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Inside Dentistry
February 2015
Volume 11, Issue 2


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Innovations of the Past 25 Years

Gordon J. Christensen, DDS, MSD, PhD

The driving principle of innovation is change. My years in dentistry have been an unbelievable blessing, in part because I have seen so much change. I have learned that everything that goes around comes around. For example, periodontal disease and dental caries have both been “cured” multiple times throughout my career, and yet we still battle these conditions every day. This shows us that change alone is not enough to define true innovation. Innovations are not just something new, but rather they must solve problems, be effective, and make a lasting impact on our profession.

Following this definition, innovation can be somewhat subjective, as you will see throughout this article. Inside Dentistry asked clinicians and thought leaders from many areas of dentistry to discuss what they consider to be the great innovations of the past 25 years, and the answers are both varied and insightful.

In my opinion, in the profession today, there are three big drivers of innovation: esthetics, implant dentistry, and dental technology. In terms of esthetics, I see the metal age in dentistry rapidly disappearing—for good or bad. Zirconia and lithium disilicate restorations are taking over the market. The advent of dental root-form implants is an obvious game-changer as well. As a prosthodontist, seldom do I make a treatment plan without some consideration for dental implants. I have long promoted the placement and restoration of root-form implants by qualified, educated/trained general dentists for healthy patients who have adequate bone. The more complicated implant cases should be treated by oral surgeons, periodontists, prosthodontists, endodontists, and others. However, the majority of currently placed implants are singles, so general dentists have a marvelous potential to increase their activity with implants.

Perhaps the most profound paradigm shift in the modern history of our profession has occurred as we rapidly move from the techniques of the past to the exciting new world of technology in clinical dentistry. I fully predict that in 5 years, you will be doing digital impressions. If you don’t have cone beam, I strongly suggest that you find access to it, as it will soon become a standard of care, particularly if you are placing implants. Finally, CAD/CAM in dental laboratories and clinical offices is taking over the indirect restoration marketplace. It’s moving faster than any other concept I have seen, other than perhaps air rotors many years ago.

Perhaps some of you have different ideas about the key innovations of the past 25 years. There is room for multiple opinions on this topic. As we think about innovations and encounter new products and technologies in the marketplace, this is the advice I give:

We are dentists; we prevent and treat oral diseases; we are honest, educated people; and our clinical judgments after experience are valid. Combine your personal judgment with legitimate research, and you are a genuine professional who can evaluate innovation and stand behind the clinical decisions you make every day.

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CAD/CAM Advantages:

• Time savings

• High accuracy and predictability

• Improved clinician-technician communication

• Better patient experience

Markus B. Blatz, DMD, PhD

CAD/CAM technologies have revolutionized clinical dentistry and dental laboratory technology. Today, almost 90% of dental laboratories offer CAD/CAM-fabricated restorations while chairside scanners and in-office CAD/CAM systems are becoming increasingly popular. Besides exceptional precision and predictability, the versatility and vast material options have made CAD/CAM the preferred fabrication method for indirect restoration. Silica-based ceramics, high-strength ceramics (eg, zirconia), composites, hybrid materials, acrylics, metal alloys, and waxes are among these options for patient-centered material selection for indirect restorations from small inlays to full-mouth implant-supported restorations. CAD/CAM-fabricated full-contour zirconia crowns have become particularly popular.

In contrast to laboratory technicians, dental practitioners have been significantly slower to adapt CAD/CAM in their practices with chairside scanning and/or in-office milling systems. Initial cost and a steep learning curve seem to be among the most limiting factors. Intraoral scanning techniques are vastly different from conventional impression-making procedures and require specific training as well as frequent use to attain a sufficient comfort level and proficiency.

Laboratory-based CAD/CAM systems provide consistent, highly accurate restorations and may limit the number of remakes. Since the information from the restoration design and fabrication method is stored on a computer, it is quite simple to duplicate or modify any existing restoration.

In terms of advantages, CAD/CAM-fabricated monolithic crowns are significantly more economic than traditionally crafted and hand-veneered ones. Intraoral scanning devices increasingly replace technique-sensitive conventional impressions, eliminating time-consuming and less predictable steps, which have great influence on the ultimate quality of the restoration. With a chairside milling system, clinicians can fabricate a variety of indirect restorations in just one patient visit. Ultimately, however, the biggest advantage is the largely improved quality of clinical care we can deliver to our patients with these modern technologies.

