working with your assistant

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1 FOR THE EXCEPTIONAL DENTAL OFFICE ~ A TEAM APPROACH~ SAM SIMOS, DDS CMESMILE50@GMAIL.COM I WOULD BE HAPPY TO LECTURE HANDOUT OR LECTURE INFORMATION OR ANSWER ANY QUESTIONS Dr Sam Simos I do what you, do everyday 27 year career & counting! Have worked with master dentists from around the world Adopted techniques/materials that I can use in almost any clinical situation to solve any problem or desire a patient may have. Worked in Crown & Bridge lab in college Master Ceramist mentor 3 key concepts; 1. Master the handling characteristics of the material you are working with 2. Have a complete understanding of the technique you will employ 3. Visualize the result before you begin INTRO WHAT THEY DIDN T TEACH ME HOW TO BUILD A TEAM HOW TO WORK WITH AN ASSISTANT HOW TO BE EFFICIENT HOW TO BUILD A CULTURE I CAN T FIX EVERYTHING SO LETS WORK ON ONE THING! working with your assistant INTRO AND THE SURVEY SAYS Assistant has worked with me for over 10 years. Assistant has worked with me for over 5 years. Assistant has worked with me 1-5 years Assistant has worked with me for under a year. INTRO AND THE SURVEY SAYS My assistant and I need to get on the same page. My assistant does not bring what she needs for the appointment My assistant could use a little training My assistant could use a lot of training My assistant does such a great job I should give her a raise but she is already making more than me! INTRO AND THE SURVEY SAYS I could communicate with my assistant better I should give my assistant more direction I should try to understand millennials better I should give my assistant more training I should give my assistant a raise GOALS TAKE A FRESH LOOK AT WHAT MATERIALS/TECHNIQUES YOU USE LOOK AT IT FROM YOUR ASSISTANT S POINT OF VIEW ASK THE QUESTION; WHY? WHY DO I USE WHAT I USE? GAIN A BETTER UNDERSTANDING OF MATERIALS & TECHNIQUES AVAILABLE SO YOU CAN USE THEM PROPERLY & IN THE PROPER CLINICAL SITUATION (EFFICIENCY) DELIVER BETTER DENTISTRY TO YOUR PATIENTS Q & A

2 INTRO Adhesives Cements Composites YOUR PARTICIPATION IS APPRECIATED If YOU could get your assistant to do one thing better what would it be? What material or technique could your assistant get better at? What does your assistant do really well? THERE HAS NEVER BEEN A BETTER TIME TO BE A DENTIST THERE HAS NEVER BEEN A MORE CONFUSING TIME TO BE A DENTIST MATERIALS Impression material Zirconia/ LiDi Adhesives Cements Composites Impression material Zirconia/ LiDi TECHNIQUE TECHNOLOGY MATERIALS TEAM Adhesives Cements Composites INTRO GET THE RIGHT PEOPLE ON THE BUS Impression material YOUR PARTICIPATION IS APPRECIATED When it comes to materials, what material(s) would you like YOUR assistant to have more knowledge of? MATERIALS Zirconia/ LiDi Adhesives Cements Impression materials Buildup materials Composites IDEAS

