todd c. snyder, dds, faacd, fiadfe, asda the nuts & …...digital smile mockup-is a proven...

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The Nuts & Bolts of Veneers

TODD C. SNYDER, DDS, FAACD, FIADFE, ASDA

Accredited Fellow, American Academy of Cosmetic Dentistry

Fellow, International Academy for Dental Facial Esthetics

Member of The American Society For Dental Aesthetics

Former Faculty, UCLA Center For Esthetic Dentistry

LEGIONpride.com, Online Training Challenge for Dentists

Todd Snyder, DDS, FAACD, FIADFE, ASDALaguna Niguel, CA

Aesthetic Dental Designs®

[email protected]

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To Learn:• Preparation Designs• Tips & Materials• Provisional Techniques• Cementation Protocols• Technology

• a d d fadf jas

Why Are YOU Here?

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• a d d fadf jas

What Do YOU Want?

Will That Get You What You Want?

Possibility of More Patients, Money…? Freedom?1006

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• Finding Patients? (advertising/marketing)

• Why they should work with YOU?!

• Close the Commitment. (Technology)

• Collect Cash or Set Up Payment Plan

What Might Be Just As Important?

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Consumer/Patient Impression

• Do they know what a Cosmetic Dentist is?

• Do they perceive you are one?

• Will they go somewhere else because they think you are a family dentist?

• Do they think you are capable of providing a great smile for them?

• How can you alter their perception?

• What is your brand image?• Your office appearance?• Website?• Your ads?• Your social media?

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According to the American Academy of Cosmetic Dentistry 50% of patients are

unhappy with their smiles and 3 out of 5 people will invest in their smiles.

How Do You Get More Cases?

Invest in technology.

-Office iPad (Large)

-35mm Digital Camera

-Big Lobby Television

-Software Systems

Personal Case Books

Office Displays

Referral Cards

Gift Cards

Custom Smocks & Bleach Kits

Modern Tools**

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One of the most powerful & fastest tools you own to create cosmetic opportunities??

What Tools Might Be Important?

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WHITENING

Immediate Call to Action Motivator

Start Here

Over-the-Counter Teeth

Whiteners: $1.4 billion

(MSNBC) ...

(Consumer Reports).

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Over The Counter Whitening

Whitening

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Opalescence GO!• Fast, Easy, Effective, Better

Experience• Convenient & affordable

professional whitening to GO• Pre-loaded, disposable UltraFit™

tray for a custom-like fit• Molar-to-molar coverage• No chair time

300

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Reduce or Eliminate Sensitivity

• Potassium Nitrate & Fluoride

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Opalescence Go Sample Tower

“Total annual revenue in the teeth whitening industry topped $11 billion at the beginning of

2015, with $1.4 billion spent on teeth whitening products. These figures suggest a steady annual increase in the teeth whitening market industry, which is expected to continually climb over the

next 10 years” AACD Research

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Cosmetic Alterations

• How many of you want to buy something sight unseen?

• How many of you want to experience something first before investing?

• Your patients are no different!

• They are concerned about how it will look and feel. They want to be excited and happy!

• Don’t Just Tell…..Show & Tell!

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So why are people willing to pay top dollar for a beautiful smile

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The Key to Success:

VisualizationWhat is the patient’s perception or desired outcome in their mind to create the EMOTION and DESIRE?

TIP

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YOU NEED CAMERAS

Please Turn On Your Cell Phones

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http://www.instagram.com/Toddsnyderdds/

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@toddsnyderdds @legionpride

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300 per Week

#5 most used app

109.5 texts a day

4.8% response rate

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•EVERY new patient

•Post-op Follow-up

•Pre-op Information

5 Minute Plan

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5 Minute Plan




5 Minute Plan

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1006

TIP

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What about example

pictures?

◆ Are they relevant and

realistic?

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Photographic Manipulation

• Cosmetic “Imaging” Software• SmileFy app• PreVue app• SmileVision• DentalGPS• DSD

• Digital Agents• Virtual Smiles ($125/image)• DreamSmiles (<$4000 a year?)

