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TRANSCRIPT
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Insights for every step!
The Keys to a… Successful, Predictable, and Efficient Single-Unit Crown Procedure
Jason H. Goodchild, [email protected]
Clinical Education Manager, North America
Dentsply Sirona Restorative
Associate Prof & Chair. Dept of Diagnostic Sciences
Creighton Univ. School of Dentistry
Introduction
From Philadelphia, PA
Private Practice (Havertown, PA)
EducationUniv. of Pennsylvania School of Dental Medicine Dept. of Oral Medicine
Creighton University School of Dentistry Chairman, Dept. of Diagnostic Sciences
Dentsply Sirona Restorative
I promise to tell the truth . . .
“Success is not an accident!”~ Tony Robbins
“Success in dentistry is mainly dependent on doing
the basics well”~Anonymous
Goodchild’s Definition of Efficiency in Dentistry
Working quickly AND
Getting it done right the first time
The Dental Solutions Company
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No Post-op
sensitivity
Low film thickness
Cavity adaptation
Bulk fill w/ 3 year clinicalsRadiopaque
Low stress – reduced microleakage
Preferred Handling
Simplified Shading
Radiopaque
Dependable Cure
Smooth surface
One component
Dentsply SironaClass II Solution
Predictable Tight Contacts
Isolation
Less flash, less finishing
Class II Success!Dependable.
Simple.Efficient.
Complex Class IIAnesthesiaPreparationCaries RemovalEtching?IsolationAdhesionMaterial PlacementLight CuringOcclusionFinishing / Polishing
BEFORE
AFTER
The Right Drug for the Right Procedure
Average Durations of Local Anesthesia after Intraoral Injection (mins)
Maxillary Infiltration Inferior Alveolar Block
Pulpal Soft Tissue Pulpal Soft Tissue
2% Lidocaine w/ 1:100K or 1:50k epi 60 170 85 190
3% Mepivacaine 25 90 40 165
4% Prilocaine 20 105 55 190
4% Prilocaine w/ 1:200k epi 60 150 75 180
4% Articaine w/ 1:100k or 1:200k epi 60 170 90 220
0.5% Bupivacaine w/ 1:200k epi 40 340 240 440
Local Anesthetic Maximum Dosages
Local Anesthetic Maximum Dose# of Carpules
Adult # of Carpules
50 lb Child
Lidocaine w/ 1:100k epi (2%-36 mg)Lidocaine w/ 1:50k epiLidocaine w/o epi
3.3 mg/lb (500 mg) 3.3 mg/lb (500 mg)2.0 mg/lb (300 mg)
13.8*5.58.3
4.6NR2.8
Mepivacaine (3% - 54 mg)Mepivacaine (2% w/ 1:20k levo)
2.6 mg/lb (400 mg)7.411.1
2.53.7
Prilocaine plain (4% - 72 mg)Prilocaine w/ 1:200k epi
4.0 mg/lb (600 mg) 8.38.3
2.82.8
Bupivacaine (0.5% - 9mg) 0.6 mg/lb (90 mg) 10 NR
Articaine (4% - 72 mg) 3.3 mg/lb (500mg) 6.9 2.3
Dent Clin N Am 2010;54:587–599.*Maximum dose of epinephrine in healthy patients is 0.2mg, accounting for epinephrine the maximum dose of lidocaine w/1:100k epi is 11 cartridges.
U.S. Retail Market Share ‐ Injectables
Injectable local anesthetics was a $159 million market in 2014 (9% ↑ from 2013)
By far the two biggest players, by molecule, are Lidocaine and Articaine
Since 2011, Articaine has surpassed Lidocaine as the revenue leader in the US
In 2014, Lidocaine was the units leader
Source: ADA, SDM
U.S. Retail Market Share ‐ Injectables
Source: ADA, SDM2014
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Articaine (1:100,000 or 1:200,000)
4% Articadent DENTAL (Articaine
HCl and epinephrine) 1:100,000 OR
1:200,000
Newest Molecule in US – Fastest Growing
Dominated by Septocaine (Septodont)
Strength: 4%
Only available with Epinephrine
Intermediate to Long Duration
Replacing Lidocaine – Works Better!
Pregnancy Category C
Articaine
Why is Articaine overtaking Lidocaine as the most commonly used local anesthetic molecule?
The answer is easy… It works better!
Dentists think it works better, and current literature supports it!
