Susan Mcmahon, DMD AAACD Modern Adhesive Dentistry: Real World Esthetics for Presentation and More Info from Catapult Education

Susan McMahon, DMD AAACD Modern Adhesive Dentistry: Real World Esthetics For presentation and more info from Catapult Education

Text SusanM to 33444 Susan McMahon DMD

• Accredited by the American Academy of Cosmetic Dentistry: One of only 350 dentists worldwide to achieve this credential

• Seven times named among America’s Top Cosmetic Dentists, Consumers Research Council of America

• Seven time medal winner Annual Smile Gallery American Academy of Cosmetic Dentistry

• Fellow International Academy Dental-Facial Esthetics

• International Lecturer and Author Cosmetic Dental Procedures and Whitening Procedures

• Catapult Education Elite, Key Opinion Leaders Pittsburgh, Pennsylvania Cosmetic dentistry is comprehensive oral health care that combines art and science to optimally improve dental health, esthetics, and function.” Why Cosmetic Dentistry?

Fun Success dependent upon many disciplines Patients desire Variety cases/materials services Insurance free Professionally rewarding Financially rewarding Life changing for Artistic! patients

“Adolescents tend to be strongly concerned about their faces and bodies because they wish to present a good physical appearance. Moreover, self-esteem is considered to play an important role in psychological adjustment and educational success”

Di Biase AT, Sandler PJ. Malocclusion, Orthodontics and Bullying, Dent Update 2001;28:464-6

“It has been suggested that appearance dissatisfaction can lead to feelings of depression, loneliness and low self-esteem among other psychological outcomes.”

Nazrat MM, Dawnavan D, Yanosvsky JA. Body dissatisfaction, self-esteem, and overweight among inner- city Hispanic children and adolescents. J Adolesc Health 2005;36:267.e16-267.e20

“It has long been recognized that many people seek and undergo orthodontic treatment not to address dental irregularities that might lead to physiologic dysfunction or to prevent destruction of tissues in the oral cavity, but to improve esthetic impairment.”

Feu D, Oliveira B, Celeste R,Miguel J AM J Orthod Dentalfacial Orthop, June 2012 Influence of orthodontic treatment on adolescents’ self- perceptions of esthetics Patient Intake Form

Would you like whiter teeth? and Are you happy with the way your smile looks? Restorative or Esthetic dentistry should be practiced as conservatively as possible…

Adhesive technologies makes it possible to preserve as much tooth structure as feasible while satisfying the patient’s restorative needs and esthetic desires. Professional Tooth Whitening Early Developments

• 1960’s Superoxol & Walking Bleach of non- vital teeth, 35% hydrogen peroxide • March 1989: Quintessence International: “Nightguard Vital Bleaching”, Drs. Harald Heymann and Van Haywood • 1994 Britesmile Laser Tooth Whitening Britesmile Laser Tooth Whitening

Argon Laser Treatment 50% hydrogen peroxide

CO2 Laser Treatment 50% hydrogen peroxide Before/After Tw o h o u r s e s s i o n Argon/CO2 laser w/50% H2O2 in proprietary Delivery system by Britesmile Whitening Today

“Number one cosmetic procedure requested by patients 20 -50 years old”

“Top cosmetic procedure requested for patients under the age of 20”

“Bleaching has increased more that 300% over the past five years

American are spending over 1.4 Billlion annually on OTC tooth whitening products

$600 Million in revenue for whitening in dental offices

More than 1 miillion Americans whiten theiir teeth annually Safety and Efficacy • Schulte JR, Morressette DB, Gasior EJ, Czajewski MV. The effects of bleaching application time on the dental pulp. J Am Dent Assoc 1994:125(10): 1330-1335. • Haywood VB, Leonard RH, Nelson CF, Brunson WD. Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc 1994; 125(9):1219-1226 • Haywood VB. A comparison of at-home and in-office bleaching. Dent Today 2000;19(4):44-53 • Li Y, Cartwright S, Lezama M, Zhang W, Feller R, Effect of light application on an in-office bleaching gel. JDR 80 January 2001 • Baik JW, Rueggeberg FA, Liewehr FR. Effect of light-enhanced bleaching on in vitro surface and intrapulpal temperature rise. J Esthet Restor Dent (Canada), 2001 13(6):370-378 • Li Y, Effect of Rembrandt Sapphire PAC light on bleaching efficacy on Rembrandt Virtuoso Lightning chairside bleaching gel. Loma Linda University School of Dentistry, January 2002 • Papathanasiou A, Kastalie S, Perry RD, et al. Clinical evaluation of a 35% hydrogen peroxide in –office whitening system. Compend Contin Educ Dent, April 2002, 23(4):335-338 • Shethri SA, Matis BA, Cochran MA, Zekonis R, Stropes M, A clinical evaluation of two in-office bleaching products. Oper Dent 2003;28(5):488-95 • Luk K, Tam L, Hubert M. Effect of light energy on peroxide tooth bleaching. J Am Dent Assoc, Feb 2004, 135(2):194-201 • Yu H, Li Q, Wang Y, Cheng H. Efffects of temperature and in-office bleaching agents on surface and subsurface properties of aesthetic restorative materials. J Dent. 2013;41:1290-1296 • Bonafe E, Bacovis CL, Iensen S, Loguerica AD, Reis A, Kossatz S. Tooth sensitivity and efficacy of in-office bleaching in restored teeth. J Dent. 2013: 41:363-369 • Li Y, Greenwall L. Safety issues of tooth whitening using peroxide-based materials. Brit Dent J. 2013;215L29-4 Hydrogen Peroxide and Carbamide Peroxide based tooth whitening is safe and effective…….

…..when manufacturer’s instructions are followed Risks

• Increased tooth sensitivity • Gingival irritation

• Tooth surface roughening and softening • Increased potential for demineralization • Degradation of dental restorations and/or unacceptable color change of dental restorations Tooth Discoloration

• Extrinsic: External staining Smoking Pigments in food or beverages Metals/minerals

Detergents and abrasives are used to remove extrinsic stains ie: Smokers toothpastes, prophy pastes

Tooth Discoloration • Intrinsic: internal staining genetics age antibiotics fluorosis developmental disorders

Peroxide based bleaching used to remove intrinsic staining.

The Chemistry

• Carbamide Peroxide 10% Carbamide peroxide breaks down in contact with water to roughly 3-4% hydrogen peroxide

• Hydrogen Peroxide H2O2 Basic mechanism of tooth whitening still not explained ….dominant THEORY is that stain molecules are oxidized into colorless compounds

Dental hard tissues are highly permeable to fluids and greatest fluid flow is interprismatic spaces in enamel and tubules in dentin

Tooth whitening is a dynamic process intitiated by the movement of whitening material into the tooth structure…interacting with stain molecules and involving micormorphologic alterations to tooth surface

Hydrogen Peroxide

Colorless liquid with low molecular weight which allows it to penetrate dentin. In dentin it releases oxygen and breaks the double bonds of organic and some inorganic compounds that cause staining of teeth Penetration of enamel and then dentin is enhanced by : Higher concentration Prolonged application Increased temperature Acid-etching, existing restorations Large Tubules (young teeth) Light Activation Specific formulations and delivery systems Chromogens:

1. Large organic compounds with conjugated double bonds….hydrogen peroxide oxidizes the double bond and makes the chromogen lighter 2. Metallic Compounds….do not react as well to hydrogen peroxide Color Shift is mostly dependent on

….The concentration of peroxide

….The length of time of exposure Whitening Options • Whitening Toothpastes ~ most contain peroxide • OTC Strips ~ peroxide delivered in a strip worn approx 30 min/day • Rinses and Gels ~ Applied with brush or rinsed twice daily • Tray Based Whiteners ~ custom fitted trays with peroxide gels used daily or overnight • In-Office Professional Whitening ~ Higher concentrations of peroxide professionally applied In-Office Whitening

• Higher concentrations of peroxides 20% to 40% Hydrogen Peroxide • Protection of soft tissues necessary • Light activation in some systems • 30 – 60 minute treatment time • Shade shift of 1-5 shades can be attained

Light Activation

Necessary? Effective? Harmful? Increased sensitivity? KPT Laser? Marketing for Whitening Social Media: “Do you know someone who is dreaming of White Christmas?” “Not only the bride wears white”

Current Patients: “Do you want whiter teeth?” “Are you happy with the way your smile looks?” In-Office Whitening

