Espertise

magazine

No. 23 | FEB 2013

Cmon Fotolia.com

EDITORIAL
Dear Readers,
Similar to edges of a forest, sea, lake or river and field
borders which characterize a landscape, margins in the
oral environment have a huge impact on the appearance
of an individual. A beautiful smile is obtained only if natural soft tissue contours are preserved or restored after
implant insertion or restoration placement. Moreover, restoration longevity and a healthy soft tissue strongly correlate with the quality of the restoration margin.

CONTENT
booth of 3M ESPE to obtain first-hand information about
new materials and devices e.g. from the product developers and pilot users. On the spot, you may test the innovations and compare them to each other. Additional insights
are given in this issue of the Espertise Magazine. It is
composed of articles written by researchers, clinicians
and developers who love to share their personal perspectives and clinical experience with you.
Enjoy reading!

Its all about the margin........................................................................... 2

Improved marginal accuracy through standardization........................ 3
Quality is an integral part of 3M ESPE!................................................. 4
Direct restorations: lifelike appearance, perfect margins.................. 6
New generation cement with efficient marginal adaptation............... 8
Faster, easier and more convenient!..................................................... 9
The effect of different retraction techniques on the gingiva............. 10
Practise-based research results on handling properties.................. 11
The impact of soft tissue management on marginal quality
of restorations........................................................................................ 12
Optimized features for even higher accuracy..................................... 14
How digital technologies may contribute to marginal quality..........16

In order to support you in obtaining perfect margins,

3MESPE offers a whole variety of innovative products,
which will all be presented in Cologne at the worlds largest dental trade fair and meeting place of the dental
industry: the IDS. This is the place to be for all those who
want to be informed about the latest trends and
approaches in dentistry. You are invited to visit the IDS

A conservative approach to indirect restorations............................18

Dentistry in the Kingdom of Belgium.............................................. 20
Dentistry in Israel............................................................................ 21
The solution for compromised patients.......................................... 22

Gerhard Kultermann, Editor

3M ESPE, Seefeld, Germany

Scientific Activities
Espertise Experts Roundtable 2012

Its all about the margin

Frdric van Vliet, 3M ESPE, Seefeld, Germany

In restorative dentistry, there are different

rence of discolouration, microleakage, second-

kinds of margins which have a decisive

ary caries and post-operative sensitivities. The

impact on the aesthetics and functioning of

gingival margin influences pink and white aes-

the final result, including the finishing line of

thetics, which is strongly dependent on perfect

the preparation, the edge of the restoration

tissue management.

and the gingival margin.

These and additional topics around the margin
were addressed by renowned speakers and an

... about recently conducted studies and their outcomes.

exclusive group of dental professionals which

were invited by 3M ESPE to attend an Espertise

different approaches towards an improved qual-

Experts Roundtable at Lake Starnberg near

ity of the restoration margin and techniques for

Munich, Germany in November 2012. Here, e.g.

soft tissue management were presented from

both, a clinical and a scientific viewpoint. After
two days of lectures, poster presentations and

Event location at Lake Starnberg in Germany.

discussions with colleagues, the participants

The preparation and its finishing line have to

agreed that the margin influences restorative

comply with certain preparation guidelines in

dentistry in many ways. It was concluded that a

order to ensure that a precisely fitting restoration

high quality of the final result can only be

can be produced and placed that remains stable

ensured through exact planning of a treatment,

over time. At the edge of the restoration, precision and smoothness are of utmost importance:

Various topics were discussed during the lecture programme ...

Irregularities at this margin may result in an

the use of advanced materials and devices and a

standardization of workflows in practice and
laboratory.

improper fit and may lead to tissue inflammation,

bone resorption and ultimately to failure of the
restoration. Apart from accuracy, a tight seal of
the interface between the tooth and the restoration must be obtained, no matter whether direct
or indirect restorations are placed. Only with a
strong bond is it possible to prevent the occur-

... and in the breaks.

Renowned speakers reported on their clinical experience

and research findings.

During the poster presentations, young researchers provided information ...

Exchange of ideas and opinions.

No. 23 | FEB 2013

Espertise

Ask the Expert

magazine

Restorative dentistry

Improved marginal accuracy through standardization

Bernd Wstmann, Giessen, Germany

The striving for a perfect margin in restorative

Original dimension of the tooth

dentistry is a well-known phenomenon: scien-

be dried successfully. If this is not possible, a

tific-based knowledge indicates that inflam-

Impression

mation of gingival tissues and bone destruction correlate directly with a poor quality of the

b)
smaller

larger
c)

Cast production

many different factors that may lead to mar-

Standardization of processes

ginal inaccuracies. Strategies to avoid the

occurrence of these imperfections are dis-

d)

e)

What should also be taken into account is that the

cussed in the following article.

altering of process steps, materials and production

Original dimension of the tooth

conditions in the treatment workflow may lead to

differences in the accuracy of the final result. For

Factors influencing accuracy

Impression

The first sources of inaccuracies evolve from tooth

example, using more than one impression material

or different types of plaster for cast production in the

larger

smaller

meet all criteria with regard to the perfect finishing

restorative processes makes the result less predictable, since e.g. the polymerization shrinkage or

line. Irregularities in the margin and a restoration

Cast production

placed closer than 3 mm to the alveolar crest, for

expansion factors are different. Only the use of the

same materials and the same work steps in every

example, foster tissue inflammation. According to

d)

process reduces the variability of the results. This

e)

in-vitro and clinical studies, the margin design is

standardization should be carried out in the dental

also important for accurate restorations. A chamfer

Original dimension of the tooth

design seems to lead to the best results.

practice and laboratory and even should involve

equal production conditions. For example, a uniform

Impression

In addition, inaccuracies are created in the pro-

temperature in the plaster room to always induce

the same material expansion is very important.

smaller

larger

mouth into the dental laboratory. Errors resulting

Conclusion

from one step in the treatment and laboratory

Cast production

The aim of modern restorative dentistry is the crea-

workflow are usually not compensated by another

tion of long-lasting restorations which perform like

but persist through the whole process and may

even add up to a greater error.

impression technique may be selected depending

on the indication and individual preferences.

a)

process of an indirect restoration, there are

cess of transferring information from the patients

latency of approximately ten days is recommended

to ensure complete healing of the soft tissue. The

restoration margin. However, in the production

preparation which, in clinical reality, often does not

immediately after tooth preparation if the area can

d)

e)

the natural teeth they replace. For a reliable perfor-

Effects of inaccuracies in the fabrication process of a

crown. In a first approximation, the size distribution of the
represented crown lumina in an impression may be
regarded as the normal distribution (above). The same
applies to the master cast (below). (e) represents the
acceptable range for the crown lumen.

mance, accuracy of a restoration and marginal qual-

lenging due to the moist oral environment and

anaesthesia reduces the risk for failure by a factor

structured management of the patient, the tissues

potential bleeding of the sulcus. Studies have

of five. In order to lay the foundation for an accu-

and the biomaterials used is highly important as well.

revealed that taking the impression under local

rate impression, the process should be carried out

The impression
The impression taking process is particularly chal-

ity play a decisive role. In order to create restorations

with perfect margins, not only high-quality dental
biomaterials and techniques are needed. A well-

Ask the Expert

Looking behind the scenes ...

Quality is an integral part of 3M ESPE!

