Dr Jeffrey Rohde, DDS currently maintains an innovative restorative and surgical practice in Santa Barbara, CA. Dr. Rohde graduated from UCLA with a bachelor’s degree in Microbiology and Molecular Genetics and a master’s degree in Biochemistry. He continued his studies at UCLA in the School of Dentistry, graduating with numerous awards, including the Robert D. Wolcott Operative Dentistry Award. In 2006, Dr. Rohde became one of the founders of Dentalcompare, an online resource that specializes in helping doctors learn about new products and techniques. His practice in Santa Barbara continues to innovate with new ideas and technology, and is often speaking across the country (and currently on Zoom) about laser dentistry, CAD/CAM technology, digital dentistry, 3D printing, and more.

Jeff Rohde, DDS

, we get to highlight new products or technologies by taking them for a test-drive. It’s a chance to give you insights that break through any marketing hype and determine how best to use that product in your practice. As I sat down to write this newest Test Drive, there was a realization that a simple “unboxing with first impressions” was not going to work for a product that takes months, if not years, to develop. So in an exciting way, this Test Drive for SureSmile® Clear Aligners has been years in the making.

I started my journey with clear aligners more than 20 years ago. Using the leading system at the time, we started to change our mindset about the role of orthodontics in restorative practice. For example, we would have a patient with crowded teeth asking for veneers. But rather than amputating healthy enamel to make room for porcelain, we were able to move those healthy teeth into a better position using clear aligners. Even if we were going to place veneers due to unsightly old restorations, there was a benefit to improving root position and occlusion for a more predictable result. It also added another dimension that broadened our treatment planning for a multidisciplinary mindset. We were able to move our dentistry from single-tooth reactive treatment (“There’s a hole; let’s fix it!”) to looking at full-mouth health with an active, anticipatory approach.

The problem we ran into with that first system is that we often had a hard time finding our way back out of the case. We would get stuck in endless refinements, and it was only a matter of time before the patient blamed us rather than their own poor adherence. We also got tired of taking impressions and waiting for weeks, only to find out our impression was rejected. But we still saw the potential. We ended up trying other systems, but nothing gave us predictability or matched with the style and workflow of our practice.

Approximately 5 years ago, we switched over to SureSmile and have had a much different experience. One of the first things that makes a difference to me as a business owner is that it maximizes the investment we already have with our equipment. SureSmile will accept scans from any digital impression system available. Although the former clear aligner provider we worked with eventually had their own scanner, we had already invested in digital impression with CEREC. Rather than our equipment sitting around between crown preparations, those machines are being used all day.

The second thing that makes a difference is the ability to use various trimlines on the trays. Although we are used to a scalloped trimline that follows the gumline, SureSmile offers a straight trimline that could be at the gumline or just above it. What this does is create a stiffness to the trays for more balanced pressure on the tooth. It also helps to hold the shape of the aligner during the time in the tray when the patient is constantly taking the tray in and out.

This results in a reduction in the number of attachments needed. More complex cases are coming back with fewer attachments because the tray has better adaptation on each tooth. Basically, it grabs the tooth better than a scalloped edge that will flare out over weeks of wear. It also allows for more constant pressure on the tooth, resulting in more predictable movement. For us, this dramatically reduces the number of refinements necessary for our cases. SureSmile itself also has an analysis where they looked at more than 150,000 cases globally completed between January 2021 and June 2023. Seventy-five percent of those cases required no refinements.

 This is quite a change from what we were experiencing before.

Another factor to consider is the educational aspect. I had not exactly received a robust orthodontic education when I was in dental school. By the time I started into clear aligners, I realized I had to go back to school in a way. At the time, this resulted in an expensive start-up class followed by the occasional class when I could find them. Although online education has grown across the spectrum from the advent of webinars and streaming lectures, SureSmile has an extremely robust online presence for education. DS Academy and SureSmileU have resources for you and your team that start with how SureSmile moves teeth, to analyzing a case for problems, to setting up your digital prescription. I also know I can call the digital laboratory directly and talk to the person designing my case directly. My personal experience with my local SureSmile team has been valuable as we are using an entirely new system for us. On the most basic level, you can find the information you need in one way or another.

