3/17/2016 - d1ue90e5sp4tcv.cloudfront.netd1ue90e5sp4tcv.cloudfront.net/1946/images/Text... · 3/17/2016 1 Todd C Snyder, DDS, AAACD The Nuts and Bolts of Indirect Anterior Aesthetic

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Todd C Snyder, DDS, AAACD

The Nuts and Bolts of Indirect Anterior Aesthetic Restorations

Catapult Group is an organization which consists of top clinicians and

educators from throughout the United States and Canada. This group of like-

minded yet diverse dentist’s goal is to bring quality education to the dental

community via multiple venues including; live lecture, participation, web based,

and written formats.

Todd Snyder, DDS, AAACD

Laguna Niguel, CAAesthetic Dental Designs®

Member of Catapult Elite

[email protected]

All the work shown is my own and unaltered

I report no financial relationships, conflicts of interest, or

other disclosures with respect to the content in this

presentation

DISCLAIMER

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Digital Handouts

WWW.DENTOOLZ.COM

Digital Handouts

The Nuts and Bolts of Indirect Anterior Aesthetic Restorations

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DIAGNOSIS & TREATMENT PLANNING

The Key to Success:

VisualizationWhat is the patient’s perception or desired outcome in their mind?

DIAGNOSIS & TREATMENT PLANNINGThe Key to Success:

DIAGNOSIS & TREATMENT PLANNINGThe Key to Success:

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QUESTIONS?

• Who is your client and what is the perceived problem vs. the

true problem?

• Ask patient about:

• Health, diet, dental history, lifestyle, habits, stress, job, sleep, airway

• Trying to access why the patient’s mouth is in its current state

• What is their ultimate goal?

• Priorities? Time frame?

• BUDGET??

What is the first step in any case

no matter how big or small?

Diagnosis of:

• How did the problem come to be?

• Occlusion (articulated models)

• Function (opening, excursives, bite pressure and contacts)

• TMJ (radigraphic interpretation)

• Periodontal Health / Bone Support (radiographs, probings)

• Mobility

• Mental Health

Three Eccentric Movements

Protrusive

Working

Balancing

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ProtrusiveWorking


Balancing

Three Eccentric Movements Right Lateral Movement

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Left Lateral Movement

Centric Occlusion

Centric Relation

Centric Relation Occlusion

Centric

Occlusion: CO

The arrangement of the

upper teeth to lower teeth

that provides the maximum

intercuspation, irrespective

of the position of the joints

in the Glenoid Fossa.

Centric Relation: CR

Any arrangement of the

upper to lower teeth

when joints are in any

relationship seated in the

upper most and midmost

position in the Glenoid

Fossa.

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Centric Relation

Occlusion: CRO

The arrangement of the upper to lower teeth

that provides the maximum intercuspation in CR.

Checking CO, CR & Excursives

Customize Teeth

Checking Occlusion is the Key to Aesthetics

Interferences

What is the perceived problem & what is the true problem?

Can we find the true cause of the problem?

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Aesthetics

Occlusion

Excursives

Restorations

Wear

Solutions

What options are available to fix the problem?

TMJ SIGNS & SYMPTOMS

• Wear facets

• Pot holes

• Abfractions

• Gingival recession

• Mobility

• Occlusal & Incisal wear

• Linea Alba

• Tongue scalloping (Crenations)

Muscle hypertrophy

Muscle tension/tenderness

Muscle rigidity

Limited opening

Guarding on CR closure

TMJ noise

Head and Neck aches

Tooth sensitivity

Ear problems, ringing, buzzing, fullness

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EXAMPLE-CENTRIC OCCLUSION

• Anteriorly positioned condyles

• Occlusion is not ideal

• Appears to have canine guidance

• Weak centric stops and limited number

• Patient okay for a few months

• Now has joint pain, noise, muscle pain, teeth are sensitive

CENTRIC RELATION

POSTERIOR INTERFERENCE (PREMATURITY)• Centric Occlusion

• Natural growth patterns

• Orthodontics

• Dental work

• Trauma

JOINT REPOSITIONED AND

STABILIZED (CR-STABILIZED)• Splint Therapy

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What happens to a Condylewhen there

is an Occlusal Prematurityon a 2nd molar?

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CHANGE!

• Larger amounts of tooth augmentation can create potential shifts in bite

pressure on teeth, CR-CO slides, and excursive interferences.

• Material properties must become more resilient to increased wear and

pressure demands.

• Higher risk of post operative complications due to occlusal modifications,

jaw positioning, and/or adhesive techniques and materials.

• A different approach to typical Restorative DentistryWhat did the patient’s teeth look like prior to veneers? Did she have any

symptoms? Braces? Dental work? Trauma? Etc…

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A Veneer Case? Not a veneer case!!

Minimally Invasive Treatment• Apply MIPaste Plus for 3 minutes

• Patient applies at home 2x/day

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BIOAVAILABLE CALCIUM, PHOSPHATE & FLUORIDEUTILIZATION

• Apply twice a day, AM & PM

• After brushing and flossing

• Pea size amount on finger and rub it on the teeth

• You can floss it between them as well

• Rub the material around all the teeth with tongue

• Leave on the teeth for approximately 3 minutes

• Spit out excess but do not rinse or drink for 30 minutes.

REMIN PRO TOOTHPASTE (VOCO)

• Fluoride, Calcium, Phosphate and Xylitol

Enamelon Now with Stannous Fluoride Optimized with ACP Technology

• Stabilized SnF2 Formula

• ACP Technology

• RDA 8

• Safe for all age groups

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CASE SELECTION:

• The Nuts and Bolts

Who is a candidate?

What do they want changed and why?

Minimal to no length change

Discolored teeth

Narrow smiles

Minor rotational cases

Good function

Healthy periodontium

Others…

Diagnosis & Treatment Planning

When to do a crown versus a veneer?

Complex rotational cases

Extensive teeth lengthening

Non-compliance

Creating function

Large fillings

Thin teeth

Cementation concerns


Diagnosis & Treatment Planning

CASE SELECTION:

Initial Appointment

Consultation


SEQUENCING FOR SUCCESSFUL CASES

First Impressions!

What is their concern?

Examination

Process/Present cases

Estimate range on cost

Will be presented when “we decide” after the waxup is approved.

Positive Verbage

Educational info/case photos

PATIENT AND LAB COMMUNICATION• Patient’s current likes and dislikes

• Patient discussion about appearance 4x

• Final time is definitive due to being adhered in permanently

• Pt’s perceived benefits from treatment, list three to accomplish

• Have they had other work done, how did it turn out?

• Aesthetic Expectation Level

• Listen carefully, ask probing questions, don’t make assumptions

• Longevity?

• Lab time frame (pre-book lab)

• Relay pictures and information

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What Records & When

Diagnostic Records

Review Health Hx & Radiographs

Comprehensive Exam

Periodontal Probing, Mobility,

Recession, Attached Tissue,

Biologic Width

First Appointment

What Records & When

Comprehensive Exam


Recession, Attached Tissue,

Biologic Width

First Appointment

GINGIVAL EMBRASURE SPACE (BLACK TRIANGLES)

• Sound to bone from margin 2.5-3mm distance.

• Contact 2mm from margin

• Always want 5mm or less from contact point to bone

• Use most incisal bone

x < 5 mm

Tarnow J. Perio. 1992;63(12) 995-996

5mm 100%

6mm 56%

7mm 27%

First Appointment

What Records & When Diagnostic Records

Review Health Hx & existing Radiographs

Comprehensive Exam


Recession, Attached Tissue, Biologic Width

Oral Cancer Screening

Occlusion and TMJ Exam

First Appointment

Occlusion and TMJ Exam Joint History

Noise

Maximum opening

Muscle palpation

Deviations

Function

Holds, excursives and interferences

Wear facets

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Diagnostic Records (continued)

Radiographs

3 Sets of Models (mounted with facebow on articulator)

Additional Model (possibly)

Bleaching trays

Pour in Snap Stone or Speed Stone

Deliver same day

What Records & When

First Appointment

Diagnostic Models and Facebow

First Appointment

Initial untouched model

Preparation design model

Diagnostic Wax-up

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth

Whiteners: $1.4 billion

(MSNBC) ...

