90

n
INTERVIEW

Supragingival Dentistry:
Easier and Healthier Restorative Care

I
n this interview with our editor-in-chief, Dr. Damon Adams, Dr.
Ruiz explains the importance of understanding and using new
materials correctly. He will share important clinical tips,
explaining the benefits of what he likes to call “supragingival den-
tistry,” specifically for indirect restorations like veneers, onlays,
and all-ceramic crowns.
Dr. Ruiz is the founder and director of the Los Angeles Institute of
Aesthetic Dentistry, where he teaches workshops on adhesive and
aesthetic dentistry, and oc-
clusion. He is past director of
the University of Southern
California’s Aesthetic Den-
tistry Continuum (from 2004
to 2009) and associate in-
structor at Dr. Gordon J.
Christensen’s PCC in Utah.
He has had a full-time pri-
vate practice in the Studio
District of Los Angeles for
more than 18 years.
therefore patients refuse them. Let’s also think about the most used
indirect restoration in dentistry, the PFM crown, which requires
subgingival margins when traditionally designed. Every dental
school and textbook teaches that a crucial step in the technique of
these restorations is the placement of the restorative margins sub-
gingivally. This is necessary to hide an unaesthetic margin. The
increase in difficulty, potential complications, and unpredictabili-
ty this routine procedure brings to the table is significant. It starts
with a difficult preparation, with the need to place a preparation
margin subgingivally, yet in an atraumatic style.
Dr. Adams: How does the concept of supragingival dentistry relate to the
clinical realities around tissue control issues and the proper use of impres-
sion materials?
Dr. Ruiz: When done correctly, traditional subgingival prepara-
tions require that we first prepare an initial equagingival prepara-
tion margin. Then retraction cord is placed in order to expose sub-
gingival tooth structure, and the margin is placed subgingivally.
After this difficult procedure, a second, smaller cord must be placed
in order to take a proper impression of the subgingival margin.

INTRODUCTION
Advances in dental materi- Advances in dental materials have truly changed
als have truly changed the the way we practice dentistry....Some new materials
way we practice dentistry.
New dental adhesives, res- may present certain challenges and require learning
torative composites, ce-
ments, impression materi-
new techniques.
als, porcelain systems, as
well as digital impression This procedure, along with taking an excellent impression, is tech-
and CAD/CAM technology nically very challenging; in fact, it is one of the most difficult and
are helping make amazing unsuccessful procedures in dentistry, as dental technicians around
changes in the way that we the country can attest to. In his lectures, Dr. Christensen found that
practice. Some new materi- interviewed dental laboratory owners report that as many as 90%
als may present certain chal- of the impressions received have less-than-adequate margin regis-
Jose-Luis Ruiz, DDS
lenges and require learning tration/definition.
new techniques. Sometimes the changes can seem radical and a bit Of course, because impressions are so frustrating, dental manu-
scary, especially if these new materials are used incorrectly and facturers continue to improve impression materials. For example,
negative results occur. However, when used properly, most of these the highly hydrophilic Aquasil Extra (DENTSPLY Caulk) presents
new materials and techniques are revolutionizing dentistry, result- just one material that has demonstrated an important improvement
ing in many benefits to the patient and doctor alike. in the vinyl polysiloxane (VPS) category, allowing good impressions
even in wet margins. Other VPS materials like Panasil (Kettenbach)
Dr. Adams: You have previously stated that using nonmetal indirect or FlexiTime (Heraeus Kulzer) have also made significant improve-
restorations with supragingival techniques is easier and more predictable ments in this area. Other manufacturers are now providing other
than doing traditional restorations such as PFMs with subgingival mar- solutions to help make taking impressions easier, more predictable,
gins. Is that correct? and accurate: digital impression systems like the iTero (Cadent) and
Dr. Ruiz: I am convinced that nonmetal supragingival dentistry is Lava C.O.S. (3M ESPE) are a couple of current examples.
easier, more predictable, and healthier for our patients than tradi- Nevertheless, even with all of these advancements, subgingival
tional dentistry. Knowing that the statement is controversial, let’s margins are still difficult to prepare and predictably reproduce out-
look at the evidence. Dental laboratories report that gold onlays are side of the mouth.
rarely used; the reason is that they exhibit unnatural aesthetics and continued on page 92