Regarding the financial aspect, as soon as I got home from my introductory class with our first system, we had expensive laboratory bills to pay for each case. Depending on which tier of treatment we chose, we would be on the hook for higher cost if we needed to do refinements. With SureSmile, I have a single fee for the laboratory case that covers any number of trays and any number of refinements for 3 years. This is for any size case, so I am not penalized financially for doing a larger case. The SureSmile fee also includes tooth whitening for the patient as well as the SureSmile VPro, which uses high-frequency vibrations to help facilitate minor anterior tooth movement and helps reduce discomfort to the patient when switching trays. Depending on tooth movements prescribed, we have been able to move patients to 1-week protocols to move through treatment fast. But in an age where everything is more expensive, it is nice to be able to cut costs for our business without any sacrifice in clinical results.

Looking back on this extended Test Drive, we have had a chance to get to know this product. Clear aligner therapy has become an essential part of our practice in diagnosis, treatment planning, and providing uncompromised care to our patients. SureSmile has been good for us, as the system has proven itself to show predictable results, making our practice more efficient and patients happier with the results.

Based on an internal analysis by Dentsply Sirona in excess of 150,000 global SureSmile aligner cases conducted between January 2021 to June 2023. Data on file with Dentsply Sirona.

Articles

“With SureSmile, I have a single fee for the laboratory case that covers any number of trays and any number of refinements for 3 years.”

SureSmile Clear Aligners Offer Predictable, Positive Outcomes 

Digital dentistry is no longer a hobby for the tech enthusiast dentist. Many companies provide solutions for your practice that offer improved workflows and enhanced treatment possibilities. I have been fabricating restorations chairside since 2006 and have enjoyed seeing the technology improve almost as fast as you might see a new smartphone come to market.

It remains my firm belief that the category of digital dentistry would not be as profound without a concurrent explosion of growth in available materials. When I started, we had a couple of options including composite and leucite glass-ceramics such as Empress from Ivoclar. Today we have dozens of incredible materials, and recently I had a chance to try out the new material from GC America: the GC Initial LiSi Block.

The GC Initial LiSi Block is a lithium disilicate glass-ceramic. At its core, lithium disilicate has incredible esthetics like the classic Empress but demonstrates a much higher level of strength. This creates an expanded indication for the material that can be used in the anterior as well as the posterior.

Before I try any material in our office, I look for research to corroborate any claims made by a company. In this case, GC again demonstrated its commitment to excellent peer-reviewed clinical research. I was able to find articles demonstrating the GC Initial block had acid dissolution similar to zirconia restorations, 2-year studies showing 100% longevity, and confirmation of the high compressive strength of the material.

One advantage of these blocks is that they have been crystallized prior to milling. Another characteristic of this material is the use of High Density Micronization (HDM) in the block fabrication. HDM is significant in that it utilizes smaller crystals that are dispersed in higher density as compared with other lithium disilicate materials. In their research, GC America’s scientists found this reduces the risk of microfracture within the restoration following milling. It also improves resistance to wear and decreases the abrasion against the opposing tooth better than the average ceramic.

The fact that the block is precrystallized is comforting because this means it was fired under the manufacturer’s optimized protocol. This saves time at the practice and reduces the potential for distortion in thin areas of a restoration fired chairside.

Of course, with all this research, I still need to know the real-life clinical impact. Milling a crystallized block improves my time in delivering the final restoration. The workflow goes from scanning, designing, and milling the restoration right into final polishing before seating. It was nice to find that GC America has videos on its website featuring useful tips on how to properly polish the restoration prior to cementation.

With GC Initial LiSi Blocks, the good news is that you can stain and glaze the restoration if you want to add characterization, and the blocks are designed to work cohesively with the GC Initial Spectrum Stain system. With GC Initial LiSi Blocks you have a range of B1, and A shades from A1 down to A3.5. Each is available in high translucency and low translucency.

With research and block choice completed, I finally got a chance to try out the material. The preparation guidelines are like those of other lithium disilicates. Years ago, we found that our preparations improved when we started scanning them. There is nothing like seeing your own crown prep blown up on a computer monitor. The technique that I have found works well is to prep down at least another half-millimeter to a full millimeter. It is not that the Initial LiSi necessarily needs the additional thickness, although it certainly gets stronger in this case. I just prefer additional room to create variable and lifelike anatomy in the restoration for esthetic purposes, especially in the premolar and first molar locations.

While testing the blocks, we tried both polishing and glaze firing in the oven. Polishing simply included removing the sprue, using a rubber wheel for the initial polish, and then using a diamond paste for that final glaze polish. It took less than 5 minutes and is something you can train yourteam to help with. The glaze firing also was under 10 minutes because you do not need to crystallize the material. For me, the choice between polishing or glazing is based on how much characterization I need.

