Espertise. magazine CONTENT EDITORIAL 24 SEP Dear Readers,

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1 Espertise No. 24 SEP 2013 Andrew Rich Getty Images EDITORIAL Dear Readers, Being named the most innovative company in the worldwide dental industry for the eighth consecutive year cannot be a coincidence. Instead, we are sure that this achievement is the result of highly productive team work at 3M ESPE and the sharing of core technologies developed at 3M Company. Adhesives, abrasives, ceramics and nanotechnology are only a few of the more than 40 technology platforms available to every single division within 3M. Ceramics, for example, are successfully used not only in dentistry, but have also become part of spacecraft construction: 3M Nextel Ceramic Fibres are used e. g. in door shields, gaskets and tiles for space shuttles. They are even able to stand up to the heat of re-entry into the earth s atmosphere. information about it in this issue of the Espertise Magazine. An interview with one of 3M ESPE s leading scientists sheds light into how knowledge is successfully passed on through all parts of 3M Company. Furthermore, articles inform about new product launches and the technologies behind the innovative materials and devices, many of them originating from earlier technology developments. And last but not least, the effective use of new materials and devices is demonstrated in various case reports. Enjoy reading! CONTENT The true spirit of innovation...2 Abrasive technologies used in dentistry...4 Always with a finger on the pulse of time...5 A nano hybrid composite for all cavity classes... 6 How to lay the foundation for precise restorations... 8 Dentistry in the Hellenic Republic...10 Five times easy, reliable and effective...11 Chairside restoration procedure with innovative materials...12 Combination of indirect and direct restorations in one quadrant...14 Complex restoration procedure in the maxilla and mandible...16 Aesthetic restoration of a discoloured maxillary incisor...18 Those who want to learn more about shared technologies being the heart of innovation at 3M ESPE are offered lots of Gerhard Kultermann, Editor 3M ESPE, Seefeld, Germany

2 Ask The Expert Most innovative company in the dental industry The true spirit of innovation Manuel Meier-Staude, 3M ESPE, Seefeld, Germany 2 Innovation is at the core of 3M ESPE, a company that aims at providing dental profes- In order to learn more about the internal strategies and structures at 3M ESPE that lead to its consist- intensive contacts of the research and development teams with dentists and dental techni- sionals with high-quality materials and ently high innovative power, we had a conversa- cians. This close customer interaction is an devices optimally supporting them during tion with Dr. Rainer Guggenberger, Corporate important basis for innovations that can set daily work processes in the dental practice Scientist at 3M ESPE. trends in the dental market. and laboratory. Therefore, it comes as no surprise that 3M ESPE has recently received Dr. Guggenberger, numerous new products However, open-minded spirit and customer input recognition as the most innovative company are launched by 3M ESPE every year. Is it a alone is not enough, we also need technical solu- in the dental industry for the eighth consecu- specific innovative spirit within the company tions. The multitude of core technologies e.g. tive year a fact that has been published by that leads to this exceptional phenomenon? adhesives, ceramics or nanotechnology availa- the Anaheim Group in its 2012 Dental Indus- ble within the multi-technology company 3M is try Review. For their annual evaluation, FDA Indeed, there is a special culture within 3M sup- another key element that is utilized very effectively 510(k) new product clearances for the U.S. ported by management and company structures at 3M ESPE. market, United States Patent Office dental promoting discovery, creativity and inventive tal- industry patents, and dental patents from ent. It is in the nature of most scientists to con- Would you please explain how it is possible the European Patent Office and the World stantly search for new solutions and pathways to make available all these core technolo- International Patent Office are taken into towards new products. Key element of this inno- gies to all departments of the company? account. In a comparison of seven compa- vative spirit is the so-called 15%-rule, which nies that have been among the top ten inno- means that all researchers have the freedom to 3M has established a powerful technical net- vators during the past five years (2007 to work 15% of their time on projects they like, out- work across all departments and business seg- 2012), 3M ESPE was way out in front of the side of the official plan. The main goal of this ments called Tech Forum, which consists of others with a total of 375 innovations versus method is to nurture great ideas at an early about 10,000 technical employees around the 213 for the company that was ranked sec- globe. As a result, there is basically an expert for ond. everything somewhere. The task is just to find him. What helps here are groups of experienced experts with a broad overview like Division Scientists and Corporate Scientists. They act like catalysts for technical exchange. Since 2008, I personally have the pleasure to be one out of 20 Product development in the research laboratory of 3M ESPE. Corporate Scientists. Our task is to enable effective communication across departments, tech- stage before they can be incorporated into a for- nologies and regions. We regularly exchange the mal project. As a result, the success story of latest information about new product develop- many blockbusters today like 3M ESPE ments and even more importantly, new techno- RelyX Unicem Self-Adhesive Resin Cement or logical achievements like easy mixing, highly 3M ESPE Scotchbond Universal Adhesive effective initiators and high-strength polymers started this way, many years ago. Quite fre- we utilize in dental products. Other colleagues Dr. Rainer Guggenberger, Corporate Scientist at 3M ESPE. quently, the 15% extra time is also used for report on recent developments e.g. in the fields No. 24 SEP 2013

