Dr. Paresh Shahd1ue90e5sp4tcv.cloudfront.net/2900/images/Asset293921_v1.pdf · Paresh Shah, DMD, MS (Physiology), Cert. Esthetic Dentistry Paresh Shah, DMD, MS, Cert. Esthetic Dentistry!

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Paresh Shah, DMD, MS (Physiology), Cert. Esthetic Dentistry

Paresh Shah, DMD, MS, Cert. Esthetic Dentistry!

Contemporary Esthetics in Everyday Practice!Dr. Paresh Shah

204-837-4517 work

204-295-2233 direct

[email protected]!

drpareshshah.com !

The Dental Industry’s Premier Speakers Bureau &

Product Evaluation Organization

catapultelite.com

CatapultGroupisanorganiza0onwhichconsistsoftopcliniciansandeducatorsfromthroughouttheUnitedStatesandCanada.Thisgroupoflike-mindedyetdiverseden0st’sgoalistobringqualityeduca0ontothedentalcommunityviamul0plevenuesincluding;livelecture,par0cipa0on,webbased,andwriEenformats.

Paresh Shah, DMD Winnipeg, Canada Member of Catapult Group [email protected]

Disclosure!

•  All photography taken on our patients has been left unaltered except for cropping to fit slides

•  Photography by other providers is acknowledged on appropriate slides

•  I serve as a consultant for a variety of manufacturers - product development & evaluations

Disclosure - Product evaluations and KOL opportunities!

•  GC America•  Dentsply•  3M ESPE•  Bisco Dental•  AMD Lasers•  Voco Dental•  Ivoclar

•  Clinical Research Dental •  Microcopy •  Doxa Dental•  Solutionreach•  Triodent•  Dentsply Implants•  Danville Dental

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• MS Physiology - U of Manitoba, 1987• DMD - U of Manitoba (Winnipeg), 1991• Hospital OS Internship - U of Manitoba, 1992• Proficiency Certificate in Esthetic Dentistry -

U of Buffalo (SUNY), 2007• Adjunct faculty at University of Pacific

Dental School - San Francisco• Clinical Instructor for Post Grad Program in

Esthetic Dentistry - U of Minnesota 2002 - 2009

• Seattle Study Club co-director since 2005• Kois Center Graduate 2013

Let’s start from the beginning with the basics of Bonding &

Adhesion..............!


Adhesion!

Paresh Shah, DMD, MS, Cert. Esthetic Dentistry! Paresh Shah, DMD, MS, Cert. Esthetic Dentistry!

Adhesion!

Adhesion to tooth structure involves the removal of the mineral portion of hydroxyapatite (calcium phosphate) and the subsequent replacement of this lost mineral with acrylic monomers.


Enamel Histology!

Consists of 90% hydroxyapatite (inorganic mineral) prisms.10% proteins & water. Enamel may be desiccated to create a hydrophobic surface to bond since

there is no direct circulation to replenish this water The outer layer typically lacks prisms which creates a challenge bonding

with self-etch systems.Exposing the enamel prisms with a bur makes the the enamel better suited

to bonding.


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Dentin Histology!

Comprised of 60% hydroxyapatite (inorganic) mineral, 30% collagen (organic) and 10% water.

Collagen is not found in enamel and typically takes the shape of a helical

strand-like network in dentin.Most of the water comes from the dentinal tubules due to pulpal pressures

which are influenced by the proximity to the pulp. A small amount of water is bound in the hydroxyapatite crystals.

Dentin is hydrophilic in nature and the extent is influenced by the proximity

to the pulp and subsequent pulpal pressures.


Combating Sensitivity!• By achieving a great bond• By using a self-etch adhesive• By using a universal adhesive• By using a liner/base


!All Adhesives and Composites are

Hydrophobic in natureThey do not like moisture and will not

stick to hydrophilic structures without the aid of a Primer


Primers and Solvents!Primers are bipolar monomers with a

hydrophobic component on one end and a hydrophilic on the otherThe hydrophilic component allows coupling with

moist surfaces such as dentin while the hydrophobic end facilitates bonding to the adhesive/composite over top


Primers and solvents!Primers are typically suspended in a

volatile solvent such as acetone, alcohol or water.The solvents allow the penetration of

primers into the dentin and tubules, but must be evaporated off


Smear Layer!Composed of hydroxyapatite, collagen

and tooth debrisLoosely attached lining over the floor of

pulp after dentin has been freshly cutBelieved to serve as a barrier to bacterial

invasion into dentinal tubules


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Smear Layer!Adhesives tend to be classified by the way they interact

with the smear layer:early generations: attempted to modify or attach to smear

layer4th & 5th generations (total etch): advised removing the

smear layercurrent generations (self-etch): incorporate the smear

layer into the bond


Bonding Agents!


Phosphoric Acid!Uni-Etch


Bonding Agents - Total Etch!

n  Key Factors:- Compatible with light cured composites- Compatible with a multitude of substrates- Use as a self-etch, total-etch or selective-etch- Some may require a separate activator for dual

cure core materials


Adhesion - Enamel (total etch)!

Enamel:Mechanism of adhesion to enamel is different to that of dentinMicromechanical retention to the ends of etched enamel rod prismsRemoves Calcium phosphate from the hydroxyapatiteExposes enamel prism rod to create a rough surface for micromechanical

retention

(BUONOCORE MG. J Dent Res. 1955 Dec;34(6):849-53.)


Enamel Bonding!n  Isolate teeth (moisture control)n  Preparationn  Etch cut/prepared enamel 15- 20 seconds - phosphoric acid (34-37%) & uncut

enamel 30 - 60 secondsn  Rinse etch for 5 secondsn  light air dryn  Apply bonding agent to entire prep by scrubbing with a stiff, dry microbrush for

2-3 applicationsn  lightly air dry to remove solventn  light cure at least 10 seconds n  place composite

de Meneszes, FC et.al. Quintessence Int. 2013;44(1):9-15


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Adhesion - Dentin!Dentin: Adhesion to dentin involves encapsulation of exposed collagen fibers.Inorganic phase removed from dentin surface by acid etching.Dentin bonding agent penetrates the vacancies and fills the tubules and

peritubular dentin.This is called the hybridization zone & is dependent on control of moistureCombination of collagen and bonding agent form a barrier to microbial invasion

and eliminates post-op sensitivity


Removes smear layer allowing for micromechanical adhesion similar to enamelDemineralizes hydroxyapatite in the intertubular and peritubular dentinOpens dentinal tubules & exposes collagen matrix in the dentin to facilitate

adhesionOpening dentinal tubules makes the technique sensitive to operator

technique if they are not suitably “sealed”Moisture control is key to collagen fiber exposure - avoid over-wetting or

over-drying

(Brännström M, Noredenvall KJ.J Dent Res. 1977 Aug;56(8):917-23.)

Adhesion - Dentin (total etch)!

Dentin Bonding!n  Isolate teeth (moisture control)n  Preparationn  Etch dentin for 10 seconds - phosphoric acid (34-37%)n  Etch enamel for 15-20 secondsn  Rinse etch and lightly air dry over dentin (moist dentin bonding) - should see a

shiny consistencyn  Apply bonding agent to entire prep by scrubbing with a stiff, dry microbrush for

2-3 applicationsn  lightly air dryn  light cure a minimum of 10 secondsn  place composite in increments

Dentin Bonding!

Smear Layer Removed/Etched Smear Layer Present/Unetched

Unetched vs. Etched Dentin

Dentin Bonding - Total Etch!

WET DRY MOIST

Attaining the ideal surface moisture

Combating Sensitivity - By Achieving a Great Bond!

§ Isolate area to prevent contamination§ Do not over-etch§ Do not pre-dispense adhesive§ Evaporation degrades adhesion§ Lowers bond strength

§ Blot excess water§ Leave surface moist§ Saturate tooth w/ adhesive & scrub§ Lightly air dry adhesive layer§ Thoroughly light cure adhesive§ Check your curing light regularly

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Bonding Agents - self-etch!

Dentin Bonding - Self-Etch!

n  Isolate teeth (moisture control)n  Preparationn  Dispense SE material according to manufacturers instructions (dish,

stiff micro-brush)n  Apply agent by scrubbing on entire preparation for at least 10 seconds

for 2-3 applicationsn  Lightly air dry to leave a shiny surfacen  Light cure at least 10 seconds n  place composite in increments

incorporates the smear layer into the bond

How about Best of Both Worlds?!

n  HIghest bond strengths acheived on enamel with phosphoric acid etchn  Technique sensitivity with phosphoric acid etching dentinn  Self-etch adhesives allow simple treatment of dentin to minimize

technique sensitivity

***** Perhaps a combination of both protocols can create a better solution..............


Selective Etch & Universal Adhesive !