(Consumer Reports).

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WHITENING


Smile Shape (Books & Photos)

Shade Analysis

Teeth Whitening!!

How long will it postpone treatment??

What Records & When

First Appointment

SMILE SHAPE REFERENCESCANINE, LATERAL AND CENTRAL SHAPES

Smile Guide (Discus)• B&W Picture and 6-11 guide

LVI Smile Catalog (LVI)

• Style and shape combinations

Smile Style Guide (Digident)

• Color picture and shape

combinations

First Appointment

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LAB / DOCTOR

COMMUNICATION

• www.4theladder.com Diagnostic Records

(continued)

Photographs

Pre-Operatives

(Additional)

Preparations

Provisionals

Final Cementation

What Records & When

First Appointment

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PRE-OPERATIVE PHOTOS

• Full face

• Smile

• Resting

• Intraoral

• Occlusal

• Video?

First Appointment

COMPUTER SIMULATION:

DIGITAL MOCKUP/PREVIEW

What about

pictures?

Are they relevant and

realistic?

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REALISTIC VIRTUAL SMILES©

• Smile Simulations

VIRTUAL SMILES©

• Tooth shape

• Length, width, & style #

• Tooth color

• Translucency, effects

• File Format

• Paper

• CD

• Email

• Flash

• Logo & Office Info

• Smile Simulations

SMILE DESIGN SOFTWARE

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What Records & When


Imaging Photos

Treatment Plan

Finances

Signatures (7)

Health Hx, Tx Plan, Financials

Imaging, Wax-up, Provisionals, & Cementation Sign Off

First Appointment

Tooth shape• Length, width, & style #

Smile line

Tooth display at rest

Gingival display when smiling

Midline

Tooth inclination

Function

Tooth color• Translucency, effects

• Composite MockUp?

Smile Design Tooth Size Averages

2nd Premolar 1st Premolar Canine Lateral Incisor Central Incisor

6.6mm 7.1mm 7.6mm 6.6mm 8.6mm

7.7mm 8.6mm 10.6mm 9.8mm 11.2mm

Width

Length

Prior to Second Appointment

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Architecture

• Incisal Length

• 1-2 mm show at rest, 2-3 youthful

• Golden proportion 0.6-1-1.68

• Contact points

• Length/Width ratio 75-80%

• Overbite/Overjet

• Gingival line & Zenith

• Gingival display 0-3mm

• Embrasures


ADDITIONAL Tools

ADDITIONAL TOOLS

Panadent: Multi Purpose Ruler Erskine: Dentagauge 1 & 2

ADDITIONAL TOOLS

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ADDITIONAL TOOLSSHIMBASHI MEASUREMENT.

CEJ #8 to CEJ #25 or

CEJ #9 to CEJ #24

Normal is 17 to 18 mm depending on

the patient.


Golden proportion

between teeth.

0.6-1-1.68

Golden Proportion Measurement.


What Records & WhenDiagnostic & Prep Reduction Models (Do your own work)


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Prepared Model & Waxup


Blueprint for Success

Diagnostic Guides Prior to Second Appointment

Diagnostic Guides Prior to Second Appointment

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Disposables

Non Adjustable

Semi Adjustable

Articulators Prior to Second Appointment Prior to Second Appointment


Semi Adjustable

not on Hinge Axis


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Semi Adjustable

not on Hinge Axis


Function & Failures

Function & FailuresWhich do you think is going to be more accurate?

Less adjustments and remakes?


BUILT IN ERRORS!

Thickness??Rotation?? Rocking??

Function & Failures

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• Closed Bite Trays (most common)

• Lack of rigidity may cause distortion

• Spring back after impression potential

• No cross arch stabilization

• Thin spots or perforations can cause distortion

• Impression material shrinks towards bulk

• Unable to recreate excursive movements

• Potential for errors & adjustments extremely high

Impression Trays Impression Trays

Bite Registration & Occlusal Indexing

Red Blood Cells 2 – 5um

200-500nm

Human Hair 60 –120um

6,000 – 12,000nm

?

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SHIMSTOCK & ARTICULATING PAPER

What do you use…..

.…and why?

SHIMSTOCK & ARTICULATING PAPER

• Parkell Accufilm II is 21µm for

dentistry

• Great Lakes articulating ribbon

12µm

• 8µm Almore Shimstock foil

• 8µm articulating paper??

What do you use…..

.…and why?

8µm articulating paper

Available in blue

And red too!

CENTRIC OCCLUSION DENTISTRY

• Shimstock-prior to prep

• Preparation

• Shimstock-checking bite

• Wax bite (why?)

• Shimstock-verifying wax bite is accurate

• Impressions

• Facebow

• Provisionals

• Shimstock-check provisional and bite

• Pouring models

• Mount maxillary model to articulator

• Articulator settings

• Mount opposing mandibularmodel

• Equilibrate

• Lab Fabrication

• Check Case

• Try-in Case

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SHIMSTOCK

• Holds

• Means that when biting firmly in C.O. the shimstock can not be pulled out

• Drags

• Means there is resistance on the shimstock but it can be pulled out slowly

• No Hold

• There is no resistance what so ever when pulled between occluding teeth.

• Verify bite

• Shimstock

• Over impression

• Preparation

• Wax bite

• Dead soft Delar Wax

• Firm, Hard Bite

• Shimstock vs. articulating paper/ribbon

• Facebow

• Impression

• Provisional

Bite Registration & Occlusal Indexing

Simplified Fixed Prosthodontics & Occlusion Simplified Fixed Prosthodontics & Occlusion

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PDL & BITE REGISTRATIONS

• The range of PDL width: 0.15mm ~ 0.38mm

• • Average PDL width by age:

• o 11 ~ 16 years old: 0.21mm

• o 32 ~ 52 years old: 0.18mm

• o 51 ~ 67 years old: 0.15mm

• • The PDL width decreases with age.

• • The PDL width is thinnest around the middle 1/3 of the root.

PDL & BITE REGISTRATIONS

1. The thickness of the periodontal ligament varies from 0.1 to 0.4 mm with a mean of around 0.2 mm.

2. The ligament is thicker in functioning than in non-functioning teeth, and in areas of tension than in areas of compression (see table below):

Comparison of periodontal width of functioning and non-functioning teeth in an adult male (Adapted from Kronfeld, R. , 1931)

_____________________________________________________________________

Premolar in heavy function Premolar in light function Molar out of function

Mean width of PDL at coronal

end of alveolus 0.35 mm 0.14 mm 0.10 mm

Mean width of PDL in middleof alveolus 0.28 mm 0.10 mm 0.06 mm

Mean width of PDL at apical

end of alveolus 0.30 mm 0.12 mm 0.06 mm

______________________________________________________________________

3. The ligament cells are capable of remodeling the ligament and adjacent bone when functional forces are altered or the lig ament is damaged.

4. The periodontal ligament plays a key role in protecting the tooth from being resorbed by the normal remodelling process that affects the adjacent

alveolar bone.

5. Excessive forces can cause localized necrosis (cell death) of the ligament by cutting off the normal blood supply to the cells. This situation

immediately results in stoppage of remodeling at the affected site. Therefore, orthodontic tooth movement is no longer possible. Repair occurs via

emigration of cells from adjoining vital periodontal ligament. In the event the ligament continuity is not restored, localized resorption and ankylosis may

occur.

