Treatment Planning, Designing and Delivering Complex and ... · 3/23/2018 · Treatment Planning,...

Marc Geissberger D.D.S., M.A., B.S., C.P.T.,F.N.S.Adjunct Clinical Professor

Department of Preventive andRestorative Dentistry

Marindentist

Marc Geissberger DDS

Treatment Planning, Designing and Delivering Complex and Multidisciplinary Cases

Delaware State Dental Society 2018 Continuing Education Series

March 23, 2018

Monday, March 19, 18

About Me:

Educator - Teach at UOP since graduation in 1991 - Full-Time Until 2018, Adjunct Clinical Professor beginning February 2018Private Practice - Marin County, Ca. since 1991 with Father and Brother.

Product Evaluator - Working with industry to test new products, materials, technologies and deliveries.Speaker / KOL - Member of “CATAPULT EDUCATION” speakers bureau.Family...

Thanks and Disclosures

Catapult Group 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 Group 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 we will be sharing with you today.

• Today we are supported in part by:• Voco Clinician’s Choice• Doxa Weave• AMD Orascoptic• Microcopy GC•

The Catapult/Personal Client Base

AG Nuevo

Air Techniques

Anutra-Medical

Denmat

Dentsply

Dentist Select

GC Amercia

Financially Fit

Heraus Kulzer

KavoKerrGroup

Kettenbach

Lending Tree

Microcopy

Perio-Protect

Premier

Proctor and Gamble

Pulp Dent

Solution Reach

Springstone Financial

SS White

Sybron

Triodent

Milestone Scientific

AMD Lasers

Garrison 3M

Ultradent

AdDent

Orascoptic

Clinician’s Choice

OverridingPrinciples

Considerations

Macro Issues1) Teeth in proportion to face2) Teeth in proportion to lips3) Teeth in relationship to tissue (gingiva)Micro Issues1) Teeth in relationship to tissue 2) Teeth in relationship to each other3) General proportion of teeth

Symmetry?Golden Percentage?

* Synonymous with unity

* Subtle diversity is needed because excessive regularity it monotonous

As Dentists We Focus on Teeth

Tree and Forest

Most Important Lesson to Learn in Focusing on The Frame of

Reference(s)

Face Lips Gingiva

New Technique - Kois Analyser

Frame of Reference

1) Face2) Lips3) Gingiva

Range of Lips is Huge

Lip RepositioningSurgery

1) Becoming a more common procedurelinked to esthetic enhancement

2) Not completely predictable

Research on SymmetryZaidel D, Aarde S, Baig K, Appearance of Symmetry, Beauty, and Health in Human Faces. Brain and Cognition, 57 (2005) 261-263

Pallett P, Link S, Lee K, New Golden Ratios for Facial Beauty. Vision Research , Nov. 2009,1878-5646

Symmetry

Frame of Reference Lip Line

Average Tooth Display 1.91mm Males 3.40mm Females 3.65mm Short Upper Lip 0.59mm Long Upper Lip 3.37mm Under 29 Years 1.26mm 30 to 50 years

Frame of ReferencePhonetic References

F and V sounds

S sound

incisal display atrest

lingual tilt of themaxillary central

incisors

vertical dimensionof speech

M sounds

Frame of ReferenceAxial Alignment

22mm Rule

Snow (1999) suggests Golden Percentages

Idealism and Proportion Golden Percentages

10 15 25 25 15 10

Frame of Reference Vertical/Horizontal Reference

1) Midline of the face2) Philtrum 3) Bridge of the nose

Symmetry and Natural Variation

Dental Midline: Coincided with facial midline in 70% of the population

Kokich , V. Klyak, A. Shapiro, P.

Comparing the Perception of Dentists and Lay People to Altered Dental Esthetics.

(J Esthet Dent. 11:311-324, 1999) Monday, March 19, 18

Our PatientClinical Condition: I don’t like the space between my front teeth. Patient refuses orthodontic treatment.

Treatment Plan: ?

Rationale: ?

Chief Concern: I don’t like the space between my front teeth. Patient refuses orthodontic treatment.

What would you do?

