 Foroud Hakim, DDS, MBA

Catapult is an organization that consists of more than 50 clinicians spread throughout Canada and the United States. As a company, manufacturers pay a fee for their product to be evaluated and what we deliver are truthful, independent answers from surveys that we develop with them. We have had many products that have either had to be altered before hitting the market or simply never arrived because of our openly honest evaluations. In this way, Catapult assists the manufacturer to avoid potentially releasing a faulty product, or simply a product that needs refinement. Lastly, our clients are omnipresent in the industry, small to large, with no favoritism, simply reviewing the latest products in our practices.

Ask any restorative dentist to list their biggest pain points or clinical challenges and, without fail, tissue management for successful final impressions rises to the top of the list. No other procedure in dentistry correlates more directly to outcome quality, and yet no new or elegant solutions for controlling bleeding and moving cervical tissue away from the prepared margin have emerged for quite some time. Until now, that is. The evaluators at Catapult Education were asked to test VOCO Retraction Paste, a novel product from VOCO America.

Historically, practitioners would stop bleeding and retract tissue using either hemostatic agents plus retraction cord or electrosurgery to cauterize bleeding capillaries and cut away cervical tissue blocking impression material from margins. Although electrosurgery units are still sold and used by some traditionalists, they have largely been replaced by diode lasers that are more precise, significantly reduce thermal damage to tissues, and improve patient comfort both during and after the procedure. I am a big fan of diode lasers and use them regularly, but I believe their utility goes far beyond tissue troughing for impressions. I use a laser to eliminate tissue that I prefer be removed and materials that offer temporary retraction of the healthy tissue that I prefer to keep. Retraction cord has served the profession reliably for countless years. Various iterations, including braided and knitted cord, have been developed, each with different handling properties. Cord is used in tandem with a number of hemostatic solutions. Because epinephrine-impregnated cord has fallen out of favor due to potential adverse cardiac effects, aluminum chloride and ferric sulfate have become the most commonly used hemostatic solutions.

Despite the efficacy of cord, doctors continue to look for alternatives for a variety of reasons. Cord packing is considered time-consuming, even for expert practitioners (2-cord technique, by definition, takes twice as long). Overzealous packing in fragile biotypes can lead to unwanted recession. Given a choice, most patients would prefer not to have cord jammed into their sulcus and avoid the reinforced anesthesia that is sometimes needed. Liquid hemostatic solutions show mixed efficacy (aluminum chloride is typically less effective than ferric sulfate), have an unpleasant taste, and can irritate soft tissues. Although ferric sulfate provides more predictable hemostasis than aluminum chloride, remnant ferric ions that are not cleansed away and remain embedded in dentin tubules can lead to progressive creeping stain that becomes visible through ceramic restorations, rendering them an esthetic failure over time. When manufacturers introduced cord alternatives in the form of gels and pastes, doctors were eager to try them, and I was no exception. These alternatives were met with mixed reviews. The consensus was that they were marginally effective and, as such, a convenient alternative for cases in which bleeding was not a significant problem and margins were not placed too far below the gingiva so that significant tissue displacement was not required. In due course, many doctors found their way back to cord or laser troughing strategies.

Case

Although VOCO Retraction Paste falls in the category of cord alternatives, Catapult evaluators were unanimously pleased with its performance. The material characteristics and highlights are as follows:

VOCO Retraction Paste features aluminum chloride as the active hemostatic agent. But reviewers found that the formulation and tissue interaction mode resulted in far better hemostasis than they have experienced with other products containing aluminum chloride. They found it to be on par with or even more effective than ferric sulfate in some instances.

Delivery and placement of VOCO Retraction Paste was remarkably easy and efficient. First, there is no dedicated dispensing gun needed as unit-dose ampules fit into any traditional composite gun. Next, the adjustable narrow tip makes it possible to place the paste very quickly. Finally, the material can be further compressed into the sulcus using the flat aspect of a cord packer or similar instrument.

