An Innovative Magazine for Dentists from 3M ESPE

Transcription

1 N o 8/2006, January An Innovative Magazine for Dentists from 3M ESPE Editorial Contents Dear Readers, How do you make an excellent and successful product like Filtek Supreme universal restorative even better? By listening to the voice of the customer, 3M ESPE invited leading experts in the field of aesthetic dentistry from all over the world, to define their needs for the perfect shading of direct resin composites. In this edition of Espertise Magazine, we are proud to present the result of this close cooperation between experienced dental clinicians and scientists from 3M ESPE research and development department: Filtek Supreme XT, the advanced universal restorative based on 3M Nano-Technology will continue the story of success of this leading resin composite. To earn dental professionals highest respect and loyalty by product ingenuity, it always needs to be close to clinical relevance. You will learn more in this magazine about the clinical relevance of the differences between silicones and Polyether impression materials, how to replace alginates in your daily practice, if Glass Ionomers can make your dental life easier and how 3M ESPE materials can support your prosthodontic clinical procedure from prep to crown. Finally, in the Dental Practice Forum, we have provided you with a sequence of articles to help you deal with clinical emergency situations. Enjoy reading! Gerhard Kultermann, Editor 3M ESPE, Seefeld, Germany Clinical relevant properties of 3M ESPE Polyethers, flow behaviour (part two) 2 Time to Break with Dusty Habits 4 Steel Crowns a well established method of restoring primary teeth 6 TIME in patient treatment 8 Nanotechnology, Appearance and Color 10 From Prep to Crown Dental Materials in Daily Practice 12 Reconstruction of anterior trauma 14 Taking a fresh look and discovering talent 16 Third Autumn 3M ESPE Espertise TM Prosthodontic conference in Moscow 17 Hypertensive emergencies 18 General Information 20

2 N o 8/2006, January, Page 2 Product Information Impregum Penta Polyether Impression Material Clinically relevant properties of 3M ESPE Polyethers, flow behaviour (part two) Thomas Klettke, 3M ESPE, Seefeld, Germany Clinically relevant snap-set behaviour and flow properties During the working phase the impression material should be completely plastic in order to ensure optimum flow. As soon as it begins to set, the material becomes more and more elastic thus resulting in decreased flow behaviour. After setting it is almost completely elastic. If the impression material already demonstrates elastic properties during the working phase, premature elasticity may cause tension in the material and, subsequently, an inaccurate impression. Therefore, the material should maintain a high flowability during working time and afterwards transfer from plasticity to elasticity as quickly as possible. In the context of impression materials the term snap set refers to the rapid transition from the unset to the set state, as shown in the figure below. In terms of rheology, snap set can best be described as the sudden transition from an extended preservation of plasticity to the manifestation of elasticity. The exact reproduction of the intra-oral situation is the most important pre-requisite for a perfect fit of prosthetic work. State of the art precision impression materials are capable of producing the intraoral situation quite well. Initial hydrophilicity of the 3M ESPE Polyethers is one of the properties that enable the dentist to take very precise impressions (see part one of this article in Espertise No. 7). Snap-set behaviour and excellent flow are further clinically important properties of the 3M ESPE Polyether impression materials convincing the dental practitioner as well as the specialist by their compelling results. Polyethers manufactured by 3M ESPE display such a snap set behavior and offer the dentist excellent flow properties during the intraoral working time. On the other hand, in silicones, pre-setting takes place quite early so that some elastic sections will be found even during the working phase and the transition from the plastic to the elastic phase is less abrupt. A sophisticated method for analysing flow properties is the Shark Fin test., 2, 3 The test simulates clinically relevant flow conditions for materials used in one step (heavy body/light body and monophase) technique. The test method is described in the following sequence of pictures. 2 Impregum Garant L Aquasil Ultra LV Aquasil Ultra XLV Exafast NDS Injection DuoSoft Results of the test when weight was applied after 25 seconds.

3 N o 8/2006, January, Page 3 Product Information Approximately ten milliliters of impression material is injected to fill the receptacle of the Shark Fin device. The mixing tip is buried into the receptacle to avoid trapping air. The fixed mold and a 147g weight is placed over the receptacle. The pin is released allowing the weight to sink slowly into the material. (The weight was reduced from the original test design to 147g to accurately reflect the pressure applied during clinical placement in the mouth.) The molds are separated and the samples are measured using a caliper accurate to 0.5mm. Two test series were carried out for each material: Compression was applied 25 seconds after mixing begins and at the end of the working time indicated by the manufacturer. 4 Both polyether impression materials exhibit significantly better flow properties than the VPS materials, at the beginning as well at the end of working time. It is also important to note that the flow properties remain very good throughout the working period which is due to their snap set behavior. The data shown has good correlation 5, 6, 7 with literature results. Flowability into crevices low viscosity 25,0 25 sec after start of mix end of working time 20,0 15,0 10,0 Height of "fin" in mm 5,0 0,0 Impregum Garant L Impregum L DuoSoft Affinis Light Body Fast Aquasil Ultra LV Fast Aquasil Ultra XLV Fast EXAFAST NDS Honigum QuadFast DuoSoft Quick # MI271 Set Set Injection Light Body # B174186, K # B174999, K # # # # Due to the snap-set behaviour of the Polyethers manufactured by 3M ESPE, the monophase materials can compete in flow with VPS light bodied materials, especially at the end of working time at mouth temperature. 8 Comparison of flow properties of different light body materials with shark fin test. Snap Set Processing Time setting phase The discussed properties of the 3M ESPE Polyethers: initial hydrophilicity, flowability and snap set behaviour enable the dentist to take a very precise impression the prerequisite for a satisfying restoration. Viscosity Polyether A-type silicones Time Detailed references available through your local 3M ESPE Dental Products office. The fast transition from the working phase (plastic) to the set state (elastic), so typical for polyether, is known as snap set. 3

