13082000_Espe_Mag-23_EN_72

Dear Readers,

Similar to edges of a forest, sea, lake or river and field

borders which characterize a landscape, margins in the

oral environment have a huge impact on the appearance

of an individual. A beautiful smile is obtained only if natu-

ral soft tissue contours are preserved or restored after

implant insertion or restoration placement. Moreover, res-

toration longevity and a healthy soft tissue strongly cor-

relate with the quality of the restoration margin.

In order to support you in obtaining perfect margins,

3M ESPE offers a whole variety of innovative products,

which will all be presented in Cologne at the world’s larg-

est dental trade fair and meeting place of the dental

industry: the IDS. This is the place to be for all those who

want to be informed about the latest trends and

approaches in dentistry. You are invited to visit the IDS

booth of 3M ESPE to obtain first-hand information about

new materials and devices e.g. from the product develop-

ers and pilot users. On the spot, you may test the innova-

tions and compare them to each other. Additional insights

are given in this issue of the Espertise™ Magazine. It is

composed of articles written by researchers, clinicians

and developers who love to share their personal perspec-

tives and clinical experience with you.

Enjoy reading!

Gerhard Kultermann, Editor

3M ESPE, Seefeld, Germany

E D I T O R I A LIt’s all about the margin ..........................................................................2

Improved marginal accuracy through standardization .......................3

Quality is an integral part of 3M ESPE! ................................................4

Direct restorations: lifelike appearance, perfect margins..................6

New generation cement with efficient marginal adaptation ..............8

Faster, easier and more convenient! ....................................................9

The effect of different retraction techniques on the gingiva ............10

Practise-based research results on handling properties .................11

The impact of soft tissue management on marginal quality

of restorations .......................................................................................12

Optimized features for even higher accuracy ....................................14

How digital technologies may contribute to marginal quality .........16

A conservative approach to indirect restorations............................18

Dentistry in the Kingdom of Belgium ............................................. 20

Dentistry in Israel ........................................................................... 21

The solution for compromised patients ......................................... 22

magazine No. 23 | FEB 2013

Espertise™

C O N T E N T

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13082000_Espe_Espertise-23_en 1 18.02.13 11:59

No. 23 | FEB 2013

In restorative dentistry, there are different

kinds of margins which have a decisive

impact on the aesthetics and functioning of

the final result, including the finishing line of

the preparation, the edge of the restoration

and the gingival margin.

The preparation and its finishing line have to

comply with certain preparation guidelines in

order to ensure that a precisely fitting restoration

can be produced and placed that remains stable

over time. At the edge of the restoration, preci-

sion and smoothness are of utmost importance:

Irregularities at this margin may result in an

improper fit and may lead to tissue inflammation,

bone resorption and ultimately to failure of the

restoration. Apart from accuracy, a tight seal of

the interface between the tooth and the restora-

tion must be obtained, no matter whether direct

or indirect restorations are placed. Only with a

strong bond is it possible to prevent the occur-

rence of discolouration, microleakage, second-

ary caries and post-operative sensitivities. The

gingival margin influences pink and white aes-

thetics, which is strongly dependent on perfect

tissue management.

These and additional topics around the margin

were addressed by renowned speakers and an

exclusive group of dental professionals which

were invited by 3M ESPE to attend an Espertise™

Experts Roundtable at Lake Starnberg near

Munich, Germany in November 2012. Here, e.g.

different approaches towards an improved qual-

ity of the restoration margin and techniques for

soft tissue management were presented from

both, a clinical and a scientific viewpoint. After

two days of lectures, poster presentations and

discussions with colleagues, the participants

agreed that the margin influences restorative

dentistry in many ways. It was concluded that a

high quality of the final result can only be

ensured through exact planning of a treatment,

the use of advanced materials and devices and a

standardization of workflows in practice and

laboratory.

It’s all about the marginFrédéric van Vliet, 3M ESPE, Seefeld, Germany

Espertise™ Experts Roundtable 2012

Event location at Lake Starnberg in Germany.

Renowned speakers reported on their clinical experience and research findings.

Various topics were discussed during the lecture pro-gramme ...

... and in the breaks.

During the poster presentations, young researchers pro-vided information ...

... about recently conducted studies and their outcomes.

Exchange of ideas and opinions.

Restorative dentistry

Espertise™

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Scientific Activities


The striving for a perfect margin in restorative

dentistry is a well-known phenomenon: scien-

tific-based knowledge indicates that inflam-

mation of gingival tissues and bone destruc-

tion correlate directly with a poor quality of the

restoration margin. However, in the production

process of an indirect restoration, there are

many different factors that may lead to mar-

ginal inaccuracies. Strategies to avoid the

occurrence of these imperfections are dis-

cussed in the following article.

Factors influencing accuracy

The first sources of inaccuracies evolve from tooth

preparation which, in clinical reality, often does not

meet all criteria with regard to the perfect finishing

line. Irregularities in the margin and a restoration

placed closer than 3 mm to the alveolar crest, for

example, foster tissue inflammation. According to

in-vitro and clinical studies, the margin design is

also important for accurate restorations. A chamfer

design seems to lead to the best results.

In addition, inaccuracies are created in the pro-

cess of transferring information from the patient’s

mouth into the dental laboratory. Errors resulting

from one step in the treatment and laboratory

workflow are usually not compensated by another

but persist through the whole process and may

even add up to a greater error.

The impression

The impression taking process is particularly chal-

lenging due to the moist oral environment and

potential bleeding of the sulcus. Studies have

revealed that taking the impression under local

anaesthesia reduces the risk for failure by a factor

of five. In order to lay the foundation for an accu-

rate impression, the process should be carried out

immediately after tooth preparation if the area can

be dried successfully. If this is not possible, a

latency of approximately ten days is recommended

to ensure complete healing of the soft tissue. The

impression technique may be selected depending

on the indication and individual preferences.

Standardization of processes

What should also be taken into account is that the

altering of process steps, materials and production

conditions in the treatment workflow may lead to

differences in the accuracy of the final result. For

example, using more than one impression material

or different types of plaster for cast production in the

restorative processes makes the result less predict-

able, since e.g. the polymerization shrinkage or

expansion factors are different. Only the use of the

same materials and the same work steps in every

process reduces the variability of the results. This

standardization should be carried out in the dental

practice and laboratory and even should involve

equal production conditions. For example, a uniform

temperature in the plaster room to always induce

the same material expansion is very important.

Conclusion

The aim of modern restorative dentistry is the crea-

tion of long-lasting restorations which perform like

the natural teeth they replace. For a reliable perfor-

mance, accuracy of a restoration and marginal qual-

ity play a decisive role. In order to create restorations

with perfect margins, not only high-quality dental

biomaterials and techniques are needed. A well-

structured management of the patient, the tissues

and the biomaterials used is highly important as well.

Improved marginal accuracy through standardizationBernd Wöstmann, Giessen, Germany

Restorative dentistry

Effects of inaccuracies in the fabrication process of a crown. In a first approximation, the size distribution of the represented crown lumina in an impression may be regarded as the normal distribution (above). The same applies to the master cast (below). (e) represents the acceptable range for the crown lumen.

Original dimension of the tooth

largersmaller

Impression

Cast production

d) e)


largersmaller

Impression

Cast production

d) e)


largersmaller

Impression

Cast production

a)

c)

b)

d) e)

Espertise™

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Ask the Expert


No. 23 | FEB 2013

“Quality means doing it right when no one is

looking,” says a quote attributed to the Ameri-

can industrialist Henry Ford, the founder of

Ford Motor Company. Indeed, the quality of a

product is defined by people and processes

that are usually invisible to the common user.

In the company’s laboratory, developers col-

lect ideas, translate customer wishes into

technological specifications and combine vari-

ous technologies and ingredients to obtain a

new material or device. The quality of the final

product is determined by how every step in

this process is performed and monitored.

