Todd C Snyder, DDS, AAACD -...
Transcript of Todd C Snyder, DDS, AAACD -...
12/2/2015
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Todd C Snyder, DDS, AAACDPrivate Practice in Laguna Niguel, California
Faculty, Esthetic Professionals
Catapult Elite, Member
The Nuts and Bolts of Veneers
DIAGNOSIS & TREATMENT PLANNING
The Key to Success:
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CASE SELECTION:
• The Nuts and Bolts of Veneers
Who is a candidate?
What do they want changed and why?
Minimal to no length change
Discolored teeth
Narrow smiles
Minor rotational cases
Good function
Healthy periodontium
Others…
Diagnosis & Treatment Planning
When to do a crown versus a veneer?
Complex rotational cases
Extensive teeth lengthening
Non-compliance
Creating function
Large fillings
Thin teeth
Cementation concerns
• The Nuts and Bolts of Veneers
Diagnosis & Treatment Planning
CASE SELECTION:
Putting A Case
Together• Case Sequencing
• What Records & When
• Smile Design, & Aesthetics
• Laboratory Communication
• Clinical Procedures
• Finale (Post-Cementation)
Color
• The Nuts and Bolts of Veneers
SEQUENCING FOR SUCCESSFUL CASES
How many appointments for veneers?
Up to 6
2? 3?
• The Nuts and Bolts of Veneers
SEQUENCING FOR SUCCESSFUL CASES Initial Appointment
Consultation
First Appointment
Comprehensive Evaluation
Dx Wax-up & Whitening?
Second Appointment
Go over diagnostic tools
Check dx wax-up & whitening
Discuss Treatment Plan (Do Last)
Set Appointment & Collect $$
Lab Work
Third Appointment/Preparation
Fourth Appointment/Try-In/Delivery
Verify margins, contacts, occlusion and shade
Fifth Appointment
Post-Op Check
Occlusal Guard Impressions
Post-Op Photos
Sixth Appointment
Deliver Occlusal Guard
Reschedule or Follow-up
OR
• The Nuts and Bolts of Veneers
Initial Appointment
Consultation
First Appointment
Comprehensive Evaluation
Dx Wax-up & Whitening?
• The Nuts and Bolts of Veneers
SEQUENCING FOR SUCCESSFUL CASES
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COMPREHENSIVE EVALUATION
• Patient Desires
• Strength, esthetics, longevity, etc.
• Visual Perception
• Function
• Morphologic Positioning & Posturing
First Appointment
FIRST APPOINTMENT
Comprehensive Evaluation
Time
Money
Patient and Lab Communication
Diagnostic Records
Time/Appointments
Diagnostic
Verification & $$$$
Preparation
Try-in / Cementation
Post-Op Check/Guard
“Under promise and
over deliver”
Money
Diagnostic
Estimate range on cost
Will be presented when “we decide” after the waxup is approved.
Comprehensive Evaluation
Time
Money
Patient and Lab Communication
Diagnostic Records
Comprehensive Evaluation
Time
Money
Patient and Lab Communication
Diagnostic Records
PATIENT AND LAB COMMUNICATION• Patient’s current likes and dislikes
• Patient discussion about appearance 4x
• Final time is definitive due to being adhered in permanently
• Pt’s perceived benefits from treatment
• Have they had other work done, how did it turn out?
• Aesthetic Expectation Level
• Listen carefully, ask probing questions, don’t make assumptions
• Longevity?
• Lab time frame (prebook lab)
• Relay pictures and information
First Appointment
FIRST APPOINTMENT
• Initial (Primary) Diagnosis
• Time
• Money
• Patient and Lab Communication
• Diagnostic Records
How soon is the case needed?
When can the lab get it done?
