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TODD SNYDER, DDS, FAACD, FIADFE

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

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

Aesthetic Dental Designs®

doc@tcsdental.com

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PATHOLOGY DRIVEN DIAGNOSTICS

Are you still diagnosing with this??

50%

accurate

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RADIOGRAPHIC ANALYSIS

Since 1896

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Portable X-Ray Units

DIAGNOSE

Is it thru conventional radiographic analysis?Approximately 25% demineralization must occur to see a cavity on a conventional radiograph.

Equates to 40-60% demineralization on the tooth surface. Radiographs miss 70-80% of

occlusal cavities.Digital radiographs provide the ability to manipulate image size and appearance.

67%

accuracy

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Fiber Optic TransilluminationMicroLux Kavo DiaLux 2300L

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Fiber Optic Transillumination

Fiber Optic Transillumination

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DRIVES

Thru intraoral photographic interpretation?

How do you diagnose decay??

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FLUORESCENT TECHNOLOGIES

What fluoresces in fluorescent-based technologies?

• Bacterial porphyrins (bacterial breakdown product),

• Stain,

• Tartar,

• Food debris

All fluoresce under the wavelengths used in most caries detection devices, whether or not caries is present.

Lussi A , Imwinkelried S, Pitts N, Longbottom C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 1999;33(4),261–266.

Lussi A, Hibst R, Paulus R . DIAGNOdent: an optical method for caries detection. J Dent Res 2004;83C, C80–83.

Verdonschot E H, van der Veen M H. Lasers in dentistry 2. Diagnosis of dental caries with lasers. Ned Tijdschr Tandheelkd 2002;109(4), 122–126.

Konig K, Flemming G, Hibst R. Laser-induced autofluorescence spectroscopy of dental caries. Cell Mol Biol (Noisy-le-grand) 1998;44(8), 1293–1300.

Alwas-Danowska HM, Plasschaert AJ, Suliborski S, Verdonschot EH. Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis. J Dent 2002;30(4):129-34.

Rechmann P, Rechmann BM, Featherstone JD. Caries detection using light-based diagnostic tools. Compend Contin Educ Dent. 2012;33(8):582-4, 586, 588-93; quiz 594, 596.

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CariVu Fiber Optic Transillumination

CariVu: Transillumination

• Near Infrared light…no radiation

• Enamel appears transparent or light

• Porous lesions appear darker by trapping and absorbing the light: these include cracks and caries

• Video capture….live scans

• Stored in Dexis, excellent for communication to patient and yes…to insurance companies

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With proximal surfaces, one can identify

where the lesions are

buccally and lingually

Utilizing CariVu

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For identifying cracks, and to a certain

level, the severity of the cracks

Utilizing CariVu

Allows superior interproximal decision making

regarding Watching, Follow-up, Infiltrating, Drilling

Utilizing CariVu

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BITEWINGS VERSUS

CARIVU

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Crystal Structure DiagnosticsThe Canary System Detects Cracks & Cavities not

Visible on X-rays

+ Around & beneath intact margins of fillings & crowns

+ Under sealants (including opaque sealants)

+ On proximal surfaces

+ On smooth surfaces, pits & grooves

+ Around orthodontic brackets

Measures tooth structure breakdown, allows for early

treatment

+ Restore conservatively

+ Remineralize back to health

+ Seal with confidence

Research claims validated by 60+ papers

15+ case reports & 2 FDA CFR 21 clinical trials

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The Science Behind The Canary System

• Pulses (2 Hz) of laser light hit the tooth surface.

• Tooth glows (Luminescence, LUM) and releases heat (Photo-Thermal Radiometry, PTR).

• Defective tooth crystal structure affects the retained heat and luminescence signatures.

➢Energy Conversion Technology

Temperature

increase < 1oC

not harmful

• Detected signals reflect the tooth’s condition.

• Detects 50 micron lesion up to 5 mm below the surface.

Delegated Scanning & Whitening Assistant

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Sensitivity & Specificity Study: University of Texas October 2012

Study Design• 20 tooth surfaces selected with

range of clinical conditions from healthy to early caries

• Visual ranking by 2 dentists • Canary Scan• DIAGNODent• Polarized Light Microscopy used as

the gold standard to confirm presence of lesion & depth in that section

Caries Detection Method Canary System DIAGNODent

Sensitivity 100% 18%

Specificity 100% 100%

Spearman Correlation with Lesion Depth

.84 .21

Canary is Superior to X-Rays for Proximal Caries DetectionJan J et al. Caries Res 2014;48:384–450 DOI: 10.1159/000360836

Objective:

To compare the accuracy of The Canary System, ICDAS-II and bitewing radiographs in detecting proximal caries

in vitro.

Methods:

ICDAS-II (Direct Visual Examination): Blinded examiners ranked 100 proximal surfaces using ICDAS-II by

direct visual examination of the surfaces

Manikin mouth models: The teeth were then set in manikin mouth models, creating contacting proximal

surfaces that very closely resemble in vivo situation.

Histological validation: All surfaces were examined by polarizing-light microscopy to confirm the presence

and depth of the caries lesions.

Conclusion:• BW radiographs could only identify 26.7% of the lesions which questions its ability to be the

gold standard

• The Canary System is the only method examined with both high sensitivity and high specificity.

