The Role of Modern Composites and Ceramics in Clinical Practice

Transcription

1 Course Numer: 138 The Role of Modern Composites nd Cermics in Clinicl Prctice Authored y Ronld D. Jckson, DDS Upon successful completion of this CE ctivity 2 CE credit hours my e wrded A Peer-Reviewed CE Activity y Dentistry Tody, Inc, is n ADA CERP Recognized Provider. ADA CERP is service of the Americn Dentl Assocition to ssist dentl professionls in indentifying qulity providers of continuing dentl eduction. ADA CERP does not pprove or endorse individul courses or instructors, nor does it imply cceptnce of credit hours y ords of dentistry. Concerns or complints out CE provider my e directed to the provider or to ADA CERP t d.org/goto/cerp. Approved PACE Progrm Provider FAGD/MAGD Credit Approvl does not imply cceptnce y stte or provincil ord of dentistry or AGD endorsement. June 1, 2009 to My 31, 2012 AGD Pce pprovl numer: Opinions expressed y CE uthors re their own nd my not reflect those of Dentistry Tody. Mention of specific product nmes does not infer endorsement y Dentistry Tody. Informtion contined in CE rticles nd courses is not sustitute for sound clinicl judgment nd ccepted stndrds of cre. Prticipnts re urged to contct their stte dentl ords for continuing eduction requirements.

2 Recommendtions for Fluoride Vrnish Use in Cries Mngement The Role of Modern Composites nd Cermics in Clinicl Prctice Effective Dte: 06/1/2011 Expirtion Dte: 06/1/2013 LEARNING OBJECTIVES After reding this rticle, the individul will lern: The types of composite nd cermic restortive mterils currently ville for posterior nd nterior esthetic dentistry. Clinicl pplictions of currently ville composite nd cermic restortive mterils. ABOUT THE AUTHOR Dr. Jckson prctices comprehensive restortive nd cosmetic dentistry in Middleurg, V. He is 1972 grdute of West Virgini University School of Dentistry. He is n ccredited Fellow in the Americn Acdemy of Cosmetic Dentistry, Fellow in the AGD, Diplomte in the Americn Bord of Aesthetic Dentistry, nd is director of the Mstering Dynmic Adhesion nd Composite Artistry progrms t the Ls Vegs Institute for Advnced Dentl Studies. He hs pulished mny rticles on esthetic, dhesive dentistry nd hs lectured extensively cross the United Sttes nd rod. Dr. Jckson hs presented t ll the mjor US scientific conferences s well s to Esthetic Acdemies in Europe, Asi, nd South Americ. He cn e reched vi e-mil t [email protected]. Disclosure: Dr. Jckson discloses tht he cted s consultnt in the development of Esthet X (DENTSPLY Culk), 4 Sesons (Ivoclr Vivdent), nd SonicFill (Kerr) ut only retins finncil interest in SonicFill. INTRODUCTION A key role modern composites nd cermics ply in current clinicl prctice is the ility to restore teeth to their nturl ppernce or, in situtions where the teeth lck n ttrctive ppernce, to enhnce it. Although detle, this uthor ritrrily reks down these 2 types of dentl services s esthetic dentistry nd cosmetic dentistry, where esthetic dentistry is defined s needed dentistry tht restores ppernce s well s helth nd function, nd cosmetic dentistry is defined s eing entirely elective nd is done strictly to improve ppernce. This rticle reviews the types of composite nd cermic restortive mterils currently ville for use in posterior nd nterior esthetic dentistry, nd their clinicl pplictions. Clinicl photogrphs re included to demonstrte importnt concepts nd techniques s discussed in the text. POSTERIOR AESTHETIC DENTISTRY Direct Composite Restortion Composite resin formultions hve improved significntly in the lst decde. Wheres mnufcturers continue to djust resin components, the mjor chnge hs een the continul reduction in filler prticle size for hyrid composites down to the nnometer level. New formultions using nnometer prticles hve incresed the polishility, strength, hndling nd overll performnce nd t the sme time, shrinkge hs decresed. Polymeriztion shrinkge nd shrinkge stresses hve lso een reduced to the 2% or less rnge while t the sme time frcture resistnce nd wer resistnce hve incresed. 1,2 Aside from the improvement in mterils, the mjor reson for n incresed use of composite resin is ptients incresing desire for esthetic, nturl looking restortions nd smile enhncements. In ddition, mny ptients tody, perhps ided y the medi, hve the impression tht gold nd mlgm re dentl mterils of the pst. Also, some ptients hve concerns regrding the mercury in mlgm fillings. The result is tht for severl countries, the use of composite resin mterils to restore posterior teeth incresingly exceeds the use of mlgm. 3,4 In fct, mlgm use hs een nned ltogether y certin countries. 5-7 In survey of Americn dentists done y the ADA in 1997, 65% of dentists reported dentl mlgm s their posterior restortive mteril. 8 In nother survey in August 2002, tht numer ws down to 54%, nd most indicted declining trend in their prctice due to ptient preference. 9 Tody, posterior composite restortions re minstrem nd represent the mjority of posterior intrcoronl restortions plced in the United Sttes nd elsewhere. 3,4 Finlly, it is well ccepted y the profession 1

