Being a partner dentist with us combines the unique knowledge & working protocols of both Mark and Keith from SBO in to a laboratory experience

that is totally unique and unbeatable.

Change your business, change your life, change your lab!

Relax in the knowledge that with us you can enhance work life balance and be more cost effective. As a small sample of the knowledge and experience we have as a lab we have put together our….

Top 5 ‘ultimate success techniques’ for modern dentists

In this FREE guide you will discover more about

1. Confidently prescribing a genuine alternative to Lumineers – save money & time!2. Relax and have confidence in your multiple veneer cases using a unique ‘smile design’ protocol3. Select shades confidently and accurately for happier patients4. Remove uncertainty in your restoration choice using a proven selection system5. Safely and reliably plan implant cases using an advanced planning protocol

SBO Dental Laboratory15 Station Close

Potters BarHerts

EN6 1TL

01707 663293

lab@sbodentallaboratory.co.uk

www.sbodentallaboratory.co.uk

1. Confidently prescribe a genuine alternative to Lumineers – save money & time!tallaboratory.co.uk

What are lumineers?Lumineers are leucite re-enforced, pressed ceramic veneers manufactured from the cerinate ceramic produced by Den-mat corporation. (1) They can be made between 0.3mm and 3mm thick (2) which is advantageous in many instances for both patient comfort and clinical indications. They have a flexural strength of 123 MPa (3) which means that often Lumineers can be made very thin with zero preparation.

So what does this technical data mean on a day to day basis and how does it compare with other systems? Let’s take each statement in turn.

Leucite reinforced pressed ceramicThis is certainly not unique, many ceramics on the market today are of this ilk, it is purely a convenient manufacturing technique for the laboratory.

They can be made 0.3mm thickAll veneers can be made this thick, however some laboratories prefer not to due to their delicate nature. Denmat claim that cerinate ceramic is strong which enables them to be made thinner than some other ceramics.

Flexural strength of 123MPaThis enables Lumineers to be made thin, but in comparison with modern ceramics it is NOT strong. The literature produced by Den-Mat compares the strength of their Cerinate against old obsolete ceramics such as Vitadur N and Mirage Body (Vitadur N is 3 generations old and we stopped using it 10 years ago, we also stopped using Mirage 10 years ago) . Compared to these ceramics cerinate is strong, but look at the chart below comparing it to modern ceramics.

What are lumineers?What is unique about lumineers?

Can SBO make them?

This article has been designed to give an overview of the lumineers system, and to then compare this overview with the alternatives available.Ceramic Flexural Strength

(MPa)

Cerinate (Lumineers) (3) 123.7

Vita VM13 (4) 120

Vita Mark II 154

The modern ceramics we use equal or even surpass Lumineers.What is unique about lumineers?DenMat have been very cleaver with their branding and advertising, but Lumineers are essentially an exercise in what is know as ‘Supply Chain Management’. A traditional supply chain would look like this:Ceramic manufacturer (Vita, or Denmat) Laboratory Dentist Patient

DenMat have re-organised the chain to look like this:

Ceramic manufacturer (Denmat) Dentist Patient

So Lumineers are made in DenMats large factory facility in the USA, therefore bypassing all laboratories and maximising profits for DenMat...quite clever really!

They have also re-organised the marketing, so rather than rely on the labs to market to the dentists and then the dentists to market to the patient, they have decided to use their considerable resources to market direct to the patient and push them in to surgeries to ask for Lumineers.

So the answer to the question, ‘What is unique about Lumineers’ is ‘a ceramic only available to DenMat’ and ‘a remodelled supply chain’ neither of which have ANY tangible benefit to either the patient or dentist. Coupled with a high cost of Lumineers and often a long waiting time I believe there are far more sensible and logical alternatives.

Can SBO make lumineers?The simple answer is no! What Lumineers offer in abundance to the patient are ‘intangible’ benefits which are achieved via the branding, image and promotional material. The benefits are primarily achieved by promising the patient ultra thin veneers and a pain free ’no prep’ technique which many patients love the idea of...who wouldn’t!

