Treatment Planning, Designing and Delivering Complex and ... · 3/23/2018 · Treatment Planning,...

Marc Geissberger D.D.S., M.A., B.S., C.P.T.,F.N.S.Adjunct Clinical Professor

Department of Preventive andRestorative Dentistry

Marindentist

Marc Geissberger DDS

Treatment Planning, Designing and Delivering Complex and Multidisciplinary Cases

Delaware State Dental Society 2018 Continuing Education Series

March 23, 2018

Monday, March 19, 18

About Me:

Educator - Teach at UOP since graduation in 1991 - Full-Time Until 2018, Adjunct Clinical Professor beginning February 2018Private Practice - Marin County, Ca. since 1991 with Father and Brother.

Product Evaluator - Working with industry to test new products, materials, technologies and deliveries.Speaker / KOL - Member of “CATAPULT EDUCATION” speakers bureau.Family...


Thanks and Disclosures


Catapult Group is an organization which consists of top clinicians and educators from throughout the United States and Canada. This group of like-minded yet diverse dentist’s goal is to bring quality education to the dental community via multiple venues including; live lecture, participation, web based, and written formats.


DISCLAIMER

• As a Catapult Group member we participate in multiple product reviews each year in order to stay at the fore front of the latest materials, techniques and services available, ensuring that the message we are delivering is current and relevant to today’s continuing education needs.

• Some of these products & services we will be sharing with you today.

• Today we are supported in part by:• Voco Clinician’s Choice• Doxa Weave• AMD Orascoptic• Microcopy GC•


The Catapult/Personal Client Base

AG Nuevo

Air Techniques

Anutra-Medical

Bisco

Denmat

Dentsply

Dentist Select

DMG

Doxa

GC Amercia

Financially Fit

Heraus Kulzer

KavoKerrGroup

Kettenbach

Lending Tree

Microcopy

Perio-Protect

Premier

Proctor and Gamble

Pulp Dent

SDI

Shofu

Solution Reach

Springstone Financial

SS White

Sybron

Triodent

VOCO

Weave

Milestone Scientific

AMD Lasers

Garrison 3M

Ultradent

AdDent

Orascoptic

Clinician’s Choice


OverridingPrinciples


Considerations

Macro Issues1) Teeth in proportion to face2) Teeth in proportion to lips3) Teeth in relationship to tissue (gingiva)Micro Issues1) Teeth in relationship to tissue 2) Teeth in relationship to each other3) General proportion of teeth


Symmetry?Golden Percentage?

* Synonymous with unity

* Subtle diversity is needed because excessive regularity it monotonous


As Dentists We Focus on Teeth


Tree and Forest


Most Important Lesson to Learn in Focusing on The Frame of

Reference(s)

Face Lips Gingiva


New Technique - Kois Analyser


Frame of Reference

1) Face2) Lips3) Gingiva


Range of Lips is Huge


Lip RepositioningSurgery

1) Becoming a more common procedurelinked to esthetic enhancement

2) Not completely predictable


Research on SymmetryZaidel D, Aarde S, Baig K, Appearance of Symmetry, Beauty, and Health in Human Faces. Brain and Cognition, 57 (2005) 261-263

Pallett P, Link S, Lee K, New Golden Ratios for Facial Beauty. Vision Research , Nov. 2009,1878-5646


Symmetry


Frame of Reference Lip Line

Average Tooth Display 1.91mm Males 3.40mm Females 3.65mm Short Upper Lip 0.59mm Long Upper Lip 3.37mm Under 29 Years 1.26mm 30 to 50 years


Frame of ReferencePhonetic References

F and V sounds

S sound

incisal display atrest

lingual tilt of themaxillary central

incisors

vertical dimensionof speech

M sounds


Frame of ReferenceAxial Alignment

22mm Rule


Snow (1999) suggests Golden Percentages

Idealism and Proportion Golden Percentages

10 15 25 25 15 10

50

30

20


Frame of Reference Vertical/Horizontal Reference

Lines

1) Midline of the face2) Philtrum 3) Bridge of the nose


Symmetry and Natural Variation

Dental Midline: Coincided with facial midline in 70% of the population


Kokich , V. Klyak, A. Shapiro, P.

Comparing the Perception of Dentists and Lay People to Altered Dental Esthetics.

(J Esthet Dent. 11:311-324, 1999) Monday, March 19, 18

Our PatientClinical Condition: I don’t like the space between my front teeth. Patient refuses orthodontic treatment.

Treatment Plan: ?

Rationale: ?


Chief Concern: I don’t like the space between my front teeth. Patient refuses orthodontic treatment.


What would you do?