In order to learn more about these invisible pro-

cesses and the internal measures that are imple-

mented at 3M ESPE to ensure an excellent prod-

uct performance, we had a conversation with Dr.

Alfred Viehbeck, Vice President, R&D Materials of

the 3M ESPE Dental Products Division. As the

head of the global R&D laboratory with locations

in St. Paul, Minnesota and in Seefeld, Ger-

many he has responsibility for the material

and technological innovations that are cre-

ated within the company and is able to pro-

vide insight into the role of quality at

3M ESPE.

Dr. Viehbeck, in Research & Development of

dental materials, Quality Management is of

major importance. Why is quality so crucial

for 3M ESPE?

The confidence our dental professional customers

have in us is at stake every single time they use

one of our products. Because of that we are com-

mitted to the highest standards in everything we

do. Our customers know that they can count on

our products to work right the first time, and the

same way time after time.

In order to ensure that the highest quality stand-

ards are met, we have a separate Quality Man-

agement Department that includes Regulatory

Affairs, Product Safety and Quality Assurance.

However, Quality Management touches every

individual employed at 3M ESPE. Quality Assur-

ance, for example, is an integral part of our New

Product Introduction process.

It is of significant importance

in making sure new products,

from the very moment they

are launched, perform the way they are intended

to perform.

Please describe the different stages of prod-

uct development from the initial idea to

product introduction.

We use a process for new product development

which includes Ideation, Concept, Feasibility,

Development/Scale-up, and Launch phases.

Essentially, new ideas are taken through a matu-

ration process, where questions of technical via-

bility, market viability, manufacturing, commer-

cialization, and of course product quality are

addressed. We have a highly disciplined gate

review process involving the leaders from each

function in order to ensure that all key questions

and concerns are appropriately addressed before

allowing the program to proceed. As part of our

efforts to make sure we get things right, we are

not afraid to stop, or delay, a program before

allowing the team to proceed.

Please give a few exam-

ples of what kinds of

quality assurance tests

are performed during the

different phases.

To gain the true voice of the

market and the voice of the

customer we do surveys, inter-

views, focus groups, applica-

tion tests, and field evaluations throughout the

product development cycle. During actual product

development, numerous tests are performed. In

vitro testing is usually done in our certified ISO

approved laboratory. For a material like 3M™ ESPE™

Quality is an integral part of 3M ESPE!Frédéric van Vliet, 3M ESPE, Seefeld, Germany

Looking behind the scenes ...

Left: St. Paul, USA. Top: Seefeld, Germany

Espertise™

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Ask the Expert


RelyX™ Ultimate Adhesive Resin Cement, e.g.

extraction tests to assess product safety, mechani-

cal property and adhesion tests to evaluate product

performance are conducted. In addition, the pro-

cess includes shelf life tests and accelerated aging

to determine the strength, durability and reliability

of the product. Stain testing serves as a means of

checking the product’s resistance to discoloura-

tion, a factor that is important for long-lasting aes-

thetics. After launch, the product performance is

continuously monitored. In addition many third-

party in vivo clinical studies are commissioned to

substantiate all product claims.

And there is evidence that this strategy leads to

success: data from independent third-party sur-

veys we conduct suggests overall satisfaction

with 3M ESPE is the highest among the dental

manufacturing companies we survey. This is how

we are rewarded for our efforts.

Is it this reward that makes you like your job

at 3M ESPE?

There are different factors that make my job satis-

fying. For me, the close interactions with custom-

ers are the most enjoyable. Another aspect is that

we are part of the bigger 3M Company and have

access to technologies and expertise across our

many businesses and the 3M Corporate Research

Laboratory. Making a difference in the lives of our

customers and having satisfied patients due to our

products is also highly rewarding.

What are your plans for the future?

We will continue to develop products that benefit

the dental industry, oral care providers, and

patients with faster, easier, and better dentistry.

For the eighth consecutive year, 3M ESPE was

named the most innovative dental company in the

industry by the Anaheim Group in its independent

evaluation published in the Dental Industry Review

2012, and hopefully our future new products will

sustain this legacy. My mission will be to ensure

that this laboratory delivers the highest quality

products, invests in technology development for

differentiation, and has the most highly motivated,

dedicated workforce.

Dr. Viehbeck, thank you for providing

insights into internal processes at 3M ESPE.

Dr. Alfred Viehbeck

Employee working in the research laboratory …

… of 3M ESPE in Seefeld, Germany. Determination of the 3-point bending strength of a zirconia specimen with a Zwick universal testing machine.

Espertise™

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No. 23 | FEB 2013

3M™ ESPE™ Filtek™ Supreme XTE Universal Restorative

Direct restorations: lifelike appearance, perfect marginsHein de Kloet, Arnhem, the Netherlands

Figure 2: The existing restorations are insufficient due to discolouration and microleakage. After a presentation of possible treatment outcomes on the basis of digital imaging, the decision is reached to restore the maxillary anterior teeth with 3M™ ESPE™ Filtek™ Supreme XTE Universal Restorative.

Figure 3: From an occlusal view, the discolouration is particularly intensive. The erosion is most severe at the lingual and incisal areas of the central incisors.

Figure 4: Situation after removal of a large part of the old fillings. Tooth structure at the lingual surface has to be removed as well to create sufficient space for composite mate-rial. Wherever possible, an equigingival preparation margin is designed in order to protect the soft tissue.

Figure 5: A metal band is used for build-up of the lateral incisors with 3M™ ESPE™ Filtek™ Supreme XTE Universal Restorative in the shade A2B. The bonding procedure is performed using the etch & rinse technique with etchant and 3M™ ESPE™ Scotchbond™ Universal Adhesive. Due to low caries activity, the initial caries at the central incisors is not treated.

Figure 6: The lingual areas of the two central incisors are built up in the same manner employing an etch & rinse bonding procedure. The same composite material in the shade A2B is applied. Then, the occlusion and articulation are checked.

Figure 1: A 37-year-old male patient with severely eroded teeth presenting in the dental practice. The maxillary anterior teeth are only just visible when the patient is smiling. The cause of the erosion remains unclear even after anamnesis.

Espertise™

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Clinical Excellence


Figure 7: Buccal view of the situation. The lingual build-up in this primary stage is per-formed to enable the placement of rubber dam for further direct restorative procedures.

Figure 8: Rubber dam is placed and the prepared teeth are sandblasted to ensure a proper adhe-sion to the residues of old composite material. After the adhesive procedure, the core restorations are created using 3M™ ESPE™ Filtek™ Supreme XTE Universal Restorative in the shades A3B on the canines and A2B on the incisors.

Figure 9: Directa® Matrix Strips (Directa) are utilized for good marginal adaptation of the filling mate-rial. In this stage, the correct definition of the midline is particularly important. During build-up of the approximal contours, care should be taken not to have too much excess material in the cervical area.

Figure 10: After removal of the excess material the planned shape of the new restorations is already visible.

Figure 11: The occlusion is checked and a small amount of grey colour liquid (Kolor + Plus®, Kerr) added before the composite facings are created. For isolation of the cervical part of the teeth, AutoMatrix® metal bands (Dentsply) are used. Subsequently, the adhe-sive procedure is performed again.

Figure 12: With the metal band in place, the canines are restored with composite material of the shade A3.5B in the cervical and A3B in the incisal area. A3B and A2B are used on the lateral incisors and on the central incisors a layer in the shade A2B is applied. A natural appearance of the incisal edge is obtained by the use of white colour liquid imitating white spots and small enamel cracks.

Figure 13: Situation after finishing of the vestibular areas using a flame shaped diamond bur and a fine diamond instrument. For polishing, 3M™ ESPE™ Sof-Lex™ Contouring and Polishing Discs and a buffing wheel are employed. Relatively deep bite conditions are visible, but these are perceived as comfortable by the patient.