Frdric van Vliet, 3M ESPE, Seefeld, Germany

Quality means doing it right when no one is

looking, says a quote attributed to the American industrialist Henry Ford, the founder of
Ford Motor Company. Indeed, the quality of a
product is defined by people and processes
that are usually invisible to the common user.
In the companys laboratory, developers collect ideas, translate customer wishes into
technological specifications and combine various technologies and ingredients to obtain a
new material or device. The quality of the final
product is determined by how every step in
this process is performed and monitored.
In order to learn more about these invisible processes and the internal measures that are implemented at 3M ESPE to ensure an excellent product performance, we had a conversation with Dr.
Alfred Viehbeck, Vice President, R&D Materials of
the 3M ESPE Dental Products Division. As the
head of the global R&D laboratory with locations

Dr. Viehbeck, in Research & Development of

dental materials, Quality Management is of
major importance. Why is quality so crucial
for 3M ESPE?

are launched, perform the way they are intended

to perform.
Please describe the different stages of product development from the initial idea to

The confidence our dental professional customers

have in us is at stake every single time they use
one of our products. Because of that we are committed to the highest standards in everything we
do. Our customers know that they can count on
our products to work right the first time, and the
same way time after time.
In order to ensure that the highest quality standards are met, we have a separate Quality Management Department that includes Regulatory
Affairs, Product Safety and Quality Assurance.
However, Quality Management touches every
individual employed at 3M ESPE. Quality Assurance, for example, is an integral part of our New

product introduction.
We use a process for new product development
which includes Ideation, Concept, Feasibility,
Development/Scale-up, and Launch phases.
Essentially, new ideas are taken through a maturation process, where questions of technical viability, market viability, manufacturing, commercialization, and of course product quality are
addressed. We have a highly disciplined gate
review process involving the leaders from each
function in order to ensure that all key questions
and concerns are appropriately addressed before
allowing the program to proceed. As part of our
efforts to make sure we get things right, we are
not afraid to stop, or delay, a program before
allowing the team to proceed.

in St. Paul, Minnesota and in Seefeld, Germany he has responsibility for the material
and technological innovations that are cre-

Please give a few exam-

ated within the company and is able to pro-

ples of what kinds of

vide insight into the role of quality at

quality assurance tests

3MESPE.

are performed during the

different phases.
To gain the true voice of the
market and the voice of the
customer we do surveys, interLeft: St. Paul, USA. Top: Seefeld,
Germany

views, focus groups, application tests, and field evaluations throughout the

Product Introduction process.

product development cycle. During actual product

It is of significant importance

development, numerous tests are performed. In

in making sure new products,

vitro testing is usually done in our certified ISO

from the very moment they

approved laboratory. For a material like 3MESPE

No. 23 | FEB 2013

Espertise

magazine

And there is evidence that this strategy leads to

success: data from independent third-party surveys we conduct suggests overall satisfaction
with 3M ESPE is the highest among the dental
manufacturing companies we survey. This is how
we are rewarded for our efforts.

What are your plans for the future?

We will continue to develop products that benefit
the dental industry, oral care providers, and
patients with faster, easier, and better dentistry.
For the eighth consecutive year, 3M ESPE was
named the most innovative dental company in the
industry by the Anaheim Group in its independent

Employee working in the research laboratory

of 3M ESPE in Seefeld, Germany.

evaluation published in the Dental Industry Review

Determination of the 3-point bending strength of a zirconia

specimen with a Zwick universal testing machine.

RelyX Ultimate Adhesive Resin Cement, e.g.

Dr. Alfred Viehbeck

2012, and hopefully our future new products will

extraction tests to assess product safety, mechani-

Is it this reward that makes you like your job

sustain this legacy. My mission will be to ensure

cal property and adhesion tests to evaluate product

at 3M ESPE?

that this laboratory delivers the highest quality

performance are conducted. In addition, the pro-

products, invests in technology development for

cess includes shelf life tests and accelerated aging

There are different factors that make my job satis-

differentiation, and has the most highly motivated,

to determine the strength, durability and reliability

fying. For me, the close interactions with custom-

dedicated workforce.

of the product. Stain testing serves as a means of

ers are the most enjoyable. Another aspect is that

checking the products resistance to discoloura-

we are part of the bigger 3M Company and have

Dr. Viehbeck, thank you for providing

tion, a factor that is important for long-lasting aes-

access to technologies and expertise across our

insights into internal processes at 3M ESPE.

thetics. After launch, the product performance is

many businesses and the 3M Corporate Research

continuously monitored. In addition many third-

Laboratory. Making a difference in the lives of our

party in vivo clinical studies are commissioned to

customers and having satisfied patients due to our

substantiate all product claims.

products is also highly rewarding.

Clinical Excellence
3M ESPE Filtek Supreme XTE Universal Restorative

Direct restorations: lifelike appearance, perfect margins

Hein de Kloet, Arnhem, the Netherlands

Figure 1: A 37-year-old male patient with severely eroded teeth presenting in the dental
practice. The maxillary anterior teeth are only just visible when the patient is smiling. The
cause of the erosion remains unclear even after anamnesis.

Figure 2: The existing restorations are insufficient due to discolouration and microleakage.
After a presentation of possible treatment outcomes on the basis of digital imaging, the
decision is reached to restore the maxillary anterior teeth with 3M ESPE Filtek Supreme
XTE Universal Restorative.

Figure 3: From an occlusal view, the discolouration is particularly intensive. The erosion is
most severe at the lingual and incisal areas of the central incisors.

Figure 4: Situation after removal of a large part of the old fillings. Tooth structure at the
lingual surface has to be removed as well to create sufficient space for composite material. Wherever possible, an equigingival preparation margin is designed in order to protect
the soft tissue.

Figure 5: A metal band is used for build-up of the lateral incisors with 3M ESPE
Filtek Supreme XTE Universal Restorative in the shade A2B. The bonding procedure is
performed using the etch & rinse technique with etchant and 3M ESPE Scotchbond
Universal Adhesive. Due to low caries activity, the initial caries at the central incisors is
not treated.

Figure 6: The lingual areas of the two central incisors are built up in the same manner
employing an etch & rinse bonding procedure. The same composite material in the shade
A2B is applied. Then, the occlusion and articulation are checked.

No. 23 | FEB 2013

Espertise

magazine

7
Figure 7: Buccal view of the situation. The lingual build-up in this primary stage is performed to enable the placement of rubber dam for further direct restorative procedures.

Figure 8: Rubber dam is placed and the prepared teeth are sandblasted to ensure a proper adhesion to the residues of old composite material. After the adhesive procedure, the core restorations
are created using 3M ESPE Filtek Supreme XTE Universal Restorative in the shades A3B on
the canines and A2B on the incisors.

Figure 9: Directa Matrix Strips (Directa) are utilized for good marginal adaptation of the filling material. In this stage, the correct definition of the midline is particularly important. During build-up of the
approximal contours, care should be taken not to have too much excess material in the cervical area.

Figure 10: After removal of the excess material the planned shape of the new restorations
is already visible.

Figure 11: The occlusion is checked and a small amount of grey colour liquid ( Kolor +
Plus , Kerr) added before the composite facings are created. For isolation of the cervical
part of the teeth, AutoMatrix metal bands ( Dentsply) are used. Subsequently, the adhesive procedure is performed again.

Figure 12: With the metal band in place, the canines are restored with composite material of the
shade A3.5B in the cervical and A3B in the incisal area. A3B and A2B are used on the lateral incisors
and on the central incisors a layer in the shade A2B is applied. A natural appearance of the incisal
edge is obtained by the use of white colour liquid imitating white spots and small enamel cracks.

Figure 13: Situation after finishing of the vestibular areas using a flame shaped diamond
bur and a fine diamond instrument. For polishing, 3M ESPE Sof-Lex Contouring and
Polishing Discs and a buffing wheel are employed. Relatively deep bite conditions are
visible, but these are perceived as comfortable by the patient.