1) Refer her to an orthodontist anyway2) Diastema closure with composite resin or veneers3) Consultation with laboratory to evaluate the possibilities 4) Refer her to another practitioner5) Other


Spacing Issues

1) Determine etiology2) Plan how to distribute space without the sacrifice of width to length proportion of individual teeth


Spacing Issues

3) Don’t create wide, short teeth unnecessarily


Diode (Soft Tissue) Laser


A"so%"&ssue"laser"incision"at"1000x"

Laser&cut

Superficial"coagula&on

Heat"dissipa&on"with"li;le/no"edema


!Features

• Number"#1"dental"laser"in"the"world

• More"power"–"3"wa;s• New"easy"to"use"presets• New"treatment"&mers"for"

perio"treatment• Wireless"foot"control• Op&onal"ba;ery"pack• Perfect"for"first"&mers"or"

hygienists• Affordable• Disposable"&ps"or"fibers• Cer&fica&on"included• MSRP:"$4,495• CE"Price:"$3,495


Ceramics


All-Ceramic SystemsGlass Ceramics Alumina-based Zirconia-basedResin-based (new)


All-Ceramic SystemsGlass Ceramics Lithium-disilicate

IPS e.max Press (Ivoclar Vivadent) IPS e.max CAD (Ivoclar Vivadent) IPS Empress 2 (Ivoclar Vivadent)

Leucite IPS Empress (Ivoclar Vivadent) IPS ProCAD (Ivoclar Vivadent)

Feldspathic VITABLOCS Mark II (VITA Zahnfabrik) VITA TriLuxe Bloc (VITA Zahnfabrik) VITABLOCS Esthetic (VITA Zahnfabrik)


All-Ceramic SystemsAlumina-based

Aluminium-oxide In-Ceram Alumina (VITA Zahnfabrik) In-Ceram Spinell (VITA Zahnfabrik) Procera (Nobel Biocare)


All-Ceramic Systems

Zirconia-based

Yttrium tetragonal zirconia polycrystals (ZrO2 stabilized by Y2O3) Lava (3M ESPE) Cercon (Dentsply - -Ceramco ) DC-Zirkon (DCS Dental ) Denzir (Decim) Procera (Nobel Biocare)


All-Ceramic SystemsResin-basedADA’s Council on Dental Benefit Programs Broadens the Definition of Porcelain/ceramics in the CDT Code

(June 13, 2012) The American Dental Association (ADA) will broaden its definition of porcelain/ceramic materials in its CDT Code classification of materials. This classification is solely to aid selection of the appropriate procedure code to achieve uniformity,consistency and specificity in accurately reporting dental treatment. This change also affects insurance claims submission, allowing 3M™ ESPE™ Lava™ Ultimate Restorative to be classified as a porcelain/ceramic. 80 percent nanoceramic particles embedded in a highly-cured resin matrix.


http://solutions.3m.com/wps/portal/3M/en_US/3M-ESPE-NA/dental-professionals/products/category/digital-materials/lava-ultimate




The Evolution of Indirect MaterialsCast Metal Feldspathic Porcelains Fused to Metal Aluminous PorcelainsThermoplastic Aluminous Porcelain Cerestore

Cast Microcrystaline GlassLeucite Crystalized FeldspathicSlip Cast Alumina with Glass InfiltrationHeat Pressed Lucite Ceramic Glass

DicorFortuneIn Ceram, Procera IPS Empress, OPC

Lithium Disilicate/Fluorapatite Glass Ceramic with dilithium oxide crystals IPS Eris

Milled (Machined) Alumina Based Crowns

Milled (Machined) Zirconium Based Crowns - Stacked

Procera

Cercon, Lava...............

Conventional Jacket Crowns, Viradur

Slip Cast Spinel In Ceram SpinelSlip Cast Zirconia In Ceram ZirconiaHeat Pressed Lithium Disilicate Empress II,

Glazed Magnesia Core Magcor

Milled (Machined) Leucite Based Crowns Pro-Cad

Emax

Milled (Machined) Zirconium Based Crowns - Monolithic Cercon, Lava...............


Flexural StrengthFlexural strength, also known as modulus of rupture, or bend strength, or transverse rupture strength is a material property, defined as the stress in a material just before it yields in a flexure test. The transverse bending test is most frequently employed, in which a specimen having either a circular or rectangular cross-section is bent until fracture or yielding using a three point flexural test technique. The flexural strength represents the highest stress experienced within the


https://en.wikipedia.org/wiki/Three_point_flexural_test




Fracture Toughness

Fracture toughness is a property which describes the ability of a material containing fracture, and is one of the most important properties of any material for many design applications. The linear-elastic fracture toughness of a material is determined from the stress intensity factor (K) at which a thin crack in the material begins to grow.


https://en.wikipedia.org/wiki/Stress_intensity_factor




Zhenzhen Zhang, Yuanping Yi , Xuesong Wang, Jiawen Guo, Ding Li, Lin He, Shaofeng Zhang A comparative study of progressive wear of four dental monolithic, veneered glass-ceramics. Journal of the Mechanical Behavior of Biomedical Materials, Volume 74, October 2017, Pages 111-117

lithium disilicate glass-ceramic

leucite reinforced glass-ceramic

feldspathic glass-ceramic

fluorapatite glass-ceramic

FractureToughnessHigh to Low

FlexuralStrength

High to Low

Wear of Opposing

High to Low

1 1 4

2 2 3

3 3 2

4 4 1

Wear of Various Dental Ceramics


http://www.sciencedirect.com/science/journal/17516161/74/supp/C

http://www.sciencedirect.com/science/journal/17516161/74/supp/C

Wear of Various Dental Ceramics

lithium disilicate glass-ceramic (Adjusted)

