3/10/2017

Text HughFlax to 33444 CONTEMPORARY COSMETIC DENTISTRY then receive PREDICTABLE PRINCIPLES THAT “FACILITATE a link via AND REPLICATE” THE SMILES OF OUR PATIENTS email to download my BY HUGH FLAX DDS, AAACD, MICOI presentation ATLANTA, GA

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 Group 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 Hugh Flax DDS, AAACD MICOI today. Atlanta ,GA • Today I am supported in part by: Flax Dental Member of Catapult Education AMD Lasers Shofu Dental [email protected] Bisco SDI Kettenbach Solution Reach DOXA Dental Intel

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DISCLOSURES

• Huge proponent of “Responsible Esthetics” • Leading edge vs. Bleeding Edge • Products that I mention I use all the time and like to share what is working for me • Learning-sharing new and reinforcing “time-tested” knowledge and learning from each other • Wet fingered real world feedback

NOVEMBER 2015

2 3/10/2017

USA TODAY STUDY (1997) OF ATTRACTIVENESS AND SELF ESTEEM

WHAT WOULD YOU CHANGE ABOUT YOUR PHYSICAL APPEARANCE ? • Weight • Height • Face • Hair

IF YOU COULD CHANGE ANYTHING IN ABC-TV’S YOUR FACE WHAT WOULD IT BE ? “EXTREME MAKEOVER” SHOW !

• Nose • Eyes • Teeth • Chin • Lips • Head shape

TODAY’S CHALLENGES OF ESTHETIC DENTISTRY

• ESTHETICS • BIOLOGY-strength of teeth and bone DIVERSITY IN CULTURE • FUNCTION AND EXPECTATIONS • ECONOMICS 1. Expectations of patients 2. Chairtime 3. Minimally invasive 4. Affordability 5. Durability/ Reparability

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TIME FOR CHANGE • Diversity of people and choices in treatment EXTREME CUSTOMIZATION • How we build value for people and meet expectations • LEVERAGING TIME • The speed and volume of providing information and care • INNOVATING • How to fit someone’s budget-time and financial • BE CREATIVE • How we perform dentistry

EXTREME CUSTOMIZATION

“Innovation distinguishes between a leader and a follower.” Steve Jobs

STONE TOOLS COMPUTER MOUSE JIM ROHN

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CREATIVITY

You need to understand how "Don't think. Thinking is the human beings bring enemy of creativity. It's self- together their brains and conscious, and anything self- enable their ideas to conscious is lousy. You can't try to combine and recombine, to do things. You simply must do meet and, indeed, to mate. things." In other words, you need to understand how ideas have sex.” http://www.ted.com/talks/lang/en/matt_ridley_when_ideas_have_sex .html

INTERDISCIPLINARY CARE

ESTHETICS

PERIODONTAL SUPPORT and CONTOURS

FUNCTION BIOMECHANICS

3 D CT Scan Courtesy of Kai-hung Fung, MD

PERIO ORTHO LAB

WHAT IS ESTHETICS ? The science of beauty in nature as ENVISION THE SMILE an art

“Begin with the end in mind” “Beauty is the association of many complex Stephen Covey associations” Charles Darwin

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FACIAL EVALUATION MIDLINE

 In repose  MATCH THE MIDLINE OF THE  Middle 1/3 =Lower 1/3 FOREHEAD (NOSE ?)

 Maxillary lip length : YAF 20-22 mm  INCISIVE PAPILLA YAM 22-24 mm

INCISAL and INTERPUPILLARY PLANES SMILE FRAME

 The “Broadway Play”

 Proportions  Parallel to each other  Symmetry

 Skeletal defect ? Ears?

LIPS SMILE LINE

 Plane of incisal edges  Form  Lower lip curve  Fullness  Convex-youthful  Competence  Concave-indicates disharmony  Symmetry esthetically (“curb appeal") and  Position (repose/smile) functionally (“under the hood”)  Affect of upper incisors (length/inclination)

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AXIAL INCLINATION GINGIVAL SYMMETRY/CONTOUR

 No excessive display  Long axis of teeth

 Centrals match each other  Harmony-occlusally and canines visually

 Laterals?  Tipping

 Edentulous  Profile spaces ? /gingival shaping

PROFILE BUCCAL CORRIDOR

 What is it ?

 Contour of facial surfaces  Factors ?  Parallelism with adjacent structures Arch width Esthetics Muscles of cheeks Function Soft tissue contour  Incisors ? Posterior teeth  Canines ?  Lab communication

EMBRASURE SPACES/ OUTLINE FORM COLOR

 3-D multi-chromicity  3 Dimensional (incisal/gingival)  Translucency- degree?  Characterization color?  Transition  Dozens of combinations clarity?  Communication tool—several resources  “Halo” -- Smile Guide (Discus)  How to communicate it -- Imaging systems Resources: Analysis (Ubassey) Image FX now called Voyage (Sieber) Patient Gallery http://www.patientgallery.com Ceramic Works (Aoshima) GPS 3D Design http://dentalgps.com/gps-store/gps-software/

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TEXTURE PROPORTION / GENDERIZING

 Ultimate in “microanatomy”

 Age factors

 Communicate with the patient and lab

From PPAD Sept,1998 (Vol.10,No.7)

DENTO-FACIAL HOW DO THESE PRACTICALLY EVALUATION RELATE TO SMILE DESIGN ?

 Esthetically pleasing?

 Tooth display?

 Incisal edge position?

 Gingival level?

 Proportional width?

 Maxillary lip position?

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RULE Create Reference Points

1. Display 2. Length: At least 10 mm 3. Width: At least 7.5 mm 4. Midline: Must be vertical 5. Lateral incisor: 2 mm rule 6. Canine: 1 mm rule

PLAN PLAN 1.Mock Incisal 1.Incisal length 2.Full waxup (function) 2.Gingival level 3.Test Final Mock 3.Implant level

GIVE ‘EM WHAT THEY WANT !!! COMMUNICATE VISUALLY ANYTHING TO ANYONE ,AT “Do what you do so well that people can’t ANYTIME ! resist telling others about you” Walt Disney

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JCD WINTER 2015

WHY NOW????????? WHY NOW???

FACT: In 2009, in the USA, video content views surpassed text content views

BOTTOM LINE

COURTESY CHRISTIAN COACHMAN

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ANALYTICAL EMOTIONAL

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Plan The Smile Your Patient Deserves

www.smiledesignerpro.com/

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DOES THIS HAPPEN TO YOU?