No-prep veneersIf this technique is preferred then we can also offer this service and make veneers down to 0.2mm where required. Please be aware that for this technique to be totally successful a ‘Smile design protocol’ (see the next section in this guide) is essential. We can then advice as to whether a no proep technique is suitable for the patient and their desired outcomes.

SummaryFor cases where the patient requires a no prep technique we can fulfil this need easily with our ceramic that easily matches the Lumineers ceramic technically.

Of course we always prefer to do a full ‘Smile Design’ with every case, this ensures you get a preparation guide, temporary stent and full waxups, this is only really possible when working directly with a technician that knows exactly what they are doing. Working in any other way, although possible, does make the likelihood of problems occurring more likely.

ConclusionI hope by now that you have a clearer understanding about Lumineers and that there is no need to pay over the odds whilst waiting an excessive amount of time sending your cases to a factory in the USA.

For a FREE quotation on any case simply call Mark, then relax in the knowledge that your veneer cases are in great hands with SBO.

Lumineers ® are a trademark of Den-mat Corporation(1) Lumineers by Cerinate, The Dental Advisor, Vol.23 No 3, 2006(2) ‘Cerinate Smile Design Studios’ leaflet. Den-Mat Corporation. Q. How thick are Cerinate Lumineers? A. The lumineers can be 0.3mm

to 3mm thick(3) Australian Prosthetic Journal 1990;4, as seen in ‘Cerinate ® Porcelain overcomes aluminous shortcomings’, Den-Mat Corporation(4) Vita working instructions for each material www.vita-zahnfabrik.com site accessed 30 8 0

Please don’t send your veneer cases to just any laboratory, make sure they have experience of smile designs and provide a detailed case planning service for your cases. (take a look at their

website and see if they have actual cases of their own work)

For examples of our cases and a simple ‘smile design protocol slide show’ please visit www.sbodentallaboratory.co.uk

“SBO really know about smile designs”Dr Steve Sharma

Following a 10 veneer & crown smile makeover“A very natural result, the patient was very pleased with her new smile”Dr Elisabeth Hersey

Following a 10 veneer smile makeover“Lovely result” Dr Keith Garber

Here’s what some of our partner dentists think of our veneers

2. Relax and have confidence in your multiple veneer cases using the unique SBO smile design protocol PART 1

Stage 3 Temporisation Take our temporisation matrix, which is specially designed to reduce excess flash, and verify that it seats intraorally. Fill the matrix with temporary material (Luxatemp works well) and seat. Location is easy as we will place a mark on the matrix in line with the buccal fraenum. Once the material has set you will have minimal finishing to do and minimal flash to remove.

Stage 4 FittingThis shows the final result with 18 veneers.

Stage 1 Pre operative design:Send us pre-operative impressions and photos if you have them.

Tip:Tell us exactly what the patient wants to change, and what they want to keep. Do they want an ‘American Hollywood’ smile, or something more natural?

At the laboratory we then wax up the veneers to the patient’s ideal requirements. We then take a duplicate model and prepare this with the ideal preps to obtain the desired result.

We then return 3 models:Pre-operative—’where they are now’A prepared model—’how to get there’The completed wax up—’where they are going’

We also supply a clear preparation stent, using this you will clearly be able to see where to prepare. We will also provide a highly detailed matrix for temporisation.

Stage 2 Preparation At the preparation appointment simply place the clear preparation stent in to the patient’s mouth, then prepare the teeth to allow a minimum veneer thickness of 0.3mm, using the preparation model we provide as a guide.

The temporaries

The finished case

Before sending multiple veneer cases to a laboratory always ask them about their smile design protocol and ask to see an example. If they don’t have such a protocol, then it may be best to look for

another lab to trust with you smile design cases.

‘The SBO 10 Steps To Smile design Success’ we recommend using this check list for every smile design case. Please call the lab for more sheets

To obtain the best result for your patient and a stress free and predictable treatment plan for you, it is crucial that we have as much information about the smile as possible. Please complete this form and return with the

smile design and when we make the finished case.Pt Name:______________________________Surgery Name: _______________________

1. Face Shape, please tick:

Should this face shape be mirrored in the overall tooth shape?