Second Appointment

Go over diagnostic tools

Check whitening

Discuss Treatment Plan

Set Appointment & Collect $$


• The Nuts and Bolts of Veneers

http://www.dental.pitt.edu/informatics/periohistology/en/references.htm#Kronfeld, R. 1931

http://www.dental.pitt.edu/informatics/periohistology/en/glossary.html#Ankylosis

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The Nuts and Bolts of Veneers

Preparations Veneers

(Third Appointment)

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VENEER PREPARATIONS

• Depth Cuts

• Tooth Reduction

• Margins

• Retention Form (Line of Draw)

Images from Bruce Crispin, DDS, MS book entitled “Contemporary

Restorative Dentistry”

Veneer Preparations



Incisal edge preparations

Veneer Preparations

Mandibular incisors-Incisal edge preparation

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PREPARATION REDUCTION

• Depth reduction burs

• Safe reduction

• Lasco

Depth Cuts

Tooth Reduction

Interproximal & Margins

Retention Form (Line of Draw)

Why extend interproximal and how far?

INDEPENDENT DEPTH CUTS (LASCO BURS)

BURS

• Organization

• Diamonds

• Carbides

K0096 Finishing Kit $126.47 each

K0095 Preparation Kit

$125.47 each

CASES

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Case #1: Prepless veneers???

Aesthetics

Veneers

Function

Bonding

Feldspathic Veneers

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VENEER PREPARATIONS

• Depth Cuts

• Tooth Reduction

• Margins

• Retention Form (Line of Draw)



• Contact lens effect

• At or above gingiva

• Masking tooth or color changes

• At gingiva, then place cord and

reduce another 0.3-0.5 mm

Veneer & Crown Margin Placement

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Shade Assumptions

Bleach, B1, B2, A1, A2,

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INSTANT ORTHO/UN-ROTATING TEETH

• Do initial workup

• Diagnostic preps

• Diagnostic waxup

Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”

Sequence

– Reduce all excess tooth structure

– Ideal reduction

– Margin placement

Case #3:Excessive Prep Interproximal

Reshape teeth

eMax

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Veneer Preparations

Facial/Lingual repositioning and margin placement

Veneer Preparations

Premolar preparation techniques

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Veneer Preparations

When to extend thru interproximal contact.

– Existing restoration interproximal, so the veneer margin extends past onto enamel.

– Small diastemas or gingival embrasure defects

– Ortho rotation cases where after removing excessive tooth structure the tooth is too thin.

Example: Aesthetics

Instant Ortho

No TMJ or bite problems

Empress

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Crown Preparations

Tooth reduction

– Existing crown restoration.

– Healthy tooth with a large diastema, defect, or fracture

– Reduction can be between 0.5mm – 2.0mm or more if a tooth needs to be rotated

Aesthetics

Smile Line

Gingival Excess

Gingival Asymmetry

Buccal Corridor

Case #5:

Aesthetics

Smile Line

Gingival Excess

Gingival Asymmetry

Buccal Corridor

Combination Crowns & Veneers

Gingival Crown Lengthening

Teeth Angulations

Function

Draw a line from subnasali down

Upper lip should be 2-5mm in front

Lower lip should be 0-3mm in front

Chin should be on the line or 4mm behind

Facial Measurements

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Difficulties?

Aesthetic

Combination Crowns &

Veneers

Existing RCT

Function

Treatment Plan & Diagnosis

Aesthetics

Gingival Harmony

Function

Periodontal Surgery & Provisionals

Full coverage off of gingiva

8-12 weeks healing

Preparations & Provisionals2 crowns and 8 veneers

C-TYPE PREP

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Preparation Guides Preparation Guides

A-TYPE PREP

Facebow / Wax BiteProvisionals (Wax-up)

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Simplified Provisionals

Provisionals (Duplicate models)

Scribe a 0.5-1mm line with a sharp instrument into the

model where the tissue and tooth come together.

Bead Line Veneer Provisional Restorations. Pract Proced Aesthet Dent 2009;21(3):E1-E7.

Provisionals (Bead Line Technique)

Duplicate model with light body wash and heavy body tray material.


The scribed line creates the Bead Line in the over impression of the cast.

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Chlorhexidine

Crowns cemented with clear temporary cement


PROVISIONALS

• Utilize an accurate preliminary over impression

• Maintain over impression

• Check contacts and occlusion

-Visalys (Kettenbach)

-Inspire (Clinician’s Choice)

-Ultradent (ExperTemp)

PROVISIONALS

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NEW MATERIAL

215

48mL cartridge

10mL cartridge

INNOVATION

216

TEMPSMART™ is an innovative, dual-cured, bis-acryl composite temporary crown and bridge

material using microfilled resin (MFR) and nano-filler technologies.

TEMPSMART maintains a smooth surface after polishing because of this revolutionary combination.

The high density polymer network for TEMPSMART makes it a strong material ideal for any sized

provisional.

• Can be repaired by TEMPSMART or any GC flowable composite: G-aenial™ Flo and

G-aenial™ Universal Flo.

• Compatible with GC TEMP ADVANTAGE® and GC FujiTEMP LT™.

• Available in US only (as of 3/4/16).

• TEMPSMART has a shorter tip than the 10:1 materials (64mm vs. 78mm).

• 11% more units per cartridge than those competitors with a 10:1 cartridge delivery system.

Source: GCC R&D

217

Because of GC’s chemistry, using a 1:1 cartridge delivery, so you can use the same gun

as any standard impression material!

TEMPSMART™ uses shorter tips than a 10:1 cartridge delivery system, which means

less waste!

Volumetric shrinkage: 0.86%

TEMPSMART comes in a 48mL cartridge delivery or a 10mL syringe.

TEMPSMART™ DELIVERY SYSTEM

218

TECHNIQUE GUIDES

Source: GCC R&D

Refer to Instructions For Use (IFU) for details.

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A1 A2 A3 A3.5 B1 BW

48mL cartridge

TEMPSMART™ is available in six Vita shades.

10mL cartridge syringe

TEMPSMART™ DELIVERY

Source: GCC R&D

221 (Method) Sample size: 25x5x2mm, Notch size: 2.5x1mm. Cross head speed: 0.25mm/min, Test span: 20mm

TEMPSMART™ shows the highest fracture toughness because it is plasticizer free.

FRACTURE TOUGHNESS

†Not a registered trademark of GC America Inc.

2.3

2.0

1.7

1.5 1.5

1.3 1.2

1.2

0

0.5

1

1.5

2

2.5

TEMPSMART™(light cure)

Structur 2† Protemp Plus†

LuxatempUltra†

Luxatemp Fluoresence†

Integrity† Structur 3† IntegrityMulti Cure†(light cure)

(MP

a√m

)

Fracture Toughness

Source: GCC R&D

Bet

ter

222

(Method) According to ISO 4049: 2009

TEMPSMART™ competes well with a high flexural strength measurement.

FLEXURAL STRENGTH


107.6

104.4

101.4 100.1

96.5

94.5 93.0 92.9

85

90

95

100

105

110

LuxatempUltra†

IntegrityMulti Cure†(light cure)

TEMPSMART™(light cure)

Protemp Plus†

Integrity† Structur 2† Luxatemp Fluoresence†

Structur 3†

(MP

a)

Flexural Strength

Source: GCC R&D

Bet

ter

223(Method) Wearing cycle: 12,000 times. Wearing speed: 180 cycles/min, Brush load: 200gf

TEMPSMART™ maintains the highest gloss value after brushing.

GLOSS RETENTION


47.5

38.5

35.6

25.8

14.8 14.7

0

5

10

15

20

25

30

35

40

45

50

TEMPSMART™ Structur 3† Protemp Plus† Integrity Multi Cure†

Luxatemp Ultra† Integrity†

(% o

f To

oth

bru

sh W

ear

)

Gloss Retention

Source: GCC R&D

Bet

ter

224

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COMPRESSIVE STRENGTH


Source: GCC R&D

454.5 445.7 423.6

338.3

300.5 297.8 274.1 272.4

0

50

100

150

200

250

300

350

400

450

500

Structur 3† TEMPSMART™(light cure)

Protemp Plus†

LuxatempUltra†

Integrity† Structur 2† Luxatemp Fluoresence†

IntegrityMulti Cure†(light cure)

(MP

a)

Compressive Strength

TEMPSMART™ shows excellent compressive strength

Bet

ter

225

Integrity† Integrity

Multi Cure†

(light cure)

Structur2† Structur3†

Thickness: 1.5mm

FLUORESCENCE

227

TEMPSMART™

(light cure)

Protemp

Plus†

LuxatempFluoresence†

LuxatempUltra†

Thickness: 1.5mm

TEMPSMART™ shows beautiful fluorescence.