Consultation Consents Desensitizers Tw o Vi s i t Pr o c e d u r e Touch up Whitening Protocol at our office • Consult/Consents ( Photos and Whitening) Dispense desensitizer. Use 3 days prior to whitening appointment

• 1 hour Whitening appt. Isolate/Whiten Dispense home tray x 3- 5 days

• One week later: 1 hour Whitening appt. Isolate/Whiten Post op photos, Dispense home tray x 3 days, Dispense Remineralization Paste

• Touch Up as needed Consult Appointment

Patient Photos – 4 Smile Evaluation Discuss Procedure, risks and benefits Sign consents Dispense desensitizer Desensitizer

Potassium Nitrate with Flouride: Sticky gel. Delivered disposable trays. Pt uses for several days prior to whitening. Applying lip protectant Positioning Dry Angles

Placing surgical cotton rolls Placing cheek retractor with Tongue retractor Applying Liquid Dam Curing Liquid Dam

Total Isolation Retractors, Cotton rolls, Gauze, Liquid Dam, Face Napkin

Risks

• Increased tooth sensitivity • Gingival irritation

Avoid with proper isolation with in-office procedures Peroxide Burn

After 20 minutes

After 10 minutes Risk: Increased susceptibility to demineralization Tooth surface is a balance between demineralization and remineralization depending on the acidity of the surrounding environment

The Caries Balance Pathologic Factors vs Protective Factors

Acidogenic bacteria Saliva flow and components Reduced salivary flow Proteins, calcium phospate, Frequency of fermentable Fluoride, immunoglobulins, Carbohydrate ingestion Antibacterials in saliva Extrinsic antibacterials such as chlorhexidine Remineralization Products

Dependent on environmental factors: Smoking Pigments in beverages and foods Some medications

Touch Up Whitening Touch Up Whitening

Once a year Usually done same day as recall cleaning Pre-schedule Patients desire pearly white teeth

White teeth have been linked to social competence, intellectual ability, successful interpersonal relationships and even psychological stability.

Mon T, Norkhafizah S, Nurhidayati H. Factors influencing patient satisfaction with dental appearance and treatments they desire to improve aesthetics. BMC Oral Health. 2011:11:6

Microabrasion Micro-abrasion Chemical and mechanical abrasion slurry to remove superficial white and brown stains. Minimally invasive treatment for fluorosis

•Chemical and Mechanical Abrasion Slurry •6.6% hydrochloric acid with silicon carbide micro-particles •Chemical stain removal with gentle microabrasion •Rubber Dam Isolation •Several Passes with Rubber cup and Slurry •Polish •TFA

Brown Staining/Hypocalcification

Micro Abrasion followed by in-office Whitening

30 min Doctor chairtime 60 min Whitening chairtime Dispense 5 days home whitening product One Zoom Session, 5 days home product, One week later: Microabrasion, 5 days home product What are treatment options for this patient?

The smile we create should be esthetically appealing and functionally sound

Our aim should be less reduction of tooth structure and greater esthetics and durability Value of Smile Design Principles

Patient communication Laboratory communication Clarifying problem areas in a case You don’t know what you don’t know Fundamental Requirements

Comprehensive Examination

Determine dentition health Determine periodontal health Determine occlusal health Radiographs Photographs Study Models Computer simulations and mock-ups Interview of the patient’s desires and expectations • Evaluate Smile as part of Whole Face….. or you can get this…….. Three Important Smile Factors to Evaluate White Esthetics Tooth size, shape, texture symmetry and arrangement Tooth translucency Tooth color, i.e hue, value chroma Tooth/face relationship, i.e. canted, centerline, etc. Tooth quality, i.e. decay, old restorations, wear, etc. Pink Esthetics How much gingival tissue is visible? Gingival symmetry Lip shape and size Papilla/black triangles

Black Esthetics Missing teeth Collapsed buccal corridor Tooth and Tissue Treatment Options

Teeth - restorative options - tooth contouring -orthodontic therapy

Soft tissue - periodontal surgery - implant therapy Many patients like this in our practice. Three Important Smile Factors to Evaluate White Esthetics Tooth size, shape, texture symmetry and arrangement Tooth translucency Tooth color, i.e hue, value chroma Tooth/face relationship, i.e. canted, centerline, etc. Tooth quality, i.e. decay, old restorations, wear, etc. Pink Esthetics How much gingival tissue is visible? Gingival symmetry Lip shape and size Papilla/black triangles

Black Esthetics Missing teeth Collapsed buccal corridor Patient’s Chief Complaint: None Patient’s mother’s Chief Complaint: “ He doesn’t brush his teeth enough”

Smile Evaluation: White: Fx #8, White spot #9, Yellow Color Pink: Gingival heights 7, 10 asymmetric Black: No concerns • “Are you happy with the way your smile looks?” on our patient intact form

• “I’d like to take a few photos for the doctor. I’d like her to take a look at the bonding on your front tooth.”

• Put photos on the monitor/print for patient to see with the doctor. White: Fx #8, White spot #9, Yellow Color Pink: Gingival heights 7, 10 asymmetric Black: No concerns

Treatment : ▪Gingival Sculpting #10 for symmetry ▪Microabrasion to remove hypocalcification #9 ▪Whitening ▪Restoration Right Central Incisor

White: Proportions good, Color?

Pink: Slight Asymmetry 7, 10

Black: Black Triangle 8/9

Contact less than or equal to 5mm from Alveolar Bone: Papilla will fill in space Contact equal to or more than 7mm from Alveolar Bone Crest: Not likely to have papilla

Basic Principles of Adhesion

Dental Adhesives Etching the enamel with 37% phosphoric acid prepares the enamel to accept the adhesive.

A strong bond is formed Adhering to Enamel……Strong and Predicatable

Beautiful Etched ENAMEL Enamel Ready for Adhesive Bond Adhering to dentin has been more challenging

Leather-like Moist DENTIN The Evolution of Dentin Adhesion Based on Treatment of the “Smear Layer”

Smear Layer What is a “Smear Layer”

• Freshly cut surface of dentin created by rotary instruments • Generally 1 – 5 microns thick, but extends into tubules in the form of amorphous “plugs” • Smear layer components – Hydroxyapatite crystals – Partially denatured collagen – Trash! • Weakly attached to dentin surface (2-6 mPa’s) • Is partly porous, but dramatically reduces fluid flow from the underlying dentin tubules • Called the “Biologic Band-Aid” in reducing post operative sensitivity with amalgams/PFM’s Copalite was used to reinforce the smear layer in amalgams.

Early Adhesives

Enamel was etched ( 60 Seconds), Dentin was not, Smear layer was left intact…

•Scotchbond by 3M and Tenure

•Bonded to the weakly attached smear layer, contraction force of the polymerization shrinkage of the CF pulled the bond from the dentinal floor and failed to seal.

•Bacterial ingress occurred and often irreversible pulpitis ensued The Next Generation of Adhesives

The smear layer on the dentin is removed…

… by etching the prepped dentin with 37%phosphoric acid for 15 seconds Etching just enamel… Leaves smear layer intact

Total Etch…..Etching both enamel and dentin Removes smear layer Etch both enamel and dentin for 15 seconds Total Etch Adhesives

• Enamel is etched …..a strong bond with the adhesive

• Dentin is etched…...the smear layer is removed. The top layer of the dentin is prepared to accept the adhesive….resulting in a strong bond to the adhesive. It became possible to bond to dentin with the development of dentin primers. “Primers” are ambiphilic molecules. Picture a carbon chain on which one end has a hydrophilic (usually containing a hydroxyl group…example is HEMA) that is water loving and will “wet” the wet dentin surface, while the other end of the chain has a hydrophobic methacrylate group that chemically unites with the hydrophobic adhesive applied as the second layer Proper Total-Etch Technique

Condition of Dentin After Preparation Smear Layer and Demineralized After 15 Seconds… Phosphoric Acid Remnants Rinsed Away – Dentin Ambiphilic PrimerDemineralizes or Primer/ hydroxyapatite Adhesive and exposes Leftcollagen MOIST fibrils Combination

SmearComposite Layer

Dentin Odontoblasts Tubule Collagen “Noodles” embedded in dentin 4Th Generation Bonding Adhesives Two Bottles: Primer + Adhesive Tot al Et ch

These are not only still on the market, many dentists (and universities) consider them as the “gold standard” of dentin bonding

Popular examples of 4th generation adhesives currently used on the market today are Scothbond Multipurpose (3M), All Bond 2 (Bisco) Optibond Fl (Kerr/Sybron). 5th Generation Dental Adhesive One Bottle TOTAL ETCH

