todd snyder, dds, aaacd aesthetics &...
TRANSCRIPT
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Aesthetics & Occlusion
Todd Snyder, DDS, AAACD
Accredited, American Academy of Cosmetic Dentistry
Fellow, International Academy for Dental Facial Esthetics
Former Faculty, UCLA Center For Esthetic Dentistry
Faculty, Esthetic Professionals
CBDO, Contentactivator.com
CBDO, Blux.com
Todd Snyder, DDS,
AAACDLaguna Niguel, CA
Aesthetic Dental Designs®
Catapult Education is an organization which consists of top clinicians and
educators from throughout the United States and Canada. This group of like-
minded yet diverse dentist’s goal is to bring quality education to the dental
community via multiple venues including; live lecture, participation, web based,
and written formats.
DISCLAIMER
As a Catapult Education member we participate in multiple product
reviews each year in order to stay at the fore front of the latest materials,
techniques and services available, ensuring that the message we are
delivering is current and relevant to today’s continuing education needs.
Some of these products & services I will be sharing with you today.
Today I am supported in part by:
All the work shown is my own and unaltered
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Lecture Handout
www.DENTOOLZ.comDigital Handouts, Products I Use & Special Offers
Digital Handouts
Dental Examinations:
Aesthetics & Occlusion Pathology Driven Diagnostics
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Show patient’s teeth to create desire and start a conversation
about options and eventually financials WHITENING
Immediate Call to Action Motivator
Start Here
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Over-the-Counter Teeth
Whiteners: $1.4 billion
(MSNBC) ...
(Consumer Reports).
THE POWER OF A SMILE
THE CASE FOR DOING MORE
ELECTIVE COSMETIC DENTISTRY
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.
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Website
Social Media
Personal Case Books
Office Displays
Referral Cards
Gift Cards
Custom Smocks & Bleach Kits
Invest in technology.
-Office iPad
-Camera
-Lobby Television
-Software
Modern Tools**
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!
Overall Feel
Appearance…what is it? who decides, Dentist? Ceramist? Patient? Combined effort?
THEIR DECISION √
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Diagnosis & Treatment Planning
The Key to Success:
VisualizationWhat is the patient’s perception or desired outcome in their mind?
What do they want or envision?
Look at books or imaging together
Bring in examples of smiles
Everyone has an opinion & priorities
How WHITE?
Translucency?
What Texture?
Color Transitions
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Photographic Manipulation
• Cosmetic “Imaging” Software• SmileFy app• PreVue app• SmileVision• DentalGPS• DSD
• Digital Agents• Virtual Smiles• DreamSmiles
Why Does this Work?
•Creates awareness
•Suggests the possibility
•Promotes discussion
•Provides bridge to clinical evaluation and
presentation of options
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
• Our goal is to help them visualize themselves with an
improved smile
DREAMSmile Is a digital simulation of how your
patient’s smile can be transformed with
your expertise
Is a tool developed to help your team
engage, educate and convert patients to
improve their smile
Provides your office with an opportunity
to easily communicate with your patients
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When you hand a DREAMSmile 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...!
Technique Evolution
• Cosmetic Imaging
• Preparation• 0.5mm tooth reduction within enamel• Improved bonding agents allow deeper preps with more durable and longer lasting
bonding• Now >1mm preparations
• Provisionals• No provisionals• Free hand composite provisionals• Very accurate mockups to create provisionals• …or back to no provisionals
• Cosmetic appearance• Enhanced Ceramic Aesthetics and physical properties
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The Key to Success:
Traditional Veneers
Diagnosis & Treatment Planning
The Key to Success:
Traditional Veneers
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You are selling the Emotion…
Do you know the outcome…
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• There never seems to be enough of it…
• It has to be built into the schedule
• Take the time to practice and setup
• Know what the case is going to entail ahead of time
Time What Records & WhenDiagnostic & Prep Reduction Models (Do your own work)
• Practice Preparations
• Waxup
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
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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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Mockup & prep-Minimally invasive-
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Mockup & prep Mockup & prep
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Mockup & prep
Tooth Preparation Conservative Preparations
Tooth Preparation Determinants of Reduction Depth
• Additive vs subtractive restoration
• Choice of ceramic (feldspathic, leucite, lithium discilicate)
• Fabrication technique (monolithic vs layered)
• Number of shade changes (A4 to A1)
• Significance of brightness changes (C4 to A1)
• Is masking of the tooth required? (increase in restoration opacity)
• The desired translucency expected in the restoration
• Weakest ceramic restoration - feldspathic
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Tooth Preparation Most Conservative Preparations No preparation - Minimal prep veneeri n d i c a t i o n s
• Additive technique is desirable (required for no prep)
• Requires no undercuts in tooth morphology (required for no prep)
• Technician establishes restoration margin location
• Contact lens affect anticipated/desired
• 0-1 color/value shade changes expected
• Skill of technician
• Non uniform ceramic thickness - variable color/value
• Alteration after fabrication is not possible –
• Aging of tooth negatively impacts esthetics
• Weakest ceramic restoration - feldspathic
Tooth Preparation Most Conservative Preparations
No preparation -Minimal prep veneerl i m i t a t i o n s
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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
• Retention Form (Line of Draw)
Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”
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
Images from Bruce Crispin, DDS, MS book entitled “Contemporary
Restorative Dentistry”
Incisal edge preparations
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Preparation Reduction
• Depth reduction burs• Safe reduction
• Lasco
Depth Cuts
Tooth Reduction
Interproximal & Margins
Retention Form (Line of Draw)
Why extend interproximal and how far?
Independent Depth Cuts (Lasco Burs)
Preparation
Aesthetics
Function
Bonding to Enamel
Material Options
Minimal Prep Case: 2 Minimal Prep Case:
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Wax-up Case: Preparation Guides:
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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
Shade Assumptions
BW, B1, B2, A1, A2
Provisional Techniques
-Free hand
-Beadline Provisionals
-Putty over impression of waxup
-Premade temps?
