How to Transform the Esthetics of Implant-Supported Restorations with Gingival-Shaded Ceramics

Courtesy of Lab Management Today and Mr. Steve Lee: 

Restorative Challenge

A male patient in his early 20s presented with the chief complaint of unesthetic restorations and lost gingival architecture. He had lost his four maxillary incisors (teeth #7 through #10) due to trauma and despite successful impact surgery, was fitted with poorly designed restorations that he had worn for about a year.

Treatment Plan

The challenging aspect of this case was that one of the implants was improperly placed between #7 and #8. Therefore I couldn’t make a complete screw-retained implant bridge because the access hole between #7 and #8 would have diminished the esthetics and the axis of the screw would go right through the incisal edge. Instead, I made a screw-retained zierconia framework with pink gingiva tissue to recreate the lost gingiva and then cemented on four single crowns made from IPS e.max (from Ivoclar Vivadent) to the framework.










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Dr. Chris Salierno Interviews Lenny Marotta

Courtesy of Dental Economics:

Lenny Marotta

What changes are you seeing at Marotta Dental Studio in the numbers of porcelain-fused-to-metal (PFM), lithium disilicate (e.max), and zirconia restorations that you are producing? 

We have been doing zirconia restorations for years, and they are still popular for multiunit restorations. Traditional PFM crowns have been decreasing, particularly due to the rising cost of alloy. We have seen a dramatic increase in single-unit lithium disilicate restorations over the last few years.

Do dentists still need impressions with the same degree of accuracy for CAD/CAM as we needed for traditional casting, or is CAD/CAM more forgiving?

It is even more important to have an accurate impression for CAD/CAM restorations. Handmade restorations have a built-in “fudge” factor, whereas to get quality restoration with CAD/CAM, everyone has to be on the same page. You can always burnish or weld a metal margin. However, with all-ceramic restorations, the only option is to use pure porcelain and compromise strength.

What preparation margin do you suggest for a full-coverage lithium disilicate restoration, and why?

For full-coverage lithium disilicate restorations, no bevel margins are preferred. We will often recommend chamfer or shoulder margins. For CAD/CAM restorations, chamfer margins ensure the best fit. Truthfully, though, we find that the best advice is to adhere to the manufacturer’s specifications.

In your opinion, what are the advantages of lithium disilicate over zirconia? 

Lithium disilicate offers some of the best strength, coupled with strong esthetic results. It can easily match existing tooth opacity, shades, and translucency without sacrificing strength or needing any veneering porcelain. Furthermore, as a technician, pressed lithium disilicate is the closest an all-ceramic restoration comes to matching a traditional wax-and-cast restoration. This allows us to have more control and margin integrity, enabling us to have, in essence, a tooth colored full-cast crown.

How do you treat a lithium disilicate restoration before you send it to the dentists? What should dentists do with them after they take them out of the bag?

We do our final quality control inspection, checking the margins, contact, and fit. We apply a ceramic etching gel to the internal surface. We apply the IPS Ceramic Etching Gel for about 20 seconds, as per the manufacturer’s specifications. It is sealed in a pouch with the alcohol to prevent contamination and sent to the doctor.

After the doctor tries it, the surfaces become contaminated by saliva and the strength of the resin bond is compromised. Washing with water or phosphoric acid only restores some of that bond strength, but Ivoclean from Ivoclar has shown to be very effective. Ivoclean was developed specifically for decontaminating the inner surface of the restoration prior to cementation.

Do you have a preference for a type of resin cement to be used with lithium disilicate? 

Several of our clients seem to prefer self-etch adhesive resin cement, such as Multilink Automix, for its high strength and reduced sensitivity for the patient. Self-adhesive resin cements will work, as well, but the bond strength is lower than that of a self-etch adhesive.

Tetric EvoCeram Eight-year Clinical Performance

Tetric EvoCeram Eight-year Clinical Performance

Courtesy of The Dental Advisor: 

The Dental Advisor Report header


Tetric EvoCeram is a universal, hybrid composite indicated for anterior and posterior esthetic restorations. The composite is radiopaque and formulated to meet any rigorous esthetic challenge with availability in Enamel, Dentin, and bleach shades. This light-cured composite consists of particles ranging in size from 40 to 3000 nm with an average particle size of about 550 nm. It is packed in 0.2 g, color-coded, unit-dose capsules and 3 g color-coded syringes.

