Todd Snyder, DDS, FAACD, FIADFE, ASDA · Accredited Fellow, American Academy of Cosmetic Dentistry Fellow, International Academy for Dental Facial Esthetics Member of The American

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Accredited Fellow, American Academy of Cosmetic Dentistry

Fellow, International Academy for Dental Facial Esthetics

Member of The American Society For Dental Aesthetics

Former Faculty, UCLA Center For Esthetic Dentistry

Speaker, Catapult Education

LEGIONpride.com, Online Training Challenge for Dentists

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

Aesthetic Dental Designs®

[email protected]

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Questions / To Learn:• Aesthetics?• Occlusion?• Tips & Materials?• Provisionals?• Technology?

• a d dfadfjas

Why Are YOU Here?

Yields / Possibilities:• Simplification of Process?• Confidence in Restorative Techniques?• Provide more Treatments?• Less Failures?

• a d dfadfjas

What will that DO?

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A PLAN:• Simplification?• Success?• Happiness?• Less Stress?

• a d dfadfjas

What will that give YOU?

• a d dfadfjas

What Do YOU Want?

• Expertise

• Emotion (Easy, Happy?)

• Less Stress

• Money

• Freedom?

Ultimately…

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Does Everyone know how to find CO or MIP?

• Least Invasive

• Assess problem

• Patient must be aware of problems and limitations

• What, Why, How.. (Cost & Time)

CO/MIP= X% of treatment?

CR= X% of treatment?• a d dfadfjas

How and when do you treat?• a d dfadfjas

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TMJ SIGNS & SYMPTOMS▪ Wear facets

▪ Pot holes

▪ Abfractions

▪ Gingival recession

▪ Mobility

▪ Occlusal & Incisal wear

▪ Linea Alba

▪ Tongue scalloping (Crenations)

◼ Muscle hypertrophy

◼ Muscle tension/tenderness

◼ Muscle rigidity

◼ Limited opening

◼ Guarding on CR closure

◼ TMJ noise

◼ Head and Neck aches

◼ Tooth sensitivity

◼ Ear problems, ringing, buzzing, fullness

◼ TMJ locking history or other

◼ Orthodontics history

OCCLUSAL & INCISAL WEAR

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WEAR FACETS

Pot Holes

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GINGIVAL RECESSION & ABFRACTION LESIONS

ABFRACTION LESIONS• Sometimes it presents as single teeth due to excursive interferences or as a

pivot, fulcrum or “teeter totter” tooth.

• Other times there are more in a quadrant and there is severe wear to the occlusion.

• Other times it maybe on the facials of anterior teeth, where there is wear on the incisal edges or wear facets on the linguals, however little to no wear on posteriors.

• Occlusal guards should be fabricated along with an occlusal analysis in CR on models.

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Flowables?

Microleakage and missing fillings from high occlusal loads on teeth can cause large cervical stress concentrations resulting in disruption of the bonds between the hydroxyapatite crystals and the eventual loss of cervical enamel and dentin.

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ABFRACTION LESIONS & CLASS V RESTORATIONS

LATIN WORDS, AB – “AWAY”, FRACTION – “BREAKING”

• Pathological loss of tooth structure caused by biomechanical loading forces.

• Static and cyclic flexural overloading of tooth structure ultimately leading to fatigue and failure of tooth structure away from the point of loading.

RESIN MODIFIED GLASS IONOMERS(RMGI)• Light cured

• Dual cured

• High flexural strength

• Lower compressive strength than conventional G.I.

• Good polishability

• Excellent wear

• Hydrophillic

• Fluoride release

• No microleakage

• No adhesives

• Acid resistant layer

• Reduces sensitivity

• True chemical adhesion

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• Resin bonding is mostly due to the intertubular dentin.

• Deep preparations have less intertubular dentin.