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EMOTIONFocus on overall appearance
Stay away from little details
“Going to look & feel great”
AestheticsSmile Line
Gingival Excess & AsymmetryCombination Crowns &
VeneersGingival Crown LengtheningFunction
Case: 3Difficulties? Aesthetic
Combination Crowns & VeneersExisting RCT
Function
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Function
Centric du Jour (CRdJ)
Centric occlusion• Shimstock holds
Lateral excursives
Protrusive
Interferences
Wear facets
Prior to Second Appointment
Silginat - Kettenbach
Counter FIT- Multipurpose Replication Silicone
(Clinician’s Choice)
Counter FIT- Multipurpose Replication Silicone
(Clinician’s Choice)
Silginat - KettenbachWear Facets & Interferences
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Mounted and Equilibrated What Records & WhenDiagnostic & Prep Reduction Models
Diagnostic Guides Prior to Second Appointment
Diagnostic Guides Prior to Second Appointment
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Treatment Plan & Diagnosis
Aesthetics
Gingival Harmony
Function
Periodontal Surgery &
ProvisionalsFull coverage off of gingiva
8-12 weeks healing
Preparations & Provisionals2 crowns and 8 veneers
Preparation Guides
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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
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
HeatWave by Clinician’s Choice
Impression Trays
HeatWave by Clinician’s Choice
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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Facebow / Wax Bite
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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)
Duplicate model with a fast setting polyvinyl impression material.
I have used light and medium body washes with a heavy body tray
material.
Provisionals (Bead Line Technique) Provisionals (Bead Line Technique)
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.
Provisionals (Bead Line Technique)
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 (Bead Line Technique)
-Visalys (Kettenbach)
-TempSmart (GC America)
-Inspire (Clinician’s Choice)
-ExperTemp (Ultradent)
Provisionals
BPA Free
High Strength
Fluorescence
Low air inhibition layer
Easy trimming & polish
Visalys Temp - Kettenbach
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A dual-cured, bis-acrylic composite temporary crown
and bridge material using micro-filled resin (MFR)
and nano-filler technologies. It maintains a smooth
surface after polishing because of this revolutionary
combination. The high density polymer network for
TEMPSMART makes it a strong material ideal for
any sized provisional.
Fast setting
Low air inhibition layer
Nice Aesthetics
TempSmart – GC America
Cling 2 for all my full crowns & bridges, retentive inlays & onlays.
My Favorite Temporary Cements
ClearTemp LC (Ultradent)
TempBond Clear (Kerr)
For either veneers or thin
anterior cosmetic restorations
RestorationsCheck Shape & Esthetics
Check Shade
Marginal Integrity
Contacts
Etch
Check Shape & Esthetics
Occlusion
Function???
Restorations
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Try-in
Presilanate Restorations before tryin. Preferrably 5-20 minutes ahead of time.
Check each restoration individually for marginal adaptation
Start from center moving laterally
Then start at midline checking two teeth at a time. Then add the third and
check, then the fourth etc.
Then remove all of the restorations and fill each with a water soluble try-in
paste.
Start from center out as though you were cementing. Clean off excess and
access. Gently touch teeth together stop at first contact.
Now let patient check aesthetics after going over instructions
Cementation – large cases
Start from center moving laterally with light curable resin
Light cure material for cases over 4 teeth (2m tacking tip)
Placing two teeth at a time. Then add the third and tack in place, then the fourth etc
Then remove all of the residual cement except a small bead
Cementation Steps
Front two crowns first with dual cured resin or now Doxa Ceramir
Then 4 veneers at a time with a light cured resin.
-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: Aesthetics
Veneers
Function
Gingival Bonding
Remove old restorations & repair abfraction lesions on cervicals
• Stump Shade (dehydration factor)
Base Shade
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Impressions Facebow & Wax Bite Registration
Provisionals Free Hand Provisionals
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Free Hand Provisionals Example
• Materials
• Rigid Bite Registration
• Light and Heavy Body
Prefabricated Over Impression
AESTHETIC RESIN TEMPORARY CEMENTS
• Materials
• Bifix Temp-VOCO
• TempBond Clear-Kerr
• ClearTemp LC-Ultradent
• Provisional Veneer Removal
• Indirectly fabricated
• Spoon on gingival margin
• Cut vertically with small bur and use crown key to gently separate
• Directly fabricated
• Spoon on gingival margin
Veneer Try-In
The Art of Aesthetics & Occlusion
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VENEER EVALUATION
• Check models
• Uncut, pindexed and individual dies
• Check veneers internally and externally
• Try on the models
• Evaluate etch
• Silanate
• Water soluble clear try-in paste
• Evaluation of esthetics and contour
• Evaluate occlusion
VENEER TRY-IN
VENEER BONDING TECHNIQUES
• Etch or Self Etch?
• Antimicrobial
• Bonding Agent
• Light cure
• Time flexibility
• Color
• Dual cure?
• Color stability?
Place cement in center of
veneer
Make sure to see cement
come out on all margins
Wipe away gross excess?
Air inhibition?
Flossing?
Bulk excess
– Bard Parker
– TC Carvers (Brasseller)
– Gold knives
– Perio knives
Interproximal saws
Finishing strips
12 & 30 fluted carbides
Cement Removal
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Post-Op Photos
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INSTANT ORTHO/UN-ROTATING TEETH
• Do initial workup
• Diagnostic preps
• Diagnostic waxup
Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”
Sequence
– Reduce all excess tooth structure
– Ideal reduction
– Margin placement
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Case #5:Excessive Prep Interproximal
Reshape teeth
eMax
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Waxup, Reduction Guides &
Temporaries (Case 6)
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Preparation Guides Preparation Guides
A-TYPE PREP
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Removing provisionals that are locked on.
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What Percent of Impressions per
Laboratories have visible errors?
89%
1-Samet N, Shofat M, Livny A, Weiss EI. A clinical evaluation of fixed partial denture
impressions. J Prosthet Dent 2005; 94:112-117.
And the key to remember, routinely, it’s voids, bubbles, and tears
“Approximately 90% of impressions have defects” G. Christensen
Types of Moisture
Saliva
Crevicular Fluid
Bleeding
Enhancing Moisture Control
Fluid/Tissue Management
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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 Fluid/Tissue Management
Fluid/Tissue Management Fluid/Tissue Management
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Lasers (Diodes) Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
Fluid/Tissue ManagementFeatures
• Number #1 dental laser in the world• More power – 3 watts
• New easy to use presets• New treatment timers for perio treatment
• Wireless foot control• Optional battery pack• Perfect for first timers or hygienists
• Affordable• Disposable tips or fibers
• Certification included• MSRP: $4,495• CE Price: $3,495
Use code
CESNYDER16
Enhancing Moisture Control
Fluid/Tissue Management Enhancing Moisture Control
Fluid/Tissue Management
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Enhancing Moisture Control
Fluid/Tissue Management Enhancing Moisture Control
Fluid/Tissue Management
Enhancing Moisture Control
Fluid/Tissue Management Picasso Troughing
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Picasso GingivectomyAesthetic Contouring
Aesthetic Contouring
Time??
ROI??
