For many years, the IPS Empress all-ceramic brand was known for the highest level of esthetics when imitating the characteristics of natural teeth. Since it was introduced, more than 37 million indirect crown and veneer restorations fabricated from the

pressed ceramic material have been placed.

It’s not surprising, then, that dentists have sought to recreate the same esthetic qualities they’ve achieved with indirect porcelain with direct composite. Unfortunately, ensuring long-term functional and esthetic durability of direct composite restorations is challenging, even with enhancements to direct restorative materials.

To keep pace with the latest trends in cosmetic dentistry, which include the need for durable, esthetic and convenient materials for placing direct restorations, the IPS Empress system has advanced significantly. The newest addition to the IPS Empress System is IPS 

IPS Empress Direct is a light-curing, nano-hybrid composite that demonstrates excellent handling properties to achieve the consistent anterior and posterior esthetics of ceramic with the on-demand ease of composite. Additionally, IPS Empress Direct is based on the latest technology and features a variety of true-to-nature dentin and enamel shades, and different levels of translucencies and opacities to create limitless opportunities for realizing esthetic results for all indications.

allows dentists to mimic the optical effects of natural tooth structures in a way that is similar to ceramic, but with the direct simplicity of composite. The basis for consistent and quality shade selection when using the IPS Empress Direct composite is two high-quality ceramic shade guides.

To demonstrate the convenience of placing IPS Empress Direct composite, the creation of an anterior restoration is illustrated. This esthetically optimized nano-hybrid composite was selected for treating a 50-year-old male who presented with a failing composite restoration on tooth No. 11 

 Before removing the defective restoration and preparing the tooth, an accurate shade was taken 

. It was determined that IPS Empress Direct A2 Dentin and IPS Empress Direct A1 Enamel composities would be used.

. To ensure complete isolation, rubber dam (OptraDam) was placed.

. The defective restoration was removed from tooth No. 11 and the tooth prepared 

 An etchant gel (Total Etch) was applied to the tooth for 15 seconds, after which the preparation was rinsed and dried.

. A fifth-generation adhesive bonding agent (ExciTE) was applied to the preparation for 10 seconds using a convenient dispensing tool (ExciTE VivaPen)

. The bonding agent was air-thinned with high pressure and light cured for 10 seconds using an LED curing light (bluephase 20i).

. After light curing, the dentin replacement layer of IPS Empress Direct A2 Dentin was placed 

. This increment was sculpted into place using an artist’s brush 

 This composite layer was cured for 40 seconds.

. IPS Empress Direct A1 Enamel was placed 

. The mylar strip was used to help adapt the composite into the mesial and distal areas of the tooth 

 The rubber dam was removed, and the restoration was initially finished using Assorted ET Carbide (Brasseler) 

 The restoration was then polished using a series of integrated products, including the green OptraPol polisher 

To further enhance the restorative process, IPS Empress Direct exhibits high stability, shade fidelity and enhanced polishing properties 

. As a result, dentists can achieve the esthetics of ceramic with the chairside, direct placement convenience of a composite. Its physical properties are specifically designed for simplified application, while low sensitivity to light ensures ample, pressure-free working time for designing restorations. To meet the highest clinical demands, this nano-hybrid composite also demonstrates an optimum radiopacity.

 is accredited by the American Academy of Cosmetic Dentistry and lectures internationally on cosmetic dentistry. He also serves as a product consultant to dental product 

Articles

For many years, the IPS Empress all-ceramic brand was known for the highest level of esthetics when imitating the characteristics of natural teeth. Since it was introduced, more than 37 million indirect crown and veneer restorations fabricated from the IPS Empress pressed ceramic material have been placed.

How to: Create an esthetic anterior restoration

Manufacturers are developing new composite materials almost every week, yet many of the popular composite polisher formulations have not changed for a decade or more.

Many of the polishers that were designed to be used on composite materials are no longer available today. Now this is not to say the older polisher formulations are not clinically acceptable, but it is to say that many of these older polishers are not capable of achieving the esthetic results possible with today’s 

The latest generation composite materials are capable of exceptional results that offer clinicians the ability to create fantastic restorations. When these materials match with polishers that were designed for use on latest generation composites, clinicians can achieve outstanding results with fewer steps in their procedure. This case study shows how 

new UltraGloss and ProGloss composite polishers can reduce chair time and produce excellent results complementing today’s composite materials.


	A male patient presented with a discolored composite restoration on tooth No. 8 (Fig. 1) and wanted to have it replaced for esthetic reasons. A dental exam indicated no caries, and it was determined that the best treatment method would be to replace the existing restoration with a new composite restoration.