Articaine Controversy
Articaine important dates:11969: Developed in GermanyEntered clinical use1976: Germany1983: Canada1998: United Kingdom2000: United States2005: Australia
Haas & Lennon – first reports about possible link between 4% solutions and nerve injury (ie, articaine and prilocaine)2
1. Malamed SF. Articaine 30 years later. Oral Health. Feb 20162. J Can Dent Assoc 1995 Apr;61(4):319‐30.
The study revealed a higher then expected frequency of paresthesia following the use of articaine and prilocaine1
A follow-up study by Haas in 2009 also found a higher then normal frequency of nerve injuries for articaine during a 10-year period (1999-2008)2
Articaine: 109Lidocaine: 23Prilocaine: 29Multiple agents: 15
1. J Can Dent Assoc 1995 Apr;61(4):319‐30.2. J Can Dent Assoc 2009 Oct;75(8):579a‐f.
Articaine Controversy
Incidence of Paresthesia?
1:42 (US FDA, Septodont NDA 120-971, 1998)1:160,571 (JADA 2000;131:901-7.)1:140,000 (Tandlaegebladet 2005;109:10.)1:609,000 (JCDA 2009;75(8):579a-f.)1:785,000 (JCDA 1995;61:319-30.)1:3,200,200 (ZWR 2000;109(12):678–81.)1:3,700,000 (CRA Newsletter 2001;25(6):1–2.)1:4,159,848 (JADA 2010;141:836–44.)1:13.3 million - (Oral Health Group, Feb 2015)
1:700,000 Still not convinced?
What does Dr. Malamed have to say on this issue?
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Dimensional Stability
AccurateStrong
Strong & Flexible
AccurateEase of Use
Precision PlacementWork Time Safeguard
Time Savings
Easy Removal & Clean UpLow Film Thickness
Low Film Thickness
No Sensitivity;
Shade StabilityStrong
Dentsply SironaSingle-Unit C&B Solution
C&B Success!Dependable.
Simple.Efficient.
Dimensional Stability
Accurate
Strong
Strong & Flexible
AccurateEase of Use
Precision Placement
Work Time Safeguard
Time Savings
Easy Removal & Clean Up
Low Film Thickness
Low Film Thickness
No Sensitivity;
Shade StabilityStrong
Dentsply SironaSingle-Unit C&B Solution
C&B Success!Dependable.
Simple.Efficient.
Indirect Restoratives: The Single-Unit Crown Solution
Patient prepProvisional matrix impressionAnesthesiaTooth preparationTissue management ImpressionProvisionalizationCementation of provisional
Fixed Prosthodontic Landscape
A typical single-unit crown and bridge procedure requires two appointments to complete (exception is the CAD-CAM dentist)
Remove provisional crown and residual cement (anesthesia)
Fit and occlusal adjustment of permanent crown
Final cementation, clean excess cement
The Dental Solutions Company
Success is the result of proper
completion of the procedural
steps
The Class II & Single-Unit Crown
solutions involve products designed
to work together flawlessly
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Definitive Cementation ofFinal Restoration
Opportunity to Educate Around Pain Points
Clinical Pain Points
• Direct vs. Indirect Restorations?• The most important factor is the size of the lesion & destruction of tooth structure1
• Clinicians should determine:• Should the remaining tooth structure gain strength and protection from the
restoration?2
• If so, then think indirect restoration!
1. Schillingburg HT. Treatment Planning for Single-Tooth Restorations. In: Fundamentals of Fixed Prosthodontics. 4th Ed. 2012. p71–79.
2. International Dentistry 2001;1(1):70–80.
• Additional factors that necessitate the need for an indirect restoration:• large failing existing restorations (greater than one-half of the buco-lingual
intercuspal distance posteriorly) • cracks (symptomatic and possibly asymptomatic) • endodontically treated teeth • cuspal fracture• esthetics
JADA 2007;138:101–103.
Clinical Pain Points
Case Example…
Don’t forget good communication skills!
What about this case? A single central incisor?
“If it isn’t presented it can’t get done.”
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If it isn’t presented it can’t get done.”
What about this case? A single central incisor?
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Opportunities to Educate Around Errors
Opportunities to Educate Around Errors
Why? Gives us an opportunity to see what we are doingSo, we can improve techniques and hopefully outcomesAnd encourage practitioners to more critically reevaluate their work
Lab Error!
Dentist Error!
The Single-Unit Crown Procedure
Provisional Impression
Final Impression
Provisional Crown
Provisional Cementation
Definitive Cementation
What are the consequences of getting these steps wrong?
