Achieving Superb Results

Transcription

1 Achieving Superb Results With Everyday Bread-n-Butter, Direct and Indirect Procedures Sam J. Halabo D.M.D.

2 Magnification Critical to early diagnosis and to complete dentistry 3.5x and up Headlight Orascoptics, Designs for Vision, Q Optics etc.

3 Indirect Restorations Homogenous- Uniform is Structure or composition throughout = MONOLITHIC Heterogenous- consisting of or involving dissimilar parts = LAMINATED Monolithic Characteristics: Generally more translucent Generally less tooth reduction is required Can be difficult to use for masking dark teeth due to translucency Laminated Characteristics: Generally more reflective Discoloration is masked well Generally more tooth reduction is required Do not require bonding

4 Materials Table Materials Minimal prep Veneers/ Veneers Anterior crown Normal prep Anterior crown Dark prep Anterior crown Short prep Anterior Bridge Posterior full Crown Posterior Bridges Powder & Liquid 80 MPa Feldspathic Porcelain Pressed Ceramic MPa Empress, Authentic Lithium Disilicate 400 MPa E-max Zirconia MPa Bruxzir Zirconia based 80 MPa Lava, Cercon Metal Ceramics 80 MPa PFM crowns x x x x x x x x

5 1. Wear of Enamel on Polished and Glazed Zirconia: Burgess J., Shah S, Michelson C, Beck P, Ramp LC, Cakir D, 2010; Washington, DC: AADR. Abstract #

6 Statistics 2014: 1.14 million BruxZir restorations, which was up 27% over k IPS e.max restorations, which was up 13% over k PFM restorations, which was down 17% from 2013

7 Ceramic Restorations Indications for all-ceramic restorations: Tooth colored restorations are preferred by patients. **Soft tissue irritations by metal containing restorations -Up to 50% of women may have a reaction to the metals found in dental restorations such as irritation of the gingiva. Thin attached gingiva around teeth. -gingival recession on PFM crowns shows dark or chalky margins Necessity for optimal esthetics -Esthetic excellence is better than PFM (CRA report -July 2012 vol. 5 issue 7)

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9 Shade Taking: Digital VITA Easyshade V Clon 3D Trios (3Shape)

10 Alginot FS (Kerr) No hand mixing. Eliminates mess and cleanup. Saves time and material. Delivery options.cartridge or Volume automix dispensing. Impressions remain stable. You can pour immediately or when it's convenient. Impressions retain dimensional stability for months. Tolerates disinfectants. Alleviates concerns about contaminated impressions.

11 3. Isolation

12 The Preparation Keep it real simple with a minimum number of burs Measure your burs 330 (1.5mm) bur for initial depth cuts & Round-End Taper 855%016(SC Course Grit Diamond (Midwest Once- single use burs) Round%End(Taper(( 855%016(sc Coarse(Grit(Diamond( Midwest(Once%((single( use)

13 Retraction Paste

14 So#$%ssue$lasers$ $Indica%ons$for$use$ Gingival(troughing( Gingivectomy(and(gingivoplasty( Gingival(incision(and(excision( Hemostasis(and(coagula7on( Excisional(and(incisional(biopsies( Exposure(of(unerupted(teeth( Fibroma(removal( Frenectomy(and(frenotomy( Implant(recovery( Incision(and(drainage(of(abscess( Leukoplakia( Operculectomy( Oral(papillectomies( Pulpotomy(as(an(adjunct(to(root( canal(therapy( Reduc7on(of(gingival(hypertrophy( Treatment(of(canker(Sores,(herpe7c( &(aphthous(ulcers(of(the(oral(mucosa( Ves7buloplasty( Sulcular(debridement(and(laser(soH( 7ssue(cureIage( LaserJassisted(whitening/bleaching(of( teeth((picasso'only)(