DENTISTRYTODAY.COM • MARCH 2010

Page 82
92
Supragingival Dentistry...
continued from page 90
Dr. Adams: So that brings us back to the
supragingival alternative, doesn’t it?
Dr. Ruiz: Yes, in my opinion, the best
solution is to implement the use of
supragingival dentistry techniques
whenever possible. Supragingival den-
tistry is a style of dentistry which uses
modern materials and techniques such
as enamel preservation and margin ele-
vation. It also involves the proper use of
the contact lens effect which employs
an important characteristic of many
ceramic systems (nonmetal restora-
tions) translucency. This allows us to
intentionally keep restorative margins
supragingival while still achieving
excellent aesthetic results. This in turn
helps to make dentistry truly easier,
more predictable, aesthetic, and health-
ier for the patient.
Dr. Adams: Can you address the issue of
translucency found in all-ceramics versus
traditional metal-ceramics in a bit more
detail?
Dr. Ruiz: Sure! Translucency allows
for an easier blend of the restoration
to the tooth because it allows some
light to go through into the tooth and
root. Teeth are like fiber-optic rods, in
that when light hits the crown it goes
down the root. We also know that
some ceramic systems’ (nonmetal)
restorative materials are more trans-
lucent than others by their very na-
There is no doubt that predictable clinical success with
bonding systems is indispensable for the overall success
of nonmetal restorations. There is a tremendous amount
of controversy and passion about this subject.
ture, based on the materials from
which they are made and how they
are manufactured.
Traditional metal-ceramic restora-
tions are completely opaque, thus
obstructing light from entering into
the crown. This makes the tooth and
root dark, creating a grey margin
appearance, forcing clinicians to sub-
merge the margins (Figure 1). This in
turn can cause darkness in the gingi-
val tissue zone adjacent to the margin,
especially when the patient has thin-
ner, more “translucent” tissue. Non-
metal restorations permit light to go
through into the tooth and root, thus
the shadowing effect of the metal cop-
ing is eliminated or diminished and
marginal blending is improved, thus
allowing for the more coronal place-
DENTISTRYTODAY.COM • MARCH 2010
INTERVIEW
Figure 1. Inflammation and unsightly margins
typically observed with subgingival margins on
existing maxillary PFM crowns.
Figure 3. Immediately after conservative
equagingival tooth preparation, discolored
tooth No. 9 was prepared 0.5 mm subgingival
for aesthetic purposes.
ment of the margin. Just imagine, by
using nonmetal restorations correct-
ly, we can leave margins either su-
pragingival in the nonaesthetic zone,
or equagingival in the aesthetic zone.
This makes taking impressions much
more simple and predictable!
Dr. Adams: You also said that modern
ceramic restorative materials are avail-
able in various translucencies. Clinically
speaking, how do you decide which mate-
rial should be used in a particular case?
Dr. Ruiz: This a great question! As pre-
viously discussed, one of the most
important characteristics of all non-
metal restorations is translucency.
Translucency allows for an easier
blend of the restoration margin to the
tooth, because it allows some light to
go through into the tooth. Trans-
lucency does vary dramatically de-
pending on the porcelain system.
Feldspathic porcelains, and pressed/
layered porcelains, tend to be very
translucent. Layered and pressed
feldspathic porcelain can be one of
the most aesthetic options available,
and for that reason it is an ideal mate-
rial choice for porcelain veneers. Also,
Page 83
Figure 2. Preoperative view before veneer
preparation. The young male patient was
unhappy with aesthetics of his teeth.
Figure 4. Cemented VenusCeram (Heraeus)
veneers with indistinguishable margins.
Figure 5. The patient was very happy with final
results, especially with the minimally invasive
nature of restorations.
these materials have some great
advantages when used for nonmetal
onlays or inlay/onlays. Crowns using
alumina and zirconia copings are
always more opaque, yet can be made
to be translucent using layering
porcelains…just to a lower degree of
translucency. And then you have lithi-
um disilicate, a very promising mate-
rial that has historically lain kind of
in the middle. Recently, it has been
further developed to include several
different levels of translucency/ opaci-
ty. For example, it is now available in a
high translucency (HT) version
(e.max HT [Ivoclar Vivadent]), which
can be used for very thin 0.3 mm
veneers. It can also be used as a mono-
lithic restoration, giving it strength
and acceptable aesthetics. It is avail-
able as a pressable ingot option, or as
block, for the E4D (D4D) and E4D
LabWorks CAD/CAM system, which
is the version I am currently using. It
is also available for the CEREC (Sir-
ona) CAD/CAM in-office and CEREC
InLab systems. Lithium disilicate is a
very promising material. We need to
keep in mind that usually, the more
translucent the material, the weaker it is,
and vice versa; this is very important
when choosing a cementation material
and technique.
The great marginal blend or con-
tact lens effect that can be achieved
with feldspathic porcelain allows for
maximum aesthetics, minimal prepa-
ration, and a more coronal placement
of the margin. Manufacturers have
made great progress on feldspathic
porcelains, pressed and layered. First
of all, compared to the materials in
this category that were manufactured
years ago, these current materials are
kinder to the opposing tooth struc-
ture because they are made out of very
small particles and are baked at low
fusing temperatures, making them
softer and gentler. Also a wide range
of translucency and opacities have
been introduced and improved, mak-
ing them incredibly aesthetic. Most of
my veneers and onlays are made out
of the VenusCeram pressed and lay-
ered system (Heraeus), but I have had
great results with other excellent
materials, like Creation (Jensen In-
dustries), Finesse (DENTSPLY Ceram-
co), and others.
Properly made, layered and when
there is enough space, pressed cut
back and then layered porcelain, can
have different shades and opacities
throughout the restoration, making it
polychromatic and allowing it to nat-
urally mimic a tooth really well.
Keep in mind though, if we use
this restorative material with subgin-
gival margins, we will really miss all
the benefits of supragingival dentistry.
In addition, we will make impression
and cementation much more difficult
than it has to be. In the highly aesthet-
ic anterior zone, through the first
bicuspids, it is desirable to leave the
preparation margins of feldspathic
porcelain veneers and porcelain jacket
crowns from approximately 0.25 mm
above the gingiva crest to equal to the
gingival crest. Excellent results can be
achieved with tooth preserving veneer
preparations, and slightly supra-gingi-
val or equigingival margins, as long as
proper translucency and good margin
blend is achieved, even if the restora-
tion margin is visible as seen on
Figures 2 to 5.
In order to achieve a good blend,
one must make sure that the color of
the tooth and the color of the restora-
tion is not dramatically different. For
93
INTERVIEW
this reason, it is best to complete the Failures with zirconia have been As previously stated, new materials Dr. Adams: Knowing how critical that
bleaching of the teeth before begin- associated with the chipping and require that we learn how to use them proper adhesion is to success with these
ning any aesthetic restorative work. breaking of the layering porcelain correctly. There is a learning curve for nonmetal materials, please tell us how
Professional home whitening with layer. This is often caused by poor cop- both the dentists and the dental labo- you decide which bonding system to use,