Wear Rate on Enamel

Low to High4

2

3

5

Nathaniel C. Lawson , Sridhar Janyavula , Sarah Syklawer , Edward A. McLaren , John O. Burgess. Wear of enamel opposing zirconia and lithium disilicate after adjustment, polishing and glazing. journal of dentistry 42 (2014) 1586–1591

lithium disilicate glass-ceramic (Adjusted/Polished)

lithium disilicate glass-ceramic (Adjusted/Glazed)

zirconia (Adjusted)

zirconia (Adjusted/Polished)

zirconia (Adjusted/Glazed)

RelativeValue in mm3

.53

.36

.47

.54

1 .33

6 .68

Veneering Porcelain (Glass) 7 2.15


Metal

TitaniumBase

NobleHigh NobleCeramic Metal Ceramic

Composite

Metal Acrylic Base

High Noble

NobleMilledPres

sed

Stacked

Stacked

CastPressed

Milled StackedStain

Cut-Back

Titanium

Base

NobleHigh Noble

Zirconia

Disilicate MilledAlumina Zirconia

Alumina

Disil

icate

Alum

ina-Z

ircon

ia

Al-Zir


Flexural Strength of Dental Ceramics (MPa)

Aluminous Porcelains

Cast Microcrystaline Glass

Slip Cast Alumina with Glass Infiltration

Heat Pressed Lucite Ceramic Glass

Dicor

In Ceram, Procera

IPS Empress, OPC

Milled (Machined) Alumina Based Crowns

Milled (Machined) Zirconium Based Crowns

Procera

Cercon, Lava

Conventional Jacket Crowns, Viradur

Slip Cast Spinel In Ceram Spinel

Slip Cast Zirconia In Ceram Zirconia

Heat Pressed Lithium Disilicate Empress II, e.max

Glazed Magnesia Core Magcor

Milled (Machined) Leucite Based Crowns Pro-Cad

125

135

140

151

269

350

400

350

650

650

900


Lava Ultimate

Monolithic Zirconia OpaqueeMax

Longevity vs. Beauty

Long Life

Great Esthetics

Short LifeYears

Poor EstheticsEsthetics

Gold

PFMMilled Zirconia - Stacked

Feldspathic Porcelain

EmpressMonolithic Zirconia Translucent


Why Have So Many Gone Away?

Answer: They Break

Fractured Dicor Crown Fractured Inceram Crown


What About Porcelain Fused to Metal?


Types of Ceramic-Metal FailurePorcelain Porcelain Porcelain

MetalMetal Oxide

Metal MetalMetal Oxide

Porcelain

PorcelainMetal Oxide

Metal

Porcelain

Metal OxideMetal

Metal OxidePorcelain

Metal Oxide

Metal

Metal

Type I: Metal-porcelain Type II: Metal oxide-porcelain Type III: Cohesive within porcelain

Type IV: Metal-metal oxide Type V: Metal oxide-metal oxide Type VI: Cohesive within metal


Porcelain IssuesDhima M, Paulosova V, Carr AB, Rieck KL, Lohse C, Salinas T, J J Prosthet Dent. 2014 Feb.

Practice-based clinical evaluation of ceramic single crowns after at least five years.Survival Rate: 95% (5 year) 92% (10 year)# 1 reason for failure: Fracture to core of layered restorations


http://www.ncbi.nlm.nih.gov/pubmed?term=Dhima%20M%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Dhima%20M%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Paulosova%20V%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Paulosova%20V%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Carr%20AB%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Carr%20AB%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Rieck%20KL%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Rieck%20KL%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Lohse%20C%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Lohse%20C%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Salinas%20TJ%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

http://www.ncbi.nlm.nih.gov/pubmed?term=Salinas%20TJ%5BAuthor%5D&cauthor=true&cauthor_uid=24331848

Porcelain IssuesRinke S, Schäfer S, Lange K, Gersdorff N, Roediger M., J Oral Rehabil. 2013 Mar.

Practice-based clinical evaluation of metal-ceramic and zirconia molar crowns: 3-year results.

Survival Rate: PFM 97.6% Zirconia 95.2% Success Rate: PFM 90.9% Zirconia 86.6%


http://www.ncbi.nlm.nih.gov/pubmed?term=Rinke%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23211063


http://www.ncbi.nlm.nih.gov/pubmed?term=Sch%C3%A4fer%20S%5BAuthor%5D&cauthor=true&cauthor_uid=23211063


http://www.ncbi.nlm.nih.gov/pubmed?term=Lange%20K%5BAuthor%5D&cauthor=true&cauthor_uid=23211063


http://www.ncbi.nlm.nih.gov/pubmed?term=Gersdorff%20N%5BAuthor%5D&cauthor=true&cauthor_uid=23211063

http://www.ncbi.nlm.nih.gov/pubmed?term=Gersdorff%20N%5BAuthor%5D&cauthor=true&cauthor_uid=23211063

http://www.ncbi.nlm.nih.gov/pubmed?term=Roediger%20M%5BAuthor%5D&cauthor=true&cauthor_uid=23211063

http://www.ncbi.nlm.nih.gov/pubmed?term=Roediger%20M%5BAuthor%5D&cauthor=true&cauthor_uid=23211063

Pieger S, Salman, A, Bidra A, Journal of Prosthetic Dentistry. 2014 July.

