Dr Zhang, who is currently serving as president of the North America Dental Partners Organization, specializes in implant dentistry and provides essential dental care for older patients covered by Medicare in Encinitas, California.

Clinical images courtesy of Jiachang Zhang, DDS.

For many patients grappling with severe bruxism, the world of dental restorations has been a conundrum with limited options. The standard choices—including zirconia, porcelain-fused-to-metal (PFM), and full-cast crowns—are effective but often bring their own limitations. But a transformative solution has been making waves in dentistry, one that mimics the brilliance of modern vehicle design, where crumple zones and safety features shield passengers from harm during an accident. Enter the era of 3D printed final restorations: a boon for patients, particularly those with a habit of grinding and gnashing.

 has aptly likened zirconia crowns to the vehicles of the 1960s and 1970s, robust and formidable on the outside but lacking the critical ability to absorb and distribute forces effectively. Zirconia, as we have come to know, can be unyielding, literally a piece of metal that can wreak havoc on opposing dentition. The analogy becomes more evident when you imagine fusing this unyielding material with a titanium implant, creating a setup that lacks the flexibility to cushion the blows of occlusal forces. Such rigidity can significantly increase the risk of implant failure and exacerbate wear on the opposing teeth.

Now, fast-forward to the 21st century, where dentistry is experiencing its own evolution. The equivalent of crumple zones and protective features in modern vehicle design can be found in 3D printed final restoration crowns. These remarkable creations possess the capacity to mimic the natural wear of tooth enamel, combining strength with a built-in fail-safe mechanism.

Rodin Sculpture Resin from Pac-Dent is a 3D printing resin that offers strength and enhanced esthetics for a variety of restorative indications. It is offered in 6 VITA shades including A1, A2, A3, B1, BL3/Bleach, and C2, each formulated using the CIELab color spectral testing method for optimal shade matching. It is designed to be fracture resistant like traditional ceramic restorations and can be polished with traditional tools and techniques, easily fitting into any dental lab’s workflow. Rodin Sculpture Resin is FDA cleared and biocompatibility certified.

Pac-Dent’s Rodin Sculpture, a ceramic-filled nanohybrid 3D printable resin, measures an impressive 175 MPa, presenting a dental material closely approximating the natural properties of dentin (240 MPa) and enamel (270 MPa). When compared with more traditional alternatives such as PFM (340 MPa), 3M’s Filtek Supreme (395 MPa), Ivoclar’s IPS e.max (400 MPa), and contour zirconia (900+ MPa), it emerges as a standout choice, especially when compared with the cost of precious and nonprecious full cast options (

This 3D printed resin is not only strong but also exhibits the potential to mimic the wear and function of natural tooth structure. Its superior biomechanical compatibility, with properties that align more closely with natural dentition, makes it an optimal selection for dental restorations. The ability to endure the rigors of occlusal forces while providing a more natural feel and wear pattern positions printed resin as a remarkable advancement in dental material science, promising resilience and a restoration that closely replicates the function of the patient’s original dentition.

Printed resin also offers a unique property of breaking when necessary to protect the implant, the abutment, and, most importantly, the surrounding bone from the destructive forces of bruxism. The journey into the realm of 3D printed crowns has ushered in an era of resilience and cost-effectiveness. This is especially significant for individuals with a proclivity for grinding their teeth, a habit that can test the durability of any dental restoration. Heavy bruxers and grinders are known to exert formidable forces that can challenge even the most robust materials. In some extreme cases, perfectly placed implants and abutments have been snapped in half by the relentless lateral forces generated by bruxism. In such situations, 3D printed crowns become an invaluable alternative to traditional options like zirconia and PFM.

One important point to consider concerns insurance reimbursements for printed crowns. Although these crowns are technically resin-based, it is noteworthy that Pac-Dent played a pivotal role in advocating for their inclusion in the American Dental Association materials group approved as of 2023. Printed resins with filler content exceeding 50% are now recognized as ceramic restorations eligible for reimbursement, like PFM and zirconia.

What sets these printed crowns apart is their ability to be quickly and easily duplicated, ensuring patients can access cost-effective replacements with minimal hassle. This not only saves patients time and money but also averts the need for expensive subsequent surgeries in case of failure. Moreover, the balanced properties of these crowns have the potential to reduce wear and tear on opposing dentition, a critical consideration for long-term oral health.

Comprehensive 3D Printed Restorations for Implants #4 and #5

Good oral hygiene, recent extraction of teeth #4 and #5 due to severe decay and infection

John Doe presented to our dental clinic with a chief complaint of missing teeth #4 and #5, which recently had been extracted due to severe decay and associated infections. He was eager to explore the best options for replacing these teeth and was particularly interested in innovative, efficient, and cost-effective solutions.

Upon clinical examination and discussion with the patient, it was determined that the best course of action was to proceed with dental implants to restore the functionality and esthetics of his smile. I had successfully placed dental implants in the #4 and #5 positions. After 4 months, the implants had fully integrated with the bone, exhibiting excellent stability of 78 on the Osstell ISQ Scale and readiness for the next phase of treatment, which involved the fabrication of custom restorations.

In preparation for 3D printed restorations, digital impressions with implant scan bodies were taken using our state-of-the-art intraoral scanner, the Medit i700. This technology allowed us to create precise digital models of the implant sites and the surrounding dentition. The accuracy of these digital impressions is paramount for the success of the 3D printed restorations, ensuring a snug fit and natural occlusion.

The digital impressions were exported to exocad to meticulously plan the restorations. Each crown and custom abutment were designed to provide optimal occlusion, esthetics, margins, and comfort. The 3D design process allowed for the fine-tuning of every detail, ensuring that John’s new teeth would seamlessly integrate into his smile. I have initiated training for my assistant in crown design, and she has enthusiastically embraced this new responsibility. With exocad’s intuitive artificial intelligence crown design generation, she has even managed to create designs in under 5 minutes.

