By Hugh Flax DDS, AAACD, FICOI Atlanta, GA
Transcription
By Hugh Flax DDS, AAACD, FICOI Atlanta, GA
AACD 2015 State of the Art 5/8/2015 FOR HANDOUT GO TO www.HughFlax.com STATE-OF-THE-ART TECHNIQUES IN COSMETIC RESTORATIVE DENTISTRY” BY HUGH FLAX DDS, AAACD, MICOI ATLANTA, GA “IF I HAVE SEEN FURTHER IT IS BY STANDING ON THE SHOULDER'S OF GIANTS.” SIR ISAAC NEWTON THANK YOU • GC AMERICA • MICROCOPY • YOU Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 DISCLOSURES • Huge proponent of “Responsible Esthetics” • Leading edge vs. Bleeding Edge • Products that I mention I use all the time and like to share what is working for me (companies that are sponsoring or contributing products for this presentation only for that reason) • Learning-sharing new and reinforcing “time-tested” knowledge and learning from each other USA TODAY STUDY (1997) OF ATTRACTIVENESS AND SELF ESTEEM WHAT WOULD YOU CHANGE ABOUT YOUR PHYSICAL APPEARANCE ? Summary In today’s rapidly changing world , technology and procedures are constantly evolving that allows dental teams to deliver better, more predictable, and oftentimes, more cost effective results that make patients and practices happier clinically and entrepreneurially. The proverbial “elephant in the room” demands that we continue to stay competitive in this arena. Learn what these new developments in technologies and materials are so that you and your cosmetic practice will continue to thrive. Learning objectives: • Understand how digital technology will get your patients more emotionally involved in their care and will decrease your time and stress • Discover materials that will strengthen your patient’s teeth and cement their long-term success • Learn about newer laser technology that cuts and preserves tooth structure better than ever. • See how to do advanced implant treatment by prescription instead of by accident IF YOU COULD CHANGE ANYTHING IN YOUR FACE WHAT WOULD IT BE ? • Nose • Eyes • Teeth • Chin • Weight • Lips • Height • Head shape • Face • Hair ABC-TV’S “EXTREME MAKEOVER” SHOW ! Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 TODAY’S CHALLENGES OF ESTHETIC DENTISTRY • ESTHETICS • BIOLOGY • FUNCTION • ECONOMICS 1. Expectations of patients 2. Chairtime 3. Minimally invasive 4. Affordability 5. Durability/ Reparability TIME FOR CHANGE • Diversity • How we build value for people and meet expectations • The speed and volume of providing information and care • How to fit someone’s budget-time and financial • How we perform dentistry EXTREME CUSTOMIZATION • LEVERAGING TIME • INNOVATING • BE CREATIVE EXTREME CUSTOMIZATION “Innovation distinguishes between a leader and a follower.” Steve Jobs JIM ROHN Hugh Flax STONE TOOLS COMPUTER MOUSE All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 CREATIVITY You need to understand how human beings bring together their brains and enable their ideas to combine and recombine, to meet and, indeed, to mate. In other words, you need to understand how ideas have sex.” "Don't think. Thinking is the enemy of creativity. It's selfconscious, and anything selfconscious is lousy. You can't try to do things. You simply must do things." http://www.ted.com/talks/lang/en/matt_ridley_when_ideas_have_sex .html INTERDISCIPLINARY CARE ESTHETICS PERIODONTAL SUPPORT and CONTOURS FUNCTION BIOMECHANICS 3 D CT Scan Courtesy of Kai-hung Fung, MD PERIO ORTHO LAB GIVE ‘EM WHAT THEY WANT !!! “Do what you do so well that people can’t resist telling others about you” Walt Disney JCD WINTER 2015 Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 COMMUNICATE VISUALLY ANYTHING TO ANYONE ,AT ANYTIME ! WHY NOW????????? FACT: In 2009, in the USA, video content views surpassed