custom trays using a product such as ing design that does not include prop- ratory technicians. and what’s new in regards to dental
Opalescence (Ultradent Products) is er support for the overlying porcelain. adhesives?
very effective. Although Op-
alescence is a personal prefer-
ence of mine, there are many
other excellent whitening
materials and techniques
available. I use translucent
pressed ceramics for porce-
lain onlays because the cavo-
margin may be placed on the
middle of the tooth. Margin
blending in the middle of the
tooth is difficult, but it is cru-
cial. In these situations, it is
indispensable to use the res-
torative material correctly to
achieve good marginal blend.
I like to use a “hybrid onlay”
made from a very translucent
pressed ingot, such as Venus-
Ceram, and then layered por-
celain to achieve good mar-
ginal blend and aesthetics.
Excellent marginal blend can
be achived using this tech-
nique as seen in Figure 6.
New, super-strong non-
metal coping and framework
materials have become avail-
able and they have been very
well received by the profes-
sion. Personally, I have had
excellent success with zirco-
nia crowns, such as Lava [3M
ESPE], Cercon [DENSTPLY
Caulk], and Aadva [GC
America]), etc. This material’s
strength allows an experi-
enced dental technician to
design a very thin coping in
the aesthetic areas for maxi-
mized translucency and aes-
thetics. It also allows the tech-
nician to design a thicker cop-
ing in the stress-bearing areas
for strength. When the cop-
ings are properly designed,
and a nonopacious veneering
porcelain is used, one can
realize natural translucency.
In addition, one can safely
place the margin 0.5 mm
supragingivally in nonaes-
thetic areas and at gingival
level in the aesthetic zone.
The ability to build in translu-
cency will avoid the tradition-
al grey appearance of the mar-
gins as seen with many PFM
crowns. This permits us to do
supragingival dentistry while
still being able to achieve
acceptable aesthetic results.
FREEinfo, circle 66 on card
92
Supragingival Dentistry...
continued from page 90
Dr. Adams: So that brings us back to the
supragingival alternative, doesn’t it?
Dr. Ruiz: Yes, in my opinion, the best
solution is to implement the use of
supragingival dentistry techniques
whenever possible. Supragingival den-
tistry is a style of dentistry which uses
modern materials and techniques such
as enamel preservation and margin ele-
vation. It also involves the proper use of
the contact lens effect which employs
an important characteristic of many
ceramic systems (nonmetal restora-
tions) translucency. This allows us to
intentionally keep restorative margins
supragingival while still achieving
excellent aesthetic results. This in turn
helps to make dentistry truly easier,
more predictable, aesthetic, and health-
ier for the patient.
Dr. Adams: Can you address the issue of
translucency found in all-ceramics versus
traditional metal-ceramics in a bit more
detail?
Dr. Ruiz: Sure! Translucency allows
for an easier blend of the restoration
to the tooth because it allows some
light to go through into the tooth and
root. Teeth are like fiber-optic rods, in
that when light hits the crown it goes
down the root. We also know that
some ceramic systems’ (nonmetal)
restorative materials are more trans-
lucent than others by their very na-
There is no doubt that predictable clinical success with
bonding systems is indispensable for the overall success
of nonmetal restorations. There is a tremendous amount
of controversy and passion about this subject.
ture, based on the materials from
which they are made and how they
are manufactured.
Traditional metal-ceramic restora-
tions are completely opaque, thus
obstructing light from entering into
the crown. This makes the tooth and
root dark, creating a grey margin
appearance, forcing clinicians to sub-
merge the margins (Figure 1). This in
turn can cause darkness in the gingi-
val tissue zone adjacent to the margin,
especially when the patient has thin-
ner, more “translucent” tissue. Non-
metal restorations permit light to go
through into the tooth and root, thus
the shadowing effect of the metal cop-
ing is eliminated or diminished and
marginal blending is improved, thus
allowing for the more coronal place-
DENTISTRYTODAY.COM • MARCH 2010
INTERVIEW
Figure 1. Inflammation and unsightly margins
typically observed with subgingival margins on
existing maxillary PFM crowns.
Figure 3. Immediately after conservative
equagingival tooth preparation, discolored
tooth No. 9 was prepared 0.5 mm subgingival
for aesthetic purposes.
ment of the margin. Just imagine, by
using nonmetal restorations correct-
ly, we can leave margins either su-
pragingival in the nonaesthetic zone,
or equagingival in the aesthetic zone.
This makes taking impressions much
more simple and predictable!
Dr. Adams: You also said that modern
ceramic restorative materials are avail-
able in various translucencies. Clinically
speaking, how do you decide which mate-
rial should be used in a particular case?
Dr. Ruiz: This a great question! As pre-
viously discussed, one of the most
important characteristics of all non-
metal restorations is translucency.
Translucency allows for an easier
blend of the restoration margin to the
tooth, because it allows some light to
go through into the tooth. Trans-
lucency does vary dramatically de-
pending on the porcelain system.
Feldspathic porcelains, and pressed/
layered porcelains, tend to be very
translucent. Layered and pressed
feldspathic porcelain can be one of
the most aesthetic options available,
and for that reason it is an ideal mate-
rial choice for porcelain veneers. Also,
Figure 2. Preoperative view before veneer
preparation. The young male patient was
unhappy with aesthetics of his teeth.
Figure 4. Cemented VenusCeram (Heraeus)
veneers with indistinguishable margins.
Figure 5. The patient was very happy with final
results, especially with the minimally invasive
nature of restorations.
these materials have some great
advantages when used for nonmetal
onlays or inlay/onlays. Crowns using
alumina and zirconia copings are
always more opaque, yet can be made
to be translucent using layering
porcelains…just to a lower degree of
translucency. And then you have lithi-
um disilicate, a very promising mate-
rial that has historically lain kind of
in the middle. Recently, it has been
further developed to include several
different levels of translucency/ opaci-
ty. For example, it is now available in a
high translucency (HT) version
(e.max HT [Ivoclar Vivadent]), which
can be used for very thin 0.3 mm
veneers. It can also be used as a mono-
lithic restoration, giving it strength
and acceptable aesthetics. It is avail-
able as a pressable ingot option, or as
block, for the E4D (D4D) and E4D
LabWorks CAD/CAM system, which
is the version I am currently using. It
is also available for the CEREC (Sir-
ona) CAD/CAM in-office and CEREC
InLab systems. Lithium disilicate is a
very promising material. We need to
keep in mind that usually, the more
translucent the material, the weaker it is,
and vice versa; this is very important
when choosing a cementation material
and technique.
The great marginal blend or con-
tact lens effect that can be achieved
with feldspathic porcelain allows for
maximum aesthetics, minimal prepa-
ration, and a more coronal placement
of the margin. Manufacturers have
made great progress on feldspathic
porcelains, pressed and layered. First
of all, compared to the materials in
this category that were manufactured
years ago, these current materials are
kinder to the opposing tooth struc-
ture because they are made out of very
small particles and are baked at low
fusing temperatures, making them
softer and gentler. Also a wide range
of translucency and opacities have
