Editorial. Contents. An Innovative Magazine for Dentists from 3M ESPE MAGAZINE

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1 MAGAZINE November 2003 No. 3 Year 1 An Innovative Magazine for Dentists from 3M ESPE Editorial Dear Readers, Do you know the most frequently asked question by dentists when meeting a Sales Rep in their office? For sure this is one of the favourites: What is new? Year after year a lot of new products are entering the dental market, but not all of them are bringing progress to dentistry. The demand for innovations expressed by our costumers is a challenge to make dentistry more comfortable for dentists and their teams as well as for the patients. Innovation for us means simplifying treatment processes, to make the handling of products easier, faster and safer by reducing the possibility for mistakes and to discover new technologies opening new paths for diagnosis and treatment. On the way to success basic scientific research for us is as important as being close to our customer s needs. In this magazine you will find the results of a Pan- European super study, where more than 400 dentists in 9 countries evaluated the new nano-composite 3M ESPE Filtek Supreme, a selection of international scientific studies presented at the annual meeting of the International Association of Dental Researchers (IADR) this year in Gothenburg, Sweden and clinical results of practitioners. In addition we offer some basic product and technology information in this third edition of our Espertise Magazine, which is the last one in Continuing the story of success: Espertise Magazine has achieved a high level of acceptance and is available in multiple languages all over the world. We have received a lot of positive feedback from you, our readers which encourages us to proceed in Enjoy reading! Gerhard Kultermann, Editor 3M ESPE, Seefeld, Germany Contents Editorial & Contents 1 Position Penta VPS Preliminary Impression Material 2 and Position Tray Directed Flow Impression Tray: Who Knows a More Impressive System? Lava All Ceramic System: 4 Zirconium Oxide Ceramic for Beautiful Crowns and Bridges Filtek Supreme Universal Composite: 6 Pan-European Super Study Results Adper Prompt L-Pop Self-Etch Adhesive: 8 International Studies Indicate Improved Performance RelyX Unicem Self-Adhesive Universal Resin Cement: 10 Easy to Choose Easy to Use: A Universal Luting Technique Comparative Clinical Study with Filtek Supreme 12 Replacing a Porcelain Laminate with a 14 Direct Composite Veneer Dental Practice Forum: 15 Creating a Sense of Well-Being General Information 16

2 Product Information Position Penta Vinyl Polysiloxane Preliminary Impression Material and Position Tray Directed Flow Impress Who Knows a More Impressive System? Laslo Faith; 3M ESPE, Germany For decades, the material used for preliminary impressions has been Alginate. This material, developed in the late 1930s, is so common that no one thinks twice about it, neither about its good nor about its risky properties. Alginates are hydrophilic and easy to remove. However the type of water, mixing ratio and temperature can interfere significantly with the quality of the impression and the setting time. The poor material properties of alginates become even more important after the impression has set. Alginates might lose water by evaporation or might absorb water. Both of these phenomena change the dimensions of the impression. Now, after 70 years of Alginates a new system, including a material, is available in order to keep what is good and help us to forget what was less than perfect: Pentamix 2 Automatic Mixing Unit, Position Penta and the new Position Tray from 3M ESPE. This system comprising of a mixing device, impression material and impression trays, will offer a significant benefit to dentistry. In practical terms users of alginates must expect an impression with the following properties: low tear strength that must be poured immediately that has poor reproduction of surface details that can only be poured once that is unstable in most cold disinfection solutions Automatic mixing, combined with the hydrophilic Position Penta preliminary impression material with long term dimensional stability and the new flow control auto retention trays will not only help to make work faster, safer and more efficient, but also more convenient for the patient, especially for the pediatric patient (3M ESPE application tests and field studies, IADR Abstracts). Automatic mixing avoids all mix ratio issues, mixing time problems and will generate void-free material. VPS materials show an excellent recovery from deformation and long term dimensional stability. Position Penta also shows an easy removal from the mouth and neutral taste. 2

3 MAGAZINE November 2003 No. 3 Year 1 ion Tray Self retention due to non-woven insert Surrounding retention lip Hard strands to avoid tooth - fleece contact The new CAD/CAM-generated singleuse polypropylene Position Trays are a significant innovation in the field of impression trays. The basis for the design were numerous anatomical studies and measurements. Their specific form requires only 3 sizes for upper and lower jaw to allow for an optimal fit Significantly higher compressive strength of Position Penta Position Penta Alginate Internal Data 3M ESPE Compressive strength (as per ISO 1563) Recovery after deformation (as per ISO 1563) Limit >0,35 Limit >95 Reduce formation of flow defects (spoilers change direction of flow) The integrated spoiler controls the flow of materials and guides it into the sulcus area. For greater patient comfort dorsal walls and impression material reservoirs were created, these can hold excess material, to avoid a flow of material into the throat. The auto-retention fleece will keep the material in the tray. The use of tray adhesive is not necessary. So no preparation of trays is needed, and as trays are disposable no cleaning is necessary either. With this approach a high level of hygiene can be maintained. Polypropylene Position Trays can be easily adapted with rotating instruments or cutting. Minimized gagging due to plate A combination of the three above mentioned components of the system are the beginning of a new era in preliminary impressioning. Time saving, easy to use, high hygiene level, patient comfort, a robust process and excellent results are the outcome. 94 Position Penta Alginate Internal Data 3M ESPE Significantly higher recovery of Position Penta. 3

