By Hugh Flax DDS, AAACD, FICOI Atlanta, GA

7/21/2016
FOR HANDOUT GO TO
www.HughFlax.com
ATLANTA GA NATIONAL MEETING
CONTEMPORARY COSMETIC DENTISTRY
PREDICTABLE PRINCIPLES THAT “FACILITATE
AND REPLICATE” THE SMILES OF OUR PATIENTS
BY HUGH FLAX DDS, AAACD, MICOI
ATLANTA, GA
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.
Hugh Flax DDS, AAACD MICOI
Atlanta ,GA
Flax Dental
Member of Catapult Group
[email protected]
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 I will be sharing with you today.
• Today I am supported in part by:
• AMD
• Bisco
• SDI
• Kettenbach
• Microcopy
• Lending Club
• Contact EZ
• DOXA
• Solution Reach
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
• Learning-sharing new and reinforcing
“time-tested” knowledge and learning
from each other
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USA TODAY STUDY (1997) OF
ATTRACTIVENESS AND SELF ESTEEM
WHAT WOULD YOU CHANGE ABOUT YOUR
PHYSICAL APPEARANCE ?
• Weight
• Height
• Face
• Hair
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IF YOU COULD CHANGE ANYTHING IN
YOUR FACE WHAT WOULD IT BE ?
ABC-TV’S
“EXTREME MAKEOVER” SHOW !
• Nose
• Eyes
• Teeth
• Chin
• Lips
• Head shape
TODAY’S CHALLENGES OF ESTHETIC DENTISTRY
DIVERSITY IN CULTURE
AND EXPECTATIONS
• ESTHETICS
• BIOLOGY
• FUNCTION
• ECONOMICS
1. Expectations of patients
2. Chairtime
3. Minimally invasive
4. Affordability
5. Durability/ Reparability
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TIME FOR CHANGE
• Diversity of people and choices in treatment
• 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
STONE TOOLS
COMPUTER MOUSE
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
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INTERDISCIPLINARY CARE
ESTHETICS
PERIODONTAL
SUPPORT and
CONTOURS
FUNCTION
BIOMECHANICS
3 D CT Scan Courtesy of Kai-hung Fung, MD
PERIO
ORTHO
LAB
WHAT IS ESTHETICS ?
ENVISION THE SMILE
The science of beauty in nature as
an art
“Beauty is the association of many complex
associations”
Charles Darwin
“Begin with the end in mind”
Stephen Covey
FACIAL EVALUATION



In repose
Middle 1/3 =Lower 1/3
Maxillary lip length : YAF 20-22 mm
YAM 22-24 mm
MIDLINE


MATCH THE MIDLINE OF THE
FOREHEAD (NOSE ?)
INCISIVE PAPILLA
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INCISAL and INTERPUPILLARY PLANES
SMILE FRAME



Parallel to each other


Skeletal defect ? Ears?
LIPS
SMILE LINE






Form
Fullness
Competence
Symmetry
Position (repose/smile)
Affect of upper incisors
(length/inclination)




Plane of incisal edges
Lower lip curve
Convex-youthful
Concave-indicates disharmony
esthetically (“curb appeal") and
functionally (“under the hood”)
AXIAL INCLINATION
GINGIVAL SYMMETRY/CONTOUR




The “Broadway Play”
Proportions
Symmetry
No excessive display
Centrals match each other
and canines
Laterals?
Edentulous
spaces ?
Long axis of teeth
Harmony-occlusally
visually
 Tipping
 Profile
/gingival shaping


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PROFILE
BUCCAL CORRIDOR






Contour of facial surfaces
Parallelism with adjacent
structures
Esthetics
Function
Incisors ?
Canines ?
Lab communication

EMBRASURE SPACES/
OUTLINE FORM





3 Dimensional (incisal/gingival)
Characterization
Transition
Dozens of combinations
Communication tool—several resources
-- Smile Guide (Discus)
-- Imaging systems
Image FX now called
Patient Gallery http://www.patientgallery.com
What is it ?
Factors ?
Arch width
Muscles of cheeks
Soft tissue contour
Posterior teeth
COLOR




