4172015

1

ULTRADENT SEMINARS

What Will You Drive

ULTRADENT SEMINARS

Todd C Snyder DDS AAACD

Private Practice in Laguna Niguel California

Accredited American Academy of Cosmetic Dentistry

Former Faculty UCLA Center For Esthetic Dentistry

Faculty Esthetic Professionals

CBDO ContentActivatorcom

Member of Catapult Elite

Consultant

Radical SR 3

ULTRADENT SEMINARS

bull ACCURACY

bull CONSISTENCY

bull SPEED

= SUCCESSFUL

ULTRADENT SEMINARS

Two years in a row dentist best health care job

Selected based on predicted growth 2012-2022 by US Bureau of Labor Statistics

Low unemployment decent worklife balance good salary predicted employment

growth of 16 with more than 23000 new openings

4172015

2

bull Corporate dentistry is growing 15 annually

bull Online reviews and searches are ever increasing

bull Dental insurance companies are systematically decreasing reimbursements

bull Discretionary income has shrunk for every segment of American society

except the top 10

bull Patient perception of dentists are changing based on work Performed

Marketing Seen and Fees offered

1 Brand Image

2 Customer Care

Protocols

3 Teamrsquos Role

YOUR TEAM

4172015

3

bull What does the patient see and why do they refer to you

bull Insurance dentist

bull Family dentist

bull Discount dentist

bull Who are you

bull More important than ever

bull Develop your brand

bull Its appearance

bull Its representation

bull Its visibility

bull Keep the same theme on everything

bull Your Tools Web page internet stationary business cards

media advertising etc

bull Look at your team

bull Is everyone trained to offer the same care and service repeatedly

bull Protocols

bull Repetition and consistency

bull Greetings and goodbyes

bull Phone skills

bull Verbal skills (not scripts)

bull Consumers are being over run with spam in many ways

bull Consumers want instant (relevant) information

bull Business owners want resultshelliphellip bull but many are not sure how to achieve them today

bull What image do we want to portray

4172015

4

These are becoming common

1 Customer focus is the key

2 Exceed the expectations

3 Respect amp EMPOWER your

employees

4172015

5

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

bull Matrix Systems

bull Curing Light

bull Teeth Whitening

bull Software ULTRADENT SEMINARS

Pathology Driven Diagnostics

Are you still diagnosing with this

50 accurate

How do you diagnose decay

Is it thru conventional radiographic analysis Approximately 25 demineralization must occur to see a cavity on a conventional radiograph

Equates to 40-60 demineralization on the tooth surface Radiographs miss 70-80 of

occlusal cavities Digital radiographs provide the ability to manipulate image size and appearance

67 accuracy

Visualization drives desire

4172015

6

Thru intraoral photographic interpretation

How do you diagnose decay

Clean the teeth prior to diagnosis KAVO DIAGNOdent

Biofilm Removal Create Healthy Biofilms

4172015

7

EvoraPro

bull Streptococcus oralis (Soralis KJ3) Streptococcus uberis (S uberis KJ2) and Streptococcus rattus (S rattus JH145) are naturally-occurring oral bacteria that can act as antagonists to reduce or replace harmful oral bacteria

bull S rattus JH145 specifically targets the reduction of acidogenic S mutans in the oral cavity

Other Brands Available KAVO Dia Lux 2300L Dexis CariVu

Paradigm Shift

bull One can place a number of restorations or fillings and yet not treat the underlying disease

bull The bacteria remain in the plaque on the teeth capable of creating new areas of tooth decay

bull Patients value a shift from a surgical approach to disease management and prevention

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

2

bull Corporate dentistry is growing 15 annually

bull Online reviews and searches are ever increasing

bull Dental insurance companies are systematically decreasing reimbursements

bull Discretionary income has shrunk for every segment of American society

except the top 10

bull Patient perception of dentists are changing based on work Performed

Marketing Seen and Fees offered

1 Brand Image

2 Customer Care

Protocols

3 Teamrsquos Role

YOUR TEAM

4172015

3

bull What does the patient see and why do they refer to you

bull Insurance dentist

bull Family dentist

bull Discount dentist

bull Who are you

bull More important than ever

bull Develop your brand

bull Its appearance

bull Its representation

bull Its visibility

bull Keep the same theme on everything

bull Your Tools Web page internet stationary business cards

media advertising etc

bull Look at your team

bull Is everyone trained to offer the same care and service repeatedly

bull Protocols

bull Repetition and consistency

bull Greetings and goodbyes

bull Phone skills

bull Verbal skills (not scripts)

bull Consumers are being over run with spam in many ways

bull Consumers want instant (relevant) information

bull Business owners want resultshelliphellip bull but many are not sure how to achieve them today

bull What image do we want to portray

4172015

4

These are becoming common

1 Customer focus is the key

2 Exceed the expectations

3 Respect amp EMPOWER your

employees

4172015

5

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

bull Matrix Systems

bull Curing Light

bull Teeth Whitening

bull Software ULTRADENT SEMINARS

Pathology Driven Diagnostics

Are you still diagnosing with this

50 accurate

How do you diagnose decay

Is it thru conventional radiographic analysis Approximately 25 demineralization must occur to see a cavity on a conventional radiograph

Equates to 40-60 demineralization on the tooth surface Radiographs miss 70-80 of

occlusal cavities Digital radiographs provide the ability to manipulate image size and appearance

67 accuracy

Visualization drives desire

4172015

6

Thru intraoral photographic interpretation

How do you diagnose decay

Clean the teeth prior to diagnosis KAVO DIAGNOdent

Biofilm Removal Create Healthy Biofilms

4172015

7

EvoraPro

bull Streptococcus oralis (Soralis KJ3) Streptococcus uberis (S uberis KJ2) and Streptococcus rattus (S rattus JH145) are naturally-occurring oral bacteria that can act as antagonists to reduce or replace harmful oral bacteria

bull S rattus JH145 specifically targets the reduction of acidogenic S mutans in the oral cavity

Other Brands Available KAVO Dia Lux 2300L Dexis CariVu

Paradigm Shift

bull One can place a number of restorations or fillings and yet not treat the underlying disease

bull The bacteria remain in the plaque on the teeth capable of creating new areas of tooth decay

bull Patients value a shift from a surgical approach to disease management and prevention

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

3

bull What does the patient see and why do they refer to you

bull Insurance dentist

bull Family dentist

bull Discount dentist

bull Who are you

bull More important than ever

bull Develop your brand

bull Its appearance

bull Its representation

bull Its visibility

bull Keep the same theme on everything

bull Your Tools Web page internet stationary business cards

media advertising etc

bull Look at your team

bull Is everyone trained to offer the same care and service repeatedly

bull Protocols

bull Repetition and consistency

bull Greetings and goodbyes

bull Phone skills

bull Verbal skills (not scripts)

bull Consumers are being over run with spam in many ways

bull Consumers want instant (relevant) information

bull Business owners want resultshelliphellip bull but many are not sure how to achieve them today

bull What image do we want to portray

4172015

4

These are becoming common

1 Customer focus is the key

2 Exceed the expectations

3 Respect amp EMPOWER your

employees

4172015

5

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

bull Matrix Systems

bull Curing Light

bull Teeth Whitening

bull Software ULTRADENT SEMINARS

Pathology Driven Diagnostics

Are you still diagnosing with this

50 accurate

How do you diagnose decay

Is it thru conventional radiographic analysis Approximately 25 demineralization must occur to see a cavity on a conventional radiograph

Equates to 40-60 demineralization on the tooth surface Radiographs miss 70-80 of

occlusal cavities Digital radiographs provide the ability to manipulate image size and appearance

67 accuracy

Visualization drives desire

4172015

6

Thru intraoral photographic interpretation

How do you diagnose decay

Clean the teeth prior to diagnosis KAVO DIAGNOdent

Biofilm Removal Create Healthy Biofilms

4172015

7

EvoraPro

bull Streptococcus oralis (Soralis KJ3) Streptococcus uberis (S uberis KJ2) and Streptococcus rattus (S rattus JH145) are naturally-occurring oral bacteria that can act as antagonists to reduce or replace harmful oral bacteria

bull S rattus JH145 specifically targets the reduction of acidogenic S mutans in the oral cavity