Yes No

4. Angulation of existing Teeth, please tickLooking at incisal 1/3:

Regular 90° retroclined >90° proclined <90°

Should the angle be corrected to 90°? Yes No

2. Buccal PlacementWhere does incisal edge fall during “f” sound?On dry part of lip________ If yes should teeth be brought back? Yes No On wet part of lip___ _____If yes should teeth be brought forward Yes No

5. Existing midline is:

OK, leave it as it is Upper midline needs moving _______mm to patient’s left Upper midline needs moving _______mm to patient’s right

3. Length of centralsA) Current length:___ _____mmB) Ideal length:___ _____mm

7. Buccal corridor

Build this out Leave as it is

2. Relax and have confidence in your multiple veneer cases using the unique SBO smile design protocol PART 2

6. Vertical opening measured from CEJ to CEJ:

_____mm

This OK, leave it as it is Open this by ____mm Close this by ____mm

7. Translucency and internal structure

Standard shade guide blend

Translucent Incisal Translucent incisal with mamelon

structure

PLEASE TICK

Standard shade guide blend

Translucent incisal

Translucent incisal with mamelon structure

Other comments:

8. Overall looked requested.

THE NATURAL LOOK

Features:Laterals shorter than centralsIncisal triangles largerNarrower contact pointsSome unevenness on incisal

Copy this exactly

Copy this with the following amendments.

THE MILD HOLLYWOOD LOOK

Features:Laterals closer to same length as centralsIncisal triangles reducedbroader contact pointsminimal unevenness on

Copy this exactly

Copy this with thefollowing amendments.

THE FULL HOLLYWOOD LOOK

Features:Laterals same length as centralsIncisal triangles smallbroadest contact pointsno unevenness on incisal edge

Copy this exactly

Copy this with the following amendments.

9 Further instructions.

To improve this communication form I recommend adding the following extra parameters.

10. FINAL CHECK

For the design wax up, please check that you have enclosed the following:

Impressions U & L Bites Photos Stick bite, level with horizontal on face completed smile design protocol sheet

For the final case, please check that you have enclosed the following:

Existing shade Required shade Prep Impressions U or/& L Opposing model/impressions Impression of agreed temporaries Bites Photos Stick bite, level with horizontal on face completed smile design protocol sheet

3. Select shades confidently and accurately for happier patients

If you are able to take shades accurately you will get a better result for your patients and make dentistry easier and less stressful. This is the biggest cause of remakes in most laboratories, so attention to this area of dentistry is vital.

Throughout this article we will cover many areas of shade matching including:

Colour Theory Lighting Psychology Recording of appropriate data Digital/computerised colour mapping

Part 1 will cover the theory of shade matching, with part to moving on to more practical techniques.

Colour TheoryIt is important that we have a good understanding of colour theory if we are to stand a chance of getting shade matches to a good standard.

Interference coloursThese are colours that we see but that do not really exist. The best example of this is blue incisal edges. There is not really any blue in a natural tooth; rather the fact the light in this particular frequency (440nm) gives us the impression of blue. This is also true with the orange (570nm) incisal edge. The ‘in’ word for this is opalescence and it is important that your laboratory understands its relevance and how to mimic its effect with ceramics. (Fig1)

Retinal MemoryOur eyes are very sensitive pieces of equipment and it is very easy to abuse them and mislead them.

Try this test.

Stare at the following black dot with one eye closed for 45 seconds.

Now look at the square with alternate eyes, you will notice that the colour seems different with each eye. We have the same colour, in the same lighting condition with the same person and still the colour looks different. Our eyes have colour receptors sensitive to specific colours (violet/blue, green & red/orange). If we over stimulate one of our retinal sensors (in this case orange) our eyes will compensate and tone down our ability to see this colour. As demonstrated each eye works independently which shows the level of adjustment that our eyes and brain make to over stimulation. This leads me on to lighting.