been introduced and improved, mak-
ing them incredibly aesthetic. Most of
my veneers and onlays are made out
of the VenusCeram pressed and lay-
ered system (Heraeus), but I have had
great results with other excellent
materials, like Creation (Jensen In-
dustries), Finesse (DENTSPLY Ceram-
co), and others.
Properly made, layered and when
there is enough space, pressed cut
back and then layered porcelain, can
have different shades and opacities
throughout the restoration, making it
polychromatic and allowing it to nat-
urally mimic a tooth really well.
Keep in mind though, if we use
this restorative material with subgin-
gival margins, we will really miss all
the benefits of supragingival dentistry.
In addition, we will make impression
and cementation much more difficult
than it has to be. In the highly aesthet-
ic anterior zone, through the first
bicuspids, it is desirable to leave the
preparation margins of feldspathic
porcelain veneers and porcelain jacket
crowns from approximately 0.25 mm
above the gingiva crest to equal to the
gingival crest. Excellent results can be
achieved with tooth preserving veneer
preparations, and slightly supra-gingi-
val or equigingival margins, as long as
proper translucency and good margin
blend is achieved, even if the restora-
tion margin is visible as seen on
Figures 2 to 5.
In order to achieve a good blend,
one must make sure that the color of
the tooth and the color of the restora-
tion is not dramatically different. For
93
INTERVIEW
this reason, it is best to complete the Failures with zirconia have been As previously stated, new materials Dr. Adams: Knowing how critical that
bleaching of the teeth before begin- associated with the chipping and require that we learn how to use them proper adhesion is to success with these
ning any aesthetic restorative work. breaking of the layering porcelain correctly. There is a learning curve for nonmetal materials, please tell us how
Professional home whitening with layer. This is often caused by poor cop- both the dentists and the dental labo- you decide which bonding system to use,
custom trays using a product such as ing design that does not include prop- ratory technicians. and what’s new in regards to dental
Opalescence (Ultradent Products) is er support for the overlying porcelain. adhesives?
very effective. Although Op-
alescence is a personal prefer-
ence of mine, there are many
other excellent whitening
materials and techniques
available. I use translucent
pressed ceramics for porce-
lain onlays because the cavo-
margin may be placed on the
middle of the tooth. Margin
blending in the middle of the
tooth is difficult, but it is cru-
cial. In these situations, it is
indispensable to use the res-
torative material correctly to
achieve good marginal blend.
I like to use a “hybrid onlay”
made from a very translucent
pressed ingot, such as Venus-
Ceram, and then layered por-
celain to achieve good mar-
ginal blend and aesthetics.
Excellent marginal blend can
be achived using this tech-
nique as seen in Figure 6.
New, super-strong non-
metal coping and framework
materials have become avail-
able and they have been very
well received by the profes-
sion. Personally, I have had
excellent success with zirco-
nia crowns, such as Lava [3M
ESPE], Cercon [DENSTPLY
Caulk], and Aadva [GC
America]), etc. This material’s
strength allows an experi-
enced dental technician to
design a very thin coping in
the aesthetic areas for maxi-
mized translucency and aes-
thetics. It also allows the tech-
nician to design a thicker cop-
ing in the stress-bearing areas
for strength. When the cop-
ings are properly designed,
and a nonopacious veneering
porcelain is used, one can
realize natural translucency.
In addition, one can safely
place the margin 0.5 mm
supragingivally in nonaes-
thetic areas and at gingival
level in the aesthetic zone.
The ability to build in translu-
cency will avoid the tradition-
al grey appearance of the mar-
gins as seen with many PFM
crowns. This permits us to do
supragingival dentistry while
still being able to achieve
acceptable aesthetic results.
FREEinfo, circle 66 on card
Page 84
94
Dr. Ruiz: There is no doubt that pre-
dictable clinical success with bond-
ing systems is indispensable for the
overall success of nonmetal restora-
tions. There is a tremendous amount
of controversy and passion about this
subject. Many academics and educa-
tors have stated that the fourth gener-
ation, total-etch bonding systems like
OptiBond FL (Kerr) and Scotchbond
Multi-Purpose (3M ESPE) are state-of-
the-art, due to their long track
records, very high bond strengths,
and excellent marginal sealing abili-
ties. All of the above are very impor-
tant characteristics, and undoubtedly
these bonding systems are excellent,
when used by experienced clinicians
who are good at using them. The
problem is that sometimes these
advocates of total-etch techniques
forget the very real problem of post-
operative sensitivity and technique
complexity, which can be a problem
with these bonding systems. There is
no more frustrating problem in den-
tistry than when we perform a beau-
tiful direct or indirect tooth color
bonded restoration, and weeks later,
the patient continues to complain of
postoperative sensitivity. Clinical
experience has shown that although
total-etch bonding systems can be
predictable, if used meticulously,
they are more technique-sensitive
than the self-etch systems.
With total-etch bonding systems,
a minor variation in moisture will
....a good understanding of the 3 golden rules of occlusion
is vital to success: equal contact, posterior disclusion, and
an unobstructed envelope of function.
result in decreased bond strength to
dentin and postoperative sensitivity.
More than 4,000 dentists surveyed by
CLINICIANS REPORT cited a 4-fold
increase in severe postoperative sensi-
tivity when using total-etch bonding
systems, compared to those using self-
etch bonding systems. The results
underscore the clinical reality; achiev-
ing that perfect moisture control and
perfect dentin tubule seal can be diffi-
cult. It is very important to point out
that the literature shows that opera-
tor skill and choice of material is very
important for success.
Dr. Adams: Everyone seems so con-
cerned about bond strengths; however,
there is more to adhesive success than just
that, right?
Dr. Ruiz: Yes, many clinicians incor-
rectly look at bond strength as the
DENTISTRYTODAY.COM • MARCH 2010
INTERVIEW
Figure 6. Same tooth No. 29 postoperative
view of the restoration. Observe the excellent
blending and unaffected gingival health as
compared to traditional PFM crown on the
molar.
primary quality of a bonding system.
However, from a clinician’s perspec-
tive, a good bonding system must
have 4 important characteristics: (1)
it must provide excellent adhesion
and seal, (2) it must be durable, (3) it
must be associated with low postop-
erative sensitivity, and (4) it must be
easy to use. Some self-etch bonding
systems fulfill all of these require-
ments, especially the 2-bottle sixth-
generation types like Clearfil SE
Bond, Clearfil SE Protect (both from
Kuraray). All-in-one bottle self-etch
seventh-generation systems are rap-
idly improving; Futurabond (VOCO)
is a great example. Self-etch bonding
systems have proven themselves to
be an excellent choice. There is plenty
of literature evidence showing that
bond strength to dentin is equally as
high with self-etch, and there is also
evidence that the bond durability to
dentin may even be better for self-
etch versus total etch.
In addition, self-etch bonding sys-
tems are considered user friendly
because they are not as moisture sen-
sitive. This also decreases the chances
of postoperative sensitivity.
The primary drawback of self-etch
systems is their inability to properly
etch enamel, especially uncut enamel,
leading to less-than-adequate seal at