Gregg A. Helvey, DDS, MAGD

In the early 1990s, when I was fulfilling requirements for my Mastership in the Academy of General Dentistry (AGD), one of the hands-on classes included using CEREC restorations. CEREC was fairly new in the US and that was my first exposure to CAD/CAM.

In 2004, I was invited to lecture at the National AGD meeting on CAD/CAM restorations and needed pictures of the CEREC In-lab unit. The local Patterson branch was sponsoring a seminar on the In-lab unit and suggested I attend. The first thing they asked me when I arrived was if I had any interest in using CEREC in my office.

I started training as a lab technician in 1996 and was doing all of my own ceramics and crown and bridge work. I immediately said that I was lab technician and “I didn’t need no stinkin’ machine—I make my own crowns.” But when the lecturer started his program and showed the new 3D capabilities, where they could actually take the prep and move it around on the screen like I would at the lab bench, I was just really, really impressed.

Driving home from Patterson that day, I thought about the time I would save by not having to spend hours after work making crowns. That was the reason why I adopted it initially, to buy myself time. Back then, the software was a lot harder to learn than it is now, so it took some trial and error. But as I got better with it, I started to realize how beneficial it was for the patient: you didn’t have to use an impression; you didn’t have to use a temporary; and the patient could have it all done in just one appointment.

Today, my patients know that I am going to use the computer to make their crown and I won’t have to use an impression. They like that. Plus, most of the emergency calls that I would get after hours were patients who would say, “My temporary came out; what do I do?” I didn’t have those calls anymore. It’s been a great asset to the practice.

As you learn to use this technology, you find what the computer is really looking for in the tooth preparation. It actually makes you become a better technical dentist, because the more exact the prep is and the clearer the margin is, the easier it is for the computer to read it, which expedites the restorative appointment.

If you take a traditional impression and there is a discrepancy (that you may or may not see), you either retake the impression or get a call from the lab telling you about the problem, and then you have to decide what to do. Using CAD/CAM technology, after scanning you will see on the screen immediately any discrepancy or problem and correct it before going any further.

Parag Kachalia, DDS

For a long time you could only get a touchpoint on CAD/CAM technology if you had the ability to spend $100,000, if you went the full route of including impressioning and milling within the office. That wasn’t necessarily the right thing for all practitioners.

It was really about 7 or 8 years ago that some companies came into the market with a different approach, that you can do almost any kind of crown and bridge case by taking a digital impression and then sending that impression to a digital laboratory. It was no longer a one-size-fits-all mentality, and now the clinician had freedom to choose how to enter the CAD/CAM market. Today they may just take digital impressions, but ultimately they may want to create restorations in office. The trend towards a more open platform means those devices can be added in the future.

With CAD/CAM and digital dentistry, you are now able to see a preparation magnified on the screen 50 to 100 times greater than in the mouth, and you see things in very high detail. The digital workflow allows you to become much more precise, and keep data that say if process X goes wrong, what step do we need to do to fix it? You start to build a database to be able to correct issues and really refine software as time goes on.

I think adoption is very dependent on age demographics. What I mean by that is those clinicians and even students today who’ve kind of grown up with the video game generation—it’s very simple for them. It’s like looking at a screen playing Xbox—they’re very used to a world where they’re touching a joystick and their actions are being displayed somewhere else. Those of us who grew up in more of an analog world, where they were always able to look at and handle the tooth directly, there’s a little bit more of a learning curve.

Even so, the learning curve in regard to the clinical use of the machine is actually pretty low. The big obstacle, I think, occurs in office implementation. There’s a cost barrier, and then there’s also a potential learning curve in terms of material usage—so not necessarily the machine, but getting comfortable with different types of restorations. The learning curve is very different based on if you want to make restorations in your office or if you only want to take a digital impression.

Clinicians know there are built-in flaws in traditional restorative dentistry and we’re trying to accommodate for that all the time. By using a digital process, we get to take a lot of those inaccuracies out of the mix, or account for them early and adjust quickly.

In a study we did at the University of the Pacific, there was about a 20% decrease in chair time in delivering CAD/CAM restorations. From a business standpoint, you’re much more likely to have a predictable end delivery, compared to what may be coming back from a laboratory—and it’s no fault to the lab, it’s just the process, or maybe the clinician. There are just more variables in the traditional restoration process, and we’re streamlining those variables now.