Source: GCC R&D


Restorations

Check Shape & Esthetics

Check Shade

Marginal Integrity

Contacts

Etch

Restorations

Check Shape & Esthetics

Occlusion

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CEMENTATION Technique

Try-inSilane restorations prior to tryin.

Check each restoration individually for marginal adaptation

Start from center moving laterally

Then start at midline checking two teeth at a time. Then add

the third and check, then the fourth etc.

Then remove all of the restorations and fill each with a water

soluble try-in paste.

Start from center out as though you were cementing. Clean

off excess and access. Gently touch teeth together stop at

first contact.

Now let patient check aesthetics after going over instructions

Cementation – large cases

Etchant based or SE adhesive systems (can be light cured)

(Bisco Universal) (AB3)

Start from center moving laterally with light curable resin

(Choice 2 or eCem)

Light cure material for cases over 4 teeth (2m tacking tip/VALO)

Placing two teeth at a time. Then add the third and tack in place,

then the fourth etc

Then remove all of the residual cement except a small bead

Do not floss contacts

Cementation – small cases

Bonding agent light cured

Start from center moving laterally

Dual cure material for cases under 4 teeth

Placing two teeth at a time. Then add the third and tack in

place, then the fourth etc

Then remove all of the residual cement except a small bead

Do not floss contacts

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CEMENTATION STEPSFront two crowns first

Then 4 veneers at a time.

-Aesthetics

-Function

-Gingival Embrasures

-Excess cement

-Patient homework & questions

Post-Op Check

From Imaging & Diagnostic Wax-up the entire case was duplicated

Direct Class II PosteriorComposite(conservative preps)

(tight contacts)

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Class II Direct Composite

QUICKMAT DELUXPolydentia SA

QUICK RINGS & SILICONE RUBBER ADAPTERS

MICROTHIN MATRICES 0.025MM (0.001 IN)

WOODEN WEDGES

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NiTi only spring

V-Shaped glass reinforced autoclavable plastic tines

(leaves room for the wedge)

Built in lip for increased

stability in forceps

Anatomically shaped

tines

Universal V3 Ring Narrow V3 Ring

TrioDent has developed Narrow V3 Ring in addition to the Universal V3

Ring to ensure ideal separation on smaller teeth.

Note how the anatomical shape of the V3 Ring matches the lingual contour of

the molar while engaging the gingival undercut

Wave Wedge

Hole to fit with positive grip

Pin-Tweezers Inter-proximal contour for a

better gingival seal and V-

shaped concavity to protect

the papillae

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4.5mm

5.5mm

6.5mm

Tab can be bent 90˚ for contra-

angle placement

Holes designed to fit with

positive grip Pin-Tweezers

by TrioDent

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3.5mm 4.5mm 5.5mm 6.5mm 7.5mm

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by TrioDent

INTERPROXIMAL CONTACTS• Consistently Tight Contacts regardless of preparation size

• Height of contour

• Stackable

• Easy pre- or post- wedging

• Band size options

• Coating options

• Anatomically shaped contact

• Bioactive material

• affinity to tooth structure. when placing a glass ionomer a weak acid or conditioner is used

to aid in releasing calcium and phosphate ions from the tooth structure. These calcium and

phosphate ions combine into the surface layer of the glass ionomer and form an

intermediate layer called the interdiffusion zone. This bond layer can be very strong and

significantly reduce the microleakage that would occur at the margins of the restoration.

• Very good fluoride and ion release helps remineralize tooth structure in the remineralization–

demineralization process that naturally occurs in the oral cavity.

• They bond to enamel, dentin, and metals.

Why Glass Ionomers?• They produce good marginal integrity.

• They shrink only one ninth the amount of composite material.

• They are fluoride-rechargeable.

• There are no free monomers in the material.

• The cavity preparation can be bulk-filled, making the materials easy to

place.

• They exhibit excellent biocompatibility.

Why Glass Ionomers?

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Deep Preparations Bonding Agent & Flowable composite

Conventional Glass Ionomer or GI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation & C Factor

Coefficient thermal expansion similar to dentin

LARGE SIZED LESIONS (>2MM)

• Mostly dentin

• Dentin has more moisture and less substance

• Open and Closed defects

• Complications & Risks are higher

• Porous, Wet, Dentin Available

• Interproximal concerns

• Increased Occlusal Loading

• Remaining Tooth StructurePulpal Proximity

Seals & Protects the Pulp:• For Direct & Indirect Pulp Capping

• Light-curable, Radiopaque Liner

• Significant Calcium Release:

• Stimulates Hydroxy Apatite & Dentin Bridge Formation.

Resin-Modified Calcium Silicate Pulp Protectant/Liner

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THERACAL LC (BISCO)

CONVENTIONAL GLASS IONOMER GLASS IONOMER SANDWICH•Class I, II, III & V posterior restorations

•Open & Closed Sandwich techniques

•Composite replacement

•Amalgam replacement

•High caries risk patients

•Pediatric patients

•Geriatric patients

•Special needs patients

•Long term resistance to microleakage

GLASS IONOMER MATERIALS• Dentsply-ChemFil Rock Restorative

• SDI-Riva LC, light cure HV, Riva SC, self cure HV

• G.C. America-Fuji II LC, Equia Fil (Fuji IX)

• VOCO-Ionolux, Ionofil Molar AC

• 3M/ESPE-Ketac Nano, Photac Fil Quick, Vitremer, Ketac Molar Quick, Ketac Fil Plus

• Shofu- FX II

http://www.chemfilrock.com/node/51/lightbox2


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COMPRESSIVE STRENGTHS• GC EquiaFil Compressive Strength 255mpa

• Riva SC compressive strength 271mpa

• Chemfil Rock Compressive 200mpa

• Voco Ionolux had higher compressive strength than Equia Fil or Chemfil Rock

• Surefil SDR compressive strength 220mpa

• Dentin 280mpa-297mpa

• Enamel 384mpa

• Grandio SO HF has compressive 417mpa

• Fuji II LC 170mpa (RMGI) Compressive strength

MINIMALLY INVASIVE PREPARATIONS

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GLASS IONOMER INTERFACE

Interface Analysis (T

EM

)

CARDOSO et al. J Dent 2010

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RESIN TO DENTIN HYBRID ZONE

Open sandwich, glass ionomer & nanohybrid composite

GLASS IONOMER VS. OPEN SANDWICH GLASS IONOMER VS. OPEN SANDWICH• 7 years later.

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A3.5 A3 A2

Glass Ionomer Bulk Fill SDI

RIVA SELF CURE HV (SDI) GC AMERICA

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COMPRESSIVE STRENGTHS

• GC EquiaFil Compressive Strength 255mpa

• Riva SC compressive strength 271mpa

• Chemfil Rock Compressive 200mpa

• voco Ionolux had higher compressive strength than Equia Fil or Chemfil Rock

• Surefil SDR compressive strength 220mpa

• dentin 280mpa-297mpa

• Enamel 384mpa

• Grandio SO HF has compressive 417mpa

• Fuji II LC 170mpa (RMGI) Compressive strength

Case #8: Aesthetics

Veneers

Function

Gingival Bonding

Feldspathic Veneers

Remove old restorations & repair abfraction

lesions on cervicalsGingival Recession &

Abfraction Lesions

The Art of Aesthetics & Occlusion

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Flowables?


