It is my pleasure to introduce the secondissue of the Clinical Masters™ magazine.A great deal has happened in the last 12months. The Clinical Masters™ Programhas become a premier source of infor-mation and inspiration for dentists seek-ing to advance their skills and training.Over the past year, dental professionalsfrom all over the world have attendedour nine comprehensive programs andcourses in esthetic and restorative den-tistry, implant dentistry, endodontics,periodontics, orthodontics, prosthodon-tics and laser dentistry. Let me thankyou for your continuing trust in our first-class training.
This magazine provides comprehensiveinformation on the content of the pro-grams, the facilities and the instructors.You can also read about exciting newpostgraduate training and courses inbeautiful locations. The Specialist forRegeneration—Dental Implantology andPeriodontology Clinical Masters™ Pro-gram in Berlin, the Online AdvancedMentoring and Clinical Program in Perio -dontics in Campinas and the clinicalcourse in micro-endodontics in Dubaiare just three examples. As with our firstissue, the magazine features relevantclinical cases that demonstrate the par-ticular skills and expertise of our instruc-tors in their various specialties.
The Tribune CME™ programs are knownfor their highly effective approach, com-bining face-to-face and online mentor-ing by established international dentalprofessionals in some of the best highereducation institutions and training cen-
ters around the world. All members canaccess our sophisticated e-learning plat-form. Furthermore, Tribune CME™graduates and other dental professionalsare entitled to join the growing ClinicalMasters™ Network, a platform for spe-cialists across to globe to share theirskills and expertise.
Tribune CME™ is a brand of DentalTribune International, the world’s lead-ing dental publisher. We take pride inkeeping dentists around the world up todate on the latest advanced technolo-gies and techniques. Therefore, we regularly add new courses and pro -grams to our education portfolio. Visitwww.tribunecme.com to learn more and register.
I wish you stimulating reading andwarmly invite you to attend our world-wide Tribune CME™ programs.
With best regards,
Torsten R. OemusPresident and CEO Dental Tribune International
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04 — issue 2016 Clinical Masters™ Contents
CONTENTS
03 EditorialTorsten R. Oemus
06 TRIBUNE CME— Global knowledge, delivered by world-class faculty in prime locations
08 TRIBUNE CMEEducational partners
Clinical Masters™ Program in Advanced Implant Esthetics
10 ProfileLake Como Institute, Como, Italy
12 ArticleDr. Philippe Russe and Prof. Patrice MargossianLATERAL MAXILLARY INCISOR IMPLANT— Key issues for esthetic successPART II — Prosthetic stages and long-term issues
20 ProfileBORG Center, Barcelona, Spain
22 ArticleDr. Xavier Vela Nebot et al.FIVE KEYS — to more predictable esthetic restoration of anterior implants
26 ProfileSteigmann Institute, Heidelberg, Germany
30 JOIN THE CLINICAL MASTERS™ NETWORK
Clinical Masters™ Program inEsthetic and Restorative Dentistry
34 ProfileGeneva Smile Center, Geneva, Switzerland
36 ArticleDr. Didier DietschiNO-PREP INTERCEPTIVE REHABILITATION— of tooth wear using a free-hand technique driven by a functional wax-up
46 ProfileMEG Center, Melegnano, Italy
48 InterviewDr. Domenico Massironi
50 FACULTY FAVORITES
52 ArticleLee Culp, Dr. Edward A. McLaren, Dr. Lida C. SwannSMILE ANALYSIS— Converting digital designs into the final smile, Part 2
58 InterviewDr. Stavros Pelekanos
60 TESTIMONIALS
Clinical Masters™ Program in Endodontics
62 ArticleProf. Gianluca Gambarini et al.MATCHING GUTTA-PERCHA CONES— To NiTi rotary instrument preparations
66 InterviewProf. Fabio Gorni
68 ProfileDr. Arnaldo Castellucci Dental Studio
70 ArticleDr. Gianluca Plotino, Dr. Nicola M. Grande and Prof. Gianluca GambariniNEW TECHNOLOGIES— to improve root canal disinfection
Online Advanced Mentoring and Clinical Program inPeriodontics
76 ArticleDr. Débora Barella Salatti et al.COMPARATIVE STUDY— of implant placement torque and resonance frequency analysis on the implant and abutment
80 ArticleNordic Institute of Dental EducationEXPAND YOUR EXPERTISE
88 REGISTRATION FORM
90 IMPRINT— about the publisher
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Projekt2_Layout 1 02.03.16 22:02 Seite 1
06 — issue 2016 Clinical Masters™Partnership
Presentation
TRIBUNE CME— Global knowledge, delivered by world-class faculty in prime locations
The concept of the Tribune CME (contin-uing medical education) programs is basedon a blended learning approach. TribuneCME’s mission is to deliver comprehen-sive, advanced hands-on training in lead-ing-edge dentistry on a global scalethrough
– Intensive face-to-face clinical educa-tional sessions and practical training,conducted at specialized state-of-the-art training facilities of prominent fac-ulty members, in locations across theworld
– Extensive self-study opportunities via asophisticated e-learning platform, aswell as ongoing support, live mentoringsessions with experts and peers via ourwebinars, premium online video trainingon demand and the opportunity to col-laborate with peers and the Tribune CMEfaculty.
The result is an unmatched opportunity fordental professionals to achieve their mostambitious goals for professional develop-ment and their practice’s success.
Clinical Masters™ Programs are offered in:
Esthetic and Restorative DentistryAdvanced Implant EstheticsEndodonticsPeriodonticsLaser DentistrySpecialist for Regeneration – DentalImplantology and Periodontology
Upon successful completion, participantsreceive a Tribune CME certificate, whichis also endorsed by the educational insti-tutions associated with Tribune CME.
Personal branding opportunities: TribuneCME graduates may make use of the Clinical Masters™ Program logo to pro-mote themselves and their practice bothonline and in print.
Tribune CME programs are recognized bythe American Dental Association (ADA)and provide ADA CERP credits. ADACERP is a service offered by the ADA toassist dental professionals in identifyingquality providers of continuing dental ed-ucation.
“Practical training conducted at specialized,state-of-the-art trainingfacilities of distinguishedfaculty members”
FIND US ON FACEBOOK!www.facebook.com/TribuneCME
Presentation_CME_00-00.qxp_Layout 1 02.03.16 21:06 Seite 1
issue 2016 — 07Clinical Masters™Partnership
Presentation
CLINICAL MASTERSTM
IN ESTHETIC AND RESTORATIVEDENTISTRY
Certificate Of Participation
This is to certify that Dr. John Smith has successfully passed the theoretical and practical examination of the Clinical MastersTM Program in Esthetic and Restorative Dentistry, pursuant to the quality criteria of the American Dental Association ADA, Arthur A. Dugoni School of Dentistry and Tribune CME.
Scan the QR code! Join our Facebook pageand engage with theTribune CME community
Presentation_CME_00-00.qxp_Layout 1 02.03.16 21:06 Seite 2
08 — issue 2016 Clinical Masters™Partnership
Presentation
University of the PacificArthur A. Dugoni School of DentistrySan Francisco, U.S.
The Arthur A. Dugoni School of Dentistry is a nationallyrenowned institution of higher learning committed to providingworld-class dental education for its students. The school is highlyregarded for its innovation in its dental curriculum, includingcomprehensive patient care, and is a pioneer in competency-based dental education—an approach that replaces the tradi-tional system of clinical requirements with experiences that en-sure graduates possess the skills, understanding and professionalvalues needed for the independent practice of general dentistry.The institution is committed to excellence and innovation in ed-ucation, research, community service and patient care.
The Clinical Masters™ Programs also qualify forcertification from the following associated edu-cational institutions: University of the Pacific in the U.S., São LeopoldoMandic in Brazil, SapienzaUniversity of Rome in Italy, who acknowledgethe quality and reputation of the Tribune CME programs.
São Leopoldo MandicSchool of DentistryCampinas, Brazil
São Leopoldo Mandic is currently among the top ten institutionsof higher education in Brazil. It is accredited to teach under-graduate and graduate health care programs and award master’sand doctoral degrees. It also provides continuing educationcourses of varying lengths, presented as live clinical procedures,workshops, practical activities, seminars, online tutorials orother variations that best support mastery of the particular sub-ject matter. The faculty carries out outstanding scientific re-search, achieving impressive results and continuously aiming toimprove the knowledge of its students using current methodsand new technologies.
TRIBUNE CME— Academic partners
University of the PacificArthur A. Dugoni School of Dentistry
issue 2016 — 09Clinical Masters™Partnership
Presentation
Sapienza University of RomeFaculty of Medicine and DentistryRome, Italy
Sapienza University of Rome is one of the oldest universities inthe world and listed among the top-performing universities ininternational rankings. Sapienza offers a vast array of courses,including degree programs, doctoral courses, one- to two-yearprofessional courses, and specialization courses in many disci-plines, run by 63 departments and 11 faculties. It is in every regarda research and teaching university and carries out outstandingscientific research in most disciplines, achieving impressive re-sults both on a national and international level.
This year, we are pleased to welcome a new partner, UniversitéSaint-Joseph, to the group of higher education institutions offering Clinical Masters™ Programs. It will be offering thecourses at its regional center in Dubai, UAE.
Université Saint-JosephBeirut, LebanonDubai, UAE
The Faculty of Dental Medicine at Université Saint-Joseph is aninstitution dating back to 1920 and has a unique standing as apioneer in the field of dentistry in the Middle East. This year, itis celebrating 96 years of existence. Around 75 percent of den-tists in Lebanon have graduated from the school and its alumniare active in all Middle Eastern countries and abroad. The facultyis a dynamic and inherent part of Université Saint-Joseph, whichwas founded in 1875 by the Society of Jesus. It currently offersmaster’s and doctoral programs in various fields of dentistry,taught by experienced lecturers.
Université Saint-Joseph has a regional center in Dubai, whereadvanced courses in all fields of dentistry are offered in collab-oration with international partners, including Dental Tribune International.
Sapienza University of RomeFaculty of Medicine and Dentistry
Université Saint-Joseph
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10 — issue 2016 AdvancedImplant Esthetics
Profile
LAKE COMO INSTITUTE— Como, Italy
LocationThe Lake Como Institute is located in thetown of Como, famous for its silk manu-facturers. Within what remains of itstwelfth-century walls is a charming histor-ical center. The town is set on the shoresof Lake Como, situated in a basin sur-rounded by wooded mountains and said tobe the most beautiful of the Italian lakes.There is plenty to see while strollingaround, including stunning villas, gardens,and sites of historical and cultural signifi-cance. www.lakecomoinstitute.com
How to get thereFrom Milano Malpensa Airport, locatedabout 1 hour away by car, you can take theMalpensa Express train to Como.www.malpensaexpress.it
From Lugano Airport in Switzerland, lo-cated about 20 minutes away by car, youcan take a shuttle bus to Lugano, and thena train from Lugano station to Como S. Giovanni station.www.trenitalia.it or www.sbb.ch
From Milano Linate Airport, you can takea connecting bus to Milano Centrale sta-tion and catch a train to Como S. Giovannistation (trains depart hourly).
The following transport options are avail-able via the institute:
– a private mini-van for up to five passen-gers, one way from Milano Malpensa Air-port to Como (at a cost of €100 + 10%VAT)
– a private mini-van for up to seven pas-sengers, one way from Milano MalpensaAirport to Como (at a cost of €120 + 10%VAT)
– a private car (up to three passengers),one way from Milano Malpensa Airportto Como (at a cost of €80 + 10% VAT)
– There is an additional cost of €30 (oneway) from Il Caravaggio InternationalAirport (Orio al Serio International Air-port).
– There is an additional cost of €10 (oneway) from Milano Linate Airport.
Where to stayAll of the following hotels are locatedwithin a reasonable distance to the insti-tute. If you would like to stay right on thelakefront, you might want to consider oneof the following hotels:
Albergo Terminus dates back to the nine-teenth century and has an enchanting viewacross Lake Como.www.albergoterminus.it | TripAdvisorCertificate of Excellence | 4-star
Palace Hotel is an historical art nouveaupalace overlooking the lakefront.www.palacehotel.it | TripAdvisor Certifi-cate of Excellence | 4-star
Hotel Metropole Suisse is located along theharbor with views of Lake Como and theAlpswww.hotelmetropolesuisse.com | 4-star
Not on the lakefront, but also centrally lo-cated are the following hotels:
Albergo Del Duca, with an attractive set-ting on a pedestrian square, offers the hos-pitality of a family-run business.www.albergodelduca.it | 3-star
Avenue Hotel is located in a historical build-ing and offers rooms with a colorful andsophisticated design. www.avenuehotel.it | TripAdvisor Certificate of Excellence | 4-star
— Lake Como Institute
The Lake Como Institute is acenter dedicated to highereducation in implantology.Our teaching is based onscientific and clinical re-search, and we adopt an in-terdisciplinary teamworkapproach to our work. Ourclinic of excellence is basedon established protocolsand attention to detail, twofactors that we regard asimportant for achieving along-lasting result. With ourwork philosophy of seekingto achieve the best results,combined with our 30 yearsof clinical experience, weoffer an innovative coursethat will allow you to givebetter treatment to pa-tients, who rely on yourprofessionalism for theiroral health.
— Prof. Tiziano Testori
received his M.D. in 1981,his D.D.S. in 1984, and hisspecialty qualification in or-thodontics in 1986, all fromthe University of Milan inItaly. He is currently head ofthe section of implantologyand oral rehabilitation atthe University of Milan’sdental clinic at I.R.C.C.S. Is-tituto Ortopedico Galeazzi.He is also a visiting profes-sor at the College of Den-tistry at New York Univer-sity in the U.S.
Dr. Testori is a fellow of theInternational College ofDentists and a referee fororal surgery and implantdentistry for the Italian Min-istry of Health for continu-ing education programs. Heis an active member of theEuropean Federation ofOral Surgery Societies andan active member of andlecturer for the Academy ofOsseointegration, AmericanAcademy of Periodontol-ogy, and American Associa-tion of Oral and Maxillofa-cial Surgeons. He is theauthor of over 200 scien-tific articles in Italian and international journals.
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issue 2016 — 11AdvancedImplant Esthetics
Profile
Where to eatI Tigli in Theoria, situated in the old palazzoand adjunct to Theoria art gallery, providesa combination of gourmet cuisine, art andhistory.www.theoriagallery.it | 1 Michelin star
La Colombetta is a cozy restaurant offeringregional cuisine with fish dishes as its spe-cialty. www.colombetta.it
The Market Place offers innovative and hipItalian cuisinewww.themarketplace.it
L’Antica Trattoria, seasonal, traditional Ital-ian cuisine with specialty meat dishescooked over barbeque in view of guestswww.lanticatrattoria.co.it
Tira, mola e meseda, Italian cuisine, espe-cially dishes from Lombardy (risotto, os-sobucco)www.tiramolameseda.it
Capitan Drake Enoteca, small eatery andbar, New Zealand, Italian and Mediter-ranean cuisinewww.facebook.com/Capitan-Drake-Enoteca
What to see and doComo is a very small old town and the bestway to get to know it is to walk around anddiscover its narrow passages, old streets,quaint markets and piazzas, stopping toenjoy a cappuccino on the terrace of oneof its many cafés.
The remarkable eleventh-century Ro -ma nesque Basilica di Sant’Abbondio has abeautiful fresco series inside the apse anda university occupies what was once thecloister.
Lake Como’s shores feature a variedlandscape of fields, forests, imposingrocks, charming villages facing the lakeand magnificent mansions with beautifulgardens, particularly from Cernobbio to
Gravedona and Bellagio. The following in-clude only some of the innumerable sights:
The middle of Lake Como, where its threebranches come together, offers a spec-tacular view of the whole promontory ofBellagio, of the northern Grigna moun-tains overlooking Valsassina, and of the up-per basin against the backdrop of the Alpsif the skies are clear. It has the mildest climate and can be reached by boat.www.taxiboat.it
Besides the glorious views of the Leccobranch of the lake, which turns south-wards, there are natural springs, like Fiumelatte, described by Leonardo daVinci, and the impressive Orrido di Bellano(gorge), situated not far from the Renais-sance Villa Monastero at Varenna.
For more information visit:www.lakecomo.it
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12 — issue 2016 Advanced ImplantEsthetics
Article
LATERAL MAXILLARY INCISORIMPLANT:— Key issues for esthetic success
— Dr. Philippe Russe
formerly worked as an assis-tant at the Reims UniversityHospital and now works at aprivate practice in Reims,France. He can be contactedat [email protected].
Dr. Philippe Russe & Prof. Patrice Margossian, France
Having discussed in the previous article(see editorial note), all of the prepros-thetic stages for the replacement of a lat-eral maxillary incisor and having explainedthe surgical procedures required to im-prove the final esthetic outcome, in thissecond part, we discuss the prostheticstages. Observation of clinical cases overa period of almost 15 years has made itpossible to assess, over the different stepsin the prosthetic chain, the impact of par-ticular choices of components or clinicalprocedures on the final esthetic outcomeof the gingival setting and the ceramiccrown. As a result, for each clinical step,there are recommendations to help opti-mize and complete the surgical outcomeand to ensure a long-lasting result.
In the last section, the esthetic outcomewill be considered in relation to itsmedium- and long-term evolution, com-pared with the initial results. The effectsof continuous tooth eruption and an analy-sis of different risk factors lead the authorsto make clinical recommendations to min-imize any negative effects.
Provisional prosthesis
A provisional prosthesis can be fabricatedat different stages of treatment: when theimplant is placed to provide an immediatetemporary solution, when the implant is
uncovered, or once the soft tissues havehealed. A temporary abutment can be uti-lized, but this will involve greater manip-ulation of the subgingival components(Figs. 1a & b).
— One abutment, one time
The concept of the single abutment beingseated early and definitively during im-plant treatment in order to preserve theattachment of soft tissues around theabutment is based on a publication manyyears ago by Abrahamsson et al.1 For theseauthors, the multiple connections and dis-connections of healing screws resulted inapicalization of the periimplant bone. Thisstudy is now considered to be biased be-cause of the cleaning of healing screwswith alcohol (which destroys the attachedfibroblasts); nevertheless, it provided thebasis for the one-abutment–one-timeconcept (OAOT) put forward by Mauriceand Henry Salama at conferences from2007. At present, the medical literature isgenerally in favor of this concept, eventhough research results are mixed:
– In dogs, the results of Iglhaut et al.2
showed a highly negative outcome ofconnection and disconnection at fourand six weeks, while in Alves et al.3 fivesuch manipulations between 6 and 14weeks had no negative consequences.
— Prof. Patrice Margossian
is former director of the implantology department at the Marseille UniversityHospital and works at a privatepractice in Marseille, France.He can be contacted at [email protected].
PART II— Prosthetic stages and long-term issues
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issue 2016 — 13Advanced ImplantEsthetics
Article
Figs. 1a & bProvisional abutment aftermodified roll flap (a). Temporary crown in placeat the end of the surgicalreopening (b).
Figs. 2a–cIntraoperative placement ofa 15° angled abutment (a).Precise rotational adjust-ment of the implant (b).Check of rotational adjust-ment in the axial plane (c).
– In humans, several recent studies haveconcluded that there is a vertical advan-tage of 0.5 mm,4 horizontal advantageof 0.3 mm,5 vertical advantage of0.2 mm6 and nonsignificant7 result forthe OAOT protocol in different clinicalsituations.
In their 2014 review of the literature onfactors influencing apicalization of peri-implant tissue, Iglhaut et al.8 documentedinterest in the concept of the single abut-
ment and proposed recording the positionof the implant at the time of placement.Thus, there is some evidence suggestingthat it is desirable to limit the number ofmanipulations of the subgingival elementsas much as possible, even though the lit-erature is not unanimous in this regard.
The OAOT technique has a drawbackpointed out by Piñeyro and Tucker:9 how-ever: the increased risk of cement over-flow where the abutment–crown limit isdeeply buried. Different clinical strategiesmake it possible to apply the OAOT con-cept:
– The fabrication, using 3-D imaging, of asurgical guide and a machined abutmentprepared during the preoperative stagemakes immediate placement possible,but it is also more risky, since any errorin the guide or any lack of precision inthe placement could make the preparedabutment unusable.
– The same technique, starting with an im-pression at time of implant placement,is less risky, since the position of the im-plant has already been finalized.
Fig. 1a
Fig. 1b
Fig. 2a Fig. 2b
Fig. 2c
Since these two techniques involve thecollaboration of the laboratory, a simpli-fied protocol was used for the majority ofthe 120 NobelActive implants (Nobel Bio-care; 3 mm) placed over the past threeyears:
– Preoperative cone beam computed to-mography imaging is used to determinewhether a straight abutment or a 15° an-gulated abutment is the best choice forthe specific clinical case.