VOCO Retraction Paste features dual-phase viscosity. Upon initial dispensing, it is more fluid and flows into the sulcus under extrusion pressure. Once in place, it becomes more viscous and essentially maintains the positive retraction by occupying the expanded sulcular space. This is why the evaluators found it to be as effective as small diameter cords.

The highly visible blue of VOCO Retraction Paste made it easy to see not only during placement but afterward as well, so complete removal could be verified before beginning the impression. Removal can also be accomplished very quickly with vigorous air/water spray using the 3-way syringe and does not leave a stain on the tooth after removal.

The following clinical case highlights the use of VOCO Retraction Paste for tissue management in preparation for a digital scan.

. Note the molar crown preparation presenting with variable margin placement, including supragingival and subgingival spans in need of hemostasis.

. VOCO Retraction Paste was dispensed and compressed or buttered into the sulcus using the flat aspect of a cord packing instrument.

. Top down and lateral screenshot views of the final Itero™ scan, showing a very clearly reflected and digitally pinned margin.

It’s worth mentioning that although VOCO Retraction Paste was effective for most clinical scenarios leading up to an analog elastomeric impression, it is perhaps the perfect complement to practices that have adopted digital impression technologies. In certain cases, cervical tissue that is under-retracted may result in thin or fragile flash that can tear upon removal. There is no minimal axial retraction required when capturing a margin digitally. As long as the camera can see clear delineation from surrounding tissue, the margin is accurately captured.

Because of the overwhelmingly positive reviews from Catapult Education Doctors, VOCO America was awarded a unanimous Catapult Vote of Confidence™ for its VOCO Retraction Paste.

Articles

Why most Catapult Education evaluators have added VOCO Retraction Paste to their trusty tackle box of go-to products.

Hemostasis and Retraction: Tackling This Age-Old Challenge Just Got a Whole Lot Easier

When asked to list the most impactful treatment modalities in modern dentistry, 3 come to mind: predictable adhesive bonding, implant-based restoration, and clear aligner therapy. This article is about aligner-based orthodontics.

The proverbial 800-lb gorilla, Invisalign® launched into market in December 1999. It is exponentially the largest clear aligner manufacturer in the market and the product I choose for my patients. That said, a growing list of competitors have followed suit, launching their product lines into the marketplace while competing for the attention of both doctors and patients.

Clear TPS® was founded in 2012 with a vision of providing consulting services for doctors who use clear aligner therapy to treat orthodontic patients. TPS stands for “treatment planning solutions.” Its value proposition is based on the fact that clear aligner manufacturers are primarily in the business of manufacturing and selling aligners to their customers. At a rudimentary level, some of the manufacturers also provide treatment plan proposals. However, case setup, treatment outcomes, necessary refinements, and an ultimate, objective measure of success hinge on several factors, including clinician experience, orthodontic training, a clear understanding of potential case complexities, clear aligner continuing education and mentorship, a doctor’s ability to evaluate and adjust the mechanics and staging of a treatment proposal, and, of course, outcomes like patient satisfaction, expediency of treatment, and practice return on investment.

Clear Treatment Planning Solutions is designed to bridge the gap between clear aligner companies and clinicians to make the clear aligner process easier and more streamlined. These treatment planning services are powered by strong communication, making consultation between clinician and company more open. Clear TPS promotes better case outcomes and cost savings across the board.

Clear TPS seeks to bridge the void of diagnosis and treatment planning in the manufacturer-doctor relationship. Its model includes intimate onboarding of a client doctor for case submission (a mechanism of enabling the Clear TPS consulting doctor to take over the treatment proposal and refinement process for a given manufacturer) and an active dialogue during case setup and staging to the consultant’s satisfaction. Once the refined proposal is ready for doctor approval, Clear TPS will communicate with the doctor to set up a preapproval consultation to answer any questions and elaborate as needed on the treatment plan.