Figure 14: Several months after the treatment: a natural surface structure including
grooves and a subtle translucency in the cutting edge are obtained. Together with the
imitated micro cracks and white spots and a smooth transition between the restorations
and the soft tissue, this ensures a lifelike appearance of the restorations.

News and Innovations

3M ESPE Ketac Cem Plus Resin Modified Glass Ionomer Cement

New generation cement with efficient marginal adaptation

Eva-Maria Popp, 3M ESPE, Seefeld, Germany

Since January 2013, a new generation of

ated. Scanning electron microscopy and a dye

3MESPE Ketac Cem Plus Resin Modified

penetration test were used to assess marginal seal

Glass Ionomer Cement is available. The fluo-

perfection before and after thermocycling and

ride-releasing luting material is indicated for

mechanical loading (TCML).

the cementation of metal and PFM crowns,

bridges, inlays and onlays as well as oxideceramic restorations, endodontic posts and
orthodontic appliances. In addition, it can be
used for luting of restorations to implant
abutments. Dentists can choose between
two different delivery systems an automix
syringe and the Clicker Dispenser.

Results
Tack-curing of 3M ESPE Ketac Cem Plus Resin Modified Glass Ionomer Cement. This procedure facilitates the
removal of excess cement.

Ketac Cem Plus revealed 100% perfect margins to

dentin before and after TCML when the tack-cure
feature was used for excess removal [1]. The marginal

Efficient marginal seal

integrity of Ketac Cem Plus to dentin and enamel

The efficient marginal seal to enamel and dentin of

before and after TCML was closer to perfect than for

Ketac Cem Plus after tack-curing could be con-

other resin-modified glass-ionomer cements [1, 2].

firmed in an in-vitro study at the University of

Regensburg, Germany [1]. In order to assess the

With the new tack-cure clean-up feature that now

quality of the margin, ceramic inlays were cemented

offers easy excess cement removal, Ketac Cem

on human molars using different materials.

Plus cement provides efficient marginal seal to

After application of each cement according to each

dentin and enamel.

manufacturers recommendations, e.g. tack-curing

of Ketac Cem Plus, as well as subsequent removal
3M ESPE Ketac Cem Plus Resin Modified Glass Ionomer Cement is available in the Clicker Dispenser and in an
automix syringe.

of excess cement, the interface between the restoration and enamel respectively dentin was evalu-

Dentin

80

predecessor, the new generation cement was

70

with the automix option: the major improvement is

the new tack-cure feature that allows for easy
excess cement removal after application of Ketac
Cem Plus cement and placement of the restoration. By light-curing each restoration surface for
five seconds, the excess cement reaches the gel
state and can easily be removed in large sections
from the margins. Alternatively, the user can wait
two minutes after seating for the excess to selfcure.

[2] Partially cited from: Rosentritt M, Behr M, Lang R, Handel G.

Influence of cement type on the marginal adaptation of all-ceramic
MOD inlays. Dent Mater. 2004 Jun; 20(5):463-9.

Enamel

90

Based on the clinically proven formulation of its

optimized not only to offer an easier application

[1] Sawaljanow A, Lang R, Handel G, Behr, M, Rosentritt M. Invitro Marginal Adaptation of Resin-Modified Glass Ionomer Cements
to dentin and enamel. Abstract #170549, IADR 2013.

100

Tack-cure clean-up feature

Median Perfect Margin (%)

60
50
100 97,6

100 98,3

90,2 87,3

92,8 86,4

Before TCML

After TCML

Before TCML

After TCML

87

83

76

85

40
30
20
10
0
3M ESPE Ketac Cem Plus
Automix [1]
no conditioner

GC Fuji CEM Automix [1]

no conditioner

Before TCML

After TCML

GC Fuji PLUS Powder/Liquid

with GC Fuji Plus
Conditioner [2]

Schematic representation of the study results (source: A. Sawaljanow, R. Lang, G. Handel, M. Behr, M. Rosentritt [1] ).

No. 23 | FEB 2013

Espertise

Backstage Report

magazine

3M ESPE Astringent Retraction Paste

Faster, easier and more convenient!

Andreas Maurer, 3M ESPE, Seefeld, Germany

As a company with a long tradition in the

sule had to be developed that enabled placement

very small. Since the transmission of the dis-

development of products for impression tak-

of the paste directly into the sulcus without dam-

penser could not be altered, the task had to be

ing, 3M ESPE knows that it is not the impres-

aging the tissue. A very small tip and an ergo-

accomplished by optimizing the selection and

sion material alone that ensures a precise

nomic capsule design were the solution. In order

ratio of fillers. The compatibility of the new paste

result. An important precondition for an

to achieve best possible astringent properties dif-

with impression materials and its suitability for the

accurate reproduction of marginal details is

ferent paste formulations were developed, tested

digital impression taking process were verified by

the retraction of the gingiva and an open, dry

and compared. The one with outstanding astrin-

extensive testing.

sulcus. Having identified the need for an

gent effect was finally chosen containing alumin-

easy-to-use paste for gingival deflection,

ium chloride and other coagulation accelerators.

3MESPE decided to initiate a development

project in 2008.

Product quality
Since there are no existing ISO norms for testing
retraction pastes, the team developed different

Development goals

analytical measurement systems and procedures

Formulating the goals of the project, it became

performance. For example, data was collected on

clear that its realization would be anything but

the time required for removal of the material, the

easy: many different features were regarded as

important in order to enhance the process of soft

to obtain detailed information about the products

Dr. Anrdreas Maurer, Research Chemist at 3M ESPE,

Seefeld.

tissue retraction.

ability of opening the sulcus and the flow resistance. The results were also compared to those
achieved with other pastes and in the last step

The task of developing a paste that is dispensed

prior to product launch, a field test was initiated

The basic goal was to invent a product that offers

without the need of a new device was particularly

worldwide. Here, 80% of the respondents stated

mechanical retraction and enables control of exu-

challenging. The idea was to enable application

that 3M ESPE Astringent Retraction Paste was

dation during impression taking as well as cemen-

with a common composite dispenser that is avail-

easier to use than the paste they usually utilized in

tation. The development team was also in agree-

able in every dental practice. The problem: the

their dental office. Together, the test results con-

ment about needing a material that is suited for

paste has to be stiff to remain in the sulcus, albeit

firmed that the new paste is indeed faster, easier

digital and conventional impression taking. A

a low extrusion force is essential for precise

and more convenient than other available prod-

decisive factor for user convenience was the

intraoral application and the tip of the capsule is

ucts.

development of a material that could be applied

without the necessity of purchasing an additional
dispenser. Last but not least, the innovation
should be faster, easier and more convenient for
both, dentist and patient, than any existing product available on the market.

A tough nut to crack

Having defined these goals, the team set to work.
In order to achieve mechanical retraction, a cap-

3M ESPE Astringent Retraction

Paste is the only stiff retraction paste
that can be applied with a common
composite dispenser.

Ask the Expert

Soft tissue management

The effect of different retraction techniques

on the gingiva
Ralph G. Luthardt, Ulm, Germany
10

Soft tissue management is an important procedure to allow for

exact capture of the preparation margin during impression taking.
Diverse techniques and materials are available to induce the effect
of gingival retraction, ranging from retraction cords to the use of
lasers. In many dental practices, impregnated retraction cords are
applied in the double-cord technique to obtain the desired effect.
However, this method is highly complex as well as time-consuming,
so that alternative techniques and materials are developed and
tested.

