CRD 2016 handoutd1ue90e5sp4tcv.cloudfront.net/2900/images/Asset303059_v1.pdf · •Resin compatibility •Strength •Efficient curing Combating Sensitivity •By achieving a great

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Paresh Shah, DMD, MS (Physiology), Cert. Esthetic DentistryParesh Shah , DM D , M S , C ert . Es thet ic D ent is try

Nov. 17, 2016Montreal, Quebec

Contemporary Esthetics for Everyday Practice Thank you!

• Clinical Research Dental• Peter Jordan

Disclosure

• All photography taken on our patients has been left unaltered except for cropping to fit slides

• Photography by other providers is acknowledged on appropriate slides

• I serve as a consultant for a variety of manufacturers -product development & evaluations

Dr. Paresh Shah

204-837-4517 work204-295-2233 direct

[email protected]

drpareshshah.com

The Dental Industry’s Premier Speakers Bureau & Product

Evaluation Organizationcatapultelite.com

CatapultGroupisanorganizationwhichconsistsoftopcliniciansandeducatorsfromthroughouttheUnitedStatesandCanada.Thisgroupoflike-mindedyetdiversedentist’sgoalistobringqualityeducationtothedentalcommunityviamultiplevenuesincluding;livelecture,participation,webbased,andwrittenformats.

PareshShah,DMDWinnipeg,Canada

[email protected]

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Paresh Shah, DMD, MS, Cert. Esthetic Dentistry

• MS Physiology - U of Manitoba, 1987• DMD - U of Manitoba (Winnipeg), 1991• Hospital OS Internship - U of Manitoba, 1992• Proficiency Certificate in Esthetic Dentistry -

U of Buffalo (SUNY), 2007• Adjunct faculty at University of Pacific

Dental School - San Francisco• Clinical Instructor for Post Grad Program in

Esthetic Dentistry - U of Minnesota 2002 -2009

• Seattle Study Club co-director since 2005• Kois Center Graduate 2013

Learning Objectives

•Learn to evaluate various direct and provisional restorative materials so as to select the most appropriate for each situation

•Learn practical restorative techniques to simplify the restoration of your cases and implement them immediately

•Learn practical layering techniques to make your anterior restorations more natural looking

•Learn techniques to improve the outcome and esthetics of your indirect restorations on natural teeth or implants

Let’s start from the beginning with the basics of Bonding &

Adhesion..............

Paresh Shah , DM D , M S , C ert . Es thet ic D ent is try

Adhesion


P aresh Shah , DM D , M S , C ert . Es thet ic D ent is try

Adhesion

Adhesion to tooth structure involves the removal of the mineral portion of hydroxyapatite (calcium phosphate) and the subsequent replacement of this lost mineral with acrylic monomers.


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Enamel Histology

Consists of 90% hydroxyapatite (inorganic mineral) prisms.10% proteins & water. Enamel may be desiccated to create a hydrophobic surface to bond since

there is no direct circulation to replenish this water The outer layer typically lacks prisms which creates a challenge bonding

with self-etch systems.Exposing the enamel prisms with a bur makes the the enamel better suited

to bonding.


Dentin Histology

Comprised of 60% hydroxyapatite (inorganic) mineral, 30% collagen (organic) and 10% water.

Collagen is not found in enamel and typically takes the shape of a helical strand-like network in dentin.

Most of the water comes from the dentinal tubules due to pulpal pressures which are influenced by the proximity to the pulp. A small amount of water is bound in the hydroxyapatite crystals.

Dentin is hydrophilic in nature and the extent is influenced by the proximity to the pulp and subsequent pulpal pressures.


Role of an Adhesive System?1.Sealthetooth 2.Retainrestorative

• Hydrophilic• GoodenamelEtch• Primerpenetrationintodentintubules

• Lowhydrolyticdegradation• Efficientcuring

• Hydrophobic• Resincompatibility• Strength• Efficientcuring

Combating Sensitivity•By achieving a great bond••


All Adhesives and Composites are Hydrophobic in nature

They do not like moisture and will not stick to hydrophilic structures without the aid of a Primer


Primers and SolventsPrimers are bipolar monomers with a

hydrophobic component on one end and a hydrophilic on the other

The hydrophilic component allows coupling with moist surfaces such as dentin while the hydrophobic end facilitates bonding to the adhesive/composite over top


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Primers and solventsPrimers are typically suspended in a

volatile solvent such as acetone, alcohol or water.

The solvents allow the penetration of primers into the dentin and tubules, but must be evaporated off


Smear LayerComposed of hydroxyapatite, collagen

and tooth debrisLoosely attached lining over the floor of

pulp after dentin has been freshly cut

Believed to serve as a barrier to bacterial invasion into dentinal tubules


Smear LayerAdhesives tend to be classified by the way they interact

with the smear layer:

early generations: attempted to modify or attach to smear layer

4th & 5th generations (total etch): advised removing the smear layer

current generations (self-etch): incorporate the smear layer into the bond


Adhesion - Enamel (total etch)

Enamel:

Mechanism of adhesion to enamel is different to that of dentin

Micromechanical retention to the ends of etched enamel rod prisms

Removes Calcium phosphate from the hydroxyapatiteExposes enamel prism rod to create a rough surface for micromechanical

retention

(BUONOCORE MG. J Dent Res. 1955 Dec;34(6):849-53.)Paresh Shah , DM D , M S , C ert . Es thet ic D ent is try

Enamel Bondingn Isolate teeth (moisture control)n Preparationn Etch cut/prepared enamel 15- 20 seconds - phosphoric acid (34-37%) & uncut

enamel 30 - 60 secondsn Rinse etch for 5 secondsn light air dryn Apply bonding agent to entire prep by scrubbing with a stiff, dry microbrush for

