Information provided by Ivoclar Vivadent Inc.

	The PrograMill One is reportedly the world’s smallest 5-axis milling machine. The machine is wireless and app-enabled, giving the user flexibility. It also reportedly offers a short processing time.

	The milling machine is indicated for a variety of options, including inlays, onlays, veneers, partial crowns, crowns and bridges up to 45 mm block length.

Ivoclar Vivadent’s 5-axis turn-milling technology means the block being processed moves around the tool. This reportedly keeps machining times short while reducing tool wear, and it results in outstanding surface quality and an excellent fit of restorations. Additionally, depending on the materials and indications, individual validated machining strategies are used, which is said to reduce rework to a minimum.

	A camera integrated within the mill automatically records all information on materials and tools. This reportedly makes using different materials easy and loading very convenient. In addition, material, shade and translucency are automatically read in by means of the Data Matrix Code, which is printed on the block. The OSD (Optical Status Display) visually informs the user about the current operating status.

	The mill is wireless and can be controlled from anywhere within the laboratory through an app. The app keeps the user informed of the machine’s status. It features order management, which allows the user to view the order list and current processing status, and it control the 5-axis block changer. The app also allows users to see the tool status and have control of the 8-position tool changer. Finally, the app gives the user an overview of machine data, the machine’s status and the filter unit’s status.

Articles

The PrograMill One is said to combine industrial manufacturing quality with a modern design.

Utilizing the PrograMill One

	Placing direct restoratives on patients is a very common procedure in most general dental practices. While esthetics are important when utilizing composite restoratives, practitioners are also concerned about post-op sensitivity and longevity of the restorations. 

	Dentists can review the results of their techniques in radiographs taken at recare appointments and consult with patients about post-op sensitivity and esthetic results. Dentists can use techniques to improve the Class II posterior direct composite procedure. While many of us received minimal training in dental school on clinical placement of posterior composite restorations, it’s important to keep current on improved restorative materials and treatment modalities to ensure more consistent results.

	A 50-year-old female patient presented for replacement of a fracture and decay in an existing composite restoration (Figs. 1-2). While crowns or onlays would be the typical treatment of choice in our office, the patient will need to put off receiving indirect restorations for a couple years. It was decided that due to the depth of the existing restorations and the recurrent caries present, it would be wisest to perform caries control for the teeth.

	Click through to see how this practitioner created great-looking restorations

	The direct composite restorative of choice in my office is Tetric EvoFlow

 Bulk Fill. When treating cavities of this size, the composite material makes placement much more efficient and predictable while still offering a high level of esthetics.

	The patient was anesthetized and a latex-free dental dam was placed with an NW clamp on the second molar (Fig. 3). Utilizing a Brasseler 6845KR.31.018 diamond, the old composite restoration was removed in its entirety. The deeper portions of the box were beveled with a 6856.018 diamond and the cavosurface margins were beveled to increase enamel bonding area and for esthetics.

	Once the preparation was complete, the preparation was micro-abraded with an air abrasion unit (PrepStart

, Danville) with a 90-degree .015 tip and 27-micron aluminum oxide powder. This step results in micro-retentive surface increases, surface area that potentially further increases dentin bonding and reduces post-op sensitivity (Fig. 4).

 (Garrison) were used to replace the missing tooth surface and form the adaptive layer of composite restoration. It is very important in this step to have a tight interface between the band and tooth to allow for ultimate adaptation of the direct restoration to the margins (Fig. 5).

The next step was the selective etching technique, utilizing 35% phosphoric acid (Ultra-Etch

, Ultradent) on enamel only. The etch was applied on the enamel for 15 seconds and rinsed thoroughly (Fig. 6).

	A universal adhesive was scrubbed on the selectively etched tooth per manufacturer’s instructions using 

	The adhesive was air-thinned with an A-dec air dryer to deliver oil- and moisture-free air and was light-cured for 10 seconds with a 

	Tetric EvoFlow Bulk Fill Shade IVA was placed as a first increment. While traditional flowable materials need to be placed as a thin increment to minimize shrinkage stresses and allow for complete curing, Tetric EvoFlow Bulk Fill can be placed in increments of up to 4 mm without worrying about shrinkage stresses or incomplete curing. Taking advantage of Ivocerin

 and its self-adapting and opacifying technologies means that practitioners get void-free restorations in the deepest of boxes, and the dark underlying tooth structure is blocked out with a similar dentin-like opacity. Figures 8 and 9 show before and after curing.