Clinical Outcomes of Lithium Disilicate Single Crowns and Partial Fixed Dental Prostheses: A Systematic Review

Single Crowns Fixed Dental Prostheses 2 Year Survival Rate: 100% 83.3% 5 Year Survival Rate: 97.8% 78.1%10 Year Survival Rate: 96.7% 70.9%

Porcelain Issues








What Haircut is this?


The Oral Cavity

The Mullet “Business in the front,partying in the back!”

The Reverse Mullet

“Party in the front,business in the back!”


Your Choices Today

Bilayer BranchMonolithic Branch

Zirconia

Disilicate

Metal

DisilicateZirconia

Metal

Pressed

CompositePressed

Milled

PressedStacked

Stacked


Production ComparisonSingle Unit Crowns - Gold vs. PFM vs. Ceramic

11 -12 Numbers

12 -13 Numbers

11 -12 Dollars

12 -13 Dollars

13 -14 Numbers

13 -14 Dollars

Gold PFM

709 1320

% %

30.7 57.3

$445,774 $841,67929.4 55.6

631 133926.0 55.2

$402,465 $889,44724.1 53.3571 100923.6 41.7

$378,390 $681,40022.8 41.1

Ceramic

276

%

12

$225,091 15

457 18.8

$378,161 22.6

835 34.7

$596,981 36.1

14 -15 Numbers

14 -15 Dollars

353 47617.8 24.0

$235,579 $313,23517.8 23.7

1152 58.2

$770,679 58.5Monday, March 19, 18

Statics from Glidewell


Solid Milled Zirconia


Solid Milled

Zirconia


Traditional Examples

1000-1400 MPa

1200 +/- 200 MPa

1100 MPa


Translucent Examples

750-560 MPa

700 +/- 100 MPa

650 MPa


3M - Lava Plus and Lava Esthetic


3M - Lava Plus


Pressed or Milled Lithium Disilicate

e.max Press e.max CAD


Benefits of eMax

Good StrengthEtchable - Bondable4 Levels of OpacityMultiple Different TechniquesVery Good Esthetics


eMax

HT ingotsThe high translucency ingots (HT) are suitable for the fabrication of minimally invasive full-contour restorations, such as inlays, onlays and veneers. The restorations are characterized with staining materials.

LT ingotsFull-contour partial crowns and crowns are fabricated with the low translucency ingots (LT). In the anterior region in particular, the esthetic appearance of the restorations is maximized by employing the cut-back technique.


eMax

MO ingotsThe medium opacity ingots (MO) are used to fabricate substructures for vital or slightly discolored teeth. They create an ideal basis for lifelike restorations completed with the layering technique.

HO ingotsIn cases where the prepared tooth structure is discolored or titanium abutments are used, the HO ingots mask the dark background to achieve highly esthetic results.


Clinician’s Choice Polishing


What Would You Do?


Is it Perfect?


MT and Impulse Ingot Added


Teeth Following Crown Removal


Reduction Matrix

Fabricated from the Diagnostic Wax-up


Pressed Material Design Anterior Teeth

1) Round End Taper (1116)2) Esthetic bevel of 1/2 to 1/3 occ-ging height3) Incisal reduction of 1.5 - 2.0 mm4) Lingual reduction of 1.5 to 2.0 mm (1900)5) Well rounded line and point angles (essential)


Types of Luting Agents1) Zinc Phosphate Cement2) Polycarboxylate Cement3) Glass-Ionomer Luting Cement4) Resin-Modified Glass-Ionomer Cement5) Polyacid-Modified Composite Cement6) Resin-Based Cement7) Bioceramic Luting Agent


RMGI Luting Cement

Advantages:1) Less sensitivity to moisture during setting2) Capable of bonding to composite

Disadvantages:1) Hydrophilic behavior2) Leakage between water-based cements and resin-based


Resin Cement

Advantages:1) High values for bond strength2) Highest adhesion

Disadvantages:1) Challenging clean-up2) Potential for post-op sensitivity


al


6th Gen. Product Examples

1) Clearfil SE Kuraray 2) Optibond XTR Kerr3) Peak SE Ultradent 4) Prelude Danville5) Adhese SE Ivoclar 6) Prompt-L-pop 3M ESPE7) Adper Scotchbond SE 3M ESPE


7th Gen. Product Examples

1) Scotchbond Universal 3M2) Optibond All-in-One Kerr3) Futurabond Voco4) Clearfil S3 Bond Kuraray 5) iBond Kulzer6) Bond Force Tokuyama


Resin Bonding Cements

Ivoclar Variolink IIDentsply Calibra


Ceramir®

The product combines Ceramir technology and some glass ionomer components to provide the best properties for the material.


