Clinical Precision with a Streamlined Digital Restorative Workflow

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Date: 01-15-2020 07:58:00 am

The iTero Element 2 intraoral scanner is equipped with next-generation computing power that enables reduced scan processing and faster start-up time, allowing a full-arch scan to be performed in as little as 60 seconds.

There are many benefits to digital intraoral scanning, but the greatest is that you can really zoom in and see whether you’ve captured everything.

And if you missed something, such as debris on a tooth, you can delete the scan in just that area, rescan that one little spot, and seamlessly reinsert it into the original scan. If you miss an area using impression material, you’d have to take a new impression of the entire arch or quadrant.

In my practice, digital scans are the vehicle that drives the entire restorative process, and this case is a great example. The patient was a 52-year-old man who had a cantilevered restoration that was in need of replacement. It was determined that replacing the cantilevered restoration with a single-tooth implant would be the best long-term option. I prepped tooth No. 12 to the gingival margin and made a cantilevered temporary over that area so the implant could be placed.

About 8 weeks later, I took a digital impression (iTero Element 2 Intraoral Scanner, Align Technology). There’s a myth circulating around dentistry that you can’t scan anatomy that’s subgingival, but with proper gingival retraction, this is something I’ve been doing successfully for years. By contrast, traditional impression taking can force impression material below the gingival margin and create a thin film of impression material. This thin film doesn’t create the most accurate impression because it can distort easily. 

Once I hit the send key on my iTero Element 2 scanner, Align Technology received the case and sent it to Dentsply Sirona, who digitally designed the custom Atlantis abutment with the proper clearance, angulation, and parallelism to the adjacent prepped tooth. It’s important that the abutment is designed in parallel with the prep so that there is no insertion issue with the crown and implant crown. My lab, Broadway Dental in Feasterville, PA, approved the design the next day.

The round-headed implant scan body (Dentsply Sirona) was converted to a replica of the abutment in the milled model right next to the adjacent natural prepared tooth No. 12. Before receiving a physical model, my dental lab was able to use the digital fi le to design the crown and implant crown on the digital model. So, within 3 days, the implant abutment was milled and shipped to my lab along with the model from Align.

The implant (Astra Tech Implant System EV, Dentsply Sirona) has a unique interface that provides one-position-only placement, which eliminates any difficulty when inserting the implant abutment and crown. The final crown was placed 2 weeks after the final impression was captured. Because of the digital scan, I had perfect impressions, perfect preps, and the case wrapped up beautifully when I inserted the final restoration.

Clinical precision is only one advantage of using the intraoral scanner. Treatment acceptance is another—it’s amazing how patients can self-diagnose once they see their problems on the screen. Sometimes, I’ll show patients a scan and they’ll ask, “Why aren’t you doing this other crown?” It’s tough to hit a patient with a $3,000 dental bill, so I might tell them that since it’s not horrible, we can take care of it down the road. To my surprise, once they see the scan, the patient will often say, “Let’s do them both.”

Intraoral scanning with a system like the iTero Element 2 scanner doesn’t just create revenue through case acceptance. It’s important to note that every time you scan, you save money. In the long run, you’ll get a better-fitting restoration with fewer remakes, fewer problems, and a “wow” factor that leaves patients with the feeling that dentistry is actually a science instead of someone just drilling on their teeth.

Figure 1: Preop radiograph

Figure 2: Digital Impression (iTero Element 2
Intraoral Scanner, Align Technology) of natural
tooth and scan body simultaneously

Figure 3: Occlusal view of impression showing
natural tooth and scan body

Figure 4: Milled model showing tooth prep No. 12
and implant abutment analog No. 13

Figure 5: Occlusal view of final restoration

Figure 6: Buccal view of final restoration

Go-To Product Used in this Case: iTero Element 2 

The iTero Element 2 provides improved screen resolution while minimizing scanner footprint due to its slim 21.5" monitor and 16:9 widescreen viewing format. The enhanced color offers a more thorough look at patients' oral health. Designed with a center-mounted wand cradle, the system provides ideal ergonomics during scanning. The integrated lithium-ion battery provides easy mobility from operatory to operatory without the need to plug in for power or reboot. The improved wand touchpad is as intuitive as gesturing on a smartphone and can be used to switch between scanning segments or rotate the model on screen. 

Simplifying the Dilemma of Shade Matching

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Date: 01-15-2020 06:12:14 am

Case Presentation:
Since the dawn of adhesive dentistry, composite resin materials have been considered the state-of-the-art standard for direct restorations. Advancements in the materials have improved features like wear resistance and polishability, but a product’s ability to mimic the surrounding tooth has depended upon the operator’s ability to correctly choose from the available shades to obtain a good match. This has required doctors to keep a large inventory of costly products. Sometimes, an otherwise perfect restoration is deemed unsatisfactory if the selected shade fails to match the surrounding tooth.

