Terri Lively

	Digital dentures continue to disrupt the conventional denture fabrication process. The technology is changing the time and resources needed to produce a denture that fits and performs well for the patient. One area in which you can observe changes is the try-in appointment.

	The try-in appointment is the third step in a traditional denture fabrication process. In a traditional workflow, the try-in was a base with teeth in a wax set-up. The main goal was to check esthetics, size and to note any adjustments needed for the final prosthesis.

	Justin Marks, CDT, and founder and CEO of Arfona says the computer-aided design (CAD) try-in is a denture where a monolithic appliance is milled or 3D printed. It allows the doctor and patient to determine if they like the proposed tooth arrangement and to verify the jaw relationship record. Marks recommends a try-in 100 percent of the time with full dentures fabricated digitally-even when the case seems like a slam-dunk.

	“Even in a situation where you are scanning the patient's existing dentures as a reference, meaning you have the bite and you have a good final impression, I still would do a try-in. It is always challenging to get the fully edentulous patient to bite down and obtain the proper jaw relationship in that appointment,” Marks says.

		The try-in appointment for a printed or milled denture shares many of the same goals. Per 

, the purposes for an appointment with a digitally-produced try-in are:

		To evaluate the esthetics of the proposed restorationTo allow clinicians to test the fit of the 3D printed or milled base

		To confirm proper speech, function, alignment and occlusal contacts           

	At Glidewell, the design of the final CAD/CAM denture is verified at the lab before they send the try-in prosthesis to the practice. Once approved, the clinician returns the try-in to the lab for final processing. However, if a denture is too loose, the clinician has an opportunity at the try-in to create a wash-reline impression to send to the lab for adjustment.

Related reading: What you should know about bite registration

	Marks does not always advocate a try-in appointment with a digitally produced removable partial denture. He says the digital fabrication technology is so accurate producing these appliances the try-in appointment is usually unnecessary. That said, many of his dentists are still doing a try-in with digitally fabricated removable partial dentures.

	“The ones who are using oral scanning are starting to bypass it. I think we are getting to a point where technology has allowed an oral scanner to capture an accurate final impression and bite registration in a single appointment and we trust that data enough that we can go straight to the final restoration and circumvent the try-in,” Marks says.

	Digital dentures have not eliminated the try-in appointment, just improved it   

	Marks schedules a try-in appointment for digitally fabricated full dentures for two reasons: to verify the centric relationship and the vertical dimension of occlusion. He says if you are using traditional denture teeth in the esthetic zone set in wax, whether through a conventional workflow or a digital denture workflow, you might also check the esthetics, meaning the shape and shade of the teeth. The try-in appointment presents a unique opportunity for the patient and clinician to ensure the teeth are the shade they want in the final appliance. However, checking the tooth shade is not an option when you print or mill the entire apparatus out of certain materials.

	“For example, I may decide to 3D print a denture mockup and use standard prototyping resin that's not necessarily tooth shade. So, I can verify the relationship, but I can't verify the tooth shade and the esthetics because I'm using just prototyping resin,” Marks says.

	Marks says accurate bite registration is essential.  He says you often hear technicians criticize the quality of a dentist’s final impressions they receive at the lab. However, he thinks the bite registration for dentures and partials is much more challenging.

	“Going back to when I used to do all my dentures traditionally, if I ever had to reset teeth after a try-in or remake a denture, it was more often because of poor registrations than poor impressions,” Marks says.

	When it comes to bite registration inaccuracies, Marks says it is not necessarily a lack of skill on the part of the dentist. Patients play a role here, too. The fully edentulous patient needs guidance into the correct position because they do not remember how biting with teeth feels. As a result, patients cannot always reproduce that position properly when the clinician tells them to “bite down”.

	“They have forgotten what that is supposed to feel like after living with the absence of teeth for so long,” he says.

	Another potential benefit of having a CAD try-in appointment for 3D printed or digital try in for full dentures is taking a new final impression using the try-in denture as an impression tray. Marks says this works if a dentist wants to capture a new impression without making a custom tray.

	“So, you potentially save another clinical appointment process. That's possibly one of the biggest benefits of the technology,” Marks says.

	Taking the try-in appointment to the next level with full-function try-ins

	A fully functional try-in is a milled or printed appliance out of a poly (methy methacrylate) (PMMA) disc or puck. These fully functional try-ins are excellent for checking the utility of a denture for phonetics and occlusion. 