Aesthetic Contouring & ExperTemp Provisional
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AMD Picasso Laser Tissue re-contouring
Panasil Initial Contact (VPS)
Kettenbach
Panasil Initial Contact
Lowest contact angle of any VPS
impression material
Fast set and Regular set
Kettenbach
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Cracked toothKettenbach
Panasil Initial ContactKettenbach
Panasil Initial ContactKettenbach Kettenbach
Identium(Vinylsiloxanether-VSXE)
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Kettenbach
Identium for single teethIdentium for multiple teeth
-two cord technique
Identium for multiple teeth Identium for multiple teeth
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Make cases easyIdentium for multiple teeth
Make cases easy, make your patients happy
Make cases easy, make your patients happy Mixed Treatment Case: 7
20 y.o. female patient presents with a missing lateral incisor, peg lateral, worn dentition.
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Modern Digital Technology
• Integration of CBCT & Intraoral Scan
• Create surgical guides
• Diagnostic waxups
• Custom healing abutments
• Custom impression analogs
• Custom implant abutments
• Finalized restorations
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Beadline Provisional technique with Teflon over implant
-Simplified technique
-Less materials
-Reduced overhead
-Faster implementation
Straumann Scan Bodies
-bone level
-tissue level
• Digital technology is making a better experience
• CareStream 3500 & 3600• No Mess
• Fast
• Accurate
• Instant Results
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Working Harder or Smarter?
• Digital Technology• Allows for faster procedure
• Higher accuracy
• Better consistency
• Easier on the patient
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Make cases easy You need the right tools to consistently have good results!
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• How many attempts?
• Hydrophobic
• Possible distortion
• Cord packing & bleeding
• Multiple pours?
• Models can break-backup?
Complex Positioning &
Gingival Tissues: #8Aesthetics
Tissue Problems
Poor Function
No TMJ Problems
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Incisal position
Gum height
2-4 mm
10-12 mm
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Instant Ortho/Un-Rotating Teeth
• Do initial workup
• Diagnostic preps
• Diagnostic waxup
Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”
Sequence
– Reduce all excess tooth structure
– Ideal reduction
– Margin placement
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Cementation**
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TMJ Signs & Symptoms
Wear facets
Pot holes
Abfractions
Gingival recession
Mobility
Occlusal & Incisal wear
Linea Alba
Tongue scalloping (Crenations)
Muscle hypertrophy
Muscle tension/tenderness
Muscle rigidity
Limited opening
Guarding on CR closure
TMJ noise
Head and Neck aches
Tooth sensitivity
Ear problems, ringing, buzzing, fullness
Occlusal & Incisal Wear
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Wear Facets Pot Holes
TMJ Signs & Symptoms
Wear facets
Pot holes
Abfractions
Gingival recession
Mobility
Occlusal & Incisal wear
Linea Alba
Tongue scalloping (Crenations)
Muscle hypertrophy
Muscle tension/tenderness
Muscle rigidity
Limited opening
Guarding on CR closure
TMJ noise
Head and Neck aches
Tooth sensitivity
Ear problems, ringing, buzzing, fullness
Gingival Recession &
Abfraction Lesions
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Flowables? Sometimes it presents as single teeth due to excursive interferences or as a
pivot, fulcrum or “teeter totter” tooth.
Other times there are more in a quadrant and there is severe wear to the occlusion.
Other times it maybe on the facials of anterior teeth, where there is wear on the incisal edges or wear facets on the linguals, however little to no wear on
posteriors.
Occlusal guards should be fabricated along with an occlusal analysis in CR on models.
Abfraction Lesions
Pathological loss of tooth structure caused by biomechanical loading forces.
Static and cyclic flexural overloading of tooth structure ultimately leading to
fatigue and failure of tooth structure away from the point of loading.
Abfraction LesionsLatin words, ab – “away”, fraction – “breaking”
Typical Composite BreakdownMicroleakage and missing fillings from high occlusal loads on teeth
can cause large cervical stress concentrations resulting in
disruption of the bonds between the hydroxyapatite crystals and the
eventual loss of cervical enamel and dentin.
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Resin Modified Glass Ionomer RestorationPost-Op Photo – notice unlike typical class V composite FUJI II LC
restorative material. Resin bonding is mostly due to the intertubular dentin.
Deep preparations have less intertubular dentin. More moisture present due to odontoblastic tissues and fluid Higher risk of post-op sensitivity
Use a New Advanced Adhesive and Flowable
Glass Ionomer (GI) True adhesion to tooth structure
Bonds to moist dentin Less technique sensitive Fluoride release
Decreased gap formation and cusp deformation Coefficient of thermal expansion is similar to dentin
No post operative sensitivity Use on dentin & cementum
Base out deep areas Place resin/composite on top of GI
Replacing Existing Restorations & Decay
Dentin Bond Strengths of Simplified Adhesives: Effect of Dentin Depth. Compendium June 2006, p.340-345
Using Cavity Liners with Direct Posterior Composite Restorations. Compendium June 2006, p.347-351
Resin Modified Glass Ionomer
Light cured
Dual cured
High flexural strength
Good polishability
Excellent wear
Hydrophillic
Fluoride release
No microleakage
No adhesives
Acid resistant layer
Reduces sensitivity
True chemical adhesion
Glass Ionomer Materials
Dentsply-none
SDI-Riva LC, light cure HV
G.C. America-Fuji II LC
VOCO-Ionolux
3M/ESPE-Ketac Nano, Photac Fil Quick
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Glass Ionomer Interface
Inte
rface
Ana
lysis (T
EM
)
CARDOSO et al. J Dent 2010
Glass Ionomer Sandwich
•Class I, II and V posterior restorations
•Open & Closed Sandwich techniques
•Composite replacement
•Amalgam replacement
•High caries risk patients
•Pediatric patients
•Geriatric patients
•Special needs patients
•Long term resistance to microleakage
Composite Leakage
Typical treatment involves the placement of a #00 retraction cord on each
tooth. Shade selection. Roughen tooth structure with air abrasion. Place cavity conditioner on all areas to be restored for 10 seconds, then wash and
dry. Teeth should be isolated from saliva.
Restorative Therapy- Case 1Mix Fuji II LC or RIVA Light Cure and syringe into place. Utilize hand instruments to
shape and remove gross excess. Cure each tooth for 20 seconds. Remove excess and contour using a handpiece with fine diamond burs.
Restorative Therapy- Case 1
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After contouring the restorations can be coated with a self etch
adhesive coating, and cure for 10 seconds.
Restorative Therapy- Case 1 Restorative Therapy- Case 1Eight year post-op photos show the integrity of the material is still excellent.