4 N o 8/2006, January, Page 4 Product Information Position Penta Vinyl Polysiloxane Preliminary Impression Material Time to Break with Dusty Habits Sigrid Hader, 3M ESPE, Seefeld, Germany his assistants, the lab technicians and the patients could only in a few cases be compensated by the people who were handling the material: Fig 1: Hygienic aspects have to be taken into account when choosing your impression material. Assistants had to mix a powder with water manually and rarely achieved a really voidfree homogeneous mix. In addition they had to clean up all the materials used for mixing (Fig. 1). The dentist took care that once the impression was taken, it was immediately forwarded to the lab to avoid dimensional inaccuracies. Desinfection also required special precautions. The laboratory had to pour the gypsum model immediately. Furthermore the impression could only be poured once or twice because after the process, the impression material was often torn from the wall of the tray or was not able to recover its original shape. It was not possible to store an alginate impression and later reutilise it e.g. as a mould for temporary restoration either. Trays needed to be cleaned up and then sent back to the dentist in Since the beginning of 20 th century a number of important inventions were made. Most of those inventions were improved or replaced by other technical devices or methods. In the past the black and white gogglebox e.g. was the only way to get pictures of the news the day things happened. Even if the screen size was not much more than that of a piece of paper and resolution was limited there was nothing better those days. Over time technology for audiovisual devices improved terrificly and nowadays most people have replaced their old black and white TV set by multipurpose colour television units appreciating all the advantages of an innovative and broadly accepted product. Alginates have been in use in dental practices for many years now. The diversity of possible indications explained the popularity of alginates as a basic material. The major drawbacks for the dentist, Fig. 2: In some cases alginates are not easy to mix and manipulate without intensive clean-up procedures after impression taking. the meantime the trays were missing in the dental office and could not be used for other precision impressions. This was very costly and time consuming for all involved persons. Now it is time to say good bye to alginates! The Position Penta System has the answer to the above issues (see opposite page, Fig. 3). 4

5 N o 8/2006, January, Page 5 Product Information A-Silicone advantages: In addition to the alginate features of excellent flow, good hydrophilicity and low shore A hardness Position Penta offers extra reliability and flexibility: High recovery after deformation, good elasticity and compressive strength. Dimensional stability approaches the limits set for precision impression materials. Possibility to store the impression allowing for delayed as well as multiple pouring even weeks after having taken the impression Smooth surface reduces adjustments on gypsum casts and temporary restorations Easy disinfection with standard products Fig. 3: The Position Penta system consists of an A-silicone which is mixed in the Pentamix automatic mixing unit and a single-use tray, Position Tray. Plus Pentamix advantages: Homogeneous, void free mixing. Perfect mixing ratio at the pressing of a fingertip Easy, timesaving, hygienic handling and tray filling, no cleaning up Plus Position Tray advantages: Less dripping of material and gagging by patient due to retention wall at tray ends and palatinal reservoir Optimized material flow through special tray design Selection of 3 sizes for upper and lower jaw respectively with high probability of fit No application of adhesive or cleaning and resending of single use tray Now it's time to switch to the Position System because it takes impressions for alginate indications to a new level of accuracy, ease of use, comfort and flexibility Or do you still use your black and white TV set? 5