• The first “5th Generation” adhesive was invented by Dentsply/Caulk with the original “Prime and Bond.” • It was revolutionary in that a single bottle contained both the ambiphilic primer and hydrophobic adhesive in the same bottle. • Optibond • Optibond Solo/Kerr • All-Bond 3/Bisco • Prime & Bond NT/Dentsply • PQ1/Ultradent • XP Bond/ Dentsply Total-Etch Product Placement in the General Practice • Enamel borne restorations in the esthetic zone – Long track record of success to combat staining, microleakage and delamination • Reliable indirect applications – Clinical success well documented for all- ceramic veneers, crowns, inlays and onlays • Direct Composite Restorations anterior and posterior…until now the most “universal” of all the adhesives Proper Total-Etch Technique

Smear Layer Composite

Dentin Odontoblasts Tubule Collagen “Noodles” embedded in dentin Proper Moist Bonding Technique to Assure Maximum Bond with No Sensitivity Importance of “Wet” Bonding

Condition of Dentin After Preparation

Proper level of “moisture” must be present to “float”Phosphoric Acid noodles!!! (collagen)

Smear Layer

Dentin Odontoblasts Tubule Collagen “Noodles” embedded in dentin Primer/Adhesive

Over-Dry Dentin – Don’t Do It!

Condition of Dentin After Preparation

Dessication of dentin leads toPhosphoric Acid “Collagen Fibril Collapse”

Smear Layer

Dentin Odontoblasts Tubule Collagen “Noodles” embedded in dentin What about Enamel? Does it have to be DRY?

• Our early adhesion training taught us to dessicate enamel – dry until we saw a “frosty” appearance • This concept was essential prior to the creation of primers when only hydrophobic unfilled resins were available • When primers followed by adhesive (4th Gen), primer/ adhesive combination (5th Gen), or self-etching systems (6th Gen) are used on enamel, Enamel can be “moist”

Moll K, Gartner T, et al. Effect of moist bonding on composite/enamel bond strength. Am J Dent 2002; 15: 85-90 Self-Etching Systems

No etching of enamel or dentin

Apply Self Etch Adhesive to prepared tooth Self-Etching Reaction

Smear layer is “solubalized” into the adhesive and acidic monomers demineralize hydroxyapatite while simultaneously filling voids created with resin Self-Etch Acidic Monomers – Allow to “dwell” for 20-30 seconds

Smear Layer

Apply Self Etch Adhesive to prepared tooth Self-Etch Products

• The dental community largely embraced their relative ease of use and lack of post operative sensitivity. • Self-etch adhesives quickly accounted for around 50% of all dental adhesive sales. • Strong bonds to enamel and dentin, as well as clinically proven technology continue to be of concern to clinicians. Self-Etching Reaction

• Etching, demineralization and infiltration of primers all occur simultaneously • Smear layer and demineralized hydroxyapatite become incorporated into the bond • Reaction is self-limiting: The pH of the product is neutralized by Ca+ Rationale for Self-Etching Systems

• By eliminating the “etching” step, collagen is never left vulnerable, and the potential for collapse is eliminated.

• The acidic component never has to be washed off, – no nasty taste after rinsing – no vulnerable phase where open tubules can become contaminated with bacteria.

• By not removing the smear layer… the “Biological Band- Aid” in essence remains undisturbed… less opportunity for sensitivity.

• May eliminate the concept of “nano-leakage.” – Since these systems etch and prime to same depth in one step… this may be eliminated. Effect of Etching Time on Dentin Demineralization

15 sec 30 sec 3-4 µm

7-8 µm

Latta, M. Dean of Clinical Research, Creighton University, 2003 What is “Nano-Leakage”?

With longer than 15 •Leaves area of 30 sec second etching demineralized dentin times, it is possible with unsupported to etch this deep… collagen •Fluids under positive pressure from pulp 7-8 µm could accumulate in “void” •Potential hydrolysis and degradation of bond •Concept primarily But only “fill” to associated with “total- 3-4 um etch” technique •Not product based When to Use Self-Etching Adhesives

• If you are currently using “total etch” products CORRECTLY, and are still having sensitivity… • If your sensitivity seems to be focused primarily on posterior composites… • If honestly you don’t see yourself routinely using a rubber dam or where isolation is other wise difficult… • If you use very few (none) indirect all-ceramic or lab processed composite restorations that require a total etch adhesive and compatible resin cement… • If the majority of the preparation is in dentin… Dental Adhesives:

Total Etch Adhesives: Etch both enamel and dentin: ie Remove the Smear Layer

Mostly Enamel Prep ( Anterior or Posterior, Indirect Restorations

Self Etch Adhesives: No etching at all: ie incorporate Smear Layer into the bond

Deep preps in Dentin, or Mostly Dentin Preps

Universal Adhesives New Class of Adhesives

Single product can be used as :

•Total Etch Adhesive

•Self Etch Adhesive

•Selective Etch Adhesive No-never 55.9% of clinicians will 26.0% Yes-often 32.7% use phosphoric acid with self etch products…..expecting to improve clinical Yes-rarely results! 18.1% Yes-sometimes 23.2%

When using self-etch adhesives, do you use phosphoric acid to help ensure a good seal? (N=256)

SDM 2012 Total Etch/Universal Adhesive Total Etch Adhesive

No Etch/Universal Adhesive Self Etch Adhesive

Selective Etch/Universal Adhesive No-never Yes-often 70 % of clinicians 29.7% 31.6% acknowledge that the remaining substrate after excavating decay will influence the adhesive Yes-rarely product that they use Yes-sometimes 29.7%

Does the amount of enamel in a clinical situation influence your selection of an etch and rinse vs self etch bonding agent?(N=256) New Class of Dental Adhesive Universal /Selective Etch

•Prime and Bond Elect, Dentsply/Caulk

•Scotchbond Universal, 3M ESPE

•All-Bond Universal, Bisco

•Peak Universal Bond, Ultradent Preparation Classification

Class I Class II Class III Class IV Class V What technique is best to use for each Cavity Classification? Phosphoric Acid • Why is it beneficial to avoid etchant in deep dentin??

• How important is it to etch the enamel margin?

•Can we improve the bond at the cavo surface margin without increasing the probability of post operative sensitivity? No Acid on Dentin Selective Etch Technique

The viscosity of the phosphoric acid gel is ideal for a selective application. The material can be restricted to the enamel margins of a class 1 or 2 or to the enamel margin in the proximal box of a Class 2 Universal Bonding Agents

Operator Chooses Technique

Total Etch Self Etch Selective Etch

Patient’s Chief Concern: “ My front tooth is getting a little dark “

Smile Evaluation:

White: Dark, Bonded #8, #8 appears shorter than #9, Multiple Diastema

Pink: Gingival heights uneven 7,8,9,10

Black: Diastema Treatment… o Gingival Sculpting for symmetry o Whitening for over all color improvement o Indirect restorations #7,#8,#9,#10 o Indirect restoration #8, Direct Bonding #7,#9,#10 to close diastema 4 Indirect Restorations vs 1 Indirect and Bonding vs All Bonding?

Material? Restoration Right Central Incisor Feldspathic Porcelain Direct Bonding to Close Diastemas Direct Composite Bonding Contraindications for Direct Composites

1. Lack of clinical understanding of the importance of proper adhesion and placement techniques 2. Inability to gain adequate moisture control 3. High incidence of caries 4. Excessively large and multiple restorations 5. Margins that end in cementum/root surface 6. Patient lacks value for a tooth-colored restoration Contraindications for Direct Composites Catastrophic Failure of Composite

• Composite placement is technique sensitive and requires considerably greater number of exacting steps required to place. • The elemental composition of amalgam serves as a bacteriostatic agent. • There is nothing in the elemental composition of resin-based composites to discourage the growth of caries- producing microorganisms. Does Amalgam Crack Teeth? What Role Does the Material Play In Fractures Like These? Indications for Direct Composite

• Patient desires an esthetic alternative • Patient expresses a desire for a mercury-free restoration • History of low caries incidence, and good oral hygiene • Conservative class I, class II, or class V restorations • High probability that all margins will be in enamel, and supragingival • Able to adequately obtain moisture control, preferably with the rubber dam

Advantages of Using Posterior Composites • Esthetically pleasing to most patients, therefore patient acceptance is high! • Recent advances in wear resistance and strength have proven to be an acceptable alternative to amalgam. • More conservative preparations are required. • Cohesive bonding may reduce potential of fractures compared to amalgam Conservative Composite Preparations