Clinical protocols were followed to analyze the patient’s smile, as well as to isolate and prepare the tooth.

. The original restoration was removed and minimal preparation was performed on the tooth. Using a shoulder preparation bur, the tooth was feather-edged 2 mm beyond the filling preparation (Fig. 2).

. The prepared area was air abraded with 50 micron aluminum oxide using a 

 Micro-etcher precision sandblaster to eliminate any contamination by the handpiece.  The preparation was then rinsed and dried.

. A 34% phosphoric acid etch was applied to the preparation for 15 seconds and then rinsed and lightly dried.

 Caulk’s Prime & Bond NT was applied to the tooth and air dried for 5 seconds.

 Renamel Nano and sculptured into position with a Thompson Tactile Tone GTX #9 composite instrument.  The instrument tips were coated slightly with DENTSPLY’s Prime &  Bond to prevent sticking.

. The composite was cured using a LED curing light for 15 seconds.

. The composite was given its initial shaping using a 12-fluted, safe end tip, trimming and finishing carbide (Fig. 3).

 The 12 mm UltraGloss coarse and medium shaping discs, from Axis Dental, were used to recreate the natural anatomical contours of the tooth (Fig. 4).

. Axis Dental’s ProGloss Single Step composite polisher was used to create a high gloss shine on the restoration (Fig. 5).

 The completed composite was given a final curing with the curing light, as per the manufacturer’s specifications. The patient’s new restoration delivered the desired esthetics (Fig. 6). 

The availability of composite shaping and polishing systems, which are designed to optimize the performance of today’s composite materials, has greatly reduced the number of steps necessary to achieve excellent results. Advanced disc systems, such as 

,  allow for rapid creation of natural anatomy and seamless margins. Single step composite polishers like

 allow clinicians to adjust, pre-polish and create a high gloss shine in just one step. These time-saving products, when used with the latest generation composite materials, reduce valuable chair time and provide patient-pleasing esthetics.

Otice Z. Helmer, DDS, MAGD, of Fort Worth, Texas received his DDS degree from the Baylor College of Dentistry in 1970. He is active in the ADA and Texas Dental Associations; serving on many committees of the AGD and is a 2009 Master member and past Fort Worth AGD - President.

How to: Use single step composite polishers

	1. With a life of 30,000-plus hours-10 times longer than halogen-the everLight eliminates the need to replace light bulbs.

	2. Using 70% less electricity than halogen-based systems the everLight’s use of less than 35W of energy is said to help lower energy bills.
	
	3. The 100% true direct LED lighting remains at a consistent, cool temperature, eliminating the need for noisy fans or reflectors.
	
	4. Equipped with nine color temperature/intensity settings, everLight is ready to meet a variety of operative needs including focused, shadow-free, color-corrected lighting.

	5. The everLight’s natural daylight illumination provides clearer oral cavity visibility and precise color matching, and the composite setting will not cause pre-maturing on composite materials.

		A delivery unit for patient comfort and clinician convenience: Group Simplicity from DentalEZ

		Comfortable operatory seating: Generation Stool from DentalEZ

	Magnification can help you take advantage of what the light illuminates, and companies such as Orascoptic (

) offer a range of loupes to fit just about any clinical need.

 1. With a life of 30,000-plus hours-10 times longer than halogen-the everLight eliminates the need to replace light bulbs.

Lasting brightness

 features Carbon Fiber, the newest of Bien-Air’s technological advancements in dental handpieces. A light-weight core combined with optimal strength offers maneuverability and longevity for the user. The base of the handpiece is a composite of carbon fiber fabric (see yarn inset to the right), plus injection molded epoxy resin.

 Gram for gram, Carbon Fiber has 10x the tensile strength of titanium.

: The Bora and Prestige models in the Blackline series are the lightest Bien-Air handpieces created since the company’s first handpiece in 1969.

 The tensile strength of carbon fiber makes it extremely resistant to surface scratches, which ensures greater longevity.

 The Blackline® Highspeed Handpiece series features Carbon Fiber, the newest of Bien-Air’s technological advancements in dental handpieces. A light-weight core combined with optimal strength offers maneuverability and longevity for the user.

APPLYING Blackline handpiece in your practice

	Reminding patients to come to their scheduled appointments can be costly. Buying recall cards, paying for postage and staff hours spent mailing the cards all take time and money. And after all that, chances are those reminders will go straight from your patients’ mailboxes to their recycle bins.

	These days, many of your patients do their communicating online or via text messaging. They don’t want to call your office during business hours; they’d rather do their confirming or any other business with your practice online, when it’s convenient for them.

	Communicating with your patients this way is an economical, efficient way to keep track of what’s going on in your practice. Intimidated? There are solutions out there from Smile Reminder, Sesame Communications and Demandforce that can help.