4 User Report Lava Zirconium Oxide Crowns and Bridges Zirconium Oxide Ceramic for Beautiful Crowns and Bridges* Andree Piwowarczyk, Peter Ottl, Timo Kuretzky, Hans-Christoph Lauer, Germany To date, the Lava system has been used in the fabrication of all-ceramic crowns and three- and four-unit bridges in the anterior and posterior regions. Tetragonal, polycrystalline zirconium oxide blanks, partially stabilised with Y 2O 3,are milled in the unsintered state, coloured in seven different framework shades and then sintered using CAD/CAM technology. The Lava frameworks produced in this way offer outstanding mechanical properties and a precise fit. A veneering ceramic specially formulated to suit the frameworks coefficient of thermal expansion offers excellent aesthetics, favourable abrasion behaviour and an ideal surface structure for ensuring inflammation-free apposition of the periodontium. System presentation The system comprises six components, a special scanner (Lava Scan), the design software, a computer-controlled milling machine (Lava Form), in which the zirconia blank (Lava Frame) is machined, a sintering furnace (Lava Therm) and the veneering ceramic (Lava Ceram). Using lightoptical scanning (white light triangulation) of the model situation, the prepared teeth, edentulous alveolar ridge and possibly an occlusal record are digitised (measuring accuracy 20 µm). 4 The restoration is designed taking into account a minimum wall thickness (0.5 mm) and defined connector cross sections (3- or 4-unit bridge: 9 mm 2 or 9/12/9 mm 2 ). A computer-controlled milling machine then produces an enlarged framework structure out of a pre-sintered zirconia blank. This structure compensates for the exactly known shrinkage of the zirconia blank during the subsequent sintering process. A special feature of the Lava system is that it enables the zirconia oxide framework to be coloured in 7 different shades according to the Vita Classic shade system. An opaquer Fig. 1: Framework in seven basic colours layer is therefore no longer required during veneering, which not only saves time but, most importantly, permits superior aesthetics. During sintering, the milled zirconium oxide framework shrinks back to the original size of the prepared tooth and is then veneered with the Lava Ceram ceramic, which is specially designed for use with the Lava base framework. Material characterisation The Lava framework ceramic is based on a tetragonal, polycrystalline zirconium oxide ceramic, partially stabilised with 3 mol-% yttrium oxide (Y-TZP = yttrium tetragonal zirconium polycrystals). Years of experience in surgical orthopaedics have already shown that this ceramic offers a high degree of biocompatibility and longterm stability. Furthermore, it is characterised by high flexural strength, a low modulus of elasticity for a ceramic material, and high fracture toughness. Three- and four-unit veneered Lava bridges demonstrated flexural strengths of 1,458 N and 979 N after masticatory simulation. In another test, Lava was found to possess significantly higher fracture resistance in comparison with other ceramics (IPS Empress II, In- Ceram Aluminia). Lava s fracture toughness was also far higher than that of glass ceramics or infiltrated cera- 0mics because of a physical effect known as transformation reinforcement which prevents crack propagation in the ceramic material. The tensile stress acting at the tip of the crack induces a phase transformation of the zirconium oxide (which is partially stabilised in the tetragonal modification) into the monoclinic phase, this is associated with a volume increase of approx. 3 4% and counteracts crack propagation. At the same time the exactly determined sintering parameters and the high degree of homogeneity of Lava Frame, means that a highprecision fit is achieved (marginal gap (MG): 38 ± 20 µm; absolute marginal discrepancy (AMD): 72 ± 36 µm). Fig. 2: Veneering with Lava Ceram

5 MAGAZINE November 2003 No. 3 Year 1 (Part I) Clinical procedure Fig. 3 shows the initial situation of a patient with insufficient crown margins on the non-vital teeth 12 and 22. With the old restorations, the unaesthetic difference in colour and form compared to the neighbouring teeth was noticeable and not aesthetic. In the case described, where the patient had badly damaged, endodontically treated teeth, the abutments were treated with the aid of a post anchored in the root. To increase aesthetics, a core build-up was carried out on both teeth using a tooth-coloured material (Fig. 4). Fig. 3: Initial state of the two upper lateral incisors with insufficient crown margins and deviations in shape and colour in comparison to the neighbouring teeth In the case of the Lava system, the preparation guidelines for fabricating aesthetically pleasing crowns and bridges apply. For modelling the preparation margin, two types of preparation can be used, the shoulder with rounded interior line angle and the chamfer. Axially a reduction of mm, is sufficient, while incisally and occlusally mm should be removed in order to meet the aesthetic and functional requirements. Sharp edges and corners must be avoided during cutting of the preparation for measurement reasons. Fig. 4: Insertion of all-ceramic post abutments and chamfering the former preparation margin Impression taking and determination of jaw relation follow the principles familiar from crown and bridge prosthetics. When taking the impression, exact reproduction of the preparation surface and margins, as well as a zone of the unprepared hard tooth substance located towards apical (emergence profile), serves to ensure precise formation of the Lava ceramic framework. Fig. 5: Checking the accuracy of fit in the patient s mouth Fig. 6: After cementation of the Lava crowns on teeth 12 and 22 with a dual-curing composite (Compolute ) The clinical trial insertion for checking the substructure s accuracy of fit (Fig. 5) was followed by permanent cementation of the veneered crowns 12 and 22, after pretreatment of the internal surfaces of the framework with the Rocatec system and silanisation, with a dual-curing composite (Fig. 6). The all-ceramic restoration enabled significantly improved aesthetics compared to the original situation. Discussion and conclusions Using CAD/CAM technology, the Lava system enables customised crowns and bridges to be fabricated from densely sintered zirconium oxide. Processing in a soft, pre-sintered state means, on the one hand, a short machining time and minimal wear to the milling tools. On the other hand, the zirconia ceramic, doped with 3 mol-% yttrium oxide is far superior to other hard-core ceramics in terms of mechanical properties and long-term load resistance. The high strength of Lava zirconia ceramic permits the fabrication of substructures with an average coping thickness of 0.5 mm and therefore minimally invasive preparation. At the same time, the frameworks offer the advantage of clinically excellent marginal integrity. The monophase ceramic used for veneering (Lava Ceram) reinforces the aesthetic advantage of the coloured frameworks and has a high degree of homogeneity and surface quality, in addition to excellent properties such as opalescence and translucence. Article will be contiued in Espertise Magazine No. 4 (March 2004) * Abridged reprint with kind authorization by Quintessenz Verlag. 5

