25th Anniversary Retrospective: Experts Assess Important Advances in Dentistry

The changes in restorative dentistry  have been significant during the last 5 years. This brief section discusses some of them.

ZIRCONIA-BASED CROWNS AND FIXED PROSTHESES

The most significant change in restorative dentistry has been the advent and cautiously enthusiastic acceptance of the CAD/CAM-manufactured zirconia-based crowns and fixed prostheses. Popular brands in the United States are Lava (3M ESPE), Cercon (DENTSPLY), IPS e.max (Ivoclar Vivadent), Everest (KaVo), and CEREC inLab (Sirona). The oldest brand of these restorations, now called Cercon, has had about 7 years of clinical research and observation on it, most of which has been favorable relative to fit and strength of the single- and multi-unit frameworks. On the other hand, reports on the service of the superficial veneering ceramic have been less favorable when compared to porcelain-fused-to-metal control restorations. The technique is being refined constantly, and it will probably become a major part of dentistry over the next few years. Generally, practitioners are pleased with the aesthetics and clinical service of these restorations to date.

Gordon J. Christensen, DDS, MSD, PhD

Restorative dentistry continues to change along with the needs and desires of the public. The refinements are impressive and useful for the patients we serve. A few of the advancements have been discussed in this section, and many more are observable.

RESIN-BASED COMPOSITES

It has been at least 30 years since there have been major changes in resin-based composites. At that time, the mean glass filler particle size of previous resin-based composites was reduced to a fraction of a micron, resulting in restorations that retained smoothness over a period of service better than previous large particle size materials. With the exception of the long-present and minimally used microfills (Durafill [Heraeus Kulzer], Heliomolar [Ivoclar Vivadent], Renamel Microfill [Cosmedent], and others), the mean particle size of glass fillers used in most microhybrid composites has remained at 0.6 to 0.4 mm. As a result, composite restorations have appeared to be smooth when placed and finished well, but they have soon lost their smoothness as a result of the well-known “plucking” phenomenon. Of importance in direct veneers, class IVs, and large class IIIs, the new 3M ESPE product Filtek Supreme Plus contains a mean zirconium oxide particle size in the nanofill level (<100 nm or <0.1 mm). In research to date, this product has provided both strength as well as retention of smoothness.

SELF-ETCH RESIN CEMENTS

Resin cements with self-etch primers included in the chemistry have eliminated the objectionable postoperative tooth sensitivity previously associated with total-etch resin cementing techniques. When high-strength and low solubility are needed in cement, new products such as RelyX Unicem (3M ESPE), Maxcem (Kerr/Sybron Dental Specialties), MonoCem (Shofu), Multilink Sprint (Ivoclar Vivadent), and others are good choices. The downside of these cements is that they do not contain fluoride. Resin-modified glass ionomer is still a great choice for routine cementation of PFM or zirconia-based crowns and fixed prostheses.

CORD REPLACEMENTS FOR IMPRESSION PROCEDURES

Placement of cords before making impressions for crowns and fixed prostheses has always been a frustrating technique for some dentists. Recent introduction of cord replacement products such as Expasyl (Kerr/Sybron Dental Specialties) and Magic FoamCord from Coltène/Whaledent have satisfied the needs of some dentists, and cord placement for simple procedures has been reduced or eliminated. However, in my opinion, the double-cord technique is still the old “standby” for difficult multi-unit cases.

PREVENTIVE RESTORATIVE MATERIALS

As the aging population continues to increase and new locations of dental caries are observed, restorative materials that reduce the incidence of subsequent caries are more necessary than in the past. Fuji IX GP (GC America), the well-known glass ion-omer restorative product, has been improved and placed in a new capsule, making it a highly useful product for restoring teeth in high-caries active patients ranging from children to senior citizens. The new 3M ESPE product, Ketac Nano, has provided the caries-preventive characteristics of a resin-modified glass ionomer with 40% nano particles, making it both a preventive and smooth surface retaining tooth-colored material.