Clear TPS is exceptionally well positioned to provide expert consulting toward improving the entire doctor-patient experience involving clear aligner therapies. It has key individuals serving in the leadership and operational roles, including doctors, developers, and advisers, some of whom are former key employees of the largest clear aligner manufacturer.

To appreciate the need for clear aligner consulting services, we need only to look at the history and projected scope of the market. To date, Invisalign has been used in over 11 million cases globally, a whopping 2.7 million in 2021 alone. Add to this sum, the cases treated with competitors like ClearCorrect®, SureSmile®, Spark®, Reveal®, Angelalign®, ArchForm®, OnyxCeph®, Arcad®, and Orchestrate®—for all of which Clear TPS provides consultation services. Alas, the arrival of direct-to-consumer (DTC) clear aligners to the marketplace has also served to dramatically increase awareness across the population. While DTC treatment options justifiably caused angst for doctors, as it turns out, the advertising exposure has led to an uptick in patients seeking treatment from trained providers.

It is easy to understand why the clear aligner industry is projected for 20% to 30% year-on-year growth. Now let’s consider the ever-expanding pool of providers. Experienced orthodontists who have years of training in the specialty make up a small fraction of the practitioner mix. The anticipated economic windfall from incorporating the treatments into general practice, coupled with the addition of basic training in most dental school curricula, has resulted in an explosion in less experienced general practitioners delivering most of the care. I firmly believe this model of service is great for our patients and the profession. There are countless benefits to improving the orthodontic condition of patients. From the functional, social, and psychological impact of improved occlusion, esthetics, and function, to improved periodontal health and maintenance related to straight teeth, and the correlation of that to systemic health, appropriate aligner therapy is one of the best services we can provide for our patients.

The notion that these services should be provided only by specialists is antiquated and defunct. That said, there is no doubt that providers with higher case counts, coupled with the experience from continuing education while observing their own good and bad outcomes, are less likely to encounter complications in treatment. This is because they are more prone to anticipate complications and plan treatment around them, and also to detect potential issues far earlier and make appropriate midcourse corrections.

Catapult Education doctors were asked to evaluate the services provided by Clear TPS. The evaluation was meaningful in the sense that we were not asked our opinion on whether a consulting service for clear aligner orthodontics “sounded like a good idea, or made sense.” To participate, we took our own patients scheduled to start orthodontics through the treatment pathway. A series of pre- and post-surveys were completed soliciting our opinions and observations. A recurring theme that emerged was the frustration with and the prevalence of treatment completion time delays. A staggering 75% of reviewers reported needing to order refinement aligners for over half of their cases. All doctors reported this as a barrier to starting more cases and a detriment to patient satisfaction and practice productivity. To provide a thumbnail sketch of the impact of unpredictable treatment timetables, we just need to simply look at practice overhead models. The typical US-based general practice runs at a $390/h overhead rate. Now imagine a 20-aligner case (the demarcation count between a moderate and comprehensive case as defined by Invisalign) is completed and the treating doctor and the patient celebrate the vast improvements from the starting point, yet notice a few areas that may not be tracking to the exact final outcome postulated.

When a refinement is initiated, it is not uncommon for the next package of aligners to range between 8 and 10 in count and for modifications in attachment count and interproximal reduction (IPR) adjustments to be prescribed. Suddenly, we have a second time-consuming impression or scanning appointment, another delivery appointment, plus several progress visits added to the overhead timetable. This includes unplanned chair time, auxiliary utilization, and all the other efficiency drains magnified even more in the post–COVID-19 era.

One can quickly see how profits may be eroded by the uncharged chair time related to the expanded treatment time. This doesn’t account for intangible costs like lowered patient satisfaction, loss of confidence, or delays in starting planned postorthodontic restorative treatment. What if doctors new to aligner therapy, as well as those with intermediate levels of experience (I put myself in this category, approaching triple-digit case counts) could streamline treatment, reduce aligner counts, eliminate refinement needs, and improve patient experiences and treatment outcomes while improving their bottom line? The case studies below highlight the impact of Clear TPS consulting for a few of my patients.