Once the designs were finalized, the crowns were uploaded to Ackuretta’s slicing software, ALPHA AI. Printing supports were automatically generated, and the design was ideally automatically positioned on the build plate of the Ackuretta SOL printer. The crowns were printed within an hour. We had a choice of utilizing either the Rodin Sculpture 2.0 or the Rodin Titan resins from Pac-Dent. The main difference was that the Titan has a flexural modulus strength much lower than Sculpture. Because this was only a 2-unit bridge and not much longer, without requiring the additional flexibility and high-impact strength, Sculpture 2.0 was selected. As for the custom abutments, those were milled by my local lab technician.

The restorations emerged with remarkable precision. These 3D printed crowns displayed the ideal combination of strength, esthetics, and durability, making them an excellent choice for implant restorations. The total estimated in-house cost, including the milled abutments, crown resin, and design labor, came to roughly $180.

Postcure procedures include the following crucial steps in the final preparation of the crowns: first, thorough cleaning with light brushing. The crowns are rinsed in 99% alcohol to remove any residual resin and contaminants, ensuring a clean and biocompatible surface. The printing supports are removed and all surfaces are trimmed and finished with a fine slow-speed acrylic carbide. Following this cleaning process, crowns undergo UV curing, which can be achieved using specialized equipment like the Otoflash G171 curing unit. This unit emits a controlled dosage of UV light to further enhance the crown’s full mechanical strength properties and biocompatibility, making it a critical step in the production of 3D printed restorations.

With the 3D printed restorations prepared, John returned to our clinic for the final phase. I conducted a meticulous assessment of the crowns, focusing on their fit and esthetics while ensuring light occlusion with anatomical contacts. Fortunately, no adjustments were necessary. The next step involved cementing the restorations with Rodin luting cement and bonding them to the abutments using Rodin Bond. To achieve the desired esthetic outcome, I employed the versatile Rodin Palette Naturalizing Kit, enhancing the restoration through a skillful application of stain and glaze (

This process elevated the overall shade, hue, and chroma to achieve optimal esthetics. The staining and glazing materials, designed specifically for 3D printed resins and resin based, allowed for convenient touch-ups during the seating process.

The result was a resounding success. John Doe’s new 3D printed crowns for teeth #4 and #5 fit flawlessly into his smile. Not only did they restore the functionality of his missing teeth, but the esthetics were so natural that they seamlessly blended with his existing dentition. He left our clinic delighted with his rejuvenated smile.

Nearly 4 months later, it is incredibly encouraging to note that John’s crowns continue to exhibit remarkable durability and resilience. The restorations showed no color or shade changes, and the surrounding tissues remained healthy. The biocompatibility of zirconia-filled resins appears comparable to that of contour zirconia.

In a compelling testament to the enduring quality of Rodin Sculpture’s 3D printed crowns, I had the privilege of connecting with Aaron Welch, DDS, another early 3D final resin adopter. Dr Welch provided documented evidence of printed crowns he had placed over 2 years ago, displaying minimal signs of wear and demonstrating their exceptional longevity in bruxism studies (

). This extended durability underscores the enduring excellence that this advanced approach to dental restorations offers to patients like John.

With 3D printed restorations, we have opened the door to a new era of affordable dental prosthetics, where precision, customization, and patient satisfaction take center stage.

1. Koutsoukis, T, Zinelis, S. 3D Printing and Ceramics in Dentistry: A Review of Current and Emerging Applications. Dentistry Journal, 2021;9(4), 41.

2. Popov, I, Stavropoulos, A, Vandeweghe, S. Comparative in-vitro Evaluation of the Mechanical Properties of 3D-Printed PMMA and milled Denture Bases. BMC Oral Health, 2020;20(1), 175.

3. Ahrberg, D, Lutz, R, Furniss, D, Rueger, C. 3D Printing in Dentistry: State of the Art. Journal of Clinical Medicine, 2018;7(9), 179.

4. Salmi, M, Tuomi, J, Paloheimo, KS. Fused deposition modeling of novel scaffold architectures for tissue engineering applications. Journal of Cranio-Maxillofacial Surgery, 2013:41(1), 47-50.

5. Willems, G, Lambrechts, P,Bream, M, Vanherle, G. pubmed.ncbi.nlm.nih.gov/8272502/. National Library of Medicine –HIH – PubMed, (1993 Sep 1994).

6. 3M ESPE Filtek – 3M Center Building 275-2SE-3 St. Paul MN 55144-100 (2018). multimedia.3m.com/mws/media/629066O/filtektm-supreme-ultra-universal-restorative.pdf

7. CAD/CAM message board > Prosthodonitcs > Fixed Prosthodontics; Full Zirconia Vs. e.max Single Units. Dentaltown Message Board, dentaltown.com/images/dentaltown/magimages/0812/dtaug12pg46.pdf. Accessed Nov. 16, 2023.

8. Sun, Q, Sauvage, MC, Balani, K, Deng, X. Additive Manufacturing of Bioceramics for Bone Tissue Engineering. Comparison to Traditional Dental Materials, 2017;10(8), 898.

9. Wang, Y, Huang, W, Yang, Y, Zhao, Y. Comparative Study of Mechanical Properties and Microstructures of 3D Printed Zirconia and CoCr Dental Restorations. Comparison to Traditional Dental Materials,2020;13(9), 2182.

10. Corbani K, Hardan L, Skienhe H, et al. Effect of material thickness on the fracture resistance and failure pattern of 3D-printed composite crowns. Int J Comput Dent. 2020;23:225-233. PMID:32789310

11. Gad MM, Alalawi H, Akhtar S, et al. Strength and wear behavior of three-dimensional printed and prefabricated denture teeth: an in vitro comparative analysis. Eur J Dent. 2023 Jan 20. doi: 10.1055/s-0042-1759885. Epub ahead of print. PMID: 36669653.

12. Mangano, FG, Hauschild, U, Veronesi, G, Imburgia, M, Mangano, C. Trueness and Precision of Four Intraoral Scanners in Oral Implantology: A Comparative In-Vitro Study. PloS One, 2018;13(9), e0202916.

13. Savoye, J, Benington, PR, Al-Sabek, FW, et al. A Review of 3D Printing in Dentistry. British Dental Journal, 2019;226(10), 761-769.