FIRST APPOINTMENT
• Initial (Primary) Diagnosis
• Time
• Money
• Patient and Lab Communication
• Diagnostic Records
What Records & When
Diagnostic Records
Review Health Hx & existing Radiographs
Comprehensive Exam
Periodontal Probing, Mobility,
Recession, Attached Tissue,
Biologic Width
First Appointment
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What Records & When
Comprehensive Exam
Periodontal Probing, Mobility,
Recession, Attached Tissue,
Biologic Width
First Appointment
GINGIVAL EMBRASURE SPACE (BLACK TRIANGLES)
• Sound to bone from margin 2.5-3mm distance.
• Contact 2mm from margin
• Always want 5mm or less from contact point to bone
• Use most incisal bone
x < 5 mm
Tarnow J. Perio. 1992;63(12) 995-996
5mm 100%
6mm 56%
7mm 27%
First Appointment
What Records & When Diagnostic Records
Review Health Hx & existing Radiographs
Comprehensive Exam
Periodontal Probing, Mobility,
Recession, Attached Tissue, Biologic Width
Oral Cancer Screening
Occlusion and TMJ Exam
First Appointment
Occlusion and TMJ Exam Joint History
Noise
Maximum opening
Muscle palpation
Deviations
Function
Holds, excursives and interferences
Wear facets
Diagnostic Records (continued)
Radiographs
3 Sets of Models (mounted with facebow on
articulator)
Initial untouched model
Preparation design model
Diagnostic Wax-up
(Duplicated diagnostic wax-up model for provisionals)
What Records & When
First Appointment
Additional Model (possibly)
Bleaching trays
Pour in Snap Stone or Speed Stone
Deliver same day
Diagnostic Models and Facebow
First Appointment
Diagnostic Records (continued)
Smile Design
Shade Analysis
Teeth Whitening!!
How long will it postpone treatment??
What Records & When
First Appointment
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SMILE DESIGN REFERENCESCANINE, LATERAL AND CENTRAL SHAPES
Smile Guide (Discus)• B&W Picture and 6-11 guide
LVI Smile Catalog (LVI)
• Style and shape combinations
Smile Style Guide (Digident)
• Color picture and shape
combinations
First Appointment
SMILE DESIGN SOFTWARE
LAB / DOCTOR
COMMUNICATION
• www.4theladder.com Diagnostic Records
(continued)
Photographs
Pre-Operatives
(Additional)
Preparations
Provisionals
Final Cementation
What Records & When
First Appointment
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PRE-OPERATIVE PHOTOS
• Full face
• Smile
• Resting
• Intraoral
• Occlusal
• Video?
First Appointment
Cognitive Mapping
EYESPECIAL C-II (SHOFU)
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UNIQUE FEATURES
EYESPECIAL C-II
• Designed for dentistry
• 8 modes
• 12 Megapixels
• Dental cropping and grid lines
• Large LCD touchscreen
• Water and chemical proof – Essential for infection control
• Durable rugged Exterior***
• Fast autofocusing & anti-shake capabilities
• Held with one hand – weighs only 1lb
• Compatible with the Eye-Fi X2 card – Immediately upload
images onto PC, iPad, Tablet or Smartphone
MAGNIFICATION RANGE• Chose the magnification ratio/range by rotating the dial key
• Icons to help you determine and select the range properly
EDIT & DRAW FUNCTION ON THE
EYESPECIAL C-II
• Edit functions are ideal for
patient education
• Under the Menu key you can:
• Draw on images to show
areas of focus
• Rotate the image
• Protect the image against
being deleted
STANDARD MODE
MIRROR MODEImages are captured in “Low Glare” mode.