	These solutions integrate with your practice management system and electronically remind patients about scheduled appointments-and with no extra work for your staff. With Demandforce’s solution (

), patients receive a text message and an e-mail; all they have to do is click to confirm. This way, staff members can easily see what their day looks like, Senior Marketing Manager Jordan MacAvoy said. They can tell who has or hasn’t confirmed, so they know who they need to reach out to.

	Not only does e-communication save money, it can add revenue to your practice, said Mark Olson, VP of Marketing for Smile Reminder (

). If you have unscheduled patients who are overdue for hygiene appointments, they’ll receive an e-mail reminder that makes it easy to request an appointment.

	And last-minute cancellations don’t have to mean lost chairtime, Olson said. Features like Smile Reminder’s ASAP find patients who asked to move their appointments up. Those patients get a text message, and within minutes someone has filled the time slot.

	These solutions make it easy to track just how much money they’re bringing into the practice.

	“Each month, we literally show the office the patients we brought in,” said Marc Watenwaker, Demandforce’s National Sales Manager, Dental. “The most important thing the doctor wants to see is ROI. We show him the exact revenue the patient spent with the office. It’s a very powerful tool.”


	While it’s important to keep your Web site updated, a complete strategy for patient connections that includes access to treatment plans, online payment, reviews and feedback mechanisms and a variety of other services is extremely important. And you can’t ignore social media’s potential to attract patients, Sesame Communications (

) CEO Frith Maier said. She recommends an online strategy that incorporates a top patient-rated Web site, social media, blogs and YouTube content. Think of Twitter as a modern chamber of commerce, she said; other businesses can serve as an active referral source for you. Use Facebook and YouTube to promote new services, something these solution providers can help with.

	And don’t forget about the power of patient referrals, Maier said. Patient reviews generated from solutions like Sesame’s also can be posted on your Facebook page for potential patients to see.


	E-communications have a longer life and further reach than a piece of mail or a phone message, Olson said. If you send a newsletter about implants to patients through the mail, they’ll likely throw it away if it doesn’t apply to them. But if it comes via e-mail and they know someone who’s interested in implants, they’re more likely to forward it on. You also can post it on Twitter or Facebook, where there’s a chance others will re-post it for their networks to see.

	“That gives you an indication of the power of the electronic message,” Olson said. “You’re actually doing more for less.”


	Not only does e-communication save you money, it’s what many of your patients want, Watenwaker said. If you’re not online, potential patients are likely to pass you by, and in the end, that will only cost you money.

	“If you’re not online, you’re not visible to patients in the first place,” Maier said. And if you’re not using the tools that make their life easier, they’re going to feel like any dentist could be as good as you. It’s a major differentiator.”

    Reminding patients to come to their scheduled appointments can be costly. Buying recall cards, paying for postage and staff hours spent mailing the cards all take time and money. And after all that, chances are those reminders will go straight from your patients’ mailboxes to their recycle bins.

Talk should be cheap

	The question arises, though, why implants? Why has Dental Products Report added a team on dental implants?

	Well, the numbers are compelling. The American Dental Association, in its 2007 Survey of Current Issues in Dentistry, found that 16% of all practicing dentists had surgically placed an implant in 2006, and the number of practitioners doing so was increasing steadily. Given this finding and trend, coupled with the United States Department of Labor Bureau of Labor Statistics projection that there will be 176,000 practicing dentists in 2016, it is easy to anticipate that there will be as many as 40,000 dentists placing implants in the next 5 years, and it goes without saying that essentially all restorative dentists will be involved with implant-supported prostheses.

	The emergence, development and refinement of osseointegrated dental implants over the last three decades, particularly in terms of simplified, ‘tooth-like’ prosthodontic treatment options, leaves the practicing dentist with no option but to consider dental implants when tooth replacement is necessary. In fact, the situations during which implants can and should be considered the treatment of choice for tooth replacement are becoming the rule rather than the exception.

	Not too many years ago, it seemed that having virgin adjacent, potential abutment teeth, along with lacking abutments posterior to the edentulous sites, were the only clear indications for implants in partially edentulous patients. And patients completely edentulous in one or both arches might have a recommendation for implants only if they complained of severely compromised function.

	Now, though, the perspective on the role of dental implants in fixed and removable prosthodontics has changed, and I suspect we can all agree this perspective has changed dramatically. There is compelling evidence that using implants in edentulous arches both slows the rates of alveolar ridge shrinkage and improves patient perceptions concerning comfort and function, leading to an improved quality of life. In fact, using implants to support a complete mandibular prosthesis imparts such a positive effect that offering a minimum of two implants to a patient who is (or is soon to be) edentulous in the mandibular arch is considered the standard of care.