3 The Role of Modern Composites nd Cermics in Clinicl Prctice tht dhesive plcement of composite resin reinforces tooth structure nd llows for more conservtive preprtion, something desired y dentists (do no hrm) s well s ptients The undisputed downside when using composite resin in lieu of mlgm for restoring posterior teeth is the meticulous operting technique required of dentists when plcing composite resin restortions, including the need for excellent isoltion during restortion plcement, the dditionl use of the dhesives, nd the use of specilized mtrices for proximl contct cquisition. Additionlly, the literture offers mixed reviews, lthough most seem to fvor mlgm when compring the longevity of composite resin to mlgm. 1,15-17 Recently, 12-yer comprison of composite resin to mlgm demonstrted excellent longevity for composite resin when compred to mlgm (Figures 1 nd 1). 18 This uthor elieves tht much of the evidence-sed literture regrding durility nd performnce of composite resin over time will improve significntly not only ecuse the mterils themselves hve improved ut lso ecuse the excting criteri for its success is incresingly emphsized nd tught in dentl schools nd postgrdute eduction. In ddition, new products hve recently een introduced (SureFil SDR Flow [DENTSPLY Culk], SonicFill [Kerr]) which clim not only to shorten the plcement time ut, y their nture, crete intimte dpttion to the cvity wlls therey reducing potentil opertor error. Figure 1. Amlgm restortion requiring replcement. Figure 1. The composite resin restortion (Surefil [DENTSPLY Culk] overlyed with Esthet X [DENTSPLY Culk]) in the molr is 10 yers post-op. The composite (Heliomolr [Ivoclr Vivdent]) in the premolr ws refinished nd polished nd is shown t 19 yers post-op. Figure 2. Aesthetic only preprtion for lower first molr. AESTHETIC INLAYS AND ONLAYS With few exceptions, most of the literture dvoctes tht direct composite resin mterils should not e used for cuspl coverge or for lrge restortions exceeding one third the uccolingul width of the tooth. 1,19,20 For lrge cvities, s prcticl mtter, it is more difficult to chieve qulity contcts (size nd loction), proper contours, occlusl ntomy, nd idelly locted functionl stops when using directly plced composite resin. Lrge volumes of light-cured composite resin cn lso pose excessive shrinkge concerns requiring lyering techniques, prticulrly in cvities with high cvity configurtion fctor (C-Fctor) Well fitting, indirectly fricted composite resin, s well s cermic inlys nd onlys, overcome these chllenges nd Figure 2. The cermic only (e.mx [Ivoclr Vivdent]) covers oth mesil cusps. reduce the mount of shrinkge due only to the smll mount of luting (cementing) resin used (Figures 2 nd 2). Additionlly, the reduction of microlekge, prticulrly when gingivl mrgins end on root surfces nd my e sugingivl where isoltion during direct plcement of composites my e compromised, my lso e fctor when choosing n inly/only over direct composite restortion. Although there re studies showing tht these types of indirect restortions demonstrte reduced microlekge in such instnces, not ll investigtions re in greement, nd 2

4 The Role of Modern Composites nd Cermics in Clinicl Prctice complete elimintion of microlekge t dentin mrgins hs not een chieved y ny of the current dhesive sys - tems. 24,25 Aesthetic in lys nd onlys re not new nd hve proven trck record Although mrginl discrepncies hve een reported to e high t 10 yers, prticulrly for cer mic in lys, this ditching does not seem to result in incresed recurrent cries long these mrgins (Fig ures 3 nd 4). 30,34 In ddition, composite res in inlys nd onlys re esily re pirle, thus extending their lon gevity (Figure 5). Undoutedly, the per formnce of these restortions over time is directly relted to the precision of preprtion, impressioning, friction, nd dhesive plcement, which in turn is relted to the cre nd skill exercised y the technicin nd the dentist. More recently, in-office CAD/CAM technologies such s CEREC 3D (Siron) nd E4D (D4D Technologies) hve incresed in populrity. These technologies llow these indirect restortions to e fricted from cermic or processed composite nd plced in single ppointment. Nevertheless, mny teching clinicins feel tht inlys nd onlys, of whtever color, re grossly underutilized restortion nd tht crowns re grossly overutilized restortion. 35,36 In fct, mny recently grduted US dentists hve indicted to the uthor tht they were exposed to these res tortions only in lectures nd hd no hnds-on experience with them. 37 It would indeed e unfortunte (for p tients) if inlys nd onlys, of whtever color, were significntly reduced or lost to dentistry. These re idel res tortions for the modertely roken down tooth the type of sitution where the cvity is too lrge for direct restortion ut cutting the whole tooth down for crown would remove n excessive mount of helthy tooth structure. Edelhoff nd Sorensen 38 found tht crown preprtions remove, on verge, 69% of the coronl tooth structure wheres on lys remove only 39%. In this regrd, esthetic inlys nd onlys my hve the sme restortive vlue s gold, ut with the dditionl enefit of nturl ppernce for ptients who desire it (Figures 6 nd 6). ALL-CERAMIC CROWNS Even though the trck record for ll-cermic crowns is not nerly s long s cst gold or PFM crowns, the movement Figure 3. Indirect composite only (Concept [Ivoclr Vivdent]) t 16 yers. Note: Concept is no longer ville in the mrketplce. Figure 4. Indirect composite inlys (Concept) t 21 yers. Note some mrginl rekdown nd the distl mrginl ridge chip on the molr. Restortions continue to e functionl. Figure 5. The distl lingul cusp of tooth in Figure 3 frctured off t 17 yers. Imge shown is 6-month post-op of repir with direct composite resin. Figure 6. Upon removl of filed restortions, crcks were discovered in the pulpl floor under the distl uccl cusp of the second molr nd oth distl cusps of the first molr. Figure 6. Aesthetic onlys (TESCERA ATL [BISCO]) re more conservtive thn crowns nd stisfy those ptients who desire nturl looking restortions. 3

5 The Role of Modern Composites nd Cermics in Clinicl Prctice towrd metl-free crowns is incresing. 39 Undoutedly, the min reson for fricting nd plcing ll-cermic crowns is esthetic. Once gin, this is driven y the ptient. However, there re lso reports tht ioincomptiility of some metls used in PFM crowns cn led to persistent low level mrginl gingivl inflmmtion in some ptients When selecting mterils for posterior llcermic crown, the clinicin hs mny choices (Tle 1). When mking the choice, clinicins hve to e wre of, nd understnd, the occlusl forces tht exist in given ptient s mouth. This is criticl in the posterior region of the mouth since the occlusl forces re higher, prticulrly for molrs. 43,44 The digrm in Figure 7 grphiclly illustrtes the flexurl strength nd frcture toughness of the vrious cermic mterils. It should e noted tht s strength vlues ecome higher, functionl uses expnd. How ever, Frcture Toughness, Mp.m^.05 Cermic Dentl Mterils Evolution Glss-infiltrted lumin Alumin/zirconi Lithium Disilicte reinforced porcelin Porcelin Dense sintered lumin Leucite reinforced porceliin Strength, MP Zirconi Figure 7. Indictions expnd s strength nd frcture toughness of mterils increse. ecuse lumin (nd to greter extent, zirconi) re more opque, esthetics generlly de crese. Further, Tle 1. Prtil list of Contemporry Cermics Mnufcturer Feldspthic Leucite- Lithium Infiltrted Alumin Zirconi lyering reinforced disilicte lumin porcelin Ivoclr Vivdent e.mx Cerm Empress e.mx CAD e.mx ZirCAD (Schn, e.mx Press Leichtenstein) Vident VM7 VM9 Incerm Vit YZ (Bre, Clif) Vitloc Mrk II NoelBiocre Procer Procer (Yor Lind, Alumin Zirconi Clif) DENTSPLY Finesse Finesse Cercon Cermco All Cermic (Burlington, NJ) 3M ESPE Prdigm C LAVA (St. Pul, Minn) Hereus Kulzer (Hnu, Germny) HerCerm Sun HerCerm Zirkoni Jensen (North Hven, Conn) Authentic Pentron Cermics OPC OPC 3G (Melville, NY) 4

