HeatWave by Clinician’s Choice HeatWave by Clinician’s...

3/9/2015

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Impression Trays

HeatWave by Clinician’s Choice

Impression Trays

HeatWave by Clinician’s Choice

LOCK-N-RELOAD WWW.INDIGREEN.COM • 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 coronally and then

to adjacent teeth

• Double Mix Single

Impression is the most

accurate

SYRINGE PLACEMENT

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What Percent of Impressions per

Laboratories have visible errors?

89%

1-Samet N, Shofat M, Livny A, Weiss EI. A clinical evaluation of fixed partial denture impressions. J Prosthet Dent 2005; 94:112-117.

And the key to remember, routinely, it’s voids, bubbles, and tears

“Approximately 90% of impressions have defects” G. Christensen

The Art of Aesthetics & Occlusion

Impression Materials (typically a Medium & a Heavy Body)

EXA’lence (G.C.)

Take One Advanced (Kerr)

Aquasil (Dentsply)

Impergum Soft (3M/ESPE)


Interocclusal Records Posterior Indirect Restorations


Interocclusal Records

Bite Registration Materials

Fast set PVS

Triple Tray

Wax

Acrylic


Preparations (Third Appointment)


Veneer Preparations The Art of Aesthetics & Occlusion

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Veneer Preparations

Depth Cuts

Tooth Reduction

Margins

Retention Form (Line of Draw)

Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”


Veneer Preparations


Incisal edge preparations


Preparation Reduction

Depth reduction burs

Safe reduction

Lasco


Depth Cuts

Tooth Reduction

Interproximal & Margins

Retention Form (Line of Draw)

Why extend interproximal and how far?

Independent Depth Cuts (Lasco Burs)


Instant Ortho/Un-Rotating Teeth

Do initial workup

Diagnostic preps

Diagnostic

waxup


Sequence – Reduce all excess tooth

structure

– Ideal reduction

– Margin placement


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Veneer Preparations

Facial/Lingual repositioning and margin placement


Veneer Preparations

Mandibular incisors-Incisal edge preparation


Veneer Preparations

Premolar preparation techniques


Veneer Preparations

When to extend thru interproximal contact. – Existing restoration so that the veneer margin

ends on enamel.

– Small diastemas or gingival embrasure defects

– Ortho rotation cases where after removing excessive tooth structure the tooth is too thin.


Crown Preparations

Tooth reduction – Existing crown restoration.

– Healthy tooth with a large diastema, defect, or fracture

– Reduction can be between 0.5mm – 2.0mm or more if a tooth needs to be rotated


Contact lens effect

At or above gingiva

Masking tooth or color changes

At gingiva, then place

cord and reduce another 0.3-0.5 mm

Veneer & Crown Margin Placement


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Ceramic Selection Criteria

Aesthetics

Strength

Placement Technique

Metal based

• 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

• Lithium disilicate/silicate

• IPS e.max Press/CAD; Obsidian

• High esthetics and strong

• 360-400 MPa

• Leucite reinforced glass ceramic

• IPS Empress Esthetic/CAD; Authentic; OPC

• 160 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

Modern

Ceramics

• Posterior Crown Indications

• Leucite-reinforced (160 mpa)

• Lithium disilicates (360-

400mpa)

• Lithium silicates (373 mpa)

• Zirconia

(Monolithic1000mpa+)

• Layered Zirconia

Feldspathic (80-120mpa)

Modern Ceramics

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0.7 mm - 2.0 mm All Ceramic 1.5 mm - 2.0 mm PFM

Above images taken from Glidewell Laboratories

Zirconia


HOW DO WE CHOOSE A

RESTORATIVE MATERIAL? Priorities

Codiagnosis

Which teeth

Esthetics

Strength

Wear

Parafunctional habits

Isolation

Periodontal status

Allergy

No Ideal Material For All Conditions.