Figure 14: Several months after the treatment: a natural surface structure including grooves and a subtle translucency in the cutting edge are obtained. Together with the imitated micro cracks and white spots and a smooth transition between the restorations and the soft tissue, this ensures a lifelike appearance of the restorations.

Espertise™

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No. 23 | FEB 2013

Since January 2013, a new generation of

3M™ ESPE™ Ketac™ Cem Plus Resin Modified

Glass Ionomer Cement is available. The fluo-

ride-releasing luting material is indicated for

the cementation of metal and PFM crowns,

bridges, inlays and onlays as well as oxide-

ceramic restorations, endodontic posts and

orthodontic appliances. In addition, it can be

used for luting of restorations to implant

abutments. Dentists can choose between

two different delivery systems – an automix

syringe and the Clicker™ Dispenser.

Tack-cure clean-up feature

Based on the clinically proven formulation of its

predecessor, the new generation cement was

optimized not only to offer an easier application

with the automix option: the major improvement is

the new tack-cure feature that allows for easy

excess cement removal after application of Ketac

Cem Plus cement and placement of the restora-

tion. By light-curing each restoration surface for

five seconds, the excess cement reaches the gel

state and can easily be removed in large sections

from the margins. Alternatively, the user can wait

two minutes after seating for the excess to self-

cure.

Efficient marginal seal

The efficient marginal seal to enamel and dentin of

Ketac Cem Plus after tack-curing could be con-

firmed in an in-vitro study at the University of

Regensburg, Germany[1]. In order to assess the

quality of the margin, ceramic inlays were cemented

on human molars using different materials.

After application of each cement according to each

manufacturer’s recommendations, e.g. tack-curing

of Ketac Cem Plus, as well as subsequent removal

of excess cement, the interface between the resto-

ration and enamel respectively dentin was evalu-

ated. Scanning electron microscopy and a dye

penetration test were used to assess marginal seal

perfection before and after thermocycling and

mechanical loading (TCML).

Results

Ketac Cem Plus revealed 100% perfect margins to

dentin before and after TCML when the tack-cure

feature was used for excess removal[1]. The marginal

integrity of Ketac Cem Plus to dentin and enamel

before and after TCML was closer to perfect than for

other resin-modified glass-ionomer cements[1, 2].

With the new tack-cure clean-up feature that now

offers easy excess cement removal, Ketac Cem

Plus cement provides efficient marginal seal to

dentin and enamel.

New generation cement with efficient marginal adaptationEva-Maria Popp, 3M ESPE, Seefeld, Germany

3M™ ESPE™ Ketac™ Cem Plus Resin Modified Glass Ionomer Cement

[1] Sawaljanow A, Lang R, Handel G, Behr, M, Rosentritt M. In-vitro Marginal Adaptation of Resin-Modified Glass Ionomer Cements to dentin and enamel. Abstract #170549, IADR 2013.

[2] Partially cited from: Rosentritt M, Behr M, Lang R, Handel G. Influence of cement type on the marginal adaptation of all-ceramic MOD inlays. Dent Mater. 2004 Jun; 20(5):463-9.

3M™ ESPE™ Ketac™ Cem Plus Resin Modified Glass Iono-mer Cement is available in the Clicker™ Dispenser and in an automix syringe.

Tack-curing of 3M™ ESPE™ Ketac™ Cem Plus Resin Modi-fied Glass Ionomer Cement. This procedure facilitates the removal of excess cement.

100

90

80

70

60

50

40100 97,6 100 98,3 90,2 87,3

Dentin Enamel

30

20

10

0Before TCML Before TCML Before TCMLAfter TCML After TCML After TCML

Med

ian

Perf

ect M

argi

n (%

)

3M™ ESPE™ Ketac™ Cem PlusAutomix[1]

no conditioner

GC Fuji CEM™ Automix[1]

no conditioner

GC Fuji PLUS™ Powder/Liquidwith GC Fuji Plus™

Conditioner[2]

92,8 86,4 87 83 76 85

Schematic representation of the study results (source: A. Sawaljanow, R. Lang, G. Handel, M. Behr, M. Rosentritt [1]).

3M™ ESPE™ Astringent Retraction Paste

Espertise™

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8

News and Innovations


As a company with a long tradition in the

development of products for impression tak-

ing, 3M ESPE knows that it is not the impres-

sion material alone that ensures a precise

result. An important precondition for an

accurate reproduction of marginal details is

the retraction of the gingiva and an open, dry

sulcus. Having identified the need for an

easy-to-use paste for gingival deflection,

3M ESPE decided to initiate a development

project in 2008.

Development goals

Formulating the goals of the project, it became

clear that its realization would be anything but

easy: many different features were regarded as

important in order to enhance the process of soft

tissue retraction.

The basic goal was to invent a product that offers

mechanical retraction and enables control of exu-

dation during impression taking as well as cemen-

tation. The development team was also in agree-

ment about needing a material that is suited for

digital and conventional impression taking. A

decisive factor for user convenience was the

development of a material that could be applied

without the necessity of purchasing an additional

dispenser. Last but not least, the innovation

should be faster, easier and more convenient for

both, dentist and patient, than any existing prod-

uct available on the market.

A tough nut to crack

Having defined these goals, the team set to work.

In order to achieve mechanical retraction, a cap-

sule had to be developed that enabled placement

of the paste directly into the sulcus without dam-

aging the tissue. A very small tip and an ergo-

nomic capsule design were the solution. In order

to achieve best possible astringent properties dif-

ferent paste formulations were developed, tested

and compared. The one with outstanding astrin-

gent effect was finally chosen containing alumin-

ium chloride and other coagulation accelerators.

The task of developing a paste that is dispensed

without the need of a new device was particularly

challenging. The idea was to enable application

with a common composite dispenser that is avail-

able in every dental practice. The problem: the

paste has to be stiff to remain in the sulcus, albeit

a low extrusion force is essential for precise

intraoral application and the tip of the capsule is

very small. Since the transmission of the dis-

penser could not be altered, the task had to be

accomplished by optimizing the selection and

ratio of fillers. The compatibility of the new paste

with impression materials and its suitability for the

digital impression taking process were verified by

extensive testing.

Product quality

Since there are no existing ISO norms for testing

retraction pastes, the team developed different

analytical measurement systems and procedures

to obtain detailed information about the product’s

performance. For example, data was collected on

the time required for removal of the material, the

ability of opening the sulcus and the flow resist-

ance. The results were also compared to those

achieved with other pastes and in the last step

prior to product launch, a field test was initiated

worldwide. Here, 80% of the respondents stated

that 3M™ ESPE™ Astringent Retraction Paste was

easier to use than the paste they usually utilized in

their dental office. Together, the test results con-

firmed that the new paste is indeed faster, easier

and more convenient than other available prod-

ucts.

Faster, easier and more convenient!Andreas Maurer, 3M ESPE, Seefeld, Germany


Dr. Anrdreas Maurer, Research Chemist at 3M ESPE, Seefeld.

3M™ ESPE™ Astringent Retraction Paste is the only stiff retraction paste that can be applied with a common composite dispenser.

Espertise™

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Backstage Report


No. 23 | FEB 2013


The effect of different retraction techniques on the gingivaRalph G. Luthardt, Ulm, Germany

Soft tissue management is an important procedure to allow for

exact capture of the preparation margin during impression taking.

Diverse techniques and materials are available to induce the effect

of gingival retraction, ranging from retraction cords to the use of

lasers. In many dental practices, impregnated retraction cords are

applied in the double-cord technique to obtain the desired effect.

However, this method is highly complex as well as time-consuming,

so that alternative techniques and materials are developed and

tested.