6 The Role of Modern Composites nd Cermics in Clinicl Prctice clinicins need to understnd tht low strength mterils (conventionl feldspthic porcelin nd leucite reinforced porcelin) re quire dhesive plcement wheres medium- to high-strength mterils cn e onded or conventionlly (non dhesive) ce mented. This uthor pre fers to ond ll types of ll-cermic crowns unless the required isoltion for the dhesive process is prolemtic (Figures 8 nd 8). Finlly, clinicins need to e wre tht mteril selection for ll-cermic crowns nd their friction is very dynmic re of dentistry. Dul-phse mterils, such s lyered cermic over zirconi copings, re un dergoing the sme evolution s PFM did lmost 50 yers go. Initil reports of high frcture rte of the lyered cermic hve led to ltertions in the friction technique. 45,46 In the sence of long-term clinicl dt, clinicins hve to mke their own choice s to when the lerning curve hs een flttened enough to incorporte new mteril or technique into their prctice. c Figures 8 nd 8. Upper nd lower rch view of 72-yer-old ptient with lost verticl dimension nd excessive nterior wer. (See Figure 22 for nterior view.) NEW CEMENTS Recently, resin cements (eg, Unicem 2 [3M ESPE], BisCem [BISCO], Mxcem Elite [Kerr], SpeedCEM [Ivoclr Viv - dent], G-Cem [GC Americ]) hve een introduced tht re promoted s self-dhesive, ie, do not require seprte dhesive ppliction step. Mnufc turers clim tht these cements re hy drophilic when mixed (cidic phse) ut ecome hydrophoic (neutrl ph) upon rection with tooth structure. Plcement of crowns (ll types) nd inlys nd onlys (ll types) re recommended uses. In itilly, ond strengths to tooth structure were not impressive; however, most of these cements hve undergone revisions nd re improved over erlier versions. 47,48 Regrding the success of esthetic inlys nd onlys, the clinicin needs to pprecite the importnce of strong, durle enmel ond t the occlusl functionl mrgins for tooth reinforcement nd to mintin the sel. It is lso necessry to understnd tht some mterils used for these restortions, such s indirect composite nd low strength cermics, require effective lmintion to tooth structure in order to withstnd posterior occlu sl forces without frcturing. At this point in time, there re conflicting re ports in the literture regrding dequcy nd durility of the enmel ond when dhesive resin cements re used to plce d Figures 8c nd 8d. Upper nd lower rch postopertive views. Verticl dimension restored with posterior onded ll-cermic crowns (e.mx) nd nterior cermic veneers (Empress [Ivoclr Vivdent]). (See Figure 22 for nterior view.) esthetic inlys nd on lys As noted ove, there is long successful trck record for these res tortions when onded with n etch nd rinse dhesive nd resin ce - ment Some dhesive resin ce ments perform etter thn others, nd there is growing volume of reserch on RelyX Unicem (3M ESPE) nd RelyX Unicem 2 (3M ESPE); however, clinicins my wish to wit for longer term clinicl trils verifying the efficcy of these cements for esthetic inlys nd onlys. 57 It is different sitution for crowns where the onded surfce is mostly or entirely dentin. In ddition, how much 5

7 The Role of Modern Composites nd Cermics in Clinicl Prctice dhesion is needed to re tin crown is function of the mount of the re mining tooth structure nd wheth er the preprtion is retentive or not. 57 Even if the ond strength using self-dhesive cement is not s high s when seprte dhesive is used, it my very well e sufficient for mny crowns It is the clinicin s judgment s to how much dhesion is needed, if ny, long with n evlution of locl conditions s to which cement to use in given sitution. Figure 9. A 17-yer-old femle who ws not stisfied with previous tretment of her white spot lesions. The white spots extended to the dentl-enmel junction nd were restored with single shde nd single opcity composite resin. ANTERIOR AESTHETIC DENTISTRY Direct Composite Mterils As stted previously, composite resin formultions hve undergone significnt evolution during the lst decde. New formultions using nnometer prticles hve incresed the polishility, strength, hndling, nd overll performnce, nd t the sme time, shrinkge hs decresed. The introduction into the mrketplce of wht this uthor descries s nturlly shded composite systems (NSCS) hs not only incresed the verstility of composite resin ut llows dentists to plce restortions nd cosmetic en - hncements tht defy detection (Fig ures 9 nd 9). The defining fetures of NSCS re hving the shdes, opcity, nd fluorescence of dentin; nd the shdes, trnslucency, nd oplescence of enmel. From this definition, one would ssume tht only 2 opcities would e required to duplicte tooth structure. However, for mny nterior pplictions, this would not e true. Wheres dentin is reltively uniform in opcity, enmel is not. Looking closely, the enmel of the incisor in Figure 10 ppers to hve 2 distinct lyers n outer lyer, which is highly trnslucent, nd n inner lyer, which is less trnslucent. Therefore, from clinicl ppliction stndpoint, to meet the true criteri of NSCS, such system would need to consist of 3 opcities (Figure 11). Adding dditionl opquing gents nd tints to NSCS rodens the potentil even more for the clinicin to mtch or enhnce ny nterior tooth structure (Tle 2). Clinicins tody re lredy wre tht esthetic stndrds hve een rised nd qulity outcomes redefined y tody s educted ptient. For mny ptients, restoring n nterior tooth with single shde nd single opcity of composite resin is no longer cceptle (Figures 12 to 13). These new composite resin mterils hve lso gretly Nturlly shded composite system hs 3 opcities Figure 9. Postopertive view of teeth re-treted with 3 opcities of composite resin (Empress Direct [Ivoclr Vivdent]) nd white tint (Tetric Color [Ivoclr Vivdent]) for chrcteriztion to lend with the rest of her teeth. Figure 10. Sectionl view of n incisor showing the chrcteristics 3 opcities. Dentin is reltively uniform in color nd opcity. Enmel cn pper to hve 2 zones of trnslucency. Figure 11. Replicting the 3 opcities of tooth structure would require composite system with 3 opcities nd vriety of dentin nd enmel shdes. rodened their scope of use in elective cosmetic dentistry s well. Undoutedly, the glmour nd excitement of cosmetic dentistry tody is performing complete smile mkeovers with cermic ve neers. However, this uthor elieves most prctices hve mny more p tients with minor to moderte im perfections, who, lthough perhps not interested in ll tht is required opertively nd finncilly for complete smile mkeover, my very well e 6