3-D multi-chromicity
Translucency- degree?
color?
clarity?
“Halo”
How to communicate it
Resources: Analysis (Ubassey)
Voyage (Sieber)
Ceramic Works (Aoshima)
GPS 3D Design http://dentalgps.com/gps-store/gps-software/
TEXTURE
PROPORTION / GENDERIZING



Ultimate in
“microanatomy”
Age factors
Communicate with the patient and lab
From PPAD Sept,1998 (Vol.10,No.7)
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DENTO-FACIAL
EVALUATION






HOW DO THESE RELATE
TO SMILE DESIGN ?
Esthetically pleasing?
Tooth display?
Incisal edge position?
Gingival level?
Proportional width?
Maxillary lip position?
RULE
Create Reference Points
1. Display
2. Length: At least 10 mm
3. Width: At least 7.5 mm
4. Midline: Must be vertical
5. Lateral incisor: 2 mm rule
6. Canine: 1 mm rule
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PLAN
1.Incisal length
2.Gingival level
3.Implant level
PLAN
1.Mock Incisal and/ or Only
2.Full waxup (function)
3.Test Final Mock
COMMUNICATE VISUALLY
ANYTHING TO ANYONE ,AT
ANYTIME !
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
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WHY NOW?????????
WHY NOW???
FACT: In 2009, in the USA, video content views surpassed
text content views
BOTTOM LINE
COURTESY CHRISTIAN COACHMAN
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ANALYTICAL
EMOTIONAL
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Plan The Smile Your Patient Deserves
www.smiledesignerpro.com/
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WHAT IF ???
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REVEAL is a light-cured, highstrength flowable composite for
the Bonded Functional Esthetic
Prototype (BFEP) Technique.
• nano-sized filler particles
contribute to REVEAL’s
excellent polishability
• while the reinforcing fillers
allow for high filler loading
giving REVEAL maximum
strength and durability.
• REVEAL allows the clinician to
diagnostically meet the
patient’s esthetic
expectations before the
definitive restorations are
fabricated
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Pink Esthetics
WAYS TO MANAGE PINK
TRADITIONAL
• ELECTROSURGERY
• SCALPEL REDUCTION
• OPEN FLAP CROWN
LENGTHENING
• FREE GRAFTING
• CONNECTIVE TISSUE
GRAFTS
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
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34 yo working
mother of 2 children
BIOMECHANICAL RISK ?
“JUST WANT TO HAVE THE SMILE I USED TO HAVE”
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http://www.highlandmetals.com
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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
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IT’S NOT ABOUT THE PAINT ! ! !
Spectrum of Medical Lasers
Diode 812nm
Diode (980nm)
ErCr:YSGG 2.78 µm
Er:YAG ( 2.94µm)
CO2 (9.6 or 10.6m)
Excimer
KTP (532nm)
KrF (248nm) XeF(351 nm)
HeNe (632nm)
Ultraviolet
Visible
100 nm
400 nm
ArF (193nm) XeCl (308 nm)
Infrared
Ruby (694nm) 750 nm Ho: YAG
Nd: YAG (2,08 µm)
(1,06 µm)
Argon (488 nm)
IT’S ABOUT THE ARTISTRY
THAT YOU DO WITH IT! ! !
-rays
x-rays
10-12
UV
visible IR
10-9
10,000 nm
Argon (514 nm)
10-6
microwaves
10-3
radio waves
1
acoustic waves
103 wavelength, meters
Scatter
FOCUS ON THE TARGET
Laser-Tissue Interaction
Laser Spectrum
Transmission
(Refraction)
Absorption
Reflection
Types of dental lasers used in 2016
All Tissue Uses
PERIODONTICS
• Effective and unrivaled pocket debridement: Bactericidal effect (disinfection)
• Excellent surgical precision: Precise & selective granulation tissue ablation avoiding unnecessary damage of
healthy tissues
• Effective and selective calculus removal
• Faster healing of surrounding tissue and bone: Minimal postoperative swelling and discomfort, leading to fewer
follow-up visits
RESTORATIVE and PEDODONTICS
CO2
• SOFT TISSUE
ONLY
• Gas-based
• Used for surgery
• Expensive
($40K+)
Nd:YAG
Er,YAG
• HARD
TISSUE/SOFT
TISSUE/BONE/E
NDO/PERIO
• Solid-state – uses an
Erbium crystal or CO2
gas
• Hard tissue cutting
• Cavity preps
• $50K+
Er,Cr:YSGG
• Solid-state – uses a
Neodymium crystal
• Soft tissue surgery
• Perio / LANAP
• Soft tissue
• Not common in ortho
• Very expensive
($85K)
Diodes
• SOFT TISSUE
ONLY
• Semiconductor diode
• Excellent for soft
tissue
• Lots of brands
• ~25K installs in USA
• Affordable ($2K$20K)
• The preferred method for treating children: No fear factor; shorter procedures; less noise; no vibrations
• Preventive Dentistry: Precise and delicate treatments; minimally invasive; enables microsurgery (pits and
fissures) that preserves healthy tissue
• Friendly equipment: Well-accepted by kids and “big kids”
• Ideal for hard or soft tissue crown lengthening either open field or closed through the sulcus
• Improves treatment of periodontal disease by sterilization of the pocket, granulation removal and stimulation
of the crestal bone
AESTHETIC DENTISTRY
• Precise manipulation: Gingival re-contouring, smile design & depigmentation of natural melanin deposits
• Excellent for debonding porcelain veneers: Allows dentists to reuse veneer while maximally preserving tooth
substance
• Anesthetic free treatment makes patient management easier on staff, doctor and patient
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TREATMENT PLANNING
FUNDAMENTALS OF
DENTISTRY
•
DATA ACQUISITION



