is your ideal patient visit? Is this happening every time? Not just at the new patient experience, but every time? Can people trust that their experience with you will be extraordinary? That you will listen? That you do notice t hem as individuals? That you do the little things consistently that make the big difference?
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As successful business pays attention to details and exudes a passion for the service being provided. Everyone on your team must exude that passion and must believe that if a patient walks out the door not receiving treatment that everyone loses. The practice loses because you do not get to do the kind of dentistry you believe in doing. The patient loses because they could have been healthier, more attractive – or both – if they had chosen to proceed. Complacency becomes a disastrous emotion anytime but particularly disastrous when difficult economic times are being faced. A leader is not afraid to face challenges and turn challenges into opportunities. A leader does not think everything is perfect and cannot be improved. A leader is willing to step up to the plate and make appropriate refinements and alterations in his/her business to make sure that he/she is doing all that is expected and more-with each and every patient in each and every circumstance.
Do you have any broken windows? What are you doing to stop the cracks before the window breaks? Yes, the world is experiencing economic challenges greater that have been seen in decades. But, the economy always comes back and, history has shown that it will come back stronger than ever. Therefore, do not be complacent. Be proactive. Do not be egotistical and think that you do not need to be everalert and ever-committed to improving your practice. Know your numbers. Review your monitors on a regular basis and notice immediately when the number indicates that a system is not working as well as it should be working. Then, quickly step up to the plate and do something about it.
Hold your practice steadfast now. Improve all 25 of your major management systems now. Evaluate your systems and continue to do all the things that are going well and identify areas where improvement could be accomplished and work on developing a strategic plan for that improvement. If you have time due to an opening in your schedule, use the time to brainstorm and work on the development plan for the practice. Here are five quick ideas you can turn into exercise or group activity to work on improving your practice: 1. Walk in silence from the patient parking area into your practice just as the patient work for an appointment. Then write down the words that come to your mind to describe that experience. Discuss that as a team. You might discuss the following:
Complacency becomes a disastrous emotion anytime but particularly disastrous when difficult economic times are being faced.
• Does this experience emulate your practice vision?
detail allows for the exercise to be meaningful and for insights to bring about real, positive change.
• Would it make you want to come back again? • How would you describe it to a friend or colleague looking for the practice? • What could be enhanced, who’s responsible for making that happen, how they’d make it happen and by when? 2. Have a business team member walk a clinical team member through ‘a day in their life’, including a detailed accounting for every aspect of their position. Have the clinical team member take notes and then share the experience with the rest of the tam. This report might include the following: • What surprised me most was/misconceptions I had were… • The basic responsibilities are… and this is how it works… • The top three or five enhancements I think we can make in the practice now that I understand this person’s role better are… 3. Do the same thing as number 2 with different team members and different roles. The key is to get as detailed as possible. For example, don’t just tell me your schedule. Go into the scheduling system and show them how it is done, explain some of the issues that come up and how that is handled. Hygienists won’t just say tell them teeth are cleaned. They’ll talk about what it’s like, what position they sit in, what issues can make it interesting, what questions they’ll get from patients, how they document what they find, etc. this level of 40 I Canadian Journal of Cosmetic Dentistry
4. Talk about your own marketing and advertising. What could be better? What message is coming across? What can be done to enhance the marketing and/or advertising of your practice? Ask everyone to pay attention to: Different dental related materials and come back with something interesting to share or teach each other. Did you know there’s a course on xyz? Did you know about this new material? Or technique? Etc. Mainstream media and come back with their three most memorable ads and why. Other dental practices: what is their signage like? What are their websites like? How do you measure up? 5. Read and post the articles from this ‘Recession proof your practice’ series. Discuss each together. Make these discussions on each subject. The economy will come back. It always does. Take advantage of this opportunity to fine-tune your practice-to make everything you are doing a little bit better. You will remain healthy throughout this recession and when it is over, you will be even stronger and much more productive. On the other side of every adversity is amazing growth.