Study design
In order to measure the gingival displacement capacity of the paste versus
two cords under healthy soft tissue conditions and with mild artificial gingivitis, a split-mouth study design was adopted. An impression was taken and
a saw model produced after application of either two retraction cords (double-cord technique) or the paste containing aluminium-chloride on the maxillary premolars of one quadrant. The other maxillary quadrant served as
control.
The intervention was the same at baseline under healthy soft tissue conditions and after six months, when the quadrant was changed and mild artificial gingivitis was induced by refraining from tooth brushing. Impressions
were taken prior to and after each intervention as well as after three and six
months. For three-dimensional analysis of the produced models, the casts
were digitized with a laboratory scanner and the amount of vertical displacement of the soft tissue measured and analyzed using specific software.

Results and conclusions

It was found that neither the application of the paste nor the use of cords for
soft tissue management did lead to permanent recession of the gingiva.
Prof. Dr. Ralph G. Luthardt, University of Ulm, Germany.

Mild artificial gingivitis did not have a negative effect on retraction when the
paste was used. A deeper penetration of the impression material was

Against the background of the development of an astringent retraction

achieved with the cords (source: http://iadr.confex.com/iadr/2012tampa/

paste, the company 3MESPE sponsored research of the Department of

webprogram/Paper158144.html).

Prosthetic Dentistry at Ulm University (Germany). The aim of the project

was to assess and compare the effect of an existing paste containing alu-

Additional study results will be published at the IADR/AADR/CADR General

minium-chloride with that achieved with impregnated retraction cords used

Session in Seattle on March 20 to 23, 2013. The available information,

in the double-cord technique on the gingiva. This comparison should help to

however, indicates that retraction pastes may be a suitable alternative to

find out if a paste is a suitable alternative to cords in the clinical environ-

cords in many situations. The new 3MESPE Astringent Retraction Paste

ment. The benefit of using a paste is the ease of use of the product and a

might even be capable of achieving a greater depth of penetration since it

less time-consuming procedure.

is applied into instead of on the sulcus.

No. 23 | FEB 2013

Espertise

Ask the Expert

magazine

3M ESPE Astringent Retraction Paste

Practise-based research results on handling properties

Trevor Burke, Birmingham, United Kingdom

Scientific studies whether in vitro or in vivo

have been published by the group and provide a

are conducted to provide evidence of a

useful source of information for colleagues.

products suitability for a defined purpose.

Recently, the new 3MESPE Astringent Retrac-

However, even clinical studies are usually

tion Paste was tested and evaluated by members

carried out under idealized conditions so that

of the panel.

11

the results are not always applicable to the

common dental practice. Therefore, practisebased research is highly important. The term

Handling properties in focus

indicates that general dental practitioners

Since existing gingival retraction techniques e.g.

conduct clinical research in the busy practice

using cords, kaolin or aluminium chloride and

environment. They evaluate products in

astringent solutions have not gained total accept-

respect of their handling or their long-term

ance so far, the introduction of a new solution in

clinical performance. This kind of assess-

this field was generally appreciated by the mem-

ment by independent practitioners reflects

bers of the PREP panel. In order to obtain informa-

real life and thus helps dentists to find a

tion about the handling properties of the new

material or device that suits their needs.

product, a study was initiated and the paste

tested by twelve evaluators. They were asked to

Prof. Dr. Trevor Burke, University of Birmingham, United

Kingdom.

On the basis of this idea, the PREP panel (Prod-

use the new retraction capsules for ten weeks in

uct Research and Evaluation by Practitioners)

their dental practice environment and complete a

several restorations. The questionnaire included

was founded by five colleagues and me in Bir-

questionnaire afterwards.

information on what kind of gingival retraction

system was usually employed so that the perfor-

mingham in 1992. By now, the group consists of

Easy-to-use product

mance of the previously preferred product and

uate new materials and devices in their own den-

During the ten weeks of testing, the new paste

tions focused e.g. on dispensing, the suitability

tal office. In the past years, numerous reports

was used for more than 150 impressions and

of the paste for gingival retraction, capsule

33 experienced dental practitioners mainly

based in the United Kingdom who test and eval-

the new paste could be compared. Other ques-

design and the efficiency of the whole retraction

procedure.
The 3M ESPE Astringent Retraction Paste
obtained good scores across all criteria. In comparison with the retraction system that was originally used by the evaluators, the new paste in the
innovative capsule received high ratings with
regard to its ease of use. The detailed scientific
results of the study will be published in the very
near future.

The new retraction paste comes in a single-use capsule.

Clinical Excellence
3M ESPE Astringent Retraction Paste

The impact of soft tissue management on marginal

quality of restorations
Rafa Mdzin, Gryfino, Poland
12

Soft tissue management has a huge impact

on the marginal quality of indirect restorations. The gingiva has to be deflected in
such a way that a detailed record of the
preparation margin can be captured with
the impression material or the intraoral
scanner if a digital procedure is chosen.
Traditionally, soft tissue retraction is
achieved with retraction cords. They are

Figure 1: Initial situation: the maxillary left central incisor of

the young female patient is restored with an insufficient
porcelain-fused-to-metal restoration

Figure 5: A provisional is produced using 3M ESPE

Protemp 4 Temporization Material and fixed with
3MESPE RelyX Temp NE Temporary Cement.

Figure 2: the right lateral incisor and canine previously received

endodontic treatment and show discolouration. The right central
and left lateral incisors are slightly discoloured as well.

Figure 6: The temporary crown helps the patient to assess

the appearance of the planned restoration. Beyond that, it
is used to support proper healing of the soft tissue.

Figure 3: After removal of the crown on the left central incisor, a heavily discoloured abutment tooth restored with a
metal post is revealed.

Figure 7: Tooth preparation: the left central incisor and right

canine are prepared for all-ceramic crowns, while a minimally
invasive preparation is carried out on the other maxillary incisors, where porcelain adhesive restorations are planned.

available in different designs and some of

them are impregnated with haemostatic
agents. Retraction paste systems and surgical methods such as laser tissue sculpting or electro-surgery have been adopted
more recently.
The new 3M ESPE Astringent Retraction
Paste for gingival deflection and haemostasis
presents a suitable alternative to the existing
cords in many cases. It is applied directly into
the sulcus to open it mechanically and to stop
exudation. Depending on the depth of the
preparation and the level of sulcular exudate
flow, it may eliminate the need for a cord
completely or may replace the second retraction cord when the double cord technique is
indicated. The innovative product proves its
worth especially in situations with a minimally invasive preparation. The benefits of its
use are a quicker and more comfortable procedure as compared to the traditional workflow.
In the following article, a patient case is presented to illustrate the combined use of
retraction cords and the innovative astringent
retraction paste that has been introduced by
3M ESPE.

Figure 4: Whenever possible, a restoration margin should

be placed on an equigingival level. Due to severe discolouration, however, a subgingival preparation is required on
this tooth. The stump with the old post is prepared, sandblasted, treated with 3MESPE Scotchbond Universal
Adhesive and covered with a composite opaquer.

Figure 8: The double-cord technique is indicated for the

teeth with crown preparations due to the subgingival margin and severe exudation. The non-invasive retraction
method using 3M ESPE Astringent Retraction Paste is
chosen for the right central incisor and both lateral incisors.

No. 23 | FEB 2013

Espertise

magazine

13

Figure 12: Retraction effect on all prepared teeth. At the

teeth with crown preparations, one cord is removed while
the other one is still in place.

Figure 16: Final restorations in place, immediately after

cementation with 3M ESPE RelyX Ultimate Adhesive
Resin Cement in combination with 3M ESPE Scotchbond
Universal Adhesive.