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16 Benefits'of'Digital'Impressioning' Better Oral Care Patient Experience Productivity It makes me a better dentist! Hi-res magnification of margins, preps and oral anatomy! Improved diagnosis! Custom-designed, precise fitting restorations and appliances! Reduced remakes Our patients love it!! Improved patient comfort! Increased engagement with procedure! Reduced chair and office time! Restorations and appliances that fit! Same-day service Our office is more efficient! Less patient chair time! Standardized processes and procedures! Reduced remakes! Reduced seating times! Same-day dentistry! Lower or eliminate lab bill

17 Function of Temps Patient Feedback/ Acceptance -(Too long, too short, too dark, too light etc.) Allows the dentist to evaluate: -Aesthetics -Function -Phonetics -Parafunctional Habits

18 Temporary Cements

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20 Resin Modified Glass Ionomer (RMGI) Long history of proven bond strength. Sustained fluoride release. Virtually no post-operative sensitivity. Moisture tolerant. Ideal for every day use such as PFMs, zirconia, metal and pediatric crowns. Does not strengthen restorations Very Easy to use

21 Resin Modified Glass Ionomer(RMGI) Cements

22 Everything we create for our patients is done in 3 Dimensions. Why are we looking at them radio graphically in 2 Dimensions?

23 Resin Self-Adhesive Cements Time-saving - no etching**, priming or bonding. Virtually no post-operative sensitivity. Easy removal of excess. Optimal consistency. Strong and moisture-tolerant. Does strengthen restorations moderately Very Easy to use

24 Ceramir Crown & Bridge Bio-Ceramic luting agent - Nano structural integration - Permanent seal of the tooth restoration interface - Bioactivity - Biocompatibility - Creates Apatite when in contact with phosphates - No shrinkage - Hydrofilic system with Alkaline ph - Thermal properties similar to tooth structure

25 Resin with Adhesive Cements High bond strength. Two component system - one or two bottles, one syringe. Total-etch, selective-etch or self-etch. Dual-cure system. High wear resistance and tooth-like fluorescence. Covers entire spectrum of indirect indications. Most retention and strength a restoration can have Can be technique sensitive

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27 Physical Properties

28 To Cement or to Bond?(That is the question) Adhesive vs. Non-Adhesive Cementation E-max and Zirconia are both strong enough to do either. We cement when we can and if conditions are ideal (prep height, isolation etc.) because its easier to clean with less steps and there is less potential for sensitivity. The highest bond strength is achieved using resin adhesive cementation! A lot depends on the preparation. Dual cure cementation of E-max is used to increase esthetics and strengthen the porcelain.

29 The Cementation Tree of Thinking! Tooth Preparation Short Prep or > 10º Taper Average Prep Ideal Prep Isolation Isolation Isolation Good Bad 1. Adhesive Cem 1. S.E. Cem 2. S. E. Cem 2. R.M.G.I. 3. R.M.G.I. 3. Adhesive Cem Good Bad 1A. R.M.G.I. 1. R.M.G.I. 1B. S. E. Cem 2. S.E. Cem. 1C. Adhesive Cem 3. Adhesive Cem Good Bad 1. R.M.G.I. 1. R.M.G.I. 2. S. E. Cem 2. S.E. Cem. 3. Adhesive Cem 3. Adhesive Cem Also Remember To Think of the Area of the Mouth: Anterior vs. Posterior & Dark vs. Normal Colored Tooth ( Shade of Cement)

30 You can say that studies show a 93% success rate for 15 years! 3500 veneers 245 failures: 7% 67% fractures 22%microleakage 11% debonding 25% of debonds and fractures occured in patients with a history of bruxism 1Peumans M. Five year Clinical Performance of Porclain Veneers. Quintessence Intl June 1998; vol 29 #4 2Walls A.W.g. et al. The use of Adhesively retained all peocelain veneers during the management offractured and worn teeth. Part II clinical results after five-year follow-up. British Dental Jurnal 1995; 17: Friedman M.J> 15 year review of porcelain veneer failure: a clinicians observation. Compendium June 1998; Vol 19 #6.