8 The Role of Modern Composites nd Cermics in Clinicl Prctice Tle 2. Prtil List of Contemporry Nturlly Shded Composite Systems Renmel Esthet X HD Venus Dimond Filtek Supreme Ultr Premise Empress Direct Cosmedent (Chicgo, Ill) DENTSPLY Culk (Milford, Del) Hereus Kulzer (South Bend, Ind) 3M ESPE (St. Pul, Minn) Kerr (Ornge, Clif) Ivoclr Vivdent (Schn, Leichtenstein) Figure 12. A 21-yer-old femle ws unhppy with the ppernce of the composite restortion on tooth No. 8 nd rettched tooth frgment tooth No. 9. Figure 12. Postopertive view of teeth restored with 3 opcities of composite resin (Empress Direct) long with lue tint (Kolor + Plus [Kerr]) to simulte incisl trnslucency. interested in the kind of smile improvement tht cn e chieved with composite resin more conservtively nd t lower cost. Often, fewer teeth or even just prts of teeth cn e treted (Figures 14 nd 14). There is little disgreement mong dentists tht mjor dvntge of direct composite resin is tht it is the most conservtive pproch ville in dentistry, whether used in the nterior region or posterior region. This is prticulrly importnt when treting young people, especilly considering the numer of tretment cycles tht my e necessry over ptient s lifetime. As prcticl mtter, it is generlly regrded tht replcing cermic veneers scrifices more tooth structure t retretment thn direct composite veneers (Figures 15 to 16). Also, the clinicin remking porcelin veneers my feel uncomfortle replcing veneers hving conventionl preprtions with new veneers, nd my tretment pln crowns. At one time cermic ws considered the ultimte in esthetic mterils. With tody s NSCS, this is no longer true (Figures 17 to 19). In order for dentists to mximize nterior esthetic results using these new systems, sic understnding of opcity, trnslucency, hue, vlue, nd chrom is necessry. In ddition, mny dentists might enefit y tking hnds-on trining to develop the skills to mimic tooth structure. These skills re esily lerned with these new systems. Artistic ility is not necessry. Longevity my e the one drwck when compring Figure 13. A 16-yer-old femle who ws disstisfied with composite veneer plced on drk ut vitl upper incisor. Figure 13. The veneer ws replced with nturlly shded composite system (NSCS) (Empress Direct) using 3 opcities nd white tint (Tetric Color). Composite resin ws dded to the mesil of the djcent incisor to crete more lnced shpe. direct composite resin veneers to cermic veneers. Al - though studies re lcking for di rect composite veneers plced using the newer mterils, nevertheless, the perception is tht the durility nd esthetic life of composite resin ve neers would e less thn tht of cermic ve neers. 61 This my e true, ut this uthor e lieves the perception of longevity for cermic ve neers my e overestimted. Al though dur le, especilly if significnt enmel is preserved, the esthetic life of cermic veneers my e the limiting fctor. 62,63 Mr gins cn e ex posed if the tissue level chnges, nd stining cn occur if mrgins 7

9 The Role of Modern Composites nd Cermics in Clinicl Prctice Figure 14. he ptient ws dentist nd wnted her smile enhnced s conservtively s possile. Figure 14. Composite resin (Empress Direct) ws onded only to the distl incisl res of oth centrls nd the mesil incisl res of oth lterls. The incisl emrsure etween the centrls ws opened slightly with enmelplsty. Virtully no preprtion ws done other thn slight roughening of enmel. Figure 16. A 40-yer-old femle ws no longer hppy with her worn composite veneers plced 15 yers prior. Becuse they were so conservtive, she specificlly sked for composite veneers gin. Figure 16. Post-op showing new composite veneers (Empress Direct). There is low risk of dditionl loss of tooth structure when replcing composite veneers s it is not lwys even necessry to remove ll of the old composite when doing so. re on dentin. Finlly, frctures re more rre with cermic veneers ut my e hrder to repir or replce thn for composite resin veneers. Figure 15. Postorthodontic view of 15-yer-old femle with multiple declcified res nd drkened, ut vitl, lterl incisor. Note the strined, gurded smile. The ptient ws very selfconscious out the ppernce of her teeth. Figure 15. Postopertive view showing full smile nd hppy fce. Six direct composite veneers (Empress Direct) were plced with miniml preprtion. CERAMIC LAMINATE VENEERS The porcelin lminte veneer ws developed y Dr. John Clmi t New York University in The use of porcelin lminte veneers is lmost lwys for cosmetic resons nd therefore elective. The emphsis on ppernce is pervsive in tody s medi-driven culture nd ecuse the smile is such significnt fctor in fcil ppernce, the impct of this culture shift on dentistry hs een enormous. In mny wys, the preprtion techniques for cermic veneers hve come full circle. Initilly, these veneers were plced with no or miniml preprtion nd onded only to enmel. This, of course, limited esthetics. Not only could they pper ulky, ut when unwnted colors were eing msked, they could lso e quite opque. As esthetic demnds incresed, more preprtion depths were performed to llow technicins to chieve more esthetic, lifelike ppernce. When pressed cermics ppered, lthough highly esthetic, 0.6 to 0.8 mm preprtion depths were necessry. Tody, ecuse p tients incresingly wnt their dentistry more esthetic ut less invsive, miniml preprtion hs returned. This hs the dditionl dhesive 8

