Beautiful Crown Preps and Impressions Made Easy

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Cutter

ArtistApprentice

Master

Prep Speed

Prep Quality

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Units Per Case

1 2 3 4 5 6 7 8 9+35424419084958718473299

6403

44,153

6 or more units = 2.80% of cases9 or more units = 0.59% of cases

Units Per Case % of Total Cases1 75.61%2 10.96%3 5.65%4 3.16%5 1.01%6 1.45%7 0.33%8 0.42%

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CR Survey Results—Electric Handpieces

• 51% of dentists use electric handpieces• 16% of them use electric handpieces exclusively

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Electric Handpiece Advantages

• High power (torque)• Minimal stalling or slowing• Smooth cutting• Quieter• Precise speed control• Multiple Attachments

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Electric Handpiece Disadvantages

• Higher cost• Larger size and weight• Overheating concerns

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Electric Handpiece Comparison

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Electric Handpiece Head Size

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Rule of 27 for Solid Zirconia Bridges

• Minimum thickness for connector size between abutment and pontic• Height squared X Width• 3 mm X 3 mm

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Rule of 27

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Rule of 27

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Reverse Preparation Technique

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Reverse Preparation Technique

• Predictable reduction through the use of depth cuts• Nearly perfect margin formation that is incredibly simple

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Depth Control Burs from Kerr Rotary

• MADC-006 0.6 mm 1 ring • MADC-010 1.0 mm 2 rings• MADC-015 1.5 mm 3 rings• MADC-020 2.0 mm 4 rings

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Reverse Preparation Technique

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Reverse Preparation Kit LS-7551

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Reverse Preparation Technique Video

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PrepSure Crown Prep Guides ContacEZ

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PrepSure Crown Prep Guides ContacEZ

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"In reality, a crown and bridge impression is merely a reflection of the dentist's integrity, nothing more and

nothing less."

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4,295 dentists with a 50% or higher remake rate in 2014

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5,232 dentists with a zero percent remake rate in 2014

660,939 restorations fabricated for them

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True Cost of Remakes

• Lab fee may or may not be covered• Average dentists overhead is $300 per hour• Lost opportunity cost for an hour—$1,200• Potential loss of confidence with patient

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Ideal Impression Requirements

1. Must capture 360 degrees of easily identifiable tooth structure apical to the margin with no guess work in die trimming.

2. The impression must capture all of the necessary esthetic and functional aspects of the unprepared teeth.

3. Making the impression must not irreversibly damage the patient’s biology including connective

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Ideal Impression Requirements

4. The impression must be free of organic and inorganic contaminants such as: blood, serum, saliva, grinding debris.

5. The set of the impression material must not have been inhabited--no slime.

6. The impression material must not have been dislodged from the tray during removal or lab handling.

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Predictable Impressions: 2-Cord Technique

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Ultrapak Cord

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Ultrapak Cord

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Double Arch TraysAlmost 80% of teeth restored are single-units and utilize double arch trays.

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Double Arch Trays

• Only one prep or two adjacent preps, no bridges.• Occlusal prematurities should be eliminated, if present, prior to

prepping.• Upper and lower teeth must be firmly together in maximum

intercuspation with the tray in place, try it in!• Posterior DA impressions should extend from most posterior tooth to

include upper and lower canines on that side.

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Double Arch Trays

• Anterior DA impressions should include all four canines.• Interocclusal wafer must be extremely thin and non-absorbing. The

QUAD-TRAY Xtreme from Clinicians Choice is 0.002 inches thick.• Posterior connector of facial and lingual aspects must be thin and not

interfere.

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Double Arch Trays

• Tray contact with teeth, preps or tori can produce distortions in DA impression. Occasionally soft tissue can touch without complications.

• Combination of tray and impression should make a rigid unit--metal tray with flexible material, plastic tray needs rigid material.

• If no distal molar is present, over closure might occur.

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Lab Technique for Double Arch Trays

1. Wash out impression and dry it.2. Pour the arch which includes the tooth preparation(s) in dies stone,

place the appropriate dowel pin(s), and let stone set.3. Pour the opposing arch in regular stone and let the stone set.