text content views WHY NOW????????? FACT: From Mashable.com New Study Shows the Mobile Web Will Rule by 2015 WHY NOW??? COURTESY CHRISTIAN COACHMAN Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 BOTTOM LINE Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art ANALYTICAL Hugh Flax 5/8/2015 EMOTIONAL All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Pink Esthetics ESTHETIC FACTORS WAYS TO MANAGE PINK TRADITIONAL • ELECTROSURGERY • SCALPEL REDUCTION • OPEN FLAP CROWN LENGTHENING • FREE GRAFTING • CONNECTIVE TISSUE GRAFTS Hugh Flax INNOVATIVE • LASER REDUCTION • CLOSED FLAP GUM LIFT • TUNNEL GRAFTING (Allen;Salama;Mahm; VISTA;Pin Hole) • PEDICLE GRAFT • ADD WITH PINK RESTORATIVE Macro-multiple teeth/ large areas Micro-1-2 teeth / small areas • • • • Midline Facial thirds are ideally equal Interpupillary line Maxillary Tooth Position 1) Labial-support maxillary lip and balance of face 2) Vertical canine position in repose—level with the lip (Misch/ Kois) 3) Centrals-1-2 mm below the horizontal line drawn from canine to canine 4) Canine tip in line with ala of the nose 5) Posterior occlusal plane meets labial angle forming a 90 degree angle GOAL : APPLY KNOWLEDGE WITH CREATIVITY TO START THINKING / DRAWING OUTSIDE THE LINES ON MONDAY All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 34 yo working mother of 2 children BIOMECHANICAL RISK ? “JUST WANT TO HAVE THE SMILE I USED TO HAVE” Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 http://www.highlandmetals.com Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 SMOOTH ROUND PREPARATIONS Axial—KS0; KS1 and KS1L coarse Fine flame shaped Lingual- Egg or pear shaped (coarse/ fine) Final polish –rubber point LumiSmile White Highlights: • 32%, 22%, 16% Carbamide Peroxide • Formulated to minimize sensitivity • Long unrefrigerated shelf life* • Flavored with real peppermint oil • Refill kits available Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 IT’S NOT ABOUT THE PAINT ! ! ! IT’S ABOUT THE ARTISTRY THAT YOU DO WITH IT! ! ! Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 GENERALIZED WEAR CASE WHEN A LASER IS USEFUL ESTHETIC RISK? Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 UNSTABLE CHEWING ENVELOPES/ OCCLUSIONS Kois Continuum #8 What pattern of wear? BIOMECHANICAL? BONE LEVELS? KOIS CONTINUUM #8 Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 “EVALUATION OF SHEAR BOND STRENGTH OF RESIN CEMENTS TO CERAMICS CONDITIONED WITH DIFFERENT CERAMIC PRIMERS” CHAIYABUTR Y. KOIS JC, KOIS CENTER RESEARCH 2013 “EVALUATION OF SHEAR BOND STRENGTH OF RESIN CEMENTS TO CERAMICS CONDITIONED WITH DIFFERENT CERAMIC PRIMERS” CHAIYABUTR Y. KOIS JC, KOIS CENTER RESEARCH 2013 • For Lithium disilicate ceramic , silane with additives [extra adhesive resin or phosphate monomer] demonstrated significantly lower bond strength than that of pre-hydrolized silane solution. • For Lithium disilicate ceramic , silane with additives [extra adhesive resin or phosphate monomer] demonstrated significantly lower bond strength than that of pre-hydrolized silane solution. • For zirconia ceramic, the application of phosphate-containing primer significantly enhanced the bond strength of resin cement. CEMENTATION PROTOCOL FOR COHESIVE RESTORATIONS A NEW PLAYER IN THE MARKET CEMENTATION Low risk biomechanics-Bonded cementation High risk biomechanics-Glass ionomer TOOTH TREATMENT 1)Particle abrasion with 27 micron aluminous oxide at 40 psi 0.015hp 2) Rinse with Consepsis LITHIUM DISILICATE (Single crowns) 1)Clean with Phosphoric Acid (3040%) 60 seconds 2)Rinse with water 3)Apply silane solutions: 60 seconds 4)Dry thoroughly ZIRCONIA (for 3-4 unit bridges) 1)Particle abrade with 