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Bonding Agents - Universal Adhesive!

n  Low Film Thicknessn  High Bond strengthn  Key Benefits:

- Total-etch technique- Self-etch technique- Selective-etch technique

Dentin Bonding - Selective-Etch!

n  Isolate teeth (moisture control)n  Preparation of tooth and placement of dentin liner (if desired)n  Selective etch of enamel only for 15 seconds (agitate)n Rinse etch for 5 seconds & lightly dryn  Dispense universal bonding agent according to manufacturers

instructions (dish, stiff micro-brush)n  Apply universal bonding agent by scrubbing onto entire prep for at least

10 seconds (apply 2-3 coats without drying in between)n  light air dry and acheive a shiny finishn  Light cure 10 seconds (manufacturers instructions)n  place composite in increments

Matrix Metalloproteases (MMP’s)!

• MMPs are not bacteria but are inactive proforms of proteolytic enzymes found within dentin collagen fibrils capable of degrading collagen within newly created adhesive hybrid layers as well as extracellular matrix proteins

• MMPs play a major role in autodegradation of collagen fibrils within the hybrid layer at adhesive tooth restoration interfaces

• MMPs are well studied. These proteolytic enzymes have been linked to Periodontal Disease/tissue destruction for years. However, degradation is an important feature of development, tissue repair, and remodeling.

Matrix Metalloproteases (MMP’s)!

• With new research, they have just recently been linked to collagen breakdown within dentin, leading to adhesive failure.

• Benzylkonium Chloride (BAC) and Chlorhexidine (CHX) are two of the only disinfectants which in addition, inhibit MMP activity on dentin surfaces. Other studied compounds include: galardin, flavonols, EGCG, tetracyclines, QAMS

MMP inhibitors!

CHX = Chlorhexidine BAC = Benzalkonium Chloride

Adhesion Basics - Summary!n  No ideal adhesive system exists when it comes to total-etch or self-etch

n  Vigorous scrubbing of adhesive during application increased bond strength for both types of adhesives

n  Prolonged light curing beyond recommended manufacturers instructions increased bond strengths

n  warm air drying of adhesive helped remove solvents better than air

Reis, Carrilho, Breschi, LoguercioOperative Dent. 2013;38(4):1-15

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Adhesion Basics - Summary!n  Difficult to get an absolute best adhesive result with just one type of adhesive

n  Total-etch and self-etch both have a place n  Bond strengths depend on type of substrate (enamel or dentin)n  When using a self-etch system, it is best to etch enamel (keep off dentin) to achieve high bond strengths

n  Vigorous application with a stiff brushn  Always overcure

John Kois - Symposium update July 2013


Combating Sensitivity - Glass Ionomer Liner/Base!

§  Deep restorations w/ near pulp exposures§  Bonds to dentin and enamel w/o surface pre-treatment§  No need to etch§  Reduces sensitivity§  Fluoride Release§  Once cured can be etched and bonded with any type of adhesive

Glass & Resin Ionomers!

• ACT as a dentin substitute• REPLACE composites as a dentin

substitute• Still REQUIRE composites as an

enamel substitute in posterior occlusal load areas and in cosmetic anterior issues

• Are Bioactive, no other restorative material is!• They can re-mineralize tooth structure so

remove the soft stuff but leave the dentin that can remineralize

•  Inhibits Plaque by fluoride release, great for lesions in furcas, deep dentin and cementum

• Glass ionomers have greater ion release than resin ionomers

Why a Dentin Replacment?!

• - They have thermal expansion properties similar to DENTIN• - They require a chemical bond with only mild etching… even less than self

etch, no over etching, NO OPENING TUBULES, you want the ions there!• - They have 1/9th the shrinkage of a composite and thus less stress. • - They release fluoride and other ions as they are exposed to water and

reactivate when exposed to fluoride• - They are easy to place!

Linings!• Linings are ResinIonomers with finer

grained contents and are meant to be placed in thin increments. No greater than 1.5mm

•  Examples are Fuji Lining Cement Paste PakIonoseal Vitrebond Plus Clicker system: studies show can reduce an effect of polymerization shrinkage by more than 50 per cent of bonding aloneIn any class they can line the dentin walls and floors

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Deep Caries! Bases - Techniques!• Bases: Applied in thicker amounts• Glass Ionomers such as– Fuji 9 Extra by GC Fast Set– KetacNano by 3M– Hi-Fi by Shofu– Riva Self Cure Fast Set

Resin Ionomersq  Fuji 2 LCq  Riva Light cure

Either can be placed as bases in open or closed sandwich

Bases - Techniques!• Open Sandwich would be a class 2 in which the

cavosurface margin would be in dentin or cementum and the margins of the restoration cervically are exposed to the oral environment and thus restored with a GIC

• Closed Sandwich would be in a class 1 where the pulpal floor and dentin are lined or built up by the GIC or in a Class 2 in which the proximal box is in enamel and the GIC is fully enclosed by the composite

Light Cured Calcium Silicates

TheraCal

Clinical Applications Direct/Indirect Pulp Capping Pulpal Protecting Liner/Base Apatite Stimulating Wonder!

MTA:!Mineral Trioxide!

Aggregate!

Calcium Hydroxide!

RMGI!

Bisco being…ProActive with…! “Liquid Apatite”!!

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C O B I S

H2O

Bis-GMA Resin (Hydrophobic)

C CaO Si

C CaO Al C CaO Si

C CaO Al

C CaO Si

Ca+2

OH- C CaO Si

C CaO Al C CaO Si

C CaO Al

C CaO Si

Very Hydrophilic

Ca+2

OH- Ca+2

OH-

Ca+2

OH-

H2O

C MTA Si C Portland Cement

TheraCal

Resin Matrix

• Pulp exposure

• Not symptomatic

• All decay removed

Carious Pulp Exposure

SEM in the body of affected demineralized dentin (~ 30,000x) showing remaining crystal remnants awaiting remineralization!

Stimulating Healing!and Apatite Formation!

Pulpal Protecting for Indirect Pulp Capping !

Deep Dentin Sealer/Apatite Stimulating!

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Thermal Insulator!

Posterior Restorations……!simple, faster, predictable!

Contacts!

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Embrasures!

Final Contour!

Bulk Fill Materials!

SureFil SDR flow!� First posterior bulk fill resin base� Low stress allows for bulk placement (4mm)� Self leveling handling and excellent adaptation to cavity walls

� Reduces procedural time� Allows the use of any methacrylate based composite on top as a capping agent

� 68% filled by weight- 44% by volume� Low volumetric shrinkage (3.6%) and low shrinkage stress (1.4Mpa)

ProductCharacteris3csFlow

SureFilSDRFlow

EsthetXFlow

•  1st Flowable composite suitable for bulk (4mm) placement in Class I and II cavities

• Time savings of up to 40%• Self-leveling consistency for ideal cavity

adaptation• Compatible with all methacrylate based

chemistries;• Use with currently available Total or Self-etch

adhesives• Use with currently available Universal composites

for capping• Universal shade for simplified placement options• Bulk fill flowable composite• Class I and Class II cavities• Place in 4mm increments (up to dentin enamel

junction)

SUMMARY!

Tetric EvoCeram - Bulk Fill Composite!

Tetric EvoCeram®

…has the same long working time, superior esthetics and excellent balance of physical properties as

3 new patented technologies were added which enables it to be the only material on the market that can be placed in bulk

Patented Polymerization Booster for deeper depth of cure.Patented Light-Sensitivity Filter for extended working time.Patented Shrinkage Stress Relievers ensure superior marginal integrity.

No additional viscosities.No additional layers.No additional equipment.

Bulk, Sculpt & Cure with Tetric EvoCeram® Bulk Fill

Tetric EvoCeram Bulk Fill!

One Material: The material’s smooth consistency provides excellent adaptation to cavity walls without the need for a flowable liner.

One Filling: Cavities can be “Bulk” filled and contoured immediately without the need for a final layer or additional equipment. Bulk & Sculpt!

One Increment: The 4-mm bulk increment provides for the faster, easier and more efficient placement of direct posterior restorations.

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Unique Features!Patented Polymerization “Booster”ensures a complete 4mm depth of cure in just 10 seconds. Patented Light Sensitivity Filterprovides over 3 ½ minutes of working time for adequate placement and contouring.

Patented Stress Relieverminimizes shrinkage stress during polymerization preserving superior marginal integrity.

Universal Shades!

A Shade (between A2-A3)

B Shade (between B1-B2)

W Shade (White for bleach shaded or pediatric teeth)

Clinical Case - Tetric evoceram bulkfill!

Dr Eduardo Mahn, Chile

Apply adhesive

Final Restorations!

Bulk Filling with Tetric EvoCeram Bulk Fill ‒ one layer, one cure cycle

Final situation immediately after treatment

Ring Systems!

Sectional Matrix!

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Sectional Matrix!

V3 Ring!NiTi only spring

V-Shaped glass reinforced autoclavable plastic tines (leaves room for the wedge)

Built in lip for increased stability in forceps.