the margins and staining. This prob-
lem can easily be eliminated by a
short selective etching of the enamel
using phosphoric acid for 10 seconds
and then applying the self-etch sys-
tem as manufacturers recommend.
For many years I have been using self-
etch bonding systems for all my
restoration needs–even porcelain
veneers—but I will always etch the
Page 85
Figure 7. Male patient with deep caries on distal
margin of tooth No. 29, before margin elevation.
enamel with phosphoric acid. This
gives me the best of both worlds:
excellent dentin bond with minimum
postoperative sensitivity and excel-
lent enamel bond with the help of the
phosphoric acid etch. It works!
Dr. Adams: Jose-Luis, could you remind
us what the advantages are in keeping
restoration margins supragingival as
related to cementation, and what is your
take on newer cement materials and
techniques?
Dr. Ruiz: Yes, Damon, it is a good idea
to remember that the cementation
protocol varies widely from one mate-
rial to the other. It depends on the
strength of the restorative material,
the location of the gingival cavo-mar-
gin and the aesthetic needs. Felds-
pathic porcelain, layered and pressed,
must be cemented with resin cement
because this material is intrinsically
weak.
Resin cements have no tolerance
for contamination, and for this reason
we should avoid them as much as pos-
sible when placing our margins sub-
gingivally. This is because it is very dif-
ficult to perfectly achieve isolation
from fluids during cementation, thus
leading to contamination of the ce-
ment/bond, early failure of our
restoration, and/or chronic tooth sen-
sitivity. The routine placement of sub-
gingival margins for porcelain veneers
or onlays is an excellent example of
how we carry unnecessary old habits
from old materials and techniques,
which lead to self-complication and
frustration with new materials.
In the area of resin cements, some
important advancements have been
made. Highly filled cements with
even smaller particle size that use
Figure 8. Final preparation after margin
elevation using a bonded composite.
Figure 9. Observe a 6-year postoperative x-ray
on the same male patient (as Figures 6 to 8),
showing the excellent result on both first
maxillary and mandibular bicuspids, after
margin elevation.
nanotechnology are now on the mar-
ket. These have better handling char-
acteristics with improved thixotropic
properties. I prefer to use light-cured,
translucent cements for veneers,
because of color stability and better
aesthetic blending. Calibra (DENST-
PLY Caulk) and RelyX Veneer (3M
ESPE) are my usual choices, but there
are other excellent choices like
Variolink Veneer (Ivoclar Vivadent) or
NX3 Nexus Third Generation (Kerr).
I like to use dual-cured cements
for onlays because I am still con-
cerned that the light may not pene-
trate deep under 2 or 3 mm of porce-
lain, as the literature attests. My usual
preference here is Clearfil Aesthetic
Cement and DC bond (Kuraray) be-
cause of it has a nice working viscosi-
ty, excellent translucency, and it is a
dual-cured self-etch bonding system
with low postoperative sensitivity. I
have also had excellent results using
dual-cured NX3 with OptiBond All-In-
One bond (Kerr) and MultiLink
(Ivoclar Vivadent), both also self-etch
systems. Self-adhesive resin cements
like RelyX Unicem (3M ESPE),
Maxcem Elite (Kerr), G-Cem (GC
95
INTERVIEW
America), BisCem (BISCO), Speed- rare, or when replacing a PFM crown FujiCem, which is much more forgiv- amalgam, or other restoration. In
CEM (Ivoclar Vivadent), MonoCem with already subgingival margins; ing with moisture or contamination, these situations, using a toffelmire
(Shofu), and Breeze (Pentron Clinical then I will choose to place an all- as previously explained. The most matrix band, I will elevate the margin
Technologies), to name a few, are be- ceramic crown, most likely a zirconia. common situation that I face clinical- to be 1.0 mm above the gingiva with
coming very popular because clini- This will allow me to cement the ly is a mesial or distal margin which is either RMGI restorative materials like
cians find them easy to use with very crown with an RMGI cement like below the gingiva due to caries, an old Fiji Filling LC (GC America) or Ketac
few postoperative sensitivity
problems. At this time, I only
use them for onlays with me-
chanical retention or as a sec-
ond choice for supragingival
zirconia crowns with unre-
tentive preparations (to im-
prove retention), or occasion-
ally for post cementation. Al-
though they are easy to use,
simplicity has its price: they
have lower bond strength,
poorer color stability, and,
because they are resin ce-
ment, they require perfect iso-
lation with no contamina-
tion, or failures will occur.
Although resin cements
continue to improve and
become more popular, resin-
modified glass ionomers
(RMGI) cements, like Fuji-
Cem (GC America) or RelyX
Luting Plus (3M ESPE) are
incredibly useful and are my
first choice when using zirco-
nia all-ceramic crowns. In
some cases with thick lithi-
um disilicate crowns, I use
these cements as well. Unlike
resin cements, RMGIs are
more forgiving to moisture
and contamination, making
them an ideal choice when
the crown margins are sub-
gingival, such as the case with
many PFMs.
Finally, supragingival den-
tistry makes cleaning cement
much easier because you can
see and access the margins,
thus eliminating the com-
mon problem of leaving
small amounts of cement sub-
gingivally.
Dr. Adams: You have made the
point that keeping the margins
supragingival is advantageous,
but sometimes caries/fractures/
old restorations extend subgingi-
vally. How do you suggest that
these situations be handled?
Dr. Ruiz: You are totally right.
Sometimes we have to deal
with subgingival margins,
and to me there are 2 ways to
handle them. One, if the mar-
gin is subgingival all around,
either because the subgingi-
val caries are almost all
around the tooth, which is
FREEinfo, circle 67 on card
94
Dr. Ruiz: There is no doubt that pre-
dictable clinical success with bond-
ing systems is indispensable for the
overall success of nonmetal restora-
tions. There is a tremendous amount
of controversy and passion about this
subject. Many academics and educa-
tors have stated that the fourth gener-
ation, total-etch bonding systems like
OptiBond FL (Kerr) and Scotchbond
Multi-Purpose (3M ESPE) are state-of-
the-art, due to their long track
records, very high bond strengths,
and excellent marginal sealing abili-
ties. All of the above are very impor-
tant characteristics, and undoubtedly
these bonding systems are excellent,
when used by experienced clinicians
who are good at using them. The
problem is that sometimes these
advocates of total-etch techniques
forget the very real problem of post-
operative sensitivity and technique
complexity, which can be a problem
with these bonding systems. There is
no more frustrating problem in den-
tistry than when we perform a beau-
tiful direct or indirect tooth color
bonded restoration, and weeks later,
the patient continues to complain of
postoperative sensitivity. Clinical
experience has shown that although
total-etch bonding systems can be
predictable, if used meticulously,
they are more technique-sensitive
than the self-etch systems.
With total-etch bonding systems,
a minor variation in moisture will
....a good understanding of the 3 golden rules of occlusion
is vital to success: equal contact, posterior disclusion, and
an unobstructed envelope of function.
result in decreased bond strength to
dentin and postoperative sensitivity.
More than 4,000 dentists surveyed by
CLINICIANS REPORT cited a 4-fold
increase in severe postoperative sensi-
tivity when using total-etch bonding
systems, compared to those using self-
etch bonding systems. The results
underscore the clinical reality; achiev-