3 Espertise of electronics or transportation industry. If a specific technology is regarded as potentially interesting, we can easily identify the experts for this technology and set up cross-functional teams. Please give a few examples of core technologies that found their way into or out of dentistry in this way. Today, about 20 out of the more than 40 different core technologies developed by 3M are already utilized in dental products. An early example was 3M ESPE Addent Anterior Restorative, the first tooth-coloured filling material, developed in the mid 1960s. It is based on fillers that were originally developed for the traffic and safety business. For the 3M ESPE Pentamix Automatic Mixing technology, it was exactly the other way round: It was originally developed for dentistry and later transferred to 3M s automotive business for mixing of high-viscosity adhesives in automotive body shops. The nanotechnology used in 3M ESPE Filtek Supreme XTE Universal Restorative and other dental materials like 3M ESPE Protemp 4 3M ESPE Pentamix 3 Automatic Mixing Unit and the 3M Dynamic Mixing System are based on the same technology. Temporization Material or 3M ESPE Lava Ultimate CAD/CAM Restorative was originally developed as a 3M core technology in the Central Research Laboratories in Saint Paul. A huge upfront investment was needed before the first products could be commercialized in dentistry and other markets. It was quite a challenge to integrate this new technology into an established class of dental materials like composites. The research team at 3M ESPE identified the potential of improving gloss and polish retention of composites with this technology as the key success factor. Together with corporate nanotechnology experts, the team succeeded in developing the first nano-filled composite. Within a short time frame it grew into a market-leading position and still today is unparalleled as a True Nano Composite. This example demonstrates that effective product development is more than just smartly combining technologies: Without listening closely to the needs of the customer, a new product would never be successful in the market. How do you involve the customer in product development? In order to ensure that a product works not only in our laboratory, but also in real life, universities and dental practitioners are involved already in the early phases of product development. They test experimental materials and devices in simulated operatory situations, compare different product variants and give feedback on their performance. Their ideas and suggestions are taken into account during the next stages of the development process. Prior to the launch of a new product, scientific laboratory tests as well as clinical investigations are an important element in our process. By these methods we ensure that only products that are easier and / or better in the natural work environment of dentists and dental technicians make their way into the market. To be successful also in the future we encourage our employees to continuously think outside the box, network with other experts and, most importantly, spend time with our customers. Let me just close with another great example of integrating proven 3M technology into a new dental product: 3M ESPE Sof-Lex Spiral Wheels for finishing and polishing! 3M ESPE Sof-Lex Spiral Wheels are based on 3M technology. Dr. Guggenberger, thank you for the insightful conversation. 3

4 Backstage Report Balkenprodukt 3M ESPE Sof-Lex Blindtext Spiral Finishing and Polishing Wheels Abrasive technologies used in dentistry Thorsten-Simon Eickholt, 3M ESPE, Seefeld, Germany 4 Many new products are launched by 3M ESPE every year, and most of them are based on They are composed of flexible bristles filled with abrasive particles. This 3M patented technology surface scratches and increase the smoothness of the surface. The second, white-coloured some proven technology that has once been allows for continuous supply of these particles to wheel is utilized as a high-gloss polisher. Since developed for another product in a com- the work surface so that a consistent perfor- both tools have flexible bristles, the original, pletely different division of 3M Company. The mance is ensured during the whole life-span of contoured shape of the restoration is preserved core technology is adjusted in a way that it the disc, which is usually longer than that of tra- and a uniform finish achieved. Due to their spe- becomes suitable for the specific require- ditional abrasive products. Due to the flexibility cific design based on that of Scotch-Brite discs, ments of dental applications and is combined of the bristles, they easily conform to irregular Sof-Lex Spiral Finishing and Polishing Wheels with other elements which, together, result in surfaces and provide for a uniform finish. Fur- adapt to every surface, work from any angle and the final, highly innovative product. thermore, the desired result is obtained quickly are effective at reaching anterior and posterior without causing a significant rise in surface tem- restorations alike. This also holds true for the latest innovation intro- perature. duced by 3M ESPE: Sof-Lex Spiral Finishing and Polishing Wheels. These versatile wheels are used after contouring for finishing and polishing direct composite, resin-modified glass-ionomer and bis-acrylic restorations. They are also perfectly suited for indirect restorations made of polymer, the resin nano ceramic 3M ESPE Lava Ultimate CAD/CAM Restorative or precious and semi-precious metal. 3M Scotch-Brite Radial Bristle Discs. Pre-polishing the interproximal area of posterior restorations with the finishing wheel.... adapted for dental applications Thus, additional polishing instruments usually used in dentistry are no longer needed. Dur ing Since all of these specific properties were the process, a low-speed handpiece (10,000 to regarded as beneficial for finishing and polishing 20,000 RPM) should be used and water-cooling of dental restorations, the developers of the basic or additional polishing paste is not required. Industrial tools... technology in the Abrasives Division were contacted by an R&D team of 3M ESPE. Soon, a The polishing wheels are designed after 3M development project was initiated with the goal of Scotch-Brite Radial Bristle Discs, which are adjusting the existing technology so that it could available in different grits, diameters and thick- be used in the oral environment. nesses. The discs are used in a variety of applications e.g. by aerospace and electronics manu- The result: A set of single-use wheels for a two- facturers, for automotive repair and engine step polishing process applied on a pop-on rebuilding as well as for cleaning, finishing, and mounting mandrel. The first, beige-coloured polishing of detailed parts in jewelery and arts. wheel is used for pre-polishing to remove minor No. 24 SEP 2013