6 N o 8/2006, January, Page 6 Product Information Stainless Crowns for Permanent and Primary Molars Steel Crowns a well established method of restoring primary teeth Christian H. Splieth, Greifswald, Germany Indications Apart from large carious defects in deciduous molars which do not allow a restoration to be anchored, steel crowns are used primarily following endodontic measures. In children with high caries activity they reduce the risk of secondary caries by covering the entire natural crown. Fig. 1: Steel crowns on deciduous molars generally last considerably longer than fillings. As the caries prevalence declines in children and adolescents, a polarisation of the incidence of caries has been witnessed. Whereas in the majority of children, only minor restorative measures are still necessary, in a minority, the degree of damage to the dentition increases. As deciduous molars are smaller than permanent molars, there is less leeway for optimal preparation and shaping of the restoration: fillings often fracture as a result of the preparation not extending far enough, while fractures of the hard dental tissues are a common result of overextending the preparation. Large restorations using GI cements can at best be regarded as a temporary solution. In many cases it is not possible to use composites in the posterior region because of continuing caries activity. Restoration with steel crowns results in significantly lower cariogenic bacterial counts compared to compomer restorations 1. Long-term studies show that steel crowns are, on average, considerably more successful than multi-surface restorations 2. The prefabricated steel crown (Fig. 1) is therefore a restoration option that has, unfortunately, been underused up to now for relatively large defects. 6 Extensive hypoplasia and lost cusps can also be treated reliably with a steel crown. Furthermore, the steel crown can be used for attaching anchors, e.g. to prevent the closure of a gap. Preparation Fig. 2: Preparation for the steel crown consists purely in an occlusal reduction and an approximal tangential preparation. Finally, the edges are rounded off. The buccal enamel ridge is preserved as an undercut retention. When preparing a steel crown, the dentist must forget all the rules of preparation for crowns on permanent teeth: the aim is minimal reduction of the hard tissues; the crown is held in place by engagement under an undercut (Fig. 2). Fig. 3: Box with prefabricated steel crowns Following local anaesthesia, occlusal reduction by mm is performed. Then the approximal surfaces are reduced as a slice-cut using a diamond point so that a probe can be fed through. The tangential preparation avoids steps, which would make it difficult to fit the crown. The buccal enamel ridge of the primary teeth serves as the retention for the steel crown and should not be reduced, or only slightly. Only very rarely is any lingual reduction necessary, and should in any event only be carried out once the steel crown has been adapted. To finish with, the edges should be rounded off. Adapting the steel crown The prefabricated nickel-chrome crown, which is available from several manufacturers (Fig. 3), is selected on the basis of the mesio-distal distance, which can be measured with a slide gauge or periodontal probe. The crown is placed lingually and fitted over the buccal enamel ridge. If the gingiva becomes anaemic because the margins are too long, the relevant sections can be marked on the crown along the gingiva using a

7 N o 8/2006, January, Page 7 Product Information Fig. 4: Contour pliers for adapting steel crowns (left) and special holding pliers for twisting and removing (available via Kinderdent.de) Fig. 5: Crooked placement of the steel crown during cementing leads to failures. It is therefore essential to check the fit of the crown and the occlusion during the curing phase of the cement. Cementing the steel crown probe and then shortened with a diamond. The ideal subgingival depth is one millimetre. Occlusal interferences must also be avoided. The crown must be given a snap fit, for which the edges can be bent with contour pliers, if necessary. There are special pliers for holding, turning and removing the crown (Fig. 4). If the gap has narrowed as a result of the distal tooth drifting, it may be necessary to press the crown together in mesio-distal direction. Finally, the prepared crown edges must be polished and the approximal contacts and occlusion checked. After isolating the tooth with cotton wool rolls and drying it, the crown is filled with glass ionomer cement. It is then placed lingually and fitted over the enamel margin buccally, so that the excess cement escapes buccally. The correct seating of the crown must be checked to avoid cementing errors and failures (Fig. 5). Excess cement must be removed carefully, especially on the approximal surface. Then the occlusion must be checked once again. It is essential to avoid premature contacts. The time required for fitting a steel crown is comparable to a three-surface restoration, whereas the crown is significantly more durable than the restoration on primary Fig. 6: When natural exfoliation takes place, the steel crown has fulfilled its function. teeth. For this reason, the steel crown should be a routine procedure for primary teeth in every dental practice. Detailed references available through your local 3M ESPE Dental Products office. This article is taken from the book Kinderzahnheilkunde in der Praxis (Paedodontics in the Dental Practice) by Ch. Splieth (editor), Quintessenz, Berlin, A video showing the preparation and placement of the steel crown can be found on the accompanying CD-ROM. 7

8 N o 8/2006, January, Page 8 Product Information Ketac Glass Ionomer Family & Friends TIME in patient treatment Annika Meyer, 3M ESPE, Seefeld, Germany Un-cooperative patients, emergency patients, caries risk patients, patients with periodontal diseases Why are these patients special patients for the general dental practitioner? Because these patients require more than a customary treatment. Apart from an increased capacity for understanding and special knowledge of the dentist these patients need customized, indication-specific treatment which allows flexibility during all treatment phases. It would be presumptuous to believe that just one product can offer you all these possibilities, but there is one class of material which can cover all these indications: glass ionomers! Because glass ionomers offer you what you need most: TIME. are also no longer necessary. 8 different shades help you to achieve natural aesthetics a convincing argument for mum and dad to invest on their youngster time you can spend on the dental education of their child, your patient of tomorrow. In addition, the dual-plus curing mechanism of Photac Fil Quick offers you a cure on demand and ensures that the material also cures in areas sheltered from light. TIME for caries risk and periodontal patients This is only one example where glass ionomers can offer you the process safety you need for treatments which take a little longer. You gain time to improve hygiene compliance and still preserve the flexibility of treatment. Periodontal treatment, for example, often needs more time to measure improvements or deficiencies so that you can develop individual treatment plans according to the actual situation. TIME for interim restoration and emergency patients T I M E to Treat to Implement to Measure to Educate TIME for kids Time is what you normally do not have when treating kids. They, as well as geriatric patients, have a low ability to take stress and can not stand longer sessions. In those situations the material should allow you to act quickly. Photac Fil Quick a lightcuring glass ionomer offers all the clinically relevant features: few steps, low technique sensitivity and high fluoride release (Fig. 1). Time consuming conditioning of the cavity or the application of dental dam 8 Vitremer a glass ionomer for fillings and core build-ups also offers the advantages of controlled curing. And, like other glass ionomers from 3M ESPE, Vitremer is very effective in reducing the risk of secondary caries. Studies prove that glass ionomers were significantly more effective than composite at reducing the incidence of secondary caries in a population of very high caries risk patients, giving a reduction in recurrent caries of greater than 80%. In a clinical study of 45 high caries risk, xerostomic patients 1, Ketac Fil Plus a glass ionomer filling material and Vitremer were compared with a bonded composite over two years. Each patient had at least three Class V restorations placed, with each of the three test materials. Patients were requested to use topical fluoride gel daily but not all the patients complied. Amongst the non-fluoride gel users none of the Ketac Fil, only one Vitremer, but eight composite restorations failed due to secondary caries. So why not use a glass ionomer filling as a preferred choice for interim restorations? The advantage of using glass ionomers such as Vitremer and Ketac Molar glass ionomer restorative material for core build-up procedures are ease of placement due to their bulk cure property, and ease of preparation as both products cut like dentin. There are very few clinical studies on core materials. Wilson et al 2 placed Vitremer cores replacing between one and three cusps in molar teeth. These Vitremer foundation restorations were contoured to be in occlusal function and in proximal contact with neighboring teeth. They were allowed to function as interim restorations for 3 months prior to being prepared for full veneer crowns. All the interim restorations were clinically acceptable at three months, and after placement of the crown with RelyX Luting resin modified glass ionomer luting cement, were clinically satisfactory at one year. Thirty-nine crowns were recalled at five years 3 and none of the cores had failed.