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REVEAL is a light-cured, high- strength flowable composite for the Bonded Functional Esthetic Prototype (BFEP) Technique. • nano-sized filler particles contribute to REVEAL’s excellent polishability • while the reinforcing fillers allow for high filler loading giving REVEAL maximum strength and durability. • REVEAL allows the clinician to diagnostically meet the patient’s esthetic expectations before the definitive restorations are fabricated

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Pink Esthetics WAYS TO MANAGE PINK

TRADITIONAL INNOVATIVE • ELECTROSURGERY • LASER REDUCTION • SCALPEL REDUCTION • CLOSED FLAP GUM LIFT • TUNNEL GRAFTING • OPEN FLAP CROWN (Allen;Salama;Mahm; VISTA;Pin Hole) LENGTHENING • PEDICLE GRAFT • FREE GRAFTING • ADD WITH PINK RESTORATIVE • CONNECTIVE TISSUE Macro-multiple teeth/ large areas GRAFTS Micro-1-2 teeth / small areas

34 yo working mother of 2 children

BIOMECHANICAL RISK ?

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“JUST WANT TO HAVE THE SMILE I USED TO HAVE”

http://www.highlandmetals.com

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SMOOTH ROUND PREPARATIONS

Axial—KS0; KS1 and KS1L coarse Fine flame shaped

Lingual- Egg or pear shaped (coarse/ fine)

Final polish –rubber point

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LumiSmile White Highlights: • 32%, 22%, 16% Carbamide Peroxide • Formulated to minimize sensitivity • Long unrefrigerated shelf life* • Flavored with real peppermint oil • Refill kits available

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IT’S NOT ABOUT THE PAINT ! ! !

IT’S ABOUT THE ARTISTRY THAT YOU DO WITH IT! ! !

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DATA ACQUISITION

 ACCURATE

 CALIBRATED

 SYSTEMATIC

TREATMENT PLANNING STRATEGY FOR “WIN WIN SUCCESS”

FUNDAMENTALS OF  CODISCOVERY—at EVERY visit

DENTISTRY 1. Build understanding

2. Verify and validate

3. Create vision AND Manage expectations

• Biomechanics  BLUEPRINT OF CONCEPTS

• Periodontal support  “TEST DRIVE”

• Occlusal/ Function  GO FOR THE WIN !!! • Habits

• Medical management

• Esthetics

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MED HX

DOCUMENTATION

 Review forms/Interview

 Digital photos (AACD; DSD)

DENTAL HX  Digital radiographs

 Periodontal exam

 Occlusal exam

 Oral cancer exam

 Caries / Cracks

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DIFFERENT CAMERAS FOR DIFFERENT NEEDS & DESIRES

• SLR

• I PHONE smilelineusa.com Smile Lite & Smile Capture Full Set - #6500/6550-SET Adaptor for better focus/ zoom 5000K Light and Polarizing filter for depth/reflection

• EYE SPECIAL II

UNIQUE FEATURES 8 DENTAL SHOOTING MODES EYESPECIAL C-II FOR EYESPECIAL C-II • Designed for dentistry • 8 pre-set shooting modes • Dental grid lines & spot focus Standard Mode – For standard intraoral photography. Low-Glare Mode – For Photographing details of anterior • Water and chemical resistant – Essential teeth; working models and indirect restorations for infection control • Durable rugged Exterior Surgery Mode – For intraoral photography from a certain • User Friendly distance. Whitening Mode – For shade comparison between before • Fast autofocusing & anti-shake and after whitening. capabilities • Easy to use – no photography skills required Mirror Mode – For intraoral photography using a mirror; the image taken can be reversed. Tele-Macro Mode – For photographing anterior teeth, • Light weight/can be held with one hand – indirect restorations and working models in higher weighs only 1lb magnification. **Attach the close-up lens when taking pictures in this mode** • Special Benefits • Compatible with the Eye-Fi X2 card – Face Mode – For shooting facial views or half-body Immediately upload images onto PC, portraits. iPad, Tablet or Smartphone Isolate Shade Mode – You can isolate the shade for • SureFile Photo management software – optimal shade matching. Keeps record of patient information

STANDARD MODE FOR STANDARD INTRAORAL PHOTOGRAPHY ISOLATE SHADE MODE Everyday dental photography – The mode that will get used most YOU CAN ISOLATE THE SHADE FOR OPTIMAL SHADE MATCHING • Ideal distance 9.4 in • Patient will be sitting up in chair or standing • Gingival shades removed • Will likely have cheek retractors in place • Improves visual acuity • Can be taken with normal operatory lighting • Excellent case selling tool • Ideal distance 5.5 in • Patient may have cheek retractors in place – could be used on a model at the bench in a laboratory

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CASE ACCEPTANCE

 Collaborative with DSD system (Interconsultation and Emotional Dentistry)

 Matter of fact presentation of:

1. The “cards” we are dealing with (Awareness of conditions/risks)

2. What are those “implications” to short and long term goals (Consequences) and determine Concerns

3. Options—including “Doing nothing” (PRESENT AT LEAST 3)

 Broad stroke description of a “progressive plan”

 Technical Q & A (with Doc)

 Plan the “first step”

CHECK GENERALIZED WEAR CASE THIS ONE OUT

WHEN A LASER IS USEFUL

ESTHETIC RISK?

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UNSTABLE CHEWING ENVELOPES/ OCCLUSIONS

What pattern of wear?

Kois Continuum #8

BIOMECHANICAL? BONE LEVELS?

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Futar® D Fast - Twice as fast

 Rigid Shore-D hardness of 43

 Dispensed with very little effort, saving time

 Thixotropic and easy to remove

 Total Set Time: 1 Min.

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Futar® Fast - The comfortable classic

 Shore-A hardness of 90

 Thixotropic and easy to remove

 Sets quickly, can also be milled and easily cut with a scalpel

 Total Set Time: 1 Min.

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Hydrophilicity: clinical aspect

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WHAT ARE MY BEST COHESIVE CEMENT CHOICES? “Universal” Adhesive Dual Cure Resin Bio-enhancing Definition

 GC LinkACE  Glass ionomer—Fujicem 2 (GC) •Usable for Direct & Indirect (Film Thickness <10 um)  Bisco Duo-cement  Bioceramic—Ceramir (DOXA) •No additional resin layer required (1-Layer Adhesive)  Ivoclar Multi-link/ •Compatible with D/C, S/C resin cement/composite without DC Variolink Esthetic Activator •Usable with TE, SE & Select-Etch

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SUMMARY of ALL-BOND UNIVERSAL:

 bonds to all dental substrates (Directs and Indirects)  can be used with Self-Etch, Total-etch or Selective-Etch techniques  hydrophilic (good wetting) before curing… after curing, it is more hydrophobic (non-permeable & durable) than other adhesives  long-lasting (durable) bond strength  doesn’t need additional resin/adhesive layer  bonds to dentin regardless of moisture level (over-wet, moist or dry)  compatible w/ S/C and D/C resin materials without additional activator

ETCH with 35 % Phosphoric Acid for 15 sec RINSE

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APPLY 2 coats thoroughly 15 sec per coat DRY lightly to remove excess LIGHT CURE – 10 seconds per tooth