• The Canary System is more sensitive than bitewing radiographs in detecting interproximal

caries

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Pain Mandibular Right Posterior Quadrant

No pathology on x-ray. Canary Scan

Revealed Pathology on Mesial & Distal

Marginal Ridge and Caries around the

Lingual Margin of the Amalgam

9758 36

Removal of Amalgam Confirms Caries

97

58 36Crack on mesial and distal

marginal ridges with caries.

Caries around the lingual

margin

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Interproximal Caries Detection

Bitewing radiograph did not detect caries.

Caries located on buccal aspect of the contact area

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Demineralized enamel

Caries Detection Method

The Canary System

DIAGNOdent

Sensitivity 83% 64%

Specificity 79% 46%

• Canary Numbers >20 when scanning sealants (3M™ ESPE™ Clinpro™ Sealant) placed over pit & fissure caries.

• The caries detection ability of the Canary System was not affected by sealant & was more accurate than DIAGNOdent.

Sensitivities and specificities for pit & fissure caries detection after sealant placement.

Canary Number 66

Canary Number 37Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

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After all the cleaning and diagnostic technology being used, what if you find something?

Topical Therapies• More caries resistant• Remineralization• Desensitization

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Minimally Invasive Treatment

• Apply MIPaste Plus for 3 minutes

• Patient applies at home 2x/day

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MI VARNISH™ WITH RECALDENT™ (CPP-ACP)Bioavailable calcium, phosphate & fluoridefor an enhanced varnish treatment

Xylitol Oral Health Products

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SALIVA-CHECK BUFFER, from GC America, tests for salivary flow and buffering capacity

• No tooth reduction.

• Adhesive and mechanical retention

• Radiolucent

Resin Infusion-ICON

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Resin Infusion-ICON

Other Materials• Clinpro 5000 with TCP (3M)• Enamelon with fluoride and ACP (Premier)• Remin Pro (Voco)• Sensodyne ProNamel• Arm & Hammer’s Enamel Care• Arm & Hammer Complete Care w/ Enamel Strengthening• Colgate Sensitive pro relief• Fluoride Varnishes• Glass Ionomers

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Huge Marketing Opportunity• Remineralizing teeth

• Non Ionizing Diagnostic Tools

• Minimally Invasive Dentistry

• Health Product Sales

• Community Educational Programs

• Internet and Local Media Advertising

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Paradigm Shift

• One can place a number of restorations or fillings and yet not treat the underlying disease

• The bacteria remain in the plaque on the teeth, capable of creating new areas of tooth decay

• Patients value a shift from a surgical approach to disease management and prevention

How will you diagnose?

How will you treat?

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Everyday Go To Minimally Invasive Burs

0512C1300F0710C 0116C

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FREE DISPOSABLE SINGLE USE DIAMONDS

Text DIAMOND3 To

770.212.2090 For

Free Pack Of

NeoDiamonds

SS WHITEConservative

Burs

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Access, viscosity, small areas

Deep, narrow, preparations

Lots of enamel

Flowables

• Voco (Grandio SO HF, Xtra Base)

• Ultradent (PermaFlo)

• Kerr (Revolution, Premise, Vertise)

• Ivoclar (Tetric Flow)

• Heraeus (Venus Diamond Flow, Bulk Fill)

• Shofu (Beautiful Flow Plus-Zero & Low Flow)

• G.C. America (G-aenial Universal Flo)

• Dentsply (SureFil SDR, EsthetX Flow)

• Kuraray (Clearfil Majesty ES Flow)

• Tokuyama (Estelite Flow Quick)

• 3M (Filtek Supreme Flow Plus)

Flowables

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Flowable

Medium Size Defects

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Small to Medium sized Lesions (<2MM)

• Mostly superficial

• Good restoration longevity

• ½ enamel with ½ extending into dentin

• Dentin is fairly dense

• Open &/or Closed defect

• Risks are low

• Minimal occlusal loading

Large Defects(occlusal)

Recurrent decay

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Think about material choices & their long term durability & susceptibility for failure in adhering to deep dentin.

pulpal proximity

Large sized Lesions (>2MM)

• Mostly dentin

• Dentin has more moisture and less substance

• Open and Closed defects

• Complications & Risks are higher

• Porous, Wet, Dentin Available

• Interproximal concerns

• Increased Occlusal Loading

• Remaining Tooth Structure

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Bond Strengths Related To Type of Dentition

0

5

10

15

20

25

30

35

40

45

50

DEJ Superficial(Sound) Dentin

Beveled Enamel Deep Dentin Affected CariousDentin

Infected CariousDentin

45 45

30 30 30

10

Irie m, suzuki k, watts dc, 2004, marginal gap formation of light activated restorative materials, affects of immediate setting shrinkage and bond strength. Dent Mat 18, 2002; 203-210

Caries Indicator Dyes• Roydent-To Dye For• Kuraray-Caries Detector*• Ultradent-Seek*/Sable Seek*• ProOptions-Caries Indicator• Danville-Caries Finder• Pulpdent-Snoop• Vista-Caries Indicator• Ronvig-See It• Patterson-• Henry Schein-• Pearson-

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Note Caries on Floor of 2nd Molar

Further Inspection Reveals More Caries

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Caries Removal Burs• SS White

– Single use

– Polymer

– Hardness

– 5000-10,000 rpms

• Komet

– Multi use

– Ceramic

– Hardness

– 1000-1500 rpms

Article on the Comparison of Caries Removal Burs

J Adhes Dent 2011 Feb;13(1):7-22. doi: 10.3290/j.jad.a18443.Current concepts & techniques for caries excavation & adhesion to residual dentin.de Almeida Neves A, Coutinho E, Cardoso MV, Lambrechts P, Van Meerbeek B.