ACCURATE
CALIBRATED
SYSTEMATIC
•
•
•
•
•
Biomechanics
Periodontal support
Occlusal/ Function
Habits
Medical management
Esthetics
STRATEGY FOR “WIN WIN SUCCESS”

CODISCOVERY—at EVERY visit
1.
2.
3.



Build understanding
Verify and validate
Create vision AND Manage expectations
BLUEPRINT OF CONCEPTS
“TEST DRIVE”
GO FOR THE WIN !!!
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MED HX
DENTAL HX
DOCUMENTATION







Review forms/Interview
Digital photos (AACD; DSD)
Digital radiographs
Periodontal exam
Occlusal exam
Oral cancer exam
Caries / Cracks
DIFFERENT CAMERAS FOR DIFFERENT NEEDS & DESIRES
• SLR
• I PHONE smilelineusa.com
Smile Lite & Smile Capture Full Set - #6500/6550-SET
Adaptor for better focus/ zoom
5000K Light and Polarizing filter for depth/reflection
• EYE SPECIAL II
UNIQUE FEATURES
EYESPECIAL C-II
• Designed for dentistry
• 8 pre-set shooting modes
• Dental grid lines & spot focus
• Water and chemical resistant – Essential
for infection control
• Durable rugged Exterior
• User Friendly
• Fast autofocusing & anti-shake
capabilities
• Easy to use – no photography skills
required
• Light weight/can be held with one hand –
weighs only 1lb
• Special Benefits
• Compatible with the Eye-Fi X2 card –
Immediately upload images onto PC,
iPad, Tablet or Smartphone
• SureFile Photo management software –
Keeps record of patient information
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8 DENTAL SHOOTING MODES
FOR EYESPECIAL C-II
Standard Mode – For standard intraoral photography.
Surgery Mode – For intraoral photography from a certain
distance.
Mirror Mode – For intraoral photography using a mirror;
the image taken can be reversed.
Low-Glare Mode – For Photographing details of anterior
teeth; working models and indirect restorations
STANDARD MODE
FOR STANDARD INTRAORAL PHOTOGRAPHY
Everyday dental photography – The mode that will get used most
•
•
•
•
Ideal distance 9.4 in
Patient will be sitting up in chair or standing
Will likely have cheek retractors in place
Can be taken with normal operatory lighting
Whitening Mode – For shade comparison between before
and after whitening.
Tele-Macro Mode – For photographing anterior teeth,
indirect restorations and working models in higher
magnification. **Attach the close-up lens when taking
pictures in this mode**
Face Mode – For shooting facial views or half-body
portraits.
Isolate Shade Mode – You can isolate the shade for
optimal shade matching.
ISOLATE SHADE MODE
YOU CAN ISOLATE THE SHADE FOR OPTIMAL SHADE MATCHING
• Gingival shades removed
•
•
•
•
Improves visual acuity
Excellent case selling tool
Ideal distance 5.5 in
Patient may have cheek
retractors in place – could
be used on a model at the
bench in a laboratory
CASE ACCEPTANCE
Collaborative with DSD system
(Interconsultation and Emotional Dentistry)
 Matter of fact presentation of:
1.
The “cards” we are dealing with (Awareness of
conditions/risks)
2.
What are those “implications” to short and long term goals
(Consequences) and determine Concerns
3.
Options—including “Doing nothing” (PRESENT AT LEAST 3)
 Broad stroke description of a “progressive plan”
 Technical Q & A (with Doc)
 Plan the “first step”
CHECK
THIS ONE
OUT