27 micron aluminous oxide 2)Maximum of 20 psi} METAL (PFM; Gold) Particle abrasion with 50 micron aluminous oxide at 80 psi 3) Coat with Metal Primer {MDP} A F T E R T R Y I N Solution Based Dentistry …aimed at addressing common clinical challenges Optimal Self-cure Mode: Innovative initiator system (chemical) • 1. DUAL-CURE, SELF-ADHESIVE 2. DOUBLE-BARREL AUTOMIX SYRINGE 3. HIGH WEAR RESISTANCE AND COLOR STABILITY 4. EASY HANDLING MAKES IT SIMPLE TO PLACE 5. LOW WATER SORPTION AND IS HEMA-FREE, DELIVERING EXCEPTIONAL COLOR STABILITY 6. ABILITY TO USE THE CEMENT IN BOTH POSTERIOR AND ANTERIOR CASES WITHOUT HAVING TO WORRY ABOUT ESTHETICS. 7. EXCESS CEMENT IS EASILY REMOVED IN ONE PIECE AFTER ONLY A 1 TO 2 SECOND TACK CURE FOR MAXIMUM CONVENIENCE. 8. THE PROPRIETARY PHOSPHATE MONOMERS OF G-CEM LINKACE PROVIDE A HIGH BOND DURABILITY TO ZIRCONIA RESTORATIONS THAT ACTUALLY INCREASES OVER TIME. “At the end of the evaluation period, 11of the 13 evaluators said they would definitely or probably recommend G-CEM LinkAce to colleagues.” DPS VOL. 7 No. 9 Hugh Flax High bond durability to Zirconia in ONE Step: Proprietary phosphate monomers (save the step of needing to place MDP) Exceptional Color Stability: Very low water sorption and HEMA-free Unsurpassed Wear Resistance: Small homogenously distributed particles Easy Excess Cement Removal: Only 1-2 second tack cure All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Optimal Self-cure Mode: In many clinical situations, light simply cannot pass through indirect restorations Tensile Bond Strength to Dentin / Self-cure 20 min 10 min 5 min 5000 TC G-CEM LinkAce™ G-CEM LinkAce™ RelyX Unicem 2 Automix† RelyX Unicem 2 Automix† Maxcem Elite† Maxcem Elite† 1 day SpeedCEM† SpeedCEM† 0 2 4 6 8 0 10 2 4 MPa 1100 mW/cm2 50 mW/cm2 0 mW/cm2 6 8 10 MPa 50 mW/cm2 Source: GCC R&D Internal Data 5000 TC = 5,000 thermal-cycle (5-55 °C) Mpa = Megapascal † Not a registered trademark of GC America Pereira et al., 2013, Sao Paulo University, Brazil Durable bond to IPS e.max (Lithium Disilicate) TENSILE BOND TO IPS E.MAX (LITHIUM DISILICATE) Maxcem Elite† Multilink Automix† RelyX Ultimate† 5 10 15 20 25 30 35 40 45 MPa 0.8 BETTER RelyX Unicem 2 Automix† 0 HYGROSCOPIC EXPANSION 1 1 day LINEAR EXPANSION COEFFICIENT [%] 5000 TC G-CEM LinkAce™ 0.6 0.4 0.2 G-CEM LinkAce™ RelyX Unicem 2 Automix† Maxcem Elite† SpeedCEM† 0 0 7 14 21 28 35 DAY Source: GCC R&D Internal Data 5000 TC = 5,000 thermal-cycle (5-55 °C) MPa = Megapascals † Not a registered trademark of GC America Prepared teeth HF acid etching of IPS e.max (lithium disilicate) crown Primer application Seating of the crown Tack cure for 1-2 seconds Removal of excess cement Source: GCC R&D Internal Data † Not a registered trademark of GC America Dispensing G-CEM LinkAce™ into crown 20 second light-cure all surfaces and margins for final results Source: Dr. Javier Tapia, Spain IPS e.max crowns pre-treated and handled according to manufacturer’s instructions Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 SEQUENCE: 8,9, 7,10 Cuspid bicuspids each side FMR PREVENTIVE MEDICINE GET TIME/FORCE OCCLUSAL INFORMATION WITHOUT RELYING ON SURFACE “PAPER MARKS” OR PATIENT/DOCTOR PERCEPTIONS USE THE T-SCAN BETTER TIMING & BALANCE LESS WEAR/FRACTURES BETTER COMMUNICATION/DOCUMENTATION Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 SALAMA, COACHMAN, GARBER, CALAMITA,ET AL Int. Journ of Perio and Restorative Dentistry Vol 29 No 6 2009; 573-581 Think 3D with color and contour gums-artificial and natural CHECK THIS NEXT ONE OUT USING TRANSITIONAL BONDING FOR INTERDISCIPLINARY CARE Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 GC GRADIA GUM shades Shade