• Sometimes it presents as single teeth due to excursive interferences or as a pivot, fulcrum or

“teeter totter” tooth.

• Other times there are more in a quadrant and there is severe wear to the occlusion.

• Other times it maybe on the facials of anterior teeth, where there is wear on the incisal

edges or wear facets on the linguals, however little to no wear on posteriors.

• Occlusal guards should be fabricated along with an occlusal analysis in CR on models.

Pathological loss of tooth structure caused by biomechanical loading forces.

Static and cyclic flexural overloading of tooth structure ultimately leading to fatigue and

failure of tooth structure away from the point of loading.


Abfraction LesionsLatin words, ab – “away”, fraction – “breaking”

Typical Composite Breakdown

Microleakage and missing fillings from high occlusal loads on teeth can

cause large cervical stress concentrations resulting in disruption of the bonds

between the hydroxyapatite crystals and the eventual loss of cervical enamel

and dentin.


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Resin Modified Glass Ionomer RestorationPost-Op Photo – notice unlike typical class V composite FUJI II LC

restorative material. Resin bonding is mostly due to the intertubular dentin. Deep preparations have less intertubular dentin.

More moisture present due to odontoblastic tissues and fluid

Higher risk of post-op sensitivity

Resin Modified Glass Ionomer (RMGI) True adhesion to tooth structure

High flexural strengths

Bonds to moist dentin Hydrophilic

Less technique sensitive

Fluoride release

Decreased gap formation and cusp deformation

No post operative sensitivity Base out deep areas

Place resin/composite on top of RMGI

Dentin Bond Strengths of Simplified Adhesives: Effect of Dentin Depth. Compendium June 2006, p.340-345

Using Cavity Liners with Direct Posterior Composite Restorations. Compendium June 2006, p.347-351.

RMGI’s coefficient of themalexpansion is similar to tooth

RMGI’s on dentin and cementum Use as a sandwich technique

Resin Modified Glass Ionomers

Resin Modified Glass Ionomer Light cured

Dual cured

High flexural strength

Good polishability

Excellent wear

Hydrophillic

Fluoride release

No microleakage

No adhesives

Acid resistant layer

Reduces sensitivity

True chemical adhesion

Glass Ionomer Materials

Dentsply-ChemFil Rock Restorative

SDI-Riva LC, Riva SC

G.C. America-Fuji II LC, Equia Forte (Fuji IX)

VOCO-Ionolux, Ionofil Molar AC

3M/ESPE-Ketac Nano, Photac Fil Quick, Vitremer, Ketac

Molar Quick, Ketac Fil Plus



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Typical treatment involves the placement of a #00 retraction cord on each

tooth. Shade selection. Roughen tooth structure with air abrasion. Place cavity conditioner on all areas to be restored for 10 seconds, then wash and

dry. Teeth should be isolated from saliva.

Restorative Therapy- Case 1Mix Fuji II LC or RIVA Light Cure and syringe into place. Utilize hand instruments to

shape and remove gross excess. Cure each tooth for 20 seconds. Remove excess and contour using a handpiece with fine diamond burs.

Restorative Therapy- Case 1

After contouring the restorations can be coated with a self etch

adhesive coating, and cure for 10 seconds.

Restorative Therapy- Case 1 Restorative Therapy- Case 1Eight year post-op photos show the integrity of the material is still excellent. Note

the lack of marginal microleakage stain often present with composite restorations.

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Fig. 15 – Graph representing the mean annual failure ratesper adhesive class, determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998–2004 [2].

Van Meerbeek B, et al. Relationship between bond-strength tests and clinical outcomes. Dent Mater (2009), doi:10.1016/j.dental.2009.11.148

• Restore defect to protect the exposed dentin and

strengthen cervical tooth structure with Glass Ionomer.

• Occlusal evaluation from Centric Relation to Centric

Occlusion, with possible occlusal adjustment.

• Lateral excursive interference evaluation, with possible

occlusal adjustment.

• Check Saliva pH levels for possible erosive problems.

• Night guard therapy.

• Stump Shade (dehydration factor)

Base Shade • Easy Shade

• Custom Shade

• Photographs

• ALL DONE PREVIOUSLY

B-TYPE PREP

Impressions

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• Facebow (SAM III)

• Wax bite (Delar)

Facebow & Wax Bite Registration Provisionals

Free Hand ProvisionalsFree Hand Provisionals

Example

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• Materials

• Rigid Bite Registration

• Light and Heavy Body

Prefabricated Over Impression TEMPORARY CEMENTS

• Provisional Veneer Removal

• Indirectly fabricated

• Spoon on gingival margin

• Cut vertically with small bur and use crown key to gently separate

• Directly fabricated

• Spoon on gingival margin

Veneer Try-In(Fourth Appointment)

VENEER EVALUATION

• Check models

• Uncut, pindexed and individual dies

• Check veneers internally and externally

• Try on the models

• Evaluate etch

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OptiCleanTM

Now – An Easy & Efficient way to remove temporary cement!

Feature Benefit

Unique design Enables excellent access

Optimized abrasive particles Faster, easier & complete removal of temporary cement

No paste or slurry required Clear view of working surface

Gentle to soft tissue Alleviates bleeding & gingival trauma

Light conical tip Low risk of abrasion to prep or adjacent teeth

Single use Highly hygienic

TOOTH CLEAN-UP

• Plastic shank material – aromatic polyamide

• Abrasive material - Al2O

3 (aluminum oxide)

• Grit size – 40 microns

• Smallest tool on market – 1.6mm tip diameter

• Total length – 24mm

• Use with or without water spray

• Operates at 3000-5000 rpm

OptiCleanTM

VENEER TRY-IN

• Water soluble clear try-in paste

• Evaluation of esthetics and contour

• Evaluate occlusion

Porcelain Adjustments

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VENEER CLEAN-UP

• Steam clean

• Acetone in a bottle drop in the ultrasonic

VENEER BONDING

Dry Air Source

Evaporate volatile solvents

Drying dentin & enamel

Do not desiccate

ADEC tooth dryer

MIDWEST FREEDOM (DENTSPLY)

WHIPMIX PREPPIES

INSTRUCTIONS FOR USE

PORCELAIN VENEERS

VENEER PREPARATION:

• Make sure veneer is properly etched with hydrofluoric acid.

• Apply 1-2 coats of Silane to internal surface of veneer. Wait 30-seconds and air dry, or let sit longer with heat.

• Try-in veneers with Water-Soluble Try-in Pastes. Remove and rinse thoroughly.

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• More efficient than Halogens

• Longer lasting

• Smaller in size/lighter

• Cordless

• Multiple wavelengths

• Curing options: Ramp, pulse, boost

• Smart Light Max (Dentsply)

• Valo (Ultradent)

• Demi Ultra (Kerr)

BENEFITS OF LED LIGHTS Bulk excess

– Bard Parker

– TC Carvers (Brasseller)

– Gold knives

– Perio knives

Interproximal saws

ContactEZ

Brasseler

Axis

Finishing strips

Brasseler

Axis

12 & 30 fluted carbides

Cement Removal

Finishing & Polishing Ceramic

30 & 15 µm diamond

8/12 &30 fluted carbide

polishing points

diamond polishing paste

diamond impregnated points & cups

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Post-Op PhotosTRENDS IN RESTORATIVE DENTISTRY

One of the primary challenges faced by today’s dental restorative

team is the need to deliver high-strength restorative options

without compromising the esthetic outcome fueled by ever-

increasing patient demands.