+

PFM, All Metal,or Zirconia on

All Teeth

or

or

Empressor eMax

or


or+

+

+

+


Non-Vital Teeth

or

or


Vital Teeth

or

Empressor eMax

+

or+

or


Magnificationand

Illumination


Orascoptic

Geissberger, M. J. (1995). The Effects of Magnification on the Performance of Fixed Prosthodontics Procedures. Journal of the California Dental Association, 23(12), 66-70.


The World’s First Loupe With A Built-In Headlight

!All electronics are completely contained within the frame. No more cables to get tangled on chairs, doorknobs, or drawers. Built-in side shield protection (separate side shields not necessary). Small ultra-lightweight headlight


OrascopticSparkLight


Magnificationand

Illumination


Orascoptic

Geissberger, M. J. (1995). The Effects of Magnification on the Performance of Fixed Prosthodontics Procedures. Journal of the California Dental Association, 23(12), 66-70.


Orascoptic - Options


Orascoptic LED Light


SimulatedSmile

Design


Before Simulation After Simulation

Van Zyl, I., Geissberger, M. J. (2001). Simulated Shape Design: Helping Patients Decide Their Esthetic Ideal. Journal of the American Dental Association, 132, 1105-1109.


Simulated Smile Design

Step One: Diagnostic Impressions

Impressions:* Must capture all tooth anatomy* Must capture entire buccal vestibule* Use Resin Rock (Ivory) or similar product



Step Two: Stick Bite

* Use fast setting bite registration * Place first stick on the incisal edge of lower anterior teeth* This must be parallel to the in. pup. line* Second stick is placed at the patient’s midline


Simulated Smile DesignStick Bite


New Technique - Kois Analyser



Step Three: Mounted Diagnostic Casts

* Can be mounted arbitrarily * Use semi-adjustable articulator



Step Four: Diagnostic Wax-up

* Can employ laboratory* Must reproduce all desired anatomy and effects* Most critical portion of entire technique* Is the make or break of the process


Midline

8.5&mm


Critical Anatomic Features


Simulated Smile DesignWax-up



Putty Splint Fabrication

* Must capture all wax-up anatomy* Must capture entire buccal vestibule* Should extend two teeth past wax-up on either side



Try-in and Midline Mark

* Make sure splint can be positioned easily* Mark the midline as a reference for seating* Ensure occlusal stops are adequate



Dry All Surfaces

* Use 2X2 to dry facial of all teeth* Have patient keep these surfaces dry



Load Bis-Acrylic

* Place mixing tip on incisal edges* Fill all aspects of the facial surfaces of teeth


Available Bis-acrylic Resins


Step Eleven: Surface Characterization

* Apply composite surface stain * Light cure when desired result accomplished* Polish lingual area with finishing disks



Before Simulation After Simulation


16 Years later


Psychologyand Patients


Roger Sperry

• “Our educational system, as well as science in general, tends to neglect the nonverbal form of intellect. What it comes

down to is that modern society discriminates against the right hemisphere.”


LEFT BRAIN FUNCTIONS

uses logic

detail orientedfacts rule

words and languagepresent and past

math and sciencecan comprehend

knowingacknowledges

order/pattern perceptionknows object name

reality basedforms strategies

practicalsafe

RIGHT BRAIN FUNCTIONS

uses feeling

"big picture" orientedimagination rules

symbols and imagespresent and future

philosophy & religioncan "get it" (i.e. meaning)

believesappreciates

spatial perceptionknows object function

fantasy basedpresents possibilities

impetuousrisk taking

http://similarminds.com/cgi-bin/brain.plMonday, March 19, 18

What Does the Opposite Sex Look At First?

Female looking at Male Male looking at Female1) Brain

2) Eyes

3) Smile

4) Height

5) Butt

1) Eyes

2) Smile

3) Breasts

4) Butt

5) Legs


Most Popular Procedures

Surgical Procedures: 2000 20161) Breast Aug. 212,500 290,4672) Liposuction 354, 015 235,2373) Rhinoplasty 389,115 223,0814) Eyelid Surgery 327,514 209,0225) Facelift 133,856 131,106

Non-Surgical1) Botox 786,991 7,056,2552) Soft Tissue Fillers 658,885 2,600,8683) Chemical Peel 1,149,457 1, 360,8504) Laser Hair Removal 735,996 1,109,3855) Microdermabrasion 868,315 775,014* American Society of Plastic SurgeonsMonday, March 19, 18

Not AllAestheticMindsets Are Alike


What Constitutes

An Appealing

Smile?

Which Celebrities have the best smile?


Best Celebrity Smiles

2006

HALLE BERRYTIGER WOODS



2008

EVA MENDESBRAD PITT



2010

JESSICA ALBABRAD PITT



2012

ANNE HATHAWAYMATT DAMON



2014

JUILA ROBERTSGEORGE CLOONEY


Beauty


Assessing Health Consciousness Kraft F, Goodell P, Identifying the Health Conscious Consumer.