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Lab Technique for Double Arch Trays

4. With arches still unseparated from impressions, mount the upper and lower casts on a small hinge articulator using low-expansion mounting stone (Mounting Stone by Whip Mix) and let it set.

5. Trim all excess anterior and posterior overlapping stone to eliminate the possibility of stone debris restricting closure to proper occlusion when arches are separated.

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Lab Technique for Double Arch Trays

• Open the articulator, separate the arches, saw the dies(s) from the working cast, trim the dies, and make the restoration(s).

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Achieving Accuracy• Die stone and model preparation have the greatest influence

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Equilibration

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Clinicians Choice QUAD-TRAY Xtreme

• Wide Arch width• Low sidewalls• Inflexible, but cannot be bent• Thin distal bar

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Triotray Pro

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Enhanced Design Considerations

• Anatomical Design • “The Accurate Fit”

• Two trays for different arch sizes (S&L)

• Fits into patient’s mouth comfortably

• Controls the tongue• Allows for flatter palates

Controls the tongue

Anatomical fit

Smooth finish for patient comfort

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Enhanced Design Considerations

• Well-supported canine to help with excursions• Even support along the arch• Back seal

• Ensures molar is captured in the distal aspect• Prevents the impression material going backwards

Buccal wall taller at the front to support the canine.

Narrower at the back to not impinge on the tissues.

Back seal: Triotray Pro hugs the molars.

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Predictable Impressions: Cordless Technique

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Diode Lasers vs. Electrosurge

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Electrosurge Advantages

• Electrosurgery cutting is easy and fast.• When adjusted properly, electrosurgery cutting is consistent and

predictable.• Electrosurgery electrodes may be bent to meet the surgical need.• The electrodes cut on their sides as well as on the end.• Hemostasis is produced relatively easily by electrosurgery.• Electrosurgery cutting produces a near painless wound.• With careful, gentle cutting, only slight trauma is produced.• The electrode is self-disinfecting, but should still be sterilized.• Electrosurgery devices are more affordable of diode lasers.

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Electrosurge Disadvantages

• Patients must be anesthetized.• The word electrosurgery causes fear for some patients. The word radiosurgery seems to be less objectionable.• A burning flesh odor is produced when cutting.• A burning flesh taste is present after cutting.• The devices cut fast. As a result, there can be low tactile sense while cutting.• The heat produced while cutting disallows monopolar electrosurgery use around implants. Most electrosurgery units are monopolar (bipolar electrosurgery devices can be used near implants).

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Diode Laser Advantages• A minimal amount of local anesthetic or none at all is needed for laser use.• Diode lasers are the least expensive of all dental lasers.• The laser does not harm dental hard tissue.• Diode lasers can be used around implants.• There is growing evidence of the value of the laser for periodontal therapy.• Laser use is antimicrobial.• The laser removes endotoxins from root surfaces.• Lasers are a significant marketing tool. Patients view lasers as state of the art, and are excited by them.

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Diode Laser Disadvantages

• Cutting soft tissue with a laser is slower than with electrosurgery.• The cost of a diode laser is more than for electrosurgery.• There is a learning period as practitioners become accustomed to use of a laser.• Care must be taken to avoid damage caused by the laser beam.

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amdlasers.com

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ViscoStat Clear

• 25% aluminum chloride gel

• Causes collagen in capillaries to swell and close off

• Will not stain hard and/or soft tissues

• Especially useful in esthetic zone

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ViscoStat Plus

• 22% ferric chloride

• Rapid hemostasis when scrubbed with Dento-Infusor tip

• Can cause temporary discoloration of soft tissue

• Will typically work when ViscoStat Clear is not strong enough

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ProductViscoStatWintermint

Ultradent

ViscoStatClear

UltradentExpasyl

KerrHemogin-L

DuxTraxodent

PremierAstringede

ntUltradent

HemodentPremier

Cost/ml $1.03-$1.63 $1.03-$5.00 $16.53/g $1.26-$1.95 $15.11-$19.65/g $1.03-$1.60 $1.61

Composition 20% ferric sulfate

25% aluminum chloride

15% aluminum chloride

25% aluminum chloride

15% aluminum chloride

15.5% ferric sulfate

21% aluminum chloride

Viscosity Thin gel Thin gel Paste w/ clay Liquid Putty-like paste Liquid Liquid

Color Dark brown Clear Olive green Blue-green Yellow-green Dark brown Clear

pH 0.8 1 1.6 2.8 3.5 0.3 1.2

Bond Strength

Compared to Control

Slightly higher Equal Slightly lower Equal Equal Equal Equal

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Disinfecting Tooth Preparations

• TRAC Research has shown that acid etch, bonding agent, sealant, composite, cement or amalgam does not kill microbes, they can continue to destruct tooth structure.