Note the lack of marginal microleakage stain often present with composite restorations.
Fig. 15 – Graph representing the mean annual failure ratesper adhesive class, determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998–2004 [2].
Van Meerbeek B, et al. Relationship between bond-strength tests and clinical outcomes. Dent Mater (2009), doi:10.1016/j.dental.2009.11.148
Typical treatment involves the placement of a #00 retraction
cord on each tooth followed by a shade selection. Roughen
tooth structure with air abrasion. Place cavity conditioner
on all areas to be restored for 10 seconds, then wash and dry.
Restorative Therapy- Case 2
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Mix RMGI and syringe into place. Utilize hand instruments to
shape and remove gross excess. Cure each tooth for 20
seconds. Remove excess and contour using a handpiece
with fine diamond burs. Teeth should be isolated from saliva.
Restorative Therapy- Case 2 After contouring the restorations can be coated with a self
etch adhesive coating, and cure for 10 seconds.
Restorative Therapy- Case 2
Eight year post-op photos show the integrity of the material is still excellent. Note
the lack of marginal microleakage stain often present with composite restorations.
Restorative Therapy- Case 2 Resin Modified Glass Ionomer
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Abfraction Lesion Treatments
• Restore defect to protect the exposed dentin and
strengthen cervical tooth structure with Glass Ionomer.
• Occlusal evaluation from Centric Relation to Centric
Occlusion, with possible occlusal adjustment.
• Lateral excursive interference evaluation, with possible
occlusal adjustment.
• Check Saliva pH levels for possible erosive problems.
• Night guard therapy.
• Open Sandwich with glass ionomer & GrandioSO
Conventional Glass
Ionomer Materials
Dentsply-ChemFil Rock Restorative
SDI- Riva SC, self cure HV
G.C. America- Equia Forte
VOCO-IonoStar Molar, IonoStar Plus
3M/ESPE- Ketac Molar Quick, Ketac Fil Plus
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EQUIA FORTE
EQUIA™ FORTE is a complete system that is an ideal solution for posterior restorations:
•Class I, II, III and V posterior restorations •Composite replacement •Amalgam replacement •High caries risk patients •Pediatric patients •Geriatric patients •Special needs patients •Buildups•Long term provisionals
How and when you diagnose this….
…determine how you prepare.
?How are you restoring
these different preparations
Basics- Posterior Direct Restorations
Starts off by marking occlusion & selecting color
Anesthetize
Preparation Caries indicator & Base
Materials? Mark occlusion again at end
with the same or a different color
What Is Your First Step??
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Red Blood Cells 2 – 5um
200-500nm
Human Hair 60 –120um
6,000 – 12,000nm
?
What do you use…..
.…and why?
Shimstock & Articulating Paper
Shimstock & Articulating Paper
Parkell Accufilm II is 21µm for
dentistry
BiteChek 19 microns
Great Lakes articulating ribbon 12µm
8µm Almore Shimstock foil
8µm articulating paper??
What do you use…..
.…and why?
8µm articulating paper
Available in blue
And red too!
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Jaw position and movement
Cases of simple fillings and how to do them and what can
throw off the bite
Anterior composite cases doing well
Posterior crown and bridge errors and how to avoid
Wear a night guard
Don’t equilibrate!!
Indirect Posterior Restorations
Steps to avoid occlusion problems.
1) Mark bite before starting
2) Accurate over impression
3) Bite registrations
- I like wax CENTRIC OCCLUSION DENTISTRYIndirect Restorations
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Centric Occlusion Dentistry
Shimstock-prior to prep
Preparation
Shimstock-checking bite
Wax bite (why?)
Shimstock-verifying wax bite is accurate
Impressions
Facebow
Provisionals
Shimstock-check provisional and bite
Pouring models
Mount maxillary model to articulator
Articulator settings
Mount opposing mandibularmodel
Equilibrate
Lab Fabrication
Check Case
Try-in Case
Deliver Case
Shimstock
Holds Means that when biting firmly in C.O. the shimstock can
not be pulled out
Drags Means there is resistance on the shimstock but it can
be pulled out slowly
No Hold There is no resistance what so ever when pulled
between occluding teeth.
Simplified Fixed Prosthodontics & Occlusion PDL & Bite Registrations
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The range of PDL width: 0.15mm ~ 0.38mm
• Average PDL width by age:
o 11 ~ 16 years old: 0.21mm
o 32 ~ 52 years old: 0.18mm
o 51 ~ 67 years old: 0.15mm
• The PDL width decreases with age.
• The PDL width is thinnest around the middle 1/3 of the root.
PDL & Bite Registrations1. The thickness of the periodontal ligament varies from 0.1 to 0.4 mm with a mean of around 0.2 mm.
2. The ligament is thicker in functioning than in non-functioning teeth, and in areas of tension than in areas of compression
(see table below):
Comparison of periodontal width of functioning and non-functioning teeth in an adult male
(Adapted from Kronfeld, R. , 1931)
_____________________________________________________________________
Premolar in heavy function Premolar in light function Molar out of function
Mean width of PDL at coronal
end of alveolus 0.35 mm 0.14 mm 0.10 mm
Mean width of PDL in middle
of alveolus 0.28 mm 0.10 mm 0.06 mm
Mean width of PDL at apical
end of alveolus 0.30 mm 0.12 mm 0.06 mm
______________________________________________________________________
3. The ligament cells are capable of remodeling the ligament and adjacent bone when functional forces are altered or the
ligament is damaged.
4. The periodontal ligament plays a key role in protecting the tooth from being resorbed by the normal remodelling process
that affects the adjacent alveolar bone.
5. Excessive forces can cause localized necrosis (cell death) of the ligament by cutting off the normal blood supply to the
cells. This situation immediately results in stoppage of remodeling at the affected site. Therefore, orthodontic tooth
movement is no longer possible. Repair occurs via emigration of cells from adjoining vital periodontal ligament. In the event
the ligament continuity is not restored, localized resorption and ankylosis may occur.
PDL & Bite Function
Simplified Fixed Prosthodontics & Occlusion
Verify bite Shimstock
Over impression
Preparation
Wax bite Dead soft Delar Wax
Firm, Hard Bite
Shimstock vs. articulating paper/ribbon
Facebow
Impression
Provisional
Lab Articulation
Bite Registration & Occlusal Indexing
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Simplified Fixed Prosthodontics & Occlusion Simplified Fixed Prosthodontics & Occlusion
Simplified Fixed Prosthodontics & Occlusion Simplified Fixed Prosthodontics & Occlusion
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Simplified Fixed Prosthodontics & Occlusion Check Occlusion and Provisional
Shimstock holds should be duplicated on teeth, wax bite
and provisional
Do not rely on articulating paper except for help in finding
high spots
Provisional must have contact occlusally and
interproximally
TRIOTRAY Triodent/Ultradent PEER REVIEWED
The Catapult Group rated the
Quad-Tray Xtreme as better
than, just as good, or tied with
other available closed bite
trays.