31 Growth'of'Composite'Procedures' Composites& 9.5%& 48.2%& Prophylaxis& 14.4%& 36.3%& Implants& 20.3%& 33.6%& Crown/Bridge& 24.2%& 33.5%& ExtracDons& 9.9%& 33.3%& Increasing& Root&Canals& 18.9%& 22.6%& Decreasing& Dentures& 18.6%& 19.6%& Bleaching& 17.4%& 32.1%& Veneers& 13.9%& 34.4%& Amalgam& 12.8%& 16.9%& *Source:&Strategic&Dental&MarkeDng&report.&& Den5sts'are'spending'more'of'their'day'comple5ng'composites,'which'produce'lower'revenue' than'some'of'the'declining'procedures.'

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34 So what do dentists want out of a composite restoration? Rapid procedure Marginal integrity Depth of Cure less sensitivity Mechanical properties Single increment High Bond Strength Esthetic Simplified shades No Staining High Radiopacity Less technique sensitive

35 Longevity Study Opdam NJ et al. A retrospective clinical study on longevity of Posterior composite and amalgam restorations. Dent Materials 2007 Jan; 23(1):2-8 5 Year Survival 10 year Survival Composite 91.7% 82.2% Amalgam 89.6% 79.2% 912 Amalgams 1955 Posterior Composites Placed over a five year period in general practice

36 Bioactive Restoratives The new generation of materials that include Theracal LC (Bisco), Biodentine (Septodont) and Pro Root (Tulsa/Dentsply) are modern, more effective delivery systems for calcium hydroxide. Activa by pulpdent is a glass ionomer and composite. Riva Bond LC utilizes SDI s proprietary ionglass filler, a radiopaque, high ion releasing, bioactive glass. It releases very high fluoride levels to assist with demineralization of the natural dentition and has bacteriostatic properties that protect teeth from decay. Shofu Giomer technology with fluoride release/recharge similar to G.I. and ability of acid neutralization & Ion release

37 Simplistic & Cost Effective

38 Bonding(Agents(Comparison( Etch%&%Rinse% Self% Etch Universal% #"of"bottles" "or"2 #"Steps" 3 2 1"or"2 1 Varies" #"Layers"of"bond"" 2 1 1"or"2 1 1 Enamel"etch" required?" Notes" Yes" Yes Yes" Yes" Yes"for"all"except" OptiBond"XTR" 21%"market" Direct"Only"" Tried"and"True" " 36%""market"" Direct"and"Indirect"" 15%$$market$$ KMix"primer"and" adhesive,"apply"" OR"" KApply"primer,"then" apply"adhesive" separately" 18%"market"" More"limited"than"the" Universal"systems"" 21%"market"" Total"Etch"" SelfKEtch"" Selective"Etch"" Examples" OptiBond"FL"" Adper"Scotchbond" OptiBond"Solo"Plus"" Adper"Easy"Bond"" Clearfil"SE"" Futurabond"DC" Adper"Prompt"L"Pop"" OptiBond"AIO"" GKBond"" Brush"&"Bond"" OptiBond"XTR"" AllKBond"Universal" Futurabond"" Scotchbond"Universal"" Prime"&"Bond"Elect""

39 All-Bond Universal Flexibility of Technique: total-etch, self-etch or selective-etch procedures Used for both direct and indirect restorations High bond strengths to all indirect substrates, including metal, glass ceramics, zirconia, alumina, porcelain (silica-based),and lithium disilicate. Designed to be fully compatible with light-cured, self-cured and dual-cured composite and luting cements. No refrigeration needed. 24 month shelf life.

40 OptiBond XTR Outstanding bond strengths to dentin and enamel. Extraordinary performance for long-lasting restorations, enhanced marginal integrity, and reduced microleakage. Self-etch adhesive. Minimizes post-operative sensitivity, maximizes patient comfort. Direct and indirect restorations. A true universal dental adhesive eliminates the need for multiple bonding agents. Proven OptiBond Technology. Dependable clinical performance and reliability.

41 Bulk Fill Composites µ

42 Bulk Fill Composites Potential Advantages & Disadvantages Advantages: Fewer voids may be present since all placed at one time Faster and easier technique with less steps No 2mm capping needed when using Bulk Restoratives Potential Disadvantages: More voids due to difficulty in controlling mass placement Challenging to create inner proximal contact in some areas Shrinkage stress due to volume placement Incomplete polymerization!