	Material manufacturers have products ready for digital fabrication of functional try-ins. AvaDent Digital Denture Solutions has a fully functional try-in appliance called the Bio-functional Try-In by Lars Bouma. Soon, Ivoclar Vivadent will have the ProArt CAD Try-In discs made from a white PMMA material to make functional try-ins. The ProArt discs can also be used for the digital fabrication of impressions or functional trays as well.  Kulzer has dima® Print materials optimized for 3D printing of prototypes for try-ins or whatever else you might need.

	Although checking the shade of the teeth might not be possible, there are a few patient benefits to having a denture that does not a use wax set up for the esthetic zone. In some cases, dentists have patients bring in foods they like to eat or give them something to eat, like a piece of candy, so the patient can test the denture’s functionality.

	Marks says he knows some dentists use the take-home try-in to give patients a chance to practice talking and eating with the appliance. The purpose is to provide the patient with more time to evaluate the prosthesis on their own, without the clinician’s input.

	“Often, the clinician also has the patient keep it as a separate denture if they ever need it for some reason such as they break or lose theirs,” Marks says. “That is potentially a cool feature of the CAD try-in technology.”

Trending: Choose the right patients for flexible removable partial dentures

	Marks also appreciates how the digital workflow for removable dentures and partial dentures fabrication allows the technician or clinician to make a new prosthesis from the old file. This opportunity for simplified remakes presents a significant improvement to the patient experience, especially compared to the traditional fabrication method. In the conventional workflow, a new denture or partial denture would require starting over from the beginning at the initial impression step.

	“Either proactively, meaning the patient wants a duplicate denture made the same time they're getting a new one, or in the future, if they ever need to remake it for whatever reason, then it is easy to do using the data you already have,” Marks says. “You can practically just do it over the phone.”

	Marks says depending on the restoration, the CAD Try-in is still an essential part of the denture workflow, although more for a full removable denture than a partial removable denture.

	“I don't know that we'll ever not need it at all, but obviously the way in which we do it has changed significantly with the adoption of digital dentures,” Marks says.

Articles

CAD dentures have changed the try-in process for edentulous patients.

Digital advances alter the denture landscape

	Flexible partial denture materials are an excellent option for many partially edentulous patients. However, what are the benefits of flexible materials in partial dentures and which partially edentulous patients are a best candidate for flexible? We asked two experts and here’s what they had to say.

	When it comes to removable dentures, you want something that fits and functions and looks great for your patient. How you get those qualities, however, depends on the materials you choose. For many cases, particularly those requiring removable partial dentures (RPDs), flexible materials can give you all three.

	Flexible RPD denture materials are not made of acrylic like traditional metal-cast RPDs. Instead, they use a thin thermoplastic, like nylon. The nylon-based materials were first introduced in the 1950s by Valplast and have been an option for partial dentures ever since, particularly for patients allergic to acrylics.

	Flexible dentures are thinner than acrylics. Their physical properties make them durable.

 Flexible denture materials provide many benefits as well. They are acknowledged as the most biocompatible material for removable dentures. Also, flexible materials do not contain BPA and resist absorbing odors or stains.

	While you can make a full or complete denture out of them, most often the flexible material is used for RPDs. Usually, a full denture is made from flexible material only when the patient is allergic to acrylics.

	Clark Damon, DDS, a private practice dentist in the Amarillo and Dallas metro areas and an lecturer on implants for Nobel Biocare says patients either love flexible RPDs or hate them. The ones that love flexible partials feel that way because there's no metal.

	“They think that it is more comfortable once it is well adjusted,” Dr. Damon says.

Related reading: What you need to know about the evolution of dentures

	Justin Marks, CDT, and founder and CEO of Arfona says from the patient’s standpoint, flexible dentures are both cosmetic and comfortable. Cosmetic, because they do not display a metal clasp, and comfortable because they are lightweight, and there is neither a metallic taste nor a rigid, bulky appliance in the mouth. 

	From a clinician’s perspective, Marks says flexible dentures are beneficial because studies show flexible materials are less destructive than a chrome-based appliance on the natural structures of the mouth. Marks thinks the most significant factor in resistance or reluctance to using flexible materials with an RPD is unfamiliarity with the material.

	“It's acknowledged in most literature on removable prosthodontics an RPD even under the best of circumstances can carry destructive forces against the teeth and tissue in the mouth. So, it's widely acknowledged the incorporation of stress breakers into the denture, whether it be in the design or in the material itself, would be favorable to reduce the stress on the natural structures of the mouth,” Marks says.