– Radiographic monitoring makes it pos-sible to check on the placement axis inthe mesiodistal plane, and the use of aparallelism guide when the 2 mm drillis being used provides a check on thebuccal–palatal plane. Once the implantis in place, an angulated prostheticabutment is seated to optimize the ro-tational position of the implant, whichis done to avoid, as far as possible, anyadjustment to the abutment by grinding(Figs. 2a–c).
In order to assist with intraoperative fit-ting, the surgical kits contain sterile angled
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14 — issue 2016 Advanced ImplantEsthetics
Article
abutments, the incisal edges of which areslightly curved, which presents the rota-tional alignment of the implant better thana straight cylindrical abutment does(Fig. 3). An adjustment of a few degreesand a check of the occlusion make it pos-sible to position the vestibular gingivaledge perfectly and, most often, to use theabutment without any alteration, whichsubstantially simplifies the rest of theprosthetic chain.
Keep manipulations of the abutment to a minimum.
In order to respect the principle of OAOTduring the fitting of the provisional crown,a provisional resin coping is prepared ona straight or angled abutment, depending
on the clinical requirement, along with aresin veneer created from a prosthetictooth (Figs. 4a–c). The resin coping isbonded in the mouth to the veneer usinga minimal quantity of resin in order toavoid direct pollution of the soft tissues bythe cytotoxic resin monomer (Figs. 5a–e).The use of a standard abutment and a pro-visional coping makes the fabrication oftemporary crowns very quick and simplewhile also respecting the principle ofOAOT.
— Emergence profile
When putting the provisional tooth inplace, it is preferable to give it an initialemergence profile that is concave in orderto allow healing of the papilla with themaximum space available. A convex profile
Fig. 3Surgical kit with 3.0, NPand RP angled abutments(NobelActive system).
Figs. 4a–cTemporary coping createdwith a brush (UNIFAST III, GC)and a veneer (a). Initial clinicalsituation with a 15° angledabutment in place (b).Temporary coping in place (c).
Fig. 3
Fig. 4a Fig. 4b Fig. 4c
Fig. 5a Figs. 5b–d
Fig. 5e
Figs. 5aBonding of the coping andveneer. Palatal view showing the small quantityof resin used.
Figs. 5b–d Bonded veneer, then relined and finished.
Figs. 5eProvisional crown after cementing.
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issue 2016 — 15Advanced ImplantEsthetics
Article
or an overcontour encourages apicaliza-tion of the gingival margin, which is gen-erally deleterious buccally (Figs. 6a–c).After stabilizing the soft-tissue margin,small amounts of resin placed mesially anddistally with a brush on the temporarytooth allow some pressure to be placed onthe papilla according to the cervical con-touring concept of Bichacho and Lands-berg10 and, in this way, to optimize the fill-ing of any gaps and the emergence profile.
Buccally, the gingival level or the crownzenith can be moved by modifying thetemporary tooth (Figs. 6d & e). In orderto reduce any excess cement and to allowit to escape during setting, a 0.75 mm holecan be drilled on the palatal side in the in-cisal half of the temporary crown.11
Optimize the emergence profileby progressive modification ofthe temporary crown.
— Taking impression
In order to comply with OAOT, the ideal,provided that the abutment has not beenadjusted, is to take an impression of theabutment. A resin impression coping fab-ricated over an abutment identical to theone seated in the mouth makes it possibleto transfer the position of the abutmentwithout unscrewing it (Figs. 7a & b). Anabutment and a laboratory copy are posi-
tioned in the impression and, if it isthought that the abutment is not suitablefor the permanent prosthesis, one couldopt for a NobelProcera abutment (NobelBiocare) or a modified abutment (Fig. 7c).
Take an impression of the abutment without removing it.
— Abutment
MaterialAccording to several publications,9, 12, 13 ti-tanium and aluminum and zirconium ox-ides are the only materials that allow attachment of soft tissues on the abut-ment. For Van Brakel et al.,14 in a study onhumans, there is no difference betweentitanium and zirconia regarding biology,with just a slight advantage in favor of zirconia for sulcular depth after threemonths. Gold alloys cause apicalization ofthe attachment to the titanium12 of the im-plant, but this conclusion has been con-tested by Linkevicius and Apse.15 A gold al-loy supports less dental plaque after 4 hin vitro,16 but more than titanium or zirco-nia does after four days in vivo.17 Thus,there is no consensus yet in the medicalliterature concerning the superiority ofone material over another in terms of bi-ology.
Zirconia and gold alloys have superioresthetic qualities when the abutment
supports a glass-ceramic crown in vitro18
or in vivo19, compared with titanium. Whenthe implant site of the lateral incisor iswide (> 6.5 mm), selecting a 3.3 or 3.5 mmdiameter implant makes it possible to usezirconia abutments. However, the majorityof small-diameter implants on the marketdo not include zirconia abutments in theirprosthetic ranges for reasons of mechan-ical resistance. In such cases, commercialtitanium abutments or abutments madeby 3-D machining are used. In this situa-tion, the thickness of buccal soft tissuemust exceed 2 mm, which is the requisitedimension specified by Van Brakel et al.20
to avoid there being any difference in lightreflection discernible by the human eyebetween a titanium and a zirconia abut-ment.
ShapeIn cement-retained prostheses, excess ce-ment has been found to be a cause of peri-implantitis.21–28 Linkevicius et al.29 havedemonstrated in an in vitro experimentthat there is a correlation between the
Figs. 6a–eBuccal compression (a).Creation of a concave pro-file on the provisionalcrown (b). Provisional clini-cal outcome: The shape ofthe incisal edge also plays arole in the esthetic result(c). Resin applied with abrush to distalize the zenith(UNIFAST III; d). Emer-gence profile optimized bythe provisional crown (e).
Fig. 6a
Fig. 6d Fig. 6e
Fig. 6b Fig. 6c
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depth of the abutment–crown joint andthe amount of excess cement on the sur-face of the abutment. This is an argumentin favor of the use of NobelProcera indi-vidual abutments. However, these individ-ualized abutments often have significantundercut areas, which are recognized riskfactors for the retention of intrasulcularcement.30 On small-diameter implants,the reduced dimensions of the abutmentsdiminish the friction surface of the im-plant-supported crown and the creationof two small mechanical retentions in theincisal zone of the abutment reduces anyloosening (Fig. 8).
Maximize retention of small-diameter abutments.
— Crown
Where edentulous gaps were narrow,3 mm Nobel Active implants were placedand only titanium abutments, standard orNobelProcera, were used. Two types ofcrown are possible: metal–ceramic crownsor all-ceramic crowns.
— IPS e.max (Ivoclar Vivadent)
If the abutment is titanium, using an all-ceramic system can present restrictionsrelated to the bucco-palatal thickness ofthe lateral incisor. When the tooth is thick,this prosthetic solution makes it possibleto achieve an acceptable esthetic out-come (Figs. 9a–d). Conversely, when thethickness is less, this type of all-ceramiccrown can sometimes result in more dis-advantages than advantages from an es-thetic perspective. In such a case, for thecoping in lithium disilicate, one has to usehigh-opacity ceramic of significant thick-ness in order to hide the titanium abut-ment as much as possible. This has the ef-fect of reducing the thickness of thecosmetic ceramic and thus reduces itsability to mimic the appearance of adja-cent teeth (Figs. 10a–d).
— Metal–ceramic crowns
Conversely, using metal-fused-to-porce-lain crowns on narrow and small teethmakes it possible to reduce the thicknessof the copings made from precious alloysor palladium (to 0.3 mm or 0.4 mm) andin this way to increase stratification(Figs. 11a–c & Figs. 12a–d). However, thetransgingival area remains the weak point
in this type of restoration with a risk of thegrey color of the titanium abutment show-ing through when the periimplant mucosais thin (see Fig. 33 in Russe & Limbour).31
Do not hesitate to use metal–ceramic crowns for small lateralincisors.
— Monoblock screwed zirconia crown
The use of hexagonal implants measuring3.3 mm externally or with an internal con-nection measuring 3.5 mm makes it pos-sible to use zirconia abutments. In thesecircumstances, two options are possible,depending on the emergence position ofthe abutment screw: either a two-stagesolution of a zirconia abutment supportinga cemented ceramic crown (Figs. 13a–d)or a monoblock crown screwed directly onto the implant (Figs. 14a & b). In these sit-uations, the semitranslucent character ofthe material makes it possible to ensureoptical continuity in both the coronal sec-tion and the gingival section, resulting inbetter esthetic integration.
— Cement
In order to reduce the visibility of titaniumshowing through when a glass-ceramic
crown is used, an opaque white cementshould be employed according to Dede etal.18 This involves a polycarboxylate ce-ment (Poly-F, DENTSPLY DeTrey), se-lected initially for its theoretical ability topotentially allow detachment of thecrown. Recent studies have demonstratedthat polycarboxylate has greater tensilestrength than does zinc oxyphosphate orglass ionomer.32 At the time of cementing,the cement-coated crown is placed on areplica abutment; any excess is removedbefore placing the crown in the mouth.33
This clinical technique has been provenbeneficial for both its qualities of retentionand reducing excess cement.34
If standard abutments are used, thenthe crown limit can be considerably sub-gingival and it is then vital to use a mini-mum amount of cement and to removeany excess immediately. The washable na-ture of polycarboxylate cement immedi-ately after placement can be an advantagefor its removal.
— Esthetic outcome
When the esthetic outcome is evaluatedaccording to the criteria specified byFürhauser et al.35 and when particular at-tention is paid to the score for the papillaeand the gingival level, use of small-diam-eter implants to replace lateral maxillary
Figs. 7a–cResin transfer coping on a standard abutment (a).Transfer coping on an abutment that has neverbeen removed (b). Transferand analog repositioned in a polyether impression (Impregum, 3M ESPE; Rim-Lock dental impressiontray, Zhermack; c).
Fig. 8Creation of cement retentions on a titaniumabutment.
Figs. 7a & b Fig. 7c
Fig. 8
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Figs. 9a–c Fig. 9d
Figs. 10a–c Fig. 10d
Figs. 9a–dIPS e.max high-opacitycrown coping (a). Initialclinical result and radiograph (b & c). Result after one year (d).
Fig. 10a–cSmile of female patientshowing restoration oftooth #12 with IPS e.max(a). Close-up photograph:The opaque armature is visible (b). Radiograph (c).
Fig. 10dThe esthetic finish of theveneer on tooth #22 is superior to that of IPSe.max on tooth #12.
Figs. 11a–cMetal–ceramic crown onmaster cast (a). Clinical result: The mesial and distalpapillae are aligned (b). Radiographic result (c).
Figs. 12a–dMaster cast with the metal–ceramic crown on a modi-fied abutment (a & b). Clinical result: The papillae are aligned (c). Radiographic result (d).
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incisors appears to result in an improve-ment compared with wider implants. Themargin of the papilla and the position ofthe collar, in relation to the contralateralincisor, are the two principal issues pre-sented by implant replacement of a lateralincisor (Fig. 15). In most cases, the mesialpapilla, between the central incisor and thelateral incisor, is at an almost normalheight, whereas the distal papilla, betweenthe lateral incisor and the canine, is oftenshorter and displays a slight vertical deficit(Fig. 16).
— Initial evolution
When the implants are well positioned andthe buccal soft and hard tissue are thick,the esthetic outcome is lasting. In the earlyyears, an improvement of the outcomemay occur owing to the soft tissue fillingthe prosthetic embrasure (Figs. 17a & b).
— Continuous eruption
Since the 1980s, authors such as Leversand Darling36 have described the phenom-enon of continuous eruption, which re-sults in a verticalization of the maxillary in-cisors. The osseointegration of implantsprevents them from following this migra-tion and, over time, the lateral incisors canend up in a more apical and buccal positionthan the central incisors. This phenome-non is sometimes perceptible after someyears have passed, whatever the age whenthe implants were placed (Figs. 18a & b).
Thus, the organization of anterior guid-ance becomes particularly important,since rapid movement of the central inci-sors can occur if these are not in occlusionwhen the implants are placed. During or-thodontic treatment, balanced anteriorguidance for the central incisors and thecanines will be one of the major objectivesfor the orthodontist. If there is bilateral
agenesis, the symmetry of the smile willbe maintained and the situation will be es-thetically more favorable than for a unilat-eral replacement. After some years, thediscrepancy may become quite significantand may be present just in the verticalplane or may be a combination, both ver-tical and horizontal (Figs. 19a–c). It wasthought that this phenomenon was the re-sult of placing implants too early, but in2004 Bernard et al.37 showed that therewas no difference between a group ofyoung adults and a group of adults in termsof infraocclusion of implant-supportedcrowns in the esthetic region. In describ-ing the problems found in implant-supported anterior restorations (bluish gingiva, infraocclusion, exposure of abut-ment), Zachrisson38 poses the question: Isan implant the best solution for treatingagenesis?
Warn the patient of the negative impact of continuouseruption on the esthetic outcome.
— Risk factors
Andersson et al.,39 who followed 34 pa-tients over a period of 17–19 years, showedthat severe infraocclusions (> 1 mm) af-fected 35% of the patients. They madeseveral findings, including the following:
Fig. 15 Fig. 16
Fig. 15The collar level of tooth#22 is ideal, but the papillaeare slightly truncated.
Fig. 16The distal papilla is slightlyshorter than the mesialpapilla (line shows difference in level).
Fig. 17aInitial situation.
Fig. 17bAfter three years, the papillae are slightly longer.
Fig. 17a Fig. 17b
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Editorial note: A list of references is available fromthe publisher. The first part of this article series, titled “Lateral maxillary incisor implant: Key issuesfor esthetic success,” was published in Clinical MastersTM, March 2015, Volume 1, Issue 1.
Conflict of interest: The authors declare that theyhave no conflict of interests relating to this article.
– Women were affected more than men.– It was more noticeable in long rather
than short faces.– There was no correlation with age.– The patients were more satisfied with
the results than were the practitioners.
The findings of the same researchers werepresented at the 2012 Academy of Os-seointegration annual meeting in Phoenix,Ariz., U.S., by Torsten Jemt, who attributedimplant-supported crown infraocclusionsto posterior mandibular rotation resultingin verticalization of natural incisors that isnot followed by the crowns on the im-plants. In the results reported, 19 out of 69cases presented infraocclusions of morethan 1 mm and the phenomenon affectedtwice as many women as men.A recommendation has been made by thepractitioners of the Brånemark clinic inGothenburg, Sweden, to place implants in
a palatal position in anticipation of possibleverticalization of the central incisors. Suchplacement also facilitates any prostheticadjustment.39
Favor a palatal positioning ofimplants.
— Conclusion
Replacement of a lateral maxillary incisoris a difficult task. The great visibility of thetooth in the smile and comparison with thecontralateral tooth in the same view arefactors with intrinsic esthetic risks. In bothparts of this article series, emphasis hasbeen placed on the most difficult situa-tions when the lateral incisor is small. Insuch circumstances, any lack of precisionin the positioning has powerful implica-tions for the esthetic plan. In this situation,
using small-diameter implants would ap-pear to offer advantages for the height ofthe papillae around the implant.
In about one-third of cases, continuousmaxillary eruption undermines the initialesthetic outcome, which may result, at thevery least, in having to change the crownon the implant. This change to the estheticoutcome should form part of the informa-tion provided to patients before startingtreatment.40
Figs. 18a & bSmile of female patient in1998 (a). Smile of femalepatient in 2014. Egressionof natural teeth (b).
Figs. 19a–cSmile of female patient in2001 (a). Clinical situationin 2013 (b). Verticalizationand egression of central incisors, lateral view (c).
Fig. 18a Fig. 18b
Fig. 19a Fig. 19b Fig. 19c
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BORG CENTER— Barcelona, Spain
LocationThe BORG Center is located in Barcelona,a city with a rich cultural heritage andknown for its Catalan culture and dis -tinctive architecture, including severalUNESCO World Heritage Sites. It is a po -pular tourist destination and boasts one ofthe best beaches in the world.www.borgbcn.com
How to get thereFrom Barcelona Airport: The center is an11- to 16-minute drive from the airport bytaxi.
From Viladecans: Two buses depart fromthe train station every 20 minutes approx-imately, the VB1 and the VB2. Ask the busdriver to stop at the Ángel Arañó/Dos deMayo bus stop. The center is located twostreets down from the bus stop.
Where to stayAC Hotel Gavà Mar, has a seafront locationin a quiet area close to the BORG Center,but a little far away from the center ofBarcelona.www.marriott.com | 4-star
Majestic Hotel & Spa, offers luxurious ac-commodation in a neoclassical building onPasseig de Gràcia, near shopping areas inthe center of Barcelonawww.hotelmajestic.es | TripAdvisor Certificate of Excellence | 5-star
W Barcelona, right on the beach and 30 min-utes from the BORG Center, commandsfantastic views over Barcelona and has amagnificent design.www.w-barcelona.com | TripAdvisor Certificate of Excellence | 5-star
Hotel 1898, on La Rambla, is housed in a re-stored colonial-style nineteenth-centurybuilding.www.hotel1898.com | TripAdvisor Certificate of Excellence | 4-star
Sidorme Viladecans is quite new and a 5-minute taxi ride to the BORG Center. www.sidorme.com | TripAdvisor Certificate of Excellence | 3-star
Where to eatABaC Restaurant serves Mediterranean/Spanish fusion cuisine.www.abacbarcelona.com | 2 Michelin stars
Freixa Tradició is a very small and old restau-rant offering traditional Catalan food.www.freixatradicio.com
Ziryab Fusion Tapas Bar serves Spanish cuisine with a Middle Eastern twist.www.ziryab.es
La Taula is a cozy restaurant providing in-ternational cuisine, as well as home fa-vorites.www.lataula.com
Silvestre is an elegant restaurant thatserves international and traditional cuisinewith the option of half-portions for everydish.www.restaurante-silvestre.com
Tast-Ller is a small, exclusive Mediter-ranean restaurant located down a side al-ley.www.tast-ller.com
What to see and do Take a stroll down La Rambla, the world-famous boulevard stretching about 1.2kilometers all the way to the Mediter-ranean Sea.
Wander through the Barri Gòtic (Gothicquarter), the center of the old city.
Visit the Museu Nacional d’Art deCatalunya (Catalonia national art museum).
— Dr. Xavier Vela Nebot
obtained his degree in den-tistry and medicine fromthe University of Barcelona.He has a private practice inBarcelona dedicated to im-plantology and prosthetics.He is a co-founder of theBORG Center, conducts re-search and regularly pub-lishes articles in leading in-ternational journals. He haslectured at prominent na-tional and internationalsymposiums.
— Dr. Xavier Rodríguez Ciurana
obtained his degree in med-icine and surgery from theUniversity of Barcelona. Hehas a private practice inBarcelona. He is an associ-ate professor at the Euro-pean University of Madridin Spain and is co-founderof the BORG Center.
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See Antoni Gaudí’s many masterpieces,seven of which are on the UNESCO WorldHeritage List, the most famous probablybeing the Sagrada Família basilica and thebeautiful Park Güell, demonstrating per-fect harmony of nature and architecture.
A UNESCO World Heritage Site, Palaude la Música Catalana is a concert hall exemplary of art nouveau architecture.Some of the most important craftsmenand artists of the time were involved in itscreation.
Housed in five Catalan-Gothic palazzosdating from the thirteenth and fourteenth
centuries, the Museu Picasso is a museumof the artist’s formative years.
El Paral·lel, a vibrant theater district, isyour destination for all entertainmentand music.
A walk up Montjuïc mountain offersspectacular views.
For a day trip, take an exhilarating hot-air balloon flight over Catalonia withpanoramic views of the Pyrenees,Montserrat, Montseny and the Mediter-ranean Sea.
Previous participants have enjoyed avisit to the FC Barcelona Museum and at-tending a game as well.www.fcbarcelona.com
For more information visit:www.barcelonaturisme.com
— The BORG Center,
or Barcelona Osseointegra-tion Research Group, is focused on research in oralimplantology and its variousclinical applications. Thecenter was established inearly 2005 when four spe-cialists in oral implantologydeveloped a common pro-tocol with good results todemonstrate that in casesin which the diameter ofthe pillar is smaller than thediameter of the implantbone loss is ostensiblylower. This research, titled“Benefits of an ImplantPlatform ModificationTechnique to Reduce Cre-stal Bone Resorption,” waspublished in Implant Den-tistry in 2006. Since then,they have lectured world-wide and have producedand collaborated on a num-ber of publications. We en-joy our work and are eagerto share it with you.
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FIVE KEYS — to more predictable estheticrestoration of anterior implants
— Dr. Xavier Vela Nebot,M.D., D.D.S.,
is a visiting professor at theimplantology department ofthe European University ofMadrid and a member of theBarcelona OsseointegrationResearch Group in Spain.
— Dr. José Miguel CastroHoyle, M.Sc., D.D.S.,
is a Master of Oral Implantol-ogy student at the Depart-ment of Oral and MaxillofacialSurgery, Faculty of Dentistry,Universitat Internacional deCatalunya, Barcelona, Spain.