BONDING AGENTS IN ONE BOTTLE

Over numerous years, bonding agents, originally packaged in 3 bottles (etch, primer, and bond), have evolved into 2 bottles (acid, primer and bond), and finally into one bottle containing all 3 ingredients. Self-etch primers have captured the US market because of their proven reduction in postoperative tooth sensitivity and acceptable attachment to dentin and enamel. One-bottle bonding products are available from almost every composite company. Popular products include Brush&Bond (Parkell); OptiBond All-In-One (Kerr/Sybron Dental Specialties); Xeno IV (DENTSPLY Caulk); G-Bond (GC America); iBond (Heraeus Kulzer), and many others. With a few exceptions, it is wise to refrigerate the one-bottle bonding agents to prolong their shelf life. Practitioners appear to be pleased with the effectiveness and simplicity of the one-bottle systems.

NO-PREP VENEERS

It is obvious that this concept, introduced about 20 years ago, has had a great revival, stimulated by the introduction of Den-Mat LUMINEERS. Many companies have copied the Den-Mat lead, and practitioners are using the no-prep veneer techniques with success. It is well to remember that thin (0.3 mm) veneers are not for everybody, but that there are some indications for no-prep veneers in every restorative practice.

CONCLUSIONS

Restorative dentistry continues to change along with the needs and desires of the public. The refinements are impressive and useful for the patients we serve. A few of the advancements have been discussed in this section, and many more are observable.

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In the past 5 years we have seen many changes in the art and science of aesthetics in dentistry. These changes have impacted the services we provide patients as well as the efficiency in our practices. Furthermore, as a result of television shows like Extreme Makeover, the public is now much more aware of how a smile impacts their quality of life and how dentistry can change lives through aesthetic/cosmetic dentistry.

Marvin A. Fier, DDS

In the past 5 years we have seen many changes in the art and science of aesthetics in dentistry. These changes have impacted the services we provide patients as well as the efficiency in our practices. Furthermore… the public is now much more aware of how a smile impacts their quality of life.

The quality of our direct restoratives has greatly improved. We have materials that more closely match the way tooth structure diffuses and reflects light, allowing us to achieve more lifelike restorations. Several manufacturers have provided “recipe” shade guides along with their materials, allowing us to achieve excellent results more efficiently with less guesswork. As for shade matching, we have computerized shade-taking devices. These can be used to select shades for direct or indirect procedures, and in many cases these devices get us to the desired shade more accurately than with the human eye. Another great way to accomplish this task for indirect restorations is via the Internet and e-mailing digital images to our technicians.
On the laboratory side, improved porcelains have been developed that mimic tooth structure better than ever. We have porcelains that exhibit lower wear characteristics, which is a big plus for opposing dentitions. Laboratory-processed polymer glasses are greatly improved and are now a viable substitute for porcelains. These hybrid materials are aesthetic and allow us to choose a porcelain alternative that is kinder to opposing dentitions. Zirconia substructures have become more prevalent due to their strength and lack of metal, which needs opaquing. We have also seen the introduction of complete porcelain systems. By using one porcelain system that can handle many different substructures, a technician can have more control over complicated combination cases involving laminates and crowns or bridges, and achieve a more consistent final shade.
The use of self-adhesive resin cements for crown and inlay/onlay cementation has increased greatly. By eliminating the technique-sensitive protocol for acid-etching and bonding, practitioners are more likely to use less soluble resin cements for the newer types of tooth-colored full- and partial-coverage restorations. This leads to a more efficient way of cementation and subsequent decrease in stress for these procedures. In addition, postoperative sensitivity is reduced significantly with these products, creating happier patients.
CAD/CAM technology has improved, and we can create customized zirconia abutments for implant-supported restorations, allowing for excellent aesthetics with crowns or bridges over implants. CAD/CAM also allows us to fabricate well-fitting tooth-shaded restorations in our offices. For the dentist who wants to provide in-office, one-visit indirect restorations, the advances in this area have made the technology more user-friendly and allow for more predictability than ever before.
Finally, one of the most important changes in the art and science of aesthetics in the past 5 years has been dentists’ increased awareness about the elements and steps necessary to plan and perform aesthetic/cosmetic dentistry. Through courses provided by organizations like the American Society for Dental Aesthetics (ASDA) and the American Academy of Cosmetic Dentistry (AACD), more dentists have been able to learn the theory of designing smiles and the techniques to achieve more lifelike results. Diagnostic aesthetic wax-ups have become an essential part of planning any significant aesthetic change. Better materials and techniques for temporizing these cases have allowed our patients to visualize changes before we create the final restorations. With excellent continuing education courses available, it is far easier than ever to get the information and practice necessary to give patients the smiles they’ve always wanted or to recreate the smiles they once had.
We have seen many changes in aesthetics in the past 5 years. I expect we will continue to develop and refine this area of dentistry even more in the years to come.