Ceramir Crown & Bridge  Ceramir C&B is a material that combines glass ionomer technology with the innovative Ceramir (Calcium Aluminate – CA) technology. Retention Values equal to self-adhesive resins  The GI contributes to: Retention (gold crown) kg/force  Low initial pH, short duration Metal 45 40  Flow and Setting characteristics 35  Early strength 30 25 20  The CA contributes to: 15 10  Increased strength and retention 5  Biocompatibility 0 Ceramir Crown & RelyX Unicem MaxCem (Kerr) Ketac Cem ZinkPhospate  Sealing of tooth material interface Bridge Cement Retention (gold crown) (kg/f)  Apatite formation Ceramir Crown & Bridge 38.6 ± 8.5  Sustained long term properties, no degradation RelyX Unicem 39.8 ± 15.3 MaxCem (Kerr) 15.9 ± 9.3  Basic end pH Ketac Cem 26.6 ± 4.4 ZinkPhospate 13.9 ± 4.5

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FMR PREVENTIVE MEDICINE GET TIME/FORCE OCCLUSAL INFORMATION WITHOUT RELYING ON SURFACE “PAPER MARKS” OR PATIENT/DOCTOR PERCEPTIONS USE THE T-SCAN BETTER TIMING & BALANCE LESS WEAR/FRACTURES BETTER COMMUNICATION/DOCUMENTATION

SALAMA, COACHMAN, GARBER, CALAMITA,ET AL LETS OPEN OUR PARACHUTES Int. Journ of Perio and Restorative Dentistry Vol 29 No 6 2009; 573-581

Watch carefully !

USING TRANSITIONAL BONDING FOR INTERDISCIPLINARY CARE

Think 3D with color and contour gums-artificial and natural

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REASONING BEHIND THE CREATION OF GINGIVA COMPOSITES

• Promotes minimally-invasive dentistry  eg. effective substitute for gingival grafts • Creates aesthetic solutions without substantial financial investment • Follows the philosophy of porcelain/ceramic side of dentistry • Aging population: desire to retain teeth & reestablish youthfulness • Direct restorative without the indirect lab work • Artistic repair of partial dentures (with CeraResin Bond adhesive and Metal/Liquid primer) • Ability to correct wedge-shaped defects, mask exposed implant abutments, and more • Offers ability to treat ethnically-diverse population

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What’s A GIOMER? Giomer is a collective term for bioactive materials (nano-hybrid resin composites— packable, flowable, bulks—cements, bonding agents, sealant, and light-cure varnish) which contain Shofu’s proprietary S-PRG fillers.

GIOMER products are characterized by their Surface Pre-Reacted Glass (S-PRG) filler. S-PRG filler have a glass core that is pre-reacted with a poly acrylic acid solution. This means that unlike GI that require light curing and water absorption for ion transfer to occur, GIOMER’s filler are protected from water sorption and material degradation by a surface modified layer.

University of Florida Functions of Glass-ionomer phase 8-Year Vs. 13-Year Results 8-Year results as published in 13-Year results as presented in S-PRG Filler JADA 2007: during IADR 2013 poster session: 16 of 26 Class I, and 25 of 35 Class II 19 of 26 Class I, and 22 of 35 restorations were observed. 1)Various Ion Release restorations were observed. • No failures • Retention rate 66% (27 of 41) Improvement of acid resistance by forming… – 52% of retained noted as excellent • No secondary caries Antibacterial effect – 41% of retained noted minor changes Remineralization of decalcified tooth substance • Maintained aesthetics • Secondary caries rate 3.27% (2 of Inhibition of dentinal hypersensitivity • No post-op sensitivity noted 61) restorations noted 2)Fluoride recharge • Overall positive results and low 3)Acid Neutralization Effect 8-Year: J Am Dent Assoc. 2007 May;138(5):621-7 secondary caries attributable to 13-Year: 2013 IADR Poster Presentation, Gordan et al. Giomer technology

13 Year Photos

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Beautifil II Gingiva Indications BEAUTIFIL II GINGIVA & ENAMEL: Beautifil II Gingiva NEW, ERGONOMIC SYRINGE • Intended for the cervical area: • Reestablishment of gingival symmetry • Esthetic correction of gingival recession • Wedge-shaped defects • Exposed cervical areas

• Splinting Ergonomic “one-push” syringe allows for more • Re-balancing of pink and white aesthetics efficient composite handling and application • Papilla replacement • Enables to artistically camouflage exposed crown and bridge margins, implant abutments • Allows to characterize removable full or partial dentures (with CeraResin Bond adhesive and Metal/Liquid primer) • Shades can be layered and coalesced to address patients’ broad clinical needs One-push syringe vs. traditional syringe

INSIDE DENTISTRY MARCH 2017

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MICROGINGIVAL PORCELAIN ENHANCEMENTS • Create a “palette” of colors/ blends Mockup • Sandblast restoration with Prepstart (27 micron AlO2) • Porcelain etch with Ultradent HF (60 sec) and rinse thoroughly • Silane (airdry for 1 min) • Ceramic Primer or bonding agent-cure for 1 min • Place restoration in the mouth • Apply composite and blend • Polish and/or glaze

OPTIONS: 1) Do nothing 2) Remove implant (s) 3) Augment the tissue and restore (single? splinted?) and add pink

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MICROGINGIVAL PORCELAIN ENHANCEMENTS • Create a “palette” of colors/ blends Mockup • Sandblast restoration with Prepstart (27 micron AlO2) • Porcelain etch with Ultradent HF (60 sec) and rinse thoroughly • Silane (airdry for 1 min) • Ceramic Primer or bonding agent-cure for 1 min • Place restoration in the mouth • Apply composite and blend • Polish and/or glaze

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WHY NOW?

• Desire to go digital with impressions—lots of choices; wanted the complete pkg. • Confluence of more user friendliness (impressions/ design/ milling) and better material choices (esthetics; seal; strength; bonding mediums) • CEREC-30 years experience and Sirona’s desire for “CAD/ CAM for everyone” • Expand the breadth of options for our patients Restorative (crowns; partial crowns; and inlays)…..YOU CAN BE CONSERVATIVE Implant surgery and restoration ( crown down approach) Ortho impressions ( Clear Correct; Invisalign 6/15) Digital waxups and integration with DSD Peter Drucker: “Business • It’s FUN and DELEGATABLE has only two functions: • Create a WOW experience-One Visit/ One Shot/ No temp Marketing and Saves time and increased case acceptance Innovation”

Finishing & polishing Comparison with e.max CAD

GC CERASMART Ivoclar e.max CAD 1. Grind off the connector

Compositon Flexible Nano Ceramic Lithium Disilicate Ceramic 2. Use medium silicone point Milling Speed Fast Standard

Crystallization No need Need 3. Use fine silicone point

Characterization Light curing composite or stains Staining with firing step 4. Use diamond paste such as GRADIA DIAPOLISHER Paste for high Finish Polishing or GC Optiglaze Color Glazing with firing step

Firing Unit No need Need gloss

Opalescence Yes No

Flexural Strength (MPa) 211 360

74 638 Vickers Hardness (Hv) (Softer than human enamel) (Harder than human enamel)

Radiopacity % 308 No

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 Shake the bottle  Dispense  Apply a thin layer with a brush  Do not air blow  Cure light-curing device having a wavelength in the range of 400-430 nm for 40 sec (exceptions Kerr Demi Ultra and 3M Elipar 10 S)

Selective etch 15/10/10

IMPROVED IMPLANT SUCCESS

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THE BU$INESS OF MAKING YOUR PRACTICE PROFITABLE

You Got A Problem With That ??

