Noah Levine

9 Members of the Oral Microbiome Rogues Gallery

Articles

A slideshow profiling some of the potentially harmful organisms making their home in the human oral cavity.

6 Sources of Terrific Valentine's Day Cards for Dental Professionals

If you're looking for a way to show some love for your favorite dental professional, or want to share a dental pun with colleagues or patients, this slideshow has you covered with links to 6 sources of great dental Valentine's day Cards.

The software platform supports a great degree of customization, allowing labs to set different data access permissions for different users and to customize the style and copy in invoices and other communications. New features include the ability to label remakes, including whether it was due to clinician or technician error, as well as bar code scanning for instant access to specific job files, and many other customizable features.

Anytime cases come in or go out of the lab, or lab operations data are needed.

Designed to promote operational efficiency, this software platform allows labs to customize how cases are tracked when they enter the lab through every step including delivery to the client. Having all case and client information in a single, intuitive platform allows Lab Manager to manage customers, jobs, products, invoices, payments and technicians while quickly and simply creating important documents such as delivery notes, invoices, statements, financial reports, and job and technician tracking reports.

This UK-based company is bringing its popular dental lab management platform to labs throughout the United States. Information provided by Transactor Systems Ltd

5Ws* Transactor Lab Manager V8.2 

A set of dentures completed using the Baltic Denture System.

dental revolution has already firmly cemented its place at the center of fixed restoration production, but the adoption of digital denture workflows and products has progressed at a slower pace.

Fixed and removable production can reap benefits from digital technologies and the materials they process. Still, the shift to digital production of removable dental appliances is happening at a more measured pace.

This pace is due to many factors, but a big one is the learning curve and the full scope of actually creating a denture or other removable appliance. A single crown is fairly straightforward but shifting from designing it in wax to designing it on a computer screen is a leap, yet not always a gigantic one. However, removable appliance cases may involve multiple teeth and gingival tissues, and doing this digitally involves a bigger analog to digital transition, but that transition is well underway, according to Gene Peterson, CDT, director of Technical Development and Learning for Sterngold Dental.

“Through the last 9 years, there’s been a lot of advancements. Some people have said it’s been a revolution. Some people say it’s still evolving. I think it’s kind of both. I think it’s a revolution that’s evolving,” he says.

Today digital dentures are a reliable and viable option for many situations, Peterson says. The latest materials and systems can produce appliances that provide great fit, function, and esthetics to meet the needs of patients. These digital denture solutions offer far greater production efficiency and can drastically reduce the number of dentist appointments for the patient. Still, the move toward digital denture production remains a slow shift for the industry.

Peterson says removables technicians looking to shift to digital workflows often struggle to translate their skills and experience from the benchtop to the desktop. Although the essential steps of creating a denture remain the same, transitioning from the tactile analog process to the virtual digital process is the biggest hurdle for many clinicians.

“The idea is to find that harmony where you can bridge that gap easily and see the symbiosis between the 2, so they come together,” Peterson says. “You have to be able to say, ‘OK, this is what I did in the old world, and this is what I do in the new world, and now I do it with a mouse instead of a handpiece, and I’m good to go.’”

Peterson admits that digital dentures may not be the best match for every lab, every technician, and every practice. It’s a technology that should be embraced, and the technician should start thinking digitally. It’s been an excellent tool for the technicians, labs, and dentists who are truly engaging with the technology.

A variety of digital denture systems and materials are currently available. Some systems feature milled or 3D-printed denture bases with the denture teeth placed and bonded using longstanding analog techniques. Other systems offer a monolithic denture by milling the appliance from a special material composed of both gingiva and teeth.

Peterson noted that some systems require a large upfront investment in equipment and materials from the dental lab, whereas others can be leveraged with a minimal initial investment. Early printed denture bases have been criticized for lacking in characterization, but digitally produced dentures can all be customized to provide whatever level of esthetics are designed for that case.

Although the workflow used to get to the finish line is vastly different between analog and digital denture workflows (and even among the workflows of other digital denture systems), as with any case, success with digital dentures depends on having good information about the case at the start.

Peterson says creating a perfect digital denture requires accurate clinical information, including detailed impressions, an accurate bite, the midline incisal edge, proper lip support, the plane of occlusion, the tooth size, and the central height. As long as those measurements are accurate, digital denture design applications should provide a guided process to fabricate a digital denture that will be a perfect fit for the patient.