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GENERALIZED WEAR CASE
WHEN A LASER IS USEFUL
ESTHETIC RISK?
UNSTABLE CHEWING
ENVELOPES/ OCCLUSIONS
Kois Continuum #8
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BIOMECHANICAL?
BONE LEVELS?
What pattern of wear?
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Futar® D Fast - Twice as fast




Rigid Shore-D hardness of 43
Dispensed with very little effort, saving
time
Thixotropic and easy to remove
Total Set Time: 1 Min.
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Futar® Fast - The comfortable classic
• Shore-A hardness of 90
• Thixotropic and easy to remove
• Sets quickly, can also be milled and easily cut
with a scalpel
• Total Set Time: 1 Min.
Hydrophilicity: clinical aspect
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WHAT ARE MY BEST COHESIVE CEMENT CHOICES?
Dual Cure Resin
 GC LinkACE
 3M Relyx Unicem
 Bisco Duo-cement
 Ivoclar Multi-link/
Variolink Esthetic
Bio-enhancing
 Glass ionomer—Fujicem 2
 Bioceramic--Ceramir
“Universal” Adhesive
Definition
•Usable for Direct & Indirect (Film Thickness <10 um)
•No additional resin layer required (1-Layer Adhesive)
•Compatible with D/C, S/C resin cement/composite without DC
Activator
•Usable with TE, SE & Select-Etch
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Shear Bond Strength to Indirect Substrates using Duo-Link
(Self-Cured Mode), MPa
Lithium Disilicate
Zirconia
SUMMARY of ALL-BOND UNIVERSAL:
 the
ONLY TRULY UNIVERSAL one-bottle dental adhesive
to all dental substrates (Directs and Indirects)
be used with Self-Etch, Total-etch or Selective-Etch techniques
 hydrophilic (good wetting) before curing… after curing, it is more
hydrophobic (non-permeable & durable) than other adhesives
 long-lasting (durable) bond strength
 doesn’t need additional resin/adhesive layer
 bonds to dentin regardless of moisture level (over-wet, moist or dry)
 compatible w/ S/C and D/C resin materials without additional activator
 doesn’t need refrigeration
 the solvent is easily evaporated (no water residue)
 bonds
 can
SEQUENCE:
8,9, 7,10
Cuspid bicuspids each side
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APPLY 2 coats thoroughly
15 sec per coat
DRY lightly to remove excess
LIGHT CURE –
10 seconds per tooth
Ceramir Crown & Bridge



Ceramir C&B is a material that combines glass ionomer technology with the
innovative Ceramir (Calcium Aluminate – CA) technology.
The GI contributes to:
 Low initial pH, short duration
 Flow and Setting characteristics
 Early strength
The CA contributes to:
 Increased strength and retention
 Biocompatibility
 Sealing of tooth material interface
 Apatite formation
 Sustained long term properties, no degradation
 Basic end pH
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Retention
Values equal to self-adhesive resins
Retention (gold crown) kg/force
Metal
45
40
35
30
25
20
15
10
5
0
Ceramir Crown &
Bridge
RelyX Unicem
MaxCem (Kerr)
Cement
Ceramir Crown & Bridge
RelyX Unicem
MaxCem (Kerr)
Ketac Cem
ZinkPhospate
Ketac Cem
ZinkPhospate
Retention (gold crown) (kg/f)
38.6 ± 8.5
39.8 ± 15.3
15.9 ± 9.3
26.6 ± 4.4
13.9 ± 4.5
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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
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LETS OPEN OUR PARACHUTES
SALAMA, COACHMAN, GARBER, CALAMITA,ET AL
Int. Journ of Perio and Restorative Dentistry Vol 29 No 6 2009; 573-581
Watch carefully !
USING TRANSITIONAL BONDING FOR INTERDISCIPLINARY CARE
Think 3D with color and contour gums-artificial and natural
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• 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)
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.
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JOIN THE REVOLUTION OF NEW
TECHNOLOGY