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Five years ago, when asked to write a short essay on how technology had changed the way I practice, Dentistry Today was celebrating its 20th birthday. Looking back over that 20-year span, it was easy to spot how digital technology had taken hold. I cited the use of digital photography and patient education tools such as CAESY playing the role of practice builders that were not only useful but fun to implement. Also noted was the use of cosmetic simulations such as those supplied by Smile-Vision to increase both the quality and quantity of smile rehab cases. And, of course, the increasing use of digital x-ray systems was referenced.

Martin B. Goldstein, DMD

One might say that 5 years ago, these digitally based modalities were in their “infancy,” or at least their earlier stages of development. The last 5 years might be looked upon as a maturation phase for these same technologies. While not new, things have certainly gotten better!

One might say that 5 years ago, these digitally based modalities were in their “infancy,” or at least their earlier stages of development. The last 5 years might be looked upon as a maturation phase for these same technologies. While not new, things have certainly gotten better!
Have you done a megapixel count of late? What were once 3-megapixel wonders have been replaced by 10- and 12-megapixel sensors as far as digital cameras are concerned. You’ll also notice that what were once postage stamp-sized LCDs are now approaching 3-inch diagonal screens. Thus, resolution and image monitoring have taken quantum leaps as have image quality and image processing speed. Perhaps even sweeter is the plummeting cost of a high-end digital single lens reflex system, costing less than half of what it did just 5 years ago. The sub-$1,000 digital SLR
body is here!
The “other” digital wonder—radiography—hasn’t stood still either. Sensors have gotten smaller, thinner, and in some cases have gone wireless, while the software to manage x-ray images has matured rapidly, even to the extent that interproximal caries can be mapped. Take a look at Kodak’s Digital Imaging (KDI) suite that complements the Practiceworks and Softdent family. The varied diagnostic modalities that include x-ray, intraoral video, and still photos are integrated into one slick module. It keeps getting easier to manage all that data under one “digital roof.”
Have you looked at a CAESY animation lately? The quality and scope of the animations have increased dramatically. You’ll note that dentistry’s current buzzwords such as NTIs, mini-implants, minimal prep veneers, CEREC, TMJ, etc, are all covered in brilliant color and computer-assisted animation.
Perhaps the one area that has had the most significant influence on personal practice growth has occurred as a result of high-speed Internet service. Speedy Internet connections, having replaced dial-up access, have opened the door to practice management usage. Insurance claims and accompanying media are now easily sent back and forth to carriers via Web-based access, while insurance company fee schedules are easily updated via Internet downloads in a matter of minutes. Of particular interest is online credit approval via CareCredit, which is cleverly built into our Kodak’s Softdent management software. Patient data, already on file, is quickly uploaded to CareCredit along with patient financial information, allowing nearly instant credit approval should the applicant qualify. Needless to say this has streamlined our case acceptance process considerably; all made possible by Internet access speeds that have now become commonplace.
In that same vein, practice Web sites now create dynamic office brochures that usher patients into our midst with advanced knowledge of what we can offer, while online practice referral services point new patients in our direction.
Finally, computer power, heightened by dual core processors and enormous hard drives, assists in speeding all of the above along. We need only keep our PC hardware current to make sure we can avail ourselves of all that digital technology has to offer our profession.
Indeed, the dental digital world has “grown up” over the last 5 years, but you can be certain that today’s digital wonders will only be improved upon by the time you read our next anniversary edition. Check back with us on Dentistry Today’s 30th birthday for a status check!

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Periodontics in 2007 is leading the way in the health revolution in dentistry. Much has happened in the past 5 years to improve how dentists can deliver periodontal care to improve the oral health of their patients.
New dental implant designs have allowed dentists to successfully replace teeth with advanced periodontal disease at the same time the tooth is extracted. The implant can even be loaded with a temporary abutment and crown when placed, conditions permitting.