Case 1

A 45-year-old man presents with a history of mucogingival recession, compromised attached gingiva, and free gingival grafting.

 demonstrate side-by-side ClinChecks® of the initial treatment plan proposal as well as the final treatment plan after the Clear TPS consulting doctor took control of the doctor tools on the Invisalign portal to make necessary adjustments.

Eliminated unnecessary expansion, which could have led to posterior open bite

Eliminated unnecessary movement of second molars

Case 2

– A 60-year-old woman presented with retroclined anterior teeth; a tight, locked-in bite; restorative spacing discrepancy for a proposed #7 implant restoration; and general esthetic reveal disharmonies.

Eliminated unnecessary movement of terminal molars

Case 3

A 65-year-old woman presented with a recent history of unsuccessful orthodontics leading to anterior and posterior open bite with bilateral single contact occlusion on left-side second molars and right-side first bicuspids.

Besides the obvious functional and guidance issues, a general esthetic zone smile alignment was also desired.

Adjusted posterior cross-bite improvement to fall within biological parameters

Overjet improvement to allow for bite closure

As the author, I can wholeheartedly attest to how utterly pleased I was with the outcome for both patient cases 1 and 2.

For the first time in a long time, I could report ideal tracking through every stage of aligner checkup and delivery with final tooth positions matching impeccably to the postulated treatment plan outcome.

Neither patient needed a refinement and they were immediately graduated to restorative and retention phases of care. Similar experiences were echoed by the other Catapult evaluators.

Armed with the new level of confidence, I chose to embark on case 3. I would have never considered treating such a complex case with the scope of an adult open bite resulting from iatrogenic orthodontics. It would have been an automatic referral to an orthodontist.

I can report that the patient is now through 50% of her aligners while tracking perfectly to projections.

My experiences raise the question: Why wouldn’t I leverage the help of a trained orthodontist with tens of thousands of treatment experiences, especially when the cost of service pales in comparison to the protracted overhead expense of a case likely to be extended?

This is exactly the reason why Catapult doctors provided a resounding vote of confidence for the services and platform of Clear TPS.

Why Catapult evaluators rated Clear TPS an invaluable service provider for their practices. 

The Expanding Pool of Clear Aligners

If you thumb through a typical dental supply catalogue, you might find 30 different adhesive systems or bonding agents. Every material manufacturer has an offering. Direct sale manufacturers also add to the marketplace.

So the million-dollar question is, “What adhesive should I use?” A lot has happened during the past 4 decades in dental bonding. In the 1980s, doctors were exposed to the early market entries. These were typically fourth-generation, 3-component systems used to adhesively bond composite restorations as an alternative to the staple material at the time, amalgam.

The Peak Universal Bond adhesive system features a universal bonding agent that is compatible with both self-etch and total-etch techniques. Its universal formulation works with all bonding substrates—including dentin, enamel, porcelain, metal, composite, and zirconia—and provides superior bond strengths, making it the ideal choice for all bonding procedures. The material’s versatile formulation is ideal for indirect and direct bonding.

Fast forwarding, there has been an explosion in adhesive material science and restorative materials. Now doctors not only bond direct restorations to teeth but they also employ a much broader range of indications across pediatric, adult, and geriatric dentistry. The restorative options range from a variety of composite resins—including viscosity variations, layered options, bulk-fill options, dual-cure materials, bioactive materials, desensitizers, and fiber and core buildup materials—to the expanded use of adhesive cementation of indirect restorations made for the continually evolving modern ceramics and related offshoots. In short, doctors rely more than ever on predictable, reliable, and lasting bonds between tooth and restoration.

The evaluators at Catapult Education clinically reviewed and tested the Peak Universal Bond adhesive system from Ultradent Products Inc. A smaller subset of evaluators also performed unbiased laboratory comparison testing among several market-leading competitive products. 