Against the background of the development of an astringent retraction

paste, the company 3M ESPE sponsored research of the Department of

Prosthetic Dentistry at Ulm University (Germany). The aim of the project

was to assess and compare the effect of an existing paste containing alu-

minium-chloride with that achieved with impregnated retraction cords used

in the doub le-cord technique on the gingiva. This comparison should help to

find out if a paste is a suitable alternative to cords in the clinical environ-

ment. The benefit of using a paste is the ease of use of the product and a

less time-consuming procedure.

Study design

In order to measure the gingival displacement capacity of the paste versus

two cords under healthy soft tissue conditions and with mild artificial gingi-

vitis, a split-mouth study design was adopted. An impression was taken and

a saw model produced after application of either two retraction cords (dou-

ble-cord technique) or the paste containing aluminium-chloride on the max-

illary premolars of one quadrant. The other maxillary quadrant served as

control.

The intervention was the same at baseline under healthy soft tissue condi-

tions and after six months, when the quadrant was changed and mild artifi-

cial gingivitis was induced by refraining from tooth brushing. Impressions

were taken prior to and after each intervention as well as after three and six

months. For three-dimensional analysis of the produced models, the casts

were digitized with a laboratory scanner and the amount of vertical dis-

placement of the soft tissue measured and analyzed using specific soft-

ware.

Results and conclusions

It was found that neither the application of the paste nor the use of cords for

soft tissue management did lead to permanent recession of the gingiva.

Mild artificial gingivitis did not have a negative effect on retraction when the

paste was used. A deeper penetration of the impression material was

achieved with the cords (source: http://iadr.confex.com/iadr/2012tampa/

webprogram/Paper158144.html).

Additional study results will be published at the IADR/AADR/CADR General

Session in Seattle on March 20 to 23, 2013. The available information,

however, indicates that retraction pastes may be a suitable alternative to

cords in many situations. The new 3M™ ESPE™ Astringent Retraction Paste

might even be capable of achieving a greater depth of penetration since it

is applied into instead of on the sulcus.

Soft tissue management

Prof. Dr. Ralph G. Luthardt, University of Ulm, Germany.

Espertise™

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Ask the Expert


Practise-based research results on handling propertiesTrevor Burke, Birmingham, United Kingdom


Scientific studies – whether in vitro or in vivo

– are conducted to provide evidence of a

product’s suitability for a defined purpose.

However, even clinical studies are usually

carried out under idealized conditions so that

the results are not always applicable to the

common dental practice. Therefore, practise-

based research is highly important. The term

indicates that general dental practitioners

conduct clinical research in the busy practice

environment. They evaluate products in

respect of their handling or their long-term

clinical performance. This kind of assess-

ment by independent practitioners reflects

real life and thus helps dentists to find a

material or device that suits their needs.

On the basis of this idea, the PREP panel (Prod-

uct Research and Evaluation by Practitioners)

was founded by five colleagues and me in Bir-

mingham in 1992. By now, the group consists of

33 experienced dental practitioners mainly

based in the United Kingdom who test and eval-

uate new materials and devices in their own den-

tal office. In the past years, numerous reports

have been published by the group and provide a

useful source of information for colleagues.

Recently, the new 3M™ ESPE™ Astringent Retrac-

tion Paste was tested and evaluated by members

of the panel.

Handling properties in focus

Since existing gingival retraction techniques e.g.

using cords, kaolin or aluminium chloride and

astringent solutions have not gained total accept-

ance so far, the introduction of a new solution in

this field was generally appreciated by the mem-

bers of the PREP panel. In order to obtain informa-

tion about the handling properties of the new

product, a study was initiated and the paste

tested by twelve evaluators. They were asked to

use the new retraction capsules for ten weeks in

their dental practice environment and complete a

questionnaire afterwards.

Easy-to-use product

During the ten weeks of testing, the new paste

was used for more than 150 impressions and

several restorations. The questionnaire included

information on what kind of gingival retraction

system was usually employed so that the perfor-

mance of the previously preferred product and

the new paste could be compared. Other ques-

tions focused e.g. on dispensing, the suitability

of the paste for gingival retraction, capsule

design and the efficiency of the whole retraction

procedure.

The 3M ESPE Astringent Retraction Paste

obtained good scores across all criteria. In com-

parison with the retraction system that was origi-

nally used by the evaluators, the new paste in the

innovative capsule received high ratings with

regard to its ease of use. The detailed scientific

results of the study will be published in the very

near future.

Prof. Dr. Trevor Burke, University of Birmingham, United Kingdom.

Espertise™

magazine

11

Ask the Expert

The new retraction paste comes in a single-use capsule.


No. 23 | FEB 2013


The impact of soft tissue management on marginal quality of restorationsRafał M´dzin, Gryfino, Poland

Espertise™

magazine

12

Clinical Excellence

Figure 3: After removal of the crown on the left central inci-sor, a heavily discoloured abutment tooth restored with a metal post is revealed.

Figure 4: Whenever possible, a restoration margin should be placed on an equigingival level. Due to severe discol-ouration, however, a subgingival preparation is required on this tooth. The stump with the old post is prepared, sand-blasted, treated with 3M™ ESPE™ Scotchbond™ Universal Adhesive and covered with a composite opaquer.

Figure 5: A provisional is produced using 3M™ ESPE™ Protemp™ 4 Temporization Material and fixed with 3M™ ESPE™ RelyX™ Temp NE Temporary Cement.

Figure 7: Tooth preparation: the left central incisor and right canine are prepared for all-ceramic crowns, while a minimally invasive preparation is carried out on the other maxillary inci-sors, where porcelain adhesive restorations are planned.

Figure 8: The double-cord technique is indicated for the teeth with crown preparations due to the subgingival mar-gin and severe exudation. The non-invasive retraction method using 3M™ ESPE™ Astringent Retraction Paste is chosen for the right central incisor and both lateral incisors.

Figure 1: Initial situation: the maxillary left central incisor of the young female patient is restored with an insufficient porcelain-fused-to-metal restoration …

Figure 2: … the right lateral incisor and canine previously received endodontic treatment and show discolouration. The right central and left lateral incisors are slightly discoloured as well.

Figure 6: The temporary crown helps the patient to assess the appearance of the planned restoration. Beyond that, it is used to support proper healing of the soft tissue.

Soft tissue management has a huge impact

on the marginal quality of indirect restora-

tions. The gingiva has to be deflected in

such a way that a detailed record of the

preparation margin can be captured with

the impression material or the intraoral

scanner if a digital procedure is chosen.

Traditionally, soft tissue retraction is

achieved with retraction cords. They are

available in different designs and some of

them are impregnated with haemostatic

agents. Retraction paste systems and sur-

gical methods such as laser tissue sculpt-

ing or electro-surgery have been adopted

more recently.

The new 3M™ ESPE™ Astringent Retraction

Paste for gingival deflection and haemostasis

presents a suitable alternative to the existing

cords in many cases. It is applied directly into

the sulcus to open it mechanically and to stop

exudation. Depending on the depth of the

preparation and the level of sulcular exudate

flow, it may eliminate the need for a cord

completely or may replace the second retrac-

tion cord when the double cord technique is

indicated. The innovative product proves its

worth especially in situations with a mini-

mally invasive preparation. The benefits of its

use are a quicker and more comfortable pro-

cedure as compared to the traditional work-

flow.

In the following article, a patient case is pre-

sented to illustrate the combined use of

retraction cords and the innovative astringent

retraction paste that has been introduced by

3M ESPE.


Dr Rafał M´dzinDentura Clinic & Lab Poland

[email protected]

Espertise™

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13

Figure 10: … and after the use of 3M™ ESPE™ Astringent Retraction Paste. The paste was removed after 2 minutes by rinsing with water.

Figure 11: The retraction effect is clearly visible: the prepa-ration margins are exposed on both teeth since the tissue is displaced. Furthermore, an open, dry and clean sulcus is obtained. There is a visible change in distance between the soft tissue and the preparation margin.

