SMART PRACTICES FOR YOUR PRACTICE 10/2/2018. Todd Snyder, DDS, FAACD, FIADFE, ASDA. Smart Practices for your Practice

Transcription

1 Smart Practices for your Practice The individual practice of dentistry is in transition now more than ever. Delivering exceptional care requires our entire team to share the same philosophy and commitment to individual dental care, procedures, and techniques, obtaining more new patients and improving one s revenue. This abbreviated program discusses modern procedures, materials and technologies that help navigate these changing times so that you can offer better dentistry and increase your treatment opportunities. Modern diagnostic devices and materials to restore teeth with minimal to no intervention along with current concepts in composites and adhesives will be presented. It will also highlight how to handle indirect cementation and the use of zirconia restorations. Topics to Include: new diagnostic devices direct restorative materials and techniques tips on avoiding complications and post-operative discomfort zirconia restoration cementation & complications with adhesion SMART PRACTICES FOR YOUR PRACTICE Todd Snyder, DDS, FAACD, FIADFE, ASDA 1

2 What are we seeing? Are we looking superficially or deep as to cause, problem and solutions? You can t expect to see change if you never do anything differently. MEG BIRAM 2

3 My Mission To make you think differently on your next case. How good is your diagnosis? Are you still diagnosing with this?? 50% accurate Adrian Lussi paper in Caries Research demonstrated that an explorer only detected caries in 14% of teeth that actually had decay histologically (Low sensitivity) 3

4 Pathology Driven Diagnostics PATHOLOGY DRIVEN DIAGNOSTICS 4

5 RADIOGRAPHIC ANALYSIS Since

6 TIP PORTABLE LIGHT WEIGHT INEXPENSIVE RUGGED HOW MANY X-RAY UNITS DO YOU HAVE AND NEED? TRADITIONAL FILM PACKET 6

7 DIAGNOSE 67% accuracy Approximately 25% demineralization must occur to see a cavity on a Is it thru conventional radiographic analysis? conventional radiograph. Equates to 40-60% demineralization on the tooth Digital surface. radiographs Radiographs provide miss the 70-80% ability of to occlusal manipulate cavities. image size and appearance. 7

8 8

9 9

10 DRIVES 10

11 How do you diagnose decay?? Thru intraoral photographic interpretation? 11

12 FLUORESCENT TECHNOLOGIES What fluoresces in fluorescent-based technologies? Bacterial porphyrins (bacterial breakdown product), Stain, Tartar, Food debris All fluoresce under the wavelengths used in most caries detection devices, whether or not caries is present. Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E. Performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 1999;33(4), Lussi A, Hibst R, Paulus R. DIAGNOdent: an optical method for caries detection. J Dent Res 2004;83C, C Verdonschot E H, van der Veen M H. Lasers in dentistry 2. Diagnosis of dental caries with lasers. Ned Tijdschr Tandheelkd 2002;109(4), Konig K, Flemming G, Hibst R. Laser-induced autofluorescence spectroscopy of dental caries. Cell Mol Biol (Noisy-le-grand) 1998;44(8), Alwas-Danowska HM, Plasschaert AJ, Suliborski S, Verdonschot EH. Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis. J Dent 2002;30(4): Rechmann P, Rechmann BM, Featherstone JD. Caries detection using light-based diagnostic tools. Compend Contin Educ Dent. 2012;33(8):582-4, 586, ; quiz 594, 596. CariVu Fiber Optic Transillumination TIP 12

13 CariVu: Transillumination Near Infrared light no radiation Enamel appears transparent or light Porous lesions appear darker by trapping and absorbing the light: these include cracks and caries Video capture.live scans Stored in Dexis, excellent for communication to patient and yes to insurance companies 13

14 14

15 Utilizing CariVu With proximal surfaces, one can identify where the lesions are buccally and lingually Utilizing CariVu For identifying cracks, and to a certain level, the severity of the cracks 15

16 Utilizing CariVu Allows superior interproximal decision making regarding Watching, Follow-up, Infiltrating, Drilling 16

17 17

18 BITEWINGS VERSUS CARIVU 18

19 19

20 20

21 21

22 22

23 23

24 24

25 25

26 26

27 27

28 EASILY DIAGNOSING 5X MORE DECAY 28

29 29

30 30

31 31

32 32

33 33

34 TIP 34

35 Minimally Invasive Burs 0710C 1300F 0512C 0116C FREE DISPOSABLE SINGLE USE DIAMONDS 35

36 Free Pack of NEODiamonds Offer not valid for previous purchases or in conjunction with any other offer. 36

37 37

38 38

39 39

40 Huge Marketing Opportunity Non Ionizing Diagnostic Tools Minimally Invasive Dentistry Longer Lasting Restorations Community Educational Programs Internet and Local Media Advertising 40