Round Burs (#6) Carbide CeraBur SmartBurs II (SS White) (Komet) (SS White)

1,000-1,500rpm 5-10,000rpm

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NSK Electric Handpieces

Handpiece Lubricants

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Long term failure occurs at gingival margins and adhesive interfaces.

Yiu CK, Hiraishi N, King NM, Tay FR. Effect of dentinal surface preparation on bond strength of self-etching adhesives. J Adhes Dent. 2008 Jun;10(3):173-82.

Higher bond strengths when using tungsten carbide burs with SE adhesives

Preparation• Limited to removal of pathology with the exception of access and bevels.

• Maintaining enamel and superficial dentin

• Preserving occlusal stops

– Marginal ridges

– Transverse ridges

– Oblique ridges

• Rounded line angles

• Purge hand piece oils

• Bur Choice

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Total etch Self etch

# of components

Etchant

Primer

Adhesive

Bonding Agents

Generation4th 5th 6th 7th

Total-Etching

Bonding to Enamel/Dentin

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Bonding to Enamel/Dentin

Self-Etching

Factors that compromise bond durability in restorative dentistry

“The major shortcoming of contemporaryadhesive restoratives is their limited durability in vivo.”

alarming

words …

but

the

reality

we

face

should

trigger

alarm

Hydrophilic dentin bonding (1956 - )

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Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong

direction

Water sorptionPolymer swelling

Decline in mechanical propertiesLeaching of hydrolyzed resin components

Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially disappeared after 6 months of

intraoral function

Instability of hybrid layers- problem may be more severe than we realize

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Factors that compromise bond durability

Hydrophilic dentin bonding (1956 - )

MMP-8MMP-2MMP-9

Demineralizing dentin is like openingthe Pandora’s box, releasing

endogenous enzymes (Matrix Metalloproteinases - MMPs)

that were trapped withinthe mineralized dentin matrix.

In the presence of water (such as thatderived from water sorption or from

adhesives, MMPs (2,8 & 9) can breakdowncollagen fibrils that are not protected

by intrafibrillar minerals

Sukala et al. (2007)Mazzoni et al. (2007)

Bond Degredation

• Pashley DH, Tay FR, Imazato S. How to increase the durability of resin-dentin bonds. Compend Contin Educ Dent. 2011 Sep;32(7):60-4, 66.

Resin-dentin bonds are not as durable as was previously thought. Microtensile bond strengths often fall 30% to 40% in 6 to 12 months.

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Without

chlorhexidine

With

chlorhexidine

as a MMP

inhibitor

Chlorhexidine prevented degradation of hybrid layers created by

Prime&Bond NT after 12 months of intraoral function

Brackett et al. Chlorhexidine preserves hybrid layers

but not nanofillers in vivo. Oper Dent (2009)

MMP inhibition with chlorhexidine

Potential ways to extend bond longevity

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•Courtesy Pacific University (Dr Marc Guisberger)

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•Courtesy Pacific University (Dr Marc Guisberger)

InstroN• Ultra Tester (Ultradent)

• Ultra Jig (Ultadent)

Ultradent’s shear bond strength testing method has been adopted as an ISO Standard. The UltraTester machine uses this highly accurate method to determine bond strengths.

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Ultradent Internal Testing

Shear Bond Test Results - 2012Average Shear Bond Strength to Dentin: 24.2 MPa

•Courtesy Pacific University (Dr Marc Guisberger)

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Maximum/Minimum Shear Bond Strength per Bonding Material

Shear Bond Test Results - 2012•Courtesy Pacific University (Dr Marc Guisberger)

Why different pH?

3.2 2.7 2.54.6

MDP Penta-P MDP BPDM

Adhesive Functional

Monomers

MDP

2.3 1.6

GPDM

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Total etch Self etch# of

components

Etchant

Primer

Adhesive

The Bonding Agents

Generation4th 5th 6th 7th

Universals

OR

• Developed by Kuraray 1983

• Acidic Monomer Activates Silanes & Chemically Bonds to Metal Oxide Ceramics (Zirconia & Alumina).

• (Key Ingredient to make a Silane Universal)

• Hydrophilic & Hydrophobic

• Very Durable Dentin Bond

(Creates An Insoluble, calcium Salt with Dentin)

• Is The Most Copied Monomer In Dentistry

• The Most Researched Monomer In Dentistry

• 20 + Years Of Research On Metal Oxide Ceramics (Zirconia & Alumina)

• Strongest & Most Durable Bond to Metal Oxide (Zirconia & Alumina) Ceramics

MDP ADHESION MONOMER:

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When bonding to enamel, an etch & rinse approach is definitely preferred, indicating that simple micro-mechanical interaction appearssufficient to achieve a durable bond to enamel. When bonding to dentin, a mild self-etch approach is superior, as it {MDP} involves (like with glass-ionomers) additional ionic bonding with residual HAp. This additional primary chemical bonding definitely contributes to bond durability. Altogether, when bonding to both enamel and dentin, selective etching of enamel followed by the application of the 2-step self-etch adhesive to both enamel and dentin currently appears the best choice to effectively and durably bond to tooth tissue