The highly accurate information captured in a digital impression is a great starting point, but the clinician should provide accurate measurements for all the details of the denture to turn a denture case into something akin to a crown appointment when the patient comes in once for prep, scanning, and design, and then returns for seating the final restoration. With accurate starting measurements, Peterson believes digital dentures can be the best and most efficient option for many patients, and clinicians can be sure of their measurements when they measure at least twice to make sure their numbers are repeatable.

“When they’re accurate, it’s going to go right in the mouth,” he says. “You’re going to have that 2-appointment denture, and that’s a key to digital dentures.”

Optimal Efficiency With Workflow Flexibility

Load pucks feature preset teeth in centric occlusion.

Sterngold recently partnered with Merz Dental which provides the Baltic Denture System (BDS), a versatile digital denture solution that standardizes parts of the design and fabrication to make the production process as simple and efficient as possible. The solution includes 

Creator® PLUS, a customized software application that guides technicians through the design steps. The designs are then milled from special 

Load® discs, which come preformed with denture teeth set up in an optimized lingualized occlusion. This allows the system to go directly from design, to milling, to finishing without the need for multiple try-ins or a lengthy setup process.

“It’s a milled premium denture,” Peterson says. “It’s a monolithic final denture that looks beautiful.

“For a premium denture, you’re getting a lot for your buck,” he continues. “In fact, in its simplicity, it will exceed your expectations because what you’re getting and what you’re able to do with this software and the final product is something that nobody else is really doing at this price point.”

Peterson has experience working with multiple digital denture solutions and working for companies behind the scenes. He likes the BDS because it offers both simplicity and versatility. The solution can be used for denture sets or single arches and can even be used for immediate dentures. Because it offers clinics the benefit of faster-finished dentures at a lower cost, labs can jump into the solution in multiple ways.

Labs with a compatible mill are ready to do everything on-site and can invest in the full solution to create their digital dentures completely in-house. Those without a mill or looking to start smaller can design in-house and send files to Sterngold for milling. Alternately, labs can take on any of the steps in-house and outsource the rest of the process. In the end, all the paths lead to digital dentures being delivered to the prescribing clinic.

Load pucks are manufactured from highly esthetic, high-impact PMMA, which can be characterized and finished like any standard denture. The preset teeth are affixed using a process that creates a true chemical interface between acrylic used for the gingiva and the material used for the teeth. This process creates a monolithic denture with distinct teeth and gingiva, and virtually eliminates the risk of teeth debonding and needing replacement.

“You’re not going to have pop-outs,” says Peterson. “You’re not going to have fracture failures because there’s no mechanical bond to break.”

Creator PLUS is used to design a set of dentures.

Like any digital solution, the software is a key part of the digital denture process, and this is the area where things have truly advanced in recent years, according to Peterson. The major dental CAD/CAM applications from companies such as exocad and 3Shape now offer removables modules that technicians can use with multiple digital denture materials and workflows, but some systems, such as BDS, offer their own software platforms tailored to the specific approach to digital dentures. Peterson describes the 

Creator PLUS application as intuitive and automated with a step-by-step approach that walks the technician through each part of the process.

“The software journey has been what’s really made the difference,” Peterson says.

Although digital denture software might be easier to use, it still requires specialized knowledge and training for the digital technician to follow the software prompts and recognize what is accurate and what needs to be adjusted. Like any system, the quality of the output is directly related to the quality of the input, so even though the system can make suggestions and automate steps, the technician using the controls still needs to know enough to recognize when the computer is heading off course.

The way Peterson sees things, digital dentures are fully ready for primetime today, and the only things holding them back are trust in the process from the clinicians and buy-in and training from the technicians. He adds that solving the first challenge is going to be easier than the second.

Getting clinicians on board with digital dentures should be achievable. When done correctly, the quality of digital dentures can meet the demands of most dental practices. Convincing dentists to commit to milled digital dentures rather than printed dentures, for the time being, is part of achieving this goal. Although Peterson says printing will be the industry standard when printers and materials improve enough to surpass the quality of milled dentures, he thinks milled restorations are the best option today.

With quality no longer a barrier, clinicians really only need to be convinced that they can get equal quality dentures in far less time by embracing a digital process. In fact, Peterson believes digital dentures could be just the thing to get clinicians excited about providing dentures for their patients.

“It’s my passion to get doctors to the point where they’re comfortable and consistent making the records, and they enjoy making dentures again,” Peterson says. “If you can get some basic consistency down in your record making, you’re going to have a lot of enjoyment out of making dentures, and it can be a hugely profitable aspect of your business.”

