Dentistry Today — June 2017

Inside this issue

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1. Page 6

   The Technology Boom Continues We have witnessed an explosion in technology that continues to increase in both the scope and the depth at which it reaches the world population. With seemingly no end to the advances, technology continues to feed new scientific research and breakthroughs. A relatively short time ago, many of our readers may recall using the first generation of cell phones that were "simple" instruments too large to fit into a pocket and sporting and unwieldy telescope external antenna. Now, we carry around a much smaller "smart" (thanks in part to quantum physics) phone capable of amazing computing…

2. Page 8

   Opportunities and Challenges of a Small Group Practice INTRODUCTION There are numerous service delivery models found currently in dentistry, notable among them being the fast-emerging category of small group practices (SGPs). Although we have no agreed upon definition for the SGP or reliable estimate of how many exist, there's no question it is a growing segment that's creating new opportunities and challenges. Defining the SGP With the definition of an SGP is still very loose, I choose to think of it as an organization of 4 to 24 offices connected through some type of legal entity. There are many varieties…

3. Page 10

   VIEWPOINT continued from page 8 • Investment Opportunity—Adding practices can yield a reasonable return on investment. Dentistry, despite the increasing supply of dentists and a growing number of dental schools, remains a profitable business in most cases, even when practices are not particularly well run. An SGP represents a relatively safe investment in comparison with most of the traditional alternatives. • Competitive Opportunity—Adding practices may provide a competitive advantage and protection for the future. When it's possible to achieve economies of scale—amortizing labor and other expenses across a number of offices—an SGP owner can often create a wider profit margin.…

4. Page 14

   FOCUS ON: In-Office Technologies Sabiha S. Bunek, DDS, discusses new in-office dental technologies available to dentists that are impacting everyday practice as well as in the future. Q: Why do you think more dentists are purchasing stand-alone digital impression scanners? A: While there are still a good many dentists milling in-office restorations, digital impression systems have gained momentum in recent years. Scanners have evolved to become smaller, portable, and easier to use, while price points have dropped. Manufacturers are starting to understand that to increase adoption rates, the technology cannot be disruptive and must fit into the flow of the…

5. Page 16

   CLINICAL REVIEWS THE DENTAL ADVISOR ClearView Single-Use Nasal Hoods ++++1/2 Accutron | (800) 531-2221 | accutron-inc.com Consultants' Comments • "Nice variety of scents; seals well around the nose." • "Patients say they are comfortable." Description ClearView Single Use Nasal Hoods, used to deliver nitrous oxide, have a double-hood design that includes a colored, scented inner hood as well as a transparent outer hood. The addition of the scented inner hood gives clinicians a visible indication (in the form of condensation) that the patient is properly breathing the nitrous oxide. Low profile and latex-free, the hoods are contoured for adaptation to…

6. Page 18

   Digital Technologies A Roundtable Discussion on Changing the Face of Dentistry In this roundtable discussion, conducted by Paul Feuerstein, DMD, Dentistry Today's technology editor, we focus on the restorative aspects of digital dentistry and look at how it is used by general practitioners (GPs) in everyday practice. There has been a lot of hype about digital impressions and 3 D cone beam technology, with some claiming it is easy to do and very predictable, implying that the technology can really do all the work. This may be an overstatement, and we probably need to go back to an old technology…

7. Page 20

   Digital Technologies: A Roundtable... continued from page 18 long-term, they have become a standard procedure in dental offices for the posterior region of the mouth. When I've recently asked dentists in my lectures how many of them have read one article on zirconia, less than 10% raise their hands. Although we talk about evidence-based dentistry, it seems that most clinicians are not using scientific, evidence-based information to determine the materials of choice in their practice. And, as far as in office CAD/CAM technology goes, I feel it is certainly a viable option for many offices, but not all. Some practices…

8. Page 22

   Digital Technologies: A Roundtable... continued from page 20 planning software can now take advantage of the hardware improvements to help us assess relative bone density, plan for implant receptor sites, bone grafting procedures, and even links to the restorative phase with ever-increasing accuracy. However, that stated, CBCT does not provide the best surface detail, especially when there are teeth and/or metal artifacts in the field of interest. The ability to merge either an intra-oral scan or an optical scan of a stone cast provides near-perfect surface reproduction, which can be superimposed on the CBCT dataset. Additionally, a diagnostic wax up…