2-3 applicationsn lightly air dry to remove solventn light cure at least 10 seconds n place composite

de Meneszes, FC et.al. Quintessence Int. 2013;44(1):9-15


Adhesion - DentinDentin:Adhesion to dentin involves encapsulation of exposed collagen fibers.Inorganic phase removed from dentin surface by acid etching.Dentin bonding agent penetrates the vacancies and fills the tubules and

peritubular dentin.This is called the hybridization zone & is dependent on control of moistureCombination of collagen and bonding agent form a barrier to microbial invasion

and eliminates post-op sensitivity


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Removes smear layer allowing for micromechanical adhesion similar to enamelDemineralizes hydroxyapatite in the intertubular and peritubular dentinOpens dentinal tubules & exposes collagen matrix in the dentin to facilitate

adhesionOpening dentinal tubules makes the technique sensitive to operator

technique if they are not suitably “sealed”Moisture control is key to collagen fiber exposure - avoid over-wetting or

over-drying

(Brännström M, Noredenvall KJ.J Dent Res. 1977 Aug;56(8):917-23.)

Adhesion - Dentin (total etch) Dentin Bondingn Isolate teeth (moisture control)n Preparationn Etch dentin for 10 seconds - phosphoric acid (34-37%)n Etch enamel for 15-20 secondsn Rinse etch and lightly air dry over dentin (moist dentin bonding) - should see a

shiny consistencyn Apply bonding agent to entire prep by scrubbing with a stiff, dry microbrush for

2-3 applicationsn lightly air dryn light cure a minimum of 10 secondsn place composite in increments

Dentin Bonding

Smear Layer Removed/EtchedSmear Layer Present/Unetched

Unetched vs. Etched Dentin

Challenges with Dentin Bonding - total etch Moistvs.DryDentin– overdryingcanresultin1.Nowatertosupportthecollagenfibers2.Poorhybridlayer3.Sensitivity

Moist Dentin Dry Dentin

Collagenfiberscollapsedandspacebetweencollagenfibersclosed

Openspacebetweencollagenfibersmaintainedbywater

Hybridlayer NoHybridlayer

Combating Sensitivity - By Achieving a Great Bond

§Isolate area to prevent contamination§Do not over-etch§Do not pre-dispense adhesive§Evaporation degrades adhesion§Lowers bond strength

§Blot excess water§Leave surface moist§Saturate tooth w/ adhesive & scrub§Lightly air dry adhesive layer§Thoroughly light cure adhesive§Check your curing light regularly

Combating Sensitivity••By using a universal adhesive•

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Selective Etch & Universal Adhesive Bonding Agents - Universal Adhesive

n Key Benefits:- Total-etch technique- Self-etch technique- Selective-etch technique

3 methods of use

Total-Etch

Self-Etch

Selective-Etch

Dentin Bonding - Selective-Etch

n Isolate teeth (moisture control)n Preparation of tooth and placement of dentin liner (if desired)n Selective etch of enamel only for 15 seconds (agitate)nRinse etch for 5 seconds & lightly dryn Dispense universal bonding agent according to manufacturers

instructions (dish, stiff micro-brush)n Apply universal bonding agent by scrubbing onto entire prep for at least

10 seconds (apply 2-3 coats without drying in between)n light air dry and acheive a shiny finishn Light cure 10 seconds (manufacturers instructions)n place composite in increments

Bonding Monomers - what you sould knowGPDM – 20 years of use

• Twomethacrylatefunctionalgroupsmeans:

– Moreeffectivecuring– Improvedmechanicalrigidity/more

bondingstrength– Morebonddurability

• Morehydrophilic– Worksbetterwithtoothstructure

MDP - 20 years of use

• Onemethacrylatefunctionalgroupmeans:

– Lesseffectivecuring– Lessmechanicalrigidity,– lowermechanicalstrength– Lessbonddurability

• Lesshydrophilic

– Doesnotworkaswellwithtoothstructure

KeepinginmindGPDMandMDPbothworkwithsolvents&othermonomersforanoverallmoreeffectivebondingsystem.

Thinkofitlikethis– whichofthesetwohooksdoyouthinkismoreeffective?

Matrix Metalloproteases (MMP’s)

• MMPs are not bacteria but are inactive proforms of proteolytic enzymes found within dentin collagen fibrils capable of degrading collagen within newly created adhesive hybrid layers as well as extracellular matrix proteins

• MMPs play a major role in autodegradation of collagen fibrils within the hybrid layer at adhesive tooth restoration interfaces

• MMPs are well studied. These proteolytic enzymes have been linked to Periodontal Disease/tissue destruction for years. However, degradation is an important feature of development, tissue repair, and remodeling.

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Matrix Metalloproteases (MMP’s)

• With new research, they have just recently been linked to collagen breakdown within dentin, leading to adhesive failure.

• Benzylkonium Chloride (BAC) and Chlorhexidine (CHX) are two of the only disinfectants which in addition, inhibit MMP activity on dentin surfaces. Other studied compounds include: galardin, flavonols, EGCG, tetracyclines, QAMS

MMP inhibitors

CHX = ChlorhexidineBAC = Benzalkonium Chloride

Adhesion Basics - Summaryn No ideal adhesive system exists when it comes to total-etch or self-etch

n Vigorous scrubbing of adhesive during application increased bond strength for both types of adhesives

n Prolonged light curing beyond recommended manufacturers instructions increased bond strengths

n warm air drying of adhesive helped remove solvents better than air

Reis, Carrilho, Breschi, LoguercioOperative Dent. 2013;38(4):1-15

Adhesion Basics - Summaryn Difficult to get an absolute best adhesive result with just one type of adhesive

n Total-etch and self-etch both have a place n Bond strengths depend on type of substrate (enamel or dentin)

n When using a self-etch system, it is best to etch enamel (keep off dentin) to achieve high bond strengths

n Vigorous application with a stiff brushn Always overcure

John Kois - Symposium update July 2013

Combating Sensitivity•••By using a liner/base

Combating Sensitivity - Glass Ionomer Liner/Base

§ Deep restorations w/ near pulp exposures§ Bonds to dentin and enamel w/o surface pre-treatment§ No need to etch§ Reduces sensitivity§ Fluoride Release§ Once cured can be etched and bonded with any type of adhesive

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Glass & Resin Ionomers

• ACT as a dentin substitute• REPLACE composites as a dentin

substitute• Still REQUIRE composites as an

enamel substitute in posterior occlusal load areas and in cosmetic anterior issues

• Are Bioactive, no other restorative material is!• They can re-mineralize tooth structure so

remove the soft stuff but leave the dentin that can remineralize

• Inhibits Plaque by fluoride release, great for lesions in furcas, deep dentin and cementum

• Glass ionomers have greater ion release than resin ionomers

Why a Dentin Replacment?