	The final layer is a single increment of Tetric EvoCeram Bulk Fill Shade IVA (IVA is a universal “A-range” shade). The material was placed from a Cavifil, injecting directly into the preparation. The material was condensed gently with an 

 composite instrument (Ivoclar Vivadent) and shaped with primary and secondary anatomy (Figs. 10-11).

	The composite was light-cured with the Bluephase Style for 10 seconds from the occlusal surface, then the band was removed and the restoration was light-cured again from the proximal surfaces for an additional 10 seconds to ensure complete curing (Fig. 12).

	The composite was contoured with a Brasseler flame 8274.31.016 and the margins were contoured and defined with discs (Cosmedent 

	The restorations were adjusted for occlusion and polished with Astropol polishing points and finished with 

	A post-operative picture and radiograph were taken to confirm ideal restoration placement with sealed proximal margins and a void-free restoration (Figs. 14-15). 

	Direct restorations can be challenging to complete with ideal results. The procedure begins with ideal isolation and is completed with regard to proper band placements and utilization of materials that facilitate ideal outcomes. Even larger restorations are completed with efficiency utilizing bulk fill restoratives that can provide not just shorter chair times for patients but also esthetics that exceed patient expectations.

When it comes to restorations, practice, a little know-how and the right materials make perfect. 

How to Create More Esthetic Restorations

When it comes to restorations, practice, a little know-how and the right materials make perfect.

How to create more esthetic restorations

	IPS e.max has been known and respected in the dental laboratory world for years now. It’s known for esthetics and clinical dependability and as an increasingly accepted option for a variety of indications. A year ago, Ivoclar Vivadent released a new entry in the IPS e.max line-IPS e.max Press Multi. This multi-shaded all-ceramic material was engineered to provide even better esthetics, using an ingot that mimics the real shade of enamel and dentin even more closely. To find out more about the creation of IPS e.max Press Multi and what led to its invention, we recently spoke with Harald Bürke, an R&D expert at Ivoclar Vivadent who was involved with its development. Here’s what he said about this innovative new product:

Tell us a little bit about yourself. What’s your role at Ivoclar Vivadent, and what part did you play in the creation/rollout of IPS e.max Press Multi? 

	I began working as a development engineer at the all-ceramics department of Ivoclar Vivadent 15 years ago. At that time, lithium disilicate in dentistry was still in its infancy. My task was to mature the material for the press and CAD/CAM technique in such a way that it was suited to meet the needs of the market. After the polychromatic CAD/CAM blocks had been introduced, my bosses discussed the idea of extending this approach to include polychromatic ingots for the press technique. In a small group, we explored various routes for achieving this. At first, nobody could really imagine how we could turn this idea into reality. I sat down and began to design a few straightforward experiments, which I subsequently implemented together with our technician, Vittorio Cadario. We soon had some success.

One year ago this week: Ivoclar Vivadent introduces IPS e.max Press Multi

What were you hearing from laboratory technicians that made you and the team realize the IPS e.max Press Multi would fill a need in the market?

	The people working in product marketing told us the manufacturing processes for crowns had to become faster and easier. At the same time, the esthetic demands continued to rise. While monolithic crowns can be pressed in a short time, they inevitably show esthetic inadequacies, and the individual layering technique is time-consuming and expensive. The 

 crowns present a middle ground between these two techniques. Ultimately, however, they must be able to stand up to a comparison with layered crowns.

What were challenges developing the product?

	We had to find a new method to press the 

. This required us to develop new accessories (wax patterns for sprueing the wax-up to the investment ring, one-way plunger, investment ring base). In particular, the shape of the wax pattern allows the ingot to be pressed correctly whilst providing a true-to-nature shade progression. The development of these components and the transfer to serial production were the biggest challenges of this project. 

The List: 5 CAD features to consider BEFORE you buy

Was there a breakthrough moment where you realized you and your team had come up with something really special?