5 Backstage Report Espertise 10th anniversary of the Espertise Magazine Always with a finger on the pulse of time Gerhard Kultermann, 3M ESPE, Seefeld, Germany Ten years ago, the first issue of the Espertise Magazine was published by 3M ESPE. Back then, shortly after the merger of 3M Dental Division and ESPE Dental AG which brought forth lots of new ideas and impulses, the presented itself in a different layout than today. The concept behind it, however, remained the same over the years: it was and is used as a medium to inform dental professionals about the latest product innovations and trends in dentistry. In diverse articles written by dental practitioners, scientists or employees working at 3M ESPE, the reader obtains relevant, up-todate information about the development of new products including insights into internal processes at 3M ESPE and their practical use. The clinical application of materials and devices in the dental practice is illustrated by case reports and additional information about investigations testing the products in-vitro and clinical performance is given. Moreover, clinicians give practical advice gathered from their own experience and experts discuss the changes e.g. induced by new, digital technologies that affect work processes in the dental practice. Topics presented back in 2003 In the first issue published in March 2003, several new products took center stage, including 3M ESPE Filtek Supreme Universal Restorative and 3M ESPE RelyX Unicem Self- Adhesive Universal Resin Cement. Both materials had just been launched and were based on somewhat revolutionary concepts: Filtek Supreme was the first composite filling material that utilized nanotechnology. The use of nanoparticles and nanoclusters as fillers led to an unprecedented combination of positive mechanical and aesthetic properties such as high strength and resistance to abrasion and natural, lasting gloss. Today, the The cover page of the first issue of the Espertise Magazine published in third generation of this material is successfully used by dentists worldwide and is one of the leading dental composites on the market. With RelyX Unicem, 3M ESPE presented the first self-adhesive resin cement. It stood out due to its unique versatility (it was truly universal) and led to a hugely simplified workflow eliminating numerous error-prone work steps in the process of cementation of indirect restorations. The product clearly helped make 3M ESPE into what it is today: the leading provider of cementation solutions. Changes In order to keep the up-to-date not only with respect to its content, the layout was altered in What has also changed during the past decade is the way of distribution: The Espertise Magazine was originally reprinted by numerous countries, leading to a global circulation of up to 200,000 copies. Today, the is still reprinted by diverse countries, but in addition to that, the content is increasingly spread online. Apart from the possibility of downloading all issues from the 3M ESPE website, the articles are made available via a monthly enewsletter. In this way, it is made sure that also those readers using new channels of information are granted access to the content of the innovative. The monthly enewsletter spreading the articles published in the Espertise Magazine. 5

6 Clinical Excellence 3M ESPE Filtek Z250 XT Nano Hybrid Universal Restorative A nano hybrid composite for all cavity classes Montri Chantaramungkorn, Chiang Mai University, Thailand 6 Today, tooth-coloured direct resin restorations play an important role in an attempt to nano hybrids are a popular choice for dentists. In the following, various clinical cases using Restorative a light-activated nano hybrid composite suited for the fabrication of anterior as well replicate tooth structure. Apart from the 3M ESPE Filtek Z250 XT Nano Hybrid Universal as posterior restorations are presented. clinical advantages of composites such as the possibility of using minimally invasive approaches, it is primarily the patients demand for impeccable and invisible restorations that has led to this material becoming the restorative of choice. Clinical Case 1 Class IV restoration Figure 1: Initial situation: young female patient with an insufficient resin restoration on tooth 12 (FDI). What is most apparent is the severely stained margin and a lack of colour match. Initially, resin composites have been used only for anterior restorations, but meanwhile, they have become state-of-the-art in the posterior region as well. Excellent results have been achieved in recent years in numerous long-term studies, particularly with hybrid composites [1,2]. The reason for Figure 2: Situation after removal of the old restoration and excavation of secondary caries. A short bevel was prepared in this case. these positive clinical results, apart from the improvement in adhesive bonding techniques, is a significant enhancement in the physical properties of hybrid composites compared with traditional microfilled and macrofilled composites. Nano hybrids and micro hybrids Figure 3: Treatment result: with only one shade of the filling material (B2), a 1 mm palatal shelf was created and light cured before the remaining part was built up, followed by finishing and polishing. The distinction between micro hybrids and nano hybrids is not always clear, however, the average particle size tends to be slightly lower for nano hybrids. Both contain a fraction of nano-sized particles which are added to fill the resin gaps between the larger particles. This results in a high Figure 4: The patient is extremely satisfied and happy with this new restoration because it blends into to the remaining tooth structure nicely. filler loading leading to improved strength and wear resistance. However, the amount of nanoparticles that can be added is limited since at some point, the handling becomes too stiff. Due to their good overall performance and versatility, usually at a reasonable cost, micro hybrids and No. 24 SEP 2013

7 Espertise Clinical case 2 Class II restoration of an occlusal and proximal carious lesion Figure 5: Initial situation: apart from the eroded occlusal lesion on tooth 37, there is a small fracture line on the mesial marginal ridge. This patient demanded for an aesthetic and long-lasting restoration. A zirconia crown was planned for tooth 36 and a nano hybrid filling for tooth 37. Clinical case 3 Restoration of a Class V carious lesion 7 Figure 6: Situation after endodontic treatment, core build-up and preparation of tooth 36 as well as caries removal and conservative cavity preparation of tooth 37, where an early proximal lesion was detected as well. A small bevel at the enamel cavosurface margin will help blending the restoration margin and lead to less gap formation as well as increased fracture resistance of the restoration.[3] Figure 9: Initial situation: carious lesion at the neck of the lower left canine. A small class IV defect is visible on the distal corner of the lower central incisor as well. Figure 7: 3M ESPE Filtek Z250 XT Nano Hybrid Universal Restorative, shade A2, is incrementally placed in the prepared cavity (each layer no more than 1 to 2 mm thick). Simple tools such as fine endodontic files and small-tip plastic instruments were used for free-hand shaping and contouring. Figure 10: After conservative removal of the infective tooth structure, creation of a small bevel and bonding, the nano hybrid composite in the shade B2 was applied. Please note the glossy surface that can easily be obtained with this material. Figure 8: According to the patient expectations, a shiny, lifelike restoration was obtained on tooth 37 after polishing. The 3M ESPE Lava Zirconia crown placed on tooth 36 nicely integrates into the overall situation including natural tooth structure and composite material. Conclusion With composite resin, invisible aesthetic restorations of all types can be produced. Those who truly understand how to properly use these innovative materials will benefit from long-lasting, aesthetic results obtained easily and efficiently. [1] Jack L. Ferracane. Resin composite State of the art. Dent Mater Volume 27, Issue 1, January 2011, [2] Chen M-H. Update on dental nanocomposites. J Dent Res 2010; 89: [3] FH Coelho et al. Fracture Resistance and Gap Formation of MOD Restorations: Influence of Restorative Technique, Bevel Preparation and Water Storage Oper Dent, 2008, 33-1, Contact Montri Chantaramungkorn DDS, TBOD, FRCDT Associate Professor dr_montri@hotmail.com