Access Adjacent Interproximal Lesions Degree of contact separation is dictated by Directly matrix selection

Dietschi, D, Spreafico: Adhesive Metal-Free Restorations, Quintessence Pub, 1995 Conservative Composite Preparations

• No “Extension for Prevention” • No extension into the “Self-Cleansing” area unless dictated by decay or unsupported enamel • Do not senseless destroy centric contacts • Mechanical retentive grooves may be helpful when marginal ridge is in occlusion • Use appropriate beveling The Importance of Properly Managing Polymerization Stress Theories of Post-Operative Sensitivity (When frank pulp exposures are not incurred) • Hydrodynamic theory

– “Open Tubule” theory –Brannstrom • Open, unsealed tubules release the normal vacuum that stabilizes fluid movement • The dentin liquid moves in the dentin tubules in response to stimulus • The stimulus is transmitted via the fluid columns in the tubules to nervous receptors, allocated on the cell body of the odontoblasts. Occlusal stimulus (pressure)

Interfacial gap The Role of Light Curing and C-Factor on Polymerization Stress Composite Shrinkage Process of curing composite is process of “shrinking”. The gelatinous mass we adapt to the cavity becomes “hard” by a chain shortening reaction

Composite placed in a two walled cavity does NOT shrink towards the light C-Factor 0.5 Graeme Milicich: Co-Cure Technique [email protected] Composite Shrinkage

It shrinks towards THE TOOTH due to flow from the large free surface C-Factor 0.5 Graeme Milicich: Co-Cure Technique [email protected] Cavity Configuration

Total of 6 Walls C-FACTOR

BONDED WALLS C= UNBONDED WALLS

Maximum of 5 Bonded Walls What Class of Restoration is Most Susceptible?

Class IV – C Factor .5 Class III – C Factor 1 Class II – C Factor 2 Class I – C Factor 5

2 Bonded 3 Bonded 4 Bonded 5 Bonded

4 Un-Bonded 3 Un-Bonded 2 Un-Bonded 1 Un-Bonded

Is it no wonder that we rarely experience “SENSITIVITY” with ANTERIOR restorations? Effects of Preparation Design on C-Factor

2 Bonded Walls 5 Bonded Walls = C-Factor 0.5 = C-Factor 5.0 4 Unbonded Walls 1 Unbonded Wall Manage Polymerization Stress Using

Vertical Incremental (“Anatomic”) Technique What Causes Gaps in the Bonding Layer? Assuming proper adhesive application

Uncontrolled polymerization stress levied by the overlying composite! How Does the Dentist Create Excessive Polymerization Stress?

1. Bulk filling with traditional composite - the bigger the bulk, the greater the volume of shrinkage and the more stress created on the bonding agent

2. Ignoring C-Factor Vertical Incremental Layering

▪ Same number of increments as horizontal ▪ 1-3 mm increments “buttered” against walls ▪ By not connecting opposing walls, “C-Factor” stresses are minimized ▪ Better adaptation ▪ Less internal cracking ▪ Less “white lines” ▪ Less post-operative sensitivity ▪ More anatomic placement means: ▪ Follows contours of cavosurface ▪ More esthetic ▪ Less Post-operative adjustment Horizontal Vs. Vertical Increments

In High C-Factor Preps, avoid Use Vertical Incremental Layering to horizontal increments that connect create a large free surface with each opposing walls increment. Do not connect walls! The amalgam is removed and the enamel cavosurface is abraded and beveled with a coarse diamond bur

Light cure for 10 Seconds

Prime and Bond Elect is applied as self etch, applying liberally both dentin and beyond the cavosurface for 30 seconds. Vertical Incremental Layering

Light cure for 10 secs

Shade A2 is adapted to the lateral wall of the prep just shy of the cavosurface, following the slopes and grooves of the surrounding tooth structure Adapt to the opposite wall and light cure Optional Placement of “Pit Stain”

Tints and stains are always applied on the dentin body layer and under the enamel layer. Light cure. Apply Translucent enamel layer and contour to cavosurface Finish and Polish

Finish

Polish Immediate Result The “Bulk Fill” Technique

• The most common direct composite procedure in dentistry is posterior amalgam replacement • Cavity forms for many amalgam replacements and large carious lesions prove too time consuming to fill with vertical incremental layering. • A rapid dentin replacement in a single or possibly two step process is attractive. Low Stress Flowables

• SureFil SDR Flow, Dentsply/Caulk

• Venus Bulk Fill, Heraeus

• Filtek Bulk Fill, 3M ESPE Controlled Polymerization Flowable imparts little stress… And the adhesive holds!!

Unique and patented formulation leads to a controlled polymerization compared to an instant Polmerization for conventional composites Low Stress Flowable offers up to 40% in placement time savings Radiopacity •Radiopacity is important to afford the clinician the opportunity to visualize the material radiographically

•Natural enamel- 2.0 •Natural dentin-1.0

•Radiolucent material is difficult to judge-voids, open margins, recurrent decay!

•Look for 2.0+mm/al for Excellent visualization Controlled Polymerization Flowable

Clinical Technique Creating Predictable Interproximal Contacts Problem & Solution Tofflemire v. Sectional Matrices

Tofflemire System Sectional Matrices™ ⊗ Fails to restore ✓Operator-friendly proximal anatomy retaining system ⊗ Thin contact at the Naturally contoured marginal ridge ✓ bands ⊗ Large food trap below ✓Anatomically correct ⊗ Increased likelihood contacts of fracture, occlusal interference, recurrent ✓Contacts at the height caries and periodontal of contour disease. ✓Contacts so tight you’ll need a hemostat to get the band out! Class II Lesion

Proper interproximal contour REDUCED STRESS

“73% of doctors say that creating interproximal contact is the most difficult part of a class II restoration”

• Combine Sectional Matrix and Controlled Polymerization Flowable – a fast and easy procedure – a tight marginal seal – Excellent adaption to a contoured contact area – Less Stress Wedges

•Compress and flare upon entry and exit •Hollow underside •Wave shape •3 sizes Wedges Matrices

•Tab for easy placement and removal •Pronounced marginal ridge •Built-in contact embrasure •Horizontal and vertical contour •Gingival Apron •4 sizes

NEW! Controlled Polymerization Flowable Controlled Polymerization Flowable

Classic “Iceberg” Lesion Access form initiated

Caries-Indicating dye Decay removed, near pulp exposure Prime and Bond Elect Adhesive

Used as a self-etcher Applied for 20 secs with scrubbing

Solvents are volatilized Light cure for 20 seconds Cured adhesive layer tooth #31

The needle-tipped compule permits proper flow and application Fill in 4 – 6 mm increments or up to the DEJ Surefill SDR is “self-leveling and uniformly adapts to the cavity form Light cure for 20 seconds A thin layer of body material is placed over Bulk Fill Flowable

And sculpted to the cavosurface margin just shy of final contour The contoured enamel layer Light cure the final enamel layer for 10 seconds The matrix is removed and the restoration is grossly refined The remaining restoration is filled in the same manner

Back to our case…

Restoration Right Central Incisor Feldspathic Porcelain Direct Bonding to Close Diastemas Whitening Gingival Sculpting Gingival Sculpting 10 days of home whitening Stabilization for 2 weeks

•Simple Shading Choices

• Cool Chameleon Effect

Provisionalize Try in Day of Insert

• Evaluate Smile as part of Whole Face….. or you can get this…….. Tooth and Tissue Features to Evaluate

Health - dental/periodontal disease Size - length, proportion Position - crowding, rotations, arch form, display, cants Contours - facial planes, texture, embrasures Wear - erosions, abrasions Color - value, translucency Tissue symmetry - lips, gingival heights, dark triangles Tooth and Tissue Treatment Options

Teeth - restorative options - tooth contouring - orthodontic therapy Soft tissue - periodontal surgery - implant therapy Smile Design Criteria

Tooth Components Soft Tissue Components

•Gingival Health •Dental Midline •Gingival Levels and Harmony •Incisal Lengths •Interdental Embrasure •Tooth Dimensions •Smile Line •Zenith Points •Axial Inclinations •Interdental contact area and point •Incisal embrasure •Sex, personality and age •Symmetry and balance Tooth Components of Smile Design: Dental Midline

• Vertical contact interface between the two maxillary incisors • Perpendicular to incisal plane and parallel to midline of face • Minor descrepancies between facial and dental midlines are acceptable • A canted midline is more obvious and less acceptable • Maxillary and mandibular midlines do not coincide in 75% of cases Midline