Figure 1Clinical Evaluation Protocol

  • 873 restorations were placed and monitored over an eight-year period.
  • 637 (73%) of these restorations were recalled over a six-month period. The restorations included both anterior and posterior teeth (Figure 1).
  • The recalled restorations were Class I, Class II, and Class IV composites (Figure 2).
  • Timeline of restorations in clinical service is shown in Figure 3.
  • At recall the following categories, esthetics, resistance to fracture/chipping, resistance to marginal discoloration, and wear resistance were rated on a scale of 1 to 5 with 1=poor, 2=fair, 3=good, 4=very good, 5=excellent. Any restoration receiving a rating of 1 or a 2 in a category is automatically replaced. Restorations receiving a rating of 3 or 4 in a category are still clinically acceptable and are not replaced.

Figure 2 and 3

Clinical Observations


The esthetics of Tetric EvoCeram was excellent at recall (Figure 4). Out of 637 recalled restorations, 93% received an excellent rating and 7% received good to very good rating and did not require replacement. Only three restorations (0.5%) required replacement because of poor esthetics. Tetric EvoCeram layered with a translucent shade often resulted in improved esthetics, opalescence and translucency. Layering is especially important in teeth that are discolored

Resistance to Fracture and Chipping 

Figure 4Over 95% of the 637 recalled Tetric EvoCeram restorations received an excellent rating (Figure 4). 2% of the restorations had chipped but did not require replacement, while 3% or 19 restorations did need to be replaced. Tetric EvoCeram proved to be very resistant to fracture and chipping at 8 years, especially given that 96% of the restorations were posterior restorations and were subjected to high occlusal forces.

Resistance to Marginal Discoloration 

Microleakage is affected by both the composite and the bonding agent. Excessive microleakage can lead to decay or poor marginal esthetics. 86% of the recalled restorations had no visible micro leakage and were rated excellent (Figure 4). 13% had slight to medium microleakage, while 1% had excessive microleakage which necessitated the replacement of the restoration. A variety of self-etch (88%) and total-etch (12%) bonding agents were used.

Wear Resistance

98% of the restorations showed no evidence of wear and received an excellent rating, whereas 1.5% of the restorations received a good or very good rating (Figure 4). Only 0.5% of the restorations required replacement because of excessive wear.


Tetric EvoCeram has excellent handling characteristic. It is non-slumping, not sticky, contours well, and is easy to finish and polish. This eight-year evaluation of 637 restorations demonstrated that Tetric EvoCeram had superior performance in esthetics, resistance to fracture/chipping, resistance to marginal discoloration, and wear resistance. Tetric EvoCeram received a 97% clinical performance rating.

Ask Dr. Johnson 8yr rpt

Dr. Jenny Sy-Munoz: Achieve Precise Detail With The Dual Arch Technique

Using this technique along with Virtual®XD VPS impression materials enhances the ability to precisely record the anatomy of the oral cavity and create a durable and stable impression.

Dr. Jenny Sy-Munoz

Clinicians and Ceramists Utilize dental impressions to create the foundation for treatment planning and designing restorations. Impressions provide a physical and visual representation of the patient’s current dentition and an invaluable tool to dental professionals.

The dual arch impression technique captures the maxillary and mandibular impression, as well as the bite, all in one step and is ideal for several indications. It utilizes two different impressions materials: a heavy body and light body material to capture precise detail.

Utilizing this technique properly along with ideal materials ensures that accurate impressions are achieved precisely and efficiently, without the common voids, runny materials and durability issues that can negatively affect impression details.

Dual Arch Technique

Although no single technique is applicable to all treatment situations, the dual arch technique creates ideal impressions for many necessary treatments.