	The very first press sequences resulted in some really funny shade patterns on the pressed restorations. While some saw this as evidence that polychromatic pressing was not possible, I took it as an incentive to try out different ways. After we were able to prove that our new press method was indeed suitable for producing crowns that show a completely natural-looking graduation of shade and translucency, a project was immediately launched. All the better that the principle can be used for the individual diversity of dental restorations.

Next page: How IPS e.max Press Multi expands the offerings of the e.max line ...

Did the popularity of standard IPS e.max help people understand the new product, or was it a challenge explaining how this new option would improve results?

tried-and-tested high-strength lithium disilicate glass-ceramic

 to implement the principle of polychromatic pressing. This material combines excellent esthetics with exceptional robustness. Technicians can feel this quality right from the beginning when they start working with the material. Chipping is no issue. However, the new sprueing technique requires explanation. When we want to explain why and how the proportions of dentin and incisal material can be individually adjusted, we need to go into depth. However, the application in practice is all the easier for it.

21 CAD tips that will take your work to the next level

What have you heard from labs who have used the product?

	Dental technicians are fascinated by the possibility of pressing restorations that show a graduated transition from dentin to incisal. 

 restorations are easy to achieve and exhibit convincing esthetic properties. Time-consuming manual layering is no longer necessary.

A webinar explaining more details of IPS e.max Press Multi

What have you heard from dentists and patients who have received restorations made with IPS e.max Press Multi?

	The feedback from dentists who have used IPS e.max Press Multi restorations on their patients has been enthusiastic so far. The combination of a monolithic crown (high strength, no risk of chipping) and the esthetics of a “layered crown” has been particularly well-received. Patients are pleased with the fantastic esthetic quality of their restorations and are appreciative of the work done by the dentist and dental lab.

What are you most proud of about the development process for IPS e.max Press Multi?

	It is my task to develop new, innovative products. I can be proud of a job well-done.

Technique: How to cooperatively fix a cosmetic case

How will Ivoclar Vivadent use the lessons learned during this process to continue to innovate in the future?

	If you want to be truly innovative, there is only a little you can take with you from your past experiences. The challenges are always new. I’m glad to work for a company that offers every opportunity for creative development. This is exactly what I studied for. I strongly advise all dental technicians to work with the IPS e.max Press Multi ingots.

For more information on IPS e.max Press Multi, call 800-533-6825 or visit 

Harald Bürke, R&D expert in dental ceramics at Ivoclar Vivadent, tells Dental Lab Products how the latest in press ceramics, the IPS e.max Press Multi, came together.

Behind the creation of IPS e.max Press Multi

Ivoclar Vivadent’s Tetric EvoCeram® Bulk Fill

 represents a significant advancement in resin-based filling materials and an entirely new technology for the faster, more efficient placement of direct composite restorations without compromise to any physical properties.

-a light initiator that provides deeper and more efficient depth of cure and shorter curing time-Tetric EvoCeram Bulk Fill is easily adaptable, completely curable (up to 4 mm) and a low shrinkage material that provides the perfect combination of productivity, performance and esthetics.


	Ivocerin is a new germanium-based light-initiator developed by 

 and used exclusively in Tetric EvoCeram Bulk Fill. The initiator allows Tetric EvoCeram Bulk Fill to cure faster and deeper than other composite materials without increasing translucency or reducing working time. The absorption spectrum of Ivocerin fills the “gap” between traditional light initiators (e.g., Lucerin TPO, PPD and Camphorquinone) used in today’s most popular composite materials. It not only cures fast, but it cures well beyond the 2 mm limit of traditional initiators, achieving an efficient depth of cure at 4 mm.

More from Ivoclar Vivadent: Ivoclar Vivadent makes several product announcements at IDS 2015

With Ivocerin, Tetric EvoCeram Bulk Fill can be cured in layers of up to 4 mm in just 10 seconds (using a light with minimum output > 1,000 mW/cm2). Additionally, because Tetric EvoCeram Bulk Fill contains a shrinkage stress reliever, the shrinkage stress distributed along cavity walls and surfaces and shrinkage volume experienced during polymerization are exceptionally low.