I found the shades matched to the standard VITA shades fairly well. Having used high translucency IPS e.max from Ivoclar in the past, I did not think it was quite as translucent as that material. The GC Initial LiSi HT blocks were closer to the MT e.max blocks in this case. For most of my adult patients, this was plenty of translucency. The low-translucency blocks were a perfect choice if I was adjacent to any classic porcelain-fused-to-metal or zirconia, while still having a bit more lifelike reflection to the material itself.

We were also able to separately evaluate and use GC G-CEM ONE, the universal self-adhesive resin cement from GC. This is a dual-mix resin cement with the same extensive research behind it. Coming in 4 shades, this cement had a usable tack cure stage, which was my favorite thing about it.

I often get stuck on other cements when their “tack cure” stage is anything but that, and I am left with rock-hard cement to clean up. Of course, this destroys any time savings I may have gotten from utilizing CAD/CAM chairside. The G-CEM ONE tack cures to a nice rubbery state that allowed me to do most of the cleanup prior to final curing. We polished the margins a bit at the end as well, and the optical connection between the tooth and the restoration really blended nicely.

After using this new CAD/CAM material for a few weeks, I found little to complain about. I think the GC Initial LiSi block is a welcome addition to the digital dentistry lineup, saving me time without compromising on the result.

Azuma T, Shigenori A, Fusejima F. Evaluation of acid resistance for novel lithium disilicate glass-ceramic block. Presented at: CED-IADR/NOF Oral Health Research Congress; September 16-18, 2021; Brussels, Belgium. Abstract 0223. https://ced-iadr2021.com/wp-content/uploads/2021/09/Abstract-book_2021-9-20_Adjusted-version.pdf

Onodera M, Azuma T, Murata Y, et al. Acid resistance of lithium disilicate glass ceramics. Presented at: 2023 AADOCR/CADR Annual Meeting; March 17, 2023; Portland, OR. Presentation ID: 0760. Accessed January 8, 2023. https://iadr.abstractarchives.com/abstract/52am-3824170/acid-resistanceof-lithium-disilicate-glass-ceramics

Azuma T, Onodera M, Murata Y, Akiyama S, Fusejima F. Evaluation of acid resistance for novel machinable lithium disilicate glass-ceramics. Presented at: 2022 AADOCR/CADR Annual Meeting; March 24, 2022; Atlanta, GA. Presentation ID: 0472. Accessed January 8, 2023. https://iadr.abstractarchives.com/abstract/51am-3649098/evaluation-ofacid-resistance-for-novel-machinable-lithium-disilicate-glass-ceramics

Cagidiaco EF, Grandini S, Goracci C, Joda T. A pilot trial on lithium disilicate partial crowns using a novel prosthodontic functional index for teeth (FIT). 

. 2019;19(1):276. doi:10.1186/s12903-019-0957-4

Miyake T, Kato K, Akiyama S, et al. Microstructure of new lithium-disilicate CAD/CAM block. 

. 2019;35(suppl 1):e25. doi:10.1016/j.dental.2019.08.050

[SPONSORED] Jeff Rohde, DDS, shares his experience using GC America’s Precrystallized GC Initial LiSi CAD/CAM blocks in his clinical practice.

Dental Product Test Drive: GC America’s Precrystallized CAD/CAM Blocks Save Time Without Compromise

Tokuyama made a big splash in our industry a few years ago with the introduction of OMNICHROMA. It was a unique product in an otherwise well established, and somewhat boring, space. The company itself has been around for a while and this by far is not its first innovation. When I first used their hard REBASE material for denture relining, it was as good as anything I got back from the lab. Accurate, chairside, no lab fee. It was a push against the norm with a simple but elegant solution. For me, OMNICHROMA was equally innovative, as well as impressive.

The whole idea of “one shade for every tooth” was obviously a compelling story. I am always looking for a way to simplify our armamentarium and streamline our product supply. OMNICHROMA’s success stems from a basic optical property of the composite. Most composites are shaded by having a particular color of the filler. A1 shaded composite has particles that are A1, for example. A light source hits the surface of the composite and reflects light to your eye for your brain to perceive color. In the case of OMNICHROMA products, the filler actually regenerates light from the surrounding tooth against the filler particles. This essentially creates the illusion that the composite itself is the same color as the structure around it. If you could isolate that composite, you would see it hasn’t actually changed color at all.