Articles

Pac-Dent’s products are helping usher in a new era of 3D printed final restorations, resulting in a boon for patients, particularly those with a habit of gnashing. 

Embracing 3D Printed Implant Crowns: A Revolution in Dental Restoration for Patients With Bruxism

As a general dentist in practice for 40 years, I can say without hesitation that most patients do not floss daily. You can have the best hygienists and the finest education on flossing, yet far too many patients still do not consistently floss. Many floss the day before they see the hygienist, or a few days after, but—much like a resolution for the new year—sticking to this daily commitment is easier said than done.

Various studies provide differing statistics on the percentage of Americans who floss, but none present positive findings. This begs the questions, “Are patients flossing correctly?” and “What is holding them back from making it a daily practice?” With the current techniques and options for flossing, it is no wonder why many choose to simply brush and rinse.

Enter SLATE, a game changer in the flossing world. How, might you ask?

It was designed by Danny Snyder, DDS, whose intent was to revolutionize flossing and make it more enjoyable for everyone. He invented a powerful flossing device with 12,000 sonic vibrations/min, making flossing far easier and more likely to become a daily habit. With its slim design, SLATE goes beyond merely guiding users to floss correctly.

The SLATE Electric Flosser utilizes its Gum Sweeps—strategically placed bristles and ribs that are meant to emulate the shape of the teeth and gums. The Gum Sweeps remove plaque that would otherwise be untouched by normal brushing. It has 3 rows of rubber bristles designed to clean while still maintaining a comfortable experience. The flosser also features a tongue scraper that can be used to clean bacteria off the tongue. Floss heads can be exchanged, cleaned, and removed as needed, touting a greener and more sustainable way to floss. It is recommended for replacement every week.

Its design includes built-in silicon bristles, known as gum sweepers, for proximal gum stimulation. Additionally, on the backside of the flosser is a tongue scraper that helps remove bacteria, food debris, and dead cells. For orthodontic patients in brackets, SLATE has created a specific insert, making it simple for those patients to properly floss—an orthodontist’s dream come true.

As for my experience with SLATE, I found that inserting the disposable heads is straightforward and easy. Each insert can last up to 2 weeks with a full dentition (the company recommends 1 per week), so 1 insert may last far longer with patients having fewer teeth. The technique is easy: Insert the floss head between 2 teeth, move vertically on each proximal surface, and then proceed in a buccal-to-lingual direction to allow the gum sweeps to stimulate your proximal tissues (my favorite). Then simply flip the handle over, scrap the dorsal surface of the tongue and rinse away the gunk. The total time is often less than a minute.

You might be wondering whether I have always been a daily flosser, and the answer is no. Since discovering SLATE, I now incorporate flossing into my daily routine because it is so simple and straightforward, providing me with a much-improved overall experience compared with traditional flossing. In our practice, the doctors loved SLATE, as did the majority of Catapult reviewers. It was interesting to learn that some of the hygienists who reviewed the product felt it was a superior product overall but still liked the traditional method. 

On the other hand, patients, including my friends and family, found that they were all flossing and tongue scraping more often with the SLATE Electric Flosser (

SLATE’s beta testers found that many patients had improved probings with less bleeding on probing, and this would be attributed to 3 factors: daily usage, utilizing the correct flossing technique, and the gum stimulators (which allow you not only to massage the gingiva but to create an additional path to remove plaque and debris). These same beta testers found that patients with dexterity issues improved their home care by implementing SLATE into their normal daily oral hygiene routine. This is a key point, especially for geriatric patients. As we all have witnessed in our practices, the need for superior home care and prevention increases with this aging population. The SLATE Electric Flosser, like water flossers, should become routine as recommendations from our hygiene teams.

Here are some key metrics from our Catapult evaluation:

Two-thirds of the evaluators gave this electric flosser the highest approval rating, with many commenting that they have already shifted to SLATE (including myself, my kids, and my siblings).

More than half of the evaluators noted SLATE cleaned better interproximally than traditional floss (you feel far more control and have a different tactile sense).

The group overall felt the retail pricing was appropriate at $79 (with 4 floss heads included).

The group felt the refill pricing at $25 for 20 floss heads was very value oriented.

) did not last as long as the company states, 7 to 10 days (I have found them to last 2 weeks).

Figure 3. Inserting the disposable heads is straightforward and easy.

“I feel that it is doing a fantastic job cleaning interproximally.”

“The way it stimulates the gums…and it’s easy to use.”

“I love both the flosser and stimulator.”

“This is such a winner for those that have trouble (which is a lot) manipulating floss.”

The SLATE Electric Flosser is powered by 2 AA batteries (lasting around 6 months) and the company’s team has plans for a rechargeable unit along with potentially offering a future model with multiple vibration settings. From using my own SLATE device, I have found that the floss begins to break down after about 7 to 10 uses. The floss is woven by hundreds of strands and this construction works to remove plaque. Additionally, the floss has no wax, no toxins, no Teflon, and no polytetrafluoroethylene or polyfluoroalkyl substances.

You might ask, what about cleaning beyond just rinsing? There are many cleansing products for aligners and nighttime appliances, and these can be used in the same manner if you so desire.

SLATE is a game changer in the world of flossing and oral care, and we are thrilled to have evaluated this product and give it the Catapult Vote of Confidence™.

The SLATE Electric Flosser is a powerful device that has impressed evaluators and earned the Catapult Vote of Confidence.

A New, Easy, Effective Way to Implement Flossing Into Your Daily Routine

Developed from a process that featured at least 48 prototypes, the Curaprox Wooden Toothbrush from Curaden is designed to provide a sustainable but effective home care option.

Made from Swiss beech wood that harvested from sustainably managed forests, the biodegradable and compostable brush handles are designed with a compact, slightly angled brush head to make it easier to access all areas of the mouth.

Featuring 4440 tightly packed, ultra-soft filaments, the brush is designed to help provide a gentle cleaning while holding up against daily use.

A new sustainable home care option, this brush is based on 4 dozen prototypes.