Figure 9: Close-up view of the minimally invasive preparations on the right central and lateral incisors before

Figure 13: An impression is taken in the monophase technique using 3M ESPE Impregum Penta Soft Polyether
Impression Material. All details of the finishing line are perfectly visible in the impression.

Figure 10: and after the use of 3M ESPE Astringent

Retraction Paste. The paste was removed after 2 minutes
by rinsing with water.

Figure 17: Thanks to the accurate record of marginal detail

obtained by soft tissue management prior to impression
taking, the fit of the crowns and veneers is excellent. Highly
aesthetic restorations are obtained which are indistinguishable from natural teeth.

Figure 14: The effect of the preparation and the efficient

gingival retraction are visible on the plaster model: the finishing lines were precisely transferred to this replica of the
situation in the patients mouth.

Figure 18: This is partly due to perfect margins: the soft

tissue is healthy and has a natural shape. The patient is
very happy with the beautiful treatment result.

Figure 11: The retraction effect is clearly visible: the preparation margins are exposed on both teeth since the tissue is
displaced. Furthermore, an open, dry and clean sulcus is
obtained. There is a visible change in distance between the
soft tissue and the preparation margin.

Figure 15: The final restorations: three glass ceramic

veneers and two crowns fabricated using the refractory die
technique after etching of the inner surface with hydro
fluoric acid and application of 3M ESPE Scotchbond
Universal Adhesive.

Dr Rafa M dzin
Dentura Clinic & Lab Poland
gabinet@dentura.pl

Ask the Expert

3M ESPE Imprint 4 VPS Impression Material

Optimized features for even higher accuracy

Julia Farr, 3M ESPE, Seefeld, Germany

14

On the occasion of the International Dental

nents would have to be added or changed to

Show in Cologne in 2013, an innovation in

reach our goals. We decided to alter the colours

impression taking is presented by a leading

for enhanced readability of the impressions and

company in this field, 3M ESPE. The new

add flavour for an improved patient experience.

3M ESPE Imprint 4 VPS Impression

But the optimization of hydrophilicity and the set-

Material stands out due to optimized features

ting behaviour were in the centre of attention. Dif-

and attracts the dentists attention with its

bright colours. Insights into material development and an overview of the benefits of

ferent approaches on how to proceed were disImpressions with the new materials: 3M ESPE Imprint 4
Penta Heavy with Imprint 4 Regular

cussed and the team of researchers developed

the basic technologies, one to enhance hydrophi-

Imprint 4 are given by Dr. Peter Osswald,

licity and the other improving the setting behav-

Research & Development Impression Materi-

iour.

als at 3MESPE.
How did you proceed in order to change the
Dr. Osswald, addition silicone impression

setting behaviour?

materials are available since the 1970 and

have been subject to continuous improvements ever since their introduction. After
such a long time, it might be assumed that

What was difficult was not to just shorten the

3M ESPE Imprint 4 Penta Putty with Imprint 4
Super Quick Light

whole setting regime, but to reduce time required

for the setting reaction in the patients mouth,

a material with the optimum composition is

while the working time had to remain the same.

already available. So for what reason did

After an intensive ideation process and testing of

you decide to initiate another product

different approaches, we reached the goal by

development project for a VPS impression

adding a self-warming mechanism to the existing

material?

formula of VPS materials.

I believe that there always is and will be room for

improvement of any material. The perfect composition does not exist, partly because trends and

and 3M ESPE Imprint 4 Penta Super Quick Heavy

with Imprint 4 Super Quick Light.

user preferences change over time and technological progress never stops. In order to deliver

What were the first steps of product devel-

products that are tailored to ideally suit the needs

opment?

Ordinary VPS impression

material

Imprint 4 Impression
Material

of our customers, we are always collaborating

The rise in temperature of 3M ESPE Imprint 4 is clearly
visible with the thermographic camera.

with users and do never stop analyzing which fea-

We did not have to start from scratch, but were

tures might be worth altering. For VPS materials,

able to build on existing knowledge and experi-

we found that a different setting behaviour with

ence from developing vinyl polysiloxane impres-

The reaction that initiates warming starts after the

faster intra-oral setting but identical working

sion materials. Furthermore, we have within 3M

working time and the rise in temperature leads to

times as existing VPS materials from 3M ESPE

the unique ability to get access to a large variety

accelerated setting. This property results in a

would be beneficial. In addition, an even higher

of different technologies. We focused on the exist-

more efficient workflow, increased patient com-

hydrophilicity is desired by dentists.

ing composition and determined which compo-

fort and less stress for the practice team.

No. 23 | FEB 2013

Espertise

magazine

Pr oduc t

Di s p e n s i n g
system

Viscosity
low

Setting
version

Working time
(23 C)

Intra-oral syringing
time (37C)

high

Intra-oral
setting time
(37 C)

ment and laboratory testing under

involvement of a lot of different functions within our company was

TRAY MATERIALS
Imprint 4 Penta Put t y

Put t y

R e g ul a r S e t

1:30

2:3 0

Imprint 4 Penta Heav y

H e av y B o d y

R e g ul a r S e t

2:0 0

2:0 0

Imprint 4 Penta Super Quick Heavy

Heavy Body

Fast Set

1:15

1:15

required to prove the outstanding

performance of all materials.
What is your conclusion regarding the success of the project?

WASH MATERIALS
Imprint 4 Super Quick Ultra-Light

Imprint 4 Light

Imprint 4 Super Quick Light

Fas t S et

1:15

0:35

1:15

R e g ul a r S e t

2:0 0

1:0 0

2:0 0

Fas t S et

1:15

0:3 5

1:15

R e g ul a r S e t

2:0 0

1:0 0

2:0 0

Fas t S et

1:15

0:3 5

1:15

Due to the highly motivated team and

with all individuals acting in concert,
we succeeded in developing not one,
but ten new impression materials with

Imprint 4 Regular

Imprint 4 Super Quick Regular

highly beneficial features. Due to

higher hydrophilicity and a faster setting in the mouth, an accurate repro-

Overview of the product portfolio of 3M ESPE Imprint 4 VPS Impression Materials.

duction of details is possible. The results of an

application test in Western Europe and the United
How was it possible to develop a VPS

So, you succeeded in developing two new basic

States confirmed the high level of user satisfaction

impression material that is even more

technologies. Was it difficult to combine them

which makes us very confident that we have

hydrophilic than existing materials?

with each other and the other components?

addressed the right issues for our customers: for

example, the intra-oral setting time received high

We know that hydrophilicity is one of the most

The two basic technologies were just merged and it

ratings. Furthermore, 80% of the respondents in

important properties of an impression material:

turned out that they did not have a negative effect

Western Europe and 88% of the US-respondents

the more hydrophilic it is, the better is its

on each other or the whole composition. However,

stated that they will or will probably use the new

potential for precise detail reproduction in a wet

it was more challenging to work out all the different

materials in their own dental office.

environment. Detailed impressions, in turn,

variants of the impression material. A whole portfo-

lead to restorations with accurate margins.

lio of Imprint 4 products was developed, consisting

Therefore, we spent a lot of time focusing on

of materials in

this topic. Many different technologies and

with

additives were tested, but the addition of the

viscosities and

novel modified polyalkylene oxide wetting ena-

setting times in

bler turned out to be the best solution. This

order to satisfy

component in combination with our long-term

all customers

proven surfactant leads to an outstanding

preferences

hydrophilicity of the material even in the

and

uncured state immediately after mixing, so right

ments. Exten-

from the start.

sive

different

requiredevelop-

Dr. Osswald, thank you for the conversation.