• Ivoclar/Kapanu?

Why Does this Work?

✓Creates awareness

✓Suggests the possibility

✓Promotes discussion

✓Provides bridge to clinical evaluation and

presentation of options

✓Creates EMOTION and DESIRE

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Digital Smile Mockup

-is a proven practice building program that can:

Dramatically increase your patient’s interest in a smile

transformation

Remember, 50% of your patients want to improve their

smile

The goal is to help them visualize themselves with an

improved smile

When you hand a Digital Simulation to your patient, you plant a seed of what is possible, a constant reminder of what their potential new smile can be. They can show it to their friends and family, you can put a copy in their chart for follow-up, have them hang it on their refrigerator...!

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VIRTUAL SMILES©

• Tooth shape

• Length, width, & style #

• Tooth color

• Translucency, effects

• File Format

• Paper

• CD

• Email

• Flash

• Logo & Office Info

• Smile Simulations

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SMILE DESIGN SOFTWARE VS DRAG AND DROP SMILE GALLERY?

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Overall Feel

Appearance…what is it? who decides, Dentist? Ceramist? Patient? Combined effort?

THEIR DECISION √

BUT YOU HAVE TO GUIDE THEM

The Key to Success:

Traditional Veneers

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Diagnosis & Treatment Planning

The Key to Success:

Traditional Veneers

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You are selling the Emotion…

Do you know “THEIR” desired outcome?

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MARKETING

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Advertising Evolution- Internet & Social Media

• Traditionally Marketing was Expensive• Internet is very Inexpensive comparatively• Website (SEO Management/Quality Code/Page Speed)• Reviews• Social Media (need to claim them all with same name)

• YouTube• Facebook• Twitter• Flickr• Instagram-no cost High Return

• Cosmetic Imaging• In Office • OUTSIDE OFFICE? www.smilevirtual.com

• There never seems to be enough of it…

• It has to be built into the schedule or out source to employee

• Take the time to huge profit

• Know what the case is going to entail ahead of time

• What is the patients Chief Complaints?• Pick 3 to address

• Why do they have these problems?

• Are they going to drive you crazy?

Consultation Time

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• Immediate Smile Change Consultation?

• Can they come back in a week?

Time (CONSULTATION)

OR

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-Patient wants to fix the small

lateral incisor

-No tooth reduction

OPPORTUNITY

Beadline Provisional Mockup

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http://d1ue90e5sp4tcv.cloudfront.net/668/images/Grid_Image_20945_22_v1.pdf

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Beadline Provisional MockupBeadline Provisional Mockup

Diagnostic Models with a waxup are duplicated. Special over impression is created and used to deliver temporary mockup

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LISTEN For Yourself

Show & Sell Possibilities..

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COSMETICChanges

3 out of 5 • Patient came in to fix small lateral incisors

• Wants “Absolutely” no tooth reduction

• What drives him?• Appearance

• No Tooth Reduction

• Emotion

• Desired Outcome…. Feel Better, more confident?

Results

Confidence, Dating,Work,Emotional Goals

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Cosmetic Dentistry

• Do YOU WANT more Cosmetic Cases?

• Patients desire a change• But don’t know what they want (typically)

• What are their Chief Complaints (pick 3)

• Why?

• And What will that accomplish? Reasoning behind Tx.

• Always look at the big picture

• Take photos

• Write down where they can see their Chief Complaints• Signature on waxup

• Signature on provisionals

• Signature for final cementation approval

REVIEW

• Existing In Office Patients (3 out of 5) want to fix their SMILES!

• Shade Evaluation every exam & everyone in Hygiene Department

• Website, Social Media Accounts all setup and posting RELEVANT content

• Photos of everyone to send home (possibly with imaging) GET A CAMERA

• Take a photo and do a Cosmetic Simulation/Mockup

• Instant visualization through software on an iPad or possibly internet

• Instant Composite Mockup in the dental chair

• Take an impression and have lab do a waxup to facilitate a Beadline

Provisional Mockup (reduced fee or no fee agreement with lab)

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Diagnostic Models & Records

How Do We Create The

Intraoral Mockup?

