Todd Snyder, DDS, AAACD Aesthetics &...

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Aesthetics & Occlusion

Todd Snyder, DDS, AAACD

Accredited, American Academy of Cosmetic Dentistry

Fellow, International Academy for Dental Facial Esthetics

Former Faculty, UCLA Center For Esthetic Dentistry

Faculty, Esthetic Professionals

CBDO, Contentactivator.com

CBDO, Blux.com

Todd Snyder, DDS,

AAACDLaguna Niguel, CA

Aesthetic Dental Designs®

[email protected]

Catapult Education 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.

DISCLAIMER

As a Catapult Education 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:

All the work shown is my own and unaltered

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Lecture Handout

www.DENTOOLZ.comDigital Handouts, Products I Use & Special Offers

Digital Handouts

Dental Examinations:

Aesthetics & Occlusion Pathology Driven Diagnostics

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Show patient’s teeth to create desire and start a conversation

about options and eventually financials WHITENING

Immediate Call to Action Motivator

Start Here

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Over-the-Counter Teeth

Whiteners: $1.4 billion

(MSNBC) ...

(Consumer Reports).

THE POWER OF A SMILE

THE CASE FOR DOING MORE

ELECTIVE COSMETIC DENTISTRY

According to the American Academy of Cosmetic Dentistry 50% of patients are

unhappy with their smiles and 3 out of 5 people will invest in their smiles.

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Website

Social Media

Personal Case Books

Office Displays

Referral Cards

Gift Cards

Custom Smocks & Bleach Kits

Invest in technology.

-Office iPad

-Camera

-Lobby Television

-Software

Modern Tools**

Cosmetic Alterations

• How many of you want to buy something sight unseen?

• How many of you want to experience something first before investing?

• Your patients are no different!

• They are concerned about how it will look and feel. They want to be excited and happy!

• Don’t Just Tell…..

Show & Tell!

Overall Feel

Appearance…what is it? who decides, Dentist? Ceramist? Patient? Combined effort?

THEIR DECISION √

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Diagnosis & Treatment Planning

The Key to Success:

VisualizationWhat is the patient’s perception or desired outcome in their mind?

What do they want or envision?

Look at books or imaging together

Bring in examples of smiles

Everyone has an opinion & priorities

How WHITE?

Translucency?

What Texture?

Color Transitions

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Photographic Manipulation

• Cosmetic “Imaging” Software• SmileFy app• PreVue app• SmileVision• DentalGPS• DSD

• Digital Agents• Virtual Smiles• DreamSmiles

Why Does this Work?

•Creates awareness

•Suggests the possibility

•Promotes discussion

•Provides bridge to clinical evaluation and

presentation of options

Digital Smile Mockup

-is a proven practice building program that can:

• Dramatically increase your patient’s interest in a smile

transformation

• Remember, 50% of your patients want to improve their

smile

• Our goal is to help them visualize themselves with an

improved smile

DREAMSmile Is a digital simulation of how your

patient’s smile can be transformed with

your expertise

Is a tool developed to help your team

engage, educate and convert patients to

improve their smile

Provides your office with an opportunity

to easily communicate with your patients

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When you hand a DREAMSmile to your patient, you plant a seed of what is possible, a constant reminder of what their potential new smile can be. They can show it to their friends and family, you can put a copy in their chart for follow-up, have them hang it on their refrigerator...!

Technique Evolution

• Cosmetic Imaging

• Preparation• 0.5mm tooth reduction within enamel• Improved bonding agents allow deeper preps with more durable and longer lasting

bonding• Now >1mm preparations

• Provisionals• No provisionals• Free hand composite provisionals• Very accurate mockups to create provisionals• …or back to no provisionals

• Cosmetic appearance• Enhanced Ceramic Aesthetics and physical properties

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The Key to Success:

Traditional Veneers

Diagnosis & Treatment Planning

The Key to Success:

Traditional Veneers

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You are selling the Emotion…

Do you know the outcome…

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• There never seems to be enough of it…

• It has to be built into the schedule

• Take the time to practice and setup

• Know what the case is going to entail ahead of time

Time What Records & WhenDiagnostic & Prep Reduction Models (Do your own work)

• Practice Preparations

• Waxup

No Prep Veneers• Do a waxup

• Duplicate into a stone model

• Over impression of stone model w/ PVS BEADLINE TECHNIQUE or Siltech Putty

• Intraoral mockup using the over impression filled with temporary acrylic**

• Is thickness and appearance okay?• Depth cuts through over impression if necessary.

• Typically no provisionals are necessary

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Mockup & prep

No Prep Case: 1

• Angulation of teeth

• Spaces

• Lingually positioned

• Lack of lip support

• Thinned enamel

• Fuller smile

• Microdontia

• Chairside Mockup**

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Mockup & prep-Minimally invasive-

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Mockup & prep Mockup & prep

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Mockup & prep

Tooth Preparation Conservative Preparations

Tooth Preparation Determinants of Reduction Depth

• Additive vs subtractive restoration

• Choice of ceramic (feldspathic, leucite, lithium discilicate)

• Fabrication technique (monolithic vs layered)

• Number of shade changes (A4 to A1)

• Significance of brightness changes (C4 to A1)

• Is masking of the tooth required? (increase in restoration opacity)

• The desired translucency expected in the restoration

• Weakest ceramic restoration - feldspathic

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Tooth Preparation Most Conservative Preparations No preparation - Minimal prep veneeri n d i c a t i o n s

• Additive technique is desirable (required for no prep)

• Requires no undercuts in tooth morphology (required for no prep)

• Technician establishes restoration margin location

• Contact lens affect anticipated/desired

• 0-1 color/value shade changes expected

• Skill of technician

• Non uniform ceramic thickness - variable color/value

• Alteration after fabrication is not possible –

• Aging of tooth negatively impacts esthetics

• Weakest ceramic restoration - feldspathic

Tooth Preparation Most Conservative Preparations

No preparation -Minimal prep veneerl i m i t a t i o n s

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Veneer Preparations

• Depth Cuts

• Tooth Reduction

• Margins

• Retention Form (Line of Draw)

Images from Bruce Crispin, DDS, MS book entitled “Contemporary Restorative Dentistry”

Veneer Preparations

• Depth Cuts

• Tooth Reduction

• Margins



Veneer Preparations

• Depth Cuts

• Tooth Reduction

• Margins



Veneer Preparations

Images from Bruce Crispin, DDS, MS book entitled “Contemporary

Restorative Dentistry”

Incisal edge preparations

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Preparation Reduction

• Depth reduction burs• Safe reduction

• Lasco

Depth Cuts

Tooth Reduction

Interproximal & Margins

Retention Form (Line of Draw)

Why extend interproximal and how far?