8 Clinical Excellence 3M ESPE Imprint 4 VPS Impression Material How to lay the foundation for precise restorations Frank Tussing, Giessen, Germany 8 What I expect from an impression material is easily summed up: it should be universal, i.e. suited for the one-step and two-step technique alike and should enable me to capture even the finest details. Thus, high hydrophilicity of the material is of great importance. This factor together with the hardness of the material ensures that the dental technician will be able to produce a precisely fitting restoration. For improved patient comfort, I expect that the impression material has a pleasant taste and the intra-oral setting time is as short as possible, while the working time should be long enough for the required preparations. Last but not least, removal from the patient s mouth should be easy. Figure 1: Situation after removal of the old crown on the mandibular right first molar, tooth preparation and placement of a temporary restoration. Figure 2: Application of the 3M ESPE Astringent Retraction Paste one week after tooth preparation. The preparation margin is on a supragingival level and equigingival in the distal area. Looking for an impression material that offers all these properties, a new VPS material aroused my interest: according to the manufacturer, this innovation offers an active self-warming mechanism that leads to accelerated setting in the patient s mouth, while the working time is comparable to that of other VPS impression materials. The second interesting feature is its true hydrophilicity in the unset state, which ensures an exact reproduction of the finest details. Figure 3: Effect of the paste: clearly exposed preparation margins. A clean, dry sulcus is obtained and the slight bleeding in the distal area is stopped. Figure 4: Application of the wash material 3M ESPE Imprint 4 Light Impression Material around the prepared tooth. The light viscosity is selected for increased flowability of the material. The material was recently launched under the name of 3M ESPE Imprint 4 VPS Impression Material. The Imprint 4 family offers putty and heavy body materials for all techniques with different viscosities and setting times. Tray and wash materials come in vivid colours for a good contrast. The use of one of the available material combinations is described on the basis of the following example case. In this case, a crown had to be replaced due to marginal leakage in a 38-year-old female patient. Figure 5: The wash material is also dispensed onto the tray filled with 3M ESPE Imprint 4 Penta Putty Impression Material. The major benefit of the high-viscosity tray material is that it does not trigger a gag reflex. Editor's remark Figure 6: The result after an intra-oral setting time of 2:30 minutes which is required for the putty material. Less time is necessary for the setting reaction than with other VPS materials. The clinician selected a material combination that is different from the manufacturer's recommendation for the one step putty-wash technique. The recommended combination is: 3M ESPE Imprint 4 Penta Putty and 3M ESPE Imprint 4 Regular Impression Material. No. 24 SEP 2013

9 Espertise 9 Figure 7: Impression detail: due to the high hydrophilicity of the innovative impression material already in the unset state, a highly accurate representation of the preparation margins is achieved. Figure 8: The fine details are also visible on the model produced in the dental laboratory. According to the dental technician, this accuracy is particularly important for the computer-aided production of restorations. Figure 9: Accurate fit of the lithium disilicate crown on the model. Virtually no adjustments were required thanks to the high precision maintained over the complete indirect restoration procedure. Figure 10: Try-in of the crown: not only does the crown fit precisely, but it also matches the colour of the adjacent natural teeth very well. Figure 11: Application of hydrofluoric acid to the inner surface of the crown prior to the use of 3M ESPE Scotchbond Universal Adhesive which contains a silane function. Figure 12: The prepared tooth is treated with 3M ESPE Scotchbond Universal Adhesive as well. Here, light-curing is recommended by the manufacturer after evaporation of the solvent. Figure 13: Application of 3M ESPE RelyX Ultimate Adhesive Resin Cement to the crown prior to its placement in the patient s mouth. Figure 14: Removal of excess cement in the gel state using a spatula. When the dual-cure cement is wiped off in the uncured state with a sponge pellet, glycerin gel should be applied prior to light-curing. Figure 15: Treatment result: the described restoration procedure using the new VPS impression material allows the production of precisely fitting restorations. Contact Frank Tussing, Dentist f.tussing@zahnarzt-giessen.de

10 Country Insights Dentistry in the Hellenic Republic Kosmas Tolidis, Thessaloniki, Greece 10 In the Hellenic Republic, a degree in dentistry can be obtained at two publicly funded dental health care will be financed by the state. During the past three to four years, this development led to the Greek system is that there are no dental hygienists and only very few dental assistants working in the schools at the Kapodistrian University of Ath- increasing emergence of private insurance compa- country. A proper education does not exist for ens and the Aristotle University of Thessaloniki. nies, although until now, most patients still pay them, so that in the regions where the two universi- A university degree is usually granted after five privately for the majority of services offered by their ties are located, typical tasks for assistants are years of study, the first two years focusing on dentist. Consequently, there is a strong correlation often fulfilled by students. theory and practical work in the laboratory between income and the likeliness of visiting a den- while, from the third year onwards, clinical tist. This is also the case in my private, independent While the most common business model in Greece training is included. In order to obtain a permis- practice specialized in paediatric and aesthetic is still a private practice with one or two practition- sion to practice dentistry, a graduate has to dentistry. Our patients pay privately or, to a lesser ers, the number of large policlinics is currently register with one of the 52 Regional Dental extent, have a private health insurance covering the growing. In my own family practice in Thessaloniki, Societies. costs. the three active practitioners are also the practice owners who have their own patient base, but share Post-graduate vocational training is not compulsory however, most dental students work as Dental workforce the facilities. I usually work at university in the morning and in the practice in the afternoon, and assistants in dental practices during their studies According to the Hellenic Dental Federation, 13,919 my job at the university results in frequent visits by in order to improve their skills. For the two recog- dentists were registered in Greece in students acting as dental assistants in our practice. nized dental specialties orthodontics and oral sur- Although the number decreased slightly during the Dental nurses are not employed here. gery, a three-year Masters programme has to be past three years, Greece still has the highest den- completed. In addition, numerous post-graduate programmes in clinical dental specializations are offered and are recognized among the profession. tist-to-population ratio among European countries. The number of female and male dentists is almost equal, but an increase in the number of female dentists is observed. One of the particularities of the Dr. Kosmas Tolidis, DDS, MSc, PhD., Associate Professor Health insurance system The health insurance system in Greece is currently in a state of transition. It was originally based on a national system with a segmented character that was funded by the employer and employee. People were simply assigned to one of 30 different social insurance organizations depending on their occupation. A uniform regulation of what kinds of services were covered by the social funds and provided by public hospitals or health centres did not exist and varied per organization. Today, the number of dental treatments offered under the umbrella of public health insurance is being reduced to a minimum. Very soon, it is likely that only emergency and his private practice in Thessaloniki. No. 24 SEP 2013