Significant developments in all-ceramic materials have created

wonderful opportunities for the fabrication of lifelike restorations

that provide reliable, long-term results. –

Lithium Disilicate: The Future of All-Ceramic Dentistry, ivoclar vivadent

NEWER CERAMICS

Feldspathic Porcelain

• MPa of 90-100

• Most esthetic and translucent porcelain

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NEWER CERAMICS

Lithium Disilicate – IPS eMax (ivoclar vivadent)• MPa of 360-400

• Highly esthetic

• Forward direction of the ceramics market is to lithium disilicate

because of its durability and esthetics

ABILITY TO PROPERLY FINISH HIGH STRENGTH

CERAMICS

Top challenges we hear from dentists

Achieving a truly smooth finish

Achieving high-gloss shine

Without proper adjusting and polishing

• Micro fractures

• Abrasion of adjacent teeth

• Lithium Disilicate (IPS e Max) has a 97.6% Success rate WHEN

finished and polished correctly

What finishing system should you use?

CERAMIC FINISHING SYSTEMS

Several brands

• Brasseler

• Meisinger

• Kenda

• Axis

• Eve

• DFS

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Available exclusively from Ultradent

INTRODUCING

The Only Universal Finishing System for

High Strength Ceramics

Universal Adjusting & Polishing System

• The only universal system in which all instruments work interchangeably

on porcelain, lithium disilicate, and zirconia.

• Equally effective and beautiful results across all ceramic materials.

• Eliminates the need for multiple or unnecessary kits and instruments

helping you achieve a better outcome while saving time and money.

• Provides a truly smooth and high gloss finish for beautiful results.

Ultradent diamond grit

Optimized number & type of adjustors and polishers

Simple 2-step sequential process

Universal Adjusting & Polishing System

Extra Oral Kit

• Grinder Wheels & Tapers – Course & Medium

• Polishing Wheels – Medium & Fine

Intra Oral Kit

• Added advantage of Diamond Burs

• Fine round end taper & football

• Polishing Points & Cups – Medium & Fine

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The Nuts and Bolts of Veneers: Tools

IMPRESSIONS & TISSUE MANAGEMENT


PREPARATION TECHNIQUE

• Margin Placement

• Supragingival

• Equigingival

• Subgingival

• Margin Design

• Clock Work Prep

• Retraction Cord Assistance

• Sonic Prep

PREPARATIONS

• Prep counter clockwise

• Less tissue damage (rotation is rolling on tissue) & faster tooth

reduction. Use above gum line.

• Prep clockwise

• Tissue removal due to bur rotating opposite direction

• Bur rolling on tooth creates less reduction of tooth structure.

• Place a single cord

• after preparing interproximal area

• after gross reduction just above tissues

• Then refine margins

ELECTRIC HANDPIECES

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Important: Minimize tissue damage allows for less time utilized in managing bleeding.

SF1LM (Komet)

K0095 Preparation Kit (Brasseler USA)

Unique Tools



Unique Tools



Unique Tools


Unique Tools


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SF1LM (Komet)


Unique Tools


SF1LM (Komet)


SF1LM (Komet)

Unique Tools

Types of Moisture

Saliva

Crevicular Fluid

Bleeding

Enhancing Moisture Control

Fluid/Tissue Management

• Oral Rinses

• 0.63% Stannous Fluoride

• Anti- cavity, -gingivitis, -

hypersensitivity, -plaque (8hrs)

• Chlorhexidine

• Anti- fungal, microbial and bacterial

• Antisialogogues

• Saltropine

• Antihistamines

• Benadryl

• Benzodiazepines

• Triazolam (halcion)

• Diazepam (valium)


Pre Appointment Therapy


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• Superoxol

Epinephrine

Ferric Sulfate

ViscoStat 20%

Astringent 15.5%

• Aluminum Chloride

• Viscostat Clear 25%

• Expa-syl

• Hemostasyl

• Aluminum Sulfate

• Tissue Goo 25%

• Various Cords

ASTRINGENTS Enhancing Moisture Control

RETRACTION CORDS

• Numerous Sizes

• 1 cord technique (pockets <3mm)

• Placed below margin

• Moisten prior to retrieval

• If bleeding do not remove first cord




◦ 1 cord technique allows subgingival

margin placement

◦ Reprep if necessary

◦ If more bleeding occurs place astringents

or pastes

RETRACTION CORDS


RETRACTION CORDS

• 2 cord technique (>3mm pockets)

• Remove uppermost cord only

• Cord and a Paste technique

• Cord is for tissue displacement, not for

hemostasis



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Fluid/Tissue Management Fluid/Tissue Management


REMEMBER WHEN YOU SAW THE LIGHT?

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REMEMBER HOW HARD THINGS USE TO BE?

REMEMBER TRYING TO CREATE A CONTACT?

810 nm

2.5 & 7 Watts

Features

• Number #1 dental laser

in the world

• More power – 3 watts

• New easy to use presets

• New treatment timers for

perio treatment

• Wireless foot control

• Optional battery pack

• Perfect for first timers or

hygienists

• Affordable

• Disposable tips or fibers

• Certification included

• MSRP: $4,495

• CE Price: $3,495

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Features

• Ideal for Implants, perio

treatment, surgery.

• High power 7.0 watts

• New treatment timers

• Wireless foot control

• Optional battery pack

• Disposable tips or fibers

• MSRP: $6995

• CE Price: $5495

PICASSSO SOFT TISSUE PROCEDURES

• Gingival Troughing for Crown Impressions

• Gingivectomy & Gingivoplasty

• Gingival Incision & Excision

• Soft-Tissue Crown Lengthening

• Hemostasis & Coagulation

• Excisional & Incisional Biopsies

• Exposure of Unerupted Teeth

• Fibromal Removal

• Frenectomy & Frenotomy

• Implant Recovery

• Incision & Drainage of Abscess

• Leukoplakia

• Pulpotomy as an Adjunct to Root Canal Therapy

• Operculectomy

• Oral Papillectomies

• Reduction of Gingival Hypertrophy

• Vestibuloplasty

• Treatment of Canker Sores, Herpetic & Aphthous Ulcers of the Oral Mucosa

PERIDONTAL PROCEDURES

• Sulcular Debridement (Removal of Diseased, Infected, Inflamed, &

Necrosed Soft-Tissue in the Periodontal Pocket to Improve Clinical Indices

Including Gingival Index, Gingival Bleeding Index, Probe Depth, Attachment

Loss, & Tooth Mobility)

• Laser Soft-Tissue Curettage

• Laser Removal of Diseased, Infected, Inflamed & Necrosed Soft-Tissue

Within the Periodontal Pocket

• Removal of Highly Inflamed Edematous Tissue Affected by Bacteria

Penetration of the Pocket Lining & Junctional Epithelium

PICASSO LITE PLUS MODES

A SOFT TISSUE LASER INCISION AT 1000X MAGNIFICATION

Laser cut

Superficial coagulation

Heat dissipation with little/no edema

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• Electrosurge devices have a much larger zone of necrosis and inflammation – up to 500 to 1,000 cell layers of tissue damage vs. 3 to 5 with a diode laser

• Unlike electrosurge devices, a diode laser will cauterize nerve endings, minimizing discomfort intra - and post-

operatively (1).

• Tissue treated with a diode laser stays exactly where the clinician leaves it post -operatively; no worry of rebound or recession (4).

DIODE LASER VS. ELECTROSURGE

Zone of Inflammation

Laser Cut Electro-surgery Cut

Zone of

coagulation

LASERS Fast

Hemostasis

No crevicular fluid

No cord

Better healing



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Frenectomy

Benefits:

• No sutures

• No bleeding

• No discomfort

• No injections

Settings:

Power:1.4W

Mode:CW

Tip:Initiated

HINT: Use tissue pen to

darker fibrous band

Frenectomy

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Frenectomy Frenectomy

Before After

Laser Troughing

Benefits:

• Predictable margins

• No tissue recession

• No bleeding

• No discomfort

• Faster procedure

Settings:

Power:1.2W

Mode: Continuous

Tip: Initiated

Tissue Management

For All Tissue Management Issues

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For All Tissue Management Issues




Fluid/Tissue Management Enhancing Moisture Control


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Fluid/Tissue Management Enhancing Moisture Control


• Closed Bite Trays (most common)

• Flexible Trays

• Lack of rigidity may cause distortion

• Spring back after impression potential

• No cross arch stabilization

• No support

• Thin spots or perforations can cause distortion

• Lack of occlusal stops for proper model articulation

• Impression material shrinks towards bulk

• Unable to recreate excursive movements

• Potential for errors & adjustments extremely high

IMPRESSION TRAYS Selection Process Selection Process

◦ Open Bite Trays

Plastic-full or quadrant

Metal-full or quadrant

Custom Trays

Non-perforated or perforated (metal or plastic)

Rigidity can eliminate tray distortion and rebound

Spring back after impression is possible with plastic

Cross arch stabilization

Ideal occlusal stops for proper model articulation

Able to recreate excursive movements if mounted on a semi or fully

adjustable articulator.