• - They have thermal expansion properties similar to DENTIN• - They require a chemical bond with only mild etching… even less than self

etch, no over etching, NO OPENING TUBULES, you want the ions there!• - They have 1/9th the shrinkage of a composite and thus less stress. • - They release fluoride and other ions as they are exposed to water and

reactivate when exposed to fluoride• - They are easy to place!

Linings• Linings are ResinIonomers with finer

grained contents and are meant to be placed in thin increments. No greater than 1.5mm

• Examples areFuji Lining Cement Paste Pak

Ionoseal Vitrebond Plus Clicker system: studies show can reduce an effect of polymerization shrinkage by more than 50 per cent of bonding aloneIn any class they can line the dentin walls and floors

Deep Caries

Bases - Techniques• Bases: Applied in thicker amounts• Glass Ionomers such as–Fuji 9 Equia–KetacNano by 3M–Hi-Fi by Shofu–Riva Self Cure Fast Set

Resin Ionomersq Fuji 2 LCq Riva Light cure

Either can be placed as bases in open or closed sandwich

Bases - Techniques• Open Sandwich would be a class 2 in which the

cavosurface margin would be in dentin or cementum and the margins of the restoration cervically are exposed to the oral environment and thus restored with a GIC

• Closed Sandwich would be in a class 1 where the pulpal floor and dentin are lined or built up by the GIC or in a Class 2 in which the proximal box is in enamel and the GIC is fully enclosed by the composite

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Flowables

Class V lesions

Selective Etch

Flowable

Universal Adhesive

Polishing

Polishing

Final Restorations

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Class V - NCCL Adhesive & application of composite

Easy placement and manipulation

Final Restorations

Posterior Restorations

Class II restorations -foundational to everyday practice

Success?10 years post-tx

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Success?10 Years post-tx Contacts

Embrasures

Final Contour

Challenges with posterior composites

• Technique sensitive - moisture control- depth of cure- contours & contacts• Time consuming - compared to traditional amalgam

restorations • Harder to do quadrant dentistry

• The #1 reason for composite failure is recurrent decay – and the floor of the proximal box of a Class II is the most vulnerable area

Posterior composites

Traditionally have been more time consuming that alloy restorations

Technique sensitivity has created a negative reputation for direct composite restorations

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Isolation is key!!

Challenges with Toffelmire MatricesTofflemireSystem

FailstorestoreproximalanatomyThincontactatthemarginalridgeLargefoodtrapbelowIncreasedlikelihoodoffracture,occlusalinterference,recurrentcariesandperiodontaldisease

Wedging & contact forming instruments

• Traditionally to create tight contact areas we need to use wedges to separate teeth.

• We also need to use contact forming instruments to assure tight contacts

• The combination allows us to create natural contact areas• With amalgam we can do multiple restorations at one time faster

Active wedging required to create contact areas

There has to be a better way!

Posterior composites - Just got easier and more predictable

1. Sectional matrices & ring systems2. Universal bonding agents3. Bulk fill materials4. Can do multiple compositee restorations

simultaneously

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Ring & Matrix Systems

Sectional Matrix

Sectional Matrix

Solutions using Sectional Matrices

TofflemireSystemFailstorestoreproximalanatomyThincontactatthemarginalridgeLargefoodtrapbelowIncreasedlikelihoodoffracture,occlusalinterference,recurrentcariesandperiodontaldisease

SectionalMatrices✓Operator-friendlyretainingsystem✓Naturallycontouredbands✓Anatomicallycorrectcontacts✓Contactsattheheightofcontour✓Contactssotightyou’llneedahemostattogetthebandout!

NiTi only spring

V-Shaped glass reinforced autoclavable plastic tines(leaves room for the wedge)

Built in lip for increased stability in forceps.

Anatomically shaped tines

6 .5 m m M a trix w ith su b -g in g iva l e x te n s io n

T a b ca n b e b e n t 9 0 ˚fo rcon tra -ang le p lacem ent

S ide ho les fo r easyre m o va l

H o le s d e s ig n e d to fit w ith p o s itive g rip P in -T w e e ze rs

T h e o n ly m a trix b a n d w ith m a rg in a l rid g e co n to u r

Developer: Dr Simon McDonald BDS MSc DDPH

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Clinical case - Narrow V3 Ring

Final Restorations

Clinical cases….

Ring System

2 rings in tandem

Universal adhesive

Bulk fill flowable

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Bulk fill and cure-through Contour & finish

Finishing

Multi-fluted carbide bur Diamond finishing strip

Polishing

Diamond or silicone carbide polishing brush

Final restoration Caries

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Sectional ring Adhesive & Sonicfill 2

Shaping and finished restoration Sonicfill 2

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Final

Shade selection tips

Tips for Accurate Shade Selection

Teeth are polychromatic in the natural state and reflect and transmit light differently

Cervical region is typically yellow due to the color of the underlying dentin

Body and mid region is has more enamel and is lighter

Incisal region is predominantly enamel and typically more blue/grey or translucent.