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Your patients can confirm by email and by text!

Recare Reminders bring your patients back to You! $805,462.00 from past Appointments

Newsletters keep your Brand in front of your Patients!

RECURRENT DECAY/ CRACKS PRESENT

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DOCUMENTATION

DENTAL BENEFITS • Better more natural smiles—conservative (preserve enamel) 3 R’s—Relocate  Replace Restore IPR Strip System • Prevention---better fitting bite (peaks; valleys; side of the hill) decrease stress; cracks; and wear 0.06mm│Single-Sided│Extra-Fine Diamond │ Serrated • Improved gum health due to less crowding • Avoid unnecessary treatment and unneeded expense 0.12mm│Double-Sided│Medium Diamond

0.15mm│Double-Sided│Coarse Diamond

0.20mm│Double-Sided│Coarse Diamond

217 SE 136th Ave. Suite 105 www.contacez.com p (360) 694-1000 Vancouver, WA 98684, USA [email protected] f (360) 694-6191

Double-Sided Optional Strips Clean Reduce enamel on two adjacent teeth. After cementation, remove excess cement with an explorer. Pass a ContacEZ Serrated Strip buccolingually in the interproximal spaces to cut and clean out any remaining excess cement. Purple IPR Super-Widener Brown IPR Mega-Widener White Serrated Strip Blue Serrated Strip 0.25mm│Coarse Diamond 0.30mm│Coarse Diamond Gentle Saw Heavy-Duty Dental Saw 0.35mm│Serrated 0.065mm│Serrated

Safely remove cement from multiple Cut into massive excess cement, and restorations without disturbing separate fused contacts of multiple veneers placement prior to light curing. after light curing.

217 SE 136th Ave. Suite 105 www.contacez.com p (360) 694-1000 217 SE 136th Ave. Suite 105 www.contacez.com p (360) 694-1000 Vancouver, WA 98684, USA [email protected] f (360) 694-6191 Vancouver, WA 98684, USA [email protected] f (360) 694-6191

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X

NeoDiamond is America's highest-rated, #1 selling TEXT diamond bur. • 20% more diamond cutting surface for a faster cut with less chair time. • NeoDiamond is individually packaged, sterilized, DIAMOND6 and color-coded with Quick Grit ID for safety and convenience. TO 24587 You will receive a text alert to receive a free box of operative shape NeoDiamonds Offer not valid for previous purchases or in conjunction with any other offer.

More patient-friendly financing helps increase case acceptance More patient-friendly financing helps increase case acceptance: MORE Flexibility: Terms up to 84 months give borrowers lower monthly payments • More Payment Plans: True No-Interest Plans* provide patient-friendly options. MORE Cases Accepted: Patients are • More Flexibility: Fixed APR based on nearly 12% more likely to move forward term selected and applicant’s credit with treatment at APRs lower than score. 14.99%*

• More Approvals: Credit policy expansion MORE Transparency: No application approves more patients. fees or prepayment penalties

So we can treat MORE patients. So we can treat MORE patients

MORE payment plans MORE of what you want White glove customer service

True No-Interest Plans* • A live Customer Care representative answers • No retroactive interest each call, giving our patients and us the attention • Simple to understand we deserve. • No unwelcome surprises • 90% of incoming calls - answered in 60 seconds or less. Extended Plans* • Fixed APR starting at 3.99% based on term selected and • A refreshing change to automated phone-trees. applicant’s credit; $5 late fee versus a default rate. They treat patients the way • Financing up to $50k; great for large cases. we do! • Terms to 84 months; payments better able to meet applicant’s budget.

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BOTTOM LINE—INCREASE RAVING FANS

• Increase the number of Do any one and you can grow in a linear manner. Do any • Dental Intel Report customers who do business combination of the three and you grow exponentially. Case in with you regularly (how many point. Most people doing nothing, with no formal understanding of • As of March 9, 2017 people you attract and keep) these dynamics or principles, have gotten to the point where they have a finite number of customers. Those customers, left on their own without any direction or great sales ability on the part of the • Increase the transaction size (i.e. production per visit) companies, have evolved to a certain fixed unit of sale that’s the average. And they’ll buy a certain number of times without anybody doing anything. If all you did was become a little bit more effective, a • Increase the purchasing little bit more proficient and adroit at selling, you could probably close a frequency (the number of few more customers. In fact, you could probably double it by just visits) being proactive and concentrating on a few simple ways to increase your effectiveness in these three areas.” — Jay Abraham

Slipping Through The Cracks The Power of Actionable Metrics

Are you measuring? 373.

For a Free Practice Snapshot For a Free Practice Snapshot (To the first 20 People) (To the first 20 People)

1. Text 77453 1. Text 77453 2. Keyword “Snapshot” 2. Keyword “Snapshot” 3. Followed by First Name, 3. Followed by First Name, 4. Last Name, 4. Last Name, 5. Email Address, 5. Email Address, 6. Position in the office 6. Position in the office 37 6

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SHADE MATCHING

CHALLENGES IN SHADE MATCHING • Lighting • Metamerism—two objects appearing to match in one situation and not matching in others (office vs. home) • Contrast Effects—visual phenomena that alter perceptions of color (skin tone; background –use blue/gray; large vs small teeth; crowding; successive shades) • Reflections on surfaces • Experience and knowledge • Eyes • Subjectivity of dental team and patient • “Hit man vs. The Healer”

CREATING A WORLD DENTAL SHADE STANDARD ADVANCING DEVELOPMENTS

Dr.Hall 1940 1998

1927 1956 2003 1950’s (Drs.Jung) 1983 Dr.Paravina Dr.Saddon

1998 2010

1983

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MOST SHADE MATCHING TODAY… TECHNOLOGY FROM THE 1950’S

WHAT ARE YOU USING? The color of the tooth

REALITY OF SHADE MATCHING TODAY SHADE SELECTION; IT’S A PROBLEM…

• Doctors are matching shades by looking at the whole tooth or incisal areas. • Doctors are mainly buying and using the enamel shades in current composite systems. • In a recent study 86% of dentists couldn’t agree on a shade. • A recent SCAD poster showed that three leading composite brands didn’t match the intended Vita shade, for numerous shades.