Van Meerbeek B, et al. Relationship between bond-strength tests and clinical outcomes. Dent Mater (2009),doi:10.1016/j.dental.2009.11.148

MDP Penta-P MDP MDP

Adhesive Functional Monomers

MDP GPDM

MDP Modified

Phosphates

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NEW “UNIVERSAL” SYSTEMS

• Simple & easy to use

• Direct & indirect techniques

• Use as Total, Selective or Self Etch

• Low sensitivity

• Lots of MDP Based Products

DRAWBACKS OF ANY COMPOSITE RESIN

• Material placement techniques

• Variable substrate

• Polymerization stress & shrinkage

• Water absorption

• Hydrophobic bonding agents

• Decreased adhesive bond strength over time

• MMPs and Cathepsins

• Microleakage

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DECREASED BOND STRENGTHS DUE TO:

• Substrate

• Preparation technique

• Bur selection

• Hand piece oils

• Bonding agent

• Curing device and position

• Material selection

• Layering technique

Direct Composite Restorations

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What substrate are we treating?

Class I or II

:Composite Preparation

3x Tubule Density Equals Higher Fluid &

Increased Difficulty for Bonding

%30 Degrease in Bond Strengths with most

bonding systems.

“Adhesive dentistry could be expressed as a

simple relationship between bonds and

stress. If the bonds can withstand the

stress, the restorative technique will be

successful.”

Unterbrink and Liebenberg (1999)

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“C-FACTOR” DEFINITION

Configuration Factor:

“The ratio of bonded to un-bonded (free) surfaces”

Feilzer, DeGee, Davidson (1987), Universtiy of Amsterdam, ACTA

Lowest Stress

Low Stress

Medium Stress

High Stress

Highest Stress

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What are you placingWhere in the tooth How are you utilizing it?

EnamelSuperficial DentinMiddle DentinDeep Dentin Sclerotic DentinInfected DentinAffected Dentin

“C-FACTOR” DEFINITION

MDP BASED BONDING AGENT AND…..X?

Excellent Flow & Handling Base/ Lining

“C-FACTOR”

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Tokyo Medical & Dental University, 2010 J. Tagami et al

FLOWABLE COMPOSITE SHRINKAGE(2MM BULK FILL W/ 71%/WT FLOWABLE ON DENTIN ONLY)

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RESIN TO DENTIN HYBRID ZONE

Dentin Replacement with Composite Cap?

Dentin substitute

Flowable Resins

-3%-6% vol. shrinkage

-1.6-3mpa shrinkage stress

-thin on pulpal floor only

-or SureFil SDR +

-What bonding agent?

Glass Ionomers

Enamel Replacement

Modern Nanohybrid Composite

CR April 2014 NanoHybrid offers best results

ADA reports flowable resins are used by

82% of dentists as bases or liners.

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82% of dentists report

using a flowable as a

liner in Class II

restorations to

increase marginal

adaptation. 1

Insight

1Council on Scientific Affairs of the American

Dental Association. Spring 2009;4(2).

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REDUCES INTERNAL STRESS BY 60% COMPARED TO TRADITIONAL RESINS.

CURES IN 20 SECONDS4MM SELF LEVELING

LOW POLYMERIZATION STRESS1/3 OF OFFICE PRODUCTION IS SAID TO COME FROM

DIRECT RESTORATIONS

LOW STRESS ADAPTATION• Marginal Integrity

• Adaptation at the

most vulnerable

interface

• Minimal shrinkage

stress

PROTECTS THE MOST VULNERABLE INTERFACE

The #1 reason for

composite failure is

recurrent decay – and

the floor of the proximal

box of a Class II is the

most vulnerable area

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NOT ALL FLOWABLES FLOW!

SureFil SDR flow Viscous, non self-

leveling flowable

Adaptation isn’t just at the floor of the proximal box

3 KEY ATTRIBUTES NEEDED FOR A BULK FILL FLOWABLE

• EXCELLENT CAVITY ADAPTATION

• EXCELLENT RADIOPACITY

• LOW STRESS

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INCREASE CLASS II EFFICIENCY

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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

Universal V3 Ring Narrow V3 Ring

TrioDent has developed Narrow V3 Ring in addition to the Universal V3 Ring to ensure ideal separation on smaller teeth.

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Selective Etch Enamel Only

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• More efficient than Halogens

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

but blue light in 400-500 nm range

• Longer lasting / Cordless / Batteries

• Faster curing (5 seconds)

• Nanometer range closely matched CQ range (450-470)

• Smaller in size/lighter

• Less heat

BENEFITS OF LED LIGHTS

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COMPARISONS - LIGHTS

Access to the curing site = Energy to the

resin

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Machined from Aerospace Aluminum

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$200 $205

$321

$73

$175 $175

$11

$0

$50

$100

$150

$200

$250

$300

$350

Demi Demi Plus Elipar S10 SmartLite Max Bluephase Style Bluephase G2, 16-20i VALO

Curing Light Replacement Battery Cost

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• Long term research?

LIGHT CURED BULK FILL COMPOSITES

• Dentin & Enamel Replacement• Requires one layer

• 1.6%-2.4% vol. shrinkage

• 2.3-2.8mpa shrinkage stress

• Bonding agent• (2 bottle highly filled system)

• Self Cured BulkFill• Danville Materials (Zest Dental Solutions)

• Coltene

• Pulpdent

• Parkell

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BULK FILL COMPOSITES

• Fastest growing dental material category in North America.