The goal of obtaining a perfect match has been simplified by the introduction of OMNICHROMA (Tokuyama Dental America). It is described as the first dental composite that matches every tooth with a single shade. This case presentation illustrates its use.

A 74-year-old male patient presented with interproximal decay on the distal surface of his lower right second premolar. The treatment plan required a disto-occlusal composite resin filling. After administering local anesthetic, I made a conservative preparation and excavated all decay. I then used Ultra-Etch 35% phosphoric acid (Ultradent) to selectively etch the enamel cavosurface margins. Using Composi-Tight 3D Fusion (Garrison Dental), I placed a sectional matrix band, wedge, and separating ring to ensure optimal contour and contact. A 2-step self-etching adhesive (CLEARFIL SE PROTECT, Kuraray America) was applied, followed by light-curing with VALO Cordless (Ultradent).

Having recently received OMNICHROMA, I was excited to evaluate its ability to match any shade. When I dispensed and placed the material, it was initially opaque white. However, after light curing, the material took on the color of the adjacent tooth structure. After removing any flash, improving the occlusal anatomy, checking the occlusion, and polishing with Enhance Finishing Points (Dentsply Sirona) and GROOVY Diamond Polishing Brushes (Clinician’s Choice), I was immediately impressed with the results.

The elimination of the shade-matching process will reduce chair time for all practitioners, and many will see cost savings by reducing their inventory of shades. Doctors—even those who stock numerous materials in dozens of shades—occasionally encounter a tooth that doesn’t match any shade in the VITA classical shade guide (VITA North America). Using a material that simplifies or eliminates the shade-matching dilemma can streamline the procedure and yield a result that satisfies even the most particular patient and doctor.

Go-To Product Used in this Case 

Tokuyama Dental America’s OMNICHROMA simplifies the restoration process by helping clinicians match the color of any tooth. Featuring high polishability and ideal physical-mechanical properties, OMNICHROMA is the first dental composite to use structural color as its main color mechanism; this helps it match the surrounding tooth color every time. Eliminating the shade-matching process streamlines clinical procedures and reduces chair time.

About the Doctor

Dr. Rosenfeld is a graduate of Cornell University and Northwestern University Dental School. He served a 1-year General Practice Residency and a second year as Chief Resident at Long Island Jewish Medical Center. He practices privately in Westwood, NJ, and is a Clinical Attending in the general residency program at Hackensack University Medical Center. Dr. Rosenfeld has advanced training in esthetic dentistry and is on faculty at the Nash Institute for Dental Learning. He is a member of the American Dental Association, American Academy of Cosmetic Dentistry, International Team for Implantology, and several dental study clubs.

Same-Day Veneers Using 3D Technology

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Date: 01-12-2020 15:05:00 pm

Case Presentation:
Temporization has always been a challenge for both clinicians and patients. The ability to eliminate the need for time-consuming and unreliable multi-unit veneer temporaries from the treatment plan greatly improves the patient’s experience, while optimizing the clinician’s workflow. The FirstFit Guided Veneers Delivery System saves valuable chair time by allowing the veneers to be prepped for and inserted in the same visit. Using this innovative technique, the case discussed here was completed in under 2 hours—from prep to insertion to cleanup.

Treatment Planning

The patient, a 29-year-old man, presented for a consultation and shared that he was unhappy with his smile. He had undergone orthodontic treatment as a teenager, and although his body continued to grow to a height of 6-feet, 4-inches, he felt that his smile had not caught up. After a full evaluation, it was determined that he had an edge-to-edge anterior bite that would require clear aligner correction prior to veneer placement.

The treatment plan included a soft-tissue laser crown lengthening of tooth No. 9 and placement of 8 FirstFit veneers (IPS e.max Press, Ivoclar Vivadent). At the first operative appointment, a full-arch intraoral scan (TRIOS, 3Shape) was taken along with a final shade and new photo protocol. All records were sent to Town & Country Dental Studios in Freeport, NY—an exclusive FirstFit Authorized Lab Provider. With their assistance, a digital design file was created and emailed to me so I could review it and make any necessary adjustments.

3D-Printed Preparation

After 15 working days in the lab, I received everything needed to achieve the necessary preparations-- the 3D-printed preparation guides, a model, ready-to-seat veneers in a tray, and 2 burs. The series of 3D-printed guides were used in sequence to achieve the exact digital design that the veneers were made to fit. Once the teeth were prepped, I tried in all the veneers at once using the delivery tray, which ensured proper fit and placement.