	Marks, whose grandfather invented Valplast’s flexible material in the 1950s, says flexible materials, like nylon, inherently have stress breaking function, making them friendlier and more forgiving to the teeth and tissues under normal use without requiring a complicated design. Traditional chrome-cobalt partial dentures need to be designed in a particular way to prevent those destructive forces.

	“Now, I am going to get a world of criticism for saying that, but it is the absolute truth, and is backed by almost seventy years of science and user experience,” Marks says.

	Marks worked with Valplast for 12 years before founding Arfona three years ago, which specializes in 3D printing for dentures and removable partial dentures. He has been addressing the issue of destructive forces on the oral environment from the traditional materials used for RPDs for his entire 15-year dental career. 

	“No literature dictates you have to use a rigid material in the first place. When you bypass all of that and find a material more harmonious with the oral environment, you eliminate some of the complications and challenges associated with partial dentures,” Marks says. 

	However, flexible materials also have some drawbacks. Dr. Damon says one of the drawbacks to flexible partials is the prosthesis moves around more.  Also, he says the material is not as sturdy as a cast-metal partial. Despite these challenges with flexible RPDs, Dr. Damon says flexible dentures have their place.

	“Often, we're able to generate better esthetics on certain cases, like the Kennedy Class III patients,” Dr. Damon says.

	Marks has never shied away from using flexible materials for patients. However, he recognizes some cases are more challenging than others. For example, with a Kennedy Class II, Marks likes having a rigid major connector, a combination flexible and chrome-cobalt RPD to ensure a proper design.

	“However, for any other situation, Kennedy Class I, III or IV, I would easily choose a flexible denture over any other chrome cobalt or rigid appliance,” Marks says.

Related reading: 5 things you need to know about implants

	Dr. Damon does not have the same all-inclusive approach to case selection for flexible dentures. If a patient is already using a flexible partial, he will keep them in it, and likewise for cast-metal partials. When a patient is getting a partial for the first time, Dr. Damon emphasizes the importance of case selection.

	“Let's say the patient is missing a few teeth, but there are natural teeth in between. That's a good case for a flexible partial,” Dr. Damon says.

	Most of his younger patients tend to move toward implants. However, if implants are not an option, Dr. Damon would also recommend a flexible RPD for his more esthetically-demanding patients, which often skew to the younger side.

	However, Dr. Damon says tried and true cast-metal partials are the way to go for Kennedy Class I and II scenarios where the posterior segments are not bound by teeth. These Kennedy classes are more common than the Kennedy Class III and IV that work well with flexible partials.

	“Using flexible materials when there aren’t any teeth in the posterior doesn’t make sense,” Dr. Damon says. “It's like running on sand in a size 16 tennis shoe.”

	Dr. Damon also does not like to use flexible partials when the patient presents with a bilateral distal extension partial. That scenario, he says, needs more support, so the cast metal version performs better than flexible RPDs. 

	Marks disagrees. He says those cases are why flexible RPDs were invented.

	“In fact, the distal extension partials are where you will get the most functional benefit out of a flexible RPD because of the way it acts as a stress breaker,” Marks explains.

	Flexible material looks like pink plastic but behaves differently than an acrylic material used for full dentures. As a result, Marks says the dentist needs to get the best tools and instruments for adjustments.

	“Contact the manufacturer of the material to find out what the best tools are to use to adjust it. For example, I use Valplast, and they have a specific adjustment kit and a polish  used for their material,” Marks says.

	Marks also recommends when placing all flexible dentures, seat them so they are entirely passive. The appliance shouldn't flex or compress the gums once it's seated in the mouth. For the best results here, Marks and his team recommend taking a static impression where the tissues are at rest.

	“The best methods for doing that are either alginate impressions or intraoral scanning. The newer generation of dentists may use all scanning, which takes a picture of the tissues at rest, so it doesn't move the tissue or touch them at all,” Marks says.

	Dr. Damon does not use digital impressions for dentures. He recommends a polyvinyl siloxane impression material that is going to capture the detail needed for a good fit. 

	“Studies show polyvinyl siloxane impressions capture more detail than scanning, at least for dentures,” Dr. Damon says.