11 Background Espertise Single tooth restorations made of resin nano ceramic Five times easy, reliable and effective Frédéric van Vliet, 3M ESPE, Seefeld, Germany For reliable processes in your dental practice, complete procedure solutions allowing sim- you can choose between different impression materials and intra-oral scanners, e.g. the innova- Cementation 11 plified workflows and top results are needed. tive 3M ESPE Imprint 4 VPS Impression The cementation process has to be easy and In order to provide you with what you desire, Material. It offers an extremely short intra-oral reliable. It should involve only a few components, the innovative materials and devices devel- setting time and high initial hydrophilicity for the and when a separate adhesive is involved, it oped by 3M ESPE are precisely adjusted to reproduction of finest details. should be technique-tolerant. The cement each other. An example is the procedure solu- should contribute to a durable aesthetic appear- tion for the production of a single tooth restoration. Restoration ance of the restoration. All this is offered by the combination of 3M ESPE RelyX Ultimate As your restoration should perform like a natural Adhesive Resin Cement and 3M ESPE Gingival deflection tooth and the production process should be highly efficient, a restorative material is needed that can Scotchbond Universal Adhesive: One bottle of Scotchbond Universal and one syringe of RelyX Retraction, haemostasis and a clean, dry working be processed easily and quickly, no matter if you Ultimate is all you need. Additional silane, or field are the most important preconditions for an choose to produce it chairside or in the laboratory. other application steps are eliminated, and a accurate impression. On that account, you begin The benefit of a monolithic design is to exclude strong bond is obtained. The shades of the with gingival tissue management using a reliable the risk of chipping and to eliminate the extra step cement are adjusted to those of the restoration material for efficient retraction of the gingiva and of veneering. Our solution is the monolithic resto- and the material is resistant to staining: beautiful control of exudation. Of course, the application ration with 3M ESPE Lava Ultimate CAD/CAM lasting results are obtained. should be easy, convenient and the whole proce- Restorative: it is available for the chairside and dure less time-consuming than using a cord. All laboratory workflow and its composition with this is offered by the 3M ESPE Astringent Retraction Paste, which comes in a convenient single-use capsule fitting in all common dispensers. For the following impression taking process, A strong combination for reliable bond strength. Simplification With the use of these highly innovative products within one workflow, the number of the required components and work steps is reduced to a mini- Resin nano ceramic material with beneficial properties. mum, leading to an efficient and reliable restoration procedure. Due to the exact adjustment of the ceramic particles embedded in a polymer matrix solutions properties be it the shades of the ensures tooth-like elasticity and strength. More- cement and the restoration or the ingredients in over, the production process is highly efficient the adhesive simplifying cement application an since a firing process is not required and a fast optimized workflow is possible. Precise, durable polish is sufficient to obtain the natural appear- and aesthetic restorations are the result. Easy-to-use capsules containing the retraction paste. ance.

12 Clinical Excellence 3M ESPE Lava Ultimate CAD/CAM Restorative Chairside restoration procedure with innovative materials Paulo Monteiro, Caparica, Portugal 12 Figure 1: Initial situation. Insufficient amalgam filling on the maxillary left first molar and insufficient composite restoration on the adjacent premolar. Figure 2: Situation after tooth preparation for an overlay (molar) and an inlay (premolar) made of 3M ESPE Lava Ultimate CAD/CAM Restorative. Figure 3: Application of 3M ESPE Astringent Retraction Paste directly into the sulcus in order to lay the foundation for an accurate digital impression. Figure 4: The effect of the retraction paste is clearly visible: a clean and dry working field is obtained and the margins can be reproduced with great detail. Figure 5: The result of the chairside production procedure including a powdering of the teeth, digital impression taking, virtual design and milling with the CEREC System (Sirona). Figure 6: Removal of the milling sprue prior to polishing of the overlay. The same work steps were adopted for the inlay as well. Figure 7: Polishing procedure: in the first step, a bristle brush was spun in Diashine Fine polishing paste (VH Technologies) to polish the restorations. Figure 8: Second polishing step using a soft bristle brush and Diashine Fine Soft polishing paste (VH Technologies). Figure 9: Final polishing with a Soft chamois Polishing Brush (VH Technologies) to obtain a surface with a gloss similar to that of natural teeth. No. 24 SEP 2013