I only do digital impressions in my practice—I don’t fabricate restorations. Appointments are much more efficient and we’ve decreased our appointment times by about 15% on either end. When they see their own mouths on the screen, patients are just kind of blown away by it. That’s going to help differentiate our practice, because the overall penetration of CAD/CAM dentistry is still pretty low.

Thomas Wade, CDT

Being a traditional “removable lab” that fabricated a fair amount of screw-retained hybrid bar restorations, we had always worked on cast bars that frequently had to be cut and welded to achieve an acceptable level of passivity/accuracy. These soldered or welded areas would often lead to breakage and failure. It was both tedious as well as a challenge to obtain a high level of accuracy and strength. When I witnessed the extreme accuracy, lightweight, strength, and durability of the CAD/CAM milled titanium bar, I knew it was the future, the near future. The decision to incorporate this technology positioned my lab to not only survive, but to be “cutting edge” and excel, especially with the explosion of the “All-on-4”® (Nobel Biocare, technology.

CAD/CAM allows for “reverse engineering” techniques and can often let us see exactly what level of success can be achieved prior to actually committing to and fabricating prostheses. In a profession where skilled technicians are a commodity, the technology can empower a smaller laboratory to compete at a high level without requiring an army of experienced and skilled technicians.

For me personally, it was an incredible paradigm shift that had an extreme impact on my laboratory as well as my career. It made us not only relevant, but cutting edge. It made our laboratory in demand, and vastly improved my perspective with regard to excitement and financial capabilities. It is my firm belief that whether clinical or laboratory, you either evolve or dissolve. It really is that simple. There have been many examples of this as laboratories have either flourished or become irrelevant, slow and unprofitable, or have disappeared altogether.

As for patient care, it has simply raised the bar across the board, again allowing most professionals to access treatment options that might have been previously unavailable to them.

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Caries Assessment Advantages:

• Easy

• Fast

• Low (or no) cost

• Raises patient awareness

Joel H. Berg, DDS, MS

The innovation I find most important is simply to incorporate a historical/environmental caries risk assessment tool into my practice. The AAPD CAT or CAMBRA are good examples of such tools. We also like to take note of the patient’s “salivary status.” The status of one’s saliva composition and flow rate is such an important factor in predicting future caries lesion experience, yet few practitioners document it. At a minimum, each patient should have their salivary flow rate (rough estimate) and consistency (viscous or thin) documented in the progress notes at each checkup visit, if not at each visit. Awareness of caries risk in the eyes of the practice, and therefore the patient, and raising the level of cognizance about the behavioral and other factors in risk is perhaps the most important agent in effecting change.

Patients (or parents, in my case) are asked about their caries preventing behaviors (diet, hygiene, and fluoride regimen), and salivary status is documented in the progress notes. We also urge all practices to designate a “coach” to improve each patient’s prevention behavior, just like a personal trainer. Patients/caregivers expect to be confronted with prevention discussion, but when it is addressed in a customized/itemized way, there is more attention granted.

We are incorporating a variety of technologies that have been introduced into the market that claim to predict/detect caries (lesions) or assess caries risk. They are variable in their effectiveness. Ultimately, a device must prove to predict future caries experience if it is truly “specific.” Many devices claim high specificity (sensitivity is easier—there are many false positives), but there generally has not been a prospective test to look for caries experience as a future outcome that is “predicted” somehow by the device. We are at an academic health center, the University of Washington, and we are engaged in testing a variety of devices and technologies including some homegrown ones. In the meantime, we will continue to emphasize the importance of raising the patients’ awareness about their risk level and their own role in reducing it.

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CBCT Advantages:

• Predictable diagnosis

• Detailed, accurate information

• Improved measurements

• Enhanced patient education

Samuel Kratchman, DMD

We use the CBCT (cone-beam computed tomography) for many purposes, such as diagnosis of periapical lesions, especially in the posterior mandible or in proximity to the sinuses, as well as to determine the location and extent of resorptive defects, the proximity of teeth to the mental foramen, mandibular canal, and sinuses for surgical cases, and the distance to apices from the cortical bone when doing apical surgery.

There are several units on the market, so it is a question of becoming familiar with the different software to manipulate the images once the CBCT is taken. Also positioning of the patient for the CBCT takes a little practice, but my assistants take all the images and are great at it.

Before the CBCT was available, there were so many diagnostic cases that I would debate with my residents at Penn or with my partners in private practice if there were true periapical lesions or not. Also, prior to doing apical surgery, especially in the posterior mandible, I would have to take several films to see how close the lesion was to the mental foramen, and this was still just an approximation. The CBCT takes all the guesswork out, and therefore removes any stress prior to surgery.