Parallel to long axis of face Perpendicular to incisal plane

Bisects the Papilla Kokich, VG., Spear, FM., Kokich, VO. Maximizing anterior esthetics:An interdisciplinary approach: Tooth Components of Smile Design: Incisal Lengths • Maxillary incisal edge position is most important determinant in smile creation: it serves a reference point for tooth proportion and gingival levels • Parameters to establish maxillary edge position • degree of tooth display • phonetics • patient input Degree of Tooth Display

When mouth is relaxed and slightly open, 3-5mm of incisal 1/3 of maxillary central should be visible in a young individual. As age increases, the decline in muscle tone results in less tooth display Tooth Components of Smile Design: Tooth Dimensions ▪ Dental proportion is related to facial morphology ▪ Central dominance essential ▪ Proportions of centrals must be esthetically and mathematically correct ▪ Width :Length of centrals approximately 4:5 ; a range for their width of 80% of length generally thought most pleasing ▪ Shape and location of centrals determines appearance and placement of laterals and canines Various Guidelines for determining esthetically pleasing proportions:

❖Golden Proportion (Lombardi) ❖Recurring Esthetic Dental (RED) Proportions(Ward) ❖M Proportions (Methot) ❖Chu’s Esthetic Gauges Golden Proportion • When viewed from the facial, the width of each anterior tooth is 60% of the width of the adjacent tooth( mathematical ratio being 1.6:1:0.6. • Strict adherence to calculations can limit creativity and may lead to cosmetic shortfalls Recurring Esthetic Dental Proportion

The successive width proportion when viewed from the facial aspect should remain constant as we move posteriorly from midline. This offers greater flexibility to match tooth properties with facial proportions M Proportions

This method compares tooth width with the facial width using software. The analysis is done via computer and hence involves more of mathematics than artistic analysis.

Mathematically enhanced Golden Proportion These principles are to used as a guide to creating harmony and balance. The eye is used to evaluate and adjust for the most pleasing esthetic results Maxillary central incisors: focal point of the smile and have central dominance Maxillary lateral incisors: provide individuality, never symmetrical, influence gender characteristics Maxillary canines: junction between anterior and posterior, support frontal muscles, buccal corridor determinate, depict gender/ personality traits Buccal Corridor

The dark space/negative space visible during smile formation between the corners of the mouth and the buccal surfaces of the maxillary teeth. Influenced by: ▪ Width of the smile and maxillary arch ▪ Tone of the facial muscles ▪ Position of the labial surface of maxillary bicuspids ▪ Prominence of the maxillary canines ▪ Decrepancies of the value of maxillary bicuspids and anterior six Buccal Corridor Negative space in smile formation Influenced by many factors, most notable is arch form

Considerations: Ortho case Treating #6-11 Value of bicuspids Tooth Components of Smile Design: Zenith Points Zenith points are the most apical position of the cervical tooth margin where the gingiva is most scalloped. It is located slightly distal to the vertical line drawn down the center of the tooth. The lateral is an exception as its zenith point may be centrally located. Considerations: • Closure of a diastema • Reduction of exaggerated triangular form • Correction of tooth angulation Zenith Points

Laterals = half oval Centrals and canines = elliptical Tooth Components of Smile Design: Tooth Inclinations

Axial inclination compares the vertical alignment of maxiallary teeth. From central to canine, there should be a natural, progressive increase in the mesial inclination of each subsequent tooth.

The guide for labiolingual inclination is: • Central positioned vertically or slightly labially • Lateral has cervical tucked in, incisal edge slightly labially • Canine has cervical positioned labially, cusp tip lingually angulated Axial Inclination

Vertical alignment Progressive increase mesially from central to cuspid Measured through middle (not zenith) Tooth Components of Smile Design: Interdental contact area and point o Broad zone in which two adjacent teeth touch o Follows the 50:40:30 rule in reference to the central incisor o Moves apically the further posterior from the midline Tooth Components of Smile Design: Incisal embrasures • Incisal embrasures should have progressive increase in size or depth from the central to the canine. This is a function of the anatomy of these teeth. The contact point moves apically from the central to the canine. Failure to provide adequate depth and variation will: ❖ Make the teeth appear to uniform ❖ Make the contact areas too long result in a over-porcelain look. The individuality of the incisors will be lost.

Tooth Components of Smile Design: Sex, age, and personality • Minor differences in the length, shape and positioning of the maxillary teeth allows for characterization • Age: youthful teeth have unworn incisal edge, defined incisal embrasures, low chroma and high value. Mature teeth are shorter, minimal incisal embrasures, high chroma and low value • Sex • Personality Tooth Components of Smile Design: Symmetry and Balance • Symmetry of the central incisors in width and length is essential • Laterals and Canines less absolute symmetry: Contralateral teeth are very similar but not identical. “Perfect Imperfection” in the laterals and canines makes for a more vital, dynamic, and natural smile. • Nothing in nature is symmetric but can be beautiful and very pleasing to the eye. Profile, Anatomy, Contour

Natural emergence profile Lobe formation Three planes of contour Soft Tissue Components of Smile Design: Gingival Health

• The gingiva acts as the frame for the teeth. • Healthy gingival is crucial prior to treatment ❖ Pale pink in color, stippled, firm and matte finish ❖ Facially 3mm above the alveolar crestal bone ❖ Interdentally 5mm above the intercrestal bone papilla should be pointed and fill gap up to contact point Soft Tissue Component of Smile Design: Gingival Level and Harmony

• Cervical gingival height of the centrals should be symmetrical. It should also match the canines. The gingival height of the laterals is pleasing when it is . 05mm-2mm below the centrals. • The gingival zenith is located distal to the long axis of the centrals and the canines. It coincides with the long axis on the laterals. Relative Gingival Heights Soft Tissue Components of Smile Design: Interdental embrasures/Cerivcal embrasures

• Dark Triangles in the interproximal area are undesirable • If the most apical point of the interproxiaml contact area of the restoration is 5mm or less from the crest of the interproximal bone, then the black triangle will be avoided. At times, this will require a long contact area. • An improperly developed cervical embrasure with overextended, bulky restorations will result in an improper emergence profile and swollen and inflammed gingival tissues. Profile, Anatomy, Contour

Things to watch for!

Dark triangles Tooth Preparation Contact area to crestal bone Temporaries Soft Tissue Components of Smile Design: Smile Line • Smile line is the imaginary line along the incisal edges of the maxillary anterior teeth which should mimic the curvature of the superior border of the lower lip when smiling • Lip line refers to the position of the inferior border of the upper lip during smile formation and determines the display of tooth or gingiva at this hard and soft tissue interface. Ideally, the gingival margin and the lip line should be congruent or 1-2mm of gingiva showing Smile Line Display

Smile line- incisal edge and lower lip Lip line- upper lip and display Incisal length- esthetics and phonetics Color

▪ Natural and Polychromic Shade Selection ▪ Whitening ▪ Hue/Chroma/Value ▪ Characterization ▪ Finish The smile we create should be esthetically appealing and functionally sound

Our aim should be less reduction of tooth structure and greater esthetics and durability Three Important Smile Factors to Evaluate White Esthetics Tooth size, shape, texture symmetry and arrangement Tooth translucency Tooth color, i.e hue, value chroma Tooth/face relationship, i.e. canted, centerline, etc. Tooth quality, i.e. decay, old restorations, wear, etc. Pink Esthetics How much gingival tissue is visible? Gingival symmetry Lip shape and size Papilla/black triangles

Black Esthetics Missing teeth Collapsed buccal corridor Esthetics are determined ultimately by:

Proportion and smile design Artistic influence of dentist Cultural influences Patient’s desires

Indirect Ceramics Patients desire for metal-free restorations led to the evolution of all-ceramic systems…

• Processing techniques novel to dentistry • Heat-pressing • Slip- casting • Computer Aided Design-Computer Aided Machining (CAD-CAM) The oral environment has very challenging working conditions:

Humidity Acidic or Basic pH Cyclic Loading High Level Peak Loads Restorative or Esthetic dentistry should be practiced as conservatively as possible…

Adhesive technologies makes it possible to preserve as much tooth structure as feasible while satisfying the patient’s restorative needs and esthetic desires. Ceramics in Dentistry Four Broad Categories

• Category 1: Powder/liquid feldspathic porcelains Traditional glass ceramics you know and love….just used for veneers (and veneering metal-ceramics). Crafted by hand using powder and liquid

• Category 2: Pressed or machined glass-ceramics Glass matrix filled with particles for strength. Pressed using process similar to lost-wax or milled using CAD/CAM . Machined

• Category 3: High-strength crystalline ceramics Alumina and Zirconia…densely sintered aluminum oxide or ziroconium oxide. Copings and frameworks made with polycrystalline ceramics manufactured by CAD/CAM. Veneered with more esthetic, translucent ceramic on top. Can also be monolithic.