Inaccurate provisional, poor margins, tissue irritation, added time
Inaccurate master model/die, inadequate final crown, added time
Inaccurate provisional, poor margins, tissue irritation, added time
Premature dislodgement, post‐op sensitivity, added time
Crown failure, tissue irritation, added time
Opportunities to Educate Around Errors
Voids at or below the finish lines Indistinct and irregular finish lines
Create linear and clearly-defined finish lines
Avoid the J-shape or ski jump
Opportunities to Educate Around Errors
Rough preparations with voids Voids at/near the finish line Short and irregular preparations
Create smooth and well-defined preparations Critically evaluate impressions for voids (avoid “the lab will just block that out”) Use buildups to avoid irregular anatomy, fill in voids, and increase retention
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Opportunities to Educate Around Errors
Crown preparations must end on tooth!Remember the “Ferrule”
Remember the minimum height of prepsCement is doing all the work!
What about the “Ferrule Effect”
“Circumferential Banding Effect”
1.5-2mm
Making crowns that are not too high
Literature review…The biggest factors seem to be related to
inaccurate reproduction of the occlusal relationshipPhysical deformation of the mandible
during eccentric or opening movements1,2
Physical displacement of teeth under an occlusal load1,2
Inaccurate counter models3
Inaccurate Interocclusal recordStorage time and temperature4,5
461. Gen Dent 2000;48(1):86-91.2. J Prosthet Dent 1975;34:491-5.3. JADA 2006;137:96-98.
4. JADA 1998;129:1014-21.5. J Appl Oral Sci. 2007;15(3):195-8
Back to Basics
The Preparation
The Fundamental Aim of Tooth Preparation
...transform the tooth by a planned process
...to a uniformly reduced geometrical form
...with a closely defined finish line
...permitting sufficient space for the planned restoration
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Frequently encountered errors in toothpreparations for crowns
Inadequate tooth reduction on incisal or occlusal surfacesInadequate tooth reduction of the axial wallsOver-reductionExcess taperInadequate buildupsIndistinct marginsExcess gingival extensionUndercuts in the axial wallsSharp angles on the preparation
50JADA 2007;138:1373-5.
Three Most Important Factors to Consider:
Dent Clin N Am 2004;48:359-385.
1.Taper
2.Height
3.Reduction
Three most important factors…Taper, Height, Reduction
Dent Clin N Am 2004;48:359-385.
Significant retention from prepNO retention from prep
Creating a Naturally Retentive Preparation
Crown Preparation-Reduction and Margin Tooth Preparation Matches Crown Substrate
•Match crown preparation to material substrate!•Substrates have different preparation requirements
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Preparation Reduction Requirements by Substrate Zirconia PFM All-Ceramic
Only differences between PFM and Zirconia preps –
amount of reduction!
Minimum reduction for strength = 0.5mm
…..practical goal ~ 1mm+
(Celtra,eMax)
Another Case Example…
Pre-operative presentation. Concerned about the discoloration on #8.
Root canal therapy is completed. Preparation of tooth #8 is completed. Note dark color of the stump.
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Final impression of tooth #8. Completed layered zirconia crown on tooth #8 immediately after insertion.
Excellent preparation design captured by an excellent final
impression gives the laboratory technician the opportunity to create
beautiful esthetics!
Excellent preparation design gives the laboratory technician the opportunity to create beautiful esthetics!
Another Big Case…
49 year-old female who lost #12 because of a fractured root. Has been wearing a chairside provisional 11-13 for last six months.
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She is has been hesitant to finalize the bridge, up to this point you don’t know why
One day, she comes in and asks, “Do you think porcelain veneers can make my smile look better?”
We did an esthetic wax-up, and together with the patient decided on the “look” The patient chose porcelain veneers on 6-10, and a zirconia 3-unit FPD 11-13
Singlue-unit provisional 6-13 using Integrity Multi-Cure, from wax-up Provisional in-place. She actually started to really like it after 1-2 weeks!?!
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One week after final cementation, adjusted occlusion. Pt ecstatic about results! One week after final cementation, adjusted occlusion. Pt ecstatic about results!
Back to Basics
Final Impressions
US Final Impression Material Market Overview Work Time Characteristics of PVS vs PE
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“Success in dentistry is mainly dependent on doing the basics well” Let’s Define
and Re-define impression
making
Definition: An unequivocal negative likeness or copy in reverse of the surface of an object, an imprint of the
teeth and adjacent structures
Source: Glossary of Prosthodontic Terms, 2013.
Dental Impressions
Definition: An unequivocal negative likeness or copy in reverse of the surface of an object, an imprint of the
teeth and adjacent structures
Source: Glossary of Prosthodontic Terms, 2013.
Dental Impressions
Definition: An unequivocal negative likeness or copy in reverse of the surface of an object, an imprint of the
teeth and adjacent structures
Source: Glossary of Prosthodontic Terms, 2013.