9 N o 8/2006, January, Page 9 Product Information Cumulative fluoride release [ppm] Measurement period in weeks Photac -Fil Quick A3 Aplicap Ionofil Molar AC GC Fuji II LC A3 Capsule Vitremer A3 Fuji IX Capsules GC Fuji II LC A3 Ketac Molar Aplicap A µm / 200,000 cycles Ketac Molar Fuji LX Dyract Z100 Fig. 1: Fluoride release of Photac Fil Quick - Glass lonomer Filling Material. Convincing data which also shows: glass ionomers offer you more: you can remain in the system of the material and profit from this easy to use material in every phase of the therapy. One of those possible combinations could also be a core build up with Vitremer and the luting of the crown with Ketac TM Cem, glass ionomer luting cement... Or take Ketac Molar, the highly viscous glass ionomer for posterior restorations. Due to its high compressive strength and surface hardness (Fig. 2) you could apply it in an emergency case and decide later if you just reduce part of the surface for a sandwich composite filling or use it as core build up for a crown. Fig. 2: Ketac Molar - Glass lonomer Restorative Material shows less wear. 3M ESPE glass ionomers offer you a high degree of flexibility you will be able to find one glass ionomer product which suits best for the indication (Fig. 3): Fissure sealing, semipermanent filling, primary teeth filling, linar and even in most classes for permanent fillings. Photac Fil Quick Ketac Molar Quick Ketac Molar Vitremer Ketac Fil Plus Ketac Silver Quick treatment with uncooperative patients Self-adhesive Use without conditioning Time saved due to light cure Use of strontium glass Level of fluoride release High abrasion resistance Deciduous teeth fillings Fissure sealing Interim fillings Permanent fillings Class I Core build-up Use in case of xerostomy Fig. 3: Ketac Family and Friends a solution for every indication. 9

10 N o 8/2006, January, Page 10 Ask the Experts Filtek Supreme XT Universal Restorative Nanotechnology, Appearance and Color Brian N. Holmes, 3M ESPE, St. Paul, USA What is color science? Color science employs methods for quantifying the relationships between the three basic components of color: the object, a light source, and an observer. The CIELAB color space is especially useful for controlling color, and for deciding if two objects have the same color. The process starts by measuring the reflectance spectrum of a sample. The spectrum is then multiplied by the spectral power distribution function of a common light source (such as indirect northern daylight) and three functions (which approximate the sensitivity of the human eye). The resultant three functions are then mathematically transformed and simplified to the three coordinates (Fig. 1) of the CIELAB color space: L* (lightness), a* (red-green), and b* (yellow-blue). Fig. 1: CIE L*a*b* color coordinate system and its relationship to the Munsell Color system of Value, Hue and Chroma. The primary particle size of the nanoparticle and nanocluster fillers used in Filtek Supreme XT Universal Restorative are much smaller than the wavelength of visible light. Thus, the particles interact with light differently than particles in hybrid and microhybrid composites. They impart less opacity while enabling high polish and polish retention. These features presented opportunities to enhance the aesthetics in Filtek Supreme XT, while maintaining the handling, physical properties and low wear characteristics of the original Filtek Supreme Universial Restorative. Fortunately, color computers make this process quite fast and easy. E, the distance between two sets of color coordinates in color space, is a useful measure of color difference. For most people, a E of >2-3 represents a threshold of perceived color difference. The Vita Classic Shade Guide used by most dentists to communicate color is based, not on CIELAB system, but on the more intuitive Munsell color space descriptors: value, hue and chroma. Although many composites on the market use Vita -based shade designations, What factors influence appearance? The appearance of a tooth or a restoration depends on many factors. There are the intrinsic optical characteristics of the material like surface texture and the color. Filler particle size, particle shape and refractive index differences between the particle and the matrix resin are intrinsic factors which influence opacity and angle dependant visual effects like opalescence. External factors such as the spectral characteristics of the lighting source (i.e. spectral power distribution), and the color of the background and surroundings can also result in dramatically different appearance. Finally, appearance is dependant on the visual acuity of the observer. The challenge in the development of Filtek Supreme XT has been to fine tune the optical properties of this nanocomposite by manipulating the color and opacity so that it is easier for the dentist to obtain high quality aesthetic restorations. Fig. 2: Coordinates for several commercial A3 composites in the a*-b* plane. 10