	Marks agrees conventional impressions are still the most common method for capturing the data a technician needs for building a removable partial denture, but stresses the importance of using mucostatic materials. However, scanning technology is improving. For the past 18 months, Marks has been producing all his flexible RPDs digitally.

	Marks says migrating to the digital workflow with flexible dentures has additional benefits. Patient acceptance is high once clinicians move to capturing impressions digitally. It also cuts down the time for the workflow.

	“All of a sudden you can have final impressions and bite registration in a single appointment,” Marks says. “Often, the dentures could be delivered at the second appointment.”

More by the author: What you should know about bite registration

	Marks compares that with the traditional five-appointment delivery timeline of a chrome-cobalt RPD workflow, beginning with two appointments for physical impressions. Then, an appointment for bite registration followed by a try-in appointment. The patient usually gets the final denture on the fifth appointment.

	“You're looking at a minimum of five appointments compared to two or three for a flexible denture,” Marks says.

	Dr. Damon recommends a try-in with flexible RPDs to check the tooth position and esthetics. While it isn’t possible to check the seal when the tooth or teeth are in wax, it is possible to see how the prosthesis looks.

	“Clinicians and patients are going to check if they like the size, shape, and color of the requested denture teeth,” Dr. Damon says.

	From a technician’s perspective, Marks says the design process is simplified with flexible materials. Flexible RPDs also require fewer appointments and less time and preparation before delivery. However, all of the requirements of a partial denture are the same and apply regardless of what materials are used.

	“It is still important to have retention, support and stability. Those are requirements you can't ignore in any partial denture,” Marks explains. “It's just addressed differently in terms of how it's designed.”

	1. Salcetti, Mary Anne. “The Pros and Cons of Thermoplastic Partial Dentures.” 

https://www.speareducation.com/spear-review/2015/09/the-pros-and-cons-of-thermoplastic-partial-dentures

We asked two experts to weigh in and here's what they had to say.

Choose the right patients for flexible removable partial dentures

	Light curing units (LCU) are essential for the successful polymerization of direct composite restorations. However, they’re rarely in the spotlight and, many times, considered supporting cast for the features and benefits of the material itself.

	Let’s take a closer look at why LCUs are vital for a direct composite restoration’s success, the types of curing lights available, and what you can do to get the most out of your LCU and keep it optimized for proper curing.

	Polymerization is crucial for composite materials. When polymerization isn’t sufficient, it reduces the strength of the restoration. Insufficient polymerization also results in water absorption, increased solubility of the composite and reduced hardness of the cured material.

Related reading: Is your curing light 'bright' enough?

	The curing light used has a vital role in polymerization. 

Per the Journal of Clinical and Experimental Dentistry

, some ways the light affects the polymerization process include:

		Where the tip of the curing light is pointed in relation to the composite and how far it is from it

		The wavelength and bandwidth of the light’s output

	Your LCU works with the photoinitiator in the material to activate the polymerization process. 

, there are three types of photoinitiators: camphorquinone (CPQ), phenyl-propanedione (PPD), and trimethylbenzoyl-diphenyl-phosphine oxide (TPO).

	Most composite materials use CPQ as the light-sensitive component.

 The activation and performance of CPQ require the LCU to have the proper intensity with the highest assimilation wavelength range of CPQ. If your LCU falls short on either intensity or wavelength, you can compromise the strength and longevity of your direct composite restoration.

	The ISO 4049 Standard is the International Organization for Standardization’s recommendation for the intensity and wavelength of curing lights. These standards are:

		A wavelength bandwidth of 400-515 nm (on the tip of the device)

	An LCU is a significant factor in the success of a direct composite restoration. Over the years, LCUs have changed a lot, improving power, reducing size and increasing efficiency.

Per the IOSR Journal of Dental and Medical Sciences

, there have been five generations of curing lights since the 1970s, including:

		Ultraviolet light (no longer available)

		Visible light curing units: quartz-tungsten halogen (QTH) lights fall into this category

The first curing lights were ultraviolet lights. However, these weren’t effective enough for curing composite because of the short wavelength that put limitations on the depth of cure. Moreover, they used ultraviolet light, which has other hazards to the patient.

	The second generation of curing lights appearing in the early 1980s were the visible light curing units. These replaced the ultraviolet lights and led to a few developments over the next 20 years, such as using blue light to initiate polymerization, developing the quartz-tungsten halogen bulb (QTH) and increasing the intensity of the light to ensure a greater depth of cure.