Unfortunately, increasing the number of digital denture technicians will be a bigger challenge. Peterson says the barriers on the lab side are more challenging because they are institutional. There is a declining number of schools and educational opportunities for new technicians, and many established removables technicians are not interested in learning a new approach to their craft.

According to Peterson, a key to breaking down this barrier is setting technicians up for success when they start learning the digital denture processes. They need to not only understand the software workflows but also how to identify when inaccurate data are causing problems with the denture design. Digital denture technicians need to be ready to coach the doctors and drive home how accurate information at the start leads to efficient production and dentures that fit right the first time. With an automated digital workflow, the problems that might arise will rarely originate at the lab.

“With digital dentures, they can’t blame a technician anymore because [they are] just putting in information that they give [them],” Peterson adds, once again noting the importance of accurate scans and measurements from the dentist.

Labs often face a barrier to entry into new digital platforms due to the cost. Peterson says this led to innovations like BDS where a lab can embrace it 1 piece at a time and build up enough business to generate a quick return on investment by automating production step.

When it comes to the need for more digital denture technicians, Peterson says it may take time. He does not expect the established generation of denture technicians to shift to digital in large numbers. They’re largely comfortable with the way they work and don’t have immense pressure forcing them to make a switch.

However, the next generation of lab technicians will be trained in a digital environment and might learn digital techniques before or in lieu of analog workflows. Even though they will enter a much more automated industry than previous generations, they will still need to learn the same key details about the engineering, chemistry, and design of dental restorations, whether they work at a bench or a keyboard.

Peterson says he’s excited about how far digital dentures have come and looks forward to being a part of the continued development of the removables side of digital dentistry. The tools and materials required to make dentures will evolve, but the core knowledge at the heart of designing a removable dental restoration will remain the same.

“I’ve been in this for 10 years, and when I first got into doing this, people would say, ‘You’re going to make my grandma’s dentures with a computer? Are you kidding me?’” Peterson says. “The format is different, but the details remain the same. Technicians, per se, aren’t going to go away. They’re just going to be doing different things.”

The latest digital removables materials, processes, and workflows such as the Baltic Denture System available via Sterngold are making denture production more efficient and simpler.

The Evolution of Digital Dentures

Dental schools across the country constantly work to keep their curricula up-to-date and comprehensive enough to prepare students for successful careers. That training includes plenty of science and clinical experience, but not every new dentist leaves school with a deep knowledge of everything they need to master to find professional success.

We asked dentists from across the industry to share some of the lessons they had to learn on their own after completing dental school. Although every dentists’ story is unique, a common theme is the lack of formal education on running the business side of the dental practice.

Read on to find out what some of your colleagues wish they had learned in school.

“You’ve examined your patient, right? Now, what are you going to do about it, ‘doctor’!?” My dental school instructor had just put me in the hot seat right in front of my patient.

I gulped and answered, “I’m not sure…initial periodontal therapy, an MOD amalgam on #29, a DO amalgam on #28, maybe a PFM crown on #30?”

Having just started my junior year in dental school, I felt as though I had jumped into the deep end of the “pool of clinical work.” Our training up to that point had been about examining patients and formulating treatment plans. That approach unconsciously dominated my patient interactions until graduation 2 years later.

Fortunately, 2 months after receiving my diploma, I enrolled in a general practice residency (GPR) at the University of Illinois Hospital in Chicago. My esteemed mentor, Dr Charles Greene, introduced me and my fellow residents to a new (for me, at least) systematic method for addressing patient care. This method consists of the following 10 steps:

In dental school we did, in fact, perform many of the above steps. However, we were not taught this logical system. I found great freedom in performing the first 7 steps (up to and including formulating the diagnosis) without the pressure of ,“What are you going to do about it, ‘doctor’!?”

A diagnosis such as “caries on teeth numbers x, y, and z plus partial edentulism” can map to several treatment options, ranging from no intervention to wall-to-wall carpeting. Each treatment option has its own risks and benefits. All aspects need to be discussed with patients as part of obtaining informed consent.

Consequently, I realized that once I had presented my diagnosis, I could detach completely from the patient’s treatment decision. I could guide patients in their treatment choice, but once I had presented the treatment options, their benefits, and risks, it was up to my patients to decide what they wanted.

Following my GPR I was very curious to know whether somehow I had missed a dental school lecture where this sequence had been taught. I spoke with a classmate. She told me that only after dental school had she learned the same 10-step approach. She assured me that my recollection was correct: At no time during dental school were the elements of this method presented.