• Category 4: Metal- Ceramics PFMs

Dark

This black Triangle!

Smile Design: Evaluation and Treatment Options What Material?

Limited Orthodontics in the Esthetic Zone Ceramics in Dentistry Four Broad Categories

• Category 1: Powder/liquid feldspathic porcelains Traditional glass ceramics you know and love….just used for veneers (and veneering metal-ceramics). Crafted by hand using powder and liquid

• Category 2: Pressed or machined glass-ceramics Glass matrix filled with particles for strength. Pressed using process similar to lost-wax or milled using CAD/CAM . Machined

• Category 4: Metal- Ceramics PFMs Category 1 Powder/Liquid Ceramics Feldspathic Porcelain • Porcelain veneers made on refractory die or platinum foil technique. Great esthetic value, very conservative preparations, (0.5mm to feather edge at margin). Placed directly onto enamel • Porcelains made for veneering cores: metal, alumina, or zirconia • Ideal for anterior veneers especially when bonded to enamel • Too weak for inlay/onlay • VM13,Vita Beautiful and Conservative Restorations Feldspathic Veneers #7, #8, #9 Category 2 Glass- Based Ceramics Pressable or Machinable Manufactured Blocks • Glass-Based systems with fillers • Lost Wax Technique • Dental Technicians are familiar • Equipment is relatively inexpensive • First Generation contains: Leucite ( VitaBloc Mark II, IPS Empress) • Second Generation contains: Lithium disilicate • Lithium Disilicates twice the strength of Leucites • Now available for pressable or for machined blocks • Lithium Disilicates used in machined restorations (E.max.) Pressable or Machinable Manufactured Blocks: Leucite or Lithium DIsilicate

• Highly esthetic, leucite-reinforced glass ceramic • Clinically tried and true for many years. • IPS Empress Esthetic,Ivoclar Vivadent: Pressable IPS Empress, CAD, Ivoclar Vivadent: CAD/CAM technology Both indicated for inlays, onlays, veneers, and single crowns • Biocompatible lithium disilicate glass ceramic ingots • Optimized esthetic properties stronger than Empress • IPS e.Max Press, Ivoclar Vivadent IPS e.Max CAD, Ivoclar Vivadent Both indicated for single tooth restorations: monolithic and stained or veneered with e.Max ceramic for high esthetic indications Thin Veneers (0.3mm), minmally invasive inlays and onlays, partial crowns and crowns, implant suprastructures, 3-unit anterior bridges(IPS e.Max Press only)

IPS e.Max ZirPress and ZirCAD…zirconia framworks with e.Max pressed on to them 3 unit bridges anterior or posterior Glass- Based Ceramics

e.Max…versatile and Esthetic

• e.Max comes in machinable and pressable forms • Very translucent even with high crystalline content because refractory index of lithium-disilicate crystals relatively low • Porcelain veneering materials contain fluoroapitite rather than leucite for improved esthetics

Empress Veneer #8 Implant #9, Zirconia Abutment with Empress Crown

Posterior Fully Layered Design vs.

Monolithic 360 – 400 90 MPa MPa

Core Lithium Monolithic Disilicate or Zirconia New York University Mouth Motion Fatigue Study

Mouth Motion Fatigue Testing

1609 1535 1304 Newtons of Force of Newtons

2mm Clearance PFM1mm Clearance MonolithicLithium2mm Clearance Disilicate Lithium Disilicate Buccal Thin Veneer

Mean characteristic strength (Wiebull) based upon load at failure during fatigue Category 3 High Strength Crystalline Ceramics Zirconia Porous infrastructure is produced by slip-casting Then infrastructure is sintered (process of heating refractory particles until they fuse at their points of contact) Then infrastructure is infiltrated with glass, producing two interpenetrating continous networks, one composed of the glassy phase the other being the crystalline infrastructure High Strength Crystalline Ceramics

Three Crystalline Phase Ceramics: Alumina In-Ceram Alumina, Procera Spinel In-Ceram Spinell Zirconia In-Ceram Zirconia, Procera Zirconia, Lava, Cercon High Strength Crystalline Ceramics Indications

o Single Crowns anterior or posterior

o All Bridges up to 48mm2 ( up to 5 units with max 2 pontics adjacent posterior, 4 pontics adjacent anterior)

o Crowns on Implants

o Splinted Crowns ( up to 4 units)

o Cantilever Bridges (not for bruxers) ( max 1 pontic bicuspid or incisor)

o Inlay and onlay bridges (not for bruxers)

o Anterior Adhesive Bridges ( not for bruxers) From felpspathic porcelains to zirconia- based all-ceramics, tremendous progress has been made in terms of mechanical performance, with a ten-fold increase in flexural strength and fracture toughness.

Common important characteristics of all-ceramic systems, such as the proportion of glassy phase and amount of porosity, both influence optical and mechanical properties. Deciding which material to use

When to use Which one?

Assessing Esthetic Factors

Assessing Environmental Factors Assessing Esthetic Factors:

Space required and color change for esthetics

Assessing Environmental Factors:

1. Substrate 2. Flexural Risk Assessement 3. Excessive Shear and Tensile Stress Risk Assessement 4. Bond/Seal Maintenance Risk Assessement Space Required and Color Change for Esthetics

Final 3D Position of the Teeth ( Smile Design) Color change desired from the Substrate Substrate ( environmental factor #1)

What material will the restoration be attached to…. …Enamel? …Dentin? …Composite? …Alloy?

We know that enamel is significantly stiffer that either dentin or composite and much more predictable for bonding….it is the ideal substrate for bonded porcelain restorations Flexure Risk Assessment(Environmental Factor #2)

Low Risk: Low wear, minimal to no fractures or lesions on teeth, reasonably healthy oral condition

Medium Risk: Signs of occlusal trauma, mild to moderate gingival recession and inflammation, bonding to mostly enamel still possible, no excessive fractures

High Risk: Occlusal trauma from parafunction is evident, more that 50% dentin exposure, significant loss of enamel due to wear 50% or more, porcelain must be built up more than 2 mm. Excessive Shear and Tensile Stress Risk Assessement (Environmental factor #3)

All types of ceramics( especially porcelains) are weak in tensile and shear stresses. Ceramic material perform best under compressive stress

If the stresses can be controlled, weaker ceramics can be used…bonded porcelain to the tooth. If a high stress field is anticipated, stronger, tougher ceramics are needed. Excessive Shear and Tensile Stress Risk Assessement (Environmental factor #3)

With deep overbites and with Large areas of ceramic material cantilevered:

Restoration should be engineered with support to redirect shear and tensile stress patterns to compression

Use… High strength core systems Metal-ceramics Bond/Seal Maintenance Risk Assessment( environmental Factor #4)

Loss of bond or seal of the restoration to the tooth over time.

Glass matrix materials(weaker powder-liquid porcelains) very susceptible to fracture under mechanical stress……a good bond with stiffer tooth substructure (enamel) is essential.

If a good bond/seal cannot be maintained…high-strength ceramics or metal-ceramics are most suitable because these materials can be placed using conventional cementation techniques. Bond/Seal Maintenance Risk Assessment( environmental Factor #4) High bond failure: • Moisture control problems • Higher shear and tensile stresses on bonded interfaces • Variable bonding interfaces(different types of dentin) • Material and technique selection of bonding agents • Experience of the operator Ceramics in Dentistry Four Broad Categories

• Category 1: Powder/liquid feldspathic porcelains Traditional glass ceramics you know and love….just used for veneers (and veneering metal-ceramics). Crafted by hand using powder and liquid

• Category 2: Pressed or machined glass-ceramics Glass matrix filled with particles for strength. Pressed using process similar to lost-wax or milled using CAD/CAM . Machined

• Category 4: Metal- Ceramics PFMs A word about veneer material selection… Feldspathic when: Restoring tetracycline banded discolorations: more flexibility with opacity and translucent areas Conservative cases: young people… less tooth needs to be removed Pressed when: Increasing incisal length more than 2-3mm Closing diastema greater than 2-3mm Restoring some wear cases Combing veneers with full coverage restorations Stage One Esthetic Restorations: A Cosmetic Solution for the Adolescent 10 year old vs his brother’s head Now

Now 14 years old and fell horsing around with other brother

Considerations for the Adolescent

• Minimal Preparation (Conservation) • Durability • Esthetic Results • Function • Ease of Procedure on Patient “Conservation can be defined as seeking a treatment course that satisfies the mutual goals of the patient and the dentist while posing the least long term harm to the patient.”

