issn 2193-1429 • Vol. 16 • Issue 1/2022 1/22 cosmetic dentistry beauty & science interview “Everyone has the power to become an innovator” case report New philosophies in ceramic layering user report Laser protocol for peri-implantitis treatment

editorial | Dr Sushil Koirala Editor-in-Chief MiCD knowledge philanthropy cosmetic dentistry has become one of the most pop- ular clinical cosmetic dentistry magazines in the world. This success has in large part been due to the high stan- dard of clinical articles submitted by the authors, the ar- ticle selection approach of the editorial team and the print quality. Because of this, we were able to offer free acces- sibility to the digital version of the magazine on Dental Tribune International’s (DTI’s) offi cial websites and those of partner academies, which was indeed a major step forward. I appreciate this knowledge-sharing initiative of DTI, which has facilitated my personal mission of promot- ing the knowledge philanthropy concept in the fi eld of dentistry. I vividly recall that, in the editorial I wrote for cosmetic dentistry 1/2009, I discussed the scope of the minimally invasive concept in cosmetic dentistry, and in issue 4/2009, I wrote a comprehensive article proposing the minimally invasive cosmetic dentistry (MiCD) concept and its treatment protocol. The MiCD concept, as we look back at it 13 years since its inception, has been widely recognised and very well received by global clini- cians. It is my pleasure to report that, thanks to the over- whelming acceptance of the MiCD concept and treat- ment protocol in aesthetic dentistry, we have expanded the clinical horizons of MiCD from cosmetic to com- prehensive dentistry. The encouraging responses, sug- gestions and requests from clinicians, researchers and academics around the world have led us to take MiCD Global Academy management from a privately gov- erned and exclusive sponsorship approach to a non- profi t and open sponsorship approach. From 1 June, this new philanthropic approach began under the philanthropic dental education wing of the Dental Community for Humanity division of the Punyaarjan Foundation in Kathmandu in Nepal to promote the MiCD mission as an independent and non-commercial initiative in dental education. With this, the MiCD Global Academy has morphed into the MiCD Knowledge Philanthropy Academy with the support of many knowledge philanthropists and open- minded dental companies. This has been done with the objective of serving the global dental profession and hu- manity through the science and technology of MiCD. To make MiCD knowledge and skills easy to understand and apply in daily practice, I have broadly divided the MiCD care and education system into four domains, namely MiCD lifestyle dentistry, MiCD functional healthy dentistry, MiCD cosmetic dentistry and MiCD practice management. MiCD care and education in all these do- mains are based on the premise of the MiCD concept that I proposed in 2009. Alongside the introduction of these domains, related free MiCD educational materials will be published in the upcoming MiCD clinical journals and DTI publications according to the need of and de- mand by readers. I hope that the global dental fraternity will greatly help us foster our initiative of MiCD knowledge philanthropy, and I urge all our readers to take the opportunity to be part of the MiCD global mission. I express my gratitude to our valued readers, esteemed authors, advertisers and everyone who has directly and indirectly supported cosmetic dentistry and thus helped bring the magazine to where it is now. I hope you will enjoy this issue of cosmetic dentistry, and I invite you to send your valuable feedback and ideas. Sincerely yours, Dr Sushil Koirala Editor-in-Chief cosmetic 1 2022 dentistry 03

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interview | “There has to be clear leadership and a desire to embrace sustainability in order to promote sustainable dentistry.” healthcare, with a focus on prevention, early diagnosis and management, using minimally invasive operative procedures and having the best long-term interests of patients at heart, while at the same time mitigating neg- ative impacts on the planet so that we do not undermine prospects for future generations. Using a minimal intervention approach to dentistry means that patients are less likely to enter the restorative downward spiral, thus reducing the need to provide resources such as dental restorative materials. You believe that great leaders should know not only why they are running a practice but also how they are running it. Could you elaborate on that? We know that greenhouse gases emitted by human activities cause climate change and that the effects of climate change, some of which are already apparent, pose a global health threat. Now, “to do no harm” is one of the pillars of medical ethics, yet globally, the health sector emits more carbon dioxide than Japan, which is currently ranked as the fi fth highest emitter of all countries. Given its mission to pro- tect and promote health, the health sector, including dentistry, has a responsibility to reduce its own climate footprint. This can only be accomplished by examining how we are providing services. Only by scrutinising how we operate can we consider the possibility of delivering the same service, but by employing an approach that has a lower environmental impact. Climate change will become an increasing concern for consumers, and the dental profession must take action to reduce the harm that healthcare is causing. To follow up on the previous question, what moti- vated you to found Green Dentistry, and how do you promote sustainable development in your business? I fi rst need to explain why I set up an eco-friendly dental practice. The catalyst came about when I was studying for my master’s degree in advanced minimum inter- vention dentistry. I was struck by the ecological plaque hypothesis. Inside a healthy mouth, there is a stable and healthy community of cells—microbial homeostasis— where a mutually benefi cial equilibrium exists between cosmetic 1 2022 dentistry 07 m o c . k c o t s r e t t u h S / a k s n i l y M a n y r I © Dr Raju, what does sustainability mean to you personally, and how would you defi ne sustainable dentistry? I’m continually amazed at the abundance of life that our planet has to offer, and it is something that future generations should have the opportunity to enjoy. To me, sustainability is about being a good custodian of the environment and ensuring the well-being of future generations. It’s about making decisions that reduce environmental impact. I’m deeply concerned about the fact that underprivileged children will suffer dispropor- tionately more in light of the consequences of un- checked climate change. As for sustainable dentistry, I would defi ne it by combining Gro Harlem Brundtland’s famous defi nition of sustain- ability with minimally invasive dentistry. Sustainable dentistry involves delivering optimal oral and dental