Independent Depth Cuts (Lasco Burs)

Preparation

Aesthetics

Function

Bonding to Enamel

Material Options

Minimal Prep Case: 2 Minimal Prep Case:

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Wax-up Case: Preparation Guides:

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• Contact lens effect

• At or above gingiva

• Masking tooth or color changes

• At gingiva, then place cord and

reduce another 0.3-0.5 mm

Veneer & Crown Margin Placement

Shade Assumptions

BW, B1, B2, A1, A2

Provisional Techniques

-Free hand

-Beadline Provisionals

-Putty over impression of waxup

-Premade temps?

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EMOTIONFocus on overall appearance

Stay away from little details

“Going to look & feel great”

AestheticsSmile Line

Gingival Excess & AsymmetryCombination Crowns &

VeneersGingival Crown LengtheningFunction

Case: 3Difficulties? Aesthetic

Combination Crowns & VeneersExisting RCT

Function

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Function

Centric du Jour (CRdJ)

Centric occlusion• Shimstock holds

Lateral excursives

Protrusive

Interferences

Wear facets

Prior to Second Appointment

Silginat - Kettenbach

Counter FIT- Multipurpose Replication Silicone

(Clinician’s Choice)

Counter FIT- Multipurpose Replication Silicone

(Clinician’s Choice)

Silginat - KettenbachWear Facets & Interferences

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Mounted and Equilibrated What Records & WhenDiagnostic & Prep Reduction Models

Diagnostic Guides Prior to Second Appointment

Diagnostic Guides Prior to Second Appointment

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Treatment Plan & Diagnosis

Aesthetics

Gingival Harmony

Function

Periodontal Surgery &

ProvisionalsFull coverage off of gingiva

8-12 weeks healing

Preparations & Provisionals2 crowns and 8 veneers

Preparation Guides

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Selection Process

◦ Open Bite Trays

Plastic-full or quadrant

Metal-full or quadrant

Custom Trays

Non-perforated or perforated (metal or plastic)

Rigidity can eliminate tray distortion and rebound

Spring back after impression is possible with plastic

Cross arch stabilization

Ideal occlusal stops for proper model articulation

Able to recreate excursive movements if mounted on a

semi or fully adjustable articulator.

Potential for errors & adjustments are low

Impression Trays

Custom trays create more

ideal placement

Thinner material creates

less distortion

USE TRAY ADHESIVES for

all open bite trays, not just

custom trays.

Only negative is time

Impression Trays Selection Process

Custom Tray

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4 upper & lower trays

60 sec. @ 158°F

Fast, efficient

Virtually custom

30% less impression

material used

Impression Trays

HeatWave by Clinician’s Choice

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Impression Trays


Impression Trays


Dry all teeth in arch

Place tip in most difficult area first

Keep tip on margin and immersed in material

Go around entire margin first

Next go to adjacent teeth

Then do coronal aspect of teeth

Double Mix Single Impression is the most accurate

Syringe Placement

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Facebow / Wax Bite

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Simplified Provisionals**

Siltech Putty Matrix

Bead Line Veneer Provisional Restorations. Pract Proced Aesthet Dent 2009;21(3):E1-E7.

Duplicate waxup model in stone

Scribe a 0.5-1mm line with a sharp instrument into the

model where the tissue and tooth come together.

Provisionals (Bead Line Technique)

Duplicate model with a fast setting polyvinyl impression material.

I have used light and medium body washes with a heavy body tray

material.

Provisionals (Bead Line Technique) Provisionals (Bead Line Technique)

The scribed line creates the Bead Line in the over impression of the cast.

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The Bead Line in the over impression creates pressure along the tissue

and preparation margin. This causes a thin cut or separation of the

acrylic flash from the provisionals for easier clean up.


The Bead Line Provisional Technique creates less work and risk of damaging tissues and tooth

structure. Typically the process takes 5-10 minutes to make provisionals. Consepsis (Ultradent)

can be placed on the teeth and dried prior to fabricating provisionals.


-Visalys (Kettenbach)

-TempSmart (GC America)

-Inspire (Clinician’s Choice)

-ExperTemp (Ultradent)

Provisionals

BPA Free

High Strength

Fluorescence

Low air inhibition layer

Easy trimming & polish

Visalys Temp - Kettenbach

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A dual-cured, bis-acrylic composite temporary crown

and bridge material using micro-filled resin (MFR)

and nano-filler technologies. It maintains a smooth

surface after polishing because of this revolutionary

combination. The high density polymer network for

TEMPSMART makes it a strong material ideal for

any sized provisional.

Fast setting

Low air inhibition layer

Nice Aesthetics

TempSmart – GC America

Cling 2 for all my full crowns & bridges, retentive inlays & onlays.

My Favorite Temporary Cements

ClearTemp LC (Ultradent)

TempBond Clear (Kerr)

For either veneers or thin

anterior cosmetic restorations

RestorationsCheck Shape & Esthetics

Check Shade

Marginal Integrity

Contacts

Etch

Check Shape & Esthetics

Occlusion

Function???

Restorations

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Try-in

Presilanate Restorations before tryin. Preferrably 5-20 minutes ahead of time.

Check each restoration individually for marginal adaptation

Start from center moving laterally

Then start at midline checking two teeth at a time. Then add the third and

check, then the fourth etc.

Then remove all of the restorations and fill each with a water soluble try-in

paste.

Start from center out as though you were cementing. Clean off excess and

access. Gently touch teeth together stop at first contact.

Now let patient check aesthetics after going over instructions

Cementation – large cases

Start from center moving laterally with light curable resin

Light cure material for cases over 4 teeth (2m tacking tip)

Placing two teeth at a time. Then add the third and tack in place, then the fourth etc

Then remove all of the residual cement except a small bead

Cementation Steps

Front two crowns first with dual cured resin or now Doxa Ceramir

Then 4 veneers at a time with a light cured resin.

-Aesthetics

-Function

-Gingival Embrasures

-Excess cement

-Patient homework & questions

Post-Op Check

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From Imaging & Diagnostic Wax-up the entire case was duplicated

Case #4: Aesthetics

Veneers

Function

Gingival Bonding

Remove old restorations & repair abfraction lesions on cervicals

• Stump Shade (dehydration factor)

Base Shade

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Impressions Facebow & Wax Bite Registration

Provisionals Free Hand Provisionals

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Free Hand Provisionals Example

• Materials

• Rigid Bite Registration

• Light and Heavy Body

Prefabricated Over Impression

AESTHETIC RESIN TEMPORARY CEMENTS

• Materials

• Bifix Temp-VOCO

• TempBond Clear-Kerr

• ClearTemp LC-Ultradent

• Provisional Veneer Removal

• Indirectly fabricated

• Spoon on gingival margin

• Cut vertically with small bur and use crown key to gently separate

• Directly fabricated

• Spoon on gingival margin

Veneer Try-In

The Art of Aesthetics & Occlusion

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VENEER EVALUATION

• Check models

• Uncut, pindexed and individual dies

• Check veneers internally and externally

• Try on the models

• Evaluate etch

• Silanate

• Water soluble clear try-in paste

• Evaluation of esthetics and contour

• Evaluate occlusion

VENEER TRY-IN

VENEER BONDING TECHNIQUES

• Etch or Self Etch?