Smarter
Quicker
More precise
More comfortable for the
patient
Greater satisfaction
Bottom line: You are “raising
the standard of care”
August 2003
Laser History and Physics
Lasers VS. High Speed
LiteTouch
Turbine Drill
Almost no anesthesia
Anesthesia is required
No post-operative numbness & sensitivity
Post-operative numbness & sensitivity
Multiple quadrant treatment
Single quadrant treatment
No drilling noise & vibrations
Drilling noise & vibrations
Bactericidal effect
Threat of bacterial contamination
Coagulation: fast healing, not bloody
Scalpel: slow healing, scars, bloody
No micro-fracturing / no smear layer
Micro-fracturing and smear layer
No etch & bond enhanced
Need for etching
1916
Einstein took Bohrs theory
of Spontaneous emission
and came up with the
stimulated emission theory
that would be the basis of
laser technology.
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Spectrum of Medical Lasers
LASER is an acronym for :
Diode 812nm
Diode (980nm)
ErCr:YSGG 2.78 µm
Er:YAG ( 2.94µm)
CO2 (9.6 or 10.6m)
L = Light
Excimer
KTP (532nm)
KrF (248nm) XeF(351 nm)
HeNe (632nm)
A = Amplification by the
S = Stimulated
Ultraviolet
Visible
100 nm
400 nm
ArF (193nm) XeCl (308 nm)
Infrared
Ruby (694nm) 750 nm Ho: YAG
Nd: YAG (2,08 µm)
(1,06 µm)
Argon (488 nm)
E = Emission of
R = Radiation
-rays
10-12
x-rays
UV
10-9
10,000 nm
Argon (514 nm)
visible IR
10-6
microwaves
radio waves
10-3
acoustic waves
103 wavelength, meters
1
Scatter
FOCUS ON THE TARGET
Laser-Tissue Interaction
Laser Spectrum
Transmission
(Refraction)
Absorption
Reflection
Treat
High Risk
®
Moderate Risk
Low Risk
Milicich GW, Rainey JT:
Clinical Presentations of
Stress Distribution in Teeth
and the Significance in
Operative Dentistry.
Pract Periodontics Aesthet
Dent 2000:12(7)
? Remin
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*
THE PERIPHERAL RIM
The
marginal
ridge is just
part of the
peripheral
rim of
enamel
The Basic Occlusal Restoration
FLOWABLE
GIC
Strong dentinal bond eliminate shrinkage
Fluoride remineralization
MORE CONSERVATIVE
Composite
Glass ionomer
How can this get better?