The following criteria should be met before selecting dual arch impression technique:

  • Maximum of two prepared teeth with intact adjacent teeth should be present
  • Patient should have stable dentition and ideal occlusal surface of opposing teeth
  • Patient should be able to bite into maximum intercuspation without interference
  • Select a rigid (preferably metal) dual arch impression tray

Together with the optimized flow of the Virtual®XD light body material and the high Shore A hardness of Virtual®XD heavy body tray material, the impression captures excellent detail reproduction that is necessary when making a dual arch impression. This combination also creates a durable and stable impression. At the same time, because it eliminates many sources of inaccuracy, it results in restorations that require no or minimal intramural adjustments.

Case Study

Step 1: Prior to making impressions, place an OptraGate® lip and cheek retractor in the patient’s mouth to provide improved access to the intraoral cavity.

Step 2: Select the appropriate impression tray and evaluate the fit. Verify that the tray does not interfere with the patient’s occlusion (Fig. 1.)

Achieve 1

Step 3: Apply Virtual® Tray Adhesive to all areas which will come into contact with the impression material, including the rims of the impression tray (Fig. 2). This will help reduce the chance of distortion when removing impressions from the mouth.

Achieve 2

The use of adhesives in trays has also been shown to achieve higher material bond strengths than mechanical retention between the impression trays and the vinylpolysiloxane impression materials. Allow the adhesive to dry for three minutes.

Step 4: Load two cartridge dispensers, one with Virtual®XD light body wash material and one with the Virtual®XD heavy body tray material (Fig. 3). The Virtual® Mixer or a hand dispenser can be used to dispense the heavy body tray material.

Achieve 3

Step 5: Bleed the cartridge to verify an even flow of base and catalyst from the cartridge chambers, prior to applying the mixing tip (Fig. 4).

Achieve 4

Step 6: Load the impression tray with tray material (Fig. 5) Keep the dispensing tip buried in the material to prevent any voids or air bubbles.

Achieve 5

Step 7: Syringe the wash material around the preparation (Fig. 6) avoid voids and air bubbles by keeping the intraoral tip buried in the material.

Achieve 6

Step 8: Seat the tray into position (Fig. 7). Guide patient to close mouth into maximum intercuspation. Hold tray in place for the minimum set time, (two-and-a-half minutes for fast set and four-and-a-half minutes for regular set) (Fig. 8).

Achieve 7 Achieve 8

Step 9: Check material to verify that it is completely set and remove tray (Fig. 9).

Achieve 9

Step 10: Rinse, dry and disinfect the final impression upon removal from the mouth. It is safe to immerse the Virtual®XD impression in a disinfection solution (e.g., glutaraldehyde 0.5% – benzalkonium chloride 0.5%) for 10 minutes without distortion.


With the variety of materials and techniques available for creating impressions available for creating impressions, determining an appropriate technique and ideal materials can be challenging. The dual arch technique can be used to capture precise and detailed maxillary and mandibular impression as well as the bite, all in one step.

The simple technique protocol ensures that accuracy and efficiency are maintained. Additionally, the Virtual®XD line of VPS impression materials from Ivoclar Vivadent provides exceptional viscosities for working with the dual arch technique. With optimized flow and advanced wetting abilities, precise details of the preparation and intraoral cavity are captured. The durable material also allows for easy disinfection and is stable up to two weeks.

Dental professionals that utilize the combined system of the dual arch technique with Virtual®XD provide their patients and ceramists with detailed and durable impressions.

“Better, Faster, More Efficent Dentistry” – Martin von Sontagh

The need for efficient, easy-to-use materials and techniques continues to grow in dentistry. Yet, this demand should not be fulfilled at the expense of quality. The particular case uses the new adhesive bonding system from Ivoclar Vivadent, Adhese Universal, meets all the requirements. Adhese Universal is a light-curing single-component system for direct and indirect restorative techniques, and stands out due to its compatibility with different etching protocols- total etch, self-etch and selective enamel-etch.

Case Study:

A 30-year old patient came to our practice with the request that we replace her old fillings. We discovered carious lesions under the restorations during the examination (Figs. 1a & 1b). Furthermore, we noted that the old fillings did not have any cusps or fissures and decided to incorporate these features when we restored the quadrant. Composite resins are well suited for posterior fillings, because they allow the teeth to be reconstructed without having to sacrifice significant amounts of tooth structure. Additional benefits of modern composites include efficient handling and improved patient friendliness.

all 7 images

text and image 8Clinical Procedure:

In preparation for the procedure, the fillings and the carious tissue were removed and a rubber dam was placed (Fig.2). At this stage, I was free to choose with approach to take in order to establish the bond between the composite resin and the tooth with Adhese Universal. In the case at hand, I will demonstrate the options that were available to me.