Potential for errors & adjustments are low

IMPRESSION TRAYS

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• Custom trays create more ideal

placement

• Thinner material creates less

distortion

• USE TRAY ADHESIVES for all

open bite trays, not just custom

trays.

• Only negative is time

IMPRESSION TRAYS Selection Process

Custom Tray

HEATWAVE BY CLINICIAN’S CHOICE• 4 upper & lower trays

• 60 sec. @ 158°F

• Fast, efficient

• Virtually custom

Selection Process

Impression Trays

• 4 upper & lower trays

• 60 sec. @ 158°F

• Fast, efficient

• Virtually custom

• 30% less impression

material used

Impression Trays

HEATWAVE BY CLINICIAN’S CHOICE

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Impression Trays


Impression Trays


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CLINICIAN’S CHOICE AFFINITY

• Dry all teeth in arch

• Place tip in most difficult area first

• Keep tip on margin and immersed in material

• Go around entire margin first

• Next go to adjacent teeth

• Then do coronal aspect of teeth

• Double Mix Single Impression is the most

accurate

SYRINGE PLACEMENT

LOCK-N-RELOADWWW.INDIGREEN.COM

WHAT PERCENT OF IMPRESSIONS PER LABORATORIES HAVE VISIBLE ERRORS?

89%

1-Samet N, Shofat M, Livny A, Weiss EI. A clinical evaluation of fixed partial denture impressions. J Prosthet

Dent 2005; 94:112-117.

And the key to remember, routinely, it’s voids, bubbles, and tears

“Approximately 90% of impressions have defects” G. Christensen

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IMPRESSION MATERIALS• EXA’Lence (GC America)

• Affinity (Clinician’s Choice)

• Panasil (Kettenbach)

• Identium (Kettenbach)

• Aquasil (Dentsply)

Panasil Initial Contact (VPS)

Kettenbach

PANASIL INITIAL CONTACT• Lowest contact angle of any VPS impression material

• Fast set and Regular set

• Best Value Materials Available

Kettenbach

PANASIL INITIAL CONTACT VS. AQUASIL

Kettenbach

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CRACKED TOOTH

Kettenbach

PANASIL INITIAL CONTACT

Kettenbach

PANASIL INITIAL CONTACT

Kettenbach Kettenbach

Identium(Vinylsiloxanether-VSXE)

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IDENTIUM

• Fast set and Regular set

• Medium or Heavy viscosity

• Light viscosity flow

• Excellent flow ability

• Exceptional hydrophilicity

• Easy removal from mouth and model

• Odorless and neutral taste

• Can be poured immediately

• Identium Scan is a new scanable Vinylsiloxanether that handles like a polyether with a long working time & snap

set

Kettenbach

Identium combines the advantages of the most tried and tested materials, A-silicone and polyether. Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORT®…volume 5, Issue 3.

Kettenbach

Identium for single teeth

Identium for multiple teeth

-two cord technique

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MAKE CASES EASY

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WHAT PERCENT OF

IMPRESSIONS PER

LABORATORIES HAVE

VISIBLE ERRORS?

89%

1-Samet N, Shofat M, Livny A, Weiss EI. A clinical evaluation of fixed partial denture impressions. J Prosthet

Dent 2005; 94:112-117.

And the key to remember, routinely, it’s voids, bubbles, and tears

“Approximately 90% of impressions have defects” G. Christensen

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DEHYDRATION / PREP SHADE PHOTOGRAPH

AQUASIL CORDLESS W/ HEAT WAVE TRAY PHOTO DOCUMENTATION W/ POLAR EYES

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CLEAR TEMPLATE MATERIAL AMD PICASSO LASER & AQUASIL CORDLESS IMPRESSION

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SUMMARY• Safeguard for working time violations use Identium (Kettenbach)

• Diodes may eliminate retraction cord & paste

• Precision placement of impression material

• Good tear strength

• Heat Wave trays (customizable) conserves material & more accurate.

A solution designed to

improve impression-making. Chairside this translates

to simplicity, efficiency, and predictability.

Case #14

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Removing provisionals that are locked on.

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ADHESION TECHNIQUES

Total vs. Self Etch

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CEMENTATION MATERIAL OPTIONS

Glass Ionomers Resin Modified Glass Ionomers

Acidic pH

Moisture Tolerant

Fluoride Release

Degrades over time

Low bond strength

Biocompatibility-Fair

Bioactivity-None

Sealing Quality-Ok

Acidic pH

Insoluble Moisture Tolerant

Fluoride Release

Stronger Than Traditional GIs

Degrades over time

Improved bond strength Biocompatibility Ok

Bioactivity-None

Sealing Quality-Ok

Silanate Restorations

Cement Selection

Cementation

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Cementation

RESIN CEMENT COSMETIC CASES….

COSMETIC CASES…. COSMETIC CASES….

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COSMETIC CASES…. PROVISIONALS

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PROVISIONALS PRE-SILANATE VENEERS• Place under heat for a few minutes

Make sure it is etched properly from lab

Silanate prior to try-in (unless using Ceramir)

Ultrasonic with ethanol after try-in

Zirconia silanate prior to try-in(Ultrasonic with ethanol after try-in)

Or

Sandblast after try-in and use a MDP based cement

Silanes

Universal Adhesives (w/MDP)

Silane Primer + MDP

Organo-Phosphate Monomer (MDP)

Silane Primers

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BONDS WITH OR WITHOUT HF

ACID ETCHING

THE “NO-WATER” SILANE

INSTANT ACTIVATION

LESS DEGRADATION

(More Stable 2 Year Shelf-Life)

Silane:

Silica based ceramics

Lucite based

ceramics

Glass Fiber Posts

Composite

Restorations

Unique Silane that bonds to Zirconia, Alumina, Porcelain, Micro Hybrid & Nano Filled Composite & Base Metals.

Contains Silane, ethanol & MDP Monomer-it is the main ingredient in Panavia resin cements which bond directly to high strength ceramics (Zirconia & Alumina).

MDP:

High-Strength

Ceramics (Zirconia &

Alumina)

Base Metals

UNIVERSAL ADHESION

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LIGHT CURED RESIN CEMENT

• Calibra Esthetic Resin Cement Veneer Kit combines ease of use and

excellent handling.