9. Page 24

   Digital Technologies: A Roundtable... continued from page 22 improve our communication with all our treatment team, and especially the dental laboratory technician team. I have a very positive attitude when the technology is used correctly and, as with guided implant surgery, "the template is only as good as the plan." Gerys, as we see more in-office processes and the need for expensive equipment and retaining the dental technicians on software instead of carrying vials, should the smaller labs simply consider shutting their doors? Dr. Kugel: I'm not sure small labs should shut their doors, as they are often in a…

10. Page 26

    Digital Radiography—Panoramic Systems Owandy Radiology I-MAX touch offers a complete unit, from 2-D panoramic to a 3-in one system. Intuitive and tactile, it allows dentists to save precious time and realize precise diagnoses. With 14 programs, the panoramic version allows you to produce several critical exams. The cephalometric option extends the capabilities of the unit by acquiring x-rays from the skull and carpus. The 3-D option allows you to obtain volumetric 3-D x rays for implantology or even more precise exams for endodontics. For more information, call (800) 713-9575. FREEinfo, Instrumentarium Dental The ORTHOPANTOMOGRAPH OP300 Maxio is a premium-quality extra-oral…

11. Page 28

    DIGITAL RADIOGRAPHY—PANORAMIC SYSTEMS Planmeca USA The ProMax 2D S3 Panoramic X-Ray System features anatomically accurate extraoral bite-wings using patented Selectively Compliant Articulated Robotic Arm technology. This technology enables precise, free-flowing arm movements, permitting a variety of imaging programs not possible with fixed rotation panoramic units. It also allows for future 3-D upgrades. This system offers a unique Autofocus feature that automatically positions the focal layer using a low-dose image of a patient's central incisors to capture an ideal panoramic image, minimizing retakes. For more information, call (855) 245 2908. FREEinfo, Genoray America PAPAYA is a digital panoramic system with a…

12. Page 29

    DIGITAL RADIOGRAPHY—PANORAMIC SYSTEMS Air Techniques From a single exposure, only ProVecta S-Pan acquires 20 layers of images and slices each of them into 20,000 fragments. The best are selected and compiled to generate a single, exceptionally sharp panoramic image automatically. All sections of the image are as sharp as possible because they include individual anatomical features including the mandibular and outward facing orientation, and positioning is assured with 3 laser guides. For more information, call (800) 247-8324 or visit the website airtechniques.com. FREEinfo, ture data and the patient's position. This means that important diagnostic information is sharply displayed, Patient comfort…

13. Page 30

    Spotlight Multitask Evacuation System Simplifies Dental Procedures While Increasing Patient Comfort IRVINE, Calif.–DryShield is a patented, state-of the art isolation system designed by a dentist for dentists to simplify dental procedures while increasing patients' comfort and overall experience. A multi award winning system, it combines the tasks of a high-suction evacuator, saliva ejector, the block, tongue shield, and oral pathway protector all in one easy-to-use system. The dry field created by the system provides for faster and better dentistry, allowing dentists to focus on exceptional procedure results. At the same time, assistants are freed up to focus more on the…

14. Page 32

    Spotlight Complete Digital Ecosystem Designed to Facilitate Endodontic Procedures TULSA, Okla.–With its complete digital ecosystem, dentsply Sirona Endodontics' new X-Smart iQ System supports clinicians through every step of the endodontic process—from patient education to treatment data. The system's app creates customizable treatment plans based on clinician-preferred techniques and allows synchronization of future products and immediate updates. It also allows clinicians to utilize a Dentsply Sirona file sequence or create their own and save the sequence for future use. They can also utilize the app to capture treatment notes, including tooth number, working length, last file used, and obturation method. Among…