Tips for Accurate Shade Selection

There are 3 dimensions to color that help us define it:1. Hue

2. Chroma

3. Value

Shade SelectionHue

Hue is a primary color or the mixture of colors. For example, blue plus yellow = green.

The current Vita® Classical shade guide tabs are organized in color groups of similar hues.

The A shades - red/brownThe B shades - yellow/brownThe C shades - yellow/greenThe D shades - low value (grayish) A shades

Shade SelectionChroma

The saturation (or intensity) of color in the tooth

In natural teeth, it’s influenced by the value and thickness of the enamel

For example, when looking at a shade guide, A-4 has a higher saturation of red-brown than A-1.

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Shade SelectionValue

The degree of darkness (low value) or lightness (high value) of a color.

The grayness of the tooth we are trying to match.

Value is the most important dimension of color when it comes to shade matching.

Low value High value

Shade Selection

What Number Do You See?

Ishihara Test for Color Blindness

Shade Selection

What Number Do You See?

Individuals with normal color vision will see the number 5 in the dot pattern.

Individuals with Red/Green (the most common) color deficiency will see 2.

Ishihara Test for Color Blindness - AnswersShade Selection

Select a room with neutral colored walls.

Ensure a proper light source:

Indoor - color-corrective light sourceOutdoor - Northern-exposure sunlight during midday (slightly overcast) optimum

Shade Selection

Take the shade at the beginning of the patient's diagnostic appointment. Confirm shade selection at the preparation appointment.

Dehydrated teeth appear more white and opaque than hydrated teeth

Shade Selection

Glance at the teeth. The longer you look at the teeth the more gray they appear.

Select a room with neutral colored walls.

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Shade Selection

Look to the gingival third of the tooth for the base shade. The incisal edge of the tooth is often translucent

Shade Selection

Intraoral photographs communicate color variations and tooth characterization.

Have two people take the shade to confirm accuracy.

A gray card next to the teeth helps neutralize extraneous light and isolate the tooth.

Shade map

Shade Selection

Arrange tabs by VALUE from light to dark

Shade Selection

Bleach shade tabs

Anterior Composites

Brushes and Brush & Sculpt

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Black Triangle Syndrome

Slender Brush Applicator

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Final Restorations

Handy Instruments

Ceramist’s brush #3 OptraSculpt Composite Instruments

Why Learn to Layer?

Improvements in resin technology

More shades and opacities

Eliminates lab fees

One visit completion

Preserve natural tooth structure

Value for patients (more affordable)

Considerations When Layering

Handling consistency

Long-term wear

Polymerization shrinkage

Shade selection choices

Curing time

Polish and polish retention

Special needs such as fluoride release

Fluorescence

Opalescence

Mechanical properties

Single Shade

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Two Shades Cosmedent - Renamel

Fractured centrals Fractured Centrals

Silicone Putty Index

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Final Restorations

Single Anterior Dead Soft Matrix

Final Layers Final Restoration

18 months

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Tints & Opaquers Tints & Opaquers

Consistent “stump” shade

Preparation

Consistent “stump” shade

Final Restorations Fractured Incisor

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Shape, contour, occlusion? “lingual shell”n Initial layer is an enamel or

translucent shade (lingual outer layer)

nThe subsequent layer will be an “opaque” shade representing the underlying dentin

n The outer enamel layer will be that of a suitable translucent shade

Final Restoration

Is there a simpler way for those everyday cases?

Diastema Calipers - spring bow divider

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Etch & adhesive Placement and polish

Matrix (mpm)

High viscosity etch - Bisco Dental

placement

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Finishing

Final

Everyday Crown & Bridge

Types of Indirect Restorations

n Crownsn Bridgesn Conventional and Maryland (adhesive)

n Inlaysn Onlaysn Veneersn Endodontic Posts

Considerations for Material Selection

nEsthetics desirednLocation of the restorationn Location of the marginsn Fit capabilities of the restorationn Ability to properly isolate the arean Costn Strength

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Are PFM’s Dying?

Glidewell labs

Glidewell labs - trends

• Full Cast Metal•Gold Alloy• PFM – Porcelain fused to metal

•Many brands, high cost, being replaced by all-ceramics; FPD

• PFT – porcelain fused to titanium•New; mixed success; implant supported restorations

• Polymer

• Leucite reinforced glass ceramic•IPS Empress Esthetic/CAD; Authentic; OPC

•160 MPa• Lithium disilicate/silicate

•IPS e.max Press/CAD; Obsidian•High esthetics and strong•360-400 MPa

• Zirconia (high strength non-etchable)•Monolithic: BruxZir; LAVA Plus; KDZ Bruxer; OccluZir; ZirLux FC•Fastest growing; improved esthetics~1000 MPa

•Zirconia supported: IPS e.max ZirPress; ZirCAD, LAVA DVS,•High esthetics; may be subject to chipping, fractures; slow cooling

•High Translucent Zirconia - improved esthetics•700-800 MPa

ALL-CERAMICMETAL BASED

Crown classification

What type of ceramic do you use?

• IPS e.max - monolithic• IPS e.max - layered• Monolithic zirconia• Layered zirconia• PFM• Feldspathic• Polymer-ceramic• Full Gold• Resin-based

• Anterior FPD’s, single units - full mouth, implants• Anterior restorations, veneers, premolars, implants?• Posterior FPD’s, single units, full mouth? Implants?• Anterior & posterior FPD’s, single units - full mouth• FPD’s, implants, full mouth• Veneers• Single units - full mouth?• 2nd Molars, non-esthetic/visible areas• Single units - posterior

Material SelectionType Strength MPa Aesthetics Interocclusal Axial Bondable

Full metal >1200 n/a .4mm 4.5mm Cohesive

Porcelain/Metal 120 Good 1-2.0mm 4.5mm Cohesive

Procera 120 Good 1.5-2.0mm >3mmAdhesive/Cohesiv

e

Porcelain

(feldspathic) 200 Excellent 1.5-2.0mm >3mm Adhesive

eMax 360 Very good 1-2.0mm >3mmAdhesive/Cohesiv

e

Zirconia >1200 Very good 0.5-1.0mm >4mmAdhesive/Cohesiv

e

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Enamel wear - various ceramics

Evaluation: This study examined the wear resistance of human enamel and feldspathic porcelain after simulated mastication against 3 zirconia ceramics, heat-pressed ceramic and conventional feldspathic porcelain

Conclusions: The wear behaviour of human enamel and feldspathic porcelain varies according to the type of substrate materials. On the other hand, 3 zirconia ceramics caused less wear in the abrader than the conventional ceramic.