	For those of us doing implants over a long period of time, the improved quality of life attributable to implants that is routinely experienced by our edentulous patients comes as no surprise. For our partially edentulous patients, the benefits of using implants rather than conventional tooth-supported partial prostheses might be seen as less life-changing, and yet the arguments in favor of considering and offering implants are nonetheless compelling. Who amongst us would still consider a conventional 3-unit fixed partial prosthesis (FPP) to be a reasonable treatment option in an otherwise esthetically pleasing and functionally intact segment when using an implant would allow replacement of the missing tooth without adversely affecting unrestored adjacent teeth?

	Digging a little deeper into the available data, the argument can be made that a single implant-supported crown is the treatment of choice for the pontic site when an existing FPP requires replacement, along with one or two new single crowns as needed for the teeth that had been serving as abutments. This argument seems justified because the long-term prognosis for single implant- and tooth-supported crowns is better than that for FPPs, with lower complication and failure rates.

	In situations where an existing FPP has failed and one or more of the supporting abutment teeth are lost in conjunction with this failure, it behooves the practitioner to take a long, hard look at using implants rather than just making a longer, more complicated bridge. Clearly, the risk factors that led to loss of the FPP and abutment teeth are still at work long-term in the patient’s mouth even if the dentist seems to have gained improved patient oral health and stability short-term.

	The images included in this article are of a patient I treated in 2004. She had a conventional tooth-supported 6-unit FPP replacing her mandibular incisors for many years. The combination of longstanding periodontitis, even though relatively well-controlled, and secondary occlusal trauma left this FPP mobile, and it ultimately failed with loss of the two abutment teeth. DEXIS digital radiographs (

) revealed favorable residual ridge height in the mandibular anterior segment and also revealed the mandibular premolars had some bone loss and less-than-ideal root morphology. I cannot imagine placing implants without digital radiographs. Even if the only thing I used my DEXIS sensors for was intraoperative orientation images, and clearly it is not as I have not had a film processor in my office since 1998, digital radiography would remain the best investment I have made in technology. Isn’t it nice, knowing whether or not you need a retake before the sensor is out of the mouth? 

	Would it have been possible to restore this patient with a 10-unit tooth-supported FPP (using all four mandibular premolars as abutments)? Sure. Would I have been nervous about these teeth holding up as bridge abutments? Absolutely.

	Implants for this patient were placed in the position of her mandibular canines, and her existing temporary removable partial was modified to serve as an immediate-load minimally functional screw-retained provisional FPP (

). When making an immediate fixed provisional, I generally use flowable composite intraorally to lute the crown or bridge to the temporary abutments. Healing in this case was uneventful, with favorable tissue and bone health at four months (

). The definitive implant-supported FPP was then fabricated and cemented 

), satisfying both the patient and the restorative dentist. Almost six years later, she continues to comment on how nice it is to be able to enjoy her favorite fruit: Granny Smith apples.

	So, am I implying that dental implants are the treatment of choice for every edentulous or partially edentulous patient? The one-word answer remains, “No.” Current research and my clinical experience leave me with a few one-word alternative answers, though: “Almost” or “Perhaps.”

	Every time we see a patient with a missing tooth or missing teeth, we should consider dental implants as a treatment planning option (commonly the treatment of choice), and we should help each patient make an informed decision consistent with his or her values and priorities.

	During my years as editor of Inscriptions, the Journal of the Arizona Dental Association, our tagline was ‘Essential Reading for Arizona Dentists.’ My goal, our goal as your Clinical 360° Dental Implants Team, is to make this column equally compelling. Essential reading for America’s implant dentists. Let us know how we are doing.

Brien Harvey, DDS, graduated from the University of Iowa, College of Dentistry in 1981, receiving his certificate in Periodontics and Masters Degree in 1983. 

 The question arises, though, why implants? Why has Dental Products Report added a team on dental implants?

A place at the table

	It’s 2010, and it’s official. With the advent of the new year, we also face an intriguing new tax-planning option, one that offers us both opportunities and challenges, especially during 2010–2112. It’s the arrival of new IRA-to-Roth-IRA conversion rules. Now that they’re here, it’s worth taking a bit of time from the bench to consider what they mean to you, your wealth, and your retirement and estate planning needs.


	There are a variety of reasons you may decide to convert your traditional IRAs to Roth IRAs, which have two major advantages over traditional IRAs:

	First, Roth IRA distributions are tax-free if they are qualified distributions. To be qualified, they must be made after a five-year holding period has passed and after the accountholder reaches age 59½.