• More moisture present due to odontoblastic tissues and fluid

• Higher risk of post-op sensitivity

• Use a New Advanced Adhesive and Flowable

• Glass Ionomer (GI)

• True adhesion to tooth structure

• Bonds to moist dentin

• Less technique sensitive

• Fluoride release

• Decreased gap formation and cusp deformation

• Coefficient of thermal expansion is similar to dentin

• No post operative sensitivity

• Use on dentin & cementum

• Base out deep areas

• Place resin/composite on top of GI

Replacing Existing Restorations & Decay

Dentin Bond Strengths of Simplified Adhesives: Effect of Dentin Depth. Compendium June 2006, p.340-345

Using Cavity Liners with Direct Posterior Composite Restorations. Compendium June 2006, p.347-351

RESIN MODIFIED GLASS IONOMER RESTORATIONPost-Op Photo – notice unlike typical class V composite RMGI restorative material.

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https://www.ncbi.nlm.nih.gov/pubmed/16792342

https://special-issues.cdeworld.com/courses/4366-using-cavity-liners-with-direct-posterior-composite-restorations

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Typical treatment involves the placement of a #00 retraction cord on each tooth followed by a shade selection. Roughen tooth structure with air abrasion. Place cavity conditioner on all areas to be restored for 10 seconds, then wash and dry.

Restorative Therapy- Case TIP

Mix RMGI and syringe into place. Utilize hand instruments to shape and remove gross excess. Cure each tooth for 20 seconds. Remove excess and contour using a handpiece with fine diamond burs. Teeth should be isolated from saliva.

Restorative Therapy- Case

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After contouring the restorations can be coated with a self etch adhesive coating, and cure for 10 seconds.


Ten year post-op photos show the integrity of the material is still

excellent. Note the lack of marginal microleakage stain often

present with composite restorations.


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RESIN MODIFIED GLASS IONOMER

Fig. 15 – Graph representing the mean annual failure rates

per adhesive class, determined according to a systematic

review of Class-V clinical trials of adhesives during the

period 1998–2004 [2].

Van Meerbeek B, et al. Relationship between bond-strength tests and clinical outcomes. Dent

Mater (2009), doi:10.1016/j.dental.2009.11.148

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CENTRIC OCCLUSION DENTISTRY*

*OUT OF OCCLUSION DENTISTRY

Red Blood Cells 2 – 5um

200-500nm

Human Hair 60 –120um

6,000 – 12,000nm

?

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SHIMSTOCK & ARTICULATING PAPER

What do you use…..

.…and why?

SHIMSTOCK & ARTICULATING PAPER

• Parkell Accufilm II is 21µm for dentistry

• Great Lakes articulating ribbon 12µm

• 8µm Almore Shimstock foil

• 8µm articulating paper??

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What do you use…..

.…and why?

8µm articulating paper

Available in blue

And red too!

TROLLDENTAL-8ΜM ARTICULATING PAPER

TIP

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• Verify bite• Shimstock

• Over Impression

• Preparation

• Bite Registration• Dead soft Delar Wax

• Firm, Hard Bite Reg

• Shimstock

• Facebow

• Full Arch Impression

• Provisional

• Lab Articulation

Bite Registration

PDL & OCCLUSAL RECORDSThe range of PDL width: 0.15mm ~ 0.38mm

• Average PDL width by age:

o 11 ~ 16 years old: 0.21mm

o 32 ~ 52 years old: 0.18mm

o 51 ~ 67 years old: 0.15mma

• The PDL width decreases with age.

• The PDL width is thinnest around the middle 1/3 of the root.

• Tooth with more function has bigger PDL space

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Occlusal Testing Hold

Drag

No Hold (None)

SHIMSTOCK

• Holds• Means that when biting firmly in C.O. the shimstock can not be

pulled out

• Drags• Means there is resistance on the shimstock but it can be pulled

out slowly

• No Hold• There is no resistance what so ever when pulled between

occluding teeth.

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BUILT IN ERRORS!Thickness??Rotation?? Rocking??

Function & Failures

• Closed Bite Trays (most common)

• Lack of rigidity may cause distortion

• Spring back after impression potential

• No cross arch stabilization

• Thin spots or perforations can cause distortion

• Impression material shrinks towards bulk

• Unable to recreate excursive movements

• Potential for errors & adjustments extremely high

Impression Trays

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QUAD TRAY EXTREME (CLINICIAN’S CHOICE)& BITE REGISTRATION

PEER REVIEWED

The Catapult Group rated the Quad-Tray Xtreme as better than, just as good, or tied with other available closed bite trays.