m o c . k c o t s r e t t u h S / a k T p o P © i interview | The fear of litigation is also a barrier to embracing sus- tainability. In the UK, Health Technical Memorandum 01-05: Decontamination in primary care dental practices has resulted in a signifi cant increase in the use of single- use plastics and increased costs for dental practices. Although aware of the importance of infection pre- vention, we seem to have tipped too far on the side of caution. If used appropriately and recycled when pos- sible, plastic is a valuable material. However, single- use plastics are now ubiquitous in the dental envi- ronment. It’s picking the low-hanging fruit that hopefully will spark a change in behaviour towards sustainable practice. What measures do you take outside of work to minimise your impact on the planet? We obtain our energy from a renewable energy provider at home, don’t eat meat (for ethical and environmental reasons) and buy organically grown food. Last year, we started growing our own vegetables fed with home- made fertiliser made from comfrey and nettles. We also compost. There is also a common perception that the changes necessary to achieve a more sustainable approach are expensive to implement. Yes, you can spend a great deal of money on capital expenditure by purchasing solar panels, ground source technology or heat pumps, but this isn’t the only way to achieve a more sustainable approach to delivering dentistry. For example, if a prac- tice wants to help reduce carbon dioxide emissions, it can simply switch to a renewable energy provider. As demand grows, renewable energy will increasingly be sourced for the grid, thus reducing the supply gen- erated from fossil fuels. We have a wild fl ower garden at the front of our house, which has never been mowed in order to help increase biodiversity. It looks a mess for a few months of the year, but it is delightful when the fl owers appear. We also recycle, of course, but more importantly, we’re not big consumers. If we buy goods, we try to buy sustainably sourced goods whenever possible. Editorial note: More information can be found online at www.greendentistry.co.uk. cosmetic cosmetic dentistry 09 1 2022 09

interview | Currently I am a partner at Mitra Chemical Consulting, an independent consulting firm, which I co-founded. “From a very early age Why did you decide to go into chemistry and how did you become concerned with dental materials? From a very early age I was fascinated by different mate- rials. I often wondered what makes one material different from another—things like why paper is different from wood, or why fabric is different from our skin. I learnt that the answer is in the molecules—it is chemistry that is the central science that defines materials. I was so awestruck by the subject that I made up my mind to study chemistry in depth. I would often visit my father in his laboratory and peer over his shoulders as he did his chemistry experi- ments. After I joined the 3M company, I got an opportu- nity to join its Dental Products Laboratory to develop new polymer matrices for dental composites. I jumped at that prospect and spent most of my career there, developing many new materials technologies, including the devel- opment of nanotechnology for use in dentistry. You have developed a nanocomposite restorative material (Filtek Supreme, 3M), that has already been used for more than 1 billion tooth restorations. How did you come up with the idea of using nano- technology? I was fascinated by different materials. I often wondered what makes one material different from another.” Until the late 1990s dentists wanting to perform natural- looking tooth repairs relied on a combination of two separate materials. Microfills were aesthetically pleasing but too weak to be used for stress-bearing regions of the incisal edges and for filling teeth in the posterior region of the mouth. Less attractive hybrid and microhybrid com- posites were stronger, but lost their shine and became rough from brushing and chewing. This was both incon- venient and expensive for dentists and their patients. So, we wanted to create one material that would not only be strong and durable but also have the long-lasting lustrous beauty of natural teeth. Fig. 2: Dr Mitra at the 3M Innovation Center in Minneapolis in Minnesota in the US. 2 cosmetic 1 2022 dentistry 11

interview | and can be used in all areas of the mouth—anterior, pos- terior, and on incisal or molar surfaces. It is highly aes- thetic and has the shine and opalescence of a natural tooth. It is extremely durable and withstands the forces of chewing and brushing without losing its shine for a long time. Dentists all over the world have expressed their enthusiasm and shared examples of their work, which is very gratifying. Your material has been patented. Aside from this product, do you hold any other patents for dental applications? I hold 100 US patents, 58 European patents and their corresponding equivalents in other countries. The major- ity of my patents are in the area of dental materials. You have been awarded and honoured many times, including being inducted into the US National Inven- tors Hall of Fame in 2018. Last year, you won the European Inventor Award 2021—in the category Non-European Patent Office countries. Congratulations! How meaningful are these awards to you? I feel greatly honoured to be recognised by organisations like the National Inventors Hall of Fame, the American Chemical Society and many others, including most re- cently the European Patent Office for this invention. It is quite humbling to be included in the same league as so many well-known inventors whose work has greatly ben- efited society. This type of recognition validates the im- portance of the scientific contributions of scientists and increases public awareness of the pivotal role that sci- ence and technology play for the advancement of soci- ety. Another important aspect is that the award creates role models for aspiring scientists who pursue careers in science, technology, engineering and mathematics (STEM)-related fields. Furthermore, awards like these give a voice to science and help in influencing greater funding for scientific research and policymaking. In your opinion, what are the essential characteris- tics that a person needs in order to start an inno- vation? Basically, it is a combination of curiosity, exploration and imagination. Of course, you need a scientific training, but above all, you have to try new ways of doing things— a way that is more convenient and or easier. The other thing is to have passion coupled with persistence. The first attempts may not be successful, but failures should never discourage us. They only show us that there is another path- way toward achieving a goal. How do you inspire young people and what would you tell the next generation of potential inno- vators? After my retirement, I have spent many hours volunteering and teach- ing at a number of local organisa- tions, encouraging STEM education at all levels, primary school to post- graduate. It is a way for me to give back to society for all the oppor- tunities I have had. Everyone has the power to become an innovator. The important thing is to understand that a solid foun- dation in STEM-related fields gives young people the toolset to un- leash their creativity and design better approaches to improving the well-being of society. I always tell young people, “Believe in yourself, seek help when needed, and never give up.” Fig. 4: Dr Mitra loves art and enjoys painting with watercolours in her free time. 4 cosmetic 1 2022 dentistry 13