Same-Day Placement

After the fit and appearance of the veneers were verified, the teeth were pumiced and then etched with 37% phosphoric acid gel and coated with a bonding agent (OptiBond Solo Plus, KaVo Kerr). The bonding agent was not light-cured because it would polymerize when the cement was cured. Prior to placement, the intaglio surface of the veneers was rinsed, lightly etched, and rinsed again. A silane primer was placed on the intaglio surface of the veneers and then air-dried, followed by a thin coat of bonding agent. Light-cured resin cement (NX3 Nexus, KaVo Kerr) was placed on the intaglio surface of the veneers and then all veneers were seated at one time using the delivery tray.

Prior to curing, I did an initial cleanup and then tacked each veneer in place before gently removing the delivery tray. After the final cure, we made sure all contacts were clear and flossable, and then evaluated the final occlusion for any necessary adjustments. The veneers were then polished with fine pumice and porcelain polish. FirstFit Technology now makes it possible to predictably prep and insert custom-fabricated porcelain veneers in one visit without placing temporaries, while also reducing overall chair time. The FirstFit guided delivery system streamlines the veneer process—making the procedure more efficient, less invasive, and more rewarding for both clinician and patient.

Go-To Product Used in this Case

FirstFit is a revolutionary system that uses innovative digital technology and a series of 3D-printed prep guides to enable clinicians to prepare and seat a bridge or veneers in a single visit. Each 3D-printed prep guide is custom-designed and enables minimal tooth reduction during treatment, resulting in a highly esthetic, precise-fitting restoration. FirstFit represents a minimally invasive, temporary-free solution for patients who don’t have time for multiple office visits, and can minimize chair time.

About the Doctor

Dr. Porcu graduated from Georgetown University Dental School in 1984 and has been in private practice for 35 years. In his Syosset, NY, practice, where he treats patients ranging in age from 3 years old to their nineties, he places an emphasis on crown-and-bridge, implant, and cosmetic dentistry. He is passionate about using the latest technology in his practice, such as digital x-rays and lasers, and maintains professional affiliations with the American Dental Association, New York State Dental Association, and Nassau County Dental Association.

Revitalization and Restoration Following Deep Caries

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Date: 01-02-2020 11:05:33 am

Case Presentation:
A 37-year-old female patient presented with concerns about tooth No. 3. Another clinician had diagnosed caries and recommended root canal treatment, so she came to our office to find out if a root canal could be avoided. Other teeth needed restoration, but we focused our attention on this particular tooth with deep caries. Testing for sensitivity was performed, and the patient told me that she experienced sensitivity when consuming cold beverages. It was determined that the sensitivity was related to the stimulus.

The provisional restoration and carious tissue were removed via both manual excavation and low-speed rotary instruments. The pulpal chamber showed a translucency, and due to the vicinity of the pulp, a liner (TheraCal LC, BISCO) was used to protect the pulp. TheraCal LC acts as a barrier and pulp protectant, with the added benefit of also releasing calcium and generating an alkaline pH.

After placing TheraCal LC, selective enamel etching was performed using 37% phosphoric acid for 20 seconds. The etched surface was rinsed and excess moisture was removed. We then used a universal adhesive system (ALL-BOND UNIVERSAL, BISCO), applying a layer over the preparation in accordance with the manufacturer’s instructions. ALL-BOND UNIVERSAL can be used as a self-etch or total-etch adhesive, depending on the clinical case and the indication of the acting professional. After light curing the adhesive, a layer of flowable composite was placed.

The tooth was now vital once again, and the patient was asked to return in 30 days. The patient no longer experienced pain or sensitivity.

A ceramic inlay was the planned final restoration. The molar was prepped and scanned (CEREC Omnicam, Dentsply Sirona) for the purpose of fabricating the inlay. When the ceramic was fully crystalized, a 20-second hydrofluoric acid treatment was performed and then cleaned before silane was applied.

I prepared the tooth using ALL-BOND UNIVERSAL and a dual-cure cement (eCEMENT, BISCO). The restoration was seated, and excess cement was eliminated and then polymerized, covering the edges with glycerin to avoid the oxygen inhibited layer. We removed the rubber dam, polished the edge, and checked the occlusion of the final restoration.

Go-To Products Used in This Case:

Theracal LC

With its unique ability to stimulate apatite, TheraCal LC, a light-cured, resin-modified calcium silicate, is ideal for direct and indirect pulp capping and for use as a protective base/liner. Because of its excellent handling properties, TherCal LC stays where it is placed to efficiently aid in the regenerative process. Its alkaline pH promotes healing and results in virtually no postoperative sensitivity. 

All-Bond Universal

All-Bond Universal is the first universal dental adhesive to combine etching, priming, and bonding in one bottle. Unlike other one-bottle adhesives, direct and indirect dental restorations; it will bond to all indirect substrates and is compatible with all composite and resin-based cements without an additional activator.