WHITENING MODEFOR SHADE COMPARISON BETWEEN BEFORE AND AFTER
WHITENING• Similar to “Low-glare” mode but with lower light intensity
• Reduces glare and emphasizes the surface texture and shade
• Delegated Whitening & Scanning Assistant
Upper arch whitened
Lower arch not whitened
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ISOLATE SHADE MODEFOR OPTIMAL SHADE MATCHING
TELE-MACRO MODEFOR PHOTOGRAPHING ANTERIOR TEETH, INDIRECT RESTORATIONS AND
WORKING MODELS IN HIGHER MAGNIFICATION **ATTACH THE CLOSE-UP LENS
WHEN TAKING PICTURES IN THIS MODE**
Quadrant Dentistry - Menu
COMPUTER SIMULATION:
DIGITAL MOCKUP/PREVIEW
What about
pictures?
Are they relevant and
realistic?
REALISTIC
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VIRTUAL SMILES©
• Smile Simulations
VIRTUAL SMILES©
• Tooth shape
• Length, width, & style #
• Tooth color
• Translucency, effects
• File Format
• Paper
• CD
• Flash
• Logo & Office Info
• Smile Simulations
What Records & When
Diagnostic Records (continued)
Imaging Photos
Treatment Plan
Finances
Signatures (7)
Health Hx, Tx Plan, Financials
Imaging, Wax-up, Provisionals, & Cementation Sign Off
First Appointment
Tooth shape• Length, width, & style #
Smile line
Midline
Tooth inclination
Function
Tooth color• Translucency, effects
• Composite MockUp?
Smile Design Tooth Size Averages
2nd Premolar 1st Premolar Canine Lateral Incisor Central Incisor
6.6mm 7.1mm 7.6mm 6.6mm 8.6mm
7.7mm 8.6mm 10.6mm 9.8mm 11.2mm
Width
Length
Prior to Second Appointment
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Architecture
• Length
• 1-2 mm show at rest, 2-3 youthful
• Golden proportion 0.6-1-1.68
• Contact points
• Length/Width ratio 75-80%
• Overbite/Overjet
• Gingival line & Zenith
• Embrasures
Prior to Second Appointment
ADDITIONAL Tools
ADDITIONAL TOOLS
Panadent: Multi Purpose Ruler Erskine: Dentagauge 1 & 2
ADDITIONAL TOOLS
ADDITIONAL TOOLSSHIMBASHI MEASUREMENT. CEJ #8 to CEJ #25 or
CEJ #9 to CEJ #24
Normal is 17 to 18 mm depending on
the patient.
Prior to Second Appointment
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Golden proportion
between teeth.
0.6-1-1.68
Golden Proportion Measurement.
Prior to Second Appointment
Wear Facets & Interferences
Prior to Second Appointment
EQUILIBRATED MODELS• Shim Stock Holds (0.001 inch)
Prior to Second Appointment
Occlusal Testing
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.
Mounted and Equilibrated
Prior to Second Appointment
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What Records & WhenDiagnostic & Prep Reduction Models (Do your own work)
Prior to Second Appointment
Prepared Model & Waxup
Prior to Second Appointment
Blueprint for Success
Diagnostic Guides Prior to Second Appointment
Diagnostic Guides Prior to Second Appointment
Disposables
Non Adjustable
Semi Adjustable
Articulators Prior to Second Appointment
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Prior to Second Appointment Prior to Second Appointment
Semi Adjustable
not on Hinge Axis
Prior to Second Appointment
Semi Adjustable
not on Hinge Axis
Prior to Second Appointment
Function & Failures Function & FailuresWhich do you think is going to be more accurate?
Less adjustments and remakes?
Prior to Second Appointment
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Initial Appointment
Consultation (Free)
First Appointment
Comprehensive Evaluation
Whitening?
Second Appointment
Go over diagnostic tools
Check whitening
Discuss Treatment Plan (Do Last)
Set Appointment & Collect $$
Reschedule or Follow-up
SEQUENCING FOR SUCCESSFUL CASES
• The Nuts and Bolts of Veneers The Nuts and Bolts of Veneers
Preparations Veneers
(Third Appointment)
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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
Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”
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)
SS WHITE: PIRANHA & PIRANHA 2X
• Single Use
• Over 500 Shapes
BURS
• Lasco Depth Cutters
• SS White Diamonds
• Piranha Diamond
• 850-016M/F
• 368-023M/F
• 392-016VF/F/M
• SS White Carbides
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PREPARATIONS
• Prep counter clockwise
• Less tissue damage (rotation is rolling on tissue) & faster tooth
reduction. Use above gum line.