• First take an impression of teeth with a material that allows you multiple repours.

• Want one original model

• One model for laboratory

• Extra model if you need bleach trays or practice preparations

• Photos

• Facebow

• Horizontal Plane Indicator

• Teeth that are too far facial will remain untouched. When photos are taken they will be less obvious.

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Silginat – Kettenbach 201

Counter FIT- Multipurpose Replication Silicone

(Clinician’s Choice)

Counter FIT- Multipurpose Replication Silicone

(Clinician’s Choice)

Silginat - Kettenbach

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Wear Facets & Interferences

3 Sets of Models-One is untouched for legal documentation-Second to practice preparations (It will be waxed up)-Third is a spare to practice on or make bleach trays

Mounted and Equilibrated

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—MEG BIRAM

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Tooth Size Averages

2nd Premolar 1st Premolar Canine Lateral Incisor Central Incisor

6.6mm 7.1mm 7.6mm 6.6mm 8.6mm

7.7mm 8.6mm 10.6mm 9.8mm 11.2mm

Width

Length

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0.6-1-1.68

Golden Proportion Measurement.

• Practice Preparations

• Waxup

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ADDITIONAL TOOLS

◆ Panadent: Multi Purpose Ruler

◆ Erskine: Dentagauge 1 & 2

ADDITIONAL TOOLS

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What Records & WhenDiagnostic & Prep Reduction Models

Diagnostic Guides

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TRAIN

Are you confident in creating beautiful outcomes on anterior teeth quickly &

easily? IF NOT, PRACTICE!

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Diagnostic Guides

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

Cosmetic Mockup or Provisionals (Bead Line Technique)

Cosmetic Provisionals (Bead Line Technique)

Scribe a 0.5mm-1mm groove into tissue & a little on tooth

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PROVISIONAL1405

• Utilize an accurate preliminary over impression

• Maintain over impression

• Check contacts and occlusion

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No Polish Necessary if you use a good model

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No Preparation Veneers

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No Prep Veneers• Do a waxup

• Duplicate into a stone model

• Over impression of stone model w/ PVS BEADLINE TECHNIQUE or Siltech Putty

• Intraoral mockup using the over impression filled with temporary acrylic**

• Is thickness and appearance okay?• Depth cuts through over impression if necessary.

• Typically no provisionals are necessary

• No undercuts

• Color change varies based on tooth position/color

Tooth Preparation Conservative Preparations

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Mockup & prep

No Prep Case: 1

• Angulation of teeth

• Spaces

• Lingually positioned

• Lack of lip support

• Thinned enamel

• Fuller smile

• Microdontia

• Chairside Mockup**

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Final Impression

• Pack #00 ReCord

• Take final impression with light body PVS and heavy body PVS tray material

• Use a custom HeatWave Tray

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Mockup & prep-Minimally invasive

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Mockup & prep

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Mockup & prep

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Mockup & prep

Preparations

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Veneer Preparations

• Depth Cuts

• Tooth Reduction

• Margins

• Retention Form (Line of Draw)

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

Veneer Preparations

• Depth Cuts

• Tooth Reduction

• Margins



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Veneer Preparations

• Depth Cuts

• Tooth Reduction

• Margins



Veneer Preparations-Feldspathic Porcelain

Depth cuts of 0.2mm-0.8mm*

1.0mm-1.5mm incisal reduction*

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Veneer Preparations-Pressed Ceramics

Modern Ceramics

• Stand Alone Strength Properties

• Feldspathic (80-120 mpa)

• Lithium disilicates (360-500mpa)

• Lithium silicate (373 mpa)

• Zirconia (Monolithic 640-1200 mpa+)• Layered Zirconia Feldspathic (80-120mpa)

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Incisal edge preparations

a) No incisal lengthening

b) Changing color or wear

c) Lengthening tooth

Veneer Preparations


labial reduction options Depth Limiting Burs - Brasseler USA

Average enamel thickness

At CEJ .3-.4 mmMiddle third .8-1.0 mmIncisal third 1.1-1.3 mm

Veneer Preparations

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Preparation Reduction• Depth reduction burs