• Convenient, Time Savings

• Reduced polymerization shrinkage

• Depth of cure

• Flow or adaptability

• Physical properties

• Wear

• Esthetics

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BULK FILL COMPOSITES

• Bulk fill composites 4mm max typically

• 10 second cure

• More translucent

• Typical shrinkage is 1.6-2.4%

• SonicFill (Kerr)

• Venus Bulk Fil (Heraeus)

• Quixx (Dentsply)

• Tetric EvoCeram Bulk Fill (Ivoclar)

• X-tra Base, X-tra Fil (VOCO)

• Filtek Bulk Fill Flowable (3M/ESPE)

EFFECTS OF COMPOSITE LAYERING ON BOND STRENGTHS

0

5

10

15

20

25

30

35

Bulk Fill Oblique Vertical Horizontal

11

17.615.7 16

19.8 19

31

MPa

1 Layer (4mm)

2 Layers (2mm)

4 Layers (1mm Each)

Influence of C-Factor & Layering Technique on Microtensile Bond Strengths to Dentin; S. Nikolaenko, R. Frankenberger et al, University of Erlangen, Nuremburg Germany, Dental Materials, 2004 Vol. 20: 579-585

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These CRA research results agree with

Dr. Tagami’s results on SonicFill.

Tagami stated SonicFill cures to only 70% on

bottom at 4 or 5mm depth of cure.

Test your light output and practice with your materials

Curing bulk fills remains a question

CRA questions the ability for most practitioners to place bulkfill materials

properly in addition to getting adequate curing.

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Internal (Polymerization) Stresses of Composites

“A Simple Pain-Free Adhesive Restorative System by Minimal

Reduction & Total-Etching (1993)

Takao Fusayma DDS,

Tokyo Medical & Dental University

SELF CURE BULKFILL….

• Danville-BulkEZ

• Coltene-Fill-Up!

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148178/

(RFA-DE-10-004) “Tooth-colored resin restorations have an

average replacement time of 5.7 years due to secondary caries precipitated by bond failure.”

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 theperiod 1998–2004 [2].

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

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

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ORAL BACTERIA DEGRADATION OF RESIN RESTORATIONS

BULK FILL SELF CURE MATERIAL

Releases/recharges calcium, phosphate and fluorideChemically bonds and seals tooth

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• No Bonding agent necessary

• No layering bulkfill

• No polymerization stress

• Bioactive

• Bioavailable

• No sensitivity

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DO Restoration

Tooth #29

CLASS V AND CLASS II TOOTH #31

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Drawbacks of Any Composite Resin• Material placement techniques

• Variable substrate

• Polymerization stress & shrinkage

• Water absorption

• Hydrophobic bonding agents

• Decreased adhesive bond strength over time

• MMPs and Cathepsins

• Microleakage

• Light polymerization

Decreased Bond Strengths due to

• Substrate

• Preparation technique

• Bur selection

• Hand piece oils

• Bonding agent

• Curing device and position

• Material selection

• Layering technique

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What problems are believed to be associated with high-

polymerization stress?

Marginal integrity issues

Enamel fracture

Cracked cusps

Failure of the composite-tooth surface

White lines around the restoration

Gaps that cause post-operative sensitivity, microleakage and/or

secondary caries

Lots of optionsWhat works best for your practice and skills?

How much time do you have?Bond Strengths?

Risks and Longevity?

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?How are you restoring

these different preparations

• Bioactive material

• affinity to tooth structure. when placing a glass ionomer a weak acid or conditioner is used to aid in releasing calcium and phosphate ions from the tooth structure. These calcium and phosphate ions combine into the surface layer of the glass ionomer and form an intermediate layer called the interdiffusion zone. This bond layer can be very strong and significantly reduce the microleakage that would occur at the margins of the restoration.

• Very good fluoride and ion release helps remineralize tooth structure in the remineralization–demineralization process that naturally occurs in the oral cavity.

• They bond to enamel, dentin, and metals.

Why Glass Ionomers?

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• They produce good marginal integrity.

• They shrink only one ninth the amount of composite material.

• They are fluoride-rechargeable.

• There are no free monomers in the material.

• The cavity preparation can be bulk-filled, making the materials easy to place.

• They exhibit excellent biocompatibility.

Why Glass Ionomers?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148178/

(RFA-DE-10-004) “Tooth-colored resin restorations have an

average replacement time of 5.7 years due to secondary caries precipitated by bond failure.”

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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 theperiod 1998–2004 [2].

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

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

Deep Preparations Bonding Agent & Flowable composite

Conventional Glass Ionomer or GI then Composite Fluoride Release

High compressive strength

Hydrophillic

Insoluble

True chemical adhesion

Minimizes microleakage

No sensitivity

Acid Base Resistant Zone

Decreased gap formation & C Factor

Coefficient thermal expansion similar to

dentin

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LARGE SIZED LESIONS (>2MM)• Mostly dentin

• Dentin has more moisture and less substance

• Open and Closed defects

• Complications & Risks are higher

• Porous, Wet, Dentin Available

• Interproximal concerns

• Increased Occlusal Loading

• Remaining Tooth StructurePulpal

Proximity

Seals & Protects the Pulp:• For Direct & Indirect Pulp Capping

• Light-curable, Radiopaque Liner

• Significant Calcium Release:

• Stimulates Hydroxy Apatite & Dentin Bridge Formation.