In terms of economics, my partners and I have looked at the CBCT more for its ability to improve patient care and allow us more accuracy in our diagnose and treatment, especially for surgical cases. Of course we charge extra for the CBCT, but often simply incorporate the fee into our surgical fee for patients. Our machine is so clear, that we have referrals sending patients to us specifically for the CBCT to help diagnose a problem such as resorption.

Tarun Agarwal, DDS

For me, guided surgery is a huge innovation, and one that I first heard about around a decade ago while attending a large dental conference. It sounded intriguing but I was lead to believe that it was mainly for complex, fancy implant cases. It wasn’t until about 7 years ago that I decided to incorporate guided surgery into my practice. It was a confluence of technological advancements and having someone truly show me that guided surgery was also well suited for a wide range of implant indications, not just complex cases. I quickly visualized the value to the practice and my patients. It’s been better than anticipated and we’ve never looked back.

Virtual implant planning is an integral part of every implant case. We use it to diagnose implant possibilities and for patient education to communicate our plan and goals with the patient. We have found that since using virtual planning, our case acceptance has increased tremendously.

Of course with any new technology there is some learning curve. I found that the learning curve was short and easily overcome.

I knew this technology was exciting and had the potential to change my practice prior to even starting. However, the true value wasn’t understood until about 12 months into the journey. Specifically, it was the increase in case acceptance and completion of our first full-arch implant case that proved it.

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Piezoelectic Ultrasonics Advantages:

• Surgical and nonsurgical use

• Efficient debris removal

• Better visualization

Allen Ali Nasseh, DDS, MMSc

I used piezoelectric ultrasonics originally for surgical endodontics, more specifically for retropreparations during an apicoectomy procedure, as well as for dislodging a post from the root canal that required retreatment; however, I have radically expanded their clinical use over the past few years. Today, I use piezoelectric ultrasonics in virtually every aspect of my nonsurgical and surgical endodontic care, spanning from using specific tips to trough dentin and find hidden canals all the way to using it for ultrasonic activation of my disinfectant and irrigating with it for gross debris removal.

Ultrasonics do not have much of a learning curve. An expert would have to demonstrate their clinical use to you only once and the rest is simple practice. What’s important to understand, however, is that ultrasonics have a very different clinical technique than rotary instruments. Because they cut upon oscillation of the tip in microscopic figure eight fashion, it’s important to use them loose in the canal and not press hard on the head. They cut at their own rate of dentin removal, which is slower than a rotary bur; however, they are more precise as they cut less aggressively and give the clinician more control over the cutting tip. Furthermore, they allow cutting in tough to reach and difficult to visualize areas that would otherwise not be possible with a rotary handpiece.

Since I increased my use of these devices gradually, I never realized how they had changed my way of practice until I spoke to colleagues who were not using them. I quickly realized that the problems they were encountering by using traditional techniques were not things I was experiencing in my clinical care. I had a moment of epiphany when I realized the way these devices had given me a clinical advantage.

Piezoelectric ultrasonic units like my Forza V3 unit (Brasseler USA, have improved both the efficiency and efficacy of my clinical care. I can create more conservative access preparations and yet achieve excellent irrigation while finding canals without removing excessive dentin. These units have helped me provide faster, better service to my patients.

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Tray Bleaching Advantages:

• Simple

• Safe

• Cost effective

• Patient-directed treatment

Van B. Haywood, DMD

Tray bleaching overnight with 10% carbamide peroxide is an innovation used to enhance the esthetics of the patient such that the color of their teeth more closely matches the color of the sclera of their eyes, creating a natural, youthful, healthy smile. Tray bleaching is used to harmonize the mismatched colors of teeth without the need for a restoration, or eliminate the discoloration of the single dark tooth without aggressive endodontic treatment or any restorative treatment. It can restore aged teeth that no longer match existing crowns to the tooth’s original crown-matching color, and hence increase the esthetic life of the restorations.