Other Brands Available KAVO Dia Lux 2300L Dexis CariVu

Paradigm Shift

bull One can place a number of restorations or fillings and yet not treat the underlying disease

bull The bacteria remain in the plaque on the teeth capable of creating new areas of tooth decay

bull Patients value a shift from a surgical approach to disease management and prevention

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

4

These are becoming common

1 Customer focus is the key

2 Exceed the expectations

3 Respect amp EMPOWER your

employees

4172015

5

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

bull Matrix Systems

bull Curing Light

bull Teeth Whitening

bull Software ULTRADENT SEMINARS

Pathology Driven Diagnostics

Are you still diagnosing with this

50 accurate

How do you diagnose decay

Is it thru conventional radiographic analysis Approximately 25 demineralization must occur to see a cavity on a conventional radiograph

Equates to 40-60 demineralization on the tooth surface Radiographs miss 70-80 of

occlusal cavities Digital radiographs provide the ability to manipulate image size and appearance

67 accuracy

Visualization drives desire

4172015

6

Thru intraoral photographic interpretation

How do you diagnose decay

Clean the teeth prior to diagnosis KAVO DIAGNOdent

Biofilm Removal Create Healthy Biofilms

4172015

7

EvoraPro

bull Streptococcus oralis (Soralis KJ3) Streptococcus uberis (S uberis KJ2) and Streptococcus rattus (S rattus JH145) are naturally-occurring oral bacteria that can act as antagonists to reduce or replace harmful oral bacteria

bull S rattus JH145 specifically targets the reduction of acidogenic S mutans in the oral cavity

Other Brands Available KAVO Dia Lux 2300L Dexis CariVu

Paradigm Shift

bull One can place a number of restorations or fillings and yet not treat the underlying disease

bull The bacteria remain in the plaque on the teeth capable of creating new areas of tooth decay

bull Patients value a shift from a surgical approach to disease management and prevention

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

5

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

bull Matrix Systems

bull Curing Light

bull Teeth Whitening

bull Software ULTRADENT SEMINARS

Pathology Driven Diagnostics

Are you still diagnosing with this

50 accurate

How do you diagnose decay

Is it thru conventional radiographic analysis Approximately 25 demineralization must occur to see a cavity on a conventional radiograph

Equates to 40-60 demineralization on the tooth surface Radiographs miss 70-80 of

occlusal cavities Digital radiographs provide the ability to manipulate image size and appearance

67 accuracy

Visualization drives desire

4172015

6

Thru intraoral photographic interpretation

How do you diagnose decay

Clean the teeth prior to diagnosis KAVO DIAGNOdent

Biofilm Removal Create Healthy Biofilms

4172015

7

EvoraPro

bull Streptococcus oralis (Soralis KJ3) Streptococcus uberis (S uberis KJ2) and Streptococcus rattus (S rattus JH145) are naturally-occurring oral bacteria that can act as antagonists to reduce or replace harmful oral bacteria

bull S rattus JH145 specifically targets the reduction of acidogenic S mutans in the oral cavity

Other Brands Available KAVO Dia Lux 2300L Dexis CariVu

Paradigm Shift

bull One can place a number of restorations or fillings and yet not treat the underlying disease

bull The bacteria remain in the plaque on the teeth capable of creating new areas of tooth decay

bull Patients value a shift from a surgical approach to disease management and prevention

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

6

Thru intraoral photographic interpretation

How do you diagnose decay

Clean the teeth prior to diagnosis KAVO DIAGNOdent

Biofilm Removal Create Healthy Biofilms

4172015

7

EvoraPro

bull Streptococcus oralis (Soralis KJ3) Streptococcus uberis (S uberis KJ2) and Streptococcus rattus (S rattus JH145) are naturally-occurring oral bacteria that can act as antagonists to reduce or replace harmful oral bacteria

bull S rattus JH145 specifically targets the reduction of acidogenic S mutans in the oral cavity

Other Brands Available KAVO Dia Lux 2300L Dexis CariVu

Paradigm Shift

bull One can place a number of restorations or fillings and yet not treat the underlying disease

bull The bacteria remain in the plaque on the teeth capable of creating new areas of tooth decay

bull Patients value a shift from a surgical approach to disease management and prevention

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

7

EvoraPro

bull Streptococcus oralis (Soralis KJ3) Streptococcus uberis (S uberis KJ2) and Streptococcus rattus (S rattus JH145) are naturally-occurring oral bacteria that can act as antagonists to reduce or replace harmful oral bacteria

bull S rattus JH145 specifically targets the reduction of acidogenic S mutans in the oral cavity

Other Brands Available KAVO Dia Lux 2300L Dexis CariVu

Paradigm Shift

bull One can place a number of restorations or fillings and yet not treat the underlying disease

bull The bacteria remain in the plaque on the teeth capable of creating new areas of tooth decay

bull Patients value a shift from a surgical approach to disease management and prevention

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

8

Crystal Structure Diagnostics The Canary System Detects Cracks amp Cavities not

Visible on X-rays

+ Around amp beneath intact margins of fillings amp crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces pits amp grooves

+ Around orthodontic brackets

Measures tooth structure breakdown allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports amp 2 FDA CFR 21 clinical trials

The Science Behind The Canary System

bull Pulses (2 Hz) of laser light hit the tooth surface

bull Tooth glows (Luminescence LUM) and releases heat (Photo-Thermal Radiometry PTR)

bull Defective tooth crystal structure affects the retained heat and luminescence signatures

Energy Conversion Technology

Temperature

increase lt 1oC

not harmful

bull Detected signals reflect the toothrsquos condition

bull Detects 50 micron lesion up to 5 mm below the surface

bull Originally created for erosion and remindemin but adapted to caries in 2008 to appeal to market

Delegated Scanning amp Whitening Assistant

Sensitivity amp Specificity Study University of Texas October 2012

Study Design bull 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

bull Visual ranking by 2 dentists bull Canary Scan bull DIAGNODent bull Polarized Light Microscopy used as

the gold standard to confirm presence of lesion amp depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100 18

Specificity 100 100

Spearman Correlation with Lesion Depth

84 21

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

9

Canary is Superior to X-Rays for Proximal Caries Detection Jan J et al Caries Res 201448384ndash450 DOI 101159000360836

Objective

To compare the accuracy of The Canary System ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro

Methods

ICDAS-II (Direct Visual Examination) Blinded examiners ranked 100 proximal surfaces using ICDAS-II by direct visual examination of the surfaces

Manikin mouth models The teeth were then set in manikin mouth models creating contacting proximal

surfaces that very closely resemble in vivo situation

Histological validation All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions

Conclusion bull BW radiographs could only identify 267 of the lesions which questions its ability to be the

gold standard

bull The Canary System is the only method examined with both high sensitivity and high specificity

bull The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

What fluoresces in fluorescent-based technologies Bacterial porphyrins (bacterial breakdown product) Stain Tartar Food debris

All fluoresce under the wavelengths used in most caries detection devices whether or not caries is present

bull Lussi A Imwinkelried S Pitts N Longbottom C Reich E Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro Caries Res 199933(4)261ndash266

bull Lussi A Hibst R Paulus R DIAGNOdent an optical method for caries detection J Dent Res 200483C C80ndash83 bull Verdonschot E H van der Veen M H Lasers in dentistry 2 Diagnosis of dental caries with lasers Ned Tijdschr Tandheelkd

2002109(4) 122ndash126 bull Konig K Flemming G Hibst R Laser-induced autofluorescence spectroscopy of dental caries Cell Mol Biol (Noisy-le-grand)

199844(8) 1293ndash1300 bull Alwas-Danowska HM Plasschaert AJ Suliborski S Verdonschot EH Reliability and validity issues of laser fluorescence measurements

in occlusal caries diagnosis J Dent 200230(4)129-34 bull Rechmann P Rechmann BM Featherstone JD Caries detection using light-based diagnostic tools Compend Contin Educ Dent