• Antimicrobial

• Bonding Agent

• Light cure

• Time flexibility

• Color

• Dual cure?

• Color stability?

Place cement in center of

veneer

Make sure to see cement

come out on all margins

Wipe away gross excess?

Air inhibition?

Flossing?

Bulk excess

– Bard Parker

– TC Carvers (Brasseller)

– Gold knives

– Perio knives

Interproximal saws

Finishing strips

12 & 30 fluted carbides

Cement Removal

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Post-Op Photos

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INSTANT ORTHO/UN-ROTATING TEETH

• Do initial workup

• Diagnostic preps

• Diagnostic waxup


Sequence

– Reduce all excess tooth structure

– Ideal reduction

– Margin placement

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Case #5:Excessive Prep Interproximal

Reshape teeth

eMax

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Waxup, Reduction Guides &

Temporaries (Case 6)

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Preparation Guides Preparation Guides

A-TYPE PREP

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Removing provisionals that are locked on.

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What Percent of Impressions per

Laboratories have visible errors?

89%

1-Samet N, Shofat M, Livny A, Weiss EI. A clinical evaluation of fixed partial denture

impressions. J Prosthet Dent 2005; 94:112-117.

And the key to remember, routinely, it’s voids, bubbles, and tears

“Approximately 90% of impressions have defects” G. Christensen

Types of Moisture

Saliva

Crevicular Fluid

Bleeding

Enhancing Moisture Control

Fluid/Tissue Management

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Superoxol

Epinephrine

Ferric Sulfate

ViscoStat 20%

Astringent 15.5%

Aluminum Chloride

Viscostat Clear 25%

Expa-syl

Hemostasyl

Aluminum Sulfate

Tissue Goo 25%

Various Cords

Astringents Enhancing Moisture Control

Fluid/Tissue Management Fluid/Tissue Management

Fluid/Tissue Management Fluid/Tissue Management

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Lasers (Diodes) Fast

Hemostasis

No crevicular fluid

No cord

Better healing


Fluid/Tissue ManagementFeatures

• Number #1 dental laser in the world• More power – 3 watts

• New easy to use presets• New treatment timers for perio treatment

• Wireless foot control• Optional battery pack• Perfect for first timers or hygienists

• Affordable• Disposable tips or fibers

• Certification included• MSRP: $4,495• CE Price: $3,495

Use code

CESNYDER16


Fluid/Tissue Management Enhancing Moisture Control


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Fluid/Tissue Management Enhancing Moisture Control



Fluid/Tissue Management Picasso Troughing

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Picasso GingivectomyAesthetic Contouring

Aesthetic Contouring

Time??

ROI??

Aesthetic Contouring & ExperTemp Provisional

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AMD Picasso Laser Tissue re-contouring

Panasil Initial Contact (VPS)

Kettenbach

Panasil Initial Contact

Lowest contact angle of any VPS

impression material

Fast set and Regular set

Kettenbach

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Cracked toothKettenbach

Panasil Initial ContactKettenbach

Panasil Initial ContactKettenbach Kettenbach

Identium(Vinylsiloxanether-VSXE)

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Kettenbach

Identium for single teethIdentium for multiple teeth

-two cord technique

Identium for multiple teeth Identium for multiple teeth

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Make cases easyIdentium for multiple teeth

Make cases easy, make your patients happy

Make cases easy, make your patients happy Mixed Treatment Case: 7

20 y.o. female patient presents with a missing lateral incisor, peg lateral, worn dentition.

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Modern Digital Technology

• Integration of CBCT & Intraoral Scan

• Create surgical guides

• Diagnostic waxups

• Custom healing abutments

• Custom impression analogs

• Custom implant abutments

• Finalized restorations

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Beadline Provisional technique with Teflon over implant

-Simplified technique

-Less materials

-Reduced overhead

-Faster implementation

Straumann Scan Bodies

-bone level

-tissue level

• Digital technology is making a better experience

• CareStream 3500 & 3600• No Mess

• Fast

• Accurate

• Instant Results

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Working Harder or Smarter?

• Digital Technology• Allows for faster procedure

• Higher accuracy

• Better consistency

• Easier on the patient

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Make cases easy You need the right tools to consistently have good results!

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• How many attempts?

• Hydrophobic

• Possible distortion

• Cord packing & bleeding

• Multiple pours?

• Models can break-backup?

Complex Positioning &

Gingival Tissues: #8Aesthetics

Tissue Problems

Poor Function

No TMJ Problems

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Incisal position

Gum height

2-4 mm

10-12 mm

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Instant Ortho/Un-Rotating Teeth

• Do initial workup

• Diagnostic preps

• Diagnostic waxup


Sequence

– Reduce all excess tooth structure

– Ideal reduction

– Margin placement

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Cementation**

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TMJ Signs & Symptoms

Wear facets

Pot holes

Abfractions

Gingival recession

Mobility

Occlusal & Incisal wear

Linea Alba

Tongue scalloping (Crenations)

Muscle hypertrophy

Muscle tension/tenderness

Muscle rigidity

Limited opening

Guarding on CR closure

TMJ noise

Head and Neck aches

Tooth sensitivity

Ear problems, ringing, buzzing, fullness

Occlusal & Incisal Wear

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Wear Facets Pot Holes

TMJ Signs & Symptoms

Wear facets

Pot holes

Abfractions

Gingival recession

Mobility

Occlusal & Incisal wear

Linea Alba

Tongue scalloping (Crenations)

Muscle hypertrophy


Muscle rigidity

Limited opening


TMJ noise

Head and Neck aches

Tooth sensitivity


Gingival Recession &

Abfraction Lesions

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Flowables? Sometimes it presents as single teeth due to excursive interferences or as a

pivot, fulcrum or “teeter totter” tooth.

Other times there are more in a quadrant and there is severe wear to the occlusion.

Other times it maybe on the facials of anterior teeth, where there is wear on the incisal edges or wear facets on the linguals, however little to no wear on

posteriors.

Occlusal guards should be fabricated along with an occlusal analysis in CR on models.

Abfraction Lesions

Pathological loss of tooth structure caused by biomechanical loading forces.

Static and cyclic flexural overloading of tooth structure ultimately leading to

fatigue and failure of tooth structure away from the point of loading.

Abfraction LesionsLatin words, ab – “away”, fraction – “breaking”

Typical Composite BreakdownMicroleakage and missing fillings from high occlusal loads on teeth

can cause large cervical stress concentrations resulting in

disruption of the bonds between the hydroxyapatite crystals and the

eventual loss of cervical enamel and dentin.