spectrum Gum Opaque (3) •orange, light red, dark red Gum Opaque Modifier (1 gel) •red Gum (5 pastes) •transparent, light orange, •dark orange, light reddish,dark reddish • Highly filled and durable for fracture resistance in thin areas • The fillers are coated with a silane coupler that allows for predictable bonding to substrate (which is already enhanced by the Composite Primer) Gum Modifier (7 gels) •6 shades + transparent Gum Trans (1 gel) •rosa transpa Gum Veins (1) 183 HOW TO BOND GRADIA GUM GC Ceramic Primer is used to bond Gradia Gum to Ceramic. GC Composite Primer is used to bond Gradia Gum to Composite/Acrylic. GC Metal Primer ll is used to bond Gradia Gum to Metal. 185 Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 CADDY WOMPUS JOURNEY Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 BOTTOM LINE: 1) No implants over 4.3 mm in the anterior zone 2) Lingualize the implant placement 3) Fill the gap with 50/ 50 mix DMFB/ cortical bone 4) Consider a connective tissue graft Hugh Flax OPTIONS: 1) Do nothing 2) Remove implant (s) 3) Augment the tissue and restore (single? splinted?) and add pink All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 MICROGINGIVAL PORCELAIN ENHANCEMENTS • Create a “palette” of colors/ blends Mockup • Sandblast with Prepstart (27 micron AlO2) • Porcelain etch with Ultradent HF (60 sec) and rinse thoroughly • Silane (airdry for 1 min) • GC Composite or Ceramic Primer-cure for 1 min • Place restoration in the mouth • Apply composite and blend • Polish and/or glaze “Good-to –great organizations avoid technology fads and bandwagons, yet they become pioneers in the application of carefully selected technologies…used technology as an accelerator of momentum not the creator of it” Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Cosmetic Restorative Clinical Applications Hard Tissue Procedures BOTTOM LINE: (for adult & pediatric patients) CO2 and Erbium lasers create clean and precise cuts on enamel - •Desensitization for bleaching •Cavity Prep - Classes I-VI •Caries and Restorative Material Removal 10 µm •Roughening & Etching ENAMEL Scanning electron micrograph of enamel cut with YSGG Hydrokinetic™ system. This surface shows hydroxyapatite columns (and interprismatic substance specific to this enamel structure) free of any mechanical or thermal damage. (x3500) •Enameloplasty •Bony recontouring No smear layer, crystalline structure preserved *All of the above slides were performed at a magnification of x3500 on a Jeol SEM model T-20. LASER ANALGESIA Proposed mechanism of action Reducing the action of the sodium potassium pump at the cellular level thereby slowing or even stopping nerve conduction in the pulpal tissues long enough to “painlessly” ablate enamel and dentin without the use of anesthesia in most cases Lasers in Dentistry (Miserdino and Pick) Quintessence Publishing 1995 Chapter 19 Modern optics and Dentistry page 287 “ For example, radiation scattered in enamel and dentin can be entrapped by these natural waveguides and transported to the pulp chamber” Wavelength Determines Absorption Absorption Determines Ablation CLINICAL PARADIGM SHIFT Low Absorption High Absorption • Micro dentistry (conservative care) • Minimally invasive soft/hard tissue treatment • Little to no need for anesthesia High Absorption = Efficient Ablation Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 How Does this Apply for Hard Tissue Ablation? WHAT’S SO DIFFERENT ABOUT SOLEA? New unique wavelength 9.3 µm Vaporizes enamel Erbium @ 2.7 or 2.9 µm Cuts soft tissue like native CO2 (10.6 µm) • Low HA Absorption/High H20 Absorption • Deep HA Penetration: 20 micrometers • Low Repetition Rate: 5 – 30 