• Prep clockwise
• Tissue removal due to bur rotating opposite direction
• Bur rolling on tooth creates less reduction of tooth structure.
• Place a single cord
• after preparing interproximal area
• after gross reduction just above tissues
• Then refine margins
ELECTRIC HANDPIECES
INSTANT ORTHO/UN-ROTATING TEETH
• Do initial workup
• Diagnostic preps
• Diagnostic waxup
Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”
Sequence
– Reduce all excess tooth structure
– Ideal reduction
– Margin placement
Example: Aesthetics
Instant Ortho
No TMJ or bite problems
Empress
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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.
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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
CASES
Case #1: Prepless veneers???
Aesthetics
Veneers
Function
Bonding
Feldspathic Veneers
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Shade Assumptions
Bleach, B1, B2, A1, A2,
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Aesthetics
Smile Line
Gingival Excess
Gingival Asymmetry
Buccal Corridor
Case #2:
Aesthetics
Smile Line
Gingival Excess
Gingival Asymmetry
Buccal Corridor
Combination Crowns & Veneers
Gingival Crown Lengthening
Teeth Angulations
Function
Draw a line from subnasali down
Upper lip should be 2-5mm in front
Lower lip should be 0-3mm in front
Chin should be on the line or 4mm behind
Facial Measurements
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
C-TYPE PREP
Preparations & Provisionals2 crowns and 8 veneers
Preparation Guides Preparation Guides
A-TYPE PREP
Facebow / Wax BiteProvisionals (Wax-up)
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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.
Bead Line Veneer Provisional Restorations. Pract Proced Aesthet Dent 2009;21(3):E1-E7.
Provisionals (Bead Line Technique)
Duplicate model with light body wash and heavy body tray material.
Provisionals (Bead Line Technique)
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 Technique)
SEQUENCING FOR SUCCESSFUL CASES
Initial Appointment
Consultation
First Appointment
Comprehensive Evaluation
Whitening?
Second Appointment
Go over diagnostic tools
Check whitening
Discuss Treatment Plan (Do Last)
Set Appointment & Collect $$
Lab Work
Third Appointment/Preparation
Fourth Appointment/Try-In/Delivery
Verify margins, contacts, occlusion and shade
• The Nuts and Bolts of Veneers
• Feldspathic Porcelain (weakest, thin, best colors)
• Numerous on the market
• Pressable (Leucite) Glass Ceramic (moderate strength and thickness, good/better color)
• Numerous on the market
• Lithium Silicate & Disilicate Ceramic (high strength, moderate thickness, good color)
• eMax
• Obsidian
• Zirconia – Translucent Ceramics
• Noritake
MATERIALS AVAILABLE
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Restorations
Check Shape & Esthetics
Check Shade
Marginal Integrity
Contacts
Etch
Restorations
Check Shape & Esthetics
Occlusion
Function???
CEMENTATION Technique
Try-inSilane restorations prior to tryin.
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
Cementation – large cases
Etchant based or SE adhesive systems (can be light cured)
(Bisco Universal) (AB3)
Start from center moving laterally with light curable resin
(Choice 2 or eCem)
Light cure material for cases over 4 teeth (2m tacking tip/VALO)
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
Do not floss contacts
Cementation – small cases
Bonding agent light cured
Start from center moving laterally
Dual cure material for cases under 4 teeth
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
Do not floss contacts
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CEMENTATION STEPSFront two crowns first
Then 4 veneers at a time.
SEQUENCING FOR SUCCESSFUL CASES
Initial Appointment
Consultation
First Appointment
Comprehensive Evaluation
Whitening?