Can we enhance the bond strength effects of
lasers?
Can you improve on stability and usability of glass
ionomer?
Make teeth and restorations more resistant to acids
when patient compliance decreased
Create a continuous supplement of fluoride
More plaque resistant
Able to enhance pulp preservation
BETTER DENTISTRY THROUGH CHEMISTRY
Micro-FTIR spectra of the non- and lased dentin (CO2 laser, 69.0
J/cm2) revealed that the laser-irradiation eliminated the amide peak
wavelengths (box) and increased the crystallinity of dentin (arrow).
Jpn J Conserv Dent 42(5): 860~877, 1999
Jpn J Conserv Dent 55(6): 411~423, 2012
Er:YAG was done at Hiroshima Univ. (former university for Morioki),
CO2 laser work was carried out in our department of Aich Gakuin University.
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The characteristic changes of the superficial layer of lased dentin actually
demonstrate the increase of the mechanical properties and acid-resistance.
Unfortunately, laser-irradiation decreases resin-bond to dentin.
Light-microscopic view of the Er:YAG lased dentin
showing heat-denatured layer observed in red with
the thickness of approximately 30 µm (Masson’s
trichrome stained)
TEM image of the Er:YAG lased dentin
demonstrating amorphous and nonfibrous subsurface
layer (☆) (demineralized, UA/LC stained). The
resultant heat might superficially denature the
dentinal collagen fibers.
Excerpta Medica, International Congress Series 1248. 1st ed. Elsevier Science B.V.:
Amsterdam; 2003. 161-166.
Information provided by Professors Akira Senda and Fujitani Morioki
Aichi Gakuin University
Functions of Glass-ionomer phase
in S-PRG Filler
What’s A GIOMER?
1)Various Ion Release
GIOMER products are characterized
by their Surface Pre-Reacted Glass (SPRG) filler. S-PRG filler have a glass
core that is pre-reacted with a poly
acrylic acid solution. This means that
unlike GI that require light curing and
water absorption for ion transfer to
occur, GIOMER’s filler are protected
from water sorption and material
degradation by a surface modified
layer.
Improvement of acid resistance by forming…
Antibacterial effect
Remineralization of decalcified tooth substance
Inhibition of dentinal hypersensitivity
2)Fluoride recharge
3)Acid Neutralization Effect
University of Florida
8-Year Vs. 13-Year Results
8-Year results as published in
JADA 2007:
13-Year results as presented
during IADR 2013 poster session:
16 of 26 Class I, and 25 of 35 Class II
restorations were observed.
19 of 26 Class I, and 22 of 35 restorations were
observed.
•
•
•
•
No failures
No secondary caries
Maintained aesthetics
No post-op sensitivity noted
8-Year: J Am Dent Assoc. 2007 May;138(5):621-7
13-Year: 2013 IADR Poster Presentation, Gordan et al.
• Retention rate 66% (27 of 41)
– 52% of retained noted as excellent
– 41% of retained noted minor changes
• Secondary caries rate 3.27% (2 of
61) restorations noted
• Overall positive results and low
secondary caries attributable to
Giomer technology
13 Year
Photos
SOME REAL PERSPECTIVE
47
7/21/2016
The LiteTouch Er:YAG laser
Introducing You To The LiteTouch
The Best Choice
• Its entire laser delivery mechanism housed within the
handpiece
• No loss of energy
• Avoids the heavy, rigid and bulky articulated arm and
fragile fibers
• Ergonomic design and maneuverability
48
7/21/2016
THE BU$INESS OF MAKING YOUR
PRACTICE PROFITABLE
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Newsletters
keep your Brand
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49
7/21/2016
RECURRENT DECAY/ CRACKS PRESENT
DOCUMENTATION
DENTAL BENEFITS
•
Better more natural smiles—conservative (preserve enamel)
•
Prevention---better fitting bite (peaks; valleys; side of the hill)
decrease stress; cracks; and wear
•
Improved gum health due to less crowding
•
Avoid unnecessary treatment and unneeded expense
3 R’s—Relocate  Replace Restore
IPR Strip System
0.06mm│Single-Sided│Extra-Fine Diamond │ Serrated
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[email protected]
p (360) 694-1000
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7/21/2016
Double-Sided Optional Strips
Clean
Reduce enamel on two adjacent teeth.
After cementation, remove excess cement with an explorer. Pass a ContacEZ
Serrated Strip buccolingually in the interproximal spaces to cut and clean out any
remaining excess cement.