The Three Bonding Options:

The self-etch protocol was chosen for tooth 14. After the matrix (from Garrison) had been placed, the adhesive was agitated on the enamel and dentin for 20 seconds and then dispersed with a weak stream of air (Fig 3). Next, the bonding agent was light-cured for 10 seconds (Fig 4). The bulk fill composite Tetric  EvoCeram Bulk Fill IVA was used to restore the tooth. Since this material can be placed in increments of up to 4mm in thickness, only two increments were necessary to fill the cavity (Figs. 5 and 6). The individual layers were cured for 10 seconds each. I like to use this technique for treating children and difficult-to-reach teeth. Fillings can be placed quickly and effectively with this treatment protocol.

The second method, selective enamel etching, was used to restore tooth 16. Before etching the tooth for 30 seconds (Fig. 7), a Garrison matrix was placed. The phosphoric acid was rinsed off with water spray after the procedure. The adhesive was agitated on the dentin and enamel for 20 seconds (Fig. 8) and then dispersed with a gentle stream of air. The next part of the procedure followed the same steps as the self-etch technique: The bonding agent was light-cured for 10 seconds and the filling was placed with two increments of Bulk Fill IVA (Figs. 9 and 10)


12 and descriptionsThe third bonding protocol that was used with Adhese Universal in this case was the total-etch technique. This method generates a strong bond between the enamel and dentin. The phosphoric acid was applied to the enamel tissue for 30 seconds and additionally on the dentin for 15 seconds (Figs. 11 and 12). Subsequently, the phosphoric acid was rinsed off with water and the tooth was dried with a weak stream of air. One of the useful features is its VivaPen delivery form, which greatly facilitates the product’s application. Difficult-to-reach areas, like in the case of tooth 17, can be optimally coated with the adhesive. Three clicks are all that is needed to we the syringe tip and dispense the required material in the cavity (Fig. 13). Next,  the bonding material was dispersed with blown air and polymerized. Each of the two composite layers were light-cured for 10 seconds. The fourth tool was also treated using the total-etch technique.


The restorations were finished with rotary diamond burs and polishing discs. The occlusal adjustments were ground in and the restorations were polished with OptraPol Next Generation. The restorations were polished to a high gloss finish with Astrobrush (Fig. 14).

13 and 14


Highly aesthetic restorations are quickly placed and contoured with 4mm increments. As a result, the treatment time is reduced. Initially, I was rather skeptical about the VivaPen delivery form in terms of its handling and materials consumption. But I was surprised to find how easy it is to dispense just the right amount of bonding agent from the pen.

Adhese Universal Demonstrates Convincing Results after Fatigue Testing

Adhese Universal Put to the Test

You probably already know that Adhese Universal is one dental bonding agent for all situations, but have you seen our latest test results? Adhese Universal was recently put through rigorous fatigue testing to determine how well the bond strength would hold up under adverse conditions, and we’re quite proud of the results.

When dentists use our product as a bonding agent for their patients’ teeth, it needs to hold up against chewing, drinking, brushing and breathing: all actions that could erode and weaken the bond over time. The fatigue testing was designed to simulate the wear and tear from years of these actions against patients’ newly bonded teeth.

So what did we find out?

1. Optimum shear bond strength before and after thermocycling

Testing conducted by the Ivoclar Vivadent R&D lab in Schann, Liechtenstein concluded that Adhese Universal demonstrated reliable shear bond strength on dentin and enamel before and after thermocycling when using either the total-etch or self-etch protocol.

Marginal integrity of posterior resin composite fillings bonded with universal adhesives to enamel and dentin before and after thermo-mechanical loading

Marginal integrity of posterior resin composite fillings bonded with universal adhesives to enamel and dentin before and after thermo-mechanical loading

2. Excellent marginal quality before and after thermocycling

In a test conducted and presided over by Dr. Uwe Blunck from Berlin, Germany, Adhese Universal proved to be highly effective in class V cavities on dentin and enamel when tested with different composite materials using either the total-etch or self-etch protocol.