41 4th 6th 5th 7th 41

42 Courtesy Pacific University (Dr Marc Guisberger) Courtesy Pacific University (Dr Marc Guisberger) 42

43 INSTRON Ultra Tester (Ultradent) Ultra Jig (Ultadent) Courtesy Pacific University (Dr Marc Guisberger) SHEAR BOND TEST RESULTS Average Shear Bond Strength to Dentin: 24.2 MPa 43

44 Courtesy Pacific University (Dr Marc Guisberger) SHEAR BOND TEST RESULTS Maximum/Minimum Shear Bond Strength per Bonding Material DRAWBACKS OF ANY COMPOSITE RESIN Material placement techniques Variable substrate Polymerization stress & shrinkage Water absorption Hydrophobic bonding agents Decreased adhesive bond strength over time MMPs and Cathepsins Microleakage 44

45 DECREASED BOND STRENGTHS DUE TO: Substrate Preparation technique Bur selection Hand piece oils Bonding agent Curing device and position Material selection Layering technique Direct Composite Restorations 45

46 What substrate are we treating? :Composite Preparation Class I or II 3x Tubule Density Equals Higher Fluid & Increased Difficulty for Bonding 30% Decrease in Bond Strengths with most bonding systems. Adhesive dentistry could be expressed as a simple relationship between bonds and stress. If the bonds can withstand the stress, the restorative technique will be successful. Unterbrink and Liebenberg (1999) 46

47 C-FACTOR DEFINITION Configuration Factor: The ratio of bonded to un-bonded (free) surfaces Feilzer, DeGee, Davidson (1987), Universtiy of Amsterdam, ACTA Lowest Stress Low Stress Medium Stress High Stress Highest Stress 47

48 C-FACTOR DEFINITION What are you placing Where in the tooth How are you utilizing it? Enamel Superficial Dentin Middle Dentin Deep Dentin Sclerotic Dentin Infected Dentin Affected Dentin MDP BASED BONDING AGENT AND..X? C-FACTOR Base/ Lining Excellent Flow & Handling 48

49 FLOWABLE COMPOSITE SHRINKAGE (2MM BULK FILL W/ 71%/WT FLOWABLE ON DENTIN ONLY) Tokyo Medical & Dental University, 2010 J. Tagami et al RESIN TO DENTIN HYBRID ZONE 49

50 Access to the curing site = Energy to the resin These CRA research results agree with Dr. Tagami s results on SonicFill. Tagami stated SonicFill cures to only 70% on bottom at 4 or 5mm depth of cure. 50

51 CRA questions the ability for most practitioners to place bulkfill materials properly in addition to getting adequate curing. Curing bulk fills remains a question Test your light output and practice with your materials Internal (Polymerization) Stresses of Composites A Simple Pain-Free Adhesive Restorative System by Minimal Reduction & Total-Etching (1993) Takao Fusayma DDS, Tokyo Medical & Dental University 51

52 SELF CURE BULKFILL. Danville-BulkEZ Coltene-Fill-Up! Pulpdent-Activa Restoration Placement? Cement Selection Cemented Margin placement Moisture Tolerant Retention Required Materials RMGI Ceramir Bonded Margin placement Moisture Control Technique Sensitive Materials Self Adhesives Bonding agent (TE or SE) & luting resin 52

53 Cement Selection Traditional Cementation Options Glass Ionomers Resin Modified Glass Ionomers Acidic ph Moisture Tolerant Fluoride Release Degrades over time Low bond strength Biocompatibility-Fair Bioactivity-None Sealing Quality-Ok Acidic ph Insoluble Moisture Tolerant Fluoride Release Stronger Than Traditional GIs Degrades over time Improved bond strength Biocompatibility Ok Bioactivity-None Sealing Quality-Ok Silanate Restorations 53

54 Cement Selection Resin Cementation Options SE Resins Acidic ph Not Moisture Tolerant Degrades over time Low bond strength Biocompatibility-Fair Bioactivity-None Sealing Quality-Fair Silanate Restorations Bonding Agent & Resin Luting Acidic ph Not Moisture Tolerant Stronger Than Traditional GIs Degrades over time Improved bond strength Biocompatibility Ok Bioactivity-None Sealing Quality-Good Silanate Restorations SE Resin Cements Calibra Universal (Dentsply) MaxCem Elite (Kerr) RelyX UniCem 2 (3M) 54

55 All Ceramic Crown Microleakage MDP Resin Cement SE Auto Resins After simulated aging through cyclic loading (1.2 million) and dye penetration test to detect Microleakage. LSU Dental School. IADR 2006, Abstract #2090. CERAMIC PRIMER Feldspathic Leucite Lithium Disilicate Lithium Silicate Zirconia 55