— Dr. Maribel Segalà Torres,M.D., D.D.S.,
is a member of the BarcelonaOsseointegration ResearchGroup.
— Dr. Jaime Jiménez García,D.D.S., Ph.D.,
is chairman of the implantol-ogy department of the Euro-pean University of Madrid anda visiting professor at the NewYork University College ofDentistry in the U.S.
— Javier Pérez López
is a laboratory technician atOral Design in Lugo, Spain.He has also lectured widely onesthetic prosthesis.
— Dr. Xavier Rodríguez Ciurana, M.D., Ph.D.,
is a visiting professor at theimplantology department ofthe European University ofMadrid and a member of theBarcelona OsseointegrationResearch Group.
Dr. Xavier Vela Nebot, Dr. José Miguel Castro Hoyle, Dr. Maribel Segalà Torres, Dr. Jaime Jiménez García, Javier Pérez López & Dr. Xavier Rodríguez Ciurana, Spain
Introduction
Dental implants have enabled clinicians toreplace missing teeth and return functionand harmony to patients owing to theirhigh predictability.1 However, it can bechallenging to create implant-supportedrestorations that emulate the natural den-tition. Among the guidelines that havebeen proposed for achieving esthetic ex-cellence, many focus on maintaining or en-hancing the volume of periimplant softand hard tissue.2 This paper describes fivekeys to achieving and maintaining dento -gingival harmony and obtaining highly esthetic anterior implant restorations. Useof an implant that facilitates adherence toseveral of these principles is illustratedwith a case description.
The five keys
— 1. Tissue optimization (Fig. 1a)
Several studies have documented post-extraction resorption patterns that de -monstrate horizontal and vertical bone lossduring the first year after extraction.3, 4
Some bone resorption has been describedat sites where the extracted teeth wereimmediately replaced with implants.5
The objectives of tissue optimizationare to diagnose the volume of soft andhard tissue and, in the absence of an ade-quate amount, prepare for augmentationof the volume. Augmentation proceduresmay be beneficial in preventing black tri-angles and creating natural emergenceprofiles.6–8 An early implant placementprotocol9 should be applied when toothextraction is required at a site with a thingingival phenotype. Although this approach
does not allow adequate time for bone toform in the extracted site, it provides a soft-tissue seal by primary intention.
— 2. Gingival remodeling (Fig. 1b)
Once the volume of the gingival tissueabove or adjacent to the implant has beenoptimized, some reshaping of the tissueshould be considered. Use of an ovatepontic has been suggested to support thegingival tissue coronal to the implantshoulder, creating pseudopapillae and anatural emergence profile. The ovate pon-tic may also expose the submerged im-plant and avoid the need for a second sur-gery to obtain access to the cover screw.Avoiding a second surgery will help to pre-serve the gingival architecture and mini-mize soft-tissue scar retraction.10
The use of provisional restorations tosculpt the soft tissue without causing re-cession or retraction is fundamental. Mostfixed and removable prostheses can ac-complish this goal.10 Another technique isto use cemented fixed provisional restora-tions and minimally invasive palatal prepa-rations.11 Pressure should gradually be im-posed on the soft tissue from the palatalto the labial aspect and the mesial to thedistal aspect in order to displace tissue vol-ume toward the areas adjacent to theprosthetic crown, where papillae and con-vex contours are desired for a naturalemergence profile.
— 3. Handling reduction (Fig. 1c)
Once an ideal tissue form has been ob-tained, it must be preserved and stabilized.Frequent disconnection and reconnection
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Figs. 1a–eSchematic view of the five-key protocol. Tissue optimization (a). Gingivalremodeling (b). Handlingreduction (c). Effectivecomponent design (d).Abutment surface cleanliness (e).
of the abutment has been associated withdetrimental effects on the periimplantbone.12 It creates a soft-tissue wound andtriggers subsequent bone resorption as aproper biologic dimension of the mucosalbarrier attachment to the stable implantsurface is re-established. In order to avoiddisturbing the mucosal periimplant sealthat preserves the crestal bone level, a customized abutment for a cement-retained prosthesis should be placed withthe objective of avoiding repeated im-plant-level impressions and try-ins.13 Anabutment-level impression should betaken. When impressions are taken at thetime of implant placement and furtherabutment manipulation can be avoided,less bone resorption has been shown toresult.13
— 4. Effective component design (Fig. 1d)
The implant macrodesign and, in particu-lar, the design of the implant–abutmentjunction (IAJ) are critical in preventing the
loss of crestal bone. Numerous publica-tions have demonstrated that some alve-olar bone resorption occurs around theIAJ of platform-matched implants whenthey are exposed to the oral environ-ment.14, 15 It has been postulated that thefirst bone-to-implant contact beginsaround 1.5–2 mm apical to the IAJ or tothe first implant thread. About 1.4 mm ofhorizontal resorption occurs. A differentbone response has been documentedwhen platform-switched implants areused. A recent systematic review andmeta-analysis showed that significantlyless bone resorption occurred when thisIAJ design was employed.16 Use of the 4/33i T3 Tapered Implant (BIOMET 3i) facili-tates following several of these keys to achieve more predictable estheticrestoration of anterior implants. The de-sign incorporates platform switching, witha 3.4 mm platform dimension in order notto impinge on the interdental space.
Histological investigation17 has foundthat platform switching appears to affect
Fig. 1a
Fig. 1d Fig. 1e
Fig. 1b Fig. 1c
the location of the circularly oriented col-lagen fibers that surround implant abut-ments and apparently stabilize the con-nective tissue and underlying alveolarcrest. While these fibers have been foundat the level of the first thread of nonplat-form-switched implants, they have devel-oped at the IAJ of platform-switched im-plants. The horizontal platform of theplatform-switched implants appeared toprovide mechanical retention for the cir-cular fibers, allowing them to developmore coronally than in standard implants.The abutment design too can help to sta-bilize the connective tissue above the IAJand preserve alveolar bone at the platformlevel. One concave design has been pro-posed18 that features a circumferentialmacrogroove that creates space for softtissue. It arguably creates a ringlike sealthat, after tissue maturation, may stabilizethe connective tissue adhesion. Connec-tive tissue stabilization has also beendemonstrated when using a narrow lasermicrogrooved cylindrical abutment.19, 20
The implant–abutment connection tooappears to have a significant impact onperiimplant crestal bone levels. Internalconnections have been demonstrated tobetter maintain bone.21 Finally, the designof the prosthetic crown and its relation-ship to the implant abutment are essentialfactors for restoring tooth anatomy andfunction. The crown should provide spacefor fiber stabilization between the cervicalcontours and the implant platform.
— 5. Abutment surface cleanliness (Fig. 1e)
Implant abutments are transgingival de-vices that interact in their most cervicalregion with the surrounding tissue, mainlyconnective tissue underneath the gingiva.Abutments allow for the re-establishmentof the biologic width: as cells attach, the
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epithelial junction forms, and the under-lying connective tissue subsequently sta-bilizes. The abutment material may influ-ence cellular attachment processes.22–24
Surface contamination occurring afterlaboratory or clinician manipulation or re-use of the abutments has been shown tohave a detrimental effect on cellular at-tachment.25, 26 Multiple protocols, includ-ing rinsing with saline solution or hydrogenperoxide,27 autoclave sterilization28 and ultrasonic treatment,25 have been devisedto restore the original biocompatibleabutment surface composition withoutchanging the surface topography. Mosthave failed to eliminate the contaminants,and some have worsened the cell adhe-sion.28, 29 However, exposure to ozone hasbeen demonstrated to eliminate plaquefilm completely,27 and the ability ofchlorhexidine to decontaminate abut-ment surfaces has also been demon-strated.30 Providing a biocompatible en-vironment before abutments are placed
Fig. 2 Fig. 3 Fig. 4
Fig. 5 Fig. 6 Fig. 7
Fig. 8 Fig. 9 Fig. 10
Fig. 2The patient was a 29-year-old woman who presentedwith pain in her maxillarycentral incisors.
Fig. 3Radiographic examinationrevealed the presence ofperiapical lesions. The teethwere deemed to be non -restorable.
Fig. 4The central incisors wereatraumatically extracted,and the sockets were imme-diately filled with collagensponges to aid with clot sta-bilization.
Fig. 5The patient returned fiveweeks after the extractionsfor early placement of im-plants.
Fig. 6Reflection of a flap re-vealed the absence of thelabial bony plate. Osteot -omies were created, andtwo 3i T3 Tapered Implants,both 4 mm in diameter and13 mm in length with a 3.4mm platform, were placed.
Fig. 7Good primary stability wasobtained for both implants,but large labial defects werepresent, as demonstratedby this occlusal view. Im-pressions were taken imme-diately after implant place-ment in order to preparethe definitive prostheticabutment.
Fig. 8Along with implant place-ment, guided bone regener-ation was carried out usingEndobon Xenograft Gran-ules and an OsseoGuardMembrane (BIOMET 3i). A connective tissue graftwas also performed.
Fig. 9Occlusal view after implantplacement and grafting.
Fig. 10Three months after place-ment of the implants, theprovisional prostheses wereremoved. The shape of thesoft tissue was progres-sively modified to improvethe emergence profile andto expose the cover screwsin a nontraumatic secondsurgery (soft-tissue remod-eling technique).
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in contact with the gingival tissue can pro-mote earlier tissue stabilization. Eliminat-ing or reducing the role of disturbingagents is thus an important goal. Figures1 to 16 illustrate the use of a 4/3 3i T3 Ta-pered Implant (platform-switched) to im-plement several of the five keys in twocompromised and esthetically demandingsites.
Conclusion
Management of anterior implant restora-tions demands a highly esthetic approach inorder to obtain successful outcomes. Mul-tiple interrelated factors influence the re-lationship between the white esthetics ofthe restoration and the pink esthetics of thesurrounding gingival tissue. None of thesefactors should be considered in isolation.Only by coordinating their application canmore predictable and harmonious estheticrestorations be created. The use of the 3i T3Tapered Implant and the marginless abut-ment can help clinicians to follow the fivesteps explained in this article in order to ob-tain better esthetic results for implant-sup-ported restorations.
Fig. 11 Fig. 12
Fig. 14
Fig. 13
Fig.15 Fig. 16
Fig. 11Four months after beingplaced, the implants wereuncovered. GingiHue Abut-ments (BIOMET 3i), modi-fied in the laboratory toachieve a 6° taper and margin-free restoration,were placed. This is the firstand only abutment swap (handling reduction).
Fig. 12The definitive abutmentscrews were tightened to20 N cm, and the screw access openings were restored with composite in preparation for placingthe cement-retained provisional bridge.
Fig. 13The patient wore the implant-supported fixedresin bridge for threemonths, enabling furthermaturation of the soft tissue.
Fig. 14Eight months after place-ment of the implants, thesoft tissue had further ma-tured and stabilized, and thedefinitive two-unit full-ceramic bridge was fabricated.
Fig. 15Nine months after place-ment of the implants, thedefinitive zirconia bridgewas cemented in place.
Fig. 16Radiograph of the definitivetwo-unit bridge.
Editorial note: A list of refer-ences is available from thepublisher.
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STEIGMANN INSTITUTENeckargemünd — near Heidelberg, Germany
LocationThe Steigmann Institute is located in thepopular vacation town of Neckargemündalong the Neckar River. The town has morethan a thousand years of history and manyof the seventeenth-century buildings haveretained their original charm. There is alively cultural scene with a wide range ofactivities, and its proximity to Germany’sfamous university town of Heidelberg is agreat attraction.www.steigmann-institute.com
How to get thereHeidelberg is located 1 hour south ofFrankfurt am Main. You can book a trainticket to Heidelberg on the national rail-way website: www.bahn.de.
Alternatively, you could take aLufthansa airport shuttle from FrankfurtAirport to Heidelberg. The bus route ter-minates at the Crowne Plaza HeidelbergCity Centre hotel. Buses run every hourbetween 7:00 a.m. and 10:15 p.m. and canbe found right across from the FrankfurtAirport meeting point in Terminal 1, Hall B,Exit B4. Seats are guaranteed if they arereserved three days prior to your arrival.The exact bus schedule and informationon reservation procedures are available atwww.transcontinental-group.com.
Where to stayBoth in the heart of the city and withinwalking distance of the Old Town, Heidel-berg University and Heidelberg Castle arethe following: Crowne Plaza Heidelberg City Centre, is ahotel providing centrally located stylishaccommodation.www.crowneplaza.com | TripAdvisor Certificate of Excellence | 4-star
Europäische Hof Heidelberg, overlookingthe city gardens, is a luxury hotel datingback to 1865 in the heart of Heidelberg’shistoric centre.www.europaeischerhof.com | TripAdvisorCertificate of Excellence | 5-star
Heidelberg Marriott Hotel looks out overthe beautiful Neckar River and is close tothe university and a short distance fromthe Old Town.www.marriott.com
Holländer Hof Hotel is located in the ro-mantic heart of Old Town Heidelberg op-posite the Old Bridge, offering a beautifulview over the Philosophers’ Way and theNeckar River.www.hollaender-hof.de | TripAdvisor Certificate of Excellence | 3-star
Another option is a vacation apartment atthe Bauer winery, where you can choosefrom four modern apartments for two tofive persons. www.heidelberger-dachsbuckel.de
Where to eatScharff’s Schlossweinstube serves moderncuisine among the ruins of HeidelbergCastle.www.heidelberger-schloss-gastronomie.de | 1 Michelin star
Backmulde is a restaurant in the historicHotel Backmulde offering regional cui-sine.www.gasthaus-backmulde.de
Wirtshaus zum Nepomuk provides tradi-tional fare in a tavern atmosphere (highlyrecommended for traditional German cuisine).www.altebruecke.com
Carl Theodor Restaurant & Destillathaus isa small restaurant located in a protectedmonument building next to the Old Bridgeproviding German cuisine.www.carltheodor-restaurant.de
— Steigmann Institute
The Steigmann Institute is aprivate teaching institutionfounded in 2006. Its mis-sion is to teach dentists allaspects of dental implantol-ogy, with the focus on soft-tissue management andbone regeneration.
— Dr. Marius Steigmann
received his degree in dental medicine in 1987 and his Ph.D. in 2005, bothfrom the University ofMedicine and Pharmacy of Tîrgu Mureş in Romania.He is the founder and director of the SteigmannInstitute.
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Seppl is one of the oldest student pubs inHeidelberg and serves regional specialtieswith a good range of home-brewed beerand great glühwein.www.heidelberger-kulturbrauerei.de
Mensurstube, one of two restaurants in theHirschgasse Hotel, serves typical Germanfood.www.hirschgasse.de
What to see and do The ruins of the once-grand HeidelbergCastle rise up on a rocky hilltop over thecity. The castle holds the largest wine bar-
rel in the world, standing seven metershigh and eight and a half meters wide, andholding 220,000 liters of wine. In the cas-tle grounds is the Deutsches Apotheken-Museum, which recounts the history ofWestern pharmacology.
Heidelberg Old Town is filled with archi-tectural gems. Visit the town hall, the OldUniversity and historic buildings like the1592 Renaissance townhouse called“Knight St. George,” and enjoy the open-air cafés dotted along the market squares.The Old Town is also home to a third of allthe shops in Heidelberg.
Untere Straße, a narrow cobblestonestreet that runs parallel to the river and
the main pedestrian street in the OldTown, is filled with great bars, coffee shopsand inexpensive eateries.
The Gothic Heiliggeistkirche, Heidel-berg’s famous church, was at one timeused by both Catholics and Protestants.The top of its spire offers a bird’s-eye viewof the town.
According to tradition, Heidelberg’sphilosophers and university professorswould walk and talk along the Philosophers’Way, which runs along the side of the Heili-genberg. It passes through the forest andcommands panoramic views of the castle.
The university library, built in Wilhelmianstyle, holds superb collections, includingrare books and prints in its exhibitionroom.
A boat trip down the Neckar offers a dif-ferent view of the townscape.www.weisse-flotte-heidelberg.de
For more information visit:www.tourism-heidelberg.com
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Clinical MastersTM Programin Advanced Implant Esthetics11 days of intensive live training with the Masters in Como (IT), Heidelberg (DE), Barcelona (ES)
Live surgery and hands-on with the masters in their own institutes plus online mentoring and on-demand learning at your own pace and location.
Learn from the Masters of Advanced Implant Esthetics:
11 days of live training with the Mastersin Como (IT), Heidelberg (DE), Barcelona (ES) + self study
Curriculum fee: €11,900(Based on your schedule, you can register for this program one session at a time.)
Tribune Group GmbH is an ADA CERP provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Tribune Group GmbH is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or province board of dentistry or AGD endorsement. The current term of approval extends from 7/1/2014 to 6/30/2016. Provider ID# 355051.
Collaborate on your casesand access hours of premium video training and live webinars
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6 modules in Berlin, TBA, 1 module in Graz, TBAA total of 14 days on location
Internationally acknowledged clinics will teach the participan
and leading experts from universitiesnts in all aspects of dental bone
s and private
and tissue
p pregeneration.
p
gRegistration
www.TribuneCME.com information:
Curriculum fee: €11,95VAT (if li bl )
m50
SpoSpo
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C.E.CREDITS84
will be
Online access to our library of Lectures & Clinical Videos
Tribune Group GmbH is an ADA CERP pthe American Dental Association to assiquality providers of continuing dental edapprove or endorse individual courses oacceptance of credit hours by boards of
me.com
provider. ADA CERP is a service ofst dental professionals in identifyingducation. ADA CERP does notor instructors, nor does it implyf dentistry.
Tribune Group GmbH is designated as an Approvof General Dentistry. The formal continuing dentaprovider are accepted by AGD for Fellowship, Mascredit. Approval does not imply acceptance by a stendorsement. The current term of approval extenProvider ID# 355051.
award
ved PACE Program Provider by the Academyl education programs of this program
stership and membership maintenancetate or province board of dentistry or AGD
nds from 7/1/2014 to 6/30/2016.
ded upon completion will be
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30 — issue 2016
CA
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Clinical Masters™Network
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Tribune CME offers dental professionalsthe unique opportunity to become fea-tured top experts in the Clinical Masters™Network, the international community ofprominent dental specialists.
The advantages of being an approved, active member of the growing ClinicalMasters™ Network include the following:
– Access to our growing library of learning resources
– Sharing your knowledge and expertiseon topics in your specialty
– Establishing yourself as a thoughtleader in your region
– Networking with world-renowneddental experts
– Promoting your practice to patientsworldwide
Attract the right patients and receive more referrals
Clinical Masters™ are featured as top experts with a profile page onwww.clinical-masters.com. This gives them the opportunity to sharetheir research with a broad audience, provides international adver-tising to prospective patients, and puts them in touch with generaldentists looking to refer cases to specialists.
The Clinical Masters™ NetworkGrowing worldwide
JOINTHE CLINICAL MASTERS™NETWORK
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Members can contribute to the networkby submitting cases and research, as wellas collaborating on cases by joining theTribune CME mentors.
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Clinical Masters™ are encouraged to de-velop their own network of excellence byinviting local dental experts to submit theircases and video materials.
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Do you have impressive cases and mate-rials to prove your experience? Please submit them to us to be admitted as amember of the Clinical Masters™ Networkafter review and approval by our faculty.
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32 — issue 2016 Clinical Masters™Network
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— Dr. Marius Steigmann
Steigmann Institute – Heidelberg, Germanywww.steigmann-institute.com
— Dr. Xavier Vela Nebot
BORG Center – Barcelona, Spainwww.borgbcn.com
— Dr. Didier Dietschi
Geneva Smile Center – Geneva, Switzerlandwww.genevasmilecenter.ch
The Clinical Masters™ Networkwww.Clinical-Masters.com
— The following experts offer our Clinical Masters™ Programs at six advanced education centers in beautiful locations:
THE CLINICAL MASTERS™NETWORK
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issue 2016 — 33Clinical Masters™Network
Presentation
— Dr. Arnaldo Castellucci
Dr. Arnaldo Castellucci Dental Studio – Florence, Italywww.endocastellucci.com
Lake Como Institute – Como, Italywww.lakecomoinstitute.com
— The Clinical Masters™Network is a select groupof dental professionalsfrom all over the worldwho are distinguished fortheir skills and expertise.You too can join this network by successfullycompleting one of ourClinical Masters™ Pro-grams or by submittingcases to demonstrateyour experience and expertise.