Figure 12: Retraction effect on all prepared teeth. At the teeth with crown preparations, one cord is removed while the other one is still in place.

Figure 13: An impression is taken in the monophase tech-nique using 3M™ ESPE™ Impregum™ Penta™ Soft Polyether Impression Material. All details of the finishing line are per-fectly visible in the impression.

Figure 14: The effect of the preparation and the efficient gingival retraction are visible on the plaster model: the fin-ishing lines were precisely transferred to this replica of the situation in the patient’s mouth.

Figure 16: Final restorations in place, immediately after cementation with 3M™ ESPE™ RelyX™ Ultimate Adhesive Resin Cement in combination with 3M™ ESPE™ Scotchbond™ Universal Adhesive.

Figure 17: Thanks to the accurate record of marginal detail obtained by soft tissue management prior to impression taking, the fit of the crowns and veneers is excellent. Highly aesthetic restorations are obtained which are indistinguish-able from natural teeth.

Figure 18: This is partly due to perfect margins: the soft tissue is healthy and has a natural shape. The patient is very happy with the beautiful treatment result.

Figure 15: The final restorations: three glass ceramic veneers and two crowns fabricated using the refractory die technique after etching of the inner surface with hydro-fluoric acid and application of 3M™ ESPE™ Scotchbond™ Universal Adhesive.

Figure 9: Close-up view of the minimally invasive prepara-tions on the right central and lateral incisors before …


No. 23 | FEB 2013

On the occasion of the International Dental

Show in Cologne in 2013, an innovation in

impression taking is presented by a leading

company in this field, 3M ESPE. The new

3M™ ESPE™ Imprint™ 4 VPS Impression

Material stands out due to optimized features

and attracts the dentist’s attention with its

bright colours. Insights into material develop-

ment and an overview of the benefits of

Imprint 4 are given by Dr. Peter Osswald,

Research & Development Impression Materi-

als at 3M ESPE.

Dr. Osswald, addition silicone impression

materials are available since the 1970 and

have been subject to continuous improve-

ments ever since their introduction. After

such a long time, it might be assumed that

a material with the optimum composition is

already available. So for what reason did

you decide to initiate another product

development project for a VPS impression

material?

I believe that there always is and will be room for

improvement of any material. The perfect compo-

sition does not exist, partly because trends and

user preferences change over time and techno-

logical progress never stops. In order to deliver

products that are tailored to ideally suit the needs

of our customers, we are always collaborating

with users and do never stop analyzing which fea-

tures might be worth altering. For VPS materials,

we found that a different setting behaviour with

faster intra-oral setting but identical working

times as existing VPS materials from 3M ESPE

would be beneficial. In addition, an even higher

hydrophilicity is desired by dentists.

What were the first steps of product devel-

opment?

We did not have to start from scratch, but were

able to build on existing knowledge and experi-

ence from developing vinyl polysiloxane impres-

sion materials. Furthermore, we have within 3M

the unique ability to get access to a large variety

of different technologies. We focused on the exist-

ing composition and determined which compo-

nents would have to be added or changed to

reach our goals. We decided to alter the colours

for enhanced readability of the impressions and

add flavour for an improved patient experience.

But the optimization of hydrophilicity and the set-

ting behaviour were in the centre of attention. Dif-

ferent approaches on how to proceed were dis-

cussed and the team of researchers developed

the basic technologies, one to enhance hydrophi-

licity and the other improving the setting behav-

iour.

How did you proceed in order to change the

setting behaviour?

What was difficult was not to just shorten the

whole setting regime, but to reduce time required

for the setting reaction in the patient’s mouth,

while the working time had to remain the same.

After an intensive ideation process and testing of

different approaches, we reached the goal by

adding a self-warming mechanism to the existing

formula of VPS materials.

The reaction that initiates warming starts after the

working time and the rise in temperature leads to

accelerated setting. This property results in a

more efficient workflow, increased patient com-

fort and less stress for the practice team.

Optimized features for even higher accuracyJulia Farr, 3M ESPE, Seefeld, Germany

3M™ ESPE™ Imprint™ 4 VPS Impression Material

Impressions with the new materials: 3M™ ESPE™ Imprint™ 4 Penta™ Heavy with Imprint™ 4 Regular …

… 3M™ ESPE™ Imprint™ 4 Penta™ Putty with Imprint™ 4 Super Quick Light …

… and 3M™ ESPE™ Imprint™ 4 Penta™ Super Quick Heavy with Imprint™ 4 Super Quick Light.

The rise in temperature of 3M™ ESPE™ Imprint™ 4 is clearly visible with the thermographic camera.

Ordinary VPS impression material

Imprint™ 4 Impression Material

Espertise™

magazine

14

Ask the Expert


How was it possible to develop a VPS

impression material that is even more

hydrophilic than existing materials?

We know that hydrophilicity is one of the most

important properties of an impression material:

the more hydrophilic it is, the better is its

potential for precise detail reproduction in a wet

environment. Detailed impressions, in turn,

lead to restorations with accurate margins.

Therefore, we spent a lot of time focusing on

this topic. Many different technologies and

additives were tested, but the addition of the

novel modified polyalkylene oxide wetting ena-

bler turned out to be the best solution. This

component in combination with our long-term

proven surfactant leads to an outstanding

hydrophilicity of the material even in the

uncured state immediately after mixing, so right

from the start.

So, you succeeded in developing two new basic

technologies. Was it difficult to combine them

with each other and the other components?

The two basic technologies were just merged and it

turned out that they did not have a negative effect

on each other or the whole composition. However,

it was more challenging to work out all the different

variants of the impression material. A whole portfo-

lio of Imprint 4 products was developed, consisting

of materials in

with different

viscosities and

setting times in

order to satisfy

all customers

preferences

and require-

ments. Exten-

sive develop-

ment and laboratory testing under

involvement of a lot of different func-

tions within our company was

required to prove the outstanding

performance of all materials.

What is your conclusion regard-

ing the success of the project?

Due to the highly motivated team and

with all individuals acting in concert,

we succeeded in developing not one,

but ten new impression materials with

highly beneficial features. Due to

higher hydrophilicity and a faster set-

ting in the mouth, an accurate repro-

duction of details is possible. The results of an

application test in Western Europe and the United

States confirmed the high level of user satisfaction

which makes us very confident that we have

addressed the right issues for our customers: for

example, the intra-oral setting time received high

ratings. Furthermore, 80% of the respondents in

Western Europe and 88% of the US-respondents

stated that they will or will probably use the new

materials in their own dental office.

Dr. Osswald, thank you for the conversation.

gnisnepsiDtcudorPsystem

Viscosity Setting version

Working time (23° C)

Intra-oral syringing time (37°C)

Intra-oral setting time (37° C)

TRAY MATERIALS

Imprint™ 4 Penta™ 03:2–03:1teS ralugeRyttuPyttuP

Imprint™ 4 Penta™ 00:2–00:2teS ralugeR ydoB yvaeHyvaeH

Imprint™ 4 Penta™ Super Quick Heavy Heavy Body Fast Set 1:15 – 1:15

WASH MATERIALS

Imprint™ 51:1teS tsaFthgiL-artlU kciuQ repuS 4 0:35 1:15

Imprint™ 00:200:100:2teS ralugeR thgiL 4

Imprint™ 51:153:051:1teS tsaF thgiL kciuQ repuS 4

Imprint™ 00:200:100:2teS ralugeRralugeR 4

Imprint™ 51:153:051:1teS tsaFralugeR kciuQ repuS 4

low high

Overview of the product portfolio of 3M™ ESPE™ Imprint™ 4 VPS Impression Materials.

Dentist’s ratings for intra-oral setting time of 3M™ ESPE™ Imprint™ 4 Tray Materials. Source: Field evalu-ation EU and US conducted by 3M ESPE and Key Group Research (total sample size: 300).