Neil R. Gottehrer, DDS

Maintenance of periodontal health has become easier with the combined use of new oral hygiene aids, including ultrasonic power toothbrushes, portable power irrigation units, and antimicrobial toothpastes and mouthrinses. Advances in ultrasonic instrumentation and instrument design of hand scalers and curettes have made it easier to remove foreign deposits on root surfaces without incidentally removing excess cementum and creating root sensitivity.
It is now possible to treat the patients taking blood thinners such as Coumadin or Plavix, and the adult patient taking a daily dosage of aspirin, without them having to stop taking the medication. The bipolar unit and some lasers allow the gingival sulcus or pocket to be clotted after instrumentation to prevent post-treatment bleeding.
Recognition of the medical/dental condition relationship with the possible increased risk of cardiac disease, stroke, and adult-onset diabetes in the patient with active periodontal disease has created additional possible benefits of periodontal treatment. The information available to our existing and prospective new patients about this connection will make it easier for patients to accept periodontal treatment recommendations.
Analgesia is now more easily achievable when performing scaling and root planing without using injectable anesthetic. Subgingival gel placement can achieve anesthesia, allowing instrumentation without patient discomfort.
Previously undetectable calculus can now be located and detected in traditionally difficult-to-access tooth/root sites and removed successfully. Diagnostic salivary tests are in use, and new tests are currently being developed for early detection of periodontal disease that can be used by all health professionals.
The past 5 years’ advances in periodontics have provided a more exciting future for dentistry. Additional developments will lead dentistry to a point where periodontal disease can be predictably managed, attracting more interest for treatment and improved dental/physical health.

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Thirty years ago, the mere mention of the term “dental implant” was controversial. Many in organized dentistry stated that implants most always fail, and the lack of separation between the oral flora and bone around an implant may lead to brain abscess and heart disease. However, a few pioneers and dentists around the world realized implants usually were successful, and patients desired dental implants to stabilize dentures or prevent the preparation of their adjacent teeth for fixed restorations.

Carl E. Misch, DDS, MDS

In the early modern implant era of 1985 to 1995, the majority of articles were related to the surgical placement of implants, and total implant sales in the United States were about $10 million each year. Today the surgical success of implants in acceptable bone volume is more than 95%. Hence, implant surgery articles have become less important. From 1995 to 2000, the implant field primarily focused on surface conditions of implants, and the total sales to the profession increased to $100 million each year. Smooth or machined surface conditions on an implant body demonstrated higher early failure rates after loading and more crestal bone loss. As a consequence, most every major implant company today provides implant bodies with a roughened surface texture. At this point in time, there does not seem to be major advantages of one rough surface condition over another.
During this intermediate time frame (1995 to 2000), bone augmentation or regeneration became popular. The concept of placing implants into existing bone volume in the early era was replaced by changing the bone volume, which allowed a more prosthetic-friendly treatment. Guided tissue regeneration, sinus grafts, and block bone grafts from the ramus and symphysis were all developed with this goal in mind. The increase in implant survival over the years is probably more related to improved anatomic conditions after bone regeneration than the implant design.
The long-term research and data available today have now introduced a new era for all of dentistry. Every graduate program in periodontics, oral surgery, and prosthodontics teaches implant dentistry. Orthodontic programs use implants as anchorage devices to move teeth and bone. Dental implants are now used in more than one half of dental school programs to support mandibular dentures. The placement of a posterior single-tooth implant to replace a missing tooth is taught in more than 25% of dental schools, and implant surgery is a class offered as an elective to senior dental students in 15% of schools.
More than 90% of general dentists now offer implants to their patients as a method to replace missing teeth within their practice. Ten-year studies demonstrate that a single-tooth implant lasts more predictably than a 3-unit fixed partial denture and with less risk of decay or endodontic failure of the teeth adjacent to the missing tooth. In many offices, single-tooth im-plants have become the best method for the treatment to replace missing teeth.
The last 5 years of implant dentistry have focused on crestal bone loss, aesthetics, and immediate restoration after implant surgery. Total implant sales to the profession have increased to $1 billion each year. There are at least 6 causes of crestal bone loss, including surgical trauma, the microgap position, biologic width, implant design, occlusal overload, and peri-implantitis.¹ Of these, the implant design features are least understood. The microgap position is the junction of the abutment to the implant body. The microgap, in and of itself, does not cause bone loss (since a cover screw in an implant is often covered with bone at a stage 2 uncovery in a 2-stage healing approach). However, an implant crest module (the top of the implant body) that is smooth below the bone increases the microgap and biologic width bone loss after the implant extends through the gingiva. Microthreads on the crest module may reduce the biologic width bone loss, and the microthread design appears to improve the soft-tissue and bone condition compar

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