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Resin Modified Glass Ionomer RestorationPost-Op Photo – notice unlike typical class V composite FUJI II LC

restorative material. Resin bonding is mostly due to the intertubular dentin.

Deep preparations have less intertubular dentin. More moisture present due to odontoblastic tissues and fluid Higher risk of post-op sensitivity

Use a New Advanced Adhesive and Flowable

Glass Ionomer (GI) True adhesion to tooth structure

Bonds to moist dentin Less technique sensitive Fluoride release

Decreased gap formation and cusp deformation Coefficient of thermal expansion is similar to dentin

No post operative sensitivity Use on dentin & cementum

Base out deep areas Place resin/composite on top of GI

Replacing Existing Restorations & Decay

Dentin Bond Strengths of Simplified Adhesives: Effect of Dentin Depth. Compendium June 2006, p.340-345

Using Cavity Liners with Direct Posterior Composite Restorations. Compendium June 2006, p.347-351

Resin Modified Glass Ionomer

Light cured

Dual cured

High flexural strength

Good polishability

Excellent wear

Hydrophillic

Fluoride release

No microleakage

No adhesives

Acid resistant layer

Reduces sensitivity

True chemical adhesion

Glass Ionomer Materials

Dentsply-none

SDI-Riva LC, light cure HV

G.C. America-Fuji II LC

VOCO-Ionolux

3M/ESPE-Ketac Nano, Photac Fil Quick

https://www.ncbi.nlm.nih.gov/pubmed/16792342

https://special-issues.cdeworld.com/courses/4366-using-cavity-liners-with-direct-posterior-composite-restorations

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Glass Ionomer Interface

Inte

rface

Ana

lysis (T

EM

)

CARDOSO et al. J Dent 2010

Glass Ionomer Sandwich

•Class I, II and V posterior restorations

•Open & Closed Sandwich techniques

•Composite replacement

•Amalgam replacement

•High caries risk patients

•Pediatric patients

•Geriatric patients

•Special needs patients

•Long term resistance to microleakage

Composite Leakage

Typical treatment involves the placement of a #00 retraction cord on each

tooth. Shade selection. Roughen tooth structure with air abrasion. Place cavity conditioner on all areas to be restored for 10 seconds, then wash and

dry. Teeth should be isolated from saliva.

Restorative Therapy- Case 1Mix Fuji II LC or RIVA Light Cure and syringe into place. Utilize hand instruments to

shape and remove gross excess. Cure each tooth for 20 seconds. Remove excess and contour using a handpiece with fine diamond burs.

Restorative Therapy- Case 1

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After contouring the restorations can be coated with a self etch

adhesive coating, and cure for 10 seconds.

Restorative Therapy- Case 1 Restorative Therapy- Case 1Eight year post-op photos show the integrity of the material is still excellent.

Note the lack of marginal microleakage stain often present with composite restorations.

Fig. 15 – Graph representing the mean annual failure ratesper adhesive class, determined according to a systematicreview of Class-V clinical trials of adhesives during theperiod 1998–2004 [2].

Van Meerbeek B, et al. Relationship between bond-strength tests and clinical outcomes. Dent Mater (2009), doi:10.1016/j.dental.2009.11.148

Typical treatment involves the placement of a #00 retraction

cord on each tooth followed by a shade selection. Roughen

tooth structure with air abrasion. Place cavity conditioner

on all areas to be restored for 10 seconds, then wash and dry.


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Mix RMGI and syringe into place. Utilize hand instruments to

shape and remove gross excess. Cure each tooth for 20

seconds. Remove excess and contour using a handpiece

with fine diamond burs. Teeth should be isolated from saliva.

Restorative Therapy- Case 2 After contouring the restorations can be coated with a self

etch adhesive coating, and cure for 10 seconds.


Eight year post-op photos show the integrity of the material is still excellent. Note

the lack of marginal microleakage stain often present with composite restorations.

Restorative Therapy- Case 2 Resin Modified Glass Ionomer

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Abfraction Lesion Treatments

• Restore defect to protect the exposed dentin and

strengthen cervical tooth structure with Glass Ionomer.

• Occlusal evaluation from Centric Relation to Centric

Occlusion, with possible occlusal adjustment.

• Lateral excursive interference evaluation, with possible

occlusal adjustment.

• Check Saliva pH levels for possible erosive problems.

• Night guard therapy.

• Open Sandwich with glass ionomer & GrandioSO

Conventional Glass

Ionomer Materials

Dentsply-ChemFil Rock Restorative

SDI- Riva SC, self cure HV

G.C. America- Equia Forte

VOCO-IonoStar Molar, IonoStar Plus

3M/ESPE- Ketac Molar Quick, Ketac Fil Plus

http://www.chemfilrock.com/node/51/lightbox2

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EQUIA FORTE

EQUIA™ FORTE is a complete system that is an ideal solution for posterior restorations:

•Class I, II, III and V posterior restorations •Composite replacement •Amalgam replacement •High caries risk patients •Pediatric patients •Geriatric patients •Special needs patients •Buildups•Long term provisionals

How and when you diagnose this….

…determine how you prepare.

?How are you restoring

these different preparations

Basics- Posterior Direct Restorations

Starts off by marking occlusion & selecting color

Anesthetize

Preparation Caries indicator & Base

Materials? Mark occlusion again at end

with the same or a different color

What Is Your First Step??

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Red Blood Cells 2 – 5um

200-500nm

Human Hair 60 –120um

6,000 – 12,000nm

?

What do you use…..

.…and why?

Shimstock & Articulating Paper

Shimstock & Articulating Paper

Parkell Accufilm II is 21µm for

dentistry

BiteChek 19 microns

Great Lakes articulating ribbon 12µm

8µm Almore Shimstock foil

8µm articulating paper??

What do you use…..

.…and why?

8µm articulating paper

Available in blue

And red too!

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Jaw position and movement

Cases of simple fillings and how to do them and what can

throw off the bite

Anterior composite cases doing well

Posterior crown and bridge errors and how to avoid

Wear a night guard

Don’t equilibrate!!

Indirect Posterior Restorations

Steps to avoid occlusion problems.

1) Mark bite before starting

2) Accurate over impression

3) Bite registrations

- I like wax CENTRIC OCCLUSION DENTISTRYIndirect Restorations

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Centric Occlusion Dentistry

Shimstock-prior to prep

Preparation

Shimstock-checking bite

Wax bite (why?)

Shimstock-verifying wax bite is accurate

Impressions

Facebow

Provisionals

Shimstock-check provisional and bite

Pouring models

Mount maxillary model to articulator

Articulator settings

Mount opposing mandibularmodel

Equilibrate

Lab Fabrication

Check Case

Try-in Case

Deliver Case

Shimstock

Holds Means that when biting firmly in C.O. the shimstock can

not be pulled out

Drags Means there is resistance on the shimstock but it can

be pulled out slowly

No Hold There is no resistance what so ever when pulled

between occluding teeth.