0

10

20

30

40

50

60

70

80

90

100

%

Much too long Somewhat too long Just Perfect Somewhat too short Much too short

Espertise™

magazine

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No. 23 | FEB 2013

Digital Dentistry

How digital technologies may contribute to marginal qualityAlbert J. Feilzer, Amsterdam, the Netherlands

Many different digital technologies are used in

dentistry today: practice management soft-

ware runs on every computer, digital radio-

graphs are taken, implant positions are planned

in computer-aided procedures and CAD/CAM

processes are employed for the production of

dental restorations. The idea behind the intro-

duction of digital technologies is that conveni-

ence and efficiency of processes is increased

and highly accurate results are obtained.

In restorative dentistry for example, improvement

of accuracy is a topic of high importance, since a

precise fit of a restoration contributes decisively

to its long-term success. However, the question

arises whether the implementation of digital tech-

nologies does indeed lead to higher precision of

processes in the dental practice and laboratory.

The current advantages of digital techniques,

their future potential and the measures that still

have to be taken in order to benefit from it are

discussed in the following article.

Impression taking

Since they belong to the most recent innovations

for the dental practice, taking a closer

look at intraoral scanners and

their capability to enhance the

quality and fit of a restoration

may be particularly interesting.

First considerations to take

optical impressions in the

patient’s mouth were pub-

lished by Prof.

Francois Duret in

1973 in his thesis

titled “The Optical

Impression.” Since then, diverse companies have

focused on the development of devices that are

capable of capturing precise three-dimensional

data in the oral cavity. Several years ago, they

finally succeeded in introducing practicable solu-

tions that met the requirements regarding the

precision of the procedure and its suitability for

the production of multi-unit restorations.

When comparing the workflows of conventional

and digital impression taking, it becomes clear

that the procedure involving intraoral scanners

like the 3M™ ESPE™ Lava™ Chairside Oral Scanner

C.O.S. has several advantages as opposed to

impressions taken with trays and polyether or

vinyl polysiloxane materials. For example, the pro-

cess is faster, just as easy, and highly precise. In

addition, some challenges associated with tradi-

tional impressions such as the dimensional stabil-

ity of the material and compatibility with model

materials like gypsum are eliminated. It is still a

matter of opinion if the technique is indeed better

than the traditional one, but it does already lead to

highly satisfying results. Other advantages arise

from the digital workflow beginning with impres-

sion taking and ending with milling of the restora-

tion. Material-related factors influencing accuracy

– e.g. the expansion of gypsum during model

production, deformation of a bite registration and

imprecision of the wax set-up due to relaxation of

the material – are not relevant here.

New approaches to dental education

For successful implementation of intraoral scanning

technologies or even complete digital workflows in

the dental practice and laboratory, however, it is

essential to train dentists and dental technicians in

how to use the new hardware and software prop-

erly. This starts with basic dental education e.g. at

university or a vocational school. However, it has to

be taken into account that it takes most students of

dentistry about five or six years before they begin

practicing the profession. Thus, universities should

not only teach digital techniques: they should even

be ahead of dental practices, implement technolo-

gies before they are available in the field and give

their students the opportunity to learn what they will

need after graduation.

When new curricula for dental education are

being developed, it is also important to know that

digital technologies have transformed the way

information is obtained in everyday life. Therefore,

the learning behaviour of individuals has changed

as well. Reading books and listening to a lecture

for more than an hour is not what young individu-

als are used to do. Modern students like to be

educated as entertainment, when they do not like

Prof. Dr. Albert J. Feilzer, Dean of the Academic Center for Dentistry Amsterdam.

Dental education with a simulator.

Espertise™

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16

Ask the Expert


the lecture they want to ‘zap’ to another ‘channel’,

however for lecturing that is not possible. Thus,

education for this new generation of stu-

dents should become ‘edutainment’ in order to

successfully impart knowledge to them.

This approach of offering edutainment and using

technologies that are new for dental practices is fol-

lowed at the Academic Center for Dentistry Amster-

dam (ACTA). For example, students currently learn

intraoral scanning techniques using the Lava C.O.S.

In the near future it will be possible to import the

captured data into their simulator with haptic burs

(Simodont), where tooth preparation skills are

acquired before the techniques are used on

patients. The simulator uses force sensors for real-

istic rendering of drill and contact forces. The hard-

ness of different tooth structures like enamel, den-

tin and the pulp has been replicated as well.

Thereafter, the scans of the real treatment will not

only be used for the production of a restoration but

also to compare the preparation executed in the

simulator with the real one. In this way, the evalua-

tion of the student's skills will be more objective.

Need for infrastructure

This simulator is only one example showing that

digital dentistry involves much more than CAD/

CAM processes. Together, the available technolo-

gies have a huge potential of leading to increased

efficiency of processes and improved quality of

treatment not only by employing them at university,

but also through their use in the dental practice.

In order to make full use of this potential, however,

some work still needs to be done: complete com-

patibility (standardization) of data produced in dif-

ferent digital systems is important to ensure quick

exchange of all available data between treatment

partners. This undisturbed transfer of digital infor-

mation which has to be made possible through

standardization of data formats will be the first step

towards the development of a digital system that

integrates the whole oral care process. After suc-

cessful integration of all available technologies, e.g.

data from the practice management system could

be directly imported into the intraoral scanning sys-

tem. Furthermore, optical impressions could be

matched with digital or conventional radiographs or

real masticatory movements simulated in a three-

dimensional model of the patient to evaluate the

shape of a planned restoration.

Interruptions of the digital process – e.g. through

use of a physical model – would no longer be

required in this future workflow. Another prereq-

uisite for this, however, is a powerful infrastruc-

ture to facilitate data transfer via secure chan-

nels and make it possible to store large amounts

of digital information. This is important for uni-

versities as well as for every dental practice. In

order to help accelerate this development, the

ACTA has become part of a consortium of organ-

izations that has set itself the target of building

up a national infrastructure for digital dentistry in

the Netherlands. If other countries follow this

example, the way will soon be paved for digital

dentistry to become an integrated process that

leads to improved quality of dental care including

much more than restorations with perfect mar-

gins.

Training course at the Academic Center for Dentistry Amsterdam.

Standardized interfaces are needed to connect different digital technologies with each other.

Infrastructure for data storage and secure channels for date transfer will help accelerate further development of digital dentistry.

© kynny – istockphoto.com

© scanrail – istockphoto.com

Espertise™

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No. 23 | FEB 2013

A conservative approach to indirect restorationsPaulo Monteiro, Caparica, Portugal

3M™ ESPE™ Lava™ Ultimate CAD/CAM Restorative

Figure 1: Initial situation: insufficient glass ionomer filling on a maxillary right second premolar. The goal is to achieve maximum preservation of natural tooth structure and to avoid damaging the periodontium.

Figure 2: Tooth preparation for an overlay. The preparation margin is created at or above the level of the soft tissue.

Figure 3: Application of 3M™ ESPE™ Astringent Retraction Paste prior to impression taking. The paste leads to gingival retraction and a clean, dry sulcus for a precise reproduction of marginal details.

Figure 4: Scanning of the preparation using the CEREC® Bluecam (Sirona Dental Systems).

Figure 5: Milled overlay made of 3M™ ESPE™ Lava™ Ultimate CAD/CAM Restorative in the shade A2 HT (high translu-cency).

Figure 6: Removal of the sprue and polishing with Renfert Opal L Polishing Paste (Renfert).

Paulo Monteiro DMD, MScAssistant Professor, Oral Rehabilitation DepartmentInstituto Superior de Ciências da Saúde Egas MonizCaparica – Portugal

Espertise™

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18

Clinical Excellence

Figure 7: Final polish using a Soft-Chamois Polishing Brush (VH Technologies). A natural, lasting glossy surface is obtained.