The main challenge with tray bleaching is the possibility of sensitivity, usually of the teeth but occasionally of the gingiva. The sensitivity is from the easy passage of both peroxide and urea through intact enamel and dentin to the pulp in 5 to 15 minutes. Through our clinical research at Georgia Regents University, we determined tooth sensitivity could be addressed by placing 5% potassium nitrate in the tray for 10 to 30 minutes when sensitivity occurred. This application could reduce or eliminate the tooth sensitivity in more than 90% of patients due to the calming effects that the potassium nitrate has directly on the dental pulp. This calming mechanism of reducing the excitability of the nerve is very different from the mechanism of the application of fluoride or other tubal blockers. Gingival irritation was addressed by substituting a softer tray (Sof-Tray®, Ultradent Products Inc., than the original published tray, and using the lowest concentration of carbamide peroxide possible, which is 10%. Potassium nitrate is the primary ingredient found in desensitizing toothpastes, and works best for bleaching sensitivity if there is no sodium lauryl sulfate, a foaming ingredient, in the toothpaste. Other options for reducing sensitivity, such as including the potassium nitrate in the bleaching material, or pre-brushing with desensitizing toothpaste for 2 weeks prior to bleaching, later followed. It is best to wait 2 weeks after a prophylaxis before initiating bleaching to allow the soft tissue to recover and the tooth to stabilize to avoid additional sensitivity.

We also realized that every patient’s teeth will respond at a different rate, and discolorations respond at a different rate, making it impossible to predict the time required for bleaching. General discolored teeth can take as little as 3 days or as long as 6 weeks to bleach; nicotine stains can take 1 to 3 months of nightly bleaching to eliminate; tetracycline-stained teeth can take 1 to 12 months, with an average of 3 to 4 months of nightly treatment to reduce or eliminate the stains. Patients must bleach until the tooth stops changing color. However, that endpoint will be different for every patient, so we cannot predict the final shade or the amount of time to achieve it.

The simplicity of the technique, the widespread application for all types of stains and genetic discolorations, and the exciting acceptance of the outcome by patients confirmed that my approach to dental esthetics would be changed forever. The impact on my practice has been profound. The tray bleaching technique provides a means for virtually all patients to have better appearing teeth without expensive or aggressive treatment. It becomes a gateway for patient to see the need for further functional or esthetic dental treatment. The sensitivity treatment option has become a means for treatment of all types of sensitivity, including post-periodontal surgery or toothbrush abrasion/abfraction. The ability of the 10% carbamide peroxide to remove plaque, elevate the pH in the mouth above that which the caries process can occur, and kill the bacteria that cause tooth decay has provided a conservative means for caries control in elderly patients with dry mouth, physically handicapped patients, and orthodontic patients. Carbamide peroxide can also remove cholorhexidine stains, as well as nicotine, coffee, tea, or wine stains, and tends to make a patient appear 10 years younger and healthier.

All of these applications provide more treatment for patients than every existed before, hence increasing both patients and services I am able to offer as a dentist.

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Modern Implant Advantages:

• Greater internal stability

• More predictable

• Higher success rates

• Higher rates of osseointegration

Michael Sonick, DMD

Thirty years ago, implants were deemed experimental and relegated to the fringes of conventional dentistry. Today, they are routine and placed in offices worldwide. In terms of innovations, we have seen the advent of altered implant surfaces, CBCT scans, growth factors, guided bone regeneration, membrane development, piezo surgery, immediate loading, routine use of computers in dentistry, and the Internet. All these technologies have led to differences in the way we deliver and perform dental services.

The initial design of dental implants has also undergone changes since the 1980s. Originally, cylindrical implants were tapered, polished titanium with an external hex. The success rate of these initial implants approached 94%. However, their initial stability was not always ideal due to their macro- and micro-geometric design. An additional concern was screw loosening, which often resulted in fractured screws and damaged implants, as well as increased patient visits and complications.

The advent of tapered implants allowed for greater implant stability. This has led to a higher success rate, especially in poorer quality (type IV) bone, such as the posterior maxilla, which showed failure rates approaching 35% with the original machined titanium straight-walled implants. Implant surfaces have also undergone a metamorphosis and are now uniformly roughened. Roughening creates a greater surface area resulting in a higher percentage of bone-to-implant contact and an increased success rate of osseointegration. The success of immediate placement of dental implants into extraction sites, as well as immediate loading of dental implants, depends upon good implant stability. Changes in implant shape and surface texture have made these procedures more predictable, with success rates for immediate placement approaching that of a delayed approach, more than 98%. Patients are well served, for there is a reduction in the number of surgeries as well as treatment time. It’s a win-win.