Hz CO2 laser that is cleared by the FDA for hard and soft tissue use Erbium (2.78 µm) CO2 @ 9.3 µm Computer controlled advanced technology Galvo optimized cutting patterns for the laser • High HA Absorption/High H20 Absorption • Shallow Penetration: 2 micrometers • High Repetition Rate: up to 10,000 Hz Variable Speed Foot Pedal facilitates control CO2 @ 9.3 µm: • Low Penetration/Very High Repetition • Strong Analgesia/High Speed Cutting CO2 (9.3 µm) Computer Aided Preparation (CAP) System enabling variable spot sizes and variable speed foot pedal (allows cutting and relaxation of tissue) 95% of Solea procedures anesthesia free 98% Solea patients feel no pain Integrated computer controls aid in cutting The CO2 laser operating at l¼9.3 has two principal advantages over other lasers when applied to ablation of tooth structure. The first advantage is that the CO2 laser can operate efficiently at high repetition rates well into the kHz regime. CO2 lasers can be operated with lower single pulse energies and irradiation intensities and the repetition rate can be increased for higher cutting rates. The second advantage is the very high absorption by the mineral phase that can be exploited for the modification of the irradiated surfaces to produce a layer that exhibits increased resistance to demineralization. The walls of a restored cavity are susceptible to secondary caries by microleakage of acids, bacteria, and cariogenic substrate between the restoration and the walls . What Makes Solea so Effective? CAP for Perfect Energy Delivery & Distribution: What Makes Solea so Effective? Simple to Use: Short Ramp Up Time Choose Tissue Select Spot Size Galvos Create Patterns – Unique to Solea Dictate Speed, Precision and Sensation based on: • • • • • Points per pattern Pulses per point Order of execution Max repetition rate Pulse width scale .25mm .5mm .75mm 1.00mm 1.25 mm XC Variable Speed Foot Pedal: • Vary cutting speed on the fly • Significantly increases control Change Speed On the Fly Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Class II Laser Preparation Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Application of Oxygel –ClO2 and aloe BW Kalore Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 WHY NOW? • Desire to go digital with impressions—lots of choices; wanted the complete pkg. • Confluence of more user friendliness (impressions/ design/ milling) and better material choices (esthetics; seal; strength; bonding mediums) • CEREC-30 years experience and Sirona’s desire for “CAD/ CAM for everyone” • Expand the breadth of options for our patients Restorative (crowns; partial crowns; and inlays)…..YOU CAN BE CONSERVATIVE Implant surgery and restoration ( crown down approach) Ortho impressions ( Clear Correct; Invisalign 6/15) Digital waxups and integration with DSD • It’s FUN and DELEGATABLE • Create a WOW experience-One Visit/ One Shot/ No temp Saves time and increased case acceptance Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 CERASMART IS A REVOLUTIONARY BLOCK FROM GC. IT COMBINES EXCEPTIONAL STRENGTH AND UNPARALLELED AESTHETICS. BEST OF ALL, IT VIRTUALLY WILL NOT CHIP, HAS A FASTER MILLING TIME, AND IS THE EASIEST MATERIAL TO FINISH. The ADA accepts these materials as ceramic under CDT code D2740 Mechanical Properties, University of Boston Mechanical Properties of New Chairside CAD/CAM Materials Conclusion: At the 95% confidence level, FNC had significantly higher values for flexural strength and modulus of resilience (p<0.05), as well as significantly lower values for flexural modulus (p<0.05) compared to all the remaining materials tested. Source: Mechanical Properties of New Chairside CAD/CAM