201233(8)582-4 586 588-93 quiz 594 596

Fluorescent Technologies

Pain Mandibular Right Posterior Quadrant

No pathology on x-ray Canary Scan

Revealed Pathology on Mesial amp Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

97 58 36

Removal of Amalgam Confirms Caries

97

58 36 Crack on mesial and distal

marginal ridges with caries

Caries around the lingual

margin

Interproximal Caries Detection

Bitewing radiograph did not detect caries

Caries located on buccal aspect of the contact area

Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83 64

Specificity 79 46

bull Canary Numbers gt20 when scanning sealants (3Mtrade ESPEtrade Clinprotrade Sealant) placed over pit amp fissure caries

bull The caries detection ability of the Canary System was not affected by sealant amp was more accurate than DIAGNOdent

Sensitivities and specificities for pit amp fissure caries detection after sealant placement

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

10

After all the cleaning and diagnostic technology being used what if you find something

Topical Therapies bull More caries resistant bull Remineralization bull Desensitization

Minimally Invasive Treatment

bull Apply MIPaste Plus for 3 minutes

bull Patient applies at home 2xday

MI VARNISHtrade WITH RECALDENTtrade (CPP-ACP)

Bioavailable calcium phosphate amp fluoride for an enhanced varnish treatment

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

11

Enamelast bull Xylitol Sweetened 5 sodium fluoride in a

resin carrier

Enamelon Now with Stannous Fluoride

Optimized with ACP Technology

bull Stabilized SnF2

Formula bull ACP Technology bull RDA 8

bull Safe for all age groups

Xylitol Oral Health Products Other Materials bull Clinpro 5000 with TCP (3M) bull Enamelon with fluoride and ACP (Premier) bull Remin Pro (Voco) bull Sensodyne ProNamel bull Arm amp Hammerrsquos Enamel Care bull Arm amp Hammer Complete Care w Enamel Strengthening bull Colgate Sensitive pro relief bull Fluoride Varnishes bull Glass Ionomers

Bacteria

Produce Acid

Attack Enamel

Demineralization

DECAY

Xylitol amp ProBiotics

MI Paste Enamelon

Remineralize

Canary System

Radiograph

SALIVA-CHECK BUFFER from GC America tests for salivary flow and buffering capacity

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

12

Phocal

Acidulated phosphate fluoride (ApF)

Non-acidic sodium fluoride (pHn)

bull No tooth reduction

bull Adhesive and mechanical retention

bull Radiolucent

Resin Infusion-ICON

Resin Infusion-ICON

Custom Brochures For Practice

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

13

ULTRADENT SEMINARS

Huge Marketing Opportunity bull Remineralizing teeth

bull Non Ionizing Diagnostic Tools

bull Minimally Invasive Dentistry

bull Health Product Sales

bull Community Educational Programs

bull Internet and Local Media Advertising

Patients can confirm their appointment by Email Text or Voice

Your Team will love the Smiley Faces Less calls to make

Recare messages for 8 months of 2014 Valued at $47281 So far in 2015 $12944

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

14

Send a personal Birthday message to your patients They will love it

Solicit Patient Feedback and Reviews Push out to Google Facebook and Your Website

Newsletters keep you in Touch with your Patients

Mapping your patients help you target your marketing dollars

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

15

14 billion 890 million

Facebook Over 50 of US population has an account

No other media source has this much attention tv newspaper magazines radios etc

Facebook Content posted in the early morning amp evening have a 20

higher activity level due to work places blocking usage

Thursdays have the highest level of engagement for brands in health amp beauty industry

Posts ending with ldquordquo have a 15 higher engagement rate

Send out mailers emails texts letting people know you are on

Solution Reach automation

Give a flier to all patients at checkout with a Call To Action

Advertisement in front office and website

Blog and patient reviews RSS Feed

Facebook

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

16

Sponsorship

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

17

EyeSpecial C-II (SHOFU) Unique Features

EyeSpecial C-II Designed for dentistry

8 modes

12 Megapixels

Dental cropping and grid lines

Large LCD touchscreen

Water and chemical proof ndash Essential for infection control

Durable rugged Exterior

Fast autofocusing amp anti-shake capabilities

Held with one hand ndash weighs only 1lb

Compatible with the Eye-Fi X2 card ndash Immediately upload images onto PC iPad Tablet or Smartphone

Magnification Range Chose the magnification ratiorange by rotating the dial key

Icons to help you determine and select the range properly

Edit amp 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

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

18

Standard Mode

Mirror Mode

Images are captured in ldquoLow Glarerdquo mode

Whitening Mode For shade comparison between before and after whitening

Similar to ldquoLow-glarerdquo mode but with lower light intensity

Reduces glare and emphasizes the surface texture and shade

Delegated Whitening amp Scanning Assistant

Upper arch whitened

Lower arch not whitened

Isolate Shade Mode for optimal shade matching

Tele-Macro Mode For 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

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

19

Shade Evaluation

Immediate Call to Action Motivator

Over-the-Counter Teeth Whiteners $14 billion (MSNBC) (Consumer Reports)

Whitening Treatment Options

bull Take home bull Opalescence with custom trays

bull 10 15 20 35 carbamide peroxide

bull Opalescence Go pre-filled disposable whitening trays bull 10 hydrogen peroxide

bull 15 hydrogen peroxide

bull In-Office bull Opalescence Boost chair-side treatment

bull 40 hydrogen peroxide

Opalescence PF Sustained Release (active for 8-10 hours)

Convenient comfortable delivery

20 water amp neutral pH

Potassium Nitrate amp Fluoride for reduced sensitivity amp strengthened enamel

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

20

Oral Health Benefits bull Added ingredients

bull Potassium Nitrate - Helps to prevent sensitivity

bull Fluoride - Strengthens enamel helps prevent caries

bull Xylitol - Helps to reduce caries causing bacteria

bull Neutralizes pH in the mouth bull Reduces caries causing bacteria

bull Prevents enamel decalcification

bull High water content bull Prevents dehydration and fade back

bull Reduces sensitivity

Opalescence GO Fast Easy Effective

Convenient amp affordable professional whitening to GO

Pre-loaded disposable UltraFittrade tray for a custom-like fit

Molar-to-molar coverage

No chair time

bull Improved experience amp better whitening results

bull Available in 10 amp 15 hydrogen peroxide with PF

bull Mint Peach and Melon flavors

bull Optimal gel quantity

Opalescence GO Opalescence Go Sample Tower

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

21

Equipment bull Diagnostic Tools

bull Technology

bull Restorative Materials

ULTRADENT SEMINARS

Essential Tool

bull Ergonomics

bull Visualization

bull Preparation design

bull Illumination

bull Precision

How will you diagnose

How will you treat

How do you prepare a cavity

bull Traditional handpiece -Diamond vs Carbide

bull Fissurotomy burs bull Slow speed burs

-Ceramic vs Polymer bull AirHelium abrasion bull Water abrasion bull Lasers bull Sonic Preparation

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

22

Air Abrasion Allows for better detection of carious lesions improved bonding of sealants and restorations and tooth structure preservation with decreased need for chemical anesthesia

Burs Are Not As Conservative And Create Microfractures

Conservative Prep

Best choice for Pit amp Fissure or treating ldquowatchesrdquo

bull 0015rdquo tip prep is about frac12 the diameter of the smallest bur or ldquofissure bursrdquo The volume of tooth reduced is dramatically less Conservatively treated ldquowatchesrdquo often disclose decay along the DEJ not seen on radiographs

bull Carious material in Pits amp Fissures is fully removed in seconds Bond for sealants is enhanced

185

Masoumeh Moslemi DDSMSc Leila Erfanparast DDS MSc Reza FekrazadDDS MSc Nike Tadayon DDSMSc Hamed DadjoDDS Mohammad Mostafa Zahra Khalili The effect of ErCrYSGG laser and air abrasion on shear bond strength of a fissure sealant to enamel JADA Vol141 February 2010 (157-161)

Stronger Bond

bull Unmatched in its ability to increase surface area on a variety of materials

bull Increase surface area up to 400

bull Improves bond strengths by 400

Typical Etching Diamond bur abrasion on alloy MicroEtcher abrasion on alloy

Increased Surface Area

Fissurotomy Burs (SS White)