technique | calcium found in hydroxyapatite. The MDP–Ca salt formed provides the basis for a stable, strong and durable hybrid layer. In combination with the resin in the bonding agent, a tight seal of the cavity after light- polymerisation is the result. To date, MDP is still an es- sential component of any adhesive product from Kuraray Noritake Dental, and it is the key component that made CLEARFIL SE BOND the gold standard self-etching adhesive system. However, convinced that dental adhesives should provide for more than a strong and long-lasting bond, Kuraray Noritake Dental started to focus on solving an- other issue: the risk of demineralisation and cavitation caused by bacteria remaining in the cavity. Based on its experience in developing other adhesive monomers, Kuraray Noritake Dental invented the MDPB mono- mer, which has an antibacterial cavity-cleansing effect. Different from antibacterial agents that might impair the bond strength of a subsequently applied adhesive, the MDPB monomer kills remaining bacteria without affecting the bonding performance. It is contained in the primer of the two-bottle self-etching adhesive CLEARFIL SE Protect and is immobilised by poly- merisation (Fig. 1). While two-bottle self-etching adhesives have already simplifi ed the adhesive procedure, single-bottle universal adhesives go the extra mile. It is a challenge to bring together components distributed in multistep systems in one bottle without compromising the stability of the product. Current technology now makes this possible. To seal the surface as soon as possible after application, the penetration of the monomers into the dental tissue must be fast and effi cient. However, the penetration is usually slowed down by monomers that need time to penetrate the tooth struc- ture—especially wet dentine—and sometimes even need to be rubbed into it. That is why Kuraray Noritake Dental focused on developing the rapid bond technol- ogy. It utilises the original MDP monomer combined with newly developed hydrophilic cross-linking amide monomers and is integrated in CLEARFIL Universal Bond Quick. The hydrophilic amide monomers pro- vide for rapid, deep and complete penetration of the dentine and form upon polymerisation a densely cross-linked polymer network responsible for a strong and durable bond. Hence, waiting and rubbing times are eliminated, and a tight and long-lasting seal of the cavity is established after light-polymerising (Figs. 2a & b). Because of their hydrophilicity (water affi nity), these amide monomers penetrate dentine very well. After light- polymerising, the bond exhibits low water absorption and therefore high ageing resistance. 2a 2b Fig. 2a: Prepared dentine with smear layer. Because of its hydrophilic- ity, very hydrophilic bonding is needed in order to be able to optimally penetrate the dentine. Fig. 2b: Dentine bonded with CLEARFIL Universal Bond Quick. During polymerisation, CLEARFIL Universal Bond Quick creates a highly cross-linked polymer network. As a result of this network, the bonding has very low water absorption, which produces a long-lasting restoration. Optimising direct restorative materials Combining multiple layers, shades and opacities—the use of highly complex layering techniques for the cre- ation of lifelike composite restorations is luckily a thing of the past in many clinical situations. The reason for this is highly developed resin composites that blend seam- lessly with the adjacent tooth structure. To provide for this favourable feature, Kuraray Noritake Dental devel- oped its proprietary light diffusion technology. The tech- nology is incorporated in special prepolymerised fi llers that act like millions of microprisms that transmit and refract light and colour from the surrounding tooth structure. Optimised in size, distribution and refractive index in relation to the matrix, the fi llers offer unsur- passed natural blending. The whole CLEARFIL MAJESTY composite line-up employs this proprietary fi ller technology. Its latest product—CLEARFIL MAJESTY ES-2 Universal—in which Kuraray Noritake Dental uses next-level light diffusion technology, allows for a single-shade tech- nique with simplifi ed shade selection (Fig. 3). It is 3 Fig. 3: Refracting and transmitting light for great optical integration: light diffusion fi llers of CLEARFIL MAJESTY ES-2 Universal. cosmetic 1 2022 dentistry 15

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case report | 4 6 5 7 Fig. 4: Build-up of the proximal wall with CLEARFIL MAJESTY ES-2 Universal (Shade U). Fig. 5: A thin layer of flowable composite (CLEARFIL MAJESTY ES FLOW High) applied to the cavity floor. Fig. 6: Restoration completed with CLEARFIL MAJESTY ES-2 Universal (Shade U). Fig. 7: Treatment outcome immediately after removal of the dental dam. mal wall with CLEARFIL MAJESTY ES-2 Universal (Shade U) was then done, after selective enamel etching with phosphoric acid (K-ETCHANT Syringe, Kuraray Noritake Dental) and bonding with CLEARFIL SE BOND (Fig. 4). After that, a thin layer of flowable composite (CLEARFIL MAJESTY ES Flow High) was applied to the cavity floor to act as a resin coat (Fig. 5). Restoration was completed with CLEARFIL MAJESTY ES-2 Universal (Shade U). Although this composite blends in very well with the surrounding tooth structure, the natural look was finished off by adding a tiny bit of brown tint to the fissure (Fig. 6). The restoration and soft tissue looked natural and healthy immediately after removal of the dental dam. The proxi- mal contact was tight, and the occlusal anatomy well shaped for the patient’s individual masticatory dynamics. The margin of the restoration was virtually invisible, but the buccal cusp appeared lighter because of dehydration of the natural tooth structure (Fig. 7). The final treatment outcome was very satisfying (Fig. 8). Conclusion The case presented demonstrates that the selected composite is well suited for simplified restorative proce- dures in the posterior region. The material handles well, offers the same mechanical properties as other materials from the CLEARFIL MAJESTY ES-2 series and blends in harmoniously with the surrounding structures without being too translucent. This way, it is possible to waive the 8 Fig. 8: Final situation. shade taking process without compromising the treat- ment outcome. The time saved in this context may be spent on functional aspects—or even on another patient. about Dr Nicola Scotti is an associate professor at the Department of Surgical Sciences at the University of Turin’s dental school in Italy. His main interests are dental biomaterials, resin-based composites, CAD/CAM materials and adhesive dentistry. cosmetic 1 2022 dentistry 19

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case report | Dentine differs from enamel in that it contains organic material and liquid within the dentinal tubules. In addition, the density of the dentine varies with depth. The water content of the dentine is lower in the superficial dentine and higher in the deep dentine.2 Bonding to these sur- faces is challenging. Adhesives are composed of both hydrophilic and hydrophobic monomers. The main difference between hydrophilic and hydrophobic adhesives is the chemical composition of their monomers and solvents. The most commonly used monomers in adhesive systems are hydroxyethylmethacrylate (HEMA) and bisphenol A-diglycidylether methacrylate. HEMA converts the ad- hesive to a more hydrophilic system by absorbing water from the dentine or the oral environment,3 consequently causing more discoloration at the margins of the restoration. “On enamel, the best adhesion is still obtained by first creating a micro-retentive pattern by means of acid etching.” is present in both components. Even though the primer contains photoinitiator, it is not meant to be polymerised separately. The function of the photoinitiator is to ensure that the infiltrated resin can efficiently polymerise in all areas, including the deeper parts of the hybrid layer. The bonding protocol Any adhesive system that emerged during the past decades falls into one of two categories, based on its application: etch-and-rinse adhesives and self-etching adhesives. Universal adhesives have recently been intro- duced, and they are distinguished by their multi-mode application. On enamel, the best adhesion is still obtained by first creating a micro-retentive pattern by means of acid etching. The benefits of acid etching on dentine are more am- biguous. Two cases are discussed here in which different etching modes were chosen for specific reasons. G2-BOND Universal (GC) is probably the best option when efficiency is desired without sacrificing bond lon- gevity (Fig. 2). Based on thorough research, it contains all elements that are needed for an optimal adhesive perfor- mance.4 The primer (1-PRIMER) allows it to be used as a total-etching adhesive or a self-etching adhesive system. 1-PRIMER contains MDP, providing enhanced chemical bonding to the tooth structure and indirect substrates such as zirconia and non-precious metals. Two additional functional monomers, 4-MET and MDTP, further ensure bonding to the tooth and precious metals, respectively. Unlike other adhesives, 2-BOND is hydrophobic and free of HEMA and MDP, what makes it very resistant to hydro- lytic degradation and staining. However, a photoinitiator First clinical case: Total-etching mode (Figs. 3–11) In this first case, the preparation of the cavity was rather shallow, and all margins were located in enamel. In such circumstances, it is important that a tight seal is obtained on the enamel margins, especially on the approximal sur- face which is most prone to recurrent caries. Therefore, a total-etching approach was chosen in this situation. Second clinical case: Selective-etching mode (Figs. 12–22) When a considerable amount of dentine is present in the cavity and especially on its margins, it is important that the adhesion to dentine is durable and prone to water degradation. Rigorous etching would expose the wet 12 13 Fig. 12—Case 2: Initial situation, showing a supra-crestal external resorption at the central incisor. The tooth was still vital, giving the option of a direct restoration after raising a flap. Fig. 13: The cavity and the soft tissue were visible after the gingival flap had been raised, making it easy to clean the area and place a dental dam. cosmetic 1 2022 dentistry 23

case report | about collagen in its protective mineral envelope. Moreover, etching dentine that is close to the pulp might cause irritation and inflammation of the latter. For these reasons, a selective-etching approach seems safer in such cases. Here, the enamel was etched at the incisal cavity margin to optimise micromechanical interlocking and to avoid discoloration, whereas on the cervical margin, the den- tine was bonded after a self-etching approach. Conclusion Dr Dimitrios Spagopoulos graduated from the School of Dentistry of the University of Athens in Greece in 2012 and the next year completed an MSc in aesthetic and restorative dentistry at the same university. Since 2012, he has been a clinical instructor at the dental school. Since 2015, he has practised G2-BOND Universal ensures a strong, durable bond and is versatile in its use. As a consequence, dentists can reduce their armamentarium and do not need to remem- ber the different protocols that need to be used for differ- ent adhesives, yet can still count on maximal bonding performance. It is a valuable asset for any dentist un- willing to accept a trade-off. Editorial note: A list of references is available from the publisher. at the Periocare Goumenos dental clinic in Athens, where he exclusively focuses on aesthetic dentistry, prosthodontics, restorative dentistry and implants. He also practises in these fields in his own private clinic. Dr Spagopoulos is part of the editorial team of the dentorama and dental journal magazines (Omnipress) and is a member of the European Academy of Esthetic Dentistry and the European Association for Osseointegration. He is a key opinion leader for Hu-Friedy. SIGN UP NOW Dental Tribune e-newsletter AD International Newsletter – 16 September 2021 16 September 2021 Europe Newsletter – 2 June 2021 The world's dental e-newsletter news / live event coverage / online education / KOL interviews / event reviews / product launches / R&D advancements www.dental-tribune.com facebook.com/DentalTribuneInt twitter.com/DentalTribuneIn linkedin.com/company/dental-tribune-international cosmetic 1 2022 dentistry 25

case report | 2b The treatment plan consisted of an initial prophy- lactic phase, including oral hygiene instructions, and extraction of tooth #21, and all necessary actions would be taken to stabilise periodontal health. Once stabilised, a second phase would be carried out, in which orthodontic aligners would be used to cor- rect the midline shift and to redistribute the spaces for placing an implant at the locus of tooth #21 (Figs. 2a & b). “With the right materials, colour deepness and natural translucency can be obtained within a space of about 0.2–0.6 mm.” The last phase would consist of the prosthetic rehabili- tation of the maxillary anterior teeth with veneers on teeth #13 and 23, a cantilever bridge from tooth #12 to a pontic in the locus of tooth #22 (Figs. 3a & b). In such a case as this one that combines teeth and implants in the anterior region, it is important to select the most suitable restorative material in terms of strength and aesthetics and to carefully consider the restora- tive design, obtaining the maximum implant integration and efficiency. Surgical intervention After orthodontic treatment with aligners, the marked bone defect caused by a long-evolving infection at the locus of tooth #21 was regenerated. For this inter- vention, autologous bone was chosen for the guided bone regeneration, being considered the gold stan- dard. The split bone block technique, initially described by Khoury and Hanser, was used.1 This technique 3a 3b Figs. 3a & b: Digital planning of the prosthetic restoration. Frontal view (a). Left lateral view (b). cosmetic 1 2022 dentistry 29

case report | 7 Fig. 7: Digital design of the restoration framework in zirconia. structure, a combination of SPS-13 (Twilight) and SPS-16 (Midnight) was used. Next, the incisal halo was accentuated using a mixture of SPS-1 (Ivory White) and SPS-2 (Melon Yellow). Mesial and distal of the incisal edge, L-A (Body A) mixed with either SPS-2 or SPS-4 (Light Terracotta) was applied alternately for bright contrast and saturation, respectively. Further mesially and distally up to the cer- vical margin, L-6 (Dark Blue) was used. In the middle and cervical thirds, L-B (Body B) was used to give the zirconia framework a bit more saturation. Here, SPS-13 was used on either side of the centro-facial lobe to further accentuate the developmental depressions towards the cervical aspect. Layering: Form and texture Once the Lustre Pastes have been fired in the furnace, all colours are fixed in place and serve as a connection layer. Depending on the chosen shade, this can be done in multiple firings. After the internal characterisa- tion, a texturising ceramic material (GC Initial IQ SQIN) that was introduced together with Lustre Pastes and Spectrum Stains as a new innovative concept was used to add shape, texture and gloss. A great advantage of this concept is that the same ceramic can serve for dif- ferent restorative materials, such as zirconia and lithium disilicate. The area of the mamelons was layered with Translu- cent TO (Opal Booster) combined with the enamels E-57 to E-59. Translucent TO was also used for the line angles of the teeth. Since the zirconia was pre- “A great difference can be seen in comparison with the older paints and stains, there being much more luminosity and incredible fluorescence.” 8 Fig. 8: Fluorescence of the GC Initial IQ Lustre Pastes ONE. cosmetic 1 2022 dentistry 31

case report | coloured in the base colour, there was no need to add dentine ceramic; only a thin enamel layer was applied (Figs. 9a–10). The SQIN ceramics are much easier to handle than conventional ceramics, as the feeling on the brush is very consistent. Owing to the Form & Texture liquid, it remains on any surface on which it is placed, and compared with other ceramics, there is virtually no shrinkage. In the case of zirconia, the restoration is fired at a temperature of approximately 760 °C, depending on the furnace. In the final phase, lithium disilicate veneers were made on the canines, combining the Lustre Pastes with the Spectrum Stains (Figs. 11a & b). 16a The great advantage of the micro-buccal layering is that adding texture is much easier than on full-body lithium disilicate or zirconia, which is more difficult to manipulate because of its extreme hardness, even though SQIN is denser than conventional veneering ceramics. It allows control of the luminosity and the fluorescence, creating a noticeable difference in black light or fluorescent light after the surface has been finished, making it resemble the natural tooth (Figs. 12–15). Gingiva The SQIN gingival shades enable the use of ceramics for atrophied jaw restorations for which pink aesthetics are needed. Combined with the Lustre Pastes gingival shades, the main colour is intensified first (Fig. 16a). This system enables micro-layering with the same philosophy as for the white aesthetics with different shades of colour, adding subtle contrasts by employing differently shaded masses and adding details to the surface (Fig. 16b), such as an orange peel effect (Fig. 16c). Conclusion The Lustre Pastes characterisation serving as a con- nection layer, the SQIN ceramics refining the form and texture, and the Spectrum Stains enabling infinite shade variations, only a minimal cutback on the vestib- ular part is needed to control the texture, fluorescence and transillumination in order to mimic natural teeth. Following the same concept for pink aesthetics by employing the gingival shades provides a complete layering concept. Reference 1. Khoury F, Hanser T. Three-dimensional vertical alveolar ridge augmen- tation in the posterior maxilla: a 10-year clinical study. Int J Oral Maxillofac Implants. 2019 Mar–Apr;34(2):471–480. doi: 10.11607/jomi.6869. 16b 16c Figs. 16a–c: Adding colour to the gingival area with GC Initial IQ Lustre Pastes NF GUM shades (a). Adding texture with the GC Initial IQ SQIN GUM shades (b). The finished gingival area showed a desirable orange peel effect (c). about Joaquín García Arranz (Quini) is the founder of the Ortodentis dental laboratory in Madrid in Spain, director of the Dental Training Center in Madrid by Quini and founding partner of the Fresdental fabrication centre in Alicante in Spain. He lectures in the master’s degree programme in implants at the European University of Madrid and in the master’s degree programme in prosthetics for dental technicians at Vericat Formación’s training centre in Madrid. He is an opinion leader for GC Iberica. Dr Ramón Asensio Acevedo holds a DDS from the Alfonso X el Sabio University in Madrid in Spain and a master’s degree in aesthetic and restorative dentistry and a master’s degree in interdisciplinary aesthetic rehabilitation, both from the Universitat Internacional de Catalunya in Barcelona in Spain. He is in private practice in Madrid, Barcelona and Toledo in Spain and an assistant professor in the aesthetic dentistry, endodontics and restorative dentistry department at the Universitat Internacional de Catalunya. cosmetic 1 2022 dentistry 33

case report | 1 2 Fig. 1: Initial situation, panoramic radiograph. Fig. 2: Initial situation, clinical photograph. sible, given the fact that she already had too much space between her teeth. The loss of these two primary molars would disrupt the relationship between the rest of her teeth and, in the end, impact her entire occlusion. I took on the task of resolving this case as a personal challenge. Because the permanent adult teeth were missing, we could not afford to lose the primary second molars. I did not know how this case would end up, so I started by taking it one step at a time. In the beginning, I treated the root canals of the two damaged and in- fected teeth with antibiotics and anti-inflammatory med- ication. After ten days, I filled the root canals of both teeth using the standard procedure for permanent teeth. On tooth #75, I also encountered a furcal perforation, and although it was very difficult to stop the haemorrhage, we man- aged eventually to place mineral trioxide aggregate on the perforation. We filled tooth #75 with EQUIA (GC) and tooth #85 with GRADIA DIRECT (GC). Two weeks later, while I was treating the rest of Patricia’s teeth, I saw through the enamel that tooth #75 had begun to turn black underneath the EQUIA filling. Also, tooth #85, owing to the extensive filling and the small amount of healthy dental structure remaining after removing the carious tissue, had begun to exhibit fissure lines. It was just a matter of time until that tooth would break, requiring an extraction, in spite of all the hard work done to save it. This was not a scenario I was willing to accept. At that point, I knew I had to come up with an alternative idea in order to help retain the primary second molars, and I had to do it fast. to be extremely strong, able to withstand all occlusal forces over a lifetime. At the time, we only had stainless- steel crowns available in our clinic, but they would not be an option. I refused to believe that I had reached the end of the road, so I began doing some research to find out what aesthetic paediatric options were available. I discovered that such a restorative option with all the characteristics that I had been hoping for did in fact exist. EZCrowns (Sprig Oral Health Technologies) would satisfy both the needs of my patient and the desires of her par- ents. Usually, when you diagnose a young patient with “I was impressed by the fact that both crowns looked so natural that you could barely notice any difference between the zirconia crowns and natural teeth.” hypodontia and talk to the parents about it, they perceive the diagnosis as a handicap, or they feel ashamed for having done something wrong that led to the situation. Now, however, it was such a joy and a relief to be able to share the option of using zirconia crowns when faced with such a difficult circumstance. I knew I had to reinforce these damaged molars if we wanted to keep them, but what I most wanted for Patricia was an aesthetic solution for her situation that would prove durable over time, because these primary molars would never be replaced by permanent teeth. In addi- tion to being aesthetic, the ideal restoration would need After assessing Patricia’s situation, I shared the good news of my discovery with her parents and proposed using EZCrowns. They were excited about the fact that the crowns had the same colour as natural teeth and gave me permission to proceed. I told Patricia that she cosmetic 1 2022 dentistry 35

case report | 7 Fig. 7: Five-year follow-up panoramic radiograph. a recent follow-up examination (Fig. 7), I can confirm that the final results continue to look amazing, despite the rough start. Patricia, who is almost 12 years old now, is no longer shy, and I can tell by the brightness of her smile that she is full of confidence. Since her initial visit, she has developed into a young girl with abundant enthusiasm and is not the timid child who first stepped into our office (Fig. 8). As the pièce de resistance of the treatment, the EZCrowns have literally demonstrated their quality. Although both primary second molars were treated endodontically as if they were permanent teeth and the mesial root of tooth #85 shows evidence of resorption, Patricia has ex- perienced no clinical symptoms. The contour of the gingival margin is still placed at a phys- iologically appropriate height. Compared with Patricia’s natural teeth, there are only insignificant signs of gingival inflammation, likely due to her still superficial personal dental hygiene habits. One of my greatest concerns when I initially placed Patricia’s zirconia crowns was how they would hold up over the long term. Would they be abrasive and damage the opposing natural teeth? Although zirconia crowns are glazed and smoothly polished, they still have a harder surface than natural teeth do. However, to my surprise, every time Patricia arrived for a clinical examination, I was unable to observe any notable pathological sign of dental abrasion on her opposing teeth. Today, Patricia has no difficulties with her mastication or occlusion. Furthermore, and most importantly, she enjoys the amazing aesthetics of a beautiful smile. She has excellent oral health, and when I talk to her, I sense her feeling of well-being at having a beautifully restored smile. Although both molars had a guarded prognosis, five years later, we are still pleased with the results of her zirconia restorations. 8 Fig. 8: Happy patient with her dentist. about Dr Ana Vînău received her dental degree from the “Victor Babeș” University of Medicine and Pharmacy in Timișoara in Romania and holds a master’s degree in periodontics. She is also currently studying for another master’s degree in orthodontics. She works as a paediatric dentist at the DENT ESTET 4 KIDS clinic in Timișoara. cosmetic 1 2022 dentistry 37

user report | In your opinion, what are the main benefi ts of choos- ing a laser system that includes two complementary wavelengths, such as Er:YAG and Nd:YAG, especially in the fi eld of oral surgery? Very often, we combine these two wavelengths to conduct treatment in a fast, safe and predictable way. For me, it’s crucial to use these two complementary wavelengths— the interaction between the tissue and laser beam is quite different, and owing to these differences in absorption, transmission and scattering, we obtain different actions. For example, during root apicectomy, after fl ap elevation, I remove granulation soft tissue with the Er:YAG laser using the H14 handpiece with a cylindrical tip (or when I want to be more precise—a Varian tip) and the apicectomy is done with the H02 non-contact handpiece. As the next step, I conduct deep disinfection with the Nd:YAG laser (trans- mission in hydroxyapatite and absorption in pigmented bacteria) before bone augmentation. Finally, I fi nish the treatment with photo-biomodulation using the Nd:YAG laser. As you can see from this example, I need both of these two complementary wavelengths to achieve fi nal success with fast healing and proper bone regeneration. One of your main fi elds of specialisation is implan- tology. Where does the laser fi t in this fi eld? We can use LightWalker for all implantology cases. Some- times, it’s only needed for better and faster wound healing (photo-biomodulation with the Nd:YAG laser), but very often it is necessary to conduct the treatment. For me, it’s the most important device during immediate implantation with immediate loading, especially when the bone must be very precisely cleaned of granulation soft tissue and disinfected. In the meantime, we can also provoke bleeding of the bone using the Er:YAG laser for superfi cial bone ablation. I also really appreciate the use of laser during bone grafting with the Khoury method. Sometimes, I combine this technique with immediate implantation, especially in the aesthetic zone. Then, after bone shield fi xation, I can use the laser for bone recontouring. With the Er:YAG laser, it’s done very precisely—I remove sharp edges and create an emergence profi le for the crown—and most importantly, everything is safe for the shield (almost no vibration, so we don’t lose stability) and the implant (no thermal effect). Of course, we can also use the Er:YAG laser for more common and “easy” procedures—like implant uncovering (Er:YAG). The healing is faster and we avoid suturing, but of course, even with the thin chisel tip, some amount of soft tissue is vapourised—so it cannot be conducted in all cases. In 2018, you defended your master’s thesis at RWTH Aachen University titled Comparison of Two Methods of Periimplantitis Treatment with the Use of Nd:YAG and Er:YAG Laser. Can you tell us more about that research? Owing to the increasing number of implants being placed, the development of peri-implantitis is a growing concern and one of the primary challenges in present-day dentistry. In cases of infl ammation, it is necessary to implement treatment, or risk implant loss. However, until now, no uniform protocol or procedure has been defi ned which could be considered the best and the most effective solution. Different methods of treatment of tissue infl am- mation around the implant are used, depending on the extent of infl ammation, method availability, type of defect, and skills and experience of the dental surgeon. We know that laser can be used for the treatment of infl ammation in soft and hard tissue around implants, such as mucositis and peri-implantitis. I wanted to inves- tigate what kind of procedure would be the most effective and minimally invasive—so the question was whether we could use a minimally invasive, fl apless procedure for proper treatment and solve the problem of infl ammation. “I really appreciate the deep disinfection with Nd:YAG, which offers the highest bacterial reduction [...]” The procedures were conducted with Er:YAG and Nd:YAG lasers. In the fi rst group of patients, a mucoperiosteal fl ap was elevated in order to gain better access to the operative area, while the second group of patients was treated using a more minimally invasive procedure without the fl ap method. The assessment of treatment effectiveness involved clinical and radiographic examination before the surgical procedures and three months after the laser procedures. After conduct- ing the intra-oral examination and defi ning plaque, probing depth and bleeding on probing indices, photographic doc- umentation of a given area was performed, bitewing and occlusal surface radiographs were taken, and professional scaling and root planing were subsequently carried out. Based on my research, we know that non-surgical treatment of peri-implantitis is effective and very often reduces infl amma- tion. Of course, when we have severe defects, it’s impossible to avoid a surgical procedure to elevate a fl ap to get proper access to the defect. In such cases too, we should use a non- surgical procedure as a fi rst step to decrease the infl ammation and, after two to three weeks, perform the fl ap procedure. Can you describe your standard laser protocol for peri-implantitis treatment? Firstly, we have to distinguish mucositis from peri-implantitis with a radiovisiograph and with the use of a periodontal probe. If possible, I remove the prosthetic restoration to get better access for the treatment. In our surgical protocol, we have fi ve steps: (1) removal of granulation tissue with the use of the Er:YAG laser (cylindrical tip); (2) decontamination m o c . k c o t s r e t t u h S / c e V n a A © l cosmetic 1 2022 dentistry 39

user report | 14 19 13 15 16 17 18 20 Fig. 13: Initial situation. Visible fistula one year after loading. Fig. 14: Bone defect of 9.27 mm in diameter. Fig. 15: Flap elevation. Fig. 16: Granulation tissue removal with Er:YAG. Fig. 17: Implant resection. Fig. 18: CBCT scan on the day of surgery. No bone augmentation. Fig. 19: CBCT scan 1.5 years post-op. Visible bone regeneration. Fig. 20: Situation 1.5 years post-op. No sign of inflammation. for both patients and practitioners. We can use a minimally invasive, non-surgical treatment, which very often is highly effective, and thus avoid a surgical procedure. However, it’s very important that we use our lasers with proper pa- rameters to protect the soft and hard tissue and not alter the implant surface. We can thoroughly remove bacterial biofilm from the implant surface without altering it, and we have the possibility of re-osseointegration. Of course, we have to be aware of risk factors and aim to avoid them, understand what the reason for the disease was and solve the underlying problem. Sometimes, it’s only improper oral hygiene, while other times, we must change or correct the restoration. Each case is individually treated. Could you share with us some of your more chal- lenging cases of peri-implantitis and explain how the treatment was performed? Case 1 was a patient who presented with deep pockets (9 mm), bleeding on probing and visible purulent effusion (Figs. 1–7) and was treated with a non-surgical protocol. In Case 2, the patient preferred a surgical procedure with bone augmentation, as a consequence of bone graft complication and graft exposure (Figs. 8–12). The implant apicectomy in Case 3 shows that one year after the immediate implantation with immediate loading there was inflammation around the implant apex. The rest was properly integrated (Figs. 13–20). What advice would you give to your dental colleagues who may be considering whether to incorporate laser technology into their practice? I can only advise them to use laser; there is no reason to hesitate. Laser technology really changes dental practice. Laser use provides new possibilities, new treatment protocols and many advantages in dental procedures. Our treatments are more comfortable, less painful (some- times even painless) and very often less invasive and more predictable. We have a great advantage of selective tissue removal based on the chosen laser wavelength and settings. Last but not least, it is better for our mar- keting, and patients now expect newer technologies. Editorial note: A shortened version of this interview was published in implants—international magazine of oral implantology, vol. 23, issue 1/2022. cosmetic 1 2022 dentistry 41