ing that perfect moisture control and
perfect dentin tubule seal can be diffi-
cult. It is very important to point out
that the literature shows that opera-
tor skill and choice of material is very
important for success.
Dr. Adams: Everyone seems so con-
cerned about bond strengths; however,
there is more to adhesive success than just
that, right?
Dr. Ruiz: Yes, many clinicians incor-
rectly look at bond strength as the
DENTISTRYTODAY.COM • MARCH 2010
INTERVIEW
Figure 6. Same tooth No. 29 postoperative
view of the restoration. Observe the excellent
blending and unaffected gingival health as
compared to traditional PFM crown on the
molar.
primary quality of a bonding system.
However, from a clinician’s perspec-
tive, a good bonding system must
have 4 important characteristics: (1)
it must provide excellent adhesion
and seal, (2) it must be durable, (3) it
must be associated with low postop-
erative sensitivity, and (4) it must be
easy to use. Some self-etch bonding
systems fulfill all of these require-
ments, especially the 2-bottle sixth-
generation types like Clearfil SE
Bond, Clearfil SE Protect (both from
Kuraray). All-in-one bottle self-etch
seventh-generation systems are rap-
idly improving; Futurabond (VOCO)
is a great example. Self-etch bonding
systems have proven themselves to
be an excellent choice. There is plenty
of literature evidence showing that
bond strength to dentin is equally as
high with self-etch, and there is also
evidence that the bond durability to
dentin may even be better for self-
etch versus total etch.
In addition, self-etch bonding sys-
tems are considered user friendly
because they are not as moisture sen-
sitive. This also decreases the chances
of postoperative sensitivity.
The primary drawback of self-etch
systems is their inability to properly
etch enamel, especially uncut enamel,
leading to less-than-adequate seal at
the margins and staining. This prob-
lem can easily be eliminated by a
short selective etching of the enamel
using phosphoric acid for 10 seconds
and then applying the self-etch sys-
tem as manufacturers recommend.
For many years I have been using self-
etch bonding systems for all my
restoration needs–even porcelain
veneers—but I will always etch the
Figure 7. Male patient with deep caries on distal
margin of tooth No. 29, before margin elevation.
enamel with phosphoric acid. This
gives me the best of both worlds:
excellent dentin bond with minimum
postoperative sensitivity and excel-
lent enamel bond with the help of the
phosphoric acid etch. It works!
Dr. Adams: Jose-Luis, could you remind
us what the advantages are in keeping
restoration margins supragingival as
related to cementation, and what is your
take on newer cement materials and
techniques?
Dr. Ruiz: Yes, Damon, it is a good idea
to remember that the cementation
protocol varies widely from one mate-
rial to the other. It depends on the
strength of the restorative material,
the location of the gingival cavo-mar-
gin and the aesthetic needs. Felds-
pathic porcelain, layered and pressed,
must be cemented with resin cement
because this material is intrinsically
weak.
Resin cements have no tolerance
for contamination, and for this reason
we should avoid them as much as pos-
sible when placing our margins sub-
gingivally. This is because it is very dif-
ficult to perfectly achieve isolation
from fluids during cementation, thus
leading to contamination of the ce-
ment/bond, early failure of our
restoration, and/or chronic tooth sen-
sitivity. The routine placement of sub-
gingival margins for porcelain veneers
or onlays is an excellent example of
how we carry unnecessary old habits
from old materials and techniques,
which lead to self-complication and
frustration with new materials.
In the area of resin cements, some
important advancements have been
made. Highly filled cements with
even smaller particle size that use
Figure 8. Final preparation after margin
elevation using a bonded composite.
Figure 9. Observe a 6-year postoperative x-ray
on the same male patient (as Figures 6 to 8),
showing the excellent result on both first
maxillary and mandibular bicuspids, after
margin elevation.
nanotechnology are now on the mar-
ket. These have better handling char-
acteristics with improved thixotropic
properties. I prefer to use light-cured,
translucent cements for veneers,
because of color stability and better
aesthetic blending. Calibra (DENST-
PLY Caulk) and RelyX Veneer (3M
ESPE) are my usual choices, but there
are other excellent choices like
Variolink Veneer (Ivoclar Vivadent) or
NX3 Nexus Third Generation (Kerr).
I like to use dual-cured cements
for onlays because I am still con-
cerned that the light may not pene-
trate deep under 2 or 3 mm of porce-
lain, as the literature attests. My usual
preference here is Clearfil Aesthetic
Cement and DC bond (Kuraray) be-
cause of it has a nice working viscosi-
ty, excellent translucency, and it is a
dual-cured self-etch bonding system
with low postoperative sensitivity. I
have also had excellent results using
dual-cured NX3 with OptiBond All-In-
One bond (Kerr) and MultiLink
(Ivoclar Vivadent), both also self-etch
systems. Self-adhesive resin cements
like RelyX Unicem (3M ESPE),
Maxcem Elite (Kerr), G-Cem (GC
95
INTERVIEW
America), BisCem (BISCO), Speed- rare, or when replacing a PFM crown FujiCem, which is much more forgiv- amalgam, or other restoration. In
CEM (Ivoclar Vivadent), MonoCem with already subgingival margins; ing with moisture or contamination, these situations, using a toffelmire
(Shofu), and Breeze (Pentron Clinical then I will choose to place an all- as previously explained. The most matrix band, I will elevate the margin
Technologies), to name a few, are be- ceramic crown, most likely a zirconia. common situation that I face clinical- to be 1.0 mm above the gingiva with
coming very popular because clini- This will allow me to cement the ly is a mesial or distal margin which is either RMGI restorative materials like
cians find them easy to use with very crown with an RMGI cement like below the gingiva due to caries, an old Fiji Filling LC (GC America) or Ketac
few postoperative sensitivity
problems. At this time, I only
use them for onlays with me-
chanical retention or as a sec-
ond choice for supragingival
zirconia crowns with unre-
tentive preparations (to im-
prove retention), or occasion-
ally for post cementation. Al-
though they are easy to use,
simplicity has its price: they
have lower bond strength,
poorer color stability, and,
because they are resin ce-
ment, they require perfect iso-
lation with no contamina-
tion, or failures will occur.
Although resin cements
continue to improve and
become more popular, resin-
modified glass ionomers
(RMGI) cements, like Fuji-
Cem (GC America) or RelyX
Luting Plus (3M ESPE) are
incredibly useful and are my
first choice when using zirco-
nia all-ceramic crowns. In
some cases with thick lithi-
um disilicate crowns, I use
these cements as well. Unlike
resin cements, RMGIs are
more forgiving to moisture
and contamination, making
them an ideal choice when
the crown margins are sub-
gingival, such as the case with
many PFMs.
Finally, supragingival den-
tistry makes cleaning cement
much easier because you can
see and access the margins,
thus eliminating the com-
mon problem of leaving
small amounts of cement sub-
gingivally.
Dr. Adams: You have made the
point that keeping the margins
supragingival is advantageous,
but sometimes caries/fractures/
old restorations extend subgingi-
vally. How do you suggest that
these situations be handled?
Dr. Ruiz: You are totally right.
Sometimes we have to deal
with subgingival margins,
and to me there are 2 ways to
handle them. One, if the mar-
gin is subgingival all around,
either because the subgingi-
val caries are almost all
around the tooth, which is
FREEinfo, circle 67 on card
Page 86
96 97