Micro Prep diamonds (Komet) Sonicys (Kavo) amp Sonic Prep (Komet)

Air Abrasion or Helium Abrasion (Crystal Mark)

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

23

Komet amp Kavo Komet SF1LM

Hard Tissue Lasers

Hard tissue lasers along with air abrasion offer some of the most ideal bonding surfaces

Access viscosity small areas

Deep narrow preparations

Lots of enamel

Flowables

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

24

bull Voco (Grandio SO HF Xtra Base)

bull Ultradent (PermaFlo)

bull Kerr (Revolution Premise Vertise)

bull Ivoclar (Tetric Flow)

bull Heraeus (Venus Diamond Flow Bulk Fill)

bull Shofu (Beautiful Flow Plus-Zero amp Low Flow)

bull GC America (G-aenial Universal Flo)

bull Dentsply (SureFil SDR EsthetX Flow)

bull Kuraray (Clearfil Majesty ES Flow)

bull Tokuyama (Estelite Flow Quick)

bull 3M (Filtek Supreme Flow Plus)

Flowables Flowable

Flowable composite

bull High-fill high-flow formula bull Fluoride-releasing bull Available in 8 shades A1 A2 A3 A35 A4 B1 Translucent Dentin

Opaquer bull Average particle size of 7m bull 68 filled bull Strong amp wear resistant bull Thixotropic bull Radiopaque

UPI Internal Testing

Medium Size Defects

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

25

Small to Medium sized Lesions (lt2MM)

bull Mostly superficial

bull Good restoration longevity

bull frac12 enamel with frac12 extending into dentin

bull Dentin is fairly dense

bull Open ampor Closed defect

bull Risks are low

bull Minimal occlusal loading

Large Defects (occlusal)

Recurrent decay

Think about material choices amp their long term durability amp susceptibility for failure in adhering to deep dentin

pulpal proximity

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Bond Strengths Related To Type of Dentition

0

10

20

30

40

50

DEJ Superficial(Sound)Dentin

BeveledEnamel

DeepDentin

AffectedCariousDentin

InfectedCariousDentin

45 45

30 30 30

10

Irie m suzuki k watts dc 2004 marginal gap formation of light activated restorative materials affects of

immediate setting shrinkage and bond strength Dent Mat 18 2002 203-210

Vanmeerbeek B Demunck et al Lambrechts P Micotenisile Bond Strengths of an Etch

and Rinse and se adhesive to en and dent as a function of oper dent 2003 657-660

Sattansuk ta the bond of resin to diff dent characteristics Caries Indicator Dyes

bull Roydent-To Dye For bull Kuraray-Caries Detector bull Ultradent-SeekSable Seek bull ProOptions-Caries Indicator bull Danville-Caries Finder bull Pulpdent-Snoop bull Vista-Caries Indicator bull Ronvig-See It bull Patterson- bull Henry Schein- bull Pearson-

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

26

Note Caries on Floor of 2nd Molar Further Inspection Reveals More Caries

Caries Removal Burs bull SS White

ndash Single use

ndash Polymer

ndash Hardness

ndash 5000-10000 rpms

bull Komet

ndash Multi use

ndash Ceramic

ndash Hardness

ndash 1000-1500 rpms

J Adhes Dent 2011 Feb13(1)7-22 doi 103290jjada18443 Current concepts amp techniques for caries excavation amp adhesion to residual dentin de Almeida Neves A Coutinho E Cardoso MV Lambrechts P Van Meerbeek B

Round Burs (6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White) 1000-1500rpm 5-10000rpm

Handpiece Lubricants

4172015

27

Long term failure occurs at gingival margins and adhesive interfaces

Yiu CK Hiraishi N King NM Tay FR Effect of dentinal surface preparation on bond strength of self-etching adhesives J Adhes Dent 2008 Jun10(3)173-82 Higher bond strengths when using tungsten carbide burs with SE adhesives

Preparation bull Limited to removal of pathology with the exception of access and bevels

bull Maintaining enamel and superficial dentin

bull Preserving occlusal stops

ndash Marginal ridges

ndash Transverse ridges

ndash Oblique ridges

bull Rounded line angles

bull Purge hand piece

bull Bur Choice

ADHESION

Total etch Self etch

of components

Etchant

Primer

Adhesive

Bonding Agents

Generation 4th 5th 6th 7th

Technique amp Errors

4172015

28

Total-Etching

Bonding to EnamelDentin

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process ndash Total Etching

Dentin fluid

Dentin

Odontoblast Dentinal tubule

Smear layer 37 Phosphoric acid

Adhesion process ndash Total Etching

Dentin fluid

Adhesive

Etched dentin

Adhesion process ndash Total Etching

Post- Operative Sensitivity

Adhesion process ndash Total Etching

Composite resin

Adhesion process ndash Total Etching

Post- Operative Sensitivity

4172015

29

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

Phosphoric acid

Problem with Total Etch Bonding (Over drying phenomenon)

Water

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

No filtration into the collagen fiber Excess drying

Dentin

Shrinkage of collagen fiber

Problem with Total Etch Bonding (Over drying phenomenon)

No filtration into the collagen fiber Excess drying

Adhesive

Dentin

Problem with Total Etch Bonding (Over wetting phenomenon)

Adhesive

Water

Insufficient drying

Dentin

4172015

30

Etching is to Bondinghellip as Braking is to Racing

Bonding to EnamelDentin

Self-Etching Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

4172015

31

Adhesion process - Self-Etching

No Post- Operative Sensitivity

Excellent sealing and desensitizing

Fixing Odontoblast

Sealing the Dentin Hybrid layer

Composite

Adhesion process - Self-Etching

Bonding

Excellent sealing and desensitizing Fixing

Odontoblast

Sealing the Dentin Hybrid layer

Factors that compromise bond durability in restorative dentistry

ldquoThe major shortcoming of contemporary adhesive restoratives is their limited durability in vivordquo

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

Factors that compromise bond durability in restorative dentistry

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57

years due to secondary caries precipitated by bond failurerdquo

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong

direction

Water sorption Polymer swelling

Decline in mechanical properties Leaching of hydrolyzed resin components

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of

intraoral function

Instability of hybrid layers - problem may be more severe than we realize

4172015

32

Factors that compromise bond durability

Hydrophilic dentin bonding (1956 - )

MMP-8 MMP-2 MMP-9

Demineralizing dentin is like opening the Pandorarsquos box releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped within

the mineralized dentin matrix

In the presence of water (such as that derived from water sorption or from

adhesives MMPs (28 amp 9) can breakdown

collagen fibrils that are not protected by intrafibrillar minerals

Sukala et al (2007) Mazzoni et al (2007)

Franklin Tay amp Dave Pashley Med College of Georgia

Bond Degredation

bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66

Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months

bullCourtesy Pacific University (Dr Marc Guisberger) bullCourtesy Pacific University (Dr Marc Guisberger)

4172015

33

InstroN

bull Ultra Tester (Ultradent)

bull Ultra Jig (Ultadent)

Shear Bond Test Results - 2012 Average Shear Bond Strength to Dentin 242 MPa

bullCourtesy Pacific University (Dr Marc Guisberger)

MaximumMinimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012 bullCourtesy Pacific University (Dr Marc Guisberger) Why different pH

32 27 25 46

MDP Penta-P MDP BPDM

Adhesive Functional Monomers

MDP

23 16

GPDM

MaximumMinimum Shear Bond Strength per

Bonding Material

Rememberhelliphellip hellipfast is typically not the best unless we are discussing car racing

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

28

Total-Etching

Bonding to EnamelDentin

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process ndash Total Etching

Dentin fluid

Dentin

Odontoblast Dentinal tubule

Smear layer 37 Phosphoric acid

Adhesion process ndash Total Etching

Dentin fluid

Adhesive

Etched dentin

Adhesion process ndash Total Etching

Post- Operative Sensitivity

Adhesion process ndash Total Etching

Composite resin

Adhesion process ndash Total Etching

Post- Operative Sensitivity

4172015

29

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

Phosphoric acid

Problem with Total Etch Bonding (Over drying phenomenon)