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Quad Tray Extreme (Clinician’s Choice)Bite Registration & Occlusal Indexing
Disposables
Non Adjustable
Semi Adjustable
Fully Adjustable
Articulators Disposable Articulators
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Semi Adjustable
not on Hinge Axis
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T scan tooth depression? On biting
Semi Adjustable
not on Hinge Axis BUILT IN ERRORS!Thickness??Rotation?? Rocking??
Function & Failures
• Closed Bite Trays (most common)
• Lack of rigidity may cause distortion
• Spring back after impression potential
• No cross arch stabilization
• Thin spots or perforations can cause distortion
• Impression material shrinks towards bulk
• Unable to recreate excursive movements
• Potential for errors & adjustments extremely high
Impression Trays
Function & Failures
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Function & FailuresWhich do you think is going to be more accurate?
Less adjustments and remakes?
Used for stable, accurate, Centric Occlusion, and excursive pathways.
Mounted and Equilibrated
• Patient’s Perceived & ACTUAL problems
• Aesthetics
• Smile
• Color
• Position
• Shape
• Function
• Jaw Position
• Bite
• Jaw opening
• Discomfort
• Myalgia
• TMD
• Joint Noise
• Headaches
• Psychological -Body Dismorphic Syndrome
• First step in any case no matter how big or small?
• Diagnosis of:
• How did the problem come to be?
• Occlusion (articulated models)
• Function (opening, excursives, bite pressure and contacts)
• Sleep Study
• TMJ (radigraphic interpretation)
• Periodontal Health / Bone Support (radiographs, probings)
• Mobility
• Mental Health
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Three Eccentric Movements
Protrusive
Working
Balancing
Three Eccentric Movements
Protrusive
Working
Three Eccentric Movements
Balancing
Three Eccentric Movements
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Right Lateral Movement Left Lateral Movement
Centric Occlusion: CO
The arrangement of the
upper teeth to lower teeth
that provides the maximum
intercuspation, irrespective
of the position of the joints
in the Glenoid Fossa.
Centric Relation: CR
Any arrangement of the
upper to lower teeth
when joints are in any
relationship seated in the
upper most and midmost
position in the Glenoid
Fossa.
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Centric Relation Occlusion: CRO
The arrangement of the upper to lower teeth
that provides the maximum intercuspation in CR.
Case #9: Checking CO, CR & Excursives
Customize Teeth
Checking Occlusion is the Key to Aesthetics
Interferences
What is the perceived problem & what is the true problem?
Can we find the true cause of the problem?
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Aesthetics
Occlusion
Excursives
Restorations
Wear
Solutions
What options are available to fix the problem?
Slow unperceivable changes
Diagnosing once it’s a problem
What about prior signs & symptoms
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Example-Centric Occlusion
Anteriorly positioned condyles
Occlusion is not ideal Appears to have canine guidance
Weak centric stops and limited number
Patient okay for a few months
Now has joint pain, noise, muscle pain, teeth are sensitive
Centric Relation
Joint in proper position
Occluding only on second molars
Restorative dentistry & orthodontics (aligners too)
TMJ SIGNS & SYMPTOMS
• Wear facets
• Pot holes
• Abfractions
• Gingival recession
• Mobility
• Occlusal & Incisal wear
• Linea Alba
• Tongue scalloping (Crenations)
Muscle hypertrophy
Muscle tension/tenderness
Muscle rigidity
Limited opening
Guarding on CR closure
TMJ noise
Head and Neck aches
Tooth sensitivity
Ear problems, ringing, buzzing, fullness
Round, Brachyfacial often
Limited smile appearance
Worn teeth or deep bite
Enlarged Masseters
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POSTERIOR INTERFERENCE (PREMATURITY)• Centric Occlusion
• Natural growth patterns
• Orthodontics
• Dental work
• Trauma
JOINT REPOSITIONED AND
STABILIZED (CRSTABILIZED)• Splint Therapy
What happens to a Condyle when there
is an Occlusal Prematurityon a 2nd molar?
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CHANGE!
• Larger amounts of tooth augmentation can create potential shifts in bite
pressure on teeth, CR-CO slides, and excursive interferences.
• Material properties must become more resilient to increased wear and
pressure demands.
• Higher risk of post operative complications due to occlusal modifications,
jaw positioning, and/or adhesive techniques and materials.
• A different approach to typical Restorative DentistryWhat did the patient’s teeth look like prior to veneers? Did she have any
symptoms? Braces? Dental work? Trauma? Etc…
Case Example: #10
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A Veneer Case? Not a veneer case!!
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HOW DO YOU TREATMENT PLAN FOR INDIRECT
RESTORATIONS??
Diagnostic model evaluations
ARTICULATED EQUILIBRATED MODELS• Shim Stock Holds (0.001 inch/8 microns)
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Occlusal TestingHoldDrag
No Hold (None)SHIMSTOCK
• Holds
• Means that when biting firmly in C.O. the shimstock can not be pulled out
• Drags
• Means there is resistance on the shimstock but it can be pulled out slowly
• No Hold
• There is no resistance what so ever when pulled between occluding teeth.
Normal Disc Reducing Non-ReducingNormal
Remodeling DJDRemodeling
Adolescent
Facial GrowthDecreasedInterruptedNormal
Bones
Disc
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Case Example: #11 Aesthetics
Trauma
Anterior Guidance
Special Protrusive Bite
Instant
Composite
Mockup
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Fully Adjustable on Hinge Axis
LABORATORY WORK
Example
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REMOVE ALL POSITIVES FROM CASTS 20 20
10-20SAM III-SEMI ADJUSTABLE ARTICULATOR
TRANSFER FORK ASSEMBLY WITH UNTRIMMED
BITE FORK TRIMMED BITE FORK
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PROPER SUPPORT AND MOUNTING MOUNTING THE OPPOSING MODEL
START CHECKING BITE & EQUILIBRATE
EQUILIBRATING MODELS
Technique Overview
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Paint opposing cast
Occlude Spray by Paskall
• Close articulator without pressure
• Check teeth that hold shimstock
• Trim teeth that are hitting to heavy
• Trim heavy red marks off
• Check with shimstock again until all teeth hold
• Check from back to front
VERIFY ALL HOLDS WITH SHIMSTOCK
VERIFY ALL HOLDS WITH SHIMSTOCK VERIFY ALL HOLDS WITH SHIMSTOCK
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• If you have a contact and then you loose it you can not always
get it back. It is okay.