J Dent. 2012 Nov;40(11):979-88. Wear evaluation of the human enamel opposing different Y-TZP dental ceramics and other porcelains.

Kim MJ1, Oh SH, Kim JH, Ju SW, Seo DG, Jun SH, Ahn JS, Ryu JJ.

Enamel wear - Various ceramics

Evaluation: The purpose of this study was to investigate the 3-body wear of enamel opposing 3 types of ceramic (dense sintered yttrium-stabilized zirconia; Crystal Zirconia; lithium disilicate (IPS e-max CAD; Ivoclar Vivadent) (E), and a conventional low-fusing feldspathic porcelain (VitaVMK-Master; Vita Zahnfabrik) (P), treated to impart a rough, smooth, or glazed surface

Conclusions: The degree of enamel wear associated with monolithic zirconia was similar to conventional feldspathic porcelain. Smoothly polished ceramic surfaces resulted in less wear of antagonistic enamel than glazing.

J Prosthet Dent. 2014 May 16. Three-body wear potential of dental yttrium-stabilized zirconia ceramic after grinding, polishing, and glazing treatments.

Amer R1, Kürklü D2, Kateeb E3, Seghi RR4

Enamel wear - Zirconia

Evaluation: The wear of tooth structure opposing anatomically contoured zirconia crowns requires further investigation.

Conclusions: polished zirconia is wear-friendly to the opposing tooth. Glazed zirconia causes more material and antagonist wear than polished zirconia. The surface roughness of the zirconia aided in predicting the wear of the opposing dentition.

J Prosthet Dent. 2013 Jan;109(1):22-9. The wear of polished and glazed zirconia against enamel.

Janyavula S1, Lawson N, Cakir D, Beck P, Ramp LC, Burgess JO.

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Enamel wear - Zirconia

Aging of dental zirconia roughens its surface through low temperature degradation. We hypothesized that age-related roughening of zirconia crowns may cause detrimental wear to the enamel of an opposing tooth. To test our hypothesis, we subjected artificially aged zirconia and reference specimens to simulated mastication in a wear device and measured the wear of an opposing enamel cusp.

All zirconia specimens showed less material and opposing enamel wear than the enamel to enamel control or veneering porcelain specimens.

Oper Dent. 2014 Mar-Apr;39(2):189-94. Enamel wear opposing polished and aged zirconia.

Burgess JO, Janyavula S, Lawson NC, Lucas TJ, Cakir D.

Prep design - ceramic thickness?

n “Lithium disilicate significantly improved fracture resistance compared to leucite-reinforced ceramic”

n A 1 mm thick restoration did not show significant reduction of fracture resistance than a 2 mm thick restoration

n“The thickness of ceramic had no significant effect on fracture resistance when the ceramics were bonded to the underlying tooth structure”

(Bakeman, E, Rego, N, Chatyabutre, Y & Kois, J. Operative Dentistry 2013 (in press)

Posterior restorations

n “Fracture resistance and failure risks of posterior partial coverage restorations are significantly influenced by material selection”

n “Lithium disilicate had the highest fracture resistance followed by Leucite ceramic, Feldspathic ceramic and indirect composite”

(Kois, DE, Isvilanonda, V & Chatyabutre, Y. J. Esthet Restor Dent. 2013:25(2): 110-22

Preparation considerations for all-ceramic restorations

n Butt-jointed margins preferred (1mm, 90-110°)

n Avoid tapered, beveled or feathered marginsn Round internal line anglesn Anterior crown preparation minimal reduction = 1.5mm, incisal reduction = 2.0mm n Posterior crown preparation minimal reduction = 1.5mm, cuspal reductions for onlays = 2.0mm (J.F. Shapiro, All-Ceramic Restorations in Everyday Practice, Dentistry Today, April 15, 1998)

Prep Design

Core materials

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Purpose of a Core?

• Function: Replace missing/degraded tooth structure in order to provide an adequate, stable foundation for a crown to be placed on the tooth.

• Foundation & Stability

Post & Core

• Post is like an anchor – its function is to secure the core material to the tooth.

• Core is a Foundation for the crown

Post & Core guidelines

Filler • Less than ½ of tooth preparation missing on a vital tooth (filling small

undercuts & voids)

Core Build-up• More than ½ of coronal tooth structure missing on a vital / non-vital tooth (reliance on mechanical retention of preparation)

Post & Core• More than ½ of coronal tooth structure missing on a non-vital tooth (strength & retention of material is important)

Core buildups

Core build-ups are performed when a significant portion of a tooth is lost via decay or fracture and there is not enough tooth structure to support a crown.n Core material will build-up the spacen Strengthens the remaining tooth structuren Provides needed support for the crown

The final restoration is a crown over the core. n Core materials are NOT meant as a aesthetic filling material / stand alone permanent restorations.

Core material Prefabricated Post & cores

nTraditionally, metal post cemented in tooth followed by some sort of a composite as a buildup material.

n Metal post weak link.n Problems: loosening of post and core, fracture of core from post, time consuming( waiting for cement to set.

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Prefabricated Post & cores

nToday with the newest bonding agents and with fiber reinforced composite posts we can quickly and effectively create a monoblock( from apex to crown) and bond our post and cores into place.

n Creating a relatively strong, long lasting restoration.