Tetric EvoCeram Bulk Fill also features layered silicates for a smooth consistency that adapts well to cavity walls and can be applied and contoured easily with conventional dental instruments. No additional equipment is required. Restorations are polished quickly and easily due to the material’s well balanced filler composition. The three universal shades (IVA for slightly reddish teeth, IVB for slightly yellowish teeth and IVW for quick deciduous fillings or light-colored teeth) demonstrate an enamel-like translucency of 15 percent so restorations blend seamlessly with natural dentition. Yet the material demonstrates high radiopacity for easy detection on dental X-rays.

Related reading: Brasseler USA and Ivoclar Vivadent collaborate to provide new innovations in dental and laboratory solutions

 Ivoclar Vivadent’s Tetric EvoCeram® Bulk Fill represents a significant advancement in resin-based filling materials and an entirely new technology for the faster, more efficient placement of direct composite restorations without compromise to any physical properties.

Ivocerin® initiator can advance your bulk fill composite

 is designed to set a new benchmark in pressing technology.

The enhanced QTK2 muffle together with the SiC bottom reflector reportedly ensures optimum temperature distribution. The investment ring warms up evenly and efficiently, which leads to quality press and firing results.

Related: Check out the Programat P310 for a user-friendly for more basic cases.

The Programat EP 5010 also features an Automatic Infrared Monitoring (AIM™) system, which measures the exact temperature at the surface of the fired object and the investment ring. In case the investment ring is preheated insufficiently, a warning is automatically displayed. If the infrared technology feature is activated, the thermal imaging camera regulates the predrying and closing process. This technology is said to increase the convenience and process reliability of press and firing procedures.

		Designed to simply press difficult-to-press objects with thin marginal areas 

		Pre-installed with the material parameters for 

		New, improved technology including the QTK2 muffle, SiC bottom reflector and Automatic Infrared Monitoring (AIM™) system 

 from Ivoclar Vivadent can be optimally fired and pressed

Step by Step article: IPS e.max for implants

The Programat EP 5010 from Ivoclar Vivadent.

 The Programat® EP 5010 is designed to set a new benchmark in pressing technology.

A better press: The Programat EP 5010 from Ivoclar Vivadent

	For quite some time, we have been hearing about minimally invasive techniques for the esthetic rehabilitation of the oral cavity. Whether a patient wishes to have stains removed, teeth bleached or the tooth shape and general appearance improved, the range of treatment options is almost unlimited.

Procedures include tooth bleaching, enamel micro-abrasion, direct composite restorations and the whole spectrum of laminate veneer restorations, ranging from full veneers-involving more aggressive preparation and the different types of thin or micro-veneers-to non-prep veneers and edge-ups. In cases where a major improvement of the shade and shape is desirable, indirect veneers are clearly the clinician’s first choice.

Because of their superior esthetic and mechanical properties, indirect veneers are ideal when extensive esthetic adjustments are required. Before the material is chosen, the clinician needs to understand the two main challenges of esthetic oral rehabilitation: selecting the proper shade and opacity of the material and determining the amount of tooth structure that needs to be removed in order to achieve the desired result. For example, in cases where teeth are moderately to severely misaligned and orthodontic treatment is not possible, aggressive preparation will be needed. The same applies to teeth with heavy staining caused by fluorosis or tetracycline.


	A diagnostic wax-up is of paramount importance in order to evaluate the feasibility of the treatment. Once the wax-up has been created, it needs to be transferred to the mouth to demonstrate the possible esthetic outcome to the patient. A mock-up based on an impression of the wax-up is normally the method of choice. If the traditional protocol is followed, the clinician will have the chance to make small adjustments to the mock-up and discuss them with the patient after the teeth have been prepared and the temporary restorations placed. These adjustments are then communicated to the dental technician before the final restoration is fabricated.
	In the case of non-prep veneers, a direct mock-up can be challenging to fabricate and the final outcome difficult to visualize due to the minimal thickness of the final restorations and the differences between the resin (used for the mock-up) and the ceramic (used for the final veneers). Presentation and imaging programs (which are easily available and affordable for everyone) are a novel option for simulating the final outcome. They allow digital mock-ups to be created on the computer screen. This method is extremely easy, accurate and reliable while saving cost and time. While a classical mock-up requires a chair time of 15-20 minutes, the digital mock-up can be done in less than one minute by the dental assistant or the clinician, if appropriate clinical and technical pictures are available. By superimposing a picture of the wax-up onto the pre-operative picture, a digital image of the final result is obtained. The only requirement is to match dimensions, inclination and perspective.