11 N o 8/2006, January, Page 11 Ask the Experts Fig. 3: 3D CIELAB color space representation of Filtek Supreme XT Universal Restorative optimized A Shade range. similar shades from different manufacturers do not share the same spectroscopically measured color coordinates. Fig. 2 reveals the large variation in commercial A3 shades as represented in the a*-b* color plane. These samples showed a range in E over 14! So, what color should an A3 shade be? Why is it easier to use Filtek Supreme XT? Color science played a key role in the development of the shades now offered in Filtek Supreme XT. To help guide us in shade development we enlisted the help of a group of dentists recognized for excellence in aesthetic restorative dentistry. Our first challenge was come to a common understanding of color terminology (CIELAB vs. Munsell) in order to facilitate translation of our customer needs. Comprehensive interviews with our panel of experts combined with field test data and benchmark testing allowed us to define a dentist-preferred color space. The optimized color space for the A-range shades takes the form of a tube (Fig. 3) and represents the area within which dentists preferred the A-range shades to reside. Similar strategies were used to define the remaining B, C and D shade ranges. The result is a dentist-defined layout of shades in color space that delivers an easyto-use system that meets the expectations of a wide range of dentists and applications. Dr. Brian N. Holmes, Ph. D. Present Position: Division Scientist St. Paul, MN USA Further information: Dr. Holmes received a B.S.(Chem.) from the University of Michigan (B.S.Chem) and a Ph. D. in organic chemistry from the University of Illinois at Urbana- Champaign. For the last 19 years he has been active in the development of dental restorative composites. He was the lead product developer for Filtek Z250 Universal Restorative System, P60 Posterior Restorative System, Supreme and Supreme XT Universal Restorative, as well as the co-leader of the Filtek Supreme development team. His research interests including resin chemistry, molecular modeling, silane treatments, formulation, filler development, composite processing and color science. 11

12 N o 8/2006, January, Page 12 User Report Replacement of Missing Teeth with Lava Crowns and Bridges From Prep to Crown Dental Materials in Daily Practice Volker Bonatz, Landau, Germany Fig. 1: The initial situation from incisal Fig. 2: Frontal view in occlusion Fig. 3: The patient s removable temporary restoration on the model Fig. 4: Bite registration with Imprint Bite vinyl polysiloxane material Fig. 5: Incisal view of the preparation Fig. 6: Syringing around the finished preparation The loss of an anterior tooth has wide-ranging consequences for the patient. Apart from the immediate negative aesthetic and phonetic effect, impending bone resorption often leads to a progressive worsening of the red-white aesthetics. Bone can then only be preserved by means of implantation. The present case report, however, concerns a young patient for whom this type of treatment was not an option. Nevertheless he wished to have a permanent restoration which would meet his expectations regarding aesthetic anterior teeth. Case presentation The patient presented at the practice with a dentition almost completely free of restorations and no gingival inflammation. Tooth 21 had been extracted years before, following anterior tooth trauma. Several removable temporary restorations had been placed over a number of years in an attempt to maintain the situation until the patient was able to 12 make up his mind concerning a definitive form of treatment. The picture of the initial situation shows clearly that the bone and gingiva had already undergone major resorption in the vestibulo-oral direction (Fig. 1). The initial situation in occlusion additionally reveals the need for a pre-prosthetic intervention so as to form a basis for the pontic (Fig. 2). In the final analysis, a model was used to make clear to the patient the discrepancy in crown length of the two central incisors. The cervical margin of the prosthetic tooth is clearly visible on the removable temporary restoration. The patient agreed to the treatment suggested, namely a gingiva transplantation in order to allow the vestibular sections of the bridge to be shaped optimally (Fig. 3). Following the operation, the artificially created papillae and the well-formed basis for the pontic are clear to see (Fig. 4/5). The abutment teeth were prepared with a conventional chamfer. The preparation line runs considerably supragingivally, especially on tooth 22. An impression of the situation is taken with Permadyne polyether impression material using the one-step tray wash technique. The hydrophilicity of the 3M ESPE polyether material proves advantageous, especially when syringing around the preparation margins in close proximity to the gingiva (Fig. 6).