• Tell the lab the teeth that hold shimstock because it may be
different than in the mouth.
VERIFY ALL HOLDS WITH SHIMSTOCK
CHECKING LAB CASES
Technique Overview
RETURNED LAB CASE CHECK LIST• Check articulator
• Number
• Parts
• Settings
• Angle of eminence
• Bennet angle
• Pin height
• Split cast/check mount
• Check margins
• Check interproximal contacts
• Check occlusion with shimstock
• Without restoration(s)
• With restoration(s)
OCCLUSION CHECK
Check Shimstock holds Without restoration(s)
Check Shimstock holds With restoration(s)
Check restoration last
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ADJUSTMENTS
• Spray opposing
• Close articulator
• No heavy pressure
• Fine diamonds
• Verify shimstock
holds
• Continue adjusting
until holds are all
present.
• Restoration should
hold as well as teeth.
EQUILIBRATION
Multiple teeth and opposing restorations
EQUILIBRATION
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Questions??
All-Ceramic Crowns565-1200+MPa
Multi-Layered
Zirconia
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Restoration Placement?
Bonded Margin placement
Moisture Control
Technique Sensitive
Materials
Self Adhesives
Bonding agent (TE or SE) & luting resin
Cemented
Margin placement
Moisture Tolerant
Retention Required
Materials
RMGI
Ceramir
Cement Selection
Case #11:
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Alkaline pH 8.5
Moisture Tolerant
Self Sealing
Apatite Formation
Insoluble/No Degredation
Stronger with time
Semi / Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation
No silane, conditioning, bonding
Ceramir® Crown & Bridge**
Cement Selection
Bioactivity by Doxa
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH.**
Cement Selection
Cementation TechniqueCement Selection
Mix for secondsmL
3-4 restorations
Cementation TechniqueCement Selection
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Final Restorations
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RESIN CEMENT COSMETIC CASES…. COSMETIC CASES….
COSMETIC CASES…. COSMETIC CASES….
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COSMETIC CASES…. COSMETIC CASES….
COSMETIC CASES…. COSMETIC CASES….
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COSMETIC CASES…. COSMETIC CASES….
PROVISONALS PROVISIONALS
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BONDS WITH OR WITHOUT HF
ACID ETCHING
THE “NO-WATER” SILANE
INSTANT ACTIVATION
LESS DEGRADATION
(More Stable 2 Year Shelf-Life)
PRE-TREAT VENEERS
• Unidose Silane (Sultan Dental)
• Place under heat for a few minutes
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3 VITA® shades2 chromatic shades
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G-CEM LINKFORCE (GC AMERICA)
• BPA free
• MDP chemistry in bonding agent & primer
• Tryin pastes
• Etchant
• G-Premio BOND™ - Bonding to ALL Preparations
• G-Multi Primer™ - Primer for ALL Restorations
• G-CEM LinkForce™ - Strength in ALL Indications
• Color stability over time
• Tooth–like fluorescence
• Four shades to match all needs
FINAL RESTORATIONS
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ZIRCONIA TRY-IN QUESTIONS???• The lab should have sandblasted the restoration at 30-50psi w/ 50 micron
aluminum oxide.
• After try-in:
• Ivoclean and silanate?
• Ultrasonic with ethanol after try-in or steam clean then silanate?
• Sand blast then ultrasonic and ethanol?
• Zirconia silanate prior to try-in
(Ultrasonic with ethanol after try-in)
Sandblast after try-in and use a MDP based cement
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.
QUESTIONS?
Aesthetics
Preparation Design
Function
Strength
Bonded Adhesion
Lithium Disilicate
Bonded Adhesion
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Bonded Adhesion Bonded Adhesion
What substrate are we treating?
3x Tubule Density Equals Higher Fluid &
Increased Difficulty for Bonding
%30 Decrease in Bond Strengths with most
bonding systems.
CEMENTATION MATERIAL OPTIONS
Cement Selection
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TRADITIONAL
CEMENTATION OPTIONS
Glass Ionomers
Resin Modified Glass Ionomers
• Acidic pH
• Moisture Tolerant
• Fluoride Release
• Degrades over time
• Low bond strength
• Biocompatibility-Fair
• Bioactivity-None
• Sealing Quality-Ok
• Acidic pH
• Insoluble
• Moisture Tolerant
• Fluoride Release
• Stronger Than Traditional GIs
• Degrades over time
• Improved bond strength
• Biocompatibility Ok
• Bioactivity-None
• Sealing Quality-Ok
• Silanate Restorations
Cement Selection
Cementation Cementation
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RESIN MODIFIED GLASS IONOMER CEMENTS• Use Ceramic Primer prior to try-in
• Clean with ethanol after try-in
• Keep tooth slightly moist and place RMGI cement as it will
chemically cure to the tooth and the Ceramic Primer
• Still want to always have good prep design
RESIN MODIFIED GLASS IONOMER CEMENT AND A CERAMIC
PRIMER
• Lab sandblasts @ 30psi w/ 50 micron aluminum-oxide particles
• Ceramic Primer II (MDP) prior to tryin (5 min & heat)
• Ultrasonic clean with ethanol
• Place FujiCEM2 RMGI cement in restoration
Features
• Number #1 dental laser in the world
• More power – 3 watts• New easy to use presets• New treatment timers for perio treatment
• Wireless foot control• Optional battery pack
• Perfect for first timers or hygienists• Affordable• Disposable tips or fibers
• Certification included• MSRP: $4,495
• CE Price: $3,495
Use code
CESNYDER16
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• Feldspathic
• Leucite
• Lithium Disilicate
• Lithium Silicate
• Zirconia
FUJICEM2 SL• Resin Modified Glass
Ionomer Cement
• Disposable Tips
• Slide & Lock technology
• Moisture Tolerant
• Biocompatible
• Hypermineralized Dentin
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BOND DEGREDATION
• Pashley DH, Tay FR, Imazato S. How to increase the durability of resin-dentin
bonds. Compend Contin Educ Dent. 2011 Sep;32(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.
Cement Selection 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 layersproblem may be moresevere than we realize
Class I or II
:Tooth Preparation
3x Tubule Density Equals Higher Fluid &
Increased Difficulty for Bonding 30% Decrease in
Bond Strengths with most bonding systems.**
What substrate are we treating?