Click here to read about the material selection and the clinical case. 


	Closing multiple diastemas with non-prep veneers can be quite a challenging task. In most cases, the veneers will be extremely thin on the labial aspect and at the same time very thick mesially and distally. While high translucency is required to “capture” some color from the underlying tooth structure and thus ensure a natural appearance, the material also requires reasonable opacity in order to mask the darkness of the oral cavity showing through in the area of the diastemas.
	Feldspathic power/liquid ceramics are well-known for their fantastic esthetic properties, but also for their weaknesses. They will fulfil the requirements of a standard case, but if wide diastemas (1.5 mm and wider) are involved, the occurring occlusal forces can be problematic. In the past few years, the esthetic properties of 

IPS e.max® lithium disilicate glass-ceramic (LS2)

 have been significantly improved due to the introduction of different gradations of translucency. Today, LS2 ceramics can be processed using either CAD/CAM or press techniques. The materials are available in up to five different levels of translucency and show flexural strengths ranging from 360 to 400 MPa. For the case at hand, the highly translucent lithium disilicate glass-ceramic 

Check out this video with image from this clinical case. 

 A 37-year-old female patient presented to our office. She was dissatisfied with her appearance. She did not like the multiple diastemas showing when she smiled (Fig. 1) and hoped to find someone to offer her durable and predictable treatment not involving any tooth preparation and at a reasonable price. She had undergone orthodontic treatment before. In another clinic, teeth Nos. 8 and 9 had been restored distally with composite fillings.
	

In our practice, the old composite fillings were removed. In non-prep veneer cases, it is essential for the dental technician to have exact knowledge of the sulcus depth. Therefore, two retractions cords were placed: triple 0 (

), which remained in place during impression taking, and 0, which retracted her gingiva and was removed before the impression was finalized. A wax-up was fabricated (Figs. 2a and b), digitized and superimposed onto the clinical picture to create a digital mock-up, which was then discussed with the patient (Fig. 3).
	

 In the laboratory, thin veneers were pressed on the basis of the wax-ups using IPS e.max Press. They were stained and glazed (Fig. 4). Their thickness was about that of a human fingernail. In the mandible, we faced a different challenge.
	

Diastemas between the laterals and canines were present on both sides. The patient did not expect a dramatic change in the shade of her teeth. Her main concern was acceptable cost and the avoidance of any kind of tooth preparation. Therefore, we decided to restore her teeth with partial veneers (edge-ups). Traditional non-prep veneers would have increased the thickness of the lateral incisors and canines so they would not have been compatible with the central incisors. This would have created the need for two or three additional veneers (Fig. 5).  
	

 In the case at hand, the luting composite provided assistance. The value concept of 

 enables the clinician to make slight adjustments to the shade of the restoration. The “High Value” shades allow the shade to be lightened gradually, while with the “Low Value” shades, the overlying all-ceramic material can be made darker in stages. For permanent cementation, a solvent-free bonding agent (

 for enamel bonding) and a light-curing luting composite (


	The photographs taken one week after incorporation of the veneers showed their seamless integration into the oral environment (Figs. 10 and 11). Two of the aspects that are always mentioned as disadvantages of non-prep veneers are their bulky appearance and the resulting cervical transition between the veneer and the tooth structure, which can lead to periodontal problems in the long term. As shown in Figure 12, both issues can be controlled if the thickness of the ceramic layer is minimal and proper finishing and polishing is done. Figure 13 shows the final result after two months.

This article originally appeared in the April 2014 issue of Dental Lab Products. To check out other great products in action, 

click here to subscribe to DLP's newsletter http://bit.ly/13JeDYN.

 For quite some time, we have been hearing about minimally invasive techniques for the esthetic rehabilitation of the oral cavity. Whether a patient wishes to have stains removed, teeth bleached or the tooth shape and general appearance improved, the range of treatment options is almost unlimited.

Bench Mastery: A smile makeover ... with no tooth prep?

 is an extensive CAD/CAM system that is comprised of products and services for the entire digital processing chain. 

The machine incorporates automatic materials management in the form of the 8-disc material changer. 

 features coordinated materials that cover a broad and comprehensive spectrum of indications. 