13 N o 8/2006, January, Page 13 User Report Fig. 7: Detail view of the Permadyne impression Fig. 8: The bridge framework viewed intraorally from labial Fig. 9: and incisal Fig. 10: Placement with RelyX Unicem selfadhesive universal resin cement Fig. 11: Frontal Fig. 12: and detail view of the cemented bridge In spite of clinically visible liquid accumulation during impression-taking, the finished impression reproduces the details precisely (Fig. 7). After taking the shade, the zirconia framework is fabricated at the milling centre. At the first try-in of the framework, the basic shade and marginal modelling can be checked before the veneering porcelain is applied (Fig. 8/9). In the anterior region, in particular, it is advisable to use a fixation impression to give the dental technician not only the position of the teeth and approximal areas, but also the exact position of the gingiva. At this point it is still possible to specify a correction to the shade selection or an enhancement of the later shade transitions. The veneered Lava bridge can then be cemented with RelyX Unicem self-adhesive universal resin cement at the next session without any other preparation. The selfadhesive composite cement with its lightpermeable shades provides very good support to the dentine-like translucence of the Lava bridge. After cementing, it is advisable to polymerise the excess briefly (for approx. 5 seconds) before removing it with a probe and curing each surface for 20 seconds with the polymerisation lamp (Fig. 10). Finished bridge immediately after cementing complete anterior view (Fig. 11) and a detail view (Fig. 12). 8 weeks after permanent cementing of the restoration, the gingival situation is so well adapted that you would not believe that a bridge has been fitted (Fig. 13). Fig. 13: Situation 8 weeks after fitting the bridge 13

14 N o 8/2006, January, Page 14 Clinical Case Report Filtek Supreme XT Universal Restorative Reconstruction of anterior trauma Claus-Peter Ernst, Mainz, Germany A patient with anterior trauma usually shows up in the dental office as an emergency. In most cases a temporary resin composite build up is performed where most emphasis is placed on the functional needs of the restoration rather than its esthetics. With the Frasaco-Strip-crown technique functional rehabilitation is possible in a single appointment without the need of renewal afterwards. The modification of this technique even allows layering of the material and bulk placement technique leading to best aesthetic results in one appointment. Fig year old patient with severe traumata, specially on tooth 11 and 22. Fig. 2 Lingual view of the same situation before reconstruction. Due to the depth of the fracture it was first considered to restore the tooth with a crown. The patient, however, preferred a direct restoration. Fig. 3 After preparation of the enamel margin and application of rubber dam. Fig. 4 Chosen Frasaco crown. Fig. 5 Perforating the Frasaco crown along the incisal edge to avoid entraption of air while filling the crown with composite. Fig. 6 Shortening of the Frasaco crown with a crown scissor. Fig. 7 Application of the enamel shade A3E in the incisal areas of the transparent crown (2 mm). Do not polymerize. Fig. 8 Application of shade A3B into the crown. A dentin core of the shade A3D was placed directly onto the tooth. Care was taken not to overextend the dentin core, as otherwise it could impair the proper fit of the Frasaco crown. Fig. 1 Fig. 2 Fig. 3 Fig. 4 14

15 N o 8/2006, January, Page 15 Clinical Case Report Fig. 5 Fig. 9 Fig. 13 Fig. 9 The Frasaco crown before fitting it directly onto the tooth. Fig. 10 Fig. 6 Fig. 10 Situation after finishing and polishing of the restoration a definite aesthetic and functional rehabilitation of a traumatized tooth in a single appointment. Fig. 11 Incisal view after finishing and polishing of the restoration. The patient is able to continue his day without severe functional and aesthetic restrictions. Fig. 12 Fig. 7 Fig. 11 Teeth 12 and 11 after one month. Fig. 13 Teeth 21 and 22 after one month. Fig. 8 Fig

16 N o 8/2006, January, Page 16 Scientific Activities in Europe Lava Crowns and Bridges Taking a fresh look and discovering talent Laurence Bergmeier, 3M ESPE, Seefeld, Germany On the 20th of October, 11 dental technicians from across Germany took part in the first 3M ESPE competition for young dental technicians. All dental technicians and master dental technicians specialising in ceramics were eligible to participate. The task of the contenders was to give a practically oriented minute presentation on their dental work, while clearly demonstrating each step. The assessment criteria were presentation, content, didactic skills, topic and personal touch. The winner of the first 3M ESPE Dental Technology Talent Award was Christian Hannker, a master dental technician from Hüde/Lower Saxony. The 26-yearold impressed the jury with his lively presentation: Taking a fresh look at tooth shapes. With striking images, he documented the insights and experiences gained during a several-monthlong study visit to Japan. Second place went to Henry Göpel and his presentation Zirconium oxide in implantology comparison of primary telescopes titanium vs zirconium oxide. The master dental technician Björn Roland was awarded third place. The talks were critically assessed by master dental technician Holger Bellmann in cooperation with the 3M ESPE experts. The jury was extremely pleased with the professional nature of the talks and the promising lecturing quality of the eleven participants. The winning presentations in particular featured excellent images and a high level of technical expertise. The lectures were well structured and were given with panache and humour. Unfortunately, talented dental technicians tend to keep their technical know-how and expertise to themselves. With the Dental Technology Talent Award we want to discover and promote such talent, Martina Wieland, 3M ESPE Germany University Consultant emphasised. Together with Dr. Gerhard Kultermann, 3M ESPE Head of Education Center, she has overseen the Talent Award for Dentists for years, and is delighted that 3M ESPE is now also looking to promote young dental technicians. This also means that technical knowledge is communicated on an international level. 16