Although I am proud of my dental school and the knowledge I gained there, I hope that the training provided currently includes the same or a similar 10-step approach that I learned in my GPR.

Deeper Training in Business and Regulatory Expertise

what I wish I had learned when I was in dental school, the first thing that comes to mind is the business of dentistry. I don’t remember learning anything about how to run a business, how to manage people, how to manage patients, how to grasp the whole nonclinical dynamic of it.

The other thing I don’t think I learned about is the laws and the rules. Now I know so much about all the different regulations, but it would have been great to have learned them in school: “Name what state you’re going to practice in, and let’s go through all the laws and regulations of that state.”

Maybe waterline testing wasn’t a big deal back in the Stone Age when I went to school, but I never learned about it. I never learned to think about, much less, test the water.

So as far as thinking about what I wish I had learned, I think it’s definitely a business, so understanding business, how to run a business, finances, and that kind of stuff would have been good. But then, also, there are rules and regulations. It’s not just, “Go out and do what’s best for your patient,” which is obviously what you want to do. It’s a lot of following the guidelines and making sure that you’re doing what you’re supposed to be doing.

A Trio of Lessons and a Lifelong Love of Learning

It is not a slight on my dental school or the amazing education I received there to say there are things I wish I had learned while still a student at the University of Pennsylvania School of Dental Medicine. Reflecting on 23 years in the profession, there are actually many things I wish I had learned in dental school: advanced procedures such as implant placement, business skills, how to effectively communicate with patients and improve case presentations, or ergonomics to help my body withstand the physical punishment of clinical dentistry.

But I want to narrow it down to 3 takeaways: one I was fortunate enough to learn in dental school, 1 I was lucky enough to learn early on in my career, and one that I am still learning. Before leaving dental school, I had the opportunity to grasp the importance of good mentors in our profession. Dentistry involves a journey of continued learning, and having a good mentor provides you with a trusted resource for questions, advice, and motivation.

In addition to clinical dentistry, there are so many things to do in our profession, and I am grateful to have learned this early on in my career. From teaching at a dental school, to ideation and new product development, to research and publishing, to participating in continuing education curricula, dental professionals should explore opportunities to grow individually and improve the profession.

Lastly, dentistry is a team sport, and we succeed when the team around us is working toward a common goal. For me and my teams, that goal has always been providing an outstanding patient experience and excellent patient care. I still enjoy learning how to be a better leader, teammate, and mentor.

Communication With Patients and Colleagues Is Key

Wow! Where do I start? Dental school gave me a lot of solid things to work from, but I quickly learned there is so much more to learn in dentistry than preparing a tooth for a filling or a crown or an extraction. There are a few key things I have learned since I left dental school around 20 years ago:

 As much as we learned in dental school, it is only the tip of the iceberg in terms of what we need to know to serve our patients in the very best way we can. This involves being a continual student and means we have to get involved with quality continuing education and find great mentors to help us along the way. You can try and do it yourself, but like so many things in life, gaining knowledge through someone else’s wisdom and experience is priceless.

2.Practice management is essential for your long-term success and happiness. 

You can be the best technical dentist in the world, but if you don’t have patients to work on or you can’t manage the numbers in your practice, you won’t be successful. And if you can’t manage to build a team that supports your vision and you, then you will be miserable fighting an uphill battle to success and happiness by yourself. Worse yet, you may be surrounded by people who make it more challenging.

3.Patient management and communication are critical.

 Again, you can be the best technical dentist in the world, but if you can’t communicate effectively with patients, you won’t be doing your best work. Communicating and building relationships with your patients are just as important as technical skills.

 Find a lab that supports the level of care you are seeking. If their best isn’t up to your standards, seek another lab that is willing to provide you with results you are happy with. Your lab is part of your team, and they can help you succeed and grow and be happy. The wrong one can lead to inconsistent results, poor outcomes, and you and the patient being frustrated.

When I think back on my dental school days, it’s mostly a blur. The sheer number of things we had to learn in such a short time was overwhelming: anatomy and physiology, pharmacology, tooth preparation, materials, infection control, the list goes on and on. Back when I graduated (1988), it was almost unheard-of for graduates to start their own practice. Many dental students had crippling student loan debt and it was a very competitive time for dental practices, leading the majority of graduates to start their careers as associates at an existing practice.