Second Appointment
Go over diagnostic tools
Check whitening
Discuss Treatment Plan (Do Last)
Set Appointment & Collect $$
Lab Work
Third Appointment/Preparation
Fourth Appointment/Try-In/Delivery
Verify margins, contacts, occlusion and shade
Fifth Appointment
Post-Op Check
Occlusal Guard Impressions
Post-Op Photos
Sixth Appointment
Deliver Occlusal Guard
• The Nuts and Bolts of Veneers
-Aesthetics
-Function
-Gingival Embrasures
-Excess cement
-Patient homework & questions
Post-Op Check
From Imaging & Diagnostic Wax-up the entire case was duplicated
QUESTIONS?
Case #3: Aesthetics
Veneers
Function
Gingival Bonding
Feldspathic Veneers
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Remove old restorations & repair abfraction
lesions on cervicals
• Stump Shade (dehydration factor)
Base Shade • Easy Shade
• Custom Shade
• Photographs
• ALL DONE PREVIOUSLY
B-TYPE PREP
Impressions
• Facebow (SAM III)
• Wax bite (Delar)
Facebow & Wax Bite Registration
Provisionals Free Hand Provisionals
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Free Hand Provisionals
Example• 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
PRE-TREAT VENEERS
• Unidose Silane (Sultan Dental)
• Clearfil Ceramic Primer (Kuraray)
• Bis-Silane (Bisco)
• Ceramic Primer II (GC America)
• Place under heat for a few minutes
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
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• 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
VENEER TRY-IN
• Water soluble clear try-in paste
• Evaluation of esthetics and contour
• Evaluate occlusion
Porcelain Adjustments VENEER CLEAN-UP
• Steam clean
• Acetone in a bottle drop in the ultrasonic
VENEER BONDING
Dry Air Source
Evaporate volatile
solvents
Drying dentin &
enamel
Do not desiccate
ADEC tooth dryer
ZEN: CORDLESS PROPHY ANGLE (ZILA)
MIDWEST FREEDOM (DENTSPLY)
WHIPMIX PREPPIES
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INSTRUCTIONS FOR USE
PORCELAIN VENEERS
VENEER PREPARATION:
• Make sure veneer is properly etched with hydrofluoric acid.
• Apply 1-2 coats of Silane to internal surface of veneer. Wait 30-seconds and air dry, or let sit longer with heat.
• Try-in veneers with Water-Soluble Try-in Pastes. Remove and rinse thoroughly. • Light-Cured Veneer Cement
• Superior Color Stability
• Highly Filled
• Enhances Strength
CHOICE 2™ Color Stable System
3 VITA® shades
2 chromatic shades
Bonding materials
Sultan Dental Silane
Prime Porcelain with Bis-Silane™
Apply Uni-Etch® with BAC Apply Bonding Agent
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Apply Porcelain Bonding Resin Place Veneer Cement
• 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
• Less heat at the tip of the light
• Nanometer range closely matched the CQ range (450-
470)
• Smaller in size/lighter
• Units can be cordless
• Curing options
• Smart Light Max (Dentsply)
• Valo (Ultradent)
BENEFITS OF LED LIGHTS Radiometers
Radiometer
Check daily in am
300mW/cm2 (600mW /cm2)
How good is your light?
Study by Nassar Barghi found
30% of units tested had
output less than
200mW/cm2
Many doctors unaware
that curing light output was
inadequate
Intensity of light inversely
proportional to age of unit
10% had cracked filters
Most doctors never
replaced the bulb
**Proper care of curing light
will ensure that your
restorations are thoroughly
cured. **
Bulk excess
– Bard Parker
– TC Carvers (Brasseller)
– Gold knives
– Perio knives
Interproximal saws
Finishing strips
12 & 30 fluted carbides
Cement RemovalFinishing & Polishing Ceramic
30 & 15 µm diamond
8/12 &30 fluted carbide
polishing points
diamond polishing paste
diamond impregnated points & cups
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Post-Op Photos
QUESTIONS??