Cement Selection
Self-Adhesive Resin Cements
No Primer or Bond? Gel State?
No Primer or Bond
Durability & Wettability ???? Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less:• Wettability
•Which Results in Less Contact to the Tooth
•Which May Result in a Less Durable Bond
•Convenience
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SELF ETCH RESIN CEMENTS G-CEM LINKACE
• Dual Cure
• MDP based cement
ZIRCONIA CERAMIC CONDITIONING FAST, SELF ETCH, ALL IN ONE, SELF CURE/DUAL CURE RESIN
• 24 hour shear bond strength for these products
typically is between 4mpa-15ma
• Why not use a product with either better sealing
capabilities and benefit to the patient’s health
• Use a stronger material that has better strength
characteristics.
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• Alkaline pH 8.5
• Moisture Tolerant
• Self Sealing
• Apatite Formation
• Insoluble/No Degredation
• Stronger with time
• Semi / Translucent
• Biocompatibility-Excellent
• Bioactivity-Apatite formation
• No silane, conditioning, bonding
CERAMIR ® CROWN & BRIDGE**
Cement Selection
Bioactivity by Doxa
A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline
pH.**
Cement Selection
CEMENTATION TECHNIQUE
Cement Selection
Mix for 8-10 seconds3-4 restorations
CEMENTATION TECHNIQUE
Cement Selection
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What do you use?
Zirconia Ceramic Conditioning MDP-containing material bonds to Zirconia
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REMEMBER:
FUNCTIONAL LIMITATIONS
The Art of Aesthetics & Occlusion
FUNCTIONAL LIMITATIONS
• Excursive Interferences
• Group function
The Art of Aesthetics & Occlusion
• Malpositioned teeth
• Occlusal interferences
• Canine guidance
• Group function
Functional Limitations
The Art of Aesthetics & Occlusion
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Functional Limitations
The Art of Aesthetics & Occlusion
Functional Limitations
The Art of Aesthetics & Occlusion
• Check excursives
• Protrusive
• Night Guard
Functional Limitations
The Art of Aesthetics & Occlusion
Functional Limitations
The Art of Aesthetics & Occlusion
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QUESTIONS
?
The Art of Aesthetics & Occlusion
Hard acrylic whose occlusal surfaces can be easily modified.
Stable fit with no rocking movements from side to side, or anterior to posterior.
Covers all the teeth in a maxillary arch.
My Criteria for a Successful Splint
Shallow Anterior guidance in all excursive movements.
Simultaneous posterior occlusal contacts in light centric closure, and no slide in hard squeeze
The Art of Aesthetics & Occlusion
My Criteria for Successful Splint
Shim stock clearance of anterior contacts in centric closure.
Immediate posterior disclusion by canine in working and balancing movements.
Guidance by maxillary centrals and laterals in protrusive movement.
Flat posterior occlusal surfaces offering eccentric movements without interferences.
Highly polished appliance that is comfortable.
The Art of Aesthetics & Occlusion
Criteria for a Successful Splint
VS VS
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Indications for Splint
Mobile teeth and /or bone loss
Protection of Cosmetic Porcelain Restorations
Symptomatic relief of acute joint pain and muscle tenderness
Nocturnal Bruxing and Clenching
Diagnostic tool for restorative dentistry.
The Art of Aesthetics & Occlusion
Occlusal Guard
• Simultaneous posterior contacts,
light contact on anterior teeth
• Shimstock drags
• Canine excursive
• Protrusive on incisors only
Occlusal Guard
• Hard Acrylic ONLY relined in mouth.
• Soft acrylic creates more interferences and does not keep the TMJ stable
• Hard/Soft allows teeth to shift slightly and does not keep the TMJ stable
• NTI should only be used short term 2-4 weeks
Occlusal Guard
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OCCLUSIONMyths, Mystical Potions,
and Black Magic
The Art of Aesthetics & Occlusion
There is not one key to success….
There are many and they all open different doors
CANINE GUIDANCE MYTHS
• Steep canine guidance eliminates posterior interferences?
• Canine guidance can be steepened without ramifications?
• Incisal edges can be restored with composite to obtain guidance?
• Increasing canine guidance and doing posterior occlusal equilibrations will eliminate interferences and TMJ problems?
MYSTICAL POTIONS
• TMJ injections
• Botulinum Toxins
• Trigger point injections
• Steroids
• Anesthetics
• Saline
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OCCLUSAL GUARD BLACK MAGIC
• Soft splints
• Hard/Soft splints
• Half arch stabilization appliances
• NTI? Best Bite?
EXAMPLE-CENTRIC OCCLUSION
• Anteriorly positioned condyles
• Occlusion is not ideal
• Appears to have canine guidance
• Weak centric stops and limited number
• Patient okay for a few months
• Now has joint pain, noise, muscle pain, teeth are sensitive
CENTRIC RELATIONAesthetic Opportunities:
Developing Beautiful Smiles
Case #24 (Complex Occlusion)
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Developing Beautiful Smiles
Assessment:Joint NoiseFacial Muscle PainPoor OcclusionInvisalign Done/RetentionAnterior WearWants to Keep Appearance
Cause & Effect Diagnosis• Functional Wear on Anteriors
• Masticatory Muscle Pain
• Headaches
• Jaw Relationship / TMJ Disorder
• Obstructive Sleep Apnea (OSA)
• Combination
Aesthetics & Occlusion
Supplemental Tests:Sleep StudyCone Beam CT (CBCT)Airway Evaluation
AIRWAY VOLUME
-50mm2 and below have an association with OSA
Aesthetics & Occlusion
TMJ EVAL/Diagnosis
CBCT-Pathology-Jaw position-Bone Appearance-Active DJD/Remodeling
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Aesthetics & Occlusion Aesthetics & Occlusion
Orthotic: Superior Repositioning Appliance (SRA)
Nociceptive Trigeminal Inhibition Tension Suppression System (NTI-tss)
Jaw Position
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NTI type appliances
Jaw PositionNITE BITE
• 5 minutes to make a Nite Bite appliance for relief of most TMJ discomfort
SRA FABRICATION:Try-in
Check Bite
Adjust Posterior
Shallow Ramp
Trim Trough
Occlusal Reline
Passive Centric & Hold
Mark Depth of Fossa
Trim Excess
Polish
Aesthetics & Occlusion Aesthetics & Occlusion
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Aesthetics & Occlusion Aesthetics & Occlusion
• Patient wears just at night the first 2-5 days
• Understands they will wear 24/7
• Patient comes back for evaluation every 2-4 weeks
• Passive reline to achieve equal contacts
• Once the bite is stable follow for another 2-4 weeks
Aesthetics & Occlusion
Orthotic: Superior Repositioning Appliance (SRA)
Aesthetics & Occlusion
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Aesthetics & Occlusion Aesthetics & Occlusion
Occlusal Analysis
Aesthetics & Occlusion Aesthetics & Occlusion
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Aesthetics & Occlusion Aesthetics & Occlusion
Aesthetics & Occlusion Impression Trays
HEATWAVE BY CLINICIAN’S CHOICE
Aesthetics & Occlusion
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The Nuts & Bolts of VeneersAesthetics & Occlusion
TISSUE AND MOISTURE CONTROL
Aesthetics & Occlusion
A laser is more precise, causes less pain, and
prevents bleeding better than traditional tools used
on soft tissues. The highly focused laser light
cauterizes nerve endings, coagulates blood
vessels, sterilizes the surgical site, and increases
the speed of healing. Instantly cauterizing nerve
endings greatly reduces pain during the procedure
and after. Healing times can be as low as a few
days where traditional surgical approaches can take
several weeks.