Answer:


Case #1: Aesthetics Smile Line Gingival Excess & Asymmetry Combination Crowns & Veneers Gingival Crown Lengthening Function


Difficulties? Aesthetic Combination Crowns & Veneers Existing RCT Function


Treatment Plan & Diagnosis

Aesthetics

Gingival Harmony

Function


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Periodontal Surgery &

Provisionals Full coverage off of gingiva

8-12 weeks healing


Preparations & Provisionals 2 crowns and 8 veneers


Preparation Guides The Art of Aesthetics & Occlusion

Facebow / Wax Bite


Provisionals (Waxup)


Provisionals (Duplicate models)

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

model where the tissue and tooth come together.


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Provisionals (Bead Line)

Duplicate model with light body wash and heavy

body tray material.

Provisionals (Bead Line)

The scribed line creates the Bead Line in the over

impression of the cast.

Chlorhexidine

Crowns cemented with tempbond clear (w/triclosan)

Provisionals (Bead Line) The Art of Aesthetics & Occlusion

Provisional Glazes

Check Esthetics & Function

If provisionals are modified take impression and send to lab

Take photos

Post-Op call to check on patient and ask about contours


Restorations Check Shape & Esthetics

Check Shade

Marginal Integrity

Contacts

Etch


Check Shape & Esthetics

Occlusion

Function???


Restorations

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Try-in

Check each restoration individually for marginal adaptation

Start from center moving laterally

Then start at midline checking two teeth at a time. Then add the third

and check, then the fourth etc.

Then remove all of the restorations and fill each with a water soluble

try-in paste.

Start from center out as though you were cementing. Clean off

excess and access. Gently touch teeth together stop at first contact.

Now let patient check aesthetics after going over instructions

The Art of Aesthetics & Occlusion The Art of Aesthetics & Occlusion


Cementation – large cases

Start from center moving laterally with light curable resin

Light cure material for cases over 4 teeth (2m tacking tip)

Placing two teeth at a time. Then add the third and tack in place, then

the fourth etc

Then remove all of the residual cement except a small bead


Cementation – small cases Optibond XTR (can be light cured)

Start from center moving laterally

Dual cure material (NXIII) for cases under 4 teeth (2m tacking tip)

Placing two teeth at a time. Then add the third and tack in place, then

the fourth etc

Then remove all of the residual cement except a small bead

If attempting larger cases with a dual cure resin (due to color

stability) place two or three teeth at a time and isolate adjacent teeth.


Cementation Steps Front two crowns first with dual cured resin or now Doxa Ceramir

Then 4 veneers at a time with a light cured resin.


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-Aesthetics

-Function

-Gingival Embrasures

-Excess cement

-Patient homework & questions

Post-Op Check


From Imaging & Diagnostic Wax-up the entire case was duplicated


Case #2: Aesthetics

Veneers

Function

Gingival Bonding


Remove old restorations & repair abfraction

lesions on cervicals


Stump Shade (dehydration factor)

Base Shade


Impressions


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Facebow

Wax bite

Facebow & Wax Bite Registration


Provisionals


Free Hand Provisionals



Kolor Plus

– 66% filled



Example


• 3 sizes

• Coarse/med, fine,

extra fine

(aluminum oxide)

• Translucent

• Flush mandrel

head

• Built in safety

• Autoclavable

• 5 star-Reality

Hawe Occlubrush

•3 shapes

•fiber impregnated

•silicon carbide


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Materials

Rigid Bite Registration

Light and Heavy Body

Prefabricated Over

Impression


Provisional Veneer Removal Indirectly fabricated

Spoon on gingival margin

Cut vertically with small bur and use crown key to gently separate

Directly fabricated

Spoon on gingival margin

Veneer Try-In (Fourth Appointment)


Veneer Evaluation

Check models

Uncut, pindexed and individual dies

Check veneers internally and externally

Try on the models

Evaluate etch


Veneer Try-In

Water soluble clear try-in paste

Evaluation of esthetics and contour

Evaluate occlusion


OptiCleanTM

Now – An Easy & Efficient way to remove temporary cement!