The Nuts and Bolts of Veneers: Tools
IMPRESSIONS & TISSUE MANAGEMENT
• The Nuts and Bolts of Veneers
PREPARATION TECHNIQUE
• Margin Placement
• Supragingival
• Equigingival
• Subgingival
• Margin Design
• Clock Work Prep
• Retraction Cord Assistance
• Sonic Prep
Technology/Tools
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PREPARATION TECHNIQUE
Important: Minimize tissue damage allows for less time utilized in managing bleeding.
SF1LM (Komet)
K0095 Preparation Kit (Brasseler USA)
Unique Tools
PREPARATION TECHNIQUE
Important: Minimize tissue damage allows for less time utilized in managing bleeding.
Unique Tools
PREPARATION TECHNIQUE
Important: Minimize tissue damage allows for less time utilized in managing bleeding.
Unique Tools
PREPARATION TECHNIQUE
Unique Tools
Important: Minimize tissue damage allows for less time utilized in managing bleeding.
PREPARATION TECHNIQUE
SF1LM (Komet)
Important: Minimize tissue damage allows for less time utilized in managing bleeding.
Unique Tools
PREPARATION TECHNIQUE
SF1LM (Komet)
Important: Minimize tissue damage allows for less time utilized in managing bleeding.
SF1LM (Komet)
Unique Tools
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Types of Moisture
Saliva
Crevicular Fluid
Bleeding
Enhancing Moisture Control
Fluid/Tissue Management
• Oral Rinses
• 0.63% Stannous Fluoride
• Anti- cavity, -gingivitis, -hypersensitivity, -plaque (8hrs)
• Chlorhexidine
• Anti- fungal, microbial and bacterial
• Antisialogogues
• Saltropine
• Antihistamines
• Benadryl
• Benzodiazepines
• Triazolam (halcion)
• Diazepam (valium)
Enhancing Moisture Control
Pre Appointment Therapy
Fluid/Tissue Management
• Superoxol
Epinephrine
Ferric Sulfate
ViscoStat 20%
Astringent 15.5%
• Aluminum Chloride
• Viscostat Clear 25%
• Expa-syl
• Hemostasyl
• Aluminum Sulfate
• Tissue Goo 25%
• Various Cords
ASTRINGENTS Enhancing Moisture Control
RETRACTION CORDS
• Numerous Sizes
• 1 cord technique (pockets <3mm)
• Placed below margin
• Moisten prior to retrieval
• If bleeding do not remove first cord
Enhancing Moisture Control
Fluid/Tissue Management
Enhancing Moisture Control
◦ 1 cord technique allows subgingival
margin placement
◦ Reprep if necessary
◦ If more bleeding occurs place astringents
or pastes
RETRACTION CORDS
Fluid/Tissue Management
RETRACTION CORDS
• 2 cord technique (>3mm pockets)
• Remove uppermost cord only
• Cord and a Paste technique
• Cord is for tissue displacement, not for
hemostasis
Enhancing Moisture Control
Fluid/Tissue Management
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Fluid/Tissue Management Fluid/Tissue Management
Fluid/Tissue Management
LASERS Fast
Hemostasis
No crevicular fluid
No cord
Better healing
Enhancing Moisture Control
Fluid/Tissue Management
Precise tissue incision,
excision, ablation
Reduced bleeding, post-
op infection
Minimizes pain, patient
inconvenience
Enhance scope & quality
of dental practice
Minimal or no healing
shrinkage
No arcing to metals
Increased productivity
Gingival Recontouring
810 nm
2.5 & 7 Watts
Enhancing Moisture Control
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Laser Indications For Use
Frenectomy
Frenotomy
Gingival Troughing
Implant Recovery
Gingivectomy
Gingivoplasty
Crown Lengthening
Hemostasis of donor site of
granulation tissue
Laser assisted flap surgery
Incisions and draining of absesses
Vestibuloplasty
Excision of lesions
Exposure of unerupted/partially erupted
teeth
Removal of hyperplastic tissue
Treatment of apthous ulcers
