Todd C Snyder, DDS, AAACD - d1ue90e5sp4tcv.cloudfront.netd1ue90e5sp4tcv.cloudfront.net/1946/images/Asset279275_v1.pdf · less from contact point to bone • Use most incisal bone

12/2/2015

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Todd C Snyder, DDS, AAACDPrivate Practice in Laguna Niguel, California

Faculty, Esthetic Professionals

Catapult Elite, Member

The Nuts and Bolts of Veneers

DIAGNOSIS & TREATMENT PLANNING

The Key to Success:

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CASE SELECTION:

• The Nuts and Bolts of Veneers

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:

Putting A Case

Together• Case Sequencing

• What Records & When

• Smile Design, & Aesthetics

• Laboratory Communication

• Clinical Procedures

• Finale (Post-Cementation)

Color


SEQUENCING FOR SUCCESSFUL CASES

How many appointments for veneers?

Up to 6

2? 3?


SEQUENCING FOR SUCCESSFUL CASES Initial Appointment

Consultation

First Appointment

Comprehensive Evaluation

Dx Wax-up & Whitening?

Second Appointment

Go over diagnostic tools

Check dx wax-up & 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

Reschedule or Follow-up

OR


Initial Appointment

Consultation

First Appointment


Dx Wax-up & Whitening?



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COMPREHENSIVE EVALUATION

• Patient Desires

• Strength, esthetics, longevity, etc.

• Visual Perception

• Function

• Morphologic Positioning & Posturing

First Appointment

FIRST APPOINTMENT


Time

Money

Patient and Lab Communication

Diagnostic Records

Time/Appointments

Diagnostic

Verification & $$$$

Preparation

Try-in / Cementation

Post-Op Check/Guard

“Under promise and

over deliver”

Money

Diagnostic

Estimate range on cost

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


Time

Money


Diagnostic Records


Time

Money


Diagnostic Records

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

• 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 (prebook lab)

• Relay pictures and information

First Appointment

FIRST APPOINTMENT

• Initial (Primary) Diagnosis

• Time

• Money

• Patient and Lab Communication

• Diagnostic Records

How soon is the case needed?

When can the lab get it done?

FIRST APPOINTMENT

• Initial (Primary) Diagnosis

• Time

• Money

• Patient and Lab Communication

• Diagnostic Records

What Records & When

Diagnostic Records

Review Health Hx & existing Radiographs

Comprehensive Exam

Periodontal Probing, Mobility,

Recession, Attached Tissue,

Biologic Width

First Appointment

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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

Diagnostic Records (continued)

Radiographs

3 Sets of Models (mounted with facebow on

articulator)

Initial untouched model

Preparation design model

Diagnostic Wax-up

(Duplicated diagnostic wax-up model for provisionals)

What Records & When

First Appointment

Additional Model (possibly)

Bleaching trays

Pour in Snap Stone or Speed Stone

Deliver same day

Diagnostic Models and Facebow

First Appointment


Smile Design

Shade Analysis

Teeth Whitening!!

How long will it postpone treatment??

What Records & When

First Appointment

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SMILE DESIGN 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

SMILE DESIGN SOFTWARE

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

Cognitive Mapping

EYESPECIAL C-II (SHOFU)

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UNIQUE FEATURES

EYESPECIAL C-II

• Designed for dentistry

• 8 modes

• 12 Megapixels

• Dental cropping and grid lines

• Large LCD touchscreen

• Water and chemical proof – Essential for infection control

• Durable rugged Exterior***

• Fast autofocusing & anti-shake capabilities

• Held with one hand – weighs only 1lb

• Compatible with the Eye-Fi X2 card – Immediately upload

images onto PC, iPad, Tablet or Smartphone

MAGNIFICATION RANGE• Chose the magnification ratio/range by rotating the dial key

• Icons to help you determine and select the range properly

EDIT & DRAW FUNCTION ON THE

EYESPECIAL C-II

• Edit functions are ideal for

patient education

• Under the Menu key you can:

• Draw on images to show

areas of focus

• Rotate the image

• Protect the image against

being deleted

STANDARD MODE

MIRROR MODEImages are captured in “Low Glare” mode.