3 Etch primer adhesive Etch primer adhesive Etch primer adhesive GOALS OF ADHESIVES Smear Layer Freshly cut surface of dentin formed by Rotary Instruments 1-5 microns deep ADHESIVE- HISTORICAL SUMMARY Early bonding agents tried to modify or attach to the Smear Layer 4th & 5th Generation Bonding Agents (total etch) attempt the removal of the Smear Layer Biologic Band-aid Limits Bond Strength Is partly porous, but dramatically reduce fluid flow from underlying dentin tubules Current Bonding Agents (self-etch) incorporate the Smear Layer into the Bond GOALS OF ADHESIVES Bonding agent penetrates the space or vacancies to fill the tubular and peritubular dentin Hybridization layer relies on moisture This replacement of Collagen + Bonding Agent creates a protective barrier from bacteria and post-op sensitivity HOW DO YOU CHOOSE YOUR BONDING AGENT? PROBLEMS ASSOCIATED W/ADHESIVES; Sensitivity Dual cure/self cure resin cements/build up mat. inhibited by some adhesives Thickness of adhesives Enzymatic breakdown of collagen layer from acid etch Poor enamel/dentin etch w/ self etch adhesives CATEGORIES OF BONDING AGENTS Total etch Self etch # of components Etchant Primer Adhesive Generation Adhesive brands 4th OptiBond FL Scotchbond Tenure All Bond TE (3) A HISTORICAL LOOK 5th Optibond Solo Plus Prime & Bond NT Scotchbond I Clearfil SE All bond Plus Xeno III Adper 6 th Scotchbond SE L-Pop Brush & Bond 7 th Prime & Bond Elect All-Bond Universal Scotchbond Universal Futurabond U G-aenial Bond 8 TH Xeno IV DC Adper Easy One Clearfil S3 Bond Plus Futura bond DC Optibond All in one CATEGORIES OF BONDING AGENTS Total etch Self etch # of components TOTAL ETCH 3-COMPONENTS (4TH GENERATION) CATEGORIES OF BONDING AGENTS Total etch Self etch # of components Etchant Etchant Primer Primer Adhesive Adhesive Generation 4th 5th 6 th 7 th Generation 4th 5th 6 th 7 th Adhesive brands Optibond Solo Plus OptiBond FL Prime & Bond NT Scotchbond Tenure Single Bond All Bond TE (ACE) All Bond TE (3) XP BOND Optibond XTR OptiBond All-In-One Xeno IV Clearfil SE Bond Single Bond IBOND All Bond SE All Bond SE (ACE) Prime & Bond Elect Adhesive brands Optibond Solo Plus OptiBond FL Prime & Bond NT Scotchbond Tenure Single Bond All Bond TE (ACE) All Bond TE (3) XP BOND Optibond XTR OptiBond All-In-One Xeno IV Clearfil SE Bond Single Bond IBOND All Bond SE All Bond SE (ACE) Prime & Bond Elect

4 Etch primer adhesive Etch primer adhesive Etch primer adhesive Swift E, et al, J Esthet Restor Dent Dec;23(6): doi: /j x. Epub 2011 Oct 17. Etch primer adhesive TOTAL ETCH 2-COMPONENTS (5TH GENERATION) CATEGORIES OF BONDING AGENTS Total etch Self etch # of components SELF ETCH 2-COMPONENTS (6TH GENERATION) Etchant Primer Adhesive Generation 4th 5th 6 th 7 th Adhesive brands Optibond Solo Plus OptiBond FL Prime & Bond NT Scotchbond Tenure Single Bond All Bond TE (ACE) All Bond TE (3) XP BOND Optibond XTR OptiBond All-In-One Xeno IV Clearfil SE Bond Single Bond IBOND All Bond SE All Bond SE (ACE) Prime & Bond Elect CATEGORIES OF BONDING AGENTS Total etch Self etch SELF ETCH 1-COMPONENT (7TH GENERATION) A HISTORICAL LOOK CATEGORIES OF BONDING AGENTS Total etch Self etch # of components # of components 1- BOTTLE SELF ETCH Etchant Etchant DIFFERENCE; UTILIZES A DIFFERENT Primer Adhesive Primer Adhesive MONOMER THAN HEMA. UTILIZES 10- MDP AS 1 MONOMER & CAN BE USED FOR ZIRCONIA OR METALS AS A PRIMER Generation 4th 5th 6 th 7 th Generation 4th 5th 6 th 7 th 8TH GEN Adhesive brands Optibond Solo Plus OptiBond FL Prime & Bond NT Scotchbond Single Bond Tenure All Bond TE (ACE) All Bond TE (3) XP BOND Optibond XTR OptiBond All-In-One Clearfil SE Bond Xeno IV Single Bond IBOND All Bond SE All Bond SE (ACE) Prime & Bond Elect Adhesive brands Optibond Solo Plus OptiBond FL Prime & Bond NT Scotchbond Tenure Single Bond All Bond TE (ACE) All Bond TE (3) XP BOND Optibond XTR OptiBond All-In-One Xeno IV Clearfil SE Bond Single Bond IBOND All Bond SE All Bond SE (ACE) Prime & Bond Elect A HISTORICAL LOOK CATEGORIES OF BONDING AGENTS Total etch Self etch Limitations OF BONDING AGENTS Limitations Are Present in All Bonding Agents Phosphoric Acid 50,000X Limitation: Reduced Enamel Etch and Adhesion of Self-Etch 6 th generation, 50,000X 7th generation, 50,000X # of components Reduced Enamel Etch/Adhesion Bond Incompatibilities Post-Op Sensitivity Excessive Film Thickness Etchant 4th Gen Primer 5th Gen 6th Gen Adhesive Generation Adhesive brands 4th 5th Optibond Solo Plus OptiBond FL Scotchbond Prime & Bond NT Scotchbond I Tenure Clearfil SE All Bond TE (3) All bond Plus 6 th 7 th 8 TH Xeno III Prime & Bond Elect Xeno IV DC Adper All-Bond Universal Adper Easy One Scotchbond SE Scotchbond Universal Clearfil S3 Bond Plus L-Pop Futurabond U Futura bond DC Brush & Bond G-aenial Bond Optibond All in one 7th Gen Self-Etch (6th/7th Gen) bonding agents are Mildly acidic Lower etch quality Lower enamel bond strength Require enamel etching