100
90
80
70
60
% 50
40
30
20
10
0
Much too long

Somewhat too long

Just Perfect

Somewhat too short

Much too short

Dentists ratings for intra-oral setting time of 3M ESPE Imprint 4 Tray Materials. Source: Field evaluation EU and US conducted by 3M ESPE and Key Group Research (total sample size: 300).

15

Ask the Expert

Digital Dentistry

How digital technologies may contribute to marginal

quality
Albert J. Feilzer, Amsterdam, the Netherlands
16

Many different digital technologies are used in

Impression. Since then, diverse companies have

essential to train dentists and dental technicians in

dentistry today: practice management soft-

focused on the development of devices that are

how to use the new hardware and software prop-

ware runs on every computer, digital radio-

capable of capturing precise three-dimensional

erly. This starts with basic dental education e.g. at

graphs are taken, implant positions are planned

data in the oral cavity. Several years ago, they

university or a vocational school. However, it has to

in computer-aided procedures and CAD/CAM

finally succeeded in introducing practicable solu-

be taken into account that it takes most students of

processes are employed for the production of

tions that met the requirements regarding the

dentistry about five or six years before they begin

dental restorations. The idea behind the intro-

precision of the procedure and its suitability for

practicing the profession. Thus, universities should

duction of digital technologies is that conveni-

the production of multi-unit restorations.

not only teach digital techniques: they should even

ence and efficiency of processes is increased

and highly accurate results are obtained.

be ahead of dental practices, implement technoloWhen comparing the workflows of conventional

gies before they are available in the field and give

and digital impression taking, it becomes clear

their students the opportunity to learn what they will

In restorative dentistry for example, improvement

that the procedure involving intraoral scanners

need after graduation.

of accuracy is a topic of high importance, since a

like the 3M ESPE Lava Chairside Oral Scanner

precise fit of a restoration contributes decisively

C.O.S. has several advantages as opposed to

When new curricula for dental education are

to its long-term success. However, the question

impressions taken with trays and polyether or

being developed, it is also important to know that

arises whether the implementation of digital tech-

vinyl polysiloxane materials. For example, the pro-

digital technologies have transformed the way

nologies does indeed lead to higher precision of

cess is faster, just as easy, and highly precise. In

information is obtained in everyday life. Therefore,

processes in the dental practice and laboratory.

addition, some challenges associated with tradi-

the learning behaviour of individuals has changed

The current advantages of digital techniques,

tional impressions such as the dimensional stabil-

as well. Reading books and listening to a lecture

their future potential and the measures that still

ity of the material and compatibility with model

for more than an hour is not what young individu-

have to be taken in order to benefit from it are

materials like gypsum are eliminated. It is still a

als are used to do. Modern students like to be

discussed in the following article.

matter of opinion if the technique is indeed better

educated as entertainment, when they do not like

than the traditional one, but it does already lead to

Impression taking

highly satisfying results. Other advantages arise

Since they belong to the most recent innovations

sion taking and ending with milling of the restora-

for the dental practice, taking a closer

tion. Material-related factors influencing accuracy

look at intraoral scanners and

e.g. the expansion of gypsum during model

their capability to enhance the

production, deformation of a bite registration and

quality and fit of a restoration

imprecision of the wax set-up due to relaxation of

may be particularly interesting.

the material are not relevant here.

from the digital workflow beginning with impres-

First considerations to take

optical

impressions

in

the

patients mouth were published by Prof.

New approaches to dental

education

Francois Duret in

For successful implementation of intraoral scanning

1973 in his thesis

technologies or even complete digital workflows in

titled The Optical

the dental practice and laboratory, however, it is

Prof. Dr. Albert J. Feilzer, Dean of the

Academic Center for Dentistry Amsterdam.

Dental education with a simulator.

No. 23 | FEB 2013

Espertise

magazine

Training course at the Academic Center for Dentistry Amsterdam.

17

the lecture they want to zap to another channel,

treatment not only by employing them at university,

Interruptions of the digital process e.g. through

however for lecturing that is not possible. Thus,

but also through their use in the dental practice.

use of a physical model would no longer be

education for this new generation of stu-

required in this future workflow. Another prereq-

dents should become edutainment in order to

uisite for this, however, is a powerful infrastruc-

successfully impart knowledge to them.

ture to facilitate data transfer via secure channels and make it possible to store large amounts

This approach of offering edutainment and using

of digital information. This is important for uni-

technologies that are new for dental practices is fol-

versities as well as for every dental practice. In

lowed at the Academic Center for Dentistry Amster-

order to help accelerate this development, the

dam (ACTA). For example, students currently learn

ACTA has become part of a consortium of organ-

intraoral scanning techniques using the Lava C.O.S.

izations that has set itself the target of building

In the near future it will be possible to import the

captured data into their simulator with haptic burs
(Simodont), where tooth preparation skills are

kynny istockphoto.com

Standardized interfaces are needed to connect different

digital technologies with each other.

acquired before the techniques are used on

In order to make full use of this potential, however,

patients. The simulator uses force sensors for real-

some work still needs to be done: complete com-

istic rendering of drill and contact forces. The hard-

patibility (standardization) of data produced in dif-

ness of different tooth structures like enamel, den-

ferent digital systems is important to ensure quick

tin and the pulp has been replicated as well.

exchange of all available data between treatment

Thereafter, the scans of the real treatment will not

partners. This undisturbed transfer of digital infor-

only be used for the production of a restoration but

mation which has to be made possible through

also to compare the preparation executed in the

standardization of data formats will be the first step

simulator with the real one. In this way, the evalua-

towards the development of a digital system that

tion of the student's skills will be more objective.

integrates the whole oral care process. After successful integration of all available technologies, e.g.

up a national infrastructure for digital dentistry in

the Netherlands. If other countries follow this

scanrail istockphoto.com

Infrastructure for data storage and secure channels for date

transfer will help accelerate further development of digital
dentistry.

Need for infrastructure

data from the practice management system could

be directly imported into the intraoral scanning sys-

example, the way will soon be paved for digital

This simulator is only one example showing that

tem. Furthermore, optical impressions could be

dentistry to become an integrated process that

digital dentistry involves much more than CAD/

matched with digital or conventional radiographs or

leads to improved quality of dental care including

CAM processes. Together, the available technolo-

real masticatory movements simulated in a three-

much more than restorations with perfect mar-

gies have a huge potential of leading to increased

dimensional model of the patient to evaluate the

gins.

efficiency of processes and improved quality of

shape of a planned restoration.

Clinical Excellence
3M ESPE Lava Ultimate CAD/CAM Restorative

A conservative approach to indirect restorations

Paulo Monteiro, Caparica, Portugal

18

Figure 1: Initial situation: insufficient glass ionomer filling

on a maxillary right second premolar. The goal is to achieve
maximum preservation of natural tooth structure and to
avoid damaging the periodontium.

Figure 2: Tooth preparation for an overlay. The preparation

margin is created at or above the level of the soft tissue.

Figure 3: Application of 3M ESPE Astringent Retraction

Paste prior to impression taking. The paste leads to gingival
retraction and a clean, dry sulcus for a precise reproduction
of marginal details.

Figure 4: Scanning of the preparation using the CEREC

Bluecam (Sirona Dental Systems).

Figure 5: Milled overlay made of 3M ESPE Lava Ultimate

CAD/CAM Restorative in the shade A2 HT (high translucency).

Figure 6: Removal of the sprue and polishing with Renfert

Opal L Polishing Paste ( Renfert).

Figure 7: Final polish using a Soft-Chamois Polishing Brush

(VH Technologies). A natural, lasting glossy surface is
obtained.

Figure 8: Finished overlay made of the new resin nano

ceramic. Apart from polishing, no further steps are necessary to obtain this beautiful result.