15. Page 34

    Radiometer Helps Ensure Complete Polymerization AMHERST, NY—To ensure that sufficient polymerization during procedures is achieved, it is imperative that the light intensity of curing lights is tested on a regular basis, and Ivoclar Vivadent's Blue-phase Meter II, hailed as most accurate dental radiometer on the market, instantly, easily, and precisely checks the light intensity of all available curing lights. A portable device, the Bluephase Meter II is ideal for use throughout all operatories and features a lightweight and ergonomic design that perfectly complements Ivoclar Vivadent's Blue-phase Style LED curing light. For more information, call Ivoclar Vivadent toll free at (800)…

16. Page 35

    Clinical Case – Gingivectomy and Depigmentation [Three clinical photographs showing: Pre-op | Immediate post-op | Ten-day post-op] KEY ATTRIBUTES This procedure included 2 extensive soft-tissue procedures with no injected anesthesia, minimal bleeding, and fast healing. CASE SUMMARY A 13-year-old patient was originally scheduled for a consult regarding a single tooth gingivectomy on tooth No. 7 due to puberty/hormone-induced gingival hyperplasia. The patient clearly needed more than a one-tooth gingivectomy. The patient and her mom then asked about lightening her dark gingiva and was ultimately treated with a 6-tooth gingivectomy and gingival depigmentation. The clinical objective was to remove the hypertrophic…

17. Page 36

    Spotlight Oral Screening Device Embraces Integration of Apple iPod Technology VANCOUVER, BC–The VELscope is the market-leading device for enhanced oral screening, with more than 15,000 practices relying on its technology to aid in the visualization of oral mucosal abnormalities, including oral cancer. Recently, it added seamless integration with the Apple iPod Touch, providing cutting-edge high-definition clinical photographic documentation with an unmatched workflow for case collaboration. The system utilizes a custom-designed iPod Touch holder combined with a state-of-the-art application that makes framing and acquiring clinical images simple and intuitive. No other adjunctive examination technology provides such a seamless path for screening,…

18. Page 38

    Spotlight Hybrid Blocks/Discs for CEREC Offered in Multiple Shades and Translucencies SAN MARCOS, Calif.—Shofu Dental's HC Blocks/Discs, proprietary hybrid ceramic materials for CAD/CAM based restorative dentistry with CEREC, are offered in multiple shades and translucencies, and their optical properties resemble the translucency and fluorescence of natural teeth, allowing them to seamlessly integrate with surrounding tissue. Additionally, their proprietary micro-architecture supports high wear resistance, allowing for a wide range of applications such as inlays/onlays, anterior posterior full-contour crowns, bridges, and aesthetic veneers. For more information, visit shofu.com. FREEinfo, Discs Provide Precise Separation of Zirconia, Lithium Disilicate, and Porcelain Restorations TORRANCE, Calif.—Continental…

19. Page 39

    Universal Composite Balances Beauty and Performance SOUTH JORDAN, Utah—Ultradent Products' Mosaic Universal Composite balances beauty and performance to yield lasting, lifelike restorations. It can be used for all restorative purposes, whether basic or complex, and its well-balanced nanohybrid formula produces restorations of the highest quality. Combining the strength required for posterior use with the aesthetic characteristics desired for anterior use, Mosaic ensures superior results, both visually and functionally. Its smooth, pliable consistency allows for total control during manipulation, and once shaped, it won't flow or slump. Available in 20 intuitive dental and enamel shades, Mosaic provides predictable shade matching using…

20. Page 40

    Spotlight Carbon-Based Toothpaste Whitens Without Bleach and Abrasive Agents CINCINNATI, Ohio—With Curaprox USA's Black is White whitening toothpaste, stains are removed by activated carbon instead of abrasion or chemical bleaching. The carbon also provides the basis for the toothpaste's color—black. The toothpaste contains no sodium lauryl sulfan, bleaching agents, or plastic particles, and it can be used as a regular toothpaste without any limitations. Also available is White is Black, which has a milder taste. For more information, call Diane Hammond, Curaprox USA, at (602) 432-4589 or email her at diane@curaproxusa.com. FREEinfo, Gloves' Ultrathin Construction Enhances User Comfort and Protection…