Louis F. Rose, DDS, MD

I use the NobelGuide system (Nobel Biocare) for single, multi-unit, and edentulous cases. I first learned of this innovation in 2004, but I didn’t truly incorporate it into my practice until 2014. The decision to use it with regularity was made after spending a significant amount of time with my implant representative reviewing the procedure and research. I always want to be on the cutting edge of new technology. Referring dentists require accurate, predictable placement of dental implants and maximum bone and soft tissue support. My representative explained the benefits of the technique and spent a lot of time teaching me. He still does.

There is a certain level of blind faith associated with a computer-generated guide. Because navigation of software is required, there may be a significant learning curve for some clinicians.

In terms of technique, I have found that injecting anesthesia into soft tissue can interfere with the fit of the surgical template. The use of the system also depends upon how much a patient can open to accommodate the instruments.

The key advantages of using the NobelGuide system include a shortened surgical procedure and predictable surgical and restorative outcomes; decreased anxiety and trauma for the patient, especially medically compromised patients; less time at chairside; fewer intraoperative surprises; and less clinician stress.

In summary, the technique demonstrates increased accuracy with implant placement as well as a decrease in complications. While the advantage is overall predictability of the case outcome, case planning does take more time, and both doctor and patient may incur additional costs. Many dentists may be fearful of the new technology and resistant to change and the need for additional education. In my practice, however, this system represents an important innovation that improves patient care.

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Clear Aligner Advantages:

• Encourages thorough treatment planning

• Better esthetics during treatment

• More comfortable for patients

Shalin Shah, DMD, MS

The benefits of clear aligners are that they are more esthetic and more comfortable. For patients who have a diagnosis that would lend itself to a clear aligner therapy option and want that esthetic, more comfortable type of treatment, compliance is the key to a successful treatment plan.

In orthodontics and dentistry, we’re trying to enhance the patient experience, and the clear aligner option completely speaks to that. It’s a treatment modality that people feel is better than what they may have experienced in the past, or what their friends and family experienced when they had braces. From the service point of view, their appointment times are much shorter, because you check to make sure that everything was well planned and the aligners are still following the projected path. If everything is okay, we can spend more time focusing on enhancing that personal relationship.

When you begin to get the data points of success, know what clear aligner therapy can achieve, and understand what strategies can help patients succeed, you became more comfortable using it. In clear aligner therapy, you are prognosticating: for example, how are we going to get to the end goal 2 years, step-by-step? If you don’t understand what are achievable movements with a clear aligner, you can have the end goal in mind that is unachievable. That’s usually the initial stumbling block, but the clear aligner companies support you through that to minimize “reroutes.” The other hurdle is compliance. Once you have this well-crafted series of aligners that will get you to that end goal, the next step is that they have to be used as directed. So as long as compliance is there, it is unlikely that you won’t meet your treatment goal.

Temporary anchorage devices (TADs) are another huge innovation in orthodontics. They are titanium alloy mini-screws placed into the bone to serve as anchors. Unlike implants, the TAD does not integrate with the bone, so it can be used temporarily for treatment.

Newton’s Third Law states that for every action, there is an equal and opposite reaction. In the ortho world, that’s the biggest challenge. Let’s say you need to slide one tooth back to get to your end goal. You have to somehow figure out a way to do that without also sliding the tooth in front of it forward. With the TAD, you can anchor the teeth you don’t want to move to the screw, and then drive everything else where you need it to go. Then when you’ve made these movements without any untoward effects, you can simply just remove the screw without any consequence to the bone tissue or the teeth.

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Dermal Allograft Advantages:

• Shortened surgical time

• Increased keratinized mucosa

• Thicker soft tissues

• Greater patient comfort

Barry P. Levin, DMD

I began using Symbios® PerioDerm® (DENTSPLY Implants, as a soft tissue thickening agent and barrier (dual-function) around implants via a soft tissue punch and adapting the material around healing abutments. I apply the material with the connective tissue side facing “up” or in contact with the periosteum of the buccal/lingual flaps. I believe this allows for optimal incorporation of the dermal allograft and prevents sloughing during the postoperative period.

Selection of the proper size to allow for generous overlapping of the bony walls is crucial. I found that using the thicker variety of PerioDerm sometimes compromised adaptation and closure, leading to delayed healing and sloughing. Increasing soft tissue thickness with a dermal allograft has been shown in the literature to prevent crestal bone loss. Experience has lead to better diagnosis and recognizing when the thicker or thinner PerioDerm material is appropriate. If possible, I prefer the thicker (0.8-1.4 mm) PerioDerm over the thinner option (0.4-0.8 mm).