Figure 8: Finished overlay made of the new resin nano ceramic. Apart from polishing, no further steps are neces-sary to obtain this beautiful result.

Figure 9: Due to the beneficial properties of the material such as very low antagonist wear and good polish reten-tion, extensive characterization or individualization is not necessary and even possible after restoration placement.


Espertise™

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19

Figure 16: Final result after sandblasting of the occlusal surface of the restoration and subsequent application of 3M™ ESPE™ Scotchbond™ Universal Adhesive, the pigments and a thin layer of 3M™ ESPE™ Filtek™ Supreme XTE Flowable Restorative.

Figure 10: Sandblasting of the inner surface of the overlay with aluminium oxide. This procedure is recommended to increase the bond between the restoration and the adhesive.

Figure 11: Application of 3M™ ESPE™ Scotchbond™ Universal Adhesive on the sandblasted surface of the restoration.

Figure 12: 3M™ ESPE™ Scotchbond™ Universal Adhesive is applied on the prepared tooth. In this case, the selective enamel etching technique is used, since in this way the highest bond strengths are obtained.

Figure 13: Intraoral application of 3M™ ESPE™ RelyX™ Ultimate Adhesive Resin Cement in the shade Translucent (TR).

Figure 14: Situation after placement of the resin nano ceramic restoration. A natural gloss is obtained.

Figure 15: In order to achieve an even better optical integration, it is decided to character-ize the overlay intraorally using white and brown pigments (Kolor + Plus® Resin Colour Modifier, Kerr).


No. 23 | FEB 2013

Dentistry in …

… the Kingdom of BelgiumBart Soetaert, Ternat, Belgium

Dentistry in …

In the Kingdom of Belgium, a degree in den-

tistry can be obtained at five different dental

schools. Two of them are located in Flanders,

two in Wallonia and one in Brussels. At the

Flemish universities, students have to pass

an entrance exam, while there is no such

restriction at the French-speaking universi-

ties. In order to obtain a degree as a Master of

Science in dentistry, five years of combined

theoretical and practical dental training at

university are required. Afterwards, one year

of practical training has to be followed. Only

then, registration with the Federal Ministry of

Health is possible in order to obtain a license

to practice the profession.

After graduation, specialist training can be under-

taken in orthodontics and periodontology, how-

ever, the proportion of specialized dentists is low

in the country: 7,878 general dentists and only

137 periodontists and 398 orthodontists were

registered in 2011 according to the Federal Public

Service (FPS) Health, Food Chain Safety and

Environment. Many general dentists follow post-

graduate training which is offered in endodontics,

implantology, paediatric dentistry and aesthetic

dentistry. Continuing education is mandatory in

order to keep the accreditation.

Insurance system

Public health insurance in Belgium is financed by

taxes paid by the citizens, the amount of payment

being dependent on their income. Patients have to

pay for all dental services directly and then claim

reimbursement from the insurance. A large pro-

portion of the fees for basic treatment, such as

paediatric dentistry, prevention and conservative

treatments are covered by the national insurance.

Since these basic costs are covered by the insur-

ance independent of the institution that provides it

(private practice versus policlinics), most patients

choose to receive dental care in practices, where

the quality of treatments is high. Approximately

25% of the patients in Belgium have

an additional private insurance which

is becoming increasingly popular –

this is also the case in my two twin

practices in Ternat (near Brussels)

and Melle (near Ghent) in Flanders.

Dental workforce and practice organization

In 2011, approximately 45% of the 8,300 dentists

in Belgium were female. In the younger age

groups, however, the proportion of women is

much larger (almost 70%) (FPS Health, Food

Chain Safety and Environment).

Within the country, the single practice remains the

most popular business model with 83.5% of all

dentists having adopted it. Only 16.5% work in

joint practices. 43% of all dentists work with an

assistant and in more than 40% of the cases, the

dentists with a single practice work with their wife

as an assistant due to the high costs of employ-

ees. What is also highly interesting is that dental

hygienists are by law prohibited in Belgium: only

dentists are allowed to work in the oral cavity. As

dental practitioners, we hope that this situation

will change, because we are convinced of the

positive impact of dental hygienists’ work on the

oral health of patients and the efficiency of our

practices.

My own business model is slightly different. In

2008, I have established a twin practice with two

locations. Each of the five dentists works in both

locations, since we have different special interests

(e.g. I have completed postgraduate education in

prosthodontics and aesthetic dentistry) and we

want our patients in Melle and Ternat to benefit

from this knowledge. The treatment focus is on

prevention, endodontics, periodontics, prostho-

dontics as well as aesthetic and paediatric den-

tistry. For implant surgery, orthodontic treatments

and periodontal surgical procedures, patients are

referred to partner practices. Together, three

assistants support us in the two locations.

Bart Soetaert

The dental practice in Ternat, Belgium.

Espertise™

magazine

20

Country Insights


In Israel, there are two faculties of universi-

ties where a Doctor of Dental Medicine (DMD)

degree can be obtained: Hebrew University

Hadassah School of Dental Medicine in Jeru-

salem and Tel Aviv University School of Den-

tal Medicine. Here, six years of combined

theoretical and practical study are required

to become a general dental practitioner. In

order to receive a license to practice general

dentistry in Israel, all graduates – no matter

whether they completed their studies within

or outside the country – have to pass a cen-

tral licensing exam.

Afterwards, they can either start working as a

general practitioner or become a specialized den-

tist by following further training in one of nine rec-

ognized specialities, including endodontics, oral

medicine, oral pathology, oral and maxillofacial

surgery, orthodontics, paediatric dentistry, perio-

dontics, prosthodontics and public health den-

tistry. The duration of study is three to six years

depending on the subject and a central exam has

to be taken again after completion of the training.

The proportion of general dentists to specialists is

approximately 1:12 in Israel. Continuing education

is strongly advocated.

Health insurance

Since 1995, every Israeli citizen has to be member

of one of four existing Health Maintenance Organi-

zations (HMO) which offer a uniform benefits pack-

age determined by the National Health Insurance

Law. The medical treatments and services are

funded by the government. Dental care is generally

not included in the basic health insurance plans,

except for paediatric dentistry, which is funded by

the government for children of up to twelve years of

age. On top of these basic services, the public

health funds offer different supplemental health

insurance programmes which cover specific dental

treatments completely and grant a discount on oth-

ers, like restorative dentistry. Public health services

are only available from service providers (e.g. den-

tists) who have entered into a contract with the

HMO. Other dentists – like me – exclusively treat

patients who have a private health insurance or pay

privately. According to the Central Bureau of Statis-

tics, 76% of all Israeli citizens had a public supple-

mentary health insurance and 27% had a private

insurance in 2010.

Statistics and the typical dental practice

Currently, there are approximately 6,400 licensed,

practicing dentists in Israel, 37% of them being

female, according to the Israeli Government

Center for Information Research. Hence, Israel is

currently ranked sixth among OECD countries in

the number of dentists per capita (0.81/1,000).

The majority of dentists in Israel have a single or

joint practice with one partner, polyclinics are not

common. There are usually one to two dental

assistants per dentist working in a practice and at

least one oral hygienist. In my joint practice in

Ramat Gan near Tel

Aviv, there are two

general dental practi-

tioners, each of us

having his own patient

base and a treatment

room. Two oral hygien-

ists work in shifts and

share an additional room, while two of the three

receptionists usually work simultaneously. If

endodontic or other specialist treatment is neces-

sary, patients are not referred to another practice,

but a collaborating specialist is brought into our

office. A laboratory technician also comes into the

dental practice if required. This team approach is

very common in Israel and contributes to a high

level of patient satisfaction.

… IsraelYoram Kornowski, Ramat Gan, Israel

Dentistry in …

… working in his private practice in Ramat Gan.