Water

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

No filtration into the collagen fiber Excess drying

Dentin

Shrinkage of collagen fiber

Problem with Total Etch Bonding (Over drying phenomenon)

No filtration into the collagen fiber Excess drying

Adhesive

Dentin

Problem with Total Etch Bonding (Over wetting phenomenon)

Adhesive

Water

Insufficient drying

Dentin

4172015

30

Etching is to Bondinghellip as Braking is to Racing

Bonding to EnamelDentin

Self-Etching Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

4172015

31

Adhesion process - Self-Etching

No Post- Operative Sensitivity

Excellent sealing and desensitizing

Fixing Odontoblast

Sealing the Dentin Hybrid layer

Composite

Adhesion process - Self-Etching

Bonding

Excellent sealing and desensitizing Fixing

Odontoblast

Sealing the Dentin Hybrid layer

Factors that compromise bond durability in restorative dentistry

ldquoThe major shortcoming of contemporary adhesive restoratives is their limited durability in vivordquo

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

Factors that compromise bond durability in restorative dentistry

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57

years due to secondary caries precipitated by bond failurerdquo

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong

direction

Water sorption Polymer swelling

Decline in mechanical properties Leaching of hydrolyzed resin components

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of

intraoral function

Instability of hybrid layers - problem may be more severe than we realize

4172015

32

Factors that compromise bond durability

Hydrophilic dentin bonding (1956 - )

MMP-8 MMP-2 MMP-9

Demineralizing dentin is like opening the Pandorarsquos box releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped within

the mineralized dentin matrix

In the presence of water (such as that derived from water sorption or from

adhesives MMPs (28 amp 9) can breakdown

collagen fibrils that are not protected by intrafibrillar minerals

Sukala et al (2007) Mazzoni et al (2007)

Franklin Tay amp Dave Pashley Med College of Georgia

Bond Degredation

bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66

Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months

bullCourtesy Pacific University (Dr Marc Guisberger) bullCourtesy Pacific University (Dr Marc Guisberger)

4172015

33

InstroN

bull Ultra Tester (Ultradent)

bull Ultra Jig (Ultadent)

Shear Bond Test Results - 2012 Average Shear Bond Strength to Dentin 242 MPa

bullCourtesy Pacific University (Dr Marc Guisberger)

MaximumMinimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012 bullCourtesy Pacific University (Dr Marc Guisberger) Why different pH

32 27 25 46

MDP Penta-P MDP BPDM

Adhesive Functional Monomers

MDP

23 16

GPDM

MaximumMinimum Shear Bond Strength per

Bonding Material

Rememberhelliphellip hellipfast is typically not the best unless we are discussing car racing

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

29

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

Phosphoric acid

Problem with Total Etch Bonding (Over drying phenomenon)

Water

Problem with Total Etch Bonding (Over drying phenomenon)

Dentin

No filtration into the collagen fiber Excess drying

Dentin

Shrinkage of collagen fiber

Problem with Total Etch Bonding (Over drying phenomenon)

No filtration into the collagen fiber Excess drying

Adhesive

Dentin

Problem with Total Etch Bonding (Over wetting phenomenon)

Adhesive

Water

Insufficient drying

Dentin

4172015

30

Etching is to Bondinghellip as Braking is to Racing

Bonding to EnamelDentin

Self-Etching Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

4172015

31

Adhesion process - Self-Etching

No Post- Operative Sensitivity

Excellent sealing and desensitizing

Fixing Odontoblast

Sealing the Dentin Hybrid layer

Composite

Adhesion process - Self-Etching

Bonding

Excellent sealing and desensitizing Fixing

Odontoblast

Sealing the Dentin Hybrid layer

Factors that compromise bond durability in restorative dentistry

ldquoThe major shortcoming of contemporary adhesive restoratives is their limited durability in vivordquo

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

Factors that compromise bond durability in restorative dentistry

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57

years due to secondary caries precipitated by bond failurerdquo

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong

direction

Water sorption Polymer swelling

Decline in mechanical properties Leaching of hydrolyzed resin components

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of

intraoral function

Instability of hybrid layers - problem may be more severe than we realize

4172015

32

Factors that compromise bond durability

Hydrophilic dentin bonding (1956 - )

MMP-8 MMP-2 MMP-9

Demineralizing dentin is like opening the Pandorarsquos box releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped within

the mineralized dentin matrix

In the presence of water (such as that derived from water sorption or from

adhesives MMPs (28 amp 9) can breakdown

collagen fibrils that are not protected by intrafibrillar minerals

Sukala et al (2007) Mazzoni et al (2007)

Franklin Tay amp Dave Pashley Med College of Georgia

Bond Degredation

bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66

Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months

bullCourtesy Pacific University (Dr Marc Guisberger) bullCourtesy Pacific University (Dr Marc Guisberger)

4172015

33

InstroN

bull Ultra Tester (Ultradent)

bull Ultra Jig (Ultadent)

Shear Bond Test Results - 2012 Average Shear Bond Strength to Dentin 242 MPa

bullCourtesy Pacific University (Dr Marc Guisberger)

MaximumMinimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012 bullCourtesy Pacific University (Dr Marc Guisberger) Why different pH

32 27 25 46

MDP Penta-P MDP BPDM

Adhesive Functional Monomers

MDP

23 16

GPDM

MaximumMinimum Shear Bond Strength per

Bonding Material

Rememberhelliphellip hellipfast is typically not the best unless we are discussing car racing

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

30

Etching is to Bondinghellip as Braking is to Racing

Bonding to EnamelDentin

Self-Etching Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

Dentin

Odontoblast Dentinal tubule

Smear layer

Adhesion process - Self-Etching

Dentin fluid

Self-etching adhesive Use Carbide Burs Large layers inhibit acidic monomers

Duration of exposure amp acidity

4172015

31

Adhesion process - Self-Etching

No Post- Operative Sensitivity

Excellent sealing and desensitizing

Fixing Odontoblast

Sealing the Dentin Hybrid layer

Composite

Adhesion process - Self-Etching

Bonding

Excellent sealing and desensitizing Fixing

Odontoblast

Sealing the Dentin Hybrid layer

Factors that compromise bond durability in restorative dentistry

ldquoThe major shortcoming of contemporary adhesive restoratives is their limited durability in vivordquo

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

Factors that compromise bond durability in restorative dentistry

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57

years due to secondary caries precipitated by bond failurerdquo

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong

direction

Water sorption Polymer swelling

Decline in mechanical properties Leaching of hydrolyzed resin components

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of

intraoral function

Instability of hybrid layers - problem may be more severe than we realize

4172015

32

Factors that compromise bond durability

Hydrophilic dentin bonding (1956 - )

MMP-8 MMP-2 MMP-9

Demineralizing dentin is like opening the Pandorarsquos box releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped within

the mineralized dentin matrix

In the presence of water (such as that derived from water sorption or from

adhesives MMPs (28 amp 9) can breakdown

collagen fibrils that are not protected by intrafibrillar minerals

Sukala et al (2007) Mazzoni et al (2007)

Franklin Tay amp Dave Pashley Med College of Georgia

Bond Degredation

bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66

Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months

bullCourtesy Pacific University (Dr Marc Guisberger) bullCourtesy Pacific University (Dr Marc Guisberger)

4172015

33

InstroN

bull Ultra Tester (Ultradent)

bull Ultra Jig (Ultadent)

Shear Bond Test Results - 2012 Average Shear Bond Strength to Dentin 242 MPa

bullCourtesy Pacific University (Dr Marc Guisberger)

MaximumMinimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012 bullCourtesy Pacific University (Dr Marc Guisberger) Why different pH

32 27 25 46

MDP Penta-P MDP BPDM

Adhesive Functional Monomers

MDP

23 16

GPDM

MaximumMinimum Shear Bond Strength per

Bonding Material

Rememberhelliphellip hellipfast is typically not the best unless we are discussing car racing