Journal of Health Care Marketing (Fall 1993) 18-25

1) I worry that there are chemicals in my food 1 2 3 4 5

2) I’m concerned about drinking water quality 1 2 3 4 5

3) I try to exercise at least 30 min. a day, 3x a week 1 2 3 4 5

4) I exercise more than I did three years ago 1 2 3 4 5

5) Good health takes active participation on my part 1 2 3 4 5

6) It is my doctor’s job to keep me well 1 2 3 4 5

7) My daily meals are nutritionally balance 1 2 3 4 5Monday, March 19, 18

Assessing Health Consciousness Kraft F, Goodell P, Identifying the Health Conscious Consumer.

Journal of Health Care Marketing (Fall 1993) 18-25

8) I try to avoid high levels of cholesterol in my diet 1 2 3 4 5

9) I attempt to avoid stressful situations 1 2 3 4 5

10) I only worry about my health when I get sick 1 2 3 4 5

11) I spend time each day trying to reduce accumulated stress 1 2 3 4 5

12) I believe that the “wellness” idea is a fad 1 2 3 4 5

13) Exercise helps me succeed in all facets of life 1 2 3 4 5

14) Air pollution does not bother me 1 2 3 4 5


Tate, Peter, The Doctor’s Communication Handbook, 5th edition


Types of Patients

The Internal Controller.This type of person believes that fundamentally they are in charge of their own future health.

There are certain implications for this type of believer, not least that they tend to get very cross if they do get ill.

As far as communication is concerned, this type of person likes explanations, dialogue and Socratic discourse.


Types of Patients

The External Controller.What will be will be. They are fatalists. There are certain implications for this type of believer, not least that they tend to get very cross if they do get ill.

They are not really much into involvement and take little or no interest in the media obsession with matters of health.


The Powerful Other.This type of patient is quite different from the others. They do not believe they are in control of their own health nor are they fatalists. They believe the Doctor and the Doctor alone is in charge of their health.

Strategies of trying to give such patients more responsibility for their own health are firmly resisted.

Types of Patients

Tate, Peter, The Doctor’s Communication Handbook, 6th edition


Our Next PatientClinical Condition: Worn dentition, periodontal disease, “looks like a rabbit”.

Treatment Plan: ? Desires: Wants problem fixed.


Chief Concern: I look like a rabbit!Monday, March 19, 18

Radiographs


On a scale of 1-10, how difficult is this case?

1) Simple (1-2)2) Routine (3-4)3) Average (5-6)4) Complex (7-8)5) Wow! Extremely Challenging (9-10)


Material Selection

1) Choose materials for aesthetics and compatibility


Material Selection

2) Utilize materials designed to maximize optical appearance when placed next to each other


Jan 2011 Emergency Visit

Your Front Tooth BrokeMonday, March 19, 18

What Would You Do?

1) New Post and Build-up #9, New Crown #92) Ext. #9, FDP # 8-103) Ext. #9, Implant #94) Ext. #9, RPD to Replace5) Other


One Year Recall PA Jan. 2012


Develop Your Own Rating System 1 through 10 ranking


Patient Disposition Patient Belief OrientationPatient Treatment GoalsLip PositionMaterials PresentSupporting StabilityGingival Biotype


Ways of Categorizing Treatment Plans

1) Urgent Care2) Disease Control3) Reconstructive Phase4) Maintenance Phase


Urgent Care

1) Pain2) Active Infection3) Chief Complaint


Disease Control

1) Periodontal Disease2) Caries3) Occlusal Disfunction - Diseases of Habit4) Asymptomatic or Endodontic Infection


Caries Data

ROBERT A. BAGRAMIAN, DDS, MPH, PHD, FRANKLIN GARCIA-GODOY, DDS, MS & ANTHONY R. VOLPE, DDS, MS

The global increase in dental caries. A pending public health crisis

(Am J Dent 2009;22:3-8) Monday, March 19, 18

≤20%21-25.9%

≥35%Data unavailable

Source: BRFSS 1995-2000

26-34.9%

Edentulism, Age 65+ 1995-2002


Edentulous Rates

Source: World Health Organization 2005 ReportMonday, March 19, 18

How Do We Stack Up World Wide?

Source: World Health Organization, Global Health Data Bank, Geneva: 2011

GambiaEgyptChina Cambodia LithuaniaAustriaIceland Slovenia ThailandIndia Italy LebanonSingapore IndonesiaPoland

Madagascar Romania United States DenmarkHungarySaudi ArabiaSri LankaFinland Slovakia United Kingdom Bulgaria Malaysia Canada Albania Bosnia

6.0 7.0 11.013.0 14.015.015.016.016.319.019.020.0 21.024.025.0

25.0 26.026.027.027.036.037.041.044.046.053.057.058.069.078.0


Periodontal Disease

1) Mechanical Approach2) Chemotheraputic Approach3) Surgical Approach


Clinical Findings

#2 large B Caries #12 F caries


Caries

1) Improve Oral Hygiene 3) Alter the Flora2) Strengthen Enamel 4) Control and Alter PH


Radiographic Findings


Restoration of Aproximal Lesions

Modern concepts in disease management must treat the disease, not the signs of disease.


Modern concepts in disease management must treat the disease, not the signs of disease.