LightingIf we over stimulate our eyes with one particular colour our brain will slowly start to reduce our sensitivity to this colour. This means that if we paint the walls of our laboratory orange, our brain will adjust and we can no longer see orange quite so well. On a more subtle scale, if we have lighting that emits orange light the same will happen. The result could be that we no longer can distinguish between the orangey ‘B3’ shades and the less orange ‘A3’ shade.

I would strongly recommend seeking out lighting in the 5500-6500K range of colour temperature – any reputable supplier of lighting should be able to tell you the colour temperature of their tubes or bulbs. If you work all day in lighting of this colour temperature (which represents natural north facing daylight at about midday- 6500K D65 light source) we will be able to see shades and colours more consistently with less adverse influence on our eyes.

Another factor to take in to account when choosing a lighting scheme Colour Rendering Index also known as Ra. This is a measurement of the lights influence on colour on a surface at a given distance away, in other words its change on colour from a standard. The best value a light can have is 100Ra; a bulb/tube with this measurement will not have any detrimental effect on the colour of the viewed object. Ra is not a percentage, as in extreme cases the value can be negative.

Generally speaking any tube with an Ra of greater than 85 is just about acceptable for laboratory use; Biolux by Osram tubes are good in this area as they have an Ra of 96 or a rating of 1A on the intentional scale.

Patient Psychology

This is an area of shade taking that is often overlooked. What we say to the patient and how we say it can affect their perception greatly.

I have learnt through my inept attempts at explaining the technical points to patients and have discovered through my own mistakes a few key areas to discuss. We often inadvertently misguide the patient along a particular train of thought for example:

Typically we could convert the following misguiding statements:“I could make your teeth longer and more bulky” to “creating a fuller smile”“I could add orange stain” to “I could add a warm colour”

By changing the way we say certain things we can often change the way a whole consultation is going. We must also take the lead from the dentist who of course is always with us during this consultation.

Many patients often want teeth that are excessively white, beyond what would look natural, the best way to avoid this (if necessary) is to always hold a shade tab up to the teeth that is far too light first. If we hold a shade tab that is darker than their natural teeth first the patient ‘gets it in to their head’ that we must go lighter,then lighter, then lighter often to bizarre degrees.

Another phrase that I often use if a patient is talking about white teeth is ‘Hollywood white’ this will always give a very positive “YES” or “NO” answer. If the answer is yes it tells us where the patient is going from an entire cosmetic approach and may affect ceramic selection, prep design and morphology. If the answer is no, then again it tells us that the patient generally wants a more ‘natural’ look.

To assist in understanding the patient I also use an ideas book. This is similar to the type of book you used to find in the barbers shop (that is when I had hair!). It consists of cut-outs from magazines of models and famous people showing their teeth. It is not only full of beautiful teeth, as the purpose is to generate discussion with the patient; I want to know what they don’t like as much as wanting to know what they do like. We simply spread the pictures out on the desk and discuss, discard or approve each one in turn, building a profile of the patient requirements.

AT the end of this booklet are some completed cases, showing these gives the patient confidence in what we are doing. Compiling this booklet has proved exceptionally useful and a great tool for communicating with the patient. I am careful not to let the patient think that we can match any of the photographs shown, it is merely a tool to gauge the patients thoughts and wishes which we must then convert in to a realistic treatment plan for the patient.

Recording Information

This generally falls in to 2 categories, written and photographical.

Photographic Records:I take the following photographs with all patients:

1. Full arch in ICP 2. teeth with relevant shade tabs held to tooth

This gives us good information about the arch in general and often helps when trying to articulate difficult bites as we can actually see the patient in ICP. The photo of the shade tab gives us an idea of the variations of colour within the tooth relative to a standard.

When taking shades I also include:

3. photos from both sides – this gives a good idea of emergence angle and how colour is distributed mesially and distally

4. full face – this serves as a reminder of the patient in general, but also tells us patient face shape5. Teeth apart but lips in rest position – this gives us the incisal display and gives an indication of how

much we can lengthen or shorten teeth. An aesthetic incisal display for females is about 3.4mm and 1.9mm for men.