• Safe reduction

• Lasco

Veneer Preparations

Independent Depth Cuts (Lasco Burs)

▪ Depth Cuts▪ Tooth Reduction▪ Interproximal & Margins▪ Retention Form (Line of Draw)

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Burs• Organization

• Diamonds

• Carbides

◼ K0096 Finishing Kit $126.47 each

◼ K0095 Preparation Kit

$125.47 each

Preparation

Aesthetics

Function

Bonding to Enamel

Material Options

Minimal Prep Case: 2

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Minimal Prep Case:

Wax-up Case:

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Preparation Guides:

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• Photomed (818) 908-5369

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SHADE SELECTION

Shade Assumptions

BW, B1, B2, A1, A2

Provisional Techniques

-Free hand

-Beadline Provisionals

-Putty over impression of waxup

-Premade temps?

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Review-Chief Complaint

-Occlusion

-Photographs/Imaging?

-Whiten first

-Waxup/BeadLine Provisional

-Material Selection

-Practice Preps

-Photograph Prep Shade

EMOTIONFocus on overall appearance

Stay away from little details

“Going to look & feel great”

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Instant Ortho/Un-Rotating Teeth

• Do initial workup

• Diagnostic preps

• Diagnostic waxup


◼ Sequence

– Reduce all excess tooth structure

– Ideal reduction

– Margin placement

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Cementation**

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Selection Process

◦ Open Bite Trays

Plastic-full or quadrant

Metal-full or quadrant

Custom Trays

Non-perforated or perforated (metal or plastic)

Rigidity can eliminate tray distortion and rebound

Spring back after impression is possible with plastic

Cross arch stabilization

Ideal occlusal stops for proper model articulation

Able to recreate excursive movements if mounted on a

semi or fully adjustable articulator.

Potential for errors & adjustments are low

Impression Trays

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Custom trays create more

ideal placement

Thinner material creates

less distortion

USE TRAY ADHESIVES for

all open bite trays, not just

custom trays.

Only negative is time

Impression Trays Selection Process

Custom Tray

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▪ 4 upper & lower trays

▪ 60 sec. @ 158°F

▪ Fast, efficient

▪ Virtually custom

▪ 30% less impression

material used

Impression Trays

HeatWave by Clinician’s Choice

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Impression Trays


Impression Trays


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Dry all teeth in arch

Place tip in most difficult area first

Keep tip on margin and immersed in material

Go around entire margin first

Next go to adjacent teeth

Then do coronal aspect of teeth

Double Mix Single Impression is the most accurate

Syringe Placement

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Simplified Provisionals**

Siltech Putty Matrix

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

Duplicate waxup model in stone

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

model where the tissue and tooth come together.

Provisionals (Bead Line Technique)

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Duplicate model with a fast setting polyvinyl impression material.

I have used light and medium body washes with a heavy body tray

material.



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

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The Bead Line in the over impression creates pressure along the tissue

and preparation margin. This causes a thin cut or separation of the

acrylic flash from the provisionals for easier clean up.


Typically the excess acrylic can be removed with fingers, a spoon or discoid instrument. Minimal

to no effort is required to remove excess flash. If a void or a margin is exposed simply fill the

void with a flowable. Etching and a bonding agent are not required as the flowable will adhere to

the air inhibition layer of the temporary acrylic and you do not want to adhere to the tooth.


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The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth

structure. Typically the process takes 5-10 minutes to make provisionals. Consepsis (Ultradent)

can be placed on the teeth and dried prior to fabricating provisionals.


Provisionals

-Visalys (Kettenbach)*strongest* 201

-TempSmart (GC America)

-Inspire (Clinician’s Choice)

-ExperTemp (Ultradent)

-LuxaTemp (DMG)

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Cling 2 (Clinician’s Choice) for all my full crowns & bridges,

retentive inlays & onlays.