17 N o 8/2006, January, Page 17 Scientific Activities in Europe Third Autumn 3M ESPE Espertise Prosthetic Conference Third Autumn 3M ESPE Espertise Prosthodontic conference in Moscow Maxim Ivanovsky, Moskow, 3M ESPE Russia 240 prosthodontists from mainly private dental clinics in Moscow visited the third autumn Espertise prosthetic conference. This was organised by 3M ESPE and held in Moscow on October 27th. The conference was opened by Professor Abakarov from the Moscow state academy of postgraduate education. In his welcome he underlined the importance of cooperation between educational centres and manufactures and in particular the collaboration between his department and 3M ESPE. The first lecture was presented by Professor Dr. Alexander Ryakhovsky from the central institute of dental research and was devoted to the clinical comparison of different impression materials and impression taking techniques. The audience was really excited by a special technique the lecturer presented by using special individual mini-trays. This prompted the dentists in the audience to ask many practical questions which continued long after the lecture had finished. The lecture also highlighted many clinical cases using Impregum Penta Soft polyether impression material. Dr. Gerhard Kultermann from 3M ESPE then focused on the state of the art in luting of dental prosthetic constructions. He explained the difference between the material groups on the market and what clinical indication they can be used for. Lots of practical details and tips were shown in his presentation. Dr. Kultermann answered many questions and the participants were especially interested in the new technologies of self adhesive luting offered by RelyX Unicem self-adhesive universal resin cement despite this material not yet being on the market in Russia. Different aspects of marginal adaptation and integration of dentures were fully described by Dr. Svetlov. Using Impregum Penta Soft polyether impression material and RelyX ARC adhesive resin cement he demonstrated the importance of high quality impressioning and luting to solve the problems of marginal adaptation with some excellent clinical cases. Following this, Dr. Yuriy Shirokov from the Moscow state medical dental university shared his clinical experience on implant treatment. His lecture was especially interesting to those dentists who are dealing with Implantology in their clinics on a day to day basisl. Implant based prosthodontic treatment is becoming very popular in Russia. The feedback from the audience after the conference reflected that the clinical issues exposed by the lecturers were very relevant and interesting. Participants expressed their gratitude to 3M ESPE for organizing this event. 17

18 N o 8/2006, January, Page 18 The Dental Practice Forum Emergency Cases in Dental Surgery Hypertensive emergencies Michael Hillebrand from reanimed in Diekholzen, Germany Picture the following situation: A patient who is in pain is waiting in your surgery. When you greet him, you notice that he is nervous, moving about on the chair and repeatedly wiping the sweat off his forehead. When you ask whether he is currently taking any medication, he says that he used to suffer from high blood pressure but that this is no longer the case thanks to medication. However, the pain and worrying about going to the dentist made him forget to take his medicine that morning. So how should you react? In view of the patient s visible nervousness it is advisable to measure his blood pressure before commencing treatment preferably with an automatic wrist-type sphygmomanometer (see illustration below). The advantage of this type of device is that it fits like a wristwatch and enables the patient s blood pressure to be taken quikkly and easily at any time, even during the dental treatment. If a pressure above 160 mmhg (systolic) and 96 mmhg (diastolic) is measured (normal pressure is around 120/80 mmhg), there is a health risk. Therefore the first thing you should do is to administer medical oxygen preferably via a nose tube. If the patient s general condition deteriorates increasingly, administer two sprays of Corangin-Nitro-Spray under his tongue. This drug reduces the preload on the heart and therefore lowers the blood pressure. While your reception assistant calls an ambulance, you should engage the patient in general conversation to distract him from his present situation, as stress can be a potential cause of sudden hypertension. When the body s stress hormone, adrenaline, is released in increased quantities, the heart rate increases (tachycardia) and the blood pressure rises (hypertension). In this situation, if the patient feels misunderstood or even abandoned, he may panic, and the already high release of adrenaline increases still further, which in turn pushes the blood pressure up even higher. Therefore it is important never to leave the patient alone in this emergency situation. Talk to him soothingly and reassuringly so that he knows that he is in good hands. The seriousness of high blood pressure must not be underestimated because, apart from stress, another possible cause of hypertension is a stroke. Specialists use the term compensatory hypertension, i.e. the body raises the blood pressure in an attempt to keep the brain supplied with oxygen. In so doing, the heart muscle, in particular, has to pump extremely hard, and this increased strain poses a risk of angina pectoris and even myocardial infarction. For this reason, caution must exercised if the patient s blood pressure is very high (200/100 mmhg and above), even if he is feeling well in himself. If it is suspected that the patient has suffered a stroke with high blood pressure, his blood pressure must not be lowered, as this would put the blood supply to the brain at risk (compensatory hypertension). 18