I went straight from dental school to a GPR and then right into a perio program, so the thought of associating with another practice just had no appeal. After 11-plus years of higher education, the thought of paying someone 40%, 50%, or more of my income wasn’t something I wanted to do, so I decided to build my own practice. This is when I realized there was 1 area for which dental school had not prepared me: I literally had no clue how to run a practice!

As any practicing dentist knows, having clinical skills is important as a base, but it has really very little to do with your success. That will, in large part, be related to hiring and training your staff, marketing the practice, learning how to maximize dental insurance, ordering and managing supplies, reducing overhead, and the 1000 other things that go into running a dental business.

When I look back, I think we had 1 total day of practice management in dental school. I might have had 2 days of it in my perio program, but whatever it was, I was woefully unprepared for the realities of starting and managing a dental practice. I really wish I had been offered multiple courses on the nuts and bolts of how to actually run a business alongside the classes of how to cut a Class II preparation. It would have made my first 2 years in practice much more enjoyable.

Clinical Best Practices and Techniques I’d Have Liked to have learned

The list of information I wish I had known in dental school is endless. Regarding operative dentistry, I wish I had:

Not been afraid of the rubber dam. It is not only a tool for achieving isolation from oral fluids, but also for retracting tissue. I cringe at the thought of my adhesive restorations that were placed without a rubber dam or even the assistance of a dental assistant.

Understood the concept of selective caries removal—removing caries at the periphery of the preparation and only leaving caries on the pulpal floor to avoid pulp exposure.

Known about intraoral air abrasion. This 15-second step of a restorative procedure can clean my preparation to allow better visualization of the remaining stain, caries, or cracks, or smooth my preparation prior to bonding.

Been taught to prepare direct restorations with diamond burs. This process is much faster and creates smooth margins.

Learned how to use finishing discs earlier. These discs are great for forming the contours of posterior and anterior composites.

Learned how to use a laser to remove soft tissue around deep direct and indirect restorations.

Started using a flowable composite in the base of my preparations.

Learned how to prepare onlays and overlays.

Other things I wish I had known about include selective etching, resin-based provisional cements, sectional matrices and rings, and contact pastes.

Looking for Leadership and Collaboration Opportunities

During those school years it’s hard to imagine squeezing in more, but it would have been nice to have learned:

The knowledge of business development and leadership books as in the 

It would have been nice to have learned the benefits of collaborating with colleagues early on. I wish I’d known how to form a free mastermind group of noncompeting dentists immediately after graduating. Dentistry can be such an isolating field. These groups can be a powerful way to accelerate business (and life) success through group problem solving and accomplishment sharing while stomping out that isolation.

Dental school prepares new dentists for many challenges ahead, but there are still plenty of important lessons to learn on the job.

What I Wish I’d learned in Dental School

In a world where artificial intelligence (AI) can handle many tasks on its own, and a range of automated services and processes help us daily, it can be easy to forget just how far back the history of automation actually stretches. From the first simple machines to our modern computerized marvels, humankind has long sought ways to make common tasks easier through the use of technology.

Dentistry is no different. Modern dental practices use any number of technologies and solutions to make treatment more effective, more efficient, and less onerous for patients and clinicians alike. The history of dentistry is filled with technological breakthroughs, and any time a machine is used to handle a task previously done manually, it’s a move to employ automation. Here are 10 of these milestones in dental automation.

 – George F. Green patents the first electric dental drill.

 – The Wilkerson chair is the first hydraulic dental chair.

 – Charles Chamberland invents the autoclave sterilizer.

 – The first electric toothbrush is developed in Switzerland.

 – John Borden introduces the first air-driven contra-angle dental handpiece.

 – Dentistry enters the era of computer-aided design and computer-aided manufacturing (CAD/CAM) with the debut of CEREC, the profession’s first CAD/CAM solution.

 – Dentrix launches, representing the first dental practice management software for computers running Microsoft Windows.

 – Planet DDS launches Denticon, the industry’s first cloud-based practice management application.

 – The Yomi from Neocis becomes the first FDA-approved robot-assisted dental implant system.

 – The first completely robotic dental implant procedure is completed in China.

These 10 milestones all represent leaps forward for the dental industry. Each is a mechanical or computerized system designed to accomplish a previously manual task. Although these innovations stretch back more than a century, the pace of such breakthroughs is increasing. In recent years, automation has come to everything, from patient communications and practice marketing to radiograph reading and treatment planning.

A look at some of the key developments and innovations in dental products and equipment through the years.