6. close up of tooth to be matched to with teeth apart – this gives a black background to the tooth which highlights any opalescence with a blue tendency

7. close up of tooth to be matched to with teeth closed – this reflects light and highlights any opalescence with an orange tendency

8. photographs of each ceramic tab that is to be used – this gives us individual ceramic samples compared to the tooth to be matched

With these photographic records in front of us when building the ceramic it makes matching the shade much easier, this will then result in a happier patient.

Written Records

To record data in a precise and consistent fashion I use a template with the following entries, each entry has a tick box which I can simply place a tick next to the correct choice.

I look at:

1. Surface texture and rate it from 1-5. with 5 being highly textured to 1 being totally smooth2. Glaze – rated high, medium or low3. Dental age range from 1 being young to 5 being old – this gives us an indication of the use of highly

chromatic dentines and yellowish enamels for example4. gum colour – rated light, medium and dark – a Shofu GUMMY is used for this – when finishing the

crown in the lab we can then use a similar gum colour around our crown5. patient concerns and requests are noted6. shade of underlying teeth if veneers are being made – this gives an idea of the amount of opacity to

use

If a standard way of recording data is adhered to it becomes easy for the technician making the crown to understand the shade if he/she did not actually see the patient themselves.

Digital and Computerised Shade MappingThese systems are becoming more and more useful in determining the shade of our tooth. Every manufacturer declares that theirs is the best, leaving us to decide which one to go for.

I believe that these systems have a huge place in the dental market covering the middle to high area of quality of crown. However I do not believe they are a useful shade matching tool for the absolute highest quality.

A tooth is a 3 dimensions object, every digital shade matching system analyses the colour of the tooth on a 2 dimensional plane, either by a photograph or scanning. Often, to get a perfect shade match, we need to use a darker colour underneath and a lighter colour layered on top – all the digital system sees is the average or total of these 2 ingredients.

Even if a digital system can determine different ceramic modifiers to use, where do we put them? IN the dentine, ON the dentine, IN the enamel, ON the enamel? Or should they be stained on after? Only by looking at the patient from differing angles and using differing light sources to gauge metamerism can we accurately take a shade.

We also need a very deep knowledge of our ceramics to be able to take a shade, we need to know the effects that layering opalescent enamel over a dentine will have. Only by mapping exactly where, on a 3D basis to put shades will we get a good result.

Digital shade mapping is fabulous compared to the regular A2 or D3 shades that we all work with everyday. They gives us far more information and the dentist will get back a crown that is superior in quality to what (s)he had before. In my opinion the best system on the market currently is SpectraShade, sold through Metalor.

I do not, however, see it these systems as a replacement to colour mapping with the technician that will make the crown (s).

Summary1. Establish a rapport with the patient so they trust your professional judgment2. Take many digital photographs using shade samples either manufactures or laboratory made3. Use colour corrected lighting -colour temp 5500-6500K with Ra >90 (rated 1A)4. Make detailed notes of all patients requirements5. Map the tooth in 3D (Draw diagrams from all angles)

If all of these points are adhered to I believe we go a long way to removing the subjectivity of shade matching; building a crown to a 3D map is a great help and speeds up the layering process as we simply follow our instruction we made with the patient present…….as easy as painting by numbers!!

4. Remove uncertainty in your restoration choice using a proven selection system

In this article we will take the major restoration categories and use their generic properties to place them in to a decision tree to help you decide what to use when. This is of course our interpretation of what to use when, it may be that others have an alternative but no less valid way of deciding what to use and when.

I have tried to keep this article as generic as possible, but I have included a non-exhaustive list of examples for each category of restoration in order that the reader may translate the categories in to actual products available today.

It is the category of restoration that I feel is most important in deciding which to use rather than the name of the restoration itself, if we are clearly able to categorise a restoration it makes selection easier whilst also facilitating easier appraisal of future restorations.