Feature Benefit

Unique design Enables excellent access

Optimized abrasive particles Faster, easier & complete removal of temporary cement

No paste or slurry required Clear view of working surface

Gentle to soft tissue Alleviates bleeding & gingival trauma

Light conical tip Low risk of abrasion to prep or adjacent teeth

Single use Highly hygienic

Tooth Clean-up The Art of Aesthetics & Occlusion

Plastic shank material – aromatic polyamide

Abrasive material - Al2O

3 (aluminum oxide)

Grit size – 40 microns

Smallest tool on market – 1.6mm tip diameter

Total length – 24mm

Use with or without water spray

Operates at 3000-5000 rpm

OptiCleanTM


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Veneer Clean-up

Steam clean

Acetone in a bottle drop in the ultrasonic

Unidose Silane (Sultan Dental)

Adhesive (Optibond AIO or XTR)

Resin (Nexus III)


Veneer Bonding Techniques

Etch or Self Etch?

Antimicrobial

Bonding Agent

Light cure Time flexibility

Color

Dual cure? Color stability?

Redox initiator (NXIII)

Place cement in

center of veneer

Make sure to see

cement come out on

all margins

Wipe away gross

excess

Flossing?


Bulk excess

– Bard Parker

– TC Carvers (Brasseller)

– Gold knives

– Perio knives

Interproximal saws

Finishing strips

12 & 30 fluted carbides

Cement Removal


Post-Op Photos


Case #3: Aesthetics

Veneers

Function

When do we lengthen the worn

dentition?


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Removing provisionals that are

locked on.



QUESTIONS??


Case #4: Aesthetics

Veneers

Function

TMJ Problems


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Remember:

Functional Limitations



Excursive Interferences

Group function


Malpositioned teeth

Occlusal interferences

Canine guidance

Group function







Check excursives

Protrusive

Night Guard



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Questions?


Case #7:

Case #8:

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Case #9: The Art of Aesthetics & Occlusion The Art of Aesthetics & Occlusion

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Case #10: Aesthetics

Tissue Problems

Poor Function

No TMJ Problems



Incisal position

Gum height


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2-4 mm

10-11 mm




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Occlusion Myths, Mystical Potions,

and Black Magic


Canine Guidance Myths

Steep canine guidance eliminates posterior interferences?

Canine guidance can be steepened without ramifications?

Incisal edges can be restored with composite to obtain guidance?

Increasing canine guidance and doing posterior occlusal equilibrations will eliminate interferences and TMJ problems?


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Mystical Potions

TMJ injections Botulinum Toxins

Trigger point injections Steroids

Anesthetics

Saline


Occlusal Guard Black Magic

Soft splints

Hard/Soft splints

Half arch stabilization appliances

NTI? Best Bite?


Hard acrylic whose occlusal surfaces can be easily

modified.

Stable fit with no rocking movements from

side to side, or anterior to posterior.

Covers all the teeth in a maxillary arch.

My Criteria for a Successful Splint

Shallow Anterior guidance in all excursive movements.

Simultaneous posterior occlusal contacts in light

centric closure, and no slide in hard squeeze


My Criteria for Successful Splint

Shim stock clearance of anterior contacts in centric

closure.

Immediate posterior disclusion by canine in working

and balancing movements.

Guidance by maxillary centrals and laterals in protrusive

movement.

Flat posterior occlusal surfaces offering eccentric

movements without interferences.

Highly polished appliance that is comfortable.


Hard acrylic whose occlusal surfaces can be easily

modified.

Stable fit with no rocking

movements from side to side, or

anterior to posterior.

Covers all the teeth in a maxillary

arch.

Criteria for a Successful Splint

Shallow Anterior guidance in all excursive

movements.

Simultaneous posterior occlusal

contacts in light centric closure, and no

slide in hard squeeze


Criteria for a Successful Splint

VS VS


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Indications for Splint

Joint pain and/or masticatory muscle pain

Mobile teeth and /or bone loss

Protection of Cosmetic Porcelain Restorations

Limited opening

Symptomatic relief of acute joint pain and muscle

tenderness

Nocturnal Bruxing and Clenching

Diagnostic tool for restorative dentistry.