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

31

Adhesion process - Self-Etching

No Post- Operative Sensitivity

Excellent sealing and desensitizing

Fixing Odontoblast

Sealing the Dentin Hybrid layer

Composite

Adhesion process - Self-Etching

Bonding

Excellent sealing and desensitizing Fixing

Odontoblast

Sealing the Dentin Hybrid layer

Factors that compromise bond durability in restorative dentistry

ldquoThe major shortcoming of contemporary adhesive restoratives is their limited durability in vivordquo

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

Factors that compromise bond durability in restorative dentistry

alarming

words hellip

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

(RFA-DE-10-004) ldquoTooth-colored resin restorations have an average replacement time of 57

years due to secondary caries precipitated by bond failurerdquo

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong

direction

Water sorption Polymer swelling

Decline in mechanical properties Leaching of hydrolyzed resin components

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of

intraoral function

Instability of hybrid layers - problem may be more severe than we realize

4172015

32

Factors that compromise bond durability

Hydrophilic dentin bonding (1956 - )

MMP-8 MMP-2 MMP-9

Demineralizing dentin is like opening the Pandorarsquos box releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped within

the mineralized dentin matrix

In the presence of water (such as that derived from water sorption or from

adhesives MMPs (28 amp 9) can breakdown

collagen fibrils that are not protected by intrafibrillar minerals

Sukala et al (2007) Mazzoni et al (2007)

Franklin Tay amp Dave Pashley Med College of Georgia

Bond Degredation

bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66

Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months

bullCourtesy Pacific University (Dr Marc Guisberger) bullCourtesy Pacific University (Dr Marc Guisberger)

4172015

33

InstroN

bull Ultra Tester (Ultradent)

bull Ultra Jig (Ultadent)

Shear Bond Test Results - 2012 Average Shear Bond Strength to Dentin 242 MPa

bullCourtesy Pacific University (Dr Marc Guisberger)

MaximumMinimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012 bullCourtesy Pacific University (Dr Marc Guisberger) Why different pH

32 27 25 46

MDP Penta-P MDP BPDM

Adhesive Functional Monomers

MDP

23 16

GPDM

MaximumMinimum Shear Bond Strength per

Bonding Material

Rememberhelliphellip hellipfast is typically not the best unless we are discussing car racing

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

32

Factors that compromise bond durability

Hydrophilic dentin bonding (1956 - )

MMP-8 MMP-2 MMP-9

Demineralizing dentin is like opening the Pandorarsquos box releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped within

the mineralized dentin matrix

In the presence of water (such as that derived from water sorption or from

adhesives MMPs (28 amp 9) can breakdown

collagen fibrils that are not protected by intrafibrillar minerals

Sukala et al (2007) Mazzoni et al (2007)

Franklin Tay amp Dave Pashley Med College of Georgia

Bond Degredation

bull Pashley DH Tay FR Imazato S How to increase the durability of resin-dentin bonds Compend Contin Educ Dent 2011 Sep32(7)60-4 66

Resin-dentin bonds are not as durable as was previously thought Microtensile bond strengths often fall 30 to 40 in 6 to 12 months

bullCourtesy Pacific University (Dr Marc Guisberger) bullCourtesy Pacific University (Dr Marc Guisberger)

4172015

33

InstroN

bull Ultra Tester (Ultradent)

bull Ultra Jig (Ultadent)

Shear Bond Test Results - 2012 Average Shear Bond Strength to Dentin 242 MPa

bullCourtesy Pacific University (Dr Marc Guisberger)

MaximumMinimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012 bullCourtesy Pacific University (Dr Marc Guisberger) Why different pH

32 27 25 46

MDP Penta-P MDP BPDM

Adhesive Functional Monomers

MDP

23 16

GPDM

MaximumMinimum Shear Bond Strength per

Bonding Material

Rememberhelliphellip hellipfast is typically not the best unless we are discussing car racing

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

33

InstroN

bull Ultra Tester (Ultradent)

bull Ultra Jig (Ultadent)

Shear Bond Test Results - 2012 Average Shear Bond Strength to Dentin 242 MPa

bullCourtesy Pacific University (Dr Marc Guisberger)

MaximumMinimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012 bullCourtesy Pacific University (Dr Marc Guisberger) Why different pH

32 27 25 46

MDP Penta-P MDP BPDM

Adhesive Functional Monomers

MDP

23 16

GPDM

MaximumMinimum Shear Bond Strength per

Bonding Material

Rememberhelliphellip hellipfast is typically not the best unless we are discussing car racing

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

34

12ml syringe OR 4ml bottle

Two Etching Options Self-Etch Peak SE Total-Etch Ultra-Etch

bull Phosphoric Acid

bull Rinse

bull AcidPrimer

bull No rinse

(Removes Smear Layer) (Modifies Smear Layer)

5th Generation 6th Generation

bull 35 phosphoric acid gel

bull Award winning

bull Leading the industry for over 20 years

bull Used for all total-etch bonding

bull Contains a surfactant rinses easily

bull 20-seconds for optimal etch pattern

Total Etch Ultra-Etch Phosphoric acid etching ldquoopensrdquo the surface to receive resin

De

ntin

E

na

me

l

Self-Etch Peak SE Peak SE Primer is a self-etching primer mixed and delivered in the unique JetMix syringe JetMix technology separates precise quantities of 12ph acid and optimized priming resin to prevent the hydrolytic breakdown and degradation that occurs with other self-etching chemistries

Peak SE bull Proven bond strengths superior to leading competitors1ndash4 bull Achieves higher bond strengths to enamel than many total-etch systems bull Reduced sensitivity bull Syringe delivery allows for minimal waste and optimal control intraorally bull Delivers fresh stable chemistry bull Facilitates an easy one-coat technique

1 Price RB McLeod M Felix CM Bond strengths of self-etching bonding systems to dentin and enamel J Dent Res 87(Spec Iss A) 0825 2008 (wwwdentalresearchorg) 2 Clinicians Report Volume 3 Issue 6 June 2010 3 Burgess J Cakir D Shear bond strength comparison of six adhesives to dentin with and without the application of chlorhexidine 2010 Data available upon request 4 In-house testing shows the superior bond strengths of Peak Universal Bond Data available upon request

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

35

Unique Delivery - JetMix trade

Precisely mixed chemistry is assured fresh for 120 days

Peak SE Application

bull Scrub into dentin for 20 seconds bull Avoid scrubbing into enamel bull Air thin 5 seconds

Cut Enamel

Enamel surface after application of Peak SE Note the keyhole appearance of the etched enamel rods

Peak Universal Bond Light-Cured Resin Adhesive

12ml syringe OR 4ml bottle

Peak Universal Bond bull Peak Universal Bond is an adhesive resin ideal for all

bonding procedures bull Can be used with a self-etch or total-etch technique bull 75 filled and can be thinned to 2microm bull Ethyl alcohol solvent carrier bull Cures with most high intensity lights including LEDs bull Contains chlorhexidine (02) which may ensure long-

term bond strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

36

Too moist Slightly Moist

Peak Universal Bond works best when the preparation is left slightly damp

Preparation bull Apply a puddle coat and agitate for 10 seconds bull Solvent chases the moisture in dentinal tubules carrying the resin

with bull The more it travels the better mechanical retention AND reduced

sensitivity

Application

bull Thinning frac12 inch ndash frac12 air pressure direct (Donrsquot wavehellip)

bull All adhesives should be ldquoSaran Wraprdquo thin and glossy

bull Solvents must be dried thoroughly for 10 seconds

ThinningDrying Solvent Ethyl alcohol chases moisture in the tooth and carries the resin with it deep into the enamel rods or dentinal tubules

Once the resin is in the tooth structure the ethyl alcohol must be evaporated to ensure optimal bond strengths

Dry air source ADEC Tooth Drier

Evaporate volatile solvents

Drying dentin amp enamel

Do not desiccate

Kerr Total Care ldquoSeal-Tightrdquo

Polymerization Cure with VALO for 10 seconds or 20 seconds for lights with output lt600mwcm2

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

37

In the SEM image shown the tooth structure has been dissolved away revealing precisely where Peak had flowed into the dentinal tubules Peak Universal Bondrsquos unique formula allows for optimal penetration into the tooth structure resulting in exceptional bond strengths