21. Page 42

    Offered in Four Simple Shades, Universal Nanohybrid Composite Facilitates Production of Brilliant Restorations ITASCA, Ill—Offered in 4 simple shades that easily equate to the VITA Shade Guide, Aura eASY SDI's universal nanohybrid composite, eliminates the guesswork in finding the right match to produce brilliant restorations. It features SDI's unique proprietary filler technology that delivers an optimal blend of handling and performance, resulting in a monolitic, easy-to-sculpt, nonsiumping universal composite that can meet virtually all your day to day dental needs. Aura eASY combines a low-shrinking resin system with the unique morphology of ultrahigh density glass filler that provides an extremely…

22. Page 44

    NEWS/TRENDS Industry News Ivoclar Vivadent's Enhanced Website Facilitates Product Shopping Ivoclar Vivadent's enhanced website, ivoclarvivadent.com, has been designed to decrease the time dentists spend purchasing materials. It combines ease of navigation with superior resources, and its fresh navigation system supports the smooth exploration of products. The website's improved content featuring such items as videos, a resource center, and product comparison charts contributes to its attractive interface and gives dentists a clear understanding of their purchasing options. Grammy Award-Winning Band to Perform at Dentsply Sirona World 2017 The Grammy Award-winning band Imagine Dragons will perform at Dentsply Sirona World 2017, the…

23. Page 45

    Indianapolis CDT Inaugurated As AACD President During its annual scientific session held this past April in Las Vegas, the American Academy of Cosmetic Dentistry (AACD) inaugurated Dwight G. Rickert, CDT, as president. A fourth generation dental technician, Mr. Rickert became a CDT in 1996 and soon after opened Preferred Dental Ceramics, a high quality boutique lab located in Indianapolis. After joining the AACD in 2000, he earned Accredited Member status in 2006 and earned the status of Accredited Fellow, the AACD's highest honor, in 2016. For more information about the AACD, visit aacd.com. Dwight G. Rickert, CDT Rodents... continued from…

24. Page 46

    MEETINGS/SEMINARS New Additions to AGD Meeting THE PREMIER MEETING FOR GENERAL DENTISTRY AGD2017 The annual AGD Meeting offers general dentists and their teams access to top-notch quality continuing education (CE), new products, exciting social events, and an unforgettable convocation ceremony, giving the opportunity to connect with highly educated dental professionals from across the country. This 3-day event will take place at Caesars Palace in Las Vegas, from July 13 to July 15. It will showcase a wide range of products and services from the leading exhibitors in dental services, equipment, biometric products, pharmaceutical products, surgery, etc. More than 3,000 visitors…

25. Page 49

    READERS' CHOICE TOP 25 FIRST IMPRESSIONS PRODUCTS EPIC to BIOLASE Many practices have at least one laser for convenience and at-hand efficiency. The portable EPIC 10 laser is indicated for soft-tissue surgery, both whitening and pain therapy and delivers up to 10W of peak power. Controlled through the intuitive touchscreen interface, there are 16 common procedure presets. Diode wavelengths cut soft tissues more cleanly and comfortably, while the EPIC 10 tooth bleaching uses only 20 minutes. The deep-tissue handpiece for the temporary relief of minor oral pain is controlled by spot size, thus avoiding inadvertent damage to surrounding tissues. For…

26. Page 50

    READERS' CHOICE TOP 25 FIRST IMPRESSIONS PRODUCTS Pola Day CP SDI (North America) Many at-home tooth-whitening regimens suffer from poor patient compliance, most often due to the extensive wear time required. Pola Day CP is a fast, 35% carbamidesperoxide at-home tooth whitening system with 2 to 3 times the concentration of most competitive systems. Aimed at unsupervised home compliance, its recommended wear time is 15 minutes, once or twice per day. Pola Day CP's neutral pH and high water content prevent tooth dehydration and bleaching sensitivity, and provide remineralizes teeth surfaces and decreases bleaching sensitivity. The high viscosity gingival gel…

27. Page 51

    READERS' CHOICE TOP 25 FIRST IMPRESSIONS PRODUCTS iLumi Super Fiber Posts iLumi Sciences Many dental infections that once resulted in tooth extraction are now treated endodontically, and mandatory post-endodontic restoration is a significant component of practice. Posts are straightforward for the practitioner and comfortable for the patient, often requiring no local anesthetic. The Super Fiber Posts, microfiber core thermally coated with low refractive index optical glass, are designed to be similar to dentin, with comparable flexibility and mechanical strength and a low modulus of elasticity. The color-coded posts are translucent, tapered, micropore-sided glass fiber-reinforced posts available in 6 sizes accurately…