More from the author: 5 mistakes you might be making with composites

	The late ‘90s presented the third generation of curing lights with the plasma arc curing light (PAC), which used a fluorescent bulb that contained plasma. PACs were fast, curing the composite material in three to five seconds.

	Light-emitting diodes (LED) emerged in the 2000s and were the fourth generation of curing lights. LEDs have long lifetimes and require no filters to produce the blue light. They also have a more concentrated bandwidth than their predecessors.

	Finally, the fifth generation of curing lights are argon lasers. First introduced into dentistry in the early 1990s, dental professionals began using argon lasers to cure composite because the wavelength enhances the thorough cure and physical properties of the material when compared with the polymerization and physical properties produced by other types of curing lights.

, technology editor for Dental Products Report, explains that curing lights had significant advances in the 2000s. LCUs decreased in size and changed to “toothbrush-style” units, which Dr. Flucke says make it easier to access challenging areas in the oral cavity, particularly in the posterior.

 over all the others for a few reasons. First of all, their wavelength is efficient for CPQ photoinitiator. Second, they’re energy-efficient, and they use less electricity, which means they don’t need AC. These battery-powered units take up less space in the operatory, and they’re also cordless and environmentally friendly. In addition, many of the LED lights allow you to change the wavelength of the curing light, which means you can change the wavelength if you have a different photoinitiator than CPQ. 

Tips for getting the most out of your LCU

	LED lights are smaller and located on the curing head, making them optimal LCUs for curing direct restorations at the proper distance. Dr. Flucke recommends keeping the light as close and parallel to the direct restoration as possible. Even moving it a few millimeters away from the composite decreases the efficiency the LCU, which can result in inadequate curing for the restoration.

	Dr. Gary DeWood, a Spear Education faculty member, 

 to cure a direct composite restoration to move it continuously during the cure.

 LED lights don’t have a homogenous spread from the tip, which affects the cure pattern of the composite. Moving it ensures that the material will cure appropriately. However, since it changes the distance of the tip from the material, Dr. DeWood says it also means you should add additional time to the process to allow for an adequate cure.

	Dr. Ed Kusek, a private practice dentist in Sioux Falls, South Dakota, encourages doctors to take care of their curing light. He also suggests putting a shield over it when in use.

Trending article: Dental care in paradise

	“We always put a shield over the top of it. If we’re putting it close to the mouth or the restoration, they don't get any bonding agent on the lamp portion,” Dr. Kusek says.

	Dr. Kusek also advises that if the assistant has the light, the doctor should ensure he or she gets in the right spot. If the light is shaking or too far away, the LCU can’t do a good job of curing.

	For Class II restorations, Dr. Kusek says you need to cure it on the buccal and lingual molar side to ensure the cure is adequate. When the cure isn’t suitable, you begin to have problems with your restoration.

	“It will start breaking down much faster. If the inner portion doesn't cure as it should, the margins will break away, and then you have recurrent decay, and the restoration will fail,” Dr. Kusek explains.

	To avoid failure, Dr. Kusek thinks the bond is essential. He always puts two layers of the bonding agent. He says he was lucky enough to do some studies with bonding and although there are plenty of decent options available, the study proved to him that Peak™ Universal Bond (Ultradent) is the best bonding agent.

	“Peak has a filler agent to it. The bond strengths are one of the highest on the market, so it will take the pounding in posterior areas or the anterior,” he says. 

	Because of the strength requirements, Dr. Kusek says he puts two layers on and then a thin layer of flowable to reduce the shrinkage value. Finally, he either uses a bulk fill composite or layered composite.	 

	Today, LEDs and QTH lights are the most common types of curing lights in an operatory. When you have either a QTH or an LED, light intensity decreases with the age of the light itself.

	The intensity of the LCU is also affected by many factors, including:

		Poor or reduced performance of the lamp or filter

	You might not know you have these problems with your curing light. You can’t see when there’s a fiber defect affecting the wavelength or if the lamp isn’t “bright enough” to cure the material properly anymore. Feeling the composite after curing isn’t going to work either; the surface can be hard even if the material deeper in the preparation suffers from inadequate curing.

Related reading: Covering a larger area in one cure

	Regular maintenance will lower the risks of an inadequate cure resulting from a loss of intensity. In Canada, the CDSPI, a nonprofit organization dedicated to providing insurance and investment solutions, says curing light maintenance is essential to protect against malpractice claims.

 also suggests testing the LCU output regularly and always ensuring that the LCU is in good working order before using it.