Anatomically shaped tines

6.5mm Matrix with sub-gingival extension

Tab can be bent 90˚forcontra-angleplacement

Side holes for easy removal

Holes designed to fit with positive grip Pin-Tweezers

The only matrix band with marginal ridge contour

Developer: Dr Simon McDonald BDS MSc DDPH

Clinical case - Narrow V3 Ring!

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Final Restorations! V4 Ring!

2 rings in tandem

Universal adhesive!

Bulk fill flowable

Bulk fill and cure-through!

Contour & finish ! Finishing!

Multi-fluted carbide bur Diamond finishing strip

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Polishing!

Diamond or silicone carbide polishing brush

Final restoration!

Bulk fill!

SonicFill! Final!

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Everyday Crown & Bridge!

Types of Indirect Restorations!

n  Crownsn  Bridgesn  Conventional and Maryland (adhesive)

n  Inlaysn  Onlaysn  Veneersn  Endodontic Posts

Considerations for Material Selection!

n Esthetics desiredn Location of the restorationn  Location of the marginsn  Fit capabilities of the restorationn  Ability to properly isolate the arean  Costn  Strength

Are PFM’s Dying?

Glidewell labs! Glidewell labs - trends!

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• Full Cast Metal • Gold Alloy • PFM – Porcelain fused to metal

• Many brands, high cost, being replaced by all-ceramics; FPD

• PFT – porcelain fused to titanium • New; mixed success; implant supported restorations

• Leucite reinforced glass ceramic • IPS Empress Esthetic/CAD; Authentic; OPC

• 160 MPa • Lithium disilicate/silicate

• IPS e.max Press/CAD; Obsidian • High esthetics and strong • 360-400 MPa

• Zirconia (high strength non-etchable) • Monolithic: BruxZir; LAVA Plus; KDZ Bruxer; OccluZir; ZirLux FC • Fastest growing; improved esthetics~1000 MPa

• Zirconia supported: IPS e.max ZirPress; ZirCAD, LAVA DVS, • High esthetics; may be subject to chipping, fractures; slow cooling

• Polymer

ALL-CERAMIC METAL BASED

Crown classificaiton! What type of ceramic do you use?!

•  IPS e.max - monolithic •  IPS e.max - layered •  Monolithic zirconia •  Layered zirconia •  PFM •  Feldspathic •  Polymer-ceramic •  Full Gold •  Resin-based

•  Anterior FPD’s, single units - full mouth, implants •  Anterior restorations, veneers, premolars, implants? •  Posterior FPD’s, single units, full mouth? Implants? •  Anterior & posterior FPD’s, single units - full mouth •  FPD’s, implants, full mouth •  Veneers •  Single units - full mouth? •  2nd Molars, non-esthetic/visible areas •  Single units - posterior

Material Selection!Type Strength MPa Aesthetics Interocclusal Axial Bondable

Full metal >1200 n/a .4mm 4.5mm Cohesive

Porcelain/Metal 120 Good 1-2.0mm 4.5mm Cohesive

Procera 120 Good 1.5-2.0mm >3mm Adhesive/Cohesive

Porcelain (feldspathic) 200 Excellent 1.5-2.0mm >3mm Adhesive

eMax 360 Very good 1-2.0mm >3mm Adhesive/Cohesive

Zirconia >1200 Very good 0.5-1.0mm >4mm Adhesive/Cohesive

8º! 10º! 12º! 16º! 20º!

4!Conventional Cement or Adhesive Cement︎

Conventional Cement or Adhesive Cement︎


Adhesive Cement︎

Adhesive Cement︎

3!Conventional Cement or Adhesive Cement︎


Adhesive Cement︎

Adhesive Cement︎

Bond ︎

2! Bond ︎ Bond ︎ Bond ︎Crown

Legnthening ︎Crown

Legnthening ︎

PREP TAPER

PREP

HEI

GH

T(m

m)

Conventional Cements – Glass Ionomer, RMGI, Zinc PhosphateAdhesive Cements – “CEM”Cements, SE primer with Hydrophobic D/C ResinsBonded – Primers/Adhesives with D/C Resin CementsDr. Sam Simos, Chicago, IL

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Enamel wear - various ceramics!

Evaluation: This study examined the wear resistance of human enamel and feldspathic porcelain after simulated mastication against 3 zirconia ceramics, heat-pressed ceramic and conventional feldspathic porcelain Conclusions: The wear behaviour of human enamel and feldspathic porcelain

varies according to the type of substrate materials. On the other hand, 3 zirconia ceramics caused less wear in the abrader than the conventional ceramic.

J Dent. 2012 Nov;40(11):979-88. Wear evaluation of the human enamel opposing different Y-TZP dental ceramics and other porcelains.

Kim MJ1, Oh SH, Kim JH, Ju SW, Seo DG, Jun SH, Ahn JS, Ryu JJ.

Enamel wear - Various ceramics!

Evaluation: The purpose of this study was to investigate the 3-body wear of enamel opposing 3 types of ceramic (dense sintered yttrium-stabilized zirconia; Crystal Zirconia; lithium disilicate (IPS e-max CAD; Ivoclar Vivadent) (E), and a conventional low-fusing feldspathic porcelain (VitaVMK-Master; Vita Zahnfabrik) (P), treated to impart a rough, smooth, or glazed surface Conclusions: The degree of enamel wear associated with monolithic zirconia

was similar to conventional feldspathic porcelain. Smoothly polished ceramic surfaces resulted in less wear of antagonistic enamel than glazing.

J Prosthet Dent. 2014 May 16. Three-body wear potential of dental yttrium-stabilized zirconia ceramic after grinding, polishing, and glazing treatments.

Amer R1, Kürklü D2, Kateeb E3, Seghi RR4

Enamel wear - Zirconia!

Evaluation: The wear of tooth structure opposing anatomically contoured zirconia crowns requires further investigation. Conclusions: polished zirconia is wear-friendly to the opposing

tooth. Glazed zirconia causes more material and antagonist wear than polished zirconia. The surface roughness of the zirconia aided in predicting the wear of the opposing dentition.

J Prosthet Dent. 2013 Jan;109(1):22-9. The wear of polished and glazed zirconia against enamel.

Janyavula S1, Lawson N, Cakir D, Beck P, Ramp LC, Burgess JO.

Enamel wear - Zirconia!

Aging of dental zirconia roughens its surface through low temperature degradation. We hypothesized that age-related roughening of zirconia crowns may cause detrimental wear to the enamel of an opposing tooth. To test our hypothesis, we subjected artificially aged zirconia and reference specimens to simulated mastication in a wear device and measured the wear of an opposing enamel cusp. All zirconia specimens showed less material and opposing enamel wear than

the enamel to enamel control or veneering porcelain specimens.

Oper Dent. 2014 Mar-Apr;39(2):189-94. Enamel wear opposing polished and aged zirconia.

Burgess JO, Janyavula S, Lawson NC, Lucas TJ, Cakir D.

Porcelain Adjustment Kit !

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Prep design - ceramic thickness?!

n  “Lithium disilicate significantly improved fracture resistance compared to leucite-reinforced ceramic”

n  A 1 mm thick restoration did not show significant reduction of fracture resistance than a 2 mm thick restoration

n “The thickness of ceramic had no significant effect on fracture resistance when the ceramics were bonded to the underlying tooth structure”

(Bakeman, E, Rego, N, Chatyabutre, Y & Kois, J. Operative Dentistry 2013 (in press)

Posterior restorations!

n  “Fracture resistance and failure risks of posterior partial coverage restorations are significantly influenced by material selection”

n  “Lithium disilicate had the highest fracture resistance followed by Leucite ceramic, Feldspathic ceramic and indirect composite”(Kois, DE, Isvilanonda, V & Chatyabutre, Y. J. Esthet Restor Dent. 2013:25(2): 110-22

Preparation considerations for all-ceramic restorations!

n  Butt-jointed margins preferred (1mm, 90-110°)

n  Avoid tapered, beveled or feathered marginsn  Round internal line anglesn  Anterior crown preparation minimal reduction = 1.5mm, incisal reduction = 2.0mm n  Posterior crown preparation minimal reduction = 1.5mm, cuspal reductions for onlays = 2.0mm (J.F. Shapiro, All-Ceramic Restorations in Everyday Practice, Dentistry Today, April 15, 1998)

Prep Design!

Microcopy (since 1970)!

•  NeoBurr•  NeoDrys•  Gazelle Polishers•  Bite-Chek Articulation Film•  Flaps

Microcopy - NeoBurs!

RoundCarbideOpera@veFG6

StraightFissureCross-CutCarbideFG557AlsoavailableinLongandShortShank

12-bladeTrimmingandFinishingDiamondNeedle

NeoMaxMetalCuOersMax2

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Microcopy - NeoDiamonds!