Simplified Fixed Prosthodontics & Occlusion PDL & Bite Registrations

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The range of PDL width: 0.15mm ~ 0.38mm

• Average PDL width by age:

o 11 ~ 16 years old: 0.21mm



• The PDL width decreases with age.

• The PDL width is thinnest around the middle 1/3 of the root.

PDL & Bite Registrations1. The thickness of the periodontal ligament varies from 0.1 to 0.4 mm with a mean of around 0.2 mm.

2. The ligament is thicker in functioning than in non-functioning teeth, and in areas of tension than in areas of compression

(see table below):

Comparison of periodontal width of functioning and non-functioning teeth in an adult male

(Adapted from Kronfeld, R. , 1931)

_____________________________________________________________________

Premolar in heavy function Premolar in light function Molar out of function

Mean width of PDL at coronal

end of alveolus 0.35 mm 0.14 mm 0.10 mm

Mean width of PDL in middle

of alveolus 0.28 mm 0.10 mm 0.06 mm

Mean width of PDL at apical

end of alveolus 0.30 mm 0.12 mm 0.06 mm

______________________________________________________________________

3. The ligament cells are capable of remodeling the ligament and adjacent bone when functional forces are altered or the

ligament is damaged.

4. The periodontal ligament plays a key role in protecting the tooth from being resorbed by the normal remodelling process

that affects the adjacent alveolar bone.

5. Excessive forces can cause localized necrosis (cell death) of the ligament by cutting off the normal blood supply to the

cells. This situation immediately results in stoppage of remodeling at the affected site. Therefore, orthodontic tooth

movement is no longer possible. Repair occurs via emigration of cells from adjoining vital periodontal ligament. In the event

the ligament continuity is not restored, localized resorption and ankylosis may occur.

PDL & Bite Function

Simplified Fixed Prosthodontics & Occlusion

Verify bite Shimstock

Over impression

Preparation

Wax bite Dead soft Delar Wax

Firm, Hard Bite

Shimstock vs. articulating paper/ribbon

Facebow

Impression

Provisional

Lab Articulation

Bite Registration & Occlusal Indexing

http://dental.pitt.edu/periodontal-ligament-clinical-considerations

http://www.dental.pitt.edu/informatics/periohistology/en/glossary.html#Ankylosis

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Simplified Fixed Prosthodontics & Occlusion Simplified Fixed Prosthodontics & Occlusion

Simplified Fixed Prosthodontics & Occlusion Simplified Fixed Prosthodontics & Occlusion

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Simplified Fixed Prosthodontics & Occlusion Check Occlusion and Provisional

Shimstock holds should be duplicated on teeth, wax bite

and provisional

Do not rely on articulating paper except for help in finding

high spots

Provisional must have contact occlusally and

interproximally

TRIOTRAY Triodent/Ultradent PEER REVIEWED

The Catapult Group rated the

Quad-Tray Xtreme as better

than, just as good, or tied with

other available closed bite

trays.

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Quad Tray Extreme (Clinician’s Choice)Bite Registration & Occlusal Indexing

Disposables

Non Adjustable

Semi Adjustable

Fully Adjustable

Articulators Disposable Articulators

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Semi Adjustable

not on Hinge Axis

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T scan tooth depression? On biting

Semi Adjustable

not on Hinge Axis BUILT IN ERRORS!Thickness??Rotation?? Rocking??

Function & Failures

• Closed Bite Trays (most common)

• Lack of rigidity may cause distortion

• Spring back after impression potential

• No cross arch stabilization

• Thin spots or perforations can cause distortion

• Impression material shrinks towards bulk

• Unable to recreate excursive movements

• Potential for errors & adjustments extremely high

Impression Trays

Function & Failures

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Function & FailuresWhich do you think is going to be more accurate?

Less adjustments and remakes?

Used for stable, accurate, Centric Occlusion, and excursive pathways.

Mounted and Equilibrated

• Patient’s Perceived & ACTUAL problems

• Aesthetics

• Smile

• Color

• Position

• Shape

• Function

• Jaw Position

• Bite

• Jaw opening

• Discomfort

• Myalgia

• TMD

• Joint Noise

• Headaches

• Psychological -Body Dismorphic Syndrome

• First step in any case no matter how big or small?

• Diagnosis of:

• How did the problem come to be?

• Occlusion (articulated models)

• Function (opening, excursives, bite pressure and contacts)

• Sleep Study

• TMJ (radigraphic interpretation)

• Periodontal Health / Bone Support (radiographs, probings)

• Mobility

• Mental Health

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Three Eccentric Movements

Protrusive

Working

Balancing


Protrusive

Working


Balancing


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Right Lateral Movement Left Lateral Movement

Centric Occlusion: CO

The arrangement of the

upper teeth to lower teeth

that provides the maximum

intercuspation, irrespective

of the position of the joints

in the Glenoid Fossa.

Centric Relation: CR

Any arrangement of the

upper to lower teeth

when joints are in any

relationship seated in the

upper most and midmost

position in the Glenoid

Fossa.

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Centric Relation Occlusion: CRO

The arrangement of the upper to lower teeth

that provides the maximum intercuspation in CR.

Case #9: Checking CO, CR & Excursives

Customize Teeth

Checking Occlusion is the Key to Aesthetics

Interferences

What is the perceived problem & what is the true problem?

Can we find the true cause of the problem?

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Aesthetics

Occlusion

Excursives

Restorations

Wear

Solutions

What options are available to fix the problem?

Slow unperceivable changes

Diagnosing once it’s a problem

What about prior signs & symptoms

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Example-Centric Occlusion

Anteriorly positioned condyles

Occlusion is not ideal Appears to have canine guidance

Weak centric stops and limited number

Patient okay for a few months

Now has joint pain, noise, muscle pain, teeth are sensitive

Centric Relation

Joint in proper position

Occluding only on second molars

Restorative dentistry & orthodontics (aligners too)

TMJ SIGNS & SYMPTOMS

• Wear facets

• Pot holes

• Abfractions

• Gingival recession

• Mobility

• Occlusal & Incisal wear

• Linea Alba

• Tongue scalloping (Crenations)

Muscle hypertrophy


Muscle rigidity

Limited opening


TMJ noise

Head and Neck aches

Tooth sensitivity


Round, Brachyfacial often

Limited smile appearance

Worn teeth or deep bite

Enlarged Masseters

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POSTERIOR INTERFERENCE (PREMATURITY)• Centric Occlusion

• Natural growth patterns

• Orthodontics

• Dental work

• Trauma

JOINT REPOSITIONED AND

STABILIZED (CRSTABILIZED)• Splint Therapy

What happens to a Condyle when there

is an Occlusal Prematurityon a 2nd molar?