Journal of Clinical and Experimental Dentistry

 suggests using a digital radiometer to measure the intensity of the LCU, especially as it ages.

 The readings will reveal whether the light needs maintenance or a repair.

	In addition to regular maintenance, the CDA also recommends regular cleaning, disinfection and sterilization of the units before every use as well as an infection control barrier. As always, you should follow the manufacturer’s instructions for cleaning and maintenance of the LCU.

	1. Omidi, Baharan-Ranjbar et al. “Intensity output and effectiveness of light curing units in dental offices.” Journal of clinical and experimental dentistry vol. 10,6 e555-e560. 1 Jun. 2018, doi:10.4317/jced.54756
	2. Ibid.
	3. DeWood, DDS, MS, Gary. “The Evolution of Composites and Light Curing.” www.speareducation.com. 17 December 2018. Web. 28 April 2019. < https://www.speareducation.com/spear-review/2016/04/the-evolution-of-composites-and-light-curing>.
	4. Ibid.
	5. Omidi, Baharan-Ranjbar et al. “Intensity output and effectiveness of light curing units in dental offices.” Journal of clinical and experimental dentistry vol. 10,6 e555-e560. 1 Jun. 2018, doi:10.4317/jced.54756
	6. Ibid.
	7. Mangat, Dr. Panna, Dhingra, Dr. Anil., Bhardwah, Dr. Garurav. “Curing Lights and the science behind them - An Overview.” IOSR Journal of Dental and Medical Sciences. (2014) 13:12; pp 35-39. From Web. Pdfs. Semantic Scholar 28 April 2019. < https://pdfs.semanticscholar.org/f679/6f3c916c6ed0104719f4a53b6316a71dbced.pdf>.
	8. Ibid.
	9. Ibid.
	10. Ibid.
	11. Ibid.
	12. Ibid.
	13. Flucke, Dr. John. “The absolute best in curing light technologies.” www.dentalproductsreport.com. 20 September 2013. Web. 29 April 2019. < http://www.dentalproductsreport.com/dental/article/absolute-best-curing-light-technologies>.
	14. DeWood, DDS, MS, Gary. “The Evolution of Composites and Light Curing.” www.speareducation.com. 17 December 2018. Web. 28 April 2019. < https://www.speareducation.com/spear-review/2016/04/the-evolution-of-composites-and-light-curing>. 
	15. Ibid.
	16. Omidi, Baharan-Ranjbar et al. “Intensity output and effectiveness of light curing units in dental offices.” Journal of clinical and experimental dentistry vol. 10,6 e555-e560. 1 Jun. 2018, doi:10.4317/jced.54756.
	17. “Practical How To: How do you clean your light curing unit?” oasisdiscussions.ca. 3 July 2014. Web. 29 April 2019. < http://oasisdiscussions.ca/2014/07/03/htcl/>.
	18. Ibid.
	19. Ibid.
	
	 

Curing lights are often considered the supporting cast for restorative materials, but learn why they’re a vital component of a restoration’s success.

Putting curing lights in the spotlight

	Maybe it’s a small chip in the anterior. It could be a stain on the upper left canine. Perhaps your patient has a diastema. His or her teeth are otherwise healthy, so you might think “That must not bother them much because they never ask me to fix it.”

	However, it could be because they don’t know how today’s composite resin materials make it possible to fix it effectively, efficiently and affordably. 

	Composite bonding can be an excellent way to correct some common issues with your patients’ teeth. Composite resin materials can be shaped and molded to the teeth to give patients a straighter or whiter smile at a fraction of the cost of some other cosmetic procedures.

Trending article: Break out of your restorative rut

	Today’s composite resins can complete the following three cosmetic bonding procedures:

	Dr. Michael Miyasaki is a private practice dentist in Sacramento, California, who has been practicing since 1987. He says offering any of these three cosmetic treatments to your patients is an excellent way to leverage your existing patient base and grow your revenue. 

	Dr. Miyasaki credits the materials for their improvements. The procedures are easier for clinicians to do, and the cost is reasonable for most patients.

“There's just a lot of work that we don't offer our patients,” Dr. Miyasaki says. “We don't value it like a full-mouth restoration case, but the value to the patients for treatments like these is invaluable.”

	Dr. Miyasaki says you see it with kids who improve their smile. They feel more confident about how they look, so they smile more and their self-esteem goes up.