1) Refer her to an orthodontist anyway2) Diastema closure with composite resin or veneers3) Consultation with laboratory to evaluate the possibilities 4) Refer her to another practitioner5) Other

Spacing Issues

1) Determine etiology2) Plan how to distribute space without the sacrifice of width to length proportion of individual teeth

Spacing Issues

3) Don’t create wide, short teeth unnecessarily

Diode (Soft Tissue) Laser

A"so%"&ssue"laser"incision"at"1000x"

Laser&cut

Superficial"coagula&on

Heat"dissipa&on"with"li;le/no"edema

!Features

• Number"#1"dental"laser"in"the"world

• More"power"–"3"wa;s• New"easy"to"use"presets• New"treatment"&mers"for"

perio"treatment• Wireless"foot"control• Op&onal"ba;ery"pack• Perfect"for"first"&mers"or"

hygienists• Affordable• Disposable"&ps"or"fibers• Cer&fica&on"included• MSRP:"$4,495• CE"Price:"$3,495

Ceramics

All-Ceramic SystemsGlass Ceramics Alumina-based Zirconia-basedResin-based (new)

All-Ceramic SystemsGlass Ceramics Lithium-disilicate

IPS e.max Press (Ivoclar Vivadent) IPS e.max CAD (Ivoclar Vivadent) IPS Empress 2 (Ivoclar Vivadent)

Leucite IPS Empress (Ivoclar Vivadent) IPS ProCAD (Ivoclar Vivadent)

Feldspathic VITABLOCS Mark II (VITA Zahnfabrik) VITA TriLuxe Bloc (VITA Zahnfabrik) VITABLOCS Esthetic (VITA Zahnfabrik)

All-Ceramic SystemsAlumina-based

Aluminium-oxide In-Ceram Alumina (VITA Zahnfabrik) In-Ceram Spinell (VITA Zahnfabrik) Procera (Nobel Biocare)

All-Ceramic Systems

Zirconia-based

Yttrium tetragonal zirconia polycrystals (ZrO2 stabilized by Y2O3) Lava (3M ESPE) Cercon (Dentsply - -Ceramco ) DC-Zirkon (DCS Dental ) Denzir (Decim) Procera (Nobel Biocare)

All-Ceramic SystemsResin-basedADA’s Council on Dental Benefit Programs Broadens the Definition of Porcelain/ceramics in the CDT Code

(June 13, 2012) The American Dental Association (ADA) will broaden its definition of porcelain/ceramic materials in its CDT Code classification of materials. This classification is solely to aid selection of the appropriate procedure code to achieve uniformity,consistency and specificity in accurately reporting dental treatment. This change also affects insurance claims submission, allowing 3M™ ESPE™ Lava™ Ultimate Restorative to be classified as a porcelain/ceramic. 80 percent nanoceramic particles embedded in a highly-cured resin matrix.

The Evolution of Indirect MaterialsCast Metal Feldspathic Porcelains Fused to Metal Aluminous PorcelainsThermoplastic Aluminous Porcelain Cerestore

Cast Microcrystaline GlassLeucite Crystalized FeldspathicSlip Cast Alumina with Glass InfiltrationHeat Pressed Lucite Ceramic Glass

DicorFortuneIn Ceram, Procera IPS Empress, OPC

Lithium Disilicate/Fluorapatite Glass Ceramic with dilithium oxide crystals IPS Eris

Milled (Machined) Alumina Based Crowns

Milled (Machined) Zirconium Based Crowns - Stacked

Procera

Cercon, Lava...............

Conventional Jacket Crowns, Viradur

Slip Cast Spinel In Ceram SpinelSlip Cast Zirconia In Ceram ZirconiaHeat Pressed Lithium Disilicate Empress II,

Glazed Magnesia Core Magcor

Milled (Machined) Leucite Based Crowns Pro-Cad

Milled (Machined) Zirconium Based Crowns - Monolithic Cercon, Lava...............

Flexural StrengthFlexural strength, also known as modulus of rupture, or bend strength, or transverse rupture strength is a material property, defined as the stress in a material just before it yields in a flexure test. The transverse bending test is most frequently employed, in which a specimen having either a circular or rectangular cross-section is bent until fracture or yielding using a three point flexural test technique. The flexural strength represents the highest stress experienced within the

Fracture Toughness

Fracture toughness is a property which describes the ability of a material containing fracture, and is one of the most important properties of any material for many design applications. The linear-elastic fracture toughness of a material is determined from the stress intensity factor (K) at which a thin crack in the material begins to grow.