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34 — issue 2016 Esthetic and RestorativeDentistry
Profile
GENEVA SMILE CENTER— Geneva, Switzerland
LocationThe Geneva Smile Center is located onLake Geneva, Europe’s largest Alpine lake,near its landmark fountain. The main shop-ping area in Geneva is just a few minutesaway from the center. Geneva, a trendyparadise, is in the French-speaking part ofSwitzerland and home to the Europeanheadquarters of the United Nations,among over 200 international organiza-tions. It is a city of culture and art and oneof the greenest cities in Europe with 20 percent of it green areas, earning it theappellation “City of Parks.” It is close tosome of the best ski areas in the Alps.www.genevasmilecenter.ch
How to get thereThe center is located seven kilometersfrom Geneva International Airport.It will take about 30 minutes to reach thecenter by taxi in good traffic conditions.An alternative is to take the No. 10 bus tothe bus stop near Genève-Cornavin rail-way station (the stop is called “22-Can-tons”), change to the No. 9 bus and get offat Place des Eaux-Vives.
Where to stayThe following hotels are all located closeto the Geneva Smile Center and the towncenter:
Hôtel Les Armures, ideally located for youto discover the hidden treasures ofGeneva’s Old Town, is an intimate luxuryhotel with origins dating back to the thir-teenth century. www.hotel-les-armures.ch | TripAdvisorCertificate of Excellence
Hôtel de la Paix, built in 1865 and overlook-ing the lake, offers refined luxury with acontemporary design that retains the el-egance of the original Italian architecture.www.ritzcarlton.com | TripAdvisor Certifi-cate of Excellence
Hôtel de la Cigogne, located between theOld Town and Lake Geneva, occupies acharming historic building and its accom-modation is distinguished by luxury, ele-gance, comfort and artistry. www.cigogne.ch | TripAdvisor Certificateof Excellence
Swissotel Métropole, on the rue du Rhône,the most luxurious shopping street inGeneva, is a stylish boutique hotel with apanoramic view over Lake Geneva.www.swissotel.com/hotels/genevaTripAdvisor Certificate of Excellence
Hôtel Longemalle, close to the lake and theJardin Anglais, is a haven of tranquility on
— The Geneva Smile Center
The Geneva Smile Centerhas a treatment philosophythat gives equal considera-tion to the esthetics of patients’ smiles and to theiroral health. It offers excel-lent care performed byleading dental specialists.The center is furnished with modern dental chairs, providing great comfortand optimal hygiene con-trol. The clinic is equippedwith fully digitalized radi-ographic equipment and astate-of-the-art computernetwork. Dentists at thecenter perform all treat-ments under magnification,using either Zeiss lenses (4–5×) or high-tech Zeissoperating microscopes for specific surgical or endodontic procedures.
— Dr. Didier Dietschi
received his D.D.M. in 1984,his M.D. in 1989, his Ph.D. in 2003 and his habilitationqualification (postdoctoral)in 2004, all from the Uni-versity of Geneva. He is currently a senior lecturer at the university and is anassociate professor at CaseWestern Reserve Universityin Cleveland, Ohio, U.S. Dr. Dietschi is in charge ofanterior adhesive restora-tions and periodontal andimplant surgery at theGeneva Smile Center.
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the edge of the Old Town.www.longemalle.ch
Where to eatVertig’O, a restaurant at the Hôtel de laPaix offering gourmet French cuisinewww.ritzcarlton.com | 1 Michelin star
Le Patio, cuisine almost exclusively basedon lobster and beef www.lepatio-restaurant.ch
Brasserie Lipp, a typical French brasseriewww.brasserie-lipp.com
La Finestra, a cozy restaurant in the OldTown serving delicious cuisine with an Ital-ian flavor www.restaurants-geneve.ch
Café Papon, casual French restaurant inthe Old Town www.cafe-papon.com
What to see and do Follow the story of the Genevan humani-tarian movement by visiting the Interna-tional Red Cross and Red Crescent Museum.
Visit the Globe of Science and Innovationat CERN, the world’s largest laboratory forparticle physics.
Climb the 157 steps of the twelfth-century Cathédrale Saint-Pierre for abreathtaking view of the city.
See the over 6,500 flowers and plantsof the Flower Clock, a fine example of Swissprecision, in the Jardin Anglais.
Take a guided tour of the Palais des Na-tions, which houses the United Nations Office at Geneva (www.unog.ch).
Go skiing in the Alps. Chamonix and MontBlanc are located 80 kilometers away.Megève, 70 kilometers away, originallyconceived in the 1920s as a destination forthe aristocracy, is a famous and fancy skiresort.
A lake tour (www.keytours.ch) offers awonderful way to discover Geneva.
Explore the shops and antique dealersof Carouge, close to the city centre, by dayand its trendy bars by night.
Visit the luxury boutiques along the ruedu Rhône to see timepieces of beauty andindulge at the master chocolatiers.
Go on an outing to the village of Dard-agny to walk among the vineyards andsample the local wines.
For more information visit:www.geneve-tourisme.ch
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NO-PREP INTERCEPTIVE REHABILITATION— of tooth wear using a free-hand technique driven by a functional wax-up
— Dr. Didier Dietschi,
is a senior lecturer at the Depart-ment of Cariology and Endodon-tics at the University of GenevaSchool of Dental Medicine,Switzerland. He is also an adjunctprofessor at the Department ofComprehensive Care at CaseWestern Reserve UniversitySchool of Dentistry, Cleveland,Ohio, U.S. Dr. Dietschi alsoworks at the Geneva Smile Cen-ter, a private practice and educa-tion center, in Switzerland. Hecan be contacted at [email protected].
Excessive abrasion (attrition) and erosionare two common conditions affecting den-tal hard tissue and occur in an increasingnumber of patients.1, 2 Both can be consid-ered growing challenges in dentistry, be-cause with such patients, especially in casesof severe parafunction, the etiology canrarely be successfully and permanentlyeliminated.3–5 Therefore, continuous mon-itoring to control related pathologies is re-quired.
The most frequent causes of erosion areunbalanced dietary habits with a high con-sumption of acidic food or beverages (suchas fruit, carbonated drinks, fruit juices andvinegar), as well as abnormal intrinsic acidproduction, such as in bulimia nervosa, acidreflux and hiatal hernia. Insufficient salivaryflow rate or buffer capacity and, in general,salivary composition changes induced byvarious diseases, medications and aging areother etiological co-factors.6–9 As regardsabrasion, awake and sleep bruxism are twodifferent forms of parafunctional activitiesthat can severely affect tooth integrity.4, 5
Preventive and restorative measures aretherefore mandatory to correct and limitthe extent of further tissue and restorationdestruction. An important clinical findingis that a large number of patients affectedby hard-tissue loss present combined eti-ologies, challenging the dental team to de-termine a multifactorial preventive andrestorativeapproach.1–9
The dental consequences of abrasionand erosion are manifold and involve a lossof enamel, with progressive exposure oflarge dentin surfaces, which significantlyaffects the occlusal, facial and lingual toothanatomy and has biological consequencestoo. Objective symptoms or complaints re-ported by patients are shortening of teeth,discoloration, tooth displacement, dentinsensitivity, as well as an increased risk of
forms of early restorative intervention andtheir potential to restrict ongoing tissuedestruction.
A comprehensive treatment approach
The modern approach to the treatment oftooth wear aims to stop its progression be-fore full prosthetic rehabilitation becomesindicated, which would require the re-moval of large amounts of additional toothsubstance with potential biological com-plications10, 11 and a rather inadequate bio-mechanical rationale. The approach in-volves three steps:
(1) a comprehensive etiological clinical in-vestigation, including diet analysis andidentification of general/medical andlocal risk factors;
(2) treatment planning and execution, in-cluding a proper functional and es-thetic wax-up defining the new smileline and tooth anatomy, transferredthen to the mouth with a combinationof direct and indirect restorations; and
(3) a maintenance program, including aprotective night guard and, potentially,repair or replacement of restorationsover a medium- or long-term timeframe.
The restorative options at hand comprisedirect partial composite restorations, in-direct partial composite or ceramicrestorations, and indirect full-ceramicrestorations. Considering the more dra-matic failure patterns observed with con-ventional prosthetic restoration,10, 11 usingmore conservative restorations, such aspartial direct and indirect restorations, ap-pears to have irrefutable advantages andpromising outcomes in the treatment ofsevere abrasion and erosion.12–14
decay and premature loss of marginaladaptation of the restoration. The signifi-cant impact of tooth wear on occlusion,function and esthetics leads the patient toseek advice and intervention. The biome-chanical challenge shall entail a range oftreatments involving different specialties,from preventive measures to full-mouthrehabilitation. Intermediate stages (slightto moderate erosion or abrasion) requireother clinical measures, such as variousforms of adhesive and partial restorations.The aim of this paper is to present a soundclinical concept for addressing various
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Dahl’s concept and controllingthe vertical dimension of occlusion
The idea of increasing the vertical dimen-sion of occlusion (VDO) to treat or restorepatients with abnormal tooth wear hasbeen described and applied for a longtime; one of the first clinicians to promotethis technique was Dahl, who publishedmany articles on this topic.15 His approachwas to use a metal appliance to elevate theocclusion and allow teeth to move pas-sively until they are again in occlusion andthen create space to restore the teeth sta-bilized by the appliance.15 The dentalmovements are intended to occur by com-bined supra-eruption of occlusally freeteeth together with simultaneous alveolargrowth and intrusion of teeth maintainingcontacts. It was shown that such phenom-ena would occur in a significant proportionof patients treated according to this con-cept16 and the outcomes of such treat-ment have been corroborated by severalrecent papers and review articles.15–19 In-creasing the VDO is a key parameter forreversing and preventing the conse-quences of pathological wear anderosion.20–25 The passive eruption that ac-companies the continuous tissue destruc-tion and loss, tremendously restricts thespace available for restorations, which dueto their limited thickness, would be veryfragile or otherwise require unnecessaryremoval of the residual tooth structure.Recent clinical reports have largely vali-dated this treatment approach.23–25
Treatment outline and restorative options
The decision regarding the optimalrestorative choice is usually based on thepre-existing dental condition (presence ofdecay, restoration, vital or nonvital status),as well as the amount and localization oftissue loss. This means that variousrestorative options have to be consideredand that treatment planning is highly in-dividual (tooth-specific).
The therapeutic scheme is logically ori-ented toward re-establishing first properlength of the central incisors and anteriorguidance, governing thereafter the newVDO. Proper anterior tooth anatomy andfunction are designed according to objec-tive esthetic guidelines,26 existing and for-mer tooth anatomy, as well as functional
and phonetic components. The first stepentails producing study casts in the formof a partial (in the case of moderate pos-terior tissue loss) or full-mouth wax-up (inthe case of advanced generalized toothwear or erosion; Fig. 1).
— Direct composite option
The direct composite option is logically in-dicated for all forms of moderate to inter-mediate tissue loss or destruction.13–16
Among the benefits of a direct compositerestoration are its highly conservative ap-proach, the ability to replace or reshapesmall portions of the tooth, reparability,simplified replacement and relatively lim-ited cost (Fig. 2). Conversely, it is moretechnique sensitive and might result in thinlayers of material over some surfaces,placing them mechanically at risk. Whenusing a sculpting technique, properanatomy can be created also with a directtechnique, favoring the selection of ahighly filled material with a firm consis-tency.27–29 In the case illustrating thistreatment modality, a highly filled homog-enous nanohybrid material (inspiro, Edel-weiss DR) was used owing to its firm con-sistency, favorable for free-hand sculptingand modeling (Figs. 2f–l).
— Indirect composite option
The indirect option is logically preferredwhen larger restorations or tissue destruc-tion of a greater severity is present. It alsoprovides greater control of the anatomyand occlusion in complex or advancedcases. Nevertheless, one should not neg-lect the direct option only in favor of thislast parameter, as occlusion seems not toplay a major role in the origin of parafunc-tion.4, 5, 30–32 Since direct and indirect tech-niques can be used together to treat thesame patient, when indirect restorationsare chosen, they have to be fabricatedfirst, at the new VDO, and then directcomposites placed.
— Material selection
Today, the debate about whether ceramicsor composite is best indicated for suchrestorations is sometimes based on per-sonal experience and belief, rather thanon scientific or clinical evidence. Therather abundant clinical literature dealingwith the clinical behavior of composite andceramic inlays and onlays has not shown amajor advantage of either material.33, 34
I clearly favor composite in the contextof tooth wear. Were ceramics to be cho-sen, the Empress material (Ivoclar Vi-vadent), which has shown limited annualfailure rates,35 and, of course, today’snew lithium disilicate pressed ceramic(IPS e.max Press, Ivoclar Vivadent), withimproved flexural strength and fatigueresistance,36 would be considered thebest choice.
Longevity of restorationsplaced to correct severe toothwear and erosion
Clinical studies have demonstrated thatthe performance of composite in thetreatment of advanced tooth wear is ad-equate and that partial fractures representthe most likely complication. These can becorrected by a repair or uncomplicated re-placement of the restoration.37–39 The ten-year survival rate of porcelain-fused-to-metal crowns has been proved to beslightly superior to that of compositerestorations, but with much more severecomplications: Porcelain-fused-to-metalfailures led mainly to endodontic treat-ments or to extractions, while compositefailures or fractures could be either re-paired or replaced.40 This again demon-strates the reason the conservative andadhesive approach is favored for treatingall kinds of mild to moderate forms oftooth wear and erosion.
Conclusion
The incidence of tooth wear represents anincreasing concern for the dental teamand has multifactorial origins. Behavioralchanges, an unbalanced diet, various med-ical conditions and medications inducingacid reflux or influencing salivary compo-sition and flow rate trigger erosion. In ad-dition, awake and sleep bruxism are wide-spread functional disorders that causesevere abrasion. It is then increasingly im-portant to diagnose early signs of toothwear so that proper preventive and, if nec-essary, restorative measures are taken,with the focus on biomechanics and long-term tissue preservation.
Acknowledgments
I would like to thank Serge Erpen (Oral Pro,Geneva, Switzerland) for the fabrication ofthe wax-ups presented in Figures 2d and f.
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Fig. 1Comprehensive treatmentscheme for anterior andposterior tooth wear or erosion. The length of theanterior teeth is reduced by combined wear or erosion (1). The VDO needsto be augmented (2). On the models and based on a wax-up, a new anteriorguidance and smile line areestablished (3), from whichan index is made and trans-ferred to the mouth whenproceeding with posteriorrestorations (4). Three different conditions are encountered in the poste-rior areas:
(a) no or minimal tooth loss(occlusal stops are madewith composite of anytype);(b) moderate tooth lossand/or small to medium-sized restorations (occlusalmorphology is re-estab-lished with a hybrid com-posite and direct tech-nique); and(c) severe tooth loss andlarge metal-based restora-tions (occlusal morphologyis re-established with indi-rect tooth-colored restora-tions—overlay).
Fig. 1
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Fig. 2a
Fig. 2b Fig. 2c
Fig. 2d Fig. 2e
Fig. 2f Fig. 2g
Figs. 2f–lDetails of the treatmentperformed in the lower leftand upper left quadrants,respectively. After rubberdam placement, amalgamfillings were removed andtooth surfaces preparedand cleaned with sandblast-ing, before applying com-posite. A highly filled homogenous nanohybridmaterial (inspiro) was usedand sculpted before lightcuring, enabling properanatomy and function to be established.
Figs. 2d & ePre-op diagnostic wax-up,creating a new and improved occlusal andanatomical posteriorscheme. The full-mouthwax-up is made prior totreatment and establishesthe new VDO. Silicone indexes can serve to buildup lingual and buccal cuspsto the correct level if needed.
Figs. 2a–cPre-op situation showingmoderate to severe toothwear, due to combinedabrasion and erosion etiologies. However, theamount of tissue loss doesnot speak in favor of a conventional prosthetic solution; rather, an interceptive solution using direct compositerestorations would be used in this case.
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Fig. 2l
Fig. 2h Fig. 2i
Fig. 2j Fig. 2k
Figs. 2f–lDetails of the treatmentperformed in the lower leftand upper left quadrants,respectively. After rubberdam placement, amalgamfillings were removed andtooth surfaces preparedand cleaned with sandblast-ing, before applying com-posite. A highly filled homogenous nanohybridmaterial (inspiro) was usedand sculpted before lightcuring, enabling properanatomy and function to be established.
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Fig. 2m Fig. 2n
Fig. 2o
Fig. 2l
Figs. 2m & nThe same treatment sequence was applied to all of the lower and upperquadrants. These imagesshow that composite servesboth to fill existing cavitiesand to replace eroded orworn tissue, creating betterfunction, restabilizingproper anatomy and esthetics, and finally protecting damaged tissuefrom further degradation.This is an ideal treatmentprotocol for moderatetooth wear combined withsmall Class I and II cavities.
Figs. 2o–qSmile and occlusal views of this full-mouth rehabili-tation, using only directrestorations. Such an approach is highly conser-vative, comfortable for thepatient owing to the shorttreatment time, and cost-effective.
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Fig. 2p
Fig. 2q
Figs. 2o–qSmile and occlusal views of this full-mouth rehabili-tation, using only directrestorations. Such an approach is highly conser-vative, comfortable for thepatient owing to the shorttreatment time, and cost-effective.
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Fig. 2r
Fig. 2s
Figs. 2r & sFive-year recall. The patientnever did wear a nightguard despite it being recommended. We can observe some additionaltooth wear, mainly of anerosive nature (see, for instance, the cervical areasof the mandibular pre -molars). The restorationshowever show minimal wear or volume loss, apart frommicrofractures of a fewmargins (i.e., teeth #46 and 47).
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46 — issue 2016 Esthetic and RestorativeDentistry
Profile
MASTER EDUCATIONAL GROUP— Melegnano, Italy
The Master Educational Group (MEG)is an educational center dedicated to es-thetic dentistry with a heart-head-handsapproach to clinical teaching and educa-tion. It offers innovative continuous edu-cation and interaction with dedicated andtalented dentists, who share their passionwith participants in exploring theory, in-novations and technologies in a supportiveenvironment. The center, in addition to ed-ucational and technological areas, offersoperating rooms for multiple live sessions.www.meg-educational.com
How to get thereThe center is located seven kilometersfrom Milano Linate Airport. From MilanoLinate Airport, you can take a connectingbus to Milano Centrale train station to thecenter of Milan. Then to get from Milan toMelegnano:
A chauffeur service is available viawww.mydriver.com. Prices vary based onthe car class, with an average of €54 for
economy class, €61 for business class, €75for a business van and €85 for first class.
Once at Milano Centrale train station,Line 3 on the subway will take you to Meleg-nano in about 20 minutes.
Where to stay
— In MelegnanoIbis Styles Milano Melegnano is located5.5 kilometers from the center and of-fers MEG special rates.www.accorhotels.com | TripAdvisor Cer-tificate of Excellence | 3-star
— In MilanHotel Milano Navigli is in the trendy Nav-igli neighborhood of historic Milan offer-ing many clubs, cafés and vintage shops. www.hotelmilanonavigli.it | TripAdvisorCertificate of Excellence | 3-star
Mercure Milano Solari is located betweenthe city center and the canals, in thefashion and design quarter, where theshowrooms of the biggest names in fash-ion and most innovative designers can befound. www.mercure.com | TripAdvisor Certifi-cate of Excellence | 4-star
NH Milano Palazzo Moscova is set in agrand neoclassical building, which wasformerly Milan’s first train station.www.nh-hotels.com | 4-star
— Dr. Domenico Massironi
graduated with honors inmedicine and surgery fromthe University of Pavia inItaly and specialized in den-tistry at the same universitywith honors too. He main-tains a private practice inMelegnano, where he spe-cializes in prosthodonticsand implant dentistry. Hehas made use of the stereomicroscope since 1988. In2013, he founded MEG withDr. Carlo Ghezzi.
He is a member of the edi-torial board of the Interna-tional Journal of EstheticDentistry and InternationalJournal of Micro Dentistry.He is an active member ofthe European Academy ofEsthetic Dentistry, a mem-ber of the American Acad-emy of Restorative Den-tistry, a diplomate of theInternational Congress ofOral Implantologists, emer-itus member of Amici diBrugg and founder of theCAD/CAM Academy.
Dr. Massironi has presentedcourses and lectured atcongresses both nationallyand internationally. He haspublished and lectured ex-tensively on fixed prostho-dontics and innovativetreatment modalities intooth preparation and es-thetic dentistry in the fieldof dental implant therapy.He has addressed promi-nent university faculties,national and internationaldental academies, and pro-fessional institutions, andhas gained widespreadrecognition internationally.
Dr. Massironi has writtenseveral articles and twobooks: Precision in Pros-thetic Restoration, co-authored with Alberto Battistelli and RomeoPascetta, and Precision inDental Aesthetics, co-authored with RomeoPascetta and GiuseppeRomeo, and translated into numerous languages.
— Dr. Carlo Ghezzi
graduated in dentistry fromthe University of Milan in1999. He has since then tu-tored in periodontology atthe university and was a vis-iting professor at the uni-versity from 2005 to 2010,teaching mucogingival sur-gery. In 2010, he openedStudio Ghezzi, a dental cen-ter specializing in periodon-tal and implant dentistrywith a focus on minimallyinvasive treatments.
Dr. Ghezzi is an activemember of the Italian Soci-ety of Periodontology andImplantology. He has lec-tured at national and inter-national courses and con-ferences, and has authoredand co-authored scientificpublications in national andinternational journals.