Courtesy of Dr. R. Nash

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BIOLOGY TOOTH SUBSTRATE MANAGEMENT ENAMEL VS DENTIN

Healthy Tooth Decalcification and decalcification are Extraction equilibrium Caries occurs

Resin filling

Bonding agent Bonding

Root breakage Root Border caries

Direct Restoration

Crow Secondary Caries n Cement

Build up core

Crown treatment

Pulpectomy

FUNCTIONAL RELIABILITY FOR COMPOSITES FUNCTIONAL RELIABILITY FOR COMPOSITES

STRENGTH and FLEXIBILIBILITY UNDER MULTIPLE FORCE LOADS and VECTORS • EFFECTS of POLYMERIZATION 1. Volumetric shrinkage 2. Shrinkage stress • FLEXURAL MODULUS—the higher the more brittle • COMPRESSIVE STRENGTH • RADIO-OPACITY

COMPRESSIVE STRENGTH

Radiopacity (mm Al) Polymerisation Shrinkage Stress 4.8 6

5 4

4 3.2 3 2.4 (MPa) 2

1 1.6

0 Radiopacity(mm Al) 0.8 Aura SonicFill Kalore Xtra Fil Surefil Quixx Venus Tetric Rok Ice Glacier

Polymerisation Shrinkage Stress Dentin SDR Bulk Fill Evo 0 A ura Filtek Supreme Est het X HD Herculite Ultra Kalo re T PH3 Ceram XTE Bulk Fill

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HUE , CHROMA & VALUE IN THE END, IT’S ALL ABOUT THE LOOKS

Patients judge their dentists by Hue - Basic color of a tooth e.g red, blue or yellow how their restoration looks! Chroma – Intensity of the color (hue) Value – Lightness or darkness of the color (hue) Opacity – ability for light to pass, translucency

Aura’s shading system • Based on natural make-up and colors of enamels and dentin • Linear, logical and scientific arrangement for predictability and customizing shades • Simple layering technique to reproduce the natural colours of teeth • Designed to simplify shade matching for busy clinicians; minimal effort. • Shade matching in ten seconds is recommended, then the clock starts ticking when the patient entering the chair.

COLORIMETRIC PROPERTIES OF AURA SHADE SELECTION METHOD DENTIN CHROMA RANGE 1. Choosing the dentin 2. Choose the enamel shade shade • Single opacity • Single hue • Large chroma scale, aka color intensity, (Db,DC1 – DC7) is equally spaced • Fluorescence

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Aura has a linear and scientific arrangement for predictability and customizing shades AURA’S FEATURESS

• Non-sticky – less uncured resin is used, creamy handling • Easy to polish to mirror finish • Large particles (60 microns) = high filler loading & strength • Low flexural modulus (big bonus); better fracture resistance, less stress at composite interface means less debonding • Lower polymerization shrinkage

Enamel shades Shade selection for layering technique Based on different colours of natural enamels:

• Shade selection must be carried out E1: most whitish/lightest, high opalescence with before isolation, ideally under day light some degree of translucency. Designed to using Aura shade guide provided emulate young enamel. Age under 20 • Do not dry the teeth • Start with Dentin shade/ bodyEnamel E2: neutral in colour, less opalescence with intermediate translucency. Designed to • Aura’s shade guide is made from actual replace adult enamel. Age 20-60 Aura’s pastes. • No shade change from pre-cured state to E3: tinge of yellow, high translucency & is cured state suitable for aged enamel. Age 60 plus

FEATURES OF E1 – E3 SHADES

• Prepolymerized microfilled composite – market advantage, stronger than a standard microfill. • Easy to polish to high gloss • Contains opalescence (bluish glow in natural light) to match natural enamels, gives life to restoration • Superb gloss retention without the “plucking effect” of large particles

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• College student (about to begin nursing school) Muscle very unhappy tenderness and with her post sense of not orthodontic results having a • Discolored teeth- consistent bite, white spots and prominent yellowed canine, slight composites fremitus of #6-11, • Prominent upper and general left canine tooth wear were • Inconsistent indicative of shapes and occlusal papilla dysfunction • Worn edges of teeth

• Discolored cervical composites and generalized “white spots” were indicative of a history of decalcification. The question at her exam was whether this was still active.

• A “bioluminescence” test demonstrated a lower than optimum pH in the oral environment. Patient was put on an aggressive remineralization program using Carifree treatment rinses and tooth pastes/ gels.

Using the Erbium laser in soft tissue mode of 2 Watts to create a better “gingival frame” prior to bonding

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• Suspicious Surface discolorations decalcifications and previous checked with composites cavity detection conservatively dye removed with a • All remaining flame shaped “affected” enamel diamond maintaining removed with the outer enamel and the Erbium or creating room for new CO2 laser forthcoming layer of Aura.

Consepsis(Ultradent) thoroughly irrigated over microabraded areas to disinfect surface

Set at 27 micron AlO2 and 40 psi

37% phosphoric acid A universal bonding resin was was placed over the placed carefully placed using a entire labial surface microbrush and thinned with an Adec warm air dryer with a 30 second exposure time (since no dentin was involved) and thoroughly rinsed with water for 15 seconds each

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Each tooth being treated was cured for 20 seconds using SDI’s Radii Plus light with its wide tip. Gross finishing is achieved with a thin 16 bladed ET 9 Aura Enamel (Shade E1) was bur to clean the gingival thinly applied and sculpted using margins and establish Cosmedent’s Titanium IPCT labial anatomy. Instrument placing the gingival Interproximal surfaces half first blending the were smoothed with interproximal. After a 40 second cure, the incisal portion is plastic finishing strips adapted to the tooth using the anatomy of the incisal edge and adjacent anatomy to guide initial contouring.

Labial surfaces were polished using a series of abrasive disks

Final gloss achieved using a flexible felt disc and aluminum oxide paste

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CONCLUSIONS

• Smile design and composites are a great entry point for patients who want smile “makeovers”—use the right tools (photos; DSD; and bonding materials) to create artistic success and “good business” • Utilizing minimally invasive preparation design like lasers; air abrasion; and bevels will help to preserve tooth structure and blend composites to look more lifelike • Properly layering composite resin with color friendly materials like Aura helps achieve the beautiful and believable results

CONTACT INFORMATION HUGH FLAX,DDS Thank (404) 255-9080 Email: [email protected] You For lecture info on cosmetic dentistry, implants and lasers

ANY QUESTIONS ???? http://www.catapulteducation.com/educators/hugh-flax

JOIN THE REVOLUTION OF NEW KRAMER VIDEO TECHNOLOGY

 Smarter  Quicker  More precise  More comfortable for the patient  Greater satisfaction  Bottom line: You are “raising the standard of care”

August 2003

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Laser History and Physics LASER is an acronym for : L = Light 1916 A = Amplification by the Einstein took Bohrs theory of Spontaneous emission S = Stimulated and came up with the stimulated emission theory E = Emission of that would be the basis of laser technology. R = Radiation

Scatter Spectrum of Medical Lasers Laser-Tissue Interaction

Diode 812nm Diode (980nm) ErCr:YSGG 2.78 µm Excimer KTP (532nm) Er:YAG ( 2.94µm) Transmission KrF (248nm) XeF(351 nm) KrF (248nm) XeF(351 nm) HeNe (632nm) CO2 (9.6 or 10.6m) (Refraction)

Absorption

Reflection Ultraviolet Visible Infrared 100 nm 400 nm Ruby (694nm) 750 nm Ho: YAG 10,000 nm ArF (193nm) XeCl (308 nm) Nd: YAG (2,08 µm) Argon (514 nm) Argon (488 nm) (1,06 µm)

-rays x-rays UV visible IR microwaves radio waves acoustic waves

-12 -9 -6 -3 3 10 10 10 10 1 10 wavelength, meters

FOCUS ON THE TARGET What happens when tissue absorbs laser Laser Spectrum energy? Ablation, vaporization and cutting

The cell Laser energy Cell expands until it vaporizes

• Laser Light is absorbed by TARGET TISSUE and turned into heat that cuts tissue. • The PRIMARY action of a laser is absorption in chromophores it is attracted to (e.g. melanin, hemoglobin, water, HA) • The photothermal reaction of absorption produces a temperature rise in the target tissue until it expands/vaporizes – and incision/excision occurs • All dental lasers are PHOTO THERMAL.