10 Milestones in Automating Dentistry

The History of Dental Filling Materials from Prehistoric to Modern Times

Dental issues have plagued humankind throughout history and evidence of preparing and filling cavities dates back at least 13,000 years. Here's a look at some of the different materials used to fill cavities over the years.

Every year the American Dental Association (ADA) announces updates, additions and deletions to the Current Dental Terminology (CDT) codes dental practices use to document the patient care they provide and submit insurance claims.

For this year, the ADA announced 28 new CDT codes, many of which reflect changes the industry has undergone because of both advances in dental technologies, and the influence of the coronavirus disease 2019 (COVID-19) pandemic. Here’s an overview of the 28 new codes and how they are intended to be applied.

 Antigen testing for a public health related pathogen, including coronavirus

Antibody testing for a public health related pathogen, including coronavirus
Both of these codes reflect the role dental practices can play in managing a public health crisis such as the COVID-19 pandemic. Specifically these codes allow practices to document and bill for testing for pathogens such as the severe acute respiratory syndrome coronavirus 2, which causes COVID-19.

Radiograph and photograph “Image Capture Only” codes for different imaging types
These 9 new codes reflect changes in dental imaging, as well as the growth of teledentistry. These new codes do not replace existing codes covering “Image Capture With Interpretation” but instead apply to instances where imaging is captured in one location while the dentist and the interpretation of the image are in another location.

Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use
This code covers counseling about managing and mitigating the impacts of substance abuse on patients’ oral, mental, and overall health.

 Caries preventive medicament application – per tooth
Although the previously established code D1354 covers application of medicaments such as silver diamine fluoride, silver nitrate, or chlorhexidine, for teeth with existing lesions, this new code covers the use of these materials as a preventive measure on high-risk teeth that do not show active lesions.

 Prefabricated porcelain/ceramic crown – permanent tooth
This code covers the placement of prefabricated ceramic crowns on permanent teeth.

 Surgical repair of root resorption for anterior, premolar, and molar teeth
These 3 new codes cover surgical treatment of root resorption. The codes cover documenting the surgical procedure and do not cover placement of a restoration on the repaired tooth.

Surgical exposure of root surface without apicoectomy or repair of root resorption for anterior, premolar, and molar teeth
This trio of new codes covers similar clinical situations but should be used when the root surface is exposed but an apicoectomy or repair of the root resorption is not performed.

 Periodontal medicament carrier with peripheral seal – laboratory processed – one code for maxillary and the other for mandibular
These codes replace the now deleted D5994 to add specificity to where in the mouth these periodontal treatment systems are being used.

 Semi-precision abutment – placement and Semi-precision attachment – placement
This pair of new codes adds specificity to cover the specific placement of semi-precision abutments and attachments in implant cases. These codes replace the now removed D6052 – semi-precision attachment abutment code.

 Buccal/labial frenectomy (frenulectomy) and 

 – Lingual frenectomy (frenulectomy)
This pair of new codes is again adding specificity to the procedure being performed, and they replace the now removed D7960 code that previously covered both lingual and buccal/labial frenectomies.

 Surgical placement of craniofacial implant – extra oral

Surgical placement: zygomatic implant
This final pair of new codes cover oral-maxillofacial surgical procedures for the placement of implants designed to manage extraoral facial reconstruction as well as the placement of zygomatic implants that anchor into facial bone structures rather than into the maxilla.

A look at the new CDT codes added for 2021 and details on when they are supposed to be applied.

The 28 New CDT Codes for 2021

In a very simplified sense, restorative dentistry comes down to removing diseased or decayed material and replacing it with something designed to replicate its shape, shade, and strength.

The choice of material for filling the negative space created by the preparation is informed by numerous factors, including the tooth being restored and the patient’s age and various demographics. At the most basic level, the material chosen must be capable of adequately replicating the restored tooth’s function while protecting from further decay and not causing harm to other teeth in the patient’s mouth.

Of course, form is a consideration almost as important as function, and the esthetics potential of the material is another choice. This drive for more natural-looking materials has led the industry to move away from gold and other precious metals for indirect restorations, and away from amalgam for direct restorations. But this shift toward tooth-colored ceramic and composite materials has not been without some trade-offs. Most newer dental materials do not provide the same durability and longevity as their less esthetic predecessors.

Studies continue regarding the wide range of dental materials constantly being introduced. However, Ken Malament, DDS—researcher, practicing dentist, and clinical professor at Tufts University School of Dental Medicine—believes the ideal answer, already widely used, is Ivoclar Vivadent’s IPS e.max lithium disilicate material. He also believes he has the data to support his belief, in the form of 3 studies showing e.max restoration survival rates during periods of 10, 10.9, and 16.9 years.