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CHANGE!

• Larger amounts of tooth augmentation can create potential shifts in bite

pressure on teeth, CR-CO slides, and excursive interferences.

• Material properties must become more resilient to increased wear and

pressure demands.

• Higher risk of post operative complications due to occlusal modifications,

jaw positioning, and/or adhesive techniques and materials.

• A different approach to typical Restorative DentistryWhat did the patient’s teeth look like prior to veneers? Did she have any

symptoms? Braces? Dental work? Trauma? Etc…

Case Example: #10

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A Veneer Case? Not a veneer case!!

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HOW DO YOU TREATMENT PLAN FOR INDIRECT

RESTORATIONS??

Diagnostic model evaluations

ARTICULATED EQUILIBRATED MODELS• Shim Stock Holds (0.001 inch/8 microns)

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Occlusal TestingHoldDrag

No Hold (None)SHIMSTOCK

• Holds

• Means that when biting firmly in C.O. the shimstock can not be pulled out

• Drags

• Means there is resistance on the shimstock but it can be pulled out slowly

• No Hold

• There is no resistance what so ever when pulled between occluding teeth.

Normal Disc Reducing Non-ReducingNormal

Remodeling DJDRemodeling

Adolescent

Facial GrowthDecreasedInterruptedNormal

Bones

Disc

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Case Example: #11 Aesthetics

Trauma

Anterior Guidance

Special Protrusive Bite

Instant

Composite

Mockup

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Fully Adjustable on Hinge Axis

LABORATORY WORK

Example

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REMOVE ALL POSITIVES FROM CASTS 20 20

10-20SAM III-SEMI ADJUSTABLE ARTICULATOR

TRANSFER FORK ASSEMBLY WITH UNTRIMMED

BITE FORK TRIMMED BITE FORK

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PROPER SUPPORT AND MOUNTING MOUNTING THE OPPOSING MODEL

START CHECKING BITE & EQUILIBRATE

EQUILIBRATING MODELS

Technique Overview

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Paint opposing cast

Occlude Spray by Paskall

• Close articulator without pressure

• Check teeth that hold shimstock

• Trim teeth that are hitting to heavy

• Trim heavy red marks off

• Check with shimstock again until all teeth hold

• Check from back to front

VERIFY ALL HOLDS WITH SHIMSTOCK

VERIFY ALL HOLDS WITH SHIMSTOCK VERIFY ALL HOLDS WITH SHIMSTOCK

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• If you have a contact and then you loose it you can not always

get it back. It is okay.

• Tell the lab the teeth that hold shimstock because it may be

different than in the mouth.

VERIFY ALL HOLDS WITH SHIMSTOCK

CHECKING LAB CASES

Technique Overview

RETURNED LAB CASE CHECK LIST• Check articulator

• Number

• Parts

• Settings

• Angle of eminence

• Bennet angle

• Pin height

• Split cast/check mount

• Check margins

• Check interproximal contacts

• Check occlusion with shimstock

• Without restoration(s)

• With restoration(s)

OCCLUSION CHECK

Check Shimstock holds Without restoration(s)

Check Shimstock holds With restoration(s)

Check restoration last

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ADJUSTMENTS

• Spray opposing

• Close articulator

• No heavy pressure

• Fine diamonds

• Verify shimstock

holds

• Continue adjusting

until holds are all

present.

• Restoration should

hold as well as teeth.

EQUILIBRATION

Multiple teeth and opposing restorations

EQUILIBRATION

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Questions??

All-Ceramic Crowns565-1200+MPa

Multi-Layered

Zirconia

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Restoration Placement?

Bonded Margin placement

Moisture Control

Technique Sensitive

Materials

Self Adhesives

Bonding agent (TE or SE) & luting resin

Cemented

Margin placement

Moisture Tolerant

Retention Required

Materials

RMGI

Ceramir

Cement Selection

Case #11:

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Alkaline pH 8.5

Moisture Tolerant

Self Sealing

Apatite Formation

Insoluble/No Degredation

Stronger with time

Semi / Translucent

Biocompatibility-Excellent

Bioactivity-Apatite formation

No silane, conditioning, bonding

Ceramir® Crown & Bridge**

Cement Selection

Bioactivity by Doxa

A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline

pH.**

Cement Selection

Cementation TechniqueCement Selection

Mix for secondsmL

3-4 restorations

Cementation TechniqueCement Selection

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Final Restorations

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RESIN CEMENT COSMETIC CASES…. COSMETIC CASES….

COSMETIC CASES…. COSMETIC CASES….

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PROVISONALS PROVISIONALS

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BONDS WITH OR WITHOUT HF

ACID ETCHING

THE “NO-WATER” SILANE

INSTANT ACTIVATION

LESS DEGRADATION

(More Stable 2 Year Shelf-Life)

PRE-TREAT VENEERS

• Unidose Silane (Sultan Dental)

• Place under heat for a few minutes

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3 VITA® shades2 chromatic shades

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G-CEM LINKFORCE (GC AMERICA)

• BPA free

• MDP chemistry in bonding agent & primer

• Tryin pastes

• Etchant

• G-Premio BOND™ - Bonding to ALL Preparations

• G-Multi Primer™ - Primer for ALL Restorations

• G-CEM LinkForce™ - Strength in ALL Indications

• Color stability over time

• Tooth–like fluorescence

• Four shades to match all needs

FINAL RESTORATIONS

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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

Silanes

Universal Adhesives (w/MDP)

Silane Primer + MDP

Organo-Phosphate Monomer (MDP)

Silane Primers

A disadvantage of many other silane products is that they are pre-hydrolyzed.

Another disadvantage is some require the use of Hydrofluric Acid etching and sometimes in addition to Micro-Etching. The new Monobond Plus requires HF and Micro-Etching as well as 60 minute

activation time period.

QUESTIONS?

Aesthetics

Preparation Design

Function

Strength

Bonded Adhesion

Lithium Disilicate

Bonded Adhesion

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Bonded Adhesion Bonded Adhesion

What substrate are we treating?

3x Tubule Density Equals Higher Fluid &

Increased Difficulty for Bonding

%30 Decrease in Bond Strengths with most

bonding systems.

