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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. iTero Element 2 intraoral scanner

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.

preop radiograph

Figure 1: Preop radiograph

 

 

 

digital impression using itero element 2

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

 

occlusal view of impression showing natural tooth

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

 

 

milled model showing tooth prep

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

 

 

occlusal view of final restoration

Figure 5: Occlusal view of final restoration

 

 

 

buccal 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. 

 

Article 15 of 15

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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.

Interproximal decay on distal surface of premolar 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.

Composite filling using Omnichroma for shade matching

Omnichroma composite resin restoration

Go-To Product Used in this Case 

Omnichroma Composite best product

 

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.

Article 14 of 15

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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.Digital Veneers 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 Veneers

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.

 

Article 13 of 15

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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.

 

Article 11 of 15

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Indirectly Speaking – Six Steps to Finding Success with Your Single Unit Crowns

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

  

View Video

Educational Objectives

Learning Objectives:
  1. Evaluate the real costs to your office to remake a crown
  2. Understand the six steps to guide successful outcomes for the single-unit crown
  3. Strategies for material selection and cementation
  4. Explore tips and techniques for streamlining the single-unit crown protocol that you can incorporate immediately into your practice

Abstract

While the emphasis should always be a comprehensive approach to patient care and treatment planning, statistics bear out that the single-unit crown accounts for a large portion of our daily production. Consequently, it becomes imperative that we develop a technique protocol to maximize efficiencies as a team while still producing excellent results for our patients. Learn about the six steps to clinical success as a systematic approach to the single-unit crown, including preparation and material selection, tissue management, impressioning, and provisionalization, plus cementation and home care.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 83 of 87

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

State of the ART: Composite Dentistry Answers, 2020

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

  

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Educational Objectives

Upon completing this article, the participant should be able to:
  1. Learn how to create invisible-margin restorations using a SINGLE SHADE of composite that can match ANY tooth.
  2. Experience two new matrix systems that create perfect contacts every time.
  3. Learn how to use bulk flow flowable for "composite Onlay phasing!"

Abstract

The "golden age of composite dentistry is NOW!" We practice dentistry in a new era where a single shade of the composite can match virtually every tooth shade. Amazing new matrix systems give us broad natural contacts virtually every time. New bulk flow flowable composites allow us to phase large cases beautifully and economically. This webinar shows how well these new products work and how they can change your dental day in many ways.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 77 of 87

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Indirect Restoration Workflow

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

  

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Educational Objectives

Indirect Restoration Workflow 

At the conclusion of this course, participants will be able to:

1. Identify the roles played by each team member in the indirect restoration workflow.
2. Understand why each procedure will follow a given workflow instead of simply using a preferred cement for each situation.
3. Recognize the difference between a retentive and a nonretentive indirect restoration workflow, and the parameters that influence the decision regarding which method to use.
4. Determine which cements are used appropriately for retentive and nonretentive preparations, as well as the steps required by each team member to use them effectively.

Abstract

Dental offices require an efficient, streamlined workflow when seating an indirect restoration. Every member of the staff is affected by this procedure. As each team member understands and embraces his or her role, the entire offices will work more effectively, thus achieving improved outcomes with fewer crowns breaking and increased long-term success.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 72 of 87

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

DIAGNOSTICS at Your Earliest Convenience: A Discussion of Disease Prevention

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Author(s):

Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

  

Download this course

Educational Objectives

The overall goal of this course is to provide information on the 2017 American Academy of Periodontology Classifications regarding gingival diseases, stage I periodontitis, and review case selection, protocols, and common chronic systemic diseases that impact oral disease. After completing this article, the reader will be able to:

1. Describe 2017 AAP Classifications as they relate to gingival diseases and early-stage I periodontitis
2. Identify appropriate case selection and protocols for managing gingival diseases and early-stage I periodontitis
3. Review common chronic systemic diseases that are exacerbated by the presence of oral disease
4. Discern contraindications in treating gingival diseases and risks of substandard therapy
5. Demonstrate appropriate patient communication techniques in delivering treatment recommendations for the management of gingival diseases.