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Tissue effects caused by thermal exposure Doctor’s advantages when using a laser Zone of Necrosis - Zone of 1. Less Hemorrhage to control tissue is coagulation - most irreversibly of the tissue will 2. Less Pain - Reduced need for prescription damaged and will recover and return drugs for pain die to normal 3. Less need for post operative bandages…lymphatic help seal Vaporized 4. Less need for local anesthesia….saves time Area for many procedures 5. Patients appreciate the technology and will pay more 6. Fewer post-op complications …..reduced microbial colonization.

Possible Soft/Hard Tissue Dental Lasers Cosmetic Restorative Clinical Applications Soft Tissue Procedures •Gingival Recontouring •Gingivectomy •Frenectomy •Troughing Nd:YAG Diodes

CO2 Er:YAG •Fibroma Removal Er,Cr:YSG • Soft Tissue • Semiconductor diode G • Soft Tissue • Excellent for soft tissue •Hemostasis • Neodymium crystal • Affordable 3k-5k • Perio / LANAP • Portable • • Hard tissue Soft tissue • Easy to use • Soft tissue (hard • • Erbium crystal Very expensive • Low Maintenance as well with • Hard tissue cutting ($100K) Solea) • Cavity preps • Gas-based • Very expensive • Used for surgery ($80K+)

AMD LASER Laser Gingival Troughing

 Gingival troughing is one of the most common procedures that can be mastered out of the gate by most new diode laser users.

 Advantages of using a laser vs. packing cord

 Eliminating packing cord – time saver

 Fast and easy perfect impressions

 Little to no post-operative pain and discomfort

Initial Trough Impression Provisionals

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Gingivectomy/Soft-Tissue Crown Lengthening Fibroma Removal  Fibroma removal is easy, fast and atraumatic for your  Lasers can make dealing with soft tissue simpler, more predictable, and provide a win-win situation for both patient. the clinician and the patient.  Advantages of using a laser vs. traditional modalities  Cut and coagulate at the same time  Advantages of using a laser vs. traditional modalities  No bleeding  Cut and coagulate at the same time  No sutures  Predictable tissue response  Little to no post-operative pain and discomfort  Little to no gingival recession

 More comfortable for your patients

 Can be performed with topical anesthetic

 0.8 W Pulsed (topical)/ 1.8 Continuous (anesth)

 Short brushlike strokes/ Metal?

 Stay within attached gingiva

Pre-op Immediate Post-op 2 weeks post op

Laser Implant Recovery Frenectomy

 A diode laser is an ideal instrument to complete a frenectomy – no more scalpels or sutures needed!

 Advantages of using a laser vs. traditional modalities

 Cut and coagulate at the same time

 No bleeding  1.8W Continuous Wave mode, initiated tip, may required  No sutures anesthetic)  Little to no post-operative pain and discomfort  Move slowly, use more energy as needed, and be sure to cool the tissue and site with lots of H20.

Soft Tissue Laser Comparison: Oral Lesions (Apthous Ulcers) Diode vs. Hard Tissue (HT)  A diode laser is an ideal tool to treat aphthous ulcers and herpectic lesions.  Both diode lasers and HT lasers are used today to manage soft tissue.  Laser is used in NON-CONTACT mode, where the tip of the laser not initiated as the goal is for the energy to penetrate  Diode lasers are more precise than HT lasers as diode laser energy is into the lesion. transmitted through an optical fiber that can reach areas where a HT

 Advantages of using a laser vs. traditional modalities large articulating arm cannot.  Reduce pain and discomfort  Diode lasers are great at coagulation and hemostasis as the wavelength  Quicker healing than corticosteriod treatment or other is absorbed by melanin and hemoglobin, the HT laser wavelength is treatment modalities absorbed by water making it more difficult to achieve coagulation.  Delayed reoccurrence of the lesion  Diode lasers are compact and weigh less than 5 lbs whereas HT lasers can weigh up to 40 lbs and are often over 3 ft high.

 Diode lasers are all electronic and optical, with very few moving parts; making diodes more cost-effective, compact and reliable than the much

larger, more cumbersome, and more expensive Erbium;Nd:YAG and CO2 Pre-op Immediate Post-op 3 days post op lasers.

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Er-YSGG vs. Laser Energy Cutting Hard Tissue with High-speed Dental Drill Comparative Clinical Evidence High-speed dental drill causes smear layer Optical Photomicrograph of a Human Tooth and microfractures ErYSGG Cut A The combination of the YSGG laser and the water spray created hydrokinetic energy, which in turn produced a precise, clean and straight cut.

100 µm 10 µm

Notice smear layer surface This SEM shows detail of the structure and microfracture of microfracture at a higher SEM of the cut tooth. approximately 10 microns in magnification. (x2000) width. (x200)

The studies were performed at the BIOLASE Technology research and development laboratory by Ioana Rizoiu, M.S., at the MIFAS, independent Southern California analytical laboratory specialized in optical microscopic high resolution SEM (scanning electron microscopy) and also at the University of California Los Angeles school of dentistry in collaboration with professor Lewis R. Eversole, D.D.S., M.S.D., M.A.

*All of the above slides were performed at a magnification of x200 and x2000 on a Jeol SEM model JSM-840.