• Burying microbes does not kill microbes, but it does slow their progress.

• G.V. Black recommended silver nitrate disinfection prior to amalgam placement, a practice until 1960 when patients complained of permanent dark gray/black stain.

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Disinfecting Tooth Preparations

Since 1980 CRA and TRAC have been testing formulations that:1) Rapid, broad-spectrum kill2) Resistant to neutralization by components in cut dentin such as:

bacteria,saliva, blood, food debris, old dental materials, gingival tissues and crevicular fluids, etc…

3) Compatibility with resin-based materials4) Good wetting and penetration into dentin5) Non-irritating to vital teeth6) Used commonly worldwide for decades

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Disinfecting Tooth Preparations

• Original choice was GLUMA • 5% Glutaraldehyde 35% HEMA

• Performed exceedingly well and…

1) Desensitizes very well2) Modestly increases bond strength

3) Modestly enhances longevity of bonds

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Disinfecting Tooth Preparations

Micro PrimeDanvilleGluma

Heraeus Kulzer

GluSenseCentrix

G5 Clinicians Choice

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Disinfecting Tooth Preparations

TRAC Protocol—

1) Water wash and damp dry prep.2) Use Extra-Small Multi-Brush (Denbur) to paint entire prep with

one coat of solution.3) Wait one minute, suction away excess (no air or water).

4) Re-apply second coat following steps 2 and 3.5) Apply resin (adhesive, sealant, flowable, RMGI…) directly to

damp dentin.

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Disinfecting Tooth Preparations

• The 2 one-minute applications are critical.• Allows penetration through smear layer and into dentinal tubules.

• TRAC protocol kills 99.9% of bacteria.

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Shade Taking

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Smile Capture and Smile Lite

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Smile Lite

www.smilelineusa.com

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Most Popular Shades

Numbers are from a study of over 4,000,000 crowns.

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100,000

200,000

300,000

400,000

a2 a3 a1 b1 a3.5 d2 d3 c2 c3 c1 b2 a4 2m22m1 1m1 c4 b3 3m23m1 1m2 d4

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Numbers From Study of Over 2 Million Crowns

Shade Percent of shades requested

Percent that came back for re-shade

Reshade vs normal percent differential

a2 17% 18% 4%a3 11% 10% -12%a1 9% 14% 63%b1 4% 11% 136%d2 4% 6% 54%d3 4% 3% -17%c2 3% 4% 34%

a3.5 4% 3% -25%c3 3% 3% 1%c1 2% 5% 93%b2 2% 3% 31%a4 1% 2% 52%

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The Tooth Color Space

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Current Shade Systems in the Tooth Color Space

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Limitations of Current Shade Systems

• Color Gaps - Shades are not uniformly positioned throughout tooth color space

• Inaccurate Interpolation - Intervals between shades do not yield a single discernible intermediate shade

• Not Systematic - Shades are not schematically organized to reflect all three color dimensions

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VITAPAN 3D-Master Color System in Tooth Color Space

• 26 shades which accurately cover known tooth colors, uniformly positioned throughout tooth color space

• Systematically organized for easy, accurate shade taking

• Addresses need for additional shades with high and low values

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Improved Communication Through the Use of Superior Clinical Instruments

• Equidistant spacing of shades yields only one discernable intermediate shade

• Eliminates much of the difficulty in communicating custom shades• Provides for predictable, repeatable results

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Advantages of Value Based Restorative Systems

• Restorations of varying thickness can have the same appearance• Characterizations can be indicated with minimal effect on the

underlying shade• Multiple types of restorative materials can be used in combination

with ease• Technicians can fire the materials repeatedly - without altering value

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VITA Easyshade Advance 4.0

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VITA Linearguide 3D-Master

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VITA LinearGuide 3D-Master

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