INTERVIEW INTERVIEW

Nano (3M ESPE); or I will elevate the
margin similar to doing a Class II
composite using a bonding system
like Futurabond (VOCO), then a small
layer of Grandio (VOCO). After elevat-
ing the margin, I will refine and finish
my onlay preparation which will now
have all supragingival margins. Of
6 to 9). There is strong evidence in the
literature pointing out that subgingi-
val margins perform better with RMGI
restorative material due to the release
Dr. Adams: Can you please comment
briefly with regard to the life expectancy
and failures with nonmetal restorations?
Dr. Ruiz: That sure is an important
...the main reason porce-
lain restorations fail and
Dr. Ruiz graduated from Universidad National
Autonoma de Mexico in 1997. Dr. Ruiz is the
founder and director of the Los Angeles
Institute of Aesthetic Dentistry, where he
thetic Dentistry Continuum (from 2004 to
2009), associate instructor at Dr. Gordon
Christensen’s PCC in Utah. He has had a full-
time private practice in the Studio District of
Los Angeles for more than 18 years. Dr. Ruiz
has published several research studies in the
lighting his aesthetic dental makeovers,
including NBC’s Channel 4 News, ABC’s Vista
LA, and Univision and Telemundo. He can be
reached at drruizonline.com or via e-mail at
ruiz@drruiz.com.

layer of the highly-filled (80%)
Grandio Flow (VOCO) and then a
course, impression and cementation of
this restoration will be a cinch (Figures
FREEinfo, circle 68 on card
of fluoride, thereby decreasing the
chance of secondary caries.
question. For the past 10 years, I have
been doing nonmetal indirect res-
torations almost exclusively.
In addition with regard to
direct restorations, I haven’t
done an amalgam in more
than 15 years, including in
second molars. These days, I
rarely prepare a full crown of
any type, and quite honestly, I
can count with my fingers
how many people have re-
quested gold restorations of
any type. So, what is the
longevity of these restora-
tions in my practice? My per-
sonal experience has been as
...PFM crowns in the
United States have
an average lifespan
of about 8 years,
based on some
insurance surveys.
a clinician practicing in the
same place for almost 18
years. This has allowed me to
witness my own successes
and failures over quite some
time. When I compare the
problems and failures I had
with traditional mechanical-
ly retained, subgingival den-
tistry, to the past 10 years
with nonmetal supragingival
dentistry, my life is easier
with less complications and
fewer failures. And although
I have published a retrospec-
tive review of my cases with
the assistance of Dr. Gordon
Christensen and other clini-
cians, showing overwhelm-
ing success, it is of greater
importance to look at what
the literature shows. In the
anterior area of the mouth,
the profession is quite com-
fortable with all-ceramic res-
torations, and the literature is
replete with success with
these restorations. In the pos-
terior area of the mouth, the
results are less positive and
conflicting; nevertheless, there
is ample literature showing
excellent long-term success
with porcelain onlays at 8-plus
break...is occlusion. teaches workshops on adhesive and aesthet- area of adhesive dentistry, many clinical arti- Disclosure: Dr. Ruiz reports no conflicts of
ic dentistry, and occlusion. He is past director cles, and lectures internationally. He has interest.
of the University of Southern California’s Aes- made numerous television appearances high-
years, when done correctly.
How long do PFM crowns last?
Some people have PFM crowns
that have lasted 20 years or
more, but looking at things
from the realistic standpoint,
PFM crowns in the United
Span have an average lifespan
of about 8 years, based on some
insurance surveys. All-ceramic
indirect restorations in the
posterior area of the mouth
should last as long, or longer,
than PFM crowns, when we
take in to consideration that
they are also more repairable.
It is important to remem-
ber that the main reason porce-
lain restorations fail and break,
especially in the posterior, is
occlusion. Therefore, a good
understanding of the 3 golden
rules of occlusion is vital to
success: equal contact, posteri-
or disclusion, and an unob-
structed envelope of function.
In addition, proper occlusal
adjustment techniques are
imperative. Your readers may
request a step-by-step short
video on my occlusal adjust-
ment technique via e-mail.
One final thing to remem-
ber is that one of the main
advantages of nonmetal restor-
ations, when done correctly, is
that they can be designed to be
more tooth conserving and
supragingival, which means
the periodontal health will be
unaffected by the restorations.
This is an important considera-
tion when thinking about
longevity. I always tell my
patients that, in my experience,
these restorations will likely
last as long as a PFM crown, but
because of the restoration’s
noninvasive nature, their teeth
will be better off, and will likely
last longer than they would
with more destructive tradi-
tional treatment options.
Dr. Adams: Jose-Luis, I want to
sincerely thank you for taking the
time to share your opinions, expe-
riences, and knowledge with our
readers. Your dedication to, and
leadership within, the dental pro-
fession is commendable.!