Canal preparation

Post & core Bond post

Core buildup

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Diamonds - Shah Carbide burs - Shah

Occlusal and Lingual reduction- various ways to “slice” it

Tooth preparation starts with depth reduction

n Breaking contactn Depth cuts- usually done with shoulder or chamfer diamond. correspond desire of depth with the diameter of the abrasiven Selection of the bur

Margin

Margin

First cord placed

000 cord - passively placed- soaked in hemostatic, and blot dried

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Second cord placed - tissue displacement

- optional hemostatic agent over the initial cord- #1 or #2 cord placed dry over the initial cord

Hemostatic Agents• Material is syringed into place and agitated with flocculent

tip• Cord is placed at site after rinsing• Cord can be soaked in liquid hemostatic agent

Good

• Stops bleeding

• Some shrink epithelial tissue which

provides very slight sulcus expansion

Bad

• Ferric Sulfate: stains

proteins (dentin/gingiva) –can ruin esthetic

restorations. Also contaminates polyether• Aluminum Chloride: High

concentrations (25%) can cause significant harm to

cells• Need to be used with retraction cord for Crown

and Bridge

Displacement with cordAfter 000 cord, Viscostat clear (aluminum Chloride) 360◦

#2 cord

Removal of Second Cord

Sometimes second cord is too small

#1

#2

Retraction pastes• Paste injected at site around circumference of

tooth• Left in place for 2 minutes, then rinsed

• Sometimes addt’l mechanical compression is used (Comprecap)

• Can also be used in place of 2nd cord in two cord technique

Good

• Expasyl stops

bleeding/fluid• Shrinks tissue slightly

• Atraumatic• Faster/easier application

• Sufficient sulcular expansion

Bad

• Higher material

expense than cord• Learning curve

• Less retraction than cord

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Traxodent - Hemodent Paste Retraction System

What is Traxodent?

nAn absorbent paste that provides hemostasis and/or retraction:n Hemostasis:n 15% Aluminum Chloride (AlCl)n Paste is preloaded into disposable syringesn Material is dispensed through a bendable tip

n Retraction:n Mechanical: Temporary displacement of tissue by the paste.n Bonus: Clay absorbs fluids & expands – helps dry the sulcus, enhances tissue displacement, and has an affinity to blood.

When do you use Traxodent?

n Hemostasis:n Before any procedure in which a dry field is required.n Blood and crevicular fluids will interfere with bonding agents, impression materials, cements, etc.

n Hemostasis and Retraction:n Before taking an impression or an optical scan.n Blood and crevicular fluids will interfere with impression materials and scans preventing them from capturing preparation margins.

Hemostasis & Retraction- Traxodent only

Traxodent only rinse after 2 minutesIm a g e s c o u r te s y o f S h a lo m M e h le r D M D , T e a n e c k , N J

Cord and Traxodent

Images courtesy of Dean Elledge, D.D.S., M.S.

Traxodent can replace the second cord

Cord, Traxodent & Cap

Images courtesy of Abdi Sameni. DDS

Place cord

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Cord, Traxodent & Cap

Adapting the cap so that it contacts the soft tissue is imperative


Expasyl - gingival retraction system

Expasyl - gingival retraction system

• Retraction by displacing tissue for marginal access.• Safe due to minimal pressure required - No danger of rupturing

epithelial attachment.• Comfortable and quick to place.• Hemostatic properties which control bleeding and crevicular

seepage.• Won't dry out - new foil pouch for the capsules.

Cord, Expasyl & Cap

Cap left for 2 minutes

2 2 0


Final results

Before After traxodent Final impression

Single cord & expasyl

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Lasers on the Market Why LASERS?• Soft-tissue lasers are fast, safe and effective – and more economical than ever

before

• Lasers are easier to use than you may think – and educational options are plentiful

• Less invasive than traditional modalities like scalpel and electrosurge

• Excellent, predictable tissue response compared to packing cord

• Effective marketing tool for the entire practice

• The transition to soft tissue lasers is seamless and easy for long-time electrosurge users

Picasso Soft Tissue Procedures• • Gingival Troughing for Crown

Impressions• • Gingivectomy & Gingivoplasty• • Gingival Incision & Excision• • Soft-Tissue Crown Lengthening• • Hemostasis & Coagulation• • Excisional & Incisional Biopsies• • Exposure of Unerupted Teeth• • Fibromal Removal• • Frenectomy & Frenotomy• • Implant Recovery

• • Incision & Drainage of Abscess• • Leukoplakia• • Pulpotomy as an Adjunct to Root Canal

Therapy• • Operculectomy• • Oral Papillectomies• • Reduction of Gingival Hypertrophy• • Vestibuloplasty• • Treatment of Canker Sores, Herpetic &

Aphthous Ulcers of the Oral Mucosa

Features:

• Number #1 dental laser in the world

• More power – 3 watts

• New easy to use presets

• New treatment timers for perio treatment

• Wireless foot control

• Optional battery pack

• Perfect for

first timers or hygienists

• Affordable

• Disposable tips or fibers

• Certification included

A soft tissue laser incision at 1000x magnification

Lasercut

Superficialcoagulation

Heatdissipationwithlittle/noedema

Diode laser vs. electrosurge• Electrosurge devices have a much larger zone of necrosis and inflammation – up to 500

to 1,000 cell layers of tissue damage vs. 3 to 5 with a diode laser• Unlike electrosurge devices, a diode laser will cauterize nerve endings, minimizing

discomfort intra- and post-operatively.• Tissue treated with a diode laser stays exactly where the clinician leaves it post-

operatively; no worry of rebound or recession.