Dental Impressions
Definition: An unequivocal negative likeness or copy in reverse of the surface of an object, an imprint of the
teeth and adjacent structures
Source: Glossary of Prosthodontic Terms, 2013.
Dental Impressions
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Definition: An unequivocal negative likeness or copy in reverse of the surface of an object, an imprint of the
teeth and adjacent structures
Source: Glossary of Prosthodontic Terms, 2013.
Dental Impressions It was reported that 89% of impressions had 1 or more observable errors!
Source: J Prosthet Dent 2005;94(2):112‐7.
Source: J Prosthet Dent 2005;94:112‐7.
What were the errors?
Source: J Prosthet Dent 2005;94(2):112‐7.
Number of different errors?
From Clinicians Report…
“Impression materials can no longer be indicted for restoration inaccuracies… Excellent impressions are most likely
achieved when clinicians are confident in their impression material and provide
adequate gingival retraction.”
July 2014
Tray Design and Viscosity Selection
Support for the material has to come from the tray or from the material itself!!!
The less supportive the tray is….the more stiff the material needs to be
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Tray Design and Viscosity Selection
Triple trays need material to provide support
Full arch/custom trays provide necessary support
• Seat the tray without impression material and instruct patient how to close into a normal bite
• Pay attention when recording a bite record unilaterally as the patient may go into lateral excursion on that side
• Instruct patient that once the tray is seated they should refrain from any movements of the tray thereby to minimize distorting the impression material at a critical phase during its set
Practice Seating the Tray!
Is there a difference in accuracy between triple trays (closed bite) and stock/custom trays (closed trays)?
Compared the die accuracy of:1
Complete arch heavy body Double-arch plastic tray heavy body Double-arch metal tray heavy body Double-arch plastic tray putty
Pros & cons of each!2
Tray flexure Differing viscosities Not appropriate for all cases Bite registrations3
951. J Prosthet Dent 2002;87:510-515.2. Gen Dent 2000;48(1):86-91.3. J Prosthet Dent 1975;34:491-5.
Impression Materials Range of Options
•Multiple viscosity options• XLV, LV, Monophase, Heavy, Rigid, Putty
•Set time options• Super Fast, Fast, Regular, Extra
What is each material best for?
Patient Experience?
97Photo courtesy of Parrish King, DMD
Criteria for Closed-bite tray
INDICATIONS1-2 prepared teethTray will fit behind the tuberosity
without impinging on the tissueClass I or II occlusionPrepared tooth has sound adjacent
teeth on each sideNatural occlusal stops
CONTRAINDICATIONSMore than 2 prepared teeth Insufficient occlusal reductionMost distal tooth in the archClass III occlusion Inadequate space for the tray
posterior to the tuberosityNo natural occlusal stops
Gen Dent 2000;48(1):86-91.
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Opportunities to Educate Around Errors
Matching Viscosity Selection to Tray Choice• Support facilitates accuracy
Work Time and Set Time Issues• Faster isn’t always better
Delivery Options are Imperfect• What are the tradeoffs?
1-Step Dual Viscosity Impressionwith Christensen “Blowing Technique”
Video
Confidential – FOR INTERNAL USE ONLY
Hemostasis must be achieved to record an impression with accurate detail.
Impact of Ferric Sulfate?
Tray selection and seating are responsible for this example
Stock trays are not always the answer, tray size and proper seating are critical
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Movement during seating can cause drags in similar
locations
Movement during seating can cause drags in similar
locations
Really?!?
Seating errors will distort the impression
Goodoccluding contacts evident
Badneed to have more contact on adjacent teeth
Take closed bite impression and shine it to the light.
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There are multiple errors on this impression… contact with the tray and loss of marginal detail. Tray selection, tray
seating, or position errors could be the cause
If the patient is biting on the tray during the making of the impression there will be distortion, in this case the occlusion
will be incorrect
Not enough tray material to support the wash material is the problem here, also cotton rolls should be removed from
impression for disinfection purposes
Gross!!! The lab can distort the impression trying to remove these before pouring
Problems with relines and additions Problems with relines and additions
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Problems with relines and additions Problems with relines and additions
Was the wash material syringed into a saliva- or blood-filled sulcus? Fluid control is critical to capturing all the marginal
details
Syringing technique is responsible for this V-shaped defect. Likely caused by
starting/stopping in the same location
Material selection?? Viscosity selection??
Note the voids at approximately the same location on both preps…syringing of wash should not begin/end at the same location. Go around twice, and end at a different location
then wear you began.
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Making sure the margins are marked…
Aquasil XLV Impression
Tear Strength?!?
