A dentist, author, lecturer, and instructor, Susan McMahon, DMD, AAACD, FAGD, is an expert in the field of cosmetic dentistry, dental care, dental services and teeth whitening. Dr McMahon is a past clinical instructor in Prosthodontics and Operative Dentistry at her alma mater, the University of Pittsburgh School of Dental Medicine. She lectures on cosmetic dentistry, minimal prep dentistry, dental technology, dental service, and teeth whitening around the world.

Susan McMahon, DMD, AAACD, FAGD

Creating the Ideal Gingival Area for Preparations


In her general and cosmetic dental practice, Susan McMahon, DMD, does veneer preparations for her patients. For these preps, Dr McMahon uses paste to retract the gingiva. Her latest choice, the new VOCO Retraction Paste, has quickly become a favorite for several reasons. In the past, Dr McMahon has used both the gingival retraction cord technique and lasers. She has found that VOCO Retraction Paste stands out.

VOCO Retraction Paste is an astringent paste with aluminum chloride that is designed to widen and dry the gingival sulcus, creating the ideal conditions for accurate, successful digital or conventional impressions. The material is a bright turquoise color, providing high contrast to tooth structure and gingiva and ensuring that the paste is visible and can be easily rinsed off after only 1 to 2 minutes. It is said to save clinicians up to 50% of procedural time compared with other methods and can be used as a replacement for or in conjunction with a retraction cord.

“When you’re working in the anterior region, it’s really nice to have a product that doesn’t do any harm to the tissue,” says Dr McMahon, whose practice is in Pittsburgh, Pennsylvania. “You can retract and get what you need without having to worry about moving the marginal lines of the tissue. You never have to worry, when you get your restoration back, that your tissues have been harmed from your retraction.”

VOCO Retraction Paste is an astringent paste with aluminum chloride. It widens and dries the gingival sulcus with 2-stage viscosity. The first stage has the paste flowing out of the capsule into the sulcus, and the second has the paste’s viscosity increasing to widen the sulcus. The thin cannula tip is said to be flexible for easier application, something Dr McMahon has noticed during her preimpressions process.

“It comes in unidoses with an extra long, thin direct cannula on it,” says Dr McMahon. “So it flows directly into the sulcus easily.”

Another feature Dr McMahon is fond of is the paste’s ability to be rinsed off with relative ease. “A lot of other retraction pastes are difficult to rinse off. They require lots of water, and sometimes a little residue color is left on the gum line,” says Dr McMahon. “This paste goes on nicely and comes off really nicely too.”

VOCO Retraction Paste comes in a bright turquoise color, making it easy to see during rinsing. Each capsule is said to contain enough for up to 3 teeth, and it contains 0.3 g per cap. Dr McMahon stresses the unidose as an important feature in best infection control practices. Each capsule, containing the correct amount of retraction paste, assists in not reusing product.

“It really helps with infection control,” says Dr McMahon. “COVID-19 has changed so much for all of us that unidose products are really important.”

However, its ability to create a fully dry field is the most important feature of VOCO Retraction Paste, according to Dr McMahon.

“Anytime I’m inserting all porcelain restorations that I’m bonding to or around the margins of the gingiva, and you have any kind of exudate or maybe just a little bit of hemorrhage, this product works great,” says Dr McMahon. “It leaves you a 100% dry field; it doesn’t hemorrhage. If you want to ensure that your field is perfectly dry and isolated for bonding or inserting restorations, it’s a really nice product to use.”

Dr McMahon says the paste eliminates certain hassles when scanning, because it rinses easily and there is no threat of an inaccurate scan or image. The high viscosity also allows for the necessary retraction when taking impressions and scans.

“VOCO Retraction Paste does all things. It gets into the sulcus with ease, retracts the tissue, and rinses off easily without leaving any residue,” says Dr McMahon. “That’s what makes it remarkable.”

Articles

This retraction paste from VOCO America is helpful for impressions and scans without causing a mess or fuss.

Creating the Ideal Gingival Area for Preparations 

Pola Rapid is a new in-office whitening treatment that is designed to safely whiten teeth in a 24-minute application time. Its higher viscosity gel enables faster application and removal thanks to its non-stick formulation. Pola Rapid can be extruded quickly and remains on the teeth when applied. It features a 38% hydrogen peroxide formulation that releases active ingredients immediately. There is no mixing required thanks to its dual barrel syringe system, which mixes as the gel is applied to the tooth. The supplied brush tip is designed to deliver precise, smoother applications.