• 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
Aesthetics & Occlusion
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Simplified Provisionals
Aesthetics & Occlusion
Provisionals (Duplicate models)
Scribe a 0.5-1mm line with a sharp instrument into the
model where the tissue and tooth come together.
Bead Line Veneer Provisional Restorations. Pract Proced Aesthet Dent 2009;21(3):E1-E7.
Aesthetics & Occlusion
Duplicate model with light body wash and heavy body tray material.
Aesthetics & Occlusion
Provisionals (Duplicate models)Aesthetics & Occlusion
• Verify shape
• Display at rest
• Protrusive
• Excursives
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CEMENTATION OPTIONS• Glass Ionomers
• Resin Modified Glass Ionomers
• Self Etch Resin Cements
• Bonding Agent w/ Resin Cement
• Calcium Aluminate
• TriSilicate Cement
Aesthetics & Occlusion
CERAMIR (CALCIUM ALUMINATE CEMENT BY - DOXA)• Alkaline pH 8.5
• Moisture Tolerant
• Self Sealing
• Apatite Formation
• Insoluble
• Stronger with time
• Semi / Translucent
• Biocompatibility-Excellent
• Bioactivity-Apatite formation
• Sealing Quality-Excellent
Aesthetics & Occlusion
Aesthetics & Occlusion Aesthetics & Occlusion
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Aesthetics & Occlusion Aesthetics & Occlusion
Aesthetics & Occlusion Aesthetics & Occlusion
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Pre-op
Post-op
Aesthetics & Occlusion
Questions?
Aesthetics & Occlusion
These are becoming the norm
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Online Real Data
THE POWEROF
ACTIONABLE METRICS
.
TWO WAYS TO INCREASE PRODUCTION
Visits
TWO WAYS TO INCREASE PRODUCTION
PRODUCTION on Visits
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New Patients
NEW PATIENTS
HOW MUCH DO WE REALLY LOVE THEM?
RECAPTURED
PATIENTS
47 $65,114
617
Before AfterHygiene Re-Appointment
$167,400 increase through Actionable Metrics
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Hygiene Re-Appointment PROVIDER-LEVEL PERFORMANCE
Slipping Through The Cracks Delivering Best Dentistry
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ACTIONABLE MONITORING DRIVES
GROWTH
37% Increase in Production
COLLECTING WHAT YOU PRODUCE
623
THE POWER OF ACTIONABLE METRICS
624Are you measuring?.
625For Your Practice Snapshot Go To: www.practicesnapshot.com
and use special code: Todd2017
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SOFTWARE & TECHNOLOGYBetter Business
The Future of Dentistry
• Two years in a row dentist best health care job.
• Predicted employment growth of 16% with more than 23,000 new openings over the next 10 years.
• Dental insurance companies are systematically decreasing reimbursements
CORPORATE DENTISTRY
• Is growing 15-20% annually
• They compete for the same patient demographics as the solo practitioner.
• Discretionary income has shrunk for every segment of American society except the top 10%.
• Patient perception of dentists are changing based on work Performed, Marketing Seen and Fees offered.
• Run at lower overheads and have leveraged purchasing power.
Working Harder or Smarter?
• Look at your team• Is everyone trained to offer the same
care and service repeatedly
• Protocols • Repetition and consistency• Scripts• Daily Procedures
• Accountability• Tracking & Monitoring Tasks• Business Phones
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Remember The Old Appointment Book?How LONG Did It Take To Answer A Question About Balances, Forgotten
Appointments?
• Integrates with existing dental practice management software (DPMS)
• Dentrix• Dentrix Ascend Cloud Based coming soon…• Eagle Soft• Easy Dental• SoftDent• Practice Works• Mac Practice• Open Dental
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TEAMWORK
• Both software offer low impact on the team but create huge opportunities
• Easy to implement with minimal time to use.
• Improve business opportunities dramatically
• Cuts down on current employee time by streamlining many tasks
• Saves money on traditional procedures
• Less postage
• Less paper goods
• Less employee time
• A recent study reported 88% of people trust online reviews
• 2011 33% reported they did not trust online reviews. In 2014 it was at 13%
• 92% or internet users read product reviews
• 89% said it influences their purchases
• 74% of internet users said they would most likely not do business if there was a negative review
ONLINE REVIEWS
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ONLINE REVIEWS
• You must actively ask for reviews
• Create opportunities easily and in expensively
• A dissatisfied person will tell dozens whereas a satisfied patient will tell only a few, so get them to share….. But make it easy to do!
WEAVE REVIEWS VIA CELL PHONE MESSAGE
WEAVE REVIEWS VIA CELL PHONE MESSAGE WEAVE REVIEWS VIA CELL PHONE MESSAGE
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• Goal of 100 Reviews in 6 months
• Staff incentive
• Select Ratings to be sent to:
• Yelp
• Customize Order of Review Sites
WEAVE REVIEWS VIA CELL PHONE MESSAGE
Weave Mobile App
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What Is In Our Future?• Softphone• ˈsäftˌfōn/• noun• plural noun: soft-phones• a piece of software that
allows the user to make telephone calls over the Internet via a computer.
VOIP Software Mobility
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Windows, Android, and iPhone
Todd C. Snyder, DDS, AAACD
(949) 643-6733doc@ tcsdental.comwww.aestheticdentaldesigns.comwww.drtoddsnyder.com
www.facebook.com/todd.snyder.ddswww.twitter.com/tcsaestheticsInstagram: toddsnyder1