	Second, Roth IRAs are not subject to the required minimum distribution (RMD) rules that apply to traditional IRAs. Therefore, a Roth IRA accountholder who reaches age 70½ does not need to begin taking distributions; instead, the funds can continue to grow tax free until they are needed or are passed to heirs.

	The tax-free nature of Roth IRA distributions may help you avoid higher tax brackets that would otherwise apply if you were withdrawing distributions from a traditional IRA. Moreover, these distributions-unlike those from traditional IRAs-do not affect the calculation of tax owed on Social Security payments.

	You should consider an IRA-to-Roth-IRA conversion if any of the following apply to you:

		You can afford to pay the tax on the converted amounts from an account other than the IRA.

		You expect to be in a higher tax bracket in the future or have certain favorable tax attributes that will lower 2010-2012 taxable income.

		You have enough time before retirement to allow assets to grow tax-free and recoup dollars lost due to the taxes upon conversion.

	Before you start immediately filling out the conversion paperwork, it’s important to assess a few essential details on how the conversion rules work and how they may impact you one way or the other.

	First, it’s important to understand that an IRA conversion is treated as a taxable distribution. It’s taxed as ordinary income at your marginal tax rate (although it does not trigger any early withdrawal penalty, as an ordinary withdrawal would). This in effect accelerates the taxable income that you would eventually have had to pay on distributions from a traditional IRA when you retire. It does so in exchange for never taxing any future appreciation in the value of your account. This can be a significant tax advantage for some taxpayers …but it may or may not be an advantage for you.

	Second, if you do choose to convert in 2010 and pay the taxes sooner than later, you face another decision on exactly how soon. Although conversion to a Roth IRA triggers immediate taxable income, Congress has provided a special incentive in 2010 to jump-start Roth conversions under the new rules: In 2010 (and 2010 only) you must elect one or the other of these two options: You can recognize all the conversion income in 2010. Or, you can average it over 2011 and 2012, spreading taxes on the converted amount over the rates in effect during those two years.

	Third, even if you can chart out your own expected income during the coming three years, several forces beyond our control take an already interesting tax-planning equation and create even greater challenges. For some taxpayers, their tax rate may rise after 2010 even if their income does not. This is because The Economic Growth and Recovery Act of 2001 expires and the top (maximum) tax bracket of 35% goes away with it. In its place, pre-2001 marginal income tax rates return in 2011, including the top two brackets of 36% and 39.6%.

	It’s possible increases will be even higher than scheduled. How so? President Obama’s 2010 budget proposal makes permanent the 10%, 15%, 25% and 28% individual income tax brackets. This would be good for individuals with taxable income of less than $190,650 and for married couples filing jointly with taxable income less than $231,300. But in 2011, as mentioned above, the 33% and 35% rate brackets become 36% and 39.6%, respectively, which means you won’t need to earn as much to reach the 36% bracket. Will all of this actually happen? We don’t know, but stay tuned for developments as budget, health care reform and other initiatives work their way through Congress.

	For now, you can at least think of it as an automatic tax increase of some sort or another, beginning in 2011. If you do not want to take the chance that your income tax rates will be higher in 2011–2012 than in 2010, you may elect to pay the full tax on the Roth conversion in 2010.

	Clearly, deciding whether to convert from traditional to Roth requires some careful planning for tax years 2010–2012. This is especially so if your income is subject to fluctuation, as is the case among many dental professionals given the recent economic turmoil. It also requires assessing the optimal way to report a conversion taken, and calculating proper payment of estimated taxes thereon. And remember, the Roth conversion is not an all-or-nothing proposition. You may convert as little or as much of your traditional IRA as you want.

	If you are planning to take advantage of the Roth IRA conversion opportunity, consider some of the following:

		Because of the economic slowdown, many individuals are postponing retirement. Roth IRAs, unlike traditional IRAs, generally have no age limitation on contributions from earned income or on mandatory payouts. This is an advantage if you are extending your career beyond traditional retirement age.

		If you can make deductible IRA contributions for 2009 before your tax return is due on April 15, we recommend you consider doing so. It can help reduce your 2009 tax bill. If you then convert the contributions to a Roth IRA in 2010, you will not have to pay back the tax savings until 2011–2012 (if you elect to ratably pay the tax over that two-year period). 

		Additionally, you may want to consider making non-deductible IRA contributions for 2009 and 2010, because you can later roll over the amounts into Roth IRAs at no tax cost.

	Just as you might seek the advice of a specialist for a particularly complex treatment plan for a patient in your dental practice, the best advice on how to sort through the many possible benefits and considerations related to the new 2010 Roth Conversion rules is to contact a trusted advisor to discuss your personal situation. Some of this planning is straightforward, but as you drill down into each facet of how a Roth conversion can affect you long term, you are really looking at some very advanced planning.
	