Americans are spending over $1.4 billion annually on OTC teeth whitening products. Beauty standards that were once only applied to celebrities and the wealthy are now the norm for everyone. Whiter and brighter teeth have been linked to social competence, intellectual ability, successful interpersonal relationships, and even psychological stability.

Today, patients have many teeth whitening options available, including whitening strips, rinses and gels, custom-fitted whitening trays, toothpastes, and in-office procedures. Many of these products are being directly advertised to patients, especially through social media, which creates a global market of all ages for whitening. More than 1 million Americans whiten their teeth annually, and it is the number 1 cosmetic procedure requested by patients between 20 and 50 years old 

. To meet the increasing demand and ensure safe techniques are being used, in-office teeth whitening procedures are desirable and should be offered in every dental practice.

Pola Rapid is a new fast in-office whitening treatment from SDI. It contains 38% hydrogen peroxide gel with built-in desensitizers. It also contains fluoride and whitens teeth in just a 24-minute treatment time 

Pola Rapid uses potassium nitrate and a high-water content ratio to maximize patient comfort and reduce treatment time. The new nonsticky gel is a vibrant blue. It is applied easily with its brush tip applicator and is also removed easily (use a surgical suction for best results). The new formula stays on the teeth well, with no dripping or slumping.

Case Presentation 

Although light activation is not necessary, the Radii Xpert light can be utilized with the Pola Whitening Stand 

. The stand is small and mobile, so it can be moved between operatories.

There have been some reports that mild increases in temperature can increase the effect of whitening.

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

Twelve Catapult reviewers participated in this evaluation. All of the reviewers currently offer in-office whitening using a variety of other whitening products.

Of these 12 reviewers, 100% found the gel was easy to apply and stayed in place. They were unanimous in finding the gel highly visible, easy to remove, and safe to use as intended.

Eighty percent found the procedure was quick and 75% were happy with the results.

When asked to rate Pola Rapid, 36% of evaluators felt it was better than their current in-office whitening system. Forty-five percent of evaluators found Pola Rapid to be similar, and just 2 reviewers liked their current product better.

In general, sensitivity is reported as the number 1 adverse effect of teeth whitening. Pola Rapid is formulated with potassium nitrate and a high-water content to minimize sensitivity. A majority (84%) of evaluators found no sensitivity when using Pola Rapid.

Reviewers also found the gingival barrier easy to use and apply. They also liked the brush tip that came with the kit.

When asked if the reviewers would recommend Pola Rapid, 100% said they would recommend it to a colleague.

Pola Rapid is a great choice for part of your in-office whitening menu. SDI Pola Rapid and the Pola Whitening Stand provide excellent results, convenience, and ease of use and has earned the Catapult Vote of Confidence.

Pola Rapid is designed to whiten teeth in one 24-minute session

A New In-Office Whitening Product That Impresses

Black triangles, also known as open gingival embrasures, are spaces or gaps of missing gum at the cervical embrasure above the contact point and are a common dental issue seen in approximately 30% of adults.

The main determinant of the interproximal papilla height is the underlying bone crest (ie, osseous peaks). Research shows that the distance from the base of the contact area to the crest of bone correlates with the presence or absence of the interproximal papilla. When the distance is less than 5 mm, the papilla fills the interproximal space nearly 100% of the time, but when the distance is 7 mm or greater, the interproximal space is completely filled in only approximately 25% of the time.

Appearance and self-esteem have long been intertwined, so as our social media and selfie use continues to grow, more people are seeking out cosmetic dentistry to enhance their appearance. Often, they’re seeking care for relatively small dental issues that are of big concern to them. Patients’ perceptions of interdental black triangles were rated as the third most disliked esthetic problem, below caries and crown margins.

Black triangles are very prevalent, and approximately 40% of adult orthodontic cases may result in them.

Black triangles may be caused by several conditions,

decreased interproximal bone height from periodontal disease, attachment loss, periodontal surgery, or trauma;

excessive embrasure space and deficient papilla form affected by root angulation, interradicular distance, crown form, and distance between alveolar bone and interproximal contact;

patients’ biologic width and inherent or thinning gingival biotype; and

other factors such as age, patient habits, and iatrogenic issues.

Depending on the size, position in the esthetic zone, and cause of the black triangle, several treatment options are available, including surgical, orthodontic, indirect, and direct.

Small Black Triangles

, direct restoration is the best and most conservative approach. Many clinicians find direct restoration in this area to be challenging, often resulting in restorations with ledges and voids that collect biofilm and stain. However, newer techniques including injection molding improve the results.