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QUADRANT & DISPOSABLE ARTICULATORS

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Bite Registration & Occlusal IndexingTIP

LITHIUM DISILLICATE (EMAX)

• Simple

• Fast

• In Occlusion

• Minimal or No Adjustment

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CEMENTATION

Disposable Articulators

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Semi Adjustable

not on Hinge Axis

Semi Adjustable

not on Hinge Axis

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is a zinc-oxide non-eugenol, automix temporary cement with a unique polycarboxylate resin

The addition of polycarboxylate optimizes adhesion, soothes the tooth, and provides an

excellent seal, while allowing the material to be easily removed from the tooth preparations

when desired.

Cling 2 (Clinician’s Choice)

30 second working time, 60-90 second set time

Good adhesion, easy removal

Low film thickness

Excellent marginal seal

Biocompatible – protects the gingival tissue

Resists forces of mastication

2 year shelf life

Utilize an accurate preliminary over impression

Maintain over impression

Check contacts and occlusion

Place temp cement only on margins

Do not fill temp with cement

Or vent holes

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TRY-IN / NO ADJUSTMENTS…

• A few steps makes a big difference

• Patients notice the difference.

• Do you want to be like everyone else?

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KEY TO ADJUSTMENTS

• Full Arch Impressions

• Facebow

• Bite Registration

• Semi Adjustable Articulator

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ASAP INDIRECT + POLISHERS(CLINICIAN’S CHOICE)

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CERAMIC ADJUSTMENT

• Jiffy Ceramic Polishers (Ultradent)

OCCLUSAL RECORD/BITE REGISTRATION

Fast Setting Rigid PVS

Or

Wax

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MODEL ARTICULATION & EQUILIBRATION

INCISAL PINS

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Selection Process

◦ Open Bite Trays

Plastic-full or quadrant

Metal-full or quadrant

Custom Trays

Non-perforated or perforated (metal or plastic)

Rigidity can eliminate tray distortion and rebound

Spring back after impression is possible with plastic

Cross arch stabilization

Ideal occlusal stops for proper model articulation

Able to recreate excursive movements if mounted on a semi or fully adjustable articulator.

Potential for errors & adjustments are low

IMPRESSION TRAYS

STOCK TRAY SIZES

Impression Trays

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DIFFICULT FOR IDEAL FIT

Impression Trays

IMPRESSION TRAYS

• Custom trays create more ideal placement

• Thinner material creates less distortion

• USE TRAY ADHESIVES for all open bite trays, not just custom trays.

• Only negative is time

Selection Process

Custom Tray

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HEATWAVE TRAYS BY CLINICIAN’S CHOICE

• 4 upper & lower trays

• 60 sec. @ 158°F

• Fast, efficient

• Virtually custom

• 30% less impression material used

Impression TraysTIP

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Impression Trays

HeatWave by Clinician’s Choice

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Impression Trays

HeatWave by Clinician’s Choice

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Affinity VPS(Clinical Research dental) Viscosities

Set times

Spectrum Pack

Large Volume Mixers

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Dry all teeth in arch

Place tip in most difficult area first

Keep tip on margin and immersed in material

Go around entire margin first

Next go to adjacent teeth

Then do coronal aspect of teeth

Double Mix Single Impression is the most accurate

Syringe Placement

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Customize Teeth

Checking Occlusion is the Key to Aesthetics

Interferences

Case Example: #1B

Checking Occlusion is the Key to Aesthetics

WHAT, WHY, HOW, APPLY

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What is the perceived problem?

WHAT IS THE ACTUAL PROBLEM?

WHAT

Can we find the true cause of the problem?

WHY

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◼ Aesthetics

◼ Occlusion

◼ Excursives

◼ Restorations

◼ Wear

◼ Solutions

HOW DO WE FIX THE PROBLEM? What

options are available to fix the problem?