	

J. Haden Werhan, CPA/PFS, is a partner at Capital Performance Advisors LLP in Walnut Creek, Calif. Haden specializes in advising dental professionals on tax and wealth management strategies. He can be reached at 800-877-0564

 It’s 2010, and it’s official. With the advent of the new year, we also face an intriguing new tax-planning option, one that offers us both opportunities and challenges, especially during 2010–2112. It’s the arrival of new IRA-to-Roth-IRA conversion rules. Now that they’re here, it’s worth taking a bit of time from the bench to consider what they mean to you, your wealth, and your retirement and estate planning needs.

The Roth IRA conversion gamble?

	Lasers have changed the way tooth preparation is performed in a variety of clinical situations, but between the cost of the devices and the individual cases that present themselves in the everyday practice of dentistry, they are not a panacea. Finances and cases dictate that the air-driven highspeed handpiece is still the method used for the vast majority of dental procedures involving the removal of tooth structure.

	It’s interesting that since the development of the air-driven highspeed in the middle of the 20th century little has been done to change or improve the device. Oh sure, we’ve had some minor updates. Things like ceramic, lube-free bearings have come along to reduce the damage done to the devices during sterilization, but that improvement is really a decrease in required maintenance and does nothing to change the clinical efficiency or overall patient experience.

	In the 1980s, we had fiberoptic lights, but those have been rendered moot for many of us who are now using some type of accessory lighting attached to our surgical telescopes. My Orascoptic Zeon Discovery is so bright I don’t even use track lights anymore.

	We’ve had changes in grips and turbine speeds, but can you really remember anything Earth shattering-the kind of improvement you can really point to as changing things? Me neither.

	The only drastic improvement in handpiece technology has been the development and implementation of the electric handpiece. For those using them, I hear great feedback with relatively few complaints, but their market penetration is still much lower than traditional air-driven units.

	So, you can imagine my response when I was approached by ProDrive Systems last year and asked to test drive their handpiece. Although they do sell handpieces, ProDrive is mainly a turbine company. Their sales model is to sell upgrade turbines at a price comparable to the cost of a turbine from the original manufacturer. Big deal you say? You can get replacement turbines from a variety of providers. This is true, but you can’t get ProDrive turbines from anywhere but authorized ProDrive providers, and, trust me, you’ll want to check them out.

	My clinical test drive was pretty simple. I took a brand new (out of the box) original manufacturer handpiece and a new round shank bur. I compared that with a brand new (out of the box) ProDrive upgraded handpiece with the same style new ProDrive bur. The handpieces were identical other than the turbines. I spent two weeks running the test. I prepared all crowns using the two handpieces in a side-by-side comparison. I would perform half the lingual reduction with one handpiece and then the other half with the other. I repeated this process on every surface. Although I was skeptical before the trial began, I quickly was aware of a noticeable difference in efficiency with the ProDrive turbine.

	What makes the ProDrive turbine so different is it uses a special chuck design. Rather than having a chuck that is round and accepts a round-shanked bur, the ProDrive chuck is triangular and uses a bur with a triangular shank. While this difference seems slight, the principle is profound.

	A round chuck with round shank provides slippage in the way the bur is gripped. Although you cannot feel this-I never noticed a feeling of slippage in all my years of clinical care-it definitely occurs. However, when a triangular chuck and a triangular shank are used, the bur cannot slip inside the chuck. It is locked in mechanically. This allows all the energy developed by the turbine to be delivered to the actual process of tooth preparation, and thereby allows the ProDrive turbine to cut more efficiently with less chatter.

	In addition, because the bur cannot move in the chuck, the bur spins more concentrically, which translates to better and easier margin finishing. The bur shanks also have two concentric grooves that allow you to extend the bur-with the rings locking it in place-to allow you to continue cutting with the same bur but with a longer shank and without concern of it “walking out” of the chuck.

	At the end of the trial, I was so impressed with the product I upgraded 10 handpieces to ProDrive turbines.

	I can truthfully say the efficiency of the cut was noticeable and clinically significant. In clocking my procedure times, I find a crown prep takes less time and is easier to perform using the new turbines.

	I love the efficiency for two reasons. The first and most important is it means less drilling for my patients. Anytime we can get a better or comparable outcome with less trauma to the patient, we should seriously consider the product. Second, less time with the handpiece means less hand fatigue and more time in the day. You can use this time to see an extra patient or to just relax and decrease your stress level.