The following case demonstrates an easy technique that employs traditional sectional matrix bands, Aura Easy composite, and Aura Easyflow, both from SDI Limited. Aura Easy is a universal nanohybrid composite that combines a low-shrinkage resin system and a unique morphology of ultra-high density glass filler. It can withstand high compressive forces and still deliver amazing handling and polishing properties. Therefore, it can be utilized in anterior and posterior restorations without compromising strength or esthetics. AuraEasy comes in 4 shades that cover the spectrum of the Vita shade guide and blends beautifully with natural enamel.

The patient shown in Figure 1 did not like the black triangle between his central incisors. He complained that, “it always looks like I have something stuck in my teeth.” Prior to closure of the black triangle, the patient is whitened with Pola Rapid in-office whitening 

It is difficult to attain proper contour interproximally with traditional mylar strips or matrix bands. Using a small, sectional matrix band placed vertically gives the perfect contour and can be adapted for an undetectable margin with no overhang.

First, isolate the left central incisor, and etch the enamel (37% phosphoric acid). After rinsing and light drying, apply Zipbond Adhesive (SDI Limited), air thin, and cure 

. The matrix band is placed interproximally. It is apparent the contour of the band will allow for a well-adapted closure of the black triangle 

Apply Aura Easy shade AE1 and contour to the band. Use Aura Easyflow to fill on the lingual as necessary 

 shows the final results after finishing and polishing.

1. Tarnow DP, Magner AW, Fletcher P. The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla. J Periodontol. 1992; 63(12):995-996. doi:10.1902/jop.1992.63.12.995

2. Cunliffe J, Pretty I. Patients’ ranking of interdental “black triangles” against other common aesthetic problems. 

3. Kurth JR, Kokich VG. Open gingival embrasures after orthodontic treatment in adults: prevalence and etiology. 

. 2001;120(2):116-123. doi:10.1067/mod.2001.114831

4. Kim J, Clark DJ. Full mouth black triangle treament protocol. 

5. Tanaka OM, Furquim BD, Pascotto RC, Ribeiro GL, Bósio JA, Maruo H. The dilemma of the open gingival embrasure between maxillary central incisors. 

Creating restorations with Aura Easy composite can help close small black triangles with ease.

How To Use This Easy Technique For Closing Small Black Triangles

 is a new 3-viscosity, addition-curing, elastomeric impression material. It’s based on a new material, vinylsiloxanether.

	Vinylsiloxanether gives Identium properties and advantages of both polyether impression materials and A-silicone impression materials. Polyether materials exhibit dimensional stability and wettability. A-silicones exhibit high elastic recovery with flexibility for mouth removal and have a neutral or good taste. 

	One of the most challenging procedures clinicians face in dentistry is obtaining an ideal impression for fixed restorations. Making an accurate impression requires precise preparation of the margins, thorough management of the surrounding gingival tissues, a good understanding of impression material properties and the correct use of impression trays.

	A recent evaluation conducted by several commercial dental laboratories determined 86 percent of crown and bridge impressions contained at least one detectable error and 55 percent contained a critical error related to the finish line.

	A quality, reliable impression material is critical. Retaking impressions is both time- and material-consuming and an expense that should be minimized.

	When considering past errors that necessitated impression retakes, our reviewers ranked missed margins as the No. 1 reason. Bubbles/voids, tear errors and distortion errors followed missed margins. Also noted were fin/folds, contamination, lack of integration between tray and injected material, inadequate working time for multi-unit impressions and incorrect tray selection. Impression errors result in ill-fitting restorations followed by restoration failure (

	A majority of our reviewers rated Identium “better or much better” than their current impression material. The reviewers cited the viscosity of light body, tray seating resistance, syringing ease, working time around multiple units, tray loading and, most importantly, consistent readable margins as favorable.

	When rating performance by individual impression characteristics, our clinicians found Identium better than their current material when considering gingival margin quality, impression detail, voids and bubbles, depth of sulcus penetration, subgingival margin detail and ease of removing the impression (

	Identium is an excellent choice for implant impressions, multi-unit impressions, impressions where isolation is compromised and impressions with subgingival preps (

	The majority of Catapult reviewers agreed Identium has improved properties compared to their current impression material. Overwhelmingly (79 percent), our reviewers state they would use it in their practices.  
	Identium, the new vinylsiloxanether impression material, gives reliable and accurate restorative impressions. It’s a great choice for consistency and value. 

	1. Rau CT, Olafsson VG, Delgado AJ, Ritter AV, Donovan TE. The quality of fixed prosthodontic impressions: an assessment of crown and bridge impressions received at commercial laboratories. JADA. 2017;148(9):654-660.

Why Catapult Education reviewers gave Identium the Catapult Education Vote of Confidence.