Resin-Modified Calcium Silicate Pulp Protectant/Liner

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THERACAL LC (BISCO)CONVENTIONAL GLASS IONOMER

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GLASS IONOMER SANDWICH

•Class I, II, III & V posterior

restorations

•Open & Closed Sandwich

techniques

•Composite replacement

•Amalgam replacement

•High caries risk patients

•Pediatric patients

•Geriatric patients

•Special needs patients

•Long term resistance to

microleakage

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GLASS IONOMER MATERIALS• Dentsply-ChemFil Rock Restorative

• SDI-Riva LC, light cure HV, Riva SC, self cure HV

• G.C. America-Fuji II LC, Equia Fil (Fuji IX)

• VOCO-Ionolux, Ionofil Molar AC

• 3M/ESPE-Ketac Nano, Photac Fil Quick, Vitremer, Ketac Molar Quick, Ketac Fil Plus

• Shofu- FX II

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• GC EquiaFil Compressive Strength 255mpa

• Equia Forte 280mpa

• Riva SC compressive strength 271mpa

• Chemfil Rock Compressive 200mpa

• Voco Ionolux had higher compressive strength than Equia Fil or ChemfilRock

• Surefil SDR compressive strength 220mpa

• Dentin 280mpa-297mpa

• Enamel 384mpa

• Grandio SO HF has compressive 417mpa

• Fuji II LC 170mpa (RMGI) Compressive strength

COMPRESSIVE STRENGTHS

GC AMERICA

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MINIMALLY INVASIVE PREPARATIONS

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Komet & Kavo

Komet SF1LM

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GLASS IONOMER INTERFACEIn

terfa

ce

An

aly

sis (TEM

)

CARDOSO et al. J Dent 2010

RESIN TO DENTIN HYBRID ZONE

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A3.5 A3 A2

Glass Ionomer Bulk Fill

EQUIA FORTEEQUIA™ FORTE is a complete system that is an ideal solution for posterior restorations:

•Class I, II, III and V posterior restorations •Composite replacement •Amalgam replacement •High caries risk patients •Pediatric patients •Geriatric patients •Special needs patients •Buildups•Long term provisionals

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EQUIA FORTECaries control/quadrant dentistry

(Class II, III, V & core buildup)

245

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WHAT DOES EQUIA COAT DO?Fill porosities to increase physical properties of the restoration and offers a much smoother surface…

(SEM

im

ag

es

x1000)

100um 100um

Some voids are observed A smooth surface is obtained

EQUIA FilPolished by using silicon

carbide paper (#600)

EQUIA FilAfter coating

SDI

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VOCO

ENDODONTIC SANDWICH TECHNIQUE

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ENDODONTIC SANDWICH TECHNIQUE

ENDODONTIC SANDWICH TECHNIQUE

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ENDODONTIC SANDWICH TECHNIQUE

ENDODONTIC SANDWICH TECHNIQUE

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ENDODONTIC SANDWICH TECHNIQUE

ENDODONTIC SANDWICH TECHNIQUE

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ENDODONTIC SANDWICH TECHNIQUE

ENDODONTIC SANDWICH TECHNIQUE

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Open Sandwich with glass ionomer & nanohybrid composite

Glass Ionomer vs. Open Sandwich

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• 7 years later.

Glass Ionomer vs. Open Sandwich

• 7 years later.

Glass Ionomer vs. Open Sandwich

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How do we create them?

Interproximal Contacts

Interproximal concerns & Issues• Voids

• Sensitivity

• Condensing

• Shape

• Flash

• Contact

– Position

– Tightness

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Problem & SolutionTofflemire vs. Sectional Matrices

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Class II Direct Composite

QUICKMAT DELUXPolydentia SA

QUICK RINGS & SILICONE RUBBER ADAPTERSMICROTHIN MATRICES 0.025MM (0.001 IN)WOODEN WEDGES

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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

Universal V3 Ring Narrow V3 Ring

TrioDent has developed Narrow V3 Ring in addition to the Universal V3 Ring to ensure ideal separation on smaller teeth.

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Note how the anatomical shape of the V3 Ring matches the lingual contour of the molar while engaging the gingival undercut

Wave Wedge

Hole to fit with positive grip Pin-Tweezers Inter-proximal contour for

a better gingival seal and V-shaped concavity to protect the papillae

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Pin-Tweezers

4.5mm

5.5mm

6.5mm

Tab can be bent 90˚ for contra-angle placement

Holes designed to fit with positive grip Pin-Tweezers

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by TrioDent

by TrioDent

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by TrioDent

by TrioDent

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3.5mm 4.5mm 5.5mm 6.5mm 7.5mm

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SuperCurveSuper snug, non-stick

•Micro-thin – 35-38µ (0.0014”)

•Color-coded for easy recognition

and re-ordering

•Matrix very stable after placement

•Less risk of catching matrix wings

during ring placement, especially

with a back-to-back MO/DO

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Palodent Plus-DentsplyIdentical except for color

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PRIME N BOND ELECT (DENTSPLY/SIRONA)

• LONG STANDING RESEARCH OVER 13 YEARS

• PENTA RESIN TECHNOLOGY (CHEMICAL ADHESION)