An even closer look reveals that Peak will fill microscopic spaces within the toothrsquos anatomy reducing the potential for air voids that create hydraulic pressure and cause post-op sensitivity

Sensitivity Peak is a semi-hydrophilic adhesive

-seeks out spaces to coverseal all open tubules

Desensitizers like Gluma are not needed

-compete for same spaces intended for high strength adhesive to go

-evidence of reduced bond strength due to desensitizers

-Neil Jessop Director of Ultradent RampD

Why 02 Chlorhexedine bull Helps prevent long-term degradation (due to MMP action) of

the collagen in the dentin-adhesive hybrid layer within a restoration

bull CHX has been proven1 to block damage caused by MMPrsquos whether it has been applied before the adhesive or as part of the adhesive

1 Brackett MG Tay FR Brackett WW Dib A Dipp FA Mai S et al (2009) In vivo chlorhexidine stabilization of hybrid layers of an acetone-based dentin adhesive Operative Dentistry 34(4)379ndash383

Carrilho MRO Carvalho RM de Goes MF di Hipoacutelito V Geraldeli S Tay FR et al (2007) Chlorhexidine preserves dentin bond in vitro J Dent Res 86(1)90ndash94

Carrilho MRO Geraldeli S Tay F de Goes MF Carvalho RM Tjaumlderhane L et al (2007) In vivo preservation of the hybrid layer by chlorhexidine J Dent Res 86(6)529ndash533

Brackett WW Tay FR Brackett MG Dib A Sword RJ Pashley DH (2007) The effect of chlorhexidine on dentin hybrid layers in vivo Operative Dentistry 32(2)107ndash111

Breschi Tay Paschley etal Influence of chlorhexidine concentration on the durability of etch and rinse dentin bonds Journal of Dental Research 2009vol 11 pages 191-198 Vol 11 pp 191-198

In vitro study placed chlorhexidine within the primer in two different concentrations to determine if it would provide long term bond strength by preserving the hybrid layer and in two different concentrations

Results

Chlorhexidine is effective in reducing rapid degradation of hybrid layers that are composed of

simplified etch-and-rinse adhesives encouraging further clinical investigation in the preservation of degradation of hybrid layers over time by the use of MMPs inhibitors prior to bonding

Enzyme inhibitors included in the adhesive composition may be even more promising in terms of simplification of the bonding procedure and improving durability

Journal of Dental Research 2009 Ultradent Internal Testing

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

38

The Standard in Bonding Ultradentrsquos shear bond strength testing method has been adopted as a new ISO Standard The UltraTester machine uses this highly accurate method to determine bond strengths

Radiometers

Radiometer Check daily in am 300mWcm2 (600mW cm2)

How good is your light Initial study by DrNassar Barghi found

30 of units tested had output less than 200mWcm2

Second study lt20

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

bull More efficient than Halogens

bull Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

bull Longer lasting Cordless Batteries

bull Faster curing (5 seconds)

bull Nanometer range closely matched CQ range (450-470)

bull Smaller in sizelighter

bull Less heat

Benefits of LED Lights VALO ndash The Clinicianrsquos 1 Choice

Comparisons - Lights VALO delivers

Access to the curing site = Energy to the resin

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

39

bull Broad spectrum LEDs bull Custom LED pack bull Intensely collimated beam bull Unmatched durability bull 3 curing powerful modes bull 10 mm footprint

VALO delivers

bull Broad spectrum wavelengths

bull Custom LED pack =gt Broad Spectrum =gt Improved Curing

465 nm

465 nm

405 nm

445 nm Competitor Competitor

The Effect of Poor Collimation

VALO

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

40

The Effect of Collimation

VALO

MARC bull Managing Accuracy of Resin Curing

MARC is a fiber-optic spectrometer based system that measures how much light an operator delivers to a resin restoration in the mouth in real time MARC shows irradiance spectrum and power delivered to the fiber-optic

VALO delivers

Energy Generated from the curing light does not always equal the Energy Delivered to the tooth

Price Richard BT BDS DDS MS PhD FDS RCS (Edin) FRCDcopy Felix Christopher M BSc Whalen Marc J PhD ldquoFactors Affecting The Energy Delivered to Simulated Class I an Class V Preparationsrdquo JCDA 2010

VALOrsquos footprint EVEN POWER AND WAVELENGTH DISTRIBUTION

COMPLETE COVERAGE

Images provided by Dr Richard Price Dalhousie University 2014 Halifax Canada

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

41

VALOrsquos Unmatched DURABILITY

Machined from Aerospace Aluminum

VALO delivers

bull 3 powerful curing modes

Comparisons - Chargers

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

42

$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2 16-20i VALO

Curing Light Replacement Battery Cost

bull Design bull Power bull Durability bull Access bull Light output range bull Cost bull Weight

Top Variables Which Affect Bonding

1) Visibility ndash MagnificationLightRetraction 2) Diagnosis and Preparation 3) Control ndash Tissue Management 4) Etching ndash Enamel ndash Dentin ndash Porcelain - Metal 5) Moisture DentinEnamel 6) Adhesive Application time 7) Adhesive Thinningdrying 8) Light curing 9) Composite Placement 10) Contamination 11) Expired Products

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

43

TODD SNYDER

Training Coaching bull Technique

bull Problem Areas

Conclusions ldquoAdhesive technology has undergone great progress in the last decade In light of the major drawbacks attributed to all-in one adhesives conventional 3-step etch amp rinse adhesives amp (mild) 2-step self-etch adhesives are still the benchmarks for dental adhesion in routine clinical practicerdquo

Relationship Between Bond-Strength Tests amp Clinical Outcomes BVan Meerbeek et al Leuven Biomat Research Center Dept of Conservative Dentistry School of Dentistry Catholic University of Leuven Belgium

ADHESION Technique

LONGEVITY SLOWER ENTRY BETTER OUTCOME

ADHESION Technique

Apex within inches

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

44

ldquoRacing could be expressed as a simple relationship between adhesion amp cornering speed If the cornering speed can

maintain the tire adhesion then the racer will be successfulrdquo

Todd Snyder DDS (2015)

Enamel amp Variable Dentin Bonding

Problem Varying tooth substrates

Class I or II

Composite Preparation

3x Tubule Density Equals Higher Fluid amp

Increased Difficulty for Bonding 30 Decrease in

Bond Strengths with most bonding systems

What substrate are we treating

ldquoAdhesive dentistry could be expressed as a simple relationship between bonds and stress If the bonds can withstand the stress the restorative technique will be successfulrdquo

Unterbrink and Liebenberg (1999)

ldquoC-Factorrdquo Definition Configuration Factor

ldquoThe ratio of bonded to un-bonded (free) surfacesrdquo

Feilzer DeGee Davidson (1987) Universtiy of Amsterdam ACTA

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

45

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

Excellent Flow amp Handling Base Lining

ldquoC-Factorrdquo

Tokyo Medical amp Dental University 2010 J Tagami et al

Flowable Composite Shrinkage (2mm Bulk Fill w 71wt Flowable ON DENTIN ONLY)

Surefill SDR amp Xeno IV

SureFill SDR amp CLEARFIL SE BOND

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

46

Resin to Dentin Hybrid Zone Preparations gt 2mm

bull Traditionally numerous increments have to be placed to diminish polymerization shrinkage as well as stress on tooth structure

Technique

05mm Flowable amp Bonding Agent

Composite

Normallyhellip

Technique

X-ray of Bond amp 5mm of Flowable

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

47

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

48

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

49

0

10

20

30

40

11 176 157 16

198 19

31

MP

a 1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Effects of Composite Layering on Bond Strengths

Influence of C-Factor amp Layering Technique on Microtensile Bond Strengths to Dentin S Nikolaenko R

Frankenberger et al University of Erlangen Nuremburg Germany Dental Materials 2004 Vol 20 579-585

Internal (Polymerization) Stresses of Composites

ldquoA Simple Pain-Free Adhesive Restorative System by Minimal

Reduction amp Total-Etching (1993)