My Favorite Temporary Cements

ClearTemp LC (Ultradent)

For either veneers or thin

anterior cosmetic restorations

-Aesthetics

-Function

-Gingival Embrasures

-Excess cement

-Patient homework & questions

Post-Op Check

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

Case #4: Single Tooth Aesthetics

Veneers

Function

Gingival Bonding

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Remove old restorations & repair abfraction lesions on cervicals

• Stump Shade (dehydration factor)

Base Shade

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• Contact lens effect

• At or above gingiva

• Masking tooth or color changes

• At gingiva, then place cord and

reduce another 0.3-0.5 mm

Veneer & Crown Margin Placement

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Impressions

What Percent of Impressions per

Laboratories have visible

errors?

89%

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

impressions. J Prosthet Dent 2005; 94:112-117.

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

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

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▪ Superoxol

Epinephrine

Ferric Sulfate

ViscoStat 20%

Astringent 15.5%

▪ Aluminum Chloride

Viscostat Clear 25%

Expa-syl

Hemostasyl

▪ Aluminum Sulfate

Tissue Goo 25%

▪ Various Cords

Astringents Enhancing Moisture Control

Fluid/Tissue Management


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Lasers (Diodes) Fast

Hemostasis

No crevicular fluid

No cord

Better healing

Enhancing Moisture Control


Aesthetic Contouring

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Aesthetic Contouring

Time??

ROI??

Aesthetic Contouring & ExperTemp Provisional

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Laser Tissue Re-contouring

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Make cases easyIdentium for multiple teeth

Make cases easy, make your patients happy

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Make cases easy, make your patients happy

Facebow & Bite Registration(Occlusion this afternoon)

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Provisionals

Three Shades of Mosaic

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Three Shades of Mosaic

Free Hand Provisionals

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Free Hand Provisionals Example

• Materials

• Rigid Bite Registration

• Light and Heavy Body

Prefabricated Over Impression

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AESTHETIC RESIN TEMPORARY CEMENTS

• Materials

• Bifix Temp-VOCO

• TempBond Clear-Kerr

• ClearTemp LC-Ultradent

Before & After Photos

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Mixed Provisionals

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Waxup, Reduction Guides &

Temporaries (Case 6)

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Preparation Guides

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Preparation Guides

A-TYPE PREP304

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Removing provisionals that are locked on.

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Removing provisionals that are locked on.

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Nine Years Later

QUESTIONS?

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RESIN CEMENT COSMETIC CASES….

COSMETIC CASES….

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COSMETIC CASES….

COSMETIC CASES….

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COSMETIC CASES….

COSMETIC CASES….

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COSMETIC CASES….

COSMETIC CASES….

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COSMETIC CASES….

COSMETIC CASES….

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PROVISONALS

PROVISIONALS

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CERAMIC TRY-IN

• Make sure it is etched properly from lab

• Ceramic Primer prior to try-in (unless using Ceramir)

• Ultrasonic with ethanol after try-in

BONDS WITH OR WITHOUT HF

ACID ETCHING

THE “NO-WATER” SILANE w/ MDP

INSTANT ACTIVATION

LESS DEGRADATION

(More Stable 2 Year Shelf-Life)

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Silanes

Universal Adhesives (w/MDP)

Silane Primer + MDP

Organo-Phosphate Monomer (MDP)

Silane Primers

A disadvantage of many other silane products is that they are pre-

hydrolyzed.

Another disadvantage is some require the use of Hydrofluric Acid

etching and sometimes in addition to Micro-Etching. The new

Monobond Plus requires HF and Micro-Etching as well as 60 minute

activation time period.

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TRYIN APPROVAL

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3 VITA® shades

2 chromatic shades

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Veneer Finishing Systems

FREE SAMPLES https://www.contacez.com/eventsample

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FINAL RESTORATIONS

• More efficient than Halogens

• Halogen produces light from 370 to 800 nm then filters out all

but blue light in 400-500 nm range

• Longer lasting / Cordless / Batteries

• Faster curing (5 seconds)

• Smaller in size/lighter

• Less heat

BENEFITS OF LED LIGHTS

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VALO DELIVERS

Access to the curing site = Energy to the resin

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Machined from Aerospace Aluminum

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