Ultradent

The viscosity and placement precision of Ultra Etch led an evaluator to deem it the “gold standard of etchants.” Once the phosphoric acid is rinsed away, the doctor proceeds with the steps above for delivery of Peak SE to all involved dentin with no concern for overlap onto enamel. The subsequent steps are the same for application of the adhesive. In summary, selective etch approach is used to customize and optimize bonds in most typical clinical scenarios involving both dentin and enamel.

As Catapult Education doctors began to present their findings and feedback on Peak, it quickly became evident how satisfied they were with the outcomes. From general praise on the delivery syringe mechanism (bottle + micro-brush delivery is also available), to notes on restorative outcomes, and finally, confidence in bond performance with regards to the commitment Ultradent Dental Products has as a manufacturer to research and development. This notion of unbiased research proved very important.

Every doctor has seen shear bond strength studies provided by manufacturers in lectures, print, social media, and meeting booths. How can every bonding agent be the best? Every company tries to develop and deliver the best product they possibly can. That said, there is undoubtedly a hierarchy. This is where the smaller subset of evaluators was truly able to investigate the shear bond strength performance of Peak Universal.

Catapult is an organization that consists of more than 50 clinicians spread throughout Canada and the United States. As a company, manufacturers pay a fee for their product to be evaluated and what we deliver are truthful, independent answers from surveys that we develop with them. We have had many products that have either had to be altered before hitting the market or simply never arrived because of our openly honest evaluations. In this way, Catapult assists the manufacturer to avoid potentially releasing a faulty product, or simply a product that needs refinement. Lastly our clients are omnipresent in the industry, small to large, no favoritism, simply reviewing the latest products in our practices.

We were provided a platform to bring what we deemed our personal preferences in bonding agents. We then prepared and bonded composite test buttons on uniformly prepared dentin sample blocks with no manufacturer involvement. The doctors simply followed manufacturer instructions for each material and compared the outcomes. Without naming the competitors tested (essentially all the major players were in the mix), the outcomes can be generalized as follows. Most products performed in a way that I, as the writer, would rate as “good.” This means their shear bond strength (SBS) values were 25 to 35 MPa. Unfortunately, a few of the products tested did not reach that range, and I would rate them as “inadequate.” However, 2 of the products tested yielded results that were a standard deviation higher than those in the “good” category. These 2 products, which yielded average SBS values approaching 50 MPa included Peak Universal, which had the highest SBS values. In fact, several samples recorded forces of more than 60 MPa being required to shear off the composite buttons.

With this background, when a doctor asks, “What adhesive should I use?” my answer really comes down to posing the question, “How strong do you want your bond to be?” As doctors, we must decide if we want to merely restore teeth above a minimum threshold of strength or to approach as high a value as possible. To make an informed decision, it might help to consider this question. What is the cohesive strength of dentin? Logic says if we are restoring a broken-down tooth, it would be nice to get it back to its original level of integrity. After all, we always say, “Nothing’s as good as virgin tooth structure.” Interestingly, the cohesive strength of dentin, meaning the force needed to break a chunk of dentin away from itself, ranges from 70 to 100 MPa.1 Does this knowledge suddenly reframe how we look at tooth reconstruction? Why wouldn’t we want to rebuild teeth to a level rivaling original strength and integrity?

With the Peak Universal Bond adhesive system, Ultradent has developed a flagship product. This was the reason why so many of our Catapult evaluators gave glowing reviews. Several doctors who were not already using Peak in their practice began doing so when they saw the outcomes. Ultimately, Peak earned a resounding Catapult Vote of Confidence.

1. Jessop N, Denehy GE, Vargas MA. Dentin shear strength: effect of depth and location. Presented at: IADR/AADR/CADR; 1999; Vancouver, BC. Abstract 342.

Why many Catapult Education evaluators rated the Peak Universal Bond adhesive system the one they are most likely to use.