Importance of Tear Strength
Tear strength measures the resistance to fracture of a material subjected to a tensile force acting perpendicular to a surface flaw
High tear strength is necessary to ensure material retrieval from the sulcus, to allow for multiple pours of the model and to maintain the
accuracy of the impression!
Increased use of retraction pastes leads to less sulcular opening, thinner films in place and therefore the need for a stronger material
Intraoral Tear Strength• What is it?
• Tear strength of material while in thin cross-sections and when being removed from the mouth
• How is it measured?• A notched specimen is torn at MRT +90” (fastest measure
has ever been done) and material strength is measured
• How is test different than what is on market?• Competitors measure tear strength in thick pieces many
minutes after material sets. Since impression material gets stronger over time, this creates a false measurement for clinicians who want performance at MRT and not 15’ later.
• Why does new test matter?• Tears remain a leading error in impressions. A material
needs to be strong when removed from the mouth. Clinicians should know the clinical/intraoral tear strength of their material.
Intraoral Tear StrengthWhat is it? Tear strength of material while in thin cross-sections and
when being removed from the mouth
How is it measured? A notched specimen is torn at MRT +90” (fastest measure
has ever been done) and material strength is measured
How is test different than what is on market? Competitors measure tear strength in thick pieces many
minutes after material sets. Since impression material gets stronger over time, this creates a false measurement for clinicians who want performance at MRT and not 15’ later.
Why does new test matter? Tears remain a leading error in impressions. A material
needs to be strong when removed from the mouth. Clinicians should know the clinical/intraoral tear strength of their material.
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Intraoral Tear Strength• What is it?
• Tear strength of material while in thin cross-sections and when being removed from the mouth
• How is it measured?• A notched specimen is torn at MRT +90” (fastest measure
has ever been done) and material strength is measured
• How is test different than what is on market?• Competitors measure tear strength in thick pieces many
minutes after material sets. Since impression material gets stronger over time, this creates a false measurement for clinicians who want performance at MRT and not 15’ later.
• Why does new test matter?• Tears remain a leading error in impressions. A material
needs to be strong when removed from the mouth. Clinicians should know the clinical/intraoral tear strength of their material.
Intraoral Tear Strength• What is it?
• Tear strength of material while in thin cross-sections and when being removed from the mouth
• How is it measured?• A notched specimen is torn at MRT +90” (fastest measure
has ever been done) and material strength is measured
• How is test different than what is on market?• Competitors measure tear strength in thick pieces many
minutes after material sets. Since impression material gets stronger over time, this creates a false measurement for clinicians who want performance at MRT and not 15’ later.
• Why does new test matter?• Tears remain a leading error in impressions. A material
needs to be strong when removed from the mouth. Clinicians should know the clinical/intraoral tear strength of their material.
Importance of Tear Strength
•Material placed into the sulcus, natural anatomic undercuts and flaws must be retrieved in one piece
•Time consuming and annoying to go back in and retrieve pieces left behind
•Timing is a critical component - retrieve at MRT not before
The Importance of Tear Strength
Source: J Esthet Restor Dent 2008;20:186-194.
Tissue Management defined: combination of hemostasis and fluid control, with displacement of tissue to allow for sufficient impression material placement
Source: Glossary of Prosthodontic Terms, 2013
How is hemostasis achieved?
Hemostasis: The stopping of blood flowVasoconstriction: Narrowing of blood vessels
Chemotherapy racemic epinephrine aluminum chloride ferric sulfate alum (potassium aluminum sulfate) aluminum acetate zinc chloride
J Prosthet Dent 2009;101:153‐157
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Alternative Category to Traditional Mechanical Retraction: Paste/Putty Chemical Retraction
Additional overhead/consumables costs Performs adequately for hemostasis and fluid control but
may underperform for retractionSome manufacturer’s instructions indicate product may work
better in conjunction with cordActive compound in majority of products is Aluminum
ChlorideWill require dwell time, and requires aggressive water rinsing
What is the purpose of Retraction?Create access for the wash material so that it can be placed into the desired area in a thick enough
volume so that it can be retrieved in one piece
“Modern Day” Retraction Techniques
Retraction Paste
Cord Placement
vs.
It is well known that placing cord creates an acute tissue injury that in some cases can
lead to post-operative discomfort, inflammation, and
marginal recession.
J Prosthodont 2006;15(2):108-12.