WHITENING MODEFOR SHADE COMPARISON BETWEEN BEFORE AND AFTER

WHITENING• Similar to “Low-glare” mode but with lower light intensity

• Reduces glare and emphasizes the surface texture and shade

• Delegated Whitening & Scanning Assistant

Upper arch whitened

Lower arch not whitened

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ISOLATE SHADE MODEFOR OPTIMAL SHADE MATCHING

TELE-MACRO MODEFOR PHOTOGRAPHING ANTERIOR TEETH, INDIRECT RESTORATIONS AND

WORKING MODELS IN HIGHER MAGNIFICATION **ATTACH THE CLOSE-UP LENS

WHEN TAKING PICTURES IN THIS MODE**

Quadrant Dentistry - Menu

COMPUTER SIMULATION:

DIGITAL MOCKUP/PREVIEW

What about

pictures?

Are they relevant and

realistic?

REALISTIC

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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

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

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

• 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

• Embrasures


ADDITIONAL Tools

ADDITIONAL TOOLS

Panadent: Multi Purpose Ruler Erskine: Dentagauge 1 & 2

ADDITIONAL TOOLS

ADDITIONAL TOOLSSHIMBASHI MEASUREMENT. CEJ #8 to CEJ #25 or

CEJ #9 to CEJ #24

Normal is 17 to 18 mm depending on

the patient.


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Golden proportion

between teeth.

0.6-1-1.68

Golden Proportion Measurement.


Wear Facets & Interferences


EQUILIBRATED MODELS• Shim Stock Holds (0.001 inch)


Occlusal Testing

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.

Mounted and Equilibrated


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


Prepared Model & Waxup


Blueprint for Success

Diagnostic Guides Prior to Second Appointment

Diagnostic Guides Prior to Second Appointment

Disposables

Non Adjustable

Semi Adjustable

Articulators Prior to Second Appointment

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Prior to Second Appointment Prior to Second Appointment

Semi Adjustable

not on Hinge Axis


Semi Adjustable

not on Hinge Axis


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

Less adjustments and remakes?


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Initial Appointment

Consultation (Free)

First Appointment


Whitening?

Second Appointment


Check whitening



Reschedule or Follow-up


• The Nuts and Bolts of Veneers 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

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)

SS WHITE: PIRANHA & PIRANHA 2X

• Single Use

• Over 500 Shapes

BURS

• Lasco Depth Cutters

• SS White Diamonds

• Piranha Diamond

• 850-016M/F

• 368-023M/F

• 392-016VF/F/M

• SS White Carbides

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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

INSTANT ORTHO/UN-ROTATING TEETH

• Do initial workup

• Diagnostic preps

• Diagnostic waxup


Sequence

– Reduce all excess tooth structure

– Ideal reduction

– Margin placement

Example: Aesthetics

Instant Ortho

No TMJ or bite problems

Empress

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Veneer Preparations

Facial/Lingual repositioning and margin placement

Veneer Preparations

Mandibular incisors-Incisal edge preparation

Veneer Preparations

Premolar preparation techniques

Veneer Preparations

When to extend thru interproximal contact.

– Existing restoration so that the veneer margin ends on enamel.

– Small diastemas or gingival embrasure defects

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

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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

• 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

CASES

Case #1: Prepless veneers???

Aesthetics

Veneers

Function

Bonding

Feldspathic Veneers

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Shade Assumptions

Bleach, B1, B2, A1, A2,

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Aesthetics

Smile Line

Gingival Excess

Gingival Asymmetry

Buccal Corridor

Case #2:

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

Difficulties?

Aesthetic

Combination Crowns &

Veneers

Existing RCT

Function

Treatment Plan & Diagnosis

Aesthetics

Gingival Harmony

Function

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Periodontal Surgery & Provisionals

Full coverage off of gingiva

8-12 weeks healing

C-TYPE PREP

Preparations & Provisionals2 crowns and 8 veneers

Preparation Guides Preparation Guides

A-TYPE PREP

Facebow / Wax BiteProvisionals (Wax-up)

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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.

Chlorhexidine

Crowns cemented with tempbond clear (w/triclosan)



Initial Appointment

Consultation

First Appointment


Whitening?

Second Appointment


Check whitening



Lab Work





• Feldspathic Porcelain (weakest, thin, best colors)

• Numerous on the market

• Pressable (Leucite) Glass Ceramic (moderate strength and thickness, good/better color)

• Numerous on the market

• Lithium Silicate & Disilicate Ceramic (high strength, moderate thickness, good color)

• eMax

• Obsidian

• Zirconia – Translucent Ceramics

• Noritake

MATERIALS AVAILABLE

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Restorations

Check Shape & Esthetics

Check Shade

Marginal Integrity

Contacts

Etch

Restorations

Check Shape & Esthetics

Occlusion

Function???