Leukoplakis
Sulcular debridement
Pulpotomy
Laser Troughing
Benefits:• Predictable margins
• No tissue recession
• No bleeding
• No discomfort
• Faster procedure
Settings:
Power:1.2WMode: Continuous
Tip: Initiated
Tissue Management
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For All Tissue Management Issues For All Tissue Management Issues
MAKES LARGE CASES EASY
Tissue Management
KETTENBACH IDENTIUM & PANASIL
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Enhancing Moisture Control
Fluid/Tissue Management Enhancing Moisture Control
Fluid/Tissue Management
Enhancing Moisture Control
Fluid/Tissue Management Enhancing Moisture Control
Fluid/Tissue Management
Enhancing Moisture Control
Fluid/Tissue ManagementFrenectomy
Benefits:
• No sutures
• No bleeding
• No discomfort
• No injections
Settings:
Power:1.4W
Mode:CW
Tip:Initiated
HINT: Use tissue pen to
darker fibrous band
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Frenectomy Frenectomy
Frenectomy
Before After
• Closed Bite Trays (most common)
• Flexible Trays
• Lack of rigidity may cause distortion
• Spring back after impression potential
• No cross arch stabilization
• No support
• Thin spots or perforations can cause distortion
• Lack of occlusal stops for proper model articulation
• Impression material shrinks towards bulk
• Unable to recreate excursive movements
• Potential for errors & adjustments extremely high
IMPRESSION TRAYS Selection Process
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
• 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
IMPRESSION TRAYS Selection Process
Custom Tray
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HEATWAVE BY CLINICIAN’S CHOICE
• 4 upper & lower trays
• 60 sec. @ 158°F
• Fast, efficient
• Virtually custom
Selection ProcessIMPRESSION TRAYS
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LOCK-N-RELOADWWW.INDIGREEN.COM
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
IMPRESSION MATERIALS
(TYPICALLY A MEDIUM & A HEAVY BODY)
• EXA’lence (G.C.)
• Panasil (Kettenbach)
• Identium (Kettenbach)
• Aquasil Cordless (Dentsply)
• Affinity VPS (Clinician’s Choice)
IMPRESSION MATERIALS
• Still account for 85%-90% of the market.
• Types
• Vinylpolysiloxanes
• Polyethers
• Vinylsiloxanether (VSXE)
IMPRESSION MATERIALS
• Dimensional stability
• Good flow ability & wettability
• High tear strength & elastic recovery
• Accurate detail reproduction <25μm
• Non slumping
Panasil Initial Contact (VPS)
Kettenbach
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PANASIL INITIAL CONTACT• Lowest contact angle of any VPS impression material
• Fast set and Regular set
• Best Value Materials Available
Kettenbach
PANASIL INITIAL CONTACT VS. AQUASIL
Kettenbach
CRACKED TOOTH
Kettenbach
PANASIL INITIAL CONTACT
Kettenbach
PANASIL INITIAL CONTACT
Kettenbach Kettenbach
Identium(Vinylsiloxanether-VSXE)
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IDENTIUM
• Fast set and Regular set
• Medium or Heavy viscosity
• Light viscosity flow
• Excellent flow ability
• Exceptional hydrophilicity
• Easy removal from mouth and model
• Odorless and neutral taste
• Can be poured immediately
• Identium Scan is a new scanable Vinylsiloxanether that handles like a polyether with
a long working time & snap set
Kettenbach
Identium combines the advantages of the most tried and tested materials, A-silicone and polyether. Test results reporting excellent flow and hydrophilic properties were published in the CLINICIANS REPORT®…volume 5, Issue 3.