Curaden Announces New Curaprox Wooden Toothbrush 

Align Technology, renowned for its Invisalign® system, iTero™ intraoral scanners, and exocad™ CAD/CAM software, has added the launch of the iTero Lumina™ intraoral scanner to its offerings.

Designed to redefine the scanning experience, this device boasts a 3X wider field of capture in a 50% smaller and 45% lighter wand, ensuring faster scanning speed, higher accuracy, superior visualization, and enhanced comfort for users, Align states.

The iTero Lumina scanner, equipped with iTero Multi-Direct Capture technology, offers several new features including:

Wider Field of Capture and Multi-Angled Scanning

: Enables simultaneous capture from multiple angles, ensuring smoother, faster, and more accurate scans.

: Up to 25mm, facilitating easy scanning of complex oral regions with minimal maneuvering.

: Quickly, easily, and accurately captures more data and detail, eliminating the need for traditional bulky digital cameras and cheek retractors.

: Sets a new standard for an effortless scanning experience, particularly beneficial for kids and teen patients.

“Today we’re excited to introduce the next generation of iTero scanning technology that pushes the boundaries of what the industry has come to expect from a scanner,” Karim Boussebaa, Align Technology executive vice president and managing director for the iTero scanner and services business, says in a press release. “iTero Lumina creates a new standard in digital scanning that achieves exceptional clinical outcomes through more detailed data capture and highly accurate, photorealistic images; increases practice eﬃciency with an eﬀortless, faster scanning experience; and delivers an elevated, more comfortable experience for clinicians and patients.”

Arie Eshco, Align Technology vice president, global product, marketing, and services, for the iTero scanner and services business, says the latest scanner will only improve the clinician's experience when it comes to digital dental workflows.

“It’s exciting to reveal the iTero Lumina intraoral scanner, designed to meet the needs of doctors and their patients, including a smaller wand with data capture capabilities and the potential to redeﬁne what scanners can do,” Escho says in the press release. “With iTero Lumina, the iTero tools and features that practices use every day with their orthodontic and comprehensive patients – tools like Invisalign® Outcome Simulator, iTero Occlusogram, iTero TimeLapse, and the recently released Align™ Oral Health Suite – are enhanced with faster, more eﬃcient, and photorealistic image capture, making iTero technology an invaluable part of digital treatment.”

The press release also included comments from global orthodontic professionals who have already embraced the iTero Lumina for its enhanced features:

•“iTero Lumina is such a leap in scanning innovation: 6 cameras, increased capture range while ﬂoating over the dentition. I can conﬁdently show my patients that I have the best, the most accurate, the fastest and importantly the most eﬀective integration of digital workﬂow when treating them with Invisalign. I want to apply this innovation to increase my eﬃciency and eﬃcacy in the Invisalign system, and to deliver the best experience possible for my patients…and that’s what the iTero Lumina allows me to do.” — Dr. Vicki Vlaskalic, orthodontist, Australia

• “iTero Lumina has amazing cameras. You capture multiple surfaces at the same time and when I work with my younger patients, I can take a scan really in a few seconds, especially in mouths where we only have 20/24 teeth, such as early deciduous or mixed dentition patients.” — Dr. Simonetta Meuli, orthodontist, Italy

• “Our practice data shows scanning quality and times have improved with the iTero Lumina scanner, which highlights to the consumer we are all about precision orthodontics and up-to-date digital technology. It’s a tremendous leap forward in imaging and visualization which translates to better communication and patient experience.” — Dr. David Boschken, orthodontist, United States

• “The accuracy, speed and ergonomics of iTero Lumina is ideal for complex scans that require more attention to details and maneuvering. For example, for full arch scans, full mouth reconstructions, multiple restorative units, and conservative preparations like veneers which were some of the most impressive features I've noticed so far during my clinical trials.” — Dr. KarlaSoto, DDS, United States

The iTero Lumina intraoral scanner is available in both cart and mobile configurations on the iTero Plus Series platform. | Image Credit: © Align Technology, Inc

To provide in-depth insights into the iTero Lumina intraoral scanner, a global broadcast is scheduled for February 15. Registration opened on February 1. For more information, visit 

iTero Lumina sets a new standard for digital scanning technology, offering a 3X wider field of capture, high accuracy, and a maximum capture distance of 25mm. The scanner ensures a smooth, comfortable experience for users and patients, with photorealistic scans enabling high-quality clinical decisions, according to Align Technology. The iTero Lumina intraoral scanner is available in both cart and mobile configurations on the iTero Plus Series platform.

Medical devices manufacturer introduces the new intraoral scanner, powered by the innovative iTero Multi-Direct Capture™ technology. 

Align Technology Unveils iTero Lumina, it’s Latest Intraoral Scanner 

Dental Creations recently announced the launch of their new Prefect PMMA Monolayer Discs.

Designed for the fabrication of milled occlusal splints and surgical guides, these discs are suited for use treating patients with bruxism. Highly abrasion resistant, the material provides the strength and comfort required in a bruxism splint.

Said to be efficient to process and polish, appliances milled from Perfect PMMA material offer a shiny, finished surface. The material is available in a single, clear shade in 98mm X 20mm, and 98mm X 25mm disc sizes.

These PMMA discs from Dental Creations are designed for fabrication of milled dental splints and surgical guides.

Dental Creations Announces New Perfect PMMA Monolayer Discs

Todd Snyder received his DDS at the UCLA School of Dentistry and trained at the F.A.C.E. institute for complex gnathological (functional) and temporomandibular joint disorders. He is the 77th Accredited Fellow of the American Academy of Cosmetic Dentistry and is a Fellow of the International Academy of Dental Facial Esthetics. He is also a member of the American Society for Dental Aesthetics and a Diplomat of the American Board of Aesthetic Dentistry.

Dr Snyder has been on the faculty at UCLA where he helped create and co-direct the first (in the world) two-year graduate program in Aesthetic and Cosmetic Restorative Dentistry. He is also a member of Catapult Education and lectures both nationally and internationally on numerous aspects of dental materials, techniques, equipment, marketing, technology, and business. He is a consultant for numerous dental manufacturing companies and has been published and featured in many books and dental journals worldwide.