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.


Initial Appointment

Consultation

First Appointment


Whitening?

Second Appointment


Check whitening



Lab Work




Fifth Appointment

Post-Op Check

Occlusal Guard Impressions

Post-Op Photos

Sixth Appointment

Deliver Occlusal Guard


-Aesthetics

-Function

-Gingival Embrasures

-Excess cement

-Patient homework & questions

Post-Op Check

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

QUESTIONS?

Case #3: Aesthetics

Veneers

Function

Gingival Bonding

Feldspathic Veneers

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Remove old restorations & repair abfraction

lesions on cervicals

• Stump Shade (dehydration factor)

Base Shade • Easy Shade

• Custom Shade

• Photographs

• ALL DONE PREVIOUSLY

B-TYPE PREP

Impressions

• Facebow (SAM III)

• Wax bite (Delar)

Facebow & Wax Bite Registration

Provisionals Free Hand Provisionals

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Free Hand Provisionals

Example• Materials

• Rigid Bite Registration

• Light and Heavy Body

Prefabricated Over Impression

• 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

PRE-TREAT VENEERS

• Unidose Silane (Sultan Dental)

• Clearfil Ceramic Primer (Kuraray)

• Bis-Silane (Bisco)

• Ceramic Primer II (GC America)

• Place under heat for a few minutes

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

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• 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 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

ZEN: CORDLESS PROPHY ANGLE (ZILA)

MIDWEST FREEDOM (DENTSPLY)

WHIPMIX PREPPIES

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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. • Light-Cured Veneer Cement

• Superior Color Stability

• Highly Filled

• Enhances Strength

CHOICE 2™ Color Stable System

3 VITA® shades

2 chromatic shades

Bonding materials

Sultan Dental Silane

Prime Porcelain with Bis-Silane™

Apply Uni-Etch® with BAC Apply Bonding Agent

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Apply Porcelain Bonding Resin Place Veneer Cement

• More efficient than Halogens

• Halogen produces light from 370 to 800 nm then filters

out all but blue light in 400-500 nm range

• Longer lasting

• Less heat at the tip of the light

• Nanometer range closely matched the CQ range (450-

470)

• Smaller in size/lighter

• Units can be cordless

• Curing options

• Smart Light Max (Dentsply)

• Valo (Ultradent)

BENEFITS OF LED LIGHTS Radiometers

Radiometer

Check daily in am

300mW/cm2 (600mW /cm2)

How good is your light?

Study by Nassar Barghi found

30% of units tested had

output less than

200mW/cm2

Many doctors unaware

that curing light output was

inadequate

Intensity of light inversely

proportional to age of unit

10% had cracked filters

Most doctors never

replaced the bulb

**Proper care of curing light

will ensure that your

restorations are thoroughly

cured. **

Bulk excess

– Bard Parker

– TC Carvers (Brasseller)

– Gold knives

– Perio knives

Interproximal saws

Finishing strips

12 & 30 fluted carbides

Cement RemovalFinishing & 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 Photos

QUESTIONS??

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

Technology/Tools

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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



SF1LM (Komet)


Unique Tools


SF1LM (Komet)


SF1LM (Komet)

Unique Tools

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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


• 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


LASERS Fast

Hemostasis

No crevicular fluid

No cord

Better healing



Precise tissue incision,

excision, ablation

Reduced bleeding, post-

op infection

Minimizes pain, patient

inconvenience

Enhance scope & quality

of dental practice

Minimal or no healing

shrinkage

No arcing to metals

Increased productivity

Gingival Recontouring

810 nm

2.5 & 7 Watts


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Laser Indications For Use

Frenectomy

Frenotomy

Gingival Troughing

Implant Recovery

Gingivectomy

Gingivoplasty

Crown Lengthening

Hemostasis of donor site of

granulation tissue

Laser assisted flap surgery

Incisions and draining of absesses

Vestibuloplasty

Excision of lesions

Exposure of unerupted/partially erupted

teeth

Removal of hyperplastic tissue

Treatment of apthous ulcers

Leukoplakis

Sulcular debridement

Pulpotomy

Laser Troughing

Benefits:• Predictable margins

• No tissue recession

• No bleeding

• No discomfort

• Faster procedure

Settings:

Power:1.2WMode: Continuous

Tip: Initiated

Tissue Management

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For All Tissue Management Issues For All Tissue Management Issues