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Magna Pars Suites is a former perfume fac-tory transformed into a stylish luxury hotel.www.magnapars-suitesmilano.itTripAdvisor Certificate of Excellence5-star
Where to eat
— In MelegnanoMelemangio, within walking distance ofMEG, offers a fusion of the traditionalcuisine of Parma and Milan, character-ized by a modern interpretation andpresentation, both satisfying and fun.www.melemangio-melegnano.itOsteria del Portone, also within walkingdistance of MEG, serves typical regionaldishes with a modern twist.www.osteriadelportone.com
— In MilanAlice Ristorante is an elegant, warm andwelcoming restaurant with its Mediter-ranean-influenced cuisine updated tosuit current tastes. www.aliceristorante.it | 1 Michelin star
Armani/Ristorante offers a combinationof style, elegance and sophistication fea-turing contemporary cuisine.milan.armanihotels.com | 1 Michelin star
Cracco serves traditional Milanese cuisineupdated with a contemporary twist,
enhanced by a superbly stocked wine cellar, boasting as many as 2,000 selectvintages.www.ristorantecracco.it | 2 Michelin stars
Joia provides vegetarian haute cuisine.www.joia.it | 1 Michelin star
D’O, in Cornaredo, offers colorful, inno-vative cuisine based on authentic Italianingredients. It is not located in the centerof Milan, but well worth an out-of-towntrip. www.cucinapop.do | 1 Michelin star
What to see and do
— In MelegnanoMelegnano is a town in the province ofMilan, in the Lombardy region. The townlies 16 kilometers southeast of the city ofMilan. For information on Melegnanoand guided visits, inquire at Pro Loco(www.prolocomelegnano.it), located inthe Medici Castle. It organizes culturalactivities and local events, including ex-hibitions.
The Medici Castle is home to history,art and culture. It boasts two imposingmedieval towers and evidence of Renais-sance refinement, among them, six-teenth-century frescos.
The Church of San Rocco was built inthe fourteenth century and has a rococo
façade and an eighteenth-century inte-rior.
The Church of San Giovanni Battista, located in Piazza Risorgimento, has me-dieval origins, but was renovated with afaçade of the early 1900s. It is home tomany artworks, among them a paintingby Bergognone.
— In MilanMilan, the busy and fashionable Italiancapital, is considered the internationalarbiter of taste in fashion and design. Asone-time Imperial Roman capital, it com-bines a rich history with a strong senseof place.
Duomo Cathedral, a Gothic cathedralin the heart of Milan, took almost six cen-turies to complete and astounds with ex-travagant detail, including 135 spires and3,400 statues.
La Scala is probably the world’s mostfamous opera house. It hosts classicalconcerts as well.
Museo del Novecento, located in thePalazzo dell’Arengario, accommodatesMilan’s museum of twentieth-centuryart.
Castello Sforzesco houses several mu-seums, among them, the Museum of An-cient Art, the Furniture Museum and thePicture Gallery.
Parco Sempione is a large park situatedin the historic center of Milan.
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48 — issue 2016 Esthetic and RestorativeDentistry
Interview
INTERVIEWwith — Dr. Domenico Massironi
Q: Dr. Massironi, you have gained wide-spread recognition as a pioneer using the op-erating microscope in esthetic prostheticdentistry since the late 1980s. What impactdoes the tool have in clinical practice today?A: Modern dentistry is anchored in veryconservative techniques, the least invasivepossible. Preserving healthy dental tissueis now not only an objective but also a clin-ician’s duty. In this sense, the microscopeoffers a key tool for clear and precise vi-sion, thus ensuring tissue integrity as faras possible and achieving a predictable andharmonious result. I always tell my stu-dents that the microscope has been a spe-cial teacher, whose constant and reliablepresence has changed my way of seeingthings.
Q: Minimally invasive treatment conceptshave become incredibly important. Whatcurrent surgical techniques stand out? A: Surgery, especially in periodontics,de mon strates better healing and moreconservative and predictable treatment ofthe soft tissue. Consider robotics used inabdominal and general surgery, the resultsin terms of reduced costs due to a shorterhospital stay and therapy without the in-vasive operations necessary in the past.This has become an area with reduced sur-gical invasiveness, owing to much im-proved visualization during surgery, whichcan only be positive for our clinical oppor-tunities.
Q: The Master Educational Group (MEG)center, which you founded together with Dr.Carlo Ghezzi in 2013, is dedicated to highereducation in esthetic dentistry and adoptsa heart-head-hands approach. Could youplease explain that further?A: St Francis said, “He who works with hishands is a worker. He who works with hishands and head is a craftsman. He whoworks with his hands, his head and his heartis an artist.” Every time I meet a studentsearching, I try to convey this love for one’sjob that comes from the heart. Talent liesin the heart. Hands follow it, as does thehead. The MEG center was born from thedesire to spread this heartfelt passion,which is made real through operating inexcellence.
Q: What sets the MEG center apart fromother institutions that focus on advancedtraining? A: MEG is a unique center, established inorder to teach and pass down knowledgegained over the years. Each workstationhas a microscope and a workbench with amonitor for viewing live sessions. The sim-ulators have been designed especially forMEG and allow for the use of every typeof rotating instrument, from endodonticsto implantation, with the possibility of us-ing any model, even animal jaws, for sur-gery. MEG is the fruit of research into thesearch for perfectionism, through whichto convey passion, enthusiasm and excel-lence.
The simulators, together with micro-scopes, monitors and video cameras,means it is possible to watch four simulta-neous live transmissions and on the stu-dents’ screens visualize four previews fromthe big screen.
Q: Whom especially are the MEG centercourses targeted at?A: MEG is open to all students who lovetheir job and want to improve their skillsby learning new techniques and evolutionsin our profession with the help of enlarginginstruments, such as loupes using Galileansystems and the operating microscope.Each year, there are numerous studentsfrom all over the world, and it is great tosee each of them committed to using theadvanced technologies offered at MEG inorder to achieve professional excellence.Their amazement upon their arrival by theunique training technology is apparent andevery time for me it is confirmation of hav-ing acted for the good of all.
Q: In addition to the training center, theMassironi Study Club aims at fostering dis-cussion and sharing knowledge among specialists. In times of social media and anomnipresent flood of information, howimpor tant is this kind of immediate exchangefor dental professionals? A:To distinguish, our blog, or social forum,was founded in 2009 and is linked to theosteocom implantology portal, which,thanks to tutors, permits us to have a sitewhere we can exchange clinical cases, sci-
entific articles and other information—aplace to grow, with the respect and helpof tutors and expert clinicians.
When the study club was established,we were a small group who wanted toshare knowledge and experience. How-ever, over time we created a nonprofitevent based in Tirrenia, Italy, which has be-come an international meeting, reachingup to 250 participants last year for thetenth anniversary of the foundation of thestudy club.
Communicating scientific evidence in aworld where everything tends toward sim-plification is an obligation. We have theduty to teach the scientific knowledgegained over time with honesty and aboveall professionalism, trying to avoid this su-perficiality and instant gratification, whichcarries the risk of burnout.
Q: Dental education differs from country tocountry and among specialties. Do you thinkthere should be general guidelines concern-ing dental training?A: A general guideline that knows noboundaries is heart, head and hands. I havetravelled the world for many years, tryingto teach in turn what I have learnt, and nomatter where I go I have always foundgreat homogeneity owing to an honest ap-proach to the profession. Dental educa-tion does not differ in the world if the goodof the patient is considered. Using the microscope with this in mind is extremelyeasy, even for those approaching it for thefirst time. I find that the secret of the train-ing center is that of having a tutor demon-strating treatment live and correcting thestudent in his or her chosen course.
Q: Among other topics, you will focus on hownew materials and simplified methods havechanged the treatment workflow in everydaypractice. From your personal experience,what has influenced the work of cliniciansthe most over the last several years?A: Dentistry nowadays has benefited fromthe introduction of metal-free materialsand digital techniques, which have defi-nitely improved therapy and simplified lab-oratory procedures. One of the most fas-cinating aspects in this specialty has beenthe progress of adhesive techniques,
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— Dr. Domenico Massironi
which have allowed us to treat estheticcases while preserving healthy dental tis-sue. Innovative technology is ever morepresent and we will introduce this in theexcellence that is our main objective.
Q: What are the main challenges in estheticand restorative dentistry today?A: The main challenge nowadays is findingthe right balance regarding minimal inva-siveness, often achieving an excellent es-thetic result from limited preparation ofthe tooth. Esthetics is a direct conse-quence of maintaining the tooth’s healthand function.
“Every time I meet a student searching, I tryto convey this love forone’s job that comesfrom the heart”
Q: Looking back on 25 years of experience,have you observed a shift in patients’ wishesand expectations regarding esthetic andrestorative procedures? A: Patients’ expectations have changed asa consequence of global access to infor-mation. The Internet has become a tool ofknowledge available to all. We need to try,against this background, to offer clinicalexcellence based on honest and unspokenknowledge, offering our patients a specialsmile every time. A dentist who has unfor-tunately passed away since, once said,
“The predictability of the result is tied to presuppositions, the presuppositions are
created from knowledge, knowledgecome from commitment and study, abilityis an added value.” Well, guided by this in-sightful sequence, each case, simple orcomplex, is manageable in the excellenceof esthetics, which makes the heart smile.
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SMILE ANALYSIS— Converting digital designs intothe final smile, Part 2
— Lee Culp,
certified dental technician, isan adjunct professor at theGraduate Prosthetics Depart-ment of the University ofNorth Carolina at Chapel HillSchool of Dentistry in the U.S.He is among the leading devel-opers of many materials, prod-ucts and techniques used indentistry today, and holds numerous patents. His writing,photography and teachingstyle have brought him inter-national recognition in digitaldentistry, dental ceramics andfunctional esthetics.
— Prof. Edward A. McLaren,
D.D.S., is the director of theUniversity of California, LosAngeles Center for EstheticDentistry in the U.S. He maintains a private practicein Los Angeles.
“The way anterior and posterior teeth have been analyzed and characterizedfor the last 50 years has not been effective, as some of those methods have correlated the shape and morphology of the teeth to the shape and proportion of the head.”
Introduction
The fabrication of restorations has entereda new technological age, moving from 2-Dto 3-D. Restoration design—whether it is aframework, full-mouth rehabilitation or all-ceramic—now can be completed on com-puter.1 This article, the second in a two-partseries (the first part of which appeared inthe first issue of the Clinical Masters™ mag-azine), addresses tooth anatomy, morphol-ogy and the various laboratory applicationsfor digital design.
Teeth are very difficult to recreate. Theway anterior and posterior teeth have beenanalyzed and characterized for the last 50years has not been effective, as some ofthose methods have correlated the shapeand morphology of the teeth to the shapeand proportion of the head. However, in-dividuals with a square head do not neces-sarily have square teeth; rounder-faced in-dividuals do not necessarily have roundteeth, etc. There are no sex-specific or eth-nic differences between teeth.2
The American Academy of CosmeticDentistry has published guidelines3 on theartistic parameters of smile design, with thegoal of esthetically replicating nature. Ob-servation is fundamental to this endeavor,as is a true understanding of patient expec-tations.
In a very pleasing smile arrangement, themaxillary central incisors tilt in, the lateralstilt in slightly more, and the canines tilt in.In the mandibular arch, the anterior teethtilt out slightly, while the canines tilt in(Fig. 1). There are three planes of a toothand three shapes of the labial surfaces ofthe tooth: convex, flat and concave. Thereare different tooth shapes: round on themesial, round on the distal, square on themesial, square on the distal, and square onthe mesial and distal.4 While the trend maybe to create symmetrical inclinations be-tween the teeth, tooth inclinations do nothave to match to achieve natural esthetics.Tooth shape and proportion are controlledby root shape, root rotation, bone, and tis-sue preparation. The midline’s facial har-mony significantly affects tooth esthetics.When the midline matches (e.g., height ofcontour to the mesial aspect, discrepan-cies regarding other esthetic aspects be-come insignificant. When two teeth areidentical in length, angulation, midline,mesiodistal contour, and gingival sculpt-ing, the irregularities of the surroundingteeth do not detract from the overall es-thetics (Fig. 2). However, with some pa-tients, a closer examination of the sur-rounding teeth shows one is more squareand the contralateral is rounder; one toothis tilted in and the other is not tilted(Fig. 2).5–7
Tooth anatomy
All tooth anatomy is imparted in the frontof the tooth, but what constitutes thefront of the tooth has to be clearly iden-tified and defined. This is predicated on un-derstanding where the contacts and em-brasures should be positioned relative toproper tooth anatomy. Embrasures mustbe properly angled, as well as openedmesially or distally, depending upon theanatomical buildup that is required. Once
— Dr. Lida C. Swann,
D.D.S., is a clinical assistantprofessor at the GraduateProsthetics Department of theUniversity of North Carolina atChapel Hill School of Dentistry.
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Fig. 1Culp classification of anterior tooth shapes.
Fig. 2All-ceramic restorations,showing natural shape nuances that create a morenatural tooth arrangement.
that has been identified, primary anatomycan be established, followed by secondaryanatomy.8–10 It is important to note thatcharacteristics of secondary anatomy,such as texture and luster, can change theperception of the tooth shape and value.Restorations that are smooth appeartranslucent and lower in value. Rougherrestorations, because of the manner inwhich light reflects off the front, appearmore brilliant but less translucent, despitepossessing the same translucency. Thevarious kinds of textures—broad, horizon-tal striations; narrow, horizontal striations;vertical striations; and a dimpled textureover the front of the tooth—create variousvisual characteristics.8–10
Digital dentistry
Although basic dentistry has not changeda great deal in the past 20 years, innovativematerials and equipment are continuallyenhancing the dental field. Owing to itsstate-of-the-art applications, allowingcreation of strong and esthetic ceramicrestorations in a single appointment uti-lizing computer software, CAD/CAM
technology has become synonymous withdigital dentistry. CAD/CAM is an innova-tive tool for creating a restoration de-signed on computer. Digital dentistry,however, encompasses communication,high- and low-resolution data, 3-D pho-tography, and computer programs thatprovide dentists with the ability to createdigital restorations and virtual patientsthrough the collection of data and the uti-lization of various software programs. Thecompilation of conventional data for plan-ning and treating patients, including de-mographic data, clinical measurements,observation, clinical analysis, thermal data,and color data, has been expanded to in-clude digital data, intra-oral photographs,scan data, cone beam computed tomog-raphy data, and digital radiographs for digi -tal planning and restorative treatment.11, 12
Conventionally, a digital restoration wasa zirconia coping built up with modifiers,dentins, and enamels, sculpted by hand,ground down where necessary, baked,then stained and glazed. Today, a dentinalstructure can be milled from a lithium dis-ilicate block and enamel added, or from ablock of ceramic prelayered with gingivaldentin and incisal materials and milled
Fig. 1
Fig. 2
using CAD/CAM technology, with no dis-cernible differences evident among thethree restorations (Fig. 3). The only dif-ference is time. The first is labor-intensive,the second less so and, as expected, themachine-milled restoration is the quickestand easiest of all to produce.
CAD/CAM
The attainment of perfection in the dupli-cation of natural dentition is the ultimategoal of contemporary esthetic dentistry.Understanding the complex relationshipbetween tooth form and function, andhow these relate and combine to createthe esthetics of natural dentition is the ba-sis of study for achieving predictable suc-cess in oral reconstruction. As patients be-come more educated about the advancesof modern dentistry (as a result of televi-sion makeover shows and professional andover-the-counter whitening systems),their motivation and desire for natural-looking, esthetic restorative dentistry isincreasing at a dramatic rate. Dentists andtechnicians are now fulfilling these patientdemands, but still use dental laboratories
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and restorative techniques that do notalways offer predictable efficiency andquality.
Based upon technology adopted fromthe aerospace, the automotive and eventhe watch-making industries, CAD/CAMis becoming widely accepted owing to itsincreased speed, accuracy and efficiency.Today’s CAD/CAM systems are being usedto design and manufacture metal, aluminaand zirconia frameworks, as well as all-ce-ramic full-contour crowns, inlays and ve-neers that are stronger, fit better and aremore esthetic than restorations fabri-cated using traditional methods. As den-tistry evolves in the digital world, the suc-cessful incorporation of computerizationand new acquisition and manufacturing
technologies will continue to providemore efficient methods of restorationfabrication and communication, while re-taining the individual creativity and artistryof the skilled dentist and technician. Theutilization of these new technologies—along with the evolution from hand designto digital design, with the addition of thelatest developments in intra-oral laserscanning, materials, and computer millingand printing technology—will only en-hance the close cooperation and workingrelationship of the dentist–laboratoryteam.
More than 20 different CAD/CAM sys-tems have been released as solutions forrestorative dentistry. The introduction ofdigital laboratory laser-scanning technol-ogy, along with its accompanying soft-ware, has allowed the dental laboratory tocreate a digital dental environment topresent an accurate 3-D virtual model thatautomatically takes into consideration theocclusal effect of the opposing and adja-cent dentition. With the model, the labo-ratory has the ability to design 32 individ-ual full-contour anatomically correctteeth at the same time. These systems es-sentially take a complex occlusal schemeand its parameters, condense the infor-mation and display it in an intuitive formatthat allows dental professionals with basicknowledge of dental anatomy and occlu-sion to make modifications to the design,and then send it to the automated millingor printing unit. For the dental laboratoryprofession, the introduction of digitaltechnology has effectively automated—and even eliminated—some of the moremechanical and labor-intensive proce-dures (waxing, investing, burnout, castingand/or pressing) involved in the conven-tional fabrication of a dental restoration,giving the dentist and technician the abilityto create functional dental restorationswith a consistent, precise method.
“As dentistry evolves in the digital world, the successfulincorporation of computeri -zation and new acquisitionand manufacturing technol -ogies will continue to providemore efficient methods ofrestoration fabrication andcommunication.”
Digital case
The patient presented with a desire to havehis anterior teeth restored and to have amore esthetic shape and color, while re-taining the natural color nuances of hisposterior teeth (Fig. 4). A comprehensiveexamination was performed to evaluatethe patient’s periodontal and occlusal orfunctional needs, as well as his overall oralhealth. Despite extreme tooth discol-oration, the basic tooth structure wasfound to be satisfactory for restoration.After esthetic and functional evaluation,it was deemed necessary to use full-coverage preparations and restorations torestore both esthetics and anterior guid-ance and function. As with any restorativeprocess that will change tooth shape, po-sition and function, a diagnostic workup(wax-up) was completed. After the pa-tient, dentist and technician had all agreedto the proposed changes, the clinicalpreparations were completed, and a copyof the wax-up was created for the tempo-rary PMMA restorations for the intra-oralevaluation. Once the provisional restora-tions had been approved, it became thetechnician’s responsibility to copy thetemporary restorations in fabricating thefinal IPS e.max lithium disilicate (Ivoclar Vi-vadent) restorations (Figs. 5–23).
Fig. 3All-ceramic restorationsshowing three differenttypes of fabrication meth-ods. Left: milled IPS e.maxCAD restoration (IvoclarVivadent), with only enamellayering. Center: milled IPSEmpress CAD Multi full-contour restoration(Ivoclar Vivadent), with surface stain and glaze.Right: zirconia coping, fully layered with severaldifferent dentin and enamel ceramics.
Fig. 18IPS e.max CAD restora-tions after the crystalliza-tion process.
Fig. 19Stain and glaze of IPS e.maxCAD restorations.
Fig. 8 Fig. 9 Fig. 10
Fig. 11 Fig. 12 Fig. 13
Fig. 16Fig. 15Fig. 14
Fig. 19Fig. 18Fig. 17
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Editorial note: A list of refer-ences is available from thepublisher.
The article was originallypublished in the Journal ofCosmetic Dentistry, Summer 2013, Volume 29,Number 2.
Fig. 20Post-op image of cementedmaxillary all-ceramicrestorations.
Fig. 21Post-op image of cementedmandibular all-ceramicrestorations.
Figs. 22 & 23Final view of digitally designed and milled IPSe.max CAD anteriorrestorations, showing excellent fit, form and natural-looking esthetics.
Conclusion
This article has provided an overview of thepossibilities of digital smile design, usingcomputer design software, for the designof the milled diagnostic wax-up, the milledprovisional restorations, and the final milledceramic restorations.
CAD/CAM technology should not be re-garded as mere machinery to fabricate full-contour ceramic restorations or frame-works; digital dentistry represents a newway to diagnose, plan treatment, and createfunctional, esthetic restorations for pa-tients in a more productive and efficientmanner. CAD/CAM dentistry will onlyfurther enhance the dentist–assistant–technician relationship as we move togetherinto this new era of patient care.