Restoration of Aproximal Lesions


Ultradent Products

Caries Management: Transitioning from Education and Research to Improve Patient Care, New Directions in Interorganizational Collaboration in Dentistry: The CAMBRA Coalition Model

Douglas A. Young, D.D.S., M.S., M.B.A.; Philip M. Buchanan, D.D.S.; Richard G. Lubman, D.D.S.; Norena Norton Badway, Ph.D.


Trivia TriviaWhich drink has the

greatest erosive potential?


Literature on Sports Drinks

Sports drinks and dental erosion.

J Calif Dent Assoc. 2011 Apr;39(4):233-8.

Noble WH, Donovan TE, Geissberger M.


http://www.ncbi.nlm.nih.gov/pubmed/?term=Noble%20WH%5BAuthor%5D&cauthor=true&cauthor_uid=21675676

http://www.ncbi.nlm.nih.gov/pubmed/?term=Noble%20WH%5BAuthor%5D&cauthor=true&cauthor_uid=21675676

http://www.ncbi.nlm.nih.gov/pubmed/?term=Donovan%20TE%5BAuthor%5D&cauthor=true&cauthor_uid=21675676

http://www.ncbi.nlm.nih.gov/pubmed/?term=Donovan%20TE%5BAuthor%5D&cauthor=true&cauthor_uid=21675676

http://www.ncbi.nlm.nih.gov/pubmed/?term=Geissberger%20M%5BAuthor%5D&cauthor=true&cauthor_uid=21675676

http://www.ncbi.nlm.nih.gov/pubmed/?term=Geissberger%20M%5BAuthor%5D&cauthor=true&cauthor_uid=21675676

CariesManagement

Measure/AlterpH

Control/AlterBacteria

Strengthen ToothStructure Enhance Salivary

Function

Patient Issues


Control/AlterpH

Strengthen ToothStructure

Control/AlterBacteria

Enhance SalivaryFunction


Measure/AlterpH

Strengthen ToothStructure


Strengthen Tooth Structure1) Clinpro Tooth Creme (3M)2) Mi Paste (Plus) (GC)3) Fluoride Varnish Profluorid (Voco)


3 Part Exam

1) Measure Volume of Salivaproduced with Stimulation<5ml in 5 minutes = dry mouth

2) Test pH

3) Test Buffering Ability


Reconstructive Phase

1) Direct Restorations2) Indirect Restorations3) Removable Prosthetics4) Implant Supported Prosthetics


Dual Force - Clinician’s Choice


Clinician’s Choice Polishing


⊗ Fails to restore proximal anatomy

⊗ Thin contact at the marginal ridge

⊗ Large food trap below

⊗ Increased likelihood of fracture, occlusal

interference, recurrent caries and periodontal disease.

!Operator-friendly retaining system

! Naturally contoured bands

! Anatomically correct contacts

! Contacts at the height of contour

! Contacts so tight you’ll need a hemostat to get the

band out!

Tofflemire & Standard Wedge

Sectional Matrix Band With Anatomic Wedges


Maintenance Phase

1) Continuing Care2) Oral Hygiene Instruction and Reinforcement 3) Prosthetic Maintenance


Develop Your Own Rating System

Patient Disposition Patient Belief OrientationPatient Treatment GoalsLip PositionMaterials PresentSupporting Stability


Three Biggies

Patient Disposition Patient Belief OrientationPatient Treatment GoalsLip PositionMaterials PresentSupporting StabilityGingival Biotype

32%

42%

26%


Develop Your Own Rating System1 through 10 ranking



Management of ComplexRestorative Cases

We will look at a number of cases whichdemonstrate many different issues commonly

confronted during treatment planning


Longevity of Restorations

FPD 3568 211 76 26Implant FPD 3844 560 176 28Implant SC 2560 356 76 26

Pjetursson, Bragger and Lang, Comparison of survival and complication rates of tooth-supported fixed partial dentures (FPDs) and implant-supported FPDs and single crowns (SCs) Clin. Oral Impl. Res, 2007


Longevity of Restorations

5 Year 10 Year

FPD 93.8% 89.2%Cantilever FPD 91.4% 80.3%Implant FPD 95.2% 86.7%Combined FPD 95.5% 77.8%Implant SC 94.5% 89.4%


Complications of Restorations 5 Year

FPD 15.7% loss of vitality 6.1% decay of abutment 4.8% loss of retention 3.3% Cantilever FPD 20.6% loss of vitality 7.9% decay of abutment 4.7% loss of retention 3.3%


Complications of Restorations 5 Year

Implant-supported FPD 38.7% fracture of porcelain 11.9% soft tissue complications 8.6% loss of retention 5.7%


Longevity of Restorations Vital Non-vital Years3 unit PFD 83% 76% 15All FPD’s 84% 64% 16Cantilever 74% 52% 16

De Backer, Van Maele, Long-term Survival of complete crowns, fixed dental prostheses, and cantilever fixed prostheses with post and cores on root canal-treated teeth Int J Prosthodont 2007; 20:229-234


Interdisciplinary Management of Anterior Dental EstheticsSpear and friendsDiagnostic and Technical Approach to Esthetic RehabilitationsRomeo and BrecianoThick vs. Thin Gingival Tissue, a Key Determinant in Tissue

Response..Kao and PasquinelliFacing the Challenges of Ceramic VeneersChristensenElective vs. Mandatory DentistryChristensen

Supporting Literature


Our PatientClinical Condition: Worn dentition, need your help Wife wants teeth fixed!