Materials, Awada A., Nathanson D., J Dent Res Vol 93 (Spec Iss A): 714,2014 BOTTOM LINE : Thanks to its specific filler treatment, the fillers included in Cerasmart are homogeneously dispersed, which provides high wear resistance, high strength and long-lasting gloss Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Finishing & polishing 1. Grind off the connector 2. Use medium silicone point 3. Use fine silicone point 4. Use diamond paste such as GRADIA DIAPOLISHER Paste for high gloss Treat with hydrofluoric acid (5%) for 60 seconds or Phosphoric acid (35-37%) can be also used for the purpose of cleaning the surface, preferably scrubbing with a microbrush for 10-15 seconds. Repair of Cerasmart restorations 1. Roughen Slightly roughen the bonding area (restoration and exposed tooth structure) using a coarse diamond point or carbide bur 2. Silane the restoration 3. Bond the exposed tooth Apply a bonding agent such as G-aenial Bond on the exposed tooth tissue, dry and light-cure following manufacturer’s instructions Apply silane coupling agent on the restoration such as Ceramic Primer II and gently dry. If other primer is used, followed the manufacturer’s instruction 4. Apply the composite OUR FIRST CERASMART Apply the chosen restorative material and light-cure it according to the manufacturer's instructions. GC G-ænial Universal Flo is recommended in order to repair the surface of Cerasmart restorations since it is based on the same technology. 263 Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Hugh Flax Shake the bottle Dispense Apply a thin layer with a brush Do not air blow Cure light-curing device having a wavelength in the range of 400-430 nm for 40 sec (exceptions Kerr Demi Ultra and 3M Elipar 10 S) All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 THE BU$INESS OF MAKING YOUR PRACTICE PROFITABLE You Got A Problem With That ?? Recare Reminders bring your patients back to You! $605,462.00 from past Appointments Your patients can confirm by email and by text! Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Newsletters keep your Brand in front of your Patients! RECURRENT DECAY/ CRACKS PRESENT DOCUMENTATION Collecting patient reviews at t he point of service is the most cost-effective and least expensive marketing available. Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Getting those reviews consistently placed on the review sites that matter materially impacts the growth of a practice. Patients participate when the request is simple and immediate. Independent Solo Dentists • • • • • NeoDiamond is America's highest-rated, #1 selling diamond bur. • 20% more diamond cutting surface for a faster cut with less chair time. • NeoDiamond is individually packaged, sterilized, and color-coded with Quick Grit ID for safety and convenience. Corporate Dentistry • 100% - 1977 76% - 2006 69% - 2010 65% - 2012 57% - 2014 • • 7 New Corporate locations Every Day In 2 Years the number of large Dental Group Practices has risen 25% 52% of dentistry is produced in Group Dental Practices *ADA Health Policy Resource Center What’s your plan? Get the benefits of a group practice while remaining fiercely independent. 