28. Page 52

    READERS' CHOICE TOP 25 FIRST IMPRESSIONS PRODUCTS Iris Digital Doc The infratreatment can only be productive if it is in the operatory, ready for use by a motivated dental team for every single patient, every appointment, education, improved oclusion, and co-treatment planning. Iris is a precision optical instrument with Sony's Hi-Resolution CCD, an easy-to-use 5-point focus wheel, a smaller and softer tip and brilliant 5-point LED illumination. Convenient camera and light on/off buttons are readily accessible, particularly the rightand left-handed capture buttons on either side of the camera, and the multistep focus wheel achieves precise sharpness from macro to infinity…

29. Page 53

    READERS' CHOICE TOP 25 FIRST IMPRESSIONS PRODUCTS ANEW narrow implants Dentatus Two significant implant dilemmas are insufficient buccolingual bone width and limited mesiodistal space. The innovative ANEW Narrow Body Implant System (1.8-, 2.2-, and 2.4-mm diameters) offers expanded and enhanced restorative options. Designed to complement mainstream implant systems, ANEW includes platforms for screw-retained single and multiple-unit prosthetics and platforms for temporary restorations that offer a comfortable dentate state throughout treatment, including protection of graft sites and maintenance of the desired soft-tissue architecture. For more information, call (800) 323-3136 or visit dentatususa.com. FREEinfo, VELscope Vx LED Dental Early, effective, and rapid…

30. Page 54

    Dental Implant Prosthetic Options Upcoming Implant Events Michael Tischler, DDS Mini Implant Training Shatkin F.I.R.S.T. is offering a series of 2-day seminars on mini dental implants. These courses cover treatment planning, case selection, placement procedure, one-visit denture stabilization, onevisit single and multiple tooth replacement, anatomical considerations, marketing tips for mini implants, case presentations, and hands-on training opportunities. Attendin Buffalo, NY from August 17 to August 18, September 14 to September 15, October 5 to October 6, and November 16 to November 17. Earn up to 16 continuing education (CE) credits. For more information, call (888) SHATKIN (474-2854) or visit shatkinfiirst.com.…

31. Page 56

    Proper Preparation for Prosthetically Driven Implants Timothy Kosinski, DDS CBCT Diagnosing and Surgical Protocol INTRODUCTION With the widespread availability of Internet searches, our patients have become aware of the benefits provided by modern implant dentistry. Realizing that there may be other options available other than conventional removable appliances, our patients often present to our practices with a desire for fixed restorations. Innovations in implant dentistry and prosthetic techniques/materials have created predictable, long-term solutions to missing teeth. Proper diagnosis and treatment planning is surely the most critical aspect of dental implant therapy. As will be shown here, the surgical protocol has…

32. Page 57

    ALL-NEW! Waterlase express Figure 3. Planning software allows for virtual placement of dental implants prior to any surgical intervention and virtual design of the final prosthesis. angulation required when using implant osteotomy burs. However, conventional digital radiographs provide the clinician with only a 2-dimensional view. Preoperative CBCT scans (Vatech America) are used to help visualize the possibility and/or options for the use of implants in 3 dimensions. Significant anatomy and available bone and contours can be easily viewed. The CBCT taken using the i-CAT 15D Green CT (Vatech America) allows us to see and assess the height and width of…

33. Page 58

    IMPLANTS FIGURE 4. From the CBCT planning software, a surgical guide was created allowing for precise placement of the implants. FIGURE 5. Keys were inserted into the surgical guide allowing for precise osteotomies to be created. A 2.0-mm diameter bur allowed for proper angulation and depth to be determined. FIGURE 6. Following the osteotomy, a tissue punch was used to remove the keratinized tissue from the surgical site prior to implant placement. FIGURE 7. A 3.5-mm diameter osteotomy bur was used to create the final osteotomy preparation. FIGURE 8. The implants were threaded into the osteotomy site. FIGURE 9. Radiographs…