Dr. Yoram Kornowski …

Espertise™

magazine

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Country Insights


No. 23 | FEB 2013

Balkenprodukt Blindtext

In the edentulous mandible with limited anatomical conditions, i.e.

severe vertical or horizontal atrophy, implant therapy is usually con-

traindicated or would involve extensive augmentation procedures.

However, in these patients, complete dentures often cause problems

as well, since sufficient retention is missing and poor stability of the

solution is obtained. This may lead to discomfort e.g. during talking

and chewing. At the Department of Prosthodontics of the University of

Bern in Switzerland, we became aware of an alternative treatment

option in 2009: the placement of mini dental implants with a diameter

of 1.8 to 2.4 mm for denture stabilization.

The clinical procedure of implant planning, placement and fixation of the pros-

thesis is explained using the following patient case.

Case report

An 82-year-old non-smoking female patient with good general health com-

plained about frequent sore spots and insufficient stability of her lower den-

ture during mastication. Two attempts to place standard diameter implants

had led to implant failure. Therefore, it was decided to place four 3M™ ESPE™

MDI Mini Dental Implants. At first, a radiograph was taken to analyze the

spatial conditions. On the basis of this data, single-piece implants with 1.8

mm diameter and 15 mm length – equipped with an o-ball head for anchor-

age of the denture – were chosen.

Subsequently, pilot holes were drilled with 1.1 mm surgical drills. This size is

sufficient because the implants have a self-tapping design. The bone conden-

sation and compression during insertion is important for the primary stability

of the implants. With the burs, the parallel position of the holes was checked.

Then, the mini implants were inserted and an impression was taken with the

existing denture to mark the implant positions.

Afterwards, radiographs were taken to check the implant positions and metal

housings were integrated in the denture base.

The mini implants were immediately loaded, which was possible due to suf-

ficient primary stability and the fact that the denture is also supported by the

soft tissue.

In regular recalls, the clinical situation was checked and the healthy soft tis-

sue conditions were observed. The radiograph after twelve months showed

no signs of periimplant bone resorption.

The solution for compromised patientsAndreas Worni and Norbert Enkling, Bern, Switzerland

3M™ ESPE™ MDI Mini Dental Implants

Initial radiograph

Parallel position of the drilling holes.

Impression showing the position of the implants.

Espertise™

magazine

22

Clinical Excellence


Research with MDI

Due to the positive results of the treatments with mini dental implants at the

university, a study was planned and initiated in early 2011. Its aim was to find

out how the mini dental implants prove itself in the clinical environment and to

study the tribological behaviour of the o-balls and metal housings. In addition,

the investigation should include data on peri-implant bone resorption and the

level of patient satisfaction.

80 implants were placed in the lower jaws of 20 patients participating in this

prospective controlled clinical trial for stabilization of complete mandibular den-

tures with four MDI from 3M ESPE. Contrary to the first impression that the tiny

implant bodies might break after loading, the preliminary results are highly con-

vincing: there was no incident of implant failure over the past year. The study will

be completed in mid 2013, so that definitive conclusions cannot be drawn to

date. However, the use of mini dental implants seems to be especially suitable

for patients with compromised anatomical and medical conditions. The patients

are very satisfied with the treatment as well as the result, since an improvement

of the denture stability led to optimized chewing ability. Due to the minimally

invasive procedure, only minor postoperative discomfort was reported.

Future research

In order to gain additional knowledge about the clinical use of mini dental implants,

it would be interesting to investigate the required insertion torque and its impact on

immediate loading. By now, 3M ESPE recommends immediate loading only when

a torque of 35 Ncm is obtained. A research question would be if a lower torque –

e.g. 25 Ncm – would also lead to sufficient primary stability to allow for successful

loading directly after implant placement. The benefits of a lower torque: The surgi-

cal procedure is simplified since fewer instruments are required.

Conclusion

Mini dental implants are a relatively new treatment option for edentulous patients.

Although there are only few long-term clinical study results available, first experi-

ence shows that the implants with minimal diameter are a suitable solution in

several cases. Medically compromised patients and those with unfavourable ana-

tomical conditions who are not willing or unable to face complex bone grafting

procedures are offered an alternative to interforaminal standard diameter implants.

The only incident that occurred during the trial – fracture of a denture – can be

prevented by addition and polymerization of a metal band into the denture base.

Denture base with built-in metal housings.

Clinical situation after six months.

Radiographs twelve months after implant placement.

PD Dr. Dr. Norbert Enkling Dr. Andreas Worni

Espertise™

magazine

23


Editor:Gerhard Kultermann

Editorial team:Julia Farr

Nicole Jaganosch

Andreas Maurer

Manuel Meier-Staude

Susanne Mohr

Eva-Maria Popp

Frédéric van Vliet

Production:www.eberl.de · Immenstadt/Germany

Design and typesetting:Comcord GmbH · Düsseldorf/Germany

We accept no liability for unsolicited manuscripts

or photographs.

Court of Jurisdiction: Munich

3M, ESPE, Clicker, Espertise, Filtek, Impregum, Imprint, Ketac Lava, Penta, Protemp, RelyX, Scotchbond and Sof-Lex are trademarks of 3M Company or 3M Deutschland GmbH. AutoMatrix, CEREC, Directa, Fuji CEM, Fuji PLUS and Kolor + Plus are not trademarks of 3M Company or 3M Deutschland GmbH.

© 3M Deutschland GmbH 2013. All rights reserved.

3M Deutschland GmbHLocation Seefeld3M ESPE · ESPE Platz82229 Seefeld · [email protected]

Calendar of Events 2013 E D I T O R I A L Information

Published by:3M Deutschland GmbH

Location Seefeld

3M ESPE · ESPE Platz

82229 Seefeld · Germany

[email protected]

www.3mespe.com

Date Event Location Website

12.03.201316.03.2013

IDS 2013 Cologne,Germany

www.ids-cologne.deGFDI

03.04.201307.04.2013

35th Australian Dental Congress

Melbourne, Australia

www.adc2013.comADA

06.04.201308.04.2013

Medexpo Saudi Arabia Dschidda, Saudi Arabia

www.medexposaudi.comdmg :: events Ltd

10.04.201312.04.2013

Stomatology Uzbekistan Taschkent

Taschkent, Uzbekistan

www.stomatologe.tihe.uz ITE Uzbekistan

11.04.201313.04.2013

Scandefa Copenhagen, Denmark

www.scandefa.dk Bella Center

19.04.201320.04.2013

DentEcpo Warsaw, Poland

www.dentexpo.pl Zarz d Targów Warszawskich S.A.

22.04.201324.10.2013

Dentalexpo Ufa Ufa, Russia www.dental-expo.com Crocus Expo IEC

22.04.201325.04.2013

Dental Salon Moscow Moscow, Russia

www.dental-expo.com Crocus Expo IEC

03.05.201305.05.2013

SIDEX 2013 Seoul, South Korea

www.sidex.or.krSeoul Dental Association and Korean Dental Trade Association

09.05.201312.05.2013

EXPODENTIS Lisboa, Portugal

www.expodentis.exponor.pt EXPONOR – Feira Internacional do Porto

14.05.201316.05.2013

Stomatology Saint Petersburg

Saint Petersburg, Russia

www.stomatology.primexpo.com PrimExpo

22.05.201324.05.2013

Sibdent Novosibirsk Novosibirsk, Russia

www.sibdent.sibfair.ru ITE Siberian Fair

23.05.201325.05.2013

Amici Di Brugg Rimini, Italy www.amicidibrugg.it Rimini Fiera

24.05.201325.05.2013

WID Wien Vienna, Austria

www.wid-dental.at Österreichischer Dentalverband

14.06.201315.06.2013

BALTDENTICA Gdansk, Poland

www.exactus.pl Exactus sp.j.

© Cmon – Fotolia.com

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