[email protected]“ZirconiumCuOer”MediumGritDiamond

FootballOpera@ve1923FFineGritDiamond

PointedConeOpera@ve1312.11CCoarseGritDiamondExtralongAssistwithextrac@ons

[email protected]

PointedConePit&FissureDiamond1300FSFineGritShortShank

NeoDiamondFanFinishingDiamonds

Restorative Burs - Shah!

• 1900 (f)• 1114.10• 1.1416

(mosquito)• 9.1212.7 (KS

burs)

Restorative Burs - Shah!

• 330 FG• 1158 FG• OS1

(finisher)• 7901 • 9903 UF

Restorative Burs - Shah!• Gazelle composite polishers

Cementation!• Zinc Phosphate

• Flecks Mizzy • Polycarboxylate

• Durelon • Glass Ionomer

• Ketac Cem • Resin-Modified Glass Ionomer

• RelyX Luting; FujiCem 2 • BioCeramic

• Ceramir

• Total-Etch • Veneers; thin translucent crowns • Examples: Choice 2; RelyX Veneer; Variolink Veneer

• Self-Etch • Self-etching primer applied separately; cement thick,

opaque ceramics • Examples: Duo-Link Universal; MultiLink Automix; RelyX

Ultimate • Self-Adhesive

RESIN ADHESIVE CONVENTIONAL

Cement Classification!

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• Light-Cure • Photo-initiators • Increased working time, decreased

finishing time, good color stability • Dual-Cure

• Chemicals and photo-initiators • High bond strength, quickly seal

margins, can be esthetic • Chemical-Cure (self-cure)

• Rxn of 2 materials mixed • Use when light curing difficult, metal

restorations, posts • Example: Panavia, C&B Cement

• Total-Etch • PO4 etch, then adhesive is applied • Technique sensitive; highest bond to tooth;

reduced microleakage • Self-Etch

• Self-etching primer applied separately; high bond strength

• Easy to use; some incompatibilities • Self-Adhesive

• One component, all-in-one

Stamatacos C, Simon JF. Cementation of Indirect Restorations: An Overview of Resin Cements. Compend Contin Edu Dent. 2013; 34(1)_:42-46.

BY ADHESIVE SCHEME BY POLYMERIZATION

Resin Cement Classification! Why Resin Cement?

•  High bond strength to tooth structure and porcelain

•  High tensile and compressive strength •  Lowest solubility •  High wear resistance •  Highest flexural strength and modulus to

prevent debonding during function •  However,

•  Can be technique sensitive •  May have difficult clean-up •  Possible color change during

Simon JF, Darnell LA. Considerations for proper selection of dental cements. Compend Contin Edu Dent. 2012; 33(1):28-36.

Desirable Properties of Cements

•  Stable bond to both the remaining tooth structure and the restoration material

•  Strength to resist the forces of mastication and parafunctional forces (flexural/modulus)

•  Lack of solubility in oral fluids •  Low film thickness (5-25 um) •  Biocompatible •  Color stability •  Ease of use and good viscosity •  Low water sorption to prevent expansion •  Radio-opaque •  Possession of anti-cariogenic properties

Zirconia: !Silica-free, acid-resistant, polycrystalline ceramic !

Since Zirconia does not contain glass, etching is not possible. Hydrofluoric acid usually works by removing a portion of the glassy matrix in a ceramic, thus “etching” the restoration and creating micro-mechanical retention

GC Initial™ Zr: Layered

Zirconia Coping Substructure

Solid Milled Zirconia Crown: No treatment except GC

Initial™ IQ Lustre Paste

GC Initial™ IQ POZ: Pressed

Zirconia Bridge Substructure

Ceramir - Doxa Dental!• injectable bioceramic

material for dental applications

• initally for orthopedic use

• first approved in Europe and US in 2008

Ceramir technology!• Ceramic powder = Calcium oxide + Aluminium-oxide

Key features!- Nano structural integration - Permanent seal of the tooth – restoration interface - Bioactivity - Biocompatibility - Creates Apatite when in contact with phosphates - No shrinkage - Hydrophilic system with Alkaline pH - Thermal properties similar to tooth structure - Adjustable handling and setting properties

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Benefits!

500nm

Ceramir

- Sealed interface – less risk of secondary caries - Basic pH, chemical stability and no shrinkage gives a stable interface

Ceramir Crown & Bridge!• Natural: biocompatible and environmentally friendly

• Permanent sealing: so it protects the tooth over time

• Easy to use: self-adhesive, self-curing, easy cleanup, not sensitive to moisture

Ceramire Crown & Bridge!• Incorporates some glass ionomer components which improve

handling and properties

Basic Properties - Ceramir!

• Working time: 2 minutes

• Net setting time: 5 minutes

• Film thickness: 15 microns

• Compressive strength: 360 MPa

• Radiopaque

Bioceramic Luting agent!1. Natural

- Similartohydroxyapa@te- Stateoftheartinbiocompa@bility- Biomime@cproper@esNaturalremineraliza@onprinciple

- PermanentSealing- Reliable- Predictable- Cariesprotectedinterface

3. Easeofuse - Quick - Lesstechniquesensi@ve

Ceramir - easy to use!

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Ceramir! Ceramir!

Ceramir! Ceramir!

Ceramir!

Resin cements!

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The Next Generation – What’s new?!New design! Clinical application!

Clinical case: Dr. Ronny Watzke, Dentist Franz Perkon, Dental Technician

Pre-operative situation [previously cemented crowns

on 21 and 23]

Inspection of the selected shade with the Try-in paste

Clinical application!

Application of Multilink Primer

1.  Sufficient quantity of Primer2.  Cover the complete contact

surface3.  Scrub in the Primer #

for 30 seconds, beginning with enamel surface

Clinical application!

Application of Multilink Primer

1.  Sufficient quantity of Primer2.  Cover the complete contact surface3.  Scrub in the Primer #

for 30 seconds, beginning with enamel surface

4.  Disperse excess of Primer with blown air until the mobile liquid film is no longer visible.[The solvent water has to be completely evaporated.]

Importance of scrubbing!

n  Diffusion of the Primer through the smear layern  Dissolved calcium ions will neutralize the Primern  Continuously moving the applicator ensures fresh and active Primer at the surface

Conditioning!

Etching of the IPS e.max crown with 5% hydrofluoric acid for 20 seconds

Application of Monobond Plus

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Cementation!

Placement of the crown Light activation of excess cement

Clean up & liquid stip!

Light cure - polymerization!

Polymerization of the cement [20 seconds per aspect]

Finishing and polishing

Final Restoration!

Easy clean up!

peels off1-2 second tack cure

Things I can’t live without…..!

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Clinical Examination & Diagnostics!“All restorative techniques!will fail if the bacterial!

infection is not controlled”!

Clinical exam !- traditional diagnostic model!

• Visual inspection

• Explorer - clinical inspection

• Traditional radiographs - bitewings, periapicals

Explorer!

•  Has been our standard of care for many years to detect caries

• Studies show its accuracy may be as low as 25%

• Should we count on clinical judgment for the other 75%

Radiographs - 2nd tool for caries detection!

•  If it shows on an x-ray it’s a cavity and if it doesn’t show it isn’t, right?

• Wrong! ……….It’s only 22% accurate for occlusal decay

Clinical experience!!

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Contemporary Diagnostic model in 2015…..!

• Digital x-rays

• Magnification

• Photography - Intraoral camera & Digital SLR

• Caries detection aids

Diagnodent!

• 632 nm cavity detection laser - based on fluorescence

• Measures light diffraction within a tooth associated with an audible sound and numbered meter

• Great adjunct to a thorough exam

Diagnodent! Spectra!• LED projects blue light at 405nm

• Light at this wavelength stimulates porphyrins (metabolites of cariogenic to bacteria) to fluoresce red, while healthy enamel fluoresces green.

• Bridges with digital x-ray software

• Allows you to record image in patient’s chart and program also quantifies the level of decay numerically and with color allowing you to track

• Remineralization or treatment.

Spectra!•  Improvement of clinical

caries diagnosis by use of a non-invasive fluorescence technology

•  Connection to an imaging software makes monitoring the progession of a lesion over time possible.

CariVu - Dexis!• DEXIS CariVu™ is a

compact, portable caries detection device that uses patented transillumination technology to support the identification of occlusal, interproximal and recurrent carious lesions and cracks.

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CariVu!• Compact, portable caries detection device that uses

patented transillumination technology

• Supports the identification of occlusal, interproximal, and recurrent carious lesions and cracks

• Bathes the tooth in safe, near-infrared light to aid in diagnosis without the use of radiation

• Allow clinicians to see “through” the tooth exposing its structure, and the actual structure of any carious lesions, with very high accuracy

CariVu!

• Similar in appearance, CariVu images read like familiar X-ray images — lesions will appear as dark areas. This provides an edge over fluorescent imaging technologies in that there is no need to clean the tooth of bacteria, calibrate the device or become versed in the meaning of multiple color codes or numeric indicators

DEXIS digital X-ray sensor and CariVu - companion tools for caries detection!