I started to see that using this material versus traditional, but quite thin, collagen/synthetic GBR membranes led to increased zones of keratinized mucosa and thicker soft tissues. Especially when non-submerged implant placement is performed, and membrane exposure is anticipated, PerioDerm cases resulted in wider zones of masticatory mucosa and obviated the need for coronally advanced flaps, which reduce the amount of buccal keratinized tissue. Radiographically, bone levels in these cases remained stable throughout and after treatment times.

It has become a routine, cost-effective way of increasing peri-implant soft tissue volume and bone graft containment. From a patient perspective, the morbidity of obtaining sub-epithelial, connective tissue grafts can be eliminated. This shortens surgical time, leading to greater patient comfort. The cost of the material is relatively conservative, and it is used a barrier, which is a routine element of many implant surgical procedures. Because I can perform more procedures in a shorter amount of time, routinely incorporating PerioDerm into many implant surgical procedures has had a positive impact on my practice.

I do continue to utilize autogenous soft tissue grafts in sites deficient in keratinized mucosa, thin periodontal biotypes, and some esthetically critical areas. However, the number of times I select to use autogenous soft tissue grafts around immediate implants has decreased based on the positive results achieved with this particular dermal allograft.

Dan J. Holtzclaw, DDS, MS

The way we approach the field of periodontics and regenerative dentistry is completely different than what was being done a quarter century ago. For me, the top innovation that has had the biggest impact on my clinical practice was the introduction of amnion-chorion membranes. Amnion-chorion is a placental-based allograft that has a multitude of inherent growth factors and unique attributes that exist in no other products on the market. Although placental tissue has been used in medical procedures for more than 100 years, in 2008, it was a new product for the field of dentistry and had not been used for many applications. The only amnion-chorion product on the market is BioXclude from Snoasis Medical ( After more than 6 years of using this product, I know it inside and out. I literally use it on a daily basis. Every extraction/site preservation procedure is covered with BioXclude. Every periodontal intrabony defect I treat with guided tissue regeneration (GTR) receives coverage with BioXclude. When performing sinus lifts, I use BioXclude for Schneiderian membrane repair and for coverage of the lateral access window. When performing larger guided bone regeneration cases, I typically employ a double barrier technique where I use a longer lasting collagen based membrane directly on the bone graft and overlay this collagen barrier with a BioXclude membrane to facilitate better soft tissue closure. If I am doing a regenerative procedure, I am using BioXclude in some fashion.

A typical collagen barrier is 800 to 1,000 microns thick, whereas BioXclude is about 350 microns thick. Being very thin does produce many advantages for BioXclude, but it also makes the membrane a little difficult to handle for practitioners who have never used the product. After using it a few times, however, most find the product easy to handle.

I have owned multiple clinics during my time in private practice. After fully incorporating BioXclude into my clinic, my clinical results improved, which led to increased referrals. These increased referrals led to increased revenues. Plus, my patients have never been happier.

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Laser Advantages:

• Minimally invasive

• Excellent outcomes

• Reduced patient discomfort

Scott D. Benjamin, DDS

Today we are using multiple lasers in our practice on a routine basis. The value of laser technologies has expanded from the original applications of soft tissue surgery and tooth preparations to additionally aid in prevention, diagnosis, pain management, and healing of a multitude of oral and systemic conditions as well as to enhance endodontic and other routine procedures. The selection of the appropriate laser depends upon the patient’s condition, the treatment needed, and the desired outcome.

The most routinely performed soft tissue procedures using a 970-nm diode or a Nd:YAG laser are for periodontal pocket decontamination as an adjunctive aid to scaling and root planing or to create access for subgingival margins and restorations. One of the most beneficial procedures of the Er:YAG laser is its routine use for disinfecting the entire root canal system utilizing the photon-induced photoacoustic streaming technique.

Approximately 20 years ago, after taking several courses on the science of lasers and discussing the technology with many of our colleagues, I invested in a Nd:YAG laser to be used specifically as an adjunct modality to scaling and root planing. I was extremely pleased with the outcomes and reattachment we accomplished. This success was motivation for expanding its use and furthering my research. This led to the incorporation of several different wavelengths, each with its own unique benefits, that I’m using today to enhance my patient care.

One of the major flaws I experienced in my education on lasers, ironically, was focusing on the laser device and how it functions rather studying the target tissue with which the laser energy is interacting. By understanding the composition of the target tissue and the true treatment objective, it simplified my understanding on what device to use, how to control it, and how to achieve the desired results.