Lambert DL. Conservative Aesthetic Solutions for the Adolescent and Young Adult Utilizing Composite Resins, Dent Clin N Am 2006;50:87-118

Restorative Options

• Orthodontic Treatment • Direct Composite Bonding • Porcelain Veneers • Periodontal Treatment for Crown Elongation Treatment: Four Stage One Veneers, minimal prepping, Composite Bonding to mesial of canines

Smile Design… Material? Minimal Preparation Stage One Veneers

Using shaded PearlPress monolithic pressable ceramic

Lower cost because restorations are not cut back and layered with powdered ceramics. They are waxed, pressed, contoured, then externally shaded and glazed.

Results are still quite life-like Provisional Restorations

Direct composite bonding used to close space distal to the laterals Stage One Esthetic Restorations

Expasyl applied for tissue retraction for insert of restorations

Day of Insert

Minimal Prepping Case 2 This is a 28 year old who is dissatisfied with the appearance of her smile. This case was done as very conservatively, mostly prep-less. The upper right and upper left canines were prepped very slightly. Treatment: 10 feldspathic veneers and whitening of remaining teeth

Upper right and upper left canines prepped very conservatively. All other teeth unprepped Lower left first biscuspid has overbuilt pfm crown to be replaced

Trauma Restoration Hockey Player vs Stick Butt

Girl playing basketball vs Gym floor e.Max Machined, cut back, veneering porcelain applied

College Freshman Vs Curb

College Senior Vs Roommates Head

Bicycling Girl vs Open Car Door 2006: Patient unhappy with appearance of lateral incisor Single feldspatic veneer placed Five years later…

2011 Patient also unhappy with #8, and #9 Two more feldspathic veneers Ceramics in Dentistry Four Broad Categories

• Category 1: Powder/liquid feldspathic porcelains Traditional glass ceramics you know and love….just used for veneers (and veneering metal-ceramics). Crafted by hand using powder and liquid

• Category 2: Pressed or machined glass-ceramics Glass matrix filled with particles for strength. Pressed using process similar to lost-wax or milled using CAD/CAM

• Category 4: Metal- Ceramics PFMs History of Dentistry… Trends in Dentistry

• Move away from opaque to translucent materials • General trends towards brighter restorations

opaque translucent Highly Translucent Zirconia

Highly Translucent Zirconia

• Lower strength than traditional zirconia – typically 50% less • Fewer indications • Requires more tooth reduction • Not as translucent as ceramic materials – lacking chameleon effect Lower Strength Fracture Toughness = Ability of a material to resist crack propagation

• HT Zirconia products generally have a fracture toughness of 2.5 MPa-m1/2

• IPS e.max Lithium Disilicate has a fracture Most HT1/2 Zirconia products utilize toughness of 2.5 – 3.0 MPa-mthe same raw material which gives it a translucent appearance and Fracture Toughness reduces strength.

2.7 When products are based on this 2.6 2.5 raw material, then a low toughness of about 2.5 MPam1/2 has to be expected.

Brand B Brand C IPS e.max

Lower Strength But Why?

HT Zirconia is not the same zirconia used in opaque substructure materials.

600 1100 MPa MPa

⇒ Tetragonal + cubic ⇒Tetragonal phase fully phase charged for cubic: no transformation transformation toughening toughening Clinical Evidence Cementation Factors influencing cement decision

• Ease of use • Cost • Strength • Solubility • Post op sensitivity • Clinical environment • Restorative material • Isolation ability

…and more Cementation Selection There are more than 100 permanent cement brands available on the market…..its confusing

Self-Adhesive? Adhesive? Conventional?

Glass Ionomer? Resin?

RMGI Cements? Zinc Phosphate?

ZOE? Polycarboxylate? Important questions to consider when determining the type of cement to use

• What type of restoration is to be placed? Veneer? Crown? Onlay? Inlay?

• What restorative material was used to create the restoration? PFM? Zirconia? Emax? Feldspathic Porcelain?

• What is the condition of the preparations? Substrate? Retentive? Cementation Field? Primary Methods of Cementation

Conventional Cementation Adhesive Cementation Filling space to create “retention” Using dental adhesives and Via luting agents restorative primers to create “adhesion” via chemical bonding Categories of Cement

Adhesive Cements

Self-Adhesive Cements

Conventional Cements Categories of Cement

Calibra, Multilink, RelyX Ultimate Adhesive Duo-link Cements

Calibra Universal, SpeedCEM, Relx Unicem, Self-Adhesive Cements

RelyX Luting, I Fuji Cem, Ceramir Conventional Cements Categories of Cement

Bond Strength Fracture Toughness

High Adhesive High Cements

Self-Adhesive Cements Low Low I

Conventional Cements Categories of Cement

Number of Steps Retentive Prep

+ Adhesive Less Critical Cements

Self-Adhesive Cements More Critical _ I

Conventional Cements Esthetic Adhesive Cements

Used with anterior veneer cases Multiple try-in pastes Light cured through restoration Everyday indirect Access for pulpal involvement/ stability

Determine restorative material

Take records

Determine provisional method Prep tooth Take Prep Shade/ photo Impress Aquasil Ultra Plus

Increased Hydrophilicity Increased Tear Strength – Highest 24 Hour Tear Strength Fabricate provisional

Black/white calibration for computer generated shade mapping TO LAB:

• Pre op photos • Shade Tab photos • Prep shade photos • Provisional photos • Impression of prep • Impression or Model of provisionals • Opposing model • Pre op impression • Bite registrations • Instructions • High Strength Glass Ceramic • Zirconia-reinforced lithium silicate

❖ High Strength ❖ High esthetics ❖ High speed fabrication • Lab scans impression of prep

• Generates model

• Lab scans my provisional

• Lab designs restoration digitally Shade mapping is generated and block is selected

Comparing restoration to provisional model Expasyl for retraction

• Celtra….Which type cement? • Adhesive Resin Cement ……Self etch adhesive

Try in restoration • Apply Elect + activator • Allow to dwell 30 seconds! Prime and bond elect has very small film thickness….cure with light Restoration:

• After try-in: clean with alcohol or Ivoclean

• Prepare with universal silanator

Apply to inside of restoration for 60 seconds Calibra Cement Adhesive Resin Cement

Day of insert

• How do we do more cosmetic cases? • Who should we be talking to? • How do we start the conversation? • Photos? • Treatment planning? • Do our patients want more options? Are we addressing our patients needs and wants? More cases

Gingival Sculpting and Provisionals

Canines Removed Orthodontic Repositioning Lateral Incisors

Susan McMahon, DMD 412.298.2734 www.wowinsmile.com [email protected] When dealing with compromised situations • Uncooperative patient (children, elderly) • Emergency patient (stabilize the situation) • Difficult clinical situation (isolation) • Financial considerations

Where are GI Restoratives used?

Glass Ionomer Restoratives are widely used when the clinical situation does not allow the use of etch & rinse procedures for composites. For example:

•Pediatric dentistry •Geriatric dentistry •Emergency treatments •Temporary restorations •Patients with a high caries risk GI Restorative Benefits

• Fast and easy treatment – No Bonding, no etching required • A true self-adhesive restorative • Cost effective • No shrinkage, biocompatible, flouride release • Technique robust – no rubber dam needed • Easy and fast finishing • Easy removal Technical Approach

To enhance durability the following new constituents have been introduced: • a zinc-modified glass for an accelerated ion-release pattern compared to conventional GI glass • a novel acrylic acid copolymer with a high molecular weight Handling

Detect Early Restore Minimally Dental Caries has traditionally be detected at the cavitation (no longer incipient) stage and management has focused strongly on operative treatment.

This model of dentistry is becoming obsolete Over the past several decades…..

• Increased preventive care • More awareness among the population

Resulting in lower caries incidence and smaller carious lesions Great Progress for the Dental Profession! Decay ‘Epidemic’ Challenge for Dental Practitioners:

Are our traditional ways of detecting and diagnosing caries effective and appropriate today?

Challenge for Dental Practitioners:

Early Detection of caries means much smaller lesions to restore. What are the preferable techniques and materials to do ultraconservative restorations?