TO REGISTER CALL 888-442-0242 or circle 69 on card

Page 87
96 97

INTERVIEW INTERVIEW

Nano (3M ESPE); or I will elevate the
margin similar to doing a Class II
composite using a bonding system
like Futurabond (VOCO), then a small
layer of Grandio (VOCO). After elevat-
ing the margin, I will refine and finish
my onlay preparation which will now
have all supragingival margins. Of
6 to 9). There is strong evidence in the
literature pointing out that subgingi-
val margins perform better with RMGI
restorative material due to the release
Dr. Adams: Can you please comment
briefly with regard to the life expectancy
and failures with nonmetal restorations?
Dr. Ruiz: That sure is an important
...the main reason porce-
lain restorations fail and
Dr. Ruiz graduated from Universidad National
Autonoma de Mexico in 1997. Dr. Ruiz is the
founder and director of the Los Angeles
Institute of Aesthetic Dentistry, where he
thetic Dentistry Continuum (from 2004 to
2009), associate instructor at Dr. Gordon
Christensen’s PCC in Utah. He has had a full-
time private practice in the Studio District of
Los Angeles for more than 18 years. Dr. Ruiz
has published several research studies in the
lighting his aesthetic dental makeovers,
including NBC’s Channel 4 News, ABC’s Vista
LA, and Univision and Telemundo. He can be
reached at drruizonline.com or via e-mail at
ruiz@drruiz.com.

layer of the highly-filled (80%)
Grandio Flow (VOCO) and then a
course, impression and cementation of
this restoration will be a cinch (Figures
FREEinfo, circle 68 on card
of fluoride, thereby decreasing the
chance of secondary caries.
question. For the past 10 years, I have
been doing nonmetal indirect res-
torations almost exclusively.
In addition with regard to
direct restorations, I haven’t
done an amalgam in more
than 15 years, including in
second molars. These days, I
rarely prepare a full crown of
any type, and quite honestly, I
can count with my fingers
how many people have re-
quested gold restorations of
any type. So, what is the
longevity of these restora-
tions in my practice? My per-
sonal experience has been as
...PFM crowns in the
United States have
an average lifespan
of about 8 years,
based on some
insurance surveys.
a clinician practicing in the
same place for almost 18
years. This has allowed me to
witness my own successes
and failures over quite some
time. When I compare the
problems and failures I had
with traditional mechanical-
ly retained, subgingival den-
tistry, to the past 10 years
with nonmetal supragingival
dentistry, my life is easier
with less complications and
fewer failures. And although
I have published a retrospec-
tive review of my cases with
the assistance of Dr. Gordon
Christensen and other clini-
cians, showing overwhelm-
ing success, it is of greater
importance to look at what
the literature shows. In the
anterior area of the mouth,
the profession is quite com-
fortable with all-ceramic res-
torations, and the literature is
replete with success with
these restorations. In the pos-
terior area of the mouth, the
results are less positive and
conflicting; nevertheless, there
is ample literature showing
excellent long-term success
with porcelain onlays at 8-plus
break...is occlusion. teaches workshops on adhesive and aesthet- area of adhesive dentistry, many clinical arti- Disclosure: Dr. Ruiz reports no conflicts of
ic dentistry, and occlusion. He is past director cles, and lectures internationally. He has interest.
of the University of Southern California’s Aes- made numerous television appearances high-
years, when done correctly.
How long do PFM crowns last?
Some people have PFM crowns
that have lasted 20 years or
more, but looking at things
from the realistic standpoint,
PFM crowns in the United
Span have an average lifespan
of about 8 years, based on some
insurance surveys. All-ceramic
indirect restorations in the
posterior area of the mouth
should last as long, or longer,
than PFM crowns, when we
take in to consideration that
they are also more repairable.
It is important to remem-
ber that the main reason porce-
lain restorations fail and break,
especially in the posterior, is
occlusion. Therefore, a good
understanding of the 3 golden
rules of occlusion is vital to
success: equal contact, posteri-
or disclusion, and an unob-
structed envelope of function.
In addition, proper occlusal
adjustment techniques are
imperative. Your readers may
request a step-by-step short
video on my occlusal adjust-
ment technique via e-mail.
One final thing to remem-
ber is that one of the main
advantages of nonmetal restor-
ations, when done correctly, is
that they can be designed to be
more tooth conserving and
supragingival, which means
the periodontal health will be
unaffected by the restorations.
This is an important considera-
tion when thinking about
longevity. I always tell my
patients that, in my experience,
these restorations will likely
last as long as a PFM crown, but
because of the restoration’s
noninvasive nature, their teeth
will be better off, and will likely
last longer than they would
with more destructive tradi-
tional treatment options.
Dr. Adams: Jose-Luis, I want to
sincerely thank you for taking the
time to share your opinions, expe-
riences, and knowledge with our
readers. Your dedication to, and
leadership within, the dental pro-
fession is commendable.!

TO REGISTER CALL 888-442-0242 or circle 69 on card

Page 88