13 Espertise 13 Figure 10: Result of the polishing procedure. In general, no further finishing steps are required for the resin nano ceramic restorations. Figure 11: In the present case, it was decided to characterize the overlay and inlay in order to obtain an improved optical appearance: application of white stains to the overlay. Figure 12: Overlay after characterization with white and brown pigments. The restoration has a shiny surface with individual colour. Figure 13: Result of the characterization procedure on the occlusal surface of the inlay. Figure 14: Selective enamel etching on the molar using 3M ESPE Scotchbond Universal Etchant to achieve a high bond strength. Figure 15: Situation after application of 3M ESPE Scotchbond Universal Adhesive on the prepared tooth surface. Light-curing of the adhesive is recommended. Figure 16: Application of 3M ESPE RelyX Ultimate Adhesive Resin Cement to the molar. The combination of this adhesive and cement allows for maximum ease of use. Figure 17: Situation immediately after cementation of the overlay made of 3M ESPE Lava Ultimate CAD/CAM Restorative (detailed recommended procedure: see page 15, chart 1). Figure 18: Final result directly after the placement of the two restorations: the overlay and inlay have a natural appearance in terms of colour and gloss. Contact Paulo Monteiro DMD, MSc Assistant Professor paulojorgemonteiro@yahoo.ca

14 Clinical Excellence Chairside procedure involving resin nano ceramic material Combination of indirect and direct restorations in one quadrant Claus-Peter Ernst, Mainz, Germany 14 Chairside restorations of a complete quadrant are challenging especially in cases largely intact, but caused food impaction in the approximal areas. Since the patient asked for a surface of the Lava Ultimate restoration was sandblasted with high-grade aluminum oxide where a complex cusp build-up is required in complete treatment in one appointment, it was (grain size 50 µm, pressure 1 to 2 bar) prior to its several teeth. A direct restoration procedure planned to combine a partial crown produced in a placement. can be problematic e.g. if all cusps of a molar chairside procedure with three direct composite have to be restored, while the procedure is well-suited for cavities with remaining dentin-supported peripheral walls and cusps. When both types of defects are present, a combination of direct and indirect procedures may be indicated. Patient case In the present case, a 40-year-old female patient restorations. Preparation and indirect procedure The first molar was prepared to receive a partial crown (Fig. 2). At this, part of the approximal composite restorations and the post-endodontic closure was preserved. In addition, the old cement restorations were removed and caries excavated. Restoration placement 3M ESPE Scotchbond Universal Adhesive and 3M ESPE RelyX Unicem Adhesive Resin Cement were used for the adhesive cementation procedure. At first, the remaining composite surfaces were sandblasted to create a micro-retentive surface structure that is decisive to obtain a strong, longlasting bond to the indirect restoration. Then, phosphoric acid was applied primarily on the enamel required a quadrant restoration. The maxillary margins (Fig. 3). After removal of the acid, right first molar received endodontic treatment. Scotchbond Universal Adhesive was applied. Figure 1 shows the initial situation with the pre- Figure 4 shows the adhesive layer after evaporation endodontic build-up and post-endodontic cavity of the solvent. At this stage, the manufacturer rec- closure. Due to the dimensions of the defect, the ommends light-curing of the adhesive on the tooth cusps had to be included in the restoration. Since surface. The sandblasted surface of the restoration the palatal and buccal areas were intact to a large extent, a partial crown was recommended. The Figure 2: Situation after caries removal and tooth preparation. was also pre-treated with Scotchbond Universal Adhesive before the dual-cure resin cement in the temporary cement restorations on the second For the indirect restoration, 3M ESPE Lava shade translucent was applied on the tooth and the molar and the premolars in the first quadrant were Ultimate CAD/CAM Restorative became the partial crown placed. After removal of the excess material of choice. This material offers a high flex- cement, the restoration was light cured from an ural strength allowing for the creation of thin vertical dimensions and ensures low antagonist wear while being resistant to abrasion. The user benefits from the fact that processing of this material is quicker and intra-oral polishing easier than that of many other permanent restoratives. The partial Figure 1: Initial situation with three cement restorations on the premolars and the second molar as well as a pre-endodontic build-up on the first molar. crown was produced using the CEREC system (Sirona Dental). Unlike pure ceramics, the inner Figure 3: Etching with phosphoric acid (enamel etching rec ommended, dentin etching optional). No. 24 SEP 2013

15 Espertise Result 15 Figure 4: Adhesive layer after evaporation of the solvent. occlusal, palatal and buccal direction for 20 seconds each. Figure 5 shows the result. The detailed work steps in the cementation procedure in accordance with the recently updated recommendations of the manufacturer are summarized in Chart 1. Direct procedure Partial matrices (Contact Matrix Ultra Thin Flex, Danville Materials) were placed on the premolars and the second molar and fixed with interproximal wedges as well as one clamping ring. Subsequently, all three cavities were etched simultaneously with 34% orthophosphoric acid (3M ESPE Scotchbond Universal Etchant) for Figure 5: Intra-oral situation after removal of excess cement. 15 to 30 seconds (Fig. 6). After rinsing with water, Scotchbond Universal Adhesive was applied and polymerized when the solvent had evaporated completely. The composite restorations were created using 3M ESPE Filtek Supreme XTE Universal Composite in the body shade A3, starting with the second molar. Figure 6: Etching of the cavities prior to the direct restoration procedure. Figure 7 shows the final result of the quadrant restoration with a partial crown made of Lava Ultimate restorative in the shade A3 LT (low translucent) and three direct composite restorations immediately after finishing and polishing. Figure 8 shows the situation two weeks later. With the combination of a partial crown and direct restorations, a stable and anatomically correct quadrant restoration was obtained. Figure 7: Quadrant restoration consisting of a partial crown and three direct composite restorations. Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 8 Step 9 Step 10 Step 11 Apply Scotchbond Universal Adhesive to the tooth surface. Direct a gentle stream of air over the liquid until the solvent has evaporated. Light-cure the adhesive. Sandblast the restoration s inner surface. Carefully remove all powder particles (ideally in an ultrasonic bath or with water spray and an oil-free air stream). Apply Scotchbond Universal Adhesive to the restoration (contains silane). Gently air-dry the adhesive layer to evaporate the solvent. Light-curing is not necessary on the Lava Ultimate restoration. Apply RelyX Ultimate Adhesive Resin Cement. Place the restoration. Remove excess cement with a sponge pellet in the uncured state or with a sharp instrument in the gel state. Light-cure the restoration (ideally under glycerin protection). Chart 1: Detailed work steps in the cementation procedure for 3M ESPE Lava Ultimate restorations in accordance with the recently updated recommendations of the manufacturer. Figure 8: Situations two weeks after completion of the restorative procedure. Contact Prof. Dr. Claus-Peter Ernst ernst@uni-mainz.de