Traditional methods of diagnosis: Visual- Tactile

Sharp Explorer Dry Field Mirror Radiographs

……Really just detect well-advanced lesions Explorer

Time-tested tool for caries detection

Probing for caries is a part of standard of care

Well accepted by dentists, dental insurance companies and patients “ A sharp explorer should be used with some pressure and if a very slight pull is required to remove it, the pit should be marked for restoration even if there are no signs of decay” G.V. Black 1900 Explorer will stick only in a very cavitated lesion

…..but gives not indication in early stages of decalcification. Some studies recommend that explorers no longer be used to detect caries, as the sharp tip of the explorer may disrupt areas of remineralization.

Stookey G. Should a dental explorer be used to probe suspected carious lesions? No – use of an explorer can lead to misdiagnosis and disrupt remineralization. J Am Dent Assoc. 2005;136(11):1527,1529,1531 Radiographically

Decay is difficult to detect on radiographs unless… 2mm-3mm into dentin (1/3 bucco-lingual distance) Effect of Fluoride

Fluoride Syndrome: Hidden, Occult, Covert Caries

Clinically healthy enamel with carious dentin lesions under the apparent healthy enamel

Prevalence is high in young adults Correct clinical diagnosis of ‘hidden caries’ is as low as 12%

Correct clinical diagnosis of visible cavities is between 62%-90% Benefits of Early Detection

• Fewer lesions progress to cavitation • More natural tooth structure is preserved • Overall reduction in lifetime treatment costs • Natural occlusion maintained • Natural tooth esthetics maintained A lot of Incipient Caries will be missed if we rely on explorer and radiographs alone. Traditional Visual Tactile Methods

Diagnosis: Decay Treatment: Drilling and Filling

Diagnosis: Slight Decay Treatment: Watch and Wait

Technology Today

Number of Modalities for Caries Detection

• Transillumination (visible light) • Fluorescence (laser, LED) • Electrical Conductance and Spectroscopy • Radiology with Computer-Aided Diagnosis Transillumination

• High intensity white light illuminated through tooth • Demineralized areas of enamel or dentin scatter light more than sound areas. • Incipient caries appear as darker in the resultant images Fluorescence

Oral micro-organisms produce orange-red fluorophores as by-products of their metabolism.

This by-product becomes the marker of bacterial invasion into tooth structure Light Induced Fluorescence

Intraoral Camera Specially developed software for image capture Measures the refractive differences between healthy tooth structure and demineralized tooth structure Healthy enamel fluoresces green Caries invaded enamel/dentin fluoresces red Caries Detection

Detection and Analysis Caries appear blue,red, orange, yellow Healthy Enamel appears green Decay numerically valued 0-5

Color map is good for visualization…Helpful for the patient to see and understand the extent of the lesion

Numerical value essential for reproducibility and tracking • Caries examples Numerical Values

• 1.0 early enamel caries • 1.5-2.0 deep enamel caries • 2.0-2.5 dentin caries • 2.5 and higher deep dentin caries Image and Numerical Data can be saved in patient’s chart

Clinician can decide: • Restore now • Remineralization therapy • Monitor lesion progression or regression over time

“Watch and Wait” is over • Pit and Fissure Decay Analysis • Smooth Surface Decay Analysis • Detect Recurrent Decay around Existing Amalgam and Composite Restorations

…Handheld and Portable easy to use in doctors operatory and hygiene operatory

Evolution in our approach to the assessment, diagnosis and treatment of dental caries….Restore Minimally & Adoption of the approach to save tissue and potentially ‘heal’ or remineralize lesions. Remineralization

Tooth surface is a balance between demineralization and remineralization depending on the acidity of the surrounding environment

The Caries Balance Pathologic Factors vs Protective Saliva flow and components Acidogenic bacteria Factors Reduced salivary flow Proteins, calcium phospate, Frequency of fermentable Fluoride, immunoglobulins, Carbohydrate ingestion Antibacterials in saliva Extrinsic antibacterials such as chlorhexidine

Remineralization Products

• MI Paste – easily applied cream that contains Recaldent. Releases calcium and phosphate in an acidic environment • ACP – Amorphous calcium phosphate triggers the slow release of calcium and phosphate ions and enhances remineralization • Novamin Paste – bioactive glass triggers remineralization • Fluoride varnishes – sodium fluoride in a resin carrier applied directly to demineralized area of tooth • High dosing fluoride rinses, gels and toothpastes RX Remineralization Products indicated for patients with: o Incipient Caries o High Caries Risk o Sensitivity o Xerostomia o Poor Quality Saliva (lacking calcium and phosphate ions) o Poor Oral Hygiene o High Carbohydrate Diet o Medications the promote demineralization o Systemic Diseases like Sjogren’s o Orthodontic and Prosthetic Appliances o Etc… ACP (Amorphous Calcium Phosphate) • Age Defying ToothPaste, Arm and Hammer • Enamel Pro Prophy Paste, Fluoride Varnish, Premier • Relief ACP Oral Gel, Discus

CPP (Casein Phosphopeptide) + ACP • Recaldent • MI Paste, GC America • Trident Extra Care Gum

Novamin • NuPro NuSolutions prophy paste, Dentsply • Topex ReNew toothpaste, Sultan

Xylitol (sugar alcohol) Not actual remineralization product, prevents demineralization by bacterial inhibition

Resin Infiltration Resin infiltration of smooth surface and interproximal caries lesions Arrests the progression of early enamel lesions ‘High Penetration’ resin drawn into lesion by capillary action, penetrating and filling the sub-surface pore system of incipient caries lesion Resin Infiltration Technique

• Apply Icon-Etch for 2 minutes (may have to repeat etching up to 3 times) • Remove etch and rinse for 30 secs, Dry • Apply Icon-Dry 30 secs • Apply Icon-Infiltrate 3 minutes, deeper lesions may need up to 6 minutes • Light cure 40 secs • Apply second layer of Icon-Infiltrate, Cure

Restore Minimally

• Tissue Preservation • Removing and replacing with as little tissue loss as possible • Bioactive materials for restoration to promote internal healing of the dentin

• Fissurotomy burs – Designed for minimal tooth reduction and no anesthesia in enamel • Air Abrasion – Microfine(20-50 micron diameter) alumina in a high pressure air stream • Hard Tissue Lasers – Er:YAG wavelength 2940nm Fissurotomy Burs

•Tip of Bur smaller the ¼ Round • Fine Carbide tip •Ideal for flowable composite •No anesthesia in incipient cases

Lasers

•Cavity Prep •Osseous Surgery •Perio Treatment •Endodontics •Implant Recovery •Peri-implantitis •Soft tissue Surgery Caries into Dentin, Spectra Orange, 2.0

Outline Form follows the decay

Minimal Prep ready to restore • Caries examples Outline form should follow the 3-D shape of the individual lesion and preserve as much tooth structure as possible. Traditional GV Black outline forms are no longer regarded as appropriate. (These older designs extended cavity margins into “self-cleansing” areas. Restorative Materials

BioActive: Material that has effect on or eliciting a response from living tissue, organisms or cell such as the formation of hydroxyapatite

Ideally: • Bactericidal and Bacteriostatic • Stimulate reparative dentin formation • Maintain pulp vitality BioActive Materials offer an alternative to traditional composites

Traditional Composite: Strong, Esthetic, Passive Glass Ionomer: BioActive , Poor Esthetics, Weak Physical Properties BioActive Composite: Strong, Esthetic, Stimulate Apatite Growth

BioActive Restoratives and Cements produce apatite Dentin Sealing and Apatite Formation Marginal Failure and Demineralization

Enamel

Activa

Dentin

University of Oregon; Dr. Jack Ferracane BioActive Restoratives and Cements produce apatite Silver Diamine Fluoride

• SDF – Combination of silver nitrate and sodium fluoride • Inhibits caries lesion progression by it’s interaction with bacteria when applied to carious tissue • Use in primary dentition •Reduction of reduce bacteria and MMPs •Reduces dental hypersensitivity Silver Diamine Fluoride •Cost effective: one drop for several teeth

Stains carious tooth structure black Detect Early Restore Minimally

• Early Caries Detection • Remineralization • Optimal Caries Prevention Measures • Minimally Invasive Operative Approach • Bioactive Restorative Materials BioActive Materials

Heal tooth structure: Grow Apatite Evolution of approach to caries detection and restoration… Detect early and restore minimally Thank you for your time today!

Susan McMahon, DMD