6 Product Information Filtek Supreme Universal Composite Pan-European Super Study Results: Over 400 Dentists Evalu Roland Richter; 3M ESPE, Germany A new innovation in dental filler technology, offering great handling, strength and aesthetics, has made its mark amongst dental experts. Between September 2002 and March 2003, Filtek Supreme, the nano-composite from 3M ESPE, was tested in approx restorations by dentists in 9 countries across Europe (Denmark, France, Finland, Germany, Italy, Norway, Sweden, Switzerland, Great Britain). The results of this survey have now been analysed. Over 90% of the dentists who took part in the survey stated that they wished to continue using Filtek Supreme in the future. Filtek Supreme's universal characteristics which combine the aesthetics of microfiller composites with the strength of hybrid composites result from a combination of nanoparticles between 20 and 75 nm in size (insert picture of nanoparticles from folder here) and nanoclusters. Nanoparticles The analysis of the survey, based on over 400 returned questionnaires, shows that dentists both recognise and highly rate the advantages offered by this product. Filtek Supreme was regarded as offering an improvement in handling compared with previously used materials: 66% of dentists rated the "overall handling" as favourable compared with previously used composites Number of Restorations with Filtek Supreme Class I Class II Class III Class IV Class V Decidious teeth Internal Data 3M ESPE The fact that with Filtek Supreme a high quality polish can be achieved effortlessly was seen as particularly positive: 68% of Filtek Supreme users considered this to be a clear advantage over other common composites. Over 60% of respondents were impressed by the product's modelling properties and reduced stickiness on instruments. Superior aesthetics, universal use Due to the simple shading process including exact shade preselection using a shade selection wheel as well as coordination with various opacities 95% of all respondents, judged Filtek Supreme better or at least as good, in terms of overall aesthetics, as filling composites used previously. Thanks to nanotechnology, Filtek Supreme is able to combine these aesthetic benefits with excellent mechanical properties such as abrasion resistance and flexural strength a combination which allows this product to be used in all anterior and posterior Nanocluster 3M ESPE Ideal combination of stability and surface aesthetics: At sizes of 20 to 75 nm the nanoparticles contained in Filtek Supreme offer a filler load of 78.5%* and thus excellent mechanical properties. So-called nanoclusters designed out of individual nanoparticles provide long-lasting gloss. * Dentine, body and enamel shades 6 Intermediate characterization before final layer of composite. Courtesy of Paul Magne, Switzerland

7 MAGAZINE November 2003 No. 3 Year 1 ated New Nano-Composite restorations. The survey also showed that in dental practices Filtek Supreme was used with almost uniform regularity in all 5 of Black's cavity classes. First-class, simple handling In the view of the evaluators, this new material has not only all the properties of a first-class product, but is also an "all-rounder". 78% of the respondents, expressed the wish to use Filtek Supreme as a universal composite in the future. Moreover, when combined with a self-etching adhesive, for example 3M ESPE Adper Prompt L-Pop (the most commonly used adhesive in the survey), the work process is made easier and thus more cost-effective. Self etch systems preferred in general practice 83% of participants said they would use Filtek Supreme together with a self-etching adhesive in the future. The results of the survey show that self-etching adhesives are being met with increasing acceptance throughout Europe. For many years, 3M ESPE has been closely following the trend for ever simpler, but nevertheless high-quality adhesives. A separate etching procedure is no longer necessary with Adper Prompt L-Pop etching, priming and bonding occur in a single step. Numerous studies have demonstrated this product's excellent adhesion to enamel and dentine New indications for Adper Prompt L-Pop The latest results from clinical studies at the University of Michigan (Dr. Feigal) provide confirmation of Prompt L-Pop's outstanding suitability as an adhesive for sealing fissures. The studies also showed that comparable results were achieved when using Prompt L-Pop as when using traditional methods with phosphoric acid etching. Furthermore, when using Prompt L-Pop the necessary working time is reduced by approximately one third. On the basis of these results, the additional indication "Adhesive for fissure sealing" will therefore be included in Adper Prompt L-Pop's instructions for use. Stickiness Shaping Overall handling Polishability Aesthetics 0 Better Equal Worse Internal Data 3M ESPE 7