Gingival Retraction Cord
Causes local inflammation and acute tissue injury1
Can be associated with gingival recession2
May require additional anesthesiaOver 125 varieties on the marketCan be knitted, braided, or twistedCan be plain or impregnated
1. J Prosthodont 2006;15(2):108-12.2. J Prosthet Dent 1980;44(5):508-14.
Placing Retraction Cord
Use gentle pressure Will be traumatic to tissue Could be responsible for post-operative pain Tissue deflection! Obtain a V-Shaped sulcus Top of cord should be visible
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Print Ads Intraoral HydrophilicityA side-by-side vs. 3M (video files)
Impregum Garant Soft LB Imprint 3 Quick Step LB Aquasil® Ultra+ XLV FSImprint 4 Light
Test Method: Contact angle measured @2” @80% Relative Humidity on uncured impression material.Impregum, Imprint 3, and Imprint 4 are not registered trademarks of Dentsply Sirona.
*Date on File**As per stated in manufacturers’ DFU-Not tested or not stated in manufacturers’ DFUCompetitive brand names are not the property of DENTSPLY International.
Product Intraoral Hydrophilicity/ Uncured Film (2” @80% RH)
Set Hydrophilicity/ Cured Film (5” @50% RH)
Intraoral Tear Strength (.245mm)
24hr Tear Strength(.245mm)
Work w/Moist Prep*
Stated Intraoral Work Time**
Easy to Use Precision Delivery Option
Aquasil® Ultra+ 15° 5° 607 678 Yes 35” Yes
Imprint 4 19° 6° 441 539 No 35” No
Take 1 Advanced 72° 88° 196 338 No - Yes
Exafast 68° 66° 242 273 No - No
Flexitime 55° 58° 291 399 No 30” No
Imprint 3 70° 43° 505 614 No 40” No
Impregum 49° 54° 165 259 No - No
Panasil 16° 6° 334 366 No - No
Competitive Performance*Aquasil® Ultra+ material stands out across all areas to deliver clinical results in even the most challenging circumstances
Temporary vs. Provisional
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Provisional or Temporary Restorations
…In dental school I was taught……
“Don’t make the temporary too nice or the patient may not come back for the final crown!”
Considerations for Provisional Restorations
• Convenient Handling • Biocompatibility• Dimensionally Stable• Easy to Contour and Polish• Strong• Wear Resistant• Esthetic
Material Requirements
Selecting the Provisional Material
Methacrylates(poly) methyl(poly) ethylVinyl methylEthyl methyl
CompositesBIS-AcrylBIS-GMA ResinsUDMA
Light Curing the Provisional?
Let the material set for 90 seconds in the mouth then remove and command set with 20 seconds of light curing
Types of Provisional Cements
Resin-Based containing di-urethane di-methacrylate TNE (Temrex)Temp Bond Clear (Kerr)
Zinc Oxide EugenolTempBond (Kerr)
Zinc Oxide NonEugenolTempGrip (Dentsply Sirona)Tempbond NE (Kerr)
Zinc PolycarboxylateDurelon w or w/o vaseline
Removal of Provisional Cement
Designed to be different!
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Case Example
All Indirect Restorations Must Be Cemented!
The Confusing Landscape of Cementation
Definitive CementsHistory of Definitive Cements
• Oxychloride/Oxysulfate Cements (pre-1870)• Zinc Phosphate Cement (1870)• Silicate Cement (1873)• Zinc Oxide Eugenol Cement (1875)• Zinc Polycarboxylate Cement (1963)• Glass Ionomer Cement (1972)• Adhesive Resin Cement (1986)• Resin-Modified Glass Ionomer Cement (1992)• Self-Adhesive Resin Cement (2004)
1. Albers HF. Tooth-colored restoratives: principles and techniques. 9th Ed. BC Decker. 2001. p43-45.2. Pameijer CH. A Review of Luting Agents. Int J Dent 2012.