About the Author To learn more about Cathy and the Jameson Management, Inc. team, visit www.JamesonManagement.com, email firstname.lastname@example.org, or call 877.369.5558.
Career & Practice Transitions
Going for Broke-r hether buying or selling a dental practice, dental professionals know t hey need to involve an accountant, a lawyer (solicitor) and financial institution (usually a bank). Each one of these professionals has a specific area of exper tise and function. The “optional” service provider appears to be a “broker”. I say optional because there are an increasing number of FSBO (For Sale By Owner) practice transitions, par ticularly in t he “hot” urban markets. The presumption is that brokers’ services provide a minimal value to Sellers and zero value to Buyers. As a licensed realtor who is specialized and strictly involved in professional private practices, I would like to take this opportunity to clear up some common misconceptions and presumptions about brokers, facilitators and others who endeavour to assist professionals in transition. First, let’s be clear, a licensed practice broker is a licensed realtor who should specialize and restrict their practice to privately-owned practices. To perform that function professionally takes time, resources and a specific expertise in the operation and management of this type of business. The role of broker is more than simply being a “middle man” or “promoter”. It is reasonable to expect that your broker is able and willing to guide and suppor t you from t he planning and preparation stages all t he way t hrough till t he completion of the transition process.
Cash flow analysis and working through the logistics of operating the practice as a new owner using business planning and projections for t he client are crucial to determining the Buyer’s opportunity for success. 42 I Canadian Journal of Cosmetic Dentistry
The brokers’ services should include (but no be limited to): • assisting the client to determine all reasonable options in transition into or out of practice ownership; • review and analysis of practice performance that results in a detailed and comprehensive practice valuation report; • understand and explain the terms and terminology involved in the sale/purchase process; • protect one’s confidentiality appropriately; • pre-qualify prospects; • liaison with both parties advisors and facilitators; • collect, catalogue and distribute essential documents; • draft and present proposals on behalf of the client; • negotiate terms and conditions; • draft a comprehensive Letter of Intent or non-binding offer; and • assist in preparing introduction letters to patients and employees. The functions offered and delivered by your broker will depend on their level of expertise and capabilities. There are tips available on our website (www.edudent.com) to help you conduct your research before hiring a broker. Those of you who have followed this column will know that I have a different philosophy about this aspect of the business of dentistry. I believe that each party – buyer and seller – deserves independent and fair representation. Fair representation includes disclosure no matter which party the broker represents. As a licensed professional, we have a higher standard of duty to our clients just as a dental professional does with their patients. Brokers prefer to offer representation to the Seller because in t hat relationship t hey are paid on commission from the proceeds of the sale on “Closing”. This is a reality in the dental profession because practice listings are “exclusive” to the listing broker.
The advantages to this for the broker are simple: 1. In high demand markets the broker can control the sale when representing the Seller which means they control their commission. 2. Their fee is much higher than if they represent the Buyer (more on that later) Dual agency, sometimes descr ibed as “doubleending” means t hat a broker has entered into a representative relationship with both the Buyer and the Seller. That means they can collect a fee from both parties on Closing, but puts the broker in a challenging, if not conflicting, position. There must be immediate and full disclosure of any dual agency relationship to both parties. Representing t he interests of Buyers is just as challenging. It is not a matter of locating a practice, writing an offer and transmission of documents – there is an element of expertise in uncovering information that may not be immediately evident within a practice valuation report or disclosed by the Seller or his broker. Cash flow analysis and working through the logistics of
operating the practice as a new owner, using business planning and projections for the client, are crucial to determining the Buyer’s oppor tunity for success. Researching the demographics of the practice and community, including drawing area and transferability to the Buyer are not commonly provided in most brokers’ analysis on behalf of the Seller but it should also be considered in determining the Buyer’s opportunity to retain the existing patients. For the Buyer, this is an investment for their future. Especially in today’s market of $1M practices, and bidding wars – the empowerment of knowledge is control of one’s future.