19 N o 8/2006, January, Page 19 The Dental Practice Forum Even if the measures described above bring the blood pressure back down to a normal level, there may still be a danger of angina pectoris or a heart attack. It is essential for the patient to receive medical attention, whether from his GP or a specialist or at a hospital. The following is a summary of the rules that apply in hypertensive emergencies: 1. If a patient says that he is not suffering from any illness but is nevertheless taking medication, this often means that he in fact has high blood pressure. Once the patient s condition has been stabilised with medication, he is no longer aware of the illness. 2. If unexplained autonomic symptoms, such as sweating, nervousness or redness of the face, are observed, the patient s blood pressure should always be taken before commencing dental treatment either with a conventional sphygmomanometer or with an automatic wrist-type device. But it is important to remember that this automatic method is not suitable in the case of corpulent patients who have fat wrists, as the measurement may often be significantly distorted! 3. If high blood pressure is detected using the automatic device (possible distorted measurement), a second measurement must be taken using a conventional (Riva-Rocci) sphygmomanometer. 4. Keep calm! This will stop the stress situation from spiralling out of control. 5. Less is more: the administration of medical oxygen, to ensure an adequate supply to the heart muscle under great strain, and Corangin-Nitro-Spray are usually adequate as simple, noninvasive measures for effective primary treatment. If the patient s blood pressure does not drop or, in the worst event, actually rises further, the patient should chew a capsule of Adalat (calcium antagonist) after puncturing the capsule with a cannula. Situation is under control when the dental nurse calls an ambulance and the dentist can give calm and effective assistance to the patient. 6. Stay with the patient! Your assistant is responsible for calling an ambulance. Also let your assistant fetch the emergency medication and ensure that you are not disturbed. This is the only way to act calmly and effectively, and give the patient reliable assistance. 19

20 N o 8/2006, January, Page 20 General Information Date Event Location Website Sao Paulo Dental Meeting Sao Paulo De Dentale Martdagen Eindhoven Asia Pacific Dental Congress Karachi st Chicago Midwinter Meeting Chicago McCormick Place AEEDC Dubai 2006 Dubai Expodental Madrid Dental Salon Usbekistan Taschkent Ukrainian International Dental Show Kiew Stomatology Uzbekistan Tashkent IDEM Singapore Dental Salon Moskau International Expo Dental AMIC Mexico Calendar of Events 2006 SIDEX Seoul International Dental Exhibition Seoul KIDE Kasachstan Almaty SALDENT Poznan Stomatology St.Petersburg St.Petersburg Australian Dental Expo Melbourne German Dental Symposium Hangzhou Sino Dental Peking th International Dental Congress Samsun / Türkei Dentalexpo Moskau (Krokus-Expo) FDI World Dental Congress Shenzhen Expodental Mailand International Dental Showcase London ExCel th World Dental Meeting Yokohama Editorial Information Published by: 3M ESPE AG ESPE Platz Seefeld, Germany Telephone: +49 (0)8152/700-0 Telefax: +49 (0)8152/ info3mespe@mmm.com Internet: Editor: Gerhard Kultermann Editorial team: Dieter Klasmeier, Annika Meyer, Maria Bauer, Laslo Faith, John Raffelt, Laurence Bergmeier-Lega Coordination: Laurence Bergmeier-Lega, Annika Meyer Production: Eberl, Immenstadt, Germany Design and typesetting: Attila Sirman Digital Consulting, Munich, Germany Global circulation: 120,000 We accept no liability for unsolicited manuscripts or photographs. Court of Jurisdiction: Munich 3M ESPE AG, Seefeld, ADA Las Vegas Swedental Gothenburg Dentech China Shanghai th Asian Congress on Oral and Maxillofacial Surgery Hong Kong Expo Dental AMIC Mexico City Greater New York Dental Meeting New York City 3M ESPE AG ESPE Platz, Seefeld, Germany Telephone: +49(0)8152/700-0 Telefax: +49(0)8152/ info3mespe@mmm.com Internet: 3M, ESPE, Aplicap, Espertise, DuoSoft, Filtek, Impregum, Ketac, Lava, Pentamix, Penta, Permadyne, Photac, Position, RelyX and Vitremer are trademarks of 3M or 3M ESPE AG. Aquasil is a trademark of Dentsply, Exafast & Fuji are trademarks of GC, Afinis is a trademark of Coltene, Honigum is a trademark of DMG, Ultrapak is a trademark of Ultradent, Racestyptine is a trademark of Septodent. Vita is a trademark of Vita Zahnfabrik H. Rauter GmbH & Co.KG, Bad Säckingen, Germany. Corangin-Nitro-Spray, Adalat, Inofill Molar and Dyract are not trademarks of 3M or 3M ESPE.

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22 N o 8/2006, January References References: Clinical relevant properties of 3M ESPE Polyethers, flow behaviour (part two) 1 Vaughn V., Kugel G., Perry R., Noonan S. T.: Measuring Flow of elastomeric impression materials using shark-fin device. IADR 1997 #3292. Steel Crowns a well established method of restoring primary teeth Source 1: (Willershausen et al. 2003) Source 2: ( Al-Eheideb, Herman 2003, Randall 2002) 2 Kim M. S., Doherty E. H., Kugel G.: Flow under pressure of four impression materials using shark-fin device. AADR 2001 # Wirz J., Schmidli F.: Moderne Werkstoffe zur Abformung und Bissregistrierung. ZWR 113/4, (2004). 4 Richter B., Kuppermann B., Führer C., Klettke T.: Flow properties of light bodied impression materials during working time. CED/NOF/IADR 2004 # Benchimol J., Perry R., Kugel G., Hallas M.: Flow of eight impression materials with 2mm slit after 25sec. IADR 2005 # Benchimol J., Perry R., Kugel G., Ferreira S.: Flow of impression materials with 2mm slit at end-working-time. IADR 2005 # Benchimol J., Perry R., Kugel G., Hoffmann J.: Impression materials flow with 1mm slit at end-working-time. IADR 2005 # M ESPE internal data.