Dr. Michael Miyasaki has practiced for 30 years and is now in Sacramento, California. He enjoys incorporating technology into his practice that benefits his patients. You can see more videos at www.p-bdi.com.

Dr. Michael Miyasaki

	A common nightmare clinicians face every day has to do with shade selection of the materials we use in our patients’ mouths.

	For most of us, gone are the days of silver amalgam fillings and gold crowns; our patients want natural-looking teeth. Natural today is relative to how many times they’ve bleached their teeth. This shade selection anxiety goes up when working in the well-lit and highly visible anterior smile zone.

	Dr. Israel Abramov, of the City University of New York, has found that women are better able to discern hues and subtle color differences; therefore, I often rely on my female team members to confirm the color choices of the material we use. In my 30-plus years in practice, I’ve just accepted that I’d have to choose colors for the rest of my career, and one of my dreams would be to not have to worry about the color of the composite restorative materials I place.

	Then, I was approached by Tokuyama Dental America to try its newest material, OMNICHROMA, a one-shade composite that it said would adapt to match the color of the surrounding tooth. Indeed, when I was told the company had a new material where one shade would be appropriate for almost every direct composite restorative need, I was very skeptical. Could a dream come true?

	Tokuyama Dental has developed a composite material based on the concept of “wide color matching.” The company has created a single material that can cover a wide range of natural tooth colors.

	This means savings with less time spent anguishing over composite shades as well as the monetary and space savings from not having to inventory so many different shades, each in varying degrees of opacity. After years of research and development, Tokuyama Dental has developed the very impressive OMNICHROMA composite, which can tout the simplest shade system I know of.

Related reading: A game-changing dental composite

	OMNICHROMA is a single-shade, structurally-colored universal composite. The single-shade OMNICHROMA has the ability to esthetically match the 16 classical VITA shades with Tokuyama Dental’s Smart Chromatic Technology, achieved using uniformly-sized 260 nm spherical fillers.

OMNICHROMA’s spherical fillers work as an additive color mixing system, which is different from most composites that use the subtractive color mixing system of pigments and dyes.

	The subtractive color mixing system requires us to select a shade matching the tooth because the material color is established by pigmentation. Using the additive color mixing system, OMNICHROMA generates a red-to-yellow structural color equivalent to the surrounding natural tooth.

	Sounds good, but we also know a tooth has many different opacities that make up its color. Typically, the dentin is more opaque than the more translucent enamel. The translucency of the enamel gives us a natural depth.
	So, with most composite materials, we load up with the more opaque dentin shades, the more translucent esthetic enamel shades, perhaps a universal shade and others. Again, OMNICHROMA fills all these shoes, but with a caveat.

	When doing a large Class III or IV restoration, the darkness of the oral cavity would make the restoration have the appearance of having a lower value (value is the relative lightness or darkness of a color). With the OMNICHROMA system, there’s OMNICHROMA BLOCKER to use as a lingual layer to maintain the higher value of large anterior restorations or to mask slight staining, unlike with most composite systems.

	OMNICHROMA is appropriate for use in both the anterior and posterior teeth. The patient in this case report needed an occlusion amalgam replaced on a posterior tooth, and we elected to use OMNICHROMA as the restorative material to demonstrate its working qualities.

	Step 1: One carpule of 1.8 cc 2% lidocaine 1:100,000 epi was administered.

	Step 2: The tooth was isolated with a rubber dam (

	Step 3: No time was taken to select the shade because we were using OMNICHROMA.

	Step 4: The tooth had areas of interproximal decay and the distal-lingual cusp was compromised. The amalgam restoration, decay and weak areas of the tooth were removed. The occlusal margins were beveled to improve the bond and color (

	Step 5: Seek™, a caries indicator from Ultradent, was used to ensure there was no decay left behind (

	Step 6: The tooth was then air abraded with Danville Material’s MicroEtcher™ CD, a 27-micron aluminum oxide abrasive (

	Fig. 3                                                                                       Fig. 4

 V3 Sectional Matrix system was used to create the distal contact (

	Step 8: The tooth was selectively etched with Clinician’s Choice’s Max Etch, a 35% phosphoric acid. The etchant was placed on the enamel margin trying to avoid any significant phosphoric acid etching of the dentin (

	Fig. 5                                                                                                 Fig. 6

	Step 9: The etchant was then rinsed off the tooth thoroughly and the dentin area of the tooth was kept moist. Clinician’s Choice G5 was scrubbed into the tooth for its antimicrobial, desensitizing properties (

	Step 10: Tokuyama Universal Bond from Tokuyama Dental America was placed on the tooth. Tokuyama Universal Bond is a two-bottle system that’s mixed in a well, and then the mixed bond is applied to the tooth (

	Fig. 7                                                                                                 Fig. 8

	Step 11: A weak air stream was applied to the surface until Tokuyama Universal Bond stops moving, and then a mild air stream is used. There’s no need to light-cure the bond before placing the OMNICHROMA composite material. Using Tokuyama Universal Bond saves chair time and negates the concern about curing light shadowing (

	Step 12: A small amount of Estelite Universal Flow from Tokuyama Dental America flowable composite in Medium Flow was placed on the bottom of the preparation to ensure complete adaptation (

	Fig. 9                                                                                 Fig. 10

	Step 13: OMNICHROMA BLOCKER, which is more opaque, was placed where the tooth was darker on the preparation floor (

). Then, OMNICHROMA composite was placed incrementally.