Milford News, c. 1929
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The 4 Major DefinitiveCement Categories
Glass Ionomer
Fuji I (GC)Ketac CEM (3M
ESPE)Ceramir (DOXA)
Resin-Modified Glass Ionomer
Rely-X Luting Plus (3M ESPE)FujiCEM Automix
(GC)Fuji Plus (GC)
Self-Adhesive Resin
Rely-X Unicem(3M ESPE)
Maxcem Elite (Kerr)
Calibra Universal (Dentsply Sirona)
Adhesive Resin
Rely-X Ultimate (3M ESPE)
Multilink (Ivoclar)Calibra Ceram
(Dentsply Sirona)
Nexus NX3 (Kerr)
10.527, 8%
49.976, 35%
41.026, 29%
39.935, 28%
GIC RMGIC ARC SARC
RMGIC
GIC
ARC
SARC
The Definitive Cements Market is valued at $141M
Source: 2014 SDM Market Share Data
GIC: Glass IonomerRMGIC: Resin Modified Glass IonomerARC: Adhesive Resin CementSARC: Self-Adhesive Resin Cement
Clinicians have more than one “go to” cement for everyday use because there are varying clinical scenarios that require the use of specific material properties-isolation & adhesion
GIC RMGIC ARC SARC
RMGIC
GIC
ARC
SARC
Definitive Cements from a Clinical Strength Perspective
Source: 2014 SDM Market Share Data
GIC: Glass IonomerRMGIC: Resin Modified Glass IonomerARC: Adhesive Resin CementSARC: Self-Adhesive Resin Cement
GI/RMGI Weak
Self AdhesiveResin Cement
Not Strong
Adhesive Resin Cement
Strong
Cement Product Summary
Cements Glass Ionomer
ResinModified
Glass Ionomer
Self AdhesiveResin
Traditional Resin
Desirable Properties
Moisture tolerantFluoride release
Moisture tolerantFluoride release
Strength/Estheticswithout adhesive
step
Highest strengthGreat esthetics
Strength Moderate Moderate Good Excellent
Esthetics Moderate Moderate Good Excellent
Technique Sensitivity
Low LowModerate(requires isolation)
High(isolation &adhesion)
Ease ofUse
Very Good Excellent Moderate Difficult
Case ExamplePFZ crowns 8 & 9 cemented with Ceramir cement
Ceramir (Doxa)
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Ceramir (Doxa)
A self-sealing, acid-base reaction cementBased on NIB (NonstructurallyIntegrating Bioceramic) technologyThe cement is a new formulation class, which is a hybrid material compromised if calcium aluminate and glass-ionomer componentsFinal pH after full setting = 8.5
Ceramir (Doxa)
Ceramir (XeraCem) shows significantly higher 24-hour compressive strength than RelyX Luting Cement, and is comparable to RelyX UnicemCompressive strength of Ceramir(XeraCem) increases approximately 20% over a period of 30 days.
Source: S. Jefferies, J. Loof, CH Pameijer, D Boston et al. Physical properties of XeraCem. IADR 2008. Poster#3100.
Pre-Operative Pre-Operative
Curing Integrity Multi-Cure Final Impression using Aquasil Ultra XLV/Heavy
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Mounted Models Scanning the Models
Scanned Models Final Restorations
Cleaning the inside of the crown with Ivoclean (Ivoclar) Seating the restorations
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Removing the excess cement Final Restorations – Post-op
What we already know about Cement Selection…..
4 Major Product Categories (GI, RMGI, SARC, ARC)
There is no perfect product for every clinical scenario
The prep, crown substrate, and esthetic requirements influence product selection
Clinicians often have more than one “everyday” cement
For adhesive resin cements, system solutions work!
Dentists rely on their “clinical history” with products
Physical properties matter… so does technique and clean-up
Forces of Mastication in Action
Clinically that’s…Biting, chewing, sliding and releasing!
CompressiveVertical forces
causing it to squeeze together
Flexural Lateral forces that bend the
object
TensileResistance to
stretching and pulling
Lets Bring Flexural Strength into Action!
The cement has to help that weak ceramic!
Crown Structure Up Close
Porcelain Veneer eMax or Celtra PFM Zirconia/Layered
WEAK NOT STRONG STRONG STRONG
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Strength of Crown Materials Commonly Used
Strength Material Flexural Strength
WeakFeldspathic Porcelains
Leucite Reinforced (Empress)65-120Mpa120-160Mpa
Somewhere in the middle but definitely
not strong!
Lithium Disilicate- eMaxZirconia Reinforced Lithium Silicate (ZRS)-
Celtra300-400Mpa
StrongAlumina
Zirconia (Bruxzir)PFM
750-800+Mpa1100+Mpa
This does not take into account the influence of tooth prep and thickness…just the crown material!!!
Conventional Cement vs Bonding Decision-Prep Geometry
Cemented- not adhered to tooth structure- ZOP,GI,RMGI• Preparation with adequate cervical-occlusal height (≥4mm)
and taper between 10-20°• High strength restoration
• Bonded- bound to the tooth-SAC, ARC• Short clinical crown (≤3mm)• Over-tapered preparation greater than 20°• Low strength restoration• Not strong restoration (eMax and Celtra)
Height
Taper
What definitive cement should I use? Bond or Cement?