Purple IPR Super-Widener
0.25mm│Coarse Diamond
217 SE 136th Ave. Suite 105
Vancouver, WA 98684, USA
Brown IPR Mega-Widener
0.30mm│Coarse Diamond
www.contacez.com
[email protected]
p (360) 694-1000
f (360) 694-6191
White Serrated Strip
Gentle Saw
Blue Serrated Strip
Heavy-Duty Dental Saw
0.35mm│Serrated
0.065mm│Serrated
Safely remove cement from multiple
restorations without disturbing
placement prior to light curing.
Cut into massive excess cement, and
separate fused contacts of multiple veneers
after light curing.
217 SE 136th Ave. Suite 105
Vancouver, WA 98684, USA
www.contacez.com
[email protected]
p (360) 694-1000
f (360) 694-6191
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7/21/2016
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SHADE MATCHING
52
7/21/2016
CHALLENGES IN SHADE MATCHING
• Lighting
• Metamerism—two objects appearing to match in one situation
and not matching in others (office vs. home)
• Contrast Effects—visual phenomena that alter perceptions of
color (skin tone; background –use blue/gray; large vs small
teeth; crowding; successive shades)
• Reflections on surfaces
• Experience and knowledge
• Eyes
• Subjectivity of dental team and patient
• “Hit man vs. The Healer”
CREATING A WORLD DENTAL SHADE STANDARD
ADVANCING DEVELOPMENTS
Dr.Hall
1940
1998
1927
1956
2003
1950’s
1983
(Drs.Jung)
Dr.Paravina
Dr.Saddon
1998
2010
1983
MOST SHADE MATCHING TODAY…
TECHNOLOGY FROM THE 1950’S
53
7/21/2016
WHAT ARE YOU USING?
The color of the tooth
REALITY OF SHADE MATCHING TODAY
SHADE SELECTION; IT’S A PROBLEM…
• Doctors are matching shades by looking at the whole
tooth or incisal areas.
• Doctors are mainly buying and using the enamel
shades in current composite systems.
• In a recent study 86% of dentists couldn’t agree on a
shade.
• A recent SCAD poster showed that three leading
composite brands didn’t match the intended Vita
shade, for numerous shades.
Courtesy of Dr. R. Nash
BIOLOGY
TOOTH SUBSTRATE MANAGEMENT
ENAMEL VS DENTIN
Healthy Tooth
Decalcification and
decalcification are
equilibrium
Extraction
Caries occurs
Bonding agent
Root breakage
Border caries
Resin filling
Direct Restoration
Secondary Caries
Crow
n
Cement
Build up core
Crown treatment
Pulpectomy
54
7/21/2016
FUNCTIONAL RELIABILITY FOR COMPOSITES
FUNCTIONAL RELIABILITY FOR COMPOSITES
STRENGTH and FLEXIBILIBILITY UNDER MULTIPLE FORCE LOADS and VECTORS
• EFFECTS of POLYMERIZATION
1. Volumetric shrinkage
2. Shrinkage stress
• FLEXURAL MODULUS—the higher the more brittle
• COMPRESSIVE STRENGTH
• RADIO-OPACITY
Radiopacity
(mm Al)
Polymerisation Shrinkage Stress
4.8
6
Radiopacity (mm Al)
Polymerisation Shrinkage Stress
(MPa)
COMPRESSIVE STRENGTH
5
4
3
2
1
0
Aura SonicFill Kalore
Dentin
Xtra Fil
Surefil
SDR
Quixx
Venus
Bulk Fill
Tetric
Evo
Ceram
Bulk Fill
Rok
Ice
IN THE END, IT’S ALL ABOUT THE LOOKS
Patients judge their dentists by
how their restoration looks!
Glacier
4
3.2
2.4
1.6
0.8
0
A ura
F ilt ek Sup reme
X TE
Est het X HD
Herculit e U lt ra
Kalo re
T PH3
HUE , CHROMA & VALUE
Hue - Basic color of a tooth e.g red, blue or
yellow
Chroma – Intensity of the color (hue)
Value – Lightness or darkness of the color
(hue)
Opacity – ability for light to pass, translucency
55
7/21/2016
Aura’s shading system
• Based on natural make-up and colors of enamels
and dentin
• Linear, logical and scientific arrangement for
predictability and customizing shades
• Simple layering technique to reproduce the natural
colours of teeth
• Designed to simplify shade matching for busy
clinicians; minimal effort.
• Shade matching in ten seconds is recommended,
then the clock starts ticking when the patient entering
the chair.
SHADE SELECTION METHOD
1. Choosing the dentin
shade
2. Choose the enamel
shade
COLORIMETRIC PROPERTIES OF AURA
DENTIN CHROMA RANGE
• Single opacity
• Single hue
• Large chroma scale,
aka color intensity,
(Db,DC1 – DC7) is
equally spaced
• Fluorescence
Aura has a linear and scientific arrangement for
predictability and customizing shades
AURA’S FEATURESS
•
•
•
•
•
Non-sticky – less uncured resin is used,
creamy handling
Easy to polish to mirror finish
Large particles (60 microns) = high filler
loading & strength
Low flexural modulus (big bonus); better
fracture resistance, less stress at composite
interface means less debonding
Lower polymerization shrinkage