8 Product Information Adper Prompt L-Pop Self-Etch Adhesive International Studies Indicate Improved Performance Andreas Syrek, Roland Richter; 3M ESPE, Germany In the last few years the field of restorative materials has been characterized by a multitude of different product developments. 3M ESPE research mainly focuses on new developments in adhesive technology, innovations in the field of nanocomposites and light polymerisation technology as well as on the systematic enhancement of modern glass ionomers. Particular emphasis has been placed on Adper Prompt L-Pop. This self-etch adhesive continues the trend of recent years towards simpler handling that still offers reliable adhesion. The following is a summary of abstracts presented at the 81 st General Session & Exhibition of the 2003 meeting of the International Association for Dental Research (IADR) in Gothenburg dealing with scientific results of the recently introduced self-etch adhesive Adper Prompt L-Pop from 3M ESPE. One of the biggest challenges for selfetching primers is to create an etching pattern on unground enamel. Therefore, it was the objective of a study from Tay et al. [1] to investigate the ultrastructure of resin-enamel bonds in unground enamel-occlusal fissures. The researchers used Scanning Electron Microscopy (SEM) for the evaluation of the enamel ultrastructure, field-emission environmental SEM for evaluation of the bond integrity and Transmission Electron Microscopy (TEM) for evaluation of resin penetration. The microscopic methodologies revealed that Adper Prompt L-Pop creates an etching pattern in aprismatic enamel comparable to phosphoric acid etching. It penetrates occlusal fissures even better than phosphoric acid and produces more uniform etching and hybridisation of fissure walls. Clinically this means that Adper Prompt L-Pop s superior ability to penetrate even into narrow fissures results in an excellent sealing of the fissures while saving application time compared to phosphoric acid etching. While Tay was looking at the enamel interface the dentin interface was investigated by means of field emission SEM in a study from Maseki et al. [2]. The researchers found that Adper Prompt L-Pop adhesive resulted in a much thicker hybrid layer compared to One-Up Bond F (Tokuyama), OptiBond Solo Self Etch (Kerr) and Clearfil SE (Kuraray). Adper Prompt L-Pop effectively permeated the decalcified dentin. This permeation contributes to the dentin adhesion. Thus the results indicate that Adper Prompt L-Pop shows good adhesion to dentin. 2,5 2 1,5 1 0,5 0 To test the dentin adhesion directly, Mazur et al. [3] performed a microtensile bond strength test on various adhesive systems. Here Adper Prompt L-Pop and One-Up Bond resulted in the highest microtensile bond strength. Clinically this means a good marginal seal, that reduces the risk of bacteria and stain penetration, and a high retention rate of the restorations bonded with Adper Prompt L-Pop Adper Prompt Mazeki One-Up Bond One-Up Bond F Adper Prompt L-Pop Optibond Clearfil SE Solo Plus SE Thickness of the Hybrid Layer in µm Mazur Clearfil SE Scotchbond 1 P&B NT Microtensile Bond Strength in MPa The bonding interface to sound and even caries affected root dentin was investigated by Kaneko et al [4]. For Adper Prompt L-Pop they found gapfree adhesion with structural continuity to both sound and caries affected root dentin. Even long storage times in water did not affect the stability of this adhesion. Thus it can be concluded that also in the oral environment, where the bonding interface is 8

9 MAGAZINE November 2003 No. 3 Year 1 exposed to fluids such as liquor in the dentin tubules or saliva at the restoration margins, Adper Prompt L-Pop exhibits long-term adhesion stability even on caries affected dentin Adper Prompt L- Pop one coat Adper Prompt L- Pop two coat Apply adhesive to the entire surface of the cavity, rubbing in the solution with moderate finger pressure for 15 sec. Do not shorten this time. Proper bonding will not occur if the solution is simply applied and dispersed. Use a gentle stream of air to thoroughly dry the adhesive to a thin film. Apply a second coat of adhesive. This coat does not need to be massaged in to the surface. Again, use a gentle stream of air to thoroughly dry the adhesive to a thin film. Light cure for ten seconds (3 second exposure with a plasma arc lamp). Nara Tensile Bond Strength on Sound Dentin [MPa] Adper Prompt L-Pop Scotchbond 1 Nara Tensile Bond Strength on Abraded Dentin [MPa] While all these studies indicate very good performance of Adper Prompt L-Pop adhesive already, Nara et al. [5] were able to further improve the adhesion by applying a second coat. In a tensile bond strength test on sound dentin the bond strength improved from 19.5 MPa after one coat application to 28,4 MPa after two-coat application. On abraded dentin Adper Prompt L-Pop with the 2-coat-technique achieved a bond strength that Two-step techique increases bond strength reached those of Adper Scotchbond 1. This indicates a high retention in cervical areas of a tooth (Class V), where abraded dentin often occurs. Jacobsen at al. [6] tested the operator variability and complexity of dentin bonding agents. Seven dentists evaluated three different bonding systems. The researchers measured the maximum gap width in dentin cavities by means of confocal microscopy. Adper Prompt L-Pop showed the lowest operator variability, while the relative gap-width for the three bonding systems was not statistically different. The low operator variability of Adper Prompt L-Pop is a result of the optimised chemistry, and is mainly attributed to the addition of BIS-GMA and a proprietary polyalkenoic copolymer. Summary: In the hierarchy of scientific test methods, micro morphology investigations, adhesion tests and marginal adaptation studies have the most impact when evaluating new adhesive systems. In all three research fields Adper Prompt L-Pop showed excellent performance. As many dentists already know, the performance of Adper Prompt L-Pop can be optimised with the application of a second coat. It does add a few seconds to the total application time, but dentists who adopt this technique will appreciate the increased bond strength and consistency. References: A complete list of references is available through your local 3M ESPE Dental Products office. 9