	The turbines are available for air-driven highspeed handpieces manufactured by Kavo, Star, and Midwest. The turbines can be purchased and installed by a ProDrive dealer and the price is similar to the cost of a stock replacement turbine.

	Although not all handpieces from every manufacturer can be upgraded, more are being considered. If you are in the market for a new handpiece, ProDrive does sell one manufactured by Sirona and sold under the ProDrive label.

	As far as durability, I have been using my upgraded handpieces since mid to late January 2009, and all 10 are still performing well with no turbines being replaced. The maintenance for sterilization is similar to stock turbines so there are no excessive or time-consuming steps involved in maintaining them. As far as my staff is concerned, there have been no changes in our pre- and post-sterilization protocols. The staff also likes using ProDrive as it increases the efficiency of the appointments and gives them a few extra minutes between patients. These little breaks can make a big difference in “catching up” in a busy practice.

	The triangular-shaped burs are currently only manufactured by Meisinger. They come in every shape and size as their regular bur inventory. The cost of the burs is similar to the cost of round shanks, and both diamond and carbide are available. The manufacturing rights to make the triangular shank may be picked up by other bur manufacturers as well. Of course as you switch over to the new turbines, you’ll need to use up your existing inventory of round shank burs.

	There are lots of ways to improve patient care and efficiency in today’s dental office, but this is one of the few things that impact an instrument used in almost every procedure. Because it means less time in the dental chair with the bur on the tooth and the handpiece in the mouth, patients will appreciate the time savings. Doctors will appreciate the time savings because it means lower stress-both mentally and physically-while helping to provide a superior clinical result.

	ProDrive is available through many authorized ProDrive dealers. If you have handpieces that need turbines, give one the ProDrive make over and see the advantages for yourself. I went from skeptic to raving fan in less than two weeks.

Taking ProDrive for a spin

1. TS2000™ diamonds save time and money by simultaneously performing rapid gross reduction and creating a marginal finish line.

	2. The permanently brazed TS2000™ features proprietary P.B.S.® bonding that provides consistent performance and longer cutting life, and helps the burs withstand the high torque of electric handpieces while delivering smooth cutting action over multiple uses.
	
	3. The TS2000™ burs are designed with the spiral channel machined into the blanks before diamonds are applied, greatly reducing the likelihood of diamond particle loss.
	
	4. The spiral circulates water spray to the cutting site and flushes away debris that would otherwise clog the tip, creating cooler, more efficient cutting.

	5. Natural diamonds in a coarse grain size produce exceptionally smoother margins and axial walls, eliminating the need to use an additional fine grit bur to correct surface irregularities.

		A reliable highspeed handpiece: COMFORTdrive 200 XDR from KaVo

		A retraction system: Traxodent Hemodent Paste Retraction System from Premier Dental

	Once you’ve prepared the tooth, a digital impression system such as the E4D Dentist from D4D Technologies (

) can capture every detail of your well-defined margins. 

 http://premusa.com1. TS2000™ diamonds save time and money by simultaneously performing rapid gross reduction and creating a marginal finish line.

Enhanced speed and accuracy

	There is no material in the history of dentistry that has undergone as much evolution as composite resin. The face of restorative dentistry changed forever when successful bonding to dentin was achieved. Since then, the goal of clinical and material science has been to find simple, predictable approaches to the composite restorative process.

	Unlike dental amalgam, the patrician of direct restoratives, placing composite requires many more steps and exacting technique to achieve the best results. The process of adhesion, conditioning the tooth surface, applying primers and adhesives, followed by layering the composite resins to complete the restorative process involves many independent steps that must be properly executed to ensure good results. Successive generations of dentin adhesives have sought to decrease the number of steps for placement without sacrificing clinical results. The seventh-generation self-etching dentin bonding systems have helped decrease technique and post-operative sensitivity issues while still yielding clinically acceptable restorations. Many clinicians even have used flowable resins as the first layer of composite resin after placing adhesive to ensure precise wetting of the adhesive surface, while creating a layer with less polymerization stress because of a lower modulus of elasticity (< 0.5 mm thickness).

	A new composite material, Kerr Corp.’s Vertise Flow (

), combines the adhesive and flowable steps into one, resulting in one of the first self adhering composite materials on the market.

	There are two distinct mechanisms of adhesion for self adhering materials-chemical and micro-mechanical. The primary bonding mechanism for Vertise Flow is chemical bonding between the calcium ions in the hydroxyapatite crystals and the phosphate groups in the glycerol diphosphate dimethacrylate (GPDM), which is the adhesive monomer common to all adhesives in Kerr’s OptiBond family of dentin adhesives.