About the Author With more than 30 years of practice and business management experience, Nadean Burkett is a career and practice transition coach to the dental and other professionals in private practice. Headquartered in Greater Vancouver, British Columbia, Nadean Burkett & Associates Inc provides consultation, counselling and assistance to dentists throughout North America since 2003. Nadean offers online resources through her web sites www.dentalbusiness.ca and www.edu-dent.com. All published articles are the intellectual property of Nadean Burkett & Associates Inc.
Canadian Journal of Cosmetic Dentistry I 43
Product Showcase Cendres+Métaux - SFI-Bar®
The SFI-Bar® is the innovative bar solution for removable dentures on implants in both upper and lower jaws. The SFI-Bar® enables a new generation treatment for edentulous patients and ensures stress-free hold of the bar/prosthesis on 2, 3, 4, 5 or even 6 implants, thus increasing the patients comfort. All components are prefabricated and machined to high tolerance; therefore problems associated with soldering and welding conventional bars are eliminated completely. Moreover, due to its simplicity, the SFI-Bar® can be easily and efficiently adapted and placed to the individual patients’ mouth situation chair-side. Its functional design ensures great flexibility and is indicated in most cases. Two female parts are available and, with the appropriate abutments, the SFI-Bar® can be used with almost any implant system. For more information and to order online, visit www.sfi-bar.ch.
Multilink® Automix “Easy” Now Available from Ivoclar Vivadent In response to market demands, Ivoclar Vivadent is pleased to introduce Multilink® Automix “Easy”. This new “Easy Clean-Up” version of the clinically proven self-etching adhesive resin cement offers extended clean-up time for those dentists choosing to prepolymerize excess material with a dental curing light. Additionally, dentists will still recognize all of the Multilink Automix advantages including: high immediate bond strengths; effective sealing of the dentin; fast and easy application; and the ability to bond restorations made from metal, metal-ceramic, all-ceramic, and composite materials. Due to its patented, hydrolytically stable phosphoric acids (acidic monomers), Multilink Automix “Easy” is capable of meeting the expectations of dentists and their patients regarding high bond strength and efficient, durable adhesion. Within only 10 minutes, Multilink Automix “Easy” establishes a reliable and long-lasting bond to a large variety of restorative materials. For more information, call 1-800-533-6825 in the U.S., 1-800-263-8182 in Canada.
44 I Canadian Journal of Cosmetic Dentistry
Ivoclar Vivadent Introduces OptraStick ® Ivoclar Vivadent introduces OptraStick®, an easy-to-use, flexible plastic instrument that enables clinicians and dental technicians to easily and quickly pick up, hold, and place/handle indirect restorations. Even if only slight pressure is applied, the OptraStick adhesive tip precisely adheres to a wide range of small objects, such as inlays, onlays, crowns or veneers. OptraStick features a ball-shaped, flexible adhesive tip that can be easily bent and flexed in all directions to accommodate a var iety of clinical or laborator y situations. The OptraStick adhesive tip is removed or separated from restorations wit h a simple rotar y movement (twist), or a hand instrument can be used to hold the restoration in place. OptraStick is available in refill packages containing 50 instruments. For more information, call 1-800-533-6825 in the U.S., 1-800-263-8182 in Canada.
Ivoclar Vivadent - IPS Empress® Direct Ivoclar Vivadent introduces IPS Empress Direct, a highlyesthetic direct composite system offering the esthetics of a ceramic combined with the convenience of a composite. A wide range of shades, various levels of translucency and a simple application protocol provide dentists with impressive options to easily mimic t he natural est hetics of teet h in all indications, similar to ceramic. Two high-quality ceramic shade guides ensure the consistency and quality of shade selection, the starting point of every highly esthetic restorative procedure. Mimicking the natural color, opacity & translucency of tooth structure, dentin is simply replaced by “dentin” shades and enamel replaced by “enamel” shades, offering simple and straight-forward shade matching. To further facilitate the restorative procedure, the IPS Empress Direct material demonstrates convenient handling characteristics in combination with superior polishing properties and long-term shade stability. Its physical properties are designed to satisfy the highest clinical demands. In addition, IPS Empress Direct offers extended working time providing freedom to design lifelike restorations. For more information, call 1-800-533-6825 in the U.S., 1-800-263-8182 in Canada.