I have also not included ‘fit’ in any category, all categories of restorations discussed have been shown to fit and I therefore do not consider it a factor when deciding between categories. (Although clearly it is a pre-requisiste for the finished restorations themselves)

Selection by category indicators

Preparation designMy first question is about prep design, if the you are unable to prepare a shoulder then in my opinion the only option is a Porcelain fused to metal (PFM) with a metal collar. All metal free options require a small shoulder, knife edge margins (or close to) put too much pressure inside the crowns with not enough marginal support –this can lead to failed restorations. Please see the diagram at the end of this section.

An analogy is it is easy to break a glass when drying up, if you put the towel inside a glass and force the glass OUT it is easier to break it than if you try to compress the glass by standing on it!

AestheticsMy next question concerns aesthetics. If aesthetics are not of primary concern a PFM is my first option; BUT I am always conscious of aesthetics, so if maximum strength is not required then I would still recommend a metal free option.

This is not to say that the metal free options are weak, rather that PFM is still the strongest and if we have no shoulder it is the ONLY option available in my opinion.

Shade of underlying toothIf the underlying tooth is very dark (more than 1 shade darker than the final result required) then I am very hesitatnt to suggest an option with no core. The cores help to cover dark teeth very well. If the shade of the

underlying tooth is the same, or close to the final shade then a dentine bonded crown (DBC) may be best; but not if strength is an issue! DBCs are strong, but there are stronger options such as zirconia.

DBCs are also only possible if you can bond to the dentine; this requires isolation, so if isolation is difficult due to a subgingival preparation for example then a DBC is contra-indicated.

Selection by category

ZirconiaThis is the strongest metal free restoration available with most systems coming out at around 950MPa. Ceramic support is also vital, so choosing a system and laboratory that provides this crucial for their success.This is where the cheaper laboratories cut corners to save on costs, it is far easier to make a thin coping in zirconia and build up with an uneven layer of ceramic, this creates an inherent weakness which is liable to failure. You need to ensure your laboratory supports the ceramic with zirconia…ask you laboratory how they do this!

Dentine Bonded CrownsThe most aesthetic option as the underlying tooth can shine through giving a very natural appearance; this however can be their Achilles heel if the underlying tooth is dark. Although they are relatively less strong, once bonded to the tooth structure failures are rare.

Porcelain Fused to MetalThe most ‘traditional’ restoration, but in some circumstances still the best; especially true when the preparation is a knife edge. PFMs are able to cover dark teeth, but may not be predictably the most aesthetic result.

SummaryBy using this decision tree it is possible to standardise restoration selection and to clearly communicate which restoration to use in any given situation. Clearly preparation design is the key deciding factor, as without the correct preparation one reduces the number of options available if truly predictable and reliable results are sought.

Having said all this, we feel the best way to decide on the restoration is to leave it up to us! Tell us the clinical situation, including heavy bites, if the underlying tooth is dark, dentine bonding possibilities and aesthetic requirements and we will make the best restoration for your patient.

Everest is a registered trademark of KavoEmpress is a registered trademark of IvoclarInceram is a registered trademark of Vita ZahnfabrikinVizion is a registered trademark of Vident Inc.i-esthetic is a registered trademark of SBO Dental LaboratoryLava is a registered trademark of 3M EspeProcera is a registered trademark of NobelBiocare

For individualised case selection help and advice or for a free quote on any case please call Mark at the laboratory or email lab@sbodentallaboratory.co.uk

5. Safely and reliably plan implant cases using an advanced planning protocol

For the reliable and least stress route to implants we strongly recommend following our implant treatment planning protocol. This will ensure your cases are planned for success from the beinning resulting in the happiest patients.

For a FREE quotation on any implant case, or to talk through a specific implant case planning please call Keith or email lab@sbodentallaboratory.co.k

So there you have it, our 5 ultimate success techniques for modern dentists. When you combine this with the knowledge and experience that Keith and Mark bring, this makes chosing the best dental laboratory simple.

Simply call Mark on 07769 898798 or email him mark@sbodentallaboratory.co.uk to

Change your business, change your life, change your lab!