HOW

APPLY

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TMJ SIGNS & SYMPTOMS

• Wear facets

• Pot holes

• Abfractions

• Gingival recession

• Mobility

• Occlusal & Incisal wear

• Linea Alba

• Tongue scalloping (Crenations)

◼ Muscle hypertrophy

◼ Muscle tension/tenderness

◼ Muscle rigidity

◼ Limited opening

◼ Guarding on CR closure

◼ TMJ noise

◼ Head and Neck aches

◼ Tooth sensitivity

◼ Ear problems, ringing, buzzing, fullness

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Case Example: #5

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Silginat - Kettenbach

Counter FIT- Multipurpose Replication Silicone

(Clinician’s Choice)

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Counter FIT- Multipurpose Replication Silicone

(Clinician’s Choice)

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Wear Facets & Interferences

Mounted and Equilibrated

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Custom Incisal Guide Table

GC Pattern Resin

Duralay

Sil-Tech (Ivoclar) -

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http://www.gcamerica.com/lab/products/PATTERN_RESIN_LS/

http://reliancedental.net/main_products

https://us.shop.ivoclarvivadent.com/en-us/shop/products/more-products/laboratory-silicone/laboratory-silicone-putty/sil-tech-plus-putty-1

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▪ Slow unperceivable changes

▪ Diagnosing once it’s a problem

▪ What about prior signs & symptoms

◼ Round, Brachyfacial often

◼ Limited smile appearance

◼ Worn teeth or deep bite

◼ Enlarged Masseters

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POSTERIOR INTERFERENCE (PREMATURITY)• Centric Occlusion

• Natural growth patterns

• Orthodontics

• Dental work

• Trauma

JOINT REPOSITIONED AND

STABILIZED (CRSTABILIZED)• Splint Therapy

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What happens to a Condyle when there

is an Occlusal Prematurityon a 2nd molar?

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A Veneer Case?

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CHANGE!

• Larger amounts of tooth augmentation can create potential shifts in bite

pressure on teeth, CR-CO slides, and excursive interferences.

• Material properties must become more resilient to increased wear and

pressure demands.

• Higher risk of post operative complications due to occlusal modifications,

jaw positioning, and/or adhesive techniques and materials.

• A different approach to typical Restorative Dentistry

Not a veneer case!!

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What did the patient’s teeth look like

prior to veneers? Did she have any

symptoms? Braces? Dental work?

Trauma? Etc…

Case Example: #10

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BUILD IN STRENGTH, RETENTION, AND

CREATE A GUARD

• Patient needs to understand limitations

• Sign off on doing short cut and wear an

occlusal guard

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Provisionals

-Visalys (Kettenbach)

-Inspire (Clinician’s Choice)

-Luxatemp (DMG)

Simplified Provisionals**

Siltech Putty Matrix

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

Duplicate waxup model in stone

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

model where the tissue and tooth come together.

Provisionals (Bead Line Technique)

Duplicate model with a fast setting polyvinyl impression material.

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

material.


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

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

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

acrylic flash from the provisionals for easier clean up.


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

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

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

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


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

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

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


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Cosmetic Provisionals (Bead Line Technique)


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

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

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PROVISIONALS

• Utilize an accurate preliminary over impression

• Maintain over impression

• Check contacts and occlusion

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No Polish Necessary if you use a good model

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

inlays & onlays.

MY FAVORITE TEMPORARY CEMENTS

ClearTemp LC (Ultradent)

For either veneers or thin

anterior cosmetic restorations

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Example-Centric Occlusion

▪ Anteriorly positioned condyles

▪ Occlusion is not ideal Appears to have canine guidance

Weak centric stops and limited number

▪ Patient okay for a few months

Now has joint pain, noise, muscle pain, teeth are sensitive

Centric Relation

▪ Joint in proper position

▪ Occluding only on second molars

▪ Restorative dentistry & orthodontics (aligners too)

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Normal Disc Reducing Non-ReducingNormal

Remodeling DJDRemodeling

Adolescent

Facial GrowthDecreasedInterruptedNormal

Bones

Disc

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Aesthetic Opportunities:

Developing Beautiful Smiles

Case #24 (Complex Occlusion)

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Developing Beautiful Smiles

Assessment:Joint NoiseFacial Muscle PainPoor OcclusionInvisalign Done/RetentionAnterior WearWants to Keep Appearance