	Step 14: Using composite instruments, such as Dr. Ronald Jordan’s, allows me to work with the composite materials without sticking (

). It should be noted that even when exposed to ambient light, OMNICHROMA had sufficient working time, allowing for its ideal contouring. Before it is cured, OMNICHROMA will typically appear more opaque and white than the surrounding tooth structure but will blend in, becoming semi-translucent, when it’s cured.

	Fig. 11                                                                                Fig. 12

	Step 15: Each increment of composite was cured with Ultradent’s VALO™ Grand curing light (

). Complete curing is critical when working with any light-cured composite material.

	Step 16: Once the preparation was completely filled, the occlusal surface was polished with Clinician’s Choice’s A.S.A.P. polishers.

	Tokuyama Dental has long been known for its high-quality and highly esthetic composites, and OMNICHROMA is an example of this lineage of high-performance composites, such as Estelite Sigma Quick. This case demonstrates that OMNICHROMA excels in many areas. It handles very well, and the single shade has excellent esthetics with the surrounding tooth structure. Polishability is easily achieved, and both patient and clinician were pleased with the results after restoring a very compromised tooth (

Articles

Why one clinician enjoyed using OMNICHROMA to restore a compromised posterior tooth.  


How to esthetically match surrounding tooth structure with a single shade

	When I first saw the Ultradent Gemini laser in its development, it did not have all of its corporate logos, but it stood apart from all other lasers in its appearance with its electroluminescent display. It draws you in to learn more about it and it delivers. This laser has so many features, but I will only highlight some of the most clinically relevant.

	Two features that set the Gemini apart is that it can deliver two wavelengths simultaneously and do so with 20 watts of peak power delivered in a super-pulsed mode. For years, the debate has been which soft tissue diode laser wavelength is the best to use, with the two common being the 810 nm and 980 nm. The 810 nm wavelength laser energy is best absorbed by pigmentation in the tissue provided by hemoglobin and melanin, while the 980 nm wavelength energy is absorbed more by water. The Gemini can deliver each wavelength individually or both simultaneously, which is genius.

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And it gets better with the 20 watts of peak super-pulsed power. This means that to deliver an average power output of 2 watts (more, than twice what I would typically use) the Gemini only needs to be active 10 percent of the time, allowing for thermal relaxation or tissue cooling, and the result is greater patient comfort and smoother, faster tissue ablation.

	I have used soft tissue diodes lasers in my practice since the 20th century because of the predictability it affords me and the comfort my patients experience. Better-fitting crowns without the need to pack cord, excisions without prolonged bleeding, frenectomies without the need for sutures-the list of advantages goes on. Telling a patient we are going to use a laser to “vaporize” the tissue to create the ideal smile or fabricate a better-fitting crown sure beats having to tell a patient you are going to “cut off” the tissue with a blade and then help them manage the bleeding and pain afterward. 

	I have the privilege of talking with clinicians around the world about lasers, and I find that there are often three main concerns in considering their adoption of a soft tissue diode laser in their practice. The first concern is the cost, the second is finding the need in their practice, and, lastly, they ask about the learning curve and education needed.

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	When discussing the cost, I think of a laser as more of an investment. It will return to you the actual cost of the laser and be a continued source of revenue. And it will change your patients’ perception of your practice, making it a powerful marketing tool. But these are the business benefits; clinically, I feel you are able to treat your patients better with a laser and that is what truly makes it priceless. It should be remembered that when it comes to reimbursement, we are reimbursed for the procedure performed, not the specific technique used. Whether we perform a gingivectomy with a surgical blade or a laser, it makes no difference, provided the service was indeed done. The concern about the cost of the laser must be tempered by the revenue it will generate, and the savings in time and material. 

	If you do crowns, place subgingival fillings, or treat patients for periodontal disease in your practice, the need is there. Let’s review some of the uses of the Gemini laser and see how easy it is.

 shows an example of a deep subgingival margin with the ensuing bleeding. If we are planning on packing a cord, we need to pack multiple cords soaked in hemostatic agent and wait for the soft tissue to move away from the tooth margin and achieve hemostasis. We have all experienced the moment of truth when the cord is removed, which oftentimes reinitiates the bleeding and the soft tissue again flops over the tooth margin, making it almost impossible to get an adequate impression the first time. This results in the loss of time, incurred cost of another tray full of material and the patient needing to undergo a mouthful of gagging material. 