• TOTAL ETCH

• SELECTIVE ETCH

• SELF ETCH

• DIRECT RESTORATIONS

• INDIRECT RESTORATIONS

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TPH SPECTRA ST LV & HV (DENTSPLY/SIRONA)

• MICROSCALED SPHERICAL

SUPERSTRUCTURES FROM SUBMICRON

GLASS

• SPHERETEC™ FILLERS’ MORPHOLOGY,

PARTICLE SIZE ALLOW FOR IMPROVED

HANDLING, ESTHETICS, & WEAR

• COVERS ALL 16 VITA SHADES IN JUST 5

SHADES

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QUICKLY POLISHES THE TPH SPECTRA ST COMPOSITE

• ENHANCE FINISHING

• POGO POLISHING SYSTEM

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Dual Force(Clinician’s

Choice)

Garrison Dental 3D Ring System

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Garrison Dental

XR = Extra Retention

Fender Wedges & Slick Bands

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Implementing various technology and software tools

-Enhance dental care-Lower overhead-Improve performance-Increase Efficiency-Create A Higher Income

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What happened to your piece of pie?

• More people working in the front than those producing the dentistry

• Layers of supervisors and managers, many of which have little or no patient contact

• A dental budget has: • rent at 5%

• equipment at 5%

• marketing needs at 3% to 10%

• lab expenses at or more than 10%

• dental supplies at 5%

• total team expenses at 20%.

• This item is one that you can control. It is the largest item in your budget. Most offices are staffed at closer to 30%.

Working Harder or Smarter?

• Look at your team• Is everyone trained to offer the same care

and service repeatedly

• Protocol Software• Repetition and consistency• Scripts• Daily Procedures

• Accountability Software• Tracking & Monitoring Tasks• Business Phones

• Technology to improve services• Software• Leverage mobile devices• Practice management software additives

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SLYDIAL-END OF DAY PATIENT PHONE CALLS

• Free voice messaging product

• Call all of your patients at one time and leave them a message

• Saves time if you have lots of patients to call

• Instantly leaves them your custom message

•

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Remember The Old Appointment Book?

How LONG Did It Take To Answer A Question About Balances, Forgotten

Appointments?

Practice Management Software

• Easy, Intuitive Management

• Faster

• Efficiency

• Consistency

• Key Performance Indicators

• Cloud Based?

• Integrations!!

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TIP

• VOIP Phone System Integrates with your existing dental practice management software (DPMS)

• Dentrix

• Dentrix Ascend Cloud Based coming soon…

• Eagle Soft

• Easy Dental• SoftDent

• Practice Works

• Mac Practice

• Open Dental

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TEAMWORK• Auto confirms appointments and adds to the Practice Management

Software

• Auto Birthday Messages

• Auto propagation of messages

• Easy to implement with minimal time to use.

• Improve business opportunities dramatically

• Cuts down on current employee time by streamlining many tasks

• Saves money on traditional procedures

• Less postage

• Less paper goods

• Less employee time

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• 2011 33% reported they did not trust online reviews.

• A recent study reported 88% of people trust online reviews

• 92% or internet users read product reviews

• 89% said it influences their purchases

• 74% of internet users said they would most likely not do business if there was a negative review

• Currently having one bad review is considered normal, but lots of bad reviews is not good.

ONLINE REVIEWS

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Reviews text message

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Reviews text message

Reviews text message

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Weave Reviews Via Cell phone message • Select Ratings to be sent to:

• Google• Yelp• Facebook

• Customize Order of Review Sites

• FYI-A dental/medical office can have more than one listing on Google, Yelp etc.. Because they typically employee more than one doctor as well as the business name (ie. Aesthetic Dental Designs and also Todd Snyder, DDS and my Associate can have a site too, just use different phone numbers and emails)

Weave Mobile App

-Same functionality

-From anywhere you have a wifi or cell connection.

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WEAVE IS THE BEST SOFTWARE TOOL I OWN

• It lets me do more in less time than what it would take three people to do in an hour.

• It replaces your existing phone with a Voice Over Internet Phone that attaches to your practice management software.

• It gives you the ability to cut your phone bill and be replaced with a modern phone platform that allows you to.

• Text your patients

• Record all phone calls

• Automated appointment reminders, followups, post op notices, birthday greetings, and more

• Collect balances instantly via text

• See unscheduled patients and have the ability to instantly send automated text messages to fill gaps in the schedule

• So much more….. YOU HAVE TO GET A DEMO IT IS AMAZING!!

• THE COST IS TYPICALLY THE SAME AS YOUR EXISITING PHONE BILL BUT YOU GET RID OF YOUR PHONE AND FOR THE SAME COST YOU REPLACE IT WITH SOMETHING BETTER THAT MAKES YOU MONEY!

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Online Real Data

THE POWEROF

ACTIONABLE METRICS

.

TIP

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TWO WAYS TO INCREASE PRODUCTION

PATIENT Visits PRODUCTION on Visits

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NEW PATIENTS

HOW MUCH DO WE REALLY LOVE THEM?

RECAPTURED

PATIENTS

47 $65,114

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356

Before AfterHygiene Re-Appointment

$167,400 increase through Actionable Metrics

Hygiene Re-Appointment

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Hygiene Re-Appointment

REAPPOINTMENT METRICS

How well is your staff reappointing patients?