CEMENTATION MATERIAL OPTIONS

Cement Selection

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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


• Fluoride Release

• Stronger Than Traditional GIs

• Degrades over time

• Improved bond strength

• Biocompatibility Ok

• Bioactivity-None

• Sealing Quality-Ok

• Silanate Restorations

Cement Selection

Cementation Cementation

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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

RESIN MODIFIED GLASS IONOMER CEMENT AND A CERAMIC

PRIMER

• Lab sandblasts @ 30psi w/ 50 micron aluminum-oxide particles

• Ceramic Primer II (MDP) prior to tryin (5 min & heat)

• Ultrasonic clean with ethanol

• Place FujiCEM2 RMGI cement in restoration

Features

• Number #1 dental laser in the world

• More power – 3 watts• New easy to use presets• New treatment timers for perio treatment

• Wireless foot control• Optional battery pack

• Perfect for first timers or hygienists• Affordable• Disposable tips or fibers

• Certification included• MSRP: $4,495

• CE Price: $3,495

Use code

CESNYDER16

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• Feldspathic

• Leucite

• Lithium Disilicate

• Lithium Silicate

• Zirconia

FUJICEM2 SL• Resin Modified Glass

Ionomer Cement

• Disposable Tips

• Slide & Lock technology


• Biocompatible

• Hypermineralized Dentin

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BOND DEGREDATION

• Pashley DH, Tay FR, Imazato S. How to increase the durability of resin-dentin

bonds. Compend Contin Educ Dent. 2011 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.

Cement Selection Factors that compromise bond durability in restorative dentistry

Hydrophilic dentin bonding (1956 - )

Intact hybrid layers created by a simplified etch-and-rinse adhesive in caries-affected primary dentin partially

disappeared after 6 months of intraoral function

Instability of hybrid layersproblem may be moresevere than we realize

Class I or II

:Tooth Preparation

3x Tubule Density Equals Higher Fluid &

Increased Difficulty for Bonding 30% Decrease in

Bond Strengths with most bonding systems.**

What substrate are we treating?

Cement Selection

Self-Adhesive Resin Cements

No Primer or Bond? Gel State?

No Primer or Bond

Durability & Wettability ???? Self-Adhesive Resin Cements Without a Primer or Bonding Agent have less:• Wettability

•Which Results in Less Contact to the Tooth

•Which May Result in a Less Durable Bond

•Convenience

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SELF ETCH RESIN CEMENTS G-CEM LINKACE

• Dual Cure

• MDP based cement

ZIRCONIA CERAMIC CONDITIONING FAST, SELF ETCH, ALL IN ONE, SELF CURE/DUAL CURE RESIN

• 24 hour shear bond strength for these products

typically is between 4mpa-15ma

• Why not use a product with either better sealing

capabilities and benefit to the patient’s health

• Use a stronger material that has better strength

characteristics.

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• Alkaline pH 8.5


• Self Sealing

• Apatite Formation

• Insoluble/No Degredation

• Stronger with time

• Semi / Translucent

• Biocompatibility-Excellent

• Bioactivity-Apatite formation

• No silane, conditioning, bonding

CERAMIR ® CROWN & BRIDGE**

Cement Selection

Bioactivity by Doxa

A reactive bioactive system that contributes to hydroxyapatite mineralization of hard tissue through ion release and alkaline

pH.**

Cement Selection

CEMENTATION TECHNIQUE

Cement Selection

Mix for 8-10 seconds3-4 restorations

CEMENTATION TECHNIQUE

Cement Selection

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What do you use?

Zirconia Ceramic Conditioning MDP-containing material bonds to Zirconia

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REMEMBER:

FUNCTIONAL LIMITATIONS


FUNCTIONAL LIMITATIONS

• Excursive Interferences

• Group function


• Malpositioned teeth

• Occlusal interferences

• Canine guidance

• Group function

Functional Limitations


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• Check excursives

• Protrusive

• Night Guard





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QUESTIONS

?


Hard acrylic whose occlusal surfaces can be easily modified.

Stable fit with no rocking movements from side to side, or anterior to posterior.

Covers all the teeth in a maxillary arch.

My Criteria for a Successful Splint

Shallow Anterior guidance in all excursive movements.

Simultaneous posterior occlusal contacts in light centric closure, and no slide in hard squeeze


My Criteria for Successful Splint

Shim stock clearance of anterior contacts in centric closure.

Immediate posterior disclusion by canine in working and balancing movements.

Guidance by maxillary centrals and laterals in protrusive movement.

Flat posterior occlusal surfaces offering eccentric movements without interferences.

Highly polished appliance that is comfortable.


Criteria for a Successful Splint

VS VS


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Indications for Splint

Mobile teeth and /or bone loss

Protection of Cosmetic Porcelain Restorations

Symptomatic relief of acute joint pain and muscle tenderness

Nocturnal Bruxing and Clenching

Diagnostic tool for restorative dentistry.


Occlusal Guard

• Simultaneous posterior contacts,

light contact on anterior teeth

• Shimstock drags

• Canine excursive

• Protrusive on incisors only

Occlusal Guard

• Hard Acrylic ONLY relined in mouth.

• Soft acrylic creates more interferences and does not keep the TMJ stable

• Hard/Soft allows teeth to shift slightly and does not keep the TMJ stable

• NTI should only be used short term 2-4 weeks

Occlusal Guard

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OCCLUSIONMyths, Mystical Potions,

and Black Magic


There is not one key to success….

There are many and they all open different doors

CANINE GUIDANCE MYTHS

• Steep canine guidance eliminates posterior interferences?

• Canine guidance can be steepened without ramifications?

• Incisal edges can be restored with composite to obtain guidance?

• Increasing canine guidance and doing posterior occlusal equilibrations will eliminate interferences and TMJ problems?

MYSTICAL POTIONS

• TMJ injections

• Botulinum Toxins

• Trigger point injections

• Steroids

• Anesthetics

• Saline

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OCCLUSAL GUARD BLACK MAGIC

• Soft splints

• Hard/Soft splints

• Half arch stabilization appliances

• NTI? Best Bite?

EXAMPLE-CENTRIC OCCLUSION

• Anteriorly positioned condyles

• Occlusion is not ideal

• Appears to have canine guidance

• Weak centric stops and limited number

• Patient okay for a few months

• Now has joint pain, noise, muscle pain, teeth are sensitive

CENTRIC RELATIONAesthetic Opportunities:

Developing Beautiful Smiles

Case #24 (Complex Occlusion)

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Developing Beautiful Smiles

Assessment:Joint NoiseFacial Muscle PainPoor OcclusionInvisalign Done/RetentionAnterior WearWants to Keep Appearance

Cause & Effect Diagnosis• Functional Wear on Anteriors

• Masticatory Muscle Pain

• Headaches

• Jaw Relationship / TMJ Disorder

• Obstructive Sleep Apnea (OSA)

• Combination


Supplemental Tests:Sleep StudyCone Beam CT (CBCT)Airway Evaluation

AIRWAY VOLUME

-50mm2 and below have an association with OSA


TMJ EVAL/Diagnosis

CBCT-Pathology-Jaw position-Bone Appearance-Active DJD/Remodeling

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Aesthetics & Occlusion Aesthetics & Occlusion

Orthotic: Superior Repositioning Appliance (SRA)