Dr Snyder owns a software company, a marketing company, and an online dental training program. He is also a professional race car driver and entrepreneur. He practices Cosmetic and Restorative dentistry in Laguna Niguel, California, and Las Vegas.

Using a Simplified 2-Layer Technique to Restore a Fractured Maxillary Central Incisor |

Recreating the natural perfection and nuances of the human tooth in the esthetic zone using direct composite resin restorative techniques can be challenging, especially if that tooth is a single central incisor. With minimally invasive dentistry guiding restorative care and patients demanding efficient yet highly esthetic, natural-looking treatment outcomes, direct composite restorative dentistry has taken on increased importance as a viable treatment modality. The ability to restore an anterior tooth chairside offers practitioners the opportunity to present patients with a restorative solution that is more cost-effective and efficient than all-ceramic indirect options.

Fortunately, advancements and refinements in material and adhesive science have created direct composite material systems that minimize the loss of healthy tooth structure while maximizing the esthetic result. Today’s direct composite resin formulations offer better handling properties, a wide selection of shades, and a streamlined restorative process that reduces the number of incremental layers needed to achieve a highly esthetic, long-lasting outcome that blends seamlessly with adjacent dentition.

Tetric® Prime is a universal composite focused on Prime handling. The material has the clinician in mind, responding to requests for a universal composite that offers smooth, creamy handling for flawless adaptation and contouring in the anterior and posterior. There are 12 streamlined shades to create esthetically optimized restorations, and high radiopacity to visualize marginal integrity and ensure proper diagnosis in future recalls.


In the case presented here, a young, healthy male patient experienced a fractured maxillary central incisor (

) that was successfully restored using a 2-layer composite protocol developed to minimize chair time, simplify clinical protocols, and ensure a predictable, highly esthetic outcome.

For young adults, the permanent teeth most commonly affected by a traumatic event are the maxillary central incisors.

The patient in this case presented to the practice with an enamel-dentin fracture on tooth #8 that he wanted permanently restored to its natural shape and shade using the most timely, efficient method possible. The only plausible restorative treatment for an emergency case such as this was to restore the tooth using direct composite dentistry.

The patient’s lips were retracted (OptraGate; Ivoclar) and tooth #8 isolated. To provide the patient with a preview of the expected shape outcome and create a guide for composite layering, a composite material that most closely matched the shade of the patient’s fractured tooth (Tetric Prime A1; Ivoclar) was used to sculpt the desired length and shape of the tooth freehand (

) and then fabricate a silicone matrix (Template Ultra Quick Matrix Material; Clinician’s Choice) (

 as a template to guide composite layering and help with color analysis.

Once set, the matrix was removed as well as the freehand composite material. The tooth was cleaned and air abraded (MicroEtcher II; Danville Engineering) on the facial lower half and along the fractured edges as well as the lingual surface of the tooth to increase the bond strength of the composite resin to the enamel (

The tooth was isolated with Mylar strips and a 35% phosphoric acid etchant (Ultra-Etch Etchant; Ultradent) applied to the air-abraded dentin and enamel surfaces of the tooth (

), then rinsed and lightly air-dried. Next, a bonding agent (All-Bond Universal; BISCO) was applied to the air-abraded surfaces (

) and the matrix filled with the first layer of composite (Tetric Prime B1; Ivoclar) was compressed into place to create adaptation while recreating the lingual aspect of the tooth (

Next, extruded excess composite on the facial surface was carefully shaped and sculpted using a nonstick anterior composite instrument (IPCL; Cosmedent) (

). Subtle undulations along the incisal edge were created with a composite tool (P.K. Thomas #3; HuFriedyGroup) to mimic those of a natural tooth and the composite layer light cured (VALO X; Ultradent). The second and final layer of composite (Tetric Prime Bleach L; Ivoclar) was carefully placed, extending from the incisal edge up onto the healthy enamel (

A thin layer of a low-viscosity unfilled resin wetting agent (ResinBlend LB; Clinician’s Choice) was then applied (Dental Composite Brush #3; Cosmedent) to manipulate, thin, blend, and smooth the composite to its final shape and length (

) and then light cured. The last step was to finish and polish the restoration (

The result looked excellent, and the patient was pleased with the esthetics (

Restoring a single central can be one of the most challenging and difficult procedures in dentistry.

The ability to restore a fractured single central incisor to its natural shape and color in a simplified and predictable 2-step direct composite process opens the door of opportunity for general dentists challenged by the once highly technique sensitive and laborious multilayer protocols. Today’s patient values efficient, same-day procedures that save tooth structure, are cost-effective, and produce highly esthetic and natural-looking results.

1. Lam R. Epidemiology and outcomes of traumatic dental injuries: a review of the literature. 

. 2016;61(suppl 1):4-20. doi:10.1111/adj.12395

2. Apponi R, Murri Dello Diago A, Colombini V, Melis G. Direct versus indirect techniques to manageuncomplicated crown fractures of anterior teeth following dentoalveolar trauma. 

3. Lambert DL. Conservative aesthetic Solutions for the adolescent and young adult utilizing composite resins. 

. 2006;50(1):87-118, vi-vii. doi:10.1016/j.cden.2005.09.007

4. Winter R. Direct vs. indirect restorations for a maxillary central incisor. 

. November 20, 2019. Accessed Oct. 9, 2023. https://www.speareducation.com/spear-review/2019/11/direct-vs-indirect-restorations-for-a-maxillary-central-incisor

5. Hatkar P. Preserving natural tooth structure with composite resin. 

6. Tempel RA. The esthetic challenge of treating a single central incisor. 

A variety of products from Ivoclar can help patients receive efficient, same-day procedures that save tooth structure, are cost-effective, and deliver great esthetics. 

Using a Simplified 2-Layer Technique to Restore a Fractured Maxillary Central Incisor

Kellie Nock is the assistant editor for Dental Products Report. She graduated from Kent State University in 2018 with a Bachelor's in Journalism. Kellie enjoys multimedia content creation with a focus on audio and video storytelling. 