• Radiograph

• Transilluminated image

•  Intra-oral photo

• provide a comprehensive picture of the health of a patient’s tooth

Source:KühnischJ.BenefitsoftheDIAGNOcamProcedurefortheDetec0onandDiagnosisofCaries[studyproject].Munich:LudwigMaximilianUniversityofMunich;2013.

Indications for use!• Detection of smooth surface caries

• Detection of occlusal caries

• Detection of proximal caries

• Detection of initial caries

• Detection of secondary caries and detection of cracks.

DEXISCariVu™byDEXIS,LLC1910NorthPennRoad,Hamield,PA19440

ToothNumber/Chart•  DefaultstonumberoftoothopeninDEXIS•  Blackoutlinedteethhaveimages•  Grayoutlinedteethdonothaveimages

1 FilmStrip•  Historyofallimagesforchosen

tooth

2

SessionWindow•  Displayslivevideo•  Displaysfrozenimage

ComparisonWindow•  Candisplayanyimagetype

fromthefilmstrip

53 ImageStrip•  Displaysnewlysavedimages

4

Case example!

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Clinical case example! Clincal case example!

Clinical case example! S3llShot

Occlusal pit caries?! Caries removed!

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Lasers on the Market! Why LASERS?!•  Soft-tissue lasers are fast, safe and effective – and more economical than ever

before

•  Lasers are easier to use than you may think – and educational options are plentiful

•  Less invasive than traditional modalities like scalpel and electrosurge

•  Excellent, predictable tissue response compared to packing cord

•  Effective marketing tool for the entire practice

•  The transition to soft tissue lasers is seamless and easy for long-time electrosurge users

Picasso Soft Tissue Procedures!•  • Gingival Troughing for Crown

Impressions•  • Gingivectomy & Gingivoplasty•  • Gingival Incision & Excision•  • Soft-Tissue Crown Lengthening•  • Hemostasis & Coagulation•  • Excisional & Incisional Biopsies•  • Exposure of Unerupted Teeth•  • Fibromal Removal•  • Frenectomy & Frenotomy•  • Implant Recovery

•  • Incision & Drainage of Abscess•  • Leukoplakia•  • Pulpotomy as an Adjunct to Root Canal

Therapy•  • Operculectomy•  • Oral Papillectomies•  • Reduction of Gingival Hypertrophy•  • Vestibuloplasty•  • Treatment of Canker Sores, Herpetic &

Aphthous Ulcers of the Oral Mucosa

Periodontal Laser Procedures!•  • Sulcular Debridement (Removal of Diseased, Infected, Inflamed, &

Necrosed Soft-Tissue in the Periodontal Pocket to Improve Clinical Indices Including Gingival Index, Gingival Bleeding Index, Probe Depth, Attachment Loss, & Tooth Mobility)

•  • Laser Soft-Tissue Curettage

•  • Laser Removal of Diseased, Infected, Inflamed & Necrosed Soft-Tissue Within the Periodontal Pocket

•  • Removal of Highly Inflamed Edematous Tissue Affected by Bacteria Penetration of the Pocket Lining & Junctional Epithelium

Features:

•  Ideal for Implants, perio treatment, surgery.

•  High power 7.0 watts

•  New treatment timers

• Wireless foot control

•  Optional battery pack

•  Disposable tips or fibers

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

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A soft tissue laser incision at 1000x magnification!

Lasercut

Superficialcoagula@on

Heatdissipa@onwithliOle/noedema

Diode laser vs. electrosurge!•  Electrosurge devices have a much larger zone of necrosis and inflammation – up to 500

to 1,000 cell layers of tissue damage vs. 3 to 5 with a diode laser•  Unlike electrosurge devices, a diode laser will cauterize nerve endings, minimizing

discomfort intra- and post-operatively.•  Tissue treated with a diode laser stays exactly where the clinician leaves it post-

operatively; no worry of rebound or recession.

Tissue contouring! Fibroma Removal!•  Fibroma removal is easy, fast and atraumatic for your patient.•  Advantages of using a laser vs. traditional modalities •  Cut and coagulate at the same time •  No bleeding •  No sutures •  Little to no post-operative pain and discomfort

Pre-op Immediatepost-tx 2weekspost-txPhotosCourtesyofDr.Glenn

vanAs

Frenectomy!•  A diode laser is an ideal instrument to complete a frenectomy – no more scalpels

or sutures needed! •  Advantages of using a laser vs. traditional modalities •  Cut and coagulate at the same time •  No bleeding •  No sutures •  Little to no post-operative pain and discomfort

Pre-op Immediatepost-tx 1monthpost-txPhotosCourtesyofDr.Phillip

Hudson

Conclusion!•  A diode laser can be a remarkable addition to a

practice•  Improves clinical outcomes, promotes faster healing•  Essential ‘bread and butter’ procedures can generate

fast ROI and get you off and running as a laser dentist•  Safe around metal – implants, amalgam, matrix bands•  Proven effective in decontaminating root canal spaces•  An excellent tool for perio and hygiene

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LiteTouch - hard tissue laser!•  Fast-cutting, high-energy non-fiber

Er:YAG dental laser for treating both hard and soft oral and maxillofacial tissues.

•  Innovative Laser-in-Handpiece technology with the familiar feel of a turbine drill. The unique design makes it easy to achieve cleaner, gentler treatments with less anesthesia and minimal recovery time.

LiteTouch Hard/Soft Tissue Laser!•  RESTORATIVE DENTISTRY•  • Exceptional Visibility: Non-contact work•  • Microsurgery: Precise & selective ablation of carious lesions; avoids unnecessary ablation of healthy

tissues; enables class 2, 3, and 4 restorations without damage to surrounding teeth•  • No vibration: No micro cracks. Etched surface, for better composite adhesion•  • Bactericidal effect: Due to thermal characteristics of laser energy•  • Desensitization of sensitive teeth and root exposure

•  IMPLANTOLOGY•  • Ergonomic & comfortable for transmucosal implantation•  • The most effective treatment modality for peri-implantitis and implant decontamination•  • Biostimulation for better bone and soft tissue healing•  • Safe when working around implants and other intraoral metals. Ideal for implant uncover and soft tissue

modification• 

LiteTouch Hard/Soft Tissue Laser!•  ENDODONTICS•  • Minimally invasive opening preparation: No thermal damage or microcracks•  • Bactericidal efficiency: Removes smear layer and cleans root canals; Venturi effect even results in clean

dentinal tubules•  • Apicoectomy: Performed with unique accessories•  • Sterilizes the canal system and improves Endodontic irritants killing both aerobic and anaerobic bacteria

•  PERIODONTICS•  • Effective and unrivaled pocket debridement: Bactericidal effect (disinfection)•  • Excellent surgical precision: Precise & selective granulation tissue ablation avoiding unnecessary damage

of healthy tissues•  • Effective and selective calculus removal•  • Faster healing of surrounding tissue and bone: Minimal postoperative swelling and discomfort, leading to

fewer follow-up visits

LiteTouch Hard/Soft Tissue Laser!•  PEDODONTICS•  • The preferred method for treating children: No fear factor; shorter procedures; less noise; no

vibrations•  • Preventive Dentistry: Precise and delicate treatments; minimally invasive; enables microsurgery (pits and

fissures) that preserves healthy tissue•  • Friendly equipment: Well-accepted by kids•  • Ideal for hard or soft tissue crown lengthening either open field or closed through the sulcus•  • Improves treatment of periodontal disease by sterilization of the pocket, granulation removal and

stimulation of the crestal bone

•  AESTHETIC DENTISTRY•  • Precise manipulation: Gingival re-contouring, smile design & depigmentation of natural melanin deposits•  • Excellent for debonding porcelain veneers: Allows dentists to reuse veneer while maximally preserving

tooth substance•  • Anesthetic free treatment makes patient management easier on staff, doctor and patient

Picasso•  2.5WaOs•  (3)pre-sets•  Membranescreenwithsimplifiedthree-buOoninterface

•  Adjustableaimingbeam•  Pulse/con@nuousmode•  2-yearwarranty•  Perfectforfirst-@melaserden@st

CE CODE: CESHAH16

The state of digital dentistry!

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•  CAD/CAM dentistry has been around for almost 30 years but only 15% of dentists have adopted

•  Labs have rapidly adopted and benefitted from CAD/CAM technology for the past decade

•  While adoption has been slow, the shift to digital dentistry is inevitable and adoption is increasing


Digital materials and workflows are proven:

•  CAD/CAM materials have gained popularity and clinical acceptance

•  CAD/CAM enabled restorations continue to grow at a faster rate than traditional direct or lab restorations

•  The number of chairside mills on the market is increasing and costs are decreasing

Digital Impressions are on the Rise!Model-less Unit Growth at Glidewell Laboratories*

*Data provided by Glidewell Laboratories

How are Model-less Crowns Performing?!