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7/21/2016
Shade selection for layering technique
• Shade selection must be carried out
before isolation, ideally under day light
using Aura shade guide provided
• Do not dry the teeth
• Start with Dentin shade/ bodyEnamel
• Aura’s shade guide is made from actual
Aura’s pastes.
• No shade change from pre-cured state to
cured state
Enamel shades
Based on different colours of natural enamels:
E1: most whitish/lightest, high opalescence with
some degree of translucency. Designed to
emulate young enamel. Age under 20
E2: neutral in colour, less opalescence with
intermediate translucency. Designed to
replace adult enamel. Age 20-60
E3: tinge of yellow, high translucency & is
suitable for aged enamel. Age 60 plus
FEATURES OF E1 – E3 SHADES
• Prepolymerized microfilled composite – market
advantage, stronger than a standard microfill.
• Easy to polish to high gloss
• Contains opalescence (bluish glow in natural
light) to match natural enamels, gives life to
restoration
• Superb gloss retention without the “plucking
effect” of large particles
• College student
(about to begin
nursing school)
very unhappy
with her post
orthodontic results
• Discolored teethwhite spots and
yellowed
composites
• Prominent upper
left canine
• Inconsistent
shapes and
papilla
• Worn edges of
teeth
Muscle
tenderness and
sense of not
having a
consistent bite,
prominent
canine, slight
fremitus of #6-11,
and general
tooth wear were
indicative of
occlusal
dysfunction
57
7/21/2016
• Discolored cervical
composites and
generalized “white spots”
were indicative of a
history of decalcification.
The question at her exam
was whether this was still
active.
• A “bioluminescence” test
demonstrated a lower
than optimum pH in the
oral environment. Patient
was put on an aggressive
remineralization program
using Carifree treatment
rinses and tooth pastes/
gels.
Using the Erbium
laser in soft tissue
mode of 2 Watts to
create a better
“gingival frame”
prior to bonding
Surface discolorations
and previous
composites
conservatively
removed with a
flame shaped
diamond maintaining
the outer enamel and
creating room for
forthcoming layer of
Aura.
• Suspicious
decalcifications
checked with
cavity detection
dye
• All remaining
“affected”
enamel
removed with
the Erbium or
new CO2 laser
58
7/21/2016
Set at 27 micron AlO2 and 40 psi
Consepsis(Ultradent)
thoroughly irrigated
over microabraded
areas to disinfect
surface
A universal bonding resin was
placed carefully placed using a
microbrush and thinned with an
Adec warm air dryer
37% phosphoric acid
was placed over the
entire labial surface
with a 30 second
exposure time (since
no dentin was involved)
and thoroughly rinsed
with water for 15
seconds each
Each tooth being treated was
cured for 20 seconds using SDI’s
Radii Plus light with its wide tip.
Aura Enamel (Shade E1) was
thinly applied and sculpted using
Cosmedent’s Titanium IPCT
Instrument placing the gingival
half first blending the
interproximal. After a 40 second
cure, the incisal portion is
adapted to the tooth using the
anatomy of the incisal edge and
adjacent anatomy to guide initial
contouring.
59
7/21/2016
CURING TIMES
Actually 10mm+
Gross finishing is achieved
with a thin 16 bladed ET 9
bur to clean the gingival
margins and establish
labial anatomy.
Interproximal surfaces
were smoothed with
plastic finishing strips
Labial surfaces were
polished using a series of
abrasive disks
Final gloss achieved
using a flexible felt disc
and aluminum oxide
paste
60
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PUTTING IT ALL TOGETHER
MARK YOUR PATH
LASE
IT !
HEAL
IT
63
7/21/2016
VERIFY
64
7/21/2016
CONCLUSIONS
• Smile design and composites are a great entry point for
patients who want smile “makeovers”—use the right tools
(photos; DSD; and bonding materials) to create artistic
success and “good business”
• Utilizing minimally invasive preparation design like lasers; air
abrasion; and bevels will help to preserve tooth structure
and blend composites to look more lifelike
• Properly layering composite resin with color friendly
materials like Aura helps achieve the beautiful and
believable results
Thank
You
ANY QUESTIONS ????
CONTACT
INFORMATION
HUGH FLAX,DDS
(404) 255-9080
Email: [email protected]
For lecture info
on cosmetic dentistry, implants and lasers
http://www.catapultelite.com/flax.php
65