• 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
Identium for single teeth
Kettenbach Kettenbach
Identium for single teeth
Identium for multiple teeth
-two cord technique
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MAKES LARGE CASES EASY
PROVISIONALS
• Utilize an accurate preliminary over impression
• Maintain over impression
• Check contacts and occlusion
-Visalys (Kettenbach)
-Inspire (Clinician’s Choice)
Ultradent (
-Structure (VOCO)
PROVISIONALS
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Putting it all Together
Case #4:
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C-TYPE PREP
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Any Questions?
Case #5:Excessive Prep Interproximal
Reshape teeth
eMax
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RESIN CEMENT COSMETIC CASES…. COSMETIC CASES….
COSMETIC CASES…. COSMETIC CASES….
COSMETIC CASES…. COSMETIC CASES….
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COSMETIC CASES…. COSMETIC CASES….
COSMETIC CASES…. COSMETIC CASES….
PROVISONALS PROVISIONALS
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PRE-TREAT VENEERS• 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
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FINAL RESTORATIONS
LITHIUM DISILICATE & SILICATE, LEUCITE AND
FELDSPATHIC RESTORATIONS
IS AN ADHESIVE CEMENTATION
SYSTEM THAT IS EASY-TO-USE,
EFFICIENT AND HIGHLY
EFFECTIVE
20 y.o. female patient presents with a missing lateral incisor, peg lateral, worn dentition.
The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
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The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers
Alkaline pH Moisture Tolerant
Self Sealing
Apatite Formation Insoluble
Stronger with time Semi / Translucent
Biocompatibility-Excellent
Bioactivity-Apatite formation Sealing Quality-Excellent
Cement Selection
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
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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
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)
Cement Selection
Cement Selection Cement Selection
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Cement Selection
Zirconia Restorations
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• 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
• Retention equal to or better than resin cements
• Material gets stronger over time & remains stable
• No etching, bonding or conditioning
• Easy seating to completion of indirect restoration
• Easy to clean up
• Does not require optimal conditions for a good seal
• Self sealing
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The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers
REMEMBER:
FUNCTIONAL LIMITATIONS
Case #7:
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The Art of Aesthetics & Occlusion
FUNCTIONAL LIMITATIONS
• Excursive Interferences
• Group function
• Malpositioned teeth
• Occlusal interferences
• Canine guidance
• Group function
FUNCTIONAL LIMITATIONS
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FUNCTIONAL LIMITATIONS FUNCTIONAL LIMITATIONS
• Check excursives
• Protrusive
• Night Guard
FUNCTIONAL LIMITATIONS FUNCTIONAL LIMITATIONS
FUNCTIONAL LIMITATIONS FUNCTIONAL LIMITATIONS
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Not a veneer case!! Not a veneer case!!
Not a veneer case!!
Choose carefully who you want to work on and get your signatures
QUESTIONS?
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Case #10: Aesthetics
Tissue Problems
Poor Function
No TMJ Problems
The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers
Incisal position
Gum height
The Nuts & Bolts of Veneers
2-4 mm
10-11 mm
The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
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The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
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The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
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The Nuts & Bolts of Veneers The Nuts & Bolts of Veneers
The Nuts & Bolts of Veneers
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Pre-op
Post-op
“The quality of a person’s life is in
direct proportion to his or her
commitment to excellence.”
-Vince Lombardi
It’s not always about the material used
sometimes its more about the technique.
Free marketing information, handouts & samples
www.DENTOOLZ.com
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DDS, AAACD
25500 Rancho Niguel Road, Suite #230
Laguna Niguel, CA. 92677
www.drtoddsnyder.com
www.facebook.com/todd.snyder.dds
www.twitter.com/tcsaesthetics
Todd C. Snyder, DDS, AAACD(949) 643-6733
doc@ tcsdental.com
www.aestheticdentaldesigns.com
www.drtoddsnyder.com