How to profit from . . . Crown and Bridge

The time is right for the abilities of the dental profession to meet the desires of the consumer. Beauty and health are, for the first time, becoming indistinguishable in the minds of our patients. The impression is that if people look good, they feel good, and vice versa. In 1995, consumers in America spent more of their dollars on alternative health care than they did on conventional health care, and the trend is likely to continue. Alternative health care includes elective procedures, alterna

When beauty meets function

A long marriage of `esthetics` and `cosmetics` in a dental practice thrives on four key elements

Gary Severance, DDS, and

James Hastings, DDS

The time is right for the abilities of the dental profession to meet the desires of the consumer. Beauty and health are, for the first time, becoming indistinguishable in the minds of our patients. The impression is that if people look good, they feel good, and vice versa. In 1995, consumers in America spent more of their dollars on alternative health care than they did on conventional health care, and the trend is likely to continue. Alternative health care includes elective procedures, alternative treatments, and medication - many simply for the pursuit of better esthetics or improved cosmetics.

In dentistry, the profession educates the public on prevention and minimally invasive dental treatment. Although there`s much more to do in this area, patients are responding, showing an awareness of the benefits and potential of cosmetic dentistry.

A Distinction in Terms

What is cosmetic and what is esthetic? The terms are used interchangeably in dentistry. Although there may be more correct and formal definitions, positioning them in your mind in the following way may assist in a clearer understanding:

- Esthetics best identifies those materials and techniques which mimic the form and function of natural dentition, regardless of shade. We have all been taught in dental school to strive to perform esthetic dentistry. An amalgam restoration can be an esthetic restoration since, if properly placed, it can mimic the form and function of natural dentition, but it is not perceived as a cosmetic procedure because of its color.

- The term cosmetic is used whenever we discuss anything (procedure or material) that is tooth-colored or white. Cosmetic procedures in the more general (or consumer) sense are used to "hide or highlight" a feature that exists (or existed) naturally and will ultimately improve the overall appearance. Our goal in dentistry should be to insist first on esthetics (form and function) and complete the restoration with a cosmetic (tooth-colored) material, if one is available. The result of this perfect combination of esthetics and cosmetics often is referred to as the "art of modern dentistry."

Clinical success in achieving this marriage of esthetics and cosmetics (and ultimately the success of a restoration) depends on four very important factors:

- Choosing the right material.

- Implementing the right technique.

- Correctly identifying the right indication and patient.

- Creating the right image.

A discussion about the right materials and indications follow. The sections about the right image and techniques appear in the related articles on the following pages.

Each factor requires an independent decision. Together, they can and will determine the success or failure of a restoration. If the correct material is selected, but placed incorrectly or in the wrong patient, it may fail sooner than necessary. If the clinician is precise in his application and case selection, but uses a material that has not been clinically tested or is being used beyond its indication, then the case also may fail prematurely. And if the office (environment and personnel) does not project a complete atmosphere or image of esthetics, patients will have lingering doubts about their final decision and may not refer others for additional cosmetic work.

The best way to become and stay successful in today`s dental world is to understand the indications, techniques, and properties of the many esthetic and cosmetic materials that are now available.

The Right Material

Although the search has been on and the claims have been made, there is no metal substitute in dentistry available today. There are, however, viable metal alternatives. The fact remains that, for many indications and for ideal treatment, metal-supported or metal-containing restorations still are the optimal choice.

More than ever, though, restorative materials present long-term and functional alternatives to metal-containing restorations. There is no argument that a properly completed gold-alloy restoration probably is the most esthetic (form and function) and clinically proven restoration in dentistry. But advances in bonding, tooth-colored restoratives, and patient demands have led us to consider and implement alternative techniques in many situations.

We recently have seen the introductions of new categories of dental materials that provide us with substantial improvement in the choices we have. Previously, the choices of tooth-colored materials were limited to either glass ionomers (or resin-modified ionomers), composites (direct or indirect), and ceramics (metal- supported or all-ceramic). While improvements have been made in the function, performance, and esthetics of each of these categories, two new categories of materials - the compomer and the ceromer - fill in the "gaps" (so to speak) and provide us with more viable options than ever before.

Each of these materials should be a part of your cosmetic practice. Their techniques should be available to you when the correct indication presents itself.

Glass Ionomers: Since their introduction over 20 years ago, glass ionomers have been a staple in most modern dental practices. Although the use of conventional glass ionomers is declining, newer resin and light-cured, modified-glass ionomers (Vitremer, 3M, Advance, Caulk, Vivaglass line, Ivoclar Vivadent) are increasing in their overall use and indications.

Glass ionomers (conventional and resin-modified) have become the primary cement used for metal and PFM restorations and are primarily used as liners or bases for indirect preparations. The unique benefit of all glass ionomers is their inherent bond to tooth structure and substantial fluoride release. The trend towards a combination of glass ionomer and resin technology has provided us with a new category of materials - the compomers.

Compomers: This fairly new category of materials was developed and introduced in North America within the last two years. A compomer is a developmental "mix" of a composite and a glass ionomer. It maintains many indications of composite materials, but features even better handling characteristics and contains some of the fluorosilicate glass of the glass ionomer to provide high fluoride release and an inherent setting reaction.

The indication of this category of dental materials is for Class V, III restorations in the permanent dentition, as well as all classes of restorations in deciduous dentition. Its most attractive role in your practice probably will be with your pediatric patients.

There are very limited indications for amalgam use (or metal-containing restorations) in pediatric patients in today`s cosmetic practice, and current glass ionomers leave much to be desired in terms of handling and function. On the other hand, compomers provide a quick and reliable bond to enamel and dentin, and also have the advantages of high fluoride release, exceptional handling, and acceptable esthetics (some manufacturers have developed a special "pedo" shade (Shade 105).

Additionally, the compomer`s quick application technique and ease of polishability lend themselves nicely to permanent Class V situations. The most popular compomers available today in North America (Compoglass, Ivoclar Vivadent, Dyract, Caulk) provide these similar benefits with continual improvements planned by the manufacturers in this new category of dental materials.

Composites: These materials are the mainstay of the "cosmetic" practice. Composites, whether placed directly for Class I through V (Heliomolar, Tetric, Ivoclar Vivadent) or indirectly for inlays and onlays (Concept, Ivoclar Williams), provide every practice with an efficient and effective material for achieving cosmetics and esthetics in a final restoration.

There are several subcategories within the composite category, and it is prudent to understand the individual placement and finishing characteristics of each material dependent upon its filler size and composition. Although most of the newest offerings in direct composites are categorized as "microhybrids," the composites with some of the most successful, long-term clinical studies and clinical history remain microfills (Heliomolar and Concept) and a conventional hybrid (Herculite, Kerr).

Ceromer: The ceromer is the newest category of esthetic/cosmetic dental materials which falls in between composites and ceramics. This CERamic Optimized polyMER combines the latest advances of ceramic and polymer technology in one system.

The Targis System from Ivoclar Williams recently has been introduced in North America, and it already has dramatically changed the restorative options available to clinicians. The Targis System is comprised of a ceromer overlay (Targis) and a fiber-reinforced composite (FRC) called Vectris. Combined, Targis and Vectris offer a high-strength, metal-free alternative for single-unit and multiple-unit posterior restorations.

Although its indications also include inlays, onlays, veneers and anterior restorations, the primary indication for Targis is for posterior restorations which have until now lacked a proven metal-free alternative. Vectris (FRC) is unique since it is made up of resin-infused, preimpregnated glass fibers, which are completely immersed and embedded into the lightly filled polymer matrix. Vectris (in contrast to the many fiber systems indicated for direct splints but which often are incorporated by hand into composites in the laboratory for restorative purposes) provides a complete and dense composition of the final substructure or framework.

In addition, Vectris frameworks are distinctly designed to provide maximum function and strength, depending on their indication and location of use. Vectris Pontics are unilateral, longitudinal fibers densely packed in a polymer matrix to provide the highest fracture strength (1000 MPa similar to PFM restorations). Vectris Frames are deep-drawn over the pontics in the laboratory process and provide maximum resistance to torsional forces. And finally, Vectris Singles are designed with a satin weave (three over, one under) to ensure "wrinkle-free" adaptation to the die and homogenous distribution of the forces of function.

Each component of the Targis System uses the same resin-matrix composition to ensure complete homogeneity and consistency of the bond between components. When a Targis/Vectris restoration is bonded into the mouth, a dual-cure resin cement (Variolink, Ivoclar Vivadent) is recommended, because it has the same polymer constituents, ensuring compatibility. When Targis is veneered over the Vectris framework, the resulting metal-free restoration provides strength, function, wear compatibility, esthetics and cosmetics.

This type of restoration also eliminates the inherent stresses that are caused when materials with different physical properties (primarily the coefficients of thermal expansion and Modulus of elasticity) are used in a restoration - for example, resin on metal or some porcelains on metal.

More importantly, Vectris-supported Targis restorations also provide clinicians with a metal-free solution to "minimally invasive techniques," such as anterior resin-bonded "Maryland-like" bridges and posterior resin-bonded inlay bridges.

Yet, the introduction of the Targis System does not eliminate the need for metal-supported restorations. In areas that it is impossible to achieve isolation or in expanded multiple-unit cases, it still is possible to take advantage of the ceromer`s functional and esthetic properties by overlaying metal copings with the Targis ceromer. Available in the Targis System is Targis Link, a single component, self-setting, metal-bonding agent that has proven to be hydrolytically stable when compared to other, more complicated and involved laboratory systems. This makes the ceromer the ideal overlay for implant superstructures, as well as more conventional metal-supported restorations.

Ceramics: The universal acceptance of all-ceramic restorations is evident in recent surveys projecting that nearly 90 percent of general practitioners provide ceramic veneers and up to 68 percent offer all-ceramic crowns. Nearly 10 million IPS Empress (Ivoclar Williams) all-ceramic restorations have been completed worldwide during the last five years, making this type of all-ceramic restoration a proven alternative to more conventional metal-containing methods. Further advances in metal-ceramic systems also provide important benefits to the clinician and patient with matched metal and ceramic systems (IPS Classic Ivoclar Williams, Golden Gate, Degussa).

The Right Indication

No matter how proficient the dental team or superior the dental material, it is vitally important to use them in the right place and with the right patient. All categories of dental materials have defined indications for use, as well as contraindications. With most of these cosmetic/esthetic materials, it is critical to consider the requirements for adhesive bonding. The operatory field must be able to be isolated completely via rubber dam or other method. It is better to consider more conventional treatment modalities when it is not possible to keep saliva or debris away from the preparation for the entire bonding procedure. Additionally, proper preparation design is critical for the long-term success of many of these materials.

Most manufacturers conduct ongoing clinical studies to evaluate the clinical efficacy of material prior to the introduction of new products or techniques. However, it is impossible to consider or clinically check all combinations of dentin-bonding agents, cements, and preparation techniques used in today`s practices. Therefore, it is important for the clinician to closely follow the manufacturer`s recommended indications of a material and its accompanying accessories (bonding agent, cement, etchant).

When mixing and matching materials from different manufacturers in a single procedure (bonding an all-ceramic restoration, for example), you risk failure due to the fact that no manufacturer has data to support the use or success of such combinations. Theoret- ically, one manufacturer`s brand should work with another manufacturer`s, but it is very possible that you may be the first clinician to use these materials in such a combination with a specific technique.

Aggressive attempts to make an existing material fit an indication for which it is not designed can result in failures that cannot be substantiated or supported. This is the primary reason new categories of materials have been developed, in order to have the material fit the indication rather than extend an existing material beyond its limitations.

Understanding the various categories of esthetic and cosmetic dental materials and their indications is critical to the continued success of today`s dental practice. While we do not yet have a metal substitute, there are metal alternatives that can and do provide patient and clinician with the benefits of esthetic and cosmetic dentistry when prescribed and placed correctly. Once the skills are obtained, then it can be valuable to the practice to market this artistic approach across the entire practice.

Dr. Gary Severance is Director of Professional Communications for Ivoclar North America and heads Full Mouth Communications, which provides practice-building educational and promotional tools to the dental professional. He also is editor of Signature™ publications, reaching over 150,000 dental professionals worldwide three times each year with clinically relevant products and techniques. Dr. James Hastings is a private practitioner from Placerville, CA. As a leading lecturer, author and instructor, Dr. Hastings provides a unique perspective on the formula for clinical success. Dr. Hastings is an associate instructor at Baylor Esthetic Continuums and Las Vegas Institute of Advanced Dental Studies.

References for this article are available upon request.

The Right Technique

Most manufacturers go to great lengths to include instructions that take you step-by-step through procedures via text. More often than not, they include graphic or photographic demonstrations of the proper technique. This can obviously improve the clinician`s and the staff`s understanding of a procedure.

But nothing can substitute for actually working with the product in a hands-on teaching environment led by an experienced instructor. A trend in the continuing education programs of many institutions is to organize multi-session continuing education curricula, most including hands-on (phantom or live) demonstrations.

Dr. George Freedman of Toronto, Canada, deserves special recognition for his continuing efforts to initiate some of the most successful continuums in this realm of teaching methods. The programs are often set up in conjunction with leading universities, and many (like the Signature Series at the Tufts, University of the Pacific, and NYU) bring together the most innovative dental professionals.

Other more formal and regular teaching institutes continue to provide intensive training on the implementation of esthetic and cosmetic dentistry (Center for Advanced Dental Studies in St. Petersburg, Fla., and the Las Vegas Institute of Advanced Dental Studies in Nevada). While many dental schools rapidly try to catch up to meet the current needs of practicing clinicians, it is promising to see the universities support and participate in this type of graduate CE program.

Additionally, indispensable reference materials for clinicians (CRA Report, Clinical Research Associates and Reality, Reality Publishing) - as well as periodicals that demonstrate effective practice management techniques (Dental Economics) and clinical guides offering continuing education credits (Compendium, Practical Periodontics, and Aesthetic Dentistry) - keep clinicians up-to-date on the latest formulas for success from around the world.

The Internet is emerging as a force in the dental industry, providing professionals a forum in which to share ideas and techniques. Manufacturers now use the Internet to provide the latest up-to-date information and techniques (for example, http://www.ivoclarna.com) and the American Dental Association`s Home Page (http://www.ada.org) provides daily updates on news and information affecting the profession as well as valuable listings about local dental societies, ADA accepted products, and vital contacts.

The Right Image

Not all clinicians have the choice of turning a practice into a purely cosmetic practice. But cosmetic services should become a part of every restorative dentist`s armamentarium for the following reasons:

- Patients are seeking metal-free dentistry.

- Cosmetic services usually are not reimbursed by insurance. They are not discounted and often are paid for in cash.

- Patients seek appearance-related dental services because of their perceived value.

- More than 20 percent of the dental dollars spent in 1995 involve some form of cosmetic service.

- The number two reason for seeking dental services in the United States is improvement of appearance.

- There is more job satisfaction for staff and patients by providing services that have the power to enhance a person`s self-image and the quality of his/her life.

For those clinicians interested in providing these services, a program of integration of cosmetic services into their practice should be implemented. Of course, it is absolutely necessary to obtain the knowledge and develop the skills to deliver high-quality cosmetic dentistry before marketing your practice as a cosmetic one.

You begin creating an image of a cosmetic practice by taking a look at your own attitude towards cosmetic dentistry. Do you have the right outlook for cosmetic services? You must believe in the value of these services to be an advocate to your patients.

The next step might be to look in your own mouth and determine if you could benefit from cosmetic dentistry, and then get it done. Your patients will have much more confidence and assurance in the techniques if you are a model.

Your staff must be behind you in this effort as well. Re-examine and treatment-plan your staff for cosmetic services, integrate them into more continuing education and ensure that they understand the value of cosmetic dentistry. Having a patient look at a staff member`s beautiful smile (one that you created) is an effective marketing tool to assist your effectiveness in marketing cosmetic dentistry.

Don`t just focus just on the anterior teeth. Once you and your patients see the value of maintaining tooth structure through esthetic and cosmetic intracoronal restorations, these types of restorations may become a mainstay of the practice.

Start by planning with your staff to make one morning or one day a week a "cosmetic day."

Treatment-plan and schedule only cosmetic services during that time period. Get your whole staff involved in the process. The excitement generated by this kind of dentistry is infectious and fun.

Once you begin to provide a mix of cosmetic services into your practice, it?s time to think about marketing your cosmetic practice. The first place to begin your marketing strategy is with your own patients. As your skills develop, you will begin to identify more and more of your current patients that could benefit from cosmetic dentistry.

Next, look at your facility ? does it reflect an esthetic or cosmetic image? Does your office need a face lift? New carpet or paint? Does the waiting room project a modern, friendly atmosphere?

Cover the walls. Many successful cosmetic practices have a Owall of smiles.O These are photos of completed cases that are updated as the clinician completes more and more cosmetic cases.

You should also have certificates from courses you have attended attractively framed and placed in full view. This will stimulate questions from patients and will promote an awareness that they have chosen a practice that is knowledgeable and attentive to the latest in technology and education.

Use chairside educational or presentation aids. The Esthetic Dentistry Systems Guide (Ivoclar North America) is a graphical tool that assists all dental professionals and patients in choosing the right material based upon the clinical indications.

Analysis, by Gerald Ubassy, a pictorial album of natural dentition, also assists dental professionals in demonstrating and communicating the subtleties of natural dentition amongst themselves and with their patients.

Perfect your photography skills. The American Academy of Cosmetic Dentistry offers a photography workshop at each of its annual meetings. This is a good way to get started the right way with intraoral photography.

Photographing every case is a resource which will provide valuable feedback to improve your technical skills and will visually document each case.

Advertise your new skills to your patients. Be creative in your approach. Use your newsletter, send a press release to the local newspaper, have an invitation-only party at your office, a local restaurant or perhaps a local art gallery.

You are creating an image in the minds of your patients (and their referrals) that, in addition to being a dentist, you are an artist ? combining esthetics and cosmetics.

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