Product Showcase Vident Introduces Walser® Matrices
3M ESPE - A Unique Temporization Solution
Vident is proud to introduce Walser® Matrices. These reusable stainless steel matrix bands are easy to fit and place in seconds. “This unique matrix system can band two teeth simultaneously like no other matrix product on the market. They even have a band design that can fit over a rubber dam clamp when isolation is critical. We may have found the new standard in matrices,” said Dr. Martin Mendelson, Director of Professional Development for Vident. Walser® matrix bands feature a built-in spring system that adapts to the shape of the individual tooth. The matrices are very simple and quick to place with one hand movement and can save hours of chair time per month. The matrices accommodate all restorative needs, including MOD preparations, extra-large molars, anterior teeth, terminal teeth and even adjacent mesial and distal restorations. Patients can close their mouths and bite while the matrix is in place and they are autoclavable up to 50 times. For information regarding Walser matrix bands and other quality products call 800-828-3839 or visit www.vident.com.
3M ESPE announces the launch of Protemp™ Plus Temporization Material, the first bis-acrylic material to include a new generation of sophisticated fillers that offers easy handling and eliminates the need to polish. With a string of unparalleled features, Protemp Plus temporization material is unique in the market and was developed to satisfy even the most demanding temporization disciplines. 3M ESPE continues to set new industry standards by offer ing revolutionar y technologies and uncompromising solutions for temporization. Protemp Plus temporization material joins a family of high quality, reliable temporization materials designed to meet t he evolving needs of dental professionals including Protemp™ Crown Temporization Material, the world’s first preformed, malleable temporary crown, ideal for posterior single crown applications. For more information visit www.3MESPE.com or call 1-888-363-3685.
Successful Launch of NobelActive™ Implant Dentsply TruRx™ - Digital Denture Solutions A new, integrated approach to tooth mould selection and denture prescription, TruRx Digital Denture Prescription software shows great promise in improving process ease-ofuse and clinical outcomes. TruRx is a chairside, digital prescr iption tool t hat facilitates t he denture consultation while addressing key t herapeutic considerations, helping to make the denture process easy, consistent, and profitable for denturists and dental professionals. Tr uRx guides t he dental professional/denturist and the patient through the key denture considerations with interactive screens. The unique strengt hs of t he Tr uRx Digital Denture Prescription software lie in built-in intelligence to select suitable dental restoration options interactively with a patient and view the results live with them. The win for patients, dentists, and laborator ies is improved information, selection accuracy, efficiencies, esthetic outcomes, and overall satisfaction. For more information, please contact 1-800-263-1437 or email email@example.com.
NobelActive – a new implant design with innovative features – was Nobel Biocare’s most successful product launch ever. More than 130,000 implants have been sold to date. NobelActive is the first product launched according to Nobel Biocare’s new scientific and clinical standards. NobelActive is a hybrid implant: slightly tapered in design, although parallel walled drilling protocols are followed in insertion site preparation. NobelActive is an implant for advanced users, especially designed for extraction sockets and soft bone indications. For additional infor mation please visit www.nobelbiocare.com.
Heraeus Kulzer - Whitening System Venus White high-perfor mance, mint-flavored whitening gel is a complementary step in Venus Smile, a complete aesthetic system that offers a range of cosmetic products for both direct and indirect application. The gel is available in 16% and 22% strengths and offers shelfstable whitening that out-performs traditional hydrogen whitening products. It contains potassium nitrate that helps decrease sensitivity associated with bleaching. For more information, call 800-431-1785. Canadian Journal of Cosmetic Dentistry I 45
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50 I Canadian Journal of Cosmetic Dentistry
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52 I Canadian Journal of Cosmetic Dentistry