10 The Role of Modern Composites nd Cermics in Clinicl Prctice Figure 17. Preopertive view of 14-yer-old ptient, with deficiently sized lterl incisor, who hs just completed orthodontics. Figure 18. A 42-yerold femle who is unhppy with the ppernce of her upper 4 incisors. Figure 17. Direct composite veneer (three qurter crown) using NSCS (4 Sesons [Ivoclr Vivdent]), 2 opcities (Enmel nd Trns Enmel) nd white tint (Tetric Color). dvntge fforded y onding to more enmel. Never - theless, the clinicin must pprecite the fct tht the preprtion is dictted y the existing clinicl sitution t the eginning of tretment nd the ultimte outcome desired y the informed ptient. This will result in miniml preprtion in some cses nd vrious levels of incresed preprtion in others, sometimes even within the sme cse. In recent yers, concern hs een expressed regrding possile over tretment of ptients who my not hve een completely informed of the consequences when ggressive preprtion ws required to chieve the desired outcome. 64,65 The criticism is lmost lwys in cses exhiiting crowded dentition. In this uthor s experience, some ptients with crowded dentitions will proceed with recommended orthodontics nd some will not (Figures 20 nd 20). The dvent of cler ligners nd certin new rpid ut limited orthodontic pproches seems to hve incresed cceptnce of minor tooth movement y ptients. The importnt point is tht ll p tients must e fully informed of ll resonle tretment possiilities nd their consequences. It is our legl nd ethicl duty. Initilly, porcelin lminte ve neers were fricted y stcking cermic powder dipped in liquid onto refrctory dies or onto dies covered with thin pltinum foil. This is still vlid technique ut mny, perhps most, veneers fricted tody re pressed. Some re even milled. Pressed veneers re Figure 18. The llcermic crowns (e.mx) were replced with lithium disilicte reinforced porcelin crowns nd the lterl incisors were conservtively veneered with Empress Direct. Figure 19. A 38-yerold femle presented with single vitl drk tooth. She sought opinions from severl dentists who recommended either veneers or crowns on oth centrls, most likely ecuse of the difficulty in chieving mtch when treting single centrl incisor with n indirect restortion. However, the ptient desired tht only the drk tooth e treted. Figure 19. Postopertive view showing tretment with single direct composite veneer (4 Sesons). Due to the drkness of the tooth, preprtion depth of 0.8 mm ws required. In ddition, n opquer ws used efore the 3 opcities of composite resin were lyered. Three different colored tints, White (Tetric Color), Honey Yellow, nd Grey (Cretive Color [Cosmedent]), were plced prior to the ppliction of the finl trns enmel lyer. mde with leucite reinfor cement nd re stronger thn stcked porcelin veneers (Figure 7). At lest one rnd (Empress [Ivoclr Vivdent]) hs een well studied nd hs high success rte over time. 66 Recently, new glss cermic reinforced with lithium disilicte (e.mx [Ivoclr Vivdent]), hs een introduced. This mteril hs 3 times 9

11 The Role of Modern Composites nd Cermics in Clinicl Prctice Figure 20. A 26-yerold femle who ws disstisfied with her smile. She ws to e mrried in 4 dys. Figure 20. Becuse of her young ge nd the lck of time, 4 direct composite resin veneers (4 Sesons) were plced. Composite resin ws lso dded to her severely worn cnines to re-estlish guidnce. c Figure 21. A 46-yerold mle desired complete smile mkeover. Figure 21. Articulted upper nd lower solid models showing preprtions. Note retined contcts for lower preprtions. Also, there ws no dditionl incisl reduction. the strength of leucite cermics nd thus offers the potentil to e fricted to 0.3 mm thickness, 67 which in turn llows significntly less prep rtion for ve neers. The rt, science, nd technology of performing complete smile mke over with cermic lminte veneers hve ecome very sophisticted over the yers in order to mximize esthetic outcomes nd minimize preprtion. Fortuntely, since dentl schools cnnot possily cover this topic in depth, postgrdute lerning centers offering hndson nd even live-p tient tretment hve een estlished in mny countries. There re lso numerous meetings, lectures, rticles, DVDs, online lerning progrms nd texts ville for dentists seeking to cquire the skills necessry to offer these services. 68,69 The plcement of nterior cermic veneers is visile dentistry nd hs gret impct on ptients. It demnds more from clinicins thn gret effort nd dediction to detil to chieve success. It lso requires, perhps more thn other forms of dentistry, higher listening skills nd greter understnding of, s well s pprecition for, unique ptient desires. However, the emotionl rewrd for improving someone s fcil ppernce nd self-esteem cn e s high for the dentist nd the tem s it is for the ptient (Figures 21 to 22). ALL-CERAMIC CROWNS Generlly, ptients demnd higher level of esthetics in d Figure 21c. Incisl view of upper cst showing conservtive preprtions entirely within enmel. Figure 21d. Since no color chnge ws necessry, very conservtive preprtions were possile. The veneers were fricted from stcked porcelin (d.sign [Ivoclr Vivdent]) nd plced with regrd to function. the nterior thn in the posterior prt of the mouth. Fortuntely, the functionl forces re generlly lower in the nterior re, llowing the use of mterils tht hve higher esthetic potentil ut less strength. The mterils, friction, plcement requirements, nd occlusl considertions, including drwcks nd enefits of ech mteril, re the sme s discussed in the previous section (Posterior Aesthetic Dentistry, All-Cermic Crowns) (Fig ure 7). Gen erlly, s mteril strengths increse, predictle esthetic potentil de creses. The point t which it is etter to plce full-coverge crown rther thn veneer for n nterior tooth is still somewht ritrry nd sed on the judgment of the dentist. Mgne nd Belser 68 hve shown tht preservtion 10

12 The Role of Modern Composites nd Cermics in Clinicl Prctice of the cingulum is significnt in retining tooth stiffness. Reten tion of this prt of nterior teeth is importnt nd should e prepred only when significnt tooth structure is missing nd preprtion of this re is needed for resistnce form. In the finl nlysis, dhesive dentistry llows clinicins to prepre teeth ccording to the tooth s requirements or cse requirements rther thn the requirements of the restortive mteril. Preprtion geometry then ecomes unique to ech individul tooth nd the line etween wht constitutes crown versus veneer ecomes lurred. CONCLUSION Successful use of modern composites nd cermics in current clinicl prctice depends on mny fctors. An indepth knowledge of these mterils is clerly necessry. However, it is eqully importnt to strt with comprehensive dignosis, including thorough ssessment of the ptient s unique occlusion nd mndiulr movements. The ptient s desired outcome nd pproprite cse selection re lso ovious ut essentil considertions for success. In ddition, ll composites, nd mny cermics, require onding to tooth structure. Even for those cermics tht don t require dhesive plcement, onding my e dvntgeous. Thus, thorough knowledge of dhesives nd dhesion is eqully criticl for successful outcomes. Moreover, precise execution of the dhesive technique cnnot e minimized, especilly when onding to dentin. Adhesion is perhps n even more Figure 22. A 72-yerold femle who ws disstisfied with her ppernce (sme ptient s in Figures 8 nd 8). Figure 22. The new verticl dimension ws restored with upper nd lower ll-cermic posterior crowns nd pressed cermic veneers were plced on ll nterior teeth (see lso Figures 8c nd 8d). dynmic re of dentistry thn the chnging world of composite resins nd cermics nd chllenges the dentist to keep current. The rpid rte of chnge in mterils nd techniques cn certinly improve dentistry s services to p tients. However, it lso cn led to erly osolescence, which mens dentists will likely see fewer long-term controlled clinicl trils investigting given mteril nd technique. This, in turn, cn ffect our ility to prctice evidencesed dentistry. The stute clinicin will e wre tht neither too much hste nor too much cution serves the clinicin or the ptient well nd tht the est tretment for confusion or indecision is continuous eduction. 11