From Reactive to Proactive Dentistry. Image credit: © Kristen Morabito / MJH Life Sciences using AI

Time is a critical factor in dentistry that can significantly influence a patient’s treatment experience, often determining the outcome and overall cost of care. The scenario of a patient experiencing tooth or jaw pain but delaying a visit to the dentist highlights the profound impact of time on oral health. There are different scenarios in which a patient may delay seeing the clinician, including but not limited to the following:

One common reason for delaying dental visits is potential anxiety. Many individuals experience fear or apprehension associated with dental appointments, leading them to postpone seeking professional care. Unfortunately, this delay can allow minor dental issues to progress into more significant problems.

Financial constraints often play a role in patients postponing dental visits. Concerns about the cost of treatments may deter individuals from seeking timely care. Paradoxically, delaying treatment due to financial reasons can lead to more substantial expenses eventually as conditions worsen.

The fast-paced nature of modern life and busy schedules also can contribute to delayed dental visits. Individuals may prioritize work, family, or other commitments over their oral health. This postponement may result in the exacerbation of dental problems that could have been addressed more effectively with timely intervention.

Unfortunately, this patient does not realize that the pain may worsen over time until few or no options remain. Dental pain, in the case of this fictional patient, can be a sign of underlying issues such as cavities, infections, or gum disease. When patients ignore or delay addressing this pain, the condition may worsen. What initially might have been a manageable concern can escalate into a severe and debilitating problem. It may get so bad that a tooth must be removed, which will be far more costly overall than if the patient had visited a clinician when the pain began.

This is an example of the complications that proactive dentistry can mitigate. Proactive dentistry, with its emphasis on preventive measures, underscores the importance of addressing dental issues early. Regular checkups, treatment planning, and sufficient patient education may enable dentists to identify and treat problems in their initial stages, preventing the need for more extensive interventions later. So, how does one take a dental practice from being reactive to proactive?

What might be the most obvious starting place, and the most vital, is taking stock of the dental practice’s armamentarium. A good armamentarium should aim to make the practice more efficient, offer more diverse treatment options, and become more clinically effective.

“Reactive dentistry typically means waiting until there are symptoms of a problem, [whereas] preventive dentistry includes employing strategies that can help prevent ever having a problem in the first place,” says dental hygienist Sarah Crow, RDH.

Crow has been a dental hygienist since 2005 and works at Salem Dental Arts in Massachusetts. She is a United States Guided Biofilm Therapy (GBT) trainer at EMS Dental as well as a senior executive consultant with the Cellerant Consulting Group. Crow is a vocal supporter and avid proactive clinician, aiming to keep her patients’ oral health at the forefront of the conversation. Crow insists that it is on the practitioner to take charge of their patient’s oral health journey.

“Dental technology is advancing rapidly, but you won’t see it if you’re not looking for it. Dental professionals have the responsibility to embrace lifelong learning. This requires taking action to learn about the latest and greatest in the field,” Crow says. “Our patients deserve to have access to these new technologies and it’s up to us as dental professionals to stay on top of the latest science.”

Cellerant offers clinicians valuable insight on products and technologies that demonstrate value in the dental practice. “Each year the Cellerant team collaborates on the latest technologies in the market and votes to award these dental product companies with the ‘Oscar of Dentistry,’ ” Crow says. “This nonprofit, unbiased team volunteers their time, seeking out top-tiered emerging and tried-and-true technologies to be recognized for their outstanding products.”

Technology is a key factor in the dental practice and an even more valuable tool in the preventive arsenal, according to dentist and Viome Scientific and Business Advisory board member Ed Zuckerberg, DDS, FAGD. “Advancements in dental technology, such as those introduced by Viome, are pivotal in transitioning dentistry from reactive to proactive and preventive. Thanks to technologies like digital imaging and saliva-based diagnostics, early detection tools and personalized treatment plans are now possible,” Dr Zuckerberg says. “These advancements allow for more precise, less invasive, and personalized care. They enhance patient education and engagement, promote continuous monitoring, and facilitate a comprehensive understanding of oral systemic health.”

Viome has a variety of dental products designed to protect and strengthen the “oral microbiome,” as it is described on the company’s website.

 One such technology offered through Viome is its Oral Health Pro.

“Viome’s Oral Health Pro with CancerDetect™ uses proprietary RNA sequencing technology and AI [artificial intelligence] to detect early signs of oral and throat cancers from a simple saliva sample. These technologies enable dental professionals to identify and address issues long before they become visible to the naked eye or cause symptoms, facilitating early intervention and preventing progression,” Dr Zuckerberg says.

The at-home saliva test is said to empower patients to take charge of their own oral health journey, with specialized plans that aim to personalize care, according to Dr Zuckerberg. “Advancements in dental technology allow for more personalized and effective treatment plans. For instance, Viome’s technology analyzes the gene expression of the oral microbiome and human cells, providing insights unique to each individual’s oral ecosystem,” he says. “This level of personalization means that dental professionals can tailor prevention and treatment strategies to the specific needs and risks of each patient, leading to better outcomes and more efficient care.”

Oral Health Pro uses proprietary RNA sequencing technology that can detect oral and throat cancers from a saliva sample. Image credit: © Viome

The thesis of proactive dentistry is just this—early intervention coupled with personalized treatment plans that allow the clinician (and the patient) to detect and prevent any issues before they become serious problems. Because preventive care is so intrinsically tied to hygiene, hygienists also are potential advocates for proactive dentistry. Per Crow, there are a plethora of products and technologies that hygienists can harness to function as preventive guardians.

Importantly, the GBT protocol from EMS Dental is a minimally invasive methodology that aims to make the patient more comfortable while effectively assessing teeth and gums for biofilm. GBT moves through a variety of steps, outlined on their website

Assess teeth and gingiva for any issues after a rinse with mouthwash.

Disclose to patient by making the biofilm visible utilizing the EMS Biofilm Discloser.