In-vitro test of the effectiveness of Adhese Universal in combination with Tetric EvoCeram and Tetric EvoCeram Bulk Fill in Class-V cavities

In-vitro test of the effectiveness of Adhese Universal in combination with Tetric EvoCeram and Tetric EvoCeram Bulk Fill in Class-V cavities

3. Outstanding marginal quality after thermo-mechanical loading

In tests conducted by Prof. Dr. Roland Frankenberger at the University Marburg in Germany, a high percentage of gap-free margins were initially identified under all conditions in enamel and dentin for both adhesives. After thermo-mechanical loading, no significant differences were observed between both adhesives using the Total-Etch and Self-Etch protocol. When compared to adhesives and filling composites previously tested under equal conditions, Adhese Universal performed very well on dentin and enamel using the Total-Etch and Self-Etch protocol.

Marginal integrity of posterior resin composite fillings bonded with universal adhesives to enamel and dentin before and after thermo-mechanical loading.

Marginal integrity of posterior resin composite fillings bonded with universal adhesives to enamel and dentin before and after thermo-mechanical loading.

For a more thorough and technical breakdown of the testing conducted, click here to view our full PDF explaining the results.

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IPS e.max success story may make PMFs quite rare

By now everyone is well aware of the successes of IPS e.max, which has proven to deliver strong, esthetic restorations in all areas of the mouth. In fact, long-time prosthodontist Dr. Kenneth Malament, a world-renowned researcher and educator on all ceramics, says his choice is Ivoclar Vivadent’s ceramic for all of his single unit restorations. But where this material really has a unique spot is in the posterior areas.

Today, a number of clinicians are using zirconia in the posterior, but Dr. Malament, DDS, M.Sc.D., believes IPS e.max is still the best option for posterior single units, the bread and butter cases for many dentists. While many patients and clinicians are moving away from PFMs, they should be aware that while zirconia is an option that provides significant strength, lithium disilicate delivers the best survival data, economics and better esthetics, according to Dr. Malament.

“e.max is the best we have ever worked with,” said Dr. Malament, who has had a prosthodontics practice in Boston since 1977.

The material and science advances that helped bring about a product like IPS e.max may very well lead to a changing of the guard for those clinicians who had grown accustomed to the traditional porcelain fused to metal (PMF) restorations.

According to Ivoclar Vivadent’s IPS e.max Scientific Report Vol. 02 (2001-2013), which is available online at:, more than 75 million IPS e.max restorations have been delivered, and the crown survival rate is 98.2%. Dr. Malament’s results have been even more impressive.

Originally, Dr. Malament and his colleagues extensively used and studied Ivoclar Vivadent’s Empress with tremendous results. Since switching to IPS e.max, his success numbers have been staggering.

“I have researched all ceramic materials 32 years and have a database where every all ceramic restoration I have ever done is studied with 29 different confounding variables,” said Dr. Malament, who practices with Dr. Dan Nathanson, Professor, Chairman Restorative Sciences, Boston University School of Graduate Dentistry, and Dr. Hans Peter Weber, Professor, Chairman Restorative Sciences, Tufts University School of Dental Medicine. “Of all the of the materials we have ever studied, Empress, all the time, was the best from the point of years of survival. I have cemented up to today, 2,133 Empress restorations over 265 months with 103 failures. A failure is a fractured crown that requires replacement. A chipped restoration is also studied in the database and of the 31 chipped Empress restorations all were easily smoothed and did not need to be replaced.”

Now that he uses IPS e.max, the success rate is significantly higher than those impressive Empress figures.

“As of today, and at 85-86 months (7 years) 546 patients, 1,896 units and I have but one failure,” he said. “We’ve never seen this performance in a ceramic material before ever.”

These are the types of numbers that keep scientists up at night. Dr. Malament and his research colleagues are more than impressed by the data they have accumulated and the science on IPS e.max.

“The one failure has been studied extensively. We were totally obsessed with how this happened and needed to understand the fracture mechanics of the event,” he said. “The lone ‘failure’ was a patient who was a severe bruxer who after four years fractured the lithium disilicate.” Continue reading