Cosmetic Restorative Clinical Applications Clinical Paradigm Shift Hard Tissue Procedures (for adult & pediatric patients)  Micro dentistry (conservative •Desensitization for bleaching care) •Cavity Prep - Classes I-VI  Minimally invasive soft/hard •Caries and Restorative Material Removal tissue treatment •Roughening & Etching •Enameloplasty  Little to no need for anesthesia •Bony recontouring

MAGNIFICATION AND BE GENEROUS TO YOUR PATIENTS !! ILLUMINATION ARE CRITICAL (as if the clinical benefits weren’t enough) IN WORKING WITH LASERS

 Give them comfort

 Give their teeth strength

 Give people courage and hope

 Give them beauty...mimic nature

 Give people a message

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YOU KNOW WHAT THEY’RE THINKING

GIVE THEM A “WOW” EXPERIENCE

Laser Analgesia

Proposed mechanism of action Lasers in Dentistry (Miserdino and Pick) Reducing the action of the sodium potassium pump at Quintessence Publishing 1995 the cellular level thereby slowing or even stopping Chapter 19 Modern optics and Dentistry nerve conduction in the pulpal tissues long enough to page 287 “painlessly” ablate enamel and dentin without the use “ For example, radiation scattered in enamel and of anesthesia in most cases dentin can be entrapped by these natural waveguides and transported to the pulp chamber”

ERBIUMand CO2 LASERS CAN TREATMENT PLANNING MAKE DENTAL CARE COMFORTABLE !!! FUNDAMENTALS OF  Reduction of intra- pulpal temperature 0° to 2° DENTISTRY C (Rizoiu, et al 1998) compared to : High speed (wet) 3° to 4°C increase High speed (dry) 14° C increase  Vibration free- fewer microfractures and less functional disturbance • Biomechanics  Theoretical • Periodontal support Photo-acoustic effect (Scott,2003) Blocking the C-fiber afferent nerves (Japan) • Occlusal/ Function Chemically- Increased endorphins Decreased serotonin • Habits Decreased pain • Medical management

• Esthetics

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* THE PERIPHERAL RIM Rainey’s Ridge

The “There are the solid marginal sections of enamel ridge is just part of the that comprise the peripheral inter-connecting rim of enamel web of the enamel occlusal surface”

J Tim Rainey. Clin Pediatr Dent 21(1) 9-13, 1996

PREOP

AFTER: STRONG,HEALTHY

CLASS 2 RESTORATION 20 yo College Student No Hx of decay Missed 2 CC Visits No Diagnodent Reading Cari-Free 6200

DUE TO RUBBER DAM WITH ANESTHESIA USING SEPTODONT INFILTRATION

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START WITH MESIAL CONTACTS FIRST

ERGONOMIC MODIFICATION OF FIRST LAYER

Paste viscosity of GICs expressed in gF

400

350

300

250

200

150

100 FIRST LAYER OF (gF) viscosity Paste THE 50 “SANDWICH”” 0 Riva SC Riva SC Chemfil Fuji IX Fuji IX Fuji IX Ketac Ketac HV Fast Rock Fast Extra Molar Molar Quick

GLASS IONOMER COMPARISON— TIMING IS EVERYTHING PLACEMENT Brand Working Initial setting Final finishing time time 37 degrees C

Riva Self Cure 1:40 4:10 6:00

Riva Self Cure (Fast) 1:05 2:30 4:30

Riva Self Cure HV 1:30 3:00 5:00

Fuji IX Regular 2:00 4:30 6:00

Fuji IX Fast 1:15 3:35 *3:00

Ketac Molar (Regular) 2:15 4:45 N/A

Ketac Molar Quick 1:40 3:30 N/A

Chemflex Regular 2:00 2-3 N/A

ChemFil Rock 3:20 4:30 6:00

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RADII PLUS—using since 2008  Excellent power and width/ Easy to charge

 Exceptional ergonomics for positioning the head with a tacking tip, as well as, bleaching/diagnostic tips

 Lightweight and cordless

 Warranty 5 years-highest in the industry

BEAUTIFYING INCISAL EDGES-QUICK AND EASY CONSERVATIVE,GENTLE,AND QUICK

T-4 tip

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MINIMALLY INVASIVE…..MAXIMALLY COMFORTABLE

BETTER SERVICE & GREATER PROFIT PER HOUR

EVERYBODY’S HAPPY !!! Dislodged Veneer

“The best dental visit I’ve ever had !”

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WHAT IF YOU TO REMOVE A VENEER?

SETTINGS: 4.5 W 20 Hz 15 % H20 35% Air

“Learn from yesterday, live for today, hope for tomorrow. The important thing is not to stop questioning.” Albert Einstein

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If we have

Health Tooth Decalcification and decalcification are  Better diagnosis Extraction equilibrium Caries occurs Resin filling

 Better understanding of anatomy agent Bonding Root breakage Root

 Better decay removal Border caries  Understanding of occlusion and how cracks develop in teeth Direct Restoration

Crown Secondary Caries

Cement HOW COULD WE IMPROVE? Build up core

Crown treatment

Pulpectomy

How can this get better?

 Can we enhance the bond strength effects of lasers?

 Can you improve on stability and usability of glass ionomer?

 Make teeth and restorations more resistant to acids when patient compliance decreased

Micro-FTIR spectra of the non- and lased dentin (CO2 laser, 69.0  Create a continuous supplement of fluoride J/cm2) revealed that the laser-irradiation eliminated the amide peak wavelengths (box) and increased the crystallinity of dentin (arrow).  More plaque resistant Jpn J Conserv Dent 42(5): 860~877, 1999 Jpn J Conserv Dent 55(6): 411~423, 2012  Able to enhance pulp preservation Er:YAG was done at Hiroshima Univ. (former university for Morioki), BETTER DENTISTRY THROUGH CHEMISTRY CO2 laser work was carried out in our department of Aich Gakuin University.

The characteristic changes of the superficial layer of lased dentin actually demonstrate the increase of the mechanical properties and acid-resistance. Unfortunately, laser-irradiation decreases resin-bond to dentin.

TEM image of the Er:YAG lased dentin Light-microscopic view of the Er:YAG lased dentin demonstrating amorphous and nonfibrous subsurface showing heat-denatured layer observed in red with layer (☆) (demineralized, UA/LC stained). The the thickness of approximately 30 µm (Masson’s resultant heat might superficially denature the trichrome stained) dentinal collagen fibers. Excerpta Medica, International Congress Series 1248. 1st ed. Elsevier Science B.V.: Amsterdam; 2003. 161-166. Information provided by Professors Akira Senda and Fujitani Morioki Aichi Gakuin University

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Able to enhance pulp How to tackle preservation

 Can you improve on stability and usability of glass Mineral Trioxide Aggregate (MTA) ionomer?  High biocompatibility  Make teeth and restorations more resistant to acids  Hydrophilic when patient compliance decreased  Highly alkaline pH of 12.5 (Bacteriostatic)  Create a continuous supplement of fluoride

 More plaque resistant  Excellent sealing ability

 Low solubility

Parirokh M, Torabinejad M Mineral trioxide aggregate (MTA). a comprehensive literature review—part I: chemical, physical & antibacterial properties. J Endodo. 2010;36:16–27

Able to enhance pulp preservation

Cannon M, Gerodias I, Vieira EM, et al. Effects of Different Pulp Capping Techniques on Hard Tissue Bridge Formation, European Academy of Pediatric Dentistry. June 2006, Amsterdam, Netherlands.

Mineral Trioxide Aggregate, Comprehensive Literature Review, Journal of Endodontics, March 2010.

Gandolfi MG, Suh B, Siboni F. Chemical-physical properties of TheraCal LC pulp capping material. Presented at: International Association of Dental Research (IADR). March 18, 2011; San Diego, CA. Abstract #2521.