	Vertise Flow also bonds to tooth structure via micro-mechanical retention, which is the result of the interpenetrating network formed between the polymerized monomers in the material and the collagen fibers and hydroxyapatite crystals within the smear layer. Brushing this first layer of material vigorously into the tooth surface enhances this penetration into the smear layer and creates a bond comparable to what most available seventh-generation dentin bonding agents can achieve.

	Two clinical cases will be presented to illustrate a “simplified approach” to matrix and placement of direct posterior composites. This technique provides an accurate reproduction of the proximal surface and contact, also decreasing the number of steps involved in the adhesive restoration process. Decreasing the amount of rotary finishing and contouring required to complete the restorative process also saves chair time.

	The patient presented with a Class II cavity present on the mesial surface of a maxillary left second molar (

). After preparation of the proximal box portion of the preparation, the interproximal gingival papillae was “nicked” with the bur, causing hemorrhage that could interfere with the bonding process. A new hemostatic product, Kerr’s Hemostasyl, is syringed into the proximal area. It remains in place for about one minute (

) and is then rinsed away with an air-water spray. Hemostasyl’s consistency keeps it in place until it is removed, unlike liquid-type hemostatic agents. 

 shows two approximating preparations in the maxillary left first and second premolars.

	After placing and rinsing Hemostasyl, the proximal area between the premolar preparations is devoid of blood, and placement of the matrix can be done easily without causing the tissue to bleed 

	A sectional matrix, Garrison Dental Solution’s Composi-Tight 3D
	(

) is used to simplify the restorative process. The “soft anatomically shaped pads” of the 3D ring fill the proximal embrasure spaces, adapting the sectional matrix strip precisely to the cavosurface margins. The contact is assured without burnishing the band against the adjacent tooth, causing deformation of the restoration. As long as the band is visually touching the adjacent surface, because the ring causes separation by compressing the periodontal ligament spaces, a curved hemostat will be required to remove the band when the restoration is complete.

	The latest improvement to the Composi-Tight 3D system is “Slick Bands.” The non-stick inner surfaces allow for more accurate and smooth proximal surfaces when placing the composite material.

	Once the sectional matrix is placed, the restorative process begins. Vertise Flow self adhering flowable composite replaces the need for the conventional bonding steps of etching, rinsing, and adhesive placement prior to the application of the flowable resin. A thin layer of Vertise Flow (less than 0.5 mm in thickness) is brushed onto all cavity walls, enamel and dentin, (bevels included) with moderate pressure for 15 to 20 seconds. Any excess around the margins is removed with the brush 

 and the material is then light cured for 15 to 20 seconds. 

 shows the preparation after application of Vertise Flow to all cavity surfaces and light curing. Notice the appearance of the cavity surface compared with the freshly prepared surfaces in 

. The surfaces of the cavity appear similar to a “faux painted,” textured surface. This is indicative of the correct amount of Vertise Flow used for the initial creation of the adhesive layer to dentin and enamel. If desired, an additional increment of Vertise Flow can then be applied (up to 0.5 mm) as a cavity liner and spread with a brush into all line and point angles of the preparation (

. This ensures complete and accurate covering of all internal cavity walls.

	As direct composites have evolved for universal application, there always has been a trade off in handling and polishablity for materials designed for anterior and posterior use. A new nanohybrid, Kerr’s Herculite Ultra, simplifies esthetic anterior and posterior placement of composite resins, according to the manufacturer. This product has been positioned for use in a mono-layering technique as an alternative to complicated layering to achieve optimal esthetic results. The consistency of Herculite Ultra is creamy, yet it is a sculptable material with no slumping and good chameleon effect.

	The first increment of Herculite Ultra is placed and condensed using a non-serrated plugger 

. A plastic filling instrument is used to sculpt the occlusal layer of the maxillary left second premolar 

. Note that in this case, where adjacent proximal surfaces require restoration, apply the matrix and restore one preparation to completion, then matrix the other tooth and restore it creating contact to the first restoration. Always contour and polish the finished composite surface as needed before filling the adjacent preparation.

), a small 8-fluted carbide finishing bur, is used to finesse the occlusal embrasure occlusal to the proposed contact area 

. Remember, the proximal contact is located 1 mm apical to the height of the marginal ridge. Once polished, the sectional matrix is applied to the adjacent tooth, and the restoration is completed 

 show the completed restorations after application of surface sealant. Note how nicely the restorations blend into the natural tooth.

	A technique has been shown using an innovative self adhering composite and a simplified mono-layering nanohybrid composite system. Vertise Flow has been shown to deliver comparable results to many of the seventh-generation bonding systems without the need for a separate bonding step. Combined with a simplified restorative system, such as Herculite Ultra, a more concise, less technique sensitive alternative to traditional direct composite placement is now available.