16 Clinical Excellence 3M ESPE Lava Ultimate CAD/CAM Restorative Complex restoration procedure in the maxilla and mandible Wolfgang H. Knupfer, Laichingen, Germany 16 Figure 1: 36-year-old male patient with substantial loss of tooth substance mainly due to erosion and attrition. Figure 2: Different kinds of defects are visible, ranging from small wear facets to severe dentin exposure. Figure 3: Abfraction lesions are detected in the incisal area, carious lesions and insufficient restorations primarily in the posterior region. Figure 4: View of the centric occlusion. There are several deficits such as a dental midline shift, asymmetry of the gingival margins and an irregular occlusal plane. Figure 5: Use of a maxillary anterior guided orthosis (MAGO) appliance to obtain a stable centric relation, to simulate anterior guidance and to check the effect on the patient. Figure 6: Transfer of the determined centric relation onto the models and verification of the position s reproducibility using the articulator. Figure 7: Wax up on the master cast. Narrowing of the diastema and scaling up of the maxillary incisors while maintaining the length-to-width ratio of the teeth. Figure 8: Substance is also added to the palatal areas of the maxillary incisors, creating palatal guidance surfaces. Figure 9: The layer of wax added to the occlusal surfaces of the posterior teeth had to be very thin since only a slight increase in the vertical dimension of occlusion was possible. Figure 10: 3M ESPE Lava Ultimate CAD/CAM Restorative (green) is the material of choice for the maxillary incisors and all molars. Composite occlusal veneers made of 3M ESPE Sinfony Indirect Lab Composite (blue) are produced for the remaining teeth. No. 24 SEP 2013

17 Espertise 17 Figure 11: Tooth preparation using a mock up to assess the amount of substance removal required for the resin nano ceramic restorations. Figure 12: Overview of the preparation guidelines for 3M ESPE Lava Ultimate restorations recommended by the manufacturer. Figure 13: Maxillary (left) and mandibular (right) restorations. The production procedure for those made of resin nano ceramic involved scanning of the master cast with and without the wax up, virtual design using the 3M ESPE Lava Design Software and fabrication with the 3M ESPE Lava CNC 500 Milling Machine as well as finishing and polishing. Figure 14a: 3M ESPE Lava Ultimate CAD/CAM Restorative: high marginal quality after milling as confirmed by the dental technician (MDT Vincenzo Salcone, Wendlingen, Germany) based on his own experience. Figure 14b: Glass ceramic: inferior marginal quality after milling (both images courtesy of 3M ESPE). Figure 16: Treatment result. The patient was satisfied with the aesthetic appearance and functional performance of the restorations. Figure 15: Tooth after enamel etching: sandblasting of the restoration and adhesive cementation is recommended for 3M ESPE Lava Ultimate restorations. Contact Dr. med. dent. Wolfgang H. Knupfer rezeption@dres-knupfer.de

18 Clinical Excellence 3M ESPE Lava Zirconia Aesthetic restoration of a discoloured maxillary incisor Stuart Campbell, Loanhead, Scotland and Ken Scott, Dundee, Scotland 18 In order to provide aesthetically harmonious anterior restorations, several critical factors have to be respected. These include a correct diagnosis and treatment plan, carefully controlled, smooth tooth preparations, careful material selection, accurate impressions and tissue management as well as close communication with the dental technician and the patient. The following case details the restoration of a single discoloured non-vital maxillary central incisor for a patient with a minimally restored anterior dentition. Patient expectations The patient had recently gained employment in the television and media industry and felt that his still noticeably discoloured tooth could have a negative effect on his career. He was accepting of the fact that conservative treatment options had been unsuccessful and that tooth preparation would be required. He expected that the left maxillary central be restored to match the colour of the remaining dentition. His preference was for a natural tooth with slight irregularities. Communication with the patient The patient was informed that several factors had to be taken into account if a successful outcome was to be achieved. An improvement of the existing tooth colour e.g. by internal bleaching was discussed but rejected by the patient as tooth whitening had been unsuccessful in the past. He accepted that management would require that his tooth be restored with a full coverage crown, even though he was made aware that this approach was likely to further weaken the tooth. The patient was also made aware of crestal bone loss around Case report The 44-year-old male patient presented to the practice expressing a desire to improve the appearance of his left maxillary central incisor. He reported that this tooth had sustained a dental trauma several years earlier, and that, following endodontic intervention, marked discolouration of the tooth had occurred. Bleaching had proved unrewarding and the patient s previous dentist had provided a porcelain veneer (Fig. 1). The patient was unhappy with this restoration and requested a more cosmetic alternative. Patient examination and diagnosis A comprehensive clinical examination was completed considering the extra- and intraoral as well as the restorative status. It was revealed that the patient had realistic aesthetic expectations and had a low smile line. He was periodontally stable with excellent oral hygiene. There was irregularity of the papilla and horizontal crestal bone loss. The occlusion was canine-guided in both left and right working side excursions. There was a non-working contact on tooth 17 (FDI) but no non-working side interfer- tooth 21 and its complicating the preservation of the dental papilla. He was unconcerned by this fact as his gingival tissues were not visible on smiling and talking. He was also unconcerned by the irregularity of the gingival zeniths in both 11 and 21 and even considered this a desirable feature. He did express a preference for an intracrevicular restoration margin. Different treatment options and material options for anterior ceramic crowns were presented to the patient. Following communication with him it was agreed that the upper left central incisor be restored using a full coverage crown fabricated using a zirconia oxide-based framework and lami- ences. Protrusive guidance was shared between nated with veneering ceramic. all four maxillary incisors and the lower anterior teeth. There were no signs of parafunction. The left maxillary central incisor was non-vital and Treatment approach noticeably discoloured. The tooth had a root filling Following hygiene phase therapy, measurements and was restored with a veneer which had short- of the dento-gingival complex were taken. Figures comings in terms of colour, form, texture and size. 2 to 4 show the approach adopted for preparation The remaining dentition was minimally restored of tooth 21. A silicone index was used to guide the Figure 1: Left maxillary central incisor at presentation. and of acceptable colour. reduction (Fig. 5). No. 24 SEP 2013