10 User Report RelyX Unicem Self-Adhesive Universal Resin Cement Easy to Choose Easy to Use: A Universal Luting Technology Al Waning; 3M ESPE, The Netherlands Indirect restorations made out of gold offer excellent long term clinical results. For a long time these restorations have been referred to as the gold standard in indirect dentistry. The restoration fit can be very good, and in addition restoration margins can often be burnished to further improve the marginal adaptation. When placed properly there is very little functional stress on the cement used to lute these restorations in place and as a result even traditional cements with low mechanical and physical properties, can function well. Gold restoration conventionally cemented. Courtesy of T. Donovan, USA 10 However, today very few people are willing to have these full metal restorations. Porcelain-fused-tometal restorations offer improved aesthetics, but also require more tooth tissue removed to function properly. Once these restorations have been produced in the dental laboratory, there is little the dentists can do to improve marginal adaptation because of the inherent rigidity of the materials used. Consequently, there is more functional stress on the cement used to lute these restorations, and the cements need better mechanical and physical properties than those used for pure gold restorations. The dentine bonded all-ceramic crown offers an interesting alternative to porcelain-fused-to-metal. Not only does this type of crown require less removal of healthy tooth tissue and offers a lower risk of pulp damage, the esthetics can be far superior. Excellent esthetics of all-ceramic crowns. Courtesy of M. Fradeani, Italy As a disadvantage it could be mentioned that there is overwhelming scientific evidence that adhesive luting with sometimes complicated bonding systems is necessary to produce state-of-the-art clinical longevity. The complexity of these bonding systems could be a compelling reason for the success or failure of these dentine bonded crowns. It could be argued that simplifying this bonding technique could help to make these tooth-tissue saving all-ceramic restorations as popular as they deserve to be. Self-adhesive resin cement Market research showed that the ideal luting cement for metal and ceramic restorations should be dual curing to ensure proper setting, should offer good and long term retention of the restoration, cause little or no postoperative sensitivity, should ideally need no special pre-treatment of the tooth surfaces, should be as insensitive as possible to humidity and lastly excess material should be easily removable. Easy removal of excess RelyX Unicem. Courtesy of Gunnar Reich, Germany Because of the scientific proof available it was clear that for state of the art longevity with ceramic restorations this material needed to be resin based, but how to address the other issues? Self etching adhesives would be a solution, but today they do not work well with dual curing systems and they would still create a separate pre-treatment step. By combining and ingeniously altering components from composites, compomers, resin modified glass ionomers and true glass ionomers, the developers at the 3M ESPE laboratories created RelyX Unicem, the first truly self adhesive universal resin cement which represents a new class of cements.

11 MAGAZINE November 2003 No. 3 Year 1 Working Steps Adhesive Adhesive Cementation Cementation with a conventional with RelyX Unicem Total-etch Composite-Cement The material s main setting mechanism is a polymerization reaction, but secondary acid-base reactions create the adhesion to the tooth tissues and the restoration and neutralize the acidity. The material is hydrophilic upon placement with easy adaptation to the tooth, but after setting it switches to a strongly hydrophobic matrix which ensures the functional longevity. A lot of data is generated to demonstrate that the product is as strong as other resin based systems, with the ease of use of traditional luting cements. While offering similar physical properties and bond strength as resin cements the necessary working steps are greatly reduced, thus saving valuable time and reducing sources of errors. Fig. 4 shows the many steps necessary to bond a ceramic restoration with a typical dental bonding system in the total etch procedure. It is obvious why the use of resin cements is considered technique-sensitive. With RelyX Unicem the procedure is significantly simplified. Throughout the world more than one million restorations have been placed with RelyX Unicem within the first year of the availability of the product, a very good indicator of its success. RelyX Unicem is indicated for inlays and onlays, crowns, bridges and posts from metal, ceramic, composite and fibre. Tooth stump freed from the provisional restoration and cleaned Etch with a phosphoric acid etching gel Thoroughly rinse with water Gently dry with oilfree and anhydrous air. Do not overdry Apply primer with a disposable applicator and rub in thoroughly Dry primer in a light air stream. Avoid dircet blowing, as excess may coagulate Apply bond with a disposable applicator and rub in thoroughly Thinly blow out the bond evenly in a light air stream. Avoid coagulation of the bond Mix cement and apply in the restoration and/or cavity. Place the restoration on the stump N/A N/A N/A N/A N/A N/A N/A Remove excess. Fig. 3: RelyX Unicem Self-Adhesive Universal Resin Cement in combination with the Rotomix Rotating Capsule Mixing Device from 3M ESPE. Light cure. Optional Fig. 4: Total etch procedure by Dr. Norbert Krämer, University of Erlangen, Germany 1999 RelyX Unicem case by Dr. Helga Schaffner, University of Mainz, Germany, 2002 Final situation: Adhesively cemented ceramic crown after final polishing 11