Night time wear/24 hour wear

Pain relief

Insurance plan

Diagnostic tool

Occlusal Guard

Simultaneous posterior contacts, light contact

on anterior teeth

Shimstock drags

Canine excursive

Protrusive on incisors only

Occlusal Guard

Hard Acrylic ONLY relined in mouth.

Soft acrylic creates more interferences and does not keep the TMJ stable

Hard/Soft allows teeth to shift slightly and does not keep the TMJ stable

NTI should only be used short term 2-4 weeks

Occlusal Guard

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Clinical Occlusal Reline

Trimming to finish

Step 4

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Case #10:


Any Questions?

CEMENTATION MATERIAL OPTIONS

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CEMENT 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


• Fluoride Release

• Stronger Than Traditional

Glass Ionomers

• Degrades over time

• Improved bond strength

• Biocompatibility Ok



RESIN MODIFIED GLASS IONOMERS

• Acidic/Neutral pH

• Not moisture tolerant

• Best initial bond strengths but can

decreases w/time

• Decreased bond strength over time

• Water sorption

• Biocompatibility-Ok


• Sealing Quality-Good but technique

sensitive

SE Resin Bonding Agent w/ Resin

• Acidic/Neutral pH

• Not moisture tolerant

• Low-moderate initial bond

strengths

• Decreased bond strength

over time

• Water sorption

• Biocompatibility-Ok



CEMENT OPTIONS

ALL PORCELAIN CEMENTATION ALL PORCELAIN CEMENTATION

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All porcelain cementation CEMENT OPTIONS

• Alkaline pH


• Self Sealing

• Apatite Formation

• Insoluble

• Stronger with time

• Semi / Translucent

• Biocompatibility-Excellent

• Bioactivity-Apatite formation

• Sealing Quality-Excellent

• Ceramir C&B is a material that combines glass ionomer technology with the

innovative Ceramir (Calcium Aluminate – C.A.) technology.

• The G.I. contributes to:

• Low initial pH, short duration

• Flow and Setting characteristics

• Early strength

• The C.A. contributes to:

• Increased strength and retention

• Biocompatibility

• Sealing of tooth material interface

• Apatite formation

• Sustained long term properties, no degradation

• Basic end pH

• 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

The technology is called NIB (Nanostructurally Integrating Bioceramics).

• Bioceramic powder

• Reacts with water

• Dissolution

• Nano crystals formed on:

• Tooth walls

• Filler particles

• Pre-existing crystals

• Prosthetic construction

• Stable sealing of the interface

Ceramir

Ceramir

Dentin

Enamel

CERAMIR ® TECHNOLOGY / NIB

Ceramir (hydrated CA) is very similar to Hydroxyapatite

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BIOACTIVITY – SELF SEALING PROPERTIES

Ceramir C&B is bioactive, enabling the

formation of a surface layer of hydroxyapatite

crystals. Clinically, this may translate into a

protective hydroxyapatite layer at the tooth-

restoration interface*

In novel saliva Ceramir C&B promotes HA

formation at its surface, and could be

expected to promote natural HA formation at

the restoration-tooth interface**

*A comparative study of the bioactivity of three materials for dental applications. Published by: J Lööf, F Svahn, T Jarmar, H Engqvist, CH Pameijer. Published as: Dental Materials (2008) 24: 653–659

**Hydroxyapatite formation on a novel dental cement in human saliva. Published by: J Engstrand, E Unosson, H Engqvist. Published as: ISRN Dentistry (2012): Article ID 6224056

CROWN RETENTION • Results 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)

• Results cast Gold crowns *

* Pameijer CH. Jefferies SR. Retentive properties and film thickness of 18 luting agents and systems. General Dentistry. 44(6):524-30, 1996 Nov-Dec. Pameijer CH, Jefferies SR, Lööf J, Hermansson L. A comparative crown retention test using XeraCem™. J Dent Res. 2008;87(B):3099.