Nociceptive Trigeminal Inhibition Tension Suppression System (NTI-tss)

Jaw Position

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NTI type appliances

Jaw PositionNITE BITE

• 5 minutes to make a Nite Bite appliance for relief of most TMJ discomfort

SRA FABRICATION:Try-in

Check Bite

Adjust Posterior

Shallow Ramp

Trim Trough

Occlusal Reline

Passive Centric & Hold

Mark Depth of Fossa

Trim Excess

Polish


https://www.youtube.com/watch?v=xT-kwc2Btrw

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• Patient wears just at night the first 2-5 days

• Understands they will wear 24/7

• Patient comes back for evaluation every 2-4 weeks

• Passive reline to achieve equal contacts

• Once the bite is stable follow for another 2-4 weeks


Orthotic: Superior Repositioning Appliance (SRA)


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Occlusal Analysis


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Aesthetics & Occlusion Impression Trays

HEATWAVE BY CLINICIAN’S CHOICE


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The Nuts & Bolts of VeneersAesthetics & Occlusion

TISSUE AND MOISTURE CONTROL


A laser is more precise, causes less pain, and

prevents bleeding better than traditional tools used

on soft tissues. The highly focused laser light

cauterizes nerve endings, coagulates blood

vessels, sterilizes the surgical site, and increases

the speed of healing. Instantly cauterizing nerve

endings greatly reduces pain during the procedure

and after. Healing times can be as low as a few

days where traditional surgical approaches can take

several weeks.

• Dry all teeth in arch

• Place tip in most difficult area first

• Keep tip on margin and immersed in material

• Go around entire margin first

• Next go to adjacent teeth

• Then do coronal aspect of teeth

• Double Mix Single Impression is the most

accurate

SYRINGE PLACEMENT


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Simplified Provisionals


Provisionals (Duplicate models)

Scribe a 0.5-1mm line with a sharp instrument into the

model where the tissue and tooth come together.

Bead Line Veneer Provisional Restorations. Pract Proced Aesthet Dent 2009;21(3):E1-E7.


Duplicate model with light body wash and heavy body tray material.


Provisionals (Duplicate models)Aesthetics & Occlusion

• Verify shape

• Display at rest

• Protrusive

• Excursives

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CEMENTATION OPTIONS• Glass Ionomers

• Resin Modified Glass Ionomers

• Self Etch Resin Cements

• Bonding Agent w/ Resin Cement

• Calcium Aluminate

• TriSilicate Cement


CERAMIR (CALCIUM ALUMINATE CEMENT BY - DOXA)• Alkaline pH 8.5


• Self Sealing

• Apatite Formation

• Insoluble

• Stronger with time

• Semi / Translucent

• Biocompatibility-Excellent

• Bioactivity-Apatite formation

• Sealing Quality-Excellent



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Pre-op

Post-op


Questions?


These are becoming the norm

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Online Real Data

THE POWEROF

ACTIONABLE METRICS

.

TWO WAYS TO INCREASE PRODUCTION

Visits

TWO WAYS TO INCREASE PRODUCTION

PRODUCTION on Visits

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New Patients

NEW PATIENTS

HOW MUCH DO WE REALLY LOVE THEM?

RECAPTURED

PATIENTS

47 $65,114

617

Before AfterHygiene Re-Appointment

$167,400 increase through Actionable Metrics

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Hygiene Re-Appointment PROVIDER-LEVEL PERFORMANCE

Slipping Through The Cracks Delivering Best Dentistry

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ACTIONABLE MONITORING DRIVES

GROWTH

37% Increase in Production

COLLECTING WHAT YOU PRODUCE

623

THE POWER OF ACTIONABLE METRICS

624Are you measuring?.

625For Your Practice Snapshot Go To: www.practicesnapshot.com

and use special code: Todd2017

http://www.practicesnapshot.com/

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SOFTWARE & TECHNOLOGYBetter Business

The Future of Dentistry

• Two years in a row dentist best health care job.

• Predicted employment growth of 16% with more than 23,000 new openings over the next 10 years.

• Dental insurance companies are systematically decreasing reimbursements

CORPORATE DENTISTRY

• Is growing 15-20% annually

• They compete for the same patient demographics as the solo practitioner.

• Discretionary income has shrunk for every segment of American society except the top 10%.

• Patient perception of dentists are changing based on work Performed, Marketing Seen and Fees offered.

• Run at lower overheads and have leveraged purchasing power.

Working Harder or Smarter?

• Look at your team• Is everyone trained to offer the same

care and service repeatedly

• Protocols • Repetition and consistency• Scripts• Daily Procedures

• Accountability• Tracking & Monitoring Tasks• Business Phones

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Remember The Old Appointment Book?How LONG Did It Take To Answer A Question About Balances, Forgotten

Appointments?

• Integrates with existing dental practice management software (DPMS)

• Dentrix• Dentrix Ascend Cloud Based coming soon…• Eagle Soft• Easy Dental• SoftDent• Practice Works• Mac Practice• Open Dental

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TEAMWORK

• Both software offer low impact on the team but create huge opportunities

• Easy to implement with minimal time to use.

• Improve business opportunities dramatically

• Cuts down on current employee time by streamlining many tasks

• Saves money on traditional procedures

• Less postage

• Less paper goods

• Less employee time

• A recent study reported 88% of people trust online reviews

• 2011 33% reported they did not trust online reviews. In 2014 it was at 13%

• 92% or internet users read product reviews

• 89% said it influences their purchases

• 74% of internet users said they would most likely not do business if there was a negative review

ONLINE REVIEWS

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ONLINE REVIEWS

• You must actively ask for reviews

• Create opportunities easily and in expensively

• A dissatisfied person will tell dozens whereas a satisfied patient will tell only a few, so get them to share….. But make it easy to do!

WEAVE REVIEWS VIA CELL PHONE MESSAGE

WEAVE REVIEWS VIA CELL PHONE MESSAGE WEAVE REVIEWS VIA CELL PHONE MESSAGE

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• Goal of 100 Reviews in 6 months

• Staff incentive

• Select Ratings to be sent to:

• Google

• Yelp

• Facebook

• Customize Order of Review Sites

WEAVE REVIEWS VIA CELL PHONE MESSAGE

Weave Mobile App

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What Is In Our Future?• Softphone• ˈsäftˌfōn/• noun• plural noun: soft-phones• a piece of software that

allows the user to make telephone calls over the Internet via a computer.

VOIP Software Mobility

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Windows, Android, and iPhone

Todd C. Snyder, DDS, AAACD

(949) 643-6733doc@ tcsdental.comwww.aestheticdentaldesigns.comwww.drtoddsnyder.com

www.facebook.com/todd.snyder.ddswww.twitter.com/tcsaestheticsInstagram: toddsnyder1

http://www.aestheticdentaldesigns.com/

http://www.drtoddsnyder.com/

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