1-888-890-9990 www.SmileSource.com FINAL HYBRID PROSTHESIS WHAT IF? INTERIM FIXED HEALING “PROTOTYPE” EXTRACTIONS/ IMPLANT PLACEMENT Hugh Flax IMPLANT PLACEMENT GRAFTING/ SINUS LIFTS • EXTRACTIONS/ IMMED DENTURE All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 Journal of Implantology Vol. 30 No.5 (2004) 283-288 ABUTMENTS TO BE SHORT, MULTIANGLED ABOUT 1 mm SUBGINGIVAL---LOCATIONS PRESCRIBED BY SURGICAL GUIDE— POSITIONS BASED ON WHERE TEETH ARE SUPPSED TO GO ZYGOMA MY EPIPHANY 55yo female CC “Front teeth unstable and shifting; ready to overhaul teeth” • Very anxious about pain and treatment affects on appearance and speech • Med HxCongenital heart disease (no premed) Arthritis; Bells Palsy • Dental HxRCT;Perio SX C&B; Bonding; Episodic Care since 2003 • • A Case of “Retrospective Thinking” Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 TREATMENT PLANNING FUNDAMENTALS OF DENTISTRY • Biomechanics-decayed multiple teeth with crowns/root canals • Periodontal support-generalized severe bone loss and 1° occlusal traumatism (OT) • Occlusal/ Function-occlusal dysfunction causing 2° OT • Habits-clenching and bruxing • Medical management-None needed (despite med hx) • Esthetics-display 10-12 upper teeth with moderate gums; midline unstable due to flaring of upper teeth due to osseous breakdown and functional overload TREATMENT PLAN Immediate Upper / Lower Overdentures (extractions and grafting) Supported by endodontically treated # 6,11,21,22,27,28 Potential implants or attachments Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 BOTTOM LINE RESULTS • Improved appearance—”beauty is in the eye of the beholder” • Eliminate periodontal infection • Better bite • Unstable and uncomfortable • Patient challenged by labial flange and palate • Difficult proprioception • Facial tissue affected by Bell’s Palsy • Demanding patient with demanding lifestyle • WAS THIS THE RIGHT “TREATMENT OF CHOICE”? • DID SHE GET WHAT “SHE” WANTED? “Good judgment comes from experience, and often experience comes from bad judgment.” Rita Mae Brown STARTING ALL OVER AGAIN BLEND OF CLASSIC PROSTHETICS WITH NEW TECHNOLOGY AND MATERIALS We need good information ESTHETIC FACTORS • Midline • Facial thirds are ideally equal • Interpupillary line • Maxillary Tooth Position 1) Labial-support maxillary lip and balance of face 2) Vertical canine position in repose—level with the lip (Misch/ Kois) 3) Centrals-1-2 mm below the horizontal line drawn from canine to canine 4) Canine tip in line with ala of the nose 5) Posterior occlusal plane meets labial angle forming a 90 degree angle Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 NEW CLINICAL DATA Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 MOUNTED IN CR WITH APPROPRIATE FREEWAY SPACE Ostectomy recommendation Canine position matching archform MOUNTING PLATE BY IVOCLAR FOR STRATOS —CAN USE WITH KOIS FACIAL ANALYZER Hugh Flax 14 mm the recommended prosthetic distance from incisal edge to implant platform for strength of materials (Misch Text :233-275) Midline position and archform that matches platform All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 ANTERIOR GUIDANCE IMPLANT PROTECTED OR SHARED PROPRIOCEPTION IN PROTRUSION and LESS ANTERIOR WEAR OR TORQUE CT IMAGING : COMMUNICATION BETWEEN ORAL SURGEON and RESTORATIVE TEAM Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 INPUT FROM LAB • ALVEOLECTOMY GUIDE—to “prescribe” how much bone to remove to hide seam, allow for implants and proper thickness for restorative materials • SURGICAL GUIDE FOR IMPLANT PLACEMENT—allow for abutment orientation to be in proper position esthetically and to decease non-axial loading for implant osseointegration • ORIENTATION BITE-index upper and lower • VERTICAL DIMENSION MEASUREMENT- reverify at beginning of surgery with Ivoclar guide SURGICAL GUIDE—clear version of projected prosthesis REVERIFY VERTICAL LANDMARKS AT THE TIME OF SURGERY • Mark positions of implants • Verify for the surgeon the location ( bucco-lingual; mesio distal, emergence trajectory) • Want to stay with the “window: that is ideal In the cingulum or just lingual on the anterior palatal Abutment orientation under the maxillary lingual cusps and the mandibular buccal cusps to decrease axial forces and blueprint future position of milled substructure bar Place implants • UPPER SIX Anterior pre-maxilla (2) Anterior to sinus wall ( 2) Zygoma (2) LOWER FIVE Anterior mandible—3 overlapping and with divergent angulations AND mesial to buccal nerve approx. 