13 The Role of Modern Composites nd Cermics in Clinicl Prctice REFERENCES 1. Anusvice KJ. Phillips Science of Dentl Mterils. 11th ed. St. Louis, MO: Sunders; 2003: , 539, Ritter AV. Direct resin-sed composites: current recommendtions for optiml clinicl results. Compend Contin Educ Dent. 2005;26: Burke FJ. Amlgm to tooth-coloured mterils implictions for clinicl prctice nd dentl eduction: governmentl restrictions nd mlgm-usge survey results. J Dent. 2004;32: Christensen GJ, Child PL Jr. Hs resin-sed composite replced mlgm? Dent Tody. 2010;29:108, Norwegin Ministry of the Environment nd Interntionl Development, Dnish Ministry for Helth, Swedish Ministry of Helth nd Socil Affirs, In your dentl prctice, is dentl mlgm still the restortive mteril of choice? J Am Dent Assoc. 1997;128: In your dentl prctice, is dentl mlgm still the restortive mteril of choice? J Am Dent Assoc. 2002;133: Mcpherson LC, Smith BG. Reinforcement of wekened cusps y dhesive restortive mterils: n in-vitro study. Br Dent J. 1995;178: Sun YS, Chen YM, Smles RJ, et l. Frcture resistnce nd microtensile ond strength of mxillry premolrs restored with two resin composite inly systems. Am J Dent. 2008;21: Shor A, Nicholls JI, Phillips KM, et l. Ftigue lod of teeth restored with onded direct composite nd indirect cermic inlys in MOD clss II cvity preprtions. Int J Prosthodont. 2003;16: Dlpino PH, Frncischone CE, Ishikirim A, et l. Frcture resistnce of teeth directly nd indirectly restored with composite resin nd indirectly restored with cermic mterils. Am J Dent. 2002;15: de Freits CR, Mirnd MI, de Andrde MF, et l. Resistnce to mxillry premolr frctures fter restortion of clss II preprtions with resin composite or ceromer. Quintessence Int. 2002;33: Mjör IA, Dhl JE, Moorhed JE. Age of restortions t replcement in permnent teeth in generl dentl prctice. Act Odontol Scnd. 2000;58: Opdm NJ, Bronkhorst EM, Roeters JM, et l. A retrospective clinicl study on longevity of posterior composite nd mlgm restortions. Dent Mter. 2007;23: Busto AL, Loguercio AD, Reis A, et l. Clinicl evlution of posterior composite restortions: 6-yer results. Am J Dent. 2001;14: Opdm NJ, Bronkhorst EM, Loomns BA, et l. 12-yer survivl of composite vs. mlgm restortions. J Dent Res. 2010;89: Deliperi S, Brdwell DN. Clinicl evlution of direct cuspl coverge with posterior composite resin restortions. J Esthet Restor Dent. 2006;18: ADA Council on Scientific Affirs; ADA Council on Dentl Benefit Progrms. Sttement on posterior resin-sed composites. J Am Dent Assoc. 1998;129: Opdm NJ, Roeters FJ, Feilzer AJ, et l. Mrginl integrity nd postopertive sensitivity in Clss 2 resin composite restortions in vivo. J Dent. 1998;26: Nikolenko SA, Lohuer U, Roggendorf M, et l. Influence of c-fctor nd lyering technique on microtensile ond strength to dentin. Dent Mter. 2004;20: Person GJ, Hegrty SM. Cusp movement of molr teeth with composite filling mterils in conventionl nd modified MOD cvities. Br Dent J. 1989;166: Llen Puy MC, Forner Nvrro L, Fus Llcer VJ, et l. Composite resin inlys: study of mrginl dpttion. Quintessence Int. 1993;24: Ziskind D, Avivi-Arer L, Hrmti O, et l. Amlgm lterntives micro-lekge evlution of clinicl procedures. Prt I: direct com posite/composite inly/cermic inly. J Orl Rehil. 1998;25: vn Dijken JW, Hörstedt P. Mrginl rekdown of 5-yer-old direct composite inlys. J Dent. 1996;24: Frdeni M, Aquilno A, Bssein L. Longitudinl study of pressed glss-cermic inlys for four nd hlf yers. J Prosthet Dent. 1997;78: Schulte AG, Vöckler A, Reinhrdt R. Longevity of cermic inlys nd onlys luted with solely light-curing composite resin. J Dent. 2005;33: Reiss B. Clinicl results of Cerec inlys in dentl prctice over period of 18 yers [in English, Germn]. Int J Comput Dent. 2006;9: Sjögren G, Molin M, vn Dijken JW. A 10-yer pro spective evlution of CAD/CAM-mnufctured (Cerec) cermic inlys cemented with chemiclly cured or dul-cured resin composite. Int J Prosthodont. 2004;17: Otto T, De Nisco S. Computer-ided direct cermic restortions: 10-yer prospective clinicl study of Cerec CAD/CAM inlys nd onlys. Int J Prosthodont. 2002;15: Krämer N, Tschner M, Lohuer U, et l. Totlly onded cermic inlys nd onlys fter eight yers. J Adhes Dent. 2008;10: Donly KJ, Jensen ME, Triolo PT, et l. A clinicl comprison of resin composite inly nd only posterior restortions nd cst-gold restortions t 7 yers. Quintessence Int. 1999;30:

14 The Role of Modern Composites nd Cermics in Clinicl Prctice 34. Reiss B. Long-term clinicl performnce of CEREC restortions nd the vriles ffecting tretment success. Compend Contin Educ Dent. 2001;22(suppl 6): Crispin BJ. Indirect composite restortions: lterntive or replcement for cermic? Compend Contin Educ Dent. 2002;23: Christensen GJ. Wht hs hppened to conservtive tooth restortions? J Am Dent Assoc. 2005;136: Heymnn HO. The enduring merits of gold. J Esthet Restor Dent. 2009;21: Edelhoff D, Sorensen JA. Tooth structure removl ssocited with vrious preprtion designs for posterior teeth. Int J Periodontics Restortive Dent. 2002;22: Christensen GJ. Porcelin-fused-to-metl versus zirconi-sed restortions, J Am Dent Assoc. 2009;140: Brune D. Metl relese from dentl iomterils. Biomterils. 1986;7: Schmlz G, Grhmmer P. Biologicl interctions of dentl cst lloys with orl tissues. Dent Mter. 2002;18: Christensen GJ. Choosing n ll-cermic restortive mteril: porcelin-fused-to-metl or zirconi-sed? J Am Dent Assoc. 2007;138: Helkimo E, Crlsson GE, Helkimo M. Bite force nd stte of dentition. Act Odontol Scnd. 1977;35: Zivko-Bi J, Pnduri J, Jerolimov V, et l. Bite force in sujects with complete dentition. Coll Antropol. 2002;26: Donovn TE. Fctors essentil for successful ll-cermic restortions. J Am Dent Assoc. 2008;139(suppl):14S-18S. 46. Mrchck BW, Futtsuki Y, Mrchck CB, et l. Customiztion of milled zirconi copings for ll-cermic crowns: clinicl report. J Prosthet Dent. 2008;99: RelyX Unicem 2 Automix Self-Adhesive Resin Cement. St. Pul, MN: 3M ESPE Dentl Products. NA/dentl-profession ls/products/ctegory/cement/relyxunicem-2/. Accessed Mrch 18, Biscem Self-Adhesive Luting Cement. Schum urg, IL: Bisco. co.com/ctlog/ple_isco_ctitemf.sp? ibrnd_id=139&ict_id=6. Accessed Mrch 18, De Munck J, Vrgs M, Vn Lnduyt K, et l. Bonding of n uto-dhesive luting mteril to enmel nd dentin. Dent Mter. 2004;20: Ao-Hmr SE, Hiller KA, Jung H, et l. Bond strength of new universl self-dhesive resin luting cement to dentin nd enmel. Clin Orl Investig. 2005;9: Irr G, Johnson GH, Geurtsen W, et l. Microlekge of porcelin veneer restortions onded to enmel nd dentin with new self-dhesive resin-sed dentl cement. Dent Mter. 2007;23: Peumns M, De Munck J, Vn Lnduyt K, et l. Two-yer clinicl evlution of self-dhesive luting gent for cermic inlys. J Adhes Dent. 2010;12: Hikit K, Vn Meereek B, DeMunck J, et l. Bonding effectiveness of dhesive luting gents to enmel nd dentin. Dent Mter. 2007;23: Tschner M, Frnkenerger R, Petschelt A, et l. IPS-Empress inlys luted with self-dhesive resin cement fter three yers. J Dent Res. 2009;88(specil issue A). Astrct Burgess JO, Ghumn T, Ckir D. Criticl pprisl: Self-dhesive resin cements. J Esthet Restor Dent. 2010;22: RelyX Unicem, Clinicl Studies St. Pul, MN: 3M ESPE Dentl Products. UuZjcFSLXTt48TVNXf6EVuQEcuZgVs6EVs6E &fn=unicem_sci_fcts_en.pdf. Accessed Mrch 18, Hrrison JL, derijk WG, Simon JF. Resin cements: A closer look t newly introduced cements. Inside Dentistry. 2007;3: Uy JN, Lin JN, Nicholls JI, et l. Lod-ftigue performnce of gold crowns luted with resin cements. J Prosthet Dent. 2006;95: Johnson GH, Lepe X, Zhng H, et l. Retention of metlcermic crowns with contemporry dentl cements. J Am Dent Assoc. 2009;140: Viotti RG, Ksz A, Pen CE, et l. Microtensile ond strength of new self-dhesive luting gents nd conventionl multistep systems. J Prosthet Dent. 2009;102: Denehy GE. Composite resins. Compend Contin Educ Dent. 2009;30: Peumns M, De Munck J, Fieuws S, et l. A prospective tenyer clinicl tril of porcelin veneers. J Adhes Dent. 2004;6: Friedmn MJ. A 15-yer review of porcelin veneer filure clinicin s oservtions. Compend Contin Educ Dent. 1998;19: Sper FM. The esthetic correction of nterior dentl mllignment: conventionl vs. instnt (restortive) orthodontics. J Clif Dent Assoc. 2004;32: Felton DA. Do no hrm. J Prosthodont. 2004;13: Frdeni M, Redemgni M. An 11-yer clinicl evlution of leucite-reinforced glss-cermic crowns: retrospective study. Quintessence Int. 2002;33: IPS e.mx system. Amherst, NY: Ivoclr Vivdent. Accessed Mrch 18, Mgne P, Belser U. Bonded Porcelin Restortions in the Anterior Dentition: A Biometric Approch. Chicgo, IL: Quintessence Pulishing; Gurel G. The Science nd Art of Porcelin Lminte Veneers. Chicgo, IL: Quintessence Pulishing;

15 The Role of Modern Composites nd Cermics in Clinicl Prctice POST EXAMINATION INFORMATION To receive continuing eduction credit for prticiption in this eductionl ctivity you must complete the progrm post exmintion nd receive score of 70% or etter. Trditionl Completion Option: You my fx or mil your nswers with pyment to Dentistry Tody (see Trditionl Completion Informtion on following pge). All informtion requested must e provided in order to process the progrm for credit. Be sure to complete your Pyment, Personl Certifiction Informtion, Answers, nd Evlution forms. Your exm will e grded within 72 hours of receipt. Upon successful completion of the postexm (70% or higher), letter of completion will e miled to the ddress provided. Online Completion Option: Use this pge to review the questions nd mrk your nswers. Return to dentlcetody.com nd sign in. If you hve not previously purchsed the progrm, select it from the Online Courses listing nd complete the online purchse process. Once purchsed the progrm will e dded to your User History pge where Tke Exm link will e provided directly cross from the progrm title. Select the Tke Exm link, complete ll the progrm questions nd Sumit your nswers. An immedite grde report will e provided. Upon receiving pssing grde, complete the online evlution form. Upon sumitting the form your Letter Of Completion will e provided immeditely for printing. Generl Progrm Informtion: Online users my log in to dentlcetody.com ny time in the future to ccess previously purchsed progrms nd view or print letters of completion nd results. POST EXAMINATION QUESTIONS 1. Which sttement is TRUE?. Cosmetic dentistry is unnecessry dentistry.. Cosmetic dentistry is est performed using composite resin. c. Cosmetic dentistry is est performed using cermic mterils. d. The choice of mteril used is determined on cse-y-cse sis following comprehensive dignosis nd informed ptient consent. 2. When plcing posterior intrcoronl restortions, the dentist should:. Choose the mteril sed on dignosis of locl conditions, ptient informed consent, nd doctor s restortive philosophy.. Alwys use mlgm ecuse it hs long-term trck record nd is low cost. c. Never use mlgm ecuse of its color nd ecuse it hs mercury in it. d. Alwys use composite resin ecuse of its color nd ecuse it doesn t contin mercury. 3. Which sttement is NOT TRUE?. Composite resin mterils hve improved significntly in the lst few yers.. Composite resin is more populr in some countries thn mlgm. c. Composite resin shrinkge is no longer n issue. d. Inclusion of nnoprticle fillers increse the polishility of composite resins. 4. The need for excellent isoltion when plcing posterior composite restortions:. Depends on the composite resin used.. Is lwys necessry. c. Depends on the dhesive used. d. Is only needed sometimes. 5. The most conservtive restortion for posterior teeth is:. Amlgm.. Cst gold inly or only. c. Composite resin. d. Aesthetic inly or only. 6. Which sttement is FALSE with regrd to esthetic inlys nd onlys?. Hve proven trck record.. Should never e done if gingivl mrgin is elow the cemento-enmel junction. c. Are osolete ecuse direct composite resin mterils hve improved so much. d. Both nd c re flse. 14