Zhenzhen Zhang, Yuanping Yi , Xuesong Wang, Jiawen Guo, Ding Li, Lin He, Shaofeng Zhang A comparative study of progressive wear of four dental monolithic, veneered glass-ceramics. Journal of the Mechanical Behavior of Biomedical Materials, Volume 74, October 2017, Pages 111-117

lithium disilicate glass-ceramic

leucite reinforced glass-ceramic

feldspathic glass-ceramic

fluorapatite glass-ceramic

FractureToughnessHigh to Low

FlexuralStrength

High to Low

Wear of Opposing

High to Low

Wear of Various Dental Ceramics

lithium disilicate glass-ceramic (Adjusted)

Wear Rate on Enamel

Low to High4

Nathaniel C. Lawson , Sridhar Janyavula , Sarah Syklawer , Edward A. McLaren , John O. Burgess. Wear of enamel opposing zirconia and lithium disilicate after adjustment, polishing and glazing. journal of dentistry 42 (2014) 1586–1591

lithium disilicate glass-ceramic (Adjusted/Polished)

lithium disilicate glass-ceramic (Adjusted/Glazed)

zirconia (Adjusted)

zirconia (Adjusted/Polished)

zirconia (Adjusted/Glazed)

RelativeValue in mm3

Veneering Porcelain (Glass) 7 2.15

TitaniumBase

NobleHigh NobleCeramic Metal Ceramic

Composite

Metal Acrylic Base

High Noble

NobleMilledPres

Stacked

CastPressed

Milled StackedStain

Cut-Back

Titanium

NobleHigh Noble

Zirconia

Disilicate MilledAlumina Zirconia

Alumina

Al-Zir

Flexural Strength of Dental Ceramics (MPa)

Aluminous Porcelains

Cast Microcrystaline Glass

Slip Cast Alumina with Glass Infiltration

Heat Pressed Lucite Ceramic Glass

In Ceram, Procera

IPS Empress, OPC

Milled (Machined) Alumina Based Crowns

Milled (Machined) Zirconium Based Crowns

Procera

Cercon, Lava

Conventional Jacket Crowns, Viradur

Slip Cast Spinel In Ceram Spinel

Slip Cast Zirconia In Ceram Zirconia

Heat Pressed Lithium Disilicate Empress II, e.max

Glazed Magnesia Core Magcor

Milled (Machined) Leucite Based Crowns Pro-Cad

Lava Ultimate

Monolithic Zirconia OpaqueeMax

Longevity vs. Beauty

Long Life

Great Esthetics

Short LifeYears

Poor EstheticsEsthetics

PFMMilled Zirconia - Stacked

Feldspathic Porcelain

EmpressMonolithic Zirconia Translucent

Why Have So Many Gone Away?

Answer: They Break

Fractured Dicor Crown Fractured Inceram Crown

What About Porcelain Fused to Metal?

Types of Ceramic-Metal FailurePorcelain Porcelain Porcelain

MetalMetal Oxide

Metal MetalMetal Oxide

Porcelain

PorcelainMetal Oxide

Porcelain

Metal OxideMetal

Metal OxidePorcelain

Metal Oxide

Type I: Metal-porcelain Type II: Metal oxide-porcelain Type III: Cohesive within porcelain

Type IV: Metal-metal oxide Type V: Metal oxide-metal oxide Type VI: Cohesive within metal

Porcelain IssuesDhima M, Paulosova V, Carr AB, Rieck KL, Lohse C, Salinas T, J J Prosthet Dent. 2014 Feb.

Practice-based clinical evaluation of ceramic single crowns after at least five years.Survival Rate: 95% (5 year) 92% (10 year)# 1 reason for failure: Fracture to core of layered restorations

Porcelain IssuesRinke S, Schäfer S, Lange K, Gersdorff N, Roediger M., J Oral Rehabil. 2013 Mar.

Practice-based clinical evaluation of metal-ceramic and zirconia molar crowns: 3-year results.

Survival Rate: PFM 97.6% Zirconia 95.2% Success Rate: PFM 90.9% Zirconia 86.6%

Pieger S, Salman, A, Bidra A, Journal of Prosthetic Dentistry. 2014 July.