Treatment Plan: ? Limitations: Funds, no desire to improve


What Would You Do?

Your Training

Your Experience

The Evidence Continued Expansionof Skills

Patient Desires


Our Next PatientClinical Condition: Heavily restored, never wants dentures, significant discomfort.

Treatment Plan: ? Desires: Wants to keep teeth!


Radiographs 1995


Clinical Findings

1) FDP fabricated 15 years earlier2) Endodontic treatment #313) 10 mm pocket on distal lingual #314) Localized infection and pain #31


Second Patient - JenniferRadiographs 1995


Clinical Findings

1) Crowns on lower arch fabricated over the last two decades2) Endodontic treatment #18, 19, 203) 10 mm pocket on mesial buccal #194) Localized infection and pain #19


What Would You Do?

1) Section FDP #29-31, Extract #19 and RPD2) Section FDP #29-31, Extract #19 and Nothing3) Section FDP #29-31, Extract #19 and Three Implants4) Section FDP #29-31, Extract #19 and Two Implants #30-31 and FDP #18-20Distal Root Amputation #31, New FDP, Implant #195) Something Else


January 2011


Selected Treatment - 1995


Recall Radiographs 2012

17 year recall


Comparison of Resected Molars and Implants (15 Year Follow Up)

• 23 of 701 resected molars lost (3%)• 44 of 1,472 implants failed (3%)• Highest failures occurred with distal root resections that

created lone-standing (last tooth in the arch) mandibular molars (25%)

• Parafunction increased failure

Fugazzotto, PA. J Periodontol 2001;72:1113-23


Our Next PatientClinical Condition: Failing FDP #18-20.

Treatment Plan: ? Desires: Doesn’t Want Removable


FPD 1975-1991


FPD 1991- 2008


What Would You Do?

1) Endo #18, Crown Lengthen #18 and New FDP2) Section FDP, Ext. #18 and Implant #193) Section FDP, Ext. #18 and Implant #18 and #194) Section FDP, Ext #18 and No Replacement5) Section FDP, Ext # 18 and RPD6) Endo #18, Distal Root Resection and New FDP7) Something Else


Next PatientClinical Condition: Multiple Broken Restorations Failing Occlusion, Difficult Referred By Another Dentist Treatment Plan: ?

Rationale: ?


“Typical” Behavior


T-scan Occlusal Adjustment


Next PatientClinical Condition: Wants 20 Year Old Veneers Restored, Referred by Periodontist Treatment Plan: ?

Rationale: ?


Treatment Options1) Do Nothing - Night guard2) New Veneers on Maxillary Arch3) Full Mouth Reconstruction4) Restore Mandibular Arch and Maxillary Anterior5) Orthodontics and Selected Restorations


Our Next PatientClinical Condition: FPD From #7-11 Failed 6 Mon. Post Cementation Treatment Plan: Remake FPD #7-11 with Improved Anterior Guidance

Rationale: Patient Wants FPD Monday, March 19, 18

Pre-Op Condition


What Would You Do?


Clinical Slides


Clinical Procedure


Completed Case


Before and After


RecallPatient at 1 year

Patient at 5 year


Vertical Dimension Changes

Mohindra N. K, Bulman J.S, The Effect of Increasing Vertical Dimension of Occlusion on Facial Aesthetics. British Dental Journal, 192, #3

(February 2002) 164-172

96 patients treated.80% reported to appear between 5-20 years younger.


Chief Concern: I’ve destroyed my teeth from bulimia and want them fixed.


What would you do?

1) Refer her to an orthodontist 2) Refer her to a prosthodontist3) Full mouth reconstruction at current VDO4) Full mouth reconstruction at new VDO5) Other


Challenging Vertical Dimension Case


Right Lateral 1:2Full Smile 1:2Left Lateral 1:2


Occlusal Pre-Operative

Views


Pre-Operative Condition


TreatmentOptions?

1) Do nothing2) Reconstruct at current vertical dimension3) Reconstruct at new vertical dimension4) Minimal restorative and splint coverage5) Orthodontics to improve positioning of teeth and vertical dimension6) Esthetic crown lengthening7) Others?


All Case Designs Must Start With Maxillary Central Incisors

Interdisciplinary Management of Anterior Dental Esthetics

Spear and friends


Critical Anatomic Features


Shape and Functional Try-in


Splint Used At Designed VDO


AnteriorRestorations


Maxillary Provisionals Removed


Tissue Management Issues


Completed Case


Vertical Dimension Changes

Mohindra N. K, Bulman J.S, The Effect of Increasing Vertical Dimension of Occlusion on Facial Aesthetics. British Dental Journal, 192, #3

(February 2002) 164-172

96 patients treated.80% reported to appear between 5-20 years younger.


Completed Case


[email protected]


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Treatment Planning, Designing and Delivering Complex and ... · 3/23/2018 · Treatment Planning,...

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