Figure 9: Due to the beneficial properties of the material

such as very low antagonist wear and good polish retention, extensive characterization or individualization is not
necessary and even possible after restoration placement.

Paulo Monteiro DMD, MSc

Assistant Professor, Oral Rehabilitation Department
Instituto Superior de Cincias da Sade Egas Moniz
Caparica Portugal

No. 23 | FEB 2013

Espertise

magazine

19

Figure 10: Sandblasting of the inner surface of the overlay

with aluminium oxide. This procedure is recommended to
increase the bond between the restoration and the adhesive.

Figure 11: Application of 3M ESPE Scotchbond Universal

Adhesive on the sandblasted surface of the restoration.

Figure 13: Intraoral application of 3M ESPE RelyX

Ultimate Adhesive Resin Cement in the shade Translucent
(TR).

Figure 14: Situation after placement of the resin nano ceramic restoration. A natural gloss is obtained.

Figure 15: In order to achieve an even better optical integration, it is decided to characterize the overlay intraorally using white and brown pigments (Kolor + Plus Resin Colour
Modifier, Kerr).

Figure 12: 3M ESPE Scotchbond Universal Adhesive is

applied on the prepared tooth. In this case, the selective
enamel etching technique is used, since in this way the
highest bond strengths are obtained.

Figure 16: Final result after sandblasting of the occlusal surface of the restoration and
subsequent application of 3M ESPE Scotchbond Universal Adhesive, the pigments and
a thin layer of 3M ESPE Filtek Supreme XTE Flowable Restorative.

Country Insights
Dentistry in

the Kingdom of Belgium

Bart Soetaert, Ternat, Belgium

20

In the Kingdom of Belgium, a degree in den-

treatments are covered by the national insurance.

ees. What is also highly interesting is that dental

tistry can be obtained at five different dental

Since these basic costs are covered by the insur-

hygienists are by law prohibited in Belgium: only

schools. Two of them are located in Flanders,

ance independent of the institution that provides it

dentists are allowed to work in the oral cavity. As

two in Wallonia and one in Brussels. At the

(private practice versus policlinics), most patients

dental practitioners, we hope that this situation

Flemish universities, students have to pass

choose to receive dental care in practices, where

will change, because we are convinced of the

an entrance exam, while there is no such

the quality of treatments is high. Approximately

positive impact of dental hygienists work on the

restriction at the French-speaking universi-

oral health of patients and the efficiency of our

Bart Soetaert

ties. In order to obtain a degree as a Master of

practices.

Science in dentistry, five years of combined

theoretical and practical dental training at
university are required. Afterwards, one year
of practical training has to be followed. Only
then, registration with the Federal Ministry of
Health is possible in order to obtain a license
to practice the profession.
25% of the patients in Belgium have
After graduation, specialist training can be under-

an additional private insurance which

taken in orthodontics and periodontology, how-

is becoming increasingly popular

ever, the proportion of specialized dentists is low

this is also the case in my two twin

in the country: 7,878 general dentists and only

practices in Ternat (near Brussels)

137 periodontists and 398 orthodontists were

and Melle (near Ghent) in Flanders.

registered in 2011 according to the Federal Public

Service (FPS) Health, Food Chain Safety and
Environment. Many general dentists follow postgraduate training which is offered in endodontics,

The dental practice in Ternat, Belgium.

Dental workforce and

practice organization

My own business model is slightly different. In

implantology, paediatric dentistry and aesthetic

In 2011, approximately 45% of the 8,300 dentists

2008, I have established a twin practice with two

dentistry. Continuing education is mandatory in

in Belgium were female. In the younger age

locations. Each of the five dentists works in both

order to keep the accreditation.

groups, however, the proportion of women is

locations, since we have different special interests

much larger (almost 70%) (FPS Health, Food

(e.g. I have completed postgraduate education in

Insurance system

Chain Safety and Environment).

prosthodontics and aesthetic dentistry) and we

Public health insurance in Belgium is financed by

Within the country, the single practice remains the

from this knowledge. The treatment focus is on

taxes paid by the citizens, the amount of payment

most popular business model with 83.5% of all

prevention, endodontics, periodontics, prostho-

being dependent on their income. Patients have to

dentists having adopted it. Only 16.5% work in

dontics as well as aesthetic and paediatric den-

pay for all dental services directly and then claim

joint practices. 43% of all dentists work with an

tistry. For implant surgery, orthodontic treatments

reimbursement from the insurance. A large pro-

assistant and in more than 40% of the cases, the

and periodontal surgical procedures, patients are

portion of the fees for basic treatment, such as

dentists with a single practice work with their wife

referred to partner practices. Together, three

paediatric dentistry, prevention and conservative

as an assistant due to the high costs of employ-

assistants support us in the two locations.

want our patients in Melle and Ternat to benefit

No. 23 | FEB 2013

Espertise

Country Insights

magazine

Dentistry in

Israel
Yoram Kornowski, Ramat Gan, Israel

In Israel, there are two faculties of universi-

the government for children of up to twelve years of

common. There are usually one to two dental

ties where a Doctor of Dental Medicine (DMD)

age. On top of these basic services, the public

assistants per dentist working in a practice and at

degree can be obtained: Hebrew University

health funds offer different supplemental health

least one oral hygienist. In my joint practice in

Hadassah School of Dental Medicine in Jeru-

insurance programmes which cover specific dental

salem and Tel Aviv University School of Den-

treatments completely and grant a discount on oth-

tal Medicine. Here, six years of combined

ers, like restorative dentistry. Public health services

theoretical and practical study are required

are only available from service providers (e.g. den-

to become a general dental practitioner. In

tists) who have entered into a contract with the

order to receive a license to practice general

HMO. Other dentists like me exclusively treat

dentistry in Israel, all graduates no matter

patients who have a private health insurance or pay

whether they completed their studies within

privately. According to the Central Bureau of Statis-

or outside the country have to pass a cen-

tics, 76% of all Israeli citizens had a public supple-

tral licensing exam.

mentary health insurance and 27% had a private

insurance in 2010.

Afterwards, they can either start working as a

general practitioner or become a specialized dentist by following further training in one of nine rec-

Dr. Yoram Kornowski

ognized specialities, including endodontics, oral

medicine, oral pathology, oral and maxillofacial
surgery, orthodontics, paediatric dentistry, perio-

Ramat Gan near Tel

dontics, prosthodontics and public health den-

Aviv, there are two

tistry. The duration of study is three to six years

general dental practi-

depending on the subject and a central exam has

tioners, each of us

to be taken again after completion of the training.

having his own patient

The proportion of general dentists to specialists is

base and a treatment

approximately 1:12 in Israel. Continuing education

is strongly advocated.

working in his private practice in Ramat Gan.

room. Two oral hygienists work in shifts and

Statistics and the typical

dental practice

share an additional room, while two of the three

Currently, there are approximately 6,400 licensed,

endodontic or other specialist treatment is neces-

Since 1995, every Israeli citizen has to be member

practicing dentists in Israel, 37% of them being

sary, patients are not referred to another practice,

of one of four existing Health Maintenance Organi-

female, according to the Israeli Government

but a collaborating specialist is brought into our

zations (HMO) which offer a uniform benefits pack-

Center for Information Research. Hence, Israel is

office. A laboratory technician also comes into the

age determined by the National Health Insurance

currently ranked sixth among OECD countries in

dental practice if required. This team approach is

Law. The medical treatments and services are

the number of dentists per capita (0.81/1,000).

very common in Israel and contributes to a high

Health insurance

funded by the government. Dental care is generally

receptionists usually work simultaneously. If

level of patient satisfaction.

not included in the basic health insurance plans,

The majority of dentists in Israel have a single or

except for paediatric dentistry, which is funded by

joint practice with one partner, polyclinics are not

21

Clinical Excellence

3M
ESPE MDIBlindtext
Mini Dental Implants
Balkenprodukt

The solution for compromised patients

Andreas Worni and Norbert Enkling, Bern, Switzerland

22

In the edentulous mandible with limited anatomical conditions, i.e.

sation and compression during insertion is important for the primary stability

severe vertical or horizontal atrophy, implant therapy is usually con-

of the implants. With the burs, the parallel position of the holes was checked.

traindicated or would involve extensive augmentation procedures.