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Tissue contouring Pre-scan laser tx

Fibroma Removal• Fibroma removal is easy, fast and atraumatic for your patient.• Advantages of using a laser vs. traditional modalities • Cut and coagulate at the same time • No bleeding • No sutures • Little to no post-operative pain and discomfort

Pre-op Immediatepost-tx 2weekspost-txPhotosCourtesyofDr.Glenn

vanAs

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 • No sutures • Little to no post-operative pain and discomfort

Pre-op Immediatepost-tx 1monthpost-txPhotosCourtesyofDr.

PhillipHudson

Conclusion• A diode laser can be a remarkable addition to a

practice• Improves clinical outcomes, promotes faster healing• Essential ‘bread and butter’ procedures can generate

fast ROI and get you off and running as a laser dentist• Safe around metal – implants, amalgam, matrix bands• Proven effective in decontaminating root canal spaces• An excellent tool for perio and hygiene

Cementation

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• Zinc Phosphate• Flecks Mizzy• Polycarboxylate

• Durelon• Glass Ionomer

• Ketac Cem• Resin-Modified Glass Ionomer

• RelyX Luting; FujiCem 2• BioCeramic

• Ceramir

• Total-Etch• Veneers; thin translucent crowns• Examples: Choice 2; RelyX Veneer; Variolink Veneer

• Self-Etch• Self-etching primer applied separately; cement thick,

opaque ceramics• Examples: Duo-Link Universal; MultiLink Automix; RelyX

Ultimate• Self-Adhesive

RESINADHESIVECONVENTIONAL

Cement Classification• Light-Cure

• Photo-initiators• Increased working time, decreased

finishing time, good color stability• Dual-Cure

• Chemicals and photo-initiators• High bond strength, quickly seal

margins, can be esthetic• Chemical-Cure (self-cure)

• Rxn of 2 materials mixed• Use when light curing difficult, metal

restorations, posts• Example: Panavia, C&B Cement

• Total-Etch• PO4 etch, then adhesive is applied• Technique sensitive; highest bond to tooth;

reduced microleakage• Self-Etch

• Self-etching primer applied separately; high bond strength

• Easy to use; some incompatibilities • Self-Adhesive

• One component, all-in-one

Stamatacos C, Simon JF. Cementation of Indirect Restorations: An Overview of Resin Cements. Compend Contin Edu Dent. 2013; 34(1)_:42-46.

BY ADHESIVE SCHEMEB Y PO LYM ER IZATIO N

Resin Cement Classification

Why Resin Cement?

• High bond strength to tooth structure and porcelain

• High tensile and compressive strength• Lowest solubility• High wear resistance• Highest flexural strength and modulus to

prevent debonding during function• However,

• Can be technique sensitive• May have difficult clean-up• Possible color change during

Simon JF, Darnell LA. Considerations for proper selection of dental cements. Compend Contin Edu Dent. 2012; 33(1):28-36.

Desirable Properties of Cements

• Stable bond to both the remaining tooth structure and the restoration material

• Strength to resist the forces of mastication and parafunctional forces (flexural/modulus)

• Lack of solubility in oral fluids• Low film thickness (5-25 um)• Biocompatible• Color stability• Ease of use and good viscosity• Low water sorption to prevent expansion• Radio-opaque• Possession of anti-cariogenic properties

What about Zirconia?

Zirconia:Silica-free, acid-resistant, polycrystalline ceramic

Since Zirconia does not contain glass, etching is not possible. Hydrofluoric acid usually works by removing a portion of the glassy matrix in a ceramic, thus “etching” the restoration and creating micro-mechanical retention

GC Initial™ Zr: Layered

Zirconia Coping Substructure

Solid Milled Zirconia Crown: No treatment except GC

Initial™ IQ Lustre Paste

GC Initial™ IQ POZ: Pressed

Zirconia Bridge Substructure

Dealing with Zirconia

n Traditionally are cemented by a cohesive process since it has not glass content

n Prep design is important - resistance and retention formn Internal surface can be treated by the lab to faciliate some degree of bonding - silicatized adhesive layer added

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Conventional cements

Ceramir - Doxa Dental

• injectable bioceramic material for dental applications

• initally for orthopedic use

• first approved in Europe and US in 2008

Ceramir technology• Ceramic powder = Calcium oxide + Aluminium-oxide

Key features- Nano structural integration- Permanent seal of the tooth – restoration interface- Bioactivity - Biocompatibility- Creates Apatite when in contact with phosphates- No shrinkage- Hydrophilic system with Alkaline pH- Thermal properties similar to tooth structure- Adjustable handling and setting properties

Benefits

500nm

Ceramir

- Sealed interface – less risk of secondary caries- Basic pH, chemical stability and no shrinkage gives a stable interface

Ceramir Crown & Bridge• Natural: biocompatible and environmentally friendly

• Permanent sealing: so it protects the tooth over time

• Easy to use: self-adhesive, self-curing, easy cleanup, not sensitive to moisture

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Ceramire Crown & Bridge• Incorporates some glass ionomer components which improve

handling and properties

Basic Properties - Ceramir

• Working time: 2 minutes

• Net setting time: 5 minutes

• Film thickness: 15 microns

• Compressive strength: 360 MPa

• Radiopaque

Bioceramic Luting agent1.Natural

- Similartohydroxyapatite- Stateoftheartinbiocompatibility- Biomimeticproperties

Naturalremineralizationprinciple- PermanentSealing- Reliable- Predictable- Cariesprotectedinterface

3.Easeofuse- Quick- Lesstechniquesensitive

Ceramir - easy to use

Ceramir Ceramir

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Ceramir Ceramir

Ceramir

Resin cements

The Next Generation – What’s new?New design Pre-treatment

Tooth #20 - large composite with previous endodontic treatment.

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Occlusal view of preparation tooth #20

Application of Ceramic Primer II to restoration surface

Adhesive application to prep

Resin cement is dispensed from an automix syringe into the crown.

The crown is seated on the tooth and excess cement is displaced.

Excess cement is removed with a brush prior to light curing.

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The cement is light cured for 20 seconds on each surface.

Excess cement is removed with a suitable instrument.