Takao Fusayma DDS

Tokyo Medical amp Dental University

Dentin Replacement with Composite Cap

Dentin substitute Composites

Bulkfil Flowables Flowable Resins

Glass Ionomers

Enamel Replacement Modern NanoHybrid Composite CR April 2014 NanoHybrid offers best

results

Substrate bull Best long term bonds to phosphoric etched enamel

bull Superficial dentin can have high bond strengths but has MMP activity and water absorption which will disrupt bonds with time even though it offers higher bond strengths than deep dentin

bull Larger thicknesses of composite

stress the bond to tooth structure

Dentin Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 31-35

bull Shrinkage stress is 16-313mpa

bull Venus Bulk Fill composite amp flowable (Kulzer)

bull SureFil SDR Flow (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Base (Voco)

bull Filtek Bulk Fill (3MESPE)

bull Beautifil Bulk Flow (Shofu)

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

50

bull Dentin amp Enamel Replacement

ndash Requires one layer

bull Bonding agent used

bull Long term research

bull C-factor

Bulk Fill Composites Bulk Fill Composites bull Bulk fill composites 4mm max typically

bull More translucent

bull Typical shrinkage is approx 15-18

bull SonicFill Kerr (5mm)

bull Venus Bulk Fill (Kulzer)

bull Quixx (Dentsply)

bull Tetric EvoCeram Bulk Fill (Ivoclar)

bull Xtra Fill (Voco)

bull Filtek Supreme Plus (3MESPE)

Lots of options What works best for your practice and skills

How much time do you have Bond Strengths

Risks and Longevity

Drawbacks of Any Composite Resin

bull Material placement techniques

bull Variable substrate

bull Polymerization stress amp shrinkage

bull Water absorption

bull Hydrophobic bonding agents

bull Decreased adhesive bond strength over time

bull MMPs and Cathepsins

bull Microleakage

Decreased Bond Strengths due to

bull Substrate

bull Preparation technique

bull Bur selection

bull Hand piece oils

bull Bonding agent

bull Curing device and position

bull Material selection

bull Layering technique

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

51

How are you restoring

these different preparations

bull Bioactive material

ndash 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

bull Very good fluoride and ion release helps remineralize tooth structure in the remineralizationndashdemineralization process that naturally occurs in the oral cavity

bull They bond to enamel dentin and metals

Why Glass Ionomers

bull They produce good marginal integrity

bull They shrink only one ninth the amount of composite material

bull They are fluoride-rechargeable

bull There are no free monomers in the material

bull The cavity preparation can be bulk-filled making the materials easy to place

bull They exhibit excellent biocompatibility

Why Glass Ionomers Deep Preparations

Bonding Agent amp Flowable composite

Conventional Glass Ionomer or RMGI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation amp C Factor

Coefficient thermal expansion similar to dentin

Large sized Lesions (gt2MM)

bull Mostly dentin

bull Dentin has more moisture and less substance

bull Open and Closed defects

bull Complications amp Risks are higher

bull Porous Wet Dentin Available

bull Interproximal concerns

bull Increased Occlusal Loading

bull Remaining Tooth Structure

Pulpal Proximity

Seals amp Protects the Pulp bull For Direct amp Indirect Pulp Capping

bull Light-curable Radiopaque Liner

bull Significant Calcium Release

bull Stimulates Hydroxy Apatite amp Dentin Bridge Formation

Resin-Modified Calcium Silicate Pulp ProtectantLiner

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

52

Glass Ionomer Sandwich bullClass I II III amp V posterior restorations bullOpen amp Closed Sandwich techniques bullComposite replacement bullAmalgam replacement bullHigh caries risk patients bullPediatric patients bullGeriatric patients bullSpecial needs patients bullLong term resistance to microleakage

Glass Ionomer Materials bull Dentsply-ChemFil Rock Restorative

bull SDI-Riva LC light cure HV Riva SC self cure HV

bull GC America-Fuji II LC Equia Fil (Fuji IX)

bull VOCO-Ionolux Ionofil Molar AC

bull 3MESPE-Ketac Nano Photac Fil Quick Vitremer Ketac Molar Quick Ketac Fil Plus

Compressive Strengths

bull GC EquiaFil Compressive Strength 255mpa bull Riva SC compressive strength 271mpa bull Chemfil Rock Compressive 200mpa bull Voco Ionolux had higher compressive strength than Equia Fil or

Chemfil Rock bull Surefil SDR compressive strength 220mpa bull Dentin 280mpa-297mpa bull Enamel 384mpa bull Grandio SO HF has compressive 417mpa bull Fuji II LC 170mpa (RMGI) Compressive strength

4172015

53

Minimally Invasive Preparations

Glass Ionomer Interface

Interface A

nalysis (TEM

)

CARDOSO et al J Dent 2010

4172015

54

Resin to Dentin Hybrid Zone

Open Sandwich with glass ionomer amp nanohybrid composite

Glass Ionomer vs Open Sandwich

bull 6 years later

Glass Ionomer vs Open Sandwich bull 6 years later

Glass Ionomer vs Open Sandwich

4172015

55

WEAVE

4172015

56

4172015

57

4172015

58

4172015

59

Weave is ldquoIDEALrdquo Communication

ULTRADENT SEMINARS

TechnologyMaterials

With the right technology one can have the potential to be very fast

How do we create them

Interproximal Contacts

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

54

Resin to Dentin Hybrid Zone

Open Sandwich with glass ionomer amp nanohybrid composite

Glass Ionomer vs Open Sandwich

bull 6 years later

Glass Ionomer vs Open Sandwich bull 6 years later

Glass Ionomer vs Open Sandwich

4172015

55

WEAVE

4172015

56

4172015

57

4172015

58

4172015

59

Weave is ldquoIDEALrdquo Communication

ULTRADENT SEMINARS

TechnologyMaterials

With the right technology one can have the potential to be very fast

How do we create them

Interproximal Contacts

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

55

WEAVE

4172015

56

4172015

57

4172015

58

4172015

59

Weave is ldquoIDEALrdquo Communication

ULTRADENT SEMINARS

TechnologyMaterials

With the right technology one can have the potential to be very fast

How do we create them

Interproximal Contacts

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

56

4172015

57

4172015

58

4172015

59

Weave is ldquoIDEALrdquo Communication

ULTRADENT SEMINARS

TechnologyMaterials

With the right technology one can have the potential to be very fast

How do we create them

Interproximal Contacts

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

57

4172015

58

4172015

59

Weave is ldquoIDEALrdquo Communication

ULTRADENT SEMINARS

TechnologyMaterials

With the right technology one can have the potential to be very fast

How do we create them

Interproximal Contacts

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

58

4172015

59

Weave is ldquoIDEALrdquo Communication

ULTRADENT SEMINARS

TechnologyMaterials

With the right technology one can have the potential to be very fast

How do we create them

Interproximal Contacts

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

59

Weave is ldquoIDEALrdquo Communication

ULTRADENT SEMINARS

TechnologyMaterials

With the right technology one can have the potential to be very fast

How do we create them

Interproximal Contacts

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

60

Interproximal concerns amp Issues bull Voids

bull Sensitivity

bull Condensing

bull Shape

bull Flash

bull Contact

ndash Position

ndash Tightness

Problem amp Solution Tofflemire vs Sectional Matrices

Direct Class II PosteriorComposite (conservative preps)

(tight contacts)

Class II Direct Composite

QUICKMAT DELUX Polydentia SA

QUICK RINGS amp SILICONE RUBBER ADAPTERS MICROTHIN MATRICES 0025MM (0001 IN) WOODEN WEDGES

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

61

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

62

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

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

63

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

Pin-Tweezers

45mm

55mm

65mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

by TrioDent

by TrioDent by TrioDent

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

64

by TrioDent by TrioDent

35mm 45mm 55mm 65mm 75mm

SuperCurve Super snug non-stick

bullMicro-thin ndash 35-38micro (00014rdquo)

bullColor-coded for easy recognition

and re-ordering

bullMatrix very stable after placement

bullLess risk of catching matrix wings

during ring placement especially

with a back-to-back MODO

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands

4172015

65

Garrison Dental 3D Ring System

Garrison Dental

XR = Extra Retention

Fender Wedges amp Slick Bands