34. Page 59

    Quality and the use of CAD/CAM design helps us visualize the case finished before any surgical intervention. Figure 15. After approximately 4 months of integration, the tissue response around the implant abutments was excellent. it during the healing period (Figure 12). A postoperative radiograph demonstrated the ideal positioning of 5 implants, which would be used to support a 7-unit screw retained implant bridge (Figure 13). The postoperative CBCT indicates adequate bone and ideal positioning of the implant precisely following the preoperative virtual design (Figure 14). The implants were left to integrate for a months; Figure 15 illustrates the soft tissue…

35. Page 60

    Failure Followed by a Successful Outcome Edward R. Kusek, DDS INTRODUCTION The First European Workshop on Periodontology in 1994 defined peri-implantitis as the inflammatory reactions in the hard and soft tissues with loss of supporting bone surrounding a dental implant exposed to the oral environment. A successful dental implant is defined as immobile when tested clinically. In addition, vertical bone loss is less than 2 mm annually following the first year of service and the absence of pain, infection, nictropathies, and paresthesia.¹ Studies have shown that between 15% and 30% of all implants will have peri-implantitis.² This is alarming. There…

36. Page 62

    Figure 3. Postoperative site shows healing at 4 months after autogenous block graft done. Figure 4. Immediate post-surgical photo (after implant placement). Figure 5. Prosthetic bridge completed in anterior maxilla. Figure 6. Surgical site after removal of granulation tissue and detoxification using the WaterLase iPlus (BIOLASE). Figure 7. Postoperative healing, showing recession of tissues around surgical site. Figure 8. Second surgery, showing a 2-wall defect. Figure 9. Recurrence of purulent exudate at 4 months postoperatively. Figure 10. Granulation tissue removal. Failure Followed by a Successful... continued from page 60 abutments were tightened into place (torqued to 35 Ncm) per the…

37. Page 63

    Figures 13 to 15. The completed final prosthesis. (Note patient's low lip-line.) then PepGen Flow with Biomend Extend membrane was placed to prevent tissue invagination, and then a final layer of PRF membrane was placed. The area was closed using 4.0 vicryl sutures (Ethicon [J&J]). Postoperative instructions (both written and verbal) were given to the patient's aftercare. The surgical site healed well and patient was checked during the next few months. There was some recession noted (Figure 7). The patient was back on her oral irrigator with CRN after 6 weeks and her regular maintenance was scheduled with a periodontist…

38. Page 64

    Test 210 dentalCEtoday.com IMPLANTS Single-Unit Cement-Retained Implant Restorations Strategies, Protocols, and Techniques This article discusses single-unit cement-retained implant crowns, the evidence justifying their use, and protocols and techniques that minimize complications. Todd R. Schoenbaum, DDS, is an associate clinical dentistry professor in the division of constitutive and regenerative sciences at the University of California Los Angeles, School of Dentistry. He can be reached via email at tschoenbaum@dentistry.ucla.edu. Richard G. Stevenson, DDS, is a professor of clinical dentistry in the division of constitutive and regenerative sciences at the University of California Los Angeles, School of Dentistry. He can be reached via…

39. Page 65

    Figure 1. Commonly, the bony architecture of the anterior maxilla is such that the implants are placed at an angle that would make a traditional screw-retained restoration challenging. Here, screw-retained provisional restorations are being fabricated and the angulation of the implants can be clearly seen to emerge through the facial surfaces. Figure 2. Screw-retained restorations are not immune from causing peri-implantitis. This alloy framework has been abused in the laboratory, resulting in a very rough implant interface and margins. Such abuse will exacerbate the effects of peri-implantitis even though there is no cement. Figure 3. One of the challenges of…

40. Page 66

    IMPLANTS FIGURE 7. Commonly, cemented implant crowns exhibit small screw holes that look unesthetic, but this is a misconception. This cemented implant crown needs to be replaced due to the development of a less than ideal occlusal embrasure (red arrow). This crown has a mark indicating where to access the screw channel (white arrow). FIGURE 8. The crown in Figure 7 has been retrieved from the mouth. The screw cover removed, allowing easy access to the abutment screw for retrieval. FIGURE 9. Many laboratories have begun using indicators or stains such as these to indicate the location of the screw…

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