Digital vs. Conventional*

•  80% reduction in returns for margin errors

•  60% reduction in returns for occlusion

•  55% reduction in returns for fit issues

•  30% overall reduction in remakes

What prevents doctors from moving forward?!

Traditional Scanners:

• Unreliable/Inconsistent

- performance and restoration quality

• Closed systems

- limits indications, materials & labs

• Expensive

- higher upfront and on-going costs

New Generation Scanners (TrueDef):

• Accurate/Reliable/Consistent

- more accurate, consistent and intuitive

• Open & Trusted

- open STL files and trusted connections expand revenue opportunities and applications

• Affordable

- more affordable and increased ROISirona

E4D

Carestream

IOS -Glidewell

Restoration Fabrication!

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CS 3500 Mill!

•  Primary focus is single unit restorations

•  Single bur milling

•  Self contained water system

•  Approximately 15 minutes of mill time

•  Total system cost approximately $70,000

CS 3500 Suite!

•  No powder scan

•  CBCT unit can scan a traditional impression an output to design

•  Color rendering scanner

•  Light guidance system allows the practitioner to look at the dentition versus the monitor

CS 3500 by Carestream

Apollo DI - Summary!•  Powder is necessary

•  Live continuos scan

•  Grey color rendering

•  Touch screen

•  Can be sent to a CEREC connect lab

•  $19,750 (No click fees)

iTero summary!•  Powder free system

•  Individual images are taken, newest software allows for continuous capture

•  Simulated color rendition

•  Open STL file format

•  Only system that Invisalign currently accepts

•  $25,000 - $32,000

Trios by 3Shape!•  3Shape has a very high percentage of

the laboratory scanner and design marketplace

•  The company actually started by imaging ear in order to create custom fit hearing aids

•  Trios monochromatic was there first entry into the market about 2 years ago

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TRIOS CART!•  Live 3D visualization - model built during

scanning•  Medical grade touch screen•  Integrated heating pad - to warm scanner•  Rechargeable battery•  Wifi•  Cost - $30,000 - $40,000

TRIOS® 3 ! Variety of Needs!

TRIOS® 3 !Your all-in-one

solution!

TRIOS® 3 !Hardware Configurations!

TRIOS® Pod TRIOS® Ortho

TRIOS® Chair Integration TRIOS® Cart

RealColorTM ! Shade measurement while scanning!

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Intraoral Camera and HD Photo !

Planmeca FIT!

•  Powder free system

•  Blue laser scanning in the mouth with immediate processing

•  Heated mirrors

•  Thunderbolt connection

•  Open STL file format

•  Open mill - compatible with 3Shape, iTero and TruDef Scanner

Planmeca FIT!n  Romexis image managementn  Super portablen  Comprehensive design toolsn  Easy workflow with 2D & 3D treatment planning

n  Open compatibility for easy sharing of resultsn  Implant planningn  Import & superimpose soft tissue, crown design, and CBCT data

n  3D tools for Orthodontic and Dental Labs

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eMax cad!

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Block Materials!

n  Compositen  Leuciten  Feldspathicn  Lithium Disilicate n  Zirconia

All - Ceramic

High Strength All-ceramic

Ceramics!

True Definition Summary!

•  Powder is mandatory

•  High image acquisition rate looks like video

•  Currently scan in rendered in a buff color

•  Open STL file format - Trusted connection

•  $15,000

True Definition 3D-in-motion !

Selecting prep and checking margin!

What about accuracy?!

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Clinical use of a direct chairside oral scanner !

Evaluation: Fifteen patients had digital models made from both intraoral scans (Lava COS; 3M ESPE, St Paul, Minn) and alginate impressions. Each procedure was timed, and patient preference was assessed with a survey. In addition, digital models were made from 5 plaster model pairs using the intraoral scanner and an orthodontic model scanner. Model pairs were digitally superimposed, and differences between models were quantified. Accuracy was assessed using the Bland-Altman method. Time differences were tested for statistical significance with the Student t test Conclusions: Digital models made using the chairside oral scanner and either impressions or

the orthodontic model scanner did not differ significantly. The chair time required to take impressions was significantly shorter than the time required for the intraoral scans. When processing time was included, the time requirement did not differ significantly between methods. Although 73.3% of the patients preferred impressions because they were "easier" or "faster," 26.7% preferred the scan because it was "more comfortable."

Am J Orthod Dentofacial Orthop. 2014 Nov;146(5):673-82. Clinical use of a direct chairside oral scanner: an assessment of accuracy, time, and patient acceptance.

Grünheid T1, McCarthy SD2, Larson BE3.

Digital vs. conventional implant impressions: efficiency outcomes!

Evaluation: The aim of this pilot study was to evaluate the efficiency, difficulty and operator's preference of a digital impression compared with a conventional impression for single implant restorations Conclusions: Digital impressions resulted in a more efficient technique than

conventional impressions. Longer preparation, working, and retake time were consumed to complete an acceptable conventional impression. Difficulty was lower for the digital impression compared with the conventional ones when performed by inexperienced second year dental students

Clin Oral Implants Res. 2013 Jan;24(1):111-5. Digital vs. conventional implant impressions: efficiency outcomes.

Lee SJ1, Gallucci GO

Fit of all-ceramic crowns: Silicone vs Digital Intra-oral Impressions!

Evaluation: The aim of this study was to compare the fit of ceramic crowns fabricated from conventional silicone impressions with the fit of ceramic crowns fabricated from intraoral digital impressions. he internal gap was determined as the vertical distance from the internal surface of the crown to the prepared tooth surface at four points (marginal gap, axial gap, crest gap, and occlusal fossa gap) using stereomicroscopy with a magnification of 40×. Data was analysed by using Wilcoxon signed rank test (α=0.05). Conclusions: Impressions obtained from an intraoral digital scanner based on

wavefront sampling technology can be used for manufacturing ceramic crowns in the normal clinical practice with better results than conventional impressions with elastomers.

J Dent. 2015 Feb;43(2):201-8. Clinical evaluation comparing the fit of all-ceramic crowns obtained from silicone and digital intraoral impressions based on wavefront sampling technology.

Pradíes G1, Zarauz C2, Valverde A2, Ferreiroa A2, Martínez-Rus F2.

Fit of all-ceramic crowns: Silicone vs Digital Intra-oral Impressions!

Evaluation: The purpose of this study was to determine and compare the marginal fit of crowns fabricated with digital and conventional methods. The maxillary right second premolar was prepared for a ceramic crown in a typodont. Circumferential marginal gap measurements were made at 8 measurement locations. Measurements were made to determine the vertical component of the marginal gap according to the definition of marginal fit. Conclusions: A total of 240 images (2 groups, 15 crowns per group, 8 sites per crown) were

recorded and measured. The overall mean ±SD vertical gap measurement for the digitally made crowns was 48 ±25 μm, which was significantly smaller than that for the conventionally made crowns (74 ±47 μm). The fully digital fabrication method provided better margin fit than the conventional method

J Prosthet Dent. 2014 Sep;112(3):555-60. A comparison of the marginal fit of crowns fabricated with digital and conventional methods.

Ng J1, Ruse D2, Wyatt C3.

3M™ True Definition Scanner Accuracy!

• Powerful “3D-in-Motion”video technology provides a true replica of dental anatomy allowing you to simultaneously capture and view in extraordinary detail.

• The accuracy is so reliable, it doesn’t require a model.

• Creates restorations and appliances with unmatched fit, eliminating the need for retakes, remakes and adjustments—instilling confidence and loyalty with your patients.

Implications of Inaccuracy!If the marginal gap is more than the width of a human hair (50 microns), a dentist can see it, a patient can feel it, and the restoration may fail prematurely.

For a 5 millimeter crown this means the errors cannot exceed more than 1%.

A simple dental bridge is at least three times larger and so requires more accuracy.

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‹#›

Accuracy Reduces Retakes, Remakes and Adjustments

Accuracy Measurements of Intraoral Scanners*

*Data acquired by van der Meer WJ, et. al. at the Academic Center for Dentistry Amsterdam

Data points that fall outside the error of margin (0.3%) typically become remakes or retakes

3D Video Capture Provides Superior Accuracy!

The only scanner designed with proprietary 3D-in-motion video data capture

Point-and-stitch Reconstruction 3D-in-motion Video Data Capture

Why powder with titanium oxide?!

• All intraoral scanners have problems scanning reflective, shiny surfaces

• A light dusting of titanium oxide enhances accuracy

• A light dusting of titanium oxide would enhance accuracy of other systems promoting powder-free scanning

Coated with CEREC Powder

Light Dusting of 3M Scanning SpraySource: 3M ESPE

What about color?!• Systems that display color scans are only presenting a

simulation of the data

• Opportunities for error may arise when designing and producing restorations or appliances based on simulated data

• The 3M™ True Definition Scanner captures true stereoscopic 3D video to ensure accuracy from scan to final production

• There is no data available to confirm that color adds clinical value

Scanning Tissue, Blood and Saliva!