5 SURFACE CARE & ETCH TIMES UNDERSTANDING ETCHING TIMES Limitation: Bond Incompatibilities of 1- Bottle Systems Dentin 3-5 sec U C Un-ground Enamel sec Sclerotic or Hyper-mineralized sec. Self/Dual-cured Resin Cement/Core Material PFM /PFZ Metal Crowns Opaque Restorations Bulk-Fill Composite Core Material D uncured Acidic Monomers Selective Total Self Solution Cut/Ground Enamel sec Suh, Johnston, Barkmeier, Goes Solution Acidic Acid/Base Reaction and Phase Separation Single Bottle Adhesive System 5th Generation Total-etch Adhesive 7th Generation Self-etch Adhesive Solution Self/Dual cure Resin Cement/Core material Know your adhesive Need additive for Dark/Dual cure? Ensure the Adhesive is compatible with the Resin coat foil w/ adhesive Incompatible Solution Compatible ADA PROFESSIONAL PRODUCT REVIEW Compatibility Adhesive compatibility with the core material or the dual-cure or self cure resin cement is the main issue. Although some manufacturers have better adhesives to match with their core material or cement than what they package with the product or recommend Sometimes their recommendations don t quite match even in their own product line. ADA PPR; Vol. 5, Issue 2; Spring 2010 Limitation: Post-operative Sensitivity of Total-Etch (4th &5th) Collagen fibers collapsed Open space and between space between collagen collagen fibers maintained fibers closed by water UNDERSTANDING ETCHING TIMES Dentin 3-5 sec D U C Un-ground Enamel sec Sclerotic or Hyper-mineralized sec. CONSIDER CORRECT SURFACE MOISTURE WET DRY Hot/Cold stimulus Cut/Ground Enamel sec Suh, Johnston, Barkmeier, Goes Solution Solution MOIST

6 Non-radiopaque adhesive layer SEM magnified of ClearFil SE Bond at 2,000X Limitation: - Excessive Film Thickness of Adhesive Layer (4th & 6th) >35µm Root cause It is the high viscosity Due to lack of solvent Higher filler loading What are some issues? Limited indirect use Pooling Caries misdiagnosis Solution BLOW OFF ADHESIVE NO PUDDLING Limitation: - MMPs - Enzymes activated by acid which consume the collagen layer (ALL) T/E Effective Hybridization Adhesive Resin Diffusion PROBLEM Weaken Bond Sensitivity Debond Bond failure Limitation: - MMPs - Enzymes activated by acid which consume the collagen layer (ALL) Brackett et al., (2009) Operative Dentistry; 34(4): (BISCO) (BISCO) New Research! Immediate (MPa) 14 mo (MPa) Control 29.3 (9.2) Control 19.0 (5.2) CHX 32.7 (7.6) CHX 32.2 (7.2) Carrilho et al., JDR 2007; 86; 529 Benzalkonium Chloride BAC infused etch Solution Consepsis (Ultradent) Wash dentin with BAC or CHX 2% CHX ADHESIVES WHAT INFO ARE YOU GOING TO TAKE BACK TO YOUR ASSISTANT?

7 CURING LIGHTS YOUR PARTICIPATION IS APPRECIATED Beyond pushing the button to turn it on: Does your assistant Understand Curing Lights? Besides looking at the pretty blue light: Do You Understand Curing lights? THE FATHER OF LIGHT CURING DR. RICHARD PRICE ALL CURING LIGHTS HAVE A BLUE LIGHT ALL CURING LIGHTS ARE NOT CREATED EQUAL MISCONCEPTIONS OF LIGHT CURING When elaborate case studies are written with multistep techniques for material manipulation and placement there are usually only 5 words that describe the most critical phase of the technique And then you light cure When lights are use incorrectly or poor quality lights are used ~ Poor results are obtained~ Under cured resin DOES NOT DELIVER the manufactures intended results Under cured Adhesives/hybrid layers DO NOT DELIVER the manufacturers intended results Bond Strengths are reduced or not existent No Manufacturer recommends under curing PHOTOS COURTESY OF DR. RICHARD PRICE DENTIST CAN ONLY SEE THE TOP OF THE BERG What you need to know about your light Power/Energy Spectral Emission Irradiance/ Effectiveness Tip Size **All of the above curing light attributes are related to each other Power/Energy Spectral Emission Irradiance/ Effectiveness Tip Size