12 Clinical Results Filtek Supreme Universal Composite: Study outline, baseline data and 6-month follow-up data Comparative Clinical Study on a Nanofiller Composite versus a Conventional Microparticle Hybrid Composite Claus-Peter Ernst and Brita Willershausen; Germany In the summer of 2002, 3M ESPE launched the first representative of a new class of polymer-based dental materials, the nanofiller composite Filtek Supreme. Filtek Supreme uses extremely small (5-20 nm diameter) filler particles. Thanks to the combination of nanoclusters with free, nonagglomerated nanofillers (nanoparticles), Filtek Supreme exhibits a filler load of % by weight. This is similar to that for conventional hybrid composites. First scientific tests indicate that this material is likely to combine the advantages of microfiller composites (polishability, elasticity) with those of a hybrid composite (mechanical stability). In order to obtain objective data, we designed a clinical study comparing the new nanofiller composite Filtek Supreme with the established fine-particle hybrid composite Tetric Ceram from Ivoclar Vivadent in a split-mouth design. Material and Methods 50 patients (age 35.7 ± 11.3 years) received at least two Class II posterior fillings by one of eight experienced dental clinicians from the Dental Clinic at Johannes-Gutenberg University, Mainz, Germany. No material-specific exclusion criteria with regard to filling size were defined. Filled teeth included 2- to 3- cusped premolars and 2- to 4- cusped molars: For all cavities, 3M ESPE Adper Scotchbond 1 Dental Adhesive System was used as the dental adhesive. Use of a rubberdam was mandatory for all fillings. Fillings were built up using an incremental technique, i.e. polymerisation layer by layer as indicated in the instructions for use and finished using a fine-grained diamond or hard-metal instruments. Restorations were polished with 3M ESPE Sof-Lex discs and Sof-Lex brushes as well as with Sof-Lex finishing strips on the approximal surfaces. Fig. 1 illustrates the procedure for pairwise restorations in patients. After placement of each filling, its quality was assessed in accordance with the Ryge and CDA criteria 1. Fig. 1: Filling procedure for the split-mouth study design: Two comparable cavities per patient are restored with the same adhesive, but different restorative materials. (ooth 14 with Filtek Supreme (upper) and tooth 24 with Tetric Ceram (below). (Indirect photography with dental mirror) 12

13 MAGAZINE November 2003 No. 3 Year 1 These scores rate overall clinical functional performance of the filling rather than highlighting single aspects such as the percentage of marginal gaps (as would be evaluated e.g. by quantitative-qualitative scanning electron microscopy analysis of preparation margins). These criteria help decide whether a filling can be regarded as clinically acceptable or not. The group of acceptable results is subdivided into very good results ("Alpha") and clinically acceptable results ("Bravo"). The latter show minor deviations from ideal filling characteristics, but clinical quality is not compromised. Special criteria such as colour match are reflected by the term "Oscar". Fillings rated "Oscar" can be regarded as clinically invisible. The group of non-acceptable fillings is subdivided into a group mandating preventive exchange of the filling ("Charlie") and those fillings requiring immediate intervention ("Delta"). Surface texture was rated using the extended CDA criteria. Further criteria such as "Tooth integrity", "Clinical symptoms", and "Quality of approximal contact" (see also: Pelka, M., Dettenhofer, G., Reinelt, C., Krämer, N., Petschelt, A.: Dtsch Zahnärzt. Z 49: (1994)) were also included in the analysis to improve the overall assessment of restoration quality. Fig. 2: Follow-up of the Filtek Supreme restoration of tooth 14: maximum scores were obtained for all study criteria. Results After 6 months, 102 of the 112 fillings (56 Filtek Supreme and 56 Tetric Ceram) were recalled for follow-up examination. This corresponds to a follow-up rate of 91.1%. Fig. 2 and 3 show the 6-month-status of the premolar restorations from Fig. 1. The two fillings shown obtained maximum scores for all criteria. The table summarizes the clinical study results at 6 months comparing Filtek Supreme and Tetric Ceram. 1) (Ryge, G:. Int Dent J 30: (1980), Ryge, G., Snyder, M.: J Am Dent Ass 87: (1973), California Dental Association: Quality evaluation for dental care. Guidelines for the assessment of clinical quality and professional performance, CDA, Los Angeles, 1977) Fig. 3: Follow-up of the Tetric Ceram restoration of tooth 24. Conclusions: According to these preliminary results of an ongoing clinical study, the new filling material Filtek Supreme appears to be a versatile, aesthetically compatible, and easy to handle restorative material which, to date, matches the clinical performance of Tetric Ceram. However before issuing a general recommendation regarding the clinical suitability of this restorative material longer-term results (i.e. 2-years) of clinical studies such as the one described should be obtained. Marginal Anatomic shape Secondary Marginal Approximal contact Shade match adaptation caries discoloration Filling Material FS TC FS TC FS TC FS TC FS TC FS TC O 85,71 85,71 Baseline A , ,64 96,43 A 14,29 14,29 [%] B ,79 0 5,36 3,57 B 0 0 C C 0 0 D D 0 0 O 43,14 62,75 6 Month recall A , , ,08 98,04 88,24 88,24 A 50,98 33,33 [%] B 0 1,96 0 1, ,92 1,96 11,76 11,76 B 1,96 3,92 C C 3,92 0 D D 0 0 Claus-Peter Ernst/Brita Willershausen Table: The table summarizes clinical results at 6-month follow-up for Filtek Supreme and Tetric Ceram restorations compared to the baseline data (assessment using Ryge and CDA criteria). 13