•Shade-stable chemistry

•Versatile light-cure/dual-cure system

•Low solubility prevents margin disintegration

•Low film thickness

• Always use a bonding agent and a light cured resin

• Do not try and use a SE dual cured resin

ECEMENT BISCO

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CONTACEZ RESTORATIVE STRIP SYSTEM

• Black Diamond Strip 0.06mm fine diamond single sided

• Orange Serrated Diamond Strip 0.05mm extra fine diamond single sided

• White Serrated Strip 0.035mm

• Blue Serrated Strip 0.065mm

• Gray Final Polishing Strip 0.05mm ultra fine diamond single sided

CONTACEZ IPR STRIP SYSTEM

• Yellow IPR Starter 0.06mm

• Red IPR Opener 0.12mm

• Dark Blue IPR Widener 0.15mm

• Green IPR Extra Widener 0.20mm

CONTACEZ IPR OPTIONAL STRIPS

• Clear IPF Single Sided Opener 0.10mm med-fine diamond

• Cyan IPR Single Sided Widener 0.12mm med-coarse diamond

• Purple IPR Super Widener 0.25mm

coarse diamond

• Brown IPR Mega Widener 0.30mm coarse diamond

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FINAL RESTORATIONS

4th6th5th

7th

•Courtesy Pacific University (Dr Marc Guisberger)

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INSTRON

• Ultra Tester (Ultradent)

• Ultra Jig (Ultadent)

SHEAR BOND TEST RESULTS - 2012

Average Shear Bond Strength to Dentin: 24.2

MPa


Maximum/Minimum Shear Bond Strength per

Bonding Material

SHEAR BOND TEST RESULTS - 2012


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Total etch Self etch# of

components

Etchant

Primer

Adhesive

The Bonding Agents

Generation4th 5th 6th 7th

Universals

OR

NEW “UNIVERSAL” SYSTEMS

• Simple & easy to use

• Direct & indirect techniques

• Use as Total, Selective or Self Etch

• Low sensitivity

• Lots of MDP Based Products*

MDP Penta-P MDP MDP

Adhesive Functional

Monomers

MDP GPDM

MDP Modified

Phosphates

Enamel & Variable

Dentin Bonding

ProblemsVarying tooth substrates

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What substrate are we treating?

Class I or II

:Composite Preparation

3x Tubule Density Equals Higher Fluid & Increased Difficulty for Bonding%30 Degrease in Bond Strengths with most

bonding systems.

“Adhesive dentistry could be expressed

as a simple relationship between bonds

and stress. If the bonds can withstand

the stress, the restorative technique

will be successful.”

Unterbrink and Liebenberg

(1999)

Case #17: Mounted and Equilibrated

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Case Example: Aesthetics

Trauma

Anterior Guidance

Special Protrusive Bite

InstantComposite

Mockup

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Custom Protrusive Jig!!

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Understanding Buffering 101

• Local Anesthetics is an acidic solution with a pH of ~ 3.9

• To achieve pulpal analgesia the body needs to raise the pH of the local anesthetic

toward physiological pH ( ~ 7.4). This can take up to 15 minutes per patient.

• Sodium Bicarbonate is a neutralizing additive solution

• Buffering (adding sodium bicarbonate to anesthetics) brings pH level closer to

physiologic pH prior to injection meaning that the burning sensation of the injection

is greatly reduced and the patient gets numb almost immediately.

• Buffered Anesthetics more profound anesthesia—6,000 times more active anesthetic

(active molecules). Logarithmic scale moving from 3.9 to 7.4 pH

• A by-product of buffered anesthetics is a CO2 enriched microbubble that readily

crosses the nerve membrane and in itself contains anesthetic properties not found in

unbuffered anesthetics. It essentially produces an immediate effect, similar to that of a

topical.

Understanding Buffering 102

ANUTRA

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CEMENT OPTIONS

CERAMIR• Alkaline pH 8.5

• Moisture Tolerant

• Self Sealing

• Apatite Formation

• Insoluble

• Stronger with time

• Semi / Translucent

• Biocompatibility-Excellent

• Bioactivity-Apatite formation

• Sealing Quality-Excellent

Cement Selection

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• Ceramir C&B is a material that combines glass ionomer technology with the

innovative Ceramir (Calcium Aluminate – C.A.) technology.

• The G.I. contributes to:

• Low initial pH, short duration

• Flow and Setting characteristics

• Early strength

• The C.A. contributes to:

• Increased strength and retention

• Biocompatibility

• Sealing of tooth material interface

• Apatite formation

• Sustained long term properties, no degradation

• Basic end pH

• Ceramir Crown & Bridge is indicated for permanent

cementation of:

• Porcelain fused to metal crowns and bridges

• Metal (gold, etc.) crowns and bridges

• Gold inlays and onlays

• Cast or prefabricated metal posts

• Strengthened core all-zirconia or all-alumina ceramic

crowns and bridges

• Lithium Disilicate (eMax)

• Stainless steel crowns

• Ortho bands and appliances

The technology is called NIB (Nanostructurally Integrating Bioceramics).

• Bioceramic powder

• Reacts with water

• Dissolution

• Nano crystals formed on:

• Tooth walls

• Filler particles

• Pre-existing crystals

• Prosthetic construction

• Stable sealing of the interface

Ceramir

Ceramir

Dentin

Enamel

Bioactivity by Doxa

A reactive bioactive system that contributes to mineralization of hard tissue through ion release and alkaline pH.

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CERAMIR C&B COMPARISON TO OTHER

CEMENT CLASSES

CROWN RETENTION• Results Zirconia crowns (Kg/F)

Material Result (Zirconia crowns) Kg/F

Ceramir Crown & Bridge 32.1 ± 6.3

RelyX Unicem (3M) 27.8 ± 11.3

Dyract Cem (Dentsply) 12.2 ± 3.1

Rely X Luting (3M) 10.9 ± 6.5

0

5

10

15

20

25

30

35

Ceramir Crown & Bridge RelyX Unicem (3M) Dyract Cem (Dentsply) Rely X Luting (3M)

Cement Selection Cement Selection

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• Silane is contraindicated

• Tooth etching or conditioning is not necessary

• Bonding agent is not needed

CEMENTATION TECHNIQUE

Cement Selection

CEMENTATION TECHNIQUE LITHIUM DISILLICATE (EMAX)

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Cement Selection

Zirconia Restorations

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MISSING CANINE ZIRCONIA ABUTMENT AND EMPRESS CROWN

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• Retention equal to or better than resin cements

• Material gets stronger over time & remains chemically stable

• No etching, bonding or conditioning

• Easy seating to completion of indirect restoration

• Easy to clean up

• Does not require optimal conditions for a good seal

• Self sealing

• Permanent seal of the tooth – restoration interface

• Biocompatibility- Creates Apatite when in contact with phosphates

• No shrinkage

• No post-op sensitivity

• Hydrophilic system with Alkaline pH

• Acid Resistant

• Bonding

• Veneers

• All Ceramic Crown

• Custom Zirconia Abutment/All Ceramic Crown

MIXED TREATMENT CASE

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MIXED TREATMENT CASE

20 y.o. female patient presents with a missing lateral incisor, peg lateral, worn dentition.

The Nuts & Bolts of Veneers

The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers

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BEADLINE PROVISIONAL TECHNIQUE WITH TEFLON OVER IMPLANT

The Nuts & Bolts of VeneersThe Nuts & Bolts of Veneers

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Case #21: Aesthetics

Tissue Problems

Poor Function

No TMJ Problems



Incisal position

Gum height


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2-4 mm

10-11 mm



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Case #24:



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Pre-op

Post-op



Initial Appointment

Consultation

First Appointment

Comprehensive Evaluation

Whitening?

Second Appointment

Go over diagnostic tools

Check whitening

Discuss Treatment Plan (Do Last)

Set Appointment & Collect $$

Lab Work

Third Appointment/Preparation

Fourth Appointment/Try-In/Delivery

Verify margins, contacts, occlusion and shade

Fifth Appointment

Post-Op Check

Occlusal Guard Impressions

Post-Op Photos

Sixth Appointment

Deliver Occlusal Guard


“The quality of a person’s life is in

direct proportion to his or her

commitment to excellence.”

-Vince Lombardi

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Lecture Handout, Free Drawing & Special Offers Available

www.DENTOOLZ.com

Todd C. Snyder, DDS, AAACD

(949) 643-6733

doc@ tcsdental.com

www.aestheticdentaldesigns.com

www.drtoddsnyder.com

http://www.aestheticdentaldesigns.com/

http://www.drtoddsnyder.com/

Documents

3/17/2016 - d1ue90e5sp4tcv.cloudfront.netd1ue90e5sp4tcv.cloudfront.net/1946/images/Text... · 3/17/2016 1 Todd C Snyder, DDS, AAACD The Nuts and Bolts of Indirect Anterior Aesthetic