Gandolfi MG, Siboni F, Taddei P, et al. Apatite-forming ability of TheraCal LC pulp capping material. Presented at: International Association of Dental Research (IADR). March, 2011; San Diego, CA. Abstract #2520.

Gandolfi MG, Siboni F, Taddei P, et al. Chemical-physical properties of TheraCal LC, a novel light-curable MTA-like material for pulp-capping, International Endodontic Journal, 2012.

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MUST REVIEW ALL OPTIONS

Apply and let • Only one coat is required stand for 10 seconds • No agitation required

• Light force to dry/spread Gently air-dry material for 3 seconds • Take care not to splash

Light cure for 10 seconds • (5 seconds LED) halogen

Fluoride/Ion Release/Rec harge Good Anti-Plaque ergonomics

Non-sticky Pre/Post- Excellent curing color flow stability

Phosphonic acid monomer enamel Chameleon Light diffuse Carboxylic acid monomer dentin properties material

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SOME REAL PERSPECTIVE

The LiteTouch Er:YAG laser Introducing You To The LiteTouch The Best Choice

• Its entire laser delivery mechanism housed within the handpiece • No loss of energy • Avoids the heavy, rigid and bulky articulated arm and fragile fibers • Ergonomic design and maneuverability

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WHAT IS ESTHETICS ? “Rules of Beauty”

The science of beauty in nature as an art

“Beauty is the association of many complex associations” Charles Darwin

ESTHETIC PROPORTION GINGIVAL SYMMETRY/CONTOUR

 No excessive display

 Centrals match each other and canines

 Laterals?

 Edentulous spaces ?

From PPAD

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Evaluating Gingival Contour* Most Common Undesirable Outcome

Using the incisal plane as FACIAL LANDMARKS the sole reference point for gingival Ophraic Line (eyebrows) evaluation.

Interpupillary Line (mid-eye)

Interalar Line (nose)

Commissural Line (lips)

*From Dr. Ken Canzoneri

SOFT TISSUE CONTOURING

LESSON LEARNED Always expect “growths” to recur

Take the dermatology approach

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EARLY SOFT TISSUE

USING A G-6 TIP

LASER STERIZATION/ETCH POST SPACE

Z-4 tip into post space .50W 34% air 24% H2O activate on outstroke

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LESSONS LEARNED: • BE CREATIVE • MANIPULATE PAPILLAE TO YOUR ADVANTAGE

Then Mommy and Daddy are Queen If we are and King the Princesses

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VICTORY COMES TO THOSE WILLING TO CHANGE (and GET OUT OF THEIR COMFORT ZONE) Reality Check

“The Biologic Zone determines the cervical limitations of tooth preparations and will ensure the preservation of a healthy periodontal attachment.” John Kois Contemporary Esthetic Dentistry Vol.2 No.1 1996

“THE MIND IS LIKE A PARACHUTE IF IT DOESN’T STAY OPEN, YOUR GONNA CRASH”

Based on a study of 100 healthy In this study it was found that 85% - patients with unrestored teeth 90% of the time

“The total dentogingival complex is more clinically significant to ensure predictable results” John Kois “Altering gingival levels: the restorative connection part I: biologic variables” J Esthet Dent Vol 6 No1 1994 John Kois Contemporary Esthetic Dentistry Vol.2 No.1 1996

The Gingival-Esthetic MY EPIPHANY ! Restorative Challenge THANK YOU BOB ! How to:

 Create an esthetically pleasing gingival architecture ?

 Maintain biologic width by mimicking the osseous scallop?

THE ANSWER: Using a Erbium Hard/Soft Tissue Laser MARGIN STRATEGY: SOFT →RESTORATIVE→ OSSEOUS

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Laser etching w/G-6 tip

LEARNING LESSON: GET RID OF INFLAMMATION FIRST !

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A WEDDING MAKEOVER- DISCOVERING THE FOUNTAIN OF YOUTH

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Diagnosis Radiographic Exam

 Generalized gingival excess

 Compromised esthetics dentally and periodontally

 Occlusal CR-CO discrepancy with a centric interference at #19

LESSON: NO HEAVY METAL!

Treatment Plan Outline Precautions

 Closed flap reduction of gingival/ osseous areas to improve  Anatomical-treating the correct genotype esthetics and vigorous home care  Esthetic-patient concerns and the demands of the dentist---  Multi-tasking healing phase of whitening lowers, occlusal therapy, and 3-D diagnostic waxup especially the metal margins around the crowns on # 8 and 9  Restorative care of all-porcelain crowns and veneers on #3-13  Air embolism and porcelain pressed to metal crown at #14  Excess heat generated –avoided by lowest level energy, tip  Ultimately update lower teeth with more esthetic restorations out of contact, H20 spray

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Postoperative Care

 Plaque removal

 Massage of the labial gingiva toward the teeth

 Oxygel application

 Rinses of 0.12 % Chlorhexidine

 Immediate post-op rinses with saline

LESSON: TRAIN YOUR LAB !

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Follow-up Care

 Vigorous homecare with Sonicare, flossing, and Fluoridex (Discus) as well as daily wear of maxillary occlusal appliance

 Regular maintenance visits at 3 month intervals during the first year

 Monitoring occlusal bite guard and natural contacts for any centric and exclusive interferences.

DIAGNOSIS IS THE KEY

 Tooth size HOW DO YOU GET RID OF  Arch width THEM ?  Missing teeth  Occlusion

 Periodontal conditions

“SPONGEBOB” SPACED-TEETH

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LESSON: WHEN YOU GO “OUTSIDE THE BOX”..TEST IT IN 3D

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MIMIMAL PREPARATION- the impossible becomes possible

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PUTTING IT ALL TOGETHER

LASE IT !

MARK YOUR PATH

HEAL VERIFY IT

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“Good-to –great organizations avoid technology fads and bandwagons, yet they become pioneers in the application of carefully selected technologies…used technology as an accelerator of momentum not the creator of it”

WHAT’S NEXT? CONCLUSIONS

 Evidence based research (co-op?)  Minimally invasive restorative care

 Better delivery systems and wavelengths  Avoid lengthy recovery times from gum surgery (less invasive.....no stitches !)  Specialty acceptance  Give the dentist more control of their  New standard of care cosmetic cases (no referrals and better  Public awareness to increase demand artistry !)

 Penetration into the dental market  The best part: Patients are happier by completing the "smile makeover“ cases 2-3 months faster (much better customer service!)

If you want to learn more about lasers and cosmetic dentistry: A FINAL THOUGHT…….

“We are not creatures of circumstance; we are creators of circumstance” Dental Clinics of North America—Cosmetic Dentistry Update April 2011 Vol. 55 No 2 Benjamin Disraeli

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THANK YOU FOR YOUR TIME AND ATTENTION CONTACT INFORMATION HUGH FLAX,DDS (404) 255-9080

Email: [email protected]

For lecture info on cosmetic dentistry, implants and lasers

ANY QUESTIONS ???? http://www.catapulteducation.com/educators/hugh-flax

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