Automation has been slow in coming todentistry and although new equipment hasbeen introduced to make our work easier,we still create complex dental prosthesesusing old techniques. Even though thelost-wax technique is still a tried-and-truemethod of fabrication, there will come a dayin the near future when all frameworks andfull anatomical crowns will be designed oncomputer. Only then will we truly realize thewonder and power of dental CAD/CAMtechnology that was introduced so long ago.
Acknowledgments
The clinical dentistry shown in this articlewas performed by Dr. Swann. The digitaland technical dentistry was performed byMr. Culp.
Competing interests
Mr. Culp receives an honorarium fromIvoclar Vivadent. Prof. McLaren and Dr. Swann declare that they have no com-peting interests regarding this article.
“Once the provisional restorations had been approved, it became the technician’s responsibility to copy the temporary restorations in fabricating the final ceramic restorations.”
Fig. 20 Fig. 21
Fig. 22 Fig. 23
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58 — issue 2016 Interview
INTERVIEWwith — Dr. Stavros Pelekanos
Q: Dr. Pelekanos, what is the role of estheticsin dental implantology today?A: Implantology in the 1980s and 1990swas bone-driven. The Albrektsson criteriafor a successful implantation back in 1986did not even refer to esthetics and werefollowed for many years to come. Nowa-days, prosthodontists start the treatmentand perform backwards planning, alwayskeeping in mind the correct positioning ofthe tooth or teeth to be replaced.
Q: Patients’ expectations regarding estheticresults are growing with the emergence ofnew technologies and materials. However,have these innovations truly arrived in everydental office?A: Well, in continuation of my response toyour first question, there are two majorproblems that the dental community hasbeen facing in recent years, incorrect im-plant positioning and periimplantitis bothbeing difficult to resolve. As patients be-come more aware of these complications,they expect and demand more estheticand predictable results. New technologiessuch as high-resolution CBCT, CAD/CAMabutment manufacture, abutments pro-duced using new zirconia technologies,and digital planning are already widely inuse in everyday dentistry, minimizing risks,as well as enhancing esthetics and treat-ment workflow.
Q: Have digital solutions changed the waydental restorations and full-mouth rehabil-itations in particular have been performedover the past several years?A: Digital planning, intra-oral digital im-pressions and CAD/CAM technologieshave really changed implantology today.First of all, preoperative planning is a help-ful tool for ensuring correct implant place-ment, for both novice and experiencedsurgeons. Furthermore, more conserva-tive (sometimes flapless) surgical ap-proaches result in much less postoperativeswelling, facilitating greater patient ac-ceptance. The digital workflow in prostho-dontics facilitates milled abutment con-
structions or even same-day teeth whenimmediate loading or provisionalization is chosen in the treatment planning.CAD/CAM laboratory procedures reducehuman error, providing more robust andaccurate frameworks and final recon-structions.
Q: In your experience, what is the best wayto achieve a natural-looking implant crown?A: Irrespective of the digital revolution,the hand skills of a talented dental tech-nician are indispensable, especially in thecase of a single implant crown next to nat-ural teeth. Machines will never replace thehuman hand, as individual perception ofevery case, the knowledge of biology andanatomy are of the greatest importance.The factors that determine the successand natural appearance of an implantcrown are accurate implant positioning,meticulous bone and soft-tissue handling,and a skilled dental technician.
Q:The number of implants placed worldwideis expected to double over the next five to sixyears. Consequently, education efforts haveto double too in order to ensure that dentistsare adequately trained in implant place-ment. Do you agree with this statement?A: Of course; however, and I say this al-though I am a faculty member of the Schoolof Dentistry of the University of Athens,which provides education at the highestlevel, students are still unfortunately notadequately trained in implants. Postgradu-ate studies in a university environment orvery well-organized implant master pro-grams are necessary for a dentist to be ableto place or restore implants.
Q: We have seen quite a few different con-cepts emerging over the last several years inesthetic dentistry, such as bio-emulation andsmile design. Which concepts will have themost impact in the future and change theway esthetic dentistry is performed?A: Well, as a prosthodontist, I have to saythere is nothing new in these concepts.Basic esthetic rules are to be applied inevery prosthodontic case, such as toothpositioning, proportion, occlusion, colorand design. However, digital technology isa very helpful tool, especially for thenovice dentist, for implementing theserules and simplifying the treatment work-flow. The same applies to bio-emulation.Biological concepts, improved materialsand techniques are always there to simplifyclinical dentistry and reduce potential er-rors and complications.
Q: What is the position of esthetic dentistryin the development of dental specialties inyour opinion? A: Esthetic dentistry is not a recognizedspecialty generally, falling mainly underprosthodontics.
I do not think esthetic dentistry shouldbe a stand-alone specialty. Being trainedin a periodontic-prosthodontic environ-ment (University of Freiburg, Germany,under Prof. J.R. Strub), I believe that amodern restorative dentist should be ad-equately trained in more than one mainarea. Periodontics, prosthodontics andrestorative dentistry all constitute what isconsidered esthetic dentistry.
“As patients becomemore aware of thesecomplications, they expect and demandmore esthetic and predictable results.”
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issue 2016 — 59Interview
“Machines will never replace the human hand, as individual perception of every case, the knowledge of biology and anatomy are of the greatest importance.”
— Dr. Stavros Pelekanos
received his D.D.S. in 1991 andhis doctoral degree in 1993.He runs a private practice in Athens specializing in prosthodontics, implantologyand esthetic dentistry. He is an assistant professor at theSchool of Dentistry of the University of Athens, Greece,and a faculty member of theGlobal Institute for Dental Education, Los Angeles, Calif.,U.S. Dr. Pelekanos lectures internationally and giveshands-on courses on implants,esthetics and restorative procedures. To date, he haspublished over 20 articles inpeer-reviewed journals andtwo chapters in books.
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60 — issue 2016 Clinical Masters™ Testimonials
Dr. Rima Ousma Mardini — UAE
— For this new editionof the Clinical Masters™magazine, we againasked participantsabout their experienceof the programs andpresenters.
APPLY NOW!www.Clinical-Masters.com
CLINICAL MASTERS™TESTIMONIALS
“The Geneva sessionwas great. Dr. Dietschiis amazing. I really enjoyed it.”
Dr. Malaka al-Kaabi — Qatar
Dr. Dimitra Tsangaratou — Greece
“The Geneva course was excellentby all means. Dr. Dietschi is notonly a great teacher, but also a really very nice person.”
Dr. Andrea Ferrazzi — Italy
“The whole program was so perfect that I intend to tell my colleagues to take this course.”
“I was fully satisfied. Flawless presentation and experienced teacher. I have gained considerable knowledge and am looking forward to applying all I’ve learned in my dailypractice.”
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issue 2016 — 61Clinical Masters™Testimonials
Dr. Curd Bollen — Netherlands
“Good proportional combination of theory and practical exercises.”
Dr. Rosa Mário — Mozambique
“The course was very clear andaccessible. A very good program to learn how to putthe theory into practice.”
Dr. Saad al-Anezi — Kuwait
“Very well organized and veryinformative. It gave me a higher level of practice andknowledge.”
Dr. Herminio Fernandes — Canada
“I enjoyed the course very much. The lecturers were all excellent. I learned a lot.”
Dr. Zahira Mendoza — U.S.
“Very well-organized course in a welcoming environment, perfect for learning. Presentations were amazingand with great content.”
Dr. Mohammed Yagmoor — Saudi Arabia
“New concepts and techniqueslearned, as well as the opportu-nity to use new material.Highly educational and wellpresented by the faculty.”
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62 — issue 2016 Endodontics Article
MATCHING GUTTA-PERCHA CONES— to NiTi rotary instrument preparations
— Gianluca Gambarini
is Professor of Endodontics atthe Sapienza University ofRome’s dental school in Italy.He is an international lecturerand researcher, and activelycollaborates with a number of manufacturers all over theworld to develop new tech-nologies, operative proceduresand materials for root canaltreatment. Prof. Gambarinialso works in a private endo -dontics practice in Rome.
Prof. Gianluca Gambarini,Dr. Gianluca Plotino, Dr. Nicola Maria Grande, Dr. Simone Staffoli, Dr. Federico Valenti Obino,Dr. Lucila Piasecki, Dr. Dario di Nardo, Dr. Gabriele Miccoli & Prof. Luca Testarelli, Italy
Introduction
With the widespread use of rotary nickel-titanium (NiTi) instruments, matched-taper gutta-percha (GP) cones of greatertapers were developed to make root canalobturation techniques easier and morepredictable, and possibly to the improvequality of 3-D fillings. Nowadays, manymanufacturers produce matched-taperGP cones intended for use with a specificinstrumentation technique. Consequently,the single-cone technique has regainedpopularity, since a single matched-tapercone can produce a satisfactory 3-D fill,and warm vertical techniques benefit fromthe use of a matched-taper master coneby a reduced risk of voids inside the filledendodontic space.
However, the larger number of and vari-ability in design and dimensions of com-mercially available NiTi instruments andGP cones of greater tapers can easily cre-ate confusion among practitioners, espe-cially if using instruments and cones of dif-ferent brands. If the GP cones selected donot precisely match with the NiTi instru-ments used, the whole concept fails andin many cases the GP cones do not reachthe desired working length or do not pre-cisely fill the apical preparation.
In order to understand how matched-taper GP cones should work, it is impor-tant that clinicians be aware of the differences in size, taper, design andmanu facturing process of these products.Even if these factors are usually taken inaccount when a manufacturer producesmatched-taper GP cones to be used witha specific instrumentation technique, thegoal of the present paper is to discuss allof these variables and give clinicians a bet-ter understanding of the possible clinicalproblems they may encounter in cone fit-ting and practical solutions to these.
Size, tolerance and manufacture of GP cones
Conventionally, GP cones are hand rolled,a manufacturing process that is neithervery precise nor consistent. Therefore, ac-cording to ISO standards, the tolerance al-lowed for GP cones is 0.05 mm, muchlarger than the tolerance allowed for en-dodontic instruments produced by grind-ing or twisting (0.02 mm). This has alwaysbeen a problem in endodontics and it ex-plains why correct fitting of the mastercones in all techniques (single-cone, lat-eral condensation, warm vertical conden-sation, continuous wave of obturation) hasalways been described as a fundamentalstep in the procedure.
With the conventional ISO 0.02-taperedcones, the problem was mainly related tothe lack of precision of the tip of the GPcones. Therefore, GP tips needed to bemanually adjusted to fit the apical prepa-ration with good retention (tug-back) inorder to avoid underfilling or overexten-sion of cones through the apical foramen.The same procedure was needed for non-
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issue 2016 — 63EndodonticsArticle
Fig. 1Comparison of instrumentsand cones with uniform andnonuniform tapers.
standardized GP cones with featheredtips. For this reason, specific calipers andinstruments to cut GP cones preciselywere developed.
With the introduction of GP cones ofgreater tapers, a problem related also tothe taper arose. These new GP cones canbe grouped into two categories: uniformand nonuniform taper. The former conesare usually marketed as 0.04- or 0.06-tapered cones, while the latter are usuallymarketed in association with a brand namerelated to a specific instrumentation tech-nique (e.g., ProTaper cones, DENTSPLY;and TF Adaptive [TFA] cones, Kerr). De-velopment of these cones was necessary,since nowadays more NiTi rotary instru-ments have a nonuniform taper (e.g., Pro-Taper; and HyFlex EDM, Coltène/Whale-dent) or a working part smaller than 16 mm(e.g., Twisted Files [TF], Kerr; and TFA).
Tip sizes and tapers of NiTi instruments
While some instruments have a nonuni-form taper, the majority of endodonticNiTi rotary instruments have a uniform ta-per, and the associated techniques are in-tended to create at least a 0.04- or 0.06-tapered preparation. For this reason, GPcones of greater tapers are usually sold in0.04 and 0.06 tapers.
However, NiTi instruments with thesame nominal size and taper may not havethe same dimensions and consequentlynot create an identical root canal prepa-ration, since the length of the working partmay be different (Fig. 1). For example, ina 25.06 K3XF instrument (Kerr; or otherinstruments, including Revo-S, MICRO-MEGA; ProFile, DENTSPLY; and Race,FKG Dentaire), the working part is 16 mm,while in a 25.06 TF instrument, it is 10 mm.Even if the taper and tip sizes are the same,a 25.06 K3XF instrument will enlarge theroot canal to 1.21 mm. This calculation canbe made as follows: 0.06 mm increase foreach millimeter, multiplied for 16 mm =0.96 mm + 0.25 mm tip size = 1.21 mm. Incontrast, a 25.06 TF instrument (a file witha reduced working part) will enlarge thecanal to a lesser extent: 0.85 mm(0.06 mm × 10 mm = 0.60 mm + 0.25 mmtip size = 0.85 mm).
Similar differences can be found be-tween any NiTi instrument with a conven-tional 16 mm working part compared withany other instrument with a reduced work-ing part. NiTi instruments with a shorterworking part are widely used because ashorter working part creates less stressduring instrumentation by reducing taperlock and torsional stress in the coronalpart, the largest section of the instrument.With a lower operative torque, efficiencyand safety are more easily improved. For
Fig. 1
25.06 GP cone16 mm long; 0.06 taper
SM2 TFA GP cone
25.06 K3
SM2 25.06 TFA
10 mm long; 0.06 taper
16 mm working part
10 mm
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64 — issue 2016 Endodontics Article
the same reason, some instruments havea nonuniform taper, which usually issmaller in the coronal part, in order to gainmore torsional strength in the apical partand more flexibility in the coronal part.Nevertheless, instruments with shorterworking parts or nonuniform tapers needGP cones with the same design and dimen-sions in order to allow a good match be-tween the prepared canals and the obtu-rating materials.
Matching instruments withnonuniform tapers with GP tapered cones
The same differences in dimensions pre-viously described between instruments(e.g., K3XF compared with TF) can befound between 0.04-/0.06-tapered GPcones and cones with nonuniform tapers(e.g., ProTaper and TFA cones). The firstfew millimeters are usually similar, but in the middle or coronal part, the GP cones might be much wider. Therefore, ifa 0.04-/0.06-tapered GP cone is used ina root canal prepared with nonuniform-ta-per instruments, the GP cone will probablynot go to working length, because of thegreater dimensions of the cone in the mid-dle or coronal part. This could be consid-ered GP taper lock.
This is a different problem to that expe-rienced by dentists in the past, which wasmainly related to cone fitting in the apicalpart, and consequently requires a differ-ent approach. Choosing a cone with asmaller tip size may not solve the problem,while choosing a smaller-taper cone maysignificantly increase the risk of iatrogenicerrors such as underfilling and overexten-sion of the cone through the apical for -amen, because the tug-back in the coronalpart does not allow for correct fitting ofthe apical part of the cone.
Therefore, the best and easiest solutionis to choose brand-associated GP conesthat precisely fit the root canal prepara-tion achieved by the specific NiTi instru-ments and allow for ideal 3-D filling andgood apical tug-back. However, with theK3XF system, clinicians could use bothtypes of cones (i.e., the 0.04–0.06 conesor TF/TFA cones) because they will bothfit the root canal preparation in the apicaland middle thirds well, where tug-back and3-D matching are more critical.
More clinical hints
Thus far, dimensions and sizes have beendiscussed to help clinicians understand thedifficulties in matching instruments andcones. However, there are also clinicalways to seek to solve problems encoun-tered during these procedures. The fol-lowing advice may be useful for both in-struments with nonuniform tapers andmany instrumentation techniques.
— Create greater coronal flaring
If a GP cone does not perfectly match theroot canal preparation and thus does notreach the working length, one possible so-lution is to increase the coronal flaring bybrushing with the last instrument used. Bydoing so, the NiTi instrument will increasethe dimensions of the prepared canal inthe coronal part, solving the problem ofGP taper lock.
— Ensure correct apical fit
Clinicians may experience two differentclinical problems in the apical fit: the needfor a better apical tug-back, which may re-quire slightly cutting the tip of the mastercone, and the fit related to the amount ofcanal transportation. The first situationmay occur when, owing to the differentdimensional tolerance, a GP cone isslightly smaller than the nominal size, in-creasing the risk of overfilling during ob-turation. In such a case, the advice is to in-crease the dimensions of the master coneslightly by cutting 0.5–1 mm off the tip, orideally to recalibrate the master cone pre-cisely using a tip-snip device. This can alsooccur if a canal is slightly overinstru-mented (e.g., owing to an error in deter-mination of the working length or in theposition of the rubber stop on the file). Insuch a situation, the apical constrictionwould have been modified and the conefit would have to compensate for the errorby increasing the tip size of the GP mastercone.
Some NiTi instruments (HyFlex; TFA;TRUShape, DENTSPLY; NEONITI, NEOLIX;etc.) are significantly more flexible thanthe majority of competing NiTi rotary in-struments. As a consequence, they tendto follow and maintain the original trajec-tory of the root canals more precisely,minimizing canal transportation. Canal
transportation frequently occurs when arigid file is inserted into a curvature andtends to straighten it by cutting more inthe inner part of the curvature coronallyand in the outer part apically. However,this error, which can affect the quality ofdebridement, makes insertion of masterGP cones easier, especially when complex,double or triple curvatures are present.For this reason, clinicians using such flex-ible NiTi instruments may experienceslightly more difficult insertion of the mas-ter GP cone to the working length. If thisproblem occurs, once again slightly in-creasing flaring by circumferential filingcan help.
Conclusion
It may be concluded that clinicians who useinstruments with nonuniform tapers orwith reduced working parts should prefer-ably use brand-associated GP cones thatperfectly match with the prepared canals.By doing so, fitting the master GP conebecomes much easier and more pre-dictable. In the very few cases in whichproblems still arise, the clinical hints pro-vided may help practitioners to under-stand the problem and find a proper solution.
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66 — issue 2016 Endodontics Interview
INTERVIEWwith — Prof. Fabio Gorni
Q: You have been a practicing dentist forabout 30 years now, with a specialization inendodontics and surgical endodontics. Inyour opinion, what has been the most impor-tant development in the field over the pastthree decades?A: Endodontics is probably the dental spe-cialty in which the most significant tech-nological innovations have been intro-duced. The major innovations haveencompassed instruments, materials andequipment. In terms of the improvementin instruments, rotary nickel-titanium(NiTi) files are the greatest innovation.
Regarding materials, bioceramic ce-ments have to be taken into consideration,since they represent an enormous oppor-tunity for the clinician. They can be useddifferently and have several applications,in particular treatment of severely com-promised teeth. Nevertheless, we have toremember that the daily employment ofmagnification is one of the most importantfactors to be considered.
Q: Developments in technology and mate-rials continue to influence the practice of en-dodontics. How has the way root canal treat-ment as practiced by endodontists changedover the years?A: Certainly, these innovations have al-lowed therapeutic advances, for both pa-tients and the dentist. In fact, it is possibleto perform a faster and more predictabletherapy. It is certainly possible to preservedentinal tissue owing to minimally invasiveshaping of the root canals, but it can stillensure proper cleaning and, last but notleast, it is possible to save teeth that justa few years ago would have been ex-tracted.
Q: Recently, a study conducted at the Uni-versity of California, Los Angeles (UCLA)demonstrated that using nanodiamonds tofortify gutta-percha could significantly im-prove outcomes in patients. Do you think thiscould be the obturation material of the fu-ture?A: First of all, I would like to congratulateProfs. Dean Ho and No-Hee Park and theirteam at the UCLA School of Dentistry forthe high quality and the innovation of their
recent article. Without any doubt, we cansay that gutta-percha has been the pre-ferred material for root canal filling, evenwith the great necessity to reduce peri -apical infection and to improve the mate-rial stability.
In this research, the authors found asuccessful method by which to improvethe manageability of gutta-percha, ob-taining an apical seal similar to the conven-tional one. In addition, it is important tounderline the relevance of the data rela-tive to amoxicillin-enriched gutta-percha.The in vitro study proved that drug-rein-forced nanodiamonds combined withgutta-percha effectively prevented bac-terial growth. However, this innovationneeds to be proven in a clinical study, withappropriate records and the necessary follow-up. In my opinion, bioceramic ma-terials could bring about even greater advances in endodontics owing to theirversatility.
Q: In the U.S., the majority of root canaltreatment is performed by general dentists.Have these dentists adopted newer tech-nologies, such as digital radiography andNiTi rotary instrumentation?A: The innovation brought about by NiTirotary instruments has been substantialand has changed daily practice both forthe endodontist and for the general prac-titioner. In fact, it offers the possibility ofobtaining a qualitatively good therapy in ashort time. Digital radiography is not asrelevant as NiTi rotary instruments are forachieving a successful therapy. However,3-D radiography had a considerably posi-tive impact on diagnostic methods. Thismethod is based on a low radiation doseand increases the ability to make an accu-rate diagnosis, which guarantees a greatresult for the patient and a notable reduc-tion of time for the operator.
Q: Could you tell us a little about Style Ital-iano Endodontics, your role within that com-munity and why it is important to you?A: Style Italiano, which has more than100,000 followers, is the largest dentalcommunity in the world. It started as arestorative sharing group and the idea of
Style Italiano Endodontics was born fromthis body, less than six months ago. StyleItaliano Endodontics is about to reach35,000 followers.