Motivate the patient by reinforcing the importance of good oral hygiene and prevention.

Use the AIRFLOW® series to remove biofilm, stains, and early calculus. Also remove biofilm from gingiva, tongue, and the palate.

Use PERIOFLOW® nozzle to remove biofilm in pockets greater than 4 to 9 mm.

Remove the remaining calculus using the PIEZON® series of instruments.

Schedule the patient’s recall and see whether they liked the treatment.

Crow is a proponent of and an expert on GBT protocol, training clinicians in the United States on how to effectively implement this protocol in the dental practice. “What is the hygienists’ biggest battle in their workday, you ask? It’s time. Racing the clock to meet each patient’s needs every hour on the hour can be exhausting, leaving hygienists feeling burnt out and unsatisfied,” Crow says. “The GBT protocol allows hygienists to have more time during their appointments to employ preventive dental technologies. This painless approach relaxes patients, which helps lead them to agree to more frequent recare appointments and reenergizes the hygienist’s passion for their work.”

Another technology that Crow finds notable is VoiceWorks, a voice-activated periodontal charting software that lets clinicians share results with the patient, further reinforcing confidence in the treatment. According to Crow, this tool is a game changer.

“Allowing the patient to hear their probing results from a ‘third party’ validates the hygienist’s findings. This technology is a data-driven approach to evaluating the efforts set forth by the patient and assists in setting individualized recare frequencies based on these results,” she says. “This method allows for a comprehensive periodontal evaluation to be completed by a solo practitioner, and a resource to refer to from future appointments to gauge if the preventive treatment plan is working.”

Creating a preventive treatment plan can be challenging if the practitioner does not have a complete look at the patient’s tooth structure, gingiva, and whole mouth. That is why imaging technology like the CALCIVIS®Imaging System comes highly recommended by Crow, aiming to eliminate subjectivity and anxiety when it comes to proactive care.

The CALCIVIS Imaging System harnesses the power of bioluminescence to visually demonstrate the release of calcium ions from demineralized tooth surfaces. The practitioner takes an image of the tooth surface using the device, which contains an LED light. Once the LED is turned off and the CALCIVIS photoprotein is sprayed on the surface, the clinician then takes another image of the bioluminescence that is generated between the photoprotein and the calcium ions. This gives practitioners a first look, before even visual defects are observed, at any problem areas on the patient’s tooth, whether it be occlusal, labial, buccal, or lingual.

“The CALCIVIS Imaging device helps to bring those blurred lines into focus when it comes to preventing caries,” Crow says. “For patients to value and comply with preventive approaches, they need evidence that preventive treatment is necessary. A wise woman once said, ‘The mind can’t know what the eye can’t see.’ This could not be truer when it comes to our patients. Utilizing technology such as this reinforces the need for remineralizing varnishes and other interventions to aid in the stability of sound enamel structure.”

Imaging technology, particularly innovative solutions like CALCIVIS, holds immense potential in propelling dental practices toward a proactive approach to oral health. As dentistry evolves, these advanced imaging tools offer a transformative avenue forward, enabling practitioners to detect, diagnose, and address dental issues in their early stages.

Even something as straightforward as an intraoral scanner can fulfill proactive measures, acting as a strong visual aid for detecting any underlying problems. “Modern dental technologies also play a critical role in patient education and engagement. Intraoral cameras and digital scans allow patients to see and understand their oral health conditions, making them more likely to engage in preventive measures,” Dr Zuckerberg says.

A comprehensive report, consolidating various components of dental care like preventive strategies and risk assessments, serves as a valuable tool for patients and practitioners. This report harbors crucial information, findings, and recommendations, fostering a collaborative approach to oral health management that the patient may find empowering, according to Dr Zuckerberg. “Additionally, platforms like Viome provide detailed, accessible reports that help patients understand their oral health status and the steps they can take to improve it, fostering a proactive approach to their own health,” he says.

Empowering Patients for Their Own Preventive Paradigm

Although a patient may trust their practitioner as a source of information and care, there are many patients who can experience a sense of distrust and fear about dentistry. It can be normal to feel a bit of anxiety concerning the health of one’s mouth and body, but certain patients will shut down at the thought of listening to and even visiting the dentist. According to a study published in 

, there are a variety of reasons why a patient may not trust their practitioner.

Although building trust or confidence may feel like a monumental task, there are little steps that practitioners may take inside and outside of the operatory to encourage patients to take initiative on their own proactive oral health journey. This may begin by having more conversation with the patient, according to Crow.

“Motivational interviewing and asking open-ended questions help the patient to have that ‘aha’ moment. When they answer their own questions with the hygienist’s nudge and feel like they figure it out themselves without being told, it allows space for the patient to be a part of the conversation during their hygiene visit,” she says. “Most people don’t like to be told what to do but giving evidence of disease and allowing the patient to come to their own conclusions lessens the blow. For example, if you have a patient in your chair with generalized gingivitis, who you know is not brushing properly, do not tell them so. Applying a disclosing agent and letting the patient see with their own eyes the bacteria that is growing in their mouth allows them to put the pieces of the puzzle together, and realize they have control.”

Because home care is so key in prevention, Crow suggests that some of these conversations with patients focus on the home care aspect because it is something over which the patient has more control. “Detailed documentation of their current home care regimen and professional suggestions allow the hygienist to follow up on how the patient has been doing with their home care routine,” Crow says. “Noting the patient’s most recent home care efforts and relating this to the results of their assessments gives the patient the satisfaction of knowing that what they are doing is either working or not working. This in turn can motivate the patient to continue or modify their proactive oral care habits.”

Good home care is crucial in protecting gingiva, preventing biofilm buildup and caries, and empowering patients to feel in control of their oral health journey.

 Alternatively, prevention inside the practice can be bolstered by a tool that continues to be a huge boon in health care: AI. AI can provide patients with the supplementary evidence that they may need regarding their oral health care journey, according to Dr Zuckerberg. Although they may trust their dentist, seeing an intelligent machine reach the same conclusion can only reinforce this trust and encourage proactive dentistry.