The number one value of laser technology is improved treatment outcomes with minimally invasive procedures that cannot be accomplished in any other way. Performing procedures proactively with lasers can also prevent the further progression of conditions, minimizing the need for more extensive and invasive measures in the future.

The enhanced efficiency of performing minimally invasive procedures combined with the reduced need of anesthesia enables increased productivity in a reduced amount of time. The reduced need for anesthesia enables treatment in multiple quadrants in the same appointment, reducing the number appointments required to complete care. Reduced discomfort during treatment and postoperatively greatly improves patient satisfaction, reduces patient anxiety, and promotes referrals.

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Bulk-Fill Composite Advantages:

• Less time to complete restorations (including less curing time)

• Reduced polymerization shrinkage

• Excellent finishing and polishing

Michael R. Sesemann, DDS

Having the capability to provide posterior direct composite restorations is absolutely critical for a practice that provides general practice services. The patented technologies of Ivoclar Vivadent’s Tetric EvoCeram® Bulk Fill ( allow me to provide this labor-intensive service efficiently and effectively while eliminating the issues that made this technique difficult to provide the past 20 years in practice.

I first learned about this material in 2008, about 2 years before it was available on the commercial market. After utilizing incremental placement technique with total-etch adhesive technology for more than 20 years, I felt that this product had a chance to revolutionize this procedure. It only took a few procedures to see and feel the difference in the technique. Once we confirmed postoperative satisfaction from our patients, my staff and I never wanted to be without this material in our armamentarium. I’ve been using the product with great satisfaction ever since.

Back in 2008 to 2010, I initially used the bulk-fill composite with fourth and fifth generation adhesive systems. So, we were still taking great care with our adhesive protocol to treat the dentin correctly and establish a hybrid layer that was optimal. That took time and always carried a certain amount of stress. Now we’ve incorporated Adhese® Universal (Ivoclar Vivadent) in a selective-etch technique, thereby eliminating all of the drama involved with the total-etch technique (ie, managing smear layer removal and dentin tubule management). As research is illustrating, for a direct composite restorations, self-etching protocols for the dentin/resin bond provides the strongest, long-lasting bond over time.

My staff and I were completing the direct restorations 30% to 60% quicker than our scheduled time. The placement was easy due to the malleability of the material. The curing was significantly shorter and the finishing and polishing was excellent. The reduced polymerization shrinkage eliminated marginal trauma and established superior interproximal contacts. Once we confirmed that our patients were going through the procedure without postoperative sensitivity, we knew we would never be able to go back to incremental fill technique with complete, total-etch adhesive protocols ever again.

Economically, I can now do a direct restoration for an allotted time that is commensurate with fair fee compensation. The time we save can be used for other things, and the patient’s appointment time is reduced, much to their liking. As operators we are not fatigued by a long, demanding procedure as we had been in the past, all while fabricating a technologically superior direct restoration.

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a | Planmeca PlanScan®

Ultrafast intraoral CAD/CAM system with blue laser technology.


b | CariVu™

Exposes the structure of carious lesions with very high accuracy.


c | GXDP-300™

Easily captures well-defined, high-quality panoramic images.


d | All-Bond Universal®

Combines etching, priming, and bonding in one bottle.


e | G-CEM LinkAce™

Self-adhesive resin cement optimized for indirect restorations.


f | Opalescence® PF Take-Home

Provides customized whitening in as little as 30 minutes per day.


g | PALA Digital Denture System

Delivers a perfect fit in a fraction of the time of conventional dentures.


h | BeautiBond®

Unique chemistry delivers equal bond strength to enamel and dentin.


i | Adhese® Universal

Delivered directly to the preparation with virtually no waste.


j | CEREC®

More than 28 million restorations placed with a long-term survival rate of 95%.


Circle 131 on Reader Service Card

k | Solea™

First CO2 laser system cleared by the FDA for hard and soft tissue.


L | OptiBond® All-In-One

Provides superior adhesion to all surfaces and substrates.


Consumer Innovations

At-Home Whitening

With a variety of delivery methods available, including strips, trays, pens, and more, newer at-home whitening options allow patients to improve the esthetics of their smiles in a way that is simple and affordable.

Electric/Sonic Toothbrushes

Marketed for their ability to remove more plaque than a manual toothbrush, these devices offer patients an easy way to improve their oral health by helping to prevent gingivitis and tooth decay.

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