The purpose is to give to modern den-tists clear and accurate guidance andpractical suggestions to apply duringtheir daily treatment of patients. Thethree keywords that describe the philos-ophy of the group are “feasible,” “teach-able” and “repeatable.”
Based on this idea, Style Italiano usesFacebook as a way to communicate all overthe world and to share clinical cases with alarge community of operators, so it be-comes easier to make and to receive criti-cism and commentary.
This high visibility allows a dentist toshare his or her work with a large numberof people and compare it with many otherideas, so it can be regarded as an opportu-nity to learn and improve new techniquesand share new and simple protocols. Themain motto of the Style Italiano team is“you can do what we do”.
Q: What role do you think courses such asthe Tribune CME Clinical Masters™ Programplay in promoting the skills and expertise ofendodontists and general dentists?A: I think that, nowadays, dentistry needsto be based on techniques recognized andaccepted by the scientific communityworldwide.
The Tribune CME Clinical Masters™Programs are held in the world’s largestcities, like San Francisco, Rio de Janeiro,Milan and Dubai, and they are led by someof the most prominent experts in den-tistry. These courses offer “lifelong learn-ing concepts for an ever-changing indus-try,” access to high-quality traininginstitutes from anywhere, the possibilityof practical training in the faculty’s ownenvironment, and live mentoring sessionswith experts and peers.
I believe that never before have such alarge number of experts in various dentalspecialties been brought together to offera program universally recognized as a cer-tificate of excellence.
“It is possible to saveteeth that just a fewyears ago would havebeen extracted.”
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— Prof. Fabio Gorni
issue 2016 — 67
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68 — issue 2016 Endodontics Profile
DR. ARNALDO CASTELLUCCIDENTAL STUDIO— Florence, Italy
LocationFlorence, the capital of Tuscany is a cul-tural, artistic and architectural gem. Oneof its most influential families, the Medicis,not only sponsored the arts, but was ofgreat importance owing to their thrivingcommercial activity and subsequent polit-ical influence. Florence is considered to bethe birthplace of the Italian Renaissance,home to creative geniuses and scientificmasterminds, who left their legacies in thecity’s many museums and art galleries. Flo-rence’s economic strength fostered thegrowth of mercantile guilds and attractedan influx of immigrants. Today, the city isknown for its dedication to its artistic andhistoric patri mony and is regarded as oneof the top destinations in the world.www.endocastellucci.com
How to get thereThe city center is located 8 kilometersfrom Peretola airport. It can be reached inabout 15 minutes by taxi and about 20 min-utes by bus on the Vola in Bus shuttle (runby Busitalia Sita Nord), which operates be-tween the airport and the central railwaystation of Santa Maria Novella. www.fsbusitalia.it
Where to stayThe following hotels are all located withintwo kilometers of Dr. Arnaldo CastellucciDental Studio and the town center:
Hotel Regency, situated in a quiet, residen-tial area, this boutique hotel is the resultof careful restoration of an original Flo-rentine villa. www.regency-hotel.com | TripAdvisorCertificate of Excellence | 5-star
Hotel Monna Lisa is housed in a fifteenth-century renaissance palace and offers old-world rooms surrounded by peaceful,landscaped gardens.www.monnalisa.it | TripAdvisor Certificateof Excellence | 4-star
Hotel Santa Maria Novella, set in a pictur-esque square, offers well-appointed
rooms and its rooftop terrace overlooksthe Basilica of Santa Maria Novella.www.hotelsantamarianovella.it | Trip -Advisor Certificate of Excellence | 4-star
Hotel Plaza Lucchesi, overlooking the ArnoRiver, is a very elegant hotel offeringamazing views of the landscape and thecity from its rooftop terrace, where youcan enjoy a drink or a swim.www.hotelplazalucchesi.it | TripAdvisorCertificate of Excellence | 4-star
Hotel Villa Liana offers accommodation ina nineteenth-century villa, a former Britishconsulate, boasting the original ceilingfrescos and set in an English-style garden.www.hotelliana.com | TripAdvisor Certifi-cate of Excellence | 3-star
— Dr. Arnaldo Castellucci, M.D., D.D.S.
graduated in medicine atthe University of Florencein 1973 and specialized indentistry at the same uni-versity in 1977. From 1978to 1980, he attended con-tinuing education courseson endodontics at BostonUniversity School of Gradu-ate Dentistry (now theBoston University Henry M.Goldman School of DentalMedicine) in the U.S. Aswell as running a practicelimited to endodontics inFlorence, he is Professor of Endodontics at the Uni-versity of Cagliari dentalschool in Italy and Profes-sor of Surgical Endodonticsat the University of NaplesFederico II oral surgery department, also in Italy.
Dr. Castellucci is thefounder and President ofthe Warm Gutta-PerchaStudy Club and of the Micro-Endodontics TrainingCenter in Florence, wherehe teaches and gives hands-on courses. He is past President of the Italian Endodontic Society, pastPresident of the Interna-tional Federation of Endodontic Associations, as well as an active memberof the European Society of Endodontology, theAmerican Association ofEndodontists and the ItalianSociety of Restorative Dentistry.
An international lecturer,Dr. Castellucci has published more than 60 articles and is the authorof the book Endodontics. Heis the past editor of the Giornale Italiano di Endodonzia (Italian journal of endodontics) and L’Informatore Endodontico(endodontic informer) andis the Editor-in-Chief ofEndo Tribune Italy.
— Dr. Arnaldo CastellucciDental Studio
With over 35 years of prac-tice, Dr. Arnaldo Castellucciis an internationally recog-nized specialist in the fieldof endodontics. Owing tohis passion for teaching andexperimenting, passed onto him by Prof. HerbertSchilder, he established atraining center at his prac-tice, where he passes on allthe knowledge he hasgained over the years tostudents and colleagues insearch of a greater degreeof specialization with to-day’s modern technologies.At the center, there is aclassroom with ten worksta-tions equipped with an op-erating microscope and thenecessary instruments toperform the procedurestaught in the best way pos-sible on mannequins andplastic models.
Dr. Castellucci offers histheoretical and practicalcourses throughout theyear, ensuring flexibility foranyone not able to partici-pate during certain periodsof the year.
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Palazzo Vecchio, located next to the UffiziGallery, is one of the most famous symbolsof Florence. From its tower, you can enjoya wonderful view of the city.
The Cappella Brancacci is a chapel in theBasilica di Santa Maria del Carmine withmagnificent frescoes painted by Masolinoda Panicale, Masaccio and Filippino Lippi.
Corridoio Vasariano, built to allow theMedicis to move between their twopalaces, is a covered passageway connect-ing Palazzo Vecchio with the Palazzo Pitti.
The Museo di Palazzo Davanzati is housedin a fourteenth-century palace, oncehome to the wealthy Davanzati family, andits present arrangement aims at recon-structing the setting of an old Florentinehome.
The Museo dell’Opera del Duomo con-tains many of the original works of art cre-ated for the Cattedrale di Santa Maria delFiore, including masterpieces by Ghiberti,Donatello, Luca della Robbia, Antonio Pol-laiolo, Verrocchio and Michelangelo.
The Museo di San Marco, occupying avast area of the Dominican convent of SanMarco, founded in 1436, showcases thework of Fra Angelico, who frescoed ex-tensive parts of the convent.
For more information visit:www.firenzeturismo.it
issue 2016 — 69EndodonticsProfile
Where to eatWinter garden by Caino, in the elegant set-ting of a sophisticated winter garden, is acollaboration between Chef MicheleGriglio and Chef Valeria Piccini that setsnew heights for a refined restaurant expe-rience.www.restaurantbycainoflorence.com1 Michelin star
Panini Toscani is an Italian delicatessenserving paninis and a selection of cheesesand cold meats (no dinner).
The following trattoria and ristoranteserve typical Tuscan cuisine:
Perseus—the house specialty is Florentinesteak.www.casatrattoria.com
Trattoria 13 Gobbiwww.casatrattoria.com
Trattoria I’ Parionewww.parione.net
Il Cibrèo offers fine, inventive cuisine in-spired by traditional dishes. www.edizioniteatrodelsalecibreofirenze.it
What to see and doThe Uffizi Gallery, one of the most famousmuseums in the world, houses unique art-works and masterpieces by artists such as Botticelli, Michelangelo, Da Vinci and Raffaello.
The Accademia Gallery is, with the Uffizi,one of the most visited museums in Flo-rence. Here you will be able to appreciatethe beauty of Michelangelo’s David.
The Ponte Vecchio, or old bridge, was fora time, the only bridge in Florence acrossthe Arno River. There have been shops onthe bridge since the thirteenth century—originally, all types of shops, but at the endof the sixteenth century limited to onlygoldsmiths and jewelers.
The Medici Chapelsform part of the com-plex of San Lorenzo. The church of SanLorenzo was the official church of theMedici family and became their final burialground.
Medici Villa at Castello, just a few kilome-ters from Florence’s historical center, is anelegant villa with a splendid Italian garden.Botticelli’s Birth of Venus and Allegory ofSpring (now at the Uffizi Gallery) were com-missioned by Lorenzo de’ Medici for thisvilla. The villa is not open to the public, butits gardens can be visited free of charge.
Palatine and Modern Art galleries at thePalazzo Pitti. The Palatine Gallery includeswonderful works by Renaissance artists.The Modern Art Gallery mostly housesworks by Italian artists from the end of theeighteenth century to the beginning of thetwentieth century.
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NEW TECHNOLOGIES— to improve root canal disinfection
— Dr. Gianluca Plotino
is a senior lecturer in theDepartment of Endodon-tics and adjunct professorin the School of Dental Hygiene at the Sapienza University of Rome in Italy. He serves on the editorialboards of and is an officialreviewer for several jour-nals, and has organized several research groupsworldwide. He is the authorand co-author of more than70 articles in internationalscientific peer-reviewedjournals with high impactfactors on different endodontic and restorativetopics. Dr. Plotino has givenseveral lectures andcourses worldwide, and heworks in a private practicelimited to endodontics and restorative dentistry in Rome.
— Dr. Nicola M. Grande
is Assistant Professor of Endodontics at UniversitàCattolica del Sacro Cuore in Rome. He completed hisPh.D. at the same universityin 2009, with a thesis on aninnovative technique he de-veloped for the restorationof endodontically treatedteeth. He has contributedto the development of vari-ous instrumentation sys-tems and new techniques,and holds internationalpatents in the fields of en-dodontics and oral surgery.Dr. Grande has publishedextensively in internationalpeer-reviewed journals andhas contributed to severalbooks of endodontic inter-est. He serves on the edito-rial boards of several inter-national peer-reviewedjournals, and he has lec-tured both nationally andinternationally as a keynotespeaker in the fields of endodontics, microsurgeryand restorative dentistry.He works in a private prac-tice limited to endodonticand microsurgery in Rome.
— Gianluca Gambarini
is Professor of Endodonticsat the Sapienza Universityof Rome’s dental school. Heis an international lecturerand researcher, and activelycollaborates with a numberof manufacturers all overthe world to develop newtechnologies, operativeprocedures and materialsfor root canal treatment.Prof. Gambarini also worksin a private endodonticspractice in Rome.
Dr. Gianluca Plotino, Dr. Nicola M. Grande & Prof. Gianluca Gambarini, Italy
Introduction
The major causative role of micro-organ-isms in the pathogenesis of pulp and peri -apical diseases has clearly been demon-strated.1 The main aim of endodontictherapy is to disinfect the entire root canalsystem, which requires the elimination ofmicro-organisms and microbial compo-nents and the prevention of its reinfectionduring and after treatment. This goal ispursued through chemomechanical de-bridement, for which mechanical systemsare used with irrigating solutions.
Standard endodontic irrigationprotocol
— Sodium hypochlorite
Sodium hypochlorite (NaOCl) is the mainendodontic irrigant used, owing to its anti -bacterial properties and its ability to dis-solve organic tissue.2 NaOCl is used duringthe instrumentation phase to increase itstime of action within the canal as much aspossible without it being chemically al-tered by the presence of other sub -stances.3 The effectiveness of this irriganthas been shown to depend on its concen-tration, temperature, pH solution andstorage conditions.3 Heated solutions(45–60 °C) and higher concentrations(5–6%) have greater tissue-dissolving
properties.2 However, the greater theconcentration, the more severe the po-tential reaction if some of the irrigant isinadvertently forced into the periapicaltissue.4 In order to reduce this risk, the useof specially designed endodontic needlesand an injection technique without pres-sure is recommended.5
— EDTA
The main disadvantage of NaOCl is its in-ability to remove the smear layer. For thisreason, combination of NaOCl with EDTA(ethylenediaminetetraacetic) is recom-mended.2 EDTA has the ability to decom-pose the inorganic component of intra-canal debris and is generally used in apercentage equal to 17%. EDTA appears toreduce the antibacterial and solvent activ-ity of NaOCl; thus, these two liquidsshould not be present in the canal at sametime.6 For this reason, during mechanicalpreparation, abundant and frequent rins-ing with NaOCl is performed, while theEDTA is used for 2 min at the end of thepreparation phase to remove the inor-ganic debris and the smear layer from thecanal walls completely.
— Ultrasonic activation of NaOCl
The use of ultrasound during and at theend of the root canal preparation phase isan indispensable step in improving en-dodontic disinfection. The range of fre-quencies used in the ultrasonic unit is be-tween 25 and 40 kHz.7 The effectivenessof ultrasound in irrigation is determinedby its ability to produce cavitation andacoustic streaming. Cavitation is mini-mized and limited to the tip of the instru-ment used, while the effect of acousticstreaming is more significant.7
Ultrasound creates bubbles of positiveand negative pressure in the molecules ofthe liquid with which it comes into contact.The bubbles become unstable, collapseand cause an implosion similar to a vacuumdecompression. Exploding and imploding
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Figs. 1 & 2Ultrasonic activation with a passive file.
they release impact energy that is respon-sible for the detergent effect. It has beendemonstrated that ultrasonic activationof NaOCl dramatically enhances its effec-tiveness in cleaning the root canal space,as ultrasonic activation greatly increasesthe flow of liquid and improves both thesolvent and antibacterial capacities andthe removal effect of organic and inor-ganic debris from the root canal walls.7
Ultrasonic activation of NaOCl of 30–60 s for each canal, with three cyclesof 10–20 s (always using new irrigant), ap-
pears to be sufficient time to obtain cleancanals at the end of the preparation phase(Figs. 1 & 2).7 Ultrasound appears to be lesseffective in enhancing the activity ofEDTA, although it may contribute to bet-ter removal of the smear layer.7 The accu-mulation of debris produced by mechan-ical instrumentation in inaccessible areasis preventable by using ultrasonic activa-tion of NaOCl even during the preparationphase.8 The use of a system of ultrasoniccontinuous irrigation might therefore beadvantageous. It involves the use of a nee-dle activated by ultrasound. With thismethod, the irrigant is released into thecanal and is activated by the action of theultrasonic needle simultaneously.9
— Chlorhexidine
A final flush with 2% chlorhexidine (CHX)after the use of NaOCl (to dissolve the or-ganic component) and EDTA (to eliminatethe smear layer) has been proposed to en-sure good results in cases of persistent in-fection, owing to its broad spectrum of ac-tion and its property of substantivity.5, 10
However, the use of CHX is hindered bythe interaction between NaOCl and CHX,which tends to create products that maydiscolor the tooth and precipitates that
may be potentially mutagenic. For this rea-son, CHX should not be used in conjunc-tion with or immediately after NaOCl.11
This interaction can be prevented or min-imized by an intermediate wash with ab-solute alcohol, saline or distilled water.12
Activation systems
Mechanical instrumentation alone can re-duce the number of micro-organismspresent within the root canal system evenwithout the use of irrigants and intracanal
dressings,13 but it is not able to ensure aneffective and complete cleaning.14 Irrigat-ing solutions without the aid of mechanicalpreparation are not able to reduce the in-tracanal bacterial infection significantly.15
For these reasons, today research is oriented toward the study of systemsthat can improve root canal disinfectionthrough mechanical activation of en-dodontic irrigants, and in particularNaOCl. Multiple agitation techniques andsystems for irrigants have been used overtime,16 demonstrating more or less posi-tive results.17
— Manual agitation techniques
The simplest technique of mechanical ac-tivation of irrigants is manual agitation,which can be performed with differentsystems. The easiest way to achieve thiseffect is to move vertically an endodonticfile that is passive in the canal. The use ofthe file facilitates the penetration of theirrigant, leads to a more effective deliveryof irrigant to the untouched canal surfacesand reduces the presence of air bubbles inthe canal space,18 but does not improvethe final cleaning.17 Another similar tech-nique moves vertically a gutta-perchacone to working length with the canal
Fig. 1 Fig. 2
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filled with irrigant. Even this method, how-ever, has not been found to improve theintracanal cleaning.9, 17 For this purpose, ineach case, well-fitting gutta-percha cones(increased taper) were more effectivethan cones with the standard taper(0.02).9 The use of endodontic brushesand of particular needles for endodonticirrigation with bristles on their surface isanother technique suggested in order tomove the irrigant more effectively withinthe canals. These systems have beenshown to be valid in the removal of thesmear layer from root canal walls and thusthey can be recommended during irriga-tion with EDTA to improve their efficacyat the end of the preparation.
— Machine-assisted agitation systems
The evolution of manual systems led to theintroduction of instruments that can berotated in handpieces at low speed insidethe canal filled with irrigant. They are ro-tary brushes too large to be brought closeto the working length; thus, they can beused effectively only in the coronal andmiddle thirds of the canal. Other similarinstruments are files in plastic with asmooth surface and increased taper orwith a surface with lateral plastic exten-sions, that have dimensions appropriate toachieve the working length if used afterthe canal preparation. Studies on thesesystems have shown conflicting results. Ingeneral, the results are better than withhand irrigation with a syringe, but lowerthan that of other more effectivesystems.16
— Continuous irrigation during instrumentation
Recently, a new system for root canalpreparation has been introduced to themarket. This system uses a particular in-strument with an abrasive surface that en-larges the canal via friction in a vibratingmotion and allows irrigant to flow throughthe file itself. This system has shown ex-cellent results in terms of respecting theanatomy and cleaning of difficult rootcanal anatomies, such as difficult isth-muses, oval canals or C-shaped canals.19The low cutting efficiency of this systemin some cases may limit its use in root canalpreparation, but makes it an excellent ad-ditional technique to enhance the cleaningand disinfection of the root canal systemat the end of the preparation.20 The con-cept of continuous irrigation was devel-
oped in the past with the use of mechanicalinstruments for sonic and ultrasonicpreparation that could concurrently cleanthrough the continuous release of irrigant.These techniques were then abandonedfor various reasons related to the poorquality of the preparation itself.
— Sonic activation
Sonic activation has been shown to be aneffective method for disinfecting the rootcanals. The recent systems use smoothplastic tips of different sizes activated ata sonic frequency by a handpiece. The sys-tem seems to be able to clean the maincanal effectively, to remove the smearlayer and to promote the filling of agreater number of lateral canals.17 Anotherrecently introduced technique uses a sy-ringe with sonic vibration that allows thedelivery and activation of the irrigant inthe root canal simultaneously. Sonic acti-vation differs from ultrasonic activation inthat it operates at a lower frequency (1–6 kHz), and for this reason it is generallyfound to be less effective in removing debris than are ultrasonic systems.17, 21, 22
— Apical negative-pressure irrigation
As the irrigant must be in direct contactwith the micro-organisms and canal wallsto be effective, the accessibility of the ir-rigant to the whole root canal system, inparticular in the apical third, is essential. Inorder to deliver the irrigant into the rootcanal for the entire length and to obtain a good flow of fluid, apical negative-pres-sure systems have been introduced thatrelease and remove the irrigant simulta-neously.
These systems consist of a macro -cannula for the coronal and middle por-tions and a microcannula for the apicalportion, and the cannulas are connectedto a syringe for irrigation and the aspira-tion system integrated with the dental unit(Fig. 3). During irrigation, a tip connectedwith a syringe delivers the irrigant to thepulp chamber without the risk of overflow,while the cannula placed in the canal pullsirrigant into the canal, through the aspira-tion system to which it is connected, andevacuates it through the suction holes.This system is intended to ensure a con-stant and continuous flow of new irrigantinto the apical third safely and with a lowerrisk of extrusion.23 Most of the studies onthis technique have shown that it is veryeffective at ensuring a greater volume of
irrigant in the apical third24 and excellentremoval of debris from this area25 and in-accessible areas,26 with results in the ma-jority of cases similar to those of ultra-sonic activation techniques.27–29 From aclinical perspective, apical negative-pressure systems can be effectively in-tegrated with ultrasonic irrigation tech-niques because they act by differentmechanisms. They can operate in synergywith the objective to obtain cleanercanals, especially in the apical third andthe most inaccessible areas.