14 Clinical Case Report Filtek Supreme Universal Restorative A Clinical Case Report Replacing a Porcelain Laminate with a Direct Composite Veneer Joseph Charpentier; Belgium The aesthetic restoration of an upper central incisor using composite is very difficult because the features of the homologous tooth have to be reproduced exactly. Background In this clinical case, a porcelain laminate, placed on the 21, fifteen years ago, had yellowed due to the colour change of the luting composite. The patient required a quick solution, so it was decided to place a Filtek Supreme direct veneer. Filtek Supreme combines good mechanical properties with polishability. It offers a large number of shades in four levels of translucency (Dentine, Body, Enamel, Tranlucent), giving many possibilities for stratification techniques. Pre-operative situation Before beginning, a careful analysis of the features of the 21 (compared to the 11) was carried out according to the Pascal Magne criteria* (Fig. 1). Criteria according to the recommendations from Pascal Magne 1. Dimension: the 21 appears a little oversized chiefly in thickness. 2. Tooth form: the outline and transition angles are relatively correct. 3. Tooth characterization: this is the distribution of the different shade and translucency areas. The Vita Lumin Vacuum shade guide was used but placing small amounts of composite directly on the reference tooth and a precise drawing were very helpful. 4. Surface texture: in this case, very smooth and regular. * Magne P., Belser U. : Bonded porcelain Restorations in the anterior dentition. A biomimetic approach. Berlin Quintessence Fig. 1: pre-operative situation of 21 Fig. 2: tooth preparation Fig. 3: masking agent and first increment Preparation After removal of the old restoration, the tooth was prepared with cervical and proximal chamfer (Fig. 2). Application of the composite No rubber dam was placed in order to allow easy access to the cervical margins. A mylar matrix prevented the composite from sticking to the adjacent teeth. After etching and bonding with Scotchbond 1 Dental Adhesive System, a thin layer of 3M ESPE Masking Agent (shade W) was placed. This was necessary to mask the dark colour of the tooth. A cervical incre- Fig. 4: second increment Fig. 5: third increment Fig. 6: after polishing ment (Body C2) was placed, beveled in its incisal part and then polymerized (Fig.3). It was partly covered with the second increment (Body B1) which was itself beveled and delimited according to the junction line between the opaque and translucent areas of the tooth (Fig. 5). Finally Translucent Grey was placed (Fig. 6). This particular shade of composite was stickier and therefore more difficult to model into a precise shape. Finishing and polishing were obtained with a diamond bur and a Sof-Lex finishing Brush, which gives good results when the surface texture has to be preserved (Fig. 6).

15 Dental Practice Forum MAGAZINE November 2003 No. 3 Year 1 Effects of Architecture, Colours and Furniture on Emotions Creating a sense of well-being Inge Händel, Architect and Color Consultant; Germany A sense of well-being depends on the complex interplay of a whole variety of objective and subjective criteria. We all know what it s like to feel well - but how do we create a feeling of well-being for ourselves and others? Ninety per cent of professional decisions are made on an emotional level, influenced by what are known as soft factors. The soul senses and seeks a sense of well-being. The atmosphere in your surgery is an important factor in deciding whether patients return, and is a subtle reflection of your corporate culture, which in turn affects the working atmosphere. Establish target group First of all, you should be clear about whether the atmosphere in your surgery should cater primarily to those providing the service or to the patients. Do you wish to shape the surroundings in accordance with your personal taste, or is it more important to you to attract a certain target group? Are you committed to a certain patient group, possibly for historical reasons in view of your location? How do you successfully address your target group? Naturally, the lifestyles and manners which appeal to senior citizens with private health insurance are different from those which appeal to young ravers. What role do families and children play? What target-groupspecific objective factors are involved in the design? E.g., would an aquarium enrich your waiting room? Or might a counter concealing the switch cupboard improve the visual impression your patients have? The spirit of a location If you really want to take the design issue seriously, start with a bio-ecological assessment of your premises, checking geopathic stress levels, material properties and vapors, electrosmog levels etc. What factors are open to change? What can be ignored? Are the sun s angle and daylight being used to their full advantage? How do you deal with extreme temperatures in the summer and the winter? What about humidity? Could rearranging the rooms possibly bring about a serious improvement? Heat and ventilation The heating system and the type of heat are extremely important for a subjective feeling of well-being. Is static electricity a problem? What materials have been used in constructing the building? What about the fresh air supply? Fragrances alone cannot compensate stale air which causes tiredness. How are the rooms proportioned? Where are the windows and doors? Is there a draught? Feng shui and other professional advice If you would like advice and tips, you can use feng shui, an ancient Chinese science dating back thousands of years. It is back in fashion, often confirms our own subjective feeling, and relates to life and the flow of life energy in gardens and rooms. You can find your local feng shui consultant in the telephone book, the yellow pages or on the Web. Or you could request information from anthroposophists who have their own guidelines on how to fit out surgeries. There are, of course, other professionals offer competent advice, e.g. architects, color consultants and lighting consultants. Ideas on how to promote well-being in your surgery Give the impression of entering a different world. The experience of waiting should be like being on a quiet island away from the hectic pace of everyday life. A view to the outside and daylight have a liberating effect. Bright, clean rooms with fresh blue tones have a liberating and restful effect. They are warmed up by complementary yellow or wooden tones. Depending on finances, materials such as wood and natural stone can create fine nuances. Last but not least: Well-groomed assistants and a friendly manner go without saying. We would like to thank Drs. Wolfgang Bolz, Markus Huerzeler, Wolf Richter, Hannes Wachtel and Otto Zuhr in Munich, who kindly provided us with photos of their surgery. The architect was Andreas Notter, Munich. 15