 Dr Malament says he hopes his research helps people understand the benefits of this established material option.

“I hope that people can finally get an understanding that e.max is generally bulletproof,” he says. “If I had to put something in my own mouth, or if I had to put something in my wife’s mouth or anyone’s mouth, I would want a material that is going to last a long time.”

IPS e.max is a lithium disilicate material classified as a glass ceramic. It has been a popular restoration option because of its high strength, high translucency, ideal esthetics, and durability. It can be produced via either the lost-wax pressing technique or via CAD/CAM milling, with the resulting restorations exhibiting similar physical characteristics. The material can be chemically bonded in place, which Dr Malament says is a key benefit.

First introduced to the dental industry in 2004, the material offers the strength for use in posterior restorations that must be able to withstand strong bite forces, but also the esthetics for use in the anterior region. IPS e.max also provides clinicians with a minimally invasive indirect material object because it can be used to create veneers as thin as 0.3 mm, and crowns with walls as thin as 1.0 mm.

Dr Malament’s IPS e.max research is built on a restoration database he has maintained since 1982. The database tracks the materials used, the type of restoration placed and where it is placed, patient demographics, and whether the restoration failed or was removed for any reason, among other metrics. This allows him to look back on the details of more than 4000 IPS e.max restorations he has placed.

The data he has collected show the durability and generally long service life of the IPS e.max restorations he has placed. He says that during the more than 16 years he has used the material, his database has logged just 28 true failures, even though some other restorations were removed and replaced for other clinical and cosmetic reasons. Consequently, IPS e.max is his go-to option for minimally invasive and partial coverage restorative cases. In the past he would have done these restorations in gold, which has served in some patients’ mouths for more than 50 years, but even though he is not certain a ceramic material will ever last that long as a dental restoration, IPS e.max has certainly proved its worth as an esthetically better, lower-cost option than something cast in gold.

“This is the minimally invasive dentistry. This is partial coverage dentistry. And in the past, partial coverage in my world, and my generation, was all gold,” he says.

With his decades-long track record of dental material research, Dr Malament says IPS e.max has proved to be the most reliable material he has ever used or tested. His 16.9-year study found a failure rate of just 0.7%, which is far better than other materials he has studied, including zirconia.

Even more telling, his 3 recent studies all found no statistically significant difference between different types of restorations fabricated from e.max. Similarly, the restorations showed no difference in performance when evaluating where in the mouth the restorations were placed, nor any demographic differences between patients. Even the thickness of the restorations did not greatly affect whether a restoration would fail.

“When you go to look at the 17 years [of research], there is no statistical significance between patient age or any other factor whatsoever, which means you’re looking at a material that’s reasonably bulletproof. And we’ve never had a material like that before, except gold. But gold has other problems,” he says, noting gold doesn’t provide the esthetics patients want these days, it also is potentially more temperature sensitive, and bacterial plaque sticks to it far more than a smooth ceramic.

The 10.9-year study of partial coverage monolithic IPS e.max restorations reports an estimated cumulative survival rate of 95.6%.

 The 10-year estimated cumulative survival rate of full-coverage crowns was even better at 99.6%.

 In the 16.9-year study of full and partial coverage crowns, Dr Malament reports an estimated cumulative survival rate of 96.49%.

 All of this points to IPS e.max as a material capable of providing patients with a long-term solution.

Dr Malament notes that he does a lot of partial coverage restorations using different materials, and he remains impressed at how rarely IPS e.max restorations break. He is now researching ceramic failures to gain a better understanding of how different ceramic dental materials break. One trend he is starting to see is that failures with IPS e.max partial coverage restorations are often related to a flaw in the prep design, which can then apply bending forces to the material.

“I would say that the failures that I’ve had—the few that I’ve had—generally are related to me, where I perhaps didn’t prepare the box to the isthmus deep enough. That could create a bending moment. But you clearly see that the survival rate at 98.3% is really extraordinary for onlays. And overall, a 96% survival rate [for both inlays and onlays] over 10 years is extraordinary,” he says.

Another key factor powering the success of IPS e.max restorations is the material’s affinity for creating a strong bond to dentin and enamel when etched, Dr Malament observes. Etching has been an important part of his bonding protocol going back to his use of dentistry’s earliest castable glass ceramic, Dentsply’s Dicor.