Excess cement in the interproximal can be easily removed with a separating saw. This is separating strip does not have any abrasive side, but only serations to loosen any cured cement that might be in excess in the interproximal regions.

Final restoration

Porcelain veneers

Aesthetic Waxup - Diagnostic

n Purpose: To give the patient some idea what the final result would look like.

n Allow you to make temporaries that will look somewhat like the final result.

n Allow the patient to evaluate temporaries to see if there is anything that they do not like.

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Diagnostic Waxup (Aesthetic) Be Prepared!

n Make sure you have matrix and or suck downs from lab for your temporaries.

n Make sure you have enough burs and know what you need.n Have everything ready for entire procedure.

Diagnostics Preparation

n Veneers & Crowns

n Shoulder or chamfern Evaluate height of smile before preparation

n High smile or low smilen This often determines if you need to go sub-gingivally or equi-gingivally

CY Initial presentation

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Diagnostic waxup & depth cuts Stent/guide

Shade tabs for “stump” Veneer Provisionals

BisGMA Provisional Materials

Remove and trim

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Trim & clean Rinse & Bond

Bond & Flowable “shrinkwrap” cure

Failing restorations

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Shade tabs Stump shades

Cutback - Emax & LiSi ceramic Cutback - Emax & LiSi ceramic

Final restorations Final restorations

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Dental implant aesthetics & tissue

Management

Acheiving predictable esthetics

• Proper tissue management - during implant surgery • Immediate provisionalization• Proper tissue management - provisionals• Healing collars (tissue formers)• Tissue “reshaping” - laser, surgery, provisional• Abutment & crown selection

Tissue Management -immediate provisionalization

LR - 3.0mm implant

Follow-up

5 days post-op 10 weeks post-op

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Follow-up

6 months post-op

Restoration time

Final Restoration Tissue Management - sugery

CS Second Stage

6 months

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Provisional4 weeks6 weeks

Final Stages6 months

Final Stages Final Restoration

7 months

KW - Tooth #21 (9) Straight from the surgeon

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Useful Components

Implant replica and healing collar

Extracted Tooth

Hollowing out Acrylic reline

Remove collagen plug Reline in mouth

Seat in mouth over healing collar Remove from mouth after setting & place on analog

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Polishing Provisional

Healing

9 days 7 weeks

Final Restorations

Final Restorations

Lab Communication

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Lab Communication? GC pattern resin

Alternative materials Lab

Final 4 weeks - tissue emergence

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title Flowable to capture emergence profile

Send to lab Pour cast

Final restoration

Abutment & Crown Selection

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Abutments for cement-retained restorations

ATLANTIS™ Direct Abutment™ TiDesign™

ZirDesign™

CastDesign™

Abutment selection• Indication; single

tooth/partial bridge/full fixed bridge

• Upper or lower jaw• Anterior or posterior

region• Implant angulations• Marginal bone levels• Soft tissue levels• Occlusal interproximal

space• Adjacent teeth and roots• Esthetic demands

Direct Abutment – restorative flexibility

• Titanium

• One-piece component with 6°tapered top

• Three diameters

• Four vertical heights

• Laser etched marked line for occlusal reduction

Direct AbutmentØ 4Four marginal and three vert. heights Ø 5Three marginal and vert. heights

Ø 5Four marginal and three vert. heights Ø 6Three marginal and vert. heights

Direct Abutment system

Cover screw in place Removed cover screw


Abutment installation

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Recommended torque for final seating 25 Ncm


Impression taking


Impression with Direct Abutment Pick-up in place

Provisional crown


Abutment replica in place

Final crown restoration

ATLANTIS™ – CAD designed “customized” abutments

ATLANTIS™ abutments

ATLAN TIS™ Abutm ent, titanium ATLAN TIS™ Abutm ent, GoldHue™ATLAN TIS™ Abutm ent, zirconia

(available in four shades)

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Compatibility• ASTRA TECH Implant System• BioHorizons• Biomet 3i• Camlog

• DENTSPLY Friadent• Keystone Dental• Nobel Biocare• Straumann• Zimmer Dental

A ll tradem arks a re the p roperty o f the ir respective ow ners

ATLANTIS™ abutment vs. stock abutment

ATLANTIS™ patient-specific abutment

Stock abutment

Atlantis Abutment - emergence width options

No tissue displacementSupport Soft tissueContour soft tissueFull anatomical dimensions

Narrow Healing Situation

Atlantis Abutment - emergence width options

No tissue displacementSupport Soft tissueContour soft tissueFull anatomical dimensions

Wide Healing Situation

ATLANTIS™ abutment vs. stock abutment

- cad/cam abutment design provides optimal support and retention for the final restoration - helps reduces costs of alloy in the framework

ProcedureImpression:• Take an

implant-level impression

• Send the impression to your laboratory

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Design and production:• The models are scanned and

generated into a virtual 3D image• An ATLANTIS™ abutment is designed

for the specific edentulous space• The customer has the option to review

and approve the design before it is send to manufacturing

Lab Procedure Virtual Implant Design:designed from the final tooth shape

The scanned model is transformed

into a 3D image, making it possible to create the final tooth shape.

When the desired tooth shape is

decided, the abutments are designed.

The final design is checked for fit

and occlusal clearance before the abutments are produced.

Scanning and design processScanning 3D image

Ideal crown Design abutmentATLANTIS™ 3D Viewer – animation

Failed bridge to implants Scan bodies - TruDef scanner (3m)

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Digital design Atlantis Abutments

Abutment placement - tissue blanching

Final restorations Thank You for your attentionQuestions?

Dr. Paresh Shah

[email protected]

www.drpareshshah.com

Documents

CRD 2016 handoutd1ue90e5sp4tcv.cloudfront.net/2900/images/Asset303059_v1.pdf · •Resin compatibility •Strength •Efficient curing Combating Sensitivity •By achieving a great