8 ENERGY HOW POWERFUL? MANAGING TODAY S DENTISTRY HOW MUCH ENERGY IS REQUIRED TO ADEQUATELY CURE THE RESIN? 16 joules energy= Light energy needs to be strong enough to create free radicals, which are molecules with an unpaired valence electron Leads to a chain reaction binding many carbon chain (monomers) to form long interconnecting chains of molecules called polymers If light energy not strong enough some monomers won t join polymer system and will leach out, form soft spots, low retention, discoloration and weakness of restoration. Chapter J/cm mw/cm light 2 energy composite 2mm 40 seconds 66 DEBRIS ON LIGHT TIP HAS A HUGE EFFECT ON THE ENERGY DELIVERED EMISSION SPECTRUM FROM CURING LIGHTS Power/Energy Spectral Emission Irradiance/ Effectiveness Tip Size CURING LIGHTS HAVE DIFFERENT SPECTRAL EMISSIONS TETRIC BULK FILL 412 nm SAME POWER DIFFERENT SPECTRAL EMISSION LUCIRIN CQ Low grade COURTESY OF DR. RICHARD PRICE Premium COURTESY OF DR. RICHARD PRICE COURTESY OF DR. RICHARD PRICE

9 IRRADIANCE Power/Energy Spectral Emission Irradiance/ Effectiveness Tip Size EFFECTIVENESS High Irradiance HIGH IRRADIANCE = HIGH POWER COURTESY OF DR. RICHARD PRICE Images courtesy of Richard Price, DDS, MS, PhD Dalhousie University

10 Power/Energy Spectral Emission Irradiance/ Effectiveness Tip Size POWER: WATTS (W) IRRADIANCE = POWER/AREA (mw/cm 2 ) COURTESY OF DR. RICHARD PRICE ZIRCONIA LITHIUM DISILICATE COURTESY OF DR. RICHARD PRICE COURTESY OF DR. RICHARD PRICE Courtesy of Dr. Richard Price D VS I RULE OF POWER I N T E N S I T Y D I S T A N C E Picture of tooth with measurement

11 A High energy LIGHT CAN BE USED IMPROPERLY Stabilization Courtesy of Dr. Richard Price ENERGY; MW/CM 2 RADIOMETER WHAT DO THESE # S TELL YOU? SAME LED MANUFACTURER WHY THE DIFFERENCE? are you testing? are you looking? ENSURE SAFETY IN LIGHT CURING RISK OF RETINAL DAMAGE Photoretinitis Premature aging of the retina Macular Degeneration

12 CURING LIGHTS WHAT INFO ARE YOU GOING TO TAKE BACK TO YOUR ASSISTANT? BETTER DENTISTRY MATRIX SYSTEMS YOUR PARTICIPATION IS APPRECIATED Do Assistants struggle with matrix systems? What if you use more than 1 system? MATRIX SYSTEMS GOALS OF MATRICES Create an anatomically correct interproximal wall Create a contact between the restored tooth and the adjacent tooth Help seal the margin of the proximal box so that there are no resulting composite overhangs Help seal the margin of the proximal box so that moisture is retarded while restoring the tooth. MATRIX SYSTEMS ANATOMICALLY CORRECT INTERPROXIMAL WALL MATRIX SYSTEMS CREATE CONTACT Amalgam & Caries Removed

13 SECTIONAL MATRICES & INSTRUMENTATION MATRIX SYSTEMS PROXIMAL WALL SEAL/MOISTURE CONTROL MATRIX SYSTEM PALODENT PLUS Caries WHAT INFO ARE YOU GOING TO TAKE BACK TO YOUR ASSISTANT? Caries Removed SonicFill Paths to improve the procedure Sonic-Activated, Bulk Fill Composite Bulk Filling MATERIAL Clinical Requirements 1. Adaptation 2. Depth of cure 3. Low shrinkage Traditional layering technique Bulk-fill flowable with universal cap Bulk-fill single viscosity PLUS : maintain critical qualities of posterior composite 1. Compressive strength 2. Wear strength 2012 Trademarks are property of their respective owners