56 THE NO-WATER SILANE INSTANT ACTIVATION LESS DEGRADATION (More Stable 2 Year Shelf-Life) BONDS WITH OR WITHOUT HF ACID ETCHING Lithium Disilicate & Silicate, Leucite and Feldspathic restorations 56

57 G-CEM LINKFORCE (GC AMERICA) 57

58 Zirconia Try-in Questions??? The lab should have sandblasted the restoration at 30-50psi w/ 50 micron aluminum oxide. After try-in: Ivoclean and silanate? Ultrasonic with ethanol after try-in or steam clean then silanate? Sand blast then ultrasonic and ethanol? Zirconia silanate prior to try-in (Ultrasonic with ethanol after try-in) Sandblast after try-in and use a MDP based cement 58

59 What do you use? 59

60 Zirconia Ceramic Conditioning MDP-containing material bonds to Zirconia 60

61 (RFA-DE ) Tooth-colored resin restorations have an average replacement time of 5.7 years due to secondary caries precipitated by bond failure. 61

62 Factors that compromise bond durability in restorative dentistry We challenged that current dentin adhesive designs that incorporate increasing concentrations of hydrophilic monomers are going in the wrong direction Water sorption Polymer swelling Decline in mechanical properties Leaching of hydrolyzed resin components Factors that compromise bond durability in restorative dentistry BOND LOCATION & DEGRADATION Pashley DH, Tay FR, Imazato S. How to increase the durability of resin-dentin bonds. Compend Contin Educ Dent Sep;32(7):60-4, 66. Resin-dentin bonds are not as durable as was previously thought. Microtensile bond strengths often fall 30% to 40% in 6 to 12 months. 3x Tubule Density Equals Higher Fluid & Increased Difficulty for Bonding %30 Degrease in Bond Strengths with most bonding systems. 62

63 Factors that compromise bond durability in restorative dentistry Demineralizing dentin is like opening the Pandora s box, releasing endogenous enzymes (Matrix Metalloproteinases - MMPs) that were trapped within the mineralized dentin matrix. Sukala et al. (2007) Mazzoni et al. (2007) MMP-8 MMP-2 MMP-9 In the presence of water (such as that derived from water sorption or from adhesives, MMPs (2,8 & 9) can breakdown collagen fibrils that are not protected by intrafibrillar minerals Factors that compromise bond durability in restorative dentistry Instability of hybrid layers problem may be more severe than we realize Intact hybrid layers created by a simplified etch-andrinse adhesive in caries-affected primary dentin partially disappeared after 6 months of intraoral function 63

64 TRADITIONAL GLASS IONOMER CEMENTATION OPTIONS Cementation 64

65 Cementation Resin Modified Glass Ionomer Cements Use Ceramic Primer prior to try-in Clean with ethanol after try-in Keep tooth slightly moist and place RMGI cement as it will chemically cure to the tooth and the Ceramic Primer Still want to always have good prep design 65

66 Resin Modified Glass Ionomer Cement and a Ceramic Primer Lab 30psi w/ 50 micron aluminum-oxide particles G-Multi Primer (MDP) prior to tryin Ultrasonic clean with ethanol Place FujiCEM2 RMGI cement in restoration 66

67 Alkaline ph 8.5 Moisture Tolerant Self Sealing Apatite Formation Insoluble/No Degradation Stronger with time Semi / Translucent Biocompatibility-Excellent Bioactivity-Apatite formation No silane, conditioning, bonding CERAMIR CROWN & BRIDGE 67

68 Bioactivity by Doxa Cement Selection A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline ph.** CEMENTATION TECHNIQUE Mix for 8-10 seconds 3-4 restorations 68

69 CEMENTATION TECHNIQUE LITHIUM DISILLICATE (EMAX) OR ZIRCONIA Silane is contraindicated Tooth etching or conditioning is not necessary Bonding agent is not needed 69

70 CROWN RETENTION Results Zirconia crowns (Kg/F) Ceramir Crown & Bridge RelyX Unicem (3M) Dyract Cem (Dentsply) Rely X Luting (3M) Material Result (Zirconia crowns) Kg/F Ceramir Crown & Bridge 32.1 ± 6.3 RelyX Unicem (3M) 27.8 ± 11.3 Dyract Cem (Dentsply) 12.2 ± 3.1 Rely X Luting (3M) 10.9 ± 6.5 Cement Selection 70

71 71

72 Journal of Esthetic & Restorative Dentistry March 2015 Cement Selection 72

73 Technique Simplify Cementation Silane/Ceramic Primers are contraindicated Tooth etching or conditioning is not necessary Bonding agent is not needed Research/Literature* Moisture Tolerant No Sensitivity Alkaline ph Apatite Forming Insoluble Stronger With Time Self Sealing TODD SNYDER (949)