16 The Role of Modern Composites nd Cermics in Clinicl Prctice 7. Which sttement is TRUE with regrd to inlys nd onlys?. Are thought to e underutilized y some teching clinicins.. Are indicted for the modertely roken down tooth. c. Neither of the ove. d. Both of the ove. 8. Aesthetic inlys nd onlys:. Should e fricted in cermic.. Should e fricted in composite resin. c. Cn e fricted successfully from either mteril. d. Don t lst s long s crowns. 9. In-office milled inlys/onlys hve een shown:. To e more ccurte thn lortory fricted restortions.. To lst longer thn lortory fricted restortions. c. By multiple studies to perform well over time. d. To only e mde from cermic. 10. Posterior metl-free crowns:. Should only e mde from zirconi ecuse it s the strongest mteril.. Should e fricted fter considering occlusl functionl forces nd ptient desires for esthetics. c. Should e fricted from leucite reinforced porcelin ecuse it s most esthetic. d. Should e fricted from lithium disilicte reinforced porcelin ecuse it cn e milled or pressed. 11. Lyered cermic crowns with zirconi copings:. Are undergoing evolutionry mteril nd technique chnges to improve performnce.. Hve een shown in the literture to hve the sme high level of performnce s PFM. c. Should e mde without lyered cermic to improve durility nd esthetics. d. Are the mteril of choice when the ptient is sensitive to metls. 12. Metl-free crowns:. Are onded or conventionlly cemented sed on the requirements of the crown mteril, the preprtion height nd tper, nd whether isoltion cn e chieved for the dhesive process.. Should lwys e onded. c. Should lwys e conventionlly cemented (nondhesive). d. Are est plced with self-dhesive cement (no seprte dhesive pplied). 13. As presented in the rticle, the uthor s definition of nturlly shded composite system:. Is one hving multiple shdes nd multiple opcities.. Requires high inte rtistic ility to chieve lifelike results. c. Cn e used in the posterior s well s nterior. d. Both nd c re true. 14. The preprtion for cermic veneers:. Should lwys rek proximl contcts.. Is determined y existing conditions nd the desired outcome of the informed ptient. c. Should not e done s they should lwys e prepless. d. Lst lifetime. 15. Skill in performing nterior cosmetic or restortions with composite resin:. Is esily lerned with study nd prctice.. Cn e improved y tking hnds-on courses. c. Is too difficult for most generl dentists. d. Both nd re true. 16. Adhesive dentistry:. Allows dentists to use tooth colored mterils.. Allows for more conservtive preprtions. c. Improves the sel of restortions. d. All of the ove. 15

17 The Role of Modern Composites nd Cermics in Clinicl Prctice PROGRAM COMPLETION INFORMATION PERSONAL CERTIFICATION INFORMATION: If you wish to purchse nd complete this ctivity trditionlly (mil or fx) rther thn online, you must provide the informtion requested elow. Plese e sure to select your nswers crefully nd complete the evlution informtion. To receive credit you must nswer t lest 12 of the 16 questions correctly. Complete online t: dentlcetody.com TRADITIONAL COMPLETION INFORMATION: Lst Nme (PLEASE PRINT CLEARLY OR TYPE) First Nme Profession / Credentils Street Address Suite or Aprtment Numer License Numer Mil or fx this completed form with pyment to: Dentistry Tody Deprtment of Continuing Eduction 100 Pssic Avenue Firfield, NJ Fx: PAYMENT & CREDIT INFORMATION: Exmintion Fee: $40.00 Credit Hours: 2.0 Note: There is $10 surchrge to process check drwn on ny nk other thn US nk. Should you hve dditionl questions, plese contct us t (973) I hve enclosed check or money order. I m using credit crd. My Credit Crd informtion is provided elow. Americn Express Vis MC Discover Plese provide the following (plese print clerly): City Stte Zip Code Dytime Telephone Numer With Are Code Fx Numer With Are Code E-mil Address ANSWER FORM: COURSE #: 138 Plese check the correct ox for ech question elow. 1. c d 9. c d 2. c d 10. c d 3. c d 11. c d 4. c d 12. c d 5. c d 13. c d 6. c d 14. c d 7. c d 15. c d 8. c d 16. c d Exct Nme on Credit Crd Credit Crd # Signture Approved PACE Progrm Provider FAGD/MAGD Credit Approvl does not imply cceptnce y stte or provincil ord of dentistry or AGD endorsement. June 1, 2009 to My 31, 2012 AGD Pce pprovl numer: / Expirtion Dte Dentistry Tody, Inc, is n ADA CERP Recognized Provider. ADA CERP is service of the Americn Dentl Assocition to ssist dentl professionls in indentifying qulity providers of continuing dentl eduction. ADA CERP does not pprove or endorse individul courses or instructors, nor does it imply cceptnce of credit hours y ords of dentistry. Concerns or complints out CE provider my e directed to the provider or to ADA CERP t d.org/goto/cerp. 16 PROGRAM EVAUATION FORM Plese complete the following ctivity evlution questions. Rting Scle: Excellent = 5 nd Poor = 0 Course ojectives were chieved. Content ws useful nd enefited your clinicl prctice. Review questions were cler nd relevnt to the editoril. Illustrtions nd photogrphs were cler nd relevnt. Written presenttion ws informtive nd concise. How much time did you spend reding the ctivity nd completing the test?