The materials include ceramics, such as zirconium oxide, as well as acrylic resins (PMMA, PU) and wax. The Zenotec software suite also contains the user-friendly Zenotec CAM program, along with proven Wieland milling strategies and milling geometries that produce high-precision results. The Zenotec select also features a 16-position tool changer and full 5-axis operation.

		Coordinated materials for a wide range of indications

		High precision and accuracy of fit due to top-quality machine components

		Automated job processing due to the 8-disc material changer

		Exceptional productivity and short processing time as a result of optimized milling strategies

This article originally appeared in the May 2014 issue of Dental Lab Products. For more great articles about products in action, click here to subscribe to DLP's newsletter: 

 The Zenotec select mill is an extensive CAD/CAM system that is comprised of products and services for the entire digital processing chain. 

Why the Zenotec select mill is a mill for every situation

Direct posterior composite restorations are among the most common dental procedures currently performed. However, their location in the mouth requires precise placement, complete isolation of the preparation and thorough polymerization to ensure longevity and adequate function.

Furthermore, these restorations have traditionally required composite materials to be placed incrementally to mitigate polymerization shrinkage and any resulting post-operative sensitivity.

 This layering process may be time-consuming and/or difficult

, and if incremental placement leads to polymerization shrinkage that results in gaps or voids, the bond between the tooth and the restoration could break, or the cusps could flex, leading to severe post-operative sensitivity and/or marginal leakage.

There are two products that streamline the restorative process while ensuring predictability and efficiency: Tetric EvoCeram Bulk Fill (

), a bulk fill direct composite, and Adhese Universal (Ivoclar Vivadent), a single-component adhesive bonding system.

Tetric EvoCeram Bulk Fill is an advanced nano-hybrid composite that can be easily placed, sculpted and polymerized in one 10-second increment.

 Additionally, the material contains pre-polymer shrinkage stress relieving filler technology, a light sensitivity filter, and a light initiator that enhances polymerization, all of which enable the material to be placed and cured in increments of up to 4 mm.

Adhese Universal is a single-component adhesive system that saves clinicians and patients valuable time. Used for both dentin and enamel, it is indicated for light-cured direct composite restorations and indirect restorations, according to the manufacturer. Its high bond strength makes it an ideal adhesive system for posterior restorations, where strong mastication forces are a concern. Additionally, Adhese Universal is a truly versatile adhesive that can be used with all etching techniques: self-etch, selective enamel-etch, and total-etch. 

When used together, Tetric EvoCeram Bulk Fill and Adhese Universal provide clinicians with the opportunity to place direct composite restorations with ease, without sacrificing quality. By placing composite restorations in bulk, they can also ensure they will save time for themselves and for patients, and enhance the predictability of the procedure.

 The following case demonstrates the capabilities of these two materials for delivering a high-quality direct posterior composite restoration.   

A patient presented with a failing amalgam restoration on tooth No. 14 (

). Although the restoration was located in the posterior region, the patient expressed a desire for a more natural looking treatment that required minimal tooth preparation. It was decided a direct bulk fill composite (Tetric EvoCeram Bulk Fill) would be placed in combination with a universal adhesive system (Adhese Universal) to provide an esthetically pleasing and conservative restoration to meet the patient’s requests. The following technique describes the protocol for achieving this clinical outcome:

The failing restoration was removed and caries were excavated (

The enamel was etched for 15 seconds followed by etching of the entire cavity for an additional 15 seconds each (

The etchant was rinsed and air dried according to the manufacturer’s instructions (

A bonding agent (Adhese Universal) was applied, scrubbed into tooth structure for 20 seconds, then dispersed with air until an immobile film layer developed (

 The adhesive was then light cured with an LED curing light (Bluephase Style, Ivoclar Vivadent) for 10 seconds (

A bulk fill composite (Tetric EvoCeram Bulk Fill, shade IVB) was placed, sculpted, and contoured using a contouring instrument (OptraSculpt Pad, Ivoclar Vivadent) (

The composite material was light cured for 10 seconds (

Empress Direct Color (Ivoclar Vivadent) in shades ochre and brown were applied to the occlusal surface of the new restoration to impart a natural look that blended with the surrounding dentition (

After the restoration was cured, the occlusion was verified (

The restoration was polished (OptraPol Next Generation, Ivoclar Vivadent) (

 A fluoride varnish system (Fluor Protector S, Ivoclar Vivadent) was applied to protect against erosion and caries development (

The restoration was evaluated one week after placement, and the patient was pleased with the outcome (

Since direct posterior composite restorations represent many of the dental procedures performed each day, it is imperative that clinicians avail themselves of advanced materials that will ensure an esthetic, predictable outcome. Tetric EvoCeram Bulk Fill and Adhese Universal are two products that enable practitioners to provide the highest quality, esthetic restorations to their patients while saving valuable chair time.