43 SonicFill (2 Similar(to(SonicFill( Adaptation( Depth(of(Cure( Shrinkage(Stress( Improved(in(these(areas:( Polishability( Overall(esthetics( Durability( Working(Time

44 A%Laboratory%Evalua.on%of%BulkAFill%Versus%Tradi.onal%Mul.AIncrementAFill%% ResinABased%Composites %%A%Tiba,%PhD;%G%Zeller,%DDS,%MS;%et.al% ADA%Professional%Product%Review% % % % % % % % %%%%%%%%%%%%%%%%%%%%October%2013% Figure'2.'Mean%Polymeriza.on%Shrinkage%Stress%(Mpa)%

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46 Clinical Research and Performance Bulk Fill Literature and Shrinkage 1) Does Incremental Filling Technique Reduce Polymerization Shrinkage Stresses? Versluis A, et.al., J Dent Res March 1996; 75(3): ) An In Vitro Study of the Effect of Restorative Technique on Marginal Leakage in Posterior Composites Neiva IF, et.al.; Oper Dent 1998, 23: ) Microleakage and adaptation of Class II packable resin-based composites using incremental or bulk filling techniques Gallo JR, et.al., Am J Dent 2000; 13: ) Microleakage of Posterior Packable Resin Composites with and without flowable linersleevailoj C, et.al., Oper Dent 2001; 26: ) Marginal adaptation of Class II resin composite restorations using incremental and bulk placement techniques: and ESEM study Idriss S, et.al., J Oral Rehab 2003; 30: ) A reappraisal of the incremental packing technique for light cured composite resinsrees JS, et.al., J Oral Rehab 2004; 31: ) Cuspal deflection and depth of cure in resin-based composite restorations filled by using bulk, incremental and transtooth-illumination techniques Campodonico, et.al., JADA 2011; 142(10):

47 Matrix Systems Triodent Matrix Garrison Dental Composi-Tight 3D Dentsply Palodent Plus Many other type of matrices

48 Theracal LC Resin-Modified Calcium Silicate Pulp Protectant/Liner Seals & Protects the Pulp: For Direct & Indirect Pulp Capping Light-curable, Radiopaque Liner based on improved MTA-technology. Significant Calcium Release: Stimulates Hydroxy Apatite & Dentin Bridge Formation.

49 Beautifil Flow Plus

50 Beautifil II Nano-Hybrid Composite with Fluoride Release & Recharge -Physical Properties Durable material Radiopacity -Handling Non-Sticky/No Slump Flip-top Cap -Aesthetics Light Diffuse Shade Stability -GIOMER Material Fluoride/Ion Release/Recharge Anti-Plaque 8 year/13 year study

51 JADA 8-Year Study University of Florida No Post-op Sensitivity No Secondary Caries No Failures Retained Luster Maintained Anatomical Form 13-year Study In Progress!

52 Curing&Uniformity:&&Uniformity+of+Beam& Beam&Uniformity&Comparison:&4mm&Core&vs.&Perimeter& Demi&Ultra& VALO& Bluephase&20i& Bluephase&Style& Elipar&S10& 96.5%& 87%& 81%& 69%& 63%& Uniformity&as&measured&by&the&average&perimeter&irradiance&as&a&percentage&of&the&4mm&diameter&core&average& irradiance.&&beams&not&to&scale.&&source:&georgia&health&sciences&university,&rueggeberg&fa,&may&2013&

53 Avoiding Failure 1.C-Factor = Ratio of bonded to unbonded surfaces -Use adhesives that fight polymerization shrinkage and composites with low polymerization shrinkage to minimizes C-Factor

54 Avoiding Failure III. Bonding & Sensitivity -Avoid very large restorations (indirect restoration?) -Avoid deep gingival preparations

55 Statistics show... Work-Learning Research by Will Thalheimer PhD. in 2002, 2006, and 2014.