	Dr. Miyasaki describes a case where a patient had a brown stain on his teeth. Dr. Miyasaki removed the stain using Opalustre™ from Ultradent, which he describes as hydrochloric acid in a slurry-like pumice. After Dr. Miyasaki polished, the brown stain was gone, and the patient was thrilled and felt more confident.

	“There are simple things we can do that usually don't cost the patients a whole lot of money but can make a big impact in their lives,” he says.

More from the author: The vital concept you probably fogot about dentures

	Tips and tricks for cosmetic bonding procedures

	Dr. Ed Kusek, a private practice dentist in Sioux Falls, South Dakota, who has been practicing for more than 35 years,  describes these cosmetic composite treatments as simple to do, provided you have the correct composites. Because these three procedures are in the anterior, esthetics is paramount. He recommends using a microfill to give the restoration the proper luster.

	“Some of the hybrid composites may not have as nice of a polish to them, so you need to have a material that will allow you to get more esthetic results,” Dr. Kusek says.

	You also want the material to handle appropriately for your bonding treatment. For example, on diastema closures, Dr. Miyasaki suggests warming the composite with composite warmers from AdDent or Vista Dental Products so that it flows better and creates the right contour.

	Warming the material allows Dr. Miyasaki’s staff members to take their favorite regular, sculptable composites and inject them to create the shape of the tooth they want, almost like a flowable composite. He says warming also makes the composite more manageable and reduces the risk of voids or getting air incorporated into the material.

	“The composite has better physical properties where we can shape it and then polish it. It turns out really nice,” Dr. Miyasaki says, adding that he warms the composite for his posterior restorations as well as the anterior ones.

Related reading: Why dentists should take a fresh new look at restorative materials

	Dr. Miyasaki also recommends using air abrasion to roughen the surface of the tooth to aid in bonding the material. He uses an air abrasion unit from Danville Materials. He says the air abrasion helps the chameleon effect, or the ability of the tooth to blend in with the surrounding teeth, making the restoration less noticeable.

	“When I do air abrasion, that gives me a better etch pattern and it helps the composite stick to the teeth better, so we get a better bond,” Dr. Miyasaki says.

	For diastema closings, Dr. Miyasaki uses Bioclear matrices to help shape the composite. He says when used with warmed composite, the forms help him to create a beautiful shape.

 by Ultadent, a direct composite template system that helps create direct composite veneers on the facial aspect of the tooth. He says the Uveneer process is fast, which means the clinician can make it affordable for the patient. First, you etch the tooth and fill the Uveneer form with composite. Then, you press that up against the facial of the tooth.

	“They are clear forms, so we can cure the composite through that form. When you peel the form off, it has the whole facial veneer all done for you,” Dr. Miyasaki says. 

	Dr. Kusek agrees that manufacturers provide excellent shortcuts that can further simplify these bonding procedures. He also likes the forms for diastema closings.

	“They are like little shields, and you can just change the shape of the composite very quickly,” Dr. Kusek says.

	Experience can help clinicians feel more confident suggesting these treatments to patients. Dr. Miyasaki encourages dentists with less experience working with composite in these ways to attend a course about it. In many cases, the course might be only a couple of hours, but it will save a dentist a lot of time in the long run.

	“Once you see somebody do it and explain to you why they're doing it and what they're doing, it's a lot easier than going through all the trials and failures of trying to do it on your own,” Dr. Miyasaki says.

	With stain removal or chip repair, Dr. Miyasaki reminds clinicians to ask if the patient is considering whitening his or her teeth.  He learned that patients who have a cosmetic bonding treatment in the anterior are so happy with the improvement that they often want to whiten their smiles afterward.

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	However, whitening after the treatment could mean the composite material used for the bonding treatment might not match the newly whitened teeth. Dr. Miyasaki wants patients considering both treatments to whiten first instead.

	“We're not trying to sell whitening, but we do want to make sure that they understand that they have that option to do it now,” Dr. Miyasaki says.  “If we do it after, then there will be an additional cost to the patient, which we don't want to have.”

	With stains, Dr. Kusek recommends taking out the stain and then putting an enamel stain over the top to make it more lifelike. When it comes to more involved cosmetic bonding procedures, he recommends using your lab to help you work efficiently and effectively.