“The true revolution comes with the integration of AI. AI’s ability to learn and adapt rapidly means that with every new sample analyzed, the system becomes more sophisticated and more nuanced in its understanding. This continuous learning process enables a level of precision and personalization previously unimaginable. AI doesn’t just analyze data; it discerns patterns, predicts outcomes, and recommends preventive measures, making it an invaluable tool in proactive dental care,” Dr Zuckerberg says.

“Moreover, as AI technology continues to advance, its potential applications in dentistry expand,” he adds. “From predicting the progression of periodontal disease to customizing treatment plans for individual patients, AI is empowering dental professionals to take a more informed, proactive approach to care. The result is more effective prevention, more timely interventions, and ultimately better overall health outcomes.”

Viome’s approach to analyzing the human oral microbiome is a pioneering fusion of advanced RNA sequencing technology and powerful AI algorithms. By combining these innovative technologies, Viome aims to provide a comprehensive and detailed understanding of the complexities within the oral microbiome. This innovative approach not only enhances our understanding of the microbial community in the mouth but also empowers practitioners to take proactive measures in oral care.

“The power of RNA sequencing lies in its ability to provide a detailed look at the active, functional components of the oral microbiome. This allows for the detection of early biomarkers for conditions such as oral and throat cancer well before they manifest into more serious issues,” Dr Zuckerberg says. “Viome’s precision sequencing captures a comprehensive snapshot of the microbial and human gene expression, providing unprecedented insight into a patient’s oral health.”

Proactive care begins at the intersection of technology and patient participation, according to Dr Zuckerberg. “[AI is] redefining the very possibilities of what can be achieved. It’s a testament to the power of modern technology to improve lives and a clear signal that the future of dentistry is proactive, personalized, and preventive,” he says. “As dental professionals, embracing these advancements is not just an opportunity; it’s our responsibility to our patients and the future of health care.”

Although a dental practice may never be able to go truly proactive, there are ways to avoid falling back on reactive old habits. These may begin with recognizing when you are engaging in a proactive treatment plan vs a reactive one.

Reactive dentistry is what we know well, from fillings to root canals to even surgery and/or extraction. These treatments and cases are vital. Proactive care does not seek to discourage patients from getting important care, but instead asks whether something is preventable.

“By focusing on early detection, risk prevention, and the maintenance of optimal oral health, proactive dentistry not only ensures better oral health outcomes but also contributes to the overall well-being of the patient,” Dr Zuckerberg says. “On the other hand, reactive dentistry typically involves treating problems after they have manifested, often requiring more complex and invasive treatments. Proactive dentistry fosters trust and loyalty in patient relationships and aligns with the broader health care shift toward preventive care.”

Shifting to a “proactive-first” mindset instills more confidence in the dental practice, from the dentists to hygienists and even patients. Being equipped with the tools to function as a shield is what proactive dentistry is all about. And even in situations where dentistry must be done in a reactive way, clinicians still can set the groundwork for more proactive dentistry in the future.

“A reactive patient typically has had nonexistent or negative past dental experiences that give rise to their current condition. This type of patient’s mentality is often more difficult for the dental team to ‘undo’ and often requires a careful choreograph of words to help the patient value their dental health and guide them to an understanding that their oral health is within their control,” Crow says. “It’s important for a dental professional to embrace a proactive mindset because, as we know, most dental issues are completely preventable. As dental professionals we must remember the oath we so proudly proclaimed on our graduation day. This was to ‘improve the oral health of the public’ and that ‘prevention is preferable to cure of disease.’ ”

As mentioned by Dr Zuckerberg, health care has been at the forefront of proactive care, with regular, vital checkups that doctors can use to get a comprehensive view of a patient’s health. Pulling from general practice in health care, dental professionals can also engage in more proactive care. The oral-systemic link demonstrates that what happens in the mouth can reflect what is going on in the rest of the body.

 is linked to a variety of systemic illnesses, according to Dr Zuckerberg, including cardiovascular disease, diabetes, dementia, and rheumatoid arthritis. There are abundant benefits of the collaboration between oral health professionals and doctors, according to Dr Zuckerberg.

“As a dental professional, I am deeply invested in the seamless integration of technology into dental care. I am a staunch advocate for a collaborative, multidisciplinary approach to health care,” he says. “Fully aware of oral health’s significant impact on overall systemic health, I am committed to actively promoting a holistic approach to preventive care.…This awareness lays the groundwork for a collaborative approach, ensuring that each specialist appreciates the significance of their role in the broader context of the patient’s health.”

Although collaboration may seem easier said than done, a variety of tools and programs exist to ensure this gap has shrunk. “Attending health care seminars outside of dentistry and inviting these health care professionals to sit on dentistry’s professional associations’ board of directors can bring an outside perspective and provide insights in an otherwise uncharted territory,” Crow says.

The integration of diagnostic tools in the realm of health care not only enhances the understanding of a patient’s condition but also revolutionizes communication among health experts. This transformative shift, coupled with secure channels for information sharing, creates a new avenue for collaboration and enables comprehensive discussions about a patient’s health. This is particularly evident in dental practices where diagnostic tools play a crucial role in showcasing the intricacies of oral health and its potential impact on systemic well-being.

“I fervently champion the use of advanced diagnostic tools. Innovations like those pioneered by Viome provide profound insights into a patient’s oral and overall health, enabling more precise and personalized care,” Dr Zuckerberg says. “By sharing these insights and methodologies with fellow health care professionals, we cultivate a more comprehensive understanding and treatment plan for the patient.”

Oral health solutions. Viome. Accessed January 15, 2024. https://www.viome.com/products/oral-health-solutions

Guided biofilm therapy. EMS Dental. Accessed January 15, 2024. https://www.ems-dental.com/en/guided-biofilm-therapy

Where nature and technology meet. Calcivis. Accessed January 15, 2024. https://calcivis.com/#nature-and-technology

Moore R. Trusting the dentist—expecting a leap of faith vs. a well-defined strategy for anxious patients. 

Dental care plays a crucial role in maintaining overall health and well-being. However, the approach to care can vary significantly.