16 General Information MAGAZINE The International All Ceramic Symposium in Stresa, Italy The international all ceramic symposium, covering the state of the art in all ceramics for prosthetic dentistry took place in Stresa, Italy, from September 21st to 23rd with participants from 13 different countries. A detailed report will be published in the next issue. Calendar of Events October 2003 to March 2004 BDTA International Dental Showcase, November 20 22, 2003 Birmingham, ADF, Paris November 26 29, GNYDM, New York November 30 December 03, Adhesive Dentistry Today, Arnheim December 05-07, 2003 CIOPS Sao Paulo Dental Meeting APCD January 24 29, Arab-Lab & Instrumentation, Dubai February 09-12, 2004 Chicago Midwinter Meeting, Chicago February 20-22, AEEDC, Dubai March 02 04, Krakdent, Kraków March, 04 06, 2004 IADR/AADR General Session, Honolulu March 10 13, Expodental, Madrid March 11 13, Saldent, Poznan March 18-20, 2004 SCANDEFA, Copenhagen March 25 27, EAED/IFED Joint Meeting, Venice May 27 29, M ESPE AG ESPE Platz, Seefeld Telephone: +49 (0) / Telefax: +49 (0) / info3mespe@mmm.com Internet: 3M, ESPE, Adper, Compolute, Espertise, Filtek, L-Pop, Penta, Pentamix, Position, Prompt, Scotchbond, Sof-Lex are trademarks of 3M or 3M ESPE. Tetric Ceram is a trademark of Ivoclar-Vivadent, One-Up Bond F is a trademark of Tokuyama, OptiBond Solo Self Etch is a trademark of Kerr and Clearfil SE is a trademark of Kuraray. All rights reserved. 3M ESPE EDITORIAL INFORMATIONS Published by: 3M ESPE AG ESPE Platz Seefeld Germany Telephone: +49 (0) 8152 / Telefax: +49 (0) 8152 / info3mespe@mmm.com Internet: Editor: Gerhard Kultermann Editorial team: Keith R. Haig, Dieter Klasmeier, Roland Richter, Markus Roepke, Laurence Settekorn, Al Waning Coordination: Laurence Settekorn Final editing and production: Markus Roepke Global circulation: We accept no liability for unsolicited manuscripts or photographs. Court of Jurisdiction: Munich 3M ESPE AG, Seefeld, 2003

17 List of References MAGAZINE International Studies Idicate Improved Performance References: 1. F.R. Tay, S.H.Y. Wei, D.H. Pashley, R.M. Carvalho. Ultrastructure of Resin-Enamel Bonds in Unground Enamel-Occlusal Fissures. IADR 2003, abstract T. Maseki, A. Shirota, T. Kimishima, Y. Nara, L. Dogon. Scanning Electron Microscopy (SEM) Observation of the Resin-Dentin Interface formed by various Self- Etching Priming Adhesive Systems. IADR2003, abstract R.F: Mazur, E.M. Souza, S. Vieira, S. Ignacio, J.R. Saad. Microtensile Bond Strength of Five Different Adhesive Systems. IADR2003, abstract T. Kaneko, S. Imazato, A.V. Kaneshiro, Y. Takahashi, S. Ebisu. SEM Observation of Bonding Interface of One-Step Adhesive Systems to Root Dentin. IADR2003, abstract Y. Nara, Y. Nagakura, Y. Ito, T. Susuki, I. Kizuki, T. Kimishima, T. Maseki, L. Dogon. Tensile Bond Strength of All-in-one Self-etch Adhesive Systems to Cervical Abrasion Lesion Dentin. IADR2003, abstract T Jacobsen, K.J. Söderholm, T.F. Watson. Operator Variability and Complexity of Dentin Bonding Agents. IADR2003, abstract M ESPE AG ESPE Platz, Seefeld Telephone: +49 (0) / Telefax: +49 (0) / info3mespe@mmm.com Internet: