Through his work at his Boston dental practice, his role as a dental educator at a local university, and his extensive experience testing new dental materials, Gerard Kugel, DMD, PhD, MS, feels confident he knows what to look for in a composite system.

Throughout his more than 3 decades of clinical experience, Dr Kugel has worked with and tested many generations of direct restoratives. He believes clinicians today have more great material options to choose from than ever, and is excited by some of the newest dental composites that take shade matching to a new level with the ability to match almost any tooth shade with a single composite shade.

“It’s the translucency and refractive index,” he says. “It picks up the color of the [surrounding] teeth, almost mirroring the color.”

Among the materials he’s used, Dr Kugel sees Ivoclar Vivadent’s Tetric Prime as a standout. He first encountered the material while conducting research with composites offering a single-shade chameleon effect.

“Other conventional composites didn’t work as well,” Dr Kugel says. “We were impressed with Tetric Prime. I’ve used it in practice as well. It has a very streamlined shading system in general. They have universal enamel shades, which are great, but you could theoretically complete a lot of restorations with just the translucent shade.”

Tetric Prime is a universal composite system featuring prime handling and a simplified shade system. Tetric Prime is said to provide the creamy handling necessary to use in the anterior and the adaptability and nonslumping characteristics needed for posterior efficiency. Tetric Prime’s T shade is 15% translucent and contains refractive index technology to match the optics of natural teeth, offering a single shade option for Class I and II restorations.

The material’s composition includes a monomer matrix and filler materials with a matching refractive index to allow light to transmit through the composite in order to produce natural-looking shade blending.

Dr Kugel says the T shade can get the job done on its own for many Class I and II and some Class V restorations, but Tetric Prime offers 11 additional shades with differing levels of translucency to allow more conventional shade matching and customization.

This versatility sets Tetric Prime apart from other composite materials, according to Dr Kugel. He says the translucent shade allows clinicians to work with Tetric Prime the same way they would with other single-shade composites. This means a simplified clinical protocol and less material in inventory. But with Tetric Prime, clinicians gain the benefits of a more traditional composite system as well.

“Ivoclar knows they’ve got a product that’s good for a lot of restorations with the translucent shade, but they’re still giving you the option, which is probably smart,” Dr Kugel says.

The 2 dentin shades are useful for cases in which opacity is critical, he adds, noting that Tetric Prime can be a go-to option for many practices. Still, Tetric Prime brings more than simplified shade matching, Dr Kugel says.

“Most of the new composites that come out are pretty decent,” he adds. “What really makes a difference for dentists with new composites is handling. [Tetric Prime is] creamy, I can sculpt it well and it’s got great handling characteristics. The other thing I found in my study is that it polishes really well.”

As impressed as he is with the material, Dr Kugel says there are still capabilities he hopes to see in restorative materials of the future. While Tetric Prime checks the boxes forsimplified shade matching, reduced inventory, and smooth handling, Dr Kugel says he’d love to have a material that adds self-adhesive to that list of capabilities.

“To me in a perfect world, the ideal composite would be a universal shaded, self-adhesive, bulk fill material that handles well and polishes well,” he says. “We’ve come very far, but we still could make it even better.”

Dr Kugel says there are numerous high-quality restorative materials available today that make it simpler for clinicians to get the results they and their patients expect. Tetric Prime is among the new materials to impress Dr Kugel, and he thinks it makes a great single-shade solution while maintaining the flexibility for use in complex situations.

“Having a product that can answer your questions, meet your needs, and not take up 800 shelves in your storage room is a good thing,” he says.

Articles

Gerard Kugel, DMD, PhD, MS, shares his experiences working with and testing Tetric Prime, a versatile universal composite from Ivoclar Vivadent.

A Composite System Primed to Meet the Needs of Any Case

A look at many of the recently announced products in the dental industry.

March 2021 New Products

9 Members of the Oral Microbiome Rogues Gallery

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

Jamie Collins, RDH, is a clinical practicing hygienist in Idaho and Washington states. She has been in the dental field for 20 years, both as an assistant and hygienist. With a passion for patient care, especially those with higher risk factors, she enjoys sharing the tips and tricks of dental profession through speaking and writing for multiple publications. In addition to clinical practice Collins is also an educator, has contributed to multiple textbooks, curriculum development and creation, and contributes as a key opinion leader with multiple companies.

Science has unlocked many questions about the oral microbiome, which has led to solutions that target bacterial strains and are designed to combat the damaging effect to oral tissues. The oral cavity is home to the most diverse and largest microbiota in humans second only to the gut. It harbors an array of viruses, bacteria, fungi, and protozoa. The term “microbiome” was introduced by Joshua Lederberg to describe “the ecological community of symbiotic, commensal, and pathogenic microorganisms.”1 Although the terminology has changed over the years, plaque, materia alba, and biofilm are common words for many of us. Regardless of the naming, individuals face many challenges regarding the prevention and treatment of dental diseases; meanwhile, there are new products and emerging technologies that can help alter the microbiome as we know it.

The oral cavity has 2 main surfaces that bacteria colonize, the hard and soft tissue. The makeup of bacteria differs in relation to their location in the oral cavity; for example, those found in the gingival sulcus are different from those in the tonsils, which differ from those on the surface of the teeth. Whereas the core microbiome is similar in most people, there are variations based on the individual. Consider the diversity among siblings you may see in your practice, ranging from 1 who hardly ever brushes and never has cavities to another who is diligent about home care yet usually has 1 or 2 cavities at each recall. Same diet, same parents, but 2 very different oral conditions and outcomes. Some patients may express frustration as to why they are the one with decay versus their sibling who seemingly rarely picks up a toothbrush let alone uses it. What most patients do not understand is that differences in oral pH and bacterial microorganism balance can make someone more prone to the oral disease process. Diet, interactions among bacteria, and gene mutations can all affect the delicate bacterial balance and, more importantly, what can be done to combat the damaging effects of oral disease.

Fortunately, with each passing year we learn more about the oral-systemic health link and therefore, as dental professionals, continue to invest in our patient education efforts. However, many patients (and even some medical providers) still believe the mouth is separate from the rest of the body. What they may not realize is that oftentimes, signs of systemic disease will be on display in the oral cavity well before other outward signs present themselves. The coronavirus disease 2019 pandemic brought to light the role of inflammation and the correlation between health and severity of disease. As a result, many individuals are taking an active role to minimize risk factors. This may be especially important, as many dental offices are seeing only a fraction of the patients they were seeing a year ago. A large number of patients are electing to postpone preventive care, putting them at greater risk of oral diseases.

In recent study results published by the University of Buffalo, investigators aimed to better understand how 

 colonizes in the mouth, when it is unable to produce its own growth molecules without being largely established in the oral microbiome. 

 is a common culprit in causing periodontal disease; in a patient with a healthy mouth it is present in smaller numbers and unable to replicate, compared with the mouth of a patient who has active periodontal disease. The study authors concluded that 

 is opportunistic and “borrows growth molecules from 

, a common yet harmless bacteria in the mouth whose growth is not population dependent.”

 Patricia I. Diaz, DDS, PhD, lead investigator on the study and professor of Empire Innovation at the University at Buffalo School of Dental Medicine, and her team established that “if dental plaque is allowed to grow unchecked due to poor oral hygiene, 

 will multiply and eventually produce enough growth molecules to also spur the reproduction of

.” The delicate balance of the oral environment can be altered by adequate home care or lack thereof.


Periodontist Sam Low, DDS, MS, an associate dean at the University of Florida, chief dental officer at BIOLASE, Inc, and consultant to various dental products companies, discussed how probiotics have come into general daily use for gut health. However, we are now beginning to see the incorporation of probiotics for oral health. The evolution of probiotics has included research to introduce specific strains that essentially force out the less desired pathogens. Low is also an advisor to ProBiora Health™, an oral health probiotic company, whose formulation is targeted to combat destructive oral pathogens including 

, deemed the “ringleader” by Dr Low. The benefit of specific formulations of probiotics such as ProBiora’s oral products is that they selectively crowd out particular pathogens in contrast tothe “kill them all” formulas that can also destroy beneficial bacteria. By targeting the undesirable bacteria, the beneficial bacteria can flourish, resulting in an alteration of the oral microbiome. As with anything in life, we look for balance, and maintaining the oral microbiome is imperative to oral and overall health.

One challenge dental professionals face is patient adherence, and it is important not to make a routine so difficult that it becomes a burden. ProBiora oral probiotics are as simple as a once-a-day dissolvable mint, leaving patients with no excuse for lack of adherence. Dr Low predicts that in 5 years, orally beneficial probiotics will be where gut probiotics are today in terms of public acceptance.


As with any home care routine, oral health ones must be kept simple to increase patient adherence. Mouth rinses have been a standard of oral care for decades. Chlorhexidine is an effective staple product used post periodontal treatment and oral surgery, although it is not meant for long-term use. Oral rinses may be an easy solution for some individuals, but the strong alcohol-based rinses take a “kill them all” approach to bacterial reduction. For individuals with xerostomia, alcohol-based products used regularly exacerbate the condition’s effect. Xerostomia can become a life-altering condition that causes discomfort and greatly increases the caries risk. Instead, patients can opt for an alcohol-free rinse such as Oxyfresh’s line of oral rinses, which contain chlorine dioxide to oxidize and “kill” bacteria causing bad breath. Formulated with xylitol, essential oils, and a balanced pH, Oxyfresh oral care products provide an alternative to alcohol-based rinses and chlorhexidine.


Patients who seem to be doing everything right yet continue to battle oral disease, such as periodontal disease and caries, may have an imbalance of oral flora. Salivary testing may provide the key to unlocking the mystery for those individuals. Using salivary testing in clinical practice enables the identification of the pathogens that are contributing to the disease process. The dental provider can then plan treatment accordingly, and identify the risk assessment and solutions moving forward. Saliva testing allows the provider to take into account other contributing risk factors, including smoking, xerostomia, poor oral hygiene, health conditions, and medication side effects. Although these factors contribute to the disease process, salivary testing provides the hard data that give oral health care professionals a more complete picture. For example, patients with gingivitis and certain high-risk bacteria likely will be at higher risk for development of periodontal disease, especially if they have or develop medical risk factors in the future.

Oxyfresh products provide an alternative to alcohol-based rinses.

Salivary testing can produce a wide variety of results, from buffering capacity to identifying prominent bacterial strains. Analyzing the saliva gives dental providers a powerful tool with which to educate and engage patients in their own oral health plan. The results of the screening may also help providers to determine and recommend professional and home care treatment to alter or maintain oral health conditions. Chairside saliva testing can be done in 5 minutes or less and be incorporated into almost any dental appointment. Saliva composition, flow, and buffering capacity play a critical role in the health of oral structures and are especially beneficial in caries risk assessment. Saliva-Check BUFFER by GC America is a quick chairside assessment that evaluates salivary consistency, resting and stimulated pH, resting and stimulated salivary flow, and buffering capacity. Xerostomia is often a slow process and many patients don’t complain until it has reached advanced stages when it begins to affect everyday life. Therefore, being able to identify at-risk individuals early can be vital for more effective treatment and prevention.

ARKRAY USA’s SillHa Oral Wellness System tests saliva using “dual wavelength reflectance technology to measure the reaction of saliva with the test pad to indicate the presence of 7 analytes. [These] can be used to assess oral health and the risk for caries and gum disease,” according to company president Bob Guest. The system uses a test strip that is analyzed by the machine and provides a visual report in only 5 minutes. SillHa uses proprietary software that creates a PDF report for the dentist’s chart and can be printed and sent home with the patient. The innovative test analyzes measurements of cariogenic bacteria, buffering capacity, ammonia, blood, leukocytes, and protein within the saliva. “These 7 biomarkers can be used to indicate or confirm a measure of oral wellness that cannot be seen without a microscope,” says Guest.


Advances in technology and the availability of chairside testing have enabled us to better prevent, diagnose, and treat oral disease. Steven Bloembergen, PhD, founder and CEO of GreenMark Biomedical Inc, states that his company’s goal, “Preserving Teeth for a Lifetime™,” represents a vision of ongoing product development to help patients keep their teeth as they age. Almost all dental professionals can agree with the sentiment, as we focus on disease prevention and the preservation of oral health in daily practice. GreenMark Biomedical, in collaboration with the University of Michigan, is the creator of LumiCare™ Caries Detection Rinse, which brings a fully bioresorbable nanoparticle technology to everyday dentistry in the form of a water-based oral rinse. The 2020 Cellerant Best of Class Technology Awards recognized LumiCare as a Best of Class winner. The science behind the innovative rinse relies on positively charged starch-based nanoparticles that are attracted to the negative-charged carious lesions. 

GreenMark Biomedical’s LumiCare is a new caries detection rinse.

The luminescent agent becomes visible by illuminating the porous subsurface of carious lesions under the blue curing light, viewed through orange glasses or an orange shield. Bloembergen is no stranger to nanotechnology and has brought his knowledge to the benefit of dentistry. Through targeted luminescence technology, the LumiCare rinse enables the dentist to identify the earliest carious lesions and provide treatment before they progress and become a larger problem. The ease of use and single-dose packaging makes the rinse, currently pending FDA clearance as a 510(k) Class II device, a simple and easy addition to any dental evaluation workflow. GreenMark is creating additions to the innovative line of products using nanotechnology and is developing a targeted, noninvasive treatment that can change how early carious lesions are arrested by delivering minerals to the enamel subsurface and restoring lesions in a more natural way.


When decay goes beyond incipient caries and restorative treatment is necessary, the dentist preps the restoration and places the filling. However, it is not possible to remove all bacteria prior to the filling replacement and the risk of recurrent caries lurks. FiteBac Antimicrobial Cavity Cleanser, created by FiteBac Dental, LLC, is dentistry’s first FDA-approved antimicrobial cavity cleanser. Looking at an x-ray, the dentist may often debate the black line under an existing restoration, pondering whether it is recurrent decay. Applying the FiteBac cleanser with a microbrush in the cavity prep inhibits the microbial presence prior to the restoration placement, reducing the risk of restoration failure in the future. An added benefit is the product’s ability to cleanse the exposed dentinal tubules, thus allowing a stronger restoration bond. FiteBac has their sights set on FDA approval in 2021 for an antimicrobial bonding agent and an antimicrobial ortho sealant. One of the biggest challenges for orthodontistry patients is effectively cleaning around orthodontic brackets, and often, decalcification and decay are exposed when the brackets are removed. It is encouraging that there is a product on the horizon to counteract the effect of the oral microbiome and poor oral care associated with orthodontic treatment.

The antibacterial properties of Infinix can be a great benefit when treating children with advanced stage caries or at-risk elderly patients with root caries.


Ervin Weiss, cofounder of Nobio Ltd, is a dentist and microbiologist who spent decades studying the complex oral environment. We know that biofilm is considered a multicellular organism and the daily mission of hygienists is to disrupt it one dentition at a time, though it is never fully eliminated. Weiss says, “Each time we brush, we injure the biofilm to help the immune system and to inhibit it from flourishing. Our oral microbiome is challenged by saliva, food, and friction on a daily basis.” Most people have active decay, restorations, periodontal disease, or a combination of risk factors making them susceptible to adverse effects. Restorations generally do not last a lifetime and whether caused by breakdown or recurrent decay, they typically must be replaced. Nobio set out with a goal not to change the whole oral microbiome, but rather to add an antimicrobial property to the localized surface. Weiss has a wealth of knowledge when it comes to the oral environment and comments, “The only way to control the disease is to fight the biofilm from the side that is protected,” which means the first few layers where it adheres to the oral structure. Biofilm is laid down in layers and mechanical means remove the newest outer layers first; damage generally happens within the deeper layers adhered to the structure or tooth.

Nobio has spent many years creating a restorative composite material known as Infinix. It has the ability to kill bacteria through its own antibacterial properties, killing the first few layers of biofilm formation it comes in contact with. Another 2020 Cellerant Award recipient, Nobio aims to change the long-term outcome of composite restorations. This could be a game changer for Class II and Class V restorations, which are generally at a higher risk of failure. For dentists, the antibacterial properties of Infinix can make all the difference when treating children with advanced stage caries or at-risk elderly patients with root caries. Infinix has received FDA clearance for “stopping demineralization” with its antibacterial properties. According to Weiss, the filler particles themselves within the composite material contain the antibacterial effect and are insoluble. Whether dentists are looking for a flowable or regular composite material in a variety of shades, Infinix by Nobio is worth considering, especially for high-risk patients.

The oral microbiome is a challenging environment, often with a mysterious makeup that can alter and vary depending on a variety of factors. Aging, dietary changes, or medications can make it difficult for the body to combat caries and periodontal disease. With innovations in technology and advancement in knowledge, we can help our patients maintain oral health, leading to improved oral health outcomes. Although 2020 brought challenges to dentistry, it also rewarded us with an array of promising products to enhance our practice.

1. Deo PN, Deshmukh R. Oral microbiome: unveiling the fundamentals. 

. 2019;23(1):122-128. doi:10.4103/jomfp.JOMFP_304_18

2. Robinson M. Microbiome study: gum disease-causing bacteria borrow growth molecules from neighbors to thrive. News release. University of Buffalo News Center. December 29, 2020. Accessed January 18, 2021. http://www.buffalo.edu/news/releases/2020/12/026.html

Technological innovations and increased knowledge of the oral microbiome can help our patients maintain oral health and improve oral health outcomes.

Working With a Mastery of the Oral Microbiome

Restoration of endodontically treated teeth frequently requires the replacement of lost tooth structure as well as support and retention of the restorative material. Through the years, many different types of endodontic posts have been used to serve this need.

Current endodontic trends are to use conservative access, shaping, and flaring during the preparation of the tooth. Removing minimal tooth structure allows increased fracture resistance, providing a better long-term prognosis.

Because teeth have varying pulpal canal diameters and shapes, various prefabricated post systems have been introduced to accommodate the differences in each clinical situation. This has led to systems of multiple diameters, as well as parallel versus tapered posts.

Endodontic posts have been fabricated from various materials including gold, stainless steel, zirconia, and fiber-reinforced composite. There are volumes of papers discussing the benefits of each. Fiber-reinforced composites have become the most popular option in America because of an elastic modulus similar to dentin, its ease of use, and the potential for the post material to bond to tooth structure.

Designed to let the clinician adapt the fiber post to the canal flare with a vertically sliding (adjustable) conical sleeve. The sleeve is made of the same fiber-reinforced composite as the post and, when needed, slides on when the post is inserted, converting a pointed, parallel post into a custom-fitted post. Replacing cement with material of high mechanical properties increases the overall strength of the post/core.


Angelus recently brought the Splendor-SAP endodontic post system to the US. This system is a unique solution to challenges in current endodontic post kits. SAP stands for single adjustable post. It is created by using a 2-part system. The first part is a narrow, apically tapered fiber post like many other posts on the market. The second part makes this product unique. A sleeve provided with the posts and made of the same material can be placed over the post to allow for adaptation to varying diameters of coronal canal preparations

. This sleeve allows for better adaptation of the post system to the canal anatomy while increasing strength and retention. This ingenious design leads to a significant decrease in the inventory of post designs, sizes, and systems needed by the clinician.


The Catapult Education evaluators participated in the review of the post system in the first half of 2020. Each evaluator was provided with a Splendor-SAP kit that contained 5 posts and sleeves. Upon completion of the evaluation each doctor submitted a survey about their experiences with and opinions of the post system. There was no compensation to the evaluators for their participation in the review.


Within our evaluation team, ¾ currently place fiber posts, whereas the other ¼ place metal posts. Half of our evaluators performed endodontic treatment in their practices. Most of our evaluators cited flexural strength (associated with decreased likelihood of root fracture), ability to bond, and esthetics as primary reasons for choosing fiber posts.

When using the SAP system with the sleeve, most of our evaluators ranked the fit as good or excellent. When the system was used without the post (for narrow canals that did not require the use of the sleeve) our evaluators again rated the fit as good or excellent.

Half of our reviewers ranked the system as better than their current post system. Of the rest, all but 1 rated the SAP post system as “good as” their current system. Only 1 of our evaluation team rated their current post system as better than the SAP post.

Comments from evaluators included the following:

“Simple to use and simplifies my procedures.”

“Like having a universal size that can be used in a majority of cases.”

In general, our team was impressed with this unique and innovative clinical solution.


An endodontically treated tooth #21 presents with minimal coronal tooth structure and requires a post and core along with a full coverage crown to restore to function.

Using the drill provided with the Splendor-SAP kit, the endodontic filling material is removed as apically as possible without removing excess existing tooth structure.

The SAP post and sleeve are tried into place (

 and excess is removed with a diamond bur and tried to place again 

. The post and sleeve are treated as per manufacturer instructions.

The post space and remaining tooth structure are conditioned with a phosphoric etch along with a compatible bonding agent. For the cement, the author likes to use a dual cure composite resin buildup material (LuxaCore Z; DMG America) as the luting agent. The core material is injected into the post space. The post and sleeve are then inserted into the canal. Holding the post to place, the area is light cured for 30 seconds. Then the core material is injected around the visible post to create the core. This is then light cured for another 30 seconds, followed immediately by the final preparation 

A final radiograph demonstrates the conservative post placement that is now bonded to the tooth with the development of an adequate clinical crown to support the final restoration 

The author would like to thank Dan Ward, DDS, fellow Catapult Education evaluator, for sharing his photography of this case. Our Catapult Evaluation team was impressed with this product and is pleased to give it the Catapult Vote of Confidence.

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

Catapult Education evaluators are impressed with this new entry into the fiber post market from Angelus Dental.

Splendor-SAP From Angelus Dental: Unique and Versatile Post System

Robert Elsenpeter is a freelance writer and frequent contributor to Dental Products Report and Dental Lab Products. He is also the author of 18 technology books, including the award-winning Green IT: Reduce Your Information System's Environmental Impact While Adding to the Bottom Line. As such, he’s particularly interested in the technological side of dentistry.

What do Superman and zirconia have in common? If you said strength (both are unquestionably strong), esthetics (they both look great—even disguised as Clark Kent, Superman is still a dreamboat), and affordability (sure, this one is a little bit of a stretch, but Superman provided his services free of charge), then you are right.

Of course, claiming either as “the best” in their respective fields is somewhat subjective, but it’s getting harder and harder to argue that opinion, especially where zirconia is concerned (Batman fans would likely disagree as to whether Superman is the best superhero).

There’s a lot to know about zirconia, and dental lab professionals need to understand how this material helps them, doctors, and patients.

Zirconia is a fairly new material used in dentistry (only in the last 20 years or so) and is usable only in the CAD/CAM workflow, supplanting porcelain-fused-to-metal (PFM) restorations.

“In the early 1990s, the Nobel Company started producing the world's first sinterable dental ceramic produced by CAD/CAM, a material called alumina,” says Ben Godfrey, application engineer at Axsys Dental Solutions. “But, due to difficulty of use and lack of longevity, this material sprung up and then died just as quickly, and the market needed a new material. On the heels of those new cylindrical dental implants, [Per-Ingvar] Brånemarklicensed and partnered with Nobel to produce Procera brand zirconia. The entry price tag was quite high, as the new digital process required investment in a probe-based scanner that touched the die as the die spun—leading to many margin breaks as the probe rode along any undercut and tended to easily break thin edges on stone dies.

“The system was intended to scan only stone dies and produced only thimble copings until software updates in the early 2000s,” he continues. “It wasn’t until the mid-2000s that the full-contour zirconia market got its legs, owing to failed porcelain-to-zirc in years previous. Around about ’08 to ’09, when proper liner agent was developed for layered zirc, the market for monolithic zirconia claimed a lot of ground from PFM and gold.”

Nathaniel Lawson, DMD, director of the Division of Biomaterials at the University of Alabama at Birmingham School of Dentistry, remembers when zirconia made it big. “When it first started, it was just the framework as zirconia,” he says. “So, it was something that they were using just for its strength. And then they had to put porcelain over it to impart enough translucency to make it look natural in the mouth. But when the zirconia revolution started was when they started making zirconia that could be monolithic, so it didn’t have to have any veneering porcelain over it.”

Claudia Fernandez, a lab technician for several decades, and currently a territory sales manager at Smart Dentistry Solutions has been working with zirconia for many years and recalls the early struggles with debonding issues, and the lack of esthetics relegating the material to posterior use. But with better complementary materials and workflows, those challenges are issues of the past, and today zirconia is well suited to play a role in almost any type of restoration.

“Now it has evolved to being more aesthetic and more translucent,” she says. That's thanks to all the technology that now used in manufacturing zirconia.”

Zirconia gained traction in dental restorations because of its strength, wear-resistance, and biocompatibility. When compared with older analog materials, like PFMs, or even newer materials, like Ivoclar Vivadent’s IPS e.max, zirconia has clear advantages.

Lawson looks to a study conducted by the 

Journal of the American Dental Association

 revealing 277 American Dental Association Clinical Evaluators’ attitudes and opinions towards zirconia.

“The biggest thing was that 57% of people said that zirconia’s biggest advantage was its strength,” Lawson says. “And then 14% of people said its [advantage is] versatility. What we meant by that was, ‘Can [zirconia] be used for a whole bunch?’ It can be used as a crown; you could use it for a hybrid prosthesis, meaning you could replace an entire arch with it; you can use it for an implant abutment; you can use it for a lot of different applications.

“The third was wear resistance because it doesn’t really wear away over time,” he continues. “And then the fourth was cost—and I’m surprised that wasn’t higher—because zirconia really has reduced laboratory costs for crowns, just because you can manufacture them relatively inexpensively.”

According to David Sipperly, sales training manager at Dentsply Sirona, a lack of metal components means that esthetics are improved, and biocompatibility is better.

“All-ceramic restorations typically have better esthetics than PFMs, because you’ve got a metal substructure and gray metal substructure base, particularly when you have tissue recession, you can see that gray line or a metal halo in a patient’s mouth,” he says. “Or you can see a gingiva tattoo that some people would have because of the metal. And some people have sensitivity to metal, so all-ceramic or metal-free is the way to go from a biocompatibility and esthetics perspective. Now that being said, PFMs were the norm 15 years ago. It was 80% of the business, [with] 20% all-ceramic. Today, it’s completely reversed. All-ceramic restorations are 70% to 80% of the and PFMs are 20% to 30%.”

Zirconia’s composition makes it not only esthetic but also strong.

“One of the benefits zirconia versus PFM is you have no metal showing,” says Raffi Hatzakortzian, co-owner of Alien Milling Technologies. “If the patient’s gums do reduce over time, you don’t have to worry about that metal showing. The second advantage would be that it’s actually stronger than PFM, so you do have less chance of breaking.”

But it isn’t just the patient who benefits from a zirconia restoration. Dental lab professionals realize the advantages of using the material.

“The first big one is labor-saving,” Godfrey says. “With the advent of zirconia produced via CNC, you now need only click the mouse to do your design digitally, and as the project is on the screen, you can click buttons and boxes to make things appear, disappear, or adapt. For example, with a click, you can adapt your crown to the contacts perfectly. Secondly, in terms of material selection, zirconia today has dozens of varieties allowing for unprecedented flexibility in adapting to shades. There are hundreds of brands of zirconia on the market, and each can come in several varieties of strength and translucency characteristics. We’ve come a million miles from dead white copings 30 years ago. It can be a daunting task finding a zirconia that works best for your case, but as many people are finding out, once you know what you need from your workflow, it’s a pretty simple process.”

According to Elke Kopp, new procedure marketer at 3M, form and function are the most critical qualities of dental restorations. On the form front, zirconia has an edge.

“The big advantages of zirconia are that they are highly biocompatible,” she says. “They are metal-free; they have a toothlike color; they have a lower minimal wall thickness than e.max, and minimally invasive restorations are possible. They can be dry milled, which is an effective manufacturing process; they have a flexible use depending on needs and are easy to cement. There is no discoloration in the mouth; and low wear. Although veneered zirconia is the golden standard in esthetics, monolithic zirconia is reaching high levels of esthetics.”

A lot of this is, of course, subjective, and it seems to vary depending on who you talk to and their role.

“This is a topic that always stirs debate,” Godfrey observes. “Esthetics are one way in the eyes of the lab [professional], another in the eyes of the dentist, and another in the eyes of the patient. If you want to have an objective discussion, you have to resort to talking about zirconia in an ‘on-paper’ sense. Zirconia can be produced as white or preshaded, and it’s often that lab professionals go for preshaded zirconia because it accelerates the workflow and eliminates the white spots that you’d see as a clinician making small adjustments to the crown at time of seating. “Therefore, if you grind into a preshaded A3 crown, you will never see white spots—the color goes through the whole material,” he continues. “There are a great many methods of achieving finer detail of stain, from pre-sinter liquid application, to glaze kits that transform the look of any zirconia according to the skill of the artist. The ceramists don’t need to fear losing their jobs to automation…yet. Many technicians today don’t put the same effort into zirconia as e.max by virtue of the fact that the 2 materials start from a different esthetic point—e.max has qualities in it that make it easier to achieve the perfect shade without much effort, and almost all technicians prefer to put porcelain on a crown to achieve a quality shade.”

A more recent advance in the esthetics possible with zirconia restorations is the development of multilayered zirconia discs that combine the strength of zirconia traditionally used in the posterior region with the enhanced translucency of zirconia designed for use in the anterior. Fernandez says these materials allow labs to use zirconia without compromising strength for translucency or vise versa, and the manufacturers of these materials are getting better and better at creating smooth transitions between the layers.

“It means that it goes from a veneer as thin as a veneer can be to inlays, onlays, and all the way to a 14-unit, implant supported structure or custom implant abutment structure,” she says.

Ultimately, the goal is the best-looking, best-performing restoration possible. However, zirconia affords lab professionals the opportunity to easily and consistently provide restorations. That is due largely to the benefits of CAD/CAM and the digital workflow.

“Zirconia is very easy to use,” Hatzakortzian says. “Then the greatest advantage you’re going to have with zirconia is that everything is done digitally, so you don’t have any more casting or waxing or anything like that. If a patient breaks the restoration or it gets lost, it can be remade because milling centers usually keep the files for up to 10 years. So anytime between that, if something does happen, we could just go in and remill it instead of the doctor bringing the patient back in and taking an impression.”

“Zirconia is easy to work with when you control the workflow and know what you want to see as a result or product of your labors,” Godfrey adds. “Every lab has its own workflow, and 2 labs produce different results, even [when] given the same zirconia. It’s the technicians in the labs that make the result work, not the zirconia itself. It should be said that every zirconia will have a different way of absorbing stains, blocking out dark stumps, or generally allowing light penetration, based on its composition. Scientifically, the majority of zirconia out there is stabilized with yttria, but different things happen when you get one that is stabilized at 3% versus 5%, and quite another thing when stabilized with calcium or erbium. Those are not quite as common but are out there still, and they produce a different result and require a different amount of work to get to the correct value/chroma. A good technician should be able to see and compensate for these things, but many dismiss these zirconia as not being worth the effort because of the amount of time it would take to correct the workflow.”

Further, according to Kopp, precolored zirconia makes the process faster and easier.

“Restoration making is established and easy, and a very good fit can be reached due to dry milling,” she says. “With the introduction of precolored zirconia material, it is easier to get restorations with good color match.”

Using a shaded zirconia not only makes it easier to achieve the desired esthetics, but it can also help create a more durable restoration, Fernandez says. While some workflows call for applying stains to the zirconia before sintering the material, Fernandez says any moisture, including that from stains and glazes can, have negative impacts on unsintered zirconia which is why zirconia is milled dry.

“We see that a lot of zirconias out there, especially monolithics, they have to use liquid stains between milling and sintering,” she says. “We don't recommend it. There is no need for it (with pre-shaded multilayer zirconia). We know it is easily stained after sintering without having to add any moisture to the zirconia. We've seen that that is something that could bring some issues.”

But, zirconia isn’t perfect. According to professionals, for as good as it is, there is still room for improvement including necessary inventory efforts and high cost.

Zirconia requires high-temperature furnaces (~1500 °C), and attention needs to be paid to maintaining the furnace and using the correct sintering temperature,” Kopp says. “Saliva contaminations can reduce cementations’ strength if not properly cleaned after try-in. Sandblasting is recommended. It has a lower translucency level than glass ceramics, and properly cemented restorations stick very strongly to the tooth. In case of a clinical need to remove the restoration, some effort is required.”

Zirconia is very strong, but only after it is sintered. Before it spends time in the sintering oven, it is very fragile.

Godfrey sees the fragility and cost of zirconia as a bit of a drawback.

The material is quite brittle, and the supply cost can be rather high when you are in the business of producing All-on-X (AOX) solutions,” he says. “You must keep inventory in that circumstance, because if it should so happen that your AOX chips or breaks before—or during, heaven forbid—sintering, you need backup discs to keep producing. Lab [professionals who] focus on crowns and bridges generally don’t need to throw multiple discs at a problem. [It] can remill a single unit with relative speed and ease. [This is] not so for an AOX. Crack one of those, and you’ve got to not only add the cost of a new disc but also 1 day of lab time, owing to sintering, milling, and postprocessing. AOX is rightly a costly affair.”

Zirconia is relatively low in cost and seems to be getting less expensive every day. This is a benefit to everyone involved—labs have cheaper operating costs, dentists can make more money, and patients don’t have to spend as much.

“It’s actually cheaper now than in the beginning,” Hatzakortzian observes. “It was more expensive, but now, because it’s all done digitally, you actually have the prices going down. With a PFM, it’s very hard to find good lab technicians to bring into the laboratory. So you have a scarce resource when it comes to lab technicians. It’s actually cheaper to fabricate as a zirconia restoration than traditional PFM.”

According to Lawson, Insurance companies are paying more for zirconia restorations than PFMs.

“Reimbursement rates are typically higher for zirconia restorations than they are for metal-based restorations,” he says. “But the laboratory bill is much lower for as the zirconia crown than it is for a PFM crown in most large dental laboratories, just because there’s no metal cost associated with zirconia. I think lab [professionals] have gotten so efficient with making zirconia crowns that [it] can offer them at sometimes outrageously low prices.”

According to Sipperly, there is another benefit on the cost-saving front because zirconia is not at the whim of the metals market; it is a fixed cost.

“Metal varies daily due to the precious metal market,” he adds. “You have nonprecious metals, semiprecious metals, and precious metals. They all have different alloys and gold content. They change on price—with the exception of nonprecious metal—daily. With zirconia, you have a fixed cost. Let’s say that a 98-millimeter disc of good quality zirconia, today, sells for about $120. You get about 20 crowns, on average, out of that. So that’s $6 per unit material cost per crown. Just a couple of weeks ago, gold was $1900 an ounce.”

Zirconia’s properties can be confusing, especially because of how it’s manufactured.

“That’s less well understood,” Lawson says. “Zirconia, essentially, is fabricated from a powder that looks like chalk dust. And then they put it into a mold and compact it into something that looks it’s like an oversized hockey puck, but it has the consistency of sidewalk chalk. The way that they compact it into that hockey puck can affect its properties. If it is compacted only from one direction, called uniaxial pressing, the zirconia may not be as homogenous as if it is compacted from all directions, called isostatic pressing.

“The composition of the powder is usually relatively standardized because there are only so many companies in the world that make powder,” he continues. “And a lot of dental manufacturing companies aren’t making their own powder; they’re buying the powder. But they will typically put some of their own additives in there. For example, many manufacturers will add their unique color additives. They don’t really specify, so it’s hard to know what else they could be adding to the powders, but you wouldn’t expect them to be too compositionally different from each other.”

According to Godfrey, there isn’t just one type of zirconia. Manufacturers offer different formulations based on desired traits, strength and esthetics, and how the material is produced.

“Today, manufacturers of zirconia differ tremendously in product offerings, primarily due to production processes and powders used,” he says. “Zirconia can be hot isostatically pressed and can offer yttria stabilizers or erbium-praseodymium stabilizers for a different effect, in terms of color and translucency. These don’t all sinter the same and vary significantly from offering to offering, [but] these things must be taken into consideration when [lab professionals] choose new products. You’ve got to give it an honest effort. It’s a science, but there is art to this science with variables all over the place. You can increase sintering temps slightly for better translucencies, and you can switch to a microlayering technique to produce a depth and warmth of color.”

Per Hatzakortzian, the restoration’s location has an impact on what type of material to use.

“If you’re looking for anterior zirconia, you got to make sure that the Yttria is pretty much 4 and higher,” he says. “The reason for that is you’re going to get much more translucency, but you’re going to lose the strength. And then anything for posterior the yttria level should be around the 3s, which is pretty much giving you much more strength, but less translucency. Again, in the back, you’re not worried about the translucency or the esthetics too much. You’re actually looking more for functionality than the esthetic.”

How do the lab professionals know the best type, and how much, of zirconia to stock? With so many shades and thickness available, inventory costs can add up quickly. Sipperly advises that most labs only need a couple of different types on hand.

“Obviously, they want to use only 2 or 3 because that’s less inventory dollars,” he says. “There are about 16 VITA shades and 1 or 2 bleach shades that they might need, and they come in all different thicknesses. So, even though there’s 1 diameter, there are 3 or 4 different thicknesses that [labs] may need to carry. The goal is that we want to try to use the least the number of zirconias that we can to do our work, but in reality, they’re going to need 2 or 3, hence the anterior zirconia and the high strength zirconia, there’s even a zirconia for abutments, even higher strength, so it’s all over the board.”

While it’s a good idea to keep multiple zirconia shades on hand, Fernandez says multilayered zirconia options allow dental labs to reduce the types of zirconia they need to keep in stock. By adopting multilayered discs of zirconia, a lab can use the same type of zirconia for any area of the mouth and any types of restoration from thin veneers to full-arch, implant-retained bridges.

“So we have the simplicity of inventory right there,” she adds. “We are not having to choose different levels of translucency nor strength. So at the end it is a type of an artistry without compromise.”

For all the things that Superman and zirconia share in common, there is 1 important difference—Although Superman exists in comic book pages, toy aisles, and in the movies, zirconia is real and it makes lives better for lab professionals, dentists, and patients every day.

Everything dental lab professionals need to know to make smart choices about which zirconia discs to use.

Zirconia from A to Z

When NSK updated its Ti-Max Z95L handpiece in 2020 to include a spray switch that lets clinicians instantly switch between water spray or water jet functions, the dental manufacturer offered the first 2-way patented spray technology designed to offer maximum protection while contributing to cooling. The development also provided a benefit that has become very desirable during the coronavirus disease 2019 (COVID-19) pandemic—a method to reduce aerosols and splatter during certain dental procedures.

When the switch valve became available, Ron Kaminer, DDS, was quick to add the technology to his 2 Long Island, New York, practices.

“I learned of the Z95L when it was launched last year during the heart of the COVID-19 pandemic. Based on potential aerosol data in dental offices, this was an easy decision to incorporate into our practice,” he says.

The addition of the switch valve on the Z95L handpiece, which turns off the coolant air, allows contra-angle handpieces to reportedly reduce water aerosols by as much as 50%. The water jet (water only) is an alternative cooling function for the water spray during procedures. The water spray (water and air) can be activated without restriction when needed by twisting the switch.

Dr Kaminer likes the speed and ease with which the handpiece switches. “The beauty of this handpiece is that you can quickly switch between water jet and water mist,” he says. “The water jet quickly cools an area while at the same time reducing aerosol and splatter. By cutting down the air coming out of the handpiece, splatter is reduced, and this could be essential in procedures such as surgical extractions or apicoectomies and more.”

The Ti-Max Z95L handpiece now includes a spray switch that allows users to instantly switch between water spray or water jet functions. This is reportedly the world’s first 2-way spray technology and is designed to offer maximum protection while contributing to cooling. The addition of the switch valve, which turns off the coolant air, allows contra-angle handpieces to reduce water aerosols by as much as 50%. The water jet (water only) is an alternative cooling function for the water spray during procedures. The water spray (water and air) can be activated when needed by twisting the switch.

NSK instruments are designed with proprietary DualDefense infection prevention, yet another infection control benefit of using the Z95L. The Clean Head System prevents suck-back into the head and the exhaust line and the Anti-Retraction Valve prevents contamination of the water supply.

Additionally, the Ti-Max Z95L features a unique head cap design that helps limit heat generation during treatment. Its ceramic bearings are 25% harder than conventional steel bearings but are only half the weight. This allows the handpiece to reduce frictional wear between the ball bearings and the bearing retainer. Anything that helps reduce aerosols in the dental operatory is going to be on clinicians’ radars during a pandemic.

“This product has given me the flexibility to cut down aerosol, which in turn makes a safer environment for myself, my staff, and my patients,” says Dr Kaminer, who suggests colleagues consider adding the Ti-Max Z95L handpiece with switch valve to their armamentarium. “This product is a great addition to any practice but is a must for anyone doing a lot of surgery where contaminated aerosol could be present.”

Another benefit is access. The handpiece is indicated for any use but its slimmer body and neck are ideal for easier access to hard-to-reach areas without obstructing the view.

NSK America’s Switch Valve on the Z95L handpiece turns off the coolant air and allows contra-angle handpieces to dramatically reduce water aerosols.

A Dental Handpiece That Switches Things Up to Reduce Aerosols

All dental practices looking for a simple 3D printing solution for chairside restorations with lower costs and high efficiency.

Equipped with auto-calibration and more than 100 precalibrated materials, DENTIQ can be used for a wide array of applications including dental models, surgical guides, denture bases, denture teeth, removable partial dentures, impression trays, splints, mouth guards, castable crowns, and more.

DENTIQ offers a simple learning curve for beginners while providing the high level of accuracy and consistency that professionals are looking for. With remote diagnostics for machine repair, easy component replacement, a built-in vat cleaning function, and a 2-year warranty, the 3D printer is designed to make digital dentistry technology accessible for every level of user to achieve great chairside results.

 Featuring an ergonomic exterior design, plug-and-play printing, fail-safe vat frame, and vat standoffs that protect the vat films, this 3D printing solution is part of Ackuretta’s ecosystem designed with hardware, software, finishing solutions, materials, and training resources to keep everything in-house and make dental 3D printing effortless.

This high-precision chairside 3D printer is designed to provide an effortless ownership experience for every user.

5Ws* Ackuretta’s DENTIQ 

Compiled by Noah Levine — Information provided by DocSites

 The DocSites Dental Websites and Marketing

 Always on when patients need practice information

 A dental practice’s online presence is among its most important assets and often the first way patients encounter and interact with the practice. The DocSites has been creating and managing the online homes of dental practices for more than a decade, and provides modern website design options that are personalized for each practice with marketing options to help practices create and manage a modern online presence that can help make a great impression on current and prospective patients. Optional marketing packages help practices manage social media sites, blogs, online reviews, and even Google and Facebook advertising.

The DocSites works directly with each practice and handles all the work of setting up the practice website. Live customer service and a dedicated account manager throughout your service are available to help practices keep their website updated, without the commitment to long-term contracts. Website monthly fees are affordable with several plans available, all of which include monthly hosting with free web updates. Additionally, moving your practice website from a different provider to DocSites is streamlined with the Easy Site Transfer service.

A website and marketing company that makes it easy and affordable to have a great website and online presence.

5Ws* The DocSites

When the coronavirus disease 2019 (COVID-19) pandemic forced most dental practices to shut down in the spring of 2020, Jennifer Clark, RDH, quickly began searching for safer methods of practicing dental hygiene to use when offices began to reopen.

Clark, who has worked in dental hygiene for 3 decades, is a proud team member of Magann Family Dentistry in Stroudsburg, Pennsylvania. The practice—like most in the country—closed last March because of the pandemic. She then began to research methods of reducing aerosol spreads during common dental procedures.

“As information came out regarding the need for dental practices to control aerosols to prevent the spread of COVID-19, I began researching high-volume evacuation (HVE) options online. This is how I discovered the ErgoFinger,” she says.


Clark was intrigued by the disposable finger-attached HVE Tip that is both ergonomic and designed to reduce aerosols.

“My first product kit arrived in June and I’ve been using it every day since,” Clark says. “The best feature…is the lightweight hose. It poses no draw on the wrist when wearing the product and allows you to move freely around the patient in an ergonomic-friendly manner. It also has an adjustable nozzle, which extends, retracts, and rotates 360 degrees for increased intraoral access. I also love that the HVE valve is removable and autoclavable—so there’s no cross-contamination.”

ErgoFinger is a disposable finger-attached HVE Tip that permits ergonomic working postures to avoid upraised arms, bending, twisting of the neck, and other stress-producing positions. Designed to reduce the physical stress a dental professional may experience when working without an assistant, the wearable tool also improves aerosol and splatter control during procedures. The ErgoFinger HVE Tip features a nozzle bore size of 11 mm that reduces aerosol contamination from the oral cavity and eliminates fluid and debris when a clinician is performing instrumentation procedures without an assistant. Each package contains 50 pieces of finger-cup, sizes S-M or L-XL with attached nozzle, and 50 pieces of tube.

She says adding this product to the regular workflow in her practice allows her to resume ultrasonic scaling in a much safer environment. She is confident in the performance of ErgoFinger for significant aerosol reduction (proven to be more than 90%) and has received many positive comments from patients.

“They notice that the overspray is greatly reduced from ultrasonic scaling now with the ErgoFinger being used, compared [with] prior visits just using the saliva ejector,” Clark says. “There have been patients [who] would not allow the ultrasonic scaler before but agreed to it after I demonstrated it with the ErgoFinger.”

Another benefit Clark likes is the additional tip, the ErgoAirTip, designed to be used with air polishing devices. You simply remove the ErgoFinger tip and attach the ErgoAirTip.

“Aerosol reduction with either tip is largely [because of] the bore hole size. The ErgoFinger opening is 11 mm and the ErgoAirTip is 14 mm,” Clark explains. “Both exceed US standards for HVE, which is 8 mm.”

Ergonomic and safety benefits during a pandemic make this product one Clark is thrilled to add to her daily routine at Magann Family Dentistry. Each package includes different finger sizes.

“I’d give this product 10 stars if I could. It has rapidly become the most valuable instrument I use. To all my dental colleagues, if you are still searching for an HVE option, try this. If you have something already in your practice, try this. Trust me, once you do, you will not be sorry,” Clark says.

Also, she adds, the ErgoFinger is simple to install without requiring special equipment or training. The wearable tool attaches to your existing HVE via a 2-in-1 adapter and no technician is needed

The ErgoFinger disposable finger-attached HVE Tip permits ergonomic working postures to avoid stress-producing positions and helps reduce aerosols during procedures.

Zirconia from A to Z

A Dental Handpiece That Switches Things Up to Reduce Aerosols

5Ws* Ackuretta’s DENTIQ

5Ws* The DocSites

Dental Product Improves Aerosol Control and Ergonomics