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	Compare this to use of the Gemini laser. We can set the power setting of the laser using the preset power settings for “Troughing” (

 at 1.1 watts. The pre-initiated tip (pigment on the laser fiber converts some of the laser energy to photothermal energy) is placed into the sulcus to ablate the soft tissue, which creates a clear separation of the soft tissue from the tooth margin and achieves instant hemostasis (

). We then have no need to wait and can immediately take the impression (

). I consider this alone as priceless in my day-to-day practice.

	This example of using a laser is one that saves me time and material, but this is not a procedure that carries with it a fee unless you charge to pack cord. The next few clinical examples show the use of a laser, and each of these would be charged out the same as if you had used a surgical blade or an electrosurgery unit, but often the patient will not have to endure an injection of anesthetic or wait for healing and return for multiple visits, thus creating the ideal win-win situation for our practice and patient.

Fig. 1                                                 Fig. 2                                              Fig. 3

	I think the use of soft tissue lasers in a smile design case demonstrates the predictability of healing in the esthetic zone, where we often have thin tissue and exact margin placement. When working on a smile design case, we want to achieve symmetry of the gingiva, and position the height of the soft tissue of the cuspids and central incisors evenly and 1-1.5 mm above that of the lateral incisors, with the gingival zenith positioned slightly distal to the midline of the teeth to help create the appearance of their mesial inclination.

To see the value of using a soft tissue diode laser, let’s look at the alternatives such as a surgical blade procedure or using an electrosurgery unit. With both these options, we need to administer an injectable local anesthetic. Using a blade, our patient will have postoperative bleeding and discomfort to manage, and we have to wait for the tissue to heal before we prepare the teeth and take a final impression. Alternatively, if we used an electrosurgery unit, we would not have the postoperative bleeding, but we would still need to wait for the tissue to heal before preparing the teeth because of tissue necrosis. 

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	With a soft tissue diode laser, we can often recontour the tissues after the simple application of a topical anesthetic, such as Ultracare, a 20% benzocaine gel. Using Ultradent’s Gemini soft tissue diode laser, we can select the preset power setting for “Gingivectomy” at 1.2 watts and wipe the tissue away. I have my assistant blow air on the area and hold the high volume evacuator close to remove any heat, which is the only sensation the patient might feel. Done properly, we will not see any significant changes after tissue healing.

	Here is a case where the tissue has been recontoured before veneer preparation (

), and during this same appointment the equi-gingival veneer preparations were finished and impressions were done. A few weeks later the veneers were placed and 

 shows the predictability in tissue position.

               Fig. 5                                                                           Fig. 6

	When it is time to uncover an implant body, I use Ultradent’s Gemini laser in the “Implant Recovery” setting at 1.5 watts. We place Ultracare 20% bezocaine on the tissue for a minute and then “wipe” the tissue away until the implant body is exposed sufficiently (

). The implant doesn’t absorb the laser energy being metallic and there is not the sparking seen with an electrosurgery unit.

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	This patient presented with a benign growth of hyperplastic tissue due to irritation from a removable partial denture. This was caught during her prophylaxis appointment and its removal was as simple as placing Ultracare 20% benzocaine topical anesthetic for a minute, placing the tissue under tension by having my assistant pull the tissue with tissue forceps while I ablated the tissue at its attachment (

). We used the “Incision/Excision” preset, which delivered 1.2 watts. When sending the sample for biopsy, one must specify how the sample was collected, which in this case was with the laser as the pathologist may see the heat artifact and needs to understand why it is present.

Fig. 7                                             Fig. 8a                                        Fig. 8b

	An area where lasers can often be used is in hygiene care by hygienists (check with your local State Board to determine what services hygienists can legally perform). The hygienist can use the laser to disinfect the sulcus and treat necrotic tissue in non-healing pockets. Using the Gemini laser, we go to the hygiene preset “Sulcular Debridement,” which gives us 0.4 watts of power now with a 7 mm non-initiated tip, and gently wipe the tip through the sulcus to warm it up 60Ë C and disinfect the sulcus. After root planing and scaling, we initiate the tip and treat the necrotic tissue in the sulcus (

). One nice feature of the Gemini is the illuminated tip, which aids in the visualization of the tissue in the difficult to see areas of the oral cavity. 

Trending article: 5 reasons to revisit lasers for your dental practice

	I have reviewed many different procedures that can be accomplished with Ultradent’s Gemini soft tissue laser and there are so many others, such as the treatment of aphthous ulcers, frenectomies and so many more. The patient benefits are the main driver for me using the laser and making the investment. The last concern I mentioned in the beginning was the training and education. Fortunately, as you can see from the cases shown, the use of the laser is very easy and safe, and with the Gemini laser, Ultradent will help you with live certification courses, online training and shorter introductory course training. Ultradent wants your laser experience to be successful and safe. 

Fig. 8c                                                                            Fig. 9                 

	I encourage doctors to join the 21st century and see how a laser can positively impact their practice; given a chance, I know it will. And best of all the use of the Gemini will be appreciated by the your patients with the need for fewer visits and amazing treatment outcomes.

One clinician describes the advantages offered by the Ultradent Gemini soft tissue laser.   