One technicality of using the product is that you do need actual structure to reflect that color. If you have an incisal extension that extends out, it would have less to reflect back and potentially look a bit too translucent or gray. In this case, Tokuyama recommends using their OMNICHROMA BLOCKER or OMNICHROMA BLOCKER Flow. It has similar regenerative properties but also creates a base layer of color to avoid that grayed-out look. Because of its ability to block color, it is only recommended to use a 0.5 mm layer of OMNICHROMA BLOCKER Flow. I find this is also useful when I have a darker base shade, such as a tooth with amalgam staining or a dark root surface. The opaque layer nicely blocks out the undesirable shades for a more esthetic color match in the final result.

The introduction of OMNICHROMA Flow BULK further redefines this category with simplicity and greater efficiency. Like other bulk composites, you don’t have to place the material in small incremental layers. The reason we used to place composites small layer by small layer is because large layers would exhibit greater shrinkage affecting marginal integrity and deeper layers could remain uncured if light could not get to the material in the deepest parts of the prep for proper curing. In the case of OMNICHROMA Flow BULK, this is no longer an issue. Its flowability and self-leveling help to not only layer evenly but the supra-nano fillers allow reflection of red to yellow structural color. It also enables the material to have a high level of polishability. Considering extensive studies that show great compressive strength, flexural strength, and lack of polymerization shrinkage, the company has definitely backed their claims with good science. 

When I first got a chance to use OMNICHROMA Flow BULK, I was most surprised by the simplicity of the packaging. A syringe and some tips were all that was in there, again reinforcing the value of OMNICHROMA products when it comes to helping declutter our storage. According to their recommendations, I can use the material on any posterior or anterior application. The instruction card had just a few steps that basically consisted of apply your bond of choice, fill it up, cure, and polish. The viscosity of the material is noticeable and flowed well into crevices, especially the floor of a Class II prep. I used the OMNICHROMA BLOCKER Flow in all cases of amalgam stain and it definitely helps keep the restoration at the brighter shade of the surrounding teeth. I did not have a single case that developed that “little white line” from poor bonding. If anything, it feathered well across any bevel.

Simplicity Goes Even Deeper with OMNICHROMA Flow BULK case images by Jeff Rohde, DDS

The only tricky part for me was for Class V applications. Due to the viscosity of the material, if I overfilled the preparation at all it would pool across onto the gingiva and make finishing a little more laborious. In this case, I found that it was best to initially wet the preparation right up to the margins, but not totally filled. After an initial cure, I would then layer the regular OMNICHROMA material over that due to its thicker handling. Sandwiching like this gave a great optical result, I still got a good seal, and simplified finishing. If this were a Class IV fracture, I would only use the original OMNICHROMA to ensure you can build out that body of the material to the intended incisal edge. One nice thing about OMNICHROMA Flow BULK is you don’t have to have that topper layer to protect it. In the Class V case switching materials to cap the restoration with the original OMNICHROMA viscosity was to be able to shape and sculpt the material.

Because of the viscosity of OMNICHROMA Flow BULK, I would recommend confirming you have nice four wall preparation to get the best results with the material. This would include a Class I, a Class II with a matrix band, a Class III with a matrix band, etc. You can also very easily adapt this for use with the Bioclear technique, especially in the posterior.

In a Class II situation, the material flowed nicely in the bevel areas of the buccal and lingual walls. Once placed in those areas, I filled the bulk of the rest with no issues. I still did another round of curing after I removed the matrix band but that was more out of habit than necessity. For anterior restorations with Bioclear matrix bands, I would place OMNICHROMA BLOCKER Flow into the deeper areas of the black triangle to block off the dark background and then fill with the regular OMNICHROMA Flow BULK material over the top of that.

OMNICHROMA Flow BULK definitely delivers on the simplicity of the system, as well as its broad range of use. It’s an excellent addition to Tokuyama’s line-up and continues to push the boundaries of what can be accomplished when solid science and research are applied to developing innovative and effective dental materials.

[SPONSORED] The latest version of Tokuyama’s one-shade composite, OMNICHROMA Flow BULK expands where and how the color-matching composite can be applied while maintaining the material’s ease of use.

Simplicity Goes Even Deeper with OMNICHROMA Flow BULK

the same 2-bottle bonding system for more than 10 years. There are 2 reasons for that. The first is that I like the chemistry allowing me to have confidence in the reliability of the bond. The second is that I have zero patients coming back in to say they are sensitive from these restorations. As dentists, we rarely like changing, especially when it’s working. But we also owe it to ourselves and patients to consider new technology as it emerges, ensuring we are using the absolute best product for our patients and our practices. This was my discovery with a new 2-bottle bonding system from GC America, their G2-BOND Universal.