Creating reliable and accurate restorative impressions

	A much more conservative approach is taking root in dentistry as technology and materials allow providers to save teeth and tissue. When faced with deep carious lesions and root lesions, we as clinicians should be changing our focus from endodontic treatment, post and cores, and deep-cut full coverage restorations to, if possible, achieving pulpal health and restoring more conservatively.  

	Catapult Education reviewers evaluated Biodentine

 made from the patented ABS technology. Active biosilicate, Septodont’s bioactive material, was primarily reviewed for its use in direct pulp caps and indirect pulp caps. Additional uses include repairing root perforations, pulpotomies, root resorption and deep caries bases. Catapult reviewers overwhelmingly reported positive feedback with Biodentine. Eighty-five percent said they would recommend Biodentine to a colleague.  

	When dentin has been compromised, whether from decay, resorption or mechanical perforation, previous restorative options have been limited. Calcium hydroxide bases have long been used to stimulate dentin formation but their weak physical properties have been a drawback. Only 60 percent of our evaluators reported using Dycal or MTA. This begs the question of how teeth with deep carious lesions and root lesions are being treated. Are we opting for more aggressive procedures in lieu of pulp caps, root repairs or other resorption repairs? Endodontic treatment followed by posts, cores and crowns is an aggressive treatment option that can result in destruction of significant tooth structure. We find many endontically treated and crowned teeth are eventually lost and replaced with implants or other restorative means.   

	Biodentine by Septodont, a calcium silicate restorative dentin substitute, maintains pulpal vitality and stimulates formation of tertiary dentin. It can be used both on the crown portion of the tooth and on the roots. With its physical properties, compressive strength, elasticity and hardness, similarity to dentin, and reparative stimulation from calcium hydroxide ion release, Biodentine is an excellent choice for direct pulp capping, indirect pulp capping, pulpotomies, furcation repair and resorption repair. Biodentine’s bioactivity is what makes it a superior clinical choice over calcium hydroxide bases and glass ionomers.  

	Case: Indirect pulp cap on deep carious lesion

	The patient is 26-year-old female with several missing teeth and gross decay of several others.  She has neglected her dental care due to limited access and financial duress. The lower right second molar had previously been restored with amalgam. The amalgam had partially fractured out and there was a deep carious lesion with close proximity to the pulp (

). The tooth was asymptomatic. The pulp tested vital with traditional pulp testing. Because of the deep decay and proximity to the pulp, I previously would have considered endodontically treating this tooth and then restoring with a passive post and core followed with a full coverage crown.  

	Fig. 1                                                                                     Fig. 2

	The patient was anesthetized with an inferior alveolar block with 4% Septocaine(1:100,000epi). Isolation was obtained with a rubber dam. The remaining amalgam restoration was removed with a high-speed carbide bur. The deep distal caries were excavated completely with a #6 round carbide bur with low torque. A very thin layer of dentin was left remaining over the pulp (

). A traditional matrix band was placed. Biodentine was prepared, triturated and placed in a layer over the thin dentin (

). The Biodentine was allowed to set for its 12-minute set time.The preparation was then refined and cleaned.

	Fig. 3                                                                                      Fig. 4

	Next, 37% phosphoric acid was applied for 15 seconds as a total etch on the enamel, dentin and Biodentine. The etchant was then rinsed off.  Adhesive was applied, air thinned and cured. A low stress bulk fill flowable was placed and topped with a universal composite resin then finished and polished (

). Thus, this tooth has been restored and the pulp has been left intact and vital. The Biodentine layer, acting as a indirect pulp cap and dentin replacement, will presumably stimulate tertiary dentin formation and keep this pulp healthy. Considerable tooth structure has been saved and the long-term prognosis much improved. This makes me feel like a dental hero, saving this young patient’s tooth from endodontic and crown treatment.  

	For use, the liquid component is added to the capsule. The capsule is then triturated for 30 seconds. The material, a malleable paste, is applied to the tooth with the supplied disposable small spatula. The set time is 12 minutes.  Some evaluators cited the mixing and handling as challenging. The set time may seem little time-consuming by today’s instantaneous standards, but the biostimulating activity with the associated clinical benefits of dentin stimulation and maintenance of pulpal vitality warrant the clinical time.  

	Overall, Catapult evaluators reported a short-term success rate of 95 percent with direct and indirect pulp caps. Pulpal health is maintained and reparative dentin is stimulated. More conservative restorations can be placed and more natural tooth structure can be maintained.  Biodentine earns the ‘Catapult Vote of Confidence.’

Why Catapult Education reviewers enjoyed using this bioactive dentin substitute from Septodont.