Ceramir Crown & Bridge 38.3 ± 8.5

Rely X Unicem (3M ESPE) 39.8 ± 15.3

Vario Link (Ivoclar) 32.94 ± 4.8

Cement it (Pentron) 29.8 ± 4.3

Ketac Cem (3M ESPE) 26.6 ± 4.4

Breeze (Pentron) 25.3 ± 7.8

Maxcem (Kerr) 15.9 ± 9.3

Zinc phosphate 13.9 ± 4.5

0

5

10

15

20

25

30

35

40

45

Ceramir Crown &Bridge

Rely X Unicem (3MESPE)

Vario Link (Ivoclar) Cement it (Pentron) Ketac Cem (3MESPE)

Breeze (Pentron) Maxcem (Kerr) Zinc phosphate

CROWN RETENTION IN VITRO TESTS, TEMPLE UNIVERSITY

24 h 8 days 30 days 90 days

Strength

(Mpa)

160 ± 27 176 ± 24 196 ± 18 210 ± 24

Rely X Luting Fuji Plus Rely X Unicem Ceramir C&B

Strength (Mpa) 96 ± 10 138 ± 15 157 ± 10 160 ± 27

Compressive strength after 24 hours storage in phosphate buffer at 37°C

Ceramir compressive strength over time, storage in phosphate buffer

Results are published in J Dent Res. 2008;87(B):3100 by Jefferies et al

0% SENSITIVITY

100% RETENTION

100% MARGINAL INTEGRITY

0% RECURRENT DECAY

0% MARGINAL DISCOLORATION

• Jeffries SR, Pameijer CH, Appleby DC, Boston D, Galbraith C, Loof

J, Glantz P-O. Prospective Observation of a New Bioactive Luting

Cement: 2 Year Follow-Up. J Pros, 2011. Published on-line, Oct 31,

2011.

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CEMENTATION TECHNIQUE CEMENTATION TECHNIQUE

LITHIUM DISILLICATE (EMAX)

SUBGINGIVAL DENTIN MARGIN & PFG

RESTORATION

• What do you use?

Zirconia Restorations -cleaning w/ ivoclean is not necessary -silane is contraindicated -no bonding agent necessary

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MISSING CANINE Concerns over implant cementation

ZIRCONIA ABUTMENT & EMPRESS CROWN

CUSTOM ABUTMENT

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CERAMIR KEY FEATURES

• Nano-structural integration

• Permanent seal of the tooth – restoration interface

• Biocompatibility

• Creates Apatite when in contact with phosphates

• No shrinkage

• No post-op sensitivity

• Hydrophilic system with Alkaline pH

• Chemically stable

• Acid Resistant

• Easy Cleanup

• Does not require optimal conditions for a good seal

MAKE CASES EASY

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RESIN CEMENT COSMETIC CASES….

COSMETIC CASES…. COSMETIC CASES….


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COSMETIC CASES…. PROVISONALS

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PROVISIONALS

BONDS WITH OR WITHOUT HF

ACID ETCHING

THE “NO-WATER” SILANE

INSTANT ACTIVATION

LESS DEGRADATION

(More Stable 2 Year Shelf-Life)

PRE-TREAT VENEERS

• Unidose Silane (Sultan Dental)

• Place under heat for a few minutes

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CHOICE 2™ Color Stable System

3 VITA® shades

2 chromatic shades

Bonding materials

LIGHT CURED RESIN CEMENT

FINAL RESTORATIONS

QUESTIONS?

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Case #4: Prepless veneers???

Aesthetics

Veneers

Function

Bonding

Feldspathic Veneers

Shade Assumptions

Bleach, B1, B2, A1, A2,

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Case #5: Excessive Prep Interproximal

Reshape teeth

eMax

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Case #8: Aesthetics

Instant Ortho

No TMJ or bite problems

Empress

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Any Questions?

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Pre-op

Post-op

Any Questions?

Lecture Handout

www.DENTOOLZ.com

THANK YOU!

Todd C. Snyder, DDS, AAACD

(949) 643-6733

[email protected]

www.drtoddsnyder.com

www.facebook.com/todd.snyder.dds

www.twitter.com/tcsaesthetics

http://www.drtoddsnyder.com/

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