Cause & Effect Diagnosis• Functional Wear on Anteriors

• Masticatory Muscle Pain

• Headaches

• Jaw Relationship / TMJ Disorder

• Obstructive Sleep Apnea (OSA)

• Combination

Aesthetics & Occlusion

Supplemental Tests:Sleep StudyCone Beam CT (CBCT)Airway Evaluation

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AIRWAY VOLUME

-50mm2 and below have an association with OSA


TMJ EVAL/Diagnosis

CBCT-Pathology-Jaw position-Bone Appearance-Active DJD/Remodeling

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Orthotic: Superior Repositioning Appliance (SRA)

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Nociceptive Trigeminal Inhibition Tension

Suppression System (NTI-tss)

Jaw Position

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NTI type appliances

Jaw Position

NITE BITE

• 5 minutes to make a Nite Bite appliance for relief of most TMJ

discomfort

• Fast fabrication

• Force distribution

• Minimal opening

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https://www.youtube.com/watch?v=xT-kwc2Btrw

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SRA FABRICATION:Try-in

Check Bite

Adjust Posterior

Shallow Ramp

Trim Trough

Occlusal Reline

Passive Centric & Hold

Mark Depth of Fossa

Trim Excess

Polish



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• Patient wears just at night the first 2-5 days

• Understands they will wear 24/7

• Patient comes back for evaluation every 2-4 weeks

• Passive reline to achieve equal contacts

• Once the bite is stable follow for another 2-4 weeks


Orthotic: Superior Repositioning Appliance (SRA)


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Occlusal Analysis



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Aesthetics & Occlusion Impression Trays

HEATWAVE BY CLINICIAN’S CHOICE


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The Nuts & Bolts of VeneersAesthetics & Occlusion

TISSUE AND MOISTURE CONTROL


A laser is more precise, causes less pain, and

prevents bleeding better than traditional tools used

on soft tissues. The highly focused laser light

cauterizes nerve endings, coagulates blood

vessels, sterilizes the surgical site, and increases

the speed of healing. Instantly cauterizing nerve

endings greatly reduces pain during the procedure

and after. Healing times can be as low as a few

days where traditional surgical approaches can take

several weeks.

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Simplified Provisionals


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Provisionals (Duplicate models)

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

model where the tissue and tooth come together.




• Verify shape

• Display at rest

• Protrusive

• Excursives

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CEMENTATION OPTIONS• Glass Ionomers

• Resin Modified Glass Ionomers

• Self Etch Resin Cements

• Bonding Agent w/ Resin Cement

• Calcium Aluminate

• TriSilicate Cement


CERAMIR (CALCIUM ALUMINATE CEMENT BY - DOXA)• Alkaline pH 8.5

• Moisture Tolerant

• Self Sealing

• Apatite Formation

• Insoluble

• Stronger with time

• Semi / Translucent

• Biocompatibility-Excellent

• Bioactivity-Apatite formation

• Sealing Quality-Excellent


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Pre-op

Post-op


Review Patient with Problems-Sleep Study Questionnaire-Sleep Study?-Cone Beam CT (CBCT)

-TMJ Diagnosis (Beamreaders.com)-Airway Evaluation

-Superior Repositioning Appliance (SRA)-Reline as needed.

-Hinge Axis-Diagnostic Model Workup-Discuss Options with Patient


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Questions?


Restoration Placement? Bonded

Margin placement Moisture Control Technique Sensitive Materials

Self Adhesives

Bonding agent (TE or SE) & luting resin

Cemented

Margin placement

Moisture Tolerant

Retention Required

Materials

RMGI

Ceramir

Cement Selection

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Cementation Material Options

Class I or II

:Tooth Preparation

3x Tubule Density Equals Higher Fluid &

Increased Difficulty for Bonding 30% Decrease in

Bond Strengths with most bonding systems.**

What substrate are we treating?