Good Choice
Acceptable Choice, a better choice may exist
Not Recommended
Cements‐ Product Indications
Cements/Substrate
Glass Ionomer
ResinModified GI
Self AdhesiveResin
Traditional Resin
PFM’s or All Metal Crn Yes Yes Yes Yes
All Zirconia or Zirconia Core Yes Yes Yes Yes
All Ceramic No No Yes Yes
Ceramic Inlays and Onlays No No Yes Yes
Implants Yes Yes Yes No
Cements/Substrate
Glass Ionomer
ResinModified GI
Self AdhesiveResin
Traditional Resin
PFM’s or All Metal Crn Yes Yes Yes Yes
All Zirconia or Zirconia Core Yes Yes Yes Yes
All Ceramic No No No Yes
Ceramic Inlays and Onlays No No Yes Yes
Implants Yes Yes Yes No
Ret
entiv
e P
rep
Non
-Ret
entiv
e P
rep
RecommendedCement
Clinical Tips
FeldspathicPorcelains
Adhesive ResinSelf-adhesive Resin
• Etch the porcelain with hydrofluoric acid• For bonding to porcelain, use a silanating
agent or appropriate ceramic primer
Leucite-ReinforcedCeramics (empress)
Adhesive ResinSelf-Adhesive Resin
• Etch the porcelain with hydrofluoric acid• For bonding to porcelain, use a silanating
agent or appropriate ceramic primer
Lithium DisilicateCeramics (eMax)
Zirconia reinforced lithium silicate (Celtra)
Adhesive ResinSelf-Adhesive ResinConventional Cement
• Etch to porcelain with hydrofluoric acid• For bonding to porcelain, use a silanating
agent or appropriate ceramic primer• Consider Monobond Etch & Prime• Can be conventionally cemented when
retention is adequate (eg, >4mm height)
Zirconia-Based Ceramics (Cercon, Bruxzir)
Conventional CementAdhesive ResinSelf-Adhesive Resin
• Good retention = conventional cement• Otherwise, use resin cement• Sanblast, use zirconia primer on intaglio• No silane, No hydrofluoric acid• Consider Ivoclean
Matching Cement and Crown Surface Treatments of Dental Ceramics
Ivoclean
Silane
Metal Primers
Hydrofluoric Acid
Micro-etching
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What is Hydrofluoric Acid?
HF is an inorganic acid capable of etching glass surfaces4-10% concentrations available (20-60 secs)Lithium disilicate: 20s, 5% HFNanoceramic: 40s, 5%Leucite reinforced: 60s, 5% HFFeldspathic: 120s, 9% HFCreates microretentive etching patterns on the internal surfaceWill not weaken the strength of silicate-ceramic material
JADA 2013;144(1):31-44.www.speareducation.com
What is Hydrofluoric Acid?
VERY hazardous!Extreme care must be used when handling hydrofluoric acidUse a rubber dam if using to repair porcelain in the mouthShould not be used on dentin or enamel
JADA 2013;144(1):31-44.www.speareducation.com
Instead of Hydrofluoric Acid…
Monobond Etch & Prime (Ivoclar)Etching and Silane in one stepHF-free
What is Ivoclean (Ivoclar)?
During intraoral try-in, the contamination of restoration surfaces with saliva cannot be avoidedIndicated for:Glass ceramicsZirconia/AluminaMetalIndirect composite restorations
Ivoclean (Ivoclar)
Creates optimum pre-requisites for the adhesive luting procedureEasy to Use: Simply apply Ivoclean to the bonding surface of the restoration Leave it to react for 20 secondsRinse the Ivoclean off thoroughly with water Dry the bonding surface with oil-free air
A silane coupling agent acts as an intermediary between crown and cement and improves adhesionSilane coupling agents are compounds with functional groups that bond with both organic (resins) and inorganic (glass, silica) materials
What is Silane Coupling Agent?
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What is Silane Coupling Agent?
Silanes also enhance the resin-silicate bond by promoting the wettability of the surface for the penetration of resin
Examples: Monobond-S (Ivoclar)Calibra Silane Coupling Agent (Dentsply Sirona)Rely-X Ceramic Primer (3M ESPE)Clearfil Ceramic Primer (Kuraray)Porcelain Primer (Bisco)
What are Metal Primers?
Similar concept to function of SilaneCoupling Agent
They contain bifunctional phosphate monomers that bond on one side to the metal or oxide-ceramic (zirconia, alumina) and to resin on the other side
Most contain an acidic phosphate monomer (eg, MDP)
JADA 2013;144(1):31-44.
Summary and Conclusions
Back to BasicsFocus on the Details – GiGoCreate preps that match the substrate, and are easy to impress and read by the techClosely evaluate your impressions for errorsMatch cementation procedure with the substrate for best outcomesCommunicate with the lab, they are our partners!
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THANK YOU!!!