MAKES LARGE CASES EASY

Tissue Management

KETTENBACH IDENTIUM & PANASIL

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Fluid/Tissue Management Enhancing Moisture Control



Fluid/Tissue Management Enhancing Moisture Control



Fluid/Tissue ManagementFrenectomy

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

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Frenectomy Frenectomy

Frenectomy

Before After

• 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

• 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

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HEATWAVE BY CLINICIAN’S CHOICE

• 4 upper & lower trays

• 60 sec. @ 158°F

• Fast, efficient

• Virtually custom

Selection ProcessIMPRESSION TRAYS

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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

IMPRESSION MATERIALS

(TYPICALLY A MEDIUM & A HEAVY BODY)

• EXA’lence (G.C.)

• Panasil (Kettenbach)

• Identium (Kettenbach)

• Aquasil Cordless (Dentsply)

• Affinity VPS (Clinician’s Choice)


• Still account for 85%-90% of the market.

• Types

• Vinylpolysiloxanes

• Polyethers

• Vinylsiloxanether (VSXE)


• Dimensional stability

• Good flow ability & wettability

• High tear strength & elastic recovery

• Accurate detail reproduction <25μm

• Non slumping

Panasil Initial Contact (VPS)

Kettenbach

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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

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.

• 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

Identium for single teeth

Kettenbach Kettenbach

Identium for single teeth

Identium for multiple teeth

-two cord technique

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MAKES LARGE CASES EASY

PROVISIONALS

• Utilize an accurate preliminary over impression

• Maintain over impression

• Check contacts and occlusion

-Visalys (Kettenbach)

-Inspire (Clinician’s Choice)

Ultradent (

-Structure (VOCO)

PROVISIONALS

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Putting it all Together

Case #4:

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C-TYPE PREP

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Any Questions?

Case #5:Excessive Prep Interproximal

Reshape teeth

eMax

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RESIN CEMENT COSMETIC CASES…. COSMETIC CASES….

COSMETIC CASES…. COSMETIC CASES….


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PROVISONALS PROVISIONALS

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PRE-TREAT VENEERS• Place under heat for a few minutes

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CHOICE 2™ Color Stable System

3 VITA® shades

2 chromatic shades

Bonding materials

LIGHT CURED RESIN CEMENT

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FINAL RESTORATIONS

LITHIUM DISILICATE & SILICATE, LEUCITE AND

FELDSPATHIC RESTORATIONS

IS AN ADHESIVE CEMENTATION

SYSTEM THAT IS EASY-TO-USE,

EFFICIENT AND HIGHLY

EFFECTIVE

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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Alkaline pH Moisture Tolerant

Self Sealing

Apatite Formation Insoluble

Stronger with time Semi / Translucent

Biocompatibility-Excellent

Bioactivity-Apatite formation Sealing Quality-Excellent

Cement Selection

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

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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

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 Cement Selection

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Cement Selection

Zirconia Restorations

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• Nano-structural integration

› 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

• Chemically stable

• Acid Resistant

• Retention equal to or better than resin cements

• Material gets stronger over time & remains 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

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REMEMBER:

FUNCTIONAL LIMITATIONS

Case #7:

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The Art of Aesthetics & Occlusion


• Excursive Interferences

• Group function

• Malpositioned teeth

• Occlusal interferences

• Canine guidance

• Group function


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FUNCTIONAL LIMITATIONS FUNCTIONAL LIMITATIONS

• Check excursives

• Protrusive

• Night Guard



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Not a veneer case!! Not a veneer case!!

Not a veneer case!!

Choose carefully who you want to work on and get your signatures

QUESTIONS?

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Case #10: Aesthetics

Tissue Problems

Poor Function

No TMJ Problems



Incisal position

Gum height


2-4 mm

10-11 mm


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Pre-op

Post-op

“The quality of a person’s life is in

direct proportion to his or her

commitment to excellence.”

-Vince Lombardi

It’s not always about the material used

sometimes its more about the technique.

Free marketing information, handouts & samples

www.DENTOOLZ.com

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DDS, AAACD

25500 Rancho Niguel Road, Suite #230

Laguna Niguel, CA. 92677

[email protected]

www.drtoddsnyder.com

www.facebook.com/todd.snyder.dds

www.twitter.com/tcsaesthetics

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

Todd C Snyder, DDS, AAACD - d1ue90e5sp4tcv.cloudfront.netd1ue90e5sp4tcv.cloudfront.net/1946/images/Asset279275_v1.pdf · less from contact point to bone • Use most incisal bone