 Direct posterior composite restorations are among the most common dental procedures currently performed. However, their location in the mouth requires precise placement, complete isolation of the preparation and thorough polymerization to ensure longevity and adequate function.1   

How to simplify direct posterior composite restorations with Adhese Universal

Dentists today rely increasingly on their partners in the dental laboratory for information about how to predictably place today’s restorations. Laboratories therefore need a thorough understanding of not only the restorative material used in the fabrication of the dental restoration, but also the 

 options and protocols to provide dentists with specific details about the options available.

For example, depending on the case, laboratories can advise dentists to place restorations using either conventional cementation or adhesive bonding techniques.

Conventional cementation combines preparation design and resistance to attach restorations to underlying tooth structure. Adhesive bonding, on the other hand, produces a micromechanical retention and chemical bond between the tooth structure and the restoration.

Multiple factors influence cement selection. These include the restorative material, preparation design, necessary bond strengths, 

 capability and desired esthetic outcomes. This article provides laboratories with an overview of conventional and adhesive cement classifications suitable for reviewing with their dentist customers.

Adhesive resin cements-a category that includes self-cured universal resin cements, light- and dual-cure resin cements, and self-adhesive resin cements-are superior options for all-ceramic restorations. In general resin cements require tooth preparation to be etched with phosphoric acid, rinsed with water, dried and then conditioned with the adhesive bonding agent. With adhesive resin cements, internal aspects of all glass-ceramic restorations are etched following manufacturer’s instructions and silanized before seating, followed by adhesive cement application in the restoration and cured upon placement. This leads to maximum, high-level bond strengths.

Adhesive resin cements require meticulous isolation procedures. When good isolation cannot be ensured, conventional cements may be considered for cementation of high-strength ceramic restoration such as those constructed from lithium disilicate or oxide ceramics. Adhesive resin cements can be self-cure, dual-cure or light-cure.

 Self-cured universal resin cements such as Ivoclar Vivadent’s 

 incorporate self-curing cement with a light-cure option for very high immediate and long-term bond strength values. Multilink Automix is used in combination with the self-etching and self-curing Primer A/B. While acting as a sealant for dentin, it also provides good marginal adaptation and high bond strength. Clinical trials have proven 

’s long-term success and reduced post-operative sensitivity. It is suitable for the adhesive cementation of indirect restorations (inlays, onlays, crowns, bridges and root posts) made of metal, metal-ceramic, glass-ceramics, lithium disilicate, oxide ceramics and composite resins with enamel and dentin 

 Variolink® Veneer, a light-cure esthetic resin cement from Ivoclar Vivadent, is amine free for long-term shade stability and has been developed for adhesive cementation of esthetic anterior restorations such as 

. This microfilled, purely light-cured resin cement offers seven light-cured value shades to enhance the esthetics of the final restoration. The Medium Value (MV 0) is very translucent and has little effect on the final restoration. The High Values allow the clinician to brighten or increase the value and the Low Values provide a “warming” effect to the final restoration. It is indicated for cementing composite restorations and delicate ceramic restorations with thickness less than 2 mm 

The dual-cure version of this cement is Variolink II, a microhybrid cement available in 6 base shades and 2 catalyst shades as well as in 3 different degrees of viscosity. It demonstrates a high degree of radiopacity and is indicated for adhesive luting of ceramic and composite restorations such as inlays, onlays, metal free bridges and veneers made in lab or chairside 

. Variolink II is a dual-cure resin cement, however, it also may be applied in a light-curing technique only, such as for luting of veneers. For this purpose only Variolink II Base is to be used.