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Traditional Cementation Options

Glass Ionomers Resin Modified Glass Ionomers

Acidic pH

Moisture Tolerant

Fluoride Release

Degrades over time

Low bond strength

Biocompatibility-Fair

Bioactivity-None

Sealing Quality-Ok

Acidic pH

Insoluble

Moisture Tolerant

Fluoride Release

Stronger Than Traditional GIs

Degrades over time

Improved bond strength

Biocompatibility Ok

Bioactivity-None

Sealing Quality-Ok

Ceramic Primer on Restorations

Cement Selection

TRADITIONAL GLASS IONOMER

CEMENTATION OPTIONS

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Resin Modified Glass Ionomer Cements

Use Ceramic Primer prior to try-in

Clean with ethanol after try-in

Keep tooth slightly moist and place RMGI cement

as it will chemically cure to the tooth and the Ceramic Primer

Still want to always have good prep design

Resin Modified Glass Ionomer

Cement and a Ceramic Primer Lab sandblasts @ 30psi w/ 50 micron aluminum-oxide

particles

G-Multi Primer (MDP) prior to tryin

Ultrasonic clean with ethanol

Place FujiCEM2 RMGI cement in restoration

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Cementation

Cementation

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Alkaline pH 8.5

Moisture Tolerant

Self Sealing

Apatite Formation

Insoluble/No Degredation

Stronger with time

Semi / Translucent

Biocompatibility-Excellent

Bioactivity-Apatite formation

No silane, conditioning, bonding

Calcium Aluminate/Glass Ionomer Hybrid Cement**

TIP

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Ceramir Crown & Bridge is indicated for permanent cementation of:

• Porcelain fused to metal crowns and bridges

• Metal (gold, etc.) crowns and bridges

• Gold inlays and onlays

• Cast or prefabricated metal posts

• Strengthened core all-zirconia or all-alumina

ceramic crowns and bridges

• Lithium Disilicate (eMax)

• Stainless steel crowns

• Ortho bands and appliances

Bioactivity

A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline

pH.**


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Cementation Technique

Mix for 8-10 seconds

.17ml vs single cap .10ml

3-4 restorations


Ceramir C&B Comparison to other

cement classes

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Lithium Disillicate (eMax)• Cleaning

w/phosphate scavengers is not necessary

• Silane is

contraindicated

• Tooth etching or

conditioning is not necessary

• Bonding agent is not needed

CEMENTATION TECHNIQUE

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Zirconia Restorations- Cleaning w/ phosphate

scavengers is not necessary

- Silane is contraindicated

- Tooth etching or conditioning

is not necessary- No bonding agent necessary

Cement Selection

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Crown RetentionResults Zirconia crowns (Kg/F)

Material Result (Zirconia crowns) Kg/F

Ceramir Crown & Bridge 32.1 ± 6.3

RelyX Unicem (3M) 27.8 ± 11.3

Dyract Cem (Dentsply) 12.2 ± 3.1

Rely X Luting (3M) 10.9 ± 6.5

0

5

10

15

20

25

30

35

Ceramir Crown &

Bridge

RelyX Unicem (3M) Dyract Cem

(Dentsply)

Rely X Luting (3M)

Cement Selection

Three year recall data yielded no loss of retention, no secondary caries, no marginal discoloration, and no

subjective sensitivity. All restorations rated excellent for marginal integrity.

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Cement SelectionJournal of Esthetic & Restorative Dentistry March 2015

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Simplify Cementation

-Silane is contraindicated

-Restoration does not have to be cleaned after tryin

-Tooth etching or

conditioning is not necessary

-Bonding agent is not needed

Technique Research/Literature**

Moisture Tolerant

No Sensitivity

Alkaline pH

Apatite Forming

Insoluble

Stronger With Time

Self Sealing

Questions?


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TODD SNYDER(949) 643-6733

[email protected]

www.aestheticdentaldesigns.com

www.drtoddsnyder.com

www.toddsnyderracing.com

www.legionpride.com246

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

http://www.facebook.com/todd.snyder.dds

http://www.instagram.com/Toddsnyder1/

Documents

Todd Snyder, DDS, FAACD, FIADFE, ASDA · Accredited Fellow, American Academy of Cosmetic Dentistry Fellow, International Academy for Dental Facial Esthetics Member of The American