— Laser activation
The interaction between the laser and theirrigant in the root canal is a new area ofinterest in the field of endodontic disin-fection. This concept is the base of laser-activated irrigation (LAI) and photon-initiated photoacoustic streaming (PIPS)technology.30 The mechanism of this in-teraction has been attributed to the ef-fective absorption of the laser light byNaOCl. This leads to the vaporization ofthe irrigant and to the formation of vaporbubbles, which expand and implode withsecondary cavitation effects. The PIPStechnique is based on the power of theEr:YAG laser to create photoacousticshock waves within the irrigant introducedinto the canal. When it is activated in a lim-ited volume of liquid, the high absorptionof the laser in NaOCl combined with thehigh peak power derived from the shortpulse duration employed (50µs) deter-mines a photomechanical phenomenon.30
A study showed that there was no differ-ence in bacterial reduction achieved byNaOCl activated by laser compared withonly NaOCl.31 Another study investigatedthe capability of LAI to remove a bacterialbiofilm created in vitro on the canal walls.32
This study found that it did not completelyremove the biofilm from the apical thirdof the root canal and infected dentinaltubules. However, the finding that laser ac-tivation generated a higher number ofsamples with negative bacterial culturesand a lower number of bacteria in the api-cal third was a promising result regardingthe effectiveness of the technique, andhas been confirmed by a more recentstudy.33
Additional disinfection systems
In addition to the above-mentioned sys-tems that were able to activate the en-dodontic irrigants and to improve their
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cleaning capability, endodontic researchis oriented toward the identification of al-ternative solutions that could further re-fine disinfection and assist in the destruc-tion of biofilms and the elimination ofmicro-organisms. For this purpose, differ-ent substances and technologies havebeen investigated over time with differentresults.
— Photoactivated disinfection
A new method recently introduced in en-dodontics is photoactivated disinfection.
This technique is based on the principlethat the photosensitizing molecules (pho-tosensitizer, PS) have the ability to bind tothe membranes of the bacteria. The PS isactivated with a specific wavelength andproduces free oxygen, which causes therupture of the bacterial cell wall on whichthe PS is associated, determining a bacte-ricidal action.34 Extensive laboratory stud-ies have shown that the two componentsdo not produce any effect on bacteria oron normal tissue when used independentlyof each other; it is only the combinationof PS and light that exert the effect on thebacteria.34
An endodontic system called light-activated disinfection (LAD) has been de-veloped based on a combination of a PSand a special light source. The PS attacksthe membranes of micro-organisms andbinds to their surface, absorbs energyfrom light and then releases this energy inthe form of oxygen, which is transformedinto highly reactive forms that effectivelydestroy micro-organisms. LAD is effectivenot only against bacteria, but also againstother micro-organisms, including viruses,fungi and protozoa. The PSs have far lessaffinity for the cells of the body; therefore,
toxicity tests carried out did not report ad-verse effects of this treatment. Clinically,after root canal preparation, the PS is in-troduced into the canal to working lengthwith an endodontic needle and is left in situfor 60 s to allow the solution to come intocontact with the bacteria and spreadthrough any structures, such as biofilms.The specific endodontic tip is then in-serted into the root canal up to the depththat can be reached and irradiation is per-formed for 30 s in each canal (Fig. 4). Thistechnique has proven to be effective inlaboratory studies at eliminating high con-
centrations of bacteria present in artifi-cially infected root canals.35 Care shouldbe taken to ensure maximum penetrationof the PS, since it is important that it comeinto direct contact with the bacteria, oth-erwise the effect of photosensitivity willnot occur. In addition, LAD appears to beeffective not only against the bacteria insuspension, but also against biofilm.5 Re-search is now directed toward evaluatingthe possibility of increasing the antibiofilmeffectiveness of LAD, combining the ben-efits of photodynamic therapy with thoseof bioactive glasses and nanoparticles,which will be described later. CurrentlyLAD is not considered as an alternative,but rather as a possible supplement tostandard protocols of root canal disinfec-tion already in use.5
— Laser
One of the main disadvantages of the cur-rent endodontic irrigants is that their bac-tericidal effect is limited primarily to themain root canal. In the endodontic field,several types of lasers have been used toimprove root canal disinfection: the diodelaser, carbon dioxide laser, Er:YAG laser
Fig. 3 Fig. 4
Fig. 3Apical negative-pressure irrigation system used toenhance debridement.
Fig. 4Disinfection activated bylight to enhance root canalcleaning.
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static and bactericidal. They generate ac-tive oxygen species that are responsiblefor their antibacterial effect through elec-trostatic interaction between positivelycharged nanoparticles and negativelycharged bacterial cells, resulting in accu-mulation of a large number of nanoparti-cles on a bacterial cell membrane and asubsequent increase in its permeability as-sociated with the loss of its functions.Nanoparticles synthesized from powdersof silver, copper oxide or zinc oxide arecurrently used for their antimicrobial ac-tivity. In addition, nanoparticles can alterthe chemical and physical properties ofdentin and reduce the strength of adhe-sion of bacteria to the dentin itself, thuslimiting recolonization and bacterialbiofilm formation. In any case, the possiblesuccess of the application of nanoparticlesin endodontics will depend essentially onthe manner in which they can be deliveredin the most complex root canal anatomy.
Bioactive glassRecently, bioactive glass or bioactiveglass-ceramics have been a subject of con-siderable interest for endodontic disinfec-tion owing to their antibacterial proper-ties, but conflicting results have beenobtained.5
Natural plant extractsA current trend is the use of natural plantextracts, taking advantage of the antibac-terial activity of polyphenolic moleculesgenerally used for storing food. Thesecompounds have been found to have poorantibacterial efficacy, but several demon-strate significant ability to reduce the for-mation of biofilms, although the mecha-nism by which this occurs is not clear.5
— Noninstrumentation techniques
The first trial of a method of cleaning with-out canal preparation was the noninstru-mentation technique conceived by Lussiet al.40 This technique did not provide forthe enlargement of the root canals be-cause there was no mechanical instrumen-tation of the root canal walls. In fact, rootcanal cleaning was exclusively obtainedwith the use of NaOCl at low concentra-tion, introduced and removed from thecanal using a vacuum pump and an electricpiston that created fields of alternatingpressure inside the canal. These caused theimplosion of the produced bubbles and hydrodynamic turbulence that facilitatedthe penetration of NaOCl into the root
canal ramifications. At the end of this pro-cedure, the canals were filled with a ce-ment conveyed by the same vacuumpump. This system did not prove to be ofsubstantial effectiveness and was nevermarketed.
Recently, a method has been developedfor cleaning the entire root canal systemthrough the use of a broad spectrum ofsound waves transmitted within an irrigat-ing solution to remove pulp tissue, debrisand micro-organisms quickly. One studyshowed that this technique was able to dis-solve the tissue tested at a rate signifi-cantly higher than that of conventional ir-rigation.4 More research is needed todetermine whether this approach is effec-tive in the root canal system with mini-mally invasive or no canal preparation.
Conclusion
According to current knowledge, endo -dontic pathology is an infection mediatedby bacteria and in particular by biofilm.From a biological perspective, endodontictherapy must then be directed toward theelimination of micro-organisms and theprevention of possible reinfection. Unfor-tunately, the root canal system, with itsanatomical complexity, represents a chal-lenging environment for the effective re-moval of bacteria and biofilm adherent tothe canal walls. Chemomechanical prepa-ration involves mechanical instrumenta-tion and antibacterial irrigation, and it isthe most important phase of the disinfec-tion of the endodontic space. The techno-logical advances of instruments havebrought significant improvements in theability to shape the root canals, with fewerprocedural complications. In the manage-ment of the infected root canal system,various antimicrobial agents have beenemployed. Furthermore, some clinicalmeasures, such as an increase in apicalpreparation and a more effective systemof irrigant delivery and activation of irri-gant, can promote and make more pre-dictable the reduction of intracanal bac-teria, especially in complex anatomical andnoninstrumented portions of the rootcanal system.
Editorial note: A list of refer-ences is available from thepublisher.
and Nd:YAG laser. The bactericidal actionof the laser depends on the characteristicsof its wavelength and energy, and in manycases is due to thermal effects. The ther-mal effect induced by the laser producesan alteration of the bacterial cell wall thatleads to changes in osmotic gradients upto cell death. Some studies have con-cluded that laser irradiation is not an al-ternative, but rather a possible supple-ment to existing protocols to disinfectroot canals.36 The laser energy emittedfrom the tip of the optical fiber is directedalong the canal and not necessarily later-ally toward the walls. In order to overcomethis limitation, a new delivery system ofthe laser was developed. The system con-sists of a tube that allows the emission of the radiation laterally instead, directedthrough a single opening at its terminalend. The objective of this modification wasto improve the antimicrobial effect of thelaser in order to penetrate and destroy mi-crobes in the root canal walls and in thedentinal tubules. However, completeelimination of the biofilm and bacteria hasnot yet been possible, and the effect ofthe laser has been found to be less relevantthan that of the classical solutions ofNaOCl.37 In conclusion, strong evidenceis not currently available to support theapplication of high-power lasers for directdisinfection of root canals.38
— Ozone
Ozone is an unstable and energetic formof oxygen that rapidly dissociates in waterand releases a reactive form of oxygenthat can oxidize cells. It has been sug-gested that ozone may have antimicrobialefficacy without inducing the develop-ment of drug resistance and for this rea-son it was also used in endodontics. How-ever, the results of the available studies on its effectiveness against endodonticpatho gens are inconsistent,39 especiallyagainst biofilms. The antibacterial effec-tiveness of ozone was found not compa-rable and less than that of NaOCl.39
— Alternative antibacterial systems
NanoparticlesNanoparticles are microscopic particlesbetween 1 and 100 nm in size that haveanti bacterial properties and a tendency toinduce much lower drug resistance com-pared with traditional antibiotics. For ex-ample, nanoparticles of magnesium oxide,calcium oxide or zinc oxide are bacterio-
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COMPARATIVE STUDY — of implant placement torqueand resonance frequency analysison the implant and abutment
— Dr. Débora Barella Salatti,
D.D.S., is a postgraduate studentat São Leopoldo Mandic dentalschool in Campinas, Brazil. She canbe contacted [email protected].
— Dr. Rafael de Mello e Oliveira,
D.D.S., M.D., is a specialist traineein implant dentistry and prostho-dontics at São Leopoldo Mandicdental school.
— Dr. Marcelo Lucchesi Teixeira,
D.D.S., M.S., Ph.D., teaches dentistry at São Leopoldo Mandicdental school. He can be contacted [email protected].
— Dr. Sérgio Rocha Bernardes,
D.D.S., M.S., Ph.D., is a researcherat ILAPEO in Curitiba, Brazil. He can be contacted at [email protected].
— Dr. André Antonio Pelegrine,
D.D.S., M.S., Ph.D., teaches dentistry at São Leopoldo Mandicdental school. He can be contacted at [email protected].
Rua das Areias, 37CambuíCampinasSão Paulo13024-530Brazil
T +55 19 3272 5219
Drs. Débora Barella Salatti, Rafael de Mello e Oliveira,Marcelo Lucchesi Teixeira,Sérgio Bernardes & André Antonio Pelegrine,Brazil
Introduction
The long-term clinical success of dentalimplants is dependent upon osseointegra-tion, which is defined as a direct functionaland structural connection between thebone and implant surface.1 Primary stabil-ity is, therefore, paramount. Several meth-ods have been used to determine implantstability; however, resonance frequencyanalysis (RFA) is considered the most ac-curate. Despite RFA having been usedsince 1980 in orthopedics, it has only beenused in implantology since the 1990s,when it was described by Meredith2 andhas been widely used ever since.3
When evaluating the stability of im-plants, quantitative methods such as RFAcan yield valuable information that couldcontribute to long-term treatment suc-cess.2 RFA allows measurements of stabil-ity on a numerical scale ranging from 0 to100, and such measurements can be ob-tained soon after implant placement or atany time during healing.4 According toNedir et al., RFA may aid in the decision-making process regarding the best timefor seating of the prosthesis on the im-plant during the healing period.5
Currently, the demand for esthetic den-tistry is increasing; therefore, immediateloading approaches, in which the prosthe-sis is seated on the implant in the same ses-sion, have been widely used.6–10 Neverthe-less, load can only be applied if the implantpresents sound primary stability. Furthertorque will be applied when seating theabutment on the implant, which may pre-vent future RFA measurements directlyon the implant, since removal of torquedabutments may impair osseointegrationduring the healing period.
In order for an implant to be able to re-ceive immediate loading, it is necessaryfor the final placement torque to behigh.11 However, studies comparing RFAwith measurements obtained directlyfrom the implant and abutment com-bined are scarce. Therefore, the objec-tives of the present study were to analyzethe resonance frequency of the implantand abutment set immediately afterplacement and to compare them with thefinal placement torque.
Patient selection
Nine patients, five males and four fe-males, were evaluated in this study, with17 implants being placed in different areasof both arches. The patients were at-tended to by undergraduate students ofthe São Leopoldo Mandic dental school(Campinas, Brazil) throughout 2014. Thepatients were assessed and those foundnot to have any systemic diseases thatwould affect the healing process of theimplant were included. Patients with asystemic disease or insufficient bonequality were excluded.
Preoperative procedures
Each patient underwent computed to-mography scans in order to survey the areawhere the implant would be placed, as wellas to classify the type of bone, includingheight and width measurements in orderto select the most suitable implant designfor each situation. A full blood count andcoagulation screen were performed foreach patient.
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Figs. 1a & bFixation of the specifictransducer inside the implant (a); RFA on the implant (b).
Figs. 2a & bFixation of the specifictransducer inside the abutment (a); RFA on the implant (b).
Intraoperative procedures
The surgical procedures followed asepsisguidelines and were performed under lo-cal anesthetic. A #15c scalpel blade wasused to make an incision along the bonecrest and, subsequently, a full mucoperio -steal flap was raised. The surgical guide wasinserted and bone drilling performed fol-lowing the manufacturer’s recommenda-tions.
After preparation of the surgical socket,a Neodent Morse taper connection implantwas placed. It was initially placed using an
electric motor and finalized with a manualtorque wrench. The final placement torquewas recorded for subsequent comparativeanalysis. Upon completion of implant place-ment, a specific transducer was fixed insidethe implant (Fig. 1a) and, subsequently, theimplant resonance frequency was measured(Fig. 1b) using the Osstell device. The im-plant was then torqued to a screwed abut-ment and, in turn, a specific transducer wasset inside the abutment (Fig. 2a). At thispoint, the resonant frequency of the abut-ments was measured using the same equip-ment (Fig. 2b).
The resonance frequencies, both from theimplant and the abutment, were takenfrom the buccal, mesial, distal and lingualaspects, and a mean value was obtainedfor each region. After the last measure-ment, an abutment protection cylinder ortemporary restoration was placed and theflap sutured.
Statistical analysis
The placement torque and stability wereanalyzed separately for each implant and
Fig. 1a Fig. 1b
Fig. 2a Fig. 2b
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abutment using nonparametric tests. Datawere analyzed comparatively using theWilcoxon and Pearson correlation tests, ata significance level of 5%.
Results
The mean values and standard deviationsfor implant and abutment placementtorques (in Ncm) and RFA (in ISQ) were53.5 ± 19.7, 67.6 ± 8.4 and 52.8 ± 2.8, re-spectively (Table 1; Figs. 3–5).
Statistical analysis did not find a linearpattern between the measurements ofplacement torque and ISQ, either on theimplant (–0.24) or the abutment (–0.18).Regarding the comparison between ISQ
for the implant and abutment, despite asignificant numerical difference (p < 0.05),a linear pattern was observed (0.68).
Discussion
RFA is a reliable method for measuring thestability of dental implants and this findinghas recently been reported by several au-thors.7, 9, 10, 12–15 It is commonly measuredusing an Osstell device immediately afterimplant placement or at any time duringthe healing process, as well as after loadingof the implants.4 Park et al. demonstratedthat two different directional measure-ments are needed for RFA, since this al-lows the detection of ISQ change patternsthat would not be identified if only unidi-rectional measurement was used.16 This information influenced the decision-making process in the present study, sincetwo RFA measurements were taken foreach implant, one from the buccal and theother from the lingual aspect, and the average was then calculated.
In the present study, mean values andstandard deviations for placement torque(in N cm) and RFA (in ISQ) on both the im-plant and abutment on the day of implantplacement (53.5 ± 19.7, 67.6 ± 8.4 and 52.8
± 2.8, respectively) were analyzed. No ob-vious linear pattern was observed. Whenthe measurements of ISQ on the implantcompared with placement torque werecompared, the linear correlation coeffi-cient was –0.24. This corroborates thefindings of Schliephake et al.17 and Akça etal.,18 yet contradicts the results of Friberget al.19 and Turkyilmaz et al.20 When com-paring the ISQ values on the abutmentwith placement torque, no linear patternwas observed; the linear correlation coef-ficient was –0.18. Therefore, if RFA is ac-cepted as the most suitable method fordetermining the best time for implantloading, it can be speculated that theplacement torque measurement would beunnecessary. However, Esposito et al.,11
in a literature review, argued that if an immediate loading approach is consid- ered among the treatment options, then the implant must be placed with a hightorque, which usually exceeds 30 Ncm21
or 40N cm.22 Therefore, RFA and torqueare two distinct methods for analyzing im-plant stability and both should be consid-ered. The main difference between themis that ISQ can be measured months afterimplant placement, whereas torque canonly be measured on the day of surgery,which makes the latter a weak method for
Measurement Mean Standard Median Lower Upper N deviation Overall picture Torque (N cm) 53.5 19.7 45 25 100 17 RFA on implant (ISQ) 67.6 8.4 68 47 78 17 RFA on abutment (ISQ) 52.8 2.8 52 47 57 17Table 1
Table 1Main descriptive statisticsof the groups for each studied measurement.
Fig. 3Association analysis between the measurementsISQ over implant vs. placement torque.
Fig. 4Association analysis between the measurementsISQ on abutment vs. installation torque.
Fig. 3 Fig. 4
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issue 2016 — 79PeriodonticsArticle
analyzing secondary or biological stability.ISQ is a reliable method for implant fol-low-up and the initial base value should berecorded in order for the clinician to havea reference for maintenance purposes. Im-plant failures are occasionally difficult todiagnose and the comparison against theinitial ISQ value can be a useful approachto assessing risk of implant failure.
Analysis of the association between theISQ values on the implant and on the abut-ment indicated a linear pattern in the data,as the linear correlation coefficient was0.68. However, a significant differencewas observed in terms of the mean ISQvalue measured on the implant and on theabutment (p < 0.05), with the highest val-ues observed on the implant. Many studieshave demonstrated that implants with ahigh initial ISQ value (> 60) are often suc-cessfully osseointegrated12, 23 and tend toperform well clinically in the long term.Sennerby and Meredith state that low ini-tial ISQ values that continue to decreaseas healing progresses may be a sign of im-plant failure.23 Glauser et al. report an im-plant failure rate of 11.2%.9 The implantswith an initial ISQ value of higher than 69had a 100% success rate, while those withan initial ISQ value of between 48 and 59had an average failure rate of 19%, and
100% of the implants with an initial ISQvalue of lower than 39 failed.
No studies were found that comparedISQ on the implant and the abutment atthe same surgical intervention, which wasthe approach chosen in this study. The ISQvalues for each implant and abutmentwere very far apart, despite the resultsshowing a linear pattern between them.This finding complicates the use of RFA onimplants where an abutment is torqued inthe same session as the implant, since re-moval of the abutments torqued duringthe osseointegration period is not indi-cated. Therefore, when the ISQ value foran implant at the time of placement is lessthan 60, an abutment should not betorqued during the same session,9 sincesuch a scenario contraindicates immediateloading. Measurements at the implantlevel are regarded as the most accurateapproaches to defining the loading proto-col for any particular prosthesis; however,measurements at the abutment levelcould be the safest way to follow up ondental implants, since premature abut-ment removal could result in implant fail-ure. Because of the linear correlation iden-tified between both measurements,abutment ISQ or implant ISQ values couldbe used equally.
Based on the results presented in thisstudy, less accuracy was observed in themeasurement of ISQ when the abutmentwas seated in the same surgical session,which is essential for immediate loading.Owing to the lack of studies using thesame methodology, further investigationis needed in order to develop methodsthat are more accurate for evaluation ofISQ on abutments. In addition, studiescomparing RFA on implants and abut-ments of different implant systems wouldbe desirable. Therefore, it can be con-cluded in the present study that no asso-ciation was found between the measure-ments of placement torque and RFA.Additionally, a statistically significant dif-ference was identified between the im-plant and abutment ISQ measurements.
Editorial note: A list of references is available fromthe publisher.
Fig. 5Association analysis between the measurementsISQ on implant vs. ISQ onabutment.
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