 Self-adhesive resin cements demonstrate some of the advantages of resin cements and the convenience of conventional cements, including moderate level bond strengths. Self-adhesive cements are contraindicated for use with intermediate strength glass-ceramic restorations such as those constructed of IPS Empress or feldspathic ceramic.

Ivoclar Vivadent’s SpeedCEM is an example of a self-adhesive cement. It can be used with high-strength ceramics to help maximize clinical efficiency. A self-adhesive, self-curing composite luting cement, SpeedCEM can be optionally light cured and also offers easy, quick and universal application. It offers the additional advantages of a resin cement, such as intermediate bond strength and translucency, as well as lower water solubility. SpeedCEM consists of an adhesive monomer that enables stable chemical bonds to zirconium oxide metal restorations. Therefore, it is suitable for cementing indirect restorations made of metal, metal-ceramics, lithium disilicate, oxide ceramics and fiber-reinforced resin composites 

 Conventional luting cements connect restorations and underlying tooth structure by creating a hardened, cement layer between the restoration and tooth. To ensure success, retentive tooth preparation design is essential to ensure retention when using conventional cements. Conventional cements are contraindicated for use with glass-ceramic restorations.

All glass-ceramic restorations are etched and silanized before adhesive cementation. However, silanization is not required for conventional cementation of IPS e.max lithium disilicate. A ceramic etching gel, such as IPS Ceramic Etching Gel from Ivoclar Vivadent, is used to produce retentive bonding surfaces on all-ceramic restorations and enhance the bonding effect between the luting composite and ceramic bonding surface.

For adhesive and self-adhesive cementation of IPS e.max lithium disilicate (LS2) restorations, as well as the adhesive cementation of IPS Empress, the restorations are silanized using Monobond Plus 

. Monobond Plus is a universal single-component restorative primer mediating an adhesive bond between the luting composite (e.g. from the Variolink and Multilink product lines) and all indirect restorative materials including glass and oxide ceramics, metal, zirconia, composites, and fiber-reinforced composites.

Intermediate strength glass-ceramics (i.e., those with a high glassy content) obtain additional support from adhesive bonding and must be adhesively cemented using a resin cement. Therefore, feldspathic, leucite-reinforced and fluorapatite ceramic restorations should be cemented with adhesive resin cements.

High-strength ceramics such as lithium disilicate materials (IPS e.max CAD, IPS e.max Press), alumina, and zirconia-based ceramics demonstrate good mechanical properties and can withstand occlusal loads in the absence of an adhesive. Although conventional cementation is permissible for these ceramics, adhesive cementation offers multiple advantages and remains the material of choice for these restorations. In fact, high-strength ceramics can be placed using self-adhesive cementation techniques, thereby gaining good bond strength while also taking advantage of a simple cementation protocol.

Preparation design is significant in cement selection for high-strength ceramics. 

 lacking adequate mechanical retention such as short preparations of less than 4 mm, or preparations with taper in excess of 8° should be adhesively bonded using a resin cement. If preparations demonstrate adequate mechanical retention with a length greater than 4 mm and a minimal taper of less than 8°, restorations may be conventionally cemented. Because 

 and partial coverage restorations lack mechanical retention, they can only be adhesively bonded.

Generally, successful outcomes with all-ceramic restorations are only achieved when preparation guidelines are closely followed and account for minimum thickness requirements. According to basic preparation guidelines for all-ceramic restorations, sharp line-angles or edges should be avoided. Shoulder preparations with rounded internal line angles (modified shoulder) are the finish lines of choice. Deep chamfer preparations also are acceptable. Preparations should reflect at least the minimum thickness allowed for the material’s use.

The quality and durability of the restorations that laboratories fabricate is predicated on dentists using the correct placement protocols. Selecting the most appropriate adhesive and conventional cementation materials and techniques are critical in achieving successful results. The clinically proven Ivoclar Vivadent adhesive and conventional cementation materials have been thoroughly tried and tested for their respective indications. This article has outlined some key considerations related to restoration placement that laboratories can share with their customers.

Dentists today rely increasingly on their partners in the dental laboratory for information about how to predictably place today’s restorations. Laboratories therefore need a thorough understanding of not only the restorative material used in the fabrication of the dental restoration, but also the cementation options and protocols to provide dentists with specific details about the options available.