To understand why we made the switch at my practice, let’s look at the science behind 2-bottle systems, what G2-BOND Universal is doing differently, and what we experienced using the product in live clinical settings.

Beyond all the hype around what “generation” your bonding system belongs to, bonding systems have essentially been distilled down to 1-bottle or 2-bottle systems. The essential challenge facing any bonding system is to get an artificial, hydrophobic material such as composite resin and bond it to a biological, hydrophilic material such as dentin. One-bottle systems certainly do well in bridging this gap, but will tend toward being either slightly hydrophilic or slightly hydrophobic. This creates a reduction in shear and tensile bond strength, with reduced interaction at the tooth for hydrophilic bonds, or reduced interaction at the composite for hydrophobic. For “Dual H” technology of G2-BOND Universal, bottle number 1 is hydrophilic to maximize its bond to dentin, while bottle number 2 is hydrophobic to maximize the bond to composite.

In choosing a bonding system, it seems like we have also gotten lost in the weeds in what etching technique we prefer to use. I have preferred self-etching systems because they reduce the chance of desiccating the dentin from drying in a total-etch technique, giving me better bonds and reduced sensitivity. The first bottle of G2-BOND Universal isn’t so much a “primer” as much as it’s a first layer of wetting, protecting the collagen for a complete bond. It also has 4-MET, MDP, and MDTP components, which allows it to act as a primer for zirconia, alumina, and most metals. This all effectively eliminates the technique sensitive application of where and how to etch, enabling a mild self-etch, or allowing for a total-etch on any unprepared enamel.

After the application of bottle 1, bottle 2 adds the chemistry of Bis-GMA and dimethacrylates for a strong interaction with composite resin. In previous bonding systems, I would still add a thin layer of flowable composite on all dentin to further seal and prevent sensitivity. With each new layer, however, there is a chance for polymerization shrinkage, creating internal stress in the restoration. The thickness of the layers of G2-BOND Universal creates a more complete seal, allowing it even to be used as a base in deeper preparations. What this does is create a shock absorbing layer that prevents debonding. I can reliably now skip the layer of flowable, and open up possibilities of using bulk fill materials as well.

One additive to many bonding systems is HEMA, or 2-Hydroxyethyl methylmethacrylate. It is often used to assist with wetting of the dentin, enabling infiltration into tooth structure after etching. It’s also used as a co-solvent when separating hydrophilic and hydrophobic stages. The problem, however, is that HEMA is often a bit too hydrophilic, attracting water to the hybrid layer in bonding. Eventually this can lead to earlier degradation of that hybrid layer, potentially causing staining along the margin or reduced flexural strength. We have all seen that Class V restoration that eventually has brown, stained margins a few years after placement. G2-BOND Universal was specifically formulated to be HEMA free to prevent this specific complication.

How and When Will I Use G2-BOND Universal?

The system itself comes with the 2 bottles, 2 bottle covers that are clearly marked “1” and “2”, some brushes, and a disposable double dappen dish. The bottles themselves are easy to drip without over dispensing. Any end tufted brush will work but their brushes pick up a nice amount of material without globbing it on. First, apply whatever etch you feel comfortable with. You brush on the first bottle (primer) and wait for 10 seconds for the self-etching to be done. Air dry, and then brush on bottle 2 (bond) and thin with air to create a uniform layer. It coats well and you don’t need to over brush the material. Light cure for 10 seconds and you are ready to place your restoration. That is really all there is to it. Compared to a 1-bottle technique, you are trading only 10 seconds for the primer, and gaining all the benefit of the 2-bottle chemistry.

Once applied, G2-BOND Universal can be used with almost any restoration, covering direct restorations, light cured core build-ups, or cementation of indirect restorations using resin light cured cements. One of my favorite applications is to use it for immediate dentin sealing. Once prepared, place G2-BOND Universal per instructions and you get a seal over the dentin that massively reduces post-operative sensitivity and provides comfort if the patient is not anesthetized for final placement. It can also be used to perform repairs of ceramic, zirconia, composite, and metal-based restorations.

The good news is that GC has done a ton of research to prove everything from stain prevention to bond strengths. In making any decision for our patients and our practice, it is important to look at the science and make solid choices based on that science. With G2-BOND Universal, GC America has done a great job creating a product based on solid thinking and structured research. At the same time, the product is also easy to use with broad applications and very little technique sensitivity. It’s refreshing to see a product that not only is based in science but has considered the impact on the clinicians themselves.

Jeff Rohde, DDS, shares his experience trying out GC America's new G2-Bond Universal.