4 user report | Fig. 4: The five shades of Beautifil II Gingiva. (Image: © SHOFU) In situations where there is moderate recession, the visual imbalance is even further impaired. The impact of the cer- vico-incisal–mesiodistal ratio is even greater on maxillary lateral incisors and mandibular incisors (average of 9 mm cervico-incisally). Maxillary and mandibular canines (aver- age of 10–11 mm cervico-incisally) are often the teeth most affected by gingival recession and are highly visible, both anteriorly and laterally. Individuals who have gingival recession, abfraction and/or caries tend to look older than they really are (long in the tooth). Covering the darker root dentine with an enamel-like resin simply makes their teeth more visible, seemingly longer, and correspondingly less aesthetic. The practitioner must solve this problem practically, aes- thetically and with minimum invasiveness. The restoration must be functional, replacing missing dental structures to natural dimensions and contours. The restoration should replace lost enamel with enamel-shaded composite resin and receded gingiva with gingiva-shaded composite resin. By creating an artificial enamel–gingiva junction in com- posite restorative material, the patient’s aesthetics and smile can be restored. Solving the gingival aesthetic dilemma Beautifil II Gingiva (SHOFU) has been specifically designed for the rebalancing of pink aesthetics in the cervical areas of the dentition (Fig. 3). It is indicated for wedge-shaped defects, cervical caries, the aesthetic rectification of gingival reces- sion, shielding exposed cervical areas and splinting of mobile teeth. The resin material is available in five tones (Dark Pink, Light Pink, Brown, Orange and Violet; Fig. 4), which can be layered and/or blended to achieve custom shades that allow the treatment of patients with various hues of gin- gival pigmentation, according to their clinical needs (Fig. 5). Beautifil II is a highly aesthetic, fluoride-releasing composite resin material indicated for all classes of restorations. Numer- ous studies over the past 20 years have shown no secondary caries, no failures, no postoperative sensitivity and a high re- tention of both shade matching and surface lustre. The material is based on SHOFU’s proprietary giomer technology. The sig- nificant advantage of the giomer class of resins is not only that they release fluoride to protect the tooth at the restorative margin, but that their fluoride content can be recharged by tooth- pastes, fluoride rinses and varnishes (Fig. 6). Thus, a giomer’s fluoride-releasing capacity does not decrease over time. 5 6 Fig. 5: Mixing chart showing the resins layered and/or blended to achieve custom gingival shades (1:1 mixing ratio). (Image: © SHOFU) Fig. 6: Fluoride release and recharge from giomers. cosmetic 1 2022 dentistry 43

user report | restoration and the free gingival margin (Fig. 9). This space prevents gingival irritation, is easily maintainable by the patient and is generally not visible even with close-up photographs. Mandibular anterior recession This is the most commonly encountered recession in the oral cavity. The mandibular anterior teeth are small, close together and not effectively cleaned at the tongue and the lower lip (Fig. 10). Owing to gravity, food debris and plaque tend to accumulate labially and interproximally (Fig. 11). In this case, the major culprit of the recession was the frenum pulling the attached gingiva apically. The preliminary pro- cess is a diode laser frenectomy to eliminate the muscular forces.21–23 The steps for the aesthetic rectification of the buccal recession are as follows: 1. Gently micro-abrade, in an incisal direction, the receded areas and the enamel nearest to the DEJ to remove food debris and plaque. Rinse thoroughly and lightly air-dry, leaving the surface slightly moist. 2. Apply BeautiBond and leave on for 10 seconds. Thor- oughly air-dry the adhesive and light-polymerise. 3. Select the appropriate Beautifil II Gingiva shade (Light Pink in this case), apply to the receded area to restore the buccal dimension and contour of the original soft tis- sue, and light-polymerise. Leave a small (0.25–0.50 mm) gap between the apical margin of the restoration and the free gingival margin (Fig. 12). This procedure restores the expected gingival height and contributes to making the patient’s smile look younger. Long-term at-home maintenance is best accomplished with procedures that are familiar to the patient and easy to implement. Regular toothbrushing is effective and prac- tised by most dental patients, interdental string flossing less so. Though the advantages of flossing are well estab- lished, patient resistance to the process and irregular appli- cation limit its benefits. Water flossing (Waterpik) not only facilitates the interdental cleaning process, but has been shown to improve the results.24 There are several models available, but the Sonic-Fusion offers simultaneous water flossing and sonic toothbrushing. Conclusion Beautifil II Gingiva enables the practitioner to overcome the gingival aesthetic dilemma. The gingival rectification tech- nique is predictable and can typically be accomplished with- out the need for local anaesthetic and without discomfort to the patient. These restorations are completely functional and replace both hard and soft missing dental structures to natural dimensions and contours with minimum invasiveness. The restoration of the coronal anatomy with tooth-coloured composite resins is well established. The development of an artificial enamel–gingiva junction and the reconfiguration of missing gingival structures with composite resins is a novel solution that restores the patient’s smile and facial aesthetics. 12 Fig. 12: Mandibular anterior teeth with gingival restorative rectification (photograph taken using the EyeSpecial, SHOFU). about Dr George Freedman maintains a private practice in Toronto in Canada limited to aesthetic dentistry. He is adjunct professor of dental medicine at Western University of Health Sciences in Pomona in California in the US and a visiting professor and director of the MClinDent programme in restorative and cosmetic dentistry at BPP University in London in the UK. He is the author or co-author of 14 textbooks, and of more than 800 dental articles and numerous webinars. He serves on the editorial team of REALITY and is the international editor-in-chief of 3D printing—international magazine of dental printing technology. Dr Freedman is a regent and fellow of the International Academy for Dental-Facial Esthetics and a diplomate and chair of the American Board of Aesthetic Dentistry. He is a founder and past president of the American Academy of Cosmetic Dentistry and a founder of the Canadian Academy for Esthetic Dentistry and the International Academy for Dental-Facial Esthetics. Dr Freedman is a recipient of the Smigel Prize in Aesthetic Dentistry (New York University College of Dentistry). Dr Paiman Lalla, a graduate of the University of the West Indies, practises dentistry in Trinidad and Tobago and has a special focus on cosmetic and implant dentistry. After completing the Advanced Education in General Dentistry program at Lutheran Medical Center in Wheat Ridge in Colorado in the US, he was awarded fellowships in the International Congress of Oral Implantologists and the American Academy of Implant Prosthodontics. Dr Lalla serves on the medical panel of Trinidad and Tobago’s ministry of national security. cosmetic 1 2022 dentistry 45

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