Clinical Outcomes of Lithium Disilicate Single Crowns and Partial Fixed Dental Prostheses: A Systematic Review

Single Crowns Fixed Dental Prostheses 2 Year Survival Rate: 100% 83.3% 5 Year Survival Rate: 97.8% 78.1%10 Year Survival Rate: 96.7% 70.9%

Porcelain Issues

What Haircut is this?

The Oral Cavity

The Mullet “Business in the front,partying in the back!”

The Reverse Mullet

“Party in the front,business in the back!”

Your Choices Today

Bilayer BranchMonolithic Branch

Zirconia

Disilicate

DisilicateZirconia

Pressed

CompositePressed

Milled

PressedStacked

Stacked

Production ComparisonSingle Unit Crowns - Gold vs. PFM vs. Ceramic

11 -12 Numbers

12 -13 Numbers

11 -12 Dollars

12 -13 Dollars

13 -14 Numbers

13 -14 Dollars

Gold PFM

709 1320

30.7 57.3

$445,774 $841,67929.4 55.6

631 133926.0 55.2

$402,465 $889,44724.1 53.3571 100923.6 41.7

$378,390 $681,40022.8 41.1

Ceramic

$225,091 15

457 18.8

$378,161 22.6

835 34.7

$596,981 36.1

14 -15 Numbers

14 -15 Dollars

353 47617.8 24.0

$235,579 $313,23517.8 23.7

1152 58.2

$770,679 58.5Monday, March 19, 18

Statics from Glidewell

Solid Milled Zirconia

Solid Milled

Zirconia

Traditional Examples

1000-1400 MPa

1200 +/- 200 MPa

1100 MPa

Translucent Examples

750-560 MPa

700 +/- 100 MPa

650 MPa

3M - Lava Plus and Lava Esthetic

3M - Lava Plus

Pressed or Milled Lithium Disilicate

e.max Press e.max CAD

Benefits of eMax

Good StrengthEtchable - Bondable4 Levels of OpacityMultiple Different TechniquesVery Good Esthetics

HT ingotsThe high translucency ingots (HT) are suitable for the fabrication of minimally invasive full-contour restorations, such as inlays, onlays and veneers. The restorations are characterized with staining materials.

LT ingotsFull-contour partial crowns and crowns are fabricated with the low translucency ingots (LT). In the anterior region in particular, the esthetic appearance of the restorations is maximized by employing the cut-back technique.

MO ingotsThe medium opacity ingots (MO) are used to fabricate substructures for vital or slightly discolored teeth. They create an ideal basis for lifelike restorations completed with the layering technique.

HO ingotsIn cases where the prepared tooth structure is discolored or titanium abutments are used, the HO ingots mask the dark background to achieve highly esthetic results.

Clinician’s Choice Polishing

What Would You Do?

Is it Perfect?

MT and Impulse Ingot Added

Teeth Following Crown Removal

Reduction Matrix

Fabricated from the Diagnostic Wax-up

Pressed Material Design Anterior Teeth

1) Round End Taper (1116)2) Esthetic bevel of 1/2 to 1/3 occ-ging height3) Incisal reduction of 1.5 - 2.0 mm4) Lingual reduction of 1.5 to 2.0 mm (1900)5) Well rounded line and point angles (essential)

Types of Luting Agents1) Zinc Phosphate Cement2) Polycarboxylate Cement3) Glass-Ionomer Luting Cement4) Resin-Modified Glass-Ionomer Cement5) Polyacid-Modified Composite Cement6) Resin-Based Cement7) Bioceramic Luting Agent

RMGI Luting Cement

Advantages:1) Less sensitivity to moisture during setting2) Capable of bonding to composite

Disadvantages:1) Hydrophilic behavior2) Leakage between water-based cements and resin-based

Resin Cement

Advantages:1) High values for bond strength2) Highest adhesion

Disadvantages:1) Challenging clean-up2) Potential for post-op sensitivity

6th Gen. Product Examples

1) Clearfil SE Kuraray 2) Optibond XTR Kerr3) Peak SE Ultradent 4) Prelude Danville5) Adhese SE Ivoclar 6) Prompt-L-pop 3M ESPE7) Adper Scotchbond SE 3M ESPE

7th Gen. Product Examples

1) Scotchbond Universal 3M2) Optibond All-in-One Kerr3) Futurabond Voco4) Clearfil S3 Bond Kuraray 5) iBond Kulzer6) Bond Force Tokuyama

Resin Bonding Cements

Ivoclar Variolink IIDentsply Calibra

Ceramir®

The product combines Ceramir technology and some glass ionomer components to provide the best properties for the material.