• No digital impression system on the market can “see through” tissue or fluid.

• All require proper retraction and isolation to accurately capture the preparation data.

“If you can’t see it - you can’t treat it”

Workflow!

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Time management!

Typical restorative appointment for single appointment crowns•  Anesthetic – Scan (time to scan opposing arch or pre-tx

scan)•  Preparation & retraction/hemostasis (Doctor time)•  Scan treatment arch & bite•  Temporization (Doctor time?)•  Cementation (Doctor time)

What happens after you press Transmit?!

3M™ Margin Marking Software! For those that prefer models……….!

Once marked and prepared, the high precision SLA working models are printed and delivered to your lab for any additional finishing work.

Failing cantilever bridge! Lab design!

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Milled zirconia! Delivery of final restoration!

Margin marking and die cutting! Prep dies!

Design! Printed models and final restorations!

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Final restorations! Pre-tx bridge!

Digital design! Final restorations!

Traumatic injury! !

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! !

Final restorations! Limited treatment with veneers!

Limited treatment - veneers! Pre-tx shade tabs!

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Stump shades! “Natural die” (lab procedure)!

Printed models! Final restorations!

Digital design! Unhappy with her crowns - monochromatic!

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Shade tabs! Metal-ceramic crowns!

Masking agent! Stump shades - “natural die”!

Digital design! Digital design!

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Digital design! Final restorations!

Final smile! Implant scans!

Scan bodies! Atlantis abutments!

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Digital vs analogue models! Final restorations!

Final Restorations!

Abutment & Crown Selection !

Abutments for cement-retained restorations!

ATLANTIS™ Direct Abutment™ TiDesign™

ZirDesign™

CastDesign™

Abutment selection!•  Indication; single tooth/

partial bridge/full fixed bridge

•  Upper or lower jaw•  Anterior or posterior

region•  Implant angulations•  Marginal bone levels•  Soft tissue levels•  Occlusal interproximal

space•  Adjacent teeth and roots•  Esthetic demands

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Direct Abutment !– restorative flexibility!

•  Titanium

•  One-piece component with 6° tapered top

•  Three diameters

•  Four vertical heights

•  Laser etched marked line for occlusal reduction

Direct Abutment!Ø 4�Four marginal and three vert. heights �Ø 5�Three marginal and �vert. heights

Ø 5�Four marginal and three vert. heights �Ø 6�Three marginal and �vert. heights

Direct Abutment system!

Cover screw in place Removed cover screw


Abutment installation


Recommended torque for final seating 25 Ncm


Impression taking

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Impression with �Direct Abutment �Pick-up in place

Provisional crown


Abutment replica in place

Final crown restoration

Direct Abutment crown fabrication!

Abutment level impression �- Align the flat surface of the abutment with the raised knob on the Impression Pick-up and seat the pick-up firmly by

snapping it into place.

Impression and temporization!

Temporization�- Healing Cap can be used in combination

with the Direct Abutment™ as a base for a temporary solution.

ATLANTIS™ !– CAD designed “customized” abutments!

ATLANTIS™ abutment!

- patient specific CAD/CAM abutments

- designed in a software

- designed after scanning of a cast with implant replicas

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ATLANTIS™ abutments!

ATLANTIS™ Abutment, titanium! ATLANTIS™ Abutment, GoldHue™ !ATLANTIS™ Abutment, zirconia (available

in four shades)!

ATLANTIS™ zirconia abutments!

•  Milled from shaded zirconia blanks for optimal esthetic result

•  One-piece ceramic component

•  Eliminates the need for field modification

Compatibility!•  ASTRA TECH Implant System•  BioHorizons•  Biomet 3i•  Camlog•  DENTSPLY Friadent•  Keystone Dental•  Nobel Biocare•  Straumann•  Zimmer Dental

All trademarks are the property of their respective owners

Virtual Implant Design:!designed from the final tooth shape!

The scanned model is transformed into a 3D image, making it possible

to create the final tooth shape.

When the desired tooth shape is decided, the abutments are

designed.

The final design is checked for fit and occlusal clearance before the

abutments are produced.

ATLANTIS™ abutment vs. stock abutment!

ATLANTIS™ patient-specific abutment

Stock abutment

Atlantis Abutment !- emergence width options!

No tissue displacement Support Soft tissue Contour soft tissue Full anatomical dimensions

Narrow Healing Situation

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Atlantis Abutment !- emergence width options!

No tissue displacement Support Soft tissue Contour soft tissue Full anatomical dimensions

Wide Healing Situation

ATLANTIS™ abutment vs. stock abutment!

- cad/cam abutment design provides optimal support and retention for the final restoration

- helps reduces costs of alloy in the framework

Procedure!Impression:•  Take an

implant-level impression

•  Send the impression to your laboratory

Design and production:•  The models are scanned and

generated into a virtual 3D image•  An ATLANTIS™ abutment is designed

for the specific edentulous space•  The customer has the option to review

and approve the design before it is send to manufacturing

Lab Procedure!

Scanning and design process!Scanning! 3D image!

Ideal crown! Design abutment!ATLANTIS™ 3D Viewer – animation

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Checklists!

APX RE-EVAL ACTIVETHERAPY Pa@entName: .

PM/CC PMX CCX

APX RE-EVAL ACTIVETHERAPY Pa@entName: .

PM/CC PMX CCX

ReviewMedHistoryMedicalAlertsandMedica@ons(uptodate) Pa3entInterview

EducatePTonPeriodontalExam

PeoplePaper/FORM

ReviewGoalsandAddressOutstandingTxPa3entInterviewandConcerns

HardTissueChar3ngExis@ngTx(uptodate) Den3stSec3on

Diagnosis

Re-Eval?/AppointmentFrequency

TreatmentRecommenda@onsPerioAssessmentPocketsRecessionCALBleedsFurca@onsMobilityCASETYPE:Den3stSec3on

RadiographsPAN2/4BWPA

IntraoralPhotosTooth#(s) Pa3entEduca3on

ReviewGoals/Needs

ReinforceFindingsandCondi@ons

DiscussTreatmentBenefits

BookNextHygieneApt(REASONCODE!!!)

PromotePrac@ceand/orAskforReferral

Pa3entEduca3onand3-5MinCheckout

AwerAppointmentClinicalNotesNextVisitwithReasonCode!!andUnitsReq.DISCprofile

Let me tell you about my story……!

Unidisciplinary Dentistry

Multidisciplinary Dentistry

Interdisciplinary Dentistry

§ Non-integrated Dx and Tx Planning

§  Ignorance of other

disciplines

§ Minimal collaboration

Adapted from R. Roblee, DMD

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Unidisciplinary Care!

Lou!

“I have Bugs Bunny teeth” Getting married in 2 months

Recession Wear/bruxer

Contact areas and interdental spaces

Ideal Treatment Options?!

Ideal treatment options: Orthodontics

Periodontal grafting Bruxism appliance Restorative/veneers

Success?.......Accomplished goals within his comfort level

Darlene!

“I never smile” Occlusal plane

Tooth proportions Peg laterals Crowding

Discolored teeth

Treatment Options?!

Full mouth C&B Orthodontics

Correct occlusal planes Extractions Restorative

Periodontal therapy?

!

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disciplines


§ Awareness of benefits of other

disciplines

§ Unstructured collaboration

§ Separate goals


Multidisciplinary Care!

Olga!

Unhappy with smile Partial upper denture

Discolored teeth Failing restorative

Recession No posterior occlusion

I want dental implants!!!

Off to the Oral Surgeon....! Restorative Challenges!

Angulation

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Esthetics??!

Communication issues? Proper treatment planning

Mounted casts Diagnostic wax up

Surgical guide Conference with surgeon

Final Restorations!

Still have a happy patient, but the process and results could have been better

Cliff - Failing tooth! Surgical stent!

Referral for Implant !

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Plan B - larger bridge! Jessica!

Congenitally missing teeth!

“I want my teeth replaced” Multiple missing teeth (8) Tooth shape/proportions?

Root angulations? Bone grafting?

Divergent root

Divergent roots

Primary E’s Primary E’s

Type to enter text

Visual the end result!

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Take home message?Proper communication (restorative dentist, surgeon, orthodontist)Treatment planning from the start

Progress films!

To be continued.........

Treatment Plan with the “end in mind”…….!

“To have an accurate starting point, every problem to long term health must be

identified…….planning the complete process to a visualized end point should come

first.”!

Dr. Peter Dawson

Interdisciplinary Care!






disciplines


§ Awareness of benefits of other

disciplines

§ Unstructured collaboration

§ Separate goals

§ Working common knowledge (“think

alike”)

§ Structured collaboration

§ Common goals


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Shauna - “I hate my smile”!