However, in these patients, complete dentures often cause problems
as well, since sufficient retention is missing and poor stability of the
solution is obtained. This may lead to discomfort e.g. during talking
and chewing. At the Department of Prosthodontics of the University of
Bern in Switzerland, we became aware of an alternative treatment
option in 2009: the placement of mini dental implants with a diameter
of 1.8 to 2.4 mm for denture stabilization.
The clinical procedure of implant planning, placement and fixation of the prosthesis is explained using the following patient case.

Case report

Parallel position of the drilling holes.

Then, the mini implants were inserted and an impression was taken with the
existing denture to mark the implant positions.

An 82-year-old non-smoking female patient with good general health complained about frequent sore spots and insufficient stability of her lower denture during mastication. Two attempts to place standard diameter implants
had led to implant failure. Therefore, it was decided to place four 3M ESPE
MDI Mini Dental Implants. At first, a radiograph was taken to analyze the
spatial conditions. On the basis of this data, single-piece implants with 1.8
mm diameter and 15 mm length equipped with an o-ball head for anchorage of the denture were chosen.

Impression showing the position of the implants.

Afterwards, radiographs were taken to check the implant positions and metal
housings were integrated in the denture base.
The mini implants were immediately loaded, which was possible due to sufficient primary stability and the fact that the denture is also supported by the
soft tissue.
Initial radiograph

In regular recalls, the clinical situation was checked and the healthy soft tisSubsequently, pilot holes were drilled with 1.1 mm surgical drills. This size is

sue conditions were observed. The radiograph after twelve months showed

sufficient because the implants have a self-tapping design. The bone conden-

no signs of periimplant bone resorption.

No. 23 | FEB 2013

Espertise

magazine

80 implants were placed in the lower jaws of 20 patients participating in this

prospective controlled clinical trial for stabilization of complete mandibular dentures with four MDI from 3MESPE. Contrary to the first impression that the tiny
implant bodies might break after loading, the preliminary results are highly convincing: there was no incident of implant failure over the past year. The study will
be completed in mid 2013, so that definitive conclusions cannot be drawn to
date. However, the use of mini dental implants seems to be especially suitable
for patients with compromised anatomical and medical conditions. The patients
are very satisfied with the treatment as well as the result, since an improvement
of the denture stability led to optimized chewing ability. Due to the minimally
Denture base with built-in metal housings.

invasive procedure, only minor postoperative discomfort was reported.

Future research
In order to gain additional knowledge about the clinical use of mini dental implants,
it would be interesting to investigate the required insertion torque and its impact on
immediate loading. By now, 3M ESPE recommends immediate loading only when
a torque of 35 Ncm is obtained. A research question would be if a lower torque
e.g. 25 Ncm would also lead to sufficient primary stability to allow for successful
loading directly after implant placement. The benefits of a lower torque: The surgical procedure is simplified since fewer instruments are required.
Clinical situation after six months.

Conclusion
Mini dental implants are a relatively new treatment option for edentulous patients.
Although there are only few long-term clinical study results available, first experience shows that the implants with minimal diameter are a suitable solution in
several cases. Medically compromised patients and those with unfavourable anatomical conditions who are not willing or unable to face complex bone grafting
procedures are offered an alternative to interforaminal standard diameter implants.
The only incident that occurred during the trial fracture of a denture can be
prevented by addition and polymerization of a metal band into the denture base.
Radiographs twelve months after implant placement.

Research with MDI

Due to the positive results of the treatments with mini dental implants at the
university, a study was planned and initiated in early 2011. Its aim was to find
out how the mini dental implants prove itself in the clinical environment and to
study the tribological behaviour of the o-balls and metal housings. In addition,
the investigation should include data on peri-implant bone resorption and the
level of patient satisfaction.

PD Dr. Dr. Norbert Enkling

Dr. Andreas Worni

23

Espertise

General Information

magazine

Calendar of Events 2013

E D I T O R I A L Information

Date

Event

Location

Website

12.03.2013
16.03.2013

IDS 2013

Cologne,
Germany

www.ids-cologne.de
GFDI

03.04.2013
07.04.2013

35th Australian Dental

Congress

Melbourne,
Australia

www.adc2013.com
ADA

06.04.2013
08.04.2013

Medexpo Saudi Arabia

Dschidda,
Saudi Arabia

www.medexposaudi.com
dmg :: events Ltd

10.04.2013
12.04.2013

Stomatology Uzbekistan
Taschkent

Taschkent,
Uzbekistan

www.stomatologe.tihe.uz
ITE Uzbekistan

11.04.2013
13.04.2013

Scandefa

Copenhagen,
Denmark

www.scandefa.dk
Bella Center

Frdric van Vliet

19.04.2013
20.04.2013

DentEcpo

Warsaw,
Poland

www.dentexpo.pl
Zarz d Targw Warszawskich S.A.

Production:

22.04.2013
24.10.2013

Dentalexpo Ufa

Ufa, Russia

www.dental-expo.com
Crocus Expo IEC

22.04.2013
25.04.2013

Dental Salon Moscow

Moscow,
Russia

www.dental-expo.com
Crocus Expo IEC

03.05.2013
05.05.2013

SIDEX 2013

Seoul,
South Korea

www.sidex.or.kr
Seoul Dental Association and Korean
Dental Trade Association

Editor:
Gerhard Kultermann

Editorial team:
Julia Farr
Nicole Jaganosch
Andreas Maurer
Manuel Meier-Staude
Susanne Mohr
Eva-Maria Popp

09.05.2013
12.05.2013

EXPODENTIS

Lisboa,
Portugal

www.expodentis.exponor.pt
EXPONOR Feira Internacional do
Porto

14.05.2013
16.05.2013

Stomatology Saint
Petersburg

Saint
Petersburg,
Russia

www.stomatology.primexpo.com
PrimExpo

22.05.2013
24.05.2013

Sibdent Novosibirsk

Novosibirsk,
Russia

www.sibdent.sibfair.ru
ITE Siberian Fair

23.05.2013
25.05.2013

Amici Di Brugg

Rimini, Italy

www.amicidibrugg.it
Rimini Fiera

24.05.2013
25.05.2013

WID Wien

Vienna,
Austria

www.wid-dental.at
sterreichischer Dentalverband

14.06.2013
15.06.2013

BALTDENTICA

Gdansk,
Poland

www.exactus.pl
Exactus sp.j.

3M Deutschland GmbH
Location Seefeld
3M ESPE ESPE Platz
82229 Seefeld Germany
info3mespe@mmm.com
www.3mespe.com

www.eberl.de Immenstadt/Germany

Design and typesetting:

Comcord GmbH Dsseldorf/Germany
We accept no liability for unsolicited manuscripts
or photographs.
Court of Jurisdiction: Munich

Published by:
3M Deutschland GmbH
Location Seefeld
3M ESPE ESPE Platz
82229 Seefeld Germany
info3mespe@mmm.com
www.3mespe.com

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