PFM, All Metal,or Zirconia on

All Teeth

Empressor eMax

Non-Vital Teeth

Vital Teeth

Empressor eMax

Magnificationand

Illumination

Orascoptic

Geissberger, M. J. (1995). The Effects of Magnification on the Performance of Fixed Prosthodontics Procedures. Journal of the California Dental Association, 23(12), 66-70.

The World’s First Loupe With A Built-In Headlight

!All electronics are completely contained within the frame. No more cables to get tangled on chairs, doorknobs, or drawers. Built-in side shield protection (separate side shields not necessary). Small ultra-lightweight headlight

OrascopticSparkLight

Magnificationand

Illumination

Orascoptic

Geissberger, M. J. (1995). The Effects of Magnification on the Performance of Fixed Prosthodontics Procedures. Journal of the California Dental Association, 23(12), 66-70.

Orascoptic - Options

Orascoptic LED Light

SimulatedSmile

Design

Before Simulation After Simulation

Van Zyl, I., Geissberger, M. J. (2001). Simulated Shape Design: Helping Patients Decide Their Esthetic Ideal. Journal of the American Dental Association, 132, 1105-1109.

Simulated Smile Design

Step One: Diagnostic Impressions

Impressions:* Must capture all tooth anatomy* Must capture entire buccal vestibule* Use Resin Rock (Ivory) or similar product

Step Two: Stick Bite

* Use fast setting bite registration * Place first stick on the incisal edge of lower anterior teeth* This must be parallel to the in. pup. line* Second stick is placed at the patient’s midline

Simulated Smile DesignStick Bite

New Technique - Kois Analyser

Step Three: Mounted Diagnostic Casts

* Can be mounted arbitrarily * Use semi-adjustable articulator

Step Four: Diagnostic Wax-up

* Can employ laboratory* Must reproduce all desired anatomy and effects* Most critical portion of entire technique* Is the make or break of the process

Midline

8.5&mm

Critical Anatomic Features

Simulated Smile DesignWax-up

Putty Splint Fabrication

* Must capture all wax-up anatomy* Must capture entire buccal vestibule* Should extend two teeth past wax-up on either side

Try-in and Midline Mark

* Make sure splint can be positioned easily* Mark the midline as a reference for seating* Ensure occlusal stops are adequate

Dry All Surfaces

* Use 2X2 to dry facial of all teeth* Have patient keep these surfaces dry

Load Bis-Acrylic

* Place mixing tip on incisal edges* Fill all aspects of the facial surfaces of teeth

Available Bis-acrylic Resins

Step Eleven: Surface Characterization

* Apply composite surface stain * Light cure when desired result accomplished* Polish lingual area with finishing disks

Before Simulation After Simulation

16 Years later

Psychologyand Patients

Roger Sperry

• “Our educational system, as well as science in general, tends to neglect the nonverbal form of intellect. What it comes

down to is that modern society discriminates against the right hemisphere.”

LEFT BRAIN FUNCTIONS

uses logic

detail orientedfacts rule

words and languagepresent and past

math and sciencecan comprehend

knowingacknowledges

order/pattern perceptionknows object name

reality basedforms strategies

practicalsafe

RIGHT BRAIN FUNCTIONS

uses feeling

"big picture" orientedimagination rules

symbols and imagespresent and future

philosophy & religioncan "get it" (i.e. meaning)

believesappreciates

spatial perceptionknows object function

fantasy basedpresents possibilities

impetuousrisk taking

http://similarminds.com/cgi-bin/brain.plMonday, March 19, 18

What Does the Opposite Sex Look At First?

Female looking at Male Male looking at Female1) Brain

2) Eyes

3) Smile

4) Height

5) Butt

1) Eyes

2) Smile

3) Breasts

4) Butt

5) Legs

Treatment Planning, Designing and Delivering Complex and ... · 3/23/2018 · Treatment Planning,...

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