“I’ve been studying statistics with dental restorations for almost 30 years, and we’ve never worked with anything even close to [IPS e.max], and I think part of it is because you can etch it and bond it,” he says.

The technique used to secure the material into the patient’s mouth could be considered an extension of the material itself, and Dr Malament also finds the material generally provides a good fit and a tight marginal seal. Lithium disilicate is also easy to identify in radiographs, making margins easy to observe.

“I almost can’t remember any e.max restorations that decayed underneath the ceramic itself,” he says.

This is important because these bonded restorations are demonstrating they are not likely to debond and fall out, which Dr Malament says is something he frequently hears about from friends placing cemented zirconia restorations. Given the track record of success, Dr Malament says using another material when lithium disilicate could be used isn’t logical.

While all 3 of his recent studies examined restorations produced with the press technique, Dr Malament also places milled lithium disilicate restorations, and he has data showing they are just as reliable. The final material being placed in the mouth is the same lithium disilicate whether it was milled and fired in a furnace or pressed using the lost-wax technique. In fact, he believes IPS e.max would be used even more widely and for a larger range of restorative situations if it were available in the puck format used in many dental lab mills.

So, although Dr Malament has placed thousands of IPS e.max restorations, the reason the majority are pressed is that he enjoys working with expert lab technicians in his practice, and he’s been able to work with some of the best in the world.

“I really feel that dental technology is still—even with CAD/CAM and everything else—the heart and soul of the dental industry,” he says.

Although he enjoys collaborating with technicians, one of the things he likes about the material is that it doesn’t always require a master technician’s hand to achieve lifelike lithium disilicate restorations. This is because the material can easily be cut back in key areas and layered back up to add shading and translucencies.

Dr Malament says IPS e.max is the easiest material he has ever worked with when it comes to achieving the desired shade. He sees the material as a great choice, whether it is being sent to a lab for press fabrication and finishing by an expert technician or being milled and fired with some esthetic details added chairside for a same-day appointment.

“Great dentistry is about the materials applied more than the technology used,” Dr Malament says.

Not only has Dr Malament’s research demonstrated the longevity of IPS e.max, but it has also validated the material’s versatility. All 3 of the studies found no statistically significant differences in the performance of restorations based on where they were placed in the mouth. In his experience anterior restorations have almost never failed, and there is always a greater risk of failure for restorations in posterior teeth.

“When you look at the posterior where people would say, ‘Oh no, you must do zirconia here,’ I don’t believe that at all. Not at all. IPS e.max is generally and reasonably bulletproof,” he says.

His research points to IPS e.max as an ideal choice for any inlay or onlay, and also as an equally sound choice for full coverage crowns in all areas of the mouth. It has the strength needed to function in the posterior, has been shown to be kind to opposing dentition, and as Dr Malament’s research shows, provides long-term form and function for patients regardless of where it is placed, who the patient is, or whether it is used for full or partial coverage. He believes his data demonstrate that lithium disilicate is an ideal material for many indirect restorative situations.

“It’s really our choices that ultimately tell us what the patient experience will be like. In the end, it’s the decisions that you make,” he says.

Malament KA, Margvelashvili-Malament M, Natto ZS, Thompson V, Rekow D, Att W. Comparison of 16.9-year survival of pressed acid etched e.max lithium disilicate glass ceramic complete and partial coverage restorations in posterior teeth: performance and outcomes as a function of tooth position, age, sex, and thickness of ceramic material. 

. Published online September 30, 2020. doi:10.1016/j.prosdent.2020.08.013

Malament KA, Margvelashvili-Malament M, Natto ZS, Thompson V, Rekow D, Att W. 10.9-year survival of pressed acid etched monolithic e.max lithium disilicate glass-ceramic partial coverage restorations: performance and outcomes as a function of tooth position, age, sex, and the type of partial coverage restoration (inlay or onlay). 

. Published online October 1, 2020. doi:10.1016/j.prosdent.2020.07.015

Malament KA, Natto ZS, Thompson V, Rekow D, Eckert S, Weber HP. Ten-year survival of pressed, acid-etched e.max lithium disilicate monolithic and bilayered complete-coverage restorations: performance and outcomes as a function of tooth position and age. 

. 2019;121(5):782-790. doi:10.1016/j.prosdent.2018.11.024

Researcher and clinician Ken Malament, DDS, explains the conclusions reached by his 16 years of longitudinal research using Ivoclar Vivadent’s IPS e.max Press material.