Abstract

In 2017, the American Academy of Periodontology (AAP) redefined the way dental professionals classify, or rather “stage,” diseases of the periodontium. With the understanding of the nature of chronic diseases, the AAP created a new set of stages and grades to better help the dental professional effectively identify and treat early and advanced disease. In the release of these stages, dental professionals have now transitioned into healthcare professionals whose clinical paradigms focus around the timely identification and effective prevention of disease. This article discusses the clinical and histologic parameters of early gingival and periodontal diseases, common chronic systemic

diseases as they relate to oral disease, and currently available therapies for the management of these diseases. As a healthcare professional, learn how clearer and more concise diagnostics will align your periodontal model to more effectively prevent and treat disease while supporting patients in evidence-based care.

COMMERCIAL SUPPORTER: This course has been made possible through an unrestricted educational grant from Dentsply Sirona Preventative.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 65 of 87

Online Continuing Education / Course Details

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Special Patients - Special Care

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Author(s):

Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

  

View Video

Educational Objectives

Providing Oral Health Care for Special Needs Patients 

  • Understand the limitations of the hybrid layer, and learn alternative treatment techniques
  • Learn about the use of “structural color” and the shading blending of restorative materials
  • Add the use of “bulk fill” materials, especially for restorative care in the primary and permanent dentition

Abstract

The dental profession is all about helping our patients achieve the best in oral health, and now even more importantly, also preventing the many systemic illnesses definitively linked to oral pathogens. Oral health professionals are seeking additional education in this oral-systemic link that has recently received significant substantiation. This is not surprising as the vast majority of oral health professionals made that long and financially burdensome commitment to dental education with the best of intentions. Sadly, more and more of our patients have severe complicating medical conditions, and being able to provide the appropriate care is important. This presentation will discuss several new dental material developments that have made providing the best care to those with special needs, more easily attainable. As the number of patients with special needs continues to increase, it is now even more necessary to develop techniques and materials that helps the profession to care for those special patients.

ADA Credits: 1 | AGD Credits: 1 | Cost: $19.00

Course 61 of 87

Online Continuing Education / Course Details

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Leveraging Advances in Restorative Dentistry

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Course Type: Self-instruction journal and web based activity

Target Audience: Dental Assistants, Dental Hygienist, Dentists from novice to advanced

  

Download this course

Educational Objectives

The overall goal of this article is to provide the reader with information on contemporary practices in general dentistry.
After reading this article, the reader will be able to:

1. Describe modern-day detection methods including current radiographic techniques and the use of transillumination.
2. Review modern techniques to remove diseased tooth structure and procedures for restoration preparation.
3. Describe the benefits and drawbacks of different adhesive techniques as well as the main reasons for postoperative sensitivity.
4. Compare various composite systems available for tooth restoration.

Abstract

Dentistry is an ever-evolving field. As technology improves, we are able to take these advances and apply them to clinical practice. Notable developments in the field of radiography have drastically improved practitioners’ ability not only to diagnose caries and pathologies more effectively but also earlier than ever before. Diagnoses with more detail, as well as the more precise location of these potential problems, are also possible with modern-day radiographs. Technological advancements in dentistry are not limited to improved diagnoses. Caries removal and tooth preparation instruments, bonding systems, and restorative materials have improved over the years and provide practitioners with a wide array of choices in treatment. Some of the purported benefits of these advancements are improved chair time management, less pain reported by patients, and more retentive restorations. It is up to the individual practitioner to stay current on the new technologies available in the field, as well as their benefits and drawbacks. This article provides some examples of advancements in the field of restorative dentistry.

ADA Credits: 2 | AGD Credits: 2 | Cost: $29.00

Course 60 of 87