5mm “safe zone” (A,C, E positions) • Hugh Flax Bilateral bicuspid positions 2 Abutments low profile and oriented for easy access for screw retrieval and the screws toward the lingual and not in the occlusal or toward the facial All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 LUTING FOR IMMEDIATE LOAD-creating reliable accuracy for locating implant position and esthetic function orientation • Highly reliable; compatible bond to acrylic that avoids errors in accuracy between implants---less complications in seating “framework” during the immediate stage • Because the patient is closing into bite index (no access to the lingual) a “self cure” is mandatory material is mandatory PRE-”LUTING” OF UPPER 1)PAINT TEMPORARY CYLINDERS WITH ACRYLIC TO ADAPT TO GROOVES (DECREASE SLIPPAGE OR BUBBLES) 2)PLACE THESE INTO THE ANTERIOR LOCATIONS AFTER REMOVING ABUTMENTS 3)CORE THE IMPRESSIONS AT THESE LOCATIONS 4)CUT DOWN THE CYLINDERS TO FIT THE “HOLES” LUTING PROSTHESIS TEMPORARILY TO THE IMPLANTS • MIX UNIFAST ACRYLIC (GC) • FILL SYRINGE (GET RID OF AIR BUBBLES BY VENT HOLE) • INJECT AROUND TEMP CYLINDERS (NOT INSIDE) • PT CLOSES (INTO BITE) • AFTER HARDENING, UNSCREW THE TEMP CYLINDERS • AND COVER IMPLANT WITH ABUTMENT OR IMPRESSION COPING FOR NEXT STEP SEND UPPER IMPRESSION TO LAB FOR “CONVERSION” ( WHILE LOWER SURGERY—OSTECTOMY; DIRECTED IMPLANT PLACEMENT-- DONE WITH PROSTHETIC PROCEDURES IN EXACT ORDER—ORIENTING IMPRESSION OF LOWER PROSTHESIS WITH MEDIUM BODY CLOSING INTO BITE WHILE UPPER LOCKED IN PLACE; CORE/LUTING OF LOWER PROSTHESIS; AND OPEN CUSTOM TRAY IMPRESSION OF LOWER IMPLANTS REMOVE FLANGES Hugh Flax PLACE GINGIFAST (ZHIRMACK) MATERIAL TO FILL TO “ IMPLANT PLATFORM” All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art Hugh Flax 5/8/2015 All materials copyrighted by Hugh Flax DDS and referred sources AACD 2015 State of the Art 5/8/2015 RETROSPECTIVE CONCLUSIONS • Better materials (restorative and graft materials; implant design) and understanding of biomechanical principles, as well as, better 3 D diagnostic protocol make this modality a reasonable choice for the more driven patient who is less tolerant of a flange or palate • Due to the difficulty and time intensiveness, it is critical to assemble a “team” to make this predictable: 1) Removable lab specialist who knows smile design principles (“pretreatment facial analysis” ), functional loading with awareness of proprioception that is more rigid than tradition removable, and meticulous with guides and “conversion” 2) Surgeon has a humble prosthetic awareness (bone removal for prosthetic thickness i.e. “ treatment by prescription”); can place pterygomaxillary implants to give posterior support distal to sinus; and office team is mutually supportive of restorative team • Time intensiveness will improve by better preplanning with 3 D printing of alveoloectomy guide; implant surgical guide; and indexing prosthesis to stable landmarks) CONTACT INFORMATION HUGH FLAX,DDS (404) 255-9080 Thank You Email: [email protected] For lecture info on cosmetic dentistry, implants and lasers http://www.catapultelite.com/flax.php ANY QUESTIONS ???? Hugh Flax All materials copyrighted by Hugh Flax DDS and referred sources
Similar documents
The Magic of Laser Assisted Cosmetic Dentistry
Applications Hard Tissue Procedures (for adult & pediatric patients)
More information