Mishaped teeth space appropriation

Missing laterals Midline

Rotations Wear

Extractions Crown & Bridge Partial Dentures

Implants Restorative

Orthodontics

Initial Presentation!

Initial Presentation!

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Mid-treatment transitional bonding!

�  Assess progress throughout treatment

�  Make necessary adjustments to contour, shape of teeth to allow orthodontist to place roots in proper position

�  Conservative treatment options: bonding vs. preparing

Final goal is to allow for ideal treatment choices!

…….Dental implants!!!

Treatment and Material Options?!

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Compromise without closing doors!

Jessica - congenitally missing teeth!

“I want my teeth replaced” Multiple missing teeth (8) Tooth shape/proportions? Root angulations? Restorative Crown & bridge Implants Bone grafting?

Completed Orthodontics!

Diagnostic waxup for bone grafting Surgical template guide

Final Impressions!

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Final Abutments - tryin! Final waxup for crown design!

Final Restorations - Transitional Bonding! !

Treating Dental Esthetics!

Important to evaluate all these key areas:•  If tooth position, gingival heights and arrangement of the

teeth are acceptable, we only have to focus on color and tooth shape

•  When any combination of tooth position, gingival heights & arrangement of teeth are not acceptable, the treatment is more complex and often may involve other disciplines and altering occlusion.

Facial assessment & pre-prosthetic planning!

•  Interview on Facial Esthetics

Dr. David Sarver, Progress in Orthodontics, 2006 7(1):66.

•  Macro-esthetic Elements of Smile Design

Jeff Morley and Jimmy Eubank, JADA, Vol. 132, January 2001, p.39-45

•  Correlation of the AACD Accreditation Criteria and the Human Biologic Model

Kenley Hunt and Mitch Turk, Journal of Cosmetic Dentistry (Fall 2005) vol. 21(3):120.

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Anterior Esthetics!•  Generally accepted values for ideal

tooth dimension of anterior teeth: 8:10 height/width ratio for the central incisors (short red lines)

•  Contact placement (yellow dot)•  Connector length (blue line)•  Papilla height (yellow highlight)•  Axial inclination of the crown and root

(long axis; long red/yellow lines)•  Gingiva shape and contour with zenith

placement (blue dot).n  Sarver, D. Journal of Esthetic and Restorative Dentistry vol 23 • No 5 • 296–302 • 2011

•  41 year-old healthy female

•  Congenitally missing laterals

•  Orthodontics in her teens which lateralized her canines

•  Retained primary canines - mobility

•  Concerns with her smile

Clinical Scenario !

•  Medical history clear with no contraindications for dental treatment

•  Heart murmur – not requiring prophylactic antibiotics

•  Medications – birth control

•  No known drug allergies

•  ASA Type I

Diagnostic Findings: medical history

•  No palpable nodes

•  Maxillary and Mandibular dental midlines near coincident with facial midline

•  Overall Facial symmetry – although tip of nose may be slightly to patient’s right

Diagnostic Findings: extra-oral & facial

•  Excessive gingival display in the posterior regions in full smile

•  Narrow buccal corridors in full smile from the canine region distally

•  Gingival zeniths irregular within full smile

Diagnostic Findings: smile framework

•  TMJ within normal limits

•  No joint pain or sounds

•  Mandibular range of motion within normal limits

•  Patient doesn’t report any functional limitations

TMJ, Muscles & ROM!

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Clinical Presentation!

! !

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! Radiographs!

Periodontal Condition! Diagnostic Casts!

Diagnostic Casts!

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Treatment Plan Time!

Patient Concerns!

•  With the current condition of the primary canines, the patient is concerned about losing her mobile tooth before treatment ensues

• The patient does not like her smile and wishes to have her “gums” more even along with her tooth proportions

• Concerns about whether she wants to have orthodontics as part of her treatment again

Questions for Considerations?!

• How can we address the patient’s concerns of replacing the mobile primary canines while improving the uneven tissue heights of the lateralized permanent canines?

• The patient has already been through orthodontics as a teenager. If she is resistant to further orthodontic treatment, how can we achieve her goals of replacing her mobile primary canines and balancing her gingival aesthetics?

Treatment Plan Rendered!

Summary of Findings!•  Mobile retained primary maxillary canines

•  Uneven gingival heights of maxillary anterior teeth within the aesthetic zone

•  Discolored restorations on maxillary primary canines

•  Maxillary primary canines are palatally positioned so that they are not aligned with the arch form.

•  Poor length to width ratio for “lateralized” maxillary canines

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•  Facial appearance & symmetry - vertical, saggital and transverse

•  Smile framework - tooth/gingival display, smile arc & width of smile, etc.

•  Tooth proportions, heights, widths, shape & Gingival details, etc.

Esthetic Assessment!

n  Sarver, D. Journal of Esthetic and Restorative Dentistry vol 23 • No 5 • 296–302 • 2011

n  Interview on Facial Esthetics - Dr. David Sarver, Progress in Orthodontics, 2006 7(1):66. Our goals should be to create

Harmony between Macro, Mini and Micro Esthetics.............!

while keeping in mind the patient’s desired outcome and best interest!

Esthetic Challenges?!

Macro-esthetic Elements of Smile DesignJ. Morley & J. Eubank

JADA, Vol. 132, January 2001, p.39-45

Treatment Options? orthodontic-implant-restorative approach

- Distalize canines into original position

- Implants to replace laterals

- Osseous & soft tissue grafting as required

- Additional restorative as required

- Implants to replace the canines

- Indirect restorations on the laterals

- Osseous & soft tissue grafting as required

- additional restorative as required

Treatment Options? implant-restorative approach

- Fixed Bridges from #5 - 7 & #10 - 12

- Additional restorative as required

- Osseous or soft tissue grafting as required

Treatment Options? restorative approach

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What about Patient Expectations?! Diagnostic Casts!

!Ovate pontic development! Provisionals!

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Pre-surgery!

Dr. A. Kelekis-Cholakis

Post-surgery!

Dr. A. Kelekis-Cholakis

Ovate pontic development! !

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Periodontal Update -

Prior to definitive restorations

Text Text

! !

! Follow-up (7 months)!

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Follow-up (7 months)!

•  59 year-old female

•  Admin assistant - retired due to stress leave

•  Recovering from breast cancer - tamoxifen, crestor, pariet, citalopram, vitamins

•  Extensive dental work - veneers, implants, extractions

•  Periodontal, Biomechanical, Functional Risks - Moderate to high Risk

•  Esthetics - MOD to HIGH Risk - High lip dynamics

Clinical Scenario ! Clinical Scenario!

Clinical Scenario! Patient Concerns?!- Pressure on #8 - fear of losing more teeth- Hides her smile- sore jaw muscles because she finds it hard to find a comfortable bite- small implant crowns (quad #3)- missing teeth #4 and 5- discolored teeth/crowns

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Biomechanical !Restorative Considerations

- Tenderness to percussion on tooth #8 (endo treated)- Second set of porcelain veneers #6-11- Implants #19, 20 &21- Crowns on several molars and bicuspids- older amalgams- missing teeth #4 and 5

Periodontal Status!

Functional Risks!Moderate Risk

- #8 percussion sensitive

- moderate to severe crowding

- muscle tenderness and fatigue

- no joint pain or sounds

!

! !

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Esthetics!Moderate to

High Risk

- Facial assymetry

- Canted occlusal plane

- Gummy smile (patient hides it with lip posture)

- Class II profile

Treatment Options?!Restorative/Surgical Approach- Stabilize periodontal condition- Partial dentures?- Additional implants- Crown and Bridge?- Bonding and/veneers

Compromises?- Tooth postion- Periodontal maintenance- Gingival architecture- Class II profile

Treatment Options?!Orthodontic/Surgical/Restorative

- Stabilize periodontal condition- Orthodontics/Orthognathic SX- Implants (grafting?)- Crown and Bridge- Bonding and/veneers- Periodontal surgery?

Compromises?- Gingival architecture flatter/blunted- “Black triangles” - restorative challenges- Gummy smile depending on surgery

Treatment Plan Time!

Treatment Progress! Treatment Progress!

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Treatment Progress!

!

Diagnostic waxup - occlusal overlay! Altered Occlusal plane!

Post orthodontic tx! Post orthodontic tx!

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Implant restorations! Provisionals!

Teflon tape! Pre-tx!

Progress photos! Progress tx!

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Progress tx! Handouts for download!

shahlectures.com

Thank You for your attention!Questions?

Dr. Paresh Shah

[email protected]

www.drpareshshah.com

Documents

Dr. Paresh Shahd1ue90e5sp4tcv.cloudfront.net/2900/images/Asset293921_v1.pdf · Paresh Shah, DMD, MS (Physiology), Cert. Esthetic Dentistry Paresh Shah, DMD, MS, Cert. Esthetic Dentistry!