14 SUREFIL SDR DEPTH OF CURE...4 mm (DENTSPLY) Venus Bulk Fill Fusio Bulk Fill In the Spirit of Time Saving Dentin Replacement SONICFILL DEPTH OF CURE...5 mm (KERR)

15 2012 Trademarks are property of their respective owners SonicFill Sonic-Activated, Bulk Fill Composite BULK FILL High Viscosity High Viscosity (Press & Sculpt) WHAT INFO ARE YOU GOING TO TAKE BACK TO YOUR ASSISTANT? Sonic energy Low Viscosity (adapt & fill cavity < 5 seconds) Sonic off SAM SIMOS, DDS CMESMILE50@GMAIL.COM I WOULD BE HAPPY TO LECTURE HANDOUT OR LECTURE INFORMATION OR ANSWER ANY QUESTIONS INTRO YOUR PARTICIPATION IS APPRECIATED COMPOSITES/ POLISH Is your assistant knowledgable about the different composite techniques in your office? Universal microfil Gayle

16 Cloud shades VITA Principles of Filler Technology The smaller the filler -The better the gloss -The lower the total degree of filler lower mechanical toughness impaired handling properties How to overcome these contradictions?! Make large fillers out of smaller ones! Filler technology - overview Ivoclar-Vivadent Pre-polymerized Filler Technologies: Tetric EvoCeram (Ivoclar) Combination of pre-polymerized macrofiller and submicron glass filler Surface after generalized wear (2500x) silanized submicronfiller resin curing resin matrix milling irregularly shaped prepolymerized macro-filler ( µm) resin submicron glass filler Latta MA (2015) Tetric EvoCeram 30 µm

17 Filler Technologies: Filtek Supreme Ultra (3M ESPE) FS combines Nanoclusters with nanofillers Filler Technologies: Filtek Supreme Ultra (3M ESPE) FS combines Nanoclusters with nanofillers. Surface after generalized wear (2500x) 1. spray-drying 1. spray-drying 4. silane 5. resin zirconia- and siliciumdioxide nanoparticles (10-20 nm) 2. calcination 3. milling irregularly shaped Nanocluster (1-20 µm) zirconia- and siliciumdioxide nanoparticles (10-20 nm) 2. calcination 3. milling + nanofiller irregularly shaped resin matrix Nanocluster (1-20 µm) Latta MA (2015) Filtek Supreme Ultra 30 µm Filler technology - overview Filler technology - overview Filler Ivoclar-Vivadent 3M Espe Ivoclar-Vivadent 3M Espe Dentsply Sirona Pre-polymerized spherical granulates Barium glass ( 0.6 µm) granulates ( 15 µm) Pre-polymerized Nanocluster * Pre-polymerized Nanocluster *patent applied Experimental paste comprising SphereTEC-Filler only Filler Blend TPH Spectra ST comprising SphereTEC and submicron glass filler Development objectives 1. Excellent handling 2. Durable restorations 3. Fast and easy polishing 4. Simplified shading 74% complain about handling + 1 Dentsply Sirona Restorative, user survey 2015 (297 dentists in Europe)

18 Polishing composite with large filler particles Polishing The amazing gloss of TPH Spectra ST Composite Primary barium glass particles filler particles Primary barium glass particles After contouring After finishing After polishing Resin matrix Resin matrix Vita Classical Shade Guide The Cloud Shade Concept How can 5 A-shades match 16 Vita shades? A composite with a distinct Chameleon Effect value versus VITA Classic shade tabs restored with Vita Shade Match TPH Spectra ST Universal Composite Restorative Exposure to black light makes the restorations visible! Genuine VITA tab Class III cavity VITA tab filled with TPH Spectra ST Composite Shade A2

19 Danna

20 Prof van der Vyver, South Africa Replacement of several Class II restorations in premolars Class I restoration on a molar Class II restoration Before Post-operative view Before Post-operative view Preparation Post-operative view Dr José Bahillo, Spain Dr. Walter Dias, Germany Class II restoration Anterior restorations Anterior Restorations Preparation Post-operative view Before Before Post-operative view Postoperative view Dr. Walter Dias, Germany Dr. Ian Cline, UK Prof Dr Gabriel Krastl, Germany COMPOSITES/ POLISH DIRECT COMPONENTS Composite Polish Adhesive Bulk Fill Matrix Bulk Fill Flowable with Universal Cap Bulk-fill single viscosity Traditional 2mm layering SAM SIMOS, DDS CMESMILE50@GMAIL.COM I WOULD BE HAPPY TO LECTURE HANDOUT OR LECTURE INFORMATION OR ANSWER ANY QUESTIONS