	“Some of the bigger things, like closing a diastema, I will always get a lab wax set up. Then, I have a putty stent, so I can use that stent to do my wax up. It makes things much easier and quicker for me to do,” Dr. Kusek explains.

	No matter which cosmetic bonding treatment the patient is considering, Dr. Kusek says he always sets patient expectations before he proceeds. He advises clinicians to have the patient approve the treatment plan and anticipated outcome.

	“We don't want to have their expectations so high that what we're trying to do won't match them or won’t work for them. We want to be at the same level as what the patient's expectations are,” Dr. Kusek says.

	On the other hand, sometimes patients don’t know what to expect-and that can create some storybook outcomes. Dr. Miyasaki had a patient in her early 20s with peg laterals that he closed up for her. He told the patient that her life was going to change because she would smile more, she would appear happier and other people would be friendlier toward her. She didn’t believe him.

	However, when he saw her six months later, she was engaged.

	Dr. Miyasaki says he sees it all the time. Patients don’t understand what a difference fixing that minor cosmetic problem will affect how they feel about their smile. They also don’t always want to mention it to their dentist either because they don’t want to sound vain.

	“They don’t want to say, ‘I don't like this space’ or ‘I don't like the staining here,’” Dr. Miyasaki says. “However, there are such conservative treatments that we can offer our patients. Once we do that, I have seen a lot of patients’ lives change.”

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	It’s easy to do. Familiarity with a particular restorative material can cause complacency in the most diligent clinician.

	Why explore new materials when you already have this one that works well enough? Sure, the restorative you use might have its problems or limitations, but you’ve adapted to them, and you’re, well, comfortable.

	However, you’re also in a restorative rut.

	“When clinicians fall into a restorative rut, they’re most likely acting out of habit, which may not be profitable or efficient. They have become comfortable with their techniques after years and years of always doing it a certain way,” says Nikki Sparacino, MBA, global manager of restorative procedure solutions from Dentsply Sirona.

	“It’s easy to get into that restorative rut because you get in your comfort zone and you’re used to the way things work,” says Carla Cohn, DMD, a private practice general dentist limited to children in Winnipeg, Manitoba, Canada.

	Improved properties, enhanced outcomes        

	Restorative materials enjoy continuous development from manufacturers seeking to enhance their offerings while improving patient outcomes and benefiting a practice’s bottom line. From better mechanical properties to more natural-looking esthetics to simpler processes than the previous class of restoratives, new materials are changing dentistry at an unprecedented pace.

	However, for dentists who have tuned out all the press releases, marketing pushes and direct sales force presentations, restorative materials are performing (or not performing) like they always have.

“They may not be getting the quality from the cases that they do,” says Justin Chi, DDS, CDT, director of clinical technologies for Glidewell Laboratories.“They may be having problems and aren’t aware of it or accept it as normal for using that type of material. They may not be getting the longevity or the esthetics some of the newer materials can provide.”

	Dr. Cohn questions the logic of using materials a dentist isn’t 100 percent satisfied with-or maybe even unsatisfied with-when there’s such a large amount of new technology and advancements in dentistry today.

	“Why do we need to leave ourselves and our patients wanting more when all we need to be willing to do is try something new?” Dr. Cohn says.

	We spoke to several clinicians and experts in dental materials to uncover the challenges for clinicians who might have fallen in a restorative rut, what benefits are possible with new materials and which restoratives they’re excited about these days. Here’s what they had to say about breaking out of your restorative rut.

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	A significant drawback to staying in a restorative rut is missing out on the improvements to materials. Material improvement brings a practice new opportunities to deliver a higher level of patient care and esthetics. However, Sparacino thinks staying in the rut could affect the practice’s bottom line as well.

	“Materials continue to progress and with them come new techniques. By not adopting those techniques dentists are not realizing the efficiencies that come with them and potentially missing out on opportunities to make their practice more profitable,” Sparacino says.

	Jean Madden, science affairs manager for 3M™, understands why clinicians would be cautious about switching their composite. They want to be assured of excellent clinical outcomes both for their patients and their practice with no unnecessary risks.

	“We also understand that there are so many choices and so many different acronyms and marketing claims for direct composites that it can be intimidating and confusing to clinicians when researching new options,” Madden says.

	“Dentists may hesitate to try new procedures outside of their comfort zone or embrace the latest innovations in new materials and restorative practices,” adds Beth Collington, director, digital materials and laboratory equipment for Zahn Dental.

New materials are changing everything from inventory to esthetics.