How many people are past due?

You run a report?

How do you follow up on the report?

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Slipping Through The Cracks

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Delivering Best Dentistry

ACTIONABLE MONITORING DRIVES GROWTH

37% Increase in Production

In One Year!

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Accuracy, Consistency, Data

• Get an analysis of your company and see where you can make more money and be more efficient!

• You have no idea what you are missing!

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Text “action” to: 77453

Text RaceData to 77453

TIP

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Google Website Speed, Responsive Design and Build Issues/Code are very IMPORTANT

WEBSITE PAGE SPEED IS VERY IMPORANT (and so is relevant content too, read why)

https://www.wordstream.com/blog/ws/2018/01/22/google-speed-update

Jan. 22 2018

https://webmasters.googleblog.com/2018/01/using-page-speed-in-mobile-search.html

Jan. 27 2018

https://www.forbes.com/sites/jaysondemers/2018/01/29/will-googles-new-page-speed-criteria-affect-your-site/#6c3dbe8f6a8f

Jan. 29 2018

July 2018

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CHECK YOUR PAGE SPEED

https://developers.google.com/speed/pagespeed/insights/

CHECK YOUR PAGE CODE

MOBILE FRIENDLY?

https://search.google.com/test/mobile-friendly?id=De1nibkdCgXmmSqhS04nzw

https://validator.w3.org/nu/?doc=https%3A%2F%2Fwww.blux.com%2F

My NGenys Built Websites

http://www.aestheticdentaldesigns.com/

http://www.drtoddsnyder.com/ just got started on

Only a couple weeks to build if you provide the photos and content.

OR they can do photography and content for you..

-

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NGenys

Pronounced Ingenious

Websites, Photography, Brand, Social Media and More

www.NGenys.com

Proof of Work / Transparency, NO ONE ELSE OFFERS

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MOST WEBSITE

COMPANIES

Do Not Service Your Account

MonthlyPROVE it, have them show you

what they did last month

TECHNOLOGY

ONLINE

Efficiency 24/7 STAFF TRAINING

Accountability/Trackability

TIP

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Unit 1 Introduction Rapport

Unit 2 Foundation of Rapport

Unit 3Fundamental Techniques in Handling People

Unit 4 Six Ways to Make People Like You

Unit 5 Mirroring & Matching

Unit 6 Outcome of Calls

Unit 7 How to Build Rapport

Module 5 Rapport 2: Personality types

Unit 1 The Know-it-All

Unit 2 The Storyteller

Unit 3 The Easy Peasy

Unit 4 The Rusher

Unit 5 The Informationalist

Unit 6 The Nervous Nelly

Unit 7 The Indecisive

Unit 8 The Price Shopper

Module 6 Rapport 3: Advanced rapport

Unit 1 Empathy

Unit 2 How Long to Build Rapport

Unit 3 VIP Process

Unit 4 Positive Language

Unit 5 Elements of the Rapport Process

Unit 6 Phone Success Quiz #02

Module 7 Engage: Foundation

Unit 1 Introduction to the Engage

Unit 2 What is Engage

Unit 3 Proactive v. Reactive Scheduling

Unit 4 GREAT vs. EAGER Calls

Module 8 Engage: Elements of engaging the patient

• 14 Modules

• Quizes

• Exam

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• 13 Modules

• Quizes

• Final Exam

Module 5 Working with Emergencies

Unit 1 Emergencies

Unit 2Scheduling Quiz #01

Module 6 Broken & Changed Appointments

Unit 1 Introduction

Unit 2Broken Appointment Policy

Unit 3Handling Broken Appointments

Unit 4Broken Appointments COSTS

Unit 5What patients must know

Unit 6Important Points

Module 7 Confirmations

Unit 1 Confirmations

Module 8 Early and Late Patients

Unit 1Early and Late Patients

Unit 2Scheduling Quiz #02

Module 9 Next Appointment Updates

Unit 1Next Appointment Updates

Module 10 Patient Reactivations

Developing

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1. Telephone Skills

2. Customer Care Protocols/Scheduling

3. Team’s Role/Training

4. Resource Library

5. 24/7

97% of offices don’t train.

(954) 323-2220

Inquire with “Heather” for a $200 Discount

Remember The Old Appointment Book?

How LONG Did It Take To Answer A Question About Balances, Forgotten

Appointments?

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www.Chip-In.orgGuaranteed lowest credit card processing fees & a charitable

give back

COST?

• Cant afford? Technology makes you money!

• All Star is the least expensive & best training I have seen

• Replace existing phone bill with Weave

• Creates income

• Social Media & Internet is FREE• Unless you hire out

• Dental Intel- Priceless..

• Olark/SlyDial Free widgets

• Chip-IN.org see how much money you could save…

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REVIEW• Modern diagnostic tools

• Good technique is critical, selective etch technique

• Thin layer of flowable as first incremental layer

• OR SureFil SDR + over 5 years proven research

• Good handling, adaptable nanohybrid composite

• Conventional Glass Ionomers as a restorative option

• Tight contacts with Palodent Plus sectional rings

• Software that is free or inexpensive to create huge income opportunities and lower overhead

• Latest in website technology to survive on the internet

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TODD SNYDER(949) 643-6733

doc@tcsdental.com

www.aestheticdentaldesigns.comwww.drtoddsnyder.com

www.toddsnyderracing.com