19 Espertise improves bond strength, reduces post-operative sensitivity and minimises bacterial microleakage. crest. After its production the restoration was tried in and approved by the patient. Occlusal contacts were checked and minor adjustments were made. Figure 2: Incisal depth grooves are cut vertically to ensure a smooth even incisal edge reduction. Figure 3: Depth grooves, further enhanced by being coloured with die spacer (Yeti Die Spacer, Keystone Industries) ensure that the appropriate amount of tooth structure is removed and areas of under-preparation can easily be visualised. PTFE tape is applied to protect the adjacent teeth. Figure 6: Immediate dentin sealing of the prepared tooth. A provisional crown was made. Afte r a period of two weeks for stabilisation of the gingival tissues retraction cords were placed and an impression was taken with VPS impression material (Figs. 7 and 8). The crown was fitted using 3M ESPE RelyX Unicem Self-Adhesive Resin Cement. Final result The patient was extremely pleased with the final restoration which demonstrated good outline, shape, form and colour (Fig. 9). A slight asymmetry was noted in the incisal embrasure between teeth 11 and 21 (Fig. 10). This did not concern the patient. 19 Figure 9: Final restoration in place. Figure 7: Tooth isolation using OptraGate (Ivoclar Vivadent) and the double retraction cord technique. Figure 4: The marginal finishing line is prepared after the incisal and mid-facial reduction. A shade prescription, an index of tooth 21 and an occlusal sketch were sent to the laboratory together Figure 10: Slight asymmetry in the incisal embrasure. Figure 5: A silicone index, sectioned in the sagittal plane, guides the reduction. Before impressions were recorded, the completed preparation was etched and sealed using 3M ESPE Adper Scotchbond Multipurpose Adhesive according to the immediate dentine sealing protocol (Fig. 6). The value of this technique is that it Figure 8: The VPS impression. with the impression for the production of the crown made of 3M ESPE Lava Zirconia laminated with porcelain. Further instructions were provided to prescribe texture, tooth form, incisal embrasure space and position of contact point relative to the alveolar Conclusion The patient was pleased with the outcome of his treatment which was achieved with the aid of careful planning, proper communication between the involved parties, application of clinical protocols and appropriate material selection. Contact Stuart Cambell, BDS campbell986@btinternet.com

20 General Information Espertise Calendar of Events 2013 E D I T O R I A L Information Date Event Location Website ADA 2013 The 35th Australian Dental Congress CEDE Dentalexpo Congress "Il Dentista Moderno" BDTA Dental Showcase Melbourne, Australia Poznan, Poland Moscow, Russia Parma, Italy Birmingham, Great Britain Australian Dental Association Exactus sp.j. Dental Expo Ltd. Senaf Srl BDTA Editor: Gerhard Kultermann Editorial team: Nicole Jaganosch Manuel Meier-Staude Eva-Maria Popp Thorsten-Simon Eickholt Frédéric van Vliet Production: Immenstadt/Germany International 2013 Expodental Dental-Expo Ufa 2013 Milano, Italy Ufa, Russia PROMUNIDI S.r.l. DENTALEXPO Design and typesetting: Comcord GmbH Düsseldorf/Germany We accept no liability for unsolicited manuscripts Dentech Shanghai, China Shanghai ShowStar Exhibition Co. Ltd. or photographs. Court of Jurisdiction: Munich ADA Annual Session New Orleans, USA American Dental Association Finnish Dental Congress and Exhibition 2013 Helsinki, Finland nnexpo.fi /Sites1/ Hammaslaakaripaivat/en/Pages/ default.aspx The Finnish Fair Corporation Dentamed 2013 Wroclaw, Poland Targi w Krakowie Sp. z o.o Swedental 2013 Stockholm, Sweden Stockholmsmässan Published by: DENTA 2013 Bucarest, Romania ROMEXPO SA 3M Deutschland GmbH Location Seefeld ADF Meeting Paris, France Association Dentaire Française 3M ESPE ESPE Platz Seefeld Germany GNYDM New York, USA GNYDM info3mespe@mmm.com 3M Deutschland GmbH Location Seefeld 3M ESPE ESPE Platz Seefeld Germany info3mespe@mmm.com 3M, ESPE, Addent, Adper, Dimension, Espertise, Filtek, Imprint, Lava, Nextel, Penta, Pentamix, Protemp, RelyX, Scotchbond, Scotch-Brite, Sinfony, Sof-Lex are trademarks of 3M Company or 